Pediatric Dentistry I

OPGD 804-04
2002 Sophomore Spring Semester

University of Louisville School of Dentistry

Orthodontic, Pediatric and Geriatric Dentistry

Faculty
Dr. Guy M. Furnish, Course Director
Dr. Kim Hansford
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TABLE OF CONTENTS
Course Schedule________________________________________________________ 5
Course Description______________________________________________________ 6
Topic: Development of the Dentition (Freshman Spring) ____________________ 10
Dental Development Review Questions_____________________________________ 18
Topic: Examination, Diagnosis and Treatment Planning ______________________ 22
Objectives ________________________________________________________________ 22
Slide Notes for Examination and Diagnosis _____________________________________ 24
Topic: Pediatric Dental Radiology and Radiographic Interpretation ___________ 34
Objectives ________________________________________________________________ 34
Slide Notes for Pediatric Oral Radiographic Technique __________________________ 35
Slide Notes for Radiographic Interpretation ____________________________________ 42
Panoramic Dental Radiology_________________________________________________ 55
Topic: Local Anesthesia & N20-02 Inhalation Sedation ______________________ 61
Lecture Notes for Local Anesthetic Injections and Child Management ______________ 63
Maximum Dosage of Lidocaine with Epinephrine 1:100,000 ______________________ 66
Slide Notes for Local Anesthesia ______________________________________________ 68
Lecture Notes for Nitrous Oxide-Oxygen Inhalation _____________________________ 74
Selection and Management of the Child Patient _________________________________ 74
Introduction ____________________________________________________________________ 74
Benefits to the Patient: ____________________________________________________________ 74
Benefits to the Dentist: ____________________________________________________________ 75
Characteristics __________________________________________________________________ 75
Contraindications ________________________________________________________________ 76
Equipment______________________________________________________________________ 76
Introducing N20-02 to the Child _____________________________________________________ 77
Technique of Initial Administration __________________________________________________ 77
Topic: Sealants and the Preventive Resin Restoration (PRR) ___________________ 79
Objectives ________________________________________________________________ 79
Lecture Notes for Preventive Dentistry, Sealants and Preventive Resin Restorations __ 81
Patient Record___________________________________________________________________ 81
Plaque Control __________________________________________________________________ 81
Diet Control ____________________________________________________________________ 81
Toothbrush vs. Rubber Cup Prophylaxis ______________________________________________ 81
Sealants________________________________________________________________________ 82
Supplemental Fluoride ____________________________________________________________ 82
Alternatives to Community Fluoridation ______________________________________________ 83
Practical Considerations of Supplementation ___________________________________________ 83
Topical Fluoride Therapy __________________________________________________________ 84
Office Therapy __________________________________________________________________ 85
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Home Therapy __________________________________________________________________ 86

Sample Fluoride Gel Prescription____________________________________________________ 86
Fluoride Recommendations for Orthodontic Patients_____________________________________ 86
Safety _________________________________________________________________________ 88
Safety with Topically Applied Fluoride _______________________________________________ 90
Safety with Home Fluoride_________________________________________________________ 90
Topic: Pediatric Restorative Dentistry _____________________________________ 91
Topic: Pulp Therapy for the Primary Dentition and Young Permanent Teeth _____ 93
Objectives ________________________________________________________________ 93
Lecture Notes for Treatment of Deep Caries, Vital Pulp Exposure, and Pulpless Teeth in
the Child and Adolescent ____________________________________________________ 95
Diagnostic Aids _________________________________________________________________ 95
Evaluation of Treatment Prognosis before Pulp Therapy__________________________________ 97
Vital Pulp Therapy - Treatment of the Deep Carious Lesion - Indirect Pulp Cap _______________ 98
Direct Pulp Cap ________________________________________________________________ 102
Vital Pulp Therapy ______________________________________________________________ 104
Summary of Pulpotomy Studies ____________________________________________________ 107
Non-Vital Pulp Therapy - Pulpectomy _______________________________________________ 108
Non-Vital Pulp Therapy - Apexification _____________________________________________ 112
Past Examples Of Midterm & Final Exams ________________________________ 114
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COURSE SCHEDULE
Pediatric Dentistry I - OPGD 804-04
Sophomore Spring 2002
Fridays - 1:00 P.M. - Room 103

DATE LECTURE TITLE SPEAKER

January 4 Course Introduction Furnish
Examination & Diagnosis Furnish

January 11 Examination & Diagnosis Furnish

January 18 Examination & Diagnosis Furnish

January 25 Pediatric Oral Radiology Furnish

February 1 Pediatric Oral Radiographic Interpretation Furnish

February 8 Pediatric Oral Radiographic Interpretation Furnish

February 15 Pediatric Oral Radiographic Interpretation Furnish

February 22 MIDTERM

March 1 Local Anesthesia and N20-02 Inhalation Sedation Hansford

March 8 Prevention, Sealants and PRR’s Hansford

March 15 Restorative Dentistry Furnish

March 22 Pediatric Pulp Therapy I Furnish

March 29 Pediatric Pulp Therapy II Furnish

April 5 SPRING BREAK Furnish

April 12 Sample Cases/Treatment Planning Furnish

April 19 FINAL

April 26 Finals Week

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COURSE DESCRIPTION
1. Course Title: Pediatric Dentistry I - OPGD 804-04
[1 credit hour]

2. Time and Location: Friday afternoons from 1:00 to 1:50 p.m. (Room 103)

3. Faculty: Dr. Guy Furnish (Course Director)

Dr. Kim Hansford

4. Office Hours and Information About Course Director:

Guy M. Furnish, DMD

Associate Professor, Pediatric Dentistry
Office room number: 306B
University telephone number: 852-5126
Office hours: posted on office door
Home telephone number: 451-1580

Department secretaries: Roxie Williams and Evelyn Tanner

Room 319 [852-5124]

5. Required Text: Pediatric Dentistry, Infancy Through Adolescence, 3rd Edition, J. R.

Pinkham, W. B. Saunders Co., Philadelphia, 1999. This text is used for junior courses as
well.

6. Course Content:

You have just completed a lecture and laboratory course designed to acquaint students
with basic psychomotor skills pertinent to contemporary pediatric dentistry. Exercises on
alginate impressions, diagnostic casts, amalgam restorations and stainless steel crowns
were included. The Orthodontic Laboratory Course taken concurrently and other
orthodontic courses in the near future will address psychomotor skills in arch length and
cephalometric analysis and fabrication of appliances commonly employed to manage the
developing occlusion, such as space maintainers, space retainers, crossbite correction
appliances, oral habit appliances and Hawley appliances.

This lecture course presents a brief introduction to the Pediatric Dentistry Clinic designed
to give the basic knowledge and clinical skills necessary for management of the simplest
and most basic pediatric patient needs. This will include an introduction to the Pediatric
Dentistry Clinic and its forms, procedure, treatment planning and case presentation
pertinent to dentistry for children, pediatric oral radiology, operative dentistry, preventive
techniques and theories, pulp therapy and an overview of what to expect encountering the
personality of the child patient. This course directly contributes to the attainment of
skills listed under ULSD Major Competencies 2, 5, 7, 9, 10, 12, and 14.

It is the first of two lecture courses designed to fulfill the Curriculum Guidelines for
Predoctoral Pediatric Dentistry developed by the Section of Pediatric Dentistry of the
American Association of Dental Schools. Objectives are given for each lecture as an aid
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in preparing for examinations. An excellent required text is utilized in this course and
throughout the remaining pediatric dentistry courses given in your junior year. Buy it.
You won’t be sorry.

After reviewing suggestions for improving this course obtained from last year's students,
the Department has decided to make a few changes in the format of the course.
Unfortunately, moving the class to another time slot, not after lunch or right before clinic
was not possible.

This year, in an attempt to make the class period more stimulating, we are changing from
a strict lecture/slide format to one that is more interactive. There are pre-class reading
assignment responsibilities. Each week you will be given a reading assignment that must
be read prior to class time. During class you will be quizzed, either orally or in writing,
on the material contained in the reading assignment. You will also be called upon at
random to respond to questions concerning pertinent patient examples presented in a
format that is similar to the format of the case analysis section of the Part II National
Boards.

7. Grading/Remediation:

Students will be evaluated on attendance, quizzes, a midterm and a final examination.

You will be responsible for material covered in all classes and handouts and assigned
readings from the required text that should be brought to class. Testable material will be
compatible with the objectives as outlined in the course description.

A one-hour midterm examination will count 30% of the final course grade and a one-hour
plus cumulative final examination will count 50%. Quizzes will be given most weeks and
will count 20% of your grade.

Quizzes 20%
Midterm 30%
Final 50%

The lectures offered in this course contain visual information we feel is necessary for the
student to successfully complete his or her clinical assignment. Attendance will be
recorded off quizzes or by student signature on the class roster distributed from the start
of the lecture until 15 minutes after the hour. Punctual attendance for lectures is expected.
More than one unexcused absence will result in a drop of one letter grade.

The course grading scale is as follows:

A 90 to 100
B 80 to 89
C 70 to 79
F 0 to 69

All scores on examinations will be adjusted such that test items that were clearly
negatively discriminating are eliminated.
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In the event of a failing grade, the student will have to perform satisfactorily on a written
make-up examination within two weeks of the end of the semester. The highest course
grade attainable will be a "C," regardless of your performance on the make-up exam.
Satisfactory performance on the make-up exam will raise that student's grade to a "C.”
Double failures, in the absence of extenuating circumstances, will require repetition of
the course.

8. Unethical Behavior:

The Department of Orthodontic, Pediatric and Geriatric Dentistry takes a grim view and
an aggressive stance on cheating and other unethical behavior. Students accused of a
breach of ethical conduct will be reported in accordance with "The Code of Professional
Responsibility and the Bylaws of the Student Review Council of the University of
Louisville School of Dentistry” (the official document given to all students). In any
hearing resulting from such an accusation, the department's recommendations will
usually range from a course failure with no available mechanism to make up the grade
(until the full course is successfully completed the following year) to dismissal from
school with the etiology of the dismissal clearly and permanently stated on school
records.

9. Reading Assignments Covered on Quizzes:

DATE CHAPTER AND PAGES TOTAL PAGES

First 2 pages of Growth and Development handouts and
January 4 Sophomore Preclinical Course alloy and stainless steel
preps
Chapter 1 (3-11) Pediatric Dentistry
January 11 Chapter 12 (139-183) Dynamics of Change Birth to 3 64
Chapter 13 (184-193) Infant/Toddler Exam
January 18 Chapter 17 (251-264) Dynamics of Change Age 3-6 36
Chapter 18 (265-286) Exam/Diag./Tx. Planning, 3-6
Chapter 29 (427-444) Dynamics of Change Age 6-12
January 25 Chapter 30 (446-474) Exam/Diag./Tx. Planning, 6-12 84
Chapter 36 (579-592) Dynamics of Change-Adolescence
Chapter 37 (594-617) Exam/Diag. & Tx. Planning/General
Orthodontics-Adolescence
Chapter 18 (280-284) All previously read.
February 1 Chapter 30 (469-474) All previously read. 15
Chapter 37 (607-610) All previously read.
February 8 & Same as February 4
15
February 22 Midterm - All of the above
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March 1 Chapter 5 (69-73) Pediatric Physiology

Chapter 6 (74-83) Nonpharmacologic Issues/Pain Control
Chapter 7 (85-91) Pain and Anxiety Control/Pain
Perception Control
Chapter 28 (411-417) Local Anesthesia 29

March 8 Chapter 32 (481-517) The Acid-Etch 37

Technique/Sealants/PRR
March 15 Chapter 20 (296-308) Dental Materials 44
Chapter 21 (309-339) Restorative Dentistry for the Primary
Dentition
March 22 Chapter 22 (341-354) Pulp Therapy for Primary Dentition
Chapter 33 (522-530) Pulp Therapy for Young Permanent 23
Teeth
March 29 Same as March 24
April 5 Spring Break
April 12 Chapters 14, 19, 31, 38 Prevention of Dental Disease 36
April 19 Final Exam - All of the above
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TOPIC: DEVELOPMENT OF THE DENTITION

(FRESHMAN SPRING)
Objectives:

Students should be able to:

l. Identify the extent of development of the primary and permanent dentition at each of the
following times:

6 weeks in utero

Dental lamina begins as invaginations of the oral ectoderm; gives rise to the deciduous
tooth buds at 6 weeks in utero.

14-18 weeks in utero

Calcification of all primary teeth begins in the following order: centrals, 1st molars,
laterals, canines, 2nd molars

Birth
primary centrals, laterals, crowns nearly complete
primary canines l/3 crown completion
primary 1st molars 3/4 crown completion
primary 2nd molars l/4 crown completion with occlusal calcification incomplete

permanent 1st molars may show calcification

3 to 5 months
all permanent anterior teeth (centrals, laterals and canines) begin calcification with the
exception of maxillary laterals that begin at 10 to 12 months

6 to 8 months
first primary tooth erupts (mandibular central incisor)

2 1/2 years
all primary teeth erupted (2 l/2 years)

1st premolars begin calcification

3 years
primary teeth in occlusion, apices closed

2nd premolars and permanent 2nd molars begin calcification

permanent 1st molar crown complete
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4 – 5 years
permanent central and lateral crowns completed

6 years
first permanent tooth erupts (mandibular central or first molar)

7 years
crowns of all permanent teeth are completed except 3rd molars (remember that 14
weeks in utero to 7 years of age is critical calcification time for esthetics)

6 – 8 years
“early” mixed dentition
Permanent 1st molars, central and lateral incisors erupt

8 years
Permanent 2nd molar crowns completed

8 - 10 years
“middle” mixed dentition
lower canines erupt at 9 -10 and all first premolars erupt
3rd molars begin calcification

10 – 13 years
“late” mixed dentition
2nd premolars, upper canines, 2nd molars erupt
apexogenesis of permanent incisors and first molars at approximately age 10

Note: The patient’s chronological age is of less value than the patient’s dental age when
supervising the developing dentition. Root development is the best guide to dental age.
Apexogenesis ages are an important consideration when planning endodontic
treatment.

17 – 21 years
eruption of 3rd molars

2. Identify the normal eruption sequence and eruption age in months of the primary dentition.

centrals (6 - 8)
laterals (7 - 9)
1st molars (12 – 14)
canines (16 – 18)
2nd molars (20 – 24)

12-month-old has 12 teeth, 16-month-old has 16 teeth, 2-year-old has 20

3. Define the terms “natal” and “neonatal teeth”.

Natal teeth are present at birth; neonatal teeth erupt within 30 days after birth.
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4. Identify the characteristics of the normal primary dentition.

Ovoid arch
No curve of Spee - flat occlusal plane
Shallow cuspal interdigitation with slight overbite and overjet
Primary incisors stand more upright than their permanent successors
Little crowding - usually interdental spacing (see #5)
Terminal plane relationship (see #10): straight or flush 50% (most common), mesial step
25% (most ideal), distal step 25%

5. Identify the two morphological arch forms of the primary dentition.

There is normally spacing between all the anterior primary teeth. This is often a concern of
the parents who miss the adult looking (lack of spacing) smile. However, while spacing may
not be pretty, it is normal and desirable.

Type I -- spaced (generalized interdental spacing -- primate spaces)

Type II -- unspaced (no generalized interdental spacing -- no primate spaces)

No spacing appears interdentally as the child gets older if the child never had spaces.

The more spacing there is the less chance of later crowding.

A primary dentition with no spaces is quite likely to have crowding later. If there is
crowding in the primary dentition, rest assured there will be crowding in the permanent
dentition.

6. Define the term “primate spaces”.

Spaces found between maxillary canines and laterals and the mandibular canines and 1st
molars in the primary dentition.

7. Differentiate between accessional and successional teeth.

Accessional teeth erupt distal to the primary dentition. Successional teeth replace teeth in the
primary dentition.
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8. Identify the normal eruption sequence and eruption age in years of the permanent dentition.

Sequence of permanent tooth eruption: maxillary arch 6-1-2-4-5-3-7

mandibular arch 6-1-2-3-4-5-7

Age of permanent tooth eruption in years:

maxillary arch mandibular arch

1st molars 6-7 1st molars 6-7
centrals 7-8 centrals 6-7
laterals 8-9 laterals 7-8
1st premolars 10-11 canines 9-10
2nd premolars 10-12 1st premolars 10-12
canines 11-12 2nd premolars 11-12
2nd molars 12-13 2nd molars 11-13
3rd molars 17-21 3rd molars 17-21

9. Identify the characteristics of the transition from primary to permanent dentition.

There is an increase in the incidence of malocclusion with minor crowding.

Slight mandibular anterior crowding is normal at age 7 to 8, when the permanent incisors
and first molars have erupted but the primary canines and molars are retained.
This crowding is later relieved by a slight increase in bicanine width, labial positioning of
the permanent incisors relative to the primary incisors, and a slight distal and buccal
repositioning of the canines as the lateral incisors erupt.

There is a decrease in both arch length and arch circumference in the transition to the
permanent dentition. Between 10 and 13 years of age the maxillary arch circumference
decreases 1-2 mm and the mandibular arch decreases 3-4 mm.

Bimolar width increases 4 mm in the maxillary arch up until age 10 and decreases slightly in
the mandibular arch.

Perhaps the main point to remember is that after age 3, there is no significant skeletal growth
in the front of the jaws. Therefore, growth will not overcome any significant early crowding
and the crowding will persists into the permanent dentition. That is why crowding of the
incisors—the most common form of Angle’s Class I malocclusion—is by far the most
prevalent form of malocclusion.
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10. Identify a distal step, mesial step, and a straight (flush) terminal plane relationship of the
second primary molars and their impact on the position of the first permanent molars in the
mixed dentition.

These primary molar relationships determine the position of the permanent first molars. Note
that the word “distal” in “distal step” refers specifically to the distal surface of the lower
primary second molar being distal to the distal surface of the upper second primary molar.

The flush terminal plane relationship, shown in the middle left, is the normal relationship in
the primary dentition. When the first permanent molars first erupt, their relationship is
determined by that of the primary molars. The molar relationship tends to shift at the time
the second primary molars are lost and the adolescent growth spurt occurs, as shown by the
arrows. If leeway space is inadequate and there is no differential forward growth of the
mandible, the change will be that shown in the top line. With available leeway space but
without good growth, the change will be that shown by the dotted line. With good growth
and a shift of the molars, the change shown by the bottom double line can be expected. One
can see that distal steps lead to Class II relationships, flush terminal planes usually lead to
Class I relationships but can lead to a Class II. Mesial steps nearly always lead to a Class I
but can lead to a Class III depending on the patient’s growth pattern.
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11. Define " leeway space" and identify its significance.

Leeway space is the difference in mesial-distal dimension of the primary canine, 1st and 2nd
molar, and the permanent canine, 1st and 2nd premolars in each quadrant. It is used to
permit relief of permanent incisor crowding, mild amounts of which are usually present after
incisor eruption. It also provides for a late mesial shift of the first permanent molars when
necessary. Nance determined leeway space to be .9 mm in the maxillary arch and 1.7 mm in
the mandibular arch. Moyer determined it to be 1.3 mm in the maxillary arch and 3.1 mm in
the mandibular arch.

12. Identify how the arch forms (spaced and unspaced) and mesial and flush terminal planes can
occur in various combinations in different children and result eventually in proper Class I
occlusions.

A 5-year-old with a spaced dentition with mandibular primate spaces and a flush terminal
plane relationship will undergo an "early mesial shift" closing the primate spaces and
become a Class I molar relationship at age 6 to 7.

A 5-year-old with an unspaced dentition with no primate spaces and a flush terminal plane
will undergo a "late mesial shift" utilizing the leeway space and become a class I molar
relationship at age 10 to 13.

"Early mesial shift" denotes the closing of mandibular primate spaces on eruption of
permanent 1st molars. "Late mesial shift" denotes the closing of the leeway spaces by the
mesial drifting of the permanent 1st molars on loss of the primary 2nd molars.

Flush terminal plane

mandibular primate space

Early mesial shift

closing primate space
at 6-8 yrs. of age

Class I molars

5 yrs. of age

Late mesial shift

utilizing leeway space
10-13 yrs. of age

Flush terminal plane

no mandibular primate space
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13. Identity the "ugly duckling" stage and its significance.

Frequently, the maxillary incisors erupt into the oral cavity with a strong distal inclination of
their crowns. This is because as the lateral incisors erupt, the canines higher up are literally
sliding down the distal surfaces of the developing roots of the lateral incisors. This tends to
force the apices of these roots toward the midline, while the crowns tend to flare laterally.
As the canines continue to erupt, however, there is an autonomous straightening up of the
lateral incisors. The temporary spacing that often occurs between the crowns of the centrals
and laterals is usually closed (if no greater than 2mm) as the canines erupt into complete
occlusion. This is a most hazardous time to place appliances due to the chance of damaging
the apices of the maxillary laterals and the possibility of deflecting the permanent canines
from their normal path of eruption.

Illustrations and references: Contemporary Orthodontics. 3rd edition, William R. Proffit, C.

V. Mosby Co.
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DENTAL DEVELOPMENT REVIEW QUESTIONS

1. There is no other organ of the human body that takes so long to attain its ultimate
morphology as the ________________.

2. There are six histogenic events or stages that participate in the progressive development
of the teeth. These are initiation (bud stage), ________________ (cap stage),
__________________, ________________(bell stage), ______________, and
________________.

3. The first sign of human tooth development is seen during the __________ week of
embryonic life.

4. Interference with the stage of _______________________ may result in extra cusps or

roots, suppression of cusps or roots, fusion, or gemination.

5. Peg-shaped teeth, micro or macrodontia, dens-in-dente, Hutchinson’s incisors, Mulberry

molars, or dilaceration could occur due to disturbances in the stage of
______________________________.

6. Interference during the stage of _________________________ may result in

amelogenesis imperfecta or osteogenesis imperfecta.

7. Missing or extra teeth could be the result of interference in the

____________________________ stage.

8. Hypocalcification may be the result of interference in the

______________________________ stage of tooth development.

9. Hypoplasia may be the result of interference in the __________________________ stage

of tooth development.

10. Calcification of all primary teeth begins between _____ to _____ months in utero.

11. Enamel deposition is completed in all the primary teeth before birth.
True or False? (circle)

12. The crowns of all primary teeth have usually completed calcification by one year of age.
True or False? (circle)

13. The average eruption sequence and eruption age of the primary teeth
is as follows:
____________________ (_________ to _________ months)
____________________ (_________ to _________ months)
____________________ (_________ to _________ months)
____________________ (_________ to _________ months)
____________________ (_________ to _________ months)
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14. Mandibular teeth usually precede their maxillary counterpart in eruption.

True or False? (circle)

15. Inclusion cysts are relatively common in newborn infants.

True or False? (circle)

16. Match the following:

A. Bohn's nodules B. Dental lamina cyst C. Epstein's pearls

________ inclusion cysts found along the mid-palatine raphe

________ inclusion cysts found along the buccal and lingual aspects of the dental
ridges
________ found along the crest of the alveolar ridges in newborns

17. When encountering natal or neonatal teeth, you must decide if the teeth are
_____________________________ prior to deciding on treatment.

18. A bluish-purple elevated area of tissue that has developed on the gum pad a few weeks
prior to the eruption of a tooth is called a ____________________. Treatment is
unnecessary.

19. A. _______________________________

B. _______________________________

C. _______________________________

D. _______________________________

20. Spacing in the primary dentition ranges from 0 to 10 mm in the maxillary arch, with an
average of ______mm. The range in the mandibular arch is 0 to 6 mm, with a mean of by
______mm.

21. Ideal overbite in the primary dentition is _______ mm.

Ideal overbite in the permanent dentition is______ mm.
Ideal overjet in the primary dentition is _______ mm.
Ideal overjet in the permanent dentition is _______mm.

22. The relationship of the maxillary and mandibular primary canines is one of the most
stable throughout the primary dentition. It is the best indication of the actual relationship
of the maxilla to the mandible. True or False? (circle)

23. If the terminal plane relationship of the primary molars is a mesial step, the first
permanent molars will probably erupt into a Class ______ relationship

24. If the terminal plane relationship of the primary molars is a distal step, the first permanent
molars will erupt into a Class ______ relationship.

25. In a spaced dentition with second primary molars displaying a flush terminal plane, the
eruptive force of the first permanent molars will tend to close the spaces. With the
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_______________ spaces located mesial to the maxillary primary canines and distal to
the mandibular primary canines, the shifting of the mandibular primary molars to allow a
Class I molar relationship is favored. This is referred to as the
________________________________.
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26. The ________________________________ refers to a mesial shifting of the first

permanent molar into a Class I relationship following the loss of the second primary
molar. This relationship is possible due to a size differential between the primary
posterior teeth and their permanent successors and has been termed by Nance as
_______________________________.

27. The four average maxillary permanent incisors are 7.6 mm larger than the primary
incisors they replace. The four mandibular permanent incisors are 6.0 mm larger than the
primary incisors they replace. This inverse size differential has been termed
___________________________________.

28. With luck, a combination of four factors, either singular or in combination, allows larger
permanent teeth to fit into the arch without crowding. They are:

1.______________________________________________________________
2.______________________________________________________________
3.______________________________________________________________
4.______________________________________________________________

29. Broadbent has referred to the period from the eruption of the maxillary lateral incisors to
the eruption of the maxillary canines as the ____________________ stage. This is often
a time of patient and parental concern over anterior esthetics.

30. Permanent first molar root formation is completed by age _____.

Permanent mandibular incisor root formation is completed by age _____.
Permanent maxillary incisor root formation is competed by age _____.

31. Fill in the eruption ages of the following permanent teeth:

A. Mandibular canine _____ to _____ years

B. Maxillary first premolar _____ to _____ years
C. Mandibular first premolar _____ to _____ years
D. Maxillary second premolar _____ to _____ years
E. Mandibular second premolar _____ to _____ years
F. Maxillary canine _____ to _____ years
G. Mandibular second molar _____ to _____ years
H. Maxillary second molar _____ to _____ years

32. A child’s blood pressure increases with age. A 3- to 5-year-old has an average blood
pressure of 100 / 60. A child’s pulse and respiration rates decrease with age. A 3-year-old
has an average pulse of approximately 105 and a respiration rate of 30 / min. A 5-year-
old has an average pulse of approximately 100 and a respiration of 26 / min.

33. Cleft lip is caused by a disruption of the developmental process in the 4th to 7th weeks of
fetal development. Cleft palate develops in the 8th to 12th intrauterine week. The
mandibular symphysis is fused by the child’s first birthday.
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TOPIC: EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

Reading Assignment

Pediatric Dentistry, Infancy Through Adolescence, 3rd Ed., Pinkham,

Orientation to the text (pp. ix, and x)

Chapters 1 (pp. 3-11)
Section I (pp. 139-140)
Chapter 12 (pp. 141-183)
Chapter 13 (184-193)
Section II (p. 251)
Chapter 17 (pp. 253-264)
Chapter 18 (pp. 265-286)
Section III (pp. 427-428)
Chapter 29 (pp. 429-444)
Chapter 30 (pp. 446-474)
Section IV (p. 579)
Chapter 36 (pp. 581-592)
Chapter 37 (pp. 594-617)

Objectives
Upon completion of the reading assignment and attendance at class lecture, the student
should be able to:

1. describe the physical changes (body, craniofacial and dental) taking place from
conception through adolescence;

2. describe the cognitive changes taking place from birth through adolescence;

3. describe the emotional changes taking place from birth through adolescence;

4. describe the social changes taking place from birth through adolescence;

5. describe the epidemiology and mechanisms of dental disease as it affects children from
birth through adolescence;

6. describe the objectives of the infant and toddler examinations;

7. describe the steps of the infant examination;

8. describe the emergency examination;

9. describe the management of electrical burns of the mouth;

10. describe the clinical implications of pre-term birth;

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11. describe the role of the dental personnel in introducing the child to dentistry;

12. describe the role of the parent in introducing the child to dentistry;

13. describe proper methods for separating a reluctant child from his/her parent;

14. describe the need for honesty in dealing with the child patient;

15. describe the purpose of a systematic approach to the examination and the components of
the physical assessment of a child patient;

16. describe the purpose for the medical and dental history questions appropriate for
children;

17. identify normal and abnormal in the child's mouth;

18. describe the rationale and method for entering progress notes in the pediatric dental
record;

19. identify factors that affect treatment decisions;

20. describe the rationale for sequencing treatments; and

21. describe a general systemic approach to treatment planning.

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Slide Notes for Examination and Diagnosis

1. The initial diagnosis begins with a telephone call from the parent. Your impression of the
child begins in the waiting room. Does the child hide behind Mom. Does the child cower
or like the place. Don't confront the child with too bold an approach. Things that you
should notice; stature, gait, speech, fast, slow, alertness. Smile. Compliment something,
nice clothes, shoes, haircut, etc. Use a slow approach, a pleasant approach. Don't loom
over the child. Talk to the child, be at ease, take your time, be prepared, have everything
ready. Re-read your manual and review the chart beforehand. Know what you are going
to do, and you won't fumble as much.

. The child can tell if you are under stress. If you are, the child is also. Stand back, look
and talk. Does the child give you eye contact? Is the child bright, alert, confident, scared,
anxious, or evasive? This lets you know if you can approach the child and at what speed.

2. The parents will have filled out the first two pages of the chart before you see the child
on the first visit. Pay careful attention to the health history and the past dental history.

3. Most children will greet you with a smile. This is a new experience for them. If there is a
significant item noted in the medical history, a medical consult would have to be obtained
before any treatment can be accomplished. If a consult has been obtained, it will be in the
pocket of the chart. Look in the pocket of each chart to see if there is a medical consult
form.

4. Children usually like some physical contact. If they will accept it, hold a hand, touch an
arm or shoulder when complimenting. "Hey, you are doing a good job! Thank you."
Praise goes a long way. You may be the only person to ever thank them. Smile. Smell
good. Be compassionate.

5. Everybody is somebody. We all like to be noticed, feel important, succeed. Use this
information to your benefit. Compliment the child about his clothes. Ask about pets,
brothers and sisters. Everybody likes to succeed. Get the child on your side. A good
assistant is invaluable.

6. If the child is anxious or afraid, you have to go slower. Talk softly and be assuring. Tell
the child what you are going to do. “It's easy, we're going to have some fun today."

7. How does the child perceive you? Does he have bright eyes and a smile or a cold stare
and distrust? Use your personality and intuition. Get the child on your side.

8. A drawing from one of Dr. Walker's patients. This child saw the dentist as a bloodshot-
eyed, big person with a bloody drill, approaching a small scared child. Do you trust
anybody in your mouth? Put yourself in their shoes.

9. If the child is anxious, or quiet and you want to get something started, ask if she has a
hand. Looking at a hand is not threatening. Turn it over and look at the other side. "Do
you have another one?" Look at it. "You really have some hands there, young lady." Now
I'm going to look at your lips. Look and write something down.
 25

10. On the initial visit and on recall, the child should be weighed and measured for height.
This is a non-threatening way to get started. Talk to the child. Ask questions. Break the
ice.

11. “Hey, have you ever had your arm pumped up?" Check for nodes, look around, and don’t
miss anything.
12. Recheck the chart. If the child is old enough, ask about health history. Fill out the rest of
the chart - the preventive page.

13. The oral exam begins with the fingers. “I’m going to look at your front teeth.” If the child
won't open, push the lips apart and say "very good, that's a nice job." Write something
down, be casual. Say "open" and look again. “Great!" Usually you get a little more done
each time. In and out. If the child is anxious, many “in and outs” are better than one long
look. Get the child used to following directions. Don't let them talk on and on and thus
evade the procedure. Say "open" and back up, praise the child. Look at soft tissue first,
then the occlusion. Does the child have any oral habits?

After face, lips and all other soft tissue has been accounted for, look at the teeth. Check
for position, number, color and caries. What radiographs will be necessary for further
information?

14. This is a nice looking lower arch of a child between three to five years of age. There are
ten teeth in each arch in the primary dentition - incisors, canines and molars - no
premolars. When primate spaces are present, they are distal to the lower canines and
mesial to the upper canines. You like to see primate spaces because they add additional
room for the larger permanent incisors. Dry the teeth with short bursts of air.
Demonstrate the air away from the patient first, then on the child’s hand and finally in
their mouth - a short burst. Talk while you are doing the exam. Don't ask for permission
saying “May I look at your teeth?” If the child says no - then what are you going to do?
Don't ask for permission - make declarative statements. “Get in the chair so we can get
started.” “Let's go take some pictures.” “Open.”
Tell the child what you are going to do. "I am going to count your teeth." Count out loud.
"Hey, you really have a lot of teeth. Did you know you have 20 teeth?" The upper arch is
ovoid. Look at the color of the tissue. This is a healthy looking mouth.

15. Class I primary dentition. Mesial step. Upper central is wider than the lower central.
Upper central touches lower central and lateral. Upper lateral touches lower lateral and
canine. This is what you want to see - each tooth in each arch touches two teeth in the
opposing arch. You also want to see generalized spacing in the primary dentition.

A Class II primary dentition. In a Class II dentition, the upper arch is generally the
offender and is more forward with a resulting horizontal overjet. Now the teeth will not
interdigitate when in occlusion but will occlude one on one.

16. Both slides depict Class II primary dentitions. The one on the left has a large overjet but a
near normal overbite. The slide on the right has a large open-bite but a near normal
overjet. This is caused by two different habits. On the left - thumb. On the right - tongue.
 26

17. Class III primary dentition. This is usually a genetic pattern. Look at the parents. The
lower arch is usually the offender in Class III malocclusion. It grows out from under the
upper arch.

18. Prominent chin of a Class III dentition.

Mixed dentition (both primary and permanent teeth present), with a maxillary
constriction resulting in a unilateral convenience cross-bite. If it were a simple unilateral
cross-bite, the upper and lower centrals would line up.

19. A 7-year-old with caries in the distal of both lower 1st primary molars. You can see the
caries appears deep. Don't bury an explorer in the caries - it will hurt the child
unnecessarily and you won't learn anything new. Lower 1st permanent molars will
usually come in 6 months before the upper 1st permanent molars. The upper centrals will
line up on their own if there is no habit and no excessive crowding.

20. Anterior view of the same child. Normal pigmentation.

Fill out the caries chart the best you can before radiographs are taken. In this manner we
can best prescribe what radiographs to take.

21. After the charting has been finished up to this point - call an instructor over. The
instructor will review the chart, the patient and then indicate which radiographs are
needed to finish the exam.

22. Protect the child with a lead apron and a collar

Show the child the film and the machine. Explain that you are taking a picture of her
teeth and she will have to be very still.

23. If a panoramic film is indicated, you or an assistant will take it.

24. This is a nice bitewing of a three-year-old. A permanent molar is developing in the lower
corner of the film behind the 2nd primary molar. There is spacing between the teeth and
this is good in the primary dentition. No caries present.

Panorex of a 3-year-old. Look for symmetry. Count the teeth. 10 primary teeth in each
arch. The developing permanent canines are the lowest teeth in the lower arch and the
highest teeth in the upper arch. Get used to finding these teeth first when looking at a
Panorex of the mixed dentition. From these teeth you ought to be able to name the rest of
the teeth.

25. The interview and counseling portion of the visit is best accomplished prior to the
examination of the infant or toddler. When you are examining an infant, know what you
are looking for. You’ll take a short, loud look. The infant will cry as soon as you place
him on his back and put your finger in his mouth. Use gauze to wipe saliva out of the
way. Get a good long look and then give the child back to mom. Then talk about it, it will
be quieter.
 27

If you want to demonstrate to the parent - an exam or brushing technique place two chairs
facing each other - knee to knee. The infant is on his back with his head in your lap, the
heel of your hands on the infant’s cheeks. Mom has the infant's legs under her elbows and
holds the infant's wrists. Do what you need to do and get it over with and the infant back
up in vertical position.

26. This is the lower arch of a 6 1/2-year-old. It has nice ovoid form, 6-year molars are in,
and the tissue color looks good. The exam should be painless. If you don't dry the teeth
before using an explorer and the caries entrance is the same size as the explorer -
hydraulic pressure can be generated if you forcibly push the explorer in the hole. This
increased pressure can cause a lot of pain. If the teeth were dry before doing the same
exam - no problem and you can see so much better.

This is a good-looking ovoid upper arch. The upper teeth usually come in about 6 months
after the corresponding lower teeth.

27. This is a bitewing of an 8-year-old. Get used to looking at developing permanent teeth for
a guide to the age of the child.

This is a Panorex of a 7-year-old with a missing permanent premolar. Always look for
symmetry and count the teeth.

28. This is an 8-year-old with a prominent frenum. Don't do any treatment for the frenum at
this age. Wait until the upper permanent canines erupt. They usually squeeze the centrals
together and solve the problem. In any event, wait before treatment.

The upper arch of the same patient.

29. This is the lower arch of the same 8-year-old. Look for symmetry. The lower right 1st
permanent molar may be trapped at an angle behind the 2nd primary molar - ectopic
eruption. This will have to be dealt with. Take a radiograph and find out.

Nice looking permanent dentition. This was an orthodontic case - molar bands are still in
place.

30. Class I permanent dentition. Look at the interdigitation - each tooth contacts two teeth in
the opposing arch.

Panorex of a 14-year-old with a fractured central incisor.

31. This is a Panorex of an 8-year-old with a prematurely missing lower right primary canine.
Crowding caused this problem - a shifting of all anterior teeth toward the missing canine
spot. Notice also that the upper left lateral resorbed the root of the primary canine next to
it . This is also a sign of crowding - the resorption of two primary teeth by one permanent
tooth.
 28

31. This is a Panorex of an 8-year-old with space loss caused by caries and loss of primary
teeth. There is also a congenitally missing upper left permanent premolar. Look for
symmetry. Count the teeth. Find the permanent canines first.

32. Thumbs up - everyone wants to succeed and be noticed. Use this to your benefit. Most
patient want to help you. This child has crowded lower anterior teeth. It may be an ortho
problem. How old is this child? Probably around 8.

33. If you need to get an impression of a patient, know what you are looking for. You won't
get it if you don't know what you are after. This is a good impression and an excellent set
of models.

34. Bacteria and the pellicle remaining on the tooth cause green stain. It houses the bad guys
and can cause demineralization of the tooth. The easiest way to remove it is to dry the
teeth and paint them with iodine. It kills the bacteria and the stain is easier to remove.
You may have to paint it on more than once. Don't splatter it.

Bacteria also cause Black stain but it causes no harm. It just looks bad. It is usually
associated with a caries-free mouth. It needs to be removed for esthetics.

35. There is a lot of caries here. Pain is not always present even though there is a hyperplastic
pulp in a lower primary molar. In all of this disaster the permanent teeth are lined up in
good fashion. Don't punch holes in this, you can see that it is bad. Get radiographs to
finish the diagnosis.

The upper arch of this 9-year-old is not as bad as the lower. These caries can be managed.
Keep the arch intact if possible to allow room for the permanent teeth.

36. This is a 4-year-old child with nursing caries. Taking a bottle to bed at night and falling
asleep with whatever is in the bottle pooled around the teeth usually causes this. This
continual onslaught will destroy most of the upper anterior teeth. The teeth usually spared
are the lower anteriors, which are protected by the tongue. When the child is asleep the
saliva flow is shut way down. The buffering action by the saliva is reduced and whatever
caries potential is in the liquid will be enhanced. Water in the bottle at night is OK -
anything else can be disastrous.

Another nursing caries child with an erupting permanent central pushed off course by an
abscessed primary central incisor. The tooth is erupting into buccal mucosa and will not
have any attached gingiva. This will have to be taken care of later with a periodontal
procedure.

37. Restorations are the best space maintainers. You have to watch band and loops space
maintainers. Cuspids will distalize with the eruption of the permanent laterals. You may
have to remove the band and loop and place a lingual arch.

Be able to read radiographs. Know the difference between primary and permanent teeth.
Be able to recognize pulp treatment and steel crowns. Look at the developing teeth to see
if the child is on schedule in his eruption pattern.
 29

38. This 5-year-old girl has been up all night with an abscess. She is tired, has sad eyes, and
would like help. She may be skeptical. She has pain now and doesn't want any additional
pain. Can you examine her without adding to her discomfort? Ask if she wants help. Tell
her what you are going to do. Do all of your looking as gently as possible. Get a
radiograph of the area. Either extract the tooth today or put her on antibiotics and wait 5
days and then extract. You must keep in constant contact with the parent to make sure the
infection doesn’t progress into a cellulitis if you choose this course of action. If the
gumboil pops, the pressure will be gone and the pain may go away. When the tissue heals
over the opening again, the pressure will build up and the pain will return. Explain this to
the child and the parents. They may think if there is no pain everything will be alright.

39. An abscess of a permanent tooth will show at the apex on a radiograph. On a primary
molar it is in the bi- or tri-furcation area. The floor of the pulp chamber of a primary
tooth is porous and the by-products of an abscess will go right through the floor.

An 8-year-old with both permanent upper laterals in cross-bite. This has to be treated
before the upper cuspids come down and trap the laterals. Treat these right away.

40. Bruxism and attrition are common in children. They usually grow out of it when they get
their permanent teeth. The pulp chambers have filled up with reparative dentin. The
parents are concerned but there is nothing you can do about it.

41. Ankyloglossia (tongue-tie) is not a severe problem. Most parents are concerned because
of the appearance and what they think may go wrong with speech. If the child is past 2
years of age the correction of the situation will usually not help change any speech
patterns but it will help the looks.

This ankyloglossia case should be treated because of the damage being done to the tissue
between the central incisors.

42. The lower arch of this 5-year-old has a few problems. When the stainless steel crowns
were placed a salivary duct was irritated and closed up. A ranula resulted but opened up
on its own within a few days, otherwise surgery would have been required. There is an
abscessed lower left 1st primary molar that will need a pulpectomy and a crown or
extraction and a band and loop. The facials of the lower canines have caries. This weak
spot on the facial of upper and lower primary canines is common. I think it is caused by
the position of the developing primary canine being pushed up against the facial bony
plate of the alveolus while it is in the crypt.

This is an upper arch of an 8-year-old with Dilantin hyperplasia. Spend a lot of time with
this type of patient in developing good oral hygiene habits. If
the tissue grows over the biting surfaces, periodontal surgery will be needed.

43. Internal resorption of a primary molar on a 10-year-old. By the time you see it like this, it
is too late. The thin root has been perforated. A pulpectomy has to be done early if it is to
 30

be successful. In this case you could leave the tooth in place (it is causing no harm) and it
may hold space long enough for the premolar to erupt without space loss.

An occlusal film of an 8-year-old with a cleft palate. They may have missing teeth or
extra teeth in the area of the cleft. They need treatment like everybody else. You would
like to retain arch length in the cleft area. Don't be befuddled by a radiograph in front of a
patient. Do your homework prior to explaining the situation to the child or the parent..

44. This is an occlusal radiograph of a 2-year-old who has had trauma. Both primary centrals
will have to be removed. There is also a mesiodens present that will have to be removed
to allow for the proper eruption of the upper centrals. If the mesiodens were near the apex
of the developing permanent centrals you would postpone its removal until the centrals
had erupted.

A ray of a central with dens-in-dente that should be restored. This mesiodens should not
be removed before the permanent centrals have erupted and the apexes have closed.

45. An occlusal radiograph of a 3-year-old with calcific metamorphosis. This is a response to

pulpal irritation - trauma in this case. The only problem with this - it may not resorb at
the same rate as its partner and will have to be extracted. Keep an eye on it to assure both
permanent centrals erupt at the same time.

Radiograph of an ankylosed primary molar in an 8-year-old. It is below the occlusal

plane and this can result in some space loss as other teeth tip over it. The crown may be
built up with composite or a stainless steel crown placed. If the tooth is removed a space
maintainer should be placed.

46. Gemination of a primary lateral in a 3-year-old. The crown tends to split into 2 crowns.
There is 1 root and 1 root canal. The crown is wider than normal and will take up more
room in the arch. There is usually the right amount of teeth in the arch. Look for possible
problems with the permanent successor.

Ray of a the geminated primary lateral. The pulp chamber is much wider than normal.
The permanent lateral looks OK
.

47. Ray of fused primary incisors. There are 2 roots and 2 pulp canals. In the mouth these
teeth can sometimes look like gemination. But if you count the odd looking tooth as one
unit, there will be one less tooth in the arch than normal. Look at the radiograph and you
can make a decision.

Ray of a 9-year-old child. When this child was 3 years old, he traumatized his upper
central. They went to a pediatrician. She said it was just a baby tooth and it would be OK.
This was their first dental visit and they only came because they suspected something was
wrong because he still had a baby tooth in the front of his mouth. The primary tooth
abscessed soon after the accident. You can tell this because there was no secondary
dentin formation in the primary central. The resulting lesion caused the permanent central
 31

to deviate from its proper course and then cease developing altogether. There has been
space loss and the midline has shifted. The permanent central has to be extracted. There is
a large defect in the area. Orthodontics will be needed to correct the spacing problem. A
costly mistake because "it was only a baby tooth."

48. This mesiodens should have been removed early on, it was low in the arch and impeded
the permanent centrals from erupting into their proper position. It is easy to remove but
the centrals will now have to be moved orthodontically to align the roots. It would have
been self-correcting if the mesiodens had been removed early in the game.

49. This 13-year-old boy has enamel dysplasia due to a disturbance during enamel formation.
His brother had the same kind of malformation. We couldn't trace anything that could
have caused this much damage. These teeth can be restored with acid-etch composites.
The canine on the right slide has been restored. A senior dental student here at U of L
restored all the teeth and published the case in the Journal of the American Dental
Association.

50. Hypoplasia. This was easy to restore with the acid-etch technique. There was virtually no
caries in this patient, who had a lot of allergies.

Amelogenesis in a 4-year-old. Primary and permanent teeth are affected. What little
enamel he had has chipped away. This patient needs stainless steel crowns to maintain
space and also to maintain vertical dimension.

51. The upper arch and the occlusion of this same amelogenesis patient. He had an abscess of
his upper central. The supporting structure was so destroyed that the tooth had to be
removed.

If stainless steel crowns aren't placed soon, vertical dimension will be lost.

52. Panorex of the amelogenesis case. The bulbous enamel of normal teeth did not form and
the teeth look like square pegs. There is no width to the teeth. The permanent teeth are
also involved in amelogenesis imperfecta.

The same patient with stainless steel crowns. There was little or no preparation required
on these teeth before the crowns were placed.

53. Same amelogenesis patient. Notice how the bite has been opened.

Another amelogenesis patient with bands and composite used to restore the canines.

54. Full mouth and Panorex of the amelogenesis imperfecta patient. Permanent anteriors
were coming in and were very sensitive. Bands were cemented in place until complete
eruption and a more esthetic restoration could be placed. Notice the lower right 1st
permanent molar. It is in bad shape now. You can get behind in a hurry with this type of
patient. Keep your eyes open.
 32

55. Dentinogenesis imperfecta in a 4-year-old child. The teeth are amber in color, iridescent.
Enamel is normal but not attached well to the dentin. It will chip away easily. These teeth
will need to be covered with stainless steel crowns just like the amelogenesis case. The
permanent teeth will be affected also.

56. Dentinogenesis imperfecta - teeth in occlusion before and after treatment. Vertical
dimension has been regained.

57. Congenitally missing teeth in a 5-year-old. When upper permanent laterals are missing
the permanent centrals sometimes are missing a lobe and are skinnier than normal. This
compounds the problem of esthetically restoring the mouth. This child will need dental
treatment over an extended period of time. Space management is a must. If this patient
has children they will have a good chance of having missing teeth also.

58. The same patient with a lower partial for space maintenance and esthetics.

59.-62. Ectodermal dysplasia. These patients have fair complexions, sparse hair, saddle nose,
little or no eyebrows, and may be missing fingernails and sweat glands. There are a lot of
these people in the state of Washington. They have missing teeth and cone shaped teeth.
If they are missing primary teeth, there will not be a permanent successor. This child had
4 primary upper anteriors and 2 lower canines. The same number of permanent teeth was
also present. All other teeth were missing. Overlay dentures are one answer to achieve
function and esthetics. If there are congenitally missing teeth, there will be no alveolar
bone in the area, just basal bone. If they don't have sweat glands, they have trouble in the
summer time, they heat up in a hurry. Maybe that's why a lot of them are in the mild
climate of Washington.

63. A common problem in the mixed dentition is ectopic eruption. Instead of the 1st
permanent molar sliding up the enamel of the 2nd primary molar like the tooth in the
lower left slide, it will approach at a more acute angle and hit the root of the 2nd primary
molar. It will then start resorbing the dentin and then get hung up under the enamel. This
is the case with the molars in the upper left of the radiograph and also on the radiograph
on the right. If no treatment is attempted, the permanent molar may be hung up for years
or resorption may go on to completion and the primary molar will be lost prematurely,
resulting in space loss. There are two modes of treatment. Push the permanent molar
distally and retain the primary molar or extract the primary molar and then push the
permanent molar distally and hold it in place with a space maintainer.

64. Habits. A thumb sucking habit will usually cause a symmetrical defect. A class II
malocclusion with a large overjet and overbite and a constricted upper arch resulting in a
cross-bite. The lower anterior teeth will be tilted to the lingual, increasing the overjet.
The upper and lower teeth will not interdigitate anymore, they will hit one on one.

65. Enlarged tonsils and adenoids can cause abnormal breathing patterns resulting in
unwanted tooth movement. If the child is a mouth breather, the lips and cheek muscles do
not perform their job and the teeth will find a new equilibrium.
 33

66. Two cephalographs showing before and after pictures of a patient with enlarged
adenoids. Controversy - Dr. Peter Vig says the amount of airflow is determined by nares
opening, not the airway in the adenoid area. You have to correct the cause of the problem
before correcting the problem or the teeth will go right back to their original position
when you remove your appliance.

67. A constricted upper arch in a 7-year-old resulting in a convenience crossbite. When the
child occludes, the teeth hit end on and this doesn't feel good so the child shifts the lower
jaw to one side or the other, ending up in a cross-bite. You can tell there was a lateral
movement of the lower jaw by looking at the midline - it doesn't coincide. Have the child
open and close and watch the movement.

A lip sucking habit can also cause a malocclusion. In all the habits we have seen, if they
are mild and are discontinued before major movements have occurred - the occlusion will
remain normal. The cases I have shown are fairly severe. Habits cause trouble by the
length of time and the energy involved in the habit.

68. After you have gathered all the information about this patient, write on a paper towel all
the procedures that have to be accomplished to put this patient in good shape. This is a
draft of your treatment plan. Call an instructor over and we will work with you in
finalizing the plan.

69. After the treatment plan is okayed, copy it in the chart. Write in the procedure codes and
the clinic fees. The parent will want to know - how many visits and how much will it cost
me. Write the procedures in groups of what can be accomplished on each visit. Try to
complete all the work in each quadrant to minimize having to repeat the same injections.
Tell the parent approximately how many visit there will be. The instructor will OK the
plan at this time but will not sign it until the parent agrees to the plan and signs it.

70. Present the treatment plan to the parent either out in the waiting room or if is quiet in the
clinic, you can bring them back. Answer any and all questions at this time.

71. One of the first items on the treatment plan is usually a PHP. Make all notations about the
preventive procedures on page 5 of the chart.

72. Explain the prophy procedure to the patient if they haven't had one before. Show the
patient the rubber cup and the suction apparatus before you start. You can have the
patient by the sink during the fluoride treatment if you wish.

73. After all procedures are finished for the day, call an instructor over and get checked off.
Have your progress notes, and grade sheet filled in properly. Make sure all radiographs
are mounted and dated.

Return the patient to the parents and explain what was accomplished and what to expect
on the next visit. Compliment the child in front of the parents. You will get better
compliance from the child with repeated compliments during treatment.

74. If your patient comes in like this child on the left, try to have him leave like the child on
the right.
 34

TOPIC: PEDIATRIC DENTAL RADIOLOGY AND RADIOGRAPHIC

INTERPRETATION

Reading Assignment

Pediatric Dentistry, Infancy Through Adolescence, 3rd Ed., Pinkham

Chapter 18 (pp. 280-284),
Chapter 30 (pp. 469-474),
Chapter 37 (pp. 607-610)

Objectives
Upon completion of the reading assignment and attendance at class lecture, the student
should be able to:

1. describe possible difficulties in obtaining radiographs from children;

2. describe some patient management techniques for overcoming these difficulties;

3. describe how the guardian may be employed to obtain necessary radiographs;

4. describe how aids such as film holders, tape, etc. may be used to facilitate radiograph
making;

5. describe four measures that should be taken to ensure radiation hygiene;

6. describe the views of and the techniques for producing a preschool radiographic series;

7. describe three ways to make the taking of bitewing radiographs more acceptable to the
patient;

8. describe the views of and the techniques for producing a mixed dentition radiographic
series;

9. describe how to determine whether two or four bitewing radiographs will be sufficient for
diagnosis in the mixed dentition;

10. identify the structures reproduced in a routine panoramic radiograph;

11. describe the radiographs that would be appropriate for diagnosing injuries following
trauma to the teeth, face or head;

12. identify common pathology or anomalies in children by how they present on radiographs;
and

13. describe the guidelines of the Academy of Pediatric Dentistry concerning indications for
radiographs on children and adolescents.
 35

Slide Notes for Pediatric Oral Radiographic Technique

1. Title: Pediatric Oral Radiology

Clinical slide of maxillary anterior occlusal technique

2. Parental concern must be addressed.

Risks to patients if radiographs are not taken: irreversible damage, compromised
treatment, increased risk of failure, and more costly care.

3. Indications for radiographs: clinical evidence of injury, disease (caries), pulpal pathosis,
delayed or accelerated eruption or exfoliation, swelling, hemorrhage, pain, or ulceration

4. High-yield criteria for exposing radiographs in asymptomatic children: In the primary

dentition, take posterior bitewings if proximal contacts closed and the child is cooperative
to determine presence of interproximal caries.
High-yield criteria are meant to identify patients who are most likely to benefit from
radiographs.

5. In the early transitional dentition (permanent first molars erupted) take anterior occlusal
radiographs to detect supernumerary teeth or missing teeth. An exam that includes all
tooth-bearing areas is recommended at this time to detect pathoses and proximal caries,
and to aid in the early diagnosis of developmental anomalies. This may consist of
posterior bitewings and one of the following: a. posterior periapical radiographs or, b.
panoramic radiograph or, c. lateral jaw 45-degree projections.

In the early permanent dentition (postpubertal; late adolescence) radiographs are made to
evaluate the same tissues as in the early transitional dentition and to evaluate the position
and development of the third molars. This examination should be made within two years
of the eruption of the permanent second molars. The practitioner who is providing the
orthodontic diagnosis and/or treatment may prescribe a cephalometric radiograph.

6. Risk of dental caries is classified as either high or low. A high risk to dental caries is
associated with; poor oral hygiene, fluoride deficiency, prolonged nursing,, high
carbohydrate diet, poor family dental health, developmental enamel defects,
developmental disability and acute or chronic medical problem, or genetic abnormality.

The child with a high risk should have bitewing radiographs made as soon as posterior
primary teeth are in proximal contact. The age of the patient is not an important variable,
If interproximal caries are detected and restored, follow-up radiographs are indicated
semi-annually until the child is caries-free and classified as having a low risk of dental
caries.

7.-10. A child with a low risk of dental caries may be defined as a normal, healthy,
asymptomatic patient exposed to optimal levels of fluoride, performing daily preventive
techniques and consuming a diet low in cariogenicity. The low risk patient with closed
proximal contacts should have posterior bitewing radiographs made. If no caries are
found, then radiographs may be made every 12 to 18 months if primary teeth are in
 36

contact, or up to 24 months if permanent teeth are in contact. Bitewing radiographs may

be made more frequently if the child enters the high-risk category. The more rapid
progression in primary teeth should be considered in determining the time interval
between bitewing radiographs.

Exposing radiographs to document treatment result, when not needed to establish the
presence of pathosis or aid in establishing a diagnosis, is considered unnecessary and an
unwarranted exposure of the child to ionizing radiation. These recommendations are an
attempt to fulfill the profession’s obligation to establish guidelines for the optimal use of
diagnostic radiography with minimal radiation exposure.

11. Film Size - #O, #1, #2, Occlusal

Comparison of film sizes

12.. Appropriate Radiographic Surveys (Blank)

13. Eight Film Series - 2 anterior occlusals, 2 posterior bitewings, 4 posterior periapicals
Example of eight film series

14. Panoramic Film - Posterior Bitewings

Panolipse of an 8-year-old

15. Anterior maxillary occlusal film showing periapical lesion above right primary central,
impeding eruption
Panoramic film of 5-year-old

16. Mesiodens (clinical and radiograph) - one of many reasons for taking radiograph.
Mesiodens between two centrals - should have been removed before centrals erupted.
Tough to treat now.

17. Clinical slide of darkened “F” with calcific metamorphosis

Radiograph of same patient showing the chamber and canal filling in

18. Introducing the Child to Intraoral Radiology

Walking with child patient to x-ray room - talk to child, make a game of it - a new
experience - you are looking for cooperation.

19. Use Tell - Show - Do; tell the child using camera analogy; show the child a film packet,
unexposed and exposed; and do a dry run
Dry run desensitizes the child and determines the child’s ability to sit still

20. 3 to 6 year old - may have difficulty cooperating. Radiographs can be delayed until
cooperation can be managed
Check all settings and position the tube before the film to allow for short attention span
and gagging.

21. Do easiest procedures first.

Do anterior occlusal films before bitewings and periapicals
 37

22. Place apron and collar on patient - don't take films without lead protection.

23. Clinical picture demonstrating proper angulation for maxillary occlusal - 60°.
Radiograph of 4-year-old - should be able to see primaries and developing permanent
teeth..

24. Important! When you push the button you are looking at the patient.
We’re Not Shooting A Movie

25. If You Can’t Get The Child To Hold Still - Don’t Expose The Child
Blurred Film

26. A panoramic film is a good aid in the diagnosis of structures in the oral area. A typical
Panorex set up with a child patient in the chair. This Panorex of a 3-year-old
demonstrates development you would expect at this age.

27. Clinical picture demonstrating proper angulation for lower occlusal film. Tilt head back
(chin up) + 30° and angle the tube up at a -30°. Or use -15Ο and head tilt of +45O.
Radiograph of 4-year-old - primaries and permanent teeth should be in view.

28-31. Another technique for obtaining anterior films on a child patient.

Upper and lower anterior teeth on one occlusal size film

Fold an occlusal film in half crosswise (crease perpendicular to the film's long axis) with
the writing side of the film toward the inside.

Tell the child what you are going to do and why. Show the child how to hold the film in
his mouth by standing in front of him and mimicking a mouth by alternately opening and
closing your thumb against its opposing fingers. Then put the film between your thumb
and fingers and at the same time, clench your teeth with lips apart and say, 'Hold the film
with your teeth just like a cracker and be very still so we can get a nice picture of your
teeth." "This is not a moving picture camera, so you have to be still. It doesn't make any
loud noises or ring bells, it just takes pictures of your teeth.

Adjust the back of the chair to its most upright position. Place the film in the child's
mouth with the crease toward the front of the mouth, and again mimic the closing
yourself. Position the child's head so the occlusal plane is parallel to the floor, and direct
the central X-ray beam at a 60° downward angle through the tip of the nose for upper
anteriors.

Tell the child to stay closed. Raise his chin upward 30° to the floor, and reposition the
central X-ray beam at a 30° upward angle through the apices of the lower central incisors.
This is a nice record of the relationships of upper and lower anterior teeth and unlike the
regular series of anterior radiographs, the radiographs cannot be mixed up. This is a nice
way to be able to show the child and parents the growth and development pattern of the
child's developing dentition.

32. Bitewings - bend the corners of the film for patient comfort
Round the film lengthwise over your finger to conform to shape of mouth
 38

33. Bitewing with all four corners creased and longitudinal crease that covers contacts. Don’t
do this.
Bitewing radiograph of a 3-year-old with interproximal caries.

34. Go To #2 Film on Eruption of Permanent First Molar

Bitewing radiograph of 9-year-old

35. Two bitewings showing effects of not centering the tab of holder, giving unequal
coverage of maxillary and mandibular developing teeth, possibly missing important
information..
Right bitewing shows missing second premolar.

36. Usually see second premolars at age 4; may not see until age 8.

37-38. For a readable radiograph - the central ray must be parallel with the marginal ridges of
the teeth

This is an acute angle with the sagittal plane - not perpendicular to it. Have the child open
his mouth and look at the direction of the marginal ridges. Get a mental image of this so
you can line up the tube head in the right direction. Most mistakes in bitewings are
overlapping contacts caused by lining up the tube head at right angles to the sagittal
plane.

Bitewing Technique: Tell the child, in words he can understand, what you are going to
do. Select the largest size film that will comfortably fit in the child's mouth. Show the
child the film. Bend all four corners of the film (if necessary) and tell the child that
bending it makes the film fit better. Show the child how you want him to close on the tab
and stay closed, by gritting your own teeth with your lips apart. Use stick-on film
cushions if you need to for painless placement..
Prior to placing the film in the child's mouth, put your own index finger in his mouth at
the site of the first exposure. Put your finger between his tongue and lower molars and
say, "This is where I will put the film and this is what it will feel like." This helps with
little people.

Stand directly in front of the child. Start with the film horizontal and rotate it vertically
into the space between the tongue ant the lower molar area. Try to keep the film far
enough distally so it won't irritate the anterior floor of the mouth.

Hold the film tab on the occlusal surfaces of the lower teeth. With the index finger of
your other hand, slightly bend the upper portion of film toward the midline. (This will
help prevent the child from biting on the film instead of the tab.) Now ask the child to
"close slowly," while guiding the upper portion of the film to the palatal side of the upper
teeth. Withdraw this finger, but continue holding the tab with the other hand as the teeth
Slowly (emphasize "slowly") come together, and close on the tab. (Note: Do not tell the
young child to "bite" on the tab, as this often results in a chewing motion.)
 39

39. As the child is doing this, you mimic the action of his closing on the tab by again
clenching your own teeth with your lips apart saying, “Now keep your teeth together
while I take the picture." The X-ray head should be positioned at +10°, and the central
ray should be directed parallel to the marginal ridges of the teeth involved and not
perpendicular to the mid-sagittal plane.

If the child should gag and open up or spit the film out, it is best to acknowledge that the
child has gagged and say, "Let me make the film smaller (fold over corner more), so it
won't bother you next time." Words of encouragement are never lost on a child. If the
child should start to rebel on the next attempt, a firm command such as "stay closed" is
usually enough to gain the child's cooperation.

Don't forget to thank the child for doing such a good job.

Bitewing radiograph that was not positioned horizontally in the child’s mouth.

40. “Bite” Vs. “Close” Sometimes kids chew when you say “bite”; “close” is better.

41. Acceptable bitewing - patient obviously has teeth tightly closed

Not as acceptable - patient failed to closed completely together

42-43. The primary maxillary molar projection. The Rinn Snap-A-Ray is used to hold the size 0
film, which should be creased at the anterior to conform to the mouth.

The child bites on the plastic that holds the film in the mouth. Be sure the occlusal
portion of the teeth is on the plastic. The central x-ray beam is directed at a point on the
ala-tragus line directly below the pupil of the eye at a vertical angle of 40°

The horizontal angulation is obtained by referring to the plastic holder as it protrudes

from the patient’s mouth.

44. The mandibular molar projection. The Rinn Snap-A-Ray is again used this time with the
patient biting on the plastic and holding the size 0 film against the primary mandibular
molar teeth. A negative vertical angulation of 10° is used and the plastic film holder again
determines the horizontal angulation. Be sure the film is anteriorly far enough to include
the distal half of the canine.

If the film impinges on the tissue in the anterior floor of the mouth, crease the anterior
corner. If this is not done the child may not bite all the way on the film and the apices of
the molars will be missed.

Mandibular molar periapical radiograph

45. A lateral jaw film may be taken in the absence of a panoramic setup. The tube head is
angled -14O under angle of mandible aiming at the occlusal plane in the area of the
permanent first molar on the opposite side of the mandible.
 40

Here are three views of an adult patient using the lateral jaw technique. Every dentist
should be able to take lateral jaw films to adequately diagnose areas outside of normal
periapical views.

46. Lateral jaw film of a child

Lateral jaw film of an adult

47-48. A lateral jaw technique to obtain both left and right views on one film is shown. Have the
child patient lie belly down on the dental chair. A lead shield divides the film cassette in
half. Place the cassette under the child's head and expose the film. Have the child turn his
head in the opposite direction and move the lead shield to the other side of the cassette
and get your other view. This is a simple method and works well with children. Lateral
jaw films of children are shown.

49. Behavior management is a must to obtain quality films. The child on the left will most
likely be an excellent patient and will offer no resistance to the new experience of film
taking.
The child on the right is likely to be a problem.

50. If you have a lot of children in your practice, gear your operatory and radiology area to
be inviting to them.-- Place a fluffy animal on the X-ray head.. Little people are
uncomfortable in unfamiliar and large surroundings. If you can make them feel wanted
and needed, that is half the job,

51. Let the child inspect your equipment; tell them about it.
Let the child hold the film and see for themselves it is not something to be afraid of.

52-54. A technique of obtaining anterior films on an eighteen-month-old. Have the child sit in his
mother’s lap. Lead aprons on both if possible. Let the child feel the film, show him the
camera. Let him put the film in his mouth and get the feel of it. Mother will have to
steady the child's head and help hold the film.

55. Another method of obtaining an anterior film on a young child. The parent holds the film
(tape may help hold the film in your hand) and places it and hold it in the child’s mouth.

56. Radiograph of parent’s finger on preceding film.

57. A partial denture can be used to help guide first permanent molars into their proper
position. In this case, a radiograph was taken to determine the distal extent of the partial
denture using lead foil was to show the end of the acrylic. A little more acrylic needs to
be removed from the appliance.

58. On some patients the only time films can be obtained is under general anesthesia on the
day of treatment. Place the film in the patient's mouth with a film holder and secure the
placement with a towel and towel clip.
The resulting radiograph allows for proper treatment.

59. An occlusal film can be taped to the side of the head and used instead of a lateral jaw
cassette.
On this radiograph, a supernumerary is seen apical to the anteriors.
 41

60-61. Angulation of the X-ray head is all important. The slide on the left
shows what appears to be an ectopic permanent second molar. The radiograph on the
right is one year later and the upper permanent second molar appears to be resorbing the
distal of the permanent first molar and being trapped in the process. The next film is
seven months later and all appears normal. The resorbed root is now OK. Angulation was
the culprit (super-imposition) Cervical burnout was also involved. Use films with
different horizontal angles when diagnosing ectopic eruption.

62. Another "case" of ectopic eruption. Two different angles on the same appointment.
Maybe this is why some "ectopic eruptions" cure themselves if left alone.

63. Tooth fragments in lower lip. Look around when there are puncture wounds in trauma
cases.

64. Cephalometric Machine

Lateral Ceph

65. A good looking cephalometric film showing hard and soft tissues and well-demarcated
airway.
Ceph tracing for orthodontic diagnosis

66. "Jaws" A double exposure of a lateral cephalometric film and an anterior radiograph on
same film. Be careful - don't overexpose the patient with unnecessary radiation.
 42

Slide Notes for Radiographic Interpretation

1. Title slide Radiographic Interpretation

2. Dissected skull of 5 -year-old. The developing permanent anterior teeth are to the lingual
of the primary teeth in both arches. Crowns of permanent anterior teeth are fully
developed at this time. The upper permanent canines are high and the lower permanent
canines are low. Upper permanent laterals are lingual to the developing permanent
centrals. Notice there is little or no bone between primary and permanent teeth at this
time.

Anterior PA of 2-year-old. Upper permanent anteriors are partially developed. Always

look for symmetrical development. The upper permanent laterals are lingual to the
permanent centrals normally. On a radiograph the laterals appear to be directly behind the
centrals but in reality they are lingual and slightly lateral to the centrals.

3. Skull of a 5-year-old, lower anterior view. Notice the relationship of the developing
permanent teeth to the primary teeth. All permanent anterior teeth develop lingual to the
primary teeth. If there is crowding at six to seven years of age, the centrals and laterals
will erupt to the lingual with the primaries sometimes remaining in place. In a crowded
mouth, the canines nearly always will go to the labial.

Lower anterior radiograph of a normal 3-year-old. Notice the generalized spacing; this
child will probably have a nice lower permanent arch.

4. Skull, upper right quadrant of a 5-year-old. The permanent canine is high. Premolars
develop between the roots of the primary molars. On a panoramic radiograph, the
permanent canines appear high and low; this gives you a reference point when counting
teeth.

Radiograph of upper posterior quadrant of a 6-year-old. The first permanent molar is in,
(child is over six years of age), permanent lateral is not in (child is less than eight years of
age). Notice the normal position of the premolars developing between the primary roots.
This is an important point if there is pulpal necrosis of a primary molar. Look at
developing premolars on the skull and on the radiograph and notice the radiolucent areas.

5. Skull, lower right quadrant of a 5-year-old. Permanent canine is lying on basal bone, far
lower than other developing permanent teeth. However, it will catch up and usually erupt
before the premolars. At an early age, there is bone between the developing permanent
premolars and the primary molars. As time goes by, there is no bone between these teeth.
This is a potential problem in the presence of an infected primary molar because the floor
of the pulp chamber of the primary molars is very porous.

If there is an infection in a primary molar, the noxious acid by-products leak into the bi-
or trifurcation area around the developing tooth, which is not fully mineralized. The
developing permanent tooth may end up with white or brown spots or may be fully
arrested in development.
 43

Radiograph of lower posterior quadrant of a 5-year-old. The primary first molar has
undergone pulpal necrosis and exhibits bifurcation involvement. The first permanent
molar is about to erupt (5 1/2-year-old). This development pattern is normal.

6. Lateral view of a dissected skull of an 8-year-old. Upper centrals and laterals are more
angulated - flaring out, to allow more room in the arch. The roots of the central incisor
and the permanent first molar will reach apexogenesis around 10 years of age.

Periapical film of upper right quadrant of an 8-year-old with normal arrangement of

primary and permanent teeth.

7. Anterior view of a dissected skull of an 8-year-old. “Ugly duckling stage” - upper

centrals and laterals are pinched in by the developing upper canines. This is a variation of
normal. Parents may ask you to straighten the centrals and laterals at this time. Wait until
the canines come down - it probably will be self-correcting. If you try to align the
centrals and laterals - their roots may be resorbed by the canine during treatment.

Clinical photograph of a crowded arch of an 11-year-old. There is not enough room in the
arch for the canines. They are erupting to the labial.

8. Radiograph of an infant's upper primary anterior teeth just prior to eruption. Primary
incisor crowns are usually completed by three months of age. Notice the symmetry and
the very fragile developing roots at this time. Lips and gingiva can be seen as a light gray
shadow.

Radiograph of upper primaries of a 1-year-old. Normally, there is little root development

at this time. If any trauma, roots will usually fracture.

9. Fourteen-month-old. Suture between centrals is normal at this time. If suture remains

prominent at 10 to 12 years of age, it is probably because connective tissue fibers from
labial frenum are present, and there will be a frenum problem (diastema between
centrals). There is little hard tissue development of permanent teeth at this time. Can't see
canines, just centrals and laterals.

Radiograph of lower anterior of 2-year-old. Permanent crowns one-half formed. Notice

the symmetry with little or no spacing of primary anterior teeth; this will be a problem
when permanent teeth try to erupt.

It should be remembered that the time of eruption of both primary and permanent teeth
varies greatly. Variations of six months on either side of the usual eruption date may be
considered normal for a given child.

10. Radiograph of a 2-year-old with developing permanent centrals and laterals. There is a
history of trauma to both centrals. Notice the area of external resorption of both roots and
wide PDM. The right central is possibly non-vital. Laterals develop behind the centrals.
Laterals can be higher or lower than centrals on a radiograph. Get used to reading apical
areas of primary teeth of normal patients, because when patients present with pain, it is
 44

hard to figure out what is wrong. You have to include patient's symptoms and the color of
hard and soft tissue in the area for a proper diagnosis.

Radiograph of upper anteriors of a 6-year-old. Permanent centrals and laterals are well
developed. Permanent teeth are now sliding down the lingual of primary teeth.

11. Radiograph of upper anterior area of a 2 year-old. There was a history of trauma to the
upper left central. There is infection in the apical area and also internal resorption. Deep
caries may also have contributed to the pathology.

Radiograph of the upper anterior area of a 4 year-old. The patient is congenitally missing
primary and permanent laterals. When this occurs, the permanent centrals may be missing
a lobe and appear skinnier than normal. This further complicates the treatment. When the
primary canines appear tall and skinny, look for missing teeth.

12. Two exposure anterior film technique. Bend an occlusal film crosswise into two equal
halves. Place the film in the patient's mouth and have her bite with her incisors near the
creased end of the film. Without opening her mouth or changing the position of the film,
expose the upper anterior area, and then lean the patient back and expose the lower
anterior area. After the film is developed, open it up like a book and read it from the
outside cover.

Radiograph of upper and lower anteriors of a 4-year-old on one occlusal film. The
generalized spacing is good, but in this case the permanent laterals appear to be pegs.

13. Two-year-old. History of trauma and caries. External root resorption, periapical infection
with bone loss. Pulpal areas similar.

Two-year-old. History of trauma - longer duration. Infection, bone loss, root resorption.
Pulpal areas of centrals are different. Trauma stopped the laying down of dentin after the
tooth became necrotic. The patient also appears to have two peg laterals.

14. Lower anterior view of a 6-year-old. One permanent central is in, the other is erupting to
the lingual with the primary remaining in place. The root of the primary is not being
resorbed and should be extracted. There appears to be enough room in the arch and
normal tongue action will move the central into alignment.

Lower anterior view of a 7-year-old patient with amelogenesis imperfecta. Little or no

enamel is present on the teeth. Stainless steel crowns were placed for function and as
space maintainers.

15. Lower anterior view of a 7-year old with dens-in-dente of a lower permanent central
incisor. The patient had symptoms of pain and there was swelling in the area. The tooth
was non-vital. There was not enough root structure to attempt an apexification procedure.

The tooth was extracted. Photo of malformed tooth with partial root formation.

16. Occlusal film of a 12-year-old with an erupted mesiodens between the permanent central
incisors. The mesiodens should have been extracted years ago because it was low in the
arch and the developing permanent centrals would have probably come in their proper
 45

position. Now orthodontic therapy will have to be done to reposition the upper anterior
segment.

Upper occlusal film of a 10-year-old with a history of trauma at a young age. A

pediatrician told the parents that it was just a baby tooth and it would come out anyway.
There was no follow-up. Now there is a very large area of pathosis. The primary central
and the permanent central will have to be removed and space regained for a bridge.

17. Photo of an upper arch of a cleft palate patient. There is a holding arch to keep the two
lateral dental segments from collapsing toward the midline.

Upper anterior occlusal film of a cleft palate patient with a holding arch. Cleft palate
patients often have missing teeth or supernumeraries in the cleft area. Dental arches
should be stabilized to prevent collapse.

18. Odontoma preventing eruption of upper lateral in an 8-year-old patient. The other lateral
was erupted and in place. Whenever the eruption pattern is off, consider a radiograph to
verify the situation.

Another case of delayed eruption - retained primary tooth. A supernumerary (possibly a

mesiodens) is in the way and should be extracted. During surgery, a bracket should be
attached to the permanent central - it may need help to get into its proper place in the
arch. Mesiodens that are near the crown end of a developing permanent tooth should be
extracted early. Mesiodens that are near the apical end of a developing tooth should be
extracted after apexogenesis of the tooth involved.

19. Three-year-old with fusion of primary central and lateral. There is a missing permanent
lateral above the fused teeth.

Gemination in the lower arch of a 2-year-old. There appears to be a missing primary and
permanent central in this case. Whenever there is a genetic disturbance in the primary
dentition look closely at the developing permanent dentition.

20. Periapical film taken in the vertical position in a “gagger”. The first primary molar has
already been extracted. A pulpectomy should be attempted in order to hold space at least
until the first permanent molar erupts.

Bitewing of a normal 3-year-old. The film has been creased in the anterior region.

21. Posterior periapical film of a 9-year-old. Caries are evident and there is internal
resorption in the primary first molar. It is probably too late to save this tooth. Internal
resorption is fairly rapid and in a matter of weeks osteoclasts can perforate the root of a
primary tooth. A tooth can be sometimes be saved if the pulp is removed before
perforation.
 46

Normal exfoliation of a primary second molar with pulp treatment and a stainless steel
crown. Observe the roots of the permanent molars. Get used to reading normal teeth so
when a patient presents with pain you have a better chance of detecting what is wrong.

22. Erupting permanent second premolar in a 7-year-old. The primary second molar was
extracted because of infection and loss of bone. After the premature loss of a primary
tooth - the permanent tooth will erupt sooner than expected if there is a lot of bone loss.
The permanent tooth will be delayed in eruption if there is good bone overlaying the
permanent tooth after the primary is lost.

Two rooted primary canine in a 4-year-old.

23. Ankylosed primary second molar trapping its successor, with loss of arch length. 85% of
ankylosed primary teeth will exfoliate on their own. The other 15% (usually ankylosed at
an early stage in development) cause a lot of trouble. This tooth, since it was ankylosed
early, should have been removed and a space maintainer placed. Now there is a lot of
work to be done.

Second primary molar with maybe a rudimentary successor down deep. Have a plan
when there are congenitally missing teeth. Let the parent know early there is a problem.
You still have to wait and make sure the permanent successor will not form before taking
action. The second permanent molar looks like it is on its side and pointing right at us.

24. A distal shoe placed on a 5 year-old to help guide the first permanent molar into its
proper position. The distal shoe had a backward tilt built into it to help regain some of the
lost space.

A follow-up radiograph shows a successful effort.

25. A second premolar is deviating from its normal eruption pattern and only resorbing one
of the roots of the primary second molar. Care must be taken when extracting these teeth
because of the weakened area about halfway up the root.

Photo of extracted tooth. The apical area is stronger than the middle area.

26. Another radiograph of a premature eruption of a second premolar after the extraction of a
primary second molar that was infected and had a lot of bone loss. The patient is 9-years-
old.

Upper posterior quadrant of an 8-year-old. There are caries and you can also see the
coronoid process of the mandible on the film.

27. Vertical bitewings of a 9-year-old. This patient had gross caries and infection over a long
period of time. At least two of the premolars were affected by the acid pus and are Turner
teeth.
 47

28. Two radiographs of the same patient 10 months apart. This patient was lucky. There was
mass destruction caused by infection around a primary second molar that had a
pulpotomy and a stainless steel crown. After the extraction, the premolar erupted into
place and everything looks normal.

29. Blank slide. Talk about panoramic films.

30. PANORAMIC DENTAL RADIOGRAPHY

Panoramic" means an unobstructed or complete view of a region in every direction.
A panoramic radiograph displays the entire maxillo-mandibular region on a single film.

SCANOGRAPHY is a method of making radiographs by the use of a narrow slit beneath

the tube in such a manner that only a line or sheet of x-rays is employed. The x-ray tube
moves over the object so that all the rays of the central beam pass through the part being
radiographed at the same angle. Scanography became more popular in the 1930's when
faster films and fast screens and more efficient x-ray machines were developed.
Scanographs are used to see whole body organs.

TOMOGRAPHY is the recording of internal body images at a predetermined plane by

means of a tomograph (also called section roentgenography). A radiograph can be
obtained of a particular tissue depth by moving the x-ray source and the film in opposite
directions at a constant speed. The amplitude (angle of movement) of the x-ray tube
influences the width of the focal trough -- the larger the angle (the farther the tube head
moves) the shallower the focal trough. By this method, the layers of tissue above and
below the desired layer are diffuse and out of focus.

LAMINOGRAPHY refers to a special technique to show, in detail, images of structures

lying in a predetermined plane or tissue, while blurring or eliminating detail in images of
structures in other planes.

31. Lower anterior view of a dissected skull of a 5-year-old. Notice the position of the
primary and permanent teeth, this is important when reading radiographs. There are a lot
of structures on a film of a 5-year-old. The primary and developing permanent teeth are
not set end to end, there is not enough height of the face to accommodate this
arrangement. The anterior permanent teeth are situated lingual to the primaries and slide
incisally and forward to resorb the roots of the primaries.

Panorex of a normal 4-year-old. Notice the symmetry. The permanent canines in the
primary and mixed dentition stages of development appear low in the mandible and high
in the maxilla. Find these developing teeth first and then you can orient yourself to find
and count the other teeth. By the nature of the machine, a Panorex will depict upper
premolars in a rotated position when they are actually normal. The Panorex will also
reverse this by showing upper laterals in a normal position when they are actually rotated.
When this needs to be confirmed, a PA film will show the true position of these
developing teeth.
 48

32. Lateral view of a dissected skull of a 5-year-old. Notice the positions of the upper and
lower permanent canines, and then find them on the Panorex. Now it is easier to count the
premolars. Second premolars are frequently congenitally missing. The roots of the
primary teeth are overlapping the crowns of the permanent teeth.

Panorex of a 4-year-old. The lower left primary second molar on this film is infected. Try
a pulpectomy on this tooth; you want to retain this tooth until the permanent first molar
slides up the distal root of the primary second molar and takes its place in the arch. The
angulation of the tube head -18O and the position of the upper permanent laterals being
lingual to the centrals, depict the laterals on the film as lower than they really are.

33. Anterior view of a dissected skull of a 7-year-old. The permanent centrals and laterals
have come down. The upper canines are “pinching in" on the roots of the laterals, causing
the “ugly duckling stage” of development.

Panorex of a 7-year-old. Look at the picture on the left and the radiograph on the right.
Look at the upper and lower canines. Look for symmetry on each panoramic film.

34. Lateral view of a dissected skull of a 7-year-old. The upper centrals and laterals are
angulated about 60O. This additional arch length allows the permanent teeth to take their
proper place in the arch. Look at the similarities of the skull and the Panorex.

Panorex of a normal 9-year-old. Caries and restorations are evident. Watch the angulation
of the permanent canines to the primary canines. These are normal. In the crowded arch,
the relationship is off.

35. Panorex of a 10-year-old. Some primary teeth have been lost early due to caries and
infection. The apices of permanent central incisors and first molars close about 10 years
of age. Keep this in mind when reading panoramic films.

Panorex of a 10-year-old This a more normal, symmetrical radiograph. The permanent

first molars were hypoplastic.

36. Panorex of an 11-year-old. Primary teeth are exfoliating; third molars are visible. In the
lower arch, the permanent teeth usually erupt in this order; first molar, and then all the
teeth in a series - central, lateral, canine, first premolar, and then second premolar, and
second molar. In the upper arch; first molar, central, lateral. The cuspid stays high and
comes in after the first premolar and second premolar. Things are better if the second
molar does not come in until after the cuspid comes down.

Panorex of a 12-year-old. All of the primary teeth have exfoliated.

 49

37. Panorex of a 4-year-old patient with dentinogenesis imperfecta. A lot of enamel has
chipped away and vertical dimension is being lost. Arch length is also compromised with
loss of enamel.

Same patient at age 9. Apices of permanent first molars are about to close. Stainless steel
crown on primary second molar. As teeth age in dentinogenesis patients, the pulpal areas
fill in and the teeth appear solid (this distinguishes these patient from those with
amelogenesis imperfecta). At this angulation, the permanent second molar looks as if it is
resorbing the distal root of the permanent first molar. If you suspect trouble, take another
radiograph from a different angle to make sure there is no resorption.

38. Panorex of a 17-year-old patient with juvenile periodontosis. This condition is

characterized by bone loss around permanent central incisors and first molars in an
otherwise normal dentition.

Panorex of a 3-year-old patient with a rivet up his nose. The rivet appears as a radiopaque
circle above the right central incisor.

39. Three-year-old with rivet up his nose.

Photo of rivet. Dr. Ken Snawder of Clarksville, Indiana (once chair of pediatric dentistry
at ULSD) took this panoramic film and noticed the round circle and then tracked down
the rivet, which had been there for some time.

40. Panorex of a 5-year-old with a silver point root canal on a primary first molar. An heroic
job that was doomed to early failure.

Periapical of silver point root canal on primary molar.

41. Panorex of an 8-year-old. When there is crowding in a dental arch, some permanent teeth
will resorb (and help exfoliate) more than one primary tooth. The lower right primary
canine has been lost and the arch has collapsed to that side, causing a shift of the midline.
In the upper arch, the left permanent lateral resorbed the root of the canine and it will
most likely be lost early. When you see faulty resorption patterns, look for crowding.

This 14-year-old patient lost both lower primary second molars early due to caries and
the space was not maintained. Now these two quadrants are short of space and the
premolars are trapped.

42. Panorex of a 5-year-old with ectopic eruption of three permanent first molars, resorbing
the distal of the primary second molars.

Periapical of ectopic eruption in a 7-year-old. Dr. Bruce Haskell, an orthodontist in

Louisville, thinks there is a relationship between developing second premolars that are
rotated and the ectopic eruption of permanent first molars. The additional space taken up
by the rotation changes the angle of eruption of the molar.

43. Panorex of a 5-year-old female with congenitally missing teeth.

 50

Panorex of a 7 1/2-year-old patient with a cleft palate and ectodermal dysplasia. This
patient also has multiple missing teeth.

44. Panorex of a 9-year-old with missing teeth.

Panorex of a 6 1/2-year-old ectodermal dysplasia patient missing all permanent teeth.

45. Mesiodens near the apex of a central incisor of a 7-year-old. The possible extraction of
this supernumerary should not occur until the apex closes around all the teeth involved. If
the supernumerary was near the crown end of the tooth, it should be extracted early.

Panorex of an 8-year-old with a supernumerary tooth impeding the eruption of #9. When
the symmetrical eruption pattern is disturbed, look for trouble.

46. Technique error. A lateral and PA cephs were exposed on one film. The patient was
exposed twice to radiation and will have to be exposed twice again.

Technique error. This film has been exposed twice

47. Panorex of three impacted permanent canines and the possible ectopic eruption of #12 in
a 10-year-old female.

Panorex of a 12-year-old with a developing upper left third molar impeding the eruption
of the permanent second molar. The patient has a lingual arch in place.

48. Panorex of a 12-year-old with a transposed canine (#11) and a resorbed primary canine
(“H”).

Periapical of the transposed canine.

49. Ankylosed lower left primary second molar of a 3-year-old. When primary teeth ankylose
at an early age there in a problem and it has to be dealt with.

Periapical of a 2-year-old with an ankylosed primary molar.

50. Panorex of a 9-year-old with a transposed lower right lateral (#26) and upper
supernumerary permanent molars impeding the eruption of the permanent second molars.

Lower occlusal film of a transposed permanent lateral. The primary lateral is still in place
- with a resorbed root.

51. Panorex of a 7-year-old with fibrous dysplasia.

Panorex of an 8-year-old with rhabdomyosarcoma that was treated with radiation,

resulting in arrested development of permanent teeth on the left side. The dentist should
be consulted when radiation therapy is to be used in the oral area of a child.

52. Dentinogenesis imperfecta in a 4-year-old. Most pulpal areas have not filled in.
 51

Same patient at 7 1/2 years of age. Note the difference in the pulpal areas. In most of the
primary teeth the pulpal areas are solid with dentin.

53. A 13-year-old female with cleidocranial dysostosis. This syndrome manifests itself with
missing clavicles, delayed eruption of permanent teeth and multiple supernumerary teeth.

Panorex of a 6-year-old with a radiopaque circle above the upper right canine.

54. Facial and close-up photograph of the preceding 6-year-old with a scar next to his nose
where a BB pellet entered and was still there when this Panorex was taken in the Pedo
clinic at ULSD. The pellet was subsequently removed.

55. Odontoma impeding eruption of permanent canine. Upon initial exam, look for
symmetry. If something doesn't look right, take a radiograph.

Compound odontoma in the way of #6. Remove the odontoma and attach a bracket to the
canine and ease it into the arch.

56. Panorex of a 16-year-old with earring. When the tubehead is on the right side of the
patient’s head and the film is on the left side - the left earring is projected onto the film at
normal size, shape and position. The right earring is reversed, enlarged, blurred and
projected onto the film over the molar area of the left side. Remove from the patient
whatever you don't want to see on the film.

Cephalometric film of patient with earrings on.

57. Panorex of a 10-year-old. The developing upper first premolars are rotated and taking up
too much room. The canines are forced mesially and the eruption path is wrong.

Panorex with smudge type static electricity. This is caused by visible light static in the
darkroom. The “naked tree” type static electricity that looks like lightning strikes is
caused by rapidly pulling the film out of its box, but no visible light is given off.

58. Bitewing radiograph of a threaded pin in the pulp.

Periapical film of a threaded pin in bone.

59. Occlusal film of a 3-year-old with a fractured root of a primary central incisor.

Lateral view using an occlusal film. Trauma (intrusion) with the central driven up into
nose.

60. Anterior periapical film of a 4-year-old. Trauma, intrusion of both primary centrals.
These patients have to be watched closely. Are the primary teeth impinging on the
developing permanent centrals? Is there infection in the area? If there is trouble, remove
the primaries. If there was an instant of force against the developing teeth, they will be
hypoplastic no matter what you do.

Anterior occlusal film of a 6-year-old. There was a history of trauma, intrusion of a

primary central, at 2 years of age. The injury itself caused the hypoplasia to the central.
 52

61. Anterior occlusal view of a 2 1/2-year-old. The primary centrals were displaced. Try to
manipulate them back into place. Splint if necessary. The developing permanent centrals
were probably not injured with this trauma.

Calcific metamorphosis and two abscessed primary centrals in this 3-year-old.

62. Taurodontism of a primary first molar in a 3-year-old.

Internal resorption of a primary first molar in a 5-year-old. This resorption can be stopped
with a partial pulpectomy if the tooth has not been perforated yet. This type of resorption
is very rapid. This tooth is hopeless.

63. External root resorption on a 12-year-old with a history of trauma. The tooth should be
packed and repacked with calcium hydroxide to slow down the replacement resorption.
This resorption is hard to stop.

Avulsion, replantation, and replacement resorption. Replacement resorption is caused by

a necrotic PDM and osteoclasts trying to clean up the area and not knowing when to stop
(can’t distinguish cementum from bone).

64. Caries in an unerupted permanent second molar of a 10-year-old. Yes, it was caries.

Failure in pulp treatment of a primary second molar of an 8-year-old. The tooth had a
formocresol pellet left in it long term. The irritation caused by the gases seeping through
the porous floor of the pulp chamber cause bone loss in the bifurcation area.

65. Anterior periapical of a 2-year-old after trauma. Mother held the film and that is her
finger at the bottom of the film.

Four-your-old, trauma, displacement, infection, bone loss, and tooth should be extracted.

66. Fusion of a primary central and lateral in a 4-year-old. There is a congenitally missing
permanent lateral above the fused teeth. (Same slide as 19L)

Gemination of a permanent central incisor.

67. Dens in dente in a permanent lateral.

Dens in dente in a permanent central incisor.

68. Natal teeth in newborn.

Talon cusp in an 8-year-old.

69. Bitewing of a 6-year-old with amelogenesis imperfecta.

Missing central incisor in an 8-year-old, with space closure.

 53

70. Ankylosed primary second molar with space loss in a 10-year-old.

Secondarily infected dentigerous cyst in a 12-year-old.

71. Transposition of a permanent canine and a first premolar in a 13-year-old.

Panorex of a normal dentition of an 8-year-old with slight crowding problem.

72. Error technique - Panorex. The chair and the tubehead were out of sync. When the
tubehead goes around behind the patient, the chair shifts 4 inches laterally away from the
tubehead. In this instance the chair shifted 4 inches toward the tubehead and the teeth
were not in the focal plane.

This Panorex film was halfway in the developer when the darkroom door was opened.

73. Panorex of a 3-year-old. Patient moved and the thyroid collar was too
high.

74. A simple film technique to determine if a supernumerary tooth is labial or lingual to the
other teeth in the arch. This is one occlusal film with two exposures taken from different
angles. The developed film is opened and read like looking at the outside of a book. The
films were made on a dry skull with a fractured incisor so you can orient yourself more
easily.

75. An occlusal film is folded in half crosswise, just like the technique for taking the upper
and lower anteriors on one film. Two exposures will be made, one from head on, the
other more laterally. Take the later shot first, making sure the film is placed in such a way
that when it is opened to read like the outer cover of a book that the lateral exposure if
taken on the right (like this one) will be on the right side of the film. If the exposure is on
the left side, make sure the film is placed so that the lateral exposure is on the left end of
the film.

76. After the lateral exposure, turn the film over and take the head on shot.

77. Open the processed film and read it like a book, not from the inside but like looking at
the outside cover. On these two slides an extra tooth was placed on the dry skull with a
piece of white rope wax. On one slide the tooth was on the labial, on the other slide the
tooth was placed on the lingual.

Compare the two exposures. If the extra tooth follows along with the direction of the
camera against the background of the other teeth, the extra tooth is on the lingual. If the
extra tooth seems to go in the opposite direction to the flow of the camera against the
background of the other teeth, the extra tooth is on the labial.

On the left slide, the extra tooth seems to move to the left when the camera is moving to
the right with respect to the teeth in the background - the extra tooth is on the labial.

On the right side, the extra tooth seems to move with the camera with respect to the other
teeth - the extra tooth is on the lingual.
 54

78. A technique using a Panorex to determine if a supernumerary tooth in the anterior area is
on the labial or lingual with respect to the other teeth in the dental arch. A Panorex was
taken of a dry skull with an extra tooth added in the anterior area. The white strip was
removed from the film but all of the anterior teeth were kept intact. This film is read just
the same as the two-exposure occlusal film technique. I like to read the film from left to
right. If the extra tooth seems to come along from left to right with respect to the other
teeth, the tooth is on the lingual. If the extra tooth seems to go against the grain and not
come with the flow, it is on the labial.

The extra tooth is on the labial on the left slide. It moves against the flow.

The extra tooth is on the lingual on the right slide. It moves with the flow and is the
farthest tooth away from us.

Radiographic Viewing Strategies

Think about radiographs in the following order:

Get oriented. Am I looking at a primary, mixed, or permanent dentition? Any permanent teeth in
occlusion? Are permanent first molars in occlusion? Are permanent second molars in occlusion?
If one quadrant is confusing (due to missing teeth, etc.) check out the other quadrants to help in
identifying the age.

Count the teeth, checking for form and bilateral symmetry. Check for permanent canine and two
premolars (erupted or unerupted) in each quadrant. First locate permanent canines, they are the
highest and lowest teeth on the panoramic film. This will help you identify congenitally missing
teeth and malformed teeth.

Check for crown completion: primary incisors at 2 – 3 months, primary second molars 11
months, permanent first molars at age 3, permanent second molars at age 8, permanent centrals
and laterals age 4 –5, premolars 5 – 7.

Tooth completion (apexogenesis): all primary teeth at age 3 1/2; permanent first molars and
incisors at age 10. Second molars at age 15.

Root completion guide: root completion three years after eruption.

 55

Panoramic Dental Radiology

The term "panoramic" means an unobstructed or complete view of a region in every direction.

A panoramic radiograph displays the entire maxillo-mandibular region on a single film.

The Panorex (S.S.White) and the Panelipse (G.E.) are two of the more popular panoramic
radiography machines on the market today.

Scanography is a method of making radiographs by the use of a narrow slit beneath the tube in
such a manner that only a line or sheet of x-rays is employed. The x-ray tube moves over the
object so that all the rays of the central beam pass through the part being radiographed at the same
angle. Scanography became more popular in the 1930's when faster films and fast screens and
more efficient x-ray machines were developed. Scanographs are used to see whole body organs.

Tomography is the recording of internal body images at a predetermined plane by means of a

tomograph (also called section roentgenography). A radiograph can be obtained of a particular
tissue depth by moving the x-ray source and the film in opposite directions at a constant speed.
The amplitude (angle of movement) of the x-ray tube influences the width of the focal trough --
the larger the angle (the farther the tube head moves) the shallower the focal trough. By this
method, the layers of tissue above and below the desired layer are diffuse and out of focus.

Laminography and stratigraphy refer to a special technique to show in detail images of

structures lying in a predetermined plane of tissue, while blurring or eliminating detail in images
of structures in other planes.

Intraoral panoramic radiography uses an x-ray head outside the patient's mouth with the x-ray
beam directed into the mouth through a cylinder about the size of a soda straw that the patient
holds with his teeth. The x-ray beam travels through the cylinder and strikes a target at the end of
the cylinder and is directed outward through the teeth and jaws to the film which is molded to the
outside to the face. The x-ray head, patient, and film are stationary. Disadvantages of this method
include the need for two separate exposures, one for the maxilla and one for the mandible. Also, a
restricted view is obtained using this method with the temporomandibular joint not appearing on
the film. Berger, a German, applied for a patent for this technique in 1943. Three companies in
Europe still manufacture this product.

Numata of Japan conceived of extra-oral panoramic radiography in 1933. The film was held
in the mouth and the x-ray head rotated around the patient. Disadvantages of this method
included restricted film size (you could only use film as large as the patient could tolerate), the
need for two exposures, distorted images, lack of definition, and superimposition of anatomic
structures. In 1949, Paatero from Finland placed the film extra-orally, and the patient and film
rotated while the x-ray source remained stationary. In 1950, Dr. Nelson was the first person to
achieve practical application of panoramic radiography in the United States.
 56

In modern panoramic radiography, the patient is mostly stationary. The x-ray head and the
film are on opposite ends of a boom that rotates about 270 degrees around the patient's head
during an exposure. The film end of the boom is close to the patient's face. During an exposure,
the film's circular path travels from behind one ear, around the front of the patient and stops
behind his other ear. The tube head at the other end of the boom is about a foot away from the
patient's head. During an exposure, the tube head's circular path rotates from in front of one ear,
moves behind the patient, and stops in front of the other ear. The tube head is directed upward
from a -10 to -18 degree position so that the x-ray beam goes below the mandible on the near
side, misses the base of the skull, and makes images of the jaws that are on the opposite side
nearest to the film.

The major problem with this circular film technique is that the jaws and face of the patient are not
circular. Another important factor to be considered is the focal trough (the layer of tissue and the
width of this layer to be focused on the film and the elimination of other layers by deliberately
having them out of focus).

The horizontal rotation center of the beam (about a foot in front of the tube head) is the functional
focus of the projection. There are two horizontal rotation centers in the Panorex technique. There
are two separate exposures in the Panorex technique. The first center of rotation is just inside and
below the dental arch distal to the last molar. The x-ray beam rotates around this point for one-
half of the exposure (from distal of the temporomandibular joint forward to the opposite lateral
incisor). At this time, the beam is turned off, the chair and patient move about four inches
laterally so that the next center of rotation is on the opposite side of the arch (just inside and
below the dental arch distal to the last molar). From this center of rotation the opposite side of the
mouth is exposed on the film. Other techniques (Orthopantomograph and Panelipse, etc.) use a
continuous sliding beam transmission while exposing the film, not a stationary point of rotation.
The patient does not move during these techniques. Because the x-ray beam is turned off while
the patient is shifted about four inches to the other rotation center, the Panorex film has a white
stripe down the middle, and both separate images cross the midline.

The width of the focal trough, the area that is actually in focus, is dependent on the relative
motion of the x-ray film to the actual motion of the x-ray head. Even though they are on opposite
ends of the boom, they do not travel around the circle at the same speed. The film is in a cassette.
The cassette is on rollers in a compartment at the end of the boom. During the exposure the
cassette moves along the rollers in the compartment. This movement of the cassette in the
opposite direction of the rotating boom slows the film down and foreshortens the image in a
horizontal direction. This determines the focal trough and also makes the image's height and
width normal. (The functional focus of the horizontal beam is the rotation center just inside the
dental arch. The functional focus of the vertical component of the beam is back in the tube head
at the anode). By slowing the film down in its path around the patient's head, the horizontal and
vertical components of the beam are now back to normal on the film.

The advantage of a narrow focal trough is that there is no superimposition. The

disadvantage is that the patient must be positioned accurately.
 57

The advantage of a wide focal trough is that you are less likely to miss something. A
disadvantage is superimposition, which could cause you to miss something.

The vertical dimension is dependent upon basic geometric factors (source to object distance and
object to film distance). Remember: the vertical component of the film's focal spot is the anode.

The horizontal dimension is dependent upon mechanical factors--how fast the film moves--not
simple geometric factors. The horizontal component of the film's focal spot is the center of
rotation. The horizontal beam is shorter than the vertical beam from focal spot to object;
therefore, the horizontal image is larger than the vertical image. If the film's rotation speed is
slowed down, the horizontal image will be foreshortened, making both the horizontal and vertical
images compatible.

There is a relationship of the rotational center to the image layer (speed of the cassette in the
compartment). A deceleration of the cassette will shift the image layer closer to the center of
rotation--the image is wider. An acceleration of the cassette (the cassette in now moving a lot
slower than the boom) will shift the image layer further from the rotation center and will make
the image narrower. Not all cassettes are rigid; some are flexible.

Focal Trough Dimension Comparisons

 58

Any structure displaced toward the center of rotation (toward the lingual) will appear wider
horizontally. Any structure displaced toward the lips or labial side (closer to the film) will appear
narrower.

The degree of magnification is not the same throughout the mouth. In the anterior region, there is
increased magnification/distortion.

All objects scanned by the x-ray beam will be projected onto the film. Ghost images may also
appear along with the desired images (the tissue in the focal trough on the side of the face nearest
the film). Earrings are common ghost images. As the beam scans the focal trough of the left side
of the face and projects a true image of the left earring, it also scans the radiopaque earring on the
right ear at the same time. Since this earring is scanned before
the beam reaches the center of rotation, the image is reversed, blurred, and larger than the earring
on the side toward the film. When this occurs with earrings, there are two clear earrings and two
larger blurred ghost images at a higher level on the film.
Images in the center of the focal trough will be projected on the film with little or no distortion.
Objects to be scanned that are not in the center of the focal trough are distorted.

Distortion increases as the distance from the centerline increases until the object is completely
out of focus. Objects on the lingual side (closer to the center of rotation) will be larger and wider.
Objects on the labial side (closer to the film) will be smaller and thinner.

Measurements of horizontal objects on a panoramic film are very unreliable. Measurements

of truly vertical objects have some reliability. A straight line that goes through several object
depths will appear as a curved line on the film.

The focal trough thickness is determined by the accepted magnitude of unsharpness.

The panoramic film is very good for a generalized view of the dental apparatus. For
specifics, individual films should be taken.

Pitfalls to avoid in panoramic techniques include:

1. If the chin is positioned too low in the craniostat, the mandibular anterior teeth are out of
the focal trough and the bony mandible is distorted into a convex grin. Detail is lost on
the condyles, and the cervical spine may show in place of the condyles.
2. If the chin is positioned too high, the mandible looks like a frown.
3. If the patient's head is too far forward (focal trough near the lingual), the teeth appear
too narrow.
 59

4. If the head is too far back, the image is magnified.

5. If the head is too far forward with chin tilted down, you may see the hyoid bone.
6. If the patient's head is not centered, the image is enlarged on one side of the film and
the other side will be narrower.
7. If the patient doesn't bite centrally, there will be distortion of teeth on one side, like
when the head is not centered in the focal trough.
8. If the maxillary teeth are out of the focal trough, detail of maxillary roots is lost.
9. If there is extreme displacement of the head to one side, some teeth will be out of the
focal trough.
10. If the patient is slumped in the chair, the beam will go through more than one vertebra,
and there will be a white shadow on the film in the lower incisor area.
11. If the cusp tips of the upper and lower teeth are superimposed on the film, a bit block
was not used to keep the bite slightly open.
12. If the film is positioned too low, the maxilla is cut off.
13. If the film is positioned too high, the mandible is cut off.
14. There may be misplaced density, the tongue not being in the roof of the mouth during
the exposure. Now the area at the apices of the upper teeth will look darker and may
be misdiagnosed as pathologic.
15. Eyeglasses and barrettes left on during film taking will interfere with reading the film.
Gun pellets could also lead to a misdiagnosis. If a necklace is projected on the film, it
will usually show up magnified in the lower anterior incisor area.
16. If the lead apron is high on the neck, it will project a curved white area on the lower
part of the film.
17. If the patient moves any time during an exposure, that portion of the film will be fuzzy.
This can lead to a misdiagnosis of normal bone being called a fracture.
18. It is hard to read a film if a patient's partial denture or full denture was in the mouth
during exposure of the film.
19. Vertical bands on the film can lead to a misdiagnosis. Dark bands are caused by the
film going too slow in that area--the film is overexposed. When there are vertical streaks
on the film, the film did not move evenly. There will be repeated areas of underexposure
and overexposure. Light bands on the film are caused by the film moving too fast or the
x-ray beam was turned off. If there is a single solid line, the cassette was locked in place.
20. If the film is mispositioned in the compartment, some or most of the film is unexposed.
21. Reverse film placement will cause marks (tire tracks) on the film.
22. The intensifying screen may be cracked, this will show as a radiopaque thin line.
23. If the film is too light (insufficient density), there was an exposure or processing error.
24. If the film is too dense, there was an exposure or processing error.
25. There could be a double exposure if the old cassette was not replaced with a new film.
26. A leaky cassette may cause one-half of the film to be dark due to light leaking into the
cassette.
27. Positive density crimp marks (dark) are caused by bending the film or by fingernail
crimp marks.
28. Panoramic film is light sensitive--there is an intensifying screen in the cassette. When this
screen is hit by the x-ray beam, it glows, further exposing the film. Make sure your dark
room is light tight.
29. Some radiographic processing pitfalls are inadequate fixing or washing, causing a yellow
to brown discoloration of the film. The film may appear spotty or faded; the emulsion
may be torn.
30. Static electricity makes black marks on the film. The naked tree type of static can be
caused by rapidly pulling the film out of the box. There is no visible light with this static.
60

Smudge-type static is caused by visible light produced by an electrical discharge next to

the film. Smudge static looks like a lot of black dots on the film.
 61

TOPIC: LOCAL ANESTHESIA & N20-02 INHALATION SEDATION

Reading Assignment:

Pediatric Dentistry, Infancy Through Adolescence, 3rd Ed., Pinkham

Chapter 5 (pp. 69-73)

Chapter 6 (pp. 74-83)
Chapter 7 (pp. 85-91)

Chapter 28 (pp. 411-417)

Objectives

Upon completion of the reading assignment and attendance at class lecture, the
student should be able to:

1. describe the armamentarium used for the administration of a local anesthetic;

2. describe the recommended dosages for children and adults;

3. describe the relationship between depth and duration of anesthesia;

4. describe the reason why the effectiveness of local anesthesia is diminished in an area of
infection;

5. describe possible reasons for inadequate anesthesia;

6. describe the types of topical anesthetics and their method of application;

7. describe the proper psychological preparation of a child prior to administering a local

anesthetic;

8. describe the different types of mouth props and indications for their use;

9. describe the different nerve blocks necessary to anesthetize the primary and mixed
dentition;

10. describe the proper chair positioning and injection techniques which will produce the
greatest patient safety and comfort;

11. describe the proper positioning of the assistant when giving injections to children;

12. describe the differences and similarities in the technique of giving an inferior alveolar
block to a child as compared to an adult and describe associated anatomical differences;
 62

13. describe the proper technique of passing the injection syringe between dentist and
assistant;

14. describe the precautions to be taken after a local anesthetic is administered to a child;

15. describe the indications and contraindications of using N2O-O2 inhalation sedation with
children;

16. describe the technique of using N2O-O2 inhalation sedation in children.

 63

Lecture Notes for Local Anesthetic Injections and Child Management

Preparation of the child psychologically to receive the local anesthetic is extremely important.
The "tell, show, do" model provides a basic approach.

Tell the child what you are going to do in terms he can understand, avoiding fear-promoting
words.

"Johnny, I'm going to make your sick tooth well today, and I want you to be comfortable while
we're working. I'm going to spray some sleepy medicine on your tooth. It will help your tooth go
to sleep so we can clean out all the sick part. When I first begin to wash your tooth with sleepy
medicine, you will feel a tiny pinch. In a short time your tooth will get sleepy but you will stay
awake and we'll be able to talk to each other."

If the child has never had a local anesthetic, the soft tissue sensations the child will experience
should be explained.

"Your lip and tongue will feel fat and silly."

Show the child what to expect. Show the child how the little pinch will feel by pinching the
child’s hand or arm slightly.

"Do you feel that? That doesn't bother you much does it?"

As the child nods in agreement, reiterate aloud, "No it doesn't." Using your finger, touch the area
where the child will feel the "pinch."

Give the child some "control" over the procedure by setting up a finger signal (child raises finger,
not whole hand or arm) to show you if it's pinching too much.

"If I see you signal, I'll go slower and fix it so it doesn’t bother you anymore.

Tell the child that "holding still" and being "very quiet" makes it pinch even less.

It is questionable that anything is to be gained by showing the child the syringe and needle. In
some cases, the child wants to see it. This can usually be successfully managed by telling the
child he can see it at the completion of the procedure if he still wants to. Many times the child
will have forgotten about it. Or, the child can be shown the anesthetic syringe with the sleeve in
place over the needle "to keep it clean."

The words "shot" and "injection" should not be employed in your conversation with the child. If a
child asks, "Are you going to give me a shot?", we must reply truthfully but tactfully. "Yes, if
that's what you call it, but really I'm going to spray some sleepy medicine on your tooth, and it
won't bother you more than that pinch."

While doing the procedure, maintain verbal communication with the child explaining what the
child is feeling just before, and at the moment they feel it to reassure the child that you know
what they are feeling. You should be planting thoughts in their consciousness at this time.
 64

"Okay, here's the pinch . . . that wasn't too bad, was it? . . . and from here on, it gets easier. Hold
real still and try not to laugh--some kids think it tickles."

Injecting very slowly (1.8 cc/min.) lessens discomfort.

For the extremely anxious child, it is sometimes of value to speak of other things, thus distracting
the child from the present procedure. But speak to the child and keep a reassuring smile on your
face.
It is important that you not show any disturbing facial expressions. The child will be observing
you during the procedure. Any uncertainty reflected in your face could upset the child.

You should exhibit confidence and have a positive attitude in your approach to the child. You
must have confidence in your ability to perform the injection, and be firm yet pleasant in order to
prevent the child from becoming upset. Some clinicians even remove their eyeglasses if the child
is extremely anxious. This prevents the child from catching a view of the syringe reflected in their
eyeglass lenses.

Remember, Keep Talking Throughout the Injection!

It may prove helpful to allow the child to look in a mirror following the injection to see that his
face is not swollen or distorted, as it sometimes feels after the onset of anesthesia.

Proper chair position is important. The child should be in the supine position (parallel to the
floor), with the hands to the sides. The dentist should be seated at the eleven o'clock position and
the assistant at two o'clock for most injections. For the right mandibular block, the dentist will be
at approximately the eight-nine o'clock position. The dentist should wipe the injection site dry
and correctly position his hands for the injection. The assistant passes the syringe, with the cap
removed to the dentist's right hand in such a way that it is below the patient's field of vision. The
injection is given, attending carefully to the psychological management of the child throughout. If
the assistant suspects that the child might be uncooperative, she should position her arm over the
child's arms, but not touching, so she can intercept any movements the child might make toward
stopping the dentist.

If the child should become upset during the procedure, it is important to continue with the
injection, slowly injecting the desired amount of anesthetic solution. Once you begin, try if at all
possible to complete the injection regardless of behavior. If you have to remove the syringe
before completing the injection, it will probably be more difficult to begin again.

If the child begins to become a management problem during the procedure, a very strong, firm "I
message" such as "Don't move, I'm afraid I might hurt you" is frequently effective in quieting the
behavior. A successful injection requires confidence timing and teamwork. Don't actively restrain
or touch the child's arms unless the child raises them. Having the child in a supine position makes
it harder for the child to raise up. Keep equipment out of sight. I have seen a well-behaved child
go out of control when a student attempts to adjust the light while holding the syringe in the same
hand.

A maxillary injection seems to be tolerated better as a first injection for a child. There is virtually
no discomfort and you can't miss. Start injecting as soon as you penetrate and keep injecting as
you advance. Use a short needle (3/4"). You don't need to go to the hub according to Benham's
study of anatomy. If the needle fractures, it can be seen and easily removed. Inject slowly, 1.8cc
in 60 seconds. There is much less discomfort if you inject slowly. Watch the child for "signs" of
 65

success (numbness). Most kids can't express numbness. "Is it numb?" is usually not understood
by the child. It is better to say "tell me where it feels funny." It is important to remember that
deep pain anesthesia only lasts 45 minutes. Soft tissue anesthesia will last about two hours.

For a hyperactive patient, a 3-year-old for example, should you give a lower block or an
infiltration? The bone becomes more dense as you go more posterior and as the child gets older.
On children older than 4 years of age, mandibular infiltrations aren't effective.

An alternative injection is intraligamental anesthesia (Ligmaject or Peripress). These were

successful in 65 of 71 restorative cases in one report. In the same report, patients overwhelmingly
preferred this technique. However, recent reports of damage to developing teeth have
contraindicated this type of injection for children.

In a case when you have a choice of a lower left or right mandibular block injection on a
potentially unruly child, give the left first. You have better head control. Inject between the deep
tendon of the temporalis on the lateral aspect and the pterygomandibular raphe on the medial
aspect. Have your thumb on the coronoid notch, middle finger just above the angle of the
mandible. The forefinger should be just below and anterior to the angle.

When there is need for long buccal anesthesia, inject into the muco-buccal fold just distal to the
most posterior molar.

The alveolar bone overlying the roots of teeth anterior to the zygomatic process is relatively thin
(incisors to the primary 1st molar). The maxillary primary 2nd molar may have l cm of bone
covering its buccal roots and you may have to give a posterior superior infiltration for adequate
anesthesia. Branches of the posterior superior & middle superior alveolar nerves innervate the
primary molars. The maxillary permanent 1st molar in a child is also hard to anesthetize because
of the thick bone in this area. As the maxilla grows in height, this becomes less of a problem.

A palatal injection may be made less painful by giving the labial or buccal injection first and then
waiting for a couple of minutes. Then from the labial, inject horizontally through the interdental
papilla into the palatal tissue until it blanches. If this in not enough, you can now inject into the
palatal tissue near the blanched area with little or no discomfort.

Following an appointment where local anesthetic has been employed (particularly a mandibular
block), both the child and parent must be cautioned about biting the lip, tongue or cheek. Severe
soft tissue trauma results from biting or rubbing anesthetized lips. This is the most common
adverse sequelum to local anesthesia administration. Children who are able to understand the
possible results of biting these tissues generally follow simple instructions and avoid injury. They
should be advised that the anesthetic effect will gradually disappear. The very young child may
need to have an object such as a cotton roll with a floss safety line placed between the teeth until
the tissue sensations return to normal. Little badges that stick to the clothing are available that
warn about lip biting. These can be used as a very effective reminder.
 66

Maximum Dosage of Lidocaine with Epinephrine 1:100,000

Cartridge Contains 36mg

Maximum Dosage: 4.4mg/Kg (2.0 mg/lb)

Weight Cartridges

Kg lbs mg mg

10 (20) 44 (40) 1 (1)

20 (40) 88 (80) 2 (2)
30 (60) 132 (120) 3.5 (3)
40 (80) 176 (160) 4.5 (4)
50 (100) 220 (200) 6 (5.5)
60 (120) 264 (240) 7 (6.5)
70 (140) 300 (280) 8 (7.5)
80 (160) 300 (300) 8 (8)
90 (180) 300 (300) 8 (8)
100 (200) 300 (300) 8 (8)

The simplest and perhaps most conservative recommendation is the “Rule of 25”, which states
that a dentist may safely use 1 cartridge of any marketed local anesthetic for every 25 lb.of body
weight: i.e. 3 cartridges for a 75 lb. patient, 6 cartridges in a 150 lb. patient. (Manual of Local
Anesthesia in Dentistry, Moore PA, Editor, 4th ed. Eastman-Kodak Co. Rochester, NY, 1996)

Metabolized by liver
Excreted by kidney
 67

With epinephrine
Pulpal anesthesia = 60-90 minutes
Soft tissue anesthesia = 3-4 hours

Without epinephrine
Pulpal anesthesia = 5-10 minutes

Soft tissue anesthesia = 60-120 minutes

 68

Slide Notes for Local Anesthesia

1. To complete injection procedures, the following are needed: aspirating syringe, short
needle (27 gauge), cotton swab, topical anesthetic, cotton roll, and a bite block for young
children when giving lower block.

Two types of anesthetics - Amides are broken down by the liver and excreted the kidney.
Carbocaine and Xylocaine are both amides. Esters (PABA) are broken down by
hydrolysis in plasma by the enzyme pseudocholenesterase in the blood stream and
excreted by the kidney. Monocaine and Ravocaine are esters (PABA).

Chemistry - Local anesthetics are weak organic bases and are poorly soluble in water.
They are reacted with HCl forming a water-soluble salt that is injectable.

Mode of action - Tissue has an alkaline pH that allows hydrolysis of an anesthetic salt,
thus liberating the anesthetic base. The free base is lipid soluble, enters lipo-protein nerve
membrane preventing depolarization and ion exchange by decreasing membrane
permeability to sodium which is essential for depolarization of the nerve fiber.

Inadequate anesthesia - The pH of tissue in an infected area is acid and the anesthetic
base may not be adequately liberated.

Percentage (Potency) of anesthetic - It is more important to have a sufficient

concentration of anesthetic at the nerve site than it is to have a higher percentage solution.

Vasoconstrictors - Epinephrine 1:100,000 and Neo-cobefrin 1:20,000 are most commonly

used vasoconstrictors for children.

Dosages - Maximum dose for children

2.17 carpules of Xylocaine 2% 1:100,000 Epinephrine - 40 lb. child

2.17 carpules of Carbocaine 2% 1:20,000 Neo-cobefrine - 40 lb. child
1.44 carpules of Citenest 4% - 40 lb. child

3.26 carpules of Xylocaine 2% 1:100,000 Epinephrine - 60 lb. child

3.26 carpules of Carbocaine 2% 1:20,000 Neo-cobefrine - 60 lb. child
2.16 carpules of Citenest 4% - 60 lb. child

There are 36 mg of anesthetic and .018 mgs of epinephrine in a 1.8 cc carpule of 2%

Xylocaine. If a physician is called in an emergency, he will want to know how many mgs
of anesthetic were given and the weight of the child.

Allergic reactions - If a patient is allergic to one of the groups (amides or esters), you
could possibly use an anesthetic from the other group. However, most allergic reactions
are caused by the preservatives in the anesthetic. Refer the patient to an allergist and then
use a preservative free anesthetic.
 69

3. Duration and depth of anesthesia - It is important to remember that while soft tissue
anesthesia will usually last 2 hours with Xylocaine 2%, deep pain anesthesia may only
last 45 minutes.

4. Topical anesthetics - Hurricaine gel or Xylocaine ointment 5% are commonly used. Dry
the area before applying topical and most importantly, give the topical enough time to do
its job. Topicals are usually not indicated for infants. The extra time involved and the
spreading of the topical just leads to more fussing on the infant's part.

5. Topical anesthetic reactions - Don't use too much topical, it will run down the throat.
Applying topical on a cotton roll can help prevent this. Spray topicals can be dangerous--
they can be inhaled. Use a gel or ointment.

6. Clinic procedure - Sterile anesthetic packages are available at the dispensary window. An
order is not needed. However, permission is needed for a refill. Two carpules are near the
maximum dosage for a 40 lb. child.

7. Needles - long (1 5/8") and short (1 1/4") needles are available at the window. For
children a short 27-gauge needle is commonly used. It is easier to handle and is not as
threatening if seen by the child.

8. Keep cap on the needle - For cleanliness, safety, and avoidance of patient anxiety, keep
the cap on the needle, before and after use.

9.-10. Establishing communication - Don't just jump in; get familiar by talking to the child.
Silence can breed fear, so keep talking, even if it is one-sided. Touching is good. Use tell,
show, and do. Most patients want to know what is going on. It's their body, and their
mouth is personal and sensitive and they will protect it. Use your fingers first, not any
instruments that may be threatening to the child. Control the conversation. When you are
working don't ask questions; make statements. Don’t ask permission. Say “open”, don’t
say “I would like for you to open, OK?”

11.-13. Getting the child to open - If the child will not open, place your finger on the incisal of
the maxillary centrals and give the command to open, while applying pressure to the
centrals. By tilting the head back, the mouth will open. Compliment the child after he
opens. Another method is to slide your index finger back to the coronoid notch and apply
pressure while saying "open" - again, compliment the child.

14. Applying topical - Dry the area before applying topical. Paint it on or put it on a cotton
roll. If you use a topical, give it enough time to work. Tell the patient how it will feel and
taste. Tell them they won't get sick if they swallow it, to put them more at ease.

15. Syrijet topical anesthetic syringe. Compressed air will inject .2 cc with a "pop." Warn the
patient about the noise. Hold the instrument firmly against the tissue. If the syringe is
held at an angle, the anesthetic could tear the tissue. The Syrijet can also be used for
simple extractions.
 70

16. Finger pressure on palate - Firm pressure on palatal injection site for 30 seconds prior to
needle penetration helps minimize pain.

17. Keep syringe hidden - Some dentists show the syringe and needle to the patient before an
injection. You have to be a good talker and have command of the situation to do this.
Most dentists will keep the syringe hidden. If you are asked to show it, say “I will show it
to you after I'm finished if you ask me." Rarely will a child ask following an injection.

18. Maxillary central injection - Dentist's wrist, forearm, and belly are used to steady the
patient's head. Shake the patient's lip or pull it down over the needle for a less painful
injection. Warm the carpule to body temperature before injection. Inject into the
mucobuccal fold directly above the central. You can steady the needle further by resting
the syringe against a finger of your other hand. Inject slowly!

19. Aspirate. If you are in a vessel, move the needle slightly and aspirate again.

Know where the bevel is. It is very painful if the periosteum is punctured or ripped
during the injection. Try to make your injection as painfree as possible. The needle
should be able to slide along the periosteum.

20. Maxillary lateral incisor injection - Hold lip firmly so you can see what you are doing.
Either shake the lip or pull it down over the needle. Inject into the mucobuccal fold right
over the apex of the lateral.

21. Maxillary primary first molar injection - One injection will do it, right between the buccal
roots. Don't hit the frenum, this is painful. Inject slowly!

22. Maxillary primary second molar injection - One injection or two, don't go through the
frenum. If you shake cheek while injecting, it will help mask the pain.

23. Distal of maxillary primary second molar and permanent first molar area - Keep bevel in
proper position and tip of needle close to bone, away from plexus. Deposit solution close
to nerve for deep anesthesia--you will need less solution.

24. Infraorbital block - Be careful. Use this injection for large working area and if there is
periapical infection of teeth involved.

25. Nasopalatine block - Use firm finger pressure on soft tissue for 30 seconds before
injection. Don't ram the needle in--when it hits periosteum, the patient will jump and you
will have to re-inject. Steady the needle with a finger of the other hand. If you are good at
injections, patients will trust you with any procedure. Nasopalatine nerve comes out of
the incisive fossa (nasopalatine foremen).

26. Anesthesia for clamp placement - Inject small amount of solution in papilla area on
lingual of molars for clamp placement. Be gentle.
 71

27. Greater palatine block - An injection in the greater palatine foramen area will anesthetize
the posterior palate to the midline and anteriorly to the first premolar area. Steady the
needle with a finger of the other hand.

28.-32. “Painless” palatal approach - Dry the mucobuccal fold area above the central incisors and
apply a topical anesthetic. Inject a warm anesthetic solution slowly over the centrals.
After the anesthetic has taken effect, inject slowly, straight through papilla into palatal
area. Remove needle. Wait for a minute, then inject directly into the incisive fossa
(nasopalatine nerve). Remember to keep injecting as you advance the needle. Use this
same procedure through a buccal papilla to anesthetize the greater palatine nerve area.

33.-45. Mandibular block - The mandibular foramen is slightly lower in relation to the occlusal
plane in youngsters. As the patient gets older, the foramen approaches occlusal plane
height. An overhead view of the mandible demonstrates an ever-increasing “V” shape.

Path of injection - Because of the “V” shape, the barrel of the syringe must pass over the
primary molars of the opposite side of the arch. If your angle is not severe enough, the
needle will slide past the foramen and into the parotid gland.
Coronoid notch landmark - The deepest portion of the coronoid notch is on a level with
the mandibular foramen. Place your thumb on the coronoid notch and use this as a guide
for the height of the foramen.

External finger position for mandibular block - With your thumb on the coronoid notch,
place your index or middle finger of the same hand on the gonial fossa (the depression on
the posterior border of the ramus just below the ear). This is an imaginary aiming point
(the tip of your finger on the fossa) when giving the lower block.

Assistant’s role - The assistant passes the syringe out of the line of sight of the patient,
usually below the level of the chin. The assistant then positions her hands either directly
above the patient’s arms or gently holds them if she suspects any sudden movement from
the patient. If the dentist agrees, the assistant can talk, thus distracting the patient. A good
assistant is invaluable during the local anesthesia procedure on an anxious patient.

Control of patient movement by the dentist - The dentist should use his fingers, hand,
forearm, and belly, when needed, to support the patient's head during the injection
procedure.

Injection procedure - Warm the carpule to body temperature (difference between room
and body temperature is 25° to 30°). SHAKE the lip or pull the soft tissue over the needle
when possible while inserting the needle. This sudden movement distracts the patient and
also gives another sensation to the brain. GIVE one or two drops immediately after
inserting the needle and wait for 5 seconds before advancing the needle while also giving
a drop or two along the way. SHAKING the lip or cheek during the actual injection of
solution helps mask the discomfort of the chemical and also the increase of volume and
the stretching of tissue in the area. ASPIRATE after reaching the nerve site. If aspiration
is positive, move needle slightly and aspirate again. If aspiration is negative, proceed with
the injection. INJECT SLOWLY, 2 minutes from start to finish for a mostly pain-free
procedure. As injection procedure goes along, note that the assistant relaxes her
protection if the patient is comfortable.
 72

Using a bite bloc - If you anticipate that the child will not stay open during the injection
procedure, use a bite block (careful not to trap soft tissue). Tell the child the bite block is
a tooth rest to help him stay open. This is not used as a punishment but as an aid. You are
after cooperation, not confrontation.

46. Long buccal injection - Insert needle distal and lateral to last molar. Shake the cheek
while injecting.

47. Field block - An injection into the buccal mucosa just apical to the lower primary molars
is an alternative to the lower block in children. This will not produce adequate anesthesia
in an adult because of the dense bone of the mandible.

48. Lower incisor injection - Inject into the mucosa just apical to the teeth involved. This can
be used as an individual injection or for coverage of anastomosing nerves from across the
midline after giving a lower block on the opposite side. Inject slowly!

Talking - Distractions before and during a painful or anticipated painful procedure are a
great help with the anxious as well as the 'normal' patient. Silence at this moment of
anxiety will lower the pain threshold and make everything seem worse. Keep the
patient’s mind occupied with your talking.

49.-51 Lip biting with anesthesia - Warn the parent as well as the child about biting or pulling on
the lip after anesthesia. Stand in front of the child and mimic biting your own lip and tell
the child not to chew on his lip because it will be like eating a sandwich. He will bite
some of his own skin off and he will be very sore for a few days. A traumatized lip is not
a good advertisement for your dental practice. The sore looks bad, but it will heal
uneventfully. Tell the parent to have the child rinse with warm salt water. Three to five
days post-op scab will be white-yellow, just like a scab that is wet after taking a bath.

52.-55. Ligmajet - This injection is controversial. Too much solution and too much pressure can
cause harm to the tissue in the immediate area. There are a multitude of instruments on
the market today to deliver this injection. This particular syringe is somewhat threatening
because of its size. Each squeeze of the handle will inject .2 cc of solution. This is the
normal amount of solution needed for one root. A flexible 30-gauge needle is used. The
opening (bevel) of the needle is toward bone (if the bevel is against the root of the tooth,
the solution cannot be squeezed out of the syringe). Push the needle firmly into the
ligament space. Resistance should be felt when squeezing the handle (if there is little or
no resistance, the solution is escaping and not going into the ligament space). Forcing the
solution into this space will stretch the PDM fibers and raise the tooth somewhat. The
epinephrine will also diminish blood supply to the area. This will cause some residual
soreness, but placing a wedge or performing orthodontic movement will also cause some
destruction. The trick is knowing how much pressure can be applied for normal healing
to take place.

Benefits of the Ligmajet injection - Less anesthetic solution is used, only tooth and soft
tissue surrounding tooth is anesthetized (no lip biting), anesthesia does not last as long as
normal block, and the injection procedure is almost painless.
 73

56.-61. Intraosseous Injection - A 30-gauge needle with a sliding collar for added strength is
used. The needle has a tri bevel point and its exterior is lubricated. The needle penetrates
1/8" into bone. Bone doesn't have any nerve endings. The injection technique takes
advantage of the thin and unusually spongiosa like interproximal bone at the injection
site. Effective anesthesia is obtained in 60 seconds and lasts for 15 to 20 minutes. Use a
plain anesthetic solution, don't use a vasoconstrictor. Inject mesial to tooth needing
anesthesia. Not more than .5 cc is used. Good for children because of the porous bone.
There is no lip anesthesia, just numbness in the immediate area.

Intraosseous injection technique - Place topical on cotton roll. Dry tissue. Place topical
next to interdental papilla for two minutes. Hold syringe at a right angle to the injection
site, the base of the triangle formed by the interdental papilla. Enter tissue and deposit a
drop of anesthetic. Punch through cortical plate into spongiosa-like bone and inject up to
.5 cc of solution. You need a lot of pressure for this injection. You can inject distal to
tooth if you think it is necessary. One injection mesial to the tooth will anesthetize tooth,
hard and soft tissue both on the labial and lingual.

Rotate the syringe when injecting to penetrate bone.

62. This is what it is all about. A smiling patient after treatment.

 74

Lecture Notes for Nitrous Oxide-Oxygen Inhalation

Selection and Management of the Child Patient

Introduction

The dentist cannot concern himself with the elimination of physical pain only, but must
constantly seek methods and means of altering the patient’s attitude toward his dental
treatment.

-- Leonard Monheim

Inhalation sedation in dentistry is used for relief of fear and apprehension and not the relief of
pain or as a substitute for routine, proven methods of child management. It should be used as a
means to reach the child patient in order to modify his response to the dental experience.

Inhalation sedation is produced by the administration of light amounts of nitrous oxide in

combination with oxygen. There are few, if any, unpleasant side effects, and the child can be up
and about immediately afterwards.

The use of nitrous oxide in the dental office has had its ups and downs over the years since it was
first used by the dentist, Horace Wells, in 1844. It is on the upswing again, and its use and abuse
is often discussed in the dental community. It is the most used form of pharmacotherapeutic
management in dental offices today.

The practitioners who use it as an aid for the patient and themselves swear by its use. They claim
the following benefits:

Benefits to the Patient:

1. Lessens apprehension and fear of dental procedures (sedation).

2. Pain is obtunded by raising the pain threshold (analgesia).

3. Lessens anticipation of discomfort.

4. Length of appointments is unimportant.

5. Memory of discomfort reduced (amnesia).

6. Need for premedication is diminished; but if needed, can have synergistic effect with
N20-02 inhalation sedation.
 75

Benefits to the Dentist:

I. Better patient cooperation.

2. Increased efficiency.

3. Reduced physical strain.

4. Reduced mental strain.

5. Promptness for appointments.

6. Better case acceptance.

7. Better dentistry.

On the other hand, the dentists who do not use nitrous oxide-oxygen inhalation say it is an
unnecessary crutch, and good patient management would work just as well. In addition, possible
psychological dependence on nitrous by the patient would be eliminated. In the end, the decision
to use N20-02 inhalation is determined by the operator's own patient management philosophy.

Characteristics

First and most important, the dentist must be well versed concerning the characteristics and
actions of nitrous oxide-oxygen inhalation sedation. Nitrous oxide characteristics include:

1. Odorless.

2. Nonexplosive.

3. Rapid onset which is easily maintained.

4. Rapid reversibility.

5. Fear and anxiety are diminished.

6. Produces euphoric state.

7. Obtunds pain.

8. Goes from lungs into blood stream back into lungs and excreted unchanged.
 76

9 Has minimal side effects.

10. Gag reflex is reduced. This helps with impressions, radiographs, and gag-prone
patients.

11. Laryngeal cough reflex is not affected. This is important for the patient's protection
against aspiration.

Contraindications

Contraindications for the use of nitrous oxide-oxygen inhalation sedation:

1. Respiratory conditions that reduce the patient’s nasal respiration such as the common
cold, acute rhinitis, deflated septum, or enlarged adenoids.

2. Pulmonary conditions such as bronchitis, emphysema, tuberculosis.

3. Psychiatric disorders.

4. History of motion sickness (may vomit).

5. Cystic fibrosis.

6. Child displaying defiant, hysterical behavior.

Equipment

Equipment used in administering nitrous oxide-oxygen mixture:

1. Oxygen tank (2,400 psi), nitrous oxide tank (750 psi).

2. Safe delivery system of pipes and hoses.

3. Pressure gauges.

4. Flow meters.

5. Monitoring equipment.

6. Nosepiece.

7. Scavenger system to reduce the amount of residual gas and keep the breathing zone of
the operating personnel below 50 ppm N20 concentration. This prevents chronic
 77

exposure of the dental personnel to N20, which has been implicated in increased
incidence of liver disease, spontaneous abortions, and birth defects.

Introducing N20-02 to the Child

To properly introduce nitrous-oxide inhalation sedation to children after obtaining parental

consent:

1. Tell the child that the "magic air" or "happy air" will make him feel happy and comfortable.
Tell the child sensations he may experience in words he can understand--tingling in the toes
and fingertips, a buzzing or humming sensation, a state of relaxation, heaviness in the arms
and legs, a happy and safe feeling. Reassure the child that he will not go to sleep--he is in
control and can stop the feeling by breathing through his mouth.

2. Show the child the equipment and explain the hoses, gauges, and nasal inhaler in terms of
what the astronauts must wear when they make their space flights. Suggest a game of
pretend-a-space ride. Demonstrate fit of nosepiece on yourself.

3. Do without pausing, calmly and slowly place mask on child's nose and begin administration
as outlined below.

Technique of Initial Administration

1. Select the appropriate size nosepiece--small, medium, and large.

2. Disinfect the nosepiece, followed by soap and water and mouthwash for a pleasant smell. An
anxious patient and a noxious-smelling nosepiece are not the way to start.

3. Adjust nosepiece air dilution valve. There are two schools of thought on whether to have the
valve-open or closed. If the valve is kept closed, the patient will get the percentage of gas
shown on the dials. If the valve is left open, a small amount of C02 from room air will get to
the patient resulting in a more normal and thus, smoother breathing pattern.

4. Have 02 flowing at 100% before putting the mask on the child to prevent claustrophobia.
Instruct the child to breathe through the nose (use of rubber dam promotes nasal breathing).
Run gases at 3 to 5 liters/minute for children. If the volume is too great, the child may be
irritated by the air blowing in his face, especially if the nosepiece fits poorly. Have the
reservoir bag filled before starting. This acts as a reserve supply for the rapid-breathing,
anxious child. The patient does not use the bag for rebreathing. A one-way check valve is at
the end of the hose by the bag. Gases go out through the nosepiece and not back into the bag.
By keeping the bag partially filled, one can see when and how fast the patient is breathing or
if the child is faking it and breathing through his mouth. The tubing to the nosepiece forms a
circle, and this circle can be made smaller by sliding the noose behind the back of the chair.
The nosepiece can be secured in this way but should not be too tight. The patient will breathe
faster at the start, so adjust the volume downward after a few minutes if needed. If the bag is
flat, the patient is either breathing all you are giving him, or you are out of gas. Keep an eye
on the bag. Patient can get room air from inlet valve located next to reservoir bag or through
nosepiece if dilution valve is open. After 2 to 3 minutes of 100% 02 increase the percentage
of N20 in increments of 10% per minute until desired symptoms appear. For preschool
 78

children who cannot adequately communicate their level of sedation, a faster induction period
may be advantageous (40% N20, 60% 02).

5. Talk a lot. The patient is in a suggestive state when N20 is at the right level. As the hypnotic
state approaches, maintain body contact because the child may feel like he is floating away.
This is not a nice feeling for everyone. Maintaining physical contact helps dispel any
uneasiness. Avoid loud sounds or sudden movements. Never leave the child alone while
administering N20.

6. 20 to 30% N20 is usually enough to produce symptoms of tingling toes, fingertips, and lips.
The child should feel good and may have a sensation of warmth. Droopy eyelids and a
faraway stare are signs of adequate sedation. When these symptoms appear in approximately
three to five minutes, it is time to start treatment. Remember, symptoms are judged by the
child’s reactions and not by the flowmeter. Don't encourage the child to speak frequently.

7. Some of the symptoms of being too deep (too much N20) are:

a. a hard stare;

b. won't keep mouth open;

c. won't follow commands;

d. an uncomfortable feeling;

e. sluggish movements; and

f. attempting to sit forward in the chair.

To overcome these symptoms, increase 02 concentration. In an emergency, hold the nosepiece to
the face with the valve on the nosepiece closed, and run 100% 02. The oxygen flush valve may be
used to rapidly inflate the reservoir bag with 100% 02 if necessary. This is noisy and will usually
startle the patient, lessening the sedative effect.

8. After the injection is completed, the N20 level can be reduced to 20-30% during the
maintenance phase.

9. A rubber dam should be used during routine restorative on children while nitrous is being
administered, because the dam will tend to close off the oral airway and force the child to
breathe through his nose, and thus have a smoother nitrous ride.

10. To properly recover following the termination of inhalation sedation, the patient should
receive 100% 02 for at least five minutes at the end of the session. Otherwise, the patient may
undergo oxygen debt produced by the influx of room air (20% 02 and 80% N2) combining
with the N20 and C02 coming out of the blood stream. This condition is referred to as
diffusion hypoxia. To save time, this recovery phase could be started as you begin to carve the
amalgam. Following inhalation sedation, the child will often feel drowsy, as if having just
awakened from a nap. Have the child sit up slowly to avoid postural hypotension, and steady
the child as he walks back to the reception room.
 79

11. Vomiting, while rare, can occur with little warning. Its occurrence is influenced by frequent
fluctuations in concentrations, overdosage (50% N20 or greater}, and prolonged
administration. Often, the only warning the child gives you is a violent contraction of the
abdomen. If vomiting does occur, the child's head should be turned to the side and lowered.
High volume suction is used to clear the mouth. Flush the patient with 100% 02 for 5 minutes
and terminate the procedure as quickly as possible. If the decision is made to use inhalation
sedation at the following appointment, you may want to give instructions not to eat two or
three hours prior to the appointment and give an anti-emetic.

12. For future reference, record in the patient's chart the child's reactions to the inhalation
sedation and the concentration of gases used.

13. Don't go past Plane 3 of Stage 1. The best place to work is in Plane 2 or 2 1/2 of Stage 1. 40%
nitrous + 60% 02 + room air (air inlet valve open on nosepiece) = 25% nitrous (what patient
receives). A loud noise will bring patient out of analgesia. Use the power of suggestion;
patient is in a suggestive state.

14. Patient symptoms of Plane 1 through Plane 4.

Plane 1 - Tingling of toes, fingers, and lips due to vasomotor excitation. This is a light
analgesic state.

Plane 2 - Deeper, warm feeling all over, lethargy, humming, and droning sounds.

Plane 2 1/2 - Voice changes, throaty, less aware, don't care, well being, euphoria.

Plane 3 - Pain will go away, deep thoughts, amnesia, and heavy limbs.

Plane 4 - Hard stare, closed mouth, won't answer, sits up, close to excitement stage,
uncomfortable.

TOPIC: SEALANTS AND THE PREVENTIVE RESIN RESTORATION

(PRR)

Reading Assignment

Pediatric Dentistry, Infancy Through Adolescence, 3rd Ed., Pinkham

Chapter 32 (pp. 451-480)

Objectives
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Upon completion of the reading assignment and attendance at class lecture, the student
should be able to apply knowledge about the following aspects of sealants and the PRR:

1. advantages;

2. indications;

3. preparation;

4. base selection and placement

(a) types of glass ionomer cements

(b) advantages of glass ionomer cements;

5. etching and bonding for composites

(a) rationale
(b) materials
(c) technique;

6. sealant application (cleaning, etching, finishing)

(a) rationale
(b) materials
(c) technique.
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Lecture Notes for Preventive Dentistry, Sealants and Preventive Resin

Restorations
You are responsible for information pertaining to children and adolescents covered in your
Preventive Dentistry Course.

Pediatric dental patients and their parents should be educated so that they have the ability to
perform all indicated preventive procedures. Five main areas of therapy comprise the focus of the
pediatric dentistry preventive philosophy: plaque removal, diet control, systemic fluoride, topical
fluoride, and sealants.

Patient Record
At the time of your patient’s first visit, you will complete the Preventive Assessment. This
information is obtained from the parent or guardian and will establish the database upon which
preventive recommendations can be made.

Plaque Control
It will be your responsibility to inform your patients and their parents about the relationship
between plaque and dental disease. They will also need instruction in plaque removal and
continual reinforcement of those principles. This information should be entered on the Preventive
Assessment and in the Treatment Record.

Diet Control
Your patients and their parents should be provided with factual information regarding the
importance of diet control and its relationship to dental caries. This should emphasize the effect
of sugar in the diet and stress the role of frequency and consistency of the sugar ingested. An
informal interview regarding regular dietary practices should be conducted leading toward the
following:

1) identification of good dietary practices, encouraging their continuation;

2) identification of poor dietary practices and alternative suggestions;

3) identification of hidden sugars in the diet that may be detrimental.

Toothbrush vs. Rubber Cup Prophylaxis

Research indicates that a rubber cup prophylaxis using an abrasive paste removes the fluoride rich
outer layer of enamel, with the removal of white spot enamel being three times greater than that
of normal enamel. This information suggests that the routine use of a rubber cup prophylaxis
prior to topical fluoride application may be detrimental. The Department of Pediatric Dentistry
currently recommends the use of a toothbrush for plaque removal prior to topical fluoride
application, since it can be an effective oral hygiene reinforcement and will not damage the
fluoride-rich enamel layer.

A rubber cup prophylaxis is indicated in the following situations only:

1) removal of stains;
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2) polishing after calculus removal;

3) cleaning prior to acid etch bonding;

4) as a desensitizing procedure for very young or handicapped patients; and

5) removing plaque prior to operative procedures.

Sealants
The following table represents the current departmental philosophy regarding occlusal sealants.
These are presented only as guidelines since clinical judgments may vary from time to time.

Indications for Occlusal Sealants

Criteria Seal Don’t Seal

occlusal morphology deep, narrow pits and fissures well-coalesced pits and
fissures

general caries activity many occlusal lesions, but few
proximal lesions
tooth age recently erupted teeth
many proximal lesions
teeth that have remained
caries-free for four years or
longer

The use of sealants in primary molars is a controversial area. If the teeth in question meet the
criteria expressed in the table, they may be considered for sealant application. When this is the
case, preapplication etching time is increased to one minutes.

Whenever sealant material is used, its application should receive the same consideration as any
restorative material. Rubber dam isolation is encouraged and when possible, sealants should be
accomplished as part of quadrant dentistry. Always follow the manufacturer's recommendations
for application since these will vary with different brands.

Recent research has shown increased sealant retention by opening the grove area with a round bur
(#1/4). The technique is called enamelplasty.

Supplemental Fluoride

Fluoride supplements represent an important, proven effective means for dental caries reduction.
They can provide both systemic and topical effects. The best results occur when supplemental
treatment is initiated early; however, when water concentrations are less than .7 ppm, they can be
effective at all ages.

For fluoride supplements to be effective, they must be tailored to the specific needs of the
individual patient. This requires that you:
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1) determine proper dosage;

2) select the appropriate type of supplement;

3) write a proper prescription or instructions for over-the-counter products,

4) teach the patient and parent proper usage of the supplement; and

5) continually reinforce and re-evaluate the propriety of your recommendations.

Fluoride supplements are generally recommended for children 14 years and under when the
community water supply has.6 ppm or less fluoride. Situations involving rampant caries or
parents wishing additional protection for their children are also indicated for fluoride
supplements.

Prior to prescribing a systemic fluoride supplement, it is mandatory that an analysis of the

fluoride in the drinking water be completed. This service is offered through the Department of
Human Resources.

Alternatives to Community Fluoridation

School fluoridation
Fluoridator installed in schools to provide 4.5 times the normal optimal concentration (only
180 school days/year).

Home supplements
Sodium fluoride tablets or drops taken at home. One tablet of 2.2 mg sodium fluoride yields 1
mg fluoride ion.

Practical Considerations of Supplementation

Fluoride/vitamin combinations available in different fluoride concentrations probably aid
compliance, but should not be recommended unless physician determines the patient would
benefit from a multiple vitamin diet supplementation. In addition, the fluoride administration
usually needs to be continued beyond the period required for vitamin supplementation.

Survey of parents indicated that inconvenience, not expense, is the main reason for dissatisfaction
and thus failure to comply.

Supplementation Schedule

Fluoride Content of Less than 0.3 ppm 0.3 - 0.6 ppm Greater than 0.6 ppm
Domestic Water
(ppm)

Age (years)

6 months to 3 0.25 mg 0 0
3 to 6 0.50 mg 0.25 mg 0
6 to 16 1 mg 0.50 mg 0
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Council on Dental Therapeutics, April, 1994

The Council on Dental Therapeutics of the American Dental Association recommends that
supplements routinely be prescribed only if less than 60% of the recommended optimal fluoride
concentration for that climatic area is found. The dosage table is adjusted for warm and dry
climates with greater water intake. For example, a prescription should be written only if fluoride
analysis is 0.6 ppm or less for a 1 ppm area.

Dose adjusted according to existing natural fluoride levels in the drinking water and age.

Young children intake and utilize less fluoride.

Children between the ages of 3 to 14 get maximum dosage adjusted to water fluoride level.

Chewable tablets are recommended for children who can manage them to take advantage of the
topical effect. Fluoride drops are available for young children unable to take tablets.

Fluoride rinses and chewable tablets provide a topical and systemic effect if swallowed.

It is not recommended that pregnant women ingest supplemental fluoride for the benefit of their
unborn child. USFDA banned advertising and marketing of prenatal fluorides in 1966 due to lack
of efficacy data (safety not questioned).

Fluoride passes the placenta, but there may be a regulatory mechanism as fluoride concentration
that reaches the fetus is considerably lower than found in the maternal circulation.

Critical period for fluoride ingestion is between the final stages of crown formation and the
beginning of gingival emergence (eruption) when the greatest concentration of surface fluoride is
incorporated into the enamel. Most caries susceptible surfaces calcify after birth.

Supplemental Fluoride Prescription Examples

1. Six-month-old infant being fully breast-fed and residing in suboptimal fluoride (fluoride ion =
0.1 ppm) area

Rx: Sodium fluoride solution (Luride drops) 0.125 mg F-/drop

Disp: 40 ml
Sig: Dispense 2 drops directly into mouth just prior to bedtime

2. Four-year-old child residing on farm with well water analyzed at 0.2 ppm fluoride ion

Rx: Chewable sodium fluoride tablet (0.5 mg F-/tablet)

Disp: 120
Sig: Slowly dissolve tablet in mouth after brushing/ flossing of teeth prior to bedtime

Topical Fluoride Therapy

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Used as supplement to systemic fluoride therapy and not as a substitute.

Given as high concentration with low frequency of application (semi annual office use), or low
concentration with high frequency of application (daily/weekly home use).

Office Therapy

Acidulated phosphate fluoride (APF, 1.23% fluoride ion in 0.1% orthophosophoric acid)
remineralization, or Stannous fluoride (8 to 10% fluoride ion) bactericidal

Both semi-annual application

30 to 50% caries reduction (suboptimally fluoridated area)

20 to 25% caries reduction (optimally fluoridated area)

APF preferred due to greater stability, better tastes and longer lasting effects.
 86

Home Therapy

Dentifrice
Recommended fluoride toothpaste--20 to 40% caries reduction

Use very small amount of fluoride toothpaste for children less than three years of age, because
they are likely to swallow some of the 2 mg fluoride per gram paste used. Not using toothpaste as
this age prevents foam from limiting parents' view of kids' teeth and might make child less
uncooperative.

Gels and Mouthrinses

Fluoride rinses are an effective means of topical fluoride application for families that show extra
concern. Rinses of low fluoride concentration can also be ingested as a supplement in areas where
water fluoridation is suboptimal. Since the swallowing reflex is poorly developed in preschool
children, they tend to swallow the rinses. Fluoride rinses are not recommended for children under
six years of age unless it is intended that they should ingest the rinse. Fluoride gels and custom
fitted trays may be used in cases of extreme need, such as with Xerostomia following radiation
therapy.

Sample Fluoride Gel Prescription

Teenager with rampant caries

First two months

Rx: Acidulated phosphate fluoride gel (Karigel, O.5% F)

Disp: 30 ml
Sig: After brushing and flossing of teeth, place several drops on toothbrush and brush gel on
teeth for one to two minutes. Spit out excess gel. Do not swallow.

Third month or until caries activity diminishes

Use rinses (0.05% NaF) daily (Fluorigard, ACT, PhosFlor)

Fluoride Recommendations for Orthodontic Patients

SnF2 gels and mouthrinses are highly effective in controlling decalcification in orthodontic
patients.

Office Application at Each Appointment

0.31% F- APF (pH 4.0) solution for 1 minute

0.46 SnF2 for 1 minute

Given before banding and at each return visit (every three weeks on average) throughout
treatment.

Decalcification reduction in one study:

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 88

Home Application Daily

Fluoride gels for brushing are Gel-Kam® (0.4%SnF2 ) and PreviDent® 5000 Plus (1.1% NaF).
Both are available by Rx only. For 6- 16-year-olds, PreviDent® 5000 is brushed on at bedtime
for two minutes and then rinsed thoroughly. Adults expectorate but don’t rinse.

Rx: Stannous fluoride (0.4%) gel (Gel-Kam®)

Disp: 7 oz. tube
Sig: Brush first with conventional dentifrice. Rinse mouth and brush with water. Brush on
gel. Swish around--hold for one minute. Spit, but don't rinse. Go to bed with remnants
of gel on teeth

Decalcification reduction from one study:

Treated teeth - 25.6% new or increased decalcification
Untreated teeth - 64% decalcification

Compliance is a problem, but even compliance at a low level produces 50% reduction and 100%
compliance virtually eliminates the problem. Best recommendation is to do both office and home
application.

Safety

Chronic Toxic Effects

Occur with daily intake in excess of 4 to 5 mg fluoride.

First signs of overdose is tooth fluorosis ("snowcapping,", etc.).

20 to 80 mg/day X 10 to 20 years causes crippling osteosclerosis.

Acute Overdose
Occur with ingestion of 30 to 50 mg fluoride/kg body weight.

Recommended maximum one-time dispensed dosage of fluoride is 264 mg sodium fluoride or the
equivalent of 120 mg fluoride ion.

Lethal dose (70 kg adult) = 2.5 to 5 g.

Lethal dose for children (assuming proportional to body weight):

3 years - 500 mg
6 years - 750 mg
9 years - 1000 mg

Fluoride is a powerful metabolic inhibitor.

Fluoride is quickly absorbed by the body (plasma levels peak in 30 minutes).

Body disposes of fluoride quickly (a good prognosis if the patient survives four hours).
 89

Large nonlethal doses are tolerated without severe toxic symptoms.

One fatality has been reported from topical fluoride, the result of gross mismanagement.
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Safety with Topically Applied Fluoride

Use small amounts.

Use saliva ejector.

Remove all excess.

Warn patient/parent of possibility of vomiting after topical application and need to act quickly--
"don't try to make it home."

Safety with Home Fluoride

Give instructions carefully.

Try not to prescribe near a lethal dose.

The ADA recommends that no more than 120 mg be prescribed at any one time. Note that a tube
of PreviDent® 5000 Plus contains 255 mg fluoride. A four-month supply of 120 1 mg-tablets is
considered safe if accidental poisoning might occur. For example, if a three-year-old weighing
the average 15 kilograms should ingest the entire bottle of 120 tablets, he would receive a dose of
7 mg/kg or one-fifth the lethal dose.

If ingestion does occur, drink the recommended antidote--a glass of milk (the calcium will help
bind the fluoride ion), or use milk of magnesia (aluminum hydroxide).

Vomiting can be induced with Ipecac, but recently the use of Ipecac has been questioned by
American and European toxicology panels. Fluoride overdose itself usually causes vomiting, thus
negating the need for Ipecac in the first place. According to Colgates’s overdosage instructions
for PreviDent® 5000 Plus, if more than 5 mg fluoride/kg body weight (i.e., more than 2.3 mg
fluoride/lb body weight) have been ingested vomiting should be induced. For accidental ingestion
of more than 15 mg fluoride/kg of body weight (i.e., more than 6.9 mg fluoride/lb body weight),
induce vomiting and admit immediately to a hospital facility.

Refer to Kosair Children's Hospital Poison Control Center (589-8222).

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TOPIC: PEDIATRIC RESTORATIVE DENTISTRY

Reading Assignment

Pediatric Dentistry, Infancy Through Adolescence, 3rd Ed., Pinkham

Chapter 20 (pp. 296-308)
Chapter 21 (pp. 309-339)

Objectives: Upon completion of the reading assignment and attendance at class lecture, the
student should be able to:

1. describe at least five advantages for using the rubber dam;

2. describe appropriate clamps that should be selected and used for treating children and
adolescents;

3. describe the layout and punching of the rubber dam, including the number of teeth isolated
and hole location, spacing and size;

4. describe the steps in placing and removing a rubber dam;

5. describe the value of restoring primary and young permanent teeth;

6. describe or list the histomorphologic differences between primary and permanent teeth;

7. describe the differences in silver alloy preparation of primary and permanent teeth;

8. indicate the reason for the establishment of axial pulpal bevel and rounded internal line
angles.

9. describe instrumentation related to cavity preparation in primary teeth;

10. describe the preparation for a stainless steel crown;

11. describe the placement of back-to-back Class II amalgam restorations;

12. describe the reason for polishing amalgam restorations;

13. describe the reason for capping the cusps of primary molars;

14 describe the restoration of primary incisors and canines, including full coronal coverage.

There are no lecture notes for this topic. The required text and your Preclinical Pediatric Dentistry
Manual should provide more than adequate coverage of the topic.
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TOPIC: PULP THERAPY FOR THE PRIMARY DENTITION AND YOUNG

PERMANENT TEETH

Reading Assignment

Pediatric Dentistry, Infancy Through Adolescence, 3rd Ed., Pinkham

Chapter 22 (pp. 341-354)

Chapter 33 (pp. 522-530)

Objectives

Upon completion of the reading assignment and attendance at class lecture, the
student should be able to:

1. describe the differences between adult and child pulp therapy in regards to:

(a) physiology
(b) anatomy
(c) technique
(d) materials;

2. describe the steps of pulpal assessment of a primary tooth;

3. describe the armamentarium for and techniques of basic pulp protection;

4. describe the rationale and objectives of indirect pulp capping;

5. describe the indications and contraindications of indirect pulp capping of primary teeth;

6. describe the technique of indirect pulp capping;

7. describe the indications for pulp capping for primary teeth;

8. describe indications for and the current technique of the formocresol pulpotomy for
primary teeth;

9. describe in histological terms the pulp tissue's reaction to formocresol;

10. describe several adverse effects of formocresol;

11. describe the indications for pulpectomy and root canal fill of primary teeth;

12. describe the technique for pulpectomy and root canal fill of primary teeth;

13. describe the steps of pulpal assessment of a young permanent tooth;

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14. describe the indications for and technique of the following pulp treatment procedures on
young permanent teeth:

(a) caries control

(b) indirect pulp capping
(c) direct pulp capping
(d) formocresol pulpotomy
(e) apexogenesis
(f) apexification.
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Lecture Notes for Treatment of Deep Caries, Vital Pulp Exposure, and
Pulpless Teeth in the Child and Adolescent

Diagnostic Aids

History of Pain (pulpal or dentinal?)

1. First consideration for selection of teeth--mildly inflamed, chronically inflamed, or

necrotic?

2. History not as reliable an aid in primary teeth as in permanent. Children are not good
historians.

3. Toothache coincident with or immediately after a meal may not mean extensive pulpal
inflammation (dentinal).

4. Spontaneous discomfort at night indicates trouble (pulpal).

5. Duration of pain: short duration of pain after stimulus (hot or cold)-dentinal; long
duration of pain after stimulus (hot or cold)-pulpal

Clinical Signs and Symptoms of Irreversible Pulpitis

1. Gingival abscess--draining fistula

2. Abnormal tooth mobility

3. Sensitivity to percussion and pressure

4. Deep carious lesion (obvious pulpal involvement)

Radiographic Interpretation (more difficult for primary teeth than permanent teeth)

1. Periapical changes

2. Interradicular changes on primary molars

3. Thickened periodontal ligament

4. Resorption of roots (internal/external)--extraction if primary tooth

5. Depth of carious process

6. Presence of calcified bodies in pulp tissue showing chronic pulpal changes

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Pulp Testing

1. Pulp testers of questionable value due to child's apprehension

2. Ice and warm gutta percha probably best

3. Vital or non vital, but not degree of inflammation

4. Not valid immediately after trauma due to pulpal shock

Physical Condition of the Patient (chronically ill)

1. Healing response of pulp is compromised

2. Extraction after proper premeditation may be treatment of choice

3. Must weigh importance of retaining the involved tooth versus possibility of having a
chronic subacute infection

Evaluation of Treatment Prognosis before Pulp Therapy

Two Dimensions

1. Must weigh chance of successful pulp therapy

2. Value of tooth and associated problems with loss of tooth

3. Other factors to consider include the following:

a. level of patient and parent cooperation and motivation in receiving the treatment;

b. level of patient and parent desire and motivation in maintaining oral health and
hygiene;

c. caries activity of the individual and overall prognosis of oral rehabilitation;

d. dental development of the patient;

e. degree of difficulty anticipated in adequately performing pulp therapy

(instrumentation) in the particular case;

f. space management considerations resulting from previous extractions, pre-existing

malocclusion, ankylosis, congenitally missing teeth, and space loss caused by the
extensive carious destruction of teeth and subsequent drifting; and
 98

g. excessive extrusion of the pulpally involved tooth resulting from missing opposing
teeth.

Vital Pulp Therapy - Treatment of the Deep Carious Lesion - Indirect Pulp Cap

Rationale

1. About 75 percent of teeth with radiographic evidence of deep caries are found to have
pulp exposures clinically.

2. Ninety percent of asymptomatic teeth with deep carious lesions can successfully be
treated without pulp exposure, using indirect pulp therapy.

3. Indirect pulp capping is indicated when a deep curious lesion is encroaching upon, but
not actually into, the pulp. A zinc oxide-eugenol or a calcium hydroxide preparation is
used over the carious dentin. The intent is to stimulate the tooth to assist in its own
recovery from the near pulp exposure. The use of the indirect pulp cap method has been
disputed. Some clinicians believe all caries should be removed; others believe indirect
pulp capping should be limited to permanent teeth, and that young permanent teeth
with deep caries present the best indication for indirect pulp cap.

4. Objectives of Indirect Pulp Capping

a. Reversal of bacterial invasion

b. Treatment of carious dentin

c. Maintenance of normal healthy pulp

5. Justification

a. Reduction of hyperemia in pulp

b. Remineralization of carious or precarious dentin

c. Reduction of anaerobic bacteria

d. Formation of reparative dentin

e. Vital pulp maintenance

f. Continued normal root closure

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Selection of Teeth

1. Pain history

a. No extremes

b. May be associated with eating, especially carbohydrates

c. Sometimes dull

2. Clinical Examination

a. No gingival pathology

b. No mobility

c. Large carious lesion

3. Radiographic Examination

a. Probably carious exposure

b. Normal periapical tissues

4. Thus the ideal candidate would present with:

a. Normal periapical tissues

b. No evidence of coronal or apical pulp degeneration

c. Probable pulp exposure if complete removal of all carious dentin

Procedure

1. Administer local anesthesia.

2. Isolate the area with a rubber dam.

3. Use an F.G. #330 bur to open the carious area. Remove all unsupported enamel. The
preparation is extended as dictated by the carious process.

4. Use a #4, #6, or #8 carbide bur (slow speed) to remove various dentin (clearing from
the dentino-enamel junction toward and to within 1 mm of the pulpal chamber. Do not
expose the pulp. Pulp morphology knowledge is important. If hand instruments are
used, a large spoon excavator is the instrument of choice.

5. Keep in mind as you progress toward the pulp chamber that

a. the outermost layer of dentin will be mushy, necrotic tissue;

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b. the next layer will be leathery but firmer;

c. the last 1 mm of dentin is left--the "indirect pulp cap" portion of the curious dentin.

6 A calcium hydroxide base is applied over the last 1 mm of carious dentin. Dycal (base
and catalyst or VLC), mixing spatula pad, and applicator are needed.

7. With an application instrument, apply calcium hydroxide paste over carious dentin
remaining. Apply Dycal to the rest of the deeper portions of the cavity preparations.

8. Using an amalgam plugger or a plastic instrument, place base of reinforced ZOE (IRM)
over the calcium hydroxide liner. Adapt the material when in a plastic state to represent
as typical a cavity preparation as possible.

9. Remove excessive Dycal or zinc oxide-eugenol from the margins of the cavity
preparation. A 169L bur or a hand instrument is used; if not, marginal voids will occur
in the amalgam. Coat with dentin primer and adhesive bonding agent..

10. Restore with silver amalgam or composite. If the tooth is beyond the physical
limitations of these materials, a stainless steel crown is indicated.

11. Establish a recall time/appointment. The radiograph represents the final indirect pulp
capping procedure.

Re-Entry

The re-entry restorative procedure is still questionable. Research has shown that carious dentin
will remineralize with the restoration. It is the opinion of these authors that if "all systems are go"
on recall, the restoration should not be redone. Thus, if the tooth is asymptomatic and the recall
radiograph shows a layer of secondary dentin, re-entry is not necessary.

If re-entry is decided upon:

1. Use anesthesia and a rubber dam.

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2. Remove the amalgam or temporary restoration.

3. Remove ZOE and calcium hydroxide base with a round bur.

4. Remove "flaky" and "fluffy" material.

5. Remove any caries left. Care should be taken not to expose the pulp tissue after all this
time and effort.

6. Place a base and coat the preparation with dentin primer and bonding adhesive.

7. Restore the tooth with a silver amalgam, composite resin, or a stainless steel crown.

Direct Pulp Cap

Definition

Direct pulp capping is the placement of a Ca(OH)2 (permanent) or ZOE (primary) preparation on
a small (pinpoint) pulp exposure.

Rationale

Pulp vitality can be maintained by stimulating repair of pinpoint exposures.

Selection of Teeth

1. Mechanical exposure or carious exposure surrounded by sound dentin under rubber

dam (less than 1 mm) or relatively uncontaminated fresh traumatic exposures.

2. No previous history of pain with possible exception of pain caused by the intake of
food (dentinal pain).

3. Lack of bleeding or an amount considered normal in the absence of a hyperemic or an

inflamed pulp.

4. Due to normal aging of the dental pulp, chances of success decreases with age due to
diminished blood supply.

5. Primary or permanent dentition

a. Primary teeth--reserved only for mechanical exposures. Pulpotomy procedure

much more successful and procedure time similar, thus carious exposures should
not be capped.

b. Young permanent teeth generally agreed a good indication.

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c. Mature permanent teeth - disagreement - many fear continued inflammation and

continued calcification that eventually renders canals non-negotiable.

6. Location of exposure important - capping not indicated if pulp tissue likely to be

trapped without access to blood supply (example: axial wall exposure).

7. Economics, time, and difficulty of achieving root canal filling may lead to choice of
pulp capping.

Medication

1. Calcium hydroxide is medicament of choice for permanent teeth.

a. Induces necrosis of adjacent pulp tissue and inflammation of continuous tissue.

b. Induces formation of secondary dentin bridge over amputation site at junction of

the necrotic tissue and the vital inflamed tissue. Exact mechanism is not
understood.

c. Study has shown calcium for the dentin bridge comes from the bloodstream, not the
Ca(OH)2.

d. Commercially available compounds (Dycal, Life, Pulpdent) are less alkaline and
thus less caustic to the pulp.

e. Induces internal resorption in primary teeth.

2. ZOE contraindicated except for primary teeth

a. No bridge formation.

b. Success rates not as high as Ca(OH)2.

Procedure

1. Administer local anesthetic.

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2. Isolate teeth with rubber dam.

3. If exposure is due to traumatic injury, the site may be gently flushed of debris using
normal saline or 2% hydrogen peroxide solution.

4. Keep a sterile, moist cotton pellet on exposure until bleeding stops and capping
material is ready. Gently dry exposure site with a sterile cotton pellet.

5. Apply capping material. To avoid pressure on pulp tissue, use a thin, creamy mix and
start by tracing the material around the outline of the exposure. Let the material flow
over exposure on its own, then flow material over the center of exposure.

6. Protect capping material by the application of a cement base on the top of the capping
material. If the capping material is a hard-setting material, for example, Dycal, this step
may not be required.

7. Restore tooth with a permanent restoration.

Evaluation

Evaluate treated tooth after a minimum of two months, but not more than six months after
treatment. Criteria for success are as follows:

1. Absence of clinical signs or symptoms of inflammation.

2. Radiographic evidence of favorable response, for example, dentin bridge formation.

3. No radiographic evidence of sequelae to pulpal pathosis.

Vital Pulp Therapy

Definition pulpotomy is the procedure of removing the coronal part of the pulp that has
been involved by dental caries.
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Justification the justification for this procedure is that the coronal pulp tissue, which is
adjacent to the carious exposure, usually contains microorganisms and shows
evidence of inflammation and degenerative change. The abnormal tissue can be
removed, and healing can be allowed to take place at the entrance of the pulp
canal in an area of essentially normal pulp. This allows pulp tissue in the root
canal to remain vital and maintain the tooth in the dental arch.

Types In recent years, two general types of material have been used most often as
dressings for the capping of amputated pulp stumps. One material is calcium
hydroxide; the other is zinc oxide-eugenol to which a small amount of
formocresol may be added. Laboratory and clinical observations indicate that a
different technique and capping material are necessary in the treatment of
primary teeth from those used for permanent teeth. As a result of these
observations, two specific pulpotomy techniques have evolved and are in general
use today.

Calcium Hydroxide Pulpotomy

Indications

1. Permanent tooth with carious pulp exposure when there is a pathologic change in the
pulp at the exposure site.

2. Permanent tooth with a pulp exposure resulting from crown fracture when trauma has
also produced a fracture of the same tooth.

3. Permanent teeth with immature root development but with healthy pulp tissue in the
root canals.

4. Tooth free of symptoms of painful pulpitis.

Procedure (single appointment)

1. Amputation of coronal portion of the pulp.

2. Control of hemorrhage.

3. Placement of a layer of zinc oxide-eugenol over calcium hydroxide to provide an

adequate seal.

4. Tooth prepared for full coverage.

5. If tissue in the pulp canals appears hyperemic after amputation of coronal tissue, a
pulpotomy is contraindicated and endodontic treatment is indicated.
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Formocresol Pulpotomy

Indications

1. Teeth - primary teeth, permanent molars where economics is a factor; pain history - no
extremes.

2. Clinical examination - no gingival pathology or evidence of a chronic fistulous tract; no

extreme mobility of the tooth; or curious lesion.

3. Radiographic Examination - probable carious exposure; normal interradicular

periapical tissues; normal root development; and no internal/ external root resorption.

Procedure (single appointment)

1. Use local anesthesia. A well-anesthetized tooth is essential. In rare instances due to

chronic inflammation, this may be a problem. A few drops of local anesthesia solution
cautiously injected directly into the pulp can be of assistance in these instances.

2. Apply a rubber dam (formocresol is a very caustic drug).

3. Treat pulpotomy as a "clean" procedure. When doing pulp therapy procedures, keep in
mind that a sterile technique is very difficult to maintain. Emphasize a so-called "clean"
procedure, realizing that a sterile condition is ideal but not realistic.

4. There are optimum locations for occlusal openings in primary teeth. Openings are
related to dental and pulp morphology. All coronal pulp tissue should be removed.

5. Place a #330 bur in the high-speed handpiece. Gain occlusal access to the pulp chamber
by preparing a Class I cavity preparation. It is better to make too large an opening than
one too small. Remove all overhanging enamel.

6. Use a "sterile" #4 or #6 round bur (slow speed) to remove all curious dentin. If
possible, all carious dentin is removed before exposing pulp horns.

7. Visualize where the pulp horns should be beneath the pulpal wall (or floor). With a
slow or high speed bur, connect the pulp horns taking care not to perforate the floor of
the pulp chamber. Excise the pulp tissue to the orifices of the root canal.

8. Use a large spoon excavator to remove any remaining pulp tissue. The pulp tissue
should be amputated to the entrance of the root canals. Gently wash out the debris with
water syringe.

9. After completing the amputation, evaluate the hemorrhage. If pulp tissue has been
removed completely, hemorrhage should be minimal. Treating a vital pulp with
minimal chronic inflammation should result in hemostasis in three to five minutes. If
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there is chronic hemorrhage, check for remaining pulp tissue. If there is purulent
exudate, a fibrotic pulp, or uncontrollable hemorrhage, alternate pulp procedures
should be considered.

10. Over the exposed pulp stump, place a sterile cotton pellet moistened (lightly blotted--
not saturated) with formocresol (1/5 dilution) using cotton forceps. Place a dry pellet
over the first pellet to maintain maximum contact of the formocresol with pulp tissue.
Formocresol is very caustic. Leave formocresol in place for five minutes. Then remove
pellet; the pulp stump should appear blackish-brown. If there is bleeding, check for
residual pulp tissue. Re-apply formocresol for two to three minutes. Fill pulp chamber
to about half its volume with a thick mixture of zinc oxide-eugenol. Some clinicians
advocate adding equal drops of formocresol to the eugenol, then mixing with zinc-
oxide powder. Beaver et al., 1966, found this an unnecessary step.

11. Prepare tooth for a stainless steel crown. Teeth where pulp therapy has been done seem
to be brittle. This may be caused by removal of tooth structure or a change in the
physical properties of the enamel or dentin after removal of the coronal portion of the
pulp. A stainless steel crown is the restoration of choice. In certain cases, a bonded
composite restoration is an alternative.

Summary of Pulpotomy Studies

Clinical and radiographic studies of formocresol pulpotomies report a high rate of success
compared to other conventional pulpotomy methods--over 95 percent clinical success. Calcium
hydroxide pulpotomies done on primary teeth have a lower success rate (61 percent) than did
formocresol. The culprit was internal root resorption.

Length of application of formocresol does not increase or decrease success.

A 1/5 dilution of formocresol is optimum. A greater concentration may cause adverse pulpal
responses. The recommended way of diluting formocresol (L. H. Straffon et al., 1972) is as
follows:

Buckley formocresol; Crosby Labs; Burbank, California.

To make 1/5 FC (20%)

1. Dilute 3 parts glycerin with 1 part distilled sterile water; mix well.

2. Add 1 part FC to 4 parts diluent:

90 ml glycerin
30 ml water
--------------------
120 ml

Add 30 ml FC to 120 ml diluent to obtain 150 ml dilute FC 1/5 strength.

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When evaluated histologically, the formocresol pulpotomy causes various degrees of chronic
inflammatory tissue.

Other medicaments have been substituted for formocresol, e.g., ferric sulfate, gluteraldehyde and
metacresyl acetate. Ferric sulfate 15.5% (Astringedent®) for 10 to 15 seconds followed by ZOE
appears most promising. This is basically a ZOE pulpotomy with ferric sulfate being used for
hemostasis. What few clinical studies have been done demonstrate success rates comparable to
formocresol pulpotomies.

Failure

Indications of failure include increased mobility, fistulous tract, premature exfoliation,

radiographic evidence of interradicular/periapical radiolucency, and internal/external root
resorption.

Cause is probably poor diagnosis and treatment selection.

Non-Vital Pulp Therapy - Pulpectomy

Definition complete removal of necrotic pulp tissue from the root canals and coronal portion
of non-vital primary teeth to maintain a tooth in the dental arch.

Justification removal of diseased tissue and space management.

Indications pulpectomy is usually limited to traumatized primary incisors with resultant

pathology (under age 4-4 1/2) and primary second molars before eruption of six-
year molars. These teeth demonstrate:

1. Dry pulp chamber when tooth is opened;

2. Excessive hemorrhage at pulp stump when attempting pulpotomy (cannot be controlled

with moist cotton pellet);

3. Intraradicular bony involvement without loss of support;

4. Internal resorption that does not perforate root;

5. Continued adverse signs or symptoms following pulpotomy procedure; and

6. Not more than one-third root resorption.

Contraindications
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1. Extensive periapical involvement or mobility.

2. Extensive resorption of root of primary tooth.

3. Internal resorption, which due to the thinness of the furcation area would already
invariably perforate allowing the inflammation process communication with the oral
cavity through the attachment mechanism. This destruction of the periodontal
attachment leads to further resorption and loss of the tooth.

4. Threat of involvement of developing permanent tooth by infectious process.

5. Uncontrollable patient behavior when sedation or hospitalization is not possible.

6. A tooth that is non-restorable. When pulpectomy is contraindicated, the tooth should be

removed and space maintenance should be considered. NOTE: If the tooth is left
untreated, pathologic sequelae may follow:

a. Abscess;

b. Granuloma or cyst;

c. Osteomyelitis;

d. Interruption of normal development and eruption of succedaneous tooth; and

e. Systemic effects as a result of chronic infection.

Pulpectomy Procedure For Primary Molars

The principle roadblock to pulpectomy success is the multiple tortuous root canals in primary
teeth. Because of various morphologic configurations in the primary dentition, mechanical
debridement and subsequent filling is difficult. Another difficulty is the apparent connection
between the coronal pulp floor and the interradicular area. Foramina allow necrotic products to
pass into the bi- or trifurcation area. This is the apparent explanation for the usual occurrence of
pathology in the interradicular area of primary teeth.

1. Use local anesthesia and isolate with a rubber dam.

2. Prepare a cavity preparation as dictated by caries.

3. Use a large round bur to remove the remaining caries and the debris in the pulp
chamber. Extreme care should be exercised to not perforate the floor of the pulp
chamber. Check that all coronal pulp tissue has been removed.

4. After opening the pulp chamber, evaluate hemorrhage or purulent exudate. If

hemorrhage is bluish or there is difficulty controlling the bleeding after five minutes,
then pulp is chronically inflamed. If there is evidence of necrotic tissue breakdown with
accompanying suppuration, a pulpectomy is indicated,
110

5. With an endodontic file, remove diseased pulp tissue from all canals. As file is being
withdrawn, it carries pulpal material with it. Using irrigation, start with file size #15
and finish with a #35. In primary teeth as compared to permanent teeth, filing is only to
remove pulp tissue, not enlarge pulp canals. If a point of resistance is encountered, do
not attempt to go beyond this point. Because of tortuous root canals in the primary
dentition, it will probably be impossible to remove all the remaining tissue. Note: It is
not necessary to take an X-ray to determine file length as is done in permanent teeth
endodontic procedures.

6. Irrigate canals with an oxidizing agent. Dry the canals with cotton pellets and paper
points. Never put air directly into a pulp canal. Repeatedly irrigate canals with an
oxidizing agent. Gently rinse the canals with water, drying with cotton pellets and
paper points. (At this point, some clinicians recommend application of a cotton pellet
with either formocresol or monochlorophenol for a period of five minutes to seven
days, filling the canals at a subsequent appointment if the patient presents no signs or
symptoms of inflammation.)

7. If hemorrhage is controlled and canals are dry, the canals can be filled with a zinc
oxide-eugenol cement. It is mixed on a pad, lifted with an amalgam carrier, and
inserted into the pulp chamber. The zinc oxide-eugenol cement should not have an
accelerator so as to allow adequate working time. Zinc oxide is a resorbable material
that will allow the tooth to exfoliate normally.

8. There are three techniques of packing:

Plugger Technique - use an amalgam plugger and constantly apply pressure to pack
the zinc oxide-eugenol cement into the canals. Condensing pressure applied to the
mass of zinc oxide-eugenol forces it into the root canals. An alternate method: use
a thin mix of zinc oxide-eugenol cement on a file or paper point and place in the
pulp canals. Shape a thick mix of zinc oxide-eugenol in a cone and pack in the
canals, using a moist cotton pellet as the condenser.

Lentulo Spiral Technique - the Lentulo Spiral method is simple and

unsophisticated. Rotate spiral slowly with fingers or slow-speed handpiece to
introduce filling material into canal. One disadvantage, especially in unskilled
hands, is the possibility of trapping air in the canal.

Pressure Syringe Technique - the pressure syringe consists of a barrel, screw-type

plungers, two wrenches and an assortment of needles ranging in size from 13 to 30
gauge. A needle is selected that fits the canals to approximately 2 mm short of the
apex; it may be bent for ease of accessibility and for reference. The filling paste is
inserted into the hub of the needle, and the needle is tightened onto the barrel with
the two wrenches. The screw plunger is then inserted and rotated until the material
starts to extrude. The needle is inserted into the root canal until resistance is felt.
The material is expressed while the syringe as slowly withdrawn. Its advantages
are:

a. the apical portion of the canal is filled first and the coronal portion last
(prevents voids in the canal);
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b. there is less chance of trapping air, which prevents complete obliteration of

the canal;

c. there is even control of the amount and extent of deposition of the material;

The 300 psi that is developed within the instrument allows a thick putty-like
consistency of the mix to be extruded with ease. At the same time, no undue
pressure against the canal walls is exerted.

After root canal obliteration, the root canal filling is sealed with a fortified zinc oxide-
eugenol paste, zinc oxyphosphate cement, or alloy.

Tooth is restored with a stainless steel crown.

Patient is routinely recalled, and tooth is checked each time.

9. Obtain a periapical X-ray to be certain that canals are filled with zinc oxide-eugenol.
Due to calcification of the pulp canals, the zinc oxide-eugenol may not reach the apex.
But, these teeth often remain in function until the first permanent molar erupts.

10. A completed pulpectomy procedure includes:

a. a ZOE filled pulp chamber and root canals and

b. a stainless steel crown.

11. Place patient on a periodic recall program to evaluate the success of the procedure.
Teeth that are symptom-free clinically and radiographically with exfoliation within
normal time limits are considered successful.

Pulpectomy Procedure for Primary Anterior Teeth - process is similar to posterior primary
teeth.

1. Isolate with a rubber dam and open into pulp chamber with a #330 high-speed bur.

With a #15 endodontic file, remove diseased pulp tissue. Use as large a file as dictated
by the size of the canal. A rubber stopper is used as a marker.

3. Irrigate canal gently with a solution of sodium hypochlorite.

4. Dry canal with paper points and cotton pellets.

5. Use a thick mix of zinc oxide-eugenol cement in the canal. A large endodontic
condenser or amalgam plugger is applied to pack the cement up the canal. Again, zinc
oxide-eugenol cement does not have an accelerator. To check the success of the
procedure, obtain a periapical X-ray. A pressure syringe can also be used to inject zinc
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oxide material into the canals. A thin mix of material is injected into the canals
followed by condensation of a thicker mix with a suitable instrument.

6. Restore with a restoration such as a stainless steel crown or composite-type crown.

Zinc oxide-eugenol paste has been condensed to the apices of the central incisors. The
teeth should be evaluated periodically for normal exfoliation.

Non-Vital Pulp Therapy - Apexification

Definition and Indication

Treatment of non-vital permanent maxillary incisors and first molars with incomplete apex
formation is termed "apexification" or "root end closure." Anterior and posterior permanent teeth
may become non-vital before apical closure. There is frequently evidence of a periapical lesion.
In these instances where vital pulpotomy techniques are not successful for immature permanent
teeth, apexification is indicated. The purpose is to stimulate root closure of the apex so a
conventional endodontic procedure with gutta percha can be completed. Frank (1966) was one of
the first to describe the clinical methods using a calcium hydroxide paste and camphorated
monochlorophenol (CMCP) as have Steiner and co-workers (1968) to stimulate root closure.

It is important to note that while apexification is a highly successful treatment, every effort
should be made to maintain the tooth's vitality to allow for the maximum amount of root length to
occur. Thus, indirect pulp therapy, vital pulp capping, and pulpotomy techniques which have
proved successful when aided by the greater blood supply that is present with an open apex
should be tried first if there is the possibility of success. However, once the tooth becomes
pulpless or periapical pathology has developed, apexification is the preferred treatment.

Also, remember that radiographic evidence of apical closure can be misleading, as the radiograph
normally details the mesiodistal plane of the root canal while the faciolingual aspect of the root is
usually the last to become convergent.

Procedure

1. After applying a rubber dam, gain access through the lingual portion of the crown of
the tooth.

2. Using large reamers and files, remove debris from coronal half of the pulp. Establish
file length radiographically.

3. Clean the canal, irrigate, and dry with a paper point. Repeated gentle use of sodium
hypochlorite assists debris removal. Avoid forcing infected contents apically as they
may be forced out into periapical area.

4. Seal a pellet of camphorated monochlorophenol in the pulp chamber with a temporary

restorative material.
 113

5. On recall, in one to two weeks, remove temporary and clean the canal.

6. Take care to avoid any instrumentation of the thin walls of the root near the apex.

7. Mix a paste of Ca(0H)2 and CMCP on a glass slab. Carry paste to the canal and force it
into the apex with a large plugger or cone-shaped instrument. The initial objective is to
fill the canal completely and obturate it with paste. Obtain a radiograph to check the
accuracy of the root canal filling.

8. On six to nine month recall, you should see radiographic evidence of apical closure.
Weine (1976) noted five alternatives evident at this time:

a. there is no apparent apex closure, but there is a resistance point when a file is
inserted;

b. radiographic evidence of a calcified bridge at the apex;

c. apical closure without canal space changes;

d. normal continuance of apical closure, and;

e. increased radiographic evidence of a pathologic apical change.

9. When apical closure is accomplished, the root canal filling is completed.

10. If apexification has not been completed, then cleaning and re-insertion of a Ca(OH)2
and CMCP paste is repeated. Some authors advocate irrigation and replacement every
three months.
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PAST EXAMPLES OF MIDTERM & FINAL EXAMS

Note: There is no guarantee that future exams will be in this format, however the information
emphasized on these tests is representative and you would be wise to know this information.
There will also be slide exam questions. The format of the midterm and the final exam will be
announced the week prior to the date of the exam.