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Essentials of

Pediatric Dentistry
Essentials of
Pediatric Dentistry

Kanchan Harikishan Asnani BDS

College of Dental Science and Hospital
Indore, Madhya Pradesh


Nagpur St Louis (USA) Panama City (Panama) London (UK) New Delhi Ahmedabad
Bengaluru Chennai Hyderabad Kochi Kolkata Lucknow Mumbai
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Essentials of Pediatric Dentistry

2010, Jaypee Brothers Medical Publishers (P) Ltd.

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or
by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the
author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error (s). In case
of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2010

ISBN 978-81-8448-742-8
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset

My Father
Mr Harikishan K Asnani
for his continuous encouragement, understanding and support

My Mother
Mrs Meena H Asnani
for loving, caring and giving me her valuable presence to
continue my concentration in studies

My Brother
Mr Amit H Asnani
for providing a unique atmosphere of friendship

The idea of writing this book took shape while I was studying as a final year student in college. As
pediatric dentistry is an expanding field, the students need to read a book which is concise, to the point
and yet provide all the essential information about the subject.
The dental students face the dilemma of selecting the book even more. This book has been written
keeping in view the requirements of the students.
In part-1 of the book, I have dealt with the basics and fundamental of pediatric dentistry, this part
introduces reader to the subject.
In part-2 of the book, I have dealt with various procedures and techniques to be undertaken in the
primary dentition yearsthree to six years.
In part-3 of the book, I have dealt with the changes which should be offered in various dental procedures
in various aspects in the transitional yearssix to twelve years.
In part-4 of the book, I had provided the information which deals with adolescence.

Kanchan Harikishan Asnani


I always dreamt of presenting a textbook of pediatric dentistry to the students all over the country.
First and foremost I would thank "The Supreme Power God" for giving me energy, inspiration,
courage to complete this arduous task and make my dream come true in two ways: first giving me first
position in university examination of final year and second fulfilling my dream of presentation of textbook.
I acknowledge the unconditional assistance given to me in my day-to-day work, by my friend
Ms Anubha Bansal (BE in electronics and telecommunications).
I am extremely grateful to Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for selecting and
finalizing my script.
I am extremely thankful to members of my family who willingly co-operated and encouraged me
throughout my work.



1. The Practical Importance of Pediatric Dentistry ..................................................................... 3

2. Pain Reaction Control : Sedation .......................................................................................... 15
3. Antimicrobials in Pediatric Dentistry .................................................................................... 19
4. Dental Public Health Issues in Pediatric Dentistry ................................................................ 22



5. General Topics to be Considered .......................................................................................... 27

6. Child Psychology .................................................................................................................. 38
7. Examination, Diagnosis and Treatment Planning ................................................................. 48
8. Prevention of Dental Diseases ............................................................................................... 53
9. Restorative Dentistry for the Primary Dentition .................................................................... 65
10. Pulp Therapy for the Primary Dentition. ............................................................................... 88
11. Periodontal Problems in Children and Adolescents ............................................................ 101
12. Space Maintenance in the Primary Dentition ...................................................................... 111
xii Essentials of Pediatric Dentistry

13. Oral Habits .......................................................................................................................... 125

14. Local Anesthesia and Oral Surgery in Children .................................................................. 138



15. Pit and Fissure Sealants and Conservative Adhesive Restoration ....................................... 149
16. Managing Traumatic Injuries in the Young Permanent Dentition ....................................... 156
17. Treatment Planning and Management of Orthodontic Problems ........................................ 170
18. Behavior Management ........................................................................................................ 192
19. Care of Special Child (Handicapped Child) ........................................................................ 202



20. Aesthetic Restorative Dentistry for the Adolescence .......................................................... 225

21. Sports Dentistry and Mouth Protection ............................................................................... 239

Index .................................................................................................................................... 241

The Practical Importance
of Pediatric Dentistry

DEFINITIONS American Academy of Pediatric Dentistry

American Academy of Pediatric Dentistry (1999)
(1985) Pediatric dentistry is age-defined speciality that
Pediatric dentistry also known as pedodontics and as provides both primary and comprehensive, preventive
Dentistry for adolescents and children, is the area of and therapeutic oral health care for infants and children
dentistry concerned with preventive and therapeutic through adolescence including those with special
oral health care for children from birth through health care needs.
adolescence. It also includes special care for special Pediatric Dentistry Incorporates Various Branches
patients beyond the age of adolescence who of Dentistry within Itself. It is shown as in Figure 1.1.
demonstrate mental, physical or emotional problem.

Fig. 1.1: Various branches of dentistry

4 Essentials of Pediatric Dentistry

What is Practical Importance of Pedodontics? iv. Permitted other maladaptive behavior:

Various evidences reports the importance of study in Encouragement or permission of other
field of paediatric dentistry. maladaptive behavior (e.g. chronic delinquency,
Evidence of child abuse and neglect severe assault) under circumstances where the
Evidence of oral burns parent and caregiver has reason to be aware of
Bitemarks evidence. the existence and seriousness of the problem but
These all evidences could be considered in general does not intervene.
under a single title of forensic pedodontics. v. Refusal of psychological care: Refusal to allow
Let us discuss all these evidences one by one. needed and available treatment for a childs
emotional or behavioral impairment or problem
(A) CHILD NEGLECT in accordance with a competent professional
DEFINITION vi. Delay in psychological care: Failure to seek or
Child neglect is generally characterized by omissions provide needed treatment for a childs emotional
in care resulting in significant harm or risk of or behavioral impairment or problem that any
significant harm. Neglect is frequently defined in terms reasonable layperson would have recognized as
of a failure to provide for the childs basic needs, such needing professional psychological attention
as adequate food, clothing, shelter, supervision or (ego suicide attempt).
medical care.
Types of Neglect Educational neglect is defined in following words:
Emotional neglect i. Permitted chronic truancy: Habitual
Educational neglect absenteeism from school averaging at least 5
Physical neglect. days a month if the parent or guardian is
informed of the problem and does not attempt
to intervene.
ii. Failure to enroll or other truancy: Failure to
Emotional neglect is defined in following words: register or enroll a child of mandatory School
i. Inadequate nurturing or affection: Marked age, causing the child to miss at least 1 month
inattention to the child's need for affection, of school, or a pattern of keeping a school-aged
emotional support or attention. child home without valid reasons.
ii. Chronic or extreme spouse abuse: Exposure of iii. Inattention to special education need: Refusal
the child to chronic or extreme spouse abuse or to allow or failure to obtain recommended
other domestic violence. remedial education services or neglect in
iii. Permitted drug or alcohol abuse: Encoura- obtaining or following through with treatment
gement or permission of drug or alcohol use by for a child's diagnosed learning disorder or other
the child. special education need without reasonable cause.
The Practical Importance of Pediatric Dentistry 5


Physical neglect is defined in following words: Types, Signs, Symptoms, Causes and Help
i. Refusal of health care: Failure to provide or The first step in helping abused or neglected children
allow needed care in accordance with is learning to recognize the signs of child abuse and
recommendations of a competent health care neglect.
professional for a physical injury, illness, (To report abuse, call the National Child Abuse
medical condition or impairment. Hotline : 1-800-4-A-CHILD).
ii. Delay in health care: Failure to seek timely and Child abuse is both shocking and commonplace.
appropriate medical care for a serious health Child abusers inflict physical, sexual, and emotional
problem that any reasonable layperson would trauma on defenseless children every day. The scars
have recognized as needing professional medical can be deep and long-lasting. Unfortunately, the more
attention. subtle forms of child abuse such as neglect and
iii. Abandonment: Desertion of a child without emotional abuse can be even more traumatizing than
arranging for reasonable care and supervision. violent physical abuse.
iv. Expulsion: Other blatant refusals of custody,
What is Child Abuse?
such as permanent or indefinite expulsion of a
child from the home without adequate Child abuse consists of any act, or failure to act, that
arrangement for care by others or refusal to endangers a childs physical or emotional health and
accept custody of a returned runway. development. Someone is abusive if he or she fails to
v. Inadequate supervision: Leaving a child nurture the child, physically injures the child, or relates
unsupervised or inadequately supervised for sexually to the child.
extended periods of time, or allowing the child
to remain away from home overnight without
knowing or attempting to determine the child's
where abouts.
vi. Other physical neglect: May include inadequate
nutrition, clothing, or hygiene, conspicuous
inattention to avoidable hazards in the home and
other forms of reckless disregard for the child's
safety and welfare.
For example,
Driving with the child while intoxicated
Leaving a young child unattended in a
car. Fig. 1.2: Abused child
6 Essentials of Pediatric Dentistry

What are the Types of Child Abuse? Drug use during pregnancy: Drug and alcohol use
during pregnancy or lactation can be harmful to
The four major types of child abuse are:
your child, leading to problems such as Fetal
Physical abuse
Alcohol Syndrome.
Sexual abuse
Hundreds of thousands of children are physically
Emotional abuse
abused each year by someone close to them, and
thousands of children die from the injuries. For those
who survive, the emotional scars are deeper than the
What is Physical Child Abuse?
physical scars.
Physical child abuse is an injury resulting from
physical aggression. Even if the injury was not What is Sexual Child Abuse?
intended, the act is considered physical abuse.
Sexual abuse of a child is any sexual act between an
The injury from physical child abuse may be the
adult and a child, including penetration, intercourse,
result of:
incest, oral sex, and sodomy. Other examples include
Beating, slapping, or hitting
Pushing, shaking, kicking, or throwing Fondling: Touching childs genitals, making a
Pinching, biting, choking, or hair-pulling child fondle an adult's genitals.
Burning with cigarettes, scalding water, or other Violations of bodily privacy: Forcing a child to
hot objects undress, spying on a child in the bathroom or
Severe physical punishment. bedroom.
Exposing children to adult sexuality: Performing
Is Physical Punishment the Same sexual acts in front of a child, exposing genitals,
as Physical Abuse? showing pornography to a child.
Commercial exploitation: Sexual exploitation
Physical abuse is an injury resulting from physical
through child prostitution or child pornography.
aggression. Physical punishment is the use of physical
Regardless of the childs behaviour or reactions,
force with the intent of inflicting bodily pain, but not
it is the responsibility of the adult not to engage in
injury, for the purpose of correction or control. As you
can see, physical punishment can easily get out of sexual acts with children. Sexual abuse is never the
control and become physical abuse. childs fault.
Some other specific types of physical child abuse Sexual child abusers can be:
are: Fathers, mothers, siblings, or other relatives
Shaken Baby Syndrome: Shaking a baby or toddler Childcare professionals or babysitters
can cause serious head injuries. Clergy, teachers, or athletic coaches.
Munchausen by Proxy Syndrome: Inducing Foster parents or host families of foreigns
medical illness in a child or wrongly convincing exchange students
others that a child is sick is both dangerous and Neighbors or friends
abusive. Strangers.
The Practical Importance of Pediatric Dentistry 7

What is Emotional Child Abuse? periods of time, or terrorizing a

Emotional child abuse is any attitude, behavior, or
failure to act that interferes with a childs mental health Exposure to Witnessing violent behavior,
or social development. It can range from a simple violence including the physical abuse of
verbal insult to an extreme form of punishment.
Emotional abuse is almost always present when Child Taking advantage of a child,
another form of abuse is found. Surprisingly, emotional exploitation including child labor.
abuse can have more long-lasting negative psychiatric Child abduction The trauma of being kidnapped,
effects than either physical abuse or sexual abuse. including kidnapping by a parent,
Other names for emotional abuse are: amounts to abuse.
Verbal abuse
Mental abuse Emotional child abuse can come from adults or
Psychological maltreatment or psychological from other children:
Parents or caregivers
Teachers or athletic coaches
Examples of Emotional Child Abuse
Bullies at school or elsewhere
Intimidation Yelling, screaming, threatening, Middle and high school girls in social cliques.
frightening, or bullying.
Belitting or Humiliating the child, name-calling, What is Neglect?
shaming making negative comparisons to Neglect is a very common type of child abuse.
others. Telling the child he or she is According to Child Welfare Information Gateway,
no good, worthless, bad, or more children suffer from neglect than from physical
a mistake. and sexual abuse combined. Yet victims are not often
Lack of Showing little to no physical identified, primarily because neglect is a type of child
affection and affection (such as hugs) or words abuse that is an act of omissionof not doing
warmth of affection (praise, saying I love something.
you). Some overlap exists between the definitions of
Habitual blaming Telling the child that everything is emotional abuse and emotional neglect. However,
his or her fault. neglect is a pattern of failing to provide for a child's
basic needs. A single act of neglect might not be
Ignoring or Withdrawing attention, giving the considered child abuse, but repeated neglect is
rejecting cold shoulder, disregarding. definitely child abuse. There are three basic types of
Extreme Confinement to a closet or neglect; physical neglect, educational neglect, and
punishment darkroom, tying to a chair for long emotional neglect.
8 Essentials of Pediatric Dentistry

Types of Neglect Warning Signs of Online Sexual

Physical neglect: Failure to provide foods, clothing Child Abuse
appropriate for the weather, supervision, a home Your child spends large amounts of time online,
that is hygienic and safe, and/or medical care, as especially at night
You find pornography on your childs computer
Educational neglect: Failure to enroll a school-
Your child receives phone calls from men you dont
age child in school or to provide necessary special
know, or is making calls, sometimes long distance,
education. This includes allowing excessive
to numbers you dont recognize.
absences from school.
Your child receives mail, gifts or packages from
Emotional neglect: Failure to provide emotional
someone you dont know
support, love, and affection. This includes neglect
of the childs emotional needs and failure to Your child turns the computer monitor off or
provide psychological care, as needed. quickly changes the screen on the monitor when
you come into the room
What are the Warning Signs and Your child becomes withdrawn from the family
Symptoms of Child Abuse? Your child is using an online account belonging to
someone else.
Signs of Physical Child Abuse
Burns, bitemarks, cuts, bruises, or welts in the Signs of Child Neglect
shape of an object Clothing unsuited to the weather
Resistance to going home Being dirty or unbathed
Fear of adults. Extreme hunger
Signs of Emotional Child Abuse Apparent lack of supervision.

Apathy, depression What are the Causes of Child Abuse?

Difficult concentrating. Why would someone abuse a defenseless child? What
kind of person abuses a child? Not all child abuse is
Signs of Sexual Child Abuse deliberate or intended. Several factors in a persons
Inappropriate interest in or knowledge of sexual life may combine to cause them to abuse a child:
acts Stress, including the stress of caring for children,
Seductiveness or the stress of caring for a child with a disability,
Avoidance of things related to sexuality, or special needs, or difficult behaviors
rejection of own genitals or body Lack of nurturing qualities necessary for caring
Either overcompliance or excessive aggression for a child
Fear of a particular person or family members. Difficulty controlling anger
The Practical Importance of Pediatric Dentistry 9

Personal history of being abused NEGATIVE CONSEQUENCES OF

Isolation from the family or community CHILD ABUSE
Physical or mental health problems, such as Emotional Effects
depression and anxiety
Alcohol or drug abuse Low self-esteem
Personal problems such as marital conflict, Depression and anxiety
unemployment, or financial difficulties. Eating disorders
No one has been able to predict which of these Relationship difficulties
factors will cause someone to abuse a child. A Alienation and withdrawal
significant factor is that abuse tends to be inter- Personality disorders.
generationalthose who were abused as children are
more likely to repeat the act when they become parents Physical Effects
or caretakers. Injury
In addition, many forms of child abuse arise from Death
ignorance, isolation, or benign neglect. Sometimes a Lifelong health problems
cultural tradition leads to abuse. For example, such Cognitive difficulties.
beliefs as :
Children are property Behavioral Effects
Parents (especially males) have the right to control
Problems in school and work
their children in any way they wish
Children need to be toughened up to face the Teen pregnancy
hardships of life Suicide attempts
Girls need to be genitally mutilated to assure Criminal or antisocial behavior
virginity and later marriage. Substance abuse
Aggressive behavior
What are the Results of Child Abuse? Spousal and child abuse
Child abuse can have dire consequences, during both Note: For more details on the results of child abuse,
childhood and adulthood. The effects of being abused see the Long-term consequences of child abuse and
as a child vary according to the severity of the abuse neglect, from the Child Welfare Information Gateway
and the surrounding environment of the child. If the of the US Department of Health and Human Services.
family or school environment is nurturing and You may be afraid to report child abuse because
supportive, the child will probably have a healthier of possible repercussions to the child or yourself. You
outcome. probably will be relieved to know that :
10 Essentials of Pediatric Dentistry

The child abuse will be confirmed before the child To identify paroled sex offenders National Sex Offender Public
is removed from the home. The authorities will who live in your neighborhood Registry and Federal Bureau of
Investigations Investigative
investigate, and if your suspicions of abuse are
Programs : Crimes Against
correct, the child will then be removed from the Children (individual state databases)
home and placed in safe care. To deal with bullies, at school Dealing with bullies (for kids)
Reporting is anonymous. In most states, you do or elsewhere and Bullying and your child
not have to give your name when you report child To deal with possible child When your child is missing :
abuse. The child abuser cannot find out who made kidnapping A family survival guide
To deal with abusive coaches Parenting: Dealing with
the report of child abuse.
abusive coaches.
Remember that suspected child abuse is sufficient
reason to make a report to authorities. You do not need
Child abuse tends to be cyclical, repeated
proof. Your call may save the life of a child.
generation after generation. A child who has
How can Child Abuse be Prevented or experienced the trauma of child abuse may repeat the
Stopped? pattern by growing into an adult who delivers abuse
to the next generation. The only way to stop such a
Tips for preventing or stopping child abuse cycle is to work with parents, prospective parents, and
What you want to accomplish? Where you can get help? other caregivers who seek help or who are referred
To keep from physically hurting Twelve alternatives to Lashing for help.
your child when you are angry out at your child and Mental health professionals and others can prevent
Disciplining Children without child abuse by:
spanking or other physical Establishing educational programs to teach
caregivers good parenting and coping skills.
To console a crying baby. Some suggestions for coping
with a crying baby Making people aware of alternatives to abusive
To intervene when you witness What can I do to stop child behaviors so that they seek help for their own
child abuse in a public place abuse in a public place? abusive tendencies.
To report suspected child abuse How do I report suspected Educating the public about abuse so that people
child abuse?
report abuse early enough for intervention.
To protect your child from abuse.. Following simple rules to
prevent child abuse Establishing relationships of trust with children so
To keep your children safe on AboutKids Safety and that they feel comfortable disclosing abuse. Then
the internet Protection from child abuse on someone can intervene early on.
the internet
To prepare your children to Self-defense (for teens) and (B) EVIDENCE OF ORAL BURNS
defend themselves self-defense resources (a
worldwide list of IMPACT Finkelstein et al have reported that children less than
style self-defense workshops 5 years of age are particularly prone to injury. The
The Practical Importance of Pediatric Dentistry 11

etiology may be varied such as thermal (Flame and

Scald), chemical, electrical and radiation. Boys of all
age groups are more prone to burn injury as compared
to girls. Health et al. have reported that 10 percent of
all cases with Battered children involve burns.
As a result of secondary wound healing and scar
contracture, burns involving the perioral and intraoral
tissues can cause varying degree of microstomia in
age between 6 months to 3 years.

Electrical Burns
Oral electrical burns most commonly occurs when
Fig. 1.3: Baby with oral electric burn
the child places the female end of a line extension
cord into the mouth A. The wound may be superficial including only the
The child sucks or chews on exposed or poorly vermillion border of one or both lips or it may be
insulated line wires. very destructive, full thickness, third degree burn.
B. The severe burns to the mouth generally involve
Pathogenesis not only a portion of the upper and lower lip, but
the commissures as well.
One possible theory is that electric arc is produced
C. Damage associated with more serious burns may
between a source of the current such as the female
extend intraorally to the tongue, labial vestibule,
end of an extension cord and oral tissues. The
floor of mouth or the buccal mucosa.
electrolyte rich saliva provides a short circuit between
D. There have been reports of damage to hard tissues
the cord terminal and oral tissues resulting in arc
such as mandible and the primary and permanent
phenomenon. This type of burn involves production
of intense heat, causing coagulation tissue necrosis
E. With 3rd degree burn, subcutaneous tissues may
(Fig. 1.3).
be damaged. The tissue destruction may be more
extensive than is initially evident since nerves are
Nature of Injury
frequently damaged the patient will probably have
Clinical manifestation depends on several factors: paresthesia or anesthesia.
(i) Degree and duration of contact, (ii) The source and F. Arterial bleeding may occur during first 3 weeks
magnitude of electric current, (iii) The state of of healing.
grounding, (iv) Relative degree of resistance at the G. Bleeding can also occur with sloughing of necrotic
point of contact. tissue that overlies regenerating granulation tissue.
12 Essentials of Pediatric Dentistry

H. The clinical appearance of an electrical burns When in place the appliance has a static base from
including lips and commissure reflects the fact that which the wings extends laterally to provide contact
wound is caused by intense and localized heat as with both commissure.
much as 300C. The shape and location of the wings are important
I. The wound is characteristic of coagulation necrosis not only in preventing contracture or cohesion of
in which there is heat induced coagulation of lips during healing but also in shaping the affected
proteins, liquefaction of fats and vaporization of commissure.
tissue fluids. The proper size of wing will enhance acceptance
J. During the first few days after the accident, the and compliance by the child and parent.
centre of lesion is generally composed of grayish After delivery of appliance patient is usually seen
or yellowish tissue that may be depressed relatively at 2 days, 1 week, 3 weeks, 7 weeks during this
and has slightly elevated narrow erythematous period, if required modification of wings are made.
margin of tissue that surrounds. Infants and toddlers who do not have primary
K. Within few hours after the injury there may be great
molars that can be used for intraoral anchorage
increase in edema. The margins of the wound may
should given headgear type of extraoral anchorage
be become ill-defined and the lips protrubent. In
7-10 days the edema begin to subside. The
Patient who did not have access to burns appliance
delineation between the central nonviable tissue
and the surrounding viable tissue become more therapy may require a commissurotomy to re-
apparent. The necrotic tissue eschar appear and establish the original dimension and symmetry of
begin to separate from surrounding viable tissues. mouth.
The eschar slough off 1-3 weeks after the burn. The American burn association injury severity
Healing occurs by secondary intention as grading system has classified burns in children as
granulation tissue proliferates and matures. Minor: I and II degree burn less than 10 percent of
body surface area in children.
Moderate: II degree of burn 10-20 percent body
i. Assess the general health of patient. surface area.
ii. Local measures are undertaken such as control
III degree burn less than 10 percent of body surface
of minor hemorrhage, conservative debridement
of non-viable tissue. area.
iii. Immunization of patient by tetanus toxoid or Major: II degree of burn more than 20 percent, III
DPT. degree burn at least 10 percent of body surface area,
iv. If bleeding persists place firm pressure with inhalational burns or electrical burns, all burns in
gauze for 10 mins. infants, and burn which the patient is at poor risk due
v. Acrylic prosthetic appliance should be given. to preconditions.
The Practical Importance of Pediatric Dentistry 13

(C) BITEMARKS EVIDENCE are formed when teeth are pressed into tissue with a
gradually increasing pressure on contrast, upper teeth
DEFINITION form a series of arches where the tissue is sucked into
Bite the mouth and pressed against the back of tooth with
Is to tear or seize with the teeth. c. Aggressive bitemarks: These marks may show
evidence of scraping, tearing and avulsion of
Bitemark the tissue. This usually involves ears, nose or
A mark caused by teeth alone or is combination with nipples. Such bites may be difficult to interpret.
other oral parts or consists of teeth marks produced
by antagonists teeth can be as two opposing arch BITE MECHANISMS
marks. Tooth Pressure

Classification of Bitemarks Marks are caused by direct application of incisal edges

of anterior teeth or occlusal surfaces of posterior teeth.
Depending on biting agent The mark will depend on
a. HumansChildren, adult Force applied
b. AnimalsMammals, reptiles, fishes Duration of force applied
c. MechanicalFull denture Movement between teeth and tissue.
Sawblade tooth marks, electric The pale area represents the incisal edges and
cord, bicycle chain, belt marks, bruising represents the margin of incisal edge.
etc. Shape of the mark may be useful in identification
Depending on material bitten of specific tooth.
a. Skin-Humans, animals Tooth bitemark as attack or defensive bitemark
b. Perishable itemsFood items like cheese, is commonly seen in battered child syndrome.
apple, etc.
c. Nonperishable itemsUndrimated objects Tongue Pressure
like pipes, pen, pencils.
Is caused when material is taken into mouth and
Depending on degree of biting
pressed by tongue against teeth or palatal rugae.
a. Definite bitemarks: Tooth pressure marks are
This leave a distinctive mark due to mechanism of
formed when a direct application of pressure
suckling, a combination of sucking and tongue
by the biting edges has caused tissue damage,
other marks are caused by tongue pressing
Suck mark has a radiating linear abrasion pattern
tissues between necks of teeth.
surrounding the central area and resembling a
b. Amorous bitemarks: These marks, made in amorous
circumstances, tend to made slowly with the absence of sunburst. These are mostly found in sexually
movement between teeth and tissue. Lower teeth marks associated assault.
14 Essentials of Pediatric Dentistry

Tooth Scrape b. Age: Infants and old people tends to bruise easily
and extensively. Infants because of delicate,
May caused by teeth scrapping across the surface
loosely attached skin and presence of subcutaneous
fat. Old people because of decreased elasticity of
These marks are usually inflicted by the anterior
skin and lost subcutaneous fat.
c. Sex: Females tend to bruise more easily than males
May appear as scratches or abrasion.
and also bruise marks persists longer in females
If scratches, they might indicate a peculiarity of
because of more subcutaneous fat and delicate
incisal edges and assist in identification.
Factors Affecting Bitemarks Injury d. Time: The duration of bitemark depends onforce
applied and amount of tissue damage. Thinner area
a. Inherent skin factor: Loose skin at the site of injury retain the marks longer.
(i.e. around the eye) will bruise easily and e. Vascularity: The intensity of discoloration depends
extensively where excess of subcutaneous fat is on vascularity. Bruises will occur and last on a
present as compared to skin supported by fibrous more vascular area like face than in the site which
tissue with a good muscular tone. is less vascular like bite on hand or foot.
Pain Reaction Control: Sedation

DEFINITION OF PAIN Levels of Sedation

The English word pain is derived from an ancient a. Minimal sedation
Greek word meaning penalty and a Latin word b. Moderate sedation
that meant punishment as well as penalty. c. Deep sedation
When the term pain is used in clinical dentistry or d. General anesthesia.
medicine, it is synonymous with strong discomfort.
Pain signals real or apparent tissue damage that (A) MINIMAL SEDATION
thereby energizes the organism to take action in
relieving or alleviating its presence.
Pain is a highly personalized state attending tissues Decrease or eliminate anxiety
damage that is either real (e.g. skin laceration) or Facilitate coping skills.
apparent (e.g. excess bowel distention) as a result
of an adequate stimulus. Patient Responsiveness
Subjectively, the patient may sense and/or express
less anxiety about the clinical procedure compared
Sedation represent a continuum whose effects vary to presedation periods.
from very mild anxiolysis to a deep sedation Objectively, the patient may appear Calmer and
indistinguishable from general anesthesia. Sedation, less overly responsive to clinical stimuli, and
depending on its depth, produces a relative reduction purposefully interactive with the clinician
in anxiety facilitating. compared to presedation periods.
i. The opportunity to invite the patient to use Physiological Changes
learned coping skills Patient remains stable and within age appropriate
ii. The raising of the pain reaction threshold. and health status norms for parameters involving
16 Essentials of Pediatric Dentistry

hemodynamic, ventilation, and oxygenation hemodynamic, ventilation, and oxygenation functions.

functions. No loss of protective reflexes.
No loss of protective reflexes. Personnel Needed Monitoring Equipment
Personnel Needed Monitoring Equipment Blood pressure cuff/sphygmomanometer, pulse
Clinical observation unless patient becomes oximetry.
moderately sedated, then appropriate monitoring Precordial/pretracheal stethoscope
needed. Capnograph/endtidal carbon dioxide monitor.


Eliminate anxiety; coping skills unaffected and
Decrease or eliminate anxiety facilitate coping skills.
overridden. Patient uneasily aroused but may respond
Younger patients show age appropriate behaviors
to purposeful stimulation.
including crying, older patients demonstrate interactive
state. Patient Responsiveness
Patient Responsiveness
The patient may sense and/or express limited or no
Subjectively feelings of anxiety associated with the clinical
The patient may sense and/or express less anxiety procedure.
about the clinical procedure compared to presedation Objectively
period. The patient may appear very relaxed, not cognizant
Objectively of an minimally or nonresponsive to clinical stimuli,
and non-interactive with the clinician at any time. The
The patient may appear less tense cognizant of, but patient would not be able independently to move his/
less overtly to clinical stimuli, responsive and her head and/or mandible to maintain optimal airway
purposefully interactive with the clinician compared patency consistent with the clinical situation and under
to presedation period. these circumstances, require continuous monitoring of
The patient if behaviorally and cognitively the airway and continual assistance of the clinician
cooperative should be able independently to move his/ (e.g. head tilt, chin lift procedure).
her head and/or mandible, as directed by the clinician, Physiological Changes
and to assist in maintaining optimal airway patency. Patient remains stable and either minimally or
moderately below the patients age and health status
Physiological Changes norms for haemodynamic, ventilation and oxygenation
Patient remain stable and within age-appropriate and functions. Accompained by partial or complete loss
health status norms for parameters involving of protective reflexes.
Pain Reaction Control: Sedation 17

Personnel Needed Monitoring Equipment (A) STANDARD TITRATION TECHNIQUE

Blood pressure cuff/sphygmomanometer
Pulse oximetry Nitrous oxide should be started at 10 percent
Precordial/pretracheal stethoscope concentration and administered in increments of
Capnograph/end-tidal carbon dioxide monitor concentration, ranging from 5 to 10 percent until
Electrocardiogram. the patient becomes comfortable and some clinical
signs of optimal sedation are noted such as
(D) GENERAL ANESTHESIA Slight relaxation of the limbs and jaw muscles.
GOAL Ptosis of the eyelids, a blank stare.
Slight change in the pitch of the patient's voice;
Eliminate sensory and skeletal motor activity and patient reports of being comfortable and
autonomic activity depressed.
Patient Responsiveness Each time the clinician increases the concentration,
he or she would wait approximately 30 seconds
Unconscious and unresponsive to surgical stimuli. while talking with the child and watch for classical
Physiological Changes signs of optimal sedation before deciding to
Partial or complete loss of protective reflexes including
increase concentration again most children seem
the airway, does not respond purposefully to verbal
comfortable and demonstrate optimal signs and
command or physical stimulus.
Personnel Needed Monitoring Equipment sedation in the concentration range of 35 to 50
Temperature percent nitrous oxide.
Blood pressure cuff/sphygmomanometer
Precordial/pretracheal stethoscope.
This technique is usually indicated for mild to
moderately anxious, potentially cooperative child
who may be on the edge of losing coping abilities
and need to be controlled quickly by clinician.
The technique involves administering 50 percent
It is inhalational route of administration for minimal nitrous oxide immediately to the patient without
and moderate sedation. any titration steps.
In either technique, nitrous oxide should be
Dose Control (Titration) discontinued if the child becomes disruptive and no
There are two ways to initially administer nitrous oxide longer breathes through nitrous oxide hood or if the
to children. child becomes nauseated, vomits or both.
18 Essentials of Pediatric Dentistry

Advantages Categories: Sedative hypnotic fall into two

Nitrous oxide lack any serious adverse effects, it is
Barbiturates: Pentobarbital, Secobarbital,
considered to be inert and nontoxic when it is
administered with adequate oxygen.
Non-barbiturates: Chloral hydrate25 to 45 mg/
kg paraldehyde
The use of nitrous oxide in pediatric dentistry also Antianxiety Drugs
has several disadvantages.
Antianxiety drugs are minor tranquilizers;
Weak agent
antipsychotics drugs are called major tranquilizers.
Lack of patient acceptance
Primary effect: Decreases anxiety.
Inconvenience, especially in small children
Site of primary effect: Limbic system, which is
Potential chronic toxicity: Dental office personnel
the 'seat of emotions'.
who were exposed to trace levels of nitrous oxide The antianxiety agents consists primarily of the
suggest a possible complications like spontaneous benzodiazepines, such as diazepam (valium),
abortions, congenital malformations, certain midazolam (versed) and triazolam (halcion).
cancers, liver disease, kidney diseases and Unfortunately, there is a lack of extensive clinical
neurologic disease. experience and research on these agents in
There results underscore the necessity for children.
scavenging (removing) waste gases adequately from
the dental operatory. Narcotics
These drugs are used also in sedation for their primary
Sedative Hypnotics action of analgesia.
Sedative hypnotics are drugs whose principal
effect is sedation or sleepiness. Site of Primary Effect
Primary effect: Sedative hypnotic used alone may Opioid receptors of the CNS.
lower the pain reaction threshold in some cases
by removing inhibitions, and at inadequate dosages Effects
it may simply produce a patient who is more These drugs modify the interpretation of the pain
responsive to pain stimulation. stimulus in the CNS and therefore raise the pain
Site of primary effect: Reticular activating system, threshold; as the dose of narcotics are increased, other
an area of the brain involved in maintaining effects such as sedation will occur.
consciousness. Narcotics used in sedation techniques include
Effect: Sedation/sleep morphine, meperidine and fentanyl.
Antimicrobials in
Pediatric Dentistry

A large number of antimicrobial agents are available for use in pediatric dentistry.
Antimicrobial spectrum and preferred therapeutic agents.
Microbial spectrum Class of preferred antimicrobial Examples
i. Gram-positive aerobic bacteria Natural penicillins Penicillin G
Penicillin VK
Penicillinase resistant penicillins Oxacillin, Nafcillin, Methicillin
Aminopenicillins Ampicillin, Amoxicillin
Macrolides Erythromycin
Glycopeptides Vancomycin
Cephalosporins Cefazolin
Cephalexin, Cefaclor
Lincosamides Clindamycin
Topicals Bacitracin, Mupirocin
ii. Gram-negative aerobic bacteria Aminoglycosides Gentamycin, Tobramycin, Amikacin
Extended spectrum penicillins Mezlocillin, Piperacillin
Antipseudomonal penicillins Carbenicillin
Monobactams Aztreonam
Carbapenems Imipenem,
Cephalosporins Ceftazidime
Sulfonamides Trimethoprim, Sulfamethoxazole
20 Essentials of Pediatric Dentistry


Microbial spectrum Class of preferred antimicrobial Examples

iii. Broad spectrum antibacterial 3rd/4th generation cephalosporins Cefotaxime, Ceftiaxone
-lactam + -lactamase inhibitor Ampicillin + Sulbactam
combinations Amoxicillin + Clavulanate
+ Ticarcillin Calvulanate
Quinolones Ciprofloxacin, Ofloxacin,
Sparfloxacin, Norfloxacin
Tetracyclines Tetracycline
Chloramphenicol Doxycycline, Minocycline
iv. Anaerobic bacteria Penicillin Penicillin G
Cephalosporins Cefotetan, Cefoxitin
Carbapenems Imipenem + Cilastin, Ertapenem
Lincosamides Clindamycin
Chloramphenicol Chloramphenicol
Metronidazole Metronidazole
v. Fungal infections Polyenes Amphotericin B
Azoles Fluconazole, Itraconazole,
Topical antifungal Nystatin, Clotrimazole
vi. Viral infections Antiherpes virus agents Acyclovir, Ganciclovir, Foscarnet,
Topical antiherpes agents Trifluridine, Idoxuridine

Antimicrobials may also be categorized according to
Azole antifungals.
their mode or site of action.
Inhibition of protein synthesis
Bind 50s ribosome
Antimicrobials: Mode of Action
Inhibition of cell wall synthesis Chloramphenicol
Cephalosporins Lincosamides
Monobactams Oxazolidinones
Carbapenems Streptogramins
Antimicrobials in Pediatric Dentistry 21


Bacterial resistance to antibiotics is one of the
significant challenges in the management of
infectious diseases.
The development of resistant bacterial strains may
Alteration of cell membrane permeability
be minimized by consistently using an appropriate
antibiotic dosage for an adequate period of time.
Clotrimazole (antifungal)
Polyene antifungals
Inhibition of nucleic acid synthesis
Rifampin For gram-negative infections, especially pseudomonas
Griseofulvin infections, or infections with enterococci, treatment
Nucleoside antivirals with combination of antibiotics -lactam and amino-
Topoisomerase inhibitors glycosides may help to prevent the emergence of
Malidixic acid resistant strains.
Quinolones Note: When planning combination drug therapy it is
Inhibition of cytochrome sterol important to select antibacterial agents that have
Azoles (antifungals). synergistic or additive activity.
Dental Public Health Issues
in Pediatric Dentistry

WHAT IS DENTAL PUBLIC HEALTH? public health. Dental public health practitioners share
the belief that the public's dental health can be
Dental public health is a field of study within the
broader field of public health. Its philosophy and improved by altering conditions-behavior, the
substance reflect public health and its focus on the environment, biological interactions, and the
community rather than on the individual patient. organizations of servicesthat might otherwise, at a
The ADA has recognized dental public health as future time, have an adverse impact on health.
one of nine-specialties of dentistry. The American The practice of dental public health requires a set
Board of Dental Public Health (ABDPH) defined of methods and skills to make that belief a reality.
dental public health as Dental public health practice can be considered
The science and art of preventing and as engaging in the processes and activities required
controlling dental diseases and promoting dental to carry out the three public health functions.
health through organized community efforts.
It is that form of dental practice that serves the Assessment
community as a patient rather than individual. It is
i. Documenting the oral health status of children
concerned with dental health education of the public,
through epidemiologic surveys.
with research and the application of the findings of
ii. Assessing the supply and availability of dentists
research with the administration of programs of dental
to meet the needs of children.
care for groups and with the prevention and control of
iii. Assessing the status of water fluoridations in
dental disease through a community approach.
iv. Assessing the need for dental care for children
with special health care needs.
Prevention is the bedrock of public health practice, v. Identifying barriers to dental access.
and it is also the foundation for the practice of dental vi. Screening children before entering school.
Dental Public Health Issues in Pediatric Dentistry 23

Policy Development viii. Integrating oral health services into appropriate

health, education, and social service programs
i. Developing policies and advocating for
legislative action to ensure access to oral health (e.g. maternal and child health, nutrition, school
services for low income, under served, hard to health).
reach, and vulnerable children. To address and respond to these core functions,
ii. Developing programs that focus on primary and three categories of management-related activities have
secondary prevention. been identified
iii. Developing programs to provide dental care to Program planning
children with special health needs or without Implementation
access to adequate dental care. Evaluation.
iv. Adopting state rules mandating oral health
screening for children entering school for the MEDICAID
first time.
Medicaid is a jointly funded federal state
entitlement program that provide benefits for
medical and health related services to Americas
i. Encouraging and coordinating efforts to provide poorest people.
oral health education and promotion in schools, Medicaid covers three main groups of low-income
clinics, community settings, and other settings. Americans: Parents and children, the disabled, the
ii. Expanding or establishing new dental clinical elderly.
iii. Developing promotional activities by the state Early Periodic Screening, Diagnostic and
health agency to meet the oral health needs of a Treatment (EPSDT) Services
specific target group or community.
iv. Targeting topical and systemic fluoride The EPSDT service is Medicaids Comprehensive and
programs to areas with nonfluoridated water preventive child health program for individuals under
supplies and high risk populations. age 21.
v. Including an oral health component in all school
health initiatives. Dental Services
vi. Establishing school-based prevention programs
and school linked dental clinics as components EPSDT dental services include diagnostic, preventive,
of comprehensive school health. and therapeutic or treatment services needed for relief
vii. Establishing programs to train medical of pain and infection, restoration of teeth, maintenance
professionals and other health related workers of dental health, starting at as early an age as deemed
to recognize oral health problems, including necessary and in accordance with current standards
early childhood caries. of dental practice.
24 Essentials of Pediatric Dentistry

Barriers to Care for Infants and Toddlers iv. Have difficulty finding a dentist who will treat
from Low Income Families children younger than 3 years.
Dental care for infants and toddlers from low income Despite EPSDT program requirements that eligible
families presents a dilemma for several reasons. children visit a dentist by age 3 (or younger in some
These children often: states), the use of dental services by low income
i. Lack financial access to care.
children ages 0-3 remains extremely low.
ii. Have caregivers who fail to recognize the
importance of early dental visits. Continuing efforts are needed to convey the
iii. Have difficulty finding a dentist who accepts importance of early dental visits for this group of
Medicaid. children.
General Topics to
be Considered

Q. Describe differences between permanent and ANS. MORPHOLOGICAL DIFFERENCES

deciduous teeth and explain how morphology and
The Crown
histology of both dentition differs?
Primary teeth Permanent teeth

Lighter in color, bluish white (milky white) also Darker in color, grayish or yellowish white
called as milk teeth as its refractive index is
same as milk, i.e. 1
Duration of deciduous dentition is from 6 months Duration of permanent teeth is 6 years onwards
to 5 yrs.
Number of teeth = 20; 2 incisors, 2 molars, 1 canine Number of teeth = 32; 2 incisors, 1 canine, 2 premolars,
(five teeth in each quadrant) 3 molars (eight in each quadrant)
Smaller in all dimension Larger in all dimensions
The crowns are wider mesiodistally in relation to The crowns are large in cervicoocclusal dimension than
cervicoocclusally this gives cup shape to anterior in mesiodistal dimension this gives larger appearance to
teeth and squat shape to posterior teeth (molars) permanent anterior teeth.
Cuspids are slender and tend to be more conical Cuspids are less conical
The cervical ridges are more pronounced especially Cervical ridges are flatter
on the buccal aspect of first primary molar
Buccal and lingual surface tend to converge towards There is less convergence of buccal and lingual surfaces
occlusal surface especially in primary I molar so that of molars towards occlusal surface
they have narrow occlusal table in buccolingual plane
Occlusal plane is relatively flat The occlusal plane has more curved contour
Molars are more bulbous and are sharply constricted They have less constriction
(bell-shaped) cervically of neck
28 Essentials of Pediatric Dentistry

Primary teeth Permanent teeth
The enamel is thinner and has a more consistent depth The enamel is thicker and has thickness of 2-3 mm
of about 1 mm thickness throughout the entire crown
The contact areas between molars are broader, flatter The contact point between permanent molars is situated
and situated gingivally occlusally
The enamel rods at the cervical slopes occlusally The enamel rods are oriented gingivally
from DEJ
The supplemental grooves are less The supplemental grooves are less
Mamelons are absent because primary teeth develop Mamelons present on incisal edges of newly erupted
from single lobe incisor teeth
First molar is smaller in dimension than the First molar is larger in dimensions than the second
second molar molar

The Root
Primary teeth Permanent teeth

The roots are larger and more slender in comparison Roots are shorter and bulbous in comparison to crown
to crown size
Furcation is more towards cervical area so the root Placement of furcation is apical thus root trunk is
root trunk is smaller larger
Roots are narrower mesiodistally Roots are broader mesiodistally
At the cervical region, the roots of primary molar Marked flaring of roots is absent
flare outwards and continued to flare as they approach
apices to accommodate permanent molars
Undergo physiologic resorption during sheding of Physiologic resorption is absent
primary teeth

The pulp: The pulp chamber anatomy in both primary and permanent teeth closely approximates the surface
shape of crown.
Primary teeth Permanent teeth
Pulp chamber is larger in relation to crown size Pulp chamber is smaller in relation to crown size
Pulpal outline follows DEJ more closely Pulpal outline follows DEJ less closely
Pulp horns are closer to the outer surface. Mesial pulp The pulp horn are comparatively away from outer
horn extends to a closer approximation of surface surface
than does the distal pulp horns

General Topics to be Considered 29

Primary teeth Permanent teeth
High degree of cellularity and vascularity (at least in Comparatively less degree of cellularity and vascularity
stages prior to advanced physiological resorption in tissue
of roots
High potential for repair Comparatively less potential for repair
Compartively less tooth structure More tooth structure protecting for repair
Greater thickness of dentin over the pulpal wall at the Comparatively lesser thickness of dentin over the
occlusal fossa of molars pulpal wall at occlusal fossa of molars
Root canals are more ribbon like. The radicular pulp Root canals are well-defined with less branching
follows a thin, branching and tortous path
Floor of pulp chamber is porous. Accessory canals Floor of pulp chamber does not have any accessory
in primary pulp chambers. Floor leads directly into canals
inter-radicular furcation

Primary teeth Permanent teeth
Roots have enlarged apical foramen. Thus, abundant Foramen are restricted. Thus, reduced blood supply
blood supply demonstrate a more typical inflamma- favors calcific response and healing by calcific scarring
tory response
Incidence of reparative dentin formation beneath Reparative dentin formation is less.
the carious lesion is more extensive and irregular
Pulp nerve fibers passes to the odontoblastic area, Pulp nerve fibers terminate mainly among the odontoblasts
where they terminate as free nerve ending and even beyond the predentin
Density of innervation is less because of which Density of innervation is more
primary teeth are less sensitive to operative
procedures. Neural tissue is first to degenerate when
root resorption begins
Localization of infection and inflammation is poorer Infection and inflammation in pulp is localized
in pulp
30 Essentials of Pediatric Dentistry

Mineral Content
Primary teeth Permanent teeth
Enamel and dentin are less mineralized Enamel and dentin are more mineralized
Neonatal lines present in both enamel and dentin Neonatal lines seen only in I permanent molars (as
mineralization takes place at birth)
Enamelbands of Retzius are less common; this may Bands of Retzius are more common
be partly responsible for bluish white color of enamel
Dentindentinal tubules are less regular Dentinal tubules are more regular
Dentin thickness is half that of permanent teeth. As a Dentin forming cells are functionally active by
result dentin forming cells are functionally active by 700 days
approximately 360 days
Interglobular dentin is absent Interglobular dentin is present just beneath the
homogeneous and well-calcified mantle layer of dentin
Dentin is less dense. This difference can be observed The dentin is difficult to cut
clinically by resistance offered to cutting of the bur.
The dentin cuts more easily and also abrades more

Periodontal Structure
Primary teeth Permanent teeth
Cementum is very thin and is of primary type; Secondary cementum is present
secondary cementum is characteristically absent
Alveolar atrophy is rare Alveolar atrophy occur
Gingivitis (Gingival inflammation) is absent in Gingivitis is common in adults
healthy child, similarly, the recession is infrequent

YOUNG PERMANENT TOOTH Features of Young Permanent Teeth

in Normal Circumstances
i. Fundamental curvaturesproximal contacts are
It is a tooth just recently erupted into oral cavity and present initially which gets transformed into
which does not have its root completed. contact areas
The eruption time is 6-12 years. ii. A lot of interdental spaces; later they get closed
Calcification time is birth to 3 years. by physiological mesial migration
General Topics to be Considered 31

iii. Embrassure Dentin is structurally made up of dentinal

iv. Crown elevations and depressions as cusp or tubules in young permanent tooth we can see
fossae, pits and fissure, ridges, development 75,000-80,000/mm2
groove, mamelonsas teeth erupts and In old permanent teeth 35000-40000 tubules/
develops these cusps get rounded, pits become mm2
shallow and mamelons is not differentiated. The incremental apposition of circumpulpal
v. Deepen gingival sulcus and pseudopocket. dentin is 4 m/day. In old age is 0.5 m/day.
vi. Active and passive eruption. Dentin is more permeable due to widened
vii. Root apex is wide open and the apical foramen dentinal tubules.
is funnel-shaped which is filled with periodontal Later they are calcified as aging process goes
tissues which get transformed into dentin and on; usually they are filled with dental lymph.
cementum. As teeth develops the apical foramen As tooth become older mineralization occur
is going to narrow down. and dentinal tubules are obliterated (sclerotic
Inorganic 45-50 percent
Enamel composition: Water and organic 50-55 percent
Inorganic86 percent Cementum is of cellular type and is more
Organic2 percent permeable.
Waterrest Periodontal ligament: Highly cellular and vascular
Enamel in young permanent tooth is more in YPT (young permanent tooth)
permeable. Pulp: Wide pulp chamber with wide open apical
Surface texture like perikymata and enamel foramen.
lamellae is seen.
More cellular and vascular
Coating of developmental origin, enamel
cuticle or nasmyth membrane or primary As the pulp gets older the fibrous tissue
enamel cuticle or dental cuticle. increases.
Reduced enamel epithelium
Coronal cementum Clinical Consideration
Coating of acquired originPlaque and Preventive Measures
salivary pellicle.
Dentin: Fluoride application: Topical and systemic,
Inorganic70 percent enameloplasty, prophylactic odontomy, pit and fissure
Water and organic content30 percent sealant
Thickness of dentin is very less with time the Treatment of young permanent tooth
dentin increases due to constant deposition of For initial caries: Normal conventional
dentin by pulpodentinal complex. restoration.
32 Essentials of Pediatric Dentistry

For Deep caries: Indirect pulp capping, direct pulp If supernumeraryextraction

capping, pulpotomy, apexogenesis Vital tooth, If it is a deciduous tooth try to retain in oral cavity
apexification nonvital tooth and at last to prevent future arch deficiencies. Round off sharp
extraction. margins to prevent injuries
For extraction of natal or neonatal teeth wait till
Natal and Neonatal Teeth patient is 10 days old. This is to prevent hemorr-
(Predeciduous Teeth) hage due to hyperprothrombinemia. This waiting
Natal teeth: Teeth present at the time of birth. period of 14 days allow the intestinal flora of infant
Neonatal teeth: Teeth that erupt within 30 days of birth. to produce vitamin that is essential for adequate
Teeth which erupt after 30 days are called as early prothrombin level
For extraction of teeth apply topical anesthesia
infancy teeth.
followed by finger with gauze piece in case of
hypermobile teeth. In case of firm tooth, use
narrow beak forceps
Extremely rare teeth when these are present they Care should be taken to prevent aspiration of tooth
cause difficulty in feeding. The sharp incisor edge of tooth may cause
laceration of lingual surface of tongue which is
Prevalence called Riga-Fede disease in such cases tooth has
to be removed
Seen 1 in 2000 births, almost 95 percent of teeth If breastfeeding is painful to mother, use of breast
(natal, neonatal are a part of deciduous teeth rest pumps and bottling of milk is recommended.
may be supernumerary teeth). However, infant can be conditioned not to bite
The commonest site of occurrence is mandibular during sucking process.
anterior region; posteriorly seen very rarely. In short period of time, if mother persists breast-
feeding it is seen that infant senses of mother
Clinical Features discomfort and learns to avoid causing injury.
Look like a miniature cells containing enamel and
dentin with or without roots.
Teeth without roots are hypermobile. Problems associated with eruption of teeth.

As soon as parent comes; take a proper history of It is physiological process of eruption of teeth into the
immunization oral cavity usually this occurs without any problem
If tooth is hypermobile; due to risk of aspiration it but in some infants, it is associated with some systemic
is extracted disturbances and local symptoms. This symptoms are
If it is firm go for IOPA to confirm it is super- usually seen during 6th month to 2nd year of age of
numerary or deciduous child.
General Topics to be Considered 33


Excessive irritability Rampant caries are suddenly occurring (acute) growing
Refusal to eat and sleep type (widespread caries) with early pulpal involvement
Excessive drooling of saliva of teeth which are usually immune to decay (Masseleu
Fever with chills, vomiting, dermatitis and gastro- 1945).
intestinal disturbances
Cough, convulsions
Jaw grinding, finger sucking. GENERAL FEATURES
Various authors have related teething to systemic
i. Many teeth are involved
disturbances and they say this is a physiological
ii. Seen in children and adolescents
process. iii. Carious lesion occurs on the surfaces generally
Where in the systemic disturbances are: considered to be at low risk of decay
i. Loss of maternal antibodies iv. Prevalence = 5-8 percent
ii. Infections v. Females are more prone than males
iii. Development of immunological response. vi. Age: 4-8 yrs Children
11-18 year Adults.
Treating the symptoms is a treatment of choice i. Diet
If there is no improvement, refer the child to a ii. Pathologic microorganisms
physician iii. Teeth (Host for microorganisms to act)
Lancing or incising the gingiva over tooth is iv. Time
contraindicated v. Behavioral pattern
Commercially available teething rings can be vi. Other factorscarbohydrate metabolization by
prescribed microorganism produces acids.
Local pain symptoms are relived by applying a. Lactobacillus and streptococcus
topical anesthetics or advising analgesics b. Teeth surfaces that are susceptible to acid
Inflammation of the gingiva may be seen which is degradation.
reduced in few days c. Parent overindulgence/parent ignorance.
Few authors have seen that teething causes day
time restlessness which in turn increases the General Factors
amount of finger sucking or rubbing of gums, Emotion, fear
which in turn increases the drooling of saliva, Dissatisfaction of achievement
leading to loss of appetite and eventually loss of Traumatic school appearances
weight. Feeling of inferiority
34 Essentials of Pediatric Dentistry

Tension and anxiety Institution of preventive procedures

Xerostomia Restoration and rehabilitation.
Radiation therapy Management is Undertaken Under
Improper removal of neoplasm. Pediatrician
Clinical Features Dental nurse
Seen in primary and permanent dentition. Pedodontist.
In primary teeth features are related to order of
tooth eruption. Control of All Active Carious Lesion
Initial lesions appears on labial surface of maxillary Gross excavation of caries and restoration with
incisors near the gingival margin as a white area/ ZOE which will temporarily arrest the caries
pitting on enamel surface. process and prevent pulp involvement
In permanent teethRelated to the eruption of Reduction in intake of carbohydrates
teeth. Diet analysis and diet counselling
Here buccal and lingual surface of premolar Snacks should be suppressed
and molar are involved.
Application of topical fluorides
Proximal and labial surface of maxillary
Repeat single fluoride application therapy every
incisors and proximal surface of mandibular
3 months.
incisors are involved.
If there is no loss of enamel, topical fluorides are
Complications given.
If there is extensive cavitation with no pulp
Affects maxillary anteriors which may lead to involvement in anterior teethGIC,
psychological problem due to loss of esthetics polycarboxylate cement and in Posterior teeth-
Minimal trauma can lead to fracture of teeth amalgam, stainless steel crown are given.
Difficulty in speech Extensive cavitation with pulp involvement
Development of abnormal habits
pulpotomy, pulpectomy.
Orthodontic problems
Multiple abscess formation NURSING BOTTLE CARIES
General health impaired
Hospitalization may be required. It is a unique pattern of caries in very young children
due to prolonged and improper feeding habits.
Aims of Treatment
Management of existing caries
Control of caries Teeth (Host for microorganisms to act)
General Topics to be Considered 35

Time Substrate (Fermentable carbohydrate)

Pathologic or pathogenic microorganisms Carbohydrates are utilized by microorganism
Diet. to produce dextrans.
a. Adhere microorganisms to tooth surface
Etiological Agents b. Initiate producing organic acid to
demineralize the tooth.
Bovine milk, milk formulas and human breast milk
In infants and toddlers, the main source of
have all been implicated in nursing caries because of
fermentable carbohydrates are:
their lactose content. Additional sweetners in form of
Bovine milk, milk formulas
juice, honey dipped pacifiers can also cause this type
Human breast milk
of caries.
Additional sweetners like juices, honey
Nursing bottle can effectively block the salivary
dipped pacifiers or pacifiers dipped in
access to the tooth surface, thereby increasing the
sugar solution
cariogenicity of oral flora.
Sweet syrups like vitamin preparations
The basic mechanism of demineralization (caries Chocolates or other sweets.
initiation, is key in the whole process of nursing caries Host
as all four variables) Teeth acts as host for microorganisms to act.
Pathologic MicroorganismStreptococcus Hypomineralized or hypoplasia of teeth
mutans is the principal microorganism principal increases the susceptibility of child to caries.
which colonises the teeth after it erupts into the
Thin enamel in primary teeth is one of reason
oral cavity.
of early spread of lesion.
It is transmitted to infants mouth primarily
Developmental grooves acts as plaque
through the mother.
retentive areas.
It is considered more virulent because of
a. It colonizes the teeth
b. It produces large amount of acids More the time child sleeps with bottle in mouth,
c. It produces large amount of extracellular the higher is risk of caries. This is because salivary
polysccharides which favor plaque flow, swallowing reflex decreases thus provide
formation. more time for accumulation of carbohydrates in
It is seen that child's infection is of 9 time mouth which is acted upon by microorganism to
greater who's maternal salivary count of produce acids leading to caries.
Streptococcus mutans is greater than 100,000 Other Predisposing Factor
colony forming unit per ml. Overindulgence of parents
S. mutans are more evident in rapid and smooth Crowded homes
surface caries and less common in pit and Malnutrition
fissure caries. Low-birth weight infants (less than 2500 gm)
36 Essentials of Pediatric Dentistry

Recently, it has been seen that salivary gland Implication

function is impaired by iron deficiency, excess
The child who have nursing caries has an increased
of lead exposure, which makes the oral
environment more caries susceptible. risk of caries in permanent dentition
The child with caries are susceptible to other health
Clinical Features hazards
The treatment of nursing caries may be a financial
The intraoral decay pattern of nursing caries is burden to some parents.
characteristic and pathognomonic of the conditions.
It affects the primary teeth in the following sequence Differential Diagnosis
of involvement Rampant caries
a. Maxillary central incisor and lateral incisors: Radiation caries
Facial, lingual, mesial and distal surfaces
Enamel hypoplasia.
b. Maxillary first molars: Facial, lingual, occlusal and
proximal surfaces Management
c. Maxillary canine and II molars: Facial, lingual and
proximal surfaces
d. Mandibular molars at the later stage Management of existing emergency
e. Mandibular incisors are usually spared because Arrest and control of caries process
i. Protection by tongue Institution of preventive procedures
ii. Cleanzing action of saliva due to the presence Restoration and rehabilitation.
of the orifice of duct of sublingual glands very
close to lower incisors. Factors Affecting Management
Progression of Lesion Extent of lesion
Initially a demineralized dull, white area is seen Age of patient
along gum line on the labial aspect of maxillary Behavioral problems of child due to young age of
incisors, which is undetected by parents. child.
These white lesions become cavities which involve
the neck of tooth in a ring-like lesion.
Finally, the whole crown of incisors is destroyed
leaving behind brown black root stumps.
This unique pattern and unequal severity of the
lesion is due to three factors i. Prevention:
Chronology of primary tooth eruption The main strategies for prevention is to
Duration of deleterious habits of feeding aware and alert the parents, prospective new
Muscular pattern of infant sucking. parents about the condition and its cause
General Topics to be Considered 37

Information on nursing caries can be The parent should be asked to try weaning the child
distributed to new parents through; from using the bottle as pacifier while in bed
obstetricians or gynecologists, pediatrics, In case, considerable emotional dependence on
paramedical staff, health workers, maternal bottle, suggest the use of plain or fluoridated water
and child health care centers The parent should be instructed to clean childs
Sealing of all caries free pits and fissures teeth after every feed
Topical fluoride application
Parents are advised to maintain a diet record of
Water fluoridation in suboptimal fluoride
the child for one week which include time, amount
water level areas
of food given to child, the type of food, number of
Topical antimicrobial therapy
sugar exposure.
Supervised home care should be taught
Professional fluoride program.
Second Visit
Broad committees at government level to
address the issue of caries and risk factors It should be scheduled one week after the first visit.
in young children and how to recognize the Analysis of diet chart and explanation of disease
early signs of the condition and promote process of childs teeth should be undertaken by
early intervention. simple equation
ii. Proper treatment: Divided into 3 visits
Isolate the sugar factors from diet charts and
First Visit control sugar exposure by intelligent use
This phase of treatment constitutes treatment of the Reassess the restoration or redo if needed
lesion, identification of cause for counseling of parents. Caries activity test can be started and repeated at
All lesions should be excavated and restored monthly interval to monitor the success of
If abscess is present it is treated through drainage treatment.
X-rays are advised to assess the condition of
succeedenous teeth Third and Subsequent Visits
Collection of saliva for determining salivary flow Restoring all groosly decayed tooth
and viscosity
Endodontic treatment
Application of fluorides topically.
In case of unrestorable teeth, extraction followed
Parent Counseling by space maintainers are used
The parents are questioned about the childs Crowns can be given for groosly destructed teeth
feeding habit, especially regarding the use of or endodontically treated teeth
noctural bottles Review and recall after 3 months.
Child Psychology

DEFINITION Psychoanalytical Theory

Psychology is the scientific study of mental processes Id
and behavior.
It is the most primitive part of personality from
Psychologists observe and record how people and
which other two systems develop later.
other animals are related to each other and to
It aims to avoid pain and obtain pleasure.
environment. It is a broad field that encompasses or
explores a variety of questions such as thoughts, Freud call it psychic reality because it represents
feelings and action. The word psychology comes from the inner world of subjective experience and has
Greek word psychemind or soul and logystudy. no knowledge of objective reality.
Id cannot tolerate increased energy that are
Theories of Psychology experienced as comfortable states of tension.
When tension is raised either by external
Psychodynamic Theory
stimulation or internally produced excitation the
a. Psychoanalytical theory Sigmund Freud (1908)
function to discharge the tension immediately and
b. Psychosexual theory return to or gain to a comfortable, constant and
c. Psychosocial theoryErik Erikson (1963) low energy level, that is called pleasure principle.
d. Theory of hierarchy of needsAbraham Maslow. To obtain pleasure Id has its command on two
Behavior Learning Theories Reflex action: The inborn and automatic
a. Classical conditioning theory by Ivan Pavlov reaction like blinking and sneezing which
b. Operant conditioning theory by BF Skinner relieves tension.
c. Cognitive development theory by Jean Piaget In primary process tension is relieved by
(1952) forming an image of object that will remove
d. Social learning theory by Albert Bandura (1963). tension for example primary process provide
Child Psychology 39

the hungry man with mental image of food. It represents ideal rather than real and strives for
This hallucinating experience in which the perfection rather than pleasure.
derived object is present in the form of memory Its concern as to decide between right and wrong
image is called wish fulfilment. so it can act in accordance with the moral standards
authorized by the agents of the society.
Ego To obtain reward and avoid punishment, the child
learn to guide its behavior along the lives laid down
That aspect of psyche which in conscious and most by the parents.
in touch with reality. Finally the Id, ego, superego work together as a
The ability to understand that their impulses cannot team under the administrative leadership of ego.
always be gratified immediately comes with
development of ego, children learn that hunger In a way,
must wait until someone provide food and Id is the biological component of personality.
satisfaction of relieving bladder or bowel must be Ego is the psychological component of personality.
delayed until bathroom is reached an ego obeys Superego is the social component of personality.
the reality principle.
The child learns to differentiate between memory Psychosexual Theory
image and actual perception of food as it exists in The child passes through the series of dynamically
the outer world. differentiated stages during the first 5 years of life
Ego obeys reality principles and operates by following which a period of latency occurs in the next
secondary process; the principle of reality principle 5-6 years, a dynamic phase which becomes more or
is to prevent discharge of tension until object of less stabilized with the advent of adolescence, the
satisfaction of need has been discovered. dynamic phase; erupts again and then gradually settle
Principal role of ego is to mediate between down as the adolescent moves into adulthood.
instinctual requirement of the organism and According to Freud as child grows and develops,
conditions of the surrounding environment. different parts of the body serves as sources of
Various Stages
It is the internal representative of the traditional values
and ideals of society as interpreted to the child by their Oral stage - 1st year of life
parents and enforced by means of reward or Anal stage - 1-3 years
punishments. Phallic stage - 3-5 years
Superego obeys moral principles it is the moral Latency stage - 6 years to puberty
arm of the personality. Genital stage - Adolescence (12-18 years).
40 Essentials of Pediatric Dentistry

Oral Stage (1st Year of Life) During this stage the process of elimination
It is the earliest stage of development. become primary source of pleasure.
The infants needs of perception and mode of Fixation at this stage caused by traumatic toilet
expression are primarily centered around the training experience, may result in individuals who
mouth, lips, tongue and other regions located near are excessively orderly or stubborn, or excessively
the oral zone. generous or undisciplined.
The oral sensation include thirst, hunger, Fixation may result in characters like anal retentive
pleasurable tactile sensation evoked by the nipple or anal expulsive.
or its substitute. The personality characteristic seen in anal retentive
The oral trait consisting of wish to eat, to sleep character involve high standard of cleanliness,
and to reach that relaxation which occurs at the punctuality, stringness, stubborness.
end of sucking. Characters in anal expulsive involve interest in
If the infant is discouraged in his search for elimination of all body wastes concern for the
pleasure via sucking by too early or too abrupted manipulation of plastic materials, artists, baker,
weaning practices substantial portion of libidinal painter or all who displace and arrange mold and
energy is forever reserved, in later childhood in semisolid materials.
adult life he will devote a lot of his time and energy
to this persuit of oral erotic activities like thumb Urethral Stage
sucking, eating, smoking, talking, etc.
Successful early separation from the mother and Seen in between anal and phallic stage.
the development of child sense of self (the ego) Here urethral erotism which refers to pleasure in
depends upon the child ability to maintain an image urination and pleasures in urinary retention
of his mother in mind thus when mother is out of analogues to anal retention.
sight she can still be present as a mental image.
Characteristic clinical events mark the struggle of Phallic Stage (3-6 Years)
separation anxiety.
At about 4 years the genital become primary source
The noticeable anxiety the 9 months old child
of pleasure. At this time child fantasies about sexual
shows towards unfamiliar person.
relations with opposite sex component.
Anal Stage (1-3 Years)
Oedipus Complex
This stage is characterized by maturation of neuro-
muscular control over sphincters particularly the anal Here the boy attracted towards his mother and consider
sphincter, thus permitting more voluntary control over father as a rival. He imagines his dominant rival which
retention or expulsion of faeces. will going to harm him of his fear in centered around
This stage occur in response to efforts by parents the genital organ, this is called fear of castration or
to toilet train other children. castration anxiety.
Child Psychology 41

Electra Complex The adolescent begin to love other for attractive

motives. Sexual attraction, socialization, group
Here the girl is attracted towards his father and her
activities, vacational planning, marring and raising
mother presence is threatening. It is the female
a family begin to manifest themselves.
counterpart of castration anxiety in boys. They too are
By the end of adolescence the person become
collectively called as castration anxiety.
transformed from pleasure seeking into a reality
oriented socialized adult.
Latency Stage (6 Years to Puberty)
The function of genital stage is reproduction, the
Major shift occurs in the school age of childs life. psychological aspect helps to achieve the end by
He is required to leave the relative security of home providing a certain measure of stability and
to enter school, where he/she is judged on his/her security.
own merit in comparison with his/her peer.
This stage creates another major step in the process Classical Conditioning Theory By Ivan Pavlov
of separation individualization.
They have sufficient self-esteem and initiative that Russian psychologist Ivan Pavlov stated that,
make them able to make friends. apparently unassociated stimuli could produce
reflexive behavior.
Classical conditioning occurs readily with young
children and can have a considerable impact on a
young childs behavior on the first visit to a dental
When child experiences pain the reflex reaction is
crying and withdrawal in pavlovian terms, the
infliction of pain is an unconditioned stimulus, but
They able to tolerate frustration and anxiety.
the environment or setting in which the pain occurs
This stage is called latency stage because it is
can become associated with this unconditioned
reasonably calm period.
Regression involves acting younger and inadequate
in period of stress.
First Visit
Projection involves attributing to others the
responsibility for ones own unacceptable behavior.

Genital Stage (Adolescence, 12-18 Years)

As the child grows the pleasure is followed on the
42 Essentials of Pediatric Dentistry

Second Visit Skinner Described 4 Types of Operant Conditioning;

Distinguished by Status of Consequence

Operant Conditioning Theory by BF Skinner

It can be viewed conceptually as a significant extension
of classical conditioning.
The basic principle of operant conditioning is that
For instances; if the unconditioned stimulus a the consequence of a behavior is itself a stimulus that
painful treatment comes to be associated with can affect future behavior.
conditioned stimulus of white coats, the child may
cry and withdraw immediately at the first sight of
white coated dentist or assistant.
Associations of this type tend to become
generalized painful and unpleasant experience
associated with medical treatment can become
generalized to the atmosphere of a physician office.
Because of this it is important that the dental office Positive reinforcement: If a pleasant consequence
should not look like physician office, the follows a response, the response has been
appearance should be different, so that it reduces positively reinforced and the behavior that led to
the anxiety of the child. this pleasant consequence becomes more likely in
Treatment that produce pain should be avoided if the future.
at all possible on the first visit to a dental office. For example, a child is given a toy as a reward
The association between a conditioned and an for behaving well during first dental visit, she is
unconditioned stimulus is strengthened or more likely to behave well during future dental
reinforced everytime they occur together. visits.
Conversely; if the association is not reinforced, The opposite of generalization of a conditioned
the association become less stronger and stimulus is discrimination, that is if a child is taken
conditioned response will no longer occur. This to other office setting where given a painful
phenomenon is called 'extinction' of the injection are not necessary a discrimination
conditioned behavior. between the two types of offices which will
In general, if the consequence of a certain response develop and generalized response of fear and
is pleasant, that response is more likely to be used crying will no longer occur.
again in future, but if the consequence is In other words, the consequence that follows a
unpleasant, the probability of that in future is response will alter the probability of that
reduced or diminished. response occurring again in similar situation.
Child Psychology 43

Negative reinforcement: Removal of undesirable His approach emphasizes the dependent interaction
stimulus involves the withdrawals of an unpleasant of individual and society.
stimulus after a response like positive In his formation of the eight stages of development
reinforcement. Negative reinforcement increases the first 5 of which detail childhood and adolescence,
the likelihood of response in the future. he has postulated a delicate balance between the
It mainly refers to the fact that reinforcement successful or unsuccessful outcome of childs ability
in a response that leads to the removal of an to master a need or task at a particular stage or to cope
undiserable stimulus. with a concomitant stress.
Omission: Involves removal of a pleasant stimulus Eriks stages of emotional development: The sequence
after a particular response, e.g. if a child who is more fixed than time when each stage is reached
throws temper tantrums has his favourable toy some adults never reach the final steps on the
taken away for a short period of time as a developmental staircase.
consequence of his behavior, then probability of
similar misbehavior is decreased. Development of Basic Trust
Punishment occurs when in unpleasant stimulus (Birth to 18 Months)
is presented after a response, this also decreases
In this initial stage of emotional development a basic
the probability that the behavior that resulted in
trust or lack of trust in the environment is developed.
punishment will occur in the future. In general
Successful development of trust depends on caring and
positive and negative reinforcement are the more
constant mother or mother substitute, who meets both
suitable types of operant conditioning for use in
the physiologic and emotional needs of infants. This
the dental office.
bond must be maintained to allow the child to develop
The other two types, omission and punishment
basic trust in the world. In fact, physical growth can
should be used sparingly with caution in the dental
be significantly retarded unless the childs emotional
office since a positive stimulus is removed in
needs are met by appropriate mothering.
omission, the child may react with anger and
The syndrome of mother deprivation in which child
frustration. When punishment is used both fear and
receives inadequate maternal support is well-
anger sometimes result.
recognized though fortunately rare. Such infant fail to
gain weight and are retarded in their physical as well
Psychosocial TheoryErik Erikson (1963)
as emotional growth. The maternal deprivation must
Erik Erikson a friend and student of Freud, elaborated be extreme to produce a deficit in physical growth.
and modified Freuds theory of superimposition of Unstable mothering that produce no apparent
psychosocial and psychosexual factors simultaneously physical efforts can result in a lack of sense of basic
contributing to the personality development of child. trust. This may occur in children from broken family
Erkisons theory postulated that society responds or who have lived in series of foster homes. The tight
to the child's basic needs or developmental tasks in bond between parent and child at this early stage of
each specific period of life. emotional development is reflected in strong sense of
44 Essentials of Pediatric Dentistry

separation anxiety in child when separated from the pursuit or various activities. The initiative is shown
parents. If it is necessary to provide dental treatment by physical activity and motion, extreme curosity and
at a early age, it is usually preferable to do so with questioning and aggressive talking. A major task for
parents present. parents and teacher at this stage is to channel the
activity into manageable task, arranging things so that
Development of Autonomy
the child is able to succeed and preventing him or her
(18 Months to 3 Years)
from undertaking task where success is not possible.
Children around the age of 2 years often are said to be At this stage a child is inherently teachable.
undergoing the terrible tows because of their The opposite of initiative is guilt resulting form
uncooperative and frequently obnoxious behavior. At goal that are contemplated but not attained from acts
this stage of emotional development, the child is initiated but not completed.
moving away from the mother and developing a sense For most children the first visit to the dentist comes
of individuality identity or autonomy. Typically, the during this stage of initiative. Going to the dentist can
child struggles to excise free choice in his life. be constructed as a new and challenging adventure in
Failure to develop a proper sense of autonomy which the child can experience success. A child at this
results in the development of doubts in child's mind stage will be intensely curious about the dentist office
about his ability to stand alone and this in turn produces and eager to learn about the things found there. An
doubts about others. Autonomy in control of bodily exploratory visit with the mother present with a little
functions is an important part of this stage as the young treatment accomplished usually is important in getting
child is toilet trained and taken out of diapers. At this the dental experience of a good start. After the initial
stage wetting pants produce feeling of shame.
experience, a child at this stage can usually tolerate
A key towards obtaining cooperation while
being separated from the mother for treatment and is
treatment from a child at this stage is to have child
likely to behave better in this arrangement, so that
think that what ever the dentist wants was his/her own
independence rather than dependence is reinforced.
choice, not something required by other person.
Allowing the parents to be present during treatment
Mastery of Skills
may be needed for even the simplest procedures.
(Age 7 to 11 Years)
Complex dental treatment of children at this age is
quite challenging and may require extraordinary At this stage, the child is working to acquire the
behavior management procedures such as sedation or academic and social skills that will allow him or her
GA. to compete in an environment where significant
recognization is given to those who produce. At the
Development of Initiative same time, the child is learning the rules by which that
(3 to 6 Years) world is organized; at this stage influence of parents
In this stage, the child continues to develop greater as role model decreases and the influence of the peer
autonomy, but now adds to it planning a vigorous group increase.
Child Psychology 45

The negative side of emotional and personality to be rejected. At the same time, some separation from
development at this stage can be the acquisition of peer group is necessary to establish ones own
sense of inferiority. A child who begins to compete uniqueness and value. An adolescence progresses, an
academically, socially and physically is certain to find inability to separate from the group indicates some
that others do something better and that someway does failure in identity development. This in them can lead
nearly anything better. Somebody else gets put in the to poor sense of direction for the future.
advanced section, is selected as leader of group or is Most of the treatment is carried out during
chosen first for team. Failure to measure up to the peer adolescent years and behavioral management of
group on a broad scale predisposes towards personality adolescents can be extremely challenging; since
characteristics of inadequacy, inferior and uselessness. parental authority is being rejected, a poor psycho-
Orthodontic treatment often begins during this logical situation is created by treatment if it is being
stage of development. Children at this stage still are carried out primarily because the parents wants it, not
not likely to be motivate by abstract concepts such as the child. At this stage treatment should be instituted
If you wear this appliance your bite will be better. only if the patient wants it, not just to please the parents.
They can be motivated however by improved
acceptance or status from the peer group. Development of Intimacy (Young Adults)
Development of Personal Identity Successful development of intimacy depends on a
(Age 12 to 17 Years) willingness to compromise and even to sacrifice to
maintain a relationship, success leads to the
Adolescence a period of intense physical development,
establishments of affiliations and partnership both with
is also the stage in psychosocial development in which
a mate and with others of same sex in working towards
a unique personal identity is acquired. It is an extremely
the attainment of future goals. Failure leads to isolation
complex stage because of the many new opportunities
from others and is likely to be accompanied by strong
that arrive, emerging sexuality complicates
prejudices and a set of attitudes that serve to keep other
relationships with others. At that time physical ability
away rather than bringing them into closer contact.
changes, academic responsibilities increases and
career possibilities begin to be defined.
Guidance of the Next Generation (Adult)
Establishing ones own identity requires a partial
withdrawal from the family and the peer group A major responsibility of mature adult is the
increases still further in importance because it offers establishment and guidance of next generation.
a sense of continuity of existence in spite of drastic Becoming a successful and supportive parent is
changes within the individual member of peer group obviously a major part of this, but another aspect of
becomes important role models and the values and the same responsibility is to provide the service to the
tastes of parent and other authority figures are likely group, community and nation.
46 Essentials of Pediatric Dentistry

Attainment of Integrity (Late Adults) object, parent might supply her a new word helicopter
and explain the difference between two. This is
At this stage, the individual has adapted to the
accommodation, i.e. the individual tendency to change
combination of gratification and disappointment that
in response to environmental demands. As a result of
every adult experiences.
this knowledge the child is temporarily in a state of
equilibrium. The processes of establishing equilibrium
Cognitive Development Theory
is known as equilibration.
by Jean Piaget (1952)
From the perspective of cognitive development
He proposes the assumption that the world is a stable theory development of a child can be divided into four
environment and that the growing child learn this basic major stages.
assumption through the acquisition of the knowledge i. Sensor motor period (Birth to 2 years of age):
of Mathematics and logic as a parts of reality. The During this stage the child develops rudimentary
child is then required to adapt to reality, those people concepts of objects including the idea that
showing the reality with him once again assuming that objects in the environment are permanent they
they share the same experience. do not disappear when the child is not looking
The process of adaptation is described by Piaget at them.
in his concept as Simple modes of thoughts are developing at
Assimilation: It describes the ability of child to deal this time, but communication between a child at
with new situations and problems with his age specific this stage and an adult is extremely limited
skills. because of the child's simple concepts and lack
of language capabilities.
Accommodation ii. Preoperational period (2 to 7 years of age):
During the preoperational period; the capacity
Is that process, which enable him to adapt and change develops to form a mental symbol representing
his way of dealing with the world and to handle a things that even not present and child learns to
problem which may at first may be too difficult to deal use words to symbolize these absent objects.
and master at his particular age and skills. In this stage capabilities for logical reasoning
Piaget calls the major mechanisms that allow are limited, e.g. if the child is first shown two
children to progress from one stage of cognitive equal sizes of glasses with water in them. The
functioning to next as assimilation, accommodation child agrees that both contain the same amount
and equilibration. of water. Then the content of one glass are
For example, assimilation can be seen when a 5-year- poured into a latter narrower glass while the child
old girl has learned that all the objects that fly in the watches. Now when asked which glass have
sky are called birds. But when she sees a low flying more amount of water child will usually say that
helicopter and tries to assimilate it to her idea of bird the tall one have more water. Childs impressions
the size and shape does not fit into her existing idea of are dominated by the greater height of water in
a bird. Here assimilation is not possible then she tall glass. In this stage child will have two types
realizes that she needs a new category for this new of characters.
Child Psychology 47

a. Primitive: The child believes that people Social Learning Theory

on TV screen can see him just as he see by Albert Bandura (1963)
b. Animistic: Child will accept any reasonable Stimulus Response Theory
explanation. During the dental treatment the The principles of the social learning theory of child
dentists should be responsible to give development are based on the basic that behavior is
reasonable explanation to satisfy a child's learned. This theory is based on the stimulus response
anxiety. He or she is much more likely to (S-R) and psychoanalytical principles.
understand brushing makes your teeth feel
Social learning theories of child development hold
clean and smooth and toothpaste makes
that all behavior is learned by reinforcement.
your mouth taste good because these
From early infancy the child strives to have his
statement rely on things the child can taste
basic needs met in order to reduce tension and to create
or feel immediately.
iii. Period of concrete operation (from 7 year of a satisfied pleasurable feeling. The infant quickly
age to puberty): Improved ability to reason learns in a reflexive manner that certain behaviors on
emerges, she or he can use a limited number of his part elicit responses from his parents. The attention
logical process especially those involving object seeking behavior is essential for normal mother child
that can be handled and manipulated. interaction. If the responses are pleasing; rewarding
iv. Formal operation: Occurs during the to the child for his initial behavior will be repeated
adolescence; this advance in cognitive develop- over and over and will eventually become part of his
ment is not simply acquired by age but appears behavior and personality. Thus the approval or
directly related to experiences in school. The disapproval of the mother acts as a powerful reinforce
major changes in this age group is ability to for certain behavior in the child and the mother shape
utilize the abstract thinking, logical operations and modify the childs behavior to socially acceptable
and hypothetical reasoning. behavior.
In this stage when the patient becomes more The importance of stimulus response reactions in
esthetic conscious and in most cases patient is the social learning theory plays great significant effect
ready for any dental procedures to be carried of parents role in child development.
48 Essentials of Pediatric Dentistry
Examination, Diagnosis and
Treatment Planning

The examination, which may take only seconds, Oral Examination of Infant
the dentist also has the opportunity to demonstrate
The oral examination of the infant is a quick process
oral hygiene, point out oral structures of
but differs from the typical child examination in several
importance, as record findings.
ways :
Most infants will cry briefly during the
Use of a dental chair is unnecessary and the least
examination, parents may need to be assured that
preferred approach.
infants who cry are normal, healthy babies and
The parent participates as a learner and
the response is expected.
At the completion of the examination, the child is
Teaching about the oral cavity occurs during the
returned to the parent who can cuddle and console
examination process.
as needed.
The child may cry which is desirable and useful.
The dentist would expect to see a healthy oral
The preferred approach to infant examination is
cavity in most infants; but there are several oral
the Knee-to-Knee Approach.
conditions like natal and neonatal teeth, Riga-Fede
disease. In addition other pathologic conditions In this parent and dental surgeon sit facing each
of infancy, including dental lamina. other, their knees should touch, creating a flat surface
Cysts (Bohns nodules, Epsteins pearls). on which child can rest.
Congenital epulis. The infant initially is held facing the parent and
Eruption cyst. then reclined onto the lap of the dentist.
Neuroectodermal tumor of infancy. The parent has the infant's legs straddling the torso
The dentist should look for development status, and uses elbows to hold the feet in place, the parent
quality of dentition in terms of caries, hypoplasia holds the childs hands and the dentist looking
and presence of plaque on teeth. down, stabilizes the childs head.
Examination, Diagnosis and Treatment Planning 49

The examination can occur wherever a suitable Palpation

light source can be found. Assessment of hearing, vision, function
Anticipatory Guidance Lymph nodes and thyroid is examined as elements
of neck region.
Parents often express interest in occlusal development Palate, pharynx, tongue, floor of mouth, buccal
and may indulge the dentist to discuss future mucosa, teeth are examined as elements of oral
orthodontic needs. Growth is difficult to predict; but cavity.
the dentist ought to take the opportunity to discuss
eruption, spacing and occlusion with parents as a part IV. Facial Examination
of anticipatory guidance.
a. Overall Facial Pattern
First, the facial profile is evaluated in anteroposterior
The examination encompasses six major sections: plane.
To begin the examination the child should be
I. Behavioral Assessment seated in an upright position, looking at a distant point,
three points on the face are identified.
Chair side examination provide two opportunities to Bridge of nose
observe the behavior and initially assess potential Base of the upper lip
cooperation. Chin.
Line segments connecting these points form an
II. General Appraisal angle that describes the profile as convex, straight, or
The general appraisal addresses the child concave.
psychological and behavioral status. The classic areas Skeletal Relationship
of this appraisal include gait, stature and presence of Case I: A well-balanced profile in the anteroposterior
gross signs and symptoms of disease. dimension has an underlying skeletal relationship
which is slightly convex that is labeled class I.
Illustration: The normal 3 to 6-year-old child is
Furthermore, the canine relationships usually will
ambulatory well-coordinated in basic tasks, engaging
be class I, and there will be overjet of 2-5 mm.
and physically healthy in appearance. Class II: Some childrens have extremely convex
profiles, these patients usually have class II permanent
III. Head and Neck Examination first molar relationships and distal step second primary
Structures like hair, scalp, ears, eyes, nose, lips, molar relationships, have increased overjet.
temporomandibular joint, skin, chin are observed as Class III: Children with concave profiles are found
elements included in head examination with using with class III permanent first molar relationships and
diagnostic techniques like mesial step second primary molar relationships, class
Visualization III canine relationships and negative overjet.
50 Essentials of Pediatric Dentistry

b. Facial Examination in the 12 Oclock position. Hair is pulled away

from the face, and a piece of dental floss can be
Including observation of positions of maxilla and
stretched down the middle of the upper face to aid
mandible giving again three possible skeletal patterns
in judging lower face symmetry.
Class I, Class II and Class III skeletal relationship.
V. Intraoral Examination
c. Vertical Facial Relationships
An important portion of the intraoral examination is
The third portion of facial examination is an evaluation
directed to the teeth. Each of the 20 primary teeth
of vertical relationships; proportionately the face is
should be explored and scrutinised visually.
divided into thirds
The upper third extends from hair line to the bridge
Intraoral Examination Includes
of nose.
( Fig. 7.1)
The middle third extends from bridge of nose to
the base of upper lip. Occlusal evaluation
The lower third extends from the base of upper Alignment of dental arches
lip to the bottom of the chin. Anteroposterior Dimension: Primary molar and
canine relationships are determined and compared
d. Lip Position with Skeletal classification. In the primary
dentition, molars are called flush terminal plane,
The anteroposterior lip position gives an estimation
mesial step or distal step. Primary canines are
of anteroposterior incisor position.
classified as class I, class II, class III, or end-to-
Lip posture is assessed by drawing an imaginary
end. These dental classification generally reflect
line from the tip of nose to the most anterior point
the skeletal classification.
on the soft tissue chin.
Incisor position is grossly reflected in lip contour
and posture.

e. Facial Symmetry
Transverse facial dimension are examined to rule
out true facial asymmetry.
Asymmetry usually manifests in the lower facial
third whereas upper facial asymmetry is extremely
rare. All faces show a minor degree of asymmetry,
but marked asymmetry is not normal.
Evaluation of facial symmetryThe patient is
reclined in the dental chair and the dentist seated Fig. 7.1: Intraoral examination of child
Examination, Diagnosis and Treatment Planning 51

Transverse relationship: Of the arches is examined Radiographic views include:

for midline discrepancies and posterior crossbites a. Maxillary periapical view (no. O film)
a. A large midline discrepancy is unusual in the b. Mandibular periapical view (no. O film)
early primary dentition, and clinicians should c. Maxillary occlusal view (no. 2 film)
be suspicious of a mandibular shift. d. Mandibular occlusal view (no. 2 film)
b. If a posterior crossbite is encountered the Radiographic evaluation:
clinician should try to determine the cause. Transition into the mixed dentition requires
Vertical relationship: The vertical overlap of the modification of the basic pediatric survey.
primary incisors, is measured and recorded in Special radiographic considerations:
millimeters or as a percentage of the total height i. Potential eruption problems may be diagnosed
of the mandibular incisor crown. from the radiographs by the study of the
Anterior openbite, lack of overbite are due to two unerupted teeth.
basic reasons: ii. Small palate size, especially early in the school
age period, prevents or complicates maxillary
i. Existence of a sucking habit
periapical radiography via a long cone film
ii. Ankylosis; the fusion of tooth to bone is common
stabilising apparatus.
in the primary dentition. iii. Identification of missing teeth, supernumerary
teeth, and the developmental status of permanent
VI. Diagnosis anteriors and premolars require greater
The dentist requires radiographs to make a periapical coverage on films.
thorough diagnosis in the 3 to 6-year-old child. iv. Greater anteroposterior length in the posterior
Radiographic projections are indicated in the occlusion requires more bite-wing coverage.
following circumstances:
a. History of pain TREATMENT PLANNING
b. Swelling Elements of treatment planning to be addressed are:
c. Trauma i. Management of primary caries: Within the age
d. Mobility of teeth period of 3 to 6 years, a decision for carious
e. Unexplained bleeding primary teeth has to be undertaken carefully
f. Disrupted eruption pattern whether to extract or restore the tooth while
g. Deep carious lesions. keeping in mind the remaining lifespan as well
For the primary dentition, no radiograph are as the length of time that the child will be without
indicated when all proximal surfaces can be replacement.
visualized and examined clinically, but when ii. Management of pathosis: Oral pathosis such as
proximal surface could not visualised and supernumerary teeth, odontomas, or missing
examined clinically, bite-wing radiographs are teeth are given definitive management in age
indicated. period of 3 to 6 years.
52 Essentials of Pediatric Dentistry

iii. Prevention of dental disease: The choice of The dentists role is to provide information about
sealants is also made during this period, as are the need for care, the benefits anticipated, the
decisions about how to manage incipient alternatives to care (including no treatment) and the
interproximal lesion of permanent teeth. burden of maintenance of care.
iv. Health issues: The child with cancer, orofacial These special patients may tax the dentists skills
clefting, cerebral palsy or other conditions may in planning care, and they may require careful and
need special consideration. frequent observation rather than treatment.
Prevention of Dental Diseases


Dental plaque is a sticky film that adheres to the teeth. The Role of Food in Oral Health
It is composed of bacteria, food debris, and salivary
components. Left undisturbed, it can cause tooth decay. The role of food in oral health is twofold. First, foods
consumed contribute to the health of the mouth as well
Parents should clean the infants gums with a damp
as to overall health. Foods that provide calcium and
cloth after feedings. As the first tooth erupts, a brush
vitamin D are vital for strong bones and teeth, and
that is easy for the parent to hold and small enough to
foods that provide vitamin C are necessary for healthy
fit in the infants mouth is recommended. To ensure
gums. Eating a balanced diet provides the foundation
that brushing is safe and effective, the infant should
for healthy dietary choices and eating practices.
be seated in the parents lap, with both parent and infant
Second, eating habits have a direct effect on the
facing the same direction. The parent should try to
caries process. When food is consumed, bacteria,
clean all tooth surfaces, lifting the lip to brush at the especially Streptococcus mutans initiate to breakdown
gum line and then behind the teeth. carbohydrates in the mouth, creating the acid that
Young children will want to hold the toothbrush causes tooth decay.
and participate in toothbrushing. An appropriate-size The ability of a food to contribute to the
toothbrush with a wide handle given to the child to development of cavities depends on how they adheres
use. However, because effective plaque removal to the tooth surface and how frequently it is consumed.
requires good motor control, young children cannot If carbohydrate consumed frequently, adhere to the
clean their teeth without parental help. After they teeth, and are not quickly cleared from the mouth and
acquire fine motor skills (e.g. the ability to tie their acid can be produced.
shoelaces), typically by age 7 they can clean their teeth It is both unrealistic and undesirable to try to
effectively but should be supervised by a parent or eliminate carbohydrates. The frequent carbohydrate
another caregiver. consumption can be reduced, however, by encouraging
54 Essentials of Pediatric Dentistry

children to have healthy, less cariogenic foods. As the Reduced cariogenic activity of plaque, through
young child is introduced to a variety of new healthful disruption of bacterial metabolic function.
meal and snack patterns can be instilled. Infants and children receive fluoride in two ways:
Fats and proteins may have a protective effect on Systemically and topically. Only fluoride ingested
enamel, making it less susceptible to acid attack by during the tooth-forming years (ages 6 months to 19
coating the teeth and increasing the buffering ability years) has the systemic effect on enhancing resistance
of saliva. Carbohydrates in combination with fats and to later acid demineralization.
proteins may therefore inhibit caries and rinsing with Either in the form of fluoride water or fluoride
water following snacking may also curtail the caries supplements (e.g. drops, swallowed liquids, and
process. tablets) is very important; systemic fluoride reaches
Snacks of healthy, less cariogenic foods such as a the developing teeth through the childs digestive and
slice of cheese, a glass of milk, nonsticks should be circulatory systems.
encouraged over sticky foods such as fruit roll-ups
and candy. Complex carbohydrates found in fruits, MECHANISM OF ACTION OF FLUORIDES
vegetables, grain products especially whole and dairy IN CARIES REDUCTION
products (milk, cheese, cottage cheese, and
a. Increased enamel resistance/reduction in enamel
unsweetened yogurt) should encouraged over foods
solubility: It has been well-established that dental
high in sugar, such as candy, cookies, cake, sweetened
caries involves dissolution of enamel by acids from
beverages (e.g. fruit drinks, soda), and fruit juice.
bacterial plaque and that dissolution is inhibited
by the presence of fluoride. Because fluoride forms
fluorapetite, fluorhydroxylapetite which is less
The primary factor in reducing the prevalence of soluble mineral.
cavities among children in the United States has been The dissolution of enamel during caries attack
the widespread availability of fluoride and fluoridated is a complete process when enamel is exposed to
products. pH of about 5.5 or lower; enamel will dissolve.
Frequent exposure to small amounts of fluoride
Ca10 (PO4)6 (OH)2 + 8 H 10Ca + 6HPO4 + 2H2O
each day is the best way to reduce the risk for
developing tooth decay. It is important to understand This reaction occurs beneath the dental plaque.
the benefits of fluoride and to know how infants and The concentration of calcium and phosphate ions
children can safely ingest it in appropriate quantities. in plaque fluid increases while leaving the
Mechanisms by which fluoride prevents or reduces dissolved enamel in their ionic form; the process
decay include: is called demineralization. The presence of fluoride
Increased resistance of the tooth structure to reduces the solubility of enamel by promoting the
demineralization. precipitation of hydroxyapetite and phosphate
Enhanced remineralization of early carious lesions. mineral.
Prevention of Dental Diseases 55

organic material are deposited from saliva. A less

soluble tooth that is more resistant to acid attack
and less prone to caries is formed.
d. Remineralization of incipient lesions: Minerals of
tooth are continuously in exchange with minerals
of saliva and thus the balance is maintained. This
equilibrium can get disturbed with organic acids
produced by fermentable carbohydrates by
microorganisms; this leads to drop in pH of plaque
on the enamel surface and in subsurface.
Minerals, particularly calcium and phosphate
leave the dissolved enamel in there ionic form and
Fig. 8.1: Intake of fluoridated water by child enter the plaque fluid this process is called
demineralizationThis gets reversed with factors
like fluoride and is termed as remineralization.
Ca10(PO4)6 (OH)2 + 2F Ca10(PO4)6 F2 + 2OH Due to loss of minerals the surface of enamel
(1ppm) diffract light, creating an opacity that appears
When hydroxyapetite is exposed to low clinically as white spot are the incipient caries.
concentration of fluoride, i.e. 1 ppm a layer of In presence of fluoride the spot (white spot)
fluorapetite forms on hydroxyapetite crystals this becomes smooth, shiny and in absence fluoride it
layer governs the rate of dissolution. becomes rough and chalky. The surface of white
b. Pre-eruptive incorporation: Fluoride get spot should not be probed two hard, though it
incorporated in fluid-filled sac, which surrounds appears intact because it is mineral deficient and
the developing tooth, it then enter into developing weak layers may break and form cavitation.
enamel. Therefore, this intact incipient lesion should be
c. Increased rate of posteruptive maturation: The treated with topical fluoride and allow to
greatest importance of fluoride to the maturation remineralize.
process lies in its ability to increase the rate of On topical fluoride application the surface and
mineralization of hypomineralized areas. Newly subsurface enamel hold and absorbs minerals,
erupted teeth often have hypomineralized areas fluoride also present in plaque fluid which enhance
that are prone to dental caries fluoride increase the growth of partially dissolved crystals. The
the mineralization or posteruptive maturation of regrowth by fluoride incooperation chemically
these hypomineralized areas. Organic material is forms new crystals that are larger and more acid
also deposited into enamel to further increase the resistant.
resistance to dental caries. Both mineral ions and e. Inhibiting demineralization
56 Essentials of Pediatric Dentistry

f. Interference with plaque microorganism: Plaque I. SYSTEMIC FLUORIDE ADMINISTRATION

is reservoir of fluoride and approximately 2 percent
of the fluoride in plaque is present as a free ion. DIETARY FLUORIDE SUPPLEMENTATION
Fluoride interact with bacterial cell rapidly and in Fluoridated Milk
pH dependent fashion; pertaining to the uptake of
fluoride into bacterial cells is the differences Jolan and Banoczy undertook longitudinal study to
between pH between the external medium and the see the effect of milk consumption in 3-9-year-old
intracellular cytoplasm Fluoride pH effect. The children with homogeneous living condition.
external pH becomes acidic\due to metabolism of Children were given 200 ml of milk with 0.4 mg
fermentable carbohydrate and so the pH gradient of fluoride for preschoolers (3-5 years) and 0.75 mg
will increase and a portion of fluoride ion in the for schoolers (6-9 years) for 300 days in years.
plaque fluid then combines with hydrogen ion and Caries reduction was seen in II and III year
rapidly diffuses in bacterial cell as HF (Hydroxy compared to I year.
fluoride). Disadvantage: It provides limited exposure to children
HF uptake into bacterial cell continues uptill the as consumption of milk tend to decline with increase
concentration of HF is equal in internal and in age.
external compartments Absorption is slow as compared to water
H+ + F HF (Bacterial cell) H+ + F fluoridation.
(Acidifying cell) Fluoridated salt: Commonly used potassium fluoride
(250 mg/kg) and sodium fluoride225 mg/kg.
Once HF is inside the bacterial cell HF dissociated All over world only 5 countriesBelgium, France,
again. Acidifying the cells and releasing fluoride Germany, Spain and Switzerland. A sixth Hungary is
ions interferes with essential enzyme (enolase)
presently, contemplating a recommendation.
activity thereby inhibiting bacterial metabolism
Fluoride in sugar: Fluoride in sugar and sugar products
and inhibiting plaque formation and
have potential to reduce cariogenic effect of sugar or
fermentable carbohydrates among population group.
g. Modification of tooth morphology: Development
42 percent reduction in caries was observed in 3 year
of shallow and self-cleansable pit and fissure which
clinical trial.
are resistant to decay.
Disadvantages: Increased consumption may lead to
Chemistry of fluoride: Exists chemically in form
nutritional imbalance
of Fluorspar (CaF2)
One type of fluoridated sugary product may not
Fluorapetite (Ca10 (PO4)6 F2)
reach to all those needing fluoride supplements.
Cryolite (Na3AlF6)
Prevention of Dental Diseases 57

Water Fluoridation Water fluoridation may also defined as the upward

adjustment of concentration of fluoride ion in a public
Definition water supply in a such a way that concentration of
fluoride ion in the water may be consistently maintained
Water fluoridation is defined as controlled adjustment at 1 ppm by weight to prevent dental caries with
of concentration of fluoride in a communal water minimum possibility of causing dental fluorosis.
supply so as to achieve maximum caries reduction and Water fluoridation was first done in Grand rapids
clinically insignificant level of fluorosis. (Michigan).
58 Essentials of Pediatric Dentistry

Community Water Fluoridation store at 4C for analysis preferably within 2-3

month, fluoride concentration is estimated by
Optimal fluoride concentration and climatic
i. Fluoride electrode coupled with standard pH
conditionThe optimum concentration of fluoride
in drinking water was assumed to be 1 ppm for
ii. Scot-Sanchis method.
incorporation of fluoride into dental enamel during
the formative stages for children living in
Fluoride Compounds Used in Water
temperate climate (Refer Fig. 8.1). Children living
in 1 ppm fluoridated area are assumed to receive
an optimal intake of fluoride from water and food i. Fluorspar
of 1 mg/day. ii. Sodium fluoride
As water intake of individuals vary widely due to iii. Sodium silicofluoride
the influence of climate. In order to determine the iv. Ammonium Silicofluoride
amount of fluoride to be added to water; Galgan and v. Silicofluoride.
Vermillion developed an empiric formula for Types of equipment for water fluoridation3 types
estimating the amount of daily fluid intake-based on
a. Saturator systemPrinciple: 4 percent saturated
body weight and climatic conditions. solution of sodium fluoride is produced and
ppm fluoride 0.34/E injected at a desired concentrated water
Where E = 0.038 + 0.0062 Temperature of Area distribution source with an aid of pump.
in F; E is the estimated daily water intake. b. Dry feeder systemsPrinciple: Sodium fluoride
Temperature in C Recommended pH or silicofluoride in the form of powder is
< 18.3 1.1-1.3 introduced into a dissolving basin with aid of an
18.926.6 0.8-1.0 automatic mechanism to ensure maintenance of
> 26.7 0.5-0.7 correct supply of fluoride according to amount of
water to be delivered.
Depending upon the community mean maximum
c. Solution feeder systemPrinciple: Volumetric
daily temperature.
pump permitting the addition of a given quantity
Cold climate 1.2 ppm.
of hydrofluosilicic acid in proportion to the amount
Temperate or summer season0.7 ppm. of water treated.
The recommended daily dose of fluoride for However, these systems incorporate electrical
children above 3 years of age is 1 mg. This can be or mechanical devices that require maintenance
obtained by drinking one litre of water with 1 ppm by a capable operator. But the venturi fluoridator
concentration of fluoride ion. and saturated suspension cone are two systems
Sample collection for fluoride estimation: 500 ml which do not suffer from these.
of water to be tested is collected from a clean This system was developed in Brazil by water and
source in a clean dry polythene container; 2 cc of sewage authority it consists of cone charged with
6 N HCl is added to inhibit microbial growth and sodium silicofluoride through which constant flow of
Prevention of Dental Diseases 59

water percolates. The solution is collected at the top Water fluoridation have both pre and
by a horizontal perforated plastic pipe which forms posteruptive effects.
the outlet. Acts both systemically and topically.
It make changes in morphology in the form of
School Water Fluoridation shallow pit.
School water fluoridation is the adjustment of If there is question regarding the fluoride
fluoride concentration of school water supply for concentration, it is naturally present to some
caries prevention. degree in water, the local authority of health
Since children spend only 6 to 8 hours in the can test samples and provide accurate
school; the concentration of fluoride is 4 to 6 times information.
more than designated for community water supply. Beverages botteled supplied to the
For instance in Elk Lake, Pennsylvania the school influoridated areas or other such products may
water supply was fluoridated at 5 ppm and in 5 pass on the beneficial effects to fluoride
years there was reduction of 29 percent seen in deficient/deprived population. This is termed
caries. After 10 years of school water fluoridation Diffusion or Halo Effect.
the children who attended school continuously had
39 percent less decayed, missing, filled teeth than II. TOPICAL FLUORIDE ADMINISTRATION
there counter parts.
By definition the term "topically applied fluorides" is
used to describe those delivery systems which provide
Advantage of School Water Fluoridation
fluoride for a local chemical reaction to exposed
It is a effective public health measure to reduce dental surfaces of erupted dentition, the delivery system
caries in communities where fluoridation of water is include measures designed for professional application
not possible. in dental office, such as fluoride containting
prophylactic paste, varnishes, gels, foams, as well as
Disadvantages system designed for unsupervised home use such as
fluoride dentifrices and Rinses (Stookey in 1990).
Have less pre-eruptive fluoride exposure
Intermittent fluoride exposure.
Benefits of Water Fluoridation Fluoride dentifrices: They contain 1000-1500 ppm of
Some tooth surface receives greater protection F formulated from either sodium fluoride or sodium
against caries. monofluorophosphate and none contain stannous
For example, smooth surface proximal surface fluoride.
derives maximum protection than do pit and Advantages: Inhibits demineralization and enhance
fissures. remineralization.
60 Essentials of Pediatric Dentistry

Precautions to be Considered Seat the patientupright position.

Preschool age children should be supervised while Use the trays with absorptive liners (Fig. 8.2).
brushing to avoid excessive ingestion of paste. Limit the amount of agent, e.g. during gel
Only a dab or pea-sized amount of dentifrice application the gel is placed in tray to no more
should be used by 6 years of age or below. than 2.5 ml (one half of a teaspoon).
At least 1 brushing with F toothpaste should be Use suction during and after treatment.
done before bedtime. Have the patient expectorate thoroughly after the
trays are removed.
Fluoride impregnated dental floss: For
interproximal surfaces.
Fluoride rinses: Usually nonprescribed F mouth
rinses contain 0.05 percent Naf they should be
swished vigorously once a day for one minute and Amount 2 percent NaF pH = 7 8 percent SnF2
(9,040 ppm) (9,360 ppm)
Method of pre- To prepare 2 percent O No. gelatin cap-
Prescribed F- rinses generally contain 0.2 percent paration NaF dissolve 20 gm of sules are priorly filled
NaF they are designed to use under supervison once a NaF in 1 litre of distilled with 0.8 gm of SnF2
water in a plastic bottle. (powdered) and stored
week for one minute. NaF should always be in air right plastic
Precautions to be considered children 5 years stored in plastic bottles if containers.
of age or handicapped child may swallow the rinse stored in glass bottles F
will react with silica of
rather than expectorating so rinses are not glass to form SiF2 thus To prepare 8 percent
recommended for them. reducing the availability SnF2, content of 1
of free F ions for capsule is dissolved
anticaries action in 10 ml of distilled
SUSTAINED RELEASE FLUORIDE water in plastic contai-
ner and shaken
Sustained release fluoride They provide a regular SnF2 solution is to be
prepared just before
release of F slowly intraorally for a longer period. each application
They effectively reduces the caries by remineralization Technique of Knuston and Feldman Muhler technique
application Technique (1948) (1957)
of incipient caries. Clean and polish the Do a thorough
A number of dental material are cements, teeth in only first of all prophylaxis
acrylics and resins while intraoral devices four applications Isolate the quadrant
Isolate the upper and with cotton rolls and
copolymer membrane beads and glass pellets. opposing lower quadrant dry the teeth
with the cotton rolls Apply the freshly
Dry the teeth thoroughly. prepared 8 percent
Professionaly Applied Fluorides Apply 2 percent NaF SnF2 continuously to
with cotton roll applicator teeth with cotton
Procedure to be Followed and allow it to dry on applicators
teeth for 4 minutes Reapply the solution
To reduce the likelihood of ingestion of fluoride during NaF is applied only once to the teeth every
a professionally applied topical fluoride, the following because once a layer of 15-30 sec, so that teeth

procedure is kept in mind Contd...

Prevention of Dental Diseases 61

Contd... Contd...
Amount 2 percent NaF pH = 7 8 percent SnF2 APF Gel and Solution
(9,040 ppm) (9,360 ppm)
Amount 1.23 percent APF 23 percent APF
CaF2 (dominant product are kept moist with pH = 3 (12,300 ppm) pH = 4-5 (12,300 ppm)
of reaction is formed) it solution for 4 min.
interferes with the further Instruct the patient Method of To prepare APF solution To prepare gel, a
diffusion of F- and react not to eat, drink or preparation dissolve 20 gm of NaF in gelling agent methyl
with hydroxyapetite rinse for 30 min. This 1 liter of 0.1 m molarity cellulose or hydroxy
this is called choking off helps in prolonging phosphoric acid ethyl cellulose is
phenomenon the availability of F To this add 50 percent added to solution and
Instruct the patient to to react with tooth hydrofluoride acid to pH is adjusted bet-
avoid eating and drinking surfaces adjust the pH at 3.0 and ween 4-5
for 30 minutes F concentration at
Number of Second, third and fourth Once per year 1.23 percent
application per application are done at Technique of Brudevold technique Do a thorough pro-
year weekly interval application (1963) phylaxis and dry the
Applications are recom- Do a thorough prophy- teeth
mended at 3, 7, 11, 13 year. laxis and isolate a quadrant Fill the U/L tray with
Advantages Chemically stable. The rapid penetra- with cotton roll APF gel.
Acceptable taste because tion of tin and fluoride APF solution is conti- Insert U/L tray
of neutral pH in enamel within 30 nuously and repeatedly simultaneously into
Nonirritating of gingiva seconds applied with cotton mouth and have the
Does not discolor the Highly insoluble tin applicator patient bite down
teeth fluorophosphate Keep the teeth moist tightly for 4 min
Cheap and inexpensive complex forms on for 4 min Thixotropic gel dis-
enamel surface that Contd...
is more resistant to
decay than enamel
Disadvantages Patient has to make four Unstable in aqueous
visits to dentist with a solution and should
relatively short period of be prepared fresh for
time each patient
It has low pH (2.1
2.3) which is an astri-
ngent and solution has
metallic taste
It cause gingival
Produces discolora-
tion of teeth parti-
cularly of hypocalci-
fied areas
Causes staining at
margins of

Contd... Fig. 8.2: Topical fluoride and application trays

62 Essentials of Pediatric Dentistry

Contd... Contd...
Amount 1.23 percent APF 23 percent APF Amount 1.23 percent APF 23 percent APF
pH = 3 (12,300 ppm) pH = 4-5 (12,300 ppm) pH = 3 (12,300 ppm) pH = 4-5 (12,300 ppm)

Pass the floss through plays a high viscosity Amount Bifluoride 12 (2.71% NaF 0.92% F (9200 ppm)
each interproximal at low shear rates and 2.92% CaF2) pH = 4.5
embrasure to ensure low viscosity at high Method of Commercially available Commercially avail-
wetting of these surface shear rate. The clinical preparation able
Repeat the procedure importance of this is Technique of Do the thorough pro-
for remaining quadrant that the gel thins out application phylaxis and dry the teeth
Instruct the patient not under the biting forces (do not use cotton for
to eat, drink or rinse for and more easily pene- isolation as varnish is
30 min trate between teeth. sticky and tend to stick
Conversely, when it is to cotton)
not under stress it rem- Drop the varnish onto
ains in tray and does the brush or foam pellet
not tend to run down Paint the varnish thinly
the patients throat. first on the lower arch
Instruct the patient (as saliva collects more
not to eat, drink or rapidly on it and then an
rinse for 30 min upper arch starting from
Number of Semiannual Semiannual the proximal surfaces.
applications Layers which are too thick,
Advantages Fluoride uptake follow- Acceptable by child separate too easily.
ing application of APF due to flavoured taste Instruct the patient
solution is greatly Easy to apply and Not to rinse at all for
accelerated whereas gel F comes in con- that day
following Naf in lower stant contact with Not to eat solid for that day
50% more effective teeth so reapplication Take liquid and semisolids
than APF is not required till next morning
APF is cheap and can be Can be self applied Not to brush that day
prepared easily Thixotropic pro-
No. of Semiannual Semiannual
It is stable with a long perty
shelf life when stored in Caries reduction
Advantages Forms a water tight It is less dense than
opaque plastic bottle increases than APF
protective film insulating gel and is able to flow
against thermal and better, allowing a free
Disadvantages Teeth must be kept wet Can cause irritation
chemical influences. movement of F ion
with solution for 4 min to inflamed gingiva and
With correct application on the tooth surface
APF solution is acidic, to open carious lesion
and proper mouth and interproximal
sour and bitter in taste so this should be
hygiene; varnish remains areas
so necessiate the use of applied only after
in place for several days Total density by
suction restoration of all
During this time fluoride weight is less than gel
carious teeth
acts on the treated surface application. This
reduce the risk of
Varnish Foam
ingestion and syste-
Used are Duraphat, fluorprotector, APF foam mic toxicity of F
flouritop, bifluoride 12 Disadvantage Patient complaince is Retention onto the
required tooth surface is less as
Contd... no polymers are
Prevention of Dental Diseases 63

Other Fluoride Application (by the Thus concentration of F in water decreases this
Professional) process depends on special conditions like pH,
temperature, flow rate, grain size of material
Fluoride impregnated prophylaxis paste and cup:
The temperature of enamel surface is raised during some of the commonly used materials are:
prophylaxis because of friction between the Activated alumina
prophylaxis cup and the tooth. High temperature Fluidised activated alumina
enhances the uptake of fluoride from prophylatic Activated bauxite
paste or solutions. Zeolite
Iontophoresis: It is based on a theory that small Tricalcium phosphate
electric current will help to drive fluoride ion Superphosphate, activated bone char,
further into the dental enamel producing the magnesium activated carbon, palan carbon,
desired effect, reduced enamel solubility, increase charcoal, clay, soil and brick.
fluorapetite formation, retarded dentin sensitivity ii. Precipitation method: In high pH condition, co-
and even sterilization of root canals. precipitation of several elements in water with
Dental Materials Containing Fluoride fluoride ions forms fluoride salts. Sometimes it
a. Carboxylate cements. cause flocculation; if the substance used is
b. Fluoride in amalgam has also been tried: 1.5 aluminum thus F concentration in water
percent stannus fluoride to silver amalgam decreases. A well-known substance of this group
alloy. is alum, which is used in water supply systems
Fluoride containing varnish and sealants: A
and water treatment.
polyurethane based material containing 10 percent
These substances include Alum, alum and
sodium monofluorophosphate commercially
lime (CaO), calcium chloride (CaCl2).
available as Epoxylite 9070.
Glass ionomer cement with fluoride leaching iii. Method based on membrane separation: All
property. elements in water gets diminished after filtration.
This method is claimed to be the best water
Defluoridation purification process available. This method
seems to be expensive for developing countries
It is a scientific means to improve the quality of water as 30 percent of raw water is lost in this process.
with high fluoride concentration by adjusting the
optimum level in drinking water. Indian Technology for Defluoridation
Nalgonda technique: Using lime and alum.
The first community plant for removal of fluoride
i. Adsorption and ion exchange method: Some from drinking water was constructed in district
substances adsorb fluoride ion by the surface Nalgonda in Andhra Pradesh; in the town Kathri thus,
and it can exchange OH group for fluoride ions; the name of technology.
64 Essentials of Pediatric Dentistry

Mechanism of Defluoridation by Parents should clean the infant's gums with a damp
Nalgonda Technique cloth after feedings. As the first tooth erupts, a
brush that is easy for the parent to hold and small
Rapid mix: It is the operation by which the coagulant
is rapidly and uniformly dispensed throughout in single to fit in the infant's mouth is recommended.
or multiple phase system. This helps in formation of Frequent exposure to small amounts of fluoride
microflocs and results in proper utilization of chemical each day is the best way to avoid the risk for
coagulant, preventing localization of concentration and developing dental caries.
premature formation of hydroxides which leads to less Infants and children receive fluoride in two ways
utilization of coagulants. systemically and topical fluoride ingested during
Flocculation: It is a second stage of formation of the tooth-forming years (ages 6 months to 19 years)
settable particles (floc) and is achieved by gentle and this has the systemic effect of enhancing resistance
prolonged mixing. to later acid demineralization.
Sedimentation: It is the separation from the water by All infants and children who drink fluoridated
gravitational setting of suspended particulates that are water get benefit from systemic intake of fluoride
heavier than water. which incorporates into their developing teeth, as
Filtration: It is process of separating suspended and well as from other important topical effects.
colloidal impurities from water by passage through Unless a dentist or other qualified health
porous media. professional advises otherwise, fluoride toothpaste
Other techniques are Prasanti technology and should be introduced at around age 2.
Combined Nalgonda and Magnesite technology. Foods that provide calcium and vitamin D are vital
for strong bones and teeth, foods that provide
KEY POINTS vitamin C are necessary for healthy gums.
Dental plaque is a sticky film that adheres to the The ability of a food to contribute to the
teeth. It is composed of food debris, and salivary development of cavities depends on its adherence
components. Left undisturbed, it can cause dental to the tooth surface and how frequently it is
(tooth decay). consumed.
Restorative Dentistry for
the Primary Dentition

In 1924, GV Black outlined several steps for the The enamel rods of the gingival third of the crown
preparation of carious permanent teeth to receive an extend in occlusal direction from the dentin-enamel
amalgam restoration. These steps have been adopted, junction in primary teeth, but enamel rods extends
with slight modification, for the restoration of primary in cervical direction in permanent teeth.
teeth. In contrast to permanent teeth, primary teeth
Restorative techniques for the primary dentition demonstrate greater constriction of the crown and
for amalgam and stainless steel crowns have remained have a greater cervical contour.
consistent for over an period of time relatively for In contrast to permanent teeth, primary teeth have
years. However, with an increased use of adhesive comparatively narrow occlusal surface.
restorative materials and bonding systems, there is shift Primary teeth have broad, flat proximal contact
to more conservative preparations. areas.

Anatomic Differences between RUBBER DAM IN PEDIATRIC

Primary and Permanent Teeth RESTORATIVE DENTISTRY
Primary teeth have thinner enamel and dentin
Benefits of Using Rubber Dam
thickness is less than permanent teeth.
Primary teeth are more whiter than permanent Moisture control is greater than other forms of
teeth. isolation.
The pulps of primary teeth are larger in relation to Provides better access and visualization by
crown size than permanent pulps. retracting soft tissues and providing a contrasting
The pulp horns of primary teeth are closer to the dark background to teeth.
outer surface of the teeth than the pulp horns of The safety of child patient is improved by
permanent teeth. preventing aspiration or swallowing of forgein
The mesiobuccal pulp horn is the most prominent. bodies and protecting the soft tissues.
66 Essentials of Pediatric Dentistry

The rubber dam acts as a separating medium or a

barrier to various in and out movements of the oral
cavity as perceived by the child patient as being
less invasive than without the use of rubber dam
in place.
With a rubber dam in place, a child becomes
primarily a nasal breather. This enhances nitrous
oxide administration, when it has been deemed
necessary from a behavioural stand point.
Fig. 9.1: Rubber dam punch
Rubber Dam not to be Used
In presence of fixed orthodontic appliance.
In presence of upper respiratory infection, Proper placement of RD allows better access, more
congested nasal passage, or other nasal ease in placing a matrix and visualization of
obstructions. adjacent marginal ridges for appropriate carving
When teeth that has recently erupted which will of the restoration.
not retain clamp. Isolation of maxillary quadrants, when isolation
of several teeth is required instead of punching
STEPS INVOLVED IN USE OF RUBBER numerous holes in RD, two holes are punched
about inch apart and RD is cut with scissors to
Preparing for Placement of the Rubber Dam connect two holes. This technique called Slit
Rubber dams are available in various colours, may
even be scented or flavored the darker the dam, The keen aspect of proper rubber dam application
the better is the contrast between the teeth and dam. is proper selection of clamp.
The holes should be properly punched with the To prevent dislodgement and easy retrieval of
help of RD punch (Fig. 9.1) so that rubber dam is clamp if dislodged, place a 1218 inch piece of
centered horizontally on the face and the upper dental floss on the bow of the appropriately
lip is covered by the upper borders of the dam, but selected clamp as a safety measure.
the dam must not cover the nostril. Floss the contacts through which RD will be taken;
For single class I or V restorations, only the teeth if floss cannot be passed through the contact
being restored must be isolated. because of reasons.
If the interproximal lesions are being restored, at a. Defective restoration.
least one tooth anterior and one tooth posterior to
b. Other factors like dental anomalies
the tooth being restored should be isolated.
Restorative Dentistry for the Primary Dentition 67

Primary incisors and caninesO Ivory,

OOHygienic corp, 209 Hufriedy.
A clamps have jaws angled gingivally to seat
below subgingival heights of contour.

Placement of Rubber Dam

Rubber dam frame: The punched RD must be
lightly stretched onto RD frame prior to placement
of the clamp.
Fig. 9.2: Rubber dam forcep RD frame holds the corners of the dam (as shown
in Fig. 9.3).
Pull the floss which is attached to the clamp from
Modification of contacts or RD will be the most posterior hole in dam that has been
necessary before placement. punched for the clamped tooth.
Next, with help of RD forcep (as shown in Fig. With widely opened childs mouth and with the
9.2), place the selected clamp on the tooth, seating operators index fingers, stretch the most posterior
it from lingual to buccal direction. hole of the rubber dam over the bows and wings
Be certain; that the jaws are seated below the of the clamp, this makes slipping the dam material
heights of contour of crown and at same time clamp over the bow easy.
To stabilize the rubber dam, first stabilize the
is not impinging on the gingival tissues.
rubber dam around the most anterior teeth which
After clamp has seated appropriately, remove RD
could be done by placing a wooden wedge
forceps and place finger on buccal and lingual jaws interproximally by either
of the clamp and apply finger pressure gingivally
so as to ensure the clamp is stable.

Rubber Dam Clamps Commonly Used in

Pediatric Restorative Dentistry
Partially erupted permanent molars14A, 8A
Ivory, 8A Hygienic corp, 8A Hufreidy.
Fully erupted permanent molars14, 8 A Ivory,
8A Hygienic Corp, 8A Hufriedy.
Second primary molars26, 27 Hufriedy, 3 Ivory,
3 Hufriedy.
First primary molars / bicuspids / permanent
canines 2, 2A Ivory, 207, 208 Hufriedy. Fig. 9.3: Rubber dam frame
68 Essentials of Pediatric Dentistry

a. Stretching a small piece of RD through the the central pit and extend into all
contact. susceptible pits and fissures to a depth of
b. Or, by ligating with dental floss which is placed 0.5 mm in dentin (Figs 9.4 and 9.5).
around the cervix of the tooth and have the Step 3: All carious dentin is removed with help
dental assistant hold the floss gingivally on the of a large round bur in the slow speed
lingual with instrument which must be blunt, handpiece or with a help of sharp
the floss is carried tightly around the tooth from excavator (spoon excavator).
the buccal and surgical knot is tied preferably Step 4: Smooth the enamel walls and finish the
below the cervical bludge. final outline form with no. 330 bur.
After the anterior stabilization is completed teeth Step 5: Inspect for any remaining caries, for sharp
are isolated by holes that have been punched. cavosurface margins, and removal of all
With the help of blunt instrument rubber dam unsupported enamel with help of hand
is inverted into gingival sulcus around each instrument.
isolated tooth.

Removing the Rubber Dam

Remove ligatures (if any) used for stabilization of
Next, stretch the rubber dam so that interproximal
septa of RD may be cut with help of pair of scissors.
Clamp, frame and dam are then removed.
After removal of RD inspection of mouth is must
to see that no small pieces of rubber dam have left
Tissues around the previously clamped tooth are
taken care by gentle massage.
Rinse and evacuate the oral cavity.


Step 1: Administer appropriate anesthesia and
proper placement of rubber dam. Figs 9.4A to C: Class I amalgam cavity preparations.
Step 2: With the help of high-speed turbine (A) maxillary right second and first primary molars (occlusal
view). (B) Maxillary second primary molar lingual view of
handpiece and using no. 330 bur, penetrate distolingual groove preparation. (C) Mandibular right first and
into the tooth parallel to its long axis in second primary molars (occlusal view)
Restorative Dentistry for the Primary Dentition 69

PEDIATRIC RESTORATIVE DENTISTRY the preparation, condensing small

overlapping increments with a firm
pressure untill the cavity is slightly
Step 8: Next to condensation, carving is done with
a carver (small cleoid discoid carver
works very well) for carving primary
a. Always keep part of the carving edges
of the instrument on the tooth structure
so that over carving of the cavosurface
margins does not occur.
b. Remove all amalgam flash from
cavosurface margins and keep the
carved anatomy in primary teeth (i.e.
grooves) shallow.
Step 9: Next to carving is burnishing the carved
amalgam (when amalgam has begun its
initial set and could resist deformation)
with a small, round burnisher, which is
lightly rubbed across the carved amalgam
surface to produce a satin-like appearance
of restoration (Fig. 9.6).
Step 10: Remove the rubber dam and check the

Fig. 9.5: Steps of cavity preparation

Step 6: Triturate the amalgam, and place one

carrier load of amalgam into the
Step 7: Using a small condenser, immediately Fig. 9.6: Initial smoothness and contour of class I
begin condensation of the amalgam into amalgam
70 Essentials of Pediatric Dentistry

STEPS OF PREPARATION AND marginal ridge by brushing the bur

RESTORATION FOR CLASS II AMALGAM buccolingually and in gingival
RESTORATION (FIG. 9.7) direction at the dentin-enamel
Step 1: Administer appropriate anesthesia and b. Placement of wooden wedge in the
proper application of rubber dam. interproximal area being restored
Step 2: Preparation of occlusal outline: Using a helps in retracting gingival papilla
no. 330 bur in the high speed turbine during instrumentation and also help
handpiece with a light and brushing in ensuring a tight proximal contact
motion an ideal depth is gained. of the final restoration.
Step 3: Preparation of proximal box: c. Preparation in gingival direction is
a. Preparation to start with begins at the continued until contact is just broken
between the adjacent tooth and the
gingival wall and the wedge is seen.
d. Round the sharp axiopulpal line angle
e. Remove any unsupported enamel of
the buccal, lingual or gingival walls
with a small enamel hatchet.
f. Remove the previously placed wedge
placed at the beginning of treatment
and place a matrix band, while holding
the matrix band in place; forcefully
reinsert the wedge between the matrix
band and the adjacent tooth beneath
the gingival seat of preparation.
Many types of matrix bands are available for use in
restorative pediatric dentistry
a. T band: No special equipment is needed
(Fig. 9.8).
b. Sectional matrix [Strip - T, Denovo, Baldwin Park,
calif]: is very easy to use, is not circumferential,
must be held in place by the wedge.
Figs 9.7A to C: Class II amalgam cavity preparations. c. Auto matrix: It is very easy to use, requires special
(A) Maxillary right second and first primary molars
(occlusal view). (B) Mandibular second primary molar tightening and removal tools.
(proximal view). (C) Mandibular right first and second d. Spot-welded matrix: A spot welder is required at
primary molars (occlusal view) chair side.
Restorative Dentistry for the Primary Dentition 71

Step 6: With a small cleoid discoid carver carving

of occlusal part is performed as in class I
restoration. Marginal ridge is carved with
a tip of an explorer or with a help of Hollen
back carver.
Step 7: Removal of wedge and matrix band is
done carefully. Check and see that the
height of the newly restored marginal
ridge is approximately equal to adjacent
marginal ridge.
Step 8: Gently floss the interproximal contact.
To check the tightness of the contact.
To check for gingival overhang.
To check for any remaining loose
amalgam particles from the
interproximal region.
Step 9: Burnish the restoration.
Figs 9.8A to C: (A) The T band matrix. (B) The T band is Step 10: Remove RD carefully and Check for
formed into a circle, and the extension wings are folded down
to secure the band. (C) The T band is adapted to fit the tooth
tightly and is trimmed with scissors, and the free end is bent
(FIGS 9.9 AND 9.10)
e. Tofflemire matrix: It is used infrequently because Adjacent interproximal lesions are not uncommon
it does not fit primary tooth contour well. in the primary dentition.
Step 4: Triturate the amalgam and then with the Preparation for adjacent proximal restoration is
amalgam carrier add the amalgam to the identical to the previously described, a matrix is
preparation in a single increments, placed on each tooth and is wedged properly.
beginning in the proximal box. T-bands, sectional, or spot-welded matrices are
Step 5: Condense the amalgam into the corners preferable because multiple matrix holders are
of the proximal box and against the matrix difficult to place side-by-side.
band to ensure the re-establishment of a Condensation pressure toward the matrix will help
tight proximal contact and with help of in developing a tight interproximal contact.
small condenser continue filling and Carve the marginal ridges to an equal height and
condensing until the entire cavity is then carefully remove the wedge and matrix bands
overfilled. one at a time.
72 Essentials of Pediatric Dentistry

Fig. 9.9: Adjacent amalgam restoration

SEALANTS FOR PRIMARY TEETH Pit and fissure caries or restorations in other primary
Pit and fissure sealing is defined as the application
and mechanical bonding of a resin material to an acid- No radiographic or clinical evidence of the
etched enamel surface, thereby sealing existing pits interproximal decay.
and fissures from the oral environment. A patient who is receiving other preventive
treatment, such as systemic and/or topical fluoride
INDICATIONS to inhibit interproximal caries formation.

Deep, retentive pits and fissure that may cause TECHNIQUE OF SEALANT APPLICATION
wedging of the explorer.
Stained pits and fissures with minimal decalcified Step 1: Isolate the tooth from salivary
or opacified appearances. contamination.
Restorative Dentistry for the Primary Dentition 73


Conservative Adhesive Restoration (CAR) is a term
that has been updated; which was first described by
Simonsen and Stallard in 1977 and refined in 1985 as
Preventive Resin Restoration (PRR).
Indicated forThe teeth that are suitable for CARs
are those that demonstrate small, discrete regions of
decay, often limited to a single pit.
Many CARs do not require anesthesia because of
minimal teeth preparation.

Type I CAR (PRR): It is a merely sealant application
Figs 9.10A and B: Back-to-Back amalgam preparations. with minimal preparation to remove the areas of
(A) After wedging, begin condensing the adjacent proximal questionable incipient decay.
boxes alternately. (B) Continue condensing the amalgams
[Preparation is Confined to Enamel]
alternately until both preparations are slightly overfilled
This is now considered as sealant application, not
a restorative technique.
Type II CAR (PRR): Technique involves a similar
Step 2: Clean the tooth surfaceby either ultraconservative preparation with a small round bur
pumice, prophylaxis paste on a low speed in the area of the decay.
bristle brush or fissuretomy (to widen the
[Preparation is Extended to Dentin]
fissures in enamel prior to sealant
Following caries removal the entire occlusal
surface is etched, rinsed and dried and bonding agent
Step 3: Acid-etch for 15 to 20 sec.
is placed.
Step 4: Rinse and dry the surface and apply
Then a wear-resistant resin-based composite or
bonding agent.
compomer material is placed in the cavity preparation.
Step 5: Apply the sealant to the etched surface.
The entire surface is then polymerised.
Step 6: Polymerize the sealant.
Step 7: Evaluate the sealant with explorer. Type III CAR (PRR): It is similar to type II CAR, except
Step 8: Evaluate and adjust the occlusion. that a sealant layer forms an integral part of restoration.
74 Essentials of Pediatric Dentistry

In type III the wear resistant resin, is used only to interproximal lesions are included in this category
restore the cavity preparation and the remaining because the morphologic appearance of the tooth
adjacent pits and fissures are sealed with pit and fissure that exhibits inadequate support for the mesial
sealants. interproximal restorations.
Restoration for primary teeth followed by
USE OF STAINLESS STEEL CROWNS procedures like pulpotomy or pulpectomy.
Restoration of hypoplastic primary or permanent
SSC were introduced in pediatric dentistry by teeth.
Humphrey in 1950. They are generally considered Restoration for anomalies like amelogenesis
superior to large multisurface amalgam restorations imperfecta or dentinogenesis imperfecta.
(Fig. 9.11). Restorations in individuals (disabled or others)
with extremely poor oral hygiene and in whom
Types failure of other materials is likely.
There are two commonly used types of SSCs: As an abutment for space maintainers or prosthetic
1. Pretrimmed Crowns [unitek (3M)] (Stainless steel appliances.
crowns and Denovo crowns): These crowns have Use of stainless steel crown must be given strong
straight, non contoured sides but are festooned to consideration in children who require general
follow a line parallel to the gingival crest. anesthesia for dental treatment.
They still require contouring and some trimming.
2. Precontoured Crowns [Ni-Chro Ion Crowns and STEPS FOR PREPARATION AND
Unitek StainlessSteel Crown (3M)]: These PLACEMENT OF STAINLESS STEEL
crowns are festooned and are precontoured, some CROWNS (FIGS 9.12 AND 9.13)
trimming and contouring may be necessary but is Step 1: a. Note the dental midline
usually minimal. b. Preoperative occlusion
A third type of SSC is available but is not widely c. Cusp-fossa relationship bilaterally.
used. Step 2: a. Administer appropriate local
Preveener SSCs (Nu Smile crowns, orthodontic anesthesia (enough to obtain lingual/
technologies, Houston, Tex). These have resin based palatal and buccal/facial anesthesia)
composite bonded to the occlusal and buccal surfaces of soft tissue surrounding the tooth to
in a laboratory process to create a more aesthetic be crowned.
posterior crown. b. Proper placement of rubber dam.
Step 3: Occlusal reduction: Reduction of occlusal
Indications for Use of Stainless Steel Crown surface is carried out with no. 169L taper
SSCs are used as restoration for extensive carious fissure bur in a high speed handpiece.
lesions in primary or young permanent teeth. First Depth: Make depth cuts by cutting the
primary molars especially with mesial occlusal grooves to a depth of 1.0-1.5 mm
Restorative Dentistry for the Primary Dentition 75

Figs 9.11: Use of stainless steel crowns

76 Essentials of Pediatric Dentistry

Fig. 9.12: Stainless steel crown

Restorative Dentistry for the Primary Dentition 77

c. Always maintain vertical walls with

only sight occlusal convergence.
d. The occlusobuccal and occlusolingual
line angles are rounded by holding the
bur at a 30-45 angle to the occlusal
surface and in a sweeping mesiodistal
e. Buccolingual reduction is often
limited to beveling and a only
confined to occlusal one-third of the
Step 6: Selecting crown:
a. Selection of a crown begins as trial
Figs 9.13A to D: Stainless steel crown preparation. and error procedure.
Mandibular second primary molar. (A) Proximal view, Bu; b. The goal is to place the smallest crown
Buccal Li; Lingual. (B) Buccal view. Note feather-edge gingival that could be seated on the tooth and
margins. (C) Occlusal view. Note rounded line angles. establish preexisting proximal
(D) Mesiolingual view. Note that lingual and buccal reduction
is limited to the beveling of the occlusal third
c. The selected crown is seated on the
tooth (tried on tooth) by seating the
and extend through buccal, lingual and crown lingually first and later applying
proximal surfaces. pressure in buccal direction so that
Maintaining cuspal inclines: Place the bur crown slides over the buccal surfaces
with sides and uniformly reduce the into the gingival sulcus. Friction
remaining occlusal surface by 1.5 mm. should be felt as the crown slips over
Step 4: Access to decay: It is by use of no. 330 or the buccal bulge.
169L bur in high speed handpiece, then Step 7: Establishing preliminary occlusal
remove decay with a large, round bur in relationship:
low-speed handpiece. Compare adjacent marginal ridge
Step 5: Proximal reduction: It is accomplished by heights If the crown does not seat to
the taper fissure bur or thin tapered the same level of adjacent teeth, the
diamond. occlusal reduction may be inadequate.
a. Contact with adjacent tooth must be i. The crown may be too long.
broken gingivally and buccolingually. ii. A gingival proximal ledge may exist.
b. The gingival proximal margin should iii. Contact may not have been broken
have feather edge finish line. with the adjacent tooth.
78 Essentials of Pediatric Dentistry

Step 8: Trimming of crowns:

a. Before trimming place the crown onto
the preparation and lightly mark the
level of gingival crest on the crown
with a sharp instrument. The crowns
are removed and trimmed 1 mm below
the mark with crown and bridge
scissors or with a low speed straight
b. The crown margins should be trimmed
to lie parallel to the contour of the
gingival tissue around the tooth and
should include various curves without
incorporating sharp angles.
Step 9: Contour and crimp the crowns:
a. Contouring and crimping is done to
form a tightly fitting crown. A tight
marginal fit aids in.
Mechanical retention of crown. Figs 9.14A and B: (A) Contouring is accomplished with a
Protection of the cement from pair of no. 114 pliers. (B) Final crimping is accomplished
with a pair of no. 800-417 pliers
exposure to oral fluids.
A proper maintenance of gingival
health. crimping pliers such as no. 800-417
b. Contouring includes bending the
Step 10: Check for a proper fit of crown:
gingival one-third of the crowns
margins in a inward direction so as to a. After contouring and crimping, firm
re-establish the normal anatomic resistance is encountered when the
features of natural crown. crown is seated over the preparation.
c. Contouring is accomplished b. After seating the crown, gingival
circumferentially with margins are examined with explorer
to check for fit of crown.
No. 114 ball and socket plier or with
c. Examine for gingival tissue blanching,
(Fig. 9.14) No. 137 Gordon pliers.
proximal contacts.
d. By crimping a final close adaptation
d. Crown is removed with a help of
is achieved, crimping is done in
carver or scaler while engaging the
cervical margin 1 mm circum-
gingival margin and finger placed
ferentially. No. 137 pliers, special
Restorative Dentistry for the Primary Dentition 79

over the crown, the crown is Step 14: After the cement has partially set excess
dislodged. cement from gingival sulcus is removed
e. The rubber dam is removed and crown with a tip of explorer. Interproximal areas
is replaced to check for occlusion are cleaned with use of dental floss.
bilaterally in centric occlusion, Step 15: a. Ask the patient to rinse the oral cavity
movement of crown in well
occlusogingival direction with biting b. Examine the occlusion
pressure. c. Examine soft tissues
Step 11: Final smoothing and polishing of crown d. Discharge the patient.
Smoothing is done with a heatless stone;
rotation of stone should be toward and at TWO PRINCIPLES OF OBTAINING
a 45 angle to the edge of crown to OPTIMAL ADAPTATION OF STAINLESS
Thin margins of crown
The two key principles are:
Smooth and flowing curves.
i. Crown length: The length of an SSC should
Rubber wheel is used to remove scratches,
allow the crown to fit just into the gingival
a wire brush is used to polish the margins
sulcus, engaging the natural undercuts.
to a nice shine.
The most important point is that the crown
Step 12: Rinse and dry the crown inside and outside
length should extend just slight apical to tooths
and preparing to cement itThe crown
height of contour.
is filled approximately two-third with
For primary teeth the buccal, lingual and
cement with all its inner surfaces covered
proximal heights of contour happen to be
(Glass ionomer, zinc phosphate, poly-
just above the gingival crest.
carboxylate or self-curing resin ionomer).
As an SSC is trimmed in length such that
Step 13: Dry the prepared tooth and seat the crown
its gingival margins comes closer to the
greatest diameters (height of contour) of the
The handle of a mirror or the flat end
tooth crown, the spaces between the
of a band pusher may be used to
margins of crown and tooth surfaces are
ensure complete seating of crown or
patients is asked to bite on a tongue
Thus, when the margins of the metal crowns
nearly approximate the greatest diameter of
Cement must be expressed from all
the tooth, the spaces are small enough so
that the metal can be easily adapted closely
Patient must close in centric occlusion
to the tooth.
before cement sets.
80 Essentials of Pediatric Dentistry

ii. Shape of the crowns gingival margins:

The shape or contour of the gingival
margins differ from first to second primary
molar, as well as from buccal to lingual to
The margins of the trimmed crown should
approximate the shape of the gingival crest
around the tooth.
The margins of the finished, trimmed steel Fig. 9.16: The proximal gingival contour of primary molars
crown consists of a series of curves or arcs has been described as a frown because the shortest
as determined by the marginal gingiva of occlusocervical heights are about midpoint buccolingually
tooth being restored.
The buccal gingival contour of second
primary molar has been described as a SPECIAL CONSIDERATION FOR
The buccal gingival contour of first primary
1. Placement of adjacent crowns: When Quadrant
molar has been described as a Stretched
Dentistry is practiced, it is necessary to place SSCs
out-S (Fig. 9.15).
on adjacent teeth; The tooth preparation and crown
The proximal gingival contour of primary
selection for placing multiple crowns are similar
molars has been described as a frown
as described for single crown.
because the shortest occlusocervical heights
Following points are to be considered in
are about midpoint buccolingually (Fig.
a. Prepare occlusal reduction of one tooth
completely before beginning occlusal
reduction of the other tooth; tendency is
towards under reducing both.
b. Contact between adjacent proximal surfaces
should be broken, producing an approximately
1.5 mm space at the gingival level.
c. Both crowns should be trimmed, contoured,
and prepared for cementation simultaneously.
Fig. 9.15: The buccal gingival contour of the second primary
It is better to begin placement and cementation
molar has been described as a smile, and the buccal gingival
contour of the first primary molar has been described as of more distal tooth first.
stretched out-S. The gingival contour of all the lingual 2. Preparing crowns in areas of space loss:
surfaces (not pictured) is a smile Frequently, when the tooth structure is lost as a
Restorative Dentistry for the Primary Dentition 81

result of caries, a loss of contact and drifting of utilizing a facial access. Axial wall is
adjacent teeth into space occurs. placed 0.5 mm into dentin gingival wall
When this happens, the crown required to fit and lingual wall should just break contact
over buccolingual dimension will be too wide with the incisal wall of the preparation to
mesiodistally, the larger crown which will fit over maintain adequate tooth structure.
tooths greatest convexity is selected and an Step 4: A dovetail or lock is placed on the lingual
adjustment is made to reduce mesiodistal width. surface of maxillary canine and on labial
This adjustment is accomplished by grasping
the marginal ridges of the crown with Howe utility
plier and squeezing it, thereby reducing the
mesiodistal dimension.
Considerable recontouring of proximal, buccal,
and lingual walls of the crown with no. 137 or no.
114 pliers will be necessary.




Presence of caries
Developmental defects of tooths hard tissue.


RATION (FIG. 9.17)
Figs 9.17A to D: Class III cavity preparations (A,B,C, labial
Step 1: Administer appropriate anesthesia, and
view). Note that a short bevel is placed on the cavosurface
proper placement of rubber dam. margins of all the three preparations. (A) Slot preparation
Step 2: Placement of a wooden wedge with a dovetail (the most frequently used class III
interproximally to protect gingival papilla preparation) the dovetail provides additional retention.
from bur and minimize gingival (B) Slot preparation used for very small class III carious
lesions. (C) Modified slot preparation, used when extensive
gingival decalcification is evident to interproximal caries.
Step 3: Remove caries with no. 330 bur or a no. 2 (D) The interproximal box is placed perpendicular to a line
round bur in a high-speed handpiece, tangent to the labial surface
82 Essentials of Pediatric Dentistry

surface of mandibular canines (To Composite polishing gloss may be

enhance retention). used for final polishing.
Step 5: A short bevel (0.5 mm) is placed on the Final interproximal polishing of the
cavo surface margins of preparation to be restoration is completed with sand
restored with resin-based composites. paper strips.
Bevel is placed with a flame-shaped Mounted abrasive disks can be used
composite finishing bur. to finish facial and lingual surfaces.
Step 6: Clean and dry the preparation with water Step 11: When finishing is completed, remove
and compressed air. rubber dam and floss interproximal areas
Place a plastic or sectional metal matrix. to remove overhangs if any.
Step 7: Etch the preparation for 15 to 20 sec; with
an acid gel. After etching, rinse and dry CLASS V RESTORATION FOR
the preparation well. INCISORS AND CANINES
Step 8: Place a dentin bonding agent in They are most often needed on the facial surface of
preparation (evenly over enamel and canines.
dentin) and polymerise the bonding agent. Step 1: Penetrate the tooth in the area of caries
Step 9: Place the composite in preparation with a with no. 330 bur until the dentin is reached
use of plastic instrument or pressure (approx 1 mm from the outer enamel
syringe. surface).
Stabilize the matrix tightly around the Step 2: Prepare an appropriate outline form while
preparation until curing is complete. moving the bur laterally into sound dentin
Visible-light cured composites are and enamel this establishes the walls of
cured with an appropriate polymeri- cavity. The lateral walls are slightly flared
zing time and visible light is held as near the proximal surfaces to prevent the
close as possible to composite. Light undermining of enamel.
is held from both lingual and facial Step 3: Pulpal wall should be convex, parallel to
surface for proper polymerization as the external enamel surface.
per manufacturer instructions. Step 4: Mechanical retentionIn preparation is
achieved with use of no. 35 inverted cone
Step 10: Finishing and polishing: Can be
bur or a no. round bur this creates
performed immediately after
gingivoaxial and incisoaxial line angles.
Step 5: For resin-based compositesShort bevel
Gross finishing is performed with fine- is placed around entire cavosurface
grit diamonds or with carbide finishing margin. Etching, bonding, material
burs. placement and finishing is similar to class
A lubricated, pointed white stone may III adhesive restorations; except that no
be used for smoothing. matrix is used.
Restorative Dentistry for the Primary Dentition 83


Incisors with large interproximal lesions.
Incisors that have been fractured and have lost an
appreciable amount of tooth structure.
Incisors that have received pulp therapy.
Incisors with small interproximal lesions that have
also large areas of decalcification in cervical
Incisors with multiple hypoplastic defects or
developmental disturbances.
Aesthetically unpleasing discoloured incisors.

Methods of Providing Full Coronal

Coverage to Primary Incisors
Adhesive resin based composite crowns or Strip
Stainless steel crowns
Open face steel crowns
Prefabricated veener steel crowns.
The most aesthetic and frequently placed crown is
Adhesive resin-based composite crown or strip crowns
(Fig. 9.18).

PREPARATION AND PLACEMENT OF Figs 9.18A and B: Strip crowns, maxillary

ADHESIVE RESIN-BASED COMPOSITE primary incisors, before and after
CROWN (FIG. 9.19)
Step 1: Administer appropriate anaesthesia. Step 4: Remove the carious lesion of tooth with a
Step 2: Proper selection of shade of composite large round bur in the low-speed
resin and proper placement of rubber dam. handpiece. Do any pulp therapy if needed
Step 3: Select a proper primary incisor celluloid at this time.
crown form with mesiodistal measurement Step 5: Reduce the incisal edge by 1.5 mm using
approximately equal to the tooth to be a fine, tapered diamond or a no. 169 L
restored. bur.
84 Essentials of Pediatric Dentistry

Figs 9.19A to C: Adhesive resin-based composite crown (strip)

preparation. (A) Labial view. (B) Proximal view. (C) Incisal view; the
proximal slice should be parallel to the natural external contours of the

Step 6: Reduction of interproximal surfaces by Step 8: Trimming and fitting of crown:

0.5 mm to 1 mm; this reduction is Trim the selected crown form by
performed to allow a crown form to slip cutting away the excess material
over the tooth; interproximal walls should gingivally with crown and bridge
be parallel and the gingival margin should scissors. A properly trimmed crown
have a feather edge. form should fit 1mm below the
Step 7: Reduction of facial surface by 1.0 mm and gingival crest and should be of a
the lingual surface by 0.5 mm. comparable height to that of adjacent
Round all line angles. teeth. (Maxillary lateral is 0.5 to 1 mm
Place a small undercut on the facial shorter than those of central incisors).
surface in the gingival one-third of After adequate trimming and fit of
teeth with no. 330 bur or no. 35 crown next, a small hole is punched
inverted cone; this under-cut serves as on a lingual surface as a vent for the
a mechanical lock when the resin escape of trapped air as the crown is
polymerizes in this undercut. placed with resin over the preparation.
Restorative Dentistry for the Primary Dentition 85

Step 9: Etch the prepared tooth with acid-gel for These all factors requires consideration for
15 to 20 sec, rinse and dry the tooth; then providing a prosthetic tooth replacement for the child.
apply bonding agent to entire tooth and
Step 10: Seat the crown which is filled
A. Fixed: Do not require patient compliance
approximately two-third with a resin-
B. Removable: Require patient compliance.
based composite material.
Excess material should flow from the
A. Fixed Prosthetic Appliance
vent prepared on lingual surface of crown
and from gingival margin; this excess of These type of appliances will always by preferred over
material is removed with explorer tip. removable appliance in preschool children because of
Step 11: Polymerise the resin material by directing compliance issue.
the curing light from both facial and One fixed appliance design is Nance-like device
lingual directions. constructed with two bands or preferably, steel crowns
Step 12: Removal of celluloid form by composite on primary molars that are connected with a palatal
finishing bur and then peel the form from wire to which replacement teeth are attached.
the tooth.
Step 13: Remove the rubber dam and evaluate Benefits of Appliance
occlusion. This appliance is cemented onto the molars and is
Step 14: Final finishing is required on facial not easily removed by the child.
surface; a flame carbide finishing bur is It requires minimal adjustments.
utilized for this purpose. The teeth can be made to sit directly on the ridge
Step 15: Final contouring is required on lingual of edentulous space (preferred) or acrylic gingiva
surface, a round or pear-shaped finishing can be added.
bur is utilised for this purpose.
Step 16: Final polishing is carried with abrasive Limitations of Appliance
discs for areas of crown that require
contouring. Difficulty in maintaining hygiene and home
PROSTHETIC REPLACEMENT OF Possible decalcification around the bands.
PRIMARY ANTERIOR TEETH Bending of the wires with fingers or with sticky
foods, which may lead to occlusal interferences
Premature loss of maxillary primary incisors are and require adjustments.
mainly the result of Need for frequent recementation due to potential
Extensive caries loosening of bands resulting from continual
Trauma trouqing of bands by the movement of wires during
Congenital absence. normal chewing.
86 Essentials of Pediatric Dentistry

B. Removable Prosthetic Appliance Step 3: Cavity preparation: Using abrasive unit

with high volume evacuation placed in
These appliances require the most compliance of
proximity of tooth; prepare cavity.
any of the prosthetic replacements.
Step 4: Etching: Etchent is applied for 20 seconds
They are not indicated in children younger than 3
and then thoroughly rinse the prepared
The removable appliances is a Hawley-like device
Step 5: Dentin bonding agent: is applied after
that replaces teeth and utilizes circumferential and
thorough rinse.
ball clasps on the molars.
Step 6: Placement of composites: After selecting
correct shade of composite; place and
Benefits of Appliance
photo-polymerise the material for 40
The ability to remove the appliance for daily seconds.
cleaning. Step 7: Finishing and polishing: After curing of
Adjustments are made easily by the dentist without material, give a proper finish to the
having to remove and recement bands. restoration and final polishing is
accomplished with a disc and polishing
Limitations of Appliance cup.
Patients compliance is required Step 8: Check occlusion.
Clasps will need adjustment, frequency of which
depends on child's handling of the appliance. What is Microdentistry?

AIR ABRASION MICRODENTISTRY Microdentistry is a new, alternative way to treat decay

in teeth. The idea behind this technology is to remove
Air abrasion microdentistry is a technique for cavity as little of the natural tooth as possible while removing
preparation as well as prophylaxis.
all of the decay. With the advent of our new bonding
techniques, decay indicating dyes, magnification, fiber-
optic lights and white filling materials, decay can be
Air abrasive technology is the use of compressed air conservatively removed from a tooth and a filling
to propel aluminium oxide particles with such a force placed that will restore a tooth to its original strength
that make possible the cutting of tooth structure. and beauty. Over 90 percent of the time, we do not
need to make you numb to do microdentistry and air
PROCEDURE abrasion so we can eliminate the need for a shot. With
Step 1: Determine the extent of caries the reduced need for anesthetic, we can complete more
With the help of radiograph. work in a shorter amount of time since we can work in
With the help of caries detecting dye. multiple areas of your mouth in the same appointment.
Step 2: Isolation of tooth: Isolate the tooth with In addition to saving time, you will enjoy the reduction
rubber dam. of noise normally caused by a traditional dental drill.
Restorative Dentistry for the Primary Dentition 87

How is this Done? abrasion machine, under magnification and special

We use air-abrasion, which is a relatively new process light sources in a very conservative manner.
in which a fine, pressurized stream of aluminum oxide Red cavity stain photo special cavity stains are used
powder is used to remove the small decayed pits and to chemically stain decay in the teeth to help us see
fissures in teeth. Research studies have shown that in any small spots so nothing is missed. Once rinsed off,
the absence of smoking and coffee drinking, if a patient the tooth is now ready for the filling.
presents with dark stained pits in their teeth, decay is The prepared tooth is treated with an acid solution
present over 90 percent of the time underneath the
to roughen the surface and get it ready for the bonding
stains. In our office we believe very strongly in
process. Once etched, the tooth is ready for bonding
prevention and early treatment of disease. It just makes
good sense to treat small cavities early with agents and the conservative filling. We use special
conservative microdentistry than to wait for things to lights to harden the filling and then complete the
get worse. process by polishing the filling.
The surface is sealed and protected leaving the
The Technique tooth restored to its original strength and beauty.
Small cavities are identified and scheduled for early Microdentistry is an excellent preventive treatment
treatment. for those who share our belief that early, conservative
The teeth are isolated either with rubber dam or care is ideal. You can have decay removed without
cotton rolls and the decay is removed with the air- the extensive preparations, loud noise, or bad smells.
Pulp Therapy for the
Primary Dentition


The objectives of pulp therapy are conservation of the

tooth in a healthy state of functioning as an integral
component of the dentition. They are:
Preservation of the arch space.
Prevention of deleterious effects on the
succedaneous tooth, and the periapical tissues and
on the systemic condition of the child.
Enhances aesthetics, mastication, prevent aberrant
tongue habits, aid in speech and prevent
psychologic effects associated with tooth loss.
Helps in maintenance of a healthy oral
environment, relief of pain, contributes to the
development and maturation of the child, growth
of the facial skeleton complex and development
of dental complex to its fullest potential.

Pulp Therapies
Pulp exposure of the tooth exists when the continuity
of dentin surrounding the pulp is broken due to the
caries nearing and extending towards pulp.
Pulp therapies are:
i. Indirect pulp capping
ii. Direct pulp capping
iii. Pulpotomy
Pulp Therapy for the Primary Dentition 89


v. Apexogenesis
Discolouration, mobility with nonvitality of tooth
vi. Apexification.
are the features which are not considered to
undergo indirect pulp capping.
I. INDIRECT PULP CAPPING Patient giving history of sharp pain indicating an
DEFINITION acute inflammatory condition; also patient
complains of prolonged pain at night.
It is a procedure where in small amount of carious When intraoral periapical radiograph is taken; if
dentin is retained in deep areas of cavity to avoid it reveals:
exposure of pulp, followed by placement of a suitable Pulp exposure
medicament and restorative material that seals off the Radiolucency at apex of roots of teeth.
carious dentin and encourages pulp recovery. Interrupted lamina dura.

i. Arresting the carious process Indirect pulp capping is undertaken in two
ii. Promoting dentin sclerosis appointments with a interappointment period of few
iii. Stimulating formation of tertiary dentin weeks.
iv. Remineralisation of carious dentin.
During First Appointment
INDICATIONS Step 1: Appropriately give local anesthesia and
isolate the tooth with the help of rubber
Deep carious lesion, which are close to, but not
involving the pulp in vital primary or young
Step 2: Prepare cavity with high speed handpiece;
permanent teeth.
during cavity preparation remove the
Patient gives history of mild pain during eating. superficial debris; majority of the soft
When pulp inflammation is seen as nominal and necrotic dentin with the use of large round
there is a definite layer of affected dentin after bur.
removal of infected dentin. Step 3: Excavate the soft decay uptil the resistance
When intraoral periapical radiograph is taken it of sound dentin is felt.
must reveal: Step 4: Rinse the prepared cavity with saline and
No radiolucency at apex of roots or in the dry it with cotton pellet.
furcation area of tooth. Step 5: At the base of cavity place calcium
Lamina dura and periodontal ligament space hydroxide and the rest of the cavity is
around tooth is normal. filled with zinc oxide eugenol cement.
90 Essentials of Pediatric Dentistry

During Second Appointment INDICATIONS

Step 1: History taking: Patient is asked about pain Very small exposure (less than 1 mm2) surrounded
(mild) which appears during eating; by a healthy dentin in a asymptomatic vital primary
patient must report negative history. teeth or a young permanent tooth.
Clinical examination: See to it that the While a pulp is exposed the oozing bright red
temporary restoration placed during first haemorrhage must be easily controlled by minimal
appointment is intact. pressure applied over the cotton pellet.
Radiographic examination: To examine
for appearance of sclerotic dentin, take a CONTRAINDICATIONS
bitewing radiograph.
Step 2: Gently remove the temporary filling, Patient gives history of spontaneous pain; also
remove the previous carious dentin that severe pain at night.
remained inside the cavity which could be Following features seen during clinical
easily removed in this appointment; due examination contraindicate direct pulp capping:
to the reason that; the remained carious Swelling in relation to particular tooth
dentin has been dried and lost its Tooth mobility
consistency. Excessive hemorrhage at the time of exposure
Step 3: The cavity is seen with a whitish and soft Serous exudate from the exposure.
area (predentin); this area must not be Radiographic contraindications are:
disturbed. External/internal resorption
Step 4: Clean the cavity and place calcium Appearance of pulp and periradicular
hydroxide over which zinc oxide eugenol degeneration.
or GIC cement is filled and over it final
restoration is placed. PROCEDURE

II. DIRECT PULP CAPPING Step 1: Isolate the tooth with appropriate
placement of rubber dam.
DEFINITION Step 2: At the site of pulp exposure; any further
It is defined as procedure in which the placement of a manipulation is avoided; only irrigate the
medicament or nonmedicated material on a pulp that cavity with saline or distilled water.
has been exposed in course of excavating the last Step 3: Bleeding from site of exposure is arrested
portions of deep dentinal caries or as a result of trauma. with use of minimal pressure over cotton
pellet at place.
OBJECTIVE Step 4: Place the pulp capping material gently
over the site of exposure; avoid forcing
Objective of direct pulp capping is to create new dentin
in the area of the exposure and allow subsequent the materials into the pulp chamber and
healing of the pulp. over it place temporary restoration.
Pulp Therapy for the Primary Dentition 91

Step 5: Various materials used for pulp cap are: b. Clinical examinationMaintained
Calcium hydroxide Ca(OH)2 pulp vitality, minimal inflammatory
Denatured proteinalbumin response.
Isobutyl cynoacrylate c. Radiographic examinationAppe-
arance of dentinal bridge.
Mineral trioxide aggregate
(a), (b), (c) determines the success of direct pulp
4-META adhesive
capping, based on this final restoration is done.
Corticosteroids and antibiotics.
Inert materialTricalcium phosphate Histological Changes after Pulp Capping
ceramic. (Fig. 10.1)
Bone morphogenic protein
Histological changes after pulp capping are seen with
Direct bonding
varying duration of time period, it is explained as
Step 6: Recall patient after few weeks. After 24 hours or 1 day: Necrotic zone adjacent to
a. History takingPatient must give a calcium hydroxide paste is separated from healthy pulp
negative history of pain. tissue by a deep staining basophilic layer.

Fig. 10.1: Histological changes after pulp capping

92 Essentials of Pediatric Dentistry

After 1 week or 7 days: Increase in cellular and ii. Preservation Glutaraldehyde

fibroblastic activity. Ferric sulphate
After 14 days: Partly calcified fibrous tissue lined by iii. Regeneration Bone morphogenic
odontoblastic layer of cells is seen below the calcium protein
protienate zone and there is disappearance of necrotic
After 28 days: Zone of new dentin or dentinal bridge.
i. Vital tooth with healthy peridontium.
III. PULPOTOMY ii. Pain if present is either spontaneous or
DEFINITION iii. Tooth which is restorable.
iv. Tooth that possess at least 2/3rd of its root length.
Pulpotomy can be defined as complete removal of the
v. Hemorrhage from the amputation side is pale
coronal portion of the dental pulp, followed by
red and easy to control.
placement of a suitable dressing or medicament that
vi. In mixed dentition stage primary tooth is
will promote healing and preserve vitality of tooth.
preferable to a space maintainer.
Pulpotomy therapy can be classified according to
the following treatment objective as:
Devitalization - Mummification, cauterization
Preservation - Minimal devitalization, i. Evidence of internal resorption.
noninductive ii. Presence of interradicular bone loss.
Regeneration - Inductive, reparative iii. Existence of abscess and fistula in relation to
Pulpotomy iv. Radiographic evidence of calcific globules in
pulp chamber.
v. Caries penetrating the floor of pulp chamber.
Vital pulpotomy technique Nonvital pulpotomy vi. Tooth close to natural exfoliation.
i. Devitalization (Mortal pulpotomy)
a. Single setting Beechwood cresol DIAGNOSTIC CONSIDERATIONS
formocresol Formocresol
Electrosurgery The importance of performing the pulpotomy on
Laser teeth in which inflammation has been confined to
b. Two stage Gysi triopaste coronal pulp and when radicular pulp is free of
Easlicks formal- inflammation. Teeth selected according to this
dehyde criteria will have successful prognosis.
Paraform devita- Radiographic interpretation can give some clues
lizing paste as to which extent of carious lesion is present,
Pulp Therapy for the Primary Dentition 93

status of lamina dura, presence of abnormal

resorptive process or interradicular rarefaction
which can give an indirect clue to the relative
presence or absence of inflammation that exist.
Formocresol pulpotomy technique (first advocated by
Sweet 1930 as shown in Fig. 10.2).
i. The formocresol is a solution of 19 percent
formaldehyde, 35 percent cresol in vehicle of
15 percent glycerine and water.
To prepare 1:5 concentration of this formula
first thoroughly mix 3 parts of glycerine with 1
part of distilled water then add 4 parts of this
preparation to 1 part Buckleys formocresol and
thoroughly mix again.
ii. Mechanism of action of formaldehyde is to
prevent tissue autolysis by bonding to proteins.

a. Tooth should be first anesthetized and isolated with
rubber dam. A surgically clean technique should
be used throughout the procedure. All remaining
caries should be removed and the overhanging
enamel should be planned back to provide a good
access to the coronal pulp.
b. The entire roof of pulp chamber should be removed
with a bur. No overhanging dentin from the roof
of pulp chamber should remain.
c. A sharp discoid spoon excavator may be used to
amputate the coronal pulp. The pulp stump should Fig. 10.2: Formocresol pulpotomy technique
be cleanly excised with no tag of tissue extending
to the floor of pulp chamber. Moist cotton pellets should be placed is pulp
d. The pulp chamber is then irrigated with light flow chamber and allowed to remain over pulp stump
of water from the water syringe and evacuated. until a clot forms.
94 Essentials of Pediatric Dentistry

e. If hemorrhage is controlled readily and the pulp Propylene glycol

stump appears normal, it may be assumed that pulp Carbowax
tissue in the canals is uninflamed hence; it is safe Carimine to color
to proceed with pulpotomy.
The pulp chamber is dried with a sterile cotton Technique
pellet. Next a pellet of cotton moistened with a
1:5 concentration of Buckleys formocresol and First Appointment
blotted on a sterile gauze to remove the excess is Step I:
placed in contact with pulp stump and allowed to Preparation of instruments and materials
remain for 5 min. The pellet is removed and the Isolation of affected tooth with rubber dam
pulp chamber is dried with new cotton pellet. Preparation of cavity
f. A thick paste consisting of zinc oxide eugenol is Excavation of deep caries.
prepared and placed over the pulp stump. Step II:
A zinc polycarboxylate cement is placed over the When exposure site is encountered during
paste and tooth is restored with stainless steel crown. excavation of deep caries, ensure that, exposed site
is free of debris.
DEVITALIZATION PULPOTOMY Prepare a cotton pellet large enough to cover the
(TWO STAGE) exposure but small enough to clear the cavity
This is a two stage procedure involving the use of margin; incorporate the paraformaldehyde paste
paraformaldehyde to fix the coronal and radicular pulp into the pellet and place it over the exposure site
tissue. then seal the tooth for 1 to 2 weeks. Formaldehyde
gas liberated from paraformal-dehyde penetrates
Formula of each agent used are
through the coronal and radicular pulp, fixing the
Gysi triopaste Tricresol tissues.
Glycerine Second Appointment
Zinc oxide On the second appointment, pulpotomy is carried
Easlicks paraformaldehyde - P4C out with the help of local anaesthesia. The roof of
Paste Paraformaldehyde pulp chamber is removed and cleaned with saline
Procaine base and dried with cotton pellet.
Powdered asbestos The pulp chamber is filled with antiseptic paste
Petroleum jelly and tooth is restored.
Carimine to color
Paraform Devitalizing Mortal Pulpotomy (NONVITAL PULPOTOMY)
Paste Paraformaldehyde Ideally, a nonvital tooth should be treated with
Lignocaine pulpectomy and root canal filling. However,
Pulp Therapy for the Primary Dentition 95

pulpectomy of primary molar may sometimes be INDICATIONS

impracticable due to nonnegotiable root canals and
i. Strategically important tooth (e.g. in case of
also due to limited patient cooperation. Hence a two
deciduous second molar where the permanent
stage pulpotomy technique is advocated.
first molar has not erupted).
ii. Irreversible pulpitis
First Appointment
iii. Minimal periapical pathology with sufficient
The necrotic coronal pulp is removed, the pulp bone support.
chamber is irrigated with saline and dried with iv. At least 2/3rd of root length is available.
cotton pellet, infected radicular pulp is treated with
a strong antiseptic solution. PROCEDURE
Dip the pellet in beechwood cresol and remove
There are two types of procedures:
the excess by damping it on a sterile cotton and
place it in pulp chamber over the radicular pulp.
a. Single Visit Pulpectomy
Seal the cavity with a temporary cement for 1 to 2
weeks. Indication

Second Appointment This procedure is an extension of pulpotomy. Where

the inflammation extends beyond coronal pulp,
Isolate the tooth and remove the temporary filling indicated by haemorrhage from the amputated
and the pellet containing beechwood cresol. radicular stumps that is oozing continuously and is
Note if the symptom persists or if there is no signs uncontrollable.
of resolution of the sinus, a decision is made either
to repeat the treatment or extract the tooth. Procedure
If there are no symptoms the pulp chamber can be
filled with a antiseptic paste which is firmly pressed Step 1: Appropriately give local anesthesia and
with cotton pellet to push antiseptic paste into the isolate the tooth with rubber dam.
root canals; The tooth is then restored with stainless Step 2: Prepare an access cavity; expose the
steel crown. coronal pulp; all the accessible pulp tissue
(coronal as well as radicular) is extirpated
IV. PULPECTOMY with the help of barbed broaches.
Step 3: After extirpation of pulp tissue is complete
DEFINITION irrigate the pulp chamber and canals with
Pulpectomy involves removal of roof and contents of saline and a diagnostic radiograph is taken
pulp chamber in order to gain access to the root canals for the working length of file.
which are debrided, enlarged and disinfected; the Step 4: Shaping, irrigating of canals is undertaken,
canals are filled with resorbable material. dry the canals with absorbent paper points.
96 Essentials of Pediatric Dentistry

Step 5: Obturate the canals and access cavity Presence of infection, abscess or chronic sinus.
completely. Nonvital primary tooth.
Step 6: Place the final restoration.
b. Multivisit Pulpectomy (Fig. 10.3) a. During first appointment
Indications Step 1: Appropriately give local anesthesia and
isolate tooth with rubber dam.
Tooth with necrotic pulp and periapical Step 2: Prepare access cavity and expose the
involvement. coronal pulp and extirpate all the pulp
tissues (coronal and radicular) with barbed
Step 3: Place the cotton pellet over the pulp
chamber soaked with formocresol and
over it place temporary restoration.
After a duration of 1 week recall the patient.
b. During second appointment
Step 4 : Gently remove temporary restoration;
irrigate the canals and start with
biomechanical preparation of canals.
Note: Use appropriate working length of files
to prevent perforation of canals.
Step 5 : Irrigate and dry the canals and place a
sterile cotton pellet and over it place
temporary restoration.
c. During third appointment
Step 6 : Gently remove the temporary restoration,
irrigate and dry the canals with absorbent
paper points.
Step 7 : Coat the walls of canals with luting
consistency of cement with help of
reamers and then fill the canals with thick
consistency of cement with help of
Step 8 : Seal the pulp chamber with temporary
Fig. 10.3: Pulpectomy (multivisit) restoration.
Pulp Therapy for the Primary Dentition 97

After duration of 1 week recall the patient. Another disadvantage of ZOE paste is difference
d. During fourth appointment between its rate of resorption and that of the tooth
Step 9 : If tooth is asymptomatic, place final root.
restoration; give a stainless steel crown.
Iodoform Paste
Several authors reported the use of KRI paste.
Root Canal Filling Materials It resorbs rapidly and has no undesirable effects
on succedenous teeth when used as pulp canal
Developmental, anatomic and physiologic differences medicaments in abscessed primary teeth.
between primary and permanent teeth call for Further KRI paste that extrudes into periapical
differences in the criteria for root canal filling tissue is rapidly replaced by normal tissue.
materials. It has found to have long-lasting bacteriocidal
Ideal requirements are: effect/potential.
i. Resorb at similar rate as the primary root Since iodoform paste does not set into hard mass
ii. Should be harmless to the periapical tissues and it can be removed if retreatment is required.
to the permanent tooth germ, resorb readily if KRI was found to have success rate of 84 percent
pressed beyond the apex compared to zinc oxide eugenol which showed
iii. It should have a stable disinfecting power success of 65 percent.
iv. It should be inserted easily into root canals and KRI paste:
removed easily if necessary Iodoform 80.8 percent
v. Should adhere to the walls of canals and should Camphor 4.86 percent
not shrink Parachlorophenol 2.025 percent
vi. It should not be soluble in water Menthol 1.21 percent
vii. Be radiopaque and not discolor the tooth. Maisto paste:
Iodoform 42 gm
Zinc Oxide-Eugenol Paste Camphor 3CC
Is probably the most commonly used filling material Chlorophenol
for primary teeth. Camp in 1984 introduced the Thymol 2 gm
endodontic pressure syringe to overcome the problem Zinc oxide 14 gm
of under filling, a relatively common finding when Lanolin 0.50 gm
thick mixes of ZOE are employed. Walk Hoff paste:
Underfilling however is clinically frequently Parachlorophenol
acceptable. Overfilling on the other hand may cause a Camphor
mild foreign body reaction. Menthol
98 Essentials of Pediatric Dentistry

Calcium Hydroxide and Iodoform Mixture iv. The syringe is introduced up to 1/5th distance
from the apex of canal and the material is slowly
Calcium hydroxide is generally not used in pulp injected as the syringe is withdrawn from the
therapy for primary teeth. However several clinical canal.
and histopathological investigations reveals the use v. Regardless of the method adopted to fill the
of Ca (OH)2 and iodoform mixture. canal, care should be taken to prevent extrusion
Vitapex of material into the periapical tissues.
Calcium hydroxide vi. The adequacy of obturation is checked by
radiographs. In the event if a small amount of
ZOE is inadvertently forced through the apical
Oily additives.
foramen it is left alone since the material is
a. This material is easy to apply and resorbs at a
slightly faster rate than that of root. vii. When the canals are satisfactory obturated a fast
b. It has no toxic effects on permanent successor and set temporary cement is placed in pulp chamber
is radiopaque for these reasons, the Ca (OH)2 to seal over ZOE canal filling. The primary tooth
Iodoform mixture can be considered to be nearly is restored with a stainless steel crown.
ideal primary tooth filling material.
Gutta-percha is not a resorbable material, its use V. APEXOGENESIS
is contraindicated in primary teeth.
Obturation Techniques It is a treatment of a vital pulp by capping or pulpotomy
Several techniques have been used for filling of in order to permit continued growth of the root and
closure of the open apex.
materials into deciduous teeth canals
i. The primary teeth with the larger canals can be
filled with thin mix; coating the walls of the
canals with the help of reamer in an Indicated for traumatized or pulpally involved vital
anticlockwise direction while taking out slowly permanent tooth when root apex is incompletely
followed by placement of thicker mix which is formed.
then pushed manually. Tenderness on percussion and sensitivity is
ii. Pastes can also be filled by means of negative.
lentulospiral mounted on the micromotor No pain, no hemorrhage and no radiographic
handpiece. The direction of rotation needs to abnormality.
be checked for the material to properly flow into
iii. The endodontic pressure syringe is also effective Apexogenesis is contraindicated in an evidence when
for placing the ZOE into the canals. The vitapex radicular pulp has undergone degenerative changes and
system also uses the syringe with material in it. showing periapical radiolucency.
Pulp Therapy for the Primary Dentition 99

PROCEDURE ii. Apex is closed with no change in root space.

Step 1: Appropriately give local anesthesia and iii. Radiographically apparent calcific bridge at the
isolate the tooth with rubber dam. apex.
Step 2: Prepare an access cavity and expose the iv. There is no radiographic evidence of apical
coronal pulp; remove the coronal pulp closure but upon clinical instrumentation there
with the help of excavators. is definite stop at the apex, indicating calcific
Note: Prevent damage to radicular pulp while repair.
removing coronal pulp.
Step 3: Rinse the access cavity and place a moist PROCEDURE
cotton pellet over the amputed radicular
During First Appointment
stumps to control haemorrhage.
Step 4: Mixture of calcium hydroxide is placed Step 1: History takingPatient must give
over the healthy radicular pulp stumps and negative history of acute signs and
followed by placement of temporary symptoms.
restoration over it. Clinical examinationEvaluate
Step 5: Recall patient after few weeks and take following features in particular tooth and
follow-up radiographs periodically to region around tooth.
check for development of root. a. Swelling,
Step 6: As indicated radiographically; that root b. Color,
development is complete; perform
c. Mobility
conventional root canal treatment.
d. Tenderness.
Radiographic examinationIntraoral
periapical radiograph should be evaluated.
DEFINITION Step 2: Appropriately give local anesthesia and
isolate tooth with rubber dam.
It is a method of inducing development of the root
Step 3: Prepare access cavity; deroof coronal
apex of an immature pulpless tooth by formation of
pulp, remove necrotic pulp tissues and
osteocementum/bone like tissue.
debris from the canals with barbed
INDICATION broaches.
Step 4: Circumferential filing of canals is done with
For nonvital permanent teeth with open apex. help of file of appropriate working length;
followed by irrigating the canals with saline
Franks Criteria for Apexification to remove infected dentin and debris from
i. Apex is closed, through minimum recession of the walls of canals; dry the canals with
the canal. absorbant paper points.
100 Essentials of Pediatric Dentistry

Step 5: Fill the canals with calcium hydroxide Either apex is not closed, then recall
cement; seal the access cavity with patient again after 6 months.
temporary restoration.
Recall patient after duration of 6 months. Or apex is closed, then take out
calcium hydroxide; irrigate root canals
During Second Appointment with normal saline, obturate canals
with gutta-percha points and followed
Step 6: Take a intraoral periapical radiograph; two
situations can exists. by final restoration.
Periodontal Problems in
Children and Adolescents

CHANGES IN TISSUES IN CHILDREN Changes in Cementum and Alveolar Bone

Changes in Gingiva Cementum in children is less denser and thinner
as compared to adults.
i. The gingiva appears to be flabbier due to the Crest of alveolar bone is flatter, lamina dura is
lesser density of the connective tissue in the thinner, smaller amount of calcification, large
lamina propria. marrow spaces.
ii. The gingiva appear more reddish due to thinner
epithelium, a lesser degree of cornification and CLASSIFICATION OF PERIODONTAL
a greater vascularity. PROBLEMS IN CHILDREN
iii. The gingiva lack stipplings, due to shorter and
flatter papillae from the lamina propria. A. Gingivitis
iv. The gingival margins appears to be rounded, B. Gingival recession
rolled due to hyperemia and edema that follows C. Juvenile periodontitis
v. There is greater sulcus depth due to relative ease
of gingival retraction.

Changes in Periodontal Ligament

The periodontal ligament in children is wider and very
less and reduced density of fibers per unit area are
present. It has more blood vessels and lymph vessles
in connective tissue than in adults.
102 Essentials of Pediatric Dentistry

Localized juvenile periodontitis a. Lateral ulceration is characterized by involvement

Generalized juvenile periodontitis of buccal wall of papillae, margins and possibly
D. Prepubertal periodontitis the attached gingiva as it occurs in the distribution
Localized of lateral blood supply; these types of ulcerations
Generalized are less common.
E. Systemic diseases associated periodontitis b. Deep ulceration and necrosis of the tissues of the
Papillon-Lefvre syndrome embrasure, giving rise to the typical truncated
Down syndrome papillae; as occurs in the distribution of the intra-
Ehlers-Danlos syndrome alveolar blood vessels; these type of ulcerations
Chdiak-Higashi syndrome are comparatively more common.
Leukocyte adhesion deficiency Interdental craters are covered by gray
Hypophosphatasia pseudomembranous slough which is
demarcated from the remainder of the gingival
GINGIVITIS mucosa by a pronounced linear erythema (Fig.
On slight provocation there is pronounced
It is also called gingivitis artefecta gingival bleeding.

Types Intraoral Symptoms

a. Major factitious gingivitis: Major form is more There is constant radiating, growing pain that is
severe and involves deeper periodontal tissue. It intensified by eating spicy or hot food.
is caused mainly due to psychological aetiology The lesions are extremely sensitive to touch and
behind the clinical appearances. patient is conscious of metallic foul taste and
b. Minor factitious gingivitis: Minor form is mainly
excessive amount of pasty saliva.
habitual; it results from rubbing or picking the
gingiva with fingernail.

It is characterized by sudden onset; may be following
an episode of debilitating disease of acute respiratory
tract infections.

Intraoral Signs
Two types of necrotizing ulcers are seen
a. Lateral ulcerations
b. Deep ulceration and necrosis. Fig. 11.1: Acute necrotizing ulcerative gingivitis (ANUG)
Periodontal Problems in Children and Adolescents 103

Extraoral Signs and Symptoms Management

In moderate cases, local lymphadenopathy and Management of acute necrotizing gingivitis is divided
there is slight elevated temperature. into steps in forms of visits of patient to the clinician's
In severe cases, patient is febrile and reports of office.
increased pulse rate, leucocytosis, loss of appetite
is seen. First Visit

Severe Sequelae Follows Treatment is confined to acutely involved areas in

first visit.
Noma or gangrenous stomatitis (Fig. 11.2) Apply topical anesthesia to acutely involved areas.
Fusospirochetal meningitis Gently swab the areas to dislodge and remove the
Toxaemia and fatal brain abscess. pseudomembrane.
With the use of ultrasonic scaler superficial
Predisposing Factors calculus is removed.
Nutritional deficiency Before sending patient; patient is instructed to rinse
Smoking the mouth every 2 hours with a glassful of a equal
Debilitating diseases mixture of warm water and 3 percent hydrogen
Pre-existing gingivitis, e.g. incubation zones peroxide. Also, if there are systemic symptoms,
Injury occured to gingiva due to malocclusion penicillin or erythromycin or metronidazole is
Psychosomatic factors. prescribed.
Patient is recalled after 3-4 days.

Second Visit
In second visit of patient, scaling is performed
Recall patient again after 3-4 days.

Third Visit
Scaling and root planing are repeated with
instructions on plaque control.
Ask the patient to discontinue the use of hydrogen
peroxide, but continue use of chlorhexidine rinses
for 2-3 weeks.

This mycotic infection is caused by Candida
Fig. 11.2: Noma or gangrenous stomatitis albicans.
104 Essentials of Pediatric Dentistry

Oral lesions are clinically of four types Clinical Features

a. Pseudomembranous typeWhite curd- like Include various intraoral and extraoral sings and
plaques. symptoms.
b. Atrophic typeusually seen on the dorsum of
the tongue with papillary atrophy and Intraoral Signs
a. Gingiva appears to be diffuse red, erythematous
c. Hyperplastic typeHyperkeratosis of the
with varying degree of oedema and gingival
epithelium with white plaques (Fig. 11.3). bleeding.
d. Epidermal and perioral typeScaling patches b. In the early stage, gray vesicles appears to be
at the corners of the lips. discrete, spherical involving labial and buccal
mucosae, soft palate, pharynx and tongue,
Management (Antimycotic Agent) approximately after 24 hours the vesicles ruptures
leaving painful ulcers (Fig. 11.4).
Cotrimoxazole (oral troches) every 3 hours, i.e. for
c. Ulcers created due to rupturing of vesicles appears
total of 6 per day for 7-10 days.
to be red, elevated with halo-like margins and a
depressed yellowish or grayish white central
Acute Herpetic Gingivostomatitis portion.
It is a viral infection of the oral mucosa caused by
herpes simplex virus, it frequently occurs in infants Intraoral Symptoms
and children of age less then 6 years. a. The ruptured vesicles are sensitive to touch,
thermal changes and food

Fig. 11.3: Moniliasis, oral thrush Fig. 11.4: Acute herpetic gingivostomatitis
Periodontal Problems in Children and Adolescents 105

Fig. 11.5: Herpes labialis Fig. 11.6: Chronic gingivitis

b. Generalized soreness of the oral cavity, which CHRONIC GINGIVITIS

interfere with eating and drinking.
Chronic marginal gingivitis is the most prevalent type
of gingival change in childhood. The gingiva exhibits
Extraoral Signs and Symptoms all the changes; in color, size, consistency, and surface
a. Involvement of the lips and faceHerpes labialis texture characteristic of chronic inflammation. A fiery
cold sore (Fig. 11.5). surface discoloration is often superimposed on
b. Cervical adenitis, fever is as high as 101F to underlying chronic changes.
105F and generalized malaise are common. Gingival color change and swelling appear to be
more common expression of gingivitis in children than
are bleeding and increased pocket depth (Fig. 11.6).
a. Palliative treatment: Food debris and superficial Plaque induced
debris is removed, relief of pain is obtained with
In children, as in adults, the cause of gingivitis is
0.5 percent Dyclonine hydrochloride mouthwash plaque, local conditions like materia alba and poor
which has a topical anesthetic effect. oral hygiene favor its accumulation.
Locally apply Talbot's iodine, Zinc chloride In preschool children, however, the gingival
(80%) riboflavin, thiamine, chlortetracycline response to bacterial plaque has been found to be
(aureomycin) markedly less than that in adults. Dental plaque appears
b. Supportive treatment: Copious fluid intake, for to form more rapidly in children of age 8-12 years
relief of pain systemically administer aspirin. than in adults.
106 Essentials of Pediatric Dentistry

Gingivitis occurs more often and with greater

severity around malposed teeth because of their
increased tendency to accumulate plaque and materia
alba. Severe changes include gingival enlargement,
bluish-red discolouration, ulceration and the formation
of deep pockets form which pus can be expressed.
Pubertal gingivitis: A higher prevalence and
severity of gingivitis and gingival enlargement is
found in the circumpubertal period, this form of
gingivitis has been termed pubertal gingivitis.
The most frequent manifestations is a
significant increase inbleeding interdental sites.
This inflammatory lesion may include a gingival Fig. 11.7: Localized gingival recession
enlargement as a result of hormonal change that
magnify the tissues response to dental plaque. It The recession may be a transitional phase in tooth
occurs in males and females and resolves partially eruption and may correct itself when the teeth
after puberty. attain proper alignment, or it may be necessary to
Gingivitis associated with tooth eruption: It is realign the teeth orthodontically.
frequent and has given raise to the term eruption
gingivitis. However, tooth eruption per se does not JUVENILE PERIODONTITIS
cause gingivitis. The inflammation results form DEFINITION
plaque accumulation around erupting teeth.
The initiation of gingivitis appears to be related It is a disease of the periodontium occurring in an
to plaque accumulation rather than to tissue otherwise healthy adolescents, which is characterised
remodeling associated with eruption. by a rapid loss of alveolar bone around more than one
tooth of the permanent dentition.
There are many causes of gingival recession but
in children the position of teeth in the arch is the It exists in two forms:
most important. a. Localized
Gingival recession occurs on teeth in labial version b. Generalized.
and on those that are tilted or rotated so that the
roots project labially (Fig. 11.7). Localized Juvenile Periodontitis (LJP)
Anterior openbite increases the prevalence of i. It mainly appears in children of age group
gingival recession. between 11-15 years.
Periodontal Problems in Children and Adolescents 107

ii. Lesion is usually seen involving

First molar and / or incisors
First molar and/or incisors with additional
teeth (not exceeding 14 teeth).
iii. The most striking feature is lack of clinical
inflammation, despite the presence of deep
periodontal pockets.
iv. Small amounts of plaque is seen which rarely
mineralised to become calculus.
v. Most common initial symptoms are mobility,
migration of the incisors and first molars
classically, a distolabial migration of the
maxillary incisors with diastema formation
occurs (Fig. 11.8).

Microbiology of LJP
Two types of bacteria are considered to be pathogenic
in LJP.
Actinobacillus actinomycetem comitans.

Reason of classic distribution of LJP

Involvement of first molars and incisors with least
distribution in the cuspid. premolar area. The reasons
could be:
Production of opsonizing antibodies against
Actinobacillus actinomycetem comitans (Aa).
Bacteria antagonistic to Aa may develop thereby
decreasing the number of colonization sites.
Aa may lose its leukotoxin producing ability for
unknown reason.
Localization of the lesions could also be due to
the defect in cementum formation. Figs 11.8 A to C: Localized juvenile periodontitis
108 Essentials of Pediatric Dentistry

Pathogenesis of LJP Quantitatively; the amount of plaque seems to be

inconsistent with the amount of periodontal
Interplay of several factors:
The specific microbiology of subgingival plaque
No specific pattern is observed, all or most of the
Defects in cementum (Hypoplastic/aplastic)
teeth are affected.
Hereditary factors
Impaired polymorphonuclear leucocytes functions Two types of gingival responses: May be seen in
and disorders of the immune system. Generalized juvenile periodontitis. One is severe,
acutely inflamed tissue which is often proliferating,
Radiographic Findings ulcerated and fiery red, spontaneous bleeding and
suppuration is commonly seen.
i. Vertical/angular bone loss around, the first
In other cases, the gingival tissue may appear
molars and incisors in an otherwise healthy
pink and free of inflammation but deep pockets
teenagers is a diagnostic sign of classic juvenile
can be demonstrated by probing (Fig. 11.9).
Some of the patients may have systemic
Arc-shaped loss of alveolar bone extending
manifestations such as weight loss, mental
from distal surface of the 2nd premolar to the
depression and general malaise.
mesial surface of the 2nd molar is seen.
ii. Bilateral symmetrical patterns of bone loss is
Radiographic Findings
seen Mirror-Image-Pattern
No definite pattern of distribution occurs but, the
Generalized Juvenile Periodontitis (GJP) radiographic picture can range form severe bone loss
associated with the minimal number of teeth, to
Generalized juvenile periodontitis or generalized advanced bone loss affecting the majority of teeth in
aggressive periodontitis is usually characterised by the dentition.
generalized interproximal attachment loss affecting
atleast three permanent teeth other than first molars
and incisors.

Microbiology of GJP
Porphyromonas gingivalis
Actinobacillus actinomycetem comitans
Bacteroides forsythus.

Clinical Features
It affects persons between puberty to 35 years (but
may be older). Fig. 11.9: Generalized juvenile periodontitis
Periodontal Problems in Children and Adolescents 109

Treatment of Juvenile Periodontitis SYSTEMIC DISEASE ASSOCIATED

In almost all cases systemic tetracycline
hydrochloride 250 mg qid for at least a week Papillon-Lefvre Syndrome
should be given in conjunction with local
It is characterized by hyperkeratotic skin lesions
mechanical therapy. If surgery is indicated systemic
and severe destruction of the periodontium, these
antibiotic are advised with patient instructed to
changes may appear before the age of 4 years.
begin taking the antibiotic approximately 1 hour
Periodontal involvement: Includes early
before surgery.
inflammatory changes that lead to bone loss and
Doxycycline 100 mg/day may also be used. exfoliation of teeth. Primary teeth are lost by 5 or
Chlorhexidine rinses should be prescribed. 6 years of age. The permanent dentition erupts
In refractory cases tetracycline resistant normally but within few years the permanent teeth
Actinobacillus species have been suspected. In are also lost.
such cases a combination of amoxicillin and
metronidazole has been suggested. Ehlers-Danlos Syndrome

PREPUBERTAL PERIODONTITIS It is an inherited disorder affecting the connective

tissue, the defect is in collagen molecular biology,
Localized Prepubertal Periodontitis but the nature of the defect is unknown.
The age of onset is approximately 4 years. Oral and periodontal manifestations
Plaque levels are usually low Oral mucosa is often fragile and susceptible
Alveolar bone loss is rapid to bruising.
Defect in neutrophil or monocyte functions has Postextraction hemorrhage can be a problem
been reported. due to fragility of blood vessels and defects in
the supporting connective tissues.
Gingival tissues: These are often fragile and
Generalized Prepubertal Periodontitis
bleed readily on tooth brushing. Some forms
Entire width of attached gingiva appears to be fiery of Ehlers-Danlos syndrome (type VII) are
red reported to have advanced periodontal
Gingival hyperplasia, cleft formation and recession destruction.
Rapid destruction of the alveolar bone Teeth in Ehlers: Danlos syndrome are fragile
Systemic involvement like recurrent bacterial and fracture easily.
infections Due to the fragility of oral mucosa and gingiva,
Defects in polymorphonuclear leukocytes and the periodontal therapy in Ehlers-Danlos
monocytes. syndrome should as atraumatic as possible.
110 Essentials of Pediatric Dentistry

Chdiak-Higashi Syndrome
This is a rare syndrome characterized by recurrent
bacterial infection; it exhibits oral ulcer and rapidly
destructive periodontitis.

Leukocyte Adhesion Deficiency

These cases are rare and begin during, or
immediately after eruption of the primary teeth.
Extreme acute inflammation and proliferation of
gingival tissues with rapid bone loss are found.
Profound defects in peripheral blood neutrophils
Fig. 11.10: Down syndrome
and monocytes are seen.
Down Syndrome (Trisomy 21)
It is a congenital disease caused by a chromosomal Hypophosphatasia
abnormality and characterized by mental This is a rare familial skeletal disease characterized
deficiency and growth retardation. by rickets, poor cranial formation, premature loss
Periodontal disease: Include the formation of deep
of primary dentition particularly incisors.
periodontal pockets associated with plaque
Patients have low levels of serum alkaline phos-
accumulation and moderate gingivitis, usually
generalized but more severe in the lower anterior phatases, teeth are lost with no clinical evidences
region, acute necrotizing lesions are also common of gingival inflammation and show reduced
(Fig. 11.10). cementum formation.
Space Maintenance in the
Primary Dentition


Consequence of proper or improper space management Although the prevalence of dental decay appears to
influence dental development in childhood to well into be declining; a small number of children still suffer
adolescence. from early childhood caries and rampant decay.
Early loss of primary teeth may lead to compromise Etiology of posterior tooth loss is mainly due to
in the eruption of succedaneous teeth if there is a dental caries; rarely are primary molars lost due to
reduction in the arch length. trauma.
In some case; if timely intervention is undertaken Space maintenance during the primary dentition years
with space maintainers it may save space for the
is aimed primarily at the replacement of primary
eruptions of the permanent dentition.
molars for the reason that:
The key to space maintenance in the primary
dentition is in knowing the basic problem and cause Loss of interproximal contact as a result of decay,
of the problem to treat. extraction, or ankylosis of an adjacent tooth result in
Premature tooth loss is in terms of anterior (incisors space loss because of mesial and occlusal drift of the
and canine) and posterior (molar) is cited tooth distal to the newly created space. There is also
according to the basic etiology of the premature an evidence that the tooth mesial to affected molar
loss. will drift distally into the space.
Etiology of anterior tooth loss is as follows: Therefore, loss of space or arch length is possible
Trauma. and can occur from both directions.
Tooth decay. But early loss of primary incisor does not result in
space loss as seen in many clinical situations.
A. Trauma There may be some rearrangement of space
Injuries to the primary incisors are common because between remaining incisors but there is not net space
child in this age is learning to crawl, walk and run. loss.
112 Essentials of Pediatric Dentistry

Also space maintenance begins with good Table 12.1: Classification of space maintainers
restorative dentistry.
The clinician should strive for ideal restoration of According to Hitchcock
all interproximal contours, early restoration of Removable or fixed or semifixed
interproximal caries ensure that no space loss occurs. With bands or without bands
Functional or nonfunctional
Active or passive
Certain combinations of above
Teeth lost during the deciduous dentition years cause According to Raymond C Throw
later than normal eruption of the permanent tooth this Removable
necessiate the qualities of appliance to include Complete arch
Appliance should be properly monitored, adjusted Lingual arch
and possibly replaced over a longer period of time. Extraoral anchorage
Individual tooth
FIXED SPACE MAINTAINERS According to Hinrichsen
Fixed space maintainers
Space maintainers which are fixed or fitted onto the Class I
teeth are called fixed space maintainers (refer Table a. Nonfunctional types
12.1). Bar type
Loop type
Advantages b. Functional types
Pontic type
Bands are used which requires no tooth
Lingual arch type
preparation. Class II
Jaw growth is not hampered. Cantilever type
The succedaneous permanent teeth are free to erupt Distal shoe
in the oral cavity. Band and loop
They do not interfere with the passive eruption of Removable space maintainers
abutment teeth. Acrylic partial dentures
They can be used in uncooperative patients.
Masticatory function is restored if pontics are If pontics are used it can interfere with vertical
placed. eruption of the abutment tooth and may prevent
eruption of replacing permanent teeth if the patient
Disadvantages fails to report.
They may result in decalcification of tooth material
under the bands.
Supraeruption of opposing teeth can take place if Band and loop space maintainer
pontics are not used. Crown and loop appliance
Space Maintenance in the Primary Dentition 113

Lingual arch space maintainer gingival dimension. Utilization of band

Esthetic anterior space maintainer pusher and band biter is accomplished.
Band and bar type space maintainer (b) A properly placed band is seated
Crown and bar space maintainer. approximately 1 mm below the mesial
Four appliances generally are used for space and distal marginal ridges. If needed
maintenance in the primary dentition orthodontic separators can be used to
Band and loop gain or create space for the band material
Lingual arch placement.
Distal shoe Step 2: Next, make a quarter arch impression of band
Removable appliances. and edentulous area with alignate impression
material with use of perforated tray so that
BAND AND LOOP impression material can flow in perforations
The appliance is used to maintain space of a lost and can prevent distortion of impression when
single tooth. it is removed.
The appliance is inexpensive and is easily Step 3: Next, stabilize the band in impression in the
fabricated. correct position.
With the use of this appliance a continuous care Step 4: The impression is poured in stone with band
and supervision is required. However, it does not in place; the cast is separated.
restore the occlusal function of the missing tooth. Step 5: The wire is shaped into a loop and is well-
contoured to fit the band and alveolar ridge
INDICATIONS (Figs 12.1A to P).
Unilateral loss of the primary first molar before or HOW TO BEND A BAND LOOP SPACER
after eruption of the permanent first molar.
Bilateral loss of a primary molar before eruption Requirements
of permanent incisors.
The loop should parallel the edentulous ridge 1 mm
off the gingival tissue and must rest against the
adjacent tooth at the contact point. Faciolingual
dimension of loop should be approximately 8 mm.
Step 1: (a) Select and fit a band on the abutment The required dimensions must be included in
tooth. Band selection is on trial and error fabrication to allow the permanent tooth to erupt
basis; bands are tried over the abutment freely but not impinge on the buccal mucosa or
tooth until one can be nearly seated on tongue.
the tooth with finger pressure and to gain The fabricated loop should not restrict any
an appropriate final occlusal and physiological tooth movement such as increase in
114 Essentials of Pediatric Dentistry

Fig. 12.1A: Cut 2.5" of 0.36 wire Fig. 12.1C: Try on cast for close fit

Fig. 12.1B: 3 prong pliers for contour Fig. 12.1D: 3 prong for vertical contour

intercanine width which occurs during eruption of Step 7: Cementation: Band should be cemented
permanent lateral incisors. onto dry, clean tooth with zinc phosphate
Step 6: Adjustment: After fabrication of band and or glass ionomer cement.
loop it should be fitted and adjusted Step 8: Patient recall visits: The patient is recalled
accordingly. every 6 months to check that appliance is
Space Maintenance in the Primary Dentition 115

Fig. 12.1H: Space maintainer

Fig. 12.1E: Vertical contour achieved contact in the middle third of tooth mesial
of the space

Fig. 12.1F: Check it for fit on the cast Fig. 12.1I: Mark for "S" bend; contour is
about 1 mm above tissue

Fig. 12.1G: Contour buccal and lingual arms Fig. 12.1J: 45 degree bend with
with 3 prong birdbeak pliers
116 Essentials of Pediatric Dentistry

Fig. 12.1N: Improved buccal contour

Fig. 12.1K: 45 degree "up" bend

Fig. 12.1O: Proper contour; horizontal

Fig. 12.1L: Wire at junction of occlusal and part of wire is at the junction of the middle
middle third of the band and occlusal third of the band

Fig. 12.1M: Wire should now be contoured

to the buccal and lingual contour of the Fig. 12.1P: Occlusal viewthe appliance
tooth may now be soldered
Space Maintenance in the Primary Dentition 117

working as per requirements as well as to new crown is to be fitted and the wire to be
check for fit of appliance and also that the resoldered.
cement has not washed out with also
taking care of condition of abutment tooth. DISTAL SHOE
Step 9: Indication of removal: Eruption of
Distal shoe appliance is otherwise known as intra-
permanent tooth is easily recognized
alveolar appliance.
indication of removal of space maintainer.
Two modifications of band and loop appliance that
are not recommended for use in space maintenance
therapy. The distal shoe appliance is used to maintain the space
of a primary second molar that has been lost before
Bonded Band and Loop the eruption of the permanent first molar.
It is wire-shaped in a loop in a similar way of a loop To prevent possible impaction of the second
portion of band and loop appliance that is bonded to premolar.
the abutment tooth with composite resin. An unerupted permanent first molar drift mesially
Two reasons of not recommending this appliance are: within the alveolar bone if the primary second
It is difficult to keep the wire bonded to the tooth molar is lost prematurely. The result of the mesial
because of shearing force of occlusion. drift is loss of arch length and possible impaction
When bond breaks there is a potential for loss of the second premolar.
of space.
Together with added danger of aspiration of FABRICATION OF APPLIANCE
wire. The appliance can be constructed from an
The adjustment of bonded band and loop is nearly impression.
impossible. a. Taken after removal of the primary second
Crown and Loop Appliance
b. An impression taken before tooth is extracted.
The technique involved in crown and loop In situation (a), the gingiva must be incised when
appliance requires preparation of abutment tooth the appliance is placed because of healing in the
for a stainless steel crown. extraction site.
Followed by soldering of a space maintaining wire In situation (b), the construction cast must be
directly to crown, failure of this soldered joint modified to simulate loss of the primary second molar,
leave no approach to repair the appliance but placement in the extraction site at the time of
intraorally. For repair, the crown must be cut off, a surgery is straight forward.
118 Essentials of Pediatric Dentistry

To ensure that the stainless steel extension is in

the proper position and in close proximity to the
permanent first molar, a periapical radiograph is
recommended before the appliance is cemented.

Problems Associated with Distal Shoe

Due to its cantilever design and the fact it is
anchored on the occlusally convergent crown of
the primary first molar, the appliance can only
replace a single tooth and is somewhat fragile.
Due to lack of strength no occlusal function is
In additional examination histologically, It shows
Fig. 12.2: Distal shoe space maintainer
that complete epithelialization does not occurs
after placement of the appliance; because the
The primary first molar is banded and the loop epithelium is not intact.
extended to the former distal contact of the primary Distal shoe appliance is contraindicated in
second molar (Fig. 12.2). medically compromised patients and in patients
who requires subacute bacterial endocarditis
SPACE MAINTAINERS antibiotic coverage.
A piece of stainless steel is soldered to the distal Appliance acts as a presence of a constant foreign
end of the loop and placed in the extraction site. body in the mouth.
The stainless steel extension acts as a guide The placement of the appliance in the oral cavity
plane for the permanent first molar to erupt into may be a possible route of inflammation into the
proper position. submucosa.
Possible breakage leading to tr auma and
A stainless steel extension is soldered to the distal LINGUAL ARCH
end of the band and 36 mil loop.
The appliance is used to maintain posterior space in
The extension is positioned 1 mm below the mesial
the primary dentition.
marginal ridge of unerupted permanent first molar
in the alveolar bone.
After the permanent molar has erupted, the
extension can be cut off or a new band-and-loop The lingual arch is often suggested when teeth are lost
appliance can be constructed. in both quadrants of the same arch.
Space Maintenance in the Primary Dentition 119

Because the permanent incisor tooth buds develop and
erupt somewhat lingual to their primary precursors in
the lower arch, a conventional mandibular lingual arch
is not recommended in the primary dentition.
The wire resting adjacent to primary incisors might
interfere with the eruption of permanent dentition
(instead, two band-loop appliances are recommended
when there is bilateral tooth loss in the mandibular

Maxillary Lingual Arch

Use of maxillary lingual arch is feasible in the primary
dentition because it can be constructed to rest away
from the incisors.

Two types of lingual arch designs are used to maintain
maxillary space.
Nance arch
Transpalatal arch.

Basis of Appliance
These appliances use a large wire (36 mil) to Figs 12.3A and B:
(A) Lingual arch space maintainer
connect the banded primary teeth on both sides of
(B) Transpalatal arch
the arch that are distal to the extraction site.
The appliance is usually indicated to preserve the
spaces created by multiple loss of primary molars.
It helps in maintaining the arch perimeter by The Nance arch incorporates an acrylic button that
preventing both mesial drifting of the molars and rests directly on the palatal rugae (Fig. 12.3A).
also lingual collapse of the anterior teeth. The transpalatal arch (TPA) is made from a wire
that traverses the palate directly without touching
The best indication of TPA is when one side of the
The difference between the two appliance was to do arch is intact, and several primary teeth on other side
with where the wire is placed on the palate: are missing.
120 Essentials of Pediatric Dentistry

Mandibular Lingual Arch

Used in case of bilateral loss of primary teeth after
the lower permanent incisors are erupted.
Retention and stabilization of the position of
mandibular anterior teeth after tooth movement to
prevent relapse (Fig. 12.4).

Anything that would require frequent adjustments Fig. 12.5: Lingual holding arch being
in the pre-existing procedure, e.g. space regaining. constructed on a model
Rampant dental caries, high plaque scores, poor
patient cooperation.
Extreme mandibular anterior crowding or lingually Step 3 : On the cast draw the position of the intended
erupting succedaneous teeth. lingual arch wire.
Step 4 : The lingual wire runs from the middle third
Fabrication of Mandibular Lingual Arch of molar band along the gingival one-third
of the primary molar and continue along the
Step 1 : Band is placed on the first permanent molar cingulum of incisors (Figs 12.6B to D ).
on either side of same arch (Fig. 12.5). The wire should not interfere with occlusion,
Step 2 : After the impression is made pour the cast tongue or erupting teeth.
and make the working model. Step 5 : Solder the wire to band, trim and polish (Fig.
Step 6 : Try in and then cement the appliance in


It was described by Steffen, Miller and Johnson in
Its method of construction is simple and also
provide esthetic component.
The space maintainer consists of a plastic tooth
fixed onto a lingual arch which, in turn, is attached
Fig. 12.4: Lower lingual holding arch to molar bands.
Space Maintenance in the Primary Dentition 121

Fig. 12.6A: Wire is soldered to band at middle third of molar Fig. 12.6C: Wire continues along the cingulum

Fig. 12.6B: Wire travels along the gingival one-third of Fig. 12.6D: Wire running from middle third of molar band
primary molar


This is a fixed space maintainer in which the abutment Introduction
teeth on either side of the extraction space are bonded
and connected to each other by a bar. Removable appliances also can be used to maintain
space in the primary dentition. The appliance is
CROWN AND BAR SPACE MAINTAINER typically used when more than one tooth has been
lost in a quadrant.
After use of bands that are placed on the abutment
teeth on either side of extraction site, stainless steel They are space maintainers which can be removed
crowns can also be used on abutment. and reinserted into the oral cavity by the patient.
122 Essentials of Pediatric Dentistry

Removable maintainers can be classified as: If multiple tooth loss is unilateral, retention
Functional space maintainers: They incorporate problem can be overcome by placing sturdy retention
teeth to aid in mastication, speech and esthetics. clasps on the apposite side of arch. However, if
Nonfunctional space maintainers: They have only multiple teeth are lost bilaterally, retention problem
acrylic extension over the edentulous area to are almost inevitable.
prevent space closure.
A problem of compliance is closely related to retention.
They are easy to clean and permit proper oral A three to six-year-old children will not tolerate
hygiene. an ill-fitting appliance and will not use it. In fact,
They maintain or restore the vertical dimension. some children will not tolerate a retentive
They serve important functions like mastication, appliance, the dentist is then resigned to waiting
esthetics and phonetics. untill the permanent teeth (molars) erupt so that
Room can be made for permanent teeth to erupt they can be used as abutments for a conventional
without changing the appliance.
lingual arch appliance.
They help in preventing development of tongue
Some children are compliant in wearing an
thrust habit into the extraction space.
appliance but not in cleaning the appliance and
Band construction is not necessary.
the underlying tissue, this can result in tissue decay,
tissue irritation and hyperplasia.
They may be lost or broken by the patient Indications
Uncooperative patients may not wear the
Removable dentures are indicated when aesthetics
Lateral jaw growth may be restricted, if clasps are is of importance.
incorporated. In case the abutment teeth cannot support a fixed
They may cause irritation to the underlying soft appliance it is recommended to use a removable
tissues. space maintainer.
In case the radiograph reveals that the unerupted
Drawbacks of the Appliances permanent tooth is not going to erupt in less than
five months time a removable space maintainer
Two drawbacks of the appliances are: can be given.
Retention In the case; if the permanent teeth have not fully
Compliance. erupted it may be difficult to adapt bands; thus it
is advisable to use removable space maintainers.
Retention In cleft palate patients who require obturation of
Is a problem because primary canines do not have large the palatal defect.
undercuts for clasps engagement. Multiple loss of deciduous teeth which may require
Space Maintenance in the Primary Dentition 123

functional replacement in the form of either partial the area approximating the mesial surface of
or complete dentures. unerupted first permanent molar.
The denture will have to be adjusted and a portion
Contraindications of it cut away as the permanent incisors erupt, and
the posterior border is contoured to guide the first
Lack of patient cooperation.
permanent molars into position, when the
In patients who are allergic to acrylic materials.
permanent incisors and first permanent molars
Epileptic patients who have uncontrolled seizures.
have erupted, a partial denture space maintainer
can be used until the remaining permanent teeth
Some Commonly Used Removable Space


Acrylic partial dentures have been used There are various factors which should be considered
successfully in patients who have undergone when space maintainer is planned following the early
multiple extractions. loss of primary teeth.
This appliance can be readily adjusted to allow
the eruption of teeth. Time Elapsed Since Loss of Teeth
The inclusion of artificial teeth in the denture It is usually advisable to place a space maintainer
restores masticatory function. as soon as the primary teeth are lost or removed.
Clasps can be fabricated on deciduous canines and Studies indicate that the maximum loss of space
molars for retention. occurs within 6 months of extraction of teeth. It
would be better to fabricate the appliance prior to
Full or Complete Dentures extraction of the primary tooth and insert the
Sometimes all the primary teeth of a preschool appliance soon after the extraction.
child may require extraction due to rampant caries
of teeth that cannot be restored. Dental Age of the Patient
Although this procedure was more common in the
The dental age of the patient should always be
pre-fluoridation era even today some children may
considered rather than chronological age. This is
require complete extraction of their deciduous
because too much variation in eruption of teeth is
teeth. These cases are managed by the use of a
complete denture.
It is usually observed that the permanent teeth erupt
These dentures not only restores masticatory
once th of their root development is complete.
function and aesthetics but also guide the
This criteria can be used to predict the age of
permanent teeth into their correct position. The
posterior border of denture should be placed over eruption of the permanent teeth.
124 Essentials of Pediatric Dentistry

Thickness of Bone Covering Illustration

the Unerupted Teeth
When the deciduous second molar is lost early, we
The more is the bone covering the unerupted tooth, should study the development of permanent second
the more would be the time it would take to erupt, and molar and the second premolar. In case the second
therefore space maintainer is indicated. molar is ahead of the second premolar in its eruption,
it is likely to exert a mesial force on the first molar
Illustration which can move mesially this results in insufficient
space for the second premolar.
Normally premolars takes 4-5 months to erupt through
a bone of 1 mm.
Congenital Absence of Permanent Tooth
Sequence of Eruption of Teeth If permanent teeth are congenitally missing the dentist
Whenever a space maintainer is planned, adequate should decide:
consideration should be given to the adjacent Is dentist is going to retain the space until a
developing and erupting teeth. The neighbouring replacement can be given.
dentition can greatly influence the closure of the Allow the other erupting teeth to drift and close
extraction space. the space.

Oral Habits

It is an act which is not socially acceptable. Pressure: Biting, sucking, thrusting, postural.
It is a fixed constant or certain practice established
Nonpressure: Mouthbreathing.
by frequent repetition of same act.
It is a response to stimuli (extrinsic or intrinsic)
Other Classification
which may persist even when the stimuli is
withdrawn. Bruxism

Classification Night grinding or clenching habit.

It is the total constriction of the masticatory
i. Compulsive iii. Intraoral muscles under rhythmic grinding of teeth during
Noncompulsive Extraoral sleep.
ii. Meaningful iv. Pressure
Empty Nonpressure
Compulsive: Are those habits which have acquired a
fixation of the extent that the child revert back to the
habit whenever his security is threatened.
Noncompulsive: Can be easily withdrawn from the
child's behavior as he matures.
Meaningful: Which have a psychological background.
Empty: No psychological background.
Intraoral: Tongue thrusting, thumb sucking, nail biting.
Extraoral: Abnormal pillowing.
126 Essentials of Pediatric Dentistry

To prevent further destruction of teeth due to habit

Stainless steel crown may be given in posterior
Mouth guards are also given.

Habit that involves manipulation of lips and perioral
structures are termed as lip habits.
Incidence15 percent in 3-16-year-old child and 5.1
percent in 17-36-year-old. CLASSIFICATION
i. Wetting the lips with tongue
Etiology ii. Pulling the lip into the mouth between teeth (Fig.
i. Occlusal prematurities, e.g. highly placed
ii. Emotional problems, e.g. psychological
nervousness, tension. i. Malocclusion
iii. In disorders like epilepsy, meningitis, GI
disturbances, pinworm infestation. Class II division I, deep bite malocclusion due to large
overbite and overjet, this habit develops when the child
Clinical Examination wants to produce a normal lip seal during swallowing
by placing the lower lip posterior to the maxillary
Worn out enamel is seen in initial stages. incisors.
Later stages which may expose dentin and pulp in
chronic cases which will lead to pain and swelling.
There may be some TMJ abnormalities.

Find the Etiology. If it is due to psychological
causes, psychological counselling and reassurance
is given (Fig. 13.8).
Any present occlusal prematurities or enhancing
restoration are corrected and lip exercises are
adviced. Fig. 13.1: Pulling the lip into the mouth
Oral Habits 127

ii. Habits The lip bumper is placed in the vestibule of

mandibular arch and serves to prohibit the lips from
In conjunction with other habits such as thumb sucking,
exerting excessive force on mandibular incisors and
digit sucking; which will further increase the overjet
to repositioning the lip away from lingual surface of
and overbite.
maxillary incisor; this prevent the distal movement of
maxillary incisor resulting in decreased overjet and
iii. Emotional stress
Children in stressful situation have increased salivary
output, thus increasing the number of swallows and CHEEK-BITING
increased lip seals are required.
MANIFESTATION It is an abnormal habit of keeping or biting the cheek
muscles in between the upper and lower posterior teeth.
i. Protrusion of maxillary incisors and retrusion
of mandibular incisor.
ii. Lip: Lip sucking can be recognized by reddened
irritated and chapped area below the vermillion Open bite
border. The vermillion border is relocated farther Tooth malpositioning in buccal segment
outside the mouth due to constant wetting of lips. Ulcers in the level of occlusion.
iii. Mentolabial sulcus becomes accentuated.
iv. Malocclusion: Lip sucking and lip biting can MANAGEMENT
maintain an exisiting malocclusion.
A removable crib
A vestibular screen.
i. Correction of malocclusionclass II NAIL-BITING
division I.
ii. Treating the primary habits.
iii. Appliance therapy: Oral shield helps to stop It is one of the most common habit in children and
habit and also the incisal alignment. The addition adults. It is a sign of internal tension ( Fig. 13.2).
of a small loop to the labial oral shield to
improve the lip tonus by helping in lip exercises, Age of Occurrence
i.e. 3-10 min a day.
This is absent before 3 years of age. The incidence
rises sharply from 4-6 years and remain at fairly
Lip Bumper
constant level between 7-10 years and rises again to a
It is used for both comprehensive and interceptive peak incidence during adolescence.
treatment regimens. Etiology: Emotional problem
128 Essentials of Pediatric Dentistry


a. Organic
Syndrome and syndrome-like abnormalities Lesch-
Nyhan disease, de Langes syndrome in which
symptoms such as repetitive lip, finger, tongue, knee
and shoulder biting is common.

b. Functional
This can be further divided into
Type A: These are injuries superimposed on pre-
Fig. 13.2: Nail biting
existing lesion, e.g. a child with finger nail biting
Effects (Dental): Crowding, rotation and attrition of is under treatment of skin lesion. The lesion will
incisal edges of incisors (mandibular) show no evidence of healing as it is perpetuated
by this injurious habit which occurs mainly at night.
Effects on nails: Inflammation of nail beds and also
Type B: They include injuries secondary to another
of nails.
established habit, e.g. Rotation of thumb during
thumb sucking can harm the soft tissue.
Type C: They include injuries of complex origin.
Mild cases no treatment is indicated. Frenum thrusting: This habit is rarely seen. If the
Avoid punitive method such as scolding, threats. maxillary incisors are slightly spaced apart, the
Treat the basic emotional factor. child may lock his labial frenum between these
Encourage outdoor activities which may easing teeth and permit to be in this position for several
tension. hours on constant repetition this may turn into habit
Application of nail polish, light cotton nuttens as and which may displace the tooth.
Treatment first initiated towards psychotherapy.
Some children experience a feeling of neglect and
loneliness and through the use of self-injurious
behaviour attempt to solicit the attention and love.
Pallative treatmentBandages for oral ulceration
Repetitive act that result in physical damage to the which will help healing of wounds as well as serve
individual. These habits show increased incidence in as habit reminder.
mentally retarded population. MechanotherapyOral shields.
Oral Habits 129


DEFINITION General Effects

Mouthbreathing is defined as habitual breathing Pulmonary development with oral respiration the
resistance is lacking and poor pulmonary
through mouth instead of nose.
compliance is seen. This gives the appearance of
pigeon chest.
Lubrication of oesophagus: In mouthbreathers the
Anatomic: Anatomic mouthbreather is one whose oropharynx is dry and mucous collected in
short upper lip does not permit complete closure expectorated. This denies the oesophagus of
without undue effort. essential lubrication and can produce a low grade
Obstructive: Children who have increased esophagitis.
resistance to, or complete obstruction of the normal Blood gas constituents: Blood gas studies reveal
flow of air through nasal passages. the mouthbreathers have 20 percent more CO2, 20
Habitual: Who continually breathes through his percent less O2 in the blood.
mouth by force of habit, although abnormal
obstruction has been removed. Effect on Dentofacial Structures
i. Facial form: Adenoid faciesCharacterised by
long narrow face, short nose, short upper lip, V-
Enlarged turbinates shaped maxilla, expression less face, nose in
Deviated septum and other nasopharyngeal tipped superiorly.
abnormalities. ii. Dentitional changes:
Allergic rhinitis, nasal polyps. Anterior open bite
Enlarged adenoids, tonsils. Proclination of maxillary anteriors
Abnormally short upper lip preventing proper lip Constricted maxilla (Fig. 13.3).
seal. High vault palate
Obstruction in the bronchiol tree or larynx. Patient is prone to oral infections
Obstructive sleep apnea syndrome. Patient is more prone to dental caries.
Genetically predisposed individualEctomorphic iii. Gingival: Chronic keratinized marginal
children having a genetic type of tapering face and gingivitis in the maxillary anterior region.
nasopharynx are prone for nasal obstruction. iv. Lip: The patient has a lip apart posture, on
Thumb sucking or similar oral habits can be the smiling, many of these patient reveal large
instigating agent. amount of gingiva producing gummy smile.
130 Essentials of Pediatric Dentistry

ii. Examination
Ask the patient to take a deep breath; The nasal
breather will inspire through nose with lips tightly
A mouthbreather when asked to deep breath with
his lips closed he will not change appreciably shape
and size of external nares rather contracts nasal origins
while inspiring.
A normal nose breather will dilate the nostril while
deep breathing.

iii. Clinical Test

Butterfly test: A whisp of water is placed in front
Fig. 13.3: Arch constricted due to the habit of
of the patient mouth if patient is a mouth breather,
the flattering of water is observed.
Water holding test: Ask the patient to hold some
Incompetent upper lip and a voluminous curled water in the mouth. If patient is a mouth breather,
over lower lip. he cant hold it for a longer time.
v. Speech: Speech performance is compromised. Mirror test: Take a double ended mouth mirror
Nasal tone in voice is seen. keep one in front of nose and one in front of mouth.
vi. External nares: Long-standing nasal airway If patient is a mouth breather fogging of the mouth
obstruction can lead to disuse atrophy of the mirror in the front of mouth is seen.
lateral cartilage. The result is a slit-like external Paper test: Ask the patient to hold a piece of paper
nares with a narrow nose; sometimes after the in between the lips. If he is a mouth breather he
airway obstruction is removed and patent airway cant hold it for long.
is established, the nose may collapse on
inspiration, making reconstructive surgery iv. Inductive plethysmography -
necessary. (Rhinomanometry)
vii. Other effects: Otitis media.
It is a reliable method to quantify the mouthbreathing
that how much is the air flow through nose and mouth.
i. History v. Cephalometrics
Parents are questioned whether the child had a frequent To establish the amount of nasopharyngeal space, size
lip apart posture. Frequent occurrence of allergic of adenoids, skeletal pattern of patient by taking
rhinitis, tonsillitis and otitis media is queried. various cephalometric angles.
Oral Habits 131

MANAGEMENT Type III Deforming lateral tongue thrust

As with other habit, correction of mouth breathing Type IV Deforming anterior and lateral tongue
is expected as child matures this is attributed to thrust.
increase in nasal passage as child grows.
Refer the child to ENT surgeon for removal of OTHER CLASSIFICATION PHFA
nasal and pharyngeal obstruction. Physiologic: This comprises of normal tongue
Preventing and intercepting the habit by physical thrust swallow of infancy.
exercise like lip exercise and appliance therapy, Habitual: The tongue thrust is present as a habit
e.g. oral/vestibular screen after the underlying ever after correction of malocclusion.
problem has been corrected. Functional: When tongue thrust mechanism is an
adaptive behaviour developed to achieve oral seal.
TONGUE THRUSTING Anatomic: Patient have enlarged tongue and can
have anterior tongue posture.
(Schneidar 1982): Tongue thrust is a forward ETIOLOGY
placement of tongue between the anterior teeth and
Retained infantile swallow.
against the lower lip during swallowing (Fig. 13.4).
Upper respiratory tract infection: Such as chronic
tonsillitis, allergies promote an anterior posture of
tongue due to pain.
Type I Nondeforming tongue thrusting Neurological disturbance: Hyposensitive palate,
Type II Deforming anterior tongue thrust moderate motor disability, disruption of sensory
control and coordination of swallowing can lead
to tongue thrust.
Functional adaptability to transient change in
anatomy: The tongue can protrude out when the
incisors are missing following the loss of
deciduous teeth and prior to full eruption of
permanent teeth (incisors) there exist a natural
opening for tongue tip to protrude during
swallowing. It has been seen that protrusive activity
will change with full eruption of permanent
Feeding practice: Development of improper
swallowing is either due to bottlefeeding or
Fig. 13.4: Tongue thrusting breastfeeding is a controversial matter.
132 Essentials of Pediatric Dentistry

Induced due to other habits: Habits like thumb mandibular teeth depending upon the type
sucking leads to anterior open bite is seen during of tongue thrust.
swallowing. iv. Generalized spacing between the teeth
Hereditary: The type of maxillary structure that v. Maxillary constriction.
favors the development of tongue thrust may be
hereditary. Intermaxillary Relationship
Tongue size: Macroglossia can have an effect on
For a newborn infant, after establishment of respiratory
reflex, it is important to obtain the milk with is to be
transferred to GIT. All newborn infants have a
characteristic swallowing pattern associated with
Extraoral Findings feeding called as sucking reflex. The part of sucking
reflex in infant is called as visceral/infantile swallow
i. Lip posture: Lip separation is greater in the
and in adults is called as somatic reflex/mature
tongue thrust this is a consistent finding both at
rest and in function.
ii. Mandibular movements: There is no
collaboration in between movements of tongue,
lip and mandibular movements. The average Characterized by mandibular thrust
path of mandibular movements is upward and Lip musculature contraction
backward and of tongue is forward. Anterior tongue thrust in between the gum pads
iii. Speech: Lisping, problems in articulation of (/ Marked furrow extending from the tip of tongue
s/, /n/,/t/, /d/, /th/, /z/, /n/) sounds. to the dorsum of tongue
iv. Facial form: Increase in anterior face height. Tongue is positioned lower than palatal vault
during swallow.
Intraoral Findings
i. Tongue movements are jerky, movement are
irregular from one swallow to another within the No mandibular thrust
individual. No lip musculature contraction
ii. Tongue posture is lower (tongue tip) at rest. No anterior tongue thrust
iii. Malocclusion: The tongue tip is placed on the lingual gingival
Features pertaining to maxilla: margin of upper and lower anterior teeth during
Proclination of maxillary anteriors resulting swallow
in an increased overjet. During the procedure, the dorsum of tongue arches
Features pertaining to mandible: over the palate, so that there is no space between
Retroclination or proclination of palate and tongue for solid bolus ingestion.
Oral Habits 133

Simple Tongue Thrust
If exaggerated anterior proclination, correct the
proclined anterior teeth by using the orthodontic
appliance, during the treatment the habit may get
corrected and there is no need for treatment for habit

Complex Tongue Thrust

a. Training the patient for normal swallowing pattern
by asking the patient to place his tongue tip in
between the hard and soft palate and then swallow.
Ask the patient to do this for 40 times a day. Fig. 13.6: Hotz modification of oral screen
b. Place the ortho elastic on the tip of tongue and ask
the patient to swallow by placing the tip on the
palate. If swallowing is corrected, the elastic is THUMB SUCKING
c. Go for the appliance therapy with cribs and can DEFINITION
be removeable, or fixed appliance with rags or oral Thumb sucking can be defined as placement of thumb
screen/vestibular screen (Fig. 13.6). or one or more finger into various depths into the
d. Surgical treatment: the treatment of retained mouth (Fig. 13.7).
infantile swallow behaviour is difficult and often
consisting of orthognathic surgeries to correct the CLASSIFICATION
skeletal malformation.
i. Normal thumb sucking
Seen during II and III year of life such a habit
disappears as the child matures. The habit at this age
does not generate any malocclusion.

ii. Abnormal thumb sucking

When habit persist beyond the preschool period then
it is considered abnormal, if this habit is not controlled
or treated at this stage it cause deleterious effect to the
Fig. 13.5: Habit breaking appliances dentofacial structures.
134 Essentials of Pediatric Dentistry

while at the same time maxillary and mandibular

anterior contact is present.
Type B: This type is seen in almost 13-24 percent of
the children where the thumb is placed in oral cavity
with out touching vault of palate, while at the same
time maxillary and mandibular, anterior contact is
Type C: Seen in 18 percent of children where thumb is
placed inside the oral cavity beyond the first joint and
contacts the hard palate and only the maxillary incisors,
but is no contact with mandibular incisors.
Type D: This type is seen in 6 percent of children where
very little portion of thumb is placed into mouth.

Fig. 13.7: Child with habit of thumb sucking Theories

Various theories have been proposed by psychologists
to explain nonnutritive digit sucking.
iii. Psychological
Classical freudian theory: The concept of this
Involves deep rooted emotional factor and may be theory is that human posses of biologic sucking
associated with insecurities, neglect, loneliness. drive.
The learning theory (Davidson): The infant
iv. Habitual associates sucking with such pleaseable feeding as
Have no psychological bearing, they are the potential hunger.
cause for malocclusion. Oral drive theory (Sears and Wise): Thumb sucking
Sucking habits are classified as is the result of prolongation of nursing and not the
Nutritive habits: frustration of weaning.
e.g. breastfeeding, bottlefeeding Johnson and Larson: That believed that it is a
Nonnutritive sucking habits (NNS): combination of psychological and learning theory
which explains that all children posses an inheritent
e.g. thumb or finger sucking, pacifier sucking. biologic drive for sucking.
Subtelny has graded thumb sucking into four types:
Type A: This type is seen in almost in 50 percent of the
children, where in the whole digit is placed inside the Parent's occupation: This can be related to the
mouth with the pad of thumb pressing over the palate socioeconomic status of family. Family living in a
Oral Habits 135

high socioeconomic status are blessed with ample Age of child: The time of appearance of digit
sources of nourishment. The mother is in the better sucking has a significance.
position to feed the baby and within short-time the In neonate: insecurities are related to primitive
baby's hunger is satisfied. demands as hunger.
Mothers belonging to low socioeconomic status During the first few weeks of life: related to feeding
is unable to provide the infant sufficient breast problem.
milk. Hence, in the process the infant suckles During the eruption of primary molar, due to teething
intensively for a long time to get the required disorder.
nourishment thus they exhausted the whole of their Still later: children use the habit for the releases of
sucking urge. This theory explains the increase in emotional tensions with which they are unable to cope.
incidence of thumbs sucking in industrialised area
when compared to the rural area. DIAGNOSIS
Working mother: The sucking habit is commonly
observed to be present in children with the working
parents such a children brought up in hands of Questioning regardingfrequency, intensity, duration
caretaker may have feeling of insecurity. Therefore of habit.
they use their thumb to obtain a secure feeling.
Number of siblings: The development of habit can Examination
be indirectly related to the number of siblings. As
the number increases the attention given by the
parents to child gets divided. A child neglected by The digits: Digits that are involved in the habit
the parents may attempt of compensate his feeling will appear reddened, exceptionally redden
of insecurity by means of this habit. chapped and with a short fingernail, i.e. clean
Order of birth of the child: It has been noticed dishpan thumb, fibrous roughened callus may be
that the later the sibling rank of a child, the greater present on the superior aspect of finger. The habit
the chance of having a oral habit. It has been is also known to cause deformation of finger.
speculated that to some extent siblings imitate one Lips: Upper lip may be short and hypotonic. Note
another in suckling. the posture of lips at rest whether they are held
Social adjustments and stress: It is associated with together or apart.
the psychological effects compounded by the Facial form analysis: Check mandibular retrusion,
emotional impact of peer group pressure and maxillary protrusion, high mandible plane angle
punitive and scolding parents. and profile.
Feeding practice: Various controversies are
present related to feeding practices like habit is Intraoral
seen in breast fed children, or abrupt weaning from Tongue: Examine for correct size and position of
bottle or breast is hypothetized. tongue at rest and tongue action during swallowing.
136 Essentials of Pediatric Dentistry

Fig. 13.8: Thumb sucking showing anterior open bite

Fig. 13.9: Professional counselling of child

Dentoalveolar structures:
i. Maxillary anterior proclination and mandibular
anterior retroclination is called Crow Bar Dunlop's Beta Hypothesis: He believed that if
Effect. subject can be forced to concentrate on the
ii. Anterior open bite (Fig. 13.8). performance of the act at time he practices it; he
iii. Constriction of maxillary arch "V-shaped can learn to stop performing the act. The child
arch". should be asked to sit in front of mirror and ask to
iv. Posterior crossbite. suck his thumb, observing himself as he indulges
in the habit.
MANAGEMENT Choosing a pacifier: If parents choose to have their
infant or child suck a pacifier, health professionals
Psychological Therapy
advise them to take certain safety precautions. The
Screen the patient for the underlying psychological following precautions are recommended.
disturbances that sustain a thumb sucking habit. Never attach a pacifier to a ribbon or string
Once the psychological dependence is suspected, around the infant's or child's neck.
the child is referred to professional for counselling Make sure the pacifier is a sturdy, one-piece
(Fig. 13.9). construction and that the material is nontoxic,
The use of positive behaviour modification flexible, and firm but not brittle.
techniques and even hypnosis has been effective Make sure the pacifier has easily grasped
in digit habit therapy. When the habit is handles (Fig. 13.10).
discontinued, the child can be rewarded with a Make sure the pacifier has inseparable nipples
favorite new toy or special outing. and mouth guards.
Oral Habits 137

Reminder Therapy

Extraoral Approach
Application of distasteful agents over thumb or finger,
e.g. - Cayenne pepper, quinene, as a foetida,
thermoplastic thumb post. About 6 week time is
required for elimination of habit.

Intraoral Approach
Figs 13.10A to C: (A) Pacifier, (B) Poddler boy Removable appliances may be usedpalatal cribs,
with pacifier, (C) Baby with pacifier rakes, palatal arch, lingual (spurs, hawleys, retainer
with or without spurs (Fig. 13.5).
Make sure the pacifier has mouth guards of Fixed appliances: Upper lingual tongue screen. If the
adequate diameter to prevent aspiration, and child has made appreciable changes in habit by 3
two ventilating holes. months the appliances can be safely removed for
Keep the pacifier clean. testing period.
Replace the pacifier when it becomes worn.
Do not dip a pacifier in sweetened foods (e.g. Mechanotherapy
sugar, honey, syrup) to encourage sucking.
Fixed intraoral antithumb sucking appliances.
Never clean or moisten a pacifier with saliva
Blue grass appliance
before giving it to an infant or children.
Quad helix.
Local Anesthesia and
Oral Surgery in Children

LOCAL ANESTHESIA It should not cause any permanent alternation of

nerve structure.
Local anesthesia has been defined as a loss of
sensation in a circumscribed area of the body caused
Sequence of Proposed Mechanism of
by a depression of excitation in nerve endings or an
Action of Local Anesthesia
inhibition of the conduction process in peripheral
nerves. Displacement of calcium ions from the sodium
channels receptor site which permits binding of the
Important Feature local anaesthetic molecule to this receptor site; which
thus produces blockadge of the sodium channel, and
Local anesthesia is that it produces the loss of sensation
a decrease in sodium conductance; which leads to
without inducing a loss of consciousness.
depression of the rate of electrical depolarization and
a failure to achive the threshold potential level, along
Desirable Properties for a Local Anesthetic
with a lack of development of propogated action
It should not be irritating to the tissue to which it potentials, which is called conduction blockadge.
is applied.
Its systemic toxicity should be low. Mode of Action of Local Anesthetics
It must be effective regardless of whether it is
injected into the tissue or applied locally to mucous It is possible for local anesthetics to interfere with the
membranes. excitation process in a nerve membrane in one or more
The time of onset of anesthesia should be as short of the following ways:
as possible. Altering the basic resting potential of the nerve
The duration of action must be long enough to membrane.
permit completion of the procedure yet not so long Altering the threshold potential (firing level)
as to require an extended recovery. Decreasing the rate of depolarization.
Local Anesthesia and Oral Surgery in Children 139

Prolonging the rate of repolarization. range of doses administered by dentists treating

Pain control is one of the most important aspect children was 0.9 to 19.3 mg/kg. As the patient's weight
of behavioral management in children undergoing increased, the number of milligrams per kilograms
dental treatment, unpleasant childhood experiences reached lower and safer levels; the maximum mg/kg
have made many adults acutely phobic with regard to range falling to 12.6 mg/kg in the 20 kg patient and
dental treatment. 7.2 mg/kg in the 35 kg patient.
Special concerns in pediatric dentistry relevant to
local anesthetic include anaesthetic overdose, Complications of Local Anesthesia
complications related to prolonged duration of soft-
Accidental biting or chewing of the lip, tongue, or
tissue anesthesia, and technique variations related to
cheek is a complication of residual soft tissue
smaller skulls and differing anatomy of younger
Soft tissue anesthesia always lasts longer than
pulpal anesthesia and may be present for 4 to 5
Local Anesthetic Overdose
hours or more after local anesthetic administration.
Overdose from a drug develops when its blood Problems related to soft-tissue anesthesia most
level in a target organ (e.g. brain) becomes involve the lower lip; much less frequently the
excessive, undesirable (toxic) effects may be tongue is injured and rarely the upper lip is
caused by intravascular injection or the involved.
administration of large volume of drug.
Local anesthetic toxicity develops when the blood Management
level of the drugs in the brain or heart becomes
Management of soft tissue trauma involves reassuring
too high.
the patient, allowing time for the anesthetic effects to
Local anesthetic toxicity produces central nervous
diminish, and coating the involved area with lubricant
system (CNS) and cardiovascular system (CVS)
(petroleum jelly) to prevent drying, cracking and pain.
depression with reactions ranging from mild tremor
to tonic-clonic convulsions (CNS), from a slight
decrease in blood pressure and cardiac output to
cardiac arrest (CVS). Topical anesthetics reduce the slight discomfort that
Maximum recommended doses (MRDs) of all may be associated with the insertion of the needle
drugs administered by injection should be calcul- before the injection of local anesthetic.
ated by body weight and should not be exceeded, Topical anesthetics are available in forms of gel,
unless it is absolutely essential to do so. liquid, ointment, pressurized spray.

Illustration Demerits
A 13 kg patient should receives no more than 91mg of If they have a disagreeable taste to the child.
lidocaine (based on high MRD of 7.0 mg/kg). The The additional time required to apply them may
140 Essentials of Pediatric Dentistry

allow the child to become apprehensive concerning high pressure can penetrate mucous membrane or
the approaching procedure. skin without causing excessive tissue trauma.


Ethyl aminobenzoate butacaine sulfate
Cocaine Posterior Superior Alveolar Nerve Block
Dyclonine Innervates the posterior maxillary deciduous molars
Lidocaine anesthetized as:
Tetracaine. Needle is inserted immediately behind the buttress
Applications of the zygoma at the height of the vestibule.
Tip of the needle must be in close proximity to the
The mucosa at the site of the intended needle periosteum.
insertion is dried with gauze, and a small amount Foramen is approximately 8 mm from the insertion
of the topical anesthetic agent is applied to tissue point in a 5 years old child and 11 mm in a 14
with a cotton swab. years old.
During the application of the topical anesthetic,
the dentist should prepare the child for injection. Middle Superior Alveolar Nerve Block
The explanation should not necessarily be a
detailed description but simply an indication that Innervates the premolars and the mesiobuccal root of
the tooth is going to be put to sleep so that the the I permanent teeth.
treatment can proceed without discomfort. The method of anesthetization is similar to
posterior superior alveolar nerve.
Maxillary Anterior Region Block
Jet injection produces surface anesthesia instantly
and is used by some dentists instead of topical Infiltration in the apical region of the anterior teeth
anesthetics. provide satisfactory anesthesia in most cases
The method is quick and essentially painless, but (Fig. 14.2).
the abruptness of the injection may produce
momentary anxiety. Infraorbital Nerve Block
This technique is useful for obtaining gingival The infraorbital foramen in a 3 year old is about 5 mm
anesthesia before a rubber dam clamp is placed above the vestibular depth.
for isolation procedures that otherwise do not
require local anesthetic. Palatal Infiltration
Principle of injection: The jet injection instrument Anesthetic agent is injected into the depth of rugae as
is based on the principle that small quantities of they contain less sensory endings. The amount
liquids forced through a very small openings under deposited is about 0.2-0.3 ml (Fig. 14.4).
Local Anesthesia and Oral Surgery in Children 141

Nasopalatine Nerve Block

Nasopalatine nerve innervates the maxillary anterior
teeth. It is indicated when vestibular infiltration is
inadequate. About 0.2-0.3 ml of local anesthetic
solution is administered at the entrance of the incisive
foramen on the incisive papilla (Fig. 14.1).

Greater Palatine Nerve Block

Greater palatine nerve innervates the maxillary
posterior teeth in the palatal aspect. It is anesthetized
at the region midway between the midline of the hard Fig. 14.2: Labial infiltration
palate and the palatal surface the posterior teeth.

Anesthesia for the Mandibular Tissue

Inferior alveolar nerve blockfor anesthetizing the
molars and premolars. The needle is penetrated into
the pterygomandibular space and the solution is
deposited close to the mandibular foramen. Factors to
be considered are
In children the mandibular foramen is located near
the posterior border of the ramus. In a 3-year-old
Fig. 14.3: Buccal infiltration maxillary molar

Fig. 14.1: Nasal palatine block Fig. 14.4: Palatal infiltration

142 Essentials of Pediatric Dentistry

the foramen is about 5 mm from the posterior

border and 20 mm from the anterior border.
The foramen invariably aligns with the deepest
concavity on the anterior border of mandible.
Mucosal depression on the medial aspect of the
mandible formed by the medial pterygoid muscle
also aligns with inferior alveolar foramen and
should be the point of insertion of the needle.

The anterior border of the ramus is palpated with
finger or thumb resting in its greater curvature.
It should be observed that as the internal pterygoid Fig. 14.5: Inferior alveolar nerve block
ligament passes inferiorly and laterally to attach
at the base of the mandible, a triangle is formed
by the anterior border of the ramus, the internal
pterygoid muscle and the vault of the palate. The
apex of the triangle is placed inferiorly. An
imaginary longitudinal line dividing the tip of
finger or thumb as its rests in the coronoid notch
passes medially over a depressed area just above
the apex. The penetration site of needle is the point
of intersection (Fig. 14.5).
The anesthetic syringe is introduced into the oral
cavity parallel with the occlusal plane of the
mandibular posterior teeth.
The needle depth is 8-10 mm from the mucosal Fig. 14.6: Long buccal nerve block
surface. The amount deposited is 0.9-1.0 ml.
Lingual nerve is anterior and medial to inferior ORAL SURGERY IN CHILDREN
alveolar nerve, so the needle has to be withdrawn
and solution deposited half the distance from INTRODUCTION
inferior alveolar foramendeposited 0.5 ml. Oral surgical procedures for children are similar to
Buccal nerve can be anesthetized by infiltration and possibly easier than those performed for adults.
in the buccal sulcus distal to the permanent teeth
Mental nerve blockAnterior teeth and The dentist treating the child patient must be careful
premolar0.5-1 ml; mandibular anterior region to consider the entire patient and not focus only on
Infiltrate in buccal and lingual vestibule 0.5-1.0 ml. the oral cavity. Important considerations are:
Local Anesthesia and Oral Surgery in Children 143

Fig. 14.7: Upper extraction forcep

Fig. 14.8: Lower extraction forcep

i. Obtaining a good medical history.

ii. Obtaining appropriate medical and dental EXTRACTIONS
iii. Anticipating and preventing emergency
situations. The height of contour of primary maxillary molar
iv. Being fully capable of managing emergency is closer to the cementoenamel junction and their
situations when they occur. roots tends to be more divergent and smaller in
Armamentarium for tooth extractions
Because of this reason there is potential
Most pediatric dentists prefer the smaller pediatric weakening of the roots during the eruption of the
extraction forceps; such as the no. 150s and no. 151s permanent tooth; root fracture in primary maxillary
for the following reasons: molar is common.
Their reduced size more easily allows placement The relationship of the primary molar roots to the
in the smaller oral cavity of the child patient. succeeding premolar crown; if the roots encircle
The smaller pediatric forceps are more easily the crown, the premolar can be inadvertently
concealed by the operators hand (Fig. 14.7). extracted with the primary molar.
The smaller working ends (beaks) more closely No. 301 straight elevator is used to luxate the tooth
adapt to the anatomy of the primary teeth after the epithelial attachment is separated.
(Fig. 14.8). Extraction is completed using a maxillary universal
forceps (No. 150s).
144 Essentials of Pediatric Dentistry

Fig. 14.9: Buccal palatal direction of forcep maxillary

molar extraction Fig. 14.10: Mandibular molar extraction

Palatal movement is initiated first, followed by Luxate tooth with 301 straight elevator and No.
alternating buccal and palatal motions with slow 151s forcep is accomplished to extract the tooth
continuous force applied to the forceps with alternating lingual and buccal motions
(Fig. 14.9). (Fig. 14.10).


The maxillary primary and permanent central The mandibular incisors, canines and premolars
incisors, lateral incisors, and canines all have single are all single rooted.
roots which are usually conical. Because of this reason carefully place the
Because of this reason they are less likely to forcep while extraction of teeth; otherwise it may
get fractured and easily allow the rotational lead to dislodgement of adjacent tooth.
movements during extraction. Rotational movements are performed in extraction
No. 1 forcep is useful in extraction of maxillary process, then continuous force is applied in
anterior teeth. alternating labial and lingual directions this
facilitates easy removal of these teeth.
Prime consideration is given to support the SOFT TISSUE SURGICAL PROCEDURES
mandible with the nonextracting hand so that no Soft tissue procedures are occasionally performed for
injury to temporomandibular joint is inflicted. the child patient; these are
Local Anesthesia and Oral Surgery in Children 145

BIOPSIES Therefore, maxillary labial frenectomy is not

indicated prior to age of 11 or 12 years.
A very small lesion is probably best managed with
Lingual frenectomies: should be performed in
an excisional biopsy, whereas lesions
0.5 cm or larger should probably have an incisional severe ankyloglossia (tongue - tie); but only after
biopsy if there is any doubt regarding the diagnosis an evaluation and therapy by a qualified speech
of lesion. therapist.
Before performing a biopsy on a lesion, the dentist
must consider the possibility that lesion is vascular. ODONTOGENIC INFECTIONS
Management of odontogenic infections is directed
FRENECTOMIES at providing adequate drainage of the infection
Maxillary labial frenectomies: This surgical which is usually accomplished by pulpectomy or
procedure is only performed when it has been extraction.
observed that high maxillary labial frenum is caus- Managing a more serious odontogenic infection
ative factor for diastema between maxillary central is best accomplished by way of surgical incision
incisors until permanent canines have erupted. and drainage.
Pit and Fissure Sealants and
Conservative Adhesive Restoration

INTRODUCTION To make significant gains in caries reduction in

the child, adolescent and adult population in the near
Pit and fissure caries represent approximately 90
future, it is necessary for the dental professional to
percent of the total caries experience in childhood and
educate and inform the general public, parents,
adolescence. The development of pit and fissure caries
physicians, underwriters of dental care plans and
occurs not only in 6-14 years old children but also in
funding agencies about the cost-effectiveness and
adolescents and young adults.
caries-preventive benefits of sealants and preventive
With the introduction of sealants, a clinical restorations.
approach to prevention of caries in pit and fissure With the widespread use of the acid-etch technique,
became available. it may be possible to provide the majority of children,
With innovative applications of the acid-etch adolescents and adults with a caries-free-dentition.
technique, tooth surfaces with isolated involvement
of pits and fissures may also benefit from the MORPHOLOGY OF SURFACES WITH
conservation of the tooth structure afforded by PITS AND FISSURES
conservative adhesive resin restorations.
With the use of both fluoride releasing sealant and The two main types of pits and fissures are:
glass ionomer-based material which acts as a fluoride i. Shallow; wide V-shaped fissures that tend to be
reservoirs for adjacent enamel and dentin, provide self-cleansing and somewhat caries resistant.
enhanced caries resistance for sound enamel and ii. Deep, narrow I-shaped fissure that are quite
dentinal caries. constricted and may resemble a bottleneck in
150 Essentials of Pediatric Dentistry

that the fissure may have an extremely narrow The enamel at base of the fissure is affected to a
slit-like opening with a larger base as it extends greater degree than that of cuspal inclines, and
towards dentino-enamel junction. These caries- lesion spreads laterally along the enamel adjacent
susceptible, I-shaped fissures may also have a to the depth of the fissure and readily towards
number of different branches extending towards dentinoenamel junction.
or into a underlying dentin. Once the caries process involves the dentin; it leads
Reason for Early Development of Caries in Pits to eventual cavitation of the fissure owing to loss
and Fissures of mineral and structural support from the adjacent
i. The fissure provide a protected niche for plaque affected enamel and dentin, resulting in a clinically
accumulation. detectable lesion.
ii. The rapidity with which dental caries occurs in
pits and fissures is most likely related to the fact
Historical Attempts in Prevention of
that the depth of the fissure is in close proximity
Pits and Fissure Caries
to the dentinoenamel junction and the underlying
dentin; which is highly susceptible to caries. In 1924, Thaddeus Hyatt, advocated
The morphology of occlusal surfaces varies from prophylactic restoration; This procedure
one tooth to the next and from individual-to- consisted of preparing a conservative class I cavity
individual. But in general; the Typical premolar that included all pits and fissures at risk for caries
has a prominent primary fissure with usually three
development and then placing amalgam
or four pits.
In typical molar as many as 10 separate pits
may be present in primary, secondary and Rationale of Prophylactic Restoration:
supplemental fissures. An otherwise caries-free surface was that the
procedure prevented further insult to the pulp from
AND FISSURES Decreased loss of tooth structure.
Required less time for restoration when the tooth
The inclines forming the walls of the fissures are
eventually succumbed to caries.
affected first by caries process.
A conservative approach by Bodecker in 1929:
The first histologic evidence of lesion formation
occurs at the orifice of the fissure and is usually Initially; cleaning of pits and fissure is performed
represented by the two independent bilateral with the use of explorer and flowing a thin mix of
lesions in the enamel composing the opposing oxyphosphate cement into the fissure in an attempt
cuspal inclines. to seal the fissures.
As the lesion progresses, the depth of the fissure Prophylactic Odontomy by Bodecker: The
walls becomes involved and coalescence of the mechanical eradication of fissures is done in order
two independent lesions into a single, contiguous to transform deep, retentive fissures into a easily
lesion occurs at the base of fissure. cleansable ones.
Pit and Fissure Sealants and Conservative Adhesive Restoration 151

These techniques were employed until the use of ALTERNATIVES OF PIT AND FISSURE
sealants became prevalent. TREATMENT
Dental practitioner can consider following alternatives:
Observation only
Clinical Examination Sealant placement
Conservative adhesive restoration
Caries is present when the explorer catches or resists Conservative restorations
removal after insertion into pit or fissure with moderate Glass-ionomer-resin conservative restoration
to firm pressure and when this is accompanied by one Glass-ionomer conservative restoration
or more of following signs of caries Sealant amalgam conservative restoration
a. Softness at the base of the area. Amalgam, glass ionomer, glass-ionomer-resin or
b. Opacity or loss of normal translucency adjacent posterior composite restorations.
to pit or fissure as evidence of undermining or
c. Softened enamel adjacent to the pit or fissure that SEALANT PLACEMENT
can be scraped away with the explorer. Deep, retentive pits and fissures, which may cause
wedging or catching of an explorer.
Radiographic Examination Stained pits and fissures with minimal appearance
Evaluation of pit and fissure caries on occlusal surfaces of decalcification or opacification.
has been found to be of minimal diagnostic value Pit and fissure caries or restoration of pits and
especially evaluating enamel caries and superficial fissures in other primary or permanent teeth.
No radiographic or clinical evidence of
dentinal caries.
interproximal caries in need of restoration on teeth
Currently, there are a number of techniques to aid
to be sealed.
the dentist in diagnosis of pits and fissure caries
Use of other preventive treatment such as systemic
RadiographyConventional, xeroradiographic,
or topical fluoride therapy; to inhibit interproximal
digital caries formation.
Fiberoptic transillumination/infrared laser Possibility of adequate isolation from salivary
Caries detecting dye contamination.
Light-induced fluorescence
Electrical resistance PLACEMENT
A promising ancillary diagnostic device.
Electronic caries detector (having sensitive and Well-coalesced, self-cleansing pits and fissures.
very specific detecting explorer). Radiographic or clinical evidence of interproximal
caries in need of restoration.
152 Essentials of Pediatric Dentistry

Presence of many interproximal lesions or sharp, fine-pointed explorer to remove

restorations and no preventive treatment to inhibit any cleansing material lodged within
interproximal caries could be given. the pits and fissures.
Tooth partially erupted and no possibility of Once the tooth surface has been
adequate isolation from salivary contamination. thoroughly cleansed, rinse and air dry
Also the presence of an operculum over the the surface.
distal marginal ridge is associated with loss of Step 3: Acid-etch tooth surfaceThe efforts of
sealant material. acid-etching on enamel were studied by
Life expectancy of primary teeth is limited. buonocore in 1955.
For dentinal caries consider preventive restoration, Before explaining clinical application
conventional restoration. of Acid-Etch Technique the Scientific
Basis for the Acid-Etch Technique must
APPLICATION Acid-etching of surface enamel has been shown
Step 1: Isolation of tooth surface from salivary to produce a certain degree of porosity.
contamination Ideally a rubber dam A sound enamel etched with phosphoric acid is affected
isolation is preferred; but also cotton roll at three levels microscopically they are:
isolation with adequate suctioning to A narrow zone of enamel is removed by etching.
remove saliva from the operating field is By this way plaque, surface and subsurface organic
also acceptable. pellicles are effectively dissolved.
Step 2: Cleaning the tooth surface: The other zone after narrow zone is etched zone is
Prophylaxis of the tooth surface is a fully reacted zone in which inert mineral crystals
carried out in several ways in the surface enamel are also removed, resulting
Using a pumice slurry applied with a in a more reactive surface, an increased surface
rubber cup or pointed bristle brush. areas, and a reduced surface tension that allows
Using a air-polishing device with an resin to wet the etched enamel more readily.
air-powder abrasive (sodium bi- Etched Zone is Approx 10 mm in Depth
carbonate slurry) system; later The next zone is qualitative porous zone which is
neutralize this slurry with phosphoric approx 20 mm in depth. The name of this zone
acid for 5-10 sec. itself explains that porosities which are created by
Using simply a tooth brush the etching process is easily distinguished
prophylaxis with toothpaste or pumice qualitatively from adjacent sound enamel.
followed by copious water rinsing to The final zone is quantitative porous zone; this
prepare the pits and fissures. zone extends into enamel for an additional
Trace the pits and fissures with a 20 mm.
Pit and Fissure Sealants and Conservative Adhesive Restoration 153

As its name suggests it has relatively small regards a gel material is preferred to have
porosities created by etching process that may be controlled etching gently rubbing the etchant with
identified by quantitative methods using polarised light including 2 to 3 mm of the cuspal inclines and
microscopy. reaching into any buccal or lingual pits and grooves
The resin material penetrates in these created that are present.
porosities by various zones. Step 4: Rinse and dry-etched tooth surface
After gaining knowledge about various zones of Rinse the etched tooth surface with an
enamel it is essential to know about various etching air-water spray for 30 seconds. This
patterns. will remove the etching agent and
Three characteristic etching patterns occurs reaction products from etched enamel
following exposure of sound enamel to phosphoric surface.
acid Dry the tooth surface for at least 15
Type I etching pattern: In this prism cores are lost but seconds with uncontaminated
compressed air. The dried, etched
the prism peripheries remains.
enamel should have a frosted-white
Type II etching pattern: In this prism core are relatively appearance. If the enamel does not
intact but prism peripheries are lost. have this appearance; repeat the
Type III etching pattern: Enamel shows a generalised etching step.
surface roughening and porosity with an areas with If etched and dried tooth surface is
no exposure of prism cores or peripheries. contaminated at this stage reisolate the
These three etching patterns are found adjacent to teeth, rinse the entire tooth surface, dry
one another. thoroughly and repeat the etching
Clinical Applications of Acid-Etch Technique Step 5: Apply sealant to etched tooth surface
Sealant material is allowed to flow in
Etching agent is applied over tooth surface with a all etched pits and fissures; with
fine brush, a cotton pledget or a minisponge using mandibular teeth; sealant is applied at
a recommended exposure time the distal aspect and allow it to flow
For permanent teethExposure time is 15 sec. at the mesial aspect and with maxillary
For primary teethExposure time is 15-30 sec. teeth sealant is applied at mesial aspect
Fluorosed teeth require an additional exposure and is allowed to flow distally. To
time. allow sealant material to flow helps
Gently rub the etchant applicator over the tooth in preventing the incorporation of air
surface; while rubbing periodically of fresh etchant in material.
is added; but while rubbing prevent spillage of A thin layer of sealant is carried using
etchant in interproximal areas (which may lead to a fine brush, or applicator to the cuspal
irritation of gingiva in interproximal areas); in this inclines to seal secondary and
154 Essentials of Pediatric Dentistry

supplemental fissures; and flow the FLUORIDE: RELEASING SEALANTS

sealant material into buccal or lingual Fluoride-releasing sealant material composed of
pits and grooves. modified urethane-BIS-GMA resin.
With photo activated sealants the A reduction of approximately 60 percent of
setting reaction is initiated by secondary caries formation occurs with use of the
exposing the sealant to visible light fluoride-releasing sealant compared with
and usually requires 10 to 20 seconds conventional sealant material.
for complete setting. The fluoride released from the sealant material
Step 6: Explore the sealed tooth surface apparently becomes incorporated into the adjacent
Explore the entire tooth surface for pits enamel and provides an increased level of caries
and fissures that may not have been sealed resistance.
and for voids in the material. It is possible to increase the fluoride load within a
If deficiencies are present, apply resin-based material, this may result in substantial
additional sealant material. increasein fluoride-release in the local environment
Step 7: Evaluate the occlusion of sealed tooth and may reduce the effect of cariogenic challenge.
surface Incorporation of organic fluorides in resin
Evaluate the occlusion of sealed tooth materials also enhances fluoride release while
surface to determine whether maintaining the physical properties of resin
excessive sealant material is present material.
and must be removed, allowing proper Organic Fluorides that may be Incorporated into
interdigitation. Polymer Matrix of Dental Material Includes
Evaluate the interproximal regions for Acrylic amine-hydrogen fluorides salt.
inadvertent sealant placement by Methacrylol fluoride-methyl methacrylate.
performing tactile examination with t-butylaminoethyl methacrylate hydrogen fluoride.
an explorer and passing dental floss Tetrabutylammonium tetrafluoroborate.
between the contact regions.
Step 8: Periodically reevaluate and reapply CONSERVATIVE ADHESIVE
sealant as necessary RESTORATIONS
During routine recall examination, it Recently, additional types of conservative adhesive
is necessary to reevaluate the sealed restorations have been introduced to deal with
tooth surface for loss of sealant more extensive caries in isolated pits and fissures
material; and or caries development. that require restoration of the prepared cavities
If reapplying of sealant is necessary: with dental materials of greater strength.
the steps involved in reapplying A well-accepted clinical procedure used for
sealant material to an existing sealant restoring isolated pits and fissures and
are identical to those used for initial simultaneously preventing caries in the remaining
placement. unaffected pits and fissures was originally
Pit and Fissure Sealants and Conservative Adhesive Restoration 155

designated the preventive resin restoration and agent or dentinal bonding agent in the
uses acid-etch technique. prepared cavity.
This restorative technique is been renamed Next; place composite resin over the
Conservative adhesive resin restoration. bonding agent. If it is chemical cured;
A conservative adhesive resin restoration allow time for complete setting
require the same steps as those used for sealant reaction to occur; and or expose light
placement except that caries are removed from cured material to the visible light
isolated pits and fissures. source to initiate the setting reaction.
Next, apply sealant material over the
Step 1: Isolate tooth surface from salivary restored area and the adjacent intact
contamination: Isolate tooth surface as etched pit and fissures.
described in pit and fissure sealant Carry the sealant material up the cuspal
placement technique. inclines for 2 to 3 mm and into buccal-
Step 2: Remove caries from isolated pits and lingual grooves and pits; provide adequate
fissures time for sealant setting reaction.
Removal of caries from isolated pit Step 7: Explore the sealed and restored tooth
and fissure is accomplished by surface: Explore the sealed and restored
inverted cone- shaped, round or pear- surface as described previously and add
shaped bur in a high-speed handpiece. sealant material in deficiencies if any.
Caries should be removed making no Step 8: Evaluate the occlusion of sealed and
attempts to incorporate retention into restored tooth surface
the preparation. Evaluate the occlusion of the sealed
The size of the bur and the resulting and restored tooth surface to
cavity preparation will be dictated by determine presence of any occlusal
the amount of caries present. interferences if any.
Step 3: Cleanse tooth surface: Perform tooth Evaluate the interproximal regions for
prophylaxis followed by rinsing and inadvertent resin placement by using
drying. explorer and dental floss.
Step 4: Place cavity base or lining material: If Step 9: Periodically reevaluate the conservative
cavity is deep leading to exposure of adhesive restoration, repair and reapply
dentin; calcium hydroxide or glass sealant as necessary: During routine
ionomer base should be placed prior to recall visits and examination it is
acid etching. necessary to reevaluate the sealed and
Step 5: Acid-etch tooth surface: Etch, rinse and restored tooth surface for
dry tooth surface similar to described Loss of sealing material if any.
previously with pit and fissure sealant Development of any carious lesion in
placement technique. already restored area.
Step 6: Place resin and sealant material Repair of the restored regions and reapplication
Place a thin layer of resin bonding of sealant material may be necessary periodically.
Managing Traumatic
Injuries in the Young
Permanent Dentition

INTRODUCTION Children engaging in contact sports are at greatest

risk for dental injury.
Injuries are defined as the damage of the part of
In the teenage years, automobile accidents cause
body due to trauma.
a significant number of dental injuries when
Traumatic injuries to anterior teeth are considered
emergency situations in the dental office because occupants not wearing seat belts hit the steering
they cause disfigurement of child along with wheel or dashboards.
psychological trauma to child and parents. Children with protruding incisors, as in developing
An injury to the teeth of a young child can have class II malocclusions, are two or three times more
serious and long-term consequences, leading to likely to suffer dental trauma than children with
their discoloration, malformation, or possible loss. normal incisal overjets.
The emotional impact of such an injury can Children with chronic seizure disorders experience
be far reaching, it is therefore important that the an increased incidence of dental trauma.
dentist treating children must be knowledgable in Another serious cause of dental injuries to young
the techniques for managing traumatic injuries. children is child abuse.
Fractures are more seen in permanent dentition Often overlooked by the dental professionals; upto
whereas displacement injury is seen in primary 50 percent of abused children suffer injuries to head
dentition due to following reasons and neck.
Less crown length
Thin labial cortical plate CLASSIFICATIONS OF INJURIES TO
Anterior teeth being more vertical YOUNG PERMANENT TEETH
Elasticity of surrounding bone.
A. Classification by Rabinowitch (1956)
PERMANENT DENTITION i. Fractures of the enamel or slightly into dentin
ii. Fractures into dentin
Falls during play account for most injuries to young
iii. Fractures into pulp
permanent teeth.
Managing Traumatic Injuries in the Young Permanent Dentition 157

iv. Fractures of roots b. Uncomplicated Crown Fracture N873.60: A

v. Comminuted fracture fracture involving enamel and dentin but not
vi. Displaced teeth. exposing the pulp.
c. Complicated Crown Fracture N873.62: A fracture
B. Classification by Ellis and Davey (1960) involving enamel, dentin and pulp.
d. Uncomplicated Crown-Root Fracture N873.64: A
Class I: Simple fracture of the crown involving
fracture involving enamel, dentin and cementum
little or no dentin.
but not involving pulp.
Class II: Extensive fracture of the crown involving
e. Complicated Crown-Root fracture N873.64: A
considerable dentin but not dental pulp.
fracture involving enamel, dentin, cementum
Class III: Extensive fracture of crown involving
including pulp or exposing pulp.
considerable dentin and exposing dental
f. Root fracture N873.63: A fracture involving dentin,
cementum and pulp.
Class IV: The traumatized teeth become nonvital
with or without loss of crown structure.
Class V: Tooth lost as result of trauma.
Class VI: Fracture of root with or without loss of TISSUES
crown structure. The most common type of injuries to primary and
Class VII: Displacement of tooth without fracture of young permanent teeth are luxation (displacement
crown and root. injuries). These injuries damage supporting structures
Class VIII: Fracture of crown-en-mass and it's of teeth, which include periodontal ligament (PDL)
replacement. and alveolar bone. The PDL is the physiologic
Class IX: Traumatic injuries to primary teeth. "Hammock" that supports tooth in its socket. Several
types of luxation injury occurs.
C. Classification by Andreasen i. Concussion (N873.66): The tooth is not mobile
The classification is based on system adopted and is not displaced. The PDL absorbs the injury
by the WHO in its application of the and is inflamed, which leaves the tooth tender
international classification of diseases of to biting pressure and percussion.
dentistry and stomatology. ii. Subluxation N873.66: The tooth is loosened but
This classification can be applied to both is not displaced from its socket.
primary and permanent dentition. iii. Intrusive Luxation N873.67: The tooth is driven
into its socket. This compresses the PDL and
INJURIES TO HARD DENTAL TISSUES commonly causes a crushing fracture of the
AND PULP alvedar socket.
iv. Extrusive Luxation (partial avulsion) N873.66:
a. Crown Infraction N873.60: An incomplete fracture
(crack) of the enamel without loss of tooth This is a central dislocation of tooth from its
structure. socket. The PDL is usually torn in this injury.
158 Essentials of Pediatric Dentistry

v. Lateral Luxation N873.66: The tooth is ii. Contusion of Gingiva or Oral Mucosa N902.
displaced in labial, lingual or lateral direction, XOA bruise usually produced by a blunt
the PDL is torn and contusion or fracture of object and not accompanied by break of
supporting alveolar bone occurs. continuity in the mucosa, causing submucosal
vi. Avulsion (Ex-articulation N873.68): The tooth hemorrhage.
is completely displaced from the alveolus. The iii. Abrasion of Gingiva or oral Mucosa N910.00
PDL is severed, and fractures of the alveolus A superficial wound produced by rubbing or
may occurs. scraping of mucosa leaving a raw bleeding
i. Comminuation of Alveolar Socket (Mandible
N802.20 Maxilla 802.40): Crushing and TIZED TEETH
compression of alveolar socket. This condition Complications following traumatic injuries to teeth
is found together with intrusive and lateral appear shortly after the injury.
luxation. The following terms describe a spectrum of clinical
ii. Fracture of Alveolar Socket Wall (Mandible signs and symptoms that accompany inflammation and
N802.20, Maxilla 802.40): A fracture contained degeneration of the pulp and/or periodontal ligament.
to facial or lingual socket wall.
iii. Fracture of Alveolar process (Mandible Reversible PulpitisThe pulps initial
N802.20 Maxilla N802.40): Fracture of alveolar response to trauma is pulpitis
process which may or may not involve alveolar
socket. Capillaries in the teeth become congested; a
iv. Fracture of Mandible and Maxilla (Mandible condition that can be clinically appearent upon
N802.21, Maxilla 802.42): A fracture involving transillumination of the crown with a bright light.
base of mandible, maxilla and often alveolar If tooth has undergone a luxation injury there is
process (Jaw Fracture). The fracture may or may PDL inflammation; so tooth with reversible pulpitis
not involve alveolar socket. in this case is tender to percussion.
Pulpitis may be totally reversible if the condition
INJURIES TO GINGIVA OR ORAL MUCOSA causing it is addressed; or else it may progress to
irreversible pulpitis state to necrosis of the pulp.
i. Laceration of Gingiva or Oral Mucosa
N873.69A shallow or deep wound in the
Infection of Periodontal Ligament (PDL)
mucosa resulting from a tear usually produced
by a sharp object. When tooth suffers from luxation injury
Managing Traumatic Injuries in the Young Permanent Dentition 159

It leads to detachment of the gingival fibers from the Pulp Necrosis

Two main mechanisms can explain how the pulp of
This allows invasion of microorganisms from the injured tooth become necrotic.
oral cavity along root to infect PDL Mechanism 1: Infection of pulp in cases of untreated
crown fracture with pulp exposure.
Infection of periodontal ligament Mechanism 2: Interrupted blood supply to the pulp
through the apex in cases of luxation injury leading to
Loss of alveolar bone support can be seen in
periapical area as well as adjacent to roots

Coronal Discoloration
Increased tooth mobility accompanied by exudation
of pus from gingival crevice As a result of trauma, the capillaries in the pulp
ruptures leaving blood pigments deposited in the
Subsequently; require extraction dentinal tubules.
of traumatized tooth In mild cases; the blood is resorbed and a very
To prevent this condition parents should be little discoloration occurs, or that which is present
informed about the risk of infection and provided with becomes lighter in several weeks.
appropriate instructions to minimize such risk. In severe cases, the discoloration persists for the
life of the tooth.
Irreversible Pulpitis Various color changes following traumatic injury are:
Irreversible pulpitis could be acute, chronic; partial Pink discoloration is observed shortly after the
or complete also called total involvement of pulp. injury may represent intrapulpal hemorrhage
Following a traumatic injury there could be either (Rupture of blood vessels in the pulp).
of two possible situations A reddish hue is noticed long after injury is usually
Situation 1: The pulpitis could be painful due to due to internal resorption in the pulp chamber.
the reason that following the injury exudate Yellow discoloration can be seen when dentin is
accompanying pulpal inflammation cannot be
thick and pulp chamber is narrower than usual;
vented. This situation is called acute irreversible
this condition is called pulp canal obliteration.
Treatment of above three color changes is just follow-
Situation 2: This situation occurs generally in child
patients; following the injury exudates up
accompanying pulpal inflammation are vented Dark Discoloration (Black, Gray, Brown and
quickly and pulpitis progresses to a chronic; Intermediate hues): If the pulp loses its vitality
painless condition; this situation is called chronic and cannot eliminate iron containing molecules;
irreversible pulpitis. the tooth may remain discoloured.
160 Essentials of Pediatric Dentistry

Diagnosis of Pulp Necrosis: If dark-discolored Treatment

tooth is present with additional signs such as Traumatized tooth with external inflammatory root
swelling, fistula, or a periapical radiolucent defect; resorption should be extracted.
the diagnosis of pulp necrosis is easy.
Note: Removal of the necrotic, and probably infected
Inflammatory Resorption pulp may stop the resorptive process. However, due
to the unfavorable preexisting conditions the benefit
Inflammatory resorption occurs subsequent to of root canal filling aimed to save the tooth is
luxation injuries and is related to a necrotic pulp questionable.
and an inflamed PDL.
Inflammatory resorption can occur either on Replacement Resorption
the external root surface or internally in the Replacement resorption; also known as Ankylosis.
pulp chamber or canal. Due to irreversible injury to periodontal ligament;
A. Internal resorption alveolar bone contacts directly and becomes fused
In case of traumatic injury, the odontoblastic layer with root surface; the root is resorbed and is
may lose its integrity exposing the dentin to adonto- replaced with bone.
clastic activity, which is then seen on radiographs
as radiolucent expansion of pulp space. Pulp Canal Obliteration
Eventually this process reaches the outer
Following traumatic injuries a pulp canal
surface of the root causing the root perforation.
obliteration is a common finding.
If the coronal dentin is resorbed completely the
Pulp canal obliteration is the result of intensified
red color of resorbing tissue becomes visible
activity of the odontoblasts that results in
through the enamel.
accelerated dentin apposition which gradually
B. External resorption
reduces the pulp space to stage that pulp space
External inflammatory root resorption is a rapid
cannot be seen on a radiograph.
process characterized clinically by
Increased mobility of the tooth
Management of Traumatic Injuries
Sensitivity to percussion
A dull sound produced by percussion Management of traumatic injuries include following
A fistula or swelling in the gums above the step:
tooth. Step 1:

The periodontal space is widened
The root surface is irregular.
Managing Traumatic Injuries in the Young Permanent Dentition 161

Step 2: Ques. 1: When did the injury occurred, i.e. Time-

elaped since the injury ?
Note: Time is an important factor in determining the
type of treatment to be provided.
Ques. 2: Where the injury occurred ?
Note: This question sheds light on severity of injury;
The information regarding this question help in
determining the need for tetanus prophylaxis.
Ques. 3: How the accident occurred ?
Step 3: Note : This question obviously provide the dentist with
most information regarding severity of injury.
Illustration : Serious head injuries should be ruled out
Step 4:
by the dentists asking if the child lost consciousness,
has vomited, or is disoriented as a result of accident.
Step 1: History Taking A positive finding indicate potential central nervous
system injury, and in such cases medical consultation
Obtaining an adequate medical and dental history is
should be immediately obtained.
essential to proper diagnosis and treatment.
Ques. 4: The dentist should ask the child if there is
Medical History spontaneous pain from any teeth ?
Note: Positive finding here may indicate pulp
Information particularly relevant to dental injury
inflammation that is due to a fractured crown or injuries
includes the following
to the supporting structures such as extravasation of
i. Cardiac disease; which may necessitate
blood into the periodontal ligament.
prophylaxis against infectious endocarditis.
ii. Bleeding disorders Ques. 5: Does the child experience a thermal change
iii. Allergic to medications with sweet or sour foods ?
iv. Seizures disorders Note: If this situation is present dentin or pulp may be
v. Medications exposed.
vi. Status of tetanus prophylaxis. Ques. 6: Are the teeth tender to touch or tender while
chewing ?
Dental History Ques. 7: Does the child note a change in occlusion?
There are certain important questions to be asked by Note: Positive findings with these questions indicate
dentist to gather an informative dental history a luxation injury or an alveolar fracture.
162 Essentials of Pediatric Dentistry

Step 2: Examination Root fractures

Extent of root development
Clinical Examination Size of pulp chambers
Once the medical and dental histories are complete, Periapical radiolucencies
the dentist is ready to begin the clinical examination. Resorptions
Extraoral Examination: Degree of tooth displacement
The child's facial skeleton should be palpated to Position of unerupted teeth
determine discontinuities of facial bones. Jaw fractures
Extraoral wounds and bruises should be recorded. Presence of any tooth fragments or foreign material
The temporomandibular joints should be palpated, in soft tissues.
and any swelling, clicking or crepitus should be Many pathological changes are not immediately
noted. apparent in radiographs following the traumatic
All mandibular excursive movements should be injuries. After approximately 3 weeks periapical
checked and recorded. radiolucencies that are due to pulpal necrosis can
Any stiffness or pain in the childs neck necessitates be usually detected.
immediate referral to a physician to rule out Inflammatory root resorption may also be evident
cervical spine injury if any. in 3 weeks of time period.
Replacement resorption or ankylosis may be
Intraoral Examination:
evident in 6 to 7 weeks time period.
All soft tissues should be examined and areas
Thus, there is adequate rationale to obtain
injured and lacerated are recorded.
postoperative radiograph at 1 month and 2 months
Each tooth in the mouth should be examined for
Fracture following the injury.
Pulp exposure
Dislocation. Step 3: Emergency Care
Displacement of teeth should be recorded; as well Basics to be followed by the dental surgeon are:
as horizontal and vertical tooth mobility is Tetanus antitoxin should be given
recorded. Cleaning of wound and laceration
iv. Reaction to palpation and percussion of teeth Debride the area with normal saline
is recorded; percussion sensitivity is recorded Suturing of area.
Note: Percussion sensitivity is a good indicator of Information and Instructions for Parents
periodontal ligament inflammation.
Pulpal vitality testing is performed. Emergency Telephone Call
Parents calls dentist stating that their child injured a
Radiographic Examination primary tooth and asking how urgent it is to bring the
Radiographs allow the clinician to detect child to the dental office.
Managing Traumatic Injuries in the Young Permanent Dentition 163

If call sounds for injury of a serious luxation; the ionomer cement, followed by a dentin bonding
child should be seen as soon as possible. The agent and the tooth then can be restored with an
management of other conditions can be postponed until acid-etch/composite resin technique.
the next day without risking the prognosis. If adequate time is not available to restore the tooth
Information and Instructions Provided at the completely, an interim covering of resin material
Emergency Visit (a resin patch) can temporise the tooth until a
Parents should be informed about possible final restoration can be placed.
complications of the injury, prognosis of the injury Fractures Involving the Pulp
and the likelihood of damage to the permanent The objective of treatment in managing these injuries
successors. is to preserve a vital pulp in the entire tooth.
In cases of luxation injuries, parents should be Maintaining a vital pulp in the tooth crown allows
given strict instructions for their child's oral the clinician to monitor the tooths vitality periodically.
hygiene. Treatment options depends on following situations
Application of an antiseptic medicament such Treatment of vital exposed pulp of tooth with
as, 0.2 percent chlorhexidine gluconate or 3
immature roots:
percent hydrogen peroxide, to the injured gingiva
Direct pulp cap
which improve the chance for healing.
Apexogenesis with calcium hydroxide
Step 4: Definitive Treatment of Pulpotomy.
Traumatic Injuries Treatment of vital exposed pulp of tooth with
matured roots (closed root apex)
Injuries to the Hard Dental Tissues
Direct pulp cap
Enamel Fractures Pulpectomy
In cases with minor enamel fractures; fractures can Root canal therapy.
be smoothed with fine disks.
In situations when pulp of traumatized tooth has
In cases of larger fractures; they are restored using
turned nonvital; treatment options then are
an acid-etch/composite resin technique.
Enamel and Dentin Fractures Treatment of Nonvital, immature tooth
The primary need in managing fractures that apexification.
expose dentin is to prevent bacterial irritants from Treatment of Nonvital mature toothpulpectomy,
reaching the pulp. root canal therapy.
In past; the standard care for covering exposed
dentin with calcium hydroxide or glass ionomer DIRECT PULP CAP
cement to seal out oral flora was performed.
But recent technique recommends covering the The direct pulp cap is only indicated in small exposures
deepest portion of dentin fractures with glass that can be treated within a few hours of the injury.
164 Essentials of Pediatric Dentistry

Clinical Technique Clinical Technique

Step 1: A rubber dam is applied, and the tooth is Step 1: Isolate tooth with rubber dam to prevent
gently cleaned with water. contamination of the pulp with oral
Step 2: After cavity preparation is done with high
Step 2: The inflamed pulp is gently removed to a
speed handpiece under the constant water level approximately 2 mm below the
spray and the caries removal with slow exposure site with a sterile diamond bur
speed handpiece; the cavity should be at high speed; copious irrigation is
rinsed with diluted sodium hypochlorite, mandatory to avoid pulp injury.
this disinfects the cavity and removes the Step 3: The preparation should provide adequate
blood clot if present. space for calcium hydroxide pulp dressing
Step 3: If bleeding persists, application of and a glass ionomer seal; Attaining a
bacteria tight coronal seal is essential for
pressure to the exposure site with a cotton
the success of this technique.
pellet moistened with saline will stop it. Step 4: The tooth can then be aesthetically
Step 4: Commercially available calcium restored with composite resin.
hydroxide paste is applied directly to the
pulp tissue and to the surrounding dentin. PULPECTOMY
Step 5: It is essential that a restoration must be Pulpectomy involves complete pulp tissue removal
placed that is capable of thoroughly from crown and root.
sealing the exposure to prevent further
contamination by oral bacteria.
It is acceptable to use an acid-etch/compo- When no vital tissue remains.
When root maturation is complete and the
site resin system for an initial restoration.
permanent restoration requires a post build-up.
Step 6: The calcific bridge stimulated by calcium In the absence of inflammatory root resorption,
hydroxide should be evident radio- treatment is to obturate the canal with gutta-percha.
graphically in 2-3 months. One of the greatest challenges facing the clinician
is the treatment of a nonvital immature permanent tooth
PULPOTOMY with an open apex. In this case; an apexification
procedure is indicated.
This technique is favoured for immature permanent APEXIFICATION
teeth with exposed pulps. Apexification is a method of treatment for immature
It is also indicated in large exposures or for pulps permanent teeth in which root growth and development
exposed for more than a few hours. ceased due to pulp necrosis.
Managing Traumatic Injuries in the Young Permanent Dentition 165

Its purpose is to allow the formation of an apical If root apex is closed; take out calcium
barrier. hydroxide an irrigate root canals with
normal saline and then obturate with
Clinical Technique gutta-percha and later followed by
permanent restoration.
Step 1: Anesthetise the tooth togather with proper
application of rubber dam.
Step 2: Gain access to pulp chamber.
Step 3: Extirpate the coronal pulp. Apexogenesis is done in immature teeth when part of
Step 4: Determining of root canal length by the pulp tissue remains vital and uninflamed as in some
placing reamer in root canal and taking trauma situations in which pulp exposure occurred and
radiograph. Extirpate radicular pulp by treatment was delayed.
barbed broach; while taking care not to Procedure allows continuation of root formation
traumatise periapical tissue. apically to calcium hydroxide; the root formed usually
is irregular but nevertheless provide additional support
Step 5: Biomechanical preparation is carried out
for the tooth.
with reamer and file.
Step 6: Irrigation of root canals with normal
Criteria for Success
Step 7: Dry root canal with paper points. Criteria of judging success of various techniques used
Step 8: Mix calcium hydroxide cement and place to manage pulpal insult in fractured teeth include the
in root canal; it is made to reach root apex following:
by plugger. i. Completion of root development in immature
Step 9: Seal access cavity with temporary teeth.
restoration. ii. Absence of any clinical findings such as pain,
Step 10: Follow-up visits mobility, or fistula.
iii. Absence of any radiographic signs and
Recall patient after 6 months and take
an intraoral periapical radiograph if pathologic processes, such as periapical
apex is not closed; then, radiolucency of bone or root resorption.
iv. Posterior Crown Fractures: This type of fracture
Recall patient again after 6 months
usually occurs secondary to hard blows to the
and take an intraoral periapical
underside of the chin; and vertical crown
radiograph if apex is still not closed;
fractures may results.
Treatment: Full coverage with stainless steel or
Replace the previous filled calcium
cast metal crowns is a frequently used mode of
hydroxide filling in canals with a fresh
calcium hydroxide. treatment.
166 Essentials of Pediatric Dentistry

v. Root Fractures: The prognosis for root fractures Concussion and Subluxation
is best when the fracture occurs in the apical
one-third of the root. The prognosis worsens Clinical features
progressively with fracture that tends to occur Teeth suffering concussion injury are sensitive to
more cervically in the root. percussion without any additional sign.
Subluxated tooth present increased mobility.
If teeth is examined shortly after injury, signs of
It is seen that 75 percent of teeth with intraalveolar
bleeding from the gingival crevice can be seen.
root fractures maintain their vitality.
A several series of radiographs are taken with Concussion and subluxation are mild injuries, they
different angulations to verify the extent of fracture. often go unnoticed; parents if questioned may
The tooth position should be verified recall the injury, when a late complication
radiographically and the pulp sensitivity should develops, such as tooth discoloration.
be tested. Radiographic features
Treatment Subluxated teeth present widening of periodontal
Former recommendations called for firm ligament space.
immobilisation with a splint for several months. In concussion injuries pulp necrosis and root
Recent recommendations indicates that root- resorption have been reported.
fractured tooth may heal better if splinted for only Treatment
3 to 4 weeks with a functional splint that allows Concussion injuries in permanent teeth must be
for some mobility of the teeth. followed closely; involved teeth can be carefully
taken out of occlusion if child complains of pain.
INJURIES TO THE SUPPORTING TISSUE Subluxated teeth must be followed closely with
radiographs for at least 1 year and root canal
Luxation injuries damage the supporting structures of therapy should be instituted at the first sign of
teeth, that is the periodontal ligament and alveolar
pathologic change.
Splinting of subluxated teeth should be avoided.
Also, in mature teeth with closed apices; the pulp
frequently becomes necrotic but pulp necrosis is very
Intrusive Luxation
less noted in immature tooth with open apex; in these
cases pulp canal obliteration is a common finding. Treatment: There are two treatment modalities for
cases with intrusive luxation.
Primary Objective Modality 1Surgical repositioning: Immediate
Objective of treatment of these injuries is to maintain surgical repositioning is indicated for intruded
periodontal ligament vitality. permanent teeth.
Managing Traumatic Injuries in the Young Permanent Dentition 167

Modality 2Orthodontic repositioning: Firmly

intruded permanent teeth should not be surgically
repositioned as this enhance both root resorption and
alveolar bone loss.
The treatment of choice is to reposition the
intruded teeth orthodontically, using light forces,
Also using technique same as apexification.
The pulp should be extirpated within 2 weeks
following the injury.
Calcium hydroxide should be placed in root canals
using the same technique.
Radiographic monitoring of the tooth should occur
for at least 1 year, and the calcium hydroxide in
the canal should be replaced if signs of root
resorption persist.

Extrusion Fig. 16.1: Extrusion injury

An extruded tooth is clinically elongated in comparison

with adjacent unaffected teeth (Fig. 16.1). Extruded teeth with open apices have a chance to
Clinical Features revascularize and maintain their vitality : so the
The tooth presents increased mobility and decision to initiate root canal therapy should be
sensitivity to percussion. delayed until initial clinical or radiographic signs
Bleeding from the gingival sulcus can be seen indicate necrosis.
shortly after the injury.
The more the tooth moves out of the alveolar Lateral Luxation
socket the higher are the chances of disruption of In lateral luxation injuries alveolar bone fractures
blood supply and development of pulp necrosis. occurs frequently, in most severe cases periodontal
Radiographic Features ligament and marginal bone loss occurs (Fig. 16.2).
A periapical radiograph of an extruded tooth will Treatment: Reposition the teeth and alveolar
show widening of periodontal ligament especially fragments; a splint should be then applied for 3 to
around the apex. 8 weeks, depending on the degree of bone
Treatment involvement.
Extruded permanent teeth with closed apices will Maintain a good oral hygiene with a use of 0.12
undergo pulpal necrosis therefore root canal percent chlorhexidine mouth rinse with this
therapy should be initiated after teeth are splinted alveolar bone regeneration can occur in children
(for 2-3 weeks). in approximately 8 weeks.
168 Essentials of Pediatric Dentistry

Fig. 16.3: Reimplantation of avulsed tooth

prior to non-rigid splinting for 7-10 days

Fig. 16.2: Lateral luxation

aseptic, and its osmolality is more favourable
Avulsion (Refer to Fig. 16.4) for maintaining vitality of periodontal ligament
Prognosis: The prognosis of avulsed permanent b. Patients mouth (Saliva).
teeth worsens more when longer the tooth is out c. The last and least effective is water.
of the socket.
Primary Objective is to maintain the vitality of
Guidelines for Treatment of Avulsed
periodontal fibers.
Tooth by Reimplantation (Refer Fig. 16.3)
TREATMENT Extraoral time is one of the most critical factors
affecting prognosis. The avulsed tooth should be
Reimplantation replaced immediately into its socket, whenever
It is imperative the avulsed tooth be immediately possible, reduce this time to an absolute minimum.
reimplanted by the first capable person whether Management of the socket:
that person is a parent, teacher, or sibling. a. The less manipulation of the socket the better
The best transport medium for avulsed teeth is prognosis is for the reimplanted tooth.
Hanks balanced salt solution (HBSS) which b. Do not curette or vent the socket.
significantly increases the likelihood of periodontal c. Use light irrigation and gentle aspiration to
ligament cells survival for several hours. remove any blood clot present in the socket,
The other alternatives for storing avulsed to permit reimplantation.
permanent tooth is: d. After reimplantation, manually compress the
a. Milk; which is readily available, relatively facial and lingual bony plate.
Managing Traumatic Injuries in the Young Permanent Dentition 169

b. If the tooth apex is open, monitor the

reimplanted tooth every 2 weeks for
revitalization of pulp.
c. If pathologic signs are noted, then extirpate
the pulp, and continue with an apexification
procedure using calcium hydroxide until such
time as endodontic treatment and root canal
filling can be completed.
d. In summary the procedure for reimplantation
of a mature tooth is as follows
i. Hold the tooth by the crown to prevent
damage to periodontal ligament.
ii. Gently rinse the tooth with tap water. No
Fig. 16.4: Anatomy of tooth avulsion attempt should be made to scrub or sterilise
the tooth.
iii. Manually reimplant the tooth in the socket
Management of the root surface
as soon as possible.
a. To preserve the vitality of root surface cells, iv. Apply a light, functional splint for 1 week.
do not handle, scrape, brush or remove any of v. Complete calcium hydroxide pulpectomy
the root surface. after 1 week and then remove splint.
b. If the root surface is dirty, rinse it with clean
tap water and if persistent debris remains on Characteristics of an Ideal Splint
the root, use cotton pliers gently to pick away a. Splint should be passive and not cause trauma.
any debris, or as a last resort, use a wet sponge b. Splint should be flexible and allow functional
to brush off debris gently. movements of the tooth.
c. Do not apply any medicaments, disinfectants, c. Splint should allow for vitality testing and
or chemicals to the root surface. endodontic access.
When to perform endodontic treatment d. Splint should be easy to apply and remove.
a. The endodontic treatment should be initiated To allow for flexibility, a light orthodontic arch
within 7 to 14 days of reimplantation and when wire or a 30 to 60 pound test monofilament finishing
the tooth is in its socket. line can be used.
Treatment Planning and Management
of Orthodontic Problems


When considering treatment for problems during the The objectives for patients with deciduous dentition
mixed-dentition years, the precise problem and the are far more limited than for older patients. Therefore,
the clinical study and study on casts will be performed
goal of treatment must be clear in mind.
without gnathological and cephalometric analysis. The
After the problem list has been generated and each latter cannot be performed as there are no
problem has been ranked in order of severity, possible cephalometric patterns for patients under 7.
solutions to each problem should be listed; the solution Cephalometric norms are established as from age 8-
list should be comprehensive that is all reasonable 9. Nevertheless, gnathological and cephalometric
solutions should be considered for each specific studies are very important tools in other stages.
problem without regard for the other problems.
Data Gathering and Recording
In some cases the best solution for one problem is
in a Database
the best solution for all problems and the treatment
plan is easily derived. It implies data gathering and recording in a database
for ready access according to field of interest.
TREATMENT PLANNING PROCESS It is a key element in the planning process.
The planning process follows these steps Classification of Problems According to
Step 1: Selection and Evaluation of
Required Diagnostic Methods All relevant information on problems encountered is
duly recorded in the database. Once spotted, these
The different developmental stages have different problems should be ranked along a priority list.
diagnostic requirements because there will be different This order of priorities will be established, on the
objectives and hence, different treatment plans. one hand, by the clinician and on the other, by the
Treatment Planning and Management of Orthodontic Problems 171

patient, whose priorities may sometimes different from These objectives aim at a deeper analysis of the
those of the clinician. case and by way of an overview involve the following
Out of sheer logic, patients expectations should aspects.
come first.
Step 2: Evaluation of Clinical Possibilities
and Selection of a Feasible Therapeutic Facial
Approach To achieve a harmonious relation of the lips in the
From the onset; clinicians should be aware of chances facial profile and an unstrained lip closure.
of solving problems, regardless of where they stand
in their priorities. This may also condition the Oral
therapeutic approach applied to solve these problems.
Perfect dental alignment.
A gummy smile on a class I adult patient with
significant upper and lower crowdings should be Orthopedic changes required.
avoided/ignored, in spite of this aesthetic problem, and Harmonious teeth positioning based on
thus not included in the planning of an orthodontic cephalometric norms.
treatment as chances of success are almost nil.
Instead, if said problem were a top priority for the Gnathological
patient, an orthodontic surgical treatment should be
To achieve a maximum intercuspation, stabilized in
used duly including the correction of the gummy smile
in the planning. centric relation and a functional occlusion in harmony
It is essential to instruct the patient on the various with temporomandibular joints.
therapeutic approaches and their subsequent treatment All these preliminary objectives should be taken
results; features, scope risk/benefit ratio, and then into account at this stage of planning process and
treatment planning will proceed accordingly. regarded as a mere intention to treat for the time
Step 3: Preliminary Goals There is a straight forward correlation between
These objectives are based on the clinician's therapeutic approach to be applied and the preliminary
observations on the basis of adequate diagnostic objective set. In some cases, a comprehensive planning
approaches relevant to the case under study. Such with two or more treatment alternatives will be
objectives are subjected to the clinicians common required. These alternatives will enable the
sense. visualization of treatment objectives (VTO).
172 Essentials of Pediatric Dentistry

In a patient with a mild class III dentoskeletal pattern
who at first refuses surgery, two VTOs should be
One aiming solely at a proper teeth correction,
masking the problem.
Another VTO depicting the outcome of a combined
orthodontic-surgical treatment.
Undoubtedly, a mere comparison of both results
may lead the patient towards the correct choice and
pave the way for the clinician to define the appropriate
therapeutic approach.

Step 4: Dynamic and Structural Fig. 17.1: Good primary spacing in radiograph
Summary of the Case
Treatment goals, on the basis of the dynamic and
structural summary of the case will enable clinicians
to determine.
Structures to be modified
Biological limitations for said changes : In view
Patients age
Facial type
Magnitude and direction of growth
Morphological and structural characteristics
Dental and/or periodontal health
Occlusion in relation to the TMJ
Aesthetics Fig. 17.2: E space, or Leeway space, demonstrated in
Patients self-assessment of the condition. radiograph

Step 5: Visualization of Treatment

Objectives (VTO) The Implementation of VTO Requires

The visualization of treatment objectives is a traced A careful clinical evaluation

plane that combines anticipated growth of the patient A radiographic examination (Figs 17.1 and 17.2)
and its influence on therapeutic procedures with the Panoral, occlusal and periapical X-rays
predicted end of treatment changes. Lateral and sometimes frontal head films
Treatment Planning and Management of Orthodontic Problems 173

Step 6: Tracing of Superimposition Areas

The superimposition areas establish a link between
static and dynamic cephalometrics that is
Between the patients initial condition and growth
related alterations (initial cephalometric analysis
and growth prediction without treatment).
Between the initial condition and prediction of
growth induced as well as treatment related
changes (initial cephalogram and VTO).
Between the VTO and the intermediate
cephalogram (evaluation of treatment outcome).
Between the above mentioned and a post-treatment
cephalogram (evaluation of long-term results).

Step 7: Treatment Design and

Sequential Use of Appliances
This is an aim of every planning process. They imply
logical steps leading from the start to an organized
treatment involving:
Selection of appliances.
Sequence in the use of the different appliances.
Estimated time of use for each of them in terms of
the partial objectives as treatment develops.
Approximate duration of treatment.
Use of other therapeutic resources (e.g. orthodontic
surgical treatment).
Type and duration of the postorthodontic retention
to be used.

Study casts mounted on the semi-adjustable MANAGEMENT OF ORTHODONTIC

articulator. PROBLEMS
Records of condylar position. Before starting with managing various orthodontic
Lateral cephalometric analysis, in some cases, problems, let us discuss for important aspects required
frontal analysis as well. to understand management of orthodontic problems
Assessment of facial type. in a better way
174 Essentials of Pediatric Dentistry

I. v. Maintenance of quadrantwise tooth shedding

time table
vi. Check-up for oral habits and habit breaking
appliance if necessary
vii. Occlusal equilibriation if there are any occlusal
A. Preventive Orthodontics viii. Prevention of damage to occlusion, e.g.
milwaukee braces
It is that part of orthodontic practice which is
ix. Extraction of supernumerary teeth
concerned with the patients and parents education,
x. Space maintenance
supervision of the growth and development of the
xi. Management of deeply locked first permanent
dentition and the craniofacial structures, the diagnostic
procedure undertaken to predict the appearance of
xii. Management of abnormal frenal attachment.
malocclusion and the treatment procedures instituted
to prevent the onset of malocclusion.
Interceptive Orthodontics
The following are some of the procedures
undertaken in preventive orthodontics: Definition
i. Parent education
Interceptive orthodontics has been defined as that
ii. Caries control
phase of the science and art of orthodontics employed
iii. Care of deciduous dentition.
to recognize and eliminate potential irregularities and
iv. Management of ankylosed teeth (Fig. 17.3)
malpositions of the developing dentofacial complex.
The procedures undertaken in interceptive
orthodontics include:
Serial extraction (Figs 17.4 and 17.5)
Correction of developing crossbites
Control of abnormal habits

Fig. 17.3: Ankylosis of 1st primary molar, very significant

Treatment Planning and Management of Orthodontic Problems 175


Figs 17.4A and B: Dewels method of serial extraction Figs 17.4C and D: Dewels method of serial extraction
(A) Step one extraction of deciduous canines to create (C) Step threeExtraction of the erupting first premolars to
space for the alignment of the incisors (B) Step two permit the permanent canines to erupt (D) Serial extraction
extraction of deciduous first molars to accelerate the eruption completed
of first premolars
176 Essentials of Pediatric Dentistry

Figs 17.5A and B: Tweeds method of serial extraction

(A) Step oneExtraction of deciduous first molar (B) Step twoExtraction of deciduous canine and first premolar

Space regaining Introduction

Muscle exercises According to Angles classification, class II
Interception of skeletal malrelation malocclusion indicates that the mandibular arch is in
Removal of soft tissue or bony barrier to enable a distal relation that of the maxilla.
eruption of teeth.
It occurs in two main forms
b. Class II, division 2
CLASS I MALOCCLUSION The only similarity that both these forms exhibit
See Figures 17.6 and 17.7 is the class II molar relation.
Treatment Planning and Management of Orthodontic Problems 177

Figs 17.8A and B: Study models of class II division 1 in

the mixed dentition

The classical feature of class II division 1

malocclusion is the presence of proclined maxillary
Fig. 17.6: Supraeruption into edentulous space anteriors with resultant increased overjet (Fig.
in primary dentition
Patient exhibits
Increased overbite and excessive curve of
Have a short hypotonic upper lip; also patient
place lower lip against palatal surface of the
upper incisors this is called lip trap.
Patient lack an anterior lip seal due to the short
upper lip.
Narrow upper arch which predisposes to
posterior crossbite.

Skeletal Features
Fig. 17.7: Class I occlusion in the mixed dentition
A class II malocclusion may be complicated by the
presence of abnormal skeletal relationship of the
Class II Division 1 Malocclusion maxilla and the mandible. The abnormal skeletal
Features features most often found are:
Maxillary protrusion
The patient exhibits a class II molar relation (Disto- Mandibular retrusion
buccal cusp of the upper first permanent molar Maxillary protrusion and mandibular retrusion.
occludes in the buccal groove of the lower first
permanent molar (Fig. 17.8). Treatment of Skeletal Class II Malocclusion
The molar relation can vary from an end on There are three basic approaches to the treatment of
molar to one that is a full-fledged class II. class II division 1 malocclusion they are (Fig. 17.9):
178 Essentials of Pediatric Dentistry

Growth Modification
Most often maxillary prognathism or mandibular
deficiency occurs; these abnormal skeletal patterns can
be intercepted by means of functional and orthopedic
appliances to reduce the severity of the skeletal

Correction of Mandibular Deficiency

Class II malocclusion complicated by mandibular
deficiency or retrognathism is treated during the mixed
dentition period by use of myofunctional appliances
such as activator or functional regulator.
In case the patient is at the end of the growth period
fixed appliances like Herbst appliance or Jasper
Jumper is indicated.

Correction of Maxillary Prognathism

Class II malocclusion exhibiting maxillary
prognathism can be intercepted by the use of face bow
with headgear to restrict further maxillary growth.

Both Maxillary Prognathism as well as

Mandibular Deficiency
In such patients an appliance such as activator with
head- gear is used to restrict maxillary growth and
promote mandibular growth.
Figs 17.9A to C: Sequence of event leading to a
spontaneous correction of a sagittal malocclusion. (A) Pre-
treatmentthe patient has excessive overjet and an end-to- Camouflage
end molar relationship. (B) The placement of the appliance
immediately creates a downward rotation of the position of Patients too old for successful growth modification
the mandible because of the posterior occlusal acrylic. During using myofunctional appliancesin patients who are
the treatment, an intrusive (and slightly protrusive) force is beyond growth period, it is not possible to undertake
produced on the skeletal and dental structures of a maxilla.
(C) During the post-expansion period, the upper dental arch
growth modification procedures.
has been widened. The lower jaw often is postured forward Thus, the underlying skeletal discrepancy can be
to achieve a more stable occlusal relationship camouflaged by orthodontic tooth movement; this is
Treatment Planning and Management of Orthodontic Problems 179

often done by extraction of certain teeth and moving retroclined upper centrals that are overlapped by the
the rest of the teeth into space created. lateral incisors (Fig. 17.10A).
Concept implies that major skeletal changes are
not possible after the cessation of growth. Features

Illustrations Molars in distoocclusion (Fig. 17.10B)

Retroclined central incisors and rarely of other
In case of a well-aligned lower arch with a class II
molar relation with excellent intercuspation, it is anteriors as well.
possible to reduce the overjet and obtain stable results Deep overbite (Fig. 17.10C)
by extracting first premolars only in the upper arch. Pleasing straight profile
Orthodontic camouflage may also be done in some Broad square face
patients by distal driving of the maxillary molars. This Backward path of closure
is done in mild class II malocclusion prior to eruption Deep mentolabial sulcus
of second molars.
Absence of abnormal muscle activity.
Surgical CorrectionOrthognathic Surgeries
Treatment of Class II Division 2
In patients exhibiting severe skeletal malrelationship, Malocclusion
surgery may be the ideal treatment modality.
Based on the underlying skeletal pattern a The deep anterior overbite and retrocliniation that is
maxillary set back or a mandibular advancement is characteristic of division 2 malocclusion is treated
undertaken after the completion of growth. by
Correction of Deep Bite and Crossbite Reduction in incisal overbite: The deep overbite
Class II malocclusion may be associated with anterior is reduced by use of anterior bite plane or fixed
deep bite; this can be treated by following ways appliances incorporating anchor bends or reverse
Use of removable anterior bite planes to encourage curve of Spee.
vertical development of the posterior dentoalveolar Alteration of incisal inclination: The incisor
segment (Fig. 17.21). inclination often necessitates the use of torquing
Use of fixed appliances to intrude the upper and
springs to move the upper incisor roots lingually
lower anteriors.
and the crowns buccally.
Class II Division 2 Malocclusion (Fig. 17.10) Role of functional appliances: During the mixed
dentition period, it is possible to procline the
The class II, division 2 malocclusion is a condition
maxillary incisors thereby converting a class II,
characterised by a class II molar relationship with
division 2 into a malocclusion that resembles class
180 Essentials of Pediatric Dentistry

II division I and then followed by Frankels

appliance used in treatment of class II division 1


According to Angle a class III molar relationship refers
to a condition where the mesiobuccal cusp of the upper
first molar occludes between the mandibular first and
Fig. 17.10A: Retroclined upper centrals second molars (Figs 17.11 and 17.12).

Fig. 17.11: Class III (mesio step) occlusion in the

Fig. 17.10B: Molars in distoocclusion primary dentition. Difficult to see

Fig. 17.10C: Deep overbite Fig. 17.12: Moderate lower anterior crowding in
Figs 17.10A to C: Models of class II division 2 patients late mixed dentition
Treatment Planning and Management of Orthodontic Problems 181

The patient has a class III molar relationship.
The incisors may be in an edge-to-edge
relationship or an anterior crossbite may occur; it
is not uncommon to find a normal incisal
relationship (Figs 17.13 and 17.14).

Fig. 17.15: Deep dental bite in the mixed dentition

Fig. 17.13: Class III, anterior crossbite Upper arch is frequently narrow and short and
lower arch is broad leads to posterior crossbites
which is a common feature of class III
Upper arch (Maxillary) teeth are usually crowded
and mandibular teeth are spaced.
Vertical growers exhibiting an increased
intermaxillary height may have an anterior open
bite. In some patients a deep overbite may occur
(Fig. 17.15).
Pseudo class III malocclusion: A type of class III
malocclusion characterised by the presence of
occlusal prematurities resulting in a habitual
Fig. 17.14: Anterior crossbite forward positioning of the mandible.
182 Essentials of Pediatric Dentistry

Skeletal Features (Fig. 17.16)

A short or retrognathic maxilla
A long or prognathic mandible
A combination of the above.

Fig. 17.16: Enamel decalcification due to poor

oral hygiene during orthodontic treatment

Treatment of Class III Malocclusion

(Fig. 17.17)

Interception During Growth

Class III malocclusion with an underlying skeletal Figs 17.17A to E: Band seating sequence: (A) Select tight
malrelationship require early treatment to intercept the band size (B) Use band seater with finger pressure or have
developing skeletal malocclusion. patient bite on the instrument... be careful! (C) Band seats
The following are some of growth modulation beneath marginal ridge (D) Adapt band with adaptation
instrument (E) Band removing plier
Frankel III, a myofunctional appliance can be used
during growth to intercept class III malocclusion
due to maxillary skeletal retrusion. Anterior Crossbite
Reverse activator Mild anterior crossbites can be treated using lower
Chin cup with high pull headgear is used to anterior inclined planes or removable appliances
intercept class III malocclusion due to mandibular incorporating screws designed for anterior expansion.
prognathism (Figs 17.18 and 17.25).
Severe class III malocclusions that are a result of Posterior Crossbite
maxillary retrusion can be treated by reverse
headgear (or face mask) to protract the maxilla The posterior crossbite can be treated by rapid
(Fig. 17.19). maxillary expansion (Fig. 17.20).
Treatment Planning and Management of Orthodontic Problems 183

Figs 17.18A and B: Headgear (A) Straight-pull headgear with J hooks. (B) High-pull headgear with J hooks

Figs 17.19A and B: The orthopedic facial mask of petit (A) lateral view. (B) Frontal view; The appliance, best used in
patients in early mixed dentition; is worn on a full-time basis for about 6 months, after which it can be worn on a night-time
basis as a retention appliance
184 Essentials of Pediatric Dentistry

Figs 17.20A and B: (A) An acrylic splint RME appliance that is bonded to the maxillary primary molars and the permanent
first molars. The occlusal coverage of acrylic produces a posterior bite block effect on the vertical dimension. (B) Maxillary
transpalatal width, as measured at the intersection of the lingual groove with the gingival margin; the distance is used as an
indicator of maxillary bony base development

Role of Extractions Treatment of Pseudo Class III Malocclusion

Class III malocclusion characterized by lower arch Remove occlusal prematurities.
length deficiency and anterior crossbite can be treated
by extracting lower first premolars followed by fixed VERTICAL PLANE MALOCCLUSION
mechanotherapy including the use of class III
intermaxillary elastics.
Treatment of Severe Class III After Growth Graber has defined deep bite as a condition of
Completion: Orthognathic surgeries excessive overbite, where the vertical measurement
between the maxillary and mandibular incisal margins
Note: This treatment option is not used in child patient
in excessive when the mandible is brought into habitual
Class III due to maxillary deficiency: Treated by or centric occlusion.
maxillary advancement procedures such as LeFort
TypeDeep bite can be broadly classified into two
- I osteotomy. types
Class III due to mandibular prognathism: Treated
a. Skeletal deep bite
by mandibular set back procedures. b. Dental deep bite.
Treatment Planning and Management of Orthodontic Problems 185

Figs 17.21A and B: Anterior bite plane (A) A clearance of 1.5-2 mm should
exist between the upper and lower posterior teeth. (B) Anterior bite plane

Features These patients have excessive curve of Spee.

The interocclusal clearance is usually normal
Skeletal Deep Bite
as the molars are fully erupted.
Patients exhibit a horizontal growth pattern. Infraocclusion of molars
The anterior facial height is reduced. Causes of infraocclusion
A reduced interocclusal clearance (free way space). Premature loss of posterior teeth.
A cephalometric examination reveals that most of The presence of a lateral tongue posture
the horizontal cephalometric planes such as prevent the molars from erupting to their
mandibular plane, FH plane, SN plane, etc. are normal occlusal level.
parallel to each other.
Treatment of Deep Bite
Dental Deep Bite
Deep bites can be treated using removable, fixed or
Dental deep bites occurs due to myofunctional appliances
Over-eruption of anteriorsDental deep bite
associated with over-eruption of lower incisors is Removable Appliances
usually seen in class II malocclusion.
Note: In class II malocclusion due to presence of Anterior Bite Plane (Fig. 17.21B)
an increased overjet allows the lower incisors to It is a modified Hawleys appliance with a flat
over-erupt until they meet the palatal mucosa. ledge of acrylic behind the upper anteriors.
186 Essentials of Pediatric Dentistry

When the patient bites, the mandibular incisors Use of utility arches:
contact the bite plane thus disoccluding the Utility arches are arch wires that are bent in
posteriors which are free to erupt. such away that they bypass the buccal segment
The height of the anterior bite plane should be just and are engaged on the incisors (Fig. 17.22C).
enough to separate the posteriors by 1.5 to 2 mm They are activated by giving a V bend in the
(Fig. 17.21A). buccal segment of the wire so as to produce a
The anterior bite plane consists of Adam's clasp intrusive force on the anteriors (Fig. 17.22D).
on the molar which help in retaining the appliance.
A labial bow is also incorporated to counter any Myofunctional Appliances
forward component of force on the upper anteriors.
Deep bites which are due to infraocclusion of
molars can be treated by an activator designed and
Fixed Appliances
trimmed to allow the extrusion of these teeth.
Fixed orthodontic appliances can be used to intrude The interocclusal acrylic is trimmed gradually to
the anteriors. encourage the eruption of the posterior teeth.

Methods Used in Fixed Appliances OPEN BITE

Use of anchorage bends (Fig. 17.22A) Introduction
Anchorage bends are given in the arch wire
mesial to the molar tubes so that the anterior Open bite is a malocclusion that occurs in vertical
part of the arch wire lies gingival to the bracket plane, characterized by lack of vertical overlap
slot. between the maxillary and mandibular dentition.
When these arch wires are pulled occlusally
and engaged into the brackets, a gingivally Types
directed intrusive force is exerted on the I. Anterior open bite can be classified as
incisors which reduces the deep bite. a. Skeletal anterior open bite
Use of arch wires with reverse curve of Spee b. Dental anterior open bite
(Fig. 17.22B) II. Posterior open bite
Rsilient arch wires that have been curved in
direction opposite to that of the curve of Spee Anterior Open Bite
can be used to intrude anteriors.
When these arch wires are inserted into the Definition: Anterior open bite is a condition where
molar tubes, the anterior segment curves there is no vertical overlap between the upper and
gingivally. lower anteriors.
Treatment Planning and Management of Orthodontic Problems 187

Figs 17.22A to D: (A) Anchorage bend for intrusion of anterior teeth (B) Arch wire with reverse curve of Spee,
(C) Utility arch used for intrusion of anteriors and (D) V bend given for activation of utility arch for anterior intrusion

Causes Features
Prolonged thumb sucking habit. Skeletal Anterior Open Bite
Tongue thrusting is also implicated for some cases Increased lower anterior facial height.
of open bite. Increased anterior and decreased posterior facial
Also possible etiologic factor is nasopharyngeal height.
airway obstruction and associated mouth Decreased upper anterior facial height.
breathing. Small mandibular body and ramus.
Inherited factors such as increased tongue size, and A steep mandibular plane angle.
abnormal skeletal growth pattern of the maxilla The patient may have a short upper lip with
and mandible can also be responsible for open bite excessive maxillary incisors exposure.
malocclusion. The patient often has a long and narrow face.
188 Essentials of Pediatric Dentistry

Cephalometric examinationReveals a downward

and forward rotation of the mandible
In some patients, an upward tipping of the
maxillary skeletal base can be observed.
Also feature commonly observed a vertical
maxillary increase.
Dental Anterior Open Bite
Proclined upper anterior teeth.
The upper and lower anteriors fail to overlap each
other resulting in a space between the maxillary
and mandibular anteriors.
The patient may have a narrow maxillary arch due
to lowered tongue posture due to a habit.

Interception of Oral Habits: By use of passive Figs 17.23A to E: Crossbites in the transverse plane
habit breaking appliances. (A) Normal transverse relation (B) Unilateral crossbite
(C) Bilateral crossbite (D) Buccal non-occlusion (E) Lingual
The habit breaker can be either a removable or
fixed type of crib.
Myofunctional Therapy: Skeletal anterior open
bites can be treated during growth using Posterior Open Bite
Functional regulatorFrankel regulator IV or
a modified activator. Definition- Posterior open bite is a condition
characterized by lack of contact between the posteriors
These appliances incorporate bite blocks
when the teeth are in centric occlusion.
interposed between the posterior teeth, that have
an intrusive action on the upper and lower posterior
Orthodontic Therapy: Mild to moderate open bites Mechanical interference with eruption
can be successfully managed using fixed mechano- Failure of the eruptive mechanism of the tooth.
therapy in conjunction with box elastics.
This type of elastic is structured to extend Treatment
between the upper and lower anteriors; this brings Interception of lateral tongue thrust by use of
about extrusion of the upper and lower anteriors. lateral tongue spikes incorporated in appliance.
Surgical Correction: Not done in child patient. The posteriors can be forcefully extruded.
Treatment Planning and Management of Orthodontic Problems 189


CROSSBITE This refers to an abnormal transverse relationship

between upper and lower posterior teeth.
Graber defined crossbite as a condition where one or Skeletal Crossbite
more teeth may be abnormally malposed buccally or This is a condition associated with a discrepancy in
lingually or labially with reference to the opposing the size of the maxilla and the mandible (Defective
tooth or teeth (as shown classified in Flow charts 17.1 Embryological Development)
and 17.2).
Due to the presence of malposed teeth in any of Dental Crossbite
the quadrant of single or both arch results in bilateral,
unilateral, buccal nonocclusion and or lingual This is a localized condition where one or more teeth
nonocclusion varieties of crossbites (Fig. 17.23). are abnormally related to that of opposing arch.
Functional Crossbite
Flow chart 17.1
Habitual forward positioning of mandible due to
presence of occlusal interference leads to functional
anterior crossbite.

Retained deciduous tooth causes abnormal
deflection of erupting successor causing single
tooth anterior crossbite.
As a result of arch length-tooth material
discrepancies various dental crossbites results.
Flowchart 17.2
Presence of habits such as thumb sucking and
mouth breathing can cause lowered tongue position
so; the tongue now no longer balances the force
exerted by the buccal group of musculature leading
to development of posterior crossbite.
Definitions of Different Crossbites Retarded development of maxilla and mandible
in any of three planes.
Anterior Crossbite IllustrationRetarded growth of maxilla in
Is defined as a malocclusion resulting from the lingual transverse as well as sagittal plane produces
position of the maxillary anterior teeth in relationship crossbites in anterior as well as posterior region.
with the mandibular anterior teeth. Cleft palate patients.
190 Essentials of Pediatric Dentistry

Decreased growth stimulation in the mid-palatal Catlan's appliance or lower anterior inclined plane
suture Use of double cantilever spring (Z spring)
Unilateral hypo or hyperplastic growth of any of Treating skeletal anterior crossbite during growth
the jaws can cause crossbite. period by use of
Reverse head gear: In cases where cause of
Treatment anterior crossbite is retrognathic maxilla.
Chincup: In cases where cause of anterior cross
Anterior Crossbite
bite is prognathic mandible (Figs 17.24 and
Use of tongue blade 17.25).

Figs 17.24A and B: The Vertical pull chin cup. (A) Unitek design. (B) Summit design

Figs 17.25A and B: The occipital pull chin cup. (A) Soft elastic appliance. (B) Interlandi type headgear
Treatment Planning and Management of Orthodontic Problems 191

e. Multi looped archwires (fixed appliance therapy)

Posterior Crossbite
Crossbite elastics
Coffin spring
Quad helix
Rapid maxillary expansionHyrax appliance
Split acrylic removable plates using jack screw
Fig. 17.26: Fixed mandibular bonded retainer Fixed appliance therapy (Fig. 17.26).
Behavior Management

INTRODUCTION emotionally compromised; this is not a large group

of children, but they do exist.
An aspect of the dental treatment of children seems to
Dental procedures, as well as many other
be predictive of those who can work with children and
challenges of life, are difficult for these children
those who cannot; this aspect is experience.
to endure because of their psychological or
Dental students and young practitioners may be
emotional problems. It is important to realize that
discouraged by the anxiety they feel and the insecurity a psychological or emotional disorder may go
they experience when certain children start to undiagnosed.
misbehave. However, with time and dedication to the
techniques taught in dental school, a practitioners Category II : Shy and Introverted Child
skills in managing child patients become refined; and
with this refinement comes self-confidence in this area The second group is the largest group of shy
of dentistry. birds. These are introverted, poorly socialized
children who are afraid of the social challenges
MISBEHAVING CHILD DENTAL PATIENTS associated with going to the dentist.
The best management technique with these
The four categories of misbehaving children have been children is to break the barriers of shyness with
outlined based on the relative frequency with which a friendship.
dentist encounters them.
Category III : Frightened Child
Category I : Emotionally Compromised
The third group is composed of children who have a
hard time with dentistry because they are frightened
This first group includes special children who are [fear of needles accounts for 90% of the cases].
Behavior Management 193


Another group of misbehaving children is those
who do not like authority. Table 18.1 : Wilsons classification
These children dont like dental appointments, and Normal or bold : The child is brave
their dislike is based on an aversion of complying enough to face new
with adult directives. situations is co-
operative, and friendly
with the dentist
DEFINITIONS Tasteful or timid : The child is shy, but
does not interfere with
Behavioral Pedodontics
the dental procedures
It is study of science which helps to understand Hysterical or rebellious : Child is influenced by
development of fear, anxiety and anger as it applies to home environment.
Throws tempertantrums
child in dental treatment.
and is rebellious
Nervous or fearful : The child is tense and
Behavior Management anxious, feared of
This is defined as the means by which the dental health dentistry
team effectively and efficiently performs dental
treatment and thereby instills a positive dental attitude. Table 18.2 : Frankels classification
(Frankels behavior rating scale)
Behavior Modification Rating Behavior
Definitely negative ( ) Refuses treatment, cries
This is defined as the attempt to alter human behavior forcefully, extremely
and emotion in a beneficial way and in accordance negative behavior asso-
with the laws of learning. ciated with fear
Negative () Reluctant to accept
Behavior Shaping treatment and displays
evidence of slight nega-
This is the procedure which slowly develops behavior tivism
by reinforcing a successive approximation of the Positive (+) Accepts treatment, but if
desired behavior until the desired behavior comes into the child has a bad
being. (Contd...)
194 Essentials of Pediatric Dentistry

(Contd...) (Contd...)
experience during treat- Timid behavior/shy
ment, may become Usually seen in overprotective child at the first
Definitely positive (++) Unique behavior, looks
forward to and under- Is shy but cooperative.
stands the importance of Whining type
good preventive care Complaining type of behavior allows for treatment
but complains throughout the procedure.
Table 18.3: Wrights classification Stoic behavior
(A) Cooperative (Positive behavior) Seen in physically abused children; they are co-
Cooperative Behavior: Child is cooperative; operative and passively accept all treatment without
relaxed with minimal apprehension any facial expression.
Lacking Cooperative Ability: Usually seen in
young child (0-3 years), disabled child, physical Table 18.4: Lampshire
and mental handicap
Potentially Cooperative: It has the potential to Cooperative: The child is physically and emotionally
cooperate, but because of the inherent fears relaxed. Is cooperative throughout the entire
(subjective/objective) the child does not procedure.
cooperate Tense cooperative: The child is tensed, and
(B) Uncooperative (Negative behavior) cooperative at the same time.
Uncontrolled/hysterical/incorrigible usually seen in Outwardly apprehensive: Avoids treatment initially,
Preschool children at their first dental visit. usually hides behind mother; eventually accepts
Temper tantrums, i.e. physical lashing out of legs dental treatment.
and arms, loud crying and refuses to cooperate with Fearful: Requires considerable support so as to
the dentist. overcome the fears of dental treatment.
Defiant behavior/obstinate behavior
Stubborn/defiant: Passively resists treatment by using
This type can be seen in any age group.
techniques that have been successful in other
Usually in spoilt or stubborn children.
These children can be made cooperative.
Tense cooperative Hypermotive: The child is actually agitated and
These children are the borderline between positive resorts to screaming, nicking, etc.
and negative behavior. Handicapped: Physically/mentally, emotionally
Does not resist treatment but the child is tensed at handicapped.
mind. Emotionally immature.
Behavior Management 195

Pain A harmful stimulus which signals current or

impending tissue damage.
Sterback defines pain as an abstract concept which
A pattern of responses which operate to protect
refers to:
the organism from harm.
A personal, private sensation of hurt.

Methods for observing, analyzing, and predicting behavior of child patient

196 Essentials of Pediatric Dentistry

APPROACHES OF BEHAVIOR Systematic : Reducing anxiety by first

MANAGEMENT desensitization presenting an object or situa-
tion that evokes little fear, then
To manage pain and anxiety of child patient
progressively introducing
Nonpharmacological approach
stimuli that are more fear
Various behavior management techniques
Communication : Use of verbal and nonverbal
Pharmacological approach
communication to promote
Local anesthesia.
positive behavior in children:
Relative analgesia
Oral or rectal sedation
Show interest in the child as
Intravenous sedation
an individual
General anesthesia.
Share free information
Give well-stated instru-
Various behavior management techniques Communicate at the childs
Tell-show-do : Informing then demonstrating, level
and finally performing part of Focus on the positive
a procedure. Show ethnic, cultural and
Playful humour : Using fun labels and suggesting gender sensitivity.
use of imagination. Reduction of A positive relationship
Distraction : Ignoring and then directing maternal anxiety between increased anxiety of
attention away from a behavior, the mother and negative
thought or feeling to something behavior of the child.
else. Attempts by the dentist
Positive : Tangible or social reward in should be made to reduce the
reinforcement response to a desired behavior. maternal anxiety prior to the
Modeling : Providing an example or childs first dental clinic
demonstration about how to do. visit.
Shaping : Successive approximations to
a desired behavior. Dental Child Patient Management by
Fading : Providing external means to Domain
promote positive behavior and
then gradually removing the There are five basic domains for securing the
external control. cooperation of children during the dental experience.
Behavior Management 197

Physical Domain Reward-oriented Domain

The physical domain has proven to be useful in treating Reward can be used to secure the cooperation of child.
emergencies on hysterical children and children who Note: Parents must not promise things like ice-cream
cannot be reached in language because of their age. or toys as a reward for going to the dentist before the
The physical domain ranges from the use of hand dental appointment. The child may misread the
restraint by a dental assistant to the use of tools intention of parents concluding that dental appointment
such as would be difficult.
Papoose board.
Pedi-wrap Linguistic Domain
Tape, sheets with tape Linguistic techniques are those communication
Cloth wraps and belts techniques that involve the conversation of the
Mouth props. dentist with the child and the child with the dentist.
The use of methods in the physical domain necessi- The linguistic domain demands that the dentist be
tates explanations to parents, guardians, or a communicator. The dentist will be a teacher, a
caretakers. coach, a rewarder, a psychologist, a distracter and
Illustration an authority figure when using linguistic
The use of a papoose board on a normal child demands
Local Anesthesia
Pharmacological Domain
Successful local anesthesia depends on
This domain include modalities as safe and easy to
Communication with the child.
deliver as nitrous oxide/oxygen to the profound Good topical anesthesia, allowing adequate
management provided by general anesthesia in a time for it to act.
hospital setting. The smaller the child, the more Slow injection of warm solution.
dramatic the danger; again this domain requires Avoid direct palatal injectionsInject through
parental understanding about the techniques. the interdental papilla after adequate buccal
Aversive Domain 2 percent lignocaine = 20 mg/ml
2.2 ml/carpule = 44 mg/carpule
A technique can be described as aversive if use of the A 20 kg child (approximately 5-year-old) can tolerate
technique on a child is objectionable enough that the a maximum dose of 2 percent lignocaine with
child will cooperate in order to avoid the technique. vasoconstrictor of :
Hand-over-mouth exercise (HOME) is regarded 7 mg/kg 20 kg = 140 mg equivalent of 3 carpules
as aversive technique. (6.6 ml).
198 Essentials of Pediatric Dentistry

Upper airways obstructions
Children with psychoses
Obstructive pulmonary disease

Conscious Sedation
The term conscious sedation is often used where
verbal communication is maintained with the child as
an indicator of an adequate level of consciousness and
maintenance of protective reflexes. In reality,
conscious sedation, deep sedation and general
anesthesia are a continuum, and it is very easy to
proceed from one level to another, especially using
intravenous medications.
It is essential in this situation to use appropriate
monitoring such as pulse oximetry, and personnel and
Relative Analgesia (Nitrous Oxide Sedation) resuscitation equipment should be available.

Nitrous oxide sedation is of great benefit in reliving Pharmacological Agents may be

anxiety. It works well on children who are anxious but Administered Orally, Nasally or Rectally
cooperative. An uncooperative child will often not If facilities for general anaesthesia are not available,
allow the mask to be placed over the nose. It also the following agents may be used beneficially.
requires a child of sufficient age to understand what is
happening during the procedure. Midazolam (Short-acting benzodiazepine)
A trial appointment in order to estimate the correct Oral or rectal0.2-0.5 mg/kg.
dosage is beneficial. The use of nitrous oxide sedation Intranasal0.25 mg/kg
undoubtedly offers the clinician working with children Intravenous0.05-0.2 mg/kg.
a very safe and relatively easy-to-use adjunct to clinical Diazepam (long-acting benzodiazepine)
care. Intravenously, rectally or orally0.25 to 0.5 mg/kg.
The long-term objective in using relative analgesia Fentanyl: A narcotic for short procedures, such as the
is to not have to use it at all ! Through careful and extraction of a single tooth or suturing of a laceration,
thoughtful behavior management its use can eventually fentanyl may be useful analgesic.
cease, leaving a cooperative child patient coping well Intravenous: 0.5-1 g/kg.
with their dental care.
Behavior Management 199

General Anesthesia as possible; this must be avoided because it is

Nonemergency general anesthesia usually for the parents convinence, not the
The need for general anesthesia represents the childs benefit the child must have a sensible
clinician's final solution to a child's dental problem. treatment plan arranged.
In most instances, a caring attitude in association After seeing the child several times, the clinician
with a period of familiarization will allow the child feels that the child needs dental work but is if
to be treated conservatively. manageable a general anesthetic should be considered.
The clinician must be certain about the need for
the dental work that is planned; when deciding to Consent for Treatment
use a general anesthetic, the clinician must look at
the whole picture Consent for Children less than 14-year-old
A. What is the dental condition? In children under 14 years of age a consent of minor
Is there gross dental caries? form is completed. The parents or guardian must sign
B. Does the child has a facial swelling? the form and a third party, usually the dentist, must
Is the child in pain? witness the signature.
C. Is the treatment absolutely necessary?
D. Could the patient be managed more Consent of Children 14-16 Years of Age
Has the child undergone a period of Children aged 14-16 years must give their consent for
familiarization? the treatment to be performed. A "responsible informed
Has there been a history of emotional child" can give this consent.
trauma associated with the dental
environment? Consent Over 16 Years
Certain clinical situations automatically indicate the A patient aged 16 years and over must consent for
need of a general anesthesia
their own treatment and a consent for adult form used.
Multiple carious and abscessed teeth in very young
Basics in Managing Children in the Dental
Severe facial cellulitis
Facial trauma
Often it is necessary for the patient to have Preappointment Experience
several routine visits before the clinician can
be sure that the dental work needs to be done, The preappointment experience entails bringing
such visits allows assessment of whether the the child to the dental office for a tour and
child's behavior precludes satisfactory orientation. The child is made aware beforehand
completion of the work. that absolutely nothing will be done that day.
In many instances, parents prevail upon the The child meets the receptionist, dental assistant
clinician to arrange general anaesthesia as soon and dentist, if things go well certain dental
200 Essentials of Pediatric Dentistry

equipments can be shown and explained in such a Okay, John, please open your mouth for me.
way Thank you.
Mr Wind and Mr Water for the Triplex or
Mr Buzzer for the handpiece. Voice Control
The preappointment experience provides two Voice control requires the dentist to interact more
offerings that make it powerful for the dentist as authority into his or her communication with
First, it eliminates for the child any unfavourable the child.
imagining as to the realities of the dental office and its The tone of voice is important; it must have an I
personnel. am in charge here. The facial expression of the
Secondly, linguistically, the experience sets up a greater dentist must also mirror this attitude of confidence.
likelihood that the requests of the dentist at the first Voice control is a useful way of reframing a request
real appointment will be objectively dealt with by that has been refused by the child.
appropriate promises of action by the child. As a purely linguistic technique, voice control
relies on tonality, cadence, and other aspects of
Tell-Show-Do the quality of the dentist's communication with the
The tell-show-do method is the backbone of the
educational phase of developing an accepting Hand-Over-Mouth Exercise (HOME)
relaxed child dental patient.
The technique dictates that before doing anything The HOME technique calls for the dentist to place
(except the injection of a local anaesthetic or other a hand over the mouth of a hysterically crying
procedures that defy explanation; such as pulp child; it is used to intercept tantrums or other fits of
extirpation), the child be told what will be done rage; it has to paired with voice control (Fig. 18.1).
and then shown by some sort of stimulation exactly
what will happen before the procedure is started.

John; I am going to clean your teeth with this special
dental toothbrush (prophy angle and rubber cup). You
see this soft rubber cup?
Well, when I step on this gas pedal this cup turns;
and when it is full of tooth paste it can really make
your teeth shine.
Now, John, pinch the cup and you will see how
soft it is. Now, let me run it on your fingernail so you
can feel how it works. Fig. 18.1: Hand-over-mouth exercise
Behavior Management 201

The technique is not intended to scare the child; it assistant, or stabilization of a shoulder by a dentist as
is intended to get the child's attention and quiet a child starts to roll over.
the child so that he or she can hear the dentist what
the dentist is saying? Ontologic Coaching
Obviously, it reframes the seriousness of a previous Physical restraining when paired with language,
request. The practice of HOME requires informed becomes part of the entire linguistic management of
consent. the child this is called ontologic coaching.
Contraindications to this technique
Praise and Communication
Disabled, immature, or medicated children whose
understanding of the desires of the dentist is Praise and communication are self-explanatory. All
compromised. people, including children, react favourably to praise;
Prevention of the child from breathing is a second furthermore, effective dentistry for children means
basic contraindication. effective communication of the dentist with the child
and vice versa. Both allow for distraction of the
Physical Restraint anxious child language obviously needs to be age
Physical restraint is its own domain, however, the Praise and effective communication combined with
touching of a childs hands during the injection tell-show-do form an unbeatable linguistic combin-
procedure by a dental assistant, stabilization of a leg ation for managing the dental experience for the
that was starting to lift from the chair by a dental majority of children three years or older.
Care of Special Child
(Handicapped Child)


The World Health Organization has defined a
von Willebrand
handicapped person as one who over an appreciable disease
period is prevented by physical or mental conditions 3. Metabolic disorder Diabetes mellitus
from full participation in the normal activities of their 4. Malignant disorder Leukemia
age groups including those of a social, recreational, 5. Congenital defects Congenital heart
educational and vocational nature. diseases
Cleft lip and palate
CLASSIFICATIONS 6. Mentally handicapped Mental
A. Frank and Winter classified handicapped as
7. Communication Deafness
Blind or partially sighted
disorders Blindness
Deaf or partially deaf Autism
Educationally subnormal 8. Osseous disorders Rickets
Epileptic Osteopetrosis
Maladjusted 9. Physically handicapped Poliomyelitis
Physically handicapped Scolosis
Defective of speech Following Nowak Classification : we shall discuss
Senile the following conditions:
B. Nowak classified handicap in nine categories
1. Convulsive disorder Epilepsy
2. Systemic disorders Hypothyroidism Medical problem : Seizure disorder.
Care of Special Child (Handicapped Child) 203

Potential Problem Related to Dental Care Emergency Care

(Follow normal recommendations)
Occurrence of generalized tonic-clonic seizure in
dental office. When the seizure occurs in dental office; the dental
Drug-induced leukopenia and thrombocytopenia chair is lowered to supine position.
(phenytoin, carbamazepine, valproic acid). The dentist has to protect the child from injuring
himself/herself; a mouth prop of rubber or plastic
Prevention of Complications must be inserted into oral cavity to prevent tongue
Identification of epileptic patient by history: biting.
Type of seizure Use of suction is important in preventing aspiration
Age at time of onset of secretions in any case if this is not possible the
Cause of seizures head of child must be turned to the side.
Medications Maintain a patent airway.
Regularity of physician visits Give oxygen.
Degree of control In severe case; where the convulsions do not stop
Frequency of seizures, last seizure within few minutes; then administer diazepam
Precipitating factors. (1 mg/kg) intravenously slowly upto 10 mg.
History of seizure: Related injuries If condition is unmanageable; consult physician
Well-controlled: Provide normal care admit to hospital.
Poorly controlled: Consult with physician : may
require medication change SYSTEMIC DISORDERS
Be alert to adverse effects of anticonvulsants.
Treatment Plan Modification Potential Problem Related to Dental Care
Maintenance of optimum oral hygiene Untreated patients with severe hypothyroidism
Surgical reduction of gingival hyperplasia if exposed to stressful situations such as trauma,
indicated. surgical procedures or infection may develop
Replace missing teeth with fixed prosthesis as hypothyroid (myxoedema) coma.
opposed to removable Untreated hypothyroid patients may be very
Choose metal over porcelain when possible. sensitive to actions of narcotics, barbiturates.

Oral Complications Prevention of Complications

Gingival hyperplasia secondary to phenytoin Detection and referral of patients suspected of

(Dilantin) being hypothyroid for medical evaluation and
Traumatic oral injuries. treatment.
204 Essentials of Pediatric Dentistry

Avoidance of narcotics, barbiturates and Hyperthyroidism (Thyrotoxicosis)

tranquilizers in untreated hypothyroid patients.
Recognition of initial stage of hypothyroid Potential problem related to dental care
(myxedema) coma: Thyrotoxic crisis (thyroid storm) may be
Hypothermia precipitated in untreated or incompletely treated
Bradycardia patients with thyrotoxicosis by:
Hypotension Infection
Epileptic seizures. Trauma
Start immediate treatment of myxoedema coma
Surgical procedures
Seek immediate medical aid
Hydrocortisone (100-300 mg)
Patients with untreated or incompletely treated
CPR as indicated.
thyrotoxicosis may be very sensitive to action of
Treatment Plan Modifications epinephrine and other pressor amines, thus these
agents must not be used; one patient is well-
In hypothyroid patients under good medical
managed from medical stand point; these agents
management, any indicated dental treatment.
can be resumed.
In patients with congenital form of disease and
severe mental retardation, assistance with hygiene Thyrotoxicosis increases risk for hypertension,
procedures may be needed. angina, MI, congestive heart failure, and severe
Oral Complications
Increased in tongue size Prevention of Complications
Delayed eruption of teeth Detection of patients with thyrotoxicosis by history
Malocclusion and examination findings.
Gingival edema. Referral for medical evaluation and treatment.
Avoidance of any dental treatment for patient with
Emergency Care thyrotoxicosis until under good medical control.
Untreated hypothyroid patients However, any acute oral infection will have to be
Control of pain with nonnarcotic analgesics dealt with by antibiotic therapy and other
Avoid precipitation of hypothyroid coma in conservative measures to prevent development of
patients with severe hypothyroidism, thus thyrotoxic crisis; suggest consultation with
avoid surgical procedures and treat acute oral patient's physician during management of acute
infection by conservative measures. oral infection.
Patients under good medical management render Avoidance of epinephrine and other pressor amines
whatever emergency care is indicated. in untreated or incompletely treated patient.
Care of Special Child (Handicapped Child) 205

Recognition of early stages of thyrotoxic crisis 2. Patients under good medical management:
Severe symptoms of thyrotoxicosis Emergency dental care as indicated; however ; if
Febrile problem involves acute infection, consult with
Abdominal pain patient's physician.
Delirious, obtunded or psychotic
Initiate immediate emergency treatment Hemophilia
Seek immediate medical aid Medical problem: Congenital disorders of coagulation.
Cool with cold towels Potential problem related to dental care: Excessive
Hydrocortisone (100-300 mg) bleeding following dental procedures.
Monitor vital signs
Start CPR if needed. Prevention of Complications
1. Identification of patient:
Treatment Plan Modifications
History: Bleeding problems in relatives,
Once under good medical management; patient excessive bleeding following trauma or
may receive any indicated dental treatment. surgery.
If acute infection occurs, physician should be Examination finding
consulted concerning management. Ecchymosis
Oral Complications Dissecting hematomas.
Osteoporosis may occur Screening tests: Prothrombin time (normal)
Periodontal disease may be more progressive Activated partial thromboplastin time
Dental caries may be more extensive (prolonged)
Premature loss of deciduous teeth and early Bleeding time (normal)
eruption of permanent teeth. Thrombin time (normal).
Early jaw development 2. Consultation and referral for diagnosis and
Tumor found in midline of posterior dorsum of treatment and for preparation before dental
tongue must not be surgically removed until procedures.
possibility of functional thyroid tissue has been 3. Replacement Options:
ruled out by 131I uptake test. Cryoprecipitate
Fresh frozen plasma
Emergency Care Factor VIII concentrates.
1. Thyrotoxic patientsConservative treatment: Heat-treated concentrates
Antibiotics for infection, analgesics for pain, Purified factor VIII
consultation with physician. Recombinant factor VIII.
206 Essentials of Pediatric Dentistry

4. Mild and moderate factor VIII deficiency: Avoid aspirin, aspirin-containing compounds and
1-desamino-8-darginine vasopressin NSAIDs-use acetaminophen (Tylenol) with or
(DDAVP) without codeine.
Epsilon-amino caproic acid (EACA)
Tranexamic acid Oral Complications
Fibrin glue Spontaneous bleeding
Factor VIII replacement for some cases. Prolonged bleeding following dental procedures
5. Severe factor VIII deficiency: that injure soft tissue or bone
Agents used in (4) above Petechiae
Higher dose (s) factor VIII Hematomas
6. Stable level of inhibitors: Oral lesions associated with HIV infection in
Agents used in (4) above patient who receive infected replacement products.
Very high dose (s) factor VIII
7. Inducible inhibitors: Emergency Care
No elective surgery
Conservative management of infection and pain,
Agents used in (4) above
if possible, otherwise, patient must be prepared
High doses of porcine factor VIII con- for surgery (cryoprecipitate, fresh frozen plasma,
centrate factor VIII concentrates, desmopressin, epsilon-
Nonactivated prothrombin-complex con- amino-caproic acid, tranexamic acid).
centrate Avoid aspirin, aspirin-containing compounds and
Activated prothrombin-complex con- NSAIDs.
Plasmapheresis von Willebrand's Disease
8. May be treated on outpatient basis depending
on results of consultation (mild to moderate Potential Problem Related to Dental Care:
deficiency; no inhibitors). Excessive bleeding following invasive dental
9. Local measures for control of bleeding splint, procedures.
thrombin, microfibrillar collagen, etc.
10. Prophylactic antibiotics to prevent postoperative Prevention of Complications
infection in surgical cases can be considered.
1. Identification of patients
11. Avoid aspirin, aspirin containing compounds,
History of bleeding problems in relatives and
and NSAIDs.
of excessive bleeding following surgery or
trauma, etc.
Treatment Plan Modification
Examination findings
No dental procedures unless patient has been Petechiae
prepared based on consultation with hematologist. Hematomas
Care of Special Child (Handicapped Child) 207

Screening tests Anemia

Prolonged bleeding time
Iron Deficiency Anemia
Possible prolonged partial thromboplastin
time. Potential Problem Related to Dental Care:
2. Consultation and referral for diagnosis and In rare cases severe leukopenia and thrombocytopenia
treatment and preparation before dental may result in problems like infection and excessive
procedures. loss of blood.
3. Type I and many type II cases.
Prevention of Complications:
Detection and referral for diagnosis and treatment.
Local measures in (6) below.
4. Type III and some type II patients In females most cases will be caused by
Fresh frozen plasma. physiologic process-menstruation or pregnancy.
Cryoprecipitate In males most cases will be secondary to
Special factor VIII concentrates underlying diseasepeptic ulcer, carcinoma of
Local measures in 6 below. colon, etc.
5. Local measures for control of bleeding
Splints G-6-PD Deficiency
Gel foam with thrombin
Oxycel, surgical Potential problem related to dental careAccelerated
6. Prophylactic antibiotics to prevent postoperative hemolysis of red blood cells.
infection in surgical cases can be considered. Prevention of Complications:
7. Avoid aspirin, aspirin-containing compounds, and Control infection.
NSAIDs. Avoid drugs containing certain antibiotics, aspirin,
Treatment Plan Modification acetaminophen.
These patients often have increased sensitivity to
No invasive dental procedures, unless patient has been
prepared based on consultation with hematologist. sulfa drugs, aspirin, chloramphenicol.

Oral complications Treatment Plan Modification: Usually none.

Spontaneous bleeding Oral Complication of G-6-PD Deficiency are Usually
Prolonged bleeding following dental procedures None
that injure soft tissue or bone.
Oral Complications of Iron Deficiency Anemia:
Hematomas. Paresthesis
Loss of papillae from tongue
Emergency care In rare cases infection and bleeding complications
Conservative management of infection and pain, if Patients with dysphagia seem to have increased
possible otherwise patient must be prepared for surgery incidence of carcinoma of oral and pharyngeal area
(fresh frozen plasma or cryoprecipitate). (Plummer-Vinson syndrome).
208 Essentials of Pediatric Dentistry

Emergency Care: Drug considerations:

Iron deficiency anemia: Usually as indicated (white a. Avoid excessive use of barbiturates and
blood cell count and platelet status should be narcotics as suppression of respiratory center
checked) can occur, leading to acidosis, which can
G-6-PD deficiency: As indicated, unless patients precipitate acute crises.
having hemolytic crises; then conservative control b. Avoid excessive use of salicylates as "acidosis"
of pain and infection. may result, again leading to possible acute
crisis; codeine and acetaminophen in moderate
Pernicious Anemia dosage can be used for pain control.
Potential Problem Related to Dental Care: c. Avoid use of general anesthesia, as hypoxia
Infection can lead to precipitation of acute crises.
Bleeding d. Nitrous oxide may be used, provided 50
percent oxygen is supplied at all times; critical
Delayed healing
to avoid diffusion hypoxia at termination of
Prevention of Complication: Detection and medical nitrous oxide administration.
treatment (early detection and treatment can prevent e. For non-surgical procedures use local
permanent neurologic damage) anaesthetic without vasoconstrictor. For
Treatment Plan Modification: None once patient is surgical procedures use 1:100,000 epinephrine
under medical care. in anesthetic solution.
Oral Complications: Paresthesia of oral tissues Aspirate before injecting.
Inject slowly.
(Burning, Tingling, Numbness)
Use no more than two cartridges.
Delayed healing (severe cases), infection, red
Must avoid infection, if infections does occur, treat
tongue, angular cheilosis.
in aggressive manner
Petechial hemorrhages.
Emergency Care:Usually can be rendered without Incise and Drain
complications, in-patient suspected of having Antibiotics
pernicious anemia, suggest conservative treatment Corrective treatment: extraction, pulpectomy,
until medical diagnosis and therapy established. etc.
Avoid dehydration is patients with infection
Sickle Cell Anemia or patient receiving surgical treatment.

Potential Problem Related to Dental Care: Sickle cell Treatment Plan Modifications
Usually none unless symptoms of severe anemia
Prevention of Complications:
Avoidance of any procedure that would produce present, and then only urgent dental needs should be
acidosis or hypoxia. met.
Care of Special Child (Handicapped Child) 209

Oral Complications cerebrovascular accident, renal failure, peripheral

neuropathy, blindness, hypertension, congestive
heart failure).
Loss of trabecular pattern
Delayed eruption of teeth
Prevention of Complications
Hypoplasia of teeth
Pallor of oral mucosa Detection by
Emergency Care Clinical findings
Screening blood glucose level.
As indicated unless crisis present then conservative
Referral for diagnosis and treatment
control of pain (with drugs) and infection (with
antibiotics) Monitor and control hyperglycemia.
Treat infection in aggressive manner Patient receiving insulin prevent insulin reaction
Avoid dehydration Advice eating normal meals before appoint-
Avoid excessive use of barbiturates and narcotics ments
Avoid excessive use of salicylates Schedule appointments in morning
Avoid use of general anesthesia Advice them to inform you of any symptoms
Moderate doses of codeine and acetaminophen can of insulin reaction when they first occur
be used for pain control Have sugar in some form to give in case of
Use only small concentration of epinephrine insulin reaction.
(1:100,000) in local anesthetic Diabetic patients being treated with insulin who
Aspirate before injecting develop oral infection may require increase in
Inject slowly insulin dosage, consult with physician in addition
No more than 2 cartridges. to aggressive local and systemic management of
infection. (Including antibiotic sensitivity testing).
METABOLIC DISORDER Drug considerations
Hypoglycemic agents-on rare occasions
Diabetes Mellitus aplastic anemia, etc.
Potential Problem Related to Dental Care In severe diabetics, avoid general anesthesia.
In uncontrolled diabetic patients Treatment Plan Modifications
Poor wound healing. In well-controlled diabetic patients, no alteration of
In patients treated with insulin, insulin reaction. treatment plan is indicated unless complication of
In diabetic patient, early onset of complications diabetes present such as:
relating to cardiovascular system, eyes, kidneys Hypertension
and nervous system (angina, myocardial infarction, Congestive heart failure
210 Essentials of Pediatric Dentistry

Myocardial infarction Prevention of Complications

Detection and referral for diagnosis and treatment
Renal failure.
Determination of platelet status on day of any
surgical procedure, including scaling of teeth,
Oral Complications:
bleeding time is within normal range, proceed; if
Accelerated periodontal disease not, postpone procedure (platelet count less than
Periodontal abscesses 80,000 mm3)
Xerostomia Avoidance of postoperative infection and osteora-
Poor healing dionecrosis by prophylactic use of antibiotics can
Infection be considered, modification of regimen for
Oral ulcerations prevention of endocarditis can be used following
Candidiasis medical consultation:
Mucormycosis a. Most situations
Numbness, burning, or pain in oral tissues. Give 2 gm penicillin V, orally at least 30
min before procedure.
Emergency Care Give 500 mg penicillin V, orally, every 6
hours for remaining part of appointment
Patients with acute infection; physician should day.
increase insulin dosage if possible, obtain sample b. Give 1 gm of cephalexin 1 hour before
of exudates and have antibiotic sensitivity testing procedure, followed by 250 mg cephalexin,
performed then start penicillin therapy, if clinical every 6 hours for 1 week.
response is poor, laboratory data can be used to c. For patients allergic to penicillin
select more effective antibiotic. Give 300 mg of clindamycin orally 1 hour
Patient with diabetes not under medical treatment- before procedure. 150 mg every 6 hours
referral and consultation is necessary so diabetes for the following 3 to 7 days.
can be brought under control. Give 500mg of erythromycin, orally, every
In general, other emergency problems can be dealt 6 hours for following 25 days.
with as in normal patients. d. Based on special conditions of medical
consultation, other agents, dosage and
MALIGNANT DISORDER durations of treatment may be indicated.

Leukemia Treatment Plan Modifications

Potential Problem Related to Dental Care During acute stages of disease avoidance of dental
care of any kind if at all possible.
Prolonged bleeding When patient is in state of remission, all active
Infection dental disease should be treated and patient placed
Delayed healing. on good oral hygiene maintenance program.
Care of Special Child (Handicapped Child) 211

Avoidance of long, drawn-out dental procedures. Lack of coagulation factor as result of

Complex restorative procedures usually not thrombosis in small vessels.
indicated for patients with poor prognosis. Anticoagulation medication used to prevent
Oral Complications Infection, leukopenia may be present in patients
with right to left shunting of blood.
Infection Congestive heart failure:
Ulceration Infection
Gingival bleeding Cardiac arrest
Ecchymosis Cardiac dysrhythmias
Petechiae Breathing difficulties (caused by pulmonary
Gingival hyperplasia edema)
Soft tissue and osseous lesions
Paresthesiasnumbness, burning, tingling Prevention of Complications
Lymphadenopathy. Detection by history and examination findings.
Referral for medical diagnosis and treatment.
Emergency Care Consultation with physician before any dental
treatment is performed.
Conservative; otherwise antibiotic sensitivity Prophylactic antibiotic coverage before and after
testing should be considered, antibiotics for any dental procedure.
infection, strong analgesics for pain. Prophylactic antibiotic coverage before and after
Drainage through pulp chamber rather than any dental procedure
extraction. Amoxicillin 50 mg/kg : orally 1 hour before
procedure, then half initial dose 6 hours later.
CONGENITAL DEFECTS Children less than 15 kg (33 lb): initial dose,
Congenital Heart Diseases 750 mg amoxicillin.
Children 15 30 kg (33 to 66 lb): initial dose,
Potential Problem Related to Dental Care 1500 mg amoxicillin.
Infective endocarditis Children over 30 kg (66 lb): initial dose 3000
Infective endarteritis mg amoxicillin. Given 1 hour before procedure
Prolonged bleeding following scaling or surgical followed 6 hours later with half initial dose.
procedures, bleeding problem may be present in Child patients allergic to penicillin/
patients with right-to-left shunting of blood caused amoxicillin. Erythromycin ethylsuccinate or
by : stearte 20 mg/kg 1 hour before procedure then
Thrombocytopenia half dose 6 hour after intial dose.
212 Essentials of Pediatric Dentistry

Child patients allergic to penicillin and Emergency Care

intolerant to erythromycin. Clindamycin 10
mg/kg 1 hour before procedure then half dose Asymptomatic patients: As indicated but protect
6 hours after initial dose. against infective endocarditis or endarteritis.
Avoidance of dehydration inpatients with oral Symptomatic patients:
Consultation with physician before any
Bleeding time and prothrombin time tested before
Analgesics for painavoid aspirin, aspirin -
any surgical procedure; consultation with physician containing compounds and NSAIDs, use
if prolonged. acetaminophen with or without codein.
White blood cell count, if very low antibiotics may Antibiotics for infection
be indicated for surgical procedures: consult with Avoidance of dehydration in patient with acute
physician to determine the need. infection
Patient may have bleeding problem, is such
Treatment Plan Modification case surgery should be avoided.

Pulpotomy is contraindicated in these patients Cleft Lip and Palate (Fig. 19.1)
because of the possibility of subsequent Cleft Lip: The abnormalities in cleft lip are the direct
bacteraemias. consequence of disruption of the muscles of the upper
Coordination of treatment, it is often better to treat lip and nasolabial region.
a child with many carious teeth under general Cleft Palate: Cleft palate results in failure of fusion of
anesthesia and complete all the work in one the two palatine shelves. This failure may be confined
session. This removes the need to change to the soft palate alone or involve both hard and soft
antibiotics or to wait 1 month between vistis. If a palate.
child is undergoing anesthesia for other medical When the cleft of the hard palate remains attached
procedures try to coordinate the dental work to be to the nasal septum and vomer the cleft is termed
performed at the same time. incomp-lete.
When the nasal septum and vomer are completely
Vasoconstrictors: There is no contraindication to
separated from the palatine processes the cleft is
the use of vasoconstrictors in local anesthetics. termed complete.

Oral Complications Primary Management

(i) Cynosis blue color
Antenatal Diagnosis
(ii) Polycythemia ruddy color
(iii) Thrombocytopenia small hemorrhages Antenatal diagnosis of cleft lip, whether unilateral
(iv) Leukopenia Infection or bilateral is possible by ultrasound scan after 18
Care of Special Child (Handicapped Child) 213

Fig. 19.1: Cleft lip and palate Fig. 19.2: Upright feeding of baby by customized bottle

weeks of gestation, isolated cleft palate cannot be Surgical Techniques

diagnosed on an antenatal scan. When antenatal There have been many different surgical techniques
diagnosis is confirmed, preferral to a cleft surgeon and sequences advocated in cleft lip and palate
is appropriate for counselling to allay fears. management.
Photographs of cleft lip shown to parents before
Cleft lip repair is commonly performed between 3 and
6 months of age.
Major respiratory obstruction is uncommon and
occur exclusively in babies with Pierre Robin Cleft palate repair is frequently performed between
sequence; Hypoxic episodes during sleep and 6-18 months.
feeding can be life- threatening. The frequently used techniques are
Intermittent airway obstruction is more (A) Rose-Thompson repair
frequent and managed by nursing the baby prone (B) Quadrangular flap repair
with the use of customized bottle (Fig. 19.2). (C) Triangular flap repair (Tennison Randall)
More severe and persistent airway compromise can (D) Rotation-advancement repair (Millard)
be managed by retained nasopharyngeal (E) Mohler modification of rotation-advancement
intubations to maintain the airway. repair
Surgical adhesion of the tongue to lower lip
Cleft lip surgery (Fig. 19.3)
labioglossopexy in the first few days after birth is
an alternative but less commonly practiced method Skin incisions are developed to restore displaced
of management. tissues including skin and cartilage to their normal
214 Essentials of Pediatric Dentistry

Fig. 19.3: (A) Rose-Thompson repair (B) Quadrangular flap repair (Hagedorn, LeMesurier). (C) Triangular flap repair
(Tennison, Randall), (D) Rotation-advancement repair (Millard). (E) Mohler modification of rotation-advancement repair
Care of Special Child (Handicapped Child) 215

position to gain access to the facial, nasal and lip Secondary Management
musculature. Following primary surgery, regular review by a
Muscular continuity is achieved by subperiosteal multidisciplinary team is essential, many aspects of
undermining over the anterior maxilla. cleft care requires long-term review
Nasolabial muscles are anchored to the premaxilla
with nonresorbable sutures. Hearing
Oblique muscles of Orbicularis Oris are sutured Eustachian tube dysfunction plays a central
to the base of the anterior nasal spine and role in the pathogenesis of otitis media with
cartilaginous nasal septum. effusion babies and children born with a cleft
Closure of the cleft lip is completed by suturing palate.
the horizontal fibres of orbicularis oris to achieve It has been recently recognized that child with
functioning oral sphincter. a craniofacial anomaly including cleft lip and
palate is at increasing risk of a sensorineural
Cleft Palate Surgery hearing defect.
Cleft palate closure can be achieved by All children born with a cleft lip and palate
palatoplasty. should undergo assessment before 12 months
The surgical principle is mobilization and of age for sensorineural and conductive hearing
construction of the aberrant soft palate musculature loss by auditory brainstem responses (ABR)
together with closure of the residual hard palate and tympanometry respectively.
cleft by minimal dissection and subsequent scar Sensorineural hearing loss is managed with a
formation. hearing aid.
Excess scar formation in the palate adversely Early (6-12 months old) prophylactic
affects growth and development of the maxilla. myringotomy and grommet temporarily
eliminates middle ear infection.
Techniques to Close a Cleft Palate Speech
There are a multitude of techniques to close a cleft Initial speech assessment should be performed
palate and promote normal function. However, early (18 months) and repeated regularly to ensure
generally techniques can be divided into the types of that problems are identified early and managed
flaps that are used appropriately.
(a) Bipedicle flapsVon Langenbecks repair Common speech problems associated with cleft lip
(b) Anteriorly based on a single pedicle of the greater and palate are:
palatine vesselsproposed by Bardach (a) Velopharyngeal incompetence: This is associated
(c) Four flap palatal closureA Veau-Wardill-Kilner with increased nasal airflow of resonance
producing a nasal or 'hypernasal' quality of speech,
(d) Recent advance in palate repairFurlows or
it frequently reflects poor function of soft palate
double-opposing Z-plasty.
associated with inadequate muscle repair.
216 Essentials of Pediatric Dentistry

Timing of primary cleft lip and palate procedures Secondary palatal surgery
Intravelar veloplasty (muscular reconstruction
of soft palate)
Speech-training devices.
Dental anomalies are common findings in children
with cleft lip and/ or palate.
Various anomalies are (occurs at region of left
Delayed eruption of teeth
Morphological abnormalities are well-
The number of teeth may be reduced (Hypo-
The number of teeth may be increased
Abnormalities can occur in both primary or
permanent dentition.
Dental management:
All children with cleft lip and palate should
undergo regular dental examination.
Preventive measures such as dietary advice,
(b) Articulation problem: These either arise as a fluoride supplements and fissure sealants.
compensatory mechanism to overcome Orthodontic Management
velopharyngeal incompetence or, less commonly, Many children with cleft lip and palate require
are due to few dental and occlusal abnormalities. orthodontic treatment. Orthodontic treatment is
Investigated by: commonly carried out in two phases.
Videofluoroscopy Mixed Dentition (8-10 years): To expand the
Nasal airflow studies (aerophonoscopy) maxillary arch as a prelude to alveolar bone
Nasendoscopy. graft.
Permanent Dentition (14-18 years): To align
Speech problems are managed by:
dentition and provide a normal functioning
Speech and language therapy
occlusion. This phase of treatment may also
Care of Special Child (Handicapped Child) 217

include surgical correction of malpositioned/ Dental anomalies like

retrusive maxilla by maxillary osteotomy. Abnormalities in sequence and time of eruption
Secondary surgery for cleft lip and palate of teeth
Enamel hypoplasia
Good outcome in cleft lip and palate is directly Malocclusion
attributable to the quality of primary surgery. Abnormality in number of teeth.
Poorly executed primary surgery leads to residual
deformity of the lip, nose together with poor Treatment plan modification for special
speech. child
Impaired growth of the midface (maxilla) is now The child patient's mental status must be assessed
attributed to poor and traumatic primary surgery. prior to any dental procedure.
Despite adequate primary surgery, residual During first visit of child patient to dental office
problems do occur and are managed with familiarize the patient to dental office, dental
appropriate secondary procedures. personnel to allay fear of unknown.
Timing of secondary cleft procedures Only single instruction must be given at a time.
Secondary procedures Age (year) Use of simple words with gentle speed of speech
Lip/nose revision 2-adult is used.
Velopharyngeal surgery 3-8 Tell-show-do approach is used with mild cases and
Alveolar bone graft 7-11 sedation can be appropriately used with moderate
Orthognathic surgery 16+ cases.
Dentist must have patience enough to listen
Rhinoplasty 16+
carefully when child speaks because usually these
MENTALLY HANDICAPPED patients have trouble with communication.
Try keep appointments during early morning and
Mental Retardation
try to finish off the dental procedures in short
Definition duration of time.
General anesthesia may be indicated in cases where
Mental retardation is defined by American Academy
adequate level of cooperation cannot be achieved
of mental deficiency as or in cases where extensive rehabilitation is
Significantly subaverage intellectual functioning, required.
existing concurrently with deficit in adaptive behavior
manifested during developmental period. COMMUNICATION DISORDERS

Oral Complications Deafness

Mentally retarded child patients show high prevalence Oral complications

of caries and periodontal diseases due to Due to learning disability and hearing impairment child
overindulgence over cariogenic diet pattern and patient has poor oral hygiene, hypoplastic teeth can
ignorance of oral hygiene. also occur in this condition.
218 Essentials of Pediatric Dentistry

Treatment plan modifications Increased gingival inflammation due to inability

to visualize and remove plaque.
During the first visit of a child patient; the manner
Hypoplastic teeth.
of communication should be elicited along with
Child patient had a prolonged immature
detailed medical history.
swallowing pattern due to reluctance to consume
If the parents/guardian are allowed to remain in solid foods.
operatory room then parents must sit /stand in front
of child to allay fear and anxiety of child. Treatment Plan Modifications
Start dental procedure in a warm, reassuring
manner with facial expressions and smile. Complete medical history along with degree of
Adjust the hearing aid while using handpiece as a visual impairment is ascertained prior to any dental
sounds may be amplified. procedure.
Tell-show-do approach is considered beneficial Explain the child patient in his/her first visit in the
along with this positive reinforcement modeling, dental office setting, office personnel and treatment
behavior modifications techniques could be procedures before starting anything.
utilized. Make a gentle physical contact assuring child while
Various hearing impaired childrens are lip readers, dental procedure.
so speak in a very slow speed with use of simple Dentist must make use of touch, smell and taste
words. technique in place of TST method.
Oral hygiene should be explained and child is
General anesthesia may be required for more
guided through the procedures by the dentist along
serious behavioral management problems.
with the use of audiocassettes and Braille
A person is considered affected by blindness if the Autism
visual acuity does not exceed 20/200 in the better eyes
Dental Management of the Autistic Child
with the correcting lenses or if visual acuity is greater
than 20/200 but accompanied by a visual field of no Autism was first described in 1943 by the American
greater than 20 degrees. child psychologist, Leo Kanner. Autism is a type of
neuro-developmental disorder, and usually appears
Oral Complications within the first three year of a child's life. The hallmark
of autism is the lack of communication skills. Affected
Trauma to anterior teeth occurs in greater
children also have problems with language, behavior,
percentage in visually impaired children as
and social skills.
compared to children of normal population.
Autism is a lifelong condition, and its cause is
Due to learning disabilities patients have poor oral
hygiene. unknown. Environmental and genetic factors do
Care of Special Child (Handicapped Child) 219

contribute to the development of autism, but most Postnatal factors such as untreated phenyl-
children with autism have normal physical health. ketonuria, infantile spasms, and herpes simplex
What is autism?
Signs and Symptoms of Autism
Autism is neurological disorder that appears during
the first three years of life. It is pervasive No two children affected by autism display the same
developmental disorder defined behaviorally as a behaviors or symptoms.
syndrome consisting of abnormal development of
social skills, limitations in the use of interactive Early Symptoms of Autism in Infants
language, and sensorimotor defects. Autism A baby who doesn't babble or gesture by the age
superficially affects brain function in the areas of 12 months.
responsible for the development of communication and A baby who lacks eye contact with its mother by
social interaction skills. the age of 12 months.
Children with autism may appear normal, but the A baby who resists being held or cuddled by its
disorder may prevent them form functioning and mother.
communicating in socially appropriate ways. The A baby who doesn't respond when its mother says
incidence of autistic disorder is seven per 10,000 its name.
persons. It is more common in males than females (4:1 A baby who appears to be deaf.
ratio). An infant who doesn't say single words by the age
The rates of caries and periodontal disease in if 16 months.
autistic children is comparable to those in the general
population. Tips for Recognizing Children with Autism
Autistic children will often run away from
Causes of Autism caretakers or health care workers. This activity is
The exact cause of autism is unknown, although it may called elopement.
be linked to brain injury and genetics. There are many About 50 percent of autistic children are nonverbal.
Autistic children may appear stubborn.
biologic causes, but none of them are unique to autism.
They may exhibit echolalia, or may exhibit
Causes of autism include: rambling speech.
There is a familial genetic tendency for autism. They may exhibit unusual self-stimulating
behavior including hand flapping or rocking back
There is a 3-8 percent risk of recurrence if a family
and forth.
already has one autistic child.
They may appear deaf or not responsive to you.
Fragile X syndrome. They may not be able to answer simple questions.
Tuberous sclerosis. They may be sensitive to sound, bright light, odors,
Prenatal factors such as intrauterine rubella, and and touch.
cytomegalic inclusion disease. Seizures occur in 25 percent of autistic children.
220 Essentials of Pediatric Dentistry

Diagnosis of Autism Childhood disintegrative disorder

Stereotypic movement disorder
Experienced clinicians can reliably diagnose autism
Selective mutism
in children younger than three years of age. The typical
Schizophrenia with childhood onset.
presenting symptoms of autistic disorder are delayed
speech, or challenging behaviour before the age three. Treatment for Autism
Although there is currently no cure for autism, early
Indications for Formal Development
diagnosis and intervention can significantly enhance
the child's social functioning later in life. Early
No babbling, pointing, or other gestures by age detection and early intensive remedial education and
12 months. behavioral therapy are the most important measure
No single words by 16 months of age. which need to be taken. Patience and time are vital to
No two-word spontaneous phrases by 24 months working with these children.
of age. Behavioral Problems in Autism
Loss of previously learned language or social skills
at any age. Impairment of social skills
Diagnosing Autism Sensor motor deficiencies
Limited interactive language skills
Two levels of evaluation are needed: First, a
Seizure disorders.
general screening for developmental problems or
Mental retardation. Seventy-five percent of autistic
risk factors. Second, another evaluation is needed
persons have some level of mental retardation
to actually establish the diagnosis of autism.
Stereotypic behavior
Metabolic and/or genetic testing to rule out other
Self-injurious behavior
conditions with manifestations similar to autism.
Problems with symbolic thinking.
Serologic studies, to see if a child has been infected
with herpes simplex, intrauterine rubella,
Tips for Dentists
cytomegalic inclusion disease.
Hearing tests, to determine if language delay is Offer parents and children the opportunity to tour
due to hearing problem. Two hearing tests are used: your dental office, so that they may ask questions,
the behavioral audiometry test, and the brainstem touch equipment, and get used to the place. Allow
auditory evoked response test. autistic children to bring comfort items, such as a
Neuroimaging, such as MRI, is performed if a blanket or a favorite toy.
structural brain lesion is suspected. Children with autism need sameness and continuity
Differential Diagnosis for Autism in their environment. A gradual and slow exposure
to the dental office and staff is therefore
Retts syndrome recommended.
Asperger's disorder
Care of Special Child (Handicapped Child) 221

Solicit suggestions from the parent or caregiver Talk in direct, short phrases. Talk calmly. Autistics
on how best to deal with the child. take everything literally so watch what you say.
Autistic children are easily overwhelmed by Avoid words or phrases with double meanings.
sensory overload. This can cause "Stimming" Once the dental patient is seated, begin a cursory
(flapping of arms, rocking, screaming. etc.) examination using only your fingers. Keep the light
Autistic children are hypersensitive to loud noises, out of the eyes.
sudden movement, and things that are felt. Next, use a toothbrush, or possibly a dental mirror
Make the first appointment short and positive. to gain access to the mouth.
Approach the autistic child in a quiet, Praise and reinforce good behavior, ignore poor
nonthreatening manner. Dont crowd the child. behavior.
Invite the parent or caregiver to hold the childs
Use a tell-show-do approach to providing care.
hand during the dental examination.
Explain the procedure before it occurs. Show the
Some autistic children can be calmed by moderate
instruments that you will use. Provide frequent
pressure, such as by using a papoose board to wrap
praise for acceptable behavior.
the child. On the other hand, light touch (such
Invite the child to sit alone in the dental chair to as by air from the dental air syringe) can agitate
become familiar with the treatment setting. them. For instance, you are more likely to have
Autistic will want to know whats going to happen problems wrapping a blood pressure cuff around
next. Explain what youre doing so it makes sense the arm then by inflating it.
to them. Explain every treatment before it happens. Some children will need sedation or general
Always tell the autistic child where and why you anaesthesia so that dental treatment can be
need to touch them, especially when using dental accomplished. Sedation of autistic children who
or medical equipment. are 8 years and older simply does not work.
Aesthetic Restorative
Dentistry for the Adolescence

To have a pleasing, attractive appearance is the dream Choice of resin composite for aesthetic restorations
of most adolescents in our society. An important can be confusing because of variety of products
component of the idealized physical appearance is a are available with slightly different physical
radiant smile displaying teeth that are attractive in properties.
shape and color and do not distract during speaking
Basically the two types of composite resins that
and smiling.
can be used are
The use of dental techniques and newly developed
and improved composite resins along with the acid- Microfilled: Those with filler particles
etch technique have made it possible to restore averaging 0.04 mm in diameter.
aesthetic defects with conservative treatment. In return Hybrid: A blend of different particle sizes,
to this effort, dentist receive the satisfaction of seeing including submicrometer (0.04 mm) and small
a young person developing a healthy self-image that particle (0.2 to 3 mm)
can have a positive effect on his or her maturation Currently, most dental manufacturers are
into adulthood. producing Microhybrid resin composites with
an average particle size of less than 1 mm.
BASIS AND FUNDAMENTALS OF When considering which material to choose for a
MATERIALS SELECTION restoration it is essential
To evaluate the tooth to be restored
Choice of materials is an important consideration To evaluate the location of the restoration
for dental aesthetic factors. The basis of clinical To evaluate the forces to which the restoration
success of composite restorations depends on will be subjected.
adhesive systems which would be able to provide Hybrid resins have traditionally been chosen as a
durable bonding of composite to dentin and universal restorative since they can be used in
enamel, effectively sealing the margins of most clinical situations.
restorations and preventing postoperative Microfilled resins are primarily indicated when
sensitivity and microleakage. aesthetic restorations are required.
226 Essentials of Pediatric Dentistry

Illustration: Class V and direct resin veneers,

because microfilled resins can be polished to an
enamel-like luster with much more ease and in
less time than hybrid resins.
Hybrid material used as a substrate that is
subsequently veneered by a microfilled resin
Regardless of whether a microfilled or hybrid
composite resin is chosen, the use of visible light
curing products is recommended. In addition to
the convenience of extended working time and
rapid polymerization, these materials also have
lower porosity and are less likely to become Fig. 20.1: Light curing unit with composite kit
discolored than the chemically cured (spatulated
two paste) systems.
Polymerization of light cured composite resins is Eye protection is important when using the
accomplished by using an intense blue light with curing lights because direct viewing of light is
a peak wavelength of approx (470 nm) which detrimental to vision.
corresponds to the absorption peak of
camphroquinone (CQ), the most popular BASIC CLINICAL TECHNIQUE
Step 1: Shade Selection
A typical light-curing polymerization unit used a
gun type handpiece that contains the bulb and The teeth to be matched should be cleaned with a
cooling fan. Then developed other technology, rubber prophylaxis cup and flour of pumice, tooth
such as light-emitting diodes (LEDs) to efficiently dehydration should be avoided because of the
produce blue light, but the bandwidth of most of concurrent color change.
these LED light is too narrow and high to produce Moistened shade tabs should be held near the tooth
activation of resin composites that contain to be matched, using only room light or indirect
camphroquinone photoinitiator. Now, present sunlight; one should not use the high-intensity
recommendation is of the use of conventional operatory light when selecting shades.
halogen-tungsten-quartz (HTQ) for composite The proper value (Munsell whitness) may be
resin polymerization. The HTQ offers determined by squinting if shade selection takes
interchangeable light transmission tips to gain more than few seconds. One may need to
access to various areas of mouth; however, light resensitize the eyes by staring momentarily at a
intensity should be periodically checked (via a dark blue or gray object.
radio-meter) so that a minimal output of 350 mw/ Resin composites are usually Keyed to the vita
cm2 can be maintained. shade guide; unfortunately, a perfect color match
Aesthetic Restorative Dentistry for the Adolescence 227

between the resin composite and the vita guide is of cavity preparation that are thought to be within
very uncommon. 0.5 to 1.0 mm of pulpal tissue.
Bleach shades are the range of shades that has The liner provides chemical adherence to tooth
increased to match the shades of teeth that have structure and slow release of fluoride.
been whitened or bleached. Common names for
these shades areSuperbright shades or extra light Step 4: Etching
Etch for 15 sec and later rinse for 5 to 10 seconds.
Another way to verify the actual shade is to place
a small portion of composite resin on the tooth Step 5: Use of Bonding Agent
surface, polymerize it, observe the appropriateness
of that shade, and then remove it with a hand After etching and proper rinsing an appropriate dentin
instrument. enamel bonding agent should be placed.
Note: One should not etch the tooth prior to doing this
otherwise removal will be difficult. Step 6: Polymerization Process
Next, to the application of bonding agent light-cured
Step 2: Moisture Control composite resin should be inserted in layers of about
It is extremely important to maintain an 2.0 mm of thickness. To get the similar translucency
uncontaminated field during the insertion of of enamel and opacity of dentin, various materials are
composite resins. available with a variety of opacities. Materials must
The most reliable way to control moisture is be placed in increments in which more opaque material
through use of replaces dentin and the more translucent material takes
Well-adapted rubber dam or if not using rubber the place of enamel, this effort produces a restoration
dam. with a optical properties similar to that of tooth
Place a cotton rolls and 22 inch gauze structure.
sponges over the tongue to prevent moisture
contamination. Step 7: Contouring of the Restoration
Commercially available lip and check Fine sable or camel hair brushes gives a better and
retractor; this plastic device when used in easy contouring and also allows proper blending of
conjunction with gauze sponges, provides composite resin into the required form.
excellent access and good field control.
Step 8: Finishing of the Restoration
Step 3: Pulp Protection
Carbide finishing burs, ultrafine diamond burs, or
Use of a base or liner to protect pulp tissue in deep finishing disks are used for finishing of restorations.
preparations is generally believed to be important. To finish the concave surfaces rounded burs may be
A glass ionomer liner should be used in deep areas used and for convex surfaces disks may be used.
228 Essentials of Pediatric Dentistry

Step 9: Polishing of Restoration required; it must get started simultaneously with

restorative procedure.
With a series of polishing disks or rubber abrasive
instruments restoration is polished. To provide finish
Step 2: Final Restoration
to the interproximal areas and final finish to the
restoration abrasive strips are preferred. Composite resin class IV restorations are considered
Aesthetic Restorations for the Adolescents would be final restoration. Steps followed in restoration are
Considered in following Situations : Administer anesthesia and proper placement of
Restoration for the fractured anterior teeth. rubber dam.
Restoration of discoloured teeth includes To develop primary retentive feature it is done by
Treatment of hypoplastic spots. beveling enamel cavosurface margins of a
Treatment of stained teeth (moderately to minimum of 1.0-2.0 mm in length by using a
severely stained)veneers medium-grit diamond bur.
Bleachingvital Note: Beveling allows maximal bond strength and
Restoration of diastemas minimises leakage by exposing the enamel rods
Aesthetic replacement of teethbonded-bridges to etching.
and splints. Next, application of base or liner to exposed dentin
is undertaken.
RESTORATION FOR THE FRACTURED Conditioning of tooth is accomplished by 37
ANTERIOR TEETH percent phosphoric acid etchant which is applied
first to enamel and than to dentin; this effort is to
prevent the dentin from etching for more than 15
There must be careful evaluation clinically and seconds.
radiographically of fractured tooth to have a reliable Rinsing for at least 5 seconds is required. Slight
diagnosis about the injuries such as these can cause moist environment is considered beneficial this
pulpal as well as aesthetic problems. prevents collapse of the exposed collagen network.
Clinical findings may range to include a little or no Application of primer resin to the dentin which
dentin exposure with a minimal thermal and pressure should be in contact with dentin for at least 15
sensitivity to the acute distress of a pulp exposure. seconds; After 15 seconds the primer must be dried
Radiographic finding revealing absence or in case with a gentle stream of air in order to evaporate
presence of root fracture. the solvent without displacing the primer. It is seen
that a shiny surface is obtained after this step.
Clinical Technique While using a two-component system, the adhesive
resin is applied with a brush over the dried primer
Step 1: Pulp Therapy
and it is then light cured for 10 seconds. Care must
Treatment must begin with pulpal therapy considering be taken to avoid overthickening or over-thining
the first aspect; if pulpotomy or pulpectomy is of the material. At a final step; composite resin is
Aesthetic Restorative Dentistry for the Adolescence 229

applied as described previously. After placing, For the reason: That maxillary anterior teeth are
finishing, polishing check the restoration for any more displayed during smiling and speaking and
interference in various excursive movements. also often veneers for mandibular teeth are less
likely to get successful due to less space and
RESTORATION OF DISCOLORED TEETH unfavorable forces acting at the junction of tooth
(i) Treatment of Hypoplastic Spots and veneer during normal masticatory function.
Veneers must always be placed with a great priority
Yellow-brown spots or any discrete hypoplastic white to periodontal health of the tooth planned for
spots can be improved by receiving veneers. For veneer to get successful
the patient must have excellent periodontal health
Enamel microabrasion because after the placement of veneers the
This is a preferred clinical technique because it is a consequent contours and margins require a good
treatment that requires less enamel removal and also oral hygiene to maintain gingival health.
does not necessitate placement of a restoration. Patient must be aware of avoiding biting on a hard
objects and stuff.
Clinical technique Veneers May be Either
Direct veneers (direct build-up of composite resin
Application of an acidic abrasive paste by a reduced
in the mouth) or
speed handpiece.
Microabrasion is sometimes used in combination Indirect veneers (constructed on laboratory
with vital bleaching. models)

Saucer-shaped preparation Direct Veneers

This includes making shallow saucer shaped Veneers made of light cured composite resins can be
preparation in enamel to remove the intensely colored constructed directly in the mouth.
tooth structure and then restoring it with composite
Greater operator control
(ii) Treatment of Stained Teeth (Moderately Placement in one appointment
to Severely Stained)Veneers No laboratory charges.
Porcelain veneers provide a better treatment option Disadvantages
for moderate to severe staining of one or more
teeth. Require more time and great skill
Maxillary anterior teeth are more anticipated for More patience on the part of clinician
veneers than mandibular anterior teeth. Results are difficult to predict.
230 Essentials of Pediatric Dentistry

Clinical Technique nonopaque shade to allow a natural-translucent

Step 1: Preparing Stained Tooth
Step 5: Contouring
Darkly stained teeth usually require some amount of
enamel removal because a space is required for After all composite resin has been added; contouring
placement of composite resin which would mask the is done with the brushes.
underlying enamel.
Celluloid matrices are used in between adjacent Step 6: Polymerization
teeth. A wider light curing (e.g. 11 mm diameter) is
After enamel removal, teeth are then pumiced and recommended. The material should be polymerized
individually etched, and a bonding agent is applied. by exposing each area to the curing light for 40-60
Step 2: Use of Opaquing Agent

It should be kept in notice that with the use of these Step 7: Finishing and Polishing
agents it can produce an unaesthetic flat appearance Done best with use of burns and disks.
in the color of final restoration.
When a dark banding is present; a way other should Indirect Veneers
be followed of replacing the tooth structure (remove The indirect veneers are also called laboratory
the band with a round bur) and then replace the tooth constructed veneers.
structure with an opaque hybrid composite resin.
Step 3: Application of Composite Resin
Excellent aesthetically pleasing contours can be
Microfilled composite resin is applied in a 1.0-1.5 mm achieved using composite resin or porcelain
thick layer and is contoured later with a brush. laboratory techniques.
Due to construction of veneers in laboratory the
Step 4: Blending the Shades total chair time required is less.
To create a natural looking and gentle color transition
Gingival third of restoration must be usually
opaque yellow shade. The remaining enamel The necessity of two appointments.
should be covered with opaque gray or universal The possibility of creating an excess bulk of
composite overlapping and blending the shades. restorative material.
Also, a incisal one-fourth could be given Laboratory expenses.
Aesthetic Restorative Dentistry for the Adolescence 231

Clinical Technique
At First Appointment
Step 1: Tooth Preparation (Fig. 20.2)
Main goal of achieving a chamfer finish line
throughout the surfaces to be covered is achieved
by using a medium grit diamond bur.
Preparation is extended to proximal surfaces just
to include the contact points.
Gingivally, the preparation must extend to cover
the stained enamel enough to improve the color.
The finish line is kept supragingivally to aid in
better maintenance of periodontal health of tooth.

Step 2: Impression Making

Following the appropriate tooth preparation an
accurate impression is made of prepared tooth with
use of elastomeric impression materials, e.g.
polysulfide or silicon.
At Second Appointment
Step 1: Clean the Prepared Tooth
With pumice and then isolate; place celluloid matrices
between the adjacent teeth.

Step 2: Trying and Adjustment of Veneer

Trying is done with the help of using water, glycerin
or a try-in-paste to help hold to veneers in place : and
adjusting the veneers.
After trying and adjusting : Veneers should be cleaned
with etching gel and silanated. Fig. 20.2: Tooth preparation
232 Essentials of Pediatric Dentistry

Step 3: Placement of Veneers Over Prepared Concentrated hydrogen-peroxide solution is

Tooth applied to tooth.
Heating of teeth is in procedure; usually with an
The preparations should be acid-etched
electric lamp.
individually or in pairs.
With this method of bleaching temporary tooth
The veneers are bonded in place (light cured or
dual cured resins of moderate viscosity are sensitivity to thermal changes have been reported.
preferred for bonding), beginning with the central This method of bleaching usually requires three
incisors. or more office visit of patient; and also periodic
Excess of resin is removed with brushes from retreatment to maintain the desired color is
margins prior to polymerization. required.

Step 4: Polymerization Night Guard Vital Bleaching

Due to some amount of shielding effort of light A dentistdirected, at-home treatment.

transmission by veneers; polymerization time of The method involves a custom made application
40-60 seconds in each area should be used. trays and a 10 percent carbamide peroxide that
the patient applies and wears outside the dental
Step 5: Finishing and Polishing
office; usually at night during sleep, for about a
Finishing and Poishing: Is mostly necessary at the period of 2-3 weeks.
margins and may be done with rubber cups and

Vital Bleaching Before beginning of restoration of diastemas an

important pretreatment consideration of
Vital bleaching involves application of peroxide Size of teeth (length and width)
solutions to increase the whiteness of teeth which Shape of teeth
are discolored. Size and location of space or spaces is
Peroxide bleaching appears to work better in undertaken.
condition when teeth are discolored mildly; when
For some patients the best treatment is partial
the discoloration which has originated from enamel
diastema closure; in which the existing space is
rather than dentin.
made smaller by enlarging the teeth with composite
There are two basic methods
resin but not make the teeth so large that they
become aesthetically displeasing.
Power Bleaching
Also; a responsibility of dentist is to provide
This is an in-office procedure. aesthetic possibilities with careful evaluation to
Clinical Technique be explained to the patient before treatment is
Isolate the tooth to be bleached with a rubber dam. begun.
Aesthetic Restorative Dentistry for the Adolescence 233

Clinical Technique After restoring a single tooth give a proper finish

Step 1: Measurement of Space to be and cotour to the interproximal area.
Restored To get started with second tooth; a celluloid matrix
is placed between teeth.
Is accomplished by calipers, periodontal probe or
Restoration of the second tooth is similar as
Boley gauge.
described for first tooth.
Note: Space to be eliminated is measured carefully
because in an effort to reduce half of space : it usually Step 5: Upon Completion
becomes difficult to determine how much of space that
has been actually restored. The celluloid matrix which was inserted between teeth
is removed.
Step 2: Cleaning of Teeth, then Shade Restoration is finished and polished. With the use of
Selection and Follows the Isolation of Teeth composite resin various changes in the form of illusions
can be created in a restored tooth structure.
Step 3: Etching of Entire Labial Surface of
Tooth Illustration
Rinsing and application of bonding agent. To create an illusion of a narrower teeth, one should
Note : Entire labial surface of teeth is etched and create mesial and distal line angles in composite resin
bonding agent is applied due to the reason that a layer that are positioned slightly nearer the middle of tooth
(thin) of composite resin would be covering the labial and could be addad with developmental depressions
surface so as to provide a subtle appearance of color (vertical anatomic highlights).
transition from composite to tooth.
Step 4: Application of Composite Resin BONDED BRIDGES AND SPLINTS
After etching; rinsing and application of bonding agent Clinical Technique
composite is applied.
Step 1: Diagnosis and Treatment Planing
A viscous and opaque composite resin to start with
is applied first at the gingival margin of interproxi- Careful evaluation of occlusion
mal area. Material is made to shape and contour Anterior teeth having the translucent incisal edge
in form of smooth-flowing gingival embrasure with which would not allow the complete coverage of
the help of an instruments or brushes. edges by the retainers due to unnatural
Note: While creating a gingival embrasure a appearance created by metallic or resin coverage;
careful precaution is kept of avoiding development diagnostic study models are helpful.
of overhanging ledge. The exposed dentin and restoration of teeth
The entire proximal surface as well as the labial significantly reduces the strength of retention of
surface of a tooth is build up incrementally and the bridge; for this reasonthe teeth must have
polymerized. adequate enamel for bonding.
234 Essentials of Pediatric Dentistry

Proceed for further steps with proper shade Step 4: Seating the Appliance in Place
selection of pontics.
Preparation of Appliance: The interior surface of
Step 2: Tooth Preparation the retainer is air abraded with aluminum oxide;
For anterior bridges and splints lingual enamel is the appliance is cleaned in an ultrasonic water bath.
reduced to (0.5 mm) to provide a space for metal Preparing abutment teeth for receiving an
retainer with the help of diamond burs. appliance.
Supragingival chamfer finish line is obtained.
Teeth is cleaned, pumiced and isolated.
To aid in resistance and retention, a proximal
grooves (small) are prepared. Etching is done of the abutment teeth.
Composite resin luting cement (autopolymerizing)
Step 3: Impression Making
is mixed and is applied over the appliance.
An accurate impression of the prepared arch is
Appliance is seated and is held with firm pressure
made with elastomeric impression material such
as polysulfide or silicon rubber. for few minutes so that resin cement gets harden.
An impression is poured to get a working model; Following cementation; rubber dam is carefully
with a sharp red pencil, the extensions of the cut and removed and the excess cement which is
preparations should be outlined. remained is removed with diamond or carbide bur.
Sports Dentistry and
Mouth Protection

Sports dentistry has basically two major components of jaw fractures is the use of an intraoral mouth-
A. The management of orofacial injuries. guard.
B. The prevention of sports-related orofacial injuries. Sports that mandate the use of mouthguards at
First component; (A) calls into play many different present time are boxing, football, ice hockey,
skills provided in various branches of dentistry. To lacrosse, and womens field hocking.
provide comprehensive care, a dentist must be But unfortunately, only a very few organized sports
knowledgeable in branches of oral surgery, provide mouthguards during practice sessions and
endodontics, operative dentistry, orthodontics, hospital in game situations.
dentistry and patient behavior management. In relation With the use of mouthguards in conjunction with
to second component; (B) automatically comes to mind helmets and facemasks has proved effective in
when treating patients is the question, why did injury reducing both the frequency and severity of
happen? craniofacial and intraoral injuries.
Why do so many young athletes have to suffer from Young athletes who participate in popular team
such preventable injuriesinjuries that can sports such as baseball, basketball, and soccer and
negatively affect the oral health of young athletes in school physical education classes where mouth
for a life time? guards are not required continue to experience a
An answer to this realization brings into the focus high incidence of intraoral injuries, concussions
the second aspect of sports dentistry and even death.
Prevention through sports safety. The most important aspect of dental professional
responsibility to a young athletic child and
MOUTH PROTECTION FOR CHILD AND adolescent patient is to act as advocate with sports
ADOLESCENT ATHLETES regulatory agencies, various school boards to
An single most important device for protecting promote the use of mouth guards in various sports
teeth, mouth as well as for reducing the likelihood in which they are mandatory so to prevent future
236 Essentials of Pediatric Dentistry

traumatic sports-related injuries and protect our

young athletes.

Classification to Categorize Mouthguards:
Type-I : Stock
Type-II : Mouth Formed
Thermoplastic variety of type II mouth guard.
Shell-lined variety of type II mouth guard.
Type III : Custom-Fabricated (Over a Model)
Two laboratory technique involved in fabrication
of custom athletic mouthguards are
Vacuum forming technique
Pressure lamination technique.
Fig. 21.1: Stock mouthguard
Type I : Stock Mouthguards (Fig. 21.1)
They interfere most with breathing and speech.
Stock mouthguards are popular due to the reason
Because; they offer less protection stock mouth
that; they are inexpensive and are readily available
guards are not recommended.
in most sporting goods stores.
Parents should be warned against a false sense of Type II : Mouth Formed Mouthguards
security; if their child or adolescent wears a stock
A proper fitting with a better retention is obtained
with this type of mouth guard when adjusted by
the dentist.
However; results are often unsatisfactory
A single advantage of this type of mouth guard is they when athletes themselves attempt to fit this type
are preformed so can be worn directly as manufactured. of mouth guard.

Limitations Varieties of Type II Mouthguard

They must be held in position by clenching the The thermoplastic varietyBoil and
teeth together. Bite Technique (Fig. 21.2)
They are least retentive. The material (thermoplastic) is placed in a boiling
They are most bulky of other mouth guards. water until it becomes softened.
Sports Dentistry and Mouth Protection 237

The rigid mouthguard shell is lined with ethyl

methacrylate material.
The liner must be changed before every game,
although some athletes dislikes to the taste of
freshly mixed ethyl methacrylate material.

Type III : Custom-Fabricated Mouthguard

(Fig. 21.3)
This type of mouthguard has various positive
features over previously described mouthguards
Type III mouthguard is far superior to type I
and II in terms of adaptation, retention and
They are the most comfortable and interfere
Fig. 21.2: Boil and bite mouthguard
least with breathing and speech.
The most compelling reason to use type III
After; it is softened it is inserted into mouth; it is mouth guard is the superior quality of custom-
molded to the oral and dental structures. fabricated mouth guards in terms of comfort
To prevent the burning of oral soft tissues or any and player safety.
possible damage to the dental pulp in immature The most important concept is type III mouth
teeth (permanent), care should be exercised in guard is maximum protection for maximal
regard to the temperature prior to inserting the prevention which is emphasised.
softened protector.
The mouthguard should be of temperature less than
132F and is inserted wet and must not be inserted
in dry mouth.
To get a tighter fit of mouth guard; this type of
mouth guard can be resoftened and remolded.
The type II thermoplastic variety is the most
commonly used athletic mouthguard, but is often
bulky and distorts easily.

The Shell Variety

This variety of type II mouth guard offers a better
retention but; the use of this variety has been
declined. Fig. 21.3: Custom made mouthguard
238 Essentials of Pediatric Dentistry

A custom-fabricated mouth guard is in fact is

a cost-effective alternative; even though the
actual cost is higher than other types of mouth
guards; the relative cost is low compared with
other equipment such as athletic shoes. The
actual cost is far more conservative than the
expense associated with treatment of
emergency and long-term management of a
traumatic athletic injury. Fig. 21.4: Pressure laminated mouthguard
Note: The dental model used for fabrication of the
original mouth guard should be preserved so that in After impression material is set completly ;
the event of damage or loss of the mouth guard; impression tray is removed from mouth and
replacement can be easily done if dental model is impression which is recorded is thoroughly washed
preserved. and is disinfected with sodium hypochlorite.
LABORATORY TECHNIQUES Before pouring the model; excess of water and
disinfecting solution is removed with exposing
Type III mouthguards are fabricated over a dental
impression to a gentle stream of air.
model using sheets of thermoplastic material.
Step 3: Preparing a Dental Model
Technique 1: Heat-pressure-lamination
Technique (Fig. 21.4) Dental model is poured immediately with a thick
mix of dental stone.
This technique utilises multiple layers of material and
After the dental stone is set completely impression
is designed for greater adaptation (retention).
is separated gently from dental model.
The model is trimmed and finished by removing
Technique 2: Vacuum Forming Technique
stone bubbles and filling the voids in model with
Step 1 a small amount of dental stone.
Complete all necessary restorations and later dental While fabricating a mouth guard for a athlete who
prophylaxis is performed. wear a fixed-orthodontic appliance; dental model
is modified by reliving with either a plaster or heat
Step 2: Impression Making resistant block out compound over the area of
appliance. So, that mouth guard which would be
An impression is made in alginate of the entire fabricated on this modified dental model will not
maxillary arch with the help of muscle molded rim- interfere with anticipated orthodontic tooth
lock tray. movement.
Sports Dentistry and Mouth Protection 239

The heat is switched off as the vacuum is switched

on while the softened sheet is compressed over
the dental model; the vacuum must be kept on for
approximately 2 minutes.
Once, the compressed sheet of material on the
dental model is adapted completely and dental
model is cooled completely; excess of sheet
extending in areas where not required is trimmed
with scissors and is peeled away. Palatal region is
cut out in U shape with a utility knife.
Step 5
The prepared mouthguard is removed from dental
model by soaking the model in water.
Mouthguard is carefully trimmed over some areas
like peripheral areas of mouth guards to keep it short
of the mucobuccal fold. Relive frenum to prevent
developing sore spots.
Fig. 21.5: Vacuum machine Step 6: Final Finishing
Final Finishing of mouth guard is accomplished by
using polishing stones or rubber wheels and then
Step 4: Preparation of Mouthguard
flaming the mouth guard lightly with an alcohol torch.
The dental model (finished and modified (if
required)) is positioned in centre of vacuum former Step 7: Delivery of Mouthguard
(Fig. 21.5). The completely fabricated custom made mouthguard
The heat is switched on in vacuum machine to heat is then ready for delivery to the athlete. After placement
a 5.5 inch square sheet of polyvinyl acetate- of mouthguard in mouth; if required adjusted by dentist
polyethylene until the sheet shows a 1-2 inch sag. and then given to the athlete.
A Apexification 99, 164 pedodontics 193
Apexogenesis 98, 165 problems in autism 220
Abnormal thumb sucking 133 APF gel and solution 61 Benefits of
Acid-etch technique 153 Appliance therapy 112 appliance 85, 86
Acrylic partial dentures 123 Approaches of behavior management using rubber dam 65
Acute 196 water fluoridation 59
gingivitis 102 Armamentarium for tooth extractions Biological and histological condition
herpetic gingivostomatitis 104 143 31
Adhesive resin-based composite crown Assessment 22 Biopsies 145
83 Assurance 23 Bite 13
Aesthetic 171 Attainment of integrity 46 Bitemarks evidence 13
replacement of teeth 233 Autism 218, 219 Blindness 218
restorative dentistry for adolescence Aversive domain 197 Boil and bite technique 236
225 Bonded band and loop 117
Air abrasion microdentistry 86 B Bruxism 125
Alternatives of pit and fissure treatment
151 Back-to-back class II amalgam C
Alveolar bone 101 restorations 71
American Academy of Pediatric Band and Calcium hydroxide 98
Dentistry 3 bar space maintainer 121 Camouflage 178
Anal stage 40 loop 113 Candidiasis 103
Anatomic differences between primary Barriers to care for infants and toddlers Canines 81
and permanent teeth 65 from low income Cementum 101
Anemia 207 families 24 Cephalometric 130, 171
Anesthesia for mandibular tissue 140, Basics in managing children in dental Changes in
141 experience 199 gingiva 101
Anterior Basis and fundamentals of materials periodontal ligament 101
crossbite 182, 189, 190 selection 225 tissues in children 101
open bite 186 Behavior Chdiak-Higashi syndrome 110
Antianxiety drugs 18 learning theories 38 Cheek-biting 127
Antibiotic resistance 21 management 192, 193 Child
Anticipatory guidance 49 modification 193 abuse 5
Antimicrobials shaping 193 neglect 4
in pediatric dentistry 19 Behavioral psychology 38
mode of action 20 assessment 49 Chronic gingivitis 105
Antimycotic agent 104 effects 9 Class I amalgam restoration 68
242 Essentials of Pediatric Dentistry

Class II amalgam restoration 70 Crown 27 Distal shoe 117

Class III adhesive restoration 81 Crown and Down syndrome (trisomy 21) 110
Classification by bar space maintainer 121 Drawbacks of appliances 122
Andreasen 157 loop appliance 117
Ellis and Davey (1960) 157 Custom-fabricated mouth guard 237 E
Finn 129
Rabinowitch (1956) 156 D Early periodic screening, diagnostic
Classification of and treatment (EPSDT)
Data gathering 170 services 23
bitemarks 13
Deep bite 184 Early symptoms of autism in infants
child behavior during dental
Defluoridation 63 219
procedures 193
Demerits 139 Educational neglect 4
periodontal problems in children
Dental 216
101 Ego 39
age of patient 123
problems according to priority 170 Ehlers-Danlos syndrome 109
anomalies like 217
PHFA 131 child patient management by domain Electra complex 41
injuries to young permanent teeth 196 Electrical burns 11
156 crossbite 189 Emergency care 205-207, 209-212
Cleft deep bite 185 Emotional
lip surgery 213 management of autistic child 218 child abuse 7
palate surgery 215 public health practice 22 effects 9
Cognitive development theory by Jean services 23 neglect 4
Piaget (1952) 46 Dentofacial structures 129 stress 127
Communication disorders 217 Desirable properties for local Emotionally compromised child 192
Community water fluoridation 58 anesthetic 138 Enamel microabrasion 229
Complete dentures 123 Development of Epilepsy 202
Complex tongue thrust 133 autonomy 44 Esthetic anterior space maintainer 120
Complications of local anesthesia 139 basic trust 43 Evidence of oral burns 10
Congenital absence of permanent tooth initiative 44
Extractions 143
124 intimacy 45
Congenital heart diseases 211 personal identity 45
Devitalization pulpotomy 93, 94 approach 137
Conscious sedation 198
Diabetes mellitus 209 findings 132
Consent for treatment 199
Diagnosis of signs and symptoms 103, 105
Conservative adhesive restorations 73,
149, 154 autism 220 Extrusion 167
Convulsive disorder 202 pit and fissure caries 151
Coronal discoloration 159 Diagnostic considerations 92 F
Correction of Dietary fluoride supplementation 56
Fabrication of
deep bite and crossbite 179 Different crossbites 189
appliance 117
mandibular deficiency 178 Direct
pulp cap 163 band and loop space maintainer 113
maxillary prognathism 178 mandibular lingual arch 120
Crossbite 189 veneers 229
Index 243

Facial H Injuries to
examination 50 gingiva 158
symmetry 50 Habits 127 hard dental tissues 157163
Factitious gingivitis 102 Handicapped periodontal tissues 157
Factors affecting child 202 supporting tissue 166
bitemarks injury 14 person 202 Interception during growth 182
management 36 Hand-over-mouth exercise 200 Interceptive orthodontics 174
Filling of primary root canals 97 Head and neck examination 49 Intermaxillary relationship 132
Fixed Heat-pressure-lamination technique Intraoral
appliances 186 238 approach 137
prosthetic appliance 85 Hemophilia 205 examination 50
space maintainers 112 Histopathology of caries in pits and findings 132
Fluoridated milk 56 fissures 150 signs 102, 104
Fluoride 54 Historical attempts in prevention of pits symptoms 102, 104
application 63 and fissure caries 150 Intrusive luxation 166
compounds used in water fluorid- Hyperthyroidism 204 Iodoform
ation 58 Hypophosphatasia 110 mixture 98
releasing sealants 154 Hypothyroidism 203 paste 97
Food in oral health 53 Iron deficiency anemia 207
Formal development evaluation 220 I Irreversible pulpitis 159
Franks criteria for apexification 99 Implementation of VTO requires 172
Frenectomies 145 Incisors 81 J
Frightened child 192 Indian Technology for Defluoridation Jet injection 140
Full coverage of incisors 83 63 Juvenile periodontitis 106
Functional crossbite 189 Indications for
pit and fissure sealant placement L
restorations of primary anteriors 81 Late adults 46
G-6-PD deficiency 207
use of stainless steel crown 74 Latency stage 41
Indirect Lateral luxation 167
effects 129
pulp capping 89 Leukemia 210
factors 33
veneers 230 Leukocyte adhesion deficiency 110
Inductive plethysmography 130 Levels of sedation 15
juvenile periodontitis 108
Infection of periodontal ligament Limitations of appliance 85, 86
prepubertal periodontitis 109
(PDL) 158 Lingual arch 118
Genital stage 41
Inflammatory resorption 160 Linguistic domain 197
Gingivitis 102
Information and instructions for Lip
Greater palatine nerve block 141
parents 162 bumper 127
Guidelines for treatment of avulsed
Infraorbital nerve block 140 habit 126
tooth by reimplantation
Injuries of supporting bone 158 position 50
244 Essentials of Pediatric Dentistry

Local anesthesia 138, 197 Methods O

Local anesthetic overdose 139 of providing full coronal coverage
Localized to primary incisors 83 Obturation techniques 98
gingival recession 106 used in fixed appliances 186 Odontogenic infections 145
juvenile periodontitis 106 Oedipus complex 40
Microbiology of GJP 107, 108
prepubertal periodontitis 109 Ontologic coaching 201
Microdentistry 86
Open bite 186
Middle superior alveolar nerve block
M 140
Operant conditioning theory by BF
Skinner 42
Malignant disorder 210 Mineral content 30 Oral
Malocclusion 126 Minimal sedation 15 complications 203-207, 209-212,
Management of Misbehaving child dental patients 192 217, 218
orthodontic problems 173 Mode of action of local anesthetics 138 examination of infant 48
traumatic injuries 160 Moderate sedation 16 habits 125
Managing traumatic injuries in young Morphological differences 27 hygiene 53
permanent dentition Morphology of surfaces with pits and mucosa 158
156 fissures 149 stage 40
Mandibular Mortal pulpotomy 94 surgery in children 138, 142
anterior teeth extraction 144 Mouth formed mouth guards 236 Organic 128
deficiency 178 Mouth protection for child and Orthodontic management 216
lingual arch 120 adolescent athletes 235 Orthognathic surgeries 179
molar extraction 144 Mouthbreathing 129 Overall facial pattern 49
Masochistic habit 128
Multivisit pulpectomy 96
Mastery of skills 44
Myofunctional appliances 186 P
Maxillary anterior
region block 140 Pain 15, 195
N Pain reaction control sedation 15
teeth extraction 144
Maxillary Nail-biting 127 Palatal infiltration 140
lingual arch 119 Narcotics 18 Palate 212
molar extraction 143 Nasopalatine nerve block 141 Papillon-Lefvre syndrome 109
prognathism 178 Natal and neonatal teeth 32 Parent counseling 37
Mechanism of Nature of injury 11 Pediatric
action of fluorides in caries reduc- Negative consequences of child abuse dentistry 3, 22
tion 54 9 restorative dentistry 67, 69
defluoridation by Nalgonda techni- Night guard vital bleaching 232 Pedodontics 4
que 64 Nitrous oxide 17, 198 Periodontal
Mechanotherapy 137 Nonvital pulpotomy 94 problems in children and adoles-
Medicaid 23 Normal thumb sucking 133 cents 101
Mental retardation 217 Nursing bottle caries 34 structure 30
Mentally handicapped 217 Nutrition 53 Pernicious anemia 208
Index 245

Phallic stage 40 Psychological therapy 136 Rhinomanometry 130

Pharmacologic agents for sedation 18 Psychology 38 Root 28
Pharmacological Psychosexual theory 39 Root canal filling materials 97
approach 197 Psychosocial theoryErik Erikson Rubber dam clamps 66, 67
domain 197 (1963) 43 Rubber dam in pediatric restorative
Physical Puberty 41 dentistry 65
domain 197 Pulp
neglect 5 canal obliteration 160 S
restraint 201 necrosis 159
Sagittal plane malocclusion 176
Pit and fissure sealants 149 therapies 88
Placement of rubber dam 67 Pulpectomy 92, 95, 164 Saucer-shaped preparation 229
Planning for space maintenance 123 School water fluoridation 59
Plaque induced 105 R Sealants for primary teeth 72
Policy development 23 Sedation 15
Radiographic Sedative hypnotics 18
examination 151, 162 Self-
crossbite 182, 189, 191
open bite 188 findings 108 applied topical fluoride 59
superior alveolar nerve block 140 Rampant caries 33 injurious habits 128
Potential problem related to dental care Rapid induction technique 17 multilating habits 128
203-204, 206, 209-211 Reason of classic distribution of LJP Sequence of eruption of teeth 124
Power bleaching 232 107 Severe sequelae follows 103
Praise and communication 201 Recording in database 170 Sexual child abuse 6
Predeciduous teeth 32 Reimplantation 168 Shy and introverted child 192
Predisposing factors 103 Removable Sickle cell anemia 208
Preoperative evaluation 142 appliances 121, 185 Signs and symptoms of autism 219
Preparing for placement of rubber dam prosthetic appliance 86 Signs of
66 space maintainers 123 child neglect 8
Prepubertal periodontitis 109 Removing rubber dam 68 emotional child abuse 8
Prevention of Replacement resorption 160 physical child abuse 8
complications 203-206, 209-211 Restoration for sexual child abuse 8
dental diseases 53 fractured anterior teeth 228 Simple tongue thrust 133
Preventive orthodontics 174 incisors and canines 82 Single visit pulpectomy 95
Problems associated with distal shoe Restoration of Site of primary effect 18
appliance 118 diastemas 232 Skeletal
Professionally applied fluorides 60 discolored teeth 229 crossbite 189
Progression of lesion 36 primary anteriors 81 deep bite 185
Prosthetic replacement of primary Restorative dentistry for primary features 177, 182
anterior teeth 85 dentition 65 Soft tissue surgical procedures 144
Psychoanalytical theory 38 Reversible pulpitis 158 Solutions 60
Psychodynamic theory 38 Reward-oriented domain 197 Somatic reflex 132
246 Essentials of Pediatric Dentistry

Space preliminary goals 171 Sustained release fluoride 60

maintainers 118 preparing dental model 238 Systemic
maintenance in primary dentition pulp protection 227 disease associated with periodontitis
111 Step 4 109
Sports dentistry and mouth protection application of composite resin 233 disorders 203
235 blending shades 230 fluoride administration 56
Stainless steel crowns 74, 79, 80 definitive treatment of traumatic
Standard titration technique 17 injuries 163 T
Step 1 dynamic and structural summary of
Technique of sealant application 72
clean prepared tooth 231 case 172
Techniques to close cleft palate 215
diagnosis and treatment planing 233 etching 227
Teething disorders 32
history taking 161 polymerization 232
Theory by
measurement of space to be restored preparation of mouth guard 239
Albert Bandura (1963) 47
233 seating appliance in place 234 Ivan Pavlov 41
preparing stained tooth 230 Step 5 Thumb sucking 133
pulp therapy 228 contouring 230 Thyrotoxicosis 204
selection and evaluation of required finishing and polishing 232 Tips for
diagnostic methods upon completion 233 dentists 220
170 use of bonding agent 227 recognizing children with autism
shade selection 226 visualization of treatment objectives 219
tooth preparation 231 (VTO) 172 Titration 17
Step 2 Step 6 Tongue
cleaning of teeth 233 final finishing 239 pressure 13
evaluation of clinical possibilities polymerization 230 thrusting 131
171 tracing of superimposition areas 173 Tooth
examination 162 Step 7 decay 111
final restoration 228 contouring of restoration 227 pressure 13
impression making 231, 238 delivery of mouth guard 239 scrape 14
moisture control 227 finishing and polishing 230 Topical
tooth preparation 234 treatment design and sequential use anesthetic agents 139, 140
trying and adjustment of veneer 231 of appliances 173 fluoride administration 59
use of opaquing agent 230 Step 8: finishing of restoration 227, Transverse plane malocclusion 189
Step 3 228 Trauma 111
application of composite resin 230 Stimulus response theory 47 Trauma in young permanent dentition
emergency care 162 Stock mouth guards 236 156
etching of entire labial surface of Subluxation 166 Treatment for autism 220
tooth 233 Superego 39 Treatment of
impression making 234 Surgical class II division 2 malocclusion 179
placement of veneers over prepared correction 179 class III malocclusion 182
tooth 232 techniques 213 deep bite 185
Index 247

hypoplastic spots 229 neglect 4, 8 Visceral reflex 132

juvenile periodontitis 109 prosthetic appliance 85 Vital bleaching 232
pseudo class III malocclusion 184 Voice control 200
severe class III after growth 184 U von Willebrands disease 206
skeletal class II malocclusion 177
Unerupted teeth 124 W
stained teeth (moderately to severely Urethral stage 40
stained)veneers 229 Use of stainless steel crowns 74 Water fluoridation 57
Treatment plan modification 203-210,
212, 218 V Y
Treatment planning and management
of orthodontic prob- Vacuum forming technique 238 Young permanent tooth 30
lems 170 Varieties of type II mouth guard 236
Types of
Vertical Z
facial relationships 50
mouth guards 236 Zinc oxide-eugenol paste 97
plane malocclusion 184