Crash Course in Pediatric Dentistry PDF 2020

CRASH COURSE IN PEDIATRIC DENTISTRY WWW.DENTISCOPE.ORG DONE BY : SIMA HABRAWI EDIT BY : HAIF ALQAHTANI DENTISCOPE 2020 Crash Course in Pediatric Dentistry Table of Contents Basics of child phycological development............................................................................... 5 Behavior management.......................................................................................................... 6 Behavior rating scales.....................................................................................................................6 Behavior modification....................................................................................................................7 Behavior management...................................................................................................................7 Early childhood caries - ECC.................................................................................................... 9 Caries in Permanent teeth.................................................................................................... 11 Diet analysis [ 24 hours diet chart ]............................................................................................... 11 Restoring caries in young permanent teeth.......................................................................... 13 ICDAS........................................................................................................................................... 13 Caries risk in pediatric patients..................................................................................................... 13 Restorative materials for primary teeth............................................................................... 15 Stainless steel crowns [ SCC]......................................................................................................... 16 Amalgam..................................................................................................................................... 17 Resin composite........................................................................................................................... 17 GIC............................................................................................................................................... 17 RMGIC......................................................................................................................................... 17 Compomers.................................................................................................................................17 Fissure sealants............................................................................................................................ 17 PRR.............................................................................................................................................. 17 Pulp therapy in primary teeth.............................................................................................. 19 Indirect pulp capping.................................................................................................................... 20 Direct pulp capping...................................................................................................................... 20 Pulpotomy................................................................................................................................... 20 Pulpectomy.................................................................................................................................. 21 Fluoride modalities in pediatrics.......................................................................................... 23 Fluoride varnish........................................................................................................................... 23 APF gel......................................................................................................................................... 24 Silver diamine fluoride [ SDF]........................................................................................................ 24 Titanium tetrafluoride.................................................................................................................. 25 Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 1 of 66 Crash Course in Pediatric Dentistry Fluoride supplements................................................................................................................... 25 Fluoride toxicity........................................................................................................................... 26 Dental fluorosis............................................................................................................................ 26 Fluoride calculations.................................................................................................................... 26 Fluoride toxicity calculcations....................................................................................................... 27 Inhalation sedation.............................................................................................................. 28 Conscious sedation....................................................................................................................... 28 Nitrous oxide............................................................................................................................... 28 Slow induction..................................................................................................................................................... 29 Rapid induction................................................................................................................................................... 29 Early to ideal sedation......................................................................................................................................... 29 Over sedation...................................................................................................................................................... 29 Dental trauma in Primary teeth........................................................................................... 31 Management of any dental trauma follows WASH protocol.......................................................... 31 Clinical examination of any trauma follows MP3 protocol............................................................. 31 Trauma in primaty teeth............................................................................................................... 32 Dental trauma to young permanent teeth............................................................................ 34 Ellis classification of permanent teeth fractures............................................................................ 34 Trauma in young permnanet teeth............................................................................................... 34 Management of avulsion in primary teeth........................................................................... 37 Management of avulsion.............................................................................................................. 38 FARAH protocol............................................................................................................................ 38 Splinting....................................................................................................................................... 38 De coronation.............................................................................................................................. 39 Auto transplantation.................................................................................................................... 39 Apexogenesis & apexification.............................................................................................. 40 Regenerative endodontics............................................................................................................ 41 Pediatric facial injuries......................................................................................................... 42 Management of facial fractures.................................................................................................... 43 Management of medically compromised children................................................................ 44 Congenital heart disease.............................................................................................................. 44 Asthma........................................................................................................................................ 45 Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 2 of 66 Crash Course in Pediatric Dentistry Cystic fibrosis : respiratory disease............................................................................................... 45 Renal disease............................................................................................................................... 45 Liver disease................................................................................................................................ 45 Diabetes...................................................................................................................................... 46 Platelet disorders......................................................................................................................... 46 Coagulopathies............................................................................................................................ 46 Thalassemia.................................................................................................................................46 Leukemia..................................................................................................................................... 46 Immunodeficiency........................................................................................................................ 47 Organ transplants......................................................................................................................... 48 Cerberal palsy.............................................................................................................................. 48 Visually impaired.......................................................................................................................... 48 Hearing impairment:.................................................................................................................... 48 Down syndrome........................................................................................................................... 49 Pediatric oral medicine & oral pathology............................................................................. 49 Odontogenic infections................................................................................................................ 49 Primary Herpetic Gingivostomatitis.............................................................................................. 50 Herpangia.................................................................................................................................... 50 Acute pseudomembranous candidosis.......................................................................................... 50 Recurrent apthous ulcers.............................................................................................................. 50 Erythema multiforme................................................................................................................... 51 Stevens Johnson syndrome........................................................................................................... 51 Eruption cyst or haematoma......................................................................................................... 51 Phenytoin enlargement................................................................................................................ 51 Cyclic neutropenia........................................................................................................................ 51 Epstein’s pearls............................................................................................................................ 51 Bohn’s nodules............................................................................................................................. 52 Anomalies in pediatric dentistry........................................................................................... 53 Developing dentition in pediatric pts.................................................................................... 57 Dentition stage............................................................................................................................. 57 Molars the relationship................................................................................................................ 58 Early mesial shift......................................................................................................................................... 58 Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 3 of 66 Crash Course in Pediatric Dentistry Late mesial shift.......................................................................................................................................... 58 Incisal liability.............................................................................................................................. 58 Leeway space of Nance................................................................................................................. 58 Ugly duckling stage [ Broadbent phenomenon]............................................................................. 59 Interceptive orthodontic procedure in pediatrics.................................................................. 60 Interceptive procedures............................................................................................................... 60 Habit breaking appliances............................................................................................................ 60 Mouth breathing................................................................................................................................................. 61 Lip bumper.......................................................................................................................................................... 61 Anterior crossbite......................................................................................................................... 62 Management of premature loss of primary teeth in mixed dentition............................................. 63 Space maintainers for unilateral space loss........................................................................................................ 63 Space maintainers for Bilateral space loss [ mandible ]..................................................................................... 64 Space maintainers for Bilateral space loss [ maxilla].......................................................................................... 64 References........................................................................................................................... 65 Disclaimer......................................................................................................................... 66 Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 4 of 66 Crash Course in Pediatric Dentistry Basics of child phycological development Stages of physcosexual development [ freud]: Stages of physcosocial development [ Erikson]: 1- Oral : First year of life – child is completely Trust vs mistrust [ oral stage – kid has dependent on the mother separation anxiety ] 2- Anal: 1-3 years old – toilet training is done Autonomy vs doubt [ anal stage – child in this stage should think that what the dentist is 3- Phallic : 3-6 years old – sexual identity doing is their own choice] develops Initiative vs guilt [ phallic stage] Kids at this stage have mutilation anxiety [ Industry vs inferiority [ latency stage] they are afraid of being injured ] Ortho tx starts at this stage 4- Latency: 6-12 years old – care free years Identity vs role confusion [ genital 5- Genital :12- 18 years old stage] Object concept: 2-3 months – child will only observe at an object 3-6 months – child will grab the object 6-11 months – child will look for a hidden object Before the age of 7 you explain things to the child using [ immediate sensation] → tell the child that they need to brush their teeth so they looks white and nice and they have a very nice smell that everyone will like. After the age of 7 you explain things to the child using [ abstract reasoning] → you need to brush your teeth to prevent plaque and caries Q: how is classic conditioning related to dentistry? The child comes the first visit and sees you wearing a lab coat , you give them an injection [ sth painful ] , the next visit when they see a lab coat they start crying. Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 5 of 66 Crash Course in Pediatric Dentistry Behavior management The first objective of behavior management is establishing communication Positive reinforcement = providing the child with a pleasant stimulus [ high five, praise tap on the back etc ] Negative reinforcement = remove a negative stimulus after the child behaves properly [ex: if they don’t like your assistant, you tell them I can ask this person to leave but you have to open wide! Omission: removal of pleasant stimulus [ ex: taking away their fav toy ] Punishment: giving un pleasant stimulus [ ex: mildest form is voice control, withdrawal of fun activities ] Positive reinforcement types : 1- Direct : gifts and rewards [ most effective] 2- Vicarious : watching someone else getting a reward 3- Self administered : child feels proud of being good Q: how do you establish effective communication with the child? Before the child gets in you already know their name, what they like what is their nickname, fav superhero etc.. get down the their level [ your eye level should be the same and the child’s eye level ] and talk to them. Behavior rating scales Frankl scale : Definitely positive : very cooperative Positive : accepts tx but is sometimes cautious Negative : reluctant to accept tx Definitely negative : refuses tx Wright’s scale : Cooperative : most children Potentially cooperative : Lacking cooperative ability / pre cooperative [very young or special needs patients] - Objective fear : caused by direct physical stimulation [ ex: you gave the child an injection that was painful ] - Subjective fear: feelings and attitudes suggested by others [ex: the child’s friend will tell them that they went to the dentist and the dentist hurted them a lot] Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 6 of 66 Crash Course in Pediatric Dentistry Q: what can you do to positively affect a child’s behavior in the clinic? 1- Gather data about the child before they enter [ their fav toy, nick name etc..] 2- Structure your treatment [ explain to the child before each stage of the treatment or show them on a model] 3- Distract the child during the procedure [ make then hold the suction or watch cartoons etc ] 4- Be flexible [ accommodate each child’s needs] 5- Wear colorful colors and scrubs [ avoid wearing a lab coat ] 6- Make sure the clinic’s environment is friendly and pleasant 7- Make appointments short [ because kids have short attention span ] + make them in the morning when they will be well rested and more cooperative Behavior modification 1- Desensitization: Tell show do [ tell them what you will do , show them on a model and then do it on them] – make sure your communication with the child is very simple and link it to things they know [ syringe = special water , LA = sleeping medicine for the tooth , rubber dam = rain coat for your teeth etc..] 2- Modeling : the child watches other kids or videos of kids getting treatment and behaving properly → the child will later behave the same way When the child watches a video of other kids getting tx this is called vicarious modelling 3- Contingency management: presentation or withdrawal of reinforces [ positive reinforcement = giving gifts, praise, high fives etc] Behavior management 1- Voice control : loud voice to gain child’s attention then go back to your normal tone. 2- Physical restraint [ aversive conditioning]: you need to brief the parents before + get consent A. Mouth props : At the time of injection When children become fatigued Stubborn or defiant children Mentally / physically handicapped children Very young children B. Parent / assistant : parents sits in the dental chair with the child in their lap, the parents places one hand over the forehead and the other over the child’s hands C. Body wrappings : papose boards, Vac pac D. Hand over mouth [ HOME] : firmly place your hand over the child’s mouth until the verbal outburst stops - Done to : Gain child’s attention Stop verbal outburst + Establish communication indications Contraindications Normal children who become Very young children momentarily defiant or hysterical Immature and frightened children Child is mature to understand simple Physical / mental / emotional handicap verbal commands Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 7 of 66 Crash Course in Pediatric Dentistry 3- Pharmacological management: LA : Maximum allowed dose of LA = 4.4 mg / kg [ one carpule for every 10 kgs ] Oral sedation: desired effect is seen in 30 -60 mins Adv: no injections, you give it orally and the child starts to get sleepy then you work on them Disadv: child is still not fully cooperative because they are sleepy and cranky + you can’t titrate the dose Intramuscular sedation: desired effect is seen in 20 mins – injection sites: A. Upper outer quadrant of gluteal region B. Anterior aspect of the thigh C. Middle of the posterior lateral aspect of the deltoid Intravenous sedation: pt is still conscious benzo diazepine – desired effect is seen in 20-25 seconds once you see dropping of the eye lids → pt is well sedated Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 8 of 66 Crash Course in Pediatric Dentistry Early childhood caries - ECC ECC = nursing bottle caries , baby bottle tooth decay A. Seen in infants and preschool children [ below the age of 6 ] B. Demineralization at the necks of the upper incisors – mandibular incisors are not affected C. Decay pattern: Maxilla: incisors , canines, first molars Mandible: canines , first molars D. Lesion progresses to grind the necks of the teeth in advanced cases only a root stump is left Q: why does ECC follow this specific pattern? 1- Chronology of primary tooth eruption 2- Duration of the deleterious habit [ bottle feeding] 3- Muscular pattern of infant sucking Early colonization of MS is the most imp risk factor for developing ECC – MS transmission can be through the mother or from peers [ other kids] MS Colonization of pre dentate children is mostly associated with maternal factors [ high level of MS in the mother, poor OH and active caries ] Q: how is nocturnal bottle feeding / breastfeeding related to ECC? When child laid to rest, the bottle or breast nipple rests against the palate and tongue covers the lower incisors [ that’s why they are not affected] - As the child becomes sleepy, saliva flow and swallow reflex are reduced → Sugar remains stagnant around the neck of the teeth Q: what practices increase the chance of developing ECC? 1- Prolonged night time bottle feeding 2- On demand breast feeding after the age of 1 3- Frequent snacking with sugary foods 4- Frequent sipping of sugary drinks throughout the day Q: why should you treat ECC ? 1- Relieve pain 2- Prevent infection 3- Improve child’s self esteem 4- Retain teeth → maintain proper nutrition, occlusion and speech Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 9 of 66 Crash Course in Pediatric Dentistry Q: how would you manage a case of ECC? 1- Identify the cause and stop the habit 2- Give parental instruction on proper oral hygiene measures + diet counselling 3- Decide if the case can be managed in clinic [ with regular LA or nitrous sedation ] or the child needs GA If the case is treated in the clinic : full assesment of all affected teeth to know which teeth can be restored, which need pulp therapy and which need extractions Q: what instructions would you give the parents to a child with ECC? 1- STOP NIGHT TIME BOTTLE FEEDING / stop breast feeding at will after the first tooth erupts 2- Feed the child while being held + burp the infant after feeding 3- Clean the teeth after each feeding [ wipe the teeth with a wet gauze] 4- regularly lift the upper lip to check for signs of demineralization of the upper Anteriors E. OH should start with the eruption of the first tooth – wipe the teeth with gauze and for ages 2- 6 brush with low fluoride tooth past [ 400-500 ppm] – parental supervision until the child can properly spit F. Children are encouraged to drink from a cup as they become 1 year old G. Avoid frequent snacking and have regular meals instead H. First dental visit should be combined with immunization dates [ at or before 6 months] Prevention of ECC ideally begins pre natally: 1- give the mother information about diet and OH 2- treat the mother’s own oral diseases and lower MS count by mouthrinses and restorative care 3- educate the mother on modes of transmission of MS [ don’t lick spoons or pacifiers etc..] Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 10 of 66 Crash Course in Pediatric Dentistry Caries in Permanent teeth Primary dentition = from 4-6 months till 6 years Mixed dentition = 6- 12 years old Permanent dentition = when all primary teeth are replaced with their permanent successors Caries in mixed or permanent dentition have the same predisposing factors [ diet high in refined carbohydrates , poor OH, decreased salivary flow etc..] Diet analysis [ 24 hours diet chart ] = should be filled for 7 days [ must include a weekend – because the child will eat different types of food when they are not at school] Q: what salivary parameters should you measure when you are determining caries risk? 1- Consistency : thin or viscous [ thin watery is better – but not too thin because it means it’s protective contents are also diluted ] 2- PH and bicarbonate content [ bi carbonate content neutralizes acids in the mouth] 3- Ca/ Po4 /fluoride content [ to determine the ability of remineralization] 4- Immunoglobins content [ ability to resist caries] 5- Flow rate Q: if the child has high MS count , how can you lower it? Treat gross caries + prescribe antibacterial mouth wash if the child is above 6 yo. most to least susceptible teeth : first molar → upper molar → second molars → premolars → upper centrals & canines → lower centrals and canines NOTE: when caries level is low most of the caries occur on the occlusal surfaces [ pits and fissure caries ] as caries level increase the proximal and smooth surfaces get affected as well. Fluoride protects against smooth and proximal surface caries but not against pits and fissures [ that’s why even in fluoridated areas you’ll still see Pits and fissure caries that need to be prevented by fissure sealants] If the child has caries on their primary dentition they will mostly develop caries in their permanent dentition as well. [ because the oral environment is not changed – this is why it is important to treat caries in the primary dentition + improve OH and diet to prevent caries in the permanent dentition] Caries on the distal of E → will increase the risk of developing caries on the mesial surface of the 6 by 15 times [ even if the lesion is arrested you need to restore it because the hole will accumulate food and plaque → bacterial colonization and caries on the mesial surface of the 6. If you detect caries on one arch → examine the opposing arch & if you detect on one side → examine the contralateral side Hidden [ occult caries ] = the surface is intact and well mineralized but actually the lesion is huge inside the tooth because caries progress underneath – this is mostly seen in well fluoridated areas. Best management of hidden occult caries is early detection using radiographs Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 11 of 66 Crash Course in Pediatric Dentistry NOTE: worldwide there was a decrease in caries prevalence because of water fluoridation but then caries prevalence increased again because many countries stopped water fluoridation and investing in other programs + the diet changed and became more cariogenic [ processed foods, high sugar foods etc] Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 12 of 66 Crash Course in Pediatric Dentistry Restoring caries in young permanent teeth ICDAS = you must clean the tooth surface first before you determine the score [ otherwise caries will be underscored] – detect surface discontinuity with a perio probe not a sharp explorer because it can induce cavitation. 0 = sound tooth 1= opacity when drying the tooth 2= opacity without drying the tooth 3= microcavities – loss of surface integrity 4= underlying shadow 5- 6= cavitation Caries risk in pediatric patients Low Moderate High - Optimal fluoride exposures - Suboptimal systemic - Suboptimal topical fluoride exposure both systemic and topical fluoride exposure with - Frequent between meal snacking (3 or - Consumption of simple optimal topical exposure more) sugars limiting to mealtime - Between meal snacking (1- - Low level caregiver socioeconomic - High caregiver 2) status. socioeconomic status - Midlevel caregiver - No usual source of dental care (financially stable) socioeconomic status - Active caries present in the mother - Regular dental visits - Irregular use of dental - Children with special health care needs services Conditions decreasing saliva flow (medications, radiotherapy) Examine the tooth surface : If you suspect caries → take BW [ enamel caries do PRR , dentine caries drill and fill ] If you are sure there are no caries → seal with fissure sealant If the first permanent molar has deep caries and signs of pulpitis: A. Crowding present → do ortho consult → extract the tooth [ usually all 4 first molars are extracted to allow the 7 and 8 to drift mesially and fill the space] B. No crowding → Acute pulpitis → pulpotomy [ CaOH2 or MTA] Chronic pulpitis → apexification or pulpectomy Before extracting the first molars you need to verify that the child as 3rd molars [ radiographical evidence of 3rd molars is usually seen at 9 year and 6 months ] If you are using composite ideally use etch and rinse adhesive systems [ it will result in the strongest bond but it results in a higher chance of post op sensitivity and needs a cooperative child] Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 13 of 66 Crash Course in Pediatric Dentistry Self etch adhesives will save time and are perfect for uncooperative child and results in less post op sensitivity but they result in a weaker bond. Self etch adhesives are very hydrophilic, If you are using self etch adhesives → apply a layer of flowable composite over it to make it more hydrophobic Diamond burs leave more uncut collagen fiber → better bond strength When you are bonding to enamel → make sure the cavity is dry When you are bonding to dentine → the cavity should not be very dry and slightly humid to erect the collagen fibers and get better bonding To ensure max bond strength : 1- Use etch and rinse adhesive systems when you can – if you use self etch cover it with a layer of flowable composite 2- Use diamond burs to leave more uncut collagen 3- Make sure if the cavity is in dentine that it is not too dry [ to erect the collagen fibers] Stainless steel crowns for permanent teeth: 1- Hypoplasia / hypomineralization 2- Large carious lesions and lesions requiring pulp therapy 3- Special needs patients If stainless steel crown is placed on a perm tooth you need to adjust the crown margins and this is temporary until the child reaches 18 and can get a PFM or a porcelain crown. Hypoplastic anterior teeth can be treated by: 1- Microabrasion 2- Small saucer like preparations over the discolored areas and then fill them with composite Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 14 of 66 Crash Course in Pediatric Dentistry Restorative materials for primary teeth Q: why do you need to restore primary teeth ? 1- Restore function [ mastication, speech , occlusion, esthetics] 2- Relive pain and prevent spread of infection 3- Maintain occlusal height and arch length [ by restoring proximal caries] 4- Prevent the need for extractions and loss of space 5- By restoring primary teeth + reinforcing OH → you change the oral environment → less chance of caries in the perm dentition 6- Prevent possible damage to perm teeth [ ex: untreated infection in primary teeth can lead to turner’s tooth in perm teeth ] Q: how is restoring primary teeth different from restoring permanent teeth? 1- Primary teeth have limited life span 2- Variable levels of cooperation by the child 3- Primary teeth have different morphology Q: how is the morphology of primary teeth different from permanent? Greatest convexity is at the cervical 3rd Different MD width and crown height Enamel and dentine are thinner [ high chance of pulp exposure ] Larger pulp with more prominent pulp horns [ high chance of pulp exposure ] Pulp is closer to the mesial surface Contact areas are broad and flat Roots are longer , more slender and more flared Enamel rods at the cervical region are directed occlusally Q: how are materials used to restore primary teeth different from perm teeth ? 1- Materials used can have less longevity [ less wear resistance, less durability and less ability to withstand masticatory forces] 2- Have adequate strength even if placed in less bulk 3- Materials must have quick setting reaction 4- Able to work in moisture and less technique sensitive 5- Have good adhesive properties since less cavity prep is required NOTE: If after caries excavation you are not sure of the prognosis of the tooth → place GIC A. Pain goes away → remove a little bit of the GIC and place composite B. Pain is still there → consider pulpotomy / pulpectomy then composite or SCC Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 15 of 66 Crash Course in Pediatric Dentistry Stainless steel crowns [ SCC] Indications : - After pulpotomies / pulpectomies - Multisurface caries / fractured teeth - Developmental defects [ amelogenesis / dentinogenesis imperfecta] - Wear and loss of occlusal height - Young kids with high caries risk being treated under GA Full coronal coverage but poor esthetics – this can be fixed by placing a labial veneer with composite [ the veneer usually debonds + it’s very expensive to place] Procedure : https://www.youtube.com/watch?v=sBYXJjgXKZQ 1- Check occlusion before you start 2- Select crown size [ proper MD width, height and SLIGHT resistance to seating] Bring 3 crown sizes before you start [ the actual size you think will fit , one size bigger and one size smaller] 3- Adequate LA [ block or STA ( single tooth anesthesia )] 4- Occlusal reduction [ 1 – 1.5 mm] following cusp anatomy Occlusal reduction should be done before caries removal or pulpotomy [ or you can do pulpotomy – restore the tooth and then do occlusal reduction] You can check occlusal reduction by comparing the tooth to the adjacent marginal ridge [ it should be 1.5 mm lower than the marginal ridge of the adjacent tooth ] or you ask the child to bite on AlUWAX [ if you have enough reduction you will not see any perforations in the wax] 5- Caries removal / pulpotomy 6- Restore tooth after pulpotomy 7- Interproximal reduction [ just open the contact] + bevel all line angles No buccal reduction Is made because you want the bulge of the cervical region buccaly to aid in retention of the crown 8- Try the selected crown by placing it on the LINGUAL side then rotating it towards BUCCAL 9- Using an explorer make a scratch line on the gingival margin – remove the crown and using scissors or acrylic bur cut 1 mm below the scratch line then reinsert the crown 10- Check for any gingival blanching [ blanching means you need to trim a little bit more from the margins] 11- With crimping pliers crimp the margins to fit into the undercuts of the prep → after this the crown should snap into position under firm pressure – seat the crown again and check all the margins [ any open margins → crimp again ] Crown should have proper occlusion – same marginal level as adjacent – margins should be 1 mm below gingival margin 12- finish the cervical margin with finishing stones and polish 13- cement the crown using RMGIC – place a cotton roll and ask the child to bite down – remove excess + the marking on the buccal side Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 16 of 66 Crash Course in Pediatric Dentistry TIPS: if you are placing crowns on the first and second primary molars → do more interproximal reduction + fit the crown on the second molar first if the 6 did not erupt yet make sure you do enough distal reduction of the primary second molar [ if you place an over sized crown on E → ectopic eruption or impaction of the 6] most common size for D = 4 or 5 most common size for E = 4 in class II → the width of the isthmus is ½ the occlusal table width + you round the axiopulpal line angle Restorative materials in pedo : Amalgam – rarely used [ sometimes used if moisture control is very difficult] Resin composite [ highest esthetics + good micromechanical retention by acid etching – technique sensitive and requires good moisture control + cooperative child] GIC [ bonds chemically to the tooth structure - can be placed if moisture control is not excellent – poor esthetics – releases fluoride + gets recharged with fluoride every time the child brushes, poor wear resistance ] RMGIC [ resin + GIC → chemical bonding + light curing , stronger than GIC and better esthetics ] Compomers [ used if you want a material that is stronger / more esthetic than GIC but less technique sensitive than composite] THE GOLD STANDARD MATERIAL IN PEDO IS PACKABLE COMPOSITE – USED IN ALL CASES Fissure sealants: for deep fissures – you etch and then apply [ no bonding] PRR if there are carious areas on the occlusal surface you drill those areas slightly place flowable or packable composite and fissure sealants on the rest of the fissures PRR TYPES: Type A – caries are confined to the enamel Type B – caries are small but extend to the dentine Type C - caries are deeper into the dentine Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 17 of 66 Crash Course in Pediatric Dentistry Restoring primary anterior teeth : Single discolored tooth due to trauma but the tooth is vital → treat by a labial composite veneers Full coronal coverage for anterior teeth is indicated when: 1- Multisurface caries / Caries involving incisal edge 2- Extensive cervical decalcification 3- After pulpotomy / pulpectomy 4- Very poor oral hygiene - high risk caries 5- If you are doing treatment under GA Composite strip crowns [ cellulose crown former]: 1- Incisal reduction + remove caries 2- Proximal reduction 3- Trail fitting of the cellulose crown – make a hole on the palatal surface 4- Etch the tooth – wash and dry then apply bonding 5- Fill the crown with composite resin - remove excess from the palatal hole and cure 6- Remove the crown former - usually no need for finishing but make sure you remove any excess cervically Anterior SCC : not esthetic but a labial composite veneer can be added Esthetic primary anterior crowns [ zirconia crowns ] Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 18 of 66 Crash Course in Pediatric Dentistry Pulp therapy in primary teeth In primary teeth the initial signs of pulpal inflammation are seen in between the roots because Pulp chamber floor is very thin and porous + most accessory canals open into the furcation area [at a later stage the PA region will have a radiolucency as well] Q: when can you only treat by a restoration ? 1- Caries confined to the enamel or slightly into dentine 2- No symptoms or pain [ or signs of reversible pulpitis ] 3- No signs of iireversible pulpitis 4- PDL + PA region are sound radiographically Q: why is the pulp easily affected in primary teeth ? Primary teeth have thin enamel + large pulp chambers + wide DT → inflammation easily reaches the pulp PULP THERAPY INDICATIONS CONTRAINDICATIONS Bleeding disorders and coagulopathies Congenital heart disease [ risk of [ hemophilia and von willbrand disease] infective endocarditis] In such cases you want to avoid extraction Immunocompromised pt [ cancer pts because you don’t want bleeding and long term corticosteroid users ] Poorly controlled diabetics [ poor healing potential ] Special needs / dis abilites In such cases you want to extract and not do pulp therapy because you don’t want to leave a source of infection If the tooth is close to it’s shedding time → extract don’t do pulp therapy Pulpotomies and pulpectomies are better done on young primary teeth that will stay for a long time If the child has on and off pain that is not annoying them very much → do indirect pulp capping [ remove caries and keep affected dentine → apply CaOH2 then GIC ] You can’t really depend on history of pain in children to determine pulp status because children don’t really know how to describe the pain If the tooth is mobile → indicates pulp necrosis + PA involvement After pulp therapy posterior teeth should be restored with SCC and Anteriors with strip crowns [celluloid crowns] Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 19 of 66 Crash Course in Pediatric Dentistry PULP THERAPY : Indirect pulp capping There should not be any signs of pulpitis Remove caries → keep affected dentine [ make sure DEJ is free of caries ] → place CaOH2 then ZOE followed by GIC [ if you want excellent coronal seal → place composite over the GIC] Direct pulp capping [ NOT DONE IN PEDO ] Unsuccessful in pedo Pulp is already inflamed so if you place pulp capping material → internal root resorption Pulpotomy : removal of the coronal pulp tissue Indications Contraindications 1- Pulp is reversibly and minimally 1- Spontaneous, unprovoked pain inflamed [Signs of irreversible pulpitis / 2- Destruction of marginal ridge in first necrosis] primary molar 2- Intra-oral swelling 3- Radiographic evidence: 3- Mobility A. Caries extends >2/3 depth 4- On coronal pulp removal: through dentine A. No haemorrhage - necrotic B. No sign of pathological root pulp resorption B. Hyperaemia - irreversible 4- Minimal hemorrhage on pulpotomy pulpitis 5- Tooth is restorable 5- Tooth close to the date of exfoliation 6- Non restorable tooth Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 20 of 66 Crash Course in Pediatric Dentistry Pulpotomy procedure : 1- Adequate LA 2- Use large size round bur to remove all caries and overhangs 3- Spoon excavator to remove all soft caries 4- Use low speed round bur to open and de roof the pulp chamber 5- If the pulp is inflamed it will start bleeding → with spoon excavator or large round bur remove the pulp from the pulp chamber Do We Still Need Formocresol in Pediatric 6- Control hemorrhage by applying a cotton soaked with CHX or saline Dentistry? 7- Place ferric sulfate [ formacresol] or MTA https://www.cda-adc.ca/jcda/vol-71/issue- 8- SCC / anterior strip crown 10/749.pdf if you place Ferric sulfate in a cotton pellet for 1 min then remove the cotton and place ZOE or IRM if after removing the coronal part of the pulp chamber, radicular pulp still bleeds → you need to do pulpectomy Insert a small file inside the canals and remove the pulp tissue → enlarge to 2 sizes larger using files → irrigate with saline / CHX→ dry canals and place Metapex [ CaOH2 + iodoform] → place ZOE then GIC then composite and next session prepare for SCC Q: what medications can be used for pulpotomy ? 1- Formocresol – contains formaldehyde ( carcinogen ) – bactericidal 2- Ferric sulphate – excellent hemostatic agent but no bactericidal effect 3- Calcium hydroxide [ not used in primary teeth because it causes internal resorption - used only for Cvek partial pulpotomy in permanent teeth ] 4- Glutardehyde 5- Electrosurgery 6- MTA Q: how can you know that the pulpotomy worked? 1- No radiographic evidence of internal resorption 2- No breakdown of periradicular tissues 3- No symptoms like pain or swelling Material from inside to outside : MTA → ZOE → GIC → composite → SCC Pulpectomy : removal of the coronal pulp tissue + radicular pulp tissue Indications Contraindications 1. Evidence of pulpal necrosis 1. Non restorable teeth 2. Hyperaemic pulp / irreversibly inflamed 2. internal root resorption 3. Evidence of furcation / periapical involvement 3. Mechanical or carious perforations of the on radiographs floor of the pulp chamber 4. Spontaneous (unstimulated) pain 4. bone loss 5. Presence of dental or follicular cyst Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 21 of 66 Crash Course in Pediatric Dentistry Q: what medications can be used in pulpectomy? 1- calcium Hydroxide (Vitapex - CaOH + iodoform) 2- Zinc Oxide Eugenol ( non - reinforced) – paste consistency in the chamber and thin consistency in the canals but takes time to mix and place 3- Iodoform paste (e.g. Kri paste) If pulpectomy fails → you need to extract the tooth Long term success after pulp therapy depends on coronal seal Most failure in pulp therapy is due to inappropriate case selection [ diagnosis] Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 22 of 66 Crash Course in Pediatric Dentistry Fluoride modalities in pediatrics Q: what are the protective mechanisms of fluoride? 1- Fluoride changes HA crystals to fluoro apetite crystals which are more acid resistant and less soluble 2- Fluoride binds to proteins in plaque and stays there to be released when the PH drops below 5.5 3- Fluoride inhibits bacterial enolase → inhibits acid production Fluoride acts in 2 ways: A. Pre eruptive : fluoride gets incorporated into the enamel while the → makes enamel stronger + alters the grooves and makes them less plaque retentive B. Post eruptive NOTE: the percentage of fluoride in the water depends on the climate of the place [ cold countries → fluoride in water = 1 ppm , hot countries fluoride in water = 0.7 ppm ] Fluoride varnish / mouthwashes are contraindicated in children below 6 because they will swallow most of it. Ages 2- 6 years old → low fluoride containing toothpaste [ 400- 600 ppm] – smear or pea amount - Children above 6 and at high caries risk → use toothpaste with 1000 ppm If the child is at high risk you tell them to spit and not rinse after brushing. children should be monitored until the age of 6-8 Fluoride varnish: DURAPHAT [ 5% sodium fluoride ] – 2.26 % fluoride ion wipe the teeth with gauze to dry them → apply varnish onto tooth surface [ you can use absorbing dental floss and insert fluoride interproximally] the varnish will form a sticky coat on the teeth that dissolves slowly over several days [ maximum absorption of fluoride into the tooth surface and minimal risk of fluoride ingestion] fluoride varnish also increases the fluoride content of saliva CAUTION: instruct the child to not eat or drink for 1 hour and do not brush their teeth same day of the application Fluoride varnish tubes are no longer used because the fluoride used to settle in the lower end of the tube and there would not be equal concentration of fluoride all over the tube. Even if you are using fluoride packs make sure you mix it well before application Prophylaxis does not increase the effect of fluoride – applying it over plaque is more beneficial [ Fl is released when PH drops below critical point ] Q: do you need to do prophylaxis before placement of fluoride varnish / APF gel? If there is a lot of calculus / plaque with gingival inflammation → do prophylaxis and apply fluoride in the NEXT session [ because there will be bleeding when you do prophylaxis] Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 23 of 66 Crash Course in Pediatric Dentistry But if plaque is minimal keep it and apply fluoride [ fluoride will adhere to the proteins in the plaque and release when the PH drops below 5.5] APF gel : 1.23% acidulated phosphate fluoride gel CAUTION: APF gel contains hydrofluoric acid to increase enamel porosity then fill it with fluoride to change HA into FA crystals – but it cannot be applied if the child has open carious lesions [ the acid will easily reach the pulp] If there are enamel or dentine lesions you can still use APF , you only can’t use it if there is frank cavitation [ in this case use sodium fluoride varnish] recommended at ages 6- 18 , every 3 – 6 months for an application time of 4 minutes APF has 3 types : 1 minute foam 1 minute gel 4 min gel [ the only one that is effective] application: APF gel is applied in foam trays [ both upper and lower arches are together ] 1- Load 3rd of the tray with the gel and insert both upper and lower trays into the mouth at the same time 2- Ask the child to grind or chew to change the thixotropic gel into a solution allowing it to go interproximally Application time = 4 minutes Patient should be sitting up right with head tipped forward and has high saliva ejector in their mouth 3- Ask the child to spit for 1 minute after application Child should not eat / drink for 30 mins Silver diamine fluoride [ SDF] : applied on active carious lesions to arrest them. Active component is SILVER [ anti bacterial and anti fungal – when applied will stabilize all cariogenic bacteria in the cavity – the lesion is then mineralized by fluoride] Ammonia is added to stabilize silver Drawback of SDF: when applied it changes the carious lesions black. SDF/ KI [ Riva star] : SDF alone will cause the lesion to turn black but if it is coated by potassium iodide the lesion does not change color [ remains brown ] Indications of SDF: 1- Caries control in all ages 2- Extreme caries risk [ xerostomia / ECC] 3- Tx Behavioral / medical compromised pt [ hospitalized pts , eldery , uncooperative children ] 4- If you can’t treat all lesions in one session SDF can also be applied for : Acute pulpitis / as cavity liner / indirect pulp capping Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 24 of 66 Crash Course in Pediatric Dentistry Application of SDF : 1- Dry the tooth surface 2- Apply 1 drop / kg of body weight per visit 3- Apply for 1 minute then rinse 4- You can cover SDF with GIC or composite Titanium tetrafluoride Excellent for caries and tooth erosion – results in glazed like layer Higher and more rapid uptake of fluoride because each titanium ion hold 4 fluoride ions that quickly remineralize any demineralized spot Sorbitol in toothpaste = laxative Nitrate containing toothpastes [ used to reduce hypersensitivity] = can cause methemoglobinemia Fluoride supplements: Indicated only in high risk children whom dental disease will cause a risk to their general health [ children at risk of infective endocarditis] They are only effective if they are given over a long time – the aim is to make the child caries free to a point where you don’t need to do any Tx. [ because each procedure would require prophylactic ABX] Q: what would you consider before prescribing fluoride supplements ? 1- Age 2- Caries risk 3- Other sources of fluoride [ specially content of fluoride in drinking water] Age Fluoride in water 50X 106/L before extraction] Coagulopathies haemophilia A (deficiency of factor 8) haemophilia B (deficiency of factor 9 ) von willebrand’s disease (abnormality of factor 8 molecule complex) Dental implications: o Extraction and periodontal therapy requires factor replacement with consultation with haematologist o Endodontic therapy can be safely carried out without factor replacement o Use rubber dam to minimize chance of ST injury Thalassemia avoid treatment if hemoglobin is less than 100 g/L Leukemia Acute lymphoblastic leukemia (ALL) : is the most common in children Oral Complications: Erosive or ulcerative lesions Oral infection & Candidiasis Gingival bleeding Gingival hypertrophy -direct invasion of tissue by an infiltrate of leukemic cells Spontaneous dental abscess formation Loss of teeth: necrosis of the PDL Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 46 of 66 Crash Course in Pediatric Dentistry NOTE: if you notice that the child has gingivitis and abscess formation without any local cause → test for leukemia Management: 1- No active dental treatment should be carried out untill the child is in remission ( remove abnormal cells from the blood and bone marrow) 2- Dental pain treated conservatively by the use of antibiotics and analgesics 3- Swabbing the mouth with chlorhexidine mouthwash and use of antifungal agents + LA preparations at mealtime [ to reduce pain from the ulcers ] Once leukaemia is in remission dental treatment done with the following adjustment: 1- Haematological information required for invasive procedures 2- Prophylactic antibiotic to prevent postoperative infection 3- Children who are immunosuppressed need active antifungal treatment 4- Long term preventative care Immunodeficiency Qualitative defects in neutrophils – Leukocyte adhesion defect – Chediak-Higashi syndrome Quantitative defects in neutrophils - Neutropenia - Cyclic neutropenia Phagocytic disorders - Agammaglobulinaemia Defect in microbial killing - Chronic granulomatous disease Primary immunodeficiencies Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 47 of 66 Crash Course in Pediatric Dentistry – Involving T cells, B cells, complement or combined defects and acquired disorders (e.g. HIV,chemotherapy and radiotherapy) Management : Dental implications: 1- Prophylactic antibiotic therapy 1- Candidiasis 2- Extraction of pulpally involved 2- Severe gingivitis/prepubertal periodontitis teeth ** 3- Gingivostomatitis 3- Acyclovir for recurrent HSV 4- Recurrent aphthous ulceration 4- Antifungals 5- Recurrent herpes simplex infection 5- Chlorhexidine 0.2% mouthwashes 6- Premature exfoliation of primary teeth ** Organ transplants : those children are mostly on cyclosporine immunosuppressants → Management : 1. Eliminate infection [ teeth with large caries, tooth soon to be exfoliated should be extracted ] 2. Perfect OH 3. ABX prophylaxis before invasive procedures 4. Gingivectomy if needed gingival overgrowth Cerberal palsy: Cognitive ability of a child with cerebral palsy should be determined because many patients have no intellectual impairment Reflex limb extension patterns may be triggered when the limbs are in extension or when the head is unsupported → transfer of the child to the dental chair should be done with care Gag, cough, bit and swallowing reflexes may be impaired or abnormal → Mouth props may be used but these kids are at risk for aspiration [ all used instruments should be tied with floss to avoid being swallowed by the child] Visually impaired Allow the child to touch the instruments and smell the materials + you need to explain to them before you do the procedure [ do not surprise them because they can have a startle reflex and push you] Use safety glasses as they are light sensitive Hearing impairment: Those children can lip read so face the child and speak slowly and clearly Try to learn basic sign language Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 48 of 66 Crash Course in Pediatric Dentistry Maintain visual contact Deaf children are sensitive to vibration so introduce high speed hand drills with care Hearing aid volume need to be adjusted [ lower the volume of the hearing aid device so they are not annoyed by the sounds in the dental clinic] Down syndrome Determine the need for endocarditis prophylaxis [ because some might have cardiac anomalies] Down syndrome children are susceptible to periodontal disease → emphasize on: daily tooth brushing with fluoride tooth paste 500ppm 0.12% chlorhexidine mouth wash in older children Pediatric oral medicine & oral pathology Presentation of pathology in children is often different from adult Odontogenic infections Acute Chronic 1. sick and upset child 1. Sinus tract 2. Raised temperature 2. Mobile tooth 3. Anxious and distressed parents 3. Halitosis [ because of the puss] 4. Red and swollen face [Facial cellulitis] 4. Discolored tooth [ because of the posterior spread of maxillary canine fossa necrotic pulp] infection may lead to cavernous sinus thrombosis Mandibular infection may compromise the airway If infection has perforated the cortical plate child may not be in pain Management of odontogenic infections in children : Removal of the cause + Local drainage and debridement If the child does not respond to oral Maintenance of fluids ABX [ persistent fever, raised tongue Use of antibiotics ( penicillin or Amoxicillin + metronidazole and difficulty breathing / swallowing ] or augmentin +/- metronidazole ] → transfer the child to the hospital to 0.2% chlorhexidine gluconate mouth wash get parental ABX Pain control with paracetamol ABX for infections in pediatrics [ abscess, odontogenic infections] Medication Dose Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 49 of 66 Crash Course in Pediatric Dentistry Augmentin 312 mg in 5 ml OR 157 mg in 5 ml [ for very young children] Amoxicillin 25 mg / kg **Both can be combined with metronidazole 7 – 7.5 mg /kg Paracetamol = 15 mg / kg Primary Herpetic Gingivostomatitis Most common cause of severe oral ulceration in children Mostly caused by HSV l [ Usually occurs after 6 months of age] Fever , malaise then appearance of Vesicles and ulcers → Self-limiting ulcers heal spontaneously with in 10 to 14 days Management: 1- Oral fluids + Analgesics 2- Mouthwash 0.2% chlorhexidine gluconate 3- Antiviral oral suspension for severe cases - Administration of aciclovir in the first 72 hrs of infection before the vesicle formation may resolve the infection Herpangia Caused by Coxsackie group A virus fever and malaise before the appearance of the vesicles → Self-limiting ulcers heal spontaneously with in 10 to 14 days Most common viral infections in Management: symptomatic care children = herpangia and primary herpetic gingiva stomatitis 1- Oral fluids + Analgesics 2- Mouthwash 0.2% chlorhexidine gluconate Most common fungal infection in children = Acute pseudomembranous Acute pseudomembranous candidosis candidosis Thrush in infants [ White plaques which on removal reveal an erythematous base ] Management : Antifungal medication Nystatin or amphotericin B for at least 4 weeks Recurrent apthous ulcers Minor aphthae : crops of shallow ulcers [ Yellow pseudomembranous slough with erythematous border ] measuring up to 5mm on the non-keratinized mucosa - Heals with in 10 – 14 days Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 50 of 66 Crash Course in Pediatric Dentistry Major aphthae: on keratinized mucosa - Last longer and heal with scarring Management: Symptomatic care + mouthwash + Topical steroids Erythema multiforme Self limiting with mucosal involvement limited to the oral cavity target lesions occur on the limbs. This lesion has concentric colour with erthematous halo and central blister. Management : Debridement with 0.2% chlorhexidine gluconate + Adequate fluid replacement + Pain control Stevens Johnson syndrome Acute febrile illness + generalized exanthema +oral lesions and purulent conjunctivitis Vesiculobullous eruption over the body Severe involvement of multiple mucous membranes: oral, vulva, penis and conjunctiva. Management : Debridement with 0.2% chlorhexidine gluconate +Adequate fluid replacement and + Pain control Eruption cyst or haematoma Follicular enlargement appearing just before tooth eruption [ Lesion tend to be blue-black ] – the erupting tooth will eventually rupture it Management : No treatment unless infected Phenytoin enlargement Enlargement of the inter dental papilla + delayed eruption due to bulk of fibrous tissue Management : Maintenance of oral hygiene + 0.2% chlorhexidine gluconate mouth wash + Gingivectomy Cyclic neutropenia Episodic decrease in the number of neutophils every 3 to 4 wks - Peripheral neutrophil count drops to zero during this period the child is susceptible to infection. Recurrent oral ulceration, gingival and periodontal involvement resulting in mobile of teeth. Management: Early preventive involvement + Dental care though all stages of cycle + 0.2% chlorhexidine gluconate mouth wash Epstein’s pearls Small nodules present on midline of the hard palate Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 51 of 66 Crash Course in Pediatric Dentistry Bohn’s nodules Remnants of dental lamina occur on the labial or buccal aspect of the maxillary alveolar ridge Management: No treatment Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 52 of 66 Crash Course in Pediatric Dentistry Anomalies in pediatric dentistry Hypodontia : less number of teeth – usually associated with microdontia / is part of a syndrome Most commonly affected teeth = lateral incisors + mand 2nd premolars I. Andontia : no teeth J. Oligodontia : few missing teeth Hypodontia Is seen in: Cleft palate can cause failure of the A. Rubella [ german measles ] tooth bud to develop → hypodontia B. Down syndrome C. Ectodermal dysplasia Or splits the tooth bud into two → D. Cleft palate [ most commonly missing tooth with CP hyperdontia = lateral incisor ] Management of hypodontia: pedodontist + orthodontist + prosthodontist A. Crowded arch → teeth are reshaped and adjusted to look like normal teeth B. Spaced arch → ortho tx + artificial teeth to act as space maintainers until the age of 20 [ so the pt can get fixed prostho] Hyperdontia : super numerary teeth – associated with (Cleido Cranial Dysostosis, Gardner Syndrome) – might occur on both sides of a cleft palate Mesiodense = extra tooth between the central incisors [ most common] Paramolar = extra tooth in molar region either buccally or lingually Distomolar = extra tooth behind the last molar Hyperdontia can be complex [ island of enamel , dentine and cementum mixed together as a disorganized mass] or can be compound [organized into tooth structures] Management of hyperdontia: extraction of the extra teeth to prevent : 1- Ectopic / disturbed eruption. 2- cystic degeneration. Fusion Union between dentin and-or enamel of two separately developed teeth One tooth missing - Radiographically, roots appear separate Gemination Incomplete division of single tooth bud + Notching of the incisal edge. Normal teeth count - One root radiographically. Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 53 of 66 Crash Course in Pediatric Dentistry Microdontia smaller teeth than normal mostly lateral incisors and 3rd molars – can be associated with Ectodermal dysplasia & pituitary dwarfism - Management: Build up when available space is convenient, consider extraction and orthodontic treatment. Sanjad Sakati Syndrome Dwarfism + Mental retardation. + Microdontia. + High arched palate. + Micrognathia. Macrodontia: larger than normal tooth - Management: crown reduction to 1 mm is acceptable. Consider extraction and prosthesis, implants and or orthodontic treatment. Dense evaginatus An enamel covered tubercle projecting from the occlusal surface of a premolar, canine or molar tooth. - Management: Composite build-up to support the tubercle – Gradual enamel reduction Dense invaginatus [ dense in dente] : A developmental invagination of the cingulum pit with only a thin hard tissue barrier between the oral cavity and the pulp - Management: Fissure seal as early as possible Talon cusp A horn like projection of the cingulum of the maxillary incisor teeth. - Management: If occlusal interference present - gradual reduction of enamel or elective pulpotomy or RCT If it is not disturbing the pt → leave it Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 54 of 66 Crash Course in Pediatric Dentistry - Enamel hypo plasia = defective quantity of enamel - Enamel hypocalcification = defective quality of enamel Turner’s hypoplasia: Localised infection or trauma to a deciduous tooth affects enamel formation of the underlying permanent tooth. Amelogenesis imperfecta : normal size and shape. normal dentine and pulp. abnormal enamel hypoplastic/ hypominiralised or both Dentinogenesis imperfecta : teeth have normal contour at eruption, but present with a distinctive amber-like hue enamel is normal, but it is weakly attached to the dentine and is rapidly lost → teeth show marked attrition Type 1 – DI with osteogenesis imperfecta. Type 2 – DI “stand alone" with no systemic involvement. Type 3 – Brandywine type with large pulp chambers. Regional odontodysplasia : Poorly mineralized enamel & Dentin - large pulp chambers with pulp stones present. Taurodontism (Bull-like tooth) : molar with elongated crown & apically placed furcation of the roots, resulting in an enlarged rectangular coronal pulp chamber. Associated with : Ectodermal dysplasia, Klinefelter's syndrome , Down's syndrome Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 55 of 66 Crash Course in Pediatric Dentistry Dilaceration : Sharp bend or angulation of the root - results from trauma during tooth development Concrescence : two or more teeth united by cementum Hypocementosis: reported in some conditions including cleidocranial dysostosis and hypophosphatasia Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 56 of 66 Crash Course in Pediatric Dentistry Developing dentition in pediatric pts Q: what are self correcting anomalies in children ? anomalies that get corrected with time and by the eruption of the permanent teeth [ Ex: large perm teeth , crowded lower anteriors , spacing between upper incisors] At 2 years the primary dentition is complete [ 20 teeth] and the primary dentition continues till the age of 6. Primary teeth will undergo attrition leading to edge to edge occlusion. Q: Edge to edge bite in children is normally seen at ? 5.5 years AGE NOTES DENTITION STAGE 0 – 6 MONTH Gum pads No teeth just gum pads The gum pads contact posteriorly resulting in anterior open bite that is occupied by the tongue 6 – 36 MONTH Eruption of primary The first primary tooth to erupt is the lower incisor teeth Anterior teeth erupt in an upright position → less overjet There is deep bite 6 M – 6 YEARS Primary dentition A. Spaced dentition = less risk of crowding later on B. Closed dentition = more risk of crowding later on [ but the increase in the intercanine width in the maxilla and the mandible + jaw growth gives space and prevents crowding] Primate spaces = physiological spaces [ present in both spaced and closed primary dentitions] Located mesial to the upper primary canine and distal to the lower primary canine. 6-9 Early mixed When the first perm molar erupts , they erupt in an end to dentition end occlusion then they will move mesially closing the lower primate space → resulting in class 1 relationship [ early mesial shift] 9-12 Late mixed Eruption of the perm premolars and canines dentition Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 57 of 66 Crash Course in Pediatric Dentistry Molars the relationship In the permenant molars the relationship is cusp to fossa and you use Angle’s classification. But in primary molar teeth the relationship is based on a line drawn distal to the primary second molars Mesial step = lower primary second molar is mesial to upper primary second molar Distal step = lower primary second molar is distal to upper primary second molar Flush terminal plane = staright line between upper and lower second primary molars If the child has mixed dentition you need to classify the primary molar relationship and the perm molar relationship Q: how does the end to end occlusion of the perm first molars change into class 1 relationship ? Either by early mesial shift ( age 6-9 ) [ when the lower perm molars erupt and move mesially utilizing the lower primate space and resulting in class I occlusion ] or by using the late mesial shift ( age 9-12) [ even if there is not enough primate space, the molar relationship will still change to class I because primary molars and canines have a larger MD width than perm premolars and canines [ leeway space] → the perm molars use this leeway space and result in class I occlusion] Early mesial shift = the molars utilize the primate spaces to result in class I occlusion Late mesial shift = the premolars erupt and the molars utilize leeway space Incisal liability the MD of the primary incisors is smaller than the MD of the perm incisors [ tooth size difference is 6-7 mm] Q: how does the incisal liability get adjusted ? 1- Interdental spacing will give 2-3 mm 2- Intercanine arch growth will give 3-4 mm 3- Incisor labiality [ labial inclincation of the upper incisors] will give 1-2 mm Leeway space of Nance the MD width of the primary molars and canine is larger than the MD width of the perm premolars and canines Leeway space in the maxilla = 0.9 mm in one side and 1.8 mm in both sides Leeway space in the mandible = 1.7 mm in one side and 3.4 mm in both sides Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 58 of 66 Crash Course in Pediatric Dentistry As you go from the primary dentition to the perm dentition the arch length is reduced [ because of the mesial movement of the perm molars – the late mesial shift ] Ugly duckling stage [ Broadbent phenomenon] – from 9- 11 years : Flaring of the upper perm central and lateral incisors – it is a transient malocclusion that will be corrected by the eruption of the perm canines. Q: what causes the ugly duckling stage / flaring in the perm incisors? because when the perm canines erupt they will apply pressure on the roots of the upper perm centrals causing the flaring. But as the canine continues to erupt down the diastema closes Ortho tx is only done if after the eruption of the canine there was residual diastema. If the molars are already in class I relationship but there is anterior crowding → hold the molars using a retainer [ nance or lingual arch ] and use the leeway space to adjust the incisor crowding. Serial extraction: sequential extractions of primary teeth to allow the proper alignment of the perm teeth ADV: no force is used to align the teeth + no problems with retention DISADV: you need proper diagnosis + pt follow and compliance 1- The primary canines are extracted to provide space and allow the eruption of the permanent lateral incisors 2- The primary first molars are extracted to accelerate the eruption of the 1st perm premolars to erupt before the perm canines if possible 3- Extraction of the first perm premolars to allow the perm canines to move distally and fill the space of the 1st perm premolars Final outcome after serial extractions: 1- Aligned incisors 2- Missing first premolar 3- Canine occupying space of 1st premolar 4- Spacing in the posterior segment Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 59 of 66 Crash Course in Pediatric Dentistry Interceptive orthodontic procedure in pediatrics Interceptive procedures you see a problem during mixed dentition and you interfere at this stage to prevent it from becoming malocclusion in the perm dentition Tongue thrusting and thumb sucking will lead to → upper anterior proclination , anterior open bite and posterior crossbite. The pressure from the tongue on the palate will cause the anterior teeth proclination + the tongue does not allow the posterior teeth to contact → supra eruption of the post molars → anterior open bite The thumb also pushes the tongue down → allowing un apposed contraction of the buccinator msucles → maxilla constricts → posterior crossbite If the thumb sucking habit is stopped → normal muscles will correct mal occlusion and the anterior open bite should close in 6 month Habit breaking appliances used for tongue thrusting and thumb sucking [ usually used around the age of 8- 9 years] Has a fence to prevent the thumb from entering the mouth and to prevent tongue thrusting The fence should not contact the lower incisors If the child cannot tolerate a removable appliance → do fixed nance appliance and then solder the fence over the wire Hayley’s reminder appliance Blue grass appliance Nance appliance + Teflon ring → prevents thumb sucking The child plays with the ring then eventually stops the habit Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 60 of 66 Crash Course in Pediatric Dentistry Mouth breathing Causes of anatomical mouth breathing : 1- Deviated nasal septum 2- Allergic rhinitis, nasal polyps 3- Enlarged adenoids or tonsils 4- Short upper lip preventing lip seal 5- Obstruction in the bronchial tree Habitual mouth breathing is not associated with any anatomical defects – as a dentist you can only fix habitual mouth breathing – using In Habitual mouth breathing – the lips are Oral screen [ acrylic plate placed on the buccal flaccid [ low lip competence ] ➔ a ring can be vestibule , the plate has perforations to allow attached to the oral screen so the child pulls breathing and you gradually close those the ring and the screen up and down to perforations with composite so the child stops stretch the lips and increase lip tonicity and mouth breathing and breathes through the competence nose. Lip bumper can be used to correct lower anterior crowding and distalize the molars + correct lower anterior retroclination caused by lower lip biting The acrylic will push the lower lip forward → prevent the child from biting on the lower lip The force of the orbicularis oris will be transmitted through the acrylic button then through the wires to the molars causing distillation providing space to correct lower crowding. Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 61 of 66 Crash Course in Pediatric Dentistry Anterior crossbite [ tx options] Tongue blade therapy Lower inclined plane (catalan’s appliance) Removable Hawley’s appliance [ simplest way to correct anterior cross bite] Fixed appliances Hawley’s appliance = acrylic plate + Z spring [ to move the teeth buccaly ] + posterior bite plane [to open the bite and bring the teeth to an edge to edge contact ] catalan’s appliance = acrylic plate fixed on the lower arch and inclined at 45° [ child wear’s it for 10 -14 days only]. During biting the upper anterior teeth will slide against the lower 45° incline and move labially correcting the crossbite Q: what happens if you give catlan’s appliance for more than 10 days? It will cause supra eruption of the posterior teeth and anterior open bite Tongue blade therapy = used when you see that the tooth is erupting in a crossbite relationship – you ask the child to bite down on a tongue blade to give a labial push while the tooth is erupting. Tonugue blade therapy is done for a few hours daily for 2-3 weeks Fixed appliance= helix appliance or acrylic plate with midline screw to cause maxillary expansion Tongue thrusting , mouth breathing , thumb sucking all cause posterior crossbite Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 62 of 66 Crash Course in Pediatric Dentistry Management of premature loss of primary teeth in mixed dentition 1- Space supervision : done when the primary teeth are removed and you don’t know wether the perm tooth is erupting or not → take an OPG + PA radiographs + upper and lower casts for space analysis It takes 6-8 months for a tooth to 2- Space maintainer : indicated if the tooth need more than 6 move 1 mm in bone. months to erupt [ there is bone covering the tooth + the root is not fully formed ] If more than 2/3 of the root is formed → the tooth is in active eruption [ no need for space maintainer] 3- Space regainer : used if there is space deficiency No bone covering the tooth + there is enough space or the tooth is in active eruption → just do space supervision Space maintainers for unilateral space loss A. Band and loop / crown and loop B. Distal shoe space maintainer: used if the 6 is not erupted Acts as an eruption guiding appliance to guide the eruption of the perm first molar + a space maintainer for the perm premolar The distal extension will guide the eruption of the perm molar in an upright position , once the 6 is erupted → remove the distal shoe and replace it with a band and loop space maintainer Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 63 of 66 Crash Course in Pediatric Dentistry Space maintainers for Bilateral space loss [ mandible ] lower lingual holding arch : the wire should contact the incisors Space maintainers for Bilateral space loss [ maxilla] A. Transpalatal Arch (Bar) : used for space loss [ as a space regainer] , both molars are moved together – can be used if the child can’t tolerate nance acrylic button B. Nance Appliance: has an acrylic button to prevent the molar from moving forward [ more effective but the acrylic can be annoying to the child] Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 64 of 66 Crash Course in Pediatric Dentistry References ▪ McDonald, R. E., Avery, D. R., & Dean, J. A. (2011). McDonald and Avery's dentistry for the child and adolescent. Maryland Heights, Mo: Mosby/Elsevier. ▪ World Health Assembly. Resolution. 60.17. New York, NY, USA: United Nations; 2006. Oral health: action plan for promotion and integrated disease prevention. ▪ United States Environmental Protection Agency. Report to Congress. section 112 (n) (16) Washington, DC, USA: Clean Air Act; 2000. Fluoride. ▪ Warren JJ, Levy SM. Current and future role of fluoride in nutrition. Dental Clinics of North America. 2003;47(2):225–243. ▪ Hellwig E, Lennon AM. Systemic versus topical fluoride. Caries Research. 2004;38(3):258–262. ▪ Limeback H. A re-examination of the pre-eruptive and post-eruptive mechanism of the anti-caries effects of fluoride: is there any anti-caries benefit from swallowing fluoride? Community Dentistry and Oral Epidemiology. 1999;27(1):62–71. ▪ Ismail AI, Hasson H. Fluoride supplements, dental caries and fluorosis: a systematic review.Journal of the American Dental Association. 2008;139(11):1457–1468. ▪ Choi AC, Sun G, Zhang Y, Grandjean P. Developmental fluoride neurotoxicity:a systematic review and meta-analysis. Environmental Health Perspectives. 2012;120(10):1362–1368. Done By : Sima Habrawi Dentiscope 2020 Edit By : Haif AlQahtani Page 65 of 66 Crash Course in Pediatric Dentistry Disclaimer By using Dentiscope, you understand that:  This is a non-profit project established by the founders, purely with the intention of relaying knowledge to dental students and young dentists around the world.  None of the contents should be sold, replicated or translated without prior formal and written consent from the team.  This is NOT a substitute for medical resources and formal education. Limitation of liability:  There may be mistakes in the published content, although it will be reviewed thoroughly before publication. It should be noted that peer-to-peer learning methods are very helpful as learning tools but their limitations should be kept in mind as it relies on the students own experience and understanding of the topic.  Information posted is all believed to be accurate and useful at the time of posting. 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Crash Course in Pediatric Dentistry PDF 2020

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