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NBDE Dental Boards Pedo 21
NBDE Dental Boards Pedo 21
Anomalies of Size
1) Microdontia
a) ectodermal dysplasia
b) hemifacial microsomia
c) Down syndrome
d) Peg lateral incisor
2) Macrodontia
a) facial hemihypertrophy
b) otodental syndrome
3) Fusion: union of two teeth/tooth buds (primary or permt; more common in primary teeth)
-fused teeth have 2 pulp chambers and 2 pulp canals
-results in large crown
-occurs almost always in anterior teeth
-can be detected by counting teeth b/c fusion results in one less tooth entity in arch
4) Gemination: division of single tooth bud into bifid crown (2 crowns on single root)
-more common in primary teeth
-b/c it occurs on a single tooth, there will be a normal complement of tooth entities
5) Concrescence: form of fusion w/ cementum contact (only cementum is fused)
-usually results from trauma
Anomalies of Shape
1) Dens evaginatus: extra cusp (talon cusp in incisors)
-extra cusp has enamel, dentin, and pulp so must be careful in restorative procedures
2) Dens invaginatus (dens in dente): caused by invagination of inner enamel epithelium
-termed tooth within a tooth
-most common in permt max. lateral incisors
-if enamel and dentin not formed correctly within defect, a direct communication with pulp can occur
-treated w/ small restoration or sealant to prevent pulpal involvement
3) Taurodontism: long vertical pulp chambers and short roots
4) Dilaceration: bent/twisted root occurring as result of intrusive or displacement injury to primary predecessor
-dilaceration also common in congenital ichthyosis
Anomalies of Structure
1) Enamel hypoplasia: refers to deficiency in QUANTITY of enamel
-no interproximal contact btw teeth
-causes: 1) genetic: amelogenesis imperfecta
2) environmental: systemic dx (fever), fluorosis, nutritional defic. (vit A, C, D, Ca, Ph)
2) Enamel hypocalcification: refers to deficiency in QUALITY of enamel
-also has genetic and environmental causes
3) Amelogenesis imperfect (AI): related to enamel only and dependent on stage of enamel formation (enamel
hypoplasia)
-normal root and pulp morphology
1) Type I: Hypoplastic (inadequate QUANTITY of enamel)
2) Type II: Hypomaturation (inadequate MATURATION of enamel)
3) Type III: Hypocalcified (inadequate QUALITY/mineralization of enamel
4) Dentinogenesis imperfect (DI): predentin matrix is defective, resulting in amorphic, atubular dentin
-teeth are reddish-brown to gray color
-slender roots
-small or absent pulp chambers/canals
1) Type I: osteogenesis imperfecta, blue sclera, hearing loss
2) Type II: no osteogenesis imperfecta (most common type)
3) Type III (Brandywine type): multiple periapical radiolucencies
5) Dentin dysplasia
-Shield type I: Normal anatomy. Short, pointed roots. Absent pulp chambers/canals. Multiple periapical
radiolucencies
-Shield type II: Primary teeth similar to DI. Permanent teeth have pulp stones, thistle tube shaped
chambers, no periapical radiolucencies
Part 2: Management of Child Behavior
Classification of Behavior
1) Cooperative: children w/ minimal apprehension, communicative, comprehending, and willing
-respond well to behavior shaping
2) Lacking cooperative ability: children are deficient in comprehension and communication skills
-includes very young children (under 3 yrs) and disabilities
3) Potentially cooperative: are capable of appropriate behavior but disruptive in dental setting
a) Uncontrolled: characterized by tantrums; 3-6 yrs old
b) Defiant: I dont want to attitude in children and passive resistance in adolescents
-can be all ages
c) Timid: char. by shielding behavior and hesitation
-usually preschool and young grade school kids
d) Tense-cooperative: want to cooperate and try to behave but are very nervous
-typically older children at least 7 yrs old
e) Whining: continuous, whining behavior but no crying
Frankl Behavioral Rating Scale
1) Rating 1: definitely negative refusal of txt
-forceful crying, fearful, extreme negativism
2) Rating 2: negative reluctance to accept txt
-uncooperative, negative attitude but not pronounced
3) Rating 3: positive acceptance of txt
-cautious behavior but willing to comply and cooperates w/ dentist
4) Rating 4: definitely positive w/ good rapport w/ dentist
-has active interest in dental procedure and laughs/enjoys visits
Variables Influencing Behavior in Dental Setting
1) Age
a) < 2yrs: typically lack cooperative ability
b) 2 yrs: wide variance in ability to communicate
-dentist should use tell-show-do technique
-may be helpful to have parent in room due to possible separation anxiety
c) 3-7 yrs: most often are cooperative and willing to comply w/ dental procedures
-familiarization techniques and behavior shaping strategies are helpful tools
d) 8+ yrs: children try to control apprehension as they get older but stressful situations may cause them to
revert to negative behaviors
-behavior shaping and familiarization techniques can still be helpful
2) Maternal anxiety
-high correlation btw maternal anxiety and childs negative behavior
-effect greatest on children under 4 yrs old
3) Past medical history
-children w/ positive past medical experiences are more likely to be better at dentist
-children who have experienced pain in past medical visits will have more negative behavior
-previous surgery correlated w/ negative behavior at first visit
4) Patient awareness of problems
-if child thinks they have a dental problem, they are more likely to exhibit negative behavior
Pulp Capping
1) Indirect pulp cap
a) Indications: pt is symptom free, no radiologic evidence of pathology, and minimal caries in area that
would cause pulp exposure if removed
b) Procedure: remove caries except that right on pulp; place CaOH and base, restore tooth, re-enter in 6-8
weeks to remove rest of caries
2) Direct pulp cap
a) Indications: small pinpoint exposure that is non-carious and symptom free
b) Procedure: place CaOH over pulp exposure and restore tooth
Pulpotomy
-coronal removal of vital pulp tissue
1) Indications
a) vital primary tooth w/ carious exposure
b) clinical signs of normal pulp canal (no swelling, drainage, or pathologic mobility, no symptoms)
c) tooth is restorable
2) Procedure
a) Remove superficial and lateral decay
b) Remove roof of pulp chamber
c) Remove coronal pulp w/ #4 round bur in slow speed w/ light pressure
d) Place dry cotton pellets to arrest pulpal bleeding
e) Five minute formocresol application
-if hemorrhage cant b stopped, consider pulpectomy or 2-visit pulpotomy
f) Build up in ZOE and place stainless steel crown
3) Medicaments
a) Formocresol: most commonly used medicament for pulpotomies
-consists of 35% cresol, 19% formalin in glycerine solution
-formocresol may be toxic
-acts by direct contact
b) Ferric sulfate
-success rates comparable to formocresol and is less toxic
c) MTA
-have shown higher success rates than formocresol
Pulpectomy
-complete removal of all remaining pulp tissue
1) Indications
a) Necrotic or chronically inflamed pulp in tooth that is strategically located
b) Normal supporting bone
2) Contraindications
a) Non-restorable tooth
b) Internal or external root resorption
c) Tooth doesnt have accessible canals (primary 1st molars)
d) Significant bone loss
3) Procedure
a) Remove coronal pulp, irrigate chamber w/ NaHClO, remove radicular pulp w/ small file
b) Obtain working length and enlarge canal 3 file sizes
c) Fill canal w/ ZOE by using syringe and condensing
d) Build up tooth in ZOE and place SSC
7) Lack of stippling
8) Flabbier tissue
9) Rounded and rolled gingival margins
10) PDL fibers run parallel to teeth (run horizontal in adult)
11) Alveolar bone thinner
Gingivitis
-very common in children and treated w/ improved oral hygiene
-parental participation needed in oral hygiene in children under 8 yrs old due to lack of manual dexterity
-parental supervision may be needed in children over 8 yrs due to lack of interest or understanding of consequences
-common conditions in children can aggravate gingivitis:
a) mouth breathing
c) erupting teeth
b) crowded teeth
d) braces
Puberty Gingivitis
-characterized by enlarged, bulbous interproximal gingival tissue on labial aspects of anterior teeth
-treatment involves improved OH, removing local irritants, and nutrition counseling
Herpes Simplex Infection (HSV-1)
1) Primary herpetic gingivostomatitis
-usually occurs in children under 6 yrs old w/ no previous exposure to HSV
-most infxns are subclinical
2) Acute herpetic gingivostomatitis
-liquid-filled yellow vesicles found intraorally and periorally
-vesicles rupture to form yellow pseudomembrane and erythematous border
-located on tonsils, palate, buccal mucosa, and gingiva
-also have fever, malaise, and lymphadenopathy
-txt: topical anesthetic, diphenydramine, antivirals (acyclovir), and analgesics (ibuprofen)
3) Recurrent herpes simplex (cold sore/fever blister)
-usually found on outside lips
-recurrence associated w/ stress or local trauma
-txt: systemic or topical antiviral, lysine
Lateral Luxation
-displacement in axial direction
-torn PDL w/ contusion or fx of bone
-nontender and nonmobile
-txt: allow passive repositioning if possible, but if not then actively reposition and splint for 1-2 wks
-active repositioned tooth will more likely have necrosis than passively repositioned
Intrusion
-apical displacement into alveolar bone
-unless it is determined that the root of intruded primary tooth is impinging on permt successor, it is left alone in
hopes it will re-erupt on its own
-should be extracted if endangering permt tooth
-tooth should be x-rayed
Extrusion
-partial displacement of tooth out of socket axially
-the greater the distance from normal position, the greater chance of severing apical vasculature and pulpal necrosis
-tooth can be repositioned and splinted for 7-14 days
-endo txt should be done to prevent pulpal necrosis which can cause problems in permt tooth
Fractures
1) Enamel only: smooth enamel and check vitality at 1, 2, 6 months due to possibility of concussion
2) Enamel and dentin: smooth edges and restore; check vitality at 1, 2, 6 months
3) Enamel, dentin, and pulp:
a) vital pulp: pulpotomy
b) necrotic pulp w/o internal/external resorption: pulpectomy
c) Necrotic pulp w/ resorption: extraction
Avulsion
-replanting primary teeth has poor prognosis
-can be considered if within 30 minutes
-if replanted, splint, recommend soft diet, give antibiotics, and follow w/ pulpectomy
-antibiotics following replantation:
a) doxycycline
b) Pen VK (if susceptible to tetracycline staining in permt teeth)
-PRIMARY TEETH SHOULD NOT BE REPLANTED
Ellis Classification
1) Class I: involves little or no dentin
-enameloplasty or bonding
2) Class II: involves dentin but not pulp
-CaOH or GI
3) Class III: involves pulp
-pulp therapy and restoration
4) Class IV: loss of entire crown
-pulpectomy and SSC
5) Class V: teeth avulsed
6) Class VI: fracture of root w/ or w/o loss of crown
7) Class VII: displacement of tooth w/ or w/o loss of crown
8) Class VIII: fracture of crown en masse
9) Class IX: traumatic injuries to primary dentition
Root Fracture
-root fractures in primary teeth are rare due to malleable bone surrounding roots
a) Fracture in apical half: splint or no txt if mobility minimal
-fxs in apical 1/3 most likely to undergo repair
b) Fracture in coronal half: rigid splint or extraction
Splinting
-use stainless steel ortho wire which must be passive (not putting pressure on teeth)
-fix to teeth w/ composite
-long-term splinting of primary teeth increases risk of ankylosis and should be avoided
Part 9: Miscellaneous Topics in Pedo
Types of Mouth Guards
1) Stock: available at sporting goods stores
-inexpensive but do not custom-adapt to teeth
2) Mouth-formed: also available at sporting goods stores
a) Boil-and-bite: softened in hot water and then adapted to teeth
b) Shell-type: has outer shell that is firm and inner liner that is made from ethyl methacrylate
3) Custom-fabricated: made by dentist from impression and model
-fit better and worn more successfully by patients
a) Vacuum-formed: material heated in vacuum molding machine
b) Pressure-laminated: has multiple layers of material
-less susceptible to distortion
Antibiotic Prophylaxis for Pedo Patients
1) Conditions requiring prophylaxis:
a) Prosthetic heart valve
b) Previous endocarditis
c) Congenital heart disease (unrepaired, repaired in last 6 months, or has residual defect)
d) Cardiac transplant w/ valvulopathy
e) Compromised immunity
f) Joint replacement within 2 yrs
2) Procedures requiring prophylaxis
a) Extractions
b) Perio procedures (probing, prophy, SRP, surgery)
c) Implant placement and re-implanting avulsed teeth
d) Endo surgery/RCT beyond apex
e) Placement of ortho bands (not brackets)
f) PDL injections
3) Dosages for Children
a) Amoxicillin: 50 mg/kg
b) Allergic to penicillin
i) Clindamycin: 20 mg/kg
ii) Cephalexin: 50 mg/kg
iii) Azithromycin: 15 mg/kg
c) Unable to take oral meds: Ampicillin 50 mg/kg
Age
birth-6
months
6 months-3
yrs
3-6 yrs
6-16 yrs
<0.3p
pm
0.30.6ppm
>0.6p
pm
0
0.25m
g
0.5mg
1 mg
0
0.25mg
0.5mg
0
0
0
-Rule of 6s:
a) if fluoride water level is over 0.6ppm, no supplementation
b) if child is under 6 months, no supplementation
c) if child is over 16 yrs, no supplementation
Fluoride Facts
1) Food and Nutrition Board recommends public water supplies be fluoridated when levels are significantly below
0.7 mg/L
2) Fluoride intake of 20-40 mg/day can inhibit enzyme phosphatase
-phosphatase needed for calcium utilization in tissues (bones and teeth)
3) Fluoride intake of 40-70 mg/day can cause heartburn and pain in extremities
4) Fluoride can displace calcium in body, as well as calcium displacing fluoride (calcium treats fluoride toxicity)
5) Topical fluoride does not cause fluorosis, only systemic
6) School water fluoridation is 4.5x city water
7) Greatest conc. of fluoride at outermost enamel layer
8) Proximal and smooth surfaces benefit most from fluoride
9) Fluoride excreted by kidney
10) Toothpaste contains 1100 ppm fluoride (1% F-)
Types of Fluoride
1) 2% Sodium fluoride (NaF): neutral pH (~9), acceptable taste, no adverse effects on restorations
2) 8% stannous fluoride (SnF2): nonstable, bad taste, stains restoration margins
-pH of 2 (acidic)
3) 1.23% acidulated phosphate fluoride (APF): acceptable taste, can cause etching of porcelain and composites
-pH of 3 (acidic)
Fluoride Toxicity (Lethal Doses)
1) Adults: 4-5g
2) Children: 15 mg/kg
Symptoms of Fluoride Toxicity
1) Nausea/vomiting
2) Hypersalivation
3) Abdominal pain
4) Diarrhea
5) Cardiac failure and resp. paralysis
6) Fluorosis
Fluorosis (Mottling)
-enamel hypoplasia char. by chalky white spots or brown staining and pitting of teeth from increased fluoride levels
affecting enamel matrix formation and calcification
-excessive fluoride impairs ameloblastic fxn
-severity increases w/ increasing amt of fluoride (low-dose, long-term excess)
-children living in temp. zones where water supply contains higher content of fluoride are most affected
-is irreversible condition
Clefting-Associated Syndromes
1) Sticklers syndrome
2) Van der Woudes syndrome
3) DiGeorge syndrome
Timing of Treatment for Clefting
1) Cleft lip at 10 weeks
-child should be 10 weeks old, 10 lbs, and 10 g/dL Hb
2) Cleft palate at 9-18 months
Growth Facts
1) At age 6, childs head is 90% of its adult size
-brain and neural tissues are fully developed at age 6
2) At birth, jaw is large enough to accommodate all primary teeth
3) At birth, width of face has reached greatest percentage of its adult size
4) At birth, palate is pretty flat
5) From age 6-12, lymph tissue is 200% of its adult mass
Neuroblastoma
-most common malignant tumor in neonates
Down Syndrome
-has high incidence of perio dx but low incidence of caries
-other characteristics:
1) hypoplasia of midface
2) prognathic class III occlusion w/ open bite
3) macroglossia
4) mouth breathers