Pedo2013 14

PEDIATRIC DENTISTRY LEG ND
Topic
abnormal teeth
Cards
1-4
Topic
primary dentition
behavior management
5-10
pulp treatment
diseases & conditions
11-31
restorative
drugs
32-34
tooth development
fluoride
35-43
tooth trauma
general information
44-57
space management
miscellaneous
58-60
abn of teeth
Radiographs of a preschool child with
will show obliteration
of the pulp chambers with secondary dentin, a characteristic finding.
amelogenesis imperfecta
dentinogenesis imperfecta
fluorosis
enamel hypoplasia
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PEDIATRIC DENTISTRY
dentinogenesis imperfecta
Dentinogenesis imperfecta (DI) is an autosomal dominant trait, its frequency of occurrence is about I in 8000.
This inherited dentin defect originates during the histodifferentiation stage of tooth development. The predentin
matrix is defective resulting in amorphic, disorganized, and atubular circumpulpal dentin. Teeth are blue-gray
or brown and abrade rapidly. Occasionally, these teeth become abscessed as a result of exposure of pulp horns
caused by wear. Full coverage is the treatment of choice. Both the primary and permanent dentitions are affected
in dentinogenesis imperfecta. Important: Radiographs of a preschool child with dentinogenesis imperfecta will
show obliteration of the pulp chambers with secondary dentin, a characteristic finding. Roots of teeth usually
are narrower and appear more fragile. Crowns generally appear more bulbous than usual due to the smaller
roots. Dentinogenesis imperfecta can be subdivided into three basic types:
Shields Type I: occurs with osteogenesis imperfecta. As a result of an inherited defect in collagen formation, there is brittle bones, bowing of the limbs, and blue sclera. Periapical radiolucencies, bulbous crowns,
obliterated pulp chambers, and root fractures are common. Teeth have amber translucent color. Primary teeth
affected more than permanent teeth.
Shields Type II: also known as hereditary opalescent dentin, tends to occur as a separate entity apart from
osteogenesis imperfecta. Same characteristics as Type I. Both primary and permanent teeth affected equally.
Shields Type III: quite rare, demonstrates teeth with a shell-like appearance and multiple pulp exposures.
Seen exclusively in a triracial isolated group in Maryland known as the Brandywine population.
Amelogenesis imperfecta is one of the major defects of enamel. It is a hereditary disease characterized by faulty
development of the enamel. There is normal pulpal and root morphology. There are four major categories according to the stages of tooth development in which each is thought to occur.
Hypoplastic Type: occur in the histodifferentiation stage of tooth development. There is an insufficient
quantity of enamel formed due to areas of the enamel organ that are devoid of inner enamel epithelium, causing a lack of cell differentiation into ameloblasts. Affects both primary and permanent dentitions. The affected
teeth appear small with open contacts; clinical crowns contain very thin or nonexistent enamel.
Hypomaturation Type: defect in enamel matrix apposition and is characterized by teeth having normal
enamel thickness but a low value of radiodensity and mineral content.
Hypoplastic or Hypomaturation Type with Taurodontism: is an example of inherited defects in both apposition and histodifferentiation stages in enamel formation. The enamel appears mottled with a yellowbrown color and is pitted on the facial surfaces. Molar teeth demonstrate taurodontism.
Hypocalcification Type: is an example of inherited defect in the calcification stage of enamel formation.
Quantitatively, the enamel is normal, but qualitatively, the matrix is poorly calcified. The enamel is soft and
fragile and is easily fractured., exposing the underlying dentin, which produces an unesthetic appearance.
abn of teeth
is a process in which a single tooth germ splits or shows an
attempt at splitting to form two completely or partially separated crowns.
concrescence
gemination
fusion
dens in dente
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PEDIATRIC DENTISTRY
gemination
Gemination is a process in which a single tooth germ splits or shows an attempt at splitting to form two
completely or partially separated crowns. This process results in incomplete formation of two teeth. Like
fusion, it is also more common in the primary dentition. It results in a bifid crown with a single pulp
chamber. It most frequently occurs in the incisor region. Concrescence is a twinning anomaly involving the union of two teeth by cementum only. Its etiology is thought to be trauma or adjacent tooth malposition.
The term dens-in-dente (also called dens invaginatus) means a "tooth within a tooth" and results from
the invagination of the inner enamel epithelium. Most frequently involves the maxillary lateral incisors. The clinical significance of this anomaly results from potential carious involvement through communication of the invaginated portion of the lingual surface of the tooth with the outside environment.
The enamel and dentin in the invaginated portion can be both defective and absent, allowing direct exposure of the pulp.
Dens evaginatus is an extra cusp, usually in the central groove or ridge of a posterior tooth and in the
cingulum area of central and lateral incisors. In incisors, these cusps appear talon-shaped. It results
from the evagination of inner enamel epithelial cells. This extra portion contains not only enamel but
also dentin and pulp tissue; therfore, care must be taken with any operative procedure.
Fusion of teeth is a condition produced when two tooth buds are joined together during development and
appear as a macrodont (a single large crown). It is more common in the primary dentition. It may involve
the entire length of two teeth (enamel, dentin, and cementum) or just the root (dentin and cementum). This
condition is usually seen in the incisor area. Although fused teeth can contain two separate pulp chambers, many appear as large bifid crowns with one chamber. Note: A radiograph is needed to confirm
whether there is fusion or gemination.
1. Taurodont teeth are characterized by a significantly elongated pulp chamber with short
Notes stunted roots resulting from the failure of the proper level of horizontal invagination of Her-
twig epithelial root sheath.

2. Dilaceration refers to an abnormal bend of the root during its development; it is thought
to result from a traumatic episode, usually to the primary dentition. It is a consistent finding
in children with congenital ichthyosis.
abn of teeth
What condition is depicted below?
enamel hypoplasia
erythroblastosis fetalis
nursing bottle caries
dentinal dysplasia
Copyright 2000-2004 University of Washington. All rights reserved. Access t<

the Atlas of Pediatric Dentistry is governed by a license. Unauthorized access o
reproduction is forbidden without the prior written permission of the University
of Washington. For information, contact:license@u.washington.edu
copyright 0 2013-2014 - Dental Decks
PEDIATRIC DENTISTRY
enamel hypoplasia
Enamel hypoplasia (EH) is a defect in tooth enamel that results in less quantity of enamel than normal.
The defect can be a small pit or dent in the tooth or can be so widespread that the entire tooth is small
and/or misshaped. This type of defect may cause tooth sensitivity, may be unsightly, or may be more susceptible to dental cavities. Some genetic disorders cause all the teeth to have enamel hypoplasia. EH can
occur on any tooth or on multiple teeth. It can appear white, yellow, or brownish in color with a rough
or pitted surface. In some cases, the quality of the enamel is affected as well as the quantity.
Environmental and genetic factors that interfere with tooth formation are thought to be responsible for
EH.
Environmental factors:
Severe infections such as exanthematous diseases and fever-producing disorders particularly
during the first year of life. Syphilis (caused by Treponema pallidum) produces classic patterns of
hypoplasia including Hutchinson incisors and mulberry molars. Rubella embryopathy has a high
correlation with prenatal enamel hypoplasia in the primary dentition.
Neurologic defects as seen in children with cerebral palsy and Sturge-Weber syndrome
Fluorosis: excess ingestion of systemic fluoride
Nutritional deficiencies: particularly vitamins A, C, and D, along with calcium and phosphorus
Other: children born prematurely and children who have received excess radiation exposure as
well as children with asthma
*** Causes of enamel hypoplasia affecting individual teeth include local infection, local trauma,
iatrogenic surgery as seen in cleft plate closure, and primary tooth overretention. Turner hypoplasia is a classic example of hypoplastic defects in permanent teeth resulting from local infection or trauma to the primary precursor.
Genetic factors: amelogenesis imperfecta (see card #1)
Treatment options depend on the severity of the EH on a particular tooth and the symptoms associated
with it. The most conservative treatment consists of bonding a tooth-colored material to the tooth to protect it from further wear or sensitivity. In some cases, the nature of the enamel prevents formation of an
acceptable bond. Less conservative treatment options, but frequently necessary, include use of stainless
steel crowns, permanent cast crowns, or extraction of affected teeth and replacement with a bridge or implant.
abn of teeth
Excessive fluoride levels in drinking water are associated with fluorosis.
begin to pose a risk for fluorosis.
Fluoride levels in excess of
one part per million

two parts per million
three parts per million
four parts per million
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PEDIATRIC DENTISTRY
three parts per million

The role of fluoride in caries prevention is a very important one. Indeed, one of the most significant contributions of world's free enterprise systems to the health of people is to market fluoridated toothpaste. Huge reductions in caries prevalence have been made in the populations of numerous countries where fluoridated
toothpastes are used regularly.
One major reason for the decrease in decay rates is that, because low concentrations of fluoride are present in
people's mouths, the use of fluoridated toothpaste is very effective in the remineralization of demineralized
teeth. For example, more than ninety 9 0 % of the toothpastes sold in the United States contain fluoride. This
amounts to a massive public health undertaking by the private sector. The significant impact on decay rates
demonstrates the importance of fluoride in caries prevention.
The mechanism of action for fluoride in caries abatement is shown in the following list:
Increased resistance of the tooth structure to demineralization.
Enhanced remineralization of early carious lesions.
Impaired cariogenic activity of dental plaque, through disruption of bacterial metabolism and function.
The studies and surveys link fluorosis to three factors:
Fluorosis is more common in geographic areas where the endemic levels of fluoride in the drinking water
are higher than three parts per million
Fluorosis is associated with fluoride supplementation at inappropriately high levels
The use of fluoridated toothpaste has been implicated in fluorosis
Important: Excessive fluoride levels in drinking water are associated with fluorosis. Fluoride levels in excess
of three parts per million begin to pose a risk for fluorosis. This has been demonstrated in numerous studies
over decades of research and in various geographic settings around the world.
Remember: Dentin Dysplasia is another group of inherited dentin disorders resulting in characteristic features
involving the circumpulpal dentin and root morphology. Two types:
Shields Type I: normal primary and permanent crown morphology with an amber translucency. The roots
tend to be short and sharply constricted. Primary and permanent dentitions demonstrate multiple radiolucencies and absent pulp chambers.
Shields Type II: primary teeth are amber - colored closely resembling dentinogenesis Type I and II. Permanent teeth are normal in appearance but radiographically demonstrate thistle - tube - shaped pulp chambers with multiple pulp stones. No periapical radiolucencies are seen.
behav mgmt
is the bedrock strategy on which all of pediatric dental behavior management rests.
tell-show-do (TSD)
positive reinforcement
distraction
nonverbal communication
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PEDIATRIC DENTISTRY
tell-show-do
(TSD)
Child patients usually will not know what to expect during dental appointments and many will be at an
age when they have considerable fears of the unknown. The TSD strategy is designed to deal with those
issues.
- This approach is the backbone of the educational phase of developing an accepting, relaxed child
dental patient.
- The effectiveness of the TSD approach depends on using language the child can understand. This
means that we must use words or anecdotes that are age-appropriate so the child can conceptualize
the idea we are trying to convey.
-Many children are helped by watching procedures done on themselves in the mirror during the procedure. It is important to provide an explanation of what is occurring as the procedure continues.
-Many children tend to be fearful of the unknown, especially in clinical situations. Being able to watch
the procedure in the handheld mirror seems to diffuse anxiety.
- This approach works especially well when treating a child with a different cultural background.
Important: The clinical examination of the infant and toddler should be accomplished with the parents' assistance in a nonthreatening environment. Most often, it is neither necessary nor recommended that the dental chair be used. The parent and dentist sit facing each other in a knee-to-knee
position, supporting the child with the head cradled on the dentist's lap.
Remember:
Aggressive behavior in the dental office is usually a fear reaction
The most realistic approach to managing a difficult child in the dental office is to attempt to recondition the child through techniques of applied psychology
Aversive conditioning: is a form of behavior training or modification in which a noxious event is used
to punish or extinguish undesirable behavior. Examples include HOME, voice control, etc.
Most pediatric dentistry graduate programs do not teach HOME (hand-over-mouth excercise), as an
acceptable behavior management technique. HOME is contraindicated in children who are unable
to understand due to age, disability, medications, or emotional immaturity.
Should always be followed by positive reinforcement (i.e., patient praise, use of tokens or "stickers,"etc.) for improved behaviors
Need parents consent if using HOME or any aversive conditioning technique
behav mgmt
When treating a child who is obviously afraid, the dentist should:
use restraint
use the hand-over-mouth technique (HOME)
permit the child to express his fear
avoid all reference to the child's fear
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PEDIATRIC DENTISTRY
permit the child to express his fear identify the fear

All behavioral patterns are motivated by anger and fear. The crying child is NOT an abnormal child.
Anger is easier to treat than fear. Fear is most likely to be exhibited by a young child on his first visit to
the dentist. This is related to the anxiety over being separated from a parent. The parent, not the dentist,
has the greatest influence on the child's reaction at this initial visit.
The angry child:
- Separate the parent and the child
- Place the child in the chair abruptly and be firm
- Use the "hand-over-mouth" excercise (HOME) - get the parent's permission !!!
- Display authority and command respect of the child by continuing with treatment if he/she is
uncooperative
- Comfort parent at the end of the visit
- Compliment child at the end of the visit
The fearful child:
- Have the parent stand quietly behind the chair
- Dentist must be consistent in tonal quality
- Permit the child to express his fears - identify the fear
- Change the child's focus off fear
- Lastly, sedation
Classification of behavior:
Cooperative: children with minimal apprehension and respond well to behavior shaping
Lacking cooperative ability: children are deficient in comprehension and/or communication skills
(i.e., very young children and children with certain disabilities).
Potentially cooperative: chidren are capable of behaving but are disruptive in the dental setting.
- Uncontrolled: characterized by temper tantrums. Typically 3-6 years of age.
- Defiant: characterized by "I don't want to" attitude or passive resistance. All ages.
Timid: typically preschool and younger grade school children. Hide behind parent or put hands
over their mouth and face.
Tense-cooperative: cooperative but are very nervous. "White-knuckler" patients because they
grip the dental chair arm rests so tightly.
Whining: they whine throughout the whole appointment.
behav mgmt
The process of shaping a patient's behavior through appropriately timed
feedback is called:
tell-show-do
voice control
distraction
nonverbal communication
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PEDIATRIC DENTISTRY
American Academy of Pediatric Dentistry's Standard for Behavior Management
Communicative
Management
Tell-Show-Do
Voice control
Description
Objectives
Explanations tailored to
cognitive level, followed by
demonstration, followed by
actual procedure
Modulation on voice volume,

tone or pace to influence and
direct patient's behavior
Indications
Contraindications
Allay fears, shape

patient's response
Give expectations of
behavior
All patients who can

communicate regardless
of method of
communication
None
Gain patient's
attention
Avert negative or
avoidance behaviors
Establish authority
Uncooperative or
inattentive but
communicative child
Children who are

unable to understand
due to age, disability,
medications, or
emotional immaturity
Positive
reinforcement
Process of shaping patient's

behavior through appropriately
timed feedback
Reinforce desired
behavior
Any patient
None
Distraction
Diverting patient's attention from

perceived unpleasant procedure
Decrease likelihood of
unpleasant perception or
threshold
Any patient
None
Nonverbal cornmunication
Conveying reinforcement and

guiding behavior through contact,
posture, and facial expressions
Any patient
None
Enhance effectiveness
of other communicatine management techniques
Gain or maintain patient's attention and
compliance
Behavior shaping means providing the child with cues and reinforcements that direct them toward desirable behavior. Positive reinforcement at every stage of the treatment process is recommended, to indicate to the child that he is making successful steps in the process of receiving treatment. The frequent
use of praise during a child's appointment, when the child performs an appropriate behavior is essential.
Note: Positive reinforcement may be verbal or nonverbal and should be immediate and specific to the
desirable behavior.
behav mgmt
All of the following procedures have proved beneficial in treating a mentally
retarded child EXCEPT one. Which one is the EXCEPTION?
speak slowly and in very simple terms

listen carefully to the patient
schedule long appointments
ask the patient if there are any questions about anything you will be doing
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PEDIATRIC DENTISTRY
schedule long appointments

*** This is false; you should keep appointments short.
In addition, the following procedures are also helpful when treating mentally retarded
children:
Give a tour to the patient before attempting to do any treatment. Introduce the
patient to the office personnel.
Give only one instruction at a time. Reward the patient with compliments after the
successful completion of the procedure.
Schedule the patient early in the day. The staff, the dentist, and the patient are less
fatigued at this time.
In treating mentally retarded children, the following is usually found:
They can be controlled in the same ways as normal children.
They respond similarly to normal children of the same mental age.
They respond inconsistently, have short attention spans, and are restless and
hyperactive when undergoing dental care.
Important: The dentist should assess the degree of mental retardation by consulting the
patient's physician before starting dental treatment.
An important caveat is that every child responds to his or her environment with an individualized style. Practitioners must be perceptive and flexible with the use of their management techniques, and they can optimize the likelihood of a successful encounter by
matching their selection of techniques to that of the patient's style of interaction.
behav mgmt
The management of a child who must undergo dental extractions is based on
which of the following factors?
the age and maturity of the child

the past medical and dental experiences that might influence the behavior of the
child
the physical status of the child
the length of time and amount of manipulation necessary to accomplish the surgery
all of the above
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PEDIATRIC DENTISTRY
all of the above

The age and maturity of the child often determine the type of anesthesia best suited for the intended procedure. Children below the age of reason generally are best managed under general anesthesia, since a
slight amount of discomfort is always associated with the administration of a local anesthetic, It is very
important to have total anesthesia before starting the procedure. Use both buccal and palatal infiltration
on maxillary teeth and block anesthesia on mandibular teeth with infiltration, if necessary.
The very young patient is best managed under general anesthesia, usually of the inhalation type or in
combination with small doses of intravenous barbiturates. The most common premedication prior to
general anesthesia is Versed.
Note: Premedication with a barbiturate may cause paradoxical excitement in a young child.
Remember: After extracting a tooth on a child patient, the biggest postoperative concern is the prevention of lip biting.
Frank! behavioral rating scale:
Class 1: child is completely uncooperative, crying, very difficult to make any progress
Class 2: child is uncooperative, very reluctant to listen/respond to questions, some progress is possible
Class 3: child is cooperative, but somewhat reluctant/shy
Class 4: child is completely cooperative and even enjoys the experience
Variables that influence the child's behavior in the dental setting:
Age: (1) less than 2 years old: usually are lacking in cooperative ability. (2) 2 years old: Tell-ShowDo technique works well and/or parent in operatory (3) 3-7 years old: generally cooperative; (4) 8
years old and older: usually cooperative.
Mother's anxiety: there is a direct correlation between the mother's anxiety and a child's negative
behavior in the dental setting.
Past medical history: if a patient has had positive medical experiences in the past, they are more
apt to have positive dental experiences as far as behavior is concerned.
Important: The great majority of children require minimal management efforts other than providing
information on what is going to happen (e.g., tell-show-do).
behav mgmt
All of the following instances may make the use of a rubber dam impractical
EXCEPT one. Which one is the EXCEPTION?
the presence of fixed orthodontic appliances

a patient with congested nasal passages or other nasal obstruction
a very nervous or anxious patient
a recently erupted tooth that will not retain a clamp
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PEDIATRIC DENTISTRY
a very nervous or anxious patient

One of the main advantages of using a rubber dam is that it can aid in the management of the child. It
seems to quiet and calm the patient because the dam acts as a separation or barrier, both physically and
psychologically.
Other advantages include:
1.Better access and visualization
2. Control of saliva and moisture in the operating field
3. Decreased operating time
4. Provides protection from aspiration or swallowing of foreign bodies
5. The child becomes primarily a nasal breather when the rubber dam is in place. This then enhances
the effects of nitrous oxide if applicable.
Nitrous oxide sedation for children: for the production of conscious sedation, the inhalational route is
limited to one agent, nitrous oxide. Desirable characteristics of nitrous oxide: it is analgesic and anxiolytic. It is important to remember, however, that nitrous oxide will not eliminate the need for local anesthetic pain control in most cases. Note: Minimum oxygen concentration = 30%. However, concentrations
of nitrous oxide in excess of 50% are usually contraindicated in dental office sedation.
Primary advantages of nitrous oxide for conscious sedation in pediatric dentistry:
Rapid onset and recovery: because nitrous oxide has a very low plasma solubility, it reaches a
therapeutic level in the blood rapidly, and conversely, blood levels decrease rapidly when it is discontinued.
Ease of dose control (Titration)
Lack of serious adverse effects: nitrous oxide is considered to be inert and nontoxic when administered with adequate oxygen. The most common side effect is nausea/vomiting.
1. Minimum alveolar concentration (which is the concentration required to produce immoNotes bility in 50% of patients) of nitrous oxide is 105%.
2.The total flow rate is 4 to 6 L/min for most children.
3. The maintenance dose during the dental appointment is usually around 30-35%.
4. On termination of nitrous oxide administration, inhalation of 100% oxygen for not less
than 3-5 minutes is recommended. This allows diffusion of nitrogen from the venous blood
into the alveolus that is then exhaled as nitrous oxide through the respiratory tract. Note:
This process will prevent diffusion hypoxia.
dis & cond

The phenomenon of "strawberry tongue" is associated with:
herpangina
scarlet fever
diphtheria
mumps
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PEDIATRIC DENTISTRY
scarlet fever
Scarlet fever is an exotoxin-mediated disease arising from group A beta-hemolytic streptococcal infection. The
peak incidence of scarlet fever occurs in children 4 to 8 years old. It is usually accompanied by symptoms of
strep throat, such as sudden onset of fever, sore throat, headache, nausea, vomiting, abdominal pain, muscle
pain, and fatigue.
An enlargement of the fungiform papillae extending above the level of the white desquamating filiform papillae gives an appearance of an unripe strawberry. During the course of scarlet fever, the coating disappears and
the enlarged red papillae extend above a smooth denuded surface, giving the appearance of a red strawberry
or raspberry. Penicillin is the drug of choice. Early diagnosis and treatment are important to prevent complications, which include local abscess formation, rheumatic fever, arthritis, and glomerulonephritis.
Herpangina is a viral infection, usually of young children, characterized by mouth ulcers, but a high fever, sore
throat, and headache may precede the appearance of the lesions. The lesions are generally ulcers with a white
to whitish-gray base and a red border - usually on the roof of the mouth and in the throat. The ulcers may be
very painful. Generally, there are only a few lesions. The disease usually runs its course in less than a week.
Treatment is palliative. The cause is often an infection by a strain of coxsackie A virus.
Diphtheria is an acute, contagious disease caused by the bacterium Corynebacterium diphtheriae, characterized by the production of a systemic toxin. The toxin is particularly damaging to the tissue of the heart and CNS.
Immunization against diphtheria is available to all children in the U.S.
Other conditions to know:
Puberty gingivitis: characterized by the enlargement of interdental areas, and spontaneous or easily stimulated bleeding. Treatment includes professional cleaning and improved oral hygiene.
Herpes simplex infection:
- Primary herpetic gingivostomatitis: HSV-1 infection, usually occurs in children under 3 years old.
Vast majority are subclinical.
- Acute herpetic gingivostomatitis:
If diagnosed within 3 days of onset, acyclovir suspension should be prescribed, 15 mg/kg five times
daily for 7 days.
All patients, including those presenting more than 3 days after disease onset, may receive palliative
care, including plaque removal, systemic NSAIDs, and topical anesthetics.
Recurrent herpetic simplex (Herpes labialis): vesicles located at the mucocutaneous junction of the lips,
corners of the mouth, and beneath the nose. Associated with emotional stress.
Recurrent aphthous ulcer: painful ulcers on unattached mucous membranes.
dis & cond

All of the following statements concerning acute necrotizing ulcerative
gingivitis (ANUG) are true EXCEPT one. Which one is the EXCEPTION?
it is also called Vincent infection, Vincent angina, or "trench mouth"

it is a gingival disease characterized by painful hyperemic gingiva, punched-out
erosions of the interproximal papilla, covered by a gray pseudomembrane with an
accompanying fetid odor
risks include poor oral hygiene, poor nutrition, smoking, and emotional stress
it usually affects children
fusiforms and spirochetes, as well as Prevotella intermedia, have been implicated in
the etiology of acute necrotizing ulcerative gingivitis (ANUG)
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PEDIATRIC DENTISTRY
it usually affects children *** This is false; ANUG occurs in young to middle-aged
ANUG is an acute fusospirochetal infection of the gingiva. It involves a progressive painful infection with ulceration, swelling, and sloughing of dead tissue from the mouth and throat due to the spread of infection from
the gums. It is usually associated with poor oral hygiene and is most common in conditions where there is
crowding and malnutrition. It is rare in preschool children.
It can be easily diagnosed because of the involvement of the interproximal papillae and the presence of a
pseudomembranous necrotic covering of the marginal tissues. The clinical manifestations of the disease include
inflamed, painful, bleeding gingival tissue; poor appetite; fever; general malaise; and a fetid odor. Treatment
includes debridement, hydrogen peroxide mouth rinses, and antibiotic therapy.
Note: Atrophic gingivitis is characterized by gingival recession without a corresponding rate of alveolar bone
loss. Minor marginal and papillary gingival inflammation is found. The predominant clinical finding is the recession.
Periodontal disease in adolescents: the clinical and histologic manifestations of gingival and periodontal disease in adolescents are similar to those seen in adults. Bone loss from periodontitis does occur in a small percentage of teenagers, but the predominant condition noted in this age group is gingivitis.
Periodontal disease in children:

A primary characteristic of aggressive periodontitis that differentiates it from chronic periodontitis
is the rapid progression of attachment and bone loss that is evident. Aggressive periodontitis may be
localized or generalized. The classic form of localized aggressive periodontitis was initially referred
to as "periodontosis" and then as "localized juvenile periodontitis" (LIP). Localized aggressive periodontitis (LA P) is the new classification designated to replace LW.
LAP is defined by several distinguishing characteristics: onset around the time of puberty, aggressive periodontal destruction localized almost exclusively to the incisors and first molars, and a familial pattern of occurrence. Actinobacillus actinomycetemcomitans is the dominant bacteria in
LAP, other microorganisms that have been associated with LAP include P. gingivalis, E. corrodens,
C. rectus, F. nucleatum, Bacillus capillus, Eubacterium brachy, and Capnocytophaga species and spirochetes. Important: The one outstanding negative feature is the relative absence of local factors
(plaque) to explain the severe periodontal destruction that is present.
Generalized aggressive periodontitis (GA P) is differentiated from the localized form by the extent
of involvement around most of the permanent teeth, and it is considered to include rapidly progressing periodontitis.
dis & cond

A Class I cleft palate involves what structures?
hard and soft palates

soft palate only
alveolar process only
hard palate only
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PEDIATRIC DENTISTRY
soft palate only

Four Classes of Cleft Palate:
Class I: involves only the soft palate.
Class II: involves soft and hard palates but not the alveolar process.
Class III: same as Class II but with alveolar process involvement on one side of
the premaxilla.
Class IV: involves the soft palate and continues through the alveolus on both
sides of the premaxilla.
*** Females more often affected
Four Classes of Cleft Lip:

Class I: a unilateral notching of the vermillion not extending into the lip.
Class II: same as Class I but the cleft extends into the lip but not to the floor of the
nose.
Class III: same as Class II but extending into the floor of the nose.
Class IV: any bilateral clefting of the lip whether incomplete notching or complete
clefting.
*** Males more often affected
dis & cond

Ectodermal dysplasia is characterized by:
Select all that apply.
sparse hair
lack of sweat glands
oversized crowns
elongated roots
normal mental status
an enlarged mandible
absence of teeth
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PEDIATRIC DENTISTRY
sparse hair
lack of sweat glands
normal mental status
absence of teeth
Ectodermal dysplasia is a sex-linked recessive trait. Although both sexes are affected, more males are affected than
females. It is characterized by a lack of sweat glands, sparse hair, dry skin, a concave nasal bridge, and the absence
of teeth. There may be complete failure of the teeth to develop (anodontia) or oligodontia (partial anodontia). Alveolar bone development is lacking because of the absence of permanent teeth. Note: Anhidrotic ectodermal dysplasia
is the X-linked recessive form of ectodermal dysplasia and the most well known. It is characterized by the conical
shape of the anterior teeth (see photo below). It is also characterized by lack of perspiration caused by the partial or
complete absence of sweat glands.
Copyright 2000-2004 University of Washington. All rights reserved. Access to the Atlas of Pediatric
Dentistry is governed by a license. Unauthorized access or reproduction is forbidden without the prior
written permission of the University of Washington. For information, contact: license@u.washington.edu
Cleidocranial dysplasia (or dysostosis) is a rare condition inherited as an autosomal dominant and characterized by
partial or complete absence of the clavicles, defective ossification of the skull, and faulty occlusion due to misplaced
or supernumerary teeth often ranging in number from 10-60. It is equally common in males and females. Prolonged
retention of primary teeth and delayed or complete failure of eruption of permanent teeth are characteristic features.
The presence of numerous supernumerary and unerupted permanent teeth is very common.
Remember: Supernumerary teeth are most often found in the maxillary midline region and are called mesiodens. Supernumerary teeth are also frequently found distal to the maxillary molars and in the mandibular premolar region.
dis & cond

The child below is most likely suffering from what condition on the lower face?
chicken pox
primary herpetic gingivostomatitis
scarlet fever
mumps
Copyright 2000-2004 University of Washington. All rights reserved.

Access to the Atlas of Pediatric Dentistry is governed by a license.
Unauthorized access or reproduction is forbidden without the prior written permission of the University of Washington. For information, contact:
license@u.washington.edu
15
PEDIATRIC DENTISTRY
primary herpetic gingivostomatitis

Gingivostomatitis is a disorder involving sores on the mouth and gingiva that result from a viral
infection (HSV-1). It is characterized by inflammation of the gingiva and mucosa and multiple mucosa] ulcerations. This is a very painful condition. The patient often does not want to eat or drink.
The major concerns are hydration, secondary infection, and prevention of contagion. This disease
is self-limiting, and the acute phase generally lasts 10-14 days. Oral fluids are very important in children so that they do not become dehydrated.
Important: Primary (acute) herpetic gingivostomatitis generally affects children under the age of
3 years. There are prodromal symptoms (fever, malaise, irritability, headache, dysphagia, vomiting and lymphadenopathy) that occur 1-2 days prior to the local lesions (ulcers) in the oral cavity. The treatment in children should be directed toward the relief of the acute symptoms so that
fluid and nutritional intake can be maintained. Symptomatic treatment for primary herpes consists
of rinsing with a 50:50 suspension of Benadryl-Kaopectate and/or Viscous Lidocaine. The antiviral drug used most frequently today to shorten the duration and severity of the primary infection is
acyclovir (Zovirax). It is prescribed as a 200 mg/5mL suspension and is to be given every 3 hrs when
awake or five times a day for 10 days. The dosage is 15 mg/kg with a maximum of 80 mg/kg per
day.
Important: The main differential diagnosis for primary herpetic gingivostomatitis in patients
with predominately gingival involvement without or with few discrete lesions is acute necrotizing ulcerative gingivitis (A NUG). Patients with ANUG also present with a sudden onset of a sore
mouth. However, ANUG can be differentiated from primary herpes by the fact that, in ANUG, the
interdental papillae are necrotic while in primary herpes, the interdental papillae are intact. In individuals with primary herpes manifesting multiple oral ulcerations, aphthous stomatitis must
be considered in the diagnosis. However, primary herpes can be distinguished from aphthous stomatitis by lesion location and history. Aphthous ulcers occur only on mobile or unattached mucosa
and there is a history of recurrence. In contrast, primary herpetic lesions occur on both mobile
and attached mucosa and there is no history of previous episodes. Most patients with aphthous
stomatitis do not have systemic symptoms such as fever.
dis & cond

Cellulitis in a child is easier to treat than in adults.
The most common causative organisms of cellulitis are group A streptococci
and Staphylococcus aureus.
both statements are true

both statements are false
the first statement is true, the second is false
the first statement is fake, the second is true
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PEDIATRIC DENTISTRY
the first statement is false, the second statement is true
Cellulitis may be caused by a necrotic primary or permanent tooth. It often causes considerable swelling of the face or neck, and the tissue appears discolored. It is a very serious infection and it can be life-threatening. The child will appear acutely ill and may have
a very high temperature with malaise and lethargy. Note: The most common causative
organisms are group A streptococci and Staphylococcus aureus.
Important: Cellulitis in a child is harder to treat because dehydration occurs more frequently, rapidly, and severely in children than in adults.
If it involves the submandibular, sublingual, and submental space it is called "Ludwig
angina." In this condition, the tongue and floor of the mouth become elevated and the
patient's airway is obstructed and swallowing is compromised. The treatment for cellulitis includes managing the source of infection, antibiotic therapy, incision and drainage in
severe cases, and hospitalization if the signs and symptoms warrant it. In the case of Ludwig angina, it is mandatory.
3 clinical stages of odontogenic infection:
1. Periapical osteitis: occurs when the infection is localized within the alveolar bone.
Although the tooth is sensitive to percussion and often slightly extruded, there is no
soft tissue swelling.
2. Cellulitis: develops as the infection spreads from the bone to the adjacent soft tissue. Subsequently, inflammation and edema occur, and the patient develops a poorly localized swelling. On palpation, the area is often sensitive, but the sensitivity is not
discrete.
3. Suppuration then occurs and the infection localizes into a discrete, fluctuant abscess.
dis & cond

Historically, the incidence of dental decay in individuals with Down syndrome
has been reported to be
. The rate of periodontal disease in
these persons has been reported to be
extremely high, extremely low

relatively the same as the general population, extremely high
extremely low, relatively the same as the general population
extremely low, extremely high
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PEDIATRIC DENTISTRY
extremely low, extremely high

Down syndrome is a congenital defect caused by a chromosomal abnormality (trisomy
21). The primary skeletal abnormality affecting the orofacial structures in Down syndrome is an underdevelopment or hypoplasia of the midfacial region. The bridge of the
nose and the, bones of the midface and maxilla are relatively smaller in size. In many instances, this causes a prognathic Class III occlusal relationship that contributes to an
open bite. The tongue may protrude and appear to be too large. With age, both the tongue
and the lips in people with Down syndrome tend to develop cracks and fissures. This is a
result of chronic mouth breathing. The eruption of teeth in individuals with Down syndrome is usually delayed and may occur in an unusual order. There is an extremely high
rate of missing teeth in both the primary and permanent dentitions. The roots of the teeth
in patients with Down syndrome tend to be small and conical.
General manifestations: mental deficiency, short, stocky build, hypotonia, cardiac anomaly in about 40%, dry skin. Remember: It is important to confirm with the parent or the
child's cardiologist as to whether or not SBD prophylaxis is required for dental treatment
due to the child's cardiac condition.
Craniofacial/ Dental Manifestations: brachycephaly, inner epicanthal folds, up-slanting
palpebral fissures, small and low set ears, microdontia, increased risk for periodontal disease, decreased risk for dental caries.
The child with Down syndrome is said to be affectionate, fearful of quick movements, but
capable of learning dental procedures. These children need a comprehensive preventive
program. These patients often have difficulty accepting dental care but cooperation can
be improved by using gradual exposure to the dental office.
dis & cond

The most common form of diabetes in children is:
type I
type II
type III
type IV
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PEDIATRIC DENTISTRY
type I
Type I, or insulin-dependent diabetes mellitus, is the most common form in children. Approximately 2 in 1000 children between the ages of 5 and 15 years have the disease. The suspicion of diabetes usually arises by one or more of the following:
Family history
Symptoms: polydipsia, polyuria, weight loss with polyphagia, enuresis, recurrent infections, and candidiasis are common findings
Glycosuria may be present
Ketoacidosis and coma are possible
Subjective findings include a history of polydipsia (excessive thirst), polyuria (excessive urination), polyphagia (excessive hunger), and weight loss. A fasting blood glucose level above
120 mg/dL is indicative of Type I diabetes mellitus.
Periodontal disease is the most consistent oral finding in patients with poorly controlled diabetes mellitus, These patients exhibit increased alveolar bone resorption and inflammatory
gingival changes, which may mimic the clinical manifestations of localized aggressive periodontitis. Xerostomia and recurrent intraoral abscesses may be present.
The goal of treatment is to control blood glucose to as normal a level as possible, thereby reducing the potential complications of hyperglycemia and ketoacidosis. This generally involves
the administration of an intermediate-acting insulin (NPH and Lente).
Dental management of the well-controlled diabetic consists of the following:
Advise the patient to eat a normal meal before the appointment to avoid development of
hypoglycemia
If the dental procedure is anticipated to be stressful, consult the patient's physician regarding adjustment of the insulin dosage
Consider utilization of prophylactic antibiotics for surgery, endodontics, and periodontal
therapy to minimize risk of infection
Have a glucose source available to treat the onset of hypoglycemia
dis & cond

The hemangioma is usually treated by conservative surgical excision.
Capillary hemangioma is the most common type.

the first statement is false, the second is true
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PEDIATRIC DENTISTRY
Hemangiomas are vascular birthmarks in which the proliferation of blood vessels leads
to a mass that resembles a neoplasm. Hemangiomas differ from other vascular birthmarks
in that they are biologically active; their growth is independent from the growth of a child.
Most hemangiomas appear within a week or two after birth. They are 5 times more common in girls than boys. They are common on lips, tongue, and buccal mucosa. These lesions appear as flat or raised, usually deep red or bluish red, and seldom
well-circumscribed. They are removed surgically, others require no treatment.
Notes
1. Neuroblastoma is one of the most common solid tumors of early childhood

usually found in babies or young children. The disease originates in the adrenal medulla or other sites of sympathetic nervous tissue. The most common site
is the abdomen (near the adrenal gland) but can also be found in the chest,
neck, pelvis, or other sites. Most patients have widespread disease at diagnosis.
2. A lymphangioma is a fairly well-circumscribed nodule or mass of lymphatic vessels. They occur most frequently in the neck and axilla. These lesions appear as red to blue translucent enlargements that are compressible and
spongy. They are treated by excisional biopsy.
3. A neurofibroma is a moderately firm, encapsulated tumor resulting from the
proliferation of Schwann cells. They occur on the tongue, buccal mucosa,
vestibule, and palate. These lesions appear as solitary or multiple submucosal
enlargements. May become malignant (5-15%). Multiple lesions are associated with neurofibromatosis (von Recklinghausen disease).
dis & cond

An outstanding oral manifestation of achondroplasia is:
rampant caries
periodontal disease
overcrowding of teeth
supernumerary teeth
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PEDIATRIC DENTISTRY
overcrowding of teeth
Achondroplasia is the most common form of short-limb dwarfism. It occurs in all races
and with equal frequency in males and females. An individual with achondroplasia has a
disproportionate short stature -- the head is large and the arms and legs are short when
compared to the trunk length. Other signs are a prominent forehead and a depressed bridge
of the nose. Many of these children die during the first year of life. Deficient growth in
the cranial base is evident in many children that survive.
Important: The maxilla may be small with the resultant crowding of the teeth.
Note: A Class III malocclusion is very common.
Remember: The oral manifestations of the following disorders in children:
Gigantism: enlarged tongue, mandibular prognathism, teeth are usually tipped to
the buccal or lingual side, owing to enlargement of the tongue. Roots may be longer
than normal.
Pituitary dwarf: the eruption rate and the shedding of the teeth are delayed, clinical crowns appear smaller as do the roots of the teeth, the dental arch as a whole is
smaller causing malocclusion, and the mandible is underdeveloped.
dis & cond

Which of the following are oral manifestations of Apert syndrome?
class II malocclusion
severely delayed eruption
trapezoidal-shaped mouth
severe crowding of the teeth
ectopic eruption
shovel-shaped incisors
byzantine-arch shaped palate
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PEDIATRIC DENTISTRY
severely delayed eruption

trapezoidal-shaped mouth
severe crowding of the teeth
ectopic eruption
shovel-shaped incisors
byzantine-arch shaped palate
Apert syndrome is a genetic defect and falls under the broad classification of cranial/limb
anomalies. It is primarily characterized by specific malformations of the skull, midface, hands,
and feet. Note: Class III malocclusion is most common.
Remember:
1. Crouzon syndrome
is an uncommon, autosomal dominant craniofacial disorder characterized by craniosynostosis and dysmorphic facial features.
Clinical features include:
Early childhood, no gender predilection
Maxillary hypoplasia, reduced width of the dental arch and crowded teeth
Short upper lip
Short head, widely spaced eyes, shallow orbits, and protruding eyeballs
Calcified stylohyoid ligaments
Possible unilateral or bilateral posterior crossbite
is characterized by delayed sexual development and hypothyroidism.
This syndrome has important dental considerations, which include hypodontia, an underdeveloped premaxillary area, cleft palate, and a protruding lower lip.
3. Treacher Collins Syndrome, also called mandibulofacial dysostosis, is a rare autosomal dominant disorder of craniofacial development. The oral manifestations are characterized by cleft palate, shortened soft palate, malocclusion, anterior open bite, and enamel
hypopoplasia.
2. Rieger syndrome
dis & cond

Which of the following are true concerning a young epileptic who has a grand
mal seizure in the dental office?
it is generally fatal
it is best treated by injecting insulin
they generally recover if restrained from self-injury and oxygen is maintained
it can be prevented with antibiotics
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PEDIATRIC DENTISTRY
they generally recover if restrained from self-injury

and oxygen is maintained
Of the multiple types of seizures, the tonic-clonic (grand mal) type is the most frightening and the one that most often requires treatment. Grand mal seizures are manifested in
four phases: the prodromal phase, the aura, the convulsive (ictal) phase, and the postictal
phase.
The prodromal phase consists of subtle changes that may occur over minutes to hours.
It is usually not clinically evident to the clinician or the patient. The aura is a neurologic
experience that the patient goes through immediately prior to the seizure. It is specifically
related to trigger areas of the brain in which seizure activity begins. It may consist of a
taste, a smell, a hallucination, motor activity, or other symptoms. As the CNS discharge
becomes generalized, the ictal phase begins. The patient loses consciousness and tonic,
rigid skeletal muscle contraction ensues. This usually lasts 1 to 3 minutes. As this phase
ends, the muscles relax and movement stops. A significant degree of CNS depression is
usually present during this postictal phase, and it may result in respiratory depression.
Management of the seizure consists of gentle restraint and positioning of the patient in
order to prevent self-injury, ensuring adequate ventilation and supportive care, as indicated, in the postictal phase, especially airway management. Single seizures do not require
drug therapy because they are self-limiting.
Important: Should the ictal phase last longer than 5 minutes or if seizures continue to develop with little time between them, a condition called status epilepticus has developed.
This may be a life-threatening medical emergency. This condition is best treated with intravenous diazepam, and transport should be arranged to take the patient to the hospital.
dis & cond

The most common of the craniofacial malformations is:
bifid tongue
macroglossia
cleft palate and cleft lip
anodontia
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PEDIATRIC DENTISTRY
cleft palate and cleft lip
*** Cleft palate and cleft lip account for half of the total number of defects. Of all cases,
25% are cleft palate alone and 75% are cleft lip with or without cleft palate.
The lip and primary palate begin to develop at 4 to 5 weeks gestational age. The two medial nasal swellings and the maxillary swellings fuse to form the upper lip. Failure of this
fusion results in cleft lip. Clefts of the lip are more frequent in males. Cleft lip involvement is more frequent on the left side than the right.
The secondary palate develops at approximately 9 weeks developmental age. The paired
palatal shelves arise from the intraoral maxillary processes. These shelves, originally in
a vertical position, reorient to a horizontal position as the tongue assumes a more inferior
position. The palatal shelves fuse with one another and with the primary palate anteriorly, which, in turn arises from the fusion of maxillary and mandibular processes. Failure
of fusion results in a cleft palate. Cleft palate is more frequent in females.
The most severe disability imposed by cleft palate is an impaired mechanism preventing
normal speech and swallowing. The child will almost always need orthodontic treatment
once the palate is surgically repaired. Also, speech therapy will be needed because these
patients have problems related to the inability of the soft palate to close the air flow into
the nasopharynx. Orthognathic surgery may be needed to correct the general concave appearance of the face. This concave appearance is generally due to deficient maxillary
growth.
dis & cond

Which type of leukemia is referred to as theleukemia of childhood"?
acute myeloid leukemia

chronic myelocytic leukemia
acute lymphocytic leukemia
chronic lymphocytic leukemia
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PEDIATRIC DENTISTRY
acute lymphocytic leukemia (ALL)

(lymphoblastic) leukemia is a life-threatening disease in which the cells that
normally develop into lymphocytes (lymphoblasts) become cancerous and rapidly replace normal cells in the bone marrow. The peak age is around 4 years old, and it is the form of acute
leukemia that is most responsive to therapy. The overall cure rate for childhood ALL is about
80%.
Acute lymphocytic
The early signs of acute leukemia in a child include fatigue, pallor, weight loss, and easy bruising. This will progress to fever, hemorrhages, extreme weakness, bone and joint pain, and repeated infections.
Oral findings include:
Gingival oozing, petechiae, hematoma, or ecchymosis

Oral ulceration, pharyngitis, and gingival infection that is unresponsive to conventional therapy
Submandibular lymphadenopathy
Note: Candidiasis is common in children with leukemia because they are especially susceptible
to this fungal infection. Nystatin rinses or popsicles are effective in clearing up this infection.
Hodgkin lymphoma or Hodgkin disease is a malignant growth of cells in the lymph system.
Hodgkin's disease is the better known form of lymphoma (the other lymphomas are grouped into
what is called the Non-Hodgkin lymphomas). The most common symptom of Hodgkin disease
is painless swelling of the lymph nodes in the neck, underarm, or groin. The common symptoms
of Non-Hodgkin disease include painless swelling in the lymph nodes in the neck, underarm, or
groin; persistent fever; feeling of fatigue; unexplained weight loss; itchy skin and rashes; small
lumps in skin; bone pain; swelling in the abdomen; liver or spleen enlargement.
dis & cond

An important diagnostic finding in congenital porphyria is the presence of
red-brown teeth in both the deciduous and permanent dentition.
The oral mucosa is rarely affected in porphyrias.

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PEDIATRIC DENTISTRY

Hereditary porphyria is a rare metabolic error resulting in failure of the conversion of porphyrins. The
urine is burgundy in color, and there is discoloration of teeth and bones. The teeth are reddish-brown
and fluoresce under ultraviolet light. These features are characteristic of tissues containing porphyrins.
Idiosyncrasies in tooth color are important in diagnosing abnormalities in teeth. However, color is usually not a reliable diagnostic criterion in itself. Clinical examination, patient history, and radiographs are
essential in making a final diagnosis. The first diagnostic consideration relating to color is whether the
color or stain in a particular case is intrinsic or extrinsic. Prophylaxis utilizing pumice can be done to remove green stains or yellow pigmentation caused by vitamin elixirs, tobacco, or other sources. If the color
is intrinsic, it will be necessary to consider its distribution and the patient's history, place of residence,
early illnesses, and family background.
Often the first evidence of variation from normal in the human dentition is an observable difference in
the color of the teeth. Some of these variations are apparent only to the trained eye, and others are so obvious that they are a cause of great concern to the parents and/or children. Questions about the color of
teeth can be the first signal of an underlying problem with the dentition or of systemic disease or an inherited syndrome.
Other causes of intrinsic tooth discoloration:
Children with cystic fibrosis have teeth that are dark in color, ranging from yellowish-gray to dark
brown. This may be related to the usual high doses of tetracycline given to children with cystic fibrosis.
Erythroblastosis fetalis is characterized by an excessive destruction of erythrocytes. The primary teeth
may have a characteristic blue-green color.
Tetracycline therapy can cause the crowns of teeth to become discolored, ranging from yellow to
brown and from gray to black. The drug will stain permanent teeth that have not completed enamel formation at the time the drug is given. For example: If a 5-year-old child receives tetracycline therapy,
the teeth affected will be the canines, premolars, and second molars. Important: The incisors and first
molars have already completed enamel formation.
Amelogenesis imperfecta: teeth vary in color from white opaque to yellow to brown.
Dentinogenesis imperfecta: opalescent teeth.
Dental fluorosis: yellow to brown pigmentation.
Hyperbilirubinemia: jaundice-like yellow-green tint on the tooth surfaces.
dis & cond

In baby bottle decay, the teeth typically are decayed in a specific order.
Place the teeth in the correct order.
maxillary posterior teeth

mandibular posterior teeth
maxillary anterior teeth
mandibular anterior teeth
26
PEDIATRIC DENTISTRY
maxillary anterior teeth, maxillary posterior teeth, mandibular

posterior teeth, mandibular anterior teeth
Inappropriate feeding of children can lead to typical nursing pattern decay. The teeth typically are decayed in
the following order: maxillary anterior teeth, maxillary posterior teeth, mandibular posterior teeth, and
mandibular anterior teeth. The mandibular incisors are in general less affected since the tongue covers them.
Note: Nursing bottle caries is also called baby bottle tooth decay (BBTD), bottle mouth syndrome, early childhood caries (ECC), nursing caries, bottle caries, and infant caries. Nursing-bottle caries is a rampant decay
that results from sleep time bottle-feeding combined with the activity of Streptococcus mutans. The stagnation
of milk about the necks of anterior teeth and the fermentation of the disaccharide lactose, a sugar found in
milk, contribute to this caries process as well.
Note: ECC definition by the American Academy of Pediatric Dentistry: the presence of more than one decayed
(noncavitated or cavited), missing (due to decay), or filled tooth surface in any primary tooth in a child 72
months (6 years) or younger.

Severe ECC:
Younger than 3 years: any sign of smooth surface decay
Ages 3-5: one or more cavitated, missing (due to decay) or filled smooth surface in primary anterior teeth,
or, a decayed, missing, or filled surface (dmfs) score of greater than 4 (age 3), greater than 5 (age 4), or
greater than 6 (age 5).
Preventive measures include:
Infants should not be put to sleep with a bottle containing a liquid other than water
Infants should be encouraged to drink from a cup prior to their first birthday
Infants should be weaned from the bottle at 12-14 months of age
Infants should start to supplement their diet with nonliquids at 4-6 months of age
Juices should only be offered from a cup
Oral hygiene should be started with eruption of the first primary tooth
Within 6 months of eruption of the first tooth (no later than the first birthday), it is time for the first den-
tal visit
Remember: Natal teeth are teeth that are already present at the time of birth. They are different from neona-
tal teeth, which grow in during the first 30 days after birth. Most develop in the mandibular incisor area. Frequently, natal teeth are removed shortly after birth while the newborn infant is still in the hospital, especially
if the tooth is loose and the child runs a risk of aspiration, or "breathing in" the tooth.
dis & cond

All of the following statements concerning recurrent aphthous ulcers
(canker sores) are true EXCEPT one. Which one is the EXCEPTION?
they occur in women more than men

they may occur at any age, but usually first appear between the ages of 10 and 40
years
the cause is a Coxsackie virus
they appear to be associated with stress
they usually appear on nonkeratinized oral mucosa, including the inner surface of the
cheeks and lips, tongue, soft palate, and the base of the gingiva
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PEDIATRIC DENTISTRY
the cause is a Coxsackie virus

*** This is false; the cause is unknown, however evidence supports they are related to the focal
immune dysfunction where T lymphocytes play a major role.
These lesions appear as painful white or yellow ulcers surrounded by a bright red area. Lay persons
refer to aphthous ulcers as "canker sores". They can be triggered by stress, dietary deficiencies
(especially iron, folic acid, or vitamin B12), menstrual periods, hormonal changes, food allergies,
and similar situations.
They usually begin with a tingling or burning sensation, followed by a red spot or bump that ulcerates. Pain spontaneously decreases in 7 to 10 days, with complete healing in 1 to 3 weeks.
Important: Recurrent aphthous ulcers and lesions of intraoral herpes are distinguished largely on
their location. Recurrent aphthous ulcers occur primarily on mobile (unattached) mucosa while
lesions of intraoral herpes occur on tissue bound (attached) to periosteum.
Three Classifications:
1. Recurrent aphthous minor (<1 cm) are common, usually resolve in 7-10 days
2. Recurrent aphthous major (>1 cm) are much less common, last over 2 weeks and heal with
scarring
3. Recurrent herpetiform: multiple, small, diffuse, painful, superficial ulcers
*** Patients with frequent recurrences should be screened for diabetes mellitus or Behcet syndrome.
Topical steroids have been suggested for the relief of symptoms as follows:
Rx: Triamcinolone acetonide (Kenalog in Orabase)
Disp: 5 g tube
Sig: Dry lesion. Coat lesion with a thin film after each meal and at bedtime
Mechanism: Decreases inflammation.
Side effects: Do not use on fungal ulcerations. Do not use for diabetics
*If significant improvement has not occurred in 7 days, discontinue treatment and reassess the
diagnosis.
dis & cond

Cretinism is a deficiency disease caused by the congenital absence of:
insulin
thyroxine
calcitonin
epinephrine
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PEDIATRIC DENTISTRY
thyroxine
*** Thyroxine is a hormone secreted by the thyroid gland.
Cretinism is severe hypothyroidism in a child and is characterized by defective mental and
physical development. Cretins have dwarfed bodies, with curvature of the spine and a
pendulous abdomen. Their limbs are distorted, their features are coarse, and their hair is
harsh and scanty. Severe mental retardation is caused by the improper development of
the CNS. Note: If this condition is recognized early, it can be markedly improved with the
use of thyroid hormones.
Dental findings in a child with cretinism (hypothyroidism) include an underdeveloped
mandible with an overdeveloped maxilla, enlarged tongue which may lead to malocclusion, delayed eruption of teeth, and deciduous teeth being retained longer. An anterior
open bite is common, and flaring of the anterior teeth often occurs. This may be related
to the abnormal size of the tongue.
Additional intraoral findings include thickened lips due to glycosaminoglycan deposits,
unerupted yet fully developed permanent dentition.
Remember: Severe hypothyroidism in adults is called myxedema.
dis & cond

In children with cystic fibrosis, halitosis is common.
In children with cystic fibrosis, both dental development and eruption
are delayed.

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PEDIATRIC DENTISTRY
Cystic fibrosis (CF) is an autosomal recessive condition. The gene responsible is on the long
arm of chromosome 7. It occurs predominantly in individuals of Caucasian origin. The disease
is progressive and finally fatal, mostly as a consequence of pulmonary complications and cor
pulmonale.
The glands most affected are those in the pancreas, the respiratory system, and sweat glands.
CF is usually recognized in infancy or early childhood. Early signs are a chronic cough; frequent, foul-smelling stools (steatorrhea); and persistent upper respiratory infections. The most
reliable diagnostic tool is the sweat test, which shows elevations of both sodium and chloride. Note: In CF cells, salt does not move properly because the protein product of the CF gene
is defective and makes a faulty channel for the chloride to exit.
Oral findings:
Nasal polyps and recurrent sinusitis are common
Most patients have a high salivary sodium concentration
The major salivary glands may become enlarged, with associated xerostomia
Halitosis is common
The lower lip may become dry, enlarged, and everted
Enamel hypoplasia may be seen
Both dental development and eruption are delayed
Tetracycline staining of the teeth was common, but should rarely be seen now
Pancreatic enzymes may cause oral ulceration if held in the mouth
Dental management for CF patients:
Short appointments are recommended
Early morning appointments are not recommended
Patients with CF are best treated in the upright position
Avoid general anesthesia
dis & cond

"Koplik spots" are associated with:
smallpox
(variola)
german measles
(rubella)
mumps
measles (rubeola)
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PEDIATRIC DENTISTRY
measles
(rubeola)
*** Before immunization, measles was very common during childhood so that 90% of the
population had been infected by age 20.
Measles (also called rubeola) is a highly contagious viral illness characterized by a fever,
cough, and a spreading rash. It is caused by a paramyxovirus. The incubation period is
1 to 2 weeks before symptoms generally appear. The oral lesions are pathognomonic of
this disease. These characteristic "Koplik spots" usually occur on the buccal mucosa.
They are 1-2 mm, yellow-white necrotic ulcers that are surrounded by a bright red margin.
Rubella (or German measles) is a fairly benign viral disease. The symptoms usually include a red, bumpy rash, swollen lymph nodes (most often around the ears and neck),
and a mild fever. Some people will feel a little achy. The virus can manifest in the oral cavity as small petechiae-like spots of the soft palate. The defects of congenital infection
from an infected mother are more severe enamel defects, hypoplasia, pitting, and abnormal tooth morphology.
Smallpox (variola) is an acute viral disease, it manifests itself clinically by the occurrence of a high fever, nausea, vomiting, chills, and headache. The skin lesions begin as
small macules and papules that first appear on the face, but they rapidly spread to cover
much of the body. Oral manifestations include ulceration of the oral mucosa and pharynx. In some cases, the tongue is swollen and painful, making swallowing difficult.
Mumps is an acute contagious viral infection characterized chiefly by unilateral or bilateral swelling of the salivary glands, usually the parotid glands(parotitis). Although it is
usually a disease of childhood, mumps may also affect adults. The papilla of the opening
of the parotid duct on the buccal mucosa is often puffy and reddened.
dis & cond

The principal characteristics of attention-deficit/hyperactivity disorder are all
of the following EXCEPT one. Which one is the EXCEPTION?
inattention
mental retardation
hyperactivity
impulsivity
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PEDIATRIC DENTISTRY
mental retardation
Attention deficit/hyperactivity disorder (A DHD) is a condition that becomes apparent in
some children in the preschool and early school years (between the ages of 3 and 5 but varies
widely). It is hard for these children to control their behavior and/or pay attention. It is estimated that between 3 and 5 percent of children have ADHD, or approximately 2 million children in the United States. This means that, in a classroom of 25 to 30 children, it is likely that
at least one will have ADHD.
The cause is unknown. The disorder is 10 times more common in males than females. Typically affected children, whether intellectually disabled or not, perform poorly in school because
of the inability to attend to tasks at hand or to sit still during the school day. Note: If there are
any questions concerning the ability of the child to handle dental treatment, contact the childs'
physician. In most cases, the child doesn't need any special treatment.
Common Medications used to treat ADHD: The medications that seem to be the most ef-
fective are a class of drugs known as stimulants.

Ritalin (methylphenidate)
Concerta (methylphenidate extended release)
Adderall (amphetamine and dextroamphetamine)
Among the more serious adverse reactions of these medications are nervousness, insomnia, and
anorexia.
drugs
Which of the following is the most common cause of endocarditis following a
dental procedure?
escherichia coil
viridans streptococci
staphylococci
bacteroides
32
PEDIATRIC DENTISTRY
viridans streptococci alpha-hemolytic streptococci

Child Prophylactic Regimens for Dental and Oral Procedures
Situation
Agent
Dosing Regimen: Single Dose 30-60 min Before

Procedure
Oral prophylaxis
Penicillin allergy
Amoxicillin
50 mg/kg (max 2 g)
Clindamycin
20 mg/kg (max 600 mg)
OR
Cephalexin or cefadroxil 50 mg/kg (max 2 g)

OR
Azithrotnycin or
Clarithromycin
15 mg/kg (max 500 mg)
Remember: 1 lb = 0.453 kg
Endocarditis prophylaxis recommended: dental procedures known to induce gingival
or mucosa] bleeding, including professional cleaning.
Endocarditis prophylaxis not recommended: dental procedures not likely to induce
gingival bleeding, such as simple adjustment of orthodontic appliances or fillings above
the gingival margin, injection of local anesthetic (except for intraligamentary injections),
and exfoliation of primary teeth.
Important: Because of the diversity of circumstances with each patient, it is recommended that the clinician consult with the patient's physician if the complete medical
status of the patient is not fully known or there is any doubt.
drugs
Which of the following is the most frequently utilized route of administration
for sedation in pediatric patients?
oral
inhalation
IV
IM
33
PEDIATRIC DENTISTRY
inhalation the agent used most frequently is nitrous oxide

Nitrous oxide is a slightly sweet smelling, colorless, inert gas. The end point in terms of maximal concentration of
nitrous oxide usually should not exceed 50% for children. Most children seem comfortable and demonstrate optimal
signs of sedation in the concentration range of 35% to 50% nitrous oxide. Nitrous oxide is quickly absorbed from the
lungs and is physically dissolved in the blood. There is no biotransformation, and the gas is rapidly excreted by the
lungs when the concentration gradient is reversed. It is recommended that the patient be maintained on 100% oxygen for 3 to 5 minutes after the sedation period.
Nitrous oxide basically creates an altered state of awareness with impaired motor function. It is a central nervous
system depressant. It produces little analgesia. The combined volume of gases being delivered (oxygen and nitrous)
should be at least 3 to 5 liters/minute. The operator should encourage the patient to breathe through the nose with
the mouth closed.
Local Anesthesia for children: An important factor is maximum dosage.
Determine the patient's weight in pounds and convert to kilograms by dividing by 2.2 (2.2 lb = 1.0 kg)
- for example, 66-lb child / 2.2 lbs/kg = 30 kg
Multiply weight in kilograms by the maximum recommended dose of local anesthetic to obtain the maximum
milligram dosage.
- for example, 30 kg x 4.4 mg/kg lidocaine = 132 mg
Calculate the number of milligrams per cartridge of anesthetic by multiplying the percent of local anesthetic
times 10, then multiply this by the size of the cartridge, typically 1.8 ml.
- for example, 2% x 10 x 1.8 mL = 36 mg/cartridge
Divide the maximum milligram dosage by the number of milligrams per cartridge to obtain the maximum allowable cartridges of anesthetic.
- for example, 132 mg maximum dose / 36 mg/cartridge 3.66 cartridges
Important: The maximum recommended dose of local anesthetic with/without vasoconstrictors, whether it be lidocaine or mepivacaine, is 4.4 mg/kg, and the absolute maximum dosage is 300 mg.
Notes'
1. For restorative dentistry, nitrous oxide is usually all you need to treat a child who is fearful of the
dentist (along with local anesthesia).
2. The feeling of floating or giddiness with tingling of the digits is the proper response to nitrous oxide.
3. Nitrous oxide is stored as a liquid under pressure. It is not flammable but will support combustion.
4. Nitrous oxide is much less soluble in blood than alveolar air, thus allowing for rapid changes in alveolar gas concentration.
drugs
alone or in combination with other drugs, is the most common
sedative agent used in pediatric dentistry.
pentobarbital
secobarbital
paraldehyde
chloral hydrate
34
copyright i0 2013-2014 - Dental Decks
PEDIATRIC DENTISTRY
chloral hydrate
Chloral hydrate acts on the CNS to induce sleep. At normal doses, the sleep induction
does not affect breathing, blood pressure, or reflexes. It may be used before some surgeries or procedures to help relieve anxiety and to induce sleep. When used in combination with analgesics, it can help manage pain after surgery. It has an onset of action of 15
to 30 minutes when given by mouth. Important: Children often enter a period of excitement and irritability before becoming sedated. As with barbiturates, pain may cause paradoxical reactions.
Chloral hydrate is bitter tasting, which can produce management problems during administration. A final disadvantage is that chloral hydrate can induce nausea and vomiting
secondary to gastric irritability.
Three primary groups of drugs are used for sedation in pediatric dentistry: the sedativehypnotics, the antianxiety agents, and the narcotic analgesics.
The short acting barbiturates secobarbital (Seconal) and pentobarbital (Nembutal) are
sedative drugs. They are sometimes considered for pediatric conscious sedation by oral
administration. They are of very limited value. They are nonanalgesic. They may cause
hyperexcitability rather than sedation in some children.
Note: Chloral hydrate and the barbiturates are classified as sedative-hypnotics whose
principal effect is sedation or sleepiness.
fluoride
A 15-year-old female has lived in a nonfluoridated area all of her life. Which
of the following is most likely to occur in this young lady when she moves
to a community where the drinking water naturally contains 6 ppm of fluoride?
50% reduction in dental caries

moderate dental fluorosis
an increase in the amount of fluoride stored in her bones
gastrointestinal problems
35
PEDIATRIC DENTISTRY
an increase in the amount of fluoride stored in her bones

Moderate fluorosis will not occur since, by age 15, all of her dentition has undergone complete enamel calcification (with the possible exception of the third molars).
A 50% reduction in dental caries is not probable for the reason listed above as well.
1. Water fluoridation is one of history's most effective public health stories. It is perhaps the
Notes- most successful public health measure in history.
2. It is effective, safe, inexpensive, and nondiscriminatory. It is the classic public health measure that works. Surveys have shown that community water fluoridation results in a reduction
in decay of about 40 to 50% in the primary dentition and about 50 to 60% in the permanent dentition.
3. Of the 50 largest cities in the United States, 43 have community water fluoridation. Fluoridation reaches 62% of the population through public water supplies, more than 144 million
people.
4. Water fluoridation and diet supplementation may affect tooth morphology, while self-applied
and professionally applied topical treatments will not.
5. The types of fluoride added to different water systems include fluorosilicic acid, sodium
fluorosilicate, and sodium fluoride.
6. Up to a level of 1 ppm fluoride, there is an inverse relation between dental decay and fluoride concentration. As fluoride concentration increases beyond 1 ppm, there is an increased
prevalence of fluorosis and no increase in the reduction of dental decay.
Pit and fissure sealants

Indications:(1) deep, retentive pits and fissures; (2) stained pits and fissures with minimal appearance of
decalcification or opacification; (3) no radiographic or clinical evidence of interproximal caries in need of
restoration on teeth to be sealed
Contraindications: (1) rampant caries; (2) interproximal caries; (3) well-coalesced grooves; (4) inability to maintain a dry field
Technique: (1) clean teeth; (2) isolate teeth with cotton rolls or rubber dam; (3) acid etch tooth surfaces
apply 35% to 40% phosphoric acid for 15 to 60 seconds (time varies for primary or permanent), rinse
for 30 seconds, dry with compressed air for 15 seconds, apply sealant, check occlusion
Resin-based sealants are most common and have superior retention as compared to glass ionomer-based
sealants. The tag formation in the enamel is about 40 pm
Any saliva contamination following isolation requires repeating the whole procedure
fluoride
Fluoridation has several mechanisms for caries inhibition.
Included are enhancement of remineralization of enamel, inhibition of
glycolysis, and the incorporation of fluoride into the enamel hydroxyapatite
crystal.

36
PEDIATRIC DENTISTRY
Fluorides exert their anticaries effect by three different mechanisms:

1.The presence of fluoride ion greatly enhances the precipitation into tooth structure of fluorapatite from calcium and phosphate ions present in saliva. This insoluble precipitate replaces the soluble salts containing manganese and carbonate, which were lost due to
bacterial-mediated demineralization. This exchange process results in the enamel becoming more acid resistant.
2. Incipient, noncavitated, carious lesions are remineralized by the same process.
3. Fluoride has antimicrobial activity. In low concentrations, fluoride ion inhibits the enzymatic production of glucosyltransferase. Glucosyltransferase prevents glucose from
forming extracellular polysaccharides, and this reduces bacterial adhesion and slows ecological succession. Intracellular polysaccharide formation is also inhibited, preventing storage of carbohydrates by limiting microbial metabolism between the host's meals. Thus, the
duration of caries attack is limited to periods during and immediately after eating.
Important: Fluoride mouth rinses have been shown to have the greatest effect on newly
erupted teeth, making it essential to have rinsing continued into the teen years to protect both
the second and third permanent molars. It seems that fluoride rinses are most beneficial to
smooth tooth surfaces, although there are some benefits to pits and fissures as well.
1. Fluorine, from which fluoride is derived, is the 13th most abundant element and
I
"Notes is released into the environment naturally in both water and air.
2. Fluoride is naturally present in all water. Community water fluoridation is the addition of fluoride to adjust the natural fluoride concentration of a community's water
supply to the level recommended for optimal dental health, approximately 1.0 ppm
(parts per million). For warmer or colder climates, the amount can be adjusted from
0.7 to 1.2 ppm.
fluoride
Which of the following fluoride therapies should be recommended to a
13-year-old child who is prone to decay and lives in a community where the
water is fluoridated at an appropriate level?
professionally applied fluoride every 6 months

fluoride toothpaste
dietary fluoride supplements
a low concentration fluoride mouth rinse
a high concentration fluoride mouth rinse
37
PEDIATRIC DENTISTRY
professionally applied fluoride every 6 months

fluoride toothpaste
a low concentration fluoride mouth rinse
*** Fluoride supplements would be contraindicated since the community water is fluoridated at
an appropriate level. Remember: "Rules of 6s" if fluoride level is greater than 0.6 ppm, if patient is less than 6 months old, and if patient is older than 16, no supplemental systemic fluoride
is indicated.
Supplemental fluoride should be administered only from the age of 6 months, and only if the following conditions prevail:
The concentration of fluoride in drinking water is less than 0.3 ppm
The child does not brush his or her teeth (or have them brushed by a parent or guardian) at
least twice a day; and if, in the judgment of a dentist or other health professional, the child is susceptible to high caries activity (family history, caries trends and patterns in communities or geographic areas)
Supplemental fluoride should be given in preparations that maximize the topical effect, such
as mouthwashes.The most common fluoride compound used in mouth rinse is sodium fluoride
(0.05% sodium fluoride).
Toothpaste is available with or without fluoride. Toothpaste tubes containing fluoride are now labeled and contain approximately 0.1% fluoride. Some tubes suggest covering the bristles with
toothpaste. A 'pea-sized' portion weighs approximately 0.75 g and contains about 0.4 mg of fluoride; a 'full cover' portion weighs approximately 2.25 g and contains about 1.0 mg of fluoride.
Thus, brushing twice a day would deliver 0.8 to 2.0 mg of fluoride, depending on which regimen
is used. If swallowed, the amount of fluoride could be excessive and could contribute to the development of fluorosis. Important: Children should use only a 'pea-sized' amount of toothpaste,
and be encouraged not to swallow the excess.
Note: The most common forms of fluoride found in toothpastes are sodium fluoride and sodium
monofluorophosphate. Amine fluoride and stannous fluoride are less common.
fluoride
All of the acidulated phosphate fluoride products should be applied for
in order to achieve the best results.
1 minute
2 minutes
3 minutes
4 minutes
38
PEDIATRIC DENTISTRY
minutes
Professionally applied topical fluoride agents are applied in the dental office or in other settings by health care providers. Currently there are four types of topical fluoride agents that are
used on the teeth by health care providers.
Acidulated phosphate fluoride (A PF) - in gel, foam, or solution form
2% neutral sodium fluoride - in gel, foam, or solution form
8% stannous fluoride - in powder form supplied in bulk containers or powder preweighted
capsule form; mixed with water immediately before use
Fluoride-containing varnishes
Each agent has advantages and disadvantages and all are used in various settings. Several of
the professionally applied topical agents carry the ADA Seal of Acceptance. All the agents are
effective and can be used in different situations to meet the range of requirements for topical
fluoride agents in pediatric practice.
Note: Acidulated phosphate fluoride (A PF) is the most popular topical fluoride used in pediatric offices.
Important: APF solutions and stannous fluoride (SNF2) should not be used on patients with
porcelain, glass ionomer, and composite restorations. They have been shown to remove the
glaze from the surface of these restorations. Neutral sodium fluoride (NaF) is best to use if
these restorations are present. Also, APF should be avoided on implant patients, it may corrode the surface of titanium implants.
Topical fluoride (along with occlusal sealants) is the primary preventive agent during adolescence (past the age of 12) because the entire dentition except for the third molars normally
erupts by age 13. Therefore, fluoride tablets may not be as beneficial.
Remember: Caries activity is directly proportional to the consistency of fermentable carbohydrates ingested, the frequency of ingesting fermentable carbohydrates, and the oral retention of fermentable carbohydrates ingested.
fluoride
Before fluoride applications:
vaseline is applied to protect any teeth with sealants

the teeth should be dry to prevent dilution of the fluoride concentration
all bacterial plaque must be removed to prevent interference with fluoride uptake by
the enamel surface
patients should be placed in a semi-supine position
39
PEDIATRIC DENTISTRY
the teeth should be dry to prevent dilution of the fluoride concentration

It is best to thoroughly dry the teeth before applying the fluoride to maximize the effectiveness of the fluoride application and prevent dilution of the agent. The teeth can be dried with compressed air or cotton
rolls.
Professionally Applied Topical Fluorides
Agent
Form
Concentration
Mode of Application
Special Notes
Sodium fluoride
(NaF)
pH = 9.2
Solution
2%
9,040 ppm
0.90% F ion
Paint on
Cotton roll isolation absorbs

excess solution
Gel
2%
9,040 ppm
0.90% F ion
Paint on or tray
Take care not to overfill tray

Request patient not to swallow
Foam
2%
9,040 ppm
0.90% F ion
Tray
Less amount needed to fill tray

Less risk of swallowing because
of consistency
Vamish
5%
22,600 ppm
2.3% F ion
Paint on
Sets promptly
Solution
1.23%
12,300 ppm
Paint on
Cotton roll isolation absorbs

excess solution
Avoid ceramic and composite
resin restorations
Gel
1.23%
12,300 ppm
Paint on or tray
Take care not to overfill tray

resin restorations
Foam
1.23%
12,300 ppm
Tray
Smaller amount needed to fill

tray; less F
resin restorations
Acidulated
phosphate
fluoride
(APF)
pH= 3.0 to 3.5
Note: The effectiveness of a professionally administered APF gel treatment in preventing caries does not
appear to be influenced by prior prophylaxis.
fluoride
You examine a 10-year-old boy in your practice and determine that he has
multiple carious lesions. The family resides in a rural area and drinks well
water. What is your advice regarding fluoride supplementation?
prescribe fluoride tablets for the patient immediately

arrange for a sample of the patient's well water to be sent to a laboratory to assess the
amount of naturally occurring fluoride in the water. Then prescribe the appropriate
dose of fluoride supplementation in lieu of the fluoride that is occurring in the water,
if any.
the child is too old for fluoride supplementation to be of benefit, so you do
not recommend it
none of the above
40
PEDIATRIC DENTISTRY
arrange for a sample of the patient's well water to be sent to a laboratory

to assess the amount of naturally occurring fluoride in the water.
Then prescribe the appropriate dose of fluoride supplementation in
lieu of the fluoride that is occurring in the water, if any.
Children who are not receiving fluoride in their water should receive dietary fluoride supplements. However, you want to avoid having the children receive too much fluoride, so you
should make sure their water is tested for any naturally occurring fluoride content if you have
any doubts about the amount of fluoride already in the water. You want to avoid fluorosis.
Fluoride supplementation is generally recommended at least until age 16 years.
Note: Fluoride is particularly efficacious as long as teeth are still forming.
Note: Sodium fluoride is approximately twice the weight of fluoride. So 1.1 mg of NaF delivers approximately 0.5 mg of fluoride.
Dietary Flouride Supplementation Schedule
Age of Child
< 0.3 ppm F
0.3 0.6 ppm F
> 0.6 ppm F
Birth 6 months
6 months 3 years
0.25 mg
3 6 years
0.50 mg
0.25 mg
6 years up to at least 16 years
1.00 mg
0.50 mg
Important: Prenatal fluoride supplements are not approved by the FDA and are not recommended. Recent data suggest that the placenta is not an effective barrier to the passage of fluoride to the fetus. No studies to date support the administration of prenatal fluorides to protect
the primary dentition against caries.
fluoride
Clinical studies demonstrate that acidulated phosphate fluoride is most effective
at what pH?
1.0
2.5
3.2
5.5
41
PEDIATRIC DENTISTRY
3.2
The APF agent is 1.23% fluoride ion, which is over 12,300 ppm. It is acidic, with a pH of 3.2.
Clinical studies demonstrate that it is most effective at that pH.
APF is formulated in solution, foam, and gel preparations. Foams and gels are the most useful, since the material stays in a fluoride delivery tray while in the child's mouth. They are
also easier to apply than a watery solution. All of the APF products should be applied for 4 minutes to achieve the best results. Note: An APF gel has been developed that is advertised as effective with a 1-minute application. However, the 4-minute products have much greater
professional acceptance and, presently, only 4-minute products carry the ADA Seal.
You are going to encounter children who gag and vomit and have problems holding the fluoride trays in their mouths for 4 minutes. All experienced care providers realize that
you are asking for lots of clean-up jobs and some unhappy children with spoiled clothes if
you insist on the 4-minute rule for all applications. Parents also are not pleased with these outcomes. The first fallback position is a 2-minute application, and a 1-minute application would
be next.
Note: Eighty percent of the absorption of fluoride into the enamel occurs during the first 2 minutes of a 4-minute application. Consequently, you should strive for at least a 2-minute application. However, you should terminate the procedure immediately if the patient is showing
signs of beginning to vomit. A 1-minute application will result in some absorption, but not as
much as a 2-minute application and certainly not as much as a 4-minute application. Nevertheless, a 1-minute application is better than nothing.
Important:
Remember:
*** The pH of APF is approximately 3.2 (acidic)
*** The pH of NaF is approximately 9.2 (basic)
*** The pH of SnF2 is approximately 2.1 to 2.3 (acidic)
fluoride
The lethal dose of fluoride for a typical 3-year-old child is approximately:
100 mg
200 mg
350 mg
500 mg
42
PEDIATRIC DENTISTRY
500 mg
The studies and surveys link fluorosis to three factors:
Fluorosis is more common in geographic areas where the endemic levels of fluoride in the
drinking water is higher than 3 ppm
Fluorosis is associated with fluoride supplementation at inappropriately high levels
The use of fluoridated toothpaste has been implicated in fluorosis
In acute fluoride toxicity, the goal is to minimize the amount of fluoride absorbed.
Therefore, syrup of ipecac is administered to induce vomiting. Calcium-binding products, such as milk or milk of magnesia, decrease the acidity of the stomach, forming insoluble complexes with the fluoride and thereby decreasing its absorption. Note: EMS should
be activated (911).
In acute fluoride toxicity, symptoms may appear within 30 minutes of ingestion and
persist for up to 24 hours. Patients may experience some nausea, vomiting, diarrhea,
and abdominal cramping. This may be due to the fact that 90-95% of ingested fluoride
is absorbed through the stomach and small intestines. Fluorides are primarily eliminated from the body by way of the kidneys. However, the fluoride that does remain in
the body is found mostly in skeletal tissue. In acute fluoride poisoning (which is rare), the
most common causes of death are cardiac failure and respiratory paralysis. Fluoride toxicity
shows up in the bones as osteosclerosis.
Important: The lethal dose of fluoride for a typical 3-year-old child is approximately 500 mg
and would be proportionately less for a younger child and smaller child. To avoid the possibility of ingestion of large amounts of fluoride, it is recommended that no more than 120 mg
of supplemental fluoride be prescribed at any one time.
Note: If a 6-year old child were receiving fluoridated water in the amount of 3 ppm,
the result would most likely be fluorosis but not systemic toxicity. On the other hand, if a
child in the same age range (6-7) were receiving 8 ppm of fluoridated water, there would
be a good chance of systemic toxicity and moderate to severe fluorosis occurring.
fluoride
What is the most effective method of reducing the dental caries problem in
the general population?
school water fluoridation

fluoridation of the communal water supply
fluoride rinses at home
frequent dental visits
43
PEDIATRIC DENTISTRY
fluoridation of the communal water supply

The optimal concentration in the communal water supply varies with mean annual temperature. In most states, it is I ppm. Fluoride supplements are recommended if the water
fluoride content is less than 0.7 ppm. Note: 1 ppm = lmg/L
The school water fluoridation optimal concentration is 4.5 times that of city water supplies because of less water consumption at school.
The US Public Health Service (PHS) has, since 1962, recommended that public water
supplies contain between 0.7 and 1.2 milligrams of fluoride per liter of drinking water
(mg/L) to help prevent tooth decay (some natural water sources have fluoride levels within
this range, or even higher).
Fluoridation is now used in the public drinking water supplied to about two-thirds of
Americans. The types of fluoride added to different water systems include fluorosilicic
acid, sodium fluorosilicate, and sodium fluoride.
Other facts concerning fluoride:
It is deposited in calcified tissues (skeletal). It normally accumulates slowly in bones
as a person ages.
Proximal tooth surfaces derive the greatest benefit from fluoridation
It is excreted by the kidney
Dental fluorosis can occur in permanent and deciduous teeth
The U.S. Public Health Department sets the optimal fluoride level at 0.7 to 1.2 ppm
for public water
The cariostatic effect of fluoride is produced during the calcification stage of tooth
development
gen info
The most common congenitally missing primary tooth is the:
primary mandibular canine

primary maxillary lateral incisor
primary maxillary canine
primary mandibular first molar
44
PEDIATRIC DENTISTRY
primary maxillary lateral incisor Note: This is rare

The most common congenitally missing permanent teeth, with the exception of the maxillary and
mandibular third molars, are the mandibular second premolars (3.4%), followed by the maxillary
lateral incisors (2.2%), and the maxillary second premolars.
I. The maxillary lateral incisor is most often atypical in size (peg-shaped, etc.).
'Notes 2. A patient who has permanent central incisors, permanent canines, and primary canines anterior to the premolars most likely has congenitally missing permanent lateral
incisors.
3. There is a strong correlation between a missing primary tooth and missing the permanent/succedaneous tooth.
Heredity is most frequently responsible for the congenital absence of teeth. The roots of the primary tooth will resorb slower than normal without the presence of the permanent tooth. As a general rule, if only one tooth is or a few teeth are missing, the absent tooth will be the most distal tooth
of any given type. If a molar tooth is congenitally missing, it is almost always the third molar. If
an incisor is missing, it is nearly always the lateral. If a premolar is missing, it almost always is the
second rather than the first. Rarely is a canine the only missing tooth.
Important: In the case of a congenitally missing second premolar, you want to hold onto the
primary second molar as long as possible. If it is still present, it may be ankylosed.
Note: Cessation of eruption (tooth is out of occlusion) is most diagnostic of an ankylosed primary
molar.
Remember: Space maintenance is of utmost importance whenever primary or permanent teeth are
congenitally missing or lost prematurely which results in the loss of arch integrity. The loss of
space, arch length, perimeter, or circumference may result. Migration of primary and/or permanent
teeth can occur and the available space may be reduced by an amount sufficient to cause some degree of crowding in the permanent dentition.
Replacement resorption, also known as ankylosis, results after irreversible injury to the periodontal ligament. Ankylosed primary teeth should be extracted if they cause a delay in or ectopic
eruption of a developing permanent tooth.
gen info
A 15-month-old child would normally have all of the following teeth erupted
EXCEPT one. Which one is the EXCEPTION?
primary lateral incisors and canines

primary canines and first molars
primary canines and second molars
primary central and lateral incisors
primary first and second molars
45
PEDIATRIC DENTISTRY
primary canines and second molars
Rule of four: This simplified rule will enable you to determine the number of teeth
present at any given time. It implies the eruption of four teeth every 4 months beginning
with four teeth at age 7 months.
Rule of Four
Specific teeth
Age
(in months)
Number of
teeth erupted
4: mandibular and maxillary central incisors
11
8: mandibular and maxillary central and lateral incisors
15
12
12: mandibular and maxillary central and lateral incisors,

four first molars
19
16

four first molars and four canines
23
20

four first molars, four canines, and four second molars
Example from question on front of card: At age 15 months, 12 teeth are erupted
four centrals, four laterals, and four first molars.
gen info
All of the following are true when comparing the normal child periodontium
to the normal adult periodontium EXCEPT one. Which one is the EXCEPTION?
there is greater blood and lymph supply

the alveolar crest is flatter
the cementum is thicker and more dense than that of the adult
gingival pocket depths are larger
attached gingiva is not as wide
46
PEDIATRIC DENTISTRY
the cementum is thicker and more dense than that of the adult
*** This is false; the cementum is
tends to increase with age.
thinner and less dense
than that of the adult. Cementum
The components of the gingival and periodontal structures are the same in childhood, adolescence, and adulthood. However, the clinical and radiographic images of the gingiva and periodontium of children and adolescents differ from those seen in adults, owing to the significant
changes that take place during growth and development.
More comparisons of the
to the adult periodontium:

so because, in the child, the gingiva is more vasc-
child periodontium
Gingival tissues are more red. This is
ular, thinner, and less keratinized.

Lack of stippling: the connective tissue of the lamina propria is shorter and flatter.
Flabbier tissue: this is due to a decreased density of connective tissue.
Rounded and rolled gingival margins: this is probably due to normal eruption patterns.
The PDL fibers run parallel to the teeth. In adults, the PDLs are more horizontal against
the tooth. The PDL is also wider in the child. This is why you may see mobility in the child's
teeth as well as a decreased resistance to forces. The fiber bundles of the PDL increase with
age.
Alveolar bone has fewer trabeculae, has larger marrow spaces, is less calcified, and has
a thinner lamina dura and wider periodontal membranes.
The width of the attached gingiva: (1) varies and changes along with changes in the sulcus and crevice depth during eruption and shedding (2) increases with age in the primary
dentition(3) is significantly narrower in newly erupted permanent teeth than in their decid
uous predecessors (4) is normally minimal to none in newly erupted permanent teeth.
A labial eruption path is the most common cause of
children.
Note:
inadequate
attached gingiva in
gen info
The permanent mandibular second premolar typically erupts when a child
is about:
5-6 years old

8-9 years old
11-12 years old
13-14 years old
47
PEDIATRIC DENTISTRY
11-12 years old

Chronology of the Human Permanent Dentition
Tooth
Maxillary
Central
incisor
First Es idence of
Calcification
Amount of Enamel
Formed at Birth
Eruption
(Years)
Crown Completed
(Years)
Root
Completed
(Years)
3-4 months
4-5
7-8
10
Lateral
incisor
10-12 months
4-5
8-9
II
Canine
4-5 months
6-7
11-12
13-15
First premolar
1.5-1.75 yrs
5-6
10-11
12-13
Second premolar
2.0-2.25 year
First molar
At birth
Second molar
Third molar
6-7
10-12
12-14
2.5-3.0
6-7
9-10
2.5-3.0 yrs
7-8
12-13
14-16
7-9 yrs
12-16
17-21
18-25
Central
incisor
3-4 months
4-5
6-7
Lateral
incisor
3-4 months
4-5
7-8
10
Canine
4-5 months
6-7
9-10
12-14
First premolar
1.75-2.0 years
5-6
10-12
12-13
Second premolar
2.25-2.5 yrs
6-7
11-12
13-14
First molar
At birth
2.5-3.0
6-7
9-10
Second molar
2.5-3.0 yrs
7-8
11-13
14-15
8-10 yrs
12-16
17-21
18-25
Sometimes a trace
Note: The eruption schedule
for the permanent dentition

was taken from the ADA web
site. Some of the literature
varies slightly with this eruption schedule.
Mandibular
Third molar
Sometimes a trace
The sequence of eruption of the permanent teeth is Mand 1st molar > Max 1st molar > Mand CI -->
Max CI --> Mand LT --> Max LI > Mand Canine > Max 1st PM > Mand 1st PM -3 Max 2nd PM >
Mand 2nd PM > Max Canine > Mand 2nd molar > Max 2nd molar > Mand 3rd molar > Max 3rd
molar
*** As a general guideline, a permanent tooth should erupt when approximately three-fourths of its root
is completed. Apex is fully developed 2 to 3 years after eruption.
gen info
The crowns of all 20 primary teeth begin to calcify between:
1.5 to 2 months in utero

10 to 12 months in utero
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PEDIATRIC DENTISTRY
3.5 to 6 months in utero - (14-24 weeks in utero)

*** On the average, they take 10 months for completion of calcification.
Chronology of the Human Primary Dentition
Tooth
Maxillary
Central
incisor
First Evidence of
Calcification
(Weeks in Utero)
Crown Completed
(Months After
Birth)
Eruption
(Months)
Root
Completed
(Years)
11 (13-16)
8-12
1.5-2.0
Lateral
incisor
16 (14 2/3-16 1/2)
9-13
1.5-2.0
Canine
17 (15-18)
16-22
2.5-3.0
First molar
15 1/2 (14 1/2-17)
13-19
2-2.5
Second molar
19 (16-23 1/2)
10-12
25-33
14 (13-16)
6-10
1.5-2.5
Lateral
incisor
16 (14 2/3-16 1/2)
4.5
10-16
1.5-2.5
Canine
17 (15-18)
17-23
2.5-3.0
First molar
15 1/2 (14 1/2-17)
14-18
2-2.5
Second molar
I8 (17-191/2)_
10-12
23-31
3.0
Mandibular
Central
incisor
Note: The eruption schedule for the primary dentition

was taken from the ADA
web site. Some of the literature varies slightly with this
eruption schedule.
According to Pinkham (*Reference) the primary dentition sequence of eruption is: Mand CI > Mand LI >
LI --> Mand 1st molar > Max 1st molar > Mand Canine > Max Canine > Mand 2nd molar MaxCI>
> Max 2nd molar
1. The largest primary tooth is the mandibular second molar.
2. The mandibular lateral incisor is the smallest primary tooth.
Notes
3. The largest permanent tooth is the maxillary first molar.
4. The mandibular central incisor is the smallest permanent tooth.
gen info
Which teeth are succedaneous teeth?
the permanent maxillary and mandibular premolars

the permanent maxillary and mandibular first molars
the permanent maxillary and mandibular second molars
the permanent maxillary and mandibular third molars
49
PEDIATRIC DENTISTRY
the permanent maxillary and mandibular premolars
A permanent tooth that moves into a position formerly occupied by a primary tooth is
called a succedaneous tooth. In each quadrant, five permanent teeth (the incisors,
canine, and premolars) succeed or take the place of the five primary teeth.
Nonsuccedaneous teeth include:
The permanent maxillary and mandibular first molars
The permanent maxillary and mandibular second molars
The permanent maxillary and mandibular third molars
*** These teeth do not move into a position formerly occupied by a primary tooth
*** These teeth do not succeed deciduous teeth
Note: The last primary tooth to be replaced by a permanent tooth is usually the maxillary canine (the permanent maxillary canine usually erupts between the age of 11-12
years). The permanent mandibular canine usually erupts between the age of 9-10 years.
Remember: Permanent molars do not replace primary teeth (see above).
gen info
All of the following syndromes demonstrate both supernumerary teeth and
hypodontia EXCEPT one. Which one is the EXCEPTION?
crouzon disease
gardner syndrome
down syndrome
hallermann-streiff syndrome
50
PEDIATR IC DENTISTRY
gardner syndrome
Syndromes Manifesting Both
Hyperdontia and Hypodontia
Syndromes Demonstrating
Microdontia
Macrodontia
Crouzon disease
Ectodermal dysplasia (hypohidrotic type)
Facial hemihypertrophy
Down syndrome
Chondroectodermal dysplasia
Otodental syndrome
Oral-facial-digital syndrome I
Hemifacial microsomia
Hallermann-Streiff syndrome
Down syndrome
Conditions Demonstrating Taurodontism
Supernumerary Teeth
Hypodontia
Klinefelter syndrome
Cleidocranial dysplasia
Trichodentoosseus syndrome
Gardner syndrome
Chondroectodermal dysplasia
Down syndrome
Amelogenesis imperfecta, Type IV
Crouzon disease
Sturge-Weber syndrome
Down syndrome
Hallcrmann-Streiff syndrome
Achondroplasia
Rieger syndrome
Incontinentia pigmenti
Seckel syndrome
Hyperdontia- term to describe an excess in tooth number

Hypodontia- or congenital tooth absence, is a deficiency in tooth number
Microdontia- teeth that are smaller than average
Macrodontia- teeth that are larger than average
Supernumerary teeth- term used to describe an excess in tooth number
Taurodontism- teeth that have significantly elongated pulp chambers with short stunted roots
gen info
The deciduous dental formula of man is:
1 1 C 1 B 1 M 2 = 10 x 2 =20
1
1
1
2
2 C-1 M2
I 2 1
2
= 10 x 2= 20
I 2 C-1 M 3
2 1
3
= 12 x 2= 24
I 2 C-B-2 M 3 = 16 x 2=32
2 1 2
3
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PEDIATRIC DENTISTRY
Om
12
21
5 per quadrant = 10 per arch

I2
CIM 2
2 1
2 = 5 per quadrant = 10 per arch
2 = 10x2=20
2
20 total teeth
I = Incisors
C = Canines
M = Molars
Note: There are no premolars (bicuspids) in the deciduous dentition.
gen info
The permanent dental formula of man is:
2 C-1
-3
I1 3
2 BM = 16 x 2 =32
2
I 2 C 1 B 1 M 3 =14 x 2 = 28
1
1
3
1 2 C1B 2 M 3 = 16 x 2 =32
2 12
3
2 C -1 M 3
- = 12 x 2 = 24
1
3
1-
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PEDIATRIC DENTISTRY
2 CBM
-1 -2 =
-3 16 x 2 = 32
I2 1 2 3
ICB 2 M 3 = 8 per quadrant = 16 per arch = 32 total teeth

2 1 2
3 = 8 per quadrant = 16 per arch
I = Incisors
C = Canines
B = Bicuspids
M = Molars
(premolars)
gen info
When do the permanent teeth begin to calcify?
at birth
1 month
4 months
1 year
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PEDIATRIC DENTISTRY
at birth
***The first molars begin to calcify at birth. Tooth buds generally initiated after
birth are the premolars and second and third molars.
Approximate time when calcification begins for the primary and permanent dentitions
Primary Dentition
Tooth
First Evidence of
Calcification
(weeks in utero)
Maxillary
Central incisor
Lateral incisor
Canine
First molar
Second molar
14
16
17
15
19
(13-16)
(14 2/3-16 1/2)
(15-18)
1/2 (14 1/2-17)
(16-23 1/2)
Mandibular
Central incisor
Lateral incisor
Canine
First molar
Second molar
14
16
17
15
18
(13-16)
(14 2/3-16 1/2)
(15-18)
1/2 (14 1/2-17)
(17-19 1/2)
Permanent Dentition
Tooth
First Evidence of
Calcification
Maxillary
Central incisor
Lateral incisor
Canine
First premolar
Second premolar
First molar
Second molar
Third molar
3-4 months
10 months
4-5 months
1.5-1.75 yrs
2-2.25 yrs
At birth
2.5-3.0 yrs
7-9 yrs
Mandibular
Central incisor
Lateral incisor
Canine
First premolar
Second premolar
First molar
Second molar
Third molar
3-4 months
3-4 months
4-5 months
1.75-2.0 yrs
2.25-2.5 yrs
At birth
2.5-3.0 yrs
8-10 yrs
Note: Typically it takes 4 to 5 years for most permanent crowns to complete formation, except for the
first molars (3 years) and canines (6 years). It takes approximately 10 years from the start of calcification to root completion, except for the canines (13 years).
gen info
The primary mandibular canines are usually exfoliated when a child is about:
6-8 years old

7-9 years old
9-12 years old
14-16 years old
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PEDIATRIC DENTISTRY
9-12 years old

Primary teeth are exfoliated by the phenomenon called resorption of the primary root. The permanent
tooth in its follicle attempts to force its way in to the position held by its predecessor. The pressure
brought to bear against the primary root evidently causes resorption of the root, which continues until
the primary crown has lost its anchorage, becomes loose, and is finally exfoliated.
If during a routine exam, you note that a permanent tooth is trying to erupt while the primary tooth is still
firmly in place, the best treatment is to extract the primary tooth and allow the permanent tooth to
erupt.
Chronology of the Human Primary Dentition
Tooth
Maxillary
Central
incisor
Amount of Enamel
Formed at Birth
Crown Completed
(Months After Birth)
Eruption
(Months)
Root
Completed
(Years)
Exfoliation
of tooth
(Years)
Five-sixths
8-12
1.5-2.0
6-7
Lateral
incisor
Two-thirds
9-13
1.5-2.0
7-8
Canine
One third
16-22
2.5-3.0
10-12
First molar
Cusps united
13-19
2.0-2.5
9-11
Second molar
Cusp tips still isolated
10-12
25-33
10-12
Three-fifths
6-10
1.5-2.5
6-7
Lateral
incisor
Three-fifths
4.5
10-16
1.5-2,5
7-8
Canine
One-third
17-23
2.5-3.0
9-12
First molar
Cusps united
14-18
2.0-2.5
9-11
Second molar
Cusp tips still isolated
10-12
23-31
10-12
Mandibular
Central
incisor
gen info
All of the following statements are true EXCEPT one. Which one is the
EXCEPTION?
the primary teeth are lighter in color than the permanent teeth
for primary teeth, the interproximal contacts are broader and flatter than permanent teeth
the pulp cavities are proportionately smaller in the primary teeth
in general, the crowns of primary teeth are more bulbous and constricted than their permanent counterpart
the pulp horns of primary teeth are closer to the surface of the tooth
the crown surfaces of all primary teeth are much smoother than the permanent teeth (in
other words, there is less evidence of pits and grooves)

primary teeth have thinner enamel
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PEDIATRIC DENTISTRY
the pulp cavities are proportionately smaller in the primary teeth

*** This is false; the pulp cavities are proportionately larger in the primary teeth.
More comparisons of primary and permanent teeth:
The crowns of the primary anterior teeth are wider mesiodistally and shorter inciso-cervically
than their permanent counterparts
The crowns of the primary molars are shorter and more narrow mesiodistally at the cervical third
than the permanent molars
The roots of the primary anterior teeth taper more rapidly than do those of the permanent anteriors
The roots of the primary molars are longer and more slender than those of the permanent molars
The enamel rods in the gingival third slope occlusally instead of cervically as in permanent teeth.
The buccal and lingual surfaces of primary molars are flatter above the crest of contour than on permanent molars
Primary molar roots are more divergent (relative to their crown width) compared to their permanent counterparts to allow room for the developing permanent dentition
Whiter
crown
color
Smaller
overall
size
Prominent
cervical
ridge
Narrower
roots
Yellower
crown
color
Larger
overall
size
Root
CEJ
Wider
roots
Extracted teeth showing the differences between the

primary and permanent teeth.
Crown
Primary Maxillary
Central Incisor
Permanent Maxillary
Central Incisor
gen info
The primary maxillary lateral incisor typically erupts when a child is about:
3-6 months old

9-13 months old
13-19 months old
25-33 months old
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PEDIATRIC DENTISTRY
9-13 months old
Primary Dentition
Tooth
Eruption
(Months)
Root
Completed
(Years)
Exfoliation
of tooth
(Years)
6-7
7-8
10-12
9-11
Maxillary
Central incisor
8-12
1.5-2.0
Lateral incisor
Canine
First molar
Second molar
9-13
16-22
13-19
25-33
1.5-2.0
2.5-3.0
2.0-2.5
3
Mandibular
Central incisor
Lateral incisor
Canine
6-10
10-16
17-23
1.5-2.5
1.5-2.5
2.5-3.0
6-7
7-8
9-12
First molar
Second molar
14-18
23-31
2.0-2.5
3
9-11
10-12
10-12
*** Eruption dates are variable (in chart above, eruption dates were taken from A DA web site). Some
infants get them early, others do so late. A 6-month variation in time of eruption is considered normal.
1. When a primary tooth clinically erupts in the mouth, one-half to two-thirds of the root
structure
has usually developed.
/Notes
2. A primary tooth usually takes 1.5 to 2 months from the beginning of clinical eruption until
it reaches the occlusal plane. Canines take the longest to erupt.
3. Calcification of the roots is normally completed by the age of 3 or 4.
4. Calcification of the primary teeth begins in the second trimester of pregnancy.
gen info
The sum of the mesiodistal widths of the primary molars in any one quadrant is:
5-10 mm greater than the permanent teeth that succeed them - premolars
2-5 mm less than the permanent teeth that succeed them - premolars
5-10 mm less than the permanent teeth that succeed them - premolars
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PEDIATRIC DENTISTRY
*** Also, the enamel on the occlusal surfaces of primary molars is of uniform thickness and is approximately 1 mm thick, as opposed to that of permanent molars, which is 2.5 mm thick.
Characteristics of primary molars (as compared to permanent molars):
Crowns are shorter with pronounced buccal and lingual cervical ridges and a constricted
cervical area.
The occlusal table is narrower faciolingually.
Anatomy is shallower (i.e., the cusps are short, the ridges are not as pronounced, and the fossae are not as deep).
A prominent mesial cervical ridge (makes it easy to distinguish rights from lefts).
Roots are longer and more slender than the roots of the permanent molars. The roots are extremely narrow mesiodistally and very broad lingually.
Roots are very divergent and less curved. There is little or no root trunk.
Remember: Leeway space is the size differential between the primary posterior teeth (canine,
first and second molars), and the permanent canine and first and second premolar. Usually the sum
of the primary tooth widths is greater than that of their permanent successors. When these primary
teeth fall out, there is usually a slight amount of space (about 3.1 mm per side in the mandibular
arch and 1.3mm per side in the maxillary arch). This space is often used to help relieve crowding.
If nothing is done to preserve this space, the permanent first molars almost always drift forward to
close it.
Note: Spaces frequently recognized in the primary dentition are the primate spaces. Primate spaces
are the spaces between the mandibular primary canine and the first primary molar, and between the
maxillary primary lateral incisor and the primary canine.
misc.
The most frequently taken radiographic views in pediatric dentistry are:
molar bitewing radiographs

mandibular molar periapical radiographs
mandibular anterior periapical radiographs
maxillary molar periapical radiographs
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PEDIATRIC DENTISTRY
molar bitewing radiographs

Molar bitewing radiographs are the most frequently taken views in pediatric dentistry. They
especially are used to detect interproximal caries between molars. The film is placed in the
bitewing tab, and the patient bites on the tab to secure the film. The cone is positioned 10%
above the horizontal plane and is directed toward the contact areas of the molars. One film is
used on each side in the primary and mixed dentitions. When second permanent molars are
present, two films are necessary on each side. The distal surface of the cuspid should be included in the radiograph and together with all posterior teeth, as well as the distal surface of
the most posterior molar in the mouth. Note: A size 0 film is used with small children. A size
2 film is used as soon as the patient can tolerate the larger film.
A child should have his/her first pediatric visit by their first birthday. Following that, if the
child's teeth are spaced far apart and there is no clinical evidence of decay, bitewings are not
needed until the establishment of contacts on the posterior teeth. At age 6 a child should have
their first panoramic x-ray to get all vital information on developing teeth, roots, and any possible malocclusion. X-rays for growth and development depend on the patient's stage of tooth
eruption. The frequency of radiographs should depend on the child's risk for decay. Situations
that make a child at higher risk for decay include lack of fluoride in the drinking water, high
sugar diet, history of cavities, poor oral hygiene, and many others.
/Notes
c44
--
1. The nice thing about panoramic x-rays is that they are taken without placement
of the film in the mouth so it does not alarm the nervous child.
2. Children are often "entertained" by the panoramic unit.
3. The drawback of a panorex is that there is a loss of image detail (it is hard to
diagnose early carious lesions). Bitewing x-rays are required for the diagnosis
of carious lesions.
misc.
Which of the following is the most common primary tooth to be retained?
maxillary second molars

maxillary first molars
mandibular second molars
mandibular first molars
59
PEDIATRIC DENTISTRY
mandibular first molars see photo below
Primary mandibular first molar

that needs sectioning for
removal.
Over-retained primary teeth in the mixed dentition:

May prevent the normal eruption of the permanent teeth
May be caused by the abnormal root resorption of the primary teeth
Are often treated by extraction
Be careful in extracting these teeth. The succedaneous tooth bud may be in close proximity. This
is especially true when placing the beaks of forceps into bifurcations of primary molars in older children.
Important: The most frequent cause of fracture of root tips in extracting a primary molar is root
resorption between the apex and the bifurcation.
1. If a permanent tooth bud is accidentally extracted while removing a primary molar,
the best treatment is to immediately orient the tooth bud, replant the bud using digital
pressure, and suture.
2. The best way to extract a primary molar that has the permanent tooth bud close to
its roots (as in the photo above) section the tooth and remove the parts individually.
3. After the tooth is removed from the socket, the surgical site should be visually evaluated. However, no attempt should be made to scrape the extraction site due to the potential for damage to the succeeding tooth bud.
misc.
At the age of 6 years, a child's head is what percentage of its adult size?
30%
50%
80%
90%
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PEDIATRIC DENTISTRY
90% - this is typical of all neural tissues in the body
Miscellaneous facts that you may need to know for boards:

At birth, the jaw is large enough to accommodate all primary teeth if they were to
erupt simultaneously.
At birth, the width of the face has reached the greatest percentage of its adult size
(as opposed to height and depth).
At birth, the palate is pretty flat, but in adults, it is vault-shaped (this occurs by deposition of alveolar crestal bone).
At birth, a newborn cannot differentiate between sour, salt, or a bitter taste.
At birth, the cranial vault is very near the size it will eventually attain in adulthood
(as compared to the cranial base, mandible, mid-face, etc.). The brain and the cranial
base are fully developed by age 6 years.
In early life, tonsils function to filter bacteria and program the production of antibodies.
From age 6-12 years, the body's lymph tissue is 200% of its normal adult mass.
Because of this, enlarged tonsils in a 6-year-old are, at age 12, most likely to be
smaller. This is because lymphoid tissue in the nasopharynx decreases at puberty. At
the same time, genital tissue is developing.
Dentists are mandated by law to report suspected child abuse or neglect. Proof of
abuse or neglect is not necessary.
Failure to report suspected child abuse may result in significant legal ramifications for
the dentist, including a fine, jail sentence, and civil liability.
Neglect: Definition from the American Academy of Pediatric Dentistry is the "willful failure of parent or guardian to seek and follow through with treatment necessary to
ensure a level of oral health essential for adequate function and freedom from pain and
infection."
prim dent
The first deciduous (primary) tooth to erupt is the:
mandibular central incisor

mandibular first molar
maxillary central incisor
maxillary first molar
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PEDIATRIC DENTISTRY
mandibular central incisor

Primary Dentition
Permanent Dengtion
Crown Completed
(Years)
Tooth
Maxillary
Central incisor
Lateral incisor
Canine
First premolar
Second premolar
First molar
Second molar
Third molar
Eruption
(Years)
Root
Completed
(Years)
4-5
4-5
6-7
5-6
6-7
2.5-3.0
7-8
12-16
7-8
8-9
I1-12
10-11
10-12
6-7
12-13
17-21
10
11
13-15
12-13
12-14
9-10
14-16
18-25
4-5
4-5
6-7
5-6
6-7
2.5-3.0
7-8
12-16
6-7
7-8
9-10
10-12
11-12
6-7
11-13
17-21
9
10
12-14
12-13
13-14
9-10
14-15
18-25
Mandibular
Central incisor
Lateral incisor
Canine
First premolar
Second premolar
First molar
Second molar
Third molar
Notes
Tooth
Eruption
(Months)
Root
Completed
(Years)
Exfoliation
of tooth
(Years)
Maxillary
Central incisor
Lateral incisor
Canine
First molar
Second molar
8-12
9-13
16-22
13-19
25-33
1.5-2.0
1.5-2.0
2.5-3.0
2.0-2.5
3
6-7
7-8
10-12
9-11
10-12
Mandibular
Central incisor
Lateral incisor
Canine
First molar
Second molar
6-10
10-16
17-23
14-18
23-31
1.5-2.5
1.5-2.5
2.5-3.0
2.0-2.5
3
6-7
7-8
9-12
9-11
10-12
1.The first permanent tooth to erupt is the mandibular first molar, followed
shortly thereafter by the maxillary first molar.
2. The first permanent tooth to begin calcifying is the mandibular first molar
(at birth).
3. The first succedaneous tooth to erupt is the mandibular central incisor.
Remember: The mandibular first molar and the maxillary first molar
neous teeth.
are not
succeda-
prim dent
Ordinarily, a 6-year-old child would have what teeth clinically visible in
the mouth?
all (20) primary teeth and 4 permanent first molars

18 primary teeth and 2 permanent mandibular central incisors
18 primary teeth, 2 permanent mandibular central incisors, and 4 permanent
first molars
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PEDIATRIC DENTISTRY
all (20) primary teeth and 4 permanent first molars ("6 year molars")
Remember:
The permanent mandibular centrals erupt between the ages of 6-7 years
The permanent maxillary centrals erupt between the ages of 7-8 years
Note: A 7-year-old child would have the following teeth present clinically:
18 primary and 6 permanent teeth -- the 6 permanent teeth include:
- Mandibular first molars (2) - right and left
- Maxillary first molars (2) - right and left
- Mandibular central incisors (2) - right and left
*** All of the primary teeth except the two mandibular central incisors (20 - 2 = 18).
prim dent
When attempting a MO Class II amalgam preparation and filling on a primary
tooth, you encounter a very large mesial marginal ridge that resembles a cusp.
You also notice a transverse ridge from mesiolingual to mesiobuccal cusp that
is rather large. This tooth proves difficult to restore, which tooth is it?

maxillary first molar
mandibular second molar
maxillary second molar
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PEDIATRIC DENTISTRY

This transverse ridge separates the mesial portion from the remainder of the occlusal surface.
Other characteristics of the primary mandibular first molar:
It does not resemble any other primary or permanent tooth
The mesiobuccal cusp is always the largest and longest cusp, occupying nearly two-
thirds of the buccal surface

The mesiolingual cusp is larger, longer, and sharper than the distolingual cusp
Crown is wider mesiodistally than high cervico-occlusally
The mesial marginal ridge is very well developed and resembles a cusp
It has a prominent mesiobuccal cervical ridge
Class II cavity preparations are difficult due to morphology
It has no central fossa
Primary Mandibular Right First Molar
Buccal
Lingual
Distal
prim dent
Match the primary molar tooth on the left with the appropriate occlusal picture
on the right.
primary mandibular right first molar

primary mandibular right second molar
primary maxillary right first molar
primary maxillary right second molar
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PEDIATRIC DENTISTRY
Primary
mandibular
right first
molar
Lingual
Meals!
Distal
Lingual
Mesial
Distal
Lingual
Mesial
Distal
Primary
mandibular
right second
molar
Buccal
Primary
maxillary
right first
molar
Primary
maxillary
right second
molar
.
Lingual
prim dent
A neophyte dental student, only about 2 weeks into the program,
gets scared when her 10-year-old cousin gets hit in the face and loses a tooth.
She calls you and says that her cousin lost his permanent mandibular
first molar. Once she tells you more about the root morphology of the tooth,
you realize it is a primary tooth and the child simply lost his:
primary mandibular canine

primary mandibular first molar
primary mandibular second molar
primary maxillary first molar
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PEDIATRIC DENTISTRY
primary mandibular second molar

*** The permanent mandibular first molar has a morphology that closely resembles the primary mandibular second molar. Note: Amalgam prep outlines on these two teeth also resemble one another.
Differences include:
Relative size of the distal cusp. The primary molar has its mesiobuccal, distobuccal, and
distal cusp almost equal in size. The distal cusp of the permanent molar, however, is smaller
than the other two cusps.
From the buccal aspect, the primary mandibular second molar has a narrow mesiodistal dimension at the cervical portion of the crown when compared with the dimension mesiodistally on the crown at the contact level. The mandibular first permanent molar, accordingly,
is wider at the cervical portion.
Groove patterns are different on the occlusal surface.
The primary molar has more divergent roots to allow for the eruption of the second premolar.
The primary molar has a more prominent facial crest of contour.
Permanent mandibular right first molar
Primary mandibular right second molar
1. The primary teeth that present the most noticeable morphologic deviations
from
the permanent teeth are the first molars.
/Notes
2. The primary second molar has the greatest faciolingual diameter of all primary
teeth.
prim dent
Which tooth is the only anterior tooth in either dentition to have a shorter
incisocervical height than the mesiodistal width?
the primary mandibular central incisor

the primary mandibular lateral incisor
the primary maxillary lateral incisor
the primary maxillary central incisor
66
PEDIATRIC DENTISTRY
the primary maxillary central incisor

The primary maxillary central incisor resembles the permanent maxillary central in shape. It is much
smaller in size than the permanent maxillary central and has a more pronounced cervical line. The crown
is the only anterior tooth in either dentition to have a shorter incisocervical height than the mesiodistal
width. This tooth erupts with no mamelons, and the labial surface is convex and smooth.
Primary
Primary
maxillary
maxillary
right lateral
right central
incisor
incisor
The primary maxillary lateral incisor is similar to the central incisor except it is smaller. Another difference is that it is longer than it is wide. The incisal edge of the primary maxillary lateral incisor is more
rounded on the mesial and distal sides than the straight incisal edge of the central incisor.
The primary mandibular central incisor more closely resembles the permanent mandibular lateral incisor than its central incisor counterpart. The crown of the tooth is slightly wider than the permanent lateral incisor. The shape and form of the incisal edge is almost exactly the same as that of the permanent
lateral. The root is slender and rather long. Mesial and distal surfaces of the root are flat, while lingual
and labial surfaces are convex.
Primary
Primary
mandibular
mandibular
right lateral
right central
incisor
incisor
M7; ,
\ D
Incisal
1..811110/
The primary mandibular lateral incisor resembles the primary mandibular central incisor except that
it is slightly longer and wider. The cingulum and the mesial and distal marginal ridges are more pronounced and the fossa is not as shallow. The root curves toward the distal at the apex.
prim dent
Morphologically, the primary maxillary second molar strikingly resembles the:
permanent maxillary third molar

permanent maxillary second molar
permanent maxillary first molar
permanent mandibular second molar
67
PEDIATRIC DENTISTRY
permanent maxillary first molar - but they are smaller

In general, the primary second molars are larger than the primary first molars and resemble the
form of the permanent first molars.
Other characteristics of the primary maxillary second molar:
The faciolingual measurement of the crown is greater than the mesiodistal measurement
May have a fifth cusp (of Carabelli)
Has a prominent mesiobuccal cervical ridge
Has an oblique ridge
MB cusp is almost equal in size or slightly larger than the ML cusp
The largest and longest pulp horn is the MB
Primary Maxillary Right Second Molar
Permanent Maxillary Right First Molar
prim dent
A 10-1 /2-year-old patient comes into your office. You are not sure whether his
maxillary canines are permanent or primary. Which of the following statements
will help you determine whether they are permanent or primary canines?
the cusp of the primary maxillary canine is much shorter than the cusp of
the permanent maxillary canine
the mesial cusp ridge on the primary maxillary canine is shorter than the distal cusp
ridge; this is opposite of all other canines
the cusp on the primary maxillary canine is much longer and sharper than the cusp
on the permanent maxillary canine
the primary maxillary canine is much narrower and longer than the permanent
maxillary canine
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PEDIATRIC DENTISTRY
the cusp on the primary maxillary canine is much longer and

sharper than the cusp on the permanent maxillary canine
The most significant differences between the primary maxillary canine and the permanent
maxillary canines are:
1. The cusp on the primary canine is much longer and sharper.
2. The mesial cusp ridge is longer than the distal cusp ridge (this is opposite of all other canines).
*** Obviously they differ in other ways, but these two differences are the most significant.
Note: The primary maxillary canine also appears especially wide and short.
The Primary Maxillary Right Canine
Labial
Distal
Lingual
The Primary Mandibular Right Canine
M
Incisal
prim dent
The occlusal form of the
varies from that of any tooth in

theprmandio.
the primary mandibular first molar

the primary maxillary first molar
the primary mandibular second molar
the primary maxillary second molar
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PEDIATRIC DENTISTRY
the primary maxillary first molar

Characteristics of the primary maxillary first molar:
In all dimensions except labiolingual diameter, it is the smallest molar. Basically the
crown of this tooth is bicuspid (two cusped)
There are two main cusps: a wide mesiobuccal and a narrow mesiolingual. Indistinct
cusps are the distobuccal and distolingual
The MB cusp is always the longest. The ML cusp is the second longest, but sharpest
The cervical line is higher mesially than distally
The cervical ridge stands out very distinctly on the mesiobuccal portion of this tooth
The occlusal pit-groove pattern is most frequently H-shaped
The number of roots (3) and the form of the roots closely resembles the permanent maxillary first molar
On the crown, the mesial surface normally is larger than the distal surface
The Primary Maxillary Right First Molar
Buccal
Lingual
Mesial
pulp tx
An 11-year-old child traumatized a permanent maxillary central incisor some
time ago. The tooth has never been restored. It is now painful and there is
evidence of swelling. A periapical x-ray discloses a pathosis associated with
the apex. The suggested treatment is:
pulpotomy
extraction
pulpectomy
observation
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PEDIATRIC DENTISTRY
pulpectomy - root canal therapy

This is treated the same way as you would treat the adult patient. At age 11 the root of a maxillary central incisor should be completely formed, therefore an apexification procedure is not indicated. If the
root were not fully formed, then an apexification process should be started. This involves the placement of calcium hydroxide pastes into the canal to stimulate continued apical closure.
The fact that the tooth is painful and there is swelling is a contraindication to a pulpotomy. You need
healthy pulp tissue in the root for success of a pulpotomy. If the tooth were nonrestorable, then a pulpectomy procedure would be contraindicated and the only alternative would be to extract the tooth.
Treatment of Vital Teeth
Mature OR Immature Teeth
1- Indirect pulp capping
2- Direct pulp capping
3- Partial or Cervical Pulpotomy
Immature Teeth (root not completely formed)
1- Apexogenesis- (can be regarded as a very deep pulpotomy)
Treatment of Nonvital Teeth
Mature Teeth
1- Root Canal Therapy
Immature Teeth (root not completely formed)
1- Apexification
Note: Apexogenesis is a vital pulp therapy procedure performed to encourage continued physiological
development and formation of the root end. This term is frequently used to describe vital pulp therapy
performed to encourage the continuation of this process. MTA (Mineral Trioxide A ggregate) is frequently used for this procedure.
Important: The best sign for success of apexogenesis is continuous completion of apex.
Note: Pulp therapy is generally contraindicated in children who have serious illnesses (i.e., leukemia,
cancer patients, etc.).
pulp tx
Indirect pulp treatment is a procedure performed in a tooth with:
a necrotic pulp
a deep carious lesion adjacent to the pulp
a periapical radiolucency
pulp tissue that is irreversibly infected due to caries or trauma
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PEDIATRIC DENTISTRY
a deep carious lesion adjacent to the pulp

Indirect pulp caps are those procedures during which, at the first appointment, all of the superficial
carious dentin is excavated. The caries that is estimated to be approximating a potential pulp exposure
is left in the tooth if it is still sufficiently healthy (i.e., affected - not infected dentin). A pulp dressing is
placed in the tooth for a predetermined period of time (usually 6-12 months). At the second appointment
(after 6-12 months), all the carious material is excavated, and the floor of the cavity is examined for pulp
exposures. If no exposures are seen and the tooth has been asymptomatic, the treatment is considered successful and a permanent restoration is placed. However, the single-appointment procedure has also gained
in popularity and is probably the most common approach in current use. In the single-appointment approach, a permanent restoration is placed at the first appointment, with periodic monitoring of the tooth.
Calcium hydroxide, hybrid ionomer materials, or glass ionomer materials are often the dressings of
choice for indirect pulp therapy. The filling material is placed over the pulp dressing on the first appointment (e.g., composite, glass ionomer, hybrid ionomer, or amalgam).
Important: The preoperative x-ray of the tooth to be treated by indirect pulp therapy must not indicate
a carious exposure of the pulp. In addition, the tooth should be asymptomatic and no periapical change
should be observable on the x-ray.
Indirect pulp capping in the primary dentition:
Absence of prolonged or repeated episodes of pain (an unprovoked toothache)
No x-ray evidence of carious penetration of the pulp chamber
Absence of furcal or periapical pathology (always ask yourself if the root ends are completely closed,
or are we observing pathological change in the case of anterior teeth?)
No percussive symptoms
Evaluation and restoration of a tooth treated with indirect pulp therapy:
Absence of subjective complaints (toothaches)
After 6-12 months, periapical and bitewing x-ray reveal deposition of new secondary dentin
Place a permanent restoration if no exposure of the pulp chamber is present after removal of the
temporary restoration and remaining soft dentin. For the primary dentition, a glass ionomer, hybrid
ionomer, composite, compomer, amalgam, or stainless steel crown may be used. For the permanent
dentition, composite, amalgam, stainless steel crown, or cast crown restorations may be selected.
pulp tx
A 4-year-old child presents with acute pain associated with a primary
mandibular second molar that has a large carious lesion with pulpal
involvement. Radiographically, there is periapical pathology on the
distal root. The child is very cooperative and is able to tolerate long
appointments. What is the preferred choice of therapy for the primary
mandibular second molar?
incision and drainage

pulpotomy
primary tooth endodontics (pulpectomy)
extraction
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PEDIATRIC DENTISTRY
primary tooth endodontics (pulpectomy)

The first and probably most important indication for primary tooth endodontics (pulpectomy) is space maintenance. Of course, the best space maintainer is the natural primary tooth. Saving the tooth is very important
so that a space maintainer will not be necessary. Constructing a space maintainer in cases where second primary molars are lost before eruption of first permanent molars is extremely difficult.
Since there is periapical pathology and the child is 4 years old, the treatment of choice is pulpectomy. If
there wasn't any periapical pathology, a formocresol pulpotomy would be indicated. If the child were older
and there was a periapical radiolucency but successful pulpectomy could not be accomplished, the treatment
of choice would be extraction with placement of a space maintainer. This should be done to prevent damage
to the surrounding bone and the developing permanent tooth.
Endodontics for the primary dentition is a relatively quick and easy procedure for treating teeth with necrotic
tissue, which cannot be treated with a pulpotomy. A high-speed bur is used to gain access into the pulp chamber and Hedstrom files are then used for filing the canals. The canals are irrigated with hypochlorite to wash
out any remaining tissue and loose dentin. The canals and chamber are then filled with zinc oxide eugenol. A
postoperative x-ray is taken to evaluate the condensation procedure. The tooth is then restored using a stainless steel crown.
Indications for primary tooth endodontics (pulpectomy):
A tooth that is restorable with a stainless steel crown
No pathological root resorption
Layer of overlying bone between permanent tooth bud and area of pathological bone resorption. The radiograph should demonstrate that a layer of healthy bone exists between the lesion and the permanent tooth
bud. This allows the lesion to fill in with normal bone once the endodontic therapy is completed.
Suppuration
Pathological periapical radiolucency
Contraindications for primary tooth endodontics (pulpectomy):
Floor of the pulp opening into the bifurcation
Radiographic indication of extensive internal resorption (tooth has been weakened to the extent that it
cannot support a stainless steel crown)
More than two-thirds of the roots have been resorbed
Teeth without accessible canals (commonly first primary molars)
pulp tx
Which treatment is the proper one for a Class II fracture of a permanent tooth
with an immature apex?
pulpectomy
apply calcium hydroxide to exposed dentin and restore tooth with a permanent
restoration
pulpotomy
observe
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PEDIATRIC DENTISTRY
apply calcium hydroxide to exposed dentin and restore

tooth with a permanent restoration
Emergency Treatment of Fractures for Permanent Teeth with Immature Apices

Class I
Smooth enamel edges, restore tooth
Class II
Apply calcium hydroxide to exposed dentin and restore tooth with a permanent restoration
Class III
Immediately after injury, apply calcium hydroxide over exposure and place a temporary
restoration. If exposure is large or the injury was several hours or days ago, perform a
calcium hydroxide pulpotomy. Once apex closes, do pulpectomy.
Class IV
Calcium hydroxide pulpotomy. Once apex closes, do pulpectomy
In an older child with a fully formed apex: If there is a pinpoint exposure and ifs been
a while (day) since the fracture, the treatment of choice would be conventional root canal
therapy using gutta-percha. If it is seen immediately, then a direct pulp cap with calcium
hydroxide is indicated, followed by a permanent restoration.
pulp tx
The first indication for a pulpotomy is carious invasion deep enough to cause
mechanical exposure of the pulp or inflammation of the coronal pulp.
Inflammation or infection of pulp tissue beyond the corona! pulp
contraindicates a pulpotomy.

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PEDIATRIC DENTISTRY

There are several specific indications and contraindications when you are considering a pulpotomy.
The first indication for a pulpotomy is carious invasion deep enough to cause mechanical exposure of the pulp
or inflammation of the coronal pulp. However, it is very important that the inflammation and/or infection not
have extended beyond the coronal pulp tissue. Important: The success of a formocresol pulpotomy for a primary tooth depends primarily on a vital root tip.
Contraindications for the pulpotomy procedure in the primary dentition include the following. All of these
symptoms indicate that inflammation and/or infection extend beyond the coronal pulp.
History of spontaneous pain
Pain from percussion
Furcal radiolucency
Periapical radiolucency
Internal resorption
Calcification of the pulp
The formocresol pulpotomy is the preferred technique at this time:
The pharmacotherapeutic agent in the formocresol pulpotomy consists of 19% formaldehyde, 35% cresol,
15% glycerin, and water.
Local anesthesia and rubber dam isolation are used for almost all pulp therapy procedures, including the
formocresol pulpotomy
Cotton pellet(s) are placed in formocresol solution (Buckleys solution is often used)
Important: It is necessary to dry the pellet(s) using a cotton roll.
Cotton pellets are pressed gently against the pulp tissue at the orifices of the canals
Cotton pellets are left in position for 5 minutes. Excessive bleeding that persists despite cotton pellet pressure and a deep purple color of the tissue may indicate that the inflammation has extended to the radicular
pulp. In this case, a pulpotomy is contraindicated.
Note: Formocresol is a tissue fixative. Typically, the tissue is a brownish-purple color when fixation is complete.
Once the formocresol pellets are removed (after 5 minutes), ZOE is used to obturate the pulp chamber. It
is placed directly on the exposed pulp tissue.
Tooth is restored
Note: Formocresol will cause surface fixation of the pulpal tissue accompanied by degeneration of the odontoblasts.
pulp tx
Direct pulp caps (DPC) involve direct placement of the capping material
is the agent that is most frequently used.
on the pulp.
cavity varnish
glass ionomer
ZOE
calcium hydroxide
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PEDIATRIC DENTISTRY
calcium hydroxide (CaOH)

Direct pulp caps (DPC) usually are not done in the primary dentition. In fact, most dental schools teach that the DPC is a contraindicated procedure in primary teeth. However,
although seldom used in the primary dentition, it occasionally is used for primary teeth if
normal exfoliation will occur in the near future (up to 6 months). When the tooth will exfoliate normally in less than 6 months, treatment with a DPC sometimes is selected to
eliminate the time, complexity, and expense associated with a pulpotomy procedure.
Direct pulp capping is primarily used on permanent teeth. The reason it is not widely
used on primary teeth is because of the alkaline pH of CaOH. CaOH can affect (irritate)
the pulp either mildly or, most often, severely. With a mild irritation, there is a mild inflammatory reaction which will resolve itself and regroup as reparative dentin. With severe irritation, there is a probability of internal resorption. In primary teeth, this severe
irritation resulting in internal resorption happens more often than not. In permanent teeth,
this rarely occurs because the severe inflammatory response will cause reparative dentin
to form.
Key point: Primary teeth do not respond well to direct pulp capping procedures. Poor
long-term prognosis is the reason most clinicians avoid DPCs on primary teeth and move
directly to the pulpotomy procedure when primary tooth pulps are exposed during cavity
preparation.
Note: A situation for which it might be appropriate to perform a DPC instead of a pulpotomy: Occasionally you will have a small surgical exposure of the pulp on a primary
tooth, and the tooth is not going to be in the child's mouth for an extended period of time
- perhaps 6 months at the most you could consider the DPC in such a situation.
pulp tx
One alternative to the traditional full-strength formocresol pulpotomy is
the formocresol pulpotomy using a diluted solution of formocresol.
A dilution has been recommended and has been shown to
produce good long-term therapeutic results.
one-third
one-quarter
one-fifth
three-fifths
76
PEDIATRIC DENTISTRY
one-fifth - 20%
The procedure for the diluted formocresol pulpotomy is the same as that of the traditional pulpotomy:
apply nonsaturated formocresol cotton pellets moistened with diluted formocresol for 5 minutes to the
pulp stumps and check for acceptable fixation before proceeding with obturation. You may experience
greater difficulty in obtaining initial fixation with the diluted formocresol compared with the full-strength
formocresol. Your options are to repeat the topical application of the formocresol or to proceed with primary endodontics (pulpectomy) or extraction.
Various alternative pulpotomy procedures that have been developed as potential replacement procedures
for the traditional formocresol pulpotomy technique:
Glutaraldehyde Pulpotomy: glutaraldehyde is a tissue fixative. However, it is milder and potentially less toxic than formocresol. These properties have favored its use by some as a pulpotomy agent.
It does not invade systemically to the same degree as formocresol. This factor, along with its potentially less toxic form, has favored its use in some areas. A 2% solution of glutaraldehyde is used on
cotton pellets to fixate the pulp. The moistened cotton pellets are placed on the pulp stumps for 4
minutes. The pulp stumps will be pinkish in color when the tissue is fixed.
Ferric Sulfate Pulpotomy: one of the main attractions of ferric sulfate is that the material is not associated with toxicity and mutagenicity. Therefore, a milder agent is being placed on vital pulp tissue
in children. A 15.5% ferric sulfate solution is used. Suitable solutions are available commercially. The
material most often used is the Ultradent astringent solution. A syringe with 2-3 mL of ferric sulfate
solution is dispensed into the tooth pulp chamber. Only a small amount is necessary, just enough to
achieve hemorrhage control. Typically, the color of pulp tissue treated with ferric sulfate is red or
slightly darkish red. The ferric sulfate is left in place for approximately 15-20 seconds and then the
pulpotomy preparation can be rinsed to remove excess medication. This is a very rapid procedure, especially in comparison with other pharmacotherapeutic approaches to pulpotomies.
Mineral trioxide aggregate (MTA): has shown clinical and radiographic success as a dressing material following pulpotomy in primary teeth after a short-term evaluation period and has a promising
potential to become a replacement for formocresol in primary teeth. Further long term clinical evaluation of MTA as a pulpotomy agent needs to be carried out.
restorative
All of the following statements are true EXCEPT one. Which one is the EXCEPTION?
the occlusal anatomy of primary teeth is not as defined as that of permanent teeth;
therefore, amalgam preps can be more conservative
enamel and dentin are thicker in primary teeth; therefore, amalgam preps are deeper
the pulpal horns of primary teeth are longer and pointed; therefore, amalgam preps
must be conservative to avoid a pulpal exposure
primary molars have an exaggerated cervical bulge that makes matrix adaptation
much more difficult
the occlusal table is narrower on primary molars
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PEDIATRIC DENTISTRY
enamel and dentin are thicker in primary teeth; therefore,

amalgam preps are deeper
*** This is false; the enamel and dentin are thinner in primary teeth; therefore, amalgam
preps are shallower (0.5 mm into dentin, 1.5 mm overall). The thickness of coronal dentin in
primary teeth is about one-half that of permanent teeth.
The morphological characteristics of primary teeth affect the way restorative procedures are
approached. In particular, the morphology of primary teeth necessitates modifications in
restorations compared to the same type of procedure in permanent teeth. Some of these modifications are subtle, but they still are important. For example, the depth of Class I cavity
preparations in primary teeth is shallower than occlusal restorations in permanent teeth. This
is due to the relatively larger pulp chamber in primary teeth. If the primary teeth were prepared
to a depth that is common for permanent teeth, the dentist would be much more apt to expose
the pulp. In addition, the enamel cap is thinner in primary teeth than in permanent teeth. Consequently, the occlusal depth for a preparation on a primary tooth can be much less than the
depth of a preparation for a permanent tooth.
Other important morphologic considerations of primary teeth include:
Primary molars have an exaggerated cervical constriction that requires special care in
the formation of the gingival floor in Class II preps
Enamel rods in the gingival third of primary teeth extend occlusally from the DEJ, eliminating the need in Class II preps for the gingival bevel that is always required when preparing Class II preps on permanent teeth
Important: When preparing a Class II amalgam prep on a primary tooth, there are several
other recommendations for the proximal box preparation:
The proximal box should be broader at the cervical than at the occlusal aspect
The buccal, lingual, and gingival walls should all break contact with the adjacent tooth,
just enough to allow the tip of an explorer to pass
The buccal and lingual walls should create a 90-degree angle with the enamel
restorative
The success rates for mandibular nerve blocks are lower in children than in
adults because the mandibular anatomy is less developed in children.
The anterioposterior position of the mandibular foramen is about the same or
slightly more mesial in children than in adults.

78
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PEDIATRIC DENTISTRY
CO
2013-2014 - Dental Decks

The success rates for mandibular nerve blocks are higher in children than in adults because of the anatomy of lessdeveloped mandibles. The anterioposterior position of the mandibular foramen is about the same or slightly more
distal in children than in adults. However, the vertical position of the mandibular foramen in young children is closer
to the occlusal plane when compared with that in adults. In adults, it is located roughly 10 mm above the occlusal
plane. In young children, it is located somewhere between 7 mm above the occlusal plane and slightly below the occlusal plane. Therefore, local anesthetic solution can more easily diffuse inferiorly from the site of deposition of the
solution to the target area. For a child, the syringe barrel should bisect the primary molars on the opposite side of the
injection. Note: An imperfect injection technique is the most common cause of problems with getting a pediatric patient numb.
In the mandibular arch, the only guaranteed way to accomplish profound pulpal anesthesia is to perform an inferior
alveolar nerve block. The long buccal nerve supplies the molar buccal gingivae and may provide accessory innervation to the teeth. It should be anesthetized along with the inferior alveolar block. Primary incisors, however, can be
anesthetized using supraperiostial injections which anesthetizes branches of the incisive nerve. Note: Local infiltration can be used for anesthetizing maxillary primary teeth. Adequate diffusion of the local anesthetic readily occurs in children because their bones are less dense than those of adults.
Remember: Young children don't always understand what "numb lip" means when you ask them this following a
mandibular block. The best indicator of a profound block would be to probe the labial-attached gingiva between the
lateral incisor and canine with an explorer. If this is done without a reaction from the child, he/she is "numb."
Important: Overdosage of local anesthesia may cause CNS complications, such as dizziness, blurred vision, seizures,
CNS depression, and death. Cardiac complications may include myocardial depression.
1. The two most commonly used injectable local anesthetics in pediatric dentistry are lidocaine 2%
with/without
epinephrine (X ylocaine) and mepivacaine 3% (Carbocaine).
Notes
2. Do not exceed the maximum recommended dose (2 mg/lb) 300 mg max.
3. Long-acting local anesthetics, such as bupivacaine (Marcaine), rarely are used in pediatric dentistry.
4. The two most commonly used topical anesthetic agents in pediatric dentistry are:
20% benzocaine gel or liquid
2 -10% lidocaine gel or liquid
5. Remember to wam the child not to bite the "numb" cheek or lips. Give the warning during the dental appointment as well at the end of the appointment.
restorative
The bulbous, conically shaped primary teeth also affect the amount of
extension of the occlusal outline of the preparation. The general rule is that
of the intercuspal distance, between
the occlusal outline is about
the buccal and lingual cusps, on the occlusal surface of primary molars.
one-half
one-third
two-thirds
three-quarters
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PEDIATRIC DENTISTRY
one-third
*** Important: Class II amalgam restorations for primary teeth are prone to isthmus fractures. Some textbooks
even go so far as to recommend removing tooth structure at the axiopulpal line angle, so that more bulk of amalgam can be obtained to strengthen the isthmus.
Other basic principles in the preparation of cavities in primary teeth include:
Occlusal outline forms also are affected by other anatomical characteristics of primary teeth. For example, because of the shallowness of the preparations and the relatively large size of the interproximal boxes,
dovetails usually are constructed to give more retention and more bulk to the restoration.
The Class I and II preparations should include those areas that have caries and those areas that retain
plaque and are potential carious areas (pits and fissures). Note: This "extension for prevention" is only
when restoring with amalgam. It is not necessary to "extend for prevention" when restoring with composite resin or resin-modified glass ionomer (it is possible to seal the remaining pit and fissures).
Flat pulpal floor
Beveled (rounded) axiopulpal line angle. This will help reduce stress in the amalgam and provide greater
bulk of material in this area.
Rounded angles throughout the preparation. This will result in less concentration of stresses and will
allow more complete condensation of the amalgam material into the extremities of the preparation.
In Class II preparations, the facial and lingual walls of the proximal box should be carried to self-cleansing areas and should be parallel to the external surfaces and converge slightly.
The gingival margin need not be beveled in Class II preps. The enamel rods in this area incline occlusally.
In Class II preparations, the gingival floor is not ideal in most cases as the preparation gets deeper in this
area. This is due to the cervical constriction found in this area on primary molars.
Problems with open contacts due to interproximal restorations can be avoided with good matrix and wedge
placement. It is important to avoid open contacts.
The critical element in filling all interproximal restorations in terms of achieving good contacts,
whether you are restoring one or two adjacent teeth, is to push the wedge far enough into the interproximal space to achieve slight separation of the teeth. Finally, a good visual check of the matrix
adaptation before the tooth is restored will yield consistently excellent results.
Remember: Three surface restorations may be done on primary teeth, however stainless steel crowns have
proven to be a more durable and predictable restoration for large multiple-surface restorations in primary
teeth.
restorative
Depth cuts can be used as a gauge to help establish the depth of the occlusal
reduction when preparing a primary tooth for a stainless steel crown.
Approximately
of the occlusal surface should be removed.
1 to 1.5 mm
3 to 3.5 mm
4 to 4.5 mm
5 to 5.5 mm
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PEDIATRIC DENTISTRY
1 tO 1.5 Mm
Posterior stainless steel crowns on primary teeth are a fast, predictable, durable, and relatively inexpensive restorative technique. Primary teeth have a limited lifespan compared to the permanent dentition;
as a result, a restoration needs to last only until exfoliation. Because primary teeth are smaller than permanent teeth, a given amount of decay causes the tooth structure to become thinner and less stable than
it would be in a larger permanent tooth. The larger pulp space of primary teeth limits the depth of amalgam preparations; these factors result in less stable Class II amalgam restorations among primary molars. Premature loss of a Class II amalgam can lead to the mesial migration of posterior teeth with a
corresponding loss of arch length.
Two commonly used types of stainless steel crowns (SSCs):
1. Pretrimmed crowns
2. Precontoured crowns
Once the rubber dam is placed, tooth preparation can begin. There are three basic steps to tooth preparation for SSCs: occlusal reduction, buccal and lingual reduction/beveling, and proximal reduction.
Depth cuts can be used as a gauge to help establish the depth of the occlusal reduction. Approximately
1-1.5 mm of the occlusal surface should be removed.
The next step involves buccal and lingual reduction/beveling. It is best to slightly reduce the cervical bulges of some teeth (usually by approximately 1-1.5 mm) just above the gingival tissue. Note: In
the case of first primary molars, the buccal bulges often are very prominent. It is sometimes necessary to remove them to get the preformed crown to fit over the buccal prominence.
Rounding all line angles and point angles is recommended
Fitting the SSC. SSC margins should be placed right at or slightly below the height of the free gingiva. Fortunately, the advent of new preformed crowns has made most trimming unnecessary.
Important: The most common error in preparing teeth for SSCs is to leave an interproximal ledge. This
has been a popular question on national board examinations for decades. A preparation with a ledge will
not allow the SSC to seat completely because it often will get caught on the ledge.
restorative
Which of the following statements are true.
dental decay in primary teeth is an infectious process that can be very painful and can
spread and affect the development of the adult teeth
dental decay in primary teeth most often means there will be dental decay in the adult
teeth
primary teeth are slightly more opaque on x-ray film than permanent teeth because of a
lower inorganic content
dental decay in primary teeth tends to progress more rapidly from initial surface demineralization to involvement of the dentin
the enamel layer of primary teeth is thinner in all dimensions as compared to
permanent teeth
dental decay is more prominent in primary teeth than in permanent teeth
81
PEDIATRIC: DENTISTRY
dental decay in primary teeth is an infectious process that can be very painful and can
spread and affect the development of the adult teeth
dental decay in primary teeth most often means there will be dental decay in the adult teeth
dental decay in primary teeth tends to progress more rapidly from initial surface
demineralization to involvement of the dentin
the enamel layer of primary teeth is thinner in all dimensions as compared to permanent teeth
***Primary teeth are slightly less opaque on x-ray film than permanent teeth because of a higher inorganic content.
Remember: There must be 30-60% loss in mineralization before caries is radiographically evident with standard Dand E-speed intraoral films. Therefore, the clinical progress of a carious lesion is advanced, sometimes significantly,
compared with its radiographic progress.
Amalgam has been used as a restorative material since early in the nineteenth century. In the past, as now, amalgam
periodically has been the object of controversy. The cause of the controversy often has been its mercury content. Currently, amalgam also is being challenged by the introduction of other restorative materials. The new materials have
many features that are more desirable than those of amalgam. Key Point: The use of amalgam is declining rapidly
in pediatric dentistry.
The major force behind the decreasing use of amalgam in pediatric dentistry is the development of alternative materials with superior features. Some of the newer materials have the following excellent features: they are easy to use,
they release fluoride, they are tooth colored, they adhere to enamel and dentin, and their durability is satisfactory.
Glass ionomers are among the most notable of the newer materials being used as alternatives to amalgam. Ionomers
attach to both dentin and enamel as well as release fluoride. They are composed of fluoroalumino silicate powder and
polyacrylic acid. They are used for small Class I and very conservative Class II preparations (they are not very strong).
The hybrid ionomer materials truly revolutionized pediatric restorative dentistry when they were introduced in the
1980s. They have the advantages of both glass ionomers and resins.
They can be light cured (many hybrid ionomer products also self They adhere to enamel and dentin
They release fluoride
cure)
They are reasonably user-friendly
They are more durable than the glass ionomers
Compomer materials contain resin and ionomer material. They are more like composite materials than they are like
ionomer materials.The most important advantage of compomers over hybrid ionomers is the strength of the material.
Note: The hybrid ionomers release more fluoride to the adjacent tooth structure and are better caries inhibitors than
the compomers.
tth dev
The minimum number of lobes from which any tooth may develop is:
two
three
four
five
82
four
Tooth development begins with increased cell activity in growth centers in the tooth germ. A growth center
(lobe) is an area of the tooth germ where the cells are particularly active. These lobes are primary centers
of calcification and are primary sections of formation in the development of the crown of a tooth. They are
represented by a cusp on posterior teeth and mamelons and cingula on anterior teeth. They are always
separated by developmental grooves, which are very prominent in the posterior teeth and form specific
patterns. With anterior teeth, their presence is much less noticeable and these lobes are separated by what
are known as developmental depressions. Note: Teeth are formed by tissues originating from both ectoderm
and mesoderm. The ectoderm will become responsible for the future enamel, and the mesoderm will become
primarily responsible for pulp and dentin.
Summary of number of lobes:

All anterior teeth: three labial and one lingual (cingulum)
Premolars: three buccal and one lingual.
Exception: The mandibular second premolar has three buccal and two lingual lobes.
First molars (maxillary and mandibular): five lobes, represented by five cusps --one lobe for each cusp
Second molars (maxillary and mandibular): four lobes, one for each cusp
Third molars: at least four lobes, one for each cusp
*** variations are seen
Usually mamelons are worn off after the tooth comes into functional position. The presence of mamelons in
a teenager or an adult is evidence of malocclusion. Most likely there is an anterior open - bite relationship
where the incisors do not touch (see photo below).
An 8-year-old with erupting maxillary incisors is
shown. Note the prominent mamelons on the incisal
edges of the teeth as well as the anterior open bite relationship.
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of Pediatric Dentistry is governed by a license. Unauthorized access or reproduction is
forbidden without the prior written permission of the University of Washington. For information, contact: license@u.washington.edu
tth dev
Listed below are the usual events in the histogenesis of a tooth. Place them in
their correct sequence from what happens first to what happens last.
deposition of the first layer of dentin

differentiation of odontoblasts
deposition of the first layer of enamel
elongation of the inner enamel epithelial cells of the enamel organ
83
PEDIATRIC DENTISTRY
elongation of the inner enamel epithelial cells of the enamel organ

this influences mesenchymal cells on the periphery of the dental
papilla to differentiate into odontoblasts (#2 below)
differentiation of odontoblasts
deposition of the first layer of dentin
deposition of the first layer of enamel
Tooth development depends on a series of sequential cellular interactions between epithelial and mesenchymal components of the tooth germ. Once the ectomesenchyme influences the oral epithelium to grow down into the ectomesenchyme and become a tooth
germ, the above events occur.
1. Some texts include the deposition of root dentin and cementum as #5 in
Notes the histogenesis of a tooth.
2. Korff fibers is a name given to the rope like grouping of fibers in the
periphery of the pulp that seem to have something to do with the formation
of the dentin matrix.
3. Abnormalities in number result from problems in the initiation or dental lamina stage of tooth development. Abnormalities in shape result from problems in
the morphodifferentiation stage of tooth development. Abnormalities in tooth
development result from problems in the histodifferentiation, apposition, and
mineralization stages of tooth development.
Remember: Histogenesis means the formation and development of the tissues of the
body, in this case the tooth.
tth dev
A young girl presents to the dentist with yellow, thin, chalky enamel, but sound
dentin. The diagnosis is amelogenesis imperfecta. In amelogenesis imperfecta,
there is an error in what stage in the life cycle of a tooth?
initiation
bud stage
cap stage
bell stage
apposition
calcification
eruption
attrition
84
PEDIATRIC DENTISTRY
bell stage
1. Initiation (sixth to seventh weeks): ectoderm lining the stomodeum gives rise to oral
epithelium and to the dental lamina, adjacent to deeper ectomesenchyme, which is influenced by the neural crest cells. Induction is the main process involved. Congenital
absence of teeth (anodontia) and supernumerary teeth result from an interruption in this
phase.
2. Bud stage (eighth week): growth of the dental lamina into bud that penetrates growing
ectomesenchyme. Proliferation is the main process involved.
3. Cap stage (ninth to tenth weeks): enamel organ forms into a cap, surrounding the
mass of the dental papilla from the ectomesenchyme, thus forming the tooth germ.
Proliferation, differentiation, and morphogenesis are the main processes involved. Dens
in dente, gemination, fusion, and tubercle formation occur during this phase.
4. Bell stage (eleventh to twelfth weeks): final shaping of tooth, cells differentiate into
specific tissue-forming cells (ameloblasts, odontoblasts, cementoblasts, and .fibroblasts)
in the enamel organ. Histodifferentiation and morphodifferentiation are the main processes involved. Macrodontia and microdontia (i.e., peg lateral incisors), as well as dentinogenesis imperfecta and amelogenesis imperfecta occur during this stage.
5. Apposition (varies per tooth): cells that were differentiated into specific tissue-forming cells begin to deposit the specific dental tissues (enamel, dentin, cementum, and
pulp). Enamel dysplasia, enamal hypoplasia, concrescence, and the formation of enamel
pearls occur during this stage.
6. Calcification (varies per tooth): mineralization. Begins at cusp tips and incisal edges
and proceeds cervically. Trauma or excessive systemic fluoride ingestion may cause
hypocalcification.
7. Eruption (varies per tooth)
8. Attrition (varies per tooth)
tth dev
Which structure functions to shape the root (or roots) and induce dentin
formation in the root area so that it is continuous with the corona! dentin?
dental papilla
dental lamina
dental sac
hertwig sheath
85
PEDIATRIC DENTISTRY
hertwig sheath
The structure responsible for root development is the cervical loop. The cervical loop is the most
cervical portion of the enamel organ, a bilayer rim that consists of only IEE (inner enamel epithelium) and OEE (outer enamel epithelium).
The cervical loop begins to grow deeper into the surrounding mesenchyme of the dental sac, elongating and moving away from the newly completed crown area to enclose more of the dental papilla
tissue and form Hertwig epithelial root sheath (HERS).
After crown formation, the root sheath grows down and shapes the root of the tooth and induces
formation of root dentin. Uniform growth of this sheath will result in the formation of a singlerooted tooth, while medial outgrowths or evaginations of this sheath will produce multirooted teeth.
Remember: Cementum, which develops from the dental sac, forms on the root after the disintegration of Hertwig epithelial root sheath. This disintegration allows the undifferentiated cells of
the dental sac to come in contact with the newly formed surface of root dentin, inducing these cells
to become cementoblasts. The cementoblasts then disperse to cover the root dentin area and undergo
cementogenesis, laying down cementoid.
When a tooth clinically erupts in the mouth, one-half to two-thirds of the root has usually developed. For primary teeth, the roots are completed between 1 1/2 and 3 years of age, 6 to 18 months
after eruption. The intact root of the primary tooth is short-lived. The roots remain fully formed only
for about 3 years. The roots of the permanent teeth are completed between 10 and 16 years of age,
2 to 3 years after eruption.
1. Accessory root canals are formed by a break or perforation in the root sheath before the root dentin is deposited.
2. Tooth development is initiated by the mesenchyme's inductive influence on the overlying ectoderm.
3. The enamel of a tooth is derived from the ectoderm of the oral cavity. All other tissues of the tooth differentiate from the associated mesenchyme (mesoderm).
4. Ectodermal cells are responsible for determining the shape of the tooth.
tth trauma
A 3-year-old patient reports to your office with an intrusion injury on teeth #E
and #F (see photograph). You inform the child's parents about the current standard of care regarding intruded teeth. Which of the following statements best
describes the current understanding regarding intruded primary teeth?
the intruded teeth should be extracted

the intruded teeth should be left to reerupt
the therapeutic approach to intrusion injuries in primary teeth is controversial. Some
authors in the field advocate extraction and
some advocate leaving the tooth to reerupt.
the intruded teeth should be gently moved Copyright 2000-2004 University of Washington. All rights reserved. Access to
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into position with gauze and stabilized by the Atlas of Pediatric Dentistry is without the byprior
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forbidden
orre production
splinting
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PEDIATRIC DENTISTRY
the therapeutic approach to intrusion injuries in primary teeth is controversial.

Some authors in the field advocate extraction and some advocate leaving the
tooth to reerupt.
Informed opinion is divided whether it is best to extract intruded teeth or to leave them alone to reerupt. It is always
best to inform parents when the choice of treatment approach is disputed by the experts. It certainly is appropriate
for you to indicate a preference over which strategy to select in each case and to provide reasons why. But parents
need to be part of the process when the choice of therapy is more scientifically unsettled. Parenthetically, researchers
and authors do not advocate repositioning and splinting intruded primary teeth. Note: For National Board purposes,
the correct treatment is to administer no treatment and let the tooth reerupt.
Immediate attention should be given to soft-tissue damage. However, as in the case of all luxation injuries, an x-ray
of the area should be taken. Reeruption usually occurs in 2 - 4 months. If the intruded incisor is contacting the permanent tooth bud, the primary tooth should be extracted. Note: Damage to the succedaneous permanent tooth, including hypoplastic defects, dilaceration of the root, or arrest of tooth development, has been reported.
For luxation injuries: It is important to take a radiograph to rule out any fractures and for comparison purposes during later examinations. It is important with all luxation injuries to evaluate them to make sure that the luxated tooth
is not interfering with the patient's occlusion. This is most apt to occur with lingually luxated maxillary teeth. Consequently, taking a radiograph and checking the patient's occlusion are both necessary. Primary endodontics (pulpectomy) or extraction would only be necessary if the tooth became necrotic later.
Note: The primary objective of treatment in these injuries is to maintain periodontal ligament vitality.
During the first 6 months after the injury, you may observe that there is pulpal necrosis, which usually manifests as
a gray or gray-black color change in the crown of the involved primary tooth at any time after the injury. The tooth
can then be endodontically treated, if necessary, as long as the tooth is sound in the socket and no pathologic root resorption is evident. Note: If the tooth is asymptomatic, leave it alone.
Important: Repositioning displaced primary teeth that are mobile is not recommended. Extraction is recommended
due to the potential of aspiration in young children.
1. Concussion- The tooth is not mobile and not displaced.
2. Subluxation- The tooth is loosened but not displaced.
3. Lateral Luxation- The tooth is displaced in a labial, lingual, or lateral direction.
4. Intrusion- The tooth is driven into its socket.
5. Extrusion- Central dislocation of the tooth from its socket.
6. Avulsion- Tooth is completely displaced from the alveolus.
tth trauma
Discolored primary teeth that are symptom-free and show no radiographic
changes are best treated by:
no treatment
extirpation of the pulp tissue followed by the placement of ZOE paste in the root
canal space
extraction
pulpotomy
87
no treatment
*** They should be examined periodically by taking a radiograph.
Primary teeth will often darken (become gray) after injury. This is due to pulp bleeding and the diffusion of biliverdin
into the dentinal tubules.
Facts about darkened teeth:
80% of primary incisors that are darkened due to injury are asymptomatic.
Occasionally, these teeth will lighten.
15% of these teeth will need to be removed in 1 year. This is due to repeated trauma.
85% of these teeth will remain until normal exfoliation.
As a result of trauma to the primary dentition, you should not expect to have problems with the successors unless
the crown is not calcified. In this case, you will see hypocalcification in the tooth. This is most common with the
mandibular incisors.
Enamel hypocalcification refers to quality deficiencies of enamel. These defects can be directly related to faults in
the mineralization of the organic matrix in enamel formation. The same factors that cause enamel hypoplasia also
cause hypocalcification. The majority of localized defects occur subsequent to localized infection and trauma. Excess
exposure to citric acid resulting from habitual sucking on citrus fruits can produce generalized erosive hypocalcified
lesions that mimic the hypocalcification type of amelogenesis imperfecta.
Possible reactions of a tooth to trauma:
Pulpal hyperemia: this is the pulp's initial response to trauma. Cause: capillary congestion. May lead to necrosis.
Pulpal bleeding (internal hemorrhage): as a result of hyperemia, the capillaries in the pulp occasionally hemorrhage, leaving blood pigments deposited in the dentinal tubules. Teeth will often discolor (darken), however, a
color change does not mean that the tooth is nonvital, particularly when the discoloration occurs within 1 to 2
days after the injury. Color changes that occur weeks or months after the injury are more indicative of a necrotic
pulp.
Pulp canal obliteration (calcific metamorphosis): the pulp chambers are gradually obliterated by progressive
deposition of dentin. 90% of primary teeth resorb normally. Frequently appear yellowish in color.
Pulpal necrosis: may occur immediately or several months after injury.
Inflammatory resorption: can occur either on the external root surface or internally in the pulp chamber or
canal. It can progress very rapidly, destroying a tooth within months.
Replacement resorption (ankylosis): results after irreversible injury to the PDL. Akylosed primary teeth should
be extracted if they cause a delay in or ectopic eruption of a developing permanent tooth.
tth trauma
An 8-year-old patient presents to your office with a small pulp exposure on
the permanent maxillary left central incisor, resulting from a fracture of the
tooth. The injury is about 1-hour old. Your clinical and radiographic
examinations show there are no other injuries. What is the indicated course of
therapy at the time of the emergency?
place a direct pulp cap and proceed with a glass ionomer Band-Aid restoration
begin partial pulpotorny therapy immediately
begin endodontic therapy immediately
schedule the patient for endodontic therapy as soon as possible, once the initial
anxiety from the traumatic episode has abated
88
PEDIATRIC, DENTISTRY
place a direct pulp cap and proceed with a glass ionomer Band-Aid restoration
Fractures of permanent teeth resulting in small pulp exposures of recent duration (usually less than 2 hours)
are treated with direct pulp caps and a glass ionomer Band-Aid build-up at the time of the emergency appointment. It is not necessary, however, to build-up the hybrid ionomer or glass ionomer Band-Aid to the
original morphology of the tooth, which might result in unnecessary manipulation of the tooth. Partial pulpotomy therapy is indicated in cases where the exposure is of longer duration (e.g., longer than 2 hours). It generally is not used in cases where the injury is of recent duration. Endodontic therapy usually is not appropriate
at the emergency visit for small pulp exposures of recent duration. And, hopefully, the direct pulp cap will
result in maintaining the vitality of the tooth, making endodontic therapy unnecessary over the longer term.
1.Permanent teeth with large, open apices, which have been fractured with resulting large pulp
Notes' exposures, and where the fracture injury is of recent duration, are treated by coronal calcium hy-
droxide pulpotomies. The hope is that pulpal vitality will be maintained in the root canal pulp
tissue and the apices eventually will close normally. Formocresol and ferric sulfate pulpotomies
generally are not recommended as pulpotomy agents in permanent teeth. Conventional endodontic therapy is appropriate for fractured permanent teeth with large pulp exposures when
the apices are already closed.
2. Traumatic injuries: a tooth with an open apex is more likely to have a good prognosis. This
concept is one of the most important in the assessment of potential outcomes in traumatic injuries
to teeth. An open apex allows a better blood supply to the pulp of the tooth and helps the pulp
of the tooth to survive an injury.
3. Traumatic injuries: most injuries to the primary teeth occur at 1.5 to 2.5 years of age (the
toddler stage). The teeth most frequently injured in the primary dentition are the maxillary central incisors. Children with protruding incisors, as in children with Class II, Division I malocclusion, are more commonly affected.
4. Avulsed primary teeth are not replanted. The prognosis for replanted primary teeth is poor
and, worse, ankylosis also can result. Replanting an avulsed primary tooth involves forcing a
child to go through a totally unnecessary and inappropriate procedure.
5. Underdeveloped motor coordination is the most common cause of dental trauma in very
young children.
6. Remember: Recently traumatized teeth may give false-negative responses to pulp vitality
tests. This impaired nerve conduction may be temporary or permanent, only time will tell.
tth trauma
A 9-year-old patient has fractured the root of the permanent maxillary right
lateral incisor. There is no other identifiable injury. The fracture occurred around
the middle of the root. What is the indicated course of therapy at this time?
begin endodontic therapy immediately

extract the tooth and t he root remnant if possible
do nothing if the tooth seems fairly stable
splint the tooth to the adjacent two or three teeth
89
PEDIATRIC DENTISTRY
splint the tooth to the adjacent two or three teeth
Splinting is the appropriate immediate choice of therapy for most root fracture injuries of permanent teeth. Endodontic therapy may be needed later if the tooth becomes necrotic. Doing nothing
may be tempting if the tooth seems quite stable. However, splinting the tooth will provide additional
stability while eating; and it will reduce the chance for additional injury to an already compromised
tooth. Important: Fractures in the middle third of the root have the poorest prognosis. However,
splinting still is the treatment of choice.
1. Fixed splinting, as opposed to flexible splinting, is the preferred approach for root
/Notes fractures. Note: 0.032 to 0.036 SS wire and bonded composite is commonly used.
2. Currently the standard monitoring period for fixed splinting for root fractures is 3
months.
3. Approximately 75% of permanent teeth with root fractures maintain their vitality.
4. Treatment of root fractures of the apical third of the root has by far the best prognosis.
You have a better chance of stabilizing and maintaining the vitality of the tooth if you are
confronted with a fracture in this area. The reason is that more surface area of the root is
in an approximate position with the alveolus with this type of injury
5.These teeth should be monitored aggressively, with follow-up clinical and radiographic
evaluations every 3 to 6 months for the first year. Any sign of necrosis or resorption warrants initiation of root canal therapy immediately.
6. Root fractures involving primary teeth are relatively uncommon because the more pliable alveolar bone allows displacement of the tooth.
7. Splinting is not recommended in the primary dentition.
8. Fractured maxillary anterior teeth occur most often in children with Class II, Division
I malocclusion (maxillary anteriors are flared).
9. For an avulsed permanent tooth, the composite resin retained arch wire splint has
been advocated as the best system to use. To allow for flexibility, a light orthodontic
wire or a 30- to 60-pound test monofilament fishing line can be used. It should be left
in place for 1-2 weeks maximum to prevent akylosis.
tth trauma
What is the most reliable method to determine the pulp vitality in the case of
a recently traumatized primary tooth?
radiograph
electric pulp test
thorough intraoral exam
there is no reliable method
90
PEDIATRIC DENTISTRY
there is no reliable method

Often, traumatized teeth will not respond to vitality testing. Pulp vitality testing is not routinely
performed in the primary dentition. This is because primary teeth do not respond to such tests
reliably and because the test requires a relaxed and cooperative patient who can objectively report a reaction.
Congestion of blood within the pulp chamber a short time after injury can often be detected
in the exam. Shining a bright light on the facial surface and holding the mirror to view the lingual will usually show a reddish hue, which is indicative of pulpal hyperemia. If this color
change is evident after several weeks, it is often indicative of a poor prognosis. Electric pulp
tests are seldom reliable to determine pulp vitality if taken immediately after the injury. The
thermal test is the most reliable test, especially in primary incisors. Failure of a tooth to respond to heat is indicative of pulpal necrosis.
Note: In young children with avulsed and replanted permanent teeth that have open apices, the
blood supply is usually regained within the first 20 days after replantation but nerve supply lags
behind.
Remember from Endodontics section: The chief cause of failure of replantation of permanent teeth is external root resorption.
space mgmt
The patient below is a 5-year-old child with acute pain associated with
tooth #K. If tooth #K was extracted, what type of space maintainer would
be needed?
band and loop space maintainer

distal shoe space maintainer
(fixed)
(removable)
crown and loop space maintainer

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PEDIATRIC DENTISTRY
distal shoe space maintainer (fixed)

A fixed distal shoe space maintainer is used. In this way, the space maintainer can be constructed so that
the first permanent molar can erupt against the distal shoe and space will be maintained for the developing bicuspid. Note: There are four appliances that are generally used for space maintenance in the
primary dentition: the band and loop, lingual arch, distal shoe, and a removable appliance.
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Washington. For informationcontact: license@u.washington.edu
This appliance is called a distal shoe space maintainer or a distal extension space maintainer. It is used
to prevent unerupted first permanent molars from moving mesially with the premature loss of second primary molars. The example shown is a crown with a distal extension segment soldered to the crown. The
distal segment is extended into the tissue against the unerupted first permanent molar. The distal extension, also called a distal shoe, is used when the second primary molars are lost prior to the eruption of
the first permanent molars (i.e., very premature loss).
Ectopic eruption reflects the eruption of a tooth in an abnormal position. The most frequently found ectopic teeth are the maxillary first permanent molars and canines, followed by the mandibular canine,
mandibular second premolar, and the maxillary lateral incisors. Ectopic eruption and impaction should
be differentiated. In the latter case, the tooth cannot erupt because something impedes it and not because
of its ectopic position.
Note: In the absence of recession, the treatment of a heavy maxillary frenum with a diastema is delayed
until the permanent canines have erupted. If the midline diastema has not closed after the canines have
erupted, orthodontic closure is accomplished first and a frenectomy is performed afterward.
space mgmt
What cement is the best choice for cementing a lower fixed bilateral holding
arch in place?
zinc phosphate cement

zinc oxide eugenol cement
IRM
glass ionomer cement:
92
PEDIATRIC DENTISTRY
glass ionomer cement

Glass ionomer cement is the best choice, and it is especially helpful to choose among the newest generation glass ionomer cements. The glass ionomer cements are very user-friendly since they mix easily
and clean up easily in the mouth. Once in the mouth, they also set up rapidly. They have low solubility
and therefore, do not dissolve and leave voids between the tooth and the band. The ionomer cements also
adhere well, especially since they form attachments to both the tooth and the band. Zinc phosphate cement is still used by many practitioners, and it provides acceptable cementation. However, it is not the
best choice, particularly since it is more soluble than glass ionomer cement. ZOE and IRM are not luting cements and should not be used for band cementation
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Pediatric Dentistry is governed by a license.
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This photograph shows an example of a fixed bilateral space maintainer. The patient is 4 years old. The
appliance is cemented on the two second primary molars. Fixed bilateral space maintainers on the
mandibular arch often are called lingual arch space maintainers. Mandibular fixed bilateral space appliances generally are preferred by clinicians over removable space maintainers. Fixed appliances are easier to maintain and they are less likely to be removed, damaged, or lost by the child.
The mandibular lingual arch space maintainer is used very commonly in the primary dentition and the
mixed dentition, where bands can be cemented to primary or permanent molars, respectively. This is
one of the most ubiquitously used space maintainers. It prevents posterior teeth from tipping mesially and
can also be used to prevent lingual movement of incisors following the premature loss of a primary canine. It is even used on occasion in the permanent dentition when bicuspids are missing and maintaining space is necessary prior to orthodontic and/or prosthetic therapy.
space mgmt
A mother of a 6-year-old female reports that her daughter has complained
of a severe spontaneous pain on the upper right side of her mouth.
Your examination indicates a large lesion on the distal aspect of the primary
maxillary right first molar which extends to the pulp. All other maxillary teeth are
present and are noncarious. You decide that extraction of the tooth is warranted.
What type of space maintainer will you advise for the patient?
maxillary right removable unilateral appliance

maxillary removable bilateral appliance
maxillary right band and loop appliance
93
PEDIATRIC DENTISTRY
maxillary right band and loop appliance

A space maintainer is indicated to prevent mesial movement of the second primary molar. A band and
loop space maintainer is the best choice. It is especially important to start space maintenance therapy prior
to the eruption phase of the first permanent molar, since the force of eruption of the permanent molar will
exert a lot of pressure to push the second primary molar forward. The eruption phase of the permanent
molar is the time of greatest force exerted against the primary molar.
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Dentistry is governed by a license. Unauthorized
access or reproduction is forbidden without the
prior written permission of the University of Washington. For information, contact: license@u.washington.edu
This photograph shows two band and loop space maintainers, an example of the bilateral use of fixed unilateral band and loop space maintainers. These are very common types of unilateral space maintainers,
and they often are used bilaterally.
1. Loss of a primary incisor in the primary dentition does not generally cause loss of overNotes all arch length, however, it may result in localized space loss, especially if there was no interdental primary spacing prior to the loss. Space maintenance is not required for primary
missing incisors. However, posterior space maintenance is a necessity.
2. Space loss can occur very quickly after the loss of a permanent incisor, an appliance
should be constructed ASAP after the tooth loss.
3. Lingual eruption of permanent incisors is a very common problem in the early mixed
dentition. These incisors almost always move labially until they contact another tooth.
4. The lateral ectopic eruption of permanent central incisors (maxillary or mandibular)
often causes early exfoliation of primary lateral incisors (maxillary or mandibular). This
often results in a midline deviation.
space mgmt
The photograph shows a maxillary fixed bilateral space maintainer. This type
of space maintainer also is known as a:
frankel appliance
nance appliance
herbst appliance
ricketts appliance
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PEDIATRIC DENTISTRY
nance appliance
Note the small acrylic button that will rest against the palatal tissue with this appliance. Some clinicians object to the button since it can create tissue irritation. Therefore, it is important that patients and parents be instructed to make sure that the patient meticulously flosses under the acrylic button. The Nance appliance (Nance
Holding Arch) is used when premature bilateral loss of maxillary primary teeth has occurred.
Space management is an important responsibility of the general dentist and the pediatric dentist. Inadequate
space management can cause problems that are long-lasting and severe. The premature loss of primary teeth
may cause loss of arch length, resulting in crowding of the permanent dentition, impaction of permanent teeth,
esthetic difficulties, malocclusion, and other problems. Note: The best space maintainer is a primary tooth.
When nature's best space maintainer is lost prematurely, space management is needed to maintain the space
for normal development of the dental arches.
Remember:
1. A Ricketts retainer is a retainer often used if the top of the mouth is supposedly taller than average.
2. A Herbst appliance is a splint with tubes and hinges to hold the mandible forward so it will grow and
push the maxilla back so it won't grow. It's for kids who won't wear their headgears or to help headgears work
better.
3. Frankel appliances are used to correct jaw imbalances and crowding problems.
1. The loss of a primary canine can cause the lingual collapse of the permanent incisors, loss of
Notes arch length, increased overbite, increased overjet, and midline deviation to the side of the canine
loss. Note: Bilateral loss of the primary canines causes the same things.
2. Factors to consider in planning space maintenance:
Amount of resorption of primary roots: if more than one-fourth of the root remains, space
maintenance is likely necessary; if less than one-fourth of the root remains and if no bone is left
between the primary tooth and permanent tooth, space maintenance is likely unnecessary
Amount of bone covering the permanent tooth: If there is no bone, no space maintenance
is necessary; if there is bone, space maintenance is usually indicated. Note: If there is any
doubt, use a space maintainer to prevent space loss.
Amount of root development: the average tooth erupts through the gingival tissue with onehalf to two-thirds root formation
Time elapsed since tooth loss: Most space loss occurs within the first 6 months

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PEDIATRIC DENTISTRY LEG ND

diseases & conditions

twig epithelial root sheath.

Copyright 2000-2004 University of Washington. All rights reserved. Access t<

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one part per million

three parts per million

permit the child to express his fear identify the fear

Modulation on voice volume,

Allay fears, shape

All patients who can

Children who are

Process of shaping patient's

Diverting patient's attention from

Conveying reinforcement and

speak slowly and in very simple terms

schedule long appointments

the age and maturity of the child

all of the above

the presence of fixed orthodontic appliances

a very nervous or anxious patient

dis & cond

dis & cond

it is also called Vincent infection, Vincent angina, or "trench mouth"

Periodontal disease in children:

dis & cond

hard and soft palates

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soft palate only

Four Classes of Cleft Lip:

dis & cond

dis & cond

Copyright 2000-2004 University of Washington. All rights reserved.

primary herpetic gingivostomatitis

dis & cond

both statements are true

the first statement is false, the second statement is true

dis & cond

extremely high, extremely low

extremely low, extremely high

dis & cond

dis & cond

both statements are true

both statements are true

1. Neuroblastoma is one of the most common solid tumors of early childhood

dis & cond

dis & cond

severely delayed eruption

dis & cond

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they generally recover if restrained from self-injury

dis & cond

cleft palate and cleft lip

dis & cond

acute myeloid leukemia

acute lymphocytic leukemia (ALL)

Gingival oozing, petechiae, hematoma, or ecchymosis

dis & cond

both statements are true

both statements are true

dis & cond

maxillary posterior teeth

maxillary anterior teeth, maxillary posterior teeth, mandibular