Psychological Theories of Behavior Development-Psychoanalytical (Freud), Psychosexual & Psychosocial (Erickson), Development of Intelligence (Piaget)**Ages 1-5 years predilection:
predilection: 9:1 Usually found in the maxilla Tx: surgical excision; recurrence is rare Palatal & Dental Lamina Cysts of Newborns Present in 75% of newborns Dental
are the most critical for behavior development. -Learning- Learning is a change produced in subsequent behavior as a result of experience. For example, infants struggle to
keep their heads upright so they may see more of their environment. -Infancy (<2 years of age)Completely dependent on parent(s) for survi]val & will have separation anxiety.
Rec.: No or minimal separation from parent(s). Stranger anxiety is common. Keep familiar parent in child’s eyesight to decrease anxiety. Keep movements slow and gentle. If
possible, have parent maintain physical contact with the infant. Develop “transitional objects” which are reminders of a “parent” & are sources of comfort/security, e.g., Teddy
bear).Have child bring T.O. into operatory unless it will interfere w/ tx. Oral cavity is the prime source of pleasure (food). Finger sucking & pacifiers are very common. May see
resistance (crying) to letting dentist/DH to touch their mouth. As the child approaches 2 yo, improved language & understanding develops. Use Tell-Show-Do and gentle,
soothing voice.Memory is just beginning. (Memory begins as early as 6 months of age!). Use of “No!” by the child is a common response to new situations. (Even if they mean
yes… -Toddler (2 – 4 years old) Autonomy is developing in self –feeding, dressing, sphincter control. Discuss good/bad foods in simple terms. Ask pt. if they need to use the
restroom before the appt. Gross motor skills are developing quickly. Walking is perfected and climbing is developing. Ask, ”Can you climb into the chair by yourself or do you
need a boost?”. Language improves rapidly. Increased comprehension of TV, toys, etc. Have familiar child objects/characters in the office. Attention span is getting longer. Can
sit still longer. Pleasant 20-30 minute appts are possible with good behavior management technique. Animism (everything is alive). Winnie the Pooh is REAL! “The alligator”
has teeth….Begin to accept separation from the parent, but may change their minds. Concept of time is here and now. You cannot reasonably say, “Just 5 more minutes.”
This age group doesn’t really know how long a minute is. Use distraction, tell a story, etc. to try to buy additional time. Fears develop, especially of bodily harm. Reality
principle begins. (They can now delay gratification, no longer needs to be immediate. They can usually be “good” enough, long enough for a prize at the end of the appt.
Willingness to help/cooperate improves greatly. Involve the pt. in activities, have him hold the saliva ejector. Concrete thinkers. Be specific with your statements. Do not say
that you are going to look at pt’s teeth and then touch them with an instrument…you must tell pt about the touching ahead of time. Clothes are very important…Don’t forget to
comment on a pretty hair ribbon or a new pair of shoes. -Pre-School (4 – 6 years) Increasing independence.Usually do not require parent in the tx room.May still require a
transitional object. Parents may interfere with signs of early independence by getting upset if the child easily walks with you to the tx room. Parent may say, “Aren’t you going
to kiss me good bye?” Which only causes emotional confusion in the child. Can usually carry on a conversation with an adult. Tell them “THE RULES.” (You must sit
quietly in the chair, you must not move (too much), you must raise your hand if you need to tell me something, etc.).If the pt. becomes upset, remind them to use “their words”
to tell you what is wrong. Natural curiosity – ask many questions … ”WHY?” Imitative behaviors are common. They want to act like “Big Kids” or parents. Try to involve
them in the procedures, have the pt. hold the saliva ejector, etc. Can’t always anticipate the results of their actions. May try to jump out of the chair when it is too high.
Animism is still present, but these pts. are generally less amused by fantasy. Learning emotions of jealousy, rivalry (peers or siblings) and sympathy. Be careful not to induce
sibling rivalry by treating siblings differently (number of stickers, saying one (or even both) of the children is “your favorite” or “your best patient.”-School Age (6 – 12 years)
Child has a more realistic view of environment, concrete thought. Abstract thought is developing…Works to acquire family’s habits & moral code. “Rules of the Game” are
important. School consumes 50% of their waking hours. -Adolescence (puberty – adulthood) Puberty - Thoughts tend to be introspective, analytic, and egocentric
THE CHILD AS A PATIENT: Developing Dentition I Growth 1.Initiation Dud stage (mesiodens) 2.Proliferation Cap stage 3.Histodifferentiation
bell stage (ameologenisis imperfecta) 4. Morphodifferentiation (tauradont, talon cusp) Advanced bell stage 5.Apposition II.Calcification fluorosis, amelo imp;hypocalcification
Calcification of primary teeth begins at 12th to 14th week in utero and completed by 12 months of age. The mesio-buccal cusp of the first permanent molars are calcified
by the time of Birth. Eruption Root formation has correlations with eruption, after completion of the crown, inner and outer epithelia fold over cemento-enamel junction
and continue their growth ( Hertwig’s epithelial root sheath ). Eruption sequence usually starts approximately 6-8 months. May be as late as 1 year old+. 2.eruptions in
groups, By age 2 1/2- 3, 70 % of all children have an intact primary, by age 2 1/2, 50% of all children have at least one cavity. Recommend first dental visit by age 12
months to stress prevention concepts (Ex. fusion, gemination (0.5-1.0% ), supernumerary 0.3%, etc.) OVERBITE 10% OVERJET 1-2mm. Gingival color is redder- more
vascularized, less keratin, less stippling, rounded papillae. Ovoid shape arch (99%). Baume Theory- Spaced primary dentition’s tend to produce favorable alignment of the
permanent incisors Unspaced arches tend to produce crowded anteriors 40% of the time. primate Space: mesial to MX canine and distal to MD canine DEVELOPMENT OF
THE MIXED DENTITION (Transitional Dentition) Early mixed dentition occurs a during ages 6-8 (no premolars erupted). Late mixed dentition occurs during ages 9-12
(premolars erupting). Teeth pairs generally erupt within 3 months of each other. (e.g.#8+9,#19+30) "Ugly Duckling" stage Diastema will usually close after 6 | 11 erupt
Incisor liability- is defined as accommodation of the "added" tooth structure from larger size permanent teeth, e.g., MX = 7.6 mm and MD 6.0 mm (arch). Use primate spaces
and “generalized" interdental spacing to accommodate the larger teeth. ovoid arch form changes as canines erupt buccally, which increases the intercanine arch width to fit
larger size teeth. Anterior positioning of erupting permanent incisors widens the arch to accommodate the larger size teeth OB = 20-50% OJ = 2 mm Interincisal angle =135 0
(decreases from 180 0 ) critical time to begin ortho treatment is age 7-10. 1.Mesial Step Terminal Plane is seen in 14% of children and allows the permanent molar to erupt
directly into a Class I position or slightly more forward >4mm into a class III position 2.Distal Step Terminal Plane is seen in 10% of children and allows the permanent
molar to erupt in Class II position . 3.Straight (76%). In these cases the permanent molar will erupt end-to-end. A.Space Present (Primate +/or Generalized Spacing). When
space is present, the erupting permanent molars will force the closure of these spaces and produce a Class I. This is called Early Mesial Shift. B. No Space Present. When no
space is present, the permanent molars erupt end to-end and must wait to slide mesial into a Class I molar relation by using the "Leeway Space" (MX =1.7-mm, MD= 3.4 mm)
to produce the class I occlusion. This is called Late Mesial Shift. Occurs at age 10-12 (when the primary molars exfoliate).
RADIOGRAPHY FOR CHILDREN 1. Oral conditions present: abscessed or fractured tooth, a periapical or occlusal radiograph is necessary b.DECAY
Children with a high caries rate or recent history of interproximal caries, should receive bite-wings every 6 months. Children with no/low caries every 12-24 3.The size of the
child's mouth(for bitewings radiographs) a. Small size use a smaller size film (#0 or #1) b.If gagging occurs or the child has a short arch length, use a smaller size (#1 or #0), or
rotate a #0 or #2 film 90o (see textbook) The rectangular collimator will reduce radiographic exposure by 40% All proximal surfaces must be visible from the distal of the cuspid
to the mesial of the first permanent molar. Snap-A-Ray (Ezee-grip) has a thick bite block, which obliterates 3 mm of space, so use size #0 or size #2 film for this bitewing (this
technique is good for patients with gag reflex b. Bitewing tabs are thinner, so use a #1 or #0 size film for younger patients c. Sure shot film holder has a thin biteblock, so use
size #0 or #1 or #2 film B.Occlusal Film 1. In the primary dentition a maxillary occlusal film is taken for history of trauma , abnormal clinical finding in the anterior
maxilla.c.Maxillary: cone angulation at 65o central ray is directed to the apices of the central incisors (1/2 inch above the tip of the nose). Occlusal plane parallel to the floor.
d. Mandibular: Vertical angulation at -60o . Cone positions is easier with head tipped back and occlusal plane angled at 45o For uncooperative child you can take extraoral
radiographs”Lateral view” by directing the cone from the other side so the central x-rays beam enters at -10 degrees and perpendicular at the film. Case I Four year old child
his first clinical exam revealed: Teeth #T, L extensive decay Tooth # F gray discoloration What radiographs should you take? Case II 9 year old child his first clinical exam
revealed high caries rate, multiple occlusal, buccal and lingual decay Case III 4 year old child his recall exam revealed discoloration of tooth #D and class I mobility, previous
radiographs taken 6 months ago revealed no interproximal decay What radiographs should you take? Case IV 5 year old child his clinical recall exam revealed extensive decay
of tooth #D and # I, previous radiographs taken 6 months ago revealed untreated interproximal deep decay of tooth #T, #B and #L Case VI 2 year old child his clinical recall
exam revealed no decay Case VII 2 year old child his clinical initial exam revealed decay on teeth #’s E,F Case VIII 12 year old child his clinical initial exam revealed no
decay , radiographical examination of the bitewings revealed bone loss around teeth 3,14,19,30 Case IX 12 year old child his clinical initial exam revealed no decay. Primary:
1 occ (mx), 2 BW, Selected Pas, Mand Occ.*, Mixed Panagram, 2 BW, Selected Pas or Anterior 2 Occ or 6 PAs Posterior, 2 BW 4 Post Pas Young Permanent: Pnaogram, 4
BWs Selected Pas or Adult FMS
Behavior Guidance Cooperative Child Majority of children >36-40 mos old are cooperative if managed correctly. Parent – Child – Dental Team interactions are
usually good. Attitude of parent is supportive and will allow you to treat the child. The child reacts appropriately to the “critical moments” of a dental appointment. (*pp. 405-
407) Emotionally Compromised Child Psychological or emotional illness exists that may not be diagnosed. Common finding is anxiety. Generally “poor” dental patients +
difficulty w/other challenges in life Greater incidence in children from broken homes, poverty, & abused/neglected children. Shy/Introverted Child Common in many young
children. If you can get them to “open up” they usually become fantastic pts. The stress of the dental appt. may cause the child to exhibit avoidance behaviors such as crying
(usually compensatory whimpering). “Break the barrier of shyness with friendship.” Frightened Child Common in children: <36-40 mos of age, slow mental dev. children in
crisis (divorce, CAN, other health problems) emotional illness *acquired fears from peers, siblings, parents, previous unpleasant, dental experiences, Child’s fears should be
identified, if possible, and addressed. (Fear of “needles” is VERY common.) May require a referral for psychological evaluation & tx. Child Who Is Adverse to Authority -
Misdirected GoalsUndue attention. Struggle for power, Retaliation & revenge, Inadequacy. Developmental changes in response to painful stimuli occur early in infancy.
(Fears of sharp objects can be seen by 1 year of age. The DDQ was shown to be a reliable instrument & helpful for parents & dentists to identify toothache in young children.
8 reliable behaviors Problems brushing upper teeth. Puts away something nice to eat, Problems with brushing lower teeth, Bites with molar teeth instead of front teeth
Chewing at one side, Problems chewing, Reaching for the cheek while eating, Crying during meals***(Crying at night, earache at night, earache at daytime, & earache during
eating were not significant factors
Prevention I
Dental caries is the most common infectious disease affecting our population and the most common chronic disease of childhood in the USA. Preventive measures should be
focused on the specific type of caries pattern (e.g., pit & fissure caries is most effectively prevented with sealants, smooth surface caries responds well to topical fluoride, ECC
requires diet changes & chemotherapeutic agents) 5 Components of a Pediatric Dentistry Prevention Program: Determination of caries risk factors/risk assessment level (AAPD
CAT), Professional prophylaxis/Oral hygiene instruction, Chemotherapeutic agents including Fluoride (systemic and topical) & CHx, Diet evaluation/instruction,
Sealants/restorations, American Academy of Pediatric Dentistry Caries-risk Assessment Tool (CAT), Classifies children into low, moderate and high risk categories. Only
children with NO Moderate or High risk factors can be in the Low category. Even one risk factor in the Moderate or High Risk categories will classify a child into that category.
A.A.P.D. Caries-risk Assessment Tool (CAT) risk factors – LOW RISK No carious teeth in the past 24 mos. No enamel demineralization. No visible plaque; no gingivitis.
Optimal systemic & topical F exposure A.A.P.D. Caries-risk Assessment Tool (CAT) risk factors – LOW RISKConsumption of simple sugars or foods strongly assoc. w/ caries
initiation primarily at mealtimes. High caregiver socioeconomic status.Regular use of dental care in an established dental home. A.A.P.D. Caries-risk Assessment Tool (CAT)
risk factors – MODERATE RISK. Carious teeth in the past 24 mos. One area of enamel demineralization,Gingivitis, Suboptimal systemic fluoride exposure w/ optimal topical
exposure MODERATE RISK, Occasional (ie. 1-2) between-meal exposures to simple sugars or foods strongly associated with caries. Midlevel caregiver socioeconomic status
(ie. Eligible for school lunch program or SCHIP),Irregular use of dental services. HIGH RISK Carious teeth in the past 12 mos. > 1 area of enamel demineralization. Visible
plaque on anterior teeth. Radiographic enamel caries. High titers of mutans streptococci. A.A.P.D. Caries-risk Assessment Tool (CAT) risk factors – HIGH RISKWearing
dental or orthodontic appliances, Enamel hypoplasia, Suboptimal topical fluoride exposureFrequent (>3) between-meal exposures to simple sugars or foods strongly associated
with caries. Low-level caregiver socioeconomic status (i.e., Eligible for Medicaid). No usual source of dental care. Active caries in the mother. Children with special health care
needs. Conditions impairing saliva composition or flow Professional Prophylaxis/OHI. Is a prophylaxis necessary? If so, what kind? How often? Tooth- brush, rubbercup,
scaling, root planing…). What is the appropriate brushing & flossing schedule? Any special considerations re: technique? Who performs/supervises? Fluoride Systemic fluoride
is recommended for children between 6 months and 16+ years of age who have suboptimal levels of fluoride in their drinking water. Recommendations are not related to caries
risk assessment. 1mg/L = 1 ppm 1 μg/mL = 1 ppm 1 mg/mL = 1,000 ppm10 mg/mL = 10,000 ppm = 1% F ion ppm = parts per million Systemic Fluoride A pea-sized amt. of
ADA-approved dentifrice (~1100 pmm F) containing fluoride is recommended for all children > 2 yo 2x/day. In-office topical fluoride application (1.23% APF or 5% NaF
varnish) should be based on risk level. Topical gel (Gel Kam (0.4% SnF2) or Prevident (1.1% neutral NaF))– parent should apply a pea-sized amount 2x/day) for children <5-6
years of age who are likely to swallow rather than rinse. Children > 5-6 years of age can generally use a fluoride rinse (ACT or Fluorigard (0.05% NaF)) or high concentration F
toothpaste (Prevident 5000) twice a day. Professional Fluoride Applications. 5% NaF varnish is now available in tinted and white colors. Professional Fluoride Applications
1.23 % APF foam or gel is usually applied in trays for four minutes. Shorter application times or brushing on fluoride instead of using trays may be indicated with some pts.
who gag easily. 2% Neutral NaF is indicated for pts. w/ large anterior composite or porcelain restorations. Fluoride Ingestion - Acute Fluoride ToxicityLethal dose varies with
body weight = 1 gram fluoride (2.2 g NaF) per 44 # body weight. 1-2 grams of sodium fluoride would produce acute fatal poisoning in a 33 # child. The ADA recommends that
no more than 264 mg of sodium fluoride (120 tablets of 1 mg doses) be dispensed at one time. Generally limited to dental fluorosis. Very high level of fluoride intake over a
long period of time may result in bone fluorosis. (~1 mg of fluoride is on this toothbrush head…enough for a whole day!)Fluorosis Fluoride Content Sorbitol gums had no
significant long-term effect on caries. Xylitol and xylitol/sorbitol gums had a long-term effect. During the 5 yrs. after habitual gum-chewing ended, xylitol gums reduced caries
risk 59%, xylitol/sorbitol gums reduced caries risk 44%. Teeth that erupted after 1 year of gum-chewing or after the two-year habitual gum use ended had long-term caries risk
reductions of 93% and 88% respectively.Teeth that erupted before the gum-chewing started had no significant long-term prevention. Conclusion: “For long-term caries-
preventive effects to be maximized, habitual xylitol gum-chewing should be started at least one year before permanent teeth erupt.”
CLINICAL RECORDS & TREATMENT PLANNING
Pediatric Treatment Planning I Luride Lozitabs (0.5 mg) Disp:120 tablets Sig: Chew, swish & swallow 1 tablet qhs Refills: 1
Child Abuse & Neglect When physical abuse is suspected in a child < 5 yo, a radiologic bone survey of the skull, thorax & long bones should be completed.
Clinical findings of fracture often disappear in 6-7 days even w/o orthopedic care. Failure to thrive is an underweight, malnourished condition; the child is usually below the 3rd
percentile in weight with a height and head circumference that are above the 3rd percentile on growth curves. Causes: 30% organic, 20% underfeeding d/t understandable error,
& 50% from parental neglect.Mainly seen in the first 2 years of life (rapid growth & dependency on adults for food). Parents should be reassured that appropriate analgesia &
anesthetic procedures will be used to assure the child’s comfort during dental procedures. If, despite these efforts the parents fail to obtain therapy, the case should be reported
to appropriate child protective services.” Initially, an oral report (telephone) is made to the Family Independence Agency in which the child resides. Within 72 hours of the oral
report, a written report (3200 form) is required. Failure to Report May Result In:
Anticipatory Guidance S. sanguis (low caries potential) colonizes infants at ~ 9 months & influences the degree of subsequent colonization of MS. Chlorhexidine
(CHx) rinse QD @ HS X 7 d/month X 1 year. Plasmid-containing strains (which are associated with moderate to severe caries rates) are present in 8% of African-Americans &
4% of Caucasians. Despite a decrease in caries prevalence among permanent teeth of 6-19 year olds, a 15.2% increase in disease was noted among the nation’s youngest
children ages 2-5 yrs. CDC reports that > 1 in 4 (28%) of preschool children have experienced tooth decay. This finding suggests that >4 million children are affected
nationwide – a jump of over 600,000 additional preschoolers over a decade. Preterm Infants. Prevalence of enamel defects increases with decreasing birthweight: 62.3%
<1500g (3.3#) 27.3% 1500-2500g 12.8% >2500g (5.5#) Preterm Infants – Palate Deformities Children intubated at birth have 2x the incidence of left-sided hypoplastic dental
defects as right-sided defects. This is probably the result of trauma from left-handed placement of the laryngoscope. Palatal deformity (grooves in hard palate) following
intubation: 48% incidence w/ orotracheal intubation; 88% incidence if intubation > 2 wks. Long-term studies indicate possible persistent detrimental effects. Prevention is
possible with custom acrylic plate to protect the palate. Children < 6 yo need an adult to place toothpaste on the brush and participate in brushing & flossing. First dental visit
should occur by the age of 12 months. Optimal Systemic Fluoride Exposure Does Not Appear to Reduce the Incidence of Dental Caries in Very Young Children
One Year Exam Visit “The AAPD emphasizes the importance of professional oral health intervention very early in childhood. Caries-risk assessment is an essential element of
contemporary clinical care for infants, children & adolescents.” Lymphiangioma Developmental malformation of lymphatic vessels Develops in the tongue, except in African-
American it may develop on the alveolar ridge Soft, cystic bluish lesion Tx: excision if size warrants Electrical Burn Most frequently occur between 6-24 months of age.
Commissure of the mouth is the most common site. Treatment is usually splinting within the first 10 days followed by surgery. Caution: risk of bleeding from the labial artery.
Facial asymmetry will develop if the injury is not splinted properly. Eruption Hematoma Bluish color, dome-shaped lesion positioned over an erupting tooth. May occur in
the primary or permanent dentition. Tx: keep clean, excise overlying tissue only if symptomatic.Eruption Cyst Well-circumscribed, dome-shaped fluctuant enlargement
overlying an erupting tooth. Usually asymptomatic; rupture spontaneously – no tx necessary. Tender if superimposed bacterial infection present – excise overlying gingiva.
Congentital Epulis of the NewbornPedunculated mass, occas. multilobular, may measure up to several cm in diameter Granular cell tumor; disputed histogenesis Female
lamina cysts – crest of alveolar ridge Epstein Pearl – midline raphe Bohn’s nodules – hard or soft palate No tx nec. - usually slough w/i a few days Neonatal & Natal Teeth
Natal teeth are present at birth Neo-natal teeth erupt w/i 30 days of birth 90% are primary teeth; 10% are supernumerary tooth-like structures; 85% are mandibular Familial
occurrences; may be assoc. w/ syndromes Tx: maintain if possible; remove only if excessively loose or significantly interfere with feeding.Teething One study of infants
concluded that 45% of infants aged 7-30 months identified as “teething” by their parents were actually suffering from a herpes simplex infection. Considerable variation in the
clinical presentation was noted, probably d/t varying levels of maternal antibodies (younger infants have higher levels). Riga-Fede Disease Traumatic ulceration of ventral
surface of the tongue from friction from a tooth May cause active bleeding & discomfort Tx: observe; cessation of breast feeding; or removal/smoothing of the tooth/teeth
Melanotic Neuroectodermal Tumor of Infancy (**See p. 52) Anterior maxilla; may be present at birth.Rapidly expanding bony lesion; surface may be blue-black color; ill-
defined, unilocular radiolucency w/ displacement of tooth buds; “floating tooth” appearance.Melanotic Neuroectodermal Tumor of Infancy Lesion mimics malignancy w/
destructive, rapid growth rate; increased incidence of dental anomalies d/t surgical tx. Tx: Surgical excision or curettage; 15% recurrence rate; reported cases of metastasis
LOCAL ANESTHESIA FOR THE PEDIATRIC PATIENTTopical anesthetic=Sleepy jelly or cream Local anesthesia=Sleepy drops 2x2
gauzeTooth towelSyringe=Silver strawInjection=Squeeze sleepy Technique The child has to be in supine position Use a 2x2 gauze or cotton applicator to dry the area of
injection for topical anesthesia, leave the topical anesthesia for 1-2 minutes. Distract the child by wiggling the cheek or talking about” happy events” Use head -lock to snuggle
the child head For mandibular injection tip the head up to help in blocking the vision of the child and increase your visibility Retract the check and find your anatomical land
mark. Once you have POSITIONED your hand, leave it in until the injection completed. Once you BEGIN the injection generally DO NOT STOP Find your landmarks
Coronoid notch Occlusal plane of the mandibular posterior teeth Pterygomandibular raphe Internal oblique ridge (RETROMOLAR TRIANGLE) The child mouth opened as
wide as possible Position the thumb on the coronoid notch on the anterior border of the mandible Insert the needle with the bevel oriented toward the bone, and at level of the
occlusal surface between the oblique ridge and the pterygomandibular raphe Insert the needle to a depth not more than 15mm until you hit bone step back and aspirate, with -ve
aspiration inject SLOWLY After deposition of the anesthetic solution{usually 1/2 -3/4 of a carpule is enough) withdraw the syringe To accomplish the lingual nerve anesthesia
during withdrawing the needle in about half of the inserted depth aspirate and deposit the anesthetic solution To accomplish the buccal nerve anesthesia insert the needle in the
mucobuccal fold at a point distal and buccal to the most posterior molar, insert small amount ~ 0.3 ml Long buccal nerve is not anastomosed in a child before eruption of the
first permanent molar.Types of anesthesia for the pediatric patient Infiltration Innervation of maxillary primary and permanent molars arises from: posterior superior alveolar
nerve (permanent molars)/not mesiobuccal root of first per. Molar Middle superior alveolar nerve (mesiobuccal root of the first permanent molar,primary molars,and premolars)
Pull the cheek outwards so that the mucous membrane is made taut Position the needle at 45º angle, insert in the mucobuccal fold about 4mm of the needle just above the tooth
to be treated Not to use posterior superior alveolar nerve block in young children because of risk of damage to the maxillary artery and or the pterygoid plexus Not to
use Gow-Gates techniques for younger children. Older children should be administer by a faculty !!! Not to use Akinosi technique in young children.??? PALATAL
TISSUE ANESTHESIA Tissues of hard palate are innervated by nasopalatine and anterior palatine nerve It is indicated for extraction, pulpectomies and may be pulpotomy of
the maxillary teeth Rubber dam placement for the maxillary teeth(using a clamp), which is indicated for all restorative procedure unless otherwise contraindicated Inject a few
drops of anesthetic solution directly to the palatal gingival sulcus middle (mesio-distally). do not insert the needle in the palatal tissue Complete mucobuccal fold infiltration
insert the needle into the buccal papillae until blanching occurs, advance gently while your injecting until you see blanching of the palatal papillae Insert the needle into the
palatal papillae Step-inject around the gingival collar Inject into the palate mid-way between the midline and the gingival sulcus Step-inject is made to make this technique less
painful, you basically preparing each area for the ~a painless injection Complication Of Local Anesthesia Hematoma Needle breakage Burning of injection Trismus Edema
and allergic reaction Sloughing of the tissue Lip or cheek chewing Hematoma Most common with PSA or IAN, WHY? Apply pressure on the area for 2 minutes Apply ice it
acts as analgesic and a vasoconstrictor. No heat for 4-6 hours Skin discoloration occur will resolve in 7-14 daysTrismus It is a motor disturbance of the trigeminal
nerve,specially spasm of the masticatory muscle Caused by trauma to muscles or blood vessels, excessive volumes of L.A. ,hemorrhage, and a low grade infection Managed by
using a heat therapy (moist hot towels for 20mins/hour). in sever cases also managed by anti-inflammatory , Codine, and Diazepam Child should be advised to initiate physical
therapy( chewing gum, opening and closing) 5 minutes every 3-4 hours Symptom start 1-6 days, improvement should be noticed within 48 hours if not antibiotic should be
considered The best prevention technique is to AVOID IT Allergic reaction hypersensitivity response with no airway involvement can be handled with oral and I.M.
antihistamine( Benadryl) Sever allergic reaction could be life- threatening because of
2 gm= 2000mg =20 mg /ml 1gm = 1000mg = 1mg = 0.01 the involvement of the airways, Seek medical assistant. Administer I.M. epinephrine
100ml mg/ml 0.01mg/kg 1:1000 sol. Repeat every 20-30 minutes CAUTION Medically
100 ml Each carpule has 1.8 ml 100.000 ml 100.000ml compromised patients medical consult is needed{e.g.CVD, RD} Always aspirate to
20mg x 1.8 ml =36 mg/cartridge 100ml avoid IV injection Methemoglobinemia may occur due to large doses of Prilocaine
1ml 0.01 mg/ml x1.8 ml =0.018 mg epi (Citanest) or Articaine (SeptanestCAUTION Most Morbidity &/or mortality that
Calculating L.A. Agent in each cartridge could occur with sedation associated with overdose of L.A. Calculate LA The
➢ 1: 100.000 = 1gm(1000mg) of Calculating L.A. Agent maximum recommended dose for children of 2% Lidocaine w/1:100.000
(drug) in 100:000 ml of solution ➢ What is the maximum dose of Epinephrine is 2 mg/lb or 4.4mg/kg. The maximum dose for Articaine w/1:100.000
2% Lidocaine with 1:100.000 Epinephrine is 2.3 mg/lb or 5mg/kg MSD for lidocaine is 300mg 1 carpule= 1.8/1.7
Epiunephrine for a 20 lb child? ml of solution 1 cartridge of Articaine = 1.7 ml of solution Duration with
vasocostrictor is 60 minutes pulpal and 3-5 hours soft tissue 2%= 2gm(2000mg) of
The maximum recommended dose The maximum recommended dose solute(drug) in a 100 ml of solution (water)
is 2mg/lb is 2mg/lb
2mg/lbx 20 lb= 40 mg ** 2mg/lbx 20 lb= 40 mg **
40 mg = 2ml of anesthesia 40 mg = 1.1 carpule
20mg/ml 36 mg
Calculating L.A. Agent Calculating vasoconstrictor Situation agent Adult Children
➢ How many carpules of ➢ How many mg of Epinephrine? Oral Amoxicillin 2g 50 mg/kg
anesthesia each carpule contain 0.018 of Epi Unable to take Ampicillin 2 g IM or IV 50 mg/kg
2ml =1.1 carpule 0.018 mg/carpule x 1.1 carpule oral or
1.8ml/ /carpule =0.0198 Cefazolin or 1 g IM or IV 50 mg/kg
Calculating L.A. Agent Ceftriaxone
➢OR Allergic to Cephalexin* 2g 50 mg/kg
penicillin or Or
ampicillin (oral) Clindamycin 600 mg 20 mg/kg
Or
Azithromycin or 500 mg 15mg/kg
clarithromycin
Allergic to Cefazolin or 1 g IM or IV 50 mg/kg IM or IV
penicillin or Ceftriaxone
ampicillin and Or 600 mg IM or IV 20 mg/kg IM or IV
unable to take Clindamycin
oral
Pediatric Restorative Treatment Indications & ContraindicationsGenerally, Class II restorations of primary molars should not exceed two tooth
surfaces unless the tooth is a large primary second molar or the tooth will be present for < 2 years. a resin-modified ionomer can tolerate some moisture Restoration of mesial
caries on primary first molars The mesio-buccal pulp horn is very close to the tooth surface near the mesial marginal ridge. Adhesive materials are placed into Class III and
Class V restorations in 1o anterior teeth. Class IV restorations may be placed - if significant tooth structure has been lost, full coverage with a crown is a superior restoration.
Class III Adhesive Restorations Very challenging to perform well. Caries often extends subgingivally and hemorrhage control and adequate isolation are difficult/impossible.
Full Coronal Coverage of 1o Incisors – Indications: Large interproximal lesions Pulpal therapy Fracture with appreciable loss of tooth structure Multiple hypoplastic defects
Discolored teeth Small interproximal lesions with large areas of decalcification (especially cervical) Full Coverage Options: Adhesive resin-based composite crowns Stainless
steel crowns Veneered SSC Open-face SSC Adhesive Resin-based Composite Crowns (“Strip Crowns”) Most aesthetic full coverage restoration for anterior teeth Stainless
Steel Crown Shows plaque accumulation easily Generally only used for canines & mandibular incisors Open-face SSC Retention is superior to adhesive resin crowns Cement
must set before “window” can be cut in SSC SSC w/ Resin Veneer Commercially available One-step aesthetic restoration/short operating time Durable Can be placed in the
presence of hemorrhage w/o affecting the final aesthetic result. Frequently require “over-preparation” of the B & L of the tooth &/or pulpal tx –allows very little recontouring or
reshaping; the tooth must be adjusted to fit the crown. More expensive (~$20/crown vs ~$10/crown)
SSC w/ Resin Veneer - Also Available for Posterior Teeth SSC’s have been avail. For ~ 20 years w/ composite facings; highly fx-prone w/i 4 years ec crowns have only been
avail. ~1 year – no fractures have been reported SSC w/ Resin Veneer - Also Available for Posterior Teeth Thermoflex material (used as a flexible denture base for ~40 years)
& Cad-cam technology. Gold plated SSC (Unitek) coping More durable (increased flexural & compressive strength than composite) SSC w/ Resin Veneer - Also Available for
Posterior Teeth Similar prep to SSC, but occlusal & buccal surfaces require ~1mm additional reduction D/t 1o pulp anatomy, may result in pulp exposure & require a
pulpotomy. Choose crown size Trim crown (~1mm) if needed w/heat-less stone & polish w/ green stone Crimp crown margin for snap fit Cement w/ GI or dual cure resin
cement
ADVANCED TECHNIQUES FOR USE WITH MISBEHAVING PEDIATRIC DENTAL PATIENTS Behavior
Modification The Shy, Introverted Child stress can lead to an avoidance behavior such as crying (usually a compensatory whimpering). The Frightened Child
Children < 36-40 months of age. Children with emotional turmoil in their lives (divorce, CAN,…) Acquired fears from siblings, etc. Learned fears from previous experiences.
Child with emotional illness. Many will respond well to communicative behavior management techniques (TSD, positive reinforcement, distraction, etc. Some of these pts.
require sedation or GA. The Child Who Is Adverse to Authority Misdirected Goals Undue attention Struggle for power Retaliation & revenge Inadequacy Undue Attention
Characteristics: annoying, irritating, teasing, disruptive. Struggle For Power Characteristics: argumentative, disobeys instructions, temper tantrums. Retaliation & Revenge
Characteristics: Violent temper, says hurtful things, “gets even,” seeks revenge. Inadequacy These children have convinced themselves that they are special in the worst way –
they refuse to grow up, achieve anything, or do anything for others. Characteristics: give up easily, rarely participates, acts incapable. Empathy Identify, then try to understand
the child’s fears/needs. If the child refuses to open his mouth, say, “I am not going to trick you, I will tell you everything I am going to do.” Give the child a mirror. Distraction
Extinction A technique of withholding reinforcement, with the assumption that an undesirable behavior will not repeat because of the absence of reinforcement. Voice Control]
be effective with deaf children …. probably related to the downward & forward body position used. Emotional Blackmail Used w/ younger children if the parent has
accompanied pt. into tx. room. Child is told that the parent will leave the room if the pt doesn’t behave correctly. (Have the parent move out of the child’s vision.) Short-term
Mechanical Restraint Examples include rubber dam and mouth props. Medical Immobilization may be considered battery (even if there was no harm) unless prior consent is
obtained. Battery is not covered by liability insurance. Specific, Informed Consent When obtaining informed consent, the dentist must describe the (1) benefits, (2) risks, and
(3) alternatives to the recommended course of action, including: Referral to a specialist Waiting or delaying tx. No tx. Alternatives Sedation w/ a specialist General anesthesia
Pulpectomy of Primary Teeth
Acceptable levels of resorption: -Early internal resorption in the crown. -Incipient furcation radiolucency Incipient external periapical resorption Irreversible Pulpitis:
-Hemorrhaging of the radicular pulp tissue that cannot be controlled in 3-5 minutes -Radicular pulp bleeding that is “blue” or dark red Pulpectomy (Primary teeth) - definition
Removal of the roof of the pulp chamber in order to gain access to the root canals, which are then debrided, enlarged, & disinfected. The canals are then filled with a resorbable
material. In primary teeth, the procedure is actually a partial pulpectomy due to the complex structure of the radicular pulp of the primary molars. Indications Primary teeth that
show evidence of chronic inflammation or necrosis in the radicular pulp. Contraindications 1. Primary teeth with gross loss of root structure, advanced internal or external
resorption, or periapical infection involving the crypt of the succedaneous tooth. 2. Children with significant, chronic illnesses such as leukemia, rheumatic & congenital heart
disease, chronic kidney disease, etc. in which the risks of infection associated with the procedure are unacceptable.The primary second molars (especially mandibular) are
strategically important teeth until the permanent first molar erupts. If these teeth are removed prematurely, space maintenance is challenging & there is risk of space loss
(possibly permanent) as the permanent first molar erupts. Failures of ZOE pulpectomies Teeth tx’ed secondary to trauma failed in 42% of cases compared to 19% for incisors
treated for dental caries Teeth restored with a composite crown failed at a higher rate than teeth restored with a more complex restoration using a chamber-retained composite
core. Gross overfill of ZOE paste filler beyond the confines of the root canal was statistically associated with failure. Delayed eruption occurred more frequently with failed
pulpectomies. Radiographs Bitewing is obtained to evaluate the furcation area & determine restorability of the tooth. Periapical radiograph allows evaluation of the entire root
including the apical area. PA & BW (or acceptable vertical BW) should be obtained at the tx planning appt. Retake PA at the operative appt. if the radiograph is > one month
old. Resorption may progress VERY quickly in primary teeth following trauma or with extensive caries Antiseptic Root Filling Materials – ZOE - most commonly used
filling material in the USA (zinc oxide powder combined with eugenol liquid) Resorbs slower than the root & may remain in the bone; this is usually not clinically significant.
Vitapex Active Ingredients: 30% Calcium Hydroxide (high pH neutralizes endotoxins) 40.4% Iodoform (Bacteriostatic, increased radiopacity) Easy to use – premixed;
disposable syringe Resorbs at slightly faster rate than 1o tooth; has no undesirable effects onsuccedaneous tooth. High pH neutralizes endotoxins produced by the bacteria
present. Iodoform is bacteriostatic. (*Beware of possible allergy – check pt. hx) Overall success rates: ZOE = 78.5% Vitapex = 100% “Both Vitapex & ZOE gave encouraging
results. Vitapex, however, can be used more safely whenever there is a doubt about the patient’s return for follow up.” Clinical Technique Amputate coronal pulp with a sterile
large round bur on a low speed handpiece. Use an endodontic barbed broach to remove the diseased pulpal tissue from the canal(s). Rinse canal(s) Determine the working
length by superimposing a file onto the PA/occlusal radiograph. Adjust the files to stop 1-2 mm short of the radiographic apex. General guide for file sizes for molars: Start
with a #15 file and maximum size = #35 file. Irrigate with sodium hypochlorite, sterile saline or LA solution. Dry the canals with paper points. If the canal(s) will be filled
with ZOE, then paper point(s) should be placed in the canal(s) and a cotton pellet moistened with Formocresol should be placed into the pulp chamber on top of the paper
points for 5 minutes; capillary action will draw the Formocresol down the paper points to the apex. During the five minutes, the ZOE should be mixed to a mayonnaise
consistency. Following removal of the paper points, the canal(s) should be filled with the ZOE using one of several techniques (see next slide) Coat the second to last file with
the ZOE, coat the canal walls, then mix a thicker ZOE, form into a cone, place into canal(s) and condense, or: Use a spiral lentulo on lshp to fill canal(s) or: Use a pressure
syringe, a disposable tuberculin syringe or local anesthetic syringe which has been emptied, dried & filled with ZOE Vitapex Fill Sterile, disposable, pre-mixed, pre-filled
syringe and needle is supplied (needle may be bent for easier access into the canal(s). Easy to use for primary incisors, challenging to use with narrow canals of the primary
molar teeth. Note: the outside diameter of the syringe is approximately equivalent to a #40 file. Depress the piston & the paste will begin to reach the apical foramen. Vitapex
does not “set” After Canal(s) Filled: Place a layer of IRM or ZOE over the canal openings If a parulis or fistula is present, use a surgical curette to remove granulation tissue &
any excess filling material from apex Obtain a post-op PA or occlusal film to evaluate the fill Restore the tooth with a stainless steel crown (posterior tooth) or a composite resin
or stainless steel crown (anterior tooth). Follow-up: Evaluate at recall appointments with radiographs and clinical examination. Radiolucencies should resolve w/i 6 months
Pathologic root resorption should not progress Anterior Teeth – Cores Severely decayed teeth may require placement of a composite core prior to a composite strip crown
Intracanal preparation is performed with retention grooves; care must be used to prevent perforation. Following preparation, the tooth is etched and a bonding agent is applied
& cured
PULP THEARAPY: Pulpotomy
Vital pulp therapy:1.Protective base 2.Indirect pulp treatment3.Direct pulp capping 4.Pulpotomy 5.Apexogenesis (will be discussed during trauma lectures) Nonvital pulp
therapy 1. Pulpectomy ( primary teeth ) 2. Apexification ( immatrure permanent teeth I. Protective base A. A material placed on the pulpal surface of a cavity preparation,
covering exposed dentin tubules, to act as a protective barrier between the restorative material and the pulp of the tooth, to minimize injury to the pulp or to promote pulp tissue
healing. II.Indirect pulp treatment Indirect pulp capping: The procedure in which all caries is removed except the caries that is directly overlying the pulp which if removed
would possibly result in pulp exposure Objective of indirect pulp treatment is to maintain pulp vitality by: 1. Arresting the carious process 2. Promoting dentin sclerosis
(reducing permeability) 3. Stimulating the formation of tertiary dentin4. Remineralizing the carious dentin Indications 1.Normal gingiva2.Normal mobility 3. Recommended
for both permanent teeth and primary teeth 4.Radiographically: Large lesion approximate the pulp, normal PDL, no furcation involvemen 5.Pain??? : tooth is not symptomatic,
or very mildintermittent associated with mastication, sweets or cold Contraindications 1.Pulp exposure during caries removal 2.Parulis or fistula, swollen gingiva3.Mobility or
discoloration of the tooth 4.Radiographically : Enlarged PDL space, radiolucency at the apex or furcation involvement, internal or external resorption 5.Non- restorable tooth
6.pain with long duration Procedure 1. Obtain recent history from parent. caries may have progressed since the treatment planning appointment resulting in irreversible
pulpitis2.Current radiograph (periapical) - no older than 2 months3. Local anesthesia 4. Rubber dam isolation is critical5.High-speed with water (#33O bur) 6.Cavity outline
with extension for prevention Remove unsupported enamel Ideal depth, remove caries from labial, lingual, mesial, distal. Leave the pulpal floor where the deep caries is to
evaluate with your instructor7.Slow-speed (#4 or #6 bur) a.Remove carious dentin slowly using air to dry surface in order to evaluate texture b.Stop 1 mm! above pulp (compare
to gingival margin and radiograph for depth)c.Avoid a spoon excavator (primary teeth) - significantly increases chance of pulp exposure d.Ensure DEJ, cavity walls and cusp
tips are caries free e.Place 1 mm calcium hydroxide??, or glass ionomer & IRM base. Permanent restoration will be placed. re-evaluate in 6- 8 weeks for placement of final
restoration 90-95% success rate Direct pulp cap Objectives Treatment to a vital pulp which has a small exposure – It is not used for primary teeth{calcium hydroxide in
direct contact with pulp tissue of primary teeth results in a high rate of internal resorption}. If there is an exposure in primary dentition (Traumatic, Iatrogenic, or carious), do
pulpotomy instead of a direct pulp cap. Indications: Only Permanent teeth a. Small mechanical or <1 mm of a permanent tooth b. Sound dentin margin (no caries remaining at
margin) c. Small (≤ 1 mm) traumatic exposure of a closed apex permanent tooth, tooth should be treated as soon as possible after the accident. d. No history of spontaneous
pain, redness, or swelling Contraindications a.Large carious/ traumatic exposure (>1 mm) b.Carious dentin margin c.Excessive pulpal hemorrhage d.Pathological involvement
and excessive mobility e.Primary tooth g.Pain: History of spontaneous pain ProcedureFollow same technique for IPT Caries removal, Hemostasis of pulp with sterile cotton
ball (do not rinse with local anesthesia containing vasoconstrictor- Why?) Place calcium hydroxide over exposure site, IRM base and final restoration Re-evaluate every 3-6
months Expectations - 93% success rate - Look for: Reparative dentin formation No internal or external root resorption Vital tooth Normal apical closure (if young permanent
tooth with open apex) Pulpotomy Indications 1.Vital tooth with inflammation limited to the CORONAL PULP intermediate step to endodontics a.Large lesion very near or
into pulp, not suitable for an Indirect Pulp Cap. B. Normal supporting bone, PDL and lamina dura are within normal limitc. No radiolucency in furcation or apex d. No internal
or external resorption ePulp exposure from a large/small carious lesion in primary dentition. F Large mechanical pulp exposure/permanent teeth. g. Soft tissues appear normal .
No marked mobility of the tooth. access opening is made, easily controlled hemorrhage (within 5 minutes) h.Pain with mastication, which subsides after removal of stimulus.
j.May present without a history of pain(caries is close to the pulp radipographically) k. No episodes of extreme throbbing or penetrating pain. Contraindications 1.Non-vital
tooth 2. Radiolucency in furcation 3.Internal and/or excessive external root resorption 4.Enlarged PDL 5.Interrupted or broken lamina dura 6. Presence of calcified masses
(calcification of the pulp (metamorphosis) 7Increased mobility of tooth (due to bone resorption) 8.Parulis or fistula (infection isspread through the alveolar bone) 9.
Uncontrolled hemorrhage 11.Necrotic and/or dry chamber 12.Non-restorable tooth ) 13.Spontaneous pain. Night pain, with long duration that does not subside with analgesic
Types of pulpotomy Formocresol pulpotomy Indicated for primary teeth with carious exposures or mechanical exposures. May be used for root end closure in young
permanent teeth prior to RCT, in specific situations Buckley's formocresol is placed over the radicular pulp stumps for 5 minutes Buckley' s Formocresol Generally 1 to 5
dilution of this solution has generally been used Tricresol 35%Formalin 19% Glycerine15% +Water Bactericidal and caustic, causes the pulpal microcirculation to be impaired.
Prevents autolysis of tissue by a complex binding of formaldehyde which diffuses through the pulp and combining with cellular protein. Spreads from pulp to dentin, PDL, and
adjacent tissues; excreted (1 %) in kidney - there is no increase in the incidence of enamel defects in succedaneous teeth. Because formaldehyde is potentially mutagenic and
carcinogenic, its use in dentistry has been questioned, but a review of the evidence suggests that formocresol presents no health hazard in the quantities used in pulpotomy
techniques (ranly et al. 1984), but we could be seeing the sunset of formocresol pulpotomyTechnique for formocresol pulpotomy (one appointment technique) 1.Evaluate the
pre-op radiograph. (Take a new one if the original treatment plan is 2 months old) and re-evaluate 2.obtain profound local anesthesia 3.Rubber dam isolation
a.Dry field to avoid contamination of the open tooth. b.Very caustic material. Be careful to not allow the formocresol leak onto adjacent tissues or under the rubber dam itself.
May need to cement an orthodontic band on tooth for isolation for rubber dam. 4.Access opening a.In most cases the outline and convenience preparations forms are
exaggerated, removing the oblique/transverse ridges. b.Remove all caries and loose enamel to avoid unnecessary contamination of pulp tissue. check caries removal from DEJ.
4.Access opening c.#33O (sterile) high speed with water, remove roof of pulp chamber by encircling pulp chamber and lifting it as one piece (an island). d.Avoid plunging into
pulp chamber, since the distance to furcation may be 1-2 mm. e.Double check to remove pulp horn. f.Do not blow air Into chamber 5.Amputate pulpal tissue a.Use #4 or #6
round (sterile) slow speed. b.Engage tissue gently but do not remove tooth structure or attempt to enter intothe canal space. c. Use a (sterile) sharp spoon excavator to remove
any tissue tags( with faculty approval), be very careful not to penetrate the furcation???. 6. Obtain hemostasis Apply cotton pellet with light pressure over root canal openings
for 2-3 minutes. Avoid use of local anesthetic with vasoconstrictor directly on pulp, Why?6.Obtain hemostasis 7. Application of formocresol a.once hemostasis has been
obtained, apply the formocresol on a small cotton pellet, moistened (not saturated) with formocresol. Place moistened cotton pellet in 2x2 gauze and squeeze the extra
formocresol before applying on the pulp b.Place over pulp stumps with pressure, then cover with a small dry cotton pellet. c.Avoid contact with the gingival tissue or allowing it
to seep or leak under the rubber dam. d.Wait 5 minutes and gently remove pellet - bleeding should have stopped and the pulp tissue formed a dark color 8.Restore Use
IRM/ZOE, it resorbs and allows for normal exfoliation Technique for two-step formocresol pulpotomy or 7-day pulpotomy same as above, however a.Seal in a slightly
moistened formocresol cotton pellet b.Re-appoint 5-7 days later c.If bleeding is now controlled, complete IRM ~ SSC placement . If uncontrolled bleeding, take new
x-ray ,the tooth may need a pulpectomy or extraction Mechanisms of action (in the root canal) In 7-14 days what happened: 1.Coronal 1/3 - fixed tissue (H & E stain), 2.
Middle 1/3 - coagulation necrosis (atrophy) 3.Apical 1/3 - initially coagulation necrosis, but in 12 months replaced by ingrowth of granulation tissue (remains vital), which
progresses to the amputation site. Success rate: 9O-95% depending on: OTHER PULPOTOMY METHODS C.Ferric Sulfate 15.5%/20% solution is the medicament that the
pediatric dentistry department will adopt as another medicament for pulpotomy. After obtaining homeostasis, a syringe is gently squirt and a small amount of ferric sulfate
applied on the pulp stump by gently wiping the cotton tip of the needle against the amputated pulp for 5-10 second Calcium hydroxide Pulpotomy for primary teeth:
Pulpotomy are affected significantly by variables in technique, the quality of materials used and the final restoration. Zinc oxide and Eugenol This is the traditional root canal
filling material that has also been used as the only medicament placed on the tooth after obtaining hemostasis. This technique is not widely accepted. Electrosurgery,
Glutaraldehyde
glutaraldehyde seems to be superior to formaldehyde for the following reasons: a.Formaldehyde reactions are reversible but glutaraldehyde reactions are not.
PEDIATRIC MEDICINE I Bacterial infections: Odontogenic, Scarlet fever, Syphilis, Actinomycosis, and Impetigo. Viral infections: Primary herpetic
gingivostomatitis, Herpes labialis, Herpangina, Hand-foot-and-mouth disease and Vercella Fungal infections: Candidasis 1. Bacterial infections Odontogenic Infections
Usually present as an emergency with a sick, upset child, raised temperature, and red and swollen face. Impetigo Caused by group A streptococcus and usually superinfected
with staphylococcus. Children ages 2 to 6 years and infants are most often infected. Easily spread by fingers, towels and clothes Clinical features: Usually starts as a red sore on
the child's face, most often around the nose and mouth. Erythematous macules that quickly evolve into thin walled vesicles and pustules, vesiculopustular stage is brief and
following rupture, sticky, healed up, brownish colored crusts are formed Treatment: Hygiene measures Topical antibiotics (ointment) Systemic antibiotics. Elective dental
treatment should be deferred until skin lesions resolve to prevent transmission Scarlet fever carlet fever is caused by an infection with group A beta-hemolytic streptococcal
bacteria Clinical presentation: Sore throat, fever, vomiting, chills, headache, rash on neck and chest and swollen, red tongue (strawberry tongue). Treatment: antibiotic
Complications are rare with proper treatment: may include rheumatic fever, otitis media and pneumonia.Otitis Media Incidence: 75% of children between 6 and 18 months,
second peak between 4 and 7 years. Etiology: Aerobic bacteria – Primary cause Anaerobic Treatment For low-risk children, the preferred treatment is to hold antibiotics for 24
hours and recheck. treatment with antibiotics (Amoxicillin). Analgesics – Acetaminophen Use of antihistamines or decongestants remains controversial. Chronic cases: use of
ear tube Consider xylitol gum. Viral infections Primary herpetic gingivostomatitis (PHG) The most common cause of oral ulceration in children. Caused by herpes simplex
type I virus. Although type 2 virus may cause it. Clinical manifestations: Small vesicles that rupture to form painful shallow ulcers with smooth margins surrounded by a red
halo Lesions occur on all areas of the mouth with gingiva and lips predominating Gingiva shows signs of acute inflammation Oral pain, fever, malaise, lymphadenopathy and
dehydration are common Disease is self-limiting (7 to 14 days). Complete healing of ulcers occurs in 10-14 days, No scarring Treatment: Palliative, supportive, and preventing
further spread of the infection. Symptomatic treatment – acetaminophen for fever, pain and muscle ach. Increase liquid consumption to prevent dehydration, dehydration is a
serious concern, especially in young children Recurrent Herpes Simplex (HSV ) Etiology: Herpes simplex Type I virus Clinical manifestations: HSV in a latent form may
infect sensory ganglia (e.g. trigeminal) in patients who recover from primary infection Reactivation of latent HSV is secondary to fever, stress, hormonal imbalance and sunlight
Reactivation of latent HSV results in recurrent herpes labialis (cold sore); it may also present in an intraoral form Itching sensation (prodrome) precedes lesions Dental
Management: Palliative Topical acyclovir (Zovirax) during prodrome may result in quicker healing Denavir cream as antiviral drug. Viscous local anesthetics Herpangina and
hand-foot-and-mouth disease These infections caused by the Coxsackie group A viruses. A prodromal phase of low-grade fever and malaise last for several days before the
appearance of the vesicles In herpangina, 4 to 5 vesicles are found on the palate, fauces and the pharynx. In hand-foot-mouth disease, more than 10 vesicles occur in the
mouth, hand and feet. Healing occur within 10 days.u Incidence: 90% under 10 years of age Etiology: Varicella-Zoster virus, Herpes Virus Varicellae Spread by direct
contact, airborne or droplet transmission Patients are infectious from 24 hours before appearance of rash until all lesions have crusted (usually 7-8 days) Incubation period is
usually 13-17 days Symptoms (anorexia, malaise, low fever) appear 24 hours before rash. Lesions begin on the trunk and spread to face and scalp, distal parts of arms and legs
usually not involved Severe itching is common Treatment: Palliative and supportive Benadryl for itching Acetaminophen for fever Vaccine is available and is 80% effective.
Use of aspirin is contraindicated due to Reye Syndrome Dental Management: Elective dental treatment should be deferred until all lesions have disappeared Emergency dental
care should be rendered with strict adherence to universal precautions and preferably after all lesions have crusted Candidiasis Treatment: Mild disease: Topical agents like
Nystatin or Clotrimazole. Moderate disease: Systemic agents like Fluconazole (Diflucan), Ketoconazole Severe disease: Amphotericin B Dental management: Defer treatment
until resolved. Pediatric Oral Pathology Orofacial infections Ulcerative lesions Others Lesions in the newborn Aphthous Ulcers Central necrosis and ulceration with
erythematous halo Involves “unbound” mucosa Heals in 7 to 10 days Major form may heal with scaring Topical Steroids – Kenalog in Orabase Topical anesthetics-Orabase
with Benzocaine. Benadryl and Maalox 1:1, Rinse with 1tsp and expectorate q2h. Epulis: fibrous epulis/pyogenic granuloma Gingival enlargement: drug induced hyperplasia
(Cyclosporine, Phenytoin) Wash hair with shampoo containing lindane or other anti-louse agent then use a fine toothed comb to remove nits. Multiple applications are required
Wash all clothing in water exceeding 130o Epstein’s pearls: may be found on the mid-palatal raphe of the hard palate Bohn’s nodules: remnants of salivary glands, are
located on the buccal or lingual mucosa Dental lamina cysts are located on the crests of the alveolar ridges No treatment is necessary.
PEDIATRIC MEDICINE II SymptomsAllergiesMedsPrevious HistoryLast Incident Events leading to problem Newborn 115-170 6 months100-150 1 year90-135
3 year80-125 5 years80-120 10 year75-110 15 years70-100 Adult70 Respiratory rate (breaths/minute)Newborn30-606 months25-401 year20-353 years20-305 years20-2510
years17-2215 year15-20Adult12-20Normal Vital Signs in ChildreSystolic Blood pressure (mmHg)Newborn60-756 months80-901 year963 years1005 years10010 years11015
year120Adult125 Syncope Syncope is loss of consciousness with an inability to maintain postural tone.Syncope occurs when cerebral perfusion decreases. Recently, the
practice has shifted to an outcomes-based model: -Cardiac (vascular disease, cardiomyopathy, arrhythmia), -Noncardiac (vasovagal response to pain, dehydration), and
-Unknown.Pre-syncope Symptoms -Warm feeling in face and neck.-Pale -Sweating-Feels cold.-Abdominal discomfort.-Lightheaded or dizziness.-Increased heart rate.
Syncope Symptoms The hallmark symptom of syncope is fainting, other signs: - Chest pressure or pain - Shortness of breath - Vision changes – Nausea Prevention Give LA
injections to patients in the supine position Return the chair slowly to the upright position Advise the parent to give the child a light meal or snack prior to the appointment if
they are hypoglycemic Follow appropriate protocols for diabetic patients Management Stop all dental treatment Position the child in the supine position to increase cerebral
blood flow Begin BLS (basic life support) and insure a patent airway Monitor vital signs Loosen tight clothing Determine the etiology and consider transportation to a medical
facility if recovery of consciousness is delayed beyond 5 minutes or is incomplete after 15 to 20 minutes. Hypoglycemia Exists when the serum glucose is less than 50 mg/100
ml regardless of whether symptoms are present Causes of hypoglycemia include: insulin therapy for Type 1 diabetes, metabolic disorder as a result of serious systemic disease,
and fasting by the child for a variety of reasons The signs and symptoms of hypoglycemia are similar to syncope The only difference is that prior to fainting, the hypoglycemic
patient may exhibit more clinical signs and symptoms instead of just having the sudden loss of consciousness. Prevention: Prevention of hypoglycemia consists of appropriate
management of the Type I diabetic and other serious systemic illness ( Careful review of medical history) May need medical management Recommend a light meal or snack
prior to future appointments Position the child in a supine position to increase cerebral blood flow Ensure a patent airway and begin BLS Monitor vital signs Consider use of a
rapid glucose determination test Administer glucose orally if patient is conscious (juice with sugar, sugar-containing soft drink) or IV as 50% dextrose until consciousness is
regained Determine the etiology of the hypoglycemia and consider transportation of the child to a medical facility Seizures Ictal (convulsive) phase Position the child supine in
the dental chair or on the floor Prevent injury by gentle restraint and move instruments away from the patient BLS Do not place anything in the mouth that can be aspirated
Postictal phase Monitor vital signs, significant degree of CNS depression is usually present Continue BLS especially insuring an adequate airway Use supplemental oxygen if
cyanotic Transport to a medical facility Administer IV diazepam (0.1-0.3 mg/kg to a max dose of 10 mg) Continue BLS if diazepam is not available Activate EMS/transport to
hospital Asthma Attack Consider administering epinephrine (1:1000, SQ, 0.01 mg/kg; max dose 0.5 mg). If no relief after 2 doses of epinephrine, arrange transportation of the
child to a hospital. Signs of Mechanical obstruction secondary to sedation Hypoxia is recognized on monitor, especially pulse oximeter Respiratory effort with chest
retraction Cyanosis Chin down on chest position Signs of Obstruction due to a foreign body Coughing, choking Universal choking sign Respiratory effort with chest
retraction Cyanosi Airway Obstruction Prevention Use appropriate doses of sedative agents Monitor respiratory function Use a towel roll or other device under the shoulders to
help maintain an open airway Mechanical obstruction secondary to sedatio Initiate BLS using head-tilt or chin-lift to open the airway Consider reversing the drug likely
causing the depression Consider transporting to a medical facility Allergic Reaction
General Anaphylactic reaction is characterized by intense pruritis, erythema, urticaria, chest tightness, dyspnea, palpations and tachycardia, which may lead to cyanosis,
respiratory and cardiovascular arrest if not managed properly. Administer epinephrine (0.01 mg/kg) - two concentrations of solution are available: 1:1000 (1 mg/ml - SQ/IM)
or 1:10,000 (0.1 mg/ml - IV) Bronchodilation occurs within 3-5 min after SQ administration Administer Diphenhydramine (Benadryl) (1-2 mg/kg IV/IM) Activate EMS
Transport the child to an appropriate medical facility
Infective Endocarditis (IE) IE prophylaxis recommendation for Patients with the highest risk of adverse outcome from IE: Prosthetic cardiac valve Previous infective
endocarditis Congenital heart disease (CHD): Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired congenital heart defect with prosthetic
material or device for the first 6 months. Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or device.Cardiac transplantation recipients
who develop cardiac valvulopathy
Regimens for a dental procedure:
Common Pediatric medications:
Penicillin: Children< Amoxicillin: Children< Clindamycin: Children< Cephalexin: 25- Augmentin: 20-40
12: 25 -50 mg/kg/ d in 12: 20 -40 mg/kg/ d in 3 12: 10 -25mg/kg/ d in 3 50mg/kg/d in 4 divided mg/kg/d in 3 divided
3-4 divided divided doses. divided doses. doses, max:4 g/d doses, max:2 g/d
doses(max:3g/d). Children Children> 12 and Sig: Take ------ tsp Sig: Take ------ tsp/
Child > 12 and adults: 250- adults: 600-1,800mg/d in q6h for 10 days. tablet q8h for 10 days.
ren> 12 and adults: 1-2 500mg 3 times/d, max:2-3 3 divided doses, max 4-
g/d in 3-4 divided g/d 8g/d.
doses. Sig: Take ------ Sig: Take ------
Sig: Take tsp/ tablets q8h for 10 d. tsp/ tablets q8h for 10 d
------ tsp/ tablets q6h
for 10 d
Oral Surgery in Children Armamentarium Forceps: #1 for Maxillary anteriors # 44 for Mandibular anteriors #150s for Maxillary Molars #151s for Mandibular
Molars Most odontogenic infections are not serious and can be managed easily without antibiotic. Odontogenic infections with systemic manifestations (e.g., elevated
temperature of 102 degrees to 104 degrees F, facial cellulitis, difficulty in breathing or swallowing, fatigue, nausea) require antibiotic therapy. Severe but rare complications of
odontogenic infections include cavernous sinus thrombosis, brain abcess and Ludwig's angina. Antibiotic therapy: for initial treatment, penicillin is given. For more
complicated infections other antibiotic such as Clindamycin and Augmentin are given. Administration of oral antibiotic for 3 to 4 days before the extraction. (infected maxillary
teeth with alveolus swelling). Infective Endocarditis (IE) Signs and Symptoms of IE Fever is almost always a symptom. Other symptoms are: loss of appetite, unexplained
weight loss, new rashes (painful/painless), headache, backache, joint pain, confusion, shortness of breath, and sudden weakness in the face or limbs suggestive of a stroke. If
untreated, most IE patients will die. Treatment of IE with antimicrobial therapy for 4 to 6 weeks. For some patients, surgery is required. Prescription Writing Calculate the
amount of antibiotic per day. For infection treatment give for 10 days. Rx: medication, format, concentration/dose Disp: Sig: Example A six year old child presented with
severely decayed # I and buccal cellulites. Child weighs 55 pounds and has no drug allergies. ( patient can not swallow pills and refused chewable tablets). 55 pounds divided
by 2.2 = 25 kg Drug of choice is Pen VK Suspension Per day: 25 to 50 mg : minimum is 25 × 25= 625, maximum is 50 × 25= 1250. the average is 937.5 mg per day, round up
to 1000mg/day Pen VK Suspension comes in 125mg/5mL and 250mg/5mL. 5mL = 1 tsp Rx Pen VK Suspension (250 mg/5mL) Disp: 200 mL Sig: 2 tsp( 10 mL) now, then
one tsp (5mL) q6h for 10 days.
Overview of Child Mental Health Disorders 5-10%Attention-deficit/hyperactivity disorder 5%Generalized anxiety disorder5%Phobias4%Separation
anxiety disorder2-5% Conduct Disorder 2-5%Depression A.D.H.D. 1940-1960 This condition was identified as “minimal brain damage or dysfunction” with speculation that
the etiology was from insults to the brain including head injury, infection, and toxic damage. In the 1960’s it became “hyperactivity” or “poor impulse control” with no
underlying organic damage identified. 1970’s – 1980’s: The “hyperactivity” symptomology took on more diagnostic significance relative to the other symptoms. In 1980 the
DSM-III (American Psychiatric Association’s Diagnostic & Statistical Manual of Mental Disorders, third edition) listed the term “hyperkinetic reaction of childhood” which
then became several other names until it was termed “attention deficit disorder” (ADD) either “with hyperactivity” or “without hyperactivity. By 1987 the focus had shifted
from hyperactivity towards inattention and impulsivity. 1994 DSM-IV-TR: Official term is Attention Deficit/Hyperactivity Disorder (ADHD) with three subgroups:-
Predominantly hyperactive-impulsive type- Predominantly inattentive type- Combined Inattention & impulse control are now regarded more as the cardinal defects of
A.D.H.D. than is hyperactivity. Occurrence: 3-6% (conservative estimate) with 10-15% in some U.S. cities. Female/Male ratio = 1:3 Responsible for 30-50% of referrals for
mental health services for children. Causes of A.D.H.D. Genetics: 25% of the close relatives in the families of ADHD children also have ADHD. Twin studies support this
etiology. Also, ADHD children who were on medication had a white matter volume = controls. Those never-medicated children had abnormally small volume of white matter.
(White matter consists of fibers that establish long-distance connections between brain regions which normally thickens as children grow older & the brain matures.) A.D.H.D.
Co-morbidities Other psychological disorders often coexist with ADHD, including:- Learning disabilities (20-30%) - Tourette Syndrome (small portion) - Oppositional Defiant
Disorder (1/3 – 1/2 - usually males) argue with adults and refuse to obey. Conduct disorder (20-40% may eventually develop CD, a more serious pattern of antisocial behavior).
These children frequently lie/steal, fight with or bully others, & are at risk of getting into trouble at school or with the police. They are greater risk for substance dependence
and abuse. Anxiety & Depression Bipolar disorder – some crossover in S/S. Medications include: - Stimulants (long & short-term forms) – MOST COMMON –
Antidrepressants – Antihypertensives About 80% of children who need medication for ADHD still need it as teenagers & over 50% need it as adults. Children with ADHD are
12x as likely to have high caries rate. Treat as high caries risk category. Autism Spectrum Disorders (ASD) Offspring of men >40 yo were 5.75x more likely to have autism
disorders compared with fathers < 30 yo. More recently, autism is reported to affect 0.7 – 26.1/10,000 children with a male to female ratio of 4.8 : 1.Autism (ASD)For a
diagnosis of autism spectrum disorder, A. A child must meet a specified number of the 12 criteria given in DSM-IV (6+ items from #1,2,3 w/ at least 2 from #1 and one each
from #2 & 3): 1. Impairment in social interactions a. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures &
gestures to regulate social interaction ASD b. failure to develop peer relationships appropriate to developmental level c. a lack of spontaneous seeking to share enjoyment,
interests, or achievements w/ other people d. lack of social or emotional reciprocity 2. Impairment in communication a. delay in, or total lack of, the development of spoken
language (not accompanied by attempts to compensate through alternative modes of communication e.g., gesture or mime) b. in individuals w/ adequate speech, marked
impairment in the ability to initiate or sustain a conversation w/ others. c. stereotyped & repetitive use of language or idiosyncratic language d. lack of varied, spontaneous
make-believe play or social imitative play appropriate to developmental level 3. Repetitive behaviors & stereotyped behavior patterns a. encompassing preoccupation with one
or more stereotyped & restricted patterns of interest that is abnormal either in intensity or focus b. apparently inflexible adherence to specific, non-functional routines or rituals
c. stereotyped & repetitive motor mannerisms (eg, hand or finger flapping or twisting, or complex whole body movements) d. persistent preoccupation with parts of objects B.
Delays of abnormal functioning in at least one of the following areas, with onset before age 3 years: (1) social interaction (2) language used in social communication (3)
symbolic or imaginative play C. The disturbance is not better accounted for by Rett’s disorder or childhood disintegrative disorder ASD-Absolute Indications No babbling or
pointing by 12 months No sharing of interest in objects with another person No single words by 16 mos, or no 2-word spontaneous phrases by 24 mos Any loss of language or
social skills at any age. Asperger’s Disorder Individuals have an intellectual ability w/i the average range, & superficially normal early language development. They use
single words by age 2 years & two-word communicative phrases by age 3 years. Their language development is, however, often significantly idiosyncratic. Interventions for
ASD Based on current evidence, intervention should be initiated before 4 years of age. It is now widely accepted that between 15-25 hours/week of specific intervention is
appropriate. depression Occurs in 2.5% of children & 8.5% of adolescents. Major Depression –Etiology Several theories: -decreased brain concentration of the
neurotransmitters norepinephrine & serotonin -overactivity of the thyroid gland & the adrenal gland during a chronic period-stress reaction that has gone untreated for too long.
Treatment Fluoxetine & paroxetine have been shown to be effective medications for children & adolescents. Levonordefrin is Pts taking tricyclic or heterocyclic
antidepressant drugs may be prone to orthostatic hypotension – avoid rapid changes in chair position for these pts. Acetaminophen decreases the metabolic rate of heterocyclics
and should be used with care. Major Depression-Dental Recommendations.
SPACE MAINTENANCE I A Class II molar relationship needs referral to an orthodontist By age 9, all the mandibular incisors should have erupted. At age
11-12, there is competition for space from the eruption of maxillay 5, 3, & 7.Systemic causes of delay in eruption (1)cleidocranial
dysplasia(2)hypothyroidism(3)hypopituitarism Systemic factors causing premature loss of primary teeth1.Familial fibrous dysplasia2.Hypophosphatasia3.Nonlipid
reticuloendothelioses4.Cyclic neutropenia5.Papillon-Lefevre syndrome CASE #1 Tooth #B is extracted on a seven year old due to caries through the furcation. You plan a
space maintainer between Teeth #A and #C. Are these good choices for abutments? Tooth #A will exfoliate at 11 years, #C will exfoliate at 11-12 years, #5 erupts at age 10.
Thus, both abutment teeth will remain in the arch until after Tooth #5 erupts. CASE #2 Tooth #S is extracted on a seven-year-old who has lower anterior crowding. Tooth #28
will erupt at age 10-11. You plan a space maintainer between Teeth #T and #R. Are these good choices for abutments? Tooth #R will exfoliate at age 9, Tooth #T will exfoliate
at age 11, Tooth #28 will erupt at age 10. Thus, you need to select a different abutment than Tooth #R, since #R will exfoliate before the #28 erupts. A bilateral appliance is
indicated. CASE #4 A six-year-old with lower anterior crowding had Tooth #S extracted. On the radiograph there was 8 mm of bone covering the premolar. How long before
#28 erupts? Do you need a space maintainer? spacer is indicated.CASE #5 A seven year old girl with Class I molar relationship has crowded mandibular incisors (arch length
analysis shows you have 3 mm of crowding). Tooth #S is extracted, and Tooth #28 should erupt at age 10. Why do you need a space maintainer? CASE #5 The molars will
most likely not drift mesially since they are locked into a Class I occlusion, Teeth #A and #T are holding their position as well. However, the forces from the mandibular
incisors to relieve the 3mm of crowding will push the canines distally into the space left by the extraction of #S. You will need a space maintainer to keep the incisor teeth from
distally migrating into the “S” space?????. CASE #6 Nine year old girl with Class I molar relationship and no crowding, has Tooth #S extracted. Tooth #28 will erupt at age 10.
Do you need a space maintainer? CASE #6 No space maintainer is indicated ??.( always consider the bone covering the permanent teeth) If this child were six years old and all
four mandibular incisors had not erupted, then we would put a space maintainer in until the eruptive forces have diminished (all four incisors erupted and no crowding). CASE
#7 A seven year old with a Class I molar relationship and without any crowding or space loss has Tooth “I” extracted. Tooth #12 should erupt at age 10. Is a space maintainer
indicated?In evaluating the forces, the major concern is the fact that the extraction site is in the maxillary arch and Tooth #14 will start to drift mesially due to the erupting path
forces on maxillary molars. We recommend putting a space maintainer on the maxillary arch since the maxillary molars will move mesially out of Class I.?????
CASE #8 A five year old girl presents with an un-spaced primary dentition (i.e., there are no primate spaces and no generalized spacing) and the permanent molars have erupted
edge-to-edge. How will the dentition become Class I?
The molars will assume a Class I relationship as a result of a “Late Mesial Drift” (using up the leeway space at age 10-12). The girl has tooth #K planned for an extraction. Do
you need a space maintainer???? In evaluating the forces, you realize that there is the force on Tooth #19 to drift mesially into the Class I relationship.. You should definitely
place a space maintainer in order to prevent Tooth #19 from moving forward. The most commonly ankylosed primary teeth are: Mandibular primary first molar Mandibular
primary second molar Maxillary primary first molar Maxillary primary second molar
SPACE MAINTENANCE II Ectopic eruption is a path of eruption that causes the resorption of a part or all of the root of the adjacent tooth. In maxillary molars,
there is a 3 to 4% prevalence and of these 65% will self-correct when the molar “Jumps” or moves distally into correct position. We recommend a 3 to 6 month observation
period. Treatment of ectopic molars: a.The goal is to move the ectopicly erupting molar away from the resorbing tooth. b.If there is sufficient room, a brass wire (.020) can be
placed as a separator. c.Continue to tighten the wire at one to two week intervals d. For greater movement use an orthodontic band+ helical spring . This is called a modified
Humphrey appliance. e.In sever cases primary second molar would need to be extracted. The permanent molar will erupt in a Class II position. Even with space maintenance,
space regaining may be necessary. Mandibular Lateral Incisors 1.A second type of ectopic eruption involves the mandibular lateral incisors, which get caught under the
primary canines. The primary canines usually exfoliate prematurely due to the eruptive forces from the lateral incisors. This can be unilaterally or bilaterally. Treatment of
ectopic lateral incisors: As an interceptive treatment, extraction of both canines may also be done. Mandibular Premolars A third type of ectopic eruption is seen in the area of
the mandibular first/second primary molar, where the premolar is not aligned directly under the furcation. Treatment of ectopic premolars:
a.The primary tooth should be extracted to allow proper eruption of the premolar Maxillary Anterior Region (D, E, F, G) Fixed appliance: A Modified Nance is used for
esthetics and functional replacement of anterior teeth. Removable appliance: A Partial Denture may use C-clasps around the cuspids and has acrylic covering the palate.
Primary FIRST Molar (B, I, L, or S) 1.PERMANENT MOLARS ERUPTED AND LOCKED IN CLASS I, NO CROWDING, PERMANENT INCISORS IN PLACE (AGE
EIGHT-NINE). a.Mandibular arch – watch (no forces)
b.Maxillary arch – place a space maintainer to prevent permanent molars from drifting mesially!!.C.Type: Band and Loop , Crown and Loop, Some times Lower lingual
holding arch appliances are also used???. Second Primary Molar (A, J, K, or T) 1.Goal: prevent mesial migration and tipping of 6-year molar. Need bilateral anchorage to
keep the permanent molars in place. Mandibular second primary molar missing with unerupted six year molar. 1. Distal Shoe Appliance This appliance is Indicated for
premature loss of the maxillary or mandibular second primary molar when the permanent first molar has not yet erupted, (child is less than 6 years of age). It is an “intra-
osseous” appliance. Difficult to construct, fit, and maintain. Mandibular second primary molar missing with partially erupted six year molar. 2.Reverse Band and Loop is
an alternative to a distal shoe. The primary first molar is banded and the loop wire braces against the mesial surface of the permanent molar as it erupts. Timing is critical when
eruption is imminent. Mandibular second primary molar missing with unerupted six year molar. 3.Acrylic Partial Denture with guide plane can act the same as
a distal shoe. If the permanent molars are partially erupted the removable appliance will act as a reverse band and loop Maxillary second primary molar missing with
partially erupted permanent molar, and space is lost 1.Humphrey Appliance: you could regain space wit this appliance 2.Traspalatal with omega loop /Nance with
omega loop (after full eruption of permanent molars)Canines (C, H, M, or R)1.Premature loss due to caries/trauma (but not ectopic eruption)???? A. Extract the contralateral
canine in order to avoid mid-line shift. B.Maxillary arch (when needed) – The maxilla requires a bilateral appliance such as a Nance, since the band and loop’s abutment tooth
would be the permanent lateral incisor which would not be an adequate abutment. C. Normal mandibular arches – bilateral loss (no permanent incisor crowding, class I
occlusion-. This situation does not require a space maintainer need to observe D.Crowded arch: The mandibular arch would require a lingual arch in order to prevent lingual
collapse of the mandibular incisors Clinical considerations for appliance selection
Pediatric Dental Treatment Planning1teaspoon (tsp) = 5 mL 1 tablespoon (Tbsp) = 3 tsp or 15 mL PcnVK, Amoxicillin, & Cepalexin dosages are 25-50mg/kg/d
(< 12 yo) 4x/d X 7-10 d Clindamycin dosage is 10-25 mg/kg/d (<12 yo) q 8h X 7-10 d Augmentin dosage is 20-40 mg/kg/d q 8h X 7-10 d Case #1 Three year old, health child
- new pt., [F] of drinking water = 0.2 ppm What factors do you need to evaluate to determine: Caries risk category: __“Recall Schedule:” ___Radiographic Evaluation:
___Home OH Program: ___Dietary Fluoride Rx Drinking water contains 0.2 ppm [F] – therefore he is in the <0.3 ppm range (first column) Child’s age is 3 years – the second
row (6 mo – 3 years) is UP TO 3 years of age, so you should move to the third row which begins with 3 years old. Dietary Fluoride Rx Luride Lozitabs (0.5 mg) Disp:120
tablets Sig: Chew, swish & swallow 1 tablet qhs Why prescribe to swish and swallow? Why prescribe qHS? Refills: 1 Case #2 Requires S.B.E. prophylaxis; cannot swallow
pills, 66# Cannot swallow pills – therefore use the liquid form Weight is 66 pounds – therefore dose is: 66# X 1 kg = 30 kg 2.2# 30 kg X 50 mg/kg/dose = 1500 mg dose
S.B.E Prophylaxis Rx Amoxicillin Suspension (250 mg/5cc) Disp: 50 cc Sig: 6 tsp (30 cc) 1 hour before dental appt. Refills: ? Case #3 Healthy 7 y.o. with buccal cellulitis,
NKDA, cannot swallow pills, 66# Antibiotic Rx for Abscess/Cellulitis Moderate-Severe infection Healthy patient NKDA Cannot swallow pills – requires liquid form Weight =
66# Dose range = 25 – 50 mg/kg/d Antibiotic Rx for Abscess/Cellulitis
66# X 1 kg = 30 kg 30 kg X 25 mg = 750 mg/d 30 kg X 50 mg = 1500 mg/d Range = 750 - 1500 mg/d
2.2 # kg/d kg/d
Antibiotic Rx for Abscess/Cellulitis
Range = 750 - 1500 mg/d Since patient is healthy, dose can be towards the lower range Infection is moderate – severe, so dose should be towards the higher range If patient is
not eating or sleeping well, then give a higher dose Antibiotic Rx for Abscess/Cellulitis Range = 750 - 1500 mg/d “Good Dose” would be approximately 1200 mg/d Drug of
choice is Pen VK If using 250 mg/5cc concentration:
Preparation/[F] ppm dose F/doseAge <0.3 0.3–0.6 ppm >0.6 ppm
1.23% APF gel 12,300 5 mL 61.5 ppm
mg 0-6 mo 0 0 0
0.05% NaF rinse 500 10 mL 5 mg6 mo-3yr 0.25 mg 0 0
0.10% F dentifrice 1000 1g 1 mg3 – 6 yr 0.5 mg 0.25 mg 0
0.4% SnF2 gel 970 2g 2 mg
(GelKam) 6 – 16 yr 1.0 mg 0.5 0
mg
1200 mg X 5 cc X day = 6 cc/dose
d 250 mg 4 doses
Antibiotic Rx for Abscess/Cellulitis
Pen VK Elixer (250 mg/5 cc)
Disp: 300 cc
Sig: 6 cc po q 6 h X 10 days
Refills: ?
SEDATION AND MONITERING : Minimal: low doses of enterally or nitrous oxide sedation with a max of 50% nitrious concetntration. Monerating
is clinical observation. Moderate Sedation: Eyes open or temporarily closed responds to light tactile stimulation or verbal. Monitoring: Equipment is pulse oximeter,
precordial stethoscope recommended, blood pressure, and must monitor heart rate, repiratory rate, oxygen saturation and blood pressure.. $$$$$ Deep sedation: non interactive,
arousable with painful stimulus. Airway requires monitoring and management. Monitering: Equipment is pulse oximeter, precordial stethoscope, blood pressure,
electrocardiography, defibrillator, and capnography is encouraged. Must monitor heart rate, respiratory rate, oxygen saturation, blood pressure, and EKG. $$$$$ PERSONEL:
Min=2, moderate= 2, Deep = 3. ALL local anesthetic can become CNS depressant. Canidates for sedation: ASA class 1 and 2 are canidates for consous sedation. CLARKS
rule: Weight /150 x Adult dose; Youngs rule: Age/ (Age + 12) x Adult Dose. Body surface area, ped. Dose determined by % of usual adult off ave adult surface area of
1.75 square meters. Diatary precautions for patients: 1) no milk or solids after midnight (2) clear liquids only for 4 hours pre-op for children 6 months to 3 years. (3) clear
liquids only for 6 hours pre op for 3 to 6 year olds. (4) Clear liquids only for 8 hours for ages 7 and up. $$$$ Need HH (including weight) Physical assessment (vitals, airway
and risk assessment, ASA) $$$$$ Nitrous Oxide: Advantage- rapid onset, easy titrate, mim side affects. Disadvantage: Potent analgesic, but weak sedative agent., lack of
patient acceptance, inconvenience. POTENTIAL for chronic toxicity. Potentiation with other sedative agents, the need for special equipments. Indication- Capicity to be
compliant. Contraindication: 1)patients with nasal obstruction. (2) Patients who are uncooperative when directed to breath through to nose. (3) Prolong exposure can be
negative effect on vitamin B12 and its role in DNA syntheses. (4) Patients with bowel obstruction (5) Patients with COPD (6) Colostomy bags. $$$$$ Total Flow adults -5 to
7 liters/min. ; 3 to 4 year old - 3-4 liters/ min. $$$$$$ tell show do with age. Technique: Start with 100% oxygen for 3 to 5 minutes to avoid “Diffusion Hypoxia.” Titrate
induction at 30 to 35% nitrous oxide for 3 to 5 min. May use up to 40-50% for LA. ---Then switch to 100% oxygen after local anesthesia is completed. Maintenance at 30 to
35% nitrous oxide. Termination- 100% oxygen for 5 min to prevent diffusion hypoxia. Nitrous Oxide for chronic exposure in breathing zone is area within 12 inches. BP and
HR increase early then return to normal. SEDATIVE HYPNOTIC- CHLORAL HYDATE- It is aliphatic alcohol which is soluable in either water or oil. Metabized into 2
active Trichloreoethanol & trichloracetric acid. Caution with preterm and term infancts. ANTIAXITY AGENTS; Diazepam (valium) Midazolam (versed) and Triazolam
(Halicon). Emergency - Must have portable oxygen delivery system- > 90% at 10 L/min. flow for at least 60 min. ORAL HABITS- - Rooting reflex-diminishes by 7
months. Sucking reflex- diminishes by 12 months. Digit sucking is considered reflexive & normallydisapperars between 12-42 months of age. Some rely on oral habit
emotional supportive and others find it meaningless. 46% of children have digit habit; 75% begin by 3 months of age. 25% begin between 3-12 months of age. Males =
females. Effects related to intensity (active or passive), duration and frequency. Max inc- labial and apical, Mand incisors go- lingual and apical; Max postior teeth lack
lingual support. $$$$$Generally a min of 4 to 6 hours a day for a digit habit to move. Habit cause Increased overjet, decaresed overbite, Posterior crossbit. Sucking habits
decrease between 2-4 years. 4-6 years olds usally respnd well to reminder therapy or a reward system. 6- 7 year old may require an appliance if habit persists after the
permanent dentition begins to erupt. Parents are “silent partners”. Show the malocclusion. REMINDER Therapy- Indicated for a child who wants to stop their hapit, but needs
some help to stop completely. Other options include Band-aid, adhesive tape, mitten, (unpleasant tasting liquids placed on the digit are not recommedded. REWARD
SYSTEM- Reward must have value to the child. Calander with stars for at least 4 wks. Remove accseory component. Limit the time or place of the habit. APPLIANCE
THERAPY- Child must be mature enough to be able to understand the reason for the tx and want to correct the problem. The appliance is a reminder not a punishment. A
malooclusion should be present. Leave the applianve in for 6 months. 80% of children stop within a 1. 9% relapse after 3 years. QUAD HELIX- Used for malocclusion and a
rminder. Pacifier Habit- If use pacifier rarely acquire a digit habit. Pre term infants lose alower perc. Of their birthwight, have lower serum bilirubin levels and have higher
pO2 leves, develop earlier and more organized sucking patterns. Gastrin and insulin secreded during pacifier sucking, has vagal effect. Less likely for SIDS. NAIL BITTING-
40% of adolexcents. Littler harm to the occlusion. SELF MUTILATION- 10-20% retards- Biochemical disorders such as Lesch Nyhan and cornelia de lange syndromes.
Refer to specialist.
ORAL HABITS IN CHILDREN: Psychoanalytical theory of oral habits: assoc w/ pleasure early in life. If habit not stopped at usual time, it is because of some underlying
psychological disturbance. If child forced to stop his habit, he will develop another, possible more objectionable habit in its place. The behavioral theory is that oral habits are
learned pattern of behavior w/o underlying causes. When the habit is stopped, the child is not expected to experience any psychological or emotional problems or develop a mor
objectionable habit. The rooting reflect stops by age 7 mos. The sucking reflex stops by 12 mos. Digit sucking is considered reflexive and normally disappears btwn 12-42
months of age. 46% of children have digit habits, same amount of males and females, 75% begin by 3 mos, the other 25% btwn 3-12 mos and there is no change in incidence
among children w/ and w/o psychological problems. Effects on dentition are related to intensity, duration and frequency. The max incisors for forced labial and apical. The
mand incisors have forces to the lingual and apical. The max post lack lingual support the tongue is displaced inferiorly and laterally. Usually, a minimum of 4-6 hrs/day of a
digit habit is needed to “move” teeth. Resulting maloccl may include: increased overjet, decreased overbite &/or ant open bite, post crossbite, no maloccl may be present, digit
deformaties, localized alveolar deformities, most investigators do not believe in a class II molar relationship. Self correction of maloccl depends on: age the habit was stopped,
severity of maloccl., effect(s) on soft tissue, development of other habits (e.g. tongue thrust, low tongue position, mouth breathing). Tx should occur after psychological factors
are no longer a big component of the habit. Digit habits are normal in infants, survival depends on instinctual sucking. They become restless if they are stopped from sucking.
Sucking habits decrease btwn 2-4 yrs old. 4-6 yrs old usually do well to reminder therapy or a reward system. 6-7 yr olds may need an appliance if the habit stays after the
perm teeth are begin erupting. Pre-term infants who use pacifiers: lose a lower % of their birthweight, have lower serum bilirubin levels, have higher resting pO2 levels,
develop earlier & more organized sucking patterns, gastrin & insulin are secreted during pacifier sucking: indirect evidence of a vagal effect. and there’s evidence that infants
that use pacifiers are less likely to die from SIDS. Make sure pacifier is sturdy, 1 piece construction, non-toxic, flexible and firm but not brittle, easily grasped handles,
inseparable nipple and mouthguards, mouthguards of adequate diamtere to prevent aspiration and 2 ventilating holes, a label warning against tying the pacifier around the
infant’s neck. They should be kept clean and never should be dipped in sugary liquids to encourage sucking. Maloccl caused by pacifiers: anterior open bite, max constriction
and labial-lingual movement of the incisors may not be as much as with digit habit. Ortho pacifiers: tongue is positioned towards the palate during use, studies show no
difference in maloccl rate up to 18 mos of age, but traditional pacifiers may have greater incidence of maloccl after 18 mos of age. Generally a pacifier habit is an easier habit to
break than a digit sucking habit, because pacifier must be present for the habit. Fingernail biting habit has an oral gratification. There is some degree of transference from
thumb sucking to nailbaiting and often a response to stress. It is rare in kids <3 yrs old, marked decrease in 3-6 yo, relatively constant in 7-10 yo. Increases from 10-puberty.
In adolescents: approximately 40%. Late adolescents it decrease. There is little harm done to the occl and more harm is done to nail beds. There was more e coli, in nailbiter.
Fingernail biting tx: emotional support of family, not punitive, groom nails well, no rough edges, when habit disappears, other habits result like gum chewing, smoking,
lip/cheek biting and pencil biting. Chewing gum daily reduced probability of having otitis media w/ effusion (OME) by 40%. It also activated jaw movement, increases
salivary flow, the rate of swallowing, and rate of activation of peritubal muscles and tubal openings. Chewing also requires nasal respiration, thus preventing mouth breathing.
Xylitol is poorly metabolized by some bacteria, it may be of value in decreasing airway surface liquid salt concentration and so enhances the innate antimicrobial defense at the
airway surface. Children who chewed gum w/ xylitol or swallowed syrup experienced a lot fewer episodes of OME. Self mutilation is repetitive acts that result in physical
damage, it’s extremely rare in normal children, manifestations include: biting of lip, tongue, oral mucosa and or digits. The etiology is tension & conflicts at home, learned
behavior (reinforced w/ attention) psychological abnormality 10-20% incidence in mentally retarded pts. Refer to specialist. Tx: distraction: behavior modification, restraints,
protective padding, sedation, extraction of selected teeth may be needed. There are biochemical disorders like Lesch-Nyhan and cornelia de lange syndrome.