Advanced Peds

Intrusion injuries: tx

Pulp coverage Reposition - May allow to re-erupt if open apex - Ortho for delayed treatment - Surgical if acute and ½ crown - >7mm will require RCT

Tell-show-do rules

First name Truthful Short simple words Answer questions Brief , clear instructions Explain what is going to be done Positive suggestions Avoid words as pain and hurt Praise and encouragement Do not threaten or scold Engage child in conversation with questions Age appropriate language "Do not let your voice betray your emotions" Give time to understand instructions Avoid instructions by parent Silent helper Try to understand the child, talk to him as an intelligent individual

Motrin dosage

Forms Tablet: 100mg, 200mg, 400mg, 600mg,800mg Chewable tablet: 50mg, 100mg Suspension: 100mg/5mL Usual Dosage Children: 4-10mg/kg/day Adults:400-800mg/dose. MDD=3.2g

Nitrous Oxide/Oxygen Inhalation Behavioral Responses

•Improves success of hypnotic suggestion - (use of imagery and story telling) •Improves behavior over sequential visits •Decreases incidence of adverse behaviors

Nitrous Oxide/Oxygen Inhalation Physiological Responses

•Increased muscle (and sphincter) relaxation •Decreased RR and PR slightly - (negative chronotropic effect) •Increased cardiac stroke volume - (positive inotropic effect) •No effect on SaO2 or breath sounds

Susceptibility of Teeth to Pit and Fissure Caries

1st & 2nd Permanent molars Primary molars Premolars Permanent maxillary incisors

Silver Diamine Fluoride (SDF)

38 percent SDF is FDA approved as a desensitizing agent. 5% F - 44,800 ppm F Research is currently being conducted on caries-arresting property of SDF. Analysis of the data so far suggests that the application of SDF, applied 1x or 2x per yr, can significantly arrest active caries, significantly reduce the incidence of new caries, and does not substantially increase the risk of adverse events. Researchers also recognized that it can blacken carious lesions (but not sound tooth surfaces). Low cost of treatment Less invasive clinically and in terms of behavior guidance requirements AAPD supports the use of 38% SDF for the arrest of cavitated caries lesions in primary teeth as part of a comprehensive caries management program. Benefits of SDF application in the target populations outweigh its possible undesirable effects (unaesthetic staining of teeth).

Decidous molar hypomineralization and molar incisor hypomineralization

9% in primary dentition Second primary molars more affected Higher caries rate High correlation of MIH in permanent molars

Desensitization

A behavioral therapy based on the premise that specific maladaptive behaviors can be replaced with more appropriate, functional behaviors Involves a gradual introduction to fearful situations. Through a combination of familiarity & relaxation techniques, the patient learns to cope with the specific stressful procedures

Mucoceles

A mucocele or mucous retention cyst is a benign pathologic lesion This lesion is a result of the extravasations of saliva from an injured minor salivary gland Collection of extravasated fluid develops a fibrous wall around itself forming a pseudocyst Lesion can fluctuate in size depending on its fluid filled state A decrease in lesion size is frequently associated with a history of drainage of a thick viscous liquid The lesion is non-painful, soft, doughy and fluctuant to palpation Lesions of longer duration may appear firmer and fibrotic, resembling a fibroma The lower lip is the most common location for a mucocele Excising a mucocele is to remove the fibrous capsule and any associated minor salivary glands surrounding the pathology Anesthesia, excision, hemostasis with suture are all included in treatment

Indications for use of physical restraint sped

A patient who is unable to cooperate due to lack of maturity. A patient who is unable to cooperate due to mental or physical disability. In situations when the safety of the patient or practitioner would be at risk without protective use of restraint.

Ranula

A ranula is a mucous retention cyst that occurs in the floor of the mouth and is associated with the sublingual gland. A ranula inn a young pediatric patient needs to be differentiated from a lymphatic malformation A ranula may be managed by marsupialization or excision of the sublingual gland. Many surgeons initally manage a ranula with marsupialization and perform excision secondarily in the ranula recurs There is a high incidence of recurrence with a ranula Referral to an Oral Surgeon is suggested for successful management of the lesion

Injuries in the primary dentition

Abrasion of Soft tissue Luxation injuries 1. Concussion No change in position 2. Subluxation Mobile, not displaced 3. Lateral Luxation Displaced, not axially 4. Intrusion Apical displaced -The most dangerous as it can impact the permanent tooth beneath 5. Extrusion Treatment based on amount and direction of displacement Prognosis based on apical formation and extra-oral time

Physical limitations

Adaptive hygiene devices Teaching parents and other caregivers to assist with oral hygiene

Frenectomy

Age to perform - After permanent canines erupted unless there is a speech impact or clefting (diastema formation)

Talon cusp

Alternative terminology - T cingulum, Y-shaped cingulum. Frequency - Primary dentition: almost unknown Permanent dentition - 1-2%

Syndroms associated with hyperdontia

Aperts Cleidocranial Dysplasia Gardners Syndrome Crouzon Syndroms Orofaciladigital Syndrome 1 Hallerman Streiff Apert Cherubism Downs

Atraumatic/alternative restorative techniques

Atraumatic/alternative restorative techniques (ART) is endorsed by the World Health Organization as a means of restoring and preventing caries in populations with little access to traditional dental care. In many countries, practitioners provide treatment in nontraditional settings and circumstances do not allow for follow-up care. ART serves as a definitive restoration

The basic principles of selecting forceps are as follows:

Beaks of the forceps should adapt to the root surface of the tooth The beaks of the forceps when positioned and engaging the tooth should be parallel to the long axis of the tooth The size of the beaks of the forceps should be small enough not to engage the adjacent teeth during luxation and removal of the tooth The first force applied by the dentist when using forceps is apically directed expanding the alveolus Rapid jerking movements are ineffective Slow expansion of buccal and lingual alveolar bone Rotational forces may be applied for conical roots as in primary anteriors.

Dentin dysplasia type II

DD ll - Amber color - Bulbous crowns - Pulp stones - Thistle-tube shape pulp - Do not abscess

Enamel defects: systemic factors

Birth-related trauma - premature, hypoxia, breech - multiple birth, labor Chemicals - Anti-neoplastic chemotherapy - Fluoride, lead, tetracycline, thalidomide, vitamin D Infections: - chicken pox, measles, rubella, syphilis, cytomegalovirus - gastrointestinal, pneumonia, respiratory infections, tetanus Malnutrition: - Generalized malnutrition - Vitamin D deficiency, Vitamin A deficiency Genetic Inherited diseases Metabolic disorders - cardiac disease, celiac disease, diabetes, gastrointestinal malabsorption, hepatobiliary disease, hyperbilirubinemia, hypocalcemia, hypothyroidism, hypoparathyroidism Neurologic disorders - cerebral palsy - mental retardation - sensorineural hearing defects Celiac Disease Defects will appear on most teeth correlating with chronologic deposition of enamel. Often normal enamel is deposited after defect

Space Available

Break arch into series of straight line segments Start mesial to 6s Stay near contact points Sum of segments= space available

Recommendations for At-Home Therapy

Brush 2x -3x/ day with a fluoride dentifrice Flossing in children 7 y.o. and up (not shown to decrease interproximal lesions) Extra protection may be recommended in the form of OTC daily fluoride rinse and prescriptive fluorides such as PhosFlur or Prevident 5000 preparations

Risk Assessment of Individuals (caries)

Caries history in primary & permanent teeth Previous dental use Use of preventive practices Family and medical history Changes in habits, health status & medication influence caries risk Can change within same patient from time to time

Primary herpes simplex

Cause: HSV-1 (90%), HSV-2 Gingivostomatitis, and pharyngitis Peak age: 2-3 yrs; 20% Ab+ age 5; 30% teens Direct contact, saliva; asymptomatic viral shedding Oropharyngeal, anogenital & cutaneous Duration: 5-14 days; inoculation: 1 wk -1-26 days Acute onset, fever, lymphadenopathy, painful, erythema, vesicles, ulcers, drooling Complication: 2° infection

Aplasia

Causes - Failure of induction - Abnormal lamina - Space deficiency - Obstruction - Genetic 1. Syndromes 2. Nonsyndromic- PAX9, MSX1, AX1N2... Primary dentition - < 1 % Usually anterior tooth Strong correlation missing permanent tooth Permanent dentition - 2-9% - 1 Male: 1.4 Female - Third molars> mandibular second premolars > maxillary laterals> maxillary second premolars (( 8, 5, 2, 5) -Numbers based on non-universal system -8= third molars -5= man second pre -2 = max lat -5 = max second pre Problems ? Timing Space management Orthodontic tx

General recommendation regarding permanent dentition trauma

Clinical Examination Radiographic Examination - PA, Occlusal, PA with lateral angulations Antibiotic use - Not routinely - Soft tissue Sensibility testing Splint - Short term non-rigid (flexible) splint Immature vs. Mature Permanent - Conservative therapy - Revascularize/ regenerate

Restoration for Dentin Caries

Clinical evidence of progression to dentin changes in color, opacity, translucency Radiographic evidence of dentin caries Conservative preparation Alternative methods are now coming into use as well

Primary HSV: when to treat

Cochrane Review: Weak positive evidence Early infections - the first 3 days Severe cases with extensive skin lesions Cases with periorbital or ocular lesions Immunosuppressive drugs, steroids Children who are immunocompromised Multiple siblings who are close in age? Caution with renal disease, dehydration

Cinnamon contact stomatitis

Common allergy from cinnamon oil Sources: Ice cream, soft drinks, gum, candy, toothpaste, breath freshener, mouthwashes, dental floss Gingiva, lips, buccal mucosa, tongue White shaggy patches with erythema; chapped lips; red, swollen gingiva; burning sensation TX: DC product - resolve in 1 week - topical steroids, if severe

Fibroma and pyogenic granuloma

Common lesions found in the pediatric patient included both the fibroma and pyogenic granuloma If the lesion is small, it may be excised completely and the specimen submitted for histological evaluation. This can usually be accomplished by making an elliptical incision within normal tissue around the lesion The depth of the dissection is determined by the appearance and feel of the lesion. Minor modifications to this basic technique are dependent on the differential diagnosis. For example, removal of the interproximal tissue and scaling of teeth may be indicated when excising a pyogenic granuloma to ensure complete removal and minimize recurrence

Fractures in the primary dentition

Crown Fracture - Infraction - Vertical fracture - Horizontal fracture Root Fracture Alveolar Fracture Facial bone fractures - Atypical with routine injury - Abuse - MVA

Enamel Development and Defects

Crowns of the primary dentition begin to mineralize at approximately the 14th week of gestation and continues until 12 months of age. Development of the crowns of the permanent dentition occurs from approximately birth to 15 years of age. Damage to the developing tooth correlates with the area of ameloblastic activity at the time of injury Systemic vs. Localized

Dentin dysplasia type I

DD l - Normal color and shape - Rootless teeth- short, blunted roots - Periapical abscess, related to anatomy of dentin tubules - Endodontics

Determination of optimum time for surgical removal of anterior supernumerary teeth

Delay beyond 10 years causes more defects Root resorption of adjacent incisors was most common effect Removal before 6-7 years led to fewer effects

Dental sequelae of XLH/VDRR

Delayed dental eruption Spontaneous (non-carious) abscesses - enlarged pulp chambers - high pulp horns - limited mineralization of dentin - dentinal/enamel clefts Decreased lamina dura Taurodontism

Radiographic eval of trauma

Dental Development Periodontal membrane space Proximity of fracture to the pulp Root fracture Alveolar fracture Foreign body presence Bony fractures maxilla, mandible, symphisis, condyle Record for future comparison Soft tissue film at 1/4 exposure Lateral film: exposure 1.5-2 times intraoral exposure (pictured)

Dentin defects differential: Dentin dysplasia

Dentin Dysplasia - AD - 1:100,000 DD l - Normal color and shape - Rootless teeth- short, blunted roots - Periapical abscess, related to anatomy of dentin tubules - Endodontics DD ll - Amber color - Bulbous crowns - Pulp stones - Thistle-tube shape pulp - Do not abscess

Dentinogenesis imperfecta

Diagnosis - 1:8,000 Child abuse ? Shields 1 - OI Shields 2 - most common Shields 3 - rare

Leeway Space

Difference between the size of the primary first and second molars and their permanent successors (premolars) Maxilla- 1.7 mm Mandible- 4.0 mm Mesiodistal differential in size between first and second molars and their permanent successors (premolars) -Maxilla: 1.7mm (0.85mm/quad) -Mandible: 4.0mm (2.0mm/quad) Leeway space is smaller in the maxilla than the mandible

Sequalae to succedaneous dentition from primary trauma

Discoloration Hypoplasia Crown Dilaceration Root Dilaceration Ankylosis Cessation of formation Delayed eruption

Gingival overgrowth

Drug-induced gingival overgrowth Hereditary gingival fibromatosis Neurofibromatosis I Leukemic gingival infiltrates Gingival hyperplasia as a manifestation of Hodgkin's lymphoma

Intrinsic color staining

Drugs Tetracyclines Systemic disease Dentition - AI - DI - DD Fluorosis Trauma

Syndromes associated with hypodontia

Ectodermal dysplasias - X-linked hypohydrotic most usual Chrondroectodermal dysplasia (Ellis van Creveld) Incontinentia pigmenti Ehlers-Danlos Goldenhar Gorlin Tricho Dento Osseous Downs syndrome Orofacial digital syndrome l Craniofacial dysostosis (Crouzon's) Achondroplasia Hallerman-Streiff Williams syndrome

Permanent dentition trauma considerations

Etiology of trauma - Group Sports - Individual Sports - Motor Vehicles Stage of tooth development - Apical status Vitality of tooth - Prevention - Car restraints - Helmet/ Face mask - Mouth guards - Early orthodontics

Office-based pediatric dentistry surgical procedures

Exodontia Frenectomy Medical and surgical management of odontogenic infections Enucleation of an odontoma Hard tissue or soft tissue pathology Clean technique or sterile conditions?

Replant timing for avlusion

Extra-oral dry time < 1 hour - Replant immediately Extra-oral dry time>1 hour - Topical treatment of root surface to disinfect - Doxycycline - Fluoride - Replant

Barriers to oral health care access

Financial - Many individuals with developmental disabilities are covered by Medicaid Behavioral Lack of dentists who have received education and/or clinical training in providing care for persons with DD

Splint therapy for avulsion

Flexible splint 1-2 week - Monofilament line - Composite with passive wire - Ortho brackets (Must have passive wire) May require up to 2 weeks NO Rigid splints -Splint should be flexible and used for as short a time as possible Alternative splints -Passive wire -Spot bond <24hrs Rigid splint or excessive time may lead to root resorption

Preventive Regimen

Fluoride varnish has become the product of choice for professional in-office fluoride applications. The following are the recommended regimens: Low risk children - up to 2X / year (1 year or 6 month recalls) - caries-free or inactive Moderate to high risk children - 3X to 4X / year (3 or 4 month recalls) - caries-active Adjunctive, at-home fluoride therapy is a must for any caries-active child

Behavioral issues sped

Food used as a frequent reward Uncooperative for daily hygiene regimen Difficult or disruptive behavior in the dental setting -increased frequency of bruxism and self-injurious behaviors

Crown-root fracture with pulp exposure

Fragment removal and gingivectomy Orthodontic extrusion of apical fragment Surgical extrusion - Removal of the fractured fragment with subsequent repositioning of the root in a more coronal position. Decoronation - Root fragment left to avoid alveolar resorption for later optimal implant installation. Extraction - Extraction with immediate or delayed implant-retained crown restoration Space maintenance is always necessary for prematurely lost permanent tooth Removable appliance - Hawley - Pedi-partial - As pontic with ortho - Essig with acrylic tooth Fixed restoration - Delay final till full growth Final restoration

Eruption of primary teeth: abberrations

Gingival erythema: 50% of teeth Gingival swelling: 12% of teeth Significant symptoms are uncommon Oscillating eruption pattern Average of 2 months for tooth to erupt

Classification of enamel defects

Grade I-Defects in color- cream, yellow, brown opacities Grade II-Defect in structure- rough enamel, horizontal grooves, pits Grade III- Deep grooves and large pits Grade IV- Severe defects Symmetric enamel defects presenting with chronologic distribution may be the first sign of undiagnosed CD and should be used to refer patients for evaluation

X-linked vitamin D-resistance rickets (VDRR) (X-linked hypophosphatemia)(XLH)

Growth retardation Rickets (softening and weakening of the bones), Hypophosphatemia (too little PO4 in the blood) Due to kidney defects in: - Vitamin D metabolism- intestinal absorption of calcium is altered - Phosphate reabsorption - Increased amounts of the FGF23 protein circulating in the bloodstream causes the kidneys to treat phosphorus as a waste product and not return enough of it to the circulation for use by bones and teeth.

Hall Technique

Hall technique (HT) - a method of providing preformed metal crowns. This method calls for cementation of an SSC over a cariesaffected primary molar without local anesthetic, caries removal or tooth preparation. It is a less invasive caries management procedure for treating carious primary teeth and involves the concept of caries control by managing the activity of the biofilm. This technique was developed for use when delivery of ideal treatment was not feasible. The HT has gained some popularity in the United Kingdom (UK), primarily from use by general dentists who provide the majority of care for young children. All prospective investigations on the effectiveness of HT have been by general dentists in UK and comparison group include restorative treatment as traditionally provided in those settings, where traditional use of SSC's to restore caries in primary teeth has not been a popular or a frequently used technique. HT has shown high clinical success rate Ease of use and acceptance Cost-effectiveness Does not require LA or isloation Acceptable for treatment of carious primary molars especially for young children limited cooperative abilities and has the added independent of parental involvement in oral home care. -Please remember to always protect the airway when fitting and cementing a SSC

Clinical examination

Head and Neck Extra-oral and Intra-oral palpation and visual Occlusion Displacement of teeth - Record amount and direction Color Fracture - Enamel, dentin or pulp Mobility Percussion Pulp test ??? Trans illumination

Syndromes with macrodontia

Hemifacial hyperlpasia Crouzon Otodental Dysplasia - Globodontia

Syndromes with microdontia

Hemifacial microsomia Crouzon Oligodontia Ectodermal Dysplasia Ellis-van Creveld Down

Indications for SDF

High caries-risk patients with anterior or posterior active cavitated lesions. Cavitated caries lesions in individuals presenting with behavioral or medical management challenges. Patients with multiple cavitated caries lesions that may not all be treated in one visit. Difficult to treat cavitated dental caries lesions. Patients without access to or with difficulty accessing dental care. Active cavitated caries lesions with no clinical signs of pulp involvement.

Long-term medication regimes

High sugar content of liquid medications Reduced salivary flow 2° to psychotropic medications Gingival hyperplasia 2° to anti-seizure medications and calcium channel blockers

Protocol for injury

History Medical Incident Clinical Examination Radiographs Diagnosis Immediate treatment Long term treatment Prognosis

Responses to trauma in the primary dentition

No response Coronal color change - Immediate - Long term -Color change may or may not be indicative of pulp vitality -Late color changemore likely due to pulp necrosis Non-vitality Calcific degeneration Ankylosis Vestibular deformation Abnormal resorption

Allergic contact mucositis

Hypersensitivity reaction to variety of products Prevalence- less common than skin Atopic individuals, ↓ salivary flow Buccal, labial mucosa, gingiva, tongue Types: Acute and chronic forms DX: Temporal relationship; allergy testing Variants: Plasma cell gingivitis, foreign body gingivitis, angioedema, perioral dermatitis, exfoliative cheilitis Signs/Symptoms of Acute Disease: - Burning sensation, diffuse swelling - Erythema, vesicles, bullae, ulcers, lingual pappillitis Chronic Disease - Burning sensation, erythema, - white plaques, - gingival swelling, - angular cheilitis, - chapped lips, - perioral dermatitis, - unpleasant or metallic taste

Amelogenesis imperfecta

Hypoplastic - Rough - Smooth Hypocalcified Hypomaturation Hypomaturation with taurodont Important to dx type • Genetic-AD, AR, X • Prognosis • Type of restorations

Allergic contact mucositis treatment

Identify and discontinue cause Plaque control Topical Coating Agents: - Benadryl/Maalox suspension - Carafate (Sucralfate) suspension 1g/mL Systemic Agents: - Zovirax (acyclovir) 200mg/5mL, caps 400mg - Valtrex (valacyclovir) caplets, 1g Nutritional Supplements: - PediaSure 237 mL Topical Antimicrobial Agent: - Chlorhexidine oral rinse .12%

Socket management after avulsion

If clot, irrigate with saline Do NOT curette or vent socket No flap, unless bony fragment Reposition alveolar bone with blunt instrument Replant Manually compress socket

Transport medium for avulsed teeth

Immediate replantation at the place of accident is the best treatment. If replantation is not possible, the ideal storage media for an avulsed tooth should have: low bacterial content Physiological osmolarity a neutral pH and essential nutrients Tissue Culture Medium Cell Transport Medium -TCM and CTM are physiologic storage media, great option but unlikely to be available Hank's Balanced Salt Solution (HBSS) Milk Saline Saliva (Buccal vestibule) -All the rest ^ are osmolality balanced media Water -Hypotonic and will lyse vital PDL cells (avoid if possible)

What is a developmental disability?

Impairment(s) in physical or mental abilities that are manifested before 22 years of age, are likely to persist indefinitely, and result in functional limitations in major life activities.* Physical Disabilities: Cerebral palsy, congenital heart disease, juvenile rheumatoid arthritis, cleft palate Intellectual disabilities Behavioral disorders: Autism, ADHD Neurologic: Epilepsy Metabolic disorders: Glycogen storage diseases, mucopolysaccharidoses Genetic disorders: Marfan Syndrome, muscular dystrophy, etc.

Pulp therapy options for decidous teeth

Indirect Pulp Therapy (IPT) - indicated when there is no pulpitis or with reversible pulpitis when the deepest carious dentin is not removed to avoid a pulp exposure. - Contraindicated when there is a history of spontaneous pain or any clinical and/or radiographic pathological signs. Pulpotomy - indicated when caries removal results in pulp exposure in a primary tooth with a normal pulp or reversible pulpitis with transitory thermal and/or chemical stimulated pain. - Contraindicated with spontaneous pain, pathologic mobility, inflamed soft tissues, hyperemia, parulis, percussion sensitivity, widened and/or discontinuous ligament space, presence of radiolucencies Pulpectomy - indicated when there is irreversible pulpitis or necrosis, pain on percussion sign of non-vitality - Contraindicated non-restorable, perforation of pulpal floor, internal resorption perforating into the underlying bone, external resorption of >1/3 of the root, or involving the follicle of the permanent tooth

Risk Assessment of Teeth

Individual's risk for developing caries Level of caries activity Pit and fissure morphology Caries pattern Life expectancy of primary teeth

Infection of the head and neck region

Infections of odontogenic etiology? Secondary to sinus, salivary gland, skin, middle ear conditions? Defining the etiology is critical to the management of the infection because the infection may persist and potentially worsen if the cause is not removed and the appropriate antibiotic is not selected based on etiology Infections can progress rapidly in both the pediatric and adult patient, however the pediatric patient is especially susceptible to rapidly becoming dehydrated and systemically ill from what may appear to be a relatively minor infection

Types of Sedation/Anesthesia

Inhalation (Nitrous Oxide) Oral Intramuscular (IM) Intravenous (IV) General Anesthesia

Stage and associated anomaly

Initiation and proliferation - Numbers- Normal and abnormal types Histodifferentiation - Defects of enamel and dentin Morphodifferentiation - Size and Shape Apposition - Enamel, dentin, and cementum Mineralization - Enamel and dentin Eruption - Timing, sequence, location

What is an intellectual disability?

Intellectual disability (ID) is a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills. This disability originates before the age of 18.*

Root surface management after avulsion

Keep moist Hold by crown Do not scrape or brush Remove debris Rinse with saline (other medicament as time indicates - doxycycline, citric acid, fluoride) Enamel matrix protein (Emdogain®) ??

Syndroms associated with taurodontism

Kleinfelter syndrome (30%) Ectodermal Dysplasia Down Syndrome Tricho-dento-osseous Syndrome (TDO) - Periapical radiopacities - High pulp horn with microexposures Mohr Syndrome(OFD ll) - Oligodontia - Lobed tongue

Position of the pediatric patient

Knee to knee Protective Stabilization/protective immobilization Maxillary occlusal plane angle at approximately 60 and 90 degrees to the floor in cooperative patient Mandibular occlusal plane angle parallel to floor in cooperative patient

Enamel defects: Local Factors

Local acute mechanical trauma - Neonatal intubation and ventilation - Trauma as intrusion of primary tooth - Surgery - MVA Electric burn Irradiation Local infection Factors -Pattern -Single/multiple teeth -different appearence -Turner tooth

Nickel and SSC: sensitivity

Low-sulfur stainless steel grades like AISI 304, 316L or 430 (S < or = 0.007%) release less than 0.03 microgram/cm2/week of nickel in acid artificial sweat and elicit no reactions in patients already sensitized to nickel. Nickel-plated samples release around 100 micrograms/cm2/week of Ni and high-sulfur stainless steel (AISI 303-S approximately 0.3%) releases about 1.5 micrograms/cm2/week in this acid artificial sweat. Applied on patients sensitized to nickel, these metals elicit positive reactions in 96% and 14%, respectively, of the patients

Abnormalities of size and shape

Macrodontia-rare Microdontia (isolated or part of a syndrome) Dens invaginatus - Dens in dente Dens evaginatus- 43% have pulp tissue - Talon cusp - Enamel pearls Hutchinson's incisors, mulberry molars Fusion/ Gemination/ Twinning Taurodontism

Interacting with people with developmental disabilities

Maintain eye contact with and speak directly to the patient Avoid assumptions about a patient's disability - allow the patient (or caregiver) to describe the disability , related limitations, needs and strengths Do not assume that if a person is unable to do one thing, she/he cannot do other things. For example, there is no need to speak loudly if a person is blind, or slowly if the person has a speech disability Try to minimize hectic, over-stimulating environments in the office. Attempt to minimize wait times before appointments. Give yourself permission to make mistakes - if you are open to learning, this can be a source of growth

Alveolar fracture Tx

Manual repositioning or repositioning using forceps of the displaced segment. Stabilize the segment with (flexible ?) splint for 4 weeks Soft food for 1 week Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Brushing with a soft brush and rinsing is beneficial to prevent accumulation of plaque and debris.

Primate Space

Maxilla - Distal to lateral incisors Mandible - Distal to canines -helps to accomodate larger permanent dentition

Submerged or ankylosed teeth

May have nonresorbed divergent roots or may have all or nearly all the root resorbed Radiographic and clinical examination may not entirely predict the considerable difference in the degree of ankylosis surrounding bone Sectioning the tooth is indicated if luxation is not accomplished, thus surgical approach is preferable Surgical drill with air vents away from surgical field prevents air embolism, air emphysema An intraoperative and/or post operative radiograph may be indicated

Tanaka-Johnson Analysis

Measure the mesial-distal widths of the maxillary and mandibular incisors Using 1/2 the width of the MANDIBULAR lower incisors: - Add 10.5 to estimate the width of the mandibular canine and premolars in a quadrant - Add 11 to estimate the width of the maxillary canine and premolar in a quadrant - Add the estimated posterior space needed for each quadrant to the corresponding incisor measurement - Subtract space required from space available - positive is spacing - Negative is crowding

Moyer's Analysis

Measure total space required Measure the mesial-distal widths of the mandibular and maxillary incisors Using the sum of the MANDIBULAR lower incisors, estimate the maxillary and mandibular canine and premolar widths Add the prediction values to the measured sum of the incisors to see if there is spacing or crowding Predictions only apply to white school children of northern European descent

Impacted teeth other than third molars/cysts/odontoma/hard tissue lesions

Mesiodens and supernumerary teeth Ectopic canines (more common palatal than buccal) Ectopic incisors due to crowding, past trauma Surgical exposure Enucleation and curettage of odontoma Complex odotoma (irregular shaped masses of enamel with no anatomic resemblance to a tooth Compound odontoma (represents multiple tooth like structures Odontogenic cysts (dentigerous cyst - unerupted permanent tooth or supernumerary, eruption cyst)

Ideal Molar Arch Width

Mixed Dentition = 34-35 mm Adult Patient = 36-38 mm

Space Analysis Systems

Moyer's Space Analysis Tanaka-Johnson Radiographic Predictions

Tongue Crib

Must be Monitored Maintain for 6 months Retrains tongue

OUTCOMES for Remineralizing Caries

No long term studies exist to report how successful this therapy is. Clinicians report highly successful outcomes in highly compliant patients, poor results with non-compliant patients. (Empirical / Anecdotal vs. Evidence-Based)

Simple Exodontia : indications for children are same as for adult

Non-restorable due to caries Apical disease Fractures of crowns or roots Prolonged retention of primary teeth because of improper root resorption or ankylosis Impacted teeth Supernumerary teeth Dentist must know eruption pattern and growth and development! Adequate visibility is required: Adequate access, adequate light good suction Minnesota Retractor "Sweetheart" Retractor Control of patient opening-Be careful with mouth prop to prevent iatrogenic injury (displacement of teeth, TMJ injury, soft tissue damage) - Bite block (place posterior to canine) - Molt Mouth prop (place most posterior, not on anterior teeth as this may cause soft tissue and Luxation of teeth) Suction - Fraser tip suction (opening on handle allows regulation of suction power) - Yankauer or Tonsillar suction Radiographic surveys of teeth to be extracted are of prime importance The dentist should observe the size and contour of the primary roots, the amount and type of resorption, the relation of the roots to the succedaneous teeth, and the extent of the disease Simple exodontia in the pediatric patient requires slight modification if the roots on the primary teeth are non-resorbed, long, slender and potentially divergent

Pericoronal odontogenic hamartoma

Odontogenic lesion Age: 7-15 yrs Permanent molar operculum , maxillary incisor Firm, pink nodule or thickening overlying unerupted tooth Delayed eruption or partial eruption of tooth; may be bilateral Excision; monitor tooth eruption Radiograph to exclude other problems

ARRESTING CARIES

Once cavitation has occurred, the enamel cannot "heal" or reverse the damage by remineralizing. The best one can achieve is to arrest the lesion.

Molar incisor hypomineralization (MIH)

One or more permanent molars and/or incisors 4%-25% Does not fit febrile or trauma pattern of hypoplasia - Cusp tips - No symmetry Highly sensitive Difficult anesthesia Failure of restorations Treatment: - Desensitizing- TP, Fluorides - Remineralization-MI Paste - Early coverage of area - Bonding affected - Full coverage Study: 19.8% children are affected Higher in rural area Most are mild with post-eruptive tooth structure loss MIH associated with higher DMFT

Enamel defect: Celiac Disease

Oral and Dental Manifestations - Enamel defects (10% primary and 50-80% permanent) - Delayed eruption - Recurrent aphthous ulcers - Cheilosis - Oral lichen planus - Atrophic glossitis

Patient's ability to cooperate?

Patient's age Systemic health Which surgery? Minimal sedation Nitrous oxide sedation Moderate sedation - Oral sedation Deep sedation - IV sedation General Anesthesia in the operating room

Initial Step in patient management is Diagnosis

Pre-operative Evaluation Taking a history Physical exam Imaging Visualize steps in their sequence Potential complications Anesthesia required Anesthetic choices Toxic Dose calculation Block vs. infiltration

Oral manifestations of bulimia and GERD

Presents in both Male and Female Enamel erosion- often more visible on lingual of incisors Increased enamel translucency Raised restorations, loss of composite

Nickel hypersensitivty in US

Prevalence: - 36% of girls under 18 years - 16% of boys under 18 years #1 cause of + patch tests (33% children tested) Nondental sources: - Body piercing, jewelry, buckles,keys, pens, paper clips, toys, zippers, snaps, cell - phones, eye glass frames Dental sources: - SSC, orthodontic band and attachments, lingual arch wires

FLUORIDE

Prevention Reversal of Caries Arresting of Caries Fluoride varnish has become the agent of choice for in-office interventions. Best material for preventing, remineralizing or arresting caries Particularly recommended for preschool and younger children - ease of application and equal efficacy to APF gels Stookey, 1998 No need for prophylaxis before application Sets under moisture/saliva Minimizes ingestion - very little gets swallowed

Development of the Dentition

Primary molar relationship Size differential- Leeway Space - 4.0 mm mandible (2.0 mm per quadrant) - 1.7 mm maxilla (0.85 mm per quadrant) Spacing- primate and generalized - Maxilla- between lateral and canine - Mandible- between canine and first molar Mandibular growth and differential growth

Diagnosing Pit & Fissure Caries

Probing with sharp explorer & firm pressure may damage non-cavitated carious enamel Visual exam of air-dried teeth alone may provide comparable or superior diagnosis Prudent approach - use light to moderate pressure if using an explorer

Diagnosis of atypical dentition

Recognition of anamoly Anamoly is associated with a specific stage of development-other involvement Consequence to atypical dental development - Exfoliation and eruption consequences - Impact on craniofacial development and occlusion - Psychosocial issues Genetic counseling - Identify condition - Possible diagnosis of a syndrome - Medical components Prognosis

REVERSING CARIES

Remineralization of early (incipient) caries has been clearly demonstrated in the scientific literature. This is particularly true of smooth surfaces and at contact points of teeth. Demineralized enamel can be remineralized if the outer layer is still intact. Once cavitation has occurred, the best you can hope for is to arrest the lesion.

Silver Nitrate

Reportedly used as early as the 1840s, and appears to be the first silver compound used for arresting caries Howe's ammoniacal silver nitrate solution was the preferred formulation from 1917 through the 1950s - it was believed to penetrate into affected dentin, and have an antibacterial effect It fell into disfavor in the latter half of the century amid concerns about clinical efficacy and possible adverse effects on the dental pulp. Other investigators have since concluded that silver nitrate penetrates sound and carious dentin, and has a mild, self-limiting, localized effect on the pulp. It is the silver ion that appears to be the major inhibitory product. A major disadvantage of silver nitrate is its black staining effect on carious dentin. This is due to oxidation of silver ions into metallic silver.

Progression of Decay

Research has shown that the clinical progression of caries today is slower than in the 1960s and 1970s and that teeth are at risk for pit & fissure caries for a longer time. "...recent studies suggest that the risk for pit and fissure caries extends into and well beyond adolescence. Adults who are at risk for developing lesions in pits and fissures...and those who may require sealant replacements...should be evaluated for sealants"

"Sweetheart" retraction

Retraction with the "Sweetheart" retraction is best achieved by placing lateral aspect of retractor firmly against the alveolus Gauze packing may be placed just medial to the retractor providing a barrier between the surgical site and the pharynx preventing the tooth, surgical debris, or irrigating (sterile saline) from potentially being swallowed, aspirated or irritating the pharynx. Adequate visibility depends on establishing a debrisfree surgical field.

Root fractures

Rinse exposed root surface with saline before repositioning, as soon as possible. Check that correct position radiographically. Stabilize the tooth with a flexible splint for 4 weeks. Cervical fractures stabilization is up to 4 months Monitor healing for at least 1 year. If pulp necrosis develops, RCT of the coronal segment Patient instructions Soft food for 1 week Brushing with a soft brush Rinsing with chlorhexidine Urgent care Observation over time - Mobility decreases over time - Necrosis requires RCT

Extracting Primary Anterior Teeth, mandibular premolars, maxillary second premolar

Rotational forces may be applied for selected roots that are conical Rapid, jerky movements are ineffective and not recommended In general, anterior teeth should be luxated to the labial aspect during the extraction procedure because of the lingual position of the permanent teeth, and posterior teeth should be luxated with buccal and lingual pressures

Contemporary Caries Management

Sealant placement over questionable or incipient occlusal caries Fluoride therapy to prevent and reverse dental caries Silver Diamine Fluoride to arrest dental caries Atraumatic Restorative Technique Interim Therapeutic Restoration Hall Technique for placement of SSC

Facts related to sealant use

Sealants...safe & effective...to prevent pit and fissure caries. Pit & fissure caries begins in childhood & continues into adulthood. Sealants can arrest caries progression. Sealants require meticulous technique should be checked within 1 year

Severe but rare complications of odontogenic infection include:

Secondary respiratory embarrassment Systemic meningitis Local periorbital cellulitis Cavernous sinus thrombosis Ludwig's angina and Sepsis These conditions can be life threatening and may require immediate hospitalization with IV antibiotics, incision and drainage, and referral/consultation with an oral and maxillofacial surgeon.

Impacted Teeth

Secondary to insufficient space in the dental arch (crowding, aberrant tooth development, mechanical obstruction secondary to pathologic lesion eg. Odontoma, supernumerary tooth, malposed tooth germs, genetic abnormalities Impacted third molars

Step by step process in exodontia

Separate the soft tissue attachment from the cervical aspect of the tooth Luxation - Dental elevator to luxate tooth to expand the alveolus disrupting the periodontal ligament causing initial mobility of the tooth - Wedging the elevator inferiorly expands the alveolus which facilitates extracting of the tooth with forceps - Critical not to use elevator between teeth, it is to be placed between tooth you are extracting and the bone. If not, you may loosen the adjacent tooth. Apically directed force to produce mobility thus reducing translational movement and possible fracture of apical third of root Last step is extracting tooth with forceps Hemostasis - Use pressure to obtain hemostasis - Suturing usually not necessary for hemostasis with single tooth extraction - Gel Foam may be place in socket to aid in hemostasis and allow patient to leave without blood oozing from socket

Nutritional Counseling

Sippy cup to be discontinued Juice limited to 8oz/day with meals Increase milk products Healthy snacks suggested

Adjunctive therapy for avulsion

Soft diet Oral Hygiene Analgesics Antibiotics- 1 week - Penicillin V : <8yr - Doxycycline:>8yr Chlorhexidine rinse Tetanus booster if last is >5yr

Eruption cyst and hematoma

Soft tissue analogue of dentigerous cyst Separation of dental follicle from crown of erupting tooth; surface trauma with bleeding Any site, especially maxillary incisor region and mandibular molar region Amber, red or blue soft tissue swelling;tender Spontaneously ruptures and resolves

Mouthguards

Sports - Bicycles highest - Baseball (7-12 yo) 0 Basketball (13-17 yo) Type of Mouthguard - Type I-custom fabricated ($60->$300)-most effective - Type II-Mouth formed - Type III- Stock Benefits - Decreased injury - Decreased Concussion: - Custom fitted 3.6% v OTC 8.3%

Head and neck injuries from trauma

Subconjunctival hemorrhage Fractured zygoma Subcondylar fracture Bleeding from external meatus - condylar head perforated the anterior wall of the meatus Examination requires parting the hair to detect lacerations and bruising Bruising of mastoid region- associated with a base-of-skull fracture. The chin-point ecchymosis - often associated with gingival degloving laceration mandibular fracture

Behavioral Management Techniques

Tell-Show-Do Firm Voice Control Desensitization Physical Restraint Sedation General Anesthesia

The "Cowhorn" Elevator

The "Cowhorn" elevator is CONTRAINDICATED when extracting primary molar teeth This elevator is appropriate for permanent molar teeth that have divergent roots The "Cowhorn" may damage the succedaneous permanent tooth that is located between the primary molars roots You may actually extract the permanent tooth bud

Interim Therapeutic Restoration (ITR)

The ITR procedure involves removal of caries using hand or rotary instruments with caution not to expose the pulp. Leakage of the restoration can be minimized with maximum caries removal from the periphery of the lesion Following preparation, the tooth is restored with an adhesive restorative material such as glass ionomer or resin-modified glass ionomer cement. ITR has the greatest success when applied to single surface or small two surface restorations. Inadequate cavity preparation with subsequent lack of retention and insufficient bulk can lead to failure.

Forceps 150 S and 151 S, or Rongeur Forceps

The armamentarium for exodontic procedures in pediatric patients is much the same as for adult patients, however the instruments themselves are just smaller in relation to 150 and 151. 150 S is for maxillary incisors and molars 151 S is for mandibular incisors and molars Rongeurs help with root tips, broken down incisors, where limited space exists between teeth Remember to elevate! Proper elevation of primary teeth will greatly help in extracting primary first and second molars Place the elevator between the primary tooth you wish to extract and the alveolar bone Place in the area of the periodontal ligament and slow expand with the small elevator, then large elevator if needed DO NOT place elevator between adjacent teeth as you will elevate both teeth!

Odontogenic Cysts

The dentigerous cyst is the most common odontogenic cyst in the pediatric population. It is usually associated with an unerupted permanent tooth or with a supernumerary tooth Traumatic cysts are also common, especially in active, young patients, and are usually unilateral and solitary An eruption cyst is a cyst-like lesion caused by eruption trauma or either primary or permanent teeth. Usually seen in erupting molar areas, it usually resolves spontaneously when the involved tooth penetrates the ginigival tissue

A root tip from a primary tooth may fracture during the procedure

The dentist should attempt to remove the root tip Proper use of an elevator will ideally have loosened the root of the tooth which facilitates root tip removal However, if removal of the root tip poses significant risk to adjacent tooth or the succedaneous tooth, then the residual root tip should be left in the bone. May eventually resorb or migrate toward the gingiva and become exposed with eruption of the permanent tooth Good written consent before extraction explaining this possibility

Soft Tissue Procedures

The pediatric dentist frequently is involved in the management of several minor intraoral soft tissue lesions. Commonly seen soft tissue pathologic conditions include: Mucoceles and ranulas Fibroma and pyogenic granuloma (scaling of teeth after procedure) Infection of head and neck region

OUTCOMES of sealents

The scientific literature has numerous well designed, long term studies documenting that sealing over incipient dental caries results in arresting the lesion. These sealants can last for many years, and, along with fluoride, represent efficient, safe and noninvasive caries management therapy.

Habit Appliance

Thumb Sucking Habit Tongue Thrust "Blue Grass Appliance" Tongue Crib

Space Analysis

To determine if there is enough space in the arch for the permanent teeth to erupt into aligned positions Impactions may occur if not enough space Compares the space available to space required for canines and premolars Primary first and second molars must be present to be accurate

REGIMEN

To remineralize incipient caries, it is recommended that the child receive more frequent in-office fluoride applications (3X or 4X per year instead of the usual 2X). Most importantly, the at-home regimen of 2X per day brushing must be beefed up This can include either daily augmentation with an OTC fluoride rinse (1X per day) or substituting a concentrated dentifrice (Prevident 5000) for regular toothpaste at the night-time brushing. Children <6yo should not be given rinses Prevident 5000 not recommended for use in children < 6 years Evidence does not show statistical support for use of these products, though clinicians may find a positive effect: Talking about prevident 5000 + MI paste

ITR Indications

To restore, arrest or prevent the progression of carious lesions in young patients, uncooperative patients, or patients with special health care needs When traditional cavity preparation and/or placement of traditional dental restorations are not feasible and need to be postponed. For step-wise excavation in children with multiple open carious lesions prior to definitive restoration of the teeth In erupting molars when isolation conditions are not optimal for a definitive restoration For caries control in patients with active lesions prior to treatment performed under general anesthesia The AAPD recognizes ITR as a beneficial provisional technique in contemporary pediatric restorative dentistry. Interim therapeutic restorations (ITR) are best utilized as part of comprehensive care in the dental home.

Factitial oral injuries

Type: Self-inflicted oral lesions Age/Gender: 80% < 12 years old; F > M Method: Fingernails, teeth, toothpick, pacifier, toothbrush, hair, pen, toy Easy to reach location; facial gingiva, lips, buccal mucosa Chronic ulcers, gingival recession, bizarre shape, sharp outlines; single or multiple Identify the cause; palliative treatment; psychological assessment

Developmental disabilities in the US

Until mid-20th century, most people with DD lived at home with family. After World War II, establishment of large residential facilities ("training schools"). Willowbrook Decree (1975) initiates movement to deinstitutionalize individuals with DD. Last large state facility in NY closed in 1998

Alveolar fracture

Unusual in primary - Abuse - MVA/ Severe injury Requires rigid fixation - Difficult to place - Difficult to maintain

A treatment plan must take into consideration the whole person

What is this person's ability to maintain oral hygiene on a daily basis? What is this person's ability to sit for prolonged procedures? Does the patient's medical status contraindicate sedation or general anesthesia? What is this person's ability or willingness to wear a removable prosthesis? Are aesthetics an issue for the patient (or the patient's family)?

Enamel defects epi

the prevalence of enamel defects in the permanent dentition was 68.4% 67.2% demonstrated opacities 14.6% revealed hypoplasia both patterns were seen in 13.4% of all children. The average number of affected teeth per individual was 3.6, with greater than 10% of the children having 10 or more teeth involved.

The present ASD mouthguard statement is,

" The ASD supports properly fitted mouthguards as a proven method to reduce dental sporting injuries." •ASD does not support or recommend mouthguards that claim to reduce concussion. •The academy does support the concussion safety testing program involving computerized neurophysiological testing. This program is called ImPact (Immediate Post concussion assessment and cognitive testing).

Dental Education sped

"In 1999, 53% of dental schools reported fewer than 5 hours of didactic training in special-care dentistry. Clinical instruction in this area constituted only 0-5% of a predoctoral student's time. . ."

What is Sports Dentistry?

"Sports Dentistry" involves the prevention and treatment of orofacial athletic injuries and related oral diseases, as well as the collection and dissemination of information on dental athletic injuries and the encouragement of research in the prevention of such injuries.

Intrusion and extrusion 5 yr follow up

(intrusion %/ extrusion %) TOOTH WITH OPEN APEX Pulp necrosis- 67% /5% Resorption Ankylosis Tooth Loss Marginal bone loss Pulp Canal Obliteration - 1 Year- 40%/ >70%

AAPD Recommendations on pulp therapy

- All pulp therapy should be performed with rubber dam or other equally effective isolation to minimize bacterial contamination - Clinical and radiographic re-evaluation every 6 months § Acute infections require more frequent evaluation - Primary teeth: § Post-pulpectomy- radiograph at time of completion and as base-line § Pulpotomy- radiograph at least annually, view of inter-radicular area as seen on Bite-wing radiograph - Immature Permanent § Re-evaluate 6-12 months after treatment

Apexification with MTA

- Biocompatible material - Earlier and increased dentin deposit and bridging in less time with less inflammation - Disadvantage - 3-4 hr to set - Possible replacement for other pulp procedures

Trends affecting dental care for individuals with ID/DD

- Deinstitutionalization more individuals with disabilities living in the community - Increased life expectancy and the anticipation of equitable health care during that lifetime

Pulp Capping Agents

- Dentin permeability increases closer to the pulp - Success of pulp capping is dependent on our ability to keep bacteria OUT - A good pulp capping material should be both biocompatible and provide a good seal • Foremost objective is to encourage hard tissue barrier formation after pulp injury • Dentinal bridge formation is a sign of wound/ pulp healing and can be visualized radiographically Agents: -Caoh: not to be used apparently -MTA: has more reliable dentin bridging and pulp health

Seizure disorders - relevance to oral health

- Increased risk for trauma from certain seizure types. - Fractures, avulsions, wear due to bruxism

Pulpectomy Technique

- Local anesthesia/rubber dam isolation - Access obtained - locate all canal orifices - Remove all organic material from canals § Canals are thin and flat-ribbon like § Easy to perforate: which is why we do not usually instrument the canals at all - Instrument just short of the radiographic apex § Only remove tissue, not shape canals. typically dont take a radiograph besides the first baseline to measure anything § Usually do not use rotary instrumentation - Irrigate canals-NaOH vs. water: if its necrotic and you need to remove some tissue, you can use NaOCl or chlorhexidine, vs straight saline or water - Obturate with resorbeable material 1. ZOE (NOT IRM, which has polycarboxylate fibers which do not resorb) 2. Vitapex-Ca(OH)2/iodoform 3. KRI paste - iodoform Process: 1. A Irreversible inflammation present 2. B Caries removal § Unroofing of the pulp chamber § Coronal pulp is amputated § Canals gently cleaned with minimal shaping using files 3. C Irrigation 4. D If root canals are not to be obturated at the same visit, use nonsetting calcium hydroxide (as a temp), or canals left empty with an interim intracoronal restoration. 5. E Obturated with a resorbable root-filling material such as zinc oxide eugenol (ZOE). 6. F Following root canal filling, tooth is restored definitively using a stainless steel crown.

Extrusion treatment

- Manually reposition - Local anesthesia - Vascularity - Inflammation - Stabilize Flexible Splint 2wk This is for an open apex Closed apex: -Manually reposition and splint -time is critical -splint 2-4 weeks

Supernumeraries

- Occurs 98% in Maxilla - Primary < 1% - Permanent 1-4% - 2Male>1Female

Pulpectomy Issues

- Overfill canal § >50% have excess fill § May resorb - Underfill canal: can harbor bacteria and cause faliure - Interradicular pathology - Perforations - Failure due to necrosis of PDL - Over retention of the primary tooth § Deflection of permanent -When you do a pulpectomy in the anterior, the single most common reason for a single tooth crossbite is an over-retained primary tooth, either from trauma or from a pulp procedure. Can damage the succedaneous tooth or deflect it

Microdontia

- Primary <0.5% - Permanent 2% - Peg lateral 2, 5,8 - More common in females

Indications for space maintenace based on early loss of which teeth; KNOW

- Primary incisors:Not required -Primary canines: required in cases of crowding to prevent drift and collapse of permanent incisors/ midline shift -Primary first molars: required previous to and during eruption of permanent first molar -Primary second molars: required -Permanent teeth: required

Examples of how biologic principles influence clinical practice:

- Rubber Dam Prevention of bacterial contamination Required for any procedure with a potential for pulpal exposure - Disinfecting Irrigation Solutions Elimination of bacteria - Coronal and Apical Seal Prevention of bacterial re-contamination - Use of Biocompatible Materials Allowing for biologic healing

Pulpal Necrosis

- The necrotic pulp is defenseless against microbial invasion - The necrotic pulp will allow microorganisms indigenous to the oral cavity to reach the pulp chamber through: • Direct pulp space exposure • Uncovered dentinal tubules • Cracks in the enamel and dentin

Ectopic eruption of permanent anteriors

-May or may not be associated with crowding and/ or an over-retained primary tooth -However, timely extraction of an over-retained primary tooth can allow for a correction in eruption path, and may prevent malocclusions such as crossbites or other malalignments

Considerations for not maintaining space

-Medical or mental health considerations -Significant space lost already -Excessive crowding -Primary exfoliating, permanent eruption imminent -inability to maintain oral hygeine appointments

Enamel/dentin exposure

-70% of injuries -Most common type of injury to the permanent dentition is crown fracture with enamel and dentin involved 1. Diagnosis Infraction lines Coronal fracture Clinical symptoms - Thermal sensitivity - Sore - Rough edges 2. Emergency Palliative Protection of pulp "Band-Aid" 3. Permanent restoration 4. Prognosis 6-8 weeks Necrosis Calcification

Pharmacologic Agents in Pediatric Dentistry: Todays agents

-Midazolam -Triazolam -Ketamine -Zolpidem

Occlusal/incisal relationship

-Molars, canines, incisors and all 3 based on Axis 1. Anteroposterior: overjet 2. Transverse: posterior overjet 3. Vertical: anterior or posterior overbite

Functionally ideal space maintainer

-Preserved mesiodistal width -Hygeinic -Prevents supra-eruption of opposing tooth -Passive -Does not interfere with occlusion -Allows eruption of succedaneous tooth -Is easy to construct -cost is low -appliance is infrequently broken -Inconspicoius -Requires minimal compliance -Does no harm

Vital pulp therapy: decision making

-A pulpectomy prcoedure should be carried out when a pulpal condition is deemed irreversible -A pulp capping/ partial pulpotomy procedure may be carried out when an exposed pulp is healthy or deemed reversibly inflamed -Under clinical conditions the cut-off point between irreversible inflamed and reversibly inflamed is hard to identify -In the case of vital pulp therapy, pulpotomies are the definitive treatment

Non-vital vs vital pulp therapy

-Pulpectomy is the only non-vital pulp therapy for primary teeth, and includes irreversible pulpitis -Pulpotomy, indirect pulp capping, and direct pulp capping are all vital pulp therapies

Space maintenance and eruption of succedaneous teeth

-A space maintaner, if required, should be placed if erution will be delayed 6 months or more: -2/3 to 3/4 root development: how much root development a tooth has before it is ready to erupt -A succedaneous tooth may erupt prematurely: regardless of how much root has or has not developed To determine when a tooth will erupt: -Erupting premolars need about 4 months for every mm of bone as measured on a BW

Scheme For Selecting Drugs by Age for Children

-18-36mo: CH+hydroxyzine -37-72mo: CH+ meperidine+hydroxyzine ->72mo: diazepam

Natal/neonatal teeth

-3:1 ratio of natal to neonatal teeth - 90% normal teeth - Extract if failure to thrive or unresolved Riga fede

Is the ASA physical status classification a valid guide to risk?

-ASA I: Normal healthy patients -ASA II: px with mild systemic disease -ASA III: px with severe systemic disease that is lmiting but not incapacitating -ASA IV: Patients with incapacitating disease which is a constant threat to life -ASA V: Moribund patients not expected to live more than 24 hrs -ASA VI: A declared brain dead patient whose organs are being removed for donor purposes Patient Selection Patients who are in ASA classes I and II are frequently considered appropriate candidates for minimal, moderate, or deep sedation

What to Look Out for: in terms of spacing / crowding

-Anterior Crossbite of Lateral Incisors -Excessive Crowding 4/5 Exchange -Constricted Maxilla -Unilateral Posterior Crossbite -"V" Shaped Maxilla -Over-retained Primary Teeth -Excessive Overjet -Anterior Crossbite -Peg Laterals/Bolton Discrepancy (must be addressed for esthetic and occlusion concerns) -Poor Position of Maxillary Canines (Surgical Canine Exposure for Impacted Canines) -Ectopic Eruption of Lateral -Severely Ectopic and Impacted Maxillary Canines -Severe Crowding -Premature Loss of Primary Teeth

Mixed Dentition analysis

-Attempts to predict spacing or crowding in permanent dentition by estimating leeway space -Compare the space required (SR) to space available (SA) for canines and premolars -If there is not enough space avaialbe, it can result in ectopic eruptions, impactions, and malalingments Certain conditions must be true in order to do a mixed dnetition space analysis 1. Early mixed dentition, after lower incisors have erupted 2. Primary first and second molars are present Why is this important? -A diagnostic tool -Knowing the predicted spacing or crowding, and the extent of it, will facilitate making treatment decision: which can include: holding space, reducing interproximally, or extracting teeth. Methods -Tanaka johnson -Moyers -Radiographic -Each one has its own way of predicting space required (SR) -But all methods have the same end goal: attempting to predict spacing or crowding or neither in the permanent dentition

Permanent Anterior Crossbite: examples of fixed and removable interceptive appliances in the early mixed dentition

-Be fammiliar with how each appliance is activated, how long crossbite correction takes, and how retention is achieved -On retention, if you achieve a positive overbite after correction, you usually dont need retention, it is self retentive How do you decide between fixed an removable maintainers? -Factor in compliance and oral hygeine -Now that we are actively moving teeth, want to consider whether we want a tipping motion or a more bodily movement Example: permanent anterior crossbite of #'s 9 and 24 in the early mixed dentition -The appliance of choice is a removable rapid palatal expander with a finger spring that will rest on the lingual of #9 to allow a tipping motion of #9. -The expansion is due to the presence of concurrent crowding in the area

Pharmacologic Agents in Pediatric Dentistry: Traditional agents

-Chloral Hydrate (CH) -Meperidine -Hydroxyzine -Promethazine -Dizaepam

Microdontia/peg laterals

-Creates isolated areas of spacing -Missing teeth can also create isolated spaces, ADA recommends a panoramic in the early mixed dentition for this purpose

AAPD CAT

-Derived from the classification you give a child based on CRA, and outlines what treatment to take -Includes parent engagement, so if parents are not engaged, usually means more aggressive tx

Sequelae to intrusion in primary dentition

-Determined by direction and amount of intrusion 1. Ankylosis -90% resolved within 6mo -Re-erupt within 1 month: no need to reposition and splint, just monitor for a month 2. Calcified canal 3. Atypical resoprtion 4. Pulp necrosis 5. Delay in exfoliation and eruption of successor Following an injury to a primary tooth, the most common sequelae to the succedaneous tooth is enamel/dentin hypoplasia

Dental growth and development chart

-Downloaded

Anterior crossbite

-Early recognition can prevent things such as assymetric jaw growth, fracture of incisal edges of permanent teeth -Need to differentiate between a psuedo- class III and a true class III

Classifications of crown and root fracture

-Ellis -WHO -Descriptive -Class I: enamel only -Class II: enamel and dentin -Class III: Enamel dentin and pulp -Class IV: mid crown fracture bisecting the entire tooth/crown

Strip crowns

-Emax cutouts of a single tooth that are filled with composite or rmgi of some sort

Following an injury to a primary tooth, the most common sequelae to the succedaneous tooth is?

-Enamel/dentin hypoplasia

Factors and frequency of traumatic injury

-Falls and play accidents cause majority of injuries 30% of children suffer trauma to primary dentition 22% of children suffer trauma to the permanent dentition by age 14 2 Male: 1 Female Only 1% of all injuries >80% of child abuse occurs in very young child

Apexification

-For a necrotic pulp on an immature tooth • Barrier created to serve as a matrix against which root canal filling material or other restorative material can be compacted with length control • No further development of the root will occur Traditional approach: -Full pulpectomy followed by months of caoh treatment in the apex, which is then sealed over by GP Apical barrier technique -Full pulpectomy followed by a 4-5mm apical barrier of MTA. The a composite root reinforcement, often with a fibre post, if placed inside

Injuries often associated with child abuse/neglect

-High percentage present with head and neck injuries -Extrusion of maxillary incisors -Torn maxillary frenum

Enamel hypoplasia: patterns

-In a febrile px/mother -Pattern can be: -Local vs general -Horizontal vs vertical -A horizontal linear pattern can be a key to timing of when the fever occured

Bilateral posterior crossbite

-Is often manifested as a unilateral posterior crossbite because when the patient is in CR they cannot occlude in MIP,so the result is a functional shift in the mandible which deviates the midline

Calculating space available using moyers or tanaka-johnson

-Start at the mesial of the first permanent molars -Stay near contact points when not ectopic -Sum of segments = space available(SA, sometimes referred to as arch perimeter or arch circumference) When SA-SR is positive, it means there is spacing predicted When SA-SR is negative, it means there is crowding predicted Space available (SA) space required (SR)

When working with adolescents:

-Talk to them away from parents -Dont focus on what could happen, show them whats happening now -Establish trust and be patient -Be ready to listen and offer assistance

Ectopic Eruption of Permanent Molars: self corrections

-The most commonly ectopically eruting teeth are maxillary molars, may be bi- or unilateral -it is critical in the early mixed dentition to take diagnostic bitewings that can pick this up -PA can also pick this up

Excessive overjet

-This can be a dental problem or a skeletal problem -Early treatment may be indicated because the child is more at risk for trauma

Constricted maxilla

-This will affect the overall space available (SA), so there will be less arch circumference and resultant crowding and the consequences of that, such as rotations -Maxilla can be V shaped or U shaped, A v-shaped is more likely to be constrictive of space, especially in the anterior segment

LLHA indications

-To passively maintain horizontal space in the mandible when primary molars or cuspids are lost prematurely, either bilaterally or unilaterally (can be used in unilateral tooth loss or even no tooth loss to maintain leeway space) -Maintain leeway space/ arch circumference -Active tooth movement -is banded on permanent molars

Tooth nomenclature

-Universal numbering system: A through T, 1-32 -Palmer notation: broken up into quadrants, with A being the beginning of each quadrant starting with the central incisors and then working back to tooth E in each quadrant. So the first primary molar in the upper right quadrant would be a quadrant drawing (backwards L) and a D in that space indicating the first molar of that quad

Risk factors for disease

-Visible plaque: means you likely have high s.mutans -White spots: at high risk for caries -Oral injury: -Nutrition -SES: used to be high risk

Distal shoe indication

-When a primary second molar is lost before the eruption of the first permanent molar -has a small extension that goes subgingivally and guides the eruption of the permanent first molar

Nance appliance indications

-When there is premature bilateral loss of maxillary primary molars -When permanent molars are to be held in a stable position -Is the maxillary equivalent of the LLHA -Has a small acrylic button that pasively rests on the incisors

Band and loop indications

-When there is unilateral premature loss of a primary first molar and the adjacent cuspid and second primary molar are present prior to the eruption of the first permanent molar -When there is a unilateral premature loss of a primary second molar and the adjacent primary first molar and permanent first molar are present -Want to maintain horizontal space

Infraction lines

-affecting only enamel Diagnosis - Transillumination - Rough Emergency - Seal/bond area Prognosis - Excellent

Number disorders in teeth

-aplasia - oligodontia (6 or more teeth) -supernumerary -supplemental -hyperdontia -anodontia -hypodontia -agenesis

Ectopic Eruption of Permanent Molars: Brass wire corrections

-other than self corrections, all of the space guidance interventions aim to distalize the first molar that is ectopically erupting -A brass wire is placed interproximally, mesial to the molar in order to distalize it

Ectopic canines

-timely extraction or eruption of the primary canines can help correct the eruption angle and prevent resorption of adjacent teeth by the incoming canines

Accident prone dental profile

1. 2.7 Male : 1 Female 2. Age Class 1 - Male 9.5 -10.5 - Female 10-11 Class 2 - 10-11 3. March and November are peak Class-II division 1 or Class 1 protrusive - Overjet 3-6 mm —2x frequency of trauma - Overjet >6 mm — 3x increase in the risk. -Need for interceptive orthodontics

Successful Pulp Therapy requires:

1. An accurate diagnosis § Caries may be more extensive than clinically visible. § The full extent of caries is only evident radiographically and shows pulpal involvement § Clinical Assessment: § With a thorough clinical and radiographic assessment it is possible to establish to a high degree of certainty whether or not the pulp is vital or nonvital. 2. Final Restoration § Functional § Microleakage: most significant to prevent

The comprehensive plan

1. Behavior guidance 2. Prevention plan -OHI -sealents -Fluoride -systemic water, supplemet, toothpastes, MI paste, etc. -Nutrition 3. Growth guidance -Space management -Interceptive/ preventive -Comprehensive ortho care --> consult 4. Tx plan -Sequence of care -Types of resto and justification -Recare frequency

Assessement of pulp status and treatment

1. Carious lesion producing pain 2. Characterize pain -Spontaneous, prolonged, nocturnal: irreversible pulpitis: nonvital pulp therapy or ext 2. Thermal, chemical, intermitent pain: reversible pulpitis: vital pulp therapy -most difficult to establish in a young patient is pain characteristic.

Clinical evaluation of child

1. Child Abuse 2. Neurologic Evaluation PERRLA 2. Medical Evaluation Cardiac Bleeding disorders Seizure disorders Immune status/Allergy Immunizations - DPT Examination may be first dental visit Knee to knee

Pulp exposure with open apex after trauma: tx options

1. Direct pulp cap Vital Pinpoint exposure Short time since exposure Previous treatment of choice Very high failure rate 2. Coronal Pulpotomy was considered treatment of choice - The apex will close and continue to develop normally if the apical tissue remains vital, but there are several problems associated with this procedure: • Placement of dentin bridge • Calcification of canal • Coronal walls thin - Fractures • MUST complete RCT (after apex closes) 3. Partial pulpotomy (apexogenesis) -Highest success rate >85%

Molar relationships

1. Distal step -Develops into class II or end-end relationship 2. Flush terminal plane -Develops into end-end or class I 3. Mesial step -Develops into class I or class III Mesial step: majority result in class I permanent molars Flush terminal plane: majority become class I, but may also stay end-on Distal step: majority become class II

Sequence of Care

1. Emergency Care What is an emergency? - Pain (duration, provoked, time of day) -symptomatic or asymptomatic -Facial swelling -Traumatic injury -ortho appliances -eruption 2. Comprehensive examination with diagnostic aids 3. Consultations to finalize plan • Endodontic • Orthodontic • Oral Medicine • Prosthodontics, Periodontics, Implant 4. Prevention plan -in office and at home 5. Restorative/surgical care (may be modified based on behavior) • Sequence of care based on significance of teeth in the arch • permanent over primary • extent of disease (more involved is usual sequence) • All care delivered in full quadrant including sealants and extractions as part of care • Preventive/ Interceptive/space management to be planned to be done simultaneously 6. Recare plan

Basic types of space maintaners

1. Fixed unilateral -Band and loop -distal shoe 2. Fixed bilateral -Lower lingual holding arch (mandible) -Nance (maxilla) 3. Removable

Endodontic Diagnosis

1. History • Subjective Information • Presence and character of painful symptoms 2. Clinical Examination • Objective Information • Caries are often more extensive than radiographically visible • Endodontic Testing: Used to evaluate pulp sensibility and periapical diagnosis 3. Radiographic Imaging • Objective Information • Caries are often more extensive than radiographically visible Endodontic testing includes: -EPT -Pulpal sensibility tests -Bite test -palpation -percussion

Hypocalcified vs hypoplastic pitted vs hypoplastic generalized vs hypomaturation

1. Hypocalcified - normal thickness, smooth surface, less hard. 2. Hypoplastic - pitted - normal thickness, pitted surface, normal hardness. 3. Hypoplastic - generalized - reduced thickness, smooth surface, normal hardness. 4. Hypomaturation - normal thickness, chipped surface, less hardness, opaque white coloration.

Responses to luxation: internal root resorption types

1. Internal inflammatory 2. Internal replacement

Objectives of Pulp Therapy

1. Maintain the integrity and health of the dentition and supporting structures. 2. Maintain the tooth affected by caries, traumatic injury, or other causes. 3. Immature Permanent Dentition-pulp preservation § Apexogenesis § Favorable Crown : Root ratio § Dentin walls for normal function

Cleidocranial dysplasia

1. Medical - AD - >50% new mutation Stature Clavicles Hypertelorism 2. Dental Maxillary hypoplasia Overretained Hyperdontia Unerupted Failure to erupt 3. Treatment Prevention Extraction? Pressure appliance

Pediatric patient assessement for pulp therapy

1. Medical history -cardiac disease -immunocomp -px with healing problems 2. behavioral factors -precooperative -Cooperative 3. Dental status -is the tooth restorable -radiogrpaphic interpretation -Stage of dental development -Ortho considerations 4. Chief complaint -Subjective intesnity, duration, stimulus, relief, spontaneity -Objective examination -Clinical tests: palpation, percussion, mobility

Risks Associated with Antibiotic Use

1. Nausea, vomiting, diarrhea and stomach cramps • Because of the disturbances of the gut microflora. 2. Oral Contraceptive Interaction • May decrease effectiveness of oral contraceptives. 3. Development of yeast infections in the mouth or vagina • Resulting from an imbalance in the body's normal flora 4. Allergic responses • Ranging from rash to the development of Stevens-Johnson syndrome and anaphylaxis • An estimated 100-300 deaths per year are due to penicillin allergy in the US. 5. Development of bacterial resistance • Each year at least two million people in the U.S. become infected with multidrug resistant bacteria • At least 23,000 people die as a result of those infections (See 2019 update on next slides) . 6. Clostridium difficile infection • C. difficile was responsible for almost half a million infections and is associated with approximately 29,000 deaths annually. (See 2019 update on next slides) • Clindamycin, amoxicillin, cephalosporins are commonly associated with C. difficile infection.

Periapical Diagnosis

1. Normal Periapical 2. Symptomatic Apical Periodontitis • Positive (hypersensitive) to percussion • Can be associated with a tooth w/ a vital or necrotic pulp 3. Asymptomatic Apical Periodontitis • No response (same response as control tooth) to percussion w/ presence of periapical lesion • Associated with a tooth with a necrotic pulp 4. Acute Apical Abscess • Swelling associated w/ a tooth with a necrotic pulp 5. Chronic Apical Abscess • Sinus tract associated w/ a tooth with a necrotic pulp

Indications for Antibiotic Therapy in Pediatric Dentistry

1. Oral Wound Management • Soft-tissue lacerations that appear to have been contaminated by extrinsic bacteria • Open fractures • Joint injury 2. Dental Trauma • Application of topical antibiotics to avulsed tooth root to increase chance of pulpal space revascularization and periodontal healing in immature teeth (open apex). • Systemic antibiotics for reimplantation of avulsed tooth 3. Pediatric Periodontal Diseases • Aggressive Periodontal Disease • Periodontal Disease associated with systemic disease such as: • Papillon-Lefèvre syndrome • Severe congenital neutropenia • Leukocyte adhesion deficiency • Immune system unable to control growth of periodontal pathogens 4. Salivary Gland Infections (of bacterial etiology) • Acute bacterial parotitis • Chronic recurrent juvenile parotitis • Acute bacterial submandibular sialadenitis • Chronic recurrent submandibular sialadenitis 5. Acute Facial Swelling of Dental Origin • Warrants prompt dental attention, and • Adjunctive antibiotic therapy with surgical intervention

Etiology of injuries

1. Pre School (30%) Motor Coordination Child Abuse - >60% head and neck injuries Play injuries 2. School Age Play activities Athletics Foreign Body 3. Adolescent Athletics-contact sports Fight Injuries Motor Vehicle Accident

Loss of Arch Perimeter

1. Premature loss of primary teeth 2. Unrestored proximal carious lesions 3. Loss of permanent incisors as a result of trauma 4. Congenitally missing teeth such as permanent lateral incisors (maxillary or mandibular), central incisors (usually mandibular) and second premolars (usually mandibular). 5. Ectopic eruption of permanent incisors, canines, premolars, or first molars 6. Dental malformation resulting in small teeth

Luxation injuries: consequences

1. Prognosis dependent on degree of displacement Apex - better prognosis if open PDL - Bacteria - Splint 2. Pulp necrosis 15-85% time more prevalent with closed apex .5mm/day for revascularization with open apex 3. Pulp Canal Obliteration occurs in teeth with immature apex 4. Internal and external resorption 5. Transient apical breakdown (2-12%) expansion of the apical periodontal ligament space 6. Open apex no indication for commencing root-canal therapy unless indicators of infection of the pulp canal 7. Chlorhexidine decreases inflammation and may help in healing PDL 8. Antibiotic short term coverage(?)

Clinical Steps: Pulp Capping (/ partial pulpotomy) on a vital pulp

1. Pulpal exposure 2. Establish hemostasis* -This is the most critical step to determine whether you need pulp capping or a pulpectomy (full pulpotomy/ apexogenesis) -if hemostasis cannot be achieved: pulpectomy is indicated. The only difference between these 2 procedures is the level of pulp disection -also disinfect at this stage with irrigants 3. Apply capping material -caoh, MTA. biodentine 4. (Cover wound dressing) 5. Permanently Restore 6. Short term follow-up 7. Long term follow-up

MORPHOLOGY OF PITS AND FISSURES

1. Shallow, wide V-shaped fissures • tend to be self-cleansing • some-what caries-resistant 2. Deep, narrow I-shaped fissures • Quite constricted and may resemble a bottleneck in that the fissure may have an extremely narrow slit like opening with a larger base as it extends toward the dentinoenamel junction • Caries-susceptible, may also have a number of different branches

Pulpal Diagnosis

1. Vital Pulp (responsive to pulpal sensibility testing) • Normal • Reversible Pulpitis (hypersensitivity) • Irreversible Pulpitis - Symptomatic Irreversible Pulpitis - Asymptomatic Irreversible Pulpitis 2. Necrotic Pulp (non-responsive to pulpal sensibility testing)

Potential ways a root fracture can heal

1. interposition of dentin 2. PDL infiltration between the fragments, round off edges? 3.Replacement 4.Inflammation 5.ankylosis

Pulp therapy for primary teeth

1. nonvital primary teeth -Pulpectomy -Antibacterial sterilization (LSTR)? 2. Immature permanent dentition -Apexogenesis -apexification -Revascularization

Dentitions

1. primary 2. Mixed -Early: when permanent first molars and lower central incisors start erupting -late: when the primary canines and molars are exfoliated 3. Permanent

What age is a referral recommended to an Orthodontist?

7 Years Old Knowing how the dentition develops and what is an abhorrent is key to treating the mixed dentition

Premature Loss of Primary Teeth

About 51% of the prematurely lost first deciduous molars and 70% of prematurely lost second deciduous molars cause loss of space and subsequent effects such as: • malposition or impaction of a permanent tooth in that quadrant • tipping of the first permanent molar, and • crowding in the dental arch. Treated by: - Band and Loop: maintaining one space mesial to a present tooth Bilateral Space Maintainers -Lower lingual holding arch -Nance appliance -Trans-palatal arch

Type II Mouth-formed (Boil and Bite) Mouthguards

Advantages • Inexpensive • Easily purchased over-the-counter Disadvantages • Limited in size • Unstable material • Difficult to customize • Poor fit • Difficult to wear • Bulky • Difficulty with speech and breathing

Type I Stock Mouthguards

Advantages • Inexpensive • Easily purchased over-thecounter at sporting goods stores • No fitting necessary • Limited in size Disadvantages • Poor fit • Bulky • Lack of Retention • Difficulty in speaking • Low level of protection, if any

Custom-fitted Vacuum-formed

Advantages: • Adequate fit • Not bulky • Easy to customize by dentist • Little interference with speech and breathing • Low dentist cost Disadvantages: • Machine • Requires professional skill • Low heat • Material retains memory

Heat/Pressure Laminated

Advantages: • Precise adaptation • Do not distort their shape Disadvantages: • Expensive machine • Office or laboratory fabrication

Fluoride Toxicity: dosage of water

An adult would have to drink 660 gallons in 2-4 hours to reach the lower limit of a fatal dose A 10 kg child (12-18 months old) would have to drink 85 gallons Fluoride works predominantly through topical mechanisms Small amounts of fluoride are needed in solution in saliva to assist in remineralization Fluoride is most effective in low doses at regular intervals on a daily basis The focus of our profession is changing from diagnosis & treatment, to disease prevention, health maintenance & health promotion.

Anesthetic injection in children

Anatomic structures in children are naturally smaller than those in an adult Therefore, there is good reason toreduce the depth of penetration of the needle during injection procedures -Do not want to go to the hub of the needle

THERAPEUTIC SEALANTS

Applied to pits and fissures in which caries is confined to enamel (incipient lesions E1-E2) to arrest caries progression. Lesions are limited to enamel White opacity or chalkiness around fissure upon visual exam No radiographic evidence of caries to dentin Sealants on enamel lesions are safe *Evidence has shown sealing active dentin lesions arrests the progression of caries Bitewing radiograph for detection of occlusal and interproximal caries Zero degree periapical radiograph for detection of occlusal/ and interproximal caries

CRA for >/= 6yrd old

Biological -Px is of low SES: HR -Px has >3 between meal sugar containing snacks or beverages: HR -Px has special needs: MR -Px is a recent immigrant: MR Protective: all LR -Px recieves optimally flouridated water -Px brushes teeth daily with flouridated toothpaste -Patient recieves topical flouride from health professional -Additional home measures (xylitol,MI paste) -Patient has dental home/ regular care Clinical findings -Px has >/= 1 interproximal lesions: HR -Px has active white spot lesions or enamel defects: HR -Px has low salivary flow: HR -Px has defective resto: MR -Px is wearing an intraoral appliance: MR

What is the most important part to check clinically during mouthguard delivery?

Borders and Flanges

Prevention of oral trauma

Anticipatory Guidance Infant/Toddler - Car restraints - Gates Helmet Mouth guards - Custom-fitted Early orthodontics

Apexification vs apexogenesis

Apexification is a method of inducing a calcified barrier at the apex of a nonvital tooth with incomplete root formation. Apexogenesis refers to a vital pulp therapy procedure performed to encourage physiological development and formation of the root end. -apexogenesis is basically a pulpotomy, for immature permanent teeth, with MTA or calcium hydroxide, to allow the tooth apex to naturally close and develop in a vital tooth -Apexification is for permanent, immature, non vital teeth, to induce root closure at the apex artifically. Use calcium hydroxide to form a calcified bridge at the apex, can also use MTA. once a firm closure has been achieved, the final obturation is performed apexogenesis and apexification are for immature permanent teeth that are vital and non-vital respectively

Indications for: -Apexogenesis -Indirect pulp cap -Direct pulp cap -partial pulpotomy for carious exposure -Partial pulpotomy for traumatic exposure (cvek pulpotomy) -Pulpectomy -Apexification

Apexogenesis (root formation). - Apexogenesis is a histological term used to describe the continued physiologic development and formation of the root's apex. - Formation of the apex in vital, young, permanent teeth can be accomplished by implementing the appropriate vital pulp therapy described in this section (i.e., indirect pulp treatment, direct pulp capping, partial pulpotomy for carious exposures and traumatic exposures). Indirect pulp cap -Indirect pulp treatment is a procedure performed in a tooth with a diagnosis of reversible pulpitis and deep caries that might otherwise need endodontic therapy if the decay was completely removed. -Indirect pulp treatment is indicated in a permanent tooth diagnosed with a normal pulp with no symptoms of pulpitis or with a diagnosis of reversible pulpitis. The pulp is judged by clinical and radiographic criteria to be vital and able to heal from the carious insult. Direct pulp cap -When a small exposure of the pulp is encountered during cavity preparation and after hemorrhage control is obtained, the exposed pulp is capped with a material such as calcium hydroxide or MTA -Indications: Direct pulp capping is indicated for a permanent tooth that has a small carious or mechanical exposure in a tooth with a normal pulp. Partial pulpotomy for carious exposures -The partial pulpotomy for carious exposures is a procedure in which the inflamed pulp tissue beneath an exposure is removed to a depth of one to three millimeters or deeper to reach healthy pulp tissue. Pulpal bleeding must be controlled by irrigation with a bacteriocidal agent such as sodium hypochlorite or chlorhexidine before the site is covered with calcium hydroxide or MTA. While calcium hydroxide has been demonstrated to have long-term success, MTA results in more predictable dentin bridging and pulp health. -Indications: A partial pulpotomy is indicated in a young permanent tooth for a carious pulp exposure in which the pulpal bleeding is controlled within several minutes. The tooth must be vital, with a diagnosis of normal pulp or reversible pulpitis. Partial pulpotomy for traumatic exposures (Cvek pulpotomy). - The partial pulpotomy for traumatic exposures is a procedure in which the inflamed pulp tissue beneath an exposure is removed to a depth of one to three millimeters or more to reach the deeper healthy tissue. -Indications: This pulpotomy is indicated for a vital, traumatically-exposed, young permanent tooth, especially one with an incompletely formed apex. Pulpal bleeding after removal of inflamed pulpal tissue must be controlled. Neither time between the accident and treatment nor size of exposure is critical if the inflamed superficial pulp tissue is amputated to healthy pulp. Pulpectomy (conventional root canal treatment) - Indications: Pulpectomy or conventional root canal treatment is indicated for a restorable permanent tooth with irreversible pulpitis or a necrotic pulp in which the root is apexified. For root canal-treated teeth with unresolved periradicular lesions, root canals that are not accessible from the conventional coronal approach, or calcification of the root canal space, endodontic treatment of a more specialized nature may be indicated. Apexification (root end closure) -Apexification is a method of inducing root end closure of an incompletely formed nonvital permanent tooth by removing the coronal and nonvital radicular tissue just short of the root end and placing a biocompatible agent such as calcium hydroxide in the canals for two to four weeks to disinfect the canal space. Root end closure is accomplished with an apical barrier such as MTA.In instances when complete closure cannot be accomplished by MTA, an absorbable collagen wound dressing (e.g., Colla-Cote®) can be placed at the root end to allow MTA to be packed within the confines of the canal space. Gutta percha is used to fill the remaining canal space. If the canal walls are thin, the canal space can be filled with MTA or composite resin instead of gutta percha to strengthen the tooth against fracture. -Indications: This procedure is indicated for nonvital permanent teeth with incompletely formed roots. - Apexogenesis is for vital immature permanent teeth -Apexification is for non-vital immature permanent teeth -Direct pulp capping / partial pulpotomy and indirect pulp capping is for primary or permanent vital teeth -Pulpectomy is for primary or permanent mature teeth Permanent, immature -Apexogenesis: vital -apexification: non -vital -direct pulp cap: vital -indrect pulp cap: vital Primary or permanent mature -Pulpectomy Immature vital -Indirect pulp cap -Direct pulp cap/ partial pulpotomy -Apexogenesis (full pulpotomy) Immature non vital -Revascularization -Apexification: For primary teeth, pulpotomy is the definitive treatment, or in rare cases pulpectomy if bleeding cannot be controlled at all and the tooth is irreversible or necrotic. Pulpectomy is never to be done on immature teeth, instead you do apexification or apexogenesis depeinding on vitality (non-vital vs vital)

Cleft lip/palate management

Assess: Cleft patients are commonly missing anterior maxillary teeth in the cleft area. Lateral incisors are most common, followed by centrals. If not missing, they may be malformed or malposed. Medication: Children with clefts may have other conditions for which they need medication, but typically no special medications are taken. Behavioral • Children may have hypernasal speech which is difficult to understand as a result of velopharyngeal insufficiency. • Many young children with clefts will exhibit shy, nervous, or uncooperative behavior. This may have to do with previous hospitalization or frequent hospital visits. General • Bone support for these teeth is generally poor. Teeth that are present may be malformed and prone to caries. • Parents appreciate education about teeth present or missing, surrounding a cleft. Simple explanations about the variability of teeth at the cleft site may allay concerns. • Panoramic and/or Occlusal radiographs are indicated to monitor development. • The majority of children with a cleft palate will require orthodontics. Orthodontic treatment may be required in the primary, mixed, and permanent dentition. Facilitate contact with an orthodontic provider if child has not been evaluated. • Prosthetic obturation of palatal fistulae may be necessary in some children. Referral to appropriate specialists in cases with velopharyngeal insufficiency is indicated. • Clefts are often associated with middle ear problems and hearing difficulties

Enamel defects systemic factors: childhood cancer treatment

Chemotherapy • interferes with cell cycle and intracellular metabolism • children with chemotherapy <5yo more likely to develop dental anomalies due to increased activity of dental stem cells during this period •Alkylating agents (Cyclophosphamide) demonstrated adverse effects in both animal models and small cohort studies Radiation Therapy • Animal models have shown radiosensitivity of developing teeth • RT may damage the tooth bud, causing malocclusion, growth retardation of teeth, arrested crown and root development • Degree of severity of dental anomaly is dependent on age of patient at time of exposure, and dosage of the drug • RT >20Gy has been shown to contribute to a 4-fold to 10-fold higher risk of developing abnormalities • Effect limited to structures within field of irradiation

Cleft Lip and Primary Palate: Embryology

Cleft Lip and Primary Palate: • 4-7 weeks gestation • Failure of fusion of median nasal process with maxillary processes Cleft Secondary Palate: • 6-9 weeks gestation • Failure of fusion of lateral palatine shelves Prenatal Diagnosis • 18-20 week ultrasound • > 75% in experienced centers

Sealing Caries-free Teeth

Consider caries risk as determined by: Pit & fissure morphology Eruption status Caries activity in mouth

Conventional Radiography and Apex Locators in Primary Teeth

Design § 4-10 year olds, tooth to be extracted § CR, Root ZX, and ProPex § Root length determined Results § The most accurate method compared with SEM in determining the working length in primary teeth was the Root ZX followed by the ProPex , with CR was the least accurate § The 3 techniques were not significantly different from each other in their accuracy in determining working length. So conventional radiography (CR) was just as accurate as apex locators

Localized Juvenile spongiotic gingival hyperplasia (LJSGH)

Distinct, new subtype of gingival hyperplasia Other names: Juvenile spongiotic gingivitis or juvenile gingival papillomas Origin: Sulcular/junctional epithelium Cause: Unknown - not strong bacterial plaque association; viral cause, especially HPV ? Factors: Orthodontics (15%), tooth eruption, lip incompetence/mouthbreathing, puberty Age/Gender/Race: Ave = 12 YO (range 5-39) F>M = 2.3:1 / White Site: Anterior facial gingivae, especially maxillary (84%); may be multifocal Papillary, pedunculated, red nodule or velvety - granular patch; bleeds easily; nontender Does not respond to traditional periodontal treatment or oral hygiene TX : Excisional biopsy; 6-16%recur within 1 year; may spontaneously resolve

Scheme for Selecting Drugs by Temperament & Behavior

Easy behavior -Midazolam: Vis, low dose CH or meperidine; N2O for titrating Difficult -Higher dose CH + Vis; CH/Dem/Vis combo (all w/ N2O) Vis= Vistaril = Hydroxyzine

Crown fractures in primary incisors

Enamel and dentin fracture Location and extent of pulp exposure is most significant Pulpectomy is sometimes indicated following necrosis A pulpectomy is indicated in a primary tooth with irreversible pulpitis or necrosis or a tooth treatment planned for pulpotomy in which the radicular pulp exhibits clinical signs of irreversible pulpitis (eg, excessive hemorrhage that is not controlled with a damp cotton pellet applied for several minutes) or pulp necrosis (eg, suppration, purulence). The roots should exhibit minimal or no resorption.

Responses to luxation: external root resorption types

External Root Resorption 1. Surface resorption - Repair of the resorption lacuna with cementum-like tissue - Self-limiting 2. Replacement resorption - Dentoalveolar ankylosis with replacement resorption. - Absence of PDL and cemental layer - Direct union of the bone and root. 3. Inflammatory resorption

Two most important indicators for success in an avulsed tooth

Extra oral condition and splint are the 2 most important indicators for success Transport Medium Soft Tissue Laceration Root surface Socket Splint Endodontic Treatment 1. Open apex - Extra-oral time and medium - > 1 hour may be a guide 2. Closed apex - Pulpectomy 7-10 days Calcium Hydroxide as medicament for up to 6-12 months

Vital pulp Clinical Scenario: Pulpal Exposure

Factors to consider after pulpal exposure: 1. Type of injury (carious exposure v. traumatic exposure) • Presence of bacteria in cases of carious exposure • Absence of significant bacteria in cases of traumatic pulpal exposure 2. Bacterial contamination is the most important factor impacting treatment outcomes after pulpal exposure 3. Size and location of the exposure • Location: Impacts ability to achieve adequate seal from bacterial microleakage • Size: May Impact body's healing ability 4. Patient Age • Younger patients have an increased capacity for healing Procedures to consider after pulpal exposure:(on a vital tooth) 1. Direct Pulp Cap/ Partial Pulpotomy • Procedures to consider when there is no history of spontaneous pain to external stimuli and the pulp has been: • Accidentally exposed to the oral environment by traumatic injury • Exposed in conjunction with the excavation of caries 2. Apexogenesis (Full pulpotomy) • Persistent bleeding from the pulp indicates need for pulpal resection at a deeper level -In the case of vital pulp therapy, pulpotomies are the definitive treatment -The only difference between direct pulp capping / partial pulpotomy and apexogenesis (full pulpotomy) is the degree of pulp dissection

Flouride is what

Fluoride is the negative ion (F-) of the element fluorine Found in bones and teeth A naturally occurring mineral in: • Water • Soil • Plants • Air

Too much of a good thing: Flourosis

Fluorosis - abnormal condition caused by excessive intake of fluoride Characterized by: Discoloration and pitting of teeth Dean's Index Score: Questionable, Very mild, Mild, Moderate, Severe - Resistant to decay - Mostly a cosmetic problem at Very Mild and below

Oral Habits

Focus on Nonnutritive oral habits • Commonly Finger or pacifier: most common and most detrimental on primary dentition • Among the more common in infancy and early childhood • Among the more detrimental when prolonged in the primary dentition Key factors: • *Duration* : key in that it correlates the most with dentoalveolar changes, know setting, time, etc. • Frequency • Intensity • Early dental visits allows for anticipatory guidance to help discontinue these habits by 24-36 (ages of 2 and 3) months of age, because this is when we can prevent dentoalveolar changes or they can be reversible if the habit is stopped at this point • Empower the parent with knowledge, and discourage punishment • If a habit persists despite anticipatory guidance, additional management may be warranted that is based on the child's: • Development • Comprehension • Ability to cooperate. Habit Treatment Modalities: • Parent/Patient counseling • Behavior modification techniques (some kind of reward system at home to break the habit) • Appliance therapy may be necessary as a reminder tool • Referral to other providers Appliance therapy • Child wants to stop • Reminder, not punishment -appropriate when the child is ideally still in the primary dentition but they are old enough to understand what can happen to their teeth and they want to stop the habit on their own and just need a reminder Habit appliances -Bluegrass appliance: similar to the W palate expander, but in this case has a spinning wheel attached to the anterior portion so if the child has a finger sucking habit it will roll off -Quad helix, used as a palate expander, but because it has an anterior component can act as a habit appliance at the same time -Appliance based on px needs -Comprehensive ortho can also incroporate a habit appliance

Vital pulp Clinical Scenario: Direct Pulp Cap after carious exposure

Follow-Up Time Point: 1 year, 7 months

Sequelae of primary tooth trauma to the permanent dentition

Following an injury to a primary tooth, the most common sequelae to the succedaneous tooth is enamel/dentin hypoplasia 2-3 mm between apex of primary and crown of permanent -The issue occurs if the tooth (primary) intrudes into the tooth bud of the permanent, if it is deflected away from the bud, not a big issue Damage to developing dention inlcudes: - White spots - Yellow spots - Hypoplasia -Crown dilaceration -Root dilaceration -Vestibular deformation -arrest of crown formation -malocclusion -Most of these are regarding an intrusive luxation Enamel/Dentin defects occur 1/3 of the time

Apexogenesis

For a vital pulp treatment on an immature permanent tooth • Indication for Apexogenesis (Full Pulpotomy): • Persistent bleeding from the pulp indicates need for pulpal resection at a deeper level -If hemostasis is excessive and cannot be controlled at all, then you need to do a pulpectomy and conclude the tooth is irreversibly inflamed -In the case of vital pulp therapy, pulpotomies are the definitive treatment -You perform a full pulpotomy, and then place a dressing and a cornoal seal, permitting continued root formation with increasing root length and wall thickness

Prescription Writing

Four Steps to Writing a Prescription 1. Patient's name and another identifier, usually date of birth. 2. Medication and strength, amount to be taken, route by which it is to be taken, and frequency. 3. Amount to be given at the pharmacy and number of refills. 4. Signature and physician identifiers like NPI or DEA numbers. • Most drugs in children are dosed according to body weight (mg/kg). • When prescribing medications for kids, remember that they often require medications to be dispensed as a suspension or a solution instead of tablets! • Metric Conversions: • 5mL = 1 teaspoon (t) • 10mL = 2 teaspoon (t) • 15 mL = 1 tablespoon (T)

Selection of Restoration and Material

Full coverage -SCC -Strip crown Internal resto -Amalgam -RMGI -GI -Composite Based on a number of factors, especially dental age -RMGI or composite can withstand occlusal forces for 1-2 years, if it is going to go beyond that (the situation) you need to consider full coverage, because a class II resto might not stay in the mouth for 5-6 years. Based on -Etiology of disease (nutritive, developmental, flouride deficit, - underlying medical issues like nebulizer usage or GERD -Dental age -Extent of disease (high cariers aka SECC or ECC, you need full coverage for these even if you only see a small occlusal or interproximal on a 3yr old, they are high risk and need full coverage)

Preoperative Health Evaluation

Health History • Allergies: previous adverse reactions • Current medications • Diseases, disorders, physical abnormalities, pregnancy status • Previous hospitalizations • History of complications with sedation or general anesthesia • Family history of disease or disorders • Review of systems • Age in years and months • Weight Physical evaluation • Vital signs (BP, heart and respiratory rates) • Evaluation of patent airway • Risk assessment (ASA classification) Brodsky Classification -Brodsky 3 and 4: Increased risk for airway obstruction

CRA for 0-5 yr olds

High risk/ moderate risk/ low risk (HR/MR/LR) 1. Biological -Mother/ primary caregiver has active caries: HR -Parent/ caregiver has low SES: HR -Child has >3 between meal sugar-containing snacks or beverages per day : HR -Child has special needs: MR -Child is a recent immigrant: MR 2. Protective: all LR -Child receives optimally fluoridated drinking water or fluoride supplements -Child has teeth brushed daily with fluoridated tooth paste -Child receives topical fluoride from health professional -Child has dental home/regular dental care 3. Clinical findings -Child has >1 decayed/missing/ filled: HR -Child has active white spot lesions or enamel defects: HR -Child has elevated s.mutans levels: HR -Child has plaque on teeth: MR -Wherever you place the highest risk is the classification

Caries Pattern

If the pattern of caries indicates susceptibility to pit & fissure caries as evidenced by occurrence of one or more lesions per year, it is advised that the remaining caries-free pit & fissure surfaces of teeth at greatest risk be sealed.

Decision tree for managing an avulsed tooth

If the tooth is permanent: 1. If replanted immediately, best prognosis: assess position and stability 2. If not immediately replanted, was the dry time <15 minutes or was the tooth stored in an appropriate medium? If yes, and the root IS developed completely, replant and plan to extirpate the pulp in 10-14 days If yes and the root is NOT completely developed, replant and closely monitor for pulpal necrosis If NO, consider the stage of dental development (risk of ankylosis increases significantly with extra-oral dry time of 15 minutes). - If the apex is closed and alveolar growth completed, replant. - If the apex is open, and considerable alveolar growth is expected, risk of ankylosis would discourage replantation If the tooth is a primary tooth, do not replant at all

Tx options for immature vital vs non vital teeth

Immature vital -Indirect pulp cap -Direct pulp cap/ partial pulpotomy -Apexogenesis (full pulpotomy) Immature non vital -Revascularization -Apexification

Uncomplicated crown fracture

Immediate tx - Atraumatic restoration - Pulp vitality dependent on seal of restoration -Medicament: GI or RMGI -Reattachment of fragment •Remove layer of dentin in fragment •Bevel fracture line •RMGI over deep pulp area •Etch and bond fragment

Troubleshooting piercing problems

In the event that you diagnose a localized piercing infection: • Important: removing jewelry in the presence of an infection may result in an abscess. Quality body jewelry or a retainer of an appropriate size, style, and material should be left in place so the infection can drain • Isotonic saline soaks and/or hot compresses can encourage drainage • Bactroban (Mupirocin) cream or gel (not ointment) has been found to be effective for topical treatment of bacterial infections

Pulpectomy in Primary Teeth

Indications - Irreversible pulpitis - A tooth planned for pulpotomy, but open opening there is: § radicular pulp exhibits clinical signs of irreversible pulpitis § excessive hemorrhage § pulp necrosis § roots should exhibit minimal or no resorption Objectives § Radiographic infectious process should resolve in six months § Pretreatment clinical signs and symptoms should resolve within a few weeks. § Radiographic evidence of successful filling without overextension or underfilling § Treatment should permit resorption of the primary tooth root and filling material to permit normal eruption of the succedaneous tooth. § There should be no pathologic root resorption or furcation/apical radiolucency. Contraindications § Medical condition § Gross loss of tooth structure, not restorable § Advanced internal/external root resorption: More than 1/3 root resorption present § Perforation of floor of pulp chamber: the area is much thinner, many accessory canals, this is the area where you first see pathology in a primary tooth § Periapical infection approaching or involving the crypt of the succedaneous tooth § Excessive mobility What is different than the permanent dentition Endodontics ? § No measurement generally taken § Canals not instrumented § Irrigation medicament may vary (depending on whether it is vital or non-vital) § No gutta percha used, only resorbeable materials § Usually one visit procedure

Fluoride Rinses

Indications: High risk patients Orthodontic appliances Prosthetic appliances Radiation to head & neck High sucrose diet Over the counter or Prescription 27% reduction in DMFS in permanent teeth & 23% DMFT

Vital pulp Clinical Scenario: No Pulpal Exposure

Indirect Pulp Cap • Used to treat normal pulp or pulp with reversible pulpitis • Treatment option in the case of deep caries excavated without pulpal exposure but the remaining dentin is very thin (thus dental tubules are large and at increased risk for bacterial invasion)

Management of the Immature Apex: Vital Pulp therapy goals, inflammation, tx

Inflammation • Aims to neutralize and eliminate noxious agents • Organizes repair of damaged tissue • Inflammatory response may take a destructive course and may result in severe pain and necrosis of the pulpal tissue Vital Pulp Therapy Goals: • Aims to prevents the development of a destructive course of pulpal inflammation and subsequent infection of the root canal space Treatment Options 1. Vital Pulp Therapy • Conservative aims to preserve the pulp and re-establish non-painful, healthy conditions in the long-term • Indirect Pulp Cap • Direct Pulp Cap/ Partial Pulpotomy • Apexogenesis (Full pulpotomy) -in the case of vital pulp therapy, pulpotomies are the definitive treatment 2. Pulpectomy • Preventative, radical aim that removes the entire pupal tissue and replaces it with a root canal filling

Crohns

Inflammatory disease of GI tract Age: Starts in childhood Oral lesions precede GI lesions: 30% Cramping pain, diarrhea, nausea, weight loss, anemia, decreased growth Aphthous-like ulcers, tissue tags, cobblestone pattern, diffuse or nodular swelling, stomatitis; orofacial granulomatosis; Staph infection TX: Sulfasalazine, steroids +/- azathioprine In picture: A-Lip swelling with fissures B -Cobblestone of buccal mucosa. C-Linear ulceration in the mandibular vestibule D-Mucosal tag on the buccal aspect of the gingiva. E- Mucogingivitis of maxillary permanent incisors. F- Pyostomatitis lesions on gingival mucosa

Ectodermal dysplasia

Inherited disorders involving ectodermal derived structures. Most common is the hypohydrotic X-linked form. ( >150 types) The usual presentation is a male child with: • Multiple missing teeth • Conical shaped teeth • Maxillary hypoplasia • Frontal bossing • Eversion of the lips • Lips showing little vermilion margin • Delay in eruption • Decreased saliva flow • Dry skin • Fine, sparse hair with shaft abnormalities Heterozygous females are often diagnosed dentally. Teeth are small and conical, often with large anterior diastema TREATMENT • Begin early • Prevention-Fluoride • Dentures - Valplast • Overdentures • Bonding • Orthodontics • Implants

Tanaka-Johnson Summary

MANDIBLE Measure space available Measure lower anterior segment Add 10.5/quadrant to 1/2 the lower anterior segment number Add previous number to total value of lower anterior segment for space required Subtract space required from space available If negative- crowding If positive- spacing MAXILLA Measure space available Add 11/quadrant to 1/2 the LOWER ANTERIOR segment number Add previous number to total value of UPPER INCISOR segment for space required Subtract space required from space available If negative- crowding If positive- spacing WARNINGS! Small bias towards overestimating the unerupted tooth size No need for radiographs or charts Based on Midwestern faces Not account for Bolton discrepancies or tooth size differences Why Important? The amount of spacing or crowding will affect treatment decisions With crowding, you may want to hold space, reduce interproximally or extract primary teeth (serial extractions) Have many diagnostic tools should make decisions easier

Anticipating and recognizing malocclusions

Malocclusions -Inherited, acquired, or both -Dental, skeletal, or both -Primary, permanent, or both -Unilateral or bilateral -Anterior, posterior, or both Types -Class I, II, or III -Crowding, spacing: anomalies of size, number, space loss -Cross bites -Ectopic eruption Early detection may allow for growth guidance -Timely extractions -space maintenance -Disking -Interceptive orthodontics -Depending on the malocclusion, one should be able to recognize it clinically, radiographically, or both

Pre-term low birth weight: medical and dental implications

Medical issues Hyaline membrane disease/respiratory insufficiency Hyperbilirubinaemia Necrotizing enterocolitis Cerebral intraventricular haemorrhage. Oxygen retinopathy Dental issues Hypoglycaemia. Hypocalcaemia with reactive pseudohyperparathyroidism Hyperbilirubinaemia, causing intrinsic staining of teeth Intubation trauma - hypoplasia/ hypocalcification. - maxillary central incisors ,most commonly the left - palatal grooving may occur. Tooth eruption may be delayed Chronological opacities or hypoplasia

Seizure disorders - relevance to oral health: Medication side effects

Medication side effects: •Phenytoin (Dilantin) - Gingival hyperplasia •Carbamazepine - Xerostomia •Valproic Acid (Depakote, Depakene) - Can cause bone marrow suppression that can impair wound healing, decrease platelet function (prolonged bleeding) - Interacts with aspirin - do not use for pain - NSAIDS to be used with caution (should check hepatic function) •Topiramate -- Metallic taste in mouth

Patient Assessment Criteria in sedation

Minimal sedation/anxiolysis -Normal response to verbal stimulation -Airway unaffected -Spontaneous ventilation unaffected -CV function unaffected Moderate sedation/ analgesia -Responsiveness: Purposeful response to verbal commands or light touch - Airway: No intervention required - Spontaneous ventilation: Adequate -CV function: Usually maintained Deep sedation -Responsiveness: Purposeful response to repeated or painful tactile stimulation - Airway: Intervention may be required - Spontaneous ventilation: May be inadequate -CV function: usually maintained General anesthesia -Responsiveness: Unarousable even to repeated or painful stimulation - Airway: Intervention often required - Spontaneous ventilation: Frequently Inadequate -CV function: May be impaired

Head injury

Most common cause of childhood mortality in accidents 25% and 50% of all accidents in children up to 14 years Signs of Head Injury Altered or loss of consciousness Disorientation Headache Nausea, vomiting Altered vision, dilated pupils (PERRLA) Seizures or convulsions Speech

Indications for Nance vs TPA

Nance • When primary molars have been lost bilaterally. • Permanent molars may tip mesially despite the transpalatal arch TPA • Best indication is when one side of the arch is intact and more than one primary tooth is missing on the other side. • Rigid attachment to the intact side usually provides adequate stability for space maintenance

ALARA: Radiographic indications

New patients -All new patients to assess disease and growth and development -Primary dentition: BW for closed contacts between posteriors, pan to assess other pathology/growth -Mixed Dentition: BW and individualized pans depending on the scenario -Adolescent: Individualized radiographs with BW and pans Recalls -No clinical caries and low risk -Primary: If contacts can be visualized or probed, BW may not be required, otherwise BW at 12-24mo intervals -Mixed: One set of BW once the first permanent molars have erupted -Adolescent: BW every 18-36mo after the eruption of the second permanent molars up to age 20 -if clinical caries or high risk of disease: BW every 6-12mo or until no new caries are evident over 12mo (for primary, mixed, and ado) Growth and development -Primary: usually not required -Mixed: individualized exam, based on anomaly or disease presence, with PA or pans Ado: Pan or PA films to assess position of 3rd molars and other ortho considerations

Behavioral Evaluation

Observation + Interaction = Profiling Components Parental interview (Parent-Dentist) - Developmental milestones (see appendix) - Social and Health history - Attitudes and Expectations Indirect observation of Child-Parent interaction by Dentist - Attachment and temperament - Child rearing practices / discipline Direct child interaction (Child-Dentist) Child Profiling from Observation Indirect observation of child-parent interactions and the child's communication and coping skills Example: observe child being weighed to evaluate temperament and attachment Components of Child Temperament Difficult: - Irregularity of biologic functions - Withdrawal response with new stimuli - Very slow in adapting - High frequency of negative moods - Frequent intense negative reactions Evidence for Influence of Temperament on Child Behavior in Dental Setting Parental report of child's anxiety when meeting unfamiliar people is associated with negative behavior during dental treatment "Shyness" best predicts child's distress at parent separation Parental report of their child as "shy" was correlated to a less successful sedation with midazolam and poorer amnesia Parental Questionnaire "Shyness Factor": to develop a temperment score Predicting Sedation Outcome From Child's Interactive Behavior Children with poor interactive behavior and high heart rates pre-operatively exhibited poorer behavior and higher heart rates intraoperatively Pre-operative interactive behavior and heart rate was judged predictive of intraoperative behavior during a sedation Predicting Sedation Outcome: Children who were unable to talk at the initial patient interaction had a higher mean heart rate during the duration of the procedure and during anesthesia Ohio State University Behavioral Rating Scale Quiet Crying: fearful tears or defiant screams Struggling: combative, hyperactive, or uncontrolled movement Crying and Struggling

Endodontic therapy after avulsion

Open Apex If extra-oral > 1 hour need treatment (text) Replant and monitor for clinical signs (actual)* Closed Apex Replant Calcium Hydroxide placed within 7-10 days - changed 6-12 months Can replace CaOH after 30 days with MTA Complete Endodontics ** Kramer states that ALL require complete RCT if extra-oral > 15 minutes

Prevalence of oral mucosal lesions from birth to 2 years

Overall prevalence - 21.3% Candidiasis - 11% Epstein pearls - 3% Erythema migrans - 3% Erosion/ulcer - 2% Angular cheilitis - 3% Primary HSV - .3% Hemangioma - .3% Papilloma - .3% Fibroma - .3% Hairy tongue - .3%

Treatment of Posterior Crossbites:

Palatal Expansion

Sublingual hematoma

Pathognomonic for a fractured mandible in symphysis or canine region

Factors other than Medications when Choosing AppropriateSedation Protocol

Patient related -age -level of maturity -Past experience -Underlying condition -Comorbidities Endoscopist related -Level and type of sedation training -Past experience -Efficiency Procedure related -Type -Complexity -Duration Institution related -Site -Availability of nursing and ancillary personnel -Policy

Adjunctive Antibiotic Therapy

Penicillin Derivatives (Ex: Penicillin V Potassium (Pen VK), Amoxicillin) • Remain the empirical choice for odontogenic infections. • However, not recommended as initial therapy for serious infections that may require hospitalization, possibly due to penicillin resistant oral anaerobes. • Forms: Tablets and Suspension (Oral Route of Administration Only!) Clindamycin • Drug of choice when penicillin-family drugs are contraindicated, more serious infection, or when infection is more anaerobic in late stage. • Forms: Capsules, suspension, Injectable (Can be given IV) Cephalosporins • Could be considered as an alternative choice for odontogenic infections.

Problem 1. Calculate the dose of Pen VK suspension in mLs for moderate acute odontogenic infection for a 3- yr-old child weighing 32 lbs

Penicillin V Potassium (Brand Name: Pen VK) Forms: • Tablets= 125mg, 250mg, 500mg • Suspension= 125mg/5mL, 250mg/5mL Usual Oral Dose • <12 years: 25-50mg/kg/day in divided doses every 6-8 hours (Max: 3g/day) • ≥12 years and adults: 250-500mg every 6-8 hours Pt. Weight: 32 lbs Dose Required: 25-50mg/kg/day q6-8h. MDD: 3g Suspension concentrations: 125mg/5mL or 250mg/5mL. Step 1. Convert pounds to kg: 32 lb × 1 kg/2.2 lb = 14.5 kg Step 2. Calculate the dose in mg: In this case, you will calculate the dose at the highest and lowest range. 14.5 kg × 25 mg/kg/day = 362.5 mg/day 14.5 kg × 50 mg/kg/day = 725 mg/day (Safe range is 362.5 mg - 725 mg per day) Step 3. Divide the dose by the frequency: (let's do q8h = 3 times per day) 362.5 mg/day ÷ 3 = 120.8 mg/dose 725 mg/day ÷ 3 = 241.6 mg/dose Step 4. Convert the mg dose to mL: (Let's use the lower concentration suspension for this step) 120 mg/dose ÷ 125 mg/5 mL = 4.8 mL q8h 241.6 mg/dose ÷ 125 mg/5mL = 9.6 mL q8h Safe Range is 4.8 mL - 9.6 mL q8h Patient Name: J. Doe Date of Birth: 08/01/16 Medication: Pen VK 125 mg/mL Sig: Take 1 tsp by mouth three times per day for 5 days. Disp: 75 mL Refills: 0 Doctor's Signature

Dens Invaginatus

Permanent dentition 4% - Maxillary Laterals most common

Space maintenance

Possible scenarios -Premature extraction (caries): most common reason that requires space maintenance -Need to maintain leeway space/ arch circumference -Ankylosis -Congenitally missing Space maintenance considerations -Time elapsed since loss -Dental age of the patient -Amount of bone covering the unerupted tooth -Sequence of the eruption of teeth -Delayed eruption of the permanent tooth -Congenital absence of the permanent tooth

Cleft lip and palate

Prevalence: Less than 1% Manifestations Clinical: Multidisciplinary teams are used to address the complex issues that need to be solved for successful habilitation. This fact sheet addresses issues for the dental provider once the child has been discharged from the Maxillofacial team. • Maxillary hypoplasia • Aberrant speech patterns • Emotional and physical distress • Conductive hearing loss in some children • Significant and persistent middle-ear infections Oral • Congenitally missing teeth • Supernumerary teeth • Malformed teeth • Fistulas may be obturated • Ectopic eruption of primary maxillary anterior dentition Other Potential Disorders/Concerns • Many conditions may have an associated cleft; understanding the condition is critical to dental management of the patient.

Principles Regarding Sealant Usage

Prevention of dental caries is better than treatment. Therefore, sound, non-diseased teeth are more highly valued than adequately restored teeth. For equivalent outcomes, the least invasive approach, using the simplest intervention for managing caries, is preferred. Minimizing the cost of preventing or controlling pit and fissure caries is desirable. Strategies for sealant use (e.g., patient selection, clinical decision making) may differ between individual care and community programs.

Eruption sequence

Primary Dentition A B D C E Permanent Dentition Maxilla 6 1 2 4 5 3 7 8 Mandible 6 1 2 3 4 5 7 8 Mandible before maxilla -These are palmer notations -infants usually get their first teeth by 6-12 mo of age -Toddlers usually complete their primary dentition by 2-2.5-3yrs of age

Relationship of Spacing and Crowding in Primary and Permanent Dentition

Primary Dentition vs % with crowding Spacing > 6 mm: No crowding Spacing 3-6 mm: 20% crowding Spacing < 3 mm: 50% No spacing: 66% crowding: 100%

Nonvital pulp treatment for primary teeth diagnosed with irreversible pulpitis or necrotic pulp

Pulpectomy. Pulpectomy is a root canal procedure for pulp tissue that is irreversibly infected or necrotic due to caries or trauma. The root canals are debrided and shaped with hand or rotary files. A pulpectomy is indicated in a primary tooth with irreversible pulpitis or necrosis or a tooth treatment planned for pulpotomy in which the radicular pulp exhibits clinical signs of irreversible pulpitis (e.g., excessive hemorrhage that is not controlled with a damp cotton pellet applied for several minutes) or pulp necrosis (e.g., suppuration, purulence). The roots should exhibit minimal or no resorption.

Posterior crossbite with functional shift

Px may or may not benefit from palatal expansion

Avulsion of primary teeth

Re-implantation of primary teeth are contraindicated

Removable space maintaners

Removable space maintaners have the shortcomings of all removable appliances -compliance issues, can be easily lost or broken -A removable space maintaner that is only worn at night is often sufficient to hold space and prevent the mesial drift of permanent molars, it also reduced the risk of loss or breakage by the patient (relative to a typical removable appliance which is worn all day) -Special case: pressure appliance : never discussed

Mesiodens

Supernumerary between 8 and 9 Tx -Age -direction -Location-displacement -Permanent tooth formation

Fluoride Delivery Systems

Systemic: • Water fluoridation • Fluoride supplements salt, milk Topical: • Toothpaste • Fluoride varnish, gels, rinses, SDF

Concusiion and subluxation 10 year follow up

TOOTH WITH OPEN APEX Pulp necrosis Resorption Ankylosis Tooth Loss Marginal bone loss Pulp Canal Obliteration - 6%/ 13% Dental Trauma Guide 2014 : 62 Teeth / 155 Teeth

Avulsion 10 yr follow up tooth with open apex

TOOTH WITH OPEN APEX Pulp necrosis- 70% Resorption- 40% Ankylosis- 45% Tooth Loss- 50% Marginal bone loss Pulp Canal Obliteration - 1 Year- 25%

Root fractures in primary teeth

TREATMENT - Location - Mobility Extraction vs. Leave fragment No fixation in primary Prognosis is directly related to location of fracture

NY State Residents in Developmental Centers

The 2008 Disability Status Report (Cornell U), estimates 777,900 individuals with cognitive disabilities residing in NY State.

Direct Pulp Cap/ Partial Pulpotomy

• Procedures to consider when there is no history of spontaneous pain to external stimuli and the pulp has been: • Accidentally exposed to the oral environment by traumatic injury • Exposed in conjunction with the excavation of caries -you do a partial puloptomy (removal of 1-2mm of exposed pulp) and then perform a direct pulp cap

Nance Appliance

• A modified maxillary lingual arch was described by Nance in 1947. • Does not contact the anterior teeth, but approximates the anterior palate. • Palatal portion incorporates an acrylic button that contacts the palatal tissue, which, in theory, provides resistance to anterior movement of the posterior teeth. • Effective space maintainer • Accumulation of bacteria and food debris often results in palatal inflammation and, in many cases, pain

Fluoride Toothpaste

• First successful clinical trial in 1954 • Most contain about 1,000 ppm fluoride • Estimated caries reduction due to fluoride containing toothpastes alone is in the 15% + range • Low level high frequency "Parents should use a tiny smear of fluoride toothpaste to brush baby teeth twice daily as soon as they erupt, instead of waiting until children are older, according to new guidelines by the American Dental Association."

Asthma - General Oral Health Guidelines

• Fluoride supplements for all, especially those taking β2 agonists • Instruct patient to rinse mouth after using an inhaler • Possible need to prescribe antifungal agents for patients who use nebulized corticosteroids

Topical fluorides

Toothpaste Fluoride rinses Fluoride varnish Silver Diamine Fluoride

The goal of endodontic treatment is

The goal of endodontic treatment is the prevention or elimination of apical periodontitis Apical Periodontitis (definition): Inflammatory reaction of the tissues surrounding the root apex of a tooth Bacterial infection is required for the development of apical periodontitis.

Mouthguard Selection

The most critical concerns regarding the selection of type of mouthguard during play include: • Comfort • Retention • Ease of speech • Least interference with breathing

Dental care for special needs

The most prevalent unmet health need among all children1 and among children with special health care needs.

Sealing Primary Molars

The need for sealants in 1st & 2nd primary molars is determined by Caries Risk of the child, pit & fissure morphology, and life expectancy of the tooth • Most pit and fissure caries on permanent molars were thought to occur within four years after eruption. • Clinical & epidemiological data indicate that posteruptive age alone should no longer be used as a major criterion for deciding if a tooth should be sealed The primary consideration should be the risk of pit & fissure caries consistent with an Individual's overall caries risk at the time of evaluation.

Autism

There are no "medical" tests for autism. It is a behavioral diagnosis, based on observation, and requires that the patient exhibit abnormal behavior in 3 categories: • Impairment of social interaction. • Impairment of communication skills. • Restricted and repetitive interests and behaviors. Autism is a "spectrum" disorder. • Individuals with autism can present with a wide variety of behavioral characteristics, ranging from mild to very severe involvement. • Individuals with autism may have over- or under-active senses. Oral sensitivities, sensitivities to sound, touch and smell are common in autism.

Neuromuscular disorders

These conditions are seen with greater frequency than in general population: Malocclusions (anterior open bite, constricted maxilla) secondary to hypotonia Persistent drooling

Eruption Status

Though previous guidelines stressed sealing teeth immediately after eruption, it is now recommended that sealant placement be delayed until the tooth is sufficiently erupted to assure success.

Mechanisms of Action of Fluoride

Topical • Inhibits demineralization • Promotes remineralization Systemic on tooth development • Improves enamel crystallinity • Reduces acid solubility • Improves tooth morphology Antibacterial • Concentrates in plaque • Disrupts enzyme system 1. Inhibits demineralization • adsorbs negative fluoride ions to the surface of crystals in teeth and acts as a physical barrier against acids • In addition, during remineralization, the newly forming crystals incorporate fluoride instead of hydroxyl ions- fluorapatite is more resistant to acid attacks 2. Enhances remineralization • Neutralizes acids with salivary buffers, and if calcium and phosphate are present in saliva, to allow crystal growth 3. Disrupts bacterial action • Hinders the ability of bacteria to metabolize carbohydrates and produce acidsby disrupting key bacterial enzyme system involved in glycolysis • Hinders the ability of the bacteria to stick to the tooth surface Bacteria in the mouth mix with sugars from foods and drinks to make acids, these acids weaken the teeth which can lead to decay Fluoride works to re-mineralize tooth enamel and protects against these acid attacks, which can reverse the early stages of tooth decay Fluoride works best on smooth surfaces

Pediatric candidiasis treatment

Topical Agents Nystatin suspension 100,000 U/mL Clotrimazole troches 10 mg Oravig (miconazole) buccal tabs 50 mg Chlorhexidine gluconate oral rinse 0.12% Systemic Agents: Diflucan, g (fluconazole) 100 mg tabs, 10 mg/mL, 40 mg/mL susp Sporanox (itraconazole) 100mg/10mL Nutritional supplements Probiotics?

Managing resorption after avulsion

Treat as soon as diagnosed - Calcium Hydroxide pulpectomy - This may stop the process and may maintain tooth

Pulp exposure after truama

Treatment is determined by 1. Root development Closed apex: Complete Endo Open apex - Vital Apexogenesis - Nonvital Apexification 2. Vitality Symptoms Time since exposure Size of exposure Bleeding Treatment Choices 1. Direct pulp cap 2. Pulpotomy - Partial - Coronal 3. Pulpectomy

Trisomy 21

Trisomy 21 Constricted maxilla (frequently resulting in crowding and/or impactions) Class III malocclusion Anomalies in tooth morphology Predisposition to periodontal disease

Radiographic Method to determine space available

True width of primary molars / Apparent width of primary molar = True width of unerupted premolar / Apparent width of unerupted premolar -Undistorted radiographs needed -Accurate bitewings are the best

Ultimate goal of treating immature permanent teeth

Ultimate Goal: Maintain Pulp Vitality In young individuals with incompletely developed roots, preservation of as much pulp tissue as possible is essential. This potentially allows for continued development of the tooth structure. If no further growth, the immature, permanent tooth is Weak and vulnerable to fracture due to thin dentin walls Has a compromised crown/ root ratio Has wide and apically diverging roots that present significant endodontic and restorative challenges

Scheme for Selecting Drugs by Procedure for Children

Ultra short procedure: Midazolam Short: Midazolam+hydroxyzine -Long: CH+ vis; CH+vic+dem; Dem+ vis; diazepam dem= demerol= meperidine vis= vistaril=hydroxyzine

Apexification is indicated when?

When a PA lesion is present, or if the tooth is determined to be non vital, and the apex is open, apexification is the procedure of choice

How does the body adapt to the transition from primary to permanent dentition?

When do things change? -Age 6, with the eruption of first permanent molars and mandibular centrals Size differential: Leeway space: size differential between primary molars and permanent premolars Spacing: Primate and generalized Mandibular growth and differential growth

Enamel defects: local factors due to damage to developing dentition

White spots, Yellow spots, Hypoplasia -Enamel/Dentin defects occur 1/3 of the time after trauma to the primary predecessor

PREVENTIVE SEALANTS

applied to at-risk, cariesfree pits and fissures to prevent caries.

Piercings complications

• 70% of those with tongue piercings report complications • 2002-2008, more than 24,000 ER visits related to OP - 72% female - 72% age 14-22 • Common complications: - Gingival recession/Perio issues - Fractured/chipped teeth - Infections - Embedded Jewelry* : very common complication, fammiliarize yourself with jewlery so you can remove it if needed - Scarring/skin irritation - Edema - Blood-borne diseases (from unsanitary piercing) - Hemorrhage - Bone Loss

Asthma

• A chronic lung disease, caused by inflammation of the lower airways and episodes of airflow obstruction. • Characterized by recurrent breathing problems: dyspnea, cough, wheezing. • Prevalence in U.S.: Overall, 14.6 million Americans have asthma, 4.8 million children under the age of 18.

EPT pulp analysis?

not to be used for primary or immature permanent teeth

General anesthesia

• A controlled state of unconsciousness accompanied by loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command • Can be done in a hospital or an ambulatory setting, including the dental office.

Long-term Outcomes of Primary Tooth Pulpectomy With Smear Layer Removal: A Randomized Split-mouth Clinical Trial

§ 3-5 year old 18 subjects with two primary anteriors, 36 teeth § K-file 1mm short of apex § irrigation with 10 mL 1% NaOCl § Experimental-final irrigation with 10 mL 6% citric acid § Final irrigation with 10 mL 0.9% saline solution. § Results § Overall success rate of pulpectomy 91% § Success with or without smear layer removal comparable results after 36 months: so no difference in removing or not removing smear layer § All pulpectomy failures occurred within 12 months.

Success rate of root canal treatment in primary molars

§ Retrospective chart review § 304 Children 5-18 yr. with 382 primary molars § One visit pulpectomy § Manual instrument 21 mm Kfile up to size 30 § Rinse with 3% hydrogen peroxide/saline § Fill with EndoFlas F.S. (50% ZOE) § Restore in 1 month § Success § No difference between 1st and 2nd primary molars § Periapical pathology: 84% § No clinical pathology: 100% Success of restorations used -SSC: (95.9)%: after a pulpectomy you should use a SSC -Amalgam/composite 92.3% -Temporary filling 28.6%: do a pulpectomy, arrange for a follow up and they never return

Midazolam Sedative Effects

• 0 - 15 minutes: - Change in mood with quietness & generalized relaxation increasing • 15 - 30 minutes: - Less intensity of reaction to stimuli and amnestic effects beginning • 30 - 60 minutes: - Any notable effects are declining

Meperidine Sedative Effects

• 0 - 20 minutes: - Slightly disinhibited, may become dysphoric or euphoric • 20 - 90 minutes: - Dysphoria or euphoria increases in intensity; analgesic effects becoming notable, if they are going to occur • N2O usually allows greater titration to effect

OBESITY

• 21% of 12-19 year olds are obese • At risk for diabetes, sleep apnea, low self-esteem • Poor nutrition poor oral health • Studies linking larger waist circumference and periodontitis

Ketamine

• A safe and reliable alternative to traditional conscious sedation and general anesthesia • Consciousness, cooperative, amnesia, analgesia • Relative absence of respiratory or cardiac complications • Partial reversal with naloxone • Induces a dissociation between the thalamoneocortical and limbic systems, thus preventing the higher centers from perceiving pain • "Ketamine stare" • Peak plasma concentrations in about 1 minute after IV and 5 min after IM • Active metabolite = norketamine • Clinical effects wane in about 15 min after IV and 30 min after IM injection • T ½ = 1 - 2 hrs in children • Protective reflexes remain intact • Stimulates secretions (laryngospasm?) • Dosage: IV = 0.25 mg/kg IM = 2 - 4 mg/kg mixed with 5 mcg/kg glycopyrrolate for salivation control

Children who are at greater risk for adverse outcomes from sedation:

• ASA classes III and IV • Children with special needs • Anatomic airway abnormalities • Moderate to severe tonsillar hypertrophy • Retrusive mandible • Obesity • Premature birth

SEXUAL ACTIVITY

• About half of teens have had sex by age 17 • 15-24 yr olds make up half of new cases of STIs • Don't be judgmental

SUBSTANCE ABUSE

• Abuse of certain drugs may show up during routine exams • Meth mouth • Damage from grinding and TMJ pain (Ecstacy and stimulants) • Persistent dry mouth and long lapses in oral hygiene can increase risk of caries • Unexplained rapid tooth decay may be a warning sign

Community Water Fluoridation

• Adjustment of fluoride to a recommended level for preventing tooth decay • Adjusting to 0.7 PPM • Similar to fortifying foods & beverages One of the four great advances in public health described as the "Four Horsemen" of public health • Fluoridation • Chlorination • Immunization • Pasteurization Fluoridation at 0.7ppm is: Safe Effective Efficient Economical Socially equitable Environmentally sound Good public policy • Population w/community water fluoridation 74.4% (CDC 2014) • Population in the US=329 million (2019) 74 million children <18 • Population with water fluoridation = 211 million Population = 19.5 million NYC population=8.6 million 4.6 million children Population with Access to Fluoridated Water = 11.8 Million New York City = 100 % fluoridated (0.7 ppm) Rest of New York = 40 % fluoridated Water Fluoridation reduces tooth decay by 25% in children and adults Filters attached to water faucets generally do not remove fluoride Reverse osmosis systems & distillation units do remove fluoride

PERIODONTAL ISSUES in adolescents

• Adolescents have higher prevalence of gingivitis than prepubertal children or adults - Increased sex hormones affects the composition of the subgingival microflora • Increased periodontal pathogens (Prevotella intermedia and Prevotells) • Highest prevalence among 13-17 year old males ADDRESSING PERIO ISSUES • Reinforce Oral Hygiene - Flossing - Brushing - Mouth rinse • Recall Intervals • Cavitron and Scaling

Vital Pulp Therapy Goals

• Aims to prevents the development of a destructive course of pulpal inflammation and subsequent infection of the root canal space

Asthma - Common Etiologies

• Allergens • Upper respiratory infections • Stress • Exercise • Pollutants • Weather (esp. cold, dry air)

Zolpidem (Ambien)

• An imidazopyridine • Unrelated to the benzodiazepines, but similar mechanism of action • Short active, T1/2 = 1.5 - 2.4 hrs • No active metabolites • Amnesia • Reversible with Flumazenil • Best used in combination with oral Valium • Used with preadolescent (age 7, 8, 9) 50 lbs: 10mg Valium, 10mg Zolpidem • Peak concentration at 1.6 hrs • Side effects: Dizziness, headache, nausea, myalgia, xerostomia, hallucinations

EATING DISORDERS

• Anorexia Nervosa - Excessive dieting - Excessive exercising - Abstaining from eating entirely • Watch for extreme weight loss over short period

Odontogenic infections in pediatric patients and antibiotic therapy

• Antibiotic therapy usually is not indicated nor effective if the dental infection is contained within the pulpal tissue or the immediate surrounding tissue. • In this case, child will have no systemic signs of an infection. • For a child presenting with acute symptoms of pulpitis, treatment with pulpotomty, pulpectomy or extraction should be rendered. Conditions not requiring andjunctive antibiotics -Acute pulpitis: pain without signs and symptoms of infection -Apical periodontitis: teeth with necrotic pulps and a radiolucency -Teeth with a draining sinus tract: chronic periradicular abscess -Localized intra-oral swelling

Role of Pediatric Dentist Establishment of Dental Home in cleft lip

• Anticipatory Guidance • Caries Prevention "Establishment of a dental home begins no later than 12 months of age" • In children with cleft it can start earlier • Upon diagnosis: In utero or at Birth

Benzodiazepines

• Anxiolysis • Muscle relaxants • Anticonvulsants • Limbic system/Thalamus • "Paradoxical" increase in aggression • Can cause respiratory depression

Trisomy 21 - What do I ask?

• Any cardiac conditions or surgical correction of cardiac conditions? • If yes, when was surgery done? • Past dental history - Behavior? - Periodontal problems? • History of frequent upper respiratory infections?

How to Mitigate the Risks Associated with Sedation?

• Appropriate patient selection • Appropriate drug selection • Presence of an individual with the skills needed to rescue the patient from an adverse reaction • Appropriate physiologic monitoring • Continuous observation by personnel not directly involved with the procedure

Silver Diamine Fluoride (38% SDF)

• Approved by the US FDA in 2014 as a topical medicament to treat dentinal hypersensitivity. • Made up of silver particles, fluoride, ammonia, water • Used OFF label for the nonsurgical arrest of caries in children and adults. o Antimicrobial agent o Kills pathogenic organisms Pros: Arrests caries No anesthetic needed Pre-cooperative children Medically comprised Interim intervention Special needs Older adults Cons: Turns the active caries black Temporarily stains soft tissue Contraindication: Silver Allergy

Midazolam Adverse Effects

• As dose increases through & beyond therapeutic range: - Respiratory drive decrease/apnea - Increased likelihood of hiccups - Increased likelihood of cardiac arrest - Increased interactive drug effects, especially with narcotic

Meperidine Adverse Effects

• As dose increases through & beyond therapeutic range: - Respiratory rate and depth decreases or ceases - Increased likelihood of myocardial depression (hypotension) - Increases likelihood of seizures/coma - Increased likelihood of vomiting/nausea - Increases likelihood of drug-interactive effects (e.g. especially with local anesthetic)

ADHD Attention Deficit Hyperactivity Disorder

• As with autism, ADHD is a behavioral diagnosis, based on observation, with specific diagnostic criteria • The primary deficit in ADHD is a problem with modulating focus or attention • Impairment of social interaction, impairment of communication skills, restricted & repetitive interests are not diagnostic criteria for ADHD (these are diagnostic for autism)

Misuse of Antibiotics

• At least 30% of antibiotic courses prescribed in the outpatient setting are unnecessary, meaning no antibiotic was needed at all. • Total inappropriate antibiotic use (which includes unnecessary antibiotic use plus inappropriate antibiotic selection, dosing, and duration) may approach 50% of all outpatient antibiotic use. • Antibiotics cause 1 out of 5 emergency department visits for adverse drug events (ADEs). • Antibiotics are the most frequent cause of ADEs leading to emergency department visits in children. Recommendations: 1. Surgery to remove the cause of infection and establish drainage is primary. Antibiotics are adjunctive treatment. 2. Use therapeutic antibiotics only when clinically indicated. 3. Use evidence-based medicine and guidelines when available.

Anatomic and Physiologic Differences Between a Child and an Adult

• Basal metabolic rate • Greater oxygen demand • Less mature alveolar system • Narrow nasal and glottis passages • Often hypertrophic tonsils and adenoids, enlarged tongue • Smaller thorax with reduced expansion capacity and less functional reserve • More susceptible to bradycardia, decreased cardiac output and hypotension HR is the primary determinate of blood pressure in children

HARM REDUCTION: Peircings

• Before: - Talk about risks - Proper infection control After: - Make sure patient is following after-care instructions - Size down jewelry after healing period ends - Soft medical grade plastic jewelry available • Bioplast • Bioflex • No scare tactics!! - Show patient any existing damage and tell her what to watch for in the future • You may see a patient more frequently than a physician • You are an important link in the referral chain • You may not be able to solve a problem but you can start the process

Salt fluoridation

• Began in 1956 in Switzerland • Many Latin American countries & some Caribbean countries use it • Very low cost • Same cariostatic potential as water fluoridation

Fluoridated Milk

• Began in Switzerland Bulgaria Thailand Chile • Low cost • Same cariostatic benefits as water fluoridation • Mostly targets children

ADHD: treatment

• Behavioral interventions • Medications - Stimulants • Ritalin, Concerta (methylphenidate) • Adderall, Dexedrine (amphetamines) - Non-stimulants • Strattera - Anti-depressants • Wellbutrin, Tofranil

Cleft Epidemiology/Genetics

• Black: White: Asian = 1/2000:1/1000:1/500 • Male > Female • Left: Right: Bilateral = 6:3:1 • One sibling = 4%; Two siblings = 9%; • One parent & one sibling = 17%, • Van der Woude (lip pits) = 50% • Multifactorial (Environmental, Genetics) • Nutritional deficiencies (Folic Acid) • Vitamin excess or deficiencies • Alcohol

DRUG USE

• Can start as early as 6th & 7 th grade • Rates of drug use increase significantly for 1st and 2nd year college students • Abuse and sale of Rx pain meds among college students • Most teens/young adults will disclose tobacco and marijuana use (without parents present) • More high school kids are marijuana smokers than cigarettes smokers • Those who disclose "harder" substances or abuse may be looking for help • Express your concern for their wellbeing and ask if they would like to talk to someone about it • 18 or over, make a direct referral • Under 18, ask if you can bring a parent into the conversation

Seizure Disorders

• Caused by excessive electrical discharge in the CNS that results in a clinically evident alteration of function or behavior. • Can be idiopathic or secondary to illness or trauma. • Can be generalized (affecting the entire brain) or partial (affecting only part of the brain). • Status Epilecticus: Any continuous seizure activity lasting more than 5 minutes.**

Down Syndrome (Trisomy 21) Oral Findings

• Class III malocclusion • Macroglossia (50%) • Microdontia • Oligodontia • Dental impactions • Increased periodontal disease • Altered dental morphology

Meperidine

• Class of drug: narcotic • Dose range: 1 - 3 mg/kg (oral) • Can be used with: hydroxyzine, Promethazine, N2O, CH, benzo's (latter 2 with caution!) • Effects: - Euphoria (great!!!), dysphoria (failure), analgesia, mood depression, irritability, obtunded responsiveness

Care of Mouthguards

• Clean the mouthguard with cool soapy water before and after each use, and rinse thoroughly with water. • DO NOT chew the mouthguard while in play or on the bench. This will damage it. • Air dry the mouthguard before storing. DO NOT store in a closed container unless completely dry. • DO NOT subject mouthguard to extreme heat. • ALWAYS keep mouthguard in a container when not in use. • Rinse in mouthwash or mild antiseptic immediately before being used again. • If a crack or other damage appears, you need a new mouthguard. Contact your dentist Basic Truths • No standards currently exist which fully cover all aspects of mouthguard fabrication • Standards have been developed for material properties • All mouthguards are of questionable quality unless evaluated and made by a professional

Clefts - Dental Findings

• Clefts usually occur in the area of the maxillary cuspids and lateral incisors. Toothbuds in this area are often affected. Clinically, may see: • Missing teeth • Supernumerary teeth • Aberrant dental morphology • Ectopic eruption of teeth Oral care of the patient with clefting is best managed by a team of surgeon, dentist, orthodontist and possibly prosthodontist.

Syndromes demonstrating supernumerary teeth:

• Cleidocranial dysplasia • Hallerman-Strieff • Oro-facial-digital • Gardner • Trisomy 21 • Crouzon • Apert • Sturge-Weber

DENTAL TRAUMA

• Common Causes: • Active sports • Active recreational hobbies • Accidents...alcohol use • Talk to patients about what to do for an avulsed permanent tooth • Replant immediately if possible (rinse with water if dirty) • Place tooth in Hank's Balanced Salt Solution, cold milk, saline or saliva • Get to a dentist ASAP • Just because it looks ok doesn't mean it is • Encourage them to follow-up with you if a trauma occurs: even if it looks ok and doesent appear to be broken Risk taking • Parents may not know, teens want to keep it that way • More honest answers if parent not present • Show consequences on individual when possible • Balance of privacy and safety • If a patient discloses something serious and/or dangerous, it's a cry for help • Have referral sources identified • 18-20% of high school students smoke cigarettes, steady decline last 10 years • 5% of 18-25 yr olds report using chewing tobacco, trending down - Mostly male, mostly southern/rural • Cigar and cigarillo use up from 7% to 12% • Hookah use among college students is close to 50% - First tobacco use for many - Users will inhale about 180 times more smoke during a session than delivered by a single cigarette - Burning coals introduce additional harmful substances • Over 250,000 middle and high school students had never smoked cigarettes but had used e-cigarettes - 3 times as many as 2011 • Students who used ecigarettes were twice as likely to report intentions to smoke conventional cigarettes • 300% increase in calls to poison control - More than half involved children age 5 and younger • Ask about tobacco use: - Not just cigarettes! - No? Great! Yes? Let's talk about it. • Don't talk long term consequences, focus on short term • Bring it up in the Spring because April showers bring...... an increase in first time smokers in May!

Autism - What do I ask?

• Has the child been to a previous dentist, and, if so, what was the experience like? • Does the child allow the parent to perform oral hygiene? • Is the child on any medications? • Is the parent aware of any specific sensitivities (visual, aural) the child has that may affect behavior during treatment?

SEXUAL ACTIVITY AND ORAL PATHOLOGY

• Common sexually transmitted oral infections: - Herpes Simplex - Gonorrhea - Human Papilloma Virus - Syphilis • You may end up breaking the bad news

Lower Lingual Holding Arch

• Commonly used space maintenance appliance in preventive and interceptive orthodontics. • Thought to maintain arch perimeter by preventing mesial tipping or drift of mandibular molars. • Molar positions are stabilized against the mandibular incisors by the appliance • When the lingual arch is placed and is active, it will rest high on the lingual surface of the incisors and should exert a downward tipping force.

Benefits to the Athletes

• Cost Effectiveness - Cost for custom-fitted mouthguards range from $60-285 (2004 National Fee Survey) - Cost to treat avulsed permanent tooth and follow-up care over a lifetime is between $5,000 - 20,000 (Estimate 2005, National Youth Sports Safety Foundation) • Offer Competitive Edge

ADHD: What do I need to know?

• Current medications • Dental history • Previous dental treatment experiences (behavior) • Any history of dental trauma

Cerebral Palsy

• Defined primarily as a movement disorder • Caused by disturbances that occurred in the fetal or infant brain ("static encephalopathy") Comorbidities may include: • Intellectual disability (30-50%) • speech difficulties • Seizures • Gastroesophageal reflux • Dysphagia or aphagia CP - Oral Findings • Malocclusions • Enamel defects • Increased incidence of dental trauma • Sialorrhea (drooling) • Bruxism Extensive calculus deposits are frequently seen in patients with dysphagia and/or aphagia

Pediatric Patients

• Dental caries (tooth decay) is the single most common chronic childhood disease--5 times more common than asthma and 7 times more common than hay fever. • Poor children suffer twice as much dental caries as their more affluent peers, and their disease is more likely to be untreated. • 51 million school hours missed annually • 18.6% of children aged 5-19 years with untreated dental caries 13.7% of children aged 2-8 years had untreated dental caries in their primary teeth -approxiamtely 23% of children aged 2-5 had dental caries in primary teeth Adults • 31.6% of adults aged 20-44 with untreated dental caries • 29.2% of adults aged 65 and over had dental insurance • 64.3% of adults aged 65 and over with a dental visit in the past year According to the CDC: • Fluoridation is safe & effective in reducing tooth decay • Cost effective - average savings of $20 per dollar invested • Doesn't discriminate- benefits all residents, young & old, rich & poor

Injury Findings and Statistics

• Dental injuries are the most common type of orofacial injury sustained during participation in sports. The majority of these dental injuries are preventable. • 13% - 39% of all dental injuries are sports-related. • Prior to the mandatory use of mouthguards, 50% of football injuries were oro-facial. The rate has since dropped to 0.5%. • It is estimated that faceguards and mouthguards prevent approximately 200,000 injuries each year in high school and college football. • An athlete is 60 times more likely to sustain damage to the teeth when not wearing protective mouthguard. • In a sample population, 40% of dental injuries occurred in baseball and basketball, sports that do not require the use of mouthguards. • An athlete involved in a contact sport has about a 10% chance per season of an oro-facial injury, or a 33% to 50% during his/her career. The National Federation of State High School Associations mandates mouthguards for only four sports • Football • Ice Hockey • Field hockey • Lacrosse

Teens: what to remember

• Not children, not full adults • Talk to your patient away from parents • Don't tell them what could happen in the future - Show them what's happening now • Establish trust and a good rapport • Be ready to listen and offer assistance

"Special Needs" can include:

• Developmental disabilities (cognitive & behavioral) • Physical disabilities • Chronic and acute medical conditions Take-home messages: • Know your patient!!! Physical, emotional, developmental status • Know how to communicate effectively with physicians. • Know how to modify your treatment plan to meet the patient's needs. • Extra emphasis on prevention.

Managing an acute asthma attack

• Discontinue dental procedure • Make sure pt has a patent airway and administer β2 agonist via inhaler • Administer oxygen via face mask or nasal hood. In no improvement, administer epi subcutaneously (1:1,000 concentration, .01mg/kg of body weight to max of .3mg • Alert emergency medical services • Maintain good oxygen level until pt stops wheezing and/or arrival of emergency personnel

The Halo Effect

• Eating & drinking food processed in an area with optimum water fluoride content • Commuting between a fluoridated and nonfluoridated community • Universal use of fluoridated toothpaste

Syndromes associated with hypodontia:

• Ectodermal dysplasia • Crouzon • Achondroplasia • Trisomy 21 • Oro-facial-digital • Chondroectodermal dysplasia • Incontinential pigmentii • Seckel • Hallerman-Streiff

cleft home

• Ensures care is provided in a coordinated, comprehensive and consistent manner and provides a home base to manage all appropriate referrals and follow up • Elevates the sense of responsibility and commitment of the specialties involved

Cleft lip/palate dental treatment and prevention

• Establish and maintain oral health. Phases of cleft surgery and orthodontic treatment are made less complex and more effective when optimal dental health is maintained. General dental examination, prophylaxis, and restorative treatment is critical. • Establish appropriate recall schedule to intercept areas of decalcification. • Coordinate care with cleft team. • Surgical scarring may limit mobility of maxillary lip and vestibule. Caution is advised when manipulating this area. • The segment containing the cleft may not be firm. Caution is advised when manipulating this area (extractions, surgery, etc.). • Emphasis should be placed on brushing the teeth in the cleft region. Parents may be concerned about damaging the area or causing bleeding. They should be shown how to effectively accomplish brushing their child's teeth. A baby size toothbrush or interdental device may be indicated, especially where the lip is tight. • Early removal of primary teeth in children with a cleft is particularly contraindicated because of possible space loss, especially in the maxillary arch, making orthodontic treatment more difficult. Look for signs of physical abuse during the examination. Note findings in chart and report any suspected abuse to Child Protective Services, as required by law. Abuse is more common in children with developmental disabilities and often manifests in oral trauma.

WISDOM TEETH

• Evaluation of third molars should happen in mid to late adolescence • Teens/young adults may forget about them until they cause pain • Smokers and females using oral contraceptives may run a high risk of postsurgical dry socket

TIME FOR ORTHO: adol

• Everyone wants braces now! • Big emphasis on keeping mouth clean - Demonstrate proper brushing, flossing, rinsing after meals - Show them the consequences of not cleaning • Talk compliance...the less they comply the longer the braces will stay • Invisalign vs Ceramic brackets vs Metal brackets • Keep in mind compliance, cost and activity levels • Bleaching - Will leave spots with brackets, Invisalign is basically a custom bleaching tray

Fluoride Varnish

• Highly concentrated form of fluoride • (5% sodium fluoride or 22,600 ppm) • Varnish holds fluoride close to tooth surface • Desensitizing agent and or cavity liner: Class II Medical Device • OFF LABEL USE: Helps prevent decay on both primary &permanent teeth • Remineralizes tooth surface • Studies show caries reduction around 30% • Ease of application • No need for prophylaxis before application • Sets under moisture/saliva • Minimizes ingestion • Promotes remineralization • Cost Effective -Dry to apply, wet to set

What do I need to know? for a sped

• If an adult, does the patient have the ability to make medical decisions, sign consent? • Does the patient have a compromised swallow reflex, does the patient eat by mouth or receive enteral feeds? • What meds (for seizures, spasticity, behavior)? • Previous dental experiences?

Immature permanent teeth

• Immature permanent teeth are those in which normal physiological apical root closure has not yet occurred. • A tooth with an immature apex is a developing organ. The proliferation and differentiation of various cells are activated, especially in the apical region of a young tooth to achieve maturation. • Immature permanent teeth possess a greater potential to rebuild the host pulp tissue and continue root maturation -Young pulp has a high number of undifferentiated mesenchymal cells -high cellular content, high vascularity, low calcium/ phosphorus content

Characteristics of mouthguard

• Impact absorbing • Close-fitting • Retentive • Resilient material • Does not have offensive odor or taste • Does not cause toxic or allergic reactions

Four Basic steps for the fabrication of custom-fitted mouthguard

• Impression and pouring a model • Fabrication • Trimming and polishing • Insertion and occlusal equilibration

3 subtypes of ADHD:

• Inattentive Type • Difficulty with organization and staying on task, following instructions; easily distracted • Hyperactive-Impulsive Type • Fidgety, restless, difficulty sitting still • May interrupt others, speak at inappropriate times • Impulsivity may make these children more prone to accidents and injuries • Combined Type • Symptoms of the above 2 types are equally present in the child

Trans-Palatal Arch

• The issue of palatal soft tissue irritation and inflammation is avoided when using a TPA. • The wire follows the vault of the palate, is comfortable, and does not interfere with normal speech. • Important to ensure passive fit

CHANGES IN DIET: adol

• Increase in consumption of sugary and high carbohydrate food and beverages • More independence in food choices - Greater purchasing power, less supervision - Going off to college WHAT ARE THE KIDS DRINKING THESE DAYS? • Water and milk still most common beverages • Juice - 30% of high school students reported drinking juice daily • Soda - Largest source of calories from sugar sweetened beverages - 1/4th of high school students report drinking a can, bottle or glass of non-diet soda daily • Over 60% of high school students reported drinking any combination of sugar sweetened beverages one or more times per day SUGAR SWEETENED BEVERAGES • Too young for bars, hang out in cafes • Large sizes and frozen drinks increase exposure time - Sweetened Iced Tea - Frozen coffee drinks - Bubble Tea - Slurpees - Smoothies Sugar-free versions available but still a whole lot of caffeine -Caffeine is bad for enamel -Excessive amounts can lead to grinding sports drinks • Developed for college and professional level athletes • Loaded with sugar and carbs • Just drink water

Why Involve Sports Dentistry in our Practice?

• Increase your quality of care • Educate the public on mouth protection • Provide the best possible protection • Prevention and Treatment of Trauma • Provide services other office do not provide The best athletic mouthguard is one which is properly fitted and properly worn

Vital Pulp Therapy Procedures

• Indirect Pulp Cap • Direct Pulp Cap/ Partial Pulpotomy • Apexogenesis (Full pulpotomy) -in the case of vital pulp therapy, pulpotomies are the definitive treatment

Autism - Common behavioral characteristics

• Insistence on sameness; resistance to change. • Stereotypical (repetitive, non-productive) movements. • Not responsive to verbal cues. • Difficulty in expressing needs. • Difficulty interacting in social situations. • Inappropriate attachments to objects. • Little or no eye contact.

Down Syndrome (Trisomy 21) Physical & Systemic Findings

• Intellectual disability • Cardiac abnormalities (approx. 50%). • Joint hypermobility due to ligamental laxity. • Muscular hypotonia. • Short neck. • Compromised immune response. • Short stature. • Short, stubby hands, simian crease of palms. • Face: underdeveloped maxilla and midface, upward slant of palpebral fissures.

Syndromes associated with taurodontism

• Klinefelter • Ectodermal dysplasia • Trisomy 21 • Tricho-dento-osseous • Amerlogenesis Imperfecta type IV • Globodontia

Posterior Crossbite

• Like anterior crossbites, may have skeletal, dental, functional or mixed etiology • Like anterior crossbites, may be unilateral or bilateral, which affects treatment modality • Left untreated, may result in skeletal defect, regardless of original etiology • Treatment typically begun as soon as the child can cooperate • Fixed and removable appliances • As with anterior crossbites, the appliance used depends on etiology, type of desired movement and amount of movement needed (can be corrected with fixed or removable appliances just like anterior crossbites) • Some examples o W-arch or Quad-Helix: for bilateral posterior crossbites, both fixed o Rapid Palatal Expander (RPE): also for bilateral posterior crossbites -Also cross elastics: unique in that the other interventions involve the early mixed dentition, while this is for a more lingual crossbite and a rubber band is drawn between premolars on the opposing arches . Usually on the buccal of the lower premolar to the lingual of the upper premolar : to fix an isolated case of crossbite and no need to involve other teeth -Treatment typically begun as soon as the child can cooperate -Be familiar with how each appliance is activated, how long crossbite correction takes, and how long the retention phase is

Cleft Lip Classification

• Lip: Bilateral Vs Unilateral/ Complete Vs Incomplete • Nose: sill, ala, floor • Alveolus: complete vs notch

Partial pulpotomy (cvek pulpotomy)(apexogenesis): procedure

• Local anesthesia and Rubber dam • Wash until hemorrhage stops • Clot should be rinsed away • High speed bur (new 330) used to remove infected pulp tissue • Calcium hydroxide placed on pulp (MTA and RMGI replacing CaOH) - Medicament placed over vital tissue, not over a blood clot • Glass-ionomer cement base • Restored with composite resin This can be performed at any level in pulp chamber

Model Preparation

• Lubricate model with a lubricant such as orthodontic model soap for approximately an hour to allow easy separation after fabrication • Allow model to dry and polish with dry cloth

Ectopic Eruption of Permanent Anteriors

• May or may not be associated with anterior crowding and/or an over-retained primary tooth • However, timely extraction of an over-retained primary tooth can allow for a correction in eruption path, and may prevent malocclusions such as crossbites and other malalignments.

Oral Disease Prevention: Sped

• More frequent recalls. • Individualized home care program. • Dietary analysis and counseling. • Fluoride regimen. • Sealants

Cleft Lip & Palate

• Most common first branchial arch defect. • Occurs in 1:700-800 births. • Clefting occurs during the first trimester of pregnancy. • Cleft can involve: - Soft palate only - Complete cleft of soft and hard palates - Alveolar process of maxilla - Lip • Can occur as an isolated anomaly or as part of a syndrome.

Risks associated with pharmacological management

• Most serious: Death • Hypoventilation • Apnea • Airway obstruction • Laryngospasm • Cardiopulmonary impairment Children are more vulnerable than adults to the sedating medication's effects on respiratory drive, patency of airway, and protective reflexes It is common for children to pass from the intended level of sedation to deeper, unintended level of sedation

How do mouthguards help prevent or reduce mouth and face injuries?

• Mouthguards protect the teeth and the supporting structures by spreading the force of blow over all the teeth and by preventing the forceful contact of the upper and lower teeth. • Mouthguards prevent or reduce the severity of injury to the soft tissues by holding the lips and cheeks away from the teeth. • Mouthguards act as shock absorbers by decreasing the force transmitted through the temporomandibular joint to the base of the skull, thereby preventing concussions.

Pharmacologic antagonists

• Naloxone hydrochloride (Opioid) • Flumazenil (Benzodiazepine) • Basic airway management equipment • Nasal & oral airways of different sizes • Portable oxygen ("E" cylinder) and resuscitation bag with masks of different sizes

WHY THE SPECIAL ATTENTION? To teens?

• No longer children, not quite adults • Increased independence, decreased supervision • Physiological and hormonal changes • Start of unhealthy and/or risk taking behaviors • Likely to be seen as a general practitioner • Are ultimately responsible for their oral health - Parent communication can still help • Feel young and Invincible! - Long term effects don't hold much sway • Aren't the greatest at showing for appointments - Get creative with appt reminders: texts, emails, etc • Are Sensitive - Hyper-aware of appearances • Need to build trust - Trust makes compliance more likely - No scare tactics and no judgments

Mouthguard Design

• Normally fitted to the maxillary arch • Angles Class III malocclusion, the mouthguard is placed over the mandibular arch • Close fitting • Extend as far back as the distal surface of the permanent first molar • Flanges of the mouthguard should extend beyond the gingival attachment, but short of the mucobuccal fold. ( 2mm short of the buccal and labial vestibular reflection)The buccal edge of the flange should be smooth and rounded and relieved around the frena and muscle attachments • Palatal aspect, extend approximately 5mm on to the palate and tapered to a thin, smooth and rounded edge • Minimal thicknesses of 3 mm. labially, 2mm. palatally, and 3 mm. occlusally • Occlude evenly and comfortably with opposing arch

Discharge Criteria following sedation

• Patient vital signs back to baseline • Able to tolerate fluids • Patient able to ambulate on their own (unassisted)

Syndromes associated with clefting

• Pierre-Robin Sequence • Crouzon • Vander-Woude • Klippel-Feil • Treacher-Collins • Turner

Materials for mouthguard fabrication (in order from most to least frequently used)

• Polyvinyl acetate-polyethylene or ethylene vinyl acetate copolymer (EVA) • Polyvinylchloride • Natural rubber soft acrylic resin • polyurethane

Fluoride Toxicity: probable toxic dose

• Probable Toxic Dose = 5 mgF/kg • Certain Lethal Dose = 29-71 mg/kg = 16-32 mg/kg = 15mg/kg

Revascularization/ Regeneration for a necrotic pulp

• Procedure Aims to: • Stimulate endogenous stem cells (SCAP) from apical papilla to promote continued root length and thickness development -You perform a full pulpectomy and then seal with MTA coronally -A blood clot scaffold fills into the open apex and is invaded by SCAP -Root formation occurs

Clinical Pharmacokinetics of Nitrous Oxide

• Rapid induction and recovery • Reversibility • Titration phenomena • Adjustability • Diffusion hypoxia • Hepatic and renal tolerance

Clinical Recommendations for pulp therapy: conclusion

• Remember the basic biologic principles of endodontics • Apical periodontitis (endodontic disease) is caused by bacteria • Make every effort to keep the pulp vital in immature, permanent teeth • Refer to an endodontist when indicated

If a patient seizes in the dental chair:

• Remove all materials from pt's mouth, clear instruments away • Place dental chair in supine position, as close to floor as possible • Place pt on side (to decrease chance of aspiration) • Do not restrain patient • Do not put your fingers in pt's mouth • Time the seizure • Call 911 is seizure lasts >3 minutes or if pt becomes cyanotic at outset • Can administer O2 at rate of 6-8 liters/minute • If a seizure lasts longer than 5 minutes, consider it status epilepticus When the seizure is over: • No further dental treatment that day • Try to talk to pt to evaluate level of consciousness • Brief oral exam to check for injuries • If pt is alone, contact family • Do not allow pt to leave office if his/her level of awareness is not fully restored • Depending on post-ictal state, can discharge to home with a responsible person or to ER for further assessment

Why is Premedication Important?

• Repeated procedures have a significant impact on a child

Necrotic Pulp/ non vital pulp Treatment Options

• Revascularization/ Regeneration: • Apexification

Characteristics of the Ideal Premedicant

• Safe • Non-noxiously administered • Rapid Onset • Rapid recovery • Reversible • Minimal side effects

BIRTH CONTROL & PREGNANCY

• Sensitive to privacy • Ask about birth control use • 56% of female teens report using a hormonal method • Talk about gingiva health • If prescribing antibiotics, talk about interaction • 7% of female teens 15-19 yrs old will become pregnant each year - 20-24 yr old women have the highest rates of unintended pregnancy

The benefits of correct use of antibiotics include

• The resolution of infection • Prevention of the spread of disease (systemic or to adjacent anatomical spaces) • Minimization of serious complications of disease

Ectopic Eruption of Permanent Molars

• Timely diagnosis/treatment may prevent space loss and possible permanent tooth loss • Possible treatment depending on severity and time of diagnosis: o Watchful waiting: in cases where it may self correct o Separator o Brass wire o Quadrant Fixed appliance o Extraction 2nd primary molar followed by passive or active appliance (to distalize the ectopically erupting permanent first molar)

Objectives of the Medical History / Physical Exam:

• To identify patients with systemic disorders that can pose complications during dental treatment. • To identify patient medications that may have oral side effects or may be potentiated by drugs used during treatment. • To enable effective communication with the patient's physician. • To allow modification of treatment plan. • To protect the dentist from a legal standpoint. • To establish good patient-doctor relationship • Always review the patient's medical history form verbally with the parent - make sure the parent understands all the questions and has not omitted any relevant info. • If a patient presents with a syndrome or medical condition that you are unfamiliar with, look it up, consult with physician if necessary, and know its characteristics before initiating treatment!!!

Piercings

• Tongue - Most common, 11% of piercings for women, 4% for men • Lip - Labret and lower lip most common sites • Cheek - Dimple and Monroe - New York State: Under 18 requires parental consent for body piercing (ear piercing excluded) • Consistent for most states • Doesn't stop self-piercing - Currently, there are no infection control training requirements for body piercers • Permits issued by county health departments - Association of Professional Piercers holds members to rigorous standards including: • CPR and First Aid Certification • Bloodborne pathogen training • Medical grade autoclave • Monthly spore testing for autoclave

Syndromes associated with enamel hypoplasia

• Trisomy 21 • Treacher-Collins • Mucopolysaccharidoses (Hunter, Hurler, Morquio Syndromes) • Tricho-dento-osseous • Lesch-Nyhan • Sturge-Weber • Turner

3 Basic Types of Mouthguards

• Type 1 Stock Mouthguard • Type 2 Mouth-Formed (Boil and Bite) Mouthguard • Type 3 Custom-Fitted Mouthguard a. Vacuum-Formed b. Heat/Pressure Laminated

Review of Basic Endodontic Principles

• Under normal, physiological conditions the pulp is well protected from injury and injurious elements in the oral cavity by the outer hard tissue encasement of the tooth and an intact periodontium. • When the integrity of these tissue barriers is breached, microorganisms and the substances they produce may gain access to the pulp and adversely affect its health condition. Caries, truama, iatrogenic injury causes: -Pulpitis -pulpal necrosis -Periapical lesion -+/- pain

Permanent Anterior Crossbite

• Untreated can lead to: oAsymmetric skeletal growth o Loss in arch length oWear facets oCrown fracture oTraumatic occlusion oGingival stripping and/or pocket formation on labial of lower anterior • May have skeletal, dental or functional etiology, or a combination • If skeletal examination reveals a class III tendency, the crossbite needs to be corrected as part of more comprehensive orthodontic treatment.

Acute Facial Swelling of Dental Origin

• Untreated odontogenic infections can lead to pain, abscess, cellulitis, and difficulty eating or drinking. Can lead to: -Fistula -Bacteria/septicemia -Deep fascial space infection -Ascending facial-cerebral infection -Osteomyelitis -Intraoral soft tissue abscess -cellulitis • Infections with systemic manifestations require antibiotic therapy. • Facial swelling/cellulitis • Elevated temperature (>100ºF) • Difficulty in breathing or swallowing • Malaise • Lymphadenopathy • Trismus • Asymmetry • Tachycardia Urgency of Intervention • A child presenting with a facial swelling or facial cellulitis secondary to an odontogenic infection should receive prompt dental attention. • Prompt diagnosis and removal of the source of infection (necrotic pulp tissue) is critical to reduce morbidity and mortality. • Patients presenting with compromised airway (stridor/abnormal breath sounds), raised floor of mouth or signs of septicemia warrant emergency referral to hospital services! Treatment may consist of: 1. Pharmacological therapy with immediate surgical intervention of the tooth or teeth in question. • In most situations, immediate surgical intervention is appropriate and contributes to a more rapid cure. 2. Pharmacological therapy with delayed surgical intervention • Prescribing antibiotics for several days to reduce patient symptoms, and then treating the involved tooth or teeth. 3. Referral to hospital for intravenous antibiotic therapy and/or medical management • Pediatric patients with facial infection become dehydrated and systemically ill very rapidly Treatment Considerations • The clinician should consider age, cooperation, the ability to obtain adequate anesthesia (local vs. general), the severity of the infection, the medical status, and any social issues of the child. • During the acute infection phase, it is often difficult or impossible to establish effective anesthesia for tooth extraction. o Management of these conditions in children, therefore, poses greater challenges to the clinician as there may be problems with behavior management. o Ability to obtain profound anesthesia will aid in positive behavior guidance.

Sports Related Orofacial Injuries

• Upper lip • Maxilla • Maxillary incisors, 50-90% of dental injuries

Diazepam (Valium)

• Used in children 4-10 years old • Slow onset: working time = 20-30 min • Poor absorption IM • Dosage: 0.7mg/kg • Elimination ½ life = 24-57 hr • Active metabolites • Anterograde amnesia

Type III Custom-fitted Mouthguard

• Vacuum Formed • Heat/Pressure laminated A correctly fitted mouthguard with adequate extensions and contours.

BULIMIA

• Vomiting or laxatives to purge food • Often paired with binge eating • More common among women • Dental consequences: - Erosion of tooth enamel - Exposed dentin - Dental sensitivity - Increased caries risk • Signs of Bulimia: - Flaky enamel - Restorations appear to have grown out - Etched surface of teeth when air dryed

Seizure Disorders - what do I ask?

• What type of seizure? (Ask patient or parent to describe) • How frequent? • When was the last seizure? • Do you know what precipitates a seizure? • What anti-epileptic medication? • Any history of status epilepticus?

Asthma - What do I ask?

• When was the last asthma attack? • How frequent? • Do you know what precipitates your asthma attacks? • What medications and how often are they taken? • Has the child ever been hospitalized for asthma? • Does the child use an inhaler or other device?

Fluoride Compound/Ion Concentration Conversions

• X% NaF = 0.45(X)%F ex. 0.5% NaF = 0.225%F = 2250 ppmF • X% SnF2 = 0.25(X)%F ex. 2% SnF2 = 0.5%F = 5000 ppmF • ppmF = mg F/L ex. NYC water = .7ppmF = .7 milligram of fluoride per liter

Oral findings in asthma

• Xerostomia - due to use of β2 agonists, corticosteroids, and mouth breathing • Oral candidiasis - due to nebulized corticosteroids • Gingivitis - due to nebulized corticosteroids and mouth breathing • Pharyngeal irritation

General anesthesia Contraindications

• a healthy, cooperative patient with minimal dental needs • a very young patient with minimal dental needs that can be addressed with therapeutic interventions (e.g., ITR, fluoride varnish) and/or treatment deferral • patient/practitioner convenience • predisposing medical conditions which would make general anesthesia inadvisable.

General anesthesia: Indications

• patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability • patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy • the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent • patients requiring significant surgical procedures • patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk • patients requiring immediate, comprehensive oral/ dental care

Apexification steps

•Local anesthesia, rubber dam •Extirpate necrotic pulp tissue 1 mm short of radiographic apex. •Canal instrumented to remove tissue. •Irrigate with sodium hypochlorite to dissolve pulp-tissue remnants and disinfect •Calcium hydroxide to fill the canal •Compress calcium hydroxide to ensure condensation in the canal to contact with apex •Place glass-ionomer temporary restoration •Change Calcium hydroxide every 2-3 months until root end closure •Follow up with final fill of canal Appearence of hard-tissue barrier at apex: -Irregularly arranged layers of coagulated soft tissue, calcified tissue, and cementum-like tissue. Included are islands of soft tissue

NasoAlveolar Molding (NAM)

•Removable Appliance •Secured to face with elastics and tapes •Stays in 24hrs/day •Baby sleeps and feeds with appliance •Clean 1x day •Change tapes 1x day •Weekly adjustments at clinic

Issues in pediatric anesthesia

-LA, iV, conscious, general -Blocks can be used, but most primary teeth can be used with infiltration -use TSD or distraction to reduce fear of needles -Showing the needle or not is a difference in schools of thought, some do, some dont

Improving Nitrous Oxide/Oxygen Inhalation Compliance Breathing Enhancers for Children

-Liners and scents for the mask -Disposable scented scavenging masks -Artificial fragrance

Protective stabalization

Protective stabilization is the term utilized in dentistry to describe the physical limitation of a patient's movement by a person or restrictive equipment, materials or devices for a finite period of time in order to safely provide examination, diagnosis, and/or treatment • Active immobilization involves restraint by another person, such as the parent, dentist, or dental auxiliary. • Passive immobilization utilizes a restraining device.

Modeling

"Personality develops though an individual's social learning experiences...development and learning that goes on is based on the individual's imitation of others." Learning through modeling is most effective when - the observer is in a state of arousal - when the model is perceived to have more status and prestige by the observer - When there are positive consequences of the model's behavior

Trends in peds practice

2003 Survey AAPD members states all non-pharmacologic techniques are readily used except HOME and active immobilization of a sedated child Hand Over Mouth Exercise HOME is being used less now than 5 years ago among 25% increase use of Nitrous oxide/oxygen inhalation more frequently than 5 yrs ago 38% increased use of general anesthesia than 5 yrs ago

Shy and Introverted Child

A very shy child will be stressed by the dental experience- it requires rapport and communication between the dentist and the patient The process of developing rapport with these children requires patience Best techniques are to talk to these children on their own level, using praise and tell-show-do

Four common mistakes are made by dentists attempting to anesthetize a child

1. Waving the needle in front of the patient 2. Not getting supportive control of the patient's head and hands 3. Using long needles 4. Using inappropriate doses

Local anesthetics are potentially more toxic in small children because

Local anesthetics are potentially more toxic in small children because the margin of safety is lower • It is common practice to calculate drug dosage on the basis of body weight because body mass is related to blood volume, which correlates to the plasma concentration achieved for a given dose. • Given an equal dose, a healthy child with greater blood volume will have a lower plasma level of anesthetic than will a child with lesser blood volume and body weight. • Obese children are at risk for toxicity if given body weight-determined dosages because their blood volume is relatively less than their weight would indicate -dont want to do 4 quads at one time, 1 or 2 at most Lidocaine: 4.4mg/kg Mepivicaine: 6.6 Articaine:4.4, did not give to peds when it first came out, now they do give it but not for blocks

Anesthesia for the Maxillary Tissues

• The needle penetration site is determined by two anatomic landmarks, the mucobuccal fold and mucogingival junction (Sweet's line) • The penetration site is 2 to 3 mm apical to the mucogingival junction and into the alveolar mucosa and 2 mm from the labial or buccalsurface

Factors influencing behavior: Family Unit

Behavior contagion - Fearful patients often note unfavorable dental attitudes among members of their family and friends Threatening the child of dentist as punishment Well-intentioned but improper preparation of the child Discussing dentistry within hearing of the child Children's anxieties, generated both externally and internally

Factors influencing behavior: Maternal Anxiety

Children of all ages can be affected by their mothers' anxieties, but the effect is greatest with those under 4 years of age Children who know that a problem exists have a tendency toward negative behavior Highly anxious mothers generally have more uncooperative children, these mothers usually able to predict their child's behavior

Factors influencing behavior: Medical History

Children who view medical experiences positively are more likely to be cooperative for the dentist. Fear of the white coat: taken seriously enough that most pediatric dentists choose to wear colored clothing instead Parental beliefs about past medical pain correlate with their child's cooperative behavior Past surgical experience adversely affects behavior at first dental appointment, but not after.

Show: desensitization

Desensitization - "gradual exposure to new stimuli or experiences of increasing intensity". Easy procedure first, then move up the ladder of anxiety producing procedures: Count fingers, then teeth Always at the child's level of understanding Tell-show-do is especially recommended for children in Piaget's pre-operational stage of cognitive development which occurs between ages 2 and 7 yrs Mirror to watch Puppets!

Factors influencing behavior: Temperament

Easy child - positive in mood and reacts to stress with low intensity - will possess flexibility to adapt to a change in plan by the dentist Slow to warm up - slow to adapt and respond to new situations - child needs time to adjust to the dental setting, - dentist should be patient, calm, and sensitive Difficult child - difficulty coping with stress, quick to withdraw from new situations - will respond to the dentist who provides a structured environment

Nitrous Oxide/Oxygen Inhalation Compliance: Recovery

•Deliver 100% oxygen at 6L/min flow for a minimum of 5 minutes to scavenge N2O and until the child has returned to baseline •Eliminate risk of diffusion hypoxia?: in a closed system (facemask or ET tube, only in very high concentrations can be problematic. In open system, given room air only at termination of procedure. N2O has no effect on SaO2, no report of headeache, lethargy, or nausea. It is still a prudent practice to permit continued scavenging of exhaled o2. Diffusion hypoxia: N2O relatively insolule in water, so when it is stopped, large quantities diffuse back out into the alveoli and displace O2. Second gas effect: NO2 Improving the uptake(not potency) of a second gas. Uptake of N2O into the blood from the alveoli creates a negative pressure vacuum that pulls in the "second gas"

Filmed Modeling

Experimental: watched videotape depicting a 4 yr old child undergoing a dental restorative procedure immediately prior to their own appointment The child was verbally rewarded by the dentist and given a toy at the end of the visit Children in experimental group showed - significantly less disruptive behavior during the restorative procedure than children in the control group - rated as being more cooperative - Children viewing the modeling film immediately before actual dental work may enhance the effectiveness

Factors influencing behavior: Crying

Expression of personality 4 types encountered in the dental setting: 1. Obstinate 2. Hurt 3. Frightened 4. Compensatory - Identifying types of crying will give the practitioner an important diagnostic tool

Characteristics of Children with Dental Fear

Fears or phobias unrelated to dentistry Parent with high dental fear No appointment in last year < 6 years old Female Previous treatment with local anesthesia

Tylenol dosage

Forms Tablet: 325mg, 500mg, 650mg Chewable tablet:80mg, 160mg Suspension= 160mg/5mL Usual Dosage Children< 12 yo= 10-15mg/kg/day. MDD=2.6g (5 doses) Adults= 325-650mg. MDD=4g

Obstinate Crying

Has no tears, siren-like quality, temper tantrums accompany Management: Do not feel agitated Reassure the child calmly and firmly Speak with a tone of authority tempered with understanding Positive reinforcement given when crying ceases This child's mother is usually no help to stop the crying

Frightened Crying

High volume of tears, wailing sound, convulsive respiration, with hysteria Management: Based in emotion, not reason Parents will be helpful to provide moral support Firmness and gentleness most effective Distraction useful Reassurance and explanation imperative when crying ceases Force always contraindicated

Barriers to Quality Dental Care

Medical cause - Developmental delay - Physical disability - Acute/Chronic disease Fears - Previous medical/dental care - Parents fears - Inadequate preparation - Dysfunctional parenting Communication failures - Inadequate - Not culturally appropriate - Create a "teacher-student" role help

Who are the models?

Mom and Dad - Maternal anxiety is well documented as having an influence on child behavior Other children and older siblings - Watching another child exhibit good behavior in the dental chair has a large influence on children with no previous dental experience - "The presence of a mother is especially beneficial for the 3 ½ to 4 year old and of an older sibling for the 4 year old." YOU!!! - The dentist's behavior influences the child's behavior and can control crying. The dentist treats the child as a mature, cooperative person who is capable of controlling their reactions. - Conversely, the dentist who is too accommodating or too authoritarian may maintain infantile crying or obstinate bad behavior

Advanced Behavior Guidance Techniques

Nitrous oxide/oxygen inhalation - a fearful, anxious, or obstreperous patient; - profound local anesthesia cannot be obtained; Protective stabilization - Protection of patient and staff Sedation - Minimize discomfort and pain - Control anxiety, minimize trauma, maximize amnesia General Anesthesia - Eliminate anxiety - Reduce movement and reaction to dental treatment - Eliminate patient pain response - Patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability - Extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent - Patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk

Compensatory Crying

No tears, no sobs, constant noise, child's own distraction method Management: Make no attempt to stop the whining as long as child is cooperative Allow the child to compensate for the sound of the handpiece

Nitrous Oxide/Oxygen Inhalation Advantages

Non-invasive Acceptable to parents Rapid onset of action Permits titration to desiredeffect Rapid elimination and recovery Provides supplemental oxygen

Emotionally Compromised Child

Often children of broken homes Dysfunctional family situations Abused/neglected children Parents usually overlook their child's behavior or have rationalized an explanation for why their child behaves that way. Most emotional diseases are diagnosable and treatable

How to Inform a Parent about Behavior Guidance

Oral methods result in over 95% of parents feeling well informed Oral delivery most effective method of informing parents, obtaining consent 2/3 of parents felt it important to be informed of each technique: including tell-show-do How parents were informed was directly correlated to how informed the parents felt and whether or not the parents consented

Factors influencing behavior: Parent Participation in the Operatory ??

Parents and some dentists have changed in attitudes towards children, others have not (and historically been very satisfactory treatment rendered in the past without parents present). Today's societies are more mobile, people don't know their neighbors names, increase in the number of parents who want to protect their children. Trend among parents is to be present during the child's treatment, visually verify child's safety.

Parental Attitudes Toward Behavior Modification Techniques

Parents viewing videotapes with explanations were significantly more accepting of techniques than those without Critical to recognize that more explanations can shape and modify opinions when presented in a positive manner "More informed parents are more accepting parents" Recent AAPD Survey showed: Parent would accept GA over nitrous and restraint Voice control not accepted

Tell: fear

Prevent scary descriptions of dentistry Fear of the unknown Familiarize with surroundings and procedure Fear of dentistry can be prevented The child fears the thing he does not understand "We seek to create an atmosphere of normalcy, one in which everything is known and understood and accepted."

Recording patient behavior

Record the child's behavior using the Frankl Scale at every visit. This documents care as well as a reference for future visits. Accompanying descriptor may help: - + Non-verbal but cooperated with direction - - Resistant to local anesthesia

Mechanisms to Manage Crying

Reinforcement: used to improve behavior by praising child, "You're not crying, you're acting like such a grown-up, I'm sure mom is very proud of you!" Modeling: dentist's behavior has a direct effect on the child's behavior. - Demonstrate calm breathing, soft and regular voice, relaxed posture, the child will find it hard to stay agitated if dentist is relaxed Suggestion: used to reduce fear, and increase relaxation - Tell-show-do, relaxation techniques using imagination

Physiology of a Fear Reaction

Sensory cues Increased heart rate Pupils dilate Blood moves internally, away from skin Sweat glands activated Adrenal glands release cortisol/epinephrine All of this is INVOLUNTARY, influenced by genetics, temperament, a variety of factors. Our goal as the pediatric dentist is to "turn down the volume" on the response

Crucial Moments in the Dental Appointment

Separation of child from parent - Discuss parent presence/absence before first treatment appointment - Discuss that parent will leave if child does not behave before child is in chair, child should know about the agreement Getting into the chair - The good patient gets right into the chair and is praised for doing so (first opportunity for praise) - This is difficult for some kids! Dentist seated at chair - Must be recognized as authority figure Injection - One of the most feared procedures by the patient (and dentist) - Honesty helps, hesitancy doesn't - Firm voice control helps with avoidance behaviors Dental procedure - For the good child patient, the procedure is easier than the injection End of the appointment - The good child ends the appointment on a high note Return of patient to parent - Good child returns to parent with pride COMMUNICATION is the key Pain inflicted by a dentist perceived as caring is likely to have less psychological impact than pain inflicted by a dentist who is cold/controlling. Good rapport between patient, parent, and dentist is essential for more than just informed consent

Hurt Crying

Tears low in volume, moaning sound, holding breath Directly related to clinical procedure you may be doing ( stop and go of hand piece) Management: Child is in pain Relieve the pain with every effort

Behavior Guidance Techniques Communicative

Tell-show-do Voice control - Controlled alteration of volume, tone or pace to direct patient's behavior Non-verbal communication - Reinforcement and guidance of behavior through contact, posture, facial expression and body language. Positive reinforcement - Social and Nonsocial Distraction - Diverting a patient's attention from possible unpleasant experience.

Nitrous Oxide/Oxygen Inhalation Pharmacokinetics

Transport - Only a small amount of N2O is absorbed into the blood as equilibrium between partial pressure gradients is quickly achieved Carried in blood as a free gas Does not undergo biotransformation Does not bind to hemoglobin nor compete with its oxygen carrying capacity

Combination of Central and Peripherally ActingAnalgesics

Tylenol #2 = Tylenol (325mg) + Codeine (15mg) Tylenol #3 = Tylenol (325mg) + Codeine (30mg) Darvocet = Tylenol (325mg) + Propoxyphene (50mg) Darvon = Aspirin (389mg) + Propoxyphene (65mg) Vicodin = Tylenol (500mg) + Hydrocodone (5mg) Vicoprofen = Ibuprofen (200mg) + hydrocodone (7.5mg) Percodan= Aspirin (325mg) + oxycodone (4.5mg) Percocet=Tylenol (325mg) + oxycodone (5mg)

Dental Fear and Anxiety

"Major factors contributing to poor cooperation can include fears transmitted from parents a previous unpleasant dental or medical experience inadequate preparation for the first encounter in the dental environment dysfunctional parenting practices." "Fear is best understood within a multi-factorial context of personal, environmental, and situational factors in combination with the child's developmental level or intelligence (mental age)"

Nitrous Oxide/Oxygen Inhalation Compliance: Induction

- Adjust flowmeter rate based upon extent of reservoir bag expansion •Total flow adjusted between 5-8L/min • Reflecting the child's minute volume - Paresthesia and Vasomotor stages: • Tingling feeling in extremitites • Sensation of warmth • Eyes open • Effect achieved within 3 minutes - Drift Stage: Stage I of Anesthesia • Floating sensation • Auditory changes • Spatial disorientation • Eyes drowsy with distant stare • Analgesia • Euphoria • Effect achieved within 3-5 minutes - Dream Stage: Stage II of Anesthesia • (avoid this depth of psychosedation) • Dreaming/ delirium • Laughing/ giddiness/ excitement • Skin flush and sweaty o (diaphoresis-peripheral vasodilation) • Whirling feeling • Angry stare of eyes closed • Nausea/vomiting • Dysphoria

The frightened child

- Fear can present itself in many forms when working with children. - A young child who is unable to communicate their feelings may present with hysterical crying and are inconsolable where a child who is able to communicate their fears may present overwhelmed. How do you behaviorally manage a frightened child. - You may need the help of the parent to understand the child's fear - the dentist will need to be gentle and direct in their communication and sometimes distraction may help with these certain cases - most children that are severely frightened though may need pharmacological behavior management

Maintaining a Safe Dental Office with N2O

- Use a well-designed, effective scavenging system • Use secure-fitting nasal hood • Reduce patient's talking/crying • Set evacuation rate at 45L/min • Vent waste gas outside - Use and open, well-ventilated operatory • Adjust room air exchange rate > 10/hour • Employ sweep fan • Monitor your office every 3 months • Leaking testing of equipment: loose-fitting connections, defective seals, and rubber goods (use soapy water)

Interligamentary Anesthesia

-Injecting directly into PDL • Decreased pain of injection • Decreased anesthesia used • Decreased soft tissue trauma • Fewer post-op issues • Less soft tissue post-anesthetic trauma -Giving anesthesia both lingually and bucally, one tooth at a time

STA

-SIngle tooth anesthesia -A bit on the buccal and a bit on the lingual of the tooth, into the PDL zone -has a special wand that allows you to inject into a tooth, slowly, one tooth at a time, using a small guage needle. -Biggest disadvantage is the cost and maintenance of the machine

Factors that influence behavior in children

-Separation anxiety -Maternal anxiety -previous medical experience -The family unit(speaking poorly of dentist etc.) -Temperment of the child

Most significant concern with anesthesia in a peds patient

-Soft tissue trauma -Can be avoided by using interligamentay anesthesia injection -No antibiotics, jsut palliative care, it is due to the child being numb and chewing on their lips -there is a reversal agent, oraverse, that is being increasingly used for peds so they dont bite their lip

Frankl scale

1. Defanitely negative. Refusal of treatmnet, forceful crying, fearfulness, or any other over evidence of extreme negativism 2. Negative. Reluctance to accept treatment, uncooperative, some evidence of negative attitude but not pronounced (sullen, withdrawn) 3. Positive. Acceptance of treatment; cautious behavior at times, willingness to comply with the dentist, at times with reservation, but patient follows the dentists directions cooperatively 4. Defanitely positive, good raport with the dentist, interest in dental procedure, laughter and enjoyment

The shy introverted child

-Will present clining to the parent -overwhelmed with the new environment -may not cooperate with dental staff at first How to manage -Get down to the childs level -Use TSD in words that a child can understand -Positive reinforcement works well with these children

The emotionally compromised child

-may present very withdrawn from the situation, or may be very sensitive to the situation that theyre in -may also present with habits that are considered age innapropriate How to manage -Use TSD with positive reinforcement -Try to understand the childs individual need

Misbehaving Child Dental Patients

1. Emotionally compromised child 2. Shy, introverted child 3. Frightened child 4. Child who is adverse to authority

Nitrous Oxide/Oxygen Inhalation Compliance Pre-op Preparation

1. Flow 100% oxygen in reservoir bag using oxygen flush valve 2. Set flow meter at 7L/min 3. Calculate total flow rate (minute volume)

Components of tell-show-do

1. Learning theory 2. Positive reinforcement 3. Modeling 4. desensitization -Especially recommneded for children ages 2-7 Tell: explain what you will be doing in words the child can understand -Tell them before, while, and after you do it -Voice should be soft, yet firm, confident -Be truthful and honest about how it will feel -Distraction is OK, as long as you remain focused on your message Show -demonstrate what will happen, through interactions or instruments Do: exactly as you have said

There are three specific anatomic differences to be conscious of in children:

1. The proximity of vascular structures in the maxillary tuberosity area - Where penetrating too deeply with the needle can result in injury to the pterygoid venous plexus or posterior superior alveolar artery and resultant hematoma 2. The mandibular ramus is shorter and is narrower anteroposteriorly - Therefore, for an inferior alveolar nerve block, the depth of penetration of the needle must be reduced 3. The bone is less calcified - Permitting expedited diffusion of the local anesthetic agent -Good for giving infiltration over blocks

Effective communication strategy

1. Voice control: alter tone, volume 2. non-verbal : contact or facial expression 3. Positive reinforcement 4. Distraction: divert attention when an unpleasent procedure is occuring The best first method for an uncooperative dental patient is TSD

Nitrous Oxide/Oxygen Inhalation Indications

1.) To reduce uncooperative behavior Produces anxiolysis - (reduces anxiety) Enhances muscle relaxation - (CP patients) Depresses gag reflex Increases tolerance for longer procedures in a cooperative patient. 2.) To create distraction Confusion/ disorientation Amnesia (not caring) -avoid needle phobia 3.) To promote analgesia 50% N2O= 15mg morphine N2O interacts with opioid receptors - (naloxone will block effect of N2O) Adjunct to inadequate local anesthesia

Calculating maximum dosage on a 44lb child (20kg)

2% Lidocaine -2% lidocaine = 20mg/cc of lidocaine -1 carpule=1.7 cc -20mg/cc *1.7 = 34mg/carpule Maximum dose = 4.4mg/kg -4.4*20kg = 88mg lidocaine -88/34mg/caprule = 2.59 carpules • 3% mepivacaine = 51 mg/carpule • 3% mepivacaine = 30mg Mepivacaine/cc • 1 carpule = 1.7cc • 30 mg/cc x 1.7 cc = 51mg • Maximum Dose = 4.4 mg/kg • 4.4 mg/ kg x 20 kg = 88 mg Mepivacaine • 88 mg/ 51 mg/carpule = 1.72 carpules • 4% articaine* = 68 mg/carpule • 4% Articaine = 40mg Articaine/cc • 1 carpule = 1.7cc • 40 mg/cc x 1.7 cc = 68mg • Maximum Dose = 7.0 mg/kg • 7.0 mg/kg x 20 kg = 140 mg • 140 mg/ 68 mg/carpule = 2.05 carpules *Articaine Should not be used for mandibular block or on a child < 4 y.o, he says you should not use it for a block on any pediatric patient Quick guide: 20lb: 1 carpule 40lb: 2 carpule 60lb: 3 carpule 80lb: 4 carpule

The defiant child

A defiant child is a child who will challenge authority. And talk back to authority. The defiant child will challenge the process the entire time you behaviorally manage - You may want to use options when able to do so but the defiant child wants to be in control of their situation. - Voice control with simple commands and positive reinforcement when the desired behavior from the child has been demonstrated. - Now you have this child in your chair. How do you proceed. - Well one way is to identify and recognize the child's cry. - Obstinate cry is a cry very familiar to all of us in the temper tantrum. How do you manage this cry - in this situation voice controlled done in an authoritative manner with the use of simple commands help to control this cry. - Examples include: Hold still put your hands down. - Once favorable behavior has been reached positive reinforcement needs to be utilized. - The hurt cry. - The child will usually present with low volume of tears moaning and moving. - How do you manage this cry - you alleviate the source of the pain. If you are doing an operative procedure. - One of the questions you can ask yourself is did I give an adequate amount of anaesthetic for this procedure. A frightened cry. - This is when the child has a continuous stream of tears a high piercing cry and convulsive breathing. - This is a child who is overwhelmed with the situation. - How is the frightened cry managed; depending on the needs of the child and the extent of the procedures this child may need pharmacological behavior management. To address the dental needs. The compensatory cry. - This is a cry that the child makes allowing them to have the procedure done. - Usually present as a monotone sound that's continuous through the procedure. - How you handle this situation. If the child is able to respond to your commands allow the child to continue the cry as long as is not disruptive to the procedure and safety is an issue. Whimpering with no tears: compensatory cry When you touch a childs tooth with a handpiece she begins to scream and kick: painful cry

Modeling and Dentistry

Adelson and Goldfried present case study with two children, Amy (age 4) and Penny (age 3.5) Amy outgoing, relaxed Penny shy, apprehensive about dental treatment Penny asked to "just to watch" while Amy received dental exam Amy received praise for a job well done, and a ring as a prize for behaving so well Penny was more willing to have her teeth examined after watching Amy, although still anxious No management problems with Penny as had been anticipated

Nitrous Oxide/Oxygen Inhalation Patient Selection - Medical Precautions*

Asthma • Prolonged use may dry bronchial secretions • N2O is delivered in an anhydrous "dry" state -OK for well controlled asthmatics, not for uncontrolled •Sickle cell anemia disease •Cyanotic cardiac disease/anomalies *Sickle cell crisis precipitated by low oxygen tension or stress • N2O/O2 can be beneficial here! But he says not to use it for sickle cell

Child Adverse to Authority

Based on the work of Dr. Alfred Adler, the child has a need to feel superior and satisfies it by adopting one of four attitudes: Undue attention (child wants people to pay attention to them any time he/she wants it) Struggle for power (this is a challenge to the child) Retaliation and revenge (this child wants to punish their parents in order to get attention) Inadequacy (this child acts incapable of doing anything and classifies him/herself as unable to do anything)

Role of Nitrous Oxide/Oxygen Inhalation in Sedation Procedure

Deepens sedation slightly without adversely affecting ventilator parameters

Protective stabalization education requirements

Didactic and hands-on mentored education beyond dental school is essential to ensure appropriate, safe, and effective implementation of protective stabilization of a patient unable to cooperate. Training can be attained through any of the following accredited post-doctoral programs: • AEGD, GPR, Pediatric Dentistry or • Extensive and focused continuing education course with both didactic and mentored handson experience. Formal training provides necessary knowledge and skills to: • Appropriately select patients • Use restraining techniques successfully • Minimize or prevent psychological stress • Prevent or mitigate risk of physical injury to the patient, parent, practitioner and staff. Education Requirements Attempts to restrain or stabilize patients without adequate training can put patient, practitioner, and staff at risk for physical harm. Use of protective stabilization requires informed consent from a parent or legal guardian which involves: • Thorough discussion of the procedure reviewing risks, benefits, and alternative behavior guidance techniques: treatment deferral, sedation, general anesthesia • Parent's signature on appropriate form • Documentation in patient's record prior to performing protective stabilization Parental presence recommended (may help both parent and child during a difficult experience) during procedure The use of protective stabilization has the potential to produce serious consequences, such as • physical or psychological harm • Ex. bone fracture/dislocation of the limbs • loss of dignity • violation of a patient's rights • restriction of respirations if placed too tightly around chest Careful, continuous monitoring of the patient is mandatory during protective stabilization. • Ongoing awareness/assessment of the patient's physical and psychological well-being during the dental procedure must be performed. • Stabilization should be terminated as soon as possible in a patient who is experiencing severe stress or hysterics to prevent possible physical or psychological trauma Remember: • Advanced dental training, beyond dental school, is required to employ advanced behavior guidance techniques such as protective stabilization. • Informed consent must be obtained and documented prior to use of protective stabilization. • Careful use of protective stabilization requires understanding of risks and consequences, thorough evaluation of each patient, and consideration of alternative approaches.

Behavior Guidance Do's and Don'ts

Do Tell-Show-Do Honesty, simply animated Non-Verbal communication Positive reinforcement Desensitization Parent in operatory Give child control Voice control Imagination PAIN MANAGEMENT Time out Deferral of treatment Don't Ignore behavior Lose control Deception Dishonesty Belittle Aversive techniques

Factors influencing behavior: Separation Anxiety

Frankl et al studied children's reactions to separation vs. non separation from the parent for one day Diminishes as child ages Anxiety more frequent in boys Children 3.5 to 5.5 yr - no past dental experience Divided into two groups 1. Separated from mother during treatment 2. Mother present for treatment Significantly more children reacted favorably with mother present 3 ½ -4 yrs were MOST negative when mother was absent Parental presence was most effective when parents were positively motivated and cooperated willingly in the role of 'silent helper' To separate the child-parent pair indiscriminately is to deny the child's source of love and security at a time of perceived threat and danger

LA dosage chart

Lidocaine -4.4mg/kg -2mg/lb -Max dose 300mg Mepivicaine -4.4 -2.0 -300 Articaine -7.0 -3.2 -500 Prilocaine -6.0 -2.7 -400 Bupivicaine -1.3 -0.6 -90 Bupivicaine has the longest duration of action

Calculating total flow rate (minute volume)

Person tidal volume X respiratory rate = minute volume Child: 300mL TV, 20/min RR, = 6L/min (minute volume) Adult: 500mL TV, 12/min = 6L/min (minute volume) -Recommended starting flow at 7L/min oxygen to compensate for anxiety related tachypnea

Characteristics of Early Unpleasant Dental Experiences

Procedures & Stimuli - Extraction, Drilling & Filling, Injection - Root canal, Cleaning & Exam, Operatory sounds, Braces, Cap (Crown), general anesthesia, Fluoride treatment Injuries - Pain - "Underfreezing", Soft tissue injury, No anesthetic, sight of blood Emotional responses - Afraid - Crying, vomiting, disgust, time dragging Dental Personnel Behavior - Rough, Incompetent, Unsympathetic, showed anger

Frightened Child

Various sources of dental fears including: Intellectual incapacity to arrest fear even when educated by a parent or dentist (due to age or slow development) Overreaction due to other emotional upsets Acquired fears from a family member or peer Learned fears from previous experience Emotional illness "If a child is so frightened that good behavior is impossible, it is the obligation of both of these adults (the dentist and the parent) to make sure that everything possible is done to avoid increasing the child's anxieties attendant to dentistry"

Peripherally acting non-opoid analgesics

Tylenol -Pain relief = aspirin -Fever +++ -Anti-inf: weak -No GI upset, but can cause renal damage if OD and liver damage in alcoholics, no increased bleeding risk. Drug of choice in children CI: px with liver or renal disorder Aspirin -Pain relief= tylenol -Fever ++ -Anti-inf +++ -Has worst GI upset, use with caution for renal damage, can cause liver damage in high doses, irreversible bleeding increase -CI: aspirin allergy, bleeding disorders, last trimester of pregnancy -Not to be used in febrile children, can cause Reyes syndrome Ibuprofen -Best pain relief -Fever ++ -Anti inf: +++ -Less GI upset than aspirin, reversible renal damage, possible liver damage, reversible increased bleeding -Same CI as aspirin -Ok for children

Advantages and Disadvantages of the Wand/STA System

• Advantages • Dynamic pressure-sensing (DPS) technology • Real-time feedback when an injection is performed • Allows the PDL injection to be used as a predictable primary injection • Allows all traditional injections techniques to be performed • Allows newer injection techniques • AMSA, P-ASA, and STA-intraligamentary injections—to be performed • Reduces pain-disruptive behavior in children and adults • Reduces stress for patient • Reduces stress for operator • Disadvantages • Requires additional armamentarium • Cost

The decision to use protective stabilization must take into consideration:

• Alternative behavior guidance modalities • Dental needs of the patient • The effect on the quality of dental care • The patient's emotional and cognitive development levels • The patient's medical and physical conditions • Parental preferences Protective stabilization should not be used as a means of discipline, convenience, or retaliation.

Unique Characteristics of Pediatric Anesthesia

• Anatomy: Body size & Airway anatomy • Drug Responsiveness: pharmacokinetics & pharmacodynamics • Route of Administration: oral, IM • Psychological Makeup: inadequate coping, lack of past experience, motivation towards cooperation

Nitrous Oxide/Oxygen Inhalation Compliance Maintenance

• Continuous monitoring • Observation o Respiratory rate o Consciousness o Displayed behavior • Pulse oximetry and head positioning should patient fall asleep

Protective stabalization: CI

• Cooperative non-sedated patients • Patients who cannot be immobilized safely due to associated medical or physical conditions • Patients who have experienced previous physical or psychological trauma from protective stabilization (unless no other alternatives are available) • Non-sedated patients with non-emergent treatment requiring lengthy appointments • Practitioner's convenience

Nitrous Oxide/Oxygen Inhalation Disadvantages

• Equipment cost and maintenance • Office space demands • Low potency—has varying effect, depends on the individual's susceptibility • Requires patient cooperation • Inhibits learning and coping strategies • Acute exposure--nausea/vomiting (rare) • Chronic exposure—health consequences?: have been thories about it being a causative factor of premature abortion -does require patient cooperation, but inhibits learning because of its effects, TSD may not be as helpful

Alternating Analgesic Therapy

• Evidence supports giving both Acetaminophen & Ibuprofen alternating (every 3 hours) as they work on different aspects of the child's pain.* • Acetaminophen best for fever • Ibuprofen best for pain • Example of schedule for alternating analgesics: 7:00am: Acetaminophen 10:00am: Ibuprofen 1:00pm: Acetaminophen 4:00pm: Ibuprofen 7:00pm: Acetaminophen *Mitigates "breakthrough pain" For antipyrretic effect, acet peaks in 2 hours and ibuprofen at 3 hours. The recommended dosing schedule for acet is every 6 hours, and every 8 hours for ibuprofen. thus theoretically they can be alternated every 3 hours

Goals in Sedation of the Pediatric Dental Patient

• Facilitate the provision of quality care • Minimize disruptive behavior • Promote a positive psychological response to treatment • Promote patient welfare and safety • Return the patient to a physiologic state in which safe discharge is possible

Protective stabalization: Indications

• For patients requiring immediate diagnosis and/or limited treatment and cannot cooperate due to lack of maturity or mental or physical disability. • When the safety of the patient, staff, dentist, or parent would be at risk without its use . • For sedated patients requiring limited stabilization to help reduce untoward movement

Pain management

• Infants, children, and adolescents can and do experience pain due to dental/orofacial injury, infection, and dental procedures. • Management of pain in children is changing rapidly as a result of improvements in the appreciation of pediatric pain and pharmacologic knowledge. • Acetaminophen, ibuprofen, and opioids are common medication choices for the treatment of acute pain in children. • Acetaminophen/ NSAIDs should be used as first line pharmacologic therapy for pain management. • Use of opioids should be rare for pain management for pediatric dental patients.

Nitrous Oxide/Oxygen Inhalation Record Documentation

• Informed consent • Rationale/indications for use • Percent concentration (% N2O/O2) • Total flow rate (L/min) • Duration of procedure (min) • Outcome/adverse effects • Duration of post-op oxygenation period

Moderate Sedation

• Old teminology "conscious sedation" or "sedation/analgesia" • A drug-induced depression of consciousness during which patients respond purposefully to verbal commands (eg. "Open your eyes" either alone or accompanied by light tactile stimulation; a light tap on shoulder or face, not a sternal rub). • For older patients, this level of sedation implies interactive state; for younger patients, age appropriate behaviors (eg. Crying) occur and are expected. • Reflex withdrawal, although a normal response to a painful stimulus, is not considered as the only age-appropriate purposeful response (eg. It must be accompanied by another response, such as pushing away the painful stimulus so as to confirm a higher cognitive function). • With moderate sedation, no intervention is required to maintain a patent airway, and spontaneous ventilation is adequate. • Cardiovascular function is usually maintained. • However, in the case of procedures that may themselves cause airway obstruction and assist the patient in opening the airway. • If the patient is not making spontaneous efforts to open their airway so as to relieve obstruction, then the patient should be considered to be deeply sedated.

Deep Sedation

• Old terminology " deep sedation/analgesia" • A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation (eg. Purposefully pushing away the noxious stimuli). • The ability to independently maintain ventilatory function may be impaired. • Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. • Cardiovascular function is usually maintained. • A state of deep sedation may be accompanied by partial or complete loss of protective airway reflexes.

Minimal Sedation

• Old terminology "anxiolysis" • A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

How to test for adequate anesthesia

• One of the most difficult tasks for the dentist is to test for adequate anesthesia following an inferior alveolar nerve block • Most commonly the dentist uses lip numbness as a subjective sign to indicate a sufficient block of the ipsilateral inferior alveolar nerve. A study performed by Ellis and coworkers (1990), indicated that the loss of gingival response to stimulation (positive gingival test) is a more rapid sign of anesthesia onset and a more reliable predictor of success than are tongue and lip signs. • The thermal response does not provide any information regarding the onset of anesthesia. The most reliable indication of an efficacious inferior alveolar nerve block is a combination of three signs (tongue, lip, and gingiva).

Inferior Alveolar Nerve Block

• The needle penetration site for the inferior alveolar never block is a depression identified by an imaginary line dividing the tip of the finger (or thumb) and intersecting with an imaginary vertical line extending superiorly from the apex of the pterygomandibular triangle. • The penetration site is 2 to 3 mm apical to the mucogingival junction and into the alveolar mucosa and 2 mm from the labial or buccal surface -use the 2-3mm rule, never go to the hub of the needle

Landmarks for IANB

• The triangle is formed next to a)The internal pterygoid ligament, b)The apex of the triangle, c)The anterior border of the ramus of the mandible, d)The vault of the palate • Mandibular foramen is below the occlusal plane of the primary teeth in children. • Therefore, injection must be made slightly lower and more posterior than an adult. • The barrel of the anesthetic syringe is positioned parallel to the line of occlusion of the posterior teeth and is directed from over the primary mandibular molar or premolar of the opposite side. • After needle penetration and the needle tip encounters the medial surface of the mandibular ramus, its hub should be about 3.0 mm from the mucosa. • At this point the area is aspirated, followed by a slow deposition of solution to affect the inferior alveolar nerve block.

Administration of Local Anesthetic in peds

• To ensure the child's comfort and safety, injection of local anesthetics should always be made slowly (approximately 1 mL/minute) • Preceded by application of topical anesthesia??? Yes but consider recent reports of reactions to topicals, caution the amount used. You have to wait a full 90 seconds for topical to take effect • Aspiration to avoid intravascular injection, which may result in systemic reactions to the local anesthetic ingredients. • Traditionally, local anesthesia is achieved by either infiltration or nerve block, sometimes in combination -Always test for adequate anesthesia

LA toxicity

• Toxicity from the administration of local anesthesia in children is rare but its occurrence can be insidious and tragic. Severe morbidity and mortality have been reported from cases of inadvertent systemic overdose The anatomic, metabolic, and physiologic differences of children from that of an adult population must be understood and appreciated by the clinician calculating the safe maximum pediatric dosage Adherence to safe maximum dose calculations, use of proper injection techniques, and attention to past medical history by the clinician will reduce the potential for adverse complications

The objectives of patient stabilization are to:

• reduce or eliminate untoward movement, • protect patient, staff, dentist, or parent from injury, and • facilitate delivery of quality dental treatment.

Nitrous Oxide/Oxygen Inhalation Patient Selection - Behavioral Precautions

•Defiant, hysterical, screaming behavior •Tearful crying •Previous negative experience •Severe emotional/psychiatric disorders •Propensity for vomiting -you need to have them relatively cooperative to accept the nose mask

Nitrous Oxide/Oxygen Inhalation Patient Selection - Contraindications

•First trimester of pregnancy •Chronic obstructive pulmonary disease/emphysema (Fragile hypoxic drive) •Severe asthma •Bleomycin sulfate (antibiotic for oncology patients) •Methylenetetrahydrofolate reductase deficiency •Hyperhomocysteinemia •Sinusitis, otitis media or recent (within 2 months) eye (retinal detachment) or ENTsurgery •Informed consent/assent not obtained •Significant otitis media - increased pressure related to N2O concentration and closure of the Eustachian tube

Nitrous Oxide/Oxygen Inhalation Complications

•Nausea/ vomiting • Very rare, but associated with: o High concentrations (>50%), over-sedation o Prolonged use (>1hr.) o Frequent adjustments ("roller coaster"ride) o Presence of food in stomach (NPO?) o Prior history of propensity •Chronic exposure—health consequences? • Folic acid synthesis can be inhibited by chronic exposure - Scavenging is required by NIOSH/ADA for the safety of your staff

Nitrous Oxide/Oxygen Inhalation Scavenging System

•Only ADA-approved system •Proven superior in effectiveness -Porter-brown scavenging nasal hood -one tube for gas, one tube for exhaled gasses into a vacuum

Nitrous Oxide/Oxygen Inhalation Compliance: Objective

•To achieve "Relative Analgesia" • Pupils normal and contracted to light • Eyes open with "far away" stare • Digits and tongue have tingling sensation • Feeling of warmth • Muscles relaxed, hands open • Euphoric attitude