Pediatric Dentistry-1 PDF

3 02 Cairo University Faculty of Dentistry Pediatric Dentistry and Dental Public Health Department 2/2 Pediatric Dentistry 2 20  3 02...

3 02 Cairo University Faculty of Dentistry Pediatric Dentistry and Dental Public Health Department 2/2 Pediatric Dentistry 2 20  3 02 Dedication 2/2 To the memory of Professor Doctor Nawal Soliman, for her outstanding achievements and efforts in the field of Pediatric Dentistry; to whom we extend our deepest gratitude, love and respect. Department Staff members October 2021 2 20 Index  Intended learning outcomes 1 Introduction 3 3 Morphological differences between primary and permanent teeth 9 Normal occlusion in children 13 Management of child behavior 16 I- Psychological management 17 02 II-Pharmacological management 30 The child’s first dental visit 38 Local anesthesia for dental child patient 43 Restoration of primary teeth 47 Management of deep carious lesions in children 60 Rampant caries 78 Early childhood caries 80 Stainless steel crown 85 2/2 Extraction of teeth in children 89 Management of traumatic dental injuries in children 93 Management of space maintenance problems in children 108 Gingival and periodontal problems in children 122 Dental management of handicapped children 137 Nutrition and dental health 153 Child Abuse and Neglect 167 2 20  Intended Learning Outcomes for Pediatric Dentistry a- Knowledge and understanding: 3 a1- Recognize the aims and benefits of Pediatric dentistry for child, dentist and nation. a2- State the importance of primary teeth. a3-Describe the factors that influence the child behavior in dental office and the 02 different psychological management approaches. a4-Describe the need for and types of premedication and their application in clinical practice (pharmacological management). a5-Recognize and illustrate the morphological differences between primary and permanent dentition and their significance in clinical practice. a6-Describe the normal occlusion of pediatric patients at different ages of life. a7- Recognize the different methods and techniques of pain control for children. a8- Identify the different restorative techniques and materials for children. a9- Describe the different types of pulp therapy. 2/2 a10- Recognize the etiology, clinical picture and management of early childhood caries. a11-Classify traumatic injuries and select the appropriate management for each class. a12-Describe different methods of space analysis and state the possible management for different cases of space problems in both primary and mixed dentitions. a13-Memorize the different types of periodontal diseases and their differential diagnosis. a14-Recognize different treatment modalities for handicapped patients. a15-Recognize the effect of nutrition on dental health. b- Intellectual skills: 2 b1- Make decisions regarding management of deep caries in both primary and permanent dentitions. b2- Integrate personal, medical and dental history together with clinical and radiographic findings to manage both immediate and delayed effects of traumatic injuries. 20 c- Professional and practical skills: c1- Clinically treat uncomplicated cases regarding cavity preparation and pulp therapy c2- Differentiate clinically between primary and permanent teeth. c3- Perform appropriate cavity preparations and pulp therapy procedures in artificial and extracted teeth. 1  d- General and transferable skills: d1- Communicate with children and their families using appropriate communication skills. 3 d2- Show merciful attitude towards children& their parents and respectful attitude towards dental staff. d3- Adhere to health and safety regulations as they greatly affect dental practice and environment. 02 2 2/2 20 2  INTRODUCTION By the end of this chapter, the student must be able to: 3 1- Define pediatric dentistry. 2- List the aims and benefits of pediatric dentistry. 3- List the importance of primary teeth. 02 4- Recognize the eruption of primary teeth and teething problems. 5- Identify the chronology of primary and permanent teeth as well as the sequence of eruption for both dentitions. 2 2/2 20 3  INTRODUCTION Pediatric dentistry is that branch of dental science, which deals with the 3 guidance of the primary and young permanent dentition in growth and development as well as the prevention and treatment of pathologic oral conditions, which may occur during childhood. 02 According to the American Association of Pediatric Dentistry: Pediatric Dentistry is an age defined specialty that provides preventive and therapeutic care for infants and children through adolescence including those with special health care needs. Scope 1. It encompasses a variety of disciplines, techniques, procedures and skills that share common basis with other specialties but are modified to the special needs of children. 2. Age specific not technique specific. 2/2 3. Deals with patients in their formative years. 4. Fulfill the needs of special children. 5. Its goal is mainly prevention. Aims and benefits of pediatric dentistry I- For the child patient: 1- The child will have a better masticatory apparatus that provides good masticatory function, which is essential for the child's optimal growth, better health and better look. Any defect in the masticatory apparatus such as dental caries, premature loss of teeth or malocclusion will result in impaired masticatory function. This in turn may lead to malnutrition and subnormal general growth. 2 2- The child will have fewer dental diseases in his adulthood as prevention is the most important aim of pediatric dentistry. 3- He will have less psychological trauma from dentistry as he is properly managed and treated. 4- From the economical point of view, pediatric dentistry is far less expensive 20 to the individual because it reduces much of the dental work later in his adulthood. II- For the dentist: He will learn more skills and abilities in the different fields of dentistry as well as learning many techniques, which are unique to children. 4  III- For the nation: Pediatric dentistry helps to ensure optimal state of growth and development 3 for the child; therefore, it will provide the nation with better healthy citizens. Importance of primary teeth: All the primary teeth are in use from age 2 to 7 years; some of the primary teeth are in use from age 2 till 12 years. 02 1- Preparation of the child's food for digestion and assimilation during active periods of growth and development. 2- Maintenance of space in the dental arches for the permanent teeth. With the premature loss of the primary teeth, severe dental irregularities may develop. 3- Development of speech: Ability to use the teeth for pronunciation is 2/2 acquired with the aid of the primary dentition. Early and accidental loss of the primary anterior teeth may lead to difficulty in pronouncing the sounds f, v, s, z and th. 4- Cosmetic function: Improving the appearance of the child. If a child accidentally loses his primary anterior teeth, his appearance will be affected, he will find himself different from the other children in his same age and accordingly this affects him from the psychological point of view. Eruption of primary teeth Definition: 2 Tooth eruption is the movement of a tooth from its site of development (bony crypt) within the alveolar bone to its functional position in the oral cavity. - The primary teeth begin to form at 7 w.i.u. Calcification of the central 20 incisor starts at 4 m.i.u. The sequence of calcification of the primary teeth is central incisors, first molars, lateral incisors, canines and second molars. - At the time of birth, there are no functioning teeth in the mouth, but radiographs of the infant's jaws show calcification of: * Five-sixths of the crown of the central incisors. 5  * Two-thirds of the crown of the lateral incisors. * The incisal tip of the canine. * Isolated cusps of the first and second primary molars. 3 * Occasionally calcification of the first permanent molar and the incisal edge of the permanent central incisor. Teething in children: Eruption of the primary dentition begins in the fifth or sixth month of a child's life. Eruption of primary teeth is preceded by increased salivation. Teething is a 02 normal physiologic process. It doesn’t increase the incidence of fever, infection or diarrhea but it causes restlessness and increased thumb sucking or gum rubbing. The signs of teething may be manifested locally and/or systemically: Local: - Redness or swelling of gingiva over erupting tooth. - Patches of erythema on the cheeks. -Child wants to put the hands or fingers into the mouth - Increased salivation and drooling. Systemic: - High fever. 2/2 - General irritability and crying. - Loss of appetite. - Diarrhea. - Increased thirst. -Circumoral rash. Most studies refer to these symptoms (fever and diarrhea) as coincidental with teething. Treatment: Local: 2 - Teething toys:. A variety of teething rings rattles and keys are available.. The baby may obtain relief from soreness by the pressure of biting.. Only well-made and smooth toys should be used. 20 -Teething foods:. Hard rusk or biscuit preparations are used in the same way as teething toys.. They should contain no sugar. -Topical medications:. Various types of ointment and gel are available for topical application to gingiva. Common ingredients include Salicylates, which have anti-inflammatory, analgesic and anti-pyretic effects. e.g.: Dentinox. 6  Systemic: Analgesics: Sugar free - paracetamol preparations 3 Dosage: up to 1 year: 5ml at bedtime 1-5 years: 10 ml at bedtime. Do not give any injections such as vitamin D and calcium to enhance teething because these prescriptions if not needed may damage the kidneys. Systemic conditions influencing eruption of teeth: 02 There are some conditions that cause delay in development and eruption of teeth as: - Down’s syndrome. - Cleido-cranial dysplasia. - Hypothyroidism. - Hypopituitarism. Chronology of primary and permanent dentition 2/2 Chronology of primary dentition: Maxillary A B C D E primary teeth 7-8 M 8-9 M 18 M 14 M 24 M Mandibular A B C D E primary teeth 6-7 M 7-8 M 16 M 12 M 20 M Sequence of eruption: A-B-D-C-E ▪ Mandibular teeth erupt earlier than maxillary teeth by 1-2 months. ▪ Teeth of girls erupt earlier than teeth of boys. ▪ Roots of primary teeth are completely formed 1-1.5 yrs following eruption. Roots of primary teeth persist without resorption for 1.5 2 years. ▪ Beginning of root resorption in primary teeth occurs after complete crown calcification of their permanent successors. ▪ Crowns of permanent teeth are completely formed 3 years before 20 eruption. ▪ Shedding of deciduous teeth coincides with dates of eruption of their permanent successors (at this stage 2/3 of the root of the permanent successor is formed). ▪ Roots of permanent teeth are completely formed 3 years following eruption. ▪ In some children deciduous teeth may not erupt till the age of about 12 7  months. This could be considered normal if the child is free from any hereditary or systemic diseases. 3 Eruption dates of permanent teeth: Maxillary teeth Mandibular teeth 1 7-8 years 1 6-7 years 02 2 8-9 years 2 7-8 years 3 11-12 years 3 9-10 years 4 10-11 years 4 10-11 years 5 10-12 years 5 11-12 years 6 6 years 6 6 years 7 12-13 years 7 12-13 years 8 18-21 years 8 17-21 years Sequence of eruption of maxillary teeth: 2/2 6-1-2-4-5-3-7-8 Sequence of eruption of mandibular teeth: 6-1-2-3-4-5-7-8 2 20 8  MORPHOLOGICAL DIFFERENCES BETWEEN PRIMARY AND PERMANENT TEETH 3 By the end of this chapter, the student must be able to: 1- Recognize and illustrate the morphological differences between primary and permanent teeth. 02 2- Define the clinical significance in cavity preparation for both primary and permanent dentitions. 2 2/2 20 9  MORPHOLOGICAL DIFFERENCES BETWEEN PRIMARY AND PERMANENT TEETH 3 There are twenty primary teeth: a central incisor, a lateral incisor, a canine, a first molar and a second molar in each quadrant. These teeth are exfoliated and replaced by the permanent central and lateral incisors, canines and first and second premolars. 02 Considerable morphological differences exist between the primary and permanent teeth both in size and color of the teeth and in their general external and internal morphology. I- Size: 1- Primary teeth are smaller in all dimensions than the corresponding permanent teeth. 2- The mesiodistal width of primary incisors and canines is less than their 2/2 permanent successors, while the mesiodistal width of primary molars is wider than their successors (premolars). 3- The thickness of enamel and dentine in primary teeth is approximately half its thickness in permanent teeth. Therefore, an occlusal cavity must be shallower than in permanent teeth to avoid pulp exposures. II- Color: The color of primary teeth is bluish white, while that of permanent teeth ranges from grayish white to yellowish white. III- Crown: 2 1- The crowns of primary teeth are wider in their mesiodistal diameter in relation to their cervico-occlusal height than those of permanent teeth. This gives the primary anterior teeth a cup shaped appearance and the primary molars a squat shape. 20 2- The crowns of primary molars are bulbous due to their markedly constricted necks and pronounced cervical ridges on the buccal aspect especially in the first primary molar. This bulbous shape and the pronounced cervical bulge in primary molars make it difficult to apply the matrix band. The constriction at the neck calls for special care in the placement of the gingival seat during class II cavity preparation. 10  3- The buccal and lingual surfaces of primary molars, converge sharply toward the occlusal surface, forming a narrow occlusal table. This characteristic is especially evident in the first primary molar, making the isthmus portion of a class II 3 amalgam filling very narrow and liable to fracture. 4- The buccal and lingual inclines in primary molars are relatively flatter above the cervical bulge than those in permanent molars. 02 5- The enamel cap in primary teeth is thinner and has nearly a constant depth throughout the crown. 6- The enamel cap in primary molars ends abruptly at the cementoenamel junction, while in permanent teeth it tapers off to a feather edge. 7- The enamel rods at the cervix slope occlusally in primary teeth instead of being oriented gingivally as in permanent teeth. This characteristic does not necessitate beveling of the gingival floor in class II cavity preparations in primary molars. 2/2 8- The interproximal contact between primary molars is not a small round area as in permanent molars but tends to be a large ellipsoid and flattened area. IV- Roots: 1- The roots of the primary anterior teeth are narrower mesiodistally than permanent anterior. 2- The roots of primary teeth are longer and more slender in comparison to the crown size than in permanent teeth. 3- The roots of primary molars flare out near the cervix leaving no root trunk. 2 4- The roots of primary molars diverge and bulge as they reach the apex to envelope the underlying permanent teeth buds. Special care must be employed in the extraction of primary molars with unresorbed root to avoid the permanent buds 20 being removed at the same time. V- Pulp: 1- The pulp outline follows the dentinoenamel junction more closely in primary than in permanent teeth. 11  2- The pulp horns are higher in primary molars, especially the mesial pulp horn. The pulp chambers are proportionately larger than permanent teeth, hence there is less tooth structure protecting the pulp in primary teeth which requires special 3 attention when establishing the depth of cavities in primary teeth. 3- The root canals of primary molars show more lateral branchings and apical ramifications than permanent molars. This characteristic makes it impossible to remove all pulp tissue in the root canals during root canal therapy. 02 4- The apical foramina in primary teeth are relatively wider than in permanent teeth. 2 2/2 20 12  NORMAL OCCLUSION IN CHILDREN By the end of this chapter, the student must be able to: 3 1- Describe the normal occlusion of pediatric patients at different ages of life. 02 2 2/2 20 13  NORMAL OCCLUSION IN CHILDREN Occlusion at 3 years of age: 3 1- The relationship between the distal surfaces of opposing second primary molars may be one of the following: A- Straight or flush terminal plane: In which the distal surfaces of opposing second primary molars are in the same coronal plane. 02 B- Mesial step terminal plane: In which the distal surface of the lower second primary molar is mesial to the distal surface of the maxillary second primary molar. C- Distal step terminal plane: In which the distal surface of the lower second primary molar is distal to the distal surface of the maxillary second primary molar. The flush terminal plane is most frequently seen at three years of age. 2/2 2- Presence of spacing between primary teeth: a. Incisor spacing to accommodate for the larger size of permanent incisors. b. Primate spaces which are mesial to upper C and distal to lower C. These spaces are greater in the mandible than the maxilla. c. Spacing between primary molars. 3- Normal overbite. 2 Occlusion at 6 years of age: 1- At the age of 6 years, spacing persists between the primary anterior teeth. 2- As a result of attrition and increase in width of maxilla compared to mandible, 20 the mandible assumes a forward position to maxilla i.e., edge-to-edge relationship. 3- At the age of 6 years, a mesial step terminal plane is present where the distal surface of lower E is about 2 mm mesial to that of upper E. This is due to: A. Bodily forward movement of mandible to maxilla. B. Closure of spacing between primary teeth especially the primate spaces which are greater in the mandible than maxilla as a result of eruption of first 14  permanent molars at 6 years of age. This allows the lower E to move more forward than upper E producing a mesial step terminal plane. 4- At 6 years of age the first permanent molars are clinically visible and may 3 assume one of the following relations: a- Class I molar relationship: mesiobuccal cusp of upper 6 is at or near the buccal groove of lower 6. b- Class II molar relationship: mesiobuccal cusp of upper 6 is mesial to buccal groove of lower 6. 02 c- Class III molar relationship: mesiobuccal cusp of upper 6 is distal to buccal groove of lower 6. The most desirable occlusion in the permanent dentition is Class I interdigitation. Occlusion at 8 to 9 years: 1. With the eruption of the upper and lower permanent incisors there is an increase in depth of overbite due to their greater height in comparison to the reduced vertical dimension in the primary molar area. This is corrected by the eruption of premolars. 2/2 2. Presence of diastema between upper permanent central incisors, which is normal for this age (ugly duckling stage). This is corrected by the eruption of the permanent canines when pressure exerted by those teeth is transferred from the roots to the crowns of permanent incisors. Occlusion at 10 to12 years: 1- Diastema between upper central incisors is closed by the eruption of permanent canines. 2- With the eruption of premolars, the vertical dimension is increased which corrects the deep overbite. 3- Closure of Leeway spaces (difference between combined mesiodistal width 2 of C, D & E (larger) and 3, 4 &5 (smaller). This space is greater in the mandible (1.7 mm) than in maxilla (0.9 mm) which allows the lower first permanent molar to move more forward than the upper 20 first permanent molar and assume a normal relationship. 15  MANAGEMENT OF CHILD BEHAVIOUR By the end of this chapter, the student must be able to: 3 1- Define and classify child behaviour management. 2- Identify the difference between treating children and adults. 3- Recognize the psychological management of child behaviour. 02 4- Identify different types of fear. 5- Classify child behaviour. 6- Describe the different techniques for behaviour management. 7- Recognize the pharmacological management of child behaviour. 2 2/2 20 16  MANAGEMENT OF CHILD BEHAVIOUR The successful outcome of all procedures in Pediatric dentistry depends on 3 the ability of the dentist to manage the child. Behaviour Management: it is the means by which the dental health team effectively performs treatment for a child and at the same time instills a positive dental attitude in the child patient towards future dental treatment. 02 Classification of behaviour management: I – Psychological management (nonpharmacological). II – Pharmacological management (sedation and general anesthesia). I-PSYCHOLOGICAL MANAGEMENT OF CHILD BEHAVIOUR (NON-PHARMACOLOGICAL) Why does treatment of children differ from treatment of adults? 2/2 1- The child is either faced with a new situation that he has no experience with or has had an unpleasant past dental experience. 2- Treatment of adults involves a one-to-one relationship (dentist-patient relationship), while treatment of a child involves a one to two relationship (dentist-child and parent relationship). So, the child’s behaviour could be influenced by his parents’ attitudes, fear and anxiety. Child patient 2 Parent Dentist 20 Pediatric patient triangle 17  Factors which influence child behaviour in the dental office: a- Main factors. b- Co-factors. 3 a- Main Factors 1- Psychological growth of the child: 02 A child grows physically as well as emotionally. A dentist who is aware of children’s abilities at various ages can use this information to communicate at the child’s level. * The Newborn (before 2 years): - Has a fairly elaborate (uncomplicated) emotional equipment. - Has the ability to express fear, anger and joy. - Grows emotionally by exploring the boundaries of the environment around him. 2/2 * Two years old: - Will cry when put into a new situation e.g., dental situation. - As long as he cries quietly the dentist can continue his work. - Has a short attention span. - Too young to be reached with words, so → Way of communication is emotional (Show gentleness and kindness). Sometimes reached through his mother. - Fears sudden movements, so → Work skillfully with no jerky movements (the dental chair must be moved slowly). - He depends on his mother, so → No need to separate them. He can stay in his mother’s lap. * Three years old (Me-too-age): 2 - Enters a period of semi-independence (can do some things for himself). - Can form sentences, so → can be reached by words. - Likes to be praised. - Likes to please (to have a reward for his good behaviour). 20 - Likes to imitate (me-too-age). - Feels more secure with parent, although you can separate them after some time. * Four years old (How and why stage): - One of the most pleasant children the dentist can have in his office. - Becomes more independent. - He is a great talker, very inquisitive, always asking about things (how and why 18  stage). - Very proud of his possessions and likes to show off. - Likes to be praised. 3 - Can be very cooperative and responds well to verbal directions. - Very imaginative so a peak of fear is reached at that age (fear of unknown) but fear from strangers becomes less. * Five or six years old: 02 - Fear declines because he has grown mentally and can evaluate fear producing situations. - Can be reached through simple explanation. - Never lie to him because he is old enough to distinguish true from false. - Likes to be praised, very proud of his hobbies, accomplishments, clothes and appearance. - By this age, the child has entered school and has friends so he may develop subjective fear from misleading stories at school. 2/2 2- Parental influence: Parents have great influence on their children’s behaviour. Sometimes parents and not the child constitute a problem in dental office. Normal behaviour of parents: Children need from their parents love and affection but at the same time they need firm guidance (they must know what is permissible and what is not permissible). Extreme parental attitudes: 1- Over affection “over love”: 2 Causes: - Only child - youngest in family - Only boy - Late marriages 20 Features: - This child is inadequately prepared to face life. - He is shy, timid, cries easily and hides behind his mother. 19  2- Over protection: - Child is protected more than he should be. - Mother interferes in his life and assists him in every minute task. 3 - His play is restricted. - He is not permitted to make decisions. Causes: Previous accident or present difficulty. 02 Features: In dental office: This child is shy, fearful, displays temper tantrum (resists the dentist). 3- Over indulgence: - Parents are yielding to all the child’s needs; he is not denied any wish or desire. Features: 2/2 - This child is spoilt, selfish and stubborn. - In dental office: He is resistant, defiant and screams without tears. 4- Over anxiety: * Usually associated with over affection, over protection and overindulgence. - There is extra concern about the child. - He is kept from school or dental appointment for any minor illness. Causes: - Previous illness. - Previous accident e.g., death of his brother. 2 Features: - In dental office: He is timid, shy and fearful. 20 5- Over authority: - Parents are critical and nagging. - Parents demand from the child excessive responsibilities more than his chronological age. - Compare him with older children. 20  Features: - In dental office: He shows physical tenseness and restlessness. 3 6- Under affection: - Parents have little time for their child because of: - Social or economical reasons. - Incompatibility or jealousy between parents. 02 Features: - Child feels insecure, uncertain, may develop bad habits as nail biting or thumb sucking. - In dental office: He is shy, timid and cries easily. 7- Rejection: - Extremely abnormal behaviour which may be due to: - Immature parents. - Financial burdens. 2/2 - Wrong sex. Features: - Child is selfish, restless, disobedient, may be lying or stealing. - In dental office: Displays temper tantrum (defiant and resistant). 3- Physical condition of child: a- The sick child “Chronically ill”: Negative influence → if the child has been sick for long periods and given special attention →he displays symptoms of overindulgence. 2 Positive influence → if the child has undergone treatment in a hospital, he will develop a spirit of “I can take it too” and usually obeys orders. 20 b- Nutrition: Deficiency of some vitamins and minerals may result in irritability, fatigue and restlessness. c- Physical and mental fatigue: - Lack of sleep or exhaustion results in poor behaviour in dental office. - Morning hours or after naptime are choice appointments for child dental patient. 21  4- School: Positive influence: 3 - If the child has gone to a nursery or preschool, he has gained experience and is more cooperative in dental office. - He has the opportunity to mix with other children and his teachers. - He has learnt to obey orders. - He is less likely to fear strangers than a child who has been confined to 02 home. * High school provides children with proper dental instructions. Negative influence: Child may develop subjective fear from misleading stories about dentistry from his friends at school. 5- Fear: Fear is one of the primary emotions acquired soon after birth. 2/2 - At first the child is unaware of the nature of the stimulus producing fear. - As he grows, he becomes aware of the stimuli producing fear. Value of fear: Should not be eradicated but directed for protection of child against danger, e.g., the child should be taught not to be afraid of dentist but of caries. Types of fear: A- Real or true fear: 1) Objective fear: 2 - Responses produced as a result of direct physical stimulation of sense organs with stimuli which are unpleasant in nature i.e., results from personal exposure to pain or discomfort. e.g., a child who was poorly managed by dentist will develop fear from future dental treatment. 20 -Objective fear may be associative in nature. e.g., a child who was poorly managed by persons wearing white uniforms will develop fear from similar uniforms on dentist or his assistant. 2) Subjective fear: - Responses based on feelings and attitudes that have been suggested to the child by others without the child having the experience personally. 22  e.g. -hearing of a painful dental experience from one of his friends or his mother. -observing fear in his mother while undergoing dental treatment → the child will imitate her (mother transmits her fear to her child). 3 -Why is subjective fear the worst type of fear? The mental picture producing fear is retained in the child’s mind & by his vivid imagination this picture becomes magnified. The longer subjective fear remains in mind, the more it becomes magnified. 02 Subjective fear is not circumscribed by a personal experience so there is no limit for the intensity of fear that can be produced. 3)Needle pain fear: If the child was subjected to previous therapeutic injections or vaccinations. B- Emphasized or not true fear: 1) Fear of unknown: 2/2 - An instinct present in every person. - Any unknown situation is fearful until experienced. - We can overcome this fear by familiarizing the child with the dental office, personnel and equipment. 2) Fear of strangers (dentist or his assistant). 3) Fear of separation from parents. b- Co-factors 2 1- Decoration & cleanliness of dental office. 2- Kindness & smile of dental personal. 3- Showing the child around dental office to get familiarized. 4- Knowledge about patient (calling him by his nick name, show interest in his hobbies, pets, brothers or sisters ………) 20 5- Time & length of appointment (15 – 20 minutes). 6- Skill & speed of dentist. 7- Avoid fear promoting words. 8- Praising good behaviour. 9- Giving gifts at end of visits. 10- Never lose your temper if child behaves badly. 23  Classification of child behaviour Many systems have been developed to classify child behaviour in dental 3 office. These include Wright's clinical classification, Frankel behaviour rating scale and Lampshire's classification. Wright's clinical classification: 02 He divided children into 3 categories: 1- Children with cooperative behaviour: - Child is relaxed and shows minimal apprehension. - He displays a reasonable level of cooperation which allows the dentist to function efficiently. 2- Children lacking cooperative behaviour: a- Very young children (less than 2.5 years). 2/2 b- Mentally handicapped children. - The dentist cannot establish communication with them → Sedation or general anesthesia. 3- Potentially uncooperative behaviour: - i.e., child with a behavioral problem but has the ability to perform cooperatively if properly managed. - This category includes: a- Timid, shy or bashful child. b- Defiant (resistant) child. 2 c- Fearful child. a- Timid, shy or bashful child: Behaviour: 20 - Child tries to hide behind his mother. - Looks down to floor when addressed. - Usually does not respond or responds in few words. 24  Management: 1- Take a child for a tour in dental office to familiarize him with dental personnel, equipment and office. 3 2- Calling him with his nick name to feel that he is at home, show interest in his hobbies, pets, brothers, sisters……. 3- Treat him with kindness. 4- Sometimes reached through his mother. 02 b- Defiant "resistant" child: Behaviour: - Child defies dentist to do anything. - Refuses to open his mouth. - May fight or kick. - Does not cry but screams loudly without tears. - Says: "I won't open my mouth." - "I don't care if my teeth have caries or not." Management: 2/2 1- Order the child with a firm tone of voice to sit calmly and open his mouth. 2- Use body control e.g., put your fingers on his sternum. 3- If he refuses to respond, perform "emotional shock therapy" or "hand over mouth technique" by putting your hand suddenly over the child's mouth (and sometimes his nose) for a few seconds, while talking calmly in his ear telling him to sit quietly because the work is going to be completed no matter how his behaviour is. Then tell him that you will remove your hand if he stops screaming. If he nods his head, remove hand immediately. If he starts screaming again, repeat procedure. Usually, the child is calm after two times. After that show kindness and praise good behaviour. 2 c- Fearful child: Behaviour: 20 - He is apprehensive. - His heart beats fast. - Looks pale. - May cry with a lot of tears but without any sound. - He may resist a little but usually obeys. 25  Management: 1- Analyze the child's fear by making a conversation with him to know the cause of fear. He usually expresses fear from a certain dental procedure e.g., 3 extraction, drilling (objective fear) or says that he has heard something about dentistry that has frightened him (subjective fear). 2- Overcome his fear by demonstration and explanation. 3- In the first appointment: a. Start with simple non painful procedures e.g., fluoride application, 02 prophylaxis, examination, taking x-rays……. b. Explain to child what you are doing (Tell, Show, Do). 4- Use voice control if needed (firm but kind). 5- Give the child a signal to use e.g., raising his left hand if he feels uncomfortable and wants you to stop working. 6- Never use force (aversive techniques) with fearful child to avoid psychological trauma. N.B. In case of emergency e.g., avulsed tooth, you can use physical restraint to 2/2 prove to child that the procedure is easy and not as what he thought. Techniques of behaviour management A) Non – Aversive techniques: 1- Pre appointment preparation: - It involves taking the child for a tour around the dental office to get oriented. - The child should be aware that nothing would be done on that day. - The child meets the receptionist, dental assistant & dentist. - Certain dental equipment can be shown & explained in child's language 2 e.g., Mr. Wind & Mr. Water for chip syringe. - This helps to remove unfavorable thoughts in child’s imagination. 2- Behaviour shaping: - A procedure by which the desired behaviour is instilled in the child. This is 20 done by a planned introduction of treatment procedures, so that the child is gradually trained to accept treatment in a relaxed and cooperative manner. - Easy and painless treatment procedures are carried out first, and then gradually proceed to difficult and long procedures. 26  Steps: 1- Examination and prophylaxis. 2- Topical fluoride application and fissure sealant. 3 3- Small occlusal cavity not requiring anesthesia. 4- Larger cavities or pulp capping with anesthesia. 5- Pulpotomy, pulpectomy and extraction. 3- Tell- Show- Do: 02 It involves: a. Verbal explanation of the procedure in words the child can understand (tell). b. Demonstrate for the child the visual, auditory and tactile aspects of the procedure (show). c. Without deviating, complete the procedure (do). N.B. Explanations should not be detailed so as not to confuse the child. e.g., When introducing a child to prophylaxis: - TELL the child that his teeth will be brushed using a special brush. - SHOW the child how the brush revolves in the hand piece (you can even try 2/2 that on his fingernail). - DO → brush the child’s teeth. 4- Positive reinforcement: - Positive behaviours of the child should be reinforced repeatedly while negative ones should be ignored. - Reinforcement could be through: 1- Material reinforcers e.g., toys and stickers. 2- Social reinforcers e.g., praise, facial expressions, nearness and physical contact. 3- Activity reinforcers e.g., allow child to adjust dental chair, dental light or hold an instrument. 2 5- Permitting the child a sense of control: The child can be given a signal to use when he feels discomfort e.g., raising his hand. This makes the child feels that he has some control (secure) especially 20 because he cannot communicate verbally when there is so much in his mouth. Dentist has to stop working immediately when the child uses this signal. 6- Voice control: - It is controlled alteration of voice volume and tone to influence child behaviour. - Tone of voice must be firm but kind. 27  7- Distraction: - The technique of diverting the child's attention from an unpleasant procedure. e.g., local anesthetic injection. 3 - The most popular distraction technique is audio-analgesia e.g., music, audio- taped stories or videotaped cartoons. 8- Modeling: - Done by making the child observe individuals (models) who demonstrate 02 appropriate behaviour during dental treatment. i.e., good example. - The child will usually imitate the model. - Models may be: - Live (parent or another child). - Videotapes. B) Aversive techniques (for the difficult, defiant and resistant child): 1- Hand-Over-Mouth exercise: 2/2 - To help the hysterical child regain self control. - This is done by putting your hand (may be wrapped with a towel) suddenly over the child's mouth for a few seconds, while talking calmly in his ear telling him to sit quietly because the work is going to be completed no matter how his behaviour is. Then tell him that you will remove your hand if he stops screaming. If he nods his head, remove hand immediately. If he starts screaming again, repeat the procedure. Usually, the child is calm after two times. After that show kindness and praise good behaviour. - Indications: 1- Hysterical, defiant child. 2- 3-6 years old children (preschool age). - Contraindications: 2 1- Child with an airway obstruction. 2- Very young children (under 3 years) and very old children. 3- Mentally handicapped children who are unable to verbally communicate or understand. 20 4- Fearful child. 2- Physical restraint: Can be performed by dentist, staff or guardian or with the use of restraining device. Parents must be informed, and the dentist obtains a consent before using restraints. 28  - Types of restraints: * Mouth (to keep mouth opened) e.g., tongue blades, mouth props, bite blocks. 3 * Head: head positioner. * Extremities: straps. * Body: papoose board, Pedi wrap, safety belts. - Indications: 1- Child who requires emergency treatment or limited treatment and cannot 02 cooperate. 2- Extremely resistant child. 3- Physically handicapped child e.g., children who perform involuntary movements (to protect child and practitioner). - Contraindications: 1- Fearful child. 2- Children who cannot be restrained due to medical condition e.g., heart disease. 2 2/2 20 29  II- PHARMACOLOGICAL MANAGEMENT OF CHILD BEHAVIOUR The great majority of children introduced to dentistry by various approaches 3 of behavior management become relaxed and cooperative. Unfortunately, a minority remain uncooperative. The most common reason for lack of cooperation is fear and anxiety. If fear persists despite carefully conducted introductory treatment, some form of sedation may be helpful. 02 I) Conscious sedation 1. Definition: “A minimally depressed level of consciousness in which the patient’s ability to maintain a patent airway independently and continuously and respond appropriately to physical simulation and or verbal command is retained” 2. Indications: a- For nervous and apprehensive children. 2/2 b- A potentially uncooperative child who wishes to be helped. 3. Contraindications: a. Severely uncooperative child b. Hypersensitivity to the agent 4. Objectives of conscious sedation: - Provide comfortable high quality dental service. - Control inappropriate behaviour of patient. - Produce in patient a positive psychological attitude towards future dental care. 2 Routes of administration: - Oral. - Intramuscular. - Intravenous. 20 - Subcutaneous. - Rectal. - Intranasal. - Inhalation (nitrous oxide). 30  Oral route: - The oral route is the most commonly employed route of drug administration for pediatric dentistry. 3 - The drug may be given at home or at the office. Giving the drug in the office has advantage of supervision (to be certain that the proper dose is given at the appropriate time). - Clinical effectiveness after 30 minutes and peak drug effect may require 1 hour or more. 02 - The duration of action is relatively prolonged after 4 to 6 hours. - Since absorption of drugs occur in the stomach, instructions should be given to the parents that no solid foods should be taken after midnight before the sedation appointment, this includes milk, since it becomes solid once introduced to the acidic environment of the stomach. These recommendations are for two reasons: 1. Drug uptake is maximized when the stomach is empty. 2. Prevent vomiting. 2/2 Advantages of oral route: 1- Universally acceptable. 2- Ease of Administration. 3- Decreased incidence of allergic reaction. Disadvantages of oral route: 1- Patient (parental) compliance. 2- Prolonged onset of action. 3- Prolonged duration of action. 4- Erratic absorption. Intravenous route: 2 - Represents the most efficient method of ensuring predictable and adequate sedation. - Children selected for intravenous sedation must be cooperative and prepared to accept intravenous injection. 20 - The dose required to produce satisfactory sedation is about 0.1 mg/kg body weight, this is injected slowly over a period of 1-2 minutes during which time the child is spoken to in a relaxing and reassuring manner. - Sedation is deepest immediately following the injection and for the next 10 minutes, during this period injection of local anesthesia is given and treatment is started. 31  - Among drugs, most commonly used are →Diazepam. - Duration of sedation is about one hour. 3 Advantages of intravenous route: 1- Very rapid effect. 2- Because the drug is injected directly into the blood stream absorption is not a complicating factor. 02 Disadvantages of intravenous route: 1- The intravenous route carries an increased potential for complications. e.g., hematoma or allergic reactions. 2- Not recommended for very young children (below 6 years of age). 3- The need for a period of postoperative recovery and subsequent restrictions of activities. Intramuscular route: - This method is used to produce deep sedation in very uncooperative 2/2 young patients who cannot be adequately sedated by oral or intravenous methods. Advantages of intramuscular route: 1- Faster absorption than oral route. 2- Does not require patient cooperation. Disadvantages of intramuscular route: 1- Delayed absorption. 2- Possibility of tissue trauma at the injection site. Subcutaneous route: 2 - Injection of the drug beneath the skin into the subcutaneous tissue. - Slow rate of absorption is noticed following the subcutaneous route, which limits the effectiveness of this route in dentistry. 20 Rectal route: - This method is most appropriate for very young children and as an alternative for those who refuse oral administration and for those who intensely dislike injection. - This method is used for reduction of mild anxiety. 32  Agents or drugs commonly used for sedation: 1. Gases --- Nitrous oxide and oxygen combination. 2. Antihistamines --- Hydroxyzine, Promethazine. 3 3. Benzodiazepines--- Diazepam (Valium), Midazolam (Dormicum). 4. Barbiturates --- Short acting such as Seconal, Pentobarbital. 5. Chloral hydrate. 6. Narcotics --- Meperidine. 7. Propophol --- (Deprivan). 02 Factors influencing Dosage: 1. Age 2. Body Weight 3. Emotional state and activity: Extremely anxious or defiant child will require more premedication than will the mildly apprehensive child. 4. Route of administration: Drugs given I.V. will act more rapidly and are given in lower dose, whereas a drug given orally acts more slowly and dosage requirements are higher. Intramuscular administration of drugs 2/2 results in intermediate onset of action and dosage requirements. 5. Time of the day: Dosage may sometimes be reduced if given during the time when the child usually takes a nap. Conversely dosages may have to be elevated if the drug is administered during the time when the child is usually engaged in active play. Inhalation Analgesia (Nitrous oxide): For production of conscious sedation, the inhalation route is limited to nitrous oxide. Characteristics of nitrous oxide: a- Colorless, odorless gas that is neither explosive nor flammable but supports 2 combustion as well as oxygen. b- It is quickly absorbed from the lungs into the blood stream, and it is transported to the brain and other tissue in the serum. c- It is excreted unchanged through the lungs. 20 Indications: 1. In children with mild anxiety (fearful and anxious) who wish to receive dental treatment and have the capacity to be compliant and follow instructions. 33  2. Children with short attention span, since it changes the patient’s perception of passage of time. 3 3. A cooperative child undergoing a lengthy dental procedure. 4. A patient whose gag reflex interferes with dental treatment. 5. A patient for whom profound local anesthesia cannot be obtained. 02 6. Helps to raise the pain threshold so it may be used to lessen the discomfort during a local anesthetic injection. However, nitrous oxide will not eliminate the need for local anesthetic injection. Contraindications: a) Upper Respiratory tract infection. b) Pulmonary diseases (bronchitis, emphysema and tuberculosis) c) Nasal obstruction due to any cause if it prevents easy breathing through the nose. 2/2 d) Children with certain psychiatric disorders. e) Children with a history of motion sickness, who may experience vomiting when given nitrous oxide. f) Pregnant females. g) Patients with otitis media as nitrous oxide increases pressure in air filled cavities. Equipment: 1) Nitrous oxide machine consisting of a flowmeter that measures the delivered oxygen and nitrous oxide. 2) Fail-safe valve that cuts off flow of nitrous oxide when oxygen level drops 2 below 3 liter/minute. 3) Reservoir Bag. 4) Nasal inhaler (mask). 5) Oxygen and nitrous oxide tanks. 20 6) Proper scavenger system. Techniques: Two techniques have been described: a. Slow induction technique. b. Rapid induction or ‘surge’ technique. 34  Slow induction technique: 1- Describe to the patient in language he understands what nitrous oxide is and 3 how it will make him feel (e.g., it will make him feel happy and kind of like he is floating in air). 2- Introduce nasal inhaler and encourage the child to breathe through the nose. 3- The delivery of nitrous oxide / oxygen should begin with 100 % oxygen for 3-5 minutes 02 4- Then the concentration of nitrous oxide may gradually be increased 5 - 10% every 3-5 minutes till it reaches final concentration of 70% oxygen and 30% nitrous oxide. The state of analgesia is reached when: * The child feels tingling sensation in fingers and toes. * Sagging of eyelids. * He smiles and will follow simple instructions. * His mouth stays open easily. 2/2 * When this state is reached local anesthesia is given. Recovery from analgesia: By inhalation of 100% oxygen for 5 minutes, the child will regain his normal state of consciousness. Rapid induction technique: 1. Initiation is done by administering equal parts of nitrous oxide and oxygen for 10-15 minutes. 2. This is followed by maintenance phase where the nitrous oxide is reduced by half for 40 minutes. 2 3. Withdrawal is by administering oxygen only. 4. Oxygen is used to prevent anoxia, which is produced if nitrous oxide is used alone. 20 Adverse side effects: 1. Acute effect (on the patient): Hypoxia. Bone marrow depression due to prolonged use in long term sedation of chronic pain. Neurotoxicity. 35  2. Chronic effect (dentist and assistants): Reduced fertility. Spontaneous abortion. 3 Neurological defects. Increased incidence of liver disease. Malignancy. 02 Safety recommendations: 1. Use the minimum effective dose. 2. Use scavenging equipment. 3. Vent exhausts gases to outside. 4. Check delivery system for leakage monthly. II) General Anesthesia If the child’s behavior is unacceptable following psychological and 2/2 pharmacological behavior management, one should consider hospitalizing the patient to provide treatment under general anesthesia. Indications: Severe dental diseases in physically, mentally or medically handicapped children. Documented allergy to local anesthesia. Extensive facial trauma. Multiple carious and abscessed teeth in very young children. 2 Pre-anesthetic assessment The anesthetist should be consulted. Operating theatre environment: 20 Children should be allowed to wear their own clothes. Local anesthetic cream should be placed on the back of the hand to allow painless insertion of the canola. Allowing the parent to be with the child during induction minimizes anxiety. Parents should be called into the recovery ward once the child has woken and is stable. 36  Normal day-stay recovery is a minimum of 2 hours after the operation. Fasting instructions: 3 Children under six years of age: No solids for 6 hours pre-operation. No breast milk for 4 hours pre-operation. No clear fluids for 2 hours pre-operation. 02 Children older than six years of age: No solids or liquids for 6 hours pre-operation. 2 2/2 20 37  THE CHILD'S FIRST DENTAL VISIT By the end of this chapter, the student must be able to: 3 1- Recognize the aims of the first dental visit. 2- Recognize how to prepare the child and his parents for the first dental visit. 02 2 2/2 20 38  THE CHILD'S FIRST DENTAL VISIT Preparation of the child and his parents before the first dental visit will result 3 in a better behavior pattern in the dental office. The aims of the first dental visit are as follows: 1- To establish good communication with the child and parent. 2- To obtain important background information (i.e., the child's social, dental 02 and medical history). 3- To examine the child and to obtain radiographs if required. 4- To perform a simple dental procedure. 5- To explain treatment aims to the child and parent. Preappointment communication with parents: The dentist must communicate with the parents before the first dental visit to: 1- Ask parents to prepare their child for the first visit. Simply inform the child as casual as possible that you are taking him to the dentist to look at 2/2 his teeth. 2- Lower the parent's anxiety. 3- Inform the parents for his plans for the first visit. The first visit is only for acquaintance & to gain the child's confidence, obtaining background information about the child, examining the child and if possible, do a simple procedure. Dental environment, appointment time and reception area: - The receptionist should greet the child in a friendly and cheerful manner. - The assistant must be nicely dressed, smiling and kindly guide the child and his parents to the reception area. 2 - The dentist should appear relaxed and establish friendly communication with the child and his parents. - Appointment: o Time → Avoid interference with nap times. →Early morning appointments or after nap times should be 20 set. o Length → First visit should be short (15 to 20 minutes). - Reception area: o Should be comfortable and attractive, simple furniture, nice colors, nice pictures on the walls, simple toys, children's books. o Should be far from operating room. 39  Obtaining information (history taking): - The assistant escorts the child and his parents to the dentist's consultation room (not the operating room). 3 - The dentist should establish friendly communication with the child and his parents. - Ask parents about their main concern (chief complaint). - Answer any questions for the child and his parents. - The dentist obtains patient's history which is divided into three parts: 02 social, dental and medical history. Personal (social) history: Name, date of birth, address, school, brothers and sisters, pets, hobbies, mother's occupation, father's occupation. Dental history: Past dental history (type of any previous treatment, regularity of visits, changing dentists) all this gives an impression about the attitudes of child and parents 2/2 towards dental treatment. Ask the child about his chief complaint using simple words with no reference to pain. Medical history: Systemic diseases, mental problems, any previous operations or serious illness, also family history of serious illness. Accompanying the child into the dental operatory: - The dentist accompanies the child into the dental operatory. - The parent is allowed to accompany the child into the dental operatory during the first visit for moral support. 2 - At subsequent visits the dentist must decide whether to keep the parent or not based on: 1- The child's age (very young usually needs moral support). 2- Child's behaviour. 20 3- Parent's character. Examination and recording: 1- A good approach is to ask the child "how many teeth has he got and to ask him to count them". 2- Proceed with counting. In this way the child will realize that there is nothing traumatic about treatment. 40  3- If the child refuses to sit in the dental chair, he can sit in his parent's lap with head supported by right parent's arm. 4- This first examination may not be detailed. However, in successive visits 3 further details may be obtained. 5- During examination: a. Avoid the sight of a sharp instrument or careless use of a probe. b. Avoid fear promoting words. c. Avoid sudden jerky movements. 02 Introductory treatment: 1- After the examination, if the child is not presenting with pain, only simple non painful procedures are carried out in the first visit. e.g., → Polishing teeth with a soft brush. a. Taking x-rays. b. Fluoride treatment. 2- Use Tell-Show-Do technique and positive reinforcement. 3- Injections and cavity preparations should be avoided during the first visit 2/2 until the dentist gains the child's confidence. Termination of visit and parent's involvement: 1- At the end of first visit the dentist can assess →Child behaviour. →Parent's reactions. 2- Praise child for good behaviour and ignore bad behaviour. 3- Prepare child for next visit by telling him in a simple way what is going to be accomplished in the second visit. 4- Parent's involvement: a. Before the child is dismissed explain the intended treatment plan to the parents. 2 b. Tell them roughly the number of visits required. c. Discuss the fees. d. Stress on importance of preventive measures. e. Request the child’s toothbrush on the second appointment. 20 Treatment planning: a- With a good history and examination, an accurate diagnosis and treatment plan can be made. b- Consider first the patient's chief complaint. c- Then proceed in a systematic manner with the more important to the less important. 41  Recall visits: If the child has been properly managed during the first visit, the recall visits 3 will proceed smoothly. 02 2 2/2 20 42  LOCAL ANESTHESIA FOR DENTAL CHILD PATIENT By the end of this chapter, the student must be able to: 3 1- Recognize the different methods and techniques of pain control for children. 02 2 2/2 20 43  LOCAL ANESTHESIA FOR DENTAL CHILD PATIENT Local anesthesia is the most common method of pain control in dentistry. 3 However, this method of eliminating pain is painful itself and can be very distressing to the child patient. Topical anesthesia or surface anesthesia: Applied to injection site to make needle insertion painless. 02 Forms of topical anesthesia: a. Paste (ointment, cream, gel). b. Solution (spray in pressurized container). c. Cotton pellets. d. Adhesive discs. Use of topical paste is better than spray because the spray splatters and reaches the soft palate causing gagging sensation. 2/2 Requirements of an acceptable topical anesthesia: 1- Of pleasant taste. 2- Fast acting and effective. 3- Causes no irritation. Steps for administration of local anesthesia: 1- Preparation of the child patient: - He is told that his tooth is going to be "put to sleep". - At first "a paste" will be applied to put the gum to sleep, and then it will be “washed away". 2 - Parents should not interfere or comment. 2- Application of topical anesthesia: - Should be applied to dried mucous membrane. - Use one end of cotton wool roll to dry site of insertion and other end to apply the 20 paste. In nerve block injection the child may hold the cotton wool roll between teeth to localize topical anesthetic paste. - Wait for about 2 minutes before giving the injection to allow topical anesthesia to work. 44  3- Injecting local anesthetic solution: 1. Warm local anesthetic carpule between hands before use. 2. Apply pressure to injection site using your finger before injection. 3 3. Stretch the tissues before insertion of needle to facilitate penetration. 4. Concealment of the syringe from the child. The assistant gives you the syringe in working position before injection and receives it when injection is complete. Pass the syringe below the child's chin and out of his field of vision. 02 5. Distract child's attention at moment of needle insertion. 6. Inject the first drop on penetration wait for a moment, then inject slowly. 7. After completing the local anesthetic injection tell the child what he is going to feel (numbness, feels big or fat…….). 8. About 1 ml of the 1.8 ml carpule produces profound anesthesia in children under 10 years of age. 9. Allow enough time before starting any procedure. 10.Use fine gauge needle (gauge 27 for aspirating and gauge 30 for non- aspirating). 2/2 Local Anesthetic techniques: Upper jaw and lower anterior teeth (Infiltration anesthesia): - All the maxillary and lower anterior teeth can be anesthetized by infiltration anesthesia using a short needle. - In case of extraction in upper jaw avoid palatal injection because it is very painful for the child patient. - As an alternative give intrapapillary injection. How? Wait for buccal infiltration to have its effect and then inject into the palatal aspect of interdental papillae from the buccal side distal and mesial to the tooth to be extracted with the needle perpendicular to the gingiva. 2 Lower posterior teeth (Nerve block anesthesia): - Used for all mandibular molars. - Used to anesthetize large area with fewer injections. 20 - Used when there is localized infection in area of infiltration site. 45  N.B.: * Lower primary molars in the very young child (before eruption of first permanent molar) can be anesthetized by infiltration anesthesia for any procedure. 3 * For extractions use buccal infiltration and lingual infiltration (you can use intrapapillary injection instead of lingual infiltration). * Nerve block injection is made in children slightly lower and more posteriorly 02 than in adults because the mandibular foramen is situated at a lower level than occlusal plane of primary teeth and the size of mandible is smaller. 2 2/2 20 46  RESTORATION OF PRIMARY TEETH By the end of this chapter, the student must be able to: 3 1- Identify the different restorative techniques. 2- Explain the basic principles in the preparation of cavities in primary teeth. 3- Explain the recent concepts in restorative dentistry. 02 4- Identify the different restorative materials. 2 2/2 20 47  RESTORATION OF PRIMARY TEETH Of all the many services the dentist provides for his child patients, the 3 restoration and preservation of carious teeth is of major importance, for if these teeth are lost prematurely by caries, not only will the child be handicapped for the present but significant impairment of his normal masticatory function may affect him for his entire lifetime. In this respect, restorative dentistry is preventive as well as corrective. 02 Isolation: The maintenance of dry operating field during cavity preparation and placement of the restorative material is important. This could be accomplished using rubber dam. 2 2/2 20 48  The rubber dam offers the following advantages: 1-Saves time: Elimination of rinsing, spitting and talking of child allows quick operative 3 work to be done. 2-Aids management: Uncooperative or apprehensive children can be better controlled with a rubber dam in place since rubber dam controls movement of tongue and lips. 02 3-Controls saliva: Minute pulp exposures can be easily detected when the tooth is isolated. Extent of exposure, amount and type of hemorrhage from pulp tissue can be easily detected. Prevents foreign materials from contacting oral structures. e.g., floor of mouth or tongue which will stimulate salivary flow and interfere with operative procedures. 2/2 4-Using a rubber dam prevents aspiration or swallowing of foreign objects by the child who is in a semi-reclining position on the dental chair. Basic principles in the preparation of cavities in primary teeth: In preparing cavities for restoring primary teeth, although the basic principles of cavity preparation are applied, there are certain modifications done in cavity design for primary teeth related to the morphologic difference between primary and permanent molars. Class I cavities in primary molars: 2 1. The outline form should include all pits, fissures and grooves into which a sharp explorer can penetrate. 20 49  2. A flat pulpal floor is generally advocated, although some prefer to make the pulpal floor slightly concave throughout to allow for greater depth of the filling material, for better distribution of stress in the restoration and to avoid 3 endangering the high pulpal horns. 02 Flat pulpal floor Concave pulpal floor 3. The depth of pulpal floor should be established just beneath the dentinoenamel junction (0.5 mm) to avoid pulp exposure due to the reduced thickness of enamel and dentin. 4. All the internal line angles should be rounded to avoid stress concentration. 2/2 5. The side walls should slightly converge towards occlusal so that the preparation will follow the outer form of the crown to aid in retention of restoration. 2 20 6. Spot preparations in primary molars: * Beside the regular class I cavity preparations done in primary molars; occlusal spot preparations have been recommended. In such preparations, only the carious pit or groove is prepared, and the tooth is restored in the usual manner. These preparations are applicable in any of the primary molars with exception of the lower second primary molars in which 50  extension for prevention including all deep pits and fissures is recommended. 3 02 * From the clinical experience it has been found that interproximal caries in primary molars usually occurs in pairs. Proximal spot preparations have been recommended for such situations. For example, if an incipient proximal carious cavity is present in the mesial surface of a second primary molar, while the adjacent first primary molar has a proximal lesion on its distal surface, a proximal spot preparation in the mesial surface of second primary molar and a regular occluso-distal cavity in the neighboring first primary molar can be done. This spot preparation should be small, not undermining the marginal ridge and can be done only in patients with low caries index. 2/2 Class II cavities in primary molars: 1. These preparations include an occlusal, an isthmus and proximal portion. The outline form of the occlusal step should be dovetail-shaped to avoid lateral displacement of restoration including all carious pits, fissures, and developmental grooves. 2 2. The side walls of the occlusal step should converge from the pulpal floor to the occlusal surface. 20 3. The pulpal floor should be established just beneath the dentinoenamel junction. 4. Angles between the side walls and the pulpal floor should be gently rounded. 51  5. Since primary molars are characterized by having a narrow occlusal table, the area of the isthmus should be made as wide as possible buccolingually without weakening the cuspal areas or endangering the pulp in order to prevent 3 fracture of amalgam restorations in this area. It has been suggested that the optimum average width of the isthmus area in primary molars should be approximately one-half of the intercuspal dimension of the tooth. 02 6. The axio-pulpal line angle should be beveled or grooved to reduce the concentration of stresses and provide greater bulk of material in the isthmus 2/2 area, which is liable to fracture. 7. The greater constriction of the necks of primary molars calls for special attention when establishing the gingival seat of the proximal box. The further the gingival seat is carried down gingivally, the deeper pulpally must be the axial wall to maintain the proper 1 mm width, which can endanger the pulp. Therefore, the gingival seat of the proximal box should be established just beneath the free margin of the interproximal gingival tissue at a higher level (occlusally) than in permanent teeth and should be of sufficient depth to break contact with the adjacent tooth (approximately 1mm). It is unnecessary to bevel the enamel of gingival seat since the enamel rods at the cervix slope 2 occlusally. 20 8. The proximal box line angles and walls should converge towards the occlusal, following the buccal and lingual surfaces of the tooth. This provides 52  for increased retention, carries the preparation into self-cleansable areas, and avoids undermining the adjacent cusps. 3 9. An axiobuccal and axiolingual retentive groove may be included in the preparation. These grooves will aid in the retention of restoration. 02 10. If extensive proximal lesions are present, excessive flaring of the proximal surfaces will result in fragile unsupported tooth structure. Therefore, covering the tooth with a stainless-steel crown will result in a more serviceable 2/2 restoration. 11. The usual matrices such as ivory, Tofflemire, and Wagner should not be used when condensing amalgam in class II cavities in primary molars, as they will not produce a desirable finished restoration since the primary molars have prominent buccocervical ridge, marked constriction of the crown in the cervical region, and sharply converging buccal and lingual surfaces towards the occlusal. A spot-welded band or T-band matrix can be successfully used producing a well contoured restoration. 2 20 53  Class III cavity preparation: 1. In these cavities caries involves proximal surfaces of anterior teeth without 3 involving the incisal angle. 2. If removal of the caries will not involve or weaken the incisal angle, a small conventional class III cavity may be prepared, and the tooth restored with composite. 02 3. If the caries is more extensive a dove tail preparation can be made, the dove tail can be prepared on the lingual or the labial surface of the tooth. This is particularly important when restoring caries on distal surface of primary canine due to the broad contact between its distal surface and the mesial surface of first primary molar and the height of interproximal gingival tissues which necessitates the use of a modified class III cavity preparation utilizing a dovetail. 2/2 4. Cavity preparations are more conservative nowadays and an adhesive fluoride releasing restorative material can be used for such cavities. 2 20 54  Class IV cavity preparation: 1. In these cavities, caries involves the inciso-proximal angle of the anterior 3 teeth. 2. If caries is not extensive, disking by sandpaper disc is performed to remove the decay, and then fluoride is applied topically. 02 3. In regular class IV cavity preparations, composite resin material can be used for restoration. 4. If caries is extensive, anterior chrome steel crowns with facing or acrylic jacket can be used. Class V cavity preparations: 1. Caries involves the gingival ⅓ of buccal & lingual surfaces. 2/2 2. Outline form includes all caries. 3. Depth of preparation is only 0.5 mm in dentin. 4. Retention of material is obtained from convergence of walls of preparation. Glass ionomer cement could be used for restoring these cavities. Recent concepts in restorative dentistry: Until recently restorative dentistry was based on G.V. Black’s principles. 2 This is now opposed by a conservative approach based upon preservation of tooth structure. Recent advances in preventive measures and the arrival of ADHESIVE DENTISTRY have greatly reduced the size of cavity preparation. 20 Guiding principles for adhesive cavity design: The following table shows principles of cavity design according to G.V. Black in comparison with adhesive cavity design. 55  Principles of cavity G.V. Black Adhesive cavity design design 1- Access - Gaining access to cavity. - Gaining access to caries. - Prepare cavity to standard - Remove caries. 3 outline. - Plan the final outline according to - Remove any remaining caries. the material used. 2- Outline form - Includes all deep fissures even - Involves carious fissures while those, which are not carious. sound deep fissures may be covered with sealant. 3- Extension - Extension for prevention i.e. - Prevention of extension i.e., no extend the preparation into need to extend the preparation into 02 self-cleansing areas. self-cleansing areas or to remove affected dentin in deep portions. The approach focuses on healing instead of removal of demineralized tissues. 4- Resistance -Removal of all undermined - Remove loose and fragile enamel and unsupported tooth rods at C.S.A., which are directly structure. exposed to occlusal load while other unsupported tooth structure may be conserved and reinforced by the bonded restoration. - Preservation of marginal ridges in 2/2 5- Retention - Macromechanical retention: case of early proximal caries by utilizing spot preparations. - Micromechanical retention, which * Convergence of walls. includes current etching and * Dovetail. bonding procedures. * Undercuts. - Beveling which increases the * Axial grooves. potential surface area for retention. 6- Cleanliness - Finishing the walls and toilet - Cleanliness of adhesive surfaces of the cavity. to ensure optimal bonding. 7- Materials used Non-adhesive restorative Adhesive restorative material material New caries classification: Based on principles of adhesive dentistry, MOUNT & HUME in 1997 advocated a new classification for caries called Sites Stages classification 2 (Si / Sta). Principles of Si/Sta: 1-Tooth structure saving: 20 - Preservation of sound caries susceptible tooth structure. - Preservation of marginal ridges by using spot preparations. - Removal of loose and fragile enamel rods only if directly exposed to occlusal load, while other unsupported tooth structure may be conserved and reinforced by the bonded restoration. 56  - Preservation of demineralized dentin in the deep portions near the pulp chamber to protect the pulp tissue from direct operative trauma. 3 2- Utilization of modern adhesion technology benefits: i. Mechanical benefits: strengthening of tooth/ restoration compound through micro retention effect. ii. Biological benefits: provision of proper marginal seal at tooth restoration interface which protects the pulp tissue and enhances its 02 reparative power by preventing microleakage. 3- Biointegration: which involves: a- Preservation of function and esthetics. b- Prevention of recurrent caries. 2/2 2 20 57  Restorative materials for primary teeth 1- Amalgam: 3 Most commonly used restorative material for primary teeth. Advantages: 1 – Requires simple procedures. 2 – Durable (high strength properties). 02 3 – Used where moisture control is a problem. Disadvantages: 1 – Has no adhesive properties so requires undue cavity preparation. 2 – Environmental and occupational hazards (mercury). 3 – No esthetic properties. 2- Composite Tooth colored restorative material for anterior teeth Advantages: 2/2 1 – High strength properties (inorganic filler). 2 – High esthetic properties. Disadvantages: 1 – Requires acid etching (requires patient cooperation). 2 – Polymerization shrinkage 3 - Discoloration. 3-Glass ionomer Tooth colored restorative material for anterior teeth and simple occlusal cavities in 2 posterior teeth. Advantages: 1 – High adhesive properties (chemical bond to enamel and dentin). 20 2 – Fluoride leaching properties (used in patients with high caries index). 3 – Used as filling material – cement – base – core. Disadvantages: 1 – Low esthetic properties. 2 – Brittle (not used in stress bearing areas). 58  4- Resin modified Glass ionomer Glass ionomer + resin component. 3 Advantages: 1 – High strength (used in stress bearing areas). 2 – High adhesive properties. 3 – Fluoride leaching properties (used in children with high caries index). 4 – High esthetics. 02 5 – Light cured (finished immediately). 6 – Its coefficient of thermal expansion is very close to that of the tooth. 5- Compomer To have advantages of both composite and glass ionomer, in terms of fluoride release, strength and esthetics. Advantages: 1 – High esthetics. 2/2 2 – High strength. 3 – Adhesive properties. 4 – Fluoride release. 5 – Can be used as a restorative material and fissure sealant. 6- Stainless steel crown: Indications: 1- Badly decayed or broken-down teeth. 2- Pulpotomized teeth. 3- Restoration of teeth affected by developmental problems e.g., enamel hypoplasia. 4- As an abutment for space maintainers. 2 5- In patients with high caries susceptibility or in patients where routine oral hygiene measures cannot be performed (handicapped patients). 20 59  MANAGEMENT OF DEEP CARIOUS LESIONS IN CHILDREN 3 By the end of this chapter, the student must be able to: 1- Identify the diagnostic aids for vital pulp therapy. 2- Know the different techniques for vital pulp therapy. 02 3- Know the different techniques for non vital pulp therapy. 4- Identify the reaction of pulp to commonly used capping materials. 5- Recognize the cause of failure following vital pulp therapy. 6- Know the different techniques of pulp therapy for young permanent teeth. 2 2/2 20 60  MANAGEMENT OF DEEP CARIOUS LESIONS IN CHILDREN 3 Pulp exposure is caused most commonly by caries but may also occur during cavity preparation or by fracture of the crown. Pulp exposures caused by caries occur more frequently in primary than in permanent teeth because primary teeth have relatively large pulp chambers, more prominent pulp horns and thinner 02 enamel and dentine. In primary molars with proximal cavities, pulp involvement occurs in about 85% of those with broken marginal ridges. Diagnostic aids in selection of teeth for vital pulp therapy 1-History of pain: The dentist should distinguish between two types of pain: provoked and spontaneous pain (unprovoked). 2/2 Provoked pain: is precipitated by stimulus (thermal, chemical or mechanical) and disappears after removal of stimulus. For example: Pain associated with eating is due to pressure from accumulated food within the carious lesion and chemical irritation to the vital pulp protected by a thin layer of dentine (good prognosis). Pain due to cold or hot food or drinks may indicate hyperemia or pulpitis. Spontaneous pain: is a throbbing constant pain that may keep the patient awake at night. It indicates advanced pulp damage (poor prognosis). 2 2-Clinical signs and symptoms: A. Abnormal tooth mobility indicates severely diseased pulp or involvement of periodontal ligament. 20 B. Sensitivity to percussion indicates apical or periodontal inflammation or both. C. Presence of swelling, sinus, draining fistula or chronic abscess indicates a non vital pulp. 61  D. Size of exposure and amount of pulpal bleeding are the most valuable observations in diagnosing the condition of the primary pulp: 3 - Small pin-point exposure surrounded by sound dentine indicates favorable condition for vital pulp therapy. - Large exposure with watery exudate or pus indicates unfavorable condition for vital pulp therapy. 02 - Small controllable amount of bleeding during and or following pulp amputation is a favorable condition for pulp therapy. - Excessive uncontrollable bleeding during and or following pulp amputation is an unfavorable condition for pulp therapy. 3-Radiographic interpretation: 2/2 Periapical and bitewings radiographs are used to examine periapical area and supporting bone. Pulp exposure cannot be accurately detected from an x-ray film. Radiographic interpretation in children is more difficult than adults due to: a. Young permanent teeth with incompletely formed root ends give the impression of periapical radiolucency. b. The roots of primary molars undergoing normal physiologic resorption may suggest a pathologic change. c. Permanent teeth are superimposed on the primary teeth. 2 Radiographs are valuable for determining the following: a) Periapical changes such as widening of periodontal membrane space. 20 b) Rarefaction in supporting bone. c) Calcified masses within pulp chamber and root canals. d) Periapical and interradicular radiolucencies of bone. 62  4-Vitality tests: Either thermal or electrical. 3 Thermal pulp vitality tests: Application of heat (hot gutta percha or hot instrument). 02 Application of cold (ethyl chloride or ice cone). The reaction of a normal tooth is tested first (pain on application of stimulus which disappears after removal of stimulus). If pain persists, this indicates hyperemia or pulpitis. If tooth does not respond, this indicates a non-vital pulp. 2/2 Electric pulp tester: Record the reading of a normal tooth first. If the affected tooth responds at a lower reading than normal, this indicates hyperemia or pulpitis. If the affected tooth responds at a higher reading, this indicates pulp degeneration. 2 Disadvantages of electric pulp tester: a) Child may become apprehensive and gives a false positive response. b) Pulp tester may give false positive response when content of pulp is liquid 20 (liquefaction necrosis). 5-Physical condition of patient: Seriously ill children e.g., heart disease, nephritis, leukemia or tumors should not be subjected to the possibility of an acute infection resulting from pulp 63  therapy. Moreover, the pulp might not possess normal regenerative power. Extraction of the involved tooth after proper premedication with antibiotics is the treatment of choice in such conditions. 3 Vital Pulp Therapy Pulp Capping 02 The aim of pulp capping is to maintain pulp vitality by placing a suitable dressing either directly on the exposed pulp (direct pulp capping) or on a thin residual layer of soft dentine at the base of the cavity (indirect pulp capping). Indirect Pulp Capping Definition: It is the procedure in which only the gross caries is removed from the lesion, 2/2 while the remaining carious dentine which if removed would result in pulp exposure is covered with a material which promotes healing. Indications: Teeth with deep carious lesions approximating the pulp, free of any clinical or radiographic signs of pulp disease. Technique: First visit: 2 1- Administer local anesthesia and isolate tooth with rubber dam. 2- Gross caries is excavated from the carious lesion, while the leathery dentine in the deepest portion is left and covered with calcium hydroxide paste and a 20 reinforced temporary dressing. 3- Tooth should not be re-entered for 6-8 weeks. During that period the carious process in t