Introduction to Pediatric Dentistry PDF

PEDIATRIC DENTISTRY Child Competency - practice and teaching of an research a specific insight into the dental and in comprehensive preventive and oral health for the child and therapeutic oral health care of adolescent...

PEDIATRIC DENTISTRY Child Competency - practice and teaching of an research a specific insight into the dental and in comprehensive preventive and oral health for the child and therapeutic oral health care of adolescent children from birth through an ability to communicate effectively adolescence with children, adolescents, and their parents Pediatric dentist (PEDODONTIST): a positive professional attitude - A specialist in the fieId of dentistry towards children, adolescents, and dealing their parents. - particularly with oral health care of children, Objectives of Pediatric Dentistry: - from infancy through the later Giving comfort, relieving pain, removing teenage years. infection and restoring functions - It also deals with medically, Alleviating fear and anxiety and modifying emotionally and physically the child's behavior compromised patient Promoting oral health by prevention and education Child: Develop a positive attitude and behavior - Biologically, a child is anyone in the towards oral health developmental e of childhood, Implement the principles of preventive between infancy and adulthood. dentistry from birth - "every human being below the age of Parental guidance and counseling 18 years unless, under the law regarding different facets of preventive applicable to the child, majority is dentistry and treatment modalities attained earlier" - Early diagnosis of the diseases and treatment Children are different from adults in a Managing children with special needs number of ways: (physically, mentally, and medically) 1. Children are individuals in growth and development ⁃ physical ⁃ psychological ⁃ social ⁃ cognitive ⁃ emotional 2. Attitudes and behavior relating to oral health 3. They are not able to foresee consequences of their own decisions and behavior. Field of Pediatric Dentistry: RESPONSIBILITIES OF PEDIATRIC 1. Preventive dentistry DENTIST Diet Oral hygiene 1. Manage and treat the average child Fluoride application patient with confidence Pits and Fissure Sealants 2.Promote positive and compliant behaviour Sports appliance in the child patients Oral/FacialDevelopment 3. Prevent à manage caries & periodontal Main Goal: To prevent malocclusions disease in children Cause of Malocclusions: 4. Monitor child's developing occlusion jaw size tooth size 5. Identify & manage dental infection early extraction anomalies affecting children habit like thumb sucking 6. Manage trauma affecting primary & young 2. Operative Dentistry permanent teeth - Restoration - Filling materials - amalgam & composite PARENT COUNSELING AND BEHAVIOR 3. Endodontics Communication - Pulpal treatment establish good rapport Pulpotomy fix appointments - In pulpotomy, the crown part of keep them well informed the pulp is removed and filled, OH education to promote home care Pulpectomy - procedure, the pulp of both the Parent's responsibility towards behavior crown and the root is removed of the child and filled. Conditioning of the child towards the treatment in terms of the following state: 4. Prosthodontic Emotional status of the child - Strip of Crown (COC) Psychological behavior of the child - Stainless steel own (SSC) Mental capability of the child - Removable Partial Denture - Complete Denture Extremes of Parental Behavior Overprotection 5. Surgery Rejection Overanxiety Domination Identification 1. Overprotection 3. Overanxiety - Exaggeration of love and affection. - this is a result of some previous It may manifest as; tragedy following: ⁃ extreme dominance Accident ⁃ extreme indulgence Illness Characteristic of an overprotective parent As pediatric patient in dental elinie to a child: patient: Shy There is difficulty overcoming their Delicate fears Submissive They need more encouragement Fearful ○ Timid, fearful and shy NOTE: This may affect the initiative or decision- making 4. Domination - Parents exemplify demand excessive As a pediatric patient: responsibility wh his incompatible to - Ideal patient their chronological age - Obedient - Polite As pediatrie patient in dental clinie - Responsive patient: With kindness and 2. Rejection consideration they may end up as good Constantly criticized patient Nagged Tormented with overt displays of 5. Over - identification displeasure - If the child does not respond Resistance to spending money on favorably, it will lead to children. disappointment NOTE: It may manifest as; delinquent child As pediatric patient: Characteristic of a rejected child - They are handled as in domineering Inferior and neglected patient Uncooperative Lack of love affection Parental behavior, in the dental office: Suspicious Should have complete confidence in Aggressive the dentist Revengeful Should assume as a passive guest Disobedient Should not speak to the dentist Restless unless asked to do so Should not give misinformation or As pediatric patient in dental clinic: extending sympathy Difficult to control Demanding Misbehaves to call attention BEHAVIORAL MANAGEMENT OF Behavioral Pediatric Dentistry PEDIATRIC DENTISTRY - a study of science which helps to understand development of fear, Introduction: anxiety and anger as it applies to - It is a care directed toward child in the dental situations communication and education of the pediatric patient. Emotion - a state of mental excitement Goals characterized by physiological, Maintain communication behavioral changes and alterations of Reduce fear feelings Extinguish inappropriate behavior Commonly seen emotions in a child Elicit behavior consistent with 1. Fear the need for successful - an unpleasant emotion or effect completion of dental treatment consisting of psycho-physiological changes in response to realistic Behavior management threat danger to one's own - It means by which dental health team experience effectively and efficiently perform - Innate treatment for a child and, at the some - Subjective time, instill positive dental attitude - Objective - Centers on the attitude and integrity of the entire dental team 2. Anxiety - a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome Types of anxiety: 1. Trait anxiety: - temperament, jittery, Different terms in behavioral management hypersensitive to stimuli Behavior - the way someone moves, functions, 2. Free-floating anxiety: or reacts to a given situation or - persistently anxious stimulus mode - the way in which a person acts in response to a particular environment 3. Situational anxiety: - seen on specific situations or objects  4. General anxiety: accompanied by - chronic pervasive whimper, initially feeling of anxiousness shows a single tears whatever the external from the corner of the circumstances eye without making any sound of 3. Phobia resistance treatment - usually defined as a persist fear of an procedure object or situation in which the sufferer commits to at lengths in d. Compensatory cry avoiding, typically disproportionate to - Not a cry at all, sound the actual hunger posed, often being that child makes to recognized as irrational drown out the noise, cry is slow monotone, 4. Anger sortof coping - an emotion characterized by mechanism to antagonism toward someone or unpleasant stimuli something you feel has deliberately done you wrong. Influencing children's dental behavior 5. Cry 1. Parental (Maternal) anxiety - is the shedding of tears in response - form of anxiety manifest to an emotional state. on the child by the mother towards the dental treatment Types of cry: a. Obstinate cry 2. Medical history - Shows temper tantrum - an experience base on the past to dental treatment, medical related visits which is loud and high pitched, translated during the dental visit siren likewall, represents child's 3. Awareness of dental problems external response to - understanding the dental need for anxiety treatment with existing dental b. Frightened cry problem - Accompanied by torrent tears, convulsive breath-catching sobs, they areover-whelmed by the situation c. Hurt cry - Loud, cries more frequently Wright's classification (1975) Lampshire’s Classification (1970) 1. Cooperative Cooperative Reasonably relaxed, minimal apprehension, enthusiastic 2. Lacking in cooperative ability Very young children - communication cannot be established Physically or mentally challenged 3. Potentially cooperative Uncontrolled or hysterical - Temper tantrums, loud cry, violent movement of extremities Defiant or obstinate - Stubborn, resists treatment Tense cooperative - Agrees to treatment but is tense, borderline negative & positive Whining - Receives treatment with continuous complaints throughout the procedure Stoic - receives treatment without any expression, physically abused FUNDAMENTALS OF BEHAVIOR and began to complain, whine and MANAGEMENT whimper. 1. Positive approach 4. Truthfulness and Credibility - Approach the child in a friendly and - pediatric patient should be dealt accommodating manner without in-between for discussion of dental treatment 2. Team attitude - Have a pleasant working environment Case 16.4 Truthfulness and with your dental auxiliaries Credibility An alert dental assistant has seated a Case 16.2 Team Attitude and Culture three-year-old patient in the dental Mrs. W. brought her six-year-old to chair. While waiting for the dentist, the dental office or a recall the child looks up and asks," Am I appointment. As they approached the going to get a shot today?" The front desk, the receptionist greeted dental assistant replies hestanty, 'I'm them: "Hello, Mrs. W. and William. not sure. Ask when the doctor comes Please fill out a medical update, give in." me your insurance card so I can copy it, and then have a seat. The doctor 5. Tolerance and Empathy will be with you in a few moments. - it is the ability of the dentist to cope with misbehavior patient 3. Organized Plans and Protocols - every appointment should be plan Case 16.5 Tolerance and Empathy ahead to deliver effective treatment Eight-year-old Paul was undergoing a one hour restorative appointment. Case 16.3 Organized Plans and Although he experienced no pain, Protocols Paul whined and fidgeted throughout Five-year-old Tammy had two the appointment. Despite the dental restorative dental appointments team's best efforts, the child's during the previous month and, behavior aggravated them. In an though noteasy to manage, she attempt to modify the situation, the cooperated adequately to allow the dentist firmly instructed Paul to stop treatment. Now Tammy requires whining and moving. This proved anterior restorations At the outset, the unsuccessful; the disturbance dentist invited Tammy's parent into continued and the child began to the dental operatory to explain the scream, finally, the dentist felt that anterior restorations. While Tammy she was about to lose control. She was seated in the dental chair, the decided to take a "time out and walk dentist explained the proposed away from the dental chair. treatment. Since the parent had several questions, the discussion dragged on for ften minutes. Eventually, Tammy became restless 6. Flexibility office had new charts on the - every dentist should be able to treat opera-tory walls, which were the child as adaptable and can be produced by a commercial company able to adjust to every situation if to demonstrate the progress of needed periodontal dis-ease. It was a family practice, but the office medium Case 16.6 Flexility catered to adults. Four-year-old Daniel was apprehensive but cooperative for his 2. Problem ownership dental exam one week earlier. Now - It is by showing the patient to send he has returned to the office for a the message of giving the proper restorative treatment. When the treatment than showing the problem dentist entered the operatory and to the child was about to begin treatment, Daniel said, I have to go to the bathroom. Case 6.8 The dentist questioned the boy's Dr. F. is fitting a band on five-year-old necessity and reluctantly Harry's maxillary second primary acknowledged.-edged Daniel's need: molar. The saliva-covered band is *OK, but hurry up!" Then he added, slippery. "Be quick, we are already half an The child, who has a small mouth, hour behind schedule whimpers and fidgets in the dental chair. Dr. F. is afraid of dropping the COMMUNICATION WITH CHILDREN’S band in Harry's mouth and says, "You BEHAVIOR must sit still and stop crying! 1. Multisensory communication 3. Active Listening - use of different senses that the - it is more on the older child that a patient or child con relate during dentist should be able to understand treatment the problem being presented and be treated Case 6.5 One week, two children were referred Case 6.7 to Dr. C as behavior problems. After Dr. S. was preparing to place a chatting with both of these children, rubber dam on nine year-old Mary. Dr. C. did not understand why they She said, "I don't want that in my were considered behavior problems. mouth." Dr.S. replied, "You don't like Trying to comprehend the reasons for the tooth rancoat?" Mary said, "No. I their misbehaviors, Dr. C. asked them can't breathe when you put that in my what frightened them during their mouth." previous dental experiences. Both chi-dren (from the same office) referred to the " ugly posters in the dentist's office. When checking with the dentist, Dr. C. learned that the 4. Appropriate response Outline for behavior-shaping model: - in every action there is suitable reaction when communicating while State the general goal or task to the treating the patient child Explain the necessity for the Case 6.6 procedure Ms. N., a senior dental student, Divide the explanation for the attempts a cavity preparation for procedure seven-year-old Tyler. Each time she Explain each procedure at the level of begins cutting the tooth, the child understanding of the child frets. The behavior baffles Ms. N., Use successive approximations who is unsure of the depth of (TSD) anesthesia, and she summons an Reinforce appropriate behavior instructor. The instructor greets the child and What is the best behavior management nuns the handpiece slightly above the techniques to be done? tooth. When Tyler frets again, the instructor stops, explains the noise, Consideration of choice of behavior solicits the child's cooperation, and management completes the procedure without - Urgency of care incident. - Need for cooperation - Skill of the practitioner 5. Message clarity Voice control - Options available at each clinic - Let the patient understand what the - Parental considerations treatment to be done in the way the child can understand Factors prior to choosing a behavioral management technique. 6. Establishment of communication - involve the child in the treatment by - alternative methods, including referral conversing - dental needs - expectations of the parents or 7. Establishment of the communicator - caregiver - make sure to address the polient your - emotional development of the child authority during treatment - past medical history - ability of caregiver or person accompanying child to give consent 8. Behavior shaping Prior to doing the behavior management: - A.k.a Stimulus- response - Informed consent is a process for - It is a procedure which very slowly getting permission before conducting develops behavior by reinforcing a healthcare intervention on a successive approximations of the patient/child desired behavior until the desired outcomes. BEHAVIORAL MEDICATION METHODS 3. Playful humor - To make use of having a positive 1. Tell-Show-Do condition of showing different means Objectives to introducing a procedure in fun label and using imagination - Teach the patient important aspects Costumes of the dental visit and familiarize with Play the dental setting Dental set up - Shape the patients response to procedures through desensitization and well-describe expectations - Involves verbal explanations in 4. Distraction phrases appropriate to the Objectives developmental level of the patient (tell) -  ecrease D the perception of - Demonstrations for the patient to unpleasantness visually, auditory. and tactile - Avert negative or avoidance of presentation of the procedure in a behavior careful manner and non threatening Ex. (show) - Without deviating from the Music explanation and the patient is ready Video to have the application of the Tolking procedure (do) White noise Hypnosis Breathing 2. Voice control Objectives Types of Positive Reinforcement - Gain patient's attention and 1. Social reinforcers compliance - Positive voice modulation - Avert negative or avoidance - Facial expression - Establish appropriate dentist-child - Verbal praise roles - Appropriate physical demonstration - A controlled aleration of voice of affection volume, tone.or pace to influence and direct the patients behavior 2. Nonsocial reinforcers - Tokens - Toys 5. Modeling TYPE OF NON-PHARMACOLOGIC - Allowing the patient to observe one or MANAGEMENT IN DENTISTRY more individual Patient frequently imitates the models Physical restraints Live - a way of immobilizing the patient Filmed using a person or person's body to Posters limit movement of the patient during Audiovisuals treatment Physical restraints 6. Fading - Head holds/locked - Providing an external means to - Knee-to-knee promote positive behavior and then - Hand guarding gradually removing the external - Hug guard/Lap locked control - Hand-over-mouth-exercise (HOME) TYPE OF BEHAVIORAL MANAGEMENT TECHNIQUES PEDIATRIC DENTISTRY Mechanical restraints - it is immobilizing the patient using Non-pharmacologic management tools, equipment, or instruments to - It is a kind of management done in limit the movement of the patient management pediatric patient by the during treatment use of physical or mechanical means of restraining the patient to effectively Oral and efficiently to do dental treatment - mouth props, Pharmacologic - bite blocks, - It is a kind of management done lo - tongue-wrap pediatric patient by the use of different drugs and there routes to Body overcome anxiety, apprehension, fear - head papoose board, and other negative behavior towards - pedi-wrop, effective and efficient dental - sheets, treatment - straps and seat belts, - towels, - vests, - wrist bracelets Pharmacologic a. Oral sedation b. Inhalation c. Rectal d. intravenous/Intramuscular sedation e. Deep sedation f. General anesthesia PHARMACOLOGIC MANAGEMENT IN 4. Inhalation PEDIATRIC DENTISTRY > Nitrous Oxide I. Sedation - slightly sweet-smelling, colorless, Types of sedation: inert gas. 1. Minimal Sedation- patient that can - Moderate sedation respond 2. Moderate sedation Opioid agonist 3. Deep sedation - 30% -50% (normal) General Anesthesia a drug-induced loss of - More than (opioid overdose) consciousness during which patients are not arousable, even by painful stimulation. - Naloxone(opioid antagonist) Guedel's Stages of General Anesthesia Stage 1 - analgesia and amnesia Stage 2- Delirium. Excitement and unconsciousness Stage 3 - Surgical anesthesia Stage 4 - Respiratory Paralysis and Cardiovascular Collapse Route of administration: 1. Oral Sedation - The most commonly employed route of drug administration for pediatric dentistry 2. Parenteral Route IV route Intramuscular route 3. Rectal route - Use of suppositories FEAR  - an unpleasant emotion caused by the 1. To determine if the child has undue belief that someone or something is fear of dentistry dangerous, likely to cause pain, or a 1. To Familiarize the child with the threat. dental treatment room and all its equipment without undue alarm To overcome fear for pediatric patient: 2. To gain complete confidence INSTRUCTIONS TO THE PARENT 3. To introduce the practice of dentistry 4. First appointment should only involve 1. Tell the parents not to voice their own minor and painless procedure personal fears in front of the child 5. Start treatment from the simpler to 2. Tell the parents never to use dentistry the more complex unless emergency as a threat of punishment treatment is necessary 3. Tell the parents to familiarize with 6. Truthfulness in the dentist is essential dentistry by taking the child to the if their first visit is in need of dentist extensive treatment 4. Explain to the parent that an 7. Rapport should be establish for too occasional display of courage on his young to understand difficult part in dental manners will build explanations courage 8. Preschool children scream loudly, the 5. Counsel the parent about the home threat of sending a parent out of the environment and the importance of room might be sufficient attitudes in building well adjusted 9. lf threat will not work, children Hand-over-mouth exercise (HOME) is 6. Emphasize to the parent the value of practice regular dental care 7. Discourage parents from bribing their TECHNIQUES IN RECONDITIONING children in going to the dentist 8. The parents should be instructed 1. Appearance of the dental clinic never to shame, scold or ridicule to 2. Personality of the dentist and dental overcome the fear aides/assistant 9. The parent should be informed of the 3. Time and length of appointment need for combating all damaging 4. Dentist's conversation towards the impressions of dentistry child 10. Instruct the parent prior to 5. Knowledge about the patient appointment regarding the visit to the 6. Attention of the patient dentist in casual manner 7. Dentist's skill and speed 11. Parent should commit to the dentist's 8. Use of admiration, subile flattery, care once the dental clinic is reached praise, and reward %.Bribery and the patient 9. Commands versus suggestions 10. Reasonableness of the dentist 11. Dentist self-control OBJECTIVES FOR RECONDITIONING OF 12. Gracefulness of the dentist THE CHILD TECHNIQUES IN RECONDITIONING 1. APPEARANCE OF THE DENTAL CLINIC Do not baby talk to a 4 or 5 year old Never underestimate the intelligence Make reception more comfortable of a child and warm Most children enjoy hearing the Set aside a room for children, placing dentist talk of children's book and toys Don't talk or ask questions while Operating room should be appealing treatment is on going to the child If child's ask question, try to answer but don't entertain question as a form 2. PERSONALITY OF THE DENTIST AND of delaying treatment HIS AIDES/ASSISTANT 5. KNOWLEDGE ABOUT THE PATIENT Show confidence at all times Greet the child in the reception on the Upon appointment, get some first visit information of the child's knowledge Call the child's first name; if not yet about the dental treatment known ask for the name DAsk child Observe the child while in the directly rather than the reception room parent/guardian If the child sits, reads and plays alone Approach the child in friendly manner in the reception it implies that the if the child is difficult to be lead to child is comfortable operating room With patient knowledge, dentist can anticipate the reaction of the child 3. TIME AND LENGTH OF APPOINTMENT during treatment Both the hour and day and length of 6. ATTENTION TO THE PATIENT each appointment are important Children should not be kept in the Never leave a very young child in the chair for periods longer than half an dental chair hour Do all the work necessary on the Preschool should not be given child in the same room appointment during the regular nap time 7. DENTIST'S SKILL AND SPEED Children should not be brought to the dental clinic soon after a serious In working with children an assistant emotional experience is valuable asset Work smoothly and carefully and do 4. DENTIST'S CONVERSATION not waste time or motions Dentist must get down to the patient's own level in position and in conversation Select subjects for conversation, 8. USE OF FEAR-PROMOTING WORDS choose objects and situations familiar to age level Avoid using words that might arouse fear  Deception should be avoided in lt will lead to fear once the dentist working with children lose temper Exact substitution of words should be Accept defeat in resolving the issue governed by the age of the patient of the child, Refer the child to different dentist if 9. USE OF ADMIRATION, SUBTLE, the dentist reach his limits FLATTERY, PRAISE, AND REWARD Most important rewards sought by the child is the approval of the dentist Acknowledge good behavior during the treatment by praising the child Give a reward for a good behavior 10. BRIBERY AND THE PATIENT Bribe is promised or given to induce good behavior Reward is recognition of good behavior after completion of the treatment 11. COMMANDS VERSUS SUGGESTIONS Never asks the child to comply with a request instead, give the child a choice When ordering a child to comply state the intention as a dentist in pleasant and determined manner 13. DENTIST'S SELF-CONTROL Dentist should never lose his temper in front of the patient it will lead to fear once the dentist lose temper Accept defeat in resolving the issue of the child, Refer the child to different dentist if the dentist reach his limits 14. DENTIST'S GRACEFULNESS PRIMARY TOOTH MORPHOLOGY Dentist should never lose his temper QUESTIONS in front of the patient  1. Smallest primary tooth? 1. Deciduous teeth play very important - Primary Mandibular lateral Incisor role in the proper alignment, spacing, 2. Smallest primary molar? and occlusion of the permanent teeth - Primary maxillary 1st molar 2. They are functional in the mouth for 3. Largest primary tooth? approximately 5 years for incisors - Primary mandibular second molar and 9 years for molars  4. Largest permanent tooth? 3. If the second molars are lost - Permanent maxillary 1st molar prematurely, it is detrimental to the 5. Smallest permanent tooth? alignment of the permanent teeth - Permanent mandibular Central 4. Premature loss of deciduous teeth Incisor due to caries is preventable and is to 6. Most unique primary tooth? be avoided - Primary mandibular first molar 7. Most atypical primary tooth NOMENCLATURE - primary maxillary first molar 8. First permanent tooth to erupt? 1. Universal numbering system / ADA - Permanent Mandibular 1st molar 2. Palmer Notation numbering system 9. First succedaneous too to erupt? 3. Federation Dentaire International - Permanent Mandibular central incisor numbering system 10. other names for non-succedaneous tooth? - Accessional tooth IMPORTANCE OF MORPHOLOGY  uman are Diphyodont - with two H sets of teeth. There are twenty (20) deciduous teeth that are classified into three classes Humans have heterodont set of teeth - 'different teeth' more than a single tooth morphology. HETERODONT IN HUMAN There are ten (10) maxillary teeth and ten (10) mandibular teeth The dentition consists of: incisors, canines and molars ROLE OF DEVELOPMENT OF DECIDUOUS TEETH Deciduous vs. Permanent 1. Smaller in overall size and crown dimensions 2. Whiter in color 3. Markedly more prominent buccal and lingual cervical ridges 4. Constricted cervical areas  5. Molar roots are widely flared, especially the maxillary molars 6. Root trunks are narrow or absent 7. Large pulp chambers - Decrease pulp - increase age, increase occlusal load, abrasion 8. Thinner and uniform enamel thickness (1mm) 9. Higher and pointed pulp horns (mesial) Lingual Aspect 10. . Enamel rods in the cervical area is - Well- developed marginal ridges, in occlusal direction highly developed cingulum seen 11. Narrow and shallow occlusal table - Cingulum extends up toward the 12. Thinner dentin incisal ridge 13. More accessory canals in the pulp - Root narrows lingually chamber Pulp - Consists of 3 slight projections on incisal border - Chambers tapers M-D cervically DIFFERENT MORPHOLOGY OF THE - No distinct demarcation between PRIMARY DENTITION canal and chamber - Chamber and canal are larger than PRIMARY MAXILLARY CENTRAL permanent INCISOR Labial Aspect: - M-D diameter is cervicoincisal length greater than the - Root is cone-shaped - Root length is greater than crown length Mesial-Distal Aspect - Similar in all aspect  - Curvature of the cervical line is curving towards the incisal ridge - Root is cone-shaped with even, tapered sides, apex is blunt - Mesial has developmental groove, Distal is convex MANDIBULAR DECIDUOUS CENTRAL INCISOR Incisal Aspect - smallest tooth in dental arch - Edge is centers over the main bulk of - Bilaterally symmetrical the crown and straight - Crown has more than half the MD - Labial is much broader and smoother dimension of maxillary incisors - Lingual tapers towards the cingulum - Labiolingual diameter is only about 1mm - Root is very narrow MD but the crown are widely labiolingually Labial Aspect - Flat face - Mesial and distal sides of the crown are tapered evenly - Crown is wide in proportion to its length - Root is long and evenly tapered down PRIMARY MAXILLARY LATERAL INCISOR to the apex which is pointed - Similar to the central incisor from all - Root is almost twice the length of the aspect, only differs with width crown - Disto-incisal angles are more rounded compared to central incisor - Pulp chamber follows the contour of the tooth, as does the canal - Root has similar, but is longer, thinner and tapering Lingual Aspect - Marginal ridges, cingulum - Middle third flattened surface  - Incisal third slight concavity PRIMARY MAXILLARY CANINE - Lingual convergence of the crown Labial Aspect and root can be seen - Widest mesiodistally at the roof - Crown is more constricted at the - Labiolingually widest at the cingulum cervix in relation to its M-D width - Oval in appearance, tapers as it - Mesial and distal surfaces are more reaches apex convex - Definite demarcation between - Cusp on the primary canine is much chamber and canal longer and sharper than permanent permanent canine Incisal Aspect - Mesial cusp ridge is longer than the distal cusp ridge Incisal ridge is straight and bisects - Root is long, slender, and tapering the crown labiolingually and is more than twice the crown Definite taper is evident toward the length cingulum on the lingual side Labial surface - flat and slightly convex Lingual surface - flattened and slightly concave Lingual Aspect - Well pronounced enamel ridges - Lingual ridge divides the lingual surface into shallow mesiolingual and Mesial Aspect distolingual fossae - Incisal ridge is centered - Root tapers lingually and usually - Convexity of the cervical third are inclined above the middle third more pronounced - Cervical bulges are important - Mesial surface of the root is nearly Mesial Aspect flat and evenly tapered: apex blunt - Measurement labiolingually at the cervical third is much greater Distal Aspect - This permits resistance against forces - Outline: opposite of mesial the tooth must withstand during - Cervical line less curved function - Development depression is evident - Function of this tooth is to punch, tear, and apprehend food material Distal Aspect - It furnishes a narrower look to the - Distal outline of this tooth reverse of cervical portion of the crown and root the mesial aspect compared to permanent first molar - Only difference being the cervical line - Relatively smaller than second molar towards the cusp ridge is less than on the mesial surface Buccal Aspect (root) - Slender and long, and they spread Pulp widely - There is a little demarcation between - Distal root is shorter than the mesial the chamber and canal one - Canal tapers as it approaches the - Bifurcation of the roots begins almost арех immediately at the site of the cer vical - Chamber follows the external contour line (CEJ) of the teeth - Central pulpal horn is projecting incisally Incisal Aspect - Diamond shape - Mesial cusp slope is longer than the distal cusp slope PRIMARY MANDIBULAR CANINE Occlusal Aspect -  imilar to Maxillary Canine except S that is; - resembles like a permanent premolar - shorter in crown dimension - smallest, atypical molar - root dimension (less 2mm compared - Has H- shaped occlusal pit groove to max canine) - labiolingual dimension Mesial Aspect * greater in - Mesiolingual cusp is longer and sharper than mesiobuccal cusp MD @ contact area - Pronounced convexity on the buccal MD @ cervix outline - distal slope longer than mesial slope - Mesiobuccal and lingual root are visible DECIDUOUS MAXILLARY FIRST MOLAR Buccal Aspect Pulp Cavity - Widest measurement of the crown is - Consists of a chamber and 3 pulpal at the contact areas mesially and canal distally - 3-4 pulp horns - Mesiobuccal pulp horn the largest  - Mesiolingual pulp horn the second in size - Distobuccal pulp horn smallest, sharp - Occlusal view of pulp chamber, somewhat trianlge Pulp Cavity - Consists of pulp chamber & 3 canals - Pulp chamber has 4 pulpal horns, Mesiolingual horn may be present - Mesiobuccal pulp horn as the largest DECIDUOUS MAXILLARY SECOND pointed occlusally MOLAR - Mesiolingual 2nd in size - Distobuccal 3rd in size Buccal Aspect (crown) - Distolingual shortest - Resemble those of the permanent ist molar, it is smaller in size DECIDUOUS MANDIBULAR FIRST - Well-defined two buccal cusps with MOLAR buccal developmental groove and nearly equal in size - It does not resemble any other - Narrow at the cervix in comparison primary or permanent tooth. with MD width at the contact areas - Mesial marginal ridge is very well - Larger thank 1st primary molar developed and resembles a cusp - UNIQUE Lingual Aspect (crown) - Distal root -short and round - Shows the three cusps: - Mesial root-long and flat ○ mesiolingual cusp - Pot belly appearance ○ distolingual cusp ○ supplemental cusp (tubercle of carabelli, or fifth cusp, cusp of carabelli) - - well-defined developmental groove separates the two cusps - Only have Oblique ridge Occlusal Aspect  - Occlusal surface nearly rectangular - Presence of central fossa Pulp cavity - Contains a chamber and 3 canals - Pulp chamber has 3 pulp horns - Mesiobuccal horn, being the largest Notes to remember and rounded Smallest teeth - Distobuccal horn, second largest and - Primary Lateral mandibular lacks in height Calcification of primary teeth - Occlusal view of pulp chamber is - 14 weeks IU rhomboidal - 2nd trimester - 3.5 - 4 months - 3.5 - 6 months Complete interdigitation of a chils 5 years old DECIDUOUS MANDIBULAR SECOND MOLAR - It resembles the permanent NOLLA’s STAGES OF TOOTH mandibular first molar but differs in DEVELOPMENT dimension - M-D narrower at the cervical portion Roots slender and long, flaring - It flare at the middle and apical third Bifurcation starts immediately below the CEJ  - Diet history. VITAL STATISTICS - a systematic approach to collect and compile all the information related to the vital events - Recording personal details of the child is required for both record purposes and for communication. DIAGNOSIS AND TREATMENT PLANNING CHILDREN AS INDIVIDUALS - Develop and design to provide high-quality restorative care for each individual child's needs. DIAGNOSIS Components of oral examination and CHIEF COMPLAINT diagnosis Recording the history - This is concerned about what made Examination of the patient the patient to visit the dentist or what Provisional diagnosis they are seeking from treatment. Special examination - It is better to ask the child about his Final diagnosis chief complaint before involving the Treatment plan (including medical parent which helps to establish a referrals). good rapport with the child. - “Sumasakit ang ngipin nya sa harap”- RECORDING THE HISTORY mother This can be further categorized for descriptive purposes into: HISTORY OF PRESENT ILLNESS - Vital statistics - Duration, mode of onset, severity, - Chief complaint nature, aggravating or relieving - History of present illness factors, associated symptoms, diurnal - Family(social)history variation, postural variation, any - Medical history medications or treatment received for - Drug history the same. - Past dental history - Gives an insight towards the possible - Pre- and postnatal history cause and nature of - Behavioral history disease/condition. - Growth and development  - Hint towards the possible - Details of the drugs being used for disease/condition. systemic ailments - Any adverse reaction to drugs FAMILY HISTORY (SOCIAL) - Any drugs already used for the condition. - provides relevant information about the social background of the child DENTAL HISTORY and his family. - The family history should also include -  he child's past experience with the T the occurrence of any genetic dental treatment should be assessed. diseases, oral or general. - The kind of dental treatment received e.g pain control measures - Identify factors that have been responsible for the existing dental MEDICAL HISTORY problems and those which might have an impact on future health. - Various diseases or functional - Include day to day oral hygiene disturbances may directly or indirectly measures (ex. Thumb sucking) cause or predispose to oral problems - explanation for the unusual and may affect the delivery of oral conditions like rampant caries, care erosion, and attrition - A comprehensive medical history -.Helps in formulation of treatment should commence with information plan relating to pregnancy and birth, the - Knowledge about patient's habits neonatal period, and early childhood Helps evaluate attitude of parents previous hospitalization, operations, towards dentistry illnesses, and traumatic injuries - Medicolegal purpose. Medical history should include BEHAVIORAL HISTORY - Cardiovascular system (e.g. - Any clues of negative or unpleasant congenital heart disease, blood behavior during the previous dental pressure, rheumatic fever) visit → behavior management or - Central nervous system (e.g. shaping. seizures, cognitive delay) - Endocrine system (e.g. diabetes) - Gastrointestinal system (e.g. hepatitis) - Respiratory system (e.g. asthma, upper respiratory tract infections) CLINICAL EXAMINATION - Hematological disorders (include General examination family history of bleeding disorders) - Urogenital system (renal disease). DRUG HISTORY  - Height and weight-both have a direct - Mesoprosopic-average facial form relation with developmental and - Euryprosopic-broad and short facial nutritional status. form - Posture-look for any abnormality. - Leptoprosopic-long and narrow - Stature and built-indicative of any face. malnutrition or other abnormality. - Vital signs-pulse, heart rate and respiratory rate differ in child at different ages till these reach the adult value. - Any other data like illness, malaise. Extraoral examination Shape of head (Figs 6.1A to C) —can be Facial profile- this is ascertained by classified as: examining the patient sideways. The three facial profiles are straight, convex, concave. - Mesocephalic-average shape of head and arch - Dolicocephalic-long and narrow head; narrow dental arches - Brachycephalic-broad and short head; broad dental arches. EXTRAORAL EXAMINATION -  acial swelling and asymmetry F - Bacterial or viral infections and trauma - Pathological facial asymmetry may be produced by cranial nerve paralysis, fibrous dysplasia and familial developmental disturbances. INTAORAL EXAMINATION - begin with the "tell-show-do" approach Include the following: Soft tissue :  acial form (Figs 6.2A to C) -three common F facial forms are:  - Examination of the oral GENERAL CONSIDERATIONS: mucosa and periodontal - Planning treatment for children tissues, as well as the salivary should take age and maturity into flow rate and quality, is also consideration necessary. - A treatment plan for preschoolers - Check for abnormal frenal may vary significantly from that tor attachment or tongue tie older children (affects speech) - Appointment length and time of the - Gingiva should be examined day may vary with age for redness, swelling, ulceration, spontaneous BEHAVIOR PATTERNS bleeding. Include the following: 2 YEARS OLD: Hard tissue: - Increased motor development - individual teeth should be - Better language development evaluated for Tooth - Mother is the center of his world number-any missing/extra - Short attention Span teeth restorations-intact/ deficient Attachment Theory - trauma-note the extent, site or - Exploratory System signs of loss of vitality tooth - Attachment System mobility - physiological/pathological; 4 YEARS OLD: tooth structure - Hard to control - Examination of occlusion - Capable of offensive language - Big talker and questioner SPECIAL EXAMINATION 8 YEARS OLD: - Radiographs - Age of intellectual exploration - Pulp vitality testing - Likes to dramatize things - Blood investigations - Resentful of parental authority - Microbiological investigations - Intraoral and extraoral Photography 12 YEARS OLD: - Diagnostics casts - Rejects parental authority - Caries activity tests - Peer-group oriented - Biopsy - Increased interest in personal appearance FINAL DIAGNOSIS - the final conclusive answer that has been reached upon by applying investigative reports to our differential diagnosis options. 13-18 YEARS OLD: 13-15 (Early Adolescence) TREATMENT PLANNING  - Time of significant - Limit treatment to 30 minutes or less change/transition - Dentist should work hard and develop 16-18 (Late Adolescence) clinical speed - Establishes a cohesive new - Several appointments are helpful identity - Do not appoint during nap time OLDER CHILDREN Give consideration to the root development of permanent dentition and the stage of root resorption of the primary teeth Do not ignore caries because "they're baby teeth" Plan to restore, extract, or attempt to arrest the progress of decay with fluoride or other preventive measures Note: Ignoring maxillary anterior caries until exfoliation is not acceptable and outdated QUADRANT SYSTEM OF TREATMENT PLANNING: By use of quadrant system dentist should consider the treatment to be done in every quadrant It is dependent on the behavior, emotional, mental and maturity of the patient TREATMENT CONCEPT: IMPORTANCE OF TREATMENT Ideal approach for restoring children's PLANNING teeth involves the practice of QUADRANT 1. It commits the operator in advance to SYSTEM a certain sequence of care. Prioritize posterior teeth in restoration 2. It provides an estimate of the time because of the following reasons: and number of appointments required to complete the treatment. Serve greater importance in 3. Fee payments can be arranged or masticatory function have a predetermined fee established Serve as space maintenance Retained for longer periods of time PRESCHOOLERS *Read Anomalies on pediatric patient DENTAL RADIOGRAPHS IN PEDIATRIC - Calcific degeneration PATIENT Periodontal diseases - Thickening of periodontal membrane IMPORTANCE OF RADIOGRAPHS - Furcation involvement - Periapical infection - Plays a vital role in the diagnosis and - Bone loss treatment planning of both children - External resorption and adults - Plays a significant role in the assessment of dental caries and in the diagnosis of cysts, tumors or any II. Developmental factors other major craniofacial disorders - Stages of development - Plays a significant role in the - Root formation assessment of growth and - Physiologic root resorption development - Bony support - Stages of eruption and exfoliation CONSIDERATIONS IN TAKING RADIOGRAPHS IN PEDIATRIC PATIENT - Avoid retakes III. Developmental anomalies - Obtain the previous radiographic Widely divergent roots history Sharply curved pulp canals - Follow the correct size, number and Number and length of roots type of film to be used shortening act, Ectopic positioned roots correct processing of the film Ankylosis - Radiographs should be an adjunct for Supernumerary teeth clinical examination and should not Congenitally missing teeth replace full mouth examination Malformed teeth - Placement of lead apron and thyroid - Microdontia and macrodontia collar on the parent - Dens in dente - Taurodontism CLINICAL SIGNIFICANCE OF - Gemination, fusion RADIOGRAPH IN PEDIATRIC DENTISTRY - Root dilacerations I. Pathologic evaluation Caries detection Traumatic injuries IV. Postoperative results of dental - Fractured roots or crown treatment - Fractured alveolar bone - Accuracy of restoration - Displaced tooth - Type and success of pulp treatment - Tooth or bone embedded in soft - Postsurgical healing tissue - Treatment failure Degree of pulpal involvement - Proximity of caries to pulp horn RADIOGRAPHIC TECHNIQUES USED: - Internal resorption 1.Intra oral Radiographs  a. Intraoral periapical radiograph 4. Sixteen film survey (IOPA b. Bitewing - 12 film survey c. Occlusal - Four permanent molar radiographs 2. Extraoral DIFFERENT SIZES OF IOPA: a. TMJ and lateral oblique view 1.Size 0 - for bite wing and IOPA of b. Lateral cephalograms small children c. Orthopantomography (OPG) panoramic 2.Size 1 - used for anterior teeth in adults DIFFERENT RADIOGRAPHIC EXAMINATIONS 3.Size 2 - standard film used for anterior occlusal, IOPA and bite wing For a new patient with NO previous mixed and permanent dentition radiographs, may be necessary to obtain a baseline series of 4.0cclusal films - 57 x 76mm for radiographs. maxillary or mandibular - Four film survey - Eight film survey MANAGEMENT TECHNIQUES FOR - Twelve film survey TAKING RADIOGRAPHS IN PEDIATRIC - Sixteen film survey PATIENT 1. Four film survey 1.Obtain quality radiographs without psychological trauma - maxillary and mandibular occlusal 2.First step, desensitize the child - 2 posterior bitewings radiographs 3. Explain what do you intend to do 4.Use "tell, show, do" technique 2. Eight film survey 5.Less than 3 years of age, necessary to sit in the parent's lap - Maxillary and mandibular anterior 6. Correct settings and properly occlusal (or periapicals) position the x-ray - Right and left maxillary posterior occlusal (or periapical - Right and left mandibular posterior LOLLIPOP RADIOGRAPH TECHNIQUE periapicals - Two posterior bitewing radiographs - A lollipop is attached to the radiograph by the use of orthodontic 3. Twelve film survey rubber band and placed inside the mouth of the patient - Four canine periapical radiographs - Two primary molar-premolar SPECIAL TECHNIQUE FOR THE periapical radiographs HANDICAPPED CHILD - Two incisor periapical radiographs - Two posterior bitewing radiographs - Radiograph can be taken by the parent holding the child or by the use of a film holding device - If the child is unable to open mouth, extraoral radiographs such as oblique lateral radiograph (extraoral view of choice)