PD 240 Pediatric Dentistry Midterm 2

SDF - Treatment Modality (Clinical Supplement Section) Composition: 25% of Silver ions, 5% of Fluoride ions, 8% of Ammonia

*Used very often in young pre-cooperative children SDF - colorless solution containing fluoride ions Composition: • Contains 25% of Silver ions, 5% of Fluoride ions, 8% of Ammonia • Contains ~44, 88 pm of Fluoride (F) + ~253,870 ppm of Silver (Ag) • pH: ~8.0 Function: • Arrest + slow rate of caries progression • How: combines tooth-strengthening effect of sodium fluoride + antibacterial effects of silver on hydroxyapatite + bacteria survival Advantages: • Arrests cavitated carious lesions in primary + permanent teeth • May control pain by arresting caries • Non-invasive + safe to use in children (from very young age) • Easy procedure for fearful + apprehensive patient • Can delay restorative treatment until child = older + avoid GA (general anesthesia) • To arrest + prevent progression of caries in children being referred for GA + on GA waitlists • Useful in high risk populations • Affordable option • Minimal support in staff or equipment required Disadvantages: • Affected area/decay will stain black permanently -> disadvantage that raises most concerns for parents + can cause parents to decline SDF • Healthy tooth structure • Tooth colored fillings + crowns may also discolor • Stains: Skin + lips (temporary), clothing (permanently), surface in dental office, including countertops (permanently) • Can irritate gingival tissues • If tooth decay isn't arrested, decay will progress; tooth will require further treatment, such as repeat SDF, a filling or crown, RCT, or extraction

Anticipatory Guidance: - Checklist of topics to be evaluated + discussed at infant + toddler oral health visits 1. Oral medications - often high sugar 2. Health history of infant & family 3. Diet & nutrition • Bottle feeding not necessary after age 1 • Children 1-6 should consume no more than 4-6 oz of 100% fruit juice per day

- Checklist of topics to be evaluated + discussed at infant + toddler oral health visits • Consider health hx of infant + family, hereditary conditions 1. Oral medications: often contain large amounts of sugar 2. Health history of infant & family: family oral health expectations + experiences, hereditary conditions (infant or family), non hereditary conditions 3. Diet & nutrition: address ECC, weaning to cup, fermentable carbs • Don't allow continual feeding w/ bottle or sippy cup • Medically healthy children can be weaned from bottle by 1 year of age • Don't let child sleep w/ bottle unless contains water only • Fruit, veggies, yogurt, cheese >>> chips, crackers, cereal • Children 1-6 should consume no more than 4-6 oz of 100% fruit juice per day • Excessive fruit juice consumption caries risk for both obesity + caries • Dilute fruit juice w/ equal amounts of water • Fruit juice should be limited in frequency + consumed with meals, not by itself • Brush child's teeth w/ water after eating sweets, chips, crackers or drinking juice or milk • Bottle feeding milk/formula isn't necessary for medically healthy children after age 1

9. Passive Restraint - holds hands over pt's hands at key points in procedure

- Dental assistant or parent holds hands over pt's hands at key points in procedure • Not necessarily touching pt Objective: prevent unexpected, unsafe, and/or unsafe patient mvmt Indications: any patient where undesirable movement possible + could have a negative result • Technique useful even for well-behaved patients, as even a Frankl 4 patient can become startled + suddenly move in an unexpected way that can cause a serious problem Contraindications: Inadequate to maintain a safe environment, + for such patients more active restraint needed

15. Sedation + General Anesthesia: B. General Anesthesia

- Drug induced loss of consciousness during which pts aren't arousable, even by painful stimulation; independent ventilatory + CV fxn impaired Location: Hospital, outpatient surgery center, or office setting by specifically trained personnel • Most states, including California, have specific licensing + certification requirements for both facilities providing GA + for practitioners administering GA • CA law requires certification for dentists based on extra training to legally practice sedation Cost: • Both sedation + GA incur additional treatment costs, which often not covered by insurance policies • Sedation procedures tend to be less costly for patient than GA, in part due to additional facility fees associated with GA in + ambulatory care or hospital setting • A recent study indicates that pediatric patients = more likely to exhibit positive behavior at 6 mos., 12 mos., + 18 mos. recall visits following GA treatment than those treated for Early Childhood Caries (ECC) under sedation at same recall intervals • Pediatric pts have better positive behavior at recall visits following GA tx

7. Ask-Tell-Ask

- Inquiring about patient's visit + feelings toward/about any planned procedures (Ask) -> Explaining procedures through demonstrations + non-threatening language appropriate to cognitive level of the patient* (Tell) -> Again inquire if the patient understands and how they feel about the impending treatment (Ask) *see euphemisms • Assess anxiety that may lead to noncompliant behavior during treatment • Teach patient about procedures + how they're to be accomplished • Confirm that patient comfortable with treatment before proceeding • Can be used for any pt who's able to dialogue Ex. • Ask Susie how she feels about getting sealants today • Explain to Susie how the sealants will be applied, and demonstrate on her fingernail • Ask Susie if she understands more now + is ready to start.

Appliance Classification: 2. Semi-fixed, cemented appliances - Made from ortho band + wire, retained by cementation of band(s) to abutment teeth. Advantage: No LAB DELAY; Easy to adjust, repair Disadvantage: More easily removed, Inventory of various sized components maintained; Difficult OH, no VDO

- Made from ortho band + wire, retained by cementation of band(s) to abutment teeth. • Wire + band has mechanical attachment -> allows removal of wire portion of appliance for adjustment or cleaning Design for attachment varies: • Tube attached to band into which wire fits, or, intricate attachment mech • Usage require an inventory of variously sized bands with attachment + wires. Advantage: • Can be placed immediately (no lab fab delay) • More easy adjusted at time of deliver (no space loss et) • More easily repaired if damaged Disadvantage: • More easily removed by pt/ displaced by food impaction • Inventory of various sized components must be maintained (cost) • Doesn't address VDO • May complicate pt OH

Frankl Scale Frankl 1: Definitely negative Frankl 2: Slightly negative: minor negativism or resistance, with minimal-moderate reserve, fear, nervousness, or crying -> TSD Frankl 3: Slightly positive: pt cautiously accepts tx but reluctant -> anxious Frankl 4: Definitely positive

- Narrative description alone doesn't always accurately communicate patient's behavior Frankl 1: Definitely negative: pt refuses tx, exhibits resistance, hostility, extreme fear, forceful crying, + massive withdrawal Ex. Frankl 1. Combative, refused to communicate 2. Slightly negative: pt exhibits minor negativism or resistance, with minimal to moderate reserve, fear, nervousness, or crying Ex. Frankl 2. Tell-Show-Do (TSD), frequent reminders, cried at end of appt 3. Slightly positive: pt cautiously accepts tx but reluctant, questions, uses delaying tactics, + has moderate willingness to comply ... at times with reservation, + to follow direction with minimal hesitance Ex. Frankl 3. Anxious but follow directions well 4. Definitely positive: pt has good rapport with operator, shows no sign of fear, interested in procedures & appropriate verbal contact Ex. Frankl 4. Pt inquisitive, happy, good helper Peds Clinic: Uses Frankl Scale + Narrative explanatory notes: • Behavior note for every patient visit recorded in our axium record in this format. • Numeric scale -> standardized description of behavior which occurred (whether positive or negative), + narrative description gives more specific info where indicated. • When reviewing patient's previous behavior in their record, most accurate prediction of future behavior can be made by comparing patient's behavior for procedures which might be similarly anxiety-provoking, require similar levels of cooperation, + of similar duration. • Closer in time a similar procedure is to upcoming visit, more likely similar behavior will be.

Fluorisis Risks - Permanent intrinsic white to brown discoloration of enamel Cause: Systemic exposure (during enamel formation stage of permanent tooth dev (from ~10 mo—6 for development age-appropriate pt), Etiology: Occurrence: increasing frequency from multivitamins, diet, chronic toothpaste/rinse ingestion, inappropriate F- prescriptions

- Permanent intrinsic white to brown discoloration of enamel Cause: Systemic exposure to excessive fluoride during enamel formation stage of permanent tooth dev (from ~10 mo—6 for development age-appropriate pt), thus all teeth developing during period of excel fluoride exposure affected • Teeth = highly resistant to caries, but very unaesthetic • Microabrasion may or may not help based on lesion intensity (better for white) Etiology: • Excessive incorporation of fluoride into enamel structure as tooth is developing -> discoloration due to systemic fluoride • Manifests in pattern which typical of systemic insult • Note that age of onset of excessive fluoride exposure can be determined by portions of tooth crown which is affected Occurrence: • Increasing frequency due to ambient fluoride exposure in multivitamins (when given to children already exposed to optimal fluoride levels in drinking water) • Increased dietary exposure (food, beverages) • Chronic toothpaste or rinse ingestion (unsupervised use) • Inappropriate fluoride prescriptions

10. Protective Stabilization Types: A. ACTIVE RESTRAINT with pt stabilization by another person (hold hand directly) B. Stabilization device: PAPOOSE Board or pedi-wrap For: • Pre-cooperative child • Disabled pt • Uncooperative child • Sedated pts. • Special needs • Require immobilization for exam or treatment, Comforted by confinement (Autistic) Contraindications: Not appropriate for multiple ongoing treatment Cooperative pts, pts w/ previous physical or psychological trauma from protective stabilization, pts who can't be immobilized safely due to medical/ physical conditions, non-sedated pts with non-emergent txt requiring lengthy appts

- Restriction of pt's freedom of mvmt w/ or w/o pt's permission to decrease injury + allow safe completion of tx (but always with documented parental consent) Types: A. ACTIVE RESTRAINT with pt stabilization by another person (hold hand directly) B. Stabilization device: PAPOOSE Board or pedi-wrap Function: Immobilizes child's limbs for difficult procedures with uncooperative child where there's danger of injury to pt, dentist, or staff • Presented to child as positive manner as possible: "Sleeping bag", "Special blanket", "Baby burrito" • Requires specific parent consent For: • Pre-cooperative child • Disabled pt • Uncooperative child • Sedated pts. • Special needs • Require immobilization for exam or treatment, comforted by confinement (Autistic) Indications: 1. IMPORTANT: Not a behavior guidance strategy appropriate for multiple ongoing treatment When patient can't be safely treated without this level of restraint, other options (Sedation/GA) should be considered for ongoing treatment. 2. Patient requires immediate diagnosis and/or limited treatment + can't cooperate due to lack of maturity or cooperative ability 3. Patient requires immediate diagnosis and/or limited treatment + can't cooperate due to mental or physical disability 4. Safety of patient, staff, dentist, or parent would be at risk without use of protective stabilization 5. Sedated patients require limited stabilization to help reduce untoward movement Contraindications: Cooperative pts, pts w/ previous physical or psychological trauma from protective stabilization, pts who can't be immobilized safely due to medical/ physical conditions, non-sedated pts with non-emergent txt requiring lengthy appts Precautions: Tightness + duration must be monitored, stabilization around extremities must not actively restrict circulation or respiration, stabilization should be terminated as soon as possible Practice Management: Protective Stability: Protective stabilization regarded less + less favorably by both parents, public, + our legal system as time progresses, due in large part to abusive + inappropriate use of this modality. It's important that whenever protective stabilization is used it be for good reason + that practitioner's rationale for its use is thoroughly documented with full informed consent from parents or court-appointed legal guardians, + a signed specific consent form for mechanical restraint..

6. Tell Show Do

- Technique of behavior shaping that involves verbal explanation of procedures in phrases that appropriate to developmental level of pt -> Demonstrations for pt of visual, auditory, olfactory, + tactile aspects of procedures -> doing procedure • Systematic desensitization + positive reinforcement • Teach & familiarize pt with important aspects of dental visit/ dental setting • Shape pt's response to procedures thru desensitization + well described expectations • May be used w/ any pt capable of understanding the concept Steps: 1. Tell patient what you're going to do, at an age-appropriate level. (Ex. explain to patient that you're going to clean his teeth) 2. Show patient any instruments to be used, tooth in question, etc. • May include visual, auditory, olfactory + tactile aspects of procedure (ex. show patient slow speed handpiece with prophy angle attached, demonstrate on patient's fingernail) 3. Do procedure as you explained it, praise a positive result. (Ex. prophy the child's teeth) • Based on systematic desensitization, positive reinforcement

4. Distraction Often during LA

- Technique of diverting pt's attention from what may be perceived as an unpleasant procedure • Decrease pt's perception of unpleasantness • Avert negative or avoidance behavior • May be used with any pt • Can be obvious or subtle • Often during LA • Story telling, singing, movie/ music on monitor

Appliance Types: 6. Acrylic Removable Appliances - Mx/md, bilateral Uses: 1. Maintain space in entire arch with premature loss of one or more primary teeth + potential for space 2. When prematurely lost primary tooth = terminal tooth in arch (loss of prim 2nd molar before eruption of perm 1st molar) -> Add a protuberance or "bump" to tissue surface of appliance to put pressure on soft tissue mesial to erupting permanent tooth, typically erupting permanent 1st molar -> Guide eruption of permanent tooth • Most effective: placed right after extraction + can lie over distal portion of healing pocket 3. Appliance of choice: most MULTIPLE TOOTH LOSS situations because of ease of construction + flexible design 4. Gingival extension that exerts pressure on gingiva mesial to mesial marginal ridge of permanent 1st molar -> used instead of distal shoe in cases where it's contraindicated Advantage: • Maintain vertical occlusal height -> Facilitate more normalized occlusion for pt • Easily adjusted • Removable -> easy to clean • Well-tolerated by pts but require pt cooperation Disadvantage: • Success completely dependent on pt compliance • Easily lost or broken

- acrylic though wire clasps and/or occlusal rests, as well as denture teeth, maybe incorporated. Bilateral appliance, variable design • Mxormd Uses: 1. Maintain space in entire arch with premature loss of one or more primary teeth + potential for space 2. When prematurely lost primary tooth = terminal tooth in arch (loss of prim 2nd molar before eruption of perm 1st molar) -> Add a protuberance or "bump" to tissue surface of appliance to put pressure on soft tissue mesial to erupting permanent tooth, typically erupting permanent 1st molar -> Guide eruption of permanent tooth • Most effective when appliance can be placed as soon as possible after extraction + can lie over distal portion of healing pocket 3. Appliance of choice in most multiple tooth loss situations because of ease of construction + flexible design 4. Can have gingival extension that exerts pressure on gingiva mesial to mesial marginal ridge of permanent 1st molar, which can be used instead of a distal shoe in cases where it is contraindicated Advantage: • Can maintain vertical occlusal height -> Facilitate a more normalized occlusion for pt • Easily adjusted to accommodate transitioning dentition + occlusion by selective removal of acrylic • Removable -> Less impediment to home OH • Well-tolerated by pts but require pt cooperation Disadvantage: • Success completely dependent on pt compliance • Easily lost or broken Design • Appliance = stable when seated in arch being treated • VDO restored + appliance doesn't present any occlusal interferences. • Primarily acrylic (including optional acrylic denture teeth) but can also utilize wire clasps and/or occlusal rests. • Acrylic portion of appliance can be readily adjusted to accommodate transitioning dentition + occlusion • Tissue surface protuberance can be incorporated when prematurely lost primary tooth = terminal tooth in arch Contraindications: Poor patient compliance/parental supervision + reliability where appliance may be lost to follow-up

Oral Head + Neck Exam: 20. Dental Maturity: age-appropriate (5y9m) A. Thumb-sucking: • Most common -> anterior open bite, excessive overjet, flared mx incisors, high arched palate, posterior crossbite, calloused thumb digit Stop prior eruption of maxillary permanent central incisors -> anterior maxillary deformity B. Mouth Breathing Chronic nasal obstruction, inadequate lip closure, behavioral patterning, sleep disorders, ADHD -> focal gingivitis in ant mx, halitosis, protrusion mx ant, dry/cracked lips C. Bruxism

- age appropriate, immature, advanced; insight to pt's probable future development & influence on tx plan Habits: digital, tongue, mouth breathing, bruxer, other, none; many habits self-extinguish w/ age A. Thumb-sucking: • Most common -> anterior open bite, excessive overjet, flared mx incisors, high arched palate, posterior crossbite, calloused thumb digit • If discontinued prior to eruption of maxillary permanent central incisors -> anterior maxillary deformity may resolve significantly as eruption of permanent incisors will tend to encourage downward movement of anterior maxilla B. Mouth breathing: indicates chronic nasal obstruction, inadequate lip closure, behavioral patterning, sleep disorders, ADHD -> focal gingivitis in ant mx, halitosis, protrusion mx ant, dry/cracked lips C. Bruxism: involves all teeth, including recently erupted permanent teeth

Oral Head + Neck Exam: 6. GERD - erosion Location: • Lingual surfaces -> incisal edge chipping • Posterior: occlusal cratering Poor candidates for intracoronal restorations -> stainless steel crowns

- atypical erosion or tooth structure in distinctive patterns: lingual surfaces -> chipping of incisal edges Posterior teeth "cratering" defects of occlusal surfaces • Children who've experienced such symptoms from early age may not be aware of anything that seems abnormal to them • Astute observation + where signs of GERD found, referral for further evaluation is an important aspect of the patient care that we provide. • Patients with erosion secondary to GERD = often poor candidates for intracoronal restorations, especially if their reflux isn't well controlled • Stainless steel crowns for such patients = typically more durable

Treatment Planning: 3. Appointment Sequencing • Complete post sextants first b/c these teeth important for maintaining dental arch + last teeth to exfoliate • Prophy -> LAST item of sequencing • Recall exams: every 6 mo, regardless of completion of restorative tx plan

- based upon pt's compliance & attention span, severity of need, (impending) symptomatic teeth, necessity & timing for req'd space maintenance, management of pt's experience, family transportations/challenges • Ideally tx sequenced by quadrant, but varies based on time, amt LA req'd, compliance • Symptomatic teeth addressed first w/ abx or tx, followed by issues of decreasing priority • May be acceptable to postpone large tx to 2nd restorative appt if new experience • Best to complete post sextants first b/c these teeth = important for maintaining dental arch + last teeth to exfoliate • Follow up care (recall w/ prophy & fluoride) scheduled as last item on tx plan, new tx plan developed at this appt • Perform recall exams on our pts every 6 mo, regardless of completion of restorative tx plan (allows for assessment of current, changing needs)

Oral Head + Neck Exam: 5. Signs of possible physical abuse: • Bruising in atypical locations, lacerations, burns • Injuries in multiple stages of healing • Unlikely history • Not all children with bruising = victims of abuse Our Job: Report suspicions + findings, not diagnose abuse

- bruising in atypical locations (not over bony prominences), lacerations, burns, injuries in multiple stages of healing, etc. • Discrepancy between your observation of an injury (location, severity, etc.), + patient's or parent's report of how injury occurred or elapsed time since injury • As an oral health provider, you're a mandated reporter + your job = report your suspicions, along with your findings supporting those suspicions. • Your job IS NOT to diagnose abuse • Should patient's history and/or your general exam -> suspect that patient is victim of physical abuse, this finding should be of higher priority than any other non-emergent treatment that was originally planned

Appliance Types: 2. Lingual Arch Image: 2 permanent molars + bar lingual of anterior - attached to bands of 1st permanent molars Uses: Exclusively in Mn arch; unilateral or bilateral space loss • Multiple primary posterior teeth missing + permanent incisors erupted • Single tooth loss where other prim posterior teeth with questionable/ poor prognosis may later be lost • Early loss of primary canine -> Add auxiliary wire to lost side • Lingual arch = commonly placed once perm md incisors have erupted Contraindications: • No anterior + posterior abutment tooth available • Significant space deficiency

- consists of a single heavy-gauge [0.036 inch (0.9mm) or higher] stainless steel wire adapted to lingual aspect of mandibular arch, attached to bands of 1st permanent molars • Stable appliance as it's anchored to 2 teeth, + design can incorporate 2 omega loops bent into wire mesial to the 1st molars, which permit adjustment in sagittal direction • Conventional lingual arch contact cingulae of md incisors while staying approximately 1- 1.5mm away from soft tissue laterally -> Prevent anterior mvmt of posterior teeth + posterior mvmt of anterior teeth Uses: 1. Almost exclusively in mn arch, management of uni- or bilateral space loss 2. Space maintenance when multiple primary posterior teeth missing + permanent incisors erupted (Single side or both side) 3. Single tooth loss where other prim posterior teeth with questionable/ poor prognosis may later be lost 4. Early loss of primary canine - to prevent incisors from shifting laterally into space -> midline deviation + asymmetry -> Add auxiliary wire • Wire soldered into lingual arch + cradles distal surface of perm lateral incisor adjacent to space 6. Lingual arch = commonly placed once perm md incisors have erupted • Otherwise, may obstruct eruption of lower incisor • If a bilateral space maintainer = required prior to eruption of mandibular incisors -> May prefer to place bilateral band + loop appliances instead of a lingual arch Design: 1. Wire: • Across edentulous areas, should lie below height of ridge to avoid unnecessary exposure of wire to chewing forces, etc. • Should contact permanent mandibular incisors at cingula • Loop follows lingual contour of arch + lie just off of mucosa (should not contact mucosa) • Omega loops can be incorporated in wire just anterior to soldered attachment to bands to facilitate minor adjustment at delivery 2. Solder joints on bands • Should completely encircle wire • Should not impinge on gingival when bands seated. 3. Available in various semi-fixed configurations • In semi-fixed systems, wire component typically requires contouring + other bending/adjustment to properly contact incisors Contraindications: 1. Poor patient reliability where appliance may be lost to follow-up 2. High caries risk - presence of appliance may hinder patient home OH 3. Cases: • Significant space loss already occurred - space regaining = necessary in these cases • No posterior abutment tooth available (i.e. extraction of primary 2nd molars prior to eruption of permanent 1st molar) • No anterior abutment teeth available • Significant space deficiency - space regaining, sequential extraction of primary teeth (serial extraction) in preparation for ortho intervention, etc., may be indicated in lieu of space maintenance Considerations: 1. Time elapsed since loss: space closure usually occurs w/in first 6 mo after ext 2. Dental age of pt: which teeth erupted, amt of primary root resorption, amt of permanent teeth development 3. Amt of bone covering unerupted teeth: erupting PM usually require 4-5 mo to move through 1 mm bone

Appliance Types: 4. Transpalatal Arch - bilateral Image: Mx 1st molars/Primary 2nd molars band + wire across Uses: • ≥ 1 prematurely lost primary posterior teeth + potential for space loss • Prevents ROTATION of maxillary molars by bracing them against each other • Single tooth loss where other primary teeth with questionable/poor prognoses Omega loop - for fit Advantage: • No anterior abutment against palate + irritation + less bothersome (more posterior)

- heavy-gauge [0.036 inch (0.9mm) or higher] stainless steel wire which crosses palate just anterior to banded abutment teeth, soldered to bands attached to permanent maxillary first molars or primary second molars. Bilateral appliance Uses: • Indicated when one or more prematurely lost primary posterior teeth + potential for space loss • Prevents rotation of maxillary molars by bracing them against each other • Single tooth loss where other primary teeth with questionable or poor prognoses in arch which may later be lost • An omega loop can be placed at mid-point of wire to facilitate minor adjustment at delivery to achieve a passive fit • Intention of this omega loop, when used = never to actively move teeth + doesn't provide adequate control to do so Advantage: • Has no anterior abutment against palate -> superior stabilization in cases with multiple missing primary teeth and/or unstable molar occlusion • Less potential mucosal irritation due to lack of acrylic palatal button • Wire portion placed further posterior, so maybe less bothersome for pt Design: 1. Wire portion • Lies just off of mucosa • Extends just anterior of abutment teeth • May incorporate an omega loop at midline 2. Solder joint on band • Should completely encircle wire • Shouldn't impinge on gingival when band seated Contraindications: 1. Poor patient reliability where appliance may be lost to follow-up 2. High caries risk - presence of appliance may hinder patient home OH effectiveness 3. Cases • Significant space loss has already occurred - space regaining necessary • No posterior abutment tooth available (i.e. extraction of primary second molars prior to eruption of permanent first molar)

8. Knee-To-Knee Exam Indications: young children who're physically small enough + adequately compliant to be safely immobilized in this way

- immobilizing young child for visual dental exam + limited tx in a minimally threatening way • Pt seated in parent/assistant lap, operator seated knee-to-knee with holder to stabilize head + manipulate lips/mouth. • Assistant/parent holds one leg under each arm while holding patient's hands • Pt reclined on operator's lap, operator stabilizes head + performs exam • Ideally performed in quiet room to avoid disturbing other patients • Safe, minimally-threatening immobilization for exam and/or limited treatment such that parent can be shown intraoral conditions/findings easily • Assistant/parent holds one leg under each arm elbows • Parents can be taught this technique to perform at home • May be used for pt who's young, small, + adequately complianto Indications: young children who're physically small enough + adequately compliant to be safely immobilized in this way Contraindications: children who're physically too large or too combative to be safely immobilized

Plaque Score: Score: Based off of 3rds

- indicative of pt/parent ability to clean teeth, determined by amount of tooth surface covered w/ plaque as displayed by disclosing solution • Helpful for teaching pt + parent brushing techniques • Doesn't indicate pt's chronic oral health status: gingival health + caries history = indicative of chronic oral health status Score: Based off of 3rds 0 = plaque free 1 = gingival 1/3 2 = gingival + middle thirds 3 = > 2/3

Considerations for Initial Office Visit 5. Social History A. Common barriers to care B. Other important SH aspects C. Helpful to build pt rapport

- insights about family's resources + challenges, child's personal environment & parent's evaluation of child, opportunity to build rapport A. Common barriers to care: • Financial inability to pay • Distance from appropriate care • Lack of dependable transportation, or large complexity/cost • Language or communication barriers • Cultural beliefs, practices, or expectations of healthcare • Fears of parent or child B. Other important SH aspects: • Parenting style • Parental insights about child: progress in school & learning style, child's concerns about dental visit, how child rxts in healthcare or anxiety-provoking situations • Adequate help w/ childcare: establish identity of adult who will be bringing child to appts • # of siblings • Parental healthcare knowledge • Previous compliance + assistance w/ care recommendations C. Helpful to build pt rapport: • Know where child lives/goes to school, what their hobbies are, about their pets + siblings, etc. • We do provide a "Caregiver Authorization Affidavit" form for parents to execute for other named individuals to bring the parent's child or children to dental visits. D. Parents can give valuable info regarding • Child's progress in school + learning style (slow, average, advanced) • Child's concerns about dental visit • How child reacts in other healthcare or anxiety-provoking situations

Causes of Space Loss: 4. Ankylosis of Primary Molars Most common: PRIMARY MANDIBULAR MOLARS A. Progressive infraocclusion i. Fast progression + slow rate of resorption of ankylosed tooth -> Extraction + space maintenance B. Long standing + untreated ankylosed PRIMARY MOLAR -> abnormal path of eruption, disturbed root dev, rotated PREMOLAR when erupted

- localized fusion of alveolar bone to cementum as result of defective or discontinuous periodontal membrane Prim M: highest incidence, 1.3- 14% Prim md M = affected 10x more than prim mx M Causes • Heredity (higher incidence between siblings) • Endocrine or metabolic diseases • Genetic tendency • Periapical infections • Trauma • Previous dental procedures A. Progressive infraocclusion -> tipping of adjacent teeth, bony defects, delay eruption of perm successors, possible delayed eruption of adjacent teeth, loss of arch length, supra eruption of opposing teeth, PDL compromise to adjacent perm teeth. Treatment: i. If not rapidly progressing or severe -> Early extraction of ankylosed M unnecessary • Severe= Submergence of ankylosed tooth below CEJ ii. If combine with fast progression, slow rate of resorption of ankylosed tooth -> Extraction & space maintenance • Extraction when perm successor in wrong position • Best to avoid extraction -> avoid risk of surgical trauma to succedaneous tooth bud B. Long standing + untreated ankylosed prim M -> abnormal path of eruption, disturbed root dev, rotated premolar when erupted.

Eruptive Tooth Movement Gist: Fibro-cellular follicle -> Gubernacular cords widen -> intraosseous phase: 1-10 um/day -> 75 um/day #s: • 4-5g sufficient to move tooth • Emerge: 3/4 roots completed • 12-20 months reach occlusion after reaching alveolar margin • 2-3 years for roots to be completed after eruption

- movement of tooth from site of development within jaws to position of function within oral cavity 1. Fibro-cellular follicle surrounding a successional tooth retains its connection with lamina propria of oral mucosa membrane by means of strand of fibrous tissue containing remnants of dental lamina = Gubernacular cords (dried up= holes on lingual aspects of deciduous teeth = Gubernacular canals) 2. As successional tooth erupts, gubernacular canal widened rapidly by local osteoclastic activity, delineating eruptive pathway for tooth. 3. Intraosseous phase: rate avg 1- 10 um/ day. Once it escapes bony cell, rate= 75 um/ day -> persists until tooth reaches occlusal plane, soft ct provides little resistance. 4. When appears in oral cavity, subjected to environmental factors -> determine final position in dental arch • Muscle forces from the tongue, cheeks + lip, forces of contact of erupting teeth with other erupted teeth • Sustained muscular force of only 4-5g = sufficient to move a tooth 5. Teeth usually emerge when 3⁄4 of roots completed • Pass thru crest of alveolar process at varying stages of root development • Takes 12-20 mo for erupting tooth to reach occlusion after reaching alveolar margin • Takes 2-3 yrs for roots to be completed after tooth has erupted into mouth

Preventative Treatment plan A. All new pts will receive preventative session at 2nd appt -> diet/diet behavior recommendations • Preventive treatment plan (located in treatment history section of axium record) will be recorded at each examination visit (ODTP or recall) in the following format: Problem ----------> Intervention • Preventive treatment plan reviewed + updated as part of parent interview at each patient visit, with compliance + success noted, along with any adjustments suggested to parents to improve outcomes B. Plaque scores = recorded at each visit ODTP appt: 1. Medical/Dental/Social Hx 2. Preventative tx plan 3. Plaque Score 4. Head and Neck Exam 5. Occlusal Exam 6. Tx planning Worksheet Tx plan consists of 2 stages: preventative + restorative

- must be recorded at every appt in axium, denoting Problem -> Recommendation A. All new pts will receive preventative session at 2nd appt, which focuses on pt's specific preventative needs as determined by ODTP appt (esp. diet and nutrition) B. Plaque scores = recorded at each visit based upon amt of tooth surface covered with disclosing solution - this is just a snapshot of pt's ability to clean their teeth, NOT overall chronic oral hygiene g. Forms filled out at every ODTP appt: 1. Medical/Dental/Social Hx 2. Preventative tx plan 3. Plaque Score 4. Head and Neck Exam 5. Occlusal Exam 6. Tx planning Worksheet Tx plan consists of 2 stages: preventative + restorative • Individualized to pt based on caries risk assessment + other exam findings • No tx performed, or altered from parent-approved tx plan, without witnessed verbal or written consent of parent or court-appointed legal guardian; parent must sign proposed tx plan indicating legally valid informed consent to tx Fees = handled by front desk staff, + discussion of fees is always deferred to end of tx plan presentation to parents

Appliance Types: 5. Distal Shoe - unilateral - contacts permanent molar 1 mm below mesial marginal ridge Image: Band + Loop with metal plate under gingiva Uses: • Exclusively maintain space for prematurely LOST PRIMARY 2nd MOLAR prior to eruption of perm 1st molar • Where perm 1st molar adjacent to edentulous space adequately developed + near alveolar crest • Extends below gingiva to provide guide plane for eruption of permanent 1st molar • Loop carrying intra-alveolar distal shoe = soldered onto band or crown on 1st perm molar ~1 mm below its mesial marginal ridge or at its emergence from bone Procedure: 2 appointments -> extraction primary 2nd molar + impression -> incision mesial to 1st perm molar -> radiograph to confirm NOTE: Once perm molar erupts, distal shoe should be replaced with a lingual arch, transpalatal arch or Nance appliance Advantage: Immediate post-extraction placement without lab fabrication delays Disadvantage : • Faulty positioning • Bacterial endocardidits • Immunocompromised as complete epithelialization around intra-alveolar portion not achieved • Invasive Contraindications: • Immune-compromised or at risk for ENDOCARDITIS or other SEPTICIMIAS • Permanent first molar inadequately developed or erupted to be engaged by appliance • 1st + 2nd primary molars have been lost - the appliance can't span more than a single tooth space

- ortho bands + stainless steel wire or metal bar, with blade extending into alveolar process so it contacts permanent molar 1 mm below mesial marginal ridge • Unilateral appliance, can be used for mx + md Uses: • Exclusively to maintain space for prematurely lost prim 2nd molar prior to eruption of perm 1st molar • Where perm 1st molar adjacent to edentulous space = adequately developed + near alveolar crest • Extends below gingiva to provide guide plane for eruption of permanent 1st molar • Loop carrying intra-alveolar distal shoe = soldered onto band or crown on 1st perm molar ~1 mm below its mesial marginal ridge or at its emergence from bone Procedure: 1st appt: Extraction of prim 2nd molar + impression 2nd appt: incision made in gingival tissue immediately mesial to 1st perm molar -> distal shoe can be embedded in tissue -> appliance cemented into place • Some clinicians combine extraction + placement -> decreases pt discomfort from LA • Careful placement essential • Post placement radiograph to confirm • Incorrect position -> remove, reposition -> radiograph to confirm • Most common problem with this appliance • Disastrous results Ideally, appliance fabricated in advance, placed at time of extraction of prim 2nd molar • If not possible -> placed shortly after extraction, BUT must be placed thru an incision in mucosa -> Radiograph to confirm NOTE: Once perm molar erupts, distal shoe should be replaced with a lingual arch, transpalatal arch or Nance appliance Patient's dental age, chronologic age + eruption sequence should be taken into account if unilateral space maintainer used (band + loop) Advantage: Obvious benefit of immediate post-extraction placement without laboratory fabrication delays Disadvantage : • Faulty positioning = common problem • Susceptible to subacute bacterial endocardidits • Immunocompromised as complete epithelialization around intra-alveolar portion not achieved • Invasive Design: 1. Shoe portion: • Extends adequately into soft tissue + bone to engage erupting permanent 1st molar + provide guide plane for eruption of that tooth • Contacts permanent 1st molar ~1 mm below marginal ridge 2. Wire portion doesn't interfere with patient's occlusion 3. Appliance must be stable in position so that any movement due to chewing, etc., minimized 4. Solder joint • Should completely encircle wire • Shouldn't impinge on gingival when band seated 5. Also available in various semi-fixed configurations Contraindications: 1. Immune-compromised or at risk for endocarditis or other septicemias 2. Poor patient reliability where appliance may be lost to follow-up 3. Cases • Significant space loss already occurred - space regaining or other ortho intervention necessary in these cases after permanent first molar erupts • Permanent first molar inadequately developed or erupted to be engaged by appliance • 1st + 2nd primary molars have been lost - the appliance can't span more than a single tooth space

Considerations for Initial Office Visit 4. Medical History A. Medical consults Only bio parent able or court appointed legal guardian can sign release forms to give/receive pt's medical history info + Update medical history form B. Updating Med Hx

- should be updated at every appt, + always ask pt how s/he is feeling that day! • Name of physician + date last seen w/ contact info A. Any medical consults for unclear or incomplete pt medical info: • Include specific questions/concerns, nature of tx anticipated, pt anxiety level, associated blood loss for procedure, your contact info • Request "summary of last visit" if need more comprehensive info abt pt's med hx • Must have release form signed by parent to give or receive pt's med hx info B. Birth history & past hospital visits, status of current medical tx C. Status of any current or ongoing medical treatment • Contraindication to treatment, adjustments to current med tct, routinely used med have oral implications/ affect caries risk (dilantin, albuterol) D. Immunizations, allergies, intolerance to food/drugs, especially sensitivities or rxns to ABX, latex, anesthetics E. Childhood disease hx, used to support suspected etiology of any oral anomalies F. Past & present medical hx, especially taking heart disease, bleeding & blood dyscrasias, birth defects, seizure disorders, sight/hearing problems, asthma, etc. into consideration for tx G. Child's school attendance record + play activities may indicate general health H. Developmental milestones + present development Updating med hx: • Review at each visit. Findings (even if there is no changes) are noted. • NOTE: Only biological parent or court-appointed legal guardian can give legally valid medical history information + sign or update medical history form. • We regularly FAX or mail forms to patients' physicians for clarification of medical history concerns as well as their management recommendations relative to patient's dental treatment • Parents / legal guardians must sign a release for any of their child's medical information to be shared with other healthcare providers ( specific area for this release at bottom of our medical consultation form).

Treatment Planning 2. Restorative Tx Plan

- tooth, problem, txt/ alternative, sequence; addresses pt's clinical disease & suggested interventions to restore form, fxn, health of the mouth; focuses on clinical procedures req'd, clinical findings involving less invasive interventions, + issues that need monitoring • Pt's cooperative ability & behavior guidance noted • Recommendations must consider pt's hx, CRA, and clinical findings

Pacific Protocol for Fitting Bandings + Delivering Space Maintainer: 1. 2 Visits required for space maintenance 2. INFORMED CONSENT: always required from parent before space maintenance performed

1. 2 Visits required for space maintenance • Fit bands (for fixed appliance) + take impression: model with bands in place -> sent to lab • Adjustment + delivery: always make parents aware that if teeth move b/w impression + delivery, it may be necessary to re-impress and re-fabricate 2. INFORMED CONSENT: always required from parent before space maintenance performed • Intent of space maintenance • Proposed appliance • Required home care • Expected outcome

Relative Flouride Concentrations of Common Topical Flouride Products Most to Least Fluoride: Fluoridated Tooth paste > NaF varnish > APF gel/foam > Naf gel/foam > OTC dentrifices > Prevident > OTC Daily rinses

1. APF gel/foam F concentration + compound: 2.7% NaF Concentration of F ion: 1.23% F PPM Flouride: 12,300 ppm 2. Naf gel/foam F concentration + compound: 2% Naf Concentration of F ion: 0.9% F PPM Flouride: 9040 ppm 3. NaF varnish F concentration + compound: 5% NaF Concentration of F ion: 2.5% F PPM Flouride: 22,500 ppm 4. Prevident F concentration + compound: 1.1% NaF Concentration of F ion: 0.5% F PPM Flouride: 500 ppm 5. OTC Dentrifices F concentration + compound: NaF or MFP Concentration of F ion: 0.1% PPM Flouride: 1000 ppm 6. OTC Daily Rinses F concentration + compound: 0.05% NaF Concentration of F ion: 0.02% F PPM Flouride: 220 ppm

Edpuzzle Answers

1. At what age should a child have an established dental home: by age 1 2. Does colonization happen only when first tooth erupts: No 3. Difference between vertical vs. horizontal transmission: Vertical transmission involves transmission from primary caregiver (mom) to a child Horizontal transmission involves transmission from siblings or other family members to a child. 4. Where do decay start usually: Cervical area of teeth 5. In which decay will the lower incisors be affected: rampant caries 6. By what age should a child be weaned from the bottle: 12 months 7. Flurohydroxyapatite will be formed under which mechanism: Systemic 8. Which of the following has the highest fluoride concentration: fluoridated toothpaste 9. What is the amount of toothpaste recommended for a child younger than 3 years old: Grain of rice + smear 10. Correct euphemism for topical fluoride: Tooth vitamins 11. Main disadvantage of SDF application: Staining

Factors necessary to support colonization process of cariogenic organisms 1. Available tooth surface 2. Fermentable carb substrate 3. Poor salivary flow • Lower during sleep + higher during day due to mouth movement A. Mouth movement -> saliva

1. Available tooth surface: allows organisms to become established 2. Fermentable carb substrate (milk, fruit juice, food debris, sweetened pacifier, etc.) -> increased # + kinds of organisms • Frequency of substrate presence + duration of exposure to substrate = determinants for colonization 3. Poor salivary flow • Can increase carious action or organisms • Lower flow when infant sleep (↑ risk) • Higher flow during day • Medications that cause xerostomia can significantly increase caries risk A. Mouth movement -> hydrostatic flow of saliva around/ between erupted teeth -> increases clearance of fermentable carbs • Less mvmt when infant sleep (↑ risk) • More movement during day • Good OH practices (oral cleansing after eating) + parenting practices (diet/ avoiding feeding ad lib) can be effective

Decay Patterns 1. Baby bottle caries: MX INCISORS -> MX/MN MOLARS -> LOWER INCISORS (SPARED) 2. Nursing caries (Baby Bottle caries): MX INCISORS -> MX/MN MOLARS 3. Rampant caries: CERVICAL LOWER INCISORS; lack of OH after eating solid food

1. Baby bottle caries - lower incisors spared (due to tongue position) + mx incisors affected first, followed by mx/mn molars Cause: Prolonged at-will (ad lib) bottle feeding at night 2. Nursing caries - same as baby bottle caries Location: mx incisors affected first -> mx/mn molars Cause: Prolonged at-will (ad lib) breast feeding at night 3. Rampant caries - lower incisors affected, begins as cervical caries throughout mouth • ALL primary teeth affected Cause: lack of OH after eating solid food • May have been initiated by baby bottle or nursing caries -> Progressed with intro of solid foods in absence of appropriate oral care

Pre-Eruptive Movement 2. Permanent molar tooth germs: Backwards extension of dental lamina A. Mx: Occlusal face DISTALLY B. Mn: Mesial inclination Posterior teeth: 2-5 years to reach alveolar crest 4. Tooth crown formation: very slow labial or buccal drift of teeth follicle within bone Following completion of crowns: 2-5 years for posterior teeth to reach alveolar crest

1. By deciduous + permanent tooth germs within tissues of jaw, starts before teeth begin to erupt 2. Permanent molar tooth germs (no predecessors), develop from backwards extension of dental lamina (little room for jaw to accommodate at first) A. Mx: molar tooth germs have occlusal surface face distally, swing into position only when mx has grown sufficiently B. Mn: molar tooth germs develop their axes with mesial inclination, becomes vertical when sufficient jaw growth has occurred. 3. Movements occur in intraosseous location, reflected in patterns of bony remodeling within crypt wall. Eg. Mesial bodily movement= mesial surface bone resorption + distal wall bone deposition. 4. Tooth crown formation: very slow labial or buccal drift of teeth follicle within bone • Eruptive movement begins soon after root begins to form 5. Metabolic activity within PDL = major part of eruption 6. Pre-emergent eruption: A. Resorption of bone + primary tooth roots overlying crown of erupting tooth B. Eruption mechanism itself then must move tooth in direction where eruptive path has been cleared • Takes from 2-5 years for posterior teeth to reach alveolar crest following completion of their crowns

Parental acceptance of behavior guidance 1. Can't proceed without parent or court-appointed legal guardian's informed consent for behavior guidance techniques Favor pharmacologic techniques (sedation or GA) over more aggressive

1. Can't proceed without parent or court-appointed legal guardian's informed consent for behavior guidance techniques which we propose 2. Overall, parents: A. Less accepting of behavior guidance techniques perceived to be "aggressive" or advanced such as voice control, physical restraint, etc. B. Favor pharmacologic techniques (sedation or GA) over more aggressive non-they perceive out-of-pocket costs to be acceptable C. As part of treatment plan presentation, likely behavior guidance strategies should be discussed + where indicated specific consent for planned techniques (such as protective immobilization "papoose board") should be obtained. 3. At txt appt, parent(s) should be reminded of planned behavior guidance strategies, + any questions should be answered before starting treatment at that visit. A. Document parents' acceptance of behavior guidance strategies + any questions that they may have had + answers to those questions

Oral Head + Neck Exam 1. Check for Pediculus capitis (Head Lice) • Seasonally exceeds 25% in elementary schools • DAU assistants check at start of every appointment 2. Acanthosis nigricans - skin: dark, velvety discoloration in body folds and creases Associated: Insulin resistance: Type 2 "pre-diabetes" 3. Perioral dermatitis - Irritation + reddening of skin around vermillion border Indicates: lip sucking (typical circumoral), digital-oral habits Consider lubricant before manipulating lips 4. Peri-ocular skin darkening (dark circles under eye) - broad range of conditions Association: Seasonal allergies, lack of sleep Consider allergies, sleep apnea, seasonal allergies

1. Check for Pediculus capitis (Head Lice): positive findings must be documented, pt will be rescheduled after MD clearance unless true dental emergency 2. Acanthosis nigricans: - skin condition characterized by areas of dark, velvety discoloration in body folds and creases, can become thickened over time, affects armpits, groin, and neck. Usually associated with insulin resistance (Type 2 "pre-diabetes") 3. Perioral dermatitis: - Irritation + reddening of skin around vermillion border of ips Indicates: lip sucking (typical circumoral), other digital-oral habits • Chapped/ dry lips -> vasoline 4. Peri-ocular skin darkening (dark circles under eye): Broad range of conditions from physiologic pigmentation, to lack of sleep or disrupted sleep, to seasonal allergies.

Considerations for Initial Office Visit 9. Oral Hygiene History Hallmark of good oral health: Effective disruption of plaque: oral cleansing, brushing, + flossing Most important time to brush: immediately before sleep Why Brush before Bed: Less salivation + Oral Movement to spread saliva decreases -> fermentable carbs left on teeth Brushing: 1. <6-7 yrs: child allowed to brush w/ follow-up brushing by parent 2. 6-10 yrs: child allowed more autonomy but still supervised 3. >10 yrs: pt encouraged to accept responsibility but parental supervision critical

1. Consistent, effective disruption of plaque = hallmark of good oral health: oral cleansing, brushing, + flossing • Effective brushing relies on good technique, appropriate timing, + frequency: occurs after all meals + snacks • Most important time to brush: immediately before sleep • Adding brushing or rinsing after meals + snacks = beneficial/ encouraged • OH should be taught to both patient + parent: • <6-7 yrs: child should be allowed to brush w/ follow-up brushing by parent • Flossing if teeth in proximal contact • Preventative info directed at parent • 6-10 yrs: child allowed more autonomy but still supervised by parent while brushing + flossing w/assistance given as required • >10 yrs: pt encouraged to accept responsibility but parental supervision of oral hygiene is still critical, instructional info directed at pt

Diet Recommendations 1. Decrease fermentable carbs in diet (high sugar content, low fiber) + sticky foods 2. Nutritionally balanced meals 3. Limit snacking + choose non-cariogenic foods for snacks (whole fruit, cheese, raw vegetables, etc) 4. Water instead of carbonated or other sweetened beverages at mealtime + after is beneficial 5. Fruit juice intake should be limited + diluted with water when given 6. Follow eating with drinking water or water rinse (compliance with drinking better than rinsing) 7. All food should be thoroughly brushed (with fluoridated toothpaste) from teeth before sleep Fruits vs. Fruit Juice: 1. Mechanical stimulation of salivary food by consumption of high fiber foods Whole fruits: high in fiber; Juices: Little or no fiber 2. Physical clearance/cleansing enhanced by mastication of foods high in fiber such as whole fruits 3. Flavonoids found in skins of whole fruits inhibit bacterial adherence + shown to have anti-bacterial activity against oral streptococci 4. Excessive ingestion of fruit juice associated with inappropriate weight gain

1. Decrease fermentable carbs in diet (high sugar content, low fiber) + sticky foods 2. Have nutritionally balanced meals 3. Limit snacking + choose non-cariogenic foods for snacks (whole fruit, cheese, raw vegetables, etc) 4. Water instead of carbonated or other sweetened beverages at mealtime + after is beneficial 5. Fruit juice intake should be limited + diluted with water when it's given 6. Follow eating with drinking water or water rinse (compliance with drinking better than rinsing) 7. All food should be thoroughly brushed (with fluoridated toothpaste) from teeth before sleep

Clinically evident lesions:

1. Dentin + pulp involvement 2. Coronal breakdown that increase plaque retention + accelerates caries process 3. Resistance to OH due to discomfort

Risk Assessment • ITR - interim therapeutic restoration

1. Determine pt's risk for ECC + address all risk factors in preventative plan • ITR (interim therapeutic restoration) considered to arrest caries • Review medical/ dental/ social histories for risk factors • Gather risk factors from conversation with mom • Note risk factors on exam of patient

Caries Risk Assessment

1. Dictate's pt's preventative tx plan + influences pt's restorative tx plan • All variables in CRA should be addressed in either preventive treatment plan or in restorative treatment plan + vice-versa • Disease indicators: clinical findings demonstrating active caries disease process (demin, clinical/radiographic caries, recent restorations) • Risk factors: findings predisposing pt to disease (plaque, deep pits/fissures, poor OH, compromised saliva flow, high carb intake, frequent snacking, ortho appliances, crowded teeth) • Protective factors: findings -> resistance to disease (copious saliva, good OH, consistent fluoride exposure) • Caries status: caries progression vs. caries neutrality (balance b/w disease indicators, risk factors, protective factors) 2. CRA determined as LOW, MEDIUM, or HIGH • Predominance of protective factors suggests low caries risk 3. Balance between disease indicators & risk factors, versus protective factors, predominance of disease indicators + risk factors suggests a patient with high to moderate caries risk

Post-Appointments Considerations

1. Discuss behavior w/ pto • Praise positive behavior + make specific suggestions for future improvement • NEVER berate pt for negative behavior 2. Discuss next procedures w/ pt + parent 3. Report child's behavior to parent • Give honest assessment by praising positive behavior + making suggestions for improvement • Discuss future behavior management techniques 4. Explain to parents how they can help you at home: reinforce what you have told pt, desensitization

Adverse Effects of space maintenance

1. Dislodged, broken, + lost appliances 2. Plaque accumulation 3. Caries 4. Interference w/ successor tooth eruption 5. Undesirable tooth movement 6. Soft tissue impingement 7. Pain

Caries 1. Early Childhood Caries: - ≥1 decayed, missing, filled surfaces in any primary tooth <6 2. Severe Early Childhood Caries: • Smooth surface caries <3 • ≥1 Cavitated, missing, filled smooth surfaces in primary MAXILLARY ANTERIOR: 3-5 • DMFT (1 down): ≥ 4 (age 3), ≥ 5 (age 4), or ≥ 6 (5) Etiology of Caries: S. Mutans ECC Stats: • 5x more common than asthma • 7x more common than hay fever • 40% children have caries by kindergarten • 50% of children have at least 1 cavity by time they enter elementary school • Prevalent disease/widespread

1. Early Childhood Caries: presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled surfaces in any primary tooth in child under age 6 2. Severe Early Childhood Caries: • Any smooth surface caries in child under 3 yrs • 1 or more cavitated, missing (due to caries) or filled smooth surfaces in primary maxillary anterior teeth in child 3-5 Decayed, missing, or filled score: • DMFT>4 at age 3 • DMFT>5 at age 4 • DMFT>6 at age 5 Etiology of Caries: Mutans Streptococci introduced into newborn's mouth (not present in newborn's oral cavity until introduced) • Can colonize epithelial tissue in form of oral development nodules + inclusion cyst -> Can be found in pre-dentate pt

Tooth Eruption 1. Eruption - crypt position through alveolar process into oral cavity/occlusion Gist: Permanent tooth root lengthens -> primary tooth resorbs -> permanent tooth moves thru bone -> alveolar height increases Factors responsible for eruption not fully understood: • Elongation of root • Forces exerted by vascular tissues around + beneath root • Pull of perio membrane • Hormonal influences, presence of viable dental follicle • Pressure from muscular action • Resorption of alveolar crest • Pituitary growth hormone + thyroid hormone: parathyroid hormone-related protein required for eruption. Environmental factors acting during odontogenesis influence eruption timing: • Environment • Pre-natal, maternal factors • Systemic diseases • Nutrition • Body height + weight • Craniofacial morphology • Hormonal factors • Socio-economic status • Climate, etc. • Genetics factor affect chronology of ERUPTION OF PRIMARY TEETH = extensively genetically determined than that of permanent dentition • GIRLS + BLACK precede in tooth development + eruption

1. Eruption - developmental process by which tooth moves from crypt position through alveolar process into oral cavity + into occlusion with its antagonist Steps: A. Permanent tooth root lengthens B. Primary tooth resorbs C. Permanent tooth moves thru bone D. Alveolar height increase (alveolus grows) Characteristics: Complex + tightly regulated process that involves cells of tooth organ + surrounding alveolus Factors responsible for eruption not fully understood: • Elongation of root • Forces exerted by vascular tissues around + beneath root • Pull of perio membrane • Hormonal influences, presence of viable dental follicle • Pressure from muscular action • Resorption of alveolar crest • Pituitary growth hormone + thyroid hormone: parathyroid hormone-related protein required for eruption. Environmental factors acting during odontogenesis influence eruption timing: • Environment • Pre-natal, maternal factors • Systemic diseases • Nutrition • Body height + weight • Craniofacial morphology • Hormonal factors • Socio-economic status • Climate, etc. • Genetics factor affect chronology of ERUPTION OF PRIMARY TEETH = extensively genetically determined than that of permanent dentition • GIRLS + BLACK precede in tooth development + eruption, but standards of tooth emergence + mineralization vary greatly between populations + may be altered by changing environmental conditions • Ethnic + sexual differences in timing of permanent tooth eruption thought to be greater than those in eruption of primary dentition • There might be stimulating pressures in mastication • Differences also exist in tooth eruption between jaws: mandibular teeth usually erupt earlier than corresponding maxillary ones

3. Positive Reinforcement Social reinforcers: positive voice modulation, facial expressions, verbal praise, physical demonstrations of affection Nonsocial reinforcers: tokens or toys

1. Establishing desirable pt behavior by giving appropriate feedback 2. Describe specifically what you're praising them for Ex. "Thank you for sitting still" 3. Effective way to reward desired behaviors + therefore increase their recurrence 4. Social reinforcers: positive voice modulation, facial expressions, verbal praise, physical demonstrations of affection 5. Nonsocial reinforcers: tokens or toys 6. Can be used for any pt

Behavior (Beh) Guidance Techniques: 1. Approaching patient in Waiting room Position yourself between parent + child when bringing child back to tx area A. PARENT ONLY ALLOWED for following reasons: • Prevention instruction & tx plan presentation • Emergencies, especially for young children • Disabled children • Interpreting if language barrier exists • Very young (pre-cooperative) children

1. Evaluate child & parent demeanors + their interaction 2. Approach at child's level + greet them • If child unreceptive -> talk with accompanying parent 1st to establish trust relationship that child can observe • If child brought to treatment area without parent, try to position yourself between patient + parent in preparation to walking them back, talk to them as you walk back (distraction) 3. For apprehensive child, approach parent + interact to gain trust 4. Make positive statement about what is to be done 5. Reassure child that parent will be waiting when they're done 6. Distract child as you walk back by talking about their hobbies, pets, siblings, etc. (non-threatening topics) 7. Position yourself between parent + child when bringing child back to tx area • Be positive + make positive statements about tx • Reassurance that parent will be waiting + distraction as walk child back 8. Instructor approval needed for parents to come back A. PARENT ONLY ALLOWED for following reasons: • Prevention instruction & tx plan presentation • Emergencies, especially for young children • Disabled children • Interpreting if language barrier exists • Very young (pre-cooperative) children

Space Maintenance + Management: Common Clinic Mistakes

1. Failure to accurately assess dental development -> misdiagnosis + inappropriate or unnecessary appliance selection 2. Failure to consider patient's social, medical, dental histories -> placement of appliance in patient whose medical conditions, appointment compliance, oral hygiene, contraindicate use 3. Inappropriate appliance selection/design - can lead to premature appliance loss (often due to loss of an abutment tooth prior to eruption of permanent tooth for which space = being saved), + subsequent space loss 4. Poor band adaptation and/or appliance fit -> appliance loss or damage + patient discomfort or injury

Lecture: Diagnosis of Soft Tissue + Perio Problems 1. Gingivitis Associated with Systemic Health

1. Gingivitis Associated with Systemic Health: A. Gingivitis Associated with Dental Plaque (Chronic Gingivitis) B. Pubertal Gingivitis C. Necrotizing Ulcerative Gingivitis (NUG) D. Acute Primary Herpetic Gingivostomatitis E. Gingival Enlargement Associated with Orthodontic Appliances F. Pericoronitis

Preparation Prior to Patient's Appointment

1. Have realistic expectations of your patients 2. Know yourself + team: strengths & weaknesses, define behavior limits 3. Create kid-friendly office: toys, videos, small pt mirrors, euphemisms 4. Pre-appt communication with parents to relay office behavior policies, get accurate information, anticipate child's behavior, guide parent behavior in preparing child for appt 5. Be prepared! Understand child behavior based on chronologic age • New pts: inquire about past behavior management problems, communicate office behavior management policies, confirm parent/legal guardian status, answer questions • Pts of record: review past notes, create a game plan

Treatment Planning Common Mistakes 1. Incomplete CRAs 2. Non-specific preventative treatment plan 3. Failure to consider dental development (tooth lifespan) in restorative treatment

1. Incomplete CRAs( due to incomplete parent interview) -> vague/incomplete treatment 2. Non-specific preventative treatment plan - results may not be as hoped even though parents comply; difficult to follow-up with parents without specificity 3. Failure to consider dental development (tooth lifespan) in restorative treatment planning decisions, especially for primary teeth • This can result in overlying aggressive or inadequate treatment, depending on lifespan of tooth + occlusal changes that it must withstand

Initial Office Contact 1. Info about patient + parent Name, gender, age Language behavior Reason for visit 2. Info about office (to parent) Policies + procedures Directions, contact info Consent requirements; Consent essential

1. Info about patient: • Nickname: know it + use it to build rapport • Age & gender may be useful in predicting pt's capabilities + setting reasonable expectations • Language preference to make child most comfortable, accommodate w/ translator • Previous dental experience: positive/ negative, accurate if pt is honest with you • Parent's prediction of child's rxn to dental tx • Special needs or medical conditions that require certain considerations • Reason for appt: 1st exam, referral, 2nd opinion, emergency? • Assessment of parents' attitude/ dental IQ: interest in child's oral health/ dental txt, emergency may indicate poor care at previous dentist, low dental IQ or trauma • Parents' concern/ limitations around dental txt: radiographs, amalgam resto, fluoride 2. Info about parent: • Assessment of parent's attitude + dental IQ • Interest in child's oral health + dental tx • Indications of poor care at previous dentist, low dental IQ, or trauma 3. Info about office: policies & procedures (financial, appt times, consent/med hx, care limitations), directions, hours, emergency contact info

Post eruptive tooth movement Includes: Movement to: 1. Accomodate growing jaw + interproximal wear 2. Compensate occlusal wear

1. Maintains position of erupted tooth in occlusion while jaw continues to grow + compensate for occlusal + proximal tooth wear. Includes: 1. Movement to accommodate growing jaw 2. Movement to compensate for continued occlusal wear 3. Movement to accommodate interproximal wear

Human Conditions Affecting Tooth Eruption 1. Mechanical interferences 2. Ankylosis - - Fusion of cementum/ dentin to alveolar bone Effect: Lost occlusal height 3. Primary failure of eruption - rare 4. Malfunction of eruptive mechanism: Mutation: PTH1R - parathyroid hormone 1 receptor

1. Mechanical interferences: • Supernumerary teeth • Crowding • Soft tissue impact • Odontogenic tumors + cysts. 2. Ankylosis: - Fusion of cementum/ dentin to alveolar bone due to changes in PDL by trauma or other pathologies • Occurs after partial eruption of tooth into oral cavity 3. Primary failure of eruption: - where tooth retention occurs without evidence of obvious mechanical interference • Rare condition • High penetrance • Variable expressivity 4. Malfunction of eruptive mechanism: Mutation: gene PTH1R "parathyroid hormone 1 receptor" cause non-ankylosed permanent teeth to fail to erupt, altho the eruption pathway has been cleared by bone resorption

Dentition analyses 1. Michigan mixed dentition analysis - table values from mesio-distal width of erupted mandibular permanent incisors -> predicted space required for unerupted canine -> compared to arch length 2. Tanaka + Johnson analysis: • Adds FIXED value (11mm for maxilla, 10.5 mm for mandible) to 1⁄2 of total mesio-distal width of erupted permanent incisors = predicted space required for unerupted canine + premolars • Less accurate/sophisticated

1. Michigan Mixed Dentition analysis (Moyer analyses): table of values derived from mesio-distal width of erupted mandibular permanent incisors, correlated at range of probability values -> Predicted space required for unerupted canine + premolars • Predicted space then compared to measurement of arch length available eruption of canine + premolars as measured along crest of alveolus 2. Tanaka + Johnson analysis: • Less sophisticated + less accurate, more user-friendly • Adds a fixed value (11mm for maxilla, 10.5 mm for mandible) to 1⁄2 of total mesio-distal width of erupted permanent incisors = predicted space required for unerupted canine + premolars • This space compared to measurement of arch length available for eruption of canine + premolars along crest of alveolus.

Occlusal Examination: 1. Molar Classification: A. Primary Molar Relationship Trend: In relation to Mandibular 2nd primary molar i. Flush terminal plane -> Mixed dentition: End to End Permanent Molar Relationship or Class I or II ii. Mesial step (Mn 2nd primary molar forward) > Mixed dentition: Class I A. Exaggerated Mesial Step > Mixed dentition: Class III 3. Distal step > Mixed dentition: Class II

1. Molar Classification: primary/permanent, left/right A. Primary noted as "flush terminal plane," "Mesial step," "distal step" B. Permanent noted as Angle Class I, II, III; make sure pt is in full retruded contact position (RCP) • Having patient swallow or put tongue in roof of mouth prior to closure can help them close into RCP instead of positioning forward

Considerations for Initial Office Visit 1. Must have bio parent or court appointed legal guardian for legally valid med hx info + consent to treat Battery - no legal consent on minor UOP: Caregiver Affidavit - only verifies individual given parent's permission to bring child in + confirm identity -> parent still has to be reachable for medical history + consent for treatment

1. Must have bio parent or court appointed legal guardian for legally valid med hx info + consent to treat (pt is minor) • Treating a minor without legally-valid consent = termed "battery" in legal parlance + criminal charge, typically not covered by your malpractice insurance • Others can bring patient to appointments but they don't have legal power of consent for patient • Ideally, parent should be present at new patient + recall visits because proposed treatment plan must be explained + approved by parent • UOP: Caregiver Affidavit" form if another adult (> 18 years old) is to accompany child, but this only verifies that individual named on form has parent's permission to bring child + allows us to confirm identity of accompanying nonparent/court-appointed legal guardian • Parent or legal guardian must still be reachable for medical history update info + give any necessary consent for treatment.

Preliminary Info

1. Praise mom for bringing child in + assess oral health literacy by asking open-ended questions • Low Oral Health Literacy (OHL) -> negative effect on outcomes • Tailor oral health messages to appropriate OHL level 2. Important info to get from mom • How teeth being cared for? • Nutrition + feeding practices • Other risk assessment info • Assess her questions + interest level 3. Important info to give mom • Answer her questions • Anticipatory guidance

Coping Strategies + Skills

1. One facet of a child's personality is his/her coping strategies/skills, especially in stressful situations 2. Coping strategies = generalizable across similar situations -> Learning a child's behavioral reaction to a haircut (similar requirements to a dental visit) or to some other similar experience, can be instructive in how that child is likely to react in dental setting. • Parents usually best + most reliable source for this information 3. Understanding + often shaping child's perceptions of dental environment = also integral in behavior guidance • Some of child's perceptions = intrinsic • Some influenced by their social environment + previously successful strategies • Some directly attributable to dental environment + outcomes of their interactions there

2. Communication styles Voice Modulation: Indications: normal hearing at cooperative developmental stage (i.e. not for pre-cooperative patients) Contraindications: Hearing impairments or patients who don't fully understand language being spoken

1. Only 1 person at time should speak to child 2. Gender may influence child's reaction + behavior 3. Voice modulation: controlled alteration of voice volume, tone, or pace to influence or direct pt behavior • Gain pt's attention + complianceo • Avert negative or avoidance behavior • Establish appropriate adult-child roles • Quiet & empathetic for scared pt • Firm & directive for confrontational pt • Always return to a calm voice after desired behavior iattained • Can be used with any pt w/ normal hearing • Indications: may be useful with any patient with normal hearing who's at a cooperative developmental stage (i.e. not for pre-cooperative patients) • Contraindications: patients with hearing impairments or patients who don't fully understand language being spoken 4. Nonverbal communication: reinforcement + guidance of behavior through appropriate contact, posture, facial expression, + body language (smile, gentle touch, tone between staff members) • Enhance effectiveness of other communicative management techniques • Gain pt's attention & compliance • Can be used with any pt

Lecture: Diagnosis + TX Planning: Med HX Review + Clinical Exam Policies: 1. Patient Privacy - CONSENT forms before any treatment 2. Medical Hx - SIGNATURE 3. Medical Consult - CONSENT 4. Caregiver Authorization Affidavit - let someone else bring child, doesn't allow person to give consent tho 5. Fluoride exposure

1. Patient Privacy: - pt + parent's right to privacy must be respected • CONSENT forms must always be filled out by parent before any tx • For discussion about med hx or other sensitive info, voice level should be kept low + conversation should be held in as private of location as possible 2. Medical Hx • Reviewed at each appt, along with social + dental hx, + requires parental signature 3. Medical Consults • Routinely faxed or mailed to pt's physicians for clarification of med hx and/or management recommendations, requires parental consent 4. Caregiver Authorization Affidavit - form allows for parents to execute for other named individuals to bring parent's child(ren) to dental visits; parent must understand that we must be able to reach them during appt or we reserve right to not tx child until parent can be present or contacted for consent 5. Fluoride exposure must always be considered when determining caries risk + need for fluoride supplementation; maps available that show municipal fluoridation of drinking water based on zip code

Barriers 1. Patient-Centered Barriers Children <4 often more sensitive to pain but less able to communicate their pain -> observe facial expressions, crying, body movement

1. Patient-Centered Barriers A. Pain (#1 = pain + fear of pain): Children <4 often more sensitive to pain but less able to communicate their pain -> observe facial expressions, crying, body movement • Must have effective pain management CRUCIAL B. Developmental delay C. Physical/cognitive disability D. Acute or chronic disease E. Fears transmitted from parents (Eg. Saying we're getting a shot today) F. Previous negative dental or medical experiences G. Inadequate preparation for 1st dental experience H. Dysfunctional parenting practices

Lecture: Space Maintenance + Management Space Management 1. Premature loss of primary teeth -> affect speech, mastication, esthetics, prevention of oral habits, + guidance of permanent tooth eruption • Arch length deficiency -> increase severity of malocclusions with crowding, rotations, ectopic eruption, crossbite, excessive overjet, excessive overbite, unfavorable molar relationships, + midline discrepancy • Disruption of arch integrity due to early loss of primary teeth -> blocked or deflected eruption of permanent teeth 2. Most important function of space management = maintain MESIAL DISTAL relationship in given dental arch

1. Premature loss of primary teeth (due to caries, trauma, ectopic eruption) can affect speech, mastication, esthetics, prevention of oral habits, + guidance of permanent tooth eruption • Can lead to undesirable tooth movements of primary and/or permanent teeth • Arch length deficiency can produce or increase severity of malocclusions with crowding, rotations, ectopic eruption, crossbite, excessive overjet, excessive overbite, unfavorable molar relationships, + midline discrepancy • Disruption of arch integrity due to early loss of primary teeth -> blocked or deflected eruption of permanent teeth, unattractive appearance, areas of food impaction, increased caries, + increased perio disease 2. Most important function of space management = maintain MESIAL DISTAL relationship in given dental arch • Restoration or carious primary tooth to act as a natural space maintainer can preserve arch length • Use of space maintainer appliance can preserve arch length, obviate consequences of loss of arch length + need for complex ortho treatment at later stage

Importance + Purpose of Dental Visits 1. Preparation 2. Knee-to-Knee Technique 3. Intraoral evaluation 4. Immediate Treatment 5. Follow-up

1. Preparation: have assistant to record findings, explain parent's role (hold hands & legs, visualize teeth), tell parent to expect crying + reassure that nothing hurts 2. Knee-to-Knee Technique : see Behavior Guidance Section for positioning; IOE of soft tissues, facial of incisors, lingual of incisors, posterior teeth if erupted A. Parents: face operator, child in lap facing parent, hold child's legs under her arm, hold child's hand with her hands, recline child onto operator's lap B. Operator: face parent, knee slightly apart, make slight depression for child's head, palms on either side of child's head for stabilization, thumbs & forefingers used to manipulate pt's lips, mirror, brush and/or mouth prop, call out findings for recorder 3. Intraoral evaluation: soft tissues, facial of incisors, lingual of incisors, posterior teeth if erupted 4. Immediate Treatment: demo tooth cleaning w/ toothbrush, possibly brush on topical fluoride/apply varnish/ITR GI restoration 5. Follow-up: what could parent see?, parent can use technique at home for OH

Predisposing Factor Gist: Caregiver is shit 1. Primary caregiver with high caries rate or poor OH, poor systemic health 2. Poor parenting skills + faulty feeding practices • Bottle feeding after 12 mo. • Bed sharing with infant + mom 3. Prenatal complications (leading to hypoplasia) 4. Low SES households or ethnic minority 5. Parents with low education 6. Inadequate help with childhood 7. Obesity in mom (poor dietary habits) 8. Correlation between oral candidiasis + ECC: 13-36 months

1. Primary caregiver with high caries rate or poor OH, poor systemic health 2. Poor parenting skills + faulty feeding practices • Bottle feeding after 12 mo. • Sleeping with bottles • Bottle feeding with sugar-containing substances • Breast feeding, bottle feeding, sippy cup ad lib • Bottle/ breast feeding without oral hygiene • Bed sharing with infant + mom • Pacifiers dipped in honey or other sugars • Snacking 3-4x per day • Snacking on cariogenic foods + beverages • Feeding w/o oral hygiene 3. Prenatal complications (leading to hypoplasia) 4. Low SES households or ethnic minority 5. Parents with low education 6. Inadequate help with childhood 7. Obesity in mom (poor dietary habits) 8. Strong correlation between oral candidiasis + ECC, especially between 13-36 months — may be considered ECC risk factor

How Space Lost 1. Primary concerns 2. Anterior teeth Cause: A. Rotation of teeth B. Unraveling of crowding in crowded anterior arch, uprighting of anterior teeth -> Potential loss of dental midline 3. Posterior + anterior: A. Lost of prim 1st M or canine -> space closes due to distal shift of incisors NOT mesial drift of posterior teeth B. Pull from transseptal fibers C. Lip pressure D. If lost only on 1 side -> permanent teeth drift distally only on that side -> asymmetry of occlusion + tendency for crowding 4. Posterior mx arch: A. When erupting mx perm adjacent to space -> move into space primarily thru rotation around palatal root • Minor tipping, some bodily mvmt -> Cumulatively decreases arch length -> Inadequate space for unerupted teeth below edentulous space. • Mx prim 1st M -> 1st PM erupts more mesially -> Mesial incline of prim 2nd molar -> Consumes space of perm canine -> Becomes blocked out 5. Posterior md arch: A. When an erupting md perm adjacent to edentulous space -> move into space by mesial tipping B. Root anatomy makes rotation unlikely. Some minor bodily mvmt. 6. Spaces in upper arch close by forward bodily mvmt of permanent 1st molars, mesial crown tipping, & mesiolingual rotation around palatal root 7. Spaces in lower arch close by mesial crown tipping of permanent 1st molars, distal mvmt w/ retroclination of teeth anterior to space (especially D mvmt of canines during lateral eruption) 8. High amount of space lost if primary M is lost prior to or during eruption of 1st permanent M

1. Primary concerns: Posterior teeth (anterior area space loss less likely), bodily movement of erupting tooth (minor if there is a developing tooth beneath edentulous space, but significant in congenitally missing successor to prematurely lost prim tooth) 2. Anterior: doesn't necessarily occur with premature loss of a tooth If space is lost, due to A. Rotation of teeth B. Unraveling of crowding in crowded anterior arch, uprighting of anterior teeth → Potential loss of dental midline 3. Posterior + anterior: A. Lost of prim 1st M or canine -> space closes due to distal shift of incisors NOT mesial drift of posterior teeth B. Pull from transseptal fibers -> consistent contributor C. Lip pressure -> variable component D. If lost only on 1 side -> permanent teeth drift distally only on that side -> asymmetry of occlusion + tendency for crowding 4. Posterior mx arch: A. When an erupting mx perm adjacent to space -> move into space primarily thru rotation around palatal root • Minor tipping, some bodily mvmt -> Cumulatively decreases arch length -> Inadequate space for unerupted teeth below edentulous space. • Mx prim 1st M -> 1st PM erupts more mesially -> Mesial incline of prim 2nd molar -> Consumes space of perm canine -> Becomes blocked out 5. Posterior md arch: A. When an erupting md perm adjacent to edentulous space -> move into space by mesial tipping B. Root anatomy makes rotation unlikely. Some minor bodily mvmt. 6. Spaces in upper arch close by forward bodily mvmt of permanent 1st molars, mesial crown tipping, & mesiolingual rotation around palatal root 7. Spaces in lower arch close by mesial crown tipping of permanent 1st molars, distal mvmt w/ retroclination of teeth anterior to space (especially D mvmt of canines during lateral eruption) 8. High amount of space lost if primary M is lost prior to or during eruption of 1st permanent M

Main Contraindications to Space Maintenance Appliances 1. Pt non-compliance - no OH 2. Systemic disease: distal shoe -> bacterial load 3. Patient acceptance: resists appliance

1. Pt non-compliance: appliances must be monitored on regular basis + pts must be diligent about OH or at serious risk for caries disease 2. Systemic disease: mainly associated with placement of distal shoe due to potential increased bacterial load 3. Patient acceptance: pts who actively resist appliance (manipulate w/ fingers, tongue, other objects) aren't good candidates

Caries Prevention 1. Risk Assessment: 2. Prenatal Counseling Mom DON'T know: • Not normal to loose tooth during pregnancy • Safe to receive dental care during pregnancy • Infant oral cleaning = important • Mom's oral health affects child's oral health

1. Risk Assessment: • Special healthcare needs • High maternal caries rate • Young maternal age at time of birth (<22 yo) • Clinical caries/plaque/demin/staining, • Sleep with bottle or breastfeed t/o night • Late-order offspring • Low SES • Difficult temperaments • Siblings who have caries • Exposure to second-hand smoke • Low parent/caregiver educational level • Mothers who demonstrate low sense of coherence (low sense of control over their lives) • May have children with less positive oral health related behaviors 2. Prenatal Counseling A. Assess mom's OH: reassure mom that radiographs+ dental care • Address all mom's restorative needs, OHI, consider chlorhexidine, diet/ dietary behavior changes, etc. to modify mom's oral flora towards less carcinogenicity B. Educate mom on infant oral care: Mom's oral health care affects child's oral health • Safe to receive dental tx during pregnancy • Not normal to loose teeth during pregnancy • Intraoral cleaning before teeth erupt: VERY IMPORTANT • Teething management • Feeding guidelines • Mom knows: correlation of sugar & caries, fluoride prevents caries, baby shouldn't sleep with a bottle Mom DON'T know: • Not normal to loose tooth during pregnancy • Safe to receive dental care during pregnancy • Infant oral cleaning = important • Mom's oral health affects child's oral health

Mechanism of erupted tooth movement 1. Root formation 2. Bone remodeling 3. Dental follicle - origin: cranial neural crest mesenchyme 4. PDL

1. Root formation: obvious cause for eruption, cause an overall increase in length -> Must be accommodated by growth of root into bone of jaw by increase in jaw height or occlusal movement of crown 2. Bone remodeling: inherent growth pattern of mandible or maxilla moves teeth by selective deposition + resorption of bone in immediate neighborhood of tooth 3. Dental follicle: • Originate from cranial neural crest mesenchyme • Loose ct surround enamel organ of each tooth, eventually become PDL • Reduced dental epithelium initiates cascade of intercellular signals that recruit osteoclasts to follicle • Dental follicle provide conduit + chemoattractant for osteoclasts to do bone remodeling for tooth mvmt 4. PDL: Formation + renewal of PDL/ fibroblasts provide traction power for tooth eruption 5. Molecular determinants of tooth eruptions: A # of molecules have been proposed to take part in signaling cascade that create balance btwn tissue destruction (bone, ct, epithelium), tissue formation (bone, PDL, root)

Appointment Considerations

1. Short, morning appointments better with minimal waiting room time 2. Be flexible with appointment goals 3. Account for translation if necessary 4. Schedule in quiet room if pt anxious or crying 5. Give parent info to prepare child for 1st visit • No promises abt what dentists will or will not do • Dental visits as routine activity • Enlist help of older siblings • Parent shouldn't ridicule or transmit their own fears • Parent practice techniques at home • Commercially available children's books may help prepare for dental visit 6. Be well prepared for child's visits — minimize waiting time between steps or visit or steps of procedures 7. Have flexible goals with back up plans if problems encountered • It may be better to end an appointment earlier than planned (providing that care can be safely discontinued at that time) if patient seems to be losing patience or becoming uncooperative than to persevere and end the appointment with the patient upset.

8. Congenital absence of permanent teeth Choices of Restorations 1. Single tooth implant: facial growth completed 2. Deciduous molar extraction -> no space maintainer 3. Edentulous space not maintained -> adjacent perm 1st molar + 1st premolar erupt into that space -> longer ortho txt + favorable alveolar ridge for implant 4. Appropriate age for implant placement determined by cessation of vertical facial growth

1. Single tooth implant once pt has completed facial growth 2. Space maintainer after deciduous molar extraction shouldn't be placed 3. If edentulous space isn't maintained, adjacent perm 1st molar + 1st premolar will erupt into space -> Require longer ortho txt to move teeth apart for implant space, but tooth mvmt will also result in more robust alveolar ridge favorable for implant • As roots of adjacent teeth move apart, they deposit bone behind that equals width of premolar + molar -> Excellent ridge to place implant = Orthodontic implant site development 4. Appropriate age for implant placement determined by cessation of vertical facial growth • Determined by comparing serial cephalometric radiographs to determine when ramus growth + therefore vertical changes in facial growth stopped.

Lecture: Infant Oral Health + Fluoride 1. Surgeon General's Report (2000): Oral health for 1st time 2. AAPD: dental home A. Dental home i. Oral health risk assessment: 6 mo ii. Establishment of dental home: 1 yr. (no later than 12 months of age) 3. AAP • Dental referrals: 6 mo - 1 yr. Public Information Access

1. Surgeon General's Report (2000): specifically addressed oral health for 1st time, specifically children's oral health + cited significant # of underserved pediatric pts, which will drive federal/state funding, direct public health policy, + will increase public awareness 2. American Academy of Pediatric Dentistry AAPD: national professional organization for specialty of pediatric dentistry long standing public awareness campaign to create a dental home for pediatric pts, combined educational efforts with American Academy of Pediatrics (AAP) A. Dental home - ongoing relationship between dentist + pt, including all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, + family centered way i. Oral health risk assessment recommended at 6 mo., establishment of dental home by 1 yr. 3. AAP: best practices standard 1st oral evaluation by 6 mo. + establishment of dental home by 1 yr. • Initial evaluations can be by non-dental health workers • Dental referrals by 6 mo - 1 yr. Public Information Access: increased internet access, state & federal initiatives via Medicaid/Healthy Families/Headstart programs

Unilateral vs. Bilateral 1. Unilateral - potential space loss in single quadrant For: Premature lost prim tooth but with good prognosis for remaining teeth 2. Bilateral - entire arch For: Potential space loss on both side of an arch, or other teeth with questionable/ poor prognosis in arch where a primary tooth has been lost prematurely.

1. Unilateral: - Only address potential space loss in single quadrant of pt's mouth For: Optimal appliance type for pt with premature lost prim tooth but with good prognosis for remaining teeth • Span space of single lost tooth • Can be used in multiple quadrants depending on space maintenance needs • However, consider bilateral to address potential space loss issues 2. Bilateral: - Address potential space loss in an entire arch where there is current or potential future risk of space loss For: Potential space loss on both side of an arch, or other teeth with questionable/ poor prognosis in arch where a primary tooth has been lost prematurely.

Acquisition of Cariogenic Organism 1. Vertical Transmission: primary caregiver via saliva inoculum 71% in mother-infant pairs - similar bacteria in composition + proportion Impractical to prevent transfer of saliva between mother + infant -> help reduce the cariogenicity of mom's oral flora 2. Horizontal Transmission: siblings + other children

1. Vertical Transmission: introduced by primary caregiver via saliva inoculum (pre-tasting bottle, pretasting or pre-chewing food, sharing utensils, mother holding pacifier in her mouth before infants, child putting fingers in mother's mouth) • Prevention: altering mom's oral flora: restoring active caries, optimizing mom's topical fluoride exposure, improving mom's diet + dietary habits, improving mom's oral hygiene, xylitol gum or mints, chlorhexidine rinse 2. Horizontal Transmission: introduced by siblings + other children, difficult to prevent, but can try to decrease carcinogenicity of siblings: restoring active caries, optimizing sibling's topical fluoride exposure, improving sibling's diet + dietary

Lecture: Behavioral Guidance Poll Everywhere Questions

1. Which type of parenting would parent presence not be helpful: Permissive

Considerations for Initial Office Visit 10. Clinical Gingival & Perio Findings 11. Compliance with previous preventative txt plan 12. Trauma History Monitored: especially for ages 1.5-2.5 yrs + 8-10 yrs

10. Clinical Gingival & Perio Findings: provide important info about pt's habitual or chronic oral hygiene habits (ie. gingival bleeding/inflammation indicative of inadequate OH) 11. Compliance with previous preventative txt plan • Always important to assess compliance with previous prevention recommendations; otherwise, new recommendations may be doomed to failure • If previous preventive treatment plan isn't being followed or isn't effective -> important to explore potential barriers to compliance with patient/parent + adjust updated plan to overcome those barriers Potential issues: too many recommendations at once, recs not adequately specific, household routine doesn't support recs, parents didn't understand 12. Trauma History: past trauma experience should be monitored, especially for ages 1.5-2.5 yrs (as injuries common when child is learning to walk) + ages 8-10 yrs (as child may start contact sports, mouth guards are encouraged) • History of trauma may explain atypical findings + need for clinical & radiographic monitoring • History or observation of repeated trauma may alert dentist to further evaluate/rule out abuse

Oral Head + Neck Exam: 11. TMJ: Asymptomatic Max opening: 40 mm Every 2 years: 4 mm Peaks: 60 mm (12-13 yrs) 12. Pericoronitis • 18-23% more common in African-American children 13. Saliva: Copius, serous Note: Infants + toddlers who are teething, excessive salivation (drooling) = common finding, but consistency of saliva should remain balanced between mucus + serous

11. TMJ: asymptomatic vs. symptomatic, max opening • Usually asymptomatic in pedo pts •Max opening: 40 mm (2-3 yrs) • Increases on average 4mm every 2 years, peaking at to 60 mm (12-13 yrs) • If symptomatic, limited opening = concerning + should be evaluated for mn condyle fracture, recent trauma, or 2. Pericoronitis; 18-23% more common in African-American children. • Mucosa: vascular, lesions, signs of trauma; usually appears vascular + regular in contour and texture • Note paruli and/ or sinus tract, lesions or signs of trauma • Additional diagnostic testing + radiographic evaluation may be needed to identify associated tooth or teeth 3. Saliva: copious, xerostomic, serious, mucous; usually copious w/ equal amts of serious + mucous; xerostomia or excessive amts of single type should be evaluated, often caused by systemic rxs Note: Infants + toddlers who are teething, excessive salivation (drooling) = common finding, but consistency of saliva should remain balanced between mucus + serous

Oral Head + Neck Exam: 14. Gingiva: Erythematous rounded margins Mucosa: Pink, moist 15. Floor of mouth: pink, moist

14. Gingiva: pink, erythematous, physiological pigmentation, rolled margins, parulis/sinus tract; healthy gingiva is pink with occasional physiological pigmentation (brown/ bluish gray); other conditions indicate inflammation or abscessed teeth. Note presence of a parulis or sinus tract abscessed teeth A. Localized trauma can result from food trauma or, in rare instances, from localized self-destructive behavior (ex. trauma from continual picking at area of gingiva with fingernail or foreign object) 15. Floor of mouth: swelling, vascular, exostoses, no abnormalities; swellings = rare unless ranula development; abscess formation may be evident on lingual • Exostoses typically appear as a child reaches adolescence but can be present in children of any age. • If primary teeth severely carious, abscess formation may be evident on lingual (as cellulitis, a parulis or sinus tract), but rarely involves true floor of mouth

Oral Head + Neck Exam: 16. Tongue: Coated, slight ankyloglossia 17. Tonsils: Brodsky 1; inflamed A. Brodsky's Tonsil Classification System (25% 0->4)

16. Tongue: coated, ankyloglossia, no abnormalities; freely mobile, even color + distribution of papilla, coated tongue related to poor OH or URIs ; ankyloglossia = highly attached lingual frenumo 17. Tonsils: enlarged, obstructive, nonobstructive; not necessarily a cause for concern depending on pt's age, as long as airway not obstructed; chronically enlarged tonsils indicative of mouth breathing due to restricted airway and development of posterior crossbite A. Brodsky's Tonsil Classification System: • 0 - tonsils lie w/in tonsilar fossae, nonobstructive • 1 - tonsils sit just outside tonsilar fossae, obstructive <25% • 2 - tonsils readily seen in airway, 25-50% obstructive • 3 - tonsils obstruct 50-75% airway • 4 - tonsils obstruct >75% airway Enlarged tonsils -> ↑ risk of experiencing sleep apnea -> inquire about quality of patient's sleep, snoring, how well rested they're during day • Anything that indicates an infectious process such as inflammation or Deitrick's Plugs (cellular debris in the tonsillar crypts) = abnormal + noted + followed up with patient's parent

Gingivitis Associated with Systemic Health: D. Acute Primary Herpetic Gingivostomatitis Subacute (NO SYMPTOMS): 80-90% of population Stage I (like flu) -> Stage II - VESICULAR LESIONS THAT FORM ULCERS WITH A RED HALO SUPPORTIVE treatment: NO ANTIBIOTICS, bland foods, liquid supplements, soothing and/or anesthetizing mouth rinses

1st oral herpetic infection is either: A. Subacute (no symptoms): 80-90% of population B. Acute (with symptoms): 10-20% -> develop lesions Stages: A. Stage I • Fever • Malaise • Lymphadenopathy • Mucosal inflammation • Flu-like symptoms May mimic a bad cold or flu -> unrecognized until oral lesions develop B. Stage II (several days later) • Severe gingivitis • Vesicular lesions anywhere in mouth + peri-oral • VESICULAR LESIONS THAT FORM ULCERS WITH A RED HALO Treatment is SUPPORTIVE: bland foods, liquid supplements, soothing and/or anesthetizing mouth rinses, NO ANTIBIOTICS • Differential diagnoses: severe gingivitis, NUG, herpangina

Oral Head + Neck Exam: 21. Appliances 22. Labial Frenum: Uninvolved A. Uninvolved - high on alveolus + no blanching/displacement of unattached mucosa when lip reflected B. Involved - opposite of uninvolved

21. Appliances: yes/no, effective/ineffective; space maintainers or ortho appliances • Pt often 1st to detect loose appliance, so parents need to call dentist immediately if pt complains • Appliances need to be checked for efficacy • Ignoring a loose appliance -> caries, damage to soft tissue, patient discomfort, etc 22. Labial Frenum: involved, uninvolved; can cause diastema in mx midline or perio problems A. Uninvolved - high on alveolus w/ no blanching or displacement of unattached mucosa when lip reflected B. Involved - low on alveolus w/ blanching & displacement of unattached mucosa

Anticipatory Guidance (Cont'd) 4. Fluoride NOTE: Most parents tend to use larger amounts of fluoridated toothpaste than recommended 5. Injury prevention + trauma 6. Oral habits 7. Oral development • 1st tooth around 6 mos • Complete dentition around 2 yrs • 1st permanent tooth around 6 yrs: 1st permanent M erupt w/o loss of primary tooth 8. Oral hygiene "Lift the lip" exam Appropriate amount of toothpaste: smear < 3 yr, pea size: > 3 yrs

4. Fluoride: systemic delivery via water source or rx supplementation; topical delivery via toothpaste, fluoride varnish, OTC rinses; safety via home supervision + age-appropriate use of fluoridated toothpaste to avoid fluorosis NOTE: Most parents tend to use larger amounts of fluoridated toothpaste than recommended. • Demonstration of appropriate amounts of toothpaste to parents = essential + improves parent's accuracy 5. Injury prevention + trauma: general childproofing, emergency contact info (dental home) 6. Oral habits: thumb + finger sucking usually self-extinguish by school age, monitor + counseling at appropriate time for cessation 7. Oral development: dental age vs. chronological age • First tooth around 6 mos • Complete dentition around 2 yrs • First permanent tooth around 6 yrs: first permanent M erupt w/o loss of primary tooth 8. Oral hygiene: oral flora acquisition, importance of mouth cleaning by parent, "lift the lip" exam, appropriate amount ("smear" < 3 yr, "pea size" 3 yrs+) fluoridated tooth paste discussed and demonstrated to parents • It's important that anticipatory guidance = reviewed at subsequent appointments because family's circumstances have changed, necessitating adjustments

Occlusal Examination: 4. Overjet: 5. Overbite: Complete: occlusion w/ VO Incomplete: no occlusion, but VO Edge to Edge: no VO 6. Open bite: Negative VO 7. Midline deviation

4. Overjet: horizontal difference b/w lingual surface of mx incisor to facial surface of lower incisor when teeth in CO as measured parallel to occlusal plane • Measured from lingual extent of incisal edge of maxillary incisor to facial surface of mandibular incisor along a line parallel to occlusal plane using perio probe as a measuring tool • Approximate in cases of crowding/ rotations. 5. Overbite: amount of vertical overlap of upper incisors over lower incisors, whether or not upper + lower incisors contact; % of facial surface of lower incisors that is covered my mx incisors when post teeth in CO Complete: occlusion w/ VO Incomplete: no occlusion, but VO Edge to Edge: no VO 6. Open bite: negative VO; one or more teeth don't overlap in vertical plane when dentition in CO; indicative of skeletal discrepancy or long-standing thumb or digit sucking habit 7. Midline deviation: no/yes, mx/mn, L/R; deviation measured relative to pt's facial midline • Midline deviations can result from variations in eruption sequence, especially between contralateral sides of arch -> may signal developing space loss + need for space maintenance or orthodontic intervention.

Oral Head + Neck Exam: 8. Lip Posture/Closure: Closed, unstrained A. Competent - upper & lower lips close with child at repose B. Incompetent - anterior open bite, mx vertical excess, excessive overjet, etc Significant overjet (>4 mm) -> increase risk of anterior tooth trauma -> early (phase I) ortho intervention 9. Lip Surface - moist 10. Lymph Nodes Enlarged: 8-12

8. Lip Posture/Closure: competent vs. incompetent • Upper & lower lips close w/ child is at repose if competent • Incompetent indicative of anterior open bite, mx vertical excess, excessive overjet, etc. • Significant overjet (> 4mm) → increased risk + severity of anterior tooth trauma -> May be an indication for early (phase I) ortho intervention in these patients 9. Lip Surface: moist, dry, cracked, angular cheilosis; irregularities exacerbated by incompetent lip closure + mouthbreathing -> Vaseline, conscious of "open wide" to prevent cracking 10. Lymph Nodes: firm, tender, nonpalpable • Submandibular, Sublingual, cervical can be readily palpable in pediatric pts, usually enlarged by non-tender for pts 8-12 yrs; palpable & tender indicative of current or recent infection (URI/ear infection, dental infections, etc.); firm indicates chronic process.

Occlusal Examination: 8. Ortho Consult/Referral Phase I: tx in mixed dentition Phase II: tx in permanent dentition 9. Spacing

8. Ortho Consult/Referral: yes/no, reason; children in early mixed dentition to harness pt's prepubertal growth spurt Phase I: tx in mixed dentition Phase II: tx in permanent dentition • After an occlusal evaluation by dental student + confirmation by Pediatric Dentistry faculty member, a member of Department of Orthodontics will come to Peds Clinic + you will present your findings + discuss appropriate Ortho management of your patient. • If a member of the Orthodontics Department isn't available, parents referred to Ortho Clinic • Often we accompany patient to Ortho clinic where they make an appointment for this evaluation 9. Spacing: crowding (mm); estimate for each arch; indicate developing ortho problems and indicate timing for consultation

1. Systemic Fluoride Recommended Fluoride Prescriptions (mg F-ion/day) as determined by age + F- concentration in local water supply (ppm) 6 months - 3 years: <0.3 ppm: 0.25; 0.3-0.6 ppm: 0 (From this point add 0.25 ppm)

>6 ppm: 0 for all 1. Birth - 6 months 2. 6 months - 3 years <0.3 ppm: 0.25 3. 3-6 <0.3 ppm: 0.5 0.3 - 0.6 ppm: 0.25 4. 6-16 <0.3 ppm: 1 0.3 - 0.6 ppm: 0.50

Considerations for Initial Office Visit 7. Dental History A. Child's 1st visit: i. Infant (<1 yr): parents have higher dental IQ, highly motivated ii. Young child (1-3 yrs): parental concern for dental health, moderate dental IQ iii. School-aged child (>3 yrs): parental lack of interest in dentistry or low dental IQ B. Seeking new dentist C. Parental expectations for behavior D. Pt's fluoride exposure + history based on zip code, but must also consider ALL potential topical + supplemental fluoride exposures E. Previous restorative dental tx

A. Child's 1st visit: shows family access to care + parent's dental IQ I. Infant (<1 yr): parents have higher dental IQ, highly motivated II. Young child (1-3 yrs): parental concern for dental health, moderate dental IQ III. School-aged child (>3 yrs): parental lack of interest in dentistry or low dental IQ B. Seeking new dentist: WHY?? • Moved: access to previous records? • Unhappy w/ previous tx: Cost? Management? Lack of communication? All potential cues to parent who is hard to please • Referral: complex: tx needs, behavior guidance * Request previous dental records if they are available. Emergency care for toothache pain: low parental dental IQ, lack of resources to care possible dental neglect C. Parental expectations for behavior: usually accurate when they're honest + child will often try to use strategies that effective at home, parents often expect dentist to deal w/ adverse behavior so be sure to discuss acceptance of behavior guidance techniques if necessary (ie. Papoose board) D. Pt's fluoride exposure + history based on zip code, but must also consider ALL potential topical + supplemental fluoride exposures to determine need for systemic supplementation (include bottled water, frozen or canned foods, fluoride containing toothpaste, etc.) E. Previous restorative dental tx: indicative of caries risk, good reference for behavior guidance and pt management strategies (ie. types of anesthesia used, pt acceptance of tx, etc.)

Considerations for Initial Office Visit 2. Observations of parent + child interactions A. Child's behavior i. Crying, struggling w/ parent: separate Indicates: pain, fear, exhaustion ii. Shy, clinging to parent: parent accompany child until gain confidence, cordial conversation with parent Indicates: fear, previous negative exp iii. Confident, friendly: no problems, slightly anxious B. Child's motor skills: determine if age-appropriate (if not, indicative of general health problems or developmental delays) C. Parenting style: indicative of how child will behave towards dental team

A. Child's behavior: determine if age-appropriate i. Crying, struggling w/ parent: usually better after separation from parent; may indicate pain, fear, or exhaustion • Often helpful to ask parent if this typical in new situations or if they know why child so unhappy - it may have nothing to do with being at dentist! ii. Shy, clinging to parent: consider having parent accompany child back until s/he gains confidence, may indicate fear, previous negative exp • Let child observe your cordial conversation with parent before you approach child as this may help their confidence when it's time for you to speak with them (i.e. you will seem less the "stranger" when they see parent interacting with you) iii. Confident, friendly: usually no problems, but still may be slightly anxious B. Child's motor skills: determine if age-appropriate (if not, indicative of general health problems or developmental delays) C. Parenting style: indicative of how child will behave towards dental team

Factors when space maintenance considered after premature loss of primary teeth: 3. Chronological Age of Pt. • Loss of primary molar before 7 yo -> delayed emergence • Loss of primary molar after 7 -> early emergence • Primary molar extraction: Scar tissue -> retarded emergence of premolar • Primary molar extraction when when premolar was well along root formation + actively erupting -> accelerates movement + emergence

A. Loss of primary molar before 7 yo -> delayed emergence of succedaneous tooth • Retarded eruptive mvmt + clinical emergence of premolar after extraction of deciduous molar may be explained by formation of scar tissue that provides a mechanical barrier to erupting permanent tooth 2. Extraction of deciduous molar when premolar was well along root formation + actively erupting -> accelerated movement + early emergence of premolar • Eruption of premolar facilitated by providing a pathway for eruption thru alveolar bone

11. Mouth props: "Tooth pillows" A. Molt mouth prop (Scissor mouth block ends) B. McKesson prop (Regular bite block)

A. Molt mouth prop (Scissor mouth block ends): ratchet type that can be adjusted + controlled extraorally • Portion contacting teeth is covered with latex or silicone padding • Can be sterilized once pads removed • Warn patient of "clicking" sound as prop = opened • Holding handles passively against patient's face keeps prop in position in mouth B. McKesson prop (Regular bite block): less effective in children because can't be adjusted + difficult to control in mouth, rely on pt to control it

C. AuthoriTARIAN (Low warmth/high control) = Mrs. In control -> cold Parent: Harsh (yelling, commands) + control through fear Child: distrustful, fearful, shy -> high caries risk Strategies: • Build trust • Negative patient perception of treatment due to pt fear of parent • Communicative strategies: Tell-show-do, voice control/modulation, distraction, positive reinforcement

A. More negative behavior than Authoritative group, fewer advanced techniques needed, parents may be needed to assist Ex. punishment, rigid, obedience, because I said so, autocratic, status, I'm the boss, rules, directive, structure, responsiveness Parent characteristics: Harsh: Yelling, commands, physical punishment • Control through fear or intimidation Behavioral control, demandingness: High Responsiveness, warmth, supportiveness: Low Child characteristics: • Distrustful + withdrawn • Fearful of parent intervention • Exhibit worse behavior in dental setting • Higher caries incidence variable depending on parents' prioritization, but worse than authoritative Strategies: • Build sense of trust • Variable success with other strategies • Negative patient perception of treatment due to pt fear of parent • Communicative strategies such as tell-show-do, voice control/modulation, distraction, and positive reinforcement are potentially effective with all children, but have varied rates of success based on parenting style

4. Tx Plan Presentation: Informed Consent A. Oral Findings • Etiology, consequences if untreated • Priority order • Visual aids

A. Oral Findings • Use models, radiographs, plaque scores, diagrams, + other visual aids to demonstrate your findings • If patient = cooperative, findings can also be demonstrated in patient's mouth. • Discuss & demonstrate problems, be sure to include preventive problems (in priority order) • Explain possible etiology of observed problems • Discuss expected consequences if conditions are left untreated

Occlusal Examination: 3. Cross Bite A. Posterior Buccal cusps of upper teeth occlude in central groove area of lower teeth B. Anterior Incisal edge(s) of maxillary tooth or teeth = lingual to incisal edges of lower tooth or teeth, with or without occluding

A. Posterior Crossbite: primary/permanent, left/right; can involve primary + permanent teeth, uni- or bilateral, limited to specific teeth or encompassing entire arch; bilateral crossbite results in more constricted, higher palatal contour + constricted mx arch • (buccal cusps of upper teeth occlude in central groove area of lower teeth) B. Anterior Crossbite: yes/no, primary/permanent, left/right; should always be monitored closely, can lead to labialized incisors + perio problems (incisal edge(s) of maxillary tooth or teeth = in a position lingual to incisal edges of lower tooth or teeth, with or without occluding)

Factors when space maintenance considered after premature loss of primary teeth: 4. Which Tooth Lost A. Primary Incisor i. Primary Canine: Not present (unerupted/prematurely lost) -> space loss + consider space maintenance B. Primary Canine Premature loss: Maxillary primary canine -> rarely significant space loss Case: If loses anterior teeth but not canine -> no space maintenance required i. Permanent incisor crowding -> arch length + midline loss ii. Maxillary arch crowded -> ectopic eruption of permanent canines -> permanent lateral incisors erupr into primary lateral + canine position -> premolars take up remaining space -> permanent maxillary canine crowding

A. Primary incisor: • Prim canines present -> rarely result in significant arch length loss • Prim canine isn't present (unerupted/ prematurely lost) -> space lost, should consider space maintenance A. Primary canine: i. Perm incisor crowding, either as permanent incisor erupt or after they're erupted into a crowded lower arch -> Arch length loss (mandible) as perm incisors drift into space left by prim canine + exert uprighting + lingual inclination • Midline loss also common + can be challenging to regain orthodontically ii. Premature loss of maxillary prim canine rarely -> significant space loss • Maxillary arch crowded -> ectopic eruption of permanent canine as permanent lateral incisor erupts into space of prim lateral + canine, erupting premolars which precede maxillary canine, use remaining space in quadrant -> erupting permanent maxillary canine with inadequate space, typically crowding it out of dental arch

Recommendations: 2. Professionally Prescribed or Applied A. Prophy paste - minimal residual fluoride levels remain due to rinsing B. Gel or foam - disposable tray 1 min with gel • Post op: avoid eating or drinking for 30 min C. Fluoride varnishes Applied: facial surfaces • Primary effect: Topical, but also slight systemic effect • Shouldn't be used for pts w/ pine nut or pine resin allergies or other sources of high amts of fluoride • NOT shown to associate with Fluorosis • Applied by brushing onto dried tooth surface (dries in 2 min) monthly for 3 months D. Rx Rinses - risk of fluoride ingestion E. Rx Gels - risk of fluoride ingestion Indications: ortho appliances, rampant caries, radiation therapy, high fermentable carb diet, reduced salivary flow, compromised OH due to inadequate motor skills, vision

A. Prophy paste: minimal residual fluoride levels remain due to rinsing B. Gel or foam • Applied in trays or brushed on, professionally applied • Disposable tray filled with fluoride gel or foam placed in child's mouth for 1 min. • Child bites down on tray + suction placed to make sure fluoride gel or foam isn't swallowed • Post op: avoid eating or drinking for 30 min C. Fluoride varnishes: organic resin impregnated w/ fluoride that's released over 2-3 day period + can be "recharged" by other topical fluoride sources; applied to facial surfaces of all teeth or specific sites (proximal demineralization, after anterior proximal stripping, to intact proximal surface adjacent to a proximal surface being restored • Primary effect = topical, but may also have a slight systemic effect • FDA approved for root sensitivity • Caries preventative is "off-label" • Pts may complain of initial funny taste or texture • Most products now tooth-colored + flavored (older ones have yellowish/ brown color) • High concentrated fluoride -> care must be excised in application • Shouldn't be used for pts w/ pine nut or pine resin allergies or other sources of high amts of fluoride • Fluoride varnish in preschoolers hasn't been shown to associate with fluorosis • Applied by brushing onto dried tooth surface (dries in 2 min) monthly for 3 months Post op: pt can eat + drink right away but shouldn't eat sticky, crunchy food = shouldn't drink hot beverages for rest of day • Pt + parents should be advised to only resume brushing + flossing following morning D. Rx Rinses: usually applied daily or weekly, but risks of alcohol based + excessive fluoride ingestion, avoid if poor compliance/ poor parenting skills E. Rx Gels: applied daily or weekly either by toothbrush or custom trays, but risks of excessive fluoride ingestion Indications: ortho appliances, rampant caries, radiation therapy, high fermentable carb diet, reduced salivary flow, compromised OH due to inadequate motor skills, vision

Factors when space maintenance considered after premature loss of primary teeth: 1. Time elapsed since tooth loss Space maintenance placed when primary tooth extraction • If not -> won't preserve/restore original arch length • Eminent significant change -> space maintenance considered

A. Space closure caused by premature loss of tooth occurs early + quite rapidly B. Space maintenance should be placed at time of primary tooth extraction or as soon thereafter as possible • Treatment planning a space maintenance appliance months after extraction of prim tooth will not preserve original arch length (space is lost) • Eminent significant change (eg. eruption of a perm 1st molar in a quadrant with a missing prim 1st molar) that could result in additional space loss -> space maintenance considered -> may prevent additional arch length loss, tho it will not restore original arch length

B. Toddler: 15 months - 2 years Object Permanence: Recovers/Finds hidden objects Play: Objects + Symbolic Receptive Language: Retrieve, 2/3 commands, Expressive Language: Acquires ~10 words by 18 months of age -> constructs 2-word sentences by age 2 General Characteristics: • Pre-cooperative • Terrible 2's • Peak in oral trauma • Cognitive/verbal skills • No sense of cause + effect • Learning to walk (Trauma) Dental: • Exam: Lap or knee-to-knee • Radiographs: parent's lap; usually uncooperative for radiographs child may sit in parent's lap with parent holding film/sensor • Prophy/Topical flouride: quick + gentle • Minor caries: no LA, SDF, ITR • Major caries (cause: extended bottle feeding (baby bottle caries): Sedation or GA • Minor Oral Surgery: Sedation or GA

B. Toddler: 15 months - 2 years Object Permanence: Recovers/Finds hidden object after multiple visible changes of position -> recovers/finds hidden object after multiple in visible changes in position Play: Awareness of social function of objects -> symbolic play based on own body (pretends to drink from toy cup) -> symbolic play directed toward doll (pretends to give doll drink from toy cup) Receptive Language: • Can bring/retrieve familiar objects from another room • Points to parts of body -> follows series of 2 or 3 commands -> points to pictures when named Expressive Language: Acquires ~10 words by 18 months of age -> constructs 2-word sentences by age 2 Other General Characteristics: • Pre-cooperative • Terrible 2's • Cognitive/verbal skills • No sense of cause + effect • Learning to walk (Trauma) Dental: • Exam: Lap or knee-to-knee • Radiographs: parent's lap; usually uncooperative for radiographs child may sit in parent's lap with parent holding film/sensor • Prophy/Topical flouride: quick + gentle • Minor caries: no LA, SDF, ITR • Major caries (cause: extended bottle feeding (baby bottle caries): Sedation or GA • Minor Oral Surgery: Sedation or GA Notes: • Peak in oral trauma as motor skills + coordination still developing + patient learning to walk • Unable to understand necessity of dental procedures Prevention: focus on parent; understand home care, ask about other caretakers, nutrition discussion essential at this age (snacking habits, sippy- cup use, etc.)

4. Tx Plan Presentation: Informed Consent B. Proposed txt • Priority order, alternative • Parent responsibility

B. Proposed txt: • Review preventive treatment plan + patient's + parent's roles. • Explain required procedures to correct previously cited problems • Discuss treatment in same order as problems (priority order) - this is easier for parents to follow • Explain alternative treatment if you feel it is appropriate, parent may be given a choice in this situation • Models, photographs + other examples may be helpful. Your pediatric typodont makes a great visual aid, as it will include examples of many of the restorative procedures that you may be discussing • Stress parent's responsibilities including home care, supervision, etc.

2. Topical Fluoride Recommendations: Based on COMPLIANCE + SEVERITY OF CARIES 1. OTC Options: A. ADA seal toothpaste • 2: smear • 2-5: pea sized • Supervised until 6 Avoid rinsing after brushing NOTE: Most ped pt can't reliably rinse + spit until age 5-7 B. Rinses • NOT replacement for brushing & spitting NOTE: Fluoridated toothpastes have 4x higher amts of fluoride than rinses

Based on compliance + severity of caries 1. OTC Options: A. ADA seal toothpaste: • Smear on infants/toddlers until age 2 • Pea-sized amount for ages 2-5 yrs • Supervised use until age 6 Store in secure place to avoid excess ingestion (long term effect= fluorosis, short term= gastric upset); provide instructions, visual aids, have parent demonstrate dispensing age-appropriate amt; kids flavors, color, sparkles; starter toothpastes normally aren't fluoridated, used to acclimate child to taste without risk of excessive ingestion, so not recommended once using fluoridated toothpaste, avoid rinsing after brushing to optimize residual fluoride levels to enhance the topical effect of fluoride, esp overnight NOTE: Most ped pt can't reliably rinse + spit until age 5-7 • This recommendation isn't appropriate for children who cannot do this AFA seal = acceptable abrasiveness, fluoride B. Rinses: • Use on a brush after toothpaste routinely by parent until age 4-5 or when child can spit to avoid accidental ingestion • Store in secure place, kid's flavors, best to use at bedtime after brushing, no eating or drinking after, effective against proximal caries; NOT replacement for brushing & spitting (less fluoride exposure) • Once a day use may be beneficial NOTE: fluoridated toothpastes have 4x higher amts of fluoride than rinses, so rinses can usually be avoided if pt demonstrates good brushing

5. Honesty

Being truthful with pt, while being empathetic + reassuring • Especially in response to pt questions • Use lease anxiety provoking terms possible • Never lie!!! If you do, you'll forever lose their trust • Build trust + rapport with your pediatric pt • Can be used on all pt • Rephrase, distract, emphathize + reassure

Gingivitis associated with Systemic Disease C. Diabetes Mellitus Associated Gingivitis

Characteristics: • Gingivitis, which seems exaggerated in severity + extent compared to that seen in healthy patients with similar amounts of plaque • Early severe gingivitis, especially if it is a significant change from patient's usual levels of gingivitis with similar oral hygiene, may be one of the earliest symptoms of pediatric onset diabetes mellitus. In such cases, a medical referral for further medical evaluation may be warranted • Altered immune response (suppressed neutrophil function) secondary to diabetes mellitus, results in a heightened immune response + exaggerated gingival redness + swelling • Xerostomia, which can also be associated with diabetes mellitus, especially in poorly controlled patients, may worsen gingivitis • As in patients with a variety of health issues which require frequent medical intervention, dental care may be pursued less regularly with negative outcomes for gingival health • Patients with Diabetes mellitus associated gingivitis are predisposed periodontitis also associated with this systemic disease, thus in patients who have diabetes mellitus and gingivitis, the possibility of periodontitis should always be investigated and treated if found. Treatment: • Good medical control of diabetes, with maintenance of stable blood glucose levels • Meticulous oral hygiene, more frequent dental evaluations as needed

I. Post-anesthesia: Cheek/Lip Bite UOP: Anesthesia sticker + bite on cotton roll

Characteristics: • Child chews on lip or cheek while still anesthetized, initial bleeding + ragged, may be uncomfortable, very alarming to parents but looks worse than it is • Progresses to yellow with sloughed tissue Tx: prevention by instructing child not to bite on cheek/lip, informing parent, suggestion of no solid foods until wears off, antibiotics if purulent drainage occurs UOP: Anesthesia sticker + bite on cotton roll

Gingivitis associated with Systemic Disease B. HIV Associated Gingivitis

Characteristics: Erythema 2-3 mm apically from FGM, gingival pain Treatment: meticulous oral hygiene, chlorohexidine 2x/d (bid)

C. Localized recession - lack of attached gingiva in MANDIBULAR ANTERIORS

Characteristics: attributed to lack of attached gingiva in mandibular anteriors; associated with malposed, ectopically erupted teeth, high frenum attachment Prevention: extraction of overretained primary teeth or ortho tx to make room so that teeth can erupt into ERUPTIVE TRENCH Tx: consider graft if <1mm attached gingiva, recession tx depends on oral hygiene, stability of recession, severity, esthetics

E. Eruption Hematoma - bluish/purple swelling of gingiva as tooth

Characteristics: bluish/purple swelling of gingiva as tooth erupting due to blood in dental follicle, occurs in mx or mn, not associated with pain Tx: self-limiting, ruptures on own

F. Mucocele - cyst like lower lip due to severance or partial obstruction of SALIVARY DUCT Ranula - large mucocele located on mouth floor Tx: surgical excision or marsupialization

Characteristics: cyst-like structure commonly found on lower lip due to severance or partial obstruction of SALIVARY DUCT can be transient Ranula - large mucocele located on mouth floor Tx: surgical excision or marsupialization • Micro-marsupialization - silk suture placed through mucocele • High risk of post-surgical recurrance

Oral Head + Neck Exam: 7. Facial Profile Trends: Normal: Convex -> straight Abnormal: Concave -> Class III Convex -> class II Facial symmetry: Symmetrical

Convex (bulge out) vs. concave vs. straight • Provides insight into pt's molar relationship & growth pattern (especially differences b/w mx + mn growth) • Usually starts as convex + should become more straight as mature • Concave -> abnormal in children + may indicate class III growth pattern. • Convex -> class II (in adolescent or young adult)

2. Topical Fluoride

Current exposure: based on municipally-fluoridated drinking water, type of toothpaste, OTC rinses, professionally applied fluoride gels, and fluoride varnish used More effects on erupted teeth

Pediatric Dental Triangle Clinic tip: Child reluctant to interact with you -> shift focus to parent to become more comfortable

Displays dynamic relationship between patient, parent, and dental team • Partnering with parents = effective if parents engaged + willing to help • Dentist's interaction w/ parents = often indicative of child's perception of dental environment + willingness to accept tx -> observation of positive interactions facilitate patient acceptance • Patient's developmental stage heavily influences pediatric dental triangle success Clinic tip: When pediatric patient seems reluctant to interact with you as you approach them in reception area, shift focus to parent + let them observe you interacting with parent -> gives child some reassurance + gives child few minutes to observe you + feel more comfortable

Barriers (cont'd) 3. Bio Barriers: Epigenetics Children from high stress/ low SES households -> negative/ exaggerated anxiety in dental visit • SOCIOLOGIC stress -> can affect which gene expressed

Emerging area of development biology with direct impact on behavior • VAST + rapidly evolving topic, recent research suggest that children from high stress/ low SES households show negative/ exaggerated anxiety in novel situation such as dental visit • SOCIOLOGIC stress -> can affect which gene expressed (turns on or off which gene expressed) • Heritable, passable to offspring • Epigenetics explains heritable changes in genetic expression which do not result from DNA sequence

K. Oral Candidiasis - white plaques

Etiology: Candida albicans, associated with change in normal flora in mouth due to abx, inhaled steroids, immunosuppression Characteristics: white plaques that can be removed to reveal erythematous mucosa Tx: topical antifungals (ie. Nystatin) and tx of underlying cause (e.g. rinse with water after each puff of inhaled steroid/asthma inhaler)

G. Dental Abscess Characteristics: • Diffuse (cellulitis) or Localized swelling of gingiva or mucosa (PARULIS)

Etiology: Pulpal necrosis secondary to caries or trauma Characteristics: • Diffuse (cellulitis) or Localized swelling of gingiva or mucosa (PARULIS) • Sinus tract may be present if rupture has occurred to allow drainage • No systemic manifestations unless immunocompromised Tx: removal or drainage of source of infection, no antibiotics necessary if tx can be immediate Primary teeth: extraction (recommended), pulpectomy (terminal primary tooth in arch, still needed to guide eruption of adjacent erupting permanent molar) + then extraction, NO antibiotics,

Gingivitis Associated with Systemic Health: E. Gingival Enlargement Associated with Orthodontic Appliances Cause: allergic or tissue compression during space closure Characteristics: gingival overgrowth WITHOUT inflammation in anterior facial

Etiology: allergic reaction (ie. nickel) or tissue compression during space closure Characteristics: gingival overgrowth WITHOUT inflammation in anterior facial, occurs in ortho patients despite meticulous oral hygiene • Affects 5-10% of Ortho pts Tx: usually resolves after removal of appliances (self limiting) Notes: • Chronic Gingivitis Assoc. w/braces seen clinically -> plaque, calculus, inflammed/rolled gingival margin, erythema (critical factor)

H. Facial Cellulitis - infection overwhelmed pt's immune system Tx: Emergency: periorbital swelling, swelling below inf border of mn, or difficulty in swallowing or breathing (ludwig's angina)

Etiology: arises from dental, bone, or perio infection that overwhelmed pt's immune system + causes diffuse response Characteristics: • Diffuse infection involving fascial planes • Pt may be moderately ill with fever + leukocytosis Tx: Emergency: immediate hospitalization for systemic abx therapy if periorbital swelling, swelling below inf border of mn, or difficulty in swallowing or breathing (ludwig's angina) • If above symptoms aren't present, remove source of infection, consider incision + drainage, antibiotics, careful monitoring

B. Aphthous Ulcers (canker sores, mouth ulcers) Characteristics: vesicles erupt + form ulcerations with red halos on NONATTACHED + MOVABLE mucosa Tx: Palliative: Benzocaine -> Oragel in patients >2 years

Etiology: auto immune response triggered by stress, trauma, foods, SLS (Sodium lauryl sulfate) Characteristics: vesicles erupt + form ulcerations with red halos on NONATTACHED + MOVABLE mucosa Tx: prevention by avoidance of triggers + use of CHX, palliative, corticosteroids if severe Palliative: Benzocaine -> Oragel in patients over 2 years of age only

D. Ankyloglossia/ Short lingual frenum • Occurs from higher than normal frenum attachment on mandibular alveolar ridge & ventral ridge of tongue

Etiology: developmental, baby is born with it • Occurs from higher than normal frenum attachment on mandibular alveolar ridge & ventral ridge of tongue that may restrict tongue mvmt -> Gingival recession on lingual Tx: rarely causes nursing or speech problems due to quick adaptation, early tx contraindicated due to submandibular gland infection risk, but frenectomy performed if severe

Gingivitis Associated with Systemic Health: F. Pericoronitis - food/plaque under operculum Image: Gum going over tooth Location: MANDIBULAR PERMANENT MOLARS INFLAMMATION + PAIN, trismus (lock jaw) Treatment: Monojet 1. Mild cases (w/o pus or abscess): Ibuprofen for 3 days (NOT ACETAMINOPHEN) • Soft food for 3 days 3. Severe cases (purulent exudate, trismus, facial swelling, fever): • Anesthesia (IA/ Lingual and Long Buccal), Exercise with scapel or laser Ibuprofen Dose Recommendation: Child's Weight: +100 1. 50-75 lbs: 200 mg q 6-8 hrs 2. 75-96 lbs: 300 mg q 6-8 hrs

Etiology: food or plaque accumulation under operculum of erupting tooth Characteristics: usually occurs in MANDIBULAR PERMANENT molars + presents with INFLAMMATION + PAIN, • Advanced cases may show fluctuant swelling and/or purulent material with fever and trismus • Fever, malaise, lymphadenopathy, foul taste/halitosis, trismus in severe cases -> lock jaw Treatment: 1. Mild cases (w/o pus or abscess): Irrigate under operculum with Monojet + warm saline, No anesthesia , Ibuprofen for 3 days (NOT ACETAMINOPHEN) (for swelling due to inflammation) • Soft food for 3 days, Monojet after meal (teach parents how to use). • If persists, exercise operculum with electrosurgery or laser (less operative bleeding than traditional surgical techniques) 3. Severe cases (purulent exudate, trismus, facial swelling, fever): Irrigate under operculum with Monojet + warm saline, • Anesthesia (IA/ Lingual and Long Buccal), Exercise with scapel or laser Ibuprofen Dose Recommendation for Relief of Fever + Pain Child's Weight: 1. 50-75 lbs: 200 mg q 6-8 hrs 2. 75-96 lbs: 300 mg q 6-8 hrs 3. 96+ lbs: 400 mg q 6-8 hrs. Adult dose

J. Pyogenic granuloma (fibrous epulis) - inflammatory response to irritation + plaque Arises from interdental papillae, vascular + asymptomatic, associated with PREGNANCY

Etiology: inflammatory response to irritation + plaque Characteristics: Arises from interdental papillae, vascular + asymptomatic, associated with pregnancy Differential dx: peripheral ginat cell granuloma, peripheral ossifying fibroma Tx: surgical excision, meticulous oral hygiene

Parenting Style: A. AuthoriTATIVE: (high warmth/control): Mrs. Greatparent Best behavior -> lowest caries Parent characteristics: Firm limit-setting, Bidirectional communication, Warmth + Compassion Child: Self-confident, Used to limits + RULES, Handle novel situations/stress well Stategies: • Communication strategies alone • Lowest use of protective stabilization

Ex. Standards, enabling, flexible, guidelines, supportive, assertive, democratic, self-regulation Parent characteristics: • Firm limit-setting • Bidirectional communication • Warmth + Compassion Behavioral control, demandingness: High Responsiveness, warmth, supportiveness: High Child Characteristics: • Self-confident • Used to limits + rules • Handle novel situations/stress well • Most favorable behavior in dental setting • Lowest caries incidence Most consistently positive impact on children • Communicative strategies alone = most effective Stategies: • Communication strategies usually successful • Lowest use of protective stabilization compared to other parenting styles

Clinical Application of Space Maintenance Appliances 4. Loss of Primary 2nd Molar For: • Reserves space for permanent 2nd premolars • Distal root guides erupting permanent 1st molar into position Depends on situations: 1. PRIOR TO, OR DURING ERUPTION OF 1st PERMANENT MOLAR: Distal Shoe + Removeable Acrylic with Gingival Extension 2. AFTER ERUPTION OF PERMANENT 1st MOLAR: Any Appliance

For: • Reserves space for permanent 2nd premolars • Distal root guides erupting permanent 1st molar into position A. Lost prematurely -> permanent 1st molar migrate mesially within bone even before it emerges into oral cavity -> space-maintaining device needed • Guide eruption of permanent 1st molar into proper position after occlusion = established • Reserve space for 2nd premolar Depends on situations: 1. PRIOR TO, OR DURING ERUPTION OF 1st PERMANENT MOLAR: Appliances: 1. Distal shoe Preferred appliance: allows max control of situation Contraindications: Medically compromised (immuno-compromised), rheumatic fever or other heart abnormalities or any other condition that may be affected by oral bacteria entering circulatory system 2. Removeable Acrylic with Gingival Extension: For: 1st permanent molar close to eruption + distal shoe not indicated • Distal extension of a removable acrylic space maintainer represents distal aspect of crown of missing primary molar, which will guide eruption of permanent molar NOTE: Gingival extensions of this removable acrylic appliance don't t penetrate gingiva but exert pressure on gingiva just mesial to mesial marginal ridge of unerupted perm 1st M 2. AFTER ERUPTION OF PERMANENT 1st MOLAR Appliances: 1. Band + Loop: Unilateral situations; mx + md if patient's eruption sequence allows 2. Lingual Arch: Unilateral + Bilateral loss situation in mandible 3. Nance Holding Arch: Unilateral + Bilateral loss situation in maxillary 4. Transpalatal Arch: Unilateral loss situations in maxillary arch 5. Removable Acrylic: May be used but patient cooperation + other disadvantages of this appliance make it inferior to fixed appliances

Causes of Space Loss: 2. Extraction A. Posterior primary tooth: Not most prevalent cause of space loss B. Extraction of primary tooth -> Loss of arch integrity -> Drift of adjacent teeth -> Loss in arch length C. Process accelerated when: • Permanent tooth erupting adjacent to space -> Drift in empty space • Permanent tooth erupting next to prim tooth next to adjacent space -> drift D. Inadequate arch length to accommodate perm teeth -> Crowding

For: • Severe carious destruction • Necrosis of pulp + resulting abscess A. Entire posterior primary tooth -> Most obvious, though not most prevalent cause of space loss B. Extraction of primary tooth -> Loss of arch integrity -> Drift of adjacent teeth into space previously occupied by extracted tooth -> Loss in arch length C. Process accelerated when: • Permanent tooth erupting adjacent to space -> Tooth will tip or rotate to take up all part of space left by extracted prim tooth • Erupting perm tooth exerts force on prim tooth adjacent to edentulous space — both erupting permanent tooth + adjacent primary tooth will move into space D. Inadequate arch length to accommodate perm teeth -> Crowding • Severe cases, later erupting teeth may be completely crowded out of arch, + either fail to erupt or erupt ectopically

15. Sedation + General Anesthesia: NEITHER performed in UOP Peds A. Sedation

For: pre-cooperative, defiant, or disabled pts • Appropriate use for behavior that can't be management by other behavior guidance techniques, extensive tx, + medically complex pts Method: Oral (elixirs, pills), parenteral (injection), intravenous, + rectal A. Sedation - drug induced state of altered consciousness of varying degrees i. Minimal sedation/ anxiollysis: pts normally respond to verbal commands; cognitive function + coordination may be impaired, but ventilatory + CV functions unaffected ii. Moderate sedation: "conscious sedation"; pts respond purposefully to verbal commands either alone or by light tactile stimulation; no intervention req'd to maintain patent airway + spontaneous ventilation adequate iii. Deep sedation: depression of consciousness during which pts can't be easily aroused but respond purposefully after repeated verbal or painful stimulation; ability to independently maintain ventilatory function may be impaired; pts may require assistance in maintaining a patent airway + spontaneous ventilation may be inadequate • Cardiovascular function usually maintained • State of deep sedation may be accompanied by partial or complete loss of protective airway reflexes

Factors Influencing Space loss 4. Dental Development Teeth actively erupting adjacent to space left by premature loss of primary tooth -> more space loss Cases: 1. Premature loss of primary 2nd molar: perm 1st molar erupts into mesially tipped position 2. Premature loss of primary 1st molar: perm 1st molar exerts M force on primary 2nd molar -> Move 2nd primary molar mesially 3. Premature unilateral loss of primary canine: perm incisors erupt into space of primary incisors + lost primary canine

General: more space loss likely to occur if teeth actively erupting adjacent to space left by premature loss of primary tooth • Eruption of permanent 1st molar with significant attendant mesial force exerted on arch = particularly problematic + can promote space loss Common clinical situations exhibiting space loss: • Premature loss of primary 2nd molar: perm 1st molar erupts into mesially tipped position • Premature loss of primary 1st molar: perm 1st molar exerts mesial force on prim 2nd molar -> Move 2nd molar mesially • Premature unilateral loss of primary canine: perm incisors (significantly larger than prim incisors), erupt into space of primary incisors + lost primary canine • While perm incisors may appear "straight", dental midline of arch has been lost, + there is a loss of arch length, which will manifest when eruption of perm canines or premolars disturbed.

Clinical Procedures for Fixed Appliances: 1. Fitting the bands: • Band slides too easily -> too large • Band can't be pushed down -> too small • Tight interproximal contacts -> ortho separators for 7-10 days • Band pusher at mesial + distal marginal ridges -> seat band further cervically • Band seater for final seating • Occlusal band edges: 1 mm cervical to mesial + distal marginal ridges Peds Clinic: 3M Unitek Stainless Steel bands + Full arch impressions 2. Impression 3. Band removal: • Mn bands -> pliers on BUCCAL surface • Mx bands -> pliers on Lingual surface 4. Model preparation: Band must be fixed w/in impression before pouring up w/ stone 5. Lab correspondence: 7-10 days completed 6. Delivery - ASAP A. Cement appliance in place: rinse/dry bands -> polish -> GI to fill bands -> seat band B. Review post-op + appliance care instructions w/ pt + parents

Generally consist of wire soldered to ortho bands that cemented into place 1. Fitting the bands: • Select a band via trial-and-error • Band should be nearly seated on tooth w/ finger pressure • If bands slides down too easily, too large • If band can't be pushed down, too small • If tight interproximal contacts prevent appropriate size from seating, ortho separators can be used for 7-10 days to create space • Band pusher at mesial + distal marginal ridges -> seat band further cervically • Band seater for final seating by placing serrated metal tip on edges of band + having pt bite down or using finger pressure to seat • Contour band into any grooves + around marginal ridges: properly adapted band will fit tightly around tooth w/ no space visible b/w edges of band and tooth • Occlusal edges of band should be 1 mm cervical to mesial + distal marginal ridges Peds Clinic: 3M Unitek Stainless Steel bands 2. Impression: Full arch impressions required to give lab tech better idea of pt's dentition • Alginate or compound impressions 3. Band removal: band removing pliers used to remove bands after impression • Mn bands removed by placing tip of pliers on buccal surface • Mx bands removed by placing tip of pliers on lingual surface 4. Model preparation: Lab receives model with each band in place for fabrication of specific space maintainers, so band must be fixed w/in impression before pouring up w/ stone • Can use sticky wax or super glue to keep band in place w/in impression while pouring up • Band must be in appropriate position + stable before stone is vibrated into impression • Mn impressions should have tongue space as flat areas b/w alveolar ridges 5. Lab correspondence: must accurately describe space maintainer that you want to be fabricated, usually completed w/in 7-10 days 6. Delivery: Delivered as quickly as possible after premature loss of primary tooth to avoid excessive space closure, appt compliance = essential • Appliance tried in using same techniques as when fitting bands • Evaluate both fit of bands + wire position of appliance (often need to adjust wire position to improve the fit) A. Cement appliance in place: • Rinse + dry bands • Polish teeth with pumice, rinse, dry, + isolate teeth w/ cotton rolls or dri-angles c. • Use GI cement to fill bands • Seat bands on teeth using finger pressure, band pusher, + band seater (same as when fitted the appliance w/o cement) • Confirm correct adaptation & appliance fit before cement sets • Remove excess cement w/ explorer, scaler, and knotted floss B. Review post-op + appliance care instructions w/ pt + parents • Importance of good oral hygiene, avoidance of sticky foods or candy, necessity of follow-up care • Strongly discourage pt's desire to play with appliance w/ fingers + tongue • If appliance becomes loose or dislodged, pt brought in ASAP w/ appliance

Treatment Planning 1. Preventative Tx Plan Re-written every 6 mo at recall visits Must be regularly reviewed + revised

Goals: accommodate all variables unique to pt, coordinated with clinical findings, + prioritized to specific needs; establish expected tx outcomes • Will be altered as necessary down road based on success/failure of interventions, changed home circumstances, developmental changes, disease progression • Re-treatment plan every patient 6 months after last treatment plan, even if procedures on that treatment plan have not been completed 1. Preventative Tx Plan: identifies strategies for improving pt's health by alteration of risk factors + optimization of protective factors • Impt to understand practicality, understanding/compliance of pt + family • Should be specific, reasonable, measurable A. Must be "do-able" for pt + parents • Patient/parent capabilities - is your patient or their parent capable of following your recommendations? • Patient / parent attitudes + compliance (hint: think of parenting style, child's attention span + psychological developmental stage) • Potential barriers to compliance • Family structure around childcare - are you working with the parent who is available when your recommendations are to be carried out? Are there older siblings or other adults available in the household who can help? • Written as "problem -> intervention indicated" B. Brushing notes: • Brush after meals • Primary teeth decay much more quickly -> don't want food debris before bed • Enamel loss inconsequential due to perm teeth later C. Assess progress of preventative txt plan at each visit during parent interview • Helps monitor compliance + success -> timely alteration as necessary • Sends a message to parent that this is important, + not merely usual "brush & floss" talk which occurs only at recalls with no subsequent follow-up D. Goals addressed in prioritized manner: address most important initially E. Good preventative tx plan: scientifically sound, consider pt's medical, dental, social hx, disease indicators, risk factors, protective factors, caries risk + disease progression, intraoral exam + oral hygiene assessment, pt variables + fam dynamics F. Re-written every 6 mo at recall visits G. Must be regularly reviewed + revised • Reviewed at each subsequent visit • Review Previous Preventive Treatment Plan from Axium Notes • Parent / Patient Interview • Patient Exam & Evaluation • Revision of Preventive Treatment Plan • Presentation of Revised Preventive Treatment Plan to Patient / Paren

Periodontitis associated with systemic disease C. HIV Periodontitis

Hallmarks: severe pain, soft tissue necrosis, rapid bone loss Tx: root planing, perio surgery, CHX, frequent recalls

Appliance Types: 1. Band + Loop: Unilateral + fixed My notes: Missing Primary 1st molar -> attached to primary 2nd Missing Primary 2nd -> Attached to permanent 1st Uses: Mx or Mn - teeth adjacent to site must be present until unerupted tooth erupts Maintain space: 1. MAIN: Primary 1st molar before eruption of permanent 1st molar 2. Primary 1st or 2nd molar after 1st permanent molar erupted 3. Bilaterally lost single 1st primary molar w/ pair of band & loop space maintaners before eruption of permanent incisors to as succedaneous tooth Limitations: • Hold space of 1 tooth, • Loop position should be wide enough BL to allow for eruption of premolar + should be in close approximation to ridge w/o harming soft tissue • Below height of ridge contour + abuts anterior tooth at contact area Considerations: (General for all) 1. Time elapsed since loss: space closures usually occur w/in first 6 mo after ext 2. Dental age of pt: teeth erupt when 3⁄4 root development regardless of child's chronologic age 3. Amt of bone covering unerupted tooth • Erupting PM require ~4-5mo to move through 1 mm of bone 4. Sequence of tooth eruption: If 2nd primary molar lost prematurely + 1st permanent molar erupted, band loop tx based upon developing premolars Contraindications: Common: poor patient reliability, high caries risk, significant space deficiency + space loss Unique: • Abutment teeth will not be present until after eruption of premolar for which space being held • Other teeth in arch with questionable long term prognosis - bilateral appliances should be considered 3. Potential space loss from multiple adjacent primary tooth spaces 5. Anterior tooth loss 6. Primary second molar loss prior to the eruption of the permanent first molar

Image: Metal band + rectangular metal (Ped's sim lab) - unilateral fixed appliance for space maintenance in posterior segments (spans single tooth only) • Ortho band + SS wire • Wire loop cradles proximal surface of anterior abutment tooth, soldered to an ortho band attached to posterior abutment tooth • Prevents tipping or rotation of teeth adjacent to space • Restricted to holding space of 1 tooth because loop has limited strength (wire is cantilevered off of band) Uses: • Mx or Mn, requires that teeth adjacent to site must be present until unerupted tooth erupts 1. Maintain space of primary 1st molar before eruption of permanent 1st molar • Band fitted to primary 2nd molar, loop fitted to primary canine 2. Maintain space of primary 1st or 2nd molar after 1st permanent molar has erupted • Strongly consider bilateral appliance in this case 3. Maintain space of bilaterally lost single 1st primary molar w/ pair of band & loop space maintaners before eruption of permanent incisors to as succedaneous tooth buds will develop + erupt lingually to primary incisors Design: 1. Wire Loop: • Wide enough to accommodate erupting premolar • Lie below height of ridge to avoid unnecessary exposure of wire to chewing forces, etc. + just off of mucosa (should not contact mucosa) 2. Divot in wire should contact abutment tooth at proximal contact + cradle proximal surface of tooth 3. Solder joint on band • Should completely encircle wire • Shouldn't impinge on gingiva when band seated 4. Also available in various semi-fixed configurations Limitations: • Can only hold space of 1 tooth • Loop position should be wide enough BL to allow for eruption of premolar + should be in close approximation to ridge w/o harming soft tissue • Loop should be placed below height of ridge contour + abuts anterior tooth at contact area Considerations: 1. Time elapsed since loss: space closures usually occur w/in first 6 mo after ext 2. Dental age of pt: teeth erupt when 3⁄4 root development regardless of child's chronologic age 3. Amt of bone covering unerupted tooth: emergency of permanent tooth accelerated when less bone, + delayed when more bone covering tooth • Space maintenance indicated when tooth won't erupt for months • Erupting PM require ~4-5mo to move through 1 mm of bone 4. Sequence of tooth eruption: If 2nd primary molar lost prematurely + 1st permanent molar erupted, band loop tx based upon developing premolars Contraindications: Common: 1. Poor patient reliability where appliance may be lost to follow-up 2. High caries risk - presence of appliance may hinder patient home oral hygiene effectiveness 3. Cases where there is significant space deficiency - space regaining, sequential extraction of primary teeth (serial extraction) in preparation for ortho intervention, etc., may be indicated in lieu of space maintenance. 4. Significant space loss already occurred - space regaining necessary in these cases Unique: • Abutment teeth will not be present until after eruption of premolar for which space being held • Other teeth in arch with questionable long term prognosis - bilateral appliances should be considered 3. Potential space loss from multiple adjacent primary tooth spaces 5. Anterior tooth loss 6. Primary second molar loss prior to the eruption of the permanent first molar

Soft Tissue Problems: A. Recurrent Herpes Labialis Characteristics: vesicles erupt + form ulcerations with red halos on perioral + ATTACHED mucosa Tx: ANTIVIRALS in early stage, highly contagious • Systemic anti-virals = effective if caught in prodromal stage, but systemic Acyclovir + Valacyclovir not approved

Initial infection -> if symptomatic = Primary Herpetic Gingivostomatitis -> seen in kids 1st Subacute for most ppl 80-90% -> no symptoms -> thus not every Pt will report infection as a child Etiology: Herpes Simplex Virus -> from symptomatic or asymptomatic initial infection -> Virus lies dormant in trigeminal ganglion until various triggers induce re-infection Etiology: secondary presentation of herpes simplex virus triggered by stress, trauma, UV light o Initial infection (if symptomatic) = primary hepatic gingivitis Characteristics: vesicles erupt + form ulcerations with red halos on perioral + ATTACHED mucosa Tx: palliative + ANTIVIRALS if caught in early stage • Try NOT to treat pt if see active lesions (highly contagious) • Systemic anti-virals = effective if caught in prodromal stage, but systemic Acyclovir + Valacyclovir not approved in children

Subsequent Visits

Look for changed circumstances at home (diff caretaker, additional children in family, increasing child autonomy), reinforce previous info, ask if help is needed with OH, re-evaluate OH maintenance (disclosing tablets or plaque index, look for demineralization, esp in cervical area), made adjustments to preventative tx plan (based on compliance, changed findings, risk assessment, or home circumstances), reevaluate fluoride and further tx needs

Causes of Space Loss: 3. Ectopic eruption - abnormal position Impaction - blocked More common: Maxillary 1st permanent molars + canine -> Md canine, 2nd PM -> Mx lateral incisors A. Md Lateral Incisor • Most common in mandible -> Premature primary canine exfoliation + Midline shift B. Mx 1st M: Tooth germ downward, backward, outward -> vertical position as erupts Factors that cause ectopic eruption

More common: Maxillary 1st permanent molars + canine -> Md canine, 2nd PM -> Mx lateral incisors Ectopic eruption - eruption of tooth in abnormal position Ectopic Impaction - tooth can't erupt because something impedes it, not because of ectopic position A. Mandibular Lateral Incisor • Ectopic eruption of permanent lateral incisor: • Most common in mandible -> resorb all or portion of primary canine root -> Premature primary canine exfoliation + Midline shift to side of ectopic eruption or impeded eruption of lateral incisor B. Mx 1st M: cause not known, tooth germ oriented downward, backward + outward before erupting → more vertical position as it erupts Factors that cause ectopic eruption: 1. Discrepancies in bone tooth size 2. Alteration in chronology of bone growth at tuberosity region in relation to calcification + eruption of molar 3. Unfavorable prim 2nd M crown morphology 4. Abnormal eruption angle of perm 1st M 5. Heredity 6. Early diagnosis + treatment -> prevent/ minimize space loss Tx: • Active appliance to upright perm 1st M • Subsequent space maintenance if prim 2nd M is extracted/ exfoliates prematurely

1. Systemic Fluoride Most Common Rx Supplements 1. NaF solution (0.125 mg F/drop) - drop placed in mouth at bedtime 2. NaF tablets (1 mg F/tablet) - chew one tablet, swish + swallow before bedine + after brushing

Most common Rx supplements: 1. NaF solution (0.125 mg F/drop) - drop placed in mouth at bedtime 2. NaF tablets (1 mg F/tablet) - chew one tablet, swish + swallow before bedine + after brushing

Periodontitis associated with systemic disease D. Leukemias Most common in children: Acute lymphocytic leukemia (ALL) Characteristics: LOA due to inability to fight infection, swollen gingiva due to leukocyte infiltration, bleeding gingiva due to decreased platelets, BLUISH gingiva due to anemia, and pain Tx: Trivalent rinse (topical anesthetic, coating agent like milk of magnesia, + Benadryl)

Most common type in children: Acute lymphocytic leukemia (ALL) due to over production of non-functional lymphocytes Characteristics: LOA due to inability to fight infection, swollen gingiva due to leukocyte infiltration, bleeding gingiva due to decreased platelets, bluish gingiva due to anemia, and pain Tx: relieve pain, maintain good oral hygiene, trivalent rinse (topical anesthetic, coating agent like milk of magnesia, + Benadryl) to manage oral mucositis discomfort, conservative management + good OHI during remission Mucositis -> epithelial cells killed -> very painful Trivalent rinse -> topical anesthetic, Coating agent - Milk of Magnesia; Benadryl - used to manage discomfort assoc. w/oral mucositis Remission Phase: Use conservative managem. during remission, OHI, scale/prophy, w/goal of decreasing soft tissue inflamm. (gingivitis).

Causes of Space Loss: 5. Trauma A. Loss of PRIMARY INCISORS prior to eruption of PRIMARY CANINE -> space loss Short period -> low incidence B. Loss of PRIMARY CANINE -> rare -> arch length + space loss + midline shift C. Loss of multiple anterior primary teeth -> abnormal tongue position during swallowing + speech aberrations

Most common: Anterior teeth • Actual space loss due to traumatic loss of prim incisors = uncommon, but possible, depending on timing of that loss • Drifting of adjacent teeth to lost tooth/teeth may alter eruption path of permanent teeth + may present an esthetic problem A. Loss of prim incisors prior to eruption of prim canine -> space loss If time period short -> low incidence B. Loss of prim canine -> rare -> arch length + space loss + midline shift Consider space maintenance for child with active digit habit, as it may reduce space for erupting permanent incisor C. Loss of multiple anterior primary teeth -> abnormal tongue position during swallowing + speech aberrations • Esthetics concern → Addressed with appliances that don't perform space maintenance function

B. Permissive (high warmth/low control) - Mr. Laidback -> spoiled Parent: no behavioral limits, no rules, spoil Child: Opposite to Authoritative Most frequent + challenging behavior guidance issues -> high caries risk Strategies: • Negative patient perception of treatment • Adjuncts (N2O, sedation, etc.) • Most frequent need for protective stabilization

Most frequent, challenging behavior issues; more advanced techniques needed Ex. You're the boss, appeasement, no guidelines, blurred roles, over-involved, indulgent, lenient Parent Characteristics: • No behavioral limits + provides few if any commands • No rules/no responsibility • "Spoil" or "coddle" Behavioral control, demandingness: Low Responsiveness, warmth, supportiveness: High Child characteristics: • Undisciplined • Challenging behavior • Negative reaction to novel situations/stress • Least favorable behavior in dental setting; most frequent & challenging behavior • High caries incidence • React more negatively to these techniques as evidenced by excessive/dangerous hand + foot movement during treatment Strategies: • Negative patient perception of treatment • Adjuncts (N2O, sedation, etc.) most often needed compared to other groups • Most frequent need for protective stabilization

13. Hand-Over Mouth Exercise (HOME) - NEVER USED

NEVER USED • Used in screaming children who're attempting to block out operator's request • Controversial + not well accepted, removed from AAPD guidelines

Factors Influencing Space loss 2. Oral Habits A. Nonnutritive sucking behavior (NNSB) Clinical findings: • Proclined MAXILLARY INCISORS • Retrocline, upright MANDIBULAR INCISORS • Posterior crossbite (either unilateral or bilateral) • High arched palate; U or V SHAPE • Anterior open bite • Calluses or other dermatologic irritation of offending thumb or digit • Deformation of nose in severe cases

Nonnutritive sucking behavior (NNSB) - habitual sucking of digits, pacifiers, or other objects without deriving any nourishment from them • Comfort habit to provide security + calmness • Cause abnormal forces on dental arch + responsible for initiating tooth loss of arch length after premature loss of primary teeth Clinical findings: • Proclined MAXILLARY INCISORS • Retrocline, upright MANDIBULAR INCISORS • Posterior crossbite (either unilateral or bilateral) • High arched palate; U or V SHAPE • Anterior open bite • Calluses or other dermatologic irritation of offending thumb or digit • Deformation of nose in severe cases

Appropriate recommendation for fluoride needs based on caries risk + current fluoride exposure: Caries Risk Assessment: 1. Systemic Fluoride - Based on source of DRINKING WATER • Systemic benefit occurs during calcification of crowns of permanent teeth NOTE: Fluoridated drinking water offers both systemic (primary) + topical effects (topical (during permanent tooth development)

OTC + professionally prescribed and/or applied) Caries Risk Assessment: See #6 of this section A. Diet (High in cariogenic foods, sugar; Frequency + duration of exposure to them), OH practice, present caries activity, past caries history, predisposing conditions (tooth morphology, medications), pt/ parent compliance 1. Systemic Fluoride • Systemic benefit occurs during calcification of crowns of permanent teeth • More effects on developing teeth • Current exposure: based on source of drinking water (consider all sources, at home + elsewhere, pediatric vitamins containing fluoride, prepared foods, filtered + bottled water, etc. Note that water filters may remove fluoride, usually ones that are installed do but ones that attach to the sink or are in a pitcher do not), supplementation, + clinical signs of fluorosis • Water fluoridation targets whole population without regard to caries risk status or a child's access to healthcare • As of 2012, 60% of country's pop has access to fluoridated water • A significant # of pediatric pts (10-50%) drink exclusively bottled or vended, non-fluoridated water, even if they live in a community with municipally fluoridated tap water NOTE: Fluoridated drinking water offers both systemic (primary) + topical effects (topical (during permanent tooth development)

A. Infant: 0-15 months Object Permanence: Following Play: banging -> peek a boo Receptive Language: Turning to voice Expressive Language: Distinct cries -> single words General Characteristics: • 6 mos: Teething -> chewing • Maternal Ab decreases (start to get sick) • "Pre-cooperative" • SDF can be recommended • GA for extensive treatment

Object Permanence: Fixation w/o following -> following -> Finding hidden object Play: banging -> shaking -> dropping -> mouth -> visual inspection -> "peek a boo" Receptive Language: Turning to voice -> searching for speaker visually -> responding to own name + tone of voice -> listening selectively to familiar words + responding to "no" + other verbal requests Expressive Language: Distinct cries -> babbling -> distinct syllables -> 1st real word -> multiple single words (uses words to express needs) Other General Characteristics: • By 6 mos: Teething -> chewing • Maternal Ab decreases (start to get sick) • "Pre-cooperative" - lacks cooperative behavior • Stranger anxiety • Pathology • Trauma • SDF can be recommended for minor decay • GA for extensive treatment Dental: • Dental intervention usually informational/preventive - off bottle/breast by 1 year of age • Gather info about home situation, caretakers, etc. (risk assessment) preventive information should be focused toward parent, but demonstrating techniques (tooth brushing, etc.) on child can be very effective strategy for teaching parents may be seen for trauma or pathologic conditions for moderate to major dental needs • General anesthesia in a hospital setting may be a good option • Inadequate fine motor skills to adequately brush teeth without supervision + assistance

D. Neglectful/uninvolved (Low warmth/control) Parent - "Disengaged", emotionally detached, uninvolved Child: attention seeking, very little concrete info Strategies: variable since little concrete info

Parent characteristics: "Disengaged", emotionally detached, uninvolved parents Difficult study population so implications not well researched Ex. distance, uninterested, neglectful, absent, passive Behavioral control, demandingness: Low Responsiveness, warmth, supportiveness: Low Child characteristics: • Attention- seeking behavior or distrustful of others • Very little concrete information for this group Strategies: • Very little concrete info for this group • Variable success with strategies

Lecture: Diagnosis of Soft Tissue + Perio Problems Poll Everywhere Questions

Poll everywhere: Gingival enlargement -> drug associated: Dilantin 2. Which feature of Trisomy 21 contributes to periodontal problems: All above?: Neutrophil function, hypotonia, malocclusion (Answer might just be malocclusion) 3. Why important to differentiate between recurrent herpes labialis + aphthous ulcers: herpes is contagious

Gingivitis Associated with Systemic Health A. Gingivitis Associated with Dental Plaque (Chronic Gingivitis) - RED, INFLAMED GINGIVA + BULBOUS ROLLED MARGINAL CONTOURS Prevalence increases with age: <5% at 3, 50% at 6, 90% at 11 • Bacterial flora: ASFTP • ALWAYS associated with plaque

Prevalence increases with age: <5% at 3, 50% at 6, 90% at 11 • Bacterial flora: Actinomyces, Streptococcus, Fusobacterium, Treponema, P. Intermedia • ALWAYS associated with plaque Factors: • Poor oral hygiene: chronic home oral hygiene measured by presence of gingivitis by RED, INFLAMED GINGIVA + BULBOUS ROLLED MARGINAL CONTOURS • Malposed, exfoliating, erupting teeth • Carious teeth (although chronic gingivitis isn't necessarily associated with caries due to competitive inhibition of S. mutans by perio bacteria) • Food impaction • Mouth breathing Sidenote: S. mutans - antagonistic with many perio pathogens so children with many caries -> little gingivitis SSCs due to marginal discrepancies + altered coronal contours Usually DOESN'T progress to periodontitis unless OH remains unchanged

Occlusal Examination: 2. Canine Classification: A. Primary Canine Relationship: Trend: maxillary canine in relation to distal part of mandibular canine (Image: distal -> mesial) i. Class I - cusp tip of maxillary primary canine is in the same vertical plane as the distal surface of the mandibular primary canine Image: Maxillary canine tip behind mandibular ii. Class II - any relationship mand. canine distal to Class I Image: Maxillary canine in front of mandibular canine iii. Class III - any relationship mand. canine mesial to Class I Image: Maxillary canine way behind mandibular canine

Primary/permanent, left/right; Angle Class I, II, III; best predictor of sagittal relationship into permanent dentition

Caries Progression: Early cervical lesions (maxillary incisors) -> Clinically evident lesions -> Severe carious lesions

Related to Inappropriate Bottle Use: 1. Early cervical lesions • Demineralization and/or cavitation, limited to maxillary incisors 2. Clinically evident lesions • Maxillary incisors more severely involved, posterior teeth carious 3. Severe carious lesions • Maxillary incisors destroyed, severe caries, possible abscess formation molars ECC Caries Progression: 1. Plaque - accumulates at cervical 2. Demineralization - starts at cervical, progresses incisally 3. Early cavitation - starts at cervical, progresses incisally 4. Frank carious lesions -> loss of tooth structure

Space Maintainers: Passive Desirable characteristics: 1. PASSIVE 2. NO interference, eruption, irritation/soft tissue damage 3. Easily cleansable 4. Durable, strong, stable 5. Readily adjustable 6. Accommodate transitioning dentition until no longer needed

Space maintenance appliances = passive - not intended to + shouldn't move teeth Desirable characteristics: 1. PASSIVE Should not exert any forces on teeth, only purpose = to hold 2. NO interference with occlusion • Ideally replace missing tooth in occlusion, but most fixed + semi-fixed appliances can't accomplish this goal 3. NO interference with eruption 4. NO irritation/ damage to soft tissue 5. Easily cleansable 6. Durable, strong, stable 7. Readily adjustable • To facilitate post-extraction delivery • Useful if minor tooth mvmt has occurred between time that tooth was prematurely lost + delivery of appliances, which can occur in a week or less 8. Accommodate transitioning dentition until no longer needed • Need to understand eruption sequence (eg. don't attach appliance to a tooth that will exfoliate) • Need to consider prognosis of teeth to be used (ef. Don't use severely compromised tooth)

Parenting Style: Study: Patient's behavior + dental caries incidence CORRELATED with parenting style

Study: communicative strategies (tell-show-do, voice control or modulation, distraction + positive reinforcement potentially effective with all children) regardless of parenting style Study: Patient's behavior + dental caries incidence can be correlated with parenting style in the child's household

Periodontitis associated with systemic disease A. Diabetes Mellitus Type 1 (greater risk) - 10% risk of periodontitis in 13-19 yo Type 2 - 1% risk of periodontitis • Neutrophil defect

Type 1 - insulin dependent, 10% risk of periodontitis in 13-19 yo Type 2 - non-insulin dependent, 1% risk of periodontitis • Related to neutrophil defect that causes altered + suppressed immune response • Tx: aggressive oral hygiene

Causes of Space Loss: 1. Caries A. Eruption of Lower Lateral Incisors: Untreated interproximal caries -> M drifting of permanent 1st Molars + D drifting of lower primary molars

Untreated extensive interproximal caries -> mesial drifting of permanent 1st M +distal drifting of lower primary molars during eruption of lower lateral incisors • Clinically less dramatic appearance of space loss compared to extraction, but far more prevalent + may result in greater space loss cumulatively, as it can occur throughout whole primary dentition • Drift + resultant space loss accelerated when pt = at developmental stage where an erupting permanent tooth exerts force on adjacent primary teeth, moving primary teeth until they're again in proximal contact

1. Systemic Fluoride Recommendations: Based on fluoridation status of drinking water Drinking H2O flouride: 0.7 ppm

Usually based on fluoridation status of drinking water Rec for fluoride conc in drinking water: 0.7 ppm • OTC: few options available except for vitamins, which can result in excess fluoride ingestion + fluorosis • Rx: ALWAYS based on pt's current exposure to fluoride in drinking water • Always ask about pt's multi-vitamins, some might contain fluoride, or has been fluoride from another source • Source of drinking water outside of home (ask for sample of water for assay if necessary), don't assume that pt is drinking tap water, some may just drink water bottle. • Consider other sources of drinking water for the pt + whether or not alternate sources might be fluoridated • Doses based on pt's age + ambient exposure + systemic fluoride can be dispensed as chewable tablets, lozenges, or liquid

Factors when space maintenance considered after premature loss of primary teeth: 4. Which Tooth Lost D. Primary 2nd molar i. Lost prior to eruption of permanent 1st molar: Erupting 1st molar -> missing guide plane, mesial position/tipped ii. Primary 1st molar present -> intra-tissue space maintenance appliance (distal shoe) iii. Lost after eruption of permanent 1st molar: space maintenance

i. Lost prior to eruption of perm 1st molar: Erupting perm 1st molar missing its guide plane, + will erupt in mesial position + mesially tipped at expense of arch length ii. If prim 1st molar is present in that quadrant -> intra-tissue space maintenance appliance (distal shoe) should be considered to provide a guide plane for erupting permanent 1st molar iii. Lost after eruption of perm 1st molar: space maintenance to prevent mesial tipping of permanent molar into space left by prim 2nd molar • The eruptive pattern + sequence of other teeth in arch must be carefully considered to prescribe an appropriate space maintenance appliance which will remain effective until eruption of 2nd premolar

Factors when space maintenance considered after premature loss of primary teeth: 4. Which Tooth Lost C. Primary 1st molar Lost: i. Prior to permanent 1st molar eruption -> space maintenance ii. After -> monitor if stable occlusion iii. Permanent 1st molar hasn't completed eruption (still exerting mesial force on primary 2nd molar) -> immediate space maintenance

i. Lost prior to eruption of perm 1st molar: space maintenance to stabilize arch -> help primary 2nd molar withstand mesial force exerted upon it from erupting 1st molar ii. Lost after eruption of perm 1st molar: if perm 1st molar + prim 2nd molar erupted + in stable occlusion, arch monitored for signs of space loss • Space maintenance doesn't need to be placed immediately. iii. Perm 1st molar hasn't completed eruption (still exerting mesial force on prim 2nd molar) -> immediate space maintenance indicated.

Barriers (cont'd) 2. Environment

• Access to care barrier have significant impact on care seeking behaviors + past care experiences of pts: • Financial hardships • Inadequate resources to pay for oral health care • Inability to find a practitioner who will accept pt's insurance or public assistance program • Perceived lack of accessible care providers in a patient's neighborhood or general area • Lack of transportation to health care providers • Lack of sibling childcare Effect: Delay of treatment and/or avoidance of care, even when an oral health problem is recognized by the parent.

Euphenisms Hard: • Dental Explorer • Etchant • Topical Fluoride • Highspeed Handpiece - tooth cleaner, whistle • Matrix • Molt Mouth Prop • Needle

• Air-water syringe - wind, air, squirt gun • Alginate material - Pudding, dough, cake mix • Alloy - Silver star, silver filling • Anesthetic - Sleepy juice • Blood - Red, heme, pink • Caries / Decay - Tooth bugs, sugar bugs, germs, sick tooth, spot • Dental Explorer - Tooth counter, tooth feeler • Etchant - Blue paint, blue shampoo • Evacuator - Vacuum cleaner, Mr. Thirsty • Extraction - Wiggle the tooth, sunshine • Topical Fluoride - Tooth vitamins • Highspeed Handpiece - Tooth cleaner, water whistle, Mr. Whistle • Hurt / Pain - Bother, discomfort, uncomfortable, "owie" • Isolite - Nemo tail of Fish tail • Matrix - Fence for star • Molt Mouth Prop - Tooth pillow • Needle - Straw

Factors Influencing Space loss 3. Existing Malocclusion Class II Division 1

• Arch length inadequacies • Inadequate space • Unstable molar classification + other forms of malocclusion (Class II, division 1) -> Potentially unstable dental arch + can promote space loss. • These characteristics usually become more severe after premature loss of mandibular primary teeth

Oral Hygiene History: Prevention/Recall Visits Recommendations should always be specific to patient, not just their age UOP: Provide: • Toothbrush, appropriately sized for their age + children's fluoridated toothpaste • Provide floss + flossing aid (FlossMan®) • Specific brushing + flossing instructions

• At each Prevention or Recall visit, you will assess pediatric patient's brushing + flossing ability + effectiveness, then instruct them and/or parent based upon child's ability with each task • Will see variability in age in which children have necessary fine motor skills to successfully brush + successfully floss, but your recommendations should always be specific to your patient, not just their age UOP: Provide: • Toothbrush, appropriately sized for their age + children's fluoridated toothpaste • Provide floss + flossing aid (FlossMan®) • We use these items for patient/parent instruction + then send them home with patient. • Specific brushing + flossing instructions based upon patient's abilities, caries risk, + success or challenge with a previous preventive treatment plan • Timing of brushing/flossing = integral part of info shared with patients + parents as part of prevention or recall appointments • If oral hygiene = significant challenge for patient, this info + preventive treatment plan will be reviewed at all subsequent visits, even if they are for procedures other than prevention or recall.

Considerations for Initial Office Visit 3. Patient's privacy • Sensitivity of info • Voice level • Others nearby • Suitable location

• Be conscious of your voice level + others nearby who may overhear your discussion with parent. • Try to speak in a quiet voice + find an area somewhat removed from others in reception area if at all possible • If you anticipate discussing sensitive topics (ex: an absent parent, history of abuse, potentially sensitive areas of the medical history, etc.) make arrangements in advance to speak with parent in a more private area • Our clinic staff will help you find a suitable location in these situations.

Gingivitis associated with Systemic Disease A. Drug Induced Location: Papillary areas -> facial of anterior teeth • NOT DOSE RELATED Drugs: 1. Dilantin - seizure disorders, 50% users 2. Cyclosporin - immunosuppressant, 25% users 3. Ca2+ channel blockers - hypertension + angina, rare

• Begins in papillary areas, facial of anterior teeth most affected with minimal BOP • Poor oral hygiene exacerbates tissue enlargement • Resolves when causative drug discontinued • NOT DOSE RELATED Drugs: 1. Dilantin - seizure disorders, 50% users 2. Cyclosporin - immunosuppressant, 25% users 3. Calcium channel blockers - hypertension and angina, rare Treatment: meticulous oral hygiene, surgical intervention if fxl or esthetic concern, drug substitution, positive pressure appliance (placed at first signs of enlargement or following surgery)

Considerations for Initial Office Visit 8. Diet History A. Development of preventative tx plan B. Follow up at subsequent appts is critical: UOP: All new patients + parents receive preventive session on 2nd visit to clinic Focuses: • Patient's specific preventive needs from ODTP last appt. • Diet + dietary behavior recommendations

• Both diet + behaviors must be addressed to successfully reduce patient's caries risk • Discussion w/ parent: roles of sugars + cariogenic foods + drinks in diet, frequency & duration of snacking, suggestions for nutrition & non-cariogenic snacks • Stress oral hygiene measures after any food intake, linking oral cleansing w/ reduction in snacking on cariogenic foods A. Development of preventative tx plan • Altering dietary behavior by linking oral cleansing (brushing, drinking water or rinsing after meals or snacks) with reduction in the number and cariogenicity of snack foods and beverages • All patients + parents should receive brief discussion of role of fermentable carbohydrates + other cariogenic foods + drinks in the diet, including meals + snacks • Suggestions should be made for nutritional, non-cariogenic foods + drinks. B. Follow up at subsequent appts is critical: shows compliance + success of preventative tx plan, reinforces to pt + parent that nutrition & good OH are paramount to health • If compliance found to be lacking in certain areas of preventive treatment plan, cause for poor compliance should be investigated with parent + patient, + appropriate alterations suggested. • This underscores importance of providing specific, individualized recommendations. UOP: all new patients + parents receive preventive session on 2nd visit to clinic, which focuses on that patient's specific preventive needs as determined at ODTP appointment Diet and dietary behavior recommendations = significant components of this session

4. Adolescent: Formal operational (>11 years) - able to think literally + figuratively, abstract + complex thinking Characteristics: • Rapid physical, emotional + social change -> puberty • Heightened self-awareness • Peer status • Priorities shift • Preventative habits may deteriorate due to distractions -> increase frequency of recalls, re-involve parents in home care, look for alternate preventive strategies • Procedures as with adults -> anxious • Sports, trauma risk • Severe behavior problems difficult, may require psychological intervention

• Can process things as adults do • Adolescent can transcend concrete situation + think about future Intro: • Marked by turmoil in many/most areas of child's life • Puberty to reach sexual maturity + manage attendant societal expectations + demands that result • Independence becomes central focus as child tests their abilities to manage in society at large • Peer influence supplants that of family or other adults or institutions in the child's life • Profound social development Clinical Applications: • Ramifications of actions today can be related to long term consequences • Assign at least part of responsibility for outcomes to patient Characteristics: • Rapid physical, emotional + social change • Heightened self-awareness • Peer status • Priorities shift • Preventative habits may deteriorate due to distractions -> increase frequency of recalls, re-involve parents in home care, look for alternate preventive strategies • Procedures as with adults but may be anxious • Sports, trauma risk • Severe behavior problems difficult, may require psychological intervention

High Caries-Risk Intervention: • Anticipatory guidance • 3-4 month recall • ITR or SDF if appropriate to arrest caries

• Carious lesions • White spot lesions/demineralized areas • Visible plaque • Inappropriate bottle/sippy cup use • No or sporadic home oral hygiene • Mom has active/untreated caries • Older siblings have history of ECC • Impaired saliva composition or flow • Frequent (3 or more) between meal exposures to simple sugars or refined carbs • Chronic meds that may include sugar or impact saliva • High S. mutans titers (requires saliva test) Intervention: • Anticipatory guidance • 3-4 month recall • Fluoride varnish • ITR or SDF if appropriate to arrest caries • Consider suggesting use of OTC fluoride rinses before bed or higher dose topical fluoride under strict supervision* • *if appropriate supervision = unlikely this may not be a good option • Consider supplementation of systemic fluoride (drops/tablets) if primary drinking water is non-fluoridated • Inquire about care-taker assistance

Psychological Development Milestones: 1. Infant/Toddler: Sensorimotor (Birth-2) - uses senses + movements - physical stimulation rather than logical reasoning

• Child begins to interact with environment Clinical Applications: • Very little verbal/cognitive interaction with patients; safety + efficiency = prioritized • Important to explain this approach to parents • Responsibility for outcome lies with dentist + parent Behavioral guidance age ranges: Infant + Toddler

1st Dental Visit 1st DENTAL VISIT SHOULD OCCUR WHEN 1ST TEETH ERUPT + IDEALLY A DENTAL HOME SHOULD BE ESTABLISHED BY AGE 1 Trend: Early dental home -> fewer treatments needed + less cost of care

• Children with early dental home tend -> fewer treatment needs, resultant cost of care significantly less than children who establish a dental home late FIRST DENTAL VISIT SHOULD OCCUR WHEN 1ST TEETH ERUPT + IDEALLY A DENTAL HOME SHOULD BE ESTABLISHED BY AGE 1 • Brief, but thorough knee-to-knee oral exam • Anticipatory guidance + OHI

Pacific Pediatric Clinic policies + procedures relating to behavior guidance.

• TellShowDo (TSD) + KneetoKnee Exams widely used • Passive restraint always used during key points in procedure (ie. injection, prepping) • Protective stabilization with Papoose board often used for long procedures or for pts who need extra restraint for their own and dental team's safety • Molt mouth prop used for the extraoral control • Hidden syringe technique

Gingivitis Associated with Systemic Health: C. Necrotizing Ulcerative Gingivitis (NUG) NO LOA Sidenote: Hydrogen peroxide not superior to other oral rinses (CHX, Listerine) as an anti-plaque agent UOP preference: CHX rinse instead of hydrogen peroxide

• Common in Asia, Africa, + South America • Associated with poor oral hygiene, emotional stress, fatigue, decreased resistance to infection, malnutrition, smoking, pre-existing gingivitis Diagnostic Features: gingival bleeding, pain, necrosis of interproximal papillae, NO LOA (difference to Necrotizing Ulcerative Periodontitis), lymphadenopathy, malaise, pseudomembrane, fetor ex oris Treatment: meticulous oral hygiene, 0.12% CHX, antibiotics if infection present, elimination of risk factors Sidenote: Hydrogen peroxide not superior to other oral rinses (CHX, Listerine) as an anti-plaque agent • Hydrogen peroxide - oxidizing agent -> other rinses aren't -> carries potential to cause harm, esp. if used chronically • Episodic, short-duration oral use of hydrogen peroxide carries less risk, but still doesn't offer superior results to other oral rinses. • Perio textbook suggests that for Tx of NUG either diluted hydrogen peroxide -> equal mix of water & 3% hydrogen peroxide OR 0.12% CHX solt'n appropr. • Note that this Tx regimen doesn't call for chronic, long term use of rinsing protocol. UOP preference: CHX rinse instead of hydrogen peroxide

Parent acceptance of various behavior management techniques

• Decreasing parent acceptance of voice control techniques • HOME technique not accepted well by parents

4. Tx Plan Presentation: Informed Consent D. Fees (Last)

• Defer this to end of presentation to give parents an idea of what procedures = required + to avoid parents thinking only in terms of cost throughout your presentation • Always be sure that parent understands that fees may have to be adjusted based on unexpected findings (both good and bad!) • Try to determine what insurance benefits are applicable (may be helpful to suggest that parent bring this information with them) • Explain your policy on billing, any available payment arrangements, etc.

Factors when space maintenance considered after premature loss of primary teeth: 8. Congenital absence of permanent teeth Factors: 1. Age Trend: younger pt -> more severe loss of space/complex situation 2. Type of malocclusion 3. Future restorative txt 4. Multidisciplinary team 5. Parents decision for future txt 6. Cost

• Dentist decides whether to hold space until fixed replacement can be provided or allow space to close when primary tooth lost prematurely Factors to be considered when prim teeth have been lost + there congenitally missing teeth: 1. Age of pt. Trend: younger the pt, more severe loss of space + more complex situation 2. Type of malocclusion 3. Choice of future restorative txt 4. A multidisciplinary team of dentists should evaluate pt before arriving at final diagnosis + txt plan (oral surgery, pediatric dentist, prosthodontist, periodontist, orthodontist, etc) 5. Parents decision for future txt 6. Cost of txt

Factors when space maintenance considered after premature loss of primary teeth: 9. Arch length vs Tooth structure Discrepancies A. Amt of permanent tooth structure to be accommodated (measured as mesio-distal dimension of unerupted permanent canine + premolar) B. Alveolar bone of ridge (measured linearly along crest of tooth bearing portion of ridge)

• Discrepancies between amt of permanent tooth structure to be accommodated (measured as mesio-distal dimension of unerupted permanent canine + premolar) + alveolar bone of the ridge (measured linearly along crest of tooth bearing portion of ridge) = Important diagnostic considerations for space management → Predicts whether pt will experience dental crowding or excess space, + quantifies any discrepancies predicted • Prediction of relationship between 2 variables prior to eruption of permanent canines + premolars = invaluable. • Prediction done using mixed dentition analysis, estimating mesio-distal width of unerupted canine + premolars • Using statistical correlation to dimensions of erupted mandibular permanent incisors, + comparing this estimation to measured dimension of alveolar ridge available for erupting teeth

Gingivitis Associated with Systemic Health: B. Pubertal Gingivitis - P. intermedia

• Due to increased levels of estrogen + progesterone, which causes overgrowth of P. intermedia Factors: • Decline in oral hygiene common in this age group • Ortho appliances complicate oral hygiene

Clinical Application of Space Maintenance Appliances 2. Loss of Primary Canine A. NO MIDLINE SHIFT - MINIMAL INTERCANINE CROWDING (<2.0 mm) ARCH CLASS I OCCLUSION Treatment: Extract remaining primary canine + place LINGUAL ARCH -> Prevent lingual tipping of lower anterior teeth + shifting of midline B. NO MIDLINE SHIFT - SIGNIFICANT INTERCANINE CROWDING (>2.0mm) - ARCH CLASS I OCCLUSION Treatment: Arch length analysis -> discrepancy 3-4 mm -> ortho consultation prior to therapy

• Erupting/ crowded perm incisor teeth tend to shift laterally into resulting space -> Midline deviation + dental asymmetry • Tendency accelerated at time permanent incisors begin to erupt, but can also develop within primary dentition • However, incidence of these teeth losing is low • Depends on situations -> institute space maintenance 1. NO MIDLINE SHIFT - MINIMAL INTERCANINE CROWDING (<2.0 mm) ARCH CLASS I OCCLUSION Treatment: Extract remaining primary canine + place a lingual arch -> Prevent lingual tipping of lower anterior teeth + shifting of midline 2. NO MIDLINE SHIFT - SIGNIFICANT INTERCANINE CROWDING (>2.0mm) - ARCH CLASS I OCCLUSION Treatment: Do an arch length analysis to determine if significant posterior space discrepancy - a discrepancy of 3-4 mm would indicate an ortho consultation prior to therapy • If there = no posterior space discrepancy -> extract remaining primary canine + place lingual arch appliance, which will prevent lingual tipping of lower permanent anterior teeth + shifting of midline MIDLINE SHIFT: • Usually caused by severe intercanine space insufficiency + ortho consultation indicated

Factors when space maintenance considered after premature loss of primary teeth: 6. Sequence of Eruption of Teeth

• Essential for appropriate diagnosis + treatment planning around space management issues • Not every pt follows expected sequence, so individual assessment necessary • Sequence of eruption influences forces which remaining teeth will have to withstand after premature loss of a tooth • Transition between prim + perm dentition exerts different forces on teeth at different dev times • Sequence of eruption will also influence type of appliance which will be effective, if an appliance is to be used to maintain space. • Designing an appliance around a tooth or teeth, which will be lost prior to predicted eruption of tooth for which space is being held, will not result in successful space maintenance

Lecture: Pediatric Behavioral Guidance Goals to increase potential for child to become cooperative + accepting patient:

• Establish communication • Alleviate fear + anxiety • Deliver quality dental care • Build a trusting relationship between dentist, child, + parent • Promote child's positive attitude towards oral + dental health & oral health care

4. Tx Plan Presentation: Informed Consent C. # of appt (Range)

• Explain concept of "quadrant dentistry" if appropriate • Explain that progress at each appointment will be based on child's cooperation, etc. • Usually best to give a range (i.e. 3 to 5 appointments) instead of specific # • Make sure that your expectations regarding promptness, "no-shows," cancellations, etc. = clear to parents along with consequences for appointment non-compliance

Factors when space maintenance considered after premature loss of primary teeth: 5. Amount of alveolar bone covering permanent successor Bone covering unerupted premolar -> bone scar -> delayed premolar -> space maintenance Premolars: 4-5 MONTHS to MOVE THROUGH 1 mm of bone from bitewing • No bone at all -> no need to place space maintenance • 4-5 mm bone -> space maintenance Trends: • Bone covering crown = delayed eruption • No bone covering crown = accelerated eruption

• Extensive bone destruction accompanying longstanding necrosis -> very early emergence of premolar, sometimes with immature root development • Bone covering unerupted premolar crown -> bone scar -> resorb more slowly than healthy bone, following premature loss of overlying prim molar + typically eruption of premolar will be delayed -> space maintenance Pm takes 4-5 months to break thru 1 mm of bone as measured on BW: • If pt has no bone at all -> no need to place space maintenance • 4-5 mm bone -> space maintenance • Bone covering crown = delayed eruption • No bone covering crown = accelerated eruption The earlier emergence of premolars with affected predecessors -> longer period at risk for caries compared to premolars replacing healthy primary molars

Clinical Application of Space Maintenance Appliances 1. Loss of Primary Incisor • Strongest factor for placing anterior esthetic appliance: parental desire • Early loss of mx incisors -> no long-lasting effect on growth + no net loss of space from canine to canine (mx + mn) + no effect on mastication Speech: Speech articulations + sounds that most frequently in error due to dentition: S, Z, th <3 yo -> Not enough info to consider appliances Appliances types: 1. Removable acrylic: multiple tooth loss 2. Fixed appliances

• Extraction needed for pts with ECC or extensive dental trauma Consideration points for anterior appliance: • Strongest factor for placing anterior esthetic appliance: parental desire • Masticatory function, speech dev, + tongue habits • No strong evidence that early loss of mx incisors will have a significant, long-lasting effect on growth + dev of child Space maintenance: anterior segment even with early loss will have no net loss of space from canine-canine • Crowded dentition -> rearrangement btwn remaining incisors, but no space maintenance required Masticatory function: Function well even with all 4 mx incisors extracted Speech: Speech articulations + sounds that most frequently in error due to dentition are: /S/ as in soap, /Z/ as in zebra, and /th/ as in think. • Not enough info to consider appliances for children under 3yo • Children over 4yo will usually compensate for tooth loss + will not exhibit any long term speech disorders Esthetic appearance: Most important + valid reason for replacing missing incisors • Children under 5yo: seldom affected socially • Children regularly attend daycare or preschool program = more affected • Children at school age have lesser problem fitting into groups of children who're in mixed dentition + actively exfoliating prim incisors Appliances types: 1. Removable acrylic: • Appliance of choice in most multiple tooth loss situations because of their ease of construction + flexibility of design. • Fairly well tolerated by most patients but patient cooperation may be a problem • Need frequent adjustments as the patient grows. 2. Fixed appliances • Various designs using bands and/or crowns on posterior teeth • Indicated if patient can't manage removable appliance or cooperation = unpredictable • Work best when replace one or two teeth • Disadvantage: cost if cast bars or framework = used + structural weakness if wire is used

Appliance Types: 3. Nance Holding Arch - bilateral Image: 2 permanent molars to palate acrylic button - attached to perm 1st molar or 2nd prim molar Uses: 1. Maintain space/ arch length in entire maxillary arch with one or more prematurely lost prim teeth + potential for space loss 2. Prevents rotation of perm 1st molar (or prim 2nd molar) 3. Hold space of multiple lost prim posterior teeth (single side or both side) 4. Acrylic button -> resistance to anterior mvmt of post teeth 5. Preferred to transpalatal arch when primary molars = lost of both sides as molars may tip mesially Disadvantage: Acrylic button -> Irritation -> Needs careful OH Contraindications: • Patient can't tolerate presence of palatal acrylic button • No posterior abutment tooth available

• Heavy gauge [0.036 inch (0.9mm) or higher] stainless steel wire soldered to palatal aspect of ortho band attached to perm 1st molar or 2nd prim molar • Wire directed from molars anteriorly + attached to an acrylic button that rests against most superior + anterior aspects of the palatal vault • Bilateral Uses: 1. Maintain space/ arch length in entire maxillary arch with one or more prematurely lost prim teeth + potential for space loss 2. Prevents rotation of perm 1st molar (or prim 2nd molar) • By bracing those teeth against anterior palate 3. Hold space of multiple lost prim posterior teeth (single side or both side) • Single tooth loss where there're other prim posterior teeth with questionable or poor prognoses in arch which may later be lost 4. Acrylic button contacts palatal tissue providing resistance to anterior mvmt of post teeth 5. Preferred to transpalatal arch when primary molars = lost of both sides as molars may tip mesially Disadvantage: Intimate contact between acrylic button + palatal mucosa -> Irritation -> Needs careful OH Advantage: Anterior abutment against palate -> Superior stabilization Design: 1. Wire portion: • Lies just off of mucosa • Embedded in an acrylic button which firmly contacts anterior palatal mucosa. 2. Anterior acrylic button shouldn't interfere with anterior occlusion + should be distal to incisive papilla 3. Solder joint on band • Should completely encircle wire • Shouldn't impinge on gingival when band seated Contraindications: 1. Poor patient reliability where appliance may be lost to follow-up 2. High caries risk - presence of the appliance may hinder patient OH effectiveness 3. Cases: • Significant space loss already occurred - space regaining necessary • No posterior abutment tooth available (i.e. extraction of primary second molars prior to eruption of permanent first molar) • Patient can't tolerate presence of palatal acrylic button

Oral Head + Neck Exam: 18. Palate: moderate vault, no lesions Most common: U-shaped V-shaped associated: • Mouth breathing, narrow mx, post cross-bite • Hypernasal speech, submucous clefting • Molding secondary to thumb-sucking 19. Calculus: slight-mand. anteriors Location: lingual of mandibular incisors, buccal of maxillary molars near salivary ducts All Calculus removed prior to prophy + topical fluoride -> if not -> fail

• High vault, shallow vault, medium vault, Ushaped, Vshaped, tori Vault height + shape indicative of current or previous digital habits, genetics, clefting • U-shaped medium is most common V-shaped high associated • Mouth breathing, narrow mx, post x-bite • Hypernasal speech, submucous clefting • Molding secondary to thumb-sucking Tori uncommon in childhood, increase as progress to wards adolescence & adulthood 19. Calculus: yes, no; less common than in adults but can still occur; lingual of mn incisors, buccal of mx molars near salivary ducts; appears chalky compared to enamel, always completely removed prior to prophy & topical fluoride tx • Essential that ALL calculus be removed from teeth for all pediatric pt (with sickle scaler or ultrasonic in severe cases) prior to prophy + subsequent topical fluoride • Fail to do this → Failing grade in procedure/ competency being evaluated

Factors when space maintenance considered after premature loss of primary teeth: 2. Dental age of pt. • Teeth erupt when 3⁄4 of root developed, regardless of chronological age • Tooth root development more related to pt's dental age Determined by : 1. Which teeth erupted 2. Amt of resorption of roots of primary teeth 3. Amt of development of permanent teeth

• Important when evaluating eruption pattern + bony covering of succedaneous teeth • Teeth erupt when 3⁄4 of root developed, regardless of child's chronological age • Tooth root dev much more closely related to pt's dental age than pt's chronological age Determined by : 1. Which teeth have erupted 2. Amt of resorption of roots of primary teeth 3. Amt of development of permanent teeth

Appliance Classification: 1. Fixed Cemented Appliances - incorporate one or more ortho bands with ortho wire soldered Advantage: • Minimal pt compliance • No inventory of components necessary (cost) • Not easily broken • Requires few adjustments Disadvantage: delayed lab time, difficult to adjust, repair, clean, no VDO

• Incorporate one or more ortho bands with ortho wire soldered to them • Bands fitted to abutment tooth/ teeth with cement • Most frequently used: fulfill most characteristics of ideal appliance without significant reliance on pt compliance Advantage: • Minimal pt compliance • No inventory of components necessary (cost) • Not easily broken • Requires few adjustments Disadvantage: 1. Lab fab time -> delay in placement 2. Difficult to: • Adjust on delivery (assuming space loss has started) • Repair if damaged • Difficult to clean: May complicate pt home OH 3. Doesn't address VDO/restore occlusal function

Periodontitis Associated with Systemic Health A. Aggressive periodontitis

• Occurs in YOUNGER population on primary or permanent dentition, can be localized or generalized • OFTEN Overlooked

Appliance Classification: 3. Removable Appliances Advantages: easy to clean, adjust, construct; VDO + esthetics, maintain occlusion Disadvantage: Lab delay, patient compliance, easily broken, many adjustments, soft tissue irritation, plaque trap

• Least used • Dependence on pt compliance • If left out of mouth for a time (day or less) -> remaining teeth will move, appliance no longer fit Disadvantage: • Patient compliance: If left out of mouth for a time (day or less) -> remaining teeth will move, appliance no longer fit • Lab fab delay in placement • Easily lost/ broken • Many adjustments: Must be altered, adjusted for other disruption in arch (additional tooth loss, eruption of other teeth) • Soft tissue irritation • Plaque trap

3. Transitional: Concrete operational (6-11) - more logical reasoning, follow rules of clinic Characteristics: • Independent identity developing - want to be considered "grown-up" • Stress reversion -> immature behavior • Peak in oral trauma at 8-11 years (like 15 month-2 years): sports Dental: All dental procedures can be performed as with adults, using patient's reactions as a guide Everything routine

• More able to comprehend + follow "rules" • Child learns rules such as conservation Intro: • Moderate physical growth and a slightly declining rate of growth • Significant psychological and social advancement. • Develops a view of world + their role in that world. • Assume more adult-like behavior patterns, but still don't necessarily have life experience or coping skills to manage stressful situations smoothly. • This is a stage of significant intellectual development (knowledge acquisition). Clinical Applications: • Clear, step-by-step expectations • Behavior guidance based on "rules of the clinic" • Literal descriptions • Motivation based on immediate effect (if you cooperate we can finish sooner) Characteristics: • Moderate physical growth • Independent identity developing - want to considered "grown-up" • Stress reversion to immature behavior • Euphemism + rules important • Peak in oral trauma at 8-11 years of age due to more autonomy in physical activities, more sports involvement, + wider range of physical size of various similarly-aged children than at previous ages (see growth curves) Dental: All dental procedures can be performed as with adults, using patient's reactions as a guide Exam: routine, inform pt Radiographs: routine Prophy/F: routine Minor caries: routine, N2O Major caries: In-office, N2O, quadrants Minor Oral surgery: N2O

Periodontitis Associated with Systemic Health B. Localized Aggressive periodontitis 11-13 yo Bacteria: Actinobacillus actinomycetemcomitans • Defective neutrophils

• Most common in African Americans with Familial Tendency • Onset at 11-13 yo • Radiographic severe angular bone loss of incisors + 1st permanent molars bilaterally • Little gingival inflammation + minimal supragingival plaque, but subgingival plaque present • Associated with Actinobacillus actinomycetemcomitans • Most patients have defective neutrophils with regards to chemotaxis Tx: • ELIMINATION OF Aa with SRP, improved oral hygiene, + antibiotics (Amoxicillin + Metronidazole 250mg each t.i.d x 7 days)

Euphenisms (cont'd) Hard: Nitrous Oxide Rubber Dam Rubber Dam Frame Sealant Slow speed Handpiece Stainless Steel Crown Study models Topical anesthetic

• Nitrous Oxide - Space gas, silly gas • Papoose Board / Pedi Wrap - Blanket, sleeping bag • Prophy Paste - Special toothpaste • Rubber Dam - Raincoat • Rubber Dam Clamp - Tooth ring • Rubber Dam Forceps - Tooth ring holder • Rubber Dam Frame - Coat rack • Sealant - Plastic covering, white paint, nail polish for your tooth • Slow speed Handpiece - Tooth cleaner, Mr. Bumpy • Stainless Steel Crown - Silver hat • Study models - Tooth statue • Topical anesthetic - Cherry or strawberry jelly • Radiograph Equipment - Tooth camera • Radiographic sensor - Tooth picture

Low-Caries Level Intervention: • Anticipatory Guidance 6-12 month recall

• No carious lesions • No white spot lesions/demineralized areas • No visible plaque • Appropriate bottle/sippy cup use • Routine home oral hygiene • Mom has no active/untreated caries • Older siblings have no history of ECC • Non-impaired saliva composition or flow • No chronic meds that may include sugar or impact saliva Intervention: • Anticipatory Guidance 6-12 month recall • Reinforce daily brushing with appropriate amount of fluoridated toothpaste • Consider supplementation of systemic fluoride (drops/tablets) if primary drinking water non-fluoridated

Factors when space maintenance considered after premature loss of primary teeth: 10. Future Ortho Care

• Ortho eval always suggested to parents of children with potential space loss issues, even if treatment can be delayed + only monitoring is necessary • Even for pt in early mixed dentition, phase I ortho care may be appropriate, + can address many space issues • If parent indicates they don't want, or can't seek ortho care -> Should be informed that there's a possibility that pt's ultimate occlusion + alignment of teeth may be compromised • Space maintenance = only passive txt modality, + thus has limited effect

Treatment Planning: 4. Tx Plan Presentation: Informed Consent

• Parents need to fully understand proposed care, along with acceptable alternatives, inherent risks, predicted prognosis, consequences of lack of tx, costs • Without informed consent, any dental tx rendered is considered "battery" + can result in a criminal charge • Discuss tx plan after thorough exam • Follow pt presentation sheet so presentation is well-organized: oral findings -> proposed tx -> # appts -> cost o Visual aids should be neat, well-organized, + thoroughly explained to parents Parent's questions can be delayed to end for more efficient use of time: • Answer w/ logical explanations • May want to discuss w/o child being present if will be distracting • May require child's present to show parent intraorally If parents = argumentative or doubtful, suggest a second opinion before starting tx: never rush or pressure parents for complex tx plans! • Give parents a copy to take home and think about/discuss w/ spouse • Give guidance on how to handle child's questions • Written materials with child's specific proposed txt is appreciated

Factors when space maintenance considered after premature loss of primary teeth: 7. Delayed Eruption of Permanent Teeth Partially impacted -> extraction + space maintainer

• Partially impacted permanent teeth or deviation in eruption path -> Abnormally delayed eruption -> Generally necessary to extract primary tooth, construct a space maintainer, + allow the permanent tooth to erupt + assume normal position.

Personalizing Behavior Guidance Techniques

• Personalize techniques to those in which you're comfortable + confident • Children = perceptive of honesty, aren't easily influenced by adult pretense, + manage their world on an immediate basis • Important to use guidance techniques that children will perceive as genuine • Personalizing Beg guidance technique PEDS • What works for me will not necessarily work for you • You must know what is possible for pt, be comfortable with technique, have CONFIDENCE in technique

Fluoride Mechanisms: 1. Topical - inhibit demineralization + promote remineralization 2. Systemic - for lacking sufficient fluoride intake

• Profound impact on caries exp, highly successful tool when used appropriately 1. Topical: exposure provides fluoride in oral cavity to inhibits demineralization, promote remineralization of demineralized areas + incorporation of fluorhydroxyapatite into remineralized enamel to make it more resistant to carious breakdown • Concentrates in plaque on erupted teeth -> buffer bacterial acids + disrupt bacterial enzyme systems • Decreases solubility of remineralized enamel 2. Systemic: prescribed for pts lacking sufficient fluoride intake • Allows fluorhydroxyapatite to be incorporated into developing enamel to make it more resistant to carious breakdown • Improves enamel crystal structure • Reduces acid solubility of enamel

14. NO/oxygen inhalation ("Silly Gas): Indications: • Compliant with mild anxiety and/or short attention span • Patient with SEVERE GAG REFLEX Contraindications: • Combative or defiant pts • Nasal or airway obstructions • Recently eat a large meal (<3 hrs.) • Claustrophobic pts • Otitis media • History of Myringoplasty (tympanic membrane repair)

• Reduces anxiety (anxiolytic) + enhance effective communication, raise pain rxn threshold, increase tolerance for longer appts, reduce gagging, tx of mentally/physically disabled or medically compromised pt • Onset: Rapid • Effects: Easily titrated + reversible • Recovery: Rapid + complete Indications: • Compliant patient with mild anxiety and/or short attention span • Patient with severe gag reflex Contraindications: • Combative or defiant pts • Nasal or airway obstructions • Recently eat a large meal (<3 hrs.) • Claustrophobic pts • Otitis media • History of myringoplasty (tympanic membrane repair) - an ENT consult should be obtained before N2O use as there is potential for displacement or damage of graft • Can be presented to patient as adjunct that patient can control • DOESN'T replace local anesthesia • Most common complication: vomiting due to recent meal and/or multiple changes in concentration of N20 o Working range: 30-50% N20 Tips: • No eating pre-op • Avoid changing level

Periodontitis Associated with Systemic Health C. Necrotizing Ulcerative Periodontitis (NUP) HAS LOA

• Same as NUG but with LOA Tx: similar to chronic adult periodontitis, root planning, anti-microbial therapy (eg. Cholorohexidine)

Periodontitis associated with systemic disease B. Trisomy 21 (Down Syndrome) Commonly -> premature loss of lower incisors Factors: Short roots, Class III malocclusion, traumatic anterior occlusion, poor fine motor skills, Hypotonia • Systemic factors may be responsible: capillary fragility, atypical collagen biosynthesis, decreased PMN (Neutrophil) chemotaxis Tx: aggressive oral hygiene

• Severe + rapid periodontitis can affect both dentitions due to impaired and/or delayed immune response • Commonly -> premature loss of lower incisors Factors: Short roots, Class III malocclusion, traumatic anterior occlusion, poor fine motor skills, Hypotonia • Systemic factors may be responsible: capillary fragility, atypical collagen biosynthesis, decreased PMN chemotaxis Tx: aggressive oral hygiene

Factors Influencing Space loss 1. Abnormal Oral musculature • Uprighting + distal drifting of anterior segment • Premature loss of posterior primary -> mentalis muscle -> incisor movement

• Stable tooth position maintained by balanced muscular forces • When disturbed, teeth can shift into less stable positions -> collapse of lower dental arch with uprighting + distal drifting of anterior segment • Tongue position + premature loss of posterior primary tooth destabilize forces on teeth -> Mentalis m. dominate -> Exert unbalanced force on incisors → Movement of those teeth

Characteristics of Children Relevant to Behavioral Guidance: General Characteristics of Children: Most prevalent in younger children, dissipate with age

• Strong sense of imagination, which can be used for distraction but can lead to irrational fears of novel situations • Strong sense of trust but must be won -> emphasizes importance of honesty with pt • Perceptions of others aren't dependent upon overt appearances, so be yourself + be sincere • Children less inhibited + act on their emotions more than adults -> their reactions = immediate to stimulus or feelings

Factors when space maintenance considered after premature loss of primary teeth: 11. Pt. Reliability

• To be effective, space maintenance appliances must be monitored • Pt reliability = important consideration in determining appropriateness of space maintenance • Neglected -> do harm • If in doubt -> avoid use of appliance + deal with space loss issue later • Pt + families should be made aware that their appointment compliance + communication with dentist -> direct impact on success of space maintenance efforts

Early Carious Breakdown of Primary Teeth Demineralization Order: 1. Cervical of MX incisors 2. Deep pits & fissures 3. Proximal surfaces

• Topical fluoride exposure can be effective — makes enamel less soluble, shifts demineralization/ remineralization cycle towards remineralization • Demineralization -> Frank cavitation Demineralization occurs in most susceptible areas 1st : 1. Cervical of mx incisors - earliest lesions — thinnest enamel, present in mouth longest 2. Deep pits & fissures - more plaque/substrate retentive, thinner enamel at base of grooves/ pits 3. Proximal surfaces - later due to thicker enamel + lack of interproximal contact at young age Caries Progression: early cervical lesions > clinically evident lesions > severe carious lesions

Clinical Application of Space Maintenance Appliances 3. Loss of Primary Molar For: Premature lost primary molar Cases: 1. PRIOR TO, OR DURING, ERUPTION OF PERMANENT 1st MOLAR 2. AFTER ERUPTION OF 1st PERMANENT MOLAR For Both Cases: Appliance types: 1. Band + Loop 2. Lingual Arch 3. Nance Holding Arch 4. Transpalatal Arch 5. Removable Acrylic

• Unlikely that space of 1st primary molar will be completely lost during primary dentition because of Mesial movement of posterior teeth • Mandible -> lateral + posterior shift of incisor -> Development of an asymmetry within arch • Space maintenance in primary dentition + mixed dentition should be considered for prematurely lost primary molars, particularly lower first primary molar Depends on situations 1. PRIOR TO, OR DURING, ERUPTION OF PERMANENT 1st MOLAR • Most critical time for space maintenance • Mesial component of force of erupting permanent 1st molar -> Primary 2nd molar into space, also primary canine may drift into space 2. AFTER ERUPTION OF 1st PERMANENT MOLAR • Beneficial in cases where loss occurs before or during active eruption of 1st permanent molars • Usage may be irrelevant in cases where 1st perm M have erupted • Erupted molars = passive, thereby not producing a mesial component of eruption force For Both Cases: Appliance types: 1. Band + Loop: Unilateral situations 2. Lingual Arch: Unilateral + Bilateral loss situation in mandible 3. Nance Holding Arch: Unilateral + Bilateral loss situation in maxillary 4. Transpalatal Arch: Unilateral loss situations in maxillary arch 5. Removable Acrylic: May be used but patient cooperation + other disadvantages of this appliance make it inferior to fixed appliances

12. Injections: sleepy juice

• Use euphemisms • Use topical, inject slowly, distract pt. • Hidden Syringe Technique • Always confirm profound anesthesia Steps: 1. Operator (dentist) stabilizes head, finds landmarks 2. Assistant transfers capped syringe under patient's chin, out of patient's line of-sight 3. Assistant uncaps syringe, places cap in instrument cassette 4. Operator performs injection while stabilizing head - assistant manages patient's hands 5. Operator removes syringe from mouth, passes it over his/her arm while maintaining head stabilization 6. Operator recaps syringe (cap in instrument cassette)

2. Pre-school: Pre-operational (2-6) - idiosyncratic "magical thinking", make-believe, animism -> use euphenisms General Characteristics: • Rapid psychological + personality dev (developing) • Social + language skills growing fast • Role playing • Dramatic fantasies • Self-awareness • No time frames until 5 yrs old • Behavior still influenced by immediate environment -> Not "pre- cooperative" • Abstract thought not part of reasoning ability at this age Dental: 6 = marked transition to less parent assistance + routine + focusing more on child than parent + N2O Transition: 2 -> 6 Dental Exam: Lap (knee-to-knee) -> unaccompanied/chair (proud of coming back alone, TSD works well) Prevention: Focus on parent -> Work with child (parental assistance) Dental Radiography: Parent assistance -> Without Parent Prophy + Fluoride: Toothbrush trophy, brush topical fluoride on teeth or use fluoride varnish -> Routine Minor Dental Caries: minimal restorations -> routine + N2O (shorter appointments) Major Dental Caries: Sedation/GA -> quadrants + N2O Minor Oral surgery: Sedation/GA -> Routine + N2O

• Use euphemisms (Ex. "Mr. Bumpy" = slow speed, "Mr. Whistle" = high speed, "Mr. Thirsty" = saliva ejector) Child begins to represent world symbolically Clinical Applications: • Story telling as distraction • Stimulus should be explained in age-appropriate terms (freezing bugs = LA; heavy or fat lip = numbness) Behavioral guidance age ranges: Pre-school General Characteristics: • Rapid psychological + personality dev (developing) • Social + language skills growing fast • Environment <-> Behavior • Role playing • Dramatic fantasies (idiosyncratic thinking = non-linear cause & effect)/ Euphemism = important (Idiosyncratic thinking) • Self-awareness (love your shoes) = source of both real + unreal fears • No time frames until 5 yrs old • Behavior still influenced by immediate environment but no longer classified as "pre- cooperative" • Play behavior involves significant role playing • Abstract thought not part of reasoning ability at this age Notes: • Distinct personality developing; initially most noticeable to parents but later to most who interact with child • Skilled in use of words + symbols; usually proud of language skills • Parroting = essential part of early language acquisition, but can be misleading when used to assess understanding of instructions or concepts Ex. Child may be able to repeat your instructions, using your words, but may have no grasp of the meaning • Can be effective in interpersonal communication Dental Procedures + Behavior Strategies: 2-6 Dental exam: Lap > unaccompanied/chair 2: With parent in room or possibly in parent's lap; may still need knee to knee 6: Parent doesn't need to accompany, child proud of coming back alone, tell-show-do works well Prevention 2: Focus on parent, gather info about child's nutrition, consider other caretakers 6: Work with child on basic skills (tooth brushing) + good oral care habits but stress importance of parental assistance to child + parents Dental radiography: parent help > Unassisted 2: May still need parent assistance 6: Can usually obtain radiographs without parent assistance Prophy + Fluoride: Toothbrush > routine 2: May do toothbrush trophy, brush topical fluoride on teeth or use fluoride varnish 6: Routine prophy + fluoride Minor Dental Caries: minimal rest > routine + N2O 2: Consider minimally invasive procedures; short working time. Sedation or GA if unable to complete in chair 6: Routine restorative treatment but short appointments key. N2O helpful Attention span is short -> work fast Major Dental Caries: Sedation/GA > quadrants + N2O 2: Sedation or GA 6: Quadrant dentistry whenever possible with N2O Minor Oral surgery: Sedation/GA > Routine + N2O 2: Sedation or GA 6: Treat as routine procedure, N2O

Fluorisis Management 1. young children (newly erupted incisors) -> parents more concerned 2. Child concerned -> minimally invasive procedures (micro-abrasion) 3. Child's concerns resurface later -> composite overlay 4. Child still unhappy -> veneers

• Varies depending on extent of fluorosis + pt's + parent's level of concern, but goal should be minimally invasive interventions which will address those concern satisfactory • Definitive txt: facial veneers on affected anterior teeth, but not appropriate for pediatric pt + thus must be delayed as long as possible for tooth maturation Typical management: approach 1. In young children (newly erupted incisors) parents may be more concerned than child with appearance of fluorosis — reassure them that you're aware of fluorosis + their concerns, but encourage them not to sensitize child • Describe developmental reasons (immature tooth, large pulp, etc) why definitive intervention may not be possible for some time 2. Once child concerned with appearance of teeth -> Minimally invasive procedures like micro-abrasion • In some cases, this is adequate or may allay a child's concern at that time + perhaps permanently 3. If child's concerns resurface later a composite overlay (with no or very minimal tooth preparation) can be attempted, but this is rarely a permanent esthetic solution • Removing tooth structure creates a situation where further treatment will be required, either periodic replacement of composite overlay, or facial veneer treatment of the teeth Note that if child is to undergo ortho txt, this procedure may be contraindicated as it can impact bracket placement and retention 4. If the child continues to be unhappy with esthetics, facial veneers considered but should be delayed as long as possible, until tooth mature (fully erupted, pulp space smaller)

Considerations for Initial Office Visit 6. Education History Attention or behavioral issues -> 1st evaluated through public school system Public school resources = typically stretched thin, so generally children who may be at risk for cognitive/emotional issues get triaged, with most severely affected or most disruptive children prioritized ahead of others who may also be at risk 1. Just because patient hasn't been evaluated -> doesn't mean that they may not be affected 2. Often inquiry from dentist to child's physician -> may trigger earlier evaluation + when indicated, intervention 3. Children's status may change over time if they receive evaluation later.

• Wealth of info, especially if child enrolled in public education • Often child who has attention or behavioral issues -> 1st evaluated, + possibly even referred for treatment, through public school system • Cognitive delays or emotional immaturity -> child being delayed entering their age-appropriate school level Relevant questions: • How is child progressing in school? • What grade in? • Aware of any problems that your child experiencing in school? (part of Social hx) • Would you consider your child a "fast learner," an "average learner," or a "slow learner?" • Tell parent that we have a lot to teach their child + want to present it to them in a way that makes child comfortable • How does your child behave at school? • Can you describe your child's attention span? • What are your child's favorite activities at school? = good "icebreaker question" Public school resources = typically stretched thin, so generally children who may be at risk for cognitive/emotional issues get triaged, with most severely affected or most disruptive children prioritized ahead of others who may also be at risk Result: 1. Just because patient hasn't been evaluated, doesn't mean that they may not be affected 2. Often inquiry from dentist to a child's physician may trigger earlier evaluation + when indicated, intervention 3. Children's status may change over time if they receive evaluation later. Children who are home-schooled may not receive same level of objective evaluation from non-family members, yet their parents may have a much more detailed idea of their progress, etc

Caries Demographics - uneven population distribution

• ≥5% US children affected, with significantly higher %s in low SES communities • 5x more common than asthma , 7x more common than hay fever • 40% of children have caries by kindergarten • 50% of children have at least one cavity by elementary school