Pocket Book of Pedodontics PDF

Pocket Book
of
Pedodontics
Nikhil Marwah BDS, MDS

Assistant Professor
Department of Pedodontics
Govt. Dental College, Rohtak, Haryana, India
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Pocket Book of Pedodontics
© 2008, Jaypee Brothers Medical Publishers
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: 2008
ISBN 978-81-8448-419-9
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, A-14, Sector 60, Noida 201 301, India
Foreword
This is a sincere effort by the author to cover the entire

syllabus of Pedodontics in an easy and simple to
comprehend manner. This book will be very helpful to
the exam appearing students, undergraduates and post-
graduates in explaining all the concepts in the subject
and at the same time will be a good source for quick
revision.
Sanjay Tewari
President FODI,
Principal, Govt. Dental College,
PGIMS, Rohtak
Preface
A textbook can never be substituted, but in the fast

paced world where all conventional things are being
shortened to encompass people on a common platform,
literary knowledge cannot be left behind. The incidence
of dental disease in the new world order is on the rise
and to counter this we must aim at making the
knowledge available to all concerned individuals.
This Pocketbook of Pedodontics would enable all
dentists, undergraduate and postgraduate students and
those preparing for entrance examinations to understand
the subject and procedures in Pedodontics in a much
quicker and efficient manner. The essence of this book
is quick understanding, reference and revision in
minimum time.
Nikhil Marwah
Contents
1. Introduction ........................................................ 1
2. Growth and Development ................................ 5
3. Tooth Eruption ................................................. 15
4. Diet and Nutrition ........................................... 25
5. Microbiology of Oral Cavity ........................... 35
6. Child Psychology ............................................. 43
7. Behavior and Behavior Management ............ 53
8. Development of Occlusion .............................. 69
9. Oral Habits ....................................................... 79
10. Pediatric Space Management ......................... 95
11. Plaque Control in Children .......................... 111
12. Pit and Fissure Sealants ................................ 125
13. Fluorides ......................................................... 135
14. Dental Caries .................................................. 151
15. Early Childhood Caries ................................ 165
16. Pediatric Operative Dentistry ....................... 177
17. Pharmacological Considerations
in Pediatric Dentistry .................................... 203
18. Pediatric Radiology ....................................... 207
19. Pediatric Endodontics ................................... 213
20. Stainless Steel Crowns .................................. 241
21. Handicapped Child ...................................... 251
22. Medically Compromised Conditions .......... 265
23. Cleft Lip and Palate ....................................... 273
24. Congenital Abnormalities in Children ....... 281
25. Traumatic Injuries in Children .................... 289
26. Lasers in Pediatric Dentistry ........................ 311
27. Forensic Pedodontics ................................... 321
Index ................................................................ 329
Chapter 1
Introduction
 Infant
 Toddler
 Preschool
 Middle year child
 Adolescent
2 Pocket Book of Pedodontics
• Pedodontics is the art and science and that branch

of dental science, which deals with compre-
hensive, interceptive oral health in children from
childhood to adolescent age particularly and
complete health in general
• Pedo is derived from Greek word ‘pais’ meaning
child and dontics is the study of teeth
• Patient-doctor relation in Pedodontics 2:1
• In pedodontics, the parent and the child both are
involved and this relation is called a pedodontic
triangle
• Recently a new parameter society has also been
added
• American Academy of Pediatric Dentistry (1999)
defined “Pediatric dentistry is an age defined
specialty that provides both primary and
comprehensive preventive and therapeutic oral
health care for infants and children through
adolescence, including those with special health
care needs.”
INFANT
• Till 15 months
• Neonate advances from relative helplessness to
a position of ambulatory toddler
• Basic needs of child are hunger, thirst, sleep and
his development is related to these factors
• During infancy the main and only environment
of child is mother
• Infant also experiences his first form of fear,
referred to as stranger anxiety
• By 4 to 6 weeks he starts to acknowledge some
one other by a smile
• Stranger anxiety: Due to fear of losing mother.
• Peek-a-boo game: He has the mother at his want
and has control over her appearance
• Gasping reflex: When a finger is placed in child’s
hand, he closes the fist in a grasping manner
which is so firm that force of hand cannot be
released by child’s whole weight
Introduction 3
• Rooting reflex: If the cheek of baby is touched he

shifts his head towards stimulus
• Moro reflex: Can be elicited as a response to
sudden, large sound or by suddenly withdraw-
ing support.
TODDLER
• 15 months – 2 years
• The child begins to get into greater contact with
the realistic principle
• Young infant strives to receive pleasure
• Displays an ambivalent nature wanting to remain
an infant one moment and yet grow up the next
instant
• Rapid development in cognitive and verbal skills
and self-awareness
• Dental Examination: This is done while the child
is in parents lap
• Dental Radiographs: Toddler is usually not co-
operative for radiographs
• Minor Dental Caries: Can be excavated with a
spoon excavator and small enamel hatchets
• Prophylactic Means: Tolerate gently administered
toothbrush prophylaxis.
PRESCHOOL
• 2-6 years
• Behavior pattern is easily observed
• Skilled in the use of words and symbols
• Influenced by his immediate environment
• Play is more role-playing
• Readily identifies people and places; uses hand
tools for intended purposes
• Bizarre storytelling
• Fears are both real and unreal
• Everything is animistic
• Euphemisms and modeling is useful.
MIDDLE YEAR CHILD

• 6-12 years
• Peaceful period of time
• Time for joining others of own sex
• Understands what is seen
• Child possesses prelogical reasoning.
ADOLESCENT
• Above 13 years
• It is a pause in the cycle of life
• Individual is no longer a child but not yet an adult
• Marked by physical growth spurt, maturation of
primary and secondary sex character
• Self-awareness becomes intensified and results
in new push for independence
• Adolescent wants to be popular with everyone
but selects his/her friends from certain set
• Have a large number of casual acquaintances
• Dentist finds working with adolescent a pleasant
experience, as they will respond in an appro-
priate manner.
• Early Adolescence:
– 12 to 14 years in girls and 13 to 15 years in
boys
– Inner social feelings are directed towards
teachers, movie stars and persons of same sex
– Fear and defensive response of repression
• Middle Adolescence:
– 14 to 16 years
– Turmoil of adolescence
– Sexual relationships are formed
– Testing out bodies and experimenting with
new sensations, relationship and limit setting
– Rebellion against parent values, life styles and
limit setting
• Late Adolescence:
– Consolidation takes places
– Struggle is done with oneself rather than with
environment
– The major tasks are source of age identity.
Chapter 2
Growth and
Development
 Factors affecting growth and
development
 Growth spurts
 Growth trends
 Scammon’s curves for growth
 Growth assessment parameters
 Growth prediction
• Growth:
– Developmental increase in mass (Stewart,
1982)
– Growth refers to increase in size or number
(Proffit, 1986)
– Changes in amount of living substance
(Moyers, 1988)
• Development:
– Defined as increase in complexity (Todd, 1931)
– Naturally occurring unidirectional changes in
the life of an individual from its existence as
a single cell to its elaboration as a multifun-
ctional unit terminating in death (Moyers 1988)
• Catch-up growth: During poor nutrition in the
children the growth slows down. They wait for
better time and with return of good nutrition
growth takes place unusually fast until the
genetically determined curve is neared once more.
This is called catch-up growth.
• Differential growth: The human body doesn’t grow
at the same rate throughout life. Different organs
grow at different rates at a different amount and
at different times. This is called differential growth
• Cephalocaudal gradient of growth (Fig. 2.1): In fetal
life at about 1/3rd month of intrauterine develop-
ment, the head takes up almost 50% of total body
length. The cranium is large relative to face and
represents more than half of total head, whereas
the limbs are still rudimentary and the trunk is
underdeveloped. By the time of birth, the trunk
Fig. 2.1: Cephalocaudal gradient of growth

Growth and Development 7
and limbs have grown faster than head and face.

So that the proportions of entire body devoted to
head has decreased by 30% with the progressive
reduction in relative size of head to about 12% the
adult. There is more growth of lower limbs than
upper limbs during postnatal life. This means
there is an axis of increased growth extending
from head towards feet. This is called Cephalo-
caudal gradient of growth.
FACTORS AFFECTING GROWTH AND

DEVELOPMENT
• Genetic factors: Orchestrating the phenomenon of
growth. Polani indicates that size at birth relates
to about 18% to genome
• Extracranial and intracranial pressure: Affects size
and shape
• Maternal factors: Size of a full term infant corre-
lates well with the size of mother
• Socio-economic factors: Lower the social class of
mother smaller will be the baby
• Nutrition: Lack of nutrition delays growth, affects
size of body part, body properties, body chemistry,
quality and texture of some tissues
• Hormones: Responsible for growth are growth
hormone, insulin, parathormone, progesterone,
estrogen, prolactin
• Muscular function: Influences as vascular supply
and as a force element
• Growth factors: Peptides that transmit signals
within and between cells and play a comprehen-
sive role in modulation of tissue growth and
development
• Race: Calcification and eruption of teeth occurs
around 1 year faster in blacks as compared to their
white counterparts
• Illness: Any prolonged debilitating disease has a
profound affect on the growth process of a child
• Climate and seasonal effect: Those living in cold
climates tend to have more of adipose tissue
whereas those living in hot climate are thinner
• Physique: Tall women mature at a later age as

compared to the other women of their age groups
• Birth order: First born child usually weighs less at
birth, have short stature and higher IQ
• Secular trend: 15-year-old boys nowadays are 5
inches taller than 15-year-old boys 50 years back
• Physiological disturbance: The amount of inhibition
will depend upon the severity of psychological
disturbances due to the fact that in stressful
conditions children will display inhibition of
growth hormone.
GROWTH SPURTS
• Growth does not take place uniformly at all times.
There seem to be periods when a sudden
acceleration of growth occurs. This sudden
increase in growth is called as growth spurt
• Prenatal growth spurt involves division of the cells
• Postnatal growth spurt is physiological alteration
due to hormonal secretion
• Growth spurt occurs: Just before birth, one year after
birth, mixed dentition growth spurt, adolescent
growth spurt
• Mixed dentition growth spurt:
– Boys: 8 to 11 years,
– Girls: 7 to 9 years
• Orthodontic treatment must be done earlier in
girls, as their growth spurt is early
• Malocclusion requiring surgical correction should
only be undertaken after the growth spurt is
completed
• Arch expansion can be done during growth spurts
• Class III tendency with mandibular prognathism
should be treated before pre-pubertal growth spurt
• If the jaw growth has to be accelerated it has to be
done before adolescent growth spurt in girls.
Adolescent Growth Spurt

• Boys: 14 to 16 years, girls: 11 to 13 years
• Girls:
Stage 1: Appearance of breast buds and early
stages of development of pubic hair.
Stage 2: Secondary sexual characteristics begin to

appear.
Stage 3: Marked by onset of menstruation.
• Boys:
Stage 1: Fat spurt with feminine like fat distribution
due to estrogen production by Leydig’s cells.
Stage 2: Increase in height, redistribution and
decrease of fat and growth of sexual organs.
Stage 3: Axillary and facial hair appear and sexual
organs reach adult size.
Stage 4: Growth in height ends, hair on full face
and increase in muscular strength.
GROWTH TRENDS
• By overlapping consequent cephalograms, tweed
discerned a pattern of growth and termed it as
growth trends
• ANB angle: It is the angle between point A on
maxilla and point B on mandible. It is the difference
between SNA and SNB and indicates the
magnitude of skeletal joint discrepancies
• Type A: The maxilla and mandible grow together
and thus ANB angle remains same should this be
accompanied by class I relationship and in mixed
dentition doesn’t exceed 4.5%. No treatment is
indicated. Seen in 25% cases
• Type A subdivision: Maxilla is protruding with
ANB angle more than 4.5°. The treatment is done
to restrict the growth of maxilla while allowing
mandible to catch up
• Type B: Mandible and maxilla are found to grow
forwards and downwards with the growth of
maxilla exceeding that of mandible. Poor
prognosis and indicates that point B will not catch
up with point A
• Type B subdivision: The ANB angle is large and
continues to grow indicating unfavorable growth
trend
• Type C: The maxilla and mandible grow forwards
and downwards, mandible growing forward
more rapidly. The ANB angle is seen to be

decreasing with the mandible catching up with
maxilla. This indicates favorable trend and no
treatment is required till the eruption of canine
• Type C subdivision: The mandible is found to be
growing more forward when compared to maxilla.
With this the mandibular incisors touch the
lingual surface of maxillary incisors. Therefore,
mandibular incisors are tipped lingually,
maxillary incisors are tipped labially.
SCAMMON’S CURVES FOR GROWTH

(FIG. 2.2)
• The body tissues namely lymphoid, general,
genital and neural grow at different stages at
different times. This pattern is discerned by
Scammon’s curve
Fig. 2.2: Scammon’s growth curve

• Lymphoid tissue: It increases rapidly in late

childhood and reaches almost 200% of its adult
size. By 18 years the lymphoid tissue undergoes
involution to reach adult size
• Neural tissue: Grows very rapidly and reaches adult
size by 6-7 years
• Genital tissue: This shows negligible growth until
puberty. But, grows rapidly reaching puberty till
adult level is achieved
• General tissue: These exhibit an ‘S’ shaped curve
with rapid growth up to 2-3 years of age followed
by a slow phase till about 10 years. Then the
growth again enters rapid phase in the 10th year
and continues till terminating about 18-20 years.
GROWTH ASSESSMENT PARAMETERS

Somatotypic age: It is defined by a series of 17 anthro-
pometrical measurements where body is divided into
3 categories, viz. ectomorph, endomorph and
mesomorph.
Chronological age: It is a developmental age parameter,
which is figured from child’s date of birth. It is easy to
determine but, chronologic age is not an accurate
indicator of development nor it is a good predictor of
growth.
Dental age: The age is estimated by seeing the last tooth
that has erupted in oral cavity in normal sequence.
The disadvantages of this technique are the wide
variations in time of eruption, influence of local and
environmental factors.
Stage I : Commencement of mineralization
Stage II : Completion of crown
Stage III : Eruption
Stage IV : Completion of root.
Skeletal Age (Fig. 2.3)

• Hand and wrists have been most commonly used
for assessment of pubertal maturation
Fig. 2.3: Skeletal age
• Skeletal age is more highly correlated with the

developmental age than any other growth
parameter
• APA view radiograph of left hand and wrist
• The hand wrist region is made up of numerous
small bones, which show a predictable and
scheduled pattern of appearance, ossification and
union from birth to maturity
• Advantages include readily recognizable stage of
ossification and characteristic pattern of
ossification
• Hand and wrist region is made up of distal ends
of long bones of forearm, eight small, irregularly
shaped carpals (scaphoid, lunate, triquetral,
pisiform, trapezium, trapezoid, capitate, hamate),
5 miniature long metacarpals, phalanges and a
small sesamoid bone in the region of thumb
• Can be evaluated by Tanner JM, Whitehouse
method (RUS Score, Carpal bone method, TW2
method); Tarranger J method (MAT), Grave KC,
Brown T method (9 stages).
GROWTH PREDICTION (FIG. 2.4)

• Rickets in 1950
• Prediction of growth changes requires speci-
fication of the amount of growth change at a given
point in a given period and also the direction of
growth
Fig. 2.4: Growth prediction
Cranial Base Prediction

• Relation with sphenoethmoidal and spheno-
occipital synchondrosis
• Cranial base is designated by a line joining the
most anterior point of foramen magnum – Basion
(Ba) with anterior point of frontonasal suture –
Nasion (Na)
• Cranial base will grow 2 mm/year. This is
expressed by 1 mm forward growth of Nasion and
1mm backward growth of Basion, both along the
original cranial baseline.
Mandibular Growth Prediction

• Condylar axis: Line from a point on the Ba-Na line
midway between anterior and posterior borders
of condylar neck (DC point), to the geometric center
of mandibular ramus (Xi point). During 1 year of
growth Xi point will grow downward along
condylar axis by 1 mm
• Corpus axis: Line from Xi point to the anterior point
on mandibular symphysis. Each year corpus axis
grows 2 mm.
Maxillary Growth Prediction

• Point A on maxilla grows forward same as Nasion
• Skeletal convexity of a patient is determined by
the relationship between point A and facial plane:
Point A forward – Convex profile
Point A backward – Concave profile.
Chapter 3
Tooth Eruption
 Anatomic stages in the eruption of the
teeth
 Pattern of tooth movement
 Shedding of deciduous teeth
 Theories of tooth eruption
 Chronology of human dentition
 Teething problems
• Maury, Massler and Schour (1941) defined

eruption as a process whereby the forming tooth
migrates from its intra-osseous location in jaws to
its functional position within the oral cavity
• James K Avery defined eruption as the movement
of the teeth through the bone of the jaws and the
overlying mucosa to appear and function in the
oral cavity
• Derived from the Latin word erumpere, meaning
‘’to break out”.
ANATOMIC STAGES IN THE ERUPTION

OF THE TEETH
Given by Noyes and Schour
Stage I: Preparatory stage (opening of the bone crypt).
Stage II: Migration of the tooth toward the oral
epithelium.
Stage III: Emergence of crown tip into the oral cavity.
(Beginning of clinical eruption).
Stage IV: First occlusal contact.
Stage V: Full occlusal contact.
Stage VI: Continuous eruption.
PATTERN OF TOOTH MOVEMENT

Pre-eruptive Phase
• Preparatory to the eruptive phase
• Movement of the developing and growing tooth
germs within the alveolar processes
• Bodily movement is a shift of the entire tooth germ,
which causes bone resorption in the direction of
tooth movement and bone apposition behind it
• Eccentric growth refers to relative growth in one
part of the tooth while the rest of the tooth remains
constant, e.g. the root elongates, yet the crown does
not increase in size.
Tooth Eruption 17
Eruptive Phase
• Begins with the initiation of the root formation
and ends when the teeth reach occlusal contact
• Roots begin their formation as a result of
proliferation of both the epithelial root sheath and
the mesenchymal tissue of the dental papilla and
dental follicle
• Histologically, the eruption pathway appears as
a zone in which connective tissue fibers have
disappeared, cells have degenerated and
decreased in number, blood vessels become fewer
and terminal nerves break up and degenerate
• An altered tissue space overlying the tooth
becomes visible as an inverted funnel shaped area
and in the periphery of this zone, the follicle fibers
direct themselves toward the mucosa and are
defined as the gubernacular cord (Fig. 3.1). This
structure guides the tooth in its eruptive
movements (Fig. 3.2).
Fig. 3.1: Gubernacular cord

Fig. 3.2: Eruption mechanism
Post-eruptive Phase
• Movements made by the tooth after it has reached
its functional position in the occlusal plane
• The final eruptive phase begins when the teeth
reach occlusion, and continues for long as each
tooth remains in the oral cavity
• To accommodate the growing jaws, to compen-
sate for continued occlusal wear, to accommodate
interproximal wear
• During this phase or process, the alveolar process
increases in height and the roots continue to grow.
Tooth Eruption 19
SHEDDING OF DECIDUOUS TEETH

• Result of progressive resorption of the roots of teeth
and their supporting tissues, the dental hard
tissues
• Pressure from the erupting successional tooth
plays a key role because the odontoclasts
differentiate at predicted sites of pressure
• Forces of mastication applied to the deciduous
tooth greater than its periodontal ligament can
withstand leads to trauma of ligament and the
initiation of resorption
• Resorption of anterior tooth starts in occluso-labial
direction. Later the crown of the permanent tooth
comes directly apical to the primary root, which
causes resorption to proceed horizontally.
THEORIES OF TOOTH ERUPTION

• Root elongation theory: Crowns of the teeth are
pushed into the oral cavity by virtue of growth
and elongation of the roots
• Pulpal constriction: Growth of the root dentin and
the subsequent constriction of the pulp may cause
sufficient pressure to move the tooth occlusally
• Growth of periodontal tissues: Connective tissue
surrounding the tooth may function in pulling
the tooth into the oral cavity or growth of the
alveolar bone might push or squeeze the tooth out
of its alveolus and into the oral cavity
• Pressure from muscular action: Action of the
musculature of the cheeks and lips upon the
alveolar process might serve to squeeze the crown

of the tooth out into the oral cavity
• Resorption of the alveolar crest: Resorption of the
alveolar crest would serve to expose the crown of
the tooth into the oral cavity
• Hormonal theory: Hormones secreted by the
thyroids and pituitary glands might govern the
eruption of the teeth
• Foreign body theory: Calcified body such as the
tooth tends to be exfoliated by the tissues just as
does any foreign body
• Cellular proliferation: Osmotic pressure and other
forces resulting from cellular proliferation in the
pulp and surrounding tissues may account for
the eruption of the teeth
• Vascularity: Blood pressure exerted in the vascular
tissue, which lies between the developing tooth
and its bony surroundings, is the active
mechanical factor in eruption
• Blood vessel thrust theory: Blood generates the force
by hydrodynamic and hydrostatic forces within
the blood vessels
• Dental follicle theory: Dental follicle is essential to
achieve the bony remodeling required to
accommodate tooth movement, for it is from this
tissue that the osteoblasts differentiate
• Periodontal ligament contraction: A contractile
element within the periodontal ligament, collagen
constriction and constriction due to fibroblasts are
the prime reasons attributed for tooth eruption
• Bony remodeling: Bony remodeling of the jaws has
been linked to tooth eruption as the inherent
growth pattern of the mandible or maxilla
supposedly moves teeth by the selective deposition
and resorption of the bone in the immediate
surroundings of the tooth.
Tooth Eruption 21
CHRONOLOGY OF HUMAN DENTITION

Primary Dentition
Tooth Hard tissue Crown Eruption Root
formation completed completed
begins
Central 4 month 4 month 7½ month 1½ year

incisor in utero
Lateral 4½ in utero 5 month 9 month 2 year
incisor
Canine 5 month 9 month 18 month 3¼ year
in utero
1st molar 5 month 6 month 14 month 2½ year
in utero
2nd molar 6 month 11 month 24 month 3 year
in utero
Central 4½ month ½ month 6 month 1½ year
incisor in utero
Lateral 4½ in utero 4 month 7 month 1½ year
incisor
Canine 5 month 9 month 16 month 3 year
in utero
1st molar 5 month 5½ month 12 month 2¼ year
in utero
2nd molar 6 month 10 month 20 month 3 year
in utero
Permanent Dentition
formation completed completed
begins
Central 3-4 month 4 -5 year 7-8 year 10 year
incisor
Lateral 10-12 month 4-5 year 8-9 year 11 year
incisor
Canine 4-5 month 6-7 year 11-12 13-15
year year
1st 1½-1¾ 5-6 year 10-11 12-13
premolar year year year
2nd 2-2¼ year 6-7 year 0-12 12-14
premolar year year
1st molar Birth 2½-3 6-7 9-10
year year year
2nd molar 2½ -3 year 7-8 year 12-15 14-16
year year
3rd molar 7-9 year 12-16 17-24 18-25
year year year
Contd…
Contd…
Formation completed completed
begins
Central 3-4 month 4-5 year 6-7 year 9 year
incisor
Lateral 3-4 month 4-5 year 7-8 year 10 year
incisor
Canine 4-5 month 6-7 year 9-10 12-14
year year
1st 1¾ -2 year 5-6 year 10-11 12-13
premolar year year
2nd 2 ¼ - 2½ 6-7 year 11-12 13-14
premolar year year year
1st molar Birth 2½-3 6-7 9-10
year year year
2nd molar 2½ -3 year 7-8 year 11-13 14-15
year year
3rd molar 8-10 year 12-16 17-21 18-25
year year year
TEETHING PROBLEMS
Eruption Hematoma (Fig. 3.3)
• A bluish purple, elevated area of tissue, occasio-
nally develops few weeks before the eruption of
primary or permanent tooth
• Seen in the primary second molar or the first
permanent molar region
Fig. 3.3: Eruption hematoma

Tooth Eruption 23
• Develops as a result of trauma to the soft tissue

during function
• Self-limiting.
Eruption Sequestrum
• Seen at the time of the eruption of the first
permanent molar
• A hard tissue fragment is generally seen overlying
the central fossa of the associated tooth embed-
ded and contoured within the soft tissue.
Ectopic Eruption
• Eruption of teeth at any other site due to arch length
inadequacy or a variety of local factors.
Natal and Neonatal Teeth (Fig. 3.4)

• Natal teeth are the teeth that are present at birth
• Neonatal teeth are those that erupt within one
month after birth
• Prevalence of natal and neonatal teeth is 1:4000
• 85% are mandibular incisors, 11% are maxillary
incisors, 3% are mandibular canines and molars,
1% are maxillary canines and molars
Fig. 3.4: Isolated natal tooth

• Attributed to superficial positioning of the

developing tooth germ, which predisposes the
tooth to erupt early
• Resemble normal primary teeth, but are poorly
developed, conical, yellowish with hypoplastic
enamel and dentin and with poor or total failure
of the development of the roots.
Classification
• Shell like crown structure loosely attached to the
alveolus by a rim of oral mucosa; no root but a
solid crown, loosely attached to the alveolus by
oral mucosa; little or no root; the incisal edge of
the crown just erupted through the oral mucosa; a
mucosal swelling with the tooth unerupted but
palpable
• If the tooth is mobile to the extent that there is
danger of aspiration, its removal is indicated
• In case the sharp incisal edge of the tooth causes
laceration of the lingual surface of the tongue then
selective grinding can be done
• If breastfeeding is painful for mother initially, the
use of a breast pump and bottling the milk are
recommended. However, the infant may be
conditioned not to bite during feeding in a
relatively short time, if the mother persists with
breastfeeding.
Chapter 4
Diet and Nutrition
 Food group guides
 Diet counseling
 Dietary goals
 Vitamins
• A balanced diet is one in which nutrients from

each food group in recommended servings is
present for the optimal functioning of the human
• Basal metabolism is the minimum amount of
energy needed to regulate and maintain the
involuntary essential life processes, such as
breathing, circulation of the blood, cellular
activity, keeping muscles in good tone, and
maintaining body temperature
• The basal metabolic rate (BMR) is defined as the
number of kilocalories expended by the organism
per square meter of body surface per hour (kcal/
m2/hour)
• Specific Dynamic Action (SDA) of food is the
term used to describe the expenditure of calories
during the digestion and absorption of food. It is
2% for fats, 6% for carbohydrates and 12% for
protein-rich foods
• Recommended Dietary Allowances (RDA) are
recommendations for the average daily amounts
of nutrients that will meet nutritional require-
ments of most people.
FOOD GROUP GUIDES (FIG. 4.1)

• The objective of national food guides has been to
translate dietary standards into simple and
reliable devices for the nutrition education of the
layperson
• The food group guides serve as a practical and
workable plan for helping the homemaker select
the type and amount of food that needs to be
included in each day’s meals in order to provide
a balanced diet
• The basic seven food groups was proposed in
1946
• A four-food group was suggested by the US
Department of Agriculture (USDA) in 1957
• Five-food group guide was proposed in March
1999
• Recent modification based on energy expendi-
ture (BMR) was proposed on 15th April 2005
Diet and Nutrition 27
Fig. 4.1: Food guide pyramid
• Vegetable-Fruit group contribute vitamins A and C;

fiber and other nutrients. Four servings daily
• Bread-Cereal group: Most economical source of
nutrients, which include wheat, rice, corn, rye,
oats, and barley. Four servings daily
• Milk-Cheese group provide about two-thirds of
calcium, one half of the riboflavin, and one-fourth
of the protein in the foods normally eaten. Two
or more servings daily
• Meat, poultry, fish and beans group: The choices
beef, lamb, veal, pork, fish, poultry, egg, dried
beans, and nuts are valued for protein, niacin,
vitamin B12, and iron. Two or more servings are
recommended
• Fats, sweets and alcohol group provide mostly calories

and included in the group are butter, margarine,
mayonnaise, fats, oils, candy, sugar, jams, jellies,
soft drinks, wine, beer, and liquor. No essential
nutrients therefore minimal or no serving is
recommended.
DIET COUNSELING
• A basic prerequisite for accomplishing dietary
change is the advice that the patient not the
counselor bears the responsibility for making the
change
• Potential candidates for counseling should give
high priority to preventive dentistry and should
be willing to expend long-term efforts to
maintain their natural dentition good health for
a lifetime
• Awareness is recognition that a problem exists,
but without an inclination to solve it, e.g. hard
candies produce acid, which can cause my teeth
to decay
• Interest is greater degree of awareness but still
with no inclination to act, e.g. May be I should
give up the hard candies; I don’t want any more
sensitive or painful teeth
• Involvement is a definite intention to act, e.g.
I definitely will give up hard candy
• Action is a trial performance, e.g. I have given
up hard candies and chew sugarless gum instead
to prevent the dry feeling in my mouth
• Habit is a commitment to perform this action
regularly over a sustained period of time, e.g. I
haven’t consumed a hard candy in six months
• Directive counseling: Role of the patient is passive
and the counselor makes the decisions
• Nondirective counseling: Counselor’s role is merely
to aid the patient in clarifying and understanding
his or her own situation and to provide guidance
so that the patient can make final decision
• Gather information: Personal identifying data, likes
and dislikes, and the patient’s perception.
Diet and Nutrition 29
• Evaluate and interpret information: Relative

adequacy of the diet and eating habits
• Develop and implement a plan of action: Qualitative
modifications of the diet
• Seek active participation of the patient’s family in
all aspects of dietary change
• Maintain overall nutritional adequacy by
conforming to the USDA daily food guide
• Prescribed diet should vary from the normal diet
pattern as little as possible
• The diet should meet the body’s requirements for
the essential nutrients
• Prescribed diet should take into consideration and
accommodate the patient’s likes and dislikes, food
habits, and other environmental factors as long
as they do not interfere with the objectives
• Dental health diet score is a simple scoring
procedure that can disclose a potential dietary
problem that is likely to adversely affect a patient’s
dental health
[Food score (adequate intake of foods from each of
the food groups) + Nutrient score (consuming
foods from especially recommended groups of ten
nutrients)] – Sweet score (ingestion of foods that
are overtly sweet sugars)
• Food score: RDA of food × No. of servings
• Nutrient score: One score for each nutrient
consumed
• Sweet score: Classify the sweet by its nature and
multiply according to severity; Liquid × 5, Solid
and Sticky × 10, Slowly Dissolving × 15.
Assessment of Dental Health Diet Score

Score Result Interpretation
72-96 Excellent Counseling not required

64-72 Adequate Educate the patient
56-64 Barely adequate Counseling required
56 or less Not adequate Counseling with
diet modifications
DIETARY GOALS
• Increase the consumption of complex carbo-
hydrates and naturally occurring sugars from
about 28 to 48%
• Reduce the consumption of refined and
processed sugars by about 45%
• Reduce overall fat consumption from approxi-
mately 40 to 30%
• Reduce saturated fat consumption
• Reduce cholesterol consumption to about
300 mg/day
• Limit sodium intake by reducing salt to about
5 g/day.
Changes in Food Selection and Preparation

Suggested by the Dietary Goals
• Increase consumption of fruits, vegetables and
whole grains
• Decrease consumption of refined sugars
• Decrease consumption of food high in total fat
and replace saturated fats with polyunsaturated
fats
• Decrease consumption of animal fat, choosing
meats such as poultry to reduce saturated fat intake
• Decrease consumption of butterfat, eggs, and other
sources high in cholesterol
• Decrease consumption of salt and foods high in
salt content.
Implementation of Dietary Goals

• Eat a variety of foods
• Eat foods with adequate starch and fiber
• Eat a minimum to moderate amount of sugar
• Eat a minimum to moderate amount of salt
• Consume alcohol only in moderation
• Achieve and maintain ideal weight.
VITAMINS
Vitamin Name Functions Deficiency RDA Food sources
B1 Thiamin • Co-enzyme Wet, dry and 1 mg/day Cereals, meat, legumes,

• Helps in DNA, RNA infantile beriberi pork, liver, peas, beef,
formation nuts, milk, leafy vegetable
• Metabolism of fats, proteins
• Role in neurophysiology
B2 Riboflavin • Co-enzyme Dermatitis, glossitis, 1.5 mg/day Milk, liver, cheese,
• ATP generation angular stomatitis eggs, cereals, whole
• Metabolism grains, vegetables
B4 Niacin • Co-enzyme Pellagra 16-33 Niacin Liver, yeast, meat,
• Tissue respiration Equivalents legumes, cereals
• CNS functioning
B5 Pantothenic • Involved in Krebs’s cycle Paresthesia, fatigue, 4-7 mg/day Eggs, cereals, legumes,
Acid • Component of sterols abdominal stress milk, potatoes
Diet and Nutrition
Contd…
31
32
Contd…
— Biotin • Stimulates growth of yeast Dermatitis, paresthesia, 100-200 μg/day Liver, milk, egg
• Constituent of DNA glossitis, yolk, yeast
B6 Pyridoxine • Co-factor for enzymes Dermatitis, glossitis, 0.3-2 mg/day Meat, liver, yeast, legumes,
• Synthesis of amino acids convulsions wheat barn, cereals
B 12 Cyanocobalamin • Co-enzyme Atrophic glossitis, 3 μ/day Meat, egg, milk, cheese,
• Maintenance of combined system fish
myelin sheath disease
— Folic Acid • Maturation of blood cells Malabsorption, 0.4 mg/day Liver, dark green leafy
Pocket Book of Pedodontics
• Co-enzyme anemia, angular vegetables, nuts, orange

• DNA synthesis cheilosis asparagus, soya
C Ascorbic Acid • Formation of collagen Scurvy, hemorrhagic 60 mg/day Pepper, turnip, citrus
• Wound healing skin, follicles, swollen fruits, cabbage, beans,
• Role in hematology and bleeding gums tomatoes, carrot,
• Role in phagocytosis tamarind
Contd…
Contd…
• Metabolism of amino acids

A Retinol • Formation of visual purple Night blindness, 5000 IU Yellow and green
• Differentiation of keratomalacia, vegetables, carrot,
epithelium xeropthalmia, cabbage, spinach,
• Promotion of bone hyperkeratosis, potatoes
remodeling hypoplasia
D Cholecalciferol • Calcium and phosphorus Rickets and 400 IU Fish, egg, liver,
absorption osteomalacia butter, milk
E Tocopherol • Antioxidant Anemia 10-20 IU Cereals, soyabean, corn,
• Stabilizes cell membrane meat, milk, egg
• Prevents fats form decay
K Menadione • Synthesis of prothrombin Clotting disorders 70-140 μg/day Lettuce, spinach,
and other clotting factors cauliflower, cabbage
Diet and Nutrition
33
Chapter 5
Microbiology of
Oral Cavity
 Classification of oral microorganisms
 Development of oral flora
 Microbiota of oral cavity
• The oral cavity of the newborn child is sterile until

the first hour of birth
• Detectable microorganisms appear within 8 hours
• Pioneer species are the organisms, which colonize
in the first few days of life in the oral cavity
• Streptococcus salivarius, which colonizes on the
tongue and saliva is the first bacteria to appear
• Other species, which can be identified, include
Staphylococci, lactobacilli, neisseria and candida
• Oral environment undergoes a major change at
around 6 months due to eruption of deciduous
teeth as this provides opportunities for the
establishment and growth of microorganisms on
hard tissue
• Streptococcus sanguis and streptococcus mutans
are especially known to favour enamel surfaces
• Climax community is the final microflora, which
once established is maintained for many years.
CLASSIFICATION OF ORAL
MICROORGANISMS
Gram-positive Bacteria
• Facultative Anaerobic cocci
– Genus Enterococcus
– Genus Stomatococcus
• Obligate Anaerobic Cocci
– Genus Peptostreptococcus
• Regular and Non-sporulating Rods
– Genus Lactobacillus
• Irregular, Non-sporulating and Facultative
Anaerobic Rods
– Genus Actinomyces
– Genus Arachnia
– Genus Bacterionema
– Genus Rothia
• Irregular, Non-sporulating and Obligate
Anaerobic Rods
– Genus Bifidobacterium
– Genus Eubacterium
– Genus Propionibacterium
Microbiology of Oral Cavity 37
Gram-negative Bacteria
• Facultative Anaerobic Cocci
– Genus Neisseria
• Obligate Anaerobic Cocci
– Genus Veillonella
• Facultatively Anaerobic Rods
– Genus Actinobacillus
– Genus Capnocytophaga
– Genus Eikenella
– Genus Hemophilus
• Microaerophilic, Motile and Helical/Vibrioid
Rods
– Genus Bacteroides
– Genus Fusobacterium
– Genus Leptotrichia
– Genus Selenomonas
Genus Wolinella
• Spirochetes
– Genus Treponema
• Fungi
– Genus Candida
• Virus
– Herpes virus group.
DEVELOPMENT OF ORAL FLORA

Adhesion of Oral Flora
• Flow of saliva in conjunction with mastication
and swallowing means that microorganism
population is limited
• Gingival crevice, fissures and proximal areas
between adjacent teeth are predominant attach-
ment sites
• Few microorganisms have the ability to colonize
on exposed surfaces such as teeth
• Factors, which help in adhesion, are host poly-
mers, bacterial polymers, physical retention,
fimbriae and site-specific receptors (adhesions)
• Cell-substratum adhesion: This phase is also
referred to as ‘deposition’ since it involves the
external surfaces of both organism and the

substrate. (Microorganism and the substratum)
• Homotypic cell-cell adhesion: It is the linking of
organisms of the same kind, i.e. the first orga-
nism interacts with the substratum (enamel or
epithelium) and then the second organism
attaches to the first
• Heterotypic cell-cell adhesion: It is the linking
identical to homotypic except that second
organism or cell attachment is of a different type.
Growth of Oral Flora

• Temperature:
Psychrophils—0 to 30 °c and an optimum of
29°c
Mesophils—10 and 45°c and an optimum of
37°c
Thermophils—25 to 75°c with an optimum
of 50 to 55°c
• Acidity:
Most microorganisms in oral cavity require
a level of acidity or pH close to neutrality
Acidouric: (acid-tolerating) Bacteria that can
survive and grow in acidic conditions
Acidogenic: Bacteria, which produce large
amount of acid
• Oxidation – reduction potential (Eh):
Obligate anaerobes: Grow only in absence of
oxygen
Obligate aerobes: Require oxygen for growth
Facultative aerobes: Basically anaerobes but
can live in aerobic conditions
Facultative anaerobes: Basically aerobes but
can live in anaerobic conditions
Microaerophilic: Need low oxygen levels to
survive.
• Nutrients:
From saliva and gingival (crevicular) fluid –
amino-acids, proteins, sugars and glycopro-
teins.
Survival of Oral Flora

Depends on their ability to withstand the defense
systems of the body like neutrophils, complement
and immunoglobulin antibodies.
MICROBIOTA OF ORAL CAVITY

Lips
• Staphylococci
• Micrococci
• Gram +ve rods on the outer aspect and Gram
–ve in the oral cavity.
Cheeks
• Streptococcus Mitior (60% of all bacteria present)
• Streptococcus Sanguis, Streptococcus Salivarius
• Streptococcus Mutans, Lactobacillus, Veillonella,
Streptococcus Milleri (less than 1%).
Palate
• Palatal Flora is not particularly well known but
is thought to be similar to that of cheeks
• Candida species have been isolated in cases of
denture stomatitis.
Tongue
• The most outstanding microorganism on the
tongue is probably Streptococcus Salivarius
(50%)
• Streptococcus Mitior, Streptococcus Milleri,
Streptococcus Sanguis
• Hemophilli, Lactobacillus
• Veillonella, Neisseria, Fusobacterium and Spiro-
chetes.
Saliva
•· Saliva tends to favor those bacteria, which can
use nitrogenous compounds
• In general, saliva is not considered having its own
flora because of removal by swallowing.
Gingival Crevice
• Microorganisms are not easily dislodged from the
gingival crevice whereas the gingival (crevicular)
fluid provides an excellent nutrient growth
• It is estimated that 10 to 1000 bacteria may be
present in each gingival crevice
• Streptococcus Sanguis, Streptococcus Mitior,
Streptococcus Salivarius
• Gram –ve species like Bacteroides, Fusobac-
terium and Spirochetes.
Teeth
• Actinomyces : A. Israeli, A. Viscous,
A. Naeslundii
• Streptococci : S. Mutans, S. Sanguis,
S. Salivarius, S. Milleri
• Others : Neisseria, Fusobacterium and
lactobacilli.
Supra-gingival Plaque
• 2 to 4 days: Streptococci, Neisseria, some gram
+ve rod forms and few filamentous forms
• 6 days: Anaerobic vibrios and Spirochetes appear
within along with the cocci, rod and filamentous
forms
• Mature supragingival plaque: Contains mostly
gram +ve facultative anaerobes. Streptococcus
Sanguis is the most commonly found Strepto-
coccus along with Streptococcus Mitis, Strepto-
coccus Mutans. A. Viscosus, A. Naeslundii and
A. Israilii are found in almost all plaque samples.
Other Gram +ve species that are regularly
detected include, Peptostreptococcus species and
Staphylococcus. Some Gram –ve species that are
present include Veillonella, Fusobacterium, and
Bacteroides.
Sub-gingival Plaque
• 50% – 85% of Gram +ve cocci and rods,
15 – 30% of gram –ve cocci and rods, 8% of
Fusobacterium and about 2% Spirochetes
• Actinomyces and Streptococcus species are the

major component of the cultivable flora
• Bacteroides is frequently isolated from the
gingival sulcus
• Spirochetes of the genera treponema are
indigenous to the gingival sulcus area.
Special Microbiota
• ANUG: Spirobacterium, Bacteroides, Spirochetes
• Juvenile Periodontitis: Actinobacillus actino-
mycetes comitans, Capnocytophaga, Eubac-
terium, Spirochetes.
Dental Caries
• Pit and Fissure: Streptococcus mutans, Strepto-
coccus sanguis, Lactobacillus, Actinomyces
• Smooth surface: Streptococcus mutans, Strepto-
coccus salivarius
• Root surface: Actinomyces viscosus, Actinomyces
naeslundii, Streptococcus mutans, Streptococcus
sanguis, Streptococcus salivarius
• Deep dentinal caries: Lactobacillus, Actinomyces
naeslundii, A. viscosus, Streptococcus mutans.
Chapter 6
Child Psychology
 Aims and objectives of child
psychology
 Psychoanalytical theory
 Psychosocial theory
 Theory of cognitive development
 Classical conditioning
 Operant conditioning
 Social learning theory
 Hierarchy of needs
AIMS AND OBJECTIVES OF CHILD

PSYCHOLOGY
• Understand the child better and therefore deal with
him more effectively and efficiently
• Better planning and interaction between
treatment plan
• To identify the problems of psychosomatic origin
• To train the child so that he understand his own
oral hygiene
• Helps modify child’s developmental process.
PSYCHOANALYTICAL THEORY
• Given by Sigmund Freud in 1905
• Freud proposed a structure called as psychic triad
that essentially has three parts Id, ego, superego
• ID is the most primitive part of a personality and
the basic structure of personality, which serves
as a reservoir of instincts
• SUPEREGO is that part of personality that is
internalized representation of the values and
morals of society as taught to the child by parents
and others
• EGO: It is the part of self that is concerned with
overall functioning and organization of
personality through its capacity to test reality and
utilization of ego defense mechanism and other
functions like memory, language and creativity.
Psychosexual Stages of Development

Oral Stage
• 0-1.5 years
• Erogenous zone in focus is mouth
• Gratifying activities include nursing, eating, as
well as mouth movement including sucking,
biting and swallowing
• Interaction with the environment: Breastfeeding
• Symptoms of oral fixation: Smoking, nail biting.
Child Psychology 45
Anal Stage
• 1.5-3 years
• Erogenous zone in focus is anus
• Gratifying activity is bowel movement
• Interaction with the environment: Toilet training
• Symptoms of anal fixation:
– Anal—Expulsive personality: disorganized,
reckless, careless and defiant
– Anal—Retentive personality: clean, orderly
and intolerant to those who aren’t clean.
Phallic Stage
• 4-5 years
• Erogenous zone in focus is genitals
• Gratifying activities: Genital fondling
• Interaction with the environment:
– Oedipus complex—Boys are attracted
towards mothers
– Electra complex—Girls are sexually attracted
towards their fathers
– Castration anxiety—Seen in boys, as they fear
that the father will punish them for their
attraction towards their mother
– Penis envy—Girl believes she once had a
penis but it was removed, in order to compen-
sate for its loss the girl wants to have a child
from her father
• Symptoms of phallic fixation:
– Men—Narcissistic personality
– Women—Maintain a sense of envy and
inferiority.
Latency
• 5 years–Puberty
• No erogenous zone in focus during this period
• Interaction with the environment: children to focus
their energy on other aspects of life friendships,
engaging in sports, etc.
Genital Stage
• From puberty onwards
• Erogenous zone in focus: Genital
• Gratifying activities: Heterosexual relationships
• Interaction with the environment: This stage is
marked by a renewed sexual interest.
PSYCHOSOCIAL THEORY
• This theory was given by Erik H Erickson
• This is also called as theory of developmental
tasks
• Each stage is characterized by a different
psychological crisis, which must be resolved by
the individual before he can move on to the next
stage.
Stage 1
• Infancy
• Age 0 to 1 year
• Trust vs Mistrust
• Infants depend on others for food and affection
and therefore must be able to blindly trust the
parents
• Positive outcome secure attachment
• Negative outcome develop mistrust towards
people, environment and even towards them-
selves.
Stage 2
• Toddler
• Age 1 to 2 years
• Autonomy vs Doubt
• Toddlers learn to walk, talk and do things for
themselves thus developing self control and self
confidence
• Positive outcome: If parents encourage their child’s
use of initiative and reassure him when he makes
mistakes, the child will develop the confidence
• Negative outcome: If parents are over protective
or disapproving of the child’s acts of indepen-
Child Psychology 47
dence he may begin to feel ashamed of his

behavior or have too much doubt of his abilities.
Stage 3
• Early childhood
• Initiative vs guilt
• Children develop motor skills and become more
engaged in social interaction with people around
them
• Positive outcome: If parents are encouraging but
consistent in discipline, children will learn to
accept without guilt that certain things are not
allowed and at the same time will not feel ashamed
• Negative outcome: If not children may develop a
sense of guilt and may come to believe that it is
wrong to be independent.
Stage 4
• Elementary and middle school years
• Competence vs inferiority
• School is the important event at this stage.
• Positive outcome productive, seeking success they
will develop a sense of competence
• Negative outcome: If not they will develop a sense
of inferiority.
Stage 5
• Adolescence
• Identity vs role confusion
• Identity crisis forms the essence of this period
• Positive outcome: Strong identity and ready to plan
for the future
• Negative outcome: Unable to make decisions about
vocation, sexual orientation and his role in life.
Stage 6
• Young adulthood
• Intimacy vs Isolation
• Important events are relationships
• Positive outcome: Individuals can form close
relationships and share with others if they have
achieved a sense of identity
• Negative outcome will fear commitment; feel
isolated and unable to depend on anybody in the
world.
Stage 7
• Middle adulthood
• Creativity vs stagnation
• Adult’s ability to look outside oneself and care
for others through parenting
• Positive outcome: Nurturing children or helping
the next generation in other ways
• Negative outcome: Person will remain self-
centered and experience stagnation later in life.
Stage 8
• Late adulthood
• Age 65 years to death
• Integrity vs despair
• Old age is a time for reflecting upon one’s own
life and seeing it filled with pleasure and
satisfaction or disappointments and failures
• Positive outcome: will accept death with a sense
of integrity just as healthy child will not fear life
• Negative outcome: If not, the individual will
despair and fear death.
THEORY OF COGNITIVE DEVELOPMENT

• Given by Jean Piaget in 1952
• It deals with cognitive development beginning
with primitive reflexes and motor co-ordination
of infancy to thinking and problem solving of
adolescence till adulthood.
Child Psychology 49
Sensorimotor Period
• Birth to 2 years of age
• Some of the following reflexes are developed
– Automatic inborn reflexes of infants, e.g.
crying
– Co-ordination of reflexes improves, e.g. child
gets digits close to mouth while crying
– Infants try to perceive interesting experiences,
e.g. kick crib to hear the bell ring.
Preoperational Period
• 2 to 7 years
• Manipulation of symbols or words in a charac-
teristic of this stage
• Preoperational period can be divided into two stages:
Pre-conceptual stage (2 to 4 years) and Intuitive
stage (4 to 7 years)
• Child can use a stimulus to represent other objects
• Prelogical reasoning appears based on precon-
ceptual appearances unhampered by reversibility
• Trial and error may lead to an intuitive discovery
of correct relationships
• At preoperational period capabilities for logical
reasoning are limited. The child’s thought
process is dominated by the immediate sensory
impressions.
Concrete Operation Period

• 7 to 11 years
• Improved ability to reason emerges
• Uses a number of logical processes involving the
object that he has handled or manipulated.
• Able to decentre, i.e. focus attention on more than
one attribute at the same time
• Capable of rationale thinking so that he can
classify objects according to their sizes, shapes.
Formal Operational Stage

• After 11 years of age
• Ability to deal with abstract concept and abstract
reasoning develops
• At this stage the child’s thought process has

become similar to that of an adult and the child
is capable of understanding concepts like health
diseases and preventive treatment.
CLASSICAL CONDITIONING
• Described by the Russian psychologist Ivan
Pavlov in 1927
• Apparently unassociated stimuli could produce
the reflexive behavior
• Pavlov classical experiment
– Food—salivation
– Bell—no salivation
– Food and bell—salivation
– Bell alone—salivation
• Dental situation
– Injection—anxiety
– Injection and dentist—anxiety
– Dentist alone—anxiety.
OPERANT CONDITIONING
• This was given by BF skinner in 1938
• Operant conditioning, which can be viewed
conceptually as a significant extension of classical
conditioning
• The basic principle of operant conditioning is that
the consequence of a behavior itself is a stimulus
that can affect future behavior response
• Skinner described four basic type of operant
conditioning depend on the nature of the
consequence
a. Positive reinforcement
b. Negative reinforcement
c. Omission or time out
d. Punishment.
SOCIAL LEARNING THEORY

• Proposed by Albert Bandura in 1963
• Reinforcement is a facilitative rather than a
necessary condition for learning and is a
Child Psychology 51
powerful method for regulating performance of

behavior but is a relatively ineffective method
for learning it
• The process for learning is divided into four steps
– Attentional process
– Retention process
– Motoric reproduction
– Reinforcement and motivation.
HIERARCHY OF NEEDS
• This was given in 1954 by Abraham Maslow
• Individual priority needs and motivations during
personality development are classified
• The levels start from most basic instinct and
elaborate to rational intellectual ones.
– Level 1: Physiologic needs – reproduction,
hunger, thirst, fear, etc.
– Level 2: Security—shelter and employment.
– Level 3: Social—sense of belonging
– Level 4: Esteem—personal needs to acquire
personal worth, competency and skills
– Level 5: Self actualization—is the attainment
of self realization.
Chapter 7
Behavior and
Behavior
Management
 Objectives of behavior management
 Factors influencing child’s behavior in
dental office
 Dental office environment
 Role of dentist in child’s behavior
 Maternal attitude: (Bayley and
Schaefer)
 Effect of the mother’s presence in the
operatory
 Classification of child’s behavior in
dental office
 Behavior management techniques
 Treatment immobilization
 Pre-anesthetic medication
 Conscious sedation
Behavior: It is an observable act, which can be

described in similar ways by more than one person.
Child management: PJ Holloway, JN Swallow defined
child management in the dental surgery as the means
by which a course of treatment for a young patient
can be completed in the shortest possible period,
while at the same time ensuring that he will return
for the next course willingly.
Behavior management: (Wright 1975) Is the means by
which the dental health team effectively and
efficiently performs treatment for a child and at the
same time, instills a positive dental attitude.
Behavior modification: (Mathewson) The attempt to
alter human behavior and emotion in a beneficial
manner according to the laws of modern learning
theory.
Behavior shaping: Is the procedure, which slowly
develops behavior by reinforcing a successive
approximation of the desired behavior until the
desired behavior comes into being, e.g. Desensiti-
zation, Tell Show Do, Modeling, Distraction,
Contingency Management.
Behavioral pedodontics: Defined as study of sciences
which help understands the development of fear,
anxiety and anger as it applies to the child in the
dental situation.
Flooding technique: Described as behavior modi-
fication technique that eliminates a child’s attempts
to avoid experiences that he perceives to be
undesirable, e.g. Hand Over Mouth (HOM), Physical
restraints.
Cooperative: Children who remain physically and
emotionally relaxed and cooperative throughout the
entire visit, regardless of treatment undertaken.
Tense cooperative: Children who are tense but
nevertheless co-operative.
Behavior and Behavior Management 55
Outwardly apprehensive: Child who hides behind the

mother in the waiting room, use stalling techniques
and avoids talking to the dentist. These children will
eventually accept dental treatment.
Fearful: Children who require considerable support
in order to overcome their fear of dental situation.
Stubborn/defiant: Children who passively resist or try
to avoid treatment by using techniques that have
been successful for them in other situations.
Hypermotive: Children who are agitated and who
adopt procedures such as screaming or kicking as
their coping defense mechanism.
Handicapped: Children who are physically, mentally
or emotionally handicapped.
Emotionally immature: This category includes the
young children who have not yet achieved sufficient
emotional maturity to rationalize the need for dental
and to satisfactory cope with it.
Hysterical/uncontrolled behavior: There is loud crying,
kicking, and temper tantrums.
Defiant/obstinate behavior: He controls his behavior
in a sense by challenging the authority of the dentist.
Timid behavior: It is a result of childish anxiety about
the dental experience and how he is expected to
perform in the office. The child’s anxiety may
prevent him from listening attentively to the dentist,
so instruction must be given slowly, quietly and
repeated when necessary.
Whining behavior: He allows treatment but he whines
throughout the entire procedure.
Stoic behavior: He sits quietly and accepts all dental
treatment including the injection without protest or
any sign of discomfort.
OBJECTIVES OF BEHAVIOR MANAGEMENT

Snowder outlined these in 1980
• To establish effective communication with child
and parent
• Gain child and parent confidence and acceptance
for dental treatment
• Teach child positive aspect of preventive dental
cure
• Provide a comfortable, relaxing environment to
the child.
FACTORS INFLUENCING CHILD’S BEHAVIOR

IN DENTAL OFFICE
Wright and Wei summarized the following factors:
• Medical history
• Maternal anxiety
• Family and peer influence
• Dental office environment
• Growth and development
• Socio-economic status
• Culture
• Sex
• Sibling relation
• Number of children
• Presence of parent
• Attitude of dentist.
DENTAL OFFICE ENVIRONMENT

• Waiting room should be made in respect to home
environment
• Make the reception room comfortable, so that the
room is not foreign to them
• Children’s chairs and table available where they
can sit and read
• Have library with books for children of all ages
• Keep toys to amuse children
• Play soothing music so as to relax a frightened
child
• Make appointment cards attractive
• Operating room may be made more appealing

to the child with pictures on the wall suggestive
of child at play
• Have an assistant skilled in making animals
object out of cotton rolls.
ROLE OF DENTIST IN CHILD’S BEHAVIOR

• Personality of dentist should be good
• Time and length of appointment should be short
• Dentist should be skilled
• Dentist should always converse during treatment
• Use of simple words
• Should be realistic and reasonable
• Use of admiration, subtle flattering, praise and
reward.
MATERNAL ATTITUDE
(BAYLEY AND SCHAEFER)
Mother’s behavior Child’s behavior
1. Over protective Submissive, shy, anxious

2. Over indulgent Aggressive, spoilt,
demanding, displays of
temper tantrums
3. Under affectionate Usually well behaved, but
may be unable to cooperate,
may cry easily.
4. Rejecting Aggressive, overactive,
disobedient
5. Authoritarian Evasive
EFFECT OF THE MOTHER’S PRESENCE IN

THE OPERATORY
Frankel found that children in age group of 42-49
months benefited from mothers presence as they
exhibit anxiety during short-term separation.
CLASSIFICATION OF CHILD’S BEHAVIOR IN

DENTAL OFFICE
Frankel’s Classification
Introduced by Frankel in 1962 and modified by
Wright in 1975.
Definitely Negative
Rating No. 1 (–)
• Refuses treatment
• Cries forcefully
• Uncontrollable behavior
• Extreme negative behavior associated with fear.
Negative Rating No. 2 (–)
• Reluctant to accept treatment
• Displays evidence of slight negativism.
Positive Rating No. 3 (+)
• Accepts treatment.
Definitely Positive: Rating No. 4 (++)
• Understands the importance of dental care and
looks forward to the visit.
Pinkham’s Classification
• Category I – Emotionally compromised child
• Category II – Shy, introvert child
• Category III – Frightened child
• Category IV – Child who is adverse to authority.
Lampshire’s Classification
• Cooperative
• Tense cooperative
• Outwardly apprehensive
• Fearful
• Stubborn/defiant
• Hypermotive
• Handicapped
• Emotionally immature.
Wright’s Classification: (1975)

• Co-operative behavior
• Lacking co-operative behavior
• Potentially co-operative behavior.
BEHAVIOR MANAGEMENT TECHNIQUES

Pre-appointment Behavior Modification
1. Audio-visual modeling: The patient observes a film
of a child undergoing treatment. The goal is for
the patient to reproduce the behavior exhibited
by model. It is best recommended to use the
model of the same age as the child so that the
patient can easily relate himself with the model.
2. Pre-appointment mailing: Contact with the child
before the first dental visit can alienate some
concerns.
Communication
By involving the child in conversation, the dentist
not only learns about the patient but also may relax
the youngster.
1. Verbal: Spoken language to gain confidence
2. Non-verbal: Expression without words like
welcome hand shake, patting, eye contact.
Voice Control (Pinkham 1985)

Sudden and firm commands that are used to get the
child’s attention and stop the child from whatever
he is doing.
Tell Show Do (TSD) (Figs 7.1A to C)

• Given by Addleston in 1959.
Fig. 7.1A: Explanation of method

Fig. 7.1B: Demonstration
Fig. 7.1C: Performing
Tell: Verbal explanations of procedures.

Show: Demonstration for the patient of visual,
auditory, olfactory and tactile aspects of the
procedure.
Do: The dentist proceeds to perform the previewed
operation.
Desensitization
• Explained by James and popularized by Wolpe
• It means to take away ones sensitivity to another
type of behavior modification.
Modeling
• Based on Bandura’s social learning theory
• Acquisition of behavior occurs through obser-
vation of suitable model performing a specific
behavior.
Contingency Management
The presentation or withdrawal of reinforcers is
termed contingency management.
Positive reinforcers is one whose contingent
presentation increases the frequency of desired
behavior.
Negative reinforcers is the one whose contingent
withdrawal increases the frequency of a behavior.
Material reinforcers: Candy, gum, cookies.
Social: Praise, positive facial expression.
Activity reinforcers: Opportunity of participating in a
preferred activity.
Externalization
• It is a process by which child’s attention is focused
away from the sensation associated with dental
treatment by involving in verbal activity.
Retraining
• Designed to fabricate positive values and to replace
the negative behavior
• Useful in a child who had a previous bad
experience or who exhibits negativism due to
parental and peer influence.
Visual Imagery
• Controlled day dreaming
• Child is asked to dream about his favorite activity
or fantasy during dental treatment.
Hand Over Mouth Technique (Fig. 7.2)

• Dr Evangeline Jordan first described this
technique in 1920
• Used in a healthy child who is able to understand
and co-operate but who exhibits defiant,
(obstreperous) or hysterical behavior
• A hand is placed over child’s mouth and
behavioral expectations are calmly explained.
Child is told that the hand will be removed as
soon as the appropriate behavior begins. When
child responds the hand is removed and child’s
appropriate behavior is reinforced
• To gain child’s attention enabling communication
with dentist
• To eliminate inappropriate avoidance behavior
to dental treatment
• It is also called as:
– Aversive Conditioning by Lenchner and
Wright (1975)
– Emotional surprise therapy by Lampshire
– Hand Over Mouth Exercise (HOME) by Levitas
(1947)
– Aversion (by Crammer) (1973).
Fig. 7.2: HOM being carried out

Hypnosis
• Given by Franz A Mesmer in 1773
• It is defined as a state of mental relaxation and
restricted awareness in which subjects are usually
engrossed in their inner experiences such as
imagery, are less analytical and logical in their
thinking and have enhanced capacity to respond
to suggestions in an automatic and dissociated
manner
• To reduce nervousness, apprehension, to control
functional or psychosomatic gapping and to
eliminate habits
• Technique involves patient preparation, hypnotic
induction, deepening, post-hypnotic suggestion
and alerting patient after therapy.
TREATMENT IMMOBILIZATION
• Indicated in a patient who requires diagnosis or
treatment and cannot cooperate because of lack of
maturity, mental or physical disabilities and after
other behavior management techniques have
failed
• Contraindications include a cooperative patient,
a patient who cannot be safely immobilized
because of underlying medical or systemic
conditions
• Immobilization aids for mouth include Tongue
blades, Open wide mouth prop, Molt mouth prop,
Rubber bite blocks
• Immobilization aids for body are Papoose Board,
Triangular sheet, Pedi-Wrap, Beanbag dental
chair insert, Safety belt
• Extremities can be immobilized by Posey straps,
Velcro straps, Towel and tape
• Head stabilizers include head positioner, Plastic
bowl.
PRE-ANESTHETIC MEDICATION
• It refers to the use of drugs before anesthesia to
make it more pleasant and safe
• Its uses include relief of anxiety and apprehension

preoperatively, amnesia for pre and postoperative
events, supplement analgesic action of anesthetics
• Drugs used:
– Opioids: Morphine (10 mg) or Pethidine (50-
100 mg) given intramuscularly (IM)
– Benzodiazepines: Diazepam (5-10 mg oral) or
Lorazepam (2 mg IM)
– Anti-cholinergics: Atropine (0.6 mg IM or IV)
– Neuroleptics: Chlorpromazine (25 mg) or
haloperiodol (2-4 mg) IM
– H2 Blockers: Ranitidine (150 mg)
– Anti-emetics: Metaclopramide (10-20 mg) IM.
CONSCIOUS SEDATION
• Conscious sedation is a controlled, pharma-
cologically induced, minimally depressed state or
level of consciousness in which the patient retains
the ability to maintain a patent airway
independently and continuously and to respond
appropriately to physical stimulation and/or
verbal command
• Goals of conscious sedation are to provide the most
comfortable, efficient and high quality dental
service for the patient, to control inappropriate
behavior on the part of the patient that interferes
with such provision of care and to promote patient
welfare and safety
• Indicated in patients requiring dental treatment
but can’t cooperate due to lack of psychological or
emotional maturity, medical, physical, cognitive
disability and fearful behavior.
Inhalation Sedation
Oral Sedation
• It is the easiest route of drug administration
• Variable results and consistency, difficult reversal
of unwanted effect and slow recovery time
• Mostly recommended for premedication and
combination therapy.
Intramuscular Sedation
• Upper outer quadrant of gluteal region is safest
• In children anterior thigh (vastus lateralis
muscle) is the preferred site.
Submucosal Sedation
• This involves deposition of the drug beneath the
mucosa
• Buccal vestibule is the most common site.
Intravenous Sedation
• Fastest method of sedation
• The onset of action of the drug is within 30 sec.
Drugs Used for Conscious Sedation
Drug Route Dosage Advantages Disadvantages Properties
Hydroxyzine Oral 0.6 mg/kg Rapidly absorbed from Dry mouth, drowsiness, • Clinical effect seen in 15-30 min
IM 1.1 mg/kg GIT hypersensitivity • Half life of 3 hour
Promethazine Oral 0.5 mg/kg Sedative and anti- Dry mouth, blurred vision, • Onset: 15 - 60 min
IM 1.1 mg/kg histaminic properties, thickening of bronchial • Metabolized in liver
well absorbed after oral secretions, hypotension, • Potentiates CNS depressants
ingestion extrapyramidal effects
Diphen- Oral, 1.0-1.5 Absorbed through GIT, Disturbed coordination, • Maximum effect in 1 hour
hydramine IM, IV mg/kg eliminated in 24 hours epigastric distress • Metabolized in liver
• Mild sedative
Diazepam Oral 0.2-0.5 mg/kg Sedative and anxiolytic, Ataxia, prolonged CNS • Lipid soluble and water
Rectal IV 0.25 mg/kg rapidly absorbed from effects, rebound effect insoluble
GIT • Half life is 20-50 hour
• Has three metabolites
• Strong anticonvulsant
Contd…
Contd…
Drug Route Dosage Advantages Disadvantages Properties
Midazolam Oral 0.25-1 mg/kg High water solubility, Apnea, respiratory • Packed at 3.3 pH but it
IM 1-0.15 mg/kg sedation in 3-5 min and depression in high doses, changes to 7.4 on entering
recovery in 2 hour, hypotension blood
no rebound effect, rapid • Highest lipid solubility
absorption from GIT • Very less half life
Chloral Oral, 25-50 mg/kg Commonly used for Irritating to gastric • Onset: 15-30 min
hydrate Rectal children due to its mucosa, drowsiness • Half life is 8-10 hour
well-known effects • Excitation before sedation
Fentanyl IM, IV 0.002-0.004 Potent analgesic, Respiratory depression • Metabolized in liver
mg/kg rapid onset • Excreted in urine
• Onset: 7-15 min
Ketamine IM, IV 1-5 mg/kg Potent analgesic, rapid Gastric distress, apnea, • Safety not yet established
Onset: 1 min in IV and CVS disorders, • Fast onset and short
Behavior and Behavior Management
5 min in IM hallucinations duration of action

67
Chapter 8
Development of
Occlusion
 Gum pads
 Deciduous dentition period
 Mixed dentition period
 Self-correcting anomalies
GUM PADS
• The alveolar process at the time of birth is called
the gum pads
• Horseshoe shaped pads that are pink, firm and
covered with a layer of dense periosteum
• Dental groove divides gum pads into labio-buccal
and lingual aspects
• Gum pad is divided into 10 segments by
Transverse groove; each segment has one
developing tooth sac
• Gingival groove separates palate and floor of
mouth
• Lateral sulcus, is present between canine and 1st
molar and helps in predicting inter-arch relation
• Infantile open bite: When the corresponding gum
pads are approximated, there is an overjet all
around with contact only in the molar region. This
is helpful during suckling.
DECIDUOUS DENTITION PERIOD

• 6 months to 3 ½ years
• Both the dental arches are ovoid in shape
• No curve of spee is present
• Shallow cuspal interdigitation
• Deep bite
• Spaced dentition
• Terminal plane relation.
Primate Spaces (Fig. 8.1)

• Present mesial to maxillary deciduous canines and
distal to mandibular deciduous canines
• These spaces are also called as anthropoid or
simian spaces.
Physiologic Spaces (Fig. 8.2)

• Present in between all the primary teeth
• 4 mm in the maxillary arch
• 3 mm in the mandibular arch.
Development of Occlusion 71
Fig. 8.1: Primate spaces
Fig. 8.2: Spacing in deciduous teeth
Non-spaced Dentition
• Lack of space between primary teeth is usually
indicative of crowding in developing permanent
dentition.
Terminal Plane
• The mesio-distal relation between the distal
surfaces of maxillary and mandibular 2nd
deciduous molars is called as terminal plane.
Flush Terminal Plane (Fig. 8.3)

• The distal surfaces of maxillary and mandibular
2nd deciduous molars are in a straight plane
Fig. 8.3: Flush relation
(flush) and therefore situated on the same vertical

plane
• Seen in 74%
• Favorable relationship to guide the permanent
molars.
Mesial Step Terminal Plane (Fig. 8.4)

• The distal surface of the mandibular 2nd
deciduous molar is more mesial to that of the
maxillary 2nd deciduous molar
• 14%
• Most favorable to guide the permanent molars into
a class I relationship.
Fig. 8.4: Mesial step relation

Distal Step Terminal Plane (Fig. 8.5)

• The distal surface of the mandibular 2nd
deciduous molar is more distal to that of the
maxillary 2nd deciduous molar
• 12%
• This relationship is unfavorable as it guides the
permanent molars into distal occlusion.
Fig. 8.5: Distal step relation
Anterior Teeth Relationship

• Overbite: It is the distance, which the incisal edge
of the maxillary incisors overlaps vertically past
the incisal edge of the mandibular incisors. The
average overbite in the primary dentition is 2 mm
• Overjet: It is the horizontal distance between the
lingual aspect of the maxillary incisors and the
labial aspect of the mandibular incisors when the
teeth are in centric occlusion. The average in
primary dentition is 1-2 mm.
Canine Relationship
The relationship of the maxillary and mandibular
deciduous canines is one of the most stable in primary
dentition.
• Class I: When mandibular canine interdigitates in
embrasure between the maxillary lateral and
canine
• Class II: When mandibular canine interdigitates

distal to embrasure between the maxillary lateral
and canine
• Class III: When mandibular canine interdigitates
in any other relation.
MIXED DENTITION PERIOD

• Both the primary and permanent teeth are in the
mouth together
• 6 years to 12 years of age
• First transitional period has emergence of the first
permanent molars and exchange of incisors
• Intertransitional period
• Second transitional period which is characteri-
zed by emergence of cuspids, bicuspids and the
second permanent molars
• Establishment of occlusion.
Emergence of 1st Permanent Molars

• The antero-posterior relation between the two
opposing first molars after eruption depends on
their positions previously occupied within the
jaws, saggital relation between the maxilla and
mandible and occlusal relationship
• The mandibular molars are the first to erupt at
around 6 years of age
• Position and relation is guided into dental arch
by the distal surfaces of 2nd deciduous molars.
• If the 2nd deciduous molar is in flush terminal
plane, then the erupting permanent molar will also
be in the same relation. For this to change into
Class I relation the molar has to move
2-3 mm in a forward direction, this is accom-
plished by mesial shift
– Early mesial shift: The eruptive forces of 1st
permanent molars are strong enough to push
the deciduous molars forward in the arch
thereby utilizing the primate spaces
– Late mesial shift: In non-spaced dentition

erupting permanent molars are not able to
establish Class I relation even as they erupt. In
these cases, the molars establish Class I
relation by drifting mesially and utilizing the
leeway space
• If the 2nd deciduous molar is in mesial-step
terminal plane, then the erupting permanent molar
will directly erupt in Class I relation
• If the 2nd deciduous molar is in distal-step
terminal plane, then the erupting permanent molar
will erupt into Class II relation. If further growth
occurs or there is more utilization of spaces then it
can lead into end on molar relation.
Exchange of Incisors
• The deciduous incisors are replaced by perma-
nent incisors
• 6 ½ to 8 ½ years
• Incisor liability is the difference between space
available and space required in the alignment of
permanent incisors
• 7 mm for maxillary arch and 5 mm for mandi-
bular arch
• Other factors that help in alignment of incisors
are:
– Utilization of inter-dental spacing of primary
incisors
– Increase in inter-canine arch width—4 to 6 mm
for maxilla and 4 to 5 mm for mandible
– Increase in inter-canine arch length
– Change in inter-incisal angulations—The
angle between the maxillary and mandibular
incisors is about 150° in primary dentition,
whereas it is about 123° in permanent dentition.
Intertransitional Period
• Permanent incisors and permanent molars that
sandwich the deciduous canines and molars
• Phase lasts for 1½ years and is relatively stable.
Second Transitional Period

• Characterized by replacement of deciduous
molars and canines by premolars and permanent
cuspids
• Ugly Duckling Stage also takes place during this
phase
• 9 to 11 years
• Leeway Space of Nance (Fig. 8.6): It is the difference
between the combined mesio-distal width of
permanent canine and premolars and deciduous
canine and molars.
• 1.8 mm (0.9 mm on each side) in maxillary arch
and 3.4mm (1.7 mm on each side) in mandibular
arch
• Ugly Duckling (Fig. 8.7): Stage or Broadbent pheno-
menon is a self-correcting malocclusion seen
around 9-11 years of age or during eruption of
canines.
• Observed by Broadbent in 1937.
Fig. 8.6: Leeway space

Fig. 8.7: Ugly duckling stage
SELF-CORRECTING ANOMALIES
• Anomalies, which arise in the child’s, developing
dentition during the period of transition from
predentate period to permanent dentition period
and get corrected on their own without any dental,
treatment.
During Predentate Period

• Retrognathic mandible
• Anterior open bite
• Infantile swallow.
During Deciduous Dentition Period

• Deep bite
• Decrease overjet
• Flush terminal plane
• Primate and physiologic spacing
• No curve of Spee.
During Mixed Dentition Period

• Anterior deep bite
• Mandibular anterior crowding
• End-on molar relation
• Ugly duckling stage.
Chapter 9
Oral Habits
 Classification of habits
 Thumb sucking
 Tongue thrusting
 Mouth breathing
 Bruxism
 Lip biting
 Nail biting
 Self-injurious habits
• Moyers: Habits are learnt pattern of muscle

contraction of very complex nature
• Boucher OC: As a tendency towards an act or an
act that has become a repeated performance,
relatively fixed, consistent, easy to perform and
almost automatic
• Useful and harmful habits (James–1923)
• Compulsive and non-compulsive habits (Finn–
1987)
• Meaningful and empty habits (Klein–1971)
• Useful habits: Include all habits of normal function
such as respiration and delectations
• Harmful habits: All those that exert perverted
stress against the teeth and dental arches
• Compulsive habit: Acquired as a fixation in the
child to the extent that he retreats to the practice
whenever his security is threatened
• Non-compulsive habit: Children appear to undergo
continuing behavior modification, which permit
them to release certain undesirable habit patterns
and form new ones which are socially accepted
• Secondary habit is a habit that is due to a supple-
mental problem, e.g. Large tongue causes tongue
thrusting habit
• Meaningful habit: Habit with a deep-rooted
psychological problem
• Empty habit: Meaningless habit that can be treated
easily by a dentist using reminder therapy
• Normal habits: Those habits that are deemed
normal by children of a particular age group
• Abnormal habits: Those habits that are pursued
after its physiological period of cessation
• Physiologic habits: Those habits that are required
for normal physiologic functioning
• Pathological habits: Those habits that are pursued
due to pathological reasons such as adenoids may
lead to mouth breathing
• Retained habits: Those that are carried over from
childhood into adulthood
• Cultivated habits: Those that are cultivated during
the socio-active life of an individual.
Oral Habits 81
CLASSIFICATION OF HABITS
Morris and Bohanna – 1969
Non-pressure habits
• Mouth breathing
Pressure habits
• Sucking habit
– Lip sucking
– Thumb and digit sucking
• Biting habit
– Nail biting
– Needle holding
• Posturing habit
– Pillow rest
– Chin rest
•. Miscellaneous
– Bruxism.
THUMB SUCKING (FIG. 9.1)

• Thumb sucking is defined as the placement of
the thumb in varying depths into the mouth
• Seen in 29 weeks of intrauterine life
• Normal thumb sucking: Considered normal during
the first one and half years of life
• Abnormal thumb sucking: When the habit persists
beyond the preschool period and may cause
deleterious effects to the dentofacial structures
• Psychological thumb sucking: Have a deep-rooted
emotional factor involved and may be associated
with neglect and loneliness experienced by the
child
• Habitual thumb sucking: The child performs the
act out of habit without any psychological
bearing
• Classical Freudian theory: (Sigmund Freud– 1919)
Fixation of oral phase
• Oral drive theory: (Sears and wise – 1982) Caused
by prolonged nursing
• Rooting reflex: (Benjamin – 1962) Thumb sucking
arises from the rooting and placing reflexes
common to all mammalian infants during the first

3 months of life
• Sucking reflex: (Engel – 1962) First coordinated
muscular activity of the infant and its deprivation
may motivate the infant to suck the thumb and
finger for additional gratification
• Learning theory: (Davidson – 1967) Stems from an
adaptive response
• Normal or subclinical significant sucking (Preschool
infant): Up to 3 years
• Clinically significant sucking (Grade school): 3-6
years
• Intractable sucking (Teenage child): Beyond
6 years.
Fig. 9.1: Child performing the habit
Classification of Thumb Sucking

• Subtelny (1973)
• Type A: (50%) whole digit is placed inside the
mouth with the pad of the thumb pressing over
the palate, while at the same time maxillary and
mandibular oral contact is present
• Type B: (13-24%) thumb is placed into the oral
cavity and at the same time maxillary and
mandibular oral contact is maintained
• Type C: (18%) thumb is placed into the mouth just
beyond the first joint and contacts hard palate and
the maxillary incisors, but there is no contact with
mandibular anterior incisors
Oral Habits 83
• Type D: (6%) only a little portion of the thumb is

placed into the mouth.
Etiology
• Socio-economic status increased incidence in
industrialized areas as compared to rural areas
• Working mother: More chances of habit due to
feelings of insecurity in children
• Number of siblings: More the no. of siblings, more
are the chances of habit
• Order of birth: Later the sibling rank of the child,
greater the chance of oral habit
• Stress: Digit sucking has also been proposed as or
emotional based behavior.
Clinical Features
• Proclination of the maxillary incisors with
anterior placement of the apical base of the maxilla
• Increased maxillary arch length and high palatal
arch
• Increased clinical crown length of maxillary
incisors
• Atypical root resorption in primary central
incisors
• Increased trauma to maxillary incisors
• Retroclination of mandibular incisors with
retrusion of mandible
• Increased overjet, decreased overbite
• Posterior crossbite
• Development of tongue thrust due to lower tongue
position
• Dishpan thumb
• Callus formation on the thumb
• Abnormally clean thumb with absence of crease.
Management
• Feeding of child naturally to satiate his drive –
Hughes (1949)
• Use of a Pacifier
• B-hypothesis or Dunlop’s hypothesis: Forced

purposeful repetition of habit eventually associates
with unpleasant reactions and the habit is
abandoned. The child should be asked to sit in
front of the mirror and asked to observe himself as
he indulges in the habit
• Chemical: Bitter chemicals like Quinine,
Asafoetida, Pepper, Castor oil, etc. are placed over
the thumb to terminate the practice but with very
minimal success
• Anti thumb sucking solutions: Femite, Thumb-up,
Anti-Thumb
• Mechanical: Thumb guard is the most effective
extraoral appliance for control of the habit
• Removable or fixed palatal crib: It breaks the suction
force of the digit on the anterior segment, reminds
the patient of his habit
• Oral screen: Prevents the child from placing the
thumb or finger into the oral cavity during
sleeping hours
• Hay rakes: Mack (1951); used in children over 3½
years; series of fence like lines that prevent the
placement of thumb in mouth
• Blue grass appliance: Bruce S Haskell (1991); fixed
appliance using a Teflon rollers, together with
positive reinforcement to manage thumb sucking
habit in children between 7-13 years of age. If the
patient tries to suck on his thumb the suction will
not be created and his thumb will slip from the
rollers thus breaking the act
• Increasing the arm length of the night suit: This is
useful in children who sincerely want to
discontinue the habit and only perform during
their sleep
• Thumb-Home concept: A small bag is given to the
child to tie around his wrist during sleep and it is
explained to the child that just as the child sleeps
in his home, the thumb will also sleep in its house.
Oral Habits 85
TONGUE THRUSTING (FIG. 9.2)

• Tongue thrust as the forward movement of the
tongue tip between the teeth to meet the lower lip
during deglutition and in sounds of speech, so
that the tongue lies interdentally – Tulley (1969)
• Tongue thrust is a forward placement of the
tongue between the anterior teeth and against the
lower lip during swallowing – Schneider (1982)
• Physiologic tongue thrust: Normal tongue thrust
swallow of infancy
• Habitual tongue thrust: Tongue thrust swallow is
present as a habit even after the correction of the
malocclusion
• Functional tongue thrust: An adaptive behavior
developed to achieve an oral seal
• Anatomic tongue thrust: Due to anatomical reasons
like enlarged tongue
• Normal infantile swallow: During this swallow the
tongue lies between the gum pads and mandible
is stabilized by contraction of facial muscles
• Transitional swallow: Intermixing of normal
infantile swallow and mature swallow during the
primary dentition and early mixed dentition
period
Fig. 9.2: Anterior tongue thrust

• Normal mature swallow: During this swallow there

is contraction of mandibular elevators with
minimal lip and cheek activity
• Simple tongue thrust swallow: During this swallow
there is contraction of lips, mentalis muscle and
mandibular elevators and the tongue protrudes
into an open bite that has a definite beginning
and ending
• Complex tongue thrust swallow: (Teeth apart
swallow) There is marked contraction of the lip,
facial and mentalis muscles but absence of
temporal muscle contraction during swallow.
Classification
• James S Brauer and Townsend V Holt
• Type 1: Non-deforming Tongue thrust
• Type 2: Deforming Anterior Tongue thrust
Subgroup 1: Anterior open bite
Subgroup 2: Associated procumbency of anterior
teeth
Subgroup 3: Associated posterior crossbite
• Type 3: Deforming lateral tongue thrust
Subgroup 1: Posterior openbite
Subgroup 2: Posterior crossbite
Subgroup 3: Deep overbite
• Type 4: Deforming anterior and lateral tongue
thrust
Subgroup 1: Anterior and posterior open bite
Subgroup 2: Associated procumbency of anterior
teeth
Subgroup 3: Associated posterior crossbite.
Etiology of Tongue Thrust

• Dental influence: High narrow palatal arch,
number, size or arch discrepancy of teeth
• Thumb sucking: Depresses the tongue and induces
malfunctions of the tongue during deglutition
• Mixed dentition: When a child loses deciduous
teeth tongue frequently protrudes into the space
during speech and swallowing activity
Oral Habits 87
• Gap filling tendency: Any space around the dental

arches not occupied by teeth will tend to be filled
by the tongue
• Allergies: Affecting tonsils and adenoids leads to
tongue thrusting
• Macroglossia and microglossia: Tongue is inade-
quate to fill the oral space resulting in a forward
thrusting
• Soft diet: Underdevelopment of orofacial muscles
• Oral trauma: Injury for a sufficient time can cause
changes in deglutition pattern
• Sleeping habits: Tongue rests in the mandibular
arch and moves forward against the teeth during
swallowing in patients who sleep with an open
mouth.
Diagnosis of Tongue Thrusting

• Place water beneath the patients tongue tip and
ask him to swallow
– Normal: No contraction of lips or facial muscles
– Tongue thrusting: Marked contraction of lips
and facial muscles
• Place handover temporalis and ask to swallow
– Normal: Temporalis contracts and mandible is
elevated
– Tongue thrusting: No temporalis contraction
• Hold the lower lip and ask the patient to swallow
– Normal: Swallow can be completed
– Tongue thrusting: Can’t complete swallow.
Clinical Features
Simple Tongue Thrusting:
• Normal tooth contact in posterior region
• Contraction of the lips, mentalis muscle and
mandibular elevators.
Complex Tongue Thrusting:
• Generalized open bite
• The absence of contraction of lip and oral
muscles.
Lateral Tongue Thrust:
• Posterior open bite with lateral tongue thrust.
Other Features
• Proclination of anterior teeth
• Midline diastema
• Posterior crossbite.
Treatment Considerations
• Orthodontic elastic exercise: The tongue tip is held
against the palate using 5/16” orthodontic elastic
• 4S exercise: (spot, salivate, squeeze and swallow)
Using the tongue the spot is identified, the tongue
tip is pressed against this spot and the child is
asked to swallow keeping the tongue at the same
spot
• Whistling and reciting the count from 60 to 69 are
also helpful
• Lip exercises: Tug of war and Button pull exercise
• Subliminal therapy: Auto suggestion which requires
the patient to give self instructions like “I will
swallow correctly all night long”
• Pre-orthodontic trainer: Acts as a reminder
• Tongue crib: Reminds the patient where to place
the tongue and prevents it from touching the teeth
• Lingual oral screen: Prevents contact with teeth.
MOUTH BREATHING (FIG. 9.3)

• It is defined as habitual respiration through the
mouth instead of nose – Sassouni (1971)
Fig. 9.3: Act of mouth breathing

Oral Habits 89
• Merle (1980) suggested the term Oro-nasal

breathing.
Classification (Finn, 1987)

• Obstructive: Complete obstruction of normal
airflow through nasal passage
• Habitual: Persistence of the habit even after
elimination of the obstructive cause
• Anatomical: Short upper lip leads to incompetence
of lips and hence mouth breathing.
Etiology
• Developmental anomalies like abnormal nasal
cavity, nasal turbinates, and short upper lip
• Partial obstruction due to deviated nasal septum
or localized benign tumors
• Local causes like infection and inflammation of
nasal mucosa, chronic allergic stomatitis, chronic
atrophic rhinitis, enlarged adenoids and tonsils,
nasal polyps
• Traumatic injuries to the nasal cavity
• Ectomorphic children having a genetic type of
tapering face and naso-pharynx are prone to nasal
obstruction.
Diagnosis
• Observe the patient
– Mouth breathers—Lips will be apart
– Nasal breathes—Lips will be touching
• Breathe deeply through nose
– Mouth breathers—No change in shape or size
of external nares
– Nasal breathes—Demonstrates good control
of alar muscles
• Mirror test: Two-surfaced mirror is placed on the
patient’s upper lip. If air condenses on upper side
of mirror the patient is nasal breather and if it
does so on the opposite side then he is a mouth
breather
• Massler’s water holding test: Mouth breathers
cannot retain the water for a long time
• Jwemen’s butterfly test: On exhalation if the fibers

of the cotton flutter downwards patient is nasal
breather and if fibers flutter upward he is a mouth
breather
• Rhinometry: (Inductive plethysmography) The
total airflow through the nose and mouth can be
quantified
• Cephalometrics: Can be used to calculate amount
of naso-pharyngeal space.
Clinical Features
• In order to breathe, the child bends the neck for-
ward straightening the Oro-naso-pharyngeal
path, which gives the appearance of a pigeon chest
• Low-grade esophagitis
• Turbinates become swollen and engorged
• Speech acquires a nasal tone
• Sleep apnea syndrome
• Blood gas studies reveal that mouth breathers
have 20% more CO2 and less O2
• Adenoid facies (Long narrow face)
• Lack of tone of oral musculature
• Short upper lip with nose tipped superiorly
• Narrow maxillary arch with high palatal vault
• Protrusion of maxillary and mandibular incisors
• Increased incidence of caries
• Chronic keratinized marginal gingivitis.
Treatment
• Treat and eliminate the underlying cause or
pathology that has created the habit
• Deep breathing exercises
• Lip exercises 15-30 min/day for 4-5 months
• Oral screen: Newell (1912) periodically reduce the
size and number of holes in oral screen and
finally completely seal all holes thus eliminating
the habit.
Oral Habits 91
BRUXISM
• Ramfgord in 1966 defined bruxism as the habitual
grinding of teeth when an individual is not
chewing or swallowing
• Diurnal bruxism conscious or subconscious with
parafunctional habits
• Nocturnal bruxism subconscious grinding of teeth
characterized by rhythmic patterns of masseter.
Etiology
• CNS: Manifestation of cortical lesions
• Psychological Factors: Manifestation of the
inability to express emotions
• Occlusal discrepancies
• Genetics
• Systemic factors: Magnesium deficiency, abdo-
minal distress, intestinal parasites
• Occupational factors: Compulsive overachievers,
stress at work.
Clinical Manifestations
• Signs and symptoms of bruxism depend on
frequency, intensity, and age of patient
• Occlusal trauma
• Toothache and mobility mainly in morning
• Extreme sensitivity due to loss of enamel
• Atypical wear facets
• Pulp exposure with fractures
• Tenderness of the jaw muscles on palpation with
muscular fatigue on waking
• Hypertrophy of masseter
• Pain, crepitation, clicking in joint, restriction of
TMJ movements
• Associated headache.
Treatment
• Occlusal adjustments of any premature contacts
• Occlusal splints/night guards
• Relaxation training
• Local anesthetic injections, tranquilizers, muscle

relaxants
• Electrogalvanic stimulation for muscle relaxation
• Acupuncture
• Orthodontic correction.
LIP BITING (FIG. 9.4)

• Habit that involve manipulation of lips and
perioral structures
• Higher predilection of the lower lip
• Lip licking: Wetting of lips the tongue
• Lip sucking habit: Pulling the lips into the mouth
between the teeth
• Can be a result of malocclusion, emotional stress
or in conjunction with other habits.
Fig. 9.4: Active lip biting
Clinical Manifestations
• Protrusion of upper incisors
• Lower incisor collapse with lingual crowding
• Lip has reddened and chapped area below the
vermilion border
• Mento-labial sulcus becomes accentuated.
Treatment
• Reminder therapy
• Oral screen prevents tongue contact with lips
Oral Habits 93
• Lip bumper removable or fixed; creates a gap

between lips and oral structures so patient is not
able to suck his lips.
NAIL BITING
• Incidence as reported by Weschsher is 43% in
adolescents and 25% in college students
• Etiology: Insecurity, psychosomatic successor of
thumb sucking and stress
• Crowding, rotation and alteration of incisal edges
of incisors
• Inflammation of the nail bed
• Treat the basic emotional factors causing the act
• Reminder therapy.
SELF-INJURIOUS HABITS
• Repetitive acts that result in physical damage to
the individual
• 10-20% in children with psychological abnormali-
ties
• Also called as Masochistic habits, Sadomaso-
chistic habits, Self-mutilating habits
• Organic: Associated with Lesch Nyhan disease
and De Lange’s syndrome
• Functional: Given by Stewart and Kernohan in
1972
Type A: Injuries superimposed on a preexisting
lesion
Type B: Injuries secondary to another established
habit
Type C: Injuries of the unknown or complex
etiology
• Clinical features include biting of fingers, knees;
frenum thrusting; picking of gingiva
• Treatment includes assessing of underlying
emotional component, palliative therapy and
mechanotherapy using protective padding, mouth
guards.
Chapter 10
Pediatric Space
Management
 Requirements of space maintainers
 Indications of space maintainers
 Contraindications of space maintainers
 Classification of space maintainers
 Factors contributing for space closure
 Factors affecting planning for space
maintainers
 Space maintenance in primary dentition
 Space maintenance in mixed dentition
 Fixed space maintainers
 Band and loop space maintainer
 Lingual arch space maintainer
 Nance palatal arch space maintainer
 Transpalatal arch
 Distal shoe space maintainer
 Space regainers
Preventive orthodontics: Graber (1966) has defined

preventive orthodontics as the action taken to
preserve the integrity of what appears to be normal
occlusion at a specific time.
Interceptive orthodontics: American association of
Orthodontists (1969) defined it as that phase of
science and art of orthodontics employed to
recognize and eliminate the potential irregularities
and malpositions in the developing dentofacial
complex.
Space maintenance: This term was coined JC Brauer
in 1941. It is defined as process of maintaining a
space in a given arch previously occupied by a tooth
or a group of teeth.
Space control: Gainsforth in 1955 defined it as careful
supervision of the developing dentition; it reflects
an understanding of the dynamic nature of occlusal
development.
Space maintainer: According to Boucher it is a fixed
or removable appliance designed to preserve the
space created by the premature loss of a tooth or a
group of teeth.
REQUIREMENTS OF SPACE MAINTAINERS

• It should maintain the entire space created by the
lost tooth
• It must restore function
• Prevent supra-eruption of opposing tooth
• It should be simple in construction
• Should be strong enough to withstand occlusal
forces
• Should permit maintenance of oral hygiene
• Must not restrict the growth of jaws
• It should not exert undue forces of it’s own.
INDICATIONS OF SPACE MAINTAINERS

• If the space after premature loss of deciduous
teeth shows signs of closing
Pediatric Space Management 97
• If the use of space maintainer will aid in or make

the future orthodontic treatment less complicated
• If the need for treatment of malocclusion at a later
date is not indicated
• When the space for a permanent tooth should be
maintained for 2 years or longer
• To avoid supra-eruption of a tooth from the
opposing arch.
CONTRAINDICATIONS OF SPACE
MAINTAINERS
• If the radiograph of extraction region shows that
the succedaneous tooth will erupt soon
• If the radiograph of extraction region shows one
third of the root of succedaneous tooth is already
calcified
• When the space left by prematurely lost tooth is
greater than the space needed for the permanent
successor
• If the space shows no signs of closing
• When there is general lack of sufficient arch
length
• When succedaneous tooth is absent.
CLASSIFICATION OF SPACE MAINTAINERS

According to Hitchcock
• Removable or fixed or semi fixed
• With bands or without bands
• Functional or non-functional
• Active or passive
• Certain combinations of the above.
According to Raymond C Thurow

• Removable
• Complete arch—Lingual arch and Extraoral
anchorage
• Individual tooth.
According to Hinrichsen (1962)

• Fixed space maintainers:
Class I (a) Non-functional types—Bar type,
Loop type
(b) Functional types—Pontic type,
Lingual arch type
Class II (a) Cantilever type (Distal shoe, Band
and loop)
• Removable space maintainers: Acrylic partial
dentures.
FACTORS CONTRIBUTING FOR SPACE

CLOSURE
• Inclination of long axis of permanent molars:
Tendency of molar to shift mesially because their
long axis is mesially inclined
• Premature loss of deciduous teeth
• Influence of buccal musculature: Buccinator exerts
forces that can derange occlusion
• Path of least resistance: This is created following
loss of support because of extraction or missing
tooth
• Effect of position of center of rotation of mandible:
More the axis of rotation of mandibular rotation
is lowered in respect to occlusal plane, less is the
amount of horizontal thrust transmitted to teeth
in occlusion.
FACTORS AFFECTING PLANNING FOR SPACE

MAINTAINERS
1. Time elapsed since tooth loss: (McDonald and
Avery) Space closure will usually take place
within six months after the loss of tooth.
2. Amount of space loss:
• According to Northway and Dmerijian:
mandibular arch is 0.8 mm/year and in
maxillary arch is 0.5-1.2 mm/year
• According to Breakspear: Space loss after loss
of 1st maxillary molar is 0.8 mm
– Space loss after loss of 1st mandibular
molar is 0.9 mm
– Space loss after loss of 2nd maxillary

molar is 2.2 mm
– Space loss after loss of 2nd mandibular
molar is 1.7 mm
• According to Clinch and Healy:
– Space loss before eruption of permanent
molar is 6.1 mm
– Space loss after eruption of permanent
molar is 3.7 mm
• Younger the patient, more is the space loss
• Maximum space is lost during first 6 months
of extraction.
3. Eruption status of the adjacent teeth helps to
ascertain mesial shift for molars and distal
tipping for canines.
4. Amount of bone coverage over the tooth 1 mm of
bone resorbs in 4-5 months.
5. Eruption status of the succedaneous tooth estimated
by amount of root completion. (Tooth erupts
in oral cavity after 2/3 rd root formation).
6. Dental age of patient recognizing the teeth
clinically present in the oral cavity in
comparison to dental eruption charts.
7. Delayed eruption of permanent teeth: Over-
retained or ankylosed primary teeth, or
impacted permanent teeth, can result in a delay
of the eruption process.
8. Available space aid the practitioner in a
prediction of the amount of available space for
the unerupted permanent teeth.
9. Arch length adequacy estimated by position of
incisors, Leeway space and Incisor liability.
10. Abnormal oral habits exert abnormal pressure on
dental arches and so may influence the type and
planning of space maintainer.
11. Miscellaneous factors influence planning because
they may be associated with either space gain
or space loss like growth of jaws, proximal
caries, wear and attrition.
SPACE MAINTENANCE IN PRIMARY

DENTITION
Missing tooth Treatment Reason
Maxillary No space No space

incisor maintainer loss occurs
Maxillary canine Band and loop Decreases
possibility of
midline shift
Maxillary 1st Band and loop Prevents loss in
molar arch dimension
Maxillary 2nd Distal shoe Guides 1st
molar permanent molar
Mandibular No space No space loss
incisor maintainer occurs
Mandibular Band and loop Decreases
canine possibility of
midline shift
Mandibular 1st Band and loop Prevents loss in
molar arch dimension
Mandibular 2nd Distal shoe Guides 1st
molar permanent molar
SPACE MAINTENANCE IN MIXED DENTITION

Maxillary • Extract antimere • Decreases possibility
incisor of midline shift
Maxillary • Before eruption • Decrease possibility
canine of permanent of midline shift
lateral incisor–
removable space
maintainer
• After eruption • Guides lateral
of permanent incisor into position
lateral incisor–
extract antimere
Maxillary • Before eruption • Prevents loss in arch
1st molar of permanent dimension
lateral incisor– • Does not interfere
Nance palatal with eruption of
arch permanent lateral
incisors
• After eruption • Prevents loss in arch
of permanent dimension
lateral incisor –
Band and loop
Contd....
Contd...
Maxillary • Nance palatal • Prevents loss in
2nd molar arch arch dimension
Mandibular • Extract antimere •Decreases possibi-
incisor lity of midline shift
Mandibular • Before eruption • Decreases possibility
canine of permanent of midline shift
lateral incisor– • Requires only minor
removable space adjustment for
maintainer alignment of
permanent incisors
• After eruption • Decreases possibility
of permanent of midline shift
lateral incisor– • Prevents lingual
Lingual arch tipping of incisors
with stopper
Mandibular • Before eruption • Prevents loss in arch
1st molar of permanent dimension
lateral incisor – • Does not interfere
Band and loop with eruption of
permanent incisors
• Repositioning of
canine
Mandibular • Before eruption • Prevents loss in arch
2nd molar of permanent dimension
lateral incisor– • Does not interfere
Band and loop with eruption of
permanent incisors
• Prevents mesial
tipping of molars
FIXED SPACE MAINTAINERS

• Fixed space maintainers are the appliances,
which are fixed onto the teeth and utilize bands
or crowns for their construction
• Advantages: Bands require no tooth preparation,
do not interfere with eruption of abutment teeth,
jaw growth is not hampered and succedaneous
tooth is free to erupt
• Disadvantages are elaborate instrumentation and

skills required, banded tooth is more prone to
caries and decalcification and supra-eruption of
opposing tooth.
Armamentarium
• Stainless steel band material or preformed bands
• Pliers—contouring pliers, band forming pliers,
band seater or pusher, band adapter, hoe pliers
straight and curved, band cutting scissors, bird
beak pliers, crimping pliers, three pronged pliers,
universal pliers
• Stainless steel wires (round)
• Spot welding unit, soldering unit, silver solder,
flux
• Wire cutter
• Finishing burs, polishing stones.
Classification of Band
• Loop bands
– Precious metal
– Chrome alloy bands
• Tailored bands
– Precious metal
– Chrome alloy
• Preformed seamless bands
– Chrome alloy or precious metal, which are
adapted, festooned and stretched to fit.
Band Material
• Anterior teeth— 0.003 × 0.125 × 2 inches
• Bicuspids— 0.004 × 0.150 × 2 inches
• Primary molars—0.005 × 0.180 × 2 inches
• Permanent molars— 0.006 × 0.180 × 2 inches.
Band Construction
Contd...
Contd...
BAND AND LOOP SPACE MAINTAINER

(FIG. 10.1)
• Unilateral, non-functional, passive, fixed appliance
• Indicated for preserving the space created by the
premature loss of single primary molar, bilateral
loss of single primary molar before eruption of
permanent incisors and loss of second primary
molar after the eruption of first permanent molar
• Construction is easy and faster but cannot
stabilize the arch and can’t be used for multiple
loss of teeth
Fig. 10.1: Band and loop

• Arms of the loop should be placed in the junc-

tion of middle and cervical third
• Contour of the loop should be similar and as close
as possible to the gingival contour
• Width of the loop should be wide enough to
allow eruption of premolar inside the loop (width
of tooth +1 mm)
• Loop should be placed just above the contact area
of the supporting tooth
• Crown and loop: Stainless steel crown is used on
abutment tooth instead of a band
• Crown-band and loop: Stainless steel crown is first
placed on abutment tooth and then it is banded
• Mayne’s space maintainer: Band and loop in which
loop is halved
• Reverse band and loop: Given when there is
premature loss of primary second molar and the
permanent molars have not erupted fully to
support a band. In such cases primary first molar
is banded and a loop is made that touches just
below the marginal ridge of permanent molars
• Band and bar prevents eruption of premolar so it
is not used now.
LINGUAL ARCH SPACE MAINTAINER

(FIG. 10.2)
• Bilateral, non-functional, passive/active, mandi-
bular fixed appliance
Fig. 10.2: Lingual arch space maintainer

• Indicated to preserve the space created by

unilateral or bilateral loss of primary molars after
eruption of lower permanent incisors
• Maintains the arch perimeter
• Prevents lingual collapse of the anterior teeth
• Can be used as space maintainer or regainer
• Arch wire should contact the erupted permanent
incisors at the cingulum and should be located 2
mm below the gingival margin or edentulous
ridge in the posterior region
• The arch wire should meet the band at the mesio-
buccal cusp and the soldered joint should be in
the middle third of the band
• Hotz lingual arch is lingual arch with U-loop
used for space regaining
• Removable lingual arch is indicated in patients
who can’t wear fixed appliances or if the space
maintenance is for minimal time
• Lingual arch with omega bends is used to prevent
interference in canine region.
NANCE PALATAL ARCH SPACE MAINTAINER

(FIG. 10.3)
• Bilateral, non-functional, passive, maxillary fixed
appliance
• The Nance arch is simply a maxillary lingual arch
that does not contact the anterior teeth, but
approximates the anterior palate via an acrylic
Fig. 10.3: Nance palatal arch

button that contacts the palatal tissue, which

provides resistance to the anterior movement of
posterior teeth in a horizontal direction
• Bilateral premature loss of primary teeth with no
loss of space and a favorable mixed dentition
analysis
• Arch wire extends anteriorly without touching
against the surface of the primary molars, as the
successor bicuspids usually are broader bucco-
lingually, and the wire could defect them form
their natural position
• Acrylic button is 0.5 inch in diameter and is
placed in the rugae area, 1-2 mm below the
incisive papilla
• Arch stabilizing space maintainer
• May cause tissue hyperplasia, irritation to palatal
tissues and pressure effects
• Can’t be used in patients allergic to acrylic.
TRANSPALATAL ARCH (FIG. 10.4)

• Unilateral, non-functional, passive, maxillary
fixed appliance
• Recommended for stabilizing the maxillary first
permanent molars when primary molars require
extraction
• Indication is when one side of arch is intact and
several primary teeth on the other side are
missing
Fig. 10.4: Transpalatal arch

• Also indicated in unilateral loss of primary

molars
• Used for arch expansion
• Transpalatal arch runs directly across the palatal
vault avoiding contact with the soft tissues and
U-shaped bend must be given to the wire in
middle of palate. As it approaches the mesial part
of the palatal surface of band, the wire should be
bent distally to assure a better joint
• Rotation and tipping of molars are common side
effects.
DISTAL SHOE SPACE MAINTAINER

(FIG. 10.5)
• Also called as the intra-alveolar appliance
• Early design was Willet’s distal shoe
• Current type of appliance is Roche’s distal shoe
• Distal surface of the second primary molar
provides a guide for unerupted first permanent
molar. When the second primary molar is
removed prior to the eruption of first permanent
molar, the intra-alveolar appliance provides
greater control of the path of eruption of the
unerupted tooth
Fig. 10.5: Distal shoe space maintainer

• Indicated when the second primary molar is

extracted or lost before the eruption of first
permanent molar
• This appliance can’t be given in multiple loss of
teeth, medically compromised patients
(congenital heart disease, kidney problems,
juvenile diabetics, generalize debilitation and
hemophilic) and congenitally missing first
permanent molar
• The intra-alveolar appliance is in controversy:
During eruption lower first permanent molar
uses the distal surface of crown as buttress and
not the root surface as thought earlier therefore
the need to give the intra-alveolar component is
not present
• In the lower arch, the contact area of distal

extension of the appliance should have a slight
lingual position over the crest of the alveolar
ridge and in the maxillary appliance it should be
slightly facial to the crest of the alveolar ridge.
SPACE REGAINERS
Jaffe’s Appliance
• Paul E Jaffe in 1963
• It is useful when the presence of ankylosed tooth,
early loss of a deciduous molar or an extraction
result in filling of adjacent segments into
proximal dental area.
Gerber’s Appliance (Fig. 10.6)

• Used to regain space in mandibular segment
• Fabricated directly in the mouth.
Fig. 10.6: Gerber’s appliance
Hotz Lingual Arch

• Used for distalization of molars
• Indicated when lower first permanent molar has
drifted mesially, but premolar or cuspid has not
drifted distally.
King’s Appliance
• Described by King in 1977
• Regaining of space in both maxillary and
mandibular arch.
Removable Appliances
• Hawley’s appliance with dumbbell spring
• Hawley’s appliance with split acrylic
• Hawley’s appliance with elastics.
Chapter 11
Plaque Control in
Children
 Disclosing solution
 Dentifrices
 Techniques of tooth brushes
 Dental floss
 Classification of chemotherapeutic
anti-plaque agents
 Mouthwash
 Chlorhexidine
 Essential oils
 Quaternary ammonium compounds
 Sanguinarine
 Guidelines for home oral hygiene
• Dental plaque is defined as the soft deposits that

from the biofilm adhering to the tooth surfaces
or other hard surfaces in the oral cavity, including
removable and fixed restoration
• Plaque control is the removal of plaque and the
prevention of its accumulation on the teeth and
adjacent gingival surfaces
• WHO (1978) defined bacterial dental plaque as a
specific but highly variable structural entity
resulting from colonization and growth of
microorganism consisting of various species and
strains embedded on an extracellular matrix
• Composed primarily of microorganism (2 × 1011
bacteria/g) and has more than 325 different
bacterial species and non-bacterial micro-
organism like yeasts, protozoa and viruses
• Intercellular matrix is derived form saliva,
gingival crevicular fluid, and bacterial products
• Organic constituents include polysaccharides,
proteins, glycoprotein and lipid
• Inorganic component is calcium and phospho-
rus, with trace amount of sodium potassium, and
fluoride
• Formation of the dental pellicle
– Initial phase of plaque development
– Surfaces of teeth get coated with a glyco-
protein pellicle of 0.1-0.8 mm
– Bacterial van der Waal and hydrophobic
forces
– Derived from saliva, crevicular fluid, bacterial
and host tissue cell products
• Initial colonization of the tooth surface
By gram-positive microorganism such as
Actinomyces viscosus and Staphylococcus and a
gram-negative microorganism Veillonella
– Specific molecular formed adhesive, on the
bacterial surface that interacts with receptors
in the dental pellicle
– Cells of A viscosus possess fibrous protein
structure called fimbriae that extend form the
bacterial cell surface and bind to protein rich
sites that are found on the dental pellicle
Plaque Control in Children 113
– In ecologic succession of the biofilm, there is a

gradual shift from the early aerobic environ-
ment characterized by grampositive facul-
tative species to a highly oxygendeprived
environment in which gramnegative anaerobic
microorganisms predominate
• Secondary colonization
– P. intermedia, P. loescheii, Capnocytophaga
species, Fusobacterium nucleatum and
P. gingivalis
– Co-aggregation: Adhere to cells of bacteria
already in the plaque mass
– F. nucleatum with S. sanguis, S. loescheii with
A. viscosus and Capnocytophaga with
A. viscosus
– Occur primarily through the highly surface
stero-chemical interaction of protein and
carbohydrate molecules located on the
bacterial cell surfaces
– Hydrophobic, electrons and van der Waal
forces.
DISCLOSING SOLUTION
• It is a preparation in liquid, tablet or lozenges
that contains a dye or other coloring agent used
to identify bacterial plaque deposits for
instruction, evaluation and research
• Indications are patient education, assessment by
the patient and clinician, preparation of plaque
indices
• Skinner solution
– Iodine crystals—3.3 g
– Potassium iodine—1.0 g
– Zinc iodide—1.0 g
– Water (distilled)—16.0 ml
– Glycerin—16.0 ml
• Mercurochrome preparations
– Mercurochrome—1.5 g
– Water—30 ml
– Oil of peppermint—3 drops
– Artificial non-calorigenic sweetener
• Easlick’s disclosing solution

– Bismark brown—3.0 g
– Ethyl alcohol—10 ml
– Glycerin—120 ml
– Flavoring agent—1 drop
• Erythrosine
– For direct topical application
– Erythrosine—0.8 g
– Water—100 ml
– Alcohol (95%) —10.0 ml
– Oil of peppermint—2 drop.
• Tablet
– FD and C Red No 3—15.0 mg
– Sodium chloride—0.747%
– Sodium sucaryl—0.747%
– Calcium stearate—0.975%
– Soluble saccharin—0.186%
– White oil—0.124%
– Flavoring—2.239%
• Two tone solution (Block and his co-workers,
1975)
– FD and C Green No 3
– FD and C Red No 3
– Thicker (older) plaque strain blue: thinner
(newer) plaque stains red
• Plak light system (Squillaro and co-workers)
– Sodium fluorescein
– Glycerin — .75%
– FD and C yellow No 8.
DENTIFRICES
• A substance used with a toothbrush or other
application to remove bacterial plaque, material
alba, and debris from the gingival teeth for
cosmetic and sanitary purposes and for applying
specific agents to the tooth surfaces for
prevention and therapeutic purposes
• Egyptian medical manual the Ebers Papyrus
written about 1500BC mentions the use of
dentifrice
• Hippocrates was the first to recommend the use of

dentifrices
• Composition
– Detergent—(12%) Lower surface tension;
emulsifier debris for easy removal and
contributes to the foaming action, e.g. sodium
lauryl sulphate
– Cleaning and polishing—(20 to 40%)
Abrasive is used to clean and a polishing
agent is used to produce a smooth, shining
tooth surface, e.g. calcium carbonate, calcium
pyrophosphate
– Binders—(1 to 2%) Prevent separation of the
solid and liquid ingredients during storage,
e.g. magnesium aluminum silicate, colloidal
silica
– Humectants—(20 to 40%) Retain moisture,
prevent hardening, e.g. glycerin, sorbitol
– Flavoring—(1 to 15%) Make the dentifrices
desirable, e.g. peppermint, cinnamon,
menthol
– Water—20 to 40%
– Therapeutic agent—(1 to 2%) Prevent
bacterial growth and to prolong shelf life, e.g.
alcohols, formaldehyde
– Sweetener and coloring agent—(2 to 3%)
Impart a pleasant flavor, e.g. sorbitol and
glycerin.
Toothbrush
• Egyptians were the first to use brushes around
5000 years ago
• Romans used toothpick of bone and metals
• In 1728, first toothbrush which evolved was made
of horse’s hair
• Powered toothbrush was invented in 1939
• Powered toothbrush is used in individual lacking
motor skill, handicapped patients, orthodontic
appliance wearers
• Braun-Oral B kids power toothbrush D10 is most
effective in removing plaque in children
• Braun-Oral B D4/EB4 is most recommended for

adults
• Frequency and duration of brushing: Jenkins
suggested that tooth brushing before meal is
optimal as saliva is a good remineralizing agent
that it will neutralize and buffer the lowered pH
of oral fluids caused by acidic foods and
fermentable carbohydrates so if tooth brushing
is done after meals it may remove saliva and
decrease the remineralizing action
• ADA specifications:
– Length – 1 to 1.25 inches
– Width – 5/16 to 3/8 inches
– Surface area – 2.54 to 3.2 cm
– No. of rows – 2 to 4 rows of brushes
– No. of tufts – 5 to 12 per row
– No. of bristles – 80 to 85 per tuft.
DENTAL FLOSS
• First paper on dental floss was published by
Parmly in 1819
• In 1882 Codman and Shurtuff made first
commercial floss made of silk
• Bass in 1948 recommended that nylon floss is
superior to silk
• Size of dental floss varies from 300-1500 denier
(D)
• Carr PM in 2000 concluded that waxed floss is
best for posterior region, whereas woven floss is
best for anterior region
• Terhune (1972) conducted a comprehensive
study on children aged 8-11years and concluded
that children cannot floss without parental help
• Methods of flossing are string floss method, circle
of floss method
• Types of floss:
– Twisted and non-twisted
– Banded and non-banded
– Thin and thick
– Microfilament and multifilament.
TECHNIQUES OF TOOTH BRUSHING (FIG. 11.1)
Method Bristle placement Motion Advantage / Disadvantage
Scrub Horizontal, on gingival margin Scrub in anterior-posterior • Easy to learn

direction keeping brush horizontal • Best suited for children
Bass Apical, towards gingival into Short back and forth vibratory • Remove plaque from cervical area and sulcus
sulcus at 45°, to tooth surface motion while bristles remain in sulcus • Easily learned
• Good gingival stimulation
Charters Coronally, 45°, sides of bristles Small circular motions with apical • Hard to learn and position brush
half on teeth and half on gingiva movement towards gingival margin • Clears interproximal
• Gingival stimulation
Fones Perpendicular to the tooth With teeth in occlusion, move brush • Easy to learn
in rotary motion over both arches • Interproximal areas not cleaned
• May cause trauma
Contd…
Contd…
Method Bristle placement Motion Advantage / Disadvantage
Roll Apically, parallel to tooth and On buccal and lingual inward • Doesn’t clean sulcus area
then over tooth surface pressure, then rolling of head to • Easy to learn
sweep bristle over gingiva and tooth • Good gingival stimulation
Stillman On buccal and lingual, apically On buccal and lingual slight rotary • Excellent gingival stimulation
at an oblique angle to long axis motions with bristle ends stationary • Moderate dexterity required
of tooth. Ends rest on gingiva • Moderate cleaning of interproximal area
and cervical part
Modified Pointing apically at an angle of Apply pressure as in Stillman’s method • Good gingival stimulation
Stillman 45° to tooth surface but vibrate brush and also move • Cleaning of interproximal area
occlusally • Easy to master
Fig. 11.1: Techniques of tooth brushing
According to ADA Specification

Type I: Unbonded dental floss composed of yarn
having no additives.
Type II: Bonded dental floss composed of yarn having
no additives other than binding agent or agent for
cosmetic performance.
Type III: Bonded or unbonded having drug for
therapeutic usage.
CLASSIFICATION OF CHEMOTHERAPEUTIC
ANTI-PLAQUE AGENTS
• Bisguanides and related compounds
– Chlorhexidine
– Alhexidine
• Quaternary ammonium compounds

– Cetylpridinium
• Antibiotics
– Penicillin
– Metronidazole
– Tetracycline
– Vancomycin
• Fluoride and inorganic ions
– Stannous fluoride
– Chlorine dioxide
– Hydrogen peroxide
– Sodium bicarbonate
– Sodium chloride
• Enzymes
– Dextranase
– Glucose – amyloglucosidase
• Organic compound
– Saguinarine
– Menthol/thymol
– Soluble pyrophosphates.
MOUTHWASH
Oxygenating Agents
• Use: The effervescence makes them effective in
debridement, antimicrobial effect
• Agents: Hydrogen peroxide, sodium perborate.
Astringents
• Use: To shrink tissue during impression making
• Agents: Zinc chloride, zinc acetates, tannic acids.
Anodynes
• Use: Alleviates pain, temporary relief for lesion
• Agents: Phenol derivatives, essential oils.
Buffering Agents
• Use: Reduce oral acidity, dissolve mucinous film,
give relief in soreness of soft tissues
• Agents: Sodium borates, sodium perborate,
sodium bicarbonate.
Deodorizing Agents
• Use: Neutralize odors from decomposed oral
debris
• Agents: Chlorophyll.
Antimicrobial Agents
• Use: Reduce oral microbial count, inhibit bacterial
activity
• Agents: Chlorhexidine, quarternary ammonium
compounds, sanguinarine.
CHLORHEXIDINE
• Cationic bisbiguanide
• Broad spectrum antibacterial activity
• Wide spectrum of activity encompassing gram-
positive and gram-negative bacteria, yeasts,
dermatophytes and some lipophylic viruses
• Bacteriostatic at low concentration and bacte-
ricidal at high concentration
• 0.12 to 0.2% of chlorhexidine is useful in reducing
plaque and gingivitis
• Oral rinse of chlorhexidine has retaining capacity
of 5 hours in saliva and 12 hours on oral tissues.
Antibacterial Mode of Action

Anti-plaque Mode of Action

• Blocking the acidic groups on the salivary
glycoprotein, thus reducing the protein
adsorption to the tooth surface
• Adsorption of plaque on the tooth surface by
binding to the bacterial surface in sub-lethal
amounts
• Precipitating the agglutination factors in saliva
and displacing calcium from the plaque matrix.
Indication for Chlorhexidine Use

Martin Addy and John M Moran (1997)
• Adjunct to mechanical oral hygiene in
periodontal treatment
• Secondary prevention following oral surgical
procedures
• Mouthwash for plaque control among physically
and mentally handicapped
• In high caries risk patient
• Fixed orthodontic appliance wearers
• In implant dentistry
• In long standing hospital patients.
ESSENTIAL OILS
• Oldest form of mouthwashes
• Combination of the phenol related essential oils,
thymol and eucalyptol mixed with menthol and
methyl salicylate
• Plaque reduction of 20-34% and gingivitis
reduction about 28-34%
• Mechanism of action is by cell wall disruption
and inhibition of bacterial enzymes
• May cause burning sensation and bitter taste in
the mouth.
QUATERNARY AMMONIUM COMPOUNDS

• Cetyl pyridinium chloride at a concentration of
0.05%
• Bind to plaque and tooth surfaces and are
released from these binding sites rapidly
• Mechanism of action is by rupture of cell wall and

alters the cytoplasmic contents
• Produces a yellow brownish discoloration of the
tongue
• Burning sensation and occasional desquamation.
SANGUINARINE
• Alkaloid extract from the bloodroot plant—
Sanguinalia canadenses
• Used in both mouth rinse and toothpaste
• Contains the extract at 0.03% (equivalent to 0.01%
sanguinarine) and 0.2% zinc chloride.
• 17-42% plaque reduction and 18-57% reduction
in gingivitis
• Burning sensation.
GUIDELINES FOR HOME ORAL HYGIENE

Prenatal Counseling
• Goal of prenatal dental counseling is education
• Counseled on how to provide an environment
that will nurture good oral health habits
• During this period the parents are more open to
health information for their child.
The Infant
• Parents begin cleaning the infant’s mouth by the
time first tooth erupts
• Parent should wrap a damp washcloth or a piece
of gauze around the index finger and clean the
teeth and gum pads once a day
• At this age toothpaste is not necessary
• Parent cuddles the infant in his or her arm with
one of the child arms gently slipped around the
parents back.
The Toddler
• Parent should be totally responsible for oral
hygiene for the toddler
• Establish a specific routine
• Brush in an orderly fashion quadrant wise

• Use a dampened, soft bristled toothbrush
• Children at this age begin to demonstrate an
interest in the procedure and parents should
encourage this behavior and allow the child to
attempt brushing procedures
• The parents face each other while the child is
supine on the parent’s knees. In this position, one
parent assumes the role of brusher while the other
parent stabilizes the child.
The Early School Age Child

• Should be encouraged to routinely attempt
brushing and flossing
• Parent must continue to provide a thorough
plaque removal for the child
• Disclosing agents may be particularly useful
• Children demonstrate the ability to expectorate
and should use a fluoridated dentifrice.
The Pre-adolescent
• Responsibility for his or her own hygiene
• Children in this age group practice oral hygiene
measures on their own but require instructions
on proper brushing and flossing techniques.
The Adolescent
• Attained the manual dexterity needed to
properly brush and floss without direct help form
an adult
• May lack the motivation.
Chapter 12
Pit and Fissure
Sealants
 Types of pit and fissure sealant
 Indications of sealant placement
 Contraindications for sealant use
 Clinical technique
• A material that is introduced into the pits and

fissures of caries susceptible teeth, thus forming
a micromechanically bonded, protective layer
cutting access of caries producing bacteria from
their source of nutrients – Simonson
• 1905 – Miller used silver nitrate
• 1922 – Hyatt advocated prophylactic odontomy
• 1939 – Gore used solution of cellulose nitrate as
fissure sealants
• 1955 – Buonocore observed that after treatment
of enamel with phosphoric acid the retention of
acrylic resin to the tooth surface was greatly in-
creased
• 1962 – Bowen developed Bis – GMA
• 1971 – First pit and fissure sealant Nuva seal
developed
• Fissure contains organic plug composed of
reduced enamel epithelium, microorganism
forming dental plaque and oral debris and this
provides a protected niche for plaque accumu-
lation
• Rapidity of spread of caries in pit and fissure may
be due to the fact that depth of the fissure is close
to DEJ, which is highly susceptible to caries
• Sealants with ADA seal of acceptance: Alpha
fluor seal II, Alpha dent cure, concise light cure
white cement, helioseal, primashield
• Types of pits and fissures (Fig. 12.1):
V type (34%)
Fig. 12.1: Pits and fissure in molars

Pit and Fissure Sealants 127
U type (14%)
I type (19%)
IK type (26%)
Inverted Y type (7%).
TYPES OF PIT AND FISSURE SEALANT

According to chemical structures of monomers used:
• MMA—Methyl methacrylate
• TEGDMA—Tri ethylene glycol dimethacrylate
• BPD—Bis phenol dimethacrylate
• Bis GMA—It is the reaction product of Bis phenol
A and glycidyl methacrylate with a methyl
methacrylate monomer
• ESPE monomer
• PMU—Propyl methacrylate urethane.
Based on Generations
• First generations sealants: Polymerized with UV
light but had incomplete polymerization
• Second generation sealants: Chemical cure resins
based on accelerator catalyst system
• Third generation sealants: Light cured.
Based on Filler Content

• Unfilled: Advantages include better flow and
more retention but, abrade rapidly
• Filled: Advantages include resistance to wear but,
may need occlusal adjustments.
Based on Color
• Clear: Esthetic but, difficult to detect in recall visit
• Tinted/Opaque: It can be identified
• Colored: Easy to see during placement and recall,
e.g. Helioseal white changes to green and Clinpro
pink based on color change technology.
Based on Curing
• Autopolymerizing
• Light cure.
INDICATIONS OF SEALANT PLACEMENT

• Deep, retentive pits and fissures, which may
cause wedging of an explorer
• Stained pits and fissures with minimum appear-
ance of decalcification
• No radiographic or clinical evidence of proximal
caries
• Possibility of adequate isolation
• Questionable enamel caries in pit and fissure
• Caries pattern indicative of more than 1 lesion
per year
• Morphology of pit at risk of caries
• Routine dental care with active preventive
dentistry program
• Community based sealant program.
CONTRAINDICATIONS FOR SEALANT USE

• Well-coalesced, self-cleansing pits and fissures
• Radiographic or clinical evidence of inter-
proximal caries
• Tooth not fully erupted
• Isolation not possible
• Life expectancy of tooth is limited
• Dentinal caries.
CLINICAL TECHNIQUE
Isolation (Fig. 12.2)
Fig. 12.2: Preoperative photograph

• Use of rubber dam or by cotton rolls and suction-

ing
• Salivary contamination causes rapid precipita-
tion of glycoproteins onto the etched surface,
greatly decreasing the bond strength.
Tooth Preparation (Fig. 12.3)

• Results in an improved surface for resin wetting,
more no of resin tag formation and more depth
of sealant penetration
• Treat the surface with slurry of pumice and water
• Brockleherst suggested air abrasion with
aluminum oxide particles
• Zervou concluded that enameloplasty reduces
microleakage.
Fig. 12.3: Fissures are enlarged
Acid Etching of Tooth (Fig. 12.4)

• 37% phosphoric acid
• Apply the etching agent using a fine brush or a
minisponge
• Apply etchant over tooth surface including
2-3 mm of cuspal inclines and reaching into any
buccal or lingual pits and grooves that are present
• May lead to gingival irritation
• Etching time is 30 seconds in primary teeth and
20 seconds in permanent teeth
Fig. 12.4: Application of gel
• Scientific basis for acid etching was given by

Silverstone
• Acid etching on the surface enamel has shown
to produce a degree of porosity by removing a
narrow zone of enamel and fully reacted inert
mineral crystals and dissolving plaque and
pellicles resulting in a more reactive surface,
increase in surface area and decrease in surface
tension that allows the resin to wet the enamel
surface more readily
• Superficial zone: 11 μm, qualitative porous zone–
20 μm, qualitative porous zone– 20 μm
• Type I etching pattern: Hollowing of prism centers
and relatively intact peripheral regions
• Type II etching pattern: Prism peripheries are
damaged with cores projecting towards original
enamel surface
• Type III etching pattern: Generalized surface
roughening.
Rinsing and Drying (Fig. 12.5)

• Washing and drying times are 30 and 15 seconds
respectively
• Removes the etching agent and reaction products
from etched enamel surface
• Etched enamel should have a frosted white
appearance.
Fig. 12.5: Post-gel application
Application of Bonding Agent

• Application of halogenated bonding agent etching
can increase the bond strength in saliva
contaminated enamel (0.0005 to 17.8 mpa) and in
uncontaminated enamel (16.7 to 20.5 mpa)
• Bonding agent displace saliva from enamel,
improving sealant wetting of surface.
Sealant Application (Fig. 12.6)

• Mandibular teeth apply the sealant distally and
allow it to flow mesially
• Maxillary teeth apply the sealant mesially and
allow it to flow distally
Fig. 12.6: Sealant application

• Allow the sealant to flow in the etched pits and

fissures and use a fine brush to apply a thin layer
up the cuspal inclines.
Sealant Curing (Fig. 12.7)

• Cure according to manufacturer’s recommenda-
tion (40 seconds).
Fig. 12.7: Light curing
Evaluate
• Explore the entire tooth surface and check for
voids.
Verify Occlusion (Fig. 12.8)

• To determine if any excessive sealant is present
Fig. 12.8: Sealed pit and fissure surface

• If unfilled sealant is used excess cement abrades

away but in case of filled resin sealant occlusal
adjustment is a necessary.
Recall
• Re-evaluate sealed tooth surface for loss of
material, exposure of voids and caries develop-
ment every 6 months.
Chapter 13
Fluorides
 Mechanism of action of fluoride
 Water fluoridation
 Shoe leather survey
 School water fluoridation
 Salt fluoridation
 Milk fluoridation
 Dietry fluoride supplements
 Topical fluorides
 Fluoride varnish
 Fluoride dentifrices
 Fluoride toxicity
 Defluoridation
 Recent advances in fluoride
• The term fluoride is derived from a Latin word

Fluore, to flow since it was used as a flux
• Described as an essential nutrient in the Federal
Register of United States Food and Drug Admi-
nistration (1973) and WHO
• Sir James Crichton Browne inspired about the
importance of Fluoride in the diet in 1892
• Later it was isolated from water supplies in 1931
• Dr Fredrick Mckay was the first person to notice
the stains on the teeth, which was due to fluoride
and called this Colorado stain
• In 1916 Mckay and Black examined 6873 indi-
viduals in 26 communities in USA in the first
fluoride survey
• Fluorine is in the list of 14 elements recognized
to be physiologically essential for the normal
development and growth of human beings
• Atomic weight of 19 and atomic number of 9
• Present as inorganic fluoride in highly silicious
igneous rocks, alkaline rocks in geothermal
waters and hot springs, volcanic gases, e.g.
apetite – 34%, cryolite – 54%
• Level of fluoride in plants is about 2-20 mg/g
• Tea has one of the highest concentrations of
fluoride, i.e. 100 ppm
• Fluoride of sea water – 0.5-1.4 mg/lit and in River
– 0.5 mg/lit
• Highest conc. of fluoride in water is in Lake
Nakuru (Kenya) – 2800 ppm
• Enamel: 2200 to 3200 ppm
Dentin: 200 to 300 ppm
Cementum: 4500 ppm
Pulp: 100 to 650 ppm.
MECHANISM OF ACTION OF FLUORIDE

Improved Crystallinity
Fluoride increases the crystal size and produces less
strain in crystal lattice by conversion of amorphous
calcium phosphate into crystalline (hydroxy-
phosphate).
Fluorides 137
Void Theory
Fluoride fills voids in the hydroxyapatite crystal thus
helping it to attain a stable form with formation of
more and stronger hydrogen bonds. Greater stability
will lead to lower solubility
Acid Solubility
Fluorapatite is less soluble than hydroxyapatite,
therefore has greater stability.
Enzyme Inhibition
Fluoride has enolase inhibition effect thus leading
to reduced acid production.
Suppressing the Flora

Stannous fluoride is a suppressor of the bacterial
growth because it oxidizes the thiol group present
in bacteria thus inhibiting bacterial metabolism.
Antibacterial Action
Decreases uptake of glucose into cells of oral
streptococci and also reduces ATP synthesis.
Lowering Free Surface Energy

Fluoride incorporated in enamel by substitution of
hydroxyl ions reduces the free surface energy and
thus indirectly reduces the deposition of pellicle and
subsequent plaque formation.
Desorption of Protein and Bacteria

Fluoride inhibits the binding of acidic protein to
hydroxyapatite thereby displaying its beneficial
effects.
Alteration in Tooth Morphology

Rounded cusps, shallow fissures due to selective
inhibition of ameloblasts.
WATER FLUORIDATION
• Defined as the upward adjustment of the concen-
tration of fluoride ion in public water supply in
such way that the concentration of fluoride ion
in the water may be consistently maintained at
one part per million (ppm) by weight
• McKay and Dean began the initial research
• December 1942 Grand Rapids – Muskegon study
by US public health service
• 25th January 1945, NaF was added to water
supply. It was for the first time permissible
quantily of a beneficial dietary nutrient was
added to communal drinking water
• Fluoride compounds used in water fluoridation
are Fluorspar, Sodium fluoride, Silicofluorides,
Sodium silicofluoride, Hydrofluosilicic acid,
Ammonium silicofluoride
• Systems for water fluoridation: Saturator system,
dry feeder system, solution feeder system
• Optimum level of Fluoride: Varies with climate
because the average consumption of water
increases in warmer climates and decreases in
colder areas.
Gallgan and Vermillion formula: ppm of fluoride
= .34/E
E = – 0.038 + 0.0062 × temp of area in ºF
• Recommended value for tropical climate =
0.7 ppm
• Recommended value for cold climate = 1.2 ppm
• Advantages include benefit to large number of
people and regular consumption
• Disadvantage are interference with human rights
and non-existance of common source of water.
SHOE LEATHER SURVEY

• The study of relationship between fluoride
concentration in drinking water, mottled enamel
and dental caries
• By Dr Clinton T Messner, Head of US Public
Health service in 1931 assigned Dr H Trendley
Dean to pursue full time research on mottled
enamel
Fluorides 139
• His task was to continue Mckay’s work and to

find the extent and geographical distribution of
mottled enamel in USA
• He sent 1197 questionnaires around USA and got
a positive reply from 97 regions
• Aim was to find out the minimal threshold of
fluorine – the level at which fluorine began to
blemish the teeth
• The severity of mottling increased with increa-
sing fluoride concentrations in the drinking water
– Water concentration was 4 ppm or more –
mottling was widespread
– Water concentration was 3 ppm or more –
signs of discrete pitting
– Water concentration was 2-3 ppm – teeth had
dull chalky appearance
– Water concentration was 1 ppm or less – no
mottling of any aesthetic significance.
SCHOOL WATER FLUORIDATION

• Started in 1954 in St Thomas VS Virgin islands
by US Public health service division
• The recommended regimen for school water
fluoridation is adding 4.5 times more fluoride
• 25 to 40% decrease in dental caries with this
program
• Advantages are good results and minimal
equipment
• Main concern is that children do not receive the
benefit until they go to school and the amount of
water drunk can’t be regulated.
SALT FLUORIDATION
• Introduced by Wespi in 1955 in Switzerland
• 200-350 mgF/kg
• Fluoridated salt is safe and cheap but salt intake
varies greatly among people.
MILK FLUORIDATION
• Ziegler in 1956
• 250ml milk bottle contains 0.625 mg
• It targets the children but many children in
developing countries do not drink milk for one
or another reason.
DIETRY FLUORIDE SUPPLEMENTS

• Fluoride drops, Fluoritab liquid, Vi-Daylin/F
ADC Drops, Pediaflor Drops
• Prenatal supplements were banned in 1969
• Can be started two weeks after birth and continue
till 16 years of age.
• The dosage will depend upon the age of the child
and the concentration of fluoride in the area.
Fluoride in Birth to 25 to 36 37 months
water (ppm) 24 months months to 13 years
0.3 or less 0.25 mg 0.5 mg 1.0 mg
0.3 to 0.7 0.0 mg 0.25 mg 0.5 mg
TOPICAL FLUORIDES
• NaF (1941), SnF2 (1947), APF (1963), Na MPP
(1963), amine fluoride (1965) and varnish
containing fluoride (1968)
• Professionally applied: Neutral NaF, Stannous
fluoride, Acidulated phosphate fluoride, Amine
fluoride, Fluoride gels, Fluoride varnishes
• Self applied: Tooth brushing dentifrices, Tooth
brushing solutions or gels, Tooth brushing
prophylaxis pastes, Mouth rinses.
Sodium Fluoride
• Bibby in 1941 and Knutson in 1942
• Knutson and Feldman (1948) recommended a
technique of 4 application of 2% NaF at weekly
intervals in a year at 3, 7, 11 and 13 years
• Neutral pH
• 9200 ppm
Fluorides 141
• Caries reduction in 1st year was 45% and in 2nd

year was 36%
• 2 % NaF = 20 gms of NaF powder + 1 litre of
distilled water
• Choking off effect is seen therefore undisturbed
appliction for 4 minutes is needed
• Store fluoride in plastic bottles to prevent
formaton of Si F2, thus reducing the availability
of free active fluoride for anticaries action
• Chemically stable, acceptable taste, non-
irritating to gingival tissues, does not discolour
the teeth and is cheap and inexpensive
• Long follow-up and multi short time visits are
difficult
• Mechanism of action:
Ca10(PO4)6(OH)2 + 20 F = 10 CaF2 + 6 PO4 + 2 OH
CaF2 + 2 Ca5(PO4)3OH = 2 Ca5(PO4)3F + Ca(OH)2
Stannous Fluoride
• First experiments were done by Muhler in 1947
• Dudding and Muhler in 1957 tried single annual
application of 8% SnF2
• 32% caries reduction
• No shelf life
• ‘O’ gelatin capsules + 0.8 gm SnF2 + 10 ml of
distilled water = 8% SnF2
• Rapid penetration of tin and fluoride in
30 seconds therefore continous reapplication
after 15 to 30 seconds is needed
• More caries reduction but is metallic in taste, may

irritate gingiva, causes discoloration of teeth and
has to be freshly prepared
Low conc. – Ca5(PO4)3OH + 2 SnF2 =
2 CaF2 + Sn2(OH)PO4 + Ca3(PO4)2
High conc. – Ca5(PO4)3OH + 16 SnF2 =

2 CaF2 + 2 SnF3PO4 + Sn2(OH)PO4 + 4 CaF2(SnF3)2
– 2 Ca5(PO4)3OH + CaF2 = 2 Ca5(PO4)3F + Ca(OH)2
Acidulated Phosphate Fluoride

• In vitro investigation of Bibby in 1947
• Brudevold in 1963 concluded that phosphate-
containing fluoride was of maximum benefical
effect
• 1.23% APF for 4 minutes
• 28% anticariogenic effect
• Semi-annual application
• 20 gm of NaF + 1 lit of .1M phosphoric acid +
50% Hydrofluoride acid = 1.23
• The amount and depth of fluoride deposited as
fluorapatite would be dependent on the amount
and depth at which Dicalcium Phosphate
Dihydrate DCPD gets formed thus continuous
supply of fluoride is required, so APF has to be
applied every 30 seconds and the teeth be kept
wet for 4 minutes
Ca5(PO4)3OH + 4 H = 5 Ca + 3 HPO4 + H2O
Ca + HPO4 = Ca.HPO4.2H2O (DCPD)
5 Ca.HPO4.2H2O + F = Ca5(PO4)3F + 2 HPO 4 + 3 H + 2 H2O
Fluorides 143
Amine Fluoride
• Muhlmann (1945), University of Zurich first
studied effects of AMF
• Amine fluoride is superior in reducing enamel
solubility because of chemical protection by
fluoride and physicochemical protection by
organic portion
• Surface active because they hold fluoride on
enamel suface for longer time.
Stannous Hexafluorozirconate
• SnZrF6
• Developed at Indiana University.
FLUORIDE VARNISH
• Schmidt in 1964
• Teeth were coated with a lacquer containing
fluoride called F-lacquer, which released fluoride
ions in high concentrations for several hours in
the moist atmosphere of the mouth
• Varnish have deeper penetration and more
retention on tooth surface
• Duraphat: NaF varnish containg 2.26% F in
organic lacquer, active fluoride available is 22,600
ppm
• Fluorprotector: Colourless, polyurethane lacquer
dissolved in chloroform, Silane fluoride with
0.7% F, active fluoride is 7000 ppm
10Ca5 (PO4)3OH + 10 F = 6 Ca5 (PO4)3F + 2CaF2
+ 6 Ca3(PO4)2 + 10 OH
2Ca5(PO4)3OH + CaF2 = 2 Ca5(PO 4)3F + Ca(OH)2
R-SiF2 OH + H2O = R-Si (OH)3 + 2 HF
FLUORIDE DENTIFRICES
• Sodium fluoride and stannous fluoride dentifrices:
Marketed in 1955 but not very popular due to
limited efficacy and objectionable taste of SnF2
• Amine Fluoride was first tested for its cariostatic
potential in Zurich, Switzerland, which was
superior to inorganic fluorides but these are used
only in Europe.
• Monofluorophosphate is in most of the major
commercial fluoridated toothpastes used
throuthout the world eversince 1969. Dentifrices
containing MFP at a concentration of 0.76%, 0.1%
F with sodium metaphosphate as abrasive, have
led to variable reductions in caries rates ranging
from 17 to 34%
• Fluoride Tooth pastes: Europe – Extrastrength Aim,
Improved crest, Colgate, Aquafresh; India –
Stolin-R, Pepsodent, Cibaca, Colgeate total,
Senquel
Fluorides 145
• Recommendations for use of fluoride dentifrice:

Age Recommendation
Below 4 years Not recommended

4 – 6 years Once daily with fluoride paste and twice
without paste
6 – 10 years Twice daily with fluoride paste and once
without paste
Above 10 years Thrice daily with fluoride paste
FLUORIDE TOXICITY
It can be defined as excess injestion of fluoride that
may be in a single dose or over a period of time.
Acute Toxicity
• Ingestion of large doses of fluoride at one time
• Safely tolerated dose: 8 mg – 16 mg/kg body wt
• Toxic dose: 16 mg – 30 mg/kg body wt
• Lethal dose: 32 mg – 64 mg/kg body wt
• Probably toxic dose is the threshold dose that
could cause life threatening systemic signs and
symptoms
• Factors affecting acute toxicity: Bioavailability,
Route of administration, Age, Rate of absorption
• Signs and Symptoms include Nausea, vomiting,
abdominal pain, diarrhea, carpopedal spasms,
weak thready pulse, fall in blood pressure,
cardiac arrhythmia, coma and death
• If fluoride ingested is less than 5 mg/kg – Give
milk and induce vomiting
• Fluoride ingested is more than 5 mg/kg – Give
milk, induce vomiting, 5% Calcium gluconate
• More than 15 mg/kg – Induce vomiting, cardiac
monitoring, slow administration of 10% Calcium
gluconate, supportive measures for shock.
Chronic Toxicity
• Ingestion of variant doses of fluoride over a
prolonged period of time
• Dental fluorosis can be defined as hypoplasia or

hypomaturation of tooth enamel or dentin
produced by the chronic ingestion of excessive
amounts of fluoride during the period when teeth
are developing
• There is direct inhibitory effect on enzymatic
action of ameloblasts leading to defective matrix
formation and subsequent hypomineralization
• Major cause is water consumption containing
high levels of fluoride during the first 6 years of
life
• Skeletal fluorosis is caused by water fluoride
levels over 8 ppm
• Clinical features are increase in bone density,
change in bone contours, roughening and
blurring of the trabeculae, cortex of long bone is
thick and dense and the medullary cavity is
diminished, ligamental and tendon calcification
with vague pain in joints, limitation of joint
movements.
Dean’s Index
Given by Trendly H Dean in 1934:
Rating Public health significance
0 Normal – The enamel shows the usual translucency.
The surface is smooth, shiny and usually of a pale,
creamy white to grey white colour
0.5 Questionable – The enamel shows slight aberrations
ranging from a few white flecks to occasional white
spots
1 Very mild – Small, opaque, paper white areas
scattered irregularly over tooth but not involving
more than 25%
2 Mild – Opaque, paper white areas that are more
extensive, involving more than 25% but less than 50%
3 Moderate – All enamel surfaces are affected and also
show attrition
4 Severe – All enamel surfaces are affected and
hypoplasia is so marked that general form of tooth is
affected. Discrete or confluent pitting with brown
stains is a charecterstic feature.
Fluorides 147
FDI Index
Dental developmental index modified in 1989.
• Normal
• Demarkated opacities
– White/Cream
– Yellow/Brown
• Diffuse opacities
– Diffuse – lines
– Diffuse – patchy
– Diffuse – confluent
– Confluent/patchy/staining/loss of enamel
• Hypoplasia
– Pits
– Missing enamel
• Any other defects.
DEFLUORIDATION
• Process of removing excess naturally occurring
fluorides from drinking water in order to reduce
the prevalence and severity of dental fluorosis
• World Health Organization in 1963 has
recommended that optimum limit of fluoride in
drinking water for the prevention of dental caries
is 0.7-1.2 ppm
• In India, the work on defluoridation was taken
up by NEERI at Nagpur in 1961.
Anion Exchange Resins

• Polystyrene anion exchange resins and basic
quarternary ammonium type resins
• Lost fluoride removal capacity on prolonged use,
more costly and altered the taste of water.
Defluoron–1
• Developed by Bhakuni
• Combination of sulphonated saw dust impre-
gnated with 2% alum solution
• Disadvantages were poor hydraulic properties
and heavy attritional losses.
Magnesia
• Investigations by VP Thergaonkar (1971)
• Recarbonation was necessary
• High initial cost of magnesia, complexity of
preparation are some of the salient inhibitive
factors.
Defluoron–2
• Developed in 1968
• Defluoron-2 is suphonated coal and works on the
aluminium cycles
• Good results, adequate shelf life of 2—4 years
and was very cost effective.
Nalgonda Technique
• Pioneered by Nawalakhe in 1974
• Addition of three readily available chemicals, i.e.
sodium aluminate or lime, bleaching powder and
filter alum to the fluoride water in the same
sequence which leads to flocculation, sedimen-
tation and filtration
• Sodium aluminate or lime hastens settlement of
preceipitate and bleaching powder ensures
disinfection.
RECENT ADVANCES IN FLUORIDE

Co-polymer Membrane Beads
• Developed in USA by Cowsar (1976)
• A membrane core reservoir type device with
inner core of HEMA/MMA
• Copolymer (50/50 mixture with a precise amount
of NaF)
• Rate of fluoride release: 0.02-1 mg/day.
Fluoride Glass Device

• Developed in UK
• Glass: 4 mm in diameter and attached to the
buccal aspect of upper molar with acid etch
composite
Fluorides 149
• Dissolves slowly when moist with saliva

releasing fluoride in the oral environment
• Concentration of fluoride in glass: 13.3-21.9%
• Continuous release upto 2 years.
Bio-adhesive Devices
• Tablets, capsules or aerosols
• Developed by Bottenberg (1998)
• Labial aspect of maxillary incisors, buccal aspect
of molars and lingual aspect of mandibular
incisors.
Chapter 14
Dental Caries
 Theories of dental caries
 Histopathology of enamel caries
 Histopathology of dentinal caries
 Role of saliva in dental caries
 Diet and dental caries
 Food sugar substitutes
 Decline in dental caries
Caries is defined as microbial disease of the calcified

tissues of teeth that is demineralization of the
inorganic components and the subsequent
breakdown of the organic moieties of enamel and
dentin.
THEORIES OF DENTAL CARIES

The Legend of the Work
• Sumerian text
• Discovered from an ancient city within the
Euphrates Valley of the lower Mesopotamian
area
• Mix beer, the plant sa-kil-bir and oil together,
repeat thereon the incantation thrice and put it
on the tooth
• Fumigation, which consisted of burning leeks
and hyocyamus was used by Chinese and
Egyptians.
Humoral Theory
• Proposed by Galen
• Elemental humors of the body were blood,
phlegm, black bile and yellow bile
• An imbalance in these humors resulted in disease
• Dental caries was produced by internal action of
acid and corroding humors.
Vital Theory
• Proposed by Hippocratic, Celsius
• Tooth decay originated, like bone gangrene, from
within the tooth itself.
Chemical Theory
• By Robertson in 1835
• Decay caused by acid formed by fermentation of
food particles around teeth.
Parasitic Theory
• In 1843, Erdl described filamentous parasites in
the membrane removed from teeth
Dental Caries 153
• Antoni van Leeuwenhock indicated that micro-

organisms were associated with the carious
process.
Miller’s Chemoparasitic Theory

• Given by Miller in 1889
• Die Mikroorganismen der Mundhohle
• Acid and microorganisms were involved in the
etiology of dental caries
• Dental decay is a chemoparasitic process consisting
of two stages: Decalcification or softening of the
tissues and dissolution of softened residue.
Proteolytic Theory
• Espoused primarily by Gottlieb (1947), Frisbie,
Nuckolls (1947) and Pincus (1950)
• Process involved de-polymerization and
liquefaction of the organic matrix of enamel
• Gottlieb proposed that microorganisms invade
the organic pathways of enamel and initiate
caries by proteolytic action. Subsequently, the
inorganic salts are dissolved by acidogenic
bacteria.
Proteolysis – Chelation Theory

• Proposed by Schatz in 1955
• Dental caries results from an initial bacterial and
enzymatic, proteolytic action on the organic
matter of enamel without preliminary deminer-

alization
• This produces an initial caries lesion and releases
a variety of complexing agents, such as amino
acids, polyphosphates and organic acids, which
dissolve the crystalline apatite.
Sulfatase Theory
• By Pincus in 1950
• Bacterial Sulfatase hydrolyzes the ‘mucoitin
sulfate’ of enamel and the chondroitin sulfate of
dentin producing sulfuric acid that in turn causes
decalcification of the dental tissues.
Complexing and Phosphorylation Theory

• High bacterial utilization of phosphate in plaque
causes a local disturbance in the phosphate
equilibrium in the plaque and the tooth enamel
resulting in loss of inorganic phosphate from
enamel. Soluble calcium complexing compounds
produced by bacteria cause further tooth
disintegration.
Keys Concept (Fig. 14.1)

• Given by Keys in 1960
• The host, the agent and environmental influences,
i.e. tooth, plaque, substrate play important role in
mediating caries.
Fig. 14.1: Key’s triad

Dental Caries 155
Newburn’s Concept (Fig. 14.2)

• By Newburn in 1982
• Secondary factors influence the rate of progres-
sion of caries
• Interaction between three primary factors is essential
for the initiation and progression of caries: A
susceptible host tissue, the tooth; microflora with
a cariogenic potential; and a suitable local
substrate to meet the requirements of the
pathodontic flora.
Fig. 14.2: Newburn’s concept
Primary factors Secondary factors

Plaque Oral hygiene
Oral Flora
Saliva-pH, composition, flow, buffer
Fluoride in plaque
Diet
Transmissibility
Substrate Type of Carbohydrates
Chemical composition of food
Physical characteristics of food
Oral clearance
Frequency of eating
Sugar intake and frequency
Tooth Fluoride concentration
Carbonate and citrate level
Age of tooth
Morphology of tooth
Trace elements
Nutrition
Saliva
Composition of enamel
HISTOPATHOLOGY OF ENAMEL CARIES

(FIG. 14.3)
The Translucent Zone
• Advancing front of a carious lesion
• The first signs of enamel breakdown are seen in
this area
• Pores at junction sites such as the prism
boundaries
• Resultant pore volume is 1%
• Increase in porosity.
Fig. 14.3: Histology of enamel caries
The Dark Zone

• Superficial to the translucent zone
• Positively birefringent
• Pore volume of 2-4%.
The Body of Lesion

• Deep to the relatively unaffected enamel surface
layer
• Enhanced Striae of Retzius and cross-striations
in the enamel prisms
• Positively birefringent denoting a significant
degree of mineral loss
• Pore volume of 5% to 25%.
Dental Caries 157
The Surface Zone

• Intact enamel surface overlying an area of
subsurface demineralization
• Partial demineralization equivalent
• Negative birefringence.
HISTOPATHOLOGY OF DENTINAL CARIES

(FIG. 14.4)
Zone of decomposed dentin (a)
• Dilations coalesce, forming the outermost zone
of decomposed dentin.
Zone of bacterial invasion (b)
• Lumen of the tubule is distended
• Liquefaction foci.
Zone of demineralization (c)
• Changes in the degree of mineralization
• Occlusion of dentinal tubules.
Zone of dentinal sclerosis (d)
• An attempt to block the advancing carious lesion
• Re-precipitation of crystalline material.
Zone of fatty degeneration (e)
• Combination of multiple dilatation
• Formation of clefts.
Fig. 14.4: Histology of dentinal caries

ROLE OF SALIVA IN DENTAL CARIES

• Anti-cariogenic effect
• Clearance from the oral cavity
• Inorganic constituents of saliva help in alkalinity
• Fluoride concentration in saliva
• Calcium and phosphate concentration in saliva
help in remineralization
• Salivary proteins like amylase increase the rate of
dissolution and removal of starch
• Antibacterial factors like Lysozyme, Lactoperoxi-
dase, Lactoferrin prevent the establishment of
more pathogenic transient invaders
• Salivary Agglutinins cause an aggregation of
various strains of oral microorganisms thus
resulting in their rapid removal from the oral cavity
when the saliva is swallowed
• Statherin inhibits formation of hydroxyapatite,
prevents precipitation of calcium phosphate salts,
thus facilitating remineralization of early carious
lesions.
DIET AND DENTAL CARIES

• Main polysaccharide (starch) is not highly
cariogenic
• Excessive use of highly fermentable mono and
disaccharides is correlated with high caries rates
• Sucrose is by far the commonest dietary sugar
and most cariogenic
• Physical properties of food have significance by
affecting food retention, food clearance, solubility
and oral hygiene. If a type of food is stickier then
there are more chances of getting caries as
compared to a food that is readily cleared from
oral cavity
• Diet effects salivary flow rates
• Foods that improve the cleansing action and
reduce the retention of food within the oral cavity
are least cariogenic
• Lemons, apples, fruit juices and carbonated
beverages, are sufficiently acidic so as to cause
Dental Caries 159
demineralization of enamel that is in prolonged

contract with them
• Decrease of vitamin D will lead to calcium and
phosphate derangement and in turn cause
hypoplasia of teeth
• Deficiency of vitamin A can lead to changes in
ameloblasts thereby causing alteration in tooth
morphology
• Fat consumed has been somewhat responsible for
anti-cariogenic effect due to protection from
demineralization by formation of fatty film in
proximal areas.
Hopewood House Study

• 1942
• Hopewood house – ‘motherhouse’ for young
children
• NSW, Australia
• Children raised on a natural diet that excluded
refined carbohydrates
• The basically vegetarian diet with spartan
porridge, biscuits, wheat gram, fresh and dried
fruit, vegetables (cooked and raw), along with
butter cheese, eggs, milk and fruit juices. Vitamin
concentrates and an occasional serving of nuts
and a sweetening agent such as honey supple-
mented the meals
• The food was uncooked as far as possible in order
to retain its natural state
• The most striking feature of this diet was the
notable absence of sugar
• The fluoride content of the water and food was
insignificant and no tea was consumed
• All meals and between meal eating were
controlled with great regularity
• At the end of a 10-year period, the 13-year old
children of Hopewood House had a mean DMF
per child of 1.6; the corresponding figure for the
general child Population of the State of NSW
was 10.7
• This work shows that in institutionalized

children, at least, dental caries can be reduced to
insignificant levels by a spartan diet, and without
the beneficial influence of fluoride and in the
presence of unfavorable oral hygiene.
Vipeholm Study
• 1939
• Collaboration of Swedish Government and Royal
Medical Board
• Vipeholm Hospital, Lund, Sweden
• 436 patients divided into control and 6
experimental groups.
– Control groups: Received low carbohydrate,
high fat diet practically free from refined
sugar
– Sucrose group: Received 300 gm of sucrose in
solution at mealtimes.
– Bread group: 345 gm of sweet bread containing
50 gm of sugar
– Chocolate group: 300 gm sugar with meals,
which was reduced to 100 gm supplemented
by 65 g of milk chocolate between meals
during next 2 years
– Caramel group: Received 22 caramels daily in 2
portions between meals
– 8-toffee groups: Received 8 toffees in two
portions
– 24-toffee group received 24 toffees between
meals
• Conclusion of the Vipeholm study
– Caries activity is greatest if the sugar
consumed has a tendency to be retained on
the surfaces of the teeth
– Risk of caries activity is greatest if the sugar
is consumed between meals
– Caries activity decreases on withdrawal of
such foodstuffs from the diet
– Caries activity is intensified if duration of
sugar clearance from saliva is slow.
Dental Caries 161
Turku Study
• 1975
• Turku, Finland
• By Scheinin and Makinen
• Aim of this study was to compare the cariogenicity
of sucrose, fructose and xylitol
• 125 subjects divided into three groups viz sucrose
group who received their ordinary sucrose
containing diet, second group received xylitol and
in the third group fructose
• Sucrose and fructose had equal cariogenicity
whereas xylitol produced almost no caries
• In second year, caries continued to increase in the
sucrose group, remained unchanged in the
fructose group and in the xylitol group some early
white spot lesions had been remineralized to a
point where they could not be scored.
Experimental Caries in Man

• In Denmark by Vonder Fehr in 1970
• In Britain by Edgar in 1978
• 9 daily rinses with 10 ml of 50% sucrose and
discontinuance of active oral hygiene procedure
• White-spot lesions on smooth surfaces were
produced in 3 weeks in the experimental group
• At the end of the experiment meticulous oral
hygiene measures were re-instituted along with a
daily mouth rinse of 0.2% NaF, which resulted in
remineralization of the white spots and a reversal
of the caries index scores.
Hereditary Fructose Intolerance

• 1959
• Froesch described an inborn error of fructose
metabolism transmitted by an autosomal recessive
gene. The metabolic error in this condition is due
to deficiency of hepatic fructose-1 phosphate
aldolase
• Persons with HFI show a strikingly reduced
dental caries experience.
FOOD SUGAR SUBSTITUTES

Aspartame
• It is a dipeptide methyl ester
• Brand names of Nutrasweet and Equal
• Discovered in 1965 and approved in 1981 for
limited use as a sweetener
• Used in diet soft drinks, yogurt, puddings, gelatin
and snack foods
• Disadvantages are relative toxic affects on
growth, glucose homeostasis, and liver functions
with long-term usage.
Acesulfame Potassium
• A non-nutritive product, for use as a sweetener
in dry food products
• Approved by the FDA in 1988 for use in foods,
beverages, cosmetics and pharmaceutical
products
• Dose-dependent cytogenetic toxicity.
Saccharin
• Oldest artificial sweetener
• 200 to 500 times sweeter than sucrose
• It is non-cariogenic and non-caloric sugar
substitute available in liquid and tablet form
• Potential bladder carcinogen.
Sucrolose
• Non-nutritive, non-caloric, trichlorinated deri-
vative of sucrose
• Tea and coffee sweetener, carbonated and non-
carbonated beverages, baked goods, chewing
gum and frozen desserts.
Sorbitol
• Sugar alcohol produced commercially from
glucose
Dental Caries 163
• Used as a “bulk” sweetener in chewing gum,

chocolates, and confectionaries
• May cause diarrhea if ingested in large quantities.
Xylitol
• Discovered in wood chips in 1890 and in wheat
in 1891
• It is a non-fermentable, pleasant tasting, non-
cariogenic polyol derived from xylose
• Approved in humans in 1986
• Primarily used in chewing gum
• Reduces the transmission of cariogenic bacteria
from mother to infant and has been shown to
have bactericidal qualities
• The FDA has not yet approved additional uses
of xylitol as a sweetener.
Stevia
• It is natural occurring, heat stable sweetener,
which is extracted from Stevia rebaudiana
Bertoni
• The active ingredient, stevioside, contains three
glucose molecules, steviol, and a ditepenic
carboxylic alcohol
• Its sweetness potency is 100 to 300 times greater
than sucrose
• Used in Paraguay, Brazil, Japan, China and
Germany
• Approved by FDA as dietary supplement, but
not as a sweetener.
Neotame
• Chemical structure similar to aspartame and
being developed commercially by the Nutra
Sweet Company
• Neotame is a high intensity sweetener, 6000 to
9000 greater than
• Used in carbonated soft drinks, powdered soft
drinks, yellow cake, and yogurt
• Not yet approved by FDA.
DECLINE IN DENTAL CARIES

Diet
• Change in diet leading to improved nutrition
• Decrease in amount of sugar consumption
• Reduced frequency of sugar consumption
• Antimicrobial effects of diet additives
• Use of sugar substitutes.
Fluorides
• Water fluoridation
• Salt or milk fluoridation
• Fluoride toothpastes
• Fluoride tablets
• Fluoride school programs
• Fluoride applications by dentists
• Dietary fluoride supplements.
Plaque
• Reduced plaque due to better brushing habits
• Reduced plaque due to better professional
removal
• Better chemical plaque control
• Use of antibiotics or other medicines
• Change in composition or virulence of the oral
microflora.
Miscellaneous
• Pit and fissure sealants
• Better dental materials
• Better training of dentists
• Better instrumentation
• Increased dental awareness
• Availability of dental resource.
Chapter 15
Early Childhood
Caries
 Terminologies used for ECC over the
years
 Stages of ECC
 Etiopathogenesis of early childhood
caries
 Fluoride treatment for children with
rampant caries
 Integrated model for prevention of ECC
 Model for high caries risk patients
• Massler (1945): Suddenly appearing widespread,

rapidly spreading, burrowing type of caries,
resulting in early involvement of pulp and
affecting those teeth, which are usually regarded
as immune to decay.
• Winter et al (1966): Caries of acute onset involving
many or all the teeth in areas that are usually not
susceptible. They further defined the condition
to be associated with rapid destruction of crowns
with frequent involvement of dental pulp.
• Davies (1998): Complex disease involving
maxillary primary incisors within a month after
eruption and spreading rapidly to other primary
teeth.
• Amid Ismail (1998): Early Childhood Caries (ECC)
Occurrence of any sign of dental caries on the
tooth surface during first 3 years of life.
TERMINOLOGIES USED FOR ECC

OVER THE YEARS
• Nursing caries—Winter (1966)
• Nursing bottle mouth—Kroll (1967)
• Nursing bottle syndrome—Shelton (1977)
• Night bottle syndrome—Dilley (1980)
• Nursing bottle caries—Tsmtasorius (1986)
• Baby bottle tooth decay—Min Kelly (1987)
• Milk bottle syndrome—Ripa (1988)
• Tooth clearing neglect—Moss (1996)
• Infant and early childhood dental decay—
Horowitz (1998)
• ECC—Davies (1998)
• MDSMD—Maternally Derived Streptococcus
Mutans Disease.
STAGES OF ECC
Stage I: Initial Reversible Stage (Fig. 15.1)
• 10-20 months
• Cervically and occasionally interproximal areas
of chalky white demineralization
• No pain.
Early Childhood Caries 167
Fig. 15.1: Stage I: Initial reversible stage
Fig. 15.2: Stage II: Damaged carious stage
Stage II: Damaged Carious Stage (Fig. 15.2)

• 16–24 months
• Lesion in maxillary anterior teeth, may spread
to dentin and show yellowish brown discolo-
ration
• Pain on having cold food items.
Stage III: Deep Lesion (Fig. 15.3)

• 20–36 months
• Molars are also affected
• Frequent complain of pain
• Pulpal involvement in maxillary incisors.
Fig. 15.3: Stage III: Deep lesion
State IV: Traumatic Stage (Fig. 15.4)

• 30–48 months
• Teeth become so weakened by caries that
relatively small forces can fracture them
• Parents may report a history of trauma
• Molars are now associated with pulpal problems
• Maxillary incisors become non-vital.
Fig. 15.4: Stage IV: Traumatic stage

ETIOPATHOGENESIS OF EARLY
CHILDHOOD CARIES
Infant Feeding Patterns
• Use of bottle is predominant in children with ECC
• Length of contact with the bottle at night-time is
also important. Greater length of bottle contact
appears to be positively associated with caries
• Shantinath – use of bottle beyond the age of
1 year of age increased the incidence of caries. He
also reported that children with caries eliminate
bottle use 4–7 months later than those without
caries
• Prolonged or at will breast-feeding can cause ECC.
Dental Plaque
• Modulation of the oral flora
• Lubrication, protection from acid attack, pre-
vention of crystal growth on enamel surfaces and
a role in enamel remineralization
• In the absence of fermentable carbohydrates,
organic acids such as acetate are produced and
when fermentable carbohydrates are present,
lactate is mainly produced, which coincides with
a pH drop in plaque
• Bacteria and their alkaline products provide major
contributions to the pH rise in plaque and the
base-generating metabolism of plaque bacteria is
considered by many to be a significant determinant
of cariogenicity of plaque.
Mutans Streptococci
• S. Mutans and S. Sobrinus are the most commonly
isolated in human dental caries.
• Mutans streptococci are the principal bacteria
isolated form children with ECC.
• Van Houte and Matte Min reported that in breast-
fed children with rampant decay, the levels of
S. mutans in dental plaque samples were 100 times

higher than in children without decay.
• Virulence of mutans streptococci
Tanger: Synthesize ∝-1,3 rich water insoluble
glucans from sucrose. These glucans increase the
thickness of plaque, and result in enhanced rates
of sugar diffusion and acid production at the
deeper plaque layers.
Van Houte: Synthesize intracellular polysaccharide
(IPS), which supports continual acid production
during periods of low concentration of exogenous
substrate.
Johnson: Produce large amounts of acid, parti-
cularly lactic acid, which are potent in driving,
tooth demineralization.
Spatafora: Aciduricity of the bacteria is extremely
high, thus allowing colonization and persistence
under cariogenic conditions.
• Colonization of mutans streptococci in dental
plaque is mediated by adhesions on the bacterial
surface interacting directly with the salivary
proteins, which form the pellicle on tooth surface.
• Establishment of mutans streptococci in infants
is related to the fact that they generally require
non-shedding surface to colonize. Thus the
organisms are usually first detected when the first
primary teeth emerge into the oral cavity, or
when obturators for palatal clefts are inserted.
• Transmission of mutans streptococci is media-
ted via the saliva.
Salivary concentrations of 10 5 CFU (colony
forming units) mutans streptococci/ml of
maternal saliva were associated with a 52%
infection rate in their children, compared to only
6% infection rate when the maternal saliva
concentration was 103 or below.
Salivary Factors
• Saliva provides the main host defense systems
against dental caries
• Clearance of food
• Buffering of acids generated by dental plaque

• Mediates selective adhesion and colonization of
bacteria on tooth surface
• Antimicrobial proteins, including lysozyme,
lactoferrin, and agglutinins are likely to be of
greater significance in dental caries.
Tooth Brushing
• Early childhood caries starts on surfaces that can
be easily accessed by routine tooth brushing.
Thus, oral hygiene levels are a definitive
associated feature
• Increased frequency and better oral hygiene levels
are associated with lower caries levels.
General Cariogenicity of Sugars

• Sucrose, glucose and fructose found in fruit juices
and vitamin C drinks as well as in solid food are
probably the main sugars associated with infant
caries
• Sucrose, is the only substrate used for bacterial
generation of plaque dextrans, which are essen-
tial for bacterial adhesion, and thus facilitates the
implantation of cariogenic bacteria in the oral
cavity.
Frequency of Consumption
• Weinstein noted that increased frequency of
eating sucrose increases the acidity of plaque, and
enhances the establishment and dominance of
the aciduric mutans streptococci
• The increased total time the sugar is in the mouth,
increased will be the potential for enamel
demineralization, and there is inadequate time
for remineralization by saliva, with the result that
demineralization becomes the predominant
mechanism.
Oral Clearance of Carbohydrates

• The low salivary flow during sleep decreases oral
clearance of the sugars and increases the length
of contact time between plaque and substrates,

thus increasing the cariogenicity of the substrate
significantly
• Hanaki (1993) reported that clearance of glucose
is slowest on the labial surfaces of the maxillary
incisors and buccal surface of mandibular molars,
which are characteristically the sites of ECC.
Bovine Milk
• The cariogenicity of milk is often questioned
because plain bovine milk is the common fluid
placed in the feeding bottle in many cases of ECC
• Studies prove that milk is not cariogenic and
infact it is cariostatic
• Milk decreases the solubility of enamel
• Intraoral cariogenicity tests (ICT)
• Decreases demineralization and increases
remineralization of enamel, increasing the
calcium and phosphate concentrations in plaque
and increasing the acid buffering capacity of
plaque
• α–casein may concentrate in the acquired pellicle
and act as inhibitors of mutans streptococci
adherence to saliva-coated hydroxyapatite and
also reduce the adherence of Streptococcus
mutans glucosyltransferases to saliva – coated
hydroxyapatite.
Human Milk
• Compared to bovine milk, human breast milk has
a lower mineral content, higher concentration of
lactose (7% vs 3%), and less protein (1.2 g vs 3.3
g per 100 ml), but these differences are probably
insignificant in terms of cariogenicity
• Many studies have reported that human milk is
cariogenic but the relationship between breast-
feeding and dental caries is likely to be complex,
and confounded by many biological variables
such as mutans streptococci infection, enamel
hypoplasia, intake of sugars, as well as social

variables such as education and socio-economic
status, all of which may affect the behavior
related to oral health.
Acidic Fruit Drinks

• Acid in fruit juices and soft drinks may decrease
the oral pH
• In the presence of sugars in the drinks, this fall
in pH is likely to enhance demineralization that
resulting from bacterial fermentation of
carbohydrates and thus cause more profound
enamel demineralization.
Immunological Factors
• Host immune mechanisms include specific
immune factors derived from saliva (secretory
immunoglobulin A, sIgA), or serum and gingi-
val crevicular fluid (immunoglobulin G, IgG) and
non-specific antimicrobial systems derived
mainly from saliva, and phagocytic cells which
transudate through the gingival crevice
• Secretory immunoglobulin A (sIgA) may inhibit
bacterial adherence or agglutination, as well as
neutralization of bacterial enzymes.
Tooth Maturation and Defects

• A combination of recently erupted immature
enamel in an environment of cariogenic flora
with frequent ingestion of fermentable carbo-
hydrates would render particularly susceptible
to caries
• The presence of developmental, structural defects
in enamel may increase the caries risk.
Fluorides
• Decreases the rate of subsurface dissolution and
enhances the deposition of fluoridated apatite in
the surface zone
• Direct inhibitor of enzymes, which affect the
metabolic activity of mutans streptococci
• Reduces the acid tolerance of mutans streptococci

by affecting the functioning of proton extruding
ATPases, which results in cytoplasmic acidi-
fication and inhibition of glycolytic enzymes.
Race and Ethnicity

• Increased risk that could be associated with
cultural norms
• Prenatal diet that could contribute to enamel
hypoplasia
• Child rearing practices
• Access to dental and medical care
• Minorities may experience significant barriers to
dental care, including cost of care and availability
of accessible services.
Socioeconomic Status
• Individuals from lower socioeconomic status
experience financial, social and material barriers.
Dental Knowledge
• Dental knowledge is regarded as an important
variable in prevention of ECC
• Higher the knowledge of the care-giver more was
the incidence of caries.
Stress
• Brown – caries and stress demonstrated a positive
relationship between parent’s anxiety about
dental treatment and children’s caries levels.
FLUORIDE TREATMENT FOR CHILDREN WITH RAMPANT CARIES (0.3 TO 0.7 PPM WATER FLUORIDE LEVEL)
Type 0-2 years 2-3 years 3-13 years >13 years
Dietary fluoride supplement Not indicated 0.25 mg F daily 0.5 mg F daily Not indicated
Operator-applied topical APF topical solution APF topical solution or APF topical solution or APF topical solution or gel,
fluoride or gel, 1.23%F, applied gel, 1.23%F, applied four gel, 1.23%F, applied four 1.23%F, applied four times
four times a year times a year times a year a year
Self-applied topical fluoride Not indicated Not indicated Self-application of gel-tray Self-application of gel-tray
daily for approximately daily for approximately
4 weeks; thereafter continue 4 weeks; thereafter
with a daily fluoride rinse continue with a daily
(0.05%NaF) fluoride rinse (0.05%NaF)
Fluoride dentifrice Brush with F- Brush with F- Brush with F-containing Brush with F-containing
containing dentifrice containing dentifrice dentifrice dentifrice
INTEGRATED MODEL FOR

PREVENTION OF ECC
MODEL FOR HIGH CARIES RISK PATIENTS

Chapter 16
Pediatric
Operative
Dentistry
 Differences between deciduous and
permanent teeth
 Modifications of cavity preparation in
primary teeth
 Matrix
 Wedges
 Isolation
 Rubber dam
 Air abrasion
 Minimal intervention
 Current concepts in cavity preparation
 Atraumatic restorative treatment (ART)
 Diagnosis of caries
 Caries vaccine
• Operative dentistry is the art and science of the

diagnosis, treatment and prognosis of defects of
teeth that do not require full coverage
restorations for correction. Such treatment should
result in the restoration of proper tooth form,
function and esthetics while maintaining the
physiologic integrity of the teeth in harmonious
relationship with the adjacent hard and soft
tissues, all of which should enhance the general
health and welfare of the patient
• Rationale for preservation of primary teeth:
Maintenance of arch length, Maintenance and
improvement of appearance, Maintenance of
healthy oral environment, Psychology of keeping
teeth, Prevention and relief of pain, Functions of
chewing and speech
• In children we use 4 handed single-minded
dentistry to promote comfort to the child and
improve quality of dental care
• Reclined position is best in children as they are
more comfortable and more manageable in this
position.
Black’s Classification
Class I: All pit and fissure restorations on occlusal

surface of premolars and molars, restorations on
occlusal 2/3rd of the facial and lingual surfaces of
molars, and restorations on lingual surface of
maxillary incisors.
Class II: Restorations on the proximal surfaces of
posterior teeth.
Class III: Restorations on the proximal surfaces of
anterior teeth that do not involve the incisal angle.
Class IV: Restorations on the proximal surfaces of
anterior teeth that involve the incisal edge.
Class V: Restorations on the gingival third of the
facial or lingual surfaces of all teeth.
Pediatric Operative Dentistry 179
Class VI: Restorations on the incisal edge of anterior

teeth or the occlusal cusp tips of posterior teeth
(Simon’s modification).
Finn’s Modification (for pediatric dentistry)
Class I: Pit and fissure cavities on occlusal surface of

molars and the buccal and lingual pits of all teeth.
Class II: Cavities on the proximal surfaces of posterior
teeth with access established from occlusal surface.
Class III: Cavities on the proximal surfaces of anterior
teeth that may or may not involve a labial or lingual
extension.
Class IV: Restorations on the proximal surfaces of
anterior teeth that involve the incisal edge.
Class V: Cavities on the cervical third of all teeth,
including proximal surfaces where the marginal
ridge is not included in cavity preparation.
DIFFERENCES BETWEEN DECIDUOUS AND

PERMANENT TEETH (FIG. 16.1)
Fig. 16.1: Difference in primary and permanent

Deciduous dentition Permanent dentition

20 32
Only two molars are Third molar is also
present present
Whiter in colour Less white as compa-
red to primary teeth
Crowns are more Less bulbous
bulbous
Small contact area Larger contact area
Enamel-dentine Enamel ends in a
junction is more gradual manner
sinus
Buccal and lingual surface Buccal and lingual
are flat surfaces are round
Marked constriction Less constriction
at the neck
Mamellons are absent Mamellons are present
in anterior teeth
Enamel cap end in a Enamel cap end in a
marked ridge feather-edge
Enamel is thin but Thicker enamel of
shows consistent varying depth
depth (1 mm)
Less tooth structure There is more covering
covering the pulp of enamel and dentin
Enamel rods slope Enamel rods slope
occlusally gingivally
All primary teeth Only 1st molars exhibit
show neonatal line neonatal line
Dentino-enamel Dentino-enamel
junction is flat junction is scalloped
Occlusal table is Occlusal table is wider
narrow
Roots of primary teeth Roots are long and
are shorter robust
Roots have a short Larger undivided
trunk portion of root is
present
Roots are more diver- Roots are less
gent and flaring divergent
contd...
contd...
Undergo physiologic Only pathologic

resorption changes can take place
Greater thickness of Less covering of dentin
dentin over the pulpal
wall
Pulp chambers are Normal sized pulp
large chambers
Pulp horns are higher Pulp horns are low
Accessory canals are Accessory canals are
located in the furcation located in the root
area apices
No regressive changes Calcifications and pulp
can be seen stones are seen
Root canals are ribbon Root canals are more
like tortuous and curved
Enlarged apical Constricted apical
foramen foramen
Abundant blood Less blood supply
supply
Response to external Response is by
stimuli is typically calcification or calcific
inflammatory scarring
Nerve fibers terminate Nerve fibers end
in odontoblastic region among odontoblasts
as free nerve endings and beyond predentin
Density of innervation Density of innervation
is less is greater
Reparative dentin Less reparative
formation is extensive dentine formation
Poor localization of Better localization of
infection and infection and
inflammation inflammation
MODIFICATIONS OF CAVITY PREPARATION IN

PRIMARY TEETH
• Due to multiple anatomical, morphological and
histological differences.
Class – I Cavity Preparation

• Narrow occlusal table
• Bucco-lingual dimensions of occlusal part of
cavity are reduced
• Limit the cavity to 0.5 mm pulpal to ameloden-
tinal junction
• Inter-cuspal cavity width should be limited
• Walls of preparation should be parallel or slightly
convergent occlusally
• The outline form should be limited to central pit
• Mesio-lingual and mesio-lingual cusp should not
be joined because of proximity to pulp horns.
Class – II Cavity Preparation

• Occlusal cavity is made before proximal aspect
• Proximal slot cavity is prepared if occlusal
involvement is not present
• Isthmus width is 1/3rd not exceed of the inter-
cuspal distance
• Pulpo-axial line angle is rounded
• Dovetail lock is contraindicated
• Depth of cavity in primary 1st mandibular molar
should not exceed 1.2 mm to avoid pulp exposure
• Care must be taken while preparation of
proximal box because of greater constriction at
the neck of primary teeth
• Depth of the proximal box must be limited as
axial wall is pulpal
• Buccal and lingual limits of gingival seat are
placed clear of contact with the adjacent tooth
• Depth of gingival seat is below contact point
• The mesio-distal width of gingival seat is 1mm
• Gingival cavosurface bevel is not given because
the enamel rods are inclined occlusally
• Axial wall must be curved parallel to outer
contour of tooth
• Line angles and walls in proximal box should
converge towards occlusal aspect.
MATRIX
• Matricing is a procedure where by a temporary
wall is created opposite the axial wall surroun-
ding the areas of tooth structure lost during

preparation. The appliance used for building
these walls is called matrix
• Accurate reproduction of contour of teeth
• Prevent interproximal excess
• Establish tight contact areas and maintain
integrity of normal gingival papillae
• Functions of matrix: To replace the missing wall,
Close adaptation of restorative material, Retain
restorative material during placement, Isolation
of cavity
• According to place of application:
Posterior: T-band, Toffelmire
Anterior: Celluloid matrix
• According to constituents:
Metallic: Ivory no. 1, Ivory no. 8, Toffelmire
Non-metallic: Mylar strips
• According to presence or absence of retainer:
With retainer: Ivory no. 1, Ivory no. 8
Without retainer: S-band
• According to form:
Anatomical: Celluloid crown form
Non-anatomical: Ivory no. 1
• According to patent:
Patent: Ivory no. 1
Non-patent: Celluloid crown form
• According to use:
Universal: Ivory no. 8, toffelmire
Unilateral: Ivory no. 1.
WEDGES
• It is used along with the matrix to prevent
gingival overhangs of restorations
• Functions include close adaptation of matrix
band to tooth, prevents gingival overhang,
assures proper health of interdental col,
stabilization of band
• Types
Anatomical: in shape of embrasure;
Non-anatomical: round, Wooden – can be made
of either hard or soft wood, Plastic – available in
various shapes.
ISOLATION
Throat Screens
• It is gauze of 2" × 2".
Cotton Rolls
• Mostly used for isolation during clinical exami-
nation and cementation
• In maxillary teeth parotid opening is blocked and
in mandibular, submandibular duct opening is
blocked.
Saliva Ejectors
• They can be either slow or high volume
• High volume ejectors are better as they are quick
and take away food debris also but have the
disadvantage of dehydration of tissues
• They can of 4 types viz: Tongue retracting type,
replacement tip type, disposable plastic type and
surgical aspiration type.
Drugs
• Anti-sialagogues and local anesthesia decrease
salivary secretions.
RUBBER DAM
In 1864, SC Barnum, a New York dentist introduced
rubber dam to dentistry.
Advantages
• Dry clean operating field with more visibility and
adequate moisture control
• Retraction of soft tissue
• Improved properties of dental materials
• Prevents aspiration or swallowing of small
instruments and restorative materials
• Prevents tissue damage by rotary burs and sharp
objects
• Effective infection control
• Reduce patient conversation; so efficiency is
increased.
Disadvantages
• Patient acceptance
• Trauma to tissues
• Frame can cause pressure marks on face.
Contraindications
• Latex allergy
• Patients with respiratory problems or transient
bacteremia
• Partially erupted tooth.
Rubber Dam Kit (Fig. 16.2)
Fig. 16.2: Rubber dam kit
Rubber Dam Sheets

• Available sizes are 5" × 5" or 6" × 6"
• Available thickness are
– Thin—0.15 mm
– Medium—0.2 mm
– Heavy—0.25 mm
– Extra heavy—0.30 mm
– Special heavy—0.35 mm
• Available colors are Green, Blue, Black, Pink and
Burgundy
• Also available in different flavors like mint,
banana and strawberry.
Retainers or Clamps
• It has 4 prongs, 2 jaws that are connected by a
bow
• Various types and sizes are present for each tooth

• Used as anchor at most posterior tooth to be
isolated and also to retract gingival tissue
• Can be classified as wingless or winged. Latter
provide more retention.
Rubber Dam retaining Forceps

• Used for placement and removal of clamps.
Rubber Dam Punch

• Precision instrument having a rotating metal table
with six holes of varying sizes and a tapered, sharp,
pointed plunger
• The largest hole being for molars and the smallest
for mandibular incisors.
Rubber Dam Frame

• It holds and positions the border of rubber dam
• Metallic (Young’s frame), Plastic (Nygard Ostby
frame).
Rubber Dam Napkin

• It is placed between rubber dam and patient’s
skin
• Prevents allergy and pressure marks on patient’s
cheeks
• Convenient method for wiping the patient’s lips
on removal of dam.
Lubricant
• Facilitates passing of dam through posterior
contacts and over clamps
• Applied over patient’s tissues to prevent injury
and dryness
For example, soap solution, petroleum jelly and
cocoa butter.
Dental Floss
• To secure the rubber dam.
Procedure for Placement of Rubber Dam

(Fig. 16.3)
Fig. 16.3: Final fitting of rubber dam

AIR ABRASION
• Also called as Micro-abrasion or Kinetic Cavity
Preparation
• Dr Robert Black of Corpus Christi Texas was the
pioneer
• First articles on the use of air abrasive technique
for cavity preparation were published in 1945
• Air abrasive unit is called AIRDENT and was
introduced in 1951
• It is painless, vibrationless and heatless treatment
• It is used for Class I, II, III, IV, and V cavity
preparations, sealants and preventive resto-
rations, repair of composite and porcelain
restorations especially margin of veneers and
removal of composite and amalgam
• Precautions to be taken while doing air abrasion
include protective eye wear for the patient and
dentist; position the tip 1-2 mm away from tooth
at a 45° angle, then activate.
Procedure
MINIMAL INTERVENTION
CURRENT CONCEPTS IN CAVITY

PREPARATION
Lamination
• It combines the attributes of GIC and composite
and at the same time reduces their disadvantages
• Advantage of GIC is ion-exchange adhesion but it

can’t be used in large cavities due to limited
strength. Composite overcomes this with its high
strength and wear resistance. However, compo-
site has a limitation of high shrinkage following
activation but this disadvantage will be covered
up by GIC as it develops a bioactive union.
Bonded Amalgam Restoration

• Panavia EX (Kuraray), a chemically active resin
that bonds to both enamel and metal
• Amalgambond (Parkell) for bonding amalgam
to etched enamel and dentin
• Advantages include conservative cavity pre-
paration, no polymerization contraction and
increased structural integrity of the tooth
• Indicated if composite or cast metal or bonded
porcelain restoration can’t be used; gingival floor
of the restoration extends near or below the
cemento-enamel junction.
Tunnel Cavity Preparation

• Indicated if the cavity is small and if placed
2 mm below the marginal ridge
• Aim is to develop an access via the occlusal aspect
so as to preserve the strength of marginal ridge.
Slot Cavity Preparation

• Small slot is made on the proximal aspect of
posterior teeth
• Indicated if there is a small lesion involving the
area of or below the marginal ridge only.
Proximal Approach
• If the lesion involves only the proximal surface
and the adjacent tooth is missing
• The lesion is visualized, prepared and restored
directly from the proximal aspect.
Biomimetic Restorative Materials

• It means imitation of nature
• Material should in some way reproduce one or
more natural phenomenon within a biologic
situation
• Biocompatible, biologically acceptable and not
rejected by adjacent tissues
• Glass-ionomer cement is not an ideal biomimetic
material but is the closest to it.
Smart Materials
• New generation restorative materials
• BRAX: I gene (responsible for genetic develop-
ment of enamel) has been isolated and researched
for the potential to produce enamel for regrowing
tissues in oral cavity.
ATRAUMATIC RESTORATIVE TREATMENT (ART)

• A procedure based on removing carious tooth
tissues using hand instruments alone and
restoring the cavity with an adhesive restorative
material
• ART was initiated first in Zimbabwe and
Thailand
• Recognized by WHO on World health day April
6, 1994.
Positions of Work
• The operator sits firmly on the stool, with straight
back, thighs parallel to the floor and both feet
flat on the floor. The head and neck should be
still, the line between the eyes horizontal and the
head bent slightly forward to look at the patient’s
mouth. The distance from the operator’s eye to
patient’s tooth is usually between 30 and 35 cm.
• The assistant works at the left side of a right-
handed operator and his head should be
10–15 cm higher than the operator; used to mix
cement and provide isolation.
• A patient lying on the back on a flat surface will
provide safe and secure body support and
comfortable and stable position for lengthy
periods of time.
• Position for upper right posterior tooth surfaces: The
operator sits directly behind the patient’s head.
Mirror vision is used and the patient’s head is
tilted backwards with the mouth fully open.
• Position for upper anterior tooth surfaces: The
operator sits directly behind the patient. Tilt the
patient’s head backward with the mouth open.
The buccal surfaces are then viewed directly and
the lingual surfaces are viewed through the
mouth mirror.
• Position for upper left posterior tooth surfaces: For
occlusal and buccal surfaces, the operator sits
directly behind the patient’s head. Tilt the
patient’s head backwards and turn it slightly to
the right with the mouth fully open for occlusal
and partly closed for buccal surfaces. For working
on the palatal surface, the operator sits slightly
to the right of the patient’s head. Tilt the patient’s
head backwards and turn it slightly to the left
with the mouth fully open for direct vision.
• Position for lower left posterior tooth surface: The
operator sits to the right rear of the patient’s head.
The patient’s head is placed in the central position
and tilted slightly forwards. For occlusal and
buccal surfaces, turn the head slightly to the right.
The mouth should be fully open for occlusal

views and partly closed for buccal surfaces to
allow access for the mouth mirror. Direct vision
may be used for most of the teeth.
• Position for lower anterior tooth surfaces: The
operator sits directly behind the patient’s head.
Tilt the patient’s head forwards in the central
position. The mouth should be fully open and
direct vision is used.
• Position for lower right posterior tooth surfaces: The
operator sits to the right rear of the patient’s head,
which should be tilted forwards. For occlusal and
lingual working surfaces, turn the head slightly
to the right with the mouth fully open for direct
vision. To view the buccal surfaces, turn the head
slightly to the left with the mouth partly closed
to allow access for the mouth mirror and hand
instruments.
Advantages of ART
• Easily available inexpensive hand instruments
are used
• Painless procedure
• Involves the removal of only decalcified tooth
tissues and conserves sound tooth tissue
• Release of fluoride remineralizes and prevents
development of secondary caries
• The combined preventive and curative treatment
can be done in one appointment
• Repairing of defects in the restoration can be
easily done
• It is less expensive and less time consuming as
in one sitting several fillings can be done
• Enables oral health workers to reach people who
otherwise never would have received any oral
health service.
Disadvantages of ART
• ART restorations are not long lasting
• Fundamental principles of cavity preparation are
not followed
• Low wear resistance and low strength of glass

ionomer materials
• Use is limited to small and medium sized one
surface cavity only
• The continuous use of hand instruments over
long period of time may result in hand fatigue.
DIAGNOSIS OF CARIES
Various diagnostic techniques and their advances:
Visual Inspection
• Oldest diagnostic method
• Clinical accuracy is between 25 to 50%.
Tactile Examination with a Probe

• Suggested by GV Black in 1924
• Examination by sharp explorer, based on tug
back action
• May cause damage to integrity of surface enamel.
Dental Floss
• String of unwaxed floss is moved on the carious
proximal tooth surfaces
• If there is resistance on withdrawal and the fibers
appear torn then it is indicative of caries.
Ultraviolet Illumination
• UV light increases the optical contrast between
carious lesion and the surrounding soft tissue
• Carious lesion appears as a dark spot against
fluorescent background.
Dyes
• Used to detect carious enamel
• 0.5% Basic fuschin, Procion dyes, 1% acid red in
propylene, Methylene blue.
Radiographs
• Accuracy between 40 – 65%.
Fiberoptic Transillumination (FOTI)

• Method of imaging teeth by multiple scattering;
light propagates from the fiber illumination
across tooth tissue to non-illuminated surfaces
and resulting images of light distribution are then
used for diagnosis
• Non-invasive examination technique with no
radiation hazards
• It is not possible to use it at all anatomic locations
and maintenance of record is not possible.
Digital Imaging Fiberoptic Transillumination

(DIFOTI)
Endoscopically Viewed Filtered

Fluorescence (EFF)
• Utilizes the fluorescence of enamel that occurs
when it is illuminated with a blue light in wave-
length range 499–500 nm
• When the tooth is viewed from a specific gelatin
green filter number 58, attached to the eyepiece,
white spot lesions appear darker than sound
enamel
• It gives a magnified view of carious lesion and
provides large range of viewing angles
• Procedure is technique sensitive and time
consuming.
White Light Fluorescence (WLF)

• A white light source is connected to an endoscope
by a fiber optic cable and teeth are viewed with
a filter.
Videoscope
• It is the integration of the camera and endoscope.
Intraoral Television Camera (IOTC)

• Used to observe magnified oral conditions
• Educate the patient.
Scanning Acoustic Microscope

• It produces an image dependent on the elastic
properties of the demineralised lesion.
Ultrasound Caries Detector (UCD)

• Ultrasonic proximal caries detector that works
by transmitting surface ultrasonic waves
• Records specific profiles of ultrasonic echoes
obtained from the enamel surface, dentino-
enamel junction and pulpo-dential junction
• Difference in the sonic conductivity between
sound and demineralised enamel indicates
demineralised lesion.
Electrical Conductance Measurement

• Proposed by Magitot
• Based on the principle that sound tooth surfaces
possess limited conductivity whereas deminera-
lised or carious enamel act as conductive
pathway
• Vanguard Electronic caries detector and Caries
Meter.
Magnetic Resonance Micro-imaging (MRMI)

• Carious regions give an intense image that is
readily distinguishable from other soft tissues but
images of highly mineralized tissue, such as
enamel cannot be produced
• Allows a specimen to be re-imaged after further

exposure to clinically relevant environment.
Photo Stimulable Phosphor Radiography

• A latent image is produced by exposing the
storage phosphor screen with X-rays
• Images can be transferred to other sites
• High cost and chances of cross-infection.
Microradiography
• Longitudinal microradiography measures
mineral changes in tooth slices with mono-
chromatic X-rays
• Transverse microradiography is well-accepted
method; used to quantify mineral loss.
Longitudinal MR: It is a highly accurate technique,

which measures mineral changes in the tooth slices
with monochromatic X-rays (de Josselin de Jonb
et al 1987, 1988).
Quantitative Laser Fluorescence (QLF)

• Designed to measure the loss of fluorescence of
carious lesions when illuminated with an argon-
ion laser blue light (488 nm)
• The lesion appears as shadowy images against
the bright fluorescence background of sound
enamel
• The reproducibility of method is high and can
detect small incipient lesions in enamel and
dentin.
Diagnodent
• Caries induced changes in teeth lead to increased
fluorescence at specific excitation wavelength
• Red laser diode light (655 nm) is directed to
occlusal surface by incident light and fed back to
the detector through the same device and
measured by photodiode
• Detection of early carious lesions and quanti-
fication of smooth surfaces
• It cannot detect secondary caries and proximal
caries accurately
• Signal comes as a number on instrument on a
scale of 0 to 99. Higher the number more is caries.
0–4 No caries, or histological caries
limited to outer half of enamel
4.01 – 10 Histological caries extending beyond
the outer half of enamel
10.01 – 18 Histological dentinal caries limited
to outer half of dentin
> 18.01 Histological dentinal caries exten-
ding into inner half of dentin.
Optical Coherence Tomography

• It was proposed in 1991 by Huang
• It creates cross-sectional images of biological
structures using, differences in reflection of light
• It reveals micro-structural detail of the perio-
dontal soft tissues
• It has low penetration depth thus difficult to
diagnose deep carious lesion.
CONVENTIONAL METHODS
Visual Magnifying lens
Tactile Probe
Dental floss
Mechanical separation
Illumination UV Illumination
Dyes Basic fuschin
Procion dyes
Radiography Intraoral periapical
Bitewing
Xeroradiography
RECENT ADVANCES
Illumination Fiberoptic transillumination
Wavelength dependent fiberoptic transillu-
mination
Digital imaging fiberoptic transillumination
Endoscopy Endoscopically viewed filtered fluorescence
White light fluorescence
Videoscope
INTRAORAL TELEVISION CAMERA

Ultrasonic Ultrasonic system
Scanning acoustic microscope
Ultrasound caries detector
Electrical Vanguard electronic caries detector
Conductance Caries meter
measurement
Radiography Digital rediography
Magnetic resonance micro-imaging
Photo stimulable phosphor radiography
Computed tomography
Microradiography
Lasers Quantitative laser fluorescence
Diagnodent
Optical coherence tomography
Species
specific
monoclonal
antibodies
Air abrasion
CARIES VACCINE
Effective Molecular Targets
• Stages in the molecular pathogenesis of dental
caries that are susceptible to immune inter-
vention
• Microorganisms can be cleared from oral cavity
by antibody-mediated aggregation, blocking off
colonization and inactivation of GTF enzymes
• Adhesins – Antigen I/II, Pac, P1
• Glucosyltransferases (GTF)-gtfB, gtfC, gtfD, gtfl,
gtfS
• Glucan binding proteins – GbpA, GbpB, GbpC.
Types of Vaccine
• Subunit vaccines are so designed that they contain
single or multiple copies of epitopes from each
domain like structural elements of either
adhesions or GTF or GBP
• Recombinant vaccines: These are also called as
Attenuated Expression vectors. These approa-
ches afford the expression of larger portions of
functional domains and are helpful in targeting
vaccine to appropriate lymphoid tissue for
mucosal response
• Conjugate vaccines: This approach intercepts more
than one aspects of mutans streptococcal
molecular pathogenesis by chemical conjugation
of functionally associated peptide components
with bacterial polysaccharides.
Routes to Protective Response

• Mucosal applications of dental caries vaccine are
generally preferred
• Routes include Oral, Intranasal, Tonsillar, Minor
salivary gland, Rectal.
Delivery System
• Mucosal routes of antigen delivery require
additional components to potentiate aspects of
the immune response
• Heat labile enterotoxins: Cholera and E Coli

• Microcapsules and Microparticles: Poly lactide – co
– gylcolide (PLGA)
• Liposomes: Phospholipid membrane vesicles
containing drugs or antigens
• Miscellaneous: Monophosphoryl lipid A with
GTF.
Current Status of Caries Vaccine

• Dr Martin Taubman (Forsyth Institute): Target for
vaccine development in his research group has
been the Glucosyltransferases (GTF) and the
Glucan binding protein (GbP). Their research has
extended to sub unit vaccines, delivery systems,
mucosal adjuvants and routes of application.
Current research is on intranasal route with
PLGA micro particles.
• Dr Noel Childers (University of Alabama): Their
studies focus on antigen I-II. They also postulated
the benefits of nasal and tonsillar administration
• Dr Michael Russel (SUNY, Buffalo) indicated his
work has focused on the antigen I-II and on
saliva-binding region where certain residues
appear to be important in attachment to the
salivary pellicle tooth surface.
• Dr Debra Trantolo (Cambridge Scientific, Boston):
Designed a delivery system that uses the bio-
polymer polyactide (PLGA). The system is called
a matrix system and is a non-encapsulation
system where the biological from of a drug is
dispersed throughout the polymer.
• Dr James Larrick (Planet Biotechnology, California)
explained their work in developing secretory IgA
antibodies in a product called cario Rx to reduce
the adherence of S. mutans to teeth.
Chapter 17
Pharmacological
Considerations in
Pediatric Dentistry
 Drug Dosages
DRUG DOSAGES
• Clark’s Rule: This is based upon the relative
weight of the child as compared with the weight
of the average adult.
Wt (pounds)
× adult dose
150
• Young’s Rule: This rule is based upon the age of
the child, regardless of the weight.
Age
× adult dose
Age + 12
• Cowling’s Rule: This is also based upon the age of
the child.
Age at next birthday
× adult dose
24
Age
• Dilling’s Rule: × adult dose.
20
• Gabius: Stated a series of fractions of the adult
dose, which were to be used at different ages.
Thus; for a child of
— year - 1/12th 7 years - 1/3rd
— years - 1/8th 14 years - 1/2nd
— years - 1/6th 20 years - 2/3rd
— years – 1/4th 21 years - adult dose.
Age of child + 3
• Bastedo’s Rule: of the fraction of
30
the adult dose.
Age of infant (in months)
• Fried’s Rule: of the
150
fraction of the adult dose.
• Catzel’s Rule:
Age Percentage of Adult dose
1 25
3 35
7 50
12 75
Pharmacological Considerations 205
• Augsberger’s Rule:
[{(1.5 × weight in kg) + 10}/100] × Adult dose
= Child’s dose.
[{(4 × age in years) + 20}/100] × Adult dose
= Child’s dose.
• Clarks Rule: (Weight in pounds/150) × Adult
dose = Child’s dose.
• Dilling’s Rule: (Age in years/20) × Adult dose
= Child’s Dose.
• Body surface area (BSA)
Dubois formula = BSA (m)2 = BW (Kg)0.425 ×
Height (cm)0.725 × 0.007184
Child's BSA
× adult dosage.
1.7 M2
Chapter 18
Pediatric
Radiology
 History of dental radiology
 Indications for pedodontic radiography
 Radiographic protocol
 Extensive or deep caries
 Behavioral considerations in pedodon-
tic radiography
 Radiovisiography
HISTORY OF DENTAL RADIOLOGY

1895 Discovery of X-rays WC Roentgen
1896 First dental radiograph O Walkhoff
1896 First dental radiograph WJ Morton
(USA-skull)
1896 First dental radiograph CE Kells
(US-Live pt)
1901 First paper on dangers WH Rollins
of X-rays
1904 Introduction of WA Price
bisecting angle techniques
1913 First pre-wrapped Eastman Kodak
dental films comp.
1913 First X-ray tube WD Coolidge
1920 First machine made Eastman Kodak
film packets comp.
1923 First dental X-ray Victor X-ray
machine Co-op-Chicago
1925 First dental text HR Raper
1925 Introduction of HR Raper
Bite-wing technique
1947 Introduction of FG Fitzgerald
Paralleling cone
technique
1957 First variable Kv General Electric
dental X-ray machine
INDICATIONS FOR PEDODONTIC

RADIOGRAPHY
• Caries
• Pulp pathology
• Traumatic injuries
• Problems of eruption
• Anomalies of development
• Orthodontic evaluation
• History of pain
• Evidence of swelling
• Unexplained tooth mobility
• Unexplained bleeding
• Deep periodontal pocket
Pediatric Radiology 209
• Fistula formation
• Unexplained sensitivity of teeth
• Evaluation of Sinus condition
• Unusual spacing or migration of teeth.
• Lack of response to conventional dental treat-
ment
• Unusual tooth morphology calcification/colour
• Evaluation of growth abnormality
• Altered occlusal relationship
• Aid in diagnosis of systemic diseases
• Family history of dental anomalies
• Postoperative evaluation.
RADIOGRAPHIC PROTOCOL
Age (yrs) Considerations Radiographs

3–5 yrs No apparent abno- None
rmalities
(Open contacts)
No apparent abnor- 2 posterior bitewing
malities size 0 film, 4-film survey
(Closed contacts)
Extensive caries 2 bitewing of size 0, 2
Deep Caries Selected periapical
radiographs in addition
to 4-film survey
6–7 yrs No apparent abnor- 8 film survey
malities
Extensive caries Selected periapical X-ray
and 8 film survey
8–9 yrs No apparent abnor- 12 film survey
malities or
Extensive or deep
caries
10–12 yrs No apparent abnor- 12or16-film survey,
malities or extensive depends on patient.
a deep caries
EXTENSIVE OR DEEP CARIES

Four film series: Maxillary and mandibular anterior
occlusal (2) and two posterior bitewing radiograph (2).
Eight film survey: Maxillary and mandibular anterior
occlusal (2), maxillary and mandibular posterior
periapical (4) and two posterior bitewing radio-
graphs (2).
Twelve film survey: Four primary molar/premolar

periapical radiographs (4), four canine periapical
radiographs (4), two incisor periapical radiographs
(2) and two posterior bitewing radiographs (2).
Sixteen film survey: Twelve film survey and 4 perma-
nent molar radiographs (4).
BEHAVIORAL CONSIDERATIONS IN
PEDODONTIC RADIOGRAPHY
• Tell, Show and Do is effective in radiographic
appointment
• Instead of using the words X-ray use euphe-
misms like pictures of your teeth, lead apron as
heavy blankets and X-ray unit as camera
• Allow the patient to inspect and touch the film
packet before it is placed in the mouth
• Adjust the X-ray tube at the needed angulations
before insertion of the film
• Easiest areas are radiographed first, like anterior
films
• Use film-holding devices for posterior projections
• Imitation or modeling is most effective
• Control gagging by distracting the child by
asking him to raise one leg or curl his toes
• If it is required to hold the film parent should
do so
• If the child has a tendency to reject the film
dampen the film packet, this reduces taste
• Insert the packet in a horizontal plane and then
gently rotate into vertical position
• Before inserting the film, curve it slightly so as
not to impinge on lingual tissue
• Encourage and reward the patient after each
exposure.
RADIOVISIOGRAPHY (FIGS 18.1A AND B)

• Digital imaging dental radiographic system
• First described in 1988
• Introduced commercially in UK in 1989
Pediatric Radiology 211
Figs 18.1A and B: Digital imaging dental

radiographic systems
• RVG comprises four basic components viz;

X-ray set with electronic timer, intra-oral sensor,
display processing unit (DPU) and a printer
• Mark 1 system: The original system, which was
based on digital hardware without a micro-
processor
• Mark 2 system: Based on a 32 bit software driven
central processing unit, but it failed to use the
memory resolving power of the sensor chip
• Mark 3 system: Very recent development. It is of
two types: 'stand-alone' and 'PC' version
• Advantages include exposure reduction,

production of instantaneous images, ability to
enlarge specific areas, storage and subsequent
transmission of the images, edge and image
enhancement
• Disadvantages are small sensor size, greater
thickness than conventional film, loss of
resolution of image from the screen to the video
print and expensive.
Chapter 19
Pediatric
Endodontics
 Functions of pulp
 Pulpal diagnosis
 Root canal instruments in pediatric
endodontics
 Indirect pulp capping
 Procedure
 Direct pulp capping
 Pulpotomy
 Pulpectomy
 Apexogenesis
 Apexification
• Pulp exposure of the dental pulp exists when the

continuity of the dentin surrounding the pulp is
broken by physical or bacterial means leading to
direct communication between the pulp and
external environment
• Chinese and Egyptians were the first to describe
caries and alveolar abscess
• Greeks and Romans treated pulp by cauterization
either with a hot needle/boiling oil/fomentation
of opium
• The Syrian Achieves realised that pain could be
relieved by drilling into pulp chamber to obtain
drainage
• Pieter Van Forest was the first to speak of root
canal therapy
• In 1910, Glove designed instruments that pre-
pared a canal to a certain size and taper, to
obturate the canal with gold points
• Development of dental pulp begins at 8th week of
embryonic life at the location of future incisor
• As peripheral dental papilla cells transform into
columnar shaped odontoblast, they develop cell
processes and begin dentin formation and is now
called pulp organ
• Primary teeth have 20 pulp organs, confining to
shape of tooth
• Mean volume of a single pulp is 0.01 cc
• Coronal pulp: located in center of crown and
resembles outer surface of coronal dentin
• Radicular pulp: Extends from cervical region of the
pulp to the root apex
• Apical Foramen: Average size in maxillary anterior
is 0.4 mm, and in mandibular is 0.3 mm. Location
and shape depends on the functional influence
• Accessory canals: These are seen laterally in apical
3rd of root due to premature loss of root sheath
cells
• Pulp organ growth: Takes place during the time the
crown and roots are developing (1 yr)
Pediatric Endodontics 215
• Pulp maturation: Time period after root is completed

until root resorption begins (3 yrs)
• Pulp regression: Beginning of root resorption time
till exfoliation (3-6 yrs).
FUNCTIONS OF PULP
• Inductive: Induces oral epithelium to differentiate
into dental lamina and enamel organ
• Formative: Produces dentin that surrounds and
protects the pulp
• Nutritive: Pulp nourishes the dentin by means of
the blood vascular system of the pulp
• Protective: Sensory nerves in the tooth respond
with pain to all stimuli
• Defensive: It responds to irritation whether
mechanical/thermal/chemical/bacterial by
producing reparative dentin and mineralizing
affected dentinal tubules.
PULPAL DIAGNOSIS
Pain
• Dull, achingpain: Bony origin
• Throbbing, pounding, pulsating: Vascular origin
• Sharp, recurrent, stabbing pain: Pathosis of nerve
root complexes, irreversible pulpitis
• Postural change pain: Maxillary sinus involvement
• Momentary pain: Pathosis is limited to the coronal
pulp
• Persistent pain: Inflammation of the pulp, extending
into the radicular filaments
• Spontaneous pain: Irreversible pulpitis
• Provoked pain: Reversible pulpitis.
Visual and Tactile Examination

• Colour, contour, consistency.
Mobility (Table 19.1)

• Tooth mobility is directly proportional to the
integrity of the attachment apparatus.
Table 19.1: Wymans Index (1975)

0 Horizontal < 0.2 mm
1 Horizontal 0.2- 1 mm
2 Horizontal 1- 2 mm
3 Horizontal > 2 mm and vertically
Percussion
• Pain from pressure on a tooth indicates that
periodontal ligament is inflamed.
Palpation
• Determines presence, intensity and location of
pain and presence of bony crepitus.
Radiographs
• Demonstrate pathological condition, position of
succedaneous permanent tooth.
The Exposure Site

• Koch and Nyberg in 1970 explained that both the
size of the exposure site and the nature of exudate
expressed from it are useful diagnostic aids
• Light red blood: inflammation limited to coronal
pulp
• Deep Red blood: inflammation has extended into
the root canals.
Thermal Tests
First reported by Jack in 1899, involves application of
cold or heat to determine sensitivity to thermal
changes.
• Cold test: By stream of cold air, cold-water bath,
ethyl chloride, CO2 ice stick (dry ice), pencil of ice,
1/4 inch diameter cone of ice
• Heat test: By warm sticks of temporary stopping,
rotating dry prophycup, heated water bath, hot
bunisher, hot gutta-percha and hot compound
• No response: Nonvital pulp
• Mild to moderate pain subsides in 1-2 sec: Normal
• Strong momentary pain subsides in 1-2 sec: Reversible

pulpitis
• Strong pain that lingers after the stimulus has been
removed: Irreversible pulpitis.
Electric Pulp Testing

• Depends on the vital sensory fibers present in the
pulp.
Anesthetic Testing (Grossman 1978)

• Used to identify the source of pain if the patient
continues to have vague, diffuse, strong pain and
prior testing has been inconclusive.
Test Cavity (Seltzer and Bender 1975)

• Test cavity is made by drilling the enamel dentin
junction of an un-anesthetized tooth using slow
speed without a water coolant.
Physiometric Tests (Taylor in 1960)

• Tests that assess the state of the pulpal circulation,
rather than the integrity of the nervous tissue thus
providing valuable information.
Photoplethysmography (Reich 1952)

• This method involves passing light on the tooth
and measuring the existing wavelengths using a
photocell and galvanometer.
Thermography
• Measurement of this radiation may provide
information on pulpal circulation.
Pulp Hemogram (Guthrie and Baume 1966)

• Blood from an exposed pulp when subjected to a
differential white cell count might be useful in
diagnosis of pulpal conditions.
Dual Wavelength Spectrometry

• Measures blood oxygenation changes within the
capillary bed of dental tissue and thus is not
dependent on a pulsatile blood flow.
Hughes Probeye Camera

• This is used in detecting temperature changes as
small as 0.1oC hence been used to measure pulp
vitality experimentally.
Liquid Crystal Testing

• Cholesteric fluid crystals have been used to show
the difference in tooth temperature with vital pulp
being hotter and necrotic pulps being cooler.
Laser Doppler Flowmetry

• It is a new method of evaluating pulp vitality by
measuring the velocity of RBC in capillaries.
Pulse Oximetry
• Atraumatic method of measuring vascular health
by evaluating oxygen saturation.
ROOT CANAL INSTRUMENTS IN PEDIATRIC

ENDODONTICS
• Exploring: To locate the canal orifice, to determine

patency of root canal, e.g. smooth broach
• Debribement: To extirpate the pulp, to remove
debris, e.g. barbed broach
• Shaping: To shape the root canal laterally and
apically, e.g. reamers and files
• Obturating: To pack root canal with material, e.g.
pluggers, spreaders, and lentulospirals.
Smooth Broach
• Smooth, pointed and tapered with either round,
pentagonal, square cross section
• Useful as pathfinder in curved fine canals
• Also called as Miller’s needles.
Barbed Broach
• It is a short handled instrument used for the
extirpation of the entire pulp and for the removal
of necrotic debris, absorbent points, cotton pledgets
and other foreign material from root canal
• Manufactured from a tapered round soft steel wire
of varying diameter into which, angle cuts are made
into the surface to produce barbs
• Procedure for pulp extirpation was given by
Healey in 1994.
H-File (Hedstroem File)

• Manufactured from round stainless steel wire,
machined to produce spiral flutes resembling
cones
• Higher cutting efficiency than K-files, but it is
fragile and fractures easily.
K- Flex File
• Rhomboidal shaped blanks, which are twisted
• Increased flexibility and cutting efficiency.
Safety H-Files
• Introduced by Kerr Manufacturing Co in 1998
• A non-cutting side characterizes the spiral of the
working end of these files with smoothened edges
to prevent ledging in curved canals.
Nickel – Titanium Root Canal Files

• Introduced by Elizabeth S Bair in 1999-2000
• 55%-Nickel and 45%-Titanium
• Flexibility and the instrument design allow the
files to closely follow the original root canal path

especially in tortuous and irregular canal walls
• Have shape memory.
INDIRECT PULP CAPPING (FIG. 19.1)

• Defined by Ingle as procedure where in small
amount of carious dentin is retained in deep areas
of cavity to avoid exposure of pulp, followed by
placement of a suitable medicament and
restorative material that seals of the carious dentin
and encourages pulp recovery
• Its rationale was given by Fusayama in 1966
• Eidelman in 1965 outlined the objective of indirect
pulp capping: Arresting the carious process,
promoting dentin sclerosis, stimulating formation
of tertiary dentin, remineralization of carious
dentin.
Indications
• Mild pain associated with eating
• Negative history of spontaneous, extreme pain
• Deep carious lesion, which are close to, but not
involving the pulp
Fig. 19.1: Procedure of IPC

• No mobility
• When pulp inflammation is seen as nominal
• Normal lamina dura, Normal PDL space
• No radiolucency in the bone around the apices of
the roots or in the furcation.
Contraindications
• Sharp, penetrating pulpalgia indicating acute
pulpal inflammation and necrosis
• Prolonged night pain
• Mobility of the tooth
• Discoloration of the tooth
• Negative reaction of electric pulp testing
• Large carious lesion producing definite pulp
exposure
• Interrupted /broken lamina dura
• Widened PDL space
• Radiolucency about the apices of the roots.
PROCEDURE
First appointment
Second appointment (6-8 weeks later)
DIRECT PULP CAPPING (FIGS 19.2A TO D)

• It is defined by Kopel (1992) as the placement of a
medicament or non-medicated material on a pulp
that has been exposed in course of excavating the
last portions of deep dentinal caries or as a result
of trauma
• Objective is to create new dentin in the area of the
exposure and subsequent healing of the pulp
• Rationale is to achieve a biologic closure of the
exposure site by deposition of hard tissue barrier
(dentin bridge) between pulp tissue and capping
material
Fig. 19.2A: After 24 hours: Necrotic zone adjacent to Ca(OH)2

paste is separated from healthy pulp tissue by a deep staining
basophilic layer
Fig. 19.2B: After 7 days: Increase in cellular and

fibroblastic activity
Fig. 19.2C: After 14 days: Partly calcified fibrous tissue lined by

odontoblastic cells is seen below the calcium proteinate zone;
disappearance of necrotic zone
Fig. 19.2D: After 28 days: Zone of new dentin

• Materials used are Ca(OH)2, Corticosteroids and

antibiotics, Isobutyl Cyanoacrylate, Collagen
fibers, 4 - META Adhesive, Direct Bonding,
Isobutyl Cyanoacrylate, Denatured Albumin,
Mineral Trioxide Aggregate (MTA), Laser, Bone
Morphogenic Protien (BMP).
Indications
• Small mechanical exposure surrounded by sound
dentin in asymptomatic vital primary teeth
• Exposure should have bright red hemorrhage that
is easily controlled by dry cotton pellet with
minimal pressure.
Contraindications
• Spontaneous pain
• Tooth mobility
• Radiographic appearance of pulp, peri-radicular
degeneration
• Excess of hemorrhage at the time of exposure
• External/internal root resorption
• Swelling/fistula.
Histological Changes after Pulp Capping

• These were illustrated be Glass and Zander in
1949
• After 24 hours: Necrotic zone adjacent to Ca(OH)2
paste is separated from healthy pulp tissue by a
deep staining basophilic layer
• After 7 days: Increase in cellular and fibroblastic
activity
• After 14 days: Partly calcified fibrous tissue lined
by odontoblastic cells is seen below the calcium
protienate zone; disappearance of necrotic zone
• After 28 days: Zone of new dentin.
Technique
PULPOTOMY (FIGS 19.3 AND 19.4)

• Finn (1995) defined it as the complete removal of
the coronal portion of the dental pulp, followed
by placement of a suitable dressing or medicament
that will promote healing and preserve vitality of
the tooth
• Objective is removal of inflamed and infected pulp
at the site of exposure thus preserving the vitality
of the radicular pulp and allowing it to heal
Fig. 19.3: Deep caries in 2nd molar

Fig. 19.4: Pulpoloyed 2nd molar
• Since radicular pulp is healthy, it is capable of

healing after surgical amputation of the infected
pulp. Pulpotomy removes infected or inflamed
pulp and preserves vitality of the radicular pulp.
Classification
Vital Pulpotomy Technique
Devitalization:
• It is intended to destroy or mummify the vital tissue
• Called as Mummification, Cautelization
• Single sitting: Formocresol, Electrosurgery, Laser
• Two stage: Indicated if sluggish bleeding at the
amputation site that is difficult to control or if there
is pus in the chamber, but none at the amputation
site. Materials used are Gysi Triopaste, Easlick’s
formaldehyde, Paraform devitalising paste.
Preservation:
• This implies maintaining the maximum vital
tissue, with no induction of reparative dentin
• Minimal devitalization, noninductive
• ZnO E, Glutaraldehyde, Ferric Sulphate.
Regeneration:
• This has formation of dentin bridge
• Inductive, reparative
• Ca(OH)2, Bone Morphogenic Protein, Mineral
Trioxide Aggregate, Enriched collagen, Freezed
dried bone, Osteogenic Protein.
Non-vital Pulpotomy
• Mortal Pulpotomy
• Beechwood cresol, Formocresol.
Indications of Pulpotomy
• Mechanical exposure of pulp during caries
excavation
• Carious exposure of less than 1mm without
radicular pulpitis
• History of only spontaneous pain
• Hemorrhage from exposure site is bright red and
can be controlled
• Absence of abscess or fistula
• No interradicular bone loss
• At least 2/3rd of root length still present to ensure
reasonable functional life.
Contraindications of Pulpotomy
• Persistent toothache with tenderness on per-
cussion
• Root resorption more than 1/3rd of root length
• Large carious lesion with non-restorable crown
• Highly viscous, sluggish hemorrhage from canal
orifice, which is uncontrollable
• Swelling or fistula
• External or internal resorption
• Pathological mobility.
Formocresol Pulpotomy
• Introduced by Buckley in 1904
• Sweet (1930): Formulated multi visit technique
• Doyle (1962): Advocated 2 sitting procedure
(complete devitalization)
• Spedding (1965): Gave 5 minute protocol (partial
devitalization)
• Venham (1967): Proposed 15 seconds procedure
• Buckley’s formula: Cresol – 35%, Glycerol – 15%,
Formaldehyde – 19%, Water – 31%
• Strength of formocresol used for pulpotomy is
1/5th
• Concerns about formocresol include toxicity,

systemic distribution, immunogenic potential, and
cytogenicity.
Cvek’s Pulpotomy
• Called as calcium hydroxide pulpotomy
• This was proposed by Mejare and Cvek in 1993
• Indicated in young permanent teeth where the
pulp is exposed by mechanical or bacterial means
and the remaining radicular tissue is judged vital
by clinical and radiographic criteria whereas the
root closure is not complete
• Rationale is to preserve vitality of radicular pulp

and allow for normal root closure.
Glutaraldehyde Pulpotomy
• It was first suggested by S Gravenmade
• Kopel in 1980 recommended 2% glutaraldehyde
solution
• Glutaraldehyde produces rapid surface fixation
of the underlying pulpal tissue. A narrow zone of
eosinophilic, stained and compressed fixed tissue
is found directly beneath the area of application,
which blends into vital normal appearing tissue
apically
• It is bifunctional reagent, which allows it to form
strong intra and intermolecular protein bonds
leading to superior fixation by cross linkage
• Causes less necrosis of the pulpal tissue
• Less toxicity, low tissue binding, readily meta-
bolized, eliminated in urine.
Laser Pulpotomy
• First reported by Ebimara in 1985
• Nd: YAG laser
• Conventional pulpotomy is done and after coronal
pulp removal laser is applied to control bleeding
and sterlize the pulp stumps.
Electrosurgical Pulpotomy
• Mark was the first US dentist to routinely perform
electrosurgical pulpotomies
• Mack and Dean in 1993 showed a success rate of
99% for primary molars
• Routine pulpotomy is carried out followed by
amputation of pulp using Hyfrecator plus
7-797 is set at 40% power and the 705A dental
electrode.
Mortal Pulpotomy: (Non–vital Pulpotomy)

• Indicated in non-negotiable root canals and
limited patient co-operation
• Medically compromised patients.
First appointment
Second appointment
PULPECTOMY (FIGS 19.5 AND 19.6)

• Mathewson defined it as the complete removal of
the necrotic pulp from the root canals of primary
teeth and filling them with an inert resorbable
material so as to maintain the tooth in the dental
arch
• Pulpectomy is the total removal of the pulp tissue
from the root canals, but this cannot be achieved
in primary dentition, because of the complexity
and irregularity of the canals, accessory canals,
Fig. 19.5: Carious 2nd molar

Fig. 19.6: Endodontically restored
ever present resorption and inability to determine

an anatomical apex, therefore the term pulp canal
treatment should be used.
Indications
• Large carious exposure with coronal and radi-
cular involvement
• Sinus or swelling without mobility and furcation
involvement
• Persistant pain
• Non-vital primary teeth
• Teeth with necrotic pulp and periapical involve-
ment
• Uncontrolled pulpal hemorrhage
• Severe pulpal necrosis
• Pulpless primary teeth with stromas, without
permanent successors, in hemophiliacs.
Contraindications
• Excessive tooth mobility
• Communication between the roof of the pulp
chamber, and the region of furcation
• Insufficient tooth structure to allow isolation by
rubber dam and extra coronal restoration
• Young patient with systemic illness such as
congenital ischemic heart disease, leukemia
• Children on long-term Corticosteroids therapy
• External root resorption

• Interradicular radiolucency that communicates
with the gingival sulcus.
Single Visit Pulpectomy

• An extension of pulpotomy procedure, probably
an on the spot decision when hemorrhage from
amputated pulp stumps is uncontrollable but the
tooth does not show any periapical changes
• Indicated in vital primary teeth with inflamma-

tion extending till radicular pulp but without any
periapical radiographic changes.
Multi-visit Pulpectomy
• Techniques of obturation: Endodontic pressure
syringe, Mechanical syringe, Tuberculin syringe,
Jiffy tubes, Lentulospiral technique, Amalgam
plugger, Paper points, Plugging action with wet
cotton pellet, Reamer and file technique.
First appointment: (Access opening)
Second appointment: (Cleaning and shaping)
Third appointment: (Obturation)
Materials Used for Obturation

1. Zinc Oxide Eugenol (ZOE)
2. Calcium Hydroxide
3. Iodoform
4. Vitapex: Calcium hydroxide + iodoform + oil
additives
5. Walkhoff paste: Parachlorophenol + camphor +

menthol
6. KRI paste: Iodoform + camphorparachlorophenol
+ menthol
7. Maisto paste: Zinc oxide + iodoform + thymol +
chlorphenolcamphor + lanolin
8. Mineral Trioxide Aggregate: Tricalcrium aluminate,
tricalcium silicate, silicate oxide, tricalcium oxide
and bismuth oxide
9. Endoflas.
APEXOGENESIS
• It is defined as the treatment of a vital pulp by
capping or pulpotomy in order to permit conti-
nued growth of the root and closure of the open
apex
• Rationale is maintenance of integrity of the
radicular pulp tissue to allow for continued root
growth.
Indications
• Indicated for traumatized or pulpally involved
vital permanent tooth when root apex is in-
completely formed
• No history of spontaneous pain or sensitivity on
percussion.
Contraindications
• Evidence that radicular pulp has undergone
degenerative changes
• Purulent drainage, Necrotic debris in canal
• History of prolonged pain
• Periapical radiolucency.
Procedure
APEXIFICATION (FIGS 19.7A TO D)

• It is defined as a method to induce development of
the root apex of an immature pulpless tooth by
formation of osteocementum/bone like tissue
• It is a method of inducing apical closure by
formation of a mineralized tissue in the apical
region of a non-vital permanent tooth with open
apex (Blunderbuss canals)
Fig. 19.7A: Tooth exhibiting open apex

Fig. 19.7B: Calcium hydroxide dressing
Fig. 19.7C: Tooth is re-entered after 6 months to

check for apical barrier
Fig. 19.7D: Post-obturation

• Objective is to induce either closure of open apical

third of root canal or the formation of an apical
calcific barrier against which obturation can be
achieved
• Materials: ZnOE, Metacresylacetate – compaho-
rated parachlorophenol, Tricalcium phosphate +
β-tricalcium phosphate, Resorbable tricalcium
phosphate, Collagen – calcium phosphate gel,
Mineral trioxide aggregate, Ca(OH)2
• Frank’s criteria for Apexification:
Apex is closed, through minimum recession of the
canal
Apex is closed with no change in root space
Radiographically apparent calcific bridge at the
apex
There is no radiographic evidence of apical closure
but upon clinical instrumentation there is definite
stop at the apex, indicating calcific repair.
First visit
Second visit
Subsequent visit
Chapter 20
Stainless Steel
Crowns
 Classification of stainless steel crowns
 Clinical procedure
 Complications
• First article on use of chrome steel in children’s

dentistry was published by Humphrey in 1950
• Mink and Bennett were the first to suggest initial
crown preparation
• Rapp and Castaldi also presented other techniques
of crown preparation
• Braff (1975) concluded that 88.7% of primary teeth
restored with amalgam required replacement
whereas 30.3% of the stainless steel crowns
required care
• Indications: Caries involving three or more surfaces,
rampant caries, recurrent caries around existing
restoration, after pulp therapy, inherited enamel
defects, fractures of teeth, severe bruxism,
abutment teeth to prosthesis, As part of a space
maintainer
• Classes of stainless steel: The heat hardenable 400
series martensitic types; the non-heat hardenable
400 series ferrite types; the austenitic types of
chromium nickel-manganese 200 series and
chromium nickel 300 series
• Rocky Mountain and Unitek stainless steel crowns
use the austenitic types for their crowns
• The austenitic types have high ductility, low yield
strength, and high ultimate strength, which make
them outstanding for deep drawing and forming
procedures
• The austenitic types provide the best corrosion
resistance of all of the stainless steels, particularly
when they have been annealed to dissolve
chromium carbides and then rapidly quenched to
retain the carbon in solution. Chromium
contributes to the formation of a very thin surface
film, probably oxide that protects against corrosive
attack
• The composition is of stainless steel crown is:
Chromium – 17 to 19%
Nickel – 10 to 13%
Iron – 67%
Minor elements – 4%
Stainless Steel Crowns 243
• The composition of Nickel-base crowns:

Nickel – 76%,
Chromium – 15%
Iron – 8%
Carbon – 0.08%
Manganese – 0.35%
Silicon – 0.2%.
CLASSIFICATION OF STAINLESS STEEL

CROWNS
According to Trimming
• Untrimmed crowns not trimmed nor contoured, e.g.
Rocky mountain
• Pretrimmed crowns straight, non-contoured sides
but are festooned, e.g. Unitek
• Precontoured crowns festooned and precontoured,
e.g. 3 M.
According to Composition
• Stainless steel crowns – 3 M
• Nickel-chromium crowns – Iconel.
According to Company Names

• Rocky mountain
• Unitek
• 3M
• Iconel.
According to Occlusal Anatomy

• Ion—compact occlusal anatomy
• Unitek—best occlusal anatomy
• Rocky mountain—occlusally small
• Ormco—smallest and least occlusally carved.
CLINICAL PROCEDURE
Armamentarium
• Crown cutting burs – pear shaped, tapering
fissure, needle shaped, smoothening burs
• Pliers—Hoe pliers, number 114 Johnson

contouring pliers, crimping pliers, number 112 ball
and socket pliers
• Scaler or spoon excavator
• Crown and bridge scissors
• Crown seater and remover
• Stone and finishing burs for crown finishing
• For cementation—luting cement, glass slab,
spatula
• Miscellaneous—articulating paper, wax sheet,
glass marking pencil.
Crown Preparation (Figs 20.1A to F)
Contd...
Contd...
Fig. 20.1A: Occlusal reduction
Fig. 20.1B: Proximal reduction
Fig. 20.1C: Crown contouring
Fig. 20.1D: Crown crimping
Fig. 20.1E: Crown fit
Fig. 20.1F: Varify excess

Adjacent Stainless Steel Crowns
Stainless Steel Crown with Class II

Amalgam Restoration
Oversized Crown (Fig. 20.2)

Fig. 20.2: Oversized crown
Undersized Crown (Fig. 20.3)

Fig. 20.3: Undersized crown
Crown Extension for Deep Proximal Lesions
COMPLICATIONS
• Interproximal ledge: If the angualtion of the tapered
fissure bur is incorrect this ledge will result in
difficulty in seating the crown
• Crown tilt: This is seen if complete lingual or
buccal wall is destructed by improper use of cutting
instrument
• Poor margins: When the crown is poorly adapted,
its marginal integrity is reduced which leads to
recurrent caries, plaque accumulation and
subsequent gingivitis
• Inhalation or ingestion of crown: This may happen

because of slippage from hand or by jerky reaction
of patient but this can be prevented by use of
rubber dam, upright seating of the patient while
doing adaptation or by soldering a hook onto the
buccal surface of crown and attaching long floss.
Chapter 21
Handicapped
Child
 WHO
 American academy of pediatric
dentistry (1996)
 Classification of handicap:
By Nowak (1976)
 Role of the dental assistant
 Disabled accessibility guidelines
 Mental retardation
 Cerebral palsy
 Childhood autism
 Visual impairment
 Hearing loss
WHO
One who over an appreciable period of time is
prevented by physical or mental conditions from full
participation in the normal activities of their age
group including those of social, recreational,
educational and vocational nature.
AMERICAN ACADEMY OF PEDIATRIC

DENTISTRY (1996)
A person should be considered dentally handi-
capped if pain, infection or lack of functional
dentition which affects the following:
• Restricts consumption of diet adequate to
support normal growth and developmental
needs
• Delays or otherwise alters growth and
development
• Inhibits performance of any major life activity
including work, learning communication and
recreation.
CLASSIFICATION OF HANDICAP:
BY NOWAK (1976)
• Physically handicapped—polio
• Mentally handicapped—retardation
• Congenital—cleft palate
• Convulsive—epilepsy
• Communication—deafness
• Systemic—hemophilia
• Metabolic—juvenile diabetes
• Osseous disorders—rickets
• Malignant disorders—leukemia.
ROLE OF THE DENTAL ASSISTANT

• A good working relationship requires effort,
time, practice, and patience
• The result should be four-handed and single-
minded dentistry
• Obtaining preliminary information which the
dentist later reviews
DISABLED ACCESSIBILITY GUIDELINES
External/internal Gradient Length Width Surface, other specifies
building features
Parking space 1:50 max slope Standard Auto: 90 inches Nonskid; paved; sign posted;
Van: 144 inches adjacent walkway
Walkway 1:12 max slope Not applicable 36 inches Nonskid; no obstructions
overhangs; smooth
Passenger loading zone Flat 20 feet 36 inches Same as above
Curb ramps door 1:12 max slope 5-foot Standard 32 inches Nonskid; side flair <1:10 slope;
entrance and exist Away from prevailing winds;
platform area lever with 10-lb pull; auto-assisted
door available; kick plate
Interior ramp 1:20 max slope 72 inches 36 inches Nonskid handrails
Wheelchair lift Bilevel 8-foot max drop 48 inches Nonskid; dependent on specific chair
Corridor flooring Not applicable flat, Standard not ½ inch max No obstacles;
firm carpet applicable thickness No doormats; level thresholds
Contd…
Handicapped Child 253
Contd…
External/internal Gradient Length Width Surface, other Specifies

building features
Signs Braille, raised letters Above 5 feet Readable Neat latch of office door
Waiting room Flat Standard 36 inch aisle No carpet pad; well insulated;
minimum low-frequency background
noise
Restrooms Flat 32 inch stall Nonskid; magnetic catch door
Public telephone No higher than 4 feet 3 feet above floor 26 inch clearance Phone directory near phone; adjustable
volume control
Elevator Flat 54 × 68 inches Nonskid; call and control box
48 inches high include incised letters

Operatory Flat 8 × 10 feet Standard 32 to 36 inch door Nonskid; rotating or movable chair;
drill and suction
• Instructing the patient or family in oral hygiene

• Assisting in the use of restraints and other
methods of behavioral control
• Anticipating problems and preparing for
emergencies
• Advising the dentist of any unusual patient,
family, or guardian problems.
MENTAL RETARDATION
• Subaverage general intellectual functioning,
which originates during the developmental
period and is associated with impairment in
adaptive behavior. (American Association of
Mental Deficiency)
• Adaptive behavior, refers, to the individual’s
effectiveness in adapting to the natural and social
demands of environment and may be reflected
in maturation, learning and social adjustment
• Subaverage general intellectual functioning is
defined by Capute as a developmental or
intelligence quotient (IQ) that is below 70 and
represents two or more standard deviation from
a mean of 100
• Cattell infant intelligence scale: Used to measure
IQ in a child less than 2 years
• Stanford-Binet intelligence scale: Used to measure
IQ in a child more than 2 years
• Wechsler intelligence scale: 6-17 years
• Wechsler adult intelligence scale: Adults
Mental age (MA)
• IQ = × l00
Chronological age (CA)
• Prenatal etiology: Genetic diseases, cretinism, fetal
alcohol syndrome
• Natal etiology: Birth injuries, infection, cerebral
trauma, hemorrhage, hypoxia
• Postnatal etiology: Cerebral infections, cerebral
trauma, poisoning, cerebral vascular accidents.
Dental Treatment
• Give the family a brief tour of the office
• Introduce the patient and family to the office staff
• Allow the patient to bring a favorite item to hold
for the visit
• Be repetitive; speak slowly and in simple terms
• Give only one instruction at a time
• Reward the patient with compliments after
completion of each procedure
• Actively listen to the patient
• Be sensitive to gestures and verbal requests
• Invite the parent into the operatory for assistance
and to aid in communication
• Keep appointment short
• Gradually progress to more difficult procedures
• Schedule the patient early in the day.
CEREBRAL PALSY
• Term given by Nelson
• Cerebral palsy describes a group of non-pro-
gressive disorders resulting from malfunction of
the motor centers and pathways of the brain
• Cerebral palsy is a heterogeneous disorder that
may result from congenital defects, mechanical
and chemical injury, and infection
• Incidence at birth is 0.6 to 5.9 per 1000
• Prevalence in children of school is 0.6 to 2.4 per
1000.
Spastic
• Occurs in more than 60 - 70% of the cases
• Caused by a lesion in the cerebral cortex
• Tendency for the antigravity muscles to maintain
a state of contraction and for the antagonists to
lengthen
• Limited control of neck muscles, resulting in
“head roll”
• Spastic quadriplegia frequently associated with
convulsions and mental retardation
• Impaired chewing and swallowing
Level Approx IQ 0-6 years 6-21 years 21 years and over
Profound 25 • Gross retardation • Delay in all areas of • May walk

• Minimal sensorimotor functions development • Needs care
• Needs nursing care • Shows emotions • Primitive speech
• Respond to training in • Incapable of self
use of hand legs and jaws maintenance
• Needs supervision
Severe 25-40 • Significant delay in motor • Usually walks • Can conform to
development • Some understanding daily activities
• Little communication skill of speech • Needs supervision
• May respond to training • Can profit from • Protective environment
systematic habit training
Moderate 40-55 • Delayed motor development • Learn communication skills • Can perform simple tasks
• Speech • Does not progress in arithmetic • Participates in recreation
• Responds to training and reading • Incapable of self
maintenance
Contd…
Contd…
Level Approx IQ 0-6 years 6-21 years 21 years and over
• Travels alone in known places

Mild 55-70 • Not noticed as retarded • Educable class • Achieve social and vocational
• Slow walking • Can progress in arithmetic and skills
reading till 6th grade level • Need support under stress
• Can be guided towards social conformity
Borderline 70-80 • Not detected as slow until • Slow learners • Achieve social and vocational
1st grade • Can acquire academic skills skills
• Physical developmental till 8th grade level • Less guidance
stages slightly below avg. • Can conform socially

• Hypertonicity of facial muscles with slow jaw

movement
• Spastic tongue-thrust with drooling
• Class II, Division II malocclusion (75%)
• Unilateral posterior crossbite with constricted
mandibular and maxillary arches.
Athetosis
• Occurs in about 25% of the cases
• Caused by a lesion in the basal ganglion
• Slow, writhing, involuntary movement (Athe-
tosis) that occurs with volitional jerky movements
(Choreathetosis) and interferes with normal
muscle action.
• Head drawn back with bull-type neck
• Involuntary movements either tremor or rotary
• Not associated with convulsions or mental
retardation
• Perioral muscles hypotonic with mouth breath-
ing
• Bruxism, grimacing and drooling
• Class II, division I malocclusion with high,
narrow palatal vault
• Poor swallowing, sucking, etc. because of
impaired function of muscles of deglutition.
Ataxia
• Occurs in 10% of cerebral palsy patients
• Caused by a lesion of the cerebellum
• Lack of positional sensation, lack of balance
leading to staggering gait, poor sense of balance
and uncoordinated voluntary movements
• Visual organs may be involved
• Poor proprioceptive response
• Slow, tremor like head movement
• Hypotonic orbicular muscles with grimacing and
drooling.
Rigidity
• Occurs in 5% of the cases
• Caused by a lesion of the basal ganglion
• Manifested by constant rigidity, voluntary
movements that are slow and stiff
• Patients resistant to flexor and extensor move-
ments.
Tremors
• Present in about 5% of the cases
• Caused by a lesion of the cerebellum
• A repetitive, rhythmic, involuntary contraction
of flexor and extensor muscles.
Mixed
• Seen in approximately 10% of cases
• Combination of characteristics of more than one
type of cerebral palsy.
Dental Management
• Consider treating a patient who uses a wheel-
chair, in the wheelchair
• Ask about a preference for the mode of transfer
(Two-person lift is recommended)
• Stabilize the patient’s head through all phases of
dental treatment
• Maintain the patient in the midline of the dental
chair with arms and legs as close to the body as
feasible
• Keep the patient’s back slightly elevated, to
minimize swallowing (supine position)
• Use immobilization judiciously for controlling
movements of the extremities
• Avoid stimuli, such as abrupt movements, noises,
and lights
• Introduce intraoral stimuli slowly to avoid
eliciting a gag reflex
• Use of the rubber dam, a highly recommended
technique, for restorative procedures.
CHILDHOOD AUTISM
• Described by Kanmer in 1944
• A clinical syndrome in which children have
inability to relate appropriately to people and
situations
• Lotter postulates that the personalities, attitudes,
and behavior of the child’s parents contribute to
the psychodynamics of autism
• Bakwin and Backwin: Autism is early manifesta-
tion of childhood schizophrenia
• Children seem to be self-sufficient and introvert
and want to be left alone
• Little or no attachment to their parents; autistic
children remain detached
• Relate well to objects like moving or shiny
inanimate objects, such as a string of keys or a
spinning top
• Display affection or anger with a toy
• Eye contact is difficult to achieve, and the
children are prone to tantrums and aggressive
or destructive behavior
• Oral hygiene is often very poor
• Robinson and Milius: Only two thirds of autistic
children achieve some functional speech.
Dental Management
• Maintain consistency in the environment
• Exhibit an extreme resistance to being held, so use
restraint judiciously
• Behavior modification techniques as reported by
Lovoos have proved to be effective in producing
behavioral changes in autistic children
• Use of positive reinforcement to promote desi-
rable behavior.
VISUAL IMPAIRMENT
• Total visual impairment (blindness) affects more
than 20 million people today
• A person is considered to be affected by blindness
if the visual acuity does not exceed 20/200 in the
better eye, with correcting lenses, or if the acuity is

greater than 20/200 but accompanied by a visual
field of no greater than 20 degrees
• Prenatal: Optic atrophy, microphthalmus,
cataracts, dermoid and other tumors, toxo-
plasmosis, syphilis, rubella, developmental
abnormalities of the orbit
• Postnatal: Trauma, hypertension, premature
birth, polycythemia vera, hemorrhagic disorders,
leukemia, diabetes mellitus, glaucoma.
Dental Management
• Determine the degree of visual impairment
• If a companion accompanies the patient, find out
if the companion is an interpreter
• Establish rapport; offer verbal and physical
reassurance
• In guiding the patient to the operatory, ask if the
patient desires assistance
• Do not grab, move or stop the patient without
verbal warning
• Paint a picture in the mind of the visually impai-
red child, describing the office setting and
treatment
• Introduce other office personnel very informally
• When making physical contact, do so reassu-
ringly. Holding the patient’s hand often promotes
relaxation
• Allow the patient to ask questions about the
course of treatment and answer them keeping in
mind that the patient is highly individual,
sensitive and responsive
• Allow a patient who wears eyeglasses to keep
them on for protection and security
• Invite the patient to touch, taste, or smell,
recognizing that these senses are acute
• Describe in detail, instruments and objects to be
placed in the patient’s mouth
• Use smaller quantities of dental materials with
such characteristics
• Use audiocassette tapes and Braille dental pam-

phlets explaining specific dental procedures
to supplement information and decrease chair
time
• Keep distractions minimal, and avoid unex-
pected loud noises.
HEARING LOSS
• 1 in 600 neonate has a congenital hearing loss
• Prenatal factors: Rubella and influenza, ototoxic
drugs, congenital syphilis, heredity
• Perinatal factors: Toxemia late in pregnancy, birth
injury, erythroblastosis fetalis
• Postnatal factors: Mumps, chickenpox, influenza,
poliomyelitis, ototoxic drugs.
Dental Management
• Welcome letter that states what is to be done and
include a medical history form
• Let the patient decide how to communicate (i.e.
interpreter, lip reading, sign language, writing
notes, or a combination of these)
• Look for ways to improve communication with
basic sign language
• Face the patient and speak slowly at a natural
pace
• Enhance visibility for communication
• Watch the patient’s expression
• Have the patient use hand gestures if a problem
arises
• Write out and display information
• Reassure the patient with physical contact; place
a hand reassuringly on the patient’s shoulder
while the patient maintains visual contact
• Use visual aids and allow the patient see the
instruments and demonstrate their working
• Adjust the hearing aid (if the patient has one)
before the handpiece is in operation, since a
hearing aid will amplify all sounds.
ISO (db) Disability Speech comprehension Psychologic problems in children
0 Insignificant Little or no difficulty None

> 25 Slight Difficulty with faint speech; language and May show a slight verbal deficit
speech development within normal limits
> 40 Mild-moderate Frequent difficulty with normal speech at 3 feet; Psychologic problems can be recognized
language skills are mildly affected
> 55 Marked Frequent difficulty with loud speech at 3 feet; Child is likely to be educationally retarded,
difficulty understanding with hearing aid in with more pronounced emotional and social
school situation problems than in children with normal hearing
> 70 Severe Might understand only shouts or amplified The prelingually deaf show pronounced
speech at 1 foot from ear educational retardation and evident motional
and social problems

> 90 Extreme Usually no understanding of speech even The prelingually deaf usually show severe
when amplified; child does not rely on educational retardation and also emotional
hearing for communication underdevelopment
Chapter 22
Medically
Compromised
Conditions
 Diabetes mellitus
 Idiopathic thrombocytopenic purpura
 Hemophilia
 Leukemia
 AIDS
 Endocarditis prophylaxis for dental
procedures
 Prophylactic regimens for dental
procedures
DIABETES MELLITUS
• Type I (IDDM) results from deficient insulin
production caused by the destruction of the beta
cells of the Islets of Langerhans
• Type II (NIDDM) results from impaired insulin
function rather than deficiency
• Oral manifestation: Reduced salivary flow,
burning mouth/tongue, candidiasis, altered
taste, progressive periodontitis, dental caries, oral
neuropathies, parotid enlargement, delayed
would healing, increased glucose content in
gingival crevicular fluid.
Dental Management
• Dental management is aimed at implementation
of a preventive protocol, symptomatic relief of
any oral manifestations of the disease and
immediate provision of primary care
• Comprehensive medical history
• Dental appointments should be short, stress free
and as atraumatic as possible
• Early morning appointments are preferred
• Patient should eat a normal breakfast before the
appointment to prevent hypoglycemia
• Conscious sedation is preferred
• Use of pulp capping and deciduous pulpotomy
procedures is questionable
• Vital pulp therapy may be preferred to a stressed
extraction procedure
• Prophylactic antibiotic may be recommended in
use of surgical procedures
• Vasoconstrictor drugs with LA to ensure pro-
found anesthesia are advocated
• Excessive adrenaline dosage is contraindicated
to prevent an increase in blood glucose levels and
for this reason glucocorticoids should be avoided.
IDIOPATHIC THROMBOCYTOPENIC
PURPURA
• Causes: Cytotoxic chemotherapy, indomethacin,
digitoxin, alcohol, thiazine diuretics, leukemia,
lymphomas, aplastic anemia
Medically Compromised Conditions 267
• General Manifestation: Sudden onset of purpura,

bruising, conjunctival and retinal hemorrhages,
epistaxis, hemorrhages, bullae and vesicles of
mucous membrane
• Oral manifestations: Ecchymoses and frank hemo-
rrhages, gingival hemorrhages, petechiae in pal-
ate appear as numerous, tiny, grouped clusters
of reddish spots.
Dental Management
• Elective dental treatment should be deferred until
a platelet count is above 50000/mm3
• Give steroids at a dose of 1 to 2 mg/kg to bring
up the platelet level
• Replacement therapy usually involves platelet
concentrate transfusion or whole blood
transfusion before oral surgical procedures
• Use local measures of hemostasis
• IV immune globulin 19 mg/kg/day twice before
dental extraction
• Avoid NSAID’s and aspirin 7 days preopera-
tively before any surgical procedures.
HEMOPHILIA
• Hemophilia A or classic hemophilia is a defi-
ciency of Factor VIII
• Hemophilia B or Christmas disease is caused by
a deficiency in Factor IX
• von Willebrand’s disease is a hereditary bleeding
disorder resulting from an abnormality of the von
Willebrand’s factor (vWF)
• Frequent bleeding episodes, common sites are
joints, muscles and skin
• Hemarthroses (joint hemorrhages) includes pain,
stiffness, limited motion
• Debilitating arthritis affecting joints include
knees, elbows, hips and shoulders
• Pseudotumors (hemorrhagic pseudocysts)
• Mouth lacerations are a common cause of
bleeding in children.
Dental Management
• Hemophilia A: Factor VIII concentrate, DDAVP
(1-deamino-8-D-arginine vasopressin)
• Hemophilia B: Purified coagulation Factor IX
concentrate (monoclonal and recombinant)
• von Willebrand’s Disease: DDAVP.
Local Anesthesia
• In the absence of factor replacement, periodontal
ligament (PDL) injections may be used
• Infiltration anesthesia without pretreatment with
epsilon-aminocaproic acid or replacement
therapy
• A minimum of a 40% factor correction before
block anesthesia.
Prevention of Dental Disease

• A total care program
• Rubber cup prophylaxis and supragingival
scaling without prior replacement therapy
• Minor hemorrhaging can be readily controlled
with local measures
• If subgingival scaling is planned, replacement
therapy may be considered.
Restorative Procedures
• Most restorative procedures on primary teeth can
be successfully completed
• The use of acetaminophen with codeine may also
help to decrease discomfort in the child
• Thin rubber dam is preferred
• Wedges and matrices can be used conven-
tionally.
Pulpal Therapy
• Pulpotomy or pulpectomy is preferable to
extraction
• Most vital pulpotomy and pulpectomy proce-
dures can be successfully completed using local
infiltration anesthesia.
Oral Surgery
• For simple extractions of erupted permanent teeth
and multirooted primary teeth, a 30% to 40% factor
correction is administered within 1 hour before
dental treatment
• Antifibrinolytic therapy
• The patient should be placed on a clear liquid
diet
• The socket should be packed with an absorbable
gelatin sponge (e.g. Gel foam). Topical thrombin
may then be sprinkled over the wound. Direct
pressure with gauze should then be applied to
the area. Stomadhesive may be placed over the
wound for further protection from the oral
environment.
Antifibrinolytics
• Epsilon-aminocaproic acid (Amicar) or trane-
xamic acid (Cyklokapron)
• Children: Epsilon-aminocaproic acid is given
immediately before dental treatment in an initial
loading dose of 100 to 200 mg/kg. Subsequently,
50 to 100 mg/kg of epsilon-aminocaproic acid is
administered orally every 6 hours for 5 to 7 days.
LEUKEMIA
• Leukemia is hematopoietic malignancy in which
there is a proliferation of abnormal leukocytes in
the bone marrow and dissemination of these cells
into the peripheral blood. The abnormal leuko-
cytes (blast cells) replace normal cells in bone
marrow and accumulate in other tissues and
organs of the body
• Regional lymphadenopathy
• Mucous membrane petechiae and ecchymoses
• Gingival bleeding, gingival hypertrophy
• Nonspecific ulcerations
• Chin and lip paresthesia
• Odontalgia, jaw pain, loose teeth, extruded teeth
• Infiltration of leukemic cells along vascular

channels can result in strangulation of pulpal
tissue and spontaneous abscess formation as a
result of infection
• Generalized osteoporosis caused by enlargement
of the haversian and Volkmann’s canals
• Loss of trabeculation, destruction of the crypts
of developing teeth, loss of lamina dura,
widening of the periodontal ligament space, and
displacement of teeth and tooth buds.
Dental Management
• Pulp therapy on primary teeth is contraindicated
• A platelet level of 100,000/mm3 is adequate for
most dental procedures
• Routine preventive and restorative treatment,
may be considered when there are at least 50,000
platelets/mm3
• If there are fewer than 20,000 platelets/mm3. No
dental treatment should be performed at such a
time without a preceding prophylactic platelet
transfusion
• The use of a soft nylon toothbrush for the re-
moval of plaque is recommended.
AIDS
• Defined as presence of antibodies to HIV and
presence of opportunistic infections
• Popovic in 1983 made identification of HTLV III
as the causative agent of AIDS
• Michael Glick (1989) detected HIV proviral DNA
in the dental pulp of a patient with AIDS
• Typical pediatric findings (Rubenstein, 1986)
include pulmonary lymphoid hyperplasia,
salivary gland enlargement, developmental
craniofacial features, chronic recurrent diarrhea,
hepatosplenomegaly, progressive encephalo-
pathy.
Oral and Perioral Findings of AIDS

in Children
• Fungal infection like candidiasis
• Bacterial infections either generalized, localized
or pyogenic
• Viral infections like herpes zoster, herpes
simplex, and hairy leukoplakia
• Petechiae
• Apthous stomatitis
• Linear gingival erythema
• Gingival and periodontal lesions like ANUG.
Sterilization
• HIV is sensitive to autoclaving at 121°C for 15
min at 1 atmospheric pressure
• Dry heat of instruments up to 170°C
• The virus can be inactivated by heating
lyophilized factor at 68°C for 72 hours
• Disinfectants for innate objects: 0.2% sodium
hypochlorite, 6% hydrogen peroxide for more
than 30 minutes, 2% glutaraldehyde and 6%
hydrogen peroxide
• HIV is completely inactivated by treatment for
10 minutes at room temperature with 10%
household bleach, 50% ethanol, 3% hydrogen
peroxide
• Gloves may be autoclaved, disinfected by immer-
sing them in boiling water for 20 minutes.
Alternatively overnight soaking of 1% sodium
hypochlorite.
ENDOCARDITIS PROPHYLAXIS FOR

DENTAL PROCEDURES
Prophylaxis recommended Prophylaxis not required
• Dental extractions • Restoration dentistry

• Periodontal procedures • Local anesthetic
including surgery, scaling injections
and root planing, probing (non intraligamentary)
and recall maintenance • Post placement
• Dental implant placement • Placement of rubber dams
Contd...
Contd...
Prophylaxis recommended Prophylaxis not required
• Reimplantation of • Postoperative suture

avulsed teeth removal
• Endodontic • Placement of removable
instrumentation prosthodontic or
orthodontic appliances
• Subgingival placement • Making oral impressions
of antibiotic fibers
or strips
• Initial placement of • Fluoride treatment
orthodontic bands • Radiographic exposures
• Local anesthetic • Orthodontic appliance
injections (nerve blocks) adjustment
PROPHYLACTIC REGIMENS FOR

DENTAL PROCEDURES
Follow-up dose no longer recommended. (Total
children’s dose should not exceed adult dose).
1. Standard general prophylaxis for patient at risk:
Amoxicillin: Adults—2.0 g (children—50 mg/kg)
orally one hour before procedure.
2. Unable to take oral medications: Ampicillin:
Adults—2.0 g (children—50 mg/kg) IM or IV 30
minutes before procedure.
3. Amoxicillin/Ampicillin/Penicillin-allergic
patients: Clindamycin: Adults—600 mg
(children—20 mg/kg) orally one hour before
procedure.
OR
Cephalexin or Cefadroxil: Adults—2.0 g
(children—50 mg/kg) orally one hour before
procedure.
OR
Azithromycin or Clarithromycin: Adults— 500
mg (children—15 mg/kg) orally one hour before
procedure.
4. Amoxicillin/Ampicillin/Penicillin-allergic
patients unable to take oral medications:
Clindamycin: Adults—600 mg (children—20 mg/
kg) IV 30 minutes before procedure.
OR
Cefazolin: Adults—1.0 g (children—25 mg/kg)
IM or IV 30 minutes before procedure.
Chapter 23
Cleft Lip and
Palate
 Etiopathogenesis of clefting
 Classification of cleft lip and palate
 Clinical features of cleft lip and palate
 Management of cleft lip and palate
• Defined as congenital abnormal gap in the palate

that may occur alone or in conjunction with lip
and alveolus cleft
• Primary palate includes lip and the area anterior
to incisive foramen
• Secondary palate includes the palate behind the
incisive foramen
• Primary palate develops from fusion of maxillary
and medial nasal process
• Secondary palate is formed as palatal shelves that
are formed by contribution of maxillary and
frontonasal process
• Complete fusion of palate occurs by 12 weeks
• Overall incidence varies from 0.3 to 6.5 per 1000
live births
• Negroid race has least incidence while Mon-
goloid have the maximum
• Cleft lip is more common in males, cleft palate is
more in females
• Unilateral clefts (left) are more common as
compared to bilateral
• Incidence is increased with increase in parental
age
• More chances of cleft in patients with family
history of the same and in consanguine
marriages.
ETIOPATHOGENESIS OF CLEFTING
• Dursy – His hypothesis: Failure of fusion between
median nasal and maxillary process.
• Veau’s hypothesis: Failure of ingrowth of meso-
derm between the two palatal shelves
• Alternations in intrinsic palatal forces
• Heredity
• Excessive tongue resistance
• Decreased blood supply in naso-maxillary region
• Non-fusion of shelves or fusion of shelves with
subsequent breakdown
• Failure of tongue to drop down as in case of Pierre
Robin syndrome
• Inclusion cyst pathology
Cleft Lip and Palate 275
• Deficiency of folic acid and vitamin A

• Teratogens like rubella virus, thalidomide
• Mutant genes, e.g. lobster defect-cleft with
ectodermal dysplasia
• Chromosomal aberrations like Trisomy 21
• Multifactorial inheritance: Conglomeration of
multiple genetic and environmental factors.
CLASSIFICATION OF CLEFT LIP AND PALATE

Davis and Ritchie’s Classification 1922
• Pre-alveolar clefts: Unilateral, bilateral and median
• Alveolar clefts: Complete cleft involving palate, lip
and alveolar ridge
• Post-alveolar cleft: Different degrees of hard and
soft palate clefts up to the alveolus.
Veau’s Classification 1931

• Group 1: Clefts of soft palate only
• Group 2: Cleft of hard and soft palate upto incisive
foramen
• Group 3: Complete unilateral clefts involving lips,
hard palate, soft palate and the alveolus
• Group 4: Complete bilateral clefts involving lips,
hard palate, soft palate and the alveolus.
Fogh Andreason’s Classification 1942

• Group 1: Clefts of lip
• Group 2: Clefts of lip and palate
• Group 3: Clefts of palate upto incisive foramen.
Schuchardt and Pfeiffer’s classification: This is symbolic
classification in which different regions depicted and
then shaded according to type of cleft depending on
whether its total or partial.
Kernahan’s stripped ‘Y’ classification (Fig. 23.1):
Symbolic classification in which numbering is given
to each site representing the oral cavity. The shaded
area denotes presence of cleft in the particular area.
Fig. 23.1: Kernahan’s stripped ‘Y’ classification
Millard’s modification of stripped ‘Y’ (Fig. 23.2): He

added another parameter to the Kernahan’s
classification and that was the addition of nasal floor.
Fig. 23.2: Millard’s modification
Lahshal’s Classification (Fig. 23.3): (Okriens in 1987).

L – lip, A – alveolus, H – hard palate, S – soft palate.
Fig. 23.3: Lahshal’s classification

CLINICAL FEATURES OF CLEFT LIP AND

PALATE
• Deformity of face
• Unable to feed
• Nasal regurgitation of fluids
• Congenital missing teeth
• Neonatal teeth
• Ectopic eruption
• Supernumerary teeth
• Anomalies of tooth size and shapes
• Micro and macrodontia
• Fused teeth
• Enamel hypoplasia
• Deep bite
• Crossbite
• Crowding or spacing of teeth
• Loss of facial morphology
• Disorders of middle ear
• Nasal twang in voice
• Difficulty in articulation.
MANAGEMENT OF CLEFT LIP AND PALATE

Obstetrician First to observe the child and sends for
referral
Pediatrician Provides routine care and contacts other
team members
Plastic surgeon Carries out esthetic repair
Surgeon Helps during surgery
Oral surgeon Carries out lip and palate repair
Neurologist Identifies syndromes
Pedodontist Helpful during all steps like pre-surgical
orthopedics, obturator fabrication, mainte-
nance of growth
Orthodontist Carries out all types of orthodontic interven-
tions during the treatment and also after it
Speech therapist Monitors speech development and prevents
any mishap
Psychologist Prevents stress for the child and family.
Prosthodontist Helps in appliance fabrication
ENT specialist For any associated defects
Social worker Important part in today’s changing world
and helps with the social component
Parents Since the child is small so the parents are
required to provide consent on his behalf.
Parental Counseling
• Support and information regarding treatment
aspects
• Hold and nurse the infant so that increased
bonding occurs
• Negate any fears and guilt regarding the child.
Nursing Management
• Mother acts as a very important nurse at this time
• Mother has to take care of the obturator appliance
• After each feed the plate is cleaned with running
water and soaked once a day for 20 minutes in
Hibitane solution.
Feeding Management
• Child is not able to create negative pressure
required for suckling of milk from the mother’s
breast
• Breast pumps, large nipple, obturators and
spoon-feeding are options for feeding
• To prevent regurgitation of milk through the
nose, child’s head is raised around 45° during
feeding.
Stage I— Maxillary Orthopedic Stage

• Birth to 18 months
• The treatment modalities in this stage are
management of feeding problems, fabrication of
feeding obturators, pre-surgical orthopedics,
surgical management of cleft lip and surgical
management of cleft palate
• Initial obturator therapy is done from birth to 3
months
• Pre-surgical orthopedics—(birth to 5 months).
The aim of this is to achieve an upper arch from
that conforms to lower arch
• Surgical lip closure—(3 to 9 months). At the time
of surgery the age of the child should not be less
that 10 weeks of age, have no less that 10 gm% of
hemoglobin and should weigh at least 10 pounds.

Types of lip repair are Millard’s repair, Tennison-
randall repair, Veau’s repair and Rose Thompson
repair
• Surgical plate repair—(10 to 18 months)
– Single stage: von Langeback repair and V-Y
pushback palatoplasty at 1½ year
– Two stage repair: Soft palate is repaired around
18 months and then hard palate is repaired
at 4 years by Schweckendiek procedure.
Stage II—Primary Dentition Stage

• 18 months to 5 years of age
• Adjustments to obturators
• Restoration of decayed teeth
• Maintenance of oral hygiene
• Evaluating the erupting dentition.
Stage III—Mixed Dentition Stage

• Correction of cross bites
• Maxillary expansion
• Secondary grafting.
Stage IV—Permanent Dentition Stage

• Fixed orthodontic treatments
• Cosmetic repair.
Chapter 24
Congenital
Abnormalities in
Children
 Classification of congenital
abnormalities
 Neurofibromatosis syndrome
 Marfan’s syndrome
 Treacher Collins syndrome
 Hypohidrotic ectodermal dysplasia
syndrome
 Turner’s syndrome
 Klinefelter’s syndrome
 Prader-Willi syndrome
 William’s syndrome
 Down’s syndrome
Malformation: A morphological defect of an organ,

part of an organ of the body that result from an
intrinsically abnormal developmental process.
Disruption: A morphological defect of an organ, part
of an organ of the body that results from the extrinsic
breakdown of, or an interference with, an originally
normal developmental process.
Deformation: An abnormal form, shape or position
of a part of the body that results from mechanical
forces.
Dysplasia: An abnormal organization of cells into
tissues and its morphological results.
Syndrome: A syndrome is a pattern of multiple
anomalies thought to be pathogenetically related and
not known to represent a single sequence or a
polytopic field defect.
Association: An association is a non-random
occurrence in two or more individual of multiple
anomalies not known to be a polytopic field defect,
sequence, or syndrome.
Sequence: A sequence is a pattern of multiple
anomalies derived from a single known or presumed
structures.
Dysmorphology: It is an area of clinical genetics that
is concerned with the diagnosis and interpretation
of pattern of structural defects.
Anomalad: A malformation together with its
subsequently derived structural changes.
Deletion: When the chromosome breaks, part of the
chromosome may be lost, e.g. partial deletion from
the short arm of chromosomes 5 causes the cri-du-
chat syndrome.
Ring chromosome is a type of deletion chromosome
from which both ends have been lost and the broken
ends have rejoined to form a ring shaped
chromosome.
Congenital Abnormalities in Children 283
Duplication: These abnormalities may be represented

as duplicated part of the chromosome within a
chromosome attached to a chromosome or as a
separate fragment. Duplication may involve part of
gene, a whole gene or a series of gene.
Inversion: This is a chromosomal aberration in which
a segment of chromosome is reversed.
Paracentric inversion is confined to a single arm of a
chromosome whereas it involves both arms and in-
cludes the centromere.
Isochromosomes: The abnormality resulting in
isochromosomes occurs when the centromere
divides transversely instead of longitudinally. In this
one arm is missing and the other duplicated.
Aneuploidy: It is any deviation from the human
diploid number of 46 chromosomes. An aneuploid
is an individual who has a chromosome number that
is not an exact multiple of the haploid number of 23
(e.g. 45 or 47).
Polyploidy: An individual that has a chromosome
number that is a multiple of haploid number of 23
other than the diploid number, e.g. 69.
CLASSIFICATION OF CONGENITAL
ABNORMALITIES
Given by Cohen in 1977
• Dominant genetic conditions:
– Neurofibromatosis
– Marfan’s syndrome
– Gardner’s syndrome
– Primary bone dysplasia
– Treacher Collins syndrome
• Autosomal recessive conditions:
– Cystic fibrosis
– Sickle cell disease
– Mucopolysaccharidoses
• X-linked conditions:
– X-linked mental retardation
– Ectodermal dysplasia
• Polygenic conditions:
– Cleft lip and cleft palate
• Chromosomal syndromes:
– Down syndrome
– Turner’s syndrome
– Klinefelter syndromes
• Imprinted genes:
– Prader-Willi syndrome
– William’s syndrome.
NEUROFIBROMATOSIS SYNDROME
• von Rechklinghausen described this disease in
1882
• Autosomal dominant
• Areas of hyper or hypopigmentation (café au lait
spots) present on trunk
• Benign tumors consisting of extracellular matrix,
Schwann like cells, fibroblast, mast cells
• Lisch nodules or pigmented iris hamartoma are
also present
• Hypoplastic bowing of lower legs with pseudo-
arthritis at birth are bony changes.
MARFAN’S SYNDROME
• Identified by Mckusick
• Connective tissue disorder
• Autosomal dominant condition
• Mutations in the fibrillin gene located on
chromosome 15q 21.1
• Skeletal abnormalities include long slim limbs
little subcutaneous fat, hypotonic musculature,
lateral curvature of vertebral column
• Narrow facies with narrow palate
• Lens subluxation, with defect in suspensory
ligament
• Retinal detachment
• Dilation with or without dissecting aneurysm of
ascending aorta
• Mitral valve prolapsed.
TREACHER COLLINS SYNDROME

• Reported by Thomson in 1846
• Described by Treacher Collins in 1900
• Also called as mandibulofacial dysostosis or
Franceschetti-Klein syndrome
• Autosomal dominant
• Anti-Mongoloid like palpebral fissures
• Malar hypoplasia, with or without cleft in
zygomatic bone
• Partial to total absence of lower eyelash
• Malformation of auricles, external ear canal
defect
• Cleft palate
• Projection of scalp hair onto lateral cheek.
HYPOHIDROTIC ECTODERMAL DYSPLASIA

SYNDROME
• Described by Thurman in 1848
• X-linked recessive trait that has an estimated 90%
female carriers
• Divided into hypohidrotic and hidrotic catego-
ries based on the deficit of sweat glands
• Skin becomes thin and hypoplastic, with
decreased pigmentation
• Hair are fine, dry and may be absent
• Hypoplasia to absence of exocrine glands,
sebaceous glands and mucous membrane
• Hypodontia to Anodontia resulting in deficient
alveolar ridge, anterior teeth are conical in shape
• Low nasal bridge, small nose with hypoplastic
alac nasi, prominent supraorbital ridge and
prominent lips.
TURNER’S SYNDROME
• XO syndrome
• Characterized by faulty chromosomal distribu-
tion leading to XO individual with 45 chromo-
somes
• 1 in 2000 born phenotypic females
• Small stature with a tendency to become obese
• IQ about 90 with performance usually below verbal

scores
• Delayed motor skills and poor coordination
• Ovarian dysgenesis with absence of germinal
elements
• Narrow maxilla, relatively small mandible, and
inner canthal folds
• Aortic stenosis, and mitral valve prolapse
• Auditory defects
• Low posterior hairline, webbed neck
• Widely spaced nipple and sparse pubic hair.
KLINEFELTER’S SYNDROME
• XXY syndrome
• Described by Klinefelter in 1942
• 1 in 500 males
• Paternal meiosis I errors account for about one
half of 47 XXY males while the remainder are
due to maternal meiosis I and meiosis II errors.
• Patients enter puberty normally but testosterone
levels decrease in late adolescence
• Behavior problems, immaturity, insecurity and
unrealistic boastful and assertive activity
• Long limbs, with slim stature
• Hypogonadism, hypogenitalism, gynecomastia
and feminized habitus
• Sparse facial hair, coarse voice and osteoporosis.
PRADER-WILLI SYNDROME
• Prader reported this pattern of abnormality in
nine children in 1956
• Normal birth length with deceleration in the first
two months of life
• Onset of obesity from 6 months to 6 years
• Almond shaped appearance to palpebral fissures
and strabismus
• Sun sensitive skin
• Mental retardation
• Excessive appetite, absent sense of satiation,
obsession with eating
• Small penis and cryptorchidism.
WILLIAM’S SYNDROME
• William’s described this disorder in 1961
• Mental deficiency
• Children have feeding problems, vomit
frequently and are constipated
• IQ ranges from 41 to 80
• Hoarse voice, hypersensitivity to sound, mild
neurological dysfunction
• Short palpebral fissure, depressed nasal bridge,
and prominent lips
• Peripheral pulmonary artery stenosis and
ventricular and atrial septal defect
• Partial Anodontia, enamel hypoplasia
• Joint limitation, scoliosis, and kyphosis.
DOWN’S SYNDROME
• Trisomy 21 syndrome
• Incidence is 3%
• Translocation of 21 chromosome
• CNS: Mental deficiency
• Craniofacial: Flat occiput, microcephaly with up
slanting palpebral fissures, thin cranium with late
closure of fontanels, hypoplasia of frontal sinuses,
small nose with low nasal bridge
• Eyes: Speckling of iris (Brushfield spots) with
peripheral hypoplasia of iris, blocked tear ducts,
acquired cataract in adults and hypertelorism
• Ears: Small in size, over folding of angulated
upper helix, small or absent earlobes and hearing
loss
• Dentition: Hypoplasia of teeth, short hard palate,
fewer caries than usual
• Skeletal: Neck appears short, hands are relatively
small with short metacarpals and phalanges,
hyperflexibility of joints, small stature with
awkward gait, fifth finger-hypoplasia of middle
phalanx, clinodactily, plantar crease between first
and second toes, pelvis shows hypoplasia with
outward lateral flare of iliac wings and shallow
acetabular angle
• Cardiac: Ventricular septal defect, patent ductus

arteriosus and aberrant subclavian artery
• Skin: Loose folds in posterior neck, cutis
marmorta, dry hyperkeratotic skin
• Hair: Fine, soft and often sparse
• Genitalia: Small penis and decreased testicular
volume and primary gonadal deficiency.
Principal Features in Neonate

• Hypodontia
• Poor Moro reflex
• Hyperflexibility of joints
• Excess skin on back of neck
• Flat facial slanted palpebral fissure
• Anomalous auricles
• Dysplasia of pelvis
• Dysplasia of middle phalanx of fifth finger
• Simian crease.
Chapter 25
Traumatic Injuries
in Children
 Extent of trauma
 Classification
 Examination and diagnosis
 Enamel Infarctions
 Enamel fractures
 Uncomplicated crown fractures
 Complicated crown fractures
 Crown-root fractures
 Root fractures
 Vertical root fractures
 Concussion
 Subluxation
 Intrusive luxation
 Extrusive luxation
 Avulsion
 Effect of traumatic injuries of
developing dentition
 Response of oral tissues to trauma
 Trauma to primary dentition
EXTENT OF TRAUMA
• Hallet in 1954 explained four factors influencing
trauma
• Energy of impact: Energy = Mass × Velocity.
Hence, if the impacting object either has more
mass or has high velocity, the impact will be more
• Resilience of impacting object: This can be either
hard or soft. More injury is bound to occur in the
case of former and less in case of later
• Shape of impacting object: The nature of wound
depends whether the object is sharp or blunt
• Direction of impacting force: Type of fracture will
directly depend on direction.
CLASSIFICATION
Rabinowitch’s Classification (1956)
Class I : Enamel fracture
Class II : Enamel and dentin fracture
Class III : Enamel and dentin fracture with pulp
exposure
Class IV : Root fracture
Class V : Comminution
Class VI : Exarticulation.
By Ellis and Davey (1960)

Class I : Simple fracture of crown involving
only enamel with little or no dentin
Class II : Extensive fracture of crown involving
considerable dentin but not exposing
dental pulp
Class III : Extensive fracture of crown involving
considerable dentin and exposing
dental pulp
Class IV : The traumatized tooth that becomes
non vital with or without loss of crown
structure
Class V : Total tooth loss
Class VI : Fracture of the root with or without
loss of crown structure
Traumatic Injuries in Children 291
Class VII : Displacement of tooth with neither

crown or root fracture
Class VIII : Fracture of crown en masse and its
displacement
Class IX : Traumatic injuries of primary teeth
: According to Cohen: Cracked tooth
: According to Matthewson: Cyclic dislo-
cation of tooth.
By Hargreaves and Craig

Class I : No fracture or fracture of enamel only
with or without displacement of tooth
Class II : Fracture of crown involving both
enamel and dentin without exposure
of pulp, with or without displacement
of tooth
Class III : Fracture of crown exposing the pulp
with or without displacement of tooth
Class IV : Fracture of root with or without coro-
nal fracture, with or without displace-
ment of tooth
Class V : Total displacement of tooth.
By Andreasen (1981)
Injuries to Hard Dental Tissues and Pulp
• Enamel infarction: incomplete fracture (Crack) of
enamel without loss of tooth substance
• Enamel fracture: (Uncomplicated crown fracture)
A fracture with loss of tooth substance confined
to enamel only
• Enamel – Dentin fracture: (Uncomplicated crown
fracture) A fracture with loss of tooth substance
confined to enamel and dentin but not involving
pulp
• Complicated crown fracture: Fracture involving
enamel and dentin and also exposing pulp
• Uncomplicated crown root fracture: Fracture
involving enamel, dentin and cementum but not
exposing pulp
• Complicated crown root fracture: Fracture involving

enamel, dentine and cementum and also expo-
sing pulp
• Root fracture: A fracture involving dentine,
cementum and pulp. They can also be classified
according to displacement of coronal fragment.
Injuries to Periodontal Tissues

• Concussion: An injury to tooth supporting
structures without abnormal loosening or
displacement of tooth but with marked reaction
to percussion
• Subluxation: An injury to the tooth supporting
structures with abnormal loosening but without
displacement of tooth
• Extrusive luxation: (Peripheral dislocation, Partial
avulsion) Partial displacement of tooth out of its
socket
• Lateral luxation: Displacement of tooth in any
other direction other than axial. Accompanied by
fracture of alveolar socket
• Intrusive luxation: (Central dislocation) Displace-
ment of tooth into alveolar socket accompanied
by fracture of alveolar socket
• Avulsion: (Exarticulation) Complete displacement
of tooth out of its socket.
Injuries to Supporting Bone

• Comminution of mandibular or maxillary alveolar
socket: Crushing and compression of the alveolar
socket found mostly with intrusive and lateral
luxation
• Fracture of maxillary or mandibular socket wall: A
fracture confined to facial or lingual socket wall
• Fracture of maxillary or mandibular alveolar process:
A fracture involving the base of the mandible or
maxilla and often the alveolar process. May or
may not involve alveolar socket.
Injuries to Gingiva or Oral Mucosa

• Laceration of gingival or oral mucosa: Shallow or
deep wound in the mucosa resulting from a tear
usually produced by sharp object
• Contusion of gingival or oral mucosa: A bruise
usually produced by impact with blunt object and
not accompanied by a break in mucosa but
usually causing submucosal hemorrhage
• Abrasion of gingival or oral mucosa: Superficial
wound produced by rubbing or scraping of
mucosa leaving a raw bleeding surface.
Ulfon’s Classification (1985): Based on Endo-

dontic Treatment
Class I : Fracture of enamel
Class II : Fracture of crown with indirect
pulp exposure
Class III : Fracture of crown with direct pulp
exposure.
WHO Classification (1993)

873.60 — Enamel fracture
873.61 — Enamel and dentine fracture
without pulp exposure
873.62 — Enamel and dentine fracture with
pulp exposure
873.63 — Root fracture
873.64 — Crown-Root fracture
873.66 — Concussion, Luxation
873.67 — Intrusion, Extrusion
873.68 — Avulsion
873.69 — Soft tissue injuries.
Bennett’s Classification
Class I : Traumatized tooth
Ia : Tooth is firm in alveolus
Ib : Tooth is subluxed in alveolus
Class II : Coronal fracture
II a : Fracture of enamel
II b : Fracture of enamel and dentin
Class III : Coronal fracture with pulp expo-

sure
Class IV : Root fracture
IV a : Without coronal fracture
IV b : With coronal fracture
Class V : Avulsion of tooth.
EXAMINATION AND DIAGNOSIS

• Patient’s details: Ability of the patient to provide
the desired information indicates general mental
status
• When did the injury occur: Time interval between
the injury and treatment significantly influences
the result, e.g. In reimplantation of avulsed teeth
• Where did the injury occur: The place of accident
may indicate a need for of tetanus prophylaxis
• How did injury occur: Nature of the accident can
yield valuable information on the type of injury
to be expected, i.e. a blow to the chin will result
in crown-root fractures in the premolar and
molar regions, accidents in which a child has
fallen with an object in its mouth, tend to cause
dislocation of teeth in a labial direction
• Treatment elsewhere: Previous treatment, such as
immobilization, reduction or reimplantation of
teeth, should be considered before further
treatment is instituted. It is also important to
ascertain how the avulsed tooth was stored, e.g.
tap water, sterilizing solutions, or dry
• History of previous dental injuries: This can
influence pulpal sensibility test and the
recuperative capacity of the pulp and perio-
dontium
• Medical history: Essential for providing
information about a number of disorders such
as allergic reactions, epilepsy, or bleeding
disorders, which can influence emergency
treatment
• Did the trauma cause drowsiness, vomiting, or
headache: Indicative of cerebral involvement
• Is there spontaneous pain form the teeth: Indicates

damage to the tooth supporting structures or
damage to the pulp due to crown or crown-root
fractures
• Are the teeth tender to touch, or during eating:
Reaction to thermal or other stimuli can indicate
exposed dentin or pulp
• Is there any disturbance in the bite: If the occlusion
is disturbed, injuries such as extrusive or lateral
luxation, alveolar fractures should be suspected
• Recording of extraoral wounds: Extraoral wound are
usually present in cases resulting from traffic
accidents. The location of these wounds can
indicate where and when dental injuries are to
be suspected, e.g. a wound located under the chin
suggests dental injuries in the premolar and
molar regions and/or concomitant fracture of the
mandibular condyle and/or symphysis
• Recording of injuries to oral mucosa or gingival
injuries: Wounds penetrating the entire thickness
of the lip can frequently be observed, often
demarcated by two parallel wounds on the inner
and/or outer labial surfaces. If present, the
possibility of tooth fragments buried between the
lacerations should be considered
• Examination of crowns of teeth: For the presence
and extent of fractures, pulp exposures, or
changes in color
• Recording of displacement of teeth: Evident by visual
examination; however, minor abnormalities can
often be difficult to detect therefore radiographic
examination is required
• Disturbances in occlusion: Abnormalities in
occlusion can indicate fractures of the jaw or
alveolar process; Disruption of the vascular
supply to the pulp should be expected in case of
axial mobility; Abnormal mobility of teeth or
alveolar fragments, uneven contours of the
alveolar process usually indicate a bony fracture
• Tenderness of teeth to percussion and change in
percussion tone: Reaction to percussion is
indicative of damage to the periodontal ligament.
A hard, metallic ring elicited by percussion in a

horizontal direction indicates that the tooth is
locked into bone, while a dull sound indicates
subluxation or extrusive luxation
• Reaction of teeth to pulpal testing: Pulpal sensibility
testing should be instituted only 15 days after the
injury as it may lead to false positive or negative
results.
ENAMEL INFARCTIONS
• Appear as crazing within the enamel substance
which do not cross the dentino – enamel junction
and appear with or without loss of tooth
substance
• Caused by direct impact to the enamel
• Occurrence on the labial surface of upper inci-
sors
• Patterns of infraction lines depend upon direc-
tion and location of trauma
• Visualized by seeing long axis of the tooth from
the incisal edge; fiber optic light sources and
transillumination.
ENAMEL FRACTURES (FIG. 25.1)

• Fracture of enamel only
• Confined to a single tooth
• Seen in the maxillary region
• Treatment of choice is restoration with composite
resin restoration and corrective grinding.
Fig. 25.1: Enamel fracture

UNCOMPLICATED CROWN FRACTURES

(FIG. 25.2)
• Fracture of enamel and dentin only
• Sensitivity to thermal changes and mastication
• Immediate provisional treatment to place
Ca(OH)2 on the exposed dentin
• Permanent treatment is re-attachment of the
crown fragment, restoration with composite resin
or full coverage crown.
Fig. 25.2: Uncomplicated crown fracture
COMPLICATED CROWN FRACTURES

(FIG. 25.3)
• Fracture of enamel, dentin along with exposure
of pulp
Fig. 25.3: Complicated crown fracture

• Presents as a fractured segment of tooth with frank

bleeding from the exposed pulp
• Type of treatment will depend upon the extent
and time of pulp exposure
• Pulp capping is done if the exposure is small and
exposure is less than 4 to 5 minutes
• Pulpotomy is done if exposure is large and pulp
has been exposed for more than 5 minutes.
CROWN-ROOT FRACTURES
• Fracture involving enamel, dentin, and cementum
• Crown root fractures in the anterior region are
usually caused by direct trauma
• In the posterior regions fractures of the buccal or
lingual cusps of premolars and molars may occur
due to indirect trauma
• Fracture line begins a few millimeters incisal to
marginal gingiva or to facial aspect of the crown
following an oblique course below the gingival
crevice orally
• Oblique fracture line is almost perpendicular to
central beam in radiographic examination
• Emergency treatment includes stabilization of
coronal fragment with acid etch splint in anterior
teeth
• In posterior teeth removal of loose fragment and
coverage of exposed supragingival dentin is done
• Vertical crown–root fractures must generally be
extracted
• In vertical fractures of immature permanent
incisors if the fracture line is apical to the level of
alveolar crest, these fractures are amenable to
orthodontic extrusion followed by endodontic
restoration.
ROOT FRACTURES (FIG. 25.4)

• Fractures involving dentin, cementum and pulp
• 0.5 to 7% in permanent dentition and 2 to 4% in
primary dentition
Fig. 25.4: Root fracture
• Caused by a frontal impact, which creates

compression zones labially and lingually,
resulting in shearing stress zone that dictates the
plane of fracture
• Coronal fragments are displaced lingually or
slightly extruded
• Temporary loss of sensitivity
• Radiographic demonstration of root fractures is
only if the central beam is directed within a
maximum range of 15-20° of fracture plane
• The principle of treatment is reduction of
displaced coronal fragments and firm immobi-
lization with rigid fixation with an acid etch
splint for 2-3 months to ensure sufficient hard
tissue consolidation
• Fracture in middle third: Extraction
• Fracture in apical third: Obturation till the possible
working length and apical surgery to remove the
fragment
• Fracture near to gingival margin: Orthodontic or
surgical extrusion of the fragment followed by
immobilization and later crown fabrication.
VERTICAL ROOT FRACTURES

• It is also called as cracked tooth syndrome
• Runs lengthwise from crown towards the apex
• Found in posterior teeth and etiology is mostly

iatrogenic like insertion of screws or after pulp
therapy
• Persistent dull pain of long standing origin,
which is more on applying pressure
• Line of fracture is visible as radiolucent line on
radiographic examination
• Single rooted teeth: Extraction
• Multi rooted teeth: Hemisection and endodontic
treatment.
CONCUSSION
• An injury to tooth supporting structures, when
there is some crushing injury to apical vas-
culature and periodontal ligament with resultant
inflammatory edema with marked reaction to
percussion but without abnormal loosening or
displacement
• Traumatized tooth is sore, tender to percussion
and sensitive to biting forces
• Radiographic features include widening of
periodontal ligament space apically and redu-
ction in size of pulp after few months
• Treatment is to relieve occlusion and take soft
diet for 10 to 14 days.
SUBLUXATION
• An injury to tooth supporting structures with
abnormal loosening but without clinically or
radiographically demonstrable displacement of
the tooth
• Tooth is tender on touch
• Mobility
• Evidence of hemorrhage at gingival margin
• Widening of periodontal ligament space and
reduction in size of pulp after few months
• Relieve occlusion
• Splinting for 10 days
• Soft diet for 10 to 14 days.
INTRUSIVE LUXATION (FIG. 25.5)

• Term used to describe displacement of tooth into
alveolar bone
• Displacement is accompanied by fracture or
crushing of alveolar bone
• Tooth is mobile
• Bleeding from gingival crevice
• Tooth is tender to percussion and masticatory
forces
• Clinically crown appears shorter
• Obliteration of apical portion of PDL space and
crushing of lamina dura
• Orthodontic or surgical repositioning of tooth
• Splint for 2 to 3 weeks after tooth has come to
normal position
• Soft diet for 14 days.
Fig. 25.5: Intrusive luxation
EXTRUSIVE LUXATION (FIG. 25.6)

• It is partial displacement of tooth out of its socket
• It is also called peripheral displacement or partial
avulsion
• Tooth is mobile
• Bleeding from gingival crevice
• Tooth is tender to percussion and masticatory
forces
Fig. 25.6: Extrusive luxation
• Clinically crown appears longer

• Widening of PDL space
• Reposition the tooth in normal position using
digital pressure
• Splint the tooth for 2 to 3 weeks
• Advise soft diet.
AVULSION (FIG. 25.7)

• Term used to describe complete displacement of
tooth from its alveolus
• It is also called as Exarticulation
• Maxillary teeth are most commonly involved
• Bleeding socket with missing tooth
Fig. 25.7: Avulsion

• Associated bone fractures

• If the wound is recent then lamina dura is visible
otherwise it is obliterated
• Reimplantation is the only treatment of choice
• If apical foramen is not closed; endodontic
therapy is delayed till first signs of apical closure
are seen
• If apical foramen is closed; endodontic therapy
is done after 1 to 2 weeks
• Complication is root resorption
• Prognosis: Tooth survival – 51 to 89%, PDL
healing – 9 to 50%, Pulp healing – 4 to 15%.
Reimplantation
Storage mediums:
• HBSS (Hanks balanced salt solution)
• Buccal vestibule
• Saline
• Saliva
• Milk
• Water
• Coconut water.
Short extra-alveolar storage: If tooth is placed in
suitable medium and the extra-alveolar time elapsed
is short.
Long extra-alveolar storage: This is done in cases where

the extra oral dry period of tooth is long.
Periodontal Healing Reactions

Healing with normal periodontal ligament:
• Histologically this is characterized by complete
regeneration of PDL
• 2 to 4 weeks to complete
• Occur if innermost cell layers along the root
surface are vital
• Radiographically there is normal PDL space
without signs of root resorption.
Healing with Surface Resorption

• Characterized by localized areas along the root
surface, which show superficial resorption
lacunae repaired by new cementum
• Localized areas of damage to PDL or cementum,
which is healed by PDL derived cells
• Clinically the tooth is in normal position and a
normal percussion tone can be heard.
Healing with Ankylosis (Fig. 25.8)

• Replacement resorption
Fig. 25.8: Healing by replacement resorption
• Ankylosis represents a fusion of the alveolar bone

and the root surface
• Etiology of replacement resorption is related to
the absence of vital PDL cover on the root surface
• Progressive replacement resorption.
• Transient replacement resorption.

Healing with Inflammatory Resorption (Fig. 25.9)

• Characterized by bowl shaped resorption cavities
in cementum and dentin associated with
inflammatory changes in the adjacent periodontal
space.
• Clinically the replanted tooth is loose, extruded
and sensitive to percussion with dull tone.
Fig. 25.9: Healing by inflammatory resorption
EFFECT OF TRAUMATIC INJURIES OF

DEVELOPING DENTITION
• White or yellow brown discoloration of enamel: Lesions
appear as sharply demarcated stained enamel
opacities on the facial surface of the crown due to
injuries to primary maxillary incisors
• White or yellow brown discoloration of enamel with

circular enamel hypoplasia: Displaced primary tooth
traumatize tissue adjacent to permanent tooth
germ and possibly odontogenic epithelium
therefore interfering with final mineralization of
enamel and clinically presents as morrow
horizontal groove, which encircles the crown
cervically to the discolored areas
• Crown dilaceration: Due to traumatic non–axial
displacement of already formed hard tissue in
relation to the developing soft tissues
• Odontoma like malformations: Due to intrusive
luxation or avulsion a conglomerate of hard tissue
having morphology of complex odontoma or
separate tooth element is seen
• Root duplication: Seen following intrusive luxation
of primary teeth which causes traumatic division
of the cervical loop at the time of injury resulting
in formation of two separate roots
• Vestibular root angulation: Trauma of developing
tooth forcing it to change its path of eruption in a
labial direction and presumably HERS remains
in the same position despite the impact and
thereby creates a curvature of root
• Lateral root angulation: Appear as a mesial or distal
bending confined to the root of the tooth
• Partial or complete arrest of root formation: Trauma
directly injures HERS thus compromising normal
root development
• Sequestration of permanent tooth germs: In case of
jaw fractures, infection can complicate healing
sometimes leading to spontaneous sequestration
of involved tooth germs
• Disturbances in eruption: Abnormal changes in the
connective tissue overlying the tooth germ.
RESPONSE OF ORAL TISSUES TO TRAUMA

• Dental follicle: Ankylosis between the tooth surface
and the crypt
• Cervical loop: Highly resistant to trauma but

profound contusion may cause arrest of
odontogenesis
• Inner enamel epithelium: Injury to ameloblasts will
cause hypomineralized enamel
• Reduced enamel epithelium: Ankylosis and tooth
retention
• Enamel and enamel matrix: Contusion of the
permanent matrix and hypomineralized enamel
defect
• Hertwig’s epithelial root sheath: Chronic trauma
leads to fragmentation and acute trauma causes
partial or complete arrest of root development
• Gingival complex: Loss of vascular supply and
cellular cover of bone
• Periodontal ligament – cementum complex:
Hemorrhage, edema, rupture or contusion of the
PDL
• Dentin – pulp complex: Fracture, inflammatory
reaction in the pulp.
TRAUMA TO PRIMARY DENTITION

• Roots of the primary teeth are in close relation-
ship to the developing permanent successors and
an acute impact can easily be transmitted to the
developing permanent dentition
• Most serious primary tooth injuries in term of
damage to the permanent successor are intrusion
• Avulsion (52%) is the most common injury
• Maxillary anterior are most commonly affected
teeth.
Enamel Infarction
• No treatment.
Enamel Fracture
• Restoration with composite
• Selective grinding.
Enamel and Dentin Fracture

• Ca(OH)2 and restoration.
Enamel and Dentin Fracture with Pulp Exposure

• Pulpotomy
• If root resorption is advanced then extraction.
Concussion, Luxation
• If the luxation injury is slight, and the tooth is
not at risk of coming out of the socket sponta-
neously, then it can be left and advice regarding
soft diet and careful oral hygiene instruction
given
• If the tooth has been luxated palatally it might
be possible to gently reposition and splint it
manually but only if the displacement is less than
2 mm
• If the tooth has been displaced by more than 2 mm
extraction may be more appropriate in such cases
Intrusion
• If the intruded tooth is not obstructing the
permanent successor then allow it to erupt on its
own
• If less than three-quarters of the crown is
intruded then the tooth can be allowed to re-erupt
spontaneously
• If more than three-quarters of the crown has
intruded, the tooth may cause symptoms such
as pain, and the tooth may require extraction.
Extrusion
• Extraction is often indicated.
Avulsion
• Reimplantation is contraindicated as ankylosis
may take place thus obstructing the eruption of
permanent successor and hence extraction is the
treatment of choice.
Chapter 26
Lasers in
Pediatric Dentistry
 Laser delivery systems
 Components of laser
 Laser interaction with biologic tissues
 Laser hazard classification according
to ANSI and OHSA standards
 Types of laser
 Diagnosis of dental caries
 Prevention of enamel and dental caries
 Miscellaneous uses
 Lasers in endodontics
 Advantages of laser
 Disadvantages of laser
• LASER is an acronym for Light Amplification by

Stimulated Emission of Radiation
• Initial experiments were done in 1900s by Danish
physicist Bohr
• In 1958, Schawlow and Townes discovered
LASER
• Goldman, Stem and Segnnaes carried out the
original research in the 1960s
• In 1960, the first working laser, a pulsed ruby
instrument, was built by Maiman of Hughes
Research Laboratories
• Vahl used ruby laser
• Kantola experimented with a CO2 laser
• Lenz et al initially experimented with the Nd:
YAG laser
• Paghdiwala (1988) in United States tested the
ability of the Er: YAG laser
• In May 1997, the Er: YAG (2.94 um) laser was
cleared for marketing by the U.S. Food and Drug
Administration (FDA).
LASER DELIVERY SYSTEMS

Flexible Hollow Wave-guide
• Tube that has an interior mirror finish
• The laser energy is reflected along this tube and
exits through a handpiece at the surgical end
• Non-contact fashion.
Glass Fiber Optic Cable

• The fiber fits snugly into a handpiece with the
bare end protruding
• This fiber system can be used in contact or non-
contact mode.
Emission Modes
• Continuous wave: Beam is emitted at one power
level continuously as long as the device is
activated
• Gated-pulse mode: Periodic alternations of the laser
energy being on and off
Lasers in Pediatric Dentistry 313
• Free-running pulsed mode: Peak energies of

laser light are emitted for an extremely short time
span, usually in microseconds, followed by a
relatively long time in which the laser is off.
COMPONENTS OF LASER
• Lasing medium: A material, which is capable of
absorbing the energy, produced by an, external
extension source through in the subatomic
configuration of its component molecules, atoms
or ions subsequently give off this excess energy
as photons of light
• Energy or pumping source: Used to excite or pump
the atoms in the lasing medium to their higher
energy levels that are necessary for the
production of laser radiation
• Optical chamber: The lasing medium is located
within resonating chamber, which has a
cylindrical structure with a fully reflecting mirror
on one side, partially reflecting mirror at other
side, which are mounted so that they are exactly
parallel to one another. This arrangement allows
for the reflection of photons of light back and
forth across the chamber, eventually resulting in
the production of an intense photo resonance
within the medium. The second mirror, which is
partially reflective, allows some of the laser light
to escape as the output device.
LASER INTERACTION WITH BIOLOGIC

TISSUES
• Photochemical interactions: Specific wavelength of
laser light is absorbed by naturally occurring
chromophores that are able to induce certain
biochemical reactions at the cellular level.
Derivatives of naturally occurring chromophores
are used as photosensitizers to induce biologic
reactions within the tissue for both diagnostic and
therapeutic applications
• Photothermal interactions: Radiant light energy

absorbed by tissue, substances and molecules
become transformed into heat energy, which
produces the tissue effect
• Photomechanical interactions: Include photo-
disruption or photodisassociation, which is the
breaking apart of structures by laser light and
photoacoustic interactions, which involve the
removal of tissue with shock wave generation
• Photoelectrical interactions: Include, photoplasmo-
lysis, which describes how tissue is removed
through the formation of electrically charged ions
and particles that exist in a semi-gaseous high-
energy state
• Thermal interaction of tissue:
Temperature Tissue effects
(°c)
42 – 45 Hypothermia (transient)
> 65 Desiccation, protein denaturation
70 – 90 Tissue welding
> 100 Vaporization
> 200 Carbonization and charring
• Reflection: Beam redirecting itself off of the tissue

surface, having no effect on the target tissue
• Absorption: Amount of energy that is absorbed
depends on the tissue characteristics, laser
wavelength and emission mode. Shorter wave-
lengths are absorbed readily in pigmented tissue,
e.g. argon and longer wavelengths are more
interactive with water and hydroxyapatite, e.g.
CO2
• Transmission: Laser energy passes directly
through the tissue, with no effect on the target
tissue, e.g. diode and Nd: YAG lasers can be
transmitted through the lens, iris, cornea, anterior
chamber, posterior chamber, vitreous, and
aqueous humors of the eye without affecting
them, yet can be absorbed easily by the tissues of
the retina
• Scattering: It weakens the energy and possibly
producing no useful biologic effect apart from
curing of composite resins.
LASER HAZARD CLASSIFICATION ACCORDING

TO ANSI AND OHSA STANDARDS
Class Description
I low powered lasers that are safe to view
II a low powered visible lasers that are hazar-
dous only when viewed directly for longer
than 1,000 seconds
II b low powered visible lasers that are
hazardous when viewed for longer than
0.25 seconds
III medium powered lasers (0.5 w max) that
can be hazardous if viewed directly
IV high powered lasers (> 05 w) that produce
ocular, skin and fire hazards
TYPES OF LASER
• Hard lasers: A longer wavelength producing
thermal effect, which cut the tissue by coa-
gulation, vaporization and carbonization. These
lasers have been used for surgical soft tissue
applications
• Soft lasers: Provide cold thermal low energy
wavelengths that stimulate circulation and
cellular activity and cause anti-inflammatory,
muscle relaxation, analgesia and tissue healing
reactions.
Laser type Wavelength Main current clinical uses

Argon 488, 514.5 nm Curing, soft tissue
desensitization
Diode 800-830, Soft tissue, periodontics
950-1010 nm
Nd: YAG 1.064 um Soft tissue, periodontics,
desensitization, analgesia,
tooth whitening, and
endodontics
Er: YSGG 2.79 um Hard tissue
Er: YAG 2.94 um Hard tissue
CO2 10.6 um Soft tissue,
desensitization
Nd: YAG = neodymium: yttrium – aluminum - garnet
Er: YSGG = erbium: yttrium – scandium – gallium – garnet
Er: YAG = erbium: yttrium – aluminum – garnet
CO2 = carbon dioxide
DIAGNOSIS OF DENTAL CARIES

Laser Induced Fluorescence
• Kutsch (1992)
• Carious and non-carious tissue illuminated with
an argon laser with dark field photography
• Carious tissue has a clinical appearance of a dark,
fiery, orange-red color
• Decalcified areas appear as a dull, opaque, orange
color.
Terahertz Pulse Imaging

• Terahertz waves are located just below the
infrared band in the electromagnetic spectrum
and are generated by lasing semiconductors with
ultra fast pulses of visible laser light.
Quantitative Laser Fluorescence

• Developed by workers in Netherlands and
Sweden in 1980s and in US in 1990s
• A system was developed that collects images, of
lesions based on excitation at 488 nm
• The blue light is used to irradiate the surface of
the tooth by a specially constructed hand piece,
and computer captures the fluorescent image.
Diagnodent
• Hibst and Gall
• The red laser diode light is directed to the occlusal
surface by a specially designed probe tip, and the
fluorescent signal is filtered from the incident
light and fed back to the detector through the
same device
• The signal comes out as a number on the instru-
ment on a scale of 0 to 99. Higher the number,
the more caries.
Optical Coherence Tomography

• An imaging technique that is capable of three-
dimensional images of subsurface tissue
• The differences in scattering or polarization

between sound and carious enamel can be
exploited.
PREVENTION OF ENAMEL AND DENTAL

CARIES
• Laser alters the surface characteristics of enamel
to make it more caries resistant
• Laser produces heat and this drives off carbonate
leaving a more resistant hydroxyapatite
• Improves uptake of fluoride
• Formation of micro spaces within the enamel,
which impart an increased acid resistance to the
enamel by trapping ions, formed during acid
demineralization
• S Tagomori and T Morioka (1989): Laser irradiation
followed by APF caused a remarkable increase
in acid resistance of the enamel
• T L Boran (1992): Reduces subsurface deminera-
lization.
MISCELLANEOUS USES
• Laser photopolymerization of composite resins: Argon
laser increases the depth of cure, diametric tensile
strength, adhesive bond strength and degree of
polymerization; reduces the acid solubility of the
surrounding enamel and the time of activation
significantly
• Laser in soft tissue surgery: A Pfizer model o-c
surgical laser has been used for soft tissue incision
and for controlled destruction of a number of oral
pathogens
• Bleaching: Laser’s light is converted to heat as it
strikes the bleaching gel, accelerating the
oxidation (bleaching function) of the peroxide
contained in the substance
• Dentin desensitization: Narrowing or occlusion of
dentinal tubules and nerve analgesia through
depression of nerve transmission
• Analgesia: Wavelengths of laser energy interfere
with the sodium pump mechanism, change cell
membrane permeability, alter temporarily the

endings of the sensory neurons, and block the
depolarization of C and A fibers of the nerves.
LASERS IN ENDODONTICS
• Diagnosis of dental pulp: Laser Doppler flowmetry
is based on the changes in red blood cell flux in
the pulp tissue
• Indirect pulp capping: By closure of dentinal
tubules and sedative effects on pulpitis
• Direct pulp capping: Laser irradiation should be
performed at 1 or 2 w after irrigating alternatively
with 8% sodium hypochlorite and 3% hydrogen
peroxide for more than 5 minutes, followed by
dressing with calcium hydroxide (89% success
rate)
• Pulpotomy: Vital pulp amputation by laser
therapy was a success because of the sterilization
and hemorrhage control properties of laser. In
1999, Jengicn Liu performed pulpotomy with
99% success at the six-month follow-up
• Pulpectomy: Er: YAG laser at 8 Hz and 2 w (Dim,
Kavo, Germany). Only straight and slightly
curved canals are indications for applying this
treatment. The laser tip must slide gently from
the apical portion to the coronal portion, while
pressing the laser tip to the root canal wall under
water spray
• Irrigation and sterilization: Pulsed Nd: YAG laser,
Er: YAG laser, and Er, Cr: YSGG laser are
recommended with 5.25% sodium chloride or
14% Ethylene-di-amine-tetra-acetic acid (EDTA)
at power of 2 to 5 w for 2 minutes
• Prevention of tooth fracture: Lased with pulsed Nd:
YAG, CO2 and 38% silver ammonium solution
• Prevention of microleakage of retrograde root canal
filling: Pulsed Nd: YAG and CO2 laser at 1 to 2 w
under air-cooling in combination with 38% silver
ammonium solution
• Removal of sealing materials and fractured instru-
ments in root canals: Nd: YAG, Er: YAG laser can
be used to remove temporary cavity materials made

of zinc oxide and gutta percha
• Laser treatment of periapical lesions of sinus tract:
pulsed Nd: YAG laser at 2 w and 20 pps is used;
fiber tip must be inserted into the tract and drawn
slowly from the root apex to the exit through the
sinus tract three or four times during one visit.
ADVANTAGES OF LASER
• Minimal damage to surrounding tissues
• Hemostatic effect by sealing blood vessels
• Precision in tissue destruction because of good
visualization of tissue planes
• Reduction of postoperative inflammation and
edema due to sealing of lymphatic vessels
• Suturing is not required for wound closing
• Sterilization of the wound due to reduction in
amount of microorganism exposed to laser
radiation.
DISADVANTAGES OF LASER
• Laser beam could injure the patient or operator
by direct beam or the reflected light
• General anesthesia is usually required for patient
undergoing laser treatment in the mouth
• Combustion hazard
• Loss of tactile feedback
• Removal of soft tissue overlying the bone can
damage the underlying bone.
• Specially trained person needed for operation
• High cost of the equipment.
Chapter 27
Forensic
Pedodontics
 Role of dentists in forensics
 Child abuse and neglect
 Bite marks in forensic dentistry
 Role of pedodontist in child abuse and
neglect
• Forensic odontology was defined by Pederson

(1969) as the branch of odontology, which deals
with the proper handling and examination of
dental evidence and with the proper examination
of dental evidence and with the proper evalu-
ation a presentation of dental findings in the
interest of justice
• Child abuse: Gil (1968) defined it as non-accidental
physical injury; minimal or fatal, inflicted upon
children by persons caring for them
• Battered baby: Selwyn (1985) defined this as a child
who shows clinical or radiographic evidence of
lesions that are frequently multiple and involve
mainly the head, long bones, soft tissues and that
cannot be unequivocally explained
• Neglected child: The child who shows evidence of
physical or mental ill health, primarily due to the
failure of the parent to provide adequately for
his needs
• Persecuted child: Is the one who shows evidence
of mental ill health caused by a deliberate
infliction of physical or psychological injury, that
is often continuous in nature
• Physical abuse: It is the most important type of
abuse, which includes injuries inflected on a
person under 18 years of age by a caretaker
• Sexual abuse: It may include child pornography;
rape, molestation and child prostitution but is not
limited to these factors
• Physical neglect: It can be defined as failure to care
for a child according to the accepted or appro-
priate standards
• Emotional abuse: It is defined as continual rejection
of a child by parents, caretakers or teachers
• Munchausen syndrome: Meadow (1982) described
this syndrome in children who are victims of
parentally induced or fabricated illness. It involves
children usually less than 6 years of age who are
too young to be aware of or be able to tell others
about this deception
Forensic Pedodontics 323
• Educational abuse: This exists when the parent or

caretaker permits chronic truancy by inte-
ntionally keeping the child home or fails to enroll
the child in the school
• Bite marks are defined as marks caused by teeth
alone or in combination with other oral parts.
ROLE OF DENTISTS IN FORENSICS

• Positive identification of living or deceased
persons using the unique traits and charac-
teristics of the teeth and jaws
• Teeth are the only method available to identify
the insults and consequences encountered at
death and during decomposition
• Comparative dental identification: It involves
comparison of ante-mortem and post-mortem
dental records to identify the body. Congenital
(anatomic) and acquired (treatment) charac-
teristics of the teeth are compared between the
ante-mortem and post-mortem records
• Reconstructive postmortem dental printing: To
determine the deceased person
• DNA profiling of oral tissues: Used when dental
treatments records are not available for
comparison. Forensic DNA profiling methods
uses the polymerase chain reaction (PCR)
techniques to amplify small amounts of
recovered DNA from pulp tissue.
CHILD ABUSE AND NEGLECT

• The 1st documented and reported case of child
abuse and neglect occurred in 1874 with a
child named Marry Ellen
• Caffey in 1946 described the classical features of
child abuse
• Henry Kempe in 1962 coined the term Battered
child syndrome
• Caffey in 1973 formulated the term ‘PITS
syndrome’ (Parent – Infant Traumatic Stress
Syndrome)
• Child abuse prevention and treatment act was

signed into law as Child Protection Act 1977
• Characteristics of child abuse: Unduly afraid or
passive child, delay in speech, repeated skin
injuries, undernourished, poor overall care and
more aggressive.
Diagnosis of Child Abuse and Neglect

• Eyewitness history
• Unexplained or implausible history
• Alleged self-inflicted history
• Delay in seeking medical care.
Examination of Child
• Display no eye contact
• Observe the child for lack of cleanliness,
evidence of malnutrition
• Overdressed children to cover signs of physical
abuse
• Marks of abuse should be suspected.
Distribution of Bruises
• Genital or inner thigh—Sexual abuse
• Cheeks—Slapping of child
• Earlobes—Pinching
• Upper lip or labial frenum or floor of mouth—
Forceful feeding
• Neck—Strangulation
• Circumferential bruises on ankles or wrists—
Placement of restraints
• Corners of mouth—Gagging of child.
Types of Marks
• Strap marks: 1 to 2 inches wide, sharp, bordered
rectangular marks
• Lash marks: Narrow, straight, edged, due to
thrashing with a tree branch
• Bite marks: Marks of teeth and surrounding
structures
• Human hand marks: Grab or squeeze marks on

upper arm or shoulder
• Slap marks: Parallel linear bruises at finger width
spacing
• Crescent shaped marks: Pinching by fingernails.
BITE MARKS IN FORENSIC DENTISTRY

• Definite marks: Tissue damage due to direct
application of pressure by the biting edge
• Amorous marks: Made in amorous circumstances,
slowly with the absence of movement between
teeth and tissue
• Aggressive marks: Evidence of scraping, tearing
or avulsion of tissues and may be difficult to
interpret
• A human bite mark is usually of elliptical or
ovoid pattern
• Simplest form of bite mark consists of tooth
marks produced by antagonist teeth
• An arch mark may indicate presence of 4 to 5
teeth marks reflecting the shape of their incisal
or occlusal surfaces
• The puncture marks of incisors are narrow
rectangular is shape
• Canines leave triangular shaped lesions
• Premolars leave ovoid marks
• Bite marks left by maxillary teeth tend to be more
diffuse, while those left by mandibular teeth are
more distinct
• Animal bite marks can be distinguished from
human bites on the basis of arch width (animals
tend to have longer, narrower bites), the width
of individual teeth (animals have narrower teeth)
and type of bite (animal bites usually result in
deep tissue penetration with accompanying
tearing and lacerations, whereas human bite
marks tend to leave more superficial lesions, like
bruising or abrasions)
• Class characteristics: These are commonly referred
to as the measurable features and shapes that
allow the forensic dentist to ascertain the biter
and to determine which teeth are present in the

pattern
• Individual characteristics: These are deviations
from standard class characteristics, e.g. rotated
tooth or a fractured tooth
• Description of bite marks: Demographic data, shape
and location of bite marks
• Evidence from victim: Photography, impressions,
salivary swabbing and tissue sampling
• Evidence from suspect: Xeroradiography, tran-
sillumination, videotape analysis, superimpo-
sition technique, scanning microscopy and DNA
fingerprinting
• Documenting the bite mark records: Eiplumenscence
microscopy—a dermatological technique
developed for evaluation of pigmented skin
lesions. This technique, through rendering the
stratum corneum translucent, aids in the visu-
alization and photographic documentation.
ROLE OF PEDODONTIST IN CHILD ABUSE

AND NEGLECT
• To observe and examine any suspicious evidence
that can be ascertained in office
• To record according to the law, any evidence
which may be helpful in the case
• To treat any dental injuries
• To establish and maintain a professional
therapeutic relationship with the family
• To transfer the child to a physician or hospital
for proper care.
Primary Level (General Population)

• Greater attention should be given towards
screening children at a higher risk of maltreat-
ment.
• Parents at risk for abusing children are frequently
screened and counseled
• Comprehensive evaluation of child and family
situation.
Secondary Level (High Risk Population)

• Interdisciplinary approach
• Enhance parenting capabilities to care for their
children.
Tertiary Level (Identified Population)

• Prevention is considered, as the goal is to prevent
recurrence of the condition
• Pedodontist should ensure that child is referred
to a designated child protection agency.
Index
A externalization 61
hand over mouth
AIDS 270 technique 62
oral and perioral hypnosis 63
findings in modeling 61
children 271 pre-appointment
sterilization 271 behavior
Air abrasion 188 modification 59
procedure 188 retraining 61
Apexification 236 visual imagery 61
Apexogenesis 235 voice control 59
contraindications 235 classification of child’s
indications 235 behavior in
procedure 236 dental office 57
Atraumatic restorative Frankel’s
treatment 191 classification 57
advantages 193 Lampshire’s
disadvantages 193 classification 58
position of work 192 Pinkham’s
classification 58
B Wright’s
classification 58
Band 102 conscious sedation 64
band construction 103 intramuscular
band material 102 sedation 65
classification 102 intravenous
loop bands 102 sedation 65
preformed oral sedation 65
seamless bands submucosal
102 sedation 65
tailored bands 102 dental office
Band and loop space environment
maintainer 104 56
Behavior and behavior maternal attitude 57
management objectives 56
53 pre-anesthetic
behavior management medication 63
techniques 59 role of dentist in
communication 59 child’s
contingency behavior 57
management treatment
61 immobilization
desensitization 60 63
Behavioral considerations Chronology of human

in pedodontic dentition 21
radiography permanent dentition
210 21
primary dentition 21
C Classification of oral
microorganisms
Caries vaccine 200 36
current status 201 gram-negative
delivery system 200 bacteria 37
routes to protective gram-positive bacteria
response 200 36
types 200 Cleft lip and palate 273
conjugate vaccines classification 275
200 Davis and Ritchie’s
recombinant classification
vaccines 200 275
subunit vaccines Fogh Andreason’s
200 classification
Child psychology 43 275
aims and objectives 44 Veau’s
classical conditioning classification
50 275
hierarchy of needs 51 clinical features 277
operant conditioning etiopathogenesis 274
50 management 277
psychoanalytical feeding 278
theory 44 nursing 278
psychosexual parental
stages of counseling 278
development Components of laser 313
44 energy or pumping
psychosocial theory source 313
46 lasing medium 313
social learning theory optical chamber 313
50 Congenital abnormalities
theory of cognitive in children 281
development classification 283
48
concrete operation
D
period 49
formal operational Dental caries 41
stage 49 deep dentinal caries
preoperational 41
period 49 pit and fissure 41
sensorimotor root surface 41
period 49 smooth surface 41
Index 331
Development of occlusion heterotypic cell-cell

69 adhesion 38
deciduous dentition homotypic cell-cell
period 70 adhesion 38
anterior teeth growth of oral flora
relationship 73 38
canine relationship survival of oral flora
73 39
distal step terminal Diabetes mellitus 266
plane 73 dental management
flush terminal 266
plane 71 Diagnosis of caries 194
mesial step dental floss 194
terminal plane diagnodent 198
72 digital imaging
non-spaced fiberoptic
dentition 71 transillumination
physiologic spaces 195
70 dyes 195
primate spaces 70 electrical conductance
terminal plane 71 measurement
gum pads 70 197
mixed dentition period endoscopically viewed
74 filtered
emergence of 1st fluorescence
permanent 196
molars 74 fiberoptic
exchange of transillumination
incisors 75 195
intertransitional intraoral television
period 75 camera 196
second transitional magnetic resonance
period 76 micro-imaging
self-correcting (MRMI) 197
anomalies 77 microradiography 197
during deciduous optical coherence
dentition tomography
period 78 199
during mixed photo stimulable
dentition phosphor
period 78 radiography
during predentate 197
period 77 quantitative laser
Development of oral flora fluorescence
37 198
adhesion of oral flora radiographs 195
37 scanning acoustic
cell- substratum microscope
adhesion 37 196
tactile examination nondirective

with a probe counseling 28
194 nutrient score 29
ultrasound caries sweet score 29
detector 196 dietary goals 30
ultraviolet illumination changes in food
195
selection and
videoscope 196
preparation 30
visual inspection 194
implementation 30
white light
fluorescence food group guides 26
196 bread-cereal group
Diagnosis of dental caries 27
316 fats, sweets and
diagnodent 316 alcohol group
laser induced 28
fluorescence meat, poultry, fish
316 and beans
optical coherence group 27
tomography milk-cheese group
316 27
quantitative laser vegetable-fruit
fluorescence group 27
316
Differences between
Terahertz pulse
deciduous and
imaging 316
Diet and dental caries 158 permanent
experimental caries in teeth 179
man 161 Direct pulp capping 223
hereditary fructose contraindications 225
intolerance 161 histological changes
Hopewood house after pulp
study 159 capping 225
Turku study 161 indications 225
Vipeholm study 160 technique 226
Diet and nutrition 25 Distal shoe space
diet counseling 28 maintainer 108
develop and Down’s syndrome 287
implement a Drug dosages 204
plan of action
Augsberger’s rule 205
29
Bastedo’s rule 204
directive
counseling 28 Body surface area 205
evaluate and Catzel’s rule 204
interpret Clark’s rule 204
information 29 Cowling’s rule 204
food score 29 Dilling’s rule 204
gather information Fried’s rule 204
28 Young’s rule 204
Index 333
E F
Early childhood caries 165 Factors affecting growth
etiopathogenesis 169 and
acidic fruit drinks development 7
173 birth order 8
bovine milk 172 climate and seasonal
dental knowledge effect 7
174 extracranial and
dental plaque 169 intracranial
fluorides 173 pressure 7
frequency of genetic factors 7
consumption growth factors 7
171 hormones 7
general illness 7
cariogenicity of maternal factors 7
sugars 171
muscular function 7
human milk 172
nutrition 7
immunological
physiological
factors 173
disturbance 8
infant feeding
patterns 169 physique 8
Mutans race 7
streptococci secular trend 8
169 socio-economic factors
oral clearance of 7
carbohydrates Factors affecting planning
171 for space
race and ethnicity maintainers 98
174 abnormal oral habits
salivary factors 170 99
socioeconomic amount of bone
status 174 coverage over
stress 174 the tooth 99
tooth brushing 171 amount of space loss
tooth maturation 98
and defects 173 arch length adequacy
stages 166 99
damaged carious available space 99
stage 167 delayed eruption of
deep lesion 167
permanent
initial reversible
teeth 99
stage 166
dental age of patient
traumatic stage
168 99
terminologies 166 eruption status of the
Endocarditis prophylaxis adjacent teeth
for dental 99
procedures 271 eruption status of the
Extensive or deep caries succedaneous
209 tooth 99
miscellaneous factors improved

99 crystallinity
time elapsed since 136
tooth loss 98 lowering free
Factors contributing for surface energy
space closure 137
98 suppressing the
effect of position of flora 137
centre of void theory 137
rotation of milk fluoridation 140
mandible 98 recent advances in
inclination of long axis fluoride 148
of permanent bio-adhesive
molars 98 devices 149
influence of buccal co-polymer
musculature membrane
98 beads 148
path of least resistance fluoride glass
98 device 148
Fixed space maintainers salt fluoridation 139
101 school water
advantages 101 fluoridation
disadvantages 102 139
Fluorides 135 shoe leather survey
defluoridation 147 138
anion exchange topical fluorides 140
resins 147 acidulated
defluoron-1 147 phosphate
defluoron-2 148 fluoride 142
dietry fluoride amine fluoride 143
supplements sodium fluoride
140 140
fluoride dentifrices stannous fluoride
144 141
fluoride toxicity 145 stannous
acute toxicity 145 hexafluoro-
chronic toxicity zirconate 143
145 water fluoridation 138
fluoride varnish 143 Forensic pedodontics 321
mechanism of action bite marks in forensic
of fluoride 136 dentistry 325
acid solubility 137 child abuse and
alteration in tooth neglect 323
morphology diagnosis of child
137 abuse and
antibacterial action neglect 324
137 distribution of
desorption of bruises 324
protein and examination of
bacteria 137 child 324
Index 335
types of marks ataxia 259

324 athetosis 259
role of dentists in dental
forensics 323 management
role of pedodontics in 260
child abuse and mixed 260
neglect 326 rigidity 260
primary level 326 spastic 256
secondary level tremors 260
327 childhood autism 261
tertiary level 327 dental
Functions of pulp 215 management
defensive 215 261
formative 215 classification 252
inductive 215 hearing loss 263
nutritive 215 dental
protective 215 management
263
mental retardation
G
255
Growth assessment dental treatment
parameters 11 256
chronological age 11 role of the dental
dental age 11 assistant 252
skeletal age 11 visual impairment 261
somatotypic age 11 dental
Growth prediction 13 management
cranial base prediction 262
13 Hemophilia 267
mandibular growth antifibrinolytics 269
prediction 13 dental management
maxillary growth 268
prediction 14 local anesthesia 268
Growth spurts 8 oral surgery 269
adolescent growth prevention of dental
spurt 8 disease 268
Growth trends 9 pulpal therapy 268
ANB angle 9 restorative procedures
type A 9 268
type B 9 Histopathology of
type C 9 dentinal caries
157
zone of bacterial
H
invasion 157
Handicapped child 251 zone of decomposed
American Academy of dentin 157
Pediatric zone of
Dentistry 252 demineralization
cerebral palsy 256 157
zone of dentinal emission modes 312

sclerosis 157 flexible hollow wave-
zone of fatty guide 312
degeneration glass fiber optic cable
157 312
Histopathology of enamel Laser interaction with
caries 156 biologic tissues
body of lesion 156 313
dark zone 156 absorption 314
surface zone 157 photochemical
translucent zone 156 interactions
History of dental 313
radiology 208 photoelectrical
Hypohidrotic ectodermal interactions
dysplasia 314
syndrome 285
photomechanical
interactions
I 314
photothermal
Idiopathic thrombocyto-
interactions
penic purpura
266 314
dental management reflection 314
267 scattering 314
Indications for pedodontic transmission 314
radiography Lasers in endodontics 318
208 diagnosis of dental
Indirect pulp capping 221 pulp 318
contraindications 222 direct pulp capping
indications 221 318
Integrated model for indirect pulp capping
prevention of 318
early childhood irrigation and
caries 176 sterilization
Isolation 184 318
cotton rolls 184 prevention of tooth
drugs 184 fracture 318
saliva ejectors 184 pulpectomy 318
throat screens 184 pulpotomy 318
Leukemia 269
K dental management
270
Klinefelter’s syndrome Lingual arch space
286 maintainer 105
L M
Laser delivery systems Marfan’s syndrome 284
312 Matrix 182
Index 337
Microbiota of oral cavity nail biting 93

39 thumb sucking 81
cheeks 39 classification 82
gingival crevice 40 clinical features 83
lips 39 etiology 83
palate 39 management 83
saliva 39 tongue thrusting 85
sub-gingival plaque classification 86
40 clinical features 87
supra-gingival plaque diagnosis 87
40 etiology 86
teeth 40 treatment
tongue 39 considerations
Model for high caries risk 88
patients 176
Modifications of cavity P
preparation in
primary teeth Pattern of tooth
181 movement 16
eruptive phase 17
post-eruptive phase
N 18
Nance palatal arch space pre-eruptive phase 16
maintainer 106 Pit and fissure sealants
Neurofibromatosis 125
syndrome 284 clinical technique 128
acid etching of
tooth 129
O application of
Oral habits 79 bonding agent
bruxism 91 131
clinical enzyme inhibition
manifestations 137
91 evaluate 132
etiology 91 isolation 128
treatment 91 recall 133
classification 81 rinsing and drying
lip biting 92 130
clinical sealant application
manifestations 131
92 sealant curing 132
treatment 92 tooth preparation
mouth breathing 88 129
classification 89 verify occlusion
clinical features 90 132
diagnosis 89 contraindications 128
etiology 89 indications 128
treatment 90 types 127
based on color 127 quaternary

based on curing ammonium
127 compounds
based on filler 122
content 127 sanguinarine 123
based on Prader-Willi syndrome
generations 286
127 Prevention of enamel and
Plaque control in children dental caries
111 317
chlorhexidine 121 Prophylactic regimens for
dental
antibacterial mode
procedures
of action 121
272
anti-plaque mode
Pulpal diagnosis 215
of action 122
anesthetic testing 217
indication for dual wavelength
chlorhexidine spectrometry
use 122 218
classification of electric pulp testing
chemotherapeutic 217
anti-plaque exposure site 216
agents 119
Hughes Probeye
dental floss 116
camera 218
dentifrices 114
laser Doppler
disclosing solution 113
flowmetry 218
essential oils 122
liquid crystal testing
guidelines for home
oral hygiene 218
123 mobility 215
adolescent 124 palpation 216
early school age percussion 216
child 124 photoplethys-
infant 123 mography 218
pre-adolescent 124 physiometric tests 217
prenatal pulp hemogram 218
counseling 123 pulse oximetry 219
toddler 123 radiographs 216
mouthwash 120 test cavity 217
anodynes 120 thermal tests 216
antimicrobial thermography 218
agents 121 visual and tactile
astringents 120 examination
buffering agents 215
120 Pulpectomy 231
deodorizing agents contraindications 232
121 indications 232
oxygenating multi-visit pulpectomy
agents 120 233
Index 339
single visit pulpe- rubber dam kit 185

ctomy 233 dental floss 186
Pulpotomy 226 lubricant 186
classification 227 retainers or clamps
non-vital 185
pulpotomy rubber dam frame
technique 228 186
vital pulpotomy rubber dam
technique 227 napkin 186
contraindications 228 rubber dam punch
Cvek’s pulpotomy 186
229 rubber dam
electrosurgical retaining
pulpotomy forceps 186
230 rubber dam sheets
formocresol 185
pulpotomy
228 S
glutaraldehyde
pulpotomy Scammon’s curves for
230 growth 10
indications 228 general tissue 11
laser pulpotomy 230 genital tissue 11
mortal pulpotomy lymphoid tissue 11
230 neural tissue 11
Self-injurious habits of
child 93
R
Shedding of deciduous
Radiographic protocol teeth 19
209 Space maintainers 96
Radiovisiography 210 classification 97
Role of saliva in dental according to
caries 158 Hinrichsen 98
Root canal instruments in according to
pediatric Hitchcock 97
endodontics according to
219 Raymond C
barbed broach 220 thurow 97
H-file (hedstroem file) contraindications 97
220 indications 96
K-flex file 220 requirements 96
nickel – titanium root Space maintenance in
canal files 220 mixed
safety H-files 220 dentition 100
smooth broach 220 Space maintenance in
Rubber dam 184 primary
advantages 184 dentition 100
contraindications 185 Space regainers 110
disadvantages 185 Gerber’s appliance 110
Hotz lingual arch 110 eruption hematoma

Jaffe’s appliance 110 22
Kings appliance 110 eruption sequestrum
removable appliance 23
110 natal and neonatal
Stainless steel crowns 241 teeth 23
classification 243 Theories of dental caries
according to 152
company chemical theory 152
names 243 complexing and
according to com- phosphorylation
position 243 theory 154
according to humoral theory 152
occlusal key concept 154
anatomy 243 legend of the work
according to 152
trimming 243 Miller’s chemoparasitic
clinical procedure 243 theory 153
adjacent stainless Newburn’s concept
steel crowns 155
247 parasitic theory 152
armamentarium proteolysis – chelation
243 theory 153
crown extension proteolytic theory 153
for deep sulfatase theory 154
proximal vital theory 152
lesions 249 Theories of tooth eruption
crown preparation 19
244 blood vessel thrust
oversized crown theory 20
247 bony remodeling 20
stainless steel cellular proliferation
crown with 20
class II dental follicle theory
amalgam 20
restoration 247 foreign body theory
undersized crown 20
248 growth of periodontal
complications 249 tissues 19
crown tilt 249 hormonal theory 20
inhalation or periodontal ligament
ingestion of contraction 20
crown 250 pressure from
interproximal muscular
ledge 249 action 19
poor margins 249 pulpal constriction 19
resorption of the
T alveolar crest
20
Teething problems 22 root elongation theory
ectopic eruption 23 19
Index 341
vascularity 20 circular enamel

Transpalatal arch 107 hypoplasia 307
Traumatic injuries in enamel fractures 296
children 289 enamel infarctions 296
avulsion 302 examination and
classification 290 diagnosis 294
Bennett’s extent of trauma 290
classification extrusive luxation 301
293 intrusive luxation 301
Rabinowitch’s response of oral
classification tissues to
290 trauma 307
Ulfon’s cervical loop 308
classification dental follicle 307
293 dentin – pulp
WHO classification complex 308
293 enamel and
complicated crown enamel matrix
fractures 297 308
concussion 300 gingival complex
crown-root fractures 308
298 Hertwig’s
effect of traumatic epithelial root
injuries of
sheath 308
developing
inner enamel
dentition 306
epithelium 308
crown
periodontal
dilacerations
ligament 308
307
reduced enamel
lateral root
epithelium 308
angulation 307
partial or complete root fractures 298
arrest of root subluxation 300
formation 307 trauma to primary
root duplication dentition 308
307 uncomplicated crown
sequestration of fractures 297
permanent vertical root fractures
tooth germs 299
307 Treacher Collins
vestibular root syndrome 285
angulation 307 Turner’s syndrome 285
white or yellow Types of laser 315
brown hard lasers 315
discoloration of soft lasers 315
enamel 306
white or yellow W
brown
discoloration of Wedges 183
enamel with William’s syndrome 287

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Pocket Book

Nikhil Marwah BDS, MDS

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD.

This is a sincere effort by the author to cover the entire

A textbook can never be substituted, but in the fast

• Pedodontics is the art and science and that branch

• Rooting reflex: If the cheek of baby is touched he

MIDDLE YEAR CHILD

Fig. 2.1: Cephalocaudal gradient of growth

and limbs have grown faster than head and face.

FACTORS AFFECTING GROWTH AND

• Physique: Tall women mature at a later age as

Adolescent Growth Spurt

Stage 2: Secondary sexual characteristics begin to

more rapidly. The ANB angle is seen to be

SCAMMON’S CURVES FOR GROWTH

Fig. 2.2: Scammon’s growth curve

• Lymphoid tissue: It increases rapidly in late

GROWTH ASSESSMENT PARAMETERS

Skeletal Age (Fig. 2.3)

Fig. 2.3: Skeletal age

• Skeletal age is more highly correlated with the

GROWTH PREDICTION (FIG. 2.4)

Fig. 2.4: Growth prediction

Cranial Base Prediction

Mandibular Growth Prediction

Maxillary Growth Prediction

• Maury, Massler and Schour (1941) defined

ANATOMIC STAGES IN THE ERUPTION

PATTERN OF TOOTH MOVEMENT

Fig. 3.1: Gubernacular cord

Fig. 3.2: Eruption mechanism

SHEDDING OF DECIDUOUS TEETH

THEORIES OF TOOTH ERUPTION

alveolar process might serve to squeeze the crown

CHRONOLOGY OF HUMAN DENTITION

Central 4 month 4 month 7½ month 1½ year

Fig. 3.3: Eruption hematoma

• Develops as a result of trauma to the soft tissue

Natal and Neonatal Teeth (Fig. 3.4)

Fig. 3.4: Isolated natal tooth

• Attributed to superficial positioning of the

• A balanced diet is one in which nutrients from

FOOD GROUP GUIDES (FIG. 4.1)

Fig. 4.1: Food guide pyramid

• Vegetable-Fruit group contribute vitamins A and C;

• Fats, sweets and alcohol group provide mostly calories

• Evaluate and interpret information: Relative

Assessment of Dental Health Diet Score

72-96 Excellent Counseling not required

Changes in Food Selection and Preparation

Implementation of Dietary Goals

B1 Thiamin • Co-enzyme Wet, dry and 1 mg/day Cereals, meat, legumes,

Vitamin Name Functions Deficiency RDA Food sources

• Co-enzyme anemia, angular vegetables, nuts, orange

Vitamin Name Functions Deficiency RDA Food sources

• Metabolism of amino acids

• The oral cavity of the newborn child is sterile until

DEVELOPMENT OF ORAL FLORA

external surfaces of both organism and the

Growth of Oral Flora

Survival of Oral Flora

MICROBIOTA OF ORAL CAVITY