‫‪:‬الرؤية‬

‫تتطلع كلية طب الفم واالسنان ‪ -‬الجامعة الحديثة للتكنولوجيا والمعلومات إلى أن تكون من أكثر الكليات تميزا‬
‫على المستوى المحلي و اإلقليمي في مجال طب االسنان‬

‫‪:‬الرسالة‬
‫تلتزم الكلية بإعداد أطباء أسنان يتميزون بالجدارة المهنية قادرين على التوافق مع متطلبات سوق العمل و‬
‫مواكبة التطور العلمي و اإلسهام فيه باألنشطة البحثية مع تلبية إحتياجات المجتمع المحيط في اطار قيم اخالقية‬

‫‪Vision:‬‬
‫‪The College of Oral and Dental Medicine - Modern University for Technology and‬‬
‫‪Information aspires to be one of the most distinguished colleges at the local and‬‬
‫‪regional levels in the field of dentistry.‬‬

‫‪Mission:‬‬
‫‪The college is committed to preparing dentists who are distinguished by professional‬‬
‫‪merit and are able to comply with the requirements of the labor market and keep‬‬
‫‪pace with scientific development and contribute to it through research activities‬‬
‫‪while meeting the needs of the surrounding community within the framework of‬‬
‫‪ethical values.‬‬
‫الغايات و األهداف‬
‫الغاية األولى‪ :‬تحقيق قدرة تنافسية متميزة فى تعليم طب األسنان‬
‫األهداف األستراتيجية‬
‫الهدف األول‪:‬تطوير إستراتيجيات التدريس و التعلم بما يتفق مع اتجاه الدولة المصرية لتطوير التعليم‬
‫الجامعي‬
‫الهدف الثاني‪ :‬تطويرالمحتوى العلمي للبرنامج و نظم التقويم و الكتاب الجامعي‬
‫الهدف الثالث‪ :‬دعم برامج التواصل مع الخريجين‬
‫الهدف الرابع‪ :‬إ ستخدام تكنولوجيا المعلومات و أساليب التعلم الحديثة‬
‫الهدف الخامس‪ :‬تنمية مهارات طالب الكلية بما يتفق مع متغيرات سوق العمل‪.‬‬
 ‫الغاية الثانية ‪ :‬التميز و اإلبداع في مجال البحث العلمي‬
‫األهداف األستراتيجية‬
‫الهدف األول‪ :‬تحفيز منظومة البحث العلمي بما يدعم تقديم خدمات بحثية و عالجية للمجتمع المحلي و‬
‫الدولي‪.‬‬
‫الهدف الثاني‪ :‬المشاركة في المؤتمرات العلمية و تنظيم مؤتمر خاص بالكلية‬
‫الهدف الثالث‪ :‬إصدار مجلة علمية دورية للكلية‬
‫الهدف الرابع‪ :‬توسيع مجاالت التعاون و الشراكة البحثية محليا و اقليميا و عالميا‬
‫الهدف الخامس‪ :‬وضع آلية لضمان اإللتزام بأخالقيات البحث العلمي و ضمان حقوق الملكية الفكرية‬
‫الهدف السادس‪ :‬إنشاء برامج تعليمية لمرحلة الدراسات العليا تلبي احتياجات الخريجين فى سوق العمل‪.‬‬

‫الغاية الثالثة ‪ :‬التكامل مع المجتمع المدنى لتقديم خدمات عالجية فى طب األسنان‬

‫األهداف األستراتيجية‬
‫الهدف األول‪ :‬التوعية التثقيفية المستمرة داخليا وخارجيا لتلبية احتياجات المجتمع المحيط بالرعاية‬
‫الصحية لألسنان‪.‬‬
‫الهدف الثانى‪ :‬التوسع فى التعاون مع مؤسسات المجتمع المدنى المحيط لتلبية احتياجات المجتمع‬
‫الهدف الثالث‪ :‬وضع خطة إستباقية الدارة األزمات‬

‫الغايــة الــرابعة‪ :‬التــ ُميز واإلبــداع الـمؤســسي‬

‫األهداف األستراتيجية‬
‫الهدف األول‪ :‬تطوير البنية التحتية و التكنولوجية للكلية‪.‬‬
‫الهدف الثاني‪ :‬إستيفاء أعداد أعضاء هيئة التدريس و الهيئة المعاونة بما يتناسب مع أعداد الطالب‬
‫الهدف الثالث‪ :‬تنمية قدرات القيادات االكاديمية و االدارية الحالية و المستقبلية‪.‬‬
‫الهدف الرابع‪ :‬تنمية قدرات اعضاء هيئة التدريس و الهيئة المعاونة‬
 ‫الغاية الخامسة‪ :‬الحصول على اإلعتماد المؤسسي‬
‫األهداف اإلستراتيجية‬
‫الهدف األول‪ :‬تطوير مركز ضمان الجودة بالكلية‬
‫الهدف الثاني‪ :‬تنمية القدر ات المادية و البشرية للكلية للوصول للمعايير القومية المرجعية‬
Modern University for Technology &
Information
Faculty of Dentistry
Pediatric Dentistry and Dental Public Health
Department

For Fifth Year Students

By

Professor Dr. /Rania Abdallah Nasr

Professor of Pediatric Dentistry and Dental Public
Health Department
Faculty of Oral and Dental Medicine
Cairo University

2024
 INDEX

Subject: Page:
 Introduction 1
 Problems Associated With Tooth Eruption. 3
 Chronology 6

 Morphological Differences between Primary and 8

Permanent teeth.
 Development of Normal Occlusion in Children. 12
 The Child's First Dental Visit. 21
 Management of Child's behavior : 26
Non-pharmacological Management of Children’s Behaviors.
Pharmacological Management of Children’s Behaviors. 36
 Local Anesthesia in Pediatric Dentistry. 44
 Cavity Preparation. 54
 Restoration of Primary Teeth. 67
 Management of Deep Carious Lesions in Children. 69
 Rampant Caries. 86
 Early Childhood Caries. 88
 Stainless Steel Crown. 93
 Pediatric Dentistry
It is that branch of dental science, which deals with guidance of the primary and
permanent dentition during growth and development, as well as prevention and
treatment of any pathological oral conditions which may occur during childhood.

Definition:

According to the American Association of Pediatric Dentistry (AAPD):

It is an age defined specialty that provides preventive and therapeutic oral health
care for infant and children through adolescence including those with special
health care needs.

Aim:

1- Health of a child as a whole.

2- Prevention of oral diseases.
3- Restore oral cavity to good health.
4- Observe and control, when necessary the developing dentition.
5- Relief of pain and sepsis.
6- Maintain or achieve esthetics.

Importance (Benefits) of Pediatric Dentistry:

1- For the Child Patient:

1- Better masticatory apparatus, which is essential for the child’s optimal

growth.
2- Less psychological trauma from dentistry (proper management and
treatment).
3- Less dental diseases in his adulthood.

1
 4- From an economic point of view pediatric dentistry will reduce the need for
dental services later in adulthood.

2- For the Dentist:

1- Improve skills and abilities in various fields of dentistry.

2- Learning many techniques which are unique to children.

3- For the Nation:

As pediatric dentistry permits for the child’s optimal state of growth and
development through maintaining good & healthy masticatory apparatus.

Importance of Primary Teeth:

All of the primary teeth are in use from age 2 to 7 years; some of the primary teeth
are in use from age 2 till 12 years.

1. Preparation of the child's food for digestion and assimilation during active
periods of growth and development.
2. Maintenance of space in the dental arches for the permanent teeth. With
the premature loss of the primary teeth, sever dental irregularities may
develop.
3. Development of speech: Ability to use the teeth for pronunciation is
acquired with the aid of the primary dentition. Early and accidental loss of
the primary anterior teeth may lead to difficulty in pronouncing the sounds f,
v, s, z and th.
4. Cosmetic function: Improving the appearance of the child. If a child
accidently loses his primary anterior teeth, his appearance will be affected,
he will find himself different from the other children in his same age and
accordingly, this will affect him from the psychological point of view.

2
Problems Associated with Tooth Eruption
Definition of "ERUPTION":
Tooth eruption is the movement of a tooth from its site of development (bony
crypt) within the alveolar bone to its functional position in the oral cavity.

The primary teeth begin to form at 7 w.i.u. Calcification of the central incisor starts
at 4 m.i.u. The sequence of calcification of the primary teeth is central incisors,
first molars, lateral incisors, canines and second molars.

At the time of birth, there are no functioning teeth in the mouth, but radiographs of
the infant's jaws show calcification of:

 Five- sixths of the crown of the central incisors.

 Two-thirds of the crown of the lateral incisors.
 The incisal tips of the canines.
 Fused cusps of the first primary molars.
 Isolated cusps of the second primary molars.
 Occasionally calcification of the mesio-buccal cusp of the first permanent
molar and the incisal edge of the lower permanent central incisor.

Teething “Difficult Eruption”:

Tooth eruption represents a natural physiological process by which a tooth moves
from its site of development to its final functional position in the oral cavity. It is
preceded by increased salivation, thumb sucking or gum rubbing. It doesn’t
increase the incidence of fever, infection or diarrhea. Gum inflammation, oral
ulcers or cheek flushness may be observed.
3
General irritability or restlessness, disturbed sleep, loss of appetite are the most
common general manifestations that can occur in association with teething.

Management:
- Reassurance of the parents regarding teething signs and symptoms.
- A sequential approach to the management of teething ranging from giving
the child objects to bite on through topical and systemic medications if
needed.

Eruption Cyst (Hematoma):

Definition: It is a type of dentigerous cyst associated with erupting tooth. Most
commonly seen in the mandibular molar region especially primary second molar or
first permanent molar regions.

Etiology: Unknown, but may be a result of mechanical trauma. It results from

accumulation of blood stained fluid in the dilated space around the crown of an
erupting tooth.

Clinical features: Bluish fluctuant swelling over an erupting tooth, occur at any
age including newborn.

Color of the cyst depends on:

- Amount of the blood present in the cavity.

- Thickness of the overlying mucosa.

Management:
- Reassuring the parents that the lesion is not serious.
- The condition is self-limiting, treatment is unnecessary.

4
 - Surgical excision of the overlying mucosa to expose the crown may be
necessary if the cyst apparently is responsible for delaying the eruption of
the tooth.

Natal & Neonatal Teeth

Natal teeth as those teeth present at birth.
Neonatal teeth are those that erupt within 30 days after birth.
- The mandibular incisor region is the most prevalent.
- 85% of natal & neonatal teeth are mandibular primary incisors and only
small % is supernumerary teeth.
- The cause is unknown with genetic predisposition.
- Can be attributed to superficial positioning of the tooth germ.
- If they have sharp edges that might lacerate the gums or cause difficulty
while breast feeding or very loose and may be aspirated, they may be
extracted 10 days or more after birth to avoid the risk of hemorrhage due to
vitamin K deficiency.

5
 Chronology of Primary and Permanent
Dentition

I- Chronology of Primary Dentition:

TEETH AT DIFFERENT AGEs

CHRONOLOGY OF THE HUMAN DECIDUOUS TEETH

Tooth Enamel Beginning Root Beginning

organ of Eruption Completed of root Shedding
appearance calcific- resorption
ation
A 7 w.i.u. 4 m.i.u. 7m 1.5 y. 4 y. 7y
A 7 w.i.u. 4 m.i.u. 6m 4 y. 7y
B 7 w.i.u. 4.5 m.i.u. 8 m. 2 y. 5 y. 8y.
B 7 w.i.u. 4.5 m.i.u. 7 m. 1.5 y. 5 y. 8 y.
C 8 w.i.u. 5 m.i.u. 18 m. 3 y. 5 y. 11 y.
C 8 w.i.u. 5 m.i.u. 16 m 3 y. 5 y. 9 y.
D 8 w.i.u. 5 m.i.u. 14 m. 2.5 y. 4 y. 10 y.
D 8 w.i.u. 5 m.i.u. 12 m. 2.5 y. 4 y. 9 y.
E 9 w.i.u. 6 m.i.u. 24 m. 3 y. 5y. 10 y.
E 9 w.i.u 6 m.i.u. 20 m. 3 y. 5y. 10 y.

 Sequence of Eruption:A – B – D – C - E
 Mandibular teeth erupt earlier than maxillary teeth by 1-2 months.
 Teeth in the girls erupt earlier than teeth in boys.
 Roots of primary teeth are completely formed 1-1.5 following the
tooth eruption and the roots persist without resorption for 1.5 years.
 Beginning of root resorption in primary teeth occurs after complete
crown calcification of their permanent successors.
 Crowns of permanent teeth are completely formed 3 years before
eruption.

6
 Shedding of deciduous teeth coincide with the dates of eruption of
their permanent successors (At this stage 2/3 of the root of
permanent successor is formed).
 Roots of permanent teeth are completely formed 3 years following
eruption.
 In some children, deciduous teeth may not erupt till the age of
about 12 months. This could be considering normal if the child is
free from any hereditary or systemic diseases.

II- Chronology of Permanent Dentition

CHRONOLOGY OF THE HUMAN PERMANENT TEETH

Tooth Enamel Beginning of Crown Eruption Root

Organ Calcification Completed completed
Appearance
1 5 m.i.u. 3-4 m 4-5 y. 7-8 y. 10 y.
1 5 m.i.u. 3-4 m. 4-5 y. 6 -7 y. 9 y.
2 5 m.i.u. 10-12 m. 4-5 y. 8-9 y. 11 y.
2 5 m.i.u. 3-4 m 4-5 y. 7-8 y. 10 y.
3 6 m.i.u. 4-5 m. 6-7 y. 12-13 y. 14-15 y.
3 6 m.i.u. 4-5 m. 6-7 y. 9-10 y. 12-14 y.
4 7 m.i.u. 1 1/2 -1 3/4 y. 5-6 y. 10-11 y. 12-13 y.
4 7 m.i.u. 1 3/4 -2 y. 5-6 y. 10-11 y. 12-13 y.
5 8 m.i.u. 2-2 1/4 y. 6-7 y. 10-12 y. 13-15 y.
5 8 m.i.u. 2 1/4-2 1/2 y. 6-7 y. 11-12 y. 13-15 y.
6 4 m.i.u. At brith 3-4 y. 6-7 y. 9-10 y.
6 4 m.i.u. At brith 2 1/2 -3 y. 6-7 y. 9-10 y.
7 1 y. 2 1/2 – 3 y. 9 y. 12-13 y. 14-16 y.
7 1 y. 2 1/2- 3 y. 9y 11-13 y. 14-16 y.
8 4 y. 7-9 y. 12 -16 y. 17-21 y. 18 -25 y.
8 4 y. 8-10 y. 12-16 y. 18-25 y.

 Sequence of Eruption of Maxillary Teeth:

6–1–2–4–5–3–7–8
 Sequence of Eruption of Mandibular Teeth:
 6 – 1 – 2 – 3 – 4 – 5–7 – 8

7
 Morphologic Differences between
Primary and Permanent Teeth
It is stated that the morphology of the primary dentition is different in
many respects from that of the permanent dentition, and not only in the
sizes of the crowns and roots. They have outlined these morphologic
differences.
Primary Dentition is 20 primary teeth as compared to 32 permanent teeth.
No premolars in the primary dentition. The primary molars are replaced
by the premolars. The permanent molars erupt distal to the primary
second molars.

Primary Crown Anatomy:

Mandibular Incisors- central is symmetrically flat when viewed from
buccal view; lateral has a more rounded DI angle. Maxillary Incisors-
central is only tooth that has a greater width than height. Maxillary 1st
Molar- unique look, 3 cusps. Mandibular 1st Molar- 4 cusps, transverse
ridge dividing occlusal surface.

Canines- maxillary is long and sharp, mandibular has similar shape but
smaller. Maxillary 2nd Molar - resembles permanent maxillary first molar
but smaller. Mandibular 2nd Molar- resembles permanent mandibular
first molar but smaller.

Size & Morphology of the Primary Pulp

Chamber:
Considerable individual variation exists in the sizes of the pulp
chambers and pulp canals of the primary teeth.

Immediately after tooth eruption, the pulp chambers are large and
generally follow the outline of the crown. They decrease in size as age

8
increases and under the influence of both function and abrasion of the
occlusal and incisal surfaces of the teeth.
No attempt is made here to describe in detail each pulp chamber outline;
rather, it is suggested that the dentist examine critically the bitewing
radiographs of the child before undertaking operative procedures. Just as
there are individual differences in the calcification and eruption times of
teeth, so are there individual differences in the morphology of the crowns
and the size of the pulp chamber. However, radiographs do not
demonstrate completely the extent of the pulp horn into the cuspal area.

-Characteristics of Teeth in the Primary

Dentition:
Crowns :
 The crowns in the primary dentition are shorter relative to the
length of the root (i.e., smaller crown: root ratio).

 The occlusal tables of primary molars are constricted

buccolingually and much narrower mesiodistally when compared
with those of the permanent molars.

 Enamel and dentin are thinner compared with permanent teeth.

 The thickness of the enamel and dentin of primary teeth is

approximately half that of permanent teeth.

 The enamel rod direction in the cervical area is angled occlusally

compared with the apical direction in permanent teeth.

 Crowns of primary teeth are characterized by significant cervical

constriction in both the mesiodistal and faciolingual dimensions.

 The primary molars have a pronounced buccal cervical bulge.

 The contact areas of primary molars are flat and very broad
buccolingually compared with the permanent molars.

 The crown color of the primary teeth is whiter and a lighter shade.

9
Roots :
 The roots of the primary molars have a greater flare, which
accommodates the developing crowns of the succedaneous
permanent premolars of the permanent dentition.
 The mesiodistal width of the roots of primary anterior teeth is
much narrower than the crown when compared with those of the
permanent anterior teeth.
 The primary molar roots are relatively longer and more slender,
i.e., mandibular molar roots are narrower mesiodistally, maxillary
MB and DB roots are narrower mesiodistally, and maxillary palatal
roots are narrower buccolingually.

Pulp and Root Canal Systems:

 The size of the pulp relative to the crown is larger in the primary
teeth.
 Pulp horns are higher in proportion and are located closer to the
DEJ and to the outer surface of the crown.
 Mesial pulp horns are higher than distal pulp horns.
 Pulp chambers are shaped comparably with the shape of the outline
of the crown from an occlusal view.
 Pulp horns are present under each cusp of the primary molars.
 The pulp chambers of primary mandibular molar teeth are normally
larger than the pulp chambers of primary maxillary molars.
 The root canal system of fully developed primary molars is
extremely tortuous and complex.

Implications of Primary Tooth Morphology

The progress of caries is much faster in the primary dentition, so incipient
lesions should be restored sooner than later!
 Thinner enamel and dentin
 Mesial pulp horn higher

Procedures in Primary Teeth:

Restorative Dentistry
 Enamel is thinner; therefore modifications are necessary in the
cavity preparation.
 Broad contacts need to be restored n Beware of the mesio-buccal
pulp horn.
10
  May need to do SSC if both proximal surfaces involved.
 Preserve the buccal cervical ridge to obtain mechanical retention
for SSC.

Surgical Procedures
 Conical anterior roots facilitate easy removal.
 Flared roots of the molars - use caution as premolar buds are
located between the roots.
 Pulp Therapy and Pulpotomy- beware of perforations.
 Pulpectomy- Difficult on molars due to tortuous and irregular pulp
canals.
 Beware of tooth buds

11
 Development of Normal Occlusion
Occlusion is defined as the anatomic alignment of teeth and their
relationship to the rest of the masticatory system. It has defined as the
relationship of the teeth in the maxilla and mandible when the jaws are
closed and the condyles are at rest in the glenoid fossae.

Normal Occlusion has defined as the class I relationship of maxillary

and mandibular 1st molars in centric occlusion.

Physiologic Occlusion is defined as that occlusion that deviates in one or

more ways from ideal yet it is well adapted to that particular environment
is esthetic and shows no pathologic manifestations.

Development of occlusion the relationship of the mandibular and

maxillary teeth when closed or during excursive movements of the
mandible; when the teeth of the mandibular arch come into contact with
the teeth of the maxillary arch in any functional relationship.

Periods of Occlusion Development:

 Pre-dental period
 Deciduous dentition period
 Mixed dentition period
 Permanent dentition period.

Pre-Dental Period:
GUM PADS:
 The alveolar processes at the time of birth are known as gum pads
 The gum pads are pink, firm & covered by a dense layer of fibrous
periosteum
 They are HORSE-SHOE shaped & develop in two parts:
The labio-buccal portion & the lingual portion.
 The two portions of the gum pads are separated from each other by
a groove called the DENTAL GROOVE

12
  LATERAL SULCUS: The transverse groove b/w canine & first
deciduous molar segment.
 The lateral sulcus of the mandibular arch is normally more
DISTAL to that of the maxillary arch.
 The gum pads are divided into TEN SEGMENTS by certain
grooves called TRANSVERSE GROOVES
 The GINGIVAL GROOVE separates the gum pads from the palate
& floor of the mouth.
 There is a complete over-jet all around.
 (1) Contact occurs between the upper & lower gum pads in the first
molar region.
 (2) A space exist between them in the anterior region.
 This infantile open bite is Open bite considered normal & it helps
in suckling.

Deciduous Dentition Period:

Primate Spaces
It was reported two morphologic arch forms of the primary dentition:
either generalized spaces between the teeth were present (Type I) or the
teeth were in proximal contact without spacing (Type II).

The arch form in both types appears congenital rather than developmental
because the original pattern exhibited upon eruption was maintained from
ages 3 to 6 years.

Spaced arches frequently exhibit two distinct diastemas—referred to as

primate spaces—one between the mandibular canine and first primary
molar and the other between the maxillary lateral incisor and primary
canine.

13
It was observed that until the eruption of the permanent first molars, the
sagittal dimension of the primary dental arches remained essentially
unchanged, with the possible exception of a slight decrease as the result
of the development of dental caries on the proximal surfaces of the molar
teeth. Only minor changes in the transverse dimension of the primary
dental arches occurred during 3 to 6 years of age unless negatively
influenced by deleterious functional patterns.

Mixed Dentition Period:

Mesial Molar Shift
The early-mixed dentition (6 to 9 years of age) is a period much more
prone to localized factors that may result in severe malocclusion
problems if undetected. In addition to a continuation of basic preventive
and space maintenance issues, problems encountered in this period
include dento-alveolar anterior crossbites, ectopic eruption of permanent
incisors and/or first permanent molars, posterior crossbites, open bite and
flared maxillary incisors associated with deleterious oral habits, and
developmental anomalies (e.g., ankylosis, supernumerary teeth, and
missing teeth).

14
“Early” mesial shift during first permanent molar eruption occurs at the
expense of any posterior spacing that might have been present to include
breakdown spaces resulting from inter-proximal caries. Moyers, agreeing
that the pattern of transition involving the straight terminal plane is
normal, suggested that the occlusion forming a mesial step (distal surface
of the lower second primary molar is mesial to the same surface of the
maxillary molar) is most ideal for ClassI development. A distal step
(distal surface of lower second primary molar is distal to the same surface
of the maxillary molar) indicates a developing Class II malocclusion.
Proper permanent molar occlusion was achieved from a straight terminal
plane by a second mesial shift of the molars as second primary molars are
exfoliated.

This “late” shift of the mandibular first molar, often under the additional
influence of the emerging second permanent molar, occurs at the expense
of the leeway space with a decrease in the arch length of 2 to 3 mm on
average.
A transverse widening of the inter-canine width of the upper and lower
dental arches occurred during eruption of the permanent incisors. The
increase represented a physiologic widening by lateral and frontal
alveolar growth to provide space for the erupting permanent incisors and
their greater mesio-distal widths. The mean increase in inter-canine width
was greater in the maxillary arch (3 to 4 mm) than in the mandibular arch
(2 to 3 mm).
In the mandibular arch, the greatest tendency to increased width was
during eruption of the lower lateral incisors, whereas in the maxillary
arch it occurred primarily during eruption of the maxillary central
incisors. Whereas the increase was slightly greater in non-spaced primary

15
arches than in spaced arches, the arches with spaces generally resulted in
favorable alignment of the permanent incisors.

About 40% of the arches without primary dental spacing resulted in

crowded anterior segments.
(1)Significant Maxillary and Mandibular arch width increases occurred
between 6 weeks and 2years of age;
(2) Mandibular inter-canine width was established by 8 years of age (i.e.,
after eruption of the four incisors);
(3)Although arch width increased between3 and 13 years of age, there
was a slight decrease in width, more in the inter-canine than in the inter-
molar area, after complete eruption of the permanent teeth.

Leeway Space
Epidemiologic studies demonstrate that crowding and mal-alignment
become significantly more prevalent and exhibit greater severity between
the mixed dentition period (6 to 12 years of age) and the adolescent
young permanent dentition (12 to 18 years of age). This suggests that
normal transitional changes do not compensate for anterior mal-alignment
and crowding, in that late mesial shift of the buccal segments upon

16
exfoliation of second primary molars results in decreased arch length and
arch circumference.
Nance observed that in the average patient’s mandibular arch, a leeway
size difference of +1.7 mm per side exists, with the combined mesio-
distal widths of the primary canine, first primary molar, and second
primary molar being larger than the mesio-distal widths of the
corresponding permanent canine and premolars.

The difference between the total width of the corresponding three primary
teeth in the maxillary arch compared with the three permanent teeth that
succeed them is +0.9 mm per side of leeway space. The control of this
leeway space in terms of arch dimensional change through space
supervision may offer opportunities for significant improvement in tooth
size–arch size adjustments for the relief of typical levels of crowding.

Occlusion at 3 years of age :

1. The relationships between the distal surfaces of opposing second
primary molars may be one of the following :

17
 A. Straight or Flush terminal plane :
In which the distal surfaces of opposing second primary molars are
in the same coronal plane.
B. Mesial step terminal plane :
In which the distal surfaces of lower second primary molar is
mesial to the distal surface of the maxillary second primary molar.
C. Distal step terminal plane :
In which the distal surfaces of lower second primary molar is distal
to the distal surface of the maxillary second primary molar.

The flush terminal plane is the most frequently seen at the age of
three years.

2. Presence of spacing between primary teeth:

a. Incisor spacing to accommodate the larger size of permanent
incisors (Incisor Liability)
b. Primate spacing, mesial to upper C and distal to lower C. These
spaces are greater in the mandible than in maxilla.
c. Spacing between primary molars.

3. Normal over bite.

A, Diagram showing straight terminal plane with primary spacing. “Early

mesial shift” of mandibular molars closing primary spaces will help
establish proper first permanent molar occlusion.

18
Straight terminal plane without primary spacing, permanent molars erupt
into end-on position in the mixed dentition. Proper first permanent molar
occlusion may be attained when the second primary molars exfoliate and
a “late mesial shift” of the mandibular first permanent molar occurs.
B, Mesial step terminal plane that allows the first permanent molar to
erupt directly into proper Class I occlusion. If differential growth of the
mandible in a forward direction persists, it can lead to Angle's Class III
molar relationship.
C, Distal step terminal plane, thus erupting permanent molars may be in
Angle's Class II occlusion.

Occlusion at 6 years of age:

1. At the age of 6 years, spacing persists between the primary anterior
teeth.
2. As the result attrition and increase in the width of the maxilla
compared to the mandible, the mandible assumes a forward
position to maxilla (Edge to edge relationship).
3. At the age of 6 years, the mesial step terminal plane is present
where the distal surface of lower E is about 2 mm mesial to that of
the upper E .This is due to :
A. Bodily forward movement of the mandible to the maxilla.
B. Closure of spacing between the primary teeth especially the
primate spaces which are greater in the mandible than in
maxilla as a result of eruption of the first permanent molars at
the age of 6. This allows the lower E to move more forward
than the upper E producing a mesial terminal plane.
4. At the age of 6 years, the first permanent molars are clinically
visible and may assume one of the following relations :

19
 a. Class I molar relationship: in which the mesio-buccal cusp of
the upper 6 is at or near the buccal groove of the lower 6.
b. Class II molar relationship: in which the mesio-buccal cusp of
the upper 6 is mesial to the buccal groove of the lower 6.
c. Class III molar relationship: in which the mesio-buccal cusp of
the upper 6 is distal to the Buccal groove of the lower 6.

The most desirable occlusion in the permanent dentition is Class I

interdigitation.

Occlusion at 8 to 9 years:
1. With the eruption of upper and lower permanent incisors, there is
an increase in the depth of overbite due to their greater height in
comparison to the reduced vertical dimension in the primary molar
area. This is corrected by the eruption premolars.
2. Presence of diastama between upper permanent central incisors,
which is normal at this age (Ugly Duckling Stage). This is
corrected by the eruption of the permanent canines when the
pressure exerted by those erupting teeth is transferred from the
roots to the crowns of permanent incisors.

Occlusion at 10 to 12 years:
1. Diastama between the upper central incisors is closed by the
eruption of the permanent canines.
2. With the eruption of the premolars, the vertical dimension is
increased which corrects the deep overbite.
3. Closure of Leeway spaces (difference between the combined
mesio-distal width of C, D &E (larger) and 3, 4& 5
(smaller).

This space is greater in the mandible (1.7mm) than in the maxilla (0.9
mm) which allows the lower first permanent molar to move more forward
than the upper first permanent molar and assume normal relationship.

20
 The Child's First Dental Visit
The first appointment should be considered a mutual assessment session.
Preparation of the child and the parents before the first visit will result in
a better behavior pattern in the dental office.

Aim of the first visit:

- Establish good communication with the child and parent.
- Obtain important background information (Patient's social,
dental, and medical history).
- Examine the child and take radiographs if needed.
- Introduce the child to a simple treatment.
- Explain treatment aims to the child and parent.

Preparation for the child's first visit:

1. Pre-appointment preparation:

The parents must be instructed to:

- Inform the child about the dental visit casually.

- Avoid conversation including unfavorable references to dentistry
(e.g. saying that dentist will not hurt you).
- Tell the child that the dentist will count your teeth and look after
them.
- Inform the dentist about the child's first name, nickname, and name
of the child's pets, toys, friends and the child's hobbies.

2. Communication with the child and parent:

Appointment time:

- Avoid interference with nap times.

- Early morning appointment or after nap times.

21
 - First visit should be short (15 to 20 minutes).

Objective: to allay anxiety.

- The receptionist should greet the child in a friendly and

cheerful manner.
- The waiting room should contain evidence that children are
welcomed (e.g. children's posters, books and toys).
- The receptionist escorts the child and his parents to the dentist's
consultation room rather than operating room, to decrease child
anxiety before placing the child in more stressful situation.
- The dentist should communicate both visually by appearing
relaxed& friendly, and physically by shaking hands& patting the
child on the shoulders.

3. History:

- Provides essential information on which treatment planning is based.

- The history must be kept updated in recall visits (4-6 months).

- It includes:

- Personal (social) history: Name, date of birth, address, school,

siblings, pets, hobbies and parent's occupation.
- Medical history: Systemic diseases, mental problems, any previous
operations or serious illness, also family history of serious illness.
- Dental history: Past dental history (type of any previous treatment,
regularity of visits, changing dentist) all this gives an impression
about the attitudes of child and parents towards dental treatment.
Ask the child about his chief complaint using simple words with no
reference to pain.

22
4. Accompanying the child into the dental operatory:

The dentist accompanies the child into the dental operatory:

- Parents are allowed to accompany the child into the dental operatory
during the first visit for moral support.

- At subsequent visits the dentist must decide whether to keep the

parent or not based on:

A- The child's age (very young usually needs moral support).

B- Child's behavior.

C- Parent's character.

5. Examination:

- A good approach is to ask the child "how many teeth do you have?",
then let's count your teeth.

- Children who refuse to sit on the dental chair can be examined on their
parent's lap. The dentist can then count the teeth loudly and start
examination using a mirror.

- This first examination may not be detailed; however in successive visits

further details may be obtained.

- During examination:

- Avoid the sight of a sharp instrument or careless use of a probe.

- Avoid fear promoting words.
- Avoid sudden jerky movements.
- Use Tell-Show-Do technique and positive reinforcement.

23
A. Clinical examination:

a) Extra-oral examination:

The general appearance of the child, weight, height, gait, and the texture
of the skin, lips and eyes are to be examined.

b) Intra-oral examination:

Soft tissues: cheeks, tongue, lips, gingiva, hard and soft palate.

Hard tissues: teeth present, color, structure, mobility, oral cleanliness,

occlusion, presence of crowding or spacing.

B. Radiographic examination:

Value of radiographs:

- Diagnose dental caries in tooth surface in accessible to clinical

examination.
- Detect abnormalities in the developing dentition.
- Investigate specific problems, e.g. periapical lesions.

C. Diagnosis:

- Information obtained from the history, clinical and radiographic

examinations allow diagnosis to be made.

- Further diagnostic aids are sometimes required, e.g. pulp vitality test for
traumatized tooth or study models for orthodontic assessment.

6. Introductory treatment:

- After the examination, if the child is not presenting with pain, only
simple non painful procedures are carried out in the first visit (e.g.
polishing with soft brush, taking x-rays or fluoride treatment).

- Injection and cavity preparation should be avoided during first visit until
the dentist gains the child's confidence.

24
7.Conducting the session:

- At the end of the first visit the dentist can assess; the child's behavior as
well as the parent's reactions.

- Praise the child for good behavior and ignore bad behavior.

- Prepare the child for the next visit by telling him in simple words what
is going to be accomplished.

- Explain aims of the treatment to the parents.

- Give an estimate of the number of visits required to complete treatment.

- Recall visits usually proceed smoothly if the child is properly managed

in the first visit.

25
 Behavior Management
Definition: it is the means by which the dental health team effectively
and efficiently performs treatment for a child and at the same time instills
a positive dental attitude.

Non-pharmacologic Management of Children’s Behaviors

AAPD introduced the term behavior guidance to emphasize that the goals
are not to deal with a child’s behavior but rather to enhance
communication and partner with the child and parent to promote a
positive attitude and good oral health.

Goals of behavior guidance:

- Establish communication.
- Alleviate fear and anxiety.
- Deliver quality dental care.
- Build a trusting relationship between dentist and child.
- Promote the child’s positive attitude toward oral/dental health and
oral health care.

The foundation of practicing dentistry for children is the ability to guide

them through their dental experiences. Therefore, the pediatric dentist
must have knowledge about the psychology, growth and development of
children. As well as, knowledge about social, cultural and medical factors
affecting health and behavior of children.

Treating a child usually relies on a one-to-two relation-ship among the

dentist, the patient, and parents or caregivers. This relationship is known
as the pediatric dentistry treatment triangle. The triangle is encircled by
society, the child is at the apex of the triangle and is the focus of both the
family and the dental team.

26
Childhood Development:
It is helpful to become acquainted with certain developmental milestones
in the life of the child.

1. Before two years old:

- The child lacks rational response and sufficient cognitive development.

- He can express fear, joy and anger.

- An oral examination and some treatment can be accomplished without

sedation.

2. Two years old child:

- Has limited vocabulary; shows early sentence formation, they are too
young to be reached by words alone, and are shy of new people
(including the dentist) and places.

- Has a short attention span.

- Children of this age should be accompanied by a parent.

- Fears falling down and sudden movement, so the dental chair must be
moved slowly.

27
- He is likely to cry in any new situation, as he cries the dentist can
accomplish his work.

3. Three years old:

- The child becomes semi-independent.

- He has very active imaginations, likes stories and can be reached by

words.

- Me-too stage.

- Likes praise, and he knows that there is a reward for good behavior.

- Fears strangers and feels more secure with the parents.

4. Four years old:

- This age is called the How and Why age.

- May be great talkers who are prone to exaggeration.

- Participates well in small social groups and can be cooperative patients.

- Fears unknown but fear of strangers becomes less.

5. Five years old:

- Plays cooperatively with peers.

- Usually has no fear of leaving his parents for a dental appointment.

- Takes pride in his possessions, and comments about clothing can be

effectively used to establish communication.

6. Six years old:

- By this age, the child is established at school and is increasingly

independent of parents.

- The fear may increase at this age but can be rationalized.

28
7. Seven years old:

- Usually independent of parents.

- More attached to friends.

- Can be managed by explanation.

Classifying Children's Behavior:

Wright classified children's behaviors in the dental office into:

1. Cooperative Behavior

Cooperative children are reasonably relaxed, showing minimal

apprehension. These children present a reasonable level of cooperation,
which allows the dentist to function effectively and efficiently.

2. Lacking Cooperative Ability

In contrast to the cooperative child is the child lacking cooperative

ability. This category includes very young children(less than three years
of age) and children with specific debilitating or handicapping conditions,
with whom communication cannot be established.

3. Potentially Cooperative Behavior

There is a difference between the potentially cooperative child and the

child lacking cooperative ability. The potentially cooperative child has
the capability to behave well and the child’s behavior can be modified.

Challenging or Defiant Behavior:

Usually a stubborn child who defies the dentist and screams loudly “I
don’t want to” or “I won’t”.

29
Timid Behavior:

The child hides behind a parent. The dentist must proceed slowly and
gain the child’s confidence. If the dentist hurries to start treatment, it
might jeopardize the complete treatment. These children do not always
hear or comprehend instructions.

Hysterical or uncontrolled:

Usually a young child (3 years old) shows this behavior. He cries loudly
with tears, he shows physical lashing out and temper tantrums.

Fearful:

An apprehensive child, his heart beats fast and cries quietly. He resists a
little but usually obeys the dentist and responds to praise.

Factors influencing child's behavior in the dental office:

A. Maternal (parental) anxiety:

There is a significant correlation between maternal anxiety and a child's

cooperative behavior at the dental office. Parents who are anxious of the
dental treatment tend to have children who are anxious too.

B. Extreme parental attitudes:

1. Over-protection:

- The mother (parent) interferes in the child's life and assists him in
everything.

- Leads to a shy delicate child who lacks courage in the dental office.

2. Over-indulgence:

- The parents yield to all the child desires.

- The child becomes spoiled, selfish and stubborn.

- Extreme indulgence results in a defiant child in the dental office.

30
3. Over-authority:

- The parents demand from the child excessive responsibilities more than
his chronological age.

- This child is tense and restless in the dental office.

4. Over-affection:

- Occurs in case of only child or youngest in the family.

- The child lacks courage in the dental office.

5. Under-affection:

- Parents don’t spend enough time with the child because of work
obligations, emotional or socio-economic reasons.

- The child feels insecure, may develop bad oral habits, will be shy and
cries easily in the dental office.

6. Rejection:

- This is an extreme behavior as a result of an emotional problem such as

jealousy, or in case of immature parents, or financial burdens.

- The child becomes selfish, restless and disobedient.

C. Child factors:

1. Child's growth and development.

2. Past dental experience.

3. Child's awareness of the dental problem.

4. Past medical history.

5. School:

- Children in schools have more dental knowledge, but may be

misleading stories about dentistry.

31
6. Fear and anxiety:

Fear: It is a protective mechanism against danger. Fear must be directed

towards danger (fear from caries not from the dentist).

Types of fear:

 Real or true fear.

 Emphasized or not true.

Real or true fear:

- Subjective fear: Due to experience of others, suggested to the child

if he hears stories about dentistry from his friends or parents. The
child's imagination magnifies the fear.
- Objective fear: Results from personal exposure to pain or
discomfort. A painful tooth can be associated with fear from
dentist. A previous dental experience can be the cause of this fear.
Also, a previous medical experience may cause the child to fear
hospitals or persons in white coat.
- Needle pain fear: If the child was subjected to previous therapeutic
injections or vaccinations.

Emphasized or not true:

- Fear of unknown: a common trait in all human beings, all

unknown situations are fearful until experienced.
- Fear of strangers: (dentist and assistant).
- Fear of separation from the parents.

7. Physical condition of the child:

- Nutrition: Children with vitamin deficiency show irritability and

fatigue.

32
 - Physical and mental fatigue: lack of sleep or exhaustion is turned
into poor behavior in the dental office. Therefore, morning
appointments or those after naptime are the appointments of
choice.

D. Factors related to the dentist:

Appearance of the dental office, personality of the dentist, dentist's skill,

use of fear promoting words, use of reward, time and length of the
appointment.

Behavioral Methods for Removing Dental Anxiety (Non-

pharmacological approach):
1. Establishing communication
The first objective in the successful management of a young child is to
establish communication. By involving a child in conversation, a dentist
not only learns about the patient, but also relaxes the youngster.

2. Tell-show-do (TSD)

The TSD procedure is as follows, the dentist explains slowly to the child
what is going to be done in language that the child can understand.
Second, the dentist shows the child what will be used, and how it works
(e.g., hi-speed drill) and how the procedure will be carried out. Finally,
the dentist performs the procedure.

3. Distraction

Ignoring undesirable acts and then directing attention away from a

behavior, thought or feeling to something else.

33
4. Positive Reinforcement

Reinforcement is an effective technique toward desired behaviors and

strengthens their recurrence. Appropriate behavior is reinforced by a
smile and/or verbal approval (“right” or “great” or “that’s good.”).
Another form of a reward is a present (balloons, stickers, or coloring
sheets). It should be given at the end of the session as a sign of approval
and shouldn’t be offered as a bribe in the hope of encouraging good
behavior.

5. Modeling

Modeling can be done with a videotaped procedure or a live model.

Providing an example or demonstration with the goal to let the child
reproduce behavior exhibited by the model. One of the parents or another
child undergoing dental treatment would be a good example.

Behavior management of the difficult child:

Voice Control

Sudden and firm commands are used to get the child’s attention or to stop
the child’s undesirable behavior.

Physical Restraint

It is the act of physically limiting the body movements of the child to

facilitate dental procedures. Parents must be informed and give consent
before using restraints. Useful for extremely resistant patients and those
who need help controlling their extremities (e.g. patients with
neuromuscular disorders).

34
Types of Restraints:
Wrap: a nylon mesh cover wrapped around the child.

Mouth prop: to control jaw movement.

Hand over mouth technique (exercise) HOME

The purpose of this technique is to gain the attention of a highly

protesting child so that communication could be established. Used by
placing hand over the child’s mouth to muffle the noise. Then speaking
quietly but clearly into the child's ear explaining that the hand will be
removed as soon as the crying stops.

35
 Pharmacological Behavior Management
The majority of pediatric dental patients can be treated in the conventional dental
environment. By establishing good rapport with the patient and parent and by
relying on sound behavior management techniques the anxiety and pain of many
pediatric dental patients can be managed effectively using only local anesthesia.
Unfortunately, a minority remain uncooperative because of fear or anxiety.
Pharmacologic management is indicated for children who cannot be managed with
traditional behavioral management techniques and local anesthesia.

The decision to sedate a child requires careful consideration by an experienced

team. The choice of a particular technique, sedative agent and route of delivery
should be made at a consultation appointment to determine the suitability of a
particular child (and their parents) to a specific technique.

Sedation and Pediatric Dentistry:

I. Conscious Sedation (Moderate Sedation).
II. General Anesthesia.

I. Conscious Sedation:
It is a drug-induced depression of consciousness enabling treatment to be carried
out, during which the patient responds appropriately to physical stimulation and
verbal command. The patient is able to maintain a patent airway (no interventions
are required) and spontaneous ventilation is adequate.

The goals of conscious sedation:

- Facilitate the provision of quality care.
- Minimize the extremes of disruptive behaviour.
- Promote a positive psychologic response to treatment.

36
 - Promote patient welfare and safety.
- Return the patient to a physiologic state in which safe discharge is possible.
Special considerations for sedation in Paediatric Dentistry:
- Children’s responses are more unpredictable than adults.
- Children may be easily over-sedated as their smaller bodies are less tolerant
to sedative agents.
- Anatomical differences between the adult and pediatric airways (children
have a relatively larger tongue and epiglottis, possible presence of large
tonsillar/adenoid mass besides having smaller lung capacity).
- The use of monitoring devices such as pulse oximetry is mandatory for
moderate and deep sedation.
- Any dentist who sedates children must be capable of resuscitating the patient
or rescuing a patient from a deeper level of sedation than the one intended.
Routes of Administration:
The primary routes of administration for minimal and moderate sedation are:
1. Inhalation sedation (relative analgesia or nitrous oxide sedation).
2. Enteral sedation (e.g., oral or rectal).
3. Parenteral sedation (e.g., intramuscular, intravenous, subcutaneous,
submucosal, or intranasal).
1. Inhalation Sedation (Nitrous Oxide):
The most common form of inhalation conscious sedation is nitrous oxide and
oxygen.
Properties of nitrous oxide:
- Sweet smelling, colorless, non-irritant and inert gas.
- Not soluble in the body fluids, and is excreted unchanged through the lungs.

37
Indications:
- Frightened patient who wishes to receive dental treatment.
- Mentally handicapped children.
Contra-indications:
- Patients with respiratory infection, pulmonary disease, common cold
(preventing breathing from the nose).
- Patients with otitis media, as nitrous oxide increases pressure in air filled
cavities.
- Patients with certain psychiatric disorders.
- Patients with a history of motion sickness; who may experience vomiting
when nitrous oxide is administered.
Advantage:
- It produces a euphoric state and reduces pain to a lesser degree.
- Rapid onset and rapid recovery.
- The depth of sedation can be easily controlled.
- Minimal side effects.
Disadvantage:
- Weak agent.
- Lack of patient acceptance.
- Inconvenience in some areas, such as the maxillary anterior teeth, the use of
a nitrous oxide nasal mask may hinder exposure of the area.
Equipment:
- Flow meter with safety valve to deliver oxygen and nitrous oxide.
- Reservoir bag filled with oxygen.
- Light weight nose piece.
- Gas cylinders.
- Scavenger system.
38
Administration of nitrous oxide sedation:
- Explain to the parent and the child what nitrous oxide sedation is, the
sequence of the procedure and how it affects the child’s behavior and
acceptance of dental treatment.
- Introduce nose-piece and encourage the child to breathe through the nose.
- Start administration with 100% oxygen, then gradually introduce nitrous
oxide(100% oxygen for 3-5 minutes, introduce 5%-10% nitrous oxide every
3-5 minutes), final concentration 70% oxygen and 30% nitrous oxide.
- Describe sensations to the patients (sensation of floating, tingling of digits,
and sagging of eyelids).
- By the end of the session introduce 100% oxygen for 3-5 minutes.
Adverse side effects:
1. Acute effect (on the patient):
- Hypoxia.
- Bone marrow depression.
2. Chronic effect (dentist and assistants):
- Reduced fertility.
- Spontaneous abortion.
- Increased incidence of liver disease.
- Malignancy.
- Neurological defects.
Safety recommendations:
- Use minimum effective dose.
- Use scavenger equipment.
- Vent exhaust gases to outside.
- Check delivery system for leakage monthly.

39
2. Enteral Sedation:
a) Oral Route:
The most accepted and easiest method of drug administration.
Advantage:
- Ease of administration and readily accepted by the patient.
- Low cost.
- Decreased incidence of allergic reactions.
Disadvantage:
- Prolonged onset/duration of action.
- Less predictable effects because many factors influence absorption.
Drugs:
- Chloral hydrate, hydroxyzine, promethazine and diazepam.
b) Rectal:
- The rectal route is not frequently used in dentistry.
3.Parenteral Sedation:
a) Intramuscular:
Advantage:
- Faster absorption than oral route and doesn’t require patient’s cooperation.
Disadvantage:
- Delayed absorption.
- Possibility of tissue trauma.
Drugs:
- Phenergan and pethidine.

40
b) Intravenous:
Advantage:

- Most efficient and immediate sedation.

- Absorption is not a complication factor.
Disadvantage:

- Complications as haematoma or allergic reactions such as anaphylactic

shock.
- Not recommended for very young children.
- The need for a period of post-operative recovery and restriction of activities.

Drugs:

- Diazepam.

c) Submucosal:
- The submucosal route involves the deposition of the drug beneath the
mucosa, usually in the area of the maxillary primary molar or canine teeth.
- Care must be taken so that sedatives are not injected into any of the muscles
of the face and jaw.
- Because of possible sloughing and necrosis of the tissues, the use of this
technique must be limited to drugs that are non-irritating to tissues.

41
II. General Anaesthesia:
It is a drug induced loss of consciousness during which patients are not arousal
even by painful stimulation. Patients often require assistance in maintaining a
patent airway.
Indications:

- Multiple carious teeth in very young children.

- Severe dental disease in handicapped children.
- Extremely uncooperative, fearful or anxious children.
- Maxillofacial surgeries.

Pre-anesthetic assessment:

- A thorough medical history and examination by the anesthetist is required

prior to the procedure.
Fasting Instructions:
Children under 6 years of age:
- No solids for 6 hours pre-operative.
- No breast milk for 4 hours pre-operative.
- No clear fluids for 2 hours pre-operative.
Children older than 6 years of age:
- No solids or liquids for 6 hours pre-operative.

42
Operating theater environment:
- Minimize the waiting time prior to the procedure.
- Children should be allowed to wear their own clothes in case of routine
restorative procedures.
- Parents are allowed to be present during induction of anesthesia, and in the
recovery area once the child is awake and stable to minimize anxiety.
- Normal day-stay recovery is a minimum of 2 hours after the procedure.

43
 Local Anesthesia in Pediatric Dentistry
1. Introduction:
The cornerstone for success of any Pediatric dental procedure is Pain-less
injection. Children who undergo early painful experiences during dental
procedures are likely to carry negative feelings toward dentistry into adulthood.
Therefore, it is important that clinicians make every effort to minimize pain and
discomfort during dental treatment.
Definition: Local anesthesia is the temporary loss of sensation in one part of the
body produced by a topically applied or injected agent without depressing the level
of consciousness.
Successful local anesthesia depends on:
- Communication with the child.
- Good topical anesthesia and allowing adequate time for it to act.
- Slow injection of warm solution.
- Proceed smoothly from start to finish.
- Control the child’s field of vision because sight of the needle causes anxiety.
2.Anatomy& Innervation:

Trigeminal (5th) Cranial nerve

44
A. Maxilla:
All maxillary, investing structures and buccalmuco-periostium are supplied by the
maxillary branch (2nd division) of Trigeminal Nerve, where:
Maxillary Central, Lateral Incisors & Canines:
- Pulp, investing structures &buccal muco-periostium: Anterior Superior
Alveolar Nerve.
- Palatal muco-periosteum: Naso-Palatine Nerve.
Maxillary Premolars:
- Pulp, investing structures & buccal muco-periostium of Maxillary Premolars
and Mesial half of Maxillary 1st Permanent Molar: Middle Superior Alveolar
Nerve.
- Palatal Muco-periosteum: Greater-Palatine Nerve.
Maxillary First & Second Permanent Molars:
- Pulp, investing structures & buccal muco-periostium of Maxillary
Permanent Molars & Distal half of Maxillary 1st Permanent Molar: Posterior
Superior Alveolar Nerve.
- Palatal Muco-periosteum: Greater-Palatine Nerve.
B. Mandible:
Mandibular Central, Lateral Incisors & Canines:
- Pulp & investing structures: Incisive Nerve (Terminal Branch of Inferior
Alveolar Nerve).
- Buccal Muco-periostium: Mental Nerve.
- Lingual Muco-periostium: Lingual Nerve.
Mandibular PreMolars:
- Pulp & investing structures: Inferior Alveolar Nerve.
- Buccal Muco-periostium: Mental Nerve.
- Lingual Muco-periostium: Lingual Nerve
45
Mandibular First & Second Permanent Molars:
- Pulp & investing structures: Inferior Alveolar Nerve.
- Buccalmuco-periostium: Long Buccal Nerve.
- Lingual Muco-periostium: Lingual Nerve.

3. Local Anesthetic Armamentarium:

A. Topical Local Anesthesia (surface Anesthesia):
1. Effective Depth: 2-3 mm.
2. Aim: reduces the discomfort of the initial penetration of the needle.
3. Forms: Ointment, Gel, Spray or patches.
4. Types: Benzocaine 20% (Ester type)
Lidocaine 5% (Amide type)
Xylocaine 10% (Amide type)
5. Benzocaine 20% is considered the best topical anesthetic agents because:
a. Depth of penetration (3-5 mm).
b. Least toxic side effects, it is poorly absorbed into cardiovascular system.
c. Prolonged duration of action.
B. The armamentarium necessary to administer local anesthesia are:
 An aspirating syringe to avoid intravascular injections.
 Disposable needles: Long, short and extra-short needles.
 Carpule: The solution most commonly used is 2% lignocaine with 1:80000
adrenaline.
 Functions of Vasoconstrictor: *Delay the absorption of the drug.
*Prolong the duration of action.
*Field with less bleeding.
*Less systemic toxicity.

46
 - Contra-indications of Vasoconstrictor: 1- Thyrotoxcicity.
2- Hypertension.
3- Asthma

4. Anatomical Difference Adults & Children:

A. Mandible: Mandibular foramen in children 4 years old and less is more
posterior and at lower level than in adults. The foramen moves superiorly in the
ramus with the eruption of the first permanent molars.

Clinical significance: Inferior alveolar nerve block is at lower level and more
posterior than in adults.

B. Bone Density: As a general rule density of bone increases by age.

Clinical significance: Infiltration anaesthesia can be performed for mandibular

molars (following the rule of 10).

5. Techniques:

MAIN & SUPPLEMENTAL Techniques:

1. Infiltration Anesthesia:

Used to anesthetize:

A. All maxillary teeth (Buccal infiltration).

B. Mandibular Anterior teeth (Buccal infiltration).

C. Mandibular posterior teeth (Rule of 10).

D. Palatal Infiltration is avoided in children and as a substitute the Intra-Papillary

Injection is recommended to anesthetize the palatal muco-periostium.

47
A solution deposited supra-periosteal infiltrates through the alveolar bone to reach
the root apex. Alveolar bone in children is more permeable than in adults, so less
amountsof solution are enough to produce anesthesia.

2. Intra- Papillary Injection:

Used to anesthetize: palatal or lingual tissues, to avoid the need for painful direct
palatal injections.

Technique: after an infiltration injection to the buccal tissues, wait for 1 minute,
inject into the interdental papilla mesial and distal to the tooth to be treated. Pass
the needle horizontally through the papilla from buccal to lingual (or palatal).

3. Inferior Alveolar Nerve Block:

Used to anesthetize:
A. Mandibular teeth to the midline.
B. Body of the mandible and inferior portion of the ramus.
C. Buccalmuco-periosteum of all mandibular primary teeth at one side.
D. Anterior two thirds of the tongue and the floor of the oral cavity (lingual nerve).
E. Lingual soft tissues and periosteum (lingual nerve).
Technique: when deep operative or surgical procedures are undertaken for
mandibular primary or permanent teeth, the inferior alveolar nerve must be
blocked. In young children the position of the mandibular foramen is relatively
low, in line with the cervical margins rather than the occlusal surfaces of the teeth.
The direction of the needle insertion should be modified accordingly. The injection
should be made slightly lower and more posterior than for an adult patient.

48
  Lay the thumb on the occlusal surface of the molars, with the tip of the
thumb resting on the internal oblique ridge and the ball of the thumb resting
on the retromolar fossa. Support the mandible during the injection by resting
the ball of the middle finger on the posterior border of the mandible.
 The barrel of the syringe should be directed between the two primary
molars on the opposite side of the arch.
 Inject a small amount of solution as the tissue is penetrated, wait 5 seconds.
 Advance the needle 4mm while injecting minute amounts (up to a ¼
cartridge).
 Stop and aspirate.
 If aspiration is negative, advance the needle until bony resistance is met.
 The average depth of insertion is about 15mm (varies with the size of the
mandible and the age of the patient). Deposit about 1 ml of solution around
the inferior alveolar nerve.
 If bone is contacted too early (less than half the length of a long needle) the
needle tip is located too anteriorly,withdraw it until approximately ¼ length
of needle is left in the tissue, reposition the syringe mesially over the area of
the cuspid and repeat as above.
 Wait 3-5 minutes before commencing dental treatment.

Lingual nerve block: blocked by bringing the syringe to the opposite side with the
injection of a small quantity of solution as needle is withdrawn.

Long buccal nerve block: must be anesthetized for extraction of mandibular

permanent molars. The solution is deposited in the muccobuccal fold at a point
distal and buccal to the indicated tooth.

49
4. Intraligamentary Injection (Periodontal Ligament Injection):

Given into the periodontal ligament using a special syringe.Intraligamentary

injections can be given with a conventional needle and syringe, but the special
syringes are preferred because they more easily produce the pressure required to
inject into the periodontal ligament. A short or ultra-short (1cm) 30-gauge needle is
usually used, and the syringe accept the standard cartridge.

Advantages:
 Less uncomfortable than other injections.
 Highly recommended for too young & disabled patients, not causing post-
anesthetic trauma to the lips & tongue.
 Completely painless.
 Requires too small quantity of anesthetic solution.
 Analgesia is obtained very quickly.
 Performed without removal of rubber dam.
 Pulpal anesthesia for 30-45 min.
 Doesn’t require aspiration before injection.
 Used in patients where inferior alveolar nerve block must be avoided e.g.
patients with bleeding disorders.
 Can be used for restorative treatment as well as for extractions.
Disadvantages:
 Minor pain following its use in restorative treatment.
 Tissue damage, but it resolves within few weeks.
 Possibility of forcing infected material from the gingival crevice into the
periodontal tissues.
 Pressure might cause damage to the developing permanent tooth.

50
5. Jet Injection (Needle Free Injector):
The Syrijet contains a compressible spring, which generates a pressure of 290 KPa
when released; injecting solution through mucous membrane and into bone to a
depth of 1cm. It accepts standard cartridges and is calibrated to deliver volumes of
0.05 and 0.2ml.
Advantage:
 Produces soft tissue analgesia (surface anesthesia) instantly therefore used
before painful injections such as palatal injections or instead of topical
anesthesia.
 Quick and painless although abruptness of injection may cause anxiety.
 Used for producing analgesia for extraction of loose primary teeth, minor
oral surgery, and rubber dam clamps application.
Disadvantage:
 High cost, so not widely used.

6. Administration Protocol:
1. Preparation of the child:
a. Avoid any fear-promoting words, use simple words “put teeth into sleep”.
b. DO NOT PROMISE PAIN-LESS INJECTION.
c. Tell- Show –Do……… Except for the syringe.
d. Instruct the parents not to interfere even with encouraging words.
Position the patient on the dental chair:
The patient is positioned with the head and heart parallel to the floor and the feet
slightly elevated. Positioning the patient in this manner reduces the incidence of
syncope that can occur as a result of increased anxiety.

2. Apply topical anesthetic paste to dried mucous membrane and give

sufficient time for topical anesthesia to work.
51
 3. Warm local anesthetic carpule between hands.
4. Apply pressure to injection site.
5. Stretch tissues.
6. Concealment of syringe.
7. Passively support child’s hands
8. Distract child’s attention.
9. Inject few drops, then wait, inject slowly.
10.1 ml of solution will be enough.
11.Use fine gauge needle, tell the child what he is going to feel
12.Use infiltration anesthesia instead of nerve block in mandibular molars in
very young children.
13.Use intra-papillary injection instead of palatal injection in case of
extraction of maxillary teeth.

7. Complications of Local Anesthesia:

A. Anesthetic toxicity (overdose):
• While rare in adults, young children are more likely to experience toxic reactions
because of their lower weight.
• Most adverse drug reactions occur within 5-10 minutes of injection.
• Overdose of local anesthetics are caused by high blood levels of anesthetic as a
result of an inadvertent intravascular injection or repeated injections.

Maximum Recommended Dose for Children: 4.4 mg \ Kg body weight + The Vasoconstrictor

B. Allergic reactions:
 Patients with a sulfa allergy should not receive Articaine.
 Allergies can manifest in a variety of ways including urticaria, dermatitis,
angioedema, fever, photosensitivity and anaphylaxis.

52
C. Syncope (Vasovegal Attack).
D. Paresthesia:
• Paresthesia is the persistence of anesthetic symptoms beyond the expected
duration. It can be caused by trauma to the nerve by the needle during injection.
E. Postoperative soft tissue injury:
• Accidental biting or chewing of the lip, tongue or cheek is the most common
problem seen pediatric patients.
• Soft tissue anesthesia lasts longer than pulpal anesthesia and may be present for
up 4 hours after local anesthesia administration. The parents and the child must
be warned about the anesthesia sensation that lasts after injection.
• The most common area of trauma is the lower lip and to a lesser extent the
tongue, followed by the upper lip.

53
 Cavity Preparation
Definition of Cavity Preparation:
Cavity preparation is the mechanical alternation of a tooth to receive a
restorative material, which will return the tooth to proper anatomical
form, function, and esthetics. The procedure of the preparing the tooth is
the removal of the defective or friable tooth structure. Any remaining
infected or friable tooth structure may result of further carious
progression, sensitivity or pain or fracture of the tooth and / restoration.

Cavity preparation is the mechanical alternation of defective, injured or

diseased tooth in order to best receive a restorative material that will
reestablish a healthy state for the tooth including esthetic correction when
indicated, along with normal form and function.

The reason of the need for restoration as follow:

• To restore the integrity of the tooth surface.

• To restore the function of the tooth.

• To restore the appearance of the tooth.

• To remove the diseased tissue from the tooth.

Objectives of Cavity Preparation:

• To remove diseased tissue as necessary and at the same time provides
the protection to the pulp.
• To locate the margins of the restoration as conservative as possible.

• To ensure the cavity form, it should not be under the force of

mastication of the tooth.

• To allow the functional placement of the restorative material.

54
Principles of Cavity Preparation
• Gain access to caries.
• Removal of all carious lesions.

• Cut away all significantly unsupported enamel.

• Extended margins so that they are accessible for

instrumentation and Cleaning.

Classification
(G.V. BLACK CLASSIFICATION)
Black suggested that it was necessary to:

• Remove additional tooth structure to gain access and visibility.

• Remove all trace of demineralized enamel and dentin from the

floor, walls and margins of the cavity.

• Make room for the insertion of the restorative material in sufficient

bulk to provide strength.

• Provide mechanical interlocking retentive designs.

• ACCORDING TO SITE INVOLVED

• Site 1. Pits, fissures and enamel defects on occlusal surfaces of

posterior teeth or other smooth surfaces.

• Site 2. Approximal enamel in relation to areas in contact with

adjacent teeth.

• Site 3. The cervical one third of the crown or, following gingival
recession, the exposed root surface.

• Size 3. The lesion is enlarged beyond moderate. Remaining tooth

structure is weakened to the extent that cusps or incisal edges are
split, or are likely to fail if left exposed to occlusal load. The cavity
needs to be further enlarged so that the restoration can be designed
to provide support to the remaining tooth structure.

55
• Size 4. Extensive caries or bulk loss of tooth structure e.g. loss of a
complete cusp or incisal edge has already occurred.

• New caries classification:

Based on principles of adhesive dentistry, Mount & Hume in 1997
advocated a new classification for caries called Sites Stages
classification (Si/Sta).

• Site 1: Cavities seen in the pits, fissures and enamel defects of the
occlusal surfaces of posterior teeth.
• Site2: Cavities seen on the proximal areas in contact with adjacent
teeth.
• Site3: Cavities seen on the cervical one- third of the crown.

• Size1: Minimal involvement of dentin that cannot be treated by re-

mineralization.
• Size2: Moderate involvement of dentin. The amount of enamel
remaining following cavity preparation is sound, well supported by
dentin and not likely to fail under normal occlusal load. The

56
 remaining tooth structure is sufficiently strong to support the
restoration.
• Size3: The cavity is enlarged beyond moderate. The remaining
tooth structure is weakened extensively that cusps or incisal edges
are split, or are likely to fail or left exposed to occlusal or incisal
load. The cavity needs to be further enlarged so that the restoration
can be designed to provide support and protection to the remaining
tooth structure. Extensive caries with bulk loss of tooth structure
has already occurred.

Design and Preparation of Cavities:

• The design and preparation of cavities are based on Black’s
principles that have been determined and re-applied with
importance directed towards protection of tooth in preparation
rather than only on the material.

• Each diseased tooth has an individual cavity form determined by

caries involvement, morphology of tooth and its location in oral
cavity – leading to new conservative cavity designs.

Steps in the Cavity Preparation

(Given by G V Black)
• Obtaining Outline Form.

• Obtaining Primary Resistance Form.

• Obtaining Primary Retention Form.

• Obtaining Convenience Form.

• Removal of Remaining Carious Dentin.

• Obtaining Secondary Resistance & Retention Form.

• Providing Pulp Protection.

• Finishing of Enamel Walls & Margins.

• Performing the Toilet of the Cavity.

57
 Principles of cavity design:
Principles of G.V. Black
Cavity Design
1- Access  Gaining access to cavity.
 Prepare cavity to standard
outline.
 Remove any remaining caries.
2- Outline  Includes all deep fissures even
those which are not carious but
form susceptible to caries.
3- Extension  Extension for prevention i.e.
extends the preparation into
self-cleansing areas.
4- Resistance  Removal of all undermined and
unsupported tooth structure.
5- Retention  Mechanical macroretentive
interlocking designs.
 Convergence of walls.
 Dovetail.
 Undercuts.
 Axial grooves.
6- Cleanliness  Finishing the walls and toilet
of the cavity.
58
Modern concept
 Gaining access to caries.
 Remove caries.
 Plan the final outline
according to the material
used.
 Involves carious fissures while
sound deep fissures may be
covered with sealant.
 Prevention of extension i.e. no
need to extend the preparation
into self-cleansing areas or to
remove affected dentin in deep
portions. The approach focuses
on healing instead of removal of
demineralized tissues.
 Remove loose & fragile enamel
rods at cavo-surface angle
(C.S.A.) which are directly
exposed to occlusal load while
other unsupported tooth structure
may be conserved and reinforced
by the bonded restoration.
 Preservation of marginal ridges
in case of early proximal caries
by utilizing slot and tunnel
preparations.
 Micromechanicalretention which
includes current etching and
bonding procedures.
 Beveling which increases the
potential surface area for
retention.
 Cleanliness of adhesive surfaces
to ensure optimal bonding.
Basic principles in the preparation of cavities in primary
teeth:
In preparing cavities for restoring primary teeth, although the basic
principles of cavity preparation are applied, there are certain
modifications in cavity design which make restorative care of these teeth
unique. Most of these modifications have to do with the difference in
morphology of the primary molars from that of the permanent molars.
Class І Cavities in Primary Molars:
1) The outline form should include all pits, fissures and grooves
into which a sharp explorer can penetrate (areas susceptible to
caries).
2) The maximum inter-cuspal cavity width should be one- quarter
to one- third of the inter-cuspal width.
3) The pulpal floor should be flat, although some prefer to make
the pulpal floor slightly concave to allow for greater depth of the
filling material, for better distribution of stress in the restoration
and to avoid endangering the high pulpal horns.
4) The depth of pulpal floor should be established just beneath the
amelodentinal junction (0.5 mm) to provide sufficient bulk for
amalgam to withstand occlusal forces and to avoid pulp exposure.
5) All the internal line angles should be rounded to reduce any stresses in
the set amalgam.
6) The cavosurface margin should be approximate 90 degree to avoid
marginal deterioration.
Spot preparation:
 Beside the regular class I cavity preparations done in
primary molars, occlusal spot preparations have been
recommended.

59
  In such preparations only the carious pits or groove is
prepared and the tooth is restored in the usual manner.
 These preparations are applicable in any of the primary
molars EXCEPT the lower 2nd primary molar

Class П Cavities in Primary Molars:

1. These preparations include an occlusal, an isthmus and
proximal portion. The occlusal part has the same outline form
as the class I cavity.
2. The side walls of the occlusal step should converge occlusally.
3. The optimum average width of the isthmus should be
approximately one-half of the intercuspal dimensions of the
tooth. This is to avoid weakening of the cusp and to give
enough bulk to the material.
4. The axio-pulpal line angle should be rounded or beveled or
grooved to reduce the concentration of stresses and provide
greater bulk of material in the isthmus area, which is liable to
fracture.
5. The lingual and the buccal of the proximal box should be
diverging to clear the contact with the adjacent tooth either
buccally or lingually. The whole margins of the proximal box
are placed in a self-cleansable area.
6. The proximal box line angles and walls should converge
occlusally, following the buccal and lingual surfaces of the tooth.
7. Axio-buccal and axio-lingual retentive grooves may be included in
the preparation. These grooves will aid in the retention of
restoration and will reduce the flow of amalgam.
8. The gingival seat of the proximal box should be extended past the
contact area to ensure caries removal, since decay is initiated at or
60
 just below the contact area.
9. Too far gingival placement of the gingival seat should be avoided
as it will endanger the pulp.

Conservative Approach for Proximal Caries in Primary

Teeth:
Tunnel Preparation:
Designed for caries in the proximal surface 2.5mm below the marginal
ridge. The caries is approached from the triangular fossa in the occlusal
surface forming a tunnel with the marginal ridge intact.
Slot Preparation:
The cavity outline is like a box with no step such that for the gingival
seat.
Proximal Approach:
Designed for primary molars with incipient proximal lesions, and in case
of direct access through a regular class II cavity establishment in the
adjacent molar or a missing neighboring molar. A spot preparation in the
mesial surface of second primary molar can be prepared. This spot
preparation should be small, not undermining the marginal ridge and can
only be done in patients with low caries index.
Matrix Bands:
Used to restore normal contact areas of primary teeth and prevent
extension of excess restorative material beyond the band into the gingival
tissues during condensation of amalgam in a class II cavity design.
T-band:
Is used for producing a well-contoured proximal restoration in primary
molars due to presence of prominent cervical ridge and marked
constriction of the crown.

61
Spot-Welded matrix band:
Can be individually preformed for each tooth, used in back-to-back
amalgam restorations.
Class Ш Cavity Preparation:
If the carious lesion has not advanced appreciably into the dentin and if
removal of the caries will not involve or weaken the incisal angle , a small
conventional class III cavity may be prepared and the tooth restored with
composite. If the caries is more extensive and the incisal angle is intact, a
dove tail preparation can be made, the dove tail can be prepared on the
palatal or the labial surface of the tooth. Because of ease to access and the
minimal aesthetic requirements of the restoration, it is placed on the labial
surface in the mandibular primary incisors and on the palatal surface in
the maxillary incisors.
Class IV Cavity Preparation:
In these cavities caries involves the incisal proximal angle of the anterior
teeth.
1. If caries is not extensive, disking by sandpaper disc performed to
remove the caries, and then fluoride is applied topically.
2. In extensive caries anterior chrome steel crowns with aesthetic
facing can be used.
Class V Cavity Preparation:
Class V cavities are prepared like those in permanent teeth with the depth
1.5mm. All decalcified areas should be included in the outline form. In
deep lesions protection of the pulp is necessary. No need to bevel the
margins as the enamel rods are directed incisally or occlusally. Fluoride
releasing restorative materials could be used for restoration of these
cavities.

62
  Cavity Preparation

1. Class I:
 Gain access using 330 bur.

 Outline form should include all pits,

fissures and grooves.

 A flat pulpal floor is generally advocated, although some

prefer to make the pulpal floor slightly concave.

63
 The depth of the pulpal floor should be just beneath
the DEJ (0.5mm) to avoid pulp exposure. This can be
judged by the 330 bur.

 All internal line angles should be rounded. The buccal

and lingual walls should be slightly converging towards
the occlusal plane.

 The mesial and distal walls should be slightly diverging

towards the occlusal plan in order to follow the outer
form of the crown and to support the marginal ridges.

64
 2. Class II:
a) Occlusal Portion: Same as class I outline. Include all
pits, fissures and grooves.

65
b) Isthmus Portion:
 Optimum average width is 1/3 to 1/2 the intercuspal
width of the occlusal surface.

1/3- 1/2

 Gingival seat is to long axis of the tooth and is

placed at a depth of 1 mm
(Just beneath free margin of interproximal
gingival tissues).
 Axial walls should follow tooth contour. 1 mm

i.e. converge occlusally (or parallel).

 No bevel at the gingival margin. As enamel rods slope
occlusally.

66
 Restoration of Primary Teeth
Isolation:
The maintenance of a dry operating field during cavity preparation and placement of the
restorative material is important. It helps ensure efficient operating procedures by
providing a dry clean operating field, improve access, visibility and development of a
restoration that will be serviceable. It involves three elements; moisture control,
retraction, access and harm prevention (aspiration or swallowing of objects).
Methods of isolation:
- Rubber dam.
- High volume suction.
- Absorbents.
- Mouth prop.
- Cottons rolls and holders.
Rubber dam:
It is generally agreed that the use of the rubber dam offers the following advantages:
1. Save time:
Elimination of the rinsing, spitting, andtalking of the child patient allows quick
operative work to be done.
2. Aids in management:
Apprehensive or uncooperative children can often be controlled easier with a
rubber dam in place controlling the movement of tongue and lips.
3. Controls saliva:
Moisture affects the setting reactions and the physical properties of amalgam and
other restorative materials, and reduces the adhesion of lining materials to
dentine.
In addition, contamination by salivary bacteria must be avoided when pulp
treatment is being performed.

67
 4. Prevents swallowing or aspirating of foreign materials be a child in a semi-
reclining position on the dental chair.
5. Protects the soft tissues.
6. Provides an aseptic environment.
7. Aid to cross-infection control by reducing aerosol spread of
microorganisms.
Disadvantages:
1. Time consuming.
2. Patient objection.
3. Some conditions that hinder its placement;
- Incompletely erupted teeth.
- Extremely mal-positioned teeth.
- Mouth breathers or asthmatic patients.

68
 Management of Deep Carious Lesions in
Children
The principle goal of pediatric operative dentistry is to prevent the extension
of dental disease and to restore damaged teeth to healthy function. Pulp exposure is
caused most commonly by caries but may also occur during cavity preparation or
by fracture of the crown. Pulp exposures caused by caries occur more frequently in
primary than in permanent teeth because primary teeth have relatively large pulp
chambers, more prominent pulp horns and thinner enamel and dentine. In primary
molars with proximal cavities pulp involvement occurs in about 85 % of those with
broken marginal ridges.
Differences between primary and permanent teeth that modify pulp
therapy techniques:
- Pulp chamber anatomy in primary teeth approximates the surface shape
of the crown more closely than in permanent teeth.
- Pulp chamber of primary teeth is proportionately larger with higher pulp
horns.
- The pulp protecting dentin thickness between the pulp chamber and the
dentino-enamel junction is less than in permanent teeth.
- Canals of primary molars have many lateral branches and apical
ramifications → Complete extirpation of pulp issues is almost
impossible.
- Accessory canals at furcation area→ Radiolucency seen at inter-radicular
region rather than the periapical region (Radiographically).
- The roots of primary molars flare outward from the cervical part of the
tooth to a greater degree than permanent teeth and continue to flare
apically to accommodate the underlying succedaneuos tooth follicle.
69
 - Less number of nerve fibers → reduced sensitivity to pain.
- The roots of primary teeth undergo physiologic root resorption, thus the
requirements of primary root canal filling materials must encompass
germicidal action, good obturation and resorbable capability.
Clinical Classification of Pulp Pathology:
Based on the extent of pulp damage, disease of the pulp can be classified into:
1. Pulpitis:
- Reversible pulpitis:It is a mild to moderate inflammation of the pulp
caused by noxious stimuli, in which the is capable of returning to the un-
inflamed state following removal of the stimuli.
Symptoms: Sharp pain lasting for a moment subsides after removal of the
stimuli.
- Irreversible pulpitis:Pulp is incapable of returning to the un-inflamed
state following removal of the stimuli.
Symptoms: spontaneous pain persisting after removal of stimulus, and
may be referred to adjacent teeth.
Chronic hyperplastic pulpitis: Also called pulp polyp, occurs in teeth
with extensive carious pulp exposures due to long standing low grade
irritation, characterized by presence of a granulation tissue covered by
epithelium, usually asymptomatic.
2. Pulp Necrosis:It is due to death of the pulp, may be partial or total. The
tooth may be asymptomatic and discoloration of the crown occurs.
The success of the treatment used depends mainly upon an accurate diagnosis.Pre-
requisite for correct diagnosis:
- Complete case history.
- Proper examination.
- Investigations.
70
Diagnostic aids in selection of teeth for vital pulp therapy:
I.History:
1. Pain History:
An accurate history of the type of painmust be obtained, including its duration,
frequency, location and spread as well as aggravating and relieving factors.
In primary dentition, the pain history rarely provides very clear information, but a
history of spontaneous pain does appear to correlate well with advanced,
irreversible pulpitis.
The dentist should distinguish between two types of pain:
Provoked pain:is precipitated by stimulus (thermal, chemical or mechanical) and
disappears after removal of stimulus. For example:
- Pain associated with eating is due to pressure from accumulated food
within the carious lesion and chemical irritation to the vital pulp
protected by a thin layer of dentine (good prognosis).
- Pain due to cold or hot food or drinks may indicate hyperemia or
reversible pulpitis.
Spontaneous pain (Unprovoked pain): is a throbbing constant pain that may
keep the patient awake at night. It indicates advanced pulp damage irreversible
pulpitis (poor prognosis).
Swelling and tenderness on biting: may indicate loss of pulp vitality and
periapical periodontitis.
While positive history of toothache suggests definite pulp pathology, absence of
pain does not preclude pulp involvement.

71
2. Medical History:
The child’s general medical history should also be reviewed to exclude any
systemic disorders or medications of dental relevance.
Examples may include:
- Children with bleeding disorder.
- Children with rheumatic fever.
- Immune-compromised children.
In case of medically compromised children extraction of the involved tooth is the
treatment of choice after proper premedication, as pulp may not possesa normal
reparative power.
3. Previous dental history:
A brief review of the child’s previous history may reveal important information on
the family’s general attitude to dentistry.
II. Clinical Examination:
1. Extra-oral examination:
Facial cellulitis or the presence of enlarged lymph nodes.
Extra-oral swelling: it is due to the spread of exudate into various spaces along the
facial planes. The drainage occurs through the path of least resistance, which is
through the skin.
2. Intra-oral examination:
a. Inspection: inspection of all teeth and associated soft tissues before focusing on
suspected problem area. Note should be made of any carious lesions, fractured or
displaced restorations, discolored teeth and areas of soft tissue swellings.
b. Intraoral swelling:it is usually apparent at the buccal surface of the alveolus,
because there is less bone on this aspect than on the lingual or palatal side, through
which inflammatory products from the inter radicular or the periapical regions

72
penetrate taking the path of least resistance.The presence of swelling, sinus,
draining fistula or chronic abscess indicates a non-vital pulp.
c. Palpation: to check for any deviation in bony contour, which may be present
denoting periapical lesion.
d. Mobility:associated with deciduous teeth mayphysiologic or may be due to any
persisting pathology.
e. Sensitivity to percussion: indicates apical or periodontal inflammation or both.
f. Discoloration:non-vital teeth tend to have a darker color. Tooth associated with
internal resorption at the pulp chamber tend to appear pink (Hence the name Pink
Tooth).
g. Size of pulp exposure and amount of pulpal bleeding: are the most valuable
observations in diagnosing the condition of the primary pulp:
- Small pin-point exposure surrounded by sound dentine indicates favorable
condition for vital pulp therapy.
- Large exposure with watery exudate or pus indicates unfavorable condition
for vital pulp therapy.
- Small controllable amount of bleeding during and/or following pulp
amputation is a favorable condition for pulp therapy.
- Excessive uncontrollable bleeding during and/or following pulp amputation
is an unfavorable condition for pulp therapy.
III. Vitality tests:
Sensitivity test will rarely give a clear picture of the extent of pulpal inflammation
and the results should be interpreted with caution. Anxious children may give an
exaggerated response to relatively minor stimulation of a healthy tooth. While
poorly innervated, immature teeth, or teeth which have been concussed by trauma
may give no response in the presence of advanced inflammation.

73
There are many methods to assess the pulp sensitivity among them: Thermal pulp
test (hot or cold), Electric pulp tester and Laser doppler flowmeter.
Thermal test:
- Application of hot (Guttapercha or hot instrument) or cold (ice cone).
- The reaction of normal tooth is tested first
- Normal response: pain disappear after removal of stimulus.
- If pain persists, indicate pulpitis or hypermia.
- If no pain is an indication of non-vital pulp.
- Ice is best for children.
Electric pulp tester:
- Record the reading of a normal tooth first.
- If the affected tooth responds at a lower reading than normal, this
indicates hyperemia or pulpitis.
- If the affected tooth responds at a higher reading, this indicates pulp
degeneration.
- 40% of irreversible pulps respond like controls.
- 70% of non-vital teeth give no response.
- 20% of vital teeth give no response.
Disadvantages of electric pulp tester:
a- Child may become apprehensive and gives a false positive response.
b- Pulp tester may give false positive response when content of pulp is liquid
(liquefaction necrosis).

74
IV. Radiographic examination:
Periapical and bitewings radiographs are used to examine periapical area and
supporting bone. Pulp exposure cannot be accurately detected from an X-ray film.
Radiographic examination in children is more difficult than adult?
- Young permanent teeth may have incompletely formed root ends giving an
impression of periapical radiolucency.
- The roots of primary teeth undergoing normal physiologic resorption may
present a misleading picture of pathologic changes.
- Permanent teeth may be superimposed on the primary teeth.
Radiographs are valuable for determining the following:
- Proximity of caries or previous restoration to pulp.
- Internal (in case of vital pulp due to osteoclastic activity) or external (in case
with a non-vital pulp) root resorption.
- Calcified masses within pulp chamber and root canals.
- Periapical changes such as widening of periodontal membrane space.
- The presence of apical or furcation pathosis.
- Bone resorption.

75
 Pulp Therapy Techniques
A. Vital pulp therapy techniques:
I. Pulp capping:
The aim of pulp capping is to maintain pulp vitality by placing a suitable dressing
either directly on the exposed pulp (direct pulp capping)or on a thin residual layer
of slightly soft dentine (indirect pulp capping).
1.Indirect pulp capping:
Definition: It is the technique used to avoid potential pulp exposure, by capping
the thin layer of dentine overlying a macroscopically unexposed pulp with a layer
of lining or cement material with the intention of preserving pulp vitality.
Indications:
- Favorable diagnostic criteria.
- Primary and young permanent teeth.
- Deep carious lesions with close proximity to the pulp.
- Asymptomatic tooth without clinical or radiographic evidence of pulp
disease.
Technique:
First visit:
- Local anesthesia and isolation.
- Access to the cavity and prepare the cavity to standard outline.
- Gross caries is excavated from the carious lesion, leave last layer of carious
dentin (affected).
- A radiopaque liner such as a dentine bonding agent, resin modified glass
ionomer, calcium hydroxide, zinc oxide eugenol, or glass ionomer cement is

76
 placed over the remaining carious dentine to stimulate healing and repair, (6-
8 weeks).
Second visit (Re-evaluation visit):
- The tooth is re-entered and any remaining carious dentin is carefully
removed. Apply calcium hydroxide dressing and restore the tooth in usual
manner.
- Current literature indicates that there is no conclusive evidence that it is
necessary to re-enter the tooth to remove the residual caries. As long as the
tooth remains sealed from bacterial contamination, the prognosis is good for
caries to arrest and reparative dentin to be formed to protect the pulp.
By the end of pulp capping, treatment is judged successful if there is:
- No sensitivity to percussion.
- No history of pain following treatment.
- No radiographic evidence of periapical pathosis or root resorption.
- No clinical evidence of pulp exposure if the tooth was re-entered.
2.Direct pulp capping:

Definition:is the procedure of covering the exposed vital pulp with a material that
promotes healing.
Aim: promote healing and repair of the vital pulp tissues.
Exposure: mechanical or traumatic pin-point exposure surrounded by sound
dentine.
Indications:
- Small pinpoint exposure surrounded by sound dentin, produced
accidentally during cavity preparation or due to trauma (recent trauma
within 6 hours).
- Normal vital pulp.

77
 - Absence of pain.
- No bleeding at exposure site or an amount that considered normal.
- Normal radiographic findings.
- Teeth with open apices (young permanent teeth).

Technique:
- Local anesthesia and isolation.
- Gentle irrigation with saline or distilled water.
- The hemorrhage arrested with light pressure from moisten cotton pellets.
- Apply the capping material (calcium hydroxide).
- Restore the tooth.
Direct pulp capping is generally contra-indicated for primary teeth due to:
As the success of pulp capping depends upon the presence of young tissues which
can regenerate, in primary teeth tissues ages early (contain less cellular elements).
Also there is rapid spread of inflammation throughout the primary coronal pulp,
due to increased blood supply. Therefore, there is less chance that the infection will
be limited to the exposed part of the pulp.
Therefore:
Minute Pulp exposures in permanent teeth →Vital pulp capping is the treatment of
choice.
Minute Pulp exposures in deciduous teeth →Vital Pulpotomy is the treatment of
choice.
II. Pulpotomy:
Definition:is the complete amputation of the coronal pulp tissues of vital pulp till
the entrance of the radicular pulp.
Indications:
- Carious or traumatic exposure in vital primary teeth.
78
 - Slight amount of bleeding at exposure site which is considered within
normal.
- No history of spontaneous or persistent pain.
- Normal clinical and radiographic signs (Absence of abscess or sinus, no
internal resorption or inter-radicular bone loss).
Contra-indications:
- Cardiac conditions.
- Spontaneous pain or pain at night.
- Swelling.
- Tenderness to percussion.
- Pathologic internal or external root resorption.
It can be classified according to the treatment objectives into:
- Devitalization: This procedure is based on complete fixation of underlying
radicular pulp tissue thereby avoiding infection and internal resorption
(Formocresol pulpotomy).
- Preservation: This procedure produces only minimal insult to underlying
pulp tissue without initiating an inductive process, thereby preserving
maximum radicular pulp tissue. This is achieved by using Glutaraldehyde
or Ferric sulphate.
- Regeneration pulpotomy: this procedure is based on induction of
reparative dentin formation by the pulp capping agent, thereby leaving the
underlying radicular pulp tissue vital and healthy. This could be achieved
by using Calcium hydroxide, Mineral trioxide aggregate, Freeze dried bone
and Bone Morphogenic protein.
- Non-Pharmacotherapeutic approaches: Electrocautary pulpotomy and
Laser pulpotomy.

79
According to the capping material, vital pulpotomy can be classified into
Formocresol (indicated in primary teeth) and calcium hydroxide pulpotomy
(indicated in young permanent teeth).

Formocresol pulpotomy:
Constituents of Buckley’s formocresol:
- Tricresol35%.
- Formaldehyde 19%.
- Glycerol 15%.
- Water 31%.
It is now recommended to use 1/5 dilution:
- Buckley’s formocresol: 1 part.
- Glycerol: 3 parts.
- Water: 1 part.
Technique:
- Local anesthesia and isolation.
- Establish outline form to ensure access to the pulp chamber.
- Remove all carious dentine with round bur and spoon excavator, this
ensures a clean operating field.
- Remove the roof of pulp chamber using bur No. 330.
- Remove any overhanging ledges of dentin as pulp tissue under ledges may
not be easy to remove.
- Amputate the coronal pulp tissue with a large spoon excavator or with a
large round bur at low speed carefully to avoid perforation of the floor of
the pulp chamber.
- Wash and flush the pulp chamber with sterile water or saline solution.
- Dry and control bleeding with sterile cotton pellets for about 4 minutes.
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 - After amputation of the coronal pulp, control of bleeding and formation of
a blood clot, apply a cotton pellet moistened with formocresol and blotted
on a sterile cotton roll to remove the excess over the radicular pulp stumps
for 4-5 minutes. On removal pulp stumps appear dark brown with minimal
oozing of blood.
- Prepare a paste of zinc oxide-eugenol. Remove the cotton pellet moistened
with formocresol and place enough paste to cover the radicular pulp
stumps.
- Pressure should be avoided on radicular pulp tissues.
- Zinc phosphate is placed as a base and prepare the tooth for a stainless
steel crown.
- A stainless steel crown is the ideal restoration after pulpotomy because
the crown of the tooth is brittle and may fracture.
III. Partial Pulpectomy:
Definition:It is the removal of coronal pulp tissue and as much as possible from
the content of the root canal without interfering deeply into the apical portion.
Indications:
- In primary molars if there is evidence of hyperemia in the coronal pulp
tissues and extending in radicular pulp with no evidence of necrosis.
- The tooth may or may not have history of pain.
- Normal radiographic findings (no evidence of widening of periodontal
membrane space or periapical pathosis).
The multiple ramifications of the radicular pulp in a primary molar make complete
debridement impossible. Also, the ribbon shape of the root canals, with a narrow
mesio-distal width compared to their bucco-lingual dimension, discourages gross
enlargement of the canals that may result in lateral perforation of the canals.
Technique:
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 - Local anesthesia and isolation.
- Remove the coronal pulp tissue (same steps as in pulpotomy).
- Remove as much as possible from the content of root canals with a serrated
broach. Care should be taken not to penetrate the apex.
- No widening of root canal is done.
- Irrigation of the root canals with saline or 3% hydrogen peroxide followed
by sodium hypochlorite.
- Dry the canals with sterile paper points.
- The root canals may be filled with zinc oxide- Eugenol (a resorbable
material which will be resorbed as normal root resorption occurs).
- Filling the root canal: A thin mix of zinc oxide- eugenol paste may be
prepared and paper points covered with the material are used to coat the
root canal walls, then a thick mix of the paste is rolled and placed in the
root canals and condensed with a plugger.
- Zinc phosphate is placed as a base and the tooth should be restored with
stainless steel crown.

B. Non-vital pulp therapy techniques:

I. Non-vital or Mortal pulpotomy:
Ideally a non-vital tooth should be treated by pulpectomy. However, pulpectomy of
primary molars is often impractical.
Technique:
- Necrotic coronal pulp tissue is removed as pulpotomy.
- A cotton pellet moistened with formocresol is placed over the radicular
pulp stumps and covered with intermediate filling material.
- At the second visit after 7-10 days, isolate tooth with rubber dam without
local anesthesia, remove the dressing and pellet.

82
 - Press the paste in the root canals with a cotton pellet and restore the tooth
in normal manner.

II. Pulpectomy:

Definition: it is the complete root removal of coronal and radicular pulp tissue.

The morphology of root canals of primary molars makes endodontic treatment

difficult and often impractical. Endodontic treatment of primary teeth with necrotic
pulps is indicated if the canals are accessible and supporting bone is normal and
confined to anterior primary teeth.
Indications:
- In non-vital primary anterior teeth where the root canals are accessible.
- Non-vital tooth associated with an abscess or fistula.
- Cellulites.
Technique:
- The canals may be prepared with help of radiograph. Care should be taken
not to traumatize the apical region.
- The root canals are filled with resorbable materials as zinc oxide-eugenol,
or premixed calcium hydroxide paste (Vitapex) which is composed of
iodoform and calcium hydroxide.

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Pulp therapy for Young Permanent Teeth:
I. Apexogenesis (Calcium hydroxide pulpotomy):
Indications:
- Vital exposures in young permanent teeth with immature root.
- Exposed young permanent teeth due to trauma.
Aim:
- Tomaintain the radicular pulp vital to allow complete root development.
- Calcium hydroxide placed over radicular pulp stumps stimulates the
formation of a calcific bridge and successful root closure.
II. Apexification (root end closure in non-vital teeth):
A technique used to induce the formation of mineralized dental tissues at the apical
pulp region of non-vital permanent tooth with incompletely formed root.
Indications:
- Permanent tooth with non-vital pulp and incompletely formed apices.
Aim:
- To promote root elongation and or calcific root closure. Even though the
pulp is necrotic, epithelial root sheath of Hertwig persists and allows
regeneration.
Technique:
- The entire pulp is removed and calcium hydroxide is used to fill the root
canals and is replaced every 3-4 months until apical closure occurs. The
tooth is then treated with root canal therapy.
III. Revascularization of Immature Permanent Teeth (Regenerative
Endodontics): Unlike apexification and artificial apical barrier techniques, allows
continuation of root development. In the optimal situation (ie, elimination of
microorganisms and their by-products and necrotic tissues and in the presence of a

84
protein scaffold and a tight coronal seal) the apical papilla stem cells can populate
in the root canal space of necrotic immature tooth.

Failures following Pulp Therapy:

1. Internal root resorption:
- Occurs within pulp canals several months following pulpotomy.
- It is destructive process due to osteoclastic activity.
- Pulp canals become widened, walls become thin and perforation may occur.
Etiology:
- A true carious pulp exposure is usually associated with some degree of
inflammation. This inflammation may be limited to coronal pulp tissue or
may extend to the entrance of pulp canals. Osteoclasts may become attracted
to the area and initiate resorption.
- All capping materials are irritating and produce some degree of
inflammation, inflammatory cells in the area of inflammation may attract
osteoclasts which initiate internal resorption.
- Because the roots of primary teeth are undergoing normal physiological
resorption there is osteoclastic activity in the area which may predispose the
tooth to internal resorption.
2. Alveolar abscess:
- Develops several months following pulp therapy.
- Infection may be present in bone around root apex or more commonly in
bifurcation area.
- May be associated with fistula in chronic conditions
- Primary teeth which develop an alveolar abscess should be removed, while
permanent teeth can be treated endodontically.

85
 Rampant Dental Caries

Definition:
Rampant caries has been defined by Massler as a suddenly appearing,
widespread, rapidly burrowing type of caries resulting in early
involvement of the pulp and affecting those teeth usually regarded as
immune to ordinary decay.

Diagnosis:
- The distinguishing characteristics of rampant caries are the
involvement of proximal surfaces of the lower anterior teeth and
development of cervical type of cavities. There is no evidence that the
mechanism of the decay process is different in rampant caries or that
it occurs only in teeth that are malformed or inferior in composition.
Some factor in the caries process seems to accelerate the process to
the extent that it becomes uncontrollable and it is, then referred to as
rampant caries.
- When a patient has what is considered an excessive amount of the
decay, it must be determined whether that person 'actually has a high
susceptibility and truly rampant caries of sudden onset or the oral
condition represents years of neglect and inadequate dental care.
- The term rampant caries should be applied to a caries rate of 10 or
more new lesions/year.

86
Etiology:

- Emotional disturbances may be the causative factor in some cases of

rampant caries.
- Depressed emotions and fears.
- Dissatisfaction with achievement.
- Rebellion against a home situation.
- Feeling of inferiority.
- Traumatic school experience.
- Continuous general tension and anxiety.

An emotional disturbance may initiate rampant caries due to:

- Unusual craving for sweets or the habit of snacking.
- Salivary deficiency is common in tense, nervous or disturbed persons.
- Medications (tranquilizers and sedatives) commonly taken to help
person cope with stress, are associated with depressed salivary flow
and decreased caries resistance caused by impaired remineralization.
- Some believe that rampant caries is attributable to primary and
secondary nutritional inadequacies. However, it is not a deficiency
disease or one associated with malnutrition.

87
 Early Childhood Caries
Terminology:
The most commonly used name is "Nursing-Bottle Caries".
Other names mentioned in the literatures are; Baby-bottlecaries, Nursing
bottle syndrome, Baby-bottle tooth decay, Nursing caries and recently
Early Childhood Caries.

Definition:
It is a specific pattern of rampant caries affecting the primary teeth of
an infant during the first three years of age.

Etiology:
The same etiological factors as for dental caries: pathogenic bacteria,
fermentable carbohydrates, susceptible tooth surface and time. A strong
association was found between Streptococcus mutans and early
childhood caries.

Aggravating or causative factors:

1- Inappropriate nursing habits, involving either the breast or the bottle-
feeding.
2- The regular use of a sweetened comforter (a bottle containing sweet
beverages of any kind or breast-feeding at night) at bedtime and/or
during the day.
3- Breast-feeding prolonged beyond the normal age for weaning.
4- Falling asleep with pacifier covered with honey or jam.
5- The regular use of syrups for therapeutic reasons duringchronic or
recurring illnesses.

88
Mechanism:
When the child falls asleep, the milk or the sweetened liquid becomes
pooled around the maxillary anterior teeth. The carbohydrate containing
liquid provides an excellent media for acidogenic bacteria (S.mutans and
Lactobacilli). As salivary flow is decreased during sleep the clearance of
the liquid from the oral cavity is slowed. Thelactosecontent of the milk
(Human or bovine) can be cariogenic as the milk is allowed to stagnate
on the teeth for long time.

Clinical picture:
- The four maxillary incisors are most affected while the four
mandibular incisors usually remain sound. The body of
thetongue lies over the lower teeth during sucking which limits the
exposure of the mandibular incisors to cariogenic substrate.
- The other primary teeth, the canines, first molars and the second
molars may exhibit caries involvement depending upon how long
thecarious process remains active, but the extensiveness of the
lesionsusually is not as severe as those of the maxillary incisors.

Developmental stages:-
I- Initial (reversible)stage:
Cervical chalky white demineralization of the tooth surfaces.
Pain is not felt at this stage.

II. Damaged stage:

The carious lesion extends into the dentin and shows marked
discoloration on the labial, lingual and interproximal surfaces.
Parents can spot the condition at this stage due to the discoloration of the

89
teeth and the child starts complaining about toothache when cold food is
ingested.

III. Deep lesion stage:

Lesions in the maxillary incisors are larger and the first primary molars
are all affected.
Complaints of pain during tooth brushing or eating, especially whenbiting
is frequent.
Pulpal problems in the maxillary incisors can occur (spontaneouspain
during; and pain after cold or hot drinks).

IV. Traumatic stage:

Maxillary incisors become so weakened by caries that relatively small
forces lead to their fracture.

V. Arrested caries:
In all the previous stages arrested caries might occur, when the cause of
the dental caries is eliminated. The lesions might get a dark brown to
black appearance.

Management of Early Childhood Caries:-

Management of Early Childhood Caries can be divided into two main
categories.
A. Prevention.
B. Treatment.

A. Prevention of Early Childhood Caries:-

There are three general approaches that should be followed toprevent
Early Childhood Caries.
90
I- Community-based strategy:
1. National educational program for mothers and caregivers to influence
their dietary habits as well as those of their infants.
2. Personal and community preventive programs.
3. Water fluoridation.

II- Professional examination and preventive care:

1- Early dental examination at or before the age of 1 year (as
recommended by AAPD).
2- Dietary counseling:-
- From birth, the infant should be held while feeding.
- The child who falls asleep while nursing should be burped and then
placed in bed.
- The mother should wean the child as soon as he can drink from a cup
at approximately 12-15 months of age.
- Parents should be cautioned about prolonged and frequent infant
feeding habits.
3- Professional application of topical fluoride.

III-Development of appropriate dietary and self-care habits at home.

1- Oral hygiene practices.
2- Mothers should be advised to brush (or wipe using gauze) the child's
teeth gently after feeding.
3- Use of fluoridated dentifrice.
4- Dietary habits.

91
B. Treatment of Early Childhood Caries:-
The treatment of children with Early Childhood Caries depends upon the
extent of the lesions, the age,the behavior of the child, and the degree of
the cooperation of the parents. Regardless of these factors, the following
steps should be followed:
1. Cessation of habit.
2. Sealing all caries-free pits and fissures.
3. Fluoride application.
4. Gross excavation of carious lesions and filling of the cavities with
zinc oxide-Eugenol (IRM) or Glass-Ionomer cement. This will arrest
the caries process and prevent its rapid progression to the dental pulp.
5. Carious lesions without pulpal involvement: treatment for anterior
teeth includes composite resin restorations or glass ionomer.
Treatment for posterior teeth includes preventive resin restorations
and amalgam restorations.
6. Carious lesions with pulpal involvement: pulpotomy or pulpectomy,
buildups of anterior restorable teeth with compomere, or composite
filling and stainless steel crowns for posterior teeth.
7. Treatment under general anesthesia is often required for small
children with extensive carious lesions.

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 Stainless Steel Crown
Stainless steel (preformed) crowns are prefabricated crown forms, which can be
adapted to individual primary molars and cemented in place to providea
definitive restoration. They are considered the most durable and reliable
restoration.
Indications:
Stainless steel crowns are the restoration of choice in the following
situations:
1- Restoration of primary or permanent teeth with extensive carious lesions
(more than two surfaces affected).
2- Following pulpotomy or pulpectomy procedures (teeth become brittle
after removal of pulp content and may fracture if not protected).
3- Restoration of teeth affected by developmental problems (e.g. enamel
hypoplasia, amelogenesis and dentinogenesis imperfecta).
4- As an abutment for certain appliances, such as space maintainers.
5- In patients with high caries susceptibility or where routine oral hygiene
measures can't be performed (handicapped patients).
Clinical procedures:
1. Appropriate local analgesia should be obtained and the tooth should be
isolated, preferably with rubber darn.
2. Caries removal and appropriate pulp treatment should be completed if
necessary.
Tooth preparation:
1. Approximal reduction to open the contact using a fine tapered diamond stone.
2. Occlusal reduction(1-1.5mm) to avoid occlusal prematurity using wheel stone.
93
3. Buccal and lingual preparation is not always necessary except where there is a
large buccal bulge.
4. The preparation should finish with a smooth feather edge cervically with no
step or shoulder.
Crown selection:
The selected crown must fit to the prepared tooth with a tight snap. Choosing the
correct size is assisted by measuring the mesio-distal dimension of the tooth using
a divider.
Crown adaptation:
1- Try the crown on the tooth, place the crown on the lingual side and rotate it
toward the buccal side. The crown should extend 1mm beneath the gingiva.
2- Most commercially available crowns are anatomically trimmed and contoured
cervically and require little or no modification.
3- If the gingival extension is too long, using a crown and bridge scissors cut
around the gingival margin of the crown, then contour it with a ball and socket
plier.
Crown cementation:
The status of the pulp influence selection of the cementing material. A cavity
varnish must be applied before cementing a crown to a vital tooth.
There are several options for the cementing media e.g. zinc phosphate cement, zinc
oxide eugenol cement, re-inforced zinc oxide eugenol cement, polycarboxylate
cement and glass ionomer cement.
Zinc phosphate cement is commonly used for cementation of stainless steel
crowns.

94
Causes of Stainless Steel Crown Failures:
1- Poor tooth preparation.
2- Poor crown adaptation and subsequent poor retention.
3- Improper cementation and presence of open margins.
4- Recurrent caries.
5- Crown abrasion through the occlusal surface.

Aesthetic Full Coverage Techniques

For Primary Anterior Teeth
It is a challenging task to repair extensively destroyed anterior teeth, with
restorations that are durable, retentive and aesthetic. Emphasis on treatment of
extensively decayed primary teeth shifted from extraction to restoration. Early
restorations consisted of placement of stainless steel bands or crowns on severely
decayed teeth. While functional, they were unaesthetic and their use was limited to
posterior teeth.

Indications for full coverage of anterior teeth are:

- Anterior primary teeth with extensive inter-proximal lesions.
- Anterior primary teeth that have received pulp therapy.
- Restoration of primary anterior teeth affected by hypoplastic defects or
developmental disturbance (e.g., Ectodermal Dysplasia).
- Unaesthetic teeth due to discoloration.

95
Types of full coverage for anterior primary teeth:
- Open faced steel crowns.
- Resin (composite) strip crowns.
- Pre-veneered steel crowns.
- Zirconia ceramic crowns

Open Faced Steel Crowns:

Open faced stainless steel crowns combine strength, durability and improved
aesthetics, however they are time consuming to place as the composite facing
cannot be placed until the stainless steel crown cement sets. The color of the metal
margins surrounding the composite adds a grayish tinge to the tooth that is
accentuated next to the white enamel of an adjoining or opposing primary tooth.
Advantages:
- Durable, retentive and fairly inexpensive.
Disadvantages:
- Time consuming (crown cementation / composite facing placement).
- Placement of the composite facing may be compromised when gingival
hemorrhage or moisture is present.
- The metal shows through the composite facing.

Composite Resin Strip Crowns:

Composite strip crowns are composite filled celluloid crowns forms. They have
become a popular method of restoring primary anterior teeth because they provide
superior aesthetics as compared to other forms of anterior tooth
coverage. Composite strip crowns rely on dentin and enamel adhesion for
retention. Therefore the lack of tooth structure, the presence of moisture or
hemorrhage contributes to compromised retention.
96
Advantages:
- Superior aesthetics.
- Reasonable cost.
- Reasonable time for placement.
Disadvantages:
- Technique sensitive.
- Not recommended on patients with a bruxism or a deep bite.

Pre-veneered Stainless Steel Crowns:

The stainless steel crown is covered on its buccal or facial surface with a tooth
colored coating of polyester/epoxy hybrid composition.
Advantages:
- Most esthetic.
- Require relatively short operating time.
- Durable.
- Less moisture sensitive during placement than composite strip crowns.
Disadvantages:
- Expensive.
- Relatively inflexible as the resin facing is brittle and tends to fracture when
subjected to heavy forces or crimping.
- Technique does not allow for major recontouring and reshaping of the
crown.
- Crimping is limited to lingual surfaces there is not close adaptation of crown
to tooth (significant removal of tooth structure must be performed).
- The tooth is adjusted to fit the crown, rather than adjusting the crown to fit
the tooth.
- Limited shade selection.
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Zirconia Ceramic Crowns:
Advantages:
- Superior esthetics (translucency of zirconia ceramic).
- Anatomically contoured.
- Strong and metal free.
- Easy to use.
- Superior durability.
- Excellent biocompatibility.
- Autoclavable.
Table: Comparison of Full coverage Techniques for Primary Teeth
Restoration and Aesthetics Durability Time for Selection
placement area Placement criteria
Stainless steel crowns. Poor Very good. Fast. Aesthetics not involved.
(Posterior teeth) Very retentive. Aesthetics not Severely decayed teeth.
Wears well. a concern. Use when unable to control gingival
hemorrhage or moisture and less
than ideal patient cooperation.
Open faced stainless steel Fair. Good. Long. Severely decayed teeth.
crowns. Metal shows Crown retentive Two step Good durability and retention
(Posterior and anterior teeth) through facing. but facing may process: needed (bruxism, trauma prone
dislodge. - Crown child).
cementation Parent concerned about aesthetics.
- Composite
placement
Pre-veneered stainless steel Good. Good. Moderate. Severely decayed teeth.
crowns. Limited shades. Crown retentive Longer than Good durability and retention
(Posterior and anterior teeth) but facings may SSC due to needed.
break. more tooth Child is trauma prone or bruxes.
reduction and Parent concerned about aesthetics.
adaptation. More expensive than other
restorations.
Resin (composite) strip Very good Requires Will vary with Aesthetics are of great concern.
crowns. adequate tooth ability to isolate Adequate tooth structure.
(Anterior teeth) structure for teeth and Patient not prone to trauma.
retention. control Patient cooperative.
Easily fractured moisture.
with trauma or Most technique
traumatic sensitive.
occlusion.
Zirconia ceramic crowns Very good Ceramic is very Similar to a pre- Aesthetics are a great concern.
(Posterior and anterior teeth) durable but veneered crown Adequate tooth structure.
retention is
unknown.

98
 Epidemiology

Subject: Page:

1- Introduction to Dental Public Health 1

2- Epidemiology of Dental Diseases 3
3- Epidemiology of Dental Caries 10
 Introduction
Dental Public Health

Health:
It is defined by the WHO as a state of complete physical, mental and social well-
being and not merely the absence of a disease.
Recent WHO definition, “Health is the extent to which an individual or group is
able on the one hand to realize aspirations and satisfy needs; and on the other hand
to change or cope with the environment”.
Public Health:
It is the art and science of preventing disease, prolonging life and promoting
physical and mental efficiency through organized community effort.
Dental Public Health:
It is defined by American Dental Association as the art and science of preventing
and controlling dental diseases and prompting dental health through organized
community efforts.
Tools of Dental Public Health:
I. Preventive Dentistry II. Epidemiology
Guidelines of dental public health practice:
1- It depends on team work; this is due partly to the necessity of efficient handling
of large groups of people and partly that many processes involved in prevention are
better applied through team work.
2- It must be done in areas where group responsibility is recognized. e.g. success in
controlling many contagious and communicable diseases in an area depends upon
the presence of group responsibility.

1
3- Public health workers should deal with healthy, apparently healthy as well as
diseased people.
4- It should deal with the search for a cause of a disease.
5- Prevention is the main goal of public health because:
- Prevention of a disease is greater good in life than cure.
- Prevention can be better performed on the mass population through public
health.
- Prevention is cheaper than cure.
6- Health education of the public.
7. Public health methods must depend on biostatistics, which helps in arithmetic
measurements of a disease in large population.
Objectives of dental public health:
1- It gives an accurate indication about dental diseases.
2- It takes into consideration the current social changes in the community that
influence the prevalence of dental diseases.
3- It provides the dentists with specialized skill and knowledge to plan dental
health programs for large population.
4- It stresses the importance of prevention in the minds of public.

2
 Epidemiology of Dental Diseases

Epidemiology: is derived from Greek origin [ Epi=Upon, demos=the people,

logas=science]
Definition:
It is defined as “a science concerned with the occurrence, distribution, and the
determinant of a states of health and dental diseases in human groups and
populations”.
The unit of interest of Epidemiological studies is the group rather than the
individual.
Epidemiological Triad:
The occurrence and manifestation of any disease whether communicable or not are
determined by the interactions between the agent, host an environment.
Objectives:
1- Determination of health and disease in communities or groups (community
diagnosis or group diagnosis).
2- Determination of factors which influence the occurrence of a condition (etiology
of disease).
3- Ascertained the public needs.
4- Planning and evaluation of health services programs.
Types of epidemiology:
1- Descriptive.
2- Analytical.

3
1-Descriptive Epidemiology:
Definition:
It is concerned with the Observation and reporting of the distribution of a disease
or condition in a population or populations. i.e. describes the pattern of occurrence
of a disease.
Parameters:
A- Prevalence. B- Incidence.
A- Prevalence: (cross-sectional)
Used to indicate what proportion of a given population is affected by a condition at
a given point of time.
“Condition existing at a particular point of time”
- It is expressed as a percentage of the population.
- Its range is from 0% to 100%.
- Used for comparisons between populations.
- Prevalence data have no base line reference point.
B- Incidence: (longitudinal)
It is the number of cases that will occur within a population during a specific
period of time.
“Change of condition over a period of time”.
- It is expressed as rate or mean (Cases per population per time).
- It ranges from 0 to infinity.
- Incidence data have a base line reference point.
N.B. Where the amount of new disease in a population is measured over a period
of time, usually one year. It is the change in a condition over a period of time. In a
progressive disease such as dental caries, it is necessary to measure the increase by
the extent of new disease. This is obtained by observing the same groups of

4
individuals on two occasions and subtracting the extent found at the first
examination from that observed at the second.
2- Analytical Epidemiology:
Definition:
Studies used to determine the etiology and mechanism of a disease. “Find the
causes of a disease and ways in which this could be modified”.
Types of the analytical studies:
A- Prospective. B- Retrospective.

A- Prospective:
Study the relationship between exposure and subsequent risk of development of a
disease. It studies a condition or a disease among healthy population.
Advantage:
Suitable for study of common diseases with common exposure.
Disadvantages:
1- Study group is observed over a long period of time.
2- Expensive as:
- Conducted over a long period of time.
- Conducted over large population.
B- Retrospective:(case control)
It is conducted by using a population that has a disease by matching with a
population that does not have the disease (control).
- Retrospective to assess risk and study causes of a disease.
- Using questionnaires and medical histories to review past events and
exposures.
Advantage:
- Inexpensive, easy and need short period of time.
5
Scientific methods in dental epidemiology
Epidemiological investigation should follow the following scientific pattern:
I- Establishing the objectives.
II- Designing the investigation.
III- Selecting the sample.
IV- Conducting the examinations.
V- Analyzing the data.
VI- Drawing the conclusions.
VII- Publishing the results.

I- Establishing the Objectives:

The investigator must be absolutely clear about the objectives of the investigation.
In many scientific experiments the objectives can be stated in the form of a
hypothesis which is to be tested.
Hypothesis means: a testable explanation for an observation.
The starting point of a study is frequently an expression of a “null hypothesis” that
is the assumption, for example, that there is no difference in the extent of dental
disease between the groups to be investigated or in cases of clinical trials, no
method is better than the other in preventing or treating the disease.
II- Designing the Investigation:
A- Types of studies:
1- Descriptive study. 2- Analytical study.
B-Controls:
1- Control group:
It is not enough to confine the examinations to the group exposed to the factor. A
parallel group not exposed to that factor must also be studied in the same way.

6
Thisis called the control group and it must be as similar as possible to the test
group.
2- Placebo:
Used in case of a clinical trial, such as the testing of a fluoride dentifrice. It is
important to supply the control group with a substance similar in appearance and
other properties to the tested dentifrice but with the tested ingredient absent i.e.
placebo.
C- Blind Study:
It is always desirable that the investigator should not know whether a subject is a
member of a test or a control group “blind study”. If the subject also ignores
whether he is using a test product or a placebo the study is termed “Double blind”.
This is to avoid unconscious bias in diagnosis.
III- Selecting the Sample:
A- Definition:
Sample is a part of population or set of things which we actually do study. As it is
impossible to examine every individual in the population (no sufficient resources),
a sample must be chosen from the population, which express the condition in this
population.
B- Advantages of Sampling:
- Saving time, effort and money.
- Allow performance of the study when the available resources are limited.
C- Types of Samples:
1- Selected sample:
It is one in which a criterion is set for the inclusion of each individual in the study,
and each individual satisfying the criterion forms part of the sample.
Sample is: Self-selected (volunteers), or selected by the researcher.

7
2- Random sample:
Each individual must have an equal chance of being included in the sample. One of
the easiest ways of doing this is to use random number tables.
3-Stratified random sample:
If the condition under investigation is known to be related to various factors such
as; age, sex, area of residence. The population is first divided into these groups
(strata) and a random sample taken within each group (Stratum).
4-Cluster sample:
In cluster sampling, a simple random sample is selected not from individual
subjects but of groups or clusters of individuals. The clusters may be schools,
villages.... etc.
D- Sample size:
The sample size is determined according to:
- The available resources, facilities and time factor.
- Prevalence of the disease, the lower the prevalence, the bigger the sample
size and vice versa.
- Number of variables and subgroups.
- Expected range of differences in the characteristics under study. e.g. age,
income and educational level. The smaller the range, the smaller the sample
size and vice versa.
IV- Conducting the examinations:
For the scientific study of any dental disease or condition, four aspects are
important:
1- Examination methods:
- National. - International
2- Diagnostic aids:
- Chair, Source of illumination e.g. fiber optic light source.
8
3- Diagnostic criteria:
Should be valid and reliable.
- The validity of a test is: its ability to measure what it is intended to measure.
- The reliability of a test is: its ability to give the same results if repeated.

4- Indices used:
Index:
Is a graduated numerical scale with definite upper and lower limits describing the
relative status of a population, designed to permit and facilitate comparison with
other populations classified by the same criteria and methods.
For an index to be accurate:
It should give an idea about:
- Prevalence of a disease in a population.
- Severity and intensity of a disease in a population.
- Past and present disease (caries) experience.
Requirements of an Ideal Index:
An ideal index should possess the following characteristics:
- Clarity: The criteria of scoring should be clear and easy to apply.
- Objectivity: Each index should have a specific and clear objective.
- Simplicity: Each index should be easy to apply even in field studies.
- Reliability: The index should be reliable so that when a condition in the
same subject is measured repeatedly, it should give the same results.
- Sensitivity: The index should be able to detect small differences in what is
being assessed.
- Acceptability: The index should be acceptable to the subject; it should not
cause pain or discomfort to the subject.

9
 - Amenability to evaluation: The index should be amenable to statistical
evaluation.
- Economical: The index should be economical in field studies.
- Not time consuming: The index should not be time consuming so that it can
be used in a large number of subjects.

Epidemiology of Dental Caries

Dental caries, one of the most common diseases of man, constitutes a major health
problem. Both the prevalence and severity of this disease have increased with the
advance of civilization.
Dental caries, develops in an individual from host-agent interaction which occurs
in a certain set of local environmental conditions. This means, changes in the host-
agent-environment balance.
Dental caries results from 3 groups of factors:
I- Host factors.
II- Agent factors.
III- Environmental factors.

I- Host Factors:
1- Age:
The risk of carious attack is greatest shortly after eruption of the tooth into the
mouth.
- Therefore, the permanent dentition experiences activity from 7 to 16 years of
age.

10
 - The next decade of life, 17 to 26 years, witnesses a slowing down of the
disease rate as the susceptible surfaces are deleted from the surfaces at risk
because of their prior disease experience.
- If the teeth have reached age 26 without developing dental caries, there is a
strong possibility that they will remain caries-free for the rest of the
individual's life.
- Another increase in caries incidence occurs at about 45-55 years which is the
proximal type. Over 60 years of age, acute root caries occurs because root
surfaces, becomes denuded by gingival recession.
2- Sex:
- Although the female might be expected to show a higher caries rate due to
earlier tooth eruption as a consequence of earlier female growth and
maturation, a sex difference was not clearly demonstrated.
3- Race:
- Race has long been considered to be an important factor in the frequency of
dental caries, yet little work has been done which would differentiate racial
from environmental.
- In USA, studies have shown marked difference in caries experience between
white and black even when income and education were standardized.
- Black have more caries than white people, the difference in caries
experience indicate that white people receive different standards of care
from that received by black or due to dietary or cultural differences between
them.
4- Familial and genetic pattern of caries:
- Good genetic studies of caries incidence are few in number and in such
studies it is difficult to distinguish between true inheritance through the
chromosomes and the dietary and other habits in the family.
11
5- Emotional disturbances:
- Particularly transitory anxiety states and severe mental stress influence the
incidence of dental caries.
6- Variation of caries within the mouth:
- Observation on the variation of caries within the mouth could be grouped
under three main headings:
A- According to tooth surfaces:
a. Pit and fissure caries c. Cervical caries
b. Proximal caries d. Root caries.

B- Frequency with which teeth are attacked:

- Lower incisors are the least teeth exposed to caries.
C- Bilateral symmetry.

II- Agent Factors:

1- Bacterial factors:
- Mainly, streptococcus mutans for initiation of dental caries and lactobacilli
for propagation.
2- Role of carbohydrates:
- Freely fermentable carbohydrates have an essential role in caries process.
Also the rate of clearance from the mouth also affects the rate by which
bacteria may act upon carbohydrates to produce acids.

12
III- Environmental Factors:
1- Geographic variation:
A- Temperature:
- Temperature acts to vary the caloric requirements as well as the water intake
of human beings.
- Inhabitants of colder climates eat more processed carbohydrates, as
carbohydrates are convenient, quick and relatively cheap source of warmth
and energy.
- This is associated with decrease in water intake and therefore, caries
incidence increases. And the reverse occurs in areas with high temperature.
B- Sunshine:
- There is an inverse relation between the mean annual sunshine and dental
caries.
- As the annual sunshine increase the amount of ultraviolet rays increase
which insure enough supply of vitamin D.
- Also, the temperature has a direct relation with the sunshine. So there will be
increased demand for water consumption, which help wash away of food
debris from the mouth.
C- Rain fall:
- Most of the crops utilize in their growth the upper thirty centimeters of the
soil, as the rain fall increases leaching of the minerals specially fluorides will
lead to reduction of fluoride concentration in the crops.
- Another factor to be considered is that rain fall is accompanied by heavy
clouds which block sunlight.

13
D- Relative humidity:
- Studies have shown a higher correlation between DMF, and relative
humidity. As relative humidity rises the DMF rises too. This is because of
decrease demand of water intake in areas with high humidity levels.
2- Fluoride:
- Fluoride can be considered an essential element for the formation of caries-
resistant dental hard tissue.
- Fluoride in the drinking water during the time of tooth formation and
mineralization results in formation of fluoroapatite crystallites, which are
more cariesresistant.
3- Total water hardness:
- Measured in terms of calcium carbonate, which is considered an etiologic
factor in dental caries. Some authors have reported an inverse relation
between DMF and the total water hardness.
4- Trace elements:
- It has been found that there is marked increase in dental caries in areas
where selenium was high both in water and food-stuffs.
- On the other hand, molybdenum and vanadium have caries inhibiting
influences.
5- Degree of urbanization:
- Urbanization may be accompanied by an increase in dental caries.
- This may be due to the type of diet in urban areas (refined & freely
fermentable carbohydrates).
6- Social factors:
- Good economic status and social pressure in the direction of good mouth
appearance are both strong factors in creating demand for dental treatment.

14
 Indices Used for Assessment of Dental Caries

The indices can express either the number of teeth or the number of surfaces
affected. All caries indices reflect the cumulative experience of the individual (s)
examined, and do not indicate whether the caries process is active at the time of
examination.
Indices of dental caries can be divided into:
I- Indices used for permanent dentition.
II- Indices used for primary dentition.
III- Indices used for mixed dentition.
I- Indices Used for Permanent Dentition:
1- Prevalence Index:
- Simplest index used for measuring dental caries.
- It describes whether the disease is present or absent.
- This index is used for observing and comparing populations with wide
difference in caries experience.
Number of all cases affected with caries
The prevalence rate = ——————————————————
Total population
2- Slack Index:
A sensitive classification of the extent of carious lesions was advocated by Slack et
al., (1958) where the size of the lesion is indicated on a scale running from 1 to 3.
D1: The probe catches in a pit and fissure but does not penetrate to the dentin.
D2: Obvious carious lesion involving the dentin, but cavitation had not proceeded
to more than one quarter of the crown.
D3: Cavitation had proceeded so that more than one quarter of the crown is
involved.

15
 Total number of the affected teeth scores
Slack Index = —————————————————
Total number of the affected teeth
3- DMF Index:
- Index denotes the number of decayed (D), missing (M), or filled teeth (F).
- In scoring this index, the examiner notes the condition of each tooth, and no
tooth is counted more than once. For example, a tooth that exhibits recurrent
caries around an existing restoration is scored as decayed. Often, it is
possible to elicit from the person why a tooth is absent. This is important, as
teeth that are unerupted, congenially missing, or extracted for orthodontic
purposes are not usually counted as missing.
- The maximum DMFT count is 28.
- Unit of measurement is the tooth.
DMF index for individual= Number of D+ M+F teeth in individual.
Number of D + M + F teeth
DMF Index for a group = ——————————————————
Total number of examined individuals

4- DMFs Index:
- This is a more sensitive measure of dental caries per person, to score the
DMFs index most accurately, bitewing radiographs are considered
necessary.
- This index counts the number of the affected tooth surfaces where each
affected tooth surface scores one.
- Here the unit of measurement is not the tooth (as DMF index) but the tooth
surface.
- It is very useful for measurements during clinical trials of caries preventing
agents.
DMFs for individual= Number of D+M+F surfaces in individual
16
 Number of D + M + F surfaces
DMFs Index for a group = ———————————————
Number of individuals examined

- Examples of decayed surfaces:

- Give score 2 for occluso-distal cavity because it involves 2 surfaces.
- Examples of missing surfaces:
- Give score 5 for extracted posterior teeth.
- Give score 4 for extracted anterior teeth.
- Examples of filled surfaces:
- Give score5 for full coverage crown for posterior teeth.
- Give score 4 for full coverage crown for anterior teeth.
- Give score 2 for an occluso-mesial amalgam filling.

II- Indices Used for Primary Dentition:

1- Prevalence index: (discussed before).
2- Slack index: (discussed before).
3- dmf Index:
- Index used for children till age six. This index may be used to summarize the
status of primary teeth.
Number of d + m + f teeth
dmf Index for a group = ————————————————
Total number of individuals examined

4- dmfs Index:
- This index is used to score the number of surfaces decayed, missed and
filled in the primary dentition.
-
17
 Number of d + m + f surfaces
dmfs Index for a group = ——————————————
Total number of individuals

III-Indices Used for Mixed Dentition:

1- def Index:
- Index used for children older than age six or seven. This index counts the
number of primary teeth that are decayed (d), indicated for extraction (e),
and that are filled (f).
Number of d + e + f teeth
def Index for a group = —————————————
Total number of individuals

- Since teeth indicated for extraction because of advanced caries are, in fact,
decayed, the index is sometimes scored as if it were simply df.
- Teeth missing for any reason are not recorded, and because of this, this
index may be regarded as a measurement of observable dental caries
prevalence.
- Missing teeth are ignored, for this reason, a population that has experienced
a high level of caries but has received dental care, especially extractions and
space maintenance, may exhibit a lower def score than a population that has
experienced fewer carious lesions and this is considered a disadvantage of
this index.
During the mixed dentition period two indices are used simultaneously, DMF
index for the permanent teeth and def index for the primary teeth, and each index
is scored separately for the individual.

18
 Requirements Sheet
Practical Course PEDO 1
Student Name: I.D. Section:

A. ACRYLIC BLOCKS :
Evaluation grades: A B C D

 Acrylic Block Class I Cavity Preparation

 Acrylic Block Class II Cavity Preparation

B. EXTRACTED PRIMARY MOLARS :

Evaluation grades: A B C D

Number Tooth Treatment Done Evaluation

1
2
3
4
5

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