Transcript Advantages: 1

‫محاضرات مادة معالجة االطفال‬
‫د‪ .‬جنان محمد رشاد شهاب ‪ /‬قسم وقاية االسنان‬
‫‪Lecture one‬‬
‫‪Introduction to pediatric dentistry‬‬
1- Definition of paediatric dentistry
Paediatric dentistry is a branch of dentistry that provides both primary and
comprehensive preventive and therapeutic oral health care for infants and children
through adolescence, including those with special health care needs (patients that are
medically compromised. This includes patients with hemophilia, leukemia, congenital
syndromes, etc.).
Objectives of paedodontic dentistry:
1.Maintain functioning, esthetics and arch integrity of the primary dentition.
2.Treatment and prevention of dental caries in primary and young permanent teeth.
3.Child dental health care education to parents.
2- Structure of the dental consultation:Each patient is a unique individuals with different needs, this is
especially so in paediatric dentistry where a clinician may have to treat a
frightened 3-year-old child at one appointment and an hour and a half later
be faced with the problem of offering preventive advice on oral health to a
15 year old. So, an outline structure to a successful dental consultation
include the following:1- Greeting:- First, we should greet the child in a friendly way, smiling and
looking steadily at him/her. Second, it is better to greet the child by name,
especially when he/she is recalled. Third, we should remember that
proceeding too quickly to an instruction could spoil a greeting.
2-Preliminary chat:- This phase has three objectives, to assess whether
the patients have any particular worries or concerns, to settle the patient
into the clinical environment, and to assess the patient’s emotional state,
preliminary chat include:(a) Begin with non-dental topics. For child who never comes before, you
may express your praise to him/her. For example, you may say‘ oh, your
eyes so beautiful’ or ‘ you are so clever’ and so on. For children who have
been before, it is helpful to record useful information such as toys, school
and hobbies.
(b) Ask an open question such as ‘How are you/are you having any
problems with your teeth?.
(c) Listen to the answer. It is important to listen to the answer.
3-Preliminary explanation:- In this stage the aim is to explain what the
clinical or preventive objectives are in terms that parents and children will
understand.
4- Business:- The patient is now worked on. This does not mean that
the visit should enter a silent phase. It is important to remain in verbal
contact. Check the patient not in pain, discuss what you are doing,
use the patient’s name to show a personal interest, and clarify any
misunderstandings.
At the end of the business stage it is helpful to summarize what has
been done and offer aftercare advice. If the parent is not present in
the surgery, the treatment summary is particularly important, as it is
useful way of maintaining contact with the parents.
5- Dismissal:- This is the final part of a visit. The patient should be
addressed by name and a definite farewell offered.
Lecture two
Aims of paedodontic dentistry:-
1.To promote physical, mental, psychological and dental health of the child.
2.To note any aberrant alterations in development of child.
3.To improve the dental health in accord to the general health.
4.To encourage the dental profession at all levels to ensure that the younger
generation in future will require less dental treatment.
First Dental Visit:The American Dental Association recommends that child’s first oral health visit
take place at 12 months of age, or shortly after the eruption of the first baby
teeth.
The first dental visit is usually short and involves very little treatment. This visit
gives child an opportunity to meet the dentist in a non-threatening and friendly
way. Some dentists may ask the parent to sit in the dental chair and hold their
child during the examination. The parent may also be asked to wait in the
reception area during part of the visit so that a relationship can be built between
child and dentist, so communication is the key to success.
Show child chair, mirror, light, and explain purpose.
During the examination, the dentist will check all of child’s existing teeth for
decay, examine child’s bite, and look for any potential problems with the gums,
jaw, and oral tissues. If indicated, the dentist will clean any teeth and assess
the need for fluoride, also dentist may educate parents about oral health care
basics for children and discuss dental developmental issues and answer any
questions.
Topics the dentist may discuss with parents might include:
Good oral hygiene practices for child’s teeth and gums
Cavity prevention
Fluoride needs
Oral habits (thumb sucking, tongue thrusting, lip sucking)
Teething
Proper nutrition
Schedule of dental checkup visits. Many dentists like to see children every 6
months to build up the child’s comfort and confidence level in visiting the
dentist, to monitor the development of the teeth, and to promptly treat any
developing problems.
Show parent child's teeth and what has done that visit.
If child in pain the source of this needs to be determined and dealt with as
quickly as possible.
Lecture three
How to fill paedodontic case - sheet:
How to fill paedodontic case - sheet:
This is by recording information which is taking either from child or parents.
Case sheet include history taken and clinical examination.
A suggested outline for history taking is listed as following:
1- Social history.
2- Dental history.
3- Medical history.
These data will assist in the overall management and treatment planning, judgment of the child’s
behavior, the ability of the child to understand and co-operate and the assessment of caries
risk.
social history: include:
Name of child.
Address.
School.
Brothers and sisters.
Simple question about home and school is the most natural way of
communicating with child. Also the type of response to the questioning
immediately gives some indication of the child characters and state of mind, he
may respond in an easy friendly manner indicating that he is shy or exited also
mother's occupation, any difficulties in bringing the child for further appointment
because mostly the mother who bring the child to clinic, also knowledge of
father's occupation explain the social class because classifying of family based
on father's occupation.
dental history: include information related to the oral cavity such as:
What is the reason for child visit today to the dental clinic. Whether child comes to
dental clinic because of tooth ache, sensitive tooth, gum infection, trauma or just
routine check up. So if the complain is toothache obtaining the following
information: 1. location of pain, 2. when it starts, and 3. stimulated by heat or clod.
Also dental history include if the child does experience any habit like thumb
sucking, nail bite, etc..
Past dental history (P.D.H): Has the child had any problem with dental treatment
in the past, has the child ever had dental radiographs (x-rays) exposed, has the
child had any orthodontic treatment. Has the child had any previous dental
treatment. If so, what was it filling, extraction, etc.
Medical history:•
•Has the child any history of heart trouble, allergies,-diabetics, asthma, kidney trouble, epilepsy or blood disorder.
•If the child has any unfavorable reaction to drugs
including antibiotic or local anaesthesia.
Clinical examination:
These include:
A. The general examination.
B. Extra-oral head and neck examination, soft tissue examination.
C. Intra-oral soft tissue examination.
A. General examination
The general examination begins as soon as the patient enters the dental office. The patient’s general
appearance may give information that relates to his or her medical condition. The clinician will observe the
patient’s stature, mobility, facial asymmetries, lesions or scars.
B. Extra oral head and neck examination
The extra oral head and neck soft tissue examination includes checking for asymmetries, a lymph node
examination and a brief temporomandibular joint examination.
C. Intraoral soft tissue examination
The intraoral soft tissue examination includes checking the soft tissues
of the mouth, the throat, the tongue. Finally, the clinician will examine the
gums. Healthy gingiva is pink, and regular. Some abnormalities include
generalized or localized swelling, redness, ulceration or bleeding.
The clinician may also palpate the area over the jaws to check for
lumps. This examination may also reveal tenderness that could be the
result of infection or inflammation.
Treatment plan:
Treatment plan taking into account diagnosis, social, medical and
psychological influencing factors for a child. Treatment plans may be
purely preventive in nature, for example placement fissure sealant on
the newly erupted permanent molars. The requirement could be one or
two surface restoration with or without pulp involvement, or the repair of
a fractured incisal tip. Where dental extractions are planned the longterm implications need to be carefully
considered.
Lecture four
Management of the child:
1. Management of the parent: it is important to advice the parent about
their child preparation which should include:Let certain parent throw their own fear.
Tell the child in the morning of visit or the day before about taking him to
have a look on his teeth.
Avoid mentioning of unfavorable experience of dentistry e.g. pain, needles.
Explain in details to the parents what will be done in 1st visit.
Management of the child:
The reception; should welcome the child with friendly & careful manner.
The waiting room should contain children posters, books.
The toys should not be from the type that makes the child over exited & tired
before seeing dentist.
If a small child want to take the toy home with him allow and ask him to
bring it back next day
Small children are better brought in the morning becomes they are less
tired.
It is ideally that the 1st meeting should not take place in the surgery room but in
the other room (office or waiting room).
If the meeting is in the surgery room it is better to let the child sit on another chair
& not on dental chair.
h. The dentist &dental assistant should use the child name or nick name.
i. for very young talk about clothes, for older children conservation can start about
his books, T.V. program & older children about school or games.
k. A full history is taken from the parent including the child social background,
school, games, brothers, sisters & previous dental treatment.
3. Management of difficult & naughty child:
(Difficult child) or naughty child:- is the child that might be difficult to be
treated for many causes such as starting school, also some children start to
display this bad behaviour when a new baby brother or sister joins the
family. It can be a way of dealing with jealousy, which often upset the
children on which dentist must act as an outlet of children feelings.
Management of difficult or naughty child:
Kindness for a few minutes with little treatment.
If child make noise, ask the parents to get out of the clinic & child is
managed firmly but not forcefully.
If the child refuses to sit on the chair, he may be picked up gently & placed
on it & tell him about what will be done for him e.g. polishing.
The dentist should have absolute control of situation, parents should leaves
the dental room & the assistant should not interfere.
Lecture five
Child development:
Child development is influenced by the interaction of:
Hereditary factors.
Environmental factors.
1. Hereditary factors: Hereditary: Children of taller parents are usually tall and
vice-versa. Genetic disorders are associated with inherently altered growth
potential e.g. short-stature in Turner syndrome, and tall-stature in Marfan
syndrome etc.
2. Environmental factors:
Cultural: Routine practice of breast- feeding is a positive growth-promoting
factor, while delayed weaning, unhygienic living conditions are important
adverse cultural influences.
Social: Children of high socioeconomic status have better growth due to better
nutrition and hygienic conditions than those of low socioeconomic status.
Malnutrition.
NOTE: it is necessary to differential between growth & development.
Development: is the increase in skills & complexity of function.
Growth: it is the increase in the physical size of the whole body or of any
part, it is measured in centimeters & Kgs. So in growth we are dealing
with the growth of maxilla & mandible & palate. So it is increase in
height & depth.
Life cycle of the tooth: evidence of development of human tooth
observes of sixth week of embryonic life.
Child development classification:
•Infant: (1-5 months) no need for dental treatment
•Toddler: (5 months- 2 years) miner dental caries may be detected & this
can be excavated & filled with amalgam filling or composite resin
material.
•Pre- school: (2-6 years) the older pre-school children present high
cooperative behavior e.g. 4-5 years.
•Middle year's age: (6-12 years) anxiety can be deal with a reasonable
way by staff personal & the dentist.
•Adolescent: the individual is no longer a child but not yet an adult some
say that is between (12-20 y) some say (11-15 y). In this period the
adolescent is characterized by sensitivity moody need more attention.
Lecture six
Behavior Management
Behavior management is defined as the means by which the dental team
effectively and efficiently performs dental treatment and thereby instills a
positive dental attitude.
Behavior management can be classified as
1- Non-pharmacological
2- Pharmacological
Non-pharmacological methods of behavior management are:
1) Communication
2) Behavior shaping [modification]
3) Behavior management
1- Communication
Types of communication
1) Verbal communication – by speech
2) Nonverbal communication – by body language, smiling, eye contact,
expression of feeling without touching, giving a hug.
3) Both using verbal and nonverbal.
2- Behavior Shaping
􀁩 Tell-Show-Do
􀁩Modeling
􀁩Reinforcement technique
􀁩 Restraints
1- “Tell-Show-Do”
Tell and show every step and instrument and explain what is going to be done.
2-Modeling
􀁩 Use an older sibling or child to model for an apprehensive patient.
􀁩 Best to use someone they look up to.
􀁩 Very effective in families that have 2 or more kids.
3- Reinforcement techniques: it may be defined as the strengthening of a pattern of behavior being
displayed in the future.
Types of reinforcements can be:1) Social – e.g. praise, positive facial expression, physical contact by shaking hand, holding hand,
patting shoulder or back.
2) Material – e.g. Toys, games
3) Activity reinforcers – e.g. Watching a TV show
3-Behaviour Management
Child can be managed by the following methods:
1) Audio analgesia:
Audio analgesia is a method of reducing pain. It consists of providing a sound stimulus of such
intensity that the patient finds it difficult to attend to anything else.
2) Voice control:
Change in tone from gentle to firm is effective in gaining the child’s attention and
reminding him that the dentist is an authority figure to be obeyed.
3) Relaxation:
Relaxation involves a series of basic exercises, which may take several months
to learn, and which require the patient to practice at home for at least 15
minutes per day.
4) Hand Over Mouth Technique:
􀁩 Used for an extremely uncooperative-defiant hysterical child.
􀁩 Talk very softly close to the ears.
􀁩 Place hand back if child starts screaming again. Keep repeating until
cooperative.
5) Physical Restraints; it is the last resort for handling uncooperative or
handicapped patients. Physical restraints involve restriction of movement of
the child’s head, hands, feet or body.
􀁩 Can be used for anesthesia administration.
􀁩 Informed consent prior to use.
It can be:
· Active – restraints performed by the dentist, staff or parent without the aid of
a restraining device.
· Passive – with the aid of restraining device.
Examples
1. Molt mouth props.
2- Papoose
Lecture seven
Pharmacological Methods
Pharmacological Methods
􀁩 Nitrous Oxide-Oxygen
􀁩 Pre-medication
􀁩 Conscious Sedation
􀁩 General Anesthesia
Nitrous Oxide-Oxygen
􀁩 “Laughing gas”.
􀁩 One of the safest pharmacologic methods of behavior management.
􀁩 Very few adverse effects, easily removed from the lungs in 4 minutes.
􀁩 Special equipment required.
􀁩 Will not work for a defiant child.
􀁩 Cannot replace local anesthesia.
􀀫 Indications:
– reduce fear in an anxious or apprehensive patient.
– to raise the pain threshold.
􀀫 Contra-indications:
– Defiant child.
– To replace poor behavior management technique or local anesthesia.
– Upper respiratory infections.
– Psychiatric disorders.
Premedication
􀁩 Can give mild sedative night before or the morning of the appointment.
􀁩 Rarely done for very young children.
􀁩 Can be used to teenage children.
􀀫 Common Drugs:
Valium.
Conscious Sedations
􀁩 Sedative drug (Oral/Nasal/IV/IM/ Rectal) + Nitrous.
􀁩 Special training required in several states.
􀁩 Patient is able to maintain their own airway. Can cry during procedure.
General Anesthesia
􀁩 Usually done in a Hospital.
􀁩 Anesthesiologist or anesthetic nurse required.
􀁩 Special training required.
General Anesthesia
Indications :
􀁩 Extremely young child with rampant caries.
􀁩 Handicapped children
􀁩 Extremely fearful children
􀁩Any systematically complication condition e.g. congenital heart condition
etc.
Lecture 8
Numbering of primary teeth
􀁩 20 primary teeth as compared to 32 permanent teeth
􀁩 No premolars in the primary dentition
􀁩 The primary molars are replaced by the premolars
􀁩 The permanent molars erupt distal to the primary second molars
General Morphologic considerations
􀁩 Crown
􀁩 Pulp
􀁩 Root
Crown of Primary Teeth
􀁩 Shorter
􀁩 Narrower occlusal table
􀁩 Constricted in the cervical portion
􀁩 Thinner enamel and dentin layers
􀁩 Broad contacts
􀁩 Color is usually lighter
Pulp of Primary Teeth
􀁩 Larger
􀁩 Pulp horns are closer to the outer surface
􀁩 Mesial pulp horn is higher
􀁩 Form of the pulp follows the external surface of the crown
􀁩 Usually a pulp horn under each cusp
Root of Primary Teeth
􀁩 Anterior teeth roots are narrower mesiodistally
􀁩 Posterior teeth have longer and more slender roots in
relation to crown size
Eruption Charts
Primary Teeth Eruption Chart
Permanent Teeth Eruption Chart
Lecture 9
Restorative materials used
in Pediatrics Dentistry
1. Amalgam owing to the simplicity of its use dental amalgam is the most popular restorative
material.
Advantages:
1. Simple
2. Quick
3. Cheap
4. Technique insensitive
disadvantages
1. Not adhesive
2. Requires mechanical retention in cavity
3. Environmental and occupational hazards
4. Aesthetically mot accepted.
2. Glass ionomers
A glass ionomer consists of a basic glass and an acidic water-soluble powder that sets by acid–
base reaction between the two components.
Advantages:
1. Adhesive
2. Aesthetic
3. Fluoride leaching
Disadvantages:
1. Brittle
2. Susceptible to erosion and wear
3. Resin modified glass ionomer: The formulation consists of about 80% glass ionomer
material combined with 20% resin component.
Advantages:
1. Fluoride releasing.
2. Conservative preparation.
3. Aesthetic appearance.
4. Composite resins
Resin-based composites have revolutionized clinical dentistry.
Advantages:
1. Adhesive
2. Aesthetic
3. Reasonable wear problem.
Disadvantages:
1. Technique sensitive
2. Rubber dam required
3. Expensive
5. Preventive resin restorations
Preserve tooth structure since they do not require extensive removal of tooth
structure. With preventive resin restorations, only caries are removed followed by
placement of a composite resin, and sealing the remaining caries-susceptible pits
and fissures on the tooth. Preventive resin restorations are used widely in pediatric
dentistry.
6. Stainless steel crown: are particularly useful in the restoration of grossly
broken down teeth, primary molars that have undergone pulp therapy, and
hypoplastic primary or permanent teeth. They are also indicated when restoring
the dentition of children at high risk of caries, particularly those having treatment
under general anesthesia.
Lecture 10
Cavity preparation
Cavity preparation: An operation in which carious material is removed from
teeth and biomechanically correct forms are established in the teeth to
receive and retain restorations.
Black (Operative Dentistry, 1908) classifies cavities mainly in reference to the
positions in which they occur and the manner in which they extend, as
follows:
Class 1-Cavities beginning in pits and fissures.
Class 2-Cavities beginning in the proximal surfaces of premolars and
molars.
Class 3-Cavities beginning in the proximal surfaces of the incisors and
canines which do not require the removal and restoration of the incisal
angle.
Class 4-Cavities beginning in the proximal surfaces of the incisors which
require the removal and restoration of the incisal angle.
Class 5-Cavities beginning in the gingival third of the labial, buccal or lingual
surfaces of teeth.
Restoration of primary teeth differs from restoration of permanent teeth, due in
part to the differences in tooth morphology. The mesiodistal diameter of a
primary molar crown is greater than the cervicoocclusal dimension. The buccal
and lingual surfaces converge toward the occlusal. The enamel and dentin are
thinner.
The pulp chambers of primary teeth are proportionately larger and closer to
the surface. Primary teeth contact areas are broad and flattened rather than
being a small distinct circular contact point, as in permanent teeth. Shorter
clinical crown heights of primary teeth also affect the ability of these teeth to
adequately support and retain intracoronal restorations.
Tooth preparation should include the removal of caries or improperly
developed tooth structure to establish appropriate outline, resistance,
retention, and convenience form compatible with the restorative material to be
utilized. Rubber-dam isolation should be utilized when possible during the
preparation and placement of restorative materials.
There will be exceptions to the recommendations based upon individual
clinical findings. For example, stainless steel crowns are recommended for
teeth having received pulp therapy. However, an amalgam or resin restoration
could be utilized in a tooth having conservative pulpal access, sound lateral
walls, and less than 2 years to exfoliation. Likewise, a conservative Class II
restoration for a primary tooth could be expanded to include more surface area
when the tooth is expected to exfoliate within 1 to 2
years.
Types of restorations:
1. Adhesive restoration: more difficult to place in baby teeth, as the treatment
needs a totally moisture-free environment, two types:
• Preventive Resin Restorations:
In case of single or multiple, small, carious pits or fissures which may extend
into enamel, dentin. Excavated and restored with resin.
• Composite/Resin Restorations - involves the excavation of single, larger
carious lesion followed by restoration with a resin based material. Retention
and resistance forms of cavity preparation do not apply, therefore more
conservative Tooth isolation is critical
2. Amalgam restoration: are found to be strongest and most durable.
Lecture 11
Tooth isolation (Moisture Control in
Dentistry):
Sources of moisture in the clinical environment:
1- Saliva.
2- Blood.
3- Gingival crevicular fluid.
4- Dental materials, materials we may use during treatment [eg. etchants,
irrigant solutions].
Why is moisture control important?
1- Patient related factors
• Comfort.
• Protects patients swallowing foreign bodies.
• Protects patient soft tissues – tongue, cheeks by retracting them from
operating field.
2- Operator related factors
• Infection control to minimize aerosol production.
• Improves visibility of the working field and diagnosis.
• Less fogging of the dental mirror.
• Prevents contamination of cavity preparation/ root canal.
Methods of moisture control:
1- Saliva ejector
2- Air- water syringe
3- Absorbent materials
4- Rubber dam
5- Pharmacological methods
1- Saliva ejector:
Advantages:
1- Cheap
2- Easy to use (can be held by patient).
Disadvantages:
1- Can be uncomfortable for patient if used inappropriately.
2- May cause soft tissue damage.
3- Active tongues can make placement difficult.
2- Air-water syringe:
Advantages:
- Easy to use.
Disadvantages:
1- Needs greater caution with use as can dehydrate dentine and cause pain and discomfort to patient
2- Not effective if large volumes of moisture, can just transfer moisture from one tooth to the next.
3- Absorbent materials
• Cotton rolls, gauze.
• Can be used with other methods of moisture control eg saliva ejector
Advantages:
1- Effective to control small amounts of moisture
2- Retract soft tissues at same time
Disadvantages:
1- Only provides short term moisture control
2- Ineffective if high volumes of fluid
3- Active tongues may make placement and retention difficult
4- Rubber dam
• Isolation of one or more teeth from the oral environment.
Rubber dam set composed of:
• Rubber dam (green, blue and black)/15cm
• Rubber dam punch
• Rubber dam clamps
• Rubber dam clamp forceps
• Rubber dam frame/holder
Advantages:
1- Complete, long term moisture control
2- Protection for both patient and dentist
3- Infection control measure
4- Prevents accidental swallowing of foreign bodies
5- Retracts soft tissues
Disadvantages:
1- Take time to apply
2- Communication with patient can be difficult
3- Patient may feel in comfort or phobic with it
5- Pharmacological methods
• Use of local anesthetic with a vasoconstrictor
• eg Adrenaline: causes transient vasoconstriction of blood vessels in site of
injection. May control haemorrhage in some situations
Lecture 12
Pulp treatment for children:
1. Vital Pulp Therapy for Primary Teeth
2. Non-Vital Pulp Therapy for Primary (Baby) Teeth.
• Three vital techniques:
1. Indirect pulp capping.
2. Direct pulp capping.
3. Coronal pulpotomy.
Treatment Objective for Vital Pulp Therapy
1. Preserve the vital pulp.
2. Preserve the space for the underlying permanent tooth.
3. Eradicate potential for infection.
1. Indirect Pulp Cap: the application of a medicament (hard-setting calcium hydroxide dressing).over a thin
layer of remaining carious dentin, with no exposure of the pulp. Can be done in primary and permanent
teeth.
Indications for the Indirect Pulp Cap
• Absence of spontaneous pain.
Contraindications for the Indirect Pulp Cap
• Prolonged spontaneous pain, particularly at night.
• Excessive tooth mobility.
2. Direct Pulp Cap
• Definition: the placement of calcium hydroxide on healthy pulp tissue that has been exposed from
caries excavation or traumatic injury.
• Treatment Objective: to seal the pulp against bacterial leakage and maintain the vitality of the
underlying pulp tissue regions.
Indications for the Direct Pulp Cap
(1) “pinpoint” exposures that are surrounded by sound dentin.
(2) asymptomatic tooth.
Contraindications for the Direct Pulp Cap
(1) Carious exposure.
(2) Spontaneous toothache.
(3) Excessive tooth mobility.
Direct Pulp Cap Technique
Dry the exposure site with a sterile cotton pellet.
Apply hard-set calcium hydroxide cement.
Seal with amalgam or composite restoration.
3. Pulpotomy
Definition: the surgical removal of the entire coronal pulp, leaving intact the vital
radicular pulp within the canals. Vital pulpotomy is performed when the top part
of the pulp has been affected by decay or if the top part has been injured from
an accident. The dentist removes this decay and any injured for the root part of
the tooth is still healthy so it is left alone. The inside of the tooth is packed with a
protective material and then the tooth is enclosed with a stainless steel crown.
Vital pulpotomy can be done on baby teeth and on adult teeth that have not
finished growing a full length root. For adult teeth, this is only a temporary
solution until the tooth finished growing its root. Vital pulpotomy can also be
done as a first step in root canal
treatment.
Indications for the Pulpotomy
(1) Cariously exposed primary teeth, when their retention is more advantageous
than extraction.
(2) When inflammation is confined to the coronal portion of the pulp.
Contraindications for the Pulpotomy
(1) Fistula or swelling.
(2) The tooth crown is non-restorable.
(3) Marked tenderness to percussion.
(4) Mobility.
(5) Spontaneous pain, especially at night.
(6) Necrotic pulp.
Definition of Pulpectomy for Primary Teeth
• The removal of necrotic pulp tissue followed by filling the root canals with
resorbable cement..
Treatment Objectives for Primary Tooth Pulpectomy
(1) Maintain the tooth free of infection.
(2) Promote physiologic root resorption.
(3) Hold the space for the erupting permanent tooth.
Lecture 13
Local anesthesia
for children:
Local anesthetics are an important tool for the control of pain and discomfort
during dental treatment. Local anesthesia is safe when the appropriate
technique is used. Children remain conscious when a local anesthetic is
given.
Local anesthetic agents:
There are 2 general types of local anesthetic chemical formulations:
(1) esters (eg, procaine, benzocaine)
(2) amides (eg, lidocaine 2%, prilocaine 4%). Local anesthetics are
vasodilators; they eventually are absorbed into the circulation, where their
systemic effect is related directly to their blood plasma level.
Vasoconstrictors are added to local anesthetics to constrict blood vessels in
the area of injection. This lowers the rate of absorption of the local anesthetic
into the blood stream, there-by lowering the risk of toxicity and prolonging the
anesthetic action in the area.
Topical anesthetics
The application of topical anesthetic may help minimize discomfort caused
during administration of local anesthesia. Topical anesthetic is effective on
surface tissues (2-3 mm in depth) to reduce painful needle penetration of the
oral mucosa. A variety of topical anesthetic agents are available in gel, liquid,
ointment, patch, and aerosol forms.
Why don’t some children get numb?
1. An imperfect injection technique is the most common cause of problems
with getting numb.
2. Another common cause of problems is that local anesthetics do not work
well in an acidic environment - such as an inflamed or abscessed area. It is
therefore sometimes useful to control a dental infection with antibiotics before
a local anesthetic can be successfully used.
Local anesthetic complications:
Deaths following local anesthetic administration are almost always the result of an
overdose. The maximum safe dose of lidocaine for a child is 4.5 mg/kg per dental
appointment.
Adverse reactions to local anesthetics occur primarily in the central nervous
system and cardiovascular system, because these tissues are also composed of
excitable membranes.
3. Allergies.
Types of anesthesia:
1. Pressure injective: it is topical anesthesia using pressure injected
device rather needle.
Inferior-alveolar nerve block.
Lingual nerve block.
Long buccal nerve block in the mucobuccal fold. Buccal & distal to the tooth to be
removed.
Infiltration anesthesia.
Mandibular conduction anesthesia (at the base of the neck of mandibular condyle).
Periodontal ligament injection.
Intra pulpal in R.C.T.
Lecture 14
Dental Caries
Dental caries is an irreversible bacterial disease causes demineralization of hard
tissues (enamel, dentin and cementum) and destruction of the organic matter of
the tooth.
Types of Dental Caries:
Primary Caries:- formed on the surface which has not been effected before.
Secondary Caries:- occurs on the surfaces which has been effected before or
around restoration.
Rampant Caries: Suddenly appearing wide spread type of cavies resulting in
early involvement of the pulp effecting those teeth usually regarded as immune to
ordinary caries this type affect mostly young teenagers and children.
Nursing Caries or Bottle Caries:- occurs in children due to prolonged bottle feeding
beyond the usual time they keep the bottle in their mouth so that the milk which
contain sugar remain in contact with the tooth surface leading to fermentation of the
milk liberation of the acid and finally destruction of their teeth. They look like chalky
area white spots & numerous cavities in all teeth spreading over a short period.
Arrested Caries:- when the lesion can last for years or probably for the life time with
out further advancement as a result of reminerelization process.
Current Concept of caries etiology:
Dental caries is a multifactorial disease.
PRIMARY (ESSENTIAL) FACTORS IN THE ETIOLOGY OF DENTAL CARIES
Interaction between four primary factors is essential for the initiation
and progression of caries: bacteria: Acidogenic bacteria that colonize the tooth
surface. Host: Quantity and quality of saliva, the quality of tooth. Diet: Intake of
fermentable carbohydrates, especially sucrose. Time: Total exposure time to
inorganic acids produced by the bacteria of the dental plaque.
Secondary Factors Causing Dental Caries:1 - Anatomic characteristics of the teeth.
Arrangement of the teeth in the arch.
Presence of dental appliances.
Hereditary factors.
Lecture 15
diseases in children
Periodontal
Many people think of periodontal disease as an adult problem. However, studies indicate that nearly all
children and adolescents have gingivitis, the first stage of periodontal disease. Advanced forms of
periodontal disease are rarer in children than adults, but can occur.
Types of periodontal diseases in children:
•Chronic gingivitis: is common in children. It usually causes gum tissue to swell, turn red and bleed
easily. Gingivitis is both preventable and treatable with a regular routine of brushing, flossing and
professional dental care. However, left untreated, it can eventually advance to more serious forms of
periodontal disease.
•Aggressive periodontitis: can affect young people who are otherwise healthy, it is of two types:
•Localized aggressive periodontitis: is found in teenagers and young adults and is characterized by
the severe loss of alveolar bone mainly affects the first molars and incisors.
•Generalized aggressive periodontitis: may begin around puberty and involve generalized
interproximal attachment loss including at least three teeth that are not first molars and incisors,
inflammation of the gums and heavy accumulations of plaque and calculus also occurred.
Eventually it can cause the teeth to become loose.
•Periodontitis associated with systemic disease: occurs in children and adolescents as it does
in adults. Conditions that make children more susceptible to periodontal disease include: Type I
diabetes, Down syndrome.
Signs of periodontal disease:
•Bleeding gums during tooth brushing, flossing or any time.
•Swollen and bright red gums.
•Gums that have receded away from the teeth, sometimes exposing the roots.
•Bad breath that does not clear up with brushing and flossing.
Periodontal Disease Runs in the Family
Periodontal disease may be passed from parents to children. Researchers
suggest that the bacteria which cause periodontal disease may be passed
from one person to another though saliva.
Genetics may also play a major role in the onset and severity of periodontal
disease.
Adolescence and oral care
Evidence shows that periodontal disease may increase during adolescence due to lack of motivation
to practice oral hygiene. Children who maintain good oral health habits up until the teen years are
more likely to continue brushing and flossing than children who were not taught proper oral care.
Hormonal changes related to puberty can put teens at greater risk for getting periodontal disease.
During puberty, an increased level of sex hormones, such as progesterone and possibly estrogen,
cause increased blood circulation to the gums. This may cause an increase in the gum's sensitivity
and lead to a greater reaction to any irritation, including food particles and plaque. During this time,
the gums may become swollen, turn red and feel tender.
Advice for parents
•If the child has an advanced form of periodontal disease, this may be an early sign of systemic disease. A
general medical evaluation should be considered for children who exhibit severe periodontitis, especially if
it appears resistant to therapy.
•The most important preventive step against periodontal disease is to establish good oral health habits
early. When the child is 12 months old, the parents can begin using toothpaste when brushing child teeth.
However, only use a pea-sized portion on the brush and press it into the bristles so the child won't eat it.
•Schedule regular dental visits for family checkups, periodontal evaluations and cleanings.
Lecture 16
Oral prophylaxis (scaling and polishing) and
fluoride application:
Oral prophylaxis:
Instruments and equipment:
Oral prophylaxis the term refers to scaling and polishing procedures which remove
calculus, other deposits, and stains from the teeth with the least trauma to tissues and
restorations and the least discomfort to the patient. The dentist and dental hygienist must
be familiar with the instruments and techniques of instrumentation in performing scaling
and polishing procedures.
Instruments and materials:
a. Parts of an Instrument: Instruments used in scaling have three common parts. The
handle is used for holding the instrument. The shank
connects the handle to the working end. The working end does the actual work of the
instrument.
Detection instruments:
Instruments designed for detecting tooth irregularities are essential for scaling
procedures.
a. Mirror
For detection of supragingival deposits.
b. Explorer
are used to detect calculus, caries, abnormalities and irregularities of teeth.
c. Periodontal Probe
Its use is for measurement of sulcus and pocket depths.
Scaling instruments:
Instruments designed to remove calculus are called scalers. Several different scaling
instruments are designed to reach the various surfaces of the teeth during calculus
removal:
a. Sickle Scalers. Sickle scalers are used to remove supragingival calculus.
b. Curettes: are used to remove subgingival calculus deposits. The shape of the blade
makes subgingival adaptation possible without trauma to the adjacent tissue.
ULTRASONIC DENTAL UNIT
The ultrasonic dental unit is widely used to perform oral prophylaxis
treatments. A continuous flow of water is required to cool the handpiece.
Using a very light guided touch, the activated tip with the bubbling action of the
water rapidly dislodges calculus and stain.
Scaling sequences:
The first surfaces scaled are the facial and proximal surfaces of the maxillary right posterior teeth, beginning
with the third molar (tooth number one). This is followed by the lingual surfaces of the same teeth. Then, the
maxillary anterior, the maxillary left posterior, the mandibular left posterior, the mandibular anterior, and the
mandibular right posterior teeth are done in turn. In each group, scaling of the facial and proximal
surfaces is followed by scaling of the lingual surfaces. When scaling is completed, the teeth are polished in the
same sequence.
Polishing procedure: The polishing agent is applied to the teeth with a small rubber cup, using the angle
handpiece. The rubber cup must be kept well-filled with paste and the dental engine set to rotate slowly so as to
avoid tissue injury and to prevent overheating the tooth. After readily accessible surfaces of the teeth are
polished, the proximal surfaces should be polished with the paste, using unwaxed floss or tape as the carrier, to
remove the polishing paste from the interproximal spaces.
Applying fluorides:
Fluorides applied in various ways will markedly reduce the incidence of dental caries.
•Systemic fluoride application:
•Community water fluoridation:
The most effective of all dental public health measures is fluoridation of
community water supplies. The optimum level of fluoride in water is one part fluoride in one
million parts of water.
b. School water fluoride
c. Fluoride supplements
d. Fluoride milk and juice
e. Fluoride salt
2. Topical application:
•Mouth Rinses: Daily mouth rinsing with a solution of 0.05% fluoride or weekly rinsing with
0.2% sodium fluoride.
•Dentifrices.
•Prophylaxis Pastes with fluoride.
Lecture 17
Methods of Application of Topical
Fluorides
Topical fluoride can be administered by three different methods. 1.
Method involves the application of fluoride solution.
This type of fluoride must be painted on the teeth with a cotton tip applicator.
2. The use of a concentrated fluoride rinse.
3. The tray technique, which is used to apply fluoride gels.
Gel application is generally regarded as the most effective means of topical
fluoride treatment.
A variety of trays are available for fluoride gel application.
The use of disposable trays reduces the chance of cross contamination and
eliminates the need to clean and sterilize reusable ones. Trays come in
several arch sizes to ensure optimal fit for each patient.
The tray should provide complete coverage of all
erupted teeth without going beyond the most distal
tooth surface in the arch.
Custom-fitted trays can be made that require less gel and promote contact of
the gel with the teeth. The extra time and expense of
custom fluoride tray fabrication will limit the use to
specific patients who require daily application of fluoride gel.
Reexamine the mouth to estimate the size of the
dental arches and identify any features such as mal
posed teeth or bony tori that will influence tray selection.
Select a maxillary tray and try it into the patient's mouth. Make sure all teeth
will be contacted by the gel. Remove it and do the same for the mandibular
arch. Refer to the manufacturer's
instructions for the amount of gel required for each tray. A narrow strip of
material along the bottom of the tray is normally adequate. This technique will
minimize the amount of gel required and will reduce
the chance that excess gel will be swallowed by the patient. The patient's
teeth must be dried and kept as dry as possible until trays are inserted.
Dry each arch separately before placing the tray into the patient's mouth. First
place the mandibular tray. Insert one end of the tray in the mouth at an angle
and then rotate the other end of the tray into the mouth. Insert the saliva ejector
before placing the maxillary tray. Place the maxillary tray in a similar fashion
and ask the patient to close his or her teeth together gently.
Refer to the manufacturer's instructions for the amount of time the gel remains
in the mouth. Generally, application is no longer than 4 minutes.
After the trays have been removed, allow the patient to spit any
remaining fluoride from the mouth. Instruct the patient not to rinse,
drink, eat, or smoke for at least 30 minutes.
Lecture 18
Oral Surgery in Children:
Definition of Oral Surgery
Oral surgery: - is that branch of dentistry that deals with the diagnosis and surgical
treatment of diseases and defects of the mouth and dental structures.
Basic Principles of Oral Surgery:
Special consideration should be considered before any surgery performed on pediatric
these include:
1. Preoperative evaluation
a. medical
Obtaining a thorough medical history, obtaining appropriate medical consultations.
b. dental
Perform a thorough clinical and radiographic preoperative evaluation of the dentition as
well as extra-oral and intra-oral soft tissues.
2. Behavioral considerations
Special attention should be given to the assessment of the social, emotional, and
psychological status of the pediatric patient prior to surgery.
3. Growth and development;
4. Developing dentition
Surgery involving the maxilla and mandible of young patients is complicated
by the presence of developing tooth follicles.
5. Pathology
6. perioperative care
Special consideration should be given to fluid and electrolyte management,
and blood replacement.
Indication for oral
surgery:
Extensive caries. 1.
Root pathology as abscess.
Fracture roots or crowns.
Ankylosis.
Supernumerary teeth.
Over retained primary teeth.
Natal or neonatal teeth.
Impacted teeth. 8.
Contra-indication
Local contra-indications
Acute inflammation.
during radiation and chemotherapy
General medical contra-indications
1. Anti-coagulation, hemophilia.
2. Acute phase of a myocardial infarction.
Aftercare following the extraction of teeth:
1. The patient should put pressure on the area by biting gently on a roll or
gauze for several hours after surgery.
2. The patient should not rinse for at least 24 hours after the extraction.
3. For the first two days after the procedure, the patient should drink liquids and
eat soft foods.
ice packs can be applied to reduce facial swelling. Swelling is a normal part of
the healing process; it is most noticeable in the first 48–72 hours after surgery.
As the swelling subsides, the patient's jaw muscles may feel stiff. Moist heat
and gentle exercise will restore normal jaw movement. The dentist or oral
surgeon may prescribe medications to relieve postoperative pain.
lecture 19
Instruments used in oral
surgery:
scalpel:
Function: To cut soft tissue
Bone file:
Function: To smooth bone.
Tissue Scissors:
Function: To cut and remove excess or diseased soft tissue
Also used to cut sutures.
Surgical curettes:
Function: To remove tissue or debris from bony sockets
Tongue and cheek retractor:
Function: To hold tongue and cheek away from surgical site
Mouth prop:
Function: To keep mouth open with extensive procedures, sedated or disabled
patients
Needle Holders
Needle holders are used for suturing the wound.
Extraction Forceps
The basic components of the extraction forceps are the handle, which is above the hinge, and the beaks,
which are below the hinge. The instrument is held in the hand by the handle, upon which pressure is exerted
during the extraction. The beaks are the functional component of the forceps and grasp the tooth.
Maxillary Extraction Forceps for the Six Anterior Teeth of the
Maxilla.
Beaks that are found on the same level as the handles characterize
these forceps, and the beaks are concave and not pointed.
Maxillary Universal Forceps.
The forceps used for premolars have a slightly curved shape and look
like an“S.” These forceps may also be used for extraction of the six
anterior teeth of the upper jaw.
2- population:
Total DMF
Average DMF =
Total number of subjects examined
Maximum score= 28
Excluding teeth (DMFT Index)
1- Third molars.
2- Unerupted teeth.
3- Congenital missing teeth.
4- Supernumerary teeth.
5- Extracted teeth (orthodontic reason, impaction, periodontal diseases).
Maxillary Molar Forceps for the First and Second Molar.
There are two of these forceps: one for the left and one for the right side. They
have a slightly curved shape that looks like an “S” . The buccal beak of each
forceps has a pointed design, which fits into the buccal bifurcation of the two
buccal roots, while the palatal beak is concave .
Maxillary Third Molar Forceps.
Are the longest forceps, due to the posterior position of the third molar. The
beaks of the forceps are concave and smooth (without pointed ends), so that
these forceps may be used for extraction of both the left and right third molar of
the upper jaw.
Mandibular Molar Forceps.
These forceps are used for both sides of the jaw and have straight handles while the beaks are curved at
approximately a right angle compared to the handles. Both beaks of the forceps have pointed ends, which fit
into the bifurcation of the roots buccally and lingually. These forceps are used for the removal of both the first
and second molar of the right and left side of the lower jaw.
Elevators
Straight Elevator:
Function: To loosen tooth or root from bony socket prior to placement of the extraction forceps
Angular elevators- cryer:
Function: To loosen tooth or root from bony socket prior to placement of the extraction forceps
lecture 20
The use of radiographs in
children
Dental radiography is a useful diagnostic aid in oral examination of children. In many
cases the radiographic findings add important information.
Indications for radiographs in children and adolescents:
The major reasons for taking radiographs of teeth and supporting tissue in paediatric
dentistry are:
1) Detection of caries
2) Dental injuries
3) Disturbances in tooth development
4) Examination of pathological conditions other than caries.
X-Ray Use and Safety:
The need for dental X-ray films varies from child to child. Films are taken only after
6
1
4a clinical examination,
reviewing the child’s medical and dental histories
and performing
and only when they are likely to yield information that a visual examination cannot.
In general, children need X-rays more often than adults. Their mouths grow and change rapidly.
They are more susceptible than adults to tooth decay. For children with a high risk of tooth decay,
the American Academy of Pediatric Dentistry recommends X-ray examinations every six months to
detect cavities developing between the teeth. Children with a low risk of tooth decay require Xrays less frequently.
Patient protection:
Leaded protective aprons with a thyroid collar should be provided for the child and for the
accompanying person. Intraoral radiography might be a frightening experience to the child.
Techniques to reduce fear should be used when necessary.
Child’s co-operation reduces the need for retake.
Bitewing radiographs: Bitewing radiographs show the crowns of the posterior teeth and are
primarily utilized to detect proximal caries.
Timing of the first (baseline) bitewing radiographs:
It should be noted that bitewing radiographs should be taken only if they are considered necessary for
adequate treatment.
Digital radiography:
Digital radiography is now possible with an intraoral silicon sensor, sensitive to X-rays, that is directly
connected to a personal computer. The image is displayed on the screen immediately after exposure and
this is time saving, because there is no processing.
In the case of digital radiography images are like any computer files may be stored on disks and easily
transferred to other computers.
Extraoral radiography:
Extraoral radiography includes the lateral oblique projection, dental panoramic radiography and
cephalometry. If an intraoral radiograph shows uncommon structures or findings that cannot be
explained by normal anatomy or covered by a single exposure, the examination has to be supplemented
by extraoral radiography. Panographic radiographs
visualize the entire oral region on one sheet of film. The panographic radiograph is primarily a
screening film, to detect cysts, impacted teeth, view tempromandibular joints, caries, abscesses and
fractures.
Radiographs with the Uncooperative Child
Many times dental radiographs are not possible due to age, maturity, or fear. Films can be exposed
during a sedation visit or during general anesthesia. In an emergency situation, extraoral techniques or
restraint may be required.
lecture 21
Prosthodontic treatment of the children and
adolescent patient:
It can be extremely difficult to encourage the children to wear dental
appliances. The use of partial dentures in young children is very common.
Rarely children need for complete dentures.
The differences between partial dentures for adults and children:
Partial dentures for children are a temporary measure, and are worn only until
the permanent teeth have erupted.
Being a temporary denture, they have simpler designs.
They are usually made of pink acrylic to allow for easy adjustment and
replacement, instead of metal (chrome cobalt) as in adult dentures.
Some dental appliances may be recommended for preventative
purposes, while others may be recommended for treatment purposes.
Appliances use for treatment purposes are of two types:
•Removable prosthetic appliances.
•Fixed prosthetic restorations for missing teeth.
Removable prosthetic appliances:
Indications for removable partial denture:
1. To restore masticatory efficiency.
2. Prevent or correct harmful habits or speech abnormalities.
3. Maintain arch space in the developing dentition.
4. Obturate congenital or acquired defects of the orofacial structures.
Contraindications for removable partial dentures:
Patient is high risk for compliance (home care, care for appliance, and keeping future appointments).
Problems with removable partial denture:
1. A child has little tolerance towards having something inserted in the mouth over a long period of time and
often will not wear it.
2. A child can easily lose the denture.
3. It is more bulky compared to a fixed prosthesis.
2. Fixed prosthetic restorations for missing teeth:
A fixed prosthetic restoration replaces 1 or more missing teeth in the primary, mixed, or permanent dentition.
This restoration attaches to natural teeth, tooth roots, or implants and is not removable by the patient.
Recommendations:
Fixed prosthetic restorations may be indicated to:
1. Establish esthetics.
2. Maintain arch space in the developing dentition.
3. Prevent or correct harmful habits.
4. Improve function.
Appliances use for preventive purposes:
1. Mouth guard.
2. Space maintainers.
1. Mouth guard:
Children most wear mouth guards when engaging in any potentially injurious activity, example sporting.
Similar mouth guards are used for children who “brux” or grind their teeth at night
There are three types of mouth guards:
•Stock mouth protectors: are preformed and come ready to wear. They are inexpensive and can be bought
at most sporting stores. Dentists do not recommend their use.
•Boil and bite mouth protectors: also can be bought at many sporting stores. The "boil and bite" mouth
guard is made from thermoplastic material. It is placed in hot water to soften, then placed in the mouth and
shaped around the teeth using finger and tongue pressure.
•Custom-fitted mouth protectors: are made in a dental office or a professional laboratory. First, the
dentist will make an impression of teeth and a mouth guard is then molded over the model using a
special material. Due to the use of the special material and because of the extra time and work
involved, this custom-made mouth guard is more expensive than the other types, but it provides the
most comfort and protection.
Generally, mouth guards cover upper teeth only, but in some cases dentist will make a mouth guard for
the lower teeth as well. If the child grinds his teeth at night, a special mouth guard-type of dental
appliance called a nocturnal bite plate or bite splint may be created to prevent tooth damage.
Lecture 22
Space maintainer
Introduction:
The loss of one or more deciduous molars or canines can result in crowding
problems, loss of arch length, or impaction. Prevention with space maintenance
appliances will help the patient avoid some of these difficulties.
Indications for Space Maintenance
When a deciduous first or second molar is lost prior to the eruption of the
permanent first molar.
Contraindications for Space Maintenance:
1. Poor compliance.
2. Poor oral hygiene.
3. Uncontrolled rampant caries.
4. Space has already been lost.
5. Severe crowding already exists.
Types of Space Maintainer Appliances
1. Fixed Space Maintainers:
a. Unilateral: Just on one side, usually "replacing" one tooth. Can be a band
and loop as you see here, or a crown and loop type. This can also be a
Distal Shoe type. The distal shoe being one used when the permanent first
molar has not yet erupted.
b. Bilateral: These are very useful. They are usually cemented with bands on
back teeth on both sides connected by a wire just behind the lower incisors.
Usually called a Lingual Arch. This can eliminate the need for two unilateral
spacers. They are most useful if there is more than one tooth
missing.
A maxillary bilateral spacer may incorporate an acrylic button and is called a
maintainer.
Nance space
2. Removable: They are the space maintainers that can be removed and reinserted into the oral cavity by the patient.
Conditions where these removable space maintainer can be used:
•Bilateral loss of posterior teeth in the mandibular arch before eruption of tooth.
•Missing anterior teeth where it is made functional.
When space maintainer is required for a short period of time. 3.
Cases where such spacers can't be used:
1. Uncooperative patients.
2. Patients allergic to acrylic.
3. Epileptic patients.
lecture 23
Instruction to prosthodontic
child:-
The care and cleaning of dentures are important to the health of the oral
tissues and the lifespan of the dental prosthetics.
Important thing that the child should not wear removable appliances (retainers,
bridges, or complete or partial dentures) when playing sports.
Cleaning of dentures:A soft nylon brush, made for natural teeth, should be used to brush the tissues
under the dentures daily, no paste is needed.
During sleep, dentures must be left out, brushed and rinsed, stored in a
denture bath of water and liquid soap solution. Rinse well in the morning before
reinserting.
Eating:Stay with soft foods that are high in nutritive value until all sores are relieved
and healed (1-3 weeks).
Do not try difficult foods like apples these difficult foods should be cut into small
pieces before chewing.
Speech:Speaking with the new dentures may be more difficult for up to a few weeks,
until the tongue adjusts to the new contour of the palate and lower jaw.
Caring for the space maintainer:1. Teeth will be tender for the first few days. Child should avoid poking at the
wire with his/her fingers.
2. It is important that the child avoids chewing gum, eating sticky things like
toffee, and hard items like corn nuts and ice. These snacks can break or
cause the appliance to become loose.
3. Brush the appliance along with the rest of the teeth at least twice daily.
Checking the space maintainer periodically will insure that it is still properly
placed.
Patients with space maintainers should be seen by the dentist at a minimum of
every 6 months for routine examination for evaluation of
the bite, fit of the bands, and tooth eruption. Failure to return for follow up visits
can lead to gum problems, cavities. Once the space maintainer is ready for
removal the dentist will remove it.
Patient Cooperation:
The space maintainer is not a toy. The child should not “flip” the appliance with
the tongue, because it may loosen the fit.
Loose Space Maintainer:
Many times a loose space maintainer can be easily re-cemented if the appliance
has not been bent or broken or if the child is seen as soon as possible. A delay in
getting in for an appointment could cause the need for the space maintainer to be
remade.
Patient Comfort:
Space maintainers are a passive (they do not move teeth) appliance, therefore,
there should not be any pain or discomfort associated with a
Space maintainer. Pain or discomfort could be an indication that something is
wrong.
Care for Mouth Guard:
Proper care will make any mouth guard last longer. Mouth guard should be rinse
with soap and water or mouthwash after each use and allowing it to air-dry. With
proper care, a mouth guard should last the length of a season. The condition of
the mouth guard should be checked before each use, particularly if the athlete
has a tendency to chew on it. Mouth guards may be checked by the dentist at the
regularly scheduled examinations. Mouth guards should generally be changed
each year to account for changes to the mouth and wear and tear on the mouth
guard.
lecture 24
Instruction for good oral hygiene:-
Good oral hygiene is essential to prevent gum diseases and dental decay.
Teaching children proper dental hygiene is an important part of their
development into healthy adults. Brushing, flossing and rinsing help prevent
dental cavities and disease as well as tooth loss. Parents should teach good
dental health by demonstration and example.
Oral hygiene instructions:Oral hygiene can easily be accomplished while baby is lying on a changing
table or in bed or with baby’s head on mom’s lap while she’s sitting on the floor.
Whether baby is fed by breast or bottle, mother should wipe the gum and new
teeth, under the tongue and inside the cheeks, after every feeding with a moist
gauze pad or a clean washcloth. Mothers who breast feed on demand should
do this frequently. This will reduce the number of bacteria in the mouth capable
of converting into acid the lactose in either human or bovine milk or other
fermentable carbohydrates.
Advise mother to inspect baby’s teeth during cleaning. Any change in color or
texture of the tooth surface, e.g., variations of white spots near the gum line of
the upper anterior teeth, a sign of demineralization, suggests incipient
pathology and the need for early referral to a pediatric dentist. Once the
posterior teeth erupt, a moist soft bristle toothbrush can be used gently to
remove plaque and any other food debris from all surfaces of the teeth.
Toddlers and Young Children:By age 2, the child should start learning to brush. On a small soft-bristle
toothbrush, caretaker should apply a pea-size drop of fluoride dentifrice and
brush child’s teeth carefully.
Ages 3-7:Children over 3 years old should begin brushing their teeth themselves,
using a soft child's toothbrush. Instruct them to brush in a gentle circular
motion, rinse thoroughly with water, and spit. They should be supervised by
their parents until they are 6 or 7 years old. Children love to imitate adults,
so brushing at this age could be a family activity, with parents demonstrating
proper teeth-cleaning techniques.
Children should also begin flossing by themselves at age 3.
Replace toothbrushes every 3 months, with the toothbrush increasing in size
according to the child's age. Choose brushes with a small head and medium
bristles.
To see how much plaque remains on the teeth after brushing, mix in a
paper cup three to four drops of red food coloring into 2 tablespoons of
water. Swish around in the mouth for 10 seconds. Spit it into the sink,
but do not rinse. Use a magnifying or regular mirror to find the red
spots of plaque. Brush these away, and note the areas where the initial
brushing failed to remove the plaque.
Dental appointments every 6 months should be a family priority to
ensure healthy teeth and gums.
Lecture 25
Nutrition and dental health
Good nutrition is essential for oral and dental health in children. Good eating
habits are established early in childhood. Poor nutrition can lead to poor
health, obesity, tooth decay, and periodontal disease.
Dietary factors that cause tooth decay:. Sugar should only be a very small part of a child’s diet, otherwise it will
cause tooth decay.
. Sticky, sweet food is very bad for teeth because it maintains high sugar
levels in the mouth, and is very likely to cause tooth decay.
A young child who frequently uses a bottle containing juice or other
sweetened liquid has an increased risk of developing early childhood caries.
Children should only have water in their bottle between meals.
Prenatal nutrition:Good nutrition during pregnancy is very important for the development of
baby teeth. Mineralization (calcification) of primary teeth occurs around
month 3 to 4 of pregnancy.
Nutritional deficiencies during pregnancy can cause serious problems,
including poor enamel formation (hypoplasia), susceptibility to dental
caries, delayed dental eruption, and small tooth size. Vitamin D
deficiency can cause hypoplastic primary tooth enamel.
Fluoride supplementation for pregnant women has not been shown to
reduce dental caries in children. Therefore, fluoride supplements are not
recommended for pregnant women.
Breast feeding:Breast milk is the best nutrient for an infant. There are many
components of breast milk which benefit the baby:
Immunoglobulins
Lysosomes
Lactoferrin
Growth factors
The role of vitamins in oral health:Vitamin A.
Function: Needed for gingival health.
Source: Milk, carrots, and dark green vegetables.
Vitamin D.
Function: Essential for healthy bones, teeth and growth of the jaws.
Source: milk, and oily fish.
Vitamin K.
Function: An important part of clotting system.
Source: Dark green leafy vegetables.
Vitamin C.
Function: Needed for periodontal and gingival health. Aids in wound
healing. Prevents bleeding gums.
Source: Fresh fruit, potatoes, and green vegetables.
Folic acid.
Function: Helps the structures of the face develop correctly. Pregnant women
need to take this.
Source: Dark green vegetables, liver.
The role of minerals in oral health:Calcium.
Function: Helps in the formation of teeth and bones.
Source: Milk, cheese, seafood, and yogurt.
Phosphorus.
Function: Needed for energy production, metabolism, and healthy bone
development.
Source: Milk, cheese, meats, eggs. .
eZinc.
Function: Needed for tissue repair and wound healing.
Source: Seafood, liver, meats.
Fluoride.
Function: Keeps bones and teeth strong.
Source: Tea, broccoli, chicken, and fluoridated water.
Iron.
Function: Needed for blood production and energy production. A deficiency in
iron results in glossitis, which is a red, painful tongue.
Source: Liver, leafy green vegetables, and meats.
The effects of juice on children's teeth:Fruit juice is not a substitute for natural fruit, and it has fewer nutrients. Water
and carbohydrates are the main ingredients in juice.
f. plaque removal instructions:
1- Keep instruction simple.
2- Floss first:
a. Review objectives
b. show how to hold the floss, inserting proximally, pressing around the tooth and
activating for plaque removal.
c. examine by a mirror to observe areas where plaque have been removed.
3- brush: give patient a soft brush and ask him to remove the stained plaque, no
specific brushing instructions are given at this time so that patient can concentrate on
the single objective related to plaque removal.
4- After brushing examine the teeth with the patient and enable him to see that he was
able to remove accessible plaque.
The major carbohydrate components of juice are: sucrose, glucose, fructose,
and sorbitol.
Malnutrition, short stature, and dental caries in children have been associated
with excessive juice consumption. Excessive consumption of juice by infants
can also cause diarrhea due to poor absorption of the carbohydrates in juice.
Abdominal pain is also common in heavy juice drinkers.
It is recommended that fruit juice be consumed during meal time.
The effects of soft drinks on children's teeth:High soft drink consumption leads to excessive caloric intake and high
consumption of sugar. There is a positive correlation between soft drink
consumption and dental decay.
Most carbonated beverages contain phosphoric acid, citric acid, and carbonic
acid. This leads to chemical erosion of teeth.
Lecture 26
Handicapped children
Handicapped children:- those children who are prevented by physical or
mental condition from full participation in the normal activities of their age
group.
Causes of handicapping:
Prenatal causes: Those disabilities that are acquired before birth. These may
be due to diseases that have harmed the mother during pregnancy, or genetic
incompatibilities between the parents.
Perinatal causes: Those disabilities that are acquired during birth. This could
be due to prolonged lack of oxygen or the obstruction of the respiratory tract,
damage to the brain during birth (due to the accidental misuse of forceps, for
example) or the baby being born prematurely.
Postnatal causes: Those disabilities gained after birth. They can be due to
accidents, infection or other illnesses.
Types of handicapping or disability:a) Mobility and Physical Impairments
including:
Upper limb(s) disability.
Lower limb(s) disability.
Manual dexterity.
b) Spinal Cord Disability:
c) Head Injuries - Brain Disability:
A disability in the brain occurs due to a brain injury. Can range from mild,
moderate and severe. There are two types of brain injuries:
Acquired Brain Injury: is not a hereditary type defect but is the degeneration
that occurs after birth.
Traumatic Brain Injury: results in emotional dysfunctioning and behavioral
disturbance.
d) Vision Disibility
e) Hearing Disability
Includes people that are completely or partially deaf.
f) Cognitive or Learning Disabilities
Are kind of impairment present in people who are suffering from learning
difficulties and includes speech disorders.
Lecture 27
Dental treatment of handicapped children
Caries:The importance of diet and oral hygiene must be stressed to avoid caries in
addition, the child must be on systemic fluoride if the local water supply is not
fluoridated. All extensive work for very young developmentally handicapped
children should be done in a hospital, under a general anesthetic, particularly
if behaviour management is a problem. When this initial part of treatment is
completed, the patient is integrated into the routine office program of
prevention. In this way, initial visits to the dental office are not traumatic and
are therefore acceptable. All the requirements of sound restorative practice
should and can be employed, just as they would be for other children in the
practice. It is the parents' responsibility to bring the child to the dental office.
Gingival disorders:The cause of most gingival disorders in handicapped children is poor oral
hygiene and/or the effect of drugs used in their general treatment for convulsive
disorders, such as sodium dilantin. Although gingival surgery may be indicated
in extreme cases, it cannot and should not be carried out unless a program of
optimal oral hygiene has been firmly established. For some patients, the
electric tooth brush is a valuable aid.
Trauma:Because the muscle co-ordination of many handicapped children is poor, they
are prone to falling and fracturing their anterior permanent teeth. The normal
practice of root-canal therapy, if necessary, and crown restoration should be
employed in order to preserve these injured teeth. Although a fixed
replacement prosthesis is a possibility, in many cases this is not practical, and
the level of patient cooperation may not permit a removeable prosthetic
appliance. In these cases, every effort should be made to preserve the natural
tooth or teeth.
Orthodontics:Many handicapped children have orthodontic problems because of skeletal
or muscle abnormalities. Habits, the most common of which are mouthbreathing and tongue thrusting, finger-sucking usually produce dental arch
malformations. Congenitally missing teeth and abnormal exfoliation and
eruption patterns of primary and permanent teeth, can produce poor
alignment and improper occlusion and function. The patient's ability to cooperate is important in the treatment of a severe skeletal malocclusion.
Often a well-timed extraction program will produce an acceptable occlusion
without any other therapy or with the additional use of a very simple
appliance. For this reason, it is necessary to evaluate the dental
development at an early stage so that a long-range program can be
formulated and explained to the parents.
Lecture 28
Instruction of handicapped
children:-
Daily Dental Care:Teaching parents and caregivers how to provide oral hygiene assistance for
their children at home is a great place to start. Children should be encouraged
to participate in their own oral care whenever possible.
If a child has dexterity problems, there are simple “home remedies” and
devices that can aid in dental hygiene and work to make the child feel included
in the day-today regimen. School nurses can go over some
of these techniques with parents and students to encourage at-home dental
care, or even in school brushing after lunch or snacks.
Tips for Caregivers Who Help with Oral Hygiene:. Caregivers should understand of the importance of special oral health issues
as the first step for a healthy smile.
• Before beginning an oral hygiene task, explain what you are about to do. “I
am going to brush your teeth now.” Or “I am going to help floss your teeth now.
• Work in a slow, calm manner to avoid startling the person.
• Support the person’s head. Take care to prevent gagging when the head is
tilted back.
• If the person is unable or unwilling to keep his or her mouth open, a mouth
prop might help.
The following methods will help children brush their teeth and floss on their
own at home.
■ Use a wide elastic band to attach the brush to their hand.
■ Enlarge the brush handle with a sponge, rubber ball or bicycle handle grip.
■ Wind an elastic bandage or adhesive tape around the handle.
■ Lengthen the handle with a piece of wood or plastic, such as a ruler, or
tongue depressor.
■ Use an electric toothbrush or commercial floss holder.
Make oral care easier for the child
Daily oral care should be a pleasant experience as well as a necessary one. Even if the
child can’t brush and floss properly, letting the child play at cleaning a little when you’re
finished can add to the fun.
Children should clean their own teeth, if possible. You can explain why daily brushing and
flossing are important and show them how to do it. By placing your hand over the child’s
hand, you can guide the child through the steps. However, caregiver has to do the
cleaning if the child is unable to do it.
Where should caregiver do it?
Use any well-lit room that’s convenient. If the child is in a wheelchair, the kitchen might be
ideal. However, the best place is where the child is most
comfortable.
Lecture 29
Instruction of handicapped children
(continue):-
Preparing for a Dental Visit:A child’s daily dental care is important, in order to prevent dental disease or
oral health problems, it is recommended that good hygiene practices be
coupled with dentist visits twice a year.
Other than dexterity, another major oral health obstacle for children with
disabilities can be their sensory development. A child’s sensory issues may
cause their dentist visit to take longer than usual in order for them
to become comfortable with unfamiliar surroundings, sound, and
instruments. School nurses can aid in this transition by taking time to teach
these children exactly what to expect in the dentist’s office. From
familiarizing them with toothpaste and its consistency, to explaining that they
will need to keep their mouth open wide for the dentist to examine them,
knowing and understanding what will happen during their visit can
help put handicapped children more at ease. A child with sensory
defensiveness may exhibit aversion to unexpected touch, particularly to the
face, teeth cleaning by the hygienist, moving backwards in the dental chair,
the bright light above their head, dental equipment noises, the smells and
feel of the glove material. .
The following techniques are recommended to make trips to the dentist more
comfortable for children with sensory disorders:
■ Allow the child to wear an X-ray vest during the entire appointment to
provide comforting pressure.
■ Use a vibrating electric toothbrush at home with the child to simulate the
vibrations of the dentist’s instruments.
■ Have the child bring a toy to play with during the appointment.
■ Allow the child to wear something that blocks bright light in case of sensitivity
to it (for example, a hat or sunglasses).
■ Bring headphones with calming music to listen to.
■ Let them know verbally what is going to happen next at each point during the
examination.
Lecture 30
Preventing dental disease in
handicapped children
Diet: A balanced diet is essential for nutrition as well as a part of the preventive program for the
handicapped children.
- Plaque Control: It can be done by mechanical means or by chemoprophylaxis.
Mechanical means: Toothbrush is effective mechanical means to remove plaque. However most of the
mentally disabled are not able to handle it properly and often need help of their caregivers.
It has been suggested that complete plaque removal with a conventional toothbrush is not realistic for
mental handicapped children. Powered brushes are particularly well suited for people with reduced
motor skills.
Chemical means: Use of chlorhexidine, the treatment of choice for gingivitis, is indicated in
developmentally disabled, medically compromised, and dependent populations who are unable to
remove plaque by mechanical means.
For persons unable to use chlorhexidine as a mouthwash, the agent can be effectively swabbed on the teeth
with an applicator, sprayed on the teeth, applied with a toothbrush, or used as a gel.
• Pit and fissure sealant: In this high-risk population, pit and fissure sealants should be applied to
permanent teeth soon after eruption, as these measures are highly effective in preventing occlusal caries and
parents should be advised of the need for regular monitoring and maintenance of fissure sealants.
- Fluoride: The benefits of fluoride for the prevention and control of dental caries is well documented.
Optimizing fluoride in drinking water remains the best method for prevention, but in its absence, dietary
fluoride supplements, fluoride toothpaste and topical applications are recommended. Use of fluoride
toothpaste would help to reduce caries risk, and the routine use of these regular behaviors might keep
children aware of oral health care.
For professional use, fluoride varnishes are the safest and most practical method for the patient, hence their use
should be recommended for these special schools. Fluoride varnish is an almost ideal preventive dental agent
for children with poor tolerance to dental procedures.
- Periodic scaling and prophylaxis: It should be performed under the preventive approaches. The proportion
of subjects with bleeding, calculus and pockets of 3-4 mm should be provided with proper oral prophylaxis and
periodontal therapies.