PEDIATRIC DENTISTRY

Nathalya Bmay A. Subido, DMD

1. Oral anatomy
2. Diagnosis/ Comprehensive
Examination
3. Development of Teeth and
Developmental Disturbances
4. Oral pathology
5. Prevention/fluoride
6. Caries and Periodontology
7. Restorative dentistry
8. Pulp therapy
9. Behavioral Management
(Non-pharmacologic)
10.Interceptive Orthodontics
11.Local Anesthesia
12.Oral surgery
13.Traumatic Dental Injury
14.Medical Conditions
15.Pharmacologic Behavioral
outline
Management
 • One of the most important aspects of
child behavior guidance
• Its important for each visit to reduce
CONTROL discomfort to a minimum and to
control painful situation
OF PAIN INDICATIONS
➢ Operative or restorative procedure
➢ Pulp therapy
➢ Placement of rubber dam
➢ Oral surgery
Contraindication
➢Bleeding disorders. Block contraindicated except
with appropriate factor replacement
➢Injection at infection site → Block analgesia or
intraligamental might be effective in this
situation
➢Known allergy to the LA drug
➢Use with caution in liver and renal dysfunction
Topical/surface Anesthesia
• Reduce slight discomfort that may be associated with
the initial insertion of the needle before deposition
Available forms: The most commonly used
1.Gel topical
2.Liquid ➢ 20% benzocaine gel or
3.Ointment liquid
4.Pressurized spray ➢ 2-10% Lidocaine gel or
forms liquid which is available in
many flavors
Topical Anesthesia: • Mucosa at the site of the intended needle
insertion is dried with gauze/cotton
Technique • Apply in small quantity on the cotton roll or
cotton buds
• Ensure that the area of application
remains dry to avoid it leeching into
saliva as the taste might then upset
some children
• Onset: 30 seconds
• You can apply it twice then dry in
between
Injectable Local Anesthesia: commonly
used

• LIDOCAINE (Xylocaine)
• Rapid onset: 2-3 minutes
• Effective conc.: 2.0%
• Usual dose: 1:80,000;
1:100,000
Dosage computation
Drug Duration of anesthetic Maximum dose
recommended
2% Lidocaine Pulpal: 60 min 4.4mg/kg
With 1:100,000 Soft tissue: 3-5hours 2.2mg/lb
epinephrine
Max dosage 300mg
2.2lb=1kg
mL = Maximum Allowable Dose (MAD) mg/kg x weight in kg
mL = 4.4mg/kg x 20kg → 88mL
# of carpules: mL Lidocaine/ 36mg
# of carpules: 88mL/36mg → 2.4 carpules
Complications • Anesthetic toxicity → rarely
of LA experienced in adult but in young
children have a higher chance
(dose related)
• Trauma to soft tissue: parents of
children should be warned that
soft tissue in the area will be
without sensation for a period of
1 hour or more.
MAXILLARY PRIMARY TEETH and
mandibular anterior
➢ Local infiltration can be used for anesthetizing
maxillary primary teeth.
➢ Adequate diffusion of the local anesthetic
readily occurs in children because their bones
are less dense than those adults
Inferior Alveolar Nerve Block (with long buccal):
Mandibular Primary Molars
• Mandibular foramen is situated at the level lower
than the occlusal plane of the primary teeth of
pediatric patient.
• injection slightly lower and more posterior
• **Success rates for mandibular nerve blocks are
higher in children than in adults because of the
anatomy of less developed mandibles.
• Below 6 years – below the occlusal plane
• 6-12 years – in line with the occlusal plane
• Above 12 years – above the occlusal plane
 ❖Seldom required for primary
Intraligamental teeth due to small risk of damage
to permanent tooth germ
❖Indications:
❖difficult to achieve analgesia
❖hypersensitive carious exposed
pulps in young permanent molar
❖extraction of permanent molars
where other forms of analgesia
have failed
Principles of Atraumatic Injection
Apply proper topical anesthesia
Always communicate with the patient
Keep syringe out of site. TSD with cap closed
Always aspirate
Bevel of needle facing bone
Check the flow of LA solution/ slow deposition
Use anesthetic solution temperature close to room
temperature
Never leave patient unattended
Review
• Commonly used Topical Anesthesia? ___________
• Onset of topical anesthesia? _________
• Onset of 2% Lidocaine HCl with 1:100,000 epinephrine?
___________
• Pulpal duration? _________
• Soft tissue duration? _____
• Inferior Alveolar Nerve Block
1. Oral anatomy
2. Diagnosis/ Comprehensive
Examination
3. Development of Teeth and
Developmental Disturbances
4. Oral pathology
5. Prevention/fluoride
6. Caries and Periodontology
7. Restorative dentistry
8. Pulp therapy
9. Behavioral Management
(Non-pharmacologic)
10.Interceptive Orthodontics
11.Local Anesthesia
12.Oral surgery
13.Traumatic Dental Injury
14.Medical Conditions
15.Pharmacologic Behavioral
outline
Management
Indication of extraction of primary teeth

• Extensive caries / unrestorable teeth

• Non vital / infected tooth
• Fractured teeth
• Overly retained teeth
• Interferes with normal eruption pattern of
permanent teeth
• Supernumerary teeth
Preoperative considerations
1. Informed consent
• Before any surgical procedure it must be obtained
from the parent or legal guardian.
2. Medical evaluation
• Obtaining: (1) thorough medical history, (2)
appropriate medical and dental consultations
• anticipating and preventing emergency situations
Preoperative considerations
3. Dental evaluation
• clinical and radiographic preoperative evaluation of the dentition as
well as extraoral and intraoral soft tissues
• complicated by the presence of developing tooth follicle.

4. Behavioral evaluation
• Many children benefit from modalities beyond local anesthesia (the need
for pharmacological technique)
• assessment of the social, emotional, and psychological status of the
pediatric patient prior to surgery.
• Children have many unvoiced fears concerning the surgical experience,
and their psychological management requires that the dentist be
cognizant of their emotional status.
Extraction Considerations
• When extracting primary teeth, consider the position of
the permanent tooth bud.
• Consider sectioning the primary teeth if its roots are
extremely divergent or if it locks into the permanent
tooth. (IMPT: diagnostic radiograph)
• Should the permanent tooth bud be accidentally
extracted, the tooth bud is replaced and sutured close.
 Maxillary and Mandibular
Anterior teeth

Movement:
rotational
 Maxillary and Mandibular Molars

•Primary molars have roots: smaller in diameter and

more divergent
•Root fracture common due to:
•(1) anatomy
•(2) potential weakening of the roots caused by the
eruption of their permanent successors.
 Mandibular
Maxillary molars:
molar:
•151s
• 150s
• 18Rss/18Ls •17s
 Cowhorn Forceps
•not used during the mixed
dentition stage due to possible
injury to the permanent teeth
•It attaches to the furcation area of
the tooth. hence, if permanent
tooth is right at the furcation area,
you can inadvertently extract it.
 Fractured primary tooth roots
Contraindication for removal:
Indication for
• root tip is very small
removal:
• located deep in the socket
• fractured root tip
• situated in close proximity to the permanent
can be removed
successor
easily
• unable to be retrieved after several attempts
• best left to be resorbed documented
PLAN • parent must be informed • patient should be monitored
• complete record of the at appropriate intervals to
discussion must be evaluate for potential adverse
effects
 Supernumerary tooth
• Causes:
• Malocclusion
• interfere with orthodontic treatment
• It may cause diastema. (T/C thick fibrous frenum
attachment or large jaw)
• Treatment:
• If erupted → extraction
• Unerupted → wait to erupt then extract
• Impacted → surgical removal
Impacted Teeth: Treatment
•Surgical exposure → teeth relevant in occlusion
•Odontectomy → teeth that causes crowding and
further problems
Frenotomy
• Cutting of lower lingual frenum
• Surgical treatment of Ankyloglossia
• Procedure:
• Lingual nerve block on both sides.
• Stabilize the tongue by holding it up with gauze or Traction Suture
• cut the frenum with surgical scissor
• Suture the underside of the tongue and not the floor of the mouth.
If you suture incorrectly, you might damage your salivary glands.
Review
• If root of molar to be extracted is extremely divergent
consider _____________
• What to do if permanent tooth bud is inadvertently
removed?
• Movement of forceps when extracting primary anterior
tooth?
• Rationale why root fracture is common in primary tooth?
1. Oral anatomy
2. Diagnosis/ Comprehensive
Examination
3. Development of Teeth and
Developmental Disturbances
4. Oral pathology
5. Prevention/fluoride
6. Caries and Periodontology
7. Restorative dentistry
8. Pulp therapy
9. Behavioral Management
(Non-pharmacologic)
10.Interceptive Orthodontics
11.Local Anesthesia
12.Oral surgery
13.Traumatic Dental Injury
14.Medical Conditions
15.Pharmacologic Behavioral
outline
Management
 •Peak incidence 2-4
years and then 8-10
years
•Male: female 2:1
ratio
Frequency of TDI
in children
History
• Question to ask:
• When and how did the trauma occur?
• Were there any other injuries sustained?
• What initial treatment was given?
• Have there been other dental injuries in the past?
• Is the child fully immunized against tetanus?
Oral Examination
• EXTRAORAL • INTRA-ORAL
• Facial skeleton, skull and • Soft tissue – laceration,
facial bone hematoma
• Soft tissue – laceration, • Fractures or displacement
grazing etc. of bone
• Assessment paresthesia • Displacement and
damage to teeth
• Alterations in the
occlusion
• Mobility, pulp exposure,
percussion
Radiographs
Fractures Radiograph
Dento-alveolar injuries Periapical films
Panoramic
radiographs
Mandibular Panoramic radiograph
fracture/condylar Cone-beam computed
head fracture tomography scan
True mandibular
occlusal
Maxillary fractures CT scan
Percussion test
• Percussion test are of great value in
determining apical inflammation.
• previously traumatize tooth is tender to
percussion usually indicates pulp necrosis

• Note: immediate vitality test might

give false negative response due to
impaired nerve conduction.
•REMEMBER:
underneath the primary
tooth are permanent
tooth
•Treatment of
traumatized primary
tooth would always
consider the
succedaneous teeth
underneath
 Traumatic Dental Injury
• Infraction
• Enamel fracture
• Enamel-dentin fracture
• Enamel-dentin-pulp fracture
• Crown-root fracture without
pulp exposure
• Crown-root fracture with
pulp exposure
• Root fracture
• Alveolar fracture
• Concussion
• Subluxation
• Extrusive luxation
• Lateral luxation
• Intrusive luxation
Ellis classification of tooth fracture
Class I Enamel fracture

Class II Enamel and dentin

fracture without pulp
exposure
Class III Crown fracture with pulp
exposure
Class IV Traumatized tooth that
became non-vital with or
without loss of tooth
structure
Ellis classification of tooth fracture

Class V Avulsion

Class VI Root fracture

Class VII Dislocation/luxation

Class VIII Fracture of entire

crown
Class IX Injuries to primary
teeth
Infraction
• An incomplete fracture (crack) in enamel
• Best diagnosed with transillumination (some use disclosing
solution to see fracture line)
• Best prognosis, low risk of pulpal necrosis
• (-)tenderness
• Tx: Etching with sealing to prevent discoloration

ENAMEL FRACTURE (ELLIS CLASS I)

(-)tenderness, (-) mobility
Tx: smoothen sharp edge or composite
build up
ENAMEL-DENTIN fracture (Ellis Class II)
• (-)tenderness, (-) mobility
• Tx: Tooth fragment can be bonded to the tooth
using flowable resin. If exposed dentin 0.5mm
near the pulp (pink w/o bleeding) place
calcium hydroxide with Glass ionomer base

ENAMEL-DENTIN-PULP fracture (Ellis Class III)

(-)tenderness, (-) mobility, (+)sensitive
to stimuli
For primary teeth: if near exfoliation
extract
 • (+)mobility of coronal segment, (+)tender to
percussion, (+)bleeding from gingival sulcus,
transient crown discoloration
Primary teeth Permanent teeth
coronal not displaced → Tx: reposition →
no treatment stabilize with splint
coronal displaced → for 4 weeks →pulp
reposition and splint or necrosis do RCT
remove fragment and let
root resorb

Note: fractures in the middle 3rd or near cervical has

Root fracture poor prognosis but splinting is still the choice
Alveolar fracture
• (+)segment mobility, dislocation of
several teeth, (+)malocclusion
• Tx: reposition any displaced
segment then splint, suture gingival
laceration → stabilize for 4 weeks
 Concussion
• Tooth not displaced with little
mobility
• (+)tender to percussion
• Tx: none
 Subluxation
• Tooth not displaced with mobility
• (+)tender to percussion, (+)bleeding from
gingival crevice
• Tx: none or flexible splint for 2 weeks
Extrusive luxation
• Tooth displaced out of socket, may
appear elongated
Primary teeth Permanent teeth
Tx: immature root or Tx: reposition gently,
developing → careful re insert to the
reposition and leave socket, stabilize for 2
for spontaneous re- weeks → becomes
eruption necrotic RCT
Tx: severe extrusion
mature root →
extraction
 Lateral Luxation
• Tooth displaced palatal/lingual or labial direction
• (-)mobility, percussion: metallic or ankylotic
sound
Primary teeth Permanent teeth
no occlusal interference Tx: reposition the tooth
→ reposition naturally digitally, stabilize for 4
minor interference → weeks → becomes
slight grinding of tooth necrotic RCT
severe interference → LA
then gently reposition
severe displacement →
extraction
Intrusive Luxation
• Displaced axially into alveolar bone
• (-)mobility, percussion: metallic or ankylotic sound

Primary teeth Permanent teeth

Tx: displaced to labial bone Tx immature root: allow

(apical tip can be visualized
tooth appears shorter)→ left
for re-eruption
2-4month reeruption usually
occurs
Tx: apex displaced tooth
germ (apical tip not
visualized and tooth appears
elongated) → extract
eruption without
intervention
Tx mature root: no
movement after 2-3 weeks
→ reposition surgical or
orthodontic → necrotic pulp
RCT
Avulsion
•Take a radiograph to make
sure that tooth not intruded
•Never reimplant primary
teeth due to poor prognosis
or worse it could alkylose
Avulsion of Permanent teeth:
First Aid
• Keep patient calm
• Find tooth and pick it up by the crown. Avoid
touching the root
• If tooth is dirty wash it briefly under cold
running water (max 10seconds)
• Encourage reimplanting the tooth, then bite
cotton or cloth/ if not possible store in a
suitable storage medium
• Seek dental treatment immediately
PDL cells viable PDL cells may be PDL cells non-
viable but viable
compromised
replanted kept in storage drytime >60min
immediately or medium <60min regardless of the
after the accident (saliva, HBSS, storage medium
saline,milk)
Closed apex vs Open apex
Avulsed permanent
• Leave in place → if not in place reimplant it in proper position
• Clean: water spray, saline or chlorhexidine
• Suture: if there are lacerations
• Verify normal position with radiograph →
• Flexible splint: 2 weeks
• Antibiotics and Tetanus
• Root canal 7-10 days after prior to splint removal
• Fractured maxillary anterior
teeth occur most often in
children with Class II, Division I
malocclusion (maxillary
anteriors are flared).
 SPLINTING
• 1. Fixed splinting, as opposed to flexible splinting, is the
preferred approach for root fractures. Note: 0.032 to
0.036 SS wire and bonded composite is commonly
used.
SPLINTING
• 2. Currently the standard monitoring period for fixed splintin
for root fractures is 3 months/ cervical fracture.
• 3. Approximately 75% of permanent teeth with root fracture
maintain their vitality.
SPLINTING
• 4. Treatment of root fractures of the
apical third of the root has by far the
best prognosis. You have a better
chance of stabilizing and maintaining
the vitality of the tooth if you are
confronted with a fracture in this area
SPLINTING
• 5. These teeth should be monitored
aggressively, with follow-up clinical and
radiographic evaluations every 3 to 6
months for the first year. Any sign of
necrosis or resorption warrants initiation
of root canal therapy immediately.
SPLINTING
• 6. Root fractures involving primary teeth are relatively
uncommon because the more pliable alveolar bone
allows displacement of the tooth.
• 7. Splinting is not recommended in the primary
dentition. Due to compliance and prognosis
General recommendation/ consideration

•Use of antibiotics
•Soft tissue injuries (gingiva,
lips, PDL involvement such
as Avulsion and Luxation)
•Sensibility tests
•Transient lack of pulpal
response
•EPT check during first
recall
 General recommendation/ consideration
• Immature permanent teeth: better prognosis, ability to
re-vascularize
• Dental injury: Crown fracture + luxation injury
• Severe luxation injury: Pulp canal obliteration in open
apex
• Post operative instructions
• Oral hygiene, adjunct: chlorhexidine gluconate 0.1% alcohol
free for 1 week
• Avoid participation in contact sports
• Soft diet: 2 weeks
• Brush teeth with soft bristle toothbrush after each meal
Facts about darkened teeth
➢80% of primary incisors that darkened due to injury are
asymptomatic
➢Occasionally these teeth will lighten
➢15% of these teeth will need to be removed in one year’s
time.
➢85% of these teeth will remain until normal exfoliation
➢You will not see any defects in permanent teeth due to
primary teeth dental trauma UNLESS they haven’t finished
calcification
Possible reactions of tooth to trauma
➢Pulpal hyperemia – pulp’s initial response to trauma. Capillary
congestion may lead to necrosis
➢Pulpal bleeding – internal hemorrhage, due to hyperemia the
capillaries leaves hemorrhage leaving blood pigments
deposited in the dentinal tubules. Teeth will darken within 1-2
days after injury. Color changes after weeks or months are
more prone to necrosis
➢Pulp canal obliteration – progressive deposition of dentin.
90% of primary teeth resorbs normally
Possible reactions of tooth to trauma
➢Pulpal necrosis- may occur immediately or after a few
months
➢Inflammatory resorption – external or internal
resorption that can destroy tooth within months
➢Replacement resorption/ankylosis – injury to PDL
 Splint duration
• Avulsion – 2 weeks
• Extrusive Luxation – 2 weeks
• Lateral Luxation – 4 weeks
• Alveolar fracture – 4 weeks
 Ellis classification of tooth fracture
Class I Enamel fracture Smooth enamel edges, restore tooth

Class II Enamel and dentin Apply calcium hydroxide to expose dentine and
fracture without pulp restore tooth with permanent restoration
exposure
Class III Crown fracture with pulp Immediately after injury apply calcium hydroxide
exposure and place temporary restoration
If exposure happened several hours or days
perform calcium hydroxide pulpotomy
Once apex close do pulpectomy
Non vital - apexification
Class IV Traumatized tooth that Calcium hydroxide pulpotomy and once apex
became non-vital with or closed do pulpectomy/apexification
without loss of tooth
structure
PEDIATRIC DENTISTRY
Nathalya Bmay A. Subido, DMD
1. Oral anatomy
2. Diagnosis/ Comprehensive
Examination
3. Development of Teeth and
Developmental Disturbances
4. Oral pathology
5. Prevention/fluoride
6. Caries and Periodontology
7. Restorative dentistry
8. Pulp therapy
9. Behavioral Management
(Non-pharmacologic)
10.Interceptive Orthodontics
11.Local Anesthesia
12.Oral surgery
13.Traumatic Dental Injury
14.Medical Conditions
15.Pharmacologic Behavioral
outline
Management
 Measles (Rubeola)
http://medical-photographs.com

▪Highly contagious viral illness characterized by fever, cough,

and spreading rash. Caused by paramyxovirus
▪Incubation period: 1-2weeks
▪Oral lesion are pathognomonic of this disease – “koplik’s
spots” usually occur in buccal mucosa 1-2mm yellow-white
necrotic ulcer that are surrounded by a bright red margin
 ▪Fairly benign viral disease
Rubella (German
Measles) ▪Usually a red, bumpy rash, swollen
lymph nodes (neck and ears), and
mild fever. some people will feel a
little achy. Virus manifest in the oral
cavity as small petechiae-like spots
of the soft palate.
▪The defects of congenital infection
from infected mother are more
severe – enamel defects,
hypoplasia, pitting and abnormal
tooth morphology
https://drhem.files.wordpress.com
➢Acute viral disease, it manifests itself

redbook.solutions.aap.org
clinically by the occurrence of high
fever, nausea, vomiting, chills and
headache
➢Skin lesions begin as small macules
and papules first appear on the face
but rapidly to cover much of the
body
➢Oral manifestation include Small pox
ulceration of the oral mucosa and
pharynx. In cases tongue is swollen (variola)
and painful making it hard to swallow
Mumps
➢acute contagious viral infection
characterized chiefly by lateral
swelling of the salivary gland
usually the parotid
➢Papilla of the opening of the
parotid duct on the buccal
mucosa is often puffy and
reddish
 Cleft lip and cleft palate
➢account for half of the total number of defects
Cleft Lip
• Lip and primary palate begin
to develop at 4-5weeks
gestational stage.
• Failure in fusion of two
medial nasal swellings and
the maxillary swelling fuse
• Males more affected and
more frequent on left side
Cleft Palate
• Secondary palate develops
approximately 10 weeks
gestational stage.
• Failure of fusion of paired
palatal shelves and primary
palate
• Females are more affected
Four classes of CLEFT LIP
Class I unilateral notching of the vermillion not extending to
the lip/failure of maxillary process to fuse with
medial nasal process
Class II class I but the cleft extends into the lip but not to the
floor of the nose
Class III class II but extending into the floor of the nose
Class IV any bilateral clefting of the lip whether incomplete
notching or complete clefting/ failure of both
maxillary process fuse with the medial process
Four classes of CLEFT PALATE
Class I involves only the soft palate
Class II involves only the soft and hard palates
Class III same as class II with alveolar process
involvement on one side of the premaxilla
Class IV involves soft palate and continues through
alveolus on both sides of premaxilla
•TYPE 1 DIABETES MELLITUS (Insulin-dependent
diabetes mellitus IDDM)
➢Juvenile onset diabetes. Rare, 5% of all cases
➢Ages 5-15 years
➢Familial history
➢Prone to infection
• TYPE 2 DIABETES MELLITUS (Non Insulin-Dependent
Diabetes Mellitus NIDDM)
➢Maturity onset diabetes, common 95% of all case
➢Onset is usually in mid or later life
Diabetic Child: Signs and Symptoms

www.cornerstones4care.com
 The diabetic child: Dental Management
➢Dental appointments should be short and stress, pain
and trauma free as possible as anxiety can increase
blood glucose levels.
➢Advise the patient to eat normal meal before
appointment to avoid hypoglycemia
➢Have a glucose source available to treat onset of
hypoglycemia
➢Severe hypothyroidism in a child
characterized by defective mental and CRETINISM
physical development.
➢Dental findings:
▪ underdeveloped mandible
▪ overdeveloped maxilla
▪ enlarged tongue which leads to malocclusion
and delayed eruption of teeth and deciduous
teeth retained longer
▪ Anterior open bite
▪ flared incisor
▪ Thickened lips
▪ unerupted yet fully developed permanent
dentition
primehealthchannel.com
➢Adults: Myxedema
Blood disorders: Anemia
▪Reduction in the oxygen
carrying capacity of the
blood. Related to a
decrease in the number of
circulating red blood cell to
an abnormality in
hemoglobin.
▪It is rather a symptom than
a disease decrease
production in RBC
Dental management:
➢ Safely managed with LA
GA: if severe anemia
➢ Preoperative correction of
hemoglobin level are
recommended
➢ Comanage with hematology
department
 Congenital heart disease:
➢problem with the structure of the heart present at birth
❖Risk of infective endocarditis
❖Increase risk of bleeding
❖Management under GA if required
➢Intraligamentary injections produces high level of
bacteremia.
➢Many cardiologist recommend that dental treatment
should be avoided in 6 months post operatively where
possible as the patient remains at risk of IE for significant
length of time following the surgery
 CHD: Infective Endocarditis
➢Infection of the lining of the heart chamber
and heart valves caused by bacteria and
viruses
➢Dental treatment is associated with IE
because the bacteria that causes IE which is
the streptococcus viridans-alpha hemolytic
streptococci is commonly found in the
mouth
➢Prophylactic antibiotic required
http://www.mayoclinic.org
➢Comanage with cardiologist
 Not recommended: dental
Recommended: dental procedures not likely to
procedure known to induce gingival bleeding
induce gingival or (simple adjustment of orthodontic
mucosal bleeding even appliance or fillings above the
gingival margin, injection of LA
scaling and polishing (except intraligamentary) and
exfoliation of primary teeth)

CHD: prophylactic antibiotic

Child Prophylactic regimens for Dental and Oral Procedures
Situations Agent Dosing regimen: single
dose 30-60 min before
procedure
Amoxicillin 50mg/kg (max 2 g)
Penicillin allergy Clindamycin 20mg/kg (max600mg)

Cephalexin or 50mg/kg (max 2g)

Cefadroxil
Azithromycin or 15mg/kg (max500mg)
Clarithromycin
Anodontia manifestations by these
medical conditions:
Ectodermal Dysplasia
• almost no eyebrows and absence of
sebaceous gland (low heat tolerance),
sparse hair, dry skin, concave nasal
bridge, alveolar bone is not evident due
to lack of teeth
• Primary teeth present may be normal or
decrease in size, anterior teeth conical
Supernumerary
• Etiology: accessory tooth buds
differentiating from dental lamina
most common in permanent
dentition (excessive Initiation)
• Found in patients with Cleidocranial
Dysostosis absence of clavicles
defective ossification of the skull
faulty occlusion due to missing,
misplaced or supernumerary teeth.
Prolonged retention of primary teeth
or delayed of absence of permanent
teeth
➢Trisomy 21 chromosomal disorder. One in 800-1000 Down
live births. syndrome (DS)
➢Learning disability is a universal feature of DS. Degree
vary from individuals.
➢Behavioral problem: most of them are amicable→
local anesthesia
➢Uncooperative→ consider GA comanage with a
physician
➢Benefit from → speech therapy, occupational therapy,
and exercises to help improve their motor skills
➢Cardiac problems: Congenital heart disease affects www.intechopen.com
around 40% of DS infants.
Downs syndrome
• lacking 31,41 Class III
• Partial anodontia etiology
congenitally missing teeth (most
common upper and lower
laterals, upper and lower 3rd
molars and lower 2nd PM)
Down syndrome (DS)
Malocclusion:
▪ cross bites, anterior open bites and class III malocclusion (common)
▪ Microdontia and Partial Anodontia (missing lower central incisors)
▪ Macroglossia causing flared incisors
Periodontal disease:
▪ increase prevalence due to compromised immunity and poor oral
hygiene
Dental caries:
▪ low due to higher salivary pH and low Strep. mutans counts with shallow
fissures
Autism Spectrum Disorder (ASD)

➢Lifelong developmental disability that becomes

evident in infancy usually within first 3 years of life
➢Affects the area of brain that:
▪controls language
▪social interaction
▪creative and abstract thinking
▪affect the way the person communicates with and
related to people and the world around them
➢Common in Males
ASD: Dental management
➢Tell Show Do, Positive Reinforcements, Modelling
➢use clear, simple language with short sentences and use
direct request
➢develop a routine in which the child is not kept waiting
and has short quiet visit, including being seen by the
same dental staff.
➢If they are disturbed by the noise of the air motor or
saliva ejector and can’t be managed GA is required
Attention deficit hyperactivity disorder (ADHD)

▪ Condition that becomes apparent in some children in the

preschool and early school years.
▪ It is hard to control their behavior and/or pay attention
▪ Cause is unknown. More common in males
▪ Children are affected whether intellectually handicapped or
not, perform poorly in school because inability to attend to
task at hand or sit during the school day.
▪ In most cases they don’t need special treatment.
▪ Common medication: Stimulants (methylphenidate,
amphetamine)
Epilepsy
disease that involves
seizures resulted from
abnormal electrical
activity in the brain

Protect the patient

from physical trauma
 Epilepsy
1. Phenytoin – anti-epileptic drug causes gingival
hyperplasia
2. Carbamazepine – anti-convulsive drug that causes
xerostomia, ulcer, glossitis and stomatitis
3. Sodium valproate
4. Phenobarbital
Emergency medications: Midazolam and Diazepam (sedative)
Epilepsy: dental management
• major difficulty a dentist faces is the high risk of seizures occurring
Three fundamental principles to prevent seizure:
1) knowledge of the patient’s previous seizure episodes and
medication
2) knowledge of the conditions that provoke epileptic seizures, in
order to avoid such conditions
3) dentist should be able to recognize the early signs of a seizure,
take precautions before it occurs, and provide the patient with supportive
care if it does occur
 Cerebral palsy
➢Most common congenital neuromuscular handicap resulting
from damage to the brain early in the course of its development
➢during fetal development
➢during birth process
➢during the first few months after birth.
➢The motor disorder of cerebral palsy are often accompanied by
disturbances of sensation, cognition, communication,
perception, behavior and/or seizure disorder
 Cerebral palsy
• Dental management
➢Issues are communication and
behavior, involuntary movements
and seizure disorders
➢Simple routine care is possible
➢GA or IV sedation would often be
required to provide comprehensive
care
Pituitary dwarfism
Pituitary gland doesn’t produce
enough Growth Hormone
• eruption rate and the shedding
of the teeth are delayed
• clinical crowns appear smaller
as do the roots of the teeth the
dental arch as a whole is
smaller causing malocclusion
• mandible is underdeveloped
Pituitary Gigantism
Growth Hormone (GH) excess
• Enlarged tongue
• mandibular prognathism
• teeth are usually tipped to the
buccal or lingual side
• Roots may be longer than
normal
 www.researchgate.net

Aspert syndrome
• Genetic defect and falls under the broad classification of
cranial/limb anomalies; premature fusion of certain skull
bones (craniosynostosis); fused fingers and toes
(Polydactyly and syndactyly )
• Dental manifestations:
➢delayed eruption, ectopic eruption, and shovel-shaped
incisors
➢anterior and posterior crossbites and severe crowding of teeth
• Retrusion of the midface is often corrected by performing
Lefort II surgical procedure
http://www.chop.edu
 http://img.medscape.com
Le fort 1 le fort 2 le fort 3
• Uncommon, craniofacial disorder
characterized by craniosynostosis and
dysmorphic facial features.
• Short head, widely spaced eyes, shallow
orbits and protruding eyeballs, Calcified
stylohyoid ligaments
• Dental Manifestations:
➢Maxillary hypoplasia
➢reduced width of the dental arch http://www.forgottendiseases.org/

and crowded teeth

➢Short upper lip
Crouzon
➢Possible unilateral or bilateral
crossbites
syndrome
http://shulamithhighschool.org

➢ involve underdevelopment of the

zygomatic complex, cheekbones, jaws,
palate and oral cavity (mouth) which can
lead to breathing (respiratory) and
feeding difficulties
Dental manifestations:
Treacher Collins ➢Cleft palate
syndrome ➢shortened soft palate
➢rare genetic disorder ➢Malocclusion
characterized by Mandibular ➢anterior open bite
Dysostosis and Craniofacial
abnormalities ➢enamel hypoplasia
Children with cancer: Considerations
➢the child has been diagnosed with a life-
threatening condition. An empathic approach is
required
➢some forms of cancer may, and frequently do,
have oral manifestations
➢cancer leads to child’s immune system being
compromised (direct immune suppression)
➢most treatment protocol causes indirect
immune suppression
➢may treatment protocol cause oral side effects
Oral effects of Chemotherapy
SHORT TERM EFFECTS LONG TERM EFFECTS
Acute dental infection Dental abnormalities
Chronic periapical infections can become acute such as:
Ulcers mucositis Hypoplasia
Bleeding and marginal gingivitis, petechiae, Microdontia
ecchymoses Taurodontism
Xerostomia can lead to caries and infection Failure of teeth to
Trismus develop
Pain in jaw Root constrictions
Delayed and abnormal development
Oral effects of Radiotherapy
SHORT TERM EFFECTS
All effects of chemotherapy can
also occur with radiotherapy.
Specific issues are:
Infection
Radiation caries
Pulp pain and necrosis
LONG TERM EFFECTS
Dental abnormalities such as:
Hypoplasia
Microdontia
Taurodontism
Failure of teeth to develop
Root constrictions
 cancer of the blood or bone marrow (which
Leukemia produces blood cells), suffers from an
abnormal production of blood cells, generally
leukocytes (white blood cells)

➢Acute lymphocytic (or lymphoblastic) leukemia (ALL) –

• diagnoses in children under the age of 15 peak is 4 years old
• form of acute leukemia that is most responsive to therapy
• 5 year survival rate
➢Acute myeloid (or myelogenous) leukemia (AML)
• common type of acute leukemia
• worst prognosis
Leukemia
Early signs of fatigue, pallor, weight loss and easy bruising, fever,
acute hemorrhages, extreme weakness, bone and joint pain
leukemia and repeated infection

Oral findings gingival oozing, petechiae, hematoma or ecchymosis,

oral ulceration, pharyngitis and gingival infection which
is unresponsive to conventional therapy, submandibular
lymphadenopathy
Candidiasis's common due to poor immune response
Special care needs
• Deaf and Mute- modification of TSD is Show-Say-Do. Some
can Lip Read or can-do sign language; you can also ask for an
interpreter
• Visually impaired- Tell-Touch-Do; some can be sensitive to
light so you need to cover their eyes. They can use Braille for
reading but you can communicate with them well. Positive
voice control is vital.
1. Oral anatomy
2. Diagnosis/ Comprehensive
Examination
3. Development of Teeth and
Developmental Disturbances
4. Oral pathology
5. Prevention/fluoride
6. Caries and Periodontology
7. Restorative dentistry
8. Pulp therapy
9. Behavioral Management
(Non-pharmacologic)
10.Interceptive Orthodontics
11.Local Anesthesia
12.Oral surgery
13.Traumatic Dental Injury
14.Medical Conditions
15.Pharmacologic Behavioral
Management
outline
Use of sedation and GA
Factors to be considered:
❖Age
❖Medical condition
❖Behavioral management problems
❖Support from parents/guardian
❖Experience and training of dental team in sedation
Use of sedation and GA
➢Pre-assessment
➢Full update medical history
➢Anesthetic history
➢Clear instructions to the parents/guardian to allay
anxieties
➢Pre-medication
➢Ensure consent form
➢Anatomical considerations
➢There are medical conditions with facial and oral
abnormalities. Airway should be assessed
Nitrous oxide sedation
▪ Sedation for children; Slightly sweet smelling, colorless, inert
gas
▪ Altered state of awareness; Analgesic, anxiolytic, amnestic
▪ Minimum oxygen conc.=30% or minimum oxygen flowrate = 3-
5L/min
Advantage:
▪ Rapid onset and recovery
▪ Ease of dose control (titration)
▪ Lack of serious adverse effect (vomiting,nauseous)
▪ After sedation required 100%oxygen for not less than 3-5 mins
Sedative agent: Chloral hydrate
➢acts on CNS to induce sleep, sedative hypnotic
➢Commonly used in pediatric patients
➢Bitter tasting can produce management problems
during administration
➢At normal doses, the sleep induction does not affect
breathing, blood pressure or reflexes
➢it may be used before some surgeries or procedure to
help relieve anxiety and to induce sleep
➢Onset 15-30min
General anesthesia
➢medically induced coma, patient unresponsive
and unconscious.
➢administered intravenously (IV) or inhaled
➢Under general anesthesia, the patient is unable
to feel pain and may also have amnesia.
• Stage 1 (induction): this phase occurs between the
administration of the drug and the loss of consciousness.
• Stage 2 (excitement stage): the period following a loss of
consciousness, characterized by excited and delirious activity.
• Stage 3 (surgical anesthesia): muscles relax, vomiting
stops and breathing is depressed. Eye movements slow
and then cease. The patient is ready to be operated on
• Stage 4 (overdose): too much medication has been
administered, leading to brain stem or medullary suppression;
this results in respiratory and cardiovascular collapse
Indications for use of general anesthesia
• Adjunct to complete dental care of the following groups
1. Children with mental retardation to the degree that
communication is impossible
2. Children in whom all other methods have proven unsuccessful
3. Patient allergic to other anesthetics
4. Patients who suffer from hemophilia
5. Patients with involuntary movements
6. Patients with systemic disorders and/or congenital anomalies
 REFERENCES
• Fundamentals of Pediatric Dentistry. 3rd Ed. Richard Mathewson; Robert E
Primosch
• Dentistry for the Child and Adolescent. 8th Ed. Ralph McDonald; David Avery;
Jeffrey Dean.
• Kaplan Medical NBDE Part II. 2009-10 edition.
• Guideline on Pediatric Dentistry. American Association of Pediatric Dentistry. 2009,
2011, 2014 revision
• Dental DECKS Part 2 Edition 2011-2012 Pediatric Dentistry
• Mosby's Review for the NBDE Part II (Mosby's Review for the Nbde: Part 2
(National Board Dental Examination)) 2nd Edition
• Special Care in Dentistry Handbook of Oral Healthcare 1st Edition. Crispian
Scully Pedro Diz Dios Navdeep Kumar
• Little and Falace's Dental Management of the Medically Compromised Patient
7th EditionJames Little Craig Miller Nelson Rhodus