Pre-Clinical Pediatric Dentistry- Combined

numbering systems

-Palmer used in ortho

-Universal system used most commonly

eruption of primary dentition

-teething

-drooling, desire to bite or chew, mild pain/discomfort

-no evidence of high fever, diarrhea, or sleep problems → pick up disease from more frequently putting hands/items in mouth

-permanent teeth develop lingual/palatal to primary dentition

-posterior permanent teeth develop in furcations

eruption patterns of primary teeth

primary dentition calcification, eruption, exfoliation

common eruption findings- eruption cyst

-fluid accumulation within a follicular space of an erupting tooth

-no treatment needed

-will rupture on their own

common eruption findings- eruption hematoma

-eruption cyst where blood fills the follicular space

common eruption findings- ectopic eruption

-see especially in mandibular teeth (most commonly anterior)

-assess mobility of primary teeth, encourage child to wiggle, watch and wait approach

-more concerning in maxilla → can lock teeth into an anterior crossbite due to lack of tongue force/strength pushing into occlusion

permanent dentition calcification, crown completion, root completion, eruption

crown of primary teeth

-shorter

-narrower occlusal table

-constricted in cervical portion

-thinner enamel and dentin layers

-enamel rods in the cervical area directed occlusally (opposite of permanent dentition)

-broad and flat contacts

-color usually lighter

-prominent mesio-buccal cervical bulge seen in primary molars

-incisors have no developmental grooves or mammelons

crown of primary teeth- posterior teeth

-microscopically, enamel rods slope occlusally

-compared to permanent dentition where enamel rods are perpendicular or slope apically

-won’t have unsupported enamel in preps as with permanent dentition preps → less use (if any) of hand instruments

primary crown anatomy- mandibular incisors

-mandibular central incisors: symmetrically flat when viewed from buccal, crown about 1/3 length of root

-mandibular lateral incisors: similar form to central, usually longer, incisal edges slopes towards distal and DI angle more rounded

primary crown anatomy- maxillary incisors

-maxillary central incisor: only tooth that has a greater mesiodistal width than height

-maxillary lateral incisor: similar form to central, smaller and DI angle rounded

primary crown anatomy- canines

-maxillary canine: crown constricted at cervical region, well-developed, sharp cusp, long root

-mandibular canine: similar form to maxillary, crown shorter and narrower labiolingually

primary crown anatomy- first molars

-maxillary first molar: unique appearance, 3 cusps- MB/DB/Lingual, prominent MB cervical bulge

-mandibular first molar: unique in appearance, 4 cusps- MB/DB/ML/DL, prominent MB cervical bulge, transverse ridge

primary crown anatomy- second molar

-maxillary second molar: resembles permanent maxillary first molar but smaller

-mandibular second molar: resembles permanent mandibular first molar but smaller

pulp of primary teeth

-relatively larger

-pulp horns closer to outer surface

-great variation in size and location

-mesial pulp horn is higher

-form of the pulp follows the external anatomy

-usually a pulp horn under each cusp

roots of primary teeth

-roots of anterior teeth narrower mesiodistally than permanent teeth

-posterior teeth have longer and more slender roots in relation to crown size

-molar roots flare more as they approach the apex

-apical foramina may be larger and accessory canals often larger and more numerous

implications of primary tooth morphology

-thinner enamel and dentin leading to faster progression of caries

-high mesial pulp horn to be aware of during restorative procedures

-numerous accessory canals making pulpectomies more difficult and less reliable in primary teeth, especially primary first molars

infant oral health- inclusion cysts

-often seen at birth

-Epstein’s pearls: midpalatal raphe, epithelial remnant, no tx

-Bohn’s nodules: side of alveolar ridge, mucous gland remnant, no tx

-Dental lamina cyst: crest of alveolar ridge, odontogenic epithelial remnant, no tx

natal and neonatal teeth

-natal teeth: present at birth

-neonatal teeth: erupts within first 30 days of life

-usually the primary teeth

-no tx indicated unless interfering with feeding or aspiration risk

-if aspiration risk concern: extraction with gauze, practically no force needed

-if feeding interference: can smooth down if necessary

-Riga Fede

-tooth irritating tissue and causing ulceration of tongue

early childhood caries (ECC)

-presence of one or more decayed, missing, or filled tooth surfaces (dmft) in any primary tooth in a child under six

-decay can be noncavitated or cavitated

-missing due to caries (not due to trauma)

severe childhood caries (S-ECC)

-under 3 years old- any sign of smooth surface caries

-3-5 years old- dmft of 1 greater than the child’s age

caries factors

first dental visit

-within 6 months of the first tooth erupting or first birthday- whichever is first

-exam

-caries risk assessment

-toothbrush prophylaxis

-fluoride application depending on risk

-**anticipatory guidance

anticipatory guidance

-information provided to child and family about the child’s current oral health and what to expect as the child enters the next phase of development

-teething, eruption, exfoliation, trauma, diet, hygiene, habits

diet/behaviors

-acids produced by bacteria after sugar intake persist for 20-40 minutes

-frequency of sugar ingestion is more important than quantity

diet

-caries promoted by carbohydrates, which breakdown to acid

-acid causes demineralization of enamel

-frequent snacking promotes acid attack

-foods with complex carbohydrates (breads, cereals, pastas) are major sources of “hidden” sugars

-high sugar content in sodas is a source of substrates

oral hygiene- fluoride toothpaste

-recommend use of fluoride toothpaste twice a day as soon as first teeth begin to erupt

-”smear” <3 years old

-”pea size” 3-6 years old

-regular use associated with reduction in caries, relatively greater in higher risk children

-greater effect (prevention) with increased concentration, frequency of use, and supervised brushing

fluoride’s MOA

-topical effect: inhibits demineralization, enhances re-mineralization, antibacterial → concentrates in plaques, disrupts bacterial enzyme systems

-systemic (weaker evidence): improves enamel structure, reduces acid solubility, improves tooth morphology

sources of fluoride

-public drinking water

-processed beverages and foods (“halo effect”)

-dentrifices

-mouth rinses

-dietary supplements

-fluoride gel

-fluoride foam

-fluoride varnish

water fluoridation

-ideal situation: effective, inexpensive, does not require conscious daily cooperation from patients

-optimal water fluoridation level = 0.7ppm

-62.8% of US population receiving fluoridated water- difficult to go above this, ~25% of population uses well water

-F already in water, more of a F “optimization”- some locations have too much Fl in water naturally

-F supplements should be considered for all children drinking fluoride-deficient (<0.6ppm F) water; all possible sources of F exposure should be considered prior to prescribing (test well water, consider school, other care settings, etc.)

dietary supplement recommendations

fluoride in infant formula

-recommend using low fluoride or fluoride free water to prepare fluoride

toothpaste

-95% of toothpastes have fluoride

-0.1-0.15% fluoride content (1000ppm-1500ppm); 1g of toothpaste has 1mg of F

-parents must supervise small children

-higher concentration prescription options available: 0.5% F content

mouth rinse

-OTC: 0.05% NaF (1mg/5mL)

-Rx: 0.2% NaF (weekly use; 4mg/5mL)

-indications: orthodontics, radiation therapy to head/face/neck, prosthetic appliances, high sucrose diet, high caries risk

fluoride varnish

-5% NaF varnish- 2.2%F = 22,500ppm = 22.5mg/mL

-applied by healthcare provider every 3-6 months in high risk population

-instructions/recommendations: dry teeth, very small amount used, no eating or drinking for 30min-1hr following application (check manufacturer’s instructions), advise parent and child of film on teeth

enamel fluorosis

-white-to-brown discoloration of enamel (varies from mild to severe)

-associated with cumulative fluoride intake during enamel development

-increase in prevalence because of increased ambient fluoride

-severity determined by: dose, timing, duration

fluoride toxicity- acute

-probable toxic dose 5mg F/kg

-probable lethal dose 15mg F/kg

-symptoms of overdose: n/v, diarrhea, abdominal pain, seizures, coma, cardiac arrhythmias

-treatment: bind F- <8mg F/kg use milk or activated charcoal and observe for 6hrs, >8mg F/kg use milk and refer for emergency care (gastric lavage, CaCl2, MgSO4)

ingestion of toothpaste

-most OTC toothpaste = 0.243% NaF, 0.15% F, 1100ppm F

-1.1mg of F in 1g of toothpaste

-average amount of toothpaste in smear = 0.1mg, pea size amount = 0.25mg

-tube of toothpaste 4.6oz (130g): 143.3mg of F = probable lethal dose for <9.5kg child (~2 years old), probable toxic dose for <28.6kg child (~8 years old)

risk factors- transmission

-if parents, siblings, etc. have caries, can transmit to pt

-inadequate cleaning of utensils, pacifiers, etc. can pass bacteria associated with caries

non-nutritive sucking habits

-pacifier or fingers

-ideally stop by 3 years

caries risk assessment

-determination of likelihood of incidence of caries during a certain time period or the likelihood that there will be a change in the size or activity of lesions already present

-purpose: focus on tx of disease v. outcome of disease, individualizes treatment plan, focus on prevention, anticipates progression or stabilization of caries

-categories: biological, protective, clinical findings

caries risk assessment forms

biological risk factors

-in adults, best tool to predict future caries is past caries experience, BUT not as useful in children

-important to determine caries risk before disease manifests

-diet

protective factors

-fluoride

-sugar substitutes: xylitol can reduce levels of S. mutans in plaque and saliva

-tooth brushing: weak relationship between brushing and dental caries reduction, unclear if due to fluoride application or mechanical removal of plaque

-dental home: known benefit of establishing regular dental visits and dental home at an early age

clinical findings

-in young children 0-3, plaque accumulation and white spot lesions are indicative of caries activity and should place them in high risk categories

-elevated S. mutans is most valuable when assessing preschool aged children because it is indicative of when patient is colonized

caries management protocols

-utilize risk assessment tool to aid in clinical decision making

-help provider create a more individualized treatment plan

-individualized treatment and prevention plan

caries management protocol for 1-2 year olds

caries management protocol for 3-5 year olds

caries management protocol for >6 year olds

managing dental caries

-old philosophy: surgical intervention is required for all carious lesions

-new philosophy: surgical intervention alone will NOT STOP the disease process- caries management is required with surgical repair

information to collect to create a differential dx and develop tx plan options

-med history: ROS, meds, allergies, sx history

-dental history: previous dental visits (continuity of care), caries experience, trauma, family dental history (caries risk assessment, malocclusion, environmental risk factors, attitudes towards dentistry), oral hygiene practices, diet, fluoride exposure

-clinical exam: intraoral and extraoral

-radiographic exam

-caries risk assessment

radiographic assessment of pediatric patients

-radiographs should be taken based on individual considerations- there is no set frequency that applies to all pts

-considerations in determining radiology prescription:

-risk assessment: caries history, fluoride status, diet

-trauma

-anomalies (supernumerary, missing permanent teeth, mesiodents)

-absence or presence of contacts (kids have generalized spacing→when first permanent molars erupt, they push teeth forward which creates contacts)

-active decay

children should take over brushing at age

-~8

child preparation and management for radiographs

-euphemisms (camera, selfie)

-role models

-contour film- not possible with digital sensors, can damage phosphor plates

-”edge ease” (cushions that go around sensor)

-distraction

-parental help

film sizes

-generally use 2 in adults

-0-1 in kids

radiographic tools

radiographic techniques

-bite wings

-periapicals

-maxillary and mandibular occlusals

-extraoral/lateral film

-soft tissue radiograph

-panoramic radiographs

bite wing radiograph

-mesial surface of canine to distal surface of 1st permanent molar

-distal contact of canine to mesial contact of last tooth in arch

horizontal v. vertical bitewing

-vertical easier to tolerate for pts who gag

occlusal radiographs

occlusal v. periapical radiographs

-occlusal: can often visualize the whole arch, angulation can vary

-periapical: a section of the arch that shows the whole tooth crown to apex- position film as if taking an occlusal

trauma

-soft tissue radiograph

-indicated after trauma to locate piece(s) of fractured tooth

panoramic radiograph

-evaluate growth and development

-take pans in children if unerupted teeth exist that should be erupted

-some practitioners say every 3 yrs starting at age 6

-look at overall development of child

-23, 24, 25, 26, 1st year molars present = good time to take pan

-anomaly: ankylosis

-peg lateral

-supernumerary primary lateral

-count the teeth

-fusion

-supernumerary tooth

-missing lateral

-concrescence: cementum fuses together

-unfavorable resorption pattern of roots

-retained primary root tips

-common in kids with high caries → don’t get tx and teeth just crumble

may take ____ demineralization to occur before it will be evident radiographically

-30-70%

dental erosion

-progressive irreversible loss of dental hard tissue that is chemically etched away from the tooth surface by intrinsic and/or extrinsic process that does not involve bacteria

-consequences of dental erosion: lack of enamel, hypersensitivity, discoloration, crazing/fractures, increased wear, restorations

signs of enamel erosion

-broad concavities on cusp tips (mandibular molars)

-smooth silky glazed appearance

-increased incisal translucency

-”raised” amalgam restorations (enamel wears away but amalgam does not)

-loss of surface anatomy in young children

-hypersensitivity

dental erosion as a sign of systemic disease

-bulimia nervosa: lingual surfaces of anterior teeth

-GERD

titratable acidity

-critical pH of enamel = 5.5

-measure of the amount of alkali which needs to be added to an acid in order to neutralize at pH 7.0

-indicates the amount of available acid, both bound and free hydrogen ions; erosive potential of a substance

dental caries

-disease of microbial origin

-communicable

-largely preventable

-described as a “silent epidemic”: 5x more common than asthma

dental caries- bacteria and biofilm

-initiated by pathogenic bacteria- Streptococcus mutans, Lactobacilli, and Streptococcus sobrinus

-formation of a complex structure called biofilms

-dental plaque biofilm: unremoved plaque promotes the caries process

-can explain biofilm as “teeth wearing sweaters”, “sugar bugs”, “sugar bug nest”

early signs of decay

-white spot lesions

-not as visible when dry → become chalky

later signs of decay

-enamel breakdown

advanced/severe decay

-decay that extends all the way to the gingiva anteriorly or very extensively occlusally in the posterior

ICDAS score

sequalae of ECC

-extreme pain

-spread of infection

-difficulty chewing

-poor weight gain

-extensive and costly dental treatment

-risk of dental decay in permanent dentition

-malocclusion

-missed school and work days

-impaired language development

-inability to concentrate in school

-reduced self-esteem

-possible facial cellulitis requiring hospitalization

-possible systemic illness

-death

dental infections

-can spread more quickly in children → tissues more compliant

high risk groups

-children with special health care needs

-children from low socioeconomic and ethnocultural groups

-children with suboptimal exposure to topical or systemic fluoride

-children with poor dietary and feeding habits

-children whose caregivers and/or siblings have caries

-children with visible caries, white spots, plaque, or decay

caries prevention- fluoride varnish

-5% NaF or 2.26% fluoride in a viscous resinous base in an alcoholic suspension with flavoring agent

-has not been associated with fluorosis

-application does not replace the dental home or is equivalent to comprehensive dental care

-ensure teeth are super dry before applying- otherwise will just slide off the teeth

additional fluoride exposures

-fluoride mouthwashes, Rx toothpastes and gels

-reservoir in saliva/vestibule → don’t want to eat/drink & have reservoir deplete

caries prevention- flossing

-once a day, preferably at night

-whenever any two teeth touch

dental sealants

-noninvasive procedures

-helps prevent pit and fissure caries (account for almost 80% of all dental caries in children)

-seals deep, narrow grooves

-BEWARE of the poorly placed sealant → can create a plaque trap

fissures caries model

-once the organic plug fails, bacteria have access to the depths of the fissure

-fissure walls are in close apposition

-unable to detect caries

clinical pathway for occlusal surface management

restorative dentistry

-adhesive dentistry: retention and resistance forms of cavity preparation do not apply, therefore more conservative, isolation is CRITICAL (moisture makes composite fail)

-amalgam restorations: follow GV Black’s principles of cavity preparation, less conservative (need bulk of amalgam to ensure success), more forgiving in terms of moisture control

-full coverage restorations: stainless steel crowns, preformed ceramic crowns

-other tools: silver diamine fluoride (SDF)

preventive resin restorations (PRR)

-a single or multiple, small, discontinuous, carious pits or fissures

-may extend into enamel, dentin, or DEJ

-excavated and restored with resin

-occlusal surface sealed for prevention

composite/resin restorations

-involves the excavation of a single, larger carious lesion followed by restoration with a resin based material

bonding tips

-etch for the appropriate length of time: too long = etch patterns that extend too deeply causing adhesives to not be able to penetrate the demineralized zone; usually 15-20 seconds

-ensure ideal dentin moisture conditions: ethanol adhesives do not require as much moisture, apply indirect air to dry, do not dessicate

-pay attention to application time and technique: watch the clock to avoid counting too fast

-scrub adhesive when recommended by manufacturer: usually scrub dentin to increase bond strength, scrubbing enamel will usually decrease bond strength, treat enamel more delicately and dentin more aggressively

-thin and dry the adhesive properly: gentle air spray at half an inch from the surface

-light cure close to the surface with a compatible light

-first increment of composite in a thin layer (0.2mm)

-thoroughly clean contamination: if contamination during bonding, clean and re-etch for 5 seconds

resin based composites- resin matrix (Bis-GMA) with inorganic filler particles

-filler content: filled v. unfilled, flowable (less filler) v. packable (more filler), anterior v. posterior composite

-particle size: macro, microfilled, and hybrids

-BPA = endocrine disruptor? → scrub top of composite with water

glass ionomer cements

-fluorosilicate glass powder (base) combined with a water soluble polymer (acid)

-set via chemical rxn

-contain fluoride

-Ketac cement, Fuji II or IX, Fuji Triage- used as sealants

resin-modified glass ionomer (RMGI)

-glass ionomers with a light polymerized resin component

-dual cure

-increased mechanical properties

-physiochemically bonds to tooth structure

-biocompatible, moisture

-similar coefficient of thermal expansion as dentin (good dentin replacement material)

-ion leachability- fluoride release (anti-cariogenic)

-minimal polymerization shrinkage