Introduction*to*Pediatric*Dentistry*

Pediatric*dentistry*–*encompasses*all*of*a*general*dentist’s*skills*as*well*as*necessitating*an*
understanding*of*child*development*and*disease*

Positive(Experience:(

Visiting*the*dentist*as*a*child*should*be*a*positive*experience*–*this*is*important*because*it*essentially*
effects*how*they*will*view*visiting*the*dentist*for*the*rest*of*their*life*

How*do*we*generate*a*positive*experience?**

1) Establish*a*rapport*with*the*parent/guardian*and*the*child*by:*asking*appropriate*questions*and*
taking*the*collected*information*and*coming*up*with*a*proper*treatment*plan*
2) Preempt*problems*–*be*prepared*
3) A*sticker/prize*

First(Appointment:(*A(large(portion(of(the(initial(dental(exam(is(completed(without(having(to(pick(up(
an(instrument(

K Initial*exam:*chief*complaint,*medical*history,*social*history,*dental*history*
K Physical*exam:*extraoral*exam,*soft*tissue*exam,*hard*tissue*exam*
K Radiographs*(if*necessary)*
K Caries*risk*assessment*
K Treatment*plan*
K Present*case*
K Prophy,*fluoride*
K Oral*hygiene*instruction/nutrition*counseling*

Evaluate*general*appearance:*overall*facial*and*physical*features,*heightKweight*proportionality,*size*
consistency*with*age,*cleanliness*of*clothes/skin/hair/nails,*obvious*signs*of*injury,*disease*or*disability,*
eye*contact,*body*language*

*
INITIAL(EXAM(
4*steps*of*the*initial*exam*(history)*
1) Chief*complaint*–*reason*the*parent*brought*the*child*in*
2) Medical*history*–*review*medical*history;*always(follow*up*with*these*open*ended*
questions:*
a. Is*your*child*in*good*health?*Past*serious*illnesses?*
b. When*was*the*last*time*your*child*was*seen*by*a*PCP*
c. Is*your*child*up*to*date*on*immunizations*
d. Medications?*Allergies?*
e. Was*your*child*ever*hospitalized*by*any*reason*at*all?*
 3) Social*history*–*determine*who*the*guardian*is;*does*the*child*go*to*school?*What*
grade*are*they*in?*Who*does*the*child*live*with?*Siblings?*Any*habits?*
4) Dental*history*–*review*dental*history*–*when*were*they*last*seen*by*a*dentist?*Was*
any*treatment*performed*at*that*time?*How*did*the*child*tolerate*that*treatment?*
Review*the*home*dental*care*–*how*often*do*they*brush/floss*and*who*does*this*for*
them?*

Review*diet;*if*child*has*numerous*caries,*try*to*find*out*why*

*These*questions*are*important*because*knowing*your*patient*well*will*aid*in*treatment,*and*
also*because*dentists*have*the*responsibility*to*check*for*signs*of*child*neglect*or*abuse*

PHYSICAL(EXAM:*extraoral*exam,*soft*tissue*evaluation,*hard*tissue*evaluation*

!*Palpation*of*the*submandibular*and*neck*regions*is*indicated,*especially*along*
the*locations*of*the*lymph*node*chains;*a*TMJ*exam*should*be*done*–*the*heads*
of*both*condyles*should*be*checked*when*the*mouth*is*open*and*closed*and*on*
opening*and*closing*

*
 *

Checking*the*gingiva*in*pediatric*patients:*gingivitis*in*children*is*extremely*common;*
nevertheless,*extensive*periodontal*disease*involving*the*deeper*periodontal*tissues*is*
uncommon*in*children*

Hard*tissue*evaluation:*examine*teeth,*occlusal*analysis,*count(the(teeth;(perform*an*
occlusal*analysis*(alignment/crowding,*overbite,*overjet,*molar*relationship/cuspid*
relation,*transverse/midline/crossbites);*check*for*caries*with*air*syringe***

Note:*be*careful*when*using*an*explorer*especially*on*young*permanent*teeth**K*you*can*
damage*the*incoming*tooth*

Order*eruption*of*primary*dentition:*

1) Primary*central*incisors*(mandibular*first)*
2) Primary*lateral*incisors*
3) Primary*first*molars*
4) Primary*cuspids*
5) Primary*second*molars*

*
Early(childhood(caries:(

Occlusal(Analysis:(

K Primary*molar*relationships:*

o Mesial*step*relationship**
o FlushKterminalKplane*relationship*
o DistalKstep*relationship**

Growth*and*Development:*the*downward*and*forward*movement*of*the*maxillary*
and*mandibular*arches*can*be*seen*in*this*image;*it*is*a*tracing*of*superimposed*
radiographic*films*of*the*head*showing*the*normal*downward*and*forward*facial*
growth*pattern*at*ages*six*months,*3*years*and*8*years*

!*Class%I%molar%relationship:*MB*cusp*of*the*maxillary*first*molar*is*
located*over*the*buccal*groove*of*the*mandibular*molar;*maxillary*
canine*is*placed*in*the*embrasure*between*the*mandibular*canine*and*
the*mandibular*first*primary*molar*

!*Class%II%Division%I:*distal*step*primary*molar*relationship*and*a*
maxillary*protrusive*relationship*in*the*anterior*
segment*

Class%II%Division%II:*lower*first*molar*distal*to*the*upper*first*molar*and*a*deep*"*
overbite*reflected*in*the*patient*profile*

Class%III:*the*mandibular*arch*is*displaced*mesially,*with*the*mesiobuccal*cusp*of*"*
the*maxillary*first*molar*occluding*distal*to*the*buccal*groove*of*the*mandibular*first*
molar*
RADIOGRAPHS*

Base*your*decisions*about*radiographs*on*the*actual*needs*of*each*individual*patient*;*radiographs*are*
essential*to*complete*a*thorough*diagnosis*

K When*there*are*no*contacts,*we*do*not*need*radiographs!*
K If*the*contacts*are*closed:*2*bitewings*(largest*size*that*fits)*and*1*occlusal*
K Panorex*taken*by*age*9*to*monitor*eruption*of*canines*

Taking*radiographs*can*be*difficult*with*some*children*–*may*have*difficulty*holding*still*or*holding*the*xK
ray*packets*in*their*mouths;*gagging;*fear.*

# Maxillary*occlusal*view:**2*of*the*more*common*abnormal*findings*=*mesiodens*and*missing*
permanent*lateral*incisors;*a*size*2*film*is*placed*between*the*teeth*as*shown*in*the*drawing:*

* *
# Bitewings:**a*size*0*film*is*used*with*small*children;*a*size*2*film*is*used*as*soon*as*the*patient*
can*tolerate*the*larger*film*
# Panorex*

KNEE*TO*KNEE*EXAM*

What*happens*if*the*patient*is*under*the*age*of*3,*the*Mom*is*concerned*about*cavities,*but*the*
child*will*not*sit*in*the*chair*=*knee(to(knee(exam("the*knee*to*knee*exam*allows*the*dentist*to*
examine*the*child,*who*is*either*too*young*or*is*unable*to*sit*in*the*dental*chair*

K What*do*we*need*to*do*a*knee*to*knee*exam?*
o Mirror*
o Explorer*(use*if*necessary*and*safe)*
o Soft*bite*block*
o 2*x*2*gauze*(wipe*teeth*to*remove*plaque)*
o Toothbrush*(use*for*toothbrush*fluoride*treatment*and*for*OHI)*
o Assistant*(to*chart*for*you)*

CARIES*RISK*ASSESSMENT*

K Based*on*AAPD*policy*
K Each*child’s*overall*assessed*risk*for*developing*decay*is*based*on*the*highest*level*of*risk*
indicator*circled*(any*single*risk*factor*checked*off*in*the*“high*risk”*category*=*at*high*risk)*
 K High*caries*risk*factors:*
o Child*has*special*health*care*needs,*especially*any*of*those*that*impact*coordination*or*
cooperation*
o Child*has*condition*that*impairs*saliva*(dry*mouth)*
o Frequency*of*routine*dental*visits*
o Child*has*decay*
o Has*been*less*than*12*months*since*last*cavity*
o Child*wears*braces*or*orthodontic/oral*appliances*
o Child’s*parents/siblings*have*decay*
o Socioeconomic*status*of*children’s*parents*
o Frequency*of*betweenKmeal*exposures*to*sugary*snacks*
o Low*exposure*to*fluoride*

TREATMENT*PLANNING*(general*guidelines)*

K Treatment(by(quadrant(should*be*completed*in*the*order*of:*
o most*serious*quadrant*first*
o permanent*teeth*before*primary*
o posterior*teeth*before*anterior*
o exception:*if*the*patient*is*in*pain,*treat*that*area*first*
K Choice*of*materials*depends*on:*age,*caries*risk,*cooperation*of*child,*restorative*situation*
o Age:*ability*to*cooperate;*how*long*the*restoration*is*required*to*remain*ie.*a*
restoration*in*a*primary*first*molar*in*a*9*year*old*does*not*require*the*same*durability*
as*one*in*a*6*year*old*
o Caries*risk:*if*at*high*risk,*may*choose*stainless*steel*crowns*vs.*fillings*
o Cooperation*of*child:*a*less*cooperative*child*would*required*a*restoration*that*is*not*
highly*technique*sensitive*
o Restorative*situation:*ie.*if*treating*under*general*anesthetic,*materials*known*to*have*
longevity*(stainless*steel*crowns)*should*be*provided*

RESTORATION*OF*PRIMARY*ANTERIOR*TEETH*

K Interproximal*stripping*
K Composite*resins/glass*ionomer*fillings*
K Composite*resin(strip(crowns(*

The Composite Strip Crown

The composite strip crown is utilized to restore primary incisors for the following indications:
1. Incisors with large interproximal lesions
2. Incisors that have received pulp therapy
3. Incisors that have been fractured
4. Incisors with multiple hypoplastic defects or developmental disturbances
5. Discolored incisors
6. Incisors with small interproximal lesions that also demonstrate large areas of decalcification
Select the shade of resin to be used.
Place and ligate rubber dam.
Select a primary incisor celluloid crown with a mesiodistal width approximately equal to the tooth being
restored.
Reduce the incisal edge by 1.5 mm using a fine tapered diamond or #169L bur.
Reduce the interproximal surfaces by 0.5 to 1.0 mm (Figure 27). The reduction should allow a crown form
to slip over the tooth.
The interproximal walls should be parallel, and the gingival margin should have a feather edge.
Reduce the facial surface by at least 1.0 mm and the lingual surface by at least 0.5 mm. Create a feather-
edge gingival margin. Round all line angles.
Place a small undercut on the facial surface in the gingival one third of the tooth with a #330 bur or a #35
inverted cone.

Trim the selected crown form by cutting away excess material gingivally with crown-and-bridge. Trial fit
the crown.
Crown form should fit 1 mm below the gingival crest.
After the crown is fitted, punch a small hole in the lingual surface with an explorer to allow for the escape
of trapped air and filling material.
Etch the tooth for 15-20 seconds.
Rinse and dry the tooth, then apply a dentin bonding agent. Blow compressed air on the tooth for a
couple of seconds.
Fill the crown form approximately 2/3 full with a resin-based composite material and seat onto the tooth.
While holding the crown in place, remove excess material with an explorer.
Polymerize the material from both buccal and lingual directions.
Peel the form from the tooth using an explorer.
Remove rubber dam and evaluate occlusion.
Finish with a flame carbide bur smoothing out any irregularities.
A football shaped bur may be used for final contouring of the lingual surface.
*

RESTORATION*OF*PRIMARY*POSTERIOR*TEETH*

K Amalgam*
K Composite*resins*
K Stainless*steel*crowns*

***Measurements:******

Primary*Mandibular*1st*molar*=*1.0*–*1.25*mm*depth,*1.25*–*1.50*mm*isthmus*

Primary*Mandibular*2nd*molar*=*1.25*–*1.50*mm,*isthmus*1.0*–*1.25*mm*

Primary*Maxillary*1st*molar*=*1.0*–*1.25*mm*depth,*1.0*–*1.25*mm*isthmus*

Primary*Maxillary*2nd*molar*=*depth*1.25*–*1.50,*1.25*–*1.50*mm*isthmus*

*Keep%in%mind%that%the%pulpal%depths%of%primary%1st%and%2nd%molars%are%different%when%preparing%
both%at%the%same%time,%which%is%a%common%practice%in%pediatrics%
 Stainless Steel Crown (SSC) #J, #L
The stainless steel crown remains one of the most useful restorations in Pediatric Dentistry. Its ability to
restore severely broken down teeth allows for teeth to be retained, in instances when amalgam and
composites would be sure to fail.
Full coverage should be used in all cases where a partial or complete pulp removal has occurred.
Learning to place stainless steel crowns requires some skill and much practice. It reverses your normal
train of thought in that the tooth must be prepared to fit the crown. Although rules are given for
preparation and crown adaptation, they are no substitute for analytical thought during tooth preparation
and placement of the crown.
Clinical note:
A local anesthetic should be used even when the involved tooth is non-vital, due to the potential
for soft tissue trauma during tooth preparation.
A rubber dam should be used for better visibility and patient control.
Wedges may be placed in the interproximal for better tissue retraction and to help avoid contact
of the bur with adjacent teeth.

Armamentarium (in addition to above)

1. Stainless Steel Crowns
2. Football diamond
3. Crown scissors
4. Contouring pliers - # 114 ball-and-socket pliers
5. Crimping pliers - # 800-417 (Unitek)
6. Heatless stone
7. Rubber wheel
8. Glass ionomer cement (K-tac cem)

Steps for Preparation:

Check occlusion. Note the dental midline and the cusp-fossa relationship bilaterally.
Place rubber dam to isolate the tooth and separate tooth from adjacent teeth using wedges.Reduce
occlusal surface with the high speed handpiece using a #169L taper fissure bur or a football diamond.
Make depth cuts by cutting the occlusal grooves to a depth of 1.0 – 1.5 mm, and extend through the
buccal, lingual, and proximal surfaces.
Next place the bur on its side and uniformly reduce the remaining occlusal surface by 1.5 mm,
maintaining the cuspal inclines of the crowns.
Use a taper fissure bur or a thin, tapered diamond to cut through the contacts.
Contact with adjacent tooth must be broken gingivally and buccolingually, maintaining vertical walls with
only a slight convergence in an occlusal direction.
The gingival proximal margin should have a feather-edge finish line.
Buccolingual reduction is often limited to the occlusal one third of the tooth.
Further reduction may be necessary if there is a large mesiobuccal bulge.
All angles of the preparation should be rounded to remove corners.

Selecting and seating the crown:

There are two commonly used types of SSC’s:
1. Ni-Chro Ion
i. These are pretrimmed, precontoured and precrimped. They are composed of a softer metal so that they can
snap over the prep without any alterations. If trimming of these crowns become necessary, the precontour
will be lost and the crown will fit more loosely.

2. Unitek [3M]
i. These are pretrimmed, but they must be contoured and crimped. They are primarily composed of chromium
and steel and are stronger than ion crowns.
.
Select the smallest crown that can be seated on the tooth. Start with #4 crown, that is the most commonly
used, and progress to a larger or smaller crown as necessary. Seat the lingual first and apply pressure in
a buccal direction so that the crown slides over the buccal surface into the gingival sulcus
Slight resistance should be felt as the crown slips over the buccal bulge.
After seating the crown, check preliminary occlusal relationship by comparing adjacent marginal ridge
heights.
If the crown does not seat, occlusal reduction may be inadequate; the crown may be too long, a gingival
proximal ledge may exist; or contact may not have been broken with the adjacent tooth. An extensive
area of gingival blanching around the crown indicates that the crown is too long or is grossly over
contoured. Ideally the crown should extend 1 mm into the gingival sulcus.
If the crown is too long, place the crown onto the preparation and lightly mark the level of the gingival
crest on the crown with a sharp instrument.
The crown is then removed and trimmed 1 mm below the mark with crown-and –bridge scissors or a
heatless wheel on the low speed straight hand piece.
Contour and crimp the crown to form a tightly fitting crown.
Contouring involves bending the gingival one third of the crown’s margins inward to restore anatomic
features of the natural crown and to reduce the marginal circumference of the crown. This aids in
ensuring a good fit.
Contouring is accomplished with a #114 ball-and-socket pliers.
Final adaptation of the crown is achieved by crimping the cervical margin 1 mm circumferentially with a
#800-417 pliers.
After contouring and crimping, resistance should be encountered when the crown is seated.
When removing the crown, a spoon excavator or amalgam carver can be used to engage the gingival
margin and dislodge the crown.
Remove rubber dam. Replace crown and check occlusion.
Final smoothing and polishing of the crown margin should be performed prior to cementation. Use a
heatless stone to thin the margin.
Rinse and dry the crown. Use glass ionomer cement, zinc phosphate or self-curing resin to cement the
crown. The crown is filled 2/3 with cement.
Dry the tooth with compressed air and seat the crown completely. Cement should be expressed from all
sides. Check centric occlusion prior to the cement setting.
Remove excess cement from gingival sulcus with a sharp explorer. The interproximal areas can be
cleaned by tying a knot in a piece of dental floss and drawing the floss through the interproximal region.
PROBLEMS SEATING THE CROWN?
Gingival ledge; contact is not broken. Inadequate occlusal reduction , Inadequate reduction of buccal
cervical bulge, SCC too long
.
Clinical Note:
CHOOSING A CROWN IN AREAS OF SPACE LOSS
Rectangles vs. squares (mandibular 1st molars vs. maxillary 1st molars)
Extensive distal caries on a mandibular or maxillary primary 1st molar will change its shape to
look more like a square or rectangle, respectively. (See figures below)
When this happens, choose a primary 1st molar crown from the opposite quadrant (opposite side,
opposite quadrant).
Note the space loss is due to mesial drift of the 2nd primary molar.

MANAGEMENT*OF*PERMANENT*TEETH*

K Fissure*sealants*–*indications:*
o Medium*to*high*risk*children*(permanent*molars*and*premolars)*
o Low*risk*children*(only*deep*and*retentive*fissures)*
K Preventive*resin*restorations*(PRR)**K*indications:**
o EnamelKonly*lesions;*incipient*lesions*just*into*the*dentin,*small*class*I*lesions*
K Composites*
K Amalgam*

**Orient*the*child*to*the*chair*and*explain*the*purpose*of*today’s*visit;*use*“tell,*show,*do”;*perform*
head*and*neck*exam,*initiate*oral*examination*with*fingers*then*a*mouth*mirror,*chart*teeth,*do*ortho*
evaluation*and*xKrays*if*necessary;*“tell,*show,*do”*regarding*handpiece*and*prophy*cup;*remove*plaque*
with*universal*scaler,*floss*and*then*polish*with*rubber*cup*and*prophy*paste;*explain*to*the*patient*that*
you’ll*be*applying*fluoride*or*“teeth*vitamins”;**encourage*the*patient*to*take*one*last*rinse*and*explain*
they*will*not*be*able*to*drink*for*½*hour*

K Explain*that*fluoride*is*good*for*teeth*and*not(for(the(stomach(*

Sit*the*child*upright,*use*fluoride*trays*for*1K4*minutes;*if*patient*cannot*tolerate,*use*one*tray*at*a*time*

Oral*hygiene*instruction:*give*a*toothbrush*and*some*floss*to*the*child*and*ask*them*to*demonstrate*
“the*way*you*usually*brush*and*floss”;*assist*the*child*in*correct*brushing*and*flossing*techniques;*
parents*with*children*8(years(old(and(younger(should*be*advised*to*assist*their*child*with*brushing*and*
flossing*

*Make*sure*you*have*answered*any*of*the*parents*questions*and*concerns*

*Document*with*PHTEN*

CLASSIFYING*BEHAVIOUR*

Cooperative*vs.*uncooperative*behaviour*–*document*in*your*notes*what*the*behavior*was*during*
treatment*–*it*may*start*out*as*being*one*way*at*the*start*and*finish*differently*
Frankel*Behaviour*Rating*Scale:*

K FI*=*definitely*negative*
K F2*=*negative*
K F3*=*positive*
K F4*=*definitely*positive*

Anesthesia*
K One*of*the*most*challenging*tasks*in*pediatric*dentistry*is*administering*local*anesthetic*
K One*of*the*most*important*factors*in*child*management*is*the*control*of*pain*
K A*comfortable*child*is*a*more*cooperative*child*
!*Anesthesia*Armamentarium:*
K Aspirating*syringe*
K Anesthetic*cartridges*
K 25*or*27*(long*or*short)*or*30*(short)*needle*
K 2x2*inch*sterile*gauze*
K Topical*anesthetic*gel*on*a*cotton*tip*
K A*recapping*device*
K Molt*mouth*prop*
K Lidocaine*(xylocaine*2%*1:100,000*epi)*is*used*most*often*in*pediatrics;*it*is*an*amide(anesthetic*
and*has*a*very*low*rate*of*associated*allergic*reactions*

Know*your*anesthetic!*

K Lidocaine(2%(((1:100,000(epinephrine(*
K 36*mg*of*lidocaine*per*carpule***
K Maximum*recommended*dose*=*4.4(mg/kg(*(
K Absolute*maximum*=*300*mg*
o Max*recommended*dose?*
$ Weight:*40*lbs;*there*are*2.2*lbs*per*kg,*therefore*40*lbs*~*18*kg*
$ 18*kg*x*4.4*mg/kg*=*79*mg*
$ 79*mg/36*mg*per*carpule*=*2*carpules!*

The*best*treatment*for*toxicity*is*prevention:(

K know*patient*history(
K know*patient*weight(
K administer*only*the*appropriate*dose/weight*of*local*anesthesia(
K inject*slowly*and*aspirate(
**Distraction(helps(to(reduce(the(anxiety(of(children(when(it(comes(to(injections*–*a*child*needs*to*be*
prepared;*your*choice*of*words*is*extremely**appropriate;*words*need*to*be*age*appropriate:*

K Ages*3K4:*keep*explanations*short*and*simple:*“we*are*going*to*put*some*sleepy*juice*near*your*
tooth*and*then*your*tooth*will*go*to*sleep”;*“it’s*going*to*feel*very*funny”;*proceed*with*the*
injection*
K Ages*5K8:*more*inquisitive,*tell*the*child*they*will*feel*weird*and*may*feel*a*little*pressure*and*
pushing;*never*tell*a*child*that*it*will*not*hurt*–*this*will*lose*their*trust;*steer*clear*of*words*like*
“stinging,*biting,*pinching”*–*these*words*may*produce*undesirable*responses*
K Ages*9K12*(fearful*ones):*they*know*they’ll*be*getting*a*shot;*explain*
that*different*parts*of*the*body*can*feel*things*differently*ie.*skin*on*the*elbow*
vs.*back*of*the*hand*
Don’t(forget(the(parents!(Discuss*the*procedure*with*the*parents*and*make*
sure*to*address*any*questions*or*concerns*
Begin*to*obtain*control*of*the*child’s*behavior*at*the*outset;*do*not*wait*until*
you*are*actually*starting*the*injection*
*
*
*

Topical(Anesthetics(

K Benzocaine*is*an*esther*anesthetic*
K Systemic*allergic*reaction*is*very*rare;*benzocaine*is*not*water*soluble*and*enters*the*systemic*
circulation*very*slowly*
K Applying:*use*gauze*to*dry*the*area,*retract*the*tissue,*apply*topical*only*to*area*of*injection*site*
K Leave*the*topical*anesthetic*at*the*site*for*a*minimum*of*one(minute((2K3*would*be*better)*

Explain(the(procedure(to(the(patient;*never*surprise*the*patient;*always*use*language*and*terminology*
appropriate*for*the*child;*use*positive*suggestions.*

K Use*positive*reinforcement*that*is*specific*for*the*behavior*you*want*to*enourage:*
o “Thank*you*for*keeping*your*mouth*open*and*holding*so*still”*
“*I*really*like*it*that*you*are*keeping*your*mouth*open*and*holding*still”*
o “We*are*going*to*help*you*hold*your*hands*on*your*tummy*to*help*you*hold*still.*Thank*
you*for*holding*so*still”*
K Praise*the*patient*throughout*the*procedure*for*their*compliance*
K Attempt*to*distract*the*patient*from*the*dental*procedure*–*talk*to*them*about*things*they*may*
be*interested*in*at*home*or*school*–*KNOW*YOUR*PATIENT*

INJECTION(–(Be(Prepared!(

K Prepare*everything*prior*to*seating*the*child*
K Keep*the*loaded*syringe*out*of*the*patient’s*sight*
 K The*patient*is*positioned*so*that*they*are*parallel*to*the*floor*with*their*feet*slightly*raised*
K It*is*sometimes*necessary*to*lower*the*head*a*little*further*to*obtain*firm*control*of*the*patient’s*
head*and*prevent*sudden*movement*during*injection*
K Sometimes*when*children*are*under*control*during*the*topical*anesthesia*phase,*they*may*begin*
to*lose*control*of*their*behavior*as*the*injection*phase*begins*
K Be*prepared*to*continue*with*your*behavior*management*strategies*as*you*proceed*
K Use*positive*suggestions*–*avoid*the*word*“hurt”;*if*you*must*send*a*message*relating*to*
discomfort,*use*a*word*like*“weird”*which*is*less*threatening*
K Never*lie*to*a*patient*about*giving*local*anesthesia*–*if*the*child*asks*if*you*are*going*to*give*
them*a*shot,*you*can*say*“I*am*going*to*squirt*a*little*sleepy*juice*on*your*gum”*
K You*must*deliver*the*truth*or*you*will*lose*the*most*important*component*in*any*therapeutic*
relationship*TRUST*
K Be*prepared*for*sudden*movements*–*by*preventing(sudden*movements*during*the*injection*

Once*the*child*is*under*control,*obtain*entry*to*the*mouth*–*may*need*a*
molt*mouth*block;*retract*the*mucosa*and*make*the*tissue*taut;*always*
make*sure*that*there*is*good*visibility*at*the*injection*site*

!*Transfer*the*syringe*from*the*dental*assistant(behind(the*patient’s*
head;*keep*the*syringe*hidden*at*all*times!*

Penetrate*the*mucosa*with*the*needle,*keep*talking*with*the*patient*–*
tell*the*child*“It*may*feel*a*little*weird*now”;*keep*talking*or*start*
counting*–*“I*know*it*feels*a*little*funny*and*now*I*am*going*to*start*counting*to*ten*and*then*that’s*
it*..*Ok*here*I*go”*(count*slowly)….*“I*need*you*to*help*me.*Please*keep*your*mouth*open*and*hold*
still”;*slowly*advance*the*needle*to*the*target*area;*rapid*advancement*of*the*needle*usually*results*
in*more*discomfort*and*anxiety*

**ALWAYS(ASPIRATE(–(the*blood*volume*in*a*child*is*much*smaller*than*that*of*an*adult,*and*it*is*easier*
to*reach*a*toxic*level;*aspirate*again*when*you*change*the*orientation*of*the*needle;*the*PSA*nerve*block*
is*a*good*example*of*an*injection*where*the*use*of*aspiration*is*especially*important*–*the*presence*of*
the*pterygoid*plexus*increases*the*risk*of*an*intravascular*injection*

o In*case*of*positive*aspiration:*withdraw*the*needle*almost*completely*and*then*redirect*
its*course;*do*not*change*the*direction*of*the*needle*while*it*is*deeply*submerged*in*the*
tissue*–*you*may*cause*breakage*of*the*needle*or*laceration*of*the*underlying*tissue*

Take*at*least*one*minute*to*deposit*one*cartridge*of*local*anesthetic*–*a*hasty*injection*may*result*in*an*
overdose*for*the*child,*especially*when*the*local*anesthetic*has*been*injected*inadvertently*into*a*blood*
vessel;*continue*using*behavior*management*strategies*during(the*injection;*distract(the*patient*–*talk*a*
lot!*Continue*talking*during*the*entire*injection*

If*the*patient*is*crying*and*trying*to*move*away*from*the*syringe*during*an*injection,*continue*the*
injection,*do(not(stop.(The*dentist,*dental*assistant*and*the*parent*must*work*together*and*use*arms*
and*hands*to*gently*restrain*the*child;*DO*NOT**pull*the*syringe*out*of*the*mouth*unless*you*are*fearful*
of*breaking*the*needle*or*injuring*the*child.*Maintain(firm(control(of(the(child’s(head;(do(not(reward(
inappropriate(behavior(by(stopping(your(injection.((Let*the*patient*know*you*are*concerned*about*how*
they*feel;*while*continuing*the*injection,*the*dentist*might*say*“I*know*it*feels*funny*now,*but*it*will*go*
away*in*just*a*little*bit”.*

In*general,*only(one(person(should*be*communicating*instructions*to*the*child*during*injections*to*avoid*
confusing*the*child.*Talk(with(the(parents(in(advance(and*advise*them*that*it*is*best*for*the*dentist*or*a*
dental*assistant*to*talk*with*the*child*during*the*injection.*When*the*injection*is*completed,*withdraw*
the*needle*slowly*and*pass*the*syringe*behind*the*patient’s*head.*Cap*the*needle*immediately.*
Behaviour*management*strategies*after(the*injection*are*very*important*to*the*success*of*the*longKterm*
management*of*the*child.*Praise(the(patient(no(matter(how(uncooperative(they*were*during*the*
injection,*but*be*truthful.*For*example*if*a*patient*was*crying*and*resisting*during*the*injection,*you*can*
say*“You*did*it!*You*opened*your*mouth*so*wide.*That*was*really*great.”*

Assure*the*patient*that*the*numb*feeling*is*only*temporary*–*“It*is*great*that*your*teeth*are*falling*
asleep,*so*it*will*feel*OK*when*I*clean*your*teeth”;*give*them*a*face(mirror(–(this*reassures*them*that*
their*face*looks*the*same*even*though*it*feels*different.*Distraction(often*helps!*

Immediately(after(completion(of(local(
anesthesia,(instruct(the(patient(not(to(
bite(on(their(lip,(tongue(or(cheek.(

Inform(the(parent(to(remind(the(child(
not(to(bite(their(lip(and(not(to(eat(
until(the(effect(of(the(anesthetic(has(subsided.(

MOST*COMMONLY*USED*INJECTIONS*FOR*CHILDREN*

1) Maxillary*anesthesia:*supraperiosteal*infiltration,*intrapapillary*injection*
a. Supraperiosteal*infiltration:*closer*to*the*gingival*margin*than*with*permanent*teeth*–*
bone*over*1st*primary*molar*is*thin;*supraperiosteal*injection*may*be*supplemented*with*
second*injection*superior*to*the*maxillary*tuberosity*area*
b. Intrapapillary*injection*for*palatal*anesthesia:*injection*directly*into*palatal*mucosa*is*
painful,*so*we*instead*infiltrate*local*anesthesia*through*already*anesthetized*buccal*
papillae*and*“chase”*the*anesthesia*through*to*the*palatal*mucosa;*blanching*should*be*
seen*
2) Mandibular*anesthesia:*inferior*alveolar*block,*long*buccal*nerve*block*
a. Inferior*alveolar*block:*most*dependable,*height*of*insertion*5*mm*above*mandibular*
occlusal*plane*of*the*primary*teeth;*injection*slightly*lower*and*more*posterior*than*in*
the*adult*patient;*needle*should*be*advanced*until*the*medial*border*of*the*mandible*is*
reached;*sufficient*time*must*be*allowed*for*anesthesia*to*take*effect;*7K10*minutes*for*
IA*block;*rarely*need*a*long*buccal*injection*following*IA*in*children*under*age*10*
 b. Long*buccal:*insert*needle*in*the*mucobuccal*fold*distal*and*buccal*to*the*most*posterior*
molar;*bevel*should*be*parallel*to*the*bone*
c. Mental*block*–*children*don’t*have*premolars,*so*put*needle*between*the*primary*
molars;*use*this*when*primary*and*permanent*anterior*mandibular*teeth*(both*sets)*are*
erupted*and*extracting;*very*hard*to*do*2*IAs,*so*do*2*mental*nerve*blocks*instead*
3) Intraligamentary*anesthesia:*method*of*intraosseous*injection*with*local*anesthesia*reaching*
the*cancellous*space*in*the*bone*via*the*periodontal*ligament;*solution*should*be*injected*under*
firm*controlled*pressure*–*use*this*when*doing*extractions;*after*you*do*a*block,*use*an*
intraligamentary*injection*to*make*sure*numb*around*tooth*

*Make*sure*the*area*is*anesthetized;*ask*the*patient*for*signs*ie.*a*fat,*funny*feeling;*test*the*area*with*
an*explorer*–*must*be*able*to*tell*whether*patient*is*feeling*pain*or*pressure;*young*children*have*
trouble*distinguishing*between*the*two*

COMPLICATIONS*OF*LOCAL*ANESTHESIA*

K Soft*tissue*injury*
o Accidental*lip,*cheek,*tongue*biting*or*scratching*from*prolonged*soft*tissue*anesthesia*
o More*common*in*the*very*young*or*developmentally*disabled*child*
o Warn*the*patient*and*the*parent*of*possible*injury*
o Advise*the*parent*to*watch*the*patient*to*prevent*injury*
o No*eating*until*the*lip*wakes*up*

Clinical%case:*what*is*the*maximum*amount*of*anesthesia*we*can*give*to*a*50*lb*child?*50lb/2.2*lb*per*kg*
=*25*kg….*25*kg*x*4.4*mg/kg*=*about*100*mg*maximum;*since*there*are*36*mg*per*carpule,*child*can*have*
approximately*3*carpules!*

Clinical%case:%6*year*old*boy*with*trauma*to*#9*–*we*have*already*given*him*the*maximum*injected*
dosage*and*he*is*still*not*sufficiently*anesthetized*–*do*not*give*him*any*more*anesthetic!*Can*either*
send*him*home*to*return*tomorrow,*or*attempt*to*do*the*procedure*in*pain;**should(have(done(an(
infraorbital(block;*use*infraorbital*blocks*only*when*truly*needed*ie.*trauma*–*anesthetizes*all*3*
maxillary*anterior*teeth*on*affected*side,*below*the*eye,*half*the*nose,*oral*musculature*of*the*upper*lip;*
achieved*by*infiltrating*the*canine/maxillary*first*primary*molar*region*

**If*you*reach*the*anesthetic*maximum*and*the*child*is*still*in*extreme*pain,*stop*the*procedure*and*
temporize*with*IRM,*have*them*return*in*4K7*days…*OR*wait*45*minutes*to*an*hour*and*anesthetize*with*
a*different*type*of*block*

Operative*Techniques*
RUBBER*DAM*

Why*do*we*use*a*rubber*dam?*

1) Prevent*aspiration**
 2) Isolation*(for*composites);*better*access*and*visualization*
3) Patient*management*–*prevents*child’s*tongue*from*getting*in*the*way!*

When*do*we*use*a*rubber*dam?*

K Sealants*–*whenever*possible*
K Fillings*(amalgams*and*composites)*–*most*of*the*time*(95%);*sometimes*can’t*get*it*on*
K Stainless*steel*crowns*K*although*sometimes*need*to*remove*to*prep*the*distal*
K Pulpotomies/pulpectomies*–*always(*

Preparation*of*the*Rubber*dam:*the*upper*limit*of*the*frame*should*coincide*with*
the*upper*edge*of*the*rubber*dam*material;**this*allows*locating*the*holes*so*that*
the*upper*extent*of*the*dam*covers*the*lip,*but*not(the(nose((

Before(applying(the(rubber(dam,(ALWAYS(check(with(an(explorer(for(adequate(
anesthesia;(always(place(dental(floss((approx..(18”)(on(the(clamp(prior(to(placing(in(the(mouth((even(if(
just(trying(on(for(size)(

Before*putting*on*the*rubber*dam*for*the*first*time,*explain*to*the*child*the*purpose*of*the*rubber*dam*
and*the*procedures*you’re*going*to*perform;*“This*is*a*raincoat*for*your*tooth*–*we*clean*your*tooth*
with*water*so*this*raincoat*keeps*the*water*from*going*down*your*throat”*

K The*clamp*is*placed*on*the*tooth*and*seated*with*the*forceps*
K Which*teeth*to*isolate?*Isolate*only*the*number*of*teeth*required*for*the*restorative*treatment:*
if*restoring*the*occlusal*surface*of*the*first*permanent*molar,*isolate*only*that*tooth;*if*restoring*
the*proximal*of*a*tooth,*isolate*on*tooth*on*either*side*of*the*tooth*being*restored*
K Quadrant*dentistry:*generally*isolate*the*first*permanent*molar*or*second*primary*molar*(most*
posterior*tooth)*to*the*canine*
o Unless*restoring*an*incisor*tooth,*never*isolate*the*incisors;*difficult*to*isolate*due*to*
their*size*and*lack*of*cervical*constriction*

Remember:(

# Always(tie(floss(around(bow(of(clamp(prior(to(placing(clamp(
# Never(leave(child(with(rubber(dam(unattended(
# Never(leave(anything(in(the(mouth(that(is(not(visible(to(you(at(all(times((ie.(leaving(cotton(rolls(
under(the(rubber(dam)(

SEALANTS*
 K Sealants*are*one*of*the*most*technique*sensitive*procedures*done*in*pediatric*dentistry;*
excellent*isolation*is*most*important*factor*insuring*success;**adequate*isolation*is*often*
achieved*using*cotton*rolls*and/or*dry*shields*
K Note:*tie*floss*to*any*isolation*aids*you*may*use*ie.*cotton*rolls*
K Sealant*failure:*the*most*common*surfaces*where*sealants*fail*are*the*surfaces*of*maxillary*
molars*distal*to*the*transverse/oblique*ridge;*if*the*sealant*is*fractured*the*rough*edge*of*the*
sealant*can*become*a*plaque*trap*
K Explore*the*sealed*tooth*surface*–*make*sure*there*are*no*voids;*if*voids*are*present,*reapply;*
remove*excess;*pass*floss*between*contact*regions*to*remove*any*inadvertently*placed*sealant*

FILLINGS*

a) PRR((preventive(resin(restoration):*clinical*caries*adjacent*to*occlusal*sealants*on*maxillary*first*
premolar*and*molar*teeth;*small*preventive*resin*preparations*made*in*image*on*left;*
completed*flowable*composite*resin*restorations*in*image*on*right**

Description*of*the*cavity*prep:*using*¼,*½*or*1*round*bur*on*slow*speed,*remove*caries.*Isolate*
the*tooth,*etch*for*15K20*seconds.*Apply*dentin*bonding*agent*and*air*dry*tooth.*Place*
composite*resin*in*the*central*pit.*Apply*a*thin*layer*of*flowable*composite*on*the*entire*occlusal*
table.*Polymerize*and*adjust*for*occlusion.*

Figure(14:(A.(The*occlusal*surface*of*a*molar*with*a*small*area*of*decay*in*the*central*pit.*B.(A*small*bur*(no.*¼*or*½*
round*using*slow*speed)*is*used*to*remove*the*decay,*which*is*confined*to*the*enamel.*C.(A*filled*sealant*(S)*is*applied*
into*the*preparation*and*over*all*pits*and*fissures.*This*is*a*sealant*procedure.*D.(In*this*example,*the*caries*extends*
into*the*dentin.*A*small*bur*(no.*¼*or*½*round)*is*used*to*remove*decay.*E.(A*bonding*agent*(BA)*and*resinKbased*
composite*(CR)*material*are*placed*in*the*preparation.*Then*a*sealant*(S)*or*flowable*composite*is*applied*over*all*
remaining*pits*and*fissures.*This*is*a*PRR*procedure.*

b) Class(I(
c) Class(II*–*the*length*of*the*245*bur*is*ideal*for*establishing*the*gingival*floor*depth*–*if*you*
extend*too*deep,*prep*for*a*stainless*steel*crown*
a. most*common*type*of*matrix*band*used*in*pediatric*dentistry*is*the*TcBandK*can*be*
placed*on*a*tooth*that*is*clamped;*a*Tofflemire*is*usually*not*used*because*it*is*difficult*
to*place*in*a*child’s*mouth,*does*not*adapt*well*to*the*primary*teeth*and*it*cannot*be*
placed*on*a*tooth*that*is*clamped*

**pulp*chambers*are*larger*in*the*primary*dentition*vs.*the*permanent*dentition,*therefore*cavity*
preparations*are*relatively*shallow*to*avoid*a*pulp*exposure*
*

STAINLESS*STEEL*CROWNS*

K one*of*the*most*important*procedures*in*pediatric*restorative*dentistry*–*covers*and*protects*
the*entire*tooth*and*is*very*durable*
K 4*basic*steps*to*tooth*preparation:*
1) Occlusal*reduction*
2) Minimal*buccal*and*lingual*reduction/beveling*(it*is*sometimes*necessary*to*reduce*
the*buccal*bulge*in*order*to*get*the*preformed*crown*to*fit*over*the*buccal*
prominence)*
3) Proximal*reduction*
4) Rounded*line*angles*
K Cement*crown*with*glass*ionomer*cement*(Ketac*Cem)*
K SCCs*are*also*indicated*for*permanent*molars*in*pediatric*patients*who*have*received*root*canal*
therapy*

ENDODONTIC*TREATMENT*FOR*PRIMARY*TEETH*

Pulpal*therapy*

K Indirect*pulp*cap*
K Direct*pulp*cap*
K Partial*pulpotomy*
K Pulpotomy*
K Pulpectomy*
*
Pulpotomy((vital(technique):a*procedure*based*on*the*idea*that*the*radicular*pulp*tissue*is*
healthy*or*is*capable*of*healing*after*amputation*of*the*infected**coronal*pulp*
o Pulpotomy*is*contraindicated*when:*
$ Swelling*of*pulpal*origin*
$ Fistula*
$ Pathologic*mobility*
$ External*or*internal*root*resorption*
$ Periapical*or*interradicular*radiolucency*
$ Pulp*calcifications*
$ Excessive*bleeding*from*radicular*stumps*
o Procedure:*anesthetize*and*isolate*with*rubber*dam;*occlusal*reduction*1K1.5*mm*for*
the*stainless*steel*crown*–*this*facilitates*rapid*and*easy*access*to*the*pulp;*a*clean*
sterilized*bur*should*be*used*to*remove*the*pulp*
$ Studies*have*shown*that*a*major*cause*of*eventual*pulpotomy*failure*involves*
bacterial*contamination*during*the*pulpotomy*procedure*
 o Remove*all*carious*dentin*to*minimize*bacterial*contamination*following*exposure;*after*
pulp*is*exposed,*remove*the*roof*of*the*chamber*with*a*330*fissure*bur;*create*a*large*
enough*access*in*order*to*remove*all*the*coronal*pulp*tissue*
o Locate*the*shape*of*the*canal*orifices*of*mandibular*right*1st*and*2nd*primary*molars*
(left)*and*maxillary*right*1st*and*2nd*primary*molars*(right)*
*

o U
se*a*large*round*
bur*(#6*or*8)*in*a*
slow*speed*handpiece*or*sharp*spoon*excavator*to*amputate*the*coronal*pulp*tissue;*
use*light*pressure*to*avoid*perforation*of*the*pulpal*floor;*remove*all*debris*from*the*
pulp*chamber*
*
!*Countersinking*using*a*#4*slow*speed*round*bur*
*
Use*a*#4*or*6*round*bur*and*countersink*down*into*the*
canal;*this*reduces*the*amount*of*surface*area*of*pulp*
tissue*that*will*be*treated;*hemorrhage*is*easier*to*control*
when*there*is*less*tissue*involved*
Following*hemostasis,*place*a*cotton*pellet*very*slightly*
moistened*with*1:5*dilution*of*Buckley’s(formacresol(over*the*pulp*stumps*for*5*minutes;*
condense*the*pellets*towards*the*pulp*stumps*in*order*to*create*better*contact*between*the*
pellets*and*the*pulp*tissue*

After*5*minutes,*remove*the*pellet.*There*should*be*very*little*or*no*hemorrhage*present;*place*a*base*
of*IRM(over*the*amputation*site*and*condense*to*cover*the*pulpal*floor;*a*second*layer*is*then*
condensed*to*fill*the*access*opening*completely.*Restore*with*a*stainless*steel*crown.*

Excessive*bleeding*that*persists*may*indicate*that*the*inflammation*has*extended*to*the*radicular*pulp*–*
this*indicates*that*the*tooth*may*need*a*two*stage*pulpotomy,*pulpectomy*or*may*need*to*be*extracted.*

Two(stage(pulpotomy:(indicated*when*hemorrhage*is*uncontrolled*before*and/or*after*the*
application*of*formacresol;*this*technique*fixed*the*coronal*pulp*tissue,*while*some*part*of*the*radicular*
tissue*remains*vital.*

o A*dried*pellet*of*formacresol*is*placed*over*the*pulp*stumps*–*formaldehyde*vapor*
liberated*from*the*cotton*pellet*permeates*through*the*pulpal*space,*producing*fixation*
of*the*tissues.**
o An*IRM*temporary*restoration*is*placed,*it*should*be*sealed*well.*
o After*7c10(days(the*formacresol*pellet*is*removed.*
o IRM*is*placed*in*the*pulp*chamber*and*the*tooth*is*restored*with*a*stainless*steel*crown.*
Pulpectomy:*when*the*pulp*is*either*irreversibly*inflamed*(hemorrhage*7K10*days*after*completion*of*a*
twoKstage*pulpotomy)*or*necrotic;*although*the*technique*is*often*considered*difficult*because*of*the*
complexity*of*the*root*canals*of*primary*teeth,*clinical*studies*have*shown*a*reasonable*prognosis.*If*the*
radicular*pulp*is*necrotic,*a*twoKstage*procedure*is*preferred,*but*if*it*is*found*to*be*irreversibly*
inflamed,*a*oneKstage*technique*may*be*done.**

K There*is*a*history*of*pain*and*fistulation*related*to*the*mandibular*left*second*primary*molar*

!*Gently*remove*organic*material*with*a*broach*from*each*canal;*adjust*
endodontic*files*to*stop*2(mm(short(of(the(radiographic(apex(of*each*canal;*this*
minimizes*the*chance*of*overinstrumenting*and*causing*periapical*damage*

K The*canals*are*dried*with*paper*points;*fill*canal*with*ZOE(paste*or*
Vitapex((these*don’t*resorb*like*IRM*would);*place*IRM*overtop*and*restore*with*a*
stainless*steel*crown*
# Children*should*start*coming*to*the*dentist*by*age*one,*or*when*the*first*
tooth*erupts,*whichever*comes*first*
*
*

Luxation*=*an*injury*to*the*toothKsupporting*structures*with*abnormal*loosening*but*without*tooth*
displacement*

Trauma*Management*
K 22%*of*children*suffer*trauma*to*permanent*dentition*by*age*14;*males*are*2X*more*likely*
K Peak*incidence*at*2K4*years*and*rises*again*at*8K10*years*
K Upper*anterior*teeth*most*commonly*involved*
K Child*abuse*–*the*orofacial*region*is*commonly*traumatized*during*child*abuse;*whenever*
injuries*are*inconsistent*with*the*history,*the*patient*must*be*investigated*for*abuse*
K Dental*injuries*may*become*the*subject*of*litigation*or*insurance*claims*therefore*a*thorough*
history*and*examination*is*mandatory;*whenever*possible,*injuries*should*be*photographed*
K Take*accurate*history:*status*of*dentition*at*presentation,*prognosis*of*injuries,*other*injuries*
sustained,*medical*complications*
K Questions*to*ask*
o When*did*the*trauma*occur?*How?*
o Were*there*any*other*injuries?*
o What*initial*treatment*was*given?*
o Have*there*been*any*other*dental*injuries*in*the*past?*
o Are*the*immunizations*up*to*date?*
 K Examination*
o ExtraKoral*wounds*and*palpation*of*the*face*
o Injuries*to*oral*mucosa/gingival*
o Palpation*of*alveolus*
o Displacement*of*teeth*
o Abnormalities*in*occlusion*
o Extent*of*tooth*fractures,*pulp*exposure,*colour*changes*
o Mobility*of*teeth*
o Sensitivity*to*percussion*

Head*injury*–*closed*head*injury*is*the*most*common*cause*of*childhood*mortality*in*accidents;*between*
25*and*50%*of*all*accidents*in*children*up*to*14*years*of*age*involve*the*head;*if*there*is*any*suggestion*
of*a*head*injury,*refer*the*child*to*the*ER;*signs*of*a*closed*head*injury:*

K Altered/loss*of*consciousness*
K Bleeding*from*the*head*or*ears*
K Disorientation*
K Prolonged*headache*
K Nausea,*vomiting,*amnesia*
K Altered*vision/unilateral*dilated*pupil*
K Seizures*or*convulsions*
K Speech*difficulties*

Glasgow(Coma(Scale(=*a*neurological*scale*that*
aims*to*give*a*reliable,*objective*way*of*
recording*the*conscious*state*of*a*person*for*
initial*as*well*as*subsequent*assessment*

CLINICAL(EXAMINATION(

Mobility*test:*degrees*of*m,.obility:*

K 0*=*no*loosening*
K 1K2mm*=*horizontal*loosening*
K 3*mm*=*axial*loosening*

Percussion*Test:*tenderness*to*percussion*=*damage*to*the*PDL;*percussion*to*the*labial*surface*
resulting*in*a*high*metallic*sound*implies*that*the*injured*tooth*is*locked*in*bone;*if*noted*on*followKup,*
may*indicated*ankylosis*
Pulp*Test:*Electric*Pulp*Test*–*primary%teeth%(usually%due%to%inability%to%cooperate)%and%young%teeth%with%
incomplete%root%formation%do%not%respond%consistently;%Thermal*sensitivity*

Radiographs:*panoramic*radiographs*–*using*extraKoral*films*will*provide*some*clinical*information*in*the*
acute*phase*of*management*

*all*traumatized*teeth*should*be*radiographed*to*assess:*stage*of*root*development*AND*injuries*to*root*
and*supporting*structures;*xKrays*should*include*information*on:*pulp*size,*apical*maturity,*PDL*space,*
alveolar*fractures,*foreign*bodies*

* K*locating*foreign*bodies:*soft*tissue*radiographs*–*use*¼*exposure*time*

* K*locating*intruded*teeth:*use*lateral*film*showing*nasal*area*–*double*exposure*time*

* K*SLOB*RULE:*Same*Lingual*Opposite*Buccal*

TRAUMA(TO(PRIMARY(TEETH(

K Luxations*
K Fractures*
K Fracture*of*the*alveolar*process*
*
1) LuxationsK*impact*to*the*tooth,*tooth*not*mobile,*not*displaced*
a. Immunization*–*if*the*child*is*not*immunized,*a*tetanus*booster*is*required*
b. Antibiotics*–*not*needed*unless*there*are*significant*soft*tissue*or*dentoalveolar*injuries*
c. Concussions*–*impact*to*the*tooth,*but*the*tooth*is*not*mobile;*damage*to*the*PDL,*
tender*to*percussion*
Note*the*slight*widening*of*the*area*of*the*PDL*around*the*
primary*maxillary*left*central*incisor;*6*months*later,*the*
PDL*returned*to*normal*on*xKray,*and*the*pulp*chambers*
have*become*calcified*
*
*
*
d. Subluxation*–*impact*to*the*tooth;*the*tooth*is(mobile*but*not*displaced;*damage*to*the*
PDL,*tender*to*percussion*
i. Management*of*concussion*and*subluxation:*PA*radiographs*as*a*baseline;*soft*
diet*for*one*week;*advise*parents*that*tooth*may*develop*pulp*necrosis;*followK
up*
e. Extrusive*and*lateral*luxation*–*impact*to*the*tooth;*the*tooth*is*mobile*and*displaced*
i. Management:*dependent*on*mobility*and*amount*of*displacement;*reposition*
tooth*if*has*moved*and*in*position*that*will*occlude*incorrectly*
f. Intrusive*luxation*–*most*common*injuries*to*upper*primary*incisors*–*one*of*the*most*
potentially*damaging*injuries*to*the*developing*permanent*teeth*
 !This*is*a*permanent*tooth*that*was*affected*by*the*intrusive*
luxation*of*the*primary*incisor*that*was*above*it*

Management:*a*lateral*xKray*should*be*taken*to*establish*the*
position*of*the*intruded*tooth;*if*the*crown*is*visible*and*there*is*
only*minor*alveolar*damage,*leave*tooth*to*reerupt;*if*the*whole*
tooth*is*intruded,*extract!*

!Radiograph*taken*to*
examine*intrusive*luxation*

*******************************Avulsion*"**

g. Avulsion*(tooth*is*knocked*out)*–*radiograph*is*essential*–*must*rule*out*intrusion*–*do(
not(replant(avulsed(primary(teeth!*
!*There*is*no*radiographic*or*soft*tissue*pathology*
present;*Treatment?*Monitor!*

h. Fractures*in*primary*teeth:*
i. Crown*fractures*not(involving*the*pulp:*smooth*out*edges;*if*necessary,*cover*
dentin*with*composite*or*strip*crown*
ii. Fractures*exposing*the*pulp:*fractures*into*the*pulp*always*require*treatment;*
Choices:*pulpectomy*or*extraction*
iii. CrownKroot*fractures:*extract*
iv. Root*fractures:**if*the*fracture*is*deep*enough*that*you*can*
reposition*the*crowns*so*they*will*stay*in*place,*that*is*all*you*
should*do;*if*the*root*is*severed*right*at*the*crown,*just*take*the*
crown*out;*we(do(not(extract(the(root(tips(–(they(are(too(close(
to(the(developing(tooth(underneath(–(leave(them(and(monitor(
them(–(they(will(resorb;(displaced*coronal*fragments*can*be*
respositioned,*but*no*splinting*
i. Periapical*pathology*surrounding*the*root*tip:*Extraction*
 j. Fracture*of*the*alveolar*process:*clinical*appearance*=*segment*containing*one*or*more*
teeth*is*displaced*axially*or*laterally*resulting*in*occlusal*disturbance*–*refer*to*oral*
surgeon*

PERMANENT(TOOTH(INJURIES(

K Concussion*and*subluxation*injuries(
K Fractures*of*permanent*teeth,*including*fractures*of*enamel,*fractures*of*dentin*and*fractures*
involving*the*pulp(
K Root*fractures(
K Intrusion*injuries(
K Avulsion*injuries(
K The(status(of(the(root(end(is(a(very(important(consideration(in(all(injuries(to(permanent(teeth(
1) Crown*fractures*without*pulp*exposure:*
a. Treatment:*composite*filling;*crown*fragment*can*be*reattached*using*dental*adhesives*
and*resin*composites*
2) Crown*fractures*involving*SMALL*pulp*exposure*
a. If*happened*in*the*past*2*hours:*direct*pulp*cap*with*calcium*hydroxide*
b. If*happened*before*2*hours*ago:*Cveck*pulpotomy*(partial*pulpotomy)*–*remove*2*mm*
of*pulp*then*place*nonKsetting*CaOH,*followed*by*setting*CaOH,*followed*by*glass*
ionomer*then*a*composite*restoration*
3) Large*crown*fractures*
a. If*roots*still*open*apex:*pulpotomy*to*preserve*growing*root*
b. If*root*apices*closed:*RCT*
K Permanent*root*fractures:*Splint*for*3*months*
K Avulsed*permanent*teeth*–*rinse*and*replant*–*hold*the*crown*only;*splint*for*2K3*weeks,*then*
will*need*RCT*

*flexible*splints*recommended*for*avulsion*

*rigid*splints*recommended*for*root*fracture*

SPACE(MAINTENANCE:(

**the*best*space*maintainer*is*a*primary*tooth*

! (band(and(loop(space(maintainer(–(goes(on(first(permanent(molar(–(when(one(side(
needs(space(maintenance((
 !*lower*lingual*holding*arch*(LLHA)*–*based*on*permanent*first*molars*–*
bilateral*space*maintenance*needed,*and*more*than*one*space*on*either*side*–*if*there*are*primary*
teeth*still,*can’t*use*band*and*loop*propped*up*against*them,*must*use*LLHA*

!*distal*shoe*–*prevents*UNERUPTED*first*permanent*molars*from*moving*
mesially*when*there*is*premature*loss*of*second*primary*molars*–*the*distal*segment*is*extended*into*
the*tissue*against*the*unerupted*first*permanent*molar*

! (Nance(appliance(–(used(when(there(is(premature(bilateral(loss(of(
maxillary(primary(teeth(

*
*
*
*
Review*clinic*guide*
o Matrix*application*15*
o Composite*strip*crown*22*
o Occlusion*summary*38*
o Clinical*responsibilities*46*
o Caries*risk*assessment*49*
o Endodontic*treatment*for*primary*teeth*58*
o Knee*to*knee*exam*62*
o Management*of*dental*trauma*72*
K Be*familiar*with*caries*risk*assessment*sheet*
K Space*maintenance*
K Write*a*paragraph*on*how*you*would*explain*a*certain*procedure*to*a*child*
 K First*visit*should*not*be*later*than*1*year*old,*should*include*a*brief*knee*to*knee*exam*
K Be*able*to*evaluate*medical*and*dental*history*–*ie.*if*child*has*asthma,*what*kinds*of*questions*
are*you*going*to*ask*
K Know*all*steps*of*medical*history***
K Know*the*social*history*–*may*help*avoid*uncomfortable*or*embarrassing*topics*
*
*
Subluxation*=*tooth*mobile,*but*not*displaced*
Luxation*=*displace*

ZOE*or*Vitapex*K*don’t*resorb*–*can*use*to*fill*a*pulpectomy*

*With*root*fractures,*leave*the*tooth*in,*unless*the*fracture*is*close*enough*to*the*crown*that*the*crown*
is*mobile,*then*extract*the*crown*piece;*do*not(extract*the*root*–*just*leave*it*–*can*cause*more*damage*
to*incoming*tooth*–*the*roots*will*resorb*on*their*own*

Nance*appliance*for*the*upper*only*

Lower*lingual*holding*arch*for*bottom*

Distal*shoe*in*–*when*permanent*molar*erupts,*take*distal*shoe*out*bc*it*is*subgingival*and*replace*with*
LLHA*–*lower*lingual*holding*arch*–*don’t*want*band*in*–*because*first*premolar*is*going*to*erupt*before*
second**

Restoration*of*primary*anterior*teeth*–*interproximal*stripping*–*resin(strip(crowns*work*really*well;*
composite*fillings*don’t*stick*so*well*

Need*space*maintainers*for*premature*loss*of*primary*1st*or*second*molars*

Pulpotomy*vs.*pulpectomy;*you*would*do*a*pulpectomy*with*severely*decayed*anterior*teeth;*
pulpotomy*is*more*for*a*small,*recent*pulp*exposure*(fill*with*ZOE*bc*doesn’t*resorb)*