PAEDIATRIC DENTISTRY - 3rd Ed.

(2005)

Front matter Title a!e Paediatri" Denti#tr$ - Third Edition Edited by Richard Welbury Professor of Paediatric Dentistry University of Glasgow Monty Duggal Professor of Child Dental Health Leeds Dental Institute and

Department of Child Dental Care University of Glasgow Co $ri!%t a!e &'F&RD (NI)ERSITY PRESS Great Clarendon Street, Oxford OX !D" Oxford #ni$er%ity "re%% i% a de&art'ent of the #ni$er%ity of Oxford( )t further% the #ni$er%ity*% ob+ecti$e of excellence in re%earch, %cholar%hi&, and education by &ubli%hing ,orld,ide in Oxford -e, .or/ 0uc/land Ca&e To,n Dar e% Salaa' 1ong 2ong 2arachi 2uala 3u'&ur Madrid Melbourne Mexico City -airobi -e, Delhi Shanghai Tai&ei Toronto With office% in 0rgentina 0u%tria 4ra5il Chile C5ech Re&ublic 6rance Greece

Guate'ala 1ungary )taly 7a&an "oland "ortugal Singa&ore South 2orea S,it5erland Thailand Tur/ey #/raine 8ietna' Oxford i% a regi%tered trade 'ar/ of Oxford #ni$er%ity "re%% in the #2 and in certain other countrie% "ubli%hed in the #nited State% by Oxford #ni$er%ity "re%% )nc(, -e, .or/ Oxford #ni$er%ity "re%%, 99: The 'oral right% of the author ha$e been a%%erted Databa%e right Oxford #ni$er%ity "re%% ;'a/er< 6ir%t edition &ubli%hed =>>? Re&rinted =>>> Second edition &ubli%hed 99= Re&rinted 99@, 99A Third edition &ubli%hed 99: 0ll right% re%er$ed( -o &art of thi% &ublication 'ay be re&roduced, %tored in a retrie$al %y%te', or tran%'itted, in any for' or by any 'ean%, ,ithout the &rior &er'i%%ion in ,riting of Oxford #ni$er%ity "re%%, or a% ex&re%%ly &er'itted by la,, or under ter'% agreed ,ith the a&&ro&riate re&rogra&hic% right% organi5ation( EnBuirie% concerning re&roduction out%ide the %co&e of the abo$e %hould be %ent to the Right% De&art'ent, Oxford #ni$er%ity "re%%, at the addre%% abo$e .ou 'u%t not circulate thi% boo/ in any other binding or co$er and you 'u%t i'&o%e the %a'e condition on any acBuirer 4riti%h 3ibrary Cataloguing in "ublication Data Data a$ailable 3ibrary of Congre%% Cataloging in "ublication Data Data a$ailable Ty&e%et by -e,gen )'aging Sy%te'% ;"< 3td(, Chennai, )ndia "rinted in )taly on acid-free &a&er by Grafiche )ndu%triali )S4- 9 => C:!:C@! ;&b/< E0- code >?C 9 => C:!:C@ @ = @ : ? > =9 C ! A Content# *i#t o+ "ontri,-tor# vii Pre+a"e to t%e t%ird edition ix A,,re.iation# xi

/ Craniofacial gro,th and de$elo&'ent 1 P H Gordon 2 )ntroduction to the dental %urgery 1! " # $lin%horn 3 1i%tory, exa'ination, ri%/ a%%e%%'ent, and treat'ent &lanning &' ( L Hunter and H D )odd 0 "har'acological 'anage'ent of &ain and anxiety *& G + )o,erts and ( - Hosey 5 3ocal anae%the%ia for children .' + G (eechan 1 Diagno%i% and &re$ention of dental carie% 1/! C Deery and 0 + -oum,a 2 Treat'ent of dental carie% in the &re%chool child 1&1 # " 1ayle 3 O&erati$e treat'ent of dental carie% in the &ri'ary dentition 12! ( # Duggal and P 1 Day 4 O&erati$e treat'ent of dental carie% in the young &er'anent dentition 1!3 + " #mallridge and $ 4illiams /0 0d$anced re%torati$e denti%try 5/& 6 ( 0ilpatric% and ) ) 4el,ury // "eriodontal di%ea%e in children 5&1 P " Heasman and P + 4aterhouse /2 Trau'atic in+urie% to the teeth 53! ) ) 4el,ury and + ( 4hitworth /3 0no'alie% of tooth for'ation and eru&tion 5'3 P + ( Crawford and ( + "ldred /0 The &aedodonticDorthodontic interface &1' 6 7 Carter /5 Oral &athology and oral %urgery &33 + G (eechan /1 Medical di%ability &.3 ( - Hosey and ) ) 4el,ury /2 Childhood i'&air'ent and di%ability 211

+ H 6unn )ndex 2&3 Contri,-tor# M( 7( 0ldred De&art'ent of Denti%try Royal Children%* 1o%&ital Melbourne 0( S( 4lin/horn "rofe%%or of Oral 1ealth #ni$er%ity of Manche%ter -( E( Carter De&art'ent of Child Dental 1ealth Dental 1o%&ital, -e,ca%tle u&on Tyne "( 7( M( Cra,ford De&art'ent of Child Dental 1ealth #ni$er%ity of 4ri%tol "( 6( Day De&art'ent of Child Dental 1ealth 3eed% Dental )n%titute C( Deery De&art'ent of "aediatric Denti%try Edinburgh Dental )n%titute M( S( Duggal "rofe%%or of Child Dental 1ealth 3eed% Dental )n%titute S( 0( 6ayle De&art'ent of Child Dental 1ealth 3eed% Dental )n%titute "( 1( Gordon De&art'ent of Child Dental 1ealth #ni$er%ity of -e,ca%tle u&on Tyne -( M( 2il&atric/ De&art'ent of Denti%try Royal Children*% 1o%&ital Melbourne "( 0( 1ea%'an De&art'ent of Re%torati$e Denti%try #ni$er%ity of -e,ca%tle u&on Tyne

M( T( 1o%ey De&art'ent of Child Dental Care #ni$er%ity of Gla%go, M( 3( 1unter De&art'ent of Child Dental 1ealth #ni$er%ity of Cardiff 7( G( Meechan De&art'ent of Oral Surgery #ni$er%ity of -e,ca%tle u&on Tyne 7( 1( -unn "rofe%%or of S&ecial -eed% Denti%try Trinity College Dublin G( 7( Robert% De&art'ent of Children*% Denti%try Ea%t'an Dental )n%titute 3ondon 1( D( Rodd De&art'ent of Child Dental 1ealth #ni$er%ity of Sheffield 7( 0( S'allridge De&art'ent of Child Dental 1ealth Guy% and St Tho'a%* Tru%t 3ondon 2( 7( Tou'ba "rofe%%or of "re$enti$e and "aediatric Denti%try 3eed% Dental )n%titute "( 7( Waterhou%e De&art'ent of Child Dental 1ealth #ni$er%ity of -e,ca%tle u&on Tyne R( R( Welbury "rofe%%or of "aediatric Denti%try #ni$er%ity of Gla%go, 7( M( Whit,orth De&art'ent of Re%torati$e Denti%try #ni$er%ity of -e,ca%tle u&on Tyne 4( Willia'% General Dental "ractitioner )&%,ich, Suffol/ Pre+a"e to t%e t%ird edition

) ,a% $ery &lea%ed ,hen 'y younger colleague% and Monty Duggal acce&ted 'y offer to +oin 'e in editing thi% third edition( Our boo/ ha% no, %old four and a half thou%and co&ie% %ince it% launch in =>>? and it i% e%%ential that ,e 'aintain a conte'&orary outloo/ and &ubli%h change% in techniBue% and &hilo%o&hie% a% %oon a% they ha$e an e$idence ba%e( Since 99= and the %econd edition, there ha$e been a %ignificant nu'ber of change% of author%hi&, a% ,ell a% a change of cha&ter% for %o'e exi%ting author%( Gerry Winter died in Dece'ber 99 ( 1e ,a% a ,i%e colleague and friend ,ho ,a% a 'entor to 'any of u%( ) continue to 'i%% hi% ex&erti%e and a$ailability for con%ultation, by &o%t or tele&hone, ,hich he freely ga$e e$en after hi% retire'ent( 7ohn Murray, 0ndre, Rugg-Gunn, and 3inda Sha, ha$e no, retired fro' clinical &ractice( ) a' indebted to the' all for their %u&&ort, both in 'y o,n &er%onal career and in the &roduction of out textboo/( ) a' grateful to the' for allo,ing the ne, cha&ter author% to u%e their text% and figure%( The re%torati$e %ection of the boo/ ha% been re'odelled( The endodontic% cha&ter in the &re$iou% edition% ha% no, been incor&orated into either cha&ter% C or = , and there are %e&arate cha&ter% relating to the o&erati$e care of the &ri'ary and the &er'anent dentition%( Without the hel& and friend%hi& of 7i' "age the original *O&erati$e care of dental carie%* cha&ter ,ould not ha$e been &o%%ible( ) a' grateful to 7i' for allo,ing u% to continue to u%e hi% original illu%tration% fro' that cha&ter( 0lthough de%igned for the undergraduate ,e ho&e the ne, edition ,ill continue to be u%ed by undergraduate, &o%tgraduate, and general dental &ractitioner ali/e, and that their &ractice of &aediatric denti%try ,ill be both fulfilling and en+oyable( R( R( W Glasgow +anuary 5//3 Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

2. Introd-"tion to t%e dental #-r!er$ - " # $lin%horn 2./ INTR&D(CTI&N )t i% a co''on belief a'ong 'any indi$idual% that being *good ,ith &eo&le* i% an inborn art and o,e% little to %cience or training( )t i% true that %o'e indi$idual% ha$e a 'ore o&en di%&o%ition and can relate ,ell to other% ; 6ig( (=<( 1o,e$er, there i% no logical rea%on ,hy all of u% %houldn*t be able to &ut young &atient% at their ea%e and %ho, that ,e are intere%ted in their &roble'%(

)t i% &articularly i'&ortant for denti%t% to learn ho, to hel& &eo&le relax, a% failure to e'&athi5e and co''unicate ,ill re%ult in di%a&&ointed &atient% and an un%ucce%%ful &racti%ing career( Co''unicating effecti$ely ,ith children i% of great $alue, a% *being good ,ith younger &atient%* i% a &ractice-builder and can reduce the %tre%% in$ol$ed ,hen offering clinical care( 0ll undergraduate and &o%tgraduate dental training %hould include a thorough under%tanding of ho, children relate to an adult ,orld, ho, the dental $i%it %hould be %tructured, and ,hat %trategie% are a$ailable to hel& children co&e ,ith their a&&rehen%ion about dental &rocedure%( Thi% cha&ter ,ill con%ider the%e ite'%, beginning ,ith a di%cu%%ion on the theorie% of &%ychological de$elo&'ent, and follo,ing thi% u& ,ith %ection% onG &arent% and their influence on dental treat'entH denti%t-&atient relation%hi&%H anxiou% and uncoo&erati$e children, and hel&ing anxiou% &atient% to co&e ,ith dental care( Fi!. 2./ 4eing good ,ith &atient% i% not nece%%arily an inborn artI ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.2 PSYC5&*&6Y &F C5I*D DE)E*&P7ENT 2.2.0 Introd-"tion 0t one ti'e the &%ychological de$elo&'ent of children ,a% %&lit into a %erie% of ,elldefined &ha%e%, but 'ore recently thi% di$i%ion ha% been critici5ed and de$elo&'ent %hould no, be %een a% a continuu'( The &ha%e% of de$elo&'ent 'ay ,ell differ fro' child to child, %o a rigidly a&&lied definition ,ill be artificial( -e$erthele%%, for the %a/e of clarity ,hen de%cribing a child*% &%ychological de$elo&'ent fro' infancy into adulthood, certain de$elo&'ental 'ile%tone% %hould be con%idered( The acade'ic con%ideration% about &%ychological de$elo&'ent ha$e been do'-inated by a nu'ber of internationally /no,n authoritie% ,ho ha$e, for the 'o%t &art, concentrated on different a%&ect% of the %y%te'atic &rogre%%ion fro' child to adult( 1o,e$er, the 'o%t i'&ortant theoretical &er%&ecti$e no, influencing thin/ing about child de$elo&'ent i% that of attach'ent theorya theory de$elo&ed by the &%ychoanaly%t 7ohn 4o,lby( )n a %erie% of ,riting% o$er three decade%, 4o,lby de$elo&ed hi% theory that child de$elo&'ent could be%t be under%tood ,ithin the fra'e,or/ of &attern% of interaction bet,een the infant and the &ri'ary caregi$er( )f there ,ere &roble'% in thi% interaction, then the child ,a% li/ely to de$elo& in%ecure andDor anxiou% &attern% that ,ould affect the ability to for' %table relation%hi&% ,ith other%, to de$elo& a %en%e of %elf-,orth, and to 'o$e to,ard% inde&endence( The other i'&ortant conce&t to note i% that de$elo&'ent i% a lifelong &roce%%, ,e do not %,itch off at =C, nor i% de$elo&'ent an e$en &roce%%( De$elo&'ent i% une$en, influenced by &eriod% of ra&id bodily change( The &%ychological literature contain% 'any account% of the change% acco'&anying de$elo&'entH therefore, thi% %ection ,ill &re%ent a general outline of the 'a+or *&%ychological %ign&o%t%* of ,hich the dental tea' %hould be a,are( 0% the ne,born child i% not a *co''on* $i%itor to the dental %urgery no %&ecific de%cri&tion of ne,born beha$iour ,ill be offered, in%tead general account% of 'otor, cogniti$e, &erce&tual, and %ocial de$elo&'ent fro' birth to adole%cence ,ill be included( )t i%

i'&ortant to under%tand that the thin/ing about child de$elo&'ent ha% beco'e le%% certain and %i'&li%tic in it% a&&roachH hence, denti%t% ,ho 'a/e hard and fa%t rule% about the ,ay they offer care to children ,ill cau%e %tre%% to both their &atient% and the'%el$e%( 2.2./ 7otor de.elo ment 0 ne,born child doe% not ha$e an exten%i$e range of 'o$e'ent%, but the%e de$elo& ra&idly and by the age of year% the 'a+ority of children are ca&able of ,al/ing on their o,n( The *'otor 'ile%tone%* occur in a &redictable order and 'any of the te%t% u%ed by &aediatrician% a%%e%% nor'al de$elo&'ent in infancy in ter'% of 'otor %/ill%( The &redictability of early 'otor de$elo&'ent %ugge%t% that it 'u%t be genetically &rogra''ed( 0lthough thi% i% true to %o'e extent, there i% e$idence that the en$iron'ent can influence 'otor de$elo&'ent( Thi% ha% led to a greater intere%t in the early diagno%i% of 'otor &roble'% %o that re'edial inter$ention can be offered( 0 good exa'&le of inter$ention i% the hel& offered to Do,n %yndro'e babie%, ,ho ha$e %lo, 'otor de$elo&'ent( S&ecific &rogra''e%, ,hich focu% on &racti%ing %en%ory'otor ta%/%, can greatly accelerate 'otor de$elo&'ent to al'o%t nor'al le$el%( Motor de$elo&'ent i% really co'&leted in infancy, the change% ,hich follo, the ,al/ing 'ile%tone are refine'ent% rather than the de$elo&'ent of ne, %/ill%( Eyehand co-ordination gradually beco'e% 'ore &reci%e and elaborate ,ith increa%ing ex&erience( The do'inance of one hand e'erge% at an early age and i% u%ually lin/ed to he'i%&here do'inance for language &roce%%ing( The left he'i%&here control% the right hand and the right he'i%&here control% the left( The 'a+ority of right-handed &eo&le a&&ear to be %trongly left-he'i%&here do'inant for language &roce%%ing, a% are nearly all left-hander%( So'e children ,ith 'otor retardation 'ay fail to %ho, %&ecific right or left 'anual do'inance and ,ill lac/ good co-ordination bet,een the hand%( Children of !-? year% of age u%ually ha$e %ufficient co-ordination to bru%h their teeth rea%onably ,ell( 4elo, that age 'any area% of the 'outh ,ill be 'i%%ed and there i% a tendency to %,allo, relati$ely large a'ount% of tooth&a%te, hence &arental %u&er$i%ion of bru%hing i% i'&ortant( 2.2.2 Co!niti.e de.elo ment The cogniti$e ca&ability of children change% radically fro' birth through to adulthood, and the &roce%% i% di$ided into a nu'ber of %tage% for ea%e of de%cri&tion( 0 S,i%% &%ychologi%t called "iaget for'ulated the *%tage% $ie,* of cogniti$e de$elo&'ent on the ba%i% of detailed ob%er$ation% of hi% o,n children, and %ugge%ted that children &a%% through four broad %tage% of cogniti$e de$elo&'ent, na'elyG =( #ensorimotorG thi% %tage la%t% until about year% of age( The &ri'e achie$e'ent i% *ob+ect &er'anence*( The infant can thin/ of thing% a% &er'anent,hich continue to exi%t ,hen out of %ightand can thin/ of ob+ect% ,ithout ha$ing to %ee the' directly( ( Preoperational thoughtG thi% run% fro' to ? year% of age( The %en%ori'otor %tage i% further de$elo&ed, allo,ing the child to &redict outco'e% of beha$iour( 3anguage de$elo&'ent facilitate% the%e change%( The thought &attern% are not ,ell de$elo&ed,

being egocentric, unable to enco'&a%% another &er%on*% &oint of $ie,, %ingle-trac/ed, and inflexible ;%u'% u& 'o%t &olitician%, %o'e dental &rofe%%or%, and ho%&ital ad'ini%trator%<( Ty&ically, children in thi% age band are unable to under%tand that area% and $olu'e% re'ain the %a'e de%&ite change% in &o%ition or %ha&e( @( Concrete operationsG thi% i% the %tage of thin/ing that occur% fro' about ? to == year% of age( Children are able to a&&ly logical rea%oning, con%ider another &er%on*% &oint of $ie,, and a%%e%% 'ore than one a%&ect of a &articular %ituation ;6ig( ( <( Thin/ing i% rooted in concrete ob+ect%, ab%tract thought i% not ,ell de$elo&ed( A( 1ormal operationsG thi% i% the la%t %tage in the tran%ition to adult thin/ing ability( )t begin% at about == year% of age and re%ult% in the de$elo&'ent of logical ab%tract thin/ing %o that different &o%%ibilitie% for action can be con%idered( The%e %tage% ha$e been highlighted becau%e of the i'&ortance of "iaget*% early ,or/ on cogniti$e de$elo&'ent( 1o,e$er, an o$er-reliance on *dog'a* 'ay ,ell li'it the de$elo&'ent of a %ub+ect, and thi% ,a% the ca%e ,ith cogniti$e de$elo&'ent( 6e, %cienti%t% challenged "iaget*% finding% %o that the field of infant &erce&tion beca'e a rather %terile area for a nu'ber of year%, but thi% changed ,ith the ,or/ of 4o,lby( Enor'ou% de$elo&'ent% in re%earch ha$e %ince led to 'any doubt% being rai%ed about "iaget*% original inter&retation of hi% data( 1e undere%ti'ated the thin/ing abilitie% of younger children, and there i% e$idence to %ho, that not all &re%chool thin/ing i% totally egocentric( Of +u%t a% 'uch intere%t i% the 'odern $ie, that not all adult thin/ing i% logical, 'any of u% are bia%ed and illogical( 0 %elf-e$ident truth ,hen one con%ider% the argu'ent% rai%ed again%t ,ater fluoridationI There i%, ho,e$er, a %eriou% &oint to thi% ob%er$ation on adult illogicality( We 'u%t be &re&ared for &arent% ,ho don*t agree ,ith our &ercei$ed ,i%do' ;6ig( (@< or do not under%tand the ba%ic tenet% of %&ecific &rogra''e%( Denti%t% ,ill lead le%% %tre%%ful &racti%ing li$e% if they re'e'ber that not all their &atient% ,ill al,ay% agree ,ith or follo, oral health ad$ice( So "iaget %hould be %een a% a &ioneer ,ho really %et in 'otion ,or/ on cogniti$e de$elo&'ent, but it i% no, recogni5ed that the de$elo&'ental %tage% are not %o clearcut and 'any /id% are %'arter than ,e thin/I Fi!. 2.2 Children aged ?-== year% are able to con%ider another &er%on*% &oint of $ie,( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2.3 4e &re&ared for &arent% ,ho don*t agree( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.2.3 Per"e t-al de.elo ment Clearly, it i% $ery difficult to di%co$er ,hat babie% and infant% are ex&eriencing &erce&tually, %o 'uch re%earch ha% concentrated on eye 'o$e'ent%( The%e ty&e% of %tudie% ha$e %ho,n that ,ith increa%ing age, %canning beco'e% broader and larger a'ount% of infor'ation are %ought( Co'&ared ,ith adult%, !-year-old children co$er le%% of the ob+ect, fixate on detail%, and gain le%% infor'ation( 1o,e$er, children do de$elo& their %electi$e attention, and by the age of ? year% can deter'ine ,hich 'e%%age% 'erit attention and ,hich can be ignored( Concentration %/ill% al%o

i'&ro$e( So'e dental ad$ice can be offered to children of thi% age, but gi$en the i'&ortance of the ho'e en$iron'ent &arent% %hould be the 'ain focu% of any infor'ation gi$en on oral health care( With increa%ing age children beco'e 'ore efficient at di%cri'inating bet,een different $i%ual &attern% and reach adult &roficiency by about > year% of age( The 'a+ority of &erce&tual de$elo&'ent i% a function of the gro,th of /no,ledge about the en$iron'ent in ,hich a child li$e%, hence the nece%%ity to %&end ti'e ex&laining a%&ect% of dental care to ne, child &atient% ; 6ig( (A<( Fi!. 2.0 S&end ti'e ex&laining the fact% about dental care( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.2.0 *an!-a!e de.elo ment 0 lac/ of the a&&ro&riate %ti'ulation ,ill retard a child*% learning, &articularly language( 0 child of : ,ho can only %&ea/ in 'ono%yllable% and ha% no %en%ible %entence %tructure ,ill not only be unable to co''unicate ,ith other% but ,ill be unable to thin/ about the thing% heD%he %ee% and hear%( Sti'ulation i% i'&ortant a% language de$elo&'ent i% %uch a ra&id &roce%% in childhood that any delay can %eriou%ly handica& a child( -e,born children %ho, a re'ar/able ability to di%tingui%h %&eech %ound% and by the age of : year% 'o%t children can u%e 999 or 'ore ,ord%( 3anguage and thought are tied together and are i'&ortant in cogniti$e de$elo&'ent, but the co'&lexitie% of the relation%hi& bet,een the t,o are not ,ell under%tood( Denti%try ha% a highly %&eciali5ed $ocabulary and it i% unli/ely that 'any children, e$en adole%cent%, ,ill under%tand our 'eaning if ,e rely on +argon( The /ey to %ucce%%ful co''unication i% to &itch your ad$ice and in%truction% at +u%t the right le$el for different age grou&% of children( There i% a ri%/ of being &atroni5ing if e$ery child &atient i% told that *little &ixie% are eating a,ay tiny bit% of your tooth and ) a' going to run 'y little engine to frighten the' a,ay to fairyland*( 0 %treet,i%e =9 year old ,ho i% a co'&uter ga'e% officionado ,ould &robably call the &olice if you u%ed %uch languageI There i% no uni$er%al a&&roach to &atient%, %o careful treat'ent &lanning and a%%e%%'ent are reBuired before children or their &arent% are gi$en %&ecific ,ritten or $erbal ad$ice( 2.2.5 So"ial de.elo ment #ntil fairly recently it ,a% belie$ed that ne,born infant% ,ere indi$idual% ,ho %&ent 'o%t of their ti'e %lee&ing( 1o,e$er, recent re%earch re$eal% that babie% interact Buite 'ar/edly ,ith their en$iron'ent, often initiating interaction% ,ith other hu'an% by 'o$e'ent of their eye% or li'b%( 4abie% tend to for' %&ecific attach'ent% to &eo&le and are &rone to %e&aration anxiety( 0t about C 'onth% infant% %ho, a definite fear of %tranger%( Thi% &otential for anxiety %e&aration re'ain% high until about : year% of age ,hen %e&aration anxiety decline% Buite 'ar/edly( Thi% i% con%i%tent ,ith %tudie% of children in ho%&ital, ,hich %ho, that after the age of : there i% le%% di%tre%% on entering ho%&ital( Se&aration

anxiety %hould al%o be con%idered by denti%t% ,ho in%i%t that all young children 'u%t enter the dental %urgery alone( Clearly, thi% ,ill cau%e %e$ere anxiety to &atient% under :( )t ha% been re&orted that a lo$ing, early &arental attach'ent i% a%%ociated ,ith a better %ocial ad+u%t'ent in later childhood and i% a good ba%i% for engendering tru%t and friend%hi& ,ith &eer%( Thi% i% i'&ortant a% a %ucce%%ful tran%ition fro' ho'e to %chool de&end% on the ability to interact ,ith other indi$idual% a&art fro' &arent%( The ho'e en$iron'ent ,ill &lay a 'a+or &art in %ocial de$elo&'ent, but the effect% of co''unity ex&ectation% %hould not be undere%ti'ated( We are all &roduct% of our broad %ocial en$iron'ent, 'ediated to %o'e extent by &arental influence%( 2.2.1 Adole#"en"e The ,aning of &arental influence can be %een in the final %tage of child de$elo&'ent, adole%cence( Thi% i% the end of childhood and the beginning of adulthood( )t i% conce&tuali5ed a% a &eriod of e'otional tur'oil and a ti'e of identity for'ation( Thi% $ie, i% a *We%tern* creation and i% culturally bia%ed( )n 'any %ocietie% *terrible teenager%* do not exi%tH childhood end% and adult re%&on%ibilitie% are offered at a relati$ely early age( )t i% intere%ting to note that e$en in We%tern indu%triali5ed %ocietie% there i% little real e$idence to %u&&ort the idea that the 'a+ority of adole%cent% are rebelliou% and nonconfor'i%t( The 'ain change i% the e$olution of a different %ort of &arental relation%hi&( There i% increa%ing inde&endence and %elf-%ufficiency( The re%earch doe% %ho, that young &eo&le tend to be 'oody, are o$er%en%iti$e to critici%', and feel 'i%erable for no a&&arent rea%on but do not on the ,hole rebel again%t their &arental role 'odel%( There are %o'e clear 'e%%age% to denti%t% ,ho ,i%h to retain their adole%cent &atient%H don*t critici5e the' exce%%i$ely a% thi% 'ay co'&ro'i%e their future oral health( The%e &atient% are loo/ing for %u&&ort and rea%%urance( Many health &rofe%%ional% need to rethin/ their a%%u'&tion% about young &eo&le, a% &er%onal beha$iour &attern% are not really related to health i%%ue% at all( #ntil there are acute &roble'% *health per se* i% of little rele$ance to adole%cent% being a rather ab%tract conce&t( 6uture orientation i% lo, and the 'a+or i%%ue% of concern are finding e'&loy'ent, ex&loring their %exuality, and ha$ing the friend%hi& and %u&&ort of their &eer%( 2.3 PARENTS AND T5EIR INF*(ENCE &N DENTA* TREAT7ENT Children learn the ba%ic a%&ect% of e$eryday life fro' their &arent%, thi% &roce%% i% ter'ed %ociali5ation and i% an ongoing and gradual &roce%%( 4y the age of A year% children /no, 'any of the con$ention% current in their culture, %uch a% 'ale and fe'ale role%( The &roce%% of tran%'itting cultural infor'ation early in life i% called &ri'ary %ociali5ation( )n indu%triali5ed countrie%, obtaining infor'ation on 'any a%&ect% of life i% gained for'ally in %chool% and college% rather than fro' the fa'ily( Thi% i% ter'ed %econdary %ociali5ation( )ntere%tingly, &ri'ary %ociali5ation can ha$e a &rofound and la%ting effect( 6or exa'&le, fear of dental treat'ent and ,hen ,e fir%t begin to clean our teeth can often

be traced bac/ to fa'ily influence( So &arent% can %ha&e a child*% ex&ectation% and attitude% about oral healthH thu%, e$ery atte'&t %hould be 'ade to in$ol$e the' ,hen atte'&ting to offer dental care or change a child*% health habit%( )n$ol$ing &arent% 'ean% that the denti%t 'u%t loo/ to &o%iti$e reinforce'ent rather than *$icti' bla'ing*( "arent% ,ho are accu%ed of oral neglect 'ay ,ell feel aggrie$ed or threatened( 0ll too often children*% oral health i% co'&ro'i%ed by a lac/ of &arental /no,ledge %o &rogra''e% ha$e to be carefully de%igned to reduce any chance% of 'a/ing &eo&le feel guilty( Guilt often re%ult% in &arent% %&ending 'ore ti'e in %ee/ing excu%e% for &roble'% than trying to i'&le'ent %olution%( "arent% ,ho are con$inced that their child ha% an oral health &roble' ,hich can be %ol$ed tend to react in a &o%iti$e ,ay, both to their dental ad$i%or and the &re$enti$e &rogra''e it%elf( )t i% e%&ecially hel&ful if the &re$enti$e %trategy can include a %y%te' of &o%iti$e reinforce'ent for the child ;6ig( (:<( 6eature% %uch a% bru%hing chart%, diet %heet%, gold %tar% for bru%hing ,ell, extra &oc/et 'oney for curtailing thu'b-%uc/ing are all u%eful ti&% to hel& &arent% 'aintain a child*% enthu%ia%' for a &articular dental &ro+ect( )t 'u%t be e'&ha%i5ed that &re$enti$e &rogra''e% 'u%t be carefully &lanned to include only one 'a+or goal at a ti'e( "arent% ,ill be unable to co&e if too 'uch i% ex&ected of the' at any one ti'e( "rogra''e% that in$ol$e fa'ilie% ha$e 'uch higher %ucce%% rate% than tho%e ,hich concentrate %olely on the &atient( )ntere%tingly, fa'ilie% al%o ha$e a &rofound influence on le$el% of dental anxiety a'ong their children( Dentally anxiou% 'other% ha$e children ,ho exhibit negati$e beha$iour at the denti%t( 1ence, the need for denti%t% to loo/ *beyond* the child ,hen a%%e%%ing the rea%on% for dental anxiety( One of the great debate% in &aediatric denti%try centre% on ,hether &arent% %hould be allo,ed in the dental %urgery ,hile their child i% recei$ing treat'ent( 0 child*% fa'ily, it could be argued, can offer e'otional %u&&ort during treat'ent( There i% no doubt that ,ithin the 'edical field there i% great %u&&ort for the conce&t of a &arent actually *li$ing in* ,hile a child i% ho%&itali5ed( 1o,e$er, the i%%ue i% not %o clear-cut in denti%try ;6ig( (!<( The fir%t i%%ue that 'u%t be rai%ed i% ,hether denti%t% ha$e the ethicalD'oral right to bar &arent% fro' %itting in ,ith their children ,hen dental care i% being underta/en( Clearly, &arent% ha$e $ie,% and anxiety le$el% 'ay be rai%ed if &arent% feel their fa'ilial right% are being threatened and a child 'ay be %tre%%ed by ten%ion bet,een &arent% and the o&erator( Wright et al( ;=>C?< in their co'&rehen%i$e boo/ on child 'anage'ent %u''ari5e the ad$antage% of /ee&ing &arent% out of the %urgery a%G ;=< the &arent often re&eat% order%, creating an annoyance for both denti%t and child &atient ;6ig( (?<H ; < the &arent% interce&t order%, beco'ing a barrier to the de$elo&'ent of ra&&ort bet,een the denti%t and the childH ;@< the denti%t i% unable to u%e $oice intonation in the &re%ence of the &arent becau%e he or %he i% offendedH

;A< the child di$ide% attention bet,een the &arent and the denti%tH ;:< the denti%t di$ide% attention bet,een the &arent and the childH ;!< denti%t% are &robably 'ore relaxed and co'fortable ,hen the &arent re'ain% in the rece&tion area( The%e %ugge%tion% ha$e 'erit but they do ha$e a rather authoritarian feel to the', %tre%%ing the ordering and $oice intonation rather than %y'&athetic co''unication( "ractical re%earch to %u&&ort &arent% *in or out* of the %urgery i% not a$ailable to %ugge%t ,hether there i% a right or ,rong ,ay to handle thi% &articular Bue%tion( )n the end it i% a &er%onal deci%ion ta/en by the denti%t in the light of &arental concern% and clinical ex&erience( 0% in any branch of 'edicine there can be no *hard and fa%t* rule% for dealing ,ith the general &ublic, an adherence to any ty&e of dog'a *co'e ,hat 'ay* i% a reci&e for confrontation and %tre%%( Therefore, &arent% %itting in ,ith children %hould be a deci%ion ta/en for each indi$idual rather than i'&le'enting a */ee& &arent% out* &olicy( "atient% ,ith %&ecial need% reBuire a high degree of &arental in$ol$e'ent in oral health care, &articularly for tho%e children ,ith educational, beha$ioural, and &hy%ical difficultie%( 6or exa'&le, toothbru%hing i% a co'&lex cogniti$e and 'otor ta%/ ,hich ,ill tax the %/ill% of 'any handica&&ed children( 0 &arent ,ill ha$e to be taught ho, to 'onitor the efficiency of the &laBue re'o$al and inter$ene ,hen nece%%ary, to en%ure the 'outh i% cleaned adeBuately( Diet i% al%o i'&ortant, %o clear ad$ice 'u%t be offered and reinforce'ent &lanned at regular inter$al%( Fi!. 2.5 "o%iti$e reinforce'ent i% i'&ortant( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2.1 Should ,e allo, &arent% into the %urgeryJ ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2.2 So'e &arent% can be $ery irritating by re&eating all your reBue%t%( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.0 DENTIST-PATIENT RE*ATI&NS5IP 2.0.0 Introd-"tion The ,ay a denti%t interact% ,ith &atient% ,ill ha$e a 'a+or influence on the %ucce%% of any clinical or &re$enti$e care( Clearly, only broad guideline% can be &re%ented on ho, to 'aintain an effecti$e relation%hi& ,ith a &atient, a% all of u% are uniBue indi$idual% ,ith different need% and a%&iration%( Thi% i% e%&ecially %o in &aediatric denti%try ,here a clinician 'ay ha$e to treat a frightened @-year-old child at one a&&oint'ent and an hour and a half later be faced ,ith the &roble' of offering &re$enti$e ad$ice on oral health to a recalcitrant =: year old( There are, ho,e$er, co''on re%earch finding% ,hich highlight the /ey i%%ue% that ,ill cau%e a denti%tD &atient con%ultation to founder or &rogre%% %ati%factorily( The fir%t Bue%tion that 'u%t be con%idered i% *Why 'e,hat factor% did the &arent% ta/e into account before 'a/ing an a&&oint'ent at 'y &racticeJ* The ob$iou% an%,er% are that your &ractice i% clo%e%t to the bu% %to&, ha% good &ar/ing, and you are the only one o&en after !(99 &('( Sur&ri%ingly, the choice i% not

%o %i'&le( Mo%t &eo&le try to find out detail% about different dental &ractice% fro' friend% and colleague%( While the technical %/ill of the denti%t i% of %o'e concern, the 'o%t i'&ortant feature% &eo&le loo/ for are, a gentle friendly 'anner, ex&lain% treat'ent &rocedure%, and trie% to /ee& any &ain to a 'ini'u'( 0% ,ith any health i%%ue the %ocial cla%% bac/ground of the re%&ondent% influence% attitude% and belief%( 6or exa'&le, &arent% of high %ocioecono'ic %tatu% are 'ore intere%ted in &rofe%%ional co'&etence and gaining infor'ation, ,herea% &arent% fro' &oorer area% ,ant a denti%t to rea%%ure and be friendly to their child( So ,hich denti%t &arent% choo%e to offer care to their child ,ill de&end to %o'e extent on re&ort% about technical %/ill fro' fa'ily and friend%, but the 'a+or dri$ing force i% ,ell-de$elo&ed inter&er%onal %/ill%( 0 'a+or &oint to e'&ha%i5e i% that technical %/ill i% u%ually +udged in ter'% of caring and %y'&athy, a finding ,hich add% further ,eight to the i'&ortance of denti%t% de$elo&ing a good *chair- %ide 'anner*( Ex&lanation, *ta/ing the ti'e to tal/ u% through ,hat our child*% treat'ent ,ill entail*, i% another factor ,hich rate% highly, and 'ay actually influence the rate of attendance for follo,-u& a&&oint'ent%( 2.0./ Str-"t-re o+ t%e dental "on#-ltation To hel& %tudent% and ne, graduate% i'&ro$e their denti%tD&atient interaction %/ill% it i% &o%%ible to gi$e an outline %tructure to a %ucce%%ful dental con%ultation( The &ro&o%ed 'odel con%i%t% of %ix %tage%, and i% ba%ed on the ,or/ of Wanle%% and 1ollo,ay ;=>>A<( =( Greeting( The denti%t greet% the child by na'e( 0$oid u%ing generali5ed ter'% %uch a% *1i %onny, hello %un%hine*, ,hich are general rather than %&ecific to the &atient ;6ig( (C<( )f &arent% are &re%ent then include the' in the con$er%ation, but do not forget that the child %hould be central to the de$elo&ing relation%hi&( 0 greeting can be %&oilt by &roceeding too Buic/ly to an in%truction rather than an in$itation( 6or exa'&le, *1ello Sarah, +u'& in the chair* i% rather abru&t and 'ay &re+udice an interacti$e relation%hi&( The greeting %hould be u%ed to &ut the child and &arent% at ea%e before &roceeding to the next %tage( ( Preliminary chat( Thi% &ha%e ha% three ob+ecti$e%, to a%%e%% ,hether the &atient or &arent% ha$e any &articular ,orrie% or concern%, to %ettle the &atient into the clinical en$iron'ent, and to a%%e%% the &atient*% e'otional %tate( The follo,ing %eBuence re&re%ent% one ,ay of 'axi'i5ing the effect of the *&reli'inary chat*G ;a< 4egin ,ith non-dental to&ic%( 6or children ,ho ha$e been before it i% hel&ful to record u%eful infor'ation %uch a% the na'e% of brother%D%i%ter%, %chool, &et%, and hobbie%( ;b< 0%/ an o&en Bue%tion %uch a%, *1o, are youDare you ha$ing any &roble'% ,ith your teethJ* 3i%ten to the an%,er and &robe further if nece%%ary( 0ll too often denti%t% a%/ Bue%tion% and then ignore the an%,erI 4y tal/ing generally and ta/ing note of ,hat the child i% %aying you are offering a degree of control and reducing anxiety(

@( Preliminary explanation( )n thi% %tage the ai' i% to ex&lain ,hat the clinical or &re$enti$e ob+ecti$e% are in ter'% that &arent% and children ,ill under%tand( Thi% i% a $ital &art of any $i%it a% it e%tabli%he% the credibility of the denti%t a% %o'eone ,ho /no,% ,hat the ulti'ate goal for the treat'ent i%, and i% &re&ared to ta/e the ti'e and trouble to di%cu%% it in non-technical language( While not ,i%hing to labour the &oint, it 'u%t be %tre%%ed that %en%ible infor'ation cannot be offered to the &atient or &arent% until the clinician ha% a full hi%tory and a treat'ent &lan ba%ed on adeBuate infor'ation( Thi% reBuire% a broad $ie, of the &atient and %hould not be totally tooth-centred( )t i% all too ea%y to lo%e the confidence of &arent% and children if you find your%elf 'a/ing excu%e% for clinical deci%ion% ta/en in a hurried and un%cientific 'anner( Thu% the &reli'inary chat %et% the %cene &rior to actual clinical acti$ity( A( $usiness( The &atient i% no, in danger of beco'ing a &a%%i$e ob+ect ,ho i% ,or/ed on rather than being in$ol$ed in the treat'ent( Many +o/e% are 'ade about denti%t% ,ho a%/ Bue%tion% of &atient% ,ho are unable to re&ly becau%e of a 'outhful of in%tru'ent%I ;6ig( (><( Thi% doe% not 'ean that the $i%it %hould enter a %ilent &ha%e( )t i% i'&ortant to re'ain in $erbal contact( Chec/ the &atient i% not in &ain, di%cu%% ,hat you are doing, u%e the &atient*% na'e to %ho, a *&er%onal* intere%t, and clarify any 'i%under%tanding%( 0t the end of the bu%ine%% %tage it i% hel&ful to %u''ari5e ,hat ha% been done and offer aftercare ad$ice( )f the &arent i% not &re%ent in the %urgery, the treat'ent %u''ary i% &articularly i'&ortant, a% it i% a u%eful ,ay of 'aintaining contact ,ith the &arent%( :( Health education( Oral health i%, to a large extent, de&endent u&on &er%onal beha$iour and a% %uch it ,ould be unethical for denti%t% not to include ad$ice on 'aintaining a healthy 'outh( 0lthough offering ad$ice to &arent% and &atient% i% u%eful, in 'any in%tance% the &rofe%%ion treat health education in a *thro,a,ay* 'anner( Thi% re%ult% in both &atient% and denti%t% being di%a&&ointed( The /ey ,ay% to i'&ro$e the $alue of ad$ice %e%%ion% are a% follo,%G ;a< Ma/e the ad$ice %&ecific, gi$e a child a &er%onal &roble' to %ol$e( ;b< Gi$e %i'&le and &reci%e infor'ation( ;c< Do not %ugge%t goal% of beha$iour change ,hich are beyond a &atient*% ca&acity to achie$e( ;d< Chec/ the 'e%%age ha% been under%tood and not 'i%inter&reted( ;e< Offer ad$ice in %uch a ,ay that the child and &arent% are not threatened or bla'ed( ;f< )f you are trying to i'&ro$e oral hygiene a$oid theoretical di%cu%%ion%, offer a &ractical de'on%tration( ;g< 0t follo,-u& $i%it% reinforce the ad$ice and offer &o%iti$e reinforce'ent( The final &art of the health education acti$ity i% goal %etting( The denti%t %et% out in %i'&le ter'% ,hat the &atient %hould try and achie$e by the next $i%it( )t i'&lie% a

for' of contract and a% %uch hel&% both children and &arent% to gain a clearer in%ight into ho, they all can hel& to i'&ro$e the child*% oral health( Goal %etting 'u%t be u%ed %en%ibly( )f goal% are 'anife%tly i'&o%%ible then &arent% and child &atient% beco'e di%illu%ioned( "arent% feel that the denti%t doe% not under%tand their &roble'% and co'&lain that they are being bla'ed for any dental %hortco'ing%( So al,ay% en%ure that you &lan goal %etting carefully in a &o%iti$e and friendly 'anner( !( Dismissal( Thi% i% the final &art of the $i%it and %hould be clearly %ign&o%ted %o that e$eryone /no,% that the a&&oint'ent i% o$er( The &atient %hould be addre%%ed by na'e and a definite fare,ell offered ;6ig( (=9<( The ob+ecti$e %hould be to en%ure that ,here$er &o%%ible the &atient and &arent% lea$e ,ith a %en%e of good,ill( Clearly, not all a&&oint'ent %e%%ion% can be di%%ected into the%e %ix %tage%( 1o,e$er, the ba%ic ele'ent of according the &atient the 'axi'u' attention and &er%onali5ing your co''ent% %hould ne$er be forgotten( Fi!. 2.3 0l,ay% greet your &atient by na'e( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2.4 )% your &atient +u%t a 'outhful of in%tru'ent%J ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2./0 Ma/e %ure you offer your &atient a definite fare,ell( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.5 AN'I&(S AND (NC&&PERATI)E C5I*DREN Dental anxiety %hould concern u% a% a &rofe%%ion becau%e it not only &re$ent% 'any &otential &atient% fro' %ee/ing care but it al%o cau%e% %tre%% to the denti%t% underta/ing dental treat'ent( )ndeed one of the 'a+or %ource% of %tre%% for general dental &ractitioner% i% *co&ing ,ith difficult &atient%* ;6ig( (==<( Denti%t% do not ,ant to be con%idered a% &eo&le ,ho inflict unnece%%ary anxiety on the general &ublic( 1o,e$er, anxiety and dental care %ee' to be loc/ed in the general fol/lore of 'any countrie%( )n order to under%tand ,hy, it i% hel&ful to con%ider *,hat i% the nature of anxiety*( Many definition% of anxiety ha$e been %ugge%ted and it i% a %o'e,hat daunting ta%/ to reconcile the'( 1o,e$er, it ,ould %ee' %en%ible to con%ider the co''ent% of 2ent ;%ee 2ent and 4lin/horn =>>=< ,ho re&orted that anxiety i% *a $ague un&lea%ant feeling acco'&anied by a &re'onition that %o'ething unde%irable i% going to ha&&en*( )n other ,ord% it relate% to ho, &eo&le feela %ub+ecti$e definition( 0nother &oint of $ie, i% that anxiety 'anife%t% it%elf in beha$iour( )f, for exa'&le, a &er%on i% anxiou%, then %heDhe ,ill act in a &articular 'anner( 0 &er%on ,ill a$oid $i%iting the denti%t( Thu%, anxiety %hould be %een a% a 'ulti- factorial &roble' 'ade u& of a nu'ber of different co'&onent%, all of ,hich can exert an effect( 0nxiety 'u%t al%o be %een a% a continuu' ,ith fearit i% al'o%t i'&o%%ible to %e&arate the t,o in 'uch of the re%earch underta/en in the field of denti%try, ,here the t,o ,ord% are u%ed interchangeably( One could con%ider that anxiety i% 'ore a general feeling of di%co'fort, ,hile fear i% a %trong reaction to a %&ecific e$ent( -e$erthele%% it i% counter&roducti$e to %earch for elu%i$e definition% a% both fear and anxiety are a%%ociated ,ith dental $i%iting and treat'ent(

6ro' a co''on-%en%e &oint of $ie, it i% clear that %o'e %ituation% ,ill arou%e 'ore anxiety than other%( 6or exa'&le, a fear of height% i% relati$ely co''on, but it i% galling to note that in the #nited State% a %tudy by 0gra% et al( ;=>!>< found that $i%iting the denti%t ran/ed fourth behind %na/e%, height%, and %tor'%( Clearly then, anxiety about dental care i% a &roble' that ,e a% a &rofe%%ion 'u%t ta/e %eriou%ly, e%&ecially a% children re'e'ber &ain and %tre%% %uffered at the denti%t and carry the e'otional %car% into adult life( So'e &eo&le 'ay de$elo& %uch a fear of denti%try that they are ter'ed &hobic%( 0 &hobia i% an inten%e fear ,hich i% out of all &ro&ortion to the actual threat( Re%earch in thi% area %ugge%t% that the extent of anxiety a &er%on ex&erience% doe% not relate directly to dental /no,ledge, but i% an a'alga'ation of &er%onal ex&erience%, fa'ily concern%, di%ea%e le$el%, and general &er%onality trait%( Such a co'&lex %ituation 'ean% that it i% no ea%y ta%/ to 'ea%ure dental anxiety and &in&oint aetiological agent%( Mea%uring dental anxiety i% &roble'atic becau%e it relie% on %ub+ecti$e 'ea%ure%, &lu% the influence of the &arent%, the denti%t*% beha$iour, and the rea%on for a $i%it 'ay all exert %o'e effect on a child*% anxiety le$el%( Kue%tionnaire% and rating %cale% are the 'o%t co''only u%ed 'ean% by ,hich anxiety ha% been Buantified, although there ha% been %o'e intere%t in &hy%iological data %uch a% heart rate( So'e Bue%tionnaire% that ha$e been u%ed to 'ea%ure anxiety can be a&&lied to a ,hole $ariety of %ituation%, %uch a% recording *exa' ner$e%* or fear of %&ider%, ,hile other% are %&ecific to the dental %ituation( The 'o%t ,idely u%ed dental anxiety 'ea%ure i% Corah*% Dental 0nxiety Scale ;%ee 2ent and 4lin/horn =>>=<, ,hich ta/e% the for' of a Bue%tionnaire( "atient% are a%/ed to choo%e an an%,er ,hich be%t %u'% u& their feeling%( The an%,er% are %cored fro' = to : %o that a total %core can be co'&uted( 0 high %core %hould alert the dental tea' that a &articular &atient i% $ery anxiou%( 1o,e$er, &atient-ad'ini%tered Bue%tionnaire% ha$e a li'ited $alue in e$aluating a young child*% anxiety becau%e of their &oorly de$elo&ed $ocabulary and under%tanding( Therefore there ha% been great intere%t in 'ea%uring anxiety by ob%er$ing beha$iour( One %uch %cale ,a% de$elo&ed by 6ran/l to a%%e%% the effect of a &arent re'aining ,ith a child in the %urgery ;%ee 2ent and 4lin/horn =>>=<( )t con%i%t% of four rating% fro' definitely negati$e to definitely &o%iti$e( )t i% %till co''only u%ed in &aediatric dental re%earch( 0nother %cale ,hich i% &o&ular ,ith re%earcher% i% one u%ed by 1ou&t, ,hich 'onitor% beha$iour by allocating a nu'erical %core to ite'% %uch a% body 'o$e'ent and crying ;%ee 2ent and 4lin/horn =>>=<( Recent %tudie% ha$e u%ed the 6ran/l %cale to %elect %ub+ect% for %tudie%, and then 'ore detailed beha$iour e$aluation %y%te'% are utili5ed to 'onitor the co'&liance ,ith treat'ent ;%ee 2ent and 4lin/horn =>>=<( 4eha$ioural ob%er$ation re%earch can be &roble'atical a% the &re%ence of an ob%er$er in the %urgery 'ay u&%et the &atient( )n addition, it i% difficult to be totally ob+ecti$e ,hen different co&ing %trategie% are being u%ed and %o'e bia% ,ill occur( The de$elo&'ent of chea& light,eight digital or $ideo ca'era% ha% greatly hel&ed ob%er$ational re%earch, a% the &atient*% beha$iour can be %cored by a nu'ber of rater% a,ay fro' the %urgery( Re%coring the $ideo% i%

al%o &o%%ible to chec/ the reliability of the index u%ed( "hy%iological 'ea%ure'ent% %uch a% a higher &ul%e rate, &er%&iration, and &eri&heral blood flo, ha$e been u%ed to Buantify children*% dental anxiety( 1o,e$er, fe, &hy%iological %ign% are %&ecific to one &articular e'otion and the 'ea%uring techniBue% often &ro$o/e anxiety in the child &atient, %o they are rarely u%ed( 0% yet, there i% no %tandard 'ea%ure of dental anxiety for children a% the re&roducibility and reliability of 'o%t Bue%tionnaire% ha$e not been de'on%trated, &lu% ob%er$ational and &hy%iological indice% are not ,ell de$elo&ed( Thi% i% a %eriou% &roble' a% the a%%e%%'ent of %trategie% to reduce anxiety i% %o'e,hat co'&ro'i%ed by a lac/ of uni$er%ally acce&ted 'ea%uring techniBue%( Fi!. 2.// Difficult &atient% can be a %ource of %tre%%I ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.1 5E*PIN6 AN'I&(S PATIENTS T& C&PE 8IT5 DENTA* CARE 2.1.0 Introd-"tion 0 nu'ber of theorie% ha$e been %ugge%ted in an effort to ex&lain the de$elo&'ent of anxiety( #ncertainty about ,hat i% to ha&&en i% certainly a factor, a &oor &a%t ex&erience ,ith a denti%t could u&%et a &atient, ,hile other% 'ay learn anxiety re%&on%e% fro' &arent%, relation%, or friend%( 0 denti%t ,ho can alle$iate anxiety or &re$ent it ha&&ening in the fir%t &lace ,ill al,ay% be &o&ular ,ith &atient%( Clearly, the ea%ie%t ,ay to control anxiety i% to e%tabli%h an effecti$e &re$enti$e &rogra''e %o that children do not reBuire any treat'ent( )n addition to an effecti$e &re$enti$e regi'en it i% i'&ortant to e%tabli%h a tru%ting relation%hi&, li%tening to a child*% %&ecific ,orrie% and concern%( E$ery effort 'u%t be ta/en to en%ure that any treat'ent i% &ain-free( 0ll too often ,e forget that local analge%ia reBuire% ti'e and &atience( With the u%e of a to&ical anae%thetic &a%te and %lo, relea%e of the anae%thetic %olution 'o%t *in+ection%* %hould be &ainle%%( There i% no excu%e for the *%tab and %Buirt 'ethod* ;6ig( (= <( Children are not *little adult%*, they are $ulnerable and afraid of ne, %urrounding% %o effecti$e ti'e 'anage'ent i% i'&ortant( Try to %ee young &atient% on ti'e and do not %tre%% your%elf or the child by ex&ecting to co'&lete a clinical ta%/ in a %hort ti'e on an a&&rehen%i$e &atient( De%&ite the dental tea'*% be%t effort% anxiety 'ay &er%i%t and routine dental care i% co'&ro'i%ed( Other o&tion% ,ill then ha$e to be con%idered to hel& the child( 0n increa%ingly &o&ular choice i% the u%e of &har'acological agent%H the%e ,ill be di%cu%%ed in Cha&ter A( The alternati$e% to the &har'acological a&&roach areG ;=< reducing uncertaintyH ; < 'odellingH ;@< cogniti$e a&&roache%H ;A< relaxationH and ;:< %y%te'atic de%en%iti5ation(

;!< hand o$er 'outh exerci%e ;1OME<( The%e are di%cu%%ed in 'ore detail belo,( Fi!. 2./2 Stab and %Buirt ha% no &lace in our anae%thetic techniBue( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.1./ Red-"in! -n"ertaint$ The 'a+ority of young children ha$e $ery little idea of ,hat dental treat'ent in$ol$e% and thi% ,ill rai%e anxiety le$el%( Mo%t children ,ill co&e if gi$en friendly rea%%urance fro' the denti%t, but %o'e &atient% ,ill need a 'ore %tructured &rogra''e( One %uch %tructured 'ethod i% the tell-%ho,-do techniBue( 0% it% na'e i'&lie% it centre% on three &ha%e%G =( -ellG ex&lanation of &rocedure% at the right ageDeducational le$el( ( #howG de'on%trate the &rocedure( @( DoG follo,ing on to underta/e the ta%/( "rai%e being an e%%ential &art of the exerci%e ;6ig( (=@<( While it i% a &o&ular techniBue there i% little ex&eri'ental ,or/ to %u&&ort it% u%e( 0nother techniBue to reduce anxiety a'ong $ery ,orried children i% to %end a letter ho'e ex&laining all the detail% of the &ro&o%ed fir%t $i%it %o that uncertainty ,ill be reduced( The e$idence for thi% a&&roach i% not clear-cut a% &arental anxiety i% changed by &reinfor'ation rather than the child*%( 0ccli'ati5ation &rogra''e% gradually introducing the child to dental care o$er a nu'ber of $i%it% ha$e been %ho,n to be of $alue( Thi% a&&roach i% rather ti'e con%u'ing and doe% little for the really ner$ou% child( Fi!. 2./3 "rai%e co%t% little, but doe% %ho, you to be a caring &er%on( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.1.2 7odellin! Thi% 'a/e% u%e of the fact that indi$idual% learn 'uch about their en$iron'ent fro' ob%er$ing the con%eBuence% of other &eo&le*% beha$iour( .ou or ) 'ight re&eat an action if ,e %ee other% being re,arded, or if %o'eone i% &uni%hed ,e 'ight ,ell decide not to follo, that beha$iour( Modelling could be u%ed to alle$iate anxiety( )f a child could be %ho,n that it i% &o%%ible to $i%it the denti%t, ha$e treat'ent, and then lea$e in a ha&&y fra'e of 'ind ;6ig( (=A<, thi% could reduce anxiety due to *fear of the un/no,n*( 0 child ,ould %ee behind that forbidding %urgery doorI )t i% not nece%%ary to u%e a li$e 'odel, $ideo% of co-o&erati$e &atient% are of $alue( 1o,e$er, the follo,ing &oint% %hould be ta/en into con%ideration ,hen %etting u& a &rogra''e(

=( En%ure that the 'odel i% clo%e in age to the ner$ou% child or children in$ol$ed( ( The 'odel %hould be %ho,n entering and lea$ing the %urgery to &ro$e treat'ent ha% no la%ting effect( @( The denti%t %hould be %ho,n to be a caring &er%on ,ho &rai%e% the &atient( Fi!. 2./0 We ,ant our &atient% to lea$e u% in a ha&&y fra'e of 'ind( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.1.3 Co!niti.e a roa"%e#

Modelling hel&% &eo&le learn about dental treat'ent fro' ,atching other%, but it doe% not ta/e account of an indi$idual*% *cognition%* or thought%( "eo&le 'ay heighten their anxiety by ,orrying 'ore and 'ore about a dental &roble' %o creating a $iciou% reinforcing circle( Thu% there ha% been great intere%t in trying to get indi$idual% to identify and then alter their dy%functional belief%( 0 nu'ber of cogniti$e 'odification techniBue% ha$e been %ugge%ted, the 'o%t co''on one% includingG ;=< a%/ing &atient% to identify and 'a/e a record of their negati$e thought%H ; < hel&ing &atient% to recogni5e their negati$e thought% and %ugge%ting 'ore &o%iti$e alternati$e%*reality ba%ed*H ;@< ,or/ing ,ith a thera&i%t to identify and change the 'ore dee&-%eated negati$e belief%( Cogniti$e thera&y i% u%eful for focu%ed ty&e% of anxietyhence it% $alue in co'bating dental anxiety( 0nother a&&roach that could be con%idered a cogniti$e a&&roach i% di%traction( Thi% techniBue atte'&t% to %hift attention fro' the dental %etting to,ard% %o'e other /ind of %ituation( Di%tracter% %uch a% $ideota&ed cartoon% and %torie% ha$e been u%ed to hel& children co&e ,ith dental treat'ent( The re%ult% ha$e been %o'e,hat eBui$ocal and the threat to %,itch off the $ideo ,a% needed to 'aintain co-o&eration( 2.1.0 Rela9ation Relaxation training i% of $alue ,here &atient% re&ort high le$el% of ten%ion, and con%i%t% of bringing about dee& 'u%cular relaxation( )t ha% al%o been u%ed in con+unction ,ith biofeedbac/ training( 0% the techniBue% reBuire the &re%ence of a trained thera&i%t, the &otential $alue in general &aediatric denti%try ha% %till to be a%%e%%ed( 2.1.5 S$#temati" de#en#iti:ation The ba%ic &rinci&le of thi% treat'ent con%i%t% of allo,ing the &atient gradually to co'e to ter'% ,ith a &articular fear or %et of fear% by ,or/ing through $ariou% le$el% of the feared %ituation, fro' the *'ilde%t* to the *'o%t anxiety* &rogra''e( Thi% techniBue relie% on the u%e of a trained thera&i%t and in 'o%t in%tance% a %i'&le

dentally ba%ed accli'ati5ation &rogra''e %hould be tried fir%t( 2.1.1 5and o.er mo-t% e9er"i#e (5&7E) The &hy%ical re%traint of children in order to underta/e clinical dental care ha% &ro'&ted 'uch debate( 1o%ey ; 99 < and Manley ; 99A< note that in the #nited 2ingdo' the u%e of &hy%ical re%traint i% &re%ently unacce&table( 1o,e$er, %o'e author% are %ugge%ting ;Connic/ et al , 999H 2u&iet%/y, 99A< that re%traint in co'bination ,ith inhalation %edation 'ay be a hel&ful &rocedure if general anae%the%ia i% not readily a$ailable( )n thi% %ection other o&tion% to re%traint ha$e been %ugge%ted and, although ti'e con%u'ing, are li/ely to &ro$o/e le%% of a ner$ou% reaction and a$oid a%%ociating dental care ,ith an un&lea%ant ex&erience( 6or tho%e reader% ,ho ,i%h to %tudy the to&ic in 'ore detail, co'&rehen%i$e clinical guideline% collated by The 0'erican 0cade'y of "aediatric Denti%try ha$e been &ubli%hed in the +ournal of Paediatric Dentistry ; 99 <( 2.2 SYN&PSIS &F T5E 6(IDE*INES ;Y T5E A7ERICAN ACADE7Y &F PAEDIATRIC DENTISTRY &N ;E5A)I&(R 7ANA6E7ENT 2.2.0 Introd-"tion To hel& tho%e reader% ,ho ,i%h to ha$e an o$er$ie, of the /ey ele'ent% in the guideline%, a brief %u''ary of the ob+ecti$e% and indication%Dcontraindication% for a nu'ber of beha$iour 'anage'ent techniBue%, a$ailable to dental &ractitioner%, are li%ted( 2.2./ Comm-ni"ation mana!ement =( 8oice control i% a controlled alteration of $oice $olu'e, tone, or &ace to influence and direct the &atient*% beha$iour( 8,9ectivesG ;i< To gain the &atient*% attention and co'&liance( ;ii< To a$ert negati$e or a$oidance beha$iour( ;iii< To e%tabli%h a&&ro&riate adult-child role%( IndicationsG May be u%ed ,ith any &atient( ContraindicationsG -one( ( -on-$erbal co''unication i% the reinforce'ent and guidance of beha$iour through a&&ro&riate contact, &o%ture, and facial ex&re%%ion( 8,9ectivesG ;i< To enhance the effecti$ene%% of other co''unicati$e 'anage'ent techniBue%( ;ii< To gain or 'aintain the &atient*% attention and co'&liance(

IndicationsG May be u%ed ,ith any &atient( ContraindicationsG -one( @( Tell-%ho,-do i% a techniBue of beha$iour %ha&ing u%ed ,ith both $erbal and non$erbal co''unication( 8,9ectivesG ;i< To teach the &atient i'&ortant a%&ect% of the dental $i%it and fa'iliari5e the &atient ,ith the dental %etting( ;ii< To %ha&e the &atient*% re%&on%e to &rocedure% through de%en%iti5ation and ,ellde%cribed ex&ectation%( IndicationsG May be u%ed ,ith any &atient( ContraindicationsG -one( A( "o%iti$e reinforce'ent i% the &roce%% of e%tabli%hing de%irable &atient beha$iour through a&&ro&riate feedbac/( 8,9ectivesG ;i< To reinforce de%ired beha$iour( IndicationsG May be u%eful for any &atient( ContraindicationsG -one( :( "arental &re%enceDab%ence in$ol$e% either allo,ing or re'o$ing the &arent;%< fro' the dental %urgery in order to gain coo&eration( 8,9ectivesG ;i< To gain the &atient*% attention and co'&liance( ;ii< To a$ert negati$e or a$oidance beha$iour%( ;iii< To e%tabli%h a&&ro&riate adult-child role%( ;i$< To enhance the co''unication en$iron'ent( IndicationsG May be u%ed ,ith any &atient( ContraindicationsG -one( !( 1and o$er 'outh exerci%e i% a techniBue for 'anaging un%uitable beha$iour that cannot be 'odified by the 'ore %traightfor,ard techniBue%( )t i% often u%ed ,ith inhalation %edation ;con%ciou% %edation<( 8,9ectivesG

;i< To redirect the child*% attention, enable co''unication ,ith the denti%t %o that a&&ro&riate beha$ioural ex&ectation% can be ex&lained( ;ii< To extingui%h exce%%i$e a$oidance beha$iour and hel& the child regain %elfcontrol( ;iii< To en%ure the child*% %afety in the deli$ery of Buality dental treat'ent( ;i$< To reduce the need for %edation or general anae%the%ia( IndicationsG ;i< 0 healthy child ,ho i% able to under%tand and co-o&erate, but ,ho exhibit% ob%tre&erou% or hy%terical a$oidance beha$iour%( ContraindicationsG ;i< )n children ,ho, due to age, di%ability, 'edication, or e'otional i''aturity are unable to $erbally co''unicate, under%tand, and co-o&erate( ;ii< 0ny child ,ith an air,ay ob%truction( Other techniBue% %uch a% %edation in all it% for'% and general anae%the%ia are de%cribed el%e,here( 2.3 S(77ARY =( To &re$ent the de$elo&'ent of anxiety it i% 'ore i'&ortant to 'aintain tru%t than concentrate on fini%hing a clinical ta%/( ( The reduction in dental carie% 'ean% that children ,ith %&ecial &%ychological, 'edical, and &hy%ical need% can be offered the oral health care they reBuire( We are not being %,a'&ed by o$er,hel'ing clinical de'and( @( The care of children ,ho are $ery anxiou% can be i'&ro$ed by u%ing the techniBue% de%cribed in thi% cha&ter( A( "re$enting dental di%ea%e %hould al,ay% be gi$en the %a'e %tatu% a% clinical inter$ention( 1o,e$er, it i% i'&ortant to en%ure that &re$enti$e care i% a&&ro&riate and rele$ant( The /ey 'e%%age% are outlined in -he scientific ,asis of oral health education ;3e$ine and Still'an-3o,e, 99A<( 2.4 F(RT5ER READIN6 4lin/horn, 0( S( and Mac/ie, )( C( ;=>> <( -reatment planning for the paedodontic patient( Kuinte%%ence, 3ondon( ;-here is a comprehensive :uestion and answer section in this ,oo% which will help you chec% up on your treatment planning %nowledge(< 6ree'an, R( ;=>>><( The deter'inant% of dental health attitude% and beha$iour%( $ritish Dental +ournal, /32, =:-=C( ;-his paper examines the role of psychosocial factors on health ,ehaviour; and case<,ased examples highlight the psychology of patient care in a practical way(<

1u'&hri%, G( M(, Mil%o', 2(, Tic/le, M(, 1olbroo/, 1(, and 4lin/horn, 0( S( ; 99 <( 0 ne, dental anxiety %cale for : year old children ;D0:<G de%cri&tion and concurrent $alidity( Health 7ducation +ournal, 1/, :-=>( ;-his paper descri,es the development of a new dental anxiety scale for children and highlights the %ey elements associated with measuring anxiety(< Rutter, M( and Rutter, M( ;=>>@<( Developing minds( "enguin 4oo/%, 3ondon( ;" fascinating insight into how we develop throughout life(< Wein'an, 7( ;=>C?<( "n outline of psychology as applied to medicine ; nd edn<, &&( =@ -A( 4utter,orth-1eine'an, 3ondon( ;-his ,oo% is for those students who want to ta%e a ,roader view on the su,9ect of psychology and medicine(< 2./0 REFERENCES 0gra%, S(, Syl$e%ter, D(, and Oli$eau, D( ;=>!><( The e&ide'iology of co''on fear% and &hobia%( Comprehensive Psychiatry, /0, =:=-:!( ;-his paper will show you that fear of dentistry is a pro,lem the dental profession must ta%e seriously(< Clinical guideline on beha$iour 'anage'ent ; 99 <( +ournal of Paediatric Dentistry, 20, !C-?@( ;"n "merican perspective on ,ehaviour management in paediatric dentistry(< Connic/, C(, "alat, M(, and "ulie%e, S( ; 999<( The a&&ro&riate u%e of &hy%ical re%traint%G con%ideration%( +ournal of Dentistry for Children, 12, :!-! ( ;" useful discussion on the role of restraint in clinical paediatric dental practice(< 1o%ey, M( T( ; 99 <( Managing anxiou% childrenG the u%e of con%ciou% %edation in &aediatric denti%try( International +ournal of Paediatric Dentistry, /2, @:>-? ( ;" useful guide to managing anxious children(< 2ent, G( G( and 4lin/horn, 0( S( ;=>>=<( -he psychology of dental care ; nd edn<( Wright, 4ri%tol( ;-his short ,oo% highlights the important psychological aspects of providing clinical care; as well as giving details of the Houpt; 1ran%l; and Corah dental anxiety scales(< 2u&iet5/y, 0( ; 99A<( Stra& hi' do,n or /noc/ hi' outG i% con%ciou% %edation ,ith re%traint an alternati$e to general anae%the%iaJ $ritish Dental +ournal, /41, =@@-C( ;" discussion on the role of conscious sedation allied to the use of restraint in paediatric dentistry(< 3e$ine, R( S( and Still'an-3o,e, C( ; 99A<( -he scientific ,asis of oral health education( 4D7 4oo/%, 3ondon ;" comprehensive guide to dental health education and promotion; including the %ey preventive messages(< Manley, M( C( G( ; 99A<( 0 #2 &er%&ecti$e( $ritish Dental +ournal, /41, =@C->( ;" view on the use of H8(7 in the United 0ingdom(< Wanle%%, M( 4( and 1ollo,ay, "( 7( ;=>>A<( 0n analy%i% of audio-recording% of general dental &ractitioner%* con%ultation% ,ith adole%cent &atient%( $ritish Dental

+ournal, /22, >A-C( ;-his article gives advice on how to improve communication s%ills in the surgery and reminds clinicians that our livelihood depends on effective communication(< Wright, G(, Star/ey, "( E(, Gardener, D( E(, and Cur5on, M( E( 7( ;=>C?<( Child management in dentistry( Wright, 4ri%tol( ;" detailed account of child management; including advice on how to introduce different clinical techni:ues(< Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

2. Introd-"tion to t%e dental #-r!er$ - " # $lin%horn 2./ INTR&D(CTI&N )t i% a co''on belief a'ong 'any indi$idual% that being *good ,ith &eo&le* i% an inborn art and o,e% little to %cience or training( )t i% true that %o'e indi$idual% ha$e a 'ore o&en di%&o%ition and can relate ,ell to other% ; 6ig( (=<( 1o,e$er, there i% no logical rea%on ,hy all of u% %houldn*t be able to &ut young &atient% at their ea%e and %ho, that ,e are intere%ted in their &roble'%( )t i% &articularly i'&ortant for denti%t% to learn ho, to hel& &eo&le relax, a% failure to e'&athi5e and co''unicate ,ill re%ult in di%a&&ointed &atient% and an un%ucce%%ful &racti%ing career( Co''unicating effecti$ely ,ith children i% of great $alue, a% *being good ,ith younger &atient%* i% a &ractice-builder and can reduce the %tre%% in$ol$ed ,hen offering clinical care( 0ll undergraduate and &o%tgraduate dental training %hould include a thorough under%tanding of ho, children relate to an adult ,orld, ho, the dental $i%it %hould be %tructured, and ,hat %trategie% are a$ailable to hel& children co&e ,ith their a&&rehen%ion about dental &rocedure%( Thi% cha&ter ,ill con%ider the%e ite'%, beginning ,ith a di%cu%%ion on the theorie% of &%ychological de$elo&'ent, and follo,ing thi% u& ,ith %ection% onG &arent% and their influence on dental treat'entH denti%t-&atient relation%hi&%H anxiou% and uncoo&erati$e children, and hel&ing anxiou% &atient% to co&e ,ith dental care( Fi!. 2./ 4eing good ,ith &atient% i% not nece%%arily an inborn artI ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.2 PSYC5&*&6Y &F C5I*D DE)E*&P7ENT 2.2.0 Introd-"tion 0t one ti'e the &%ychological de$elo&'ent of children ,a% %&lit into a %erie% of ,elldefined &ha%e%, but 'ore recently thi% di$i%ion ha% been critici5ed and de$elo&'ent %hould no, be %een a% a continuu'( The &ha%e% of de$elo&'ent 'ay ,ell differ fro'

child to child, %o a rigidly a&&lied definition ,ill be artificial( -e$erthele%%, for the %a/e of clarity ,hen de%cribing a child*% &%ychological de$elo&'ent fro' infancy into adulthood, certain de$elo&'ental 'ile%tone% %hould be con%idered( The acade'ic con%ideration% about &%ychological de$elo&'ent ha$e been do'-inated by a nu'ber of internationally /no,n authoritie% ,ho ha$e, for the 'o%t &art, concentrated on different a%&ect% of the %y%te'atic &rogre%%ion fro' child to adult( 1o,e$er, the 'o%t i'&ortant theoretical &er%&ecti$e no, influencing thin/ing about child de$elo&'ent i% that of attach'ent theorya theory de$elo&ed by the &%ychoanaly%t 7ohn 4o,lby( )n a %erie% of ,riting% o$er three decade%, 4o,lby de$elo&ed hi% theory that child de$elo&'ent could be%t be under%tood ,ithin the fra'e,or/ of &attern% of interaction bet,een the infant and the &ri'ary caregi$er( )f there ,ere &roble'% in thi% interaction, then the child ,a% li/ely to de$elo& in%ecure andDor anxiou% &attern% that ,ould affect the ability to for' %table relation%hi&% ,ith other%, to de$elo& a %en%e of %elf-,orth, and to 'o$e to,ard% inde&endence( The other i'&ortant conce&t to note i% that de$elo&'ent i% a lifelong &roce%%, ,e do not %,itch off at =C, nor i% de$elo&'ent an e$en &roce%%( De$elo&'ent i% une$en, influenced by &eriod% of ra&id bodily change( The &%ychological literature contain% 'any account% of the change% acco'&anying de$elo&'entH therefore, thi% %ection ,ill &re%ent a general outline of the 'a+or *&%ychological %ign&o%t%* of ,hich the dental tea' %hould be a,are( 0% the ne,born child i% not a *co''on* $i%itor to the dental %urgery no %&ecific de%cri&tion of ne,born beha$iour ,ill be offered, in%tead general account% of 'otor, cogniti$e, &erce&tual, and %ocial de$elo&'ent fro' birth to adole%cence ,ill be included( )t i% i'&ortant to under%tand that the thin/ing about child de$elo&'ent ha% beco'e le%% certain and %i'&li%tic in it% a&&roachH hence, denti%t% ,ho 'a/e hard and fa%t rule% about the ,ay they offer care to children ,ill cau%e %tre%% to both their &atient% and the'%el$e%( 2.2./ 7otor de.elo ment 0 ne,born child doe% not ha$e an exten%i$e range of 'o$e'ent%, but the%e de$elo& ra&idly and by the age of year% the 'a+ority of children are ca&able of ,al/ing on their o,n( The *'otor 'ile%tone%* occur in a &redictable order and 'any of the te%t% u%ed by &aediatrician% a%%e%% nor'al de$elo&'ent in infancy in ter'% of 'otor %/ill%( The &redictability of early 'otor de$elo&'ent %ugge%t% that it 'u%t be genetically &rogra''ed( 0lthough thi% i% true to %o'e extent, there i% e$idence that the en$iron'ent can influence 'otor de$elo&'ent( Thi% ha% led to a greater intere%t in the early diagno%i% of 'otor &roble'% %o that re'edial inter$ention can be offered( 0 good exa'&le of inter$ention i% the hel& offered to Do,n %yndro'e babie%, ,ho ha$e %lo, 'otor de$elo&'ent( S&ecific &rogra''e%, ,hich focu% on &racti%ing %en%ory'otor ta%/%, can greatly accelerate 'otor de$elo&'ent to al'o%t nor'al le$el%( Motor de$elo&'ent i% really co'&leted in infancy, the change% ,hich follo, the ,al/ing 'ile%tone are refine'ent% rather than the de$elo&'ent of ne, %/ill%( Eyehand co-ordination gradually beco'e% 'ore &reci%e and elaborate ,ith increa%ing ex&erience( The do'inance of one hand e'erge% at an early age and i% u%ually lin/ed to he'i%&here do'inance for language &roce%%ing( The left he'i%&here control% the right hand and the right he'i%&here control% the left( The 'a+ority of right-handed

&eo&le a&&ear to be %trongly left-he'i%&here do'inant for language &roce%%ing, a% are nearly all left-hander%( So'e children ,ith 'otor retardation 'ay fail to %ho, %&ecific right or left 'anual do'inance and ,ill lac/ good co-ordination bet,een the hand%( Children of !-? year% of age u%ually ha$e %ufficient co-ordination to bru%h their teeth rea%onably ,ell( 4elo, that age 'any area% of the 'outh ,ill be 'i%%ed and there i% a tendency to %,allo, relati$ely large a'ount% of tooth&a%te, hence &arental %u&er$i%ion of bru%hing i% i'&ortant( 2.2.2 Co!niti.e de.elo ment The cogniti$e ca&ability of children change% radically fro' birth through to adulthood, and the &roce%% i% di$ided into a nu'ber of %tage% for ea%e of de%cri&tion( 0 S,i%% &%ychologi%t called "iaget for'ulated the *%tage% $ie,* of cogniti$e de$elo&'ent on the ba%i% of detailed ob%er$ation% of hi% o,n children, and %ugge%ted that children &a%% through four broad %tage% of cogniti$e de$elo&'ent, na'elyG =( #ensorimotorG thi% %tage la%t% until about year% of age( The &ri'e achie$e'ent i% *ob+ect &er'anence*( The infant can thin/ of thing% a% &er'anent,hich continue to exi%t ,hen out of %ightand can thin/ of ob+ect% ,ithout ha$ing to %ee the' directly( ( Preoperational thoughtG thi% run% fro' to ? year% of age( The %en%ori'otor %tage i% further de$elo&ed, allo,ing the child to &redict outco'e% of beha$iour( 3anguage de$elo&'ent facilitate% the%e change%( The thought &attern% are not ,ell de$elo&ed, being egocentric, unable to enco'&a%% another &er%on*% &oint of $ie,, %ingle-trac/ed, and inflexible ;%u'% u& 'o%t &olitician%, %o'e dental &rofe%%or%, and ho%&ital ad'ini%trator%<( Ty&ically, children in thi% age band are unable to under%tand that area% and $olu'e% re'ain the %a'e de%&ite change% in &o%ition or %ha&e( @( Concrete operationsG thi% i% the %tage of thin/ing that occur% fro' about ? to == year% of age( Children are able to a&&ly logical rea%oning, con%ider another &er%on*% &oint of $ie,, and a%%e%% 'ore than one a%&ect of a &articular %ituation ;6ig( ( <( Thin/ing i% rooted in concrete ob+ect%, ab%tract thought i% not ,ell de$elo&ed( A( 1ormal operationsG thi% i% the la%t %tage in the tran%ition to adult thin/ing ability( )t begin% at about == year% of age and re%ult% in the de$elo&'ent of logical ab%tract thin/ing %o that different &o%%ibilitie% for action can be con%idered( The%e %tage% ha$e been highlighted becau%e of the i'&ortance of "iaget*% early ,or/ on cogniti$e de$elo&'ent( 1o,e$er, an o$er-reliance on *dog'a* 'ay ,ell li'it the de$elo&'ent of a %ub+ect, and thi% ,a% the ca%e ,ith cogniti$e de$elo&'ent( 6e, %cienti%t% challenged "iaget*% finding% %o that the field of infant &erce&tion beca'e a rather %terile area for a nu'ber of year%, but thi% changed ,ith the ,or/ of 4o,lby( Enor'ou% de$elo&'ent% in re%earch ha$e %ince led to 'any doubt% being rai%ed about "iaget*% original inter&retation of hi% data( 1e undere%ti'ated the thin/ing abilitie% of younger children, and there i% e$idence to %ho, that not all &re%chool thin/ing i% totally egocentric( Of +u%t a% 'uch intere%t i% the 'odern $ie, that not all adult thin/ing i% logical, 'any of u% are bia%ed and illogical( 0 %elf-e$ident truth ,hen one con%ider% the argu'ent% rai%ed again%t ,ater fluoridationI

There i%, ho,e$er, a %eriou% &oint to thi% ob%er$ation on adult illogicality( We 'u%t be &re&ared for &arent% ,ho don*t agree ,ith our &ercei$ed ,i%do' ;6ig( (@< or do not under%tand the ba%ic tenet% of %&ecific &rogra''e%( Denti%t% ,ill lead le%% %tre%%ful &racti%ing li$e% if they re'e'ber that not all their &atient% ,ill al,ay% agree ,ith or follo, oral health ad$ice( So "iaget %hould be %een a% a &ioneer ,ho really %et in 'otion ,or/ on cogniti$e de$elo&'ent, but it i% no, recogni5ed that the de$elo&'ental %tage% are not %o clearcut and 'any /id% are %'arter than ,e thin/I Fi!. 2.2 Children aged ?-== year% are able to con%ider another &er%on*% &oint of $ie,( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2.3 4e &re&ared for &arent% ,ho don*t agree( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.2.3 Per"e t-al de.elo ment Clearly, it i% $ery difficult to di%co$er ,hat babie% and infant% are ex&eriencing &erce&tually, %o 'uch re%earch ha% concentrated on eye 'o$e'ent%( The%e ty&e% of %tudie% ha$e %ho,n that ,ith increa%ing age, %canning beco'e% broader and larger a'ount% of infor'ation are %ought( Co'&ared ,ith adult%, !-year-old children co$er le%% of the ob+ect, fixate on detail%, and gain le%% infor'ation( 1o,e$er, children do de$elo& their %electi$e attention, and by the age of ? year% can deter'ine ,hich 'e%%age% 'erit attention and ,hich can be ignored( Concentration %/ill% al%o i'&ro$e( So'e dental ad$ice can be offered to children of thi% age, but gi$en the i'&ortance of the ho'e en$iron'ent &arent% %hould be the 'ain focu% of any infor'ation gi$en on oral health care( With increa%ing age children beco'e 'ore efficient at di%cri'inating bet,een different $i%ual &attern% and reach adult &roficiency by about > year% of age( The 'a+ority of &erce&tual de$elo&'ent i% a function of the gro,th of /no,ledge about the en$iron'ent in ,hich a child li$e%, hence the nece%%ity to %&end ti'e ex&laining a%&ect% of dental care to ne, child &atient% ; 6ig( (A<( Fi!. 2.0 S&end ti'e ex&laining the fact% about dental care( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.2.0 *an!-a!e de.elo ment 0 lac/ of the a&&ro&riate %ti'ulation ,ill retard a child*% learning, &articularly language( 0 child of : ,ho can only %&ea/ in 'ono%yllable% and ha% no %en%ible %entence %tructure ,ill not only be unable to co''unicate ,ith other% but ,ill be unable to thin/ about the thing% heD%he %ee% and hear%( Sti'ulation i% i'&ortant a% language de$elo&'ent i% %uch a ra&id &roce%% in childhood that any delay can %eriou%ly handica& a child( -e,born children %ho, a re'ar/able ability to di%tingui%h %&eech %ound% and by the age of : year% 'o%t children can u%e 999 or 'ore ,ord%( 3anguage and thought are tied together and are i'&ortant in cogniti$e de$elo&'ent,

but the co'&lexitie% of the relation%hi& bet,een the t,o are not ,ell under%tood( Denti%try ha% a highly %&eciali5ed $ocabulary and it i% unli/ely that 'any children, e$en adole%cent%, ,ill under%tand our 'eaning if ,e rely on +argon( The /ey to %ucce%%ful co''unication i% to &itch your ad$ice and in%truction% at +u%t the right le$el for different age grou&% of children( There i% a ri%/ of being &atroni5ing if e$ery child &atient i% told that *little &ixie% are eating a,ay tiny bit% of your tooth and ) a' going to run 'y little engine to frighten the' a,ay to fairyland*( 0 %treet,i%e =9 year old ,ho i% a co'&uter ga'e% officionado ,ould &robably call the &olice if you u%ed %uch languageI There i% no uni$er%al a&&roach to &atient%, %o careful treat'ent &lanning and a%%e%%'ent are reBuired before children or their &arent% are gi$en %&ecific ,ritten or $erbal ad$ice( 2.2.5 So"ial de.elo ment #ntil fairly recently it ,a% belie$ed that ne,born infant% ,ere indi$idual% ,ho %&ent 'o%t of their ti'e %lee&ing( 1o,e$er, recent re%earch re$eal% that babie% interact Buite 'ar/edly ,ith their en$iron'ent, often initiating interaction% ,ith other hu'an% by 'o$e'ent of their eye% or li'b%( 4abie% tend to for' %&ecific attach'ent% to &eo&le and are &rone to %e&aration anxiety( 0t about C 'onth% infant% %ho, a definite fear of %tranger%( Thi% &otential for anxiety %e&aration re'ain% high until about : year% of age ,hen %e&aration anxiety decline% Buite 'ar/edly( Thi% i% con%i%tent ,ith %tudie% of children in ho%&ital, ,hich %ho, that after the age of : there i% le%% di%tre%% on entering ho%&ital( Se&aration anxiety %hould al%o be con%idered by denti%t% ,ho in%i%t that all young children 'u%t enter the dental %urgery alone( Clearly, thi% ,ill cau%e %e$ere anxiety to &atient% under :( )t ha% been re&orted that a lo$ing, early &arental attach'ent i% a%%ociated ,ith a better %ocial ad+u%t'ent in later childhood and i% a good ba%i% for engendering tru%t and friend%hi& ,ith &eer%( Thi% i% i'&ortant a% a %ucce%%ful tran%ition fro' ho'e to %chool de&end% on the ability to interact ,ith other indi$idual% a&art fro' &arent%( The ho'e en$iron'ent ,ill &lay a 'a+or &art in %ocial de$elo&'ent, but the effect% of co''unity ex&ectation% %hould not be undere%ti'ated( We are all &roduct% of our broad %ocial en$iron'ent, 'ediated to %o'e extent by &arental influence%( 2.2.1 Adole#"en"e The ,aning of &arental influence can be %een in the final %tage of child de$elo&'ent, adole%cence( Thi% i% the end of childhood and the beginning of adulthood( )t i% conce&tuali5ed a% a &eriod of e'otional tur'oil and a ti'e of identity for'ation( Thi% $ie, i% a *We%tern* creation and i% culturally bia%ed( )n 'any %ocietie% *terrible teenager%* do not exi%tH childhood end% and adult re%&on%ibilitie% are offered at a relati$ely early age( )t i% intere%ting to note that e$en in We%tern indu%triali5ed %ocietie% there i% little real e$idence to %u&&ort the idea that the 'a+ority of adole%cent% are rebelliou% and nonconfor'i%t( The 'ain change i% the e$olution of a different %ort of &arental relation%hi&( There i% increa%ing inde&endence and %elf-%ufficiency( The re%earch doe%

%ho, that young &eo&le tend to be 'oody, are o$er%en%iti$e to critici%', and feel 'i%erable for no a&&arent rea%on but do not on the ,hole rebel again%t their &arental role 'odel%( There are %o'e clear 'e%%age% to denti%t% ,ho ,i%h to retain their adole%cent &atient%H don*t critici5e the' exce%%i$ely a% thi% 'ay co'&ro'i%e their future oral health( The%e &atient% are loo/ing for %u&&ort and rea%%urance( Many health &rofe%%ional% need to rethin/ their a%%u'&tion% about young &eo&le, a% &er%onal beha$iour &attern% are not really related to health i%%ue% at all( #ntil there are acute &roble'% *health per se* i% of little rele$ance to adole%cent% being a rather ab%tract conce&t( 6uture orientation i% lo, and the 'a+or i%%ue% of concern are finding e'&loy'ent, ex&loring their %exuality, and ha$ing the friend%hi& and %u&&ort of their &eer%( 2.3 PARENTS AND T5EIR INF*(ENCE &N DENTA* TREAT7ENT Children learn the ba%ic a%&ect% of e$eryday life fro' their &arent%, thi% &roce%% i% ter'ed %ociali5ation and i% an ongoing and gradual &roce%%( 4y the age of A year% children /no, 'any of the con$ention% current in their culture, %uch a% 'ale and fe'ale role%( The &roce%% of tran%'itting cultural infor'ation early in life i% called &ri'ary %ociali5ation( )n indu%triali5ed countrie%, obtaining infor'ation on 'any a%&ect% of life i% gained for'ally in %chool% and college% rather than fro' the fa'ily( Thi% i% ter'ed %econdary %ociali5ation( )ntere%tingly, &ri'ary %ociali5ation can ha$e a &rofound and la%ting effect( 6or exa'&le, fear of dental treat'ent and ,hen ,e fir%t begin to clean our teeth can often be traced bac/ to fa'ily influence( So &arent% can %ha&e a child*% ex&ectation% and attitude% about oral healthH thu%, e$ery atte'&t %hould be 'ade to in$ol$e the' ,hen atte'&ting to offer dental care or change a child*% health habit%( )n$ol$ing &arent% 'ean% that the denti%t 'u%t loo/ to &o%iti$e reinforce'ent rather than *$icti' bla'ing*( "arent% ,ho are accu%ed of oral neglect 'ay ,ell feel aggrie$ed or threatened( 0ll too often children*% oral health i% co'&ro'i%ed by a lac/ of &arental /no,ledge %o &rogra''e% ha$e to be carefully de%igned to reduce any chance% of 'a/ing &eo&le feel guilty( Guilt often re%ult% in &arent% %&ending 'ore ti'e in %ee/ing excu%e% for &roble'% than trying to i'&le'ent %olution%( "arent% ,ho are con$inced that their child ha% an oral health &roble' ,hich can be %ol$ed tend to react in a &o%iti$e ,ay, both to their dental ad$i%or and the &re$enti$e &rogra''e it%elf( )t i% e%&ecially hel&ful if the &re$enti$e %trategy can include a %y%te' of &o%iti$e reinforce'ent for the child ;6ig( (:<( 6eature% %uch a% bru%hing chart%, diet %heet%, gold %tar% for bru%hing ,ell, extra &oc/et 'oney for curtailing thu'b-%uc/ing are all u%eful ti&% to hel& &arent% 'aintain a child*% enthu%ia%' for a &articular dental &ro+ect( )t 'u%t be e'&ha%i5ed that &re$enti$e &rogra''e% 'u%t be carefully &lanned to include only one 'a+or goal at a ti'e( "arent% ,ill be unable to co&e if too 'uch i% ex&ected of the' at any one ti'e( "rogra''e% that in$ol$e fa'ilie% ha$e 'uch higher %ucce%% rate% than tho%e ,hich concentrate %olely on the &atient( )ntere%tingly, fa'ilie% al%o ha$e a &rofound influence on le$el% of dental anxiety a'ong their children( Dentally anxiou% 'other% ha$e children ,ho exhibit negati$e beha$iour at

the denti%t( 1ence, the need for denti%t% to loo/ *beyond* the child ,hen a%%e%%ing the rea%on% for dental anxiety( One of the great debate% in &aediatric denti%try centre% on ,hether &arent% %hould be allo,ed in the dental %urgery ,hile their child i% recei$ing treat'ent( 0 child*% fa'ily, it could be argued, can offer e'otional %u&&ort during treat'ent( There i% no doubt that ,ithin the 'edical field there i% great %u&&ort for the conce&t of a &arent actually *li$ing in* ,hile a child i% ho%&itali5ed( 1o,e$er, the i%%ue i% not %o clear-cut in denti%try ;6ig( (!<( The fir%t i%%ue that 'u%t be rai%ed i% ,hether denti%t% ha$e the ethicalD'oral right to bar &arent% fro' %itting in ,ith their children ,hen dental care i% being underta/en( Clearly, &arent% ha$e $ie,% and anxiety le$el% 'ay be rai%ed if &arent% feel their fa'ilial right% are being threatened and a child 'ay be %tre%%ed by ten%ion bet,een &arent% and the o&erator( Wright et al( ;=>C?< in their co'&rehen%i$e boo/ on child 'anage'ent %u''ari5e the ad$antage% of /ee&ing &arent% out of the %urgery a%G ;=< the &arent often re&eat% order%, creating an annoyance for both denti%t and child &atient ;6ig( (?<H ; < the &arent% interce&t order%, beco'ing a barrier to the de$elo&'ent of ra&&ort bet,een the denti%t and the childH ;@< the denti%t i% unable to u%e $oice intonation in the &re%ence of the &arent becau%e he or %he i% offendedH ;A< the child di$ide% attention bet,een the &arent and the denti%tH ;:< the denti%t di$ide% attention bet,een the &arent and the childH ;!< denti%t% are &robably 'ore relaxed and co'fortable ,hen the &arent re'ain% in the rece&tion area( The%e %ugge%tion% ha$e 'erit but they do ha$e a rather authoritarian feel to the', %tre%%ing the ordering and $oice intonation rather than %y'&athetic co''unication( "ractical re%earch to %u&&ort &arent% *in or out* of the %urgery i% not a$ailable to %ugge%t ,hether there i% a right or ,rong ,ay to handle thi% &articular Bue%tion( )n the end it i% a &er%onal deci%ion ta/en by the denti%t in the light of &arental concern% and clinical ex&erience( 0% in any branch of 'edicine there can be no *hard and fa%t* rule% for dealing ,ith the general &ublic, an adherence to any ty&e of dog'a *co'e ,hat 'ay* i% a reci&e for confrontation and %tre%%( Therefore, &arent% %itting in ,ith children %hould be a deci%ion ta/en for each indi$idual rather than i'&le'enting a */ee& &arent% out* &olicy( "atient% ,ith %&ecial need% reBuire a high degree of &arental in$ol$e'ent in oral health care, &articularly for tho%e children ,ith educational, beha$ioural, and &hy%ical difficultie%( 6or exa'&le, toothbru%hing i% a co'&lex cogniti$e and 'otor ta%/ ,hich ,ill tax the %/ill% of 'any handica&&ed children( 0 &arent ,ill ha$e to be taught ho, to 'onitor the efficiency of the &laBue re'o$al and inter$ene ,hen nece%%ary, to en%ure the 'outh i% cleaned adeBuately( Diet i% al%o i'&ortant, %o clear ad$ice 'u%t be offered and reinforce'ent &lanned at regular inter$al%(

Fi!. 2.5 "o%iti$e reinforce'ent i% i'&ortant( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2.1 Should ,e allo, &arent% into the %urgeryJ ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2.2 So'e &arent% can be $ery irritating by re&eating all your reBue%t%( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.0 DENTIST-PATIENT RE*ATI&NS5IP 2.0.0 Introd-"tion The ,ay a denti%t interact% ,ith &atient% ,ill ha$e a 'a+or influence on the %ucce%% of any clinical or &re$enti$e care( Clearly, only broad guideline% can be &re%ented on ho, to 'aintain an effecti$e relation%hi& ,ith a &atient, a% all of u% are uniBue indi$idual% ,ith different need% and a%&iration%( Thi% i% e%&ecially %o in &aediatric denti%try ,here a clinician 'ay ha$e to treat a frightened @-year-old child at one a&&oint'ent and an hour and a half later be faced ,ith the &roble' of offering &re$enti$e ad$ice on oral health to a recalcitrant =: year old( There are, ho,e$er, co''on re%earch finding% ,hich highlight the /ey i%%ue% that ,ill cau%e a denti%tD &atient con%ultation to founder or &rogre%% %ati%factorily( The fir%t Bue%tion that 'u%t be con%idered i% *Why 'e,hat factor% did the &arent% ta/e into account before 'a/ing an a&&oint'ent at 'y &racticeJ* The ob$iou% an%,er% are that your &ractice i% clo%e%t to the bu% %to&, ha% good &ar/ing, and you are the only one o&en after !(99 &('( Sur&ri%ingly, the choice i% not %o %i'&le( Mo%t &eo&le try to find out detail% about different dental &ractice% fro' friend% and colleague%( While the technical %/ill of the denti%t i% of %o'e concern, the 'o%t i'&ortant feature% &eo&le loo/ for are, a gentle friendly 'anner, ex&lain% treat'ent &rocedure%, and trie% to /ee& any &ain to a 'ini'u'( 0% ,ith any health i%%ue the %ocial cla%% bac/ground of the re%&ondent% influence% attitude% and belief%( 6or exa'&le, &arent% of high %ocioecono'ic %tatu% are 'ore intere%ted in &rofe%%ional co'&etence and gaining infor'ation, ,herea% &arent% fro' &oorer area% ,ant a denti%t to rea%%ure and be friendly to their child( So ,hich denti%t &arent% choo%e to offer care to their child ,ill de&end to %o'e extent on re&ort% about technical %/ill fro' fa'ily and friend%, but the 'a+or dri$ing force i% ,ell-de$elo&ed inter&er%onal %/ill%( 0 'a+or &oint to e'&ha%i5e i% that technical %/ill i% u%ually +udged in ter'% of caring and %y'&athy, a finding ,hich add% further ,eight to the i'&ortance of denti%t% de$elo&ing a good *chair- %ide 'anner*( Ex&lanation, *ta/ing the ti'e to tal/ u% through ,hat our child*% treat'ent ,ill entail*, i% another factor ,hich rate% highly, and 'ay actually influence the rate of attendance for follo,-u& a&&oint'ent%( 2.0./ Str-"t-re o+ t%e dental "on#-ltation To hel& %tudent% and ne, graduate% i'&ro$e their denti%tD&atient interaction %/ill% it i% &o%%ible to gi$e an outline %tructure to a %ucce%%ful dental con%ultation( The &ro&o%ed

'odel con%i%t% of %ix %tage%, and i% ba%ed on the ,or/ of Wanle%% and 1ollo,ay ;=>>A<( =( Greeting( The denti%t greet% the child by na'e( 0$oid u%ing generali5ed ter'% %uch a% *1i %onny, hello %un%hine*, ,hich are general rather than %&ecific to the &atient ;6ig( (C<( )f &arent% are &re%ent then include the' in the con$er%ation, but do not forget that the child %hould be central to the de$elo&ing relation%hi&( 0 greeting can be %&oilt by &roceeding too Buic/ly to an in%truction rather than an in$itation( 6or exa'&le, *1ello Sarah, +u'& in the chair* i% rather abru&t and 'ay &re+udice an interacti$e relation%hi&( The greeting %hould be u%ed to &ut the child and &arent% at ea%e before &roceeding to the next %tage( ( Preliminary chat( Thi% &ha%e ha% three ob+ecti$e%, to a%%e%% ,hether the &atient or &arent% ha$e any &articular ,orrie% or concern%, to %ettle the &atient into the clinical en$iron'ent, and to a%%e%% the &atient*% e'otional %tate( The follo,ing %eBuence re&re%ent% one ,ay of 'axi'i5ing the effect of the *&reli'inary chat*G ;a< 4egin ,ith non-dental to&ic%( 6or children ,ho ha$e been before it i% hel&ful to record u%eful infor'ation %uch a% the na'e% of brother%D%i%ter%, %chool, &et%, and hobbie%( ;b< 0%/ an o&en Bue%tion %uch a%, *1o, are youDare you ha$ing any &roble'% ,ith your teethJ* 3i%ten to the an%,er and &robe further if nece%%ary( 0ll too often denti%t% a%/ Bue%tion% and then ignore the an%,erI 4y tal/ing generally and ta/ing note of ,hat the child i% %aying you are offering a degree of control and reducing anxiety( @( Preliminary explanation( )n thi% %tage the ai' i% to ex&lain ,hat the clinical or &re$enti$e ob+ecti$e% are in ter'% that &arent% and children ,ill under%tand( Thi% i% a $ital &art of any $i%it a% it e%tabli%he% the credibility of the denti%t a% %o'eone ,ho /no,% ,hat the ulti'ate goal for the treat'ent i%, and i% &re&ared to ta/e the ti'e and trouble to di%cu%% it in non-technical language( While not ,i%hing to labour the &oint, it 'u%t be %tre%%ed that %en%ible infor'ation cannot be offered to the &atient or &arent% until the clinician ha% a full hi%tory and a treat'ent &lan ba%ed on adeBuate infor'ation( Thi% reBuire% a broad $ie, of the &atient and %hould not be totally tooth-centred( )t i% all too ea%y to lo%e the confidence of &arent% and children if you find your%elf 'a/ing excu%e% for clinical deci%ion% ta/en in a hurried and un%cientific 'anner( Thu% the &reli'inary chat %et% the %cene &rior to actual clinical acti$ity( A( $usiness( The &atient i% no, in danger of beco'ing a &a%%i$e ob+ect ,ho i% ,or/ed on rather than being in$ol$ed in the treat'ent( Many +o/e% are 'ade about denti%t% ,ho a%/ Bue%tion% of &atient% ,ho are unable to re&ly becau%e of a 'outhful of in%tru'ent%I ;6ig( (><( Thi% doe% not 'ean that the $i%it %hould enter a %ilent &ha%e( )t i% i'&ortant to re'ain in $erbal contact( Chec/ the &atient i% not in &ain, di%cu%% ,hat you are doing, u%e the &atient*% na'e to %ho, a *&er%onal* intere%t, and clarify any 'i%under%tanding%(

0t the end of the bu%ine%% %tage it i% hel&ful to %u''ari5e ,hat ha% been done and offer aftercare ad$ice( )f the &arent i% not &re%ent in the %urgery, the treat'ent %u''ary i% &articularly i'&ortant, a% it i% a u%eful ,ay of 'aintaining contact ,ith the &arent%( :( Health education( Oral health i%, to a large extent, de&endent u&on &er%onal beha$iour and a% %uch it ,ould be unethical for denti%t% not to include ad$ice on 'aintaining a healthy 'outh( 0lthough offering ad$ice to &arent% and &atient% i% u%eful, in 'any in%tance% the &rofe%%ion treat health education in a *thro,a,ay* 'anner( Thi% re%ult% in both &atient% and denti%t% being di%a&&ointed( The /ey ,ay% to i'&ro$e the $alue of ad$ice %e%%ion% are a% follo,%G ;a< Ma/e the ad$ice %&ecific, gi$e a child a &er%onal &roble' to %ol$e( ;b< Gi$e %i'&le and &reci%e infor'ation( ;c< Do not %ugge%t goal% of beha$iour change ,hich are beyond a &atient*% ca&acity to achie$e( ;d< Chec/ the 'e%%age ha% been under%tood and not 'i%inter&reted( ;e< Offer ad$ice in %uch a ,ay that the child and &arent% are not threatened or bla'ed( ;f< )f you are trying to i'&ro$e oral hygiene a$oid theoretical di%cu%%ion%, offer a &ractical de'on%tration( ;g< 0t follo,-u& $i%it% reinforce the ad$ice and offer &o%iti$e reinforce'ent( The final &art of the health education acti$ity i% goal %etting( The denti%t %et% out in %i'&le ter'% ,hat the &atient %hould try and achie$e by the next $i%it( )t i'&lie% a for' of contract and a% %uch hel&% both children and &arent% to gain a clearer in%ight into ho, they all can hel& to i'&ro$e the child*% oral health( Goal %etting 'u%t be u%ed %en%ibly( )f goal% are 'anife%tly i'&o%%ible then &arent% and child &atient% beco'e di%illu%ioned( "arent% feel that the denti%t doe% not under%tand their &roble'% and co'&lain that they are being bla'ed for any dental %hortco'ing%( So al,ay% en%ure that you &lan goal %etting carefully in a &o%iti$e and friendly 'anner( !( Dismissal( Thi% i% the final &art of the $i%it and %hould be clearly %ign&o%ted %o that e$eryone /no,% that the a&&oint'ent i% o$er( The &atient %hould be addre%%ed by na'e and a definite fare,ell offered ;6ig( (=9<( The ob+ecti$e %hould be to en%ure that ,here$er &o%%ible the &atient and &arent% lea$e ,ith a %en%e of good,ill( Clearly, not all a&&oint'ent %e%%ion% can be di%%ected into the%e %ix %tage%( 1o,e$er, the ba%ic ele'ent of according the &atient the 'axi'u' attention and &er%onali5ing your co''ent% %hould ne$er be forgotten( Fi!. 2.3 0l,ay% greet your &atient by na'e( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2.4 )% your &atient +u%t a 'outhful of in%tru'ent%J ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< Fi!. 2./0 Ma/e %ure you offer your &atient a definite fare,ell( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(<

2.5 AN'I&(S AND (NC&&PERATI)E C5I*DREN Dental anxiety %hould concern u% a% a &rofe%%ion becau%e it not only &re$ent% 'any &otential &atient% fro' %ee/ing care but it al%o cau%e% %tre%% to the denti%t% underta/ing dental treat'ent( )ndeed one of the 'a+or %ource% of %tre%% for general dental &ractitioner% i% *co&ing ,ith difficult &atient%* ;6ig( (==<( Denti%t% do not ,ant to be con%idered a% &eo&le ,ho inflict unnece%%ary anxiety on the general &ublic( 1o,e$er, anxiety and dental care %ee' to be loc/ed in the general fol/lore of 'any countrie%( )n order to under%tand ,hy, it i% hel&ful to con%ider *,hat i% the nature of anxiety*( Many definition% of anxiety ha$e been %ugge%ted and it i% a %o'e,hat daunting ta%/ to reconcile the'( 1o,e$er, it ,ould %ee' %en%ible to con%ider the co''ent% of 2ent ;%ee 2ent and 4lin/horn =>>=< ,ho re&orted that anxiety i% *a $ague un&lea%ant feeling acco'&anied by a &re'onition that %o'ething unde%irable i% going to ha&&en*( )n other ,ord% it relate% to ho, &eo&le feela %ub+ecti$e definition( 0nother &oint of $ie, i% that anxiety 'anife%t% it%elf in beha$iour( )f, for exa'&le, a &er%on i% anxiou%, then %heDhe ,ill act in a &articular 'anner( 0 &er%on ,ill a$oid $i%iting the denti%t( Thu%, anxiety %hould be %een a% a 'ulti- factorial &roble' 'ade u& of a nu'ber of different co'&onent%, all of ,hich can exert an effect( 0nxiety 'u%t al%o be %een a% a continuu' ,ith fearit i% al'o%t i'&o%%ible to %e&arate the t,o in 'uch of the re%earch underta/en in the field of denti%try, ,here the t,o ,ord% are u%ed interchangeably( One could con%ider that anxiety i% 'ore a general feeling of di%co'fort, ,hile fear i% a %trong reaction to a %&ecific e$ent( -e$erthele%% it i% counter&roducti$e to %earch for elu%i$e definition% a% both fear and anxiety are a%%ociated ,ith dental $i%iting and treat'ent( 6ro' a co''on-%en%e &oint of $ie, it i% clear that %o'e %ituation% ,ill arou%e 'ore anxiety than other%( 6or exa'&le, a fear of height% i% relati$ely co''on, but it i% galling to note that in the #nited State% a %tudy by 0gra% et al( ;=>!>< found that $i%iting the denti%t ran/ed fourth behind %na/e%, height%, and %tor'%( Clearly then, anxiety about dental care i% a &roble' that ,e a% a &rofe%%ion 'u%t ta/e %eriou%ly, e%&ecially a% children re'e'ber &ain and %tre%% %uffered at the denti%t and carry the e'otional %car% into adult life( So'e &eo&le 'ay de$elo& %uch a fear of denti%try that they are ter'ed &hobic%( 0 &hobia i% an inten%e fear ,hich i% out of all &ro&ortion to the actual threat( Re%earch in thi% area %ugge%t% that the extent of anxiety a &er%on ex&erience% doe% not relate directly to dental /no,ledge, but i% an a'alga'ation of &er%onal ex&erience%, fa'ily concern%, di%ea%e le$el%, and general &er%onality trait%( Such a co'&lex %ituation 'ean% that it i% no ea%y ta%/ to 'ea%ure dental anxiety and &in&oint aetiological agent%( Mea%uring dental anxiety i% &roble'atic becau%e it relie% on %ub+ecti$e 'ea%ure%, &lu% the influence of the &arent%, the denti%t*% beha$iour, and the rea%on for a $i%it 'ay all exert %o'e effect on a child*% anxiety le$el%( Kue%tionnaire% and rating %cale% are the 'o%t co''only u%ed 'ean% by ,hich anxiety ha% been Buantified, although there ha% been %o'e intere%t in &hy%iological data %uch

a% heart rate( So'e Bue%tionnaire% that ha$e been u%ed to 'ea%ure anxiety can be a&&lied to a ,hole $ariety of %ituation%, %uch a% recording *exa' ner$e%* or fear of %&ider%, ,hile other% are %&ecific to the dental %ituation( The 'o%t ,idely u%ed dental anxiety 'ea%ure i% Corah*% Dental 0nxiety Scale ;%ee 2ent and 4lin/horn =>>=<, ,hich ta/e% the for' of a Bue%tionnaire( "atient% are a%/ed to choo%e an an%,er ,hich be%t %u'% u& their feeling%( The an%,er% are %cored fro' = to : %o that a total %core can be co'&uted( 0 high %core %hould alert the dental tea' that a &articular &atient i% $ery anxiou%( 1o,e$er, &atient-ad'ini%tered Bue%tionnaire% ha$e a li'ited $alue in e$aluating a young child*% anxiety becau%e of their &oorly de$elo&ed $ocabulary and under%tanding( Therefore there ha% been great intere%t in 'ea%uring anxiety by ob%er$ing beha$iour( One %uch %cale ,a% de$elo&ed by 6ran/l to a%%e%% the effect of a &arent re'aining ,ith a child in the %urgery ;%ee 2ent and 4lin/horn =>>=<( )t con%i%t% of four rating% fro' definitely negati$e to definitely &o%iti$e( )t i% %till co''only u%ed in &aediatric dental re%earch( 0nother %cale ,hich i% &o&ular ,ith re%earcher% i% one u%ed by 1ou&t, ,hich 'onitor% beha$iour by allocating a nu'erical %core to ite'% %uch a% body 'o$e'ent and crying ;%ee 2ent and 4lin/horn =>>=<( Recent %tudie% ha$e u%ed the 6ran/l %cale to %elect %ub+ect% for %tudie%, and then 'ore detailed beha$iour e$aluation %y%te'% are utili5ed to 'onitor the co'&liance ,ith treat'ent ;%ee 2ent and 4lin/horn =>>=<( 4eha$ioural ob%er$ation re%earch can be &roble'atical a% the &re%ence of an ob%er$er in the %urgery 'ay u&%et the &atient( )n addition, it i% difficult to be totally ob+ecti$e ,hen different co&ing %trategie% are being u%ed and %o'e bia% ,ill occur( The de$elo&'ent of chea& light,eight digital or $ideo ca'era% ha% greatly hel&ed ob%er$ational re%earch, a% the &atient*% beha$iour can be %cored by a nu'ber of rater% a,ay fro' the %urgery( Re%coring the $ideo% i% al%o &o%%ible to chec/ the reliability of the index u%ed( "hy%iological 'ea%ure'ent% %uch a% a higher &ul%e rate, &er%&iration, and &eri&heral blood flo, ha$e been u%ed to Buantify children*% dental anxiety( 1o,e$er, fe, &hy%iological %ign% are %&ecific to one &articular e'otion and the 'ea%uring techniBue% often &ro$o/e anxiety in the child &atient, %o they are rarely u%ed( 0% yet, there i% no %tandard 'ea%ure of dental anxiety for children a% the re&roducibility and reliability of 'o%t Bue%tionnaire% ha$e not been de'on%trated, &lu% ob%er$ational and &hy%iological indice% are not ,ell de$elo&ed( Thi% i% a %eriou% &roble' a% the a%%e%%'ent of %trategie% to reduce anxiety i% %o'e,hat co'&ro'i%ed by a lac/ of uni$er%ally acce&ted 'ea%uring techniBue%( Fi!. 2.// Difficult &atient% can be a %ource of %tre%%I ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.1 5E*PIN6 AN'I&(S PATIENTS T& C&PE 8IT5 DENTA* CARE 2.1.0 Introd-"tion 0 nu'ber of theorie% ha$e been %ugge%ted in an effort to ex&lain the de$elo&'ent of anxiety( #ncertainty about ,hat i% to ha&&en i% certainly a factor, a &oor &a%t ex&erience ,ith a denti%t could u&%et a &atient, ,hile other% 'ay learn anxiety

re%&on%e% fro' &arent%, relation%, or friend%( 0 denti%t ,ho can alle$iate anxiety or &re$ent it ha&&ening in the fir%t &lace ,ill al,ay% be &o&ular ,ith &atient%( Clearly, the ea%ie%t ,ay to control anxiety i% to e%tabli%h an effecti$e &re$enti$e &rogra''e %o that children do not reBuire any treat'ent( )n addition to an effecti$e &re$enti$e regi'en it i% i'&ortant to e%tabli%h a tru%ting relation%hi&, li%tening to a child*% %&ecific ,orrie% and concern%( E$ery effort 'u%t be ta/en to en%ure that any treat'ent i% &ain-free( 0ll too often ,e forget that local analge%ia reBuire% ti'e and &atience( With the u%e of a to&ical anae%thetic &a%te and %lo, relea%e of the anae%thetic %olution 'o%t *in+ection%* %hould be &ainle%%( There i% no excu%e for the *%tab and %Buirt 'ethod* ;6ig( (= <( Children are not *little adult%*, they are $ulnerable and afraid of ne, %urrounding% %o effecti$e ti'e 'anage'ent i% i'&ortant( Try to %ee young &atient% on ti'e and do not %tre%% your%elf or the child by ex&ecting to co'&lete a clinical ta%/ in a %hort ti'e on an a&&rehen%i$e &atient( De%&ite the dental tea'*% be%t effort% anxiety 'ay &er%i%t and routine dental care i% co'&ro'i%ed( Other o&tion% ,ill then ha$e to be con%idered to hel& the child( 0n increa%ingly &o&ular choice i% the u%e of &har'acological agent%H the%e ,ill be di%cu%%ed in Cha&ter A( The alternati$e% to the &har'acological a&&roach areG ;=< reducing uncertaintyH ; < 'odellingH ;@< cogniti$e a&&roache%H ;A< relaxationH and ;:< %y%te'atic de%en%iti5ation( ;!< hand o$er 'outh exerci%e ;1OME<( The%e are di%cu%%ed in 'ore detail belo,( Fi!. 2./2 Stab and %Buirt ha% no &lace in our anae%thetic techniBue( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.1./ Red-"in! -n"ertaint$ The 'a+ority of young children ha$e $ery little idea of ,hat dental treat'ent in$ol$e% and thi% ,ill rai%e anxiety le$el%( Mo%t children ,ill co&e if gi$en friendly rea%%urance fro' the denti%t, but %o'e &atient% ,ill need a 'ore %tructured &rogra''e( One %uch %tructured 'ethod i% the tell-%ho,-do techniBue( 0% it% na'e i'&lie% it centre% on three &ha%e%G =( -ellG ex&lanation of &rocedure% at the right ageDeducational le$el( ( #howG de'on%trate the &rocedure( @( DoG follo,ing on to underta/e the ta%/( "rai%e being an e%%ential &art of the exerci%e ;6ig( (=@<(

While it i% a &o&ular techniBue there i% little ex&eri'ental ,or/ to %u&&ort it% u%e( 0nother techniBue to reduce anxiety a'ong $ery ,orried children i% to %end a letter ho'e ex&laining all the detail% of the &ro&o%ed fir%t $i%it %o that uncertainty ,ill be reduced( The e$idence for thi% a&&roach i% not clear-cut a% &arental anxiety i% changed by &reinfor'ation rather than the child*%( 0ccli'ati5ation &rogra''e% gradually introducing the child to dental care o$er a nu'ber of $i%it% ha$e been %ho,n to be of $alue( Thi% a&&roach i% rather ti'e con%u'ing and doe% little for the really ner$ou% child( Fi!. 2./3 "rai%e co%t% little, but doe% %ho, you to be a caring &er%on( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.1.2 7odellin! Thi% 'a/e% u%e of the fact that indi$idual% learn 'uch about their en$iron'ent fro' ob%er$ing the con%eBuence% of other &eo&le*% beha$iour( .ou or ) 'ight re&eat an action if ,e %ee other% being re,arded, or if %o'eone i% &uni%hed ,e 'ight ,ell decide not to follo, that beha$iour( Modelling could be u%ed to alle$iate anxiety( )f a child could be %ho,n that it i% &o%%ible to $i%it the denti%t, ha$e treat'ent, and then lea$e in a ha&&y fra'e of 'ind ;6ig( (=A<, thi% could reduce anxiety due to *fear of the un/no,n*( 0 child ,ould %ee behind that forbidding %urgery doorI )t i% not nece%%ary to u%e a li$e 'odel, $ideo% of co-o&erati$e &atient% are of $alue( 1o,e$er, the follo,ing &oint% %hould be ta/en into con%ideration ,hen %etting u& a &rogra''e( =( En%ure that the 'odel i% clo%e in age to the ner$ou% child or children in$ol$ed( ( The 'odel %hould be %ho,n entering and lea$ing the %urgery to &ro$e treat'ent ha% no la%ting effect( @( The denti%t %hould be %ho,n to be a caring &er%on ,ho &rai%e% the &atient( Fi!. 2./0 We ,ant our &atient% to lea$e u% in a ha&&y fra'e of 'ind( ;With than/% to Da$id Myer% and /ind &er'i%%ion of Eden 4ianchi "re%%(< 2.1.3 Co!niti.e a roa"%e#

Modelling hel&% &eo&le learn about dental treat'ent fro' ,atching other%, but it doe% not ta/e account of an indi$idual*% *cognition%* or thought%( "eo&le 'ay heighten their anxiety by ,orrying 'ore and 'ore about a dental &roble' %o creating a $iciou% reinforcing circle( Thu% there ha% been great intere%t in trying to get indi$idual% to identify and then alter their dy%functional belief%( 0 nu'ber of cogniti$e 'odification techniBue% ha$e been %ugge%ted, the 'o%t co''on one% includingG ;=< a%/ing &atient% to identify and 'a/e a record of their negati$e thought%H ; < hel&ing &atient% to recogni5e their negati$e thought% and %ugge%ting 'ore &o%iti$e alternati$e%*reality ba%ed*H

;@< ,or/ing ,ith a thera&i%t to identify and change the 'ore dee&-%eated negati$e belief%( Cogniti$e thera&y i% u%eful for focu%ed ty&e% of anxietyhence it% $alue in co'bating dental anxiety( 0nother a&&roach that could be con%idered a cogniti$e a&&roach i% di%traction( Thi% techniBue atte'&t% to %hift attention fro' the dental %etting to,ard% %o'e other /ind of %ituation( Di%tracter% %uch a% $ideota&ed cartoon% and %torie% ha$e been u%ed to hel& children co&e ,ith dental treat'ent( The re%ult% ha$e been %o'e,hat eBui$ocal and the threat to %,itch off the $ideo ,a% needed to 'aintain co-o&eration( 2.1.0 Rela9ation Relaxation training i% of $alue ,here &atient% re&ort high le$el% of ten%ion, and con%i%t% of bringing about dee& 'u%cular relaxation( )t ha% al%o been u%ed in con+unction ,ith biofeedbac/ training( 0% the techniBue% reBuire the &re%ence of a trained thera&i%t, the &otential $alue in general &aediatric denti%try ha% %till to be a%%e%%ed( 2.1.5 S$#temati" de#en#iti:ation The ba%ic &rinci&le of thi% treat'ent con%i%t% of allo,ing the &atient gradually to co'e to ter'% ,ith a &articular fear or %et of fear% by ,or/ing through $ariou% le$el% of the feared %ituation, fro' the *'ilde%t* to the *'o%t anxiety* &rogra''e( Thi% techniBue relie% on the u%e of a trained thera&i%t and in 'o%t in%tance% a %i'&le dentally ba%ed accli'ati5ation &rogra''e %hould be tried fir%t( 2.1.1 5and o.er mo-t% e9er"i#e (5&7E) The &hy%ical re%traint of children in order to underta/e clinical dental care ha% &ro'&ted 'uch debate( 1o%ey ; 99 < and Manley ; 99A< note that in the #nited 2ingdo' the u%e of &hy%ical re%traint i% &re%ently unacce&table( 1o,e$er, %o'e author% are %ugge%ting ;Connic/ et al , 999H 2u&iet%/y, 99A< that re%traint in co'bination ,ith inhalation %edation 'ay be a hel&ful &rocedure if general anae%the%ia i% not readily a$ailable( )n thi% %ection other o&tion% to re%traint ha$e been %ugge%ted and, although ti'e con%u'ing, are li/ely to &ro$o/e le%% of a ner$ou% reaction and a$oid a%%ociating dental care ,ith an un&lea%ant ex&erience( 6or tho%e reader% ,ho ,i%h to %tudy the to&ic in 'ore detail, co'&rehen%i$e clinical guideline% collated by The 0'erican 0cade'y of "aediatric Denti%try ha$e been &ubli%hed in the +ournal of Paediatric Dentistry ; 99 <( 2.2 SYN&PSIS &F T5E 6(IDE*INES ;Y T5E A7ERICAN ACADE7Y &F PAEDIATRIC DENTISTRY &N ;E5A)I&(R 7ANA6E7ENT 2.2.0 Introd-"tion

To hel& tho%e reader% ,ho ,i%h to ha$e an o$er$ie, of the /ey ele'ent% in the guideline%, a brief %u''ary of the ob+ecti$e% and indication%Dcontraindication% for a nu'ber of beha$iour 'anage'ent techniBue%, a$ailable to dental &ractitioner%, are li%ted( 2.2./ Comm-ni"ation mana!ement =( 8oice control i% a controlled alteration of $oice $olu'e, tone, or &ace to influence and direct the &atient*% beha$iour( 8,9ectivesG ;i< To gain the &atient*% attention and co'&liance( ;ii< To a$ert negati$e or a$oidance beha$iour( ;iii< To e%tabli%h a&&ro&riate adult-child role%( IndicationsG May be u%ed ,ith any &atient( ContraindicationsG -one( ( -on-$erbal co''unication i% the reinforce'ent and guidance of beha$iour through a&&ro&riate contact, &o%ture, and facial ex&re%%ion( 8,9ectivesG ;i< To enhance the effecti$ene%% of other co''unicati$e 'anage'ent techniBue%( ;ii< To gain or 'aintain the &atient*% attention and co'&liance( IndicationsG May be u%ed ,ith any &atient( ContraindicationsG -one( @( Tell-%ho,-do i% a techniBue of beha$iour %ha&ing u%ed ,ith both $erbal and non$erbal co''unication( 8,9ectivesG ;i< To teach the &atient i'&ortant a%&ect% of the dental $i%it and fa'iliari5e the &atient ,ith the dental %etting( ;ii< To %ha&e the &atient*% re%&on%e to &rocedure% through de%en%iti5ation and ,ellde%cribed ex&ectation%( IndicationsG May be u%ed ,ith any &atient( ContraindicationsG -one( A( "o%iti$e reinforce'ent i% the &roce%% of e%tabli%hing de%irable &atient beha$iour through a&&ro&riate feedbac/( 8,9ectivesG

;i< To reinforce de%ired beha$iour( IndicationsG May be u%eful for any &atient( ContraindicationsG -one( :( "arental &re%enceDab%ence in$ol$e% either allo,ing or re'o$ing the &arent;%< fro' the dental %urgery in order to gain coo&eration( 8,9ectivesG ;i< To gain the &atient*% attention and co'&liance( ;ii< To a$ert negati$e or a$oidance beha$iour%( ;iii< To e%tabli%h a&&ro&riate adult-child role%( ;i$< To enhance the co''unication en$iron'ent( IndicationsG May be u%ed ,ith any &atient( ContraindicationsG -one( !( 1and o$er 'outh exerci%e i% a techniBue for 'anaging un%uitable beha$iour that cannot be 'odified by the 'ore %traightfor,ard techniBue%( )t i% often u%ed ,ith inhalation %edation ;con%ciou% %edation<( 8,9ectivesG ;i< To redirect the child*% attention, enable co''unication ,ith the denti%t %o that a&&ro&riate beha$ioural ex&ectation% can be ex&lained( ;ii< To extingui%h exce%%i$e a$oidance beha$iour and hel& the child regain %elfcontrol( ;iii< To en%ure the child*% %afety in the deli$ery of Buality dental treat'ent( ;i$< To reduce the need for %edation or general anae%the%ia( IndicationsG ;i< 0 healthy child ,ho i% able to under%tand and co-o&erate, but ,ho exhibit% ob%tre&erou% or hy%terical a$oidance beha$iour%( ContraindicationsG ;i< )n children ,ho, due to age, di%ability, 'edication, or e'otional i''aturity are unable to $erbally co''unicate, under%tand, and co-o&erate( ;ii< 0ny child ,ith an air,ay ob%truction( Other techniBue% %uch a% %edation in all it% for'% and general anae%the%ia are de%cribed el%e,here( 2.3 S(77ARY

=( To &re$ent the de$elo&'ent of anxiety it i% 'ore i'&ortant to 'aintain tru%t than concentrate on fini%hing a clinical ta%/( ( The reduction in dental carie% 'ean% that children ,ith %&ecial &%ychological, 'edical, and &hy%ical need% can be offered the oral health care they reBuire( We are not being %,a'&ed by o$er,hel'ing clinical de'and( @( The care of children ,ho are $ery anxiou% can be i'&ro$ed by u%ing the techniBue% de%cribed in thi% cha&ter( A( "re$enting dental di%ea%e %hould al,ay% be gi$en the %a'e %tatu% a% clinical inter$ention( 1o,e$er, it i% i'&ortant to en%ure that &re$enti$e care i% a&&ro&riate and rele$ant( The /ey 'e%%age% are outlined in -he scientific ,asis of oral health education ;3e$ine and Still'an-3o,e, 99A<( 2.4 F(RT5ER READIN6 4lin/horn, 0( S( and Mac/ie, )( C( ;=>> <( -reatment planning for the paedodontic patient( Kuinte%%ence, 3ondon( ;-here is a comprehensive :uestion and answer section in this ,oo% which will help you chec% up on your treatment planning %nowledge(< 6ree'an, R( ;=>>><( The deter'inant% of dental health attitude% and beha$iour%( $ritish Dental +ournal, /32, =:-=C( ;-his paper examines the role of psychosocial factors on health ,ehaviour; and case<,ased examples highlight the psychology of patient care in a practical way(< 1u'&hri%, G( M(, Mil%o', 2(, Tic/le, M(, 1olbroo/, 1(, and 4lin/horn, 0( S( ; 99 <( 0 ne, dental anxiety %cale for : year old children ;D0:<G de%cri&tion and concurrent $alidity( Health 7ducation +ournal, 1/, :-=>( ;-his paper descri,es the development of a new dental anxiety scale for children and highlights the %ey elements associated with measuring anxiety(< Rutter, M( and Rutter, M( ;=>>@<( Developing minds( "enguin 4oo/%, 3ondon( ;" fascinating insight into how we develop throughout life(< Wein'an, 7( ;=>C?<( "n outline of psychology as applied to medicine ; nd edn<, &&( =@ -A( 4utter,orth-1eine'an, 3ondon( ;-his ,oo% is for those students who want to ta%e a ,roader view on the su,9ect of psychology and medicine(< 2./0 REFERENCES 0gra%, S(, Syl$e%ter, D(, and Oli$eau, D( ;=>!><( The e&ide'iology of co''on fear% and &hobia%( Comprehensive Psychiatry, /0, =:=-:!( ;-his paper will show you that fear of dentistry is a pro,lem the dental profession must ta%e seriously(< Clinical guideline on beha$iour 'anage'ent ; 99 <( +ournal of Paediatric Dentistry, 20, !C-?@( ;"n "merican perspective on ,ehaviour management in paediatric dentistry(<

Connic/, C(, "alat, M(, and "ulie%e, S( ; 999<( The a&&ro&riate u%e of &hy%ical re%traint%G con%ideration%( +ournal of Dentistry for Children, 12, :!-! ( ;" useful discussion on the role of restraint in clinical paediatric dental practice(< 1o%ey, M( T( ; 99 <( Managing anxiou% childrenG the u%e of con%ciou% %edation in &aediatric denti%try( International +ournal of Paediatric Dentistry, /2, @:>-? ( ;" useful guide to managing anxious children(< 2ent, G( G( and 4lin/horn, 0( S( ;=>>=<( -he psychology of dental care ; nd edn<( Wright, 4ri%tol( ;-his short ,oo% highlights the important psychological aspects of providing clinical care; as well as giving details of the Houpt; 1ran%l; and Corah dental anxiety scales(< 2u&iet5/y, 0( ; 99A<( Stra& hi' do,n or /noc/ hi' outG i% con%ciou% %edation ,ith re%traint an alternati$e to general anae%the%iaJ $ritish Dental +ournal, /41, =@@-C( ;" discussion on the role of conscious sedation allied to the use of restraint in paediatric dentistry(< 3e$ine, R( S( and Still'an-3o,e, C( ; 99A<( -he scientific ,asis of oral health education( 4D7 4oo/%, 3ondon ;" comprehensive guide to dental health education and promotion; including the %ey preventive messages(< Manley, M( C( G( ; 99A<( 0 #2 &er%&ecti$e( $ritish Dental +ournal, /41, =@C->( ;" view on the use of H8(7 in the United 0ingdom(< Wanle%%, M( 4( and 1ollo,ay, "( 7( ;=>>A<( 0n analy%i% of audio-recording% of general dental &ractitioner%* con%ultation% ,ith adole%cent &atient%( $ritish Dental +ournal, /22, >A-C( ;-his article gives advice on how to improve communication s%ills in the surgery and reminds clinicians that our livelihood depends on effective communication(< Wright, G(, Star/ey, "( E(, Gardener, D( E(, and Cur5on, M( E( 7( ;=>C?<( Child management in dentistry( Wright, 4ri%tol( ;" detailed account of child management; including advice on how to introduce different clinical techni:ues(< Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

3. 5i#tor$< e9amination< ri#= a##e##ment< and treatment lannin! ( L Hunter and H D )odd 3./ INTR&D(CTI&N The &ro$i%ion of dental care for children &re%ent% %o'e of the greate%t challenge% ;and re,ard%< in clinical dental &ractice( 1igh on the li%t of challenge% i% the need to de$i%e a co'&rehen%i$e yet reali%tic treat'ent &lan for the%e young &atient%( Succe%%ful outco'e% are $ery unli/ely in the ab%ence of thorough %hort- and longter' treat'ent &lanning( 6urther'ore, deci%ion-'a/ing for children ha% to ta/e into account 'any 'ore factor% than i% the ca%e for adult%( Thi% cha&ter ai'% to highlight ho, hi%tory-ta/ing, exa'ination, and ri%/ a%%e%%'ent are all critical %tage% in the treat'ent &lanning &roce%%( "rinci&le% of good treat'ent &lanning ,ill al%o be outlined( 3.2 C&NSENT Con%ent to exa'ination, in$e%tigation, or treat'ent i% funda'ental to the &ro$i%ion of dental care( The 'o%t i'&ortant ele'ent of the con%ent &rocedure i% en%uring that the &atientD&arent under%tand% the nature and &ur&o%e of the &ro&o%ed treat'ent, together ,ith any alternati$e% a$ailable, and the &otential benefit% and ri%/%( )n thi% context, ,here clinician and &atientD&arent do not %hare a co''on language, the a%%i%tance of an inter&reter i% e%%ential( >e$ Point 0 %ignature on a con%ent for' i% not con%ent if the &atientD&arent ha% not been gi$en and under%tood the rele$ant infor'ation( )n the #nited 2ingdo', for the &ur&o%e% of 'edical and dental treat'ent, a child i% defined a% being le%% than =! year% of age( )f a child i% %ub+ected to exa'ination, in$e%tigation, or treat'ent ,ithout the con%ent of an indi$idual ,ho ha% &arental re%&on%ibility, thi% can con%titute an a%%ault, actionable in ci$il or cri'inal la, a% a breach of the hu'an right( While 'o%t children ,ill attend the dental %urgery acco'&anied by an adult, it i% i'&ortant to bear in 'ind that thi% indi$idual ,ill not al,ay% ha$e &arental re%&on%ibility ;the Children 0ct =>C> %et% out the &er%on% ,ho 'ay ha$e &arental re%&on%ibility for a child<( >e$ Point )t i% e%%ential to e%tabli%h ,hat relation%hi& exi%t% bet,een the child and the acco'&anying adult at the out%et( 6o%ter &arent% do not auto'atically ha$e &arental re%&on%ibility( )n circu'%tance% ,here a child i% a ,ard of Court, the &rior con%ent of the Court i% reBuired for %ignificant inter$ention%( )n an e'ergency, it i% +u%tifiable to treat a child ,ithout the con%ent of the &er%on ,ith &arental re%&on%ibility if the treat'ent i% $ital to the health of the child( 6or exa'&le, ,hile it 'ay be acce&table to re&lant an a$ul%ed &er'anent inci%or, the &arent %hould

be contacted before &roceeding to other for'% of treat'ent( #%ing the &rinci&le of Gillic/ co'&etence, a child under the age of =! year% can gi$e $alid con%ent &ro$ided that the clinician con%ider% hi' or her to be 'ature enough to fully under%tand the &ro&o%ed inter$ention( 1o,e$er, a% the under%tanding reBuired for different inter$ention% ,ill $ary, a child aged le%% than =! year% 'ay ha$e the ca&acity to con%ent to %o'e inter$ention% but not to other%( >e$ Point )f a child i% con%idered to be Gillic/ co'&etent, hi% or her con%ent ,ill be $alid( 0dditional con%ent by a &er%on ,ith &arental re%&on%ibility ,ill not be reBuired( .oung &eo&le aged =! or =? year% are entitled to con%ent to their o,n dental treat'ent and anae%thetic ,here the treat'ent offer% direct benefit to the indi$idual( 1o,e$er, the refu%al of a co'&etent indi$idual of thi% age to undergo treat'ent 'ay in certain circu'%tance% be o$er-ridden by either a &er%on ,ho ha% &arental re%&on%ibility or by a Court( 3.3 5IST&RY 3.3.0 Introd-"tion Ta/ing a co'&rehen%i$e ca%e hi%tory i% an e%%ential &relude to clinical exa'ination, diagno%i%, and treat'ent &lanning( )t i% al%o an excellent o&&ortunity for the denti%t to e%tabli%h a relation%hi& ,ith the child and hi% or her &arent( Generally %&ea/ing, infor'ation i% be%t gathered by ,ay of a relaxed con$er%ation ,ith the child and hi% or her &arent in ,hich the denti%t a%%u'e% the role of an intere%ted li%tener rather than that of an inBui%itor( While %o'e clinician% 'ay &refer to e'&loy a &rofor'a to en%ure the co'&letene%% of the &roce%%, thi% i% le%% i'&ortant than the adherence to a %et routine( 0 co'&lete ca%e hi%tory %hould con%i%t ofG &er%onal detail%H &re%enting co'&laint;%<H %ocial hi%toryH 'edical hi%toryH dental hi%tory( Table @(= %u''ari5e% the /ey infor'ation that %hould be included under each heading( 3.3./ Per#onal detail# 0 note %hould be 'ade of the &atient*% na'e ;including any abbre$iated na'e or nic/na'e<, age, addre%%, and tele&hone nu'ber( Where the%e detail% ha$e been entered in the ca%e note% &rior to the a&&oint'ent they %hould be $erified( Detail% of the &atient*% 'edical &ractitioner %hould al%o be noted(

3.3.2 Pre#entin! "om laint(#) )t i% i'&ortant to a%certain fro' the child and hi% or her &arent ,hy the $i%it ha% been 'ade or ,hat they are %ee/ing fro' treat'ent( )t i% good &ractice to a%/ thi% Bue%tion to the child before in$ol$ing the &arent a% thi% e%tabli%he% the child*% i'&ortance in the &roce%%, though the denti%t %hould be &re&ared to recei$e different an%,er% fro' the%e t,o %ource%( Where a child &re%ent% in &ain or ha% a &articular concern, thi% %hould be recorded in the child*% o,n ,ord% and, if rele$ant, the hi%tory of the &re%ent co'&laint ;e(g( duration, 'ode of on%et, &rogre%%ion< %hould be docu'ented( )t %hould be recogni5ed that, e$en ,here other ;&erha&% 'ore i'&ortant< treat'ent i% reBuired, failure to ta/e into con%ideration the &atient*%D&arent*% need% or ,i%he% at thi% %tage 'ay be detri'ental to both the de$elo&'ent of the denti%tD&atientD&arent relation%hi& and the outco'e of care( 3.3.3 So"ial (+amil$) %i#tor$ 0 child i% a &roduct of hi% or her en$iron'ent( 6actor% %uch a% ,hether both &arent% are ali$e and ,ell, the nu'ber and age of %ibling%, the &arent%* occu&ation%, ea%e of tra$el, a% ,ell a% attendance at %chool or day-care facilitie% are all i'&ortant if a reali%tic treat'ent &lan i% to be arri$ed at( 1o,e$er, %ince %o'e &arent% ,ill con%ider thi% /ind of infor'ation confidential, the denti%t 'ay need to exerci%e con%iderable tact in order to obtain it( Thi% %tage of hi%tory-ta/ing al%o &re%ent% an o&&ortunity to engage the child in con$er%ation( )n thi% ,ay, the denti%t gain% an in%ight into the child*% intere%t% ;e(g( &et%, fa$ourite %ub+ect% at %chool, fa$ourite &a%ti'e%< and i% able to record &otential to&ic% of con$er%ation that can act a% *ice-brea/er%* in future a&&oint'ent%( 3.3.0 7edi"al %i#tor$ 8ariou% di%ea%e% or functional di%turbance% 'ay directly or indirectly cau%e or &redi%&o%e to oral &roble'%( 3i/e,i%e, they 'ay affect the deli$ery of oral and dental care( Condition% that ,ill be of %ignificance include allergie%, %e$ere a%th'a, diabete%, cerebral &al%y, cardiac condition%, hae'atological di%order%, and oncology( Where$er &o%%ible, a co'&rehen%i$e 'edical hi%tory %hould co''ence ,ith infor'ation relating to &regnancy and birth, the neonatal &eriod, and early childhood( )ndeed, a%/ing a 'other about her child*% health %ince birth ,ill not infreBuently %ti'ulate the &roduction of a co'&lete 'edical hi%toryI "re$iou% and current &roble'% a%%ociated ,ith each of the 'a+or %y%te'% %hould be elicited through careful Bue%tioning, and here a &rofor'a 'ay ,ell be hel&ful( Detail% about &re$iou% ho%&itali5ation%, o&eration% ;or &lanned o&eration%<, illne%%e%, allergie% ;&articularly ad$er%e reaction% to drug%<, and trau'atic in+urie% %hould be recorded, a% ,ell a% tho%e relating to &re$iou% and current 'edical treat'ent( >e$ Point )f any rele$ant condition% beco'e a&&arent, the%e 'ay need to be in$e%tigated in greater detail, contacting the child*% general 'edical &ractitioner or ho%&ital con%ultant

,here nece%%ary( )t i% u%eful to end by a%/ing the &arent ,hether there i% anything el%e that they thin/ the denti%t %hould /no, about their child( ;So'eti'e%, i'&ortant detail% are not $olunteered until thi% &ointI< Thi% i% a &articularly u%eful a&&roach in relation to children ,ho %uffer fro' beha$ioural or learning &roble'%, %uch a% attention deficit and hy&eracti$ity di%order ;0D1D< or auti%'( >e$ Point Sen%iti$e Bue%tioning i% reBuired if the child a&&ear% to ha$e a beha$ioural &roble' that ha% not been 'entioned by the &arent during the for'al 'edical hi%tory( )t i% i'&ortant to bear in 'ind that 'any children ,ith %ignificant 'edical &roble'% ,ill ha$e been %ub+ected to 'ulti&le ho%&ital ad'i%%ion%Dattendance%( The%e ex&erience% 'ay ha$e a negati$e effect on the attitude of both the child and hi% or her &arent% to,ard% dental treat'entH in addition, dental care 'ay not be %een a% a &riority in the context of total care( 6inally, a brief enBuiry %hould al%o be 'ade regarding the health of %ibling% and clo%e fa'ily( Significant fa'ily 'edical &roble'%, for in%tance &roble'% in relation to general anae%the%ia, 'ay not only alert the &ractitioner to &otential ri%/% for the child, but 'ay al%o be factor% to con%ider ,hen treat'ent &lanning( 3i/e,i%e, if the &atient ha% a %ic/ %ibling, it 'ay not be &o%%ible for the &arent% to co''it to a &rolonged cour%e of dental treat'ent( 3.3.5 Dental %i#tor$ 0 child*% &re$iou% dental ex&erience% 'ay affect the ,ay in ,hich he or %he react% to further treat'ent( E$aluation of a child*% &re$iou% beha$iour reBuire% the denti%t to obtain infor'ation about the /ind of dental treat'ent a child ha% recei$ed ;including the 'ethod of &ain and anxiety control ,hich ha% been offered< and the ,ay in ,hich he or %he ha% reacted to thi%( )n %o doing, %&ecific &rocedure% 'ay e'erge a% ha$ing &ro$ed &articularly &roble'aticH %uch &rior /no,ledge ,ill enable the denti%t to 'odify the treat'ent &lan a&&ro&riately( The dental hi%tory %hould al%o identify factor% that ha$e been re%&on%ible for exi%ting oral and dental &roble'% a% ,ell a% tho%e ,hich 'ight ha$e an i'&act on future health( The%e include dietary, oral hygiene, du''yDdigit %uc/ing, and &arafunctional habit%( S&ecific Bue%tion% %hould be a%/ed about drin/% ;&articularly the u%e of a bottle at bedti'e in the younger age grou&,<, bet,een-'eal %nac/%, freBuency of bru%hing, and ty&e of tooth&a%te u%ed( 6inally, a thorough dental hi%tory i% an o&&ortunity to e$aluate the attitude of the &arent to hi% or her child*% dental treat'ent( 6or exa'&le, the regularity of &re$iou% dental care 'ay be an indicator of the $alue that the &arent &lace% on hi% or her child*% dental health( >e$ Point E'bar/ing on a treat'ent &lan that i% at %ignificant $ariance ,ith &arental attitude% and ex&ectation% ,ithout clear ex&lanation and +u%tification in$ite% non-co'&letion(

3.0 E'A7INATI&N 3.0./ Fir#t im re##ion# 0n initial i'&re%%ion of the child*% o$erall health and de$elo&'ent can be gained a% %oon a% he or %he i% greeted in the ,aiting roo' or enter% the %urgery( )n &articular, it i% u%eful to noteG general healthdoe% the child loo/ ,ellJ o$erall &hy%ical and 'ental de$elo&'entdoe% it %ee' a&&ro&riate for the child*% chronological ageJ ,eighti% the child gro%%ly under- or o$er,eightJ co-ordinationdoe% the child ha$e an abnor'al gait or ob$iou% 'otor i'&air'entJ While the hi%tory i% being ta/en, the clinician %hould al%o be 'a/ing an *unofficial* a%%e%%'ent of the child*% li/ely le$el of co-o&eration in order that the 'o%t a&&ro&riate a&&roach for the exa'ination can be ado&ted right fro' the %tart ;ho&efully %a$ing both ti'e and tear%<( 4roadly %&ea/ing, &ro%&ecti$e young &atient% 'ay fall into one of the follo,ing categorie%G ha&&y and confidentthi% child i% li/ely to ho& into the chair for a chec/-u& ,ithout further coaxingH a little anxiou% or %hy but di%&laying %o'e ra&&ort ,ith the dental tea'thi% child ,ill &robably allo, an exa'ination after %o'e %i'&le accli'ati5ation and rea%%urance ;if the child i% $ery young, the o&tion of %itting on the 'other*% /nee could be gi$en<H $ery frightened, crying, clutching their &arent, a$oiding eye contact, or not re%&onding to direct Bue%tion%thi% child i% unli/ely to acce&t a con$entional exa'ination at thi% $i%it ;though the child 'ay allo, a brief exa'ination ,hile %itting on a non-dental chair, &erha&% e$en in the ,aiting roo'<H further accli'ati5ation ,ill be reBuired before a thorough exa'ination can be underta/enH %e$ere beha$ioural &roble' or learning di%abilityin a fe, ca%e%, thi% 'ay &reclude the child fro' e$er $oluntarily acce&ting an exa'inationH re%traint ;,ith or ,ithout &har'acological 'anage'ent< 'ay be indicated to facilitate an intraoral exa'ination( 3.0.2 Re#traint >e$ Point )t i% not good &ractice to for'ulate a definiti$e treat'ent &lan, e%&ecially one in$ol$ing a general anae%thetic, ,ithout fir%t &erfor'ing a thorough exa'ination( )n an ideal ,orld, unco-o&erati$e children ,ould be gi$en the ti'e and o&&ortunity to $oluntarily acce&t a dental exa'ination o$er a %erie% of de%en%iti5ing $i%it%( )n reality, if a child &re%ent% ,ith a re&orted &roble' but re'ain% unco-o&erati$e after gentle coaxing and nor'al beha$iour 'anage'ent %trategie%, re%traint 'ay be nece%%ary( "hy%ical re%traint %hould only be con%idered for infant%D$ery young children, or children ,ith %e$ere learning difficultie% ;&ro$iding they are not too big or %trong to 'a/e any re%traint &otentially dangerou% or uncontrolled<( The i%%ue of infor'ed

con%ent i% i'&ortant here, a% it i% i'&erati$e that the need for the exa'ination and the 'anner in ,hich it i% going to be conducted i% clearly under%tood by all concerned( )t i% be%t toG ex&lain in ad$ance ho, the child i% to be &o%itioned, a%/ &arent% for their acti$e hel&, gi$e rea%%urance that the child i% not going to be hurt in any ,ay( )n the 'o%t controlled a&&roach, the child i% laid acro%% the &arent*% /nee% ,ith hi% or her head on tho%e of the o&erator ;6ig( @(=<( The &arent i% able to hold the child*% ar'% though a dental nur%e 'ay need to re%train the child*% leg%( )t 'ay be ea%ier to exa'ine bigger children ,ho ha$e %&ecial need% ,hile they are re%trained in their o,n ,heelchair, the dental nur%e %u&&orting the child*% head during the exa'ination( ;See al%o Cha&ter =? &age A=>(< Fi!. 3./ Controlled exa'ination of a young boy laid acro%% hi% 'other*% /nee( 3.0.3 E9traoral e9amination 6eneral e9amination 4efore carrying out a detailed exa'ination of the craniofacial %tructure%, a 'ore general &hy%ical a%%e%%'ent %hould be underta/en( 8aluable infor'ation about a child*% o$erall health, de$elo&'ent, or e$en habit% can often be deter'ined by notingG heighti% the child $ery tall or $ery %'all for their ageJ )n a fe, ca%e%, it 'ay be a&&ro&riate to ta/e an accurate height 'ea%ure'ent ;6ig( @( < and &lot data on a %tandard gro,th chart ;6ig( @(@<( Children ,ho%e height lie% belo, the third centile, abo$e the ninety-%e$enth centile, or ,ho exhibit le%% than @-: c' gro,th &er year %hould be referred to a &aediatrician for further in$e%tigationH ,eightcould there be an underlying eating di%orderJ )% general anae%the%ia contraindicated due to the child*% obe%ityJ )% there an underlying endocrine &roble'J %/inloo/ for any notable brui%ing or in+ury on ex&o%ed ar'% or leg% ;6ig( @(A<H hand%a%%e%% for e$idence of digit %uc/ing or nail biting, ,art%, finger clubbing, abnor'al nail, or finger 'or&hology ;6ig( @(:<( T%e %ead and ne"= During the exa'ination of the head and nec/, the follo,ing %tructure% %hould be briefly a%%e%%edG headnote %i5e, %ha&e ;abnor'alitie% 'ay be %een in certain %yndro'e%<, and any facial a%y''etry ;6ig( @(!<H hairnote if %&ar%e ;loo/ out for head liceI<H eye%i% there any $i%ual i'&air'ent or abnor'ality of the %cleraJ ear%record any abnor'al 'or&hology or &re%ence of hearing aid%H %/indocu'ent any %car%, brui%ing, laceration%, &allor, birth'ar/% ;6ig( @(?< and be a,are of contagiou% infection%, %uch a% i'&etigoH

 te'&oro'andibular +ointi% there any &ain, cre&itu%, de$iation, or re%tricted o&eningJ ly'&h node%&al&ate for enlarged %ub'andibular or cer$ical ly'&h node% ;bear in 'ind that ly'&hadeno&athy i% not unco''on in children, due to freBuent $iral infection%< ;6ig( @(C<H li&%note the &re%ence of cold %ore%, %,elling, or abnor'al colouring ;6ig( @(><( 0ny &o%iti$e finding% %hould be recorded carefully( Clinical &hotogra&h% or annotated %/etche% ;6ig( @(=9< 'ay be $ery hel&ful for future reference, &articularly ,ith re%&ect to 'edico-legal &ur&o%e%, or in ca%e% of %u%&ected child &hy%ical abu%e ;%ee Cha&ter = <( Ob$iou%ly, ,hen the child &re%ent% ,ith a %&ecific &roble', %uch a% a facial %,elling, a 'ore thorough exa'ination of the &re%enting condition i% needed ;%ee Cha&ter =:<( Fi!. 3.2 #%e of a ,all-'ounted %tedio'eter to ta/e an accurate height 'ea%ure'ent ;the &atient*% %hoe% %hould be re'o$edI<( Fi!. 3.3 Standard gro,th chart %ho,ing &lot of height again%t age for boy in 6ig( @( ,ho ha% a %e$ere gro,th deficiency( Fi!. 3.0 Multi&le brui%e% on ar' of child ,ith a &latelet di%order( Fi!. 3.5 6inger clubbing in child ,ith a congenital heart di%order( Fi!. 3.1 6acial a%y''etry in a teenage girl( Fi!. 3.2 Telangiecta%ia noted on the face of a young boy( Fi!. 3.3 Three-year-old girl ,ith %,elling &o%%ibly in &re-auricular ly'&h node or &arotid gland( Fi!. 3.4 Multi&le $e%icle% on li& of young &atient ,ith acute her&etic gingi$o%to'atiti%( Fi!. 3./0 Exa'&le of annotated %/etch u%ed to record trau'a( 3.0.0 Intraoral e9amination 0 %y%te'atic a&&roach %hould be ado&ted for the intraoral exa'ination( The follo,ing i% a %ugge%ted orderG %oft ti%%ue% gingi$al and &eriodontal ti%%ue% teeth occlu%ion( So+t ti##-e# 0n abnor'al a&&earance of the oral %oft ti%%ue% 'ay be indicati$e of an underlying %y%te'ic di%ea%e or nutritional deficiency( )n addition, a $ariety of oral &athologie% 'ay be %een in children ;%ee Cha&ter =:<( )t i% therefore i'&ortant to carefully exa'ine the tongue, &alate, throat, and chee/%, noting any colour change%, ulceration, %,elling, or other &athology ;6ig( @(==<(

)t i% al%o %en%ible to chec/ for abnor'al frenal attach'ent or tongue-tie, ,hich 'ay ha$e functional i'&lication%( )f a tongue-tie or abnor'al tongue function i% ob%er$ed, %o'e con%ideration %hould be gi$en to the child*% %&eech( During exa'ination of the %oft ti%%ue%, an o$erall i'&re%%ion of %ali$ary flo, rate and con%i%tency %hould al%o be gained( 6in!i.al and eriodontal ti##-e# 0 $i%ual exa'ination of the gingi$al ti%%ue% i% u%ually all that i% indicated for young children, a% &eriodontal di%ea%e i% $ery unco''on in thi% age grou&( The &re%ence of colour change ;redne%%<, %,elling, ulceration, %&ontaneou% bleeding, or rece%%ion ;6ig%( @(= and @(=@(< %hould be carefully noted, and the aetiology %ought( >e$ Point The &re%ence of &rofound gingi$al infla''ation in the ab%ence of gro%% &laBue de&o%it%, lateral &eriodontal ab%ce%%e%, &re'aturely exfoliating teeth, or 'obile &er'anent teeth 'ay indicate a 'ore %eriou% underlying &roble', ,arranting further in$e%tigation( During in%&ection of the gingi$al ti%%ue%, an a%%e%%'ent of oral cleanline%% %hould al%o be 'ade, and the &re%ence of any &laBue or calculu% de&o%it% noted( 0 nu'ber of %i'&le oral hygiene indice% ha$e been de$elo&ed to &ro$ide an ob+ecti$e record of oral cleanline%%( One %uch index, the oral debri% index ;Green and 8er'illion, =>!A<, reBuire% di%clo%ing &rior to an e$aluation of the a'ount of &laBue on %elected teeth ;fir%t &er'anent 'olar%, and u&&er right and lo,er left central inci%or%< a% %ho,n in 6ig( @(=A( Sy%te'atic &eriodontal &robing i% not routinely &racti%ed in young children, unle%% there i% a %&ecific &roble' ;%ee Cha&ter ==<( 1o,e$er, it i% &rudent to carry out %o'e %electi$e &robing for teenager% in order to detect any early ti%%ue attach'ent lo%%, ,hich 'ay indicate the on%et of adult &eriodontiti%( Teet% 6ollo,ing a%%e%%'ent of the oral %oft ti%%ue%, a full dental charting %hould be &erfor'ed( 0 thorough /no,ledge of eru&tion date% for the &ri'ary and &er'anent dentition i% e%%ential a% any delayed or &re'ature eru&tion 'ay alert the clinician to a &otential &roble'( 1o,e$er, %i'&ly recording the &re%ence or ab%ence of a tooth i% not adeBuateG clo%er %crutiny of each tooth*% condition, %tructure, and %ha&e i% al%o reBuired( Sugge%ted feature% to note are briefly li%ted belo,G carie%i% it acti$eDarre%ted, re%torableDunre%torableJ Chec/ for the &re%ence of a chronic %inu% a%%ociated ,ith gro%%ly cariou% teethH re%toration%are they intactDdeficientJ fi%%ure %ealant%are they intactDdeficientJ tooth %urface lo%%note any ero%ionDattrition, %ite, extent ;6ig( @(=:<H trau'anote extent, %ite, or %ign% of lo%% of $italityH tooth %tructurerecord any ena'el o&acitie%Dhy&o&la%ia ;are defect% locali%edD

generali%edJ< ;6ig%( @(=!, @(=?, and @(=C<H tooth %ha&eD%i5enote &re%ence of double teeth, conical teeth, 'acrodontiaD 'icrodontia, talon cu%&%, dee& cingulu' &it% ;6ig( @(=><H tooth nu'berany 'i%%ingDextra teethJ tooth 'obilityi% it &hy%iological or &athologicalJ tooth eru&tionare there any i'&action%, infraoccluded &ri'ary 'olar%, or ecto&ically eru&ting fir%t &er'anent 'olar%J &""l-#ion Clearly, a full orthodontic a%%e%%'ent i% not indicated e$ery ti'e a child i% exa'ined( 1o,e$er, tooth align'ent and occlu%ion %hould be briefly con%idered, a% the%e 'ay &ro$ide an early &ro'&t a% to the need for interce&ti$e orthodontic treat'ent( )t i% certainly ,orth notingG %e$ere %/eletal abnor'alitie%H o$er+et and o$erbiteH fir%t 'olar relation%hi&%H &re%ence of cro,dingD%&acingH de$iation%Ddi%&lace'ent%( There are al%o t,o /ey %tage% of dental de$elo&'ent, ,hen the clinician %hould be &articularly $igilant in chec/ing tooth eru&tion and &o%itionG =( 0ge C-> year%eru&tion of u&&er &er'anent inci%or% increa%ed o$er+et'ay &redi%&o%e to trau'a cro%%-biteneed for early inter$entionJ ;6ig( @( 9< trau'atic bitea%%ociated ,ith locali5ed gingi$al rece%%ion of lo,er inci%orJ anterior o&en bite%/eletal &roble', digit-%uc/ing habit, or tongue thru%tJ ;6ig( @( =< failure of eru&tion&re%ence of a %u&ernu'ary, cro,nDroot dilaceration, retained &ri'ary inci%or, congenitally 'i%%ing lateral inci%or%J ;6ig( @( <( ( 0ge =9F year%eru&tion of u&&er &er'anent canine% are the &er'anent canine% &al&able buccallyif not, they 'ay be heading in a &alatal direction are the &ri'ary canine% beco'ing 'obileif not, the &er'anent canine% 'ay be ecto&ic( Fi!. 3.// Mucocoele of labial 'uco%aG an incidental finding( Fi!. 3./2 "laBue-induced gingi$al infla''ation( Fi!. 3./3 Se$ere gingi$al infla''ation in &atient ,ith cyclical neutro&enia(

Fi!. 3./0 Oral debri% index by Green and 8er'illion ;=>!A<( Fi!. 3./5 #nu%ual &attern of ero%ion affecting labial %urface of 'axillary &ri'ary inci%or% attributed to u%e of le'on tea in feeder cu&( Fi!. 3./1 3ocali5ed ,hite ena'el o&acitie% affecting &er'anent 'axillary central inci%or%( Fi!. 3./2 Generali5ed inherited ena'el defect ;a'elogene%i% i'&erfecta<( Fi!. 3./3 "artially eru&ted 'andibular fir%t &re'olar %ho,ing %e$ere ena'el hy&o&la%ia( Fi!. 3./4 Maxillary central inci%or ,ith talon cu%&( Fi!. 3.20 Cro%%-bite in early 'ixed dentition( Fi!. 3.2/ Se$ere anterior o&en bite ;in a%%ociation ,ith a'elogene%i% i'&erfecta<( Fi!. 3.22 6ailure of eru&tion of 'axillary left central inci%orG ti'e to be concernedI 3.5 F(RT5ER IN)ESTI6ATI&NS 3.5.0 Introd-"tion 1a$ing carried out a thorough extra- and intraoral exa'ination a% de%cribed abo$e, the clinician 'ay feel that further in$e%tigation% are indicated for diagno%tic &ur&o%e%( Table @( highlight% the range of dental ;and 'ore general< in$e%tigation% that 'ay be e'&loyed to aid diagno%i% of the &re%enting co'&laint( The u%e of radiogra&h% i% 'ore fully de%cribed in the follo,ing %ection( 3.5./ Radio!ra %# >e$ Point Since &atient% %hould not be o$er-ex&o%ed to ioni5ing radiation, e$ery radiogra&hic in$e%tigation %hould be clinically +u%tified and ha$e a clear diagno%tic &ur&o%e( Co'&rehen%i$e clinical guideline% for radiogra&hic a%%e%%'ent of children ha$e been &ro&o%ed by the Euro&ean 0cade'y of "aediatric Denti%try ; 99@<( *Routine* radiogra&hic %creening i% certainly not indicated for children( 1o,e$er, radiogra&h% 'ay be indicated in order to facilitateG carie% diagno%i%H trau'a diagno%i%H orthodontic treat'ent &lanningH identification of any abnor'alitie% in dental de$elo&'entH detection of any bony or dental &athology( Carie# dia!no#i# 4ite,ing radiogra&h% are in$aluable for the detection of early inter&roxi'al cariou%

le%ion% ;6ig( @( @<, or occult occlu%al le%ion%( )ndeed, bite,ing radiogra&hy ,ill increa%e the identification of inter&roxi'al le%ion% by a factor of bet,een and C, co'&ared to $i%ual a%%e%%'ent alone( 4ite,ing radiogra&h% are u%ually reco''ended for all ne, &atient%, e%&ecially high carie% ri%/ indi$idual%, to &ro$ide a ba%eline carie% a%%e%%'ent( 1o,e$er, they 'ay not be nece%%ary for $ery young &atient% ,ith o&en &ri'ary 'olar contact%( The bite,ing radiogra&h i% the $ie, of choice for inter&roxi'al carie% detection, but it doe% reBuire a rea%onable degree of &atient co-o&eration( 6or &atient% unable to tolerate intraoral fil'%, the lateral obliBue radiogra&h &ro$ide% a u%eful alternati$e ;6ig( @( A<( Thi% $ie, ha% the added ad$antage of including the de$elo&ing &er'anent dentition( 6ollo,ing the initial radiogra&hic in$e%tigation of carie%, a deci%ion %hould be 'ade regarding the freBuency of any future a%%e%%'ent( The inter$al ,ill de&end on the &atient*% indi$idual carie% ri%/ ;%ee Section @(!< a% follo,%G high carie% ri%/re&eat bite,ing% in = 'onth% ;6ig( @( :< lo, carie% ri%/re&eat bite,ing% in A-@! 'onth% Tra-ma a##e##ment Radiogra&h% 'ay be indicated for &atient% ,ho ha$e %u%tained facial or dental trau'a( Thi% to&ic ,ill be di%cu%%ed in 'ore detail in Cha&ter = ( &rt%odonti" treatment lannin! 0 di%cu%%ion of radiogra&hic $ie,% for orthodontic treat'ent &lanning i% not ,ithin the re'it of thi% cha&ter( 1o,e$er, a &anoral radiogra&h i% u%ually 'andatory &rior to any orthodontic treat'ent( The need for other $ie,%, %uch a% an u&&er %tandard occlu%al or lateral ce&halo'etric radiogra&h, i% de&endent on the indi$idual clinical %ituation ;Cha&ter =A<( Dental de.elo ment The need for radiogra&hic a%%e%%'ent of the de$elo&ing dentition 'ay be &ro'&ted by any of the follo,ing clinical feature%G ;=< delayedD&re'ature dental de$elo&'entH ; < %u%&ected 'i%%ingDextra teeth ;6ig( @( !<H ;@< &otential ecto&ic tooth &o%ition ;e%&ecially u&&er 'axillary canine%<H ;A< fir%t &er'anent 'olar% of &oor &rogno%i%in ca%e% ,here fir%t &er'anent 'olar% are to be extracted it i% 'andatory to chec/ for the radiogra&hic &re%ence of all other &er'anent teeth, including third 'olar%, and to a%%e%% the %tage of dental de$elo&'ent of the lo,er %econd &er'anent 'olar% in order to deter'ine the o&ti'u' ti'e for any fir%t &er'anent 'olar extraction% ;%ee Cha&ter =A<( The &anoral radiogra&h &ro$ide% the o&ti'u' $ie, for an o$erall a%%e%%'ent of nor'al or abnor'al dental de$elo&'ent( 6urther'ore, accurate deter'ination of chronological age can be achie$ed by calculating dental age, u%ing a &anoral

radiogra&h and a techniBue for dental aging, %uch a% that de%cribed by De'ir+ian ;=>?@<( 0 &anoral radiogra&h 'ay be %u&&le'ented ,ith an intraoral radiogra&h, %uch a% an u&&er %tandard occlu%al, ,hen an *abnor'ality* &re%ent% in the anterior 'axilla( The co'bination of the%e t,o $ie,% &ro$ide% the o&&ortunity to confir' the exact &o%ition of any uneru&ted 'axillary canine% or %u&ernu'ary teeth, u%ing the $ertical &arallax techniBue ;6ig( @( ?<( >e$ Point The *S3O4* ruleG if the tooth in Bue%tion 'o$e% in the #a'e direction a% the xray tube, then the tooth i% lingually or &alatally &o%itioned ;in relation to the reference &oint<( 1o,e$er, if the tooth 'o$e% in the o&&o%ite direction to the X-ray tube, it i% ,uccally &laced( Dete"tion o+ at%olo!$ Selected radiogra&h% 'ay be reBuired in ca%e% of %u%&ected &athology( The actual $ie, i% ob$iou%ly dictated by the &re%enting co'&laint, but a &eria&ical radiogra&h i% freBuently indicated for locali5ed &athologie%, %uch a%G &eria&ical or interadicular infection ;&ri'ary 'olar%< a%%ociated ,ith non-$ital teethH &eriodontal condition%H trau'a-related %eBuelae, %uch a% root re%or&tion( 0 &anoral $ie, i% &articularly $aluable ,here the &athology in$ol$e% 'ore than one Buadrant or ha% exten%i$e bony in$ol$e'ent( 0 %ectional &anoral radiogra&h 'ay be &re%cribed in %o'e %ituation% %ince thi% a&&roach hel&% to reduce ioni5ing ex&o%ure( Fi!. 3.23 3eft and right bite,ing radiogra&h% %ho,ing 'ulti&le a&&roxi'al cariou% le%ion% not e$ident clinically( Fi!. 3.20 Right lateral obliBue radiogra&h %ho,ing carie% in lo,er &ri'ary 'olar%( Fi!. 3.25 3eft and right bite,ing radiogra&h% of young boy fro' high cariou%ri%/ fa'ily at ;a< @ year% =9 'onth% and ;b< A year% =9 'onth% de'on%trating ra&id cariou% de$elo&'ent( Fi!. 3.21 "anoral radiogra&h of =9-year-old boy ,ith %e$ere hy&odontia ;only t,o &er'anent unit% are &re%ent<( -ote taurodont 'andibular %econd &ri'ary 'olar%( Fi!. 3.22 ;a< "anoral radiogra&h and ;b< u&&er %tandard occlu%al radiogra&h u%ed to confir' the &alatal &o%ition of the uneru&ted 'axillary left canine by the $ertical &arallax techniBue( 3.1 RIS> ASSESS7ENT 3.1.0 Introd-"tion 1a$ing gathered rele$ant infor'ation by ta/ing a hi%tory, conducting an exa'ination,

and carrying out any %&ecial in$e%tigation%, there i% one final con%ideration to 'a/e &rior to treat'ent &lanningG that i%, ri%/ a%%e%%'ent( >e$ Point Ri%/ a%%e%%'ent i% %i'&ly an a%%e%%'ent of the li/elihood of a di%ea%e or condition de$elo&ing in an indi$idual &atient( Ri%/ a%%e%%'ent i% certainly not a ne, conce&t, but it ha% no, beco'e a 'ore recogni5ed %te& in the deci%ion-'a/ing &roce%%( When conducting a ri%/ a%%e%%'ent, the clinician need% to con%ider all factor% that 'ay ha$e a negati$e or &o%iti$e effect on oral health( Generally, ri%/ a%%e%%'ent% are underta/en ,ith re%&ect to carie%, but there are other recogni5ed *ri%/%* to con%ider for the young dental &atient includingG &eriodontal di%ea%eH ero%ionH orofacial trau'a( The rationale for ri%/ a%%e%%'ent i% to target re%ource% to tho%e ,ho 'o%t need the'I )deally, any &re$enti$e or o&erati$e treat'ent &rogra''e %hould be directed by an a&&reciation of the &atient*% ri%/ %tatu%, thu% en%uring that %er$ice deli$ery i% both effecti$e and co%t-efficient( Ri%/ a%%e%%'ent i% al%o rele$ant ,hen deter'ining an o&ti'u' recall inter$al, a% not all &atient% need to be %een ,ith the %a'e freBuency( 6urther'ore, a child*% ri%/ %tatu% i% not %taticH it 'ay change due to any nu'ber of change% in &er%onal circu'%tance%( )t i% therefore i'&ortant to continually re-a%%e%% ri%/ %tatu% at future $i%it%( 3.1./ Carie# The ai' of carie% ri%/ a%%e%%'ent i% to &redict ,hether the di%ea%e i% li/ely to de$elo& in an a% yet carie%-free indi$idual, or to deter'ine the rate of di%ea%e &rogre%%ion in a &atient ,ho already ha% %o'e carie% ex&erience( )t ha% been &ro&o%ed that a rea%onable 'odel for carie% ri%/ a%%e%%'ent %hould ha$e a co'bined %en%iti$ity and %&ecificity of =!9L ,hereG %en%iti$ity M &ro&ortion of &eo&le actually ,ith a di%ea%e ,ho ha$e a &o%iti$e te%t re%ultH %&ecificity M &ro&ortion of &eo&le ,ithout a di%ea%e ,ho ha$e a negati$e te%t re%ult( )n general, carie% &rediction 'odel% ha$e higher %&ecificity than %en%iti$ity( 1o,e$er, the *%cience* of carie% ri%/ a%%e%%'ent i% %till in it% de$elo&'ental %tage% and, to date, no %ingle 'odel &ro$ide% a =99L accurate &rediction of carie% ri%/( )ndeed, due to the co'&lex nature of carie%, it 'ay not be &o%%ible to de$i%e the &erfect ri%/ a%%e%%'ent 'odel for clinical u%e( )ntere%tingly, re%earch ha% %ho,n that the ex&erienced clinician can actually achie$e a high le$el of &rediction %i'&ly on the ba%i% of a %ocio-de'ogra&hic hi%tory and clinical exa'ination( Thu% the need for %&ecific te%ting, %uch a% 'icrobiological in$e%tigation, 'ay not confer %ignificant additional benefit( )n &articular, &a%t carie% ex&erience ha% &ro$ed to be the 'o%t u%eful clinical &redictor of carie% ri%/(

0dditionally, &oor oral hygiene ;$i%ible &laBue on 'axillary inci%or%< in $ery young children ha% al%o been found to be a reliable indicator of high carie% ri%/( Table @(@ highlight% the /ey ri%/ factor% that %hould be ta/en into con%ideration ,hen conducting a ri%/ a%%e%%'ent( 8ery %i'&ly, children 'ay be categori5ed a% lo,, 'oderate, or high carie% ri%/ according to the follo,ing criteriaG lo, ri%/intact dentition, good oral hygiene, ,ell-educated affluent fa'ily bac/ground, good dietary control, and u%e of fluoride regi'en%H 'oderate ri%/=- ne, le%ion% &er year, &oor oral hygiene, and non-o&ti'u' fluoride u%eH high ri%/three or 'ore ne, le%ion% &er year, &oor oral hygiene and dietary control, %ignificant 'edical hi%tory, i''igrant %tatu%, &o$erty, lo, education, and &oor u&ta/e of fluoride regi'en%( )t i% al%o i'&ortant to bear in 'ind that the ri%/ of carie% de$elo&'ent al%o $arie% %ignificantly forG different age grou&%G children aged =- year% and :-? year% are con%idered high ri%/ age grou&%H indi$idual teethG fir%t &ri'ary 'olar% and fir%t &er'anent 'olar% are high ri%/H different tooth %urface%G inter&roxi'al &ri'ary 'olar %urface% and occlu%al %urface% of fir%t &er'anent 'olar% are high ri%/( 3.1.2 Periodontal di#ea#e While &eriodontal di%ea%e i% not co''on in children, a fe, recogni5ed ri%/ factor% are a%%ociated ,ith increa%ed li/elihood of it% de$elo&'ent( The%e includeG %'o/ingH diabete%H &laBue accu'ulationalthough thi% i% not %uch a reliable indicator at an indi$idual le$elH fa'ily hi%tory ;genetic factor%<( 1or'onal change% around &uberty, lo, $ita'in C or calciu' inta/e, %ocio-econo'ic %tatu%, &%ycho%ocial factor%, tooth &o%ition, and occlu%al relation%hi&% 'ay al%o influence &eriodontal health, but are not con%idered reliable ri%/ indicator%( 3.1.3 Ero#ion There i% no e%tabli%hed 'odel for ri%/ &rediction in relation to ero%ion( 1o,e$er it ha% been %ugge%ted thatG inta/e of 'ore than ! carbonated drin/% ,ee/ly i% a%%ociated ,ith 'oderate ero%ion ri%/H inta/e of 'ore than =A carbonated drin/% ,ee/ly i% a%%ociated ,ith high ero%ion

ri%/( )n addition, the follo,ing ri%/ factor% ha$e been re&orted to ha$e %o'e a%%ociation ,ith ero%ionG inta/e of 'ore than t,o citru% fruit% dailyH freBuent %&ort% &artici&ationH eating di%order%H ga%tric reflux, ru'ination( 3.1.0 &ro+a"ial tra-ma The 'a+ority of orofacial trau'a cannot be &re$ented, a% it u%ually re%ult% fro' an una$oidable accidentI 1o,e$er, there are %o'e recogni5ed trau'a ri%/ factor% that ,arrant con%ideration and a&&ro&riate &re$ention ,here &o%%ibleG increa%ed o$er+etG children ,ith an o$er+et of >> '' are t,ice a% li/ely to %u%tain dental trau'aH contact %&ort%G acti$e &artici&ation in %&ort%, %uch a% rugby, hoc/ey, and 'artial art%, carrie% an increa%ed ri%/ of %u%taining orofacial trau'aH &re$iou% dental trau'aG there i% a %ignificant ri%/ of %u%taining further trau'aI 'otor di%abilitie%G children ,ith &oor co-ordination are 'ore at ri%/ of %u%taining trau'aH neurological di%abilitie%G uncontrolled e&ile&tic% are high trau'a ri%/ candidate%H ageG &ea/ age% for %u%taining orofacial trau'a are around =- year% and C-=9 year%H genderG boy% are 'ore at ri%/ than girl%( 3.2 PRINCIP*ES &F TREAT7ENT P*ANNIN6 3.2.0 Introd-"tion )n &lanning dental care for child &atient%, the denti%t 'u%t %ati%fy t,o, %o'eti'e% a&&arently conflicting, ob+ecti$e%( 6ir%t, it i% clearly nece%%ary to en%ure that the child reache% adulthood ,ith the o&ti'u' achie$able dental health( Second, it i% e%%ential that the child both learn% to tru%t the dental tea' and de$elo&% a &o%iti$e attitude to,ard% dental treat'ent( 0t any &oint in ti'e, therefore, the de%irability of the *ideal* care ;,hate$er thi% 'ight be< 'u%t be carefully balanced again%t the child*% &otential to co&e ,ith the &ro&o%ed treat'entH the ability and ,illingne%% of the child and &arent to attend for careH &arental &reference( Thu%, the denti%t 'ay be reBuired to exerci%e a degree of co'&ro'i%e ,hich tho%e 'ore u%ed to treating adult% 'ay find unfa'iliar and e$en a little unco'fortable( 1o,e$er, it i% i'&ortant to acce&t that there ,ill be no ,inner% if, at the out%et, a treat'ent &lan i% unreali%tic or in%ufficiently flexible to allo, 'odification, %hould thi% beco'e nece%%ary, a% treat'ent &rogre%%e%(

6ro' the foregoing co''ent%, it %hould be e$ident that it i% not &o%%ible to ta/e a *one %i5e fit% all* a&&roach to treat'ent &lanningG $ery different treat'ent &lan% 'ay be dra,n u& for children ,ho &re%ent ,ith $ery %i'ilar &roble'%( 1o,e$er, ba%ic &rinci&le% &er$ade all treat'ent &lan% and the%e are %et out in 6ig( @( C( ;The reader %hould note the e'&ha%i% that ha% been &laced on re&eated a%%e%%'ent and di%cu%%ion(< Se$eral a%&ect% of thi% a&&roach are ,orthy of %&ecial co''ent( Fi!. 3.23 "rinci&le% of treat'ent &lanning for a &aediatric dental &atient( 3.2./ 7ana!ement o+ a"-te dental ro,lem# The 'anage'ent of acute &roble'% &re%ent at the ti'e of the child*% fir%t $i%it i% undoubtedly a &riority( 1o,e$er it i% i'&ortant that any treat'ent that i% &ro$ided %it% ,ell in the context of a holi%tic treat'ent &lan and doe% not +eo&ardi5e it% co'&letion( )n 'o%t ca%e%, therefore, &ain relief %hould be &ro$ided ,ithout recour%e to extraction( 3.2.2 Pre.ention 0ny treat'ent &lan relie% for it% %u&&ort on a *%&ine* of &re$ention ;Cha&ter !<( Re%toration% &laced in a 'outh in ,hich the carie% &roce%% i% %till acti$e are &rone to failureG re&eated re%toration% 'ay be detri'ental to the child*% ability to co-o&erate and the denti%t-&arent relation%hi& ;a% ,ell a% fru%trating to the dental tea'<( 3i/e,i%e, 'anaging a child*% gro%%ly cariou% teeth by 'ulti&le extraction% ,ithout en%uring that he or %he recei$e% a&&ro&riate &re$enti$e in&ut doe% nothing to a%%i%t that child in 'aintaining dental health in the future( 0n added ad$antage of a *&re$ention fir%t a&&roach* i% it% i'&ortance in beha$iour 'anage'ent, accli'ati5ing the child to future treat'ent( "rocedure% %uch a% fluoride $arni%h a&&lication% or di%clo%ing are good confidence-building %te&%( >e$ Point "re$enti$e ad$ice, ,hether thi% i% in relation to diet, oral hygiene, fluoride %u&&le'entation, or e$en the &re$ention of dental trau'a, %hould be reali%tic and %&ecifically tailored to the indi$idual child and &arent( 0ny &re$enti$e %trategy %hould be dictated by an indi$idual*% ri%/ a%%e%%'entG for in%tance lo, carie% ri%/ children do not routinely reBuire fi%%ure %ealant%( The deli$ery of &re$enti$e ad$ice and inter$ention% %hould not be re%tricted to the co''ence'ent of treat'ent( Rather, &re$ention %hould be reinforced a% treat'ent &rogre%%e%, 'odification% being incor&orated %hould the%e beco'e nece%%ary( Clearly, &re$ention i% not %i'&ly a +ob for the 'e'ber% of the dental tea'( )t de'and% the creation of a &artner%hi& in ,hich both the child and the &arent are /ey &layer%, though the relati$e role and &ro'inence of each ,ill differ ,ith the age of the child( )n the ca%e of young children, &arent% are ;or, at lea%t, %hould be< re%&on%ible for food choice% and oral hygiene, though the latter re%&on%ibility i% not infreBuently abdicated before the child ha% %ufficient 'anual dexterity to bru%h adeBuately alone( 0% the child a&&roache% the teenage year% ;and &articularly ,hen he or %he enter% %econdary %chooling<, &arental control ine$itably decrea%e%( 0ny di%cu%%ion of the

&ro&o%ed treat'ent &lan %hould, therefore, include an agree'ent a% to ,hat i% reBuired of the child andDor &arent a% ,ell a% ,hat ,ill be offered by $ariou% 'e'ber% of the dental tea' ;including &rofe%%ional% co'&le'entary to denti%try<( )t 'ay be hel&ful to docu'ent thi% agree'ent in the for' of a ,ritten *contract*( 3.2.3 Sta,ili:ation Where a child ha% o&en ca$itie%, a &ha%e of %tabili5ation %hould &recede the &ro$i%ion of definiti$e treat'ent, ,hether thi% i% to be entirely re%torati$e in nature or a co'bination of re%toration% and extraction%( )n thi% &roce%%, no atte'&t i% 'ade to render the ca$itie% carie% freeH rather, 'ini'al ti%%ue i% re'o$ed ,ithout local anae%the%ia, allo,ing &lace'ent of an a&&ro&riate te'&orary dre%%ing( The inclu%ion of %uch a &ha%e in a holi%tic treat'ent &lan reduce% the o$erall bacterial load and %lo,% carie% &rogre%%ion, render% the child le%% li/ely to &re%ent ,ith &ain and %e&%i%, and buy% ti'e for the i'&le'entation of &re$enti$e 'ea%ure% and for the child to be accli'ati%ed to treat'ent( 1o,e$er, one ,ord of caution i% offeredG it i% e%%ential that the &arent under%tand% the &ur&o%e of %tabili5ation and that ,hat ha$e been &ro$ided are not &er'anent re%toration%( Other,i%e, it i% &o%%ible that they ,ill &ercei$e that treat'ent i% failing to &rogre%%( 6ollo,ing %tabili5ation, the child*% re%&on%e to accli'ati5ation and co'&liance ,ith the %ugge%ted &re$enti$e regi'e %hould be a%%e%%ed( Thi% i% &articularly i'&ortant before &roceeding ,ith definiti$e treat'ent( 6or exa'&le, in a %cenario in ,hich a child ha% not re%&onded to accli'ati5ation and ha% either refu%ed %tabili5ation or acce&ted thi% only ,ith extre'e difficulty, the denti%t 'ay be entirely +u%tified in con%idering extraction%( Thi% ,ill allo, the child and hi% or her fa'ily to en+oy a &eriod ,here no acti$e treat'ent i% reBuired and in ,hich &re$ention can be e%tabli%hed ;al,ay% &ro$ided, of cour%e, they return for continuing care<( 3.2.0 S"%ed-lin! o erati.e treatment )n any treat'ent &lan, it i% nece%%ary to gi$e careful con%ideration to the order in ,hich ite'% of o&erati$e care are &ro$ided( The follo,ing are general rule% of thu'bG %'all, %i'&le re%toration% %hould be co'&leted fir%tH 'axillary teeth %hould be treated before 'andibular one% ;%ince it i% u%ually ea%ier to ad'ini%ter local anae%the%ia in the u&&er +a,<H &o%terior teeth %hould be treated before anterior% ;thi% u%ually en%ure% that the &atient return% for treat'ent<H Buadrant denti%try %hould be &racti%ed ,here$er &o%%ible ;thi% reduce% the nu'ber of $i%it% to a 'ini'u'< but only if the ti'e in chair i% not exce%%i$e for a $ery young &atientH endodontic treat'ent %hould follo, co'&letion of %i'&le re%torati$e treat'entH extraction% %hould be the la%t ite'% of o&erati$e care ;at thi% %tage, &atient coo&eration can 'ore reliably be a%%ured< unle%% the &atient &re%ent% ,ith an acute &roble' 'id-treat'ent(

3.2.5 Re"all Treat'ent &lanning ;in it% broade%t %en%e< clearly doe% not end ,ith the co'&letion of one treat'ent +ourney( The deter'ination of a recall %chedule tailored to the need% of the indi$idual child i% an e%%ential &art of the treat'ent-&lanning &roce%%( )t i% generally acce&ted that children %hould recei$e a dental a%%e%%'ent 'ore freBuently than adult% %ince there i% e$idence that the rate of &rogre%%ion of dental carie% can be 'ore ra&id in children than in adult%H the rate of &rogre%%ion of carie% and ero%i$e tooth ,ear i% fa%ter in &ri'ary than in &er'anent teethH &eriodic a%%e%%'ent of orofacial gro,th and the de$elo&ing occlu%ion i% reBuired( )n the latter context, there i% con%iderable 'erit in en%uring that recall exa'ination% coincide ,ith &articular 'ile%tone% in dental de$elo&'ent, for exa'&le, around !, >, and = year%( Generally %&ea/ing, recall inter$al% of no 'ore than = 'onth% offer the denti%t the o&&ortunity to deli$er and reinforce &re$enti$e ad$ice during the crucial &eriod ,hen a child i% e%tabli%hing the ba%i% for their future dental health( 1o,e$er, the exact recall inter$al ;@, !, >, or = 'onth%< %hould be tailored to 'eet, and $ary ,ith the child*% need%( Thi% reBuire% an a%%e%%'ent of di%ea%e le$el% a% ,ell a% ri%/ ofDfro' dental di%ea%e( 3.2.1 Treatment lannin! +or !eneral anae#t%e#ia Treat'ent &lanning for general anae%the%ia i% an extre'ely co'&lex area that 'erit% %&ecial 'ention( 1o,e$er, a full di%cu%%ion lie% out%ide the %co&e of the current cha&ter( )t i% %ufficient to e'&ha%i5e here that, in thi% context, a co'&rehen%i$e a&&roach 'u%t be ta/en( "ro$iding treat'ent under general anae%the%ia for a child ,ho ha% been %ho,n to be unable to co&e ,ith o&erati$e dental care under local anae%the%ia ;,ith or ,ithout the %u&&ort of con%ciou% %edation< ,ill do ab%olutely nothing to i'&ro$e hi% or her future co-o&eration( Such treat'ent %hould, therefore, include the re%toration or extraction ;a% a&&ro&riate< of 033 cariou% teeth( >e$ Point The &ractice of extracting only the 'o%t gro%%ly cariou% or %y'&to'atic teeth ;and a%%u'ing that other cariou% teeth can be re%tored under local anae%thetic at a later %tage< &redi%&o%e% to a high rate of re&eat general anae%the%ia and %hould be di%couraged( The orthodontic i'&lication% of any &ro&o%ed treat'ent %hould al,ay% be con%idered( Thi% i% &articularly %o ,hen the lo%% of one or 'ore &er'anent unit% i% to be included in the treat'ent &lan( )n %uch ca%e%, the latter %hould ideally be dra,n u& in con%ultation ,ith a %&eciali%t in orthodontic%( Treat'ent under general anae%the%ia, irre%&ecti$e of ,hether thi% include% re%torati$e treat'ent or i% li'ited to extraction%, %hould be follo,ed ,ith an a&&ro&riate &re$enti$e &rogra''e( 6ailure to &ro$ide thi% al'o%t ine$itably lead% to the child undergoing further treat'ent ;u%ually extraction%< under general anae%the%ia(

3.2.2 Treatment lannin! +or "om le9 "a#e# The clinician %hould al,ay% ha$e a clear long-ter' *$i%ion* for the 'anage'ent of the indi$idual &atient( )n creating thi%, a&&ro&riate %&eciali%t in&ut to treat'ent &lanning %hould be %ought ,here indicated( 0t the %i'&le%t le$el, an orthodontic o&inion %hould be obtained before co''itting a child to 'ulti&le $i%it% to re%tore fir%t &er'anent 'olar% of &oor &rogno%i%( 1o,e$er, it i% in the treat'ent &lanning of co'&lex ca%e% ;%uch a% tho%e &re%enting ,ith generali5ed defect% of ena'el or dentine for'ation, hy&odontia, or cleft% of li& and &alate< that interdi%ci&linary %&eciali%t in&ut i% e%%ential( 6or exa'&le, %uch in&ut 'ay re%ult in the retention of anterior root% to 'aintain al$eolar bone in &re&aration for future i'&lant%H the u%e of &refor'ed 'etal cro,n% to 'aintain clinical cro,n height in &re&aration for definiti$e cro,n%H the u%e of directDlaboratory-for'ed co'&o%ite $eneer% in &re&aration for &orcelain $eneer% ,hen gro,th ;and any orthodontic treat'ent< i% co'&lete( >e$ Point The one o$er-riding con%ideration i% thi%G 'anage'ent in early adulthood %hould ne$er be co'&ro'i%ed by ina&&ro&riate treat'ent at a young age( 3.3 S(77ARY Treat'ent &lanning for young &atient% %hould not only addre%% current need% but %hould &lan ahead for tho%e of the future, thu% en%uring that e$ery child reache% adulthood ,ith a healthy, functional, and ae%thetic dentition a% ,ell a% &o%iti$e attitude% to,ard% denti%try( Meticulou% hi%tory-ta/ing, clinical exa'ination, and ri%/ a%%e%%'ent contribute to the deci%ion-'a/ing &roce%%, but one %hould ne$er lo%e %ight of ,hat i% reali%tic and &ractical for the child in the context of hi% or her en$iron'ent( To do other,i%e not only court% non-co'&liance but al%o fail% to recogni5e the 'o%t i'&ortant a%&ect of alla child*% indi$iduality( 3.4 F(RT5ER READIN6 De'ir+ian, 0(, Gold%tein, 1(, and Tanner, 7( M( ;=>?@<( 0 ne, %y%te' of dental age a%%e%%'ent( Human $iology, 05, ==- ?( ;-his paper descri,es how to underta%e an accurate dental age assessment for patients using a panoral radiograph(< E%&elid, )(, Me+are, )(, and Weerhei+', 2( ; 99@<( E0"D guideline% for the u%e of radiogra&h% in children( 7uropean +ournal of Paediatric Dentistry, 0, A9-C( ;-his excellent and comprehensive paper descri,es the appropriate use of dental radiographs for young patients(< Ma%carenha%, 0( 2( ;=>>C<( Oral hygiene a% a ri%/ indicator of ena'el and dentine carie%( Community Dentistry and 8ral 7pidemiology, 21, @@=->( ;-his study reviews the clinical indicators employed in caries ris% assessment and highlights the relationship ,etween poor oral hygiene and caries(<

"o,ell, 3( 8( ;=>CC<( Carie% ri%/ a%%e%%'entG rele$ance to the &ractitioner( +ournal of the "merican Dental "ssociation, /24, @A>-:@( ;-his comprehensive paper reviews the practical aspects of caries ris% assessment(< Rodd, 1( D(, and Wray, 0( ; 99A<( -reatment planning for the developing dentition( Kuinte%%ence "ubli%hing, 3ondon( ;-his practical and easily read ,oo% covers all aspects of treatment planning for children(< 3./0 REFERENCE The Children 0ct ;=>C><( De&art'ent of 1ealth( 1MSO 3ondon( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

0. P%arma"olo!i"al mana!ement o+ ain and an9iet$ - G + )o,erts and ( - Hosey 0./ INTR&D(CTI&N Effecti$e &ain 'anage'ent of a child, e%&ecially an anxiou% one, i% a challenge to e$ery denti%t( The need for good 'anage'ent of anxiety and &ain in &aediatric denti%try i% &ara'ount( 0 co''on cau%e of co'&laint fro' &arent% and their children i% that a denti%t *hurt* unnece%%arily( Such a co'&laint can +eo&ardi5e acce%% to lifelong dental care( Children are anato'ically and &hy%iologically different fro' adult%( The anato'y of the air,ay 'ean% that breathing i% through a narro,er, 'ore fixed *,ind &i&e*( "hy%iologically, a child i% le%% ca&able of ta/ing in a bigger $olu'e of air e$en ,hen urgently reBuired( Cou&led ,ith thi%, both the de'and for oxygen ;con%u'&tion< and the incidence of &eriodic breathing and a&noea% are higher co'&ared to adult%( The%e difference% 'ean that a child can beco'e hy&oxic 'ore ea%ily( 0.2 C5I*DREN?S PERCEPTI&N &F PAIN 0 child*% &erce&tion of &ain i% &urely %ub+ecti$e and $arie% ,idely, &articularly ,ith age( )nfant% u& to about year% of age are unable to di%tingui%h bet,een &re%%ure and &ain( 0fter the age of a&&roxi'ately and u& to the age of =9, children begin to ha$e %o'e under%tanding of *hurt* and begin to di%tingui%h it fro' &re%%ure or *a hea$y &u%h*( The &roble' i% that it i% not al,ay% &o%%ible to identify ,hich children are a'enable to ex&lanation and ,ho ,ill re%&ond by being co-o&erati$e ,hen challenged ,ith local anae%the%ia and dental treat'ent in the for' of drilling or extraction%( Children o$er the age of =9 are 'uch 'ore li/ely to be able to thin/ ab%tractly and &artici&ate 'ore acti$ely in the deci%ion to u%e local anae%the%ia, %edation, or general anae%the%ia( )ndeed, a% children enter their teenage year% they are ra&idly beco'ing 'ore and 'ore li/e adult% and are able to deter'ine 'ore directly, %o'eti'e% aggre%%i$ely, ,hether or not a &articular 'ethod of &ain control ,ill be u%ed( The re%&on%e i% further deter'ined by the child*% co&ing ability influenced by fa'ily $alue%, le$el of general anxiety ;trait<, and intelligence( >e$ Point# Children are anato'ically and &hy%iologically different fro' adult% thi% re%ult% in the' beco'ing hy&oxic 'ore ea%ily( Children*% re%&on%e to &ain i% influenced by age, 'e'ory of &re$iou% negati$e dental ex&erience, and co&ing ability( 0.3 C&NSENT

4efore you can do anything to a &atient, e$en a %i'&le exa'ination, con%ent 'u%t be obtained( Con%ent 'ay be i'&lied, $erbal, or ,ritten( The 'ain &ur&o%e of ,ritten con%ent i% to de'on%trate post hoc, in the e$ent of a di%&ute, that infor'ed con%ent ,a% obtained( )t ha% the con%iderable ad$antage of 'a/ing clinician% and &atient% &au%e to con%ider the i'&lication% of ,hat i% &lanned and to ,eigh the ad$antage% and di%ad$antage% %o that a rea%oned and infor'ed choice can be 'ade( The re%&on%ibility for infor'ed con%ent i% often %hared bet,een the referring &ri'ary care denti%t and the %econdary care %er$ice &ro$ider, e%&ecially ,here %edation and general anae%the%ia are in$ol$ed( Many health tru%t% and other e'&loying authoritie% are increa%ingly de'anding that ,ritten con%ent i% obtained for all &rocedure%( Thi% i% e%&ecially difficult no, a% the lo,er age of con%ent i% no longer %&ecifically li'ited( The %ole criterion i% ,hether or not the &atient i% *able to under%tand* the &rocedure% and their i'&lication%( )f %o, the &atient i% con%idered *co'&etent* and the child 'ay gi$e ;or refu%e< con%ent( )t i% u%ual to arri$e at a con%en%u% $ie, a'ong &arent%, child, and dental %urgeon( 0 %ufficiently infor'ati$e entry %hould be &laced in the &atient*% ca%e record%( 0% a &rag'atic rule the age of =! year% %till act% a% a guide( 4ut if a &rocedure i% &ro&o%ed and a child under =! year% %ay% *no* then con%ent ha% been refu%ed( 6ortunately, in &aediatric denti%try the &ro%&ect of a life-%a$ing o&eration i% rare %o a refu%al of con%ent can be 'anaged by a change in the &rocedure or by e%tabli%hing a te'&oral re%&ite( The current ad$ice fro' the &rotection %ocietie% i% that ,ritten con%ent 'u%t be obtained for a cour%e of treat'ent( The &lan of treat'ent &ro&o%ed 'u%t indicate the nature and extent of the treat'ent and the a&&roxi'ate nu'ber of ti'e% that local anae%the%ia andDor %edation i% to be u%ed( There i% no need to obtain ,ritten con%ent for each %e&arate ti'e that %edation i% u%ed( )f the &lan of treat'ent change% and along ,ith it the freBuency or nature of %edation, then it i% &rudent to obtain ,ritten con%ent for the change( The greater ri%/% a%%ociated ,ith general anae%the%ia reBuire %&ecific ,ritten con%ent for each and e$ery occa%ion that treat'ent i% carried out under general anae%the%ia( Exa'&le% of %uitably ,orded for'% are a$ailable fro' the Medical Defence Societie%( >e$ Point# 0 conference that in$ol$e% both the &arent and child hel&% to gain infor'ed con%entG -di%cu%% the dental &roble'%H -di%cu%% the treat'ent o&tion%Dalternati$e%H -agree the treat'ent &lan( Write-u& in the ca%e record( Obtain ,ritten ;%igned< con%ent 0.0 SYSTE7IC PAIN C&NTR&* Children 'ay need &ain control for *toothache* for a day or t,o before the re'o$al of cariou% teeth( Often, the teeth are al%o ab%ce%%ed %o that it i% nece%%ary to co'bine antibiotic thera&y ,ith analge%ia to obtain o&ti'u' &ain relief( 0dditionally, analge%ia i% reBuired &o%to&erati$ely u%ually after dento-al$eolar %urgery( The 'o%t co''on 'ethod of ad'ini%tration i% by 'outh( S'all children, and %o'e recalcitrant adole%cent%, refu%e to ta/e tablet% %o liBuid &re&aration% are needed( )f other 'ethod% of ad'ini%tration, %uch a% intra'u%cular or intra$enou%, are reBuired then the%e in+ection% %hould be ad'ini%tered by clinical %taff ex&erienced ,ith the%e

%&ecial techniBue%( Rectal ad'ini%tration i% increa%ingly co''on a% ab%or&tion fro' the rectal 'uco%a i% ra&id( )f %uch a route of ad'ini%tration i% to be u%ed, %&ecific con%ent 'u%t be obtained( )t %hould be re'e'bered that the do%e for children of different age% need% to be carefully e%ti'ated to a$oid the ri%/ of an o$erdo%e ;dangerou%< or of an underdo%e ;ineffecti$e<( The &arent% 'u%t be ad$i%ed that all drug% 'u%t be %tored in a %afe &lace, in a child-&roof container( 4athroo' cabinet% or /itchen cabinet% are the %afe%t &lace% a% they are out of reach and out of %ight of %'all children( S&ecific ad$ice on &re%cribing for children can be obtained fro' a local &har'aci%t or the 4riti%h -ational 6or'ulary ;4-6<( The do%age% for children can be calculated on the ba%i% of a &ercentage chart ;Table A(=<( Often *a$erage* do%e% are u%ed but the &re%criber ha% the ab%olute re%&on%ibility to confir' that the do%age% reco''ended are correct( The co''on drug% u%ed for &ain control in children are &araceta'ol 4-6 and ibu&rofen 4-6( The &otential %ide-effect% and the do%age% %hould be chec/ed ,ith the for'ulary before &re%cribing( 0%&irin %hould not be u%ed on children becau%e of the ri%/ of Reye*% %yndro'e( The increa%e in a%th'a a'ong children reBuire% that thi% be con%idered before ibu&rofen i% &re%cribed( -arcotic analge%ic% %uch a% codeine or 'or&hine can be u%ed on children but only after le%% &o,erful analge%ic% ha$e been %ho,n to be ineffecti$e( 0% abo$e, the do%age %hould be chec/ed ,ith the 4-6( 0.5 7ET5&DS &F PAIN C&NTR&* The different 'ethod% of &ain control $ary fro' %i'&le beha$iour 'anage'ent to full intubational general anae%the%ia in a ho%&ital o&erating theatre ;6ig( A(=<( There i% a %trong relation%hi& bet,een the &erce&tion of &ain ex&erienced and the degree of anxiety &ercei$ed by the &atient( "ainful &rocedure% cau%e fear and anxietyH fear and anxiety inten%ify &ain( Thi% circle of cau%e and effect i% central to the 'anage'ent of all &atient%( Good beha$iour 'anage'ent reduce% anxiety, ,hich in turn reduce% the &ercei$ed inten%ity of &ain, ,hich further reduce% the ex&erience of anxiety( 4eha$iour 'anage'ent ha$e been co$ered in detail in Cha&ter and local anae%thetic techniBue% in Cha&ter :( The 'a+ority of dental &rocedure% on children can be carried out u%ing a co'bination of the%e t,o techniBue%( Thi% cha&ter ,ill deal ,ith the 'ethod% of %edation and general anae%the%ia that are a&&licable to dental treat'ent in children( Fi!. 0./ The figure %ho,%, on the left-hand %cale, the a&&roxi'ate freBuency ,ith ,hich a &articular &ain control techniBue i% u%ed, and on the botto' %cale the increa%ing degree of &hy%iological intru%ion fro' local analge%ia, through %edation to general anae%the%ia( 0.1 7EDICA* STAT(S The ,ide $ariety of 'edical &roble'% 'a/e% it difficult to be &reci%e about the 'anage'ent %trategy a&&ro&riate for each &atient( Detailed de%cri&tion% of 'anage'ent of a $ariety of 'edical &roble'% a&&ear in a co'&rehen%i$e boo/ by Scully and Ca,%on ;=>>C<( With regard to %edation, the 0'erican Society of 0ne%the%iologi%t%* ;0S0< cla%%ification &ro$ide% an excellent guide to the ty&e of

%edation or anae%the%ia a&&ro&riate to an indi$idual &atient*% 'edical and beha$ioural &roble'% ;Table A( <( The deci%ion a% to ,hether a &atient %hould be treated under general anae%the%ia or local anae%the%ia, or local anae%the%ia ,ith %edation de&end% on a co'bination of factor%, the 'o%t i'&ortant of ,hich areG ;=< the age of the childH ; < the degree of %urgical trau'a in$ol$edH ;@< the &ercei$ed anxiety and ho, the &atient 'ay ;or ha%< re%&onded to %i'ilar le$el% of %urgical trau'aH ;A< the co'&lexity of the o&erati$e &rocedureH ;:< the 'edical %tatu% of the child( There are no hard and fa%t rule%, and e$ery &rocedure in e$ery child 'u%t be a%%e%%ed indi$idually and the different ele'ent% con%idered in collaboration ,ith the &arent and, ,here a&&ro&riate, ,ith the child( 6or exa'&le, the younger the child the greater the li/elihood of a need for general anae%the%ia( 0t the other end of the age range it i% unli/ely that a =:-year old ,ill need general anae%the%ia for %i'&le orthodontic extraction%, although thi% 'ight be reBuired for 'oderately co'&lex %urgery, %uch a% ex&o%ing and bonding an i'&acted canine( The degree of trau'a in$ol$ed i% al%o another factorH a %ingle extraction i% 'o%t li/ely to be carried out under local anae%the%ia, re'o$al of the four fir%t &er'anent 'olar% i% 'o%t li/ely to be carried out under general anae%the%ia( 0nxiety &ercei$ed a% exce%%i$e, e%&ecially after an atte'&t at treat'ent under local anae%the%ia and %edation, ,ould lead to %i'&le treat'ent %uch a% con%er$ati$e denti%try being carried out under a general anae%thetic u%ually in$ol$ing endotracheal intubation( Seriou% 'edical &roble'%, for exa'&le, cy%tic fibro%i% ,ith the a%%ociated re%&iratory &roble'% ,ould +u%tify u%ing %edation in%tead of general anae%the%ia e$en for 'ore trau'atic %urgery, %uch a% re'o$al of i'&acted canine%, but it ,ould be a&&ro&riate to carry out thi% %edation in a ho%&ital en$iron'ent( The degree of intellectual andDor &hy%ical i'&air'ent in handica&&ed children ,ould al%o be a factor to be con%idered( General anae%the%ia carrie% ,ith it a finite ri%/ of %eriou% 'orbidity %uch a% &%ychological trau'a and e$en death ;@ to A &er 'illion<( -o child %hould be %ub'itted to a general anae%thetic ,ithout con%ideration of thi% &otentially de$a%tating outco'e( )nter'ediate bet,een the 'ini'ally intru%i$e techniBue% of local anae%the%ia and the 'a+or intru%ion of general anae%the%ia are the techniBue% of con%ciou% %edation ;6ig( A(=<( >e$ Point# Each child %hould be a%%e%%ed on their 'erit% and an a&&ro&riate 'ethod of &ain control u%ed( The $a%t 'a+ority of children are a'enable to %ati%factory treat'ent u%ing beha$iour 'anage'ent and local anae%the%ia alone( -o child %hould be %ub'itted to a general anae%thetic ,ithout con%ideration of &otential ri%/( 0.2 C&NSCI&(S SEDATI&N TEC5NI@(ES

0.2.0 Introd-"tion Con%ciou% %edation i% defined a%G 0 techniBue in ,hich the u%e of a drug or drug% &roduce% a %tate of de&re%%ion of the central ner$ou% %y%te' enabling treat'ent to be carried out, but during ,hich $erbal contact ,ith the &atient i% 'aintained throughout the &eriod of %edation( The drug% and techniBue% u%ed to &ro$ide con%ciou% %edation for dental treat'ent %hould carry a 'argin of %afety ,ide enough to render unintended lo%% of con%ciou%ne%% unli/ely( The le$el of %edation 'u%t be %uch that the &atient re'ain% con%ciou%, retain% &rotecti$e reflexe%, and i% able to under%tand and re%&ond to $erbal co''and%( The route% of ad'ini%tration of %edati$e drug% u%ed in clinical &aediatric denti%try are oral, inhalational, intra$enou%, and tran%'uco%al ;e(g( na%al, rectal, %ublingual<( 1o,e$er, the tran%'uco%al route% are little u%ed in the #nited 2ingdo' and currently, intra$enou% %edation i% con%idered un%uitable for the o&eratorD%edationi%t ,hen ,or/ing on children( Current de$elo&'ent% in intra$enou% techniBue%, e%&ecially the u%e of target-controlled infu%ion &u'&% and &atient-controlled %edation ;"CS< 'ay &ro$e to be %ufficiently effecti$e and %afe for u%e by the o&eratorD%edationi%t, but further re%earch i% reBuired( >e$ Point The goal of con%ciou% %edation i% to u%e a &har'acological agent to aug'ent beha$ioural 'anage'ent to decrea%e anxiety le$el% ,hile 'aintaining a re%&on%i$e &atient( 0.2./ 6eneral +a"ilitie# The u%e of %edati$e drug% carrie% the ri%/ of inad$ertent lo%% of con%ciou%ne%%( 0lthough the techniBue% are de%igned to reduce thi% ri%/ to a 'ini'u' it %hould al,ay% be borne in 'ind that e$ery ti'e a %edati$e i% gi$en to a &atient there i% a ri%/ of an idio%yncratic reaction to the drug, ,hich 'ay re%ult in hy&oxia or unex&ected lo%% of con%ciou%ne%%( The clinician 'u%t arrange the clinical %e%%ion %o that %edation, irre%&ecti$e of co'&lication%, can &roceed %'oothly and %afely( Thi% include% the need for all &atient% ,ho are ha$ing %edation to be acco'&anied( Thi% can be any adult, ,ho under%tand% the i'&lication% and &otential &roble'% of caring for a child during the later %tage% of reco$ery( )n addition, the clinical facilitie% need to include %uitable re%u%citation eBui&'ent cou&led ,ith the /no,ledge and %/ill% to u%e the'( >e$ Point# The 'ain co'&lication% related to &aediatric con%ciou% %edation areG -hy&oxia, -nau%ea, -$o'iting, -inad$ertent lo%% of con%ciou%ne%% ;general anae%the%iaDo$er %edation<( Morbidity and 'ortality increa%e ,ithG -young age, -,or%ening 0S0 cla%%ification( 0.2.2 Emer!en"$ eA-i ment

Suitable e'ergency eBui&'ent 'u%t be a$ailable ea%ily to hand %ince ti'e i% of the ut'o%t i'&ortance( 6or thi% rea%on e'ergency eBui&'ent and drug% %hould be ,ithin ar'% reach of the o&erator and ready for i''ediate u%e( Training of the dental tea' i% a reBuire'ent, irre%&ecti$e of ,hether con%ciou% %edation i% &racti%ed( Training %hould be u&dated at regular inter$al% of not 'ore than = year( )t i% e%%ential that each 'e'ber of the dental tea' /no,% exactly ,hat i% reBuired of the' in an e'ergency( The dental %urgeon ha% the re%&on%ibility of en%uring the ea%y a$ailability of drug%, &articularly oxygen, and to %ee that the drug% in the e'ergency /it are not &a%t their *u%e by* date( 0.2.3 Emer!en"$ eA-i ment +or t%e dental #-r!eon The follo,ing are ite'% of eBui&'ent that a dental %urgeon %hould be &re&ared to u%e in an e'ergency( =( 1igh $olu'e %uction for clearing the air,ay% of %ali$a, debri%, and blood( Thi% 'u%t be ca&able of reaching the floor a% a &atient 'ay be re'o$ed fro' the dental chair to lie on the floor to enable re%u%citation( ( 0n e'ergency %u&&ly of oxygen( 0 regular ,or/ing %u&&ly of oxygen fro' an inhalation %edation unit i% an alternati$e( @( "o%iti$e &re%%ure $entilation a&&aratu% ,ith a %elf-inflating bag( A( 6ace 'a%/% to fit children and adole%cent%( :( Three %i5e% of oral air,ay%( 6oteG The%e ite'% %hould for' &art of an ar'a'entariu' of any denti%t ,hen treating &atient% u%ing local anae%the%ia alone( 0.2.0 Emer!en"$ dr-!# Suitable e'ergency drug% 'u%t be a$ailable and becau%e of the need for %&eed, the drug% 'u%t be %tored ,ith the e'ergency eBui&'ent( Training of the dental %urgeon and their %taff in the u%e of drug% ha% the %a'e reBuire'ent% a% for eBui&'ent( The nature and content of *e'ergency drug%* /it% are u%ually deter'ined by a local re%u%citation ad$i%er( 0.2.5 Emer!en"$ dr-!# +or t%e dental #-r!eon The follo,ing are drug% that the denti%t %hould be &re&ared to u%e in an e'ergencyG =( Oxygen( ( 0drenaline hydrochloride = 'gD'l ;=999 'gD'l<, that i%, = G =999 on a = 'l a'&oule for %ubcutaneou% or intra'u%cular in+ection( The )MS Min-)-7et %y%te' i% &articularly Buic/ and ea%y to u%e(

@( 1ydrocorti%one %odiu' &ho%&hate =99 'g &er $ial( To be 'ade u& to = 'l ,ith &hy%iological %aline i''ediately before u%e( 6or intra$enou% in+ection( A( )n addition to the abo$e drug% %uitable needle% and %yringe% %hould be a$ailable to enable drug% to be dra,n u& and ad'ini%tered &arenterally( :( 6lu'a5enil ;ben5odia5e&ine anatagoni%t< for re$er%ing unex&ected o$er-%edation fro' orally, intra$enou%ly, or rectally ad'ini%tered ben5odia5e&ine( 0.2.1 Emer!en"$ eA-i ment +or medi"all$ A-ali+ied and t%o#e #ta++ trained in ad.an"ed li+e #- ort =( 0 laryngo%co&e, endotracheal tube%, and force&% to 'ani&ulate the endotracheal tube% during intubation( ( 0 cricothyroto'y /it( @( 0n electrocardiogra&h( A( 0 defibrillator( 0.2.2 Emer!en"$ dr-!# +or medi"all$ A-ali+ied andBor # e"iall$ trained #ta++ =( 0drenaline = G =9, 999 ;=9 'l $ial%<( ( 0tro&ine = 'gD=9 'l ;=9 'l $ial%<( @( Calciu' chloride =9L ;=9 'l $ial%<( A( 3ignocaine =99 'gD=9 'l ;=L< ;=9 'l $ial%<( :( )%o&renaline 9( 'gD'l ;=9 'l $ial%<( !( 6ru%e'ide C9 'gDC 'l ;C 'l $ial%<( ?( Sodiu' bicarbonate C(AL ;:9 'l $ial%<( C( Gluco%e :9L ;:9 'l $ial%<( >( -aloxone A 'gD'l ;= 'l $ial%<( =9( 0'ino&hylline :9 'gD=9 'l ;=9 'l $ial%<( ==( Dia5e'ul% =9 'gD 'l ; 'l $ial%<( = ( 6lu'a5enil :99 ugD: 'l ;: 'l $ial%<( Many of the%e drug% are a$ailable in &refilled %yringe%( )t i% the re%&on%ibility of the denti%t to en%ure the a$ailability of the drug% reBuired by the 'edical %taff ,ho 'ay be called to deal ,ith an e'ergency( EBually, it i% the re%&on%ibility of the %a'e

'edical %taff to ad$i%e the dental %urgeon of hi% or her &reci%e reBuire'ent% ,ith regard to e'ergency drug%( Thi% ad$ice 'u%t be in ,riting( The%e can be re$ie,ed by reading the follo,ingG Euro&ean Re%u%citation Council ;=>> <( Guideline% for ba%ic and ad$anced life %u&&ort( )esuscitation, 20, =9@-=9( >e$ Point# Dental %urgeon% and their %taff %hould at lea%t be ca&able of &ro$iding ba%ic life %u&&ortG -Air,ay%H -;reathingH -CirculationH -A;C( The dental tea' %hould ha$e at lea%t yearly ba%ic life %u&&ort training( The dental %urgeon i% re%&on%ible for en%uring the readine%% of e'ergency eBui&'ent and drug%( 0.3 PREPARATI&N F&R C&NSCI&(S SEDATI&N 0.3./ En.ironment There %hould be a %uitable area ,here the child can %it Buietly before the o&eration %o that the %edati$e can be ad'ini%tered and the child 'onitored ,hile it i% ta/ing effect( 0% a general rule it i% not ,i%e to let children ha$e 'edication at ho'e a% Buiet %u&er$i%ion of the child ,ithin the %urgery &re'i%e% i% &rudent( 0 +ourney to the %urgery under the increa%ing influence of a 'ood-altering drug i% not the 'o%t &ro&itiou% ,ay of &re&aring di%tre%%ed children for treat'ent( The%e %tricture% do not a&&ly to inhalation %edation or intra$enou% %edation( 1o,e$er, the facilitie% %uitable for &ro$iding care a&&ly eBually to oral, inhalational, and intra$enou% %edation( During treat'ent there 'u%t be effecti$e %uction eBui&'ent and in the e$ent of a &o,er failure, a 'echanically o&erated bac/u&( Sedated &atient% often hallucinate or 'i%inter&ret ,ord% and action% and %o, a cha&erone to %afeguard the o&erator%edationi%t i% al%o e%%ential( Once treat'ent i% co'&lete the child %hould be able to %it ;or lie< Buietly until %ufficiently reco$ered to be acco'&anied ho'e( 0 further i'&ortant %trategy i% to ha$e a chec/li%t %o that the dental %urgeon can be %ure that all i'&ortant ele'ent% of %edation ha$e been &ro&erly con%idered( 0.3.2 Preo erati.e in#tr-"tion# The%e %hould be &ro$ided in ,riting and co$er %uch &oint% a% en%uring that a %uitable co'&anion bring% the child to and fro' the %urgery, that only a light 'eal i% eaten h or 'ore before an a&&oint'ent for %edation( )n thi% context, a light 'eal i% a cu& of tea and a %lice of toa%t( "o%to&erati$ely, %uitable arrange'ent% need to be in &lace for tra$el and to en%ure that the child &lay% Buietly at ho'e( )n addition to the%e %&ecific &oint% *local* rule% are li/ely to a&&ly( >e$ Point# To carry out con%ciou% %edationG infor'ed con%ent i% 'andatoryH

 &reo&erati$e and &o%to&erati$e in%truction% %hould be gi$en &rior to the %edation $i%itH &atient a%%e%%'ent include% 'edical, dental, and anxiety hi%toryH a&&ro&riate facilitie%, child-friendly en$iron'ent and %edation trained %taff are e%%entialH the o&erator-%edationi%t, irre%&ecti$e of gender, 'u%t be cha&eroned at all ti'e%H the child 'u%t be acco'&anied by an adult e%cortH a chec/li%t i% i'&ortant to en%ure all &re&aration% are in &lace( 0.4 7&NIT&RIN6 T5E SEDATED C5I*D 0.4./ Clini"al #tat-# Sedati$e drug% are al%o central ner$ou% %y%te' and re%&iratory de&re%%ant% and a% %uch, cau%e a $ariety of effect% fro' 'ild %edation, dee& %edation, and general anae%the%ia and, in exce%%i$e concentration%, e$en death( 6or thi% rea%on, the facilitie% outlined abo$e are nece%%ary in the unli/ely e$ent of unex&ected lo%% of con%ciou%ne%%( )t i% i'&ortant that dental %urgeon% ,or/ing ,ith children ha$e a $ery clear idea of the clinical %tatu% of %edated &atient%( The%e areG ;=< the &atient*% eye% are o&enH ; < the &atient i% able to re%&ond $erbally to Bue%tion%H ;@< the &atient i% able to inde&endently 'aintain an o&en 'outh ;thi% 'ay &reclude the u%e of a 'outh-&ro&<H ;A< the &atient i% able to inde&endently 'aintain a &atent air,ayH ;:< the ability to %,allo,H ;!< the child i% a nor'al &in/ colour( 0ll the%e criteria are e$idence of con%ciou% %edation( 6or thi% rea%on it i% i'&ortant not to let a child go to %lee& in the dental chair ,hile recei$ing treat'ent ,ith %edation a% clo%ed eye% 'ay be a %ign of %lee&, o$er-%edation, lo%% of con%ciou%ne%%, or cardio$a%cular colla&%e( 0.4.2 P-l#e o9imetr$ "ul%e oxi'etry i% a non-in$a%i$e 'ethod of 'ea%uring arterial oxygen %aturation u%ing a %en%or &robe &laced on the &atient*% finger or ear lobe, ,hich ha% a red light %ource to detect the relati$e difference in the ab%or&tion of light bet,een %aturated and de%aturated hae'oglobin during arterial &ul%ation( The &robe i% %en%iti$e to &atient 'o$e'ent, relati$e hy&other'ia, a'bient light, and abnor'al hae'oglobinae'ia%, %o fal%e reading% can occur( )n roo' air, a child*% nor'al oxygen %aturation ;SaO < i% >?L to =99L( 0deBuate oxygenation of the ti%%ue% occur% abo$e >:L ,hile oxygen %aturation% lo,er than thi% are con%idered hy&oxae'ic( >e$ Point# Monitoring a %edated child in$ol$e%G alert clinical 'onitoring%/in colour, re%&on%e to %ti'ulu%, ability to /ee& 'outh o&en, ability to both %,allo, and to 'aintain an inde&endent air,ay, nor'al radial &ul%eH

 the u%e of a &ul%e oxi'eter ;exce&t for nitrou% oxide inhalation %edation<( 0./0 &RA* SEDATI&N 0./0.0 Introd-"tion The on%et of the effect of oral %edati$e% i% $ariable and i% largely de&endent on the indi$idual*% rate of ab%or&tion fro' the ga%tro-inte%tinal tract, ,hich can be affected by the rate of ga%tric clearance, the a'ount of food in the %to'ach, and e$en the ti'e of the day( )n addition, the do%age i% deter'ined by the body ,eight( Therefore, a %et of &ro&erly calibrated bathroo' %cale% i% needed to enable the correct do%e of %edati$e to be e%ti'ated for each &atient( De%&ite thi%, %o'e children 'ay %&it out the drug, lea$ing the clinician uncertain about the exact do%age that ,a% ad'ini%tered( To co'bat thi%, %o'e %edationi%t% ad'ini%ter the liBuid %edati$e u%ing a %yringe &laced in the buccal 'uco%a or 'ix the drug ,ith a fla$oured elixir( The &atient 'ay reBuire u& to an hour of %u&er$i%ed &o%to&erati$e reco$ery( 0./0./ &ral #edati.e# Dia:e am The 'o%t fa'iliar of the ben5odia5e&ine% i% dia5e&a', u%ually ad'ini%tered at a do%age of :9 ugD/g( 6or a !-year-old child thi% i% a&&roxi'ately : 'g but could be a% lo, a% @(> 'g or a% high a% !(! 'g( 6or a 'uch older &atient, for exa'&le, a =:-year old, the a$erage do%e ,ould be =@(! 'g and 'ay $ary fro' >(? 'g to =C(> 'g( 7ida:olam Mida5ola' i% another ben5odia5e&ine that i% 'ore co''only u%ed a% an intra$enou% agent( 1o,e$er, it% u%e a% an oral %edati$e i% gro,ing though, currently it doe% not ha$e a &roduct licence for thi% a&&lication( The intra$enou% liBuid i% bitter to ta%te and %o the &re&aration i% often 'ixed ,ith a fruit fla$oured drin/( The oral do%e i% higher ;9(@-9(? 'gD/g< than the intra$enou% do%e becau%e the oral 'ida5ola' reache% the %y%te'ic circulation $ia the &ortal circulation ,hich decrea%e% the drug*% bioa$ailability, nece%%itating a higher oral do%age( E$idence i% %till relati$ely %cant, e%&ecially in children under C year% of age, and %o the u%e of oral 'ida5ola' i% %till largely re%tricted to %&eciali%t ho%&ital &ractice( C%loral %$drate Chloral hydrate i% a chlorinated deri$ati$e of ethyl alcohol, the *Mic/y 6inn*( )t i% a ,ea/ analge%ic and &%ycho%edati$e ,ith an eli'ination half-life of about C h( )n %'all do%e% ;A9-!9 'gD/g, but not exceeding = g<, 'ild %edation occur% but it can be ineffecti$e in the 'anage'ent of the 'ore anxiou% child( -au%ea and $o'iting are co''on due to ga%tric irritation( The drug al%o de&re%%e% the blood &re%%ure and the re%&iratory rate, 'yocardial de&re%%ion and arrhyth'ia can al%o occur( Recently, there ha% been concern that there i% a ri%/ of carcinogene%i%( 0lthough it i% %till in ,ide%&read u%e around the ,orld it i% gradually beco'ing ob%olete( &t%er dr-!#

There are other oral %edati$e drug% that are co''only re&orted in the literature in relation to &aediatric dental %edation( The%e includeG hydroxy5ine hydrochloride and &ro'etha5ine hydrochloride ;&%ycho%edati$e% ,ith an antihi%ta'inic, antie'etic, and anti%&a%'odic effect<, and /eta'ine ,hich i% a &o,erful general anae%thetic agent ,hich, in %'all do%age%, can &roduce a %tate of di%%ociation ,hile 'aintaining the &rotecti$e reflexe%( Co''on %ide-effect% of hydroxy5ine hydrochloride and &ro'etha5ine hydrochloride are dry 'outh, fe$er, and %/in ra%h( Side-effect% of /eta'ine include hy&erten%ion, $i$id hallucination%, &hy%ical 'o$e'ent, increa%ed %ali$ation, and ri%/ of laryngo%&a%', ad$anced air,ay &roficiency training i%, therefore, e%%ential( 2eta'ine carrie% the additional ri%/ of increa%e in blood &re%%ure, heart rate, and a fall in oxygen %aturation ,hen u%ed in co'bination ,ith other %edati$e%( E$idence to %u&&ort the %ingle u%e of either hydroxy5ine hydrochloride, &ro'etha5ine hydrochloride, or /eta'ine i% &oor( 7onitorin! d-rin! oral #edation Thi% in$ol$e% alert clinical 'onitoring and at lea%t the u%e of a &ul%e oxi'eter( 0./0.2 Clini"al te"%niA-e The follo,ing regi'en, u%ing the exa'&le of dia5e&a', ,a% found to be effecti$e in clinical &racticeG ;=< on arri$al of the &atient chec/ ,hether, &reo&erati$e in%truction% ha$e been follo,edH ; < ,eigh the &atient and e%ti'ate the do%e of dia5e&a'H ;@< ha$e the do%age chec/ed by a %econd &er%onH ;A< ad'ini%ter dia5e&a' N= h before the treat'entH ;:< allo, the &atient to %it in a *Buiet* roo'H ;!< once ready, %tart and co'&lete the treat'ent ,ith ;or ,ithout< local anae%the%iaH ;?< once the treat'ent i% co'&lete, allo, the &atient to reco$er in the Buiet roo' until ready to return ho'eH ;C< reiterate the &o%to&erati$e in%truction% to e%cort( 0.// IN5A*ATI&N SEDATI&N 0.//.0 Introd-"tion Thi% i% %ynony'ou% ,ith inhalation of an oxygen-nitrou% oxide ga% 'ixture in relati$ely lo, concentration%, u%ually 9-:9L nitrou% oxide( The techniBue i% uniBue a% the o&erator i% able to titrate the ga% again%t each indi$idual &atient( That i% to %ay, the o&erator increa%e% the concentration to the &atient, ob%er$e% the effect, and a% a&&ro&riate, increa%e% ;or %o'eti'e% decrea%e%< the concentration to obtain o&ti'u' %edation in each indi$idual &atient( )nhalation %edation con%i%t% of three ele'ent% ;6ig( A( <G

=( The ad'ini%tration of lo,-to-'oderate concentration% of nitrou% oxide in oxygen to &atient% ,ho re'ain con%ciou%( The &reci%e concentration of nitrou% oxide i% carefully titrated to the need% of each indi$idual &atient( ( 0% the nitrou% oxide begin% to exert it% &har'acological effect%, the &atient i% %ub+ected to a %teady flo, of rea%%uring and %e'i-hy&notic %ugge%tion( Thi% e%tabli%he% and 'aintain% ra&&ort ,ith the &atient( @( The u%e of eBui&'ent that exceed% the current 4S) Standard for %afety cut-out de$ice% in%talled ,ithin inhalation %edation eBui&'ent( Thi% 'ean% that it i% not &o%%ible to ad'ini%ter =99L nitrou% oxide either accidentally or deliberately ;the cutoff &oint i% u%ually ?9L<( Thi% i% an i'&ortant and critical clinical %afety feature that i% e%%ential for the o&eratorD%edationi%t( Fi!. 0.2 The triad of ele'ent% of inhalation %edation( 0.//./ EA-i ment +or in%alation #edation Cit% o9$!en-nitro-# o9ide !a# mi9t-re The 'o%t ,idely u%ed eBui&'ent for inhalation %edation i% the Kuantiflex MDM ;6ig( A(@<, ,hich enable% the o&erator to deli$er carefully controlled $olu'e% and concentration% of ga%e% to the &atient( )n addition to the 'achine head that control% the deli$ery of ga%e%, it i% al%o nece%%ary to ha$e a %uitable %ca$enging %y%te', and an a%%e'bly for the ga% cylinder%, either a 'obile %tand ;6ig( A(A< or a &i&eline %y%te' ,ith cylinder% %tored re'ote fro' the 'achine head ;6ig( A(:<( Fi!. 0.3 The MDM inhalation %edation unit( Fi!. 0.0 The 'obile cylinder %tand %ho,ing the u&&er &art of the oxygen and nitrou% oxide cylinder% and the re%er$oir bag( Fi!. 0.5 The MDM unit 'ounted unobtru%i$ely under a ,or/to&( 0.//.2 Clini"al te"%niA-e Of the inhalation %edation techniBue% a$ailable, the follo,ing i% the ea%ie%t, the 'o%t flexible, and the lea%t li/ely to cau%e %urgery &ollution( The control unit for the Kuantiflex MDM ;6ig( A(@< ha% a %ingle control for the total flo, of ga%e% ;6ig( A(@ *=*<, and a central, $ertically &laced, dial i% turned to regulate %i'ultaneou%ly the &ercentage flo, of both ga%e% ;6ig( A(@ * *<( Either of the%e control% can be changed ,ithout altering the other( The actual &ercentage of ga%e% being deli$ered i% 'onitored by ob%er$ing the flo, 'eter% for oxygen and nitrou% oxide, re%&ecti$ely ;6ig( A(@G *@* O *A*<( There are =: %te&% for the techniBueG =( Chec/ the 'achine( ( Select the a&&ro&riate %i5e of na%al 'a%/ and clean it ,ith alcohol( @( Connect u& the %ca$enging &i&e( A( Set the 'ixture dial to =99L oxygen( ;6ig( A(@ * *<

:( Settle the &atient in the dental chair( !( Turn the flo, control ;6ig( A(@ *=*< to @ lD'in and allo, the re%er$oir bag to fill ,ith oxygen( ?( With the &atient*% hel&, &o%ition the na%al 'a%/ gently and co'fortably to &reclude any lea/%( )f nece%%ary ex&lain the ,ay the 'a%/ i% u%ed( C( Turn the flo, control /nob to the left until the flo, rate of oxygen ;lD'in< 'atche% the &atient*% tidal $olu'e( Thi% can be 'onitored by ,atching the re%er$oir bag, and %hould ta/e =:- 9 %( When the &atient in%&ire%, the re%er$oir bag get% %'aller( When the &atient breathe% out the re%er$oir bag get% larger a% it fill% ,ith the 'ixture of ga%e% e'anating fro' the 'achine( >( Si'ultaneou%ly, rea%%ure the &atient about the %en%ation% that ,ill be felt( Encourage the &atient to concentrate on breathing gently through the no%e( )f the re%er$oir bag a&&ear% to be getting too e'&ty then the flo, of oxygen %hould be increa%ed until the flo, rate in lD'in 'atche% the &atient*% 'inute $olu'e( =9( Turn the 'ixture dial $ertically to >9L oxygen ;=9L nitrou% oxide< ;6ig( A(@ * *<( Wait for !9 %( ==( Turn the 'ixture dial to C9L oxygen ; 9L nitrou% oxide< ;6ig( A(@ * *<( Wait !9 %, abo$e thi% le$el the o&erator %hould exerci%e 'ore caution and con%ider ,hether further incre'ent% %hould be only :L( With ex&erience, o&erator% ,ill be able to +udge ,hether further incre'ent% are needed( = ( 0t the a&&ro&riate le$el of %edation dental treat'ent can be %tarted( =@( To bring about reco$ery turn the 'ixture dial to =99L oxygen and oxygenate the &atient for 'in before re'o$ing the na%al 'a%/( =A( Turn the flo, control to 5ero and %,itch off the 'achine( =:( The &atient %hould breathe a'bient air for a further : 'in before lea$ing the dental chair( The &atient %hould be allo,ed to reco$er for a total &eriod of =: 'in before lea$ing( 0t all ti'e% the &atient 'u%t re'ain con%ciou%( Thi% i% +udged by the fi$e clinically di%cernible %ign% de%cribed &re$iou%ly( The abo$e 'ethod of ad'ini%tration i% the ba%ic techniBue that i% reBuired in the early %tage% of clinical ex&erience for any o&erator( Thi% 'ethod en%ure% that the change% ex&erienced by the &atient do not occur %o Buic/ly that the &atient i% unable to co&e( Once the o&erator ha% %ufficient %/ill and confidence the %tage% can be *concertinaed*, for exa'&le, by %tarting at 9L nitrou% oxide and reducing the ti'e inter$al% bet,een incre'ent%( The initial ti'e inter$al% of !9 % are u%ed becau%e clinical ex&erience %ho,% that

%horter inter$al% bet,een incre'ent% can lead to too ra&id an induction and o$erdo%age( 0.//.3 T%e "orre"t le.el o+ "lini"al #edation Cit% nitro-# o9ide One of the &roble'% for the inex&erienced clinician i% to deter'ine ,hether or not the &atient i% adeBuately %edated for treat'ent to %tart( 4y careful attention to %ign% and %y'&to'% ex&erienced by the &atient the denti%t ,ill %oon be able to decide ,hether the &atient i% ready for treat'ent( The $ery ra&id u&ta/e and eli'ination of nitrou% oxide reBuire% the o&erator to be acutely $igilant %o that the &atient doe% not beco'e %edated too ra&idly( 0.//.0 &,De"ti.e #i!n# The ob+ecti$e %ign% %ho,ing the &atient i% ready for treat'ent are ;6ig( A(!<G ;=< the &atient i% a,a/eH ; < the &atient i% relaxed and co'fortableH ;@< the &atient re%&ond% coherently to $erbal in%truction%H ;A< &ul%e rate i% nor'alH ;:< blood &re%%ure i% nor'alH ;!< re%&iration i% nor'alH ;?< %/in colour i% nor'alH ;C< &u&il% are nor'al and contract nor'ally if a light i% %hone into the'H ;>< the laryngeal reflex i% nor'alH ;=9< the gag reflex i% reducedH ;==< reaction to &ainful %ti'uli i% le%%enedH ;= < there i% a general reduction in %&ontaneou% 'o$e'ent%H ;=@< the 'outh i% 'aintained o&en on reBue%t ;6ig( A(?<( Fi!. 0.1 Ob%er$able %ign% of %edation in relation to the concentration of nitrou% oxide u%ed( Fi!. 0.2 The *'outh o&en* %ign( 0.//.5 S-,De"ti.e #$m tom# Sub+ecti$e %y'&to'% ex&erienced by the &atient are ;6ig( A(C<G ;=< 'ental and &hy%ical relaxationH ; < a tingling %en%ation ;&arae%the%ia< %ingly or in any co'bination of li&%, finger%, toe%, or o$er the ,hole bodyH ;@< 'ild intoxication and eu&horiaH ;A< lethargyH ;:< a %en%e of detach'ent, %o'eti'e% inter&reted a% a floating or drifting %en%ationH ;!< a feeling of ,ar'thH ;?< indifference to %urrounding% and the &a%%age of ti'eH ;C< drea'ingH ;>< le%%ened a,arene%% of &ain(

)f the &atient tend% to co''unicate le%% and le%%, and i% allo,ing the 'outh to clo%e, then the%e are %ign% that the &atient i% beco'ing too dee&ly %edated( The concentration of nitrou% oxide %hould be reduced by =9 or =:L to &re$ent the &atient 'o$ing into a %tate of total analge%ia( Fi!. 0.3 Sub+ecti$e %y'&to'% ex&erienced by the &atient in relation to the nitrou% oxide concentration( 0.//.1 7onitorin! d-rin! nitro-# o9ide #edation During inhalation %edation it i% e%%ential that the clinician 'onitor% both the &atient and the 'achinery( 6or healthy &atient% ,ith 0S0 ) or )), u%e of a radial &ul%e i% %ufficient( 6or &atient% ,ith 0S0 ))) or )8, treat'ent ,ithin a ho%&ital en$iron'ent and &ul%e oxi'etry, blood &re%%ure cuff, andDor electrocardiogra&h 'onitoring ,ould be &rudent( Thi% a&&lie% to only a $ery %'all &ro&ortion of &atient% %uch a% tho%e ,ith cy%tic fibro%i% ,ith 'ar/ed lung %carring or children ,ith %e$ere congenital cardiac di%ea%e ,here there i% high blood &re%%ure or cyano%i%( T%e atient The clinician %hould &ay careful attention to the &atient*% le$el of anxiety( Thi% i% achie$ed by a%%e%%ing the &atient*% re%&on%e% to an o&erati$e %ti'ulu% %uch a% the dental drill( The le$el of %edation i% a%%e%%ed by the &atient*% de'eanour co'&ared ,ith hi% or her &re%edation beha$iour( )t i% i'&ortant to note that different &atient% exhibit %i'ilar le$el% of i'&air'ent at different concentration% of nitrou% oxide( )f the &atient a&&ear% to be too hea$ily %edated then the concentration of nitrou% oxide %hould be reduced( There i% no need to u%e &ul%e oxi'etry or ca&nogra&hy ;to 'ea%ure exhaled carbon dioxide le$el%< a% i% currently reco''ended for &atient% being %edated ,ith intra$enou%ly ad'ini%tered drug%( T%e ma"%iner$ 0t all %tage% of inhalation %edation, it i% nece%%ary to 'onitor inter'ittently the oxygen and nitrou% oxide flo, 'eter% to $erify that the 'achine i% deli$ering the ga%e% a% reBuired( )n addition, it i% e%%ential to loo/ at the re%er$oir bag to confir' that the &atient i% continuing to breathe through the no%e the nitrou% oxide ga% 'ixture( 3ittle or no 'o$e'ent of the re%er$oir bag %ugge%t% that the &atient i% 'outh breathing, or that there i% a gro%% lea/, for exa'&le, a &oorly fitting na%al 'a%/( >e$ Point# 6or nitrou% oxide inhalation %edationG %et the flo,H %lo,ly titrate the do%eH 'onitor the &atient*% re%&on%eH 'onitor the eBui&'ent( 0.//.2 T%e lane# o+ in%alation #edation The ad'ini%tration of oxygen-nitrou% oxide ga% 'ixture for %edating child &atient%

induce% three le$el% or &lane% of analge%ia and %edation( Plane /E moderate #edation and anal!e#ia Thi% &lane i% u%ually obtained ,ith concentration% of :- :L nitrou% oxide ;>:-?:L oxygen<( 0% the &atient i% being encouraged to inhale the 'ixture of ga%e% through the no%e, it i% nece%%ary to rea%%ure hi' or her that the %en%ation% de%cribed by the clinician 'ay not al,ay% be ex&erienced( The &atient 'ay feel tingling in the finger%, toe%, chee/%, tongue, bac/, head, or che%t( There i% a 'ar/ed %en%e of relaxation, the &ain thre%hold i% rai%ed, and there i% a di'inution of fear and anxiety( The &atient ,ill be ob$iou%ly relaxed and ,ill re%&ond clearly and %en%ibly to Bue%tion% and co''and%( Other %en%e%, %uch a% hearing, $i%ion, touch, and &ro&rioce&tion, are i'&aired in addition to the %en%ation of &ain being reduced( The &u&il% are nor'al in a&&earance and contract ,hen a light i% %hone into the'( The &eri-oral 'u%culature, %o often ten%ed in$oluntarily by the &atient during treat'ent, i% 'ore ea%ily retracted ,hen the dental %urgeon atte'&t% to obtain good acce%% for o&erati$e ,or/( The ab%ence of any %ide-effect% 'a/e% thi% an extre'ely u%eful &lane ,hen ,or/ing on 'oderately anxiou% &atient%( Plane 2E di##o"iation #edation and anal!e#ia Thi% &lane i% u%ually obtained ,ith concentration% of 9-::L nitrou% oxide ;C9-A:L oxygen<( 0% ,ith &lane =, &atient% do not al,ay% ex&erience all the %y'&to'%( Thi% %hould be re'e'bered ,hen rea%%uring and encouraging the'( 0% the &atient enter% thi% &lane, &%ychological %y'&to'%, de%cribed a% di%%ociation or detach'ent fro' the en$iron'ent, are ex&erienced( So'eti'e% thi% di%%ociation i% 'ini'al, at other ti'e% it i% &rofound( )t 'ay al%o ta/e the for' of a eu&horia %i'ilar to alcoholic intoxication ;,itne%% the laughing ga% &artie% of the 'id-nineteenth century<( The &atient 'ay feel %uffu%ed by a ,ar' ,a$e, and 'ay ex&erience a %light hu''ing or bu55ing in the ear%, and a dro,%ine%% or light-headedne%% %o'eti'e% de%cribed by the &atient a% a *floaty* or *,oo5y* feeling( The o$erall de'eanour of the &atient ,ill be relaxed and acBuie%cent( 0&art fro' the o$erall a&&earance of relaxation, one of the fe, tangible &hy%ical %ign% i% a reduction in the blin/ rate( 0t the dee&er le$el of thi% &lane of %edation the &%ychological effect% beco'e 'ore &ronounced( Occa%ionally, a &atient ,ill re&eat ,ord% or &hra%e% %e$eral ti'e% in %ucce%%ion( The ,ord% re&eated 'ay or 'ay not 'a/e %en%e( There i% a noticeable tendency for the &atient to drea', the drea'% u%ually being of a &lea%ant nature( )t i% belie$ed by 'any o&erator% that the drea'% ex&erienced by the &atient are to %o'e extent conditioned by the idea% and thought% introduced by the dental %urgeon during the induction &ha%e of %edation( The %edati$e effect i% con%iderably &ronounced, ,ith both &%ycho%edation and %o'atic %edation being &re%ent( The &%ycho%edation ta/e% the for' of a relaxed de'eanour, and a ,illingne%% on the &art of the &re$iou%ly un,illing &atient to allo, treat'ent regarded a% frightening or

e%&ecially trau'atic( The %o'atic %edation ta/e% the for' of &hy%ical relaxation, unre%i%ting &eri-oral 'u%culature, and occa%ionally an ar' or leg %liding off the %ide of the dental chair indicating &rofound relaxation( The analge%ic effect i% &robably accentuated by the %edation and %en%e of detach'ent( The &atient i% %till able to re%&ond to Bue%tion% and co''and%, although there 'ay be a con%iderable 'ental effort in$ol$ed in thin/ing out the an%,er( The re%&on%e i% u%ually delayed and %luggi%h( "arae%the%ia 'ay be 'ore &ronounced and co$er a greater area of the body than in &lane =( The &atient i% ne$erthele%% ob$iou%ly con%ciou% and can de'on%trate thi% by /ee&ing the 'outh ,ide o&en to a%%i%t the dental %urgeon during o&erati$e treat'ent( On reco$ery, the &atient 'ay exhibit total a'ne%ia( -au%ea i% a rare %ideeffect and $ery occa%ionally ;in le%% than 9(99@L of ad'ini%tration%< a &atient 'ay $o'it( Plane 3E total anal!e#ia Thi% &lane i% u%ually obtained ,ith concentration% of :9-?9L nitrou% oxide ;:9-@9L oxygen<( )t ha% been clai'ed, that analge%ia i% %o co'&lete that extraction of teeth 'ay be carried out in thi% &lane( Thi% ha% not been our ex&erience( )n thi% &lane there i% an increa%ed tendency to drea'( )t i% i'&ortant to recogni5e that in a %'all nu'ber of &atient% a% little a% :9L nitrou% oxide 'ay bring about lo%% of con%ciou%ne%%( )t i% for thi% rea%on that denti%t% 'u%t exerci%e con%iderable caution if the concentration of ga% co'ing fro' the 'achine ri%e% abo$e A9L nitrou% oxide( )f the &atient doe% beco'e too dee&ly %edated and enter% thi% third &lane of total analge%ia, he or %he begin% to lo%e the ability to inde&endently 'aintain an o&en 'outh and ,ill be unable to co-o&erate or re%&ond to the denti%t*% reBue%t%( )f thi% *o&en 'outh* %ign i% lo%t, the o&erator can be %ure that the &atient i% too dee& in the &lane of total analge%ia and ,ithin a fe, 'inute% i% li/ely to enter the &lane of light anae%the%ia( )t i% for thi% rea%on that a 'outh &ro& 'u%t ne$er be u%ed, for if a &ro& i% u%ed the o&en 'outh %ign ,ould not function( )f %edation i% too dee& and the &atient %ho,% %ign% of failing to co-o&erate, then the denti%t %hould reduce the concentration of nitrou% oxide by =9 or =:L for a cou&le of 'inute%( )f it i% con%idered nece%%ary to lighten the %edation e$en 'ore ra&idly, the na%al hood %hould be re'o$ed and the &atient allo,ed to breathe a'bient air( The &atient ,ill return to a lighter &lane ,ithin =:- 9 %( Thi% &lane of total analge%ia i% regarded a% a buffer 5one bet,een the clinically u%eful &lane% of 'oderate and di%%ociation %edation and analge%ia, and the &otentially ha5ardou% &lane of light anae%the%ia( 0.//.3 Clini"al a li"ation

The techniBue of nitrou% oxide %edation can be u%ed for a ,ide range of &rocedure% in$ol$ing the cutting of hard or %oft ti%%ue ,here local anae%the%ia ,ill u%ually be needed to %u&&le'ent the general analge%ia fro' the nitrou% oxide( The 'a+or di%ad$antage ;or 'inor if handled &ro&erly< i% the incon$enience of the na%al hood re%tricting acce%% to the u&&er inci%or area if an a&icecto'y i% reBuired( Thi% &roble' can be o$erco'e by careful retraction of the u&&er li& and counter&re%%ure fro' the thu'b held on the bridge of the no%e(

0.//.4 S"a.en!in! Re&eated ex&o%ure to en$iron'ental &ollution ,ith nitrou% oxide can cau%e 'egalobla%tic anae'ia and &roble'% ,ith both conce&tion and &regnancy( The Control of Sub%tance% 1a5ardou% to 1ealth ;COS11< ad$i%e% that o$er a ti'e,eighted a$erage ;TW0< of C h, the ex&o%ure %hould not exceed =99 &(&('( Thi% i% fi$e ti'e% lo,er than the %afe%t do%e found in ani'al %tudie%( Surgery conta'ination i% affected by the modus operandi of the dental %urgeon( Con%iderable care need% to be ta/en to di%courage the &atient% fro' 'outh breathing, to u%e rubber da' ,hene$er &o%%ible, and en%ure that full reco$ery i% carried out ,ith the na%al hood in &lace( Effecti$e %ca$enging eBui&'ent i% extre'ely %i'&le in de%ign ;6ig( A(><( Thi% de%ign of %ca$enger can be u%ed on a nor'al relati$e analge%ia 'achine ,ithout any %&ecific 'odification% to the 'achine it%elf( 0ll that i% reBuired i% a change in the de%ign of the na%al hood and the tubing leading fro' the 'achine to the hood( 6ir%t, the ex&iratory andDor air entrain'ent $al$e on the na%al hood it%elf i% re'o$ed and re&laced ,ith a %i'&le blan/ becau%e the u%e of thi% $al$e i% ob%olete( The efferent tube that lead% a,ay fro' the na%al 'a%/ i% doubled in dia'eter to reduce re%i%tance and connect% to a %&ecially de$i%ed exhau%t &i&e built into the ,all or floor of the %urgery( )f con%idered e%%ential, negati$e &re%%ure can be a&&lied at thi% connection to increa%e the efficiency of the %ca$enging ;acti$e %ca$enging<( >e$ Point# To reduce nitrou% oxide &ollution u%e a %ca$enging %y%te'H u%e a %ca$enging na%al hood ;bloc/ air entrain'ent $al$e% in older na%al hood%<H di%courage 'outh breathing ;do not let the child tal/<H u%e rubber da'( Fi!. 0.4 Sca$enging %y%te' a&&lied to an inhalation %edation 'achine ,ith outlet in the floor( 0./2 INTRA)EN&(S SEDATI&N 0./2.0 Introd-"tion The circu'%tance% ,hen intra$enou% %edation can be u%ed in &aediatric denti%try are li'ited, although there i% a %lo, but %teady trend to extending it% u%e e%&ecially in adole%cent%( 0./2./ Intra.eno-# a!ent# There are 'any intra$enou% agent% a$ailable in the 4-6, but for dental &ur&o%e% the &ractical choice i% bet,een 'ida5ola', a ben5odia5e&ine that i% ,ater %oluble and ,ell tolerated by ti%%ue% ;i'&ortant if %o'e 'ida5ola' inad$ertently beco'e% de&o%ited out%ide rather than in%ide a $ein< and &ro&ofol, ,hich lead% to ra&id %edation and ra&id reco$ery( #nfortunately, the ri%/ of unintended lo%% of con%ciou%ne%% i% high ,ith &ro&ofol becau%e of the narro, thera&eutic range of the drug that lead% Buic/ly to anae%the%ia( Therefore, &ro&ofol i% u%ed only ,hen there i%

an anae%theti%t &re%ent( 0./2.2 EA-i ment +or intra.eno-# #edation The general %urgery %et u& i% the %a'e a% for inhalation %edation( 0 di%&o%able tray %hould be &re&ared ,ith the follo,ingG ;=< a : 'l %yringeH ; < a $enflonH ;@< adhe%i$e ta&eH ;A< a green needle gauge =H ;:< i%o&ro&yl alcohol %,abH ;!< a %ingle a'&oule of the intra$enou% %edation drugH ;?< an a'&oule of flu'a5enil ;for urgent re$er%al of ben5odia5e&ine %edation<H ;C< a tourniBuet( The techniBue can be carried out a% %ho,n in the follo,ing %ection%( 0./2.3 Intra.eno-# te"%niA-e The %tandard regi'en i% to u%e 9(9? 'gD/g of 'ida5ola' infu%ed %lo,ly until the %ign% of %ati%factory %edation are reached( Thi% u%ually entail% a loading do%e of 'g follo,ed by further incre'ent% a% a&&ro&riate( The techniBue reBuire% the in%ertion of a $enflon that i% allo,ed to re'ain in situ until the treat'ent for that $i%it i% co'&lete( Thi% a&&lie% to 'anual infu%ion by the dental %urgeon, diffu%ion &u'& infu%ion %u&er$i%ed by the dental %urgeon, and &atient controlled anae%the%ia ;"C0<( 6or anxiou% children thi% i% an al'o%t in%u&erable &roble' a% *the needle* i% the cau%e of their fear( -e$erthele%%, there a&&ear% to be a grou& of older children, u%ually adole%cent% reBuiring dento-al$eolar %urgery, ,ho are ,illing to allo, the &lace'ent of a needle in the dor%u' of the hand or the antecubital fo%%a for infu%ion of ben5odia5e&ine drug%( Intra.eno-# a""e## The t,o 'o%t co''on %ite% of acce%% are the antecubital fo%%a and the dor%u' of the hand( )n children e%&ecially, the antecubital fo%%a carrie% ,ith it the danger of the needle cau%ing da'age to the $ein and %urrounding %tructure% if the ar' i% bent during %edation( 6or thi% rea%on the dor%u' of the hand i% the &referred %ite( Pro"ed-re =( The &atient*% 'edical hi%tory i% chec/ed( ( The ar' i% extended and a tourniBuet a&&lied( @( The &ul%e oxi'eter i% a&&lied to the contralateral ar'( 6oteG a $ery anxiou% &atient 'ight be di%tre%%ed by the%e &rocedure% %o they can be left until the &atient i% %edated( A( The $enflon i% in%erted into the $ein and ta&ed into &lace(

:( The &atient i% a%/ed to touch the ti& of the no%e to de'on%trate good neuro'otor control( !( The fir%t do%e of drug i% ad'ini%tered o$er @9 % ;6ig( A(=9<( ?( The &atient*% re%&on%e i% a%%e%%ed after 'in to deter'ine ,hether further ;%'aller< incre'ent% of the %edati$e agent are reBuired( C( Dental treat'ent i% carried out( )f %edation beco'e% inadeBuate further incre'ent% of the %edati$e agent 'ay be gi$en( >( Once dental treat'ent i% co'&lete, the &atient i% allo,ed to reco$er %ufficiently to be hel&ed to the reco$ery area( =9( Reco$ery 'u%t be under the %u&er$i%ory eye of a %&ecially trained &er%onnel( ==( Once the &atient i% *%treet fit*, they are di%charged into the care of an acco'&anying adult( = ( "o%to&erati$e in%truction% are reiterated( 7onitorin! d-rin! intra.eno-# #edation Thi% in$ol$e% alert clinical 'onitoring and at lea%t the u%e of a &ul%e oxi'eter( Fi!. 0./0 )ntra$enou% ad'ini%tration of 'ida5ola' through a $ein in the dor%u' of the hand( (ne9 e"ted lo## o+ "on#"io-#ne## 0./2.0 On the rare occa%ion% ,hen the &atient beco'e% uncon%ciou% the denti%t and their (%taff %hould follo, the follo,ing routine

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=( Cea%e the o&erati$e &rocedure i''ediately( ( En%ure that the 'outh i% cleared of all fluid% by u%ing high-$olu'e %uction( @( Turn the &atient on to hi% or her %ide in the *reco$ery* &o%ition ;6ig( A(==<( A( Con%ider the ad'ini%tration of =99L oxygen( :( )f intra$enou% %edation i% being u%ed, lea$e the $enflon in &lace %o that e'ergency drug% can be ad'ini%tered through it if reBuired( !( Con%ider 'onitoring &ul%e, blood &re%%ure, and re%&iration( 4e ready to %tart re%u%citation( ?( Denti%t to %tay ,ith the &atient until full %ign% of being a,a/e are &re%ent ;eye% o&en, inde&endent 'aintenance of the air,ay%, and $erbal contact<( C( 6ollo,-u& of the &atient by re$ie, ,ithin @ day%( >( 6ull docu'entation of the incident( =9( )nfor' the &atient*% general 'edical &ractitioner of the incident( Fi!. 0.// Reco$ery &o%ition( 0./3 6ENERA* ANAEST5ESIA 0./3.0 Introd-"tion The u%e of general anae%the%ia in &aediatric denti%try ha% a ,ide a&&lication, u%ually for the extraction of teeth( 6ortunately, referral% ha$e reduced, due to both the reduction in dental di%ea%e and to the u%e of %edation( -e$erthele%%, there ,ill al,ay% be a need for general anae%the%ia in denti%try, e%&ecially for &re-co-o&erati$e children( >e$ Point# )n the #nited 2ingdo', general anae%the%ia can no, only ta/e &lace in a ho%&ital %etting, and be ad'ini%tered by a con%ultant anae%theti%t( Ri%/ of general anae%the%iaG -'ortalityN @ &er 'illionH -'orbidity%y'&to'% a%%ociated ,ith the &rocedure, di%tre%% at induction and during reco$ery, &rolonged crying, nau%ea, %ic/ne%%, and &o%to&erati$e bleeding( Referring denti%t% are obliged toG -ex&lain the ri%/% of general anae%the%iaH -di%cu%% the alternati$e treat'ent 'odalitie%H -ex&lain ,hy the o&tion of general anae%the%ia ha% been %electedH

-/ee& a co&y of their referral letterH -the referring denti%t 'u%t be a%%ured of the a&&ro&riatene%% of the care &ro$ided by %edation or general anae%thetic %er$ice( )ndication% for general anae%the%ia -the child i% &re coo&erati$e ;too young to co&e< -uncontrolled fear -co'&lexity of &rocedure( 0./3./ T$ e o+ anae#t%e#ia )n denti%try, anae%the%ia fall% into three 'ain grou&%G ;=< out-&atient %hort-ca%e *dental chair* anae%the%ia traditionally ,ith a no%e 'a%/ but no, 'ore often ,ith a laryngeal 'a%/ ; < out-&atientDday-%tay *intubation* anae%the%iaH ;@< in-&atientDho%&ital-%tay *intubation* anae%the%ia( Within the%e categorie% there are $ariation% deter'ined by anae%theti%tic &reference( 0nae%the%ia for dental treat'ent reBuire% the hel& of a con%ultant anae%theti%t( The organi5ation of dental general anae%the%ia li%t%, at lea%t in the &reli'inary %tage%, i% &erfor'ed by a dental %urgeon ,ho therefore 'u%t under%tand the ty&e of anae%the%ia and the i'&lication% of any underlying 'edical condition( 0./3.2 De+inition o+ anae#t%e#ia The %tate of anae%the%ia i% defined a%G *The ab%ence of %en%ation artificially induced by the ad'ini%tration of ga%e% or the in+ection of drug% or a co'bination of both*( The i'&ortant feature of anae%the%ia i% that the &atient i% co'&letely ,ithout the ability to inde&endently 'aintain &hy%iological function, %uch a% breathing and &rotecti$e reflexe%, and i% acutely $ulnerable to the lo%% of any foreign bodie% or fluid% do,n the throat( 0./3.3 &-t- atient ?#%ort-"a#e? !eneral anae#t%e#ia Thi% i% u%ed for 0S0 cla%% ) or cla%% )) &atient% reBuiring %hort, -=9 'in, &rocedure% ,ith ra&id induction and early reco$ery, for exa'&le, dental extraction%( 0nae%the%ia i% induced either by inhalation of an anae%thetic $a&our in an oxygen-nitrou% oxide 'ixture u%ing a face 'a%/ or by an intra$enou% in+ection for exa'&le, &ro&ofol( Occa%ionally, the child i% &re'edicated ,ith a ben5odia5e&ine( The &arent co''only acco'&anie% the child to hel& the' co&e ,ith the anae%thetic induction( )rre%&ecti$e of the induction 'ethod, anae%the%ia i% 'aintained by the anae%thetic $a&our, for exa'&le, %e$ofluorane, carried in a 'ixture of oxygen and nitrou% oxide, and the face 'a%/ i% exchanged for a no%e 'a%/ or a laryngeal 'a%/ ;6ig( A(= different %i5e% of laryngeal 'a%/%<( 6ollo,ing thi%, the oro&harynx i% &ac/ed ,ith gau5e to &rotect the air,ay( Thi% gau5e i% the rea%on ,hy children %o'eti'e% later co'&lain of a %ore throat( Monitoring for thi% ty&e of anae%the%ia u%ually con%i%t% of an electrocardiogra&h, &ul%e oxi'eter, and a blood &re%%ure cuff( On co'&letion of treat'ent, the gau5e i% re'o$ed and the &atient turned into the reco$ery &o%ition and re'o$ed to a Buiet reco$ery roo' %o that heD%he can be

'onitored during their final reco$ery( The child i% di%charged ,hen he or %he i% able to drin/ a gla%% of ,ater ,ithout being %ic/ and able to %tand ,ithout %,aying or a&&earing di55y( 0lthough the child i% dee'ed *%treet fit*, once he or %he ha% arri$ed ho'e the co'bined effect% of anxiety, the general anae%thetic, and the dental %urgery, 'a/e it nece%%ary for the child to &lay *Buietly at ho'e* for the re%t of that day( Fi!. 0./2 Different %i5e% of laryngeal 'a%/%( 0./3.0 &-t- atient ?da$-#ta$? !eneral anae#t%e#ia Thi% i% u%ually re%er$ed for 0S0 cla%% ) or cla%% )) &atient% ,ho reBuire dental treat'ent that la%t% 'ore than =9 'in, for exa'&le, re'o$al of %u&ernu'erarie%, co'&lex and co'&ound odonto'e%, ex&o%ing and bonding i'&acted teeth, or exten%i$e con%er$ati$e denti%try( Day %urgery unit% co''only offer &re'edication and &re-anae%thetic $i%it% to facilitate the child*% ability to co&e ,ith the $i%it( 0nae%thetic induction i% %i'ilar to that for *%hort ca%e* anae%the%ia but an endotracheal tube i% u%ed, in%tead of a no%e 'a%/, either in%erted through the no%e ;na%otracheal tube< or through the 'outh ;orotracheal tube<( To in%ert it, a %hort-acting neuro'u%cular &araly%ing agent need% to be u%ed, ,hen thi% ,ear% off the &atient then breath% %&ontaneou%ly( Occa%ionally, a longer-acting neuro'u%cular &araly%ing agent i% %elected to enable the anae%theti%t to $entilate the &atient artificially( The%e for'% of anae%the%ia ha$e a greater intru%ion u&on the &atient*% &hy%iological %tate( 1o,e$er, the u%e of a laryngeal 'a%/ in%tead of an endotracheal tube i% gaining in &o&ularity becau%e it a$oid% the u%e of the &araly%ing agent reducing &o%to&erati$e 'u%cle &ain( -e$erthele%%, the %a'e &rinci&le% of &rotecting the air,ay% a&&ly( )n addition to the tube, the throat ,ill be &ac/ed ,ith gau5e( )f con%er$ation i% reBuired it i% &rudent to u%e a rubber da', a% good i%olation i% e%%ential for a high %tandard of o&erati$e denti%try ;6ig( A(=@<( 6or %urgical &rocedure%, local anae%the%ia infiltration ; L lignocaine ,ith = G C9,999 adrenaline< reduce% bleeding and aid% $i%ibility during %urgery ,hile reducing the ri%/ of cardiac dy%rhyth'ia%( Once the treat'ent i% co'&lete the &atient i% &laced in the reco$ery &o%ition and ,heeled to a reco$ery %uite( The reco$ery fro' %uch exten%i$e anae%the%ia i% %uch that the &atient 'ay not be able to return ho'e for %e$eral hour%( #%ually it i% nece%%ary to ha$e acce%% to a car a% the children are ne$er Buite a% *%treet fit* a% tho%e ,ho ha$e had a %hort anae%thetic, %o &ublic tran%&ort i% be%t a$oided( Fi!. 0./3 Rubber da' a&&lied during general anae%the%ia( In- atientB%o# ital-#ta$ ?int-,ation? anae#t%e#ia 0./3.5 "atient% ,ho are unfit for %hort or 'ediu' length general anae%thetic% are u%ually in 0S0 cla%% )))( The%e &atient% ha$e a 'edical &roble' that con%titute% a %ignificant increa%ed ri%/, %o anae%theti%t% ad$i%e that they are treated in a ho%&ital o&erating theatre, ,hich i% al,ay% clo%e to the facilitie% of an inten%i$e care unit( The dental %urgery i% no 'ore co'&lex than that carried out for *%hort-* and *day-%tay* anae%the%ia, but the underlying 'edical condition reBuire% the increa%ed le$el of care that 'ay be needed in the o&erating theatre en$iron'ent and during &o%t-o&erati$e reco$ery, and

(e$en later on the ,ard >e$ Point# There are different ty&e% of dental anae%the%ia, de&endent on the co'&lexity and (length of ti'e for the &lanned dental &rocedure ( Children ,ith a 'edical condition 'ay reBuire ho%&ital ad'i%%ion S(77ARY 0./0 Mo%t &atient% can be treated u%ing local anae%the%ia and good beha$iour (= ('anage'ent 0 %ignificant 'inority of &atient% ,ill reBuire %o'e for' of %edation to enable the' ( (to undergo dental treat'ent (0 %'all 'inority of &atient% reBuire general anae%the%ia (@ 0ll techniBue% reBuire careful and %y%te'atic a%%e%%'ent of the &atient before being (A (u%ed Denti%t% and their %taff reBuire careful training and regular u&date% in the (: (techniBue% of anae%the%ia and %edation for children F(RT5ER READIN6 0./5 Chad,ic/, 4( 3( and 1o%ey, M( T( ; 99@<( Child taming= how to manage children in dental practice ;Kuinte%%ential% %erie% nu'ber ><( Kuinte%%ence &ubli%her%, 3ondon( ;"n easy read for the whole dental team that also provides insight on how to ;(incorporate inhalation sedation into a treatment plan Cote, C( 7(, -otter'an, D( 0(, 2arl, 1( W, Weinberg, 7( 0(, and McClo%/ey, C( ; 999<( 0d$er%e %edation e$ent% in &ediatric%G a critical incident analy%i% of contributing factor%( P%ee co''ent%Q( Pediatrics; /05, C9:-=A( ;" rather scary paper ;(that highlights the need for appropriate training; facilities and resuscitation s%ill Craig D( and S/elly M( ; 99A<( Practical conscious sedation ;Kuinte%%ential% Serie% nu'ber =:<( Kuinte%%ence &ubli%her%, 3ondon( ;" user<friendly guide for the dental ;(team that mainly focuses on intravenous sedation Euro&ean Re%u%citation Council ;=>> <( Guideline% for ba%ic and ad$anced life %u&&ort( )esuscitation, 20, =9@-=9( ;Guidelines that all practitioners should read and ;(put into effect 1ealth Ser$ice% 0d$i%ory Co''ittee( ;=>>:<( "naesthetic agents= controlling exposure under C8#HH( 1MSO( ;-he current U0 safety standard of nitrous oxide ;(environmental exposure 3ind%ay, S( 7( E( and .ate%, 7( 0( ;=>C:<( The effecti$ene%% of oral dia5e&a' in anxiou% child dental &atient%( $ritish Dental +ournal, /54, =A>-:@( ;"n o,9ective ;(study on the efficacy of oral premedication

Re&ort of the Wor/ing "arty on Training in Dental 0nae%the%ia( ;=>>@<( Standing Dental 0d$i%ory Co''ittee, De&art'ent of 1ealth, #nited 2ingdo'( ;"n excellent guide to sedation and anaesthesia in general dental practice and community dental ;(practice Robert%, G( 7( and Ro%enbau', -( 3( ;=>>9<( " colour atlas of dental analgesia and sedation( Wolfe "ubli%hing, 3ondon( ;"ll you need to %now a,out local analgesia and ;(sedation Standard% in Con%ciou% Sedation for Denti%try( ; 999<( Re&ort of an )nde&endent Ex&ert Wor/ing Grou&( October( 0$ailable fro' S00D :@ Wi'&ole Street 3ondon( W=G C.1 htt&GDD,,,(%aadu/(org ;" matter<of fact document that outlines the ;(facilities and training expected in the U0 Wil%on, 2( E(, Welbury, R( R(, and Girdler, -( M( ; 99 <( 0 rando'i%ed double blind cro%%o$er trial of oral 'ida5ola' for &aediatric dental %edation( "naesthesia 52, C!9;(?( ;8ne of the few oral mida>olam trials conducted in children Scully, C( and Ca,%on, R( 0( ; 99A<( (edical pro,lems in dentistry( Churchill 3i$ing%tone, Edinburgh ;:th edn<( ;-he most comprehensive account of how to cope ;(with medical pro,lems

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Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy 5. *o"al anae#t%e#ia +or "%ildren - + G (eechan 5./ INTR&D(CTI&N Thi% cha&ter con%ider% the u%e of local anae%the%ia in children and de%cribe% 'ethod%

of in+ection that %hould &roduce 'ini'al di%co'fort( The co'&lication% and contraindication% to the u%e of local anae%the%ia in children are al%o di%cu%%ed( The 'a+or u%e of local anae%thetic% i% in &ro$iding o&erati$e &ain control( )t %hould not be forgotten, ho,e$er, that the%e drug% can be u%ed a% diagno%tic tool% and in the control of hae'orrhage( 5.2 S(RFACE ANAEST5ESIA 5.2.0 Introd-"tion Surface anae%the%ia can be achie$ed by &hy%ical or &har'acological 'ethod% ;to&ical anae%thetic%<( One &hy%ical 'ethod e'&loyed in denti%try in$ol$e% the u%e of ethyl chloride( )t relie% on the latent heat of e$a&oration of thi% $olatile liBuid to reduce the te'&erature of the %urface ti%%ue to &roduce anae%the%ia( Thi% 'ethod i% rarely u%ed in children a% it i% difficult to direct the %trea' of liBuid accurately ,ithout in$ol$ing a%%ociated %en%iti$e %tructure% %uch a% teeth( )n addition, the general anae%thetic action of ethyl chloride %hould not be forgotten( 5.2./ Intraoral to i"al a!ent# The %ucce%% of to&ical anae%the%ia i% techniBue de&endent( To&ical anae%thetic agent% ,ill anae%theti5e a -@ '' de&th of %urface ti%%ue ,hen u%ed &ro&erly( The follo,ing &oint% are ,orth noting ,hen u%ing intraoral to&ical anae%thetic%G =( The area of a&&lication %hould be dried( ( The anae%thetic %hould be a&&lied o$er a li'ited area( @( The anae%thetic %hould be a&&lied for %ufficient ti'e( 0 nu'ber of different &re&aration% $arying in the acti$e agent and in concentration are a$ailable for intraoral u%e( )n the #nited 2ingdo' the agent% 'o%t co''only e'&loyed are lidocaine ;lignocaine< and ben5ocaine( To&ical anae%thetic% are &ro$ided a% %&ray%, %olution%, crea'%, or oint'ent%( S&ray% are the lea%t con$enient a% they are difficult to direct( So'e %&ray% ta%te un&lea%ant and can lead to exce%% %ali$ation if they inad$ertently reach the tongue( )n addition, unle%% a 'etered do%e i% deli$ered, the Buantity of anae%thetic u%ed i% &oorly controlled( )t i% i'&ortant to li'it the a'ount of to&ical anae%thetic u%ed( The acti$e agent i% &re%ent in greater concentration in to&ical &re&aration% co'&ared ,ith local anae%thetic %olution% and u&ta/e fro' the 'uco%a i% ra&id( Sy%te'ic u&ta/e i% e$en Buic/er in da'aged ti%%ue( 0n effecti$e 'ethod of a&&lication i% to %&read %o'e crea' on the end of a cotton bud ;6ig( :(=<( 0ll the con$entional intraoral to&ical anae%thetic% are eBually effecti$e ,hen u%ed on reflected 'uco%a( The length of ti'e of ad'ini%tration i% crucial for the %ucce%% of to&ical anae%thetic%( 0&&lication% of around =: % or %o are u%ele%%( 0n a&&lication ti'e of around : 'in i% reco''ended( )t i% i'&ortant that to&ical anae%thetic% are gi$en %ufficient ti'e to ,or/, becau%e for 'any children thi% ,ill be their initial ex&erience of intraoral &ain-control techniBue%( )f the fir%t 'ethod encountered i% un%ucce%%ful then confidence in the o&erator and hi% ar'a'entariu' ,ill not be e%tabli%hed( 0lthough the 'ain u%e of to&ical anae%thetic% i% a% a

&rein+ection treat'ent, the%e agent% ha$e been u%ed in children a% the %ole 'ean% of anae%the%ia for %o'e intraoral &rocedure% including the extraction of deciduou% teeth( Fi!. 5./ #%e of a cotton bud to a&&ly a to&ical anae%thetic o$er a li'ited area( 5.2.2 To i"al anae#t%eti"# t%at Cill anae#t%eti:e #=in EM30 crea' ;a :L eutectic 'ixture of the anae%thetic agent% &rilocaine and lidocaine ;lignocaine<< ,a% the fir%t to&ical anae%thetic to be %ho,n to &roduce effecti$e %urface anae%the%ia of intact %/in( Therefore it i% a u%eful ad+unct to the &ro$i%ion of general anae%the%ia in children a% it allo,% &ain-free $ene&uncture( When u%ed on %/in it ha% to be a&&lied for = h and i% thu% only a&&ro&riate for electi$e general anae%thetic%( Clinical trial% of the u%e of EM30 intraorally ha$e %ho,n it to be 'ore effecti$e than con$entional local anae%thetic% ,hen u%ed on attached gingi$a %uch a% the hard &alate and interdental &a&illae( )t a&&ear% to be no 'ore effecti$e than con$entional to&ical agent% ,hen a&&lied to reflected 'uco%a( 0t &re%ent, the intraoral u%e of EM30 i% not reco''ended by it% 'anufacturer%( 0n intraoral for'ulation of the co'bination of &rilocaine and lidocaine ;OraBix< ha% %ho,n &ro'i%e in clinical trial% but at the ti'e of ,riting ,a% not a$ailable for u%e( Tetracaine ;a'ethocaine< AL gel i% another %/in to&ical anae%thetic that 'ay be u%eful &rior to $ene&uncture( #nli/e EM30, ,hich con%i%t% of a'ide local anae%thetic%, tetracaine ;a'ethocaine< i% an e%ter-ty&e anae%thetic agent( 5.2.3 Controlled-relea#e de.i"e# The u%e of to&ically acti$e agent% incor&orated into 'aterial% that ,ill adhere to 'uco%a and allo, the %lo, relea%e of the agent i% a &otential gro,th area in the field of local anae%thetic deli$ery( Such techniBue% 'ight &ro$e to be of $alue in &aediatric denti%try( Clinical %tudie% in$e%tigating the relea%e of lidocaine ;ligno-caine< fro' intraoral &atche% ha$e %ho,n %o'e &ro'i%e( 5.2.0 jet inDe"tor# 7et in+ector% belong to a category %o'e,here bet,een to&ical and local anae%the%ia but ,ill be di%cu%%ed here for co'&letene%%( The%e de$ice% allo, anae%the%ia of the %urface and to a de&th of o$er = c' ,ithout the u%e of a needle( They deli$er a +et of %olution through the ti%%ue under high &re%%ure ;6ig( :( <( Con$entional local anae%thetic %olution% are u%ed in %&eciali5ed %yringe% and ha$e been %ucce%%ful in children ,ith bleeding diathe%e% ,here dee& in+ection i% contraindicated( 7et in+ection ha% been u%ed both a% the %ole 'ean% of achie$ing local anae%the%ia and &rior to con$entional techniBue%( Thi% 'ethod of anae%the%ia ha% been u%ed alone and in co'bination ,ith %edation to allo, the &ain-free extraction of &ri'ary teeth( The u%e of +et in+ection i% not ,ide%&read for a nu'ber of rea%on%( Ex&en%i$e eBui&'ent i% reBuired, %oft ti%%ue da'age can be &roduced if a carele%% techniBue i% e'&loyed, and the %&eciali5ed %yringe% can be frightening to children both in a&&earance and in the %ound &roduced during anae%thetic deli$ery( )n addition, the un&lea%ant ta%te of the anae%thetic %olution, ,hich can acco'&any the u%e of thi% techniBue, can be off&utting( 0lthough no needle i% e'&loyed the techniBue i% not &ainle%%(

Fi!. 5.2 The +et in+ector( ;4y /ind &er'i%%ion of Dental Update(< 5.3 N&N-P5AR7AC&*&6ICA* PAIN C&NTR&* 0 nu'ber of non-&har'acological 'ethod% for reducing the &ain of o&erati$e denti%try are no, a$ailable, including the u%e of electrical %ti'ulation and radio ,a$e%( 1y&no%i% al%o belong% to thi% category( Electroanalge%ia or TE-S ;tran%cutaneou% electrical ner$e %ti'ulation< ha% been %ho,n to be $ery effecti$e in &ro$iding anae%the%ia for re%torati$e &rocedure% in children aged @-= year%( The techniBue ha% al%o been u%ed to &ro$ide &ain control during the extraction of &ri'ary teeth( )t can al%o be u%ed a% a *dee& to&ical* agent to reduce the &ain of local anae%thetic in+ection%( )n younger children the le$el of %ti'ulation i% controlled by the o&erator( Children o$er =9 year% can %ufficiently under%tand the 'ethod to be able to control the le$el of %ti'ulu% the'%el$e%( The ba%i% of TE-S bloc/ing tran%'i%%ion of the acute &ain of dental o&erati$e &rocedure% i% due to the fact that large 'yelinated ner$e fibre% ;%uch a% tho%e re%&onding to touch< ha$e a lo,er thre%hold for electrical %ti'ulation than %'aller un'yelinated &ain fibre%( Sti'ulation of the%e fibre% by the current fro' the TE-S 'achine clo%e% the *gate* to central tran%'i%%ion of the %ignal fro' the &ain fibre%( Thi% i% Buite different fro' the u%e of TE-S in the treat'ent of chronic &ain ,here the relea%e of endogenou% &ain/iller% %uch a% -endor&hin% i% %ti'ulated( )n addition, if the &atient o&erate% the 'achine, the feeling of control can allay anxiety and aid in &ain 'anage'ent( -on-&har'acological 'ethod% of &ain control offer t,o ad$antage%( 6ir%t, %y%te'ic toxicity ,ill not occur, and, %econd, the %oft ti%%ue anae%the%ia re%ol$e% at the end of the &rocedure( Thi% reduce% the chance% of %elf-inflicted trau'a( 1y&no%i% can be u%ed a% an ad+unct to local anae%the%ia in children by decrea%ing the &ul%e rate and the incidence of crying( )t a&&ear% to be 'o%t effecti$e in young children( 5.0 *&CA* ANAEST5ETIC S&*(TI&NS 0 nu'ber of local anae%thetic %olution% are no, a$ailable that can &ro$ide anae%the%ia la%ting fro' =9 'in to o$er ! h( There are fe,, if any, indication% for the u%e of the %o-called *long-acting* agent% in children( The gold %tandard i% lidocaine ;lignocaine< ,ith e&ine&hrine ;adrenaline<( #nle%% there i% a true allergy to lidocaine then L lidocaine ,ith = G C9,999 e&ine&hrine i% the %olution of choice in the #nited 2ingdo'( *Short-acting* agent% %uch a% &lain lidocaine are %eldo' e'&loyed a% the %ole agent becau%e, although &ul&al anae%the%ia 'ay be %hort-li$ed, %oft ti%%ue effect% can %till la%t o$er an hour or %o( More i'&ortantly, the efficacy of &lain %olution% i% 'uch le%% than tho%e containing a $a%ocon%trictor( 5.5 TEC5NI@(ES &F *&CA* ANAEST5ESIA 5.5.0 Introd-"tion There are no techniBue% of local anae%thetic ad'ini%tration that are uniBue to childrenH ho,e$er, 'odification% to %tandard 'ethod% are %o'eti'e% reBuired( 0% far a%

&o%itioning the child i% concerned the u&&er body %hould be around @9 degree% to the $ertical( Sitting u&right can increa%e the chance% of a faint, ,hile at the other extre'e ;fully %u&ine< the child 'ay feel ill at ea%e( When there i% a choice of %ite% at ,hich to ad'ini%ter the fir%t local anae%thetic in+ection the &ri'ary 'axillary 'olar area %hould be cho%en( Thi% i% the region that i% 'o%t ea%ily anae%theti5ed ,ith the lea%t di%co'fort( 5.5./ In+iltration anae#t%e#ia )nfiltration anae%the%ia i% the 'ethod of choice in the 'axilla( The infiltration of 9(:=(9 'l of local anae%thetic i% %ufficient for &ul&al anae%the%ia of 'o%t teeth in children( The ob+ecti$e i% to de&o%it local anae%thetic %olution a% clo%e a% &o%%ible to the a&ex of the tooth of intere%tho,e$er, the &re%ence of bone &re$ent% direct a&&o%ition( 0% the a&ice% of 'o%t teeth are clo%er to the buccal %ide, a buccal a&&roach i% e'&loyed and the needle i% directed to,ard% the a&ex after in%ertion through reflected 'uco%a( Direct de&o%ition under &erio%teu' can be &ainful, therefore a co'&ro'i%e i% 'ade and the %olution i% deli$ered %u&ra&erio%teally( The one area ,here &ul&al anae%the%ia can &ro$e trouble%o'e in the child*% 'axilla i% the u&&er fir%t &er'anent 'olar region ,here the &roxi'ity of the 5ygo'atic buttre%% can inhibit the %&read of %olution to the a&ical area ;%ee further<( )n the 'andible, the u%e of buccal infiltration anae%the%ia ,ill often &roduce &ul&al anae%the%ia of the &ri'ary teethH ho,e$er, it i% u%ually unreliable ,hen o&erating on the &er'anent dentition ,ith the exce&tion of the lo,er inci%or teeth( The 'o%t de&endable for' of anae%the%ia in the &o%terior 'andible i% inferior al$eolar ner$e bloc/ anae%the%ia( 5.5.2 Re!ional ,lo"= anae#t%e#ia In+erior al.eolar and lin!-al ner.e ,lo"=# The ad'ini%tration of the inferior al$eolar and lingual ner$e bloc/ i% ea%ier to &erfor' %ucce%%fully in children co'&ared to adult%( 0 co''on fault in adult% i% &lacing the needle too lo, on the ra'u% of the 'andible ,ith de&o%ition of %olution inferior to the 'andibular fora'en( )n children, the 'andibular fora'en i% lo, in relation to the occlu%al &lane ;6ig( :(@<, and it i% difficult to &lace the needle inferior to the 'andibular fora'en if it i% introduced &arallel to the occlu%al &lane( Thu% in children it i% ea%ier to en%ure that the %olution i% de&o%ited around the ner$e before it enter% the 'andibular canal( The techniBue of ad'ini%tration i% identical to that u%ed in adult% and i% be%t &erfor'ed ,ith the child*% 'outh fully o&en( The direct a&&roachintroducing the needle fro' the &ri'ary 'olar% of the o&&o%ite %idei% reco''ended a% le%% needle 'o$e'ent i% reBuired after ti%%ue &enetration ,ith thi% 'ethod co'&ared to the indirect techniBue( The o&erator*% non-do'inant hand %u&&ort% the 'andible ,ith the thu'b intraorally in the retro'olar region of the 'andible( The index or 'iddle finger i% &laced extraorally at the &o%terior border of the ra'u% at the %a'e height a% the thu'b( The needle i% ad$anced fro' the &ri'ary 'olar region of the o&&o%ite %ide ,ith the %yringe held &arallel to the 'andibular occlu%al &lane( The needle i% in%erted through 'uco%a in the 'andibular retro'olar region lateral to the &tery-go'andibular ra&he 'id,ay bet,een the ra&he and the anterior border of the a%cending ra'u% of the 'andible, ai'ing for a &oint half,ay bet,een the o&erator*% thu'b and index finger( The height of in%ertion i% about : '' abo$e the 'andibular occlu%al &lane, although in young children entry at the height of

the occlu%al &lane %hould al%o be %ucce%%ful( The needle %hould be ad$anced until the 'edial border of the 'andible i% reached( )n young children bone ,ill be reached after about =: '' and thu% a :-'' needle can be u%edH ho,e$er, in older children a long ;@: ''< needle %hould be e'&loyed a% &enetration u& to : '' 'ay be reBuired( Once bone ha% been touched the needle i% ,ithdra,n %lightly until it i% %u&ra&erio%teal, a%&iration i% &erfor'ed, and =(: 'l of %olution de&o%ited( The lingual ner$e i% bloc/ed by ,ithdra,ing the needle half,ay, a%&irating again, and de&o%iting 'o%t of the re'aining %olution at thi% &oint( The final content% of the cartridge are ex&elled a% the needle i% ,ithdra,n through the ti%%ue%( 0 co''on fault i% to contact bone only a fe, 'illi'etre% follo,ing in%ertion( )n 'o%t children thi% ,ill lead to un%ucce%%ful anae%the%ia( Thi% u%ually occur% due to entry at too obtu%e an angle( )f thi% occur% the needle %hould not be co'&letely ,ithdra,n but &ulled bac/ a cou&le of 'illi'etre%, and then ad$anced &arallel to the ra'u% for about = c' ,ith the barrel of the %yringe o$er the 'andibular teeth of the %a'e %ide( The body of the %yringe i% then re&o%itioned acro%% the &ri'ary 'olar% or &re'olar% of the o&&o%ite %ide and ad$anced to,ard% the 'edial border of the ra'u%( *on! ,-""al< mental< and in"i#i.e ner.e ,lo"=# The long buccal in+ection u%ually eBuate% to a buccal infiltration in children( The 'ental and inci%i$e ner$e bloc/ i% readily ad'ini%tered in children a% the orientation of the 'ental fora'en i% %uch that it face% for,ard rather than &o%teriorly a% in adult% ;6ig( :(A<( Thu% it i% ea%ier for %olution to diffu%e through the fora'en ,hen a&&roached fro' an anterior direction( The needle i% ad$anced in the buccal %ulcu% and directed to,ard% the region bet,een the fir%t and %econd &ri'ary 'olar a&ice%( 4loc/ade of tran%'i%%ion in the 'ental ner$e &ro$ide% excellent %oft ti%%ue anae%the%iaH ho,e$er, anae%the%ia of the inci%i$e ner$e ;,hich %u&&lie% the dental &ul&%< by thi% a&&roach i% not a% reliable a% an inferior al$eolar ner$e bloc/( The &ul&% of lo,er inci%or teeth 'ay not be %ati%factorily anae%theti5ed by inferior al$eolar ner$e or 'ental and inci%i$e ner$e bloc/ in+ection% a% a re%ult of cro%%-o$er %u&&ly fro' the contralateral inferior al$eolar ner$e( 0 buccal infiltration ad+acent to the tooth of intere%t i% %ufficient to deal ,ith thi% %u&&ly( The 'ethod of choice for &ul&al anae%the%ia in the &er'anent lo,er inci%or% i% a co'bination of buccal and lingual infiltration%( 7a9illar$ ,lo"= te"%niA-e# Regional bloc/ techniBue% are %eldo' reBuired in a child*% 'axilla( Greater &alatine and na%o&alatine ner$e bloc/% are a$oided by infiltrating local anae%thetic %olution through already anae%theti5ed buccal &a&illae and *cha%ing* the anae%thetic through to the &alatal 'uco%a ;%ee further<( Thi% techniBue i% eBually effecti$e in anae%theti5ing lingual gingi$ae in the lo,er +a, if infiltration or 'ental bloc/ techniBue% ha$e been u%ed ;it i% ob$iou%ly not needed if a lingual bloc/ ha% been ad'ini%tered ,ith an inferior al$eolar ner$e bloc/ in+ection<( The effect% of an infraorbital bloc/ are often achie$ed by infiltration anae%the%ia in the canineD'axillary fir%t &ri'ary 'olar region in young children( Fi!. 5.3 The 'andibular fora'en i% belo, the occlu%al &lane in children( ;4y /ind &er'i%%ion of Dental Update(<

Fi!. 5.0 The 'ental fora'en face% anteriorly in children ;left< co'&ared ,ith &o%teriorly in adult%( ;4y /ind &er'i%%ion of Dental Update(< 5.5.3 Intrali!amentar$ anae#t%e#ia )ntraliga'entary or &eriodontal liga'ent ;&dl< anae%the%ia i% a $ery effecti$e techniBue in children ;6ig( :(:<( Thi% i% a 'ethod of intrao%%eou% in+ection ,ith local anae%thetic reaching the cancellou% %&ace in the bone $ia the &eriodontal liga'ent( Thi% 'ethod allo,% the u%e of %'all a'ount% of local anae%thetic %olution( The reco''ended do%e &er root i% 9( 'l( 0lthough &ul&al anae%the%ia i% not due to i%chae'ia, the techniBue i% %ignificantly 'ore %ucce%%ful ,hen a $a%ocon%trictorcontaining %olution i% e'&loyed( The anae%thetic of choice i% L lidocaine ;lignocaine< ,ith = G C9,999 e&ine&hrine ;adrenaline<( Sen%ible do%e li'itation% 'u%t be u%ed, a% entry into the circulation of intrao%%eou%ly ad'ini%tered drug% i% a% ra&id a% by the intra$enou% route( The techniBue in$ol$e% in%erting a @9-gauge needle at an angle of a&&roxi'ately @9 to the long axi% of the tooth into the gingi$al %ulcu% at the 'e%iobuccal a%&ect of each root, and ad$ancing the needle until fir' re%i%tance i% 'et( )t ,ould %ee' %en%ible to ha$e the be$el facing the bone ,hen the %olution i% being ex&elledH ho,e$er, it ha% ne$er been de'on%trated that the direction to ,hich the be$el face% affect% the efficacy of the techniBue( The needle ,ill not ad$ance far do,n the liga'ent, a% e$en a @9-gauge needle i% 'any ti'e% ,ider than a healthy &eriodontal liga'ent( The needle nor'ally re'ain% ,edged at the al$eolar cre%t( The %olution i% then in+ected under fir' controlled &re%%ure until 9( 'l ha% been deli$ered( The a&&lication of the a&&ro&riate &re%%ure i% ea%ier ,ith %&eciali5ed %yringe% ;6ig%( :(! and :(?< but the techniBue i% eBually effecti$e ,ith con$entional dental %yringe%( 0nother ad$antage of the %&eciali5ed %yringe% i% that they deli$er a %et do%e &er de&re%%ion of the trigger ;9(9!-9( 'l de&ending on de%ign<( When u%ing con$entional %yringe% for intraliga'entary in+ection% the reco''ended do%e of 9( 'l for each root can be $i%uali5ed a% thi% i% a&&roxi'ately the $olu'e of the rubber bung in the cartridge( )t i% i'&ortant not to in+ect too Buic/lyH about =: % &er de&re%%ion of the %&eciali5ed %yringe le$er i% needed( 0l%o, it i% be%t to ,ait about : % after the in+ection before ,ithdra,ing the needle to allo, the ex&re%%ed %olution to diffu%e through the bone, other,i%e it e%ca&e% $ia the gingi$al %ulcu% into the 'outh( )ntraliga'entary anae%the%ia reduce%, but doe% not co'&letely eli'inate, the %oft ti%%ue anae%the%ia ,hich acco'&anie% regional bloc/ anae%the%ia in the 'andible( Thi% hel&% reduce the occurrence of %elf-'utilation of li& and tongue( )ntraliga'entary anae%the%ia i% often 'i%ta/enly con%idered a *one tooth* anae%thetic( 0d+acent teeth 'ay exhibit anae%the%ia and care 'u%t be u%ed if thi% 'ethod i% being u%ed a% a diagno%tic tool in the location of a &ainful tooth( There are fe, indication% for the u%e of the &dl techniBue in the 'axilla becau%e reliable &ain-free anae%the%ia %hould be &o%%ible in all region% of the u&&er +a, u%ing infiltration techniBue%( )n the 'axilla, intraliga'entary anae%the%ia i% be%t con%idered a% a %u&&le'entary 'ethod of achie$ing &ain control if con$entional techniBue% ha$e failed( The techniBue can be in$aluable in the &o%terior 'andible and can eli'inate the need for unco'fortable regional bloc/ in+ection%( Fi!. 5.5 )ntraliga'entary in+ection in a child(

Fi!. 5.1 "i%tol-gri& intraliga'entary %yringe%( Fi!. 5.2 0 &en-gri& intraliga'entary %yringe( Thi% i% a le%%-aggre%%i$e loo/ing in%tru'ent than the &i%tol-gri& ty&e and i% &referred in children( 5.1 PAIN-FREE *&CA* ANAEST5ESIA 5.1.0 Introd-"tion The ad'ini%tration of &ain-free local anae%the%ia de&end% u&on a nu'ber of factor% ,hich are ,ithin the control of the o&erator( The%e factor% relate toG ;=< eBui&'entH ; < 'aterial%H ;@< techniBue%( 5.1./ EA-i ment 0ll co'&onent% of the local anae%thetic deli$ery %y%te' can contribute to the di%co'fort of the in+ection( -eedle% %hould be %har& and the fine%t a$ailable gauge %hould be u%ed( The narro,e%t needle u%ed in denti%try i% @9 gauge( 0 narro, gauge doe% not interfere ,ith the ability to a%&irate blood, but it i% ,orth noting that narro, needle% are 'ore li/ely to &enetrate blood $e%%el% than their ,ider counter&art%( The choice of %yringe u%ed for con$entional local anae%thetic in+ection% in children 'u%t allo, a%&iration both before and during in+ection( There i% e$idence that inad$ertent intra$a%cular in+ection i% 'ore li/ely to occur in younger &atient%( "o%iti$e a%&irate incidence% of 9L of inferior al$eolar ner$e bloc/ in+ection% in the ?-= year age grou& ha$e been re&orted( One a%&ect of local anae%thetic deli$ery that can contribute to di%co'fort i% the %&eed of in+ection( The u%e of co'&uteri5ed deli$ery %y%te'% %uch a% *The Wand* &er'it% $ery %lo, deli$ery of %olution ;6ig( :(C<( Thi% i% &articularly u%eful ,hen in+ecting into ti%%ue of lo, co'&liance %uch a% the &alatal 'uco%a and &eriodontal liga'ent( When u%ing con$entional %yringe% the choice of anae%thetic cartridge can al%o contribute to the di%co'fort ex&erienced during in+ection( The ty&e of cartridge u%ed %hould be one that allo,% de&re%%ion of the rubber bung at a con%tant rate ,ith a con%tant force( Cartridge% that &roduce a +uddering action %hould not be e'&loyed( Fi!. 5.3 The Wand co'&uteri5ed in+ection %y%te', ,hich &er'it% %lo, deli$ery of %olution( 5.1.2 7aterial# )n the &a%t, heating the content% of local anae%thetic cartridge% to body te'&erature &rior to in+ection ha% been ad$i%ed( There i% no %ound ba%i% for thi% reco''endation( There i% a'&le e$idence to %ugge%t that &atient% cannot differentiate bet,een local anae%thetic% bet,een roo' and body te'&erature( )ndeed, %torage of cartridge% at higher te'&erature% can be detri'ental to the %olution a% thi% can increa%e the chance% of bacterial conta'ination, decrea%e the acti$ity of e&ine&hrine ;adrenaline< in the %olution due to increa%ed oxidation, and finally decrea%e the &1 of the %olution ;%ee further<( Cartridge% %tored in a refrigerator %hould be allo,ed to reach roo' te'&erature before u%e( The &1 of the in+ected %olution 'ay affect the di%co'fort of

the in+ection( 3ocal anae%thetic %olution% $ary in their &1%, tho%e containing $a%ocon%trictor% ha$ing lo,er $alue%( 6or exa'&le, L &lain lidocaine ;lignocaine< ha% a &1 of !(C co'&ared ,ith &1 @( for L lidocaine ,ith = G C9,999 e&ine&hrine ;adrenaline<( Thu% if 'ini'al %en%ation i% to be &roduced it 'ay be ,orth,hile u%ing a %'all do%e of a &lain %olution a% an initial in+ection before u%ing a $a%ocon%trictorcontaining %olution a% the definiti$e local anae%thetic( 5.1.3 Te"%niA-e# Po#terior ma9illar$ ,-""al in+iltration# 0%%u'ing the &ro&er 'aterial% and eBui&'ent ha$e been cho%en then the follo,ing techniBue can be u%ed to reduce the di%co'fort of buccal infiltration in+ection% in the 'axilla &o%terior to the canineG =( Dry the 'uco%a and a&&ly a to&ical anae%thetic for : 'in( ( Wi&e off exce%% to&ical anae%thetic( @( Stretch the 'uco%a( A( Di%tract the &atient ;%tretching the 'uco%a and gentle &re%%ure on the li& bet,een finger and thu'b can achie$e thi%<( :( )n%ert the needleif bone i% contacted ,ithdra, %lightly( !( 0%&irate, if &o%iti$e re&o%ition the needle ,ithout ,ithdra,ing fro' 'uco%a and ,hen negati$e &roceed( ?( )n+ect 9(:-=(9 'l %u&ra&erio%teally $ery %lo,ly ;=:-@9 % or $ia co'&uteri5ed %y%te'<( Anterior ma9illar$ ,-""al in+iltration# )n+ection into the anterior a%&ect of the 'axilla can be unco'fortable if %o'e &re&aratory %te&% are not ta/en( #%ing the 'ethod de%cribed in %te&% =-! abo$e, about 9( 'l of local anae%thetic i% de&o%ited &ainle%%ly in the fir%t &ri'ary 'olar buccal %ulcu% on the %ide to be treated ;6ig( :(><( The next in+ection i% &laced anteriorly to thi% a 'inute later ,hen %oft ti%%ue anae%the%ia ha% %&read radially fro' the initial in+ection %ite, and further 9( 'l incre'ent% are &laced in the anterior a%&ect of the already anae%theti5ed area until the tooth of intere%t i% reached( The buccal infiltration of 9(:-=(9 'l can no, be deli$ered &ainle%%ly through the already anae%theti5ed %oft ti%%ue( Palatal anae#t%e#ia )n+ection directly into the &alatal 'uco%a i% &ainful( )n %o'e indi$idual% the de&o%ition of the %olution clo%e to a cotton-,ool bud coated ,ith to&ical anae%thetic and a&&lied ,ith fir' &re%%ure 'ay reduce di%co'fort, e%&ecially ,hen the &re%%ure on the bud i% increa%ed %i'ultaneou%ly ,ith needle in%ertion and the child i% ,arned

of thi% &re%%ure increa%e ;6ig( :(=9<( 1o,e$er, a% 'entioned earlier, con$entional to&ical anae%thetic% are not $ery effecti$e on the attached 'uco%a of the hard &alate and thi% 'ethod i% not uni$er%ally %ucce%%ful( The u%e of co'&uteri5ed deli$ery %y%te'% 'ay reduce in+ection &ain during &alatal in+ection%( When u%ing con$entional %yringe% a 'ethod of reducing the di%co'fort of &alatal in+ection% i% to a&&roach the &alatal 'uco%a $ia already anae%theti5ed buccal interdental &a&illae( Thi% i% 'o%t readily achie$ed u%ing ultra-%hort ;= ''< @9-gauge needle% ,hich are in%erted into the ba%e of the interdental &a&illa at an angle of a&&roxi'ately >9 to the %urface( The needle i% ad$anced &alatally ,hile in+ecting local anae%thetic into the &a&illa( Thi% i% &erfor'ed through both the di%tal and 'e%ial &a&illae( 4lanching %hould be %een around the &alatal gingi$al 'argin ;6ig%( :(==, :(= , and :(=@<( With &ractice thi% techniBue can be u%ed ,ithout the needle breaching the &alatal 'uco%al %urface, ,hich &re$ent% the un&lea%ant-ta%ting %olution inad$ertently a&&earing in the 'outh( Thi% 'ethod u%ually &ro$ide% %ufficient anae%the%ia for extraction%H ho,e$er, it 'ay be %u&&le'ented by a &ainle%% gingi$al %ulcu% in+ection on the &alatal %ide( 7andi,-lar anae#t%e#ia )nferior al$eolar ner$e bloc/ in+ection% can be unco'fortable, but infiltration anae%the%ia i% not %ucce%%ful in the &o%terior &er'anent dentition( 0lternati$ely, intraliga'ental ;&dl< in+ection% 'ay be e'&loyed to anae%theti5e the &o%terior 'andibular teeth( Thi% techniBue i% not $ery %ucce%%ful in the lo,er &er'anent inci%or%( Thi% i% &robably due to a &aucity of &erforation% in the cribrifor' &late of lo,er inci%or %oc/et%( 0% 'entioned abo$e infiltration anae%the%ia i% the 'ethod of choice for the inci%or teeth( 3ingual anae%the%ia can be obtained by cha%ing through the buccal &a&illae a% de%cribed for &alatal in+ection% abo$e( Studie% in adult% ha$e %ugge%ted that &dl techniBue% are le%% un&lea%ant than con$entional 'ethod%, but 'any children find deli$ery of anae%thetic %olution $ia the &dl unco'fortable( The di%co'fort can be o$erco'e by u%ing the follo,ing 'ethod%( The 'e%ial buccal &a&illa can be treated ,ith to&ical anae%thetic a&&lied ,ith &re%%ure( While &re%%ure i% %till being a&&lied, a &a&illary in+ection i% ad'ini%tered follo,ed by the intraliga'ental in+ection( 0% con$entional to&ical local anae%thetic% are not $ery effecti$e on attached gingi$a thi% 'ethod i% not %ucce%%ful ,ith all children( 0lternati$ely, a %'all-do%e buccal infiltration i% gi$en a&ical to the tooth ;thi% can be gi$en a% one de&re%%ion of the &dl %yringe<( Thi% i% follo,ed by a &a&illary in+ection, ,hich no, %hould be &ainle%%, and finally by the intraliga'ental in+ection ;6ig%( :(=A, :(=:, and :(=!<( 3ingual gingi$al anae%the%ia i% obtained $ia the &dl by directing the needle through the interdental %&ace ;6ig( :(=?<( The techniBue% de%cribed %hould &roduce 'ini'al di%co'fort during local anae%thetic ad'ini%tration in children( When the%e 'ethod% are co'bined ,ith relati$e analge%ia the &roduction of in+ection &ain i% e$en le%% li/ely to ari%e( When &ain-free reliable local anae%the%ia i% achie$ed in children confidence i% gained both by the child and the o&erator, and a %ound ba%i% for a %ati%factory &rofe%%ional relation%hi& i% e%tabli%hed( Thi% 'ean% that 'any of the treat'ent% traditionally &erfor'ed under general anae%the%ia ;%uch a% 'ulti&le-Buadrant extraction% and 'inor oral %urgery< can readily be &erfor'ed in the con%ciou% %edated child(

Fi!. 5.4 4uccal infiltration in+ection in the u&&er &ri'ary 'olar region( ;4y /ind &er'i%%ion of Dental Update(< Fi!. 5./0 #%e of &re%%ure and to&ical anae%the%ia to le%%en the di%co'fort of a &alatal in+ection( ;4y /ind &er'i%%ion of Dental Update(< Fi!. 5.// 0d$ancing local anae%thetic to,ard% the &alate $ia the buccal &a&illa( ;4y /ind &er'i%%ion of Dental Update(< Fi!. 5./2 "alatal $ie, of 6ig( :(=9 %ho,ing blanching of the &alate( ;4y /ind &er'i%%ion of Dental update(< Fi!. 5./3 )t i% %i'&le to ad$ance to,ard% the &alate ,hen the teeth are %&aced( ;4y /ind &er'i%%ion of Dental Update(< Fi!. 5./0 S'all-do%e buccal infiltration in the lo,er &re'olar region for re'o$al of a lo,er %econd 'olar( Fi!. 5./5 "a&illary in+ection after buccal infiltration( Fi!. 5./1 )ntraliga'entary in+ection after &a&illary in+ection( Fi!. 5./2 3ingual $ie, of %ho,ing blanching of the lingual gingi$a( 5.2 C&7P*ICATI&NS &F *&CA* ANAEST5ESIA 5.2.0 Introd-"tion Co'&lication% can be cla%%ified a% generali5ed and locali5ed and di$ided into early and late( 5.2./ 6enerali:ed "om li"ation# P#$"%o!eni" The 'o%t co''on &%ychogenic co'&lication of local anae%the%ia i% fainting( The chance% of thi% ha&&ening are reduced by %y'&athetic 'anage'ent and ad'ini%tration of the anae%thetic to children in the %e'i-%u&ine &o%ition( Aller!$ 0llergy to local anae%thetic% i% a $ery rare occurrence, e%&ecially to the a'ide grou& to ,hich 'o%t of the co''only u%ed dental local anae%thetic% ;%uch a% lidocaine ;lignocaine< &rilocaine, 'e&i$acaine and articaine< belong( The only 'e'ber% of the e%ter grou& of local anae%thetic% routinely u%ed in the #nited 2ingdo' are ben5ocaine and tetracaine ;a'ethocaine<, ,hich are a$ailable a% to&ical anae%thetic &re&aration%( 0llergy to other con%tituent% of local anae%thetic cartridge% 'ay occur, for exa'&le, 'etabi%ulfite a reducing agent ,hich &re$ent% oxidation of e&ine&hrine( 0llergy can 'anife%t in a $ariety of for'% ranging fro' a 'inor locali5ed reaction to the 'edical e'ergency of ana&hylactic %hoc/( )f there i% any %ugge%tion that a child i% allergic to a local anae%thetic they %hould be referred for allergy te%ting to the local der'atology or clinical &har'acology de&art'ent( Such te%ting ,ill confir' or refute the diagno%i%, and in addition %hould deter'ine ,hich alternati$e local anae%thetic can %afely be u%ed on the child( The 'a+ority of referral% &ro$e to ha$e no local anae%thetic allergy(

Children ,ho are allergic to latex 'erit con%ideration a% thi% 'aterial i% included in the rubber bung% of %o'e cartridge%( When treating %uch a child it i% i'&erati$e to u%e a latex-free cartridge( Detail% of ,hich cartridge% are latex-free can be obtained fro' the 'anufacturer%( To9i"it$ O$erdo%age of local anae%thetic% leading to toxicity i% rarely a &roble' in adult% but can readily occur in children( Children o$er ! 'onth% of age ab%orb local anae%thetic% 'ore ra&idly than adult%H ho,e$er, thi% i% balanced by the fact that children ha$e a relati$ely larger $olu'e of di%tribution and eli'ination i% al%o ra&id due to a relati$ely large li$er( -e$erthele%%, do%e% ,hich are ,ell belo, toxic le$el% in adult% can &roduce &roble'% in children, and fatalitie% attributable to dental local anae%thetic o$erdo%e ha$e been re&orted( 0% ,ith all drug% do%age% %hould be related to body ,eight( The 'axi'u' do%e of lidocaine ;lignocaine< i% A(A 'gD/g( Thi% i% an ea%y do%e to re'e'ber if one note% that the large%t L ;i(e( 9 'gD'l< lidocaine anae%thetic cartridge% a$ailable in the #nited 2ingdo' are ( 'l, ,hich 'ean% they contain AA 'g of lidocaine( Thu% a %afe 'axi'u' do%e i% one-tenth of the large%t cartridge a$ailable &er /ilogra'( )f the =9th of a cartridge &er /ilogra' rule i% adhered to then o$erdo%e ,ill not occur( "rilocaine, the other co''only u%ed local anae%thetic drug in the #nited 2ingdo', ha% a 'axi'u' do%e of !(9 'gD/g and a% it i% nor'ally &re%ented a% a @L %olution the rule i% one-ele$enth of the cartridge &er /ilogra'( When it i% noted that a ty&ical : year old ,eigh% 9 /g it i% ea%y to %ee that o$er-do%e can ea%ily occur unle%% care i% exerci%ed( The u%e of $a%ocon%trictor-containing local anae%thetic% for definiti$e local anae%the%ia i% reco''ended in children, a% agent% %uch a% e&ine&hrine ;adrenaline< 'ight reduce the entry of local anae%thetic agent% into the circulation( )n addition, a% $a%ocon%trictor-containing %olution% are 'ore effecti$e, the need for 'ulti&le re&eat in+ection% i% reduced( CARDI&)ASC(*AR EFFECTS Cardio$a%cular effect% cau%ed by the in+ection of a dental local anae%thetic %olution ,ill be due to the co'bined action of the anae%thetic agent and the $a%ocon%trictor( 3ocal anae%thetic% affect the cardio$a%cular %y%te' by their direct action on cardiac ti%%ue and the &eri&heral $a%culature( They al%o act indirectly $ia inhibition of the autono'ic ner$e% that regulate cardiac and &eri&heral $a%cular function( Mo%t local anae%thetic agent% ,ill decrea%e cardiac excitability, and indeed lidocaine ;lignocaine< i% u%ed in the treat'ent of cardiac arrhyth'ia%( 4oth $a%ocon%trictor% co''only u%ed in the #nited 2ingdo', na'ely e&ine&hrine ;adrenaline< and fely&re%%in, can influence cardio$a%cular function( )n addition to the beneficial effect of &eri&heral $a%ocon%triction for %urgical &rocedure%, e&ine&hrine ha% both direct and indirect effect% on the heart and the do%e% u%ed in clinical denti%try ,ill increa%e cardiac out&ut, although thi% i% unli/ely to be ha5ardou% in healthy children( 6ely&re%%in at high do%e% cau%e% coronary artery $a%ocon%triction, but the &la%'a le$el% that &roduce thi% are unli/ely to be achie$ed during clinical denti%try( CENTRA* NER)&(S SYSTE7 EFFECTS The fact that local anae%thetic agent% influence acti$ity in ner$e% other than &eri&heral %en%ory ner$e% i% ob$iou% to any &ractitioner ,ho ha% inad$ertently &araly5ed the &eri&heral branche% of the 'otor facial ner$e during an inferior al$eolar ner$e bloc/ in+ection( Si'ilarly, the central ner$ou% %y%te' i% not i''une to the effect% of local

anae%thetic agent%( )ndeed, &la%'a concentration% of local anae%thetic% that are inca&able of influencing &eri&heral ner$e function can &rofoundly affect the central ner$ou% %y%te'( 0t lo, do%e% the effect i% excitatory a% central ner$ou% %y%te' inhibitory fibre% are bloc/ed, at high do%e% the effect i% de&re%%ant and can lead to uncon%ciou%ne%% and re%&iratory arre%t( 6atalitie% due to local anae%thetic o$erdo%e in children are generally due to central ner$ou% ti%%ue de&re%%ion( 7ET5AE7&6*&;INAE7IA So'e local anae%thetic% cau%e %&ecific ad$er%e reaction% ,hen gi$en in o$erdo%e( "rilocaine cau%e% cyano%i% due to 'ethae'oglobinae'ia( )n 'ethae'oglobinae'ia the ferrou% iron of nor'al hae'oglobin i% con$erted to the ferric for' ,hich cannot co'bine ,ith oxygen( TREAT7ENT &F T&'ICITY The be%t treat'ent of toxicity i% &re$ention( "re$ention i% aided byG ;=< a%&irationH ; < %lo, in+ectionH ;@< do%e li'itation( When a toxic reaction occur% then the &rocedure i%G ;=< Sto& the dental treat'ent( ; < "ro$ide ba%ic life %u&&ort( ;@< Call for 'edical a%%i%tance( ;A< "rotect the &atient fro' in+ury( ;:< Monitor $ital %ign%( Dr-! intera"tion# S&eciali%t ad$ice fro' the a&&ro&riate &hy%ician %hould be reBue%ted in the treat'ent of children on %ignificant long-ter' drug thera&y( 0&&arently innocuou% drug co'bination% can interact and cau%e %ignificant &roble'% in children, for exa'&le, an e&i%ode of 'ethae'oglobinae'ia ha% been re&orted in a @-'onth-old child follo,ing the a&&lication of EM30( )t ,a% concluded fro' that ca%e that &rilocaine ;in the EM30< had interacted ,ith a %ulfona'ide ;,hich can al%o &roduce 'ethae'oglobinae'ia< that the child ,a% already recei$ing( In+e"tion The introduction of agent% ca&able of &roducing a generali5ed infection, %uch a% hu'an i''unodeficiency $iru% ;1)8< infection and he&atiti%, i% a co'&lication ,hich %hould not occur ,hen a&&ro&riate cro%%-infection control 'ea%ure% are e'&loyed( 5.2.2 Earl$ lo"ali:ed "om li"ation# Pain "ain re%ulting fro' local anae%thetic in+ection% can occur at the ti'e of the in+ection due to the needle &enetrating 'uco%a, too ra&id an in+ection, or in+ection into an ina&&ro&riate %ite( The %ite% at ,hich in+ection 'ay be &ainful includeG ;=< intrae&ithelialH ; < %ub&erio%tealH ;@< into the ner$e trun/H ;A< intra$a%cular( 0n intrae&ithelial in+ection i% unco'fortable becau%e at the %tart of the in+ection the %olution doe% not di%&er%e and thi% cau%e% the ti%%ue% to balloon out( Sub&erio%teal in+ection 'ay &roduce &ain both at the ti'e of in+ection and &o%to&erati$ely( The initial &ain i% due to in+ection into a confined %&ace, ,ith the deli$ery of %olution cau%ing the &erio%teu' to be %tri&&ed fro' the bone( Direct contact of the ner$e trun/ by the needle &roduce% an electric-%hoc/ ty&e of %en%ation and i''ediate anae%the%ia(

Thi% i% 'o%t li/ely to occur in the lingual and inferior al$eolar ner$e% during inferior al$eolar ner$e bloc/%( #nfortunately, thi% co'&lication i% 'ore co''on ,ith ex&erienced o&erator% a% it re&re%ent% good location of the needle( When it doe% occur the %olution %hould not be in+ected at that &oint but deli$ered after the needle ha% been ,ithdra,n %lightly, thu% a$oiding an intraneural in+ection( )f the needle doe% contact the ner$e then the &atient and &arent %hould be ,arned that anae%the%ia of the ner$e 'ay be &rolonged( 0ltered %en%ation 'ay la%t u& to a fe, ,ee/% in %o'e ca%e%( Intra.a#"-lar inDe"tion 0ccidental intra$a%cular in+ection% can occur in children if a%&iration i% not &erfor'ed( )ntra$a%cular in+ection% can cau%e local &ain if the $e%%el &enetrated i% an artery and arterial %&a%' occur%( )ntra$enou% in+ection% can &roduce %y%te'ic effect% %uch a% tachycardia and &al&itation%( )ntra-arterial in+ection% are 'uch rarer than intra$enou% in+ection%, ho,e$er the effect% of an intra-arterial in+ection can be alar'ing( Such effect% range fro' local &ain and cutaneou% blanching ;6ig( :(=C< to %e$ere intracranial &roble'%( The re&orted, rare ca%e% of he'i&legia follo,ing local anae%thetic in+ection% can be accounted for by ra&id intra-arterial in+ection( Thi% can &roduce %ufficient intracranial blood le$el% of the local anae%thetic to &roduce central ner$ou% ti%%ue de&re%%ion( Fail-re o+ lo"al anae#t%e#ia The inability to co'&lete the &re%cribed treat'ent due to failure of the local anae%thetic can be due to a nu'ber of cau%e%, includingG ;=< anato'yH ; < &athologyH ;@< o&erator techniBue( 0nato'ical cau%e% of failed local anae%the%ia can re%ult fro' either bony anato'y or acce%%ory inner$ation( 4ony anato'y can inhibit the diffu%ion of a %olution to the a&ical region ,hen infiltration techniBue% are u%ed( Thi% can occur in children in the u&&er fir%t &er'anent 'olar region due to a lo, 5ygo'atic buttre%%( To o$erco'e thi% &roble' the anae%thetic i% infiltrated both 'e%ially and di%tally to the u&&er fir%t 'olarD5ygo'atic buttre%% region( 0cce%%ory inner$ation 'ay al%o &roduce failed local anae%the%ia( )n the u&&er 'olar region thi% 'ay be due to &ul&al %u&&ly fro' the greater &alatine ner$e%, ,hich can be bloc/ed by %u&&le'entary &alatal anae%the%ia( )n the 'andible, acce%%ory %u&&ly fro' the 'ylohyoid, auriculote'&oral, and cer$ical ner$e% ,ill not be bloc/ed by inferior al$eolar, lingual, and long buccal ner$e bloc/% and 'ay reBuire %u&&le'entary in+ection%( The co''one%t area of acce%%ory %u&&ly occur% near the 'idline, ,here bilateral %u&&ly often nece%%itate% %u&&le'ental in+ection% ,hen regional bloc/ techniBue% are e'&loyed( The &re%ence of acute infection interfere% ,ith the action of local anae%thetic%( Thi% i% &artly due to the reduction in ti%%ue &1 decrea%ing the nu'ber of unioni5ed local anae%thetic 'olecule%, ,hich in turn inhibit% their diffu%ion through li&id to the %ite of action ;the nu'ber of ioni5ed $er%u% unioni5ed 'olecule% i% go$erned by the &1 and &0a of the agent<( More i'&ortantly, ner$e ending% %ti'ulated by the &re%ence of acute infection are hy&eralge%ic( Regional bloc/ and intraliga'ental 'ethod% of local anae%the%ia are techniBue de&endent, and often failure of the%e for'% of local anae%the%ia are due to the o&erator( Thi% cau%e of failure beco'e% le%% co''on ,ith ex&erience( )nfiltration

anae%the%ia i% a $ery %i'&le 'ethod ,hich i% readily 'a%tered by no$ice%( When thi% in+ection fail% rea%on% other than o&erator techniBue %hould be %ought( 7otor ner.e aral$#i# "araly%i% of the facial ner$e can occur follo,ing de&o%ition of local anae%thetic %olution ,ithin the %ub%tance of the &arotid gland due to 'al&o%itioning of the needle during inferior al$eolar ner$e bloc/ in+ection%( The ter'inal branche% of the facial ner$e run through the &arotid gland and ,ill be &araly5ed by the anae%thetic agent( The 'o%t dra'atic 'anife%tation of thi% co'&lication i% the lo%% of ability to clo%e the eyelid% on the affected %ide( 0n eye &atch %hould be &ro$ided until the &araly%i% ,ear% off( Thi% %ide effect i% &robably 'ore co''on in adult%the anato'y of the child*% 'andible i% %uch that inability to %ucce%%fully &al&ate the 'edial a%&ect of the 'andible ,ith the needle i% unco''on( 0lthough &araly%i% of the eyelid i% 'o%t often due to faulty techniBue during inferior al$eolar ner$e bloc/ anae%the%ia, it can al%o re%ult fro' the u%e of exce%%i$e a'ount% of %olution in the 'axillary buccal %ulcu%( Inter+eren"e Cit% # e"ial #en#e# There ha$e been re&ort% of interference ,ith $i%ion and hearing after the intra-oral in+ection of local anae%thetic%( Such occurrence% 'o%t &robably re%ult fro' accidental intra-arterial in+ection%( 5aematoma +ormation "enetration of a blood $e%%el can occur during local anae%thetic ad'ini%tration( 1ae'ato'a for'ation i% rarely a &roble', ho,e$er, unle%% it occur% in 'u%cle follo,ing inferior al$eolar ner$e bloc/ techniBue% ,hen it 'ay lead to tri%'u% ;%ee further<( Fi!. 5./3 4lanching of the chee/ after an intra-arterial in+ection in a child( 5.2.3 *ate lo"ali:ed "om li"ation# Sel+-in+li"ted tra-ma Self-inflicted trau'a 'ay occur after local anae%thetic in+ection% in children( )t 'ay follo, regional techniBue% in the 'andible and infiltration anae%the%ia in the 'axilla( The co''one%t %ite i% the lo,er li& ;6ig( :(=><, but the tongue and u&&er li& can al%o be affected( )t can be &re$ented by adeBuate ex&lanation to the &atient and &arent by the clinician( The u%e of &dl techniBue% 'ay reduce the freBuency of thi% co'&licationH ho,e$er, it 'u%t be %tre%%ed that %oft ti%%ue anae%the%ia i% not co'&letely a$oided ,ith thi% 'ethod in all ca%e%( &ral -l"eration Occa%ionally children ,ill de$elo& oral ulceration a fe, day% follo,ing local anae%thetic in+ection%( Thi% i% u%ually due to trau'a initiating an a&hthou% ulcer( -eedle trau'a 'ay acti$ate a latent for' of her&e% %i'&le on rare occa%ion%(

*on!-la#tin! anae#t%e#ia 0% 'entioned abo$e long-la%ting anae%the%ia can re%ult fro' direct trau'a to a ner$e trun/ fro' the needle, in+ection of %olution into the ner$e, or occa%ionally fro' the u%e of 'ore concentrated anae%thetic %olution%( Thi% 'ay occur after regional bloc/ techniBue% but it i% a rare co'&lication( Tri#m-# Tri%'u% 'ay follo, inferior al$eolar ner$e bloc/ in+ection% and i% u%ually the re%ult of bleeding ,ithin 'u%cle due to &enetration of a blood $e%%el by the needle( )n+ection of a %olution directly into 'u%cle ti%%ue 'ay al%o re%ult in tri%'u%( The condition i% %elf-re%ol$ing, although it 'ay ta/e a fe, ,ee/% before nor'al o&ening i% re%tored( In+e"tion 3ocali5ed infection due to the introduction of bacteria at the in+ection %ite i% a co'&lication that i% rarely encountered( De.elo mental de+e"t# 3ocal anae%thetic agent% are cytotoxic to the cell% of the ena'el organ( )t i% &o%%ible that the incor&oration of the%e agent% into the de$elo&ing tooth-ger' could cau%e de$elo&'ental defect%( There i% ex&eri'ental e$idence that %uch defect% can ari%e follo,ing intraliga'ental in+ection% in &ri'ary teeth in ani'al 'odel%( Such occurrence% in hu'an% ha$e not been re&orted( )n addition to cytotoxic effect% of the anae%thetic agent, it i% &o%%ible that &hy%ical da'age cau%ed by the needle to &er'anent %ucce%%or% could re%ult fro' the o$erenthu%ia%tic u%e of intraliga'entary anae%the%ia in the &ri'ary dentition( Fi!. 5./4 Self-inflicted trau'a follo,ing an inferior dental bloc/ in+ection( ;4y /ind &er'i%%ion of Dental Update(< 5.3 C&NTRAINDICATI&NS T& *&CA* ANAEST5ESIA 5.3.0 Introd-"tion )n certain children %o'e local anae%thetic 'aterial% ,ill be contraindicated, in other% %&ecific techniBue% are not ad$i%ed( 5.3./ 6eneral Immat-rit$ 8ery young children are not %uited to treat'ent under local anae%the%ia a% they ,ill not &ro$ide the degree of coo&eration reBuired for co'&letion of treat'ent( 0 child ,ho cannot differentiate bet,een &ainful and non-&ainful %ti'uli ;%uch a% &re%%ure< i% un%uitable for treat'ent under local anae%the%ia(

7ental or %$#i"al %andi"a 3ocal anae%the%ia i% contraindicated ,here the degree of handica& &re$ent% coo&eration( Treatment +a"tor# Certain factor% related to the &ro&o%ed treat'ent 'ay contraindicate the u%e of local anae%the%ia( The%e factor% include duration and acce%%( "rolonged treat'ent %e%%ion%, e%&ecially if %o'e di%co'fort 'ay be &roduced %uch a% during %urgical &rocedure%, cannot %ati%factorily be co'&leted under local anae%the%ia( )t i% unrea%onable to ex&ect a child to coo&erate for 'ore than @9-A9 'in under %uch circu'%tance% e$en ,hen %edated( Si'ilarly, ,here acce%% &ro$e% difficult or unco'fortable, for exa'&le, during bio&%ie% of the &o%terior &art of the tongue or %oft &alate, %ati%factory coo&eration 'ay be i'&o%%ible under local anae%the%ia( A"-te in+e"tion 0% 'entioned abo$e, acute infection reduce% the efficacy of local anae%thetic %olution%( 5.3.2 S e"i+i" a!ent# Aller!$ 0llergy to a %&ecific agent or grou& of agent% i% an ab%olute contraindication to the u%e of that local anae%thetic( Cartridge% containing latex in their bung 'u%t be a$oided in tho%e allergic to thi% 'aterial( 7edi"al "ondition# So'e 'edical condition% &re%ent relati$e contraindication% to the u%e of %o'e agent%( 6or exa'&le, in li$er di%ea%e the do%e of a'ide local anae%thetic% %hould be reduced( E%ter local anae%thetic% %hould be a$oided in children ,ho ha$e a deficiency of the en5y'e &%eudocholine%tera%e( Poor ,lood #l$

The u%e of $a%ocon%trictor-containing local anae%thetic %olution% %hould be a$oided in area% ,here the blood %u&&ly ha% been co'&ro'i%ed, for exa'&le after thera&eutic irradiation( 5.3.3 S e"i+i" te"%niA-e# ;leedin! diat%e#e# )n+ection into dee& ti%%ue% %hould be a$oided in &atient% ,ith bleeding diathe%e% %uch a% hae'o&hilia( )nferior al$eolar ner$e bloc/ techniBue% %hould not be u%ed unle%% a&&ro&riate &ro&hylaxi% ha% been &ro$ided ;e(g( 6actor 8))) for tho%e ,ith hae'o&hilia<( Thi% can be o$erco'e by the u%e of intraliga'entary in+ection% in the

'andible in %uch &atient% for re%torati$e denti%try( S-#"e ti,ilit$ to endo"arditi# )ntraliga'entary anae%the%ia ,ill &roduce a bacterae'ia( )n &atient% %u%ce&tible to endocarditi% thi% 'ethod %hould not be u%ed for &rocedure% in ,hich gingi$al 'ani&ulation ,ould not nor'ally be in$ol$ed( Thi% i% becau%e it i% unrea%onable to &ro$ide antibiotic &ro&hylaxi% for the anae%thetic ,hen other 'ethod% of local anae%the%ia can be e'&loyed( When antibiotic &ro&hylaxi% ha% been &ro$ided to co$er the o&erati$e &rocedure then intraliga'ental in+ection% can be e'&loyed( In"om lete root +ormation The u%e of intraliga'ental techniBue% for re%torati$e &rocedure% on &er'anent teeth ,ith &oorly for'ed root% could lead to a$ul%ion of the tooth if ina&&ro&riate force i% a&&lied during the in+ection( Tri#m-# Tri%'u% ,ill &reclude the u%ual direct a&&roach to the inferior al$eolar ner$e bloc/( E ile #$ 0% %ei5ure di%order% can be triggered by &ul%ing %ti'uli ;%uch a% &ul%e% of light< it i% &erha&% un,i%e to u%e electroanalge%ia in children ,ith e&ile&%y( 5.4 S(77ARY =( Surface anae%the%ia i% be%t achie$ed ,ith a to&ical agent on a cotton bud a&&lied to dry 'uco%a for : 'in( ( 4uccal infiltration anae%the%ia i% %ucce%%ful in the 'axilla( @( Regional bloc/ anae%the%ia i% %ucce%%ful in the 'andible( A( )ntraliga'entary anae%the%ia i% %ucce%%ful in children( Thi% 'ethod 'ay be the fir%t choice in the &o%terior 'andible and a% a %u&&le'entary techniBue in the 'axilla( :( "ain-free local anae%the%ia in the 'axilla i% &o%%ible ,ith buccal infiltration and by anae%theti5ing the &alate $ia the buccal &a&illae( !( )n the 'andible, intraliga'ental techniBue% 'ay be u%ed to a$oid the di%co'fort of regional bloc/ in+ection%( ?( Co'&lication% of local anae%the%ia are reduced by careful techniBue and %en%ible do%e li'itation%( C( Contraindication% to local anae%the%ia 'ay be related to certain agent% or to %&ecific techniBue%(

5./0 F(RT5ER READIN6 Mala'ed, S( 6( ;=>>?<( Hand,oo% of local anesthesia ;Ath edn<( Mo%by, St 3oui%( ;"n excellent reference ,oo% < Meechan, 7( G( ; 99 <( Practical dental local anaesthesia( Kuinte%%ence "ubli%hing Co 3td, 3ondon ;" practical guide to the administration of local anaesthesia < Moore, "( 0( ;=>> <( "re$enting local ane%thetic toxicity( + "m Dent "ssoc, /23, !9( ;" salutary case report of a paediatric local anaesthetic fatality < 5.// REFERENCES Meechan, 7( G(, Cole, 4(, and Welbury, R( R( ; 99=<( The influence of t,o different dental local anae%thetic %olution% on the hae'odyna'ic re%&on%e% of children undergoing re%torati$e denti%tryG a rando'i%ed, %ingle-blind, %&lit-'outh %tudy( $r Dent +, /40, :9 -A( "ri'o%ch, R( E( and 4roo/%, R( ; 99 <( )nfluence of flo, rate deli$ered by the Wand 3ocal 0ne%thetic Sy%te' on &ain re%&on%e% to &alatal in+ection%( "m + Dent, /5, =:9( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

1. Dia!no#i# and re.ention o+ dental "arie# - C Deery and 0 + -oum,a 1./ DE)E*&P7ENT &F DENTA* CARIES 0l'o%t all re%earch on the &roce%% of dental carie% %u&&ort% the che'o&ara%itic theory &ro&o%ed by W( D( Miller in =C>9( Thi% i% no, 'ore co''only /no,n a% the

acidogenic theory of carie% aetiology( The 'ain feature% of the carie% &roce%% areG ;=< fer'entation of carbohydrate to organic acid% by 'icro-organi%'% in &laBue on the tooth %urfaceH ; < ra&id acid for'ation, ,hich lo,er% the &1 at the ena'el %urface belo, the le$el ;the critical &1< at ,hich ena'el ,ill di%%ol$eH ;@< ,hen carbohydrate i% no longer a$ailable to the &laBue 'icro-organi%'%, the &1 ,ithin &laBue ,ill ri%e due to the out,ard diffu%ion of acid% and their 'etaboli%' and neutrali5ation in &laBue, %o that re'inerali5ation of ena'el can occurH and ;A< dental carie% &rogre%%e% only ,hen de'inerali5ation i% greater than re'inerali5ation( The reali5ation that de'inerali5ation and re'inerali5ation i% an eBuilibriu' i% /ey to under%tanding the dyna'ic% of the cariou% le%ion and it% &re$ention( One of the intere%ting feature% of an early cariou% le%ion of the ena'el i% that the le%ion i% %ub%urfaceH that i%, 'o%t of the 'ineral lo%% occur% beneath a relati$ely intact ena'el %urface( Thi% contra%t% %trongly ,ith the hi%tological a&&earance of ena'el after a clean tooth %urface ha% been ex&o%ed to acid, ,here the %urface i% etched and there i% no %ub%urface le%ion( Thi% di%%olution of the %urface of ena'el, or etching, i% a feature of ena'el ero%ion cau%ed, a'ong other thing%, by dietary acid%( The ex&lanation for the intact %urface layer in ena'el carie% %ee'% to lie in diffu%ion dyna'ic%G the layer of dental &laBue on the tooth %urface acting a% a &artial barrier to diffu%ion( 6urther ero%ion occur% at 'uch lo,er &1% ;<A< than carie%( Dental &laBue for'% on uncleaned tooth %urface% and i% readily a&&arent if toothbru%hing i% %to&&ed for -@ day%( Contrary to &o&ular o&inion, &laBue doe% not con%i%t of food debri%, but co'&ri%e% ?9L 'icro-organi%'%about =99 'illion organi%'% &er 'illigra' of &laBue( When &laBue i% young, cocci &redo'inate but a% &laBue age% the &ro&ortion% of fila'entou% organi%'% and $eillonellae increa%e( Diet influence% the co'&o%ition of the &laBue flora con%iderably, ,ith 'utan% %tre&tococci 'uch 'ore nu'erou% ,hen the diet i% rich in %ugar and other carbohydrate%, and the%e organi%'% are &articularly good at 'etaboli5ing %ugar% to acid%( 2no,ledge of the dental carie% &roce%% increa%ed con%iderably ,ith the de$elo&'ent of &1 electrode%, &articularly 'icroelectrode% that could be in%erted into &laBue before, during, and after the inge%tion of $ariou% food%( The &ioneer of thi% area of re%earch ,a% Robert Ste&han, and the &lot of &laBue &1 again%t ti'e ;6ig( !(=< ha% beco'e /no,n a% the Ste&han cur$e( Within -@ 'in of eating %ugar or rin%ing ,ith a %ugar %olution, &laBue &1 fall% fro' an a$erage of about !(C to near &1 :, ta/ing about A9 'in to return to it% original $alue( 4elo, &1 :(: de'inerali5ation of the ena'el occur%, thi% i% /no,n a% the critical &1( The clinical a&&earance of the%e early le%ion% i% no, ,ell recogni5ed ;6ig%( !( , !(@, !(A, and !(:<( They a&&ear a% a ,hite area that coincide% ,ith the di%tribution of &laBue( Thi% 'ight be around the gingi$al 'argin, a% in 6ig( !( , or bet,een the teeth, a% in 6ig( !(@( 0 hi%tological %ection through a le%ion %uch a% that %ho,n in 6ig( !(@ ,ould loo/ li/e 6ig( !(A and a 'icroradiogra&h li/e 6ig( !(:in both the %ub%urface body of the le%ion and %urface 5one can be %een clearly( )f the &roce%% of dental carie% continue%, %u&&ort for the %urface layer ,ill beco'e %o ,ea/ that it ,ill cru'ble li/e an egg%hell, creating a ca$ity( Once a ca$ity i% for'ed, the &roce%% of dental carie%

continue% in a 'ore %heltered en$iron'ent and the &rotein 'atrix of ena'el and then dentine i% re'o$ed by &roteolytic en5y'e% &roduced by &laBue organi%'%( The &rogre%%ion of carie% i% traditionally de%cribed a% ena'el carie% &rogre%%ing through to the a'elodentine +unction at ,hich the ena'el brea/% do,n and a ca$ity for'%( 0lthough it i% no, under%tood that the &roce%% i% not thi% %i'&le and ca$itation can occur at an earlier %tagethe ena'el ca$ity and freBuently at a 'uch later %tage ,hen the carie% ha% &rogre%%ed %ignificantly into dentine( 6igure !(! %ho,% the labial %urface of a 'axillary canine ,ith a $ariety of %tage% of cariou% le%ion ranging fro' ,hite %&ot ena'el carie% to dentine ca$ity( The ability of early cariou% le%ion% ;*&reca$itation cariou% le%ion%*< to re'inerali5e i% no, ,ell under%toodH &eriod% of de'inerali5ation are inter%&er%ed ,ith &eriod% of re'inerali5ation, and the outco'ehealth or di%ea%ei% the re%ult of a &u%h in one direction or the other on thi% dyna'ic eBuilibriu'( The %horter the ti'e during ,hich &laBue-co$ered teeth are ex&o%ed to acid attac/ and the longer the ti'e re'inerali5ation can occur, the greater i% the o&&ortunity for a cariou% le%ion to heal( Sati%factory healing of the cariou% le%ion can only occur if the %urface layer i% unbro/en, and thi% i% ,hy the *&reca$itation*%tage in the &roce%% of dental carie% i% %o rele$ant to &re$enti$e denti%try( Once the %urface ha% been bro/en and a ca$ity ha% for'ed, it i% u%ually nece%%ary to re%tore the tooth %urface ,ith a filling( The cariou% &roce%% i% dri$en by the &laBue on the %urface and therefore it i% &o%%ible to arre%t the carie% by effecti$e re'o$al of &laBue e$en after ca$itation ha% occurred( 1o,e$er, the lo%t ti%%ue cannot be re&laced( The fir%t %tage of dental carie% to be $i%ible i% the *,hite %&ot* &reca$itation le%ion %tage( Thi% can occur ,ithin a fe, ,ee/% if condition% are fa$ourable to it% de$elo&'ent( )n the general &o&ulation, though, it co''only ta/e% -A year% for carie% to &rogre%% through ena'el into dentine at a&&roxi'al %ite%( The 'o%t i'&ortant of the natural defence% again%t dental carie% i% %ali$a( )f %ali$ary flo, i% i'&aired, dental carie% can &rogre%% $ery ra&idly( Sali$a ha% 'any function%, ,hich are li%ted in Table !(=( The &re%ence of food in the 'outh i% a &o,erful %ti'ulu% to %ali$ation, ,ith %trong-ta%ting acid food% being the be%t %ti'ulant%( Sali$a not only &hy%ically re'o$e% dietary %ub%trate% and acid% &roduced by &laBue fro' the 'outh, but it ha% a 'o%t i'&ortant role in buffering the &1 in %ali$a and ,ithin &laBue( 6a%t-flo,ing %ali$a i% al/alinereaching &1 $alue% of ?(:-C(9and i% $itally i'&ortant in rai%ing the &1 of dental &laBue &re$iou%ly lo,ered by ex&o%ure to %ugar and carbohydrate%( 4ecau%e teeth con%i%t largely of calciu' and &ho%&hate, the concentration of calciu' and &ho%&hate in %ali$a and &laBue i% thought to be i'&ortant in deter'ining the &rogre%%ion or regre%%ion of carie%( 0l%o, it i% ,ell /no,n that fluoride aid% the re'inerali5ation &roce%%( 0lthough it 'ay %ee' %en%ible to try to 'axi'i5e the a$ailability of calciu', &ho%&hate, and fluoride in the en$iron% of the tooth, in &ractice, fluoride i% 'uch the 'o%t i'&ortant( >e$ Point# Dental carie%G occur% in &laBue-co$ered area% freBuently ex&o%ed to dietary carbohydrate%H the initial le%ion i% %ub%urface before the thin %urface layer colla&%e%H

 the initial or &re-ca$itation le%ion i% re$er%ibleH %ali$a &lay% an e%%ential &art in carie% &re$entionH if all &laBue i% re'o$ed fro' the %urface the cariou% &roce%% %to&%( Fi!. 1./ "lot of the &1 of dental &laBue again%t ti'eG thi% i% co''only /no,n a% a Ste&han cur$e( The cur$e ,a% &roduced by rin%ing ,ith a =9L gluco%e %olution( The dotted line re&re%ent% a ty&ical &1 $alue belo, ,hich ena'el ,ill di%%ol$e ;the critical &1<( ;Re&roduced ,ith &er'i%%ion fro' 7en/in% =>?C(<( Fi!. 1.2 Clinical a&&earance of &reca$itation cariou% le%ion% on the buccal %urface% of 'axillary inci%or teeth ;,hite %&ot le%ion<( Fi!. 1.3 Clinical a&&earance of a &reca$itation cariou% le%ion on the 'e%ial %urface of a 'axillary fir%t 'olar tooth ;bro,n %&ot le%ion<( Fi!. 1.0 3ongitudinal ground %ection through a cariou% le%ion of the ty&e %ho,n in 6ig( !(@ exa'ined in ,ater by &olari5ed lightG :9( ;Re&roduced ,ith &er'i%%ion fro' Soa'e% and Southa', =>>C(<( Fi!. 1.5 Microradiogra&h of a longitudinal ground %ection through a le%ion of the ty&e %ho,n in 6ig% !(@ and !(A( The body of the le%ion %ho,% 'ar/ed radiolucency ;lo%% of 'ineral< in contra%t to %ound ena'el and the %urface layerG ?9( ;Re&roduced ,ith &er'i%%ion fro' Soa'e% and Southa', =>>C(<( Fi!. 1.1 Maxillary &er'anent canine tooth %ho,ing a $ariety of cariou% le%ion% ranging fro' ,hite %&ot ena'el carie% to ca$itated dentine carie%( 1.2 T5E EPIDE7I&*&6Y &F DENTA* CARIES Dental carie% i% one of our 'o%t &re$alent di%ea%e% and yet there i% con%iderable $ariation in it% occurrence bet,een countrie%, region% ,ithin countrie%, area% ,ithin region%, and %ocial and ethnic grou&%( One of the ta%/% of e&ide'iology i% to record the le$el of di%ea%e and the $ariation bet,een grou&%( 0 %econd ta%/ i% to record change% in the le$el% of dental carie% in &o&ulation% o$er ti'e, ,hile a third ta%/ i% to try to ex&lain the%e $ariation%( The #nited 2ingdo' ha% one of the be%t %erie% of national %tati%tic% on dental carie%( The dental health of adult% and children ha% been recorded e$ery =9 year%, beginning ,ith the 0dult Dental 1ealth Sur$ey of =>!C ;Table !( <( The ad$antage% of thi% %erie% of %ur$ey% areG =( They are national, u%ing %ound %a'&ling 'ethod% to obtain re&re%entati$e %a'&le% of the &o&ulation%( ( They include both clinical and %ociological data, gi$ing the interaction bet,een /no,ledge, attitude, beha$iour, and di%ea%e( @( The 'ethod% are ,ell de%cribed and carefully %tandardi5ed, re%ulting in 'eaningful longitudinal infor'ation( Data on children at the age% of :, = , and =A are al%o a$ailable through the annual %tudie% conducted under the au%&ice% of the 4riti%h 0%%ociation for the Study of Co''unity Denti%try(

The ra$age% of dental carie% ,ere %o %e$ere in the &a%t that the extent of di%ea%e in a &o&ulation ,a% 'ea%ured by the &ro&ortion of the &o&ulation ,ith no natural teeth or edentulou%ne%%( 0 'ar/ed decrea%e in the &er cent edentulou% bet,een =>!C and =>>C ,a% recorded, e%&ecially in adult% aged @:-:A year%( 6or younger &eo&le, it i% co''on to record the &re$alence ;the &ro&ortion of &eo&le affected<, the %e$erity ;nu'ber of teeth affected &er &er%on< of dental carie% and the &ercentage of cariou% teeth re%tored ;Care )ndex<( The dra%tic i'&ro$e'ent in the%e &ara'eter% in the #2 bet,een =>?@ and 99@ i% %ho,n in Table !(@( 0bout half of all children are no, clinically *carie%free*( What i% of concern i% o&inion that in the younge%t age grou&% the i'&ro$e'ent i% not continuing, and indeed there are %ign% that carie% ex&erience i% increa%ing in %o'e area%( Thi% i% co'&ounded by a decline in the Care )ndex in the #2( 0 decline in carie%, fir%t noticed during the =>?9%, ha% been recorded in a large nu'ber of indu%triali5ed countrie%( The dental health of older children continued to i'&ro$e in the =>C9% but carie% ex&erience in &ri'ary teeth, 'ea%ured at age% : or ! year%, had %tayed fairly con%tant( The -ordic countrie% u%ed to ha$e $ery high carie% ex&erience and the dra%tic i'&ro$e'ent in all fi$e -ordic countrie% can be %een in 6ig( !(?, although it occurred %o'e,hat later in )celand( One of the 'o%t dra'atic i'&ro$e'ent% ha% been recorded in S,it5erland ,here the 'ean DM6T ;decayed, 'i%%ing, filled teeth< in = year old% fell fro' C(9 in =>!A, to :(= in =>? , @(9 in =>C9, and to =(= in =>> ( )n =: year old% it fell fro' =@(> DM6T in =>!A to ( DM6T in =>> ( Carie% ex&erience in 0u%tralian children ha% been ,ell recorded indicating a dra'atic i'&ro$e'ent in dental health ;6ig( !(C<( Re&ort% fro' -orth 0'erica indicate that carie% &re$alence and %e$erity in the &er'anent dentition ha$e continued to decline %ince =>C in Canada and the #nited State%, but that carie% ex&erience in the &ri'ary dentition 'ay ha$e %tabili5ed %ince about =>C!-?( While dental %ur$ey% of %choolchildren ha$e been Buite co''on, there i% 'uch le%% infor'ation on the dental health of &re%chool children 'ainly becau%e acce%% to the' i% 'ore difficult ;Table !(A<( The &re$alence and %e$erity of dental carie% in 4riti%h &re%chool children ,a% re$ie,ed by 1olt ;=>>9<, and in &re%chool children around the ,orld by 1ol' ;=>>9<( )n 'o%t Euro&ean countrie%, -orth 0'erica, and 0u%tralia, carie% ex&erience ha% declined in &arallel ,ith the increa%ing u%e of fluoride tooth&a%te%, although thi% decline a&&ear% to ha$e %to&&ed in the #nited 2ingdo'( Carie% ex&erience of &re%chool children in South-Ea%t 0%ia, Central 0'erica, and &art% of 0frica i% high and there are di%cernible trend% of increa%ing &re$alence in &arallel ,ith the ri%e in a$ailability of %ugar-containing %nac/% and drin/%( While the %tate of the &er'anent dentition in children ha% i'&ro$ed dra'atically in 'any countrie%, carie% in &ri'ary teeth i% %till a con%iderable &roble' in &re%chool and %chool-aged children( )n indu%triali5ed countrie%, carie% ex&erience i% highe%t in the 'ore de&ri$ed grou&% of %ociety and often in ethnic 'inority grou&%( )n de$elo&ing countrie%, the re$er%e %ocial trend i% ob%er$ed, ,ith the ,ell-off, urban children ha$ing the 'o%t carie% ex&erience( Mo%t of the%e $ariation% in children*% dental health can be ex&lained in ter'% of the &re$enti$e role of fluoride and the carie%-inducing role of %ugary %nac/%( )n adult%, &ro$i%ion of dental %er$ice% and &atient &reference for treat'ent% can ha$e a 'a+or effect on the %tate of the dentition, in addition to the aetiological and &re$enti$e role% of %ugar, fer'entable carbohydrate%, and fluoride(

>e$ Point# Dental carie% E&ide'iology indicate% the %i5e of the &roble' of carie% and change% o$er ti'e( Since =>!C there ha$e been %ur$ey% e$ery =9 year% of adult*% and children*% dental health in the #nited 2ingdo'( "re$alence and extent ha$e fallen 'ar/edly %ince the late =>?9% in 'any countrie%, ho,e$er, thi% decline a&&ear% to ha$e cea%ed( Dental carie% re'ain% a %ignificant &roble'( Fi!. 1.2 Carie% ex&erience ;DM6T< for = -year-old children in -ordic countrie% ;Re&roduced fro' $on der 6ehr ;=>>A< ,ith /ind &er'i%%ion of the International Dental +ournal(<( Fi!. 1.3 Carie% ex&erience in 0u%tralian = year old% ;Re&roduced fro' S&encer et al( ;=>>A< ,ith /ind &er'i%%ion of the International Dental +ournal(<( 1.3 CARIES DETECTI&N AND DIA6N&SIS The &re%entation of carie% ha% been de%cribed a% re%e'bling an iceberg ,ith the clinically $i%ual %tage% co''encing ,ith the ,hite-%&ot le%ion being abo$e the ,aterline( 4elo, the ,aterline lie the le%ion% ,hich need the u%e of %o'e for' of additional aid to be identified( Thi% can range fro' radiogra&h% in the clinical %ituation to hi%to&athology in the in vitro %etting( Carie% diagno%i% i% difficult, it i% a 'ulti-%tage &roce%%( #nfortunately, current training of undergraduate dental %tudent% and re'uneration %y%te'% lead denti%t% freBuently +u%t to thin/ of the diagno%tic &roce%% a% a treat'ent, that i%, a dentinal cariou% le%ion on the di%tal %urface of a &re'olar being recorded a% a DO a'alga'( The identification of carie% de&end% on a %y%te'atic exa'ination of clean dry teeth( The ba%ic eBui&'ent con%i%t% of adeBuate lighting, co'&re%%ed air for drying, dental 'irror, and blunt or ball ended &robe( The e'&ha%i% i% on a $i%ual exa'ination, rather than a $i%ual-tactile exa'ination( Shar& &robe% ,hich ,ere traditionally u%ed to aid diagno%e% are contra-indicated for a nu'ber of rea%on%G The &robe doe% not i'&ro$e diagno%i%all a *%tic/y* fi%%ure 'ean% i% that the &robe fit% the fi%%ure( "robing a de'inerali5ed le%ion ,ill brea/ the ena'el 'atrix 'a/ing re'inerali5ation i'&o%%ible, thu% creating an iatrogenic ca$ity( The &robe 'ay tran%fer cariogenic bacteria fro' one %ite to another, in effect inoculate carie% free %ite% ,ith cariogenic bacteria( 0 ball-ended or blunt &robe 'ay be u%ed gently to confir' the &re%ence of ca$itation, %ealant%, and re%toration%( The fir%t $i%ible %ign of carie% i% the ,hite %&ot le%ion, at fir%t thi% can only be %een ,hen the %urface i% dried ;6ig( !(><( Thi% i% becau%e ,hen de'inerali5ed ena'el beco'e% &orou%, the%e &ore% contain ,ater, if dried, the ,ater in the &ore% i% re&laced ,ith air and the le%ion beco'e% 'ore ob$iou%( 0% the carie% &rogre%%e% the le%ion ,ill

beco'e ob$iou% e$en ,hen ,et( #nfortunately acti$e cariou% le%ion% are not the only cau%e% of ,hite area% on teethH hy&o&la%ia, fluoro%i%, and arre%ted hy&er'inerali5ed cariou% le%ion% to na'e but a fe, can all 'i'ic a ,hite %&ot cariou% le%ion( The deci%ion a% to the aetiology de&end% on factor% %uch a% %ite and %urface characteri%tic%( Carie% tend% to occur at &redilection %ite%, therefore a ,hite area at the gingi$al 'argin i% 'uch 'ore li/ely to be carie% than one of %i'ilar a&&earance at the inci%al edge( 0cti$e cariou% le%ion% are 'att ,hite, ,hile arre%ted le%ion% are glo%%y( 0 %i'ilar &roce%% i% conducted for bro,n %&ot le%ion%( 0lthough large ca$itie% are relati$ely ea%ily identified dentine carie% &re%ent% it% o,n &roble'%( On occlu%al %urface% there 'ay be no $i%ible brea/ in the %urface, the e$idence of carie% being %hado,ing under the ena'el( 0 %i'ilar &icture i% %een for a&&roxi'al le%ion%( Therefore a% e$en the 'o%t thorough $i%ual clinical exa'ination ,ill detect only %o'e of the ena'el and dentine cariou% le%ion% &re%ent, the clinician need% to be hel&ed by diagno%tic aid%( The 'o%t co''only u%ed of the%e are radiogra&h%( The $ie,% ,hich are of $alue for carie% diagno%i% areG bite,ing%, ortho&anto'ogra' ;O"T<, bi'olar%, &eria&ical%( 4ite,ing% are the fir%t choice $ie, for carie% diagno%i%( The%e &ro$ide infor'ation on both occlu%al dentine carie% and a&&roxi'al ena'el and dentine carie%( O"T% can detect the &re%ence of an occlu%al dentine cariou% le%ion ,ith a high degree of accuracy( O"T% ha$e 'uch le%% $alue in the detection of a&&roxi'al le%ion%( 4i'olar% are not a% u%eful a $ie, a% bite,ing% becau%e there i% often o$erla& of %tructure%( 1o,e$er, they are of u%e in the &re-coo&erati$e child ,ho ,ill not co&e ,ith bite,ing% or an O"T( "eria&ical% are a% accurate a% bite,ing% for carie% diagno%i% but ob$iou%ly le%% infor'ation i% a$ailable on any one fil'( 0% ,ith the $i%ual exa'ination it i% $ital that the radiogra&h% are $ie,ed in a %y%te'atic ,ay ,ith a&&ro&riate illu'ination and ideal 'agnification( 0lthough not all children ,ill tolerate the', bite,ing radiogra&h% %hould be con%idered for all children fro' the age of A year% and abo$e ,ho are at ri%/ of carie%( The clinician %hould a%/ the Bue%tion *Why not ta/e bite,ing%J* rather than *Why ta/e bite,ing%J* The deci%ion to ta/e and the freBuency of further radiogra&hic exa'ination% need% to be ba%ed on a thorough cariou%-ri%/ a%%e%%'ent, the denti%t ha$ing to balance the benefit% of the additional diagno%tic yield ,ith the ri%/% of ex&o%ure to ioni5ing radiation( Current guideline% fro' the 6aculty of General Dental "ractitioner% #2 ;=>>C< %ugge%t annually for the cariou%-acti$e child and biennially for the child ,ith controlled carie%(

0n intere%ting clinical &heno'enon ,hich 'ay hel& the clinician decide if radiogra&h% are ,arranted i% the &re%ence of a bleeding &a&illa, thi% %ugge%ting the &re%ence of an a&&roxi'al ca$ity( Thi% occur% becau%e the ca$ity ,ill be full of &laBue, ,hich together ,ith dri$ing the cariou% &roce%% on ,ill cau%e gingi$iti% and thu% the bleeding &a&illa( Other diagno%tic aid% ,hich 'ay a%%i%t ,ith a&&roxi'al carie% diagno%i% include fibre-o&tic tran%illu'ination ;6OT)< and te'&orary tooth %e&aration ;6ig( !(=9<( 6OT) con%i%t% of the &lace'ent of a 9(: '' light %ource in the e'bra%ure( )f a cariou% le%ion i% &re%ent it ,ill %ho, a% a dar/ %hado,( So'e %tudie% ha$e %ugge%ted that 6OT) i% a% accurate a% radiogra&h% but the %ituation i% confu%ed by other %tudie% ,hich Bue%tion the benefit of 6OT)( Certainly if it i% u%ed 6OT) &ro$ide% the clinician ,ith 'ore infor'ation to ba%e a deci%ion on( Te'&orary tooth %e&aration con%i%t% of the &lace'ent of an orthodontic ela%ta'eric %e&arator bet,een the teeth ;6ig( !(== ;a< and b<<( The &atient return% after @-A day%, the teeth ha$ing %e&arated allo,ing direct acce%% for exa'ination( To a%%i%t ,ith the diagno%i% of occlu%al cariou% le%ion% three ad+unct% ha$e been de$elo&edH 6OT) a% di%cu%%ed abo$e, la%er fluore%cence de$ice%, and electronic carie% 'eter%( 3a%er fluore%cence de$ice% 'ea%ure the fluore%cence of the tooth and of &articular i'&ortance the fluore%cence of bacterial by-&roduct% in the cariou% le%ion ;6ig( !(= <( Thi% &ro$ide% a digital reading indicating the %tatu% of the %urface( Re%earch on the%e de$ice% i% $ery &ro'i%ing but fal%e reading% are generated by %taining, calculu%, and hy&er&la%ia( When u%ed a&&ro&riately the%e &ro$ide a %tandardi5ed, re&roducible 'ea%ure, ,hich not only hel&% ,ith the diagno%tic deci%ion but allo,% the &o%%ibility of 'onitoring o$er ti'e( Electronic carie% 'eter% al%o exi%t ,hich 'ea%ure the decrea%e in re%i%tance of cariou% le%ion% co'&ared to %ound %urface%( When u%ed 'eticulou%ly the%e 'eter% ha$e %ho,n good accuracy in clinical trial%( The reading% of electronic carie% 'eter% are confounded by area% of hy&er&la%ia, i''ature teeth, and &articularly 'oi%ture( >e$ Point# The %tage% in carie% diagno%tic &roce%% Detect, Diagno%e, Record( Fi!. 1.4 Clinical a&&earance of ,hite %&ot le%ion% on the labial and a&&roxi'al %urface% of the u&&er &er'anent inci%or%( Fi!. 1./0 6OT) of a&&roxi'al %urface% of &o%terior &er'anent teeth( The arro, &oint% to a %hado, cau%ed by an a&&roxi'al cariou% le%ion( ;)llu%tration fro' Mitro&oulo% ;=>C:< ,ith /ind &er'i%%ion of Caries )esearch(<( Fi!. 1.// ;a< Te'&orary tooth %e&aration, an ela%to'eric %e&arator bet,een a lo,er %econd &re'olar and fir%t &er'anent 'olar( ;b< The a&&earance after

%e&aration, %ho,ing acce%% for exa'ination of the a&&roxi'al %urface%( Fi!. 1./2 The ti& of a la%er fluore%cence de$ice in &lace on the occlu%al %urface of a 'axillary fir%t &er'anent 'olar( 1.0 PRE)ENTI&N &F DENTA* CARIES 1.0.0 Introd-"tion The dra'atic i'&ro$e'ent in dental health, e%&ecially in children, in 'any de$elo&ed countrie% during the &a%t 9 year% i% &roof that &re$ention ,or/%( Dental carie% i% not ine$itableH the cau%e% are ,ell /no,n, di%couraging carie% de$elo&'ent and encouraging carie% healing are realitie% to be gra%&ed( 6ailure to do %o i%, at lea%t, to &ro$ide %econd-cla%% dental care( There are four &ractical &illar% to the &re$ention of dental carie%G &laBue controlD toothbru%hing, diet, fluoride, and fi%%ure %ealing( Each of the%e ,ill be con%idered in turn before being brought together in treat'ent &lanning and in relation to carie%-ri%/( "re$ention of carie% i% %o ea%y in theory but in &ractice in$ol$e% 'any %/ill%( The 'ain rea%on for thi% i% that control of the aetiological agent%&laBue and fer'entable carbohydrate%in$ol$e a change in beha$iour( The $alue of fluoride i% that it can be deli$ered in a $ariety of ,ay%, %o'e of ,hich reBuire 'ini'al action by the &atient( There i% no *'agic bullet* that can be a&&lied to teeth ,hich ,ill render the' totally re%i%tant to carie%( 6i%%ure %ealant% co'e clo%e to thi% but they are ex&en%i$e to a&&ly, %o'e fall off, and they only &re$ent carie% of &it% and fi%%ure%( )n denti%try there i% no doubt that &re$ention i% better than cure( "re$ention of dental carie% under&in% all dental care &ro$ided to children( 0ll children reBuire &re$enti$e in&ut( The ty&e of in&ut de&end% on the child and their carie% ri%/( 6or'ing a co'&rehen%i$e treat'ent %trategy, tailored to the need% of each indi$idual child, i% an e%%ential co'&onent of all &aediatric treat'ent &lanning( De%&ite dental carie% being a &re$entable di%ea%e e&ide'iological %ur$ey% in children in 'any countrie% ha$e %ho,n that the di%tribution of dental carie% ha% beco'e *bi'odal*, ,ith C9L of the di%ea%e &re%ent in only 9L of the child &o&ulation( Con%eBuently t,o a&&roache% are reBuired to i'&ro$e dental health( Thi% %trategy ,ill in$ol$e 'aintaining good dental health in tho%e ,ithout dental decay, and %econdly targeting re%ource% to tho%e that are at ri%/ of de$elo&ing decay( Thi% 'ean% targeting the *high carie%-ri%/* grou&% co'&ri%ingG the carie% &ronee%&ecially early childhood carie% ;nur%ing bottle carie%<( the handica&&ed'edical and &hy%ical( the %ocially de&ri$ed, that i%, lo, %ocio-econo'ic grou&%( ethnic 'inority grou&% u%ually re%iding in inner city area%( 3o, carie%-ri%/ children are tho%e ,ho are carie%-free or ha$e ,ell-controlled carie%, ha$e good oral and dietary habit%, are highly 'oti$ated and attend their dental a&&oint'ent% regularly( )t i% thu% i'&ortant to in%titute effecti$e &re$enti$e 'ea%ure% for children and ad$ice

for their &atient%( Thi% i% be%t achie$ed at treat'ent &lanning &rior to co''encing any re%torati$e ,or/ ;other than e'ergency and %tabili5ing &rocedure%<( )t i% al%o i'&ortant to clarify ,hat con%titute% high and lo, carie%-ri%/ children ;Cha&ter @<( The 'ain%tay of &re$enti$e 'ea%ure% areG ;=< &laBue control and regular toothbru%hing ,ith a fluoride tooth&a%teH ; < %en%ible dietary ad$iceH ;@< u%e of fluoride%H ;A< fi%%ure %ealant%H ;:< regular dental chec/% ,ith a&&ro&riate radiogra&h%( 0ll of the%e 'ea%ure% need to be co-ordinated and %u&er$i%ed by the dental tea' and reinforced ,ith good &atient and &arental 'oti$ation( 1.0./ PlaA-e "ontrol and toot%,r-#%in! There are a nu'ber of &laBue di%clo%ing tablet% and %olution% a$ailable( Children need clo%e %u&er$i%ion ,hen u%ing the%e agent% and a&&ro&riate ad$ice %hould be gi$en to &arent% and guardian%( "laBue chart% can be u%ed to 'onitor &rogre%% and to identify area% ,here cleaning i% not ideal( )t i% cu%to'ary to re&ort the &ercentage nu'ber of clean %urface% %o that &atient% ai' to achie$e a% clo%e to =99L clean a% &o%%ible( 0fter de'on%trating the &laBue di%clo%ing &rocedure ;6ig( !(=@< and &erfor'ing the charting it i% initially ad$i%able to in%truct &atient% to u%e the di%clo%ing agent &rior to toothbru%hing( 0fter = ,ee/ it i% ad$i%able for &atient% to bru%h fir%t and then di%clo%e in order to identify area% that are being 'i%%ed( Toot%,r-#%in! 0d$i%e regular toothbru%hing ,ith an a&&ro&riate concentration of fluoride tooth&a%te( Toothbru%hing %hould beco'e a routine and on at lea%t t,o occa%ion% e$ery day( There are nu'erou% ty&e% of bru%he% ;'anual and electric< and tooth&a%te% a$ailable( Many bru%he% and &a%te% ha$e cartoon character% etc(, ,hich can be good 'oti$ator% for 'any children( 4oth 'anual ;&referably ,ith a %'all head< and electric bru%he% are eBually effecti$e for &laBue re'o$al( 1o,e$er, the co%t of bru%he% and &a%te% can be &rohibiti$e for %o'e lo, %ocio-econo'ic grou&% ,herein reality toothbru%hing ha% beco'e a lo, &riority( Thi% i% ,here co''unity and %chool-ba%ed &rogra''e% are needed to en%ure &ro$i%ion of oral health 'ea%ure%( .oung children under : year% need hel& ,ith toothbru%hing ;6ig( !(=A<( Children do not ha$e the 'anual dexterity to bru%h their teeth effecti$ely until they can tie their o,n %hoelace% ;about ? year% of age<( 1o,e$er, e$en after thi% children %hould %till be %u&er$i%ed to e%tabli%h a regular routine and to en%ure a good oral health &ractice( Only a %'all %'ear of fluoride tooth&a%te %hould be u%ed u& to ! year% of age( 6luoride i% cleared Buic/ly fro' the oral ca$ity that 'any ad$i%e to %,i%h the tooth&a%te %ali$a %lurry around the 'outh and not to rin%e ,ith ,ater in order to 'aintain ele$ated intra-oral fluoride le$el% for longer &eriod% of ti'e( 0 %i'&le 'e%%age for &atient% i% *bru%h your teeth fir%t thing in the 'orning and la%t thing at night*( 0% dental carie% i% cau%ed by bacteria in &laBue fer'enting dietary carbohydrate% to acid% ,hich di%%ol$e ena'el, it i% logical to &re$ent carie% by re'o$ing &laBue fro'

teeth, u%ually ,ith a toothbru%h( #nfortunately, 'any in$e%tigation% indicate that carie% reduction i% not brought about by i'&ro$ed toothbru%hing alone( 1o,e$er, it 'u%t be %aid %traight a,ay that, fir%t, toothbru%hing i% a $ery i'&ortant ,ay of controlling gingi$iti% and &eriodontal di%ea%e and, %econd, that toothbru%hing ,ith tooth&a%te i% a $ery i'&ortant ,ay of con$eying fluoride to the tooth %urface( The re%ult% of the fe, %tudie% to in$e%tigate the effect of flo%%ing on dental carie% are 'ixed( Daily flo%%ing of the teeth of young children reduced carie% in one %tudy but no &re$enti$e effect ,a% ob%er$ed in older children ,ho flo%%ed their o,n teeth( T,enty-fi$e year% ago, in 2al%taad, S,eden, carie% incre'ent% ,ere $irtually eli'inated in children ,ho had fortnightly &ro&hylaxe% and inten%i$e &re$enti$e ad$ice by dental hygieni%t%( Other ,or/er% ha$e tried to re&roduce tho%e %en%ational re%ult% ;>!L carie% reduction co'&ared ,ith a control grou&< but ha$e failed to do %o, illu%trating the difficulty of extra&olating finding% of trial% fro' one country to another( "laBue gro,th can be &re$ented by t,ice-daily rin%ing ,ith chlorhexidine but becau%e of the intra-oral %ide-effect% of chlorhexidine ;changed ta%te %en%ation, &oor ta%te, and tooth %taining<, it i% u%ually reco''ended for %hort-ter' u%e only to aid &eriodontal care( Fi!. 1./3 "laBue di%clo%ure of u&&er and lo,er dentition( Fi!. 1./0 "arent a%%i%ting toothbru%hing of their young child*% teeth( 1.0.2 N-trition and diet in "arie# "ontrol We are con%tantly eating and %nac/ing and it i% $ery i'&ortant to be able to gi$e %en%ible &ractical ad$ice regarding diet and dental carie%( So'e con%ider that there are *good food%* and *bad food%* ,hile other% con%ider that there are *good diet%* and *bad diet%*( 6urther, %o'e con%ider %ugar to be the arch $illain and ene'y of denti%try( Carie% ha% declined de%&ite increa%ed %ale% and con%u'&tion of %ugar%( 1o,e$er, the literature i% contro$er%ial and there are 'any conflicting $ie,% and o&inion% regarding %ugar con%u'&tion( The COM0 re&ort cla%%ified %ugar% a% being either intrin%ic ;%ugar ,ithin cell 'e'brane, for exa'&le, fruit%< or extrin%ic ;readily a$ailable %ugar%, for exa'&le, refined %ugar%<( 0re intrin%ic %ugar% con$erted to extrin%ic %ugar% on che,ingJ Thi% i% &robably irrele$ant, a% bacteria need a fer'entable %ource of carbohydrate to &roduce acid( The re$ie, &a&er of 4urt and "ai ; 99=< %u''ari5e% the conflict in o&inion% on %ugar( 1o,e$er, ,e %hould concentrate on gi$ing %en%ible &ractical e$eryday ad$ice to our &atient% a% %ho,n in Table !(:( 0d$i%ing &arent% to co'&letely %to& their children fro' eating %ugary food% i% not achie$ableI We %hould ai' to en%ure that our &atient% eat %en%ibly and %afely( 4aby drin/% gi$en in baby bottle% led to *nur%ing bottle* carie%( "laBue &1 re%&on%e% of the%e drin/% %ho,ed fall% to belo, the critical &1 of a&atite ;&1 M :(:<( We %hould ad$i%e that only 'il/ or ,ater i% gi$en to children in a baby bottle( Many are not a,are that no added %ugar drin/% contain natural %ugar( We %hould &ro'ote that for young children drin/% are con%u'ed fro' trainer cu&%, bea/er%, and to u%e %tra,%( *Safer food%* ha$e been reco''ended a% alternati$e% for freBuent %nac/er% or nibbler%( The%e alternati$e% include chee%e% that ha$e been %ho,n to rai%e &laBue &1( )n addition to fruit and $egetable%, cri%&% and &eanut% ha$e al%o been reco''ended a% %afer alternati$e%(

1o,e$er, citru% fruit% ha$e been i'&licated in the aetiology of dental ero%ion and &eanut% are a%%ociated ,ith inhalation ri%/ in %'all children( The de$elo&'ent of one *%afer* drin/ ha% been accredited by the 4riti%h Dental 0%%ociation ;4D0< and %ho,ed that the &laBue &1 did not fall belo, the critical &1 for ena'el ;Tou'ba and Duggal, =>>><( FreA-en"$ o+ eatin! 6reBuency of eating ha% an i'&ortant effect on teeth( 1o,e$er, i% thi% anecdotal or ba%ed on %cientific e$idenceJ Eating 'eal% lead% to &eriod% of acid attac/ ,hen tooth 'ineral i% lo%t( 0t the end of the 'eal or %nac/ the acid i% buffered by %ali$a and the 'ineral lo%% %to&% and re$er%e% under fa$ourable condition%( 6reBuent %nac/er% ha$e &redo'inantly 'ineral lo%% and little if any re'inerali5ation( Duggal et al( ; 99=< de'on%trated the i'&ortance of fluoride and freBuency of %ugar con%u'&tion in an in situ %tudy u%ing ena'el %lab% and tran%$er%e 'icroradiogra&hy( When $olunteer% did not u%e a fluoride tooth&a%te 'ineral de'inerali5ation ,a% ob%er$ed ,ith the freBuency a% lo, a% three ti'e% &er day( 1o,e$er, ,hen fluoride tooth&a%te ,a% u%ed t,ice daily no %ignificant 'ineral de'inerali5ation ,a% ob%er$ed u& to a freBuency of %ugar con%u'&tion of %e$en ti'e% &er day( Therefore, bru%hing t,ice &er day ,ith a fluoride tooth&a%te, %ub+ect% %hould %afely be able to ha$e fi$e 'eal 'o'ent% &er day( Thi% i% a %en%ible and achie$able dietary 'e%%age for &atient%( Non-#-!ar #Ceetener# Tho%e allo,ed for u%e in food% and drin/% in the #nited 2ingdo' are gi$en in Table !(!( The li%t i% $ery %i'ilar for 'o%t countrie%( There i% 'uch e$idence that they are non-cariogenic or $irtually %o( The inten%e %,eetener% and xylitol are non-cariogenic ,hile the other bul/ %,eetener% can be 'etaboli5ed by &laBue bacteria but the rate i% %o %lo, that the%e %,eetener% can be con%idered %afe for teeth( The u%e of non-%ugar %,eetener% i% gro,ing ra&idly &articularly in confectionery and %oft drin/%( Confectionery &roduct% ,hich ha$e &a%%ed a ,ell-e%tabli%hed acidogenicity te%t can be labelled ,ith the Mr 1a&&y-Tooth logo ;6ig( !(=:< ,hich i% a &rotected trade'ar/, ,hich infor'% the &urcha%er and con%u'er that the%e &roduct% are dentally %afe( Tooth-friendly %,eet% are a$ailable in about ! countrie%H in S,it5erland about 9 &er cent of confectionery %old carrie% the Tooth-friendly ;or Mr 1a&&y-Tooth< logo( There i% good e$idence that %ugarle%% che,ing gu'% are not only non-cariogenic but al%o &o%iti$ely &re$ent dental carie%, by %ti'ulating %ali$ary flo,( )ndeed, xylitol gu'% are u%ed in %chool-ba%ed &re$enti$e &rogra''e% in 6inland( )n the #nited 2ingdo', the 4D0 accredit% &roduct% ,hich benefit oral health ;6ig( !(=!<( 0% an exa'&le, they ha$e accredited dentrifice% ,hich ha$e &ro$en effecti$ene%%, for 'any year%( More recently, food% and drin/% ha$e been accreditedfor exa'&le, a fruitfla$oured drin/ ,hich de'on%trated to ha$e negligible cariogenic and ero%i$e &otential( The Tooth-friendly and 4D0 accreditation %che'e% hel& the con%u'er to 'a/e better choice%( The bul/ %,eetener% can ha$e a laxati$e effect and %hould not be gi$en to children belo, @ year% of age( "eo&le $ary in their %en%iti$ity to the%e &olyol% a% %o'e adult% in the Tur/u %ugar %tudie% ,ere con%u'ing u& to =99 g of xylitol &er day ,ithout effect( Dietar$ ad.i"e +or t%e re.ention o+ dental "arie#

The ba%ic ad$ice i% %traightfor,ardreduce the freBuency and a'ount of inta/e of fer'entable carbohydrate%( Dietary ad$ice %hould be at t,o le$el%( 6ir%t, e$ery &atient %hould recei$e ba%ic ad$ice( Thi% e%&ecially a&&lie% to &arent% of young children ,ho need to be gi$en the correct ad$ice at the a&&ro&riate age of the child( Dietary ad$ice i% often too negati$eH energy that ha% been &ro$ided by confectionery ha% to be re&laced and it i% $ery i'&ortant to e'&ha%i5e &o%iti$e eating habit%( The $ariety of food% a$ailable ha% increa%ed enor'ou%ly in 'o%t countrie% in recent year%H ,e 'u%t u%e thi% increa%ed choice to a%%i%t our &atient% to 'a/e better food choice%( The %econd le$el of ad$ice i% a 'ore thorough analy%i% of the diet of children ,ith a carie% &roble'( 0 ,ell-acce&ted 'ethod i% the @-day diary record( One &ractical dra,bac/ of thi% 'ethod i% that it reBuire% at lea%t three $i%it%an introductory $i%it ,here the &atient i% 'oti$ated and infor'ed about the &rocedure and the diet diary gi$en out, the diary collection $i%it, and a %e&arate $i%it for ad$ice and to agree target%( Each of the%e %tage% i% i'&ortant( 0t the fir%t $i%it it i% $ital that the &atient and &arent a&&reciate that there i% a dental &roble' and that you are offering your ex&ert ad$ice to hel& the' o$erco'e thi% &roble'( Once 'oti$ated they 'u%t under%tand ho, the diary i% to be co'&leted( 0ny reBue%t% by &arent% for ad$ice at the fir%t $i%it %hould be &arried and delayed until the third $i%it( 0t the third $i%it, ad$ice 'u%t be &er%onal, &ractical, and &o%iti$eall three of the%e are i'&ortant ;Table !(:<( 6ood &reference of children, coo/ing %/ill%, food a$ailability, and financial con%ideration% $ary enor'ou%lyad$ice 'u%t be &er%onally tailored and &ractical for that &atient( "o%iti$e ad$ice ha% a 'uch greater chance of acce&tance than negati$e ad$ice %uch a% *a$oid thi%*, *don*t eat that*nagging i% a de-'oti$ator( Dietary change% are difficult, target% often ha$e to be li'ited and con%tant reinforce'ent of ad$ice and encourage'ent i% e%%ential( 1o,e$er, health gain% can be con%iderable, to general a% ,ell a% dental health and often to other 'e'ber% of the fa'ily, %o that dietary ad$ice i% an e%%ential &art of care of children( Fi!. 1./5 "ictogra' of Mr 1a&&y-Tooth( Thi% i% the &rotected logo of the )nternational Toothfriendly 0%%ociation to be %een on &roduct% that ha$e &a%%ed the internationally acce&ted toothfriendly te%t( ;Re&roduced by /ind &er'i%%ion of the 0%%ociation( Tooth friendly S,eet% )nternational, 1au&t%tra%%e !@, C1A=9 , 4inningen =, S,it5erland(< Fi!. 1./1 4D0 logo, ,hich indicate% that the &roduct ha% been accredited by it ;Re&roduced by /ind &er'i%%ion of the 4riti%h Dental 0%%ociation, Education and Science De&art'ent, 4riti%h Dental 0%%ociation, !A Wi'&ole Street, 3ondon W=M C.S(<( 1.0.3 Fl-oride and "arie# "ontrol The u%e of fluoride% date bac/ to a% early a% =C?A ,hen the Ger'an Erharde %ugge%ted the u%e of &ota%%iu' fluoride tablet% for ex&ectant 'other% and children in order to %trengthen teeth( Thi% reco''endation ,a% ,ithout any %cientific e$idence( What ,e no, /no, to be dental fluoro%i% ;'ottling< ,a% noted by denti%t% long ago ,ho re&orted on *Colorado Stain* ,ithout the aetiology of the tooth defect being e%tabli%hed( 7ode o+ a"tion o+ +l-oride and t%e "arie# ro"e##

The 'ineral of tooth ti%%ue% exi%t% a% a carbonated a&atite, ,hich contain% calciu', &ho%&hate, and hydroxyl ion%, 'a/ing it a hydroxya&atite PCa=9(;"OA<!(;O1< Q( Carbonated &ortion% ,ea/en the %tructure and render the ti%%ue %u%ce&tible to attac/( 6ood re'nant% and debri% 'ix ,ith %ali$a and adhere to tooth %urface% a% a %li'y fil' /no,n a% dental &laBue( Oral bacteria, and 'o%t i'&ortantly certain ty&e% of cariogenic bacteria ;e(g( Mutan% %tre&tococci and 3actobacilli %&ecie%<, 'etaboli5e dental &laBue and &roduce acid ,hich lo,er% the &1 of the oral en$iron'ent( When the &1 i% belo, the critical &1 for hydroxya&atite ;<:(:<, de'inerali5ation occur% ,ith a net out,ard flo, of calciu' and &ho%&horou% ion% fro' the ena'el %urface into &laBue and %ali$a( When the &1 return% to ?(9, re'inerali5ation occur% ,ith a net in,ard flo, of ion% into the ena'el %urface( )f fluoride i% &re%ent during re'inerali5ation, it i% incor&orated to for' fluora&atite PCa=9(;"OA<!(6 Q, ,hich i% 'ore %table and re%i%tant to further acid attac/%( The &roce%% of de'inerali5ation and re'inerali5ation i% an ongoing one and freBuently referred to a% *the ionic %ee-%a,* or *tug-of-,ar*( Thi% i% no, ,idely belie$ed to be the 'o%t i'&ortant &re$enti$e action of fluoride, and a con%tant &o%t-eru&ti$e %u&&ly of ionic fluoride i% thought to be 'o%t effecti$e( 0 nu'ber of 'echani%'% ha$e been &ro&o%ed to ex&lain the action of fluoride ;Table !(?<( The fir%t i% that fluoride ha% an effect during tooth for'ation by %ub%titution of hydroxyl ion% for fluoride ion%, thereby reducing the %olubility of the tooth ti%%ue%( Second, fluoride can inhibit &laBue bacterial gro,th and glycoly%i%( 0t &1 ?(9, fluoride ion% are &recluded fro' entering bacteria( 1o,e$er, at &1 :(9, fluoride exi%t% a% hydrofluoric acid, ,hich cro%%e% the bacterial cell 'e'brane to interfere ,ith it% 'etaboli%', by %&ecifically inhibiting the en5y'e enola%e in the glycolytic &ath,ay( Third fluoride inhibit% the de'inerali5ation of tooth 'ineral ,hen &re%ent in %olution at the tooth %urface( 6ourth, fluoride enhance% re'inerali5ation by co'bining ,ith calciu' and &ho%&hate to for' fluora&atite( 6luoride enhance% cry%tal gro,th, %tabili5e% and 'a/e% the ti%%ue re%i%tant to further acid attac/( Ena'el a&atite de'inerali5e% ,hen the &1 dro&% to &1 :(:( 1o,e$er, ,hen fluora&atite i% for'ed during re'inerali5ation, it i% e$en 'ore re%i%tant to de'inerali5ation a% the critical &1 for fluora&atite i% &1 @(:( Therefore, it i% 'o%t i'&ortant to ha$e an intraoral %ource of fluoride ,hen re'inerali5ation i% ta/ing &lace( 3a%tly, fluoride affect% the 'or&hology of the cro,n of the tooth, 'a/ing the coronal &it% and fi%%ure% %hallo,er( Such %hallo,er &it% and fi%%ure% ,ill be le%% li/ely to collect food debri%, allo, %tagnation and beco'e decayed( The 'o%t i'&ortant of the%e 'echani%'% i% that ,hen fluoride i% &re%ent in the oral en$iron'ent at the ti'e of the acid attac/ it inhibit% de'inerali5ation and &ro'ote% re'inerali5ation( 0% early a% =C>9, Miller dre, attention to the di%%oluti$e &roce%% of dental carie% and directed effort% to inhibit di%%olution( The clinical finding% of the anti-carie% acti$ity of drin/ing ,ater ,ith fluoride cau%ed re%earcher% to %ee/ rea%on% for thi%( The finding that fluoride-treated ena'el had a lo,er %olubility led 'any to con%ider thi% a% a cau%e and effect relation%hi&( The anti-carie% action of fluoride ,a% thought to be one of &re$enting di%%olution of ena'el, and effort% ,ere 'ade to incor&orate 'ore and 'ore a'ount% of fluoride into %urface ena'el( The fir%t to&ical agent u%ed, after ,ater fluoridation, ,a% a L %odiu' fluoride %olution and there ,a% a greater u&ta/e of fluoride into ena'el fro' acidified %olution%( -u'erou% fluoride &re&aration% ,ith $arying concentration% of fluoride ,ere e'&loyed for to&ical a&&lication and u%ed a% anti-carie% agent%( )t ,a% noted that there ,a% not 'uch difference in the carie%

reduction% re&orted fro' the to&ical fluoride %tudie% de%&ite great $ariation% in the fluoride concentration% u%ed( )n addition, the difference in the le$el% of fluoride in %urface ena'el of re%ident% of fluoridated and non-fluoridated area% ,a% li'ited( Therefore, it i% difficult to ex&lain the :9L reduction of carie% ob%er$ed, on the ba%i% of the fluoride le$el in the %urface ena'el( 6urther'ore, there ha% been no %tudy to %ho, any clear-cut in$er%e relation%hi& bet,een fluoride content of %urface ena'el and dental carie%( 0ll the a$ailable e$idence i% that carie% re%ult% fro' the &re%ence of an acidogenic &laBue on ele'ent% of the tooth 'ineral( The diffu%ion of acidic co'&onent% into the tooth 'ineral i% acco'&anied by the re$er%e diffu%ion of co'&onent% of the 'ineral( During the cariou% &roce%% there i% a &referential lo%% of calciu', acco'&anied by di%%olution of 'agne%iu' and carbonate( The fir%t clinical %ign of ena'el carie% i% the %o-called *,hite %&ot* le%ion, ,here an a&&arently %ound %urface o$erlie% an area of decalcification( The re'inerali5ation effect of fluoride ha% %ince co'e into fa$our( )t ha% been re&orted that attac/ed ena'el could re-harden on ex&o%ure to %ali$a and that %oftened ena'el could be re-hardened by %olution% of calciu' &ho%&hate% in vitro( 1o,e$er, it i% no, /no,n that it i% the &re%ence of fluoride in the oral ca$ity, and in &articular, it% &re%ence in the liBuid &ha%e at the ena'el-&laBue interface, that i% of 'o%t i'&ortance( )n the &a%t it ,a% thought that the %y%te'ic action of fluoride ,a% i'&ortant for carie% &re$ention( Thi% $ie, ha% co'&letely changed and it i% no, /no,n that it i% the to&ical action of fluoride that i% e%%ential for carie% &re$ention( )t i% the &re%ence of fluoride in the liBuid &ha%e at the &laBue-ena'el interface that i% of 'o%t i'&ortance( Studie% ha$e %ho,n that e$en lo, le$el% of fluoride ;9(=9 &&'< ,ere effecti$e in &re$enting the di%%olution of ena'el( )t ha% been %tated that the acti$ity of the fluoride ion in the oral fluid that i% i'&ortant in reducing the %olubility of the ena'el rather than a high content of fluoride in the ena'el( Sali$a, the fluid that bathe% the teeth ha% been exten%i$ely %tudied( The le$el of fluoride in %ali$a i% thought to be i'&ortant for carie% &re$ention and it ha% been %ho,n that carie% %u%ce&tible %ub+ect% had %ali$ary fluoride le$el% of <9(9 &&', ,herea% carie% re%i%tant %ub+ect% had le$el% of >9(9A &&'( >e$ Point# 6luoride% )t i% the acti$ity of the fluoride ion in the oral fluid that i% of 'o%t i'&ortance in reducing ena'el %olubility rather than ha$ing a high content of fluoride in %urface ena'el( 0 con%tant %u&&ly of lo, le$el% of intraoral fluoride, &articularly at the %ali$aD &laBueDena'el interface, i% of 'o%t benefit in &re$enting dental carie%( There are a $a%t nu'ber of fluoride &roduct% that are a$ailable for %y%te'ic and to&ical u%e( They can be a&&lied &rofe%%ionally by the dental tea' or by the &atient at ho'e( 8ater +l-oridation Thi% i% a %y%te'ic 'ethod of &ro$iding fluoride on a co''unity ba%i%( O$er @99 'illion &eo&le ,orld,ide recei$e naturally or artificially fluoridated ,ater( =(9 &&'

fluoride ,a% %ho,n by Dean to be the o&ti'u' le$el in =>A ( Thi% ,a% in a &refluoride era and &erha&% the o&ti'u' le$el need% to be re$ie,ed( There ha$e been ==@ %tudie% in @ countrie% o$er the la%t !9 year% %ho,ing that dental carie% i% reduced by :9L( )t i% chea& and co%t-effecti$e but there are o&&onent% to it% u%e( Fl-oride #lement#

The%e are in the for' of tablet% and dro&%( Carie% reduction% $ary fro' 9L to C9L( There i% u%ually $ery &oor &atient co'&liance e%&ecially for high-carie% ri%/ grou&%( 0 *Catch * %ituation i% the ca%e in that tho%e &atient% that are co'&liant do not need %u&&le'ent% ,herea% tho%e that ,ill benefit ,ill not ta/e the'( The do%e% $ary ,orld,ide and are being increa%ingly held re%&on%ible for the ri%e in fluoro%i%( The fluoride %u&&le'ent do%e% de&end on the age of the &atient and the le$el of fluoride in the drin/ing ,ater( -o %u&&le'ent% %hould be &re%cribed if the ,ater fluoride le$el i% greater than 9(? &&'( The Euro&ean $ie, on %u&&le'ent% i% that they ha$e no role a% a &ublic health 'ea%ure, and ,hen they are &re%cribed 9(: 'g &er day %hould be the 'axi'u' do%e( The tablet% %hould be allo,ed to di%%ol$e %lo,ly in the 'outh, thu% &ro$iding a to&ical a&&lication of fluoride to the teeth( &t%er met%od# +or ro.idin! #$#temi" +l-oride There are of cour%e other %y%te'ic 'ethod% for &ro$iding fluoride to the co''unity( The%e areG ;=< %alt:9L carie% reduction% in S,it5erland and 1ungaryH ; < 'il/=:-!:L carie% reduction%H ;@< 'ineral WaterA!L carie% reduction% in 4ulgaria( 0re ,e therefore recei$ing 'ore than the o&ti'u' daily a'ount of fluoride and therefore at increa%ed ri%/ of fluoro%i%J 0re there other hidden %ource% of fluorideJ Mineral ,ater% are u%ed exten%i$ely a% the 'ain %ource of hou%ehold drin/ing ,ater( The fluoride le$el% of bottled ,ater% $ary con%iderably fro' 9(9 to (9 &&' 'ainly, but can be a% high a% =9(9-=@(9 &&' in %o'e countrie%( Therefore, before &re%cribing fluoride %u&&le'ent% ,e 'u%t fir%t deter'ine the fluoride le$el of the &atient*% drin/ing ,ater, be that ta& or bottled ,ater( )n addition %o'e baby 'il/ for'ula% ha$e high a'ount% of fluoride the'%el$e%, and if 'ade u& ,ith a high fluoride bottled ,ater the infant 'ay be at increa%ed ri%/ of de$elo&ing dental fluoro%i%( The 'axillary &er'anent central inci%or% are 'o%t %u%ce&tible to fluoro%i% at about year% of age( On the continent fluoride che,ing gu' i% a$ailable &ro$iding 9( : 'g fluoride &er %tic/ of gu'( So'e food%, for exa'&le, fi%h and tea ha$e high fluoride content%( We al%o inge%t fluoride fro' %ource% ,ithout reali5ing it( The *1alo Effect* i% the ter' u%ed to de%cribe the inge%tion of fluoride fro' hidden %ource%( 6or exa'&le, fi55y drin/% li/e *&e&%i* or *coca-cola* 'ay contain fluoride if the bottling &lant i% in a fluoridated area and therefore u%e% fluoridated ,ater( The *fluoridated* drin/% 'ay be tran%&orted to non-fluoridated area%( The %a'e a&&lie% to food% that are &roce%%ed and canned or &ac/aged in &lant% u%ing fluoridated ,ater( Toot% a#te# 0 dra'atic decrea%e in ,orld,ide carie% le$el% ha% been %een %ince their introduction

in the early =>?9%( They u%ually contain =999 or =A:9 &&' fluoride( The fluoride i% either %odiu' fluoride or %odiu' 'onofluoro&ho%&hate ;M6"< or a co'bination of both( There are 'any different brand% to %uit all ta%te%( Child for'ulation% contain u& to ::9 &&' fluoride to li'it fluoride inge%tion and therefore reduce the ri%/ of fluoro%i%( There are li'ited %tudie% on the efficacy of child for'ulation% on carie%( 0 %y%te'atic re$ie, of lo, fluoride tooth&a%te% %ho,ed a reduced efficacy of :9 &&' fluoride in co'&ari%on to =999 &&' fluoride( Therefore, it i% ad$i%able to reco''end tooth&a%te% for children containing at lea%t :99 &&' fluoride to en%ure carie% &re$enti$e efficacy( )t i% %o'eti'e% difficult to decide ,hich concentration of fluoride tooth&a%te i% to be reco''ended to &arent% for their children( There i% a balance bet,een carie%-ri%/ and fluoro%i%-ri%/( )f the child i% carie%-free, lo, fluoride ;:99 &&' 6< children*% &a%te% can be reco''ended to 'ini'i5e the ri%/ of fluoro%i%( 1o,e$er, if a young child under ! year% &re%ent% ,ith carie%, a fluoride tooth&a%te of at lea%t =999 &&' i% indicated a% the%e ha$e been &ro$en to be 'ore efficaciou% for carie% &re$ention( Fl-oride !el# The%e can be a&&lied in tray% or by bru%h and !L carie% reduction% ha$e been re&orted( They are high in fluoride ;=( @L M = ,@99 &&'< for &rofe%%ional u%e and lo,er ;=999 &&'< for ho'e u%e( There i% a ri%/ of toxicity ,ith the high fluoride containing gel% and the follo,ing %afety reco''endation% %hould be follo,edG ;=< no 'ore than 'l &er trayH ; < %it &atient u&right ,ith head inclined for,ardH ;@< u%e a %ali$a e+ectorH ;A< in%truct the &atient to %&it out for @9 % after the &rocedure ;u%ually A 'in% but ne,er ty&e% are for = 'in<( ;:< Do not u%e for children under ! year%( 1o'e u%e gel% contain =999-:999 &&' fluoride for u%e by &atient% at ho'e at bedti'e in addition to toothbru%hing( Thirty-%ix &ercent carie% reduction% ha$e been re&orted( Fl-oride mo-t% rin#e# The%e can be either daily rin%e% containing 9(9:L ; : &&'< or ,ee/ly rin%e% 9( 9L ;>99 &&'< of %odiu' fluoride( )t i% be%t to ad$i%e &atient% to u%e their fluoride rin%e% at a different ti'e to toothbru%hing %o that the nu'ber of fluoride ex&o%ure% increa%e%( Carie% reduction% of 9-:9L ha$e been re&orted for fluoride rin%e %tudie%( The effect of toothbru%hing and rin%ing ,ith fluoride ha% been %ho,n to be additi$e( 0ll orthodontic &atient% %hould be u%ing a daily fluoride rin%e to 'ini'i5e the ri%/ of de'inerali5ation and ,hite %&ot le%ion%( Children under the age of ! year% %hould not be reco''ended to u%e fluoride 'outh rin%e% due to the increa%ed ri%/ of %,allo,ing the &roduct( )arni#%e# Dura&hat :L by ,t fluoride M ,!99 &&' fluoride i% the 'ain fluoride $arni%h( Thi% ha% a $ery high fluoride concentration( )t i% %u&&lied in a %'all tube, but u%ed la$i%hly by 'o%t denti%t% a% if it ,ere tooth&a%te( 0gain there i% the &o%%ibility of toxicity ,ith

young children( )t %hould be u%ed %&aringly ,ith a cotton bud, a %'all &ea-%i5e a'ount i% %ufficient for a full 'outh a&&lication in children u& to ! year%( Carie% reduction% of :9-?9L ha$e been re&orted in Scandina$ian %tudie%( SloC-relea#e +l-oride de.i"e# Many dental 'aterial% li/e a'alga', co'&o%ite%, ce'ent%, acrylic%, and fi%%ure %ealant% ha$e had fluoride added, but the fluoride relea%e ,a% either %hort ter' or the &ro&ertie% of the 'aterial% ,ere ad$er%ely affected, to 'a/e the' of any u%e to &ro$ide a long-ter' %ource of intraoral fluoride( Gla%% iono'er ce'ent% are a grou& of 'aterial% that ha$e fluoride, but long-ter' relea%e i% debatable( So'e re%earcher% ha$e re&orted that the%e 'aterial% ha$e a fluoride *recharging* ca&acity( That i% ,hen the fluoride i% relea%ed fro' the 'aterial it later ta/e% u& fluoride fro' other dental &roduct% that are u%ed by the &atient, for exa'&le, fluoride tooth&a%te or 'outh rin%e, and thi% fluoride i% relea%ed at a later ti'e( The $ery late%t fluoride re%earch i% ,ith %lo,-relea%e de$ice%( The ob+ecti$e i% to de$elo& an intraoral de$ice that ,ill relea%e a con%tant %u&&ly of fluoride o$er a &eriod of at lea%t a year( The fluoride gla%% %lo,relea%e de$ice% ;6ig( !(=?< ,ere de$elo&ed at 3eed% and %ho,n to relea%e fluoride for at lea%t year%( Studie% in 3eed% de'on%trated that there ,ere !?L fe,er ne, cariou% teeth and ?!L fe,er ne, cariou% %urface% in high carie%-ri%/ children after year% in a clinical carie% trial for children ,ith the fluoride de$ice% in co'&ari%on to the control grou& ,ith &lacebo de$ice%( There ,ere ::L fe,er ne, occlu%al fi%%ure cariou% ca$itie% %ho,ing that occlu%al %urface% ,ere al%o &rotected by the fluoride relea%ed fro' the de$ice%( The fluoride gla%% de$ice% relea%e lo, le$el% of fluoride for at lea%t year% and ha$e great &otential for u%e in &re$enting dental carie% in high *carie%-ri%/* grou&% and irregular dental attender%( The fluoride gla%% de$ice% ha$e been &atented and co''ercial de$elo&'ent i% no, under &rogre%%( The &ro$i%ion of fluoride for each indi$idual 'u%t be tailor-'ade to %uit $arying %ocial and ,or/ing circu'%tance%( Slo,-relea%e fluoride de$ice% %ee' ideal for targeting the high carie%ri%/ grou&% ,ho are notoriou%ly bad dental attender% ,ith $ery &oor oral hygiene and 'oti$ation( Thi% i% a $ery &ro'i%ing de$elo&'ent ,ith a&&lication for u%e in nu'erou% high-ri%/ grou&% including the 'edically co'&ro'i%ed( De"idin! C%i"% +l-oride re aration to -#e +or di++erin! "lini"al #it-ation#E Thi% ,ill de&end onG ;=< Which grou&% of childrenJ ; < Which fluoride &re&arationJ ;@< Daily or ,ee/ly u%eJ ;A< To&ical or %y%te'ic a&&licationJ )n addition, the ex&ected &atientD&arent 'oti$ation and co'&liance i% $ery i'&ortant in deciding ,hat to u%e( Each indi$idual &atient ,ill reBuire a *tailor-'ade* fluoride regi'e, and the denti%t ,ill need to u%e hi% ex&erti%e and /no,ledge of each &atient in for'ulating indi$idual fluoride regi'e% and &re$enti$e treat'ent &lan%( Table !(C gi$e% %o'e %ugge%tion% for %o'e different clinical %ituation%( Fi!. 1./2 0 fluoride %lo,-relea%e gla%% de$ice attached to the buccal %urface of the u&&er right fir%t &er'anent 'olar tooth(

1.0.0 Fi##-re #ealin! "it and fi%%ure %ealant% ;%ealant%< ha$e been de%cribed a% 'aterial% ,hich are a&&lied in order to obliterate the fi%%ure% and re'o$e the %heltered en$iron'ent in ,hich carie% 'ay thri$e( )nitially de$elo&ed to &re$ent carie% their u%e ha% been de$elo&ed further and they no, ha$e a &lace in the treat'ent of carie%( The decline in carie% ob%er$ed in indu%triali5ed countrie% o$er recent decade% ha% affected all tooth %urface% but ha% been greate%t on %'ooth %urface%( Therefore the &it and fi%%ured %urface%, &articularly of the 'olar% ha$e the greate%t di%ea%e %u%ce&tibility( Thi% 'ean% that the &otential benefit% of effecti$ely u%ed %ealant% continue to increa%e( The techniBue for &lace'ent of %ealant% i% relati$ely %i'&le but i% techniBue %en%iti$e( Sali$ary conta'ination of a% little a% half a %econd can affect the bond and therefore the retention of the %ealant( Se$eral %ealant 'aterial% are a$ailable but the 'o%t effecti$e i% bi%-GM0 re%in( Current re%in 'aterial% are either auto&oly'eri5ing or &hoto-initiated, and 'o%t o&erator% &refer the ad$antage% of de'and %et offered by &hoto-initiation( 0lthough there are theoretical ad$antage% to che'ically cured 'aterial% in ter'% of retention, a% the%e 'aterial% ha$e longer re%in tag% extending into the etched %urface( 6illed and unfilled re%in% are a$ailable, the filled 'aterial% being &roduced to &ro$ide greater ,ear re%i%tance( 1o,e$er, thi% i% not clinically rele$ant and clinical trial% de'on%trate %u&erior efficacy for unfilled 'aterial%( )rre%&ecti$e of the &re%ence of filler% %o'e 'aterial% are o&aBue or tinted to aid e$aluation( Thi% i% an ad$antage but 'ean% the clinician i% unable to $ie, the ena'el %urface to a%%i%t ,ith carie% detection and to detect the &re%ence of re%toration% %uch a% %ealant re%toration%( >e$ Point# 6i%%ure %ealing techniBue "ro&hylaxi% before etching doe% not enhance retention but i% ad$i%able if abundant &laBue i% &re%ent( 0 dry bru%h %hould be u%ed rather than &a%te a% the%e are retained in the de&th% of the fi%%ure% &re$enting &enetration of the re%in( )%olate the tooth %urface, Etch for 9-@9 % ,ith @?L &ho%&horic acid, Wa%h and dry the %urface 'aintaining i%olation, 0&&ly the re%in, Cure, Chec/ for adeBuacy( )%olation i% critical to %ucce%%ful %ealant a&&lication( O&erator and a%%i%tant 'u%t act a% a tea' a% it i% i'&o%%ible for %ingle o&erator% to a&&ly %ealant effecti$ely( The $a%t 'a+ority of trial% ha$e de'on%trated cotton ,ool and %uction to be an effecti$e 'ean% of i%olation( Rubber da' i% ad$ocated by %o'e becau%e of the %u&erior i%olation offered by thi% 'aterial( Thi% i% &robably true but it% u%e i% freBuently not &o%%ible becau%e of the %tage of eru&tion of the tooth or le$el of co-o&eration of the &atient( )t ,ould be ina&&ro&riate to delay %ealant a&&lication to allo, further eru&tion to &er'it

the a&&lication of rubber da'( The a&&lication of %ealant i% a relati$ely non-in$a%i$e techniBue, freBuently u%ed to accli'ati5e a &atient( )t i% difficult to +u%tify the u%e of rubber da' ,ith the a%%ociated u%e of local anae%thetic and cla'&% for the 'a+ority of &atient%, on both clinical and econo'ic ground%( Gla%% iono'er% ha$e al%o been u%ed a% %ealant%, the a&&lication techniBue i% le%% %en%iti$e, than that for re%in%( #nfortunately gla%% iono'er %ealant% ha$e &oor retention( )t i% %ugge%ted that the fluoride relea%e fro' gla%% iono'er% &ro$ide% additional &rotection but the clinical rele$ance of thi% re'ain% doubtful( The addition of fluoride to re%in %ealant% ha% been de'on%trated to &ro$ide no additional benefit( Gla%% iono'er %ealant% only ha$e a &lace a% te'&orary %ealant% during tooth eru&tion, ,hen adeBuate i%olation to &er'it the a&&lication of re%in i% not &o%%ible or in &atient% ,ho%e le$el of anxiety or co-o&eration %i'ilarly &re$ent &lace'ent of re%in( Gla%% iono'er% ha$e been de$elo&ed %&ecifically for thi% role but clinical e$idence of their effecti$ene%% i% not yet a$ailable( >e$ Point# 0&&lication of gla%% iono'er %ealant% Clean the %urface )%olate the tooth Run the gla%% iono'er into the fi%%ure% "rotect the 'aterial during initial %etting 0&&ly unfilled re%in, &etroleu' +elly, or fluoride $arni%h to &rotect the 'aterial( 6or anxiou% &atient% a&&lication can be done ,ith a glo$ed finger until the 'aterial i% %et( Re%in fi%%ure %ealant% are effecti$eH a recent %y%te'atic re$ie, ha% de'on%trated :?L carie% reduction% at A year%, ,ith retention of ?=-C:L at year% falling to : L at A year% ;0ho$uo-Saloranta et al(, 99A<( To gain the full carie% &re$enti$e benefit %ealant% %hould be 'aintained, that i%, %ealant% ,ith le%% than o&ti'al co$erage identified and additional re%in a&&lied( Since the de$elo&'ent of %ealant% there ha% been a Bue%tion regarding the effect of %ealing o$er carie%, the concern being that carie% ,ill &rogre%% unidentified under the %ealant( Gi$en the difficulty in diagno%ing carie% thi% 'u%t be a freBuent occurrence in daily &ractice( 0 nu'ber of trial% ha$e exa'ined thi% by acti$ely %ealing o$er carie%, and all ha$e %ho,n that %ealant% arre%t or %lo, the rate of carie% &rogre%%ion( We are not at the &oint ,here %ealing of acti$e carie% i% reco''ended by 'o%t authoritie% but the 'axi' if in doubt %eal i% good ad$ice( The %urface %hould then be 'onitored clinically and radiogra&hically at regular inter$al% until it% %tatu% i% confir'ed( One in%tance ,here acti$ely %ealing o$er carie% i% to be reco''ended i% in the &recoo&erati$e &atient ,here the &lace'ent of %ealant 'ay hel& accli'ati5ation of the &atient, ,ith the added benefit of controlling the carie%, until a definiti$e re%toration can be &laced( Sealant% are al%o effecti$e at &re$enting &it and fi%%ure carie% in &ri'ary teeth( "ri'ary teeth ha$e 'ore a&ri%'atic ena'el than &er'anent teeth, and doubt about the effecti$ene%% of etching deciduou% ena'el lead to a belief that they reBuired &rolonged etching ti'e%( Thi% ha% been de'on%trated not to be the ca%e and the

techniBue for %ealant a&&lication to &ri'ary teeth i% identical to that e'&loyed ,ith &er'anent teeth( 0lthough the effecti$ene%% of fi%%ure %ealant% i% beyond doubt, to be u%ed co%t effecti$ely their u%e %hould be targeted( Guideline% for &atient %election and tooth %election ha$e been &ubli%hed by the 4riti%h Society for "aediatric Denti%try, and the%e are %u''ari5ed belo,( Patient #ele"tion =( Children ,ith %&ecial need%( 6i%%ure %ealing of all occlu%al %urface% of &er'anent teeth %hould be con%idered for tho%e ,ho are 'edically co'&ro'i%ed, &hy%ically or 'entally di%abled, or ha$e learning difficultie%, or for tho%e fro' a di%ad$antaged %ocial bac/ground( ( Children ,ith exten%i$e carie% in their &ri'ary teeth %hould ha$e all &er'anent 'olar% %ealed %oon after their eru&tion( @( Children ,ith cariou%-free &ri'ary dentition% do not need to ha$e fir%t &er'anent 'olar% %ealed routinelyH rather the%e teeth %hould be re$ie,ed at regular inter$al%( Toot% #ele"tion =( 6i%%ure %ealant% ha$e the greate%t benefit on the occlu%al %urface% of &er'anent 'olar teeth( Other %urface% %hould not be neglected, in &articular the cingulu' &it% of u&&er inci%or%, the buccal &it% of lo,er 'olar%, and the &alatal &it% of u&&er 'olar%( ( Sealant% %hould nor'ally be a&&lied a% %oon a% the %elected tooth ha% eru&ted %ufficiently to &er'it 'oi%ture control( @( 0ny child ,ith occlu%al carie% in one fir%t &er'anent 'olar %hould ha$e the fi%%ure% of the %ound fir%t &er'anent 'olar% %ealed( A( Occlu%al carie% affecting one or 'ore fir%t &er'anent 'olar% indicate% a need to %eal the %econd &er'anent 'olar% a% %oon a% they ha$e eru&ted %ufficiently( Since their de$elo&'ent in the 'id-=>!9% there ha$e been a nu'ber of ad$ance% in %ealant technology( We are &o%%ibly at another ti'e of change ,ith the de$elo&'ent of non-rin%e bonding( There i% e$idence that the u%e of bonding agent% during %ealant &lace'ent hel&% reduce the effect on retention of %light %ali$ary conta'ination( There i% al%o one %'all trial %ho,ing that %ealant% &laced ,ith non-rin%e bonding are a% retenti$e a% tho%e &laced follo,ing traditional acid etching( 6urther larger trial% are reBuired to confir' thi% but the ad$antage% in ea%e of &lace'ent are ob$iou% if thi% &ro$e% to be the ca%e ;6ig( !(=C<( Fi!. 1./3 6i%%ure %ealant &lace'ent on a fir%t &er'anent 'olar tooth( ;a< Etching gel a&&lied ,ith a bru%hH ;b< fi%%ure %ealant a&&lication after ,a%hing and drying(

1.5 TREAT7ENT P*ANNIN6 F&R CARIES PRE)ENTI&N The abo$e %u''arie% of the $ariou% 'ethod% of &re$enting dental carie% ha$e highlighted the ad$antage% and di%ad$antage% of the four &ractical 'ethod% of carie% &re$entionG diet, fluoride, fi%%ure %ealing, and &laBue control( Each i% ca&able of &re$enting carie%, but achie$ing change% in diet and toothbru%hing, underta/ing fi%%ure %ealing, and a&&lying fluoride in the dental chair are all ti'e-con%u'ing( )t i% unreali%tic to atte'&t to u%e each 'ethod to it% 'axi'u' &otential and it i% nece%%ary to agree an o$erall &hilo%o&hy( E$eryone %hould recei$e %o'e ad$ice in carie% &re$ention and tho%e &ercei$ed to be at greater ri%/ of and fro' dental carie% %hould recei$e a 'ore thorough in$e%tigation and &re$enti$e treat'ent &lan( 6our clear &re$enti$e 'e%%age% are &ro'oted by the 1ealth Education 0uthority ;1E0< in England ;Table !(><( Thi% i% the 'ini'u' ad$ice( "arent% of infant% and young children %hould be ad$i%ed on %en%ible eating habit%H the abu%e of %ugarcontaining fruit-fla$oured drin/% and the need for 'eal% ,hich ,ill reduce the de'and for %nac/%( Toothbru%hing %hould be ob%er$ed in the %urgery gi$ing an o&&ortunity to di%cu%% the ty&e of toothbru%h and tooth&a%te( So'e &atient% are 'ore li/ely to de$elo& dental carie% than other%, and the%e &atient% need 'ore aggre%%i$e &re$enti$e ad$ice and thera&y( Effecti$e toothbru%hing ,ith an a&&ro&riate fluoride tooth&a%te i% an e%%ential fir%t goal( Other for'% of fluoride thera&y %hould be con%idered, a% outlined abo$eG dro&%Dtablet% ;if the drin/ing ,ater i% fluoride deficient<, 'outh rin%e%, and to&ical a&&lication% of %olution%, gel or $arni%h( Dietary habit% %hould be in$e%tigated u%ing a @-day diet diary and a&&ro&riate ad$ice gi$en that i% &er%onal, &ractical, and &o%iti$e( 0% toothbru%hing, rin%ing, and dietary control all reBuire change% in life-%tyle e%&ecially at ho'e, continuou% encourage'ent i% e%%ential( 6i%%ure %ealing i% li/ely to be %en%ible, in line ,ith the guideline% %et out abo$e( The order in ,hich the $ariou% cariou% &re$enti$e 'ea%ure% are %cheduled in the treat'ent &lan i% of %o'e i'&ortance( )t i% %en%ible to in$e%tigate toothbru%hing early, a% it i% a good bridge bet,een the ho'e and the dental %urgery and it gi$e% &ro&er e'&ha%i% to thi% $ital &re$enti$e 'ea%ure( )f done fir%t, it allo,% you to ,or/ on clean teeth( 0% in$e%tigation of diet and dietary ad$ice reBuire% at lea%t three $i%it%, it i% %en%ible to introduce thi% at an early a&&oint'ent( 6i%%ure %ealing can be co''enced early in the treat'ent &lan a% a relati$ely ea%y &rocedure gi$ing e'&ha%i% to &re$ention rather than re%toration, ,hile to&ical fluoride thera&y could be carried out after fi%%ure %ealing( )f fluoride dietary %u&&le'ent% andDor 'outh rin%e% are going to be reco''ended, it i% %en%ible to introduce the' on the fir%t or %econd a&&oint'ent %o that continuou% encourage'ent in their u%e 'ight be gi$en at later a&&oint'ent%( The abo$e inten%i$e &re$enti$e thera&y i% for &atient% *at ri%/* of de$elo&ing carie%( Thi% beg% the Bue%tion on ho, to &redict future carie% de$elo&'ent( There ha% been 'uch ,or/ on thi% to&ic ,ith 'any ri%/ factor% or 'ar/er% of carie% ri%/ &ro&o%ed( O$erall, the finding% are not encouraging( The 'o%t %ucce%%ful areG &a%t carie% ex&erience, %ali$a &ro&ertie% ;flo, rate, buffering &o,er, and 'icrobiological content<, and %ocial %tatu%( The%e can be u%ed in co'bination to increa%e di%cri'inatory &o,er( De%&ite 'uch ,or/, one large 0'erican in$e%tigation %ho,ed that the be%t &redictor of future carie% incre'ent in children ,a% *intuition of the denti%t*(

1.1 S(77ARY =( Dental carie% i% cau%ed by dietary carbohydrate% being fer'ented by &laBue bacteria to acid( ( Carie% detection and diagno%i% reBuire% a 'eticulou% %y%te'atic a&&roach( @( The &re-ca$itation le%ion i% a danger %ign indicating the need for &re$ention( A( The four &ractical &illar% to carie% &re$ention areG toothbru%hing, diet, fluoride, and fi%%ure %ealing( :( "re$enti$e ad$ice 'u%t be to &arent and child and %hould be a&&ro&riate to the age and circu'%tance% of the child( !( Moti$ation and continuou% encourage'ent i% e%%ential if &re$ention i% to be %ucce%%ful( 1.2 AC>N&8*ED6E7ENT So'e &art% of thi% text ha$e been re&roduced fro' Dental #&date, by &er'i%%ion of George War'an "ublication%( 1.3 F(RT5ER READIN6 0%hley, "( 6(, 4lin/horn, 0( S(, and Da$ie%, R( M( ;=>>C<( Occlu%al carie% diagno%i%G an in $itro hi%tological $alidation of the Electronic Carie% Monitor ;ECM< and other 'ethod%( +ournal of Dentistry, 21, C@-C( 4riti%h Society of "aediatric Denti%try( ; 999<( 0 &olicy docu'ent on fi%%ure %ealant%( International +ournal of Paediatric Dentistry, /0, =?A-?( E/%trand, 2( R(, Ric/ett%, D( -(, and 2idd, E( 0( ; 99=<( Occlu%al carie%G &athology, diagno%i% and logical 'anage'ent( Dental Update, 23, @C9-?( 6eigal, R( 7( ; 99 <( The u%e of &it and fi%%ure %ealant%( Pediatric Dentistry, 20, A=:( 2idd, E( 0( M( and 7oy%ton-4echal, S( ;=>>!<( 7ssentials of dental caries( ; nd edn(< Oxford #ni$er%ity "re%%, Oxford( 3u%%i, 0(, )',in/elried, S(, "itt%, -( 4(, 3ongbotto', C(, and Reich, E( ;=>>><( "erfor'ance and re&roducibility of a la%er fluore%cence %y%te' for detection of occlu%al carie% in $itro( Caries )esearch, 33, !=-!( Marinho, 8( C( C(, 1iggin%, 7( "( T(, Sheiha', 0(, and 3ogan, S( ; 99A<( Co'bination% of to&ical fluoride ;tooth&a%te%, 'outhrin%e%, gel%, $arni%he%< $er%u% %ingle to&ical fluoride for &re$enting dental carie% in children and adole%cent%( -he Cochrane Data,ase of #ystematic )eviews 99A, )%%ue =( 0rt( -o(G CD99 ?C=(&ub (DO)G=9(=99 D=A!:=C:C(CD99 ?C=(&ub (

-aylor, M( -( ;=>>A<( Second international conference on declining carie%( International Dental +ournal, 00 ;Su&&l( =<, @!@-A:C( -y$ad, 4(, ten Cate, 7( M(, Robin%on, C(, ;ed%(< ; 99A<( Cariology in the =%t Century( Caries )esearch, 33, =!?-@ >( Rugg-Gunn, 0( 7(, -unn, 7( 1( ;=>>><( -utrition, diet and dental health( Oxford #ni$er%ity "re%%, Oxford( Scotti%h )ntercollegiate Guideline% -et,or/ -ational Guideline A?( ; 999<( Preventing dental caries in high ris% children( Royal College of "hy%ician%, Edinburgh( Scotti%h )ntercollegiate Guideline% -et,or/ -ational Guideline( ; 99:<( Preventing dental caries in the pre<school child( Royal College of "hy%ician%, EdinburghG 99: ;in &re%%<( Selection Criteria for Dental Radiogra&hy( "roduced by the 6aculty of General Dental "ractitioner% ;#2< =>>C( 1.4 REFERENCES 0ho$uo-Saloranta, 0(, 1iirri, 0(, -ordblad, 0(, Worthington, 1(, and Ma/ela, M( ; 99A<( "it and fi%%ure %ealant% for &re$enting dental decay in the &er'anent teeth of children and adole%cent%( -he Cochrane Data,ase of #ystematic )eviews 99A, )%%ue @( 0rt( -o(G CD99=C@9(&ub (DO)G=9(=99 D=A!:=C:C(CD99=C@9(&ub ( 0xel%%on, "(, 3indhe, 7(, and Wa%eby, 7( ;=>?!<( The effect of $ariou% &laBue control 'ea%ure% on gingi$iti% and carie% in %choolchildren( Community Dentistry 8ral epidemiology, 0, @ ->( 4urt, 4( 0(, "ai, S( ; 99=<( Sugar con%u'&tion and carie% ri%/G 0 %y%te'atic re$ie,( +ournal of Detal 7ducation, 15, =9=?- @( Duggal, M( S(, Tou'ba, 2( 7(, 0'aechi, 4( T(, 2o,a%h, M( 4(, and 1igha', S( M( ; 99=<( Ena'el de'inerali%ation in situ ,ith $ariou% freBuencie% of carbohydrate con%u'&tion ,ith and ,ithout fluoride tooth&a%te( +ournal of Detal )esearch, 30, =? =-A( E/%trand, 2( R(, 4ruun, G(, and 4ruun, M( ;=>>C<( "laBue and gingi$al %tatu% a% indicator% for carie% &rogre%%ion on a&&roxi'al %urface%( Caries )esearch, 32, A=-:( 1ol', 0( 2( ;=>>9<( Carie% in the &re%chool childH international trend%( +ournal of Dentistry, /3, >=-:( 1olt, R( D( ;=>>9<( Carie% in the &re-%chool childG 4riti%h trend%( +ournal of Dentistry, /3, >!->( 7en/in%, G( -( ;=>?C<( -he physiology and ,iochemistry of the mouth( ;Ath edn<(

4lac/,ell, Oxford( Soa'e%, 7( 8( and Southa', 7( C( ;=>>C<( 8ral pathology ;@rd edn<( Oxford #ni$er%ity "re%%, Oxford( S&encer, 0( 7(, Da$ie%, M(, Slade, G(, and 4rennan, D( ;=>>A<( Carie% &re$alence in 0u%trala%ia( International Dental +ournal, 00, A=:- @( Tou'ba, 2( 7( and Duggal, M( S( ;=>>><( Effect on &laBue &1 of fruit drin/% ,ith reduced carbohydrate content( $ritish Dental +ournal, /31, ! !->( Tou'ba, 2( 7( ; 99=<( Slo,-relea%e de$ice% for fluoride deli$ery to high-ri%/ indi$idual%( Caries )esearch, 35 ;Su&&l( =<, =9-=@( $on der 6ehr, 6( R( ;=>>A<( Carie% &re$alence in the -ordic countrie%( International Dental +ournal, 00, @?=-C( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

2. Treatment o+ dental "arie# in t%e re#"%ool "%ild - # " 1ayle 2./ INTR&D(CTI&N

Dental carie% i% %till one of the 'o%t &re$alent &athological condition% in the child &o&ulation of 'o%t We%tern countrie%( 0 #2 %tudy of =(:-A(:-year-old children de'on%trated that =?L ha$e decay, and in 'any &art% of the #2 u& to :9L of the child &o&ulation ha% ex&erience of decay by the ti'e they are : year% of age( Succe%%fully 'anaging decay in $ery young children &re%ent% the denti%t ,ith a nu'ber of %ignificant challenge%( Thi% cha&ter ,ill outline a&&roache% to the 'anage'ent of the &re%chool child ,ith dental carie%( >e$ Point# Dental carie% i% one of the 'o%t &re$alent di%ea%e% in the &re%chool child &o&ulation of We%tern countrie%( 4y : year% of age u& to :9L of the child &o&ulation ha$e ex&erienced dental decay( 2.2 PATTERNS &F DENTA* DISEASE SEEN IN PRESC5&&* C5I*DREN 2.2./ Earl$ "%ild%ood "arie# Early childhood carie% ;ECC< i% a ter' u%ed to de%cribe dental carie% &re%enting in the &ri'ary dentition of young children( Ter'% %uch a% *nur%ing bottle 'outh*, *bottle 'outh carie%*, or *nur%ing carie%* are u%ed to de%cribe a &articular &attern of dental carie% in ,hich the u&&er &ri'ary inci%or% and u&&er fir%t &ri'ary 'olar% are u%ually 'o%t %e$erely affected( The lo,er fir%t &ri'ary 'olar% are al%o often cariou%, but the lo,er inci%or% are u%ually %&aredbeing either entirely carie%-free or only 'ildly affected ;6ig( ?(=<( So'e children &re%ent ,ith exten%i$e carie% that doe% not follo, the *nur%ing carie%* &attern( Such children often ha$e 'ulti&le cariou% teeth and 'ay be %lightly older ;@ or A year% of age< at initial &re%entation ;6ig( ?( <( Thi% &re%entation of carie% i% %o'eti'e% called *ra'&ant carie%*( There i%, ho,e$er, no clear di%tinction bet,een ra'&ant carie% and nur%ing carie%, and the ter' *early childhood carie%* ha% been %ugge%ted a% a %uitable, all-enco'&a%%ing ter'( )n 'any ca%e%, early childhood carie% i% related to the freBuent con%u'&tion of a drin/ containing %ugar% fro' a bottle or *din/y* ty&e co'forter% ;the%e ha$e a %'all re%er$oir that can be filled ,ith a drin/< ;6ig( ?(@<( 6ruit-ba%ed drin/% are 'o%t co''only a%%ociated ,ith nur%ing carie%( E$en 'any of tho%e clai'ing to ha$e *lo, %ugar* or *no added %ugar* a&&ear to be ca&able of cau%ing carie%( The %&aring of the lo,er inci%or% %een in nur%ing carie% i% thought to re%ult fro' the %hielding of the lo,er inci%or% by the tongue during %uc/ling, ,hil%t at the %a'e ti'e they are being bathed in %ali$a fro' the %ublingual and %ub'andibular duct%( The u&&er inci%or%, on the other hand, are bathed in fluid fro' the bottleDfeeder( 6reBuency of con%u'&tion i% a /ey factor( 0ffected children often ha$e a hi%tory of ta/ing a bottle to bed a% a co'forter, or u%ing a bottle a% a con%tant co'forter during the dayti'e( Re%earch ha% %ho,n that children ,ho tend to fall a%lee& ,ith the bottle in their 'outh% are 'o%t li/ely to get ECC, and thi% i% &robably a reflection of the dra'atic reduction in %ali$ary flo, that occur% a% a child fall% a%lee&( 1o,e$er, the lin/ bet,een bottle habit% and ECC i% not ab%olute and %tudie% ha$e %ugge%ted that other factor%, %uch a% linear ena'el defect% and 'alnutrition, 'ay &lay an i'&ortant role in the aetiology of thi% condition(

There i% %o'e circu'%tantial e$idence that, in a fe, ca%e%, ECC 'ay be a%%ociated ,ith &rolonged, on-de'and brea%t-feeding( 4rea%t 'il/ contain% ?L lacto%e and, again, freBuent, &rolonged, on-de'and con%u'&tion a&&ear% to be an i'&ortant aetiological factor( Mo%t affected children %lee& ,ith their &arent%, %uc/le during the night, and are often %till being brea%t-fed at or 'ore year% of age( )t i% i'&ortant to a&&reciate that thi% doe% not i'&ly that nor'al brea%t- feeding u& to around = year of age i% bad for teeth, but that &rolonging on-de'and feeding beyond that age &o%%ibly carrie% a ri%/ of cau%ing dental carie%( Ex&eri'ent% in ani'al 'odel% %ugge%t that co,%* 'il/ ;,hich contain% AL lacto%e< i% not cariogenic, although %o'e clinical %tudie% ha$e %ugge%ted that the night-ti'e con%u'&tion of co,%* 'il/ fro' a bottle 'ight be a%%ociated ,ith early childhood carie% in %o'e children( Whether or not co,%* 'il/ ha% the &otential to contribute to carie% i% currently uncertain( >e$ Point# Early childhood carie% ;ECC< i% an all-enco'&a%%ing ter' that can be u%ed to de%cribe dental carie% &re%enting in &re%chool children( The 'o%t co''only &re%enting &attern of ECC i% often called *nur%ing carie%* or *bottle 'outh carie%*, ,here the u&&er anterior &ri'ary teeth are cariou% but the lo,er anterior teeth are u%ually %&ared( 0 &ri'e aetiological factor i% freBuent con%u'&tion of a %,eetened or fruit-ba%ed drin/ fro' a bottle or din/y feeder( Ena'el defect% and 'alnutrition 'ay al%o &lay a role in the cau%ation of ECC( Fi!. 2./ Early childhood carie% &re%enting a% nur%ing carie% in a -year-old child( Fi!. 2.2 Exten%i$e carie% affecting &ri'ary 'olar% in a A-year-old child( Fi!. 2.3 Din/y ty&e co'forter ,ith a %'all re%er$oir that can be filled ,ith %o'ething to drin/( 2.3 IDENTIFYIN6 PRESC5&&* C5I*DREN IN NEED &F DENTA* CARE )dentification of dental carie% at an early %tage i% highly de%irable if &re$enti$e 'ea%ure% and re%torati$e care are to be %ucce%%ful( .et, at : year% of age a %ignificant nu'ber of children ,ill %till not ha$e had their fir%t chec/-u& $i%it to a denti%t( )n the #2, the Co''unity Dental Ser$ice often identifie% untreated carie% in children of : year% and o$er at %chool dental %creening%( 1o,e$er, the large-%cale %creening of &re%chool children i% fraught ,ith logi%tical difficultie%( )n addition, 'any &arent% are under the 'i%conce&tion that they do not need to ta/e their child for a dental chec/u& $i%it until they are A or : year% of age( "arent% %hould be encouraged to bring their child for a dental chec/ a% %oon a% the child ha% teeth, u%ually around ! 'onth% of age( Thi% allo,% a&&ro&riate &re$enti$e ad$ice regarding tooth cleaning, fluoride tooth&a%te%, and the a$oidance of bottle habit%( )t al%o allo,% the child to be beco'e fa'iliar ,ith the dental en$iron'ent and enable% the denti%t to identify any cariou% deterioration of the teeth at an early %tage( Other health &rofe%%ional%, %uch a% health $i%itor%, can al%o be $aluable in deli$ering /ey &re$enti$e ad$ice and hel&ing to identify young children ,ith &o%%ible decay( 1ence, 'a/ing contact ,ith local health $i%itor% and deli$ering dental health 'e%%age% $ia 'other and toddler grou&% can be u%eful %trategie%(

>e$ Point# "arent% %hould be encouraged to bring their children for a dental chec/-u& a% %oon a% the child ha% teeth ;around ! 'onth% of age<( Ma/ing contact ,ith local health $i%itor%, baby clinic%, and 'other-and-baby grou&% can be effecti$e ,ay% of getting dental infor'ation to the &arent% of &re%chool children( 2.0 7ANA6E7ENT &F PAIN AT FIRST ATTENDANCE #nfortunately, the &re%chool child ,ith carie% i% often already in &ain ,hen they fir%t attend a dental %urgery( -ot only doe% thi% &re%ent the i''ediate &roble' of ha$ing to con%ider acti$e treat'ent in a $ery young, inex&erienced &atient, but the%e &roble'% are often co'&ounded by the child*% lac/ of %lee& and ti'e con%traint% on the denti%t( "ul&iti% can %o'eti'e% be effecti$ely 'anaged, in the %hort ter', by gentle exca$ation of carie% and dre%%ing ,ith a 5inc oxide and eugenol-ba%ed 'aterial, %uch a% )RM ;inter'ediate re%torati$e 'aterial<( "olyantibiotic and %teroid &a%te% ;e(g( 3eder'ix< 'ay be u%eful beneath %uch dre%%ing%, and o$er ex&o%ure%Dnear-ex&o%ure% of the &ul&( The &ul& cha'ber of ab%ce%%ed teeth can %o'eti'e% be acce%%ed by careful hand exca$ation, in ,hich ca%e &lacing a dre%%ing of dilute for'ocre%ol on cotton ,ool ,ithin the &ul& cha'ber ,ill freBuently lead to re%olution of the %,elling and %y'&to'%( 0n acute andDor %&reading infection or %,elling 'ay reBuire the &re%cri&tion of %y%te'ic antibiotic%, although there i% little rationale for the u%e of antibiotic% in ca%e% of toothache ,ithout a%%ociated %oft ti%%ue infectionD infla''ation( Dental infection cau%ing %ignificant %,elling of the face, e%&ecially ,here the child i% febrile or un,ell, con%titute% a dental e'ergency and con%ideration %hould be gi$en to referral to a %&eciali5ed centre for i''ediate 'anage'ent( >e$ Point# "ain i% a co''on &re%enting feature in &re%chool children( 0&&ro&riate dre%%ing of teeth ,ill u%ually hel& to te'&orarily 'anage &ain and locali5ed infection( 0ntibiotic% %hould be &re%cribed ,here acute %oft ti%%ue %,elling or %ign% of %y%te'ic in$ol$e'ent ;e(g( &yrexia< are &re%ent( Children ,ith increa%ing facial %,elling andDor %eriou% %y%te'ic in$ol$e'ent %hould be referred to a %&eciali5ed centre for urgent 'anage'ent( 2.5 PRINCIP*ES &F DIA6N&SIS AND TREAT7ENT P*ANNIN6 F&R PRESC5&&* C5I*DREN When &lanning dental treat'ent for &re%chool children, it i% i'&ortant to a&&reciate that dental carie% of ena'el i% e%%entially a childhood di%ea%e and that &rogre%%ion of carie% in the &ri'ary dentition can be ra&id( Therefore, early diagno%i% and &ro'&t

in%tigation of a&&ro&riate treat'ent i% i'&ortant( "re%chool children %hould be routinely exa'ined for dental carie% relati$ely freBuently ;at lea%t -@ ti'e% &er year<( More freBuent exa'ination ;e(g( e$ery @ 'onth%< 'ay be +u%tified for children in high-ri%/ grou&% ;Cha&ter !<( 0&&roxi'al carie% i% co''on in &ri'ary 'olar% %o, in children con%idered to be at increa%ed ri%/ of de$elo&ing dental carie% and ,here &o%terior contact% are clo%ed, a fir%t %et of bite,ing radiogra&h% %hould be ta/en at A year% of age, or a% %oon a% &ractically &o%%ible after that ;6ig( ?(A<( )n %uch children con%ideration %hould be gi$en to re&eating bite,ing% at lea%t annually( >e$ Point# Coronal ena'el carie% i% e%%entially a childhood di%ea%e( )n children dee'ed to be at increa%ed ri%/ of de$elo&ing carie%, bite,ing radiogra&h% %hould be obtained at A year% of age, or a% %oon a% &ractically &o%%ible after that, and con%ideration %hould be gi$en to re&eating %uch radiogra&h% at lea%t annually( Fi!. 2.0 4ite,ing radiogra&h% of a A-year-old child( The carie% in the u&&er right 'olar% ,ould be clinically ob$iou% but the early a&&roxi'al le%ion% in the lo,er left 'olar% ,ould not( 4ite,ing radiogra&h% not only enable an accurate diagno%i%, but early le%ion% can be co'&ared on %ucce%%i$e radiogra&h% to enable a +udge'ent to 'ade about carie% acti$ity and &rogre%%ion( 2.1 PRE)ENTI)E CARE 2.1.0 Introd-"tion "re$enti$e 'ea%ure% are the corner%tone to the 'anage'ent of dental carie% in children( There i% often a failure to a&&reciate that tho%e a%&ect% of care ,e refer to a% &re$ention are actually a funda'ental &art of the treat'ent of dental carie%( Re&airing the da'age cau%ed by dental carie% i% al%o i'&ortant, but thi% ,ill only be %ucce%%ful if the cau%e% of that da'age ha$e been addre%%ed( 0 good analogy i% that of a burning hou%e( Re&airing the hou%e ;ne, ,indo,%, roof, furniture, etc(< i% i'&ortant, but all thi% ,ill be of little benefit in the long ter' if the fire ha% not been &ut outI 0 %tructured a&&roach to &re$ention %hould for' a /ey &art of the 'anage'ent of e$ery &re%chool child( >e$ Point "re$enti$e 'ea%ure% are the corner%tone to the %ucce%%ful treat'ent of dental carie% in children( 2.1./ Fl-oride# Sel+-admini#tered F*(&RIDE T&&T5PASTE "arent% %hould be ad$i%ed to %tart bru%hing their child*% teeth ,ith a fluoride tooth&a%te a% %oon a% the fir%t tooth eru&t%, at around ! 'onth% of age( 6or children con%idered to be at lo, ri%/ of de$elo&ing carie% a tooth&a%te containing A:9-!99 &(&('( fluoride 'ay be u%ed( Tooth&a%te% ,ith a lo,er fluoride concentration are a$ailable, but there i% %o'e Bue%tion about their efficacy( Many authoritie% no,

%u&&ort the &re%cribing of tooth&a%te% containing higher concentration% of fluoride ;around =999 &(&('(< to &re%chool children dee'ed to be at higher ri%/ of de$elo&ing carie%, irre%&ecti$e of their age( )n children at highe%t ri%/, tooth&a%te% ,ith higher concentration% ;i(e( =A99-=:99 &(&('( 6-< 'ay e$en be +u%tified, e%&ecially in children aged ! and abo$e( Where higher concentration tooth&a%te% are &re%cribed for &re%chool children, &arent% %hould be coun%elled to en%ure that bru%hing i% %u&er$i%ed ;%ee Section ?(!(A<, %'all a'ount% of tooth&a%te are a&&lied to the bru%h ;*%'all &ea %i5e blob* or *thin %'ear*<, and that children %&it out a% ,ell a% &o%%ible after bru%hing( >e$ Point )n area% ,ithout o&ti'u' le$el% of fluoride in the ,ater %u&&ly, fluoride tooth&a%te i% the 'o%t i'&ortant 'ethod of deli$ering fluoride to &re%chool children( F*(&RIDE S(PP*E7ENTS Su&&le'entary fluoride, in the for' of either dro&% or tablet%, %hould be con%idered in tho%e at high ri%/ of carie% and in children in ,ho' dental di%ea%e ,ould &o%e a %eriou% ri%/ to general health ;e(g( children at increa%ed ri%/ of endocarditi%<( Such %u&&le'entation i% only 'axi'ally effecti$e if gi$en long ter' and regularly( #nfortunately, %tudie% ha$e %ho,n that long-ter' co'&liance ,ith daily fluoride %u&&le'ent &rotocol% i% &oor( "arental 'oti$ation and regular reinforce'ent are e%%ential for %uch 'ea%ure% to be effecti$e( Do%age %hould follo, the &rotocol ad$i%ed by the 4riti%h Society of "aediatric Denti%try ;Table ?(=<( -o %u&&le'ent% %hould be &re%cribed if the ,ater fluoride le$el i% greater than 9(? &&'( The Euro&ean $ie, on %u&&le'ent% i% that the 'axi'u' do%e %hould be 9(: 'gDday( F*(&RIDE 7&(T5RINSES 6luoride 'outhrin%e% are contraindicated in children le%% than ! year% of age, becau%e of the ri%/ of exce%%i$e inge%tion( Pro+e##ionall$ a lied +l-oride#

Site-%&ecific a&&lication of fluoride $arni%h can be $aluable in the 'anage'ent of early, %'ooth %urface and a&&roxi'al cariou% le%ion% ;6ig( ?(:<( 1o,e$er, the 'o%t &o&ularly u%ed $arni%he% contain :L %odiu' fluoride ;i(e( , !99 &(&('( of fluoride<( 1ence, ,hen u%ing the%e &roduct% in young children great care %hould be ta/en to a$oid o$erdo%age ;%ee belo,<( Fl-oride o.erdo#a!e 0 do%e of = 'g of 6D/g body ,eight can be enough to &roduce %y'&to'% of toxicity and a do%e of : 'g of 6D/g i% con%idered to be &otentially fatal( Sy'&to'% of toxicity include nau%ea, $o'iting, hy&er%ali$ation, abdo'inal &ain ;&roduction of hydrogen fluoride, 16<, and diarrhoea( Sub%eBuently, de&re%%ion of &la%'a calciu' le$el% re%ult% in con$ul%ion%, and cardiac and re%&iratory failure( The a&&ro&riate 'anage'ent of fluoride o$erdo%age i% detailed in Table ?( ( So'e of the ter'% u%ed ,hen de%cribing fluoride toxicity are gi$en in Table ?(@( )n a =9-/g, =C-'onth-old child, the inge%tion of 9(: 'l of a ( !L fluoride $arni%h can &roduce toxicity, and %lightly 'ore than 'l 'ay be a &otentially lethal do%e ;"3D<( )n thi% =9-/g child the STD ;%afely tolerated do%e< ,ould be =9 'g of 6, the "3D :9

'g, and the C3D ;certain lethal do%e< @ 9-!A9 'g of 6( Tooth&a%te containing =999 &(&('( 6 ,ill contain = 'g of 6 in a gra' or = inch ; : ''< of &a%te( Tooth&a%te tube% $ary fro' : g to =A9 g( E$en if the larger tube ,a% co'&letely %,allo,ed the a'ount of 6 ;=A9 'g of 6< ,ould %till be le%% than the C3D for the =9-/g child, but ,ould exceed the "3D( 0 container of = 9 tablet%, each of = 'g, ,ould contain = 9 'g of fluoride( 0gain, thi% ,ould be ,ithin the C3D but exceed the "3D( 0ll container% ,ith fluoride tablet% %hould ha$e child&roof to&% and be /e&t out of reach of young children( 0cidulated &ho%&hate-fluoride ;0"6< gel% and foa'% are contraindicated in &re%chool children( Fi!. 2.5 Site-%&ecific a&&lication of fluoride $arni%h( 2.1.2 C%lor%e9idine !el# Clinical re%earch in $ery young children i% li'ited, but there i% %ub%tantial agree'ent that daily &rofe%%ional a&&lication% of chlorhexidine follo,ed by a&&lication% e$ery fe, 'onth% can be %ignificant in controlling carie%( Thi% &robably re%ult% fro' chlorhexidine*% ability to reduce the le$el% of 'utan% %tre&tococci in both %ali$a and &laBue( 2.1.3 Fi##-re #ealant# 0lthough not u%ed routinely in the &ri'ary dentition, fi%%ure %ealant% 'ay be of $alue on &ri'ary 'olar% ;e%&ecially %econd &ri'ary 'olar%< ,here one or 'ore &ri'ary 'olar% ha% already de$elo&ed occlu%al carie%( 2.1.0 Toot%,r-#%in! "laBue re'o$al ,ith a %oft, %'all-headed toothbru%h in co'bination ,ith a %uitable fluoride tooth&a%te %hould %tart a% %oon a% the child*% fir%t tooth eru&t%( "re%chool children need hel& fro' their &arent% if effecti$e oral hygiene i% to be 'aintained, %o &arental in$ol$e'ent in oral hygiene in%truction i% e%%ential( So'e toddler% can be re%i%tant to &arental ;and &rofe%%ionalI< atte'&t% to bru%h their teeth( "arent% %hould be encouraged to &er%e$ere through %uch difficultie%, en%uring that their child*% teeth are thoroughly cleaned at lea%t once daily( Standing or /neeling behind the child in front of the %in/ or 'irror i% often the ea%ie%t ,ay to effecti$ely bru%h a young toddler*% teeth ;6ig( ?(!<( Su&er$i%ion of toothbru%hing i% al%o i'&ortant to a$oid o$eringe%tion of tooth&a%te( >e$ Point# "re%chool children need hel& ,ith toothbru%hing( "arent% %hould hel& ,ith bru%hing to en%ure effecti$e cleaning and a$oid o$eringe%tion of fluoride tooth&a%te( Fi!. 2.1 Standing or /neeling behind the child in front of the %in/ or 'irror i% often the ea%ie%t ,ay to effecti$ely bru%h a young toddler*% teeth(

2.1.5 Diet 6reBuent con%u'&tion of drin/% and food containing %ugar% i% a /ey aetiological feature in 'any &re%chool children ,ho &re%ent ,ith carie%( 1ence, reducing the freBuency of %ugar-containing food and drin/% i% a /ey dietary 'e%%age to deli$er to &arent%( 1o,e$er, for %uch ad$ice to be effecti$e, it 'u%t be deli$ered in an under%tanding ,ay and %hould ta/e into account %o'e of the difficultie% &arent% 'ay face in 'a/ing %uch change% to their child*% diet( .oung children ha$e a high 'etabolic rate and their dietary calorific reBuire'ent% are high( Many young children ,ith early childhood carie% are al%o *&oor eater%*, their &arent% often re&orting that the child doe% not eat ,ell at 'eal ti'e%( Such children often 'a/e u& the calorie% 'i%%ed at 'eal ti'e% by con%u'ing fruit-ba%ed drin/% bet,een 'eal%, ,hich are high in calorie%( 0% ,ell a% hel&ing to 'eet the child*% nutritional reBuire'ent% thi% al%o %u&&re%%e% the a&&etite %o that ,hen the next 'ealti'e a&&roache% the child i% not $ery hungry( "arent% freBuently 'i%inter&ret thi%, and thin/ the child a%/% for drin/% becau%e of thir%t( 0 hi%tory of &oor %lee&ing i% al%o co''on, ,ith &arent% relating that the child *,ill not %lee& ,ithout the bottle*( Once e%tabli%hed, %uch cycle% of beha$iour can be difficult to brea/ and 'any &arent% ha$e a %en%e of guilt that their child ha% dental decay, feeling that they 'u%t ha$e done %o'ething ,rong( 6or coun%elling to be effecti$e it i% e%%ential to a$oid 'a/ing the &arent feel exce%%i$ely guilty, but to concentrate on the aetiology of the condition and &ractical %trategie% to deal ,ith the%e &roble'%( Sto&&ing a night-ti'e bottle habit can be achie$ed Buic/ly by %o'e &arent%, but can &ro$e difficult for other%( The idea of lea$ing the child to cry rather than gi$ing it a bottle 'ight %ee' a good idea ,hil%t in the dental %urgery, but i% a 'ore challenging &ro&o%ition at three o*cloc/ in the 'orningI Weaning children fro' a night or dayti'e bottle of +uice can often be achie$ed by gradually 'a/ing the +uice in the bottle 'ore dilute o$er a &eriod of a fe, ,ee/% until the content% beco'e +u%t ,ater( 0t thi% &oint the child ,ill either di%card the bottle or ,ill continue to %uc/le on ,ater alone, ,hich i%, of cour%e, noncariogenic( Thir%ty children ,ill al,ay% drin/ ,ater( >e$ Point# Children ha$e a high calorific reBuire'ent( Children ,ho are &oor eater% at 'ealti'e% and %nac/ and drin/ freBuently bet,een 'eal% are 'ore li/ely to get decay( 2.2 7ANA6IN6 ;E5A)I&(R 2.2./ 7ana!in! t%e re#"%ool "%ild?# ,e%a.io-r in t%e dental #ettin! The i'&ortance of e%tabli%hing effecti$e co''unication and ado&ting %trategie% ,hich hel& to alle$iate anxiety, in both child and &arent, ha$e already been fully di%cu%%ed ;Cha&ter <( Where &o%%ible, re%torati$e treat'ent %hould be carried out under local analge%ia alone, but %trategie% %uch a% %edation, by either the inhalation or oral route, or general anae%the%ia are %o'eti'e% indicated, e%&ecially in young children ,ith exten%i$e di%ea%e ,ho are in acute &ain, or ,here a non&har'acological a&&roach to beha$iour 'anage'ent ha% failed ;Cha&ter A<( Whiche$er %trategy i% cho%en, it i% e%%ential to in$ol$e the &arent in the deci%ion and

to obtain ,ritten con%ent( The funda'ental &rinci&le% of effecti$ely 'anaging child beha$iour in the %urgery are fully co$ered in Cha&ter ( 1o,e$er, there are %o'e %&ecific a%&ect% that relate &articularly to $ery young children( 2.2.2 Parental re#en"e Thi% ha% been a to&ic of great contro$er%y for 'any year%( Denti%try for children i% co'&licated by the fact that the denti%t 'u%t e%tabli%h a ,or/ing relation%hi& and co''unicate effecti$ely ,ith both child and &arent( 8irtually all %tudie% de%igned to in$e%tigate the effect of &arental &re%ence in the %urgery on the child*% co-o&eration ,ith dental treat'ent ha$e failed to de'on%trate any difference bet,een beha$iour ,ith or ,ithout the &arent &re%ent( Only one rea%onably ,ell-de%igned %tudy, by 6ran/l in =>! ;fro' ,hich ca'e the u%eful 6ran/l %cale<, ha% e$er %ugge%ted that &arental &re%ence 'ight affect child beha$iour( 6ran/l*% re%ult% indicated that children of around A year% old and younger beha$e 'ore &o%iti$ely ,hen &arent% ,ere &re%ent( 1o,e$er, no difference ,a% de'on%trated in older children( )n 'o%t of the afore'entioned %tudie%, &arent% ,ere carefully in%tructed to %it Buietly in the %urgery and not to interfere ,ith denti%t-child co''unication, %o a% to a$oid the introduction of incon%i%tent $ariable%( 6ran/l co''ented u&on thi% in hi% concluding co''ent%G the presence of a passively o,serving mother can ,e an aid to the child -his can ,e accomplished if the mother is motivated positively; is instructed explicitly and co< operates willingly in the role of a ?silent helper? Certainly ha$ing the &arent &re%ent in the %urgery ,hen treating young children facilitate% effecti$e co''unication and hel&% to fulfil the reBuire'ent% of infor'ed con%ent( )t al%o ha% the ad$antage that %hould any &roble'% ari%e, or the child beco'e% u&%et during treat'ent, the &arent i% fully a,are of the circu'%tance% and of the denti%t*% a&&roach to 'anage'ent( )f a &arent i% %at out%ide and hear% their @-yearold child %tart to cry in the %urgery, e$ent% a%%ociated ,ith the child*% di%tre%% can ea%ily be 'i%inter&reted( 0l%o, %tudie% ha$e %ho,n that 'any &arent% ,ould ,i%h to be &re%ent during dental treat'ent, e%&ecially at the child*% fir%t $i%it( 1a$ing %aid thi%, in the ab%ence of any con$incing e$idence one ,ay or the other, ha$ing the &arent &re%ent during the treat'ent of &re%chool children re'ain% a 'atter of indi$idual choice( 2.2.3 Sedation Sedation ,ill not nece%%arily con$ert an uncoo&erati$e child into a co-o&erati$e one( 1o,e$er, it can hel& to alle$iate anxiety, i'&ro$e a child*% tolerance of in$a%i$e &rocedure%, and increa%e the child*% ability to co&e ,ith &rolonged treat'ent( Se$eral route% of ad'ini%tration are a$ailable and of the%e, t,o are generally %uitable for out&atient u%eG inhalation and oral( )ntra$enou% %edation i% un%uitable for &re%chool children( >e$ Point#

 Whether or not the &arent i% &re%ent doe% not %ee' to ha$e a great effect on the child*% beha$iour in the %urgery( 8ery young children are &robably 'ore %ettled ,hen the &arent i% &re%ent( "arent% %hould be encouraged to ado&t the role of *%ilent hel&er*( )nhalation %edation ,ith nitrou% oxide and oxygen &roduce% both %edation and analge%ia( The reader i% referred to Cha&ter A for a full re$ie, of thi% techniBue( The techniBue ,or/% 'o%t effecti$ely on children ,ho ,i%h to co-o&erate, but are too anxiou% to do %o( )t% u%e for &re%chool children i% li'ited to tho%e ,ho are able to tolerate the na%al hood, but ,here thi% can be achie$ed, the techniBue i% often effecti$e( Orally ad'ini%tered %edation ha% the ad$antage that, once ad'ini%tered, no further acti$e co-o&eration of the child i% reBuired for the drug to ta/e effect( 1o,e$er, unli/e inhalation or intra$enou% %edation, it i% i'&o%%ible to titrate the do%e of the drug to the &atient*% re%&on%e, ,hich re%ult% in %o'e $ariation in effect fro' one &atient to another( O$er the year%, 'any agent% ha$e been ad$ocated for u%e in denti%try a% oral %edati$e agent%, and none of the%e are ideal( )n %tudie%, 'o%t of the 'ore &o&ular agent% &roduce a %ucce%%ful outco'e in !9-?9L of ca%e%( 6or thi% rea%on, %o'e ,or/er%, e%&ecially in the #nited State% of 0'erica, ad$ocate co'bination% of oral drug%, %o'eti'e% %u&&le'ented ,ith inhaled nitrou% oxide and oxygen, in order to achie$e a 'ore reliable re%ult( 1o,e$er, ad'ini%tering 'ulti&le %edation drug% doe% not fall ,ithin the definition of *%i'&le dental %edation*, ,here only a %ingle %edati$e drug %hould be u%ed( Many authoritie% con%ider %uch *&oly-&har'acy* to carry an increa%ed ri%/ and di%courage the &ractice( Of the orally ad'ini%tered %edation agent% a$ailable, the 'o%t u%eful for &re%chool children are the chloral deri$ati$e% and %o'e of the ben5odia5e&ine%( C%loral deri.ati.e# Chloral hydrate i% a long-%tanding and effecti$e %edati$e hy&notic( )t% u%e in children*% denti%try ha% been ,ell re%earched, it ha% a good 'argin of %afety, cau%e% little or no re%&iratory de&re%%ion at thera&eutic le$el%, and ha% fe, %eriou% %ide-effect%( The o&ti'u' do%age i% @9-:9 'gD/g, u& to a 'axi'u' of =(9 g( 1o,e$er, it% bitter ta%te 'a/e% it un&lea%ant to ta/e and it i% a &otent ga%tric irritant, &roducing $o'iting in 'any children( Thi% not only ha% the &otential to increa%e the child*% di%tre%%, but al%o reduce% the efficacy of the drug( Trichlofo%, a deri$ati$e of chloral hydrate, cau%e% le%% ga%tric irritation, but other,i%e a&&ear% to &roduce %i'ilar re%ult%, although there ha% been little re%earch to confir' thi%( ;en:odia:e ine# Many ben5odia5e&ine% ha$e been in$e%tigated a% &otential %edation agent% for u%e in children*% denti%try( They ha$e a ,ide thera&eutic index and can be re$er%ed by flu'a5enil( Dia5e&a' can be u%ed for oral %edation, but &roduce% &rolonged %edation and ha% &ro$ed %o'e,hat un&redictable in young children( Te'a5e&a' ,a% &o&ular %o'e year% ago, e%&ecially a% it% duration of action i% %horter than dia5e&a'(

1o,e$er, idio%yncratic reaction% in %o'e children ha$e cau%ed te'a5e&a' to fall fro' fa$our( )n the #2, te'a5e&a' al%o ha% the di%ad$antage of being a Schedule @ controlled drug( Recent %tudie% u%ing 'ida5ola', another %hort-acting ben5odia5e&ine, ha$e re&orted good re%ult%( Mida5ola' i% ea%y to ta/e orally and %ee'% to offer %afe and reliable %edation, ,ith far fe,er idio%yncratic reaction% than ,ith te'a5e&a'( On%et of %edation i% ra&id ;around 9 'inute%< and reco$ery i% al%o relati$ely Buic/( The o&ti'u' do%e i% 9(@-9(: 'gD/g ,hen gi$en orally( The &re&aration de%igned for intra$enou% ad'ini%tration i% u%ed, often 'ixed into a %'all $olu'e of a %uitable fruit drin/( So'e %tudie% re&ort %ucce%%ful deli$ery $ia the na%al 'uco%a, ,here do%e% of 9( -9(@ 'gD/g ha$e been ad$ocated( 1o,e$er, 'ida5ola' i% not yet a$ailable a% an oral or na%al &re&aration and i% not yet licen%ed for oral %edation( "ractitioner% are therefore ad$i%ed to %ee/ %&ecific training before &re%cribing 'ida5ola' for oral %edation( When u%ing any %edati$e agent in children it i% e%%ential that %uitable &recaution% are ta/en and that a&&ro&riate e'ergency drug% and eBui&'ent are a$ailable( The%e i'&ortant a%&ect% are detailed fully in Cha&ter A and, hence, ,ill not be further rehear%ed here( 2.2.0 6eneral anae#t%e#ia Dental extraction under general anae%the%ia ha% been u%ed ,idely in the #2 a% a %trategy for the treat'ent of dental carie% in &re%chool children( Recently, the +u%tification for %uch exten%i$e u%e ha% been Bue%tioned, and it i% no, ,idely agreed that general anae%the%ia %hould only ta/e &lace in ho%&ital and %hould only be e'&loyed ,here other beha$iour 'anage'ent %trategie% ha$e failed or are ina&&ro&riate( General anae%the%ia i%, ho,e$er, indicated for %o'e child &atient%( Co'&rehen%i$e full 'outh care under intubated general anae%the%ia enable% children ,ith 'ulti&le cariou% teeth to be ex&ediently rendered carie%-free in one &rocedure ;6ig( ?(?<( Thi% a&&roach doe% ha$e a &lace in the 'anage'ent of young, anxiou%, or handica&&ed children ,ith exten%i$e carie%, and in %o'e 'edical condition% ,here 'ulti&le treat'ent e&i%ode% o$er a &rolonged &eriod increa%e the ri%/% of %y%te'ic co'&lication%( Extraction% under general anae%the%ia 'ay be &referable to no treat'ent at all in the 'anage'ent of exten%i$e carie% in young children, e%&ecially ,hen facilitie% for re%torati$e care under general anae%the%ia are not a$ailable or &arental 'oti$ation i% &oor and reatten-dance for 'ulti&le $i%it% i% unli/ely to occur( )n addition, general anae%the%ia 'ay be the only &ractical a&&roach for children ,ith acute infection( Where general anae%the%ia i% e'&loyed in the dental treat'ent of the &re%chool child, the e'&ha%i% 'u%t be on a$oiding the need for re&eated general anae%the%ia( 1ence, each &rocedure need% careful &lanning ,ith con%ideration being gi$en to the 'anage'ent of all di%ea%e &re%ent in the child*% 'outh, ,hile al%o con%idering the effect of &re'ature extraction% on the de$elo&ing dentition( Thi% 'ay reBuire the extraction &lan to be Buite radical, e%&ecially ,here facilitie% for re%torati$e care under general anae%the%ia are not a$ailable( >e$ Point#

 Sedation can be a u%eful ad+unct for anxiou% &re%chool children( General anae%the%ia %hould only be u%ed ,here other 'anage'ent %trategie% ha$e failed or are dee'ed ina&&ro&riate( Fi!. 2.2 Co'&rehen%i$e full 'outh care under intubated general anae%the%ia enable% children ,ith 'ulti&le cariou% teeth to be ex&ediently rendered carie%free in one &rocedure( 2.3 TREAT7ENT &F DENTA* CARIES 2.3./ Tem ori:ation o+ o en "a.itie# 0% an initial %te& in the 'anage'ent of carie%, o&en ca$itie% %hould be handexca$ated and te'&ori5ed ,ith a %uitable 'aterial %uch a% a reinforced 5inc oxide and eugenol ce'ent, or, better %till, a &ac/able gla%% iono'er ce'ent ;6ig( ?(C<( Cariou% ex&o%ure% of $ital or non-$ital teeth can be dre%%ed ,ith a %'all a'ount of a &olyantibiotic %teroid &a%te ;3eder'ix< on cotton ,ool co$ered by a %uitable dre%%ing 'aterial( Dre%%ing o&en ca$itie% ha% a nu'ber of ad$antage%( )t %er$e% a% a %i'&le and %traightfor,ard introduction for the child to dental &rocedure%( 4y re'o$ing %oft carie% and te'&orarily occluding ca$itie%, the oral loading of 'utan% %tre&tococci i% %ignificantly reduced( )t hel&% to reduce %en%iti$ity, 'a/ing toothbru%hing and eating 'ore co'fortable, and al%o 'a/e% inad$ertent toothache le%% li/ely( )f a %uitable 'aterial i% u%ed, it can &roduce a %ource for lo,-le$el fluoride relea%e ,ithin the 'outh( >e$ Point# Te'&ori5ation of teethG hel&% to reduce dental %en%iti$ity and &re$ent toothache occurring before definiti$e care i% co'&leteH reduce% the oral 'utan% %tre&tococci loadH %er$e% a% an introduction to dental treat'entH and &ro$ide% a %ource for fluoride relea%e if a gla%% iono'er-ba%ed 'aterial i% u%ed( Fi!. 2.3 The large ca$ity in the lo,er right, %econd &ri'ary 'olar ha% been hand exca$ated and te'&ori5ed ,ith a &ac/able gla%% iono'er ce'ent( 2.3.2 De+initi.e re#toration o+ teet% The highly acti$e nature of dental carie% in the young &ri'ary dentition %hould be borne in 'ind ,hen &lanning re%torati$e care, but it i% al%o i'&ortant to &lan to carry out %uch care in a ,ay that the child can %ucce%%fully acce&t( 0&&roache% %uch a% *tell%ho,-do* ;Cha&ter < and beha$iour %ha&ing utili5ing &o%iti$e reinforce'ent to encourage a&&ro&riate beha$iour% are i'&ortant( Co''unicating in ter'% the child can under%tand, and u%ing $ocabulary that a$oid% negati$e a%%ociation%, i% al%o i'&ortant( 6or exa'&le, the ter' *local anae%thetic* ,ill 'ean nothing to 'o%t children and ,ord% %uch a% *in+ection* and *needle* 'ay con$ey the %ugge%tion of &ain or di%co'fort( Suitable alternati$e ter'% 'ight be *%lee&y +uice* or *+ungle +uice*( Such

*childrene%e* can be de$elo&ed for 'o%t routine dental eBui&'ent and &rocedure% ;Table ?(A< The &ace of treat'ent %hould ta/e into account the &re%chool child*% need to be fa'iliari5ed ,ith the dental en$iron'ent and eBui&'ent( Starting treat'ent by te'&ori5ing any o&en ca$itie% a% de%cribed abo$e %er$e% a% an ea%y introduction to o&erati$e care( 6ro' that &oint on, &lanning to include both a &re$enti$e and a re%torati$e co'&onent at each $i%it allo,% effecti$e treat'ent to &rogre%% at a rea%onable &ace( Table ?(: %ho,% one ,ay of con%tructing a treat'ent &lan for a ty&ical young child ,ith carie%( )t i% cu%to'ary to %tart ,ith treat'ent in the u&&er arch fir%t, a% thi% i% u%ually ea%ier for both the child and the denti%t, although thi% a&&roach 'ay need to be 'odified if there are lo,er teeth in urgent need of attention( 0&&ro&riate u%e of local analge%ia ;Cha&ter :< and rubber da' ;Cha&ter C< cannot be o$ere'&ha%i5ed and any denti%t treating young children need% to be &roficient at both( Many &re%chool children are far 'ore acce&ting of carefully deli$ered local analge%ia than 'o%t denti%t% reali5e( #%ing techniBue% to deli$er local analge%ia &ainle%%ly are crucial ;Cha&ter :, Section :(!< and care %hould be ta/en to a$oid o$erdo%age ,ith local analge%ic% ;Table ?(!<( )t i% al%o i'&ortant to ex&lain to the child the unu%ual feeling% a%%ociated ,ith %oft ti%%ue analge%ia, and to ,arn both the child and &arent of the need to a$oid li& bitingD%uc/ing ,hil%t the%e effect% &er%i%t ;Cha&ter :, Section :(?(@<( "lace'ent of rubber da' u%ing a trough techniBue, ,here the cla'& i% &laced on the tooth fir%t, then the da' i% %tretched o$er ;a% de%cribed in Cha&ter C< i%, in the author*% ex&erience, the 'o%t %traightfor,ard a&&roach in the young child( Careful attention to obtaining adeBuate analge%ia of the gingi$al ti%%ue%, both buccally and lingually, en%ure% co'fortable cla'& &lace'ent( )ntra&a&illary in+ection% are $ery u%eful for thi% ;Cha&ter :, Section :(!(@<( Encouraging the child to ,atch in a hand 'irror hel&% to di%tract the child*% attention fro' the intraoral 'ani&ulation% during actual &lace'ent of the da' ;6ig( ?(><( The techniBue% e'&loyed for definiti$e re%toration in young children %hould ta/e into account the often acti$e nature of the di%ea%e in thi% age grou&( The u%e of &la%tic re%torati$e 'aterial% %hould be li'ited to occlu%al and %'all a&&roxi'al le%ion%( Exten%i$e carie%, teeth ,ith carie% affecting 'ore than t,o %urface%, and teeth reBuiring &ul&oto'y or &ul&ecto'y %hould be re%tored ,ith %tainle%%-%teel cro,n%( 0'alga' i% %till ,idely u%ed a% a re%torati$e 'aterial, but 'aterial% including ne,er gla%% iono'er ce'ent%, re%in-'odified gla%% iono'er%, &olyacid-'odified re%in% ;co'&o'er%<, and co'&o%ite re%in% 'ay be &referred( 1o,e$er, all the latter 'entioned 'aterial% are far 'ore %en%iti$e to 'oi%ture conta'ination and techniBue than a'alga', %o adeBuate i%olation, &referably ,ith rubber da', i% e%%ential( Cer'et re%toration% &erfor' &oorly in &ri'ary teeth and are be%t a$oided( 0 fuller di%cu%%ion on 'aterial %election for the re%toration of &ri'ary 'olar% i% gi$en in Cha&ter C( Co'&o%ite %tri& cro,n re%toration% are the 'o%t effecti$e ,ay of re&airing cariou% anterior teeth ;Cha&ter C<( >e$ Point# "lan to carry out treat'ent at a &ace that the child ;and you< can co&e ,ith(

 )ntroduce young children to ne, eBui&'ent u%ing a *tell, %ho,, do* a&&roach( Ma/e a co'&rehen%i$e treat'ent &lan at an early %tage( #%e local analge%ia and rubber da'( Select re%torati$e 'aterial ta/ing into account the high ri%/ of further carie% in the young child( Stainle%%-%teel cro,n% are the 'o%t effecti$e re%toration for &ri'ary 'olar% ,ith carie% on 'ore than t,o %urface%( Fi!. 2.4 Encouraging the child to ,atch in a hand 'irror hel&% to di%tract the child*% attention fro' the intraoral 'ani&ulation% during rubber da' &lace'ent( 2.3.3 E9tra"tion o+ teet% Extraction i% indicated for teeth that are unre%torable, and it 'ay al%o be enforced by acute &ain or infection( )n &re%chool children the extraction of one or t,o teeth can often be acco'&li%hed under local analge%iainhalation or oral %edation being a u%eful ad+unct for anxiou% children( )f 'ore extraction% are needed, the%e can %o'eti'e% be carried out at the %a'e ti'e a% re%toring ad+acent teeth( 1o,e$er, general anae%the%ia i% the only &ractical %trategy for %o'e children, in ,hich ca%e referral to an a&&ro&riate dental general anae%the%ia facility i% 'andatory( When &lanning extraction%, it i% i'&ortant to con%ider the need for balancing ;Cha&ter =A<( 6actor% %uch a% the li/elihood of continued future attendance and co-o&eration of the child %hould al%o be borne in 'ind( )n &re%chool children ,ith exten%i$e carie%, extraction of fir%t &ri'ary 'olar% ,ith 'aintenance and re%toration of the %econd &ri'ary 'olar% ,here &o%%ible i% often a good &lan ;6ig( ?(=9<( -ot only doe% thi% li'it the ri%/ of further decay by eli'inating &o%terior &ri'ary contact area%, but it al%o 'ini'i5e% the deleteriou% effect of early extraction on the de$elo&ing dentition( Fi!. 2./0 Extraction of fir%t &ri'ary 'olar% ,ith 'aintenance and re%toration of the %econd &ri'ary 'olar%( 2.3.0 Re la"in! mi##in! teet% Where the child i% 'oti$ated, denture% are %u&ri%ingly ,ell tolerated( 0 %i'&le re'o$able acrylic denture ,ith gu'-fitted &ri'ary &ro%thetic teeth and cla%&% on the %econd 'olar% can effecti$ely re%tore ae%thetic% ;6ig( ?(==<( E$en full denture% can be highly %ucce%%ful in ca%e% ,here the child i% /een to ha$e teeth re&laced( The 'ethod% of con%tructing denture% are e%%entially the %a'e a% tho%e in adult%( )t i% i'&ortant that careful attention i% gi$en to cleaning %uch a&&liance% to a$oid the' contributing to further di%ea%e( >e$ Point# 4alancing extraction% %hould be con%idered ,hen extracting in the &ri'ary dentition( Denture% to re&lace 'i%%ing anterior teeth are ,ell tolerated by 'oti$ated children( Fi!. 2.// Extracted &ri'ary inci%or% can be ea%ily and effecti$ely re&laced by &ro$iding a re'o$able acrylic denture ,ith gu'-fitted &ri'ary &ro%thetic teeth

and cla%&% on the %econd 'olar%( 2.4 S(77ARY =( Dental carie% i% a &re$alent di%ea%e in the &re%chool &o&ulation( ( -ur%ing carie% and ra'&ant carie% are co''on &attern% of carie% in &re%chool children( @( "arent% %hould be encouraged to bring their children for a dental chec/-u& a% %oon a% the child*% fir%t tooth ha% eru&ted( A( "re$ention i% a corner%tone of the 'anage'ent of carie% in the &re%chool child( :( "lanned treat'ent %hould be carried out at a &ace the child can acce&t( !( "re%chool children need careful introduction to dental eBui&'ent and &rocedure%( ?( )nhalation or oral %edation can be effecti$e %trategie% for anxiou% &re%chool children( C( General anae%the%ia %hould be re%er$ed for tho%e ca%e% ,here other a&&roache% to 'anage'ent ha$e either failed or are dee'ed ina&&ro&riate( >( 3ocal analge%ia i% ad$i%able for definiti$e re%toration of all but %'all ca$itie%, but care %hould be exerci%ed to a$oid o$erdo%age in the %'all child( =9( Rubber da' 'a/e% good Buality treat'ent ea%ier to achie$e for both the child and denti%t( ==( Choice of re%torati$e 'aterial% %hould reflect the high ri%/ of further carie% in the young child( = ( Stainle%%-%teel cro,n% are the 'o%t effecti$e re%toration for &ri'ary 'olar% ,ith carie% on 'ore than t,o %urface%( 2./0 F(RT5ER READIN6 4riti%h Society of "aediatric Denti%try ;=>>?<( 0 &olicy docu'ent on the dental need% of children( International +ournal of Paediatric Dentistry, 2, 9@-?( ;$#PD consensus view document which reviews current standards of U0 child dental care and suggests how these might ,e improved < 4riti%h Society of "aediatric Denti%try ; 99@<( 0 &olicy docu'ent on oral health care in &re%chool children( International +ournal of Paediatric Dentistry, /3, ?>-C:( ;$#PD concensus document giving guidance for the delivery of oral health care to preschool children < Duggal, M( S(, Cur5on, M( E( 7(, 6ayle, S( 0(, "ollard, M( 0(, and Robert%on, 0( 7( ; 99 <( )estorative techni:ues in paediatric dentistry( ; nd edn<( Taylor O 6ranci%,

3ondon( ;" practical guide to the restoration of carious primary teeth < Seo,, W( 2( ;=>>C<( 4iological 'echani%'% of early childhood carie%( Community Dentistry and 8ral 7pidemiology, 21, ;Su&&l( =<, C- ?( ;"n excellent review of the various aetiological factors involved in early childhood caries < 2.// REFERENCE 6ran/l, S( -(, Shiere, 6( R(, 6ogel%, S( 1( R( ;=>! <( Should the &arent re'ain ,ith the child in the dental o&eratoryJ +ournal of Dentistry for Children, 24, =:9-!@( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

3. & erati.e treatment o+ dental "arie# in t%e rimar$ dentition - ( # Duggal and P 1 Day

3./ INTR&D(CTI&N While there i% no doubt that the be%t ,ay to tac/le the &roble' of dental carie% i% through an effecti$e &rogra''e of &re$ention a% outlined in the &re$iou% cha&ter%, it i% unfortunate that 'any children %till %uffer fro' the di%ea%e and it% con%eBuence%( 1ence there i% a need to con%ider o&erati$e treat'ent to &re$ent the brea/do,n of the dentition( O$er the year% the treat'ent of dental carie% in children ha% been di%cu%%ed and 'any atte'&t% 'ade to rationali5e the 'anage'ent of the di%ea%e( Writing 'ore than =:9 year% ago, 1arri% ;=>@>< ,a% one of the fir%t to addre%% the &roble' of re%toring the &ri'ary dentition( E$en in tho%e day% he ,a% e'&ha%i5ing the i'&ortance of &re$ention by good toothbru%hing( Carie% could be arre%ted by *&lugging*, but fro' hi% de%cri&tion he ob$iou%ly found treat'ent for the young &atient difficult and not a% %ucce%%ful a% in adult%( 1o,e$er, he did e'&ha%i5e the i'&ortance of loo/ing after the teeth of childrenG *)f &arent% and guardian% ,ould &ay 'ore attention to the teeth of their children, the %er$ice% of the denti%t ,ould 'uch le%% freBuently be reBuired*, and, *Many &er%on% %u&&o%e that the teeth, in the early &eriod% of childhood, reBuire no attention, and thu% are guilty of the 'o%t cul&able neglect of the future ,ell-being of tho%e entru%ted to their care*( #nfortunately, thi% %tate'ent %till a&&lie% today( The huge nu'ber of different techniBue% and 'aterial% that ha$e been ad$ocated o$er the year% %ince 1arri% ,rote tho%e ,ord% te%tify to the fact that no ideal %olution% ha$e %o far been found( #nfortunately, 'o%t treat'ent% are ad$ocated on the ba%i% of denti%t%* clinical i'&re%%ion% and there ha$e been $ery fe, ob+ecti$e %tudie% that ha$e atte'&ted to di%co$er ,hich treat'ent% %ucceed and ,hich do not( Treat'ent can be a %tre%%ful ex&erience for the child, the &arent, and the denti%t( )t i% i'&ortant that there i% a &o%iti$e health gain fro' any treat'ent that i% &ro$ided( )t i% i'&o%%ible to co$er the ,hole field of o&erati$e treat'ent for children in one cha&ter and the reader i% directed to other text% for a fuller account of a$ailable techniBue%( 1o,e$er, it i% &o%%ible to outline the rationale for &ro$iding o&erati$e treat'ent, to gi$e ad$ice on the %election of a&&ro&riate ,ay% of &ro$iding care, and to de%cribe a fe, of the 'ore u%eful treat'ent 'ethod%( 3.2 P5I*&S&P5Y &F CARE Children are the future dental &atient% and, therefore, the dental care that they recei$e %hould &ro'ote &o%iti$e dental ex&erience%, ,hich in turn ,ould &ro'ote &o%iti$e dental attitude%( When faced ,ith a tooth that ha% carie%, the fir%t deci%ion ha% to be ,hether it doe% in fact reBuire treat'ent or not( )t 'ay be felt that the carie% i% %o 'inor and &re$ention %o effecti$e that further &rogre%% of the le%ion i% unli/ely( 3e%% rationally it 'ay be felt that a cariou% tooth ,ith a non-$ital &ul& i% unli/ely to cau%e great &roble'% and 'ay be left to it% o,n de$ice%( Recently there ha% been 'uch di%cu%%ion in the #nited 2ingdo' on ,hether 'o%t cariou% &ri'ary 'olar% need to be re%tored at allI )n the author% $ie, there i% no doubt that untreated carie% in the &ri'ary dentition cau%e% ab%ce%%e%, &ain, and %uffering in children( Thi% can then need ho%&ital ad'i%%ion and in$a%i$e treat'ent, %o'eti'e% under general anae%the%ia,

,herea% a %i'&le re%toration, at the ti'e ,hen the carie% ,a% diagno%ed, ,ould ha$e &re$ented thi% extre'ely di%tre%%ing e&i%ode for the child( )t i% therefore e%%ential for all denti%t% in$ol$ed in the care of young children to learn re%torati$e techniBue% that gi$e the be%t re%ult% in &ri'ary teeth and thi% %hould al,ay% be along%ide excellent &re$enti$e &rogra''e%, and thi% cha&ter i% de$oted to the di%cu%%ion of %uch techniBue%( Good Buality re%torati$e care ;6ig( C(= ;a< and ;b<<, a% and ,hen carie% i% diagno%ed, ,ould al%o ob$iate the need for extraction% of &ri'ary teeth under general anae%the%ia for thou%and% of children, &articularly in the #nited 2ingdo'( 0 treat'ent &hilo%o&hy ,hich the author% belie$e i% effecti$e in the 'anage'ent of carie% in children i% %ho,n in Table C(=( Fi!. 3./ 0 ,ell-re%tored &ri'ary dentition ;a< u&&er arch and ;b< lo,er arch in a child( 1igh Buality re%torati$e care i% %u&&le'ented ,ith &re$ention in the for' of %ealant% &laced in other 'olar% dee'ed to be %u%ce&tible to future cariou% attac/( 3.3 RE7&)E< REST&RE< &R *EA)E 3.3.0 Introd-"tion There are certain %ituation% ,here the clinician 'ight decide not to carry out in$a%i$e re%torati$e &rocedure% in &ri'ary teeth and in%tead u%e a rigorou% &re$enti$e a&&roach( Such an a&&roach can be +u%tified ,here it i% li/ely that re'inerali5ation ,ould occur or the tooth 'aintained in a %tate, free fro' &ain or infection until exfoliation( Recently ;"itt% and 3ongbotto', =>>:< it ha% been &ro&o%ed that it %hould be &o%%ible to di$ide le%ion% into tho%e for ,hich &re$enti$e care i% ad$i%ed ;"C0< and tho%e for ,hich o&erati$e care i% ad$i%ed ;OC0<( More ,or/ i% reBuired on thi% conce&t but the follo,ing %ection% di%cu%% conflicting rea%on% to treat or not to treat &articular cariou% le%ion%( 3.3./ Rea#on# not to treat The%e can be di$ided into %e$eral di%tinct categorie%( =( -he damage done ,y treatment to= ;a< -he affected tooth( 1o,e$er con%er$ati$e the techniBue it i% ine$itable that %o'e %ound tooth ti%%ue ha% to be re'o$ed ,hen o&erati$e treat'ent i% underta/en( Thi% ,ea/en% the tooth and 'a/e% it 'ore li/ely that &roble'% %uch a% crac/ing of the tooth or lo%% of $itality of the &ul& 'ay occur in the future( >e$ Point E$ery ti'e that a re%toration i% re&laced 'ore %ound ti%%ue ha% to be re'o$ed, &utting the tooth at further ri%/( ;b< -he ad9acent tooth( )t i% al'o%t ine$itable ,hen treating an a&&roxi'al le%ion that the ad+acent tooth ,ill be da'aged( The outer %urface ha% a far higher fluoride content than the re%t of the ena'el %o that e$en a %light nic/ of the intact %urface ,ill re'o$e thi% re%er$oir of fluoride( 0dditionally, it ha% been %ho,n that early le%ion% that re'inerali5e are le%% %u%ce&tible to carie% than intact %urface% and the%e area% of

the tooth are all too ea%ily re'o$ed ,hen &re&aring an ad+acent tooth( >e$ Point Early le%ion% that re'inerali5e are le%% %u%ce&tible to carie%( ;c< -he periodontal tissues( Dental treat'ent can cau%e both acute and long-ter' da'age to the &eriodontiu'( )t i% $irtually i'&o%%ible to a$oid da'aging the interdental &a&illae ,hen treating a&&roxi'al carie%( The &a&illae can be &rotected by u%ing rubber da' andDor ,edge% and if ,ell-fitting re%toration% are &laced the ti%%ue% ,ill heal fairly ra&idly, but long-ter' da'age can be 'ore critical( Many adult% can be %een to be %uffering fro' o$erenthu%ia%tic treat'ent of a&&roxi'al carie% in their youthH and ,hile the relati$e i'&ort-ance of &oor 'argin% co'&ared to bacterial &laBue can be debated, the &otential da'age fro' a&&roxi'al re%toration% i% %ufficient rea%on to a$oid treat'ent unle%% a definite indication i% &re%ent( ;d< -he occlusion( "oor re%toration of the teeth can, o$er ti'e, lead to con%iderable alteration of the occlu%ion( )t i% te'&ting ,hen re%toring occlu%al %urface% to lea$e the 'aterial ,ell clear of the o&&o%ing teeth to a$oid difficultie%, or to be unconcerned if the filling i% %lightly *high*( 1o,e$er, thi% can allo, the teeth to eru&t into contact again or the interocclu%al &o%ition to change and alter the occlu%ion( Often thi% i% felt to be of little concern, but there are a large nu'ber of adult% ,here the cu'ulati$e effect of 'any &oorly re%tored teeth ha% %e$erely di%turbed the occlu%ion, thu% 'a/ing further treat'ent difficult, ti'e con%u'ing, and ex&en%i$e( ( -he difficulty of diagnosis( )t i% ,ell /no,n that it i% difficult to diagno%e dental carie% accurately( E$en ,hen coar%e criteria %uch a% tho%e de$elo&ed for the #nited 2ingdo' Child Dental 1ealth Sur$ey% are u%ed, there i% ,ide $ariation bet,een exa'iner%( )t i% not +u%t $ariation% bet,een exa'iner% that need to be con%idered a% there i% al%o a 'ar/ed difference bet,een the %a'e exa'iner on different occa%ion%( The i'&lication% need to be con%idered in relation to the deci%ion to treat or not( @( -he slow rate of caries attac%( Carie% u%ually &rogre%%e% relati$ely %lo,ly, although %o'e indi$idual% ,ill %ho, 'ore ra&id de$elo&'ent than other%( The 'a+ority of children and adole%cent% ,ill ha$e a lo, le$el of carie% and &rogre%% of cariou% le%ion% ,ill be %lo,( )n general, the older the child at the ti'e that the carie% i% fir%t diagno%ed the %lo,er the &rogre%%ion of the le%ion( 1o,e$er, a %ub%tantial grou& of children ,ill ha$e carie% that de$elo&% ra&idly( A( -he fact that reminerali>ation can arrest and repair enamel caries( )t ha% long been /no,n that early, %'ooth %urface le%ion% are re$er%ible( )n addition, it i% no, acce&ted that the chief 'echani%' ,hereby fluoride reduce% carie% i% by encouraging re'inerali5ation, and that the re'inerali5ed early le%ion i% 'ore re%i%tant to carie% than intact ena'el( 0lthough it i% difficult to %ho, re$er%al of le%ion% on radiogra&h%, 'any %tudie% ha$e de'on%trated that a %ub%tantial &ro&ortion of early ena'el le%ion% do not &rogre%% o$er 'any year%( :( -he short life of dental restorations( Sur$ey% of dental treat'ent ha$e often %ho,n a rather di%a&&ointing le$el of %ucce%%( )n general, :9L of a'alga' re%toration% in &er'anent teeth can be ex&ected to fail during the =9 year% follo,ing &lace'ent( So'e %tudie% ha$e %ho,n an e$en &oorer %ucce%% rate ,hen loo/ing at &ri'ary teeth,

and thi% ha% been &ut for,ard a% a rea%on for not treating the%e teeth( 3.3.2 Rea#on# to treat =( "dverse effects of neglect( The fact that the treat'ent of a&&roxi'al carie% can cau%e da'age to the affected tooth, the ad+acent tooth, the &eriodontiu', and the occlu%ion i% a $alid rea%on to thin/ t,ice before &utting bur to tooth( 4ut, of cour%e, a ca%e could eBually ,ell be 'ade that the neglect of treat'ent ,ill cau%e a% 'uch or 'ore da'age( 3ac/ of treat'ent can, and all too often doe%, lead to lo%% of contact ,ith ad+acent and o&&o%ing teeth, ex&o%ure of the &ul& re%ulting in the de$elo&'ent of &eria&ical infection, andDor lo%% of the tooth( 0t ,or%t, the child 'ay end u& ha$ing a general anae%thetic for the re'o$al of one or 'ore teeth( 0 &rocedure ,hich ha% a %ignificant 'orbidity and 'ortality( ( Unpredicta,ility of the speed of attac%( While it i% true that the rate of attac/ i% u%ually %lo,, it i% Buite &o%%ible for the rate in any one indi$idual to be ra&id %o that any delay in treat'ent ,ould not then be in the be%t intere%t% of the child( @( Difficulty in assessing if a lesion is arrested or not( 4ecau%e of the nor'ally %lo, rate of attac/ it i% difficult to be %ure if a le%ion i% arre%ted or 'erely de$elo&ing $ery %lo,ly( )t i% true that re'inerali5ation ,ill arre%t and re&air early ena'el le%ion%, but there i%, in fact, little e$idence that re'inerali5ation of the dentine or the late ena'el le%ion i% co''on( A( #uccess when careful treatment is provided( The 'a+ority of &ubli%hed %tudie% %ho, that cla%% )) a'alga' re%toration% in &ri'ary teeth ha$e a &oor life ex&ectancy, but thi% i% not the ex&erience of the careful denti%t( So'e of the%e denti%t% ha$e &ubli%hed their re%ult%, ,hich %ho, that the great 'a+ority of their re%toration% in &ri'ary teeth %ur$i$e ,ithout further attention until they exfoliate( The treat'ent &rocedure% u%ed are not &articularly difficult in co'&ari%on to other% that denti%t% atte'&t on adult%, and it i% difficult to a$oid the conclu%ion that the rea%on% for &oor re%ult% in %o'e %tudie% are due to &oor &atient 'anage'ent and lac/ of attention to detail( )t %hould be the ai' of the &rofe%%ion to de$elo& better and 'ore effecti$e ,ay% of treating the di%ea%e rather than thro,ing our hand% u& in %urrender( :( 7arly treatment is more successful than late( S'all re%toration% are 'ore %ucce%%ful than large, and therefore if a cariou% le%ion i% going to need treat'ent it i% better treated early rather than late( Thi% ,a% the rationale behind the early %ugge%tion% of 1yatt of a *&ro&hylactic filling* for &it% and fi%%ure% and for the 'odern $er%ion% in the for' of fi%%ure %ealant% and &re$enti$e re%in re%toration%( The fact that %'all re%toration% are often 'ore %ucce%%ful 'a/e% for difficult deci%ion% ,hen the 'anage'ent of carie% in$ol$e% &re$enti$e &rocedure%, ,hich need both ti'e to ,or/ and ti'e to a%%e%% ,hether they ha$e been effecti$e( 3.3.3 Remo.e or re#tore Once a deci%ion ha% been 'ade to treat a cariou% tooth a further deci%ion ha% to be 'ade a% to ,hether to re'o$e or re%tore it( Thi% deci%ion %hould ta/e into account the follo,ingG

=( -he child( Each child i% an indi$idual and treat'ent %hould be &lanned to &ro$ide the be%t that i% &o%%ible for that indi$idual( Too often treat'ent i% gi$en ,hich i% the 'o%t con$enient for the &arent or, 'ore li/ely, the denti%t( )% it really in the be%t intere%t of the child to re'o$e a tooth ,hich could be %a$edJ )n the #nited 2ingdo', general anae%the%ia i% %till ,idely u%ed for re'o$ing the teeth of young children de%&ite the ri%/% of death, it% un&lea%antne%%, and the co%t in$ol$ed( >e$ Point Treat the childnot the con$enience of &arent% or denti%t( ( -he tooth( )t i% not u%ually in a child*% intere%t for a &er'anent tooth to be re'o$ed( 1o,e$er, if the &ul& of a cariou% &er'anent tooth i% ex&o%ed then a con%iderable a'ount of treat'ent 'ay be reBuired to retain it, and the &rogno%i% for the tooth ,ould %till be &oor( )t 'ay therefore be in the child*% long-ter' intere%t to lo%e it and to allo, another tooth to ta/e it% &lace, either by natural drift or ,ith orthodontic a%%i%tance( "ri'ary teeth are often con%idered by &arent% and %o'e denti%t% a% being di%&o%able ite'% becau%e there co'e% a ti'e ,hen they ,ill be exfoliated naturally( 1o,e$er, it i% an unu%ual child ,ho thin/% the %a'e ,ayI 3o%% of a tooth before it% ti'e ha% a con%iderable %ignificance in a child*% life( 3o%ing a tooth early gi$e% a 'e%%age to the child that teeth are not $aluable and not ,orth loo/ing after( )t can then be difficult to &er%uade a child to care for their teeth( 0 ,ell-re%tored &ri'ary dentition can be a %ource of &ride to young children and an encourage'ent for the' to loo/ after the %ucceeding teeth( )t i% u%ually 'ore i'&ortant and fortunately rather ea%ier to %a$e and re%tore a %econd &ri'ary 'olar than a fir%t( While anterior teeth 'ight be le%% i'&ortant for the 'aintenance of %&ace, their &re'ature lo%% can cau%e lo, e%tee' in both child and &arent( @( -he stage of the disease( )t i% ea%ier for both child and denti%t to re%tore teeth at an early %tage of decay( 3ater the &ul& 'ay beco'e in$ol$ed and %ub%eBuent re%toration difficult, 'a/ing lo%% of the tooth 'ore li/ely( A( -he extent of the disease( 0 large nu'ber of teeth reBuiring treat'ent 'ay &ut a %train on a young child and, le%% i'&ortantly, on the &arent and denti%t( Carie% in children i% %ignificantly le%% than it ,a% 9 year% ago, and it ,ould be good to thin/ that the dental &rofe%%ion ,ould be able to re%tore the reduced nu'ber of decayed teeth that no, &re%ent( 3.0 DIA6N&SIS AND TREAT7ENT P*ANNIN6 3.0.0 Introd-"tion Thi% ,a% di%cu%%ed in Cha&ter @ and ,ill be only briefly outlined here( 0% %tated abo$e the treat'ent of cariou% teeth %hould be ba%ed on the need% of the child( The long-ter' ob+ecti$e %hould be to hel& the child reach adulthood ,ith an intact &er'anent dentition, ,ith no acti$e carie%, a% fe, re%tored teeth a% &o%%ible, and a

&o%iti$e attitude to their future dental health( )f re%toration i% reBuired it %hould be carried out to the highe%t %tandard &o%%ible in order to 'axi'i5e longe$ity of the re%toration and a$oid re-treat'ent( 3.0./ Dia!no#i# 0n accurate diagno%i% of dental carie% i% i'&ortant in the 'anage'ent of the &ri'ary dentition( Ena'el of the &ri'ary tooth i% thin co'&ared ,ith that of the &er'anent teeth, and carie% &rogre%%e% Buic/ly through the ena'el into the dentine, e%&ecially at the &roxi'al area belo, the contact &oint 'a/ing an early diagno%i% &ara'ount( When carie% i% %till confined to the ena'el then &re$enti$e 'ea%ure% %tand a chance of halting and re$er%ing the le%ion a% di%cu%%ed in Cha&ter !( P-l al in.ol.ement Once the carie% i% into the dentine then re'o$al of the cariou% ti%%ue and re%toration of the tooth i% reBuired( Carie% &rogre%%e% $ery ra&idly through the &ri'ary dentine ,ith early &ul& in$ol$e'ent( When thi% %tage of the &roce%% i% reached the 'arginal ridge beco'e% under'ined and colla&%e%( The diagno%i% of the integrity of the 'arginal ridge in &ri'ary 'olar% i% i'&ortant in treat'ent &lanning for children( Re%earch ha% %ho,n that once the 'arginal ridge of a &ri'ary 'olar ha% bro/en a,ay the &ul& of the tooth i% affected and irre$er%ible change% ha$e co''enced ;6ig( C( <( Radio!ra %# The i'&ortance of radiogra&h% for the diagno%i% of carie% in children cannot be o$ere'&ha%i5ed, a% clinical exa'ination alone ,ould 'ean that 'any &roxi'al le%ion% could be 'i%%ed ;6ig( C(@<( 0% 'entioned earlier 'any early le%ion% 'ay be halted or re$er%ed by a rigorou% &re$enti$e &rogra''e( 4ut thi% de&end% on adeBuate early diagno%i%( While %e$eral techniBue% for carie% diagno%i% ha$e been introduced recently, 'o%t notable of ,hich i% Diagnodent ;208O<, bite,ing ;4W< radiogra&hy i% by far the 'o%t acce&table and ,idely a$ailable for u%e in general &ractice( Radiogra&h% %hould for' a routine &art of any dental exa'ination and it i% nece%%ary to re&eat radiogra&h% for dental carie% diagno%i% at %uitable inter$al%( The inter$al% that are a&&ro&riate to children $ary according to the le$el of carie% that a child &re%ent% ,ith( 0fter an initial exa'ination and 4W radiogra&h% a %econd %erie% %hould be ta/en ,ithin = year if the child i% carie% free but at ! 'onth% if thi% i% acti$e carie%( Once it ha% been e%tabli%hed that a child re'ain% carie% free, then, the inter$al bet,een 4W% can be increa%ed to A 'onth% or e$en longer( 1o,e$er, if acti$e carie% re'ain% a &roble', then ! 'onthly inter$al% bet,een 4W% are nece%%ary( >e$ Point De%truction by carie% of the 'arginal ridge of a &ri'ary 'olar indicate% li/ely &ul&al in$ol$e'ent( Fi!. 3.2 The 'arginal ridge% of both the lo,er left fir%t and lo,er right %econd &ri'ary 'olar ha$e been in$ol$ed in the cariou% &roce%%, the &ul& in the%e teeth i% li/ely to be infla'ed( Fi!. 3.3 ;a< 0 clinical exa'ination in the u&&er arch gi$e% a little clue to the &re%ence of &roxi'al cariou% le%ion% on both the u&&er right fir%t and %econd

&ri'ary 'olar%( ;b< 1o,e$er, exten%i$e carie% i% e$ident ,hen the%e ,ere exa'ined ,ith 4W radiogra&h%( 3.0.2 Treatment lannin! 6ollo,ing diagno%i% of the extent of carie% in each tooth and the &robable %tate of the &ul&, a logical treat'ent &lan %hould be 'ade ,hich ,ould u%ually in$ol$e treating a Buadrant of the 'outh at a ti'e( )t u%ed to be felt that 'ulti&le %hort $i%it% &laced lea%t %tre%% on a child &articularly if they ,ere under ! year% of age( 1o,e$er, the 'o%t i'&ortant a%&ect of child 'anage'ent i% to gain the confidence of the child and 'a/e %ure that there i% a% little di%co'fort a% &o%%ible( Re%torati$e care 'u%t be conducted ,ith good &ain control and 'anage'ent of a child*% beha$iour( 3ocal analge%ia i% therefore 'andatory and i% ea%ily &erfor'ed the%e day% ,ith to&ical analge%ia, fine gauge needle%, and %hort-acting local analge%ia agent%( Due con%ideration %hould be gi$en to the u%e of a rubber da' that en%ure% a 'uch higher Buality of re%toration% that la%t for the duration of a tooth a% ,ell a% being an aid in beha$iour 'anage'ent( Once the ti%%ue% ha$e been anae%theti5ed and the child i% confident that there ,ill be no &ain, it i% u%ually be%t to co'&lete treat'ent on a ,hole Buadrant( The nu'ber of $i%it% can then be /e&t to a 'ini'u' and a re%er$oir of co-o&eration 'aintained( )f a child i% in &ain then it 'atter% little if an a&&oint'ent i% : or A: 'in( Where there i% &ul&al in$ol$e'ent of &ri'ary teeth then &ul&oto'ie% or &ul&ecto'ie% are e%%ential( Such teeth al%o need re%toration ,ith &refor'ed 'etal cro,n%, ,hich ha$e re&eatedly been %ho,n to ha$e one of the highe%t %ucce%% rate% of any re%toration for children*% teeth( -o doubt, the lea%t inter$entioni%t a&&roach can be the correct one for %o'e children, but integrated ,ithin a treat'ent &lan ,hich i% be%t in the long-ter' intere%t of the child and not an ea%y ,ay out for the denti%t( )f thi% &redi%&o%e% the child to re&etiti$e treat'ent, and ,or%e %till &ain, ab%ce%%e%, and extraction% under general anae%the%ia, then it %hould be re+ected in fa$our of co'&rehen%i$e care u%ing re%torati$e techniBue%, %uch a% de%cribed in thi% cha&ter( 3.5 D(RA;I*ITY &F REST&RATI&NS 3.5.0 Introd-"tion )n contra%t to the a'ount of u%eful re%earch that ha% been carried out ,ith regard to the diagno%i% and &re$ention of dental carie%, 'ethod% of treat'ent are %till e'&irical( Treat'ent deci%ion% ought to be ba%ed on %ound %cientific e$idence but, unfortunately, de%&ite the great effort that ha% been %&ent &ro$iding treat'ent o$er 'any year%, little in the ,ay of re%ource% ha% been %&ent on clinical re%earch into the %ucce%% or other,i%e of dental treat'ent 'ethod%( Thi% i% e%&ecially true ,ith regard to the &ri'ary dentition( There are fe, re&ort% in the literature on the relati$e %ucce%% in the &ri'ary dentition of different treat'ent 'ethod% or 'aterial%( The 'a+ority of tho%e re&ort% are retro%&ecti$e and therefore need to be treated ,ith caution( The choice of re%toration for &ri'ary teeth i% ba%ed u&on the degree of cariou% in$ol$e'ent, ,hether the 'arginal ridge i% intact or not and the length of ti'e that ,ill ela&%e before exfoliation( The deci%ion regarding the ty&e of re%toration to be u%ed i% therefore ba%ed on the diagno%i% of the extent of the dental carie%( 1ere again if the 'arginal ridge ha% bro/en a,ay then %i'&le Cla%% )) ty&e re%toration ,ill fail a% the &ul& in$ol$e'ent ha% &o%%ibly occurred already(

3.5./ Con.entional re#torati.e material# Many different 'aterial% ha$e been ad$ocated o$er the year%, but, a% indicated abo$e, $ery little re%earch ha% been carried out to find out ,hich one% 'ight be the 'o%t u%eful( Therefore the &o&ularity of any &articular 'aterial ha% de&ended on clinical i'&re%%ion and fa%hion( Thi% %ection &ro$ide% a brief o$er$ie, of tho%e 'aterial% that are both currently ,idely a$ailable and ha$e been %ub+ect to %o'e clinical re%earch( Sil.er amal!am Sil$er a'alga' ha% been u%ed for re%toring teeth for o$er =:9 year% and, de%&ite the fact that it i% not tooth coloured and that there ha$e been re&eated concern% about it% %afety ;largely unfounded<, it i% %till ,idely u%ed( Thi% i% &robably becau%e it i% relati$ely ea%y to u%e, i% tolerant of o&erator error, and ha% yet to be bettered a% a 'aterial for econo'ically re%toring &o%terior teeth( Modern, non-ga''a alloy re%toration% ha$e been %ho,n to ha$e extended lifeti'e% in &er'anent teeth ,hen &laced under good condition%, and ha$e al%o been %ho,n to be 'uch le%% %en%iti$e to &oor handling than tooth-coloured 'aterial%( )n clinical trial% and retro%&ecti$e %tudie%, no intracoronal 'aterial ha% %o far &erfor'ed 'ore %ucce%%fully than a'alga'( Stainle##-#teel "roCn# The%e ,ere introduced in =>:9 and ha$e gained ,ide acce&tance in -orth 0'erica( )n Euro&e they ha$e been le%% &o&ular, being %een by 'o%t denti%t% a% too difficult to u%e, although in reality they are often ea%ier to &lace than %o'e intracoronal re%toration% ;6ig( C(A<( 0ll &ubli%hed %tudie% ha$e %ho,n %tainle%%-%teel cro,n% to ha$e a higher %ucce%% rate in &ri'ary teeth than all other re%torati$e 'aterial%( They are certainly the &referred treat'ent o&tion for fir%t &ri'ary 'olar% ,ith anything other than 'ini'al carie%( Stainle%%-%teel cro,n% are al%o ad$ocated for hy&o&la%tic or $ery cariou% fir%t &er'anent 'olar%, ,here they act a% &ro$i%ional re%toration% &rior either to %trategic re'o$al at age >-= year% or later re%toration ,ith a ca%t cro,n ;6ig( C(:<( Etched retained ca%ting% 'ay no, be u%ed for the definiti$e re%toration of &er'anent hy&o&la%tic teeth ,ithout in$ol$e'ent of the a&&roxi'al %urfaceH 'ore con%er$ati$e &ro$i%ional re%toration% than %tainle%%-%teel cro,n% %hould be con%idered if thi% i% intended( Com o#ite re#in Co'&o%ite re%in% ca'e on the 'ar/et in the early =>?9% and ha$e been 'odified %ince then in an atte'&t to i'&ro$e their &ro&ertie%( Current 'aterial% are %till be%t a&&lied to anterior teeth and %'all re%toration% in &o%terior teeth( The de$elo&'ent of acid etching at the ti'e that the%e 'aterial% ,ere introduced ha% en%ured that they ha$e &erfor'ed rea%onably ,ell in ter'% of 'arginal %eal( They are %en%iti$e to $ariation% in techniBue and ta/e longer to &lace than eBui$alent a'alga' re%toration%( They

'u%t be &laced in a dry field ;6ig( C(!<( The long-ter' %ucce%% of co'&o%ite re%in% i% +eo&ardi5ed by their in%tability in ,ater( The be%t 'aterial% ha$e 'axi'u' inorganic filler le$el% and lo, ,ater ab%or&tion, but ,ill deteriorate o$er ti'e( >e$ Point 0ll co'&o%ite re%in and gla%% iono'er re%toration% 'u%t be &laced in a dry field( 6la## ionomer Gla%% iono'er ce'ent% ca'e on to the 'ar/et in the late =>?9% and ha$e al%o been 'odified %ince then in order to enhance their &ro&ertie%( Current 'aterial% are 'uch i'&ro$ed and ha$e %o'e ad$antage% o$er co'&o%ite re%in%( 4eing 'ade fro' gla%%e% ,ith a high fluoride content they not only &ro$ide a %u%tained relea%e o$er an extended &eriod but al%o act a% a rechargeable re%er$oir of fluoride, ,hich 'ay &rotect ad+acent %urface% fro' carie% &rogre%%ion( They adhere to ena'el and dentine ,ithout the need for acid etching, do not %uffer fro' &oly'eri5ation %hrin/age, and, once %et, are di'en%ionally %table in condition% of high hu'idity %uch a% exi%t in the 'outh ;6ig( C(?<( Si'ilarly to co'&o%ite re%in% it i% i'&erati$e that they are &laced in a dry field( Fi!. 3.0 Re%toration of lo,er %econd &ri'ary 'olar% ,ith %tainle%%-%teel cro,n% ? year% after &lace'ent( Fi!. 3.5 Te'&orary re%toration of cariou% u&&er fir%t &er'anent 'olar% ,ith %tainle%%-%teel cro,n% in an C-year-old child ,ith a high carie% rate( Fi!. 3.1 Rubber da' &lace'ent &rior to re%toration of a&&roxi'al le%ion% ,ith co'&o%ite re%in( Fi!. 3.2 Di%tal-occlu%al re%toration% on both lo,er %econd &ri'ary 'olar% after @ year%one re%tored ,ith con$entional a'alga', the other ,ith gla%% iono'er ce'ent( 3.5.2 NeC re#torati.e material# Recently, a nu'ber of ne, 'aterial% ha$e co'e on to the 'ar/et ,hich ai' to 'axi'i5e the be%t Bualitie% of both co'&o%ite re%in% and gla%% iono'er%( So'e of the%e %ho, &ro'i%e and %hould be con%idered for the re%toration of children*% teeth( -one of the' ha$e had 'ore than @-A year clinical trial% %o it i% %till unclear ho, $aluable they are co'&ared to con$entional 'aterial%( They can be cla%%ified according to ,hether they retain the e%%ential acid-ba%e reaction of the gla%% iono'er% or not( Re#in-modi+ied !la## ionomer The%e con%i%t of a gla%% iono'er ce'ent to ,hich ha% been added a re%in %y%te' that ,ill allo, the 'aterial to %et Buic/ly u%ing light or che'ical cataly%t% ;or both< ,hile allo,ing the acid-ba%e reaction of the gla%% iono'er to ta/e &lace( Thu%, the 'aterial% ,ill %et, albeit rather %lo,ly, ,ithout the need for the re%in %y%te' and the e%%ential

Bualitie% of a gla%% iono'er ce'ent %hould be retained ;6ig( C(C<( Pol$a"id-modi+ied "om o#ite re#in (Com omer) )n contra%t, the%e 'aterial% ha$e a 'uch higher content of re%in and the acid-ba%e reaction of the gla%% iono'er% doe% not ta/e &lace( Therefore although they are ea%ier to u%e ;being &re'ixed in ca&%ule%<, there i% %o'e doubt a% to the longer ter' benefit% o$er con$entional co'&o%ite re%in% ;6ig( C(><( 1o,e$er, recently &ubli%hed ,or/ ha% %ho,n co'&o'er to be a% durable a% a'alga' after @ year% in a&&roxi'al ca$itie% in &ri'ary 'olar% ;Mar/% et al( =>>>H Welbury et al( 999<( Fi!. 3.3 Re%in-'odified gla%% &oly'er re%toration after year% in a lo,er %econd &ri'ary 'olar( Fi!. 3.4 Me%ial-occlu%al re%toration after = year in an u&&er %econd &ri'ary 'olar ,ith &olyacid-'odified co'&o%ite re%in( 3.1 R(;;ER DA7 3.1.0 Introd-"tion Mo%t text% that di%cu%% o&erati$e treat'ent for children ad$ocate the u%e of rubber da', but it i% u%ed $ery little in &ractice de%&ite 'any %ound rea%on% for it% ado&tion( )n the #nited 2ingdo' le%% than L of denti%t% u%e it routinely( )t i% &ercei$ed a% a difficult techniBue that i% ex&en%i$e in ti'e and arduou% for the &atient( )n fact, once 'a%tered, the techniBue 'a/e% dental care for children ea%ier and a higher %tandard of care can be achie$ed in le%% ti'e than ,ould other,i%e be reBuired( )n addition, it i%olate% the child fro' the o&erati$e field 'a/ing treat'ent le%% in$a%i$e of their &er%onal %&ace( The benefit% can be di$ided into three 'ain categorie% a% %ho,n belo,( 3.1./ Sa+et$ Dama!e o+ #o+t ti##-e# The ri%/% of o&erati$e treat'ent include da'age to the %oft ti%%ue% of the 'outh fro' rotary and hand in%tru'ent% and the 'edica'ent% u%ed in the &ro$i%ion of endodontic and other care( Rubber da' ,ill go a long ,ay to &re$enting da'age of thi% ty&e( Ri#= o+ #CalloCin! or in%alation There i% al%o the ri%/ that the%e ite'% 'ay be lo%t in the &atient*% 'outh and %,allo,ed or e$en inhaled and there are re&ort% in the literature to %ub%tantiate thi% ri%/( Ri#= o+ "ro##-in+e"tion )n addition, there i% con%iderable ri%/ that the u%e of high-%&eed rotary in%tru'ent% di%tribute an aero%ol of the &atient%* %ali$a around the o&erating roo', &utting the

denti%t and %taff at ri%/ of infection( 0gain, a ri%/ that ha% been %ub%tantiated in the literature( Nitro-# o9ide #edation )f thi% i% u%ed it i% Buite li/ely that 'outh breathing by the child ,ill increa%e the le$el of the ga% in the en$iron'ent, again &utting denti%t and %taff at ri%/( The u%e of rubber da' in thi% %ituation ,ill 'a/e %ure that exhaled ga% i% routed $ia the %ca$enging %y%te' attached to the no%e &iece( #%ually le%% nitrou% oxide ,ill be reBuired for a %edati$e effect, increa%ing the %afety and effecti$ene%% of the &rocedure( 3.1.2 ;ene+it# to t%e "%ild I#olation One of the rea%on% that dental treat'ent cau%e% anxiety in &atient% i% that the o&erati$e area i% $ery clo%e to and in$ol$ed ,ith all the 'o%t $ital function% of the body %uch a% %ight, hearing, breathing, and %,allo,ing( When o&erati$e treat'ent i% being &erfor'ed, all the%e $ital function% are &ut at ri%/ and any %en%ible child ,ould be concerned( )t i% u%eful to di%cu%% the%e fear% ,ith child &atient% and ex&lain ho, the ri%/% can be reduced or eli'inated( Gla%%e% %hould be u%ed to &rotect the eye% and rubber da' to &rotect the air,ay% and the oe%o&hagu%( 4y doing thi%, and &ro$ided that good local analge%ia ha% been obtained, the child can feel the'%el$e% di%tanced fro' the o&eration( So'eti'e% it i% e$en hel&ful to %ho, the child their i%olated teeth in a 'irror( The $ie, i% %o different fro' ,hat they nor'ally %ee in the 'irror that they can di$orce the'%el$e% fro' the reality of the %ituation( Rela9ation The i%olation of the o&erati$e area fro' the child ,ill $ery often cau%e the child to beco'e con%iderably relaxedal,ay% &ro$ided that there i% good &ain control( )t i% co''on for both adult and child &atient% to fall a%lee& ,hile undergoing treat'ent in$ol$ing the u%e of rubber da'a %ituation that rarely occur% ,ithout ;6ig( C(=9<( Thi% i% a function of the %afety &ercei$ed by the &atient and the relaxed ,ay in ,hich the dental tea' can ,or/ ,ith it% a%%i%tance( Fi!. 3./0 Sho,% rubber da' &laced in the a child and ,ith the co'fort it &ro$ide% it i% not unu%ual for children to fall a%lee& in the dental chair during treat'ent under rubber da'( 3.1.3 ;ene+it# to t%e denti#t Red-"ed #tre## 0% noted abo$e, once rubber da' ha% been &laced the child ,ill be at le%% ri%/ fro' the &rocedure% that ,ill be u%ed to re%tore their teeth( Thi% reduce% the effort reBuired by the o&erator to &rotect the %oft ti%%ue% of the 'outh and the air,ay%( Treat'ent can be carried out in a 'ore relaxed and controlled 'anner, therefore le%%ening the %tre%%

of the &rocedure on the dental tea'( Retra"tion o+ ton!-e and "%ee=# Correctly &laced rubber da' ,ill gently &ull the chee/% and tongue a,ay fro' the o&erati$e area allo,ing the o&erator a better $ie, of the area to be treated( Retra"tion o+ !in!i.al ti##-e Rubber da' ,ill gently &ull the gingi$al ti%%ue% a,ay fro' the cer$ical 'argin of the tooth, 'a/ing it 'uch ea%ier to %ee the extent of any carie% clo%e to the 'argin and often bringing the cer$ical 'argin of a &re&ared ca$ity abo$e the le$el of the gingi$al 'argin thu% 'a/ing re%toration con%iderably ea%ier( )nterdentally, thi% retraction %hould be a%%i%ted by &lacing a ,edge fir'ly bet,een the ad+acent teeth a% %oon a% the da' ha% been &laced( Thi% ,edge i% &laced hori5ontally belo, the contact area and abo$e the da', thu% co'&re%%ing the interdental gingi$ae again%t the underlying bone( 0&&roxi'al ca$itie% can then be &re&ared, any da'age fro' rotary in%tru'ent% being inflicted on the ,edge rather than the child*% gingi$al ti%%ue( Kuite often it can be difficult and ti'e con%u'ing to ta/e the rubber da' bet,een the contact% becau%e of dental carie% or bro/en re%toration%( )t i% &o%%ible to 'a/e life ea%ier by u%ing a *trough techniBue*, ,hich in$ol$e% %ni&&ing the rubber da' bet,een the &unched hole%( 0ll the benefit% of rubber da' are retained exce&t for the retraction and &rotection of the gingi$al ti%%ue% ;6ig( C(==<( 7oi#t-re "ontrol 0% 'entioned &re$iou%ly, %il$er a'alga' i% &robably the only re%torati$e 'aterial that ha% any tolerance to being &laced in a da'& en$iron'ent, and there i% no doubt that it and all other 'aterial% ,ill &erfor' 'uch 'ore %ati%factorily if &laced in a dry field( Rubber da' i% the only techniBue that readily en%ure% a dry field( Fi!. 3.// *Trough techniBue* of rubber da' &lace'ent( 3.1.0 Te"%niA-e Mo%t text% on o&erati$e denti%try de'on%trate techniBue% for the u%e of rubber da'( )t i% not intended to du&licate thi% effort, but it ,ould %ee' u%eful to &oint out feature% of the techniBue that ha$e 'ade life ea%ier for the author% ,hen u%ing rubber da' ,ith children( Anal!e#ia "lace'ent of rubber da' can be unco'fortable e%&ecially if a cla'& i% needed to retain it( E$en if a cla'& i% not reBuired the %har& cut edge of the da' can cau%e 'ild &ain( Soft ti%%ue analge%ia can be obtained u%ing infiltration in the buccal %ulcu% follo,ed by an inter&a&illary in+ection( Thi% ,ill u%ually gi$e %ufficient analge%ia to re'o$e any di%co'fort fro' the da'( 1o,e$er, 'ore &rofound analge%ia 'ay be reBuired for the &articular o&erati$e &rocedure that ha% to be &erfor'ed(

7et%od o+ a

li"ation

There are at lea%t four different 'ethod% of &lacing the da', but 'o%t authoritie% reco''end a 'ethod ,hereby the cla'& i% fir%t &laced on the tooth, the da' %tretched o$er the cla'& and then o$er the re'aining teeth that are to be i%olated( 4ecau%e of the ri%/ of the &atient %,allo,ing or inhaling a dro&&ed or bro/en cla'& before the da' i% a&&lied, it i% i'&erati$e that the cla'& be re%trained ,ith a &iece of flo%% tied or ,ra&&ed around the bo,( Thi% add% con%iderable incon$enience to the techniBue and the author% fa$our a %i'&ler 'ethod ,hereby the cla'&, da', and fra'e are a%%e'bled together before a&&lication and ta/en to the tooth in one 'o$e'ent( 4ecau%e the cla'& i% al,ay% on the out%ide of the da' relati$e to the &atient there i% no need to u%e flo%% to %ecure the cla'&( 0 :-inch ;about = (: c'< %Buare of 'ediu' da' i% %tretched o$er an )$ory fra'e and a %ingle hole &unched in the 'iddle of the %Buare( Thi% hole i% for the tooth on ,hich the cla'& i% going to be &laced and further hole% %hould be &unched for any other teeth that need to be i%olated( 0 ,inged cla'& i% &laced in the fir%t hole and the ,hole a%%e'bly carried to the tooth by the cla'& force&%( The tooth that i% going to be cla'&ed can be %een through the hole and the cla'& a&&lied to it( The da' i% then tea%ed off the ,ing% u%ing either the finger% or a hand in%tru'ent( )t can then be carried for,ard o$er the other teeth ,ith the interdental da' being */nifed* through the contact area%( )t 'ay need to be %tabili5ed at the front u%ing either flo%%, a %'all &iece of rubber da', a *Wed+et* ;6ig%( C(! and C(==<, or a ,ooden ,edge( 3.2 &PERATI)E TREAT7ENT &F PRI7ARY TEET5 3.2./ Pit and +i##-re "arie# "it and fi%%ure carie% i% le%% of a &roble' in &ri'ary teeth than in &er'anent one%( The fi%%ure% are u%ually 'uch %hallo,er and le%% %u%ce&tible to decay, %o the &re%ence of a ca$ity in the occlu%al %urface of a &ri'ary 'olar i% a %ign of high carie% acti$ity( 4ecau%e of thi% it i% Buite li/ely that the children ,ho reBuire treat'ent of the%e %urface% ,ill be young( 1o,e$er, treat'ent i% not difficult and can u%ually be acco'&li%hed ,ithout &roble'( )nfiltration analge%ia %hould be gi$en together ,ith %u&&le'ental intra&a&illary in+ection( Carie% i% re'o$ed u%ing a @@9 bur in a high%&eed hand&iece( 6or re%torationalthough, a% indicated abo$e, %il$er a'alga' ha% not %o far been bettered in clinical trialbecau%e occlu%al carie% in the &ri'ary dentition indicate% high carie% acti$ity, the 'aterial of choice 'ay be a re%in-'odified gla%% iono'er ce'ent ,ith it% &o%%ible carie% &re$enti$e &ro&ertie% ;6ig( C(C<( 3.2.2 A ro9imal "arie#

Sil.er amal!am 6ailure of a'alga' it%elf a% ,ell a% fault% in the ca$ity de%ign ha$e been the 'o%t co''only re&orted cau%e% of failure of a&&roxi'al re%toration% in &ri'ary teeth( 0tte'&t% to o$erco'e the%e deficiencie% and to i'&ro$e durability ha$e co'e through alteration in ca$ity de%ign and the choice of 'aterial u%ed( 0 reduction in the %i5e of the occlu%al loc/, rounded line angle%, and 'ini'u' exten%ion for &re$ention all

re%ult in le%% de%truction of %ound tooth ti%%ue( )n addition, the *'ini'al* a&&roxi'al ca$ity ,ith no occlu%al *do$etail* ha% been de%cribed for both a'alga' and adhe%i$e re%toration%, and incor&orate% %o'e 'echanical retention in the for' of %'all internal re%i%tance groo$e% &laced ,ith a $ery %'all round bur +u%t in%ide the ena'el-dentine +unction( 6igure C(= ;a<-;f< de'on%trate the clinical %tage% in the &lace'ent of t,o%urface a'alga' re%toration% in the &ri'ary dentition( )t i% unli/ely that the *&erfect ca$ity de%ign* exi%t% for an a'alga' re%toration in &ri'ary 'olar% due to certain anato'ical feature%G =( Widened contact area% 'a/e a narro, box difficult to achie$e( ( Thin ena'el 'ean% that crac/ing and fracture of &art% of the cro,n are 'ore co''on( @( "ri'ary teeth 'ay undergo con%iderable ,ear under occlu%al %tre%% the'%el$e% and thi% in turn ,ill affect the re%toration%( )t i% therefore nece%%ary to in$e%tigate other 'aterial% for u%e in re%toring the &ri'ary dentition( Com o#ite re#in Co'&o%ite re%in ha% been u%ed Buite ,idely to re%tore &ri'ary teeth and re%ult% are generally acce&table( Ca$ity de%ign i% u%ually a 'odified a&&roxi'al de%ign ,ith be$elling of the 'argin% to increa%e the a'ount of ena'el a$ailable for etching and bonding( The u%e of rubber da' i% e%%ential if a dry field i% to be achie$ed( Thi% fact together ,ith the 'aterial*% relati$e ex&en%e &robably reflect% the lac/ of ,ide%&read u%e of co'&o%ite re%in in 'any countrie%( 6la## ionomer "ement More %tudie% ha$e been conducted u%ing gla%% iono'er ce'ent% than co'&o%ite re%in%( 1o,e$er, the ca$ity de%ign% u%ed in the different %tudie% $ary con%iderably and it i% difficult to dra, fir' conclu%ion%( Certainly, gla%% iono'er ce'ent ,ill undergo %ignificantly 'ore lo%% of anato'ical for' than a'alga' in the a&&roxi'al area, and a% %uch con$entional gla%% iono'er% ha$e not been %ho,n to be a% durable a% a'alga'( 1o,e$er, the o&erator ,ill need to balance thi% fact ,ith the ob$iou% 'echanical and che'ical ad$antage% of the ce'entna'ely it% ability to bond to ena'el and dentine, thu% reBuiring a 'ore con%er$ati$e &re&aration, and it% ability to act a% a re%er$oir of fluoride( Com omer# Co'&o'er% are no, ,idely u%ed in general dental &ractice for the re%toration of a&&roxi'al le%ion% in &ri'ary teeth( 0fter good initial re%ult%, longer follo,-u& &eriod% ha$e %ho,n that thi% 'aterial indeed li$ed u& to it% early &ro'i%e and good %ur$i$al rate% ha$e been re&orted for re%toration% in &ri'ary 'olar%( 1o,e$er, it 'u%t

be &laced in ca$itie% &re&ared to the u%ual &rinci&le% of ca$ity de%ign for a 'o%t fa$ourable outco'e( Fi!. 3./2 ;a<-;f< TechniBue %eBuence for the &lace'ent of t,o-%urface a'alga' re%toration% in lo,er &ri'ary 'olar%( The fir%t 'olar could ha$e been re%tored ,ith a %tainle%%-%teel cro,n( 3.2.3 Stainle##-#teel "roCn# Stainle%%-%teel cro,n% %hould be con%idered ,hene$er &o%terior &ri'ary teeth ;e%&ecially fir%t 'olar%< reBuire re%toration( They ,ere originally de$elo&ed to &ro$ide a *re%toration of la%t re%ort* for tho%e teeth that ,ere not %al$ageable by any other 'ean%( 0t the ti'e that they ,ere introduced in the early =>:9% the only alternati$e% ,ere %il$er or co&&er a'alga' or a %election of ce'ent%, 'aterial% co'&letely un%uited to the re%toration of gro%%ly cariou% teeth or tho%e that had been ,ea/ened by &ul& treat'ent( O$er the year%, it ha% beco'e a&&arent that the life ex&ectancy of the%e cro,n% i% far better than any other re%toration for &ri'ary &o%terior teeth and that they co'e clo%e to the ideal of ne$er ha$ing to be re&laced &rior to exfoliation( )n addition, they are le%% de'anding technically than intracoronal re%toration% in &ri'ary teeth( They %hould therefore no, be con%idered for any tooth ,here the denti%t cannot be %ure that an alternati$e ,ould %ur$i$e until the tooth i% lo%t( )t i% unfair to &ut a child through 'ore treat'ent %ituation% than nece%%ary becau%e a le%% %ucce%%ful 'aterial, ,hich need% freBuent re&lace'ent, ,a% cho%en( The indications for %tainle%%-%teel cro,n% are %ho,n in Table C( ( T%e te"%niA-e Where$er &o%%ible local anae%the%ia %hould be gi$en, although in certain %ituation%, for exa'&le, ,hile &re&aring a non-$ital tooth, thi% i% not al,ay% nece%%ary( -e$erthele%%, e$en in the%e teeth there ,ill need to be %o'e tooth &re&aration in$ol$ing the gingi$al 'argin, ,hich can cau%e %o'e di%co'fort for ,hich local anae%the%ia i% ad$i%able( )t i% %o'eti'e% &o%%ible to u%e only a to&ical anae%the%ia, %uch a% a ben5ocaine oint'ent on the gingi$al cuff( )n other in%tance%, ,hen the &re&aration for a cro,n i% carried out at the %a'e $i%it a% a &ul&oto'y, local analge%ia ,ould already ha$e been ad'ini%tered( Where cro,n% are being fitted becau%e of exten%i$e ca$itie% or decalcification, a rubber da' i% ad$i%able, e$en though the author% ac/no,ledge that the u%e of rubber da' for re%toration% in children in general dental &ractice i% Buite lo,( "rior to &re&aration, all carie% i% re'o$ed and any &ul& treat'ent that 'ay be reBuired carried out( 0 recent &reo&erati$e radiogra&h 'u%t be a$ailable to 'a/e %ure that the &eria&ical and interradicular ti%%ue% are healthy and that the tooth i% unli/ely to be exfoliated in the near future( "re&aration and fitting i% ea%ier if rubber da' i% in &lace but e$en if thi% i% not the ca%e it i% ad$i%able to &lace ,edge% 'e%ially and di%tally, gingi$al to the contact area ;6ig( C(=@ ;a<<( The%e ,edge% %hould be &laced fir'ly u%ing the a&&licator %u&&lied ,ith

the' or a &air of flat-bea/ed &lier%( )t i% e%%ential that good %oft ti%%ue anae%the%ia be obtained %o that thi% &rocedure i% not &ainful, although the ,edge% %hould co'&re%% the gingi$ae a,ay fro' the contact area and not be dri$en into the ti%%ue( The u%e of ,edge% in thi% 'anner &rotect% the ti%%ue% and reduce% the conta'ination of the o&erating field a% ,ell a% 'a/ing the 'argin% of the &re&aration ea%ier to %ee( The 'e%ial and di%tal %urface% of the tooth are re'o$ed u%ing a @@9 bur or a fine ta&ered fi%%ure bur or dia'ond ;6ig( C(=@ ;b<<( )t i% i'&ortant to cut through the tooth, a,ay fro' the contact area, to a$oid da'age to the ad+acent tooth( The bur %hould be angled a,ay fro' the $ertical %o that a %houlder i% not created at the gingi$al 'argin( The %a'e bur 'ay be u%ed for the ,hole &re&aration, although it can be Buic/er to u%e a larger dia'ond for the next %tage, ,hich i% to reduce the occlu%al %urface to allo, =(:- '' of %&ace bet,een the &re&ared tooth and it% o&&o%ite nu'ber( Many authoritie% ad$ocate doing no 'ore &re&aration than thi% but it ta/e% little further ti'e to reduce the buccal and lingual %urface% %ufficiently to re'o$e any undercut% abo$e the gingi$al 'argin( 0ny %har& line angle% are rounded off to a$oid interference% that 'ight &re$ent the cro,n %eating( The 'e%ial and di%tal &re&aration 'ight %ee' rather radical in co'&ari%on to that reBuired ,hen a ca%t cro,n i% con%tructed for a &er'anent tooth, but the &rinci&le% of retention and re%i%tance of the t,o ty&e% of cro,n are different( 0 ca%t cro,n i% retained by friction bet,een the ,all% of the &re&ared tooth and the internal %urface of the cro,n( )t i%, therefore, i'&ortant to ha$e near &arallel ,all% of adeBuate height( 0 %tainle%%-%teel 'etal cro,n i% retained by contact bet,een the 'argin% of the cro,n and the undercut &ortion of the tooth belo, the gingi$a( The %ha&e of the &re&aration abo$e the gingi$a i% relati$ely uni'&ortant and difficulty in fitting the%e cro,n% i% 'o%t often becau%e of under-&re&aration( 1o,e$er, it i% 'o%t i'&ortant that a %houlder i% not for'ed at the gingi$al 'argin a% thi% ,ould 'a/e the %eating of a ,ell-ada&ted cro,n i'&o%%ible( Try the cro,n on and chec/ to feel that it i% ,ithin the gingi$al cre$ice ;6ig( C(=@ ;c<< by &robing( )f it re%t% on the gingi$al cre$ice then cri'& in ,ith %o'e &lier%( 0gain %eat the cro,n( )f it i% o$er-extended, cut do,n in that area ,ith a %tone or %ci%%or% and %'ooth off before retrying( Chec/ contact% ,ith ad+acent teeth and finally &oli%h the 'argin% ,ith a %tone or rubber ,heel( Wa%h and dry the tooth before ce'entation ,ith a gla%% iono'er ce'ent( Seat the cro,n fro' lingual to buccal &re%%ing do,n fir'ly ;6ig( C(=@ ;d<<( Re'o$e exce%% ce'ent ,hen %et ,ith a &robe and dental flo%% ;6ig( C(=@ ;e<<, before re'o$ing rubber da' and chec/ing the occlu%ion( 0lthough not &ro$en %tati%tically beneficial, %o'e o&erator% fa$our 'a/ing %'all hole% in the a&&roxi'al %urface% of the %tainle%%-%teel cro,n, to confer the benefit% of fluoride relea%e fro' the gla%% iono'er ce'ent to the ad+acent teeth ;6ig( C(=@ ;f<<( 6igure C(=A ;a<-;d< %ho,% ho, the re%toration of hea$ily cariou% &ri'ary 'olar% ,ith %tainle%%-%teel cro,n% ha% 'aintained arch %&ace and allo,ed &er'anent &re'olar% to eru&t into ideal occlu%ion( S-""e## rate# o+ #tainle##-#teel "roCn re#toration O$er the la%t 9-@9 year% author% ha$e con%i%tently recorded and re&orted higher %ucce%% rate% for %tainle%%-%teel cro,n% a% co'&ared ,ith other re%toration% in &ri'ary

'olar%( )n a recently &ubli%hed 'eta-analy%i%, it ,a% clear that %tainle%%-%teel cro,n% ,ere by far the 'o%t durable re%toration% for &ri'ary 'olar%, and the 'o%t re'ar/able fact ,a% that once &laced they %eldo' needed re&lacing( Fi!. 3./3 ;a< Rubber da' and ,edge% in &lace, &ul&oto'y and coronal reduction co'&leted( ;b< Me%ial and di%tal %urface% reduced( ;c< Cro,n *try-in*( ;d< Ce'entation of cro,n( ;e< Exce%% ce'ent re'o$ed &rior to rubber da' re'o$al and occlu%al analy%i%( ;f< 0&&roxi'al hole in %tainle%%-%teel cro,n &rior to &lace'ent( Fi!. 3./0 ;a< Cariou% u&&er and lo,er &ri'ary 'olar%( ;b< 0fter &lace'ent of %tainle%%-%teel cro,n%( ;c< Occlu%ion in the 'ixed dentition( ;d< *)deal* final occlu%ion in the &er'anent dentition( 3.2.0 Anterior teet% The treat'ent of decayed &ri'ary inci%or% de&end% on the %tage of decay and the age and co-o&eration of the &atient( )n the &re%chool child, carie% of the u&&er &ri'ary inci%or% i% u%ually a% a re%ult of *nur%ing carie% %yndro'e* due to the freBuent or &rolonged con%u'&tion of fluid% containing fer'entable carbohydrate fro' a bottle or feeder cu& ;Cha&ter !<( The lo,er inci%or% are rarely affected a% they are &rotected during %uc/ling by the tongue and directly bathed in %ecretion% fro' the %ub'andibular and %ublingual gland%( )n *nur%ing carie%* the &rogre%%ion of decay i% ra&id, co''encing on the labial %urface% and Buic/ly encircling the teeth( )t i% i'&o%%ible to &re&are %ati%factory ca$itie% for re%toration and after a co'&rehen%i$e &re$enti$e &rogra''e the 'o%t %uitable for' of re%toration i% the *%tri& cro,n techniBue*( Thi% utili5e% celluloid cro,n for'% and a light-cured co'&o%ite re%in to re%tore cro,n 'or&hology( Either calciu' hydroxide or gla%% iono'er ce'ent can be u%ed a% a lining and the high &oli%hability of 'odern hybrid co'&o%ite% 'a/e the' ae%thetically, a% ,ell a% &hy%ically, %uitable for thi% ta%/( )n older children o$er @ or A year% of age ne, le%ion% of &ri'ary inci%or%, although not u%ually a%%ociated ,ith the u%e of &acifier%, do indicate high carie% acti$ity ;6ig( C(=:<( Such le%ion% do not &rogre%% %o ra&idly and u%ually a&&ear on the 'e%ial and di%tal %urface%, here a gla%% iono'er ce'ent or co'&o%ite re%in can be u%ed for re%toration( Gla%% iono'er lac/% the tran%lucency of co'&o%ite re%in but ha% the u%eful ad$antage% of being adhe%i$e and relea%ing fluoride( 6racture% of the inci%al edge% in &ri'ary teeth, a% in &er'anent teeth, %hould be re%tored ,ith co'&o%ite re%in( Stri& Cro,n% ;@M ES"EE< are a u%eful aid in the re%toration of &ri'ary inci%or%( #nfortunately, o,ing to their lo, %ale% in the #nited 2ingdo' and the re%t of Euro&e, the co'&any ha% di%continued the %ale of the%e cro,n% and no, they are only a$ailable on %&ecial reBue%t( They are ho,e$er, freely a$ailable in the #nited State%( )n the author% o&inion, the%e cro,n% are excellent for building &ri'ary inci%or% ,here exten%i$e tooth ti%%ue ha% been lo%t due to either carie% or trau'a( The techniBue for their u%e i% %i'ilar to that of %uch cro,n% u%ed in &er'anent teethH the cro,n% are ea%ily tri''ed ,ith %har& %ci%%or%, filled ,ith co'&o%ite, and %eated on a &re&ared and conditioned tooth( The celluloid cro,n for' can be %tri&&ed off after the

co'&o%ite ha% been cured( 6igure C(=! ;a< and ;b< %ho, that excellent re%ult% can be obtained ,ith the u%e of %tri& cro,n%( Fi!. 3./5 3abial and a&&roxi'al carie% in u&&er anterior &ri'ary teeth( Fi!. 3./1 The figure %ho,% ;a< cariou% &ri'ary inci%or% that ,ere re%tored ;b< u%ing %tri& cro,n%, and co'&o%ite re%in% to gi$e an ae%thetically &lea%ing re%ult( 3.3 P(*P T5ERAPY IN PRI7ARY TEET5 3.3.0 Introd-"tion Conte'&orary ad$ance% in &ri'ary &re$ention ha$e reduced dental di%ea%e in the de$elo&ed ,orld( 4ut there i% no roo' for co'&lacency( Dental carie% and trau'atic dental in+urie% are %till &re$alent and treat'ent of the da'age they cau%e i% %till a 'a+or co'&onent of &aediatric dental &ractice( The &rinci&al goal% of &aediatric o&erati$e denti%try are to &re$ent the exten%ion of dental di%ea%e and to re%tore da'aged teeth to healthy function( To thi% end, a range of con%er$ati$e endodontic &rocedure% can &ro$ide alternati$e% to extraction for 'any &ul&ally co'&ro'i%ed &ri'ary teeth( They are ,ithin the gra%& of all &ractitioner% and are central to the &ractice of &aediatric denti%try( While 'any of the general &rinci&le% and o&erati$e &rocedure% in &aediatric endodontic% are %hared ,ith adult endodontic%, a nu'ber of i'&ortant difference% exi%t ,hich +u%tify the %&ecial co$erage gi$en in thi% cha&ter( >e$ Point# Di%ad$antage% of un&lanned extraction% in the &ri'ary and 'ixed dentition%G lo%% of %&ace, &ro'oting 'alocclu%ionH reduced 'a%ticatory function ;e%&ecially &o%terior teeth<H i'&aired %&eech de$elo&'ent ;e%&ecially anterior teeth<H &%ychological di%turbance ;e%&ecially anterior teeth<H anae%thetic and %urgical trau'a%( 3.3./ T%e dental -l Dental &ul& i% the li$ing, %oft ti%%ue %tructure ,hich re%ide% in the coronal &ul& cha'ber and root canal% of &ri'ary and &er'anent teeth( 1i%tologically, it i% co'&o%ed of loo%e connecti$e ti%%ue, %urrounded on it% &eri&hery by a continuou% layer of %&eciali5ed %ecretory cell%, the odontobla%t%( Odontobla%t% are uniBue to the dental &ul& and are re%&on%ible for dentine de&o%ition( 4lood $e%%el% and ner$e% enter the &ul& through the a&ical fora'en and occa%ionally through lateral or acce%%ory root canal%( The &ul&% of &ri'ary and young &er'anent teeth, e%&ecially tho%e ,ith inco'&lete a&ice%, ha$e a $ery rich blood %u&&ly( The 'o%t i'&ortant function of the &ul& i% to lay do,n dentine ,hich for'% the ba%ic %tructure of teeth, define% their general 'or&hology, and &ro$ide% the' ,ith

'echanical %trength and toughne%%( Dentine de&o%ition co''ence% 'any 'onth% ;&ri'ary teeth< or year% ;&er'anent teeth< before tooth eru&tion and ,hile the cro,n of a ne,ly eru&ted tooth ha% a 'ature external for', the &ul& ,ithin %till ha% con%iderable ,or/ to do in co'&leting tooth de$elo&'ent( -e,ly eru&ted teeth ha$e %hort root%, their a&ice% are ,ide and often di$erging, and the dentine ,all% of the entire tooth are thin and relati$ely ,ea/( "ro$ided the &ul& re'ain% healthy, dentine de&o%ition ,ill continue during the &o%teru&ti$e year for &ri'ary teeth( One of the /ey goal% of &aediatric denti%try i% therefore to &rotect and &re%er$e the &ul&% of teeth in a healthy %tate at least until thi% critical &ha%e of tooth de$elo&'ent i% co'&lete( 3.3.2 Dia!no#i# o+ -l at%o#i# and rationale

Studie% in the early =>?9% had %ho,n that in o$er :9L of the &ri'ary 'olar% ,here the lo%% of the 'arginal ridge had occurred, &ul& infla''ation ,a% irre$er%ible( Re%earch carried out recently in the De&art'ent of "aediatric Denti%try of the 3eed% Dental )n%titute ;Duggal et al(, 99 <, ha% corroborated the%e finding%( )n thi% %tudy, it ,a% %ho,n that 'o%t teeth had &ul& infla''ation in$ol$ing the &ul& horn ad+acent to the &roxi'al cariou% le%ion, e$en ,hen carie% had in$ol$ed le%% than half the 'arginal ridge, %tudied by 'ea%uring the inter-cu%&al di%tance ;bucco-lingual< in$ol$ed in the cariou% &roce%%( Thi% %ugge%t% that infla''ation of the &ul& in &ri'ary 'olar% de$elo&% at an early %tage of &roxi'al cariou% attac/ and by the ti'e 'o%t &roxi'al carie% i% 'anife%t clinically, the &ul& infla''ation i% Buite ad$anced( The%e finding% ha$e i'&ortant clinical i'&lication%, the 'o%t i'&ortant being that re%toration carried out ,ithout &ul& thera&y in 'o%t &ri'ary 'olar%, ,here &roxi'al carie% ha% 'anife%t clinically ,ith the in$ol$e'ent of the 'arginal ridge, ,ill fail( Once the brea/do,n of 'arginal ridge i% e$ident &ul& thera&y i% in$ariably reBuired( )t al%o reiterate% the i'&ortance of early diagno%i% of &roxi'al carie% ,ith the u%e of 4W radiogra&h%( 4ecau%e of thi% early on%et of infla''ation in &ri'ary 'olar% direct &ul& ca&&ing i% al%o contraindicated( 3.3.3 Indire"t -l "a in!

)n the 'a+ority of circu'%tance%, cariou% le%ion% can and %hould be fully exca$ated before tooth re%toration( 0 clinical dile''a i% &re%ented by a dee& le%ion in a $ital, %y'&to'-free tooth ,here co'&lete re'o$al of %oftened dentine on the &ul&al floor i% li/ely to re%ult in fran/ ex&o%ure( The ad$ancing front of a cariou% le%ion contain% $ery fe, cariogenic bacteria( "ro$ided the bul/ of infected o$erlying dentine i% re'o$ed, a %'all a'ount of %oftened dentine 'ay often be left in the dee&e%t &art of the &re&aration ,ithout endangering the &ul&( Thi% i% the ba%i% of indirect &ul& ca&&ing( 0ll carie% i% fir%t cleared fro' the ca$ity 'argin% ,ith a %teel round bur running at %lo, %&eed( Gentle exca$ation then follo,% on the &ul&al floor, re'o$ing a% 'uch of the %oftened dentine a% &o%%ible ,ithout ex&o%ing the &ul&( "reci%ely ho, 'uch dentine %hould be re'o$ed beco'e% a 'atter of ex&erience and clinical +udge'ent, although %o'e ha$e ad$ocated the u%e of indicator dye% ;e(g( 9(:L ba%ic fuch%in< to %ho, ,hen all infected dentine ha% been eli'inated( 0 thin layer of %etting calciu'

hydroxide ce'ent i% then &laced on the ca$ity floor to de%troy any re'aining 'icroorgani%'% and to &ro'ote the de&o%ition of re&arati$e %econdary dentine( )n it% cla%%ical a&&lication, the indirect &ul& ca& ,a% co$ered ,ith 5inc oxide-eugenol ce'ent, and follo,ing %e$eral ,ee/%* ob%er$ation, the ca$ity ,a% re-entered to re'o$e all re'aining %oftened dentine( More co''only, the calciu' hydroxide &ul& ca& i% %i'&ly co$ered ,ith a layer of hard %etting ce'ent and the tooth &er'anently re%tored at the %a'e $i%it( "eriodic clinical and radiogra&hic re$ie, i% then underta/en to 'onitor the &ul& re%&on%e( )f, a% ha% been di%cu%%ed in the &re$iou% %ection%, the &ul& i% dee'ed to be infla'ed, &ul& thera&y %hould be con%idered e$en in the ab%ence of a clinical ex&o%ure( Direct &ul& ca&&ing %hould not be carried out if an ex&o%ure i% found on re'o$al of carie%, a% &lacing a 'edica'ent, %uch a% calciu' hydroxide on an infla'ed &ul& ,ill lead to failure( 3.3.0 T%e .ital -l otom$ "ul& thera&y u%ually refer% to t,o ter'%H &ul&oto'y and &ul&ecto'y( 0 &ul&oto'y in$ol$e% the coronal re'o$al of the &ul& ti%%ue that i% diagno%ed to be infla'ed or infected a% a re%ult of dee& carie%( Thi% u%ually lea$e% an intact radicular &ul& ti%%ue u&on ,hich a 'edica'ent i% a&&lied before &lacing a coronal re%toration( Indi"ation# +or a -l otom$ The indication% for a &ul&oto'y that are of direct rele$ance to general dental &ractitioner% are gi$en in Table C(@( There are certain condition% %uch a% congenital heart defect%, hi%tory of heart %urgery ,here &ul&oto'y i% not u%ually &erfor'ed due to the ri%/ of &reci&itating bacterial endocarditi%( 0l%o, in i''uno-co'&ro'i%ed ;e(g( leu/ae'ia< or deficient condition%, &ul&oto'y i% contraindicated and extraction ,ith the rele$ant e%%ential &recaution% i% u%ually &referred( T%e -l otom$ te"%niA-e The $ariou% %te&% in$ol$ed in carrying out a &ul&oto'y in a &ri'ary 'olar are %ho,n in 6ig%( C(=?, C(=C, C(=>, and C( 9( P-l otom$ medi"ament 6or'ocre%ol ha% traditionally been u%ed and ,idely recogni5ed ,ithin the &rofe%%ion, a% a 'edication that ha% deli$ered the be%t long-ter' re%ult%( 0 one-fifth dilution of original 4uc/ley% for'ulation ha% been %ho,n to be a% effecti$e a% the full %trength concentrate( 6or'ocre%ol i% not ea%ily a$ailable in the #nited 2ingdo' and there ha$e been %o'e concern% about it% toxicity, both locally and %y%te'ically( The%e concern% ha$e gro,n recently ,ith for'aldehyde, one of the i'&ortant co'&onent% of for'ocre%ol lin/ed to certain for'% of cancer( 0tte'&t% ha$e been ongoing for the la%t fe, year% to find a %uitable re&lace'ent and one 'aterial that ha% generated a lot of intere%t recently a% a %uitable alternati$e to for'ocre%ol i% ferric %ulfate( 6erric %ulfate

ha% been ,idely u%ed to control gingi$al bleeding, &rior to i'&re%%ion ta/ing and al%o in endodontic%( )t i% an excellent hae'o%tatic agent, for'ing a ferric ion-&rotein co'&lex on contact ,ith blood, ,hich then %to&% further bleeding by %ealing the $e%%el% ;6ig( C( = ;a<-;c<<( )t ha% al%o no, been %ho,n to be a% effecti$e a% for'ocre%ol in 'ediu'-and long-ter' %tudie% ,hen u%ed in a concentration of =:(:L( Thi% i% a$ailable co''ercially a% 0%tringident( The author% $ie, i% that ferric %ulfate ,ill e'erge a% the 'o%t %uitable alternati$e to for'ocre%ol in the next fe, year%( )n light of recent e$idence, ferric %ulfate can be u%ed a% a %uitable alternati$e for tho%e concerned about the toxicity of for'ocre%ol or ha$e difficulty obtaining it in the #nited 2ingdo'( 1o,e$er, it 'u%t be re'e'bered that ferric %ulfate ha% no Rfixati$eR effect( 6or thi% rea%on, an accurate diagno%i% of the %tate of the &ul& ti%%ue being left behind and on ,hich ferric %ulfate i% being a&&lied ,ill need to be 'ade( >e$ Point# 6erric Sulfate i% a %uitable 'edica'ent for &ul&oto'y in &ri'ary 'olar% ,hen the infla''ation i% diagno%ed to be re%tricted only to the coronal &ul&( Though it %to&% bleeding at the %ite of a'&utation of the coronal &ul&, it %hould be a&&lied, al'o%t i''ediately, for about = 'in( FolloC-Teeth that ha$e undergone &ul&oto'y %hould be re$ie,ed clinically and if &o%%ible radiogra&hically, though the author% acce&t that routine radiogra&hic follo,-u& i% not &o%%ible in general dental &ractice( Clinically, the follo,ing criteria indicate %ucce%%G ab%ence of %y'&to'%H ab%ence of any ab%ce%% or draining %inu%H no exce%%i$e 'obility or tenderne%%( Radiogra&hically there %hould beG =( Either no further bone lo%% in the furcation region or regeneration of bone in thi% area( 6igure C(=> ;e< de'on%trate% good bone condition in the bifurcation region ! 'onth% after the &ul&oto'y ,a% &erfor'ed( ( -o e$idence of internal re%or&tion( )nternal re%or&tion u%ually indicate% chronic infla''ation and the acti$ity of giant cell% cau%ing re%or&tion of the dentine( )t create% fe, %y'&to'%, and i% u%ually detected a% an incidental finding on radiogra&hic exa'ination( )t %hould be con%idered a% a for' of irre$er%ible &ul&iti% ;6ig( C( <( >e$ Point# Direct &ul& ca&&ing ha% a &oor &rogno%i% in cariou% &ri'ary 'olar%( "ul&oto'y ha% a better &rogno%i% than &ul& ca&&ing( 0 &ul&oto'y %hould only be &erfor'ed ,hen the &ul& infla''ation i% thought to be li'ited to the coronal &ul&( 6erric %ulfate ;=:(:L<, a$ailable a% 0%tringident i% e'erging a% a good alternati$e to for'ocre%ol for u%e a% a &ul& 'edica'ent(

Fi!. 3./2 The &ul&oto'y techniBue( ;See al%o 6ig%( C(=C, C(=>, and C( 9(< Fi!. 3./3 On re'o$al of carie% an ex&o%ure of the &ul& belo, the 'e%io-lingual cu%& i% clearly e$ident( Fi!. 3./4 ;a< The figure %ho,% a lo,er right %econd &ri'ary 'olar ,here after re'o$ing the roof of the &ul& cha'ber the coronal &ul& i% being co'&letely re'o$ed u%ing exca$ator%( ;b< Cotton &ledget ,ith the 'edica'ent &laced o$er the radicular &ul& ti%%ue to control the bleeding( ;c< On re'o$al of the cotton &ledget bleeding fro' the a'&utation %ite% ha% %to&&ed( ;d< 2al5inol ;or any other 5inc oxide eugenol &re&aration< &laced in the &ul& cha'ber &rior to &lacing the coronal re%toration( ;e< "eria&ical radiogra&h of right u&&er fir%t &ri'ary 'olar %ho,ing a co'&leted &ul&oto'y( -ote excellent conden%ation of ce'ent in the &ul& cha'ber and coronal re%toration ,ith %tainle%%-%teel cro,n( Fi!. 3.20 Sho,% &erforation in the floor of the &ul& cha'ber in a %econd &ri'ary 'olar( )f thi% ha&&en% extraction i% u%ually indicated( Fi!. 3.2/ ;a< 6erric %ulfate in a concentration of =:(:L %olution i% a$ailable co''ercially a% 0%tringident ;#ltradent, #S0<( ;b< 6erric %ulfate being a&&lied on the root canal ti%%ue after the a'&utation of coronal &ul& in the u&&er right %econd &ri'ary 'olar( ;c< 4leeding %to&% al'o%t i''ediately on a&&lication of ferric %ulfate( Fi!. 3.22 )nternal infla''atory re%or&tion, identified a% an incidental finding on routine radiogra&hic exa'ination( 3.3.5 7ana!ement o+ non-.ital and a,#"e##ed rimar$ molar# t%e -l e"tom$ te"%niA-e "ri'ary 'olar% ,ith ab%ce%%e% are u%ually indicated for extraction%( "er%i%tent and chronic infection in &ri'ary 'olar% can cau%e da'age to the de$elo&ing &er'anent tooth ger'% and %uch foci of infection %hould be re'o$ed( )n %o'e ca%e% the non-$ital &ri'ary 'olar% ;6ig( C( @< or one% ,ith a chronic di%charging %inu% 'ight need to be retained( So'e of the rea%on% for thi% could beG orthodontic, 'edical, ,here extraction i% not a&&ro&riate, %uch a% in %e$ere hae'o&hiliac%, &arent% refu%al to acce&t extraction( )n %uch ca%e% the%e teeth can be retained by carrying out the Pulpectomy &rocedure( )n the #nited 2ingdo', there i% reluctance a'ong 'any denti%t% to carry out a &ul&ecto'y a% it i% &ercei$ed to be difficult in a young child, ,ith extraction being &referred( The author% feel that thi% i% a 'i%conce&tion( Thi% techniBue %hould be learnt by all &aediatric denti%t%, a% it can often %a$e the child fro' the trau'a of a G0 for extraction of &ri'ary teeth( "ul&ecto'y in$ol$e% acce%%ing the root canal %y%te' of &ri'ary 'olar%, cleaning the' a% be%t a% i% &o%%ible, and then u%ing an a&&ro&riate 'aterial, u%ually &ure 5inc oxide eugenol, to obturate the root canal%( "ure 5inc oxide eugenol i% &referred a% it i% entirely re%orbable and i% ea%ily re'o$ed a% the root% of the &ri'ary teeth undergo re%or&tion( 0l%o, if it i% extruded through the a&ice%, it get% co'&letely re%orbed by the a&ical ti%%ue%( Other 'aterial% %uch a% )odofor' &a%te, and e$en calciu' hydroxide are al%o %o'eti'e% u%ed(

The root canal 'or&hology of &ri'ary 'olar% i% Buite %i'ilar to that of &er'anent 'olar% ,ith either three of the four root canal% &re%ent( )n the lo,er &ri'ary 'olar% there are al,ay% t,o 'e%ial root canal%'e%io-buccal and 'e%io-lingual, ,ith one or %o'eti'e% t,o di%tal root canal%( )n u&&er &ri'ary 'olar% there are three root canal%'e%io-buccal, di%to-buccal, and &alatal ;6ig( C( A ;a<-;c<<( Indi"ation# +or -l e"tom$ )rre$er%ible &ul&iti% in$ol$ing both the coronal and radicular &ul&( -on-$ital &ri'ary 'olar% or inci%or% that need to be 'aintained in the arch( 0b%ce%%ed &ri'ary 'olar%( "ri'ary 'olar% ,ith radiogra&hic e$idence of furcation &athology( The %te&% for &erfor'ing a &ul&ecto'y are %ho,n in the flo, diagra'( ;6igure C( :<( 6igure C( ! %ho,% a diagra''atic re&re%entation of the techniBue( )n %o'e ca%e% ,here there i% acute infection or &er%i%tent di%charge fro' the root canal%, it 'ay be nece%%ary to defer the root canal obturation to a second visit( )n %uch ca%e% a 'edicated cotton &ledget, barely 'oi%tened ,ith for'ocre%ol i% %ealed in the &ul& cha'ber ,ith either gla%% iono'er ce'ent or )RM( ;6or tho%e ,ho are concerned about the %afety of for'ocre%ol, 3eder'ix ,ould be a %uitable alternati$e(< )n the %econd $i%it the &ledget i% re'o$ed and the &ul&ecto'y &rocedure co'&leted( FolloC-- and re.ieC Though the &ul&ecto'y techniBue carrie% a good &rogno%i%, the outco'e i% not a% good a% a $ital &ul&oto'y( Clinical follo,-u& aug'ented by one &eria&ical radiogra&h on a yearly ba%i% i% reBuired ;6ig( C( ? ;a<-;b<<( The follo,ing clinical and radiogra&hic &ara'eter% can be ta/en a% indication% of %ucce%%G Clinical alle$iation of acute %y'&to'%H tooth free fro' &ain and 'obility( Radiogra&hic i'&ro$e'ent or no further deterioration of bone condition in the furcation area( Root "anal treatment o+ rimar$ in"i#or# The techniBue de%cribed abo$e can al%o be u%ed to treat non-$ital or ab%ce%%ed &ri'ary inci%or%( )ncrea%ingly, &arent% are reluctant to ha$e their child*% u&&er anterior teeth extracted( )n a 'odern %ociety, ,here a child*% %elf-e%tee' i% i'&ortant, it i% the duty of the denti%t% to 'aintain ae%thetic% ,here$er &o%%ible( Many &ri'ary inci%or% ,ith ab%ce%%e% that are extracted can be retained ,ith the hel& of a &ul&ecto'y techniBue, and the root canal 'or&hology i% %uch that thi% can ea%ily be &erfor'ed ;6ig( C( C<, the only li'iting factor being the child*% co-o&eration( )ndication% for a

&ul&ecto'y in &ri'ary inci%or% include cariou% or trau'ati5ed &ri'ary inci%or% ,ith &ul& ex&o%ure% or acute or chronic ab%ce%%e%( 6igure C( > %ho,% an exa'&le of &ri'ary central inci%or% treated ,ith &ul&ecto'y( >e$ Point# 0 &ul&ecto'y %hould be con%idered ,here$er it i% e%%ential to &re%er$e a &ri'ary tooth that cannot be treated ,ith other 'ean%, %uch a% a &ul&oto'y( 4oth &ri'ary 'olar% and inci%or% can be treated ,ith a &ul&ecto'y techniBue( Fi!. 3.23 0 non-$ital left lo,er &ri'ary 'olar( Fi!. 3.20 Root canal 'or&hology of &ri'ary 'olar%, ;a< 'axillary fir%t &ri'ary 'olarH ;b< 'axillary %econd &ri'ary 'olarH ;c< 'andibular &ri'ary 'olar%( Re&roduced ,ith the /ind &er'i%%ion of "rof( 1( S( Cha,la, "G)MER, )ndia( Fi!. 3.25 The "ul&ecto'y TechniBue( Fi!. 3.21 -on-$ital &ul& thera&y&ri'ary tooth( ;a< 0 cariou%, but re%torable, non-$ital &ri'ary 'olar( ;b< Carie% i% eli'inated and acce%% 'ade to the &ul&( Gentle canal debride'ent i% underta/en ,ith %'all file% and irrigation( ;c< Di%infection of the canal %y%te'( 0 &ledget of cotton ,ool barely 'oi%tened ,ith leder'ix i% %ealed into the &ul& cha'ber for ?-=9 day%( ;d< The tooth i% reo&ened at a %econd $i%it, and, after irrigation and drying, a %oft 'ixture of %lo,-%etting 5inc oxide-eugenol ce'ent i% gently &ac/ed into the canal% ,ith the cotton-,ool &ledget( ;e< The &ul& cha'ber i% &ac/ed ,ith accelerated 5inc oxide-eugenol ce'ent before definiti$e re%toration of the tooth( Fi!. 3.22 ;a< "eria&ical radiogra&h %ho,ing file% &laced in the root canal% of left lo,er %econd &ri'ary 'olar( ;b< Root canal% ha$e been filled ,ith &ure 5inc oxide eugenol( Re&roduced ,ith the /ind &er'i%%ion of "rof( 1( S( Cha,la, "G)MER, )ndia( Fi!. 3.23 Radiogra&h %ho,ing the ty&ical 'or&hology of the root canal in u&&er &ri'ary inci%or%( Fi!. 3.24 Root canal filling in an u&&er &ri'ary central inci%or( 3.4 TREAT7ENT &F A C5I*D 8IT5 5I65 CARIES RATE )t i% ab%olutely true that re%toration of children*% teeth ,ithout adeBuate &re$ention i% li/e re&lacing ,indo,% in a burning hou%e( When &re%ented ,ith a child ,ith a high carie% rate, e%tabli%hing a good &re$enti$e regi'e %hould be the fir%t and fore'o%t ite' in the treat'ent &lan( 1o,e$er, it ,ould be a folly to thin/ that &re$ention alone ,ill 'aintain the child in a &ain free %tate( Re%torati$e treat'ent or extraction of decayed teeth that are not %uitable for re%toration %hould be &lanned along%ide %ecuring good &re$ention( Therefore, ,hen dealing ,ith a high carie% ri%/ child, a co'&rehen%i$e $i%it by $i%it treat'ent &lan that deal% ,ith the &re$enti$e and re%torati$e care of the child %hould be e%tabli%hed( The ty&e of treat'ent in%tituted for &atient% ,ith ra'&ant carie% de&end% on the &atient%* and &arent%* 'oti$ation to,ard% dental treat'ent, the extent of decay, and the age and co-o&eration of the child( )nitial treat'ent, including te'&orary re%toration%, diet a%%e%%'ent, oral hygiene in%truction, and ho'e and &rofe%%ional

fluoride treat'ent%, %hould be &erfor'ed before any co'&rehen%i$e re%torati$e &rogra''e co''ence%( 1o,e$er, in &atient% &re%enting ,ith acute and %e$ere %ign% and %y'&to'% of gro%% carie%, &ain, ab%ce%%, %inu%, or facial %,elling, i''ediate treat'ent i% indicated( Thi% 'ay in$ol$e extraction% and e$en a general anae%thetic in a young child( )t i% ,i%er to extract all the teeth ,ith a dubiou% &rogno%i% under one general anae%thetic rather than ha$e an accli'ati5ation &rogra''e interru&ted by a &ainful e&i%ode in the future( Table C(A %u''ari5e% the &re$enti$e regi'en% that %hould be e'&loyed for ra'&ant carie% in different age grou&%( Once ra'&ant carie% i% under control, then co'&rehen%i$e re%torati$e treat'ent can be underta/en( Thi% %hould ai' to retain the &ri'ary dentition ,ith the 'ethod% de%cribed in thi% cha&ter and in Cha&ter ?, and deli$er the child &ain free into adole%cence and adulthood( 3./0 S(77ARY =( 0 full &re$enti$e &rogra''e 'u%t be in%tituted before any definiti$e re%toration% in a child ,ith a high carie% rate( ( Re&etiti$e treat'ent %hould be a$oided and ,ith careful treat'ent &lanning and choice of re%torati$e 'aterial% long-la%ting re%toration% can be carried out in children( @( The %tainle%%-%teel 'etal cro,n i% the 'o%t durable re%toration in the &ri'ary dentition for large ca$itie% and endodontically treated teeth( A( Re%in-'odified gla%% iono'er% and &olyacid-'odified co'&o%ite re%in% 'ay ha$e an increa%ed role in the future in the re%toration of &ri'ary teeth( :( Rubber da' %hould be &laced, if at all &o%%ible, &rior to the re%toration of all teeth( !( Careful e$aluation of the %tate of &ul& infla''ation %hould be carried out before the &lace'ent of &roxi'al re%toration% in &ri'ary teeth( Where$er the &ul& i% dee'ed to be in$ol$ed, &ul& thera&y %hould be carried out &rior to the coronal re%toration( ?( 6or'ocre%ol i% li/ely to be re&laced ,ith ne,er, %afer 'edica'ent% %uch a% 6erric Sul&hate( 3.// AC>N&8*ED6E7ENTS So'e &art% of thi% text ha$e been re&roduced fro' Dental #&date, ,ith the /ind &er'i%%ion of George War'an "ublication%( 3./2 F(RT5ER READIN6 Cur5on, M( E( 7( and Robert%, 7( S( ;=>>!<( 0ennedy?s paediatric operative dentistry ;Ath edn<( Wright, 3ondon( ;" comprehensive text on the technical aspects of operative dentistry for children(<

Dental "ractice 4oard ;=>>?<( #etting standards in dental care for children( Dental "ractice 4oard, Ea%tbourne( ;"n attempt to give guidance to dentists in General Dental Practice(< Duggal, M( S(, Cur5on, M( E( 7(, 6ayle, Tou'ba, 2( 7(, and Robert%on, 0( 7( ; 99 <( )estorative techni:ues in paediatric dentistry ; nd edn<( Taylor O 6ranci%, 3ondon ;" super, colour atlas and pictorial guide(< Duggal, M( S(, Gautu', S( 2(, and -icol, R( ; 99@<( "aediatric denti%try in the ne, 'illenniu'G A( Co%t effecti$e re%torati$e techniBue% for &ri'ary 'olar%( Dental Update, 30, A=9-=:( 6aculty of Dental Surgery Clinical Effecti$ene%% Co''ittee ;=>>><( U0 national clinical guidelines in paediatric dentistry 1 #tainless steel pre<formed crowns for primary molars@ 5 (anagement of the stained fissure in the first permanent molar( Dental "ractice 4oard for England and Wale%, Ea%tbourne( ;Invalua,le clinical guidelines and aide<memories(< 6aculty of General Dental "ractitioner% ;=>>C<( #election criteria for dental radiography( 6GD" ;#2<, 3ondon( ;"n excellent guide as to when to ta%e radiographs for the diagnosis of caries in children(< 2idd, E( 0( M(, S'ith, 4( G( -( and Wat%on, T( ; 99@<( Pic%ard?s manual of operative dentistry ;Cth edn<( Oxford #ni$er%ity "re%%, Oxford( ;"n ideal reference manual for the restoration of permanent teeth(< "ater%on, R( C(, Watt%, 0(, Saunder%, W( "(, and "itt%, -( 4( ;=>>=<( (odern concepts in the diagnosis and treatment of fissure cries( Kuinte%%ence, 3ondon( ;" very practical and clear approach to the pro,lem(< Reid, 7( S(, Challi%, "( D(, and "atter%on, C( 7( W( ;=>>=<( )u,,er dam in clinical practice( Kuinte%%ence, 3ondon( ;-his guide will prove to you that you can easily use ru,,er dam(< 3./3 REFERENCES Duggal, M( S(, -ooh, 0(, and 1igh, 0( ; 99 <( Re%&on%e of the &ri'ary &ul& to infla''ationG a re$ie, of the 3eed% %tudie% and challenge% for the future( 7uropean +ournal of Paediatric Dentistry, 3, ===-=A( 1arri%, C( 0( ;=C@><( -he dental art( 0r'%trong and 4erry, 4alti'ore, MD( Mar/%, 3( 0( M(, Weerhei+', 2( 3(, and $an 0'erongen, W( E( ;=>>><( Dyract $er%u% Tylin cla%% )) re%toration% in &ri'ary 'olar%G @! 'onth% e$aluation( Caries )esearch, 33, @C?-> ( "itt%, -( 4( and 3ongbotto', C( ;=>>:<( "re$entati$e care ad$i%ed ;"C0<Do&erati$e care ad$i%ed ;OC0<-categori%ing carie% by the 'anage'ent o&tion( Community Dentistry and 8ral 7pidemiology, 23, ::->(

Welbury, R( R(, Sha,, 0( 7(, Murray, 7( 7(, Gordon, "( 1(, and McCabe, 7( 6( ; 999<( Clinical e$aluation of &aired co'&o'er and gla%% iono'er re%toration% in &ri'ary 'olar%G final re%ult% after A 'onth%( $ritish Dental +ournal, /34, >@-?( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

4. & erati.e treatment o+ dental "arie# in t%e $o-n! ermanent dentition - + " #mallridge and $ 4illiams 4./ INTR&D(CTI&N

Carie% i% %till a con%iderable &roble' in children and adole%cent%( )n the recent re&ort fro' the 99 D 99@ 40SCD Sur$ey ,hich loo/ed at dental di%ea%e le$el% in ??,!>@ =A-year-old children in England and Wale%, "itt% et al( ; 99A< found that on a$erage half of the children exa'ined had dentinal decay, ,ith a 'ean of three &er'anent teeth decayed into dentine( The fir%t &er'anent teeth eru&t into the 'outh at a&&roxi'ately ! year% of age, but 'ay a&&ear a% early a% the age of A( The eru&tion of the anterior teeth u%ually cau%e% great excite'ent, a% it i% a%%ociated ,ith *the fluttering of tooth fairy ,ing%*( 1o,e$er, the eru&tion of the fir%t &er'anent 'olar% largely goe% unnoticed until there i% a &roble'( The 'ean eru&tion ti'e for fir%t &er'anent 'olar% ha% been deter'ined a%, !(= year% in girl% and !(@ year% in boy%, but there i% a tre'endou% $ariation in both the ti'e of eru&tion and the ti'e it ta/e% for the tooth to e'erge into the 'outh( )t ta/e% = -=C 'onth% for a fir%t or %econd 'olar to eru&t fully( The fir%t &er'anent 'olar% are teeth that co''only exhibit di%ru&ted ena'elH the re&orted incidence of defect% range fro' @(!- :L( The occlu%al %urface% of the%e 'olar teeth account for about >9L of carie% in children( Re%toration of the young &er'anent dentition i% &art of a continuu' and cannot be regarded in i%olation( The re%toration i% only one %'all &art of the child*% treat'ent and i% the *%urgery* to re'o$e the cariou% infected area of the tooth and re&lace it ,ith a %uitable re%torati$e 'aterial( )t doe% nothing to cure the di%ea%e and 'u%t for' &art of a 'uch ,ider treat'ent 'odality, ,hich include% identification of the ri%/ factor% contributing to the di%ea%e follo,ed by introduction of %&ecific &re$ention counter 'ea%ure%( Effort% 'u%t be a&&lied to all of the%e area% to atte'&t to &ro$ide the o&ti'u' condition% for future tooth %ur$i$al( The%e ri%/ factor% and &re$enti$e 'ea%ure% are addre%%ed in other cha&ter%, %uch that the author% can confine the'%el$e% to a&&rai%al of 'ethod% of treat'ent of carie% in the young &er'anent dentition( They cannot ho&e to co'&letely co$er e$ery a%&ect of o&erati$e treat'ent in one cha&terH there are other text% that %hould be read to gi$e a fuller account of the a$ailable techniBue% ;%ee %ection% >(=: and >(=!<( 1o,e$er, the author% intend to gi$e an outline of %o'e of the o&tion% a$ailable( 4.2 ASSESS7ENT &F CARIES RIS> Carie% ri%/ 'u%t influence deci%ion% on ,hen to treat, ,hen to 'onitor, ,hich 'aterial to u%e, etc(H the author% ,ill re$ie, it briefly, de%&ite the fact that it ha% been di%cu%%ed in Cha&ter @( The idea of a carie% ri%/ a%%e%%'ent for each child &atient i% to en%ure that the cho%en diagno%tic te%t%, &re$enti$e treat'ent, and any &ro$ided re%toration%, are geared %&ecifically to the need of that &atient( 6actor% reBuiring con%ideration areG ;=< &re%ent carie% acti$ityH ; < &a%t carie% acti$ityH ;@< &arent D%ibling carie% acti$ityH ;A< %ugar con%u'&tionH ;:< oral hygieneH

;!< fluoride ex&o%ureH ;?< teeth 'or&hologyH ;C< #treptococcus 'utan% le$el%H ;>< %ali$a characteri%tic%, flo, rate, and con%i%tency( 6actor% ;=<-;?< ,ill beco'e clear ,hen a full hi%tory and exa'ination are carried outH ,hile ;C< and ;>< ,ill only co'e into &lay if there i% ra'&ant carie%, ,hich the denti%t cannot ex&lain fro' the hi%tory ;6ig( >(=<( Fi!. 4./ 0n exa'&le of carie% in a = -year-old girl, ,ho %uc/ed &olo% non-%to&, *! &ac/et% &er day*( 4.3 TREAT7ENT DECISI&NS 4.3.0 Introd-"tion The clinician 'u%t al,ay% gi$e con%ideration to ,hether it i% better either to treat a cariou% le%ion or re'inerali5e it( 4.3./ Im ortant oint# in relation to treatment =( Gaining acce%% to the carie% ine$itably 'ean% de%truction of %ound tooth ti%%ue( The o&erator 'u%t /ee& thi% to a 'ini'u', con%i%tent ,ith co'&lete carie% eradication( ( Once the o&erator &lace% an initial re%toration, he or %he cannot *undo* it and that tooth ,ill ine$itably reBuire further re%toration in it% lifeti'e( @( E$ery ti'e an o&erator &lace% a re%toration, he or %he de%troy% 'ore of the original tooth %tructure, thereby ,ea/ening the tooth( A( E$en though the occlu%ion in a young &er%on change% a% gro,th occur% and teeth eru&t, it i% i'&ortant to reali5e, that ,hen the o&erator &lace% re%toration%, he or %he 'u%t re&licate the original occlu%al contact% in the tooth( 0lthough, it 'ay be te'&ting to /ee& the re%toration totally out of the occlu%ion, teeth ,ill 'o$e bac/ into the occlu%ion, ,hich ,ill thereafter be %lightly different and the cu'ulati$e effect of a lot of little change% can %e$erely di%ru&t the occlu%ion in the long ter'( :( When treating an a&&roxi'al le%ion on one tooth ,ith an ad+acent neighbour, the o&erator ,ill al'o%t certainly da'age the latter( The i'&ortant %urface layer of the neighbouring tooth, ,hich contain% the highe%t le$el of fluoride i% the 'o%t re%i%tant, %o da'age inflicted increa%e% the chance% of the ad+acent %urface of the neighbouring tooth beco'ing cariou%( )t al%o create% an area of roughne%% on that %urface, ,hich in turn ,ill accu'ulate 'ore &laBue, thereby increa%ing the ri%/ of further decalcification( !( When &lacing an inter&roxi'al re%toration it i% ine$itable that there i% %o'e da'age to the &eriodontal ti%%ue%( There i% the tran%ient da'age cau%ed by &lace'ent of the 'atrix band and ,edge, and there i% al%o an enduring effect cau%ed by the &re%ence of the re%toration 'argin( The $ery &re%ence of the ne, re%toration re%ult% in a contour change of the inter%titial %&ace( 1o,e$er %'ooth the o&erator atte'&t% to 'a/e it, the

altered %tate ,ill increa%e &laBue accu'ulation( >e$ Point E$ery ti'e a re%toration i% &laced, 'ore of the original tooth %tructure ,ill be de%troyed, thereby ,ea/ening the tooth( 4.3.2 Im ortant oint# in relation to reminerali:ation =( Early %'ooth %urface le%ion% are re$er%ible in the right condition%( ( There i% little e$idence to %ugge%t that re'inerali5ation occur% in le%ion% already into dentine( @( The rate of carie% &rogre%%ion i% u%ually %lo, but can be ra&id in %o'e indi$idual%, &articularly younger children( )n general, the older the child i% at diagno%i% of a cariou% le%ion the %lo,er the &rogre%% of the le%ion, a%%u'ing con%tancy of other ri%/ factor%( A( The re'inerali5ed ti%%ue of early carie% i% le%% %u%ce&tible to further carie%( :( S'all re%toration% are generally 'ore %ucce%%ful than large, %o a balance ha% to be %truc/, allo,ing &re$enti$e &rocedure% adeBuate ti'e to function, again%t the ri%/ of le%ion enlarge'ent( The &rogre%%ion rate of a&&roxi'al carie% can $ary fro' tooth to tooth ,ithin the %a'e 'outh( )t i% thought that if the circu'%tance% for re'inerali5ation are fa$ourable, clinician% %hould u%e the 'odality, a% o&&o%ed to a re%toration that ha% a finite but li'ited life%&an ;6ig%( >( and >(@<( Re'inerali5ation %ource% a$ailable areG fluoride rin%e, fluoride $arni%h, chlorhexidine thy'ol $arni%h, oral hygiene 'ea%ure%, ad+acent gla%% iono'er re%toration%( Deter'ination of the 'o%t effecti$e 'ethod to retard the &rogre%%ion of a&&roxi'al carie% reBuire% not only identification of the 'o%t effecti$e re'inerali5ing agent but al%o the freBuency ,ith ,hich to e'&loy it( >e$ Point The re'inerali5ed ti%%ue of early carie% i% le%% %u%ce&tible to further carie%( Exi%ting %tudie% indicate that fluoride $arni%he%, %olution%, and tooth&a%te% all &ro$ide a %ignificant effect on the &rogre%%ion of a&&roxi'al carie% in &er'anent 'olar% ,hen a%%e%%ed radiogra&hically( 1o,e$er, 'o%t of the%e %tudie% ,ere of li'ited duration ;@ year%<( )t ,ould be intere%ting to /no, ,hat ha&&ened after the co'&letion of the %tudie% and &o%e% the follo,ing Bue%tion%G

 Would the le%ion% ha$e de$elo&ed to the re%torati$e %tageJ What i% an acce&table freBuency to 'onitor the le%ion% radiogra&hically if thi% i% the only acce&table ,ay of deter'ining &rogre%%J )% the co%t of re'inerali5ation thera&y le%% than re%torati$e treat'ent, &articularly if it entail% 'ulti&le attendance% of the &atientJ "rogre%% of carie% through the ena'el %ee'% to be fairly %lo, but once the dentine i% reached it accelerate%( So a% a rule of thu'b, re%tore a&&roxi'al %urface% once the le%ion reache% the ena'elDdentine interface( Fi!. 4.2 0 bite,ing radiogra&h of a =@-year-old boy %ho,ing early carie% u&&er right fir%t &er'anent &re'olar and 'olar, and both lo,er 'olar%( Fi!. 4.3 The %a'e boy, =C 'onth% later, %ho,ing ra&id &rogre%% of carie% in the u&&er fir%t &re'olar, 'olar, and the lo,er %econd 'olar, ,ith little or no change in the lo,er %econd &re'olar and fir%t 'olar( 4.0 DIA6N&SIS While 'o%t denti%t% ,ould agree that a&&roxi'al carie% i% be%t diagno%ed fro' bite,ing radiogra&h%, detection of occlu%al carie% i% 'uch 'ore difficult( Where there i% no o$ert or o&en ca$ity, diagno%ing the %tatu% of a di%coloured or %tained fi%%ure can be incredibly difficult if not i'&o%%ible on occa%ion%( Many 'ethod% ha$e been &ro&o%ed, both alone and in co'bination( The%e includeG $i%ual 'ethod% ;dry tooth<H &robeDex&lorerH bite,ing radiogra&h%H electronicH fibre o&tic tran%illu'inationH la%er diagno%i%( When t,o or three 'ethod% are u%ed in co'bination, there i% greater accuracy and higher rate% of detection of carie%( The 'o%t ,idely u%ed co'bination i% $i%ual in%&ection under a good light, to exa'ine a dry tooth for %tain%, o&acitie%, etc(, along ,ith a good Buality bite,ing radiogra&h( Drying the tooth to be exa'ined i% e%%ential a% early le%ion% ,ill only beco'e $i%ible, ,here the de'inerali5ation i% 'ini'al, ,hen there i% a dry %urface( Different reco''endation% are 'ade for the ti'ing of bite,ing radiogra&h% and the%e are di%cu%%ed in Cha&ter @( 4ite,ing radiogra&h% ,ill %ho, dentinal carie% in teeth that are de%ignated a% clinically %ound but there ,ill al%o be teeth $i%ually de%ignated a% cariou% in ,hich there are no radiological %ign% of carie%, hence the need for 'ore than one 'ethod of diagno%i%( )n 'a/ing a diagno%i% of carie%, the o&erator ha% to decide, not only that there i% a le%ion &re%ent but al%oG Whether or not de'inerali5ation i% &re%ent( The de&th of the le%ion(

 The rate of &rogre%%ion of the le%ion( Whether it i% an arre%ted or acti$e le%ion( )t ,ould be nice to ha$e a 'ethod of Buantifying the%e factor%( Mea%ure'ent% of electrical conductance and la%er fluore%cence ha$e the &otential to chart le%ion &rogre%%ionDretardation a% they &ro$ide a Buantitati$e record, ,hich if re&eated o$er %e$eral a&&oint'ent% ,ill de'on%trate ,hether the le%ion i% acti$e or arre%ting( They can be re&eated %afely 'ore freBuently than radiogra&h%( 1o,e$er, it %hould be re'e'bered that the electrical conductance and la%er fluore%cence 'ethod% ,ould incorrectly inter&ret hy&o'inerali5ation a% carie% and that %i'ilarly the la%er-ba%ed in%tru'ent ,ill routinely inter&ret %taining to be carie%( >e$ Point Diagno%i% of early carie% i% i'&ortant to be able to &lan the ,hole treat'ent &ac/age( 4.5 FISS(RE SEA*IN6 4.5.0 Introd-"tion 6i%%ure %ealant% cannot be di%cu%%ed in i%olation fro' carie% diagno%i% or treat'ent of &it and fi%%ure carie%( The author% di%cu%% u%e of the%e 'aterial% both &re$enti$ely and thera&eutically( Toothbru%h bri%tle% cannot acce%% the &it and fi%%ure %y%te' becau%e the di'en%ion% of the fi%%ure% are too %'all( 0% a re%ult 'icro-organi%'% re'ain undi%turbed ,ithin the fi%%ure %y%te'( The tooth i% 'o%t %u%ce&tible to &laBue %tagnation during eru&tion, that i%, a &eriod of bet,een = and =C 'onth%( During thi% ti'e, children need extra &arental hel& in 'aintaining their oral hygiene( 3e%ion for'ation ta/e% &lace in the &laBue %tagnation area at the entrance to the fi%%ure and co''ence% ,ith %ub%urface de'inerali5ation( De'inerali5ed ena'el i% 'ore &orou% than %ound ena'el( The 'ore de'inerali5ed and &orou% the affected ena'el, the 'ore it %ho,% u& both clinically and on radiogra&h%( >e$ Point To detect the earlie%t ,hite %&ot% the tooth 'u%t be dried to render the' 'ore ob$iou%( Once the initial le%ion ha% de$elo&ed, carie% 'ay %&read laterally %uch that a %'all %urface le%ion 'ay hide a 'uch greater area of de%truction belo, the %urface ;6ig%( >(A and >(:<( Re'inerali5ation of occlu%al le%ion% i% 'uch 'ore difficult to achie$e( 6i%%ure %ealing, ! 'onthly ( !L fluoride $arni%h a&&lication ,ith oral hygiene in%truction, and a ,ee/ly 9( L %odiu' fluoride rin%e, ha$e all been found to hel& %tabili5e the di%ea%e and retard the &rogre%% of occlu%al carie%, but the fi%%ure %ealing grou& exhibited the be%t effecti$ene%%( Many %tudie% ha$e %ho,n that generally a% the carie% rate% decline, the &ro&ortion of carie% that affect% &it% and fi%%ure% of 'olar teeth increa%e%, and al%o that the carie% a&&ear% to be concentrated in a %'aller cohort of children'o%t of the decay occur% in :L of the child &o&ulation( Thi% &redilection ha% 'eant that correct u%e of fi%%ure %ealant% %hould ha$e a 'axi'al effect(

There i% no di%&ute that ,hen correctly a&&lied and 'onitored, fi%%ure %ealant% are highly effecti$e at &re$enting dental carie% in &it% and fi%%ure%, but inter&retation of the correct a&&lication and 'onitoring reBuire% %crutiny( >e$ Point 6i%%ure %ealant% reduce carie% incidence but 'u%t be carefully 'onitored and 'aintained( Fi!. 4.0 1idden carie%although the occlu%al %urface loo/% 'o%tly intact it hide% exten%i$e carie%( Fi!. 4.5 Carie% ha% been re'o$ed( The %i5e of the ca$ity e'&ha%i5e% the extent of the le%ion( 4.5./ 8%o Cill ,ene+itk -ot e$ery fi%%ure ,ill beco'e cariou% if it i% not %ealed( Therefore, each tooth for each child 'u%t be a%%e%%ed on it% o,n 'erit%( The clinician 'u%t a%%e%% the ri%/ factor% for that tooth de$elo&ing &it or fi%%ure carie%( 0% a general guide to ,ho ,ill benefit, re$ie, the 4riti%h Society for "aediatric Denti%try "olicy Docu'ent ;-unn et al(, 999<( The 'ain beneficiarie% areG =( Children and young &eo&le ,ith 'edical, intellectual, &hy%ical, and %en%ory i'&air'ent%, %uch that their general health ,ould be +eo&ardi5ed by either the de$elo&'ent of oral di%ea%e or the need for dental treat'ent( )n %uch children all %u%ce&tible %ite% in both the &ri'ary and &er'anent dentition% %hould recei$e con%ideration( ( 0ll %u%ce&tible %ite% on &er'anent teeth %hould be %ealed in children and young &eo&le ,ith carie% in their &ri'ary teeth ;d'f% M or 'ore<( @( Where occlu%al carie% affect% one &er'anent 'olar, the o&erator %hould %eal the occlu%al %urface% of all the other 'olar%( A( )f the anato'y of the tooth i% %uch that %urface% are dee&ly fi%%ured, then the%e %hould be %ealed( :( Where &otential ri%/ factor%, %uch a% dietary factor% or oral hygiene factor%, indicate a high ri%/ of carie%, then all %ite% at ri%/ %hould be %ealed( !( Where there i% a doubt about the carie% %tatu% of a fi%%ure or it i% /no,n to ha$e carie% confined to the ena'el, fi%%ure %ealant% 'ay be u%ed thera&eutically( 0fter a&&lication, it i% e%%ential to 'onitor the %urface both clinically and radiologically( Sealant u%e 'u%t be ba%ed on &er%onal, tooth, and %urface ri%/, and the clinician 'u%t a%%e%% the%e ri%/% %ince it 'ight change at any ti'e in the life of the &atient( So ,herea% it ,a% traditionally %tated that denti%t% %hould co'&lete %ealant a&&lication u& to a year or t,o after eru&tion, he or %he %hould a%%e%% the &otential ri%/ factor%

regularly, and &lace the %ealant, ,hen indicated irre%&ecti$e of age( 6ailure rate% are higher ,hen %ealant% are &laced on ne,ly eru&ted teeth and in 'outh% ,ith higher &re$iou% carie% ex&erience( Monitoring the integrity of %ealant i% $ital in tho%e circu'%tance% and any deficiencie% in a %ealant %hould be corrected ;6ig%( >(! and >(?<( Fi!. 4.1 Thi% tooth ,hich i% too early to %eal ,ith re%in, %hould be &ainted ,ith fluoride $arni%h or if the carie% ri%/ i% $ery high %hould be %ealed ,ith gla%% iono'er until further eru&tion ha% ta/en &lace( Fi!. 4.2 Thi% 'olar i% +u%t at the correct %tage to a&&ly fi%%ure %ealant( The $ery %'all o&erculu' of gingi$al ti%%ue can be held a,ay fro' the tooth gently ,ith a flat &la%tic( 4.5.2 Clini"al te"%niA-e Pretreatment rior to #ealant a li"ation

Tooth &re&aration ,ith &u'ice and a rotary bru%h re%ult% in a good clinical retention rate( Dry bru%hing achie$e% %i'ilar re%ult%( 0ir &oli%hing, u%ing a *"ro&hy-7et*, an early air abra%ion %y%te' that u%e% %odiu' bicarbonate &article% a% the abra%i$e 'ediu', &ro$ide% good bond %trength and %ealant &enetration but ha% not recei$ed general acce&tance, &robably, becau%e 'o%t dental %urgerie% do not &o%%e%% thi% eBui&'ent( So'e re%earcher% ha$e ad$ocated the u%e of *Ena'elo&la%ty*, a 'ore aggre%%i$e inter$ention into the tooth, that i%, 'echanical enlarge'ent of the fi%%ure% ,ith a bur or ,ith air abra%ion, to i'&ro$e %ealant &enetration and reduce 'icro-lea/age( 0lthough %o'e %tudie% ha$e confir'ed the%e clai'%, the author% feel that thi% i% an unnece%%ary extra &rocedure to %ub+ect the child to, and do not reco''end it( Et"%in! 0ll the 'ethod% of cleaning the tooth, di%cu%%ed abo$e, %hould be acco'&anied ,ith etching of the ena'el %urface( Etching for +u%t 9 % ,ith a range of concentration% of acid but 'o%t often, @:-@?(:L &ho%&horic acid i% the tried and te%ted 'ethod( )t% one dra,bac/ i% the %u%ce&tibility of the etched %urface to %ali$a or 'oi%ture conta'ination, ,hich reduce% the bond %trength( Sali$ary conta'ination re%ult% in %ignificantly reduced bond %trength% unle%% re'o$ed by thorough ,a%hing( Re-etching of the %urface i% u%ually nece%%ary if %ali$ary conta'ination ha% occurred( ;ondin! a!ent# 4onding agent% u%ed a% an additional layer under a re%in %ealant yield bond %trength% %ignificantly greater than the bond %trength obtained ,hen u%ing %ealant alone( )nitial re%ult% of clinical trial% al%o %ho, increa%ed retention of the %ealant ,hen an inter'ediate bond i% u%ed( -e, bonding techniBue% are &ro$ing to be le%% techniBue %en%iti$e, ,ith re%&ect to 'oi%ture control than er%t,hile &rocedure%( The u%e of a bonding agent under a %ealant on ,et conta'inated %urface% yield% bond %trength% eBui$alent to the bond %trength obtained ,hen %ealant i% bonded directly to

clean etched ena'el ,ithout conta'ination( Mo%t of the data on the %ub+ect of u%ing a bonding agent a% &art of the %ealant &rocedure %u&&ort% it% u%e( #%e of a bonding agent ,ould tend to increa%e the ti'e and co%t of the %ealant a&&lication but in ca%e% ,here 'aintaining a dry %urface i% difficult or ,here there are area% of hy&o'inerali5ation on the %urface, it ,ould ha$e 'any ad$antage%( 3ogically, co'bination of the%e technologie% to achie$e better &enetration ,ith le%% %te&% in the a&&lication %eBuence ,ould be beneficial and there i% %o'e e$idence already in the u%e of %elf-etching &ri'er-adhe%i$e %y%te'%( 0% yet, there ha% only been a -year follo,-u& but the early re%ult% are &ro'i%ing in relation to retention( Other %tudie% ha$e %ho,n that there are concern% about 'icro-lea/age co'&ared ,ith con$entional acid etching( The big bonu% of the %elf-etching &ri'er-adhe%i$e %y%te' i% the %&eed ,ith ,hich the o&erator can a&&ly it( )n the a&&lication &rocedure for the "ro'&t-3-"o& %y%te', the o&erator bru%he% the %elf-etching adhe%i$e on to the %urfaceH air thin% it, and follo,% thi% by i''ediate &lace'ent of the %ealant and &oly'eri5ation( )n the %tudy, the a$erage ti'e o&erator% too/ for the &rocedure ,a% =(C 'in co'&ared ,ith @(= 'in for con$entional techniBue( Such ti'e %a$ing i% $ery u%eful in young fidgety children( 0t &re%ent, therefore, there are conflicting $ie,% on the%e %y%te'% but ,ith technology 'o$ing e$er on,ard% it doe% %ee' li/ely that in the future it %hould be &o%%ible to achie$e good etching and bonding ,ith a %i'&ler a&&lication 'ethod( Mo%t clinician% ,ill e'&loy a re%in-ba%ed %ealant, becau%e they ha$e a good trac/ record( Many clinical trial% ha$e de'on%trated the effecti$ene%% of re%in %ealant% and there are %e$eral long-ter' %tudie%, ,hich %ho, the benefit%( 6ifteen year% after a %ingle a&&lication, re%in %ealant% ha$e %ho,n CL co'&lete retention of %ealant% and @:L &artial retention on fir%t &er'anent 'olar%( Where re%earcher% re-a&&lied %ealant to tho%e %urface% that had deficient %ealant a% deter'ined by yearly exa'%, !:L co'&lete retention ,a% obtained and only =@L of the %urface% had carie% or re%toration% after 9 year%( Retreatment Sealant% &laced in the fir%t &er'anent 'olar% in children of age% !, ?, and C and in %econd &er'anent 'olar% in children of age% == and = reBuired 'ore re-a&&lication than tho%e &laced in older teeth( )f the clinician &lace% fi%%ure %ealant in ne,ly eru&ted teeth it i% 'ore li/ely to fail, but %hould %till be &laced a% early a% &o%%ible, becau%e the teeth are 'ore $ulnerable to carie% at thi% ti'e( Modifying the re%in to incor&orate fluoride i% a logical rationale( 1o,e$er, fluoride relea%e occur% only for a $ery %hort ti'e and at a $ery lo, le$el( Many %tudie% o$er @-year &eriod% ha$e re&orted good retention but ,ith a %i'ilar carie% incidence to con$entional %ealant( Since the addition of fluoride to %ealant re%in doe% not ha$e any detri'ental effect it could certainly be u%ed, but until the che'i%try can be ada&ted to readily unloc/ the fluoride, the anti-cariogenicity cannot be attributed to the fluoride( Greater relea%e of fluoride can be achie$ed u%ing gla%% iono'er ;&oly-al/enoate<( Such ce'ent% ha$e high le$el% of fluoride a$ailable for relea%e but they %uffer fro' the dra,bac/ of &oor retention( E$en ,ith the $ery &oor retention rate%, %ealing ,ith gla%% iono'er doe% %ee' to infer %o'e carie% &rotecti$e effect( Thi% 'ay be due to

both the fluoride relea%ed by the gla%% iono'er and re%idual 'aterial retained in the botto' of the fi%%ure, in$i%ible to the na/ed eye( 1ence, gla%% iono'er%, u%ed a% %ealant% can be cla%%ed a% a fi%%ure %ealant but 'ore reali%tically a% a fluoride de&ot 'aterial( They can be u%efully e'&loyed to %eal &artially eru&ted 'olar% in high ri%/ children %ince eru&tion of the 'olar% ta/e% = -=C 'onth% and during thi% ti'e they are often $ery difficult to clean( Once the teeth are %ufficiently eru&ted the o&erator 'ay &lace a re%in %ealant( They are al%o u%eful in children ,here there are difficultie% ,ith the le$el of co-o&eration, a% the techniBue doe% not de&end on ab%olute 'oi%ture control( 3ogically, i'&ro$e'ent in gla%% iono'er technology ha% occurred and both re%in'odified gla%% iono'er% ;RMG)< and co'&o'er% ha$e been u%ed a% %ealant%( 0% yet, %tudie% of the%e 'aterial% u%ed a% fi%%ure %ealant% ,hile a$ailable, %ho, no i'&ro$e'ent o$er re%in-ba%ed %ealant% and %o there i% nothing to reco''end the' in &reference to re%in%( Filled or -n+illed re#in#k Retention i% better for unfilled re%in% &robably becau%e it &enetrate% into the fi%%ure% 'ore co'&letely( )t al%o doe% not need occlu%al ad+u%t'ent a% it abrade% $ery ra&idly( )f a filled re%in i% not ad+u%ted there i% a &erce&tible occlu%al change, &o%%ible di%co'fort, and ,ear of the o&&o%ing antagoni%t tooth( Colo-red or "lear materialk O&aBue %ealant% ha$e the ad$antage of high $i%ibility at recall( )t ha% been found that identification error for o&aBue re%in ,a% only =L ,hile for clear re%in the corre%&onding figure ,a% @L ,ith the 'o%t co''on error being fal%e identification of the &re%ence of clear re%in on an untreated tooth( The di%ad$antage of o&aBue %ealant i% that the denti%t cannot exa'ine the fi%%ure $i%ually at future recall% ;6ig%( >(C and >(><( The choice of an o&aBue $er%u% a clear %ealant i% u%ually one of &er%onal choice( Sa+et$ i##-e# There ha% only been one re&ort of an allergy to the re%in u%ed for &it and fi%%ure %ealing and concern ha% been rai%ed about the oe%trogenicity of re%in-ba%ed co'&o%ite%( The &ro&o%ed cul&rit, bi%-&henol 0 ;4"0<, i% not a direct ingredient of fi%%ure %ealant%, but i% a che'ical that a&&ear% in the final &roduct ,hen the ra, 'aterial% fail to fully react( The a'ount relea%ed orally i% undetectable in the %y%te'ic circulation and concern% about &otential oe%trogenicity are &robably unfounded( Sealant ,-l= in relation to a li"ation

)t i% i'&ortant to re'e'ber that the %ealant 'u%t be /e&t to a 'ini'u', con%i%tent ,ith the co$erage of the co'&lete fi%%ure %y%te' including buccal and lingual &it%( O$erfilling can lead to reduction in retention and increa%ed 'icro-lea/age( Sealant monitorin!

Once the %ealant ha% been &laced the o&erator 'u%t 'onitor it at recall a&&oint'ent% and re&air or re&leni%h a% nece%%ary( Teeth lo%e i% bet,een :L and =9L of %ealant $olu'e &er year( "artial lo%% of re%in %ealant allo,% ingre%% of bacteria into the fi%%ure %y%te'( Thi% lea$e% that %urface eBually at ri%/ fro' carie% co'&ared to an un%ealed %urface( Co#t-e++e"ti.ene## Co%t-effecti$ene%% ,ill de&end on the carie% rate for the children in the &o&ulation( Where there i% a higher carie% rate, generali5ed %ealing ,ill &rotect 'ore %urface% that ,ould ha$e beco'e cariou% in the future( 1o,e$er, if the carie% rate i% $ery high, then the ri%/ of de$elo&ing inter&roxi'al le%ion% i% al%o higher and 'ay lead to a t,o %urface re%toration e$en ,hen the fi%%ure %ealed %urface% re'ain carie% free( )n lo, carie% area%, the co%t-effecti$ene%% of %ealant a&&lication en masse i% Bue%tionable and the denti%t %hould a%%e%% each child*% indi$idual ri%/ factor%( )n contra%t to thi% general conce&t, one %tudy ha% %ho,n that it i% =(! ti'e% a% co%tly to re%tore the cariou% le%ion% in the fir%t &er'anent 'olar% in an un%ealed grou& of :-=9-year-old children li$ing in a fluoridated area than it i% to &re$ent the' ,ith a %ingle a&&lication of &it and fi%%ure %ealant( Thi% %tudy al%o re$ealed a greater nu'ber of le%ion% if %ealant ,a% not utili5ed( Sealin! o.er "arie# Once carie% ha% been diagno%ed it i% i'&ortant to deter'ine it% extent( )f there i% clear uneBui$ocal e$idence that the le%ion doe% not extend beyond the ena'el, then the %urface 'ay be %ealed and 'onitored both clinically and radiologically( )f the le%ion extend% into the dentine, the denti%t ,ould nor'ally &lace either a &re$enti$e re%in re%toration ;"RR<, or if in an area of occlu%al load, a con$entional re%toration( 1o,e$er, %e$eral author% ha$e %ho,n that dentinal cariou% le%ion% do not &rogre%% under intact %ealant%( -e$erthele%%, if the %ealant ,ere to fail i''ediately or %hortly after a&&lication, then the le%ion ,ould ha$e A-! 'onth% to &rogre%% before the next re$ie,( We do not ad$ocate %ealing o$er carie% exce&t in $ery exce&tional circu'%tance%, that i%, $ery ner$ou% children ,ho cannot co&e ,ith e$en 'ini'al inter$ention denti%try( Fi!. 4.3 White fi%%ure %ealant% can ea%ily be chec/ at recall, they are al%o $i%ible to %ho, the &atient and &arent to hel& the' under%tand the &rocedure( Fi!. 4.4 Clear fi%%ure %ealant i% le%% ea%y to %ee though it% &re%ence can be chec/ed, if an area i% gi$ing cau%e for concern, by etching( 4.1 R(;;ER DA7 0lthough often &ercei$ed a% difficult to a&&ly on children, the u%e of rubber da' create% a better ,or/ing en$iron'ent for both the denti%t and the child( Once the techniBue i% 'a%tered it can be a&&lied both Buic/ly and ,ith 'ini'al di%co'fort( The ad$antage% of the rubber da' areG =( )t &rotect% the %oft ti%%ue% ;tongue, chee/%, and gingi$ae< fro' da'age fro' in%tru'ent% or 'edica'ent%(

( )t reduce% the ri%/ of %,allo,ing and inhalation of in%tru'ent%, and &article% and debri%( @( )t 'a/e% the %ali$ary aero%ol &roduced by high %&eed rotary in%tru'ent% ea%ier to control thereby reducing the ri%/ of infection to the dental %taff( A( )f u%ed ,ith inhalation %edation it ,ill reduce the a'ount of 'outh breathing thereby allo,ing le%% nitrou% oxide to be u%ed and thu% reducing the ga% le$el in the general en$iron'ent of the dental %urgery( :( )t often 'a/e% the child feel i%olated fro' the treat'ent, thu% hel&ing the child to feel 'ore relaxed and able to co&e( !( )t &ro$ide% the be%t &o%%ible dry fieldH for 'aterial% ,here 'oi%ture control i% e%%ential it% u%e i% i'&erati$e ;6ig( >(=9<( Other text% gi$e full detail% of the $ariou% a&&lication techniBue% of the rubber da'( )t 'u%t be re'e'bered that good analge%ia i% $ery i'&ortant, a% &lace'ent of rubber da' &articularly ,hen a cla'& i% u%ed i% &ainful( 0n infiltration bac/ed u& by intra&a&illary in+ection% i% u%ually needed( Fi!. 4./0 Rubber da' in &lace &rotecting gingi$ae and eli'inating 'oi%ture( 4.2 ANTERI&R CARIES Carie% of &er'anent anterior teeth in childhood and adole%cence, i% not that co''on and u%ually occur% either ,here there i% defect in the for'ation of the teeth, ,hich lead% to &laBue accu'ulation, or in children ,ith ra'&ant carie%, ,here the %ugar inta/e i% %o high that the dentition i% o$er,hel'ed( The be%t 'aterial for re%toring anterior teeth i% co'&o%ite re%in( The u%e of thi% 'aterial in the treat'ent of &atient% affected by either trau'a or a% a %olution for co%'etic &roble'% i% de%cribed in Cha&ter% =9 and = ( )n &atient% %uffering *nor'al* carie%, ,ith inter&roxi'al ca$itie%, co'&o%ite re%toration i% the 'aterial of choice( )n &atient% ,ith ra'&ant carie% it 'ay be &referable to u%e gla%% iono'er to re%tore the le%ion% a% an interi' 'ea%ure ,hile the ri%/ factor% are addre%%ed( 4.3 &CC*(SA* CARIES 4.3.0 Introd-"tion Where the denti%t ha% e%tabli%hed a diagno%i% that a %tained fi%%ure i% a cariou% le%ion into dentine, re%torati$e treat'ent i% indicated( )f the le%ion i% li'ited to area% of the tooth not bearing occlu%al load% then a "RR i% a&&ro&riate ;S'allridge et al(, 999<( )f the le%ion i% 'ore exten%i$e, then the clinician %hould con%ider a co'&o%ite or an a'alga' re%toration(

4.3./ T%e re.enti.e re#in re#toration Clini"al te"%niA-e =( 0d'ini%ter local analge%ia, after a&&lication of to&ical anae%thetic &a%te at the in+ection %ite( ( "lace rubber da'( @( Ex&lore the %u%&ect area of the fi%%ure %y%te' ,ith a high %&eed %'all bur, re'o$ing only enough ena'el to gain acce%% to the carie%( The acce%% 'u%t by ,ide enough to en%ure that the o&erator can re'o$e carie% fro' the &eri&heral ti%%ue( )f the radiogra&h% %ho, dentinal carie%, e$en if the ena'el %ee'% intact, acce%% 'u%t &rogre%% into dentine( #nder'ined ena'el can be left in situ a% the bi%-GM0 re%in re%toration $irtually re%tore% the original %trength of the tooth( A( 3ine the ca$ity ,ith calciu' hydroxide( There i% %o'e debate a% to ,hether it i% nece%%ary to line the%e ca$itie%( So'e %tudie% re&ort no &ul&al &roble'% in teeth ,here the o&erator ha% directly etched and bonded the dentine( :( Etch( "reci%e detail% are de&endent on the cho%en *re%torati$e* %y%te' for %te&% ;:<;C< and the 'anufacturer% in%truction% 'u%t be follo,ed( !( Wa%h( ?( Dry( C( 4ond( >( "lace the cho%en co'&o%ite in the ca$ity( )n %'aller ca$itie% gla%% iono'er ce'ent i% an alternati$e( =9( Seal all the re'aining fi%%ure %y%te' ,ith fi%%ure %ealant( ==( Chec/ the occlu%ion( = ( Re$ie, the integrity of the %ealant at the routine recall a&&oint'ent%( )f the $i%ual a&&earance i% inconclu%i$e, re-etch the %urface to identify %ealant retention( The techniBue i% %ho,n in 6ig%( >(==, >(= , >(=@, >(=A, >(=:, >(=!, >(=?, >(=C, >(=>, and >( 9( Where the diagno%tic 'ethod% are inconclu%i$e, the clinician %hould ex&lore the fi%%ure to $alidate carie% free %tatu% or eradicate occult carie%( De&ending on the extent of any le%ion, re%toration by fi%%ure %ealing or co'&o%ite co'&lete% the &rocedure( Fi!. 4.// #nre%tored cariou% fir%t 'olar( Carie% identified in 'e%ial fo%%a on radiogra&h( Fi!. 4./2 Ca$ity &re&aration co''enced after local analge%ia and a&&lication of rubber da'( 0cce%% and outline for' %hould only be of a %i5e that enable%

re'o$al of carie%( Fi!. 4./3 Tooth re%tored ,ith gla%% iono'er( Fi!. 4./0 Re%toration co$ered ,ith fi%%ure %ealant( Fi!. 4./5 Rubber da' re'o$ed and occlu%ion chec/ed( Fi!. 4./1 The %a'e &rinci&le% can a&&ly ,ith a %lightly larger le%ion( Fi!. 4./2 #nder'ined ena'el can be left a% long a% the o&erator can reach all the carie%( Fi!. 4./3 "lace a calciu' hydroxide lining in the dee& &art% of the ca$ity( Fi!. 4./4 0fter etching and bonding, &lace co'&o%ite re%in incre'entally( Fi!. 4.20 6ini%h the re%toration ,ith fi%%ure %ealing( 4.3.2 &""l-#al re#toration# in $o-n! ermanent teet% )f carie% affect% 'o%t of the occlu%al fi%%ure %y%te', the clinician %hould &lace a cla%%ical cla%% ) re%toration( The choice of 'aterial for thi% re%toration i% de&endent on the o&erator and a&&ro&riately infor'ed &arent( The &lethora of a$ailable tooth coloured 'aterial% together ,ith the continuing de$elo&'ent and introduction of ne, 'aterial% 'a/e% choice both exten%i$e and difficult( Sil.er amal!am Sil$er a'alga' i% the %tandard 'aterial again%t ,hich the %ucce%% of alternati$e 'aterial% i% often +udged ;Rugg-Gunn et al(, 999<( 0'alga' ha% a /no,n trac/ record( Denti%t% ha$e u%ed it for re%toring teeth for 'ore than =:9 year%( When loo/ing at the literature it 'u%t be re'e'bered that a'alga' technology ha% e$ol$ed o$er a $ery long &eriod and tho%e a'alga' alloy% a$ailable today are &robably $ery different in co'&o%ition to tho%e u%ed e$en a% recently a% =: year% ago( 8ariou% %tudie% ha$e co'&ared a'alga' ,ith co'&o%ite re%in( One %uch %tudy found no %ignificant difference% bet,een the', ,hen the 'aterial% ,ere u%ed in %'all occlu%al %ituation%( 0'alga' ha% 'any u%eful &ro&ertie%G =( )t i% ea%y to handle( ( 1a% good durability( @( 1a% relati$ely lo, co%t( A( )t exhibit% reducing 'icro-lea/age ,ith ti'e ;high co&&er a'alga'% can ta/e u& to year% for a 'arginal %eal to be &roduced, double the ti'e for lo, co&&er a'alga'%, but high co&&er a'alga'% are not a% %u%ce&tible to corro%ion &heno'ena and re%ulting &oro%ity and therefore retain their %trength(<

:( )t i% le%% techniBue %en%iti$e co'&ared ,ith other re%torati$e 'aterial%( )t i% %till i'&ortant to control 'oi%ture a% exce%% 'oi%ture cau%e% delayed ex&an%ion &articularly in 5inc-containing alloy%, and for thi% rea%on rubber da' %hould al,ay% be u%ed if &o%%ible( De%&ite the%e good &ro&ertie%, a'alga' ha% t,o 'ain di%ad$antage% ;=< it i% not ae%thetic and ; < it contain% 'ercury, a /no,n &oi%on( 3ittle can be done to co'bat the &oor ae%thetic%( Re'e'bering to &oli%h a'alga'% doe% i'&ro$e characteri%tic%, including a&&earance and lead% to a %ignificant reduction in their re&lace'ent( Clinician% concerned about the toxicity of %il$er a'alga' %ee/ re-a%%urance on the continuing u%e of the alloy( There are four 'ain area% of concernG ;=< )nhalation of 'ercury $a&our or a'alga' du%tH ; < The inge%tion of a'alga'H ;@< 0llergy to 'ercuryH ;A< En$iron'ental con%ideration%( )nhalation of a'alga' du%t i% 'o%t li/ely to occur during re'o$al of a &re$iou% re%toration( Thi% effect i% tran%ient and the effect% 'ini'i5ed, if the o&erator u%e% rubber da' and high %&eed a%&iration( )t i% not in di%&ute that 'ercury i% relea%ed fro' a'alga' re%toration%, during &lace'ent, &oli%hing, che,ing, and re'o$al, but the a'ount% are $ery %'all and co'e no,here near the a'ount% inge%ted fro' other daily %ource%, for exa'&le, air, ,ater, and diet( True allergy to a'alga' i% rare( There ha$e been only :9 ca%e% re&orted in =99 year%( Many countrie% are trying to reduce all indu%trial u%e% of 'ercury for en$iron'ental rea%on% and better 'ercury hygiene in dental &ractice i% one of the area% targeted( )n %'all occlu%al re%toration% the only difference needed in the tooth &re&aration bet,een co'&o%ite and a'alga' i% that ,hen an a'alga' i% to be &laced, under'ined ena'el 'u%t be re'o$ed( )n both ca%e% a re%in %ealant 'aterial %hould be &laced o$er the 'argin% of the re%toration and the re'aining fi%%ure %y%te'( Re%earcher% re&ort $ery high %ucce%% rate% ,hen a'alga' i% u%ed in thi% 'anner ;6ig( >( =<( Com o#ite re#in# Many denti%t% ad$ocate the u%e of co'&o%ite a% a re%torati$e in the treat'ent of children( Since their introduction in the =>?9%, there ha$e been 'any 'odification%( 0bra%i$e ,ear of 'any co'&o%ite %y%te'% i% co'&arable to that of %il$er a'alga' in the region of =9- 9 u'Dyear, and colour %tability i% no, excellent co'&ared ,ith earlier 'aterial%( 0fter &lace'ent and occlu%al ad+u%t'ent of the re%torati$e 'aterial, the o&erator %hould &lace a layer of %ealant on the fini%hed %urface to fill any 'icro-crac/% ,ithin the %urface of the re%in, follo,ed by curing the re%in to en%ure 'axi'al &oly'eri5ation( >e$ Point

Co'&o%ite re%in re%toration% are extre'ely techniBue %en%iti$e( They %hould only be &laced ,hen i%olation i% guaranteed( 4efore 'a/ing deci%ion% concerning the 'o%t a&&ro&riate re%torati$e 'aterial in the treat'ent of children, the clinician %hould con%iderG =( (oisture exclusion( )% it reali%tic for thi% &atientJ ( Patient compliance( Will the &atient %it %till through the re%torationJ @( -he si>e of the cavity( 3e%ion extent deter'ine% o&erati$e duration( A( Patient compliance after the procedure( Will he or %he return for 'onitoring and re$ie,J 0% long a% the clinician allo,% due con%ideration in relation to the%e &ro$i%o% concerning u%e of the 'aterial, it ,ill be a&&ro&riate to e'&loy it re%torati$ely, %ince it% inherent &ro&ertie% 'a/e it an excellent choice in the treat'ent of children for occlu%al ca$itie%( 0% long a% the re%&on%e% to Bue%tion% =, , and A are affir'ati$e and the re%toration i% relati$ely %'all, the co'&o%ite can be u%ed ,ith confidence( The ad$ent of dentine bonding %y%te'% ha% enabled clinician% to achie$e bonding of 'aterial%, to the dentine a% ,ell a% to the ena'el, thereby i'&ro$ing the %trength of the re%toration( Dentine bonding i% $ery techniBue %en%iti$e( 0dherence to 'anufacturer in%truction% i% axio'atic at all ti'e%( )nitially the techniBue con%i%ted of etching and rin%ing follo,ed by a&&lication of &ri'er containing a %ol$ent re%in 'ono'er to ,et and &enetrate the collagen 'e%h,or/( 6inally the o&erator a&&lied a bonding agent, ,hich &enetrate% into the &ri'ed dentine( One-bottle %y%te'% in ,hich the &ri'er and the bonding agent are co'bined ,ithin one %olution are no, on the 'ar/et( When co'bined, they reBuire a 'oi%t %urface to facilitate etching and bonding( With %uch agent% there i% %o'e e$idence to %ugge%t that &atient% 'ay %uffer a high incidence of &o%to&erati$e %en%iti$ity( There are al%o a fe, %y%te'% in the 'ar/et, ,here the 'anufacturer ha% co'bined etch, &ri'e, and bond %olution% into a %ingle %olution( There i% little inde&endent re%earch a% yet to %u&&ort the%e %y%te'% in relation to long-ter' &erfor'ance, but initial re%ult% a&&ear to indicate that there i% $ery lo, &o%to&erati$e %en%iti$ity( The &otential ti'e-%a$ing ad$antage ,ould, of cour%e, be ,elco'e if re%earcher% &ro$e in the future that the%e %y%te'% &ro$ide high bond %trength bet,een the &oly'eri5ed 'aterial and the dentine( >e$ Point -e, techniBue% and 'aterial% ,ill al,ay% e'erge in the 'ar/et, but it i% e%%ential for the &ractitioner to be %ce&tical until re%earcher% re&ort clinical trial% of adeBuate de%ign and duration( Extro$ert ex&onent% of a &articular techniBue or 'aterial freBuently %,ay u% into &urcha%ing a 'aterial &re'aturely, but to our co%t later( 6la## ionomer "ement#

Thi% grou& of 'aterial% tend to be 'ore brittle than co'&o%ite%, but ha$e the ad$antage of adherence to both ena'el and dentine ,ithout etching( The coefficient of ex&an%ion of gla%% iono'er i% $ery clo%e to that of dentine and once %et, the%e 'aterial% re'ain di'en%ionally %table in the 'outh de%&ite con%tantly changing 'oi%ture and te'&erature le$el%( Their bigge%t ad$antage o$er co'&o%ite% i% that they are able to relea%e fluoride o$er an extended &eriod of ti'e( Their lac/ of %trength li'it% their u%e in the &er'anent dentition but they can be u%ed in "RR% ,here there i% no occlu%al load and a% an interi' re%toration ,hile carie% i% brought under control ;6ig%( >( and >( @<( They are al%o the author%* choice of 'aterial for ce'enting %tainle%%-%teel cro,n%( Re#in-modi+ied !la## ionomer Reinforce'ent of gla%% iono'er ,ith re%in ha% been u%ed to &roduce a fa%t %etting ce'ent but the%e 'aterial% reBuire etching &rior to &lace'ent( On 'odifying the 'aterial%, fracture toughne%%Dre%i%tance and abra%ion re%i%tance i'&ro$e, and they %till retain bioco'&atibility, fluoride ion hydrodyna'ic%, fa$ourable ther'al ex&an%ion and contraction characteri%tic%, and 'o%t i'&ortant of all, they retain &hy%icoche'ical bonding to tooth %tructure( Com omer ( ol$a"id-modi+ied re#in-,a#ed "om o#ite) The%e 'aterial% are a co'bination of co'&o%ite and iono'er( They ha$e better ae%thetic% than gla%% iono'er a% a %ingle 'aterial and ha$e the ad$antage of %o'e fluoride relea%e, but there i% %till a need to etch during the re%torati$e &rocedure( 1o,e$er, it ,ould a&&ear that they %uffer fro' the di%ad$antage% of lo%% of retention together ,ith ga& for'ation bet,een the 'aterial and tooth %ub%tance( De%&ite the%e generally acce&ted li'itation% there i% one recent re&ort of a > (@L %ucce%% rate u%ing co'&o'er in %tre%% bearing re%toration% in &er'anent &o%terior teeth( 6urther %tudie% ,ill clarify the i%%ue( Fi!. 4.2/ 0fter re%toration ,ith a'alga', &lace fi%%ure %ealant to co$er the a'alga' and %eal the fi%%ure %y%te'( Fi!. 4.22 0 deficient gla%% iono'er re%toration %een after a year( Fi!. 4.23 The o&erator %i'&ly add% 'ore gla%% iono'er to the deficient re%toration( 4.4 APPR&'I7A* CARIES )n children carie% occur% 'ore often occlu%ally than a&&roxi'ally, but a% they &rogre%% to adulthood, the relati$e le$el of a&&roxi'al carie% increa%e%( The author% ad$ocate 'anaging occlu%al carie% i''ediately by %ealing or "RR%( They al%o %u&&ort re'inerali5ation techniBue% a% an early inter$ention a&&roach in a&&roxi'al carie%, ,here the le%ion ha% not reached the dentine( Whiche$er ,ay the clinician choo%e% to re%tore a&&roxi'al carie%, it ,ill al,ay% entail lo%% of %o'e %ound tooth ti%%ue( )n a&&roxi'al re%toration%, %ufficient tooth &re&aration +u%t to gain acce%% to the cariou% dentine i% nece%%ary( Sha&e the outline for' only to include the cariou% dentine and to re'o$e de'inerali5ed ena'el( 6ini%h the ca$o %urface 'argin% to re'o$e un%u&&orted ena'el(

0'alga' ,or/% ,ell in the%e %ituation% but clinician% are eBually u%ing co'&o%ite re%in% 'ore freBuently in a&&roxi'al re%toration% of young &er'anent teeth( 0lthough there are %o'e %tudie% re&orting good %ucce%% rate%, the o$erall con%en%u% %ee'% to be that tooth coloured re%toration% are &rone to earlier failure than a'alga' re%toration%( O&erator% %hould infor' &arent% of thi% &ro$i%o ,hen di%cu%%ing the choice of re%torati$e 'aterial( ;See 6ig%( >( A, >( :, >( !, >( ?, and >( C(< Fi!. 4.20 Me%ial carie% in a lo,er fir%t 'olar( The le%ion i% not readily a&&arent( Fi!. 4.25 The le%ion i% o&ened( Thi% $ie, %ho,% the extent of the carie% 'ore clearly( The o&erator doe% not need to extend for &re$ention( Fi!. 4.21 The carie% ha% been re'o$ed, a band &laced ,ith ,edge, and the ca$ity lined( Fi!. 4.22 The o&erator ha% &ac/ed a'alga' into the 'e%ial %lot( Fi!. 4.23 The o&erator ha% %ealed the re'ainder of the fi%%ure %y%te'( 4./0 E'TENSI)EBDEEP CARIES 4./0.0 Introd-"tion #nfortunately, a %ituation %o'eti'e% ari%e% ,here the carie% i% already exten%i$e &rior to the initial con%ultation, and the clinician need% to con%ider &re%er$ation $er%u% extraction i%%ue%( Ra'&ant carie% doe% occur in the &er'anent dentition a% ,ell a% the &ri'ary dentition and once again treat'ent &lanning ha% to con%ider the &er%on a% a ,holeindeed ,ith children, %o'eti'e% the ,hole fa'ilynot +u%t the teeth in$ol$ed in one &articular indi$idual( Thi% in$ol$e% deci%ion-'a/ing on The ad$i%ability of re%toration $er%u% &lanned extraction( 1o, to re%tore if that i% the fa$oured 'odality( 1o, to &re$ent on%et of further le%ion%, that i%, reduce the ri%/ factor% by exa'ining diet, oral hygiene, fi%%ure %ealing, fluoride treat'ent, and a rigid recall regi'e( 4./0./ E9tra"tion "on#ideration# )f there i% exten%i$e carie% affecting the fir%t &er'anent 'olar% it 'ay be ex&edient to con%ider extraction rather than re%toration( )t i% ho,e$er, i'&ortant to chec/ for the &re%ence and de$elo&'ent of the %econd &re'olar% before &re%cribing extraction of the fir%t &er'anent 'olar% %ince lac/ of the &re'olar% nece%%itate% all &o%%ible 'ea%ure% to atte'&t to retain the fir%t &er'anent 'olar%( The deci%ion on extraction i% de&endent on the age of the child, the %tage of de$elo&'ent of the dentition, and the occlu%ion( Thi% i% di%cu%%ed in detail in Cha&ter =A( Wherea% there 'ay be different treat'ent o&tion% ,ith regard to cariou% fir%t &er'anent 'olar%, the clinician %hould u%ually atte'&t to retain inci%or% andDor canine%, ,ith exten%i$e carie% ,hene$er &o%%ible(

4./0.2 Con#er.ati.e treatment o tion# 8ariou% techniBue% ha$e a &art to &lay in con%er$ation of teeth ,ith dee& carie%( )ndirect &ul& ca&&ing( Direct &ul& ca&&ing "ul&oto'y "ul&ecto'y When the tooth eru&t% it% root% are inco'&letely for'ed and a&&roxi'ately 9-A9L %horter than the 'ature root( )t 'ay ta/e u& to : year% after eru&tion for the root to co'&lete it% for'ation and de$elo& an a&ical con%triction( >e$ Point Whene$er it i% thought that carie% re'o$al 'ight re%ult in a &ul&al ex&o%ure, effort% %hould be 'ade to &re%er$e &ul& $itality in order to enable nor'al root 'aturation to occur( Indire"t -l "a in!

)f it i% thought that ex&o%ure i% li/ely to occur ,ith full carie% re'o$al then %o'eti'e% it i% ex&edient to lea$e carie% in the dee&e%t &art of the le%ion( "lace a radio-o&aBue, bioco'&atible ba%e o$er the re'aining cariou% dentine to %ti'ulate healing and re&air( )t i% i'&ortant to co'&letely re'o$e carie% fro' all the lateral ,all% of the ca$ity before &lace'ent of a re%toration %ince failure to do %o ,ill re%ult in %&read of %econdary carie% and the need for future inter$ention(;See 6ig%( >( >, >(@9, >(@=, >(@ , and >(@@(< Traditionally o&erator% ha$e u%ed calciu' hydroxide for indirect &ul& ca&&ing becau%e it ha% a good %ucce%% rate( 0lternati$e% %ugge%ted include adhe%i$e re%in%, and gla%% iono'er ce'ent%, but a% yet there are no &ubli%hed %tudie% loo/ing at the%e techniBue% in &er'anent teeth( Whiche$er 'aterial i% utili5ed, the crucial factor i% to i%olate the &ul& ,ell fro' the oral en$iron'ent( Re-in$e%tigation of the%e teeth after about ! 'onth% ,hen the &ul& ha% had an o&&ortunity to lay do,n re&arati$e dentine u%ed to be reco''ended( 1o,e$er %tudie% ha$e found that the re%idual cariou% dentine 'o%tly re-'inerali5e% and harden% and carie% &rogre%%ion doe% not occur in the ab%ence of 'icro-lea/age( Returning to the o&erati$e %ite, to co'&lete carie% re'o$al increa%e% the ri%/ of &ul& ex&o%ure, therefore the author% con%ider it ,i%er to &erfor' the indirect &ul& ca&&ing and definiti$e re%toration in one a&&oint'ent( T%e dire"t -l "a When a %'all ex&o%ure i% encountered during ca$ity &re&aration the o&erator can &lace a direct &ul& ca&( The conce&t once again i% to &re%er$e the $itality of the &ul&( Calciu' hydroxide ha% traditionally been u%ed a% the direct ca&&ing agent( Total etching and %ealing ,ith a dentine-bonding agent ha% been tried but thi% re%ulted in increa%ed non-$itality, %o it i% no, contraindicated( 0% in trau'atic ex&o%ure%, &ul& ca&&ing ha% gi$en di%a&&ointing re%ult% co'&ared ,ith the techniBue of &artial &ul&oto'y, %o %hould only be u%ed if a &ul&oto'y cannot be &erfor'ed(

6or all techniBue% in ,hich the &ul& i% &re%er$ed it i% i'&ortant to a%%e%% the %ituation correctly before e'bar/ing on the treat'entG There %hould be no hi%tory of %&ontaneou% &ain( There %hould be no %,elling, 'obility, di%co'fort to &ercu%%ion( 0 nor'al &eriodontal a&&earance %hould be &re%ent radiogra&hically( "ul& ti%%ue %hould a&&ear nor'al and $ital( Ce%%ation of bleeding fro' the &ul& ex&o%ure %ite %hould occur ,ith i%otonic irrigation ,ithin 'in( P-l otom$ "ul&oto'ie% are %ucce%%ful in young teeth due to their increa%ed &ul&al circulation and ability to re&air( The &rocedure con%i%t% of a&&lying rubber da' after local analge%ia and then clearing all lateral 'argin% around the ex&o%ure and the &ul&al floor of any carie%( The %u&erficial layer of the ex&o%ed &ul& and the %urrounding dentine are exci%ed to a de&th of '' u%ing a high %&eed dia'ond bur( The techniBue i% the %a'e a% the C$e/ &ul&oto'y de%cribed in Cha&ter = for &ul& ex&o%ure in trau'ati5ed teeth( Only ti%%ue +udged to be infla'ed %hould be re'o$ed( Whether %ufficient ti%%ue ha% been re'o$ed i% a%certained by gently irrigating the re'aining &ul& %urface ,ith i%otonic %aline until bleeding %to&%( )f bleeding doe% not cea%e ea%ily, it i% &robable that the ti%%ue i% %till infla'ed and a further 'illi'etre of &ul& ti%%ue i% re'o$ed( Si'ilarly if there i% no bleeding at all then further &ul& ti%%ue %hould be re'o$ed until bleeding i% found( 0fter hae'o%ta%i% ha% been obtained a %oluble &a%te of calciu' hydroxide i% a&&lied to the ,ound %urface( )t i% i'&ortant that there i% no blood clot bet,een the ,ound %urface and the dre%%ing a% thi% ,ill &re$ent re&air and reduce the chance% of %ucce%%( Recently, MT0 ;'ineral trioxide aggregate< ha% been &ro&o%ed for &ul& ca&&ing and &ul&oto'y dre%%ing%, but 'o%t of the &ubli%hed %tudie% %o far on thi% to&ic ha$e been &erfor'ed on ani'al%( 1ence at &re%ent calciu' hydroxide, the tried and te%ted re'edy %hould %till be u%ed( )n order to aid re&air, the clinician %hould a&&ly dry %terile &ellet% of cotton ,ool carefully ,ith 'ode%t &re%%ure to ada&t the calciu' hydroxide 'edica'ent to the &re&ared ca$ity and re'o$e exce%% ,ater fro' the &a%te( 0% in &ul& ca&&ing it i% e%%ential that the o&erator fill% the ca$ity ,ith a 'aterial that &ro$ide% a good her'etic %eal( The latter can be the final re%toration a% there i% no need to re-enter the ,ound %ite( 0lthough the &re%ence of a dentinal bridge radiogra&hically re&re%ent% a %ucce%%, it% ab%ence doe% not indicate failure( 0fter a year, %ucce%% i% re&re%ented by a tooth ,here there are no %ign% of clinical or radiogra&hic &athology and ,here the root ha% de$elo&ed a&ically and thic/ened laterally( The &ul&oto'y techniBue ha% 'uch to reco''end it, vi> a good %ucce%% rate and continued root de$elo&'ent( )t i% therefore con%idered the treat'ent of choice ,hen there ha% been a &ul& ex&o%ure in an i''ature &er'anent tooth(;See 6ig%( >(@A, >(@:, >(@!, >(@?, and >(@C(< P-l e"tom$ Root canal thera&y follo,ing &ul&ecto'y ha% a &oor %ucce%% rate in young &er'anent

'olar%( )n a recent %tudy only @!L of young root filled 'olar teeth ,ere con%idered a %ucce%%( 1ence, &ul&ecto'y %hould be re%er$ed only for ca%e% exhibiting %y'&to'% ,here the &ul& i% irre$er%ibly da'aged( Fi!. 4.24 0 $ery large cariou% le%ion ,ith a definite ri%/ of &ul& ex&o%ure( Fi!. 4.30 Re'o$e carie% fro' the a'elo-dentinal +unction( Fi!. 4.3/ Re'o$e further carie% fro' all area% exce&t ,here the o&erator con%ider% %uch re'o$al ,ill ex&o%e the &ul&( Fi!. 4.32 "lace a calciu' hydroxide dre%%ing( Fi!. 4.33 Co$er the dre%%ing ,ith gla%% iono'er &rior to &re&aration for a %tainle%% %teel cro,n( Fi!. 4.30 Where a &ul& ex&o%ure occur%, in an i''ature &er'anent 'olar, cut out the %u&erficial &ul& ti%%ue ;about = ''< ,ith a high-%&eed dia'ond bur( 4leeding %hould cea%e ea%ily( Fi!. 4.35 "re%%ure ,ith %aline %oa/ed cotton ,ool &ledglet con%olidate% the &o%ition( )t i% i'&ortant to %tre%% that the hae'orrhage 'u%t cea%e before &lacing the lining( Fi!. 4.31 "lace a calciu' hydroxide lining( Fi!. 4.32 "lace a gla%% iono'er ba%e o$er the calciu' hydroxide( Fi!. 4.33 Re%tore ,ith etched, bonded, co'&o%ite re%in to &ro$ide a her'etic %eal( There i% no need to re-in$e%tigate the %ite, %o con%ider the re%toration a% definiti$e( 4.// 5YP&7INERA*IlED< 5YP&7AT(RE< &R 5YP&P*ASTIC FIRST PER7ANENT 7&*ARS 4.//.0 Introd-"tion 0% carie% ha% declined generally, it ha% beco'e 'ore a&&arent that there i% another &roble' that co''only affect% fir%t &er'anent 'olar% and inci%or%( 8ery recently thi% condition ha% been called *'olar-inci%or hy&o'inerali5ation* ;M)1<( Thi% ter' co$er% a range of de$elo&'ental ano'alie% fro' %'all ,hite, yello,, or bro,n &atche% to exten%i$e lo%% of ti%%ue fro' al'o%t the ,hole ena'el %urface( )t i% characteri5ed by a $ery ra&id brea/do,n of the ena'el, ,hich can be extre'ely %en%iti$e( The brea/do,n 'ay e$en occur in a fe, 'onth% ,hile the tooth i% %till eru&ting( The difficultie% of cleaning a &artially eru&ted tooth are then co'&ounded by the %en%iti$ity( Thi% &roduce% an area ,here &laBue build% u& and ,hich lead% to ra&id cariou% attac/( 0% i% al,ay% the ca%e ,ith fir%t &er'anent 'olar%, exfoliation of &ri'ary 'olar% doe% not &recede their eru&tion, %o children and &arent% are often una,are of their &re%ence and thu% they do not %ee/ treat'ent until the teeth %tart to cau%e &roble'%( Molar-inci%or hy&o'inerali5ation ha% been defined a% *hy&o'inerali5ation of %y%te'ic origin of one to four &er'anent 'olar% freBuently a%%ociated ,ith affected inci%or%*( The ex&re%%ion of the &heno'enon can $ary in %e$erity bet,een &atient% but

al%o ,ithin a 'outh, %o in one Buadrant there 'ay only be a %'all hy&o'inerali5ed area, ,hile in other% al'o%t total de%truction of the occlu%al %urface(;See 6ig%( >(@> and >(A9(< #%ually the inci%or% do not %uffer the %a'e brea/do,n of the %urface and %en%iti$ity a% the 'olar%( 1o,e$er, they do freBuently cau%e a co%'etic defect( Thi% can be treated a% the child beco'e% con%ciou% of it, either by co$erage ,ith co'&o%ite ;$eneer< or &artial re'o$al of the defect and co$erage ,ith co'&o%ite ;locali5ed co'&o%ite re%toration<( Detail% of the%e treat'ent techniBue% ,ill be co$ered in Cha&ter =9( The fir%t &roble' to re'edy in 'olar% i% the %en%iti$ity( 8ariou% de%en%iti5ing agent% theoretically and anecdotally do hel&, but no clinical trial% %&ecifically related to M)1 ha$e been re&orted( They includeG Re&eated a&&lication of :L %odiu' fluoride $arni%h ;Dura&hat<( Co''ercially a$ailable *%en%iti$e tooth tooth&a%te%*( Daily u%e of 9(AL %tannou% fluoride gel%( 6i%%ure %ealant% can be u%eful ,here the affected area% are %'all and the ena'el i% intact( The u%e of bonding agent% a% de%cribed abo$e under the re%in %ealant %hould hel& ,ith bonding if the 'argin of the %ealant i% left on an area of hy&o'inerali5ed ena'el( The a&&lication of the bonding agent% alone, once &oly'eri5ed 'ay reduce the %en%iti$ity in the affected teeth per se( )t i% i'&ortant to re'e'ber to 'onitor fi%%ure %ealant% in the%e teeth $ery carefully a% there i% a high chance of 'arginal brea/do,n( )f there i% %urface brea/do,n the tooth ,ill reBuire %o'e for' of re%toration( The fir%t deci%ion to 'a/e i% ,hether the clinician need% to 'aintain the tooth throughout life or if it i% 'ore &rag'atic to con%ider extraction ;Cha&ter =A<( )f the deci%ion i% that the fir%t 'olar% ,ill be extracted a% &art of a long-ter' orthodontic &lan, it i% &robable that they ,ill %till need te'&ori%ation becau%e of the high le$el of %en%iti$ity( The%e teeth are $ery difficult to anae%theti5e, often %taying %en%iti$e ,hen the o&erator ha% gi$en nor'al le$el% of analge%ic agent( )f a child co'&lain% during treat'ent of a hy&o'inerali5ed 'olar tooth, credibility %hould be gi$en to their grie$ance( )f a child ex&erience% &ain or di%co'fort during treat'ent, they ,ill beco'e increa%ingly anxiou% in %ucce%%i$e treat'ent%( Thi% ha% been %ho,n to be true for >-year-old children, ,here dental fear, anxiety, and beha$iour 'anage'ent ,ere far 'ore co''on in tho%e children ,ith %e$erely hy&o'inerali5ed fir%t &er'anent 'olar% ,hen co'&ared ,ith unaffected control%( )ne$itably, a balance ha% to be 'ade bet,een u%ing %i'&ler 'ethod%, %uch a% dre%%ing ,ith a gla%% iono'er ce'ent that 'ay ,ell need re&leni%h'ent often on %e$eral occa%ion% before the o&ti'u' ti'e for extraction, and deciding early ,ithin the treat'ent to &ro$ide a full co$erage re%toration, for exa'&le( a %tainle%%-%teel cro,n ,hich %hould la%t ,ithout reBuiring re&lace'ent &rior to extraction ti'e( 0ll ad+unct% to hel& the analge%ia, %uch a% inhalation %edation %hould be u%ed, if indicated( )t i% al%o u%eful to u%e rubber da' for all the u%ual rea%on% &lu% the &rotection afforded by exclu%ion of %&ray fro' the other three un-anae%theti5ed 'olar%, ,hich &robably ,ill al%o be $ery %en%iti$e( )f the intention i% to 'aintain the 'olar in the long ter', then the choice of re%torati$e techniBue% ex&and%( )f the area of brea/do,n of the hy&o'inerali5ed ena'el i%

relati$ely confined then the o&erator %hould u%e con$entional re%torati$e techniBue%( )t i% ho,e$er difficult to deter'ine ,here the 'argin% of a &re&aration %hould be left a% %o'eti'e% %ee'ingly nor'al ena'el ;to $i%ual exa'ination< undergoe% brea/do,n( 0'alga' i% of li'ited u%e, becau%e, further brea/do,n often occur% at the 'argin%, and it i% non-adhe%i$e %o doe% not re%tore the %trength of the tooth( Co'&o%ite re%in%, on the other hand, ,hen u%ed ,ith an a&&ro&riate bonding agent in ,ell, de'arcated le%ion%, %hould ha$e a good %ucce%% rate( Deciding ,here to lea$e the 'argin in the%e teeth &re%ent% difficulty( 6ayle ; 99@< de%cribed hi% a&&roach of in$e%tigating abnor'al loo/ing ena'el at the 'argin% of the defect ,ith a %lo, rotating %teel bur extending into the%e area% until good re%i%tance i% detected( Thi% a&&roach i% at &re%ent not bac/ed u& by clinical %tudie% but i% a techniBue ado&ted by 'any denti%t% and could hel& a$oid unnece%%ary %acrifice of %ound ti%%ue( ;See 6ig( >(A=(< Mo%t hy&o'inerali5ed 'olar% ,ith %urface brea/do,n in$ol$ing one cu%& or 'ore ,ill need a re%toration ,ith greater co$erage( Either %tainle%%-%teel cro,n% or ca%t adhe%i$e co&ing% &ro$ide the 'o%t %ati%factory o&tion%( Fi!. 4.34 M)1 effect% on the inci%or%H a 'ild ,hite &atch on one tooth can occur in the %a'e 'outh a% 'ore %e$ere bro,n di%colouration ,ith %o'e %urface brea/do,n( Fi!. 4.00 M)1 affecting the fir%t &er'anent 'olar%H %o'e brea/do,n of the hy&o'inerali%ed ena'el i% already occurring( Fi!. 4.0/ Carie% and further brea/do,n around an a'alga' in a hy&o'inerali%ed 'olar( 4.//./ Pre+ormed metal "roCn# (#tainle##-#teel "roCn#) The ad$antage% of the%e areG =( Single $i%it for &lace'ent( ( Relati$ely Buic/ and %i'&le &rocedure( @( #%ually reduce %en%iti$ity totally, becau%e they co$er the ,hole tooth( A( )nex&en%i$e co'&ared ,ith ca%t re%toration%( :( Good retention rate( The di%ad$antage% areG =( ReBuire 'ore tooth &re&aration than ca%t &re&aration%( ( Once a tooth ha% been &re&ared for a %tainle%%-%teel cro,n, it ,ill need a full co$erage re%toration e$entually( )t ha% been %ugge%ted that &lacing orthodontic %e&arator% = or ,ee/% &rior to &re&aration reduce% the a'ount of ti%%ue reBuiring re'o$al( 1o,e$er, %o'e reduction i% u%ually nece%%ary( @( Gingi$al 'argin% are %ub-gingi$al(

& erati.e te"%niA-e =( Obtain adeBuate anae%the%ia( ( )%olate the tooth to be cro,ned( @( Select the cro,n %i5e( A( Re'o$e any cariou% dentine and ena'el( :( Re&lace tooth bul/ ,ith gla%% iono'er( !( Reduce the occlu%ion 'ini'ally( ?( Reduce the 'e%ial and di%tal %urface%, %licing ,ith a fine ta&ered bur( De&ending on the natural anato'y of the tooth it 'ay be nece%%ary to create a &eri&heral cha'fer on the buccal and lingual %urface%( C( Try the %elected cro,nH ad+u%t the %ha&e cer$ically, %uch that the 'argin% extend N= '' belo, the gingi$al cre%t e$enly around the ,hole of the &eri'eter of the cro,n( Shar& 4ee 4ee %ci%%or% u%ually achie$e thi% 'o%t ea%ily, follo,ed by cri'&ing &lier% to contour the edge to gi$e %&ring and gri&( "er'anent 'olar &refor'ed 'etal cro,n% need thi% becau%e they are not %ha&ed accurately cer$ically( Thi% i% becau%e there i% %uch a $ariation in cro,n length of the fir%t &er'anent 'olar%( >( 0fter the contouring, %'ooth and &oli%h the cro,n to en%ure that it doe% not attract exce%%i$e a'ount% of &laBue( =9( 0fter te%t fitting of the cro,n re'o$e the rubber da' to chec/ the occlu%ion then re-a&&ly for ce'entation( ==( Ce'ent the cro,n u%ually ,ith a gla%% iono'er ba%ed ce'ent( = ( Re'o$e exce%% ce'ent carefully ,ith an ex&lorer and /notted flo%%( 6inally rechec/ the occlu%ion(;See 6ig%( >(A , >(A@, >(AA, >(A:, and >(A!(< Fi!. 4.02 Stainle%%-%teel cro,n &re&aration( The occlu%al %urface i% reduced 'ini'ally +u%t enough to allo, roo' to &lace the cro,n ,ithout di%ru&ting the occlu%ion( Fi!. 4.03 Stainle%%-%teel cro,n &re&aration( Obtain 'e%ial and di%tal reduction ,ith a fine ta&ered dia'ond bur ,ith 'ini'al buccal and &alatal reduction that i% +u%t %ufficient to allo, the o&erator to &lace the cro,n( )t i% te'&ting not to effect any di%tal reduction if there i% no eru&ted %econd &er'anent 'olar but re'e'ber it i% i'&ortant not to change the &ro&ortion% of the tooth or create an o$erhang that ,ill i'&ede %econd 'olar eru&tion( Fi!. 4.00 Stainle%%-%teel cro,n i% tried in and fit deter'ined( Thi% cro,n ,ill no, need to be contoured and %'oothed around the 'argin% %o that they fit e$enly = '' belo, gingi$al le$el around the ,hole &eri&hery( )t i% i'&ortant that the cro,n ha% a good contact &oint 'e%ially( Contour the tooth ,ith the

correct &lier%( Fi!. 4.05 Gla%% iono'er ce'ent i% &laced in the cro,n, and o$erfilled to &re$ent $oid% for'ing under the cro,n( Exce%% ce'ent i% re'o$ed ,ith cotton ,ool roll% and hand in%tru'ent%, and the inter%titial area cleared ,ith dental flo%%( Fi!. 4.01 0 %tainle%%-%teel cro,n that ,a% &laced = year &re$iou%ly 4.//.2 Ca#t ad%e#i.e "o in!# Thi% ty&e of re%toration offer% t,o 'ain ad$antage% o$er &refor'ed 'etal cro,n%G a$oid% unnece%%ary a&&roxi'al reductionH enable% 'argin% to re'ain %u&ragingi$al( 1o,e$er three di%ad$antage% areG %till need% local analge%iaH ta/e% t,o $i%it% to co'&leteH techniBue i% 'ore ex&en%i$e( ;See 6ig( >(A?(< & erati.e te"%niA-e (5arle$ and I,,et#on< /443) 8i%it =( =( 3ocal analge%ia( ( Rubber da'( @( "re&aration to re'o$e any cariou% or %oftened ena'el( A( Gingi$al retraction ,ith cord% ;to &re$ent cre$icular fluid and other 'oi%ture conta'inating the &re&aration %ite and i'&re%%ion%<( :( )'&re%%ion ,ith rubber ba%e 'aterial( !( Te'&ori5ation if 'uch tooth ti%%ue ha% been re'o$ed( The ca%ting i% con%tructed in the laboratory, and the fit %urface i% %and bla%ted( 8i%it ( ?( 3ocal analge%ia( C( Rubber da'( >( Tooth i% bru%hed ,ith &u'ice, ,a%hed, and dried(

=9( Ca%ting i% tried in to chec/ 'arginal ada&tation and fit( ==( Ca%ting i% re-%andbla%ted to obtain o&ti'u' condition% for bonding( = ( Tooth i% etched, ,a%hed, and dried( =@( Ce'ent i% a&&lied to fit %urface of ca%ting en%uring there are no bubble%( =A( The ca%ting i% held in &o%ition under &re%%ure for @ 'in( =:( Exce%% ce'ent i% re'o$ed( =!( Oxygen inhibiting 'aterial ;oxyguard< i% a&&lied o$er the 'argin% of the ca%ting and 'aintained in &o%ition for a further @ 'in( =?( The oxyguard i% re'o$ed by ,a%hingH 'argin% rechec/edH and occlu%ion chec/ed( Fi!. 4.02 0n etched co&ing co$ering the occlu%al %urface of a hy&o&la%tic 'olar( 4./2 A*TERNATI)ES T& C&N)ENTI&NA* CA)ITY PREPARATI&N 4./2./ Air a,ra#ion There ha% recently been a re%urgence of intere%t in air abra%ion technology ,ith %e$eral different co''ercial unit% a$ailable( With air abra%ion 'achine%, alu'iniu' oxide &article% ; ? or :9 u'< are bla%ted again%t the teeth under a range of &re%%ure% ;@9-=!9 &%i< ,ith $ariable &article flo, rate%( One $ery ob$iou% concern i% the %afety a%&ect due to the &re%ence of Buantitie% of free alu'iniu' oxide in the %urgery en$iron'ent( )n theory alu'iniu' oxide i% con%idered har'le%%( )t i% found in a ,ide $ariety of &roduct% fro' tooth&a%te% to &oli%hing ,heel%( The %i5e of the &article% i% con%idered too big to enter the di%tal air,ay% or al$eoli of the lung%( What du%t doe% enter the lung% %hould be ea%ily re'o$ed by ciliary action( 1o,e$er, anyone ,ho ha% u%ed one of the%e unit% ,ill /no, that control of the du%t i% an ongoing challengeH rubber da' and $ery good %uction hel&, but it %till %ee'% to %&read( 0ir abra%ion &roduce% a ca$ity &re&aration ,ith both rounded ca$o-%urface 'argin% and internal line angle%( The %urface it create% i% irregular ,ith 'any fine $oid% and defect%( )nitially it ,a% con%idered that thi% %urface 'ight &ro$ide enough retention ,ithout etching but %tudie% %ho, thi% a% erroneou%( So'e of the clear ad$antage% &ro&o%ed for air abra%ion areG Eli'ination of $ibration, le%% noi%e, and decrea%ed &re%%ure( Reduction in &ain during ca$ity &re&arationH C:L of &atient% do not reBuire local analge%ia( 3e%% da'aging &ul&al effect% than ,ith con$entional hand-&iece u%age, ,hen u%ed at higher &re%%ure% of =!9 &%i and ,ith %'aller &article %i5e of ? u'(

 3e%% fracture and cra5ing of ena'el and dentine during ca$ity &re&aration( Root canal acce%% through &orcelain cro,n% ,ithout fracturing &orcelain( 0ir abra%ion ha% been &ro&o%ed forG Cleaning and re'o$ing %tain% and inci&ient carie% fro' &it% and fi%%ure% &rior to %ealant and "RR%( S'all cla%% ), ))), )8, and 8 ca$ity &re&aration% and %elected cla%% )) &re&aration%( Re&air and re'o$al of co'&o%ite%, gla%% iono'er%, and &orcelain re%toration%( Cleaning and &re&aration of ca%ting%, orthodontic band%, and brac/et% &rior to ce'entation( What it cannot do i% re'o$e leathery dentinal carie% or &re&are exten%i$e ca$itie% reBuiring cla%%ical retenti$e for'( To u%e it %ucce%%fully, the clinician 'u%t learn a ne, techniBue a% the ti& doe% not touch the tooth and therefore there i% no tactile feedbac/( The ti& ,idth and the ti& to tooth di%tance %ee' to ha$e 'o%t influence on the ca$ity ,idth and de&th( )ncrea%ing the di%tance &roduce% larger %hallo,er cut%( )ncrea%ing the ti& dia'eter &roduce% larger dee&er cut%( Therefore, the 'o%t &reci%e re'o$al of tooth ti%%ue i% achie$ed ,ith a %'all inner dia'eter ti& ;9(@C ''<, held '' fro' the tooth %urface( )f cutting a cla%% )) ca$ity, it i% e%%ential to &rotect the ad+acent tooth( Care 'u%t al%o be ta/en around the %oft ti%%ue% to &re$ent %urgical e'&hy%e'a( Gla%%D'irror %urface% 'ay be da'aged by the du%t( )n the &re&aration of "RR%, thi% techniBue gi$e% a% good a re%ult a% con$entional 'ethod%( )t ,a% thought that ca$itie% ,ould be %'aller ,ith air abra%ion but thi% ha% not been reali5ed &ractically( )n conclu%ion, air abra%ion 'ay be u%eful in &re&aration of %'all ca$itie% ,ith reduced &atient di%co'fort, ,hen co'bined ,ith acid etching to obtain a good bond ,ith adhe%i$e 'aterial%, and ,hen correctly and carefully u%ed( 1o,e$er, the du%t i% a &ractical &roble'( 4./2.2 &:one t%era $ Dental treat'ent% are con%tantly e$ol$ing( One %uch inno$ation, o5one thera&y ;healo5one< ha% hit the 'edia headline%, %&i/ing 'uch &ublic intere%t( The technology i% a$ailable and co%tly de$ice% for deli$ery of o5one for dental &ur&o%e% exi%t, but a% yet the %u&eriority of thi% 'odality o$er con$entional treat'ent ha% not been &ro$en ,ith &ro&erly conducted clinical trial%( The theory of the action of o5one i% that it /ill% 'icro-organi%'%, by oxidi5ing their cell ,all% to ru&ture their cyto&la%'ic 'e'brane%, that i%, it i% bactericidal( )n laboratorie% it ha% been %ho,n that o5one can %ub%tantially reduce the nu'ber% of 'icro-organi%'% ,ithin cariou% dentine on %hort ex&o%ure% of =9- 9 %( 1o,e$er, the clinical %ignificance of thi% ha% not been e%tabli%hed( )t ha% been &o%tulated that the u%e of o5one together ,ith a re'inerali5ing regi'e of fluoride &a%te and rin%e, oral hygiene in%truction, and dietary ad$ice ,ould be beneficial and that it ,ould arre%t

&ri'ary root carie% to a greater extent than re'inerali5ing regi'e alone( )t ha% al%o been %ugge%ted that o5one treat'ent can %tabili5e &it and fi%%ure carie% &re$enting further deterioration( 1o,e$er, the author% ,ill %tay ,ith 'ore traditional 'ethod% of carie% control until &ro&er controlled trial% of rea%onable duration ;>A year%< ha$e been re&orted( 4./2.3 *a#er# The &ublic &erce&tion of la%er% in denti%try i% that they can do re'ar/able thing% &ainle%%ly, %o ob$iou%ly thi% a&&eal% to a greater nu'ber of &eo&le( 1o,e$er, the nu'ber of denti%t% offering la%er% a% an o&tion in their &ractice% i% %till %'all( The co%t of eBui&'ent i% ob$iou%ly a %ignificant factor, but a% ,ith all ne, technologie% it i% i'&ortant that each denti%t con%ider% the &ro$en clinical outco'e%, that i%, ,hat the recorded literature %tate% regarding the %afety, efficacy, and effecti$ene%%( With la%er% thi% i% further co'&licated by the fact that there are 'any different ty&e% of la%er%, ,ith different u%e% and ne, ty&e% and a&&lication% being &roduced con%tantly( *a#er t$ e# and -#e# Carbon dioxide la%er% Soft ti%%ue inci%ionDablation Gingi$al troughing 0e%thetic contouring of gingi$ae Treat'ent of oral ulcer% 6raenecto'y and gingi$ecto'y Dee&itheli5ation of gingi$al ti%%ue during &eriodontal regenerati$e &rocedure% -d G .0G Si'ilar to abo$e &lu% re'o$al of inci&ient carie% but becau%e of the de&th of &enetration there i% a greater ri%/ of collateral da'age than ,ith dioxide la%er%( Er G .0G Carie% re'o$al Ca$ity &re&aration in both ena'el and dentine "re&aration of root canal% 0rgon la%er Re%in curing Tooth bleaching Treat'ent of ulcer% 0e%thetic gingi$al contouring 6raenecto'y and gingi$ecto'y 3a%er% &roduce light energy ,ithin a narro, freBuency range( They are na'ed after the acti$e ele'ent ,ithin the', ,hich deter'ine% the ,a$elength of the light e'itted( So %o'e of the co''oner la%er% ha$e the follo,ing characteri%tic% -eody'iu' G yttriu'-alu'iniu'-garnet ;-d G .0G< ,a$elength M =(9!Au' Carbon dioxide la%er% ,a$elength M =9(!u' Erbiu' G .0G M (>Au' 0rgon M A:?-:9 n' Galliu'-0r%enide ;diode< M >9A n' 1ol'iu' G .0G M (=u' The ,a$elength of light i% the &ri'ary deter'inant of the degree to ,hich the target 'aterial ab%orb% light( The dee&er the la%er energy &enetrate%, the 'ore it %catter% and di%tribute% throughout the ti%%ue, for exa'&le, carbon dioxide la%er &enetrate% 9(9=9(9@ '' into the ti%%ue ,hile -d G .0G la%er &enetrate% -: ''( The light fro' dental la%er% i% ab%orbed and con$erted to heat, ,hile the ther'al effect% cau%ed de&end on the ti%%ue co'&o%ition and the ti'e the bea' i% focu%ed on the target ti%%ue( The increa%e in te'&erature 'ay cau%e the ti%%ue to change in %tructure and co'&o%ition, for exa'&le, denaturation, $a&ouri5ation, carboni5ation, and 'elting follo,ed by recry%talli5ation( The argon la%er ha% a 'a+or ad$antage o$er the other la%er% in that the ,a$elength at ,hich it o&erate% i% ab%orbed by hae'oglobin and

therefore &ro$ide% excellent hae'o%ta%i%( 3et u% loo/ fir%t at %afety( )n order for a &rocedure to be dee'ed %afe, collateral da'age 'u%t be ,ithin acce&table li'it%, that i%, the ri%/-benefit ratio 'u%t be %'all ,ith the benefit to the &atient being %ignificantH for exa'&le, la%er-induced ti%%ue trau'a to the %urgical %ite can add %e$eral 'ore day% to the healing &roce%% and cau%e dra'atically abnor'al a&&earance% for u& to =9-=A day% &o%to&erati$ely( 4alanced again%t thi%, &o%to&erati$e &ain i% u%ually 'ini'al( (#in! an Er E YA6 la#er +or "a.it$ re aration and "arie# remo.al "ro&o%ed ad$antage%G 3a%er u%e re%ult% in clean %har& 'argin% in ena'el and dentine( The &ul& i% &rotected and %afe a% the de&th of energy &enetration i% negligible( ;There i% one %tudy that %ho,% dee&er da'age to ner$e ter'inal% and fibre% $i%ible under electron 'icro%co&e exa'ination though it% clinical %ignificance i% un/no,n(< "atient% re&ort little or no &ain ,ith the u%e of Er G .0G la%er in ca$ity &re&aration( Ti'e ta/en for ca$ity &re&aration i% %hort( Di%ad$antage%G Co%t( The need to learn a ne, techniBue in ,hich there i% no &ro&rioce&ti$e feedbac/ %ince the la%er ti& doe% not i'&inge dental ti%%ue( *a#er "arie# dete"tionBla#er +l-ore#"en"e Thi% i% a lo,-&o,er la%er a&&lication, ,hich doe% not rai%e %afety concern%( The %y%te' i% co''ercially a$ailable and /no,n a% *Diagnodent*;2a8o<( Many ,or/er% ha$e %tudied it and re&orted the la%er fluore%cence %y%te' o$er%core% le%ion% ,hile the con$entional $i%ual 'ethod under%core% the'( The &roble' ,ith the la%er fluore%cence in%tru'ent i% that it cannot differentiate bet,een carie% and hy&o'inerali%ation( 6urther'ore, %taining i% inter&reted a% carie% and the &re%ence of &laBue deleteriou%ly affect% &erfor'ance( Therefore, it %hould only be u%ed a% an ad+unct to clinical exa'ination and diagno%i%( Ar!on la#er irradiation a# a re.enti.e treatment 0t certain %etting% -d G .0G la%er irradiation of %ound ena'el ha% been re&orted to increa%e %urface 'icro-hardne%%( So'e re%earcher% re&ort that argon la%er irradiation &roduce% a %urface ,ith enhanced carie% re%i%tance( Se$eral author% ha$e %tudied the%e by creating &laBue retenti$e area% on teeth de%tined to be re'o$ed for orthodontic rea%on% and recorded the effect that different &re-treat'ent% had &rior to ! ,ee/% of &laBue accu'ulation( "re-treat'ent ,ith an argon la%er led to le%% le%ion for'ation and i'&ro$ed further if co'bined ,ith to&ical fluoride a&&lication( The re%ult% %ee' $ery i'&re%%i$e but need re&lication in the long ter', in the for' of controlled clinical trial%, to deter'ine the %ignificance in a &o&ulation a% a ,hole in%tead of %&ecific artificially created carie% &rone area%( )f &ro$en they 'ay yield a %i'&le non-

in$a%i$e and &ain free techniBue for reducing carie% %u%ce&tibility of ena'el( Re#in "-rin! 0rgon la%er% are able to &oly'eri5e co'&o%ite re%in% in a %horter ti'e than con$entional light %ource%( The u%e of thi% ty&e of la%er ha% the additional ad$antage of increa%ing the ability of tooth %tructure to re%i%t cariogenic challenge% and 'ay al%o increa%e re%i%tance of the ena'el %urrounding the &oly'eri5ed re%in( One %tudy al%o found that la%er &oly'eri5ation lo,ered the &ro&ortion of non-&oly'eri5ed 'ono'er and %lightly i'&ro$ed the &hy%ical &ro&ertie% of the re%in in co'&ari%on to $i%iblelight 'ethod% of curing( )t i% i'&ortant to re'e'ber that re%in% cured ,ith la%er% do not nece%%arily ha$e %u&erior &hy%ical &ro&ertie% and it i% &articularly i'&ortant to chec/ that the initiator% ,ithin the re%in are acti$ated at the %&ecific ,a$elength of the la%er( 0gain there i% a &aucity of clinical %tudie% to %u&&ort the%e conce&t%( *a#er ,lea"%in! 4oth carbon dioxide and argon la%er% ha$e been %ugge%ted a% a 'ethod of tooth ,hitening( There ha$e been no controlled clinical %tudie% and there are concern% regarding the &ul&al %afety in connection ,ith carbon dioxide la%er%, %o the u%e of thi% ty&e of la%er i% not reco''ended( )n one %tudy an argon ion la%er &roduced le%% te'&erature ri%e ,hen u%ed to increa%e the acti$ity of a bleaching gel co'&ared ,ith con$entional Buart5 tung%tenH hence, &la%'a arc light% 'ay be acce&table( Enamel et"%in! )t ha% been %ugge%ted that la%er irradiation 'ay eli'inate the need for etching, but a% yet there i% not %cientific literature to bac/ thi% clai'( )n %u''ary, %o'e of the &reli'inary re&ort% on the u%e of la%er% gi$e 'uch roo' for o&ti'i%'( They not only %ugge%t that it 'ight be &o%%ible to u%e la%er% to hel& &re$ent decay, but it 'ay al%o be &o%%ible to &erfor' certain %urgerie% and &re&are ca$itie% ,ith little &ain for the &atient( 1o,e$er, greater clinical trial $alidation of the%e clai'% i% needed before la%er% can be con%idered %u&erior to con$entional 'ethod%, %o that failure to utili5e the for'er ,ill be con%idered a% a di%%er$ice to the &atient%( 0% yet the eBui&'ent co%t and the need for different la%er ty&e% for $ariou% ty&e% of treat'ent 'a/e their u%e &rohibiti$e for 'o%t #2 denti%t%( 4./3 RA7PANT CARIES )t i% i'&ortant to con%ider the 'any factor% that deter'ine the treat'ent of a child ,ith a high carie% rate ;6ig( >(AC<( )f the child &re%ent% ,ith an acute &roble' of &ain or %,elling, then i''ediate treat'ent i% indicated to relie$e the child of the &ain( 0fter that, it i% i'&ortant that the clinician con%ider% the attitude of the child and hi% or her &arent% together ,ith 'oti$ation to,ard% dental treat'ent, the co-o&eration of the child, the age, and the extent of decay( )t 'ay be &o%%ible to &lace te'&orary re%toration% ,hile &re$enti$e %trategie% are co''enced( The%e ,ill includeG

=( Dietary analy%i% and a&&ro&riate ad$ice to the child and the &arent( ( "laBue control, oral hygiene in%truction de&ending on age to the child or the &arent, the techniBue% of toothbru%hing, and di%clo%ure( @( 6luoride -tooth &a%te -'outh rin%eH -$arni%h a&&lication e$ery ! 'onth%( A( 6i%%ure %ealant% :( Regular recall( Once the carie% i% under control, definiti$e re%torati$e treat'ent can co''ence( Fi!. 4.03 Ra'&ant carie% in a =@-year-old girl( She only attended becau%e the inci%or had fractured( 1er ,hole attitude to denti%try need% to change in order to treat her %ucce%%fully( 4./0 S(77ARY =( 0 full &re$enti$e &rogra''e, to atte'&t to treat the cau%e of the carie%, 'u%t acco'&any any re%torati$e treat'ent( ( #tili5e rubber da' if at all &o%%ible &rior to the re%toration of all teeth( @( Early treat'ent of occlu%al %urface carie% %a$e% tooth ti%%ue but ,ith early a&&roxi'al le%ion% u%e re'inerali5ation ,here$er the le%ion ha% not reached the dentine( A( Con%ideration %hould be gi$en to &ul& &re%er$ation in dee& le%ion% in i''ature &er'anent teeth( :( 1y&o'inerali5ed fir%t 'olar% deteriorate ra&idly, can be extre'ely %en%iti$e and reBuire early treat'ent !( -e, 'aterial% and technologie% con%tantly a&&ear for e$aluation( Treat ,ith caution until long-ter' clinical trial re%ult% $erify the clai'% of the initial re%earcher%( 4./5 F(RT5ER READIN6 2idd, E( 0( M(, S'ith, 4( G( -(, and Wat%on, T( 6( ; 99@<( Pic%ard?s manual of operative dentistry, ;Cth edn<( Oxford Medical "ublication%, Oxford #ni$er%ity "re%%, Oxford( ;" very full and informative guide to restoration of permanent teeth < Reid 7( S(, Challi%, "( D(, and "atter%on, C( 7( W( ;=>>=<( )u,,er dam in clinical practice( Kuinte%%ence, 3ondon( ;-his provides a guide to the simple use of ru,,er dam <

4./1 REFERENCES 6ayle, S( 0( ; 99@<( Molar )nci%or 1y&o'inerali%ationG re%torati$e 'anage'ent( 7uropean +ournal of Paediatric Dentistry, 0;@<, = =-!( 1arley, 2( E( and )bbet%on, R( 7( ;=>>@<( Dental ano'alie%G are adhe%i$e ca%ting% the %olutionJ $ritish Dental +ournal, /20, =:- ( -unn, 7( 1(, Murray, 7( 7(, and S'allridge, 7( ; 999<( 4riti%h Society of "aediatric Denti%tryG a &olicy docu'ent on fi%%ure %ealant% in &aediatric denti%try( International +ournal Paediatric Dentistry, /0; <, =?A-?( "itt%, -( 4(, 4oyle%, 7(, -ugent, S( 7(, Tho'a%, -(, "ine, C( M( ; 99A<( The dental carie% ex&erience of =A-year-old children in England and Wale%( Sur$ey% co-ordinated by the 4riti%h 0%%ociation for the Study of Co''unity Denti%try in 99 D 99@( Community Dental Health, 2/;=<, A:-:?( Rugg-Gunn, 0( 7(, Welbury, R( R(, and Tou'ba, 7( ; 999<( 4S"D "olicy Docu'entG 0 &olicy docu'ent on the u%e of a'alga' in &aediatric denti%try( International +ournal of Paediatric Dentistry, //, @@-C( S'allridge, 7( 6aculty of Dental Surgery, and Royal College of Surgeon% ; 999<( #2 national clinical guideline% in &aediatric denti%try( Manage'ent of the %tained fi%%ure in the fir%t &er'anent 'olar( International +ournal of Paediatric Dentistry, /0;=<, ?>C@( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

/0. Ad.an"ed re#torati.e denti#tr$ - 6 ( 0ilpatric% and ) ) 4el,ury /0./ INTR&D(CTI&N The ai' of thi% cha&ter i% to co$er the 'anage'ent of 'ore co'&licated clinical &roble'% a%%ociated ,ith children and adole%cent%H tooth di%colouration, inherited ena'el and dentine defect%, hy&odontia and tooth %urface lo%%( There i% con%iderable

o$erla& in the a&&lication of the $ariou% re%torati$e techniBue%H therefore the cha&ter i% di$ided into t,o &art%G the fir%t outline% the clinical %te&% in$ol$ed in the $ariou% &rocedure%, ,hile the %econd co$er% the 'ore general &rinci&le% of 'anage'ent of the &articular dental &roble'%( /0.2 AD)ANCED REST&RATI)E TEC5NI@(ES /0.2.0 Introd-"tion )t i% not the re'it of thi% cha&ter to co$er ad$anced re%torati$e denti%try in detail, but 'any of the techniBue% u%ed in children are the %a'e a% tho%e for adult% ;Table% =9(= and =9( <( With the aid of %o'e clinical exa'&le%, %e$en of the re%torati$e &rocedure% ,ill be de%cribed in %i'&le %tage%( O'itted fro' thi% li%t are the %tage% in$ol$ed in the &ro$i%ion of full cro,n re%toration% and bridge,or/, ,hich are the %&ecific re'it of a re%torati$e denti%try textboo/( 1o,e$er, the &ro$i%ion of &orcelain $eneer%, 'ore co''only a%%ociated ,ith adult &atient%, ,ill be 'entioned briefly( /0.2./ T%e %$dro"%lori" a"id- -mi"e mi"roa,ra#ion te"%niA-e Thi% i% a controlled 'ethod of re'o$ing %urface ena'el in order to i'&ro$e di%coloration% that are li'ited to the outer ena'el layer( )t i% achie$ed by a co'bination of abra%ion and ero%ionthe ter' *abro%ion* i% %o'eti'e% u%ed( )n the clinical techniBue that ,ill be de%cribed no 'ore than =99 u' of ena'el are re'o$ed( Once co'&leted the &rocedure %hould not be re&eated again in the future( Too 'uch ena'el re'o$al i% &otentially da'aging to the &ul& and co%'etically the underlying dentine colour ,ill beco'e 'ore e$ident( Indi"ation# ;=< fluoro%i%H ; < idio&athic %&ec/lingH ;@< &o%torthodontic treat'ent de'inerali5ationH ;A< &rior to $eneer &lace'ent for ,ell-de'arcated %tain%H ;:< ,hiteDbro,n %urface %taining, e(g( %econdary to &ri'ary &redece%%or infection or trau'a ;Turner teeth<( Armamentari-m ;=< bicarbonate of %odaD,aterH ; < Co&alite $arni%h or $a%elineH ;@< fluoridated tooth&a%teH ;A< non-acidulated fluoride ;9- year%G dro&%<H ;:< &u'iceH ;!< rubber da'H ;?< rubber &ro&hylaxi% cu&H ;C< Soflex di%c% ;@M<H ;>< =CL hydrochloric acid(

Te"%niA-e =( "erfor' &reo&erati$e $itality te%t%, ta/e radiogra&h% and &hotogra&h% ;6ig( =9(= ;a<<( ( Clean the teeth ,ith &u'ice and ,ater, ,a%h, and dry( @( )%olate the teeth to be treated ,ith rubber da', and &aint Co&alite $arni%h around the nec/% of the da' or $a%eline under the da'( A( "lace a 'ixture of %odiu' bicarbonate and ,ater on the da' behind the teeth, a% &rotection in ca%e of %&illage ;6ig( =9(= ;b<<( :( Mix =CL hydrochloric acid ,ith &u'ice into a %lurry and a&&ly a %'all a'ount to the labial %urface on either a rubber cu& rotating %lo,ly for : % or a ,ooden %tic/ rubbed o$er the %urface for : % ;6ig( =9(= ;c<<, before ,a%hing for : % directly into an a%&irator ti&( Re&eat until the %tain ha% reduced, u& to a 'axi'u' of =9 :-% a&&lication% &er tooth( 0ny i'&ro$e'ent that i% going to occur ,ill ha$e done %o by thi% ti'e( !( 0&&ly the fluoride dro&% to the teeth for @ 'in( ?( Re'o$e the rubber da'( C( "oli%h the teeth ,ith the fine%t Soflex di%c%( >( "oli%h the teeth ,ith fluoridated tooth&a%te for = 'in( =9( Re$ie, in = 'onth for $itality te%t% and clinical &hotogra&h% ;6ig( =9(= ;d<<( ==( Re$ie, biannually chec/ing &ul&al %tatu%( Critical analy%i% of the effecti$ene%% of the techniBue %hould not be 'ade i''ediately, but delayed for at lea%t = 'onth a% the a&&earance of the teeth ,ill continue to i'&ro$e o$er thi% ti'e( Ex&erience ha% %ho,n that bro,n 'ottling i% re'o$ed 'ore ea%ily than ,hite, but e$en ,here ,hite 'ottling i% inco'&letely re'o$ed it ne$erthele%% beco'e% le%% &erce&tible( Thi% &heno'enon ha% been attributed to the relati$ely &ri%'le%% layer of co'&acted %urface ena'el &roduced by the *abro%ion* techniBue, ,hich alter% the o&tical &ro&ertie% of the tooth %urface( 3ong-ter' %tudie% of the techniBue ha$e found no a%%ociation ,ith &ul&al da'age, increa%ed carie% %u%ce&tibility, or %ignificant &rolonged ther'al %en%iti$ity( "atient co'&liance and %ati%faction i% good and any di%%ati%faction i% u%ually due to inadeBuate &reo&erati$e ex&lanation( The techniBue i% ea%y to &erfor' for the o&erator and &atient, and i% not ti'e con%u'ing( Re'o$al of any 'ottled area i% &er'anent and achie$ed ,ith an in%ignificant lo%% of %urface ena'el( 6ailure to i'&ro$e the a&&earance by the 1Cl-&u'ice 'icroabra%ion techniBue ha% no har'ful effect% and 'ay 'a/e it ea%ier to 'a%/ %o'e le%ion% ,ith $eneer%(

Fi!. /0./ ;a< Characteri%tic a&&earance of fluorotic di%coloration( ;b< Rubber da' i%olation ,ith bicarbonate of %oda in &o%ition( ;c< 0&&lication of hydrochloric acid&u'ice %lurry ,ith a ,ooden %tic/( ;d< 0&&earance at year%* &o%t-treat'ent( /0.2.2 Non-.ital ,lea"%in! Thi% techniBue de%cribe% the bleaching of teeth that ha$e beco'e di%coloured by the diffu%ion into the dentinal tubule% of hae'oglobin brea/do,n &roduct% fro' necrotic &ul& ti%%ue( Indi"ation# ;=< di%coloured non-$ital teethH ; < ,ell-conden%ed gutta &ercha root fillingH ;@< no clinical or radiological %ign% of &eria&ical di%ea%e( Contraindi"ation# ;=< hea$ily re%tored teethH ; < %taining due to a'alga'( Armamentari-m ;=< rubber da'H ; < 5inc &ho%&hate or )RM ce'entH ;@< @?L &ho%&horic acidH ;A< bleaching agent, for exa'&le, hydrogen &eroxide, carba'ide &eroxide, or %odiu' &erborateH ;:< cotton ,oolH ;!< gla%% iono'er ce'entH ;?< ,hite gutta &ercha te'&orary re%torati$eH ;C< co'&o%ite re%inH ;>< non-%etting calciu' hydroxide( Te"%niA-e =( Ta/e &reo&erati$e &eria&ical radiogra&h%H the%e are e%%ential to chec/ for an adeBuate root filling ;6ig( =9( ;a<<( ( Clean the teeth ,ith &u'ice and 'a/e a note of the %hade of the di%coloured tooth( @( "lace rubber da', i%olating the %ingle tooth( En%ure adeBuate eye and clothing &rotection for the &atient, o&erator, and dental nur%e( A( Re'o$e &alatal re%toration and &ul& cha'ber re%toration( :( Re'o$e root filling to the le$el of the dentogingi$al +unctionyou 'ay need to u%e adult bur% in a 'ini-head ;6ig( =9( ;b< and ;c<<(

!( "lace = '' of ce'ent o$er the gutta &ercha( ?( 6re%hen dentine ,ith a round bur( Do not re'o$e exce%%i$ely( C( Etch the &ul& cha'ber ,ith @?L &ho%&horic acid for @9-!9 %, ,a%h, and drythi% ,ill facilitate the ingre%% of the hydrogen &eroxide( >( "lace the bleaching agent, either alone or on a cotton ,ool &ledget into the &ul& cha'ber( "lace into the tooth, either alone ,ith a flat &la%tic in%tru'ent or on a cotton-,ool &ledget( =9( "lace a dry &iece of cotton ,ool o$er the 'ixture( ==( Seal the ca$ity ,ith gla%% iono'er ce'ent( = ( Re&eat the &roce%% at ,ee/ly inter$al% until the tooth i% %lightly o$erbleached( =@( "lace non-%etting calciu' hydroxide into the &ul& cha'ber for gla%% iono'er ce'ent( ,ee/%( Seal ,ith

=A( 6inally, re%tore the tooth ,ith ,hite gutta &ercha ;to facilitate reo&ening the &ul& cha'ber again, if nece%%ary, at a later date< and co'&o%ite re%in( 6igure% =9(@ ;a< and ;b< %ho, an exa'&le of a highly %ucce%%ful re%ult( )f the colour of a tooth ha% not %ignificantly i'&ro$ed after three change% of bleach then it i% unli/ely to do %o, and further bleaching %hould be abandoned( The 'axi'u' nu'ber of bleach a&&lication% i% u%ually acce&ted a% =9( 6ailure of a tooth to bleach could be due to either inadeBuate re'o$al of filling 'aterial% fro' the &ul& cha'ber or to *ti'e ex&ired* bleaching agent( 4oth the%e factor% %hould be chec/ed before abandoning a &rocedure( Slight o$erbleaching i% de%irable, but the &atient %hould be in%tructed to attend the %urgery before the next a&&oint'ent if 'ar/ed o$erbleaching ha% occurred( -on-$ital bleaching ha% a re&utation of cau%ing brittlene%% of the tooth( Thi% i% &robably the re%ult of &re$iou% in+udiciou% re'o$al of dentine ;,hich only need% to be *fre%hened* ,ith a round bur<, rather than a direct effect of the bleaching &rocedure it%elf( Thi% 'ethod of bleaching ha% been a%%ociated ,ith the later occurrence of external cer$ical re%or&tion( The exact 'echani%' of thi% a%%ociation i% unclear, but it i% thought that the hydrogen &eroxide diffu%e% through the dentinal tubule% to %et u& an infla''atory reaction in the &eriodontal liga'ent around the cer$ical region of the tooth( )n a %'all nu'ber of teeth there i% a ga& bet,een the end of the ena'el and the beginning of the ce'entu', and in the%e ca%e% the abo$e ex&lanation i% tenable( The &ur&o%e of the =-'' layer of ce'ent i% to co$er the o&ening% of the dentinal tubule% at the le$el ,here there 'ay be a co''unication to the &eriodontal liga'ent( )n the %a'e ,ay, non-%etting calciu' hydroxide i% &laced in the &ul& cha'ber for ,ee/% &rior to final re%toration in order to eradicate any infla''ation in the &eriodontal liga'ent that 'ay ha$e been initiated(

Clinical %tudie% ha$e de'on%trated that regre%%ion can be ex&ected ,ith thi% techniBue( The longe%t %tudy after C year% ga$e a =L failure rate( 1o,e$er, if ,hite gutta &ercha ha% been &laced ,ithin the &ul& cha'ber then it i% readily re'o$ed and the tooth ea%ily rebleached( The ad$antage% of the techniBue are 'anyG ea%y for o&erator and &atientH con%er$ation of tooth ti%%ue and 'aintenance of the original cro,n 'or&hologyH no irritation to gingi$al ti%%ue%H no &roble'% ,ith changing gingi$al le$el in young &atient% co'&ared to $eneer% or cro,n%H no technical a%%i%tance reBuired( Fi!. /0.2 ;a< Radiogra&h of u&&er right central inci%or ,ith a ,ell-conden%ed root filling( ;b< Standard bur in a contra-angled head 'ay not reach the dentogingi$al +unction( ;c< Correct de&th achie$ed u%ing a %tandard bur in a 'iniature head( Fi!. /0.3 ;a< and ;b< )nten%ely dar/ened, non-$ital, u&&er left central inci%or treated by four change% of bleach( /0.2.3 T%e in#ideBo-t#ide ,lea"%in! te"%niA-e Recently, an alternati$e a&&roach to the 'anage'ent of the di%coloured endodontically treated tooth ha% been de%cribed( 2no,n a% the in%ideDout%ide bleaching techniBue, it i% e%%entially a co'bination of the ,al/ing and $ital bleaching techniBue%( Tooth &re&aration i% the %a'e a% de%cribed for the ,al/ing bleach techniBue ;%ection =9( ( < ,ith &articular attention being &aid to re'o$al of the gutta &ercha belo, the ce'ento-ena'el +unction follo,ed by the &lace'ent of a barrier ;u%ually a gla%% iono'er ce'ent or 5inc oxide eugenol ce'ent< to %eal the root canal fro' the oral ca$ity( 0 cu%to' 'ade tray ;%ee 6ig( =9(: ;b<< i% con%tructed a% a $ehicle for the bleaching gel( 1o,e$er, rather than creating %&ace labially a% in the $ital bleaching techniBue a %'all re%er$oir i% created &alatal to the affected tooth only( The gel, =9L carba'ide &eroxide, i% &laced by the &atient into both the acce%% ca$ity of the non-$ital tooth and the tray( The tray i% then ,orn full ti'e for u& to A day%, the gel being re&laced e$ery -A h( Once an ae%thetically acce&table re%ult i% achie$ed the acce%% ca$ity i% refilled a&&ro&riately( 3ong-ter' re%ult% are not yet a$ailable for thi% a&&roach ,ith rela&%e being a% li/ely a% any of the other bleaching techniBue%( Fi!. /0.5 ;a< Model of u&&er arch ,ith ,ax relief for con%truction of a night guard( ;b< Mouthguard being loaded ,ith carba'ide &eroxide gel( /0.2.0 )ital ,lea"%in! "%air#ide Thi% techniBue in$ol$e% the external a&&lication of hydrogen &eroxide to the %urface of the tooth follo,ed by it% acti$ation ,ith a heat %ource( The techniBue ha% achie$ed con%iderable %ucce%% in the #nited State%, but it i% a lengthy and ti'e-con%u'ing &rocedure that reBuire% a high degree of &atient co'&liance and 'oti$ation( Indi"ation# ;=< $ery 'ild tetracycline %taining ,ithout ob$iou% bandingH ; < 'ild fluoro%i%H

;@< yello,ing due to ageingH ;A< %ingle teeth ,ith %clero%ed &ul& cha'ber% and canal%( Armamentari-m ;=< rubber da' ,ith cla'&% and flo%% ligature%H ; < Oraba%e gelH ;@< to&ical anae%theticH ;A< gau5eH ;:< @?L &ho%&horic acidH ;!< heating light ,ith rheo%tatH ;?< @9-$olu'e hydrogen &eroxideH ;C< &oli%hing %tone%H ;>< fluoride dro&% ;9- year%G dro&%<( Te"%niA-e =( Ta/e &reo&erati$e &eria&ical radiogra&h% and &erfor' $itality te%t%( Re&lace any lea/ing re%toration%( ( Clean the teeth ,ith &u'ice and ,ater to re'o$e extrin%ic %taining( Ta/e &reo&erati$e &hotogra&h% ,ith a tooth fro' a *8ita* %hade guide regi%tering the %hade, ad+acent to the &atient*% teeth( @( 0&&ly to&ical anae%thetic to gingi$al 'argin%( A( Coat the buccal and &alatal gingi$ae ,ith Oraba%e gel a% extra &rotection fro' the bleaching %olution( :( )%olate each tooth to be bleached u%ing indi$idual ligature%( The end teeth %hould be cla'&ed ;u%ually fro' %econd &re'olar to %econd &re'olar<( !( Co$er the 'etal rubber da' cla'&% ,ith da'& %tri&% of gau5e to &re$ent the' fro' getting hot under the influence of the heat %ource( ?( Etch the labial and a third of the &alatal %urface% of the teeth ,ith the &ho%&horic acid for !9 %, ,a%h, and dry( Thoroughly %oa/ a %tri& of gau5e in the @:L hydrogen &eroxide and co$er the teeth to be bleached( C( "o%ition the heat la'& =@-=: inche% ;@@-@C c'< fro' the &atient*% teeth( Set the rheo%tat to a 'id-te'&erature range and increa%e it until the &atient can +u%t feel the ,ar'th in their teeth, and then reduce it %lightly until no %en%ation i% felt( >( 2ee& the gau5e da'& by rea&&lying the hydrogen &eroxide e$ery @-: 'in u%ing a cotton bud( Ma/e %ure the bottle i% clo%ed bet,een a&&lication% a% the hydrogen &eroxide deacti$ate% on ex&o%ure to air( =9( 0fter @9 'in re'o$e the rubber da', clean off the Oraba%e gel, and &oli%h the teeth u%ing the %hofu %tone%( 0&&ly the fluoride dro&% for -@ 'in(

==( -ote that &o%to&erati$e %en%iti$ity 'ay occur and %hould be relie$ed ,ith &araceta'ol( = ( 0%%e%% the changeit 'ay be nece%%ary to re&eat the &roce%% @-=9 ti'e% &er arch( Treat one arch at a ti'e( 2ee& the &atient under re$ie, a% rebleaching 'ay be reBuired after = or 'ore year%( =@( Ta/e &o%to&erati$e &hotogra&h% ,ith the original *8ita* %hade tooth included( Thi% techniBue i% $ery ti'e con%u'ing and retreat'ent 'ay be nece%%ary %o the &atient 'u%t be highly 'oti$ated( The techniBue can be u%ed in the treat'ent of di%colouration cau%ed by &ul& cha'ber %clero%i% ;6ig( =9(A ;a<-;c<<( The%e ca%e% reBuire i%olation of the %ingle tooth( Fi!. /0.0 ;a< and ;b< 0 di%coloured, u&&er right central inci%or ,ith radiogra&h confir'ing %clero%i% of the &ul& cha'ber and root canal( ;c< 0&&earance of u&&er right central inci%or after four chair%ide bleaching treat'ent%( /0.2.5 )ital ,lea"%in! ni!%t!-ard Thi% techniBue in$ol$e% the daily &lace'ent of carba'ide &eroxide gel into a cu%to'fitted tray of either the u&&er or the lo,er arch( 0% the na'e %ugge%t%, it i% carried out by the &atient at ho'e and i% initially done on a daily ba%i%( Indi"ation# ;=< 'ild fluoro%i%H ; < 'oderate fluoro%i% a% an ad+unct to hydrochloric acid-&u'ice 'icroabra%ionH ;@< yello,ing of ageing( Armamentari-m ;=< u&&er i'&re%%ion and ,or/ing 'odelH ; < %oft 'outhguarda$oiding the gingi$aeH ;@< =9L carba'ide &eroxide gel( Te"%niA-e =( Ta/e an alginate i'&re%%ion of the arch to be treated and ca%t a ,or/ing 'odel in %tone( ( Relie$e the labial %urface% of the teeth by about 9(: '' and 'a/e a %oft, &ulldo,n, $acuu'- for'ed %&lint a% a 'outhguard ;6ig( =9(: ;a<<( The %&lint %hould be no 'ore than '' in thic/ne%% and %hould not co$er the gingi$ae( )t i% only a $ehicle for the bleaching gel and not intended to &rotect the gingi$ae( @( )n%truct the &atient on ho, to flo%% their teeth thoroughly( "erfor' a full 'outh &ro&hylaxi% and in%truct the' ho, to a&&ly the gel into the 'outh-guard ;6ig( =9(: ;b<<(

A( -ote that the length of ti'e the guard %hould be ,orn de&end% on the &roduct u%ed( :( Re$ie, about ,ee/% later to chec/ that the &atient i% not ex&eriencing any %en%iti$ity, and then at ! ,ee/%, by ,hich ti'e C9L of any colour change %hould ha$e occurred( Carba'ide &eroxide gel ;=9L< brea/% do,n in the 'outh into @L hydrogen &eroxide and ?L urea( 4oth urea and hydrogen &eroxide ha$e lo, 'olecular ,eight%, ,hich allo, the' to diffu%e ra&idly through ena'el and dentine and thu% ex&lain% the tran%ient &ul&al %en%iti$ity occa%ionally ex&erienced ,ith ho'e bleaching %y%te'%( "ul&al hi%tology ,ith regard to the%e 'aterial% ha% not been a%%e%%ed, but no clinical %ignificance ha% been attributed to the change% %een ,ith @:L hydrogen &eroxide o$er ?: year% of u%age, exce&t ,here teeth ha$e been o$erheated or trau'ati5ed( 4y extra&olation, @L hydrogen &eroxide in the ho'e %y%te'% %hould therefore be %afe( 0lthough 'o%t carba'ide &eroxide 'aterial% contain trace a'ount% of &ho%&horic and citric acid% a% %tabili5er% and &re%er$ati$e%, no indication of etching or a %ignificant change in the %urface 'or&hology of ena'el ha% been de'on%trated by %canning electron 'icro%co&y analy%i%( There ,a% early concern that bleaching %olution% ,ith a lo, &1 ,ould cau%e de'inerali5ation of ena'el ,hen the &1 fell belo, the *critical* &1 of :( -:(C( 1o,e$er, no e$idence of thi% &roce%% ha% been noted to date in any clinical trial% or laboratory te%t%, and thi% 'ay be due to the urea ;and %ub%eBuently the a''onia< and carbon dioxide relea%ed on degradation of the carba'ide &eroxide ele$ating the &1( There i% an initial decrea%e in bond %trength% of ena'el to co'&o%ite re%in% i''ediately after ho'e bleaching but thi% return% to nor'al ,ithin ? day%( Thi% effect ha% been attributed to the re%idual oxygen in the bleached tooth %urface ,hich inhibit% &oly'eri5ation of the co'&o%ite re%in( The ho'e bleaching %y%te'% do not affect the colour of re%torati$e 'aterial%( 0ny &ercei$ed effect i% &robably due to %u&erficial clean%ing( Minor ulceration or irritation 'ay occur during the initial treat'ent( )t i% i'&ortant to chec/ that the 'outhguard doe% not extend on to the gingi$ae and that the edge% of the guard are %'ooth( )f ulceration &er%i%t% a decrea%ed ex&o%ure ti'e 'ay be nece%%ary( )f there i% %till a &roble' then allergy i% a &o%%ibility( There are no biological concern% regarding the %hort-ter' u%e of carba'ide &eroxide( )t ha% a %i'ilar cytotoxicity on 'ou%e fibrobla%t% a% 5inc &ho%&hate ce'ent and Cre%t tooth&a%te, and ha% been u%ed for a nu'ber of year% in the #nited State% to reduce &laBue and &ro'ote ,ound healing( 1o,e$er, there are no long-ter' %tudie% on it% %afetyH laboratory %tudie% ha$e %ho,n that carba'ide &eroxide ha% a 'utagenic &otential on $a%cular endotheliu' and there 'ay be har'ful effect% on the &eriodontiu', together ,ith delayed ,ound healing( "ubli%hed clinical %tudie% of =- year%* duration ha$e %ho,n that the yello,ing of ageing re%&ond% be%t to treat'ent( 0lthough thi% ,ould a&&ear to ta/e ho'e bleaching out of the re'it of &aediatric denti%try, it 'ay %till ha$e a &art to &lay in the &reli'inary lightening of tetracycline-%tained teeth &rior to $eneer &lace'ent, and

al%o in ca%e% of 'ild fluoro%i%( )rre%&ecti$e of the clinical a&&lication, e$idence %ugge%t% that annual retreat'ent 'ay be nece%%ary to 'aintain any effecti$e lightening( Thi% further highlight% the i'&ortance of 'ore re%earch into the long-ter' effect% of thi% treat'ent on the teeth, the 'uco%a, and the &eriodontiu'( The exact 'echani%' of bleaching in any of the three 'ethod% de%cribed i% un/no,n( Theorie% of oxidation, &hoto-oxidation, and ion exchange ha$e been %ugge%ted( Con$er%ely, the cau%e of redi%colouration i% al%o un/no,n( Thi% 'ay be a co'bination of che'ical reduction of the oxidation &roduct% &re$iou%ly for'ed, 'arginal lea/age of re%toration% allo,ing ingre%% of bacterial and che'ical by&roduct%, and %ali$ary or ti%%ue fluid conta'ination $ia &er'eable tooth %tructure( /0.2.1 *o"ali:ed "om o#ite re#in re#toration# Thi% re%torati$e techniBue u%e% recent ad$ance% in dental 'aterial% %cience to re&lace defecti$e ena'el ,ith a re%toration that bond% to and blend% ,ith ena'el( Indi"ation# =( Well-de'arcated ,hite, yello,, or bro,n hy&o'inerali%ed ena'el( Armamentari-m ;=< rubber da'Dcontoured 'atrix %tri&% ;8i$adent<H ; < round and fi%%ure dia'ond bur%H ;@< ena'elDdentine bonding /itH ;A< ne, generation, highly &oli%hable, hybrid co'&o%ite re%inH ;:< Soflex di%c% ;@M< and inter&roxi'al &oli%hing %tri&%( Te"%niA-e =( Ta/e &reo&erati$e &hotogra&h% and %elect the %hade ;6ig( =9(! ;a<<( ( 0&&ly rubber da' or contoured 'atrix %tri&%( @( Re'o$e de'arcated le%ion ,ith a round dia'ond bur do,n to the a'elodentinal +unction ;0D7<( A( Cha'fer the ena'el 'argin% ,ith a dia'ond fi%%ure bur to increa%e the %urface area a$ailable for retention( :( Etch the ena'el 'argin%,a%h and dry( !( 0&&ly the dentine &ri'er to dentine and dry( ?( 0&&ly the ena'el- and dentine-bonding agent and light-cure( C( 0&&ly the cho%en %hade of co'&o%ite u%ing a bru%h lubricated ,ith the bonding agent to %'ooth and %ha&e, and light-cure for the reco''ended ti'e(

>( Re'o$e the 'atrix %tri&Drubber da'( =9( "oli%h ,ith graded Soflex di%c% ;@M<, fini%hing bur%, and inter&roxi'al %tri&% if reBuired( 0dd characteri5ation to the %urface of the co'&o%ite( ==( Ta/e &o%to&erati$e &hotogra&h% ;6ig( =9(! ;b<<( The locali5ed re%toration i% Buic/ and ea%y to co'&lete( De%&ite the re'o$al of defecti$e ena'el do,n to the 0D7 there i% often no %ignificant %en%iti$ity and therefore no need for local anae%the%ia( )f the hy&o&la%tic ena'el ha% beco'e cariou% and thi% extend% into dentine then a liner of gla%% iono'er ce'ent ;correct %hade< &rior to &lace'ent of the co'&o%ite re%in ,ill be nece%%ary( 3ocal anae%the%ia ,ill &robably be reBuired in the%e ca%e%( 0d$ance% in bonding and re%in technology 'a/e the%e re%toration% %i'&le and ob$iate the need for a full labial $eneer( Di%ad$antage% are 'arginal %taining, accurate colour 'atch, and reduced co'&o%ite tran%lucency ,hen lined by a gla%% iono'er ce'ent( Fi!. /0.1 ;a< and ;b< Well-de'arcated ,hite o&acitie% on the u&&er central inci%or% treated by locali5ed co'&o%ite re%toration%( /0.2.2 Com o#ite re#in .eneer# 0lthough the &orcelain +ac/et cro,n ;"7C< 'ay be the 'o%t %ati%factory long-ter' re%toration for a %e$erely hy&o&la%tic or di%coloured tooth, it i% not an a&&ro&riate %olution for children for t,o rea%on%G ;=< the large %i5e of the young &ul& horn% and cha'berH and ; < the i''ature gingi$al contour( Co'&o%ite $eneer% 'ay be direct ;&laced at initial a&&oint'ent< or indirect ;&laced at a %ub%eBuent a&&oint'ent ha$ing been fabricated in the laboratory<( The con%er$ati$e $eneering 'ethod% 'ay not +u%t offer a te'&orary %olution, but a %ati%factory longter' alternati$e to the "7C( Mo%t co'&o%ite $eneer% &laced in children and adole%cent% are of the *direct* ty&e, a% the durability of the indirect co'&o%ite $eneer% i% a% yet un/no,n( 4efore &roceeding ,ith any $eneering techniBue, the deci%ion 'u%t be 'ade ,hether to reduce the thic/ne%% of labial ena'el before &lacing the $eneer( Certain factor% %hould be con%ideredG =( )ncrea%ed labio&alatal bul/ 'a/e% it harder to 'aintain good oral hygiene( Thi% 'ay be courting di%a%ter in the adole%cent ,ith a dubiou% oral hygiene techniBue( ( Co'&o%ite re%in ha% a better bond %trength to ena'el ,hen the %urface layer of 99-@99 '' i% re'o$ed( @( )f a tooth i% $ery di%coloured %o'e %ort of reduction ,ill be de%irable, a% a thic/er layer of co'&o%ite ,ill be reBuired to 'a%/ the inten%e %tain( A( )f a tooth i% already in%tanding or rotated, it% a&&earance can be enhanced by a thic/er labial $eneer(

-e, generation, highly &oli%hable, hybrid co'&o%ite re%in% can re&lace relati$ely large a'ount% of 'i%%ing tooth ti%%ue a% ,ell a% being u%ed in thin %ection% a% a $eneer( Co'bination% of %hade% can be u%ed to %i'ulate natural colour gradation% and hue%( Indi"ation# ;=< di%colourationH ; < ena'el defect%H ;@< dia%te'ataH ;A< 'al&o%itioned teethH ;:< large re%toration%( Contraindi"ation# ;=< in%ufficient a$ailable ena'el for bondingH ; < oral habit%, e(g( ,ood,ind 'u%ician%( Armamentari-m ;=< rubber da'Dcontoured 'atrix %tri&% ;8i$adent<H ; < &re&aration and fini%hing bur%H ;@< ne, generation, highly &oli%hable, hybrid co'&o%ite re%inH ;A< Soflex di%c% ;@M< and inter&roxi'al &oli%hing %tri&%( Te"%niA-e =( #%e a ta&ered dia'ond bur to reduce labial ena'el by 9(@-9(: ''( )dentify the fini%h line at the gingi$al 'argin and al%o 'e%ially and di%tally +u%t labial to the contact &oint%( ( Clean the tooth ,ith a %lurry of &u'ice in ,ater( Wa%h and dry and %elect the %hade ;6ig( =9(? ;a<<( @( )%olate the tooth either ,ith rubber da' or a contoured 'atrix %tri&( 1old thi% in &lace by a&&lying unfilled re%in to it% gingi$al %ide again%t the gingi$a and curing for =9 % ;6ig( =9(? ;b<<( A( Etch the ena'el for !9 %, ,a%h, and dry( :( Where dentine i% ex&o%ed a&&ly dentine &ri'er( !( 0&&ly a thin layer of bonding re%in to the labial %urface ,ith a bru%h and cure for =: %( )t 'ay be nece%%ary to u%e an o&aBuer at thi% %tage if the di%colouration i% inten%e( ?( 0&&ly co'&o%ite re%in of the de%ired %hade to the labial %urface and roughly %ha&e it into all area% ,ith a &la%tic in%tru'ent, then u%e a bru%h lubricated ,ith unfilled re%in to *&addle* and %'ooth it into the de%ired %ha&e( Cure !9 % gingi$ally, !9 % 'e%ioinci%ally, !9 % di%toinci%ally, and !9 % fro' the &alatal a%&ect if inci%al co$erage

ha% been u%ed( Different %hade% of co'&o%ite can be co'bined to achie$e good 'atche% ,ith ad+acent teeth and a tran%ition fro' a relati$ely dar/ gingi$al area to a lighter 'ore tran%lucent inci%al region ;6ig( =9(? ;c<<( C( 6lic/ a,ay the unfilled re%in holding the contour %tri& and re'o$e the %tri&( >( 6ini%h the 'argin% ,ith dia'ond fini%hing bur% and inter&roxi'al %tri&% and the labial %urface ,ith graded %and&a&er di%c%( Characteri5ation %hould be added to i'&ro$e light reflection &ro&ertie% ;6ig( =9(? ;d<<( The exact de%ign of the co'&o%ite $eneer ,ill be de&endent u&on each clinical ca%e, but ,ill u%ually be one of four ty&e%G intraena'el or ,indo, &re&arationH inci%al be$elH o$erla&&ed inci%al edgeH or feathered inci%al edge ;6ig( =9(C<( Tooth &re&aration ,ill not nor'ally ex&o%e dentine, but thi% ,ill be una$oidable in %o'e ca%e% of locali5ed hy&o&la%ia or ,ith carie%( Sound dentine 'ay need to be co$ered by gla%% iono'er ce'ent &rior to &lace'ent of the co'&o%ite $eneer( 6igure =9(> ;a< and ;b< %ho, an exa'&le of %ucce%%ful co'&o%ite $eneer% that ha$e been in &lace for : year%( Studie% ha$e %ho,n that co'&o%ite $eneer% are durable enough to la%t through adole%cence until a 'ore ae%thetic &orcelain $eneer can be &laced( Thi% i% nor'ally only con%idered at about the age of =C- 9 year% ,hen the gingi$al 'argin ha% achie$ed an adult le$el and the %tandard of oral hygiene and dental 'oti$ation are acce&table( Fi!. /0.2 ;a< 0 young &atient ,ith a'elogene%i% i'&erfecta( ;b< Contoured 'atrix %tri& in &o%ition( ;c< )ncre'ental &lace'ent of dentine %hade co'&o%ite( ;d< "o%to&erati$e $ie, %ho,ing final co'&o%ite $eneer%( Fi!. /0.3 Ty&e% of $eneer &re&aration( Fi!. /0.4 ;a< Teenaged girl ,ith dar/, tetracycline di%coloration and an ena'el fracture( ;b< : year%* &o%t&lace'ent of co'&o%ite $eneer%( /0.2.3 Por"elain .eneer# "orcelain ha% %e$eral ad$antage% o$er co'&o%ite a% a $eneering 'aterialG it% a&&earance i% %u&eriorH it ha% a better re%i%tance to abra%ionH and it i% ,ell tolerated by the gingi$al ti%%ue%( 1o,e$er, it i% $ital that the &orcelain fit% exactly and that the fil' thic/ne%% of the luting ce'ent i% /e&t to a 'ini'u'( The%e luting ce'ent% are only 'oderately filled co'&o%ite re%in% and they ab%orb ,ater, hydroly%e, and %tain( Thi% cou&led ,ith the a&ical 'igration of the gingi$al 'argin in young &atient% can re%ult in an unacce&table ae%thetic a&&earance in a relati$ely %hort ti'e( )n%truction in %tandard &orcelain $eneer &re&aration i% co$ered in re%torati$e denti%try textboo/%( )f there are occa%ion% ,hen they are u%ed at an earlier age then the %a'e &rinci&le% a&&ly( 1o,e$er, a non-%tandard a&&lication that i% being u%ed 'ore freBuently at a younger age i% the re%toration of the &eg lateral inci%or ;6ig( =9(=9 ;a<<( Thi% utili5e% a no-&re&aration techniBue and the technician i% a%/ed to &roduce a three-Buarter ,ra&-around $eneer fini%hed to a /nife edge at the gingi$al 'argin ;6ig( =9(=9 ;b<<( 0n ela%to'eric i'&re%%ion i% ta/en after gingi$al retraction to obtain the

'axi'u' length of cro,n, and ce'entation %hould be under rubber da' ;6ig( =9(=9 ;c<<( Fi!. /0./0 ;a< "eg-%ha&ed lateral inci%or% in a =:-year old( ;b< 3aboratory 'odel %ho,ing three-Buarter ,ra&-around, &orcelain $eneer% on the u&&er lateral%( ;c< 6inal re%toration% on the u&&er lateral% year%* &o%tce'entation( /0.2.4 Ad%e#i.e metal "a#tin!# The de$elo&'ent of acid-etched, retained ca%t re%toration% ha% allo,ed the fabrication of ca%t occlu%al onlay% for &o%terior teeth and &alatal $eneer% for inci%or% and canine%( The%e re%toration% are 'anufactured ,ith 'ini'al or no tooth &re&aration and are ideal for ca%e% ,here there i% a ri%/ of tooth ti%%ue lo%%( Indi"ation# ;=< a'elogene%i% i'&erfectaH ; < dentinogene%i% i'&erfectaH ;@< dental ero%ion, attrition, or abra%ionH ;A< ena'el hy&o&la%ia( Armamentari-m ;=< gingi$al retraction cordH ; < ela%to'eric i'&re%%ion 'aterialH ;@< facebo, %y%te'H ;A< %e'i-ad+u%table articulatorH ;:< rubber da'H ;!< "ana$ia Ex ;2uraray<( Te"%niA-e =( Obtain %tudy 'odel% ;the%e are e%%ential< and &hotogra&h% if &o%%ible( ( "erfor' a full 'outh &ro&hylaxi%( @( En%ure good 'oi%ture i%olation( A( "lace retraction cord into the gingi$al cre$ice% of the teeth to be treated and re'o$e i''ediately &rior to ta/ing the i'&re%%ion( :( Ta/e an i'&re%%ion u%ing an ela%to'eric i'&re%%ion 'ateriala &uttyD,a%h %y%te' i% the be%t and chec/ the 'argin% are ea%ily di%tingui%hable( !( Ta/e a facebo, tran%fer and interocclu%al record in the retruded axi% &o%ition( ?( Mount the ca%t% on a %e'i-ad+u%table articulator( C( Con%truct ca%t onlay%, a 'axi'u' of =(: '' thic/ occlu%ally in either nic/elD chro'e or gold(

>( Grit-bla%t the fitting %urface% of the occlu%al onlay%( =9( Return to the 'outh and chec/ the fit of the onlay%( ==( "oli%h the teeth ,ith &u'ice and i%olate under rubber da' ,here &o%%ible( = ( Ce'ent onlay% u%ing "ana$ia Ex( =@( Chec/ occlu%ion( =A( Re$ie, in = ,ee/ for &roble'%, and regularly thereafter( 6igure =9(== ;a< and ;b< %ho, gold onlay% ce'ented on to the lo,er fir%t &er'anent 'olar% of a =!-year-old boy ,ith ero%i$e tooth %urface lo%%( Such ca%t re%toration% 'ay be &ro$ided for both &o%terior and anterior teeth ,ith $ery little or no tooth &re&aration( -e$erthele%%, %o'e children 'ay find thi% treat'ent challenging a% it de'and% high le$el% of &atient co-o&eration( 3ocal anae%the%ia 'ay be needed a% the hy&o&la%tic teeth are often %en%iti$e to the etching and ,a%hing &rocedure and the &lace'ent of gingi$al retraction cord can be unco'fortable( 6urther'ore, 'oi%ture control can be difficult and, ,hile &referable, rubber da' i% not al,ay% fea%ible( When u%ed to &rotect the &alatal a%&ect of u&&er anterior teeth there 'ay be an ae%thetic &roble' a% the 'etal 'ay *%hine through* the tran%lucent inci%al ti& of young teeth( The durability of thi% for' of re%toration ha% no, been confir'ed by =9-year e$aluation %tudie%( Fi!. /0.// ;a< Mar/ed occlu%al ena'el lo%% of lo,er fir%t &er'anent 'olar%( ;b< Ca%t occlu%al onlay% in situ after re&lace'ent of a'alga' re%toration% ,ith co'&o%ite re%in( /0.2./0 Indire"t "om o#ite re#in onla$# 0n alternati$e to ca%t 'etal onlay% are indirect co'&o%ite onlay%( )n addition to the ob$iou% ae%thetic ad$antage% the%e re%toration% can be 'odified relati$ely ea%ily( Thi% i% &articularly u%eful for condition% %uch a% ero%ion ,here the di%ea%e &roce%% 'ay ,ell be ongoing and therefore the tooth andDor re%toration 'ay reBuire re&air or addition%( Studie% %ugge%t that the%e re%toration% are durable in the anterior region, ho,e$er, in re%&on%e to &atient de'and indirect co'&o%ite onlay% are increa%ingly being u%ed in the &o%terior region ;6ig( =9(= ;a<-;c<<, ,here their durability i% currently unclear( The di%ad$antage of the%e re%toration% i% that they need to be thic/er than their ca%t counter&art%, are bul/ier and can cau%e greater increa%e% in $ertical di'en%ion( 1o,e$er, in young &atient%, &ro$iding the occlu%ion re'ain% balanced and there i% no &eriodontal &athology, then increa%e% in $ertical di'en%ion a&&ear ,ell tolerated( Fi!. /0./2 Direct Co'&o%ite Onlay% 'ade for lo,er &o%terior Buadrant%(

/0.3 T&&T5 DISC&*&(RATI&N The colour of a child*% teeth can be of great i'&ortance( "eer-grou& &re%%ure can be $ery %trong and tea%ing about the %i5e, &o%ition, and colour of the teeth can be $ery har'ful to a child or adole%cent( The cau%e% of di%coloured teeth 'ay be cla%%ified in a nu'ber of ,ay%G congenitalD acBuiredH ena'elDdentineH extrin%icDintrin%icH %y%te'icDlocal( The 'o%t u%eful 'ethod of cla%%ification for the clinical 'anage'ent of di%colouration i% one that identifie% the 'ain %ite of di%colouration ;Table =9(@<( Once the aetiology of the di%colouration had been identified the 'o%t a&&ro&riate 'ethod of treat'ent can be cho%en( )deal and &er'anent re%ult% 'ay not be reali%tic in the young &atientH ho,e$er, %ignificant i'&ro$e'ent% are achie$able ,hich do not co'&ro'i%e the teeth in the long ter'( The a&&roach to treat'ent for all for'% of di%colouration %hould be cautiou%, ,ith the e'&ha%i% on 'ini'al tooth &re&aration( 6or exa'&le, in a ca%e of fluoro%i% the 'icroabra%ion techniBue 'ay &roduce %o'e i'&ro$e'ent but the &atientD&arent 'ay %till be di%%ati%fied( Co'&o%ite $eneer% can then be &laced, although if the child reBuire% %ub%eBuent fixed a&&liance treat'ent the%e 'ay be da'aged and reBuire re&lace'ent before &lacing &orcelain $eneer% a% the definiti$e re%toration in the late teenage year%( Di%colouration originating in the dentine i% often difficult to treat( The %ingle, non$ital dar/ inci%or &re%ent% &articular &roble'%( )n the young &atient, the a&ex 'ay be i''ature, root canal thera&y inco'&lete, and non-$ital bleaching therefore &recluded( 0 co'&o%ite $eneer can i'&ro$e the ae%thetic% but 'ay fail to adeBuately di%gui%e the di%colouration e$en ,ith the u%e of o&aBueing agent%( #lti'ately, a +ac/et cro,n 'ay be the be%t o&tion in the older &atient( Si'ilarly, 'oderate-to- %e$ere tetracycline di%colouration, ,hich fortunately i% le%% co''on today, i% $ery difficult to treat in the young &atient( 3ong-ter' full cro,n% or &orcelain $eneer% often &ro$ide definiti$e treat'ent, but co'&o%ite $eneer% can be acce&table in the adole%cent ,ithout co'&letely 'a%/ing the underlying di%colouration ;6ig( =9(=@ ;a<-;c<<( )ndirect co'&o%ite $eneer%, &laced ,ith 'ini'al tooth &re&aration, 'ay be u%eful in the 'anage'ent of thi% &roble' but thi% techniBue ha% yet to be e$aluated( >e$ Point# Microabra%ion %hould be the fir%t line of treat'ent in all ca%e% of ena'el o&acitie%( Co'&o%ite %hould be u%ed in &reference to &orcelain in children( 6inally, it i% $ery i'&ortant to bear in 'ind the ex&ectation% of the &atient and, often 'ore i'&ortantly, the &arent( 0n unreali%tically high ex&ectation of brilliant ,hite *fil' %tar* teeth ,ill re%ult in &o%to&erati$e di%a&&oint'ent( 6or in%tance, in fluoro%i% ca%e% it i% the exce%%i$ely ,hite, 'ottled area% ,hich ,ill be re'o$ed by the 'icroabra%ion techniBue re%ulting in a unifor' colour that i% the %a'e a% the original bac/ground colour, but %o'e &atient% ,ill feel their treated teeth are *too yello,*( 0deBuate &reo&erati$e ex&lanation, &referably ,ith &hotogra&hic exa'&le%, 'ay hel& to 'ini'i5e thi% &roble'( -e$erthele%%, there ,ill re'ain a grou& of di%%ati%fied &atient% and for 'edico-legal rea%on% careful docu'entation of all ca%e% of co%'etic treat'ent %hould be /e&t(

Fi!. /0./3 ;a< Se$ere tetracycline di%colouration in a =A year old( ;b< Co'&o%ite $eneer% &laced under o&aBueing agent% to 'a%/ the di%coloration( ;c< "orcelain +ac/et cro,n% ,ere &ro$ided at 9 year% of age( /0.0 T&&T5 S(RFACE *&SS /0.0.0 Introd-"tion Denti%t% ha$e been a,are of the &roble' of tooth ,ear or non-cariou% lo%% of tooth ti%%ue for a long ti'e( 1o,e$er, it i% only 'ore recently that it ha% been increa%ingly a%%ociated ,ith our younger &o&ulation( There are three &roce%%e% that 'a/e u& the &heno'enon of tooth ,earG ;=< attrition,ear of the tooth a% a re%ult of tooth-to-tooth contactH ; < erosionirre$er%ible lo%% of tooth %ub%tance brought about by a che'ical &roce%% that doe% not in$ol$e bacterial actionH ;@< a,rasion&hy%ical ,ear of tooth %ub%tance &roduced by %o'ething other than tooth-to-tooth contact( )n children, abra%ion i% relati$ely unco''on( The 'o%t freBuent cau%e of abra%ion i% o$er5ealou% toothbru%hing, ,hich tend% to de$elo& ,ith increa%ing age( 0ttrition during 'a%tication i% co''on, &articularly in the &ri'ary dentition ,here al'o%t all u&&er inci%or% %ho, %o'e %ign% of attrition by the ti'e they exfoliate ;6ig( =9(=A<( 1o,e$er, o$er the &a%t decade the contribution of ero%ion to the o$erall &roce%% of tooth ,ear in the younger &o&ulation ha% been highlighted( While ero%ion 'ay be the &redo'inant &roce%%, attrition and abra%ion 'ay be co'&ounding factor%, for exa'&le, toothbru%h abra%ion 'ay be increa%ed if bru%hing i% carried out i''ediately after the con%u'&tion of ero%i$e food%tuff% or drin/%( )t i% often difficult to identify a %ingle cau%ati$e agent in a ca%e of tooth ,ear %o the general ter' *tooth %urface lo%%* 'ay be 'ore a&&ro&riate( Fi!. /0./0 "ri'ary inci%or% %ho,ing &hy%iological ,ear( /0.0./ Pre.alen"e The &roble' ,ith trying to a%%e%% the &re$alence of tooth ,ear i% that a degree of tooth ti%%ue lo%% i% a &art of the nor'al &hy%iological &roce%% of ageingH ho,e$er, ,hen it i% li/ely to &re+udice the %ur$i$al of the teeth it can be %aid to be &athological( S'ith and 2night in =>CA de%cribed a Tooth Wear )ndex ;TW)<, ,hich included certain feature% that they felt ,ere diagno%tic of &athological tooth ,ear( The%e feature% are %ho,n in Table =9(A( There i% $ery little &ubli%hed e$idence on the &re$alence or %e$erity of tooth ,ear in children( )n =>>@ the -ational Child Dental 1ealth Sur$ey included an a%%e%%'ent of the &re$alence of ero%ion of both &ri'ary and &er'anent inci%or teeth for the fir%t ti'e( The %ur$ey re&orted that : L of :-year-old children had ero%ion of the &alatal %urface% of their &ri'ary inci%or%, ,ith AL %ho,ing &rogre%%ion into the &ul& ;6ig( =9(=:<( The &re$alence of ero%ion of the &alatal %urface% of &er'anent inci%or% ,a% al%o alar'ingly high ?L of =: year old%H ho,e$er, only L %ho,ed &rogre%%ion

into the &ul&( What i% unclear at the &re%ent ti'e i% ,hether the &roble' of tooth %urface lo%% i% actually increa%ing or ,hether the%e figure% reflect an increa%ed a,arene%%( Fi!. /0./5 "ri'ary inci%or% %ho,ing &athological ,ear and &ul& ex&o%ure( /0.0.2 Aetiolo!$ )n young &atient% there are three 'ain cau%e% of tooth %urface lo%%G ;=< dietaryH ; < ga%tric regurgitationH and ;@< &arafunctional acti$ity( )n addition to the%e three factor% certain en$iron'ental factor% ha$e been lin/ed to tooth ,ear( 1o,e$er, ,ith the exce&tion of freBuent u%e of chlorinated %,i''ing &ool%, 'o%t en$iron'ental and occu&ational ha5ard% do not a&&ly to children( Dietar$ "a-#e# o+ toot% #-r+a"e lo## The 'o%t co''on cau%e of ero%i$e tooth %urface lo%% i% an exce%%i$e inta/e of acidic food or drin/( Table =9(: %ho,% the ty&e% of food%tuff% i'&licated in ero%i$e tooth %urface lo%% in young &atient%( 0cidic drin/%, in &articular, are a$ailable to all age grou&% of children( "ure *baby* fruit +uice% are 'ar/eted for con%u'&tion by infant% and the%e ha$e been %ho,n to ha$e &1 $alue% belo, the critical &1 for the di%%olution of ena'el ;&1 M :(:<( Many of the%e drin/% are gi$en to infant% in a feeding bottle, and the co'bination of the highly acidic nature of the drin/ and the &rolonged ex&o%ure of the teeth to the acidic %ub%trate 'ay re%ult in exce%%i$e tooth %urface lo%% a% ,ell a% dental carie%( While a ,ide range of food% and drin/% are i'&licated in the aetiology of tooth %urface lo%%, %oft drin/% 'a/e u& the bul/ of the &roble'( Soft drin/ con%u'&tion ha% increa%ed dra'atically o$er the &a%t A9 year% to a %taggering =:= litre% &er ca&ita of the &o&ulation in the #nited 2ingdo' in =>>=, ,ith adole%cent% accounting for u& to !:L of the%e &urcha%e%( "ure fruit +uice% do contribute to thi% figure, but, increa%ingly, carbonated drin/% 'a/e u& a large &art of the younger &o&ulation*% inta/e and are no, ,idely a$ailable in $ending 'achine% located in %chool%, %&ort% centre%, and other &ublic area%( 4oth nor'al and %o-called *diet* carbonated drin/% ha$e $ery lo, &1 $alue% and are a%%ociated ,ith tooth %urface lo%%( While there i% no direct relation%hi& bet,een the &1 of a %ub%trate and the degree of tooth %urface lo%%, &1 doe% gi$e a u%eful indication a% to the &otential to cau%e da'age( Other factor% %uch a% titratable acidity, the influence on &laBue &1, and the buffering ca&acity of %ali$a ,ill all influence the ero%i$e &otential of a gi$en %ub%trate( )n addition, it ha% been %ho,n that ero%i$e tooth %urface lo%% tend% to be 'ore %e$ere if the $olu'e of drin/ con%u'ed i% high or if the inta/e occur% at bedti'e( >e$ Point# The degree of ero%i$e, tooth-%urface lo%% 'ay be related toG the freBuency of inta/eH

 the ti'ing of inta/eH toothbru%hing habit%( The &attern of dietary, ero%i$e tooth %urface lo%% de&end% on the 'anner in ,hich the %ub%trate i% con%u'ed( Carbonated drin/% are not unco''only held in the 'outh for %o'e ti'e a% the child *en+oy%* the %en%ation of the bubble% around the 'outh( Thi% habit 'ay re%ult in a generali5ed lo%% of %urface ena'el ;6ig( =9(=! ;a< and ;b<<( -ote the chi&&ing of the inci%al edge% of the u&&er anterior teeth in 6ig( =9(=!thi% i% an exa'&le of attrition contributing to the o$erall &attern of tooth %urface lo%%( 0 generali5ed lo%% of the %urface ena'el of &o%terior teeth i% often e$ident &articularly on the fir%t &er'anent 'olar%, and characteri%tic %aucer-%ha&ed le%ion% de$elo& on the cu%&% of the 'olar%( Thi% &heno'enon i% /no,n a% &eri'oly%i%( More &eculiar habit% are not unco''onH 6ig( =9(=? %ho,% the dentition of a young cycli%t ,ho $ery freBuently con%u'ed a le'on drin/ $ia a %tra, in hi% bicycle*% drin/ bottle( 6igure =9(=C i% an exa'&le of a young adult ,ho, for 'any year%, daily con%u'ed lb% ;al'o%t = /g< of ra, 4ra'ley coo/ing a&&le%( The extent of tooth %urface lo%% ha% left hi% a'alga' re%toration% *&roud*( 6a#tri" re!-r!itation and toot% #-r+a"e lo## The acidity of the %to'ach content% i% belo, &1 =(9 and therefore any regurgitation or $o'iting i% &otentially da'aging to the teeth( 0% 'any a% :9L of adult% ,ith %ign% of tooth %urface lo%% ha$e a hi%tory of ga%tric reflux( The aetiology of ga%tric regurgitation 'ay be di$ided into t,o categorie%G ;=< tho%e ,ith u&&er ga%trointe%tinal di%order%H and ; < tho%e ,ith eating di%order%( )n young &atient%, long-ter' regurgitation i% a%%ociated ,ith a $ariety of underlying &roble'% ;Table =9(!<( )n addition, there are a grou& of &atient% ,ho %uffer fro' ga%tro-oe%o&hageal reflux di%ea%e ;GORD<( Thi% 'ay be either %y'&to'aticin ,hich ca%e the indi$idual /no,% ,hat &ro$o/e% the refluxor, 'ore in%idiou%ly, a%y'&to'atic GORD, ,here the &atient i% una,are of the &roble' and continue% to inge%t reflux-&ro$o/ing food%( #nex&lained, ero%i$e tooth %urface lo%% i% one of the &rinci&al %ign% of an eating di%order( There are three %uch di%order% to be a,are ofG anorexia ner$o%aH buli'ia ner$o%aH and, 'ore rarely, ru'ination ;thi% i% a condition of un/no,n aetiology in ,hich food i% $oluntarily regurgitated into the oral ca$ity and either ex&elled or %,allo,ed again<( 0norexia ner$o%a i% a %ociocultural di%ea%e 'ainly affecting 'iddle-cla%%, intelligent, fe'ale% bet,een = and @9 year% of age( 3i/e buli'ia ner$o%a it i% a %ecreti$e di%ea%e ,ith %ufferer% denying illne%% and refu%ing thera&y( "eo&le ,ith anorexia exhibit con%iderable ,eight lo%% ;u& to :L of their body ,eight in %e$ere ca%e%<, ha$e a fear of gro,ing fat, and a di%torted $ie, of their body %ha&e( While tho%e ,ith buli'ia %uffer characteri%tic binge% on *+un/ food%tuff%* and follo, thi% ,ith %elf-induced $o'iting, o$er5ealou% exerci%e, and the u%e of laxati$e% to &re$ent ,eight gainthey 'ay %ub%eBuently de$elo& GORD, ,hich cau%e% ty&ical %ign% of heartburn and oe%o&hagiti%(

The &attern of ero%i$e tooth lo%% %een in all &atient% ,ho %uffer fro' chronic ga%tric regurgitation i% %i'ilar, ,ith 'ar/ed ero%ion of the &alatal %urface of u&&er inci%or% and &re'olar%( There i% a %ur&ri%ing lac/ of tooth %en%iti$ity( O$er ti'e, the buccal and occlu%al %urface% of the lo,er 'olar% and &re'olar% al%o beco'e affected ;6ig( =9(=> ;a< and ;b<<( 0% a re%ult of the a%y'&to'atic nature of %o'e of the ga%trointe%tinal di%order% and the %ecreti$e nature of the eating di%order%, denti%t% 'ay ,ell be the fir%t &rofe%%ional% to %ee the %ign% of ga%tric regurgitation( The &re%ence of ero%i$e tooth %urface lo%% 'ay be the only %ign of an underlying di%order, and %uch a finding %hould be ta/en %eriou%ly and handled carefully in co''unication ,ith 'edical colleague%( Para+-n"tional a"ti.it$ 3ocali5ed, tooth %urface lo%% freBuently occur% in &atient% ,ho exhibit abnor'al &arafunctional habit%( The exce%%i$e grinding that i% a feature of thi% &roble' i% not al,ay% a&&arent to the &atientH ho,e$er, a&art fro' the 'ar/ed tooth ti%%ue lo%%, other %ign% of bruxi%' 'ay be e$ident including hy&ertro&hy of the 'u%cle% of 'a%tication, chee/ biting, and tongue faceting( 0n exa'&le of ero%ion and &arafunction ha$ing a di%a%trou% effect on the dentition 'ay be %een ;and heard< in children ,ho ha$e cerebral &al%y( The%e children often ha$e chronic ga%tric regurgitation and al%o %e$ere bruxi%' re%ulting in exce%%i$e tooth %urface lo%%( Fi!. /0./1 ;a< and ;b< Teeth of a teenager ,ho con%u'ed con%iderable a'ount% of carbonated drin/%( -ote chi&&ing of inci%al edge% and characteri%tic &alatal tooth %urface lo%%( Fi!. /0./2 0 = year old ,ith an unu%ual &attern of tooth %urface lo%%( Fi!. /0./3 Mar/ed tooth %urface lo%% 'ay e$entually lea$e an a'alga' re%toration *&roud*( Fi!. /0./4 ;a< and ;b< #&&er and lo,er arch of a =9-year-old boy ,ith chronic ga%tro-oe%o&hageal reflux( /0.0.3 7ana!ement Immediate The 'o%t i'&ortant a%&ect of the 'anage'ent of tooth %urface lo%% i% early diagno%i%( While it i% i'&ortant to treat any dental %en%iti$ity re%ulting fro' the tooth %urface lo%% it i% e%%ential to e%tabli%h the aetiology and, ,here &o%%ible, to eli'inate the cau%e( Thi% 'ay not al,ay% be &o%%iblethe exi%tence of an underlying eating di%order cannot be re%ol$ed Buic/ly or %i'&ly( )ndeed, a% ,ith all for'% of beha$iour 'odification, the eli'ination of dietary cau%e% of ero%ion ,ill often be difficult, &articularly in young adole%cent% ,ho are no longer under &arental control and ,ho often find it hard to ad+u%t to alternati$e life-%tyle% and dietary habit%( )deally, the cau%e of the tooth %urface lo%% %hould be eli'inated before re%torati$e treat'ent i% %tarted( )n order to achie$e thi%, all &atient% and &arent% %hould be gi$en dietary coun%elling ,hich %hould be &er%onal, &ractical, and &o%iti$e( )t i% i'&ortant not to %i'&ly ad$i%e again%t all carbonated drin/% but to offer &o%iti$e alternati$e%, and to

%ugge%t that %uch drin/% 'ay be ta/en a% a treat occa%ionally and that inta/e %hould be li'ited to 'eal ti'e%( Table =9(? gi$e% %o'e &ractical %ugge%tion% that 'ay be 'ade to &atient% de&ending on the aetiology of the &roble'( )n young &atient% dental %en%iti$ity 'ay be a &roble'( Ero%i$e tooth lo%% 'ay be ra&id and ,ith the large &ul& cha'ber% &ul&al infla''ation i% co''on and %econdary dentine doe% not ha$e ti'e to for'( The u%e of gla%% iono'er ce'ent% or re%in-ba%ed co'&o%ite% a% te'&orary co$erage 'ay re%ol$e the %en%iti$ity and al%o act a% a diagno%tic aid( De+initi.e treatment )n 'any ca%e%, if the tooth %urface lo%% i% diagno%ed early, &re$enti$e coun%elling 'ay be %ufficient( )t i% a good idea to 'a/e %tudy ca%t% of all &atient% ,ith %ign% of tooth %urface lo%% and to gi$e the%e to the &atient to /ee&( The rate of &rogre%%ion of the ,ear can then be 'onitored( 1o,e$er, in 'ore ad$anced ca%e%, ,here there are %en%iti$ity or co%'etic &roble'%, acti$e inter$ention i% reBuired( Table =9(C %ho,% the relati$e 'erit% of the o&tion% a$ailable( >e$ Point# Main treat'ent ob+ecti$e% for tooth-%urface lo%%G re%ol$e %en%iti$ityH re%tore 'i%%ing tooth %urfaceH &re$ent further tooth ti%%ue lo%%H 'aintain a balanced occlu%ion( )n %o'e ca%e% there ,ill be only locali5ed tooth ,ear and an inco'&lete o$erbite, lea$ing enough %&ace to &lace the re%toration%( 6igure =9( 9 ;a< and ;b< %ho, the %a'e &atient a% %ho,n earlier in 6ig( =9(=! ;a< and ;b< ,ho con%u'ed con%iderable Buantitie% of carbonated drin/% in a%%ociation ,ith %&orting acti$itie%( Thi% habit cau%ed con%iderable &alatal ,ear of hi% u&&er inci%or% ,ith characteri%tic chi&&ing of the inci%al edge%( Ca%t adhe%i$e $eneer% ,ere &laced on the &alatal a%&ect of the u&&er inci%or% to &rotect fro' further ,ear, and direct re%in-ba%ed co'&o%ite labial $eneer% ,ere u%ed to re%tore the ae%thetic%( -ote in thi% ca%e the %light grey *%hine through* effect on the inci%al ti&% due to the ca%t re%toration%( )n 'any other ca%e% co'&en%atory gro,th, ,hich ,ill hel& to 'aintain the occlu%al $ertical di'en%ion, or the &re%ence of a %ignificant 'alocclu%ion, 'ay re%ult in inadeBuate %&ace for the nece%%ary re%toration%( 6igure =9( = ;a< %ho,% a ca%e of a = year-old boy ,ho ha% a cla%% )), di$i%ion )) 'alocclu%ion and ,ho con%u'ed three can% of carbonated drin/% e$eryday( The co'bination of the ero%i$e drin/ and the attrition brought about by the clo%e tooth-to-tooth contact ha% re%ulted in a lo%% of &alatal tooth ti%%ue fro' the u&&er central inci%or%( There i% in%ufficient %&ace &alatally to &lace any for' of re%toration, but a %i'&le re'o$able orthodontic a&&liance ,ith a flat anterior bite &lane can be u%ed to reduce the o$erbite ;6ig( =9( = ;b<<( )n children thi% occur% relati$ely Buic/ly ;,ithin ! ,ee/%< &rinci&ally by co'&en%atory o$ereru&tion of the &o%terior %eg'ent%( Once %ufficient %&ace ha% been created ca%t 'etal &alatal $eneer% can be &laced( 0lternati$ely, if there ha% been 'ar/ed ,ear of the &o%terior teeth, a% %ho,n in 6ig(

=9( ;a<, it ,ill be nece%%ary to re%tore the occlu%al %urface% and &rotect the' fro' further ,ear &rior to &lacing anterior re%toration%( Ca%t adhe%i$e occlu%al onlay% are reco''ended in the%e ca%e% ;6ig( =9( ;b<<( .oung &atient% ,ill acco''odate the increa%e in $ertical di'en%ion ea%ily, &ro$iding a balanced occlu%al contact i% achie$ed( The u%e of a facebo, record facilitate% thi%( The 'ain ad$antage of u%ing ca%t 'etal onlay% i% the 'ini'al thic/ne%% of 'aterial needed and it% re%i%tance to abra%i$e ,ear( )ndirect co'&o%ite $eneer% are a recent addition to our ar'a'entariu' and they offer con%iderable ad$antage%, &articularly in ca%e% ,here the aetiology i% unclear or the &atient cannot %to& the habitD&roble'( The%e re%toration% facilitate future addition% and re&air% ;u%ing direct co'&o%ite< if the ero%ion continue% or re%tart%( 1o,e$er, if there i% an ele'ent of attrition or %ign% of &arafunction co'&o%ite onlay% ,ill not be adeBuately durable in the &o%terior %eg'ent%, %o ca%t re%toration% are reco''ended( *on!-term re.ieC 0ll &atient% ,ith tooth %urface lo%% %hould be re$ie,ed regularly for three rea%on%G ;=< to 'onitor future tooth %urface lo%%H ; < to 'aintain the exi%ting re%toration%H and ;@< to &ro$ide %u&&ort for the &atient( "atient% ,ith eating di%order% in &articular are &rone to &eriod% of rela&%e and the denti%t i% in an ideal &o%ition to diagno%e the%e &eriod%( The denti%t can de$elo& a %&ecial and tru%ting relation%hi& ,ith the young &atient o$er the longer ter', ,hich i% ba%ed not %i'&ly on %eeing the &atient ,hen they are *ill* and therefore to ad'oni%h the', but al%o ,hen they are ,ell to %u&&ort and encourage the'( 3i/e,i%e in &atient% ,ith dietary ero%ion, continual reinforce'ent of good dietary habit% i% needed throughout the child*% life and into adulthood( "eo&le change their diet a% they get olderone exa'&le i% the young adole%cent ,ho 'anage% to %to& drin/ing Coca Cola but %tart% drin/ing lager to exce%% in%tead and the ero%ion continue%I Fi!. /0.20 ;a< and ;b< Ca%t &alatal $eneer% on u&&er central inci%or%( -ote the *%hine through* de%&ite &lace'ent of labial co'&o%ite $eneer%( Fi!. /0.2/ ;a< S/eletal &attern )) ,ith dee& o$erbite co'&ounding &alatal ero%ion in a = -year-old boy( ;b< 0n u&&er re'o$able a&&liance in &o%ition to reduce the o$erbite( Fi!. /0.22 ;a< 0 =!-year-old boy ,ith 'ar/ed tooth %urface lo%% of lo,er &er'anent 'olar%( -ote the &eri'oly%i% of the fir%t 'olar%( ;b< "o%tce'entation of gold onlay% on the &er'anent 'olar%( /0.5 IN5ERITED AN&7A*IES &F ENA7E* AND DENTINE Cha&ter =@ co$er% the ,hole range of dental ano'alie%H ho,e$er, the treat'ent of a'elogene%i% i'&erfecta and dentinogene%i% i'&erfecta &o%e% %&ecific challenge% to the denti%t( )n $ie, of the ,ide $ariety of &re%entation% and degree to ,hich each indi$idual ca%e i% affected, it i% difficult to 'a/e generali5ation%( Early diagno%i% of the%e condition% i% i'&ortant to their long-ter' &rogno%i%H &arent% need to be educated a% to the i'&lication% of the conditionH 'onitoring of the a'ount of tooth ,ear can %tart, and, ,here nece%%ary, teeth can be &rotected( There are four 'ain clinical

&roble'% a%%ociated ,ith inherited ena'el and dentine defect%G ;=< &oor ae%thetic%H ; < chi&&ing and attrition of the ena'elH ;@< ex&o%ure and attrition of the dentine cau%ing %en%iti$ityH and ;A< &oor oral hygiene, gingi$iti%, and carie%( While it i% i'&o%%ible to dra, u& a definiti$e treat'ent &lan for all ca%e%, it i% &o%%ible to define the &rinci&le% of treat'ent &lanning for thi% grou& of &atient%( )t i% i'&ortant to reali5e that not all children ,ith a'elogene%i% i'&erfecta or dentino- gene%i% i'&erfecta are affected eBually( Many ,ill not ha$e 'ar/ed tooth ,ear or %y'&to'%, and ,ill not reBuire ad$anced inter$ention( Table =9(> de%cribe% the &rinci&le% of treat'ent in ter'% of the age of the childDadole%cent and ,ith regard to the three a%&ect% of careG &re$ention, re%toration, and ae%thetic%( >e$ Point# Main treat'ent ob+ecti$e% for dental ano'alie%G to alle$iate %y'&to'%H to 'aintainDre%tore occlu%al heightH and to i'&ro$e ae%thetic%( Pre.ention "re$ention i% an e%%ential &art of the 'anage'ent of children ,ith ena'el and dentine ano'alie%( Oral hygiene in the%e children i% often &oor, due in &art to the rough ena'el %urface ,hich &ro'ote% &laBue retention and to the %en%iti$ity of the tooth to bru%hing( 0% a re%ult there 'ay be 'ar/ed gingi$al infla''ation and bleeding( The co'bination of gingi$al %,elling and ena'el hy&o&la%ia can re%ult in area% of food %tagnation and a generally lo, le$el of oral health( Oral hygiene in%truction 'u%t be gi$en %y'&athetically, ,ith &lenty of encourage'ent, and %hould be continually reinforced( )n %o'e ca%e% it 'ay be nece%%ary to carry out %o'e re%torati$eDco%'etic treat'ent before good oral hygiene 'ea%ure% can be &racti%ed( 6or exa'&le, the &lace'ent of anterior co'&o%ite $eneer% 'ay reduce dentine %en%iti$ity and i'&ro$e the ena'el %urface %o that the &atient can bru%h their teeth 'ore effecti$ely( Con$entional carie% &re$ention ,ith diet ad$ice, fluoride %u&&le'ent%, and to&ical fluoride a&&lication% i% 'andatory( )n thi% grou& of children it i% &articularly i'&ortant to &re%er$e tooth ti%%ue and not allo, carie% to co'&ro'i%e further the dental hard ti%%ue%( Re#toration Re%torati$e treat'ent $arie% con%iderably de&ending on the age of the child and extent of the &roble'( The ba%ic &rinci&le of treat'ent i% that of 'ini'al inter$ention( )f there i% %en%iti$ity or %ign% of ena'el chi&&ing, techniBue% to co$er and &rotect the teeth %hould be con%idered( )n the $ery young child it i% often i'&o%%ible to carry out exten%i$e o&erati$e treat'ent, but the &lace'ent of gla%% iono'er ce'ent o$er area% of ena'el hy&o&la%ia i% %i'&le and effecti$e( )n olderD'ore co-o&erati$e children %tainle%%-%teel ;or nic/elDchro'e< &refor'ed cro,n% %hould be &laced on the %econd &ri'ary 'olar% to 'ini'i5e further ,ear due to tooth on tooth contact ;Cha&ter C<( )t i% ad$i%able ;and u%ually &o%%ible< to &lace %uch re%toration% ,ith 'ini'u' tooth

&re&aration becau%e of the &re-exi%ting tooth ti%%ue lo%%( .oung children ,ith dentinogene%i% i'&erfecta often &o%e the greate%t &roble'%( The teeth undergo %uch exce%%i$e ,ear that they beco'e ,orn do,n to gingi$al le$el and are unre%torable( Teeth affected by dentinogene%i% i'&erfecta are al%o &rone to %&ontaneou% ab%ce%%e% due to the &rogre%%i$e obliteration of the &ul& cha'ber%( )n the%e ca%e% &ul& thera&y i% un%ucce%%ful and extraction of the affected teeth i% nece%%ary( 0% the &er'anent dentition de$elo&% clo%e 'onitoring of the rate of tooth ,ear ,ill guide the deci%ion about ,hat inter$ention i% needed( Ca%t occlu%al onlay% on the fir%t &er'anent 'olar% not only &rotect the underlying tooth %tructure but al%o 'aintain function and control %y'&to'%( The re%ulting increa%e in the $ertical di'en%ion i% a%%ociated ,ith a decrea%e in the $ertical o$erla& of the inci%or%( Within a fe, ,ee/% full occlu%ion i% u%ually re-e%tabli%hed, the ,hole &rocedure being ,ell tolerated by young &atient%( 0% the &re'olar% eru&t %i'ilar ca%ting% 'ay be &laced if ,ear i% 'ar/ed ;6ig( =9( @ ;a<-;c<<( 0lternati$ely, locali5ed co'&o%ite or gla%% iono'er ce'ent re%toration% 'ay be &laced o$er area% of hy&o&la%ia( The e'&ha%i% %hould re'ain on 'ini'al tooth &re&aration until the child gain% adulthood( 0t thi% &oint, if clinically indicated, full 'outh rehabilitation 'ay be con%idered and %hould ha$e a good &rogno%i% in $ie, of the con%er$ati$e a&&roach that ha% been ado&ted throughout the early year% ;6ig( =9( A ;a< and ;b<<( "atient% ,ith dentinogene%i% i'&erfecta %hould be treated ,ith caution( The characteri%tic for' of the teeth in thi% condition i% unfa$ourable for cro,ningH the teeth being %u&&orted by %hort, thin root%( The &er'anent dentition, li/e the &ri'ary dentition, i% &rone to %&ontaneou% ab%ce%%e% and the &rogno%i% for endodontic treat'ent i% $ery &oor( The long-ter' &lan for the%e &atient% i% often %o'e for' of re'o$able &ro%the%i%, either an o$erdenture &laced o$er the ,orn &er'anent teeth or a 'ore con$entional co'&lete denture( The role of i'&lant% in the%e &atient% ha% yet to be defined fully( Ae#t%eti"# 0e%thetic% i% not u%ually a &roble' in the &ri'ary dentition( Where the child i% %ufficiently co-o&erati$e the u%e of gla%% iono'er ce'ent% to re%tore and i'&ro$e the a&&earance of &ri'ary inci%or% can be u%eful in gaining the re%&ect and %u&&ort fro' the &atient and &arent( )n a fe, exce&tional ca%e% the lo%% of &ri'ary teeth 'ay cau%e u&%et, but can be co'&en%ated for by con%tructing denture%( )n ca%e% of dentinogene%i% i'&erfecta ,here the teeth are $ery ,orn but re'ain a%y'&to'atic, o$erdenture% can be con%tructed to ,hich young children ada&t re'ar/ably ,ell( The%e ,ill need to be re'ade regularly a% the child gro,%( 0% the &er'anent inci%or% eru&t they 'u%t be &rotected fro' chi&&ing of the ena'el( The &lace'ent of co'&o%ite $eneer% not only i'&ro$e% the a&&earance but al%o &ro'ote% better gingi$al health and &rotect% the teeth fro' further ,ear( )n a fe, ca%e% the Buality of the ena'el i% %o &oor that the bond bet,een co'&o%ite and tooth ,ill be un%ucce%%ful( )t %hould be noted that in the%e ca%e% &orcelain $eneer% are al%o li/ely to be un%ucce%%ful and full coronal re%toration% are the only o&tion( Early con%ultation ,ith an orthodonti%t i% ad$i%able in order to /ee& the orthodontic

reBuire'ent% %i'&le( Treat'ent for the%e &atient% i% &o%%ible and in 'any ca%e% &roceed% ,ithout &roble'%( The u%e of re'o$able a&&liance%, ,here a&&ro&riate, and orthodontic band% rather than brac/et% ,ill 'ini'i5e the ri%/ of da'age to the abnor'al ena'el( The &roble' i% t,ofoldG there 'ay be freBuent bond failure during acti$e treat'ent or the ena'el 'ay be further da'aged during debonding( So'e orthodonti%t% &refer to u%e band% e$en for anterior teeth, ,hile other% ,ill u%e gla%% iono'er ce'ent a% the bonding agent in &reference to 'ore con$entional re%in-ba%ed agent%( )n other in%tance% co%'etic re%torati$e techniBue% ;$eneer% and cro,n%< 'ay be 'ore a&&ro&riate than orthodontic treat'ent( Fi!. /0.23 #&&er and lo,er arche% of a =A-year-old girl ,ith dentinogene%i% i'&erfecta %ho,ing ca%t onlay% on the %econd &er'anent 'olar% and the &re'olar%, and labial and &alatal co'&o%ite $eneer% on the u&&er inci%or%( Fi!. /0.20 ;a< 0 =A-year-old boy ,ith %e$ere a'elogene%i% i'&erfecta( Stainle%%-%teel cro,n% ,ere &laced on the fir%t &er'anent 'olar% at > year% of age ;lo,er arch<( ;b< 0t 9 year% of age a full 'outh rehabilitation ,a% co'&leted ;u&&er arch<( /0.1 5YP&D&NTIA )ndi$idual% ,ith 'i%%ing teeth 'ay &re%ent at any age reBue%ting re&lace'ent of their 'i%%ing teeth for both ae%thetic and functional rea%on%( 0 detailed di%cu%%ion on the 'anage'ent of hy&odontia i% beyond the re'it of thi% text, ho,e$er, there are a fe, &rinci&le% that can be con%idered( During infancy and early %chool year% there i% rarely a need for any acti$e inter$ention( 0n exce&tion 'ay be infant% ,ith Ectoder'al Dy%&la%ia ,ho can ha$e 'ulti&le teeth 'i%%ing( )n %uch ca%e% the &ro$i%ion of re'o$able &artial or e$en co'&lete denture% can be highly %ucce%%ful( 1o,e$er, a% children 'o$e through the 'ixed and &er'anent dentition &ha%e%, ae%thetic% beco'e increa%ingly i'&ortant( Re&lacing one or t,o teeth 'ay be relati$ely %traightfor,ard u%ing either re'o$able &artial denture% or adhe%i$ely retained bridge% ;6ig( =9( : ;a<;e<<( 1o,e$er, tho%e indi$idual% ,ith 'ulti&le 'i%%ing teeth often ha$e a%%ociated %/eletal and dentoal$eolar di%cre&ancie% ,hich de'and a 'ultidi%ci&linary a&&roach ;6ig( =9( ! ;a<-;c<<( The core to %uch a clinical tea' include% a &aediatric denti%t, orthodonti%t, and &ro%thodonti%t( )n addition a &eriodonti%t and a 'axillofacial %urgeon 'ay be reBuired for i'&lant%, bone grafting, andDor orthognathic %urgery in later year%( 6inally, acce%% to a genetici%t ,ith ex&erti%e in orofacial ano'alie% can be beneficial a% adole%cent% begin to conte'&late the i'&lication% of their dental ano'aly on fa'ily &lanning( Children ,ith 'ulti&le 'i%%ing teeth and their fa'ilie% %hould be referred early to a 'ultidi%ci&linary tea' for di%cu%%ion and &reli'inary &lanning( Con%ideration need% to be gi$en to the nu'ber and &o%ition of the 'i%%ing dental unit%, the age of the child, their le$el of and attitude to,ard% oral health, and i'&ortantly the ,i%he% and ex&ectation% of the indi$idual and their fa'ily( The ai' of orthodontic treat'ent i% to con%olidate the %&acing and &lace the exi%ting teeth in the o&ti'u' &o%ition to %u&&ort the definiti$e re%toration%( 1o,e$er con%ideration al%o need% to be gi$en to any underlying %/eletal di%cre&ancy or dentoal$eolar deficiency that 'ay reBuire a 'ore %urgical a&&roach( )nteri' re%torati$e %olution%, %uch a% re'o$able denture%, co'&o%ite $eneer, or &artial $eneer re%toration%, can be &laced during the 'ixed dentition &ha%e but ,ill reBuire 'aintenance throughout adole%cence( "roacti$e

&re$enti$e %trategie% need to be %u&&orted in order to achie$e o&ti'u' dental and &eriodontal health( Thi% i% e%%ential for the long-ter' %ucce%% of definiti$e &ro%thodontic %olution% ,hich 'ay include re'o$able denture%, &orcelain $eneer% or cro,n%, fixed con$entional or adhe%i$ely retained bridge%, and o%%eointegrated i'&lant%( >e$ Point# Children ,ith 'ulti&le 'i%%ing teeth %hould beG -referred early to a 'ultidi%ci&linary clinical tea'H -ex&o%ed to &roacti$e &re$ention to o&ti'i5e their &eriodontal health( Treat'ent o&tion% 'ay includeG -interi' 'ea%ure%, for exa'&le, &artial denture% or co'&o%ite $eneer% in childhood and adole%cenceH -definiti$e re%toration%, for exa'&le, cro,n%, bridge%, $eneer%, and dental i'&lant% -%urgical inter$ention%, for exa'&le, orthognathic %urgery and bone grafting Fi!. /0.25 ;a< 0nterior $ie, of an adole%cent ,ith hy&odontia( ;b< 3o,er arch of the %a'e adole%cent ,ith hy&odontia( ;c< O"G radiogra&h confir'ing 'ulti&le 'i%%ing teeth( ;d< and ;e< 3o,er &artial interi' denture in situ( )ncrea%ing $ertical di'en%ion and &ro$iding a 'ore balanced occlu%ion( Fi!. /0.21 ;a< 0nterior clinical $ie, of a =:-year-old 'ale ,ith a %ignificant %/eletal di%cre&ancy, &o%terior o&en bite%, and 'ulti&le 'i%%ing teeth( ;b< and ;c< Radiogra&h% of the %a'e =:-year-old 'ale( /0.2 S(77ARY =( The 'anage'ent of children ,ith ad$anced re%torati$e &roble'% %hould be $ie,ed a% a long-ter' co''it'ent( ( 0d$anced re%torati$e &roble'% in children %hould be treated a% con%er$ati$ely a% &o%%ible( @( )dentification of the aetiology of tooth di%colouration i% e%%ential for %electing the 'o%t a&&ro&riate treat'ent techniBue( A( Microabra%ion %hould be the fir%t treat'ent o&tion in all ca%e% of ena'el %urface di%colouration( :( "orcelain $eneer% %hould be delayed until a 'ature gingi$al contour i% attained( !( -early @9L of all =: year old% ha$e ex&erience of ero%i$e tooth %urface lo%%( ?( The cau%e of tooth %urface lo%% %hould be deter'ined and eli'inated before acti$e treat'ent i% %tarted( C( Maintenance of occlu%al face height i% e%%ential in &atient% ,ith a'elogene%i% or dentinogene%i% i'&erfecta( /0.3 F(RT5ER READIN6

4i%ho&, 2(, 4rigg%, "(, and 2elleher, M( ;=>>A<( The aetiology and 'anage'ent of locali5ed anterior tooth ,ear in the young adult( Dental Update, 2/, =:@-!9( ;" good review with a lot of references and clinical examples < Dahl, 7( E(, and "alle%en, #( ; 99@<( Tooth bleachingG a criticial re$ie, of the biological a%&ect%( Critical )eviews in 8ral $iology and (edicine, /0, > -@9A( ;" well<referenced review on the efficacy of tooth ,leaching(< 1arley, 2( E( and )bbet%on, R( 7( ;=>>@<( Dental ano'alie%are adhe%i$e ca%ting% the %olutionJ $ritish Dental +ournal, /20, =:- ( ;" well<written study covering the clinical techni:ue and the follow<up of 15 children with amelogenesis or dentinogenesis imperfecta < 2il&atric/, -( M( and Welbury, R( R( ;=>>@<( 1ydrochloric acid-&u'ice 'icroabra%ion techniBue for the re'o$al of ena'el &ig'entation( Dental Update, 20, =9:-?( ;" clinical study assessing the effectiveness of the microa,rasion techni:ue < 2ing, "( 0( ;=>>><( Tooth %urface lo%%G adhe%i$e techniBue%( $ritish Dental +ournal, /31, @ =-!( ;" good description of current techni:ues < -unn, 7( 1(, Carter, -( E(, Gillgra%%, T( 7(, 1ob%on, R( S(, 7e&%on, -( 7(, Meechan, 7( G(, and -ohl, 6( S( ; 99@<( The interdi%ci&linary 'anage'ent of hy&odontiaG &art% =:( $ritish Dental +ournal, /40, A:- :=, >>-@9A, @!=-!, A @-?, A?>-C ( ;" comprehensive series of papers addressing the complexities of management of hypodontia(< "oy%er, -( 7(, 2elleher, M( G(, and 4rigg%, "( 6( ; 99A<( Managing di%coloured non$ital teethG the in%ideDout%ide bleaching techniBue( Dental Update, 3/, 9A-=9( ;" simple report of the techni:ue(< Welbury, R( R( ;=>>=<( 0 clinical %tudy of a 'icrofilled co'&o%ite re%in for labial $eneer%( International +ournal of Paediatric Dentistry, /, >-=:( ;" longitudinal clinical study evaluating composite veneers in adolescents < /0.4 REFERENCES S'ith, 4( G( and 2night, 7( 2( ;=>CA<( 0n index for 'ea%uring the ,ear of teeth( $ritish Dental +ournal, /51, A@:-C( O*4rien, M( ;=>>A<( Children?s dental health in the United 0ingdom 1''&( 1MSO, 3ondon( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

//. Periodontal di#ea#e# in "%ildren - P " Heasman and P + 4aterhouse //./ INTR&D(CTI&N "eriodontal di%ea%e% co'&ri%e a grou& of infection% that affect the %u&&orting %tructure% of the teethG 'arginal and attached gingi$aH &eriodontal liga'entH ce'entu'H and al$eolar bone(

0cute gingi$al di%ea%e%&ri'arily her&etic gingi$o%to'atiti% and necroti5ing gingi$iti%are ulcerati$e condition% that re%ult fro' %&ecific $iral and bacterial infection( Chronic gingi$iti%, ho,e$er, i% a non-%&ecific infla''atory le%ion of the 'arginal gingi$a ,hich reflect% the bacterial challenge to the ho%t ,hen dental &laBue accu'ulate% in the gingi$al cre$ice( The de$elo&'ent of chronic gingi$iti% i% enhanced ,hen routine oral hygiene &ractice% are i'&aired( Chronic gingi$iti% i% re$er%ible if effecti$e &laBue control 'ea%ure% are introduced( )f left untreated the condition in$ariably con$ert% to chronic &eriodontiti%, ,hich i% characteri5ed by re%or&tion of the %u&&orting connecti$e ti%%ue attach'ent and a&ical 'igration of the +unctional e&ithelia( Slo,ly &rogre%%ing, chronic &eriodontiti% affect% 'o%t of the adult &o&ulation to a greater or le%%er extent, although the early %tage% of the di%ea%e are detected in adole%cent%( Children are al%o %u%ce&tible to aggre%%i$e &eriodontal di%ea%e% that in$ol$e the &ri'ary and &er'anent dentition%, re%&ecti$ely, and &re%ent in locali5ed or generali5ed for'%( The%e condition%, ,hich are di%tinct clinical entitie% affecting other,i%e healthy children, 'u%t be differentiated fro' the exten%i$e &eriodontal de%truction that i% a%%ociated ,ith certain %y%te'ic di%ea%e%, degenerati$e di%order%, and congenital %yndro'e%( "eriodontal ti%%ue% are al%o %u%ce&tible to change% that are not, &ri'arily, of an infectiou% nature( 6actitiou% %to'atiti% i% characteri5ed by %elf-inflicted trau'a to oral %oft ti%%ue% and the gingi$a are in$ariably in$ol$ed( Drug-induced gingi$al enlarge'ent i% beco'ing increa%ingly 'ore &re$alent ,ith the ,ide%&read u%e of organ tran%&lant &rocedure% and the u%e of long-ter' i''uno%u&&re%%ant thera&y( 3ocali5ed enlarge'ent 'ay occur a% a gingi$al co'&lication of orthodontic treat'ent( 0 cla%%ification of &eriodontal di%ea%e% in children i% gi$en in Table ==(=( //.2 ANAT&7Y &F T5E PERI&D&NTI(7 IN C5I*DREN Marginal gingi$al ti%%ue% around the &ri'ary dentition are 'ore highly $a%cular and contain fe,er connecti$e ti%%ue fibre% than ti%%ue% around the &er'anent teeth( The e&ithelia are thinner ,ith a le%%er degree of /eratini5ation, gi$ing an a&&earance of increa%ed redne%% that 'ay be inter&reted a% 'ild infla''ation( 6urther'ore, the locali5ed hy&erae'ia that acco'&anie% eru&tion of the &ri'ary dentition can &er%i%t, leading to %,ollen and rounded inter&roxi'al &a&illae and a de&th of gingi$al %ulcu% exceeding @ ''( During eru&tion of the &er'anent teeth the +unctional e&itheliu' 'igrate% a&ically fro' the inci%al or occlu%al %urface to,ard% the ce'entoena'el +unction ;CE7<( While the e&ithelial attach'ent i% abo$e the line of 'axi'u' cro,n con$exity, the gingi$al %ulcu% de&th often exceed% ! or ? '', ,hich fa$our% the accu'ulation of &laBue( When the teeth are fully eru&ted, there continue% to be an a&ical %hift of +unctional e&itheliu' and the free gingi$al 'argin%( Stability of the gingi$a i% achie$ed at about = year% for 'andibular inci%or%, canine%, %econd &re'olar%, and fir%t 'olar%( The ti%%ue% around the re'aining teeth continue to recede %lo,ly until about =! year%( Thu% the gingi$al 'argin% are freBuently at different le$el% on ad+acent teeth that are at different %tage% of eru&tion( Thi% %o'eti'e% gi$e% an erroneou% a&&earance that gingi$al rece%%ion ha% occurred around tho%e teeth that ha$e been in the 'outh

longe%t( 0 $ariation in %ulcu% de&th% around &o%terior teeth in the 'ixed dentition i% co''on( 6or exa'&le, %ulcu% de&th% on the 'e%ial a%&ect% of E% and !% are greater than tho%e on the di%tal of D% and E%, re%&ecti$ely( Thi% i% accountable to the di%cre&ancy in the hori5ontal &o%ition of ad+acent CE7% due to the difference in the occlu%oa&ical ,idth% of ad+acent 'olar cro,n%( The attached gingi$a extend% fro' the free gingi$al 'argin to the 'ucogingi$al line 'inu% the %ulcu% de&th in the ab%ence of infla''ation( 0ttached gingi$a i% nece%%ary to 'aintain %ulcu% de&th, to re%i%t functional %tre%%e% during 'a%tication, and to re%i%t ten%ional %tre%% by acting a% a buffer bet,een the 'obile gingi$al 'argin and the loo%ely %tructured al$eolar 'uco%a( The ,idth of attached gingi$a i% le%% $ariable in the &ri'ary than in the &er'anent dentition( Thi% 'ay &artly account for the %carcity of 'ucogingi$al &roble'% in the &ri'ary dentition( The &eriodontal liga'ent %&ace i% ,ider in children, &artly a% a con%eBuence of thinner ce'entu' and al$eolar cortical &late%( The liga'ent i% le%% fibrou% and 'ore $a%cular( 0l$eolar bone ha% larger 'arro, %&ace%, greater $a%cularity, and fe,er trabeculae than adult ti%%ue%, feature% that 'ay enhance the rate of &rogre%%ion of &eriodontal di%ea%e ,hen it affect% the &ri'ary dentition( The radiogra&hic di%tance bet,een the CE7 and the healthy al$eolar bone cre%t for &ri'ary canine and 'olar teeth range% fro' 9 to ''( )ndi$idual %urface% di%&lay di%tance% of u& to A '' ,hen ad+acent &er'anent or &ri'ary teeth are eru&ting or exfoliating, re%&ecti$ely, and eru&ti$e and 'aturation change% 'u%t be con%idered ,hen radiogra&h% are u%ed to diagno%e &eriodontal di%ea%e in children( When %uch change% are excluded, a CE7-al$eolar cre%t di%tance of 'ore than '' %hould arou%e %u%&icion of &athological bone lo%% in the &ri'ary dentition( >e$ Point# 0nato'yG +unctional e&itheliu'H 'arginal gingi$aH attached gingi$aH al$eolar bone( //.3 AC(TE 6IN6I)A* C&NDITI&NS //.3.0 Introd-"tion The &rinci&al acute gingi$al condition% that affect children are &ri'ary her&etic gingi$o%to'atiti% and necroti5ing ulcerati$e gingi$iti%( The latter i% 'o%t freBuently %een in young adult%, but it al%o affect% teenager%( //.3./ Primar$ %er eti" !in!i.o#tomatiti# 1er&etic gingi$o%to'atiti% i% an acute infectiou% di%ea%e cau%ed by the her&e%$iru% ho'ini%( The &ri'ary infection i% 'o%t freBuently %een in children bet,een and : year% of age, although older age grou&% can be affected( 0 degree of i''unity i%

tran%ferred to the ne,born fro' circulating 'aternal antibodie% %o an infection in the fir%t = 'onth% of life i% rare( 0l'o%t =99L of urban adult &o&ulation% are carrier% of, and ha$e neutrali5ing antibodie% to, the $iru%( Thi% acBuired i''unity %ugge%t% that the 'a+ority of childhood infection% are %ubclinical( Tran%'i%%ion of the $iru% i% by dro&let infection and the incubation &eriod i% about = ,ee/( The child de$elo&% a febrile illne%% ,ith a rai%ed te'&erature of =99-=9 6 ;@?(C-@C(> C<( 1eadache%, 'alai%e, oral &ain, 'ild dy%&hagia, and cer$ical ly'&hadeno&athy are the co''on %y'&to'% that acco'&any the fe$er and &recede the on%et of a %e$ere, oede'atou% 'arginal gingi$iti%( Characteri%tic, fluid-filled $e%icle% a&&ear on the gingi$a and other area% %uch a% the tongue, li&%, buccal, and &alatal 'uco%a( The $e%icle%, ,hich ha$e a grey, 'e'branou% co$ering, ru&ture %&ontaneou%ly after a fe, hour% to lea$e extre'ely &ainful yello,i%h ulcer% ,ith red, infla'ed 'argin% ;6ig( ==(= ;a< and ;b<<( The clinical e&i%ode run% a cour%e of about =A day% and the oral le%ion% heal ,ithout %carring( 8ery rare but %e$ere co'&lication% of the infection are a%e&tic 'eningiti% and ence&haliti%( The clinical feature%, hi%tory, and age grou& of the affected children are %o characteri%tic that diagno%i% i% rarely &roble'atic( )f in doubt, ho,e$er, %'ear% fro' recently ru&tured $e%icle% re$eal degenerating e&ithelial cell% ,ith intranuclear inclu%ion%( The $iru% &rotein al%o tend% to di%&lace the nuclear chro'atin to &roduce enlarged and irregular nuclei( 1er&etic gingi$o%to'atiti% doe% not re%&ond ,ell to acti$e treat'ent( 4ed re%t and a %oft diet are reco''ended during the febrile %tage and the child %hould be /e&t ,ell hydrated( "yrexia i% reduced u%ing a &araceta'ol %u%&en%ion and %econdary infection of ulcer% 'ay be &re$ented u%ing chlorhexidine( 0 'outhrin%e ;9( L, t,o to three ti'e% a day< 'ay be u%ed in older children ,ho are able to ex&ectorate, but in younger children ;under ! year% of age< a chlorhexidine %&ray can be u%ed ;t,ice daily< or the %olution a&&lied u%ing a %&onge %,ab( )n %e$ere ca%e% of her&e% %i'&lex, %y%te'ic acyclo$ir can be &re%cribed a% a %u%&en%ion ; 99 'g< and %,allo,ed, fi$e ti'e% daily for : day%( )n children under year% the do%e i% hal$ed( 0cyclo$ir i% acti$e again%t the her&e%$iru% but i% unable to eradicate it co'&letely( The drug i% 'o%t effecti$e ,hen gi$en at the on%et of the infection( >e$ Point# 1er&etic gingi$o%to'atiti%clinicalG &ri'aryDrecurrentH $iralH $e%icular le%ion%H co'&lication% rare( >e$ Point# 1er&etic gingi$o%to'atiti%treat'entG %y'&to'aticH re%t and %oft dietH &araceta'ol %u%&en%ionH acyclo$ir(

0fter the &ri'ary infection the her&e%$iru% re'ain% dor'ant in e&ithelial cell% of the ho%t( Reacti$ation of the latent $iru% or reinfection in %ub+ect% ,ith acBuired i''unity occur% in adult%( Recurrent di%ea%e &re%ent% a% an attenuated intraoral for' of the &ri'ary infection or a% her&e% labiali%, i(e( the co''on *cold %ore* on the 'ucocutaneou% border of the li&% ;6ig( ==( <( Cold %ore% are treated by a&&lying acyclo$ir crea' ;:L, fi$e ti'e% daily for about : day%<( Fi!. //./ #lcerati$e %tage of &ri'ary her&etic gingi$o%to'atiti%G;a< &alatal gingi$aH ;b< lo,er li& 'uco%a( Fi!. //.2 1er&etic *cold %ore* at the $er'ilion border of the lo,er li&( //.3.2 Ne"roti:in! -l"erati.e !in!i.iti# -ecroti5ing ulcerati$e gingi$iti% ;-#G< i% one of the co''one%t acute di%ea%e% of the gingi$a( )n the #nited State% and Euro&e, -#G affect% young adult% in the =!-@9 age range ,ith re&orted incidence figure% of 9(?-?L( )n de$elo&ing countrie%, -#G i% &re$alent in children a% young a% = or year% of age ,hen the infection can be $ery aggre%%i$e leading to exten%i$e de%truction of %oft and hard ti%%ue% ;6ig( ==(@<( E&ide'ic-li/e occurrence% of -#G ha$e been re&orted in grou&% %uch a% ar'y recruit% and fir%t-year college %tudent%( The%e outbrea/% are 'ore li/ely to be a con%eBuence of the &re$alence of co''on &re-di%&o%ing factor% rather than co''unicability of infection bet,een %ub+ect%( Clini"al +eat-re# -#G i% characteri5ed by necro%i% and ulceration, ,hich fir%t affect the interdental &a&illae and then %&read to the labial and lingual 'arginal gingi$a( The ulcer% are *&unched out*, co$ered by a yello,i%h-grey &%eudo'e'branou% %lough, and extre'ely &ainful to the touch ;6ig( ==(@<( The acute exacerbation i% often %u&eri'&o%ed u&on a &re-exi%ting gingi$iti%, and the ti%%ue% bleed &rofu%ely on gentle &robing( The %tandard of oral hygiene i% u%ually $ery &oor( 0 di%tincti$e halito%i% i% co''on in e%tabli%hed ca%e% of -#G, although fe$er and ly'&hadeno&athy are le%% co''on than in her&etic gingi$o%to'atiti%( The clinical cour%e of -#G i% %uch that the acute %tage enter% a chronic &ha%e of re'i%%ion after :-? day%( Recurrence of the acute condition i% ine$itable, ho,e$er, and if thi% acute-chronic cycle i% allo,ed to continue then the 'arginal ti%%ue% lo%e their contour and a&&ear rounded( E$entually, the infla''ation and necro%i% in$ol$e the al$eolar cre%t and the %ub%eBuent necroti5ing &eriodontiti% lead% to ra&id bone re%or&tion and gingi$al rece%%ion( "rogre%%i$e change% are al%o a con%eBuence of inadeBuate or inco'&lete treat'ent( Aetiolo!$ 0 %'ear ta/en fro' an area of necro%i% or the %urface of an ulcer ,ill re$eal nu'erou% dead cell%, &oly'or&honuclear leucocyte%, and a %a'&le of the 'icro-organi%'% that are freBuently a%%ociated ,ith -#G( 6u%ifor' bacteria and %&irochaete% are both nu'erou% and ea%y to detect( 0 fu%o%&irochaetal co'&lex ha% been %trongly

i'&licated a% the cau%ati$e organi%'% in -#G( Other Gra'-negati$e anaerobic organi%'% including Porphyromonas gingivalis; Aeillonella %&ecie%, and #elenomonas %&ecie% ha$e been detected, ,hich %ugge%t% that -#G could be a broad anaerobic infection( 0 $iral aetiology ha% al%o been %ugge%ted, &ri'arily becau%e of the %i'ilarity bet,een -#G and /no,n $iral di%ea%e%( The re%triction of the di%ea%e to children and young adult%, for exa'&le, 'ay infer that older %ub+ect% ha$e undergone %erocon$er%ion ;and are thu% i''une< a% a con%eBuence of clinical or %ubclinical $iral infection in earlier life( The recurring e&i%ode% of the di%ea%e 'ay al%o be ex&lained by a $iral hy&othe%i%( The ability to undergo latent infection that i% %ub+ect to reacti$ation i% a characteri%tic of the her&e%$iru%( The argu'ent for the i'&lication of a $iru% in -#G i% therefore $alid and no$el, although a %&ecific $iru% ha% yet to be i%olated fro' oral le%ion%( Predi# o#in! +a"tor# "oor oral hygiene and a &re-exi%ting gingi$iti% in$ariably reflect the &atient*% attitude to oral care( Many young adult% ,ith -#G are hea$y %'o/er%( The effect of %'o/ing on the gingi$a 'ay be 'ediated through a local irritation or by the $a%ocon%tricti$e action of nicotine, thu% reducing ti%%ue re%i%tance and 'a/ing the ho%t 'ore %u%ce&tible to anaerobic infection( S'o/ing i% ob$iou%ly not a &redi%&o%ing factor in young children( )n underde$elo&ed countrie%, ho,e$er, children are often undernouri%hed and debilitated, ,hich 'ay &redi%&o%e to infection( Outbrea/% of -#G in grou&% of %ub+ect% ,ho are under %tre%% ha% i'&licated e'otional %tatu% a% an i'&ortant &redi%&o%ing factor( Ele$ated &la%'a le$el% of cortico%teroid% a% a re%&on%e to an e'otional u&%et are thought to be a &o%%ible 'echani%'( )t i% concei$able that all the &redi%&o%ing factor% ha$e a co''on action to initiate or &otentiate a %&ecific change in the ho%t %uch a% lo,ering the cell-'ediated re%&on%e( )ndeed, &atient% ,ith -#G ha$e de&re%%ed &hagocytic acti$ity and che'otactic re%&on%e of their &oly'or&honuclear leucocyte%( >e$ Point# -ecroti5ing ulcerati$e gingi$iti%clinicalG yello,-grey ulcer%H fu%o%&irochaetal infectionH &o%%ible $iral aetiologyH ,ell-e%tabli%hed &redi%&o%ing factor%( Treatment )t i% i'&ortant at the out%et that the &atient i% infor'ed of the nature of -#G and the li/elihood of recurrence of the condition if the treat'ent i% not co'&leted( S'o/er% %hould be ad$i%ed to reduce the nu'ber of cigarette% %'o/ed( 0 %oft, 'ultitufted bru%h i% reco''ended ,hen a 'ediu'-textured bru%h i% too &ainful( Mouthrin%e% 'ay be reco''ended but only for %hort-ter' u%e ;?-=9 day%<( Rin%ing ,ith chlorhexidine ;9( L for about = 'in< reduce% &laBue for'ation, ,hile the u%e of

a hydrogen &eroxide or %odiu' hydroxy&erborate 'outhrin%e oxygenate% and clean%e% the necrotic ti%%ue%( Mechanical debride'ent %hould be underta/en at the initial $i%it( 0n ultra%onic %caler ,ith it% acco'&anying ,ater %&ray can be effecti$e ,ith 'ini'al di%co'fort for the &atient( 6urther, if -#G i% locali5ed to one &art of the 'outh, local anae%the%ia of the %oft ti%%ue% can allo, %o'e %ubgingi$al %caling to be underta/en( )n %e$ere ca%e% of -#G, a @-day cour%e of 'etronida5ole ; 99 'g three ti'e% a day< alle$iate% the %y'&to'%, but the &atient% 'u%t be infor'ed that they are reBuired to reattend for further treat'ent( Occa%ionally, it i% nece%%ary to %urgically recontour the gingi$al 'argin ;gingi$o&la%ty< to i'&ro$e ti%%ue architecture and facilitate %ubgingi$al cleaning( >e$ Point# -ecroti5ing ulcerati$e gingi$iti%treat'entG inten%e oral hygieneH re'o$e &redi%&o%ing factor%H 'echanical debride'entH 'etronida5ole( Fi!. //.3 0 :-year-old Ethio&ian boy ,ith necroti5ing ulcerati$e gingi$iti%( //.0 C5R&NIC 6IN6I)ITIS -ational Sur$ey% ;=>?@, =>C@, and =>>@< of children*% dental health in the #nited 2ingdo' %ho, that the &re$alence of chronic gingi$iti% increa%e% %teadily bet,een the age% of : and > year% and i% clo%ely a%%ociated ,ith the a'ount of &laBue, debri%, and calculu% &re%ent ;6ig( ==(A<( 6or exa'&le, in =>>@, !L of :-year-old% had %o'e %ign% of gingi$iti%, and the &ro&ortion increa%ed to ! L at the age of >( The &re$alence of gingi$iti% &ea/% at about == year% and then decrea%e% %lightly ,ith age to =: year%( )n ter'% of gingi$iti%, there ha% been no i'&ro$e'ent o$er the decade% bet,een %ur$ey%( )ndeed, in =>>@, bet,een == and =AL 'ore children of all age% bet,een ! and = year% had %ign% of gingi$iti% ,hen co'&ared ,ith =>C@( The%e difference% ,ere not 'aintained ,ith increa%ing age, ho,e$er, a% : L of =:-yearold% had gingi$iti% in =>>@ co'&ared ,ith ACL in =>C@( 6urther'ore, there ,ere no difference% bet,een =>C@ and =>>@, in the &ro&ortion of =:-year-old% ,ith &oc/et% bet,een @(: and :(: '' ;> and =9L, re%&ecti$ely<( The%e data %ugge%t that the gingi$al condition of children in the #nited 2ingdo' ha% deteriorated o$er the =9 year% bet,een =>C@ and =>>@, ,herea% the &eriodontal %tatu% of =:-year-old% ha% not changed( Certainly, change% in gingi$al health do not 'irror the dra'atic i'&ro$e'ent in the &re$alence of carie% o$er the %a'e &eriod( Children*% 'outh% tended to be cleaner in =>C@ than in =>?@( Thi% trend ,a% re$er%ed by =>>@ ,hen bet,een =9 and 9L 'ore children of all age% had &laBue de&o%it%( 3e$el% of calculu% ,ere %i'ilar in both %ur$ey%( The on%et of &uberty and the increa%e in circulating le$el% of %ex hor'one% i% one ex&lanation for the increa%e in gingi$iti% %een in ==-year-old%( Oe%trogen increa%e% the

cellularity of ti%%ue% and &roge%terone increa%e% the &er'eability of the gingi$al $a%culature( Oe%tradiol al%o &ro$ide% %uitable gro,th condition% for %&ecie% of blac/ &ig'enting organi%'% ,hich are a%%ociated ,ith e%tabli%hed gingi$iti%( 5i#to at%olo!$ The infla''atory infiltrate a%%ociated ,ith 'arginal gingi$iti% in children i% analogou% to that %een in adult% during the early %tage% of gingi$al infla''ation( The do'inant cell i% the ly'&hocyte, although %'all nu'ber% of &la%'a cell%, 'acro&hage%, and neutro&hil% are in e$idence( Re%earch finding% ha$e not yet deter'ined uneBui$ocally ,hether the ly'&hocyte &o&ulation i% one of unacti$ated 4 cell% or i% T-cell do'inated( The relati$e ab%ence of &la%'a cell%, ,hich are found in abundance in 'ore e%tabli%hed and ad$anced le%ion% in adult%, confir'% that gingi$iti% in children i% Buie%cent and doe% not &rogre%% inexorably to in$ol$e the dee&er &eriodontal ti%%ue%( >e$ Point# Chronic gingi$iti%G &laBue-a%%ociatedH ly'&hocyte-do'inatedH co'&lex floraH lin/ed to the on%et of &uberty( 7i"ro,iolo!$ The fir%t organi%'% to coloni5e clean tooth %urface% are the &eriodontally har'le%%, Gra'-&o%iti$e cocci that &redo'inate in &laBue after A-? day%( 0fter ,ee/%, a 'ore co'&lex flora of fila'entou% and fu%ifor' organi%'% indicate% a con$er%ion to a Gra'-negati$e infection, ,hich, ,hen e%tabli%hed, co'&ri%e% %ignificant nu'ber% of Capnocytophaga; #elenomonas; Leptotrichia; Porphyromonas, and #pirochaete %&&( The%e %&ecie% are culti$able fro' e%tabli%hed and ad$anced &eriodontal le%ion% in ca%e% of adult &eriodontiti%( Thi% %ugge%t% that the ho%t re%&on%e ;rather than the %ubgingi$al flora< confer% a degree of i''unity to the de$elo&'ent of &eriodontal di%ea%e in children, thu% &re$enting %&read of the contained gingi$iti% to dee&er ti%%ue%( 7an-al .er#-# oCered toot%,r-#%e# The treat'ent and &re$ention of gingi$iti% are de&endent on achie$ing and 'aintaining a %tandard of &laBue control that, on an indi$idual ba%i%, i% co'&atible ,ith health( Toothbru%hing i% the &rinci&al 'ethod for re'o$ing dental &laBue, and &o,ered toothbru%he% no, &ro$ide a ,idely a$ailable alternati$e to the 'ore con$entional, 'anual toothbru%he% for cleaning teeth( There i% con%iderable e$idence in the literature to %ugge%t that &o,ered toothbru%he% are beneficial for %&ecific grou&%G &atient% ,ith fixed orthodontic a&&liance%for ,ho' there i% al%o e$idence that &o,ered toothbru%he% are effecti$e in reducing decalcificationH children and adole%cent%H and children ,ith %&ecial need%( )t re'ain% Bue%tionable ,hether children ,ho are already highly 'oti$ated ,ith re%&ect to tooth

cleaning ,ill benefit fro' u%ing a &o,ered toothbru%h( )t i% &o%%ible that, &articularly in children, any i'&ro$ed &laBue control a% a con%eBuence of u%ing a &o,ered toothbru%h 'ay re%ult fro' a *no$elty effect* of u%ing a ne, toothbru%h rather than becau%e the &o,ered toothbru%h i% 'ore effecti$e a% a cleaning de$ice( 0 %y%te'atic re$ie, e$aluating 'anual and &o,ered toothbru%he% ,ith re%&ect to oral health ha% 'ade %o'e i'&ortant conclu%ion%( Co'&ared to 'anual toothbru%he%, rotatingDo%cillating de%ign% of &o,ered toothbru%he% reduced &laBue and gingi$iti% by ?-=?L although the clinical %ignificance of thi% could not be deter'ined( "o,ered bru%he%, therefore, are at lea%t a% effecti$e and eBually a% %afe a% their 'anual counter&art% ,ith no e$idence of increa%ed incidence of %oft ti%%ue abra%ion% or trau'a( -o clinical trial% ha$e loo/ed at the durability, reliability, and relati$e co%t of &o,ered and 'anual bru%he% %o it i% not &o%%ible to 'a/e any reco''endation regarding o$erall toothbru%h %u&eriority( Fi!. //.0 Chronic 'arginal gingi$iti% in a =9-year-old girl( //.5 DR(6-IND(CED 6IN6I)A* EN*AR6E7ENT //.5.0 Introd-"tion Enlarge'ent of the gingi$a i% a ,ell-recogni5ed un,anted effect of a nu'ber of drug%( The 'o%t freBuently i'&licated are &henytoin, cyclo%&orin, and nifedi&ine ;6ig( ==(:<( Fi!. //.5 Drug ;&henytoin<-induced gingi$al enlarge'ent in a = -year-old boy( //.5./ P%en$toin "henytoin i% an anticon$ul%ant u%ed in the 'anage'ent of e&ile&%y( Gingi$al enlarge'ent occur% in about :9L of dentate %ub+ect% ,ho are ta/ing the drug, and i% 'o%t %e$ere in teenager% and tho%e ,ho are cared for in in%titution%( The exact 'echani%' by ,hich &henytoin induce% enlarge'ent i% unclear( The gingi$al enlarge'ent reflect% an o$er&roduction of collagen ;rather than a decrea%e in degradation<, and thi% 'ay be brought about by the action of the drug on &henoty&ically di%tinct grou&% of fibrobla%t% that ha$e the &otential to %ynthe%i5e large a'ount% of &rotein( "henytoin-induced enlarge'ent ha% been a%%ociated ,ith a deficiency of folic acid, ,hich 'ay lead to i'&aired 'aturation of oral e&ithelia( //.5.2 C$"lo# orin Cyclo%&orin i% an i''uno%u&&re%%ant drug that i% u%ed ,idely in organ tran%&lant &atient% to &re$ent graft re+ection( 0&&roxi'ately @9L of &atient% ta/ing the drug de'on%trate gingi$al enlarge'ent, ,ith children being 'ore %u%ce&tible than adult%( The exact 'echani%' of the drug in cau%ing enlarge'ent i% un/no,n( There i% e$idence to %ugge%t both a %ti'ulatory effect on fibrobla%t &roliferation and collagen &roduction a% ,ell a% an inhibitory effect on collagen brea/do,n by the en5y'e collagena%e(

//.5.3 Ni+edi ine -ifedi&ine i% a calciu'-channel bloc/er that i% u%ed in adult% for the control of cardio$a%cular &roble'%( )t i% al%o gi$en to &o%t-tran%&lant &atient% to reduce the ne&hrotoxic effect% of cyclo%&orin( The incidence of gingi$al enlarge'ent in dentate %ub+ect% ta/ing nifedi&ine i% =9-=:L( The drug bloc/% the calciu' channel% in cell 'e'brane%intracellular calciu' ion% are a &rereBui%ite for the &roduction of collagena%e% by fibrobla%t%( The lac/ of the%e en5y'e% could be re%&on%ible for the accu'ulation of collagen in the gingi$a( Clini"al +eat-re# o+ !in!i.al enlar!ement The clinical change% of drug-induced enlarge'ent are $ery %i'ilar irre%&ecti$e of the drug in$ol$ed( The fir%t %ign% of change are %een after @-A 'onth% of drug ad'ini%tration( The interdental &a&illae beco'e nodular before enlarging 'ore diffu%ely to encroach u&on the labial ti%%ue%( The anterior &art of the 'outh i% 'o%t %e$erely and freBuently in$ol$ed %o that the &atient*% a&&earance i% co'&ro'i%ed( The ti%%ue% can beco'e %o abundant that oral function%, &articularly eating and %&ea/ing, are i'&aired( Enlarged gingi$a i% &in/, fir', and %ti&&led in %ub+ect% ,ith a good %tandard of oral hygiene( When there i% a &re-exi%ting gingi$iti% the enlarged ti%%ue% co'&ro'i%e an already &oor %tandard of &laBue control( The gingi$a then exhibit the cla%%ical %ign% of gingi$iti% ;6ig( ==(:<( >e$ Point# Gingi$al enlarge'entG drug-inducedH collagen accu'ulationH %urgical treat'entH %u&eri'&o%ed gingi$iti%( 7ana!ement o+ !in!i.al enlar!ement 0 %trict &rogra''e of oral hygiene in%truction, %caling, and &oli%hing 'u%t be i'&le'ented( Se$ere ca%e% of gingi$al enlarge'ent ine$itably need to be %urgically exci%ed ;gingi$ecto'y< and then recontoured ;gingi$o&la%ty< to &roduce an architecture that allo,% adeBuate acce%% for cleaning( 0 follo,-u& &rogra''e i% e%%ential to en%ure a high %tandard of &laBue control and to detect any recurrence of the enlarge'ent( 0% the cau%ati$e drug% need to be ta/en on a long-ter' ba%i%, recurrence i% co''on( When a &henytoin-induced enlarge'ent i% refractory to long-ter' treat'ent, the &atient*% &hy%ician 'ay be reBue%ted to 'odify or change the anticon$ul%ant thera&y to drug% %uch a% %odiu' $al&roate or carba'a5e&ine, ,hich do not cau%e gingi$al &roble'%( There i% no alternati$e 'edication to cyclo%&orin, ho,e$er, and the &atient% ine$itably reBuire indefinite oral care( //.1 TRA(7ATIC 6IN6I)ITIS (6IN6I)ITIS ARTEFACTABFACTITI&(S

6IN6I)ITIS) Gingi$iti% artefacta ha% 'inor and 'a+or $ariant%( The 'inor for' re%ult% fro' rubbing or &ic/ing the gingi$a u%ing the fingernail, or &erha&% fro' abra%i$e food% %uch a% cri%&%, and the habit i% u%ually &ro$o/ed by a locu% of irritation %uch a% an area of &er%i%tent food &ac/ing or an already infla'ed &a&illa ;6ig( ==(!<( The le%ion% re%ol$e ,hen the habit i% corrected and the %ource of irritation i% re'o$ed( The in+urie% in gingi$iti% artefacta 'a+or are 'ore %e$ere and ,ide%&read and can in$ol$e the dee&er &eriodontal ti%%ue% ;6ig( ==(? ;a<<( Other area% of the 'outh %uch a% the li&% and tongue 'ay be in$ol$ed and extraoral in+urie% 'ay be found on the %cal&, li'b%, or face ;factitiou% der'atiti%< ;6ig( ==(? ;b<<( The le%ion% are u%ually $ie,ed ,ith co'&lete indifference by the &atient ,ho i% unable to for,ard detail% of their ti'e of on%et or &o%%ible cau%e( The treat'ent of the%e &atient%, other than the dre%%ing and &rotection of oral ,ound%, doe% not lie ,ith the denti%t( "%ychological rea%on% for inflicting the le%ion% 'ay be co'&lex and ob%cure( 0 &%ychological or &%ychiatric con%ultation, rarely ,elco'ed either by older children or their &arent%, i% nece%%ary if the &atient i% to be &re$ented fro' ulti'ately inflicting %eriou% da'age u&on the'%el$e%( >e$ Point# Gingi$iti% artefactaG 'inorD'a+orH %elf-inflictedH habitualH &%ychological( Fi!. //.1 Trau'atic gingi$al in+ury inflicted by the fingernail ;arro,ed< that ha% been tea%ed fro' the gingi$al cre$ice of =T( ;Re&roduced ,ith /ind &er'i%%ion of the Editor, $ritish Dental +ournal and Mr "( R( Greene, General Dental "ractitioner, Manche%ter(< Fi!. //.2 ;a< Generali5ed, %elf-inflicted ulceration of the attached gingi$a and exten%i$e lo%% of attach'ent around T!( ;b< #lcerati$e le%ion at the hairline on the %cal&( The le%ion% ,ere &roduced by rubbing ,ith a fingernail( ;Re&roduced ,ith /ind &er'i%%ion of the Editor, +ournal of Periodontology(< //.2 7(C&6IN6I)A* PR&;*E7S IN C5I*DREN )n adult% 'uch attention ha% focu%ed on ,hether rece%%ion i% 'ore li/ely to occur locally ,here there i% a reduced ,idth of /eratini5ed gingi$a ;2G<( Con$er%ely, of cour%e, gingi$al rece%%ion ine$itably lead% to a narro,ing of the 5one of 2G( )t i%, therefore, often difficult to deter'ine uneBui$ocally ,hether a narro, 5one of 2G i% the cau%e or the effect of rece%%ion( 0 narro, or finite ,idth of 2G i% co'&atible ,ith gingi$al health, &ro$iding the ti%%ue% are 'aintained free of infla''ation and chronic, trau'atic in%ult( 0 ,ider 5one of 2G i% con%idered 'ore de%irable to ,ith%tand gingi$al infla''ation, trau'a fro' 'a%tication, toothbru%hing, and force% fro' 'u%cle &ull(

0nterior teeth ,ith narro, 5one% of 2G are freBuently encountered in children, a% the ,idth of 2G $arie% greatly during the 'ixed dentition( 6or exa'&le, ,hen &er'anent teeth eru&t labially to their &redece%%or% they freBuently a&&ear to eru&t through al$eolar 'uco%a ,ith a co'&lete ab%ence of 2G ;6ig( ==(C<( When the tooth ha% fully eru&ted an ob$iou% ,idth of 2G i% &re%ent( The ,idth of 2G alone %hould not be the %ole indicator of &otential %ite% of gingi$al rece%%ion in children( The &o%ition of a tooth in the arch i% a better guide a% %tudie% ha$e %ho,n that, of tho%e &er'anent inci%or% ,ith rece%%ion, about C9L are di%&laced labially( 0ggra$ating factor% %uch a% gingi$iti% or 'echanical irritation fro' exce%%i$e and incorrect toothbru%hing further increa%e the li/elihood of rece%%ion( Gingi$al rece%%ion i% al%o a co''on &eriodontal co'&lication of orthodontic thera&y ,hen labial ti&&ing of inci%or% i% underta/en( When root% 'o$e labially through the %u&&orting en$elo&e of al$eolar bone the &otential for rece%%ion increa%e%( When gingi$al rece%%ion occur% in children, a con%er$ati$e a&&roach to treat'ent %hould be ado&ted( The 'axi'u' di%tance fro' the gingi$al 'argin to the CE7 %hould be recorded( O$erenthu%ia%tic toothbru%hing &ractice% are 'odified and a %cale and &oli%h gi$en if nece%%ary( The rece%%ion 'u%t then be 'onitored carefully until the &er'anent dentition i% co'&lete( 3ongitudinal %tudie% of indi$idual ca%e% ha$e %ho,n that, a% the %u&&orting ti%%ue% 'ature, the gingi$al attach'ent tend% to cree& %&ontaneou%ly in a coronal direction to co$er at lea%t &art of the &re$iou%ly denuded root %urface( Thi% cautiou% a&&roach i% &referred to correcti$e %urgical inter$ention to increa%e the ,idth of 2G( >e$ Point# Gingi$al rece%%ionG narro, /eratini5ed gingi$aH local trau'aH &o%t orthodontic%H con%er$ati$e treat'ent a&&roach( Fi!. //.3 3o,er central inci%or% that ha$e eru&ted %o'e,hat labially to the &artially eru&ted buccal to the ( ( There i% only a 'ini'al ,idth of /eratini5ed gingi$a

//.3 C5R&NIC PERI&D&NTITIS 0 nu'ber of e&ide'iological %tudie% ;Table ==( < ha$e in$e%tigated the &re$alence of chronic &eriodontiti% in children( The $ariation in &re$alence bet,een %tudie% i% con%iderable and attributable to different 'ethod% of diagno%ing attach'ent lo%% and the u%e of different cut-off le$el% to deter'ine di%ea%e &re%ence( So'e ,or/er% u%e intraoral radiogra&h% to 'ea%ure fro' the CE7 to the al$eolar cre%t, ,hile other% u%e a &eriodontal &robe to deter'ine clinically the di%tance fro' the CE7 to the ba%e of the &eriodontal cre$ice or &oc/et( Radiogra&hic %tudie% on children ,ith a &ri'ary or a 'ixed dentition indicate that lo%% of attach'ent i% unco''on under the age of > year%( 0 'icro%co&ic exa'ination of the root %urface% of 99 extracted 'olar%,

ho,e$er, de'on%trated a 'ean attach'ent lo%% of 9( ! '' on t,o-third% of the %urface% on >AL of teeth( Clinically, %uch %'all change% are in%ignificant and difficult to detect( Cut-off le$el% at ,hich di%ea%e i% diagno%ed in adole%cent% ha$e been %et at =, , or @ ''( 3arger cut-off $alue% &ro$ide 'ore %tringent criteria for the detection of attach'ent lo%% and con%eBuently the di%ea%e a&&ear% le%% &re$alent( 0n exce&tion to thi% trend ,a% %een in a %tudy of !9 , =A-=:-year-old% in the #nited 2ingdo'H :=(:L of the %ub+ect% ,ere diagno%ed a% ha$ing &eriodontal di%ea%e deter'ined by a CE7al$eolar cre%t di%tance of @ ''( 0dditional radiogra&hic feature% ,ere al%o u%ed, na'ely an irregular contour of the al$eolar cre%t and a ,idened, coronal &eriodontal liga'ent %&ace( Such ob%er$ation% 'ay re%ult fro' 'inor tooth 'o$e'ent% follo,ing eru&tion of the %econd 'olar% and con%olidation of the occlu%ion, or fro' re'odelling of bone after orthodontic treat'ent( )t i%, therefore, li/ely that :=(:L i% a con%iderable o$ere%ti'ate of di%ea%e &re$alence in thi% age grou&( )f a cut-off $alue of '' i% dee'ed acce&table, the 'a+ority of %tudie% &ut the &re$alence of di%ea%e in adole%cent% at =-==L( Thi% %ugge%t% that chronic adult &eriodontiti% initiate% and &rogre%%e% during the early teenage year%( Ob%er$ation% 'ade ,ith re%&ect to &eriodontal di%ea%e in children includeG When lo%% of attach'ent occur% at inter&roxi'al %ite% it i% a con%eBuence of &athological change and correlate% clo%ely ,ith the &re%ence of %ubgingi$al calculu%H The &re$alence of &eriodontal de%truction correlate% &o%iti$ely ,ith DM6 ;decayed, 'i%%ing, and filled< teeth or %urface%( Thi% %ugge%t% either, that cariou% or bro/en do,n %urface% &redi%&o%e to &laBue accu'ulation, or &erha&% 'ore li/ely, that in the ab%ence of oral health care, &eriodontal di%ea%e and carie% &rogre%% inde&endentlyH When the lo%% of attach'ent occur% on buccal or &alatal %urface%, it i% 'ore often a%%ociated ,ith trau'a fro' an incorrect toothbru%hing techniBue than ,ith an infla''atory re%&on%e( >e$ Point# 3o%% of attach'entG &laBue-inducedH trau'a-inducedH detected radiogra&hicallyH decayed, 'i%%ing, and filled ;teeth< lin/( //.4 RIS> FACT&RS F&R PERI&D&NTA* C&NDITI&NS AND DISEASES //.4.0 Introd-"tion 0 ri%/ factor can be defined a% a %tate or occurrence that increa%e% the &robability of an indi$idual de$elo&ing a di%ea%e( Ri%/ factor% for &eriodontal di%ea%e can be cla%%ified a% local or general( 3ocal factor%, for exa'&le, an in%tanding lateral inci%or, 'ay %er$e to co'&ro'i%e local &laBue control by hindering effecti$e cleaning and re%ulting in dental &laBue accu'ulation( On the other hand, general ri%/ factor%, %uch a% an inherited di%order 'ay &redi%&o%e an indi$idual to &eriodontal di%ea%e de%&ite a good le$el of &laBue control(

)t i% i'&ortant to under%tand that if a child &o%%e%%e% a ri%/ factor for &eriodontal di%ea%e, it doe% not nece%%arily follo, that the child ,ill de$elo& the condition( Con$er%ely, a &atient 'ay a&&ear to ha$e no ri%/ factor%, but the di%ea%e 'ay de$elo& %ub%eBuently( 4earing thi% in 'ind, ri%/ factor% ;both local and general< %hould be con%idered ,hen a%%e%%ing, diagno%ing, treating, and 'aintaining child &atient% ,ith &eriodontal di%ea%e( //.4./ *o"al ri#= +a"tor# The%e can be grou&ed %i'&ly into four area%( There 'ay be o$erla& bet,een the%e area%( Malocclu%ion%( 6ollo,ing trau'atic dental in+urie%( "laBue retenti$e factor%( Ecto&ic eru&tion 7alo""l-#ion# 0n in%tanding or rotated tooth 'ay be difficult to clean and can cau%e increa%ed &laBue retention( 0 trau'atic occlu%ion 'ay re%ult in direct da'age to the &eriodontal %u&&ort( 0ngle*% Cla%% )) di$i%ion ii 'alocclu%ion% ,ith increa%ed and co'&lete o$erbite% 'ay &redi%&o%e to da'age of the gingi$a &alatal to the u&&er inci%or teeth( Si'ilarly, %e$erely retroclined u&&er inci%or teeth 'ay da'age the labial gingi$a of the lo,er teeth( FolloCin! a tra-mati" dental inD-r$ 3uxation, intru%ion and a$ul%ion in+urie% all re%ult in $arying degree% of da'age to the &eriodontal liga'ent and if %e$ere, al$eolar bone( Thi% re%ult% in increa%ed tooth 'obility ,hich i% 'anaged by &ro$iding the affected teeth ,ith a %&lint( )f a trau'ati%ed tooth i% left in a %e$erely 'obile %tate or in trau'atic occlu%ion, the &eriodontal liga'ent fibre% ,ill not heal and further da'age 'ay en%ue( PlaA-e retenti.e +a"tor# There i% a 'ultitude of &laBue retenti$e factor% ,hich 'ay %er$e to co'&ro'i%e the health of the &eriodontiu'( They 'ay be naturally occurring ;in the ca%e of a dental ano'aly< or be iatrogenic( Exa'&le% of dental ano'alie% includeG Eru&ted %u&ernu'erary teeth ;locali5ed 'alocclu%ion<( )n$aginated odonto'e%( Talon cu%&%( "itted, groo$ed a'elogene%i% i'&erfecta ;,ith %en%iti$ity<( Ena'el &earl% or root groo$e%(

Exa'&le% of iatrogenic factor% includeG Orthodontic a&&liance%( "artial denture%( 3edge% and o$erhang% on &oorly fitting &refor'ed 'etal cro,n%( 3edge% and o$erhang% fro' intracoronal re%toration%( //.4.2 6eneral ri#= +a"tor# General ri%/ factor% for &eriodontal di%ea%e 'ay ha$e a genetic ba%i%, ,ith certain inherited condition% &o%%e%%ing &eriodontal 'anife%tation% ;e(g( "a&illon 3efe$re Syndro'e<( The genetic condition% are dealt ,ith &re$iou%ly in thi% cha&ter( There are al%o 'etabolic, hae'atological, and en$iron'ental ri%/ factor% ,ithin the general category( 0 full di%cu%%ion of each i% out,ith the %co&e of thi% cha&ter, %o the t,o 'o%t &re$alent exa'&le% of general ri%/ factor%, diabete% 'ellitu% and %'o/ing ,ill be di%cu%%ed( Dia,ete# mellit-# Children ,ith Ty&e ) diabete% with poor dia,etic control are at ri%/ of de$elo&ing &eriodontal di%ea%e( The lin/ a&&ear% not to be directly ,ith the le$el of &laBue control but to the &re%ence of %y%te'ic co'&lication%, %uch a% retinal and renal &roble'%( The o$erall %e$erity of &eriodontal di%ea%e 'ay increa%e ,ith increa%ing duration of the diabete%( There are a nu'ber of factor% ,hich 'ay contribute to a child*% ri%/ %tatu%( They 'ay be inherited or %econdary to high le$el% of blood gluco%e ;hy&erglycae'ia<( The%e can be outlined a%G Defecti$e &oly'or&honuclear leucocyte function ;che'otaxi%, &hagocyto%i%, and adherence<H Di%ordered collagen 'etaboli%' ;gingi$al fibrobla%t% &roduce le%% collagen and the &oly'or&honuclear leucocyte% &roduce 'ore of the en5y'e collagena%e than in nondiabetic%<( Thi% re%ult% in &oor ,ound healingH The hy&erglycae'ic %tate 'ay fa$our certain infla''atory 'ediator% and increa%e oxygen radical &roduction by 'acro&hage%( To,a""o #mo=in! S'o/ing i% no, thought to be a %ignificant en$iron'ental ri%/ factor for &eriodontal di%ea%e( S'o/er% ha$e @-! ti'e% the le$el of &eriodontal di%ea%e ,hen co'&ared ,ith non-%'o/er% and young &eo&le are thought to be 'ore $ulnerable( Often, the %ign% of di%ea%e are 'a%/ed becau%e nicotine and other tobacco &roduct% cau%e $a%ocon%triction, reducing the blood %u&&ly to the gingi$ae and lo,ering the tendency to bleed( There are a nu'ber of %'o/ing-related 'echani%'% &ertaining to %'o/ing a% a ri%/ factor for &eriodontal di%ea%e( The%e includeG

 )ncrea%ed &re$alence of %o'e &eriodontal &athogen%H Reduction in the le$el% of %ali$ary )g0H Reduction in effecti$e &hagocyto%i%H 0lteration% in the nu'ber% of certain T cell &o&ulation%( )f an indi$idual %to&% %'o/ing thi% ,ill allo, an i'&ro$ed re%&on%e to the 'anage'ent of &eriodontal di%ea%e, but the ti'e ta/en for thi% *reco$ery* to occur i% unclear( The underlying defect a%%ociated ,ith general ri%/ factor% i% co'&ro'i%ed &hagocyto%i% and or che'otaxi%( The i'&ortance of &oly'or&honuclear leucocyte ;neutro&hil< function to the ho%t re%&on%e i% al%o de'on%trated in le%% co''on condition% %uch a% the neutro&aenia% ;%ee &age : <( //./0 PERI&D&NTA* C&7P*ICATI&NS &F &RT5&D&NTIC TREAT7ENT //./0.0 Introd-"tion Orthodontic treat'ent in adole%cent%, &articularly ,ith fixed a&&liance%, can &redi%&o%e to a deterioration in &eriodontal health and a nu'ber of ,ell-recogni5ed co'&lication%( //./0./ 6in!i.iti# 0cce%% for inter&roxi'al toothbru%hing i% reduced con%iderably during fixed a&&liance thera&y and the accu'ulation of &laBue induce% gingi$iti% ;6ig( ==(><( The &roble' i% co'&ounded ,hen teeth are banded rather than bonded a% &eriodontal health i% 'ore ea%ily 'aintained ,hen the gingi$al %ulcu% i% not encroached u&on by 'etal band%( When %u&ragingi$al &laBue de&o%it% are &re%ent on teeth that are being re&o%itioned orthodontically, the ty&e of 'o$e'ent u%ed 'ay &lay an i'&ortant &art in the de$elo&'ent of &eriodontal &roble'%( Su&ragingi$al &laBue de&o%it% are %hifted into a %ubgingi$al location by ti&&ing 'o$e'ent%( Con$er%ely, bodily 'o$e'ent% are le%% li/ely to induce a relocation of %u&ragingi$al &laBue( Fi!. //.4 Chronic 'arginal gingi$iti% a%%ociated ,ith fixed a&&liance thera&y( //./0.2 6in!i.al enlar!ement The anterior &alatal gingi$a and 'uco%a ha$e a &ro&en%ity for enlarge'ent ,hen ti%%ue% are *rolled u&* bet,een inci%or% that are being retracted and the fixed anterior 'argin of the acrylic &late of a re'o$able a&&liance ;6ig( ==(=9 ;a< and ;b<<( Generally, ho,e$er, the%e change% tend to be tran%ient and re%ol$e ,hen a&&liance% are re'o$ed( Fi!. //./0 ;a< Gingi$al enlarge'ent on the &alatal a%&ect of retracted 'axillary inci%or%( ;b< 0&&liance in situ( ;Re&roduced by /ind &er'i%%ion of Mr -( E(

Carter, Con%ultant in Orthodontic%, -e,ca%tle(< //./0.3 Atta"%ment and ,one lo## The 'ean, annual rate of coronal attach'ent lo%% during a&&liance thera&y range% fro' 9(9: to 9(@9 '', ,hich co'&are% fa$ourably ,ith figure% for the 'ean annual attach'ent lo%% in untreated &o&ulation%( 0 ,ell-recogni5ed co'&lication of orthodontic tooth 'o$e'ent i% a&ical root re%or&tion, &articularly ,hen exce%%i$e force% are u%ed ;6ig( ==(==<( Such change% 'u%t al%o be regarded a% lo%% of attach'ent, albeit at an a&ical rather than a coronal %ite( Fi!. //.// 0&ical root re%or&tion of @ =T= @ follo,ing orthodontic treat'ent( ;Re&roduced by /ind &er'i%%ion of Dr )( 3( Cha&&le, "rofe%%or of "eriodontology, 4ir'ingha', #2(< //./0.0 6in!i.al re"e##ion The re%&on%e of the facial &eriodontal ti%%ue% to labial tooth 'o$e'ent in anterior %eg'ent% i% un&redictable( 3abial 'o$e'ent of inci%or% i% %o'eti'e% a%%ociated ,ith gingi$al rece%%ion( The ri%/ of rece%%ion i% greater ,hen the al$eolar bone &late i% thin or ,here dehi%cence% or fene%tration% in the bone exi%t( //./0.5 Tra-ma Direct local irritation of the %oft ti%%ue% by co'&onent% of a fixed a&&liance can be 'ini'i5ed if due care and attention i% exerci%ed during bonding, banding, and &lace'ent of ,ire% and ela%tic%( )f chronic irritation of the gingi$a doe% occur then a locali5ed, acute infla''atory reaction ,ill Buic/ly follo,( Thi% 'ay de$elo& further into a region of gingi$al enlarge'ent or a fibrou% e&uli% that i% %u&eri'&o%ed u&on a burro,ing infrabony le%ion( >e$ Point# Orthodontic &roble'%G gingi$iti%H enlarge'entH root re%or&tionH gingi$al trau'a( //.// A66RESSI)E PERI&D&NTA* DISEASES //.//.0 Introd-"tion 0ggre%%i$e &eriodontal di%ea%e% co'&ri%e a grou& of rare, but ra&idly &rogre%%ing infection% that affect the &ri'ary and &er'anent dentition%( The di%order% are a%%ociated ,ith a 'ore %&ecific 'icrobial challenge and an inherent defect in the ho%t*% i''unological re%&on%e( The nature of the%e di%ea%e% can lead to &re'ature tooth lo%% at an early age( "ro'&t diagno%i% i% e%%ential if treat'ent i% to be %ucce%%ful, and the &eriodontal %tatu% 'u%t be 'onitored regularly to en%ure that the treated di%ea%e re'ain% Buie%cent(

0ggre%%i$e &eriodontal di%ea%e% ,ere &re$iou%ly /no,n a% early-on%et di%ea%e%, na'ely, &re&ubertal and +u$enile &eriodontiti%( 0 cla%%ification %y%te' for &eriodontal di%ea%e% and condition% &ubli%hed in =>>> effecti$ely co'bined the%e t,o di%ea%e% into oneaggre%%i$e &eriodontiti% ;%ee 6urther Reading<( Thi% cla%%ification, ,hich i% u%ed in thi% cha&ter, re'o$ed the arbitrary age li'itation% that ,ere &re$iou%ly inferred by ter'% %uch a% &re&ubertal, +u$enile, and e$en adult &eriodontiti%( )t i% no, recogni5ed that aggre%%i$e &eriodontiti% can affect the &ri'ary and &er'anent dentition% both in locali5ed and generali5ed for'%( //.//./ Primar$ dentition ( re -,ertal eriodontiti#) The di%ea%e 'ay &re%ent i''ediately after the teeth ha$e eru&ted( )n the generali5ed for' the gingi$a a&&ear fiery red, %,ollen, and hae'orrhagic( The ti%%ue% beco'e hy&er&la%tic ,ith granular or nodular &roliferation% that &recede gingi$al clefting and exten%i$e area% of rece%%ion( Gro%% de&o%it% of &laBue are ine$itable a% the %oft ti%%ue change% 'a/e it difficult to 'aintain oral hygiene( The di%ea%e &rogre%%e% extre'ely ra&idly, ,ith &ri'ary tooth lo%% occurring a% early a% @-A year% of age( The entire dentition need not be affected, ho,e$er, a% the bone lo%% 'ay be re%tricted to one arch( Children ,ith generali5ed di%ea%e are %u%ce&tible to recurrent general infection%, &rinci&ally otiti% 'edia and u&&er re%&iratory tract infection%( 3ocali5ed di%ea%e &rogre%%e% 'ore %lo,ly than the generali5ed for' and bone lo%% characteri%tically affect% only inci%or-'olar teeth( "laBue le$el% are u%ually lo,, con%eBuently %oft ti%%ue change% are 'ini'al ,ith gingi$iti% and &roliferation in$ol$ing only the 'arginal ti%%ue%( The &redo'inant 'icro-organi%'% that ha$e been identified are aggre%%i$e &eriodonto&athogen%G "ctino,acillus actinomycetemcomitans; Porphyromonas gingivalis; 1uso,acterium nucleatum, and 7i%enella corrodens( Thi% %ugge%t% that there i% an infecti$e co'&onent to the di%ea%e, although defect% in the ho%t%* re%&on%e ha$e al%o been identified( "rofound abnor'alitie% in che'otaxi% and &hagocyto%i% of &oly'or&honuclear neutro&hil% and 'onocyte% are freBuently re&orted in the%e &atient%( The%e i''unological defect% are heritable ri%/ factor% that hel& to define &henoty&ically the di%ea%e entity( Con$er%ely, they 'ay al%o be a%%ociated ,ith 'ore %eriou% and life-threatening condition%, and thu% a full 'edical %creen i% indicated( Oral hygiene in%truction, %caling, and root &laning %hould be underta/en at freBuent inter$al%( 4acterial culturing of the &oc/et flora identifie% %&ecific &eriodonto&athogen%( )f &athogen% &er%i%t after oral debride'ent, an antibiotic %uch a% 'etronida5ole or a'oxycillin ;a'oxicillin< %hould be gi$en %y%te'ically after %en%iti$ity te%ting, a% a %hort cour%e o$er =- ,ee/%( Generali5ed di%ea%e re%&ond% &oorly to treat'ent( So'e i'&ro$e'ent ha% been achie$ed follo,ing a granulocyte tran%fu%ion in a &atient ,ith a defect in neutro&hil function( Extraction of in$ol$ed teeth ha% al%o &roduced an i'&ro$e'ent in neutro&hil che'otaxi%, ,hich %ugge%t% that the defect 'ay be induced by certain organi%'% in the &eriodontal flora( 6urther'ore, in %e$ere ca%e% of generali5ed &eriodontiti%, extraction of all &ri'ary teeth ;and the &ro$i%ion of a re'o$able &ro%the%i%< can li'it the di%ea%e to the &ri'ary dentition( "re%u'ably, anaerobic &athogen% are unable to thri$e in the ab%ence of teeth( When the &er'anent teeth eru&t, bacterial culturing of the %ubgingi$al flora

en%ure% that reinfection i% detected early( >e$ Point# "ri'ary dentition ;&re&ubertal &eriodontiti%<G locali5edDgenerali5edH aggre%%i$e &athogen%H inten%e treat'ent( //.//.2 Permanent dentition (D-.enile eriodontiti#) )n the &er'anent dentition, aggre%%i$e &eriodontiti% in$ol$e% %e$ere &eriodontal de%truction ,ith an on%et around &uberty( The locali5ed for' occur% in other,i%e healthy indi$idual%, ,ith de%truction cla%%ically locali5ed and around the fir%t &er'anent 'olar% and inci%or%, and not in$ol$ing 'ore than t,o other teeth( Generali5ed &eriodontiti% al%o occur% in other,i%e healthy indi$idual% but in$ol$e% 'ore than =A teeth, that i%, being generali5ed to an arch or the entire dentition( So'e re&ort% ha$e 'onitored children %uffering fro' aggre%%i$e &eriodontiti% of the &ri'ary dentition to find that, at around &uberty, the di%ea%e beca'e generali5ed to in$ol$e the entire dentition( E idemiolo!$ Studie% %ho, a &re$alence of about 9(=L in de$elo&ed countrie% and about :L in underde$elo&ed nation%, although %o'e $ariation 'ay be due to different 'ethod% of %creening and different criteria u%ed to define the di%ea%e( The di%ea%e i% clearly 'ore &re$alent in certain ethnic grou&%( )n the #nited 2ingdo' an e&ide'iological %tudy of ? !! %choolchildren in Co$entry and 4ir'ingha' %ho,ed an o$erall &re$alence of 9(9 L in Cauca%ian%, 9( L in 0%ian%, and 9(CL in the 0froCaribbean &o&ulation( There ,a% no difference in &re$alence bet,een 'ale% and fe'ale%, ,hich doe% not concur ,ith the data of 'any earlier e&ide'iological %tudie% of the di%ea%e ,hich re&orted a fe'ale to 'ale ratio of @ G =( Clini"al and radio!ra %i" +eat-re# The age of on%et i% bet,een == and =: year%( The clinical feature% are &oc/et for'ation and lo%% of attach'ent a%%ociated ,ith the &er'anent inci%or% and fir%t 'olar teeth( The radiogra&hic &attern of bone lo%% i% Buite di%tincti$e( 4ilateral angular bone defect% are identified on the 'e%ial and, or di%tal %urface% of 'olar% ;6ig( ==(= ;a< and ;b<<( 0ngular defect% are %o'eti'e% %een around the inci%or%, although the $ery thin inter&roxi'al bone i% re%orbed 'ore e$enly to gi$e a hori5ontal &attern of re%or&tion( The bone lo%% around the 'olar% can be detected on routine bite,ing radiogra&h%( The inter&retation of the fil'% 'u%t be 'ade ,ith a %ound /no,ledge of the &atient*% dental hi%tory, ho,e$er, a% locali5ed angular defect% are found ad+acent to teeth ,ith o$erhanging or deficient inter&roxi'al re%toration%, and teeth that ha$e tilted %lightly ;6ig( ==(=@<( The gingi$a can a&&ear healthy ,hen the le$el% of &laBue are lo,, but a 'arginal gingi$iti% ,ill be &re%ent if a good %tandard of &laBue control i% not e$ident( The generali5ed for' 'ay al%o &re%ent at &uberty( Se$ere generali5ed bone lo%% i% the characteri%tic feature ;6ig( ==(=A<( The &attern 'ay be a co'bination of angular and

hori5ontal re%or&tion &roducing an irregular al$eolar cre%t( When &atient% ha$e good &laBue control the degree of bone re%or&tion i% not co''en%urate ,ith the le$el of oral hygiene( The 'ore generali5ed nature of the di%ea%e &redi%&o%e% to 'ulti&le and recurrent ab%ce%% for'ation ,hich i% a co''on &re%enting feature( )n$ariably, one of the &re%enting %ign% i% tooth 'igration or drifting of inci%or%( Tooth 'o$e'ent i% not nece%%arily a con%eBuence of ad$anced di%ea%e a% drifting 'ay occur ,hen only a fraction of a tooth*% &eriodontal %u&&ort i% lo%t( Con$er%ely, exten%i$e bone lo%% can occur ,ith no %&ontaneou% 'o$e'ent of teeth and the %ub+ect 'ay only be alerted to the &roble' ,hen a 'inor trau'atic e&i%ode, %uch a% a blo, to the 'outh during a %&orting acti$ity, cau%e% unex&ected loo%ening of teeth( ;a"teriolo!$ and at%o!ene#i# The %ubgingi$al 'icroflora co'&ri%e% loo%ely adherent, Gra'-negati$e anaerobe% including 7i%enella corrodens; Capnocytophaga %&&(, and Prevotella intermedia( The 'o%t freBuently i'&licated organi%' i% "ctino,acillus actinomycetemcomitans, ,hich ha% been found in o$er >9L of &atient%( Sufferer% al%o ha$e rai%ed )gG titre% to " actinomycetemcomitans, but le$el% of the bacteria fall %ignificantly follo,ing %ucce%%ful treat'ent of the condition( >e$ Point# "er'anent dentition ;7u$enile &eriodontiti%<G on%et around &ubertyH locali5edDgenerali5edH "ctino,acillus actinomycetemcomitansH neutro&hil che'otaxi% defect( The extre'e &athogenicity of " actinomycetemcomitans i% due to it% ability to in$ade connecti$e ti%%ue% and the ,ide range of $irulence factor% that it &roduce%( The%e include a &otent li&o&oly%accharide that induce% bone re%or&tion, collagena%e, an e&itheliotoxin, a fibrobla%t-inhibiting factor, and a leucotoxin that /ill% neutro&hil% and %o da'&en% the ho%t*% fir%t line of defence again%t bacterial challenge( 0bout ?9L of &atient% ha$e defect% in neutro&hil che'otaxi% and &hagocyto%i%( The che'otactic defect i% lin/ed to reduced a'ount% of cell-%urface glyco&rotein% and i% tran%'itted a% a do'inant trait( 0bout :9L of %ibling% of &atient% ,ho ha$e both aggre%%i$e &eriodontiti% and che'otactic defect%, al%o de'on%trate i'&aired neutro&hil function( Treatment 0 co'bined regi'en of regular %caling and root &laning ,ith a -,ee/ cour%e of %y%te'ic tetracycline thera&y ; :9 'g, four ti'e% daily< ha% been u%ed exten%i$ely in the 'anage'ent of thi% condition( " actinomycetemcomitans i% %en%iti$e to tetracycline, ,hich al%o ha% the ability to be concentrated u& to =9 ti'e% in gingi$al cre$icular fluid ,hen co'&ared ,ith %eru'( More recently, a co'bination of 'etronida5ole ; :9 'g< and a'oxicillin ;a'oxycillin< ;@?: 'g<, three ti'e% a day for = ,ee/, in a%%ociation ,ith %ubgingi$al %caling, ha% al%o been found to be effecti$e(

0 'ore radical a&&roach i% to underta/e fla& %urgery %o that better acce%% i% achie$ed for root cleaning, and the %u&erficial, infected connecti$e ti%%ue% are exci%ed( 0n anti'icrobial regi'en can al%o be i'&le'ented in con+unction ,ith a %urgical a&&roach( >e$ Point# "er'anent dentition ;+u$enile &eriodontiti%<treat'entG &laBue controlH 'echanical debride'entH %y%te'ic anti'icrobial%H &eriodontal %urgery( Fi!. //./2 ;a< Clinical a&&earance of a =@-year-old girl ,ith locali5ed aggre%%i$e &eriodontiti%( ;b< Radiogra&hic a&&earance of $ertical bone lo%% on the 'e%ial a%&ect of !T( ;Re&roduced by /ind &er'i%%ion of Mr D( G( S'ith, Con%ultant in Re%torati$e Denti%try, -e,ca%tle u&on Tyne<( Fi!. //./3 Radiogra&hic $ie, of T? that ha% eru&ted and ti&&ed 'e%ially into the T! extraction %ite( The contour of the bone cre%t on the 'e%ial of T? gi$e% the i'&re%%ion of a $ertical bony defect( Fi!. //./0 0ggre%%i$e &eriodontiti% ,ith generali5ed bone lo%% in a =!-year-old 'ale( //.//.3 6eneti" +a"tor# and a!!re##i.e di#ea#e# The increa%ed &re$alence of aggre%%i$e &eriodontiti% in certain ethnic grou&% and ,ithin fa'ilie% %trongly %ugge%t% that %u%ce&tibility to the%e di%ea%e% 'ay be influenced by a nu'ber of genetic deter'inant%( 6urther'ore, genetic factor% are i'&licated in the &athogene%i% of the di%ea%e% a% 'any affected &atient% ha$e functionally defecti$e neutro&hil%( The 'ode of tran%'i%%ion ha% not been deter'ined uneBui$ocally( The a&&arent increa%ed incidence in fe'ale% %ugge%t% an X-lin/ed do'inant 'ode of inheritance ,ith reduced &enetrance( The a%%ociation ,ith fe'ale%, ho,e$er, 'ay reflect e&ide'iological bia% a% fe'ale% are 'ore li/ely to %ee/ dental attention( 3arge fa'ily %tudie% of %ub+ect% ,ith aggre%%i$e &eriodontiti% %ugge%t an auto%o'al-rece%%i$e &attern of inheritance( The role of hereditary co'&onent% in &eriodontal di%ea%e% ha% been %u&&orted by the lin/ ,ith %&ecific ti%%ue 'ar/er%( The 'a+or hi%toco'&atibility co'&lex ;M1C< deter'ine% the %u%ce&tibility of %ub+ect% to certain di%ea%e%( Cla%% ) and )) gene% in the M1C encode for %&ecific hu'an leucocyte antigen% ;130 ) and ))<, ,hich account for indi$idual $ariation in i''unore%&on%i$ene%%( There are clear a%%ociation% bet,een 130 %eroty&e% and diabete% 'ellitu% and rheu'atoid arthriti%( 0 %trong lin/ bet,een an 130 %eroty&e and aggre%%i$e di%ea%e% ha% %till to be deter'ined, although a 'ild a%%ociation bet,een the 130-0> antigen and aggre%%i$e &eriodontiti% ha% been found( >e$ Point# Genetic co'&onent% of &eriodontiti%G

 fa'ily a%%ociation%H ethnic a%%ociation%H 'a+or hi%toco'&atibility co'&lex lin/H lin/ ,ith %yndro'e%( //./2 PERI&D&NTITIS AS A 7ANIFESTATI&N &F SYSTE7IC DISEASE //./2.0 Introd-"tion The genetic ba%i% for aggre%%i$e &eriodontiti% in &articular i% %ub%tantiated by the definite a%%ociation bet,een the condition and a nu'ber of rare inherited 'edical condition% and %yndro'e% ;Table ==(=<( The &attern of inheritance reflect% a %ingle gene di%order, co''only in$ol$ing inherited defect% of neutro&hil%, en5y'e reaction%, or collagen %ynthe%i%( //./2./ Pa illon-*e+e.re #$ndrome (P*S) Thi% %yndro'e i% characteri5ed by &al'ar-&lantar hy&er/erato%i%, &re'ature lo%% of &ri'ary and &er'anent dentition%, and ecto&ic calcification% of the falx cerebri( So'e &atient% %ho, an increa%ed %u%ce&tibility to infection( The %yndro'e i% an auto%o'alrece%%i$e trait ,ith a &re$alence of about =-A &er 'illion of the &o&ulation( Con%anguinity of &arent% i% e$ident in about one-third of ca%e%( Ra&id and &rogre%%i$e &eriodontal de%truction affect% the &ri'ary dentition ,ith an on%et at about year% ;6ig( ==(=:<( Exfoliation of all &ri'ary teeth i% u%ual before the &er'anent %ucce%%or% eru&t and &atient% 'ay be edentulou% by the 'id to late teen%( Ca%e% of a late-on%et $ariant of "3S ha$e al%o been de%cribed in ,hich the &al'ar&lantar and &eriodontal le%ion% are relati$ely 'ild and only beco'e e$ident in the &er'anent dentition( 0n exten%i$e fa'ily dental hi%tory %u&&orted by clinical, laboratory, and radiogra&hic exa'ination% confir'% the diagno%i%( Fi!. //./5 "a&illon-3efe$re %yndro'e in a @-year-old boy( ;a< Radiogra&hic a&&earance %ho,ing al'o%t total bone lo%% around 'axillary anterior teeth( ;b< 1y&er/erato%i% of the &al'% of the hand( //./2.2 Ne-tro enia# The neutro&enia% co'&ri%e a heterogeneou% grou& of blood di%order% that are characteri5ed by a &eriodic or &er%i%tent reduction in the nu'ber of circulating &oly'or&honuclear neutro&hil%( -eutro&enia% can be drug-induced or be %econdary to %e$ere bacterial or $iral infection% or autoi''une di%ea%e% %uch a% lu&u% erythe'ato%u%( Cyclic neutro&enia, benign fa'ilial neutro&enia%, and %e$ere fa'ilial neutro&enia% are all heritable condition% tran%'itted a% auto%o'al-do'inant trait% and diagno%e% are often 'ade during early childhood( The chronic benign neutro&enia of childhood i% diagno%ed bet,een ! and A 'onth% of age and i% characteri5ed by freBuent and 'ulti&le &yogenic infection% of the %/in and 'ucou% 'e'brane%( The &eriodontal &roble'% a%%ociated ,ith the neutro&enia% are $ery %i'ilar, and in 'any ca%e% the &atient &re%ent% ,ith a locali5ed or generali5ed aggre%%i$e &eriodontiti%( Occa%ionally, the &ri'ary dentition 'ay not be in$ol$ed, and clinical

%ign% do not a&&ear until the &er'anent dentition ha% eru&ted( The gingi$a are infla'ed and oede'atou%H gingi$al rece%%ion, ulceration, and de%Bua'ation can al%o occur( The treat'ent of a neutro&enic-induced &eriodontiti% in$ol$e% local re'o$al of &laBue and calculu%( Strict &laBue control 'ea%ure% are difficult to achie$e in younger children, %o u%e of an antibacterial 'outhrin%e 'ay &ro$e u%eful( //./2.3 C%edia=-5i!a#%i #$ndrome Thi% i% a rare and $ery often fatal di%ea%e inherited a% an auto%o'al-rece%%i$e trait( Clinical feature% include &artial albini%', &hoto&hobia, and ny%tag'u%( The &atient% %uffer fro' recurrent &yogenic infection% and 'alignant ly'&ho'a,hich i% acco'&anied by neutro&enia, anae'ia, and a thro'bocyto&enia( The neutro&hil% %ho, defect% in 'igration, che'otaxi%, and &hagocyto%i% &roducing a di'ini%hed bactericidal ca&acity( "eriodontal change% a%%ociated ,ith the %yndro'e include %e$ere gingi$al infla''ation and ra&id, and exten%i$e, al$eolar bone re%or&tion that can lead to &re'ature exfoliation( The nature of the change% ha% not been fully e%tabli%hed, but they 'ay be &laBue-induced, %econdary to infection, or related to the underlying defect in neutro&hil function( //./2.0 *e-"o"$te-ad%e#ion de+i"ien"$ #$ndrome (*AD) Thi% auto%o'al-rece%%i$e trait i% characteri5ed clinically by a delayed %e&aration of the u'bilical cord, %e$ere recurrent bacterial infection%, i'&aired ,ound healing, for'ation of &u%, and an aggre%%i$e gingi$iti%, ,hich 'ay be the &re%enting %ign of the di%order( Con%anguinity bet,een the &arent% of affected children confir'% the 'ode of the inheritance a% auto%o'al-rece%%i$e( The %yndro'e de'on%trate% the i'&ortant role of leucocyte% ;and other ,hite blood cell%< in &rotecting the ho%t again%t &eriodontal di%ea%e( Moderate &heno- ty&e%, ho,e$er, 'ay a&&ear relati$ely di%ea%e-free, but then de$elo& %y'&to'% and &rogre%% *do,nhill* extre'ely ra&idly( The 'a+ority of &atient% do not %ur$i$e beyond @9 year%( The &rogre%%i$e &eriodontal condition i% $ery difficult to control and i% often of %econdary i'&ortance to other life-threatening infection%( //./2.5 E%ler#-Danlo# #$ndrome The %yndro'e i% an auto%o'al-do'inant trait ,ith nine $ariant% that di%&lay defect% in the %ynthe%i%, %ecretion, or &oly'eri5ation of collagen( The $ariant% of the %yndro'e exhibit exten%i$e clinical heterogeneity and collecti$ely re&re%ent the 'o%t co''on of the heritable di%order% of connecti$e ti%%ue%( The clinical finding% are &rinci&ally exce%%i$e +oint 'obility, %/in hy&erexten%ibility, and %u%ce&tibility to %carring and brui%ing of the %/in and oral 'ucou% 'e'brane% ;6ig( ==(=!<( Defecti$e ty&e )8 collagen %u&&orting the ,all% of %'all blood $e%%el% &redi%&o%e% to &er%i%tent &o%textraction hae'orrhage( Gingi$al ti%%ue% are fragile and ha$e a tendency to bleed on toothbru%hing( The ty&e

8))) %yndro'e i% a%%ociated ,ith ad$anced &eriodontal di%ea%e( "eriodontiti% ha% al%o been lin/ed ,ith the ty&e )8 $ariant, although other $ariant% do not a&&ear to be affected( #ltra%tructural change% al%o occur in the teeth, ,ith abnor'alitie% of the a'elodentinal +unction, $a%cular inclu%ion% in dentine, fibrou% degeneration of the &ul&, and di%organi5ation of ce'entu'( Ty&e 8))) &atient% reBuire a thorough &re$enti$e &eriodontal &rogra''e a% root debride'ent can cau%e exten%i$e trau'a to the fragile %oft ti%%ue%( "eriodontal %urgery %hould be a$oided becau%e of the ri%/ of hae'orrhage and the &otential &roble'% encountered ,ith %uturing %oft ti%%ue fla&%( Fi!. //./1 Cutaneou% hy&erexten%ibility of the u&&er eyelid% in a >-year-old child ,ith Ehler%-Danlo% %yndro'e( //./2.1 *an!er%an#? "ell %i#tio"$to#i# 3angerhan%* cell hi%tiocyto%i% ;3C1< i% a non-'alignant granulo'atou%, childhood di%order that i% characteri5ed &athologically by uncontrolled &roliferation and accu'ulation of 3angerhan%* cell%, 'ixed ,ith $arying &ro&ortion% of eo%ino&hil% and 'ultinucleated giant cell%( 3C1 re&laced the ter' *hi%tiocyto%i% X* and the clo%ely related %yndro'e% eo%ino&hilic granulo'a, 1and-Schuller-Chri%tian di%ea%e, and 3etterer-Si,e di%ea%e( The clinical hall'ar/ of 3C1 i% the &re%ence of lytic bone le%ion% that 'ay be %ingle or 'ulti&le( When le%ion% are ,ide%&read they can affect the &ituitary gland and retro-orbital region, thu% cau%ing diabete% in%i&idu% and exo&hthal'o%, re%&ecti$ely( The di%%e'inated for' of 3C1 i% extre'ely aggre%%i$e and ha% a &oor &rogno%i%( )t i% often diagno%ed in the fir%t ! 'onth% of life before beco'ing ,ide%&read by about @ year% of age( The &eriodontal 'anife%tation% of 3C1 'ay be the &re%enting %ign%, ,hich include a 'arginal gingi$iti%, bleeding gingi$a, ab%ce%% for'ation, &ain, and drifting and 'obility of the teeth( Radiogra&h% %ho, locali5ed or generali5ed bone lo%%, characteri%tic o%teolytic le%ion%, and *floating teeth* ,ith no al$eolar bone %u&&ort ;6ig( ==(=?<( 0 bio&%y ,ill confir' the diagno%i% and a full radiogra&hic %creening deter'ine% the %e$erity of the %yndro'e( 3ocal le%ion% that are confined to bone re%&ond ,ell to curettage and exci%ion( The 'ortality rate increa%e% in the 'ore ,idely di%%e'inated for'% of the %yndro'e and ,hen o$erlying %oft ti%%ue% are in$ol$ed( Treat'ent i% by radiothera&y and che'othera&y( Fi!. //./2 Exten%i$e bone lo%% around 'andibular left &re'olar% in a =:-yearold child ,ith 3angerhan% cell hi%tiocyto%i%( ;Re&roduced by /ind &er'i%%ion of Dr )( 3( Cha&&le, "rofe%%or of "eriodontology, 4ir'ingha', #2(< //./2.2 5$ o %o# %ata#ia 1y&o&ho%&hata%ia i% a rare, inborn error of 'etaboli%' characteri5ed by defecti$e bone 'inerali5ation, a deficiency of al/aline &ho%&hata%e ;03"< acti$ity, and an increa%ed excretion of &ho%&hoethanola'ine in the urine( 03" &lay% a 'a+or &art in the 'inerali5ation of hard ti%%ue% and %o the ab%ence of the en5y'e &redi%&o%e% to a

range of bone and cartilage defect%( The condition i% an auto%o'al-rece%%i$e trait, although the inheritance &attern of %o'e 'ilder for'% of hy&o&ho%&hata%ia 'ay be auto%o'al-do'inant( >e$ Point# "re&ubertal &eriodontiti%D%y%te'ic di%ea%e%G $ery rareH auto%o'al 'ode of inheritanceH aggre%%i$e &eriodontal de%truction( The le%ion% of +u$enile or childhood hy&o&ho%&hata%ia beco'e a&&arent before year% of age( 4one defect% are u%ually Buite 'ild ,ith bo,ing of the leg%, &ro&to%i%, and ,ide-o&en fontanelle% being &ro'inent %ign%( Dental feature% are re%or&tion of al$eolar bone ;in the ab%ence of 'ar/ed gingi$iti%<, &re'ature exfoliation of anterior deciduou% teeth, hy&o&la%ia or co'&lete ab%ence of ce'entu', and the &re%ence of *%'all teeth* that ha$e enlarged &ul& cha'ber% a% a con%eBuence of defecti$e 'inerali5ation ;6ig( ==(=C ;a< and ;b<<( The a&la%tic or hy&o&la%tic ce'entu' and a ,ea/ened &eriodontal attach'ent i% thought to render the &atient% %u%ce&tible to infection ,ith &eriodonto&athogen%( The diagno%i% of hy&o&ho%&hata%ia i% confir'ed bioche'ically by lo, acti$ity of %eru' 03" and a rai%ed le$el of &ho%&hoethanola'ine in a A-h urine %a'&le( Fi!. //./3 ;a< "re'ature lo%% of 40T04 in a @ =D -year-old child ,ith hy&o&ho%&hata%ia( The ha$e already eru&ted( ;b< Exten%i$e root re%or&tion

led to exfoliation of at A year% of age( ;Re&roduced by /ind &er'i%%ion of Dr )( 3( Cha&&le, "rofe%%or of "eriodontology, 4ir'ingha', #2(< //./2.3 DoCn #$ndrome Children ,ith Do,n %yndro'e ;tri%o'y =< do not %uffer aggre%%i$e &eriodontal di%ea%e, 1o,e$er, there are a %ignificant nu'ber of local and general ri%/ factor% that 'ay exi%t a% a re%ult of the %yndro'e( 3ocal factor% that 'ay %er$e to increa%e dental &laBue retention areG 0ngle% Cla%% ))) 'alocclu%ion% ,ith cro,dingH 3ac/ of an anterior li& %ealH 0nterior o&en bite%( General ri%/ factor% for &eriodontal di%ea%e are 'ainly centred on leucocyte defect% and 'ay includeG Defect% of &oly'or&honuclear leucocyte function ;che'otaxi%, /illing, and &hagocyto%i%<H Reduced T-cell acti$ity( //./3 S(77ARY

=( 0nato'ical $ariation, ,hich occur% during tooth eru&tion, and the 'aturation of the &eriodontal ti%%ue% can 'i'ic %ign% of gingi$iti%, rece%%ion, and bone lo%%( ( 1er&etic gingi$o%to'atiti% i% 'o%t freBuently %een in children under : year% of age, ,herea% necroti5ing ulcerati$e gingi$iti% i% 'ore &re$alent in young adult%( @( 0lthough the &re$alence of dental carie% ha% declined in the #2 and other Euro&ean countrie%, the &re$alence of &laBue-induced gingi$iti% in children ha% not reduced o$er the la%t 9 year%( A( Chronic gingi$iti% in children a&&ear% to be a relati$ely %table le%ion, ,hich doe% not nece%%arily &rogre%% to &eriodontal de%truction( :( Gingi$al change% can al%o occur in children ,ho are &re%cribed drug% to control e&ile&%y or follo,ing tran%&lant %urgery, during orthodontic thera&y, a% ,ell a% at %ite% of %elf-inflicted trau'a( !( Early %ign% of chronic &eriodontiti% are %o'eti'e% %een during adole%cence, and targeting thi% age grou& ,ith a &ri'ary &re$ention %trategy 'ay hel& to reduce tooth lo%% in later life( ?( Extre'e $igilance i% nece%%ary to diagno%e aggre%%i$e &eriodontal di%ea%e% and tho%e &eriodontal condition% that 'ay be a%%ociated ,ith %y%te'ic di%ea%e( 4leeding after gentle &robing in the &re%ence of a&&arently healthy gingi$a indicate% the need for further in$e%tigation( //./0 F(RT5ER READIN6 0r'itage, G( C( ;=>>><( De$elo&'ent of a cla%%ification %y%te' for &eriodontal di%ea%e% and condition%( "nnals of Periodontology, 0, =-!( 1eanue, M(, Deacon, S( 0(, Deery, C(, Robin%on, "( G(, Wal'%ley, 0( D(, Worthington, 1( 8(, and Sha,, W( C( ; 99@<( Manual $er%u% &o,ered toothbru%hing for oral health( )n -he Cochrane Li,rary ;)%%ue =<( Oxford( O*4rien, M( ;=>>@<( Children?s Dental Health in the U0; 1''&( Office of "o&ulation Cen%u%e% and Sur$ey%, 1MSO, 3ondon( Sabi%ton, C( 4(, 7r ;=>C!<( 0 re$ie, and &ro&o%al for the etiology of acute necroti%ing gingi$iti%( +ournal of Clinical Periodontology, /3, ? ?-@A( ;"n overview of the epidemiology of 6UG with an emphasis on a viral rather than a ,acterial aetiology < Schen/ein, 1( 0( ;=>>A<( Genetic% of early-on%et &eriodontal di%ea%e%( )n (olecular pathogenesis of periodontal disease ;ed( R( Genco, S( 1a'ada, T( 3ehner, 7( McGhee, and S( Mergenhagen<, &&( @?@-C!( 0SM "re%%, Wa%hington( ;"n appraisal of the role that genetic factors play in the pathogenesis of 9uvenile and prepu,ertal periodontitis < Sey'our, R( 0( ;=>>@<( Drug-induced gingi$al enlarge'ent( "dverse Drug )eactions

and -oxicology )eview, /2, =:-@ ( ;" general account of the drugs that induce gingival overgrowth < Sey'our, R( 0( and 1ea%'an, "( 0( ;=>> <( Drugs; diseases and the periodontium( Oxford Medical "ublication%, Oxford #ni$er%ity "re%%, Oxford( ;Comprehensive accounts of early<onset diseases; systemic disease and the periodontium; and gingival overgrowth < //./5 REFERENCES 0a%%, 0( M(, 0labandar, 7(, 0a%enden, R(, Tollef%en, T( and G+er'o, "( ;=>CC<( 8ariation in &re$alence of radiogra&hic al$eolar bone lo%% in %ubgrou&% of =A-yearold %choolchildren in O%lo( +ournal of Clinical Periodontology, /5, =@9-@( 4i'%tein, E(, Trea%ure, E( T(, Willia'%, S( M( and De$er, 7( G( ;=>>A<( 0l$eolar bone lo%% in :-year-old -e, Sealand childrenG it% &re$alence and relation%hi& to carie% &re$alence, %ocio-econo'ic %tatu% and ethnic origin( +ournal of Clinical Periodontology, 2/, AA?-:9( Clerehugh, 8(, 3ennon, M( 0( and Worthington, 1( 8( ;=>>9<( :-year re%ult% of a longitudinal %tudy of early &eriodontiti% in =A- to =>-year-old adole%cent%( +ournal of Clinical Periodontology, /2, ?9 -C( 1an%en, 4( 6(, G+er'o, "( and 4erg,it5-3ar%en, 2( R( ;=>CA<( "eriodontal bone lo%% in =:- year-old -or,egian%( +ournal of Clinical Periodontology, //, = :-@=( 1ull, "( S(, 1illa', D( G( and 4eal, 7( 6( ;=>?:<( 0 radiogra&hic %tudy of the &re$alence of chronic &eriodontiti% in =A-year-old Engli%h %choolchildren( +ournal of Clinical Periodontology, 2, 9@-=9( 2e%5thelyi, G( and S5abo, )( ;=>C?<( 0ttach'ent lo%% in &ri'ary 'olar%( +ournal of Clinical Periodontology, /0, AC-:=( 3ennon, M( 0( and Da$ie%, R( M( ;=>?A<( "re$alence and di%tribution of al$eolar bone lo%% in a &o&ulation of =:-year-old %choolchildren( +ournal of Clinical Periodontology, /, =?:-C ( S+odin, 4( and Mat%%on, 3( ;=>>A<( Marginal bone lo%% in the &ri'ary dentition( 0 %ur$ey of ?->-year-old children in S,eden( +ournal of Clinical Periodontology, 2/, @=@-=>( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

/2. Tra-mati" inD-rie# to t%e teet% - ) ) 4el,ury and + ( 4hitworth /2./ EPIDE7I&*&6Y Dental trau'a in childhood and adole%cence i% co''on ;6ig( = (=<( 0t : year% of age @=-A9L of boy% and =!-@9L of girl%, and at = year% of age = -@@L of boy% and A=>L of girl% ,ill ha$e %uffered %o'e dental trau'a( 4oy% are affected al'o%t t,ice a% often a% girl% in both the &ri'ary and the &er'anent dentition%( The 'a+ority of dental in+urie% in the &ri'ary and &er'anent dentition% in$ol$e the anterior teeth, e%&ecially the 'axillary central inci%or%( Concu%%ion, %ubluxation, and luxation are the co''one%t in+urie% in the &ri'ary dentition ;6ig( = ( <, ,hile unco'&licated cro,n fracture% are co''one%t in the &er'anent dentition ;6ig( = (@<( "rogno%i% of trau'atic in+urie% ha% i'&ro$ed %ignificantly in the la%t 9 year%( Thi% ha% been largely due to a greater under%tanding and /no,ledge of &ul&al &rocedure%( Fi!. /2./ 0 ?-year-old girl ,ho fell off her bicycle and %u%tained orofacial in+urie%( Fi!. /2.2 0 @-year-old child ,ith a co'bination of in+urie% to her u&&er anterior teeth( Fi!. /2.3 0 fracture of the u&&er left central inci%or in$ol$ing ena'el and dentine( /2.2 AETI&*&6Y The 'o%t accident &rone ti'e% are bet,een and A year% for the &ri'ary dentition and ? and =9 year% for the &er'anent dentition( )n the &ri'ary dentition co-ordination and +udge'ent are inco'&letely de$elo&ed and the 'a+ority of in+urie% are due to fall% in and around the ho'e a% the child beco'e% 'ore ad$enturou% and ex&lore% it% %urrounding%( )n the &er'anent dentition 'o%t in+urie% are cau%ed by fall% and colli%ion% ,hile &laying and running, although bicycle% are a co''on acce%%ory( The &lace of in+ury $arie% in different countrie% according to local cu%to'% but accident% in the %chool yard re'ain co''on( S&ort% in+urie% u%ually occur in teenage year% and are co''only a%%ociated ,ith contact %&ort%( )n+urie% due to road traffic accident% and a%%ault% are 'o%t co''only a%%ociated ,ith the late teenage year% and adulthood and are often clo%ely related to alcohol abu%e( One for' of in+ury in childhood that 'u%t ne$er be forgotten i% child &hy%ical abu%e or non-accidental in+ury ;-0)<( More than :9L of the%e children ,ill ha$e orofacial in+urie% ;6ig( = (A<( Dental in+urie% can be the re%ult of either direct or indirect trau'a( Direct trau'a occur% ,hen the tooth it%elf i% %truc/( )ndirect trau'a i% %een ,hen the lo,er dental arch i% forcefully clo%ed again%t the u&&er, for exa'&le, blo, to chin( Direct trau'a i'&lie% in+urie% to the anterior region ,hile indirect trau'a fa$our% cro,n or cro,nroot fracture% in the &re'olar and 'olar region% a% ,ell a% the &o%%ibility of +a, fracture% in the condylar region% and %y'&hy%i%( The factor% ,hich influence the outco'e or ty&e of in+ury are a co'bination ofG ;=< energy i'&actH ; < re%ilience of i'&acting ob+ectH ;@< %ha&e of i'&acting ob+ectH and ;A< angle of direction of the i'&acting force(

)ncrea%ed o$er+et ,ith &rotru%ion of u&&er inci%or% and in%ufficient li& clo%ure are %ignificant &redi%&o%ing factor% to trau'atic dental in+urie%( )n+urie% are al'o%t t,ice a% freBuent a'ong children ,ith &rotruding inci%or% and the nu'ber of teeth affected in a &articular incident for an indi$idual &atient al%o increa%e( Fi!. /2.0 0 @-year-old boy ,ith brui%e% and abra%ion% re%ulting fro' nonaccidental in+ury( /2.3 C*ASSIFICATI&N Table = (= %u''ari5e% the cla%%ification of dento-al$eolar in+urie% ba%ed on the World 1ealth Organi5ation ;W1O< %y%te'( /2.0 5IST&RY AND E'A7INATI&N /2.0.0 Introd-"tion 0 hi%tory of the in+ury follo,ed by a thorough exa'ination %hould be co'&leted in any %ituation( /2.0./ Dental %i#tor$ =( When did in+ury occurJ The ti'e inter$al bet,een in+ury and treat'ent %ignificantly influence% the &rogno%i% of a$ul%ion%, luxation%, cro,n fracture% ,ith or ,ithout &ul&al ex&o%ure%, and dento-al$eolar fracture%( ( Where did in+ury occurJ May indicate the need for tetanu% &ro&hylaxi%( @( 1o, did in+ury occurJ The nature of the accident can yield infor'ation on the ty&e of in+ury ex&ected( Di%cre&ancy bet,een hi%tory and clinical finding% rai%e% %u%&icion of &hy%ical abu%e( A( 3o%t teethDfrag'ent%J )f a tooth or fractured &iece cannot be accounted for ,hen there ha% been a hi%tory of lo%% of con%ciou%ne%% then a che%t radiogra&h %hould be obtained to exclude inhalation( :( Concu%%ion, headache, $o'iting or a'ne%iaJ 4rain da'age 'u%t be excluded and referral to a ho%&ital for further in$e%tigation organi5ed( !( "re$iou% dental hi%toryJ "re$iou% trau'a can affect &ul&al %en%ibility te%t% and the recu&erati$e ca&acity of the &ul& andDor &eriodontiu'( 0lternati$ely are there %u%&icion% of &hy%ical abu%eJ "re$iou% treat'ent ex&erience, age, and &arentalDchild attitude ,ill affect the choice of treat'ent( /2.0.2 7edi"al %i#tor$ =( Congenital heart di%ea%e, a hi%tory of rheu'atic fe$er or %e$ere i''uno%u&&re%%ionJ The%e 'ay be contra-indication% to any &rocedure that i% li/ely to reBuire &rolonged endodontic treat'ent ,ith a &er%i%tent necroticDinfected focu%(

0ll congenital heart defect% do not carry the %a'e ri%/% of bacterial endocarditi% and the child*% &aediatricianDcardiologi%t %hould be con%ulted before a deci%ion regarding endodontic treat'ent i% 'ade( ( 4leeding di%order%J 8ery i'&ortant if %oft ti%%ue% are lacerated or teeth are to be extracted( @( 0llergie%J "enicillin allergy reBuire% alternati$e antibiotic%( A( Tetanu% i''uni5ation %tatu%J Referral for tetanu% toxoid in+ection i% nece%%ary if there i% %oil conta'ination of the ,ound and the child ha% not had a *boo%ter* in+ection ,ithin the la%t : year%( /2.0.3 E9traoral e9amination When there are a%%ociated %e$ere in+urie% a general exa'ination i% 'ade ,ith re%&ect to %ign% of %hoc/ ;&allor, cold %/in, irregular &ul%e, hy&oten%ion<, %y'&to'% of head in+ury %ugge%ting brain concu%%ion, or 'axillofacial fracture%( 6acial %,elling, brui%e%, or laceration% 'ay indicate underlying bony and tooth in+ury( 3aceration% ,ill reBuire careful debride'ent to re'o$e all foreign 'aterial and %uturing( 0ntibiotic% andDor tetanu% toxoid 'ay be reBuired if ,ound% are conta'inated( 3i'itation of 'andibular 'o$e'ent or 'andibular de$iation on o&ening or clo%ing the 'outh indicate either +a, fracture or di%location( Cro,n fracture ,ith a%%ociated %,ollen li& and e$idence of a &enetrating ,ound %ugge%t% retention of tooth frag'ent% ,ithin the li&( Clinical and radiogra&hic exa'ination %hould be underta/en ;6ig( = (: ;a<-;d<<( Fi!. /2.5 ;a< 0 = -year-old child &re%ented ,ith an ena'el and dentine fracture of the u&&er right, &er'anent central inci%or( ;b< The lo,er li& ,a% %,ollen ,ith a 'uco%al laceration( ;c< 0 lateral radiogra&h confir'ed the &re%ence of tooth frag'ent% in the li&( ;d< 6rag'ent% ,ere retrie$ed under local anae%the%ia fro' the li&( /2.0.0 Intraoral e9amination Thi% 'u%t be %y%te'atic and include the recording ofG =( 3aceration, hae'orrhage, and %,elling of the oral 'uco%a and gingi$a ;6ig( = (!<( 0ny laceration% %hould be exa'ined for tooth frag'ent% or other foreign 'aterial( 3aceration% of li&% or tongue reBuire %uturing but tho%e of the oral 'uco%a heal $ery Buic/ly and 'ay not need %uturing( ( 0bnor'alitie% of occlu%ion, tooth di%&lace'ent, fractured cro,n%, or crac/% in the ena'el( The follo,ing %ign% and reaction% to te%t% are &articularly hel&fulG =( (o,ility( Degree of 'obility i% e%ti'ated in a hori5ontal and a $ertical direction(

When %e$eral teeth 'o$e together *enbloc/* a fracture of the al$eolar &roce%% i% %u%&ected( Exce%%i$e 'obility 'ay al%o %ugge%t root fracture or tooth di%&lace'ent( ( )eaction to percussion( )n a hori5ontal and $ertical direction and co'&ared again%t a contralateral unin+ured tooth( 0 duller note 'ay indicate root fracture( @( Colour of tooth( Early colour change a%%ociated ,ith &ul& brea/do,n i% $i%ible on the &alatal %urface of the gingi$al third of the cro,n( A( )eaction to sensitivity tests( Ther'al te%t% ,ith ,ar' gutta &ercha or ethyl chloride ;e(c(<are ,idely u%ed( 1o,e$er, an electric &ul& te%ter ;e(&(t(< in the hand% of an ex&erienced o&erator i% 'ore reliable( -e$erthele%%, %en%ibility te%ting, e%&ecially in children i% notoriou%ly unreliable and %hould ne$er be a%%e%%ed in i%olation fro' the other clinical and radiogra&hic infor'ation( -either negati$e nor &o%iti$e re%&on%e% %hould be tru%ted i''ediately after trau'a( 0 &o%iti$e re%&on%e doe% not rule out later &ul&al necro%i% and a negati$e re%&on%e ,hile indicating &ul&al da'age doe% not nece%%arily indicate a necrotic &ul&( The negati$e reaction i% often due to a *%hoc/ ,a$e* effect da'aging a&ical ner$e %u&&ly( The &ul& in %uch ca%e% 'ay ha$e a nor'al blood %u&&ly( )n all %en%ibility te%ting al,ay% include and docu'ent the reaction of unin+ured contralateral teeth for co'&ari%on( )n addition, all neighbouring teeth to the ob$iou%ly in+ured teeth %hould be regularly a%%e%%ed a% they ha$e &robably %uffered concu%%ion in+urie%( Fi!. /2.1 Deglo$ing in+ury to the lo,er labial %ulcu% that reBuired ex&loration to re'o$e grit( /2.0.5 Radio!ra %i" e9amination Peria i"al Re&roducible *long cone techniBue* &eria&ical% are the be%t for accurate diagno%i% and clinical audit( T,o radiogra&h% at different angle% 'ay be e%%ential to detect a root fracture( 1o,e$er, if acce%% and co-o&eration are difficult then one anterior occlu%al radiogra&h rarely 'i%%e% a root fracture( "eria&ical fil'% &o%itioned behind li&% can be u%ed to detect foreign bodie%( &""l-#al To detect root fracture% ,hen u%ed intaorally, and foreign bodie% ,ithin the %oft ti%%ue% ,hen held by &atientDhel&er at the %ide of the 'outh in a lateral $ie, ;6ig( = (: ;c<<( &rt%o antomo!ram E%%ential in all trau'a ca%e% ,here underlying bony in+ury i% %u%&ected( *ateral o,liA-e %&eciali%t $ie, for 'axillofacial fracture% *ateral #=-ll %&eciali%t $ie, for 'axillofacial fracture% AP #=-ll %&eciali%t $ie, for 'axillofacial fracture% &""i itomental %&eciali%t $ie, for 'axillofacial fracture%

)n the &atient% clinical note% the clinical and radiogra&hic exa'ination% at each $i%it can be co'bined into a %i'&le aide-'e'oir in the for' of a *trau'a %ta'&* ;6ig( = (?<( )nfor'ation that i% collected in thi% %tandardi5ed ,ay i% ea%ily acce%%ible ,hen 'a/ing clinical deci%ion% and co'&aring re%&on%e% at re$ie, a&&oint'ent%( Fi!. /2.2 The *trau'a %ta'&*( /2.0.1 P%oto!ra %i" re"ord# Good clinical &hotogra&h% are u%eful to a%%e%% outco'e of treat'ent and for 'edicolegal &ur&o%e%( Written con%ent 'u%t be obtained and in the ca%e of digital i'age%, uncro&&ed original% held in an a&&ro&riately %ecure for'at and location( >e$ Point# De$elo& a %y%te'atic a&&roach to hi%tory and exa'ination /2.5 INj(RIES T& T5E PRI7ARY DENTITI&N /2.5.0 Introd-"tion During it% early de$elo&'ent the &er'anent inci%or i% located &alatally to and in clo%e &roxi'ity ,ith the a&ex of the &ri'ary inci%or( With any in+ury to a &ri'ary tooth there i% ri%/ of da'age to the underlying &er'anent %ucce%%or( Mo%t accident% in the &ri'ary dentition occur bet,een and A year% of age( Reali%tically, thi% 'ean% that fe, re%torati$e &rocedure% ,ill be &o%%ible and in the 'a+ority of ca%e% the deci%ion i% bet,een extraction or 'aintenance ,ithout &erfor'ing exten%i$e treat'ent( 0 &ri'ary inci%or %hould al,ay% be re'o$ed if it% 'aintenance ,ill +eo&ardi5e the de$elo&ing tooth bud( 0 trau'ati5ed &ri'ary tooth that i% retained %hould be a%%e%%ed regularly for clinical and radiogra&hic %ign% of &ul&al or &eriodontal co'&lication%( Radiogra&h% 'ay e$en detect da'age to the &er'anent %ucce%%or( Soft ti%%ue in+urie% in children %hould be a%%e%%ed ,ee/ly until healed( Tooth in+urie% %hould be re$ie,ed e$ery @-A 'onth% for the fir%t year and then annually until the &ri'ary tooth exfoliate% and the &er'anent %ucce%%or i% in &lace( Trau'atic in+urie% that occur &rior to eru&tion of &ri'ary teeth can al%o interfere ,ith their de$elo&'ent( /2.5./ (n"om li"ated "roCn +ra"t-re Either %'ooth %har& edge% or re%tore ,ith an acid-etch re%toration if co-o&eration i% %ati%factory( /2.5.2 Com li"ated "roCn +ra"t-re -or'ally, extraction i% the treat'ent of choice( 1o,e$er, &ul& extir&ation and canal

obturation ,ith 5inc oxide ce'ent, follo,ed by an acid-etch re%toration i% &o%%ible ,ith rea%onable co-o&eration( /2.5.3 CroCn-root +ra"t-re The &ul& i% u%ually ex&o%ed and any re%torati$e treat'ent i% $ery difficult( The tooth i% be%t extracted( /2.5.0 Root +ra"t-re Without di%&lace'ent and ,ith only a %'all a'ount of 'obility the tooth %hould be /e&t under ob%er$ation( )f the coronal frag'ent beco'e% non-$ital and %y'&to'atic then it %hould be re'o$ed( The a&ical &ortion u%ually re'ain% $ital and undergoe% nor'al re%or&tion( Si'ilarly ,ith 'ar/ed di%&lace'ent and 'obility only the coronal &ortion %hould be re'o$ed( /2.5.5 Con"-##ion< #-,l-9ation< and l-9ation inD-rie# 0%%ociated %oft ti%%ue da'age %hould be cleaned by the &arent t,ice daily ,ith 9( L chlorhexidine %olution u%ing cotton bud% or gau5e %,ab% until it heal%( Con"-##ion Often not brought to a denti%t until the tooth di%colour%( S-,l-9ation )f %light 'obility then the &arent% are ad$i%ed on a %oft diet for =- ,ee/% and to /ee& the trau'ati5ed area a% clean a% &o%%ible( Mar/ed 'obility reBuire% extraction( E9tr-#i.e l-9ation Mar/ed 'obility reBuire% extraction( *ateral l-9ation )f the cro,n i% di%&laced &alatally the a&ex 'o$e% buccally and hence a,ay fro' the &er'anent tooth ger'( )f the occlu%ion i% not gagged then con%er$ati$e treat'ent to a,ait %o'e %&ontaneou% realign'ent i% &o%%ible( )f the cro,n i% di%&laced buccally then the a&ex ,ill be di%&laced to,ard% the &er'anent tooth bud and extraction i% indicated in order to 'ini'i5e further da'age to the &er'anent %ucce%%or( Intr-#i.e l-9ation Thi% i% the 'o%t co''on ty&e of in+ury( The ai' of in$e%tigation i% to e%tabli%h the direction of di%&lace'ent by thorough radiological exa'ination( )f the root i% di%&laced &alatally to,ard% the &er'anent %ucce%%or then the &ri'ary tooth %hould be extracted to 'ini'i5e the &o%%ible da'age to the de$elo&ing &er'anent %ucce%%or( )f the root i% di%&laced buccally then &eriodic re$ie, to 'onitor %&ontaneou% re-eru&tion %hould be allo,ed ;6ig( = (C ;a< and ;b<<( Re$ie, %hould be ,ee/ly for a 'onth then

'onthly for a 'axi'u' of ! 'onth%( Mo%t re-eru&tion occur% bet,een = and ! 'onth% and if thi% doe% not occur then an/ylo%i% i% li/ely and extraction i% nece%%ary to &re$ent ecto&ic eru&tion of the &er'anent %ucce%%or ;6ig( = (><( E9arti"-lation (A.-l#ion) Re&lantation of a$ul%ed &ri'ary inci%or% i% not reco''ended due to the ri%/ of da'age to the &er'anent tooth ger'%( S&ace 'aintenance i% not nece%%ary follo,ing the lo%% of a &ri'ary inci%or a% only 'inor drifting of ad+acent teeth occur%( The eru&tion of the &er'anent %ucce%%or 'ay be delayed for about = year a% a re%ult of abnor'al thic/ening of connecti$e ti%%ue o$erlying the tooth ger'( Fi!. /2.3 ;a< 0 A-year-old boy ,ith co'&lete intru%ion of the u&&er right inci%or( ;b< ! 'onth% &o%t-trau'a, the tooth ha% %&ontaneou%ly re-eru&ted( Fi!. /2.4 Se$ere intru%ion of an u&&er &ri'ary central inci%or nece%%itating extraction( /2.1 SE@(E*AE &F INj(RIES T& T5E PRI7ARY DENTITI&N /2.1./ P-l al ne"ro#i# -ecro%i% i% the co''one%t co'&lication of &ri'ary trau'a( E$aluation i% ba%ed u&on colour and radiogra&hy( Teeth of a nor'al colour rarely de$elo& &eria&ical infla''ation but con$er%ely 'ildly di%coloured teeth 'ay be $ital( 0 'ild grey colour occurring %oon after trau'a 'ay re&re%ent intra&ul&al bleeding ,ith a &ul& that i% %till $ital( Thi% colour 'ay recede, but if it &er%i%t% then necro%i% %hould be %u%&ected( Radiogra&hic exa'ination %hould be @ 'onthly to chec/ for &eria&ical infla''ation ;6ig( = (=9 ;a< and ;b<<( 6ailure of the &ul& ca$ity to reduce in %i5e i% an indicator of &ul&al death( Teeth %hould be extracted ,hene$er there i% e$idence of &eria&ical infla''ation, to &re$ent &o%%ible da'age to the &er'anent %ucce%%or( Fi!. /2./0 ;a< Se$ere di%colouration of the u&&er right &ri'ary central inci%or( ;b< Radiogra&hic e$idence of &eria&ical &athology( Extraction ,a% nece%%ary( /2.1.2 P-l al o,literation Obliteration of the &ul& cha'ber and canal i% a co''on reaction to trau'a ;6ig( = (==<( Clinically, the tooth beco'e% yello,Do&aBue( -or'al exfoliation i% u%ual but occa%ionally &eria&ical infla''ation 'ay inter$ene and therefore annual radiogra&hy i% ad$i%able( Fi!. /2.// "ul& canal obliteration and external %urface re%or&tion of u&&er &ri'ary central inci%or% after a luxation in+ury( /2.1.3 Root re#or tion Extraction i% ad$i%ed for all ty&e% of root re%or&tion ,here there i% e$idence of infection ;6ig( = (= <(

Fi!. /2./2 External infla''atory re%or&tion of &re$iou%ly in+ured &ri'ary inci%or%( /2.1.0 InD-rie# to de.elo in! ermanent teet% )n+urie% to the &er'anent %ucce%%or tooth can be ex&ected in bet,een = L to !>L of &ri'ary tooth trau'a and =>L to !CL of +a, fracture%( )ntru%i$e luxation cau%e% 'o%t di%turbance% but a$ul%ion of a &ri'ary inci%or ,ill al%o cau%e da'age if the a&ex 'o$ed to,ard% the &er'anent tooth bud before the a$ul%ion( Mo%t da'age to the &er'anent tooth bud occur% under @ year% of age during it% de$elo&'ental %tage( 1o,e$er, the ty&e and %e$erity of di%turbance are clo%ely related to the age at the ti'e of in+ury( Change% in the 'inerali5ation and 'or&hology of the cro,n of the &er'anent inci%or are co''one%t but later in+urie% can cau%e radicular ano'alie%( )n+urie% to de$elo&ing teeth can be cla%%ified a% follo,%G =( White or yello,-bro,n hy&o'inerali5ation of ena'el( )n+ury at -? year% ;6ig( = (=@ ;a<-;c<<( ( White or yello,-bro,n hy&o'inerlai5ation of ena'el ,ith circular ena'el hy&o&la%ia( )n+ury at -? year% ;6ig( = (=A<( @( Cro,n dilaceration( )n+ury at about year% ;6ig( = (=: ;a<-;c<<(

A( Odonto'a-li/e 'alfor'ation( )n+ury at <=-@ year%( :( Root du&lication( )n+ury at -: year%( !( 8e%tibular or lateral root angulation and dilaceration( )n+ury at -: year% ;6ig( = (=! ;a< and ;b<<( ?( "artial or co'&lete arre%t of root for'ation( )n+ury at :-? year% ;6ig( = (=? ;a< and ;b<<( C( SeBue%tration of &er'anent tooth ger'%( >( Di%turbance in eru&tion( The ter' dilaceration de%cribe% an abru&t de$iation of the long axi% of the cro,n or root &ortion of the tooth( Thi% de$iation re%ult% fro' the trau'atic di%&lace'ent of already for'ed hard ti%%ue in relation to de$elo&ing %oft ti%%ue( The ter' angulation de%cribe% a cur$ature of the root re%ulting fro' a gradual change in the direction of root de$elo&'ent, ,ithout e$idence of abru&t di%&lace'ent of the tooth ger' during odontogene%i%( Thi% 'ay be $e%tibular, that i%, labio&alatal, or lateral, that i%, 'e%iodi%tal( E$aluation of the full extent of co'&lication% follo,ing in+urie% 'u%t a,ait co'&lete eru&tion of all &er'anent teeth in$ol$ed( 1o,e$er, 'o%t %eriou% %eBuelae ;di%turbance% in tooth 'or&hology< can u%ually be diagno%ed radiogra&hically ,ithin the fir%t year &o%t-trau'a(

Eru&tion di%turbance% 'ay in$ol$e delay due to connecti$e ti%%ue thic/ening o$er a &er'anent tooth ger', ecto&ic eru&tion due to lac/ of eru&ti$e guidance, and i'&action in teeth ,ith 'alfor'ation% of cro,n or root( >e$ Point# )n &ri'ary tooth trau'aG Ri%/ of da'age to &er'anent %ucce%%or% i% high,arn &arent% )ntru%i$e in+urie% carry the highe%t ri%/ to the &er'anent %ucce%%or% Fi!. /2./3 ;a<-;c< )n$e%tigation of delayed eru&tion of the &er'anent u&&er central inci%or% re$ealed an intruded u&&er left &ri'ary central inci%or on radiogra&h( 6ollo,ing re'o$al of the retained &ri'ary inci%or the &er'anent %ucce%%or eru&ted %&ontaneou%ly ,ith a ,hite hy&o&la%tic %&ot on the labial %urface( Fi!. /2./0 4ro,n hy&o&la%tic area on the lo,er left &er'anent central inci%or re%ulting fro' trau'a to the &ri'ary &redece%%or( Fi!. /2./5 ;a<-;c< Se$ere cro,n dilaceration of the u&&er right &er'anent central inci%or ,hich eru&ted %&ontaneou%ly( Fi!. /2./1 ;a< and ;b< #neru&ted, dilacerated, u&&er left &er'anent central inci%or re%ulting fro' an accident %u%tained by a @-year-old child( Fi!. /2./2 ;a< and ;b< 6ailure of root for'ation of the u&&er left &er'anent lateral inci%or in a :-year-old child ,ith a hi%tory of intru%i$e trau'a to the &ri'ary &redece%%or( /2.1.5 Treatment o+ inD-rie# to t%e ermanent dentition YelloC-,roCn %$ ominerali:ation o+ enamel Cit% or Cit%o-t %$ o la#ia =( 0cid-&u'ice 'icroabra%ion( ( Co'&o%ite re%in re%torationG locali5ed, $eneer, or cro,n( @( "orcelain re%torationG $eneer or cro,n ;anterior<H fu%ed to 'etal cro,n ;&o%terior<( Con%er$ati$e a&&roache% are &referred ,hene$er &o%%ible( CroCn dila"eration =( Surgical ex&o%ure F orthodontic realign'ent( ( Re'o$al of dilacerated &art of cro,n( @( Te'&orary cro,n until root for'ation co'&lete( A( Se'i or &er'anent re%toration( )e#ti,-lar root an!-lation Co'bined %urgical and orthodontic realign'ent(

&t%er mal+ormation Extraction i% u%ually the treat'ent of choice( Di#t-r,an"e in er- tion Surgical ex&o%ure F orthodontic realign'ent( InD-rie# to #ortin! ,one

Mo%t fracture% of the al$eolar %oc/et in &ri'ary dentition do not reBuire %&linting due to ra&id bony healing in %'all children( 7a, fracture% are treated in the con$entional 'anner, although %tabili5ation after reduction 'ay be difficult due to lac/ of %ufficient ad+acent teeth( /2.2 INj(RIES T& T5E PER7ANENT DENTITI&N /2.2.0 Introd-"tion Mo%t trau'ati5ed teeth can be treated %ucce%%fully( "ro'&t and a&&ro&riate treat'ent i'&ro$e% &rogno%i%( The ai'% and &rinci&le% of treat'ent can be broadly categori5ed intoG =( E'ergencyG ;a< retain $itality of fractured or di%&laced toothH ;b< treat ex&o%ed &ul& ti%%ueH ;c< reduction and i''obili5ation of di%&laced teethH ;d< anti%e&tic 'outh,a%h, FD- antibiotic% and tetanu% &ro&hylaxi%( ( )nter'ediateG ;a< F &ul& thera&yH ;b< 'ini'ally in$a%i$e cro,n re%toration( @( "er'anentG ;a< a&exogene%i%Da&exificationH ;b< root filling F root extru%ionH ;c< F gingi$al and al$eolar collar 'odificationH ;d< %e'i or &er'anent coronal re%toration( Trau'a ca%e% reBuire &ain%ta/ing follo, u& to identify any co'&lication% and in%titute the correct treat'ent( The *trau'a %ta'&* i% in$aluable in thi%( )n the re$ie, &eriod the follo,ing %chedule i% a guideG = ,ee/H =, @, !, and = 'onth%H and then annually for A-: year%( /2.2./ InD-rie# to t%e %ard dental ti##-e# and t%e -l

Enamel in+ra"tion The%e inco'&lete fracture% ,ithout lo%% of tooth %ub%tance and ,ithout &ro&er illu'ination are ea%ily o$erloo/ed( Re$ie, i% nece%%ary a% abo$e a% the energy of the blo, 'ay ha$e been tran%'itted to the &eriodontal ti%%ue% or the &ul&( Enamel +ra"t-re -o re%toration i% needed and treat'ent i% li'ited to %'oothing of any rough edge% and %&linting if there i% a%%ociated 'obility( "eriodic re$ie, a% abo$e( Enamel-dentine (-n"om li"ated) +ra"t-re )''ediate treat'ent i% nece%%ary and the &ul& reBuire% &rotection again%t ther'al o%'otic irritation and fro' bacteria $ia the dentinal tubule%( Re%toration of cro,n 'or&hology al%o %tabili5e% the &o%ition of the tooth in the arch( E'ergency &rotection of the ex&o%ed dentine can be achie$ed byG =( 0 co'&o%ite re%in ;acid etched< or Co'&o'er bandage ( Gla%% iono'er ce'ent ,ithin an orthodontic band or inci%al end of a %tainle%%-%teel cro,n if there i% in%ufficient ena'el a$ailable for acid-etch techniBue( )nter'ediate re%toration of 'o%t ena'el-dentine fracture% can be achie$ed byG =( 0cid-etched co'&o%ite either a&&lied freehand or utili5ing a celluloid cro,n for'er( The 'a+ority of the%e re%toration% can be regarded a% %e'i-&er'anentD &er'anent( 3arger fracture% can utili5e 'ore a$ailable ena'el %urface area for bonding by e'&loying a co'&lete celluloid cro,n for'er to con%truct a *direct* co'&o%ite cro,n( 0t a later age thi% could be reduced to for' the core of a full or &artial co$erage &orcelain cro,n &re&aration( ( Reattach'ent of cro,n frag'ent( 6e, long-ter' %tudie% ha$e been re&orted and the longe$ity of thi% ty&e of re%toration i% uncertain( )n addition, there i% a tendency for the di%tal frag'ent to beco'e o&aBue or reBuire further re%torati$e inter$ention in the for' of a $eneer or full co$erage cro,n ;6ig( = (=C<( )f the fracture line through dentine i% not $ery clo%e to the &ul& then the frag'ent 'ay be reattached i''ediately( )f, ho,e$er, it run% clo%e to the &ul& then it i% ad$i%able to &lace a %uitably &rotected calciu' hydroxide dre%%ing o$er the ex&o%ed dentine for at lea%t = 'onth ,hile %toring the frag'ent in %aline, ,hich %hould be rene,ed ,ee/ly( Te"%niA-e =( Chec/ the fit of the frag'ent and the $itality of the tooth( ( Clean frag'ent and tooth ,ith &u'ice-,ater %lurry( @( )%olate the tooth ,ith rubber da'(

A( 0ttach frag'ent to a &iece of %tic/y ,ax to facilitate handling( :( Etch ena'el for @9 % on both fracture %urface% and extend for line on tooth and frag'ent( Wa%h for =: % and dry for =: %( '' fro' fracture

!( 0&&ly bonding agent FD- dentine &ri'er according to 'anufacturer*% in%truction% and light cure for =9 %( ?( "lace a&&ro&riate %hade of co'&o%ite re%in o$er both %urface% and &o%ition frag'ent( Re'o$e gro%% exce%% and cure !9 % labially and &alatally( C( Re'o$e any exce%% co'&o%ite re%in ,ith %and&a&er di%c%( >( Re'o$e a =-'' gutter of ena'el on each %ide of fracture line both labially and &alatally to a de&th of 9(: '' u%ing a %'all round or &ear-%ha&ed bur( The fini%hing line %hould be irregular in outline( =9( Etch the ne,ly &re&ared ena'el, ,a%h, dry, a&&ly co'&o%ite, cure, and fini%h( Enamel-dentine- -l ("om li"ated) "roCn +ra"t-re The 'o%t i'&ortant function of the &ul& i% to lay do,n dentine ,hich for'% the ba%ic %tructure of teeth, define% their general 'or&hology, and &ro$ide% the' ,ith 'echanical %trength and toughne%%( Dentine de&o%ition co''ence% 'any year% before &er'anent tooth eru&tion and ,hen a tooth eru&t% the &ul& ,ithin %till ha% ,or/ to do in co'&leting root de$elo&'ent( -e,ly eru&ted teeth ha$e %hort root%, their a&ice% are ,ide and often di$erging, and the dentine ,all% of the entire tooth are thin and relati$ely ,ea/ ;6ig( = (=> ;a<<( "ro$ided the &ul& re'ain% healthy, dentine de&o%ition and nor'al root de$elo&'ent ,ill continue for -@ year% after eru&tion in &er'anent teeth ;6ig( = (=> ;b<<( 3o%% of &ul& $itality before a tooth ha% reached 'aturity 'ay lea$e the tooth $ulnerable to fracture, and ,ith an unfa$ourable cro,nroot ratio( )n addition endodontic treat'ent of non-$ital, i''ature teeth can al%o &re%ent technical difficultie% ,hich 'ay co'&ro'i%e the long-ter' &rogno%i% of the tooth( The 'a+or concern after &ul&al ex&o%ure% in i''ature teeth i% the &re$ention of &hy%ical, che'ical, and 'icrobial in$a%ion and the &re%er$ation of &ul&al $itality in order to allo, continued root gro,th( The radicular &ul& ha% enor'ou% ca&acity to re'ain healthy and undergo re&air if all infected and infla'ed coronal ti%%ue i% re'o$ed and an a&&ro&riate ,ound dre%%ing and %ealing coronal re%toration i% a&&lied( "ul& a'&utation by &artial &ul&oto'y or co'&lete coronal &ul&oto'y i% often the treat'ent of choice but &ul& ca&&ing can be con%idered in certain circu'%tance%( )ital -l t%era $ "ul& ca&&ing "ul&oto'y &artialDco'&lete Non-.ital -l t%era $

 "ul&ecto'y )ITA* P(*P T5ERAPY P(*P CAPPIN6 The &rocedure 'u%t be done ,ithin A h of the incident( The tooth %hould be i%olated ,ith rubber da' and no in%tru'ent% %hould be in%erted into the ex&o%ure %ite( 0ny bleeding %hould be controlled ,ith %terile cotton ,ool ,hich 'ay be 'oi%tened ,ith %aline or %odiu' hy&ochlorite, and not ,ith a bla%t of air fro' the @ in = %yringe ,hich 'ay dri$e debri% and 'icro-organi%'% into the &ul&( 0 layer of %etting calciu' hydroxide ce'ent i% gently flo,ed onto the ex&o%ed &ul& and %urrounding dentine Buic/ly o$erlaid ,ith a *bandage* of adhe%i$e 'aterial( for exa'&le, co'&o'er &ending definiti$e ae%thetic re%toration at a later date( 0 %ucce%%ful direct &ul& ca& ,ill &re%er$e the re'aining &ul& in health and %hould &ro'ote the de&o%ition of a bridge of re&arati$e dentine to %eal off the ex&o%ure %ite( Re$ie, after a 'onth, then @ 'onth%, and e$entually at ! 'onthly inter$al% for u& to A year% in order to a%%e%% &ul& $itality( "eriodic radiogra&hic re$ie, %hould al%o be arranged to 'onitor dentine bridge for'ation, root gro,th, and to exclude the de$elo&'ent of necro%i% and re%or&tion( On the radiogra&h chec/ the follo,ingG root i% gro,ing in lengthH root canal i% 'aturing ;narro,ing<H Co'&are ,ith anti'ere( )f gro,th i% not occuring the &ul& %hould be a%%u'ed to be non-$ital( )ITA* P(*P T5ERAPY P(*P&T&7Y )n &ul&oto'y a &ortion of ex&o%ed $ital &ul& i% re'o$ed to &re%er$e the radicular $itality and allo, co'&letion of a&ical root de$elo&'ent ;a&exogene%i%< and further de&o%ition of dentine on the ,all% of the root( Thi% &rocedure i% the treat'ent of choice follo,ing trau'a ,here the &ul& ha% been ex&o%ed to the 'outh for 'ore than A h( O&erati$e &rocedure ;6ig( = ( 9< #nder local anae%the%ia and rubber da', &ul& ti%%ue i% exci%ed ,ith a dia'ond bur running at high %&eed under con%tant ,ater cooling( Thi% cau%e% lea%t in+ury to the underlying &ul& and i% &referred to hand exca$ation or the u%e of %lo,-%&eed %teel bur%( Microbial in$a%ion of an ex&o%ed, $ital &ul& i% u%ually %u&erficial and generally only -@ '' of &ul& ti%%ue %hould be re'o$ed ;&artial &ul&oto'y PC$e/Q<( Exce%%i$e bleeding fro' the re%idual &ul& ,hich cannot be controlled ,ith 'oi%t cotton ,ool, or indeed no bleeding at all, indicate% that further exci%ion i% reBuired to reach healthy ti%%ue ;coronal &ul&oto'y<( Re'o$al of ti%%ue 'ay occa%ionally extend 'ore dee&ly into the tooth ;full coronal &ul&oto'y< in an effort to &re%er$e the a&ical &ortion of the &ul& and %afeguard a&ical clo%ure( Gently rin%e the ,ound ,ith %terile %aline or %odiu' hy&ochlorite ;=- L<and re'o$e any %hredded ti%%ue( 0ll re'aining tag% of ti%%ue in the coronal &ortion 'u%t

be re'o$ed a% they 'ay act a% a nidu% for re-infection, and a &ath,ay for coronal lea/age( 0&&ly a calciu' hydroxide dre%%ing to the &ul& to de%troy any re'aining 'icroorgani%'% and to &ro'ote calcific re&air( )n %u&erficial ,ound%, a %etting calciu' hydroxide ce'ent 'ay be gently flo,ed onto the &ul& %urface, but if the exci%ion ,a% dee&, it i% often ea%ier to &re&are a %tiff 'ixture of calciu' hydroxide &o,der ;analytical grade< in %terile %aline or local anae%thetic %olution, ,hich i% carried to the canal in an a'alga' carrier and gently &ac/ed into &lace ,ith &lugger%( O$erlay the calciu' hydroxide dre%%ing ,ith a hard ce'ent to &re$ent it% forceful in+ection into the &ul& by che,ing force% and a final adhe%i$e re%toration ,hich ,ill %eal the &re&aration again%t the re-entry of 'icro-organi%'%( RE)IE8 after a 'onth, @ 'onth%, ! 'onthly inter$al% for u& to A year% in order to a%%e%% &ul& $itality, &eriodic radiogra&hic re$ie, %hould al%o be arranged to 'onitor dentine bridge for'ation, root gro,th, and to exclude the de$elo&'ent of necro%i% and re%or&tion( )f $itality i% lo%t, non-$ital &ul& thera&y %hould be underta/en ,hether or not there i% a calcific bridge ;%ee belo,<, %ucce%% rate% for &artial ;C$e/< &ul&oto'ie% are Buoted at >?L( Tho%e for coronal &ul&oto'ie% at ?:L( Electi$e &ul&ecto'y and root canal treat'ent of a $ital &ul& 'ay be con%idered at a later date only if the root canal i% reBuired for re%torati$e &ur&o%e%( >e$ Point "ul&oto'y &rocedure% Gi$e a better &rogno%i% than &ul& ca&&ing for %'all ex&o%ure% ex&o%ed for 'ore than A h, are not reco''ended if there are %ign% and %y'&to'% of radicular &atho%i%( N&N-)ITA* P(*P T5ERAPY P(*PECT&7Y "re'ature lo%% of &ul& $itality lea$e% a thin and relati$ely ,ea/ tooth %tructure ,hich %hould not be ,ea/ened further by exce%%i$e dentine re'o$al during canal &re&aration( The o&en and often di$erging a&ice% of i''ature &er'anent teeth create technical difficultie% for the controlled conden%ation of root filling 'aterial%, and a root end clo%ure ;a&exification< &rocedure i% u%ually reBuired to &roduce an a&ical calcific barrier again%t ,hich filling 'aterial% 'ay be &ac/ed ;6ig( = ( =<( The 'o%t i'&ortant &re-condition for calcific barrier for'ation i% the eli'ination of 'icroorgani%'% fro' the root canal %y%te' by thorough canal debride'ent and the longter' a&&lication of a non-toxic, anti'icrobial 'edica'ent %uch a% non-%etting calciu' hydroxide( Traditional root end clo%ure of thi% %ort 'ay ta/e >- A 'onth% before definiti$e canal obturation and re%toration i% &o%%ible( & erati.e ro"ed-re (Fi!. /2.22)

 0cce%% ,ith a high-%&eed, 'ediu' ta&ered fi%%ure bur( )n the &ul& cha'ber u%e %afe-ended bur% to re'o$e the entire roof ,ithout the danger of o$ercutting or &erforation( Re'o$e loo%e debri% fro' the &ul& cha'ber ,ith hand in%tru'ent%, acco'&anied by co&iou%, gentle irrigation ,ith %odiu' hy&ochlorite %olution ;=- L<( Gate% Glidden drill% 'ay be u%ed to i'&ro$e acce%% to canal% for in%tru'ent% and irrigant( They %hould not be u%ed dee& in the canal% of i''ature teeth ,here they 'ay o$ercut and create a %tri& &erforation( Canal &re&aration in$ol$e% t,o &roce%%e%G cleaning ,ith irrigant% to free the root canal %y%te' of organic debri%, 'icro-organi%'% and their toxin%H and shaping ,ith enlarging in%tru'ent%, to 'odify the for' of the exi%ting canal to allo, the &lace'ent of a ,ell-conden%ed root filling( )n canal% ,hich are often a% ,ide a% thi%, little dentine re'o$al and %ha&ing i% needed( Sodiu' hy&ochlorite %olution ;=- L< a% an irrigant ,ill continue di%%ol$ing organic debri% and /illing 'icro-organi%'% dee& in the canal( Wor/ing a&ically, file% are directed around the canal ,all% ,ith a light ra%&ing action to re'o$e adherent debri%( )n%tru'entation i% freBuently &unctuated by high$olu'e, lo,-&re%%ure irrigation to flu%h out debri%( )rrigant i% deli$ered either by &re-'ea%ured, ? gauge needle and %yringe or ,ith the aid of %onicDultra%onic energy( The latter in$ol$e% flooding the canal ,ith irrigant before in%erting a %'all ;%i5e =!- 9< file attached to a %onicDultra%onic unit to %tir the irrigant in the canal( Wall contact ,ith the file %hould be a$oided, a% the action i% liable to cau%e turbulence in the irrigant ,hich %crub% the ,all% of debri%( "ro$i%ional ,or/ing length %hould be -@ '' fro' the radiogra&hic a&ex, e%ti'ated fro' an undi%torted &re-o&erati$e &eria&ical fil'( 0 ,or/ing length radiogra&h i% then ta/en to e%tabli%h a definiti$e ,or/ing length = '' %hort of the radiogra&hic root a&ex( 6urther gentle filing and irrigation i% then continued to the definiti$e ,or/ing length( Dry canal ,ith &re-'ea%ured &a&er &oint% to a$oid inad$ertent o$er-exten%ion and da'age to the &eria&ical ti%%ue%( 6ill canal ,ith a relati$ely fluid &ro&rietary calciu' hydroxide &a%te %uch a% #ltracal ;O&tident, #2( Thi% 'ay be %yringed into the canal $ia a di%&o%able flexible ti& ;6ig( = ( ;d<< or alternati$ely %&un into the canal ,ith a %&iral &a%te filler( The anti'icrobial and 'ild ti%%ue %ol$ent acti$ity of non-%etting calciu' hydroxide ,ill continue to clean%e the canal, and it% high &1 i% belie$ed to encourage calcific root end clo%ure( 0 radiogra&h 'ay be ta/en to en%ure a den%e fill to each root ter'inu% ;6ig( = ( @<( Seal acce%% ca$ity tightly bet,een a&&oint'ent% to &re$ent the leaching of calciu' hydroxide, and critically, to &re$ent the re-entry of 'icro-organi%'% fro' the 'outh ,hich ,ould di%turb the &roce%% of root end clo%ure( 0 @ '' thic/ne%% of gla%% iono'er ce'ent or co'&o%ite re%in i% adeBuate to &ro$ide a bacteria-tight %eal( Cotton-,ool fibre% %hould not be allo,ed to re'ain at the ca$o-%urface of the ca$ity( RE)IE8 @ 'onthly to 'onitor root end clo%ure( 0t each a&&oint'ent the calciu' hydroxide dre%%ing i% carefully ,a%hed fro' the canal and the &re%ence of a calcified barrier a%%e%%ed by gently ta&&ing a &re-'ea%ured &a&er &oint at the ,or/ing length( Radiogra&h% %hould be ta/en to a%%e%% the &rogre%% of barrier for'ation(

 )f the canal i% clo%ed, obturation 'ay &roceed( )f calcific barrier for'ation i% not co'&lete, the canal %hould be redre%%ed for a further @ 'onth%( Calcific barrier for'ation i% u%ually co'&lete ,ithin >-=C 'onth%, but could ta/e u& to year%( >e$ Point Root-end clo%ure Gi$e% &redictable re%ult% if infection i% controlled and canal %ealed bacteria-tightH )nfection i% controlled by irrigation and di%infectionH Canal i% enlarged enough only to allo, irrigant acce%% and den%e obturationH 0dd% nothing to the %trength of the toothH Coronal re%toration i% critical to long-ter' %ucce%%( Te"%niA-e# +or o,t-ration Obturation ,ith gutta &ercha and %ealer &re$ent the re-entry of oral 'icro-organi%'% to the a&ical ti%%ue%( Cold lateral conden%ation of gutta &ercha and %ealer 'ay &ro$ide %ati%factory re%ult% in regular, a&ically con$erging canal%, but in irregular and di$erging canal%, a ther'o&la%tic gutta &ercha techniBue i% reBuired to i'&ro$e ada&tation( The u%e of %ingle cone techniBue% cannot be reco''ended in any circu'%tance( (anual o,turation in apically divergent canal ;6ig( = ( A ;a<-;c<<( Select a 'a%ter &oint and try into the canal( Thi% i% u%ually the ,ide%t &oint ,hich ,ill reach the canal ter'inu%, and 'ay be in$erted in the ,ide%t canal%( Dry the canal and lightly coat it% ,all% ,ith a %lo, %etting %ealer( Soften the ti& of the 'a%ter &oint by &a%%age through a bun%en burner fla'e( )n%ert the &oint to the a&ical li'it of the canal and &re%% gently again%t the calcific barrier to ada&t the %oftened gutta &ercha( Cold lateral conden%ation ,ith a %&reader to ,ithin = '' of the a&ical li'it of the canal adding acce%%ory gutta &ercha cone% lightly coated ,ith %ealer( Continue conden%ation until the %&reader can ad$ance no 'ore than or @ '' into the canal( Chec/ radiogra&h to a%%e%% the Buality of fill before re'o$ing exce%% gutta &ercha ,ith a hot in%tru'ent and $ertically conden%ing the ,ar' gutta &ercha at the canal entrance( 6urther cold or ,ar' conden%ation 'ay be underta/en at thi% %tage if reBuired to obtain a unifor'ly den%e obturation( T%ermo la#ti" o,t-ration (Fi!#. /2.25 and /2.21). War' gutta &ercha techniBue% offer the &o%%ibility of extre'ely ra&id and den%e obturation of the 'o%t irregularly %ha&ed %&ace%( Dry the canal and lightly coat it% ,all% ,ith a %lo, %etting %ealerH )n+ect ther'o&la%tic gutta &ercha into the a&ical &ortion of the canal and conden%eH Radiogra&h to chec/ a&ical G" i% in the correct &laceH 4ac/-fill ,ith G" and %eal acce%% ca$ity ,ith an adhe%i$e re%toration( While allo,ing den%e and controlled canal obturation, the root-end clo%ure &rocedure

add% nothing to the canal ,all thic/ne%% or 'echanical %trength of i''ature teeth( The final re%toration %hould therefore be &lanned to o&ti'i5e the durability of the re'aining tooth %tructure( Dentine bonded co'&o%ite re%in% 'ay be &articularly hel&ful in thi% regard, e%&ecially if extended %e$eral 'illi'etre% into the root canal to &ro$ide internal %&linting( The ad$ent of light-tran%'itting fibre &o%t% o&en% ne, &otential for rehabilitation and al%o &ro$ide% a ready &atency for canal re-entry if needed( "eriodic clinical and radiogra&hic re$ie, %hould be arranged( Alternati.e# to t%e root-end "lo#-re ro"ed-re Recently the &otential ha% ari%en to %eal o&en a&ice% ,ith 'ineral trioxide aggregate ;MT0<( 4a%ed on "ortland building ce'ent it i% &ac/ed into the canal ,ith &re'ea%ured &lugger% and %et% to for' a hard, %ealing, bioco'&atible barrier ,ithin A h( Moi%t cotton ,ool i% &laced into the canal to &ro'ote %etting and the 'aterial i% chec/ed after at lea%t A h before filling the re'ainder of the canal ,ith gutta &ercha and %ealer, or ,ith co'&o%ite and a fibre &o%t( Clinical %tudie% are ongoing, but thi% 'aterial %ee'% li/ely to allo, root end clo%ure in = or $i%it% ,hich ,ill de'and le%% &atient co'&liance ;6ig( = ( ?<( When &ul& $itality i% lo%t in an al'o%t fully for'ed tooth, it 'ay be &o%%ible to a$oid lengthy root-end clo%ure &rocedure% by creating an a&ical %to& again%t ,hich a root filling 'ay be &ac/ed( 6ollo,ing cro,n to a&ex &re&aration a% de%cribed abo$e, endodontic hand file% 'ay be u%ed in gentle ,atch-,inding or balanced-force 'otion at ,or/ing length to %ha$e an a&ical %eat for canal obturation( 0lternati$ely, MT0 can be &ac/ed into the a&ical =- '' of the canal ,ith &lugger% to &ro$ide an i''ediate a&ical %eal( Endodontic %urgery ,ith root-end filling i% beco'ing le%% &o&ular a% a 'ean% of treat'ent in the ca%e of non-clo%ure( 1o,e$er, it 'ay be con%idered to addre%% &roble'% of %eriou%, irretrie$able o$erfill ,hich 'ay ari%e if the calcific barrier ,a% erroneou%ly diagno%ed a% co'&lete, or if the barrier ,a% bro/en by hea$y-handed obturation( (n"om li"ated "roCn-root +ra"t-re 0fter re'o$al of the fractured &iece of tooth the%e $ertical fracture% are co''only a fe, 'illi'etre% inci%al to the gingi$al 'argin on the labial %urface but do,n to the ce'ento-ena'el +unction &alatally( "rior to &lace'ent of a re%toration the fracture 'argin ha% to be brought %u&ragingi$al either by gingi$o&la%ty or extru%ion ;orthodontically or %urgically< of the root &ortion( Com li"ated "roCn-root +ra"t-re 0% abo$e ,ith the addition of endodontic reBuire'ent%( )f extru%ion i% &lanned then the final root length 'u%t be no %horter than the final cro,n length other,i%e the re%ult ,ill be un%table( Root extru%ion can be %ucce%%ful in a 'oti$ated &atient and lead% to a %table &eriodontal condition( Root +ra"t-re Root fracture% occur 'o%t freBuently in the 'iddle or the a&ical third of the root( The coronal frag'ent 'ay be extruded or luxated( )f di%&lace'ent ha% occurred the

coronal frag'ent %hould be re&o%itioned a% %oon a% &o%%ible by gentle digital 'ani&ulation and the &o%ition chec/ed radiogra&hically( O&ti'al re&o%itioning fa$our% both healing ,ith hard ti%%ue and reduce% the ri%/ of &ul&al necro%i%( Mobile root fracture% need to be %&linted to encourage re&air of the fracture( With the &o%%ible exce&tion of coronal third fracture% ,hich 'ay reBuire longer %&linting &eriod%, it a&&ear% that a &eriod of A ,ee/% ,ith a %e'i-rigid or functional %&lint i% %ufficient to en%ure healing( 0 functional %&lint i% one that include% one abut'ent teeth on either %ide of the fractured tooth( S&linting for longer &eriod% 'ay be reBuired in indi$idual ca%e%( The %&lint %hould allo, colour ob%er$ation% and %en%iti$ity te%ting and acce%% to the root canal if endodontic treat'ent i% reBuired( The %&lint de%ign and &lace'ent techniBue% are di%cu%%ed in the next %ection on *%&linting*( Three 'ain categorie% of re&air are recogni5edG =( re&air ,ith calcified ti%%ueG in$i%ible or hardly di%cernible fracture line ;6ig( = ( C ;a<-;c<<H ( re&air ,ith connecti$e ti%%ueG narro, radiolucent fracture line ,ith &eri&heral rounding of the fracture edge% ;6ig( = ( ><H @( re&air ,ith bone and connecti$e ti%%ueG a bony bridge %e&arate% the t,o frag'ent% ;6ig( = (@9<( )n addition to the%e change% in the fracture area, &ul& canal obliteration i% co''only %een( 6racture% in the cer$ical third of the root ,ill re&air a% long a% no co''unication exi%t% bet,een the fracture line and the gingi$al cre$ice( )f %uch a co''unication exi%t% then %&linting i% not reco''ended and an early deci%ion 'u%t be 'ade eitherG to extract the coronal frag'ent and retain the re'aining rootH internally %&lint the root fractureH or extract the t,o frag'ent%( E'TRACTI&N &F C&R&NA* FRA67ENT AND R&&T RETENTI&N The re'aining radicular &ul& %hould be re'o$ed and the canal te'&orarily dre%%ed &rior to obturating ,ith gutta &ercha( Three o&tion% are no, a$ailable for the root treated radicular &ortionG =( "o%t, core, and cro,n re%toration if acce%% i% adeBuate( ( Extru%ion of root either %urgically or orthodontically if the fracture extend% too %ubgingi$ally for adeBuate acce%%( Ra&id orthodontic extru%ion o$er A-! ,ee/% ai'ing to 'o$e the root a 'axi'u' of A '' i% the be%t o&tion( Thi% i% achie$ed by ce'enting a *7* hoo/ 'ade fro' 9(?-'' %tainle%% %teel ,ire into the canal and u%ing ela%tic traction a&&lied o$er an arch ,ire ce'ented bet,een one abut'ent tooth on either %ide of the in+ured tooth( Retention for one 'onth at the end of 'o$e'ent i% ad$i%ed to &re$ent rela&%e ;6ig( = (@=<( )f ae%thetic% are a &articular concern then an orthodontic brac/et can be bonded to a te'&orary cro,n 'ade o$er the *7* hoo/( The te'&orary cro,n length ,ill need to be reduced a% extru%ion occur% ;6ig( = (@ ;a<;d<<( @( Co$er the root ,ith a 'uco&erio%teal fla&( Thi% ,ill 'aintain the height and ,idth of the arch and ,ill facilitate later &lace'ent of a %ingle tooth i'&lant(

INTERNA* SP*INTIN6 6racture% ari%ing in the coronal and 'iddle third of the root often re%ult in exce%%i$e 'obility of the coronal frag'ent and techniBue% ha$e been de%cribed to internally %&lint the coronal and a&ical &ortion% together ,ith a rigid root filling 'aterial( )nternal %&lint% ha$e ranged fro' hed%troe' file% to nic/el-chro'iu' &oint%, %cre,ed and ce'ented into &o%ition( The%e a&&roache% are in effect %ingle cone root filling &rocedure%, and cannot be relied u&on to gi$e a long-ter' %afeguard again%t the reentry of oral 'icro-organi%'% to the canal and fracture line( Mo%t are doo'ed to failure and other re%torati$e o&tion% are &referred( P(*PA* NECR&SIS IN R&&T FRACT(RE "ul&al necro%i% occur% in about 9L of root fracture% and i% the 'ain ob%tacle to adeBuate re&air( The initial a'ount of di%&lace'ent of the coronal &ortion rather than the le$el of the fracture or the &re%ence of an o&en or clo%ed a&ex i% the 'o%t %ignificant factor in deter'ining future &ul&al &rogno%i%( Mo%t ca%e% of necro%i% are diagno%ed ,ithin @ 'onth% of a root fracture( 0 &er%i%tent negati$e re%&on%e to electric %ti'ulation i% u%ually confir'ed on radiogra&hy by radiolucencie% ad+acent to the fracture line( The a&ical frag'ent al'o%t al,ay% contain% $iable &ul& ti%%ue and in$ariably %clero%e%( Rarely it 'ay reBuire %urgical re'o$al( )n a&ical and 'iddle third fracture% any endodontic treat'ent i% u%ually confined to the coronal frag'ent only( 0 barrier i% achie$ed on the coronal a%&ect of the fracture line by &re&aration of a %to& ,ith non-%etting calciu' hydroxide or MT0, and the coronal canal i% obturated ,ith gutta &ercha( 0fter co'&letion of endodontic treat'ent, re&air and union bet,een the t,o frag'ent% ,ith connecti$e ti%%ue i% a con%i%tent finding( )n coronal third fracture% that de$elo& necro%i% either the radicular &ortion can be retained ;%ee abo$e<, both &ortion% extracted, or the fracture internally %&linted ;%ee abo$e<( Fi!. /2./3 0n u&&er left &er'anent central inci%or @ year% after reattach'ent of a fractured inci%al frag'ent( Fi!. /2./4 Maturation of &er'anent inci%or%( ;a< )''ature inci%or% %ho,ing %hort root% ,ith inco'&lete, ,ide-o&en a&ice%( The lateral ,all% of the root% are thin and %tructurally ,ea/( ;b< The %a'e teeth year% later, the root% are no, al'o%t co'&lete follo,ing continued dentine de&o%ition by healthy &ul&( Fi!. /2.20 "ul& a'&utation ;a&exogene%i% &rocedure< of a &er'anent inci%or( ;a< Co'&licated fracture of an i''ature inci%or ,ith 'icrobial in$a%ion of the coronal &ul&( The &ul& ha% been ex&o%ed to the 'outh for 'ore than A h( ;b< 0cce%% to the coronal &ul& and a'&utation of coronal &ul& ti%%ue ,ith a dia'ond bur running at high %&eed ,ith con%tant ,ater cooling( ;c< Dre%%ing the &ul&al ,ound to &ro'ote calcific re&air( -on-%etting calciu' hydroxide ce'ent i% flo,ed on to the &ul&, then o$erlaid ,ith a hard ce'ent, and the tooth re%tored ,ith co'&o%ite re%in( ;d< The %a'e tooth after = 'onth% %ho,ing calcific barrier for'ation( The calcific barrier ,a% directly in%&ected in thi% ca%e, ;not al,ay% reBuired<, and a ne, layer of %etting calciu' hydroxide ce'ent &laced on the barrier before definiti$e re%toration( The re'aining &ul& ha% %tayed healthy and de&o%ited dentine to co'&lete root for'ation(

Fi!. /2.2/ Root-end clo%ure ;a&exification<( ;a< )''ature, &er'anent central inci%or de$itali5ed by trau'a( ;b< The %a'e tooth =C 'onth% later( Canal debride'ent and calciu' hydroxide thera&y ha% allo,ed the de$elo&'ent of an a&ical calcific barrier( The canal ha% been den%ely obturated ,ith ther'o&la%tic gutta &ercha and %ealer( Fi!. /2.22 ;a< 6ollo,ing irrigation and gentle debride'ent in a cro,n-to-a&ex direction, the ,or/ing length i% deter'ined( ;b< -on-%etting calciu' hydroxide &a%te i% %yringed into the canal $ia a flexible ti&( ;c< The %a'e tooth =C 'onth% later( 0 calcific barrier i% a&&arent, and the tooth i% ready for definiti$e obturation and re%toration( ;d< The flexible ti& %y%te' ;#ltracal<( Fi!. /2.23 Radiogra&h to confir' den%e obliteration of the &re&ared canal ,ith non-%etting calciu' hydroxide &a%te( Fi!. /2.20 Obturation follo,ing root-end clo%ure in an a&ically di$erging canal( ;a< The ,ide%t gutta &ercha &oint that ,ill reach the a&ical ter'inu% of the canal i% ,ar'ed by &a%%age of it% ti& through a fla'e( ;b< Without delay, the &oint i% introduced to the canal ;the canal i% already lightly coated ,ith %ealer<, and ad$anced to ada&t again%t the a&ical barrier( ;c< 0dditional &oint% are no, &ac/ed around the 'a%ter &oint ,ith cold or ,ar' conden%ation until the canal i% den%ely filled( Fi!. /2.25 Obtura ))( 3o,-te'&erature, in+ection-'oulded, ther'o&la%tic gutta &ercha( Fi!. /2.21 Ra&id, den%e obturation of a ,ide and irregularly %ha&ed canal ,ith in+ection- 'oulded, ther'o&la%tic gutta &ercha and %ealer( Fi!. /2.22 ;a< )''ature a&ex tooth ==( ;b< 0&ical *&lug* of MT0 and bac/fill ,ith ther'o&la%tic G"( ;Courte%y of "rofe%%or M(S(Duggal(< Fi!. /2.23 ;a< 0n a&ical third root fracture of the u&&er right &er'anent central inci%or ,ith a rigid %&lint( ;b< 0&&earance of the fracture =: 'onth% later( ;c< Good calcified ti%%ue re&air e$ident @ year%* &o%t-trau'a( Fi!. /2.24 Middle third root fracture of the u&&er right &er'anent central inci%or ,ith connecti$e ti%%ue re&air( Fi!. /2.30 Middle third root fracture of both &er'anent central inci%or% ,ith bony re&air and %clero%i% of the a&ical frag'ent%( Fi!. /2.3/ Extru%i$e force being a&&lied $ia a *7* hoo/ ce'ented into the root canal of the u&&er left &er'anent lateral inci%or( Fi!. /2.32 ;a< )nitial &re%entation of a high coronal root fracture ,hich extended &alatally belo, al$eolar bone( ;b< and ;c< "o%t, core, and dia&hrag' after root extru%ion( /2.2.2 S lintin! Trau'a 'ay loo%en a tooth either by da'aging the &eriodontal liga'ent ;&(l(< or fracturing the root( S&linting i''obili5e% the tooth in the correct anato'ical &o%ition %o that further trau'a i% &re$ented and healing can occur( Different in+urie% reBuire different %&linting regi'en%( 0 functional %&lint in$ol$e% one, and a rigid %&lint t,o, abut'ent teeth either %ide of the in+ured tooth( Re!imen# P.*. INj(RIES

Sixty &er cent of &(l( healing ha% occurred after =9 day% and it i% co'&lete ,ithin a 'onth( The %&linting &eriod %hould be a% %hort a% &o%%ible and the %&lint %hould allo, %o'e functional 'o$e'ent to &re$ent re&lace'ent root re%or&tion ;an/ylo%i%<( 0% a general rule exarticulation ;a$ul%ion< in+urie% reBuire ?-=9 day% and luxation in+urie% -@ ,ee/% of functional %&linting( R&&T FRACT(RES The%e reBuire A ,ee/% of functional %&linting( )ndi$idual ca%e% 'ay reBuire longer %&linting( Exce%%i$e 'obility lead% to the fracture %ite beco'ing filled ,ith granulation ti%%ue( DENT&A*)E&*AR FRACT(RES The%e reBuire @-A ,ee/% of rigid %&linting( T$ e# and met%od# o+ "on#tr-"tin! # lint# C&7P&SITE RESINBACRY*IC AND 8IRE SP*INT Thi% 'ethod u%e% either a co'&o%ite re%in or a te'&orary cro,n 'aterial( The co'&o%ite re%in i% ea%ier to &lace but the acrylic re%in i% ea%ier to re'o$e( 0lthough acrylic re%in doe% not ha$e the bond %trength to ena'el a% the co'&o%ite re%in it i% %uitable for all ty&e% of functional %&linting ;6ig( = (@@<( TechniBue for a functional re%in-,ire %&lintG =( 4end a flexible orthodontic ,ire to fit the 'iddle third of the labial %urface of the in+ured tooth and one abut'ent tooth either %ide( ( Stabili5e the in+ured tooth in the correct &o%ition ,ith %oft red ,ax &alatally( @( Clean the labial %urface%( )%olate, dry, and etch 'iddle of cro,n of teeth ,ith @?L &ho%&horic acid for @9 %, ,a%h, and dry( A( 0&&ly @-'' dia'eter circle either of unfilled then filled co'&o%ite re%in or of acrylic re%in, to the centre of the cro,n%( :( "o%ition the ,ire into the filling 'aterial then a&&ly 'ore co'&o%ite or acrylic re%in( !( #%e a bru%h lubricated ,ith unfilled co'&o%ite re%in to 'ould and %'ooth the co'&o%ite( 0crylic re%in i% 'ore difficult to handle and %'oothing and exce%% re'o$al can be done ,ith a flat &la%tic in%tru'ent( ?( Cure the co'&o%ite for !9 %( Wait for the acrylic re%in to cure( C( S'ooth any %har& edge% ,ith %and&a&er di%c%( 6igure = (@@ %ho,% an exa'&le of a functional %&lint( 6or a rigid %&lint u%e the %a'e techniBue but incor&orate t,o abut'ent teeth on either %ide of the in+ured tooth( The%e %&lint% %hould not i'&inge on the gingi$a and %hould allo, a%%e%%'ent of colour change and %en%iti$ity te%ting(

&RT5&D&NTIC ;RAC>ETS AND 8IRE 6or di%&lace'ent in+urie% and exarticulation% the%e %&lint% ha$e the ad$antage of allo,ing a 'ore accurate reduction of the in+ury by gentle force% ;6ig( = (@A;a and b<<( F&I*BCE7ENT SP*INT 0 te'&orary %&lint 'ade of %oft 'etal ;coo/ing foil< and ce'ented ,ith Buic/ %etting 5inc oxide-eugenol ce'ent i% an effecti$e te'&orary 'ea%ure either during the night ,hen it i% difficult to fit a co'&o%ite-,ire %&lint a% a %ingle-handed o&erator or ,hile a,aiting con%truction of a laboratory 'ade %&lint( TechniBueG =( Cut 'etal to %i5e, long enough to extend o$er t,o or three teeth on each %ide of the in+ured tooth and ,ide enough to extend o$er the inci%al edge% and @-A '' o$er the labial and &alatal gingi$a( ( "lace foil o$er teeth and 'ould it o$er labial and &alatal %urface%( Re'o$e any exce%%( @( Ce'ent the foil to the teeth ,ith Buic/ %etting 5inc oxide-eugenol ce'ent( *A;&RAT&RY SP*INTS ;=< acrylicH ; < ther'o&la%tic( The%e are u%ed ,here it i% i'&o%%ible to 'a/e a %ati%factory %&lint by the direct 'ethod, for exa'&le, a ?-C year old ,ith trau'ati5ed 'axillary inci%or%, uneru&ted lateral inci%or%, and either cariou% or ab%ent &ri'ary canine%( 4oth 'ethod% reBuire alginate i'&re%%ion% and $ery loo%e teeth 'ay need to be %u&&orted by ,ax, 'etal foil, or ,ire ligature %o they are not re'o$ed ,ith the i'&re%%ion( =( "crylic( There i% full &alatal co$erage and the acrylic i% extended o$er the inci%al edge% for -@ '' of the labial %urface% of the anterior teeth( The occlu%al %urface% of the &o%terior teeth %hould be co$ered to &re$ent any occlu%al contact in the anterior region( Thi% al%o aid% retention and 0da'% Crib% 'ay not be reBuired( The %&lint %hould be re'o$ed for cleaning after 'eal% and at bedti'e( ( -hermoplastic( The %&lint i% con%tructed fro' &oly$inylacetate-&olyethylene ;"80C-"E< co&oly'er in the %a'e ,ay a% a 'outhguard ,ith exten%ion onto the 'uco%a( )t %hould be re'o$ed li/e the acrylic %&lint after 'eal% and at bedti'e( 1o,e$er, ,ith 'ore %e$erely loo%ened teeth it could be retained at night( 4oth for'% of laboratory %&lint allo, functional 'o$e'ent and therefore &ro'ote nor'al &eriodontal healing( They are not %uitable for root fracture% a% they co'&ro'i%e oral hygiene( Fi!. /2.33 Co'&o%ite re%in and ,ire %&lint for a luxation in+ury of both u&&er &er'anent central inci%or%(

Fi!. /2.30 ;a< and ;b< Gentle reduction and %&linting of luxated u&&er right &er'anent central inci%or( /2.2.3 InD-rie# to t%e eriodontal ti##-e# Con"-##ion The i'&act force cau%e% oede'a and hae'orrhage in the &(l( and the tooth i% tender to &ercu%%ion ;t(t(&(<( There i% no ru&ture of &(l( fibre% and the tooth i% fir' in the %oc/et( S-,l-9ation )n addition to the abo$e there i% ru&ture of %o'e &(l( fibre% and the tooth i% 'obile in the %oc/et, although not di%&laced ;6ig( = (@:<( The treat'ent for both the%e in+urie% i%G ;=< occlu%al reliefH ; < %oft diet for ? day%H ;@< i''obili5ation ,ith a %&lint if teeth ha$e fully for'ed a&ice% or if t(t(&( i% %ignificantH ;A< chlorhexidine 9( L 'outh,a%h, t,ice daily( 6igure% for &ul&al %ur$i$al : year% after in+ury ;Table = ( < %ho, that there i% 'ini'al ri%/ of &ul&al necro%i%( )n addition, in o$er >?L of ca%e% there i% no e$idence of any re%or&tion( E9tr-#i.e l-9ation There i% a ru&ture of &(l( and &ul&( *ateral l-9ation There i% a ru&ture of &(l, &ul&, and the al$eolar &late ;6ig( = (@! ;a<<( The treat'ent for both the%e in+urie% i%G ;=< atrau'atic re&o%itioning ,ith gentle but fir' digital &re%%ure ;6ig( = (@! ;b<<H ; < local anae%thetic i% reBuired if there i% an al$eolar &late in+uryH ;@< non-rigid functional %&lint for -@ ,ee/% ;6ig( = (@! ;c<<H ;A< antibiotic%, for exa'&le, a'oxycillin :9 'g three ti'e% daily ;<=9 year% old = : 'g three ti'e% daily< for : day%H ;:< chlorhexidine 9( L 'outh,a%h t,ice daily ,hile %&lint i% in &o%itionH ;!< %oft diet -@ ,ee/%( 0ntibiotic% 'ay ha$e a beneficial effect in &ro'oting re&air of the &(l( They do not a&&ear to affect &ul&al &rogno%i%( 0fter -@ ,ee/% the teeth are radiogra&hed( )f there i% no e$idence of 'arginal brea/do,n the %&lint can be re'o$ed( )f 'arginal brea/do,n i% &re%ent then it %hould be retained for a further -@ ,ee/%(

6or both the%e in+urie% the deci%ion ,hether to &rogre%% to endodontic treat'ent de&end% on the co'bination of clinical and radiogra&hic %ign% at regular re$ie, ;6ig( = (?<( 6i$e-year &ul&al %ur$i$al figure% ;Table = ( < %ho, that &rogno%i% i% %ignificantly better for o&en a&ex teeth but ne$erthele%% a &ro&ortion of 'ature clo%ed a&ex teeth ,ill retain $itality( )n addition, o$er AL of 'ature teeth in$ol$ed in luxation in+urie% ,ill exhibit on radiogra&h% a natural healing &heno'enon /no,n a% *tran%ient a&ical brea/do,n* ;t(a(b(< ,hich can 'i'ic a&ical infla''ation( 0'bi$alent clinical and radiogra&hic %ign% %hould be gi$en the *benefit of the doubt* until the next re$ie,( With 'ore %ignificant da'age to the &(l( in both extru%i$e and lateral luxation in+urie% there i% an increa%ed ri%/ of root re%or&tion( Thirty-fi$e &er cent of 'ature teeth that ha$e undergone lateral luxation %ho, %ub%eBuent e$idence of %urface re%or&tion( )n %o'e ca%e% of lateral luxation the di%&lace'ent cannot be reduced ,ith gentle finger &re%%ure( )t i% not ad$i%able to u%e 'ore force a% thi% can further da'age the &eriodontal liga'ent( Orthodontic a&&liance%, either a re'o$able or a %ectional fixed a&&liance can be u%ed to reduce the di%&lace'ent o$er a &eriod of a fe, ,ee/% ;6ig( = (@?;a-c<<( Intr-#i.e l-9ation The%e in+urie% are the re%ult of an axial, a&ical i'&act and there i% exten%i$e da'age to &(l, &ul&, and al$eolar &late;%<( T,o di%tinct treat'ent categorie% exi%tG the o&en and clo%ed a&ex( 4oth categorie% can be di%cu%%ed de&ending on ,hether the intru%i$e in+ury i%G 'ild;<@ ''<H 'oderate ;@! ''<H or %e$ere ;>! ''<( &PEN APE' Mild intru%ion <@ ''( Excellent eru&ti$e &otential( Treat con%er$ati$ely and re$ie,( )f no 'o$e'ent in -A 'onth% 'o$e orthodontically( Moderate )ntru%ion @-! ''( Di%i'&act ;,ith force&% if nece%%ary< and either allo, to eru&t %&ontaneou%ly for -A 'onth% before extruding orthodontically or a&&ly orthodontic force% early( Se$ere intru%ion >! ''( Orthodontic re&o%itioning 'ay be i'&o%%ible and di%i'&action follo,ed by %urgical re&o%itioning under either 30, 30D%edation, or G0 i% a&&ro&riate( 6unctional %&lint for -@ ,ee/%( Monitor &ul&al %tatu% clinically and radiogra&hically at regular inter$al% during the fir%t ! 'onth% after in+ury, and then ! 'onthly, and %tart endodontic% if nece%%aryG -on-%etting calciu' hydroxide in root canal doe% not &reclude again%t orthodontic 'o$e'ent( Once a&exification ha% occurred and orthodontic 'o$e'ent ha% cea%ed ;6ig( = (@C;a-c<< obturate canal ,ith gutta &ercha( C*&SED APE' Mild intru%ion <@ ''( Orthodontic extru%ion i% &robably indicated %traight a,ay although %o'e author% ha$e ad$ocated con%er$ati$e treat'ent( The danger of a tooth an/ylo%ing in an intruded &o%ition %hould al,ay% be borne in 'ind and in thi% re%&ect

acti$e treat'ent i% &referable to a con%er$ati$e a&&roach( Moderate intru%ion @-! ''( Orthodontic extru%ion i% indicated %traight a,ay( Se$ere intru%ion >! ''( Surgical re&o%itioning( 6unctional %&lint for -@ ,ee/%( Electi$e &ul& extir&ation ,ill be nece%%ary for all %ignificant intru%i$e luxation in+urie% in clo%ed a&ex teeth ;Table = (@< at about=9 day%( Maintain non-%etting calciu' hydroxide in root canal during orthodontic 'o$e'ent before obturation ,ith gutta &ercha ;6ig( = (@> ;a-d<<( )f endodontic treat'ent i% co''enced ,ithin ,ee/% after any in+ury to the &(l( then the initial intracanal dre%%ing %hould be ,ith an antibioticD%teroid ;3eder'ix, 3ederle< &a%te( Thi% 'ay hel& to reduce the incidence of infla''atory re%or&tion( 0t the initial exa'ination both o&en and clo%ed a&ex teeth %hould recei$e antibiotic%, chlorhexidine 'outh,a%h, and a %oft diet( The ri%/ of &ul&al necro%i% in the%e in+urie% i% high, e%&ecially in the clo%ed a&ex ;Table = ( <( The incidence of re%or&tion and an/ylo%i% %eBuelae i% al%o high ;Table = (@< >e$ Point )n &(l(in+urie% The incidence of &ul&al necro%i% i% higher in clo%ed a&ex teethH The incidence of re%or&tion increa%e% ,ith %e$erity of in+ury( A.-l#ion and re lantation Re&lantation %hould nearly al,ay% be atte'&ted e$en though it 'ay offer only a te'&orary %olution due to the freBuent occurrence of external infla''atory re%or&tion ;e(i(r(<( E$en ,hen re%or&tion occur% the tooth 'ay be retained for year% acting a% a natural %&ace 'aintainer and &re%er$ing the height and ,idth of the al$eolu% to facilitate later i'&lant &lace'ent( Succe%%ful healing after re&lantation can only occur if there i% 'ini'al da'age to the &ul& and the &(l( The extra-al$eloar dry ti'e ;e(a(d(t(<, the ty&e of extra-al$eolar %torage 'ediu', and the total extra-al$eolar ti'e ;e(a(t(<, that i%, the ti'e the tooth ha% been out of the 'outh are critical factor%( The fir%t Bue%tion that 'u%t be /no,n i% *,hat i% the e(a(d(t( of the toothJ )f the e(a(d(t( i% not greater than = h then the %ugge%ted &rotocol for re&lantation can be di$ided intoG ad$ice on &honeH i''ediate treat'ent in %urgeryH and re$ie,( Re lantation o+ teet% Cit% a dr$ #tora!e time o+ le## t%an / % AD)ICE &N P5&NE (T& TEAC5ER< PARENT< ETC.) =( Don*t touch roothold by cro,n( ( )f tooth i% dirty, ,a%h briefly ;=9 %< under cold running ,ater(

@( Re&lace into %oc/et or tran%&ort in 'il/ to %urgery( A( )f re&laced bite gently on a hand/erchief to retain it and co'e to %urgery( The be%t tran%&ort 'ediu' i% the tooth*% o,n %oc/et( #nder%tandably non-denti%t% 'ay be unha&&y to re&lant the tooth and 'il/ i% an effecti$e i%o-o%'olar 'ediu'( Sali$a, the &atient*% buccal %ulcu%, or nor'al %aline are alternati$e%( I77EDIATE S(R6ERY TREAT7ENT =( Do not handle root( )f re&lanted re'o$e tooth fro' %oc/et( ( Rin%e tooth ,ith nor'al %aline( -ote %tate of root de$elo&'ent( Store in %aline( @( 3ocal analge%ia( A( )rrigate %oc/et ,ith %aline and re'o$e clot and any foreign 'aterial( :( "u%h tooth gently but fir'ly into %oc/et( !( -on-rigid functional %&lint for ?-=9 day%( ?( Chec/ occlu%ion( C( 4a%eline radiogra&h%G &eria&ical or anterior occlu%al( 0ny other teeth in+uredJ >( 0ntibiotic%, chlorhexidine 'outh,a%h, %oft diet a% &re$iou%ly( =9( Chec/ tetanu% i''uni5ation %tatu%( RE)IE8 =( Radiogra&h&rior to %&lint re'o$al at ?-=9 day%( ( Re'o$e %&lint ?-=9 day%( @( Endodontic%co''ence &rior to %&lint re'o$al for categorie% ;b< and ;c<G ;a< o&en a&ex( e(a(t( <@9-A: 'in( Ob%er$e( ;b< o&en a&ex( e(a(t( >@9-A: 'in( Endodontic%( ;i< initial intracanal dre%%ingantibioticD%teroid ;3eder'ix, 3ederle< &a%te( ;ii< %ub%eBuent intracanal dre%%ing%non-%etting calciu' hydroxide &a%te( ;iii< re&lace calciu' hydroxide @ 'onthly until a&ical barrier ;u& to 'axi'u' of year%( ;i$< obturate canal ,ith G" ;c< Clo%ed a&ex( Endodontic%( ;i< initial intracanal dre%%ing antibioticD%teroid ;3eder'ix, 3ederle< &a%teH ;ii< %ub%eBuent intracanal dre%%ing ,ith non-%etting calciu' hydroxide &a%teH ;iii< obturate ,ith gutta &ercha at ! 'onth% a% long a% no &rogre%%i$e re%or&tion( A( Radiogra&hic re$ie,G =, @, and ! 'onthly for year% then annually(

:( )f re%or&tion i% &rogre%%ing unhalted /ee& non-%etting calciu' hydroxide in the tooth until exfoliation, changing it ! 'onthly( The i''ature tooth ,ith an e(a(t( of le%% than @9-A: 'in 'ay undergo &ul& re$a%culari5ation ;Table = ( <( 1o,e$er, the%e teeth reBuire regular clinical and radiogra&hic re$ie, becau%e once e(i(r( occur% it &rogre%%e% ra&idly( Re lantation o+ teet% Cit% a dr$ #tora!e time o+ !reater t%an / % The con%enu% o&inion i% that teeth ,ith $ery i''ature a&ice% %hould not be re&lanted( The incidence of re%or&tion, an/ylo%i%, and %ub%eBuent lo%% i% high due to the high rate of bone re'odelling in thi% age grou&( Mature teeth ,ith a dry %torage ti'e of greater than = h ,ill ha$e a non-$ital &(l( The necrotic &(l( and the &ul& %hould be re'o$ed at chair%ide ,ith &u'ice and ,ater on a bri%tle bru%h &rior to rin%ing ,ith nor'al %aline( The root canal i% then obturated ,ith gutta &ercha and the tooth re&lanted and %&linted for a longer &eriod of u& to ! ,ee/%( The ai' of thi% treat'ent i% to &roduce an/ylo%i% allo,ing the tooth to be 'aintained a% a natural %&ace 'aintainer, &erha&% for a li'ited &eriod only( P-l al and eriodontal #tat-# in .d.l. inD-rie# "ul&al necro%i% i% the 'o%t co''on co'&lication and i% related to the %e$erity of the &eriodontal in+ury ;Table = ( <( )''ature teeth ha$e a better &rogno%i% than 'ature teeth due to the ,ide a&ical o&ening ,here %light 'o$e'ent% can occur ,ithout di%ru&tion of the a&ical neuro$a%cular bundle( -ecro%i% can be diagno%ed in 'o%t ca%e% ,ithin @ 'onth% of in+ury but in %o'e ca%e% 'ay not be e$ident for at lea%t year%( 0 co'bination of clinical and radiological %ign% are often reBuired to diagno%e necro%i%( SENSITI)ITY TESTIN6 The 'a+ority of in+ured teeth te%t negati$ely to e(&(t( i''ediately follo,ing trau'a( Mo%t &ul&% that reco$er te%t &o%iti$ely ,ithin 'onth% but re%&on%e% ha$e been re&orted a% late a% year% after in+ury( 0 negati$e te%t alone therefore %hould not be regarded a% &roof of necro%i%( "o%t&one endodontic% until at lea%t one other clinical andDor radiogra&hic %ign i% &re%ent( T&&T5 DISC&*&(RATI&N )nitial &in/i%h di%colouration 'ay be due to %ubtotal %e$erance of a&ical $e%%el% leading to &enetration of hae'oglobin fro' %uch ru&ture% into the dentine tubule%( )f the $a%cular %y%te' re&air% then 'o%t of thi% di%colouration ,ill di%a&&ear( )f the tooth beco'e% &rogre%%i$ely grey then necro%i% %hould be %u%&ected( 0 grey colour that a&&ear% for the fir%t ti'e %e$eral ,ee/% or 'onth% after trau'a, %ignifie% deco'&o%ition of necrotic &ul& ti%%ue and i% a deci%i$e %ign of necro%i%( Colour change% are u%ually 'o%t a&&arent on the &alatal %urface of the in+ured teeth( TENDERNESS T& PERC(SSI&N Thi% 'ay be the 'o%t reliable i%olated indicator of &ul&al necro%i%(

PERIAPICA* INF*A77ATI&N Radiological &eria&ical in$ol$e'ent %econdary to &ul& necro%i% and infection can be %een a% early a% @ ,ee/% after trau'a( )n 'ature teeth tran%ient a&ical brea/do,n ;t(a(b(< 'ay be 'i%ta/en for &eria&ical infla''ation and 'ay be &re%ent u& to -@ 'onth% after trau'a( )t re&re%ent% the re%&on%e to an ingro,th of ne, ti%%ue into the &ul& canal( ARREST &F R&&T DE)E*&P7ENT )f necro%i% in$ol$e% the e&ithelial root %heath before root de$elo&'ent i% co'&lete, then no further root gro,th ,ill occur ;6ig( = (=? ;a< and ;b<<( )n an in+ured &ul& necro%i% 'ay &rogre%% fro' coronal to a&ical &ortion and hence re%idual a&ical $itality 'ay re%ult in for'ation of a calcific barrier acro%% a ,ide a&ical fora'en( 6ailure of the &ul& cha'ber and root canal to 'ature and reduce in %i5e on %ucce%%i$e radiogra&h% co'&ared ,ith contralateral unin+ured teeth i% al%o a reliable indicator of necro%i%( Fi!. /2.35 Subluxated u&&er &er'anent central inci%or%( Fi!. /2.31 ;a< "alatally luxated u&&er left &er'anent inci%or ,ith other a%%ociated in+urie%( ;b< #&&er left &er'anent central inci%or re&o%itioned atrau'atically( ;c< -on-rigid orthodontic %&lint in &lace( Fi!. /2.32 ;a< Delayed &re%entation of &alatally luxated u&&er &er'anent central inci%or% in trau'atic occlu%ion( ;b< and ;c< 0n u&&er re'o$able a&&liance u%ed to &rocline the u&&er inci%or% o$er 'onth%( Fi!. /2.33 ;a< 0 ?-year-old child ,ith intru%ion of the u&&er right &er'anent central inci%or ,hich failed to re-eru&t %&ontaneou%ly( ;b< and ;c< Orthodontic extru%ion of the u&&er right central inci%or( Fi!. /2.34 ;a< 0 %e$ere intru%i$e in+ury in a =:-year-old girl( ;b< Surgical extru%ion of the u&&er right &er'anent inci%or%( ;c< Orthodontic %&linting( ;d< Co'&leted co'&o%ite re%toration%( /2.2.0 Re#or tion Root re%or&tion i% a %eriou% and de%tructi$e co'&lication ,hich 'ay follo, trau'a to &ri'ary and &er'anent teeth( "ri'ary teeth ,hich de$elo& &athological re%or&ti$e le%ion% are not good candidate% for con%er$ati$e treat'ent and %hould be extracted( "er'anent teeth on the other hand 'ay often be %ucce%%fully treated &ro$ided ti%%ue de%truction ha% not ad$anced to an unre%torable %tate( T,o general for'% of &athological root re%or&tion are recogni5ed, infla''atory and re&lace'ent( INF*A77AT&RY R&&T RES&RPTI&N )nternal and external root %urface% in+ured a% a re%ult of trau'a are ra&idly coloni5ed by 'ultinuclear giant cell%( )f giant cell% are continuou%ly %ti'ulated, 'o%t co''only by 'icrobial &roduct% fro' an infected root canal or &eriodontal &oc/et, &rogre%%i$e infla''atory root re%or&tion 'ay follo, ,ith cata%tro&hic con%eBuence%( )nfla''atory root re%or&tion 'ay be cla%%ified according to it% %ite of origin a% external root re%or&tion, cer$ical re%or&tion ;a %&ecial for' of external re%or&tion<, or internal root re%or&tion(

E'TERNA* INF*A77AT&RY R&&T RES&RPTI&N Teeth affected by external infla''atory root re%or&tion are in$ariably non-$ital ,ith infected &ul& canal%( Re%or&ti$e acti$ity i% initiated by da'age to &(l( in trau'a but &ro&agated by infected root canal content% %ee&ing to the external root %urface through &atent dentinal tubule%, and 'ay be extre'ely aggre%%i$e( 1o,e$er, if the infected canal content% are re'o$ed, the &ro&agating %ti'ulu% i% lo%t and the le%ion ,ill &redictably arre%t( =( Diagnosis( External infla''atory root re%or&tion i% u%ually detected a% a chance radiogra&hic finding, and i% characteri5ed by change of the external contour of the root, ,hich i% often %urrounded by a bony lucency ;6ig%( = (A9 and = (A=<( So'eti'e% it 'ay &re%ent a% a radiolucency o$erlying the root, and can be di%tingui%hed fro' internal re%or&tion by it% a%y''etrical %ha&e, by the %u&eri'&o%ed contour of the intact root canal ,all%, and by the fact that it 'o$e% in relation to the root canal on &eria&ical fil'% of different hori5ontal angle( ( -reatment( "ro$ided the tooth i% %till re%torable, external infla''atory root re%or&tion %hould be treated ,ithout delay( 6ollo,ing acce%% ca$ity &re&aration, the root canal %hould be cleaned and %ha&ed, ta/ing care not to ,ea/en the root exce%%i$ely, or to ri%/ &erforation into the re%orbed area( )t i% co''on &ractice to dre%% the root canal ,ith non-%etting calciu' hydroxide &a%te and to 'onitor the tooth for %e$eral 'onth% &rior to definiti$e obturation to en%ure that the le%ion ha% arre%ted( -e$erthele%%, control of intracanal infection i% the /ey deter'inant of %ucce%%, and there i% good e$idence to %ugge%t that if the canal i% adeBuately &re&ared, it 'ay be filled ,ithout &rotracted calciu' hydroxide treat'ent( "eriodic clinical and radiogra&hic re$ie, %hould be arranged( CER)ICA* RES&RPTI&N Cer$ical re%or&tion i% an unu%ual for' of external infla''atory root re%or&tion, initiated by da'age to the root %urface in the cer$ical region, and &ro&agated either by infected root canal content%, or by the &eriodontal 'icroflora( 6ro' a $ery %'all entry &oint, the re%or&ti$e &roce%% 'ay extend ,idely before &enetrating the &ul& cha'ber ;6ig( = (A ;a and b<<( =( Diagnosis( Exten%i$e intracoronal exten%ion 'ay occa%ionally &re%ent cer$ical re%or&tion a% a clinically $i%ible &in/ %&ot( More co''only, it i% identified on routine radiogra&h% a% a characteri%tically %ited radiolucency ;6ig( = (A <( ( -reatment( )f the tooth i% non-$ital, con$entional root canal thera&y %hould be underta/en to eli'inate the &ro&agating %ti'ulu%( 0rrange'ent% %hould then be 'ade to o&en the re%or&ti$e defect in a %i'ilar 'anner to ca$ity &re&aration, and to curette a,ay all trace% of infla''atory ti%%ue before re%toring the re%ultant defect ;6ig( = (A@<( Often, a fla& 'u%t be rai%ed to adeBuately eli'inate re%or&ti$e ti%%ue and contour the %ubgingi$al re%toration( )f the tooth i% $ital, and the &ul& ha% not been in$aded, treat'ent 'ay be li'ited to o&ening and curetting the re%or&tion lacuna before &lacing a %etting calciu' hydroxide lining and re%toring the defect ,ith an a&&ro&riate 'aterial(

"eriodic clinical and radiogra&hic re$ie, %hould again be arranged( INTERNA* INF*A77AT&RY R&&T RES&RPTI&N )nternal infla''atory root re%or&tion i% %een in the canal% of trau'ati5ed teeth ,hich are undergoing &rogre%%i$e &ul& necro%i%( )nfected 'aterial in the non-$ital, coronal &art of the canal i% belie$ed to &ro&agate re%or&tion by the underlying $ital ti%%ue, and ra&id ti%%ue de%truction follo,%( =( Diagnosis( 3arge re%or&ti$e defect% affecting the coronal third of the canal 'ay &re%ent a% a &in/ di%coloration of the affected tooth( More co''only, it i% detected a% a chance finding on routine radiogra&hic exa'ination( Radiogra&hically, internal re%or&tion &re%ent% a% a rounded, %y''etrical radiolucency, centred on the root canal( The contour% of the root canal ,all% are rarely %u&eri'&o%ed ;6ig%( = (AA and = (A:<( ( -reatment( )nternal re%or&tion %hould be con%idered to be a for' of irre$er%ible &ul&iti% and treated ,ithout delay( 6ollo,ing %tandard acce%% ca$ity &re&aration, the &ul& cha'ber and coronal &ortion of the canal i% u%ually found to contain necrotic debri%( 1o,e$er, dee&er &enetration of the canal often &ro$o/e% torrential hae'orrhage a% the $a%cular, re%or&ti$e ti%%ue i% entered( Root canal &re&aration i% underta/en in the u%ual 'anner, and follo,ing a&ical enlarge'ent, hae'orrhage fro' the canal i% greatly reduced a% the blood %u&&ly to the re%or&ti$e ti%%ue i% %e$ered( )n%tru'entation of the ex&anded, re%orbed area i% difficult, and can be greatly enhanced by the u%e of %onic or ultra%onic de$ice% ,hich are able to thro, irrigant into unin%tru'ented area%( The anti'icrobial and ti%%ue %ol$ent action% of %odiu' hy&ochlorite 'a/e it the irrigant of choice in %uch ca%e%( 0% in the ca%e of external infla''atory re%or&tion, it i% u%ual to dre%% the canal ,ith non-%etting calciu' hydroxide follo,ing debride'ent( Thi% 'ay be highly ad$antageou% in the internal re%or&tion ca%e ,here the anti'icrobial and 'ild ti%%ue %ol$ent action% of calciu' hydroxide 'ay be ex&loited further to clean the re%orbed area( Obturation 'ay then be underta/en ,ith gutta &ercha and %ealer, u%ually e'&loying a ther'o&la%tic techniBue to allo, %ati%factory conden%ation and ada&tation in the re%orbed area ;6ig( = (A!<( Where internal reinforce'ent i% indicated, dual curing co'&o%ite re%in and fibre &o%t% 'ay offer %o'e ad$antage% o$er full canal filling ,ith gutta &ercha and %ealer( REP*ACE7ENT RES&RPTI&N Re&lace'ent re%or&tion i% a di%tinct for' of root re%or&tion ,hich follo,% %eriou% luxation or a$ul%ion in+ury that ha% cau%ed da'age to the in$e%ting &eriodontal liga'ent( 0 cla%%ic %cenario i% the a$ul%ed tooth, ,hich ha% been %tored dry, or &(l( re'o$ed before re&lantation, ,ith re%ultant death of &eriodontal fibrobla%t% on 'uch of the root %urface( )f 'ore than 9L of the &eriodontal liga'ent i% da'aged or lo%t and the tooth i% %ub%eBuently rei'&lanted, bone cell% are able to gro, into contact ,ith the root %urface 'ore Buic/ly than the re'aining &eriodontal fibrobla%t% are able to recoloni5e the root %urface and inter$ene bet,een tooth and bone( The con%eBuence i% that the root no, beco'e% in$ol$ed in the nor'al re'odelling &roce%% of the bone

in ,hich it i% i'&lanted, and i% gradually re&laced by bone o$er the cour%e of the follo,ing year%( )n young children ,here the rate of bone re'odelling i% high, the root 'ay be entirely lo%t ,ithin @-A year%( )n adole%cent%, it 'ay be =9 year% or 'ore before the tooth i% lo%t( =( Diagnosis( The ab%ence of a liga'entou% +oint bet,een the tooth and it% %u&&orting bone ;an/ylo%i%< 'ean% that e$en ,hen root re%or&tion i% ad$anced, the tooth ,ill a&&ear roc/ %olid( 0 bright, 'etallic tone ,ill al%o be noted if the tooth i% &ercu%%ed( Radiogra&hically, the root ,ill a&&ear ragged in outline, ,ith no ob$iou% &eriodontal liga'ent %&ace %e&arating it fro' the %urrounding bone ;6ig( = (A?<( ( -reatment( There i% no effecti$e treat'ent for an/ylo%i% but the rate of &rogre%%ion i% relati$ely %lo, and the tooth can be 'aintained for =9 year% or 'ore( 1o,e$er, %uch teeth can be a &roble' in the gro,ing child a% they 'ay cea%e to *'o$e* or *gro,* ,ith the re%t of the +a,% and cannot be 'o$ed orthodontically( There i% no effecti$e treat'ent for e%tabli%hed re&lace'ent re%or&tion and &arent% and carer% %hould be ad$i%ed of the ine$itable cour%e of e$ent%( 6ro' an endodontic &oint of $ie,, it i% i'&ortant to reiterate that if &ul& extir&ation i% underta/en ,ithin ,ee/% of rei'&lantation then the initial root canal dre%%ing %hould be an antibioticD%teroid ;3eder'ix, 3ederle< &re&aration ,hich %hould be re&laced %ub%eBuently ,ith non-%etting calciu' hydroxide, no %ooner than ,ee/% after tooth rei'&lantation( The antibioticD%teroid &a%te 'ay hel& to reduce %ub%eBuent re%or&tion( )f endodontic treat'ent ,a% not underta/en %oon after rei'&lantation and the tooth %ub%eBuently lo%e% $itality, con$entional root canal thera&y 'ay be underta/en in order to addre%% any &ainful &eria&ical &atho%i% and to a$oid the additional in%ult of infla''atory re%or&tion ,hich ,ould lead to 'ore ra&id lo%% of root %ub%tance( 0 re%orbable root filling 'aterial %uch a% root canal %ealer alone or reinforced 5inc oxide eugenol ce'ent 'ay be &referred to gutta &ercha in %o'e ca%e%( Where re%or&tion i% &rogre%%i$e then con%ideration %hould be gi$en to autotran%&lantation of either an u&&er %econd &re'olar or lo,er fir%t or %econd &re'olar if any of the%e teeth ,ere to be re'o$ed a% &art of an orthodontic treat'ent &lan( )f autotran%&lantation i% co'&leted ,hile the root of the &re'olar i% about t,othird% for'ed then there i% a good chance of re$a%culari%ation and further root gro,th ;6ig( = (AC ;a and b<<( )f the autotran%&lanted tooth ha% a 'ature a&ex then re$a%culari5taion i% unli/ely and the tooth %hould be ex&tir&ated at %&lint re'o$al and the canal dre%%ed ,ith antibioticD%teroid ;3eder'ixD3ederle< initially, then non-%etting calciu' hydroxide( The tooth can be obturated ,ith gutta &ercha ,hen there i% no e$idence of &rogre%%i$e re%or&tion( >e$ Point# "athological root re%or&tion infla''atoryG external ;including cer$ical<and internalH infla''atory 'ay arre%t if cau%e i% re'o$edH re&lace'ent re%or&tion i% not a'enable to treat'entH 'aintain a re%orbing tooth for a% long a% &o%%ible( )t i% the be%t %&ace 'aintainerI

Fi!. /2.00 External infla''atory re%or&tion( Fi!. /2.0/ External infla''atory root re%or&tion( #%ually &re%ent% a% an a%y''etrical radiolucency on the lateral %urface of the root( )f the le%ion o$erlie% the root canal, it% lateral ,all% are u%ually %till $i%ible( Fi!. /2.02 Cer$ical re%or&tion( ;a< Re%or&tion co''ence% fro' a %'all entry &oint belo, the gingi$al cre$ice, and often %&read% ,idely ,ithin the cro,n before the root canal i% in$aded( The lateral ,all% of the &ul& cha'ber are often %u&eri'&o%ed o$er the defect( ;b< "eria&ical radiogra&h %ho,ing a ty&ical clinical ca%e( Fi!. /2.03 Cer$ical re%or&tion follo,ing endodontic treat'ent of the necrotic &ul& and %urgical re&air of the external defect( Fi!. /2.00 )nternal infla''atory re%or&tion of both u&&er central inci%or%( Fi!. /2.05 )nternal infla''atory root re%or&tion( ;a< Sy''etrical ex&an%ion of the root canal ,all% in a &er'anent central inci%or( ;b< "eria&ical radiogra&h %ho,ing a ty&ical clinical ca%e( Fi!. /2.01 )nternal infla''atory root re%or&tion( Maxillary central inci%or de'on%trating internal re%or&ti$e defect% at t,o le$el%( The canal ,a% cleaned, %ha&ed, and obturated ,ith ther'o&la%tici5ed gutta &ercha and %ealer( Fi!. /2.02 Re&lace'ent re%or&tion( ;a< Root% affected by re&lace'ent re%or&tion ha$e ragged outline%, and 'erge ,ith the %urrounding bone to ,hich they are fu%ed( ;b< "eria&ical radiogra&h %ho,ing ad$anced re&lace'ent re%or&tion( Clinically, the tooth i% roc/ %olid( Fi!. /2.03 ;a< 0utotran%&lanted &re'olar in = &o%ition( ;b< Continued gro,th and re$a%culari5ation of autotran%&lanted &re'olar Courte%y of "rofe%%or M(S( Duggal( /2.2.5 P-l "anal o,literation There i% &rogre%%i$e hard ti%%ue for'ation ,ithin the &ul& ca$ity leading to a gradual narro,ing of the &ul& cha'ber and root canal and &artial or total obliteration( There i% a reduced re%&on%e to $itality te%ting and the cro,n a&&ear% %lightly yello,Do&aBue( The exact initiating factor ,hich &roduce% thi% re%&on%e fro' the odontobla%t% i% un/no,n( )t i% 'ore co''on in i''ature teeth and in luxation in+urie% rather than in concu%%ion and %ubluxation in+urie%( 0lthough radiogra&h% 'ay %ugge%t co'&lete calcification there i% u%ually a 'inute %trand of &ul&al ti%%ue re'aining( "ul&al obliteration ha% been de%cribed a% *nature% o,n root filling*and although the late de$elo&'ent of necro%i% and infection in the thin thread of &ul&al ti%%ue in the %clero%ed canal ha% been re&orted, it i% le%% co''on than the endodontic co'&lication% that ,ould be nece%%ary to treat it( The obturation of an *obliterating* canal i% not +u%tification for &re-eru&ti$e root canal treat'ent in the ab%ence of %ign% of &ul& brea/do,n( /2.2.1 InD-rie# to t%e #ortin! ,one

The extent and &o%ition of the al$eolar fracture %hould be $erified clinically and radiogra&hically( )f there i% di%&lace'ent of the teeth to the extent that their a&ice% ha$e ri%en u& and are no, &o%itioned o$er the labial or lingualD&alatal al$eolar &late% ;*a&ical loc/*< then they ,ill reBuire extruding fir%t to free the a&ice% &rior to

re&o%itioning( The %eg'ent of al$eolu% ,ith teeth reBuire% only @-A ,ee/% of rigid %&lintage ;co'&o%ite-,ire ty&e< ,ith t,o abut'ent teeth either %ide of the fracture, together ,ith antibiotic%, chlorhexidine, %oft diet, and tetanu% &ro&hylaxi% chec/ ;6ig( = (A> ;a<-;c<<( "ul&al %ur$i$al i% 'ore li/ely if re&o%itioning occur% ,ithin = h of the in+ury( Root re%or&tion i% rare( Fi!. /2.04 ;a< Dentoal$eolar fracture of the lo,er labial %eg'ent( ;b< 6racture reduced into the correct occlu%ion( ;c< S&lint in %itu &rior to re'o$al( /2.3 C5I*D P5YSICA* A;(SE 0 child i% con%idered to be abu%ed if he or %he i% treated in a ,ay that i% unacce&table in a gi$en culture at a gi$en ti'e ;6ig( = (A<( Child &hy%ical abu%e or non-accidental in+ury ;-0)< i% no, recogni5ed a% an international i%%ue and ha% been re&orted in 'any countrie%( Each ,ee/ -@ children in 4ritain and C9 children in the #nited State% ,ill die a% a re%ult of abu%e or neglect( 0t lea%t one child &er =999 in 4ritain %uffer% %e$ere &hy%ical abu%eH for exa'&le, fracture%, brain hae'orrhage, %e$ere internal in+urie% or 'utilation, and in the #nited State% 'ore than >:L of %eriou% intracranial in+urie% during the fir%t year of life are the re%ult of abu%e( 0lthough %o'e re&ort% ,ill &ro$e to be unfounded the co''on ex&erience i% that &ro$ed ca%e% of child abu%e are four to fi$e ti'e% a% co''on a% they ,ere a decade ago( "hy%ical abu%e i% not a full diagno%i%, it i% 'erely a %y'&to' of di%ordered &arenting( The ai' of inter$ention i% to diagno%e and cure the di%ordered &arenting( )t ha% been e%ti'ated in the #nited State% that @:-:9L of %e$erely abu%ed children ,ill recei$e %eriou% rein+ury and :9L ,ill die if they are returned to their ho'e en$iron'ent ,ithout inter$ention( )n %o'e ca%e% the occurrence of &hy%ical abu%e 'ay &ro$ide an o&&ortunity for inter$ention( )f thi% o&&ortunity i% 'i%%ed, there 'ay be no further o&&ortunity for 'any year%( More than :9L of ca%e% diagno%ed a% &hy%ical abu%e ha$e extra and intraoral facial trau'a and %o the dental &ractitioner 'ay be the fir%t &rofe%%ional to %ee or %u%&ect abu%e( )n+urie% 'ay ta/e the for' of contu%ion% and ecchy'o%e% ;6ig( = (:9<, abra%ion% and laceration%, burn%, bite%, dental trau'a ;6ig( = (:=<, and fracture%( The incidence of co''on orofacial in+urie% are %ho,n in Table = (A( The follo,ing == &oint% %hould be con%idered ,hene$er doubt% and %u%&icion% are arou%ed( =( Could the in+ury ha$e been cau%ed accidentally and if %o ho,J ( Doe% the ex&lanation for the in+ury fit the age and the clinical finding%J @( )f the ex&lanation of cau%e i% con%i%tent ,ith the in+ury, i% thi% it%elf ,ithin nor'ally acce&table li'it% of beha$iourJ A( )f there ha% been any delay %ee/ing ad$ice are there good rea%on% for thi%J :( Doe% the %tory of the accident $aryJ !( The nature of the relation%hi& bet,een &arent and child(

?( The child*% reaction to other &eo&le( C( The child*% reaction to any 'edicalDdental exa'ination%( >( The general de'eanour of the child( =9( 0ny co''ent% 'ade by child andDor &arent that gi$e concern about the child*% u&bringing or life-%tyle( ==( 1i%tory of &re$iou% in+ury( Dental &rofe%%ional% %hould be a,are of any e%tabli%hed %y%te' in their locality ,hich i% de%igned to co&e ,ith the%e ca%e%( )n the #nited 2ingdo' each 3ocal 0uthority Social Ser$ice% De&art'ent i% reBuired to %et u& an *0rea Child "rotection Co''ittee* ,hich are coordinated by *De%ignated Doctor%* in "ri'ary Care Tru%t%( Dental &rofe%%ional% are ad$i%ed ho, to refer and to ,ho', if they are concerned( Fi!. /2.50 Characteri%tic &arallel brui%ing of a %la& 'ar/( ;Re&roduced ,ith the /ind &er'i%%ion of Mun/%gaard(< Fi!. /2.5/ Torn labial frenu' in a young child not yet learning to ,al/ could be an indicator of a non-accidental in+ury( ;Re&roduced ,ith the /ind &er'i%%ion of Mun/%gaard(< /2.4 S(77ARY =( 4oy% ex&erience dental trau'a al'o%t t,ice a% often a% girl%( ( Maxillary central inci%or% are the 'o%t co''only in$ol$ed teeth( @( Regular clinical and radiogra&hic re$ie, i% nece%%ary to li'it un,anted %eBuelae, in%titute a&&ro&riate treat'ent, and i'&ro$e &rogno%i%( A( )n+urie% to the de$elo&ing &er'anent dentition occur in half of all trau'a to the &ri'ary dentition( :( S&linting for a$ul%ion, luxation, and root fracture% %hould be functional to allo, &hy%iological 'o$e'ent and &ro'ote nor'al healing of the &(l( S&linting for dentoal$eolar fracture% %hould be rigid( !( )n all luxation in+urie% the &rogno%i% for &ul&al healing i% better ,ith an i''ature a&ex( ?( Root re%or&tion increa%e% ,ith the %e$erity of da'age to the &(l( C( The &rogno%i% for re&lantation of a$ul%ed teeth i% be%t if it i% underta/en ,ithin = h of the in+ury, ,ith a hydrated &(l( >( Orofacial in+urie% are found in at lea%t :9L of ca%e% of &hy%ical abu%e(

=9( Succe%%ful endodontic% de'and% the co-o&eration of a co'fortable child( Effecti$e local anae%the%ia %hould be &ro$ided if there i% any ri%/ of &ain during treat'ent( ==( 6ro' indirect &ul& ca&&ing to non-$ital &ul& thera&y, control of 'icrobial infection i% the /ey deter'inant of endodontic treat'ent %ucce%%( 0 ,ell-fitting rubber da' %hould be in &lace ,here$er &o%%ible, and all %tage% of all endodontic &rocedure% %hould be conducted ,ith due regard to the eli'ination of infection and the &re$ention of it% recurrence( = ( Root canal %y%te'% in young teeth are cleaned &rinci&ally by anti'icrobial and ti%%ue-%ol$ent irrigant% and 'edica'ent%, not by exuberant dentine re'o$al( Dentine re'o$al, e%&ecially in fragile &ri'ary and young &er'anent teeth, %hould be rational and re%tricted to that reBuired for effecti$e irrigation and %ucce%%ful obturation only( /2./0 F(RT5ER READIN6 0ndrea%en, 7( O( and 0ndrea%en, 6( M( ;=>>A<( Textboo/ and color atla% of trau'atic in+urie% to the teeth ;@rd edn<( Mun/%gaard, Co&enhagen( ;"n excellent reference ,oo% with colour slides of each clinical procedure< 0ndrea%en, 7( O(, 4oru', M( 2(, 7acob%en, 1( 3(, and 0ndrea%en 6( M( ;=>>:<( Re&lantation of A99 a$ul%ed &er'anent inci%or%( 7ndodontics and Dental -raumatology II, :=-C>( ;-he largest pu,lished series on avulsed permanent incisors< Cohen, S( and 4urn%, R( C( ; 99=<( Pathways of the Pulp ;Cth edn<( Mo%by, St 3oui%( ;-he definitive endodontic reference ,oo%< Euro&ean Society of Endodontology ;=>>A<( Con%en%u% Re&ort of the Euro&ean Society of Endodontology on Buality guideline% for endodontic treat'ent( International 7ndodontic +ournal, 22, ==:- A( ;" synopsis of current terminology and good practice in endodontics< 2iniron% M( 7( ;=>>C<( Treat'ent of trau'atically intruded &er'anent inci%or teeth( International +ournal of Paediatric Dentistry, C, =!:-C ;U0 6ational Clinical Guideline<( Welbury R( R( ;=>>A<( Child "hy%ical 0bu%e ;-on 0ccidental )n+ury< )n Textboo/ and color atla% of trau'atic in+urie% to the teeth ;ed( 7( O( and 6( M( 0ndrea%en< ;@rd edn<( Mun/%gaard, Co&enhagen( ;" reference of prevalence and orofacial signs in non<accidental in9ury<( /2.// REFERENCE 0ndrea%en, 7( O(, 0ndrea%en, 6( M(, Me+are, )(, C$e/, M( ; 99A<( 1ealing of A99 intraal$eolar root fracture%H Effect of treat'ent factor% %uch a% treat'ent delay, re&o%itioning, %&linting ty&e and &eriod and antibiotic%( Dental -raumatology, 9, 9@-==(

Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

/3. Anomalie# o+ toot% +ormation and er- tion - P + ( Crawford and ( + "ldred /3.0 AC>N&8*ED6E7ENT 0t the out%et, ,e ,ould ,i%h to record both our &er%onal and &rofe%%ional gratitude to the late "rofe%%or G4 ;Gerry< Winter( 1e al,ay% encouraged our ,or/ and ,a% generou% in hi% co''ent% and %haring of 'aterial( 0bo$e all, he ,a% an enthu%ia%t and a cha'&ion of hi% &atient%( 1e i% 'i%%ed( /3./ INTR&D(CTI&N 4oth the &ri'ary and &er'anent dentition% 'ay be affected by $ariation% in the nu'ber, %i5e, and for' of the teeth, a% ,ell a% the %tructure of the dental hard ti%%ue%( The%e $ariation% 'ay be exclu%i$ely genetically deter'ined, brought about by either local or %y%te'ically acting en$iron'ental factor%, or &o%%ibly fro' a co'bination of both genetic and en$iron'ental factor% acting together( The %a'e inter&lay of influence% 'ay affect the eru&tion and exfoliation of &ri'ary teeth, a% ,ell a% the eru&tion of &er'anent teeth( Thi% cha&ter con%ider% a range of condition% in$ol$ing abnor'alitie% of the nu'ber, %i5e, for', and %tructure of teeth and their eru&tion( )t i% i'&ortant to be a,are of the &%ycho-%ocial a%&ect ,hen 'eeting children and fa'ilie% affected by the%e condition%( We ha$e too often heard %torie% of %ocial i%olation of e$en $ery young children a% a re%ult of their 'i%%ing or di%coloured teeth( )n the ca%e of di%coloured teeth, &arent% ha$e told u% that they ha$e been *ta/en to ta%/* by other adult% for *not loo/ing after* their child*% teeth,hen the di%colouration ,a% intrin%ic and una$oidable( While in$e%tigating inherited condition%, it i% i'&ortant to enBuire both %ide% of the fa'ily tree eBually( -ot only doe% thi% en%ure that the in$e%tigation i% co'&lete, but it 'ay al%o hel& to alle$iate the %en%e of *guilt* felt by an affected &arent( Where$er &o%%ible, ,e try to a$oid the u%e of the ,ord *nor'al* in our clinical care although the ,ord ,ill be u%ed in thi% text( Clinically ,e ,ould %&ea/,hen offering re%torati$e treat'ent for exa'&le of 'a/ing a %'ile *ordinary*, or *boring*( The $a%t 'a+ority of children ,ith the%e condition% ,ant to beco'e *one of the cro,d*( We ha$e found thi% a&&roach %ucce%%ful in our &ractice%H our reader% 'ay choo%e thi% or one of 'any other a&&roache% in order to further the care of the%e children( We ha$e been Bue%tioned re&eatedly about the &o%%ibility of genetic treat'ent for %o'e of the%e inherited condition%( We are not a,are of any &rogre%% in thi% direction at &re%ent, out%ide the laboratory( /3.2 7ISSIN6 TEET5 /3.2.0 Introd-"tion 1y&odontia i% the ter' 'o%t often a&&lied to a %ituation ,here a &atient ha% 'i%%ing teeth a% a re%ult of their failure of de$elo&'ent( 0nodontia de%cribe% the total lac/ of teeth of one or both dentition%( Oligodontia i% a ter' u%ed to de%cribe a %ituation

,here 'ulti&leu%ually 'ore than %ixteeth are 'i%%ing( /3.2./ Pre.alen"e )n the &ri'ary dentition, 'i%%ing teeth occur 'ore co''only in the 'axilla and ty&ically the 'axillary lateral inci%or i% the tooth in$ol$ed( 8ariou% %tudie% ha$e %ho,n the &re$alence of 'i%%ing &ri'ary teeth to be bet,een 9(= L and 9(> L of Cauca%ian &o&ulation%, ,ith 'ale% and fe'ale% affected eBually( De$elo&'entally 'i%%ing &er'anent teeth are %een in both the 'axilla and 'andible ;6ig( =@(=<( )n Cauca%ian &o&ulation% the third 'olar% are the 'o%t co''only 'i%%ing teeth, follo,ed by the 'andibular %econd &re'olar, the 'axillary lateral inci%or, and the 'axillary %econd &re'olar( 0 fe'ale to 'ale ratio of A G = ha% been re&orted( Mi%%ing third 'olar% occur in >-@9L of indi$idual%( )f the third 'olar% are excluded, the &re$alence in the &er'anent $arie% bet,een @(: L and !(: L according to the %tudy Buoted( >e$ Point# 1y&odontia 9(=-9(>L in the &ri'ary dentitionH @(:-!(:L in the &er'anent dentitionH Mi%%ing &er'anent teeth are %een in @9-:9L of &atient% ,ho ha$e 'i%%ing &ri'ary teeth( Fi!. /3./ 1y&odontia, ab%ent A=, retained C=( /3.2.2 Aetiolo!$ The cau%e of an i%olated 'i%%ing tooth i% often unclearH thi% 'ay be genetic in origin or a%%ociated ,ith %o'e en$iron'ental in%ult during de$elo&'ent( Mi%%ing teeth ha$e been re&orted in a%%ociation ,ith 'ulti&le birth%, lo, birth ,eight, and increa%ed 'aternal age( Rubella and thalido'ide e'bryo&athie% 'ay al%o be a%%ociated ,ith 'i%%ing teeth( Single gene di%order% ha$e been a%%ociated ,ith 'i%%ing teeth( Multi&le 'i%%ing teeth, a% ,ell a% teeth ,ith %'all cro,n%, 'ay be %een in a nu'ber of %yndro'e% including X-lin/ed hy&ohidrotic ectoder'al dy%&la%ia ;6ig( =@( <, auto%o'al do'inant and auto%o'al rece%%i$e ca%e% of ectoder'al dy%&la%ia and auto%o'al rece%%i$e chondroectoder'al dy%&la%ia ;Elli%-$an Cre$eld %yndro'e<( Do,n %yndro'e ;tri%o'y =< i% al%o a%%ociated ,ith hy&odontia( 1y&odontia and 'icrodontia in$ol$ing the 'axillary lateral inci%or occur% in cleft% in$ol$ing the li& and &alate( X-lin/ed hy&ohidrotic ectoder'al dy%&la%ia i% characteri5ed in 'ale% by thin %&ar%e hair, dry %/in, ab%ence of %,eating and therefore heat intolerance, and 'ulti&le 'i%%ing teeth( The%e children are at ri%/ due to their inability to cool the'%el$e% and 'ay die in infancy if undiagno%ed( Thi% condition, ,hile rare, i% of &articular i'&ortance a% the dental &rofe%%ional be the fir%t to co'e to a diagno%i%, and thu% to introduce fa'ilie% to %u&&ort 'echani%'%( )n hetero5ygou% fe'ale% the change% are

'ilder and 'ay be re%tricted to the teeth, although a di%tincti$e facial &rofile ;%light retru%ion of the 'axilla< 'ay be recogni5ed( Mo%t co''only, one or both 'axillary lateral inci%or% andDor the %econd &re'olar% are 'i%%ing( )n %o'e &atient% one 'axillary lateral inci%or 'ay be of &eg for'( The re%&on%ible gene i% the 7D1 gene on the X chro'o%o'e ,hich encode% the &rotein ectody%&la%in-0( 0uto%o'al do'inant inheritance of 'i%%ing teeth i% %een in fa'ilie% ,ith 'utation% in the (#B1 gene on chro'o%o'e A( Mi%%ing third 'olar% and %econd &re'olar% are the 'o%t co''on finding( The%e fa'ilie% 'ay al%o ha$e clefting %egregating ,ith the 'i%%ing teeth( Mutation% in the (#B1 gene are al%o %een in the tooth-nail ;Wit/o&< %yndro'e( 0 &attern of auto%o'ally do'inant inheritance of 'i%%ing teeth, &articularly 'olar%, i% %een a% a re%ult of 'utation% in the P"B' gene on chro'o%o'e =A( So'e &atient% ha$ing a %olitary 'edian 'axillary central inci%or ha$e been found to ha$e 'utation% in the %onic hedgehog ;#HH< gene on chro'o%o'e ? ;6ig( =@(@<( Fi!. /3.2 1y&ohidrotic ectoder'al dy%&la%iaH eru&ted &er'anent teeth( Fi!. /3.3 Median 'axillary central inci%or %yndro'e( /3.2.3 Treatment The care of children ,ith 'ulti&le 'i%%ing teeth can be co'&lex and ideally reBuire% 'ultidi%ci&linary in&ut fro' &aediatric denti%t%, orthodonti%t%, and &ro%thodonti%t% a% ,ell a% genetic coun%elling( Mi%%ing teeth and %'all teeth often &re%ent together, %o 'a%/ing of conical or %i'ilarly di%tincti$e teeth ,ith co'&o%ite i% %trongly ad$i%ed( )n ca%e% of anodontia, full denture% are reBuired( The%e can be &ro$ided, albeit ,ith li/ely li'ited %ucce%%, fro' about @ year% of age, ,ith the &o%%ibility of i'&lant %u&&ort for &ro%the%e% &ro$ided in adulthood( ;6ig( =@(A ;a< and ;b<<( Multi&le 'i%%ing teeth can be treated by the u%e of &artial denture%, ,ith i'&lant% a% &art of the treat'ent &rotocol at a later age( )'&lant &lace'ent i% be%t left until %/eletal 'aturity( Denture% ,ill need to be re&laced a% the +a,% gro,( "rogre%%i$e &ro$i%ion of denture% ,ith annual re&lace'ent% during the %chool holiday% ;*the long $acation*<, 'i'ic/ing the de$elo&ing dentition at the child*% age, can do 'uch to 'ini'i5e the %tig'a of the%e condition%( 0lthough, ulti'ately, denture% can be retained by i'&lant%, the lac/ of de$elo&'ent of the al$eolar bone 'ay &ro$e to be a li'iting factor( Fi!. /3.0 1y&ohidrotic ectoder'al dy%&la%iaH eru&ted &er'anent teeth 'a%/ed by *&orthole* denture ,ith canine retractor% during eru&tion( /3.3 E'TRA TEET5 Extra teeth ;%u&ernu'erary teeth< ha$e been re&orted to occur in 9( -9(CL of Cauca%ian% in the &ri'ary dentition and =(:-@L in the &er'anent dentition in the %a'e &o&ulation%( There i% a 'ale to fe'ale ratio of a&&roxi'ately G =( "atient% ,ith %u&ernu'erary &ri'ary teeth ha$e a @9-:9L chance of the%e being follo,ed by %u&ernu'erary &er'anent teeth( Teeth ,hich re%e'ble tho%e of the nor'al %erie% are referred to a% %u&&le'ental teeth ;6ig( =@(:< ,hile tho%e of le%% ty&ical, often reduced,

for'-%o'eti'e% further de%cribed a% tuberculate or conical-can be ter'ed acce%%ory %u&ernu'erary teeth( Su&ernu'erary teeth are 'o%t often located in the anterior 'axilla in the 'idline, or i''ediately ad+acent to the 'idline, and are then referred to a% a 'e%ioden%( Su&ernu'erary teeth in the 'olar region% ad+acent or di%tal to the nor'al %eBuence of teeth are referred to a% &ara'olar% or di%to'olar% re%&ecti$ely( )n %o'e ca%e% the %u&ernu'erary teeth 'ay be an odonto'e( Su&ernu'erary teeth are 'ore co''on in the 'axilla than the 'andible, ,ith a ratio of about : G =( 0&art fro' tho%e in the 'idline, they 'ay be &re%ent bilaterally and %y''etrically, hence the &re%ence of a %u&ernu'erary in one &art of the +a,% %hould lead to con%ideration of further %u&ernu'erarie% el%e,here( Su&ernu'erary teeth 'ay fail to eru&t and 'ay delay eru&tion of a &er'anent tooth ,hich i% de$elo&ing dee&er ,ithin the +a,( Thi% co''only occur% in the ca%e of a 'e%ioden%( ;6ig( =@(! ;a< and ;b<<( There i% a %ignificant a%%ociation bet,een %u&ernu'erary teeth and in$aginated teeth ;%ee Section =@(:(@<( There i% al%o an a%%ociation ,ith &alatal cleft%, ,ith a&&roxi'ately A9 L of &atient% ,ith a cleft of the anterior &alate ha$ing %u&ernu'erary teeth( Multi&le %u&ernu'erary teeth are %een in cleidocranial dy%&la%ia a% ,ell a% in other %yndro'e% %uch a% oral-facial-digital %yndro'e ty&e = and Gardner %yndro'e( The 'anage'ent of %u&ernu'erary teeth i% di%cu%%ed in Cha&ter =A( >e$ Point# Su&ernu'erary teeth 9( -9(CL of the &ri'ary dentitionH =(:-@(:L of the &er'anent dentitionH G = 'ale to fe'ale ratioH : G = 'axilla to 'andible ratio( Fi!. /3.5 Su&&le'ental tooth = ( Fi!. /3.1 Su&ernu'erary tooth delaying the exfoliation of teeth !=, ! , and the eru&tion of tooth =( /3.0 A;N&R7A*ITY &F T&&T5 SIlE /3.0./ CroCn #i:e There i% a degree of %ub+ecti$ity regarding ,hat con%titute% nor'al ;*ordinary*< tooth %i5e ;and %ha&e<( Teeth ,hich are ob$iou%ly larger than nor'al are referred to a% 'egadont or 'acrodont ,herea% teeth ,hich are %'aller than nor'al are ter'ed 'icrodont( Cro,n %i5e i% often related to root %i5e, %o teeth ,ith large cro,n% often ha$e large ;broad< root%, teeth ,ith %'all cro,n% tend to ha$e %'all ;%lender< root%( Microdontia can be a%%ociated ,ith hy&odontia a% in the exa'&le of X-lin/ed hy&ohidrotic ectoder'al dy%&la%ia, ,here a hetero5ygou% fe'ale 'ight ha$e one

'i%%ing lateral inci%or and a &eg-%ha&ed cro,n of the contralateral 'axillary lateral inci%or ;6ig( =@(?<( 7e!adont teet% Megadont 'axillary inci%or% can occur% a% a re%ult of fu%ion of ad+acent tooth ger'% or a% a re%ult of an atte'&t at %e&aration of a %ingle tooth ger' to for' t,o %e&arate teeth( )t i% i'&ortant in the%e circu'%tance% to count the nu'ber of teeth to deter'ine ,hich of the%e &o%%ibilitie% ha% occurred, a% thi% ,ill influence treat'ent &lanning( The &er'anent 'axillary central inci%or% are 'o%t often affected ;6ig( =@(C< follo,ed by the 'andibular %econd &re'olar%( )%olated 'egadontia ha% been e%ti'ated to occur in a&&roxi'ately =L of &atient% in the &er'anent dentition( The condition 'ay be %y''etrical( Generali5ed 'egadontia ha% been re&orted in a%%ociation ,ith &ituitary giganti%', in unilateral facial hy&er&la%ia and in hereditary gingi$al fibro'ato%i%( 7i"rodontia Microdont &ri'ary teeth are unco''on, ,ith a re&orted &re$alence of 9( -9(:L( )n the &er'anent dentition the &re$alence i% a&&roxi'ately (:L for indi$idual teeth, ,ith generali5ed 'icrodontia occurring in a&&roxi'ately 9( L of indi$idual%( 6e'ale% are 'ore often affected than 'ale%, ,ith the 'axillary lateral inci%or being 'o%t co''only affected, ha$ing a &eg-%ha&ed or conical cro,n( ;6ig( =@(><( 0% noted in the &re$iou% %ection ;=@( <, there i% an a%%ociation bet,een 'icrodontia and hy&odontia( Fi!. /3.2 1y&odontia concurrent ,ith 'icrodontia( Fi!. /3.3 Megadont tooth ==, ab%ent tooth = ( Fi!. /3.4 )%olated 'icrodontia affecting %ugge%ti$e of occult cleft( /3.0.2 Root #i:e Root length a&&ear% to be %ub+ect to %o'e racial $ariation, ,ith %horter root% being %een in &eo&le of Oriental bac/ground and larger root% in &atient% of 0frican origin( *ar!e root #i:e 3arger than nor'al root% are 'o%t ty&ically %een affecting the &er'anent 'axillary central inci%or%, ,ith a &o&ulation &re$alence in one S,edi%h %tudy of (@L( Male% ,ere four ti'e% 'ore li/ely to be affected than fe'ale%( Small root #i:e Short-rooted teeth in the &ri'ary dentition 'ay be a%%ociated ,ith other dental abnor'alitie%( Short root% 'ay al%o be %een in a nu'ber of condition% affecting the dentine andDor &ul&( The%e ,ill be con%idered in a later %ection( Short root% 'ay be %een affecting the &er'anent 'axillary central inci%or%( The in a fe'ale( Gingi$al architecture

%hortening affect% a&&roxi'ately (:L of children and %o'e =:L of the%e 'ay ha$e %hortened root% on other teeth, 'o%t often &re'olar% andDor canine%( The cau%e i% often un/no,n, though thi% can occur a% a re%ult of orthodontic treat'ent( )n regional odontody%&la%ia ;Section =@(?(=< there i% ty&ically abnor'al root for'ation a% ,ell a% abnor'alitie% of the cro,n% of the teeth( )rradiation of the +a,%, or che'othera&y, during the &eriod of root for'ation 'ay lead to truncation of the root% of teeth ,ho%e root% ,ere de$elo&ing at the ti'e of treat'ent ;6ig( =@(=9 ;a< and ;b<<( Fi!. /3./0 Di%turbed dental de$elo&'entanti-leu/ae'ic thera&y( /3.0.3 Treatment 0% ,ith hy&odontia, the acti$e coo&eration of &aediatric denti%t, orthodonti%t, and re%torati$e denti%t %hould be encouraged to o&ti'i5e treat'ent &lanning for young &eo&le affected by the%e condition% fro' an early age( 0 'egadont 'axillary central inci%or can be co%'etically unae%thetic and treat'ent deci%ion% 'ay need to be con%idered %oon after ;or, in %o'e ca%e%, before< eru&tion of the tooth( The o&tion% include acce&tance, re'odelling of the tooth, extraction of the tooth ,ith orthodontic treat'ent if nece%%ary, and %ub%eBuent 'a%/ing of the %&ace ,ith a bridge, denture, or i'&lant ;6ig( =@(==<( 0 'icrodont tooth, &articularly if thi% affect% the 'axillary lateral inci%or%, 'ay be 'odified by acid-etch co'&o%ite 'aterial being added to the tooth to re&roduce the ty&ical contour% of the cro,n( ;6ig( =@(= <( )n adult life, &orcelain $eneer% 'ay al%o be u%ed or the tooth can be cro,ned( Fi!. /3.// Megadont tooth ==( Mini'al ad+u%t'ent of tooth for' ==, =@, fro' original %tate in 6ig( =@(C Fi!. /3./2 )%olated 'icrodontia affecting in a fe'ale( Re%tored ,ith co'&o%ite( /3.5 A;N&R7A*ITY &F T&&T5 F&R7 /3.5./ A,normalit$ o+ "roCn +orm F-#ion and !emination So'e ca%e% of 'egadont cro,n% are a% a re%ult of fu%ion of ad+acent tooth ger'% ;fu%ion<, or atte'&t% at de$elo&'ental %e&aration of a %ingle tooth ger' to &roduce t,o %e&arate teeth ;ge'ination< and a $ariety of ter'% ha$e been u%ed for %uch %ituation%( The ter' *double teeth* ha% been a&&lied to co$er both %ituation%( )t i% i'&ortant to count the nu'ber of teeth &re%ent clinically and, ,ith the aid of radiogra&h% to deter'ine ,hether fu%ion or ge'ination i% 'ore li/ely to ha$e occurred( The &re$alence of %uch abnor'alitie% range% fro' 9(:L to =(!L of Cauca%ian &o&ulation% %tudied in the &ri'ary dentition( The &er'anent dentition i%

le%% co''only affected ;&re$alence 9(=-9( L<( Male% and fe'ale% are affected eBually( 0 genetic ba%i% ha% been %ugge%ted but not confir'ed( The clinical 'anife%tation 'ay $ary fro' a 'inor notch on the inci%al edge of an abnor'ally ,ide inci%or cro,n to t,o %e&arate cro,n% ,ith a %ingle root( The cro,n% and root 'ay be in continuity along their entire length or 'ay be al'o%t %e&arateH %o'e &ul& interco''unication i% often &re%ent( The 'o%t ty&ical area% affected are the anterior %eg'ent% of the arche% in the &ri'ary dentition, ,ith the 'andible 'ore co''only affected than the 'axilla ;6ig( =@(=@ ;a< and ;b<<( There 'ay be an a%%ociation ,ith hy&odontia, %o that a larger than nor'al tooth of the &ri'ary %erie% together ,ith a 'i%%ing tooth in that %erie% 'ay re&re%ent an inter'ediate %tage bet,een the &re%ence or ab%ence of a tooth( "hy%iological root re%or&tion of &ri'ary fu%ed or ge'inated teeth 'ay be delayed and thi% 'ay lead to delayed eru&tion of the &er'anent %ucce%%or%( Treatment When thi% condition affect% the &ri'ary dentition no treat'ent per se i% reBuired( )t i% i'&ortant, ho,e$er, to con%ider the &o%%ibility of abnor'alitie% of the nu'ber andDor for' of the &er'anent dentition in the area( One &roble' ,hich can occur i% that carie% can de$elo& at the interface bet,een the t,o cro,n %eg'ent% ;6ig( =@(=A<( Thi% can be &re$ented by an etch-retained re%toration to fill in the defect, ,hich ,ill al%o i'&ro$e the co%'etic a&&earance( )n the &er'anent dentition, the final deci%ion on ,hether to retain, extract, %urgically di$ide or other,i%e treat %uch teeth ,ill de&end on 'any factor% including %&ace a$ailable ,ithin the arch, the 'or&hology of the &ul& cha'ber% andDor root canal% and the degree of attach'ent bet,een the t,o &art% of the tooth or teeth( >e$ Point# Double teeth 9(=-=(!L in the &ri'ary dentitionH 9(=-9( L in the &er'anent dentitionH -o %ex &redilectionH "er'anent ano'alie% in @9-:9 L of &ri'ary ca%e%( Fi!. /3./3 Clinical and radiogra&hic a&&earance of ge'inated lo,er &ri'ary lateral inci%orDcanine( Fi!. /3./0 Carie% in extracted ge'inated teeth( /3.5.2 A""e##or$ "-# # Extra cu%&% are not unco''on in the hu'an dentition and 'ay occur in both the &ri'ary and &er'anent dentition, 'o%t co''only affecting 'olar teeth( )n the &ri'ary dentition the 'o%t co''on acce%%ory cu%&% are %een either on the 'e%iobuccal a%&ect% of the 'axillary fir%t 'olar or the 'e%io&alatal a%&ect of the 'axillary %econd 'olar, the latter being %i'ilar to the cu%& of Carabelli %een on the fir%t &er'anent 'olar( The latter i% a relati$ely freBuent finding on the 'e%io&alatal a%&ect of the cro,n of the 'axillary fir%t 'olar%, i% ty&ically bilateral and 'ay be %een

in =9-!9L of $ariou% &o&ulation%( "er'anent inci%or teeth 'ay ha$e an additional cu%& ari%ing fro' the lingual cingulu', often referred to a% a *talon cu%&*( Thi% affect% the 'axillary central inci%or 'o%t co''only( Talon cu%&% 'ay interfere ,ith the occlu%ion and 'ay be ae%thetically un&lea%ing( ;6ig( =@(=: ;a< and ;b<<( 0% ,ith double teeth, carie% 'ay occur in the groo$e bet,een the cu%& and &alatal %urface of the inci%or( Other inci%or e$agination% ha$e been re&orted( ;6ig( =@(=!;a and b<<( "er'anent canine% 'ay al%o ha$e a &ro'inent lingual cu%&, &erha&% indicating a tendency to,ard% a &re'olar tooth for'( 0dditional cu%&% 'ay unco''only be %een on &re'olar%( Treatment The talon cu%& 'ay reBuire action for both ae%thetic and occlu%al rea%on%( Selecti$e grinding, re&eated o$er a &eriod of ti'e, ,ill reduce the height of the cu%& and allo, de&o%ition of reactionary dentine on the &ul&al %urface of the dentine( Single $i%it %ectioning of the cu%& fro' the tooth follo,ed by electi$e &ul&oto'y can al%o be con%idered( Fi!. /3./5 E$aginationtalon cu%& ,ith &laBue accu'ulation and interfering ,ith the occlu%ion( Fi!. /3./1 E$agination%trifor' and crucifor' teeth, ==, =( /3.5.3 In.a!inated teet% Thi% ter' refer% to the &re%ence of an in$agination in the cro,n of the tooth, for'ing an infolding lined by ena'el ,ithin the cro,n of the tooth, %o'eti'e% extending into the root( 0n in$agination of ena'el e&itheliu' into the dental &a&illa during de$elo&'ent lead% to the for'ation of the abnor'ality( The ter'% in$aginated tooth or den% in$aginatu% can be u%edH other ter'% co''only a&&lied ;but not nece%%arily correctly< are den% in dente, ge%tant co'&o%ite odonto'e, and dilated co'&o%ite odonto'e( The 'axillary lateral inci%or i% the 'o%t co''only affected tooth ;6ig( =@(=? ;a< and ;b<<( The 'axillary central inci%or% are le%% co''only affected and, occa%ionally, the canine% are affected( )n it% 'ilde%t for' an in$aginated tooth i% ty&ically a 'axillary lateral inci%or ,ith a dee& cingulu' &it on the &alatal a%&ect of the cro,n( )n it% 'ore extre'e for' the in$agination i% a%%ociated ,ith a gro%%ly abnor'al cro,n for' and root for' ;6ig( =@(=C<( )n the%e gro%% exa'&le% the cro,n i% tuberculate ,ith the in$agination a&&earing on the cu%& of the abnor'al tooth( Radiogra&h% %ho, the extent of the in$agination cha'ber( Ena'el, ,hich 'ay be extre'ely thin and 'ay e$en be ab%ent, can be %een lining thi% cha'ber( The &ul& 'ay be di%&laced and %urround the in$agination ca$ity, a&&earing radiogra&hically a% narro, %lit% around the dentine for'ing the ,all of the in$agination( So'eti'e% the root i% %ignificantly ex&anded( )n$agination of &ri'ary teeth i% unco''on but in the &er'anent dentition ha% been e%ti'ated to affect bet,een =L and :L of different grou&%( Male% are 'ore co''only affected than fe'ale%, ,ith a ratio of G =( )n$agination% 'ay al%o differ in different racial grou&%, ,ith &eo&le of Chine%e ethnicity being re&ortedly 'ore

co''only affected( )n$aginated teeth 'ay cau%e &roble'% becau%e of the de$elo&'ent of carie% and &ul&al &athology( Thi% can occur %oon after tooth eru&tion, ,ith the child &re%enting an acute ab%ce%% or facial celluliti%( )n %uch ca%e% the radiogra&h ,ill in$ariably de'on%trate inco'&lete root for'ation a% ,ell a% &eria&ical rarefaction ;6ig( =@(=? ;a< and ;b<<( The &re%ence of one in$aginated tooth %hould lead to con%ideration of the contralateral tooth andDor ad+acent teeth being affected( )n$agination% are often bilateral, though not nece%%arily %y''etrical( So'e &atient% ,ith in$aginated teeth 'ay al%o ha$e %u&ernu'erary teeth and therefore full radiogra&hic exa'ination i% ,arranted( Treatment )f in$agination% are identified at an early %tage after eru&tion of the tooth then etchretained re%in %ealant% can be &laced to &re$ent bacteria entering the in$agination and %ub%eBuent de$elo&'ent of carie%( 0cute infecti$e e&i%ode%, &articularly ,hen a%%ociated ,ith celluliti%, %hould be treated ,ith a&&ro&riate antibiotic thera&y a% ,ell a% inci%ion and drainage of any &ointing ab%ce%%( The tooth %hould be o&ened, or extracted if the long-ter' &rogno%i% i% &oor( Thi% tend% to be the ca%e ,ith the 'ore gro%% exa'&le% ,here the cro,n and root for' are abnor'al( )n le%% extre'e for'% endodontic treat'ent, fir%tly in$ol$ing a&exification, can be con%idered( Fi!. /3./2 )nfected, &alatal in$agination, tooth = ( Fi!. /3./3 )nfected, in$aginated odonto'e, tooth = ( /3.5.0 E.a!inated teet% E$aginated teeth, or den% e$aginatu%, 'o%t co''only affect the &re'olar teeth( "er'anent 'olar teeth 'ay al%o be affected( Ty&ically there i% a %'all tubercule on the occlu%al %urface of the &re'olar in the central &art of the fi%%ure &attern( The condition i% 'ore co''on in &atient% of Chine%e de%cent and ha% been e%ti'ated to occur in =-AL of the grou&( The e$agination% are ty&ically fractured off or ,orn do,n by $irtue of nor'al ,ear, leading to &ul&al ex&o%ure, &ul&al &athology, and &eria&ical in$ol$e'ent( Treatment Careful radiogra&hic e$aluation i% nece%%ary to deter'ine the extent of any &ul&al exten%ion into the e$agination( Re%tricted and re&eated grinding of the tubercule can be underta/en to &ro'ote reactionary dentine de&o%ition on the &ul&al a%&ect of the e$agination( 1o,e$er, thi% a&&roach 'ay only be a&&licable in a %'all nu'ber of ca%e% and, 'ore co''only, re'o$al of the tubercule and a li'ited &ul&oto'y are reBuired( /3.1 A;N&R7A*ITY &F R&&T F&R7 /3.1./ Ta-rodonti#m

The ter' taurodonti%' ;literallybull-li/e teeth, re%e'bling a bull*% nec/< i% u%ed to de%cribe 'olar teeth in ,hich the body of the tooth i% enlarged $ertically at the ex&en%e of the root%( The nor'al con%triction of a tooth at the le$el of the a'eloce'ental +unction i% freBuently reduced or ab%ent in affected teeth( The 'echani%' leading to taurodonti%' i% the late in$agination ;or failure< of 1ert,ig*% root %heath, ,hich 'a&% out the %ha&e of root for'ation( The furcation i% di%&laced a&ically( 8arying degree% of taurodonti%' are %een, ,ith the 'o%t extre'e exa'&le being ,hen only a %ingle root i% &re%ent rather than %e&arate root%( Taurodont teeth 'ay al%o be de%cribed a% &yra'idal, cuneifor', or fu%ed( The root canal 'or&hology 'ay ha$e i'&lication% ,hen endodontic treat'ent or extraction i% reBuired( Taurodonti%' i% 'o%t co''only recogni5ed in the &er'anent dentition( 0lthough the ter' i% traditionally a&&lied only to 'olar%, in %o'e &atient% ,ith taurodonti%' of the 'olar teeth the &ul&% of %ingle-rooted teeth 'ay be larger than nor'al( The &re$alence of taurodonti%' $arie% according to the criteria u%ed( )n 4riti%h %choolchildren a &re$alence of !L for 'andibular fir%t &er'anent 'olar% ha% been re&orted( 1igher &re$alence% ha$e been recorded in certain racial grou&% %uch a% the 4antu in South 0frica( )n %o'e fa'ilie% taurodonti%' %ee'% to follo, an auto%o'al do'inant &attern of inheritance( Taurodonti%' ha% al%o been con%idered to be an ata$i%tic trait( )t i% found in a%%ociation ,ith a'elogene%i% i'&erfecta, the trichodento-o%%eou% %yndro'e, ectoder'al dy%&la%ia%, and a nu'ber of other %yndro'e%( Taurodonti%' i% al%o 'ore co''on in X-chro'o%o'al aneudo&loidy( /3.1.2 A""e##or$ root# 0cce%%ory root% 'ay occur in al'o%t any tooth( )n the &ri'ary dentition thi% 'o%t co''only affect% the 'olar% but the &ri'ary canine% and 'axillary inci%or% can al%o be affected( )n the &er'anent dentition, acce%%ory root% are occa%ionally %een in 'axillary inci%or%, 'andibular canine%, &re'olar%, and 'olar%( The%e acce%%ory root% are often %ituated on the di%tolingual a%&ect of the tooth, 'ay $ary in %ha&e, and 'ay be difficult to identify radiogra&hically( 0cce%%ory root% ha$e been re&orted to occur in =->L of the &ri'ary dentition and fro' =L to A:L of the &er'anent dentition( There i% an a%%ociation bet,een acce%%ory root% and large cu%&% of Carabelli on the 'axillary fir%t &er'anent 'olar and ,ith acce%%ory cu%&% on 'axillary %econd and third 'olar%( )n %o'e ca%e% the &re%ence of acce%%ory root% reflect% 'acrodontia( /3.2 A;N&R7A*ITY &F T&&T5 STR(CT(RE /3.2./ All ti##-e# Arre#ted de.elo ment o+ toot%-!erm# 0rre%ted de$elo&'ent of tooth-ger' for'ation 'ay occur follo,ing %uch external influence% a% trau'a, ioni5ing radiation, o%teo'yeliti%, or che'othera&y( The teeth affected and the &articular ti%%ue% affected ,ill be de&endent u&on the nature and ti'ing of the in%ult( )n teeth ,ho%e cro,n% are de$elo&ing, thi% 'ay re%ult in ena'el defect% and corre%&onding dentine defect% 'ay be %een on 'icro%co&ic %ection% %hould the tooth ulti'ately be extracted ;6ig( =@(=9 ;a< and ;b<<( )f root% are de$elo&ing at the ti'e of the in%ult the%e 'ay a&&ear %tunted(

3ocally, one or 'ore &er'anent tooth-ger'% 'ay be affected by infection fro' an o$erlying &ri'ary &redece%%or( Such teeth are ter'ed Turner teeth and ty&ically ha$e area% of ena'el hy&o&la%ia andDor ena'el hy&o'inerali5ation( The 'andibular &re'olar% are 'o%t co''only affected ;6ig( =@(=><( Re!ional odontod$# la#ia Thi% i% an unco''on de$elo&'ental ano'aly, ty&ically affecting the &ri'ary teeth and corre%&onding &er'anent %ucce%%or% ,ithin a %eg'ent of the dentition( The anterior teeth are 'ore co''only affected than the &o%terior teeth and the defect 'ay cro%% the 'idline( The ter' *gho%t teeth* i% %o'eti'e% a&&lied to reflect the radiogra&hic a&&earance %een( 0ffected &atient% 'ay &re%ent ,ith ab%ce%%e% &rior to the eru&tion of the teeth( The abnor'al teeth ha$e &oorly de$elo&ed cro,n% ,ith ena'el and dentine change%, large &ul& cha'ber%, and o&en a&ice%( The &er'anent teeth 'ay be le%% %e$erely affected than the &ri'ary &redece%%or% ;6ig( =@( 9 ;a< and ;b<<( Treatment The re'o$al of teeth affected by regional odontody%&la%ia i% often nece%%ary( 0% thi% i% often the ca%e in the &ri'ary dentition, con%ideration then need% to be gi$en to 'anage'ent of the affected &er'anent %ucce%%or%( While there are re&ort% of the effecti$e u%e of etch-retained re%toration% in the%e ca%e%, the teeth are often %lo, to eru&t, ,ith a di%tincti$e local gingi$iti%, and the &ul&al 'or&hology i% %uch that infection i% a freBuent outco'e( Root de$elo&'ent 'ay be %lo, but re%torati$ely u%eful( 0 ca%e-by-ca%e a&&roach to treat'ent &lanning i% reBuired( 4loc/ re'o$al of uneru&ted teeth ,ith %urrounding bone i% not reBuired( Fi!. /3./4 Turner tooth( 1y&o&la%tic lo,er &re'olar&re$iou% infection in &ri'ary tooth( Fi!. /3.20 Regional odontody%&la%iaclinical and radiogra&hic a&&earance( /3.2.2 Enamel de+e"t# Ena'el defect% 'ay be cau%ed by genetic or en$iron'ental factor%, acting alone or in co'bination( Where le%% ena'el 'atrix than nor'al i% &roduced the re%ulting ena'el ,ill be thinner ;hy&o&la%ia<( )f there i% a defect in 'inerali5ation of the ena'el 'atrix &rotein% then the re%ult ,ill be &oorly 'inerali5ed ena'el ;hy&o'inerali5ation%o'eti'e% %ubdi$ided into hy&ocalcification for 'ore %e$ere defect% and hy&o'aturation for 'ilder change%<( )n 'any ca%e% there ,ill be a co'bination of both hy&o&la%ia and hy&o'inerali5ation, although %o'eti'e% the defect ,ill be &ercei$ed clinically a% &redo'inantly one or the other( When ena'el hy&o&la%ia i% %een the ena'el 'ay be unifor'ly thin, or groo$ed or &itted( )n hy&o'inerali5ation the ena'el ,ill ty&ically be di%coloured, u%ually a yello,-bro,n colour( Thi% i% &articularly %o ,here the defect i% %e$ere ;hy&ocalcification< ,herea% in a le%% %e$ere &re%entation ;hy&o'aturation< the ena'el 'ay be al'o%t nor'al but a&&ear 'ottled or e$en only %lightly o&aBue rather than tran%lucent( >e$ Point#

 Ena'el defect%H 1y&o&la%iadeficient 'atrixH 1y&o'inerali%ation&oor 'inerali%ation( Amelo!ene#i# im er+e"ta 0'elogene%i% i'&erfecta i% the ter' a&&lied to generali5ed ena'el defect% affecting all ;or &redo'inantly all< of the teeth of both the &ri'ary and &er'anent dentition%( )t i% of geno'ic origin and thu% there 'ay be a fa'ily hi%tory of %i'ilar defect% in other fa'ily 'e'ber%( 0lthough the ter' %trictly relate% to ena'el defect% only, in %o'e &atient% there 'ay be %ubtle or %ub%tantial change% in other dental ti%%ue% and craniofacial %tructure%, or the condition 'ay in$ol$e 'ore ,ide%&read abnor'alitie% a% &art of a %yndro'e( Dentally, there 'ay be failure% of eru&tion ,ith re%or&tion of the uneru&ted teeth( 0 ca%e 'ay be 'ade for regular radiogra&hic re$ie, of the%e &atient% ;6ig( =@( =<( 0'elogene%i% i'&erfecta i% %een in %ingle gene 'utation% ,ith auto%o'al do'inant, auto%o'al rece%%i$e, and X-lin/ed &attern% of inheritance( 0&&arently %&oradic ca%e% are al%o %eenit i% not clear ,hether the%e re&re%ent ne, 'utation%, or ,hether the%e ,ill then be &a%%ed on to future off%&ring ;6ig( =@( <( 0) i% relati$ely unco''on, but there are 'ar/ed &o&ulation difference% in &re$alence( )n &art% of S,eden the condition i% relati$ely co''on ;one in a&&roxi'ately ?99 of the &o&ulation<( )n one %tudy in the #nited State% the &re$alence ,a% found to be a&&roxi'ately = in =A,999( The cla%%ification of a'elogene%i% i'&erfecta ha% traditionally been ba%ed on the &henoty&ethe clinical a&&earance( 6ollo,ing thi% %y%te', &atient% are allocated according to the &ercei$ed defecthy&o&la%ia, hy&ocalcification, or hy&o'aturation( So'e cla%%ification% ha$e an additional category of hy&o'aturation-hy&o&la%ia ,ith taurodonti%' to reflect the fact that %o'e fa'ilie% %ho, a co'bination of thin andDor &oorly 'inerali5ed ena'el a% ,ell a% taurodonti%'( 1o,e$er, it i% i'&ortant to reali5e, both fro' a diagno%tic and fro' a cla%%ification &oint of $ie,, that not all indi$idual% ,ithin a fa'ily 'ay %ho, the %a'e finding( 0% a re%ult, &henoty&e cla%%ification% beco'e &roble'atic ,hen different 'e'ber% of the %a'e fa'ily are grou&ed into different categorie%( 6urther'ore, thi% cla%%ification %y%te' fail% ,hen there i% uncertainty a% to ,hich i% the &re%u'ed &redo'inant defect( )t i% &o%%ible that the inheritance &attern ,ill be forgotten in atte'&ting to categori5e indi$idual%( 6or thi% rea%on an alternati$e cla%%ification %y%te' ha% been %ugge%ted ,here the 'ode of inheritance ;auto%o'al do'inant, auto%o'al rece%%i$e, X-lin/ed or a&&arently %&oradic< i% con%idered before the clinical &henoty&e( Thi% cla%%ification al%o allo,% for the fact that there 'ay be %o'e o$erla& bet,een the clinical defect% in the %a'e or different 'e'ber% of a fa'ily( The full cla%%ification %che'e include% the geno'ic and bioche'ical identity of the defectH ho,e$er, for &ractical &ur&o%e%, a %i'&lified u%e of thi% 'odern cla%%ification 'ight, for exa'&le, define a &atient*% &re%entation a% *auto%o'al do'inant hy&o&la%tic a'elogene%i% i'&erfecta*( A-to#omal dominant amelo!ene#i# im er+e"ta )n auto%o'al do'inant 0) there i% ty&ically a clear &attern of inheritance ,ith

indi$idual% in %ucce%%i$e generation% being affected ;6ig( =@( @<( 4ecau%e the 'utant gene i% on one of the auto%o'e% there i% a :9L chance of an affected indi$idual &a%%ing thi% on to each off%&ring( Male% and fe'ale% are eBually affected( The &ri'ary and &er'anent dentition% are generally both in$ol$ed, although the &er'anent dentition 'ay be the 'ore %e$erely affected of the t,o ;6ig( =@( A<( There i% a ,ide range of &re%entation% ;&henoty&e%<( The ena'el 'ay be thin and hard ,ith nor'al tran%lucency but 'ay be difficult to di%cern on radiogra&h% becau%e of it% li'ited thic/ne%%( )n %o'e ca%e% the ena'el 'ay be both hy&o&la%tic and hy&o'inerali5ed, in ,hich ca%e the ena'el i% thin and di%coloured ,ith a lo%% of nor'al tran%lucency( So'e &atient% 'ay ha$e ena'el of nor'al thic/ne%% ,hich i% &oorly 'inerali5ed, and yet other% 'ay ha$e ena'el of nor'al thic/ne%% ,hich lac/% the nor'al tran%lucency and i% therefore regarded a% %ho,ing feature% of hy&o'aturation( Occa%ionally, %ubtle ena'el defect% 'ay only be identified on hi%to&athological exa'ination of extracted teeth( )n %o'e fa'ilie% taurodonti%' i% %een( 0nterior o&en bite 'ay occur in auto%o'al do'inant a'elogene%i% i'&erfecta a% ,ell a% in other inheritance &attern%( The 'echani%' &roducing the %o'eti'e% a%%ociated anterior o&en bite ha% not yet been elucidated( Aetiolo!$ The ena'elin gene on chro'o%o'e A ha% been %ho,n to be 'utated in %o'e fa'ilie% ,ith auto%o'al do'inant a'elogene%i% i'&erfecta( Other gene% in$ol$ed in nor'al ena'el for'ation ha$e been i'&licated in auto%o'al do'inant a'elogene%i% i'&erfecta( "atient% ,ith tricho-dento-o%%eou% %yndro'e, an auto%o'al do'inant %yndro'e characteri5ed by a'elogene%i% i'&erfecta ,ith taurodonti%' a% ,ell a% curly hair and bone change%, ha$e been found to ha$e 'utation% in the DLB& gene on chro'o%o'e =?( A-to#omal re"e##i.e amelo!ene#i# im er+e"ta 0uto%o'al rece%%i$e condition% are ty&ically %een ,hen there i% &arental con%anguinity, %o that that the &arent% 'ay be fir%t cou%in% ;6ig( =@( :<( There 'ay be cultural rea%on% for thi% or, alternati$ely, con%anguinity 'ay be %een in i%olated co''unitie% ,ith little out%ide contact and ,here there i% con%eBuently a li'ited gene &ool( )n other rece%%i$e condition%, %uch a% cy%tic fibro%i%, the%e re%triction% do not a&&ly and the relati$e &re$alence of the condition i% related to the freBuency of gene carrier% in the &o&ulation( Where the &arent% are clo%e relati$e%, both carrier adult% ,ill be unaffected but there ,ill be a one in four chance of off%&ring inheriting t,o co&ie% of the 'utant gene( 0uto%o'al rece%%i$e 'utation% cau%ing a'elogene%i% i'&erfecta %ee' to be unco''on a&art fro' "olyne%ia, ,here, &re%u'ably, the 'utation i% relati$ely co''on( Such indi$idual% 'ay ha$e ena'el hy&o&la%ia andDor ena'el hy&o'inerali5ation and the de%ignator *&ig'ented ena'el* ha% been a&&lied( 0 gene on chro'o%o'e ha% been lin/ed to auto%o'al rece%%i$e a'elogene%i% i'&erfecta a%%ociated ,ith ocular defect%( '-lin=ed amelo!ene#i# im er+e"ta X-lin/ed a'elogene%i% i'&erfecta i% characteri5ed by a difference in the a&&earance

of the teeth of affected 'ale% and fe'ale%( The 'a+ority of fa'ilie% %tudied to date ha$e an alteration in the a'elogenin gene on the %hort ar' of the X chro'o%o'e( 0ffected 'ale% cannot &a%% on the condition to their %on% ;by $irtue of &a%%ing on their . chro'o%o'e to their %on%< but their daughter% ;to ,ho' they nece%%arily &a%% on their X chro'o%o'e< ,ill all inherit the 'utant gene( Such daughter% ,ill al,ay% %ho, %o'e dental feature% although the%e 'ight be %ubtle in %o'e ca%e%( The%e hetero5ygou% fe'ale% can &a%% on the 'utant gene to children of either %ex( ;6ig( =@( !<( The ena'el in both %exe% 'ay be hy&o&la%tic, hy&o'inerali5ed, or %ho, ele'ent% of both feature%( The a&&earance %een ,ill be the re%ult of the exact nature of the change in the a'elogenin gene and the %ex of the &atient( Male%, by $irtue of ha$ing a %ingle X chro'o%o'e, ,ill be 'ore %e$erely and unifor'ly affected( The ena'el 'ay be thin ;hy&o&la%ticreduced in Buantity< or di%coloured ;,ith affected 'inerali%ation< or a co'bination of both ;6ig( =@( ?<( 6e'ale% ,ithin the %a'e fa'ily ,ho inherit the affected gene ,ill %ho, a $ertical &attern of 'ar/ing% of the ena'el, either $ertical ridge% and groo$e% ;the eBui$alent of the 'ale, unifor' hy&o&la%ia<, ,ith or ,ithout di%colouration or lo%% of tran%lucency of the ena'el ;,here the 'inerali5ation i% affected< ;6ig( =@( C<( Aetiolo!$ The a'elogenin gene, ,hich encode% the ena'el &rotein a'elogenin, i% located on the %hort ar' of the X chro'o%o'e( Mutation% in the gene are re%&on%ible for 'o%t ca%e% of X-lin/ed a'elogene%i% i'&erfecta but there al%o a&&ear% to be another gene on the long ar' of the X chro'o%o'e ,hich i% re%&on%ible for %i'ilar clinical a&&earance% in another fa'ily( 6eneti" enamel de+e"t# a##o"iated Cit% !enerali:ed di#order# Wide%&read ena'el defect% can be %een in a nu'ber of condition% ,ith extraoral 'anife%tation%( The%e include condition% %uch a% e&ider'oly%i% bullo%a, tuberou% %clero%i%, oculo-dento-o%%eu% dy%&la%ia, a% ,ell a% the a'elogene%i% i'&erfecta a%%ociated ,ith tricho-dento-o%%eou% %yndro'e( The exact geno'ic relation%hi& bet,een the%e and other condition% and a'elogene%i% i'&erfecta re'ain% to be e%tabli%hed in 'o%t ca%e%( >e$ Point# 0'elogene%i% i'&erfecta )nheritance, 0uto%o'al do'inant, 0uto%o'al rece%%i$e, X-lin/ed, 0&&arently %&oradic( P%enot$ e 1y&o&la%tic FD- hy&o'inerali5ation ;hy&ocalcification to hy&o'aturity<

"ure hy&o&la%ia or hy&o'inerali5ation are &robably rare "rofound hy&o'inerali5ation lead% to teeth %o %oft that they are reduced in %i5e although thi% i%, in fact, a later change( 7olar-in"i#or %$ o la#ia )n recent year% re&ort% ha$e been &ubli%hed of children ,ith 'inerali5ation defect% of the fir%t &er'anent 'olar% and, %o'eti'e%, the &er'anent inci%or%( Thi% ha% been referred to a% 'olar-inci%or hy&o'inerali5ation or hy&o&la%ia and al%o a% *chee%e 'olar%* becau%e of the friable nature of the ena'el of the 'olar tooth ena'el( 0lthough the condition ,ould %ee' to ha$e a chronological di%tribution ;6ig( =@( > ;a< and ;b<<, clo%e in%&ection ,ill often %ho, *un-'atched* teeth to be affectedteeth that ,ould ha$e been for'ing at the %a'e ti'e do not &re%ent ,ith %y''etrical affliction( Only one 'olar, or &erha&% three of the four, 'ay be affected( The defect% in the inci%or%,hich are u%ually le%% %e$ere and 'o%t li/ely to %ho, i%olated 'ottling,ill li/e,i%e be irregularly di%tributed( ;6ig( =@(@9 ;a,b, and c<<( To the be%t of our /no,ledge, thi% i% the fir%t &ublication of %uch a fa'ilial a%%ociation( The cau%e of thi% ano'aly, and e$en ,hether it re&re%ent% a ne, &heno'enon, i% uncertain( )t ha% been %ugge%ted that there 'ight be a genetic &redi%&o%ition co'bining ,ith an en$iron'ental in%ult that &roduce% the%e change%, but thi% ha% yet to be %ub%tantiated( Treatment The condition i% &roble'atic for both &atient% and &ractitioner%( The de%truction of the 'olar teeth in &articular, although &robably a &o%t-eru&ti$e change, &re%ent% in 'any ca%e% at a ti'e ,hen children are not accli'ati5ed to dental treat'ent( Treat'ent o&tion% %hould include a careful analy%i% of the occlu%ion, %ince 'any of the 'olar teeth are %e$erely co'&ro'i%ed, and the child 'ay benefit in the long ter' by their electi$e lo%% a% &art of a co'&rehen%i$e treat'ent &lan( 6or the year% bet,een the eru&tion of the fir%t &er'anent 'olar teeth and the co''only reco''ended ti'e for their re'o$al, 'anage'ent 'ay be difficult( )t i% clear that 'any children ,ith thi% condition are a&&rehen%i$e &atient% for dental treat'ent( Thi% i% li/ely to be becau%e, in it% early %tage%, &ractitioner% ado&t a 'ini'ali%t a&&roach ,ith the atte'&ted u%e of fi%%ure %ealant% and adhe%i$e re%toration%( The%e are often a&&lied ,ithout local anae%the%ia, are &ainful in the &roce%%, and freBuently un%ucce%%ful any,ay( "refor'ed 'etal cro,n% a&&lied under local anae%the%ia &ro$ide a u%eful 'ea%ure in the%e ca%e%( The inci%or defect% are not noticeably unco'fortable and %hould be 'anaged ,ith the techniBue% de%cribed in Cha&ter =9( ?En.ironmentall$ determined? enamel de+e"t# Ena'el defect% 'ay ari%e a% a re%ult of an *en$iron'ental* in%ult( Within thi% %en%e ,e include both a %y%te'ic u&%et and the re%ult of a local factor in$ol$ing a de$elo&ing tooth ;a% di%cu%%ed &re$iou%ly in Section =@(?<(

Where there i% a %y%te'ic in%ult the teeth ,ill be affected in a chronological &attern, %o that a band of abnor'al ena'el i% %een in hori5ontal di%tribution at %o'e &art on the tooth cro,n( Ty&ically thi% re%ult% in a groo$e in the ena'el of affected teeth( The ter' chronological hy&o&la%ia i% often u%ed to de%cribe %uch ca%e% ;6ig( =@(@=<( 0 /no,ledge of the ti'ing of co''ence'ent of for'ation of the teeth ,ill aid in under%tanding the ti'ing of %uch an in%ult( S$#temi" ("%ronolo!i"al) enamel de+e"t# Ena'el for'ation in utero 'ay be affected by a ,ide range of 'aternal and foetal condition%( The%e ,ill include endocrine di%turbance% ;hy&o&arathyroidi%'<, infection% ;rubella<, drug% ;thalido'ide<, nutritional deficiencie%, and hae'atological and 'etabolic di%order% ;Rhe%u% inco'&atibility<( )n %uch ca%e%, the ena'el co$ering the inci%al &ortion% of the cro,n% of the &ri'ary inci%or% ,ill ty&ically be affected in the &attern %ho,n in 6ig( =@(@ ;a< and ;b<( Si'ilar change% 'ay be %een in &re-ter', lo, birth ,eight, infant%( )t i% not yet clear ,hether thi% i% a%%ociated ,ith the u%e of intubation for the%e children in the neonatal &eriod although the latter ha% been identified a% a local cau%e affecting for'ing inci%or% only( When there i% a %y%te'ic u&%et or 'ar/ed &hy%iological change% occur at birth or in the neonatal &eriod, corre%&onding ena'el defect% 'ay be %een in the &ri'ary dentition( )llne%% in the neonatal &eriod 'ay al%o affect the ti&% of the fir%t &er'anent 'olar% a% the%e co''ence de$elo&'ent at around birth( Ena'el defect% 'ay al%o ari%e a% a re%ult of acute or chronic childhood illne%%e% ;6ig( =@(@@<( Thi% ,ill include hy&othyroidi%' and hy&o&arathyroidi%', chronic renal di%ea%e, and ga%trointe%tinal di%order% &roducing 'alab%or&tion, %uch a% coeliac di%ea%e( The u%e of tetracycline during &regnancy and childhood i% to be a$oided becau%e of de&o%ition of the tetracycline in de$elo&ing dental 'atrice%, &roducing a di%tincti$e blueDgrey di%colouration of the teeth, %o'eti'e% in a chronologically banded di%tribution ;6ig( =@(@A<( )n the &a%t, exanthe'atou% fe$er% cau%ed by 'ea%le% and other infection% ,ere a%%ociated ,ith a di%turbance of nor'al ena'el for'ation and a corre%&onding chronological hy&o&la%ia affecting the cro,n% of de$elo&ing teeth( Modern 'edical care ha% no, 'ade thi% unco''on, unle%% %uch change% 'ay occur in the ca%e of babie% and infant% ,ho de$elo& &neu'onia( Ena'el for'ation i% al%o %en%iti$e to che'ical agent%, %uch a% fluoride( Exce%%i$e inta/e of fluoride, either fro' naturally occurring %ource% %uch a% drin/ing ,ater ,ith fluoride le$el% o$er =- &&', or fro' o$er u%e of fluoride %u&&le'ent% or fluoride tooth&a%te%, can cau%e ena'el 'ottling( )n it% 'ilde%t for' fluoro%i% a&&ear% a% an o&acity of the ena'el( The condition i% do%e-de&endant, ,ith increa%ing inta/e of fluoride being a%%ociated ,ith 'ore 'ar/ed o&acity, area% of di%colouration of the ena'el a% ,ell a% &itting, and 'ore exten%i$e hy&o&la%tic defect% ;6ig( =@(@: ;a<<( Confu%ion bet,een fluoro%i% and a'elogene%i% i'&erfecta can occur( One di%tingui%hing feature 'ay be that a'elogene%i% i'&erfecta doe% not %ho, a chronological di%tribution and that fluoro%i%, de&ending on the ti'ing of the exce%%i$e inta/e, doe%( 3ocal, fluorotic le%ion% 'ay re%&ond $ery ,ell to the 'icroabra%ion

techniBue ;6ig( =@(@: ;b<<( *o"al +a"tor# 0% ,ell a% the &o%%ibility of da'age to the for'ing teeth that 'ay be cau%ed by dental in+urie% ;6ig( =@(@!< ;%ee Cha&ter = <, &re%%ure on the &re'axilla fro' the u%e of an oro-tracheal tube 'ay cau%e da'age to the de$elo&ing &ri'ary inci%or teeth( Children ,ith a cleft li& and &alate often ha$e ena'el defect% of the 'axillary inci%or%( So'eti'e% thi% 'ay be related to %urgical treat'ent rather than the effect of the cleft per se( Treatment The treat'ent of children ,ith ena'el defect% reBuire% 'ore con%ideration than %i'&ly 'echanical treat'ent of the teeth( Children ,ith a'elogene%i% i'&erfecta, in &articular, 'ay be %ub+ect to tea%ing( Thi% i% a %eriou% i%%ue and reBuire% the 'o%t %en%iti$e handling by &rofe%%ional%( 0ffected adult fa'ily 'e'ber% ,ill often de%cribe their o,n childhood in lurid and &ainful ter'%( Many children ,ill not ad'it to thi% fro' the out%et and need to be gi$en *&er'i%%ion* ;,ith their &arent*% /no,ledge< to contact the &ractitioner at a later date to re$i%it the%e i%%ue%( Ty&ically, a% ,ell a% the ae%thetic%, there 'ay be ther'al, contact or o%'otic %en%iti$ity of the teeth( Oral hygiene 'ay be &oor and irre'ediable a% a re%ult ;6ig( =@( <( The occlu%ion 'ay be co'&ro'i%ed by lac/ of $ertical di'en%ion a% a re%ult of thinner ena'el than nor'al, or there 'ay be lo%% of ena'el becau%e of &oorly 'inerali5ed ena'el 'atrix( So'e &ractitioner% ad$ocate the early &re$enti$e u%e of full co$erage re%toration% in the &ri'ary dentition for the%e children( 3ocali5ed defect% are 'uch 'ore a'enable to %i'&le 'ea%ure%( Fi!. /3.2/ S&oradic ca%eH 0'elogene%i% i'&erfectaH hy&o'inerali5ed ,ith anterior o&en bite( Sho,% failure of eru&tion teeth =?, =:, =@, ?, @?, A?( Fi!. /3.22 S&oradic ca%eH 0'elogene%i% i'&erfectaH hy&o'inerali5edH anterior o&en bite( The &oor oral hygiene and %taining are ty&ical ,hen, a% here, the teeth are %en%iti$e to ther'al and 'echanical %ti'uli( Fi!. /3.23 "edigree chart( 0uto%o'al do'inant inheritance of 0)( Fi!. /3.20 0uto%o'al do'inant 0)( 0ll teeth affected %i'ilarly( Fi!. /3.25 "edigree chart( 0uto%o'al rece%%i$e inheritance of 0)( Fi!. /3.21 "edigree chart( X-lin/ed inheritanceno 'ale to 'ale tran%'i%%ion( Fi!. /3.22 X-lin/edH 0)H MaleH thin, %'ooth ena'el( Fi!. /3.23 X-lin/edH 0)H fe'aleH ridged, &redo'inantly hy&o&la%tic ena'el( Fi!. /3.24 Molar-inci%or hy&o'inerali5ation ;M)1< ,ith feature% of chronological di%turbance but no rele$ant 'edical hi%tory( Fi!. /3.30 M)1 in a %i%ter and t,o brother%(

Fi!. /3.3/ 1y&o&la%ia in a *chronological di%tribution*( Fi!. /3.32 "ri'ary dentition&re-ter' hy&o&la%ia( Fi!. /3.33 "ri'ary teethH both +a,% affected by icteru% gra$i% neonatoru' ;Rhe%u% di%ea%e<, u&&er teeth ,ith %u&eradded *bottle carie%*( Fi!. /3.30 Tetracycline %taining a%%ociated ,ith hori5ontal, hy&o&la%tic banding re&re%enting re&eated childhood illne%% and it% treat'ent( Fi!. /3.35 Di%turbed dental de$elo&'ent, fluorotic 'ottlingG&re-and &o%t'icroabra%ion( Fi!. /3.31 Di%turbed dental de$elo&'ent&re$iou% &ri'ary tooth in+ury( /3.2.3 Dentine de+e"t# 0% ,ith ena'el defect%, dentine defect% 'ay be of genetic origin or cau%ed by en$iron'ental effect%( 6eneti"all$ determined dentine de+e"t# DENTIN&6ENESIS I7PERFECTA Dentinogene%i% i'&erfecta i% an auto%o'al do'inant inherited condition( )t 'ay occur in i%olation or in a%%ociation ,ith o%teogene%i% i'&erfecta( Thi% re&re%ent% t,o condition%, rather than a %&ectru' of effect( The ter' hereditary o&ale%cent dentine i% %o'eti'e% a&&lied becau%e of the ty&ical o&ale%cent hue of the teeth( Dentinogene%i% i'&erfecta, both the ty&ical $ariant and the *4randy,ine i%olate* $ariant in the ea%tern #nited State%, ha% been 'a&&ed to chro'o%o'e A and the D#PP gene ha% been %ho,n to be 'utated in %e$eral fa'ilie% ;%o'e of ,ho' al%o ha$e had hearing defect%<( )n %o'e of the 4randy,ine i%olate fa'ilie%, occa%ional indi$idual% ha$e teeth ,hich are indi%tingui%hable fro' the 'ore ty&ical for' of dentinogene%i% i'&erfectaH it i% therefore li/ely that thi% re&re%ent% an allelic $ariant of the %a'e genetic condition( Si'ilarly, the diagno%i% of coronal dentinal dy%&la%ia ha% been &ro&o%ed but thi% al%o %ee'% li/ely to be a $ariant of dentinogene%i% i'&erfecta( Dentinogene%i% i'&erfecta occurring in a%%ociation ,ith o%teogene%i% i'&erfecta i% a re%ult of 'utation% in one of the t,o collagen ty&e = gene% on chro'o%o'e ? or =?( The dentine defect% 'ay be $ery a&&arent or rather %ubtle, in %o'e ca%e% reBuiring electron-'icro%co&y for their identification( Dentine ;%o'eti'e% ,ith ena'el< change% can al%o be %een in %o'e ty&e% of Ehler% Danlo% %yndro'e in$ol$ing 'utation% in the collagen = gene%( Dentinogene%i% i'&erfecta occurring in the ab%ence of o%teogene%i% i'&erfecta i% inherited a% an auto%o'al do'inant trait( The &ri'ary and &er'anent dentition% are u%ually affected( The teeth are o&ale%cent ,ith a greyi%h or bro,ni%h colour ;6ig%( =@(@?, =@(@C<( There 'ay be %o'e $ariation in the %e$erity of the a&&earance in different 'e'ber% of the %a'e fa'ily( So'e $ariability 'ay al%o be %een in the

%e$erity of affliction of indi$idual teeth in any one indi$idual ;6ig( =@(@><( The ena'el 'ay chi& a,ay fro' the dentine to ex&o%e the dentine and the cro,n% 'ay %uffer fro' attrition %o that the teeth are ,orn do,n to the le$el of the gingi$ae ;6ig( =@(A9<( Thi% %ituation i% 'o%t co''only %een to affect the &ri'ary dentition( )n the &ri'ary dentition the &ul&% 'ay be large and hence &ul&al ex&o%ure 'ay occur early( )n 'any ca%e%, the &ul&% of the teeth tend to be obliterated, hence &ul&al ex&o%ure and ab%ce%% for'ation tend to occur later than 'ight other,i%e be ex&ected( The chi&&ing of the ena'el ha% often been clai'ed to re%ult fro' a %'ooth ena'el-dentine +unction but %o'e %tudie% ha$e de'on%trated that the contour of the ena'el-dentine +unction i% not a factor, ,ith the ,ea/ne%% being ,ithin the dentine( Radiogra&hically the cro,n% a&&ear relati$ely bulbou%, the root% are %hortened and 'ay be thinner than nor'al( The &ul& cha'ber% 'ay be large initially, &articularly in the &ri'ary dentition, but 'ore ty&ically the &ul&% are obliterated a% a re%ult of de&o%ition of dentine in a rather ha&ha5ard 'anner ;6ig( =@(A= ;a< and ;b<<( Thi% can be %een in hi%to&athological %ection% ,here the 'antle dentine ad+acent to the ena'eldentine +unction i% e%%entially nor'al but the dee&er dentine i% gro%%ly abnor'al( &STE&6ENESIS I7PERFECTA O%teogene%i% i'&erfecta ari%e% a% a re%ult of a 'utation in one of the t,o collagen ty&e = gene%( 0lthough it u%ed to be regarded a% ha$ing auto%o'al do'inant and auto%o'al rece%%i$e 'ode% of inheritance, it i% no, belie$ed that auto%o'al do'inant 'utation% are the nor' but that the %e$erity $arie% in different indi$idual% and fa'ilie%( Ca%e% %uch a% tho%e &re$iou%ly thought to be auto%o'al rece%%i$e are no, con%idered 'o%t li/ely to ari%e a% a re%ult of gonadal 'o%aici%'( The condition i% characteri5ed by bone fragility %o that children 'ay ha$e a hi%tory of fracture% ;fro' %uch 'ild trau'a a% ,al/ing into furniture<, blue %clera, deafne%% ;though thi% doe% not u%ually de$elo& until the third decade of life<, and lax liga'ent% around +oint%( There 'ay or 'ay not be dentinal change%, or the%e 'ay be %o %ubtle that they are not a&&arent clinically or radiogra&hically( >e$ Point# Dentinogene%i% i'&erfecta 0uto%o'al do'inant conditioni%olated trait or a%%ociated ,ith o%teogene%i% i'&erfecta or other collagen abnor'alitie%( DENTINA* DYSP*ASIA Dentinal dy%&la%ia ,a% fir%t de%cribed in the => 9%H *rootle%% teeth* i% an alternati$e, de%cri&ti$e, title( The condition i% an auto%o'al do'inant trait ,ith both dentition% being affected( The teeth 'ay be clinically nor'al but root for'ation i% abnor'al to $arying degree%( So'e teeth 'ay ha$e extre'ely %hort blunt root%, other% ta&er 'ar/edly to,ard% the a&ex ;6ig( =@(A <( The &ul& i% &artially obliterated, a&&earing in the 'olar teeth a% a %'all de'ilune( #nder the 'icro%co&e the coronal dentine i% nor'al but the root dentine i% not, ,ith 'a%%e% of abnor'al dentine obliterating the &ul& %&ace( The 'icro%co&ic a&&earance ha% been li/ened to boulder% in a flo,ing %trea'( The %hort root% 'ay cau%e &roble'% becau%e of 'obility and thi% 'ay lead to the condition being identified(

The abo$e condition i% often referred to a% dentinal dy%&la%ia ty&e ) to di%tingui%h it fro' a condition referred to by %o'e a% dentinal dy%&la%ia ty&e )) ;coronal dentinal dy%&la%ia<( The latter i% 'o%t li/ely to re&re%ent an allelic $ariant of dentinogene%i% i'&erfecta a% genetic lin/age %tudie% ha$e %ho,n it to 'a& to the %a'e region of chro'o%o'e A a% dentinogene%i% i'&erfecta and a 'utation in the D#PP gene ha% al%o been identified in one fa'ily diagno%ed a% ha$ing dentinal dy%&la%ia ty&e ))( )t re'ain% to be %een ,hether dentinal dy%&la%ia ;ty&e )< i% al%o allelic to dentinogene%i% i'&erfecta( )ITA7IN D-RESISTANT RIC>ETS 8ita'in D-re%i%tant ric/et% i% an X-lin/ed inherited condition( 0ffected 'ale% tend to be %hort in %tature ,ith bo,ed leg% and other %/eletal change%( They 'ay &re%ent dentally ,ith ab%ce%%e% for'ing in the ab%ence of carie%( Of the dental hard ti%%ue%, the dentine i% 'o%t 'ar/edly affected ,ith interglobular dentine being the chief hi%to&athological finding( Radiogra&hically the &ul& %&ace% are larger than nor'al and &ul&al exten%ion% of the &ul& horn% 'ay be ex&o%ed a% a re%ult of attrition of the teeth ;6ig( =@(A@< 1etero5ygou% fe'ale% tend to be 'ore 'ildly affected and 'ay not exhibit any dental 'anife%tation%( ?En.ironmentall$ determined? dentine de+e"t# 3ocal trau'a 'ay interfere ,ith dentine for'ation( Thi% 'ay be &er'anently recorded in the dentine a% a &ro'inent incre'ental line( Sy%te'ic influence% including nutritional deficiencie%, tetracycline ad'ini%tration, and che'othera&eutic agent% %uch a% anti-cancer thera&y in$ol$ing cytotoxic drug% can al%o affect the for'ation of dentine( Treatment 0% ,ith ena'el defect% there 'ay be %e$ere &%ycho-%ocial &roble'% a% a re%ult of the a&&earance of the teeth( Many of the argu'ent% &re%ented in the con%ideration of ena'el condition% ,ill a&&ly to dentine al%o( )n dentinogene%i% i'&erfecta, 'anage'ent i% focu%ed on the &re$ention of tooth ,ear, the 'aintenance of the $ertical di'en%ion and i'&ro$e'ent of the a&&earance ;Cha&ter =9<( )n ric/et%, the treat'ent %hould be %i'ilarly directed but ca%e% &re%enting late 'ay reBuire acute 'anage'ent of dental ab%ce%%e% on the teeth a% a re%ult of &ul& death( Fi!. /3.32 Dentinogene%i% i'&erfectaearly 'ixed dentition( Fi!. /3.33 Dentinogen%i% i'&erfectaH =C-year-old-'aleH co'&o%ite addition% teeth = , ==, A , A=( Ty&ical dar/ dentine colourationH %hort clinical cro,n%( Fi!. /3.34 Dentinogene%i% i'&erfectaH $ariable ex&re%%ion in one indi$idual( Fi!. /3.00 Dentinogene%i% i'&erfecta %ho,ing tooth ,ear ::, !:( Fi!. /3.0/ Dentinogene%i% i'&erfecta radiogra&h %ho,ing bulbou% 'olar cro,n%, and obliterated &ul& cha'ber%( Fi!. /3.02 Radicular dentinal dy%&la%ia(

Fi!. /3.03 8ita'in D re%i%tant Ric/ett%( D"T of 'ale %ho,ing large &ul& cha'ber%, le%% den%e dentine ad+acent to ED7( /3.2.0 Cement-m de+e"t# The ce'entu' can be affected in a nu'ber of genetic di%order%( The con%eBuence% of alteration% in ce'entu' can ha$e &rofound effect% on the fate of the dentition( There are a nu'ber of rare but %ignificant condition% a%%ociated ,ith the early lo%% of &ri'ary teeth( 0ny ca%e of early or %&ontaneou% lo%% of teeth i% a cau%e for further in$e%tigation( )n one of the%e, hy&o&ho%&hata%ia ;both auto%o'al do'inant and auto%o'al rece%%i$e inheritance are /no,n<, there 'ay be &re'ature exfoliation of the &ri'ary teeth or lo%% of the &er'anent teeth( The %eru' al/aline &ho%&hata%e le$el i% lo,H &ho%&hoethanola'ine i% excreted in the urine( 1i%to&athological exa'ination in hy&o&ho%&hata%ia ,ill %ho, a&la%ia or 'ar/ed hy&o&la%ia of the ce'entu'( There 'ay al%o be abnor'al dentine for'ation ,ith a ,ide &redentine 5one and the &re%ence of interglobular dentine ;%i'ilar to $ita'in D-re%i%tant ric/et%<( Treatment 3ocal 'ea%ure% %uch a% %cru&ulou% oral hygiene 'ay %lo, the lo%% of teeth in ca%e% of hy&o&ho%&hata%ia but the &ri'e focu% of treat'ent 'ay be the re&lace'ent of teeth of the &ri'ary and &er'anent dentition% a% they are lo%t( /3.3 DIST(R;ANCES &F ER(PTI&N /3.3.0 Introd-"tion Con%iderable $ariation% exi%t in the ti'ing of eru&tion of the &er'anent dentition( There 'ay be %o'e racial $ariation and eru&tion 'ay al%o be influenced by en$iron'ental factor% %uch a% nutrition and illne%%( Eru&tion ti'e% of &er'anent teeth in fe'ale% tend to be %lightly ahead of the corre%&onding eru&tion ti'e% in 'ale%H thi% beco'e% a 'ore 'ar/ed difference ,ith the later eru&ting teeth( /3.3./ Premat-re er- tion So'e fa'ilie% re&ort that early tooth eru&tion i% a fa'ily feature( Children ,ith high birth ,eight ha$e been re&orted to ha$e earlier eru&tion of their &ri'ary teeth than children ,ith nor'al or lo, birth ,eight%( Early eru&tion of the &er'anent dentition 'ay occur in children ,ith &recociou% &uberty and children ,ith endocrine abnor'alitie%, &articularly tho%e of the gro,th or thyroid hor'one%( Natal and neonatal teet% Teeth &re%ent at birth are /no,n a% natal teeth and tho%e that eru&t ,ithin the fir%t 'onth of life a% neonatal teeth( 0&&roxi'ately one in 999-@999 li$e birth% are %o affected( The 'andibular central inci%or i% the 'o%t co''on natal or neonatal tooth( Occa%ionally 'axillary ;central< inci%or% or the fir%t 'olar% 'ay a&&ear a% natal teeth( The $a%t 'a+ority of ca%e% re&re%ent &re'ature eru&tion of a tooth of the nor'al %eBuence( )t ha% been %ugge%ted that thi% condition i% a re%ult of an ecto&ic &o%ition of

the tooth-ger' during foetal life( -atal or neonatal teeth 'ay al%o be %een in a%%ociation ,ith %o'e %yndro'e% including &achyonychia congenita, Elli%-$an Cre$eld %yndro'e, and 1aller'annStreiff %yndro'e( -atal or neonatal teeth are often 'obile becau%e of li'ited root de$elo&'ent and 'ay be a danger to the air,ay if they are inhaled( The cro,n% 'ay be abnor'al in for' and the ena'el 'ay be &oorly for'ed or thinner than nor'al( The 'obility of the tooth freBuently al%o cau%e% infla''ation of the %urrounding gingi$ae( Trau'a to the $entral %urface of the tongue 'ay cau%e ulceration ;6ig( =@(AA< and difficulty during feeding 'ay occur if the infant i% brea%tfed( Treatment 3ocal 'ea%ure% %uch a% %'oothing of the %har& edge% of the tooth ,ith a rubber cone in a dental hand&iece 'ay hel& re%ol$e the ulceration( )n a nu'ber of ca%e%, if the tooth i% 'ar/edly loo%e it %hould be extracted a% it i% unli/ely to for' a u%eful &art of the dentition( 6ir' a&&lication of S&encer-Well% force&% to the tooth cro,n i% ad$i%ed, follo,ed by 'inor local curettage to re'o$e re'ain% of the de$elo&ing tooth-ger' at that %ite( Fi!. /3.00 -atal teeth ?=, C=( #lceration of $entral %urface of tongue( /3.3.2 Dela$ed er- tion Delayed eru&tion of &ri'ary teeth 'ay ari%e fro' either %y%te'ic or local factor%( )t 'ay be a%%ociated ,ith &re'aturity or lo, birth ,eight( Delayed eru&tion of teeth of both dentition% 'ay occur in a%%ociation ,ith Do,n %yndro'e and Turner*% %yndro'e( Delayed eru&tion 'ay al%o be a%%ociated ,ith nutritional abnor'alitie% or endocrine di%order% %uch a% hy&othyroidi%' or hy&o&ituitari%'( Cleidocranial dy%&la%ia i% an auto%o'al do'inant condition characteri5ed by a&la%ia or hy&o&la%ia of the cla$icle% and ,ide%&read cranial change%( The%e include a brachyce&halic %/ull ;%hort in the antero-&o%terior di'en%ion<, frontal and &arietal bo%%ing, hy&o&la%ia of the 'axilla and 5ygo'atic arche%, hy&ertelori%' a% ,ell a% delayed clo%ure of the anterior fontanelle and %/ull %uture%( Multi&le ,or'ian bone% are &re%ent in the line of the cranial %uture%, &articularly the la'bdoid %uture( With re%&ect to the +a,%, the 'o%t %tri/ing dental feature i% the &re%ence of 'ulti&le %u&ernu'erary teeth, &articularly of the &er'anent dentition, and &articularly in the anterior &art% of the +a,%( "er'anent tooth eru&tion i% often delayed or there i% failure of eru&tion, &artly becau%e of the nu'ber of %u&ernu'erary teeth( The &ri'ary teeth 'ay fail to re%orb( 0lthough it ha% been %ugge%ted that there 'ay be hy&o&la%ia of ce'entu' on the root% of the teeth, thi% ha% not been definiti$ely e%tabli%hed( The &ro&ortion of cellular to acellular ce'entu' doe% not %ee' to be %ignificant( 1ereditary gingi$al fibro'ato%i% 'ay be a%%ociated ,ith delayed eru&tion,

&re%u'ably becau%e of a local effect ,hereby the teeth are unable to &enetrate the enlarged and thic/ened gingi$ae( Other, truly locali5ed cau%e% of delayed eru&tion include ecto&ic cry&t &o%ition( Thi% 'o%t often affect% the 'axillary or 'andibular &er'anent canine%, or 'ay &re%ent ,ith the i'&action of the 'axillary fir%t &er'anent 'olar% again%t the di%tal a%&ect of the ad+acent &ri'ary %econd 'olar( 3ocal cau%e% %uch a% the &re%ence of %u&ernu'erarie% or odonto'e% 'ay al%o interfere ,ith eru&tion of an ad+acent &er'anent tooth ;6ig( =@(! ;a< and ;b<<( 0 delay of 'ore than ! 'onth% bet,een the eru&tion of a tooth and it% anti'ere reBuire% in$e%tigation, 'o%t u%ually radiogra&hically( The &o%ition of the &er'anent canine%, &articularly tho%e in the 'axilla, %hould be a%certained by &al&ation not later than the =9th birthday of the child( 0ny uncertainty a% to their &re%ence or &o%ition %hould be follo,ed by radiogra&hic exa'ination( The &otential for &alatal i'&action of the%e teeth 'ay be identified by thi% %i'&le 'ea%ure and %i'&le inter$ention in %elected ca%e%, by the &ro'&t re'o$al of the &ri'ary canine, 'ay &re$ent the need for later %urgery ;Cha&ter =A<( Delayed eru&tion of &er'anent teeth 'ay al%o be due to dilaceration of de$elo&ing root% and cro,n% a% a re%ult of trau'a to the &ri'ary dentition ;Cha&ter = <( Early extraction of a &ri'ary tooth 'ay be a%%ociated ,ith delayed eru&tion of the &er'anent %ucce%%or due to thic/ening of the o$erlying 'uco%a( Treatment 0ny %y%te'ic condition 'ay reBuire treat'ent if thi% i% a$ailable( 3ocal ob%truction% %uch a% %u&ernu'erary teeth or odonto'e% need to be re'o$ed( Surgical ex&o%ure and orthodontic traction 'ay be nece%%ary for late-&re%enting &er'anent canine% and &atient% ,ith hereditary gingi$al fibro'ato%i% 'ay reBuire gingi$ecto'y( )n cleidocranial dy%&la%ia, a co'bined re%torati$e and %urgical and occlu%al 'anage'ent a&&roach to treat'ent &lanning i% reBuired( Retained &ri'ary teeth ,ill li/ely need to be extracted, together ,ith the %urgical re'o$al of uneru&ted %u&ernu'erary teeth( Thi% reBuire% careful treat'ent &lanning, a% the %ucce%%ful eru&tion of the &er'anent dentition cannot be guaranteed( Orthodontic treat'ent to guide the teeth into occlu%ion 'ay be one of the treat'ent o&tion%, ,ith &ro%thetic re&lace'ent of the teeth being con%idered %hould the teeth fail to eru&t( /3.4 DIST(R;ANCES &F E'F&*IATI&N /3.4./ Premat-re e9+oliation "re'ature exfoliation i% al,ay% a cau%e for further in$e%tigation( )t% a%%ociation ,ith hy&o&ho%&hata%ia ha% been con%idered abo$e ;Section =@(?(A<( "re'ature exfoliation 'ay al%o be %een in ca%e% of %e$ere congenital neutro&aenia, cyclical neutro&aenia, Chedia/-1iga%hi %yndro'e ;,here it i% a%%ociated ,ith gro%% &eriodontal de%truction< and in the 3angerhan% cell hi%tiocyto%e% /3.4.2 Dela$ed e9+oliation

In+rao""l-#ion The ter'% infraocclu%ion, %ub'erged teeth and an/ylo%ed teeth are often u%ed to de%cribe teeth ,hich ha$e failed to co'e into nor'al occlu%ion or, 'ore ty&ically, ha$e re'ained in their relati$e &o%ition in the arch ,hile other teeth ha$e continued to eru&t( Thi% i% 'o%t co''only %een ,hen one or 'ore &re'olar% fail% to de$elo&, hence the &ri'ary 'olar% ha$e no %ti'ulu% to beco'e re%orbed( 0% the ad+acent &er'anent teeth eru&t al$eolar gro,th occur%, but in %o'e ca%e% the &ri'ary 'olar% beco'e an/ylo%ed ,ithin the bone and fail to alter their &o%ition ;6ig( =@(A: ;a<<( 0% a re%ult, there i% an o&en bite in the affected area ,ith the occlu%al &lane of the &ri'ary 'olar% being lo,er than that of the ad+acent &er'anent teeth( )t %hould be recogni5ed that the &roce%% of &hy%iological re%or&tion of &ri'ary teeth i% not unre'itting and there are &ha%e% of re%or&tion and re&air( )f there i% an i'balance bet,een the t,o, ,ith the latter &redo'inating ;&articularly in the ab%ence of nor'al &hy%iological %ti'ulu% for re%or&tion<, then the net re%ult i% an/ylo%i%( Genetic factor% 'ay be i'&ortant but the aetiology ha% not yet been re%ol$ed( Treatment 0 %ub%tantial %tudy ha% %ho,n that re'o$al of infraoccluded &ri'ary 'olar% ,ill lead to &rogre%%i$e %&ace lo%% at that %ite ,ith a &otential either to gi$e ri%e to or to focu% cro,ding at that %iteH that all of the infraoccluded teeth in the %tudy ,ere %hed ,ithin the ex&ected ti'e li'it% and that a 'ore con%er$ati$e a&&roach to the 'anage'ent of the%e teeth 'ay be indicated( Where there i% no &er'anent %ucce%%or, the infraoccluded &ri'ary teeth 'ay be retained and the cro,n% built u& ,ith acid-etch co'&o%ite re%toration% or other re%torati$e 'aterial( Onlay%, either in 'etal or laboratory cured co'&o%ite, 'ay be con%idered( ;6ig( =@(A: ;b<< )f extraction i% conte'&lated, then con%ideration need% to be gi$en to orthodontic align'ent, a denture, bridge, or i'&lant( &t%er "a-#e# o+ dela$ed e9+oliation Delayed exfoliation of &ri'ary teeth 'ay be %een in a%%ociation ,ith a nu'ber of local cau%e%, including fu%edDge'inated &ri'ary teeth, ecto&ically de$elo&ing &er'anent teeth and %ub%eBuent to trau'a or %e$ere infection of &ri'ary teeth( >e$ Point# There i% a ti'e range in ,hich teeth eru&tbut thi% range ,ill affect the dentition a% a ,hole( Dentition% falling %ub%tantially out%ide thi% range, or indi$idually affected teeth delayed by ! 'onth%, %hould be in$e%tigated( "re'ature exfoliation al,ay% de'and% in$e%tigation( There i% a &lace for a con%er$ati$e a&&roach to the 'anage'ent of infraoccluded &ri'ary teeth( When %ee/ing a diagno%i% of a de$elo&'ental dental condition &lea%e re'e'berG Co''on thing% occur co''only ;raritie% are rarely %eenI< )% thi% a chronological di%tributionJ

0re any other 'e'ber% of the fa'ily affectedJ 0re all the teeth ;'ore or le%%< eBually affectedJ 0nd finally, *When e$erything el%e ha% been excluded, that ,hich re'ain%, ho,e$er i'&robable, 'u%t be the an%,er* ;Sherloc/ 1ol'e%&ara&hra%e<( Fi!. /3.05 )nfra-occlu%ion tooth ?:H before and after re%toration ,ith a laboratory 'ade co'&o%ite inlay( /3./0 S(77ARY =( Dental ano'alie% 'ay ha$e both a functional and &%ycho-%ocial i'&act on the child and their fa'ily( ( The &re%ence of one dental ano'aly 'ay be a%%ociated ,ith other%( Thorough clinical exa'ination and radiogra&hic in$e%tigation% are e%%ential( @( 0n ano'aly in the &ri'ary dentition 'ay be a%%ociated ,ith a %i'ilar ano'aly in the &er'anent dentition( A( 0ll ca%e% of 'i%%ing teeth reBuire treat'ent &lanning ,ith 'ultidi%ci&linary in&ut( :( 4oth de$elo&'ental ena'el defect% and de$elo&'ental dentine defect% 'ay be genetic or en$iron'ental in origin( !( 4oth de$elo&'ent ena'el defect% and de$elo&'ental dentine defect% 'ay be %een in i%olation or in a%%ociation ,ith extraoral feature%( ?( The di%tribution of an en$iron'entally induced ena'el defect ,ill de&end u&on the %tage of tooth de$elo&'ent at the ti'e of the in%ult( C( Exce%%i$e fluoride inge%tion can cau%e ena'el defect%( >( Dental &rofe%%ional% ha$e an i'&ortant &art to &lay in the diagno%i% and care of children ,ith the%e condition%( =9( Careful 'onitoring of dental de$elo&'ent, together ,ith interce&tion ,hen a&&ro&riate, 'ay reduce the i'&act of the%e condition%( /3.// F(RT5ER READIN6 0ldred, M( 7(, Cra,ford, "( 7( M(, Sa$arirayan, R( ; 99@<( 0'elogene%i% i'&erfectaa cla%%ification and catalogue for the =%t century( 8ral Diseases, >, =>@( 0ldred, M( 7(, Cra,ford, "( 7( M( ;=>>?<( Molecular biology of hereditary ena'el defect%( )n Dental 7namel( &&( 99- 9>, Chiche%terG Wiley( 0ldred, M( 7( ; 99@<( 1u'an Genetic%( )n 8xford Hand,oo% of "pplied Dental #cience ;ed( C( Scully<, &&( @C>-A9!( Oxford Medical "ublication%, Oxford(

4roo/, 0( 1(, Winter, G( 4( ;=>?9<( Double teeth( 0 retro%&ecti$e %tudy of *ge'inated* and *fu%ed* teeth in children( $ritish Dental +ournal, 0, = >;@<, = @-@9( Cra,ford, "( 7( M(, 0ldred, M( 7( ;=>C><( Regional odontody%&la%iaG a bibliogra&hy( +ournal of 8ral Pathology (edicine, /3, :=-!@( Cra,ford, "( 7( M(, 0ldred, M( 7( ;=>> <( X-lin/ed a'elogene%i% i'&erfecta( "re%entation of t,o /indred% and a re$ie, of the literature( 8ral surgery; 8ral (edicine; and 8ral Patholgy 23, AA>-::( Gorlin, R( 7(, Cohen, M( M(, Cohen, R(, and 1enne/a', R( ; 99=<( #yndromes of the Head and 6ec% ;Oxford Monogra&h% on Medical Genetic%<( Oxford #ni$er%ity "re%%, Oxford( 1all, R( 2(, 4an/ier, 0(, 0ldred, M( 7(, 2an, 2(, 3uca%, 7( O(, and "er/%, 0( G( 4( ;=>>?<( Solitary 'edian 'axillary central inci%or, %hort %tature, choanal atre%iaD'idna%al %teno%i% ;SMMC)< %yndro'eG an analy%i% of the clinical feature% of => con%ecuti$e ca%e% of the %yndro'e, a re$ie, of the literature and con%ideration of it% aetiology( Oral Surgery, 8ral (edicine; and 8ral Pathology 30, !:=-!! ( 2urol, 7( and 2och, G( ;=>C:<( The effect of extraction of infraoccluded deciduou% &ri'ary 'olar%G 0 longitudinal %tudy( "merican +ournal of 8rthodontics, 32;=<, A!::( Online Mendelian )nheritance in Man, OM)M ;TM<( Mc2u%ic/--athan% )n%titute for Genetic Medicine, 7ohn% 1o&/in% #ni$er%ity ;4alti'ore, MD< and -ational Center for 4iotechnology )nfor'ation, -ational 3ibrary of Medicine ;4ethe%da, MD<, 999( htt&GDD,,,(ncbi(nl'(nih(go$D,o'i'D Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

/0. T%e aedodonti"Bort%odonti" inter+a"e - 6 7 Carter /0./ INTR&D(CTI&N The long-ter' 'anage'ent of a child*% de$elo&ing occlu%ion often benefit% greatly

fro' a good ,or/ing relation%hi& bet,een the &aediatric denti%t and the orthodonti%t( Ty&ical &roble'% range fro' 'ini'i5ing da'age to the occlu%ion cau%ed by enforced extraction of &oor Buality teeth, through the 'anage'ent of %&ecific local abnor'alitie% %uch a% i'&acted teeth, to referral for co'&rehen%i$e treat'ent of all a%&ect% of the 'alocclu%ion( Thi% cha&ter di%cu%%e% the &rinci&le% of ,hen to refer to a %&eciali%t colleague, and loo/% at %o'e co''on clinical %ituation% ,here collaboration i% often needed( /0.2 REC&6NITI&N &F 7A*&CC*(SI&N /0.2./ &rt%odonti" a##e##ment 0ll children fro' the age of C year% %hould be %creened for the &re%ence of 'alocclu%ion ,hen they attend for a routine dental exa'ination( 0lthough orthodontic treat'ent i% u%ually carried out in the late 'ixed and early &er'anent dentition, %o'e condition% do benefit fro' treat'ent at an earlier %tage( The %creening need only be a brief clinical a%%e%%'ent, but it %hould be carried out %y%te'atically to en%ure that no i'&ortant finding% are o$erloo/ed( 0n outline of a ba%ic orthodontic a%%e%%'ent i% gi$en in Table =A(=( With &ractice thi% can be carried out Buite Buic/ly to gi$e an o$erall i'&re%%ion of the nature and %e$erity of a 'alocclu%ion( )n e%%ence, it co'&ri%e% a%%e%%'ent% of the follo,ing ele'ent%G ;=< the &atient*% a,arene%% of their 'alocclu%ion ;the co'&laint, if any<H ; < their general le$el of dental a,arene%%H ;@< an extraoral exa'ination of facial for' ;%/eletal &attern and %oft ti%%ue%<H ;A< general oral conditionoral hygiene and tooth BualityH ;:< the &re%ence or ab%ence of all teethH ;!< the align'ent and for' of each archH ;?< the teeth in occlu%ion( Radiogra&h% are not nece%%ary routinely ,hen %creening for the &re%ence of 'alocclu%ion, and %hould only be ta/en ,hen there i% a clinical indication( 0 &anora'ic radiogra&h gi$e% a u%eful general %can of the dentition and indicate% the &re%ence or ab%ence of teeth( So'e authoritie% ad$i%e that it %hould be %u&&le'ented ,ith a na%o-occlu%al $ie, a% the &re'axillary region i% often &oorly %ho,n on &anora'ic $ie,% and i% co''only the %ite of dental ano'alie%( 4ut, &ro$ided that the &anora'ic $ie, i% of rea%onable Buality, intraoral $ie,% of thi% region are only nece%%ary if there i% a %&ecific indication for the', %uch a% delayed eru&tion of an inci%or or a hi%tory of trau'a( 0 radiogra&hic a%%e%%'ent 'u%t al,ay% be 'ade ,hen con%idering any extraction%( Good Buality %tudy 'odel% are often hel&ful ,hen &lanning orthodontic treat'ent, and full orthodontic record% co'&ri%ing %tudy 'odel%, rele$ant radiogra&h%, and &hotogra&h% %hould be obtained before any acti$e treat'ent i% %tarted( 6ull-face and &rofile &hotogra&h% are a record of facial for', including li& 'or&hology( )ntraoral &hotogra&h% are a further record of the 'alocclu%ion, gi$e %o'e indication of the %tandard of oral hygiene, and are $aluable ,here ena'el defect% are &re%ent before treat'ent(

/0.2.2 Need and demand +or ort%odonti" treatment The )ndex of Orthodontic Treat'ent -eed ;)OT-< i% ba%ed u&on the %e$erity of the 'alocclu%ion, and ha% been de$elo&ed to try to e%tabli%h a con%en%u% ,ithin the &rofe%%ion a% to ,hich 'alocclu%ion% ,ill gain a ,orth,hile benefit fro' orthodontic treat'ent( The co'&lexity and difficulty of treat'ent do not nece%%arily de&end u&on the %e$erity of the 'alocclu%ion, and 'ild 'alocclu%ion% often need exten%i$e and %o&hi%ticated treat'ent if any i'&ro$e'ent i% to be 'ade at all( Other indice% ha$e been de$elo&ed to a%%e%% the co'&lexity and %ucce%% of treat'ent( The )OT- ha% t,o co'&onent%G =( -he Dental Health Component categori5e% 'alocclu%ion into fi$e grade% ;Table =A( < according to %e$erity, ba%ed u&on current e$idence for the detri'ental effect% of $ariou% occlu%al feature%( 0 'alocclu%ion i% graded according to it% ,or%t feature( "atient% in grade% = and ha$e little or no indication for treat'ent on dental health ground%, ,hile tho%e in grade% A and : are con%idered to ha$e a definite need for treat'ent( The borderline ca%e% in grade @ reBuire a degree of +udge'ent ,hen deciding u&on their need for treat'ent, and the a&&earance of the dentition can be ta/en into account u%ing the 0e%thetic Co'&onent of the )OT-( ( -he "esthetic Component of the )OT- u%e% a %cale of =9 &hotogra&h% %ho,ing different le$el% of dental attracti$ene%% ;6ig( =A(=<( The a&&earance of the dentition i% rated u%ing the &hotogra&h% a% a guideline( Grade% =-A indicate little or no need, for treat'ent on ae%thetic ground%, grade% :-? are borderline, and &atient% in grade% C-=9 ,ould clearly benefit fro' orthodontic treat'ent( )t i%, ho,e$er, difficult to be truly ob+ecti$e ,hen 'a/ing +udge'ent% of thi% /ind about an indi$idual*% a&&earance, and the 0e%thetic Co'&onent ha% not achie$ed uni$er%al u%e becau%e of it% %ub+ecti$e nature( De'and for orthodontic treat'ent i% affected by 'any factor%( "atient% $ary enor'ou%ly in ho, they &ercei$e their o,n dental a&&earance, %o'e a&&arently being una,are of ob$iou% 'alocclu%ion% ,hile other% ex&re%% di%%ati%faction about $ery 'inor irregularitie%( De'and for treat'ent thu% de&end% u&on the %e$erity of the 'alocclu%ion a% &ercei$ed by &atient% and &arent% rather than by denti%t%( )t i% al%o affected by &atient%* attitude% to ,earing orthodontic a&&liance%, ,hich are influenced by the a&&earance of the a&&liance% and ho, acce&table they thin/ a&&liance treat'ent i% a'ong their &eer%( De'and for orthodontic treat'ent tend% to increa%e a% a&&liance% beco'e 'ore co''on and acce&ted a'ong a &o&ulation, but it i% al%o greatly affected by the a$ailability of treat'ent ;geogra&hic acce%%ibility, ,aiting li%t%, etc(<( Fi!. /0./ The 0e%thetic Co'&onent of the )ndex of Orthodontic Treat'ent -eed( ;R( E$an% and W( Sha, ;=>C?<( Re&roduced ,ith /ind &er'i%%ion of the Editor of the 7uropean +ournal of 8rthodontics(< /0.2.3 Re+erral +or ort%odonti" ad.i"e The referring denti%t can gi$e the orthodonti%t a lot of in$aluable infor'ation(

Timin! o+ re+erral The right ti'e for orthodontic inter$ention ,ill $ary according to the condition, but if %&eciali%t ad$ice i% needed it i% better to refer too early rather than too late( The 'a+ority of orthodontic treat'ent% are carried out in the late 'ixed and early &er'anent dentition, but %o'e condition% 'ay be treated earlier ;%ee Section =A(A<, and %o'e treat'ent%, %uch a% functional a&&liance%, de&end on acti$e facial gro,th and %hould not be delayed too long before %tarting( Patient and +amil$ attit-de# )n 'any ca%e% the denti%t ,ill ha$e /no,n the fa'ily for %o'e ti'e, and ,ill /no, their le$el of dental a,arene%%, their degree of concern about the 'alocclu%ion, and their attendance record( Thi% infor'ation can be difficult for the orthodonti%t to &ic/ u& during one or t,o %hort con%ultation%, but i% $ital ,hen a%%e%%ing the li/ely co'&liance ,ith orthodontic treat'ent( &ral %$!iene 0&&liance thera&y i% ina&&ro&riate for &atient% ,ho%e oral hygiene i% &oor and in general thi% %hould be i'&ro$ed before referring for orthodontic treat'ent( 1o,e$er, thi% %hould not be at the ex&en%e of exce%%i$e delay in referring tho%e &atient% ,ith 'ore %e$ere 'alocclu%ion% ,ho 'ay gain %o'e benefit fro' %i'&le interce&ti$e 'ea%ure%( Pro!no#i# o+ teet% The fa'ily denti%t i% in a 'uch better &o%ition than the orthodonti%t to e%ti'ate the &rogno%i% of re%tored or trau'ati5ed teeth( Radio!ra %# 0ny rele$ant radiogra&h% %hould be for,arded ,ith the referral to a$oid unnece%%ary re&etition( >e$ Point# Screening 0ll children %hould be %creened for 'alocclu%ion fro' C year% of age( 7udge the need for treat'ent u%ing the )ndex of Treat'ent -eed ;)OT-<G dental health and ae%thetic%( Chec/ the oral hygiene and attitude to treat'ent( Refer in good ti'e and gi$e a% 'uch bac/ground infor'ation a% &o%%ible( /0.3 E'TRACTI&NS IN T5E 7I'ED DENTITI&N /0.3.0 Introd-"tion The extraction of teeth in children 'ay be needed a% &art of orthodontic treat'ent, or 'ay be nece%%ary becau%e of carie%, trau'a, or de$elo&'ental ano'alie%( The extraction of teeth in the 'ixed dentition for &urely orthodontic rea%on%, u%ually

cro,ding, can %o'eti'e% be hel&ful, but 'anaging the enforced extraction of cariou% or &oor Buality teeth i% a 'atter of trying to 'ini'i5e di%ru&tion of the de$elo&ing dentition( /0.3./ E9tra"tion o+ rimar$ teet% )n general, ,here a child ha% a tendency to dental cro,ding, the extraction of &ri'ary teeth ,ill ,or%en thi% a% it allo,% the ad+acent teeth to drift into the re%ulting %&ace( #%ually, it i% the teeth di%tal to the extraction that 'igrate for,ard% a% a re%ult of 'e%ial drift( Thi% drifting i% generally unhel&ful ,here the extraction i% enforced, but in %o'e %ituation% it can be harne%%ed to hel& ,ith the 'anage'ent of dental cro,ding( 0% there i% a %ignificant increa%e in the %i5e of the arche% during the 'ixed dentition %tage, deci%ion% about the treat'ent of cro,ding %hould be deferred until the &er'anent inci%or% ha$e eru&ted for at lea%t a year, u%ually at about C =D - > year% of age( Where there i% %e$ere cro,ding, the extraction of &ri'ary teeth 'ay be con%idered at thi% &oint a% &art of a &rogra''e of %erial extraction%, but ,here the cro,ding i% 'ild the deci%ion %hould be delayed until the &er'anent canine% and &re'olar% are eru&ting( The ter' *balancing extraction* refer% to the contralateral tooth in the %a'e arch, ,hile a *co'&en%ating extraction* refer% to the eBui$alent tooth in the o&&o%ite arch( /0.3.2 Serial e9tra"tion Serial extraction i% a for' of interce&ti$e orthodontic treat'ent ,hich ai'% to relie$e cro,ding at an early %tage %o that the &er'anent teeth can eru&t into good align'ent, thu% reducing or a$oiding the need for later a&&liance thera&y( )t con%i%t% of a &lanned %eBuence of extraction%G =( Primary caninesextracted a% the &er'anent lateral inci%or% eru&t to allo, the' %&ace to align( ( 1irst primary molarsabout = year later, or ,hen the root% of the fir%t &ri'ary 'olar% are half re%orbed or 'ore, to encourage eru&tion of the fir%t &re'olar%( )n the lo,er arch the%e often tend to eru&t after the canine%( @( 1irst premolarson eru&tion to 'a/e %&ace for the eru&tion of the &er'anent canine% into align'ent( )n effect, the extraction of &ri'ary canine% tran%fer% the cro,ding fro' the inci%or% to the canine region% ,here it i% 'ore ea%ily treated by extracting the fir%t &re'olar% ;6ig( =A( <( )t i% e%%ential to carry out a full orthodontic a%%e%%'ent before e'bar/ing on a cour%e of %erial extraction%( The indication% for %erial extraction areG ;=< %ignificant inci%or cro,dingH ; < &atient aged about > year%H ;@< cla%% ) occlu%ion ,ithout a dee& o$erbiteH ;A< all &er'anent teeth &re%entH

;:< fir%t &er'anent 'olar% in good condition( The intended ad$antage of %erial extraction i% to 'ini'i5e or eli'inate the need for a&&liance% to align the arche% after the &er'anent teeth ha$e eru&ted( So'eti'e% thi% i% $ery %ucce%%ful ;6ig( =A(@<, but the re%ult% can be di%a&&ointing( Where cro,ding i% %e$ere it 'ay be nece%%ary to fit a %&ace 'aintainer follo,ing extraction of the fir%t &re'olar%, to en%ure that 'e%ial drift of &o%terior teeth doe% not lea$e the canine% %hort of %&ace ;%ee Section =A(A(A<( The great di%ad$antage of %erial extraction i% the 'ulti&le e&i%ode% of extraction%, %tarting ,hen the child i% Buite young( The%e 'ay ,ell be a child*% fir%t ex&erience of dental treat'ent and 'ight cau%e %ub%eBuent &%ychological &roble'% ,ith their attitude to denti%try, e%&ecially a% the ex&erience i% to be re&eated a% the &rogra''e of extraction% &roceed%( The li/ely benefit of the extraction% 'u%t be con%idered $ery carefully, and in only a %'all 'inority of ca%e% ,ould general anae%the%ia be +u%tified for thi% &ur&o%e( )n &ractice, the extraction of the fir%t &ri'ary 'olar% i% u%ually o'itted, and the deci%ion thu% beco'e% ,hether the &ri'ary canine% %hould be extracted( Extraction of the%e teeth 'ight be indicated ,here it i% clear that orthodontic a&&liance% %hould be 'ini'i5ed or a$oided for %o'e rea%on, or ,here the cro,ding i% ob$iou%ly %e$ere and i% cau%ing gro%% inci%or di%&lace'ent or cro%%-bite( )t i% al%o %o'eti'e% indicated to encourage the eru&tion of an ecto&ic &er'anent tooth ;%ee Section =A(:(A<( 1o,e$er, it 'u%t al,ay% be borne in 'ind that the extraction% ,ill allo, %o'e 'e%ial 'igration of the buccal %eg'ent%, %o increa%ing the cro,ding( The extraction% %hould al,ay% be balanced by re'o$ing the contralateral canine to &re$ent a centreline %hift, but it i% not nece%%ary to co'&en%ate by extracting the canine% in the o&&o%ite arch( Fi!. /0.2 Serial extraction%( ;a< Cla%% ) occlu%ion ,ith inci%or cro,ding in the 'ixed dentition( ;b< )'&ro$ed inci%or align'ent follo,ing extraction of &ri'ary canine%( The &ri'ary fir%t 'olar% are extracted to encourage eru&tion of the fir%t &re'olar%( ;c< 6ir%t &re'olar% are extracted on eru&tion to relie$e cro,ding of the &er'anent canine%( ;d< The re%ult follo,ing eru&tion of the canine%( Fi!. /0.3 ;a< Cla%% ) occlu%ion ,ith cro,ding of the lateral inci%or% in an C =D year old &atient, before extraction of &ri'ary canine%( ;b< 0ged =9 =D -, ! 'onth% before extraction of fir%t &re'olar%( #&&er canine% &al&able in buccal %ulcu%, lo,er canine% cro,ded buccally( ;c< 0ged =@exce%% %&ace in lo,er arch( ;d< 0ged =:u&&er %&ace% clo%ed, lo,er %&ace% reducing( ;"hoto% courte%y of Mr T( G( 4ennett(< /0.3.3 En+or"ed e9tra"tion o+ rimar$ teet% The 'ain co'&lication of the enforced extraction of &oor Buality &ri'ary teeth i% 'e%ial drift of the teeth di%tal to the extraction %&ace, cau%ing cro,ding of the &er'anent %ucce%%or%( Me%ial drift i% greate%t ,here there i% a tendency to cro,ding, and it al%o beco'e% greater the 'ore di%tal the tooth to be extracted i%( )t i% greater in the u&&er arch than in the lo,er, a% the u&&er &er'anent 'olar% are di%tally inclined on eru&tion and readily 'o$e 'e%ially by u&righting, ,herea% the lo,er &er'anent 'olar% are 'e%ially inclined on eru&tion and 'o$e for,ard le%% readily, but tilt 'e%ially a% they do %o(

Extraction of primary incisors u%ually cau%e% $irtually no drifting of other teeth, but if done $ery early 'ay delay the eru&tion of the &er'anent inci%or%( ;3o%% of a &er'anent inci%or i% a $ery different 'atter%ee Section =A(?(=(< Extraction of a primary canine cau%e% %o'e 'e%ial drift of the buccal %eg'ent, de&ending u&on the degree of cro,ding( There i% al%o drift of the inci%or% into the %&ace, ,hich cau%e% a centreline %hift to,ard% the extraction %ite( Thi% %hould be &re$ented by balancing the extraction ,ith lo%% of the contralateral canine( )n the %a'e ,ay the extraction of a primary first molar allo,% 'e%ial drift of the teeth di%tal to it, 'ore than ,ith the lo%% of a canine, and there 'ay al%o be %o'e effect on the centreline( Where the di%tribution of carie% indicate% lo%% of a &ri'ary canine on one %ide and a &ri'ary fir%t 'olar on the other, the%e extraction% can be regarded a% balancing each other rea%onably ,ell and the contralateral teeth can be retained( Extraction of a primary second molar allo,% %ignificant 'e%ial 'igration of the fir%t &er'anent 'olar in that Buadrant, cau%ing &otentially %e$ere local cro,ding ,ith di%&lace'ent or i'&action of the %econd &re'olar, e%&ecially in the u&&er arch ,here 'e%ial drift i% greate%t ;6ig( =A(A<( 1o, %e$ere thi% i% de&end% on the degree of cro,ding, and in a %&aced arch the extraction ha% little effect( )n &rinci&le, ho,e$er, the lo%% of a &ri'ary %econd 'olar %hould be a$oided if at all &o%%ible, e%&ecially in the u&&er arch( 0 %&ace 'aintainer, either re'o$able or fixed, can be con%idered, unle%% the &atient*% carie% rate i% high or the oral hygiene i% &oor( "ri'ary %econd 'olar extraction% %hould ne$er be balanced on the contralateral %ide a% there i% $ery little effect on the centreline and the &otential cro,ding beco'e% co'&licated e$en further( )n general, there i% no need to co'&en%ate &ri'ary tooth extraction% ,ith extraction% in the o&&o%ing arch( >e$ Point# Mixed dentition extraction% Early lo%% of &ri'ary teeth generally ,or%en% cro,ding( "ri'ary %econd 'olar% %hould be &re%er$ed if at all &o%%ible( Extraction of &ri'ary canine% 'ay hel& inci%or cro,ding( 4enefit of thi% 'u%t be balanced again%t the trau'a of extraction%( Extraction of &ri'ary canine% %hould be balanced on the contralateral %ide( Fi!. /0.0 ;a< and ;b< 3ocali5ed cro,ding of u&&er %econd &re'olar% due to the early lo%% of &ri'ary u&&er %econd 'olar%( ;"hoto% courte%y of "rofe%%or 7( 1( -unn(< /0.3.0 En+or"ed e9tra"tion o+ +ir#t ermanent molar# 6ir%t &er'anent 'olar% are $ery rarely the teeth of choice for extraction for orthodontic rea%on%in &ractice their re'o$al often 'a/e% treat'ent 'ore difficult( =( The %&ace they &ro$ide i% re'ote fro' the labial %eg'ent% and i% &oorly &laced either for the relief of anterior cro,ding or for o$er+et reduction(

( De&ending on the ti'ing of the extraction%, 'uch of the %&ace i% lo%t to 'e%ial 'igration of the %econd 'olar%, e%&ecially in the u&&er arch ;%ee Section =A(@(@<( @( The beha$iour of the lo,er %econd 'olar% i% fairly un&redictable follo,ing lo%% of lo,er fir%t &er'anent 'olar% and i% greatly influenced by the ti'ing of the extraction%( )n general, therefore, fir%t &er'anent 'olar% are only extracted if their long-ter' &rogno%i% i% felt to be &oor, and the orthodontic 'anage'ent of the%e extraction% ai'% to 'ini'i5e di%ru&tion of the de$elo&ing dentition( Where the lo%% of one or 'ore fir%t 'olar% i% nece%%ary in the 'ixed dentition, the 'anage'ent of the extraction% de&end% on ,hether or not the &atient i% li/ely to ha$e acti$e treat'ent ,ith orthodontic a&&liance% in the futureoften a difficult +udge'ent to 'a/e( 0 &anora'ic radiogra&h 'u%t be ta/en to confir' the &re%ence of all &er'anent teeth ;exce&t for third 'olar%< before finali5ing the extraction%( The follo,ing di%cu%%ion a%%u'e% the &re%ence of all &er'anent teethif a &re'olar i% congenitally ab%ent then the fir%t 'olar in that Buadrant %hould be %a$ed if &o%%ible( E9tra"tion o+ +ir#t ermanent molar# C%ere no ort%odonti" treatment i# lanned The ob+ecti$e i% to 'ini'i5e di%ru&tion of the occlu%ion( 6ollo,ing the extraction of a fir%t 'olar, the &ath% of eru&tion of ad+acent uneru&ted teeth alter, and eru&ted ad+acent and o&&o%ing teeth al%o %tart to drift( Many of the%e change% are unhel&ful, but %o'e can be u%ed to ad$antage ,ith careful &lanning( )n general, the 'o%t ob$iou% change i% 'e%ial drift of the %econd 'olar, e%&ecially in the u&&er arch( 1o,e$er, in the lo,er arch %o'e di%tal 'o$e'ent of &re'olar% and canine% 'ay al%o be ex&ected, e%&ecially ,here the arch i% cro,ded( The extraction of fir%t 'olar% can be a con$enient ,ay of relie$ing &re-'olar cro,ding, e%&ecially in the lo,er arch( )n the lo,er arch the ti'ing of the extraction i% i'&ortant( )f carried out $ery early the uneru&ted lo,er %econd &re-'olar 'igrate% di%tally, %o'eti'e% lea$ing a %&ace bet,een the fir%t and %econd &re'olar% if the arch i% uncro,ded ;6ig( =A(:<( )f carried out late, a% or after the lo,er %econd 'olar% eru&t%, that tooth tilt% 'e%ially under occlu%al force% and can cau%e an occlu%al interferencee%&ecially if the o&&o%ing u&&er fir%t 'olar o$ereru&t% into the lo,er extraction %&ace ;6ig( =A(! ;a< and ;b<<( There i% often re%idual %&ace 'e%ial to the tilted %econd 'olar and thi% &oor relation%hi& ,ith the %econd &re'olar 'ay cau%e a %tagnation area( The%e un,anted effect% can be 'ini'i5ed in t,o ,ay%G =( Extraction of the u&&er fir%t 'olarthi% eli'inate% the &roble' of o$ereru&tion of the o&&o%ing fir%t 'olar, and re'o$e% the occlu%al contact ,hich exaggerate% 'e%ial tilting of the lo,er %econd 'olar ;6ig( =A(? ;a< and ;b<<( ( Careful ti'ing of the extraction%ideally ,hen the bifurcation of the root% of the lo,er %econd 'olar i% %tarting to calcify, u%ually at about C =D - > =D year% of age ;6ig( =A(C ;a< and ;b<<( )n the upper arch the beha$iour of the %econd 'olar i% 'ore &redictable, although

ti'ing i% %till i'&ortant( The tendency to 'e%ial drift i% 'uch greater than in the lo,er arch, and there i% al'o%t no di%tal drift of the u&&er &re'olar%( )f the u&&er fir%t 'olar i% extracted early, the uneru&ted %econd 'olar 'igrate% 'e%ially %o that it eru&t% into the &o%ition of the fir%t 'olar( )f the %econd 'olar ha% eru&ted before the extraction it %till 'igrate% for,ard, ta/ing u& 'o%t or all of the %&ace de&ending on the degree of cro,ding, and it u%ually tilt% 'e%ially and rotate% 'e%io&alatally about the &alatal root( 1o,e$er, co'&en%ating extraction of the lo,er fir%t 'olar i% not indicated ;6ig( =A(> ;a< and ;b<<( 4alancing extraction% of the contralateral fir%t &er'anent 'olar% are not routinely nece%%ary unle%% they al%o are in &oor condition( Where the arch i% cro,ded an extraction on the o&&o%ite %ide i% u%ually needed to relie$e cro,ding and &re$ent any %hift of the centreline, but if the fir%t &er'anent 'olar% are in good condition the extraction of fir%t &re'olar% 'ay ,ell be 'ore a&&ro&riate( >e$ Point# 6ir%t &er'anent 'olar extraction% The%e are ne$er the teeth of choice for orthodontic extraction( The be%t age for lo%% i% C =D - > =D year%( Extraction of the u&&er fir%t 'olar 'ay reduce occlu%al di%turbance ,here the lo,er fir%t 'olar ha% to be extracted( There i% no need to extract the lo,er fir%t 'olar if the u&&er fir%t 'olar ha% to be extracted( Contralateral extraction% de&end on the degree of cro,ding( E9tra"tion o+ +ir#t ermanent molar# C%ere ort%odonti" treatment i# lanned Where future a&&liance treat'ent i% antici&ated, the ob+ecti$e i% to try to a$oid co'&licating it( )t i% difficult to gi$e hard and fa%t rule% a% the 'anage'ent %trategy ,ill differ for each &atient, but the 'ain factor to con%ider i% the a'ount of %&ace that ,ill be needed( Where the extraction %&ace i% to be u%ed to relie$e cro,ding or reduce an increa%ed o$er+et, un,anted 'e%ial drift of the %econd &er'anent 'olar% 'u%t be 'ini'i5ed( On the other hand, ,here there ,ill be exce%% %&ace, 'e%ial drift of the %econd &er'anent 'olar% %hould be encouraged( )n the lower arch the extraction% are 'anaged according to %e$erity of cro,ding( Where there i% little or no cro,ding the extraction %hould, if &o%%ible, be carried out at the *ideal* age of about C =D - > =D year%, %o a% to encourage 'e%ial 'igration of the %econd 'olar( Where there i% %ignificant cro,ding it i% better to delay the extraction, if &o%%ible, until after the lo,er %econd 'olar ha% eru&ted, %o that the %&ace i% a$ailable for align'ent of the arch( The upper arch i% al%o 'anaged according to %&ace reBuire'ent%, but the%e are deter'ined not only by the a'ount of cro,ding but al%o by the cla%% of 'alocclu%ion( Where there i% %ignificant cro,ding the u&&er fir%t 'olar% %hould be &re%er$ed if &o%%ible until after the u&&er %econd 'olar% ha$e eru&ted and can be included in an a&&liance( Si'ilarly, in a cla%% )) 'alocclu%ion %&ace ,ill be u%eful to reduce an increa%ed o$er+et and, again, ,here &o%%ible the extraction% %hould be delayed( )f the u&&er fir%t 'olar ha% to be re'o$ed earlier it i% %o'eti'e% &o%%ible to %tart treat'ent

,ith a&&liance% before the u&&er %econd 'olar% ha$e eru&ted, but the treat'ent tend% to be 'ore co'&lex, ,ith headgear to 'o$e the u&&er &re'olar% di%tally( Con$er%ely, exce%% u&&er arch %&ace in a cla%% ))) 'alocclu%ion co'&licate% treat'ent, a% &roclining the u&&er inci%or% i% a for' of ex&an%ion ,hich it%elf create% 'ore %&ace( Clearly, ,here acti$e orthodontic treat'ent i% &lanned the lo%% of a lo,er fir%t 'olar i% not auto'atically co'&en%ated by the extraction of the o&&o%ing u&&er fir%t 'olar( The broad &rinci&le% of the 'anage'ent of enforced extraction of fir%t 'olar% are %u''ari5ed in Table =A(@( Fi!. /0.5 S&ace% bet,een the lo,er fir%t and %econd &re'olar% re%ulting fro' $ery early extraction of the lo,er fir%t 'olar%( Fi!. /0.1 ;a< and ;b< 3o%% of the lo,er fir%t 'olar after eru&tion of the %econd 'olar% cau%e% %e$ere ti&&ing of the lo,er %econd 'olar and o$ereru&tion of the u&&er fir%t 'olar( Fi!. /0.2 ;a< and ;b< Extraction of the u&&er fir%t 'olar a% ,ell a% the lo,er &re$ent% o$ereru&tion of the o&&o%ing fir%t 'olar and reduce% the 'e%ial tilting of the lo,er %econd 'olar( Fi!. /0.3 ;a< and ;b< Extraction of the fir%t 'olar% ,hen the bifurcation of the root% of the lo,er %econd 'olar i% %tarting to calcify, u%ually C =D - > =D year% of age, gi$e% the be%t chance of a good re%ult( Fi!. /0.4 ;a< and ;b< Extraction of the u&&er fir%t 'olar doe% not need to be co'&en%ated ,ith extraction of the lo,er fir%t 'olar( /0.0 APP*IANCE TREAT7ENT IN T5E 7I'ED DENTITI&N /0.0.0 Introd-"tion The great 'a+ority of orthodontic treat'ent% are carried out during the late 'ixed and early &er'anent dentition%, to a$oid &rolonged a&&liance ,ear ,hile &er'anent teeth eru&t( 1o,e$er, a fe, condition% can benefit fro' earlier inter$ention( /0.0./ Anterior "ro##-,ite 0lthough it 'ay be a %ign of a de$elo&ing cla%% ))) &roble', a local anterior cro%%-bite in$ol$ing one or t,o inci%or% i% often %i'&ly due to the &o%ition% of the de$elo&ing tooth-ger'% cau%ing the teeth to eru&t into cro%%-bite( "o%%ible co'&lication% of a locali5ed anterior cro%%-bite include a &re'ature contact ,ith the tooth in cro%%-bite, ,hich cau%e% the 'andible to di%&lace for,ard% a% the teeth co'e into 'axi'u' intercu%&al &o%ition, or one lo,er inci%or in cro%%-bite 'ay be dri$en labially through the %u&&orting ti%%ue%, cau%ing locali5ed gingi$al rece%%ion ;6ig( =A(=9<( Early correction encourage% de$elo&'ent of a cla%% ) occlu%ion, and treat'ent in the 'ixed dentition i% often %traightfor,ard &ro$ided that the%e criteria are 'etG =( 6ormal s%eletal pattern( Treat'ent of ob$iou% cla%% ))) &roble'% %hould be delayed until the nature of the &atient*% gro,th &attern beco'e% clearer( 1o,e$er, it i% e%%ential to chec/ for the &re%ence of a for,ard di%&lace'ent of the 'andible, a% thi%

can 'a/e a nor'al facial &attern a&&ear to be %lightly &rognathic( ( "de:uate space in the arch( There 'u%t be enough %&ace to acco''odate the tooth in align'ent( )n a cro,ded u&&er arch, %&ace 'ay be 'ade for align'ent of u&&er lateral inci%or% by extracting the &ri'ary u&&er canine% ;%ee %erial extraction, Section =A(@( <( Thi% treat'ent 'u%t be %tarted fairly early ,hile the &er'anent canine i% %till high, becau%e labial 'o$e'ent of the lateral inci%or ,ill be &re$ented if the canine cro,n i% labial to the root of the lateral( )t i% therefore e%%ential to &al&ate the &o%ition of the &er'anent canine cro,n, and, if it ha% co'e do,n too far, treat'ent 'u%t be delayed until the fir%t &re'olar% ha$e eru&ted( @( "de:uate over,ite( Stable correction of the cro%%-bite de&end% on there being &o%iti$e o$erbite after treat'ent( 3abial ti&&ing of u&&er inci%or% ,ith a re'o$able a&&liance tend% to reduce o$erbite, and %&eciali%t ad$ice %hould be %ought ,here lac/ of o$erbite i% a &roble'( There are 'any de%ign% of re'o$able a&&liance to correct anterior cro%%-bite% and a ty&ical exa'&le i% %ho,n in 6ig( =A(== ;a< and ;b<( )t% e%%ential feature% areG =( "n active component %uch a% a S-%&ring or a %cre, &alatal to the tooth to be 'o$ed( ( )etention a% far anteriorly a% &o%%ible to re%i%t the tendency of the %&ring to di%&lace the front of the a&&liance( @( Posterior capping to o&en the occlu%ion ,hile the u&&er inci%or 'o$e% labially o$er the lo,er%( Fi!. /0./0 3ocali5ed gingi$al rece%%ion a%%ociated ,ith inci%or cro%%-bite( Fi!. /0.// ;a< and ;b< 0&&liance to &rocline u&&er inci%or( -ote &o%terior ca&&ing to di%engage occlu%ion and retention anterior to !T! to re%i%t the di%&lacing force generated by the S-%&ring( /0.0.2 Po#terior "ro##-,ite Cit% di# la"ement 4ilateral &o%terior cro%%-bite% are often acce&ted a% they u%ually reflect a tran%$er%e %/eletal di%cre&ancy and cau%e no functional &roble'( Where the u&&er arch i% %lightly narro,, the buccal teeth 'ay initially occlude cu%& to cu%& and only achie$e full intercu%&ation ,hen the 'andible di%&lace% laterally ;6ig( =A(= ;a< and ;b<<, cau%ing a unilateral &o%terior cro%%-bite( Thi% can be difficult to detect if the &atient cannot relax the +a, 'u%cle% fully during exa'ination, but it i% i'&ortant to deter'ine ,hether or not there i% a lateral di%&lace'ent( 0 unilateral &o%terior cro%%bite ,ith a di%&lace'ent i% ea%ily corrected during the 'ixed dentition, but one ,ithout an a%%ociated di%&lace'ent i% &robably %/eletal in origin and correction %hould not be atte'&ted( 0 unilateral &o%terior cro%%-bite ,ith a di%&lace'ent i% treated by ex&an%ion of the u&&er arch to re'o$e the initial cu%&-to-cu%& contact, u%ing an a&&liance %uch a% that %ho,n in 6ig( =A(= ;c<( )t ha% a 'id-line ex&an%ion %cre, ,hich i% turned by the &arent once or t,ice a ,ee/, and double 0da'% cla%&% on !eTe!( The dTd are u%ually

un%uitable for cla%&ing a% they ha$e little or no undercut( The a&&liance %hould contact cTc a% the%e u%ually need to be ex&anded, but need not contact the inci%or% unle%% a bite &lane i% reBuired( Fi!. /0./2 #nilateral &o%terior cro%%-bite ,ith lateral 'andibular di%&lace'ent( ;a< )nitial contact on clo%ure( ;b< 3ateral di%&lace'ent of the 'andible on clo%ure into 'axi'u' intercu%&al &o%ition cau%ing unilateral &o%terior cro%%-bite( ;c< #&&er ex&an%ion a&&liance( ;d< Di%&lace'ent ha% been eli'inated after u&&er arch di%&lace'ent( /0.0.3 In"rea#ed o.erDet The incidence of trau'a to the u&&er inci%or% i% greater ,here the o$er+et i% increa%ed, to the extent that a'ong =@ year old% t,ice a% 'any children ,ith o$er+et% of =9 '' or 'ore ha$e trau'ati5ed u&&er inci%or% co'&ared ,ith children ,ith o$er+et% of le%% than : ''( 4oy% are at greater ri%/ than girl%( Reducing the ri%/ of trau'a i% a good rea%on for early reduction of a large o$er+et, e$en ,ithout co%'etic con%ideration%( )n the 'ixed dentition thi% i% u%ually done ,ith a functional a&&liance( Detail% of the 'anage'ent and effect% of the%e a&&liance% can be found in orthodontic text%, but they induce correction of the inci%or and 'olar relation%hi&% by a co'bination of dentoal$eolar and %/eletal change%( Thi% i% not done by acti$e co'&onent% %uch a% %&ring%, but in%tead the a&&liance% harne%% force% generated by the 'a%ticatory and facial 'u%culature( They achie$e thi% by holding the 'andible in a for,ard &o%tured &o%ition, and all de%ign% of functional a&&liance are %i'ilar in that they engage both dental arche% and cau%e 'andibular &o%turing and di%&lace'ent of the condyle% ,ithin the glenoid fo%%ae ;6ig( =A(=@ ;a<-;f<<( 6unctional a&&liance% ha$e t,o 'ain li'itation%G they only ,or/ in gro,ing children, 'o%t effecti$ely during &eriod% of ra&id gro,thH and, ,hile they change the occlu%ion bet,een the arche%, they cannot treat irregularitie% of arch align'ent %uch a% cro,ding( )n &ractice, the%e li'itation% 'ean that functional a&&liance treat'ent can beco'e $ery lengthy ,hen %tarted early( "rogre%% can be %lo, in &re&ubertal children becau%e of their relati$ely %lo, gro,th rate, and d,indling co-o&eration ,ith the%e de'anding a&&liance% can beco'e a real &roble' during &rolonged treat'ent%( The a&&liance %hould be ,orn a% a retainer until after the &ubertal gro,th %&urt, ,hich in boy% 'ay be =: or =! year% of agea long ti'e if treat'ent %tarted at the age of >( Treat'ent for cro,ding can u%ually only begin after the &re'olar% %tart to eru&t, and the &atient effecti$ely ha% t,o cour%e% of treat'entone to reduce the o$er+et and one to align the arche%( 0 &otential difficulty of thi% a&&roach i% that the o$er+et reduction 'u%t be retained ,hile the cro,ding i% being treated, ,hich can 'a/e 'anage'ent co'&lex( Early treat'ent i% often +u%tifiable for &atient% ,ith %e$ere o$er+et%, but the &o%%ible di%ad$antage% 'u%t be balanced carefully again%t the &otential benefit%( Fi!. /0./3 ;a< 0n ==-year-old boy ,ith a cla%% )), di$i%ion ) 'alocclu%ion( ;b< 0 =9-'' o$er+et and cla%% )) 'olar relation%hi&( ;c< 6unctional a&&liance in &lace ,ith %ectional fixed a&&liance to a%%i%t u&&er inci%or align'ent( ;d< The

functional a&&lianceGa ty&e of acti$ator( ;e< Slight o$ercorrection( ;f< "o%ttreat'ent facial &rofile( /0.0.0 S a"e maintenan"e )t i% often i'&ortant that drifting of teeth into an extraction %&ace i% &re$ented, %uch a%G follo,ing lo%% of a &ri'ary 'olar ;Section =A(@(@<H follo,ing lo%% of an u&&er inci%or ;Section =A(?( <H ,here the cro,ding i% %e$ere enough that extraction% gi$e only +u%t enough %&ace( )n the%e %ituation% a %&ace 'aintainer i% indicated( )n the u&&er arch thi% can be a %i'&le acrylic a&&liance ,ith cla%&%, but in the lo,er a lingual arch i% better tolerated ;6ig( =A(=A ;a< and ;b<<( Fi!. /0./0 ;a< Si'&le u&&er re'o$able a&&liance 'aintaining %&ace follo,ing extraction of ATA ,hile @T@ eru&t( ;b< 3o,er lingual arch %er$ing a% a %&ace 'aintainer( /0.0.5 Di!it-#-"=in! %a,it# Thu'b- and finger-%uc/ing habit% ,hich &er%i%t into the 'ixed dentition 'ay cau%eG anterior o&en biteH increa%ed o$er+etH unilateral &o%terior cro%%-bite ,ith di%&lace'ent( 0 unilateral &o%terior cro%%-bite can occur becau%e during digit %uc/ing the tongue &o%ition i% lo,, allo,ing acti$ity of the buccal 'u%culature to narro, the u&&er arch %lightly ;%ee Section =A(A( <( 0lthough a fe, children continue the habit into their teenage year%, nearly all gro, out of it by about =9 year% of age( 0n anterior o&en bite cau%ed by a %uc/ing habit ;6ig( =A(=: ;a<< ,ill u%ually then re%ol$e, but it 'ay &er%i%t and reBuire treat'ent if the tongue ha% ada&ted to the o&en bite by contacting the lo,er li& to 'a/e an anterior %eal during %,allo,ing( Correction of an increa%ed o$er+et or a &o%terior cro%%-bite ,ill need acti$e treat'ent, and in 'o%t ca%e% the &re%ence of an a&&liance in the 'outh finally brea/% the habit( 6or the%e rea%on% a %uc/ing habit in a young child i% rarely a cau%e for concern, and &arent% can be rea%%ured that dra%tic 'ea%ure% to %to& the habit are unnece%%ary( *1abit-brea/ing* a&&liance% are thu% rarely indicated and do not al,ay% ,or/, but they 'ay be con%idered if the effect on the occlu%ion i% %e$ere or if the habit i% unu%ually &er%i%tent ;6ig( =A(=: ;b<<( There are 'any de%ign% of habit-brea/er%, %o'e Buite barbaric, but a co''on one i% an u&&er re'o$able a&&liance ,ith a %tee&ly inclined anterior bite &lane ;6ig( =A(=! ;a<-;c<<( The 'id-line %&lit in the acrylic of an ex&an%ion a&&liance 'ay al%o hel& by brea/ing the %uction( Fi!. /0./5 0 >-year-old child ,ith an anterior o&en bite a%%ociated ,ith thu'b %uc/ing( ;b< 0 =!-year-old girl ,ith a continuing digit-%uc/ing habit cau%ing a locali5ed o&en bite( Fi!. /0./1 ;a< 0 = -year-old girl ,ho%e digit-%uc/ing habit ha% cau%ed an anterior o&en bite and increa%ed o$er+et( ;b< and ;c< S&lit &late ,ith a %tee& anterior bite &lane to brea/ the habit ,hile the o$er+et i% being reduced(

/0.0.1 In"i#or # a"in! mid-line dia#tema Thi% i% 'entioned only to &oint out that treat'ent +u%t for %&acing i% rarely indicated in the 'ixed dentition %tage( "arent% are often concerned about %&acing of the u&&er inci%or%, and they can be rea%%ured that it ,ill often reduce a% the &er'anent u&&er canine% eru&t( )t i%, ho,e$er, i'&ortant to en%ure that an u&&er 'id-line dia%te'a i% not due to a %u&ernu'erary tooth ;%ee Section =A(!(=<( 0 dia%te'a 'ay al%o be due to generali5ed %&acing, di'inuti$e teeth, congenital ab%ence of u&&er lateral inci%or%, or to a fle%hy u&&er labial frenu'( There i% %o'e di%agree'ent about the role of frenecto'y in the treat'ent of dia%te'ata, but it i% $ery rarely indicated in the 'ixed dentition %tage and i% &robably be%t carried out during acti$e orthodontic treat'ent( >e$ Point# Mixed dentition Cro%%-bite% ,ith di%&lace'ent 'ay be treated in the 'ixed dentition( Treat'ent of increa%ed o$er+et can beco'e lengthy if %tarted early( "er%i%tent digit-%uc/ing habit% u%ually re%ol$e ,hen a&&liance treat'ent i% %tarted( #&&er inci%or %&acing u%ually reduce% a% the &er'anent canine% eru&t( 0n u&&er 'id-line dia%te'a 'ay be a %ign of an ano'aly of tooth %i5e or nu'ber( /0.5 AN&7A*IES &F ER(PTI&N T5E ECT&PIC 7A'I**ARY CANINE /0.5.0 Introd-"tion The &ath of eru&tion of any tooth can beco'e di%turbed( So'eti'e% the rea%on i% ob$iou%, %uch a% a %u&ernu'erary tooth i'&eding an u&&er inci%or ;%ee Section =A(!(=<, but often it i% ob%cure( )n clinical orthodontic%, the 'o%t co''on &roble' of aberrant eru&tion i% the i'&acted 'axillary canine, ,hich i% %econd only to the third 'olar in the freBuency of i'&action( /0.5./ Pre.alen"e o+ im a"ted ma9illar$ "anine# Ecto&ic 'axillary canine% occur in about L of the &o&ulation, of ,hich about C:L of canine% are &alatal and =:L buccal to the line of the u&&er arch( The ri%/ of i'&action of the u&&er canine i% greater ,here the lateral inci%or i% di'inuti$e or ab%entthe lateral inci%or root i% /no,n to guide the eru&ting canine( 0n i'&acted canine can %o'eti'e% re%orb ad+acent inci%or root%, and thi% ri%/ 'ay be a% high a% = L( )nci%or re%or&tion i% %o'eti'e% Buite dra'atic ;6ig( =A(=?<( Fi!. /0./2 0n T@ cau%ing root re%or&tion of T= ( /0.5.2 Clini"al a##e##ment During the 'ixed dentition %tage the nor'al &ath of eru&tion of the 'axillary canine% i% %lightly buccal to the line of the arch, and fro' about =9 year% of age the cro,n% %hould be &al&able a% bulge% on the buccal a%&ect of the al$eolu%(

)f not, an abnor'al &ath of eru&tion %hould be %u%&ected, &articularly ,here eru&tion of one canine i% $ery delayed co'&ared ,ith the other %ide( #neru&ted 'axillary canine% %hould be &al&ated routinely on all children fro' the age of =9 year% until eru&tion( /0.5.3 Radio!ra %i" a##e##ment Where the canine i% not &al&able it %hould be a%%e%%ed radiogra&hically( 0 &eria&ical radiogra&h %ho,% ,hether the &ri'ary canine root i% re%orbing nor'ally and ,hether the canine follicle i% enlarged( )f the a&ex of the &ri'ary canine i% not re%orbing, ,ith either no root re%or&tion or only lateral re%or&tion, the &ath of eru&tion of the &er'anent canine 'ay be abnor'al( 1o,e$er, a %ingle radiogra&h cannot fully deter'ine the uneru&ted canine*% &o%ition relati$e to the other teetht,o $ie,% are needed for thi%, either at right angle% to each other or for the &arallax techniBue( Paralla9 te"%niA-e Thi% 'ethod, al%o /no,n a% the tube-%hift 'ethod, co'&are% t,o $ie,% of the area ta/en ,ith the X-ray tube in t,o different &o%ition%( 6igure =A(=C ;a< %ho,% a &alatal canine on a &eria&ical fil' being ta/en ,ith the tube &o%itioned for,ard or 'e%ially( 0 %econd fil' ta/en ,ith the tube &o%itioned further di%tally gi$e% an i'age ,hich a&&arently %ho,% the canine cro,n in a different &o%ition relati$e to the ad+acent root% ;6ig( =A(=C ;b<<( )n thi% ca%e the i'age of the canine a&&ear% to ha$e %hifted di%tally ,hen co'&ared ,ith the fir%t fil', that i% in the %a'e direction that the tube ,a% 'o$ed, ,hich indicate% that the canine i% &alatal to the other teeth( 0n a&&arent %hift in the o&&o%ite direction to the tube %hift ,ould indicate that the tooth i% lying buccally to the other teeth( The &arallax techniBue ,or/% be%t u%ing t,o &eria&ical $ie,%, but ,ith care it can al%o be a&&lied to a &anora'ic to'ogra' ,ith a %tandard occlu%al $ie,, u%ing $ertical %hift ;6ig( =A(=> ;a< and ;b<<( The tube &o%ition i% lo, do,n for the &anora'ic to'ogra' and 'uch higher for the occlu%al $ie,, and %o in thi% exa'&le the &alatal canine a&&ear% to be nearer the inci%or a&ice% in the occlu%al $ie,, i(e( it% a&&arent 'o$e'ent i% u&,ard% ,ith the tube( The %i5e of the i'age of a di%&laced tooth on a &anora'ic radiogra&h i% another indicator, being enlarged if it i% &alatal and reduced if it i% labial or buccal( 1o,e$er, a &eria&ical $ie, i% %till nece%%ary to chec/ for a%%ociated &athology, and thi% can be u%ed ,ith the occlu%al $ie, to 'a/e another &arallax &air( The co'bination of &anora'ic, %tandard occlu%al, and &eria&ical $ie,%, %uch a% that in 6ig( =A(=>, allo,% co'&rehen%i$e a%%e%%'ent of a 'axillary canine( TCo +ilm# at ri!%t an!le# Thi% 'ethod i% 'ore a&&licable to the %&eciali%t a% it in$ol$e% a ta/ing lateral %/ull $ie, and a &o%teroanterior ;&-a< $ie,G &o%%ibly a &-a %/ull, but 'ore co''only u%ing a &anora'ic radiogra&h for the %a'e &ur&o%e ;6ig( =A( 9 ;a< and ;b<<( The lateral %/ull $ie, %ho,% ,hether the canine cro,n i% buccal or &alatal to the inci%or root%, and the &-a or &anora'ic $ie, %ho,% ho, clo%e it i% to the 'id-line( The angulation of the tooth and it% $ertical &o%ition are a%%e%%ed u%ing both $ie,%( 0n intraoral $ie, 'u%t al%o be ta/en to chec/ for any a%%ociated &athology(

The &o%ition of the i'&acted canine*% cro,n %hould be deter'ined a% being buccal, &alatal, or in the line of the arch( The degree of di%&lace'ent %hould be a%%e%%ed hori5ontally, that i% ho, clo%e it i% to the 'id-line, in ter'% of ho, far it o$erla&% the root% of the inci%or%( The canine cro,n*% $ertical &o%ition i% a%%e%%ed relati$e to the inci%or a&ice%( 0n e%ti'ate %hould al%o be 'ade of the tooth*% angulation and the &o%ition of it% a&ex relati$e to the line of the arch( Other radiogra&hic %ign% that 'ay %ugge%t an abnor'al &ath of eru&tion areG ob$iou% a%y''etry bet,een the &o%ition% of the t,o u&&er canine%H lac/ of re%or&tion of the root of the &ri'ary canine on the affected %ide ;6ig( =A(=><H and re%or&tion of &er'anent inci%or root% ;6ig( =A(=?<( )f there are %ign% of inci%or re%or&tion, urgent ad$ice and treat'ent %hould be %ought( Fi!. /0./3 "arallax location of T@( ;a< Radiogra&h ta/en ,ith the tube &o%itioned for,ard %ho,% that the i'age of the canine cro,n i% %lightly 'e%ial to the i'age of T=( ;b< Radiogra&h ta/en ,ith the tube &o%itioned further di%tally %ho,% that the i'age of T@ i% further di%tally( The i'age of T@ ha% %hifted in the %a'e direction a% the tube %hiftGT@ i% therefore nearer to the fil' than T=, i(e( it i% &alatal to the line of the arch( ;c< Diagra''atic re&re%entation of ho, a &alatally &o%itioned tooth 'o$e% *,ith* the tube fro' left to right( Fi!. /0./4 ;a< and ;b< Thi% co'bination of $ie,% allo,% the u%e of $ertical and hori5ontal &arallax to a%%e%% ecto&ic canine%( Fi!. /0.20 ;a< The &anora'ic $ie, %ho,% that the cro,n of the T@ i% clo%e to the 'id-line( ;b< The lateral $ie, %ho,% that it i% &alatal to the root% of the inci%or%( /0.5.0 Earl$ treatment During the later 'ixed dentition, if an u&&er canine i% not &al&able nor'ally and i% found to be ecto&ic, extraction of the &ri'ary canine ha% a good chance of correcting or i'&ro$ing the &ath of eru&tion of the &er'anent canine, &ro$ided it i% not too %e$erely di%&laced( Extraction of the &ri'ary canine i% only a&&ro&riate under the%e condition%G ;=< early detection'ixed dentitionH ; < canine cro,n o$erla& of no 'ore than half the ,idth of the ad+acent inci%or root a% %een on a &anora'ic $ie,H ;@< canine cro,n no higher than the a&ex of the ad+acent inci%or rootH ;A< angle of @9 or le%% bet,een the canine*% long axi% and the 'id-%agittal &laneH ;:< rea%onable %&ace a$ailable in the archno 'ore than 'oderate cro,ding( #nle%% the u&&er arch i% %&aced, the contralateral &ri'ary canine %hould al%o be re'o$ed to &re$ent the u&&er centreline %hifting( Eru&tion of the &er'anent canine %hould be 'onitored clinically and if nece%%ary radiogra&hically, and %&eciali%t ad$ice %ought if it fail% to %ho, rea%onable i'&ro$e'ent after a year( The 'ain di%ad$antage of extracting the &ri'ary canine i% lo%ing the o&tion of retaining it if the &er'anent canine fail% to eru&t( )t 'ay al%o allo, for,ard drift of the u&&er buccal teeth ,here there i% a tendency to cro,ding, and if %&ace i% critical a %&ace 'aintainer %hould be fitted(

/0.5.5 *ater treatment The treat'ent o&tion% in the &er'anent dentition are toG ;=< ex&o%e the canine and align it orthodonticallyH ; < tran%&lant the canineH ;@< extract the canineH ;A< lea$e the i'&acted canine in situ( E9 o#-re and ort%odonti" ali!nment Thi% i% the treat'ent of choice for a ,ell-'oti$ated &atient, &ro$ided the i'&action i% not too %e$ere( The canine %hould lie ,ithin the%e li'it%G ;=< canine cro,n o$erla&&ing no 'ore than half the ,idth of the central inci%or rootH ; < canine cro,n no higher than the a&ex of the ad+acent inci%or rootH ;@< canine a&ex in the line of the arch( The tooth can either be ex&o%ed into the 'outh and the ,ound &ac/ed o&en, or a brac/et attached to a gold chain can be bonded to it and the ,ound clo%ed( 0n orthodontic a&&liance, u%ually fixed, then a&&lie% traction to bring the tooth into align'ent( Thi% treat'ent can ta/e u& to year%, de&ending on the %e$erity of the canine*% di%&lace'ent( Ex&o%ure ,or/% ,ell for &alatally i'&acted canine%, but buccally i'&acted canine% u%ually ha$e a &oor gingi$al contour follo,ing ex&o%ure, e$en ,hen an a&ically re&o%itioned fla& &rocedure ha% been u%ed( 6or thi% rea%on %o'e o&erator% &refer to attach a chain to buccally i'&acted canine% and to clo%e the ,ound, %o that the uneru&ted canine i% brought do,n to eru&t through attached, rather than free, gingi$a( Tran# lantation The attraction of tran%&lantation i% that orthodontic treat'ent i% a$oided and yet the canine i% brought into function( T,o criteria 'u%t be 'etG the canine can be re'o$ed intact ,ith a 'ini'u' of root handlingH and there 'u%t be adeBuate %&ace for the canine in the arch( The 'a+or cau%e of failure i% root re%or&tion, but the incidence of thi% i% reduced if the %urgical techniBue i% atrau'atic and the tran%&lanted tooth i% root- filled ,ith calciu' hydroxide %hortly after %urgery( The %ucce%% rate for canine tran%&lantation i% about ?9L %ur$i$al at : year%, but 'any clinician% regard it a% being a&&ro&riate in only a fe, ca%e%( E9tra"tion o+ t%e ermanent "anine Thi% i% a&&ro&riate if the &o%ition of the canine &ut% it beyond orthodontic correction, or if the &atient doe% not ,ant a&&liance treat'ent( )f &re%ent, the &ri'ary canine can be left in situ, and although the &rogno%i% i% un&redictable, a canine ,ith a good root 'ay la%t for 'any year%( When it i% e$entually lo%t a &ro%the%i% ,ill be needed, and &ro$i%ion of thi% can be difficult if the o$erbite i% dee&another factor to be ta/en

into account ,hen con%idering treat'ent o&tion%( Extraction of the &er'anent canine 'ay al%o be con%idered ,here the lateral inci%or and &re'olar are in contact, gi$ing a good a&&earance( )n thi% ca%e it i% often ex&edient to acce&t the eru&ted teeth and extract the canine( *ea.in! t%e -ner- ted "anine in situ During the early teenage year% there i% a ri%/ of re%or&tion of ad+acent inci%or root% %o that annual radiogra&hic re$ie, i% nece%%ary, although the ri%/ of root re%or&tion reduce% ,ith increa%ing age( The on%et of root re%or&tion can be Buite ra&id, and for thi% rea%on 'any i'&acted canine% are re'o$ed( There 'ay be a ca%e for retaining the canine in the %hort ter' in a younger &atient, in ca%e they ha$e a change of heart about orthodontic treat'ent to align the tooth( >e$ Point# Ecto&ic canine% 0bout L of children ha$e ecto&ic u&&er canine%, of ,hich C:L are &alatal( 0l,ay% &al&ate for u&&er canine% fro' the age of =9 year% until eru&tion( -on-&al&able u&&er canine% %hould be located radiogra&hically or referred for in$e%tigation( Con%ider extraction of a &ri'ary canine if a &er'anent canine i% mildly di%&laced( #ntreated, uneru&ted &er'anent canine% 'ay re%orb inci%or root% and %hould be radiogra&hed annually during the teenage year%( /0.5.1 &t%er anomalie# o+ er- tion )n the 'ixed dentition, three other ano'alie% of eru&tion are fairly co''onG =( Infraoccluded primary teeth ;Cha&ter =@< u%ually exfoliate &ro$ided that the &er'anent %ucce%%or% are &re%ent, but they %hould be /e&t under re$ie,( )f they are not %hed and eru&tion of the &er'anent tooth i% %eriou%ly delayed, or if the infraocclu%ion beco'e% $ery 'ar/ed, then they %hould be extracted and a %&ace 'aintainer fitted if a&&ro&riate( ( Impaction of the upper first permanent molar into the di%tal of the u&&er %econd &ri'ary 'olar cau%ing re%or&tion ;6ig( =A( =<( )t i% &o%%ible to di%i'&act the tooth ,ith an a&&liance, but the &roble' u%ually re%ol$e% %&ontaneou%ly ,hen the &ri'ary 'olar i% %hed( The re%or&tion 'ay cau%e &ain if it in$ol$e% the &ul&, in ,hich ca%e the &ri'ary 'olar %hould be re'o$ed( Thi% allo,% the &er'anent 'olar to 'o$e ra&idly 'e%ially, and a %&ace 'aintainer or an acti$e a&&liance to 'o$e it di%tally %hould be con%idered ;%ee Section =A(@(@<( @( #econd premolars in unfa$ourable &o%ition% are %o'eti'e% %een a% incidental finding% on &anora'ic radiogra&h%, but fortunately they u%ually correct %&ontaneou%ly and e$entually eru&t %ati%factorily( 8ery occa%ionally thi% doe% not ha&&en, and a fe, ca%e% ha$e been re&orted of a lo,er %econd &re'olar 'igrating to,ard% the 'andibular ra'u%( #&&er or lo,er %econd &re'olar% that are bloc/ed out of the arch becau%e of cro,ding u%ually eru&t, but are di%&laced lingually(

Fi!. /0.2/ )'&action of T! cau%ing di%tal re%or&tion of Te( /0.1 AN&7A*IES &F T&&T5 SIlE AND N(7;ER /0.1.0 Introd-"tion The%e ano'alie% are di%cu%%ed in Cha&ter =@, but their clinical 'anage'ent often ha% orthodontic i'&lication%( /0.1./ S- ern-merar$ teet% Su&ernu'erary teeth are $ery co''on in the &re'axilla, and can interfere ,ith the eru&tion of nor'al teeth, or cau%e locali5ed cro,ding if they eru&t( )n ter'% of clinical 'anage'ent, %u&ernu'erarie% in the u&&er labial %eg'ent fall into three grou&%G =( Conical supernumeraries are u%ually clo%e to the 'id-line bet,een the central inci%or% ;'e%ioden%<, and are u%ually one or t,o in nu'ber( They are %o'eti'e% in$erted, and their &o%ition% can range fro' ha$ing eru&ted to lying abo$e the inci%or a&ice%( The 'a+ority do not &re$ent eru&tion of inci%or%, but 'ay cau%e %o'e di%&lace'ent or a 'edian dia%te'a, in ,hich ca%e they %hould be extracted ;6ig( =A( <( They %hould al%o be extracted if they eru&t or if the ad+acent inci%or% are to be 'o$ed orthodontically( 1o,e$er, they can other,i%e be left in situ if high and %y'&to'-free( ( -u,erculate supernumeraries are the 'ain cau%e of failure of eru&tion of u&&er &er'anent inci%or% ;6ig( =A( @ ;a< and ;b<<( Early detection i'&ro$e% the &rogno%i% for treat'ent( 0 central inci%or ,hich fail% to eru&t before the ad+acent lateral inci%or %hould be radiogra&hed, and any %u&ernu'erary teeth locali5ed ;%ee Section =A(:(@<( The%e %hould be re'o$ed %urgically a% %oon a% &o%%ible, and it i% e%%ential that the %&ace i% 'aintained or, if already lo%t, re-o&ened ,ith an a&&liance( 0bout ?:L of uneru&ted inci%or% eru&t %&ontaneou%ly ,ithin year% of re'o$al of %u&ernu'erarie%, %o it i% ,orth ,aiting for at lea%t =C 'onth% before con%idering %urgical ex&o%ure( E$en if the inci%or ha% not eru&ted it ha% u%ually co'e do,n %uch that the cro,n i% +u%t %ub'uco%al and only reBuire% 'ini'al ex&o%ure of the inci%al edge, ai'ing to 'ini'i5e lo%% of attached gingi$a ;6ig( =A( A ;a<-;c<<( @( #upplemental teeth of nor'al 'or&hology cau%e locali5ed cro,ding unle%% there i% generali5ed %&acing in the arch( 6igure =A( : %ho,% a %u&&le'ental u&&er lateral inci%or, and treat'ent con%i%t% of extracting one of the t,o lateral inci%or% in that Buadrant( One i% often %'aller than the other and, if &o%%ible, the tooth that 'atche% the contralateral inci%or %hould be retained, but the %e$erity of di%&lace'ent and difficulty of orthodontic align'ent 'u%t al%o be ta/en into account( Fi!. /0.22 0n eru&ted conical 'id-line %u&ernu'erary ,hich ha% not &re$ented eru&tion of =T=, but ha% di%&laced T=( Fi!. /0.23 ;a< and ;b< 6ailure of eru&tion of =T= due to the &re%ence of t,o tuberculate %u&ernu'erary teeth( ;"hoto% courte%y of Mr T( G( 4ennett(< Fi!. /0.20 ;a< Surgical ex&o%ure of uneru&ted T=( ;b< Orthodontic align'ent of T =( ;note the &oor gingi$al contour a% a re%ult of ex&o%ure<( ;c< "oor gingi$al

contour &er%i%t% for %e$eral year% after treat'ent( Fi!. /0.25 Su&&le'ental lateral inci%or cau%ing locali5ed cro,ding( /0.1.2 5$ odontia 0ny tooth in the arch can be congenitally ab%ent but, a%ide fro' third 'olar%, the teeth 'o%t co''only affected are lo,er %econd &re'olar% and u&&er lateral inci%or% ;Cha&ter =@<( Where one or t,o teeth are ab%ent the orthodontic o&tion% are to o&en, 'aintain, or clo%e the %&ace( Where 'ulti&le teeth are ab%ent orthodontic treat'ent 'ay be able to gi$e a 'ore fa$ourable ba%i% for re%torati$e re&lace'ent( Se"ond remolar# Where the arch i% aligned or %&aced the &ri'ary %econd 'olar %hould be left in situ, but ,here there i% cro,ding the %&ace can be u%ed for arch align'ent( )n the u&&er arch, and in a %ignificantly cro,ded lo,er arch, the &ri'ary %econd 'olar %hould be retained until the %tart of orthodontic treat'ent( Where there i% 'ild lo,er arch cro,ding ,hich i% to be treated, the &ri'ary %econd 'olar can be extracted earlier to allo, %o'e of the %&ace to be lo%t to 'e%ial drifting of the fir%t 'olar( ( er lateral in"i#or#

Where one or both u&&er lateral inci%or% are ab%ent in an uncro,ded arch the exce%% %&ace i% often di%tributed a% generali5ed anterior %&acing ;6ig( =A( ! ;a<-;e<<( 0n u&&er fixed a&&liance can be u%ed to locali5e the %&ace in the lateral inci%or area &rior to &ro$i%ion of bridge,or/( So'e o$erbite reduction i% often needed to create enough interocclu%al %&ace for the retaining ,ing% of the bridge( The bridge %hould not be 'ade for at lea%t ! 'onth% after re'o$al of the fixed a&&liance, during ,hich ti'e a re'o$able retainer %hould be ,orn ,hich ha% ,ire %&ur% to &re$ent any drifting into the reo&ened %&ace( The bridge it%elf often act% a% a &er'anent orthodontic retainer, and careful thought %hould be gi$en to thi% a%&ect of it% de%ign( 6or exa'&le, if an u&&er canine ha% been 'o$ed di%tally, a fixed-fixed de%ign en%ure% that the canine cannot rela&%e 'e%ially( 0 cantile$er de%ign 'ight allo, rela&%e, cau%ing the lateral inci%or &ontic to o$erla& the central inci%or( Where the u&&er arch i% inherently cro,ded, the lateral inci%or %&ace could be clo%ed( There i% %o'e debate a% to the 'erit% or other,i%e of the re%ulting ae%thetic%, but, in general, it %ee'% unfortunate to extract a %ound &re'olar to o&en %&ace for a &ro%the%i%, and in the long ter' the a&&earance follo,ing %&ace clo%ure i% u%ually acce&table ;6ig( =A( ? ;a< and ;b<<( The Buality of the a&&earance de&end% on the %ha&e of the canine, but &ointed canine% can be 'ade to loo/ 'ore li/e lateral inci%or% by reducing the cu%& ti& and adding co'&o%ite 'e%io-inci%ally( 7ore #e.ere %$ odontia Cit% m-lti le mi##in! teet% Thi% often need% co'&lex treat'ent( "reli'inary orthodontic treat'ent can often hel& re%toration by 'a/ing the %&ace di%tribution 'ore fa$ourable, u&righting tilted teeth, and reducing the o$erbite( 6ixed a&&liance% are u%ually needed and orthodontic retention reBuire% careful 'anage'ent ;6ig( =A( C ;a<-;f<<(

Fi!. /0.21 ;a< S&aced arch co'&licated by the ab%ence of T and a $ery di'inuti$e T ( ;b< T to be extracted and fixed a&&liance o&ening %&ace for re&lace'ent T ( ;c< Re'o$able retainernote ,ire %&ur% to en%ure %&ace i% 'aintained( ;d< 0dhe%i$e bridge% in &lace, and co'&o%ite addition% to enlarge =T =( ;e< 4ridge de%ign( Fi!. /0.22 ;a< Congenital ab%ence of T , ,here cro,ding tendency indicate% %&ace clo%ure( ;b< 0fter align'ent, ,ith @=T=@ in contact( Fi!. /0.23 ;a< Se$ere hy&odontia( ;b< -ote tilted teeth and unfa$ourable %&ace di%tribution( ;c< 6ixed a&&liance% to u&right the teeth and redi%tribute %&ace( ;d< Re%ult of orthodontic treat'ent( ;e< )nitial retention ,ith &artial denture% incor&orating %&ur% to &re$ent any orthodontic rela&%e( ;f< Definiti$e fixed re%toration%( /0.1.3 Anomalie# o+ toot% #i:e 0no'alie% of tooth %i5e are di%cu%%ed in Cha&ter =@( 0ny tooth 'ay be affected, but the u&&er lateral inci%or i% 'o%t co''only in$ol$ed( 7e!adontia )f the u&&er and lo,er teeth do not 'atch for %i5e it i% i'&o%%ible for the' to be both aligned and in nor'al occlu%ion( 0n abnor'ally large u&&er inci%or i% a%%ociated ,ith cro,ding or increa%ed o$er+et, or both( 0 gro%%ly o$er%i5ed tooth 'ay ha$e to be extracted and re&laced ,ith a &ontic after co'&letion of any orthodontic treat'ent( )n 'ilder ca%e% it i% &o%%ible to narro, the tooth by reducing the ena'el interdentally( #& to = '' 'ay be re'o$ed after the teeth ha$e been aligned but before a&&liance% are re'o$ed, %o that the re%ulting %&ace% can be clo%ed( >e$ Point# Su&ernu'erary teeth 8ariation% fro' the nor'al eru&tion %eBuence %hould be in$e%tigated( Su&ernu'erary teeth that interfere ,ith the eru&tion of &er'anent teeth %hould be re'o$ed( The %&ace for the &er'anent tooth %hould be 'aintained ,hile it eru&t%( Gi$e the &er'anent tooth at lea%t =C 'onth% to eru&t before con%idering %urgical ex&o%ure( S&acing due to congenitally ab%ent teeth 'ay be o&ened or clo%ed de&ending on the degree of cro,ding( 7i"rodontia #&&er lateral inci%or% are 'o%t co''only affected( 0ny orthodontic treat'ent %hould &recede the re%toration of a di'inuti$e tooth, and %hould lea$e adeBuate %&ace for it to be enlarged ;6ig( =A( > ;a<-;c<<( The retainer %hould carry interdental %&ur% to &re$ent ad+acent teeth fro' drifting into the %&ace, and it %hould be ,orn for at lea%t @ 'onth% before the tooth i% built u&( Where the u&&er arch i% inherently cro,ded but the lateral inci%or% are di'inuti$e on one %ide and congenitally ab%ent on the other, it 'ay be a&&ro&riate to extract the di'inuti$e tooth and clo%e the %&ace%( Thi% relie$e% the cro,ding and gi$e% a %y''etrical a&&earance(

Fi!. /0.24 ;a< "atient ,ith cro,ding and di'inuti$e T ( ;b< 6ollo,ing orthodontic treat'ent to align the arche%( ;c< Di'uti$e T enlarged ,ith co'&o%ite( /0.2 &RT5&D&NTICS AND DENTA* TRA(7A /0.2.0 Introd-"tion Orthodontic brac/et% are often u%ed a% an i''ediate 'ea%ure after trau'a to %tabili5e loo%ened or rei'&lanted teeth, to realign di%&laced teeth, or to extrude teeth that ha$e been intruded ;Cha&ter = <( Teeth that ha$e been fractured at the gingi$al le$el 'ay reBuire extru%ion later, to facilitate re%toration( /0.2./ &rt%odonti" "on#ideration# +or t%e mi##in! ( er "entral in"i#or er in"i#or

The %&ace %tart% to clo%e $ery Buic/ly, ,ithin day% of lo%ing the tooth, and it %hould be 'aintained by in%erting a &artial denture i''ediately ;6ig( =A(@9<( )n a cro,ded arch it i% often &o%%ible to 'o$e the lateral inci%or into the central %&ace, but the re%ulting a&&earance i% u%ually $ery &oor( 4uilding u& or cro,ning the lateral inci%or to 'i'ic the central tooth i% rarely %ati%factory a% it gi$e% the tooth a $ery triangular %ha&e, and it i% difficult to 'aintain &eriodontal health around the enlarged cro,n( Where a &re'olar i% to be extracted for orthodontic rea%on% it can %o'eti'e% be tran%&lanted into the central inci%or %ite, and then re%tored to 'i'ic the 'i%%ing inci%or( ( er lateral in"i#or

3ateral inci%or %&ace% can be either 'aintained or clo%ed, de&ending on the a'ount of cro,ding in the arch ;%ee Section =A(!( <( Fi!. /0.30 S&ace lo%% follo,ing a$ul%ion of =T=( /0.2.2 &rt%odonti" mo.ement o+ tra-mati:ed teet% )n general, root-filled teeth can be 'o$ed orthodontically Buite nor'ally, ,ith no increa%ed ri%/ of external root re%or&tion co'&ared ,ith nor'al teeth( The ri%/ factor% a%%ociated ,ith root re%or&tion during orthodontic treat'ent are di%cu%%ed in Section =A(C(@( Trau'ati5ed teeth, ho,e$er, are already at an increa%ed ri%/ of root re%or&tion, e%&ecially tho%e ,hich ha$e been di%&laced or rei'&lantedorthodontic treat'ent increa%e% the ri%/ further( )n the%e ca%e% the need for orthodontic% %hould be a%%e%%ed $ery carefully, but ,here it i% needed the ri%/ of re%or&tion during tooth 'o$e'ent %hould be 'ini'i5ed byG ;=< 'aintaining a calciu' hydroxide dre%%ing in the root canal during orthodontic treat'ent, and ; < en%uring that orthodontic force% are a% light a% &o%%ible( 6ixed a&&liance% %hould be u%ed ,ith great care a% they can ea%ily generate high

force%, and treat'ent ,ith the' %hould be /e&t to a 'ini'u'( 6unctional a&&liance% are u%eful for reducing an o$er+et a% they do not a&&ly high force% to indi$idual teeth( 0 tooth that ha% beco'e an/ylo%ed cannot be 'o$ed orthodontically and ,ill e$entually be lo%t, but in the %horter ter' it ,ill %er$e a% a %&ace 'aintainer unle%% the an/ylo%i% cau%e% exce%%i$e infraocclu%ion( >e$ Point# Trau'a 0 %&ace 'aintainer %hould be fitted immediately if an u&&er inci%or i% lo%t( Trau'ati5ed teeth 'ay re%orb during orthodontic treat'ent( Thi% i% 'ini'i5ed by &utting calciu' hydroxide in the root canal and /ee&ing orthodontic force% light( Teeth ,ith a &oor &rogno%i% %er$e a% u%eful %&ace 'aintainer% in the %hort ter'( /0.3 C&7P*ICATI&NS &F &RT5&D&NTIC TREAT7ENT /0.3.0 Introd-"tion The 'o%t co''on &roble' ,ith orthodontic treat'ent i% lac/ of co-o&eration by the &atient, ,hich in %o'e ca%e% can lead to the treat'ent conferring no benefit or e$en 'a/ing the 'alocclu%ion ,or%e ;%ee Section =A( ( <( Di%cu%%ed belo, are four i%%ue% ,hich 'ay concern the &aediatric denti%t( /0.3./ Po#tort%odonti" de"al"i+i"ation White %&ot% of ena'el decalcification are %o'eti'e% left after orthodontic treat'ent if the &atient*% co'&liance ,ith oral hygiene and &re$enti$e ad$ice ha% been &oor ;6ig( =A(@= ;a< and ;b<<( The &roble' i% greate%t ,ith fixed a&&liance%, ,ith decalcification being 'o%tly related to area% of &laBue accu'ulation around the brac/et%, and co''only in$ol$ing the labial %urface% of anterior teeth( The le%ion% can de$elo& $ery Buic/ly, ,ithin a fe, ,ee/%, and con%i%t of %o'e %oftening of the ena'el %urface ,ith &rogre%%i$e 'ineral lo%% of the %ub%urface layer to a de&th of u& to =99 u'( "re$ention of the &roble' %tart% ,ith careful &atient %election, but if oral hygiene during treat'ent i% &oor, and e%&ecially if there are %ign% of decalcification, &re$enti$e 'ea%ure% %hould be i'&le'ented i''ediately, The%e includeG ;=< regular reinforce'ent of oral hygiene ;%ee Section =A(C( <H ; < dietary ad$iceH ;@< &re%cri&tion of daily %odiu' fluoride 'outh,a%he%( )f the &atient doe% not re%&ond then the orthodontic treat'ent %hould be %to&&ed a% Buic/ly a% &o%%ible, and it i% often better to lea$e %o'e re%idual 'alocclu%ion than to continue and ri%/ %e$ere da'age( )f ,hite ena'el le%ion% are &re%ent ,hen the a&&liance i% re'o$ed, a daily %odiu' fluoride 'outh,a%h %hould be %tarted ;if not already in u%e<( Thi% encourage% re'inerali5ation, and the chal/y a&&earance and degree of o&acity of the le%ion% u%ually reduce during the @ 'onth% follo,ing a&&liance re'o$al( The 'a+ority of le%ion% that re'ain un%ightly re%&ond to the hydrochloric acid-&u'ice 'icroabra%ion

techniBue ;Cha&ter =9<, but %e$ere le%ion% and tho%e ,ith %urface brea/do,n 'ay reBuire locali5ed co'&o%ite re%toration% or e$en $eneer%( Fi!. /0.3/ ;a< -eglected fixed a&&liance ,ith a%%ociated gingi$al infla''ation and decalcification( ;b< The decalcification i% ob$iou% follo,ing brac/et re'o$al( /0.3.2 &rt%odonti"# and eriodontal %ealt% Fi9ed a lian"e#

Gingi$al infla''ation i% a freBuent co'&lication of fixed a&&liance% ;6ig( =A(@=<, and the &atient 'u%t be encouraged to 'aintain good oral hygiene( They 'u%t recogni5e that it ta/e% longer to clean the teeth ,ith fixed a&&liance% than ,ithout( 0 %tandard toothbru%h ,ith a fairly %'all t,o- or three-ro, head i% %uitable in 'o%t ca%e%, or %&ecial orthodontic bru%he% are a$ailable ,ith a groo$e ,hich i% intended to facilitate cleaning behind the arch,ire( So'e &atient% find inter%&ace bru%he% hel&ful, e%&ecially for local &roble' area%( Marginal gingi$al infla''ation re%ol$e% ,hen the brac/et% and band% are re'o$ed, and there i% no e$idence that orthodontic treat'ent cau%e% clinically %ignificant longter' da'age to the &eriodontiu' ;Cha&ter ==<( 1o,e$er, exce%%i$e arch ex&an%ion or &roclination of teeth, e%&ecially the lo,er inci%or%, %hould be a$oided a% there i% a ri%/ of fene%tration of the buccal al$eolar bone or e$en gingi$al clefting( Remo.a,le a lian"e#

Mild &alatal 'arginal gingi$iti% i% Buite co''on under re'o$able a&&liance%, but re%ol$e% at the end of treat'ent( Good oral and a&&liance hygiene i% $ery i'&ortant( The &atient %hould ta/e the a&&liance out to bru%h it and to clean the teeth at lea%t t,ice a day, and to rin%e it after 'eal%( More ,ide%&read candidal infection occa%ionally occur% under the acrylic, but u%ually re%ol$e% if the &atient ,ear% the a&&liance &art-ti'e for a fe, day%( Se$ere infla''ation &alatal to the u&&er inci%or% can occur during o$er+et reduction, due to co'&re%%ion of the ti%%ue% bet,een the acrylic and the teeth ;6ig( =A(@ ;a< and ;b<<( Thi% %hould be a$oided by /ee&ing the a&&liance under freBuent re$ie,, and en%uring at each $i%it that enough &alatal acrylic ha% been tri''ed a,ay to allo, tooth 'o$e'ent( Fi!. /0.32 ;a< #&&er re'o$able a&&liance for retraction of the u&&er inci%or%( ;b< Se$ere gingi$al infla''ation re%ulting fro' co'&re%%ion of the gingi$al ti%%ue% under the a&&liance during inci%or retraction( /0.3.3 Root re#or tion Mo%t orthodontic treat'ent% &robably cau%e %o'e re%or&tion of root a&ice%( )n 'o%t ca%e% it i% %light, but %ignificant a&ical re%or&tion doe% occur in a fe, &atient% ;6ig( =A(@@ and 6ig( ==(==<( 0ny tooth can be affected, although %tudie% ha$e focu%ed on the 'axillary inci%or%( The aetiology i% 'ultifactorial and indi$idual %u%ce&tibility to re%or&tion i% $ery $ariable, but factor% a%%ociated ,ith increa%ed ri%/ includeG

;=< hi%tory of trau'a to 'axillary inci%or%H ; < %ign% of &re-exi%ting re%or&tionG %hort root% or blunted a&ice%H ;@< thin, &i&ette-%ha&ed root a&ice%H ;A< &rolonged u%e of fixed a&&liance%, e%&ecially inter'axillary ela%tic%H ;:< intru%i$e force% and torBuing of a&ice%H ;!< reduction of large o$er+et%, other than ,ith functional a&&liance%H ;?< treat'ent to align i'&acted 'axillary canine%( Orthodontic treat'ent for &atient% in the fir%t three categorie% %hould be a% %hort and %i'&le a% &o%%ible, /ee&ing fixed a&&liance% to a 'ini'u' and en%uring that force% are $ery light( 6unctional a&&liance% a$oid a&&lying high force% to inci%or% during o$er+et reduction( Mild 'alocclu%ion% are better left untreated in the%e circu'%tance%( Fi!. //.// 0&ical root re%or&tion of @ =T= @ follo,ing orthodontic treat'ent( ;Re&roduced by /ind &er'i%%ion of Dr )( 3( Cha&&le, "rofe%%or of "eriodontology, 4ir'ingha', #2(< Fi!. /0.33 "anora'ic radiogra&h %ho,ing ,ide%&read root re%or&tion during fixed a&&liance orthodontic treat'ent( /0.3.0 &rt%odonti"# and tem oromandi,-lar Doint (T7j) di#order# )n general, the &re%ence of 'alocclu%ion i% not a%%ociated ,ith an increa%ed &re$alence of TM7 di%order%( There i% a %lightly greater &re$alence in %ub+ect% ,ith 'alocclu%ion% of the ty&e that often ha$e a%%ociated occlu%al interference%, including cla%% ))) ca%e%, cro%%-bite%, and o&en bite%, but the correlation i% ,ea/( E$en %o, %i'&le orthodontic treat'ent, often in the 'ixed dentition, to correct a cro%%-bite ,ith an a%%ociated 'andibular di%&lace'ent i% ,ell ,orth,hile( )n older &atient%, orthodontic treat'ent to re'o$e the interference can be co'&lex and an alternati$e a&&roach 'ay be better, %uch a% occlu%al ad+u%t'ent, unle%% treat'ent i% needed any,ay for other a%&ect% of the 'alocclu%ion( Orthodontic treat'ent %hould al,ay% ai' to lea$e the occlu%ion ,ith no interference%( )t ha% been clai'ed that 'any for'% of orthodontic treat'ent cau%e TM7 di%order%, ,ith &re'olar extraction% co'ing under the greate%t attac/( 1o,e$er, exten%i$e %tudie% ha$e found no e$idence of an increa%ed &re$alence of TM7 di%order% in %ub+ect% ,ho ha$e had orthodontic treat'ent, including extraction%, co'&ared ,ith untreated control%( /0.4 TE7P&R&7ANDI;(*AR j&INT (T7j) DIS&RDERS 0lthough %e$eral %tudie% include children aged :-? year%, 'o%t ob%er$ation% ha$e been 'ade on the young adole%cent( 0 %'all nu'ber of te'&oro'andibular &roble'% are a%%ociated ,ith functional 'alocclu%ion ;occlu%al interference%< and 'or&hological 'alocclu%ion %uch a% cro%%-bite and anterior o&en bite%, but bruxi%' and 'u%cular hy&eracti$ity &robably &lay an i'&ortant &art in the de$elo&'ent of TM7 di%order% in childhood( >e$ Point# Orthodontic in+ury Teeth ,ith blunted or thin root% ha$e a greater ri%/ of re%or&tion during orthodontic

treat'ent( "rolonged treat'ent ,ith high force% increa%e% the ri%/ or root re%or&tion( There i% little e$idence that 'alocclu%ion or orthodontic treat'ent are a%%ociated ,ith te'&oro'andibular +oint di%order%( There i% no e$idence of %ignificant long-ter' &eriodontal di%ea%e a%%ociated ,ith orthodontic treat'ent( Good oral hygiene and diet control are e%&ecially i'&ortant during orthodontic treat'ent( Daily fluoride 'outh,a%he% reduce ena'el decalcification( The co''one%t clinical %y'&to'% in children and adole%cent% are clic/ing ;=9-@9L< and 'u%cle tenderne%% on &al&ation ; 9-!9L<( Clinical %ign% %uch a% reduced o&ening, &ain and 'o$e'ent, and tenderne%% of the +oint% on &al&ation are le%% freBuent than in adult%( There %ee'% to be no con%i%tent &attern in the de$elo&'ent of either %ub+ecti$e %y'&to'% or clinical %ign% during gro,th( 1eadache i% co''on in children ;girl% 'ore than boy%< and it% &re$alence increa%e% ,ith age( The connection bet,een headache, bruxi%', hy&eracti$ity of +a, 'u%cle%, and 'andibular dy%function i% ,ell recogni5ed and %hould not be 'i%%ed( Children ,ith TM7 %y'&to'% and tho%e %tarting orthodontic treat'ent %hould ha$e a full exa'ination for occlu%ion, tooth ,ear, 'andibular 'obility, TM7 function and &al&ation, and +a, 'u%culature function and &al&ation( One clinical %y'&to' that ha% con%i%tently di%clo%ed the &re%ence of a TM7 dy%function i% reduced o&ening( Treat'ent &rinci&le% u%ed in adult% can be broadly a&&lied to children and adole%cent%, after ta/ing into account the dyna'ic change% in occlu%ion in connection ,ith tooth eru&tion and facial gro,th( The 'a+ority of treat'ent i% by acti$ator% andDor %&lint%( Occlu%al ad+u%t'ent i% not generally underta/en in the young &er'anent dentition a% 'o%t occlu%al di%&lace'ent in gro,ing indi$idual% ,ill change ,ith ti'e( 1o,e$er, %electi$e grinding 'ay be nece%%ary ,hen a direct cau%al connection i% %u%&ected( )t 'ay be difficult to 'oti$ate children and adole%cent% to do +a, exerci%e%, co'&ared ,ith adult%( Training in one or t,o 'o$e'ent% again%t re%i%tance i% u%ually acce&ted( The TM7 can al%o be affected by di%ea%e% or condition% ,hich 'ight influence 'andibular gro,th( The 'o%t freBuent are +u$enile idio&athic arthriti% ;7)0<, trau'atic in+urie%, unilateral hy&er&la%ia, and congenital a&la%ia( 7)0 affect% the TM7 in o$er :9L of tho%e ,ith the di%ea%e( Thi% cau%e% de%truction of the condyle% and glenoid fo%%a leading to 'andibular 'icrognathia, 'andibular a%y''etry, o&en bite, abnor'al bite, reduced o&ening, and lo%% of 'u%cle %trength( Trau'atic in+urie% in$ol$ing the condyle% can lead to abnor'al gro,th and de$elo&'ent and %hould be follo,ed clo%ely( #nilateral hy&er&la%ia of the condyle, although rare, 'ay occur around &uberty( Thi% can lead to cro%%-bite and 'id-line de$iation, a% ,ell a% a%y''etrical +a, 'o$e'ent% and tenderne%% and &ain fro' 'u%cle% and +oint%( Congenital a&la%ia of the TM7 'ay occur in %yndro'e% %uch a% he'ifacial 'icro%o'ia and Treacher-Collin% %yndro'e, and re%ult% in abnor'al gro,th and function( Such ca%e% reBuire a co'bined interdi%ci&linary a&&roach(

/0./0 C*EFT *IP AND PA*ATE "atient% ,ith cleft% of the li& and &alate co''only need exten%i$e and %&eciali5ed treat'ent, &ro$ided by a 'ultidi%ci&linary tea' of %&eciali%t% including &la%tic %urgeon, orthodonti%t, &aediatric denti%t, %&eech thera&i%t, 'axillofacial %urgeon, E-T %urgeon, and other%( 0&&roache% to 'anage'ent $ary greatly( )t i% not the &ur&o%e of thi% %ection to di%cu%% the detail% of the condition or it% treat'ent, for ,hich the reader i% referred to %&eciali%t text%, but rather to highlight the crucial &art the denti%t &lay% in 'aintaining dental health throughout the &rolonged &eriod o$er ,hich the treat'ent u%ually extend%( Manage'ent begin% at birth ,ith coun%elling of the &arent% to rea%%ure the', ex&lain the li/ely cour%e of e$ent%, and to gi$e &ractical ad$ice on feeding( So'eti'e% &re%urgical intraoral a&&liance% are fitted to try to reduce the %i5e of the defect and facilitate %urgical re&air( The li& i% re&aired ,ithin the fir%t fe, ,ee/% or 'onth%, follo,ed later by clo%ure of the &alate( The &ri'ary re&air% are follo,ed by a &eriod of ob%er$ation, u%ually in 'ultidi%ci&linary clinic% attended by the $ariou% %&eciali%t%( 0% ,ell a% ob%er$ing facial de$elo&'ent, %&eech i% 'onitored and correcti$e 'ea%ure%, %uch a% %&eech thera&y or &alato&haryngeal %urgery, in%tituted ,here nece%%ary( The%e children often %uffer 'iddle ear infection% for ,hich E-T ad$ice ,ill be needed( 0% ,ith all children, ad$ice on &re$enti$e dental care %hould be gi$en to the fa'ily and reinforced regularly( 0 co'&lication of %urgical re&air i% that %car contraction in the &alate cau%e% narro,ing of the u&&er arch( So'eti'e% thi% i% Buite dra'atic, although 'odern techniBue% are reducing the %e$erity of thi% &roble'( Orthodontic treat'ent often begin% during the 'ixed dentition %tage, at about C or > year%, ,ith ex&an%ion of the u&&er arch in &re&aration for a bone graft into the al$eolar defect at about the age of =9 year%( Grafting at thi% age &ro$ide% bone into ,hich teeth can eru&t, &articularly the ad+acent canine, and greatly aid% occlu%al de$elo&'ent( Cleft% are often a%%ociated ,ith other dental ano'alie% %uch a% %u&ernu'erary, 'icrodont, or i'&acted teeth( 6urther orthodontic treat'ent, nor'ally ,ith fixed a&&liance%, i% needed ,hen the &er'anent dentition ha% eru&tedif thi% include% %ignificant arch ex&an%ion, the &atient ,ill ha$e to ,ear an a&&liance &er'anently to &re$ent rela&%e of the ex&an%ion( Secondary %urgery to the li& and &alate re&air% 'ay be needed( )f %carring ha% re%tricted for,ard gro,th of the 'axilla, %urgical correction of a cla%% ))) facial defor'ity 'ay be con%idered in the late teenage year% after gro,th i% co'&lete( Thi% u%ually reBuire% orthodontic &re&aration to gi$e a %ati%factory &o%to&erati$e occlu%ion( 6inally, re%torati$e treat'ent 'ay be needed becau%e of 'i%%ing teeth or other defect%, and often to &ro$ide &er'anent retention of the orthodontic tooth 'o$e'ent( )t i% ob$iou% that the %ucce%% of all thi% treat'ent de&end% on the 'aintenance of a %ound dentition o$er 'any year%, and that the lo%% of teeth due to carie% greatly co'&licate% and hinder% treat'ent( The denti%t thu% ha% a $itally i'&ortant &art in 'aintaining continuity of routine &re$enti$e and re%torati$e care( )t i% ,ell recogni5ed that &atient co'&liance ,ith long and co'&lex treat'ent% d,indle%, and unfortunately 'any &atient% ,ith cleft%, and their fa'ilie%, do not gi$e routine denti%try a high enough &riority co'&ared ,ith other a%&ect% of their treat'ent %uch

a% %urgery( 0n enthu%ia%tic and %u&&orti$e dental tea' 'u%t therefore &lay a central &art in the 'ultidi%ci&linary 'anage'ent of cleft% of the li& and &alate( /0.// S(77ARY =( 0ll children fro' the age of C year% %hould be %creened for 'alocclu%ion( ( #neru&ted 'axillary canine% %hould be &al&ated routinely on all children fro' the age of =9 year% until eru&tion( @( 0 'axillary canine ,hich i% not &al&able %hould be in$e%tigated( A( Significant $ariation fro' the nor'al %eBuence of eru&tion %hould be in$e%tigated, e(g( u&&er lateral inci%or eru&ting before u&&er central inci%or( :( Refer for orthodontic ad$ice in good ti'e and gi$e a% 'uch bac/ground infor'ation a% &o%%ible( !( Good oral hygiene and co-o&eration are e%%ential for %ucce%%ful orthodontic a&&liance treat'ent( ?( Con%ider orthodontic a%&ect% ,hen extraction% in the 'ixed dentition are nece%%ary( C( 0 %&ace 'aintainer %hould be fitted i''ediately if a trau'ati5ed u&&er inci%or i% lo%t( >( Cro%%-bite% ,ith di%&lace'ent 'ay be treated in the 'ixed dentition( =9( Treat'ent of increa%ed o$er+et in the 'ixed dentition can beco'e lengthy( ==( "er%i%tent digit-%uc/ing habit% u%ually re%ol$e ,hen a&&liance treat'ent i% %tarted( /0./2 F(RT5ER READIN6 0ndrea%on, 7( O( and 0ndrea%on, 6( M( ;=>>A<( -ext,oo% and color atlas of traumatic in9uries to the teeth, ;@rd edn<( Mun/%gaard, Co&enhagen( ;Comprehensive coverage of the management of dental trauma; including the role of orthodontics(< 1ou%ton, W( 7( 4(, Ste&hen%, C( D(, and Tulley, W( 7( ;=>> <( " text,oo% of orthodontics, ; nd edn<( Wright, Oxford( ;"n excellent introductory text,oo%<( )%aac%on, 2( G(, Reed, R( T(, and Ste&hen%, C( D( ;=>>9<( 1unctional orthodontic appliances( 4lac/,ell Scientific, Oxford( ;" clear and thorough review of the role; management and effects of functional appliances(< O/e%on, 7( "( ;=>C><( Te'&oro'andibular di%order% in children( Pediatric Dentistry, //, @ :->( ;" useful short summary on the su,9ect(< "roffitt, W( R( ;=>>@<( Contemporary orthodontics ; nd edn<( Mo%by, St 3oui%( ;" super,; comprehensive orthodontic text,oo%(<

Richard%on, 0( ;=>C><( Interceptive orthodontics ; nd edn<( $ritish Dental +ournal "ublication%, 3ondon( ;" concise hand,oo% of the role of orthodontics in the mixed dentition(< Sha,, W( C( ;ed(< ;=>>@<( 8rthodontics and occlusal management( 4utter,orth1eine'ann, 3ondon( ;"n authoritative orthodontic text,oo%; including cleft lip and palate; and ris%C,enefit of treatment(< /0./3 REFERENCES 4roo/, "( and Sha,, W( ;=>C><( The de$elo&'ent of an index of orthodontic treat'ent &riority( 7uropean +ournal of 8rthodontics, //, @9>- 9( E$an%, R( and Sha,, W( ;=>C?<( "reli'inary e$aluation of an illu%trated %cale for rai%ing dental attracti$ene%%( 7uropean +ournal of 8rthodontics, 4, @=A-=C( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

/5. &ral at%olo!$ and oral #-r!er$ - + G (eechan /5./ INTR&D(CTI&N The incidence of &athological condition% of the 'outh and &erioral %tructure% differ% bet,een children and adult%( 6or exa'&le, 'ucocele% are 'ore co''on in the young, ,herea% %Bua'ou% cell carcino'a% occur 'ore freBuently in older indi$idual%( The

'anage'ent of &athology in the child differ% fro' that in the adult( Gro,th and de$elo&'ent 'ay be affected by the di%ea%e, or it% treat'ent( On a 'ore &ractical ba%i%, anae%thetic con%ideration% for %urgical treat'ent of %i'&le &athological condition% can 'a/e 'anage'ent 'ore co'&lex( Thi% cha&ter deal% ,ith tho%e condition% that occur exclu%i$ely, or 'ore co''only in children( )t i% not an exhau%ti$e guide to &aediatric oral &athology, for ,hich reader% %hould refer to oral &athology textboo/%( Surgical treat'ent of the %i'&ler condition% i% di%cu%%ed in the oral %urgery %ection of thi% cha&ter ;Section =:(:<( /5.2 *ESI&NS &F T5E &RA* S&FT TISS(ES /5.2.0 Introd-"tion Condition% affecting the oral 'uco%a and a%%ociated %oft ti%%ue% can be cla%%ified a%G infection%, ulcer%, $e%iculobullou% le%ion%, ,hite le%ion%, cy%t%, and tu'our%( /5.2./ In+e"tion# 8iru%e%, bacteria, fungi, or &roto5oa 'ay cau%e infection% of the oral 'uco%a( Odontogenic infection% ,ill be di%cu%%ed under *oral %urgery* later in thi% cha&ter( )iral in+e"tion# 5ERPETIC INFECTI&NS PRI7ARY 5ERPES SI7P*E' INFECTI&N Thi% condition u%ually occur% in children bet,een the age% of ! 'onth% and : year%( Circulating 'aternal antibodie% u%ually &rotect% young babie%( The %y'&to'%, %ign%, and treat'ent are co$ered in Cha&ter ==( SEC&NDARY 5ERPES SI7P*E' INFECTI&N Secondary infection ,ith her&e% %i'&lex u%ually occur% at the labial 'ucocutaneou% +unction and &re%ent% a% a $e%icular le%ion ,hich ru&ture% and &roduce% cru%ting ;Cha&ter ==<( 5er e# .ari"ella-:o#ter Shingle%, ,hich i% cau%ed by the $aricella 5o%ter $iru%, i% 'uch co''oner in adult% than children( The $e%icular le%ion de$elo&% ,ithin the &eri&heral di%tribution of a branch of the trige'inal ner$e( Chic/en&ox, a 'ore co''on &re%entation of $aricella-5o%ter in children, &roduce% a $e%icular ra%h on the %/in( The intraoral le%ion% of chic/en&ox re%e'ble tho%e of &ri'ary her&etic infection( The condition i% highly contagiou%( 7(7PS Mu'&% &roduce% a &ainful enlarge'ent of the &arotid gland%( )t i% u%ually bilateral( The cau%ati$e agent i% a 'yxo$iru%( 0%%ociated co'&laint% include headache, $o'iting, and fe$er( Sy'&to'% la%t for about a ,ee/ and the condition i% contagiou%( 7EAS*ES The intraoral 'anife%tation of 'ea%le% occur% on the buccal 'uco%a( The le%ion%

a&&ear a% ,hite %&ec/ling %urrounded by a red 'argin and are /no,n a% 2o&lic/*% %&ot%( The oral %ign% u%ually &recede the %/in le%ion% and di%a&&ear early in the cour%e of the di%ea%e( The %/in ra%h of 'ea%le% nor'ally a&&ear% a% a red 'aculo&a&ular le%ion( 6e$er i% &re%ent and the di%ea%e i% contagiou%( R(;E**A Ger'an 'ea%le% doe% not u%ually &roduce %ign% in the oral 'uco%aG ho,e$er, the ton%il% 'ay be affected( "rotection again%t the di%ea%e% of 'u'&%, 'ea%le%, and rubella can be achie$ed by $accinating children in their early year% ,ith MMR $accine( 5ERPAN6INA Thi% i% a cox%ac/ie$iru% 0 infection( )t can be differentiated fro' &ri'ary her&etic infection by the different location of the $e%icle%, ,hich are found in the ton%illar or &haryngeal region( 1er&angina le%ion% do not coale%ce to for' large area% of ulceration( The condition i% %hort-li$ed( 5AND< F&&T< AND 7&(T5 DISEASE Thi% cox%ac/ie$iru% 0 infection &roduce% a 'aculo&a&ular ra%h on the hand% and feet( The )ntraoral $e%icle% ru&ture to &roduce &ainful ulceration( The condition la%t% for =9-=A day%( INFECTI&(S 7&N&N(C*E&SIS The E&%tein-4arr $iru%, cau%e% thi% condition( )t i% not unco''on a'ong teenager%( The u%ual for' of tran%'i%%ion i% by /i%%ing( Oral ulceration and &etechial hae'orrhage at the hardD%oft &alate +unction 'ay occur( There i% ly'&h node enlarge'ent and a%%ociated fe$er( There i% no %&ecific treat'ent( )t %hould be noted that the &re%cri&tion of a'&icillin and a'oxicillin ;a'oxycillin< can cau%e a ra%h in tho%e %uffering fro' infectiou% 'ononucleo%i%( The%e antibiotic% %hould be a$oided during the cour%e of the di%ea%e( Treat'ent of the $iral illne%%e% i% %y'&to'atic and relie% on analge%ia and 'aintenance of fluid inta/e( )t 'u%t be re'e'bered that a%&irin %hould be a$oided in children under = year% of age ;%ee later<( 5(7AN PAPI**&7A)IR(S Thi% i% a%%ociated ,ith a nu'ber of tu'our-li/e le%ion% of the oral 'uco%a, ,hich are di%cu%%ed belo,( ;a"terial in+e"tion STAP5Y*&C&CCA* INFECTI&NS Sta&hylococci and %tre&tococci 'ay be cau%e i'&etigo( Thi% can affect the angle% of the 'outh and the li&% ;6ig( =:(=<( )t &re%ent% a% cru%ting $e%iculobullou% le%ion%( The $e%icle% coale%ce to &roduce ulceration o$er a ,ide area( "ig'entation 'ay occur during healing( The condition i% %elf-li'iting, although antibiotic% 'ay be &re%cribed in %o'e ca%e%( Sta&hylococcal organi%'% can cau%e o%teo'yeliti% of the +a,% in children( 0lthough the introduction of antibiotic% ha% reduced the incidence of %e$ere for'% of the condition, it can %till be de$a%tating( )n addition to aggre%%i$e antibiotic thera&y, %urgical inter$ention i% reBuired to re'o$e bony %eBue%trae( STREPT&C&CCA* INFECTI&N

Stre&tococcal infection% in childhood $ary fro' a 'uco&urulent na%al di%charge to ton%illiti%, &haryngiti%, and gingi$iti%( Scarlet fe$er i% a -hae'olytic %tre&tococcal infection con%i%ting of a %/in ra%h ,ith 'aculo&a&ular le%ion% of the oral 'uco%a( )t i% a%%ociated ,ith ton%illiti% and &haryngiti%( The tongue %ho,% characteri%tic change% fro' a %tra,berry a&&earance in the early %tage% to a ra%&berry-li/e for' in the later %tage%( C&N6ENITA* SYP5I*IS Congenital %y&hili% i% tran%'itted fro' an infected 'other to the fetu%( Oral 'uco%al change% %uch a% rhagade%, ,hich i% a &attern of %carring at the angle of the 'outh, 'ay occur( )n addition, thi% di%ea%e 'ay cau%e characteri%tic dental change% in the &er'anent dentition( The%e include 1utchin%on*% inci%or% ;the teeth ta&er to,ard% the inci%al edge rather than the cer$ical 'argin< and 'ulberry 'olar% ;globular 'a%%e% of ena'el o$er the occlu%al %urface<( T(;ERC(*&SIS Tuberculou% le%ion% of the oral ca$ity are rareH ho,e$er, tuberculou% ly'&hadeniti% affecting %ub'andibular and cer$ical ly'&h node% i% occa%ionally %een( The%e &re%ent a% tender enlarged node%, ,hich 'ay &rogre%% to ab%ce%% for'ation ,ith di%charge through the %/in( Surgical re'o$al of infected gland% &roduce% a 'uch neater %car than that cau%ed by %&ontaneou% ru&ture through the %/in if the di%ea%e i% allo,ed to &rogre%%( CAT-SCRATC5 DISEASE Thi% i% a %elf-li'iting di%ea%e ,hich &re%ent% a% an enlarge'ent of regional ly'&h node%( The node% are &ainful and enlarge'ent occur% u& to @ ,ee/% follo,ing a cat %cratch( The node% beco'e %u&&urati$e and 'ay &erforate the %/in( Treat'ent often in$ol$e% inci%ion and drainage( F-n!al in+e"tion# CANDIDA -eonatal acute candidia%i% ;thru%h< contracted during birth i% not unco''on( 3i/e,i%e young children 'ay de$elo& the condition ,hen re%i%tance i% lo,ered or after antibiotic thera&y ;6ig( =:( <( Ea%ily re'o$ed ,hite &atche% on an erythe'atou% or bleeding ba%e are found( Treat'ent ,ith ny%tatin or 'icona5ole i% effecti$e ;tho%e under year% of age %hould recei$e (: 'l of a 'icona5ole gel ; : 'gD'l< t,ice dailyH : 'l t,ice daily i% &re%cribed for tho%e under ! year% of age, and : 'l four ti'e% a day for tho%e o$er ! year% of age<( A"tinom$"o#i# 0ctino'yco%i% can occur in children( )t 'ay follo, intraoral trau'a including dental extraction%( The organi%'% %&read through the ti%%ue% and can cau%e dy%&hagia if the %ub'andibular region i% in$ol$ed( 0b%ce%%e% 'ay ru&ture on to the %/in and longter' antibiotic thera&y i% reBuired( "enicillin %hould be &re%cribed and 'aintained for at lea%t ,ee/% follo,ing clinical cure( Proto:oal in+e"tion#

)nfection by -oxoplasma gondii 'ay occa%ionally occur in children( The &rinci&al re%er$oir of infection being cat%( Glandular toxo&la%'o%i% i% %i'ilar in &re%entation to infectiou% 'ononucleo%i% and i% found 'ainly in children and young adult%( There 'ay be a granulo'atou% reaction in the oral 'uco%a and there can be &arotid gland enlarge'ent( The di%ea%e i% %elf-li'iting, although an anti-&roto5oal %uch a% &yri'etha'ine 'ay be u%ed in ca%e% of %e$ere infection( Fi!. /5./ 4acterial infection on the li& of an i''unoco'&ro'i%ed child( ;4y /ind &er'i%%ion of Dental Update(< Fi!. /5.2 Oral candidia%i% in an i''unoco'&ro'i%ed child undergoing che'othera&y for acute ly'&hobla%tic leu/ae'ia( ;4y /ind &er'i%%ion of Dental Update(< /5.2.2 (l"er# Trau'atic ulceration of the tongue, li&%, and chee/ 'ay occur in children, e%&ecially after local anae%the%ia ha% been ad'ini%tered ;6ig( =:(@<( Recurrent a&hthou% oral ulceration not a%%ociated ,ith %y%te'ic di%ea%e i% often found in children ;6ig( =:(A<( One or 'ore %'all ulcer% in the non-attached gingi$a 'ay occur at freBuent inter$al%( )n the young child the %y'&to'% 'ay be 'i%ta/en for toothache by a &arent( The 'a+ority of a&hthou% ulcer% in children are of the 'inor $ariety ;le%% than : '' in dia'eter<( The%e u%ually heal ,ithin =9-=A day%( Treat'ent other than rea%%urance i% often unnece%%aryH ho,e$er, to&ical %teroid% ;0dcortyl in Oraba%e or Corlan &ellet%< 'ay be &re%cribed in %e$ere ca%e%( Older children 'ay benefit fro' the u%e of anti%e&tic rin%e% to &re$ent %econdary infection( )n the ab%ence of a hi%tory of 'a+or a&hthou% ulceration any ulcer la%ting for longer than ,ee/% %hould be regarded ,ith %u%&icion and bio&%ied( Fi!. /5.3 #lceration of the lo,er li& &roduced by biting ,hile %till anae%theti5ed fro' an inferior bloc/( Fi!. /5.0 Minor a&hthou% ulceration( ;4y /ind &er'i%%ion of Wolfe "ubli%hing(< /5.2.3 )e#i"-lo,-llo-# le#ion# 8e%iculobullou% le%ion% cau%e ulcer% in the later %tage% of %uch condition%( 8iral cau%e% ha$e been 'entioned abo$e( Si'ilarly, condition% %uch a% e&ider'oly%i% bullo%a and erythe'a 'ultifor'e can &roduce oral ulceration in children( The 'a+or $e%iculobullou% condition% %uch a% &e'&higu% and &e'&higoid are rare in young &atient%( E&ider'oly%i% bullo%a i% a ter' that co$er% a nu'ber of %yndro'e%, %o'e of ,hich are inco'&atible ,ith life( The %/in i% extre'ely fragile and 'uco%al in$ol$e'ent 'ay occur( The act of %uc/ling 'ay induce bullae for'ation in babie%( )n older children effecti$e oral hygiene 'ay be difficult a% e$en 'ild trau'a can &roduce &ainful le%ion%( The oral le%ion% of erythe'a 'ultifor'e u%ually affect the li&% and anterior oral 'uco%a ;6ig( =:(:<( There i% initial erythe'a follo,ed by bullae for'ation and ulceration( The &athogene%i% of the condition i% %till unclear, ho,e$er, &reci&itating

factor% include drug thera&y and infection( Treat'ent include% the u%e of %teroid% and oral anti%e&tic and analge%ic rin%e% to ea%e the &ain( Fi!. /5.5 Erythe'a 'ultifor'e in a teenager( /5.2.0 8%ite le#ion# Trau'a of either a che'ical or &hy%ical nature, for exa'&le, burn% and occlu%al trau'a, can cau%e ,hite &atche% intraorally( 85ITE SP&N6Y NAE)(S The ,hite %&ongy nae$u% ;al%o /no,n a% the oral e&ithelial nae$u%< i% a rough folded le%ion that can affect any &art of the oral 'uco%a( )t often a&&ear% in infancy( )t i% benign( *E(C&EDE7A Thi% i% a folded, ,hite tran%lucent a&&earance found in children of race% ,ho exhibit &ig'entation of the oral 'uco%a( )t i% con%idered a $ariation of nor'al( CANDIDIASIS The ,hite &atche% of acute fungal candidia%i% 'entioned abo$e are readily re'o$ed, in contra%t to the ,hite le%ion% di%cu%%ed here( 6E&6RAP5IC T&N6(E Thi% condition 'ay be %een in children( )t i% nor'ally %y'&to'le%%, although %o'e &atient% co'&lain of di%co'fort ,ith %&icy food%( 0rea% of the tongue a&&ear %hiny and red due to lo%% of filifor' &a&illae ;6ig( =:(!<( The%e red &atche% are %urrounded by ,hite 'argin%( The%e area% di%a&&ear before rea&&earing in other region% of the tongue( The condition i% benign and reBuire% no treat'ent a&art fro' rea%%urance to the child and &arent( Fi!. /5.1 Geogra&hic tongue( ;4y /ind &er'i%%ion of Wolfe "ubli%hing(< /5.2.5 C$#t# 7(C&CE*ES The &ea/ incidence of 'ucocele% i% in the %econd decade of lifeH ho,e$er, they are not unco''on in younger children ;6ig( =:(?< including neonate%( Mucocele% are cau%ed by trau'a to 'inor %ali$ary gland% or duct% and are often located on the lo,er li&( They are the co''one%t non-infecti$e cau%e of %ali$ary gland %,elling in children( Sali$ary tu'our% are rare in thi% age grou&( RAN(*A Thi% a&&ear% a% a blui%h %,elling of the floor of the 'outh ;6ig( =:(C<( )t i% e%%entially a large 'ucocele( )t 'ay ari%e fro' &art of the %ublingual %ali$ary gland( ;&5N?S N&D(*ES The%e gingi$al cy%t% ari%e fro' re'nant% of the dental la'ina( They are found in -eonate%( They u%ually di%a&&ear %&ontaneou%ly in the early 'onth% of life(

EPSTEIN?S PEAR*S The%e %'all cy%tic le%ion% are located along the &alatal 'id-line( They are thought to ari%e fro' tra&&ed e&itheliu' in the &alatal ra&he( They are &re%ent in about C9L of neonate% and di%a&&ear ,ithin a fe, ,ee/% of birth( DER7&ID CYSTS The%e are rare le%ion% of the floor of the 'outh( They a&&ear a% intraoral and %ub'ental %,elling% ;6ig( =:(><( They are deri$ed fro' e&ithelial re'nant% re'aining fro' fu%ion of the 'andibular &roce%%e%( *Y7P5&EPIT5E*IA* CYST )n the &a%t thi% ,a% ter'ed branchial arch cy%t a% it ,a% thought to ari%e fro' e&ithelial re'nant% of a branchial arch( They are nor'ally found in the %terno'a%toid region, although they can &re%ent in the floor of the 'outh( 1i%tologically the cy%t ,all contain% ly'&h ti%%ue( The ti%%ue of origin i% thought to be %ali$ary e&itheliu'( T5YR&6*&SSA* CYST Thi% cy%t, ,hich ari%e% fro' the thyroglo%%al duct e&itheliu', 'ay &re%ent intraorally( The 'outh ho,e$er, i% a rare %ite( Mo%t ari%e in the region of the hyoid bone( Fi!. /5.2 4ilateral 'ucocele% in a @-year-old girl( ;4y /ind &er'i%%ion of the +ournal of Dentistry for Children(< Fi!. /5.3 0 ranula in a =A-year-old girl( Fi!. /5.4 0 der'oid cy%t( /5.2.1 T-mo-r# C&N6ENITA* EP(*IS Thi% i% a rare le%ion that occur% in neonate%( )t nor'ally &re%ent% in the anterior 'axilla( )t con%i%t% of granular cell% co$ered by e&itheliu' and i% thought to be reacti$e in nature( Thi% i% a benign le%ion and %i'&le exci%ion i% curati$e( 7E*AN&TIC NE(R&ECT&DER7A* T(7&(R Thi% rare tu'our occur% in the early 'onth% of life, u%ually in the 'axilla( The le%ion con%i%t% of e&ithelial cell% containing 'elanin ,ith a fibrou% %tro'a( So'e locali5ed bone ex&an%ion 'ay occur( The condition i% benign and %i'&le exci%ion i% curati$e( S@(A7&(S-CE** PAPI**&7A Thi% i% a benign condition that occur% in children( The %'all cauliflo,er-li/e gro,th%, ,hich $ary in colour fro' &in/ to ,hite ;6ig( =:(=9<, are u%ually %olitary le%ion%( They 'ay be due to the hu'an &a&illo'a$iru%( )ERR(CA )(*6ARIS Thi% condition al%o /no,n a% the co''on ,art 'ay &re%ent a% %olitary or 'ulti&le intraoral le%ion%( The%e 'ay be a%%ociated ,ith %/in ,art%( They are &robably cau%ed by the hu'an &a&illo'a$iru%(

F&CA* EPIT5E*IA* 5YPERP*ASIA Thi% i% a rare condition al%o /no,n a% 1ec/*% di%ea%e( )t i% a%%ociated ,ith hu'an &a&illo'a$iru%( )t &re%ent% a% 'ulti&le %'all ele$ation% of the oral 'uco%a e%&ecially in the lo,er li&( FI;R&EPIT5E*IA* P&*YP Thi% i% a fairly co''on le%ion that &re%ent% a% a fir' &in/ lu'&( )t nor'ally affect% the buccal 'uco%a at the occlu%al le$el( They are cau%ed by trau'a( They are u%ually %y'&to'le%% unle%% further trau'ati5ed and are ea%ily re'o$ed( FI;R&(S EP(*IS Thi% &re%ent% a% a 'a%% on the gingi$a( Colour $arie% fro' &in/ to red de&ending u&on the degree of $a%cularity of the le%ion( ;6ig( =:(==<( )t con%i%t% of an infla''atory cell infiltrate and 'ature fibrou% ti%%ue, occa%ionally a calcified $ariant i% found( Surgical exci%ion i% curati$e( PY&6ENIC 6RAN(*&7A The%e co''only occur on the gingi$a u%ually in the anterior 'axilla( They are &robably a reaction to chronic trau'a, e%&ecially fro' a %ub-gingi$al calculu%( Due to their aetiology they ha$e a tendency to recur after re'o$al( PERIP5ERA* 6IANT-CE** 6RAN(*&7A Thi% dar/-red %,elling of the gingi$a can occur in children( )t often ari%e% interdentally( Radiogra&h% 'ay re$eal %o'e lo%% of the interdental cre%t( The central giant-cell granulo'a ;%ee belo,< %ho,% 'uch greater bone de%truction( Thi% condition i% thought to be a reacti$e hy&er&la%ia( #nle%% exci%ion i% co'&lete it ,ill recur( 5AE7AN6I&7AS 1ae'angio'a% are relati$ely co''on in children( They are 'alfor'ation% of blood $e%%el%( They are di$ided into ca$ernou% and ca&illary $ariant%, although %o'e le%ion% contain ele'ent% of both( Ca&illary hae'angio'a% 'ay &re%ent a% facial birth'ar/%( The ca$ernou% hae'angio'a i% a ha5ard during %urgery if in$ol$ed ,ithin the %urgical %ite( )t i% a large blood-filled %inu% that ,ill bleed &rofu%ely if da'aged ;6ig( =:(= <( The extent of a ca$ernou% hae'angio'a can be e%tabli%hed &rior to %urgery u%ing either angiogra&hy or 'agnetic re%onance i'aging ;MR)< %canning( S'all hae'angio'a% are readily treated by exci%ion or cryothera&y( 3arger le%ion% are a'enable to la%er thera&y( ST(R6E-8E;ER SYNDR&7E Sturge-Weber angio'ato%i% i% a %yndro'e con%i%ting of a hae'angio'a of the le&to'eninge% ,ith an e&ithelial facial hae'angio'a clo%ely related to the di%tribution of branche% of the trige'inal ner$e( Mental deficiency, he'i&legia, and ocular defect% can occur( )ntraoral in$ol$e'ent 'ay interfere ,ith the ti'ing of eru&tion of the teeth ;both early and delayed eru&tion ha$e been re&orted<( *Y7P5AN6I&7AS 3y'&hangio'a% are benign tu'our% of the ly'&hatic%( The $a%t 'a+ority are found in children( The head and nec/ region i% a co''on %ite ;6ig( =:(=@<( The cy%tic hygro'a i% a $ariant that a&&ear% a% a large nec/ %,elling, ,hich 'ay extend intraorally to

in$ol$e the floor of the 'outh and tongue( NE(R&FI;R&7AS The%e 'ay &re%ent a% %olitary or 'ulti&le le%ion%( They are con%idered ha'arto'a% ;a ha&ha5ard arrange'ent of ti%%ue<( They &re%ent intraorally a% 'uco%al %,elling% on the tongue or gingi$ae( Multi&le oral neuro'a% are a feature of the 'ulti&le endocrine neo&la%ia %yndro'e( 0% the oral %ign% 'ay &recede the de$elo&'ent of 'ore %eriou% a%&ect% of thi% condition ;%uch a% carcino'a of the thyroid<, children &re%enting ,ith 'ulti&le le%ion% %hould be referred to an endocrinologi%t( &ro+a"ial !ran-lomato#i# Orofacial granulo'ato%i% ;O6G< i% not a tu'our in the true %en%e nor a di%tinct di%ea%e entity, but de%cribe% a clinical a&&earance( Ty&ically there i% diffu%e %,elling of one or both li&% and chee/%, folding of the buccal reflected 'uco%a and occa%ionally gingi$al %,elling and oral ulceration ;6ig( =:(=A ;a< and ;b<<( Thi% 'ay re&re%ent a locali5ed di%turbance due to an allergic reaction to food%tuff%, tooth&a%te, or e$en dental 'aterial%( 0lternati$ely, the a&&earance 'ay be due to an underlying %y%te'ic condition %uch a% %arcoido%i% or Crohn*% di%ea%e( 7E*>ERSS&N-R&SSENT5A* SYNDR&7E Thi% i% a condition that generally begin% during childhood( )t con%i%t% of chronic facial %,elling ;u%ually the li&%<, facial ner$e &araly%i%, and fi%%ured ;%crotal< tongue( 7ali!nant t-mo-r# o+ t%e oral #o+t ti##-e# EPIT5E*IA* T(7&(RS Malignant tu'our% of the oral e&itheliu', %uch a% %Bua'ou%-cell carcino'a, are rare in children( Malignant %ali$ary neo&la%'% are al%o unco''on, although 'ucoe&ider'oid carcino'a% ha$e been re&orted in young &atient%( *Y7P5&7AS 1odg/in*% and non-1odg/in*% ly'&ho'a% ha$e been re&orted in childrenH ho,e$er, they are relati$ely rare in the &aediatric age grou&( 0n exce&tion i% 4ur/itt*% ly'&ho'a, ,hich i% ende'ic in &art% of 0frica and occur% in tho%e under =A year% of age( )ndeed, in the%e area% the condition account% for al'o%t half of all 'alignancy in children( 4ur/itt*% ly'&ho'a i% 'ultifocal, but a +a, tu'our ;'ore often in the 'axilla< i% often the &re%enting %y'&to'( 4ur/itt*% ly'&ho'a i% %trongly lin/ed to the E&%tein-4arr $iru% a% a cau%al agent( R5A;D&7Y&SARC&7AS The%e 'alignant tu'our% of %/eletal 'u%cle &re%ent in &atient% around > to = year% of age( The u%ual %ite i% the tongue( Meta%ta%e% are co''on and the &rogno%i% i% &oor( Fi!. /5./0 SBua'ou%-cell &a&illo'a in a >-year-old girl( ;4y /ind &er'i%%ion of Dental Update(< Fi!. /5.// 0 fibrou% e&uli% in a =9-year-old girl ;a &yogenic granulo'a a&&ear% %i'ilar<( Fi!. /5./2 Ca$ernou% hae'angio'a of the right buccal 'uco%a( ;4y /ind &er'i%%ion of Wolfe "ubli%hing(<

Fi!. /5./3 3y'&hangio'a of the tongue and floor of the 'outh( ;4y /ind &er'i%%ion of "rofe%%or C( Scully(< Fi!. /5./0 ;a< and ;b< S,elling of the lo,er li& and attached 'uco%a and gingi$a in a @-year-old girl ,ith orofacial granulo'ato%i%( /5.3 *ESI&NS &F T5E jA8S /5.3.0 Introd-"tion The%e can be di$ided intoG cy%t%, de$elo&'ental condition%, o%teody%tro&hie%, and tu'our%( /5.3./ C$#t# ER(PTI&N Eru&tion cy%t% are really dentigerou% cy%t% ;%ee belo,< that &re%ent a% %,elling% of the al$eolar 'uco%a( They 'ay &recede the eru&tion of both &ri'ary and &er'anent teeth ;6ig( =:(=:<( When filled ,ith blood they are often called eru&tion hae'ato'a%( The treat'ent of eru&tion cy%t% i% di%cu%%ed in Section =:(:(:( DENTI6ER&(S Thi% i% the co''one%t +a, cy%t in children ;6ig( =:(=!<( )t% origin i% the reduced ena'el e&itheliu', and attach'ent to the tooth occur% at the a'eloce'ental +unction( There are often no %y'&to'% but eru&tion of the affected tooth ,ill be &re$ented( The treat'ent of dentigerou% cy%t% i% di%cu%%ed in Section =:(:(:( RADIC(*AR The%e cy%t% related to the a&ex of a non-$ital tooth do occur in children, although they are rare in the &ri'ary dentition( They are often %y'&to'le%% and are di%co$ered radiogra&hically( Extraction, a&icecto'y, or con$entional endodontic% ,ill effect a cure( 3ateral &eriodontal cy%t% are $ery rare in children( &D&NT&6ENIC >ERAT&CYSTS The odontogenic /eratocy%t i% the 'o%t aggre%%i$e of the +a, cy%t%( )t ha% a high rate of recurrence due to the fact that re'nant% left after %ubtotal re'o$al ,ill regenerate( The%e cy%t% 'ay be found in children and 'ay be a%%ociated ,ith the Gorlin-Golt5 %yndro'e( 2eratocy%t% a%%ociated ,ith thi% %yndro'e a&&ear in the fir%t decade of life, ,herea% the %yndro'ic ba%al-cell carcino'a% are rare before &uberty( Other %ign% and %y'&to'% includeG 'ulti&le ba%al-cell carcino'a%, bifid rib%, calcification of the falx cerebri, hy&ertelori%', and frontal and te'&oral bo%%ing( N&N-&D&NT&6ENIC The%e include the na%o&alatine duct cy%t ,hich 'ay occur clinically a% a %,elling in the anterior 'id-line of the hard &alate( The radiogra&hic a&&earance i% a radiolucency of greater than ! '' in dia'eter in the &o%ition of the na%o&alatine duct( The anterior teeth ha$e $ital &ul&%( Surgical exci%ion i% curati$e( The %o-called globulo'axillary cy%t, ,hich occur% bet,een the lateral inci%or and canine teeth, i% no, thought to be odontogenic in origin( )t i% either a radicular cy%t or an odontogenic /eratocy%t(

The hae'orrhagic bone cy%t i% a condition that 'ay be found in children and adole%cent%( )t occur% 'o%t co''only in the 'andible in the &re'olarD'olar region( )t i% often a chance radiogra&hic finding and nor'ally a%y'&to'atic( Radiogra&hically it a&&ear% a% a %callo&ed radiolucency bet,een the root% of the teeth( )t regre%%e% %&ontaneou%ly or after %urgical in$e%tigation( Fi!. /5./5 Eru&tion cy%t &rior to the a&&earance of the u&&er &er'anent fir%t 'olar( Fi!. /5./1 Radiogra&hic a&&earance of a dentigerou% cy%t a%%ociated ,ith a lo,er %econd &re'olar( ;4y /ind &er'i%%ion of Dental Update(< /5.3.2 De.elo mental "ondition# -u'erou% de$elo&'ental condition% 'ay affect the oral and &erioral %tructure%( The%e range fro' 'inor &roble'% ;e(g( tongue-tie< that are readily treated under local anae%the%ia, to %e$ere craniofacial di%order% ;e(g( Crou5on*% %yndro'e< reBuiring a co'bined interdi%ci&linary a&&roach bet,een 'axillofacial and neuro%urgery( Reader% %hould refer to %&eciali5ed text% for a full de%cri&tion of congenital +a, abnor'alitie%( )t i% i'&ortant to re'e'ber that &atient% ,ith de$elo&'ental orofacial abnor'alitie% 'ay ha$e other congenital di%order%, %uch a% cardiac defect%, ,hich 'ay influence routine dental treat'ent( /5.3.3 &#teod$#tro %ie# FI;R&(S DYSP*ASIA Thi% can occur a% one of three $ariant%, na'elyG 'ono%totic, &olyo%totic, or a% &art of 0llbright*% %yndro'e ;,here a%%ociated condition% include %/in &ig'entation and &recociou% &uberty in fe'ale%<( The 'ono%totic ty&e i% the 'o%t co''on to affect the +a,%, e%&ecially the 'axilla( The di%ea%e &re%ent% a% a %lo,-gro,ing bony ex&an%ion that &roduce% facial a%y''etry and 'alalign'ent of teeth( Radiogra&hically there i% a fine granular radio&acity ;6ig( =:(=?<( Surgery can correct the a%y''etry( C5ER(;I7 )n thi% rare condition there i% a characteri%tic fullne%% of the chee/% and +a,%( )nitial &re%entation i% co''only bet,een and A year% of age( Si5e increa%e% during gro,th( )t i% %elf-li'iting and regre%%ion occur% in adulthood( Co%'etic %urgery 'ay be e'&loyed after acti$e gro,th ha% fini%hed( Multilocular radiogra&hic radiolucencie% occur at the angle% of the 'andible ;6ig( =:(=C< and the 'axillary tubero%itie%( 1i%tologically the le%ion i% %i'ilar to the giant-cell granulo'a( Fi!. /5./2 Mono%totic fibrou% dy%&la%ia of right 'andibular angle and a%cending ra'u% in a =:-year-old boy( Fi!. /5./3 4ilateral 'ultilocular radiolucencie% affecting the angle% of the 'andible in a :-year-old child ,ith cherubi%'( /5.3.0 T-mo-r# o+ t%e DaC# &D&NT&7ES Odonto'e% are ha'arto'a% that contain dental calcified ti%%ue( They are cla%%ified a%

co'&ound ;a collection of di%crete tooth-li/e %tructure%< and co'&lex ;a ha&ha5ard arrange'ent of dental ti%%ue<( Co'&ound odonto'e% are 'o%t co''only found in the anterior 'axilla ;6ig( =:(=><( The co'&lex ty&e are u%ually located in the &re'olarD 'olar region% of both +a,%( Odonto'e% are u%ually %y'&to'le%% and are diagno%ed radiogra&hically( The 'ean age of &atient% at diagno%i% i% =: year%( Occa%ionally an odonto'e ,ill beco'e infected ,hen &artially eru&ted and %urgical exci%ion i% reBuired( Si'ilarly, re'o$al i% indicated if an odonto'e i% interfering ,ith the eru&tion of a neighbouring tooth or i% needed a% &art of an orthodontic treat'ent &lan( j()ENI*E &SSIFYIN6 FI;R&7A Thi% benign le%ion differ% fro' the adult o%%ifying ;or ce'ento-o%%ifying< fibro'a in that gro,th i% ra&id( )t con%i%t% of fibrou% ti%%ue ,ith a $arying a'ount of 'inerali5ed 'aterial( )t u%ually affect% the 'andible( Radiogra&h% %ho, a ,ellcircu'%cribed radiolucency ,ith *%&ec/ling*( Surgical exci%ion i% reBuired( CENTRA* 6IANT-CE** 6RAN(*&7A Thi% %,elling of bone u%ually affect% the 'andible ;6ig( =:( 9<( Radiogra&hically there i% a ,ell-defined radiolucency ,ith occa%ional re%or&tion of a%%ociated teeth( 1i%tologically there are large nu'ber% of o%teocla%t-li/e cell% in a $a%cular %tro'a( Surgical curettage i% curati$e( 5ISTI&CYT&SES 3angerhan%* cell hi%tiocyto%i%, for'erly /no,n a% hi%tiocyto%i% X i% a condition that &redo'inantly affect% children ;Cha&ter ==<( 4one i% re&laced by 3angerhan%* cell%, %o &roducing %har&ly defined radiogra&hic radiolucencie%( A7E*&;*AST&7A 0lthough 'ore co''only found in adult%, thi% locally in$a%i$e neo&la%' can occur in children( )t i% u%ually found in the 'andible( )t i% %lo, gro,ing, and i% often %y'&to'le%% in the early %tage%( 0% it &rogre%%e% it cau%e% a bony %,elling, ,hich a&&ear% a% a 'ultilocular radiolucency in the +a,( Surgical re%ection to %ound bone i% nece%%ary for a cure( A7E*&;*ASTIC FI;R&7A Thi% rare le%ion u%ually affect% a younger age grou& than the a'elobla%to'a( The a$erage age of &atient% at diagno%i% i% =A year%( )t i% a benign tu'our( 0 related le%ion i% the a'elobla%tic fibro-odonto'a( Thi% le%ion contain% dentine and ena'el and occur% in children under =9 year% of age( PRI7ARY INTRA&SSE&(S CARCIN&7A Thi% i% a $ery rare tu'our but ,hen it occur% it i% u%ually in children( )t i% thought to ari%e fro' odontogenic e&itheliu' and %ho,% ra&id gro,th( SARC&7AS Sarco'a% of the +a,% are rareH ho,e$er, the highly 'alignant E,ing*% %arco'a occur% in children bet,een the age% of : and =: year% of age( The 'andible i% u%ually the bone affected and the &rogno%i% i% &oor(

Fi!. /5./4 Co'&ound odonto'e in the u&&er left canine region( Fi!. /5.20 Central giant-cell granulo'a in a >-year-old girl( /5.0 &RA* 7ANIFESTATI&NS &F SYSTE7IC DISEASE )n addition to %&ecific &athological oral condition%, di%ea%e% that affect other %y%te'% of the body can &roduce oral 'anife%tation%, for exa'&le, Crohn*% di%ea%e( )n addition, di%order% %uch a% chronic renal failure and diabete% can &redi%&o%e to &eriodontal di%ea%e and there 'ay be &oor re%i%tance to the %&read of odontogenic infection( )t i% not only the oral %oft ti%%ue% that are affected by %y%te'ic condition%( The te'&oro'andibular +oint can be in$ol$ed in +u$enile rheu'atoid arthriti% and the +a,% can be affected in hy&er&arathyroidi%' ;giant-cell tu'our%<( )n %o'e ca%e% an oral condition 'ay be the &re%enting feature of a %y%te'ic di%ea%e and dental &ractitioner% %hould not he%itate to refer children ,ith abnor'al oral %ign% for further in$e%tigation( /5.5 &RA* S(R6ERY /5.5.0 Introd-"tion Thi% %ection deal% ,ith dental extraction% and 'inor oral %urgical &rocedure% for children( The &rocedure% de%cribed are tho%e that can be &erfor'ed under local anae%the%ia ,ith or ,ithout %edation ;nor'ally inhalational< or day-%tay general anae%the%ia in healthy children( Oral %urgery &rocedure% that reBuire in-&atient facilitie%, other than the treat'ent of %e$ere infection, ,ill not be con%idered in thi% text( /5.5./ E9odontia Di++eren"e# ,etCeen rimar$ and ermanent teet% =( #i>e( "ri'ary teeth are %'aller in e$ery di'en%ion co'&ared ,ith their &er'anent counter&art%( 0lthough the root% of &ri'ary teeth are %'aller than tho%e of the &er'anent dentition they do for' a &ro&ortionately greater &art of the tooth( ( #hape( The cro,n% of &ri'ary teeth are 'ore bulbou% than the cro,n% of &er'anent teeth( The root% of &ri'ary 'olar% are 'ore %&layed than the root% of &er'anent 'olar teeth( The furcation of &ri'ary 'olar root% i% &o%itioned 'ore cer$ically than in the corre%&onding &er'anent teeth( @( Physiology( The root% of &ri'ary teeth re%orb naturally, ,herea% in the &er'anent dentition re%or&tion i% nor'ally a %ign of &athology( A( #upport( The bone of the al$eolu% i% 'uch 'ore ela%tic in the younger &atient( The%e difference% 'ean that there are %o'e 'odification% to extraction techniBue% in children( The ty&e% of force&% e'&loyed for the re'o$al of &ri'ary teeth differ fro' that u%ed for the re'o$al of &er'anent teeth( The bea/% and handle% are %'aller( )n

addition, to acco''odate the 'ore bulbou% cro,n, the bea/% are 'ore cur$ed in force&% de%igned for the re'o$al of &ri'ary teeth( The ,ide %&laying of &ri'ary 'olar root% 'ean% that 'ore ex&an%ion of the %oc/et i% reBuired for the extraction of &ri'ary teeth( The 'ore ela%tic al$eolu% of the younger &atient allo,% thi% to be achie$ed( Due to the relati$ely cer$ical &o%ition of the bifurcation in &ri'ary 'olar% it i% in+udiciou% to u%e force&% ,ith dee&ly &lunging bea/% ;%uch a% the adult co,horn de%ign< a% the%e could da'age the underlying &er'anent %ucce%%or%( Thi% i% e%&ecially %o ,ith the lo,er &ri'ary 'olar%( 0% &ri'ary root% are re%orbed it i% often &referable to lea$e %'all frag'ent% in situ if the root fracture%( When &art of a fractured root i% $i%ible then it %hould be re'o$ed( 4lind in$e%tigation of &ri'ary %oc/et% %hould not be &erfor'ed a% there i% a danger of da'aging the underlying &er'anent %ucce%%or( Si'ilarly, blind in$e%tigation of the di%tal root %oc/et of fir%t &er'anent 'olar teeth 'u%t not be carried out in children ,ith uneru&ted %econd 'olar%, a% unintentional ele$ation of the %econd 'olar can occur( Pro,lem# e"-liar to t%e "%ild atient 0 nu'ber of &roble'% &eculiar to the child &atient ,ill affect the ,ay in ,hich extraction% are carried out( The follo,ing %hould be con%ideredG ;=< natal and neonatal teethH ; < infraocclu%ion of teethH ;@< fu%ionDge'ination of t,o teethH ;A< da'age to the &er'anent %ucce%%orH ;:< di%location of the 'andible( NATA* AND NE&NATA* TEET5 Mo%t neonatal teeth ;C:L< are found in the 'andible( 0bout :L of the%e are %u&ernu'erarie%( Their 'anage'ent i% di%cu%%ed in Cha&ter =@( INFRA&CC*(SI&N Surgical di$i%ion i% %o'eti'e% nece%%ary to re'o$e the%e teeth ;Cha&ter =@<( F(SI&NB6E7INATI&N (C&NNATI&N) Such teeth 'ay not lend the'%el$e% to force&% extraction due to their unu%ual coronal %ha&e( Ele$ator% are u%ually e'&loyed, ,ith or ,ithout tooth di$i%ion and bone re'o$al, to effect extraction( DA7A6E T& PER7ANENT S(CCESS&R Thi% 'ay occur if force&% ,ith large bea/% are u%ed or during root ele$ation( DIS*&CATI&N &F T5E 7ANDI;*E )t i% $ery ea%y to di%locate a child*% 'andible during extraction% under general anae%the%ia ;,hen the 'u%cle% are relaxed< unle%% adeBuate %u&&ort i% &ro$ided by the *non-,or/ing* hand( Thi% i% becau%e the articular e'inence i% not a% &ronounced in

young &atient% a% in adult%( )t i% e%%ential to $erify that di%location ha% not occurred before the &atient i% allo,ed to regain con%ciou%ne%%( /5.5.2 E9tra"tion te"%niA-e# PATIENT P&SITI&N The child %hould be %eated in a dental chair reclined about @9 to the $ertical for extraction% under local anae%the%ia( #nder general anae%the%ia the &atient i% u%ually %u&ine( When re'o$ing u&&er teeth under local anae%the%ia the o&erator %tand% in front of the &atient, ,ith a %traight bac/ and the &atient*% 'outh at a le$el +u%t belo, the o&erator*% %houlder( 0 right-handed o&erator re'o$e% lo,er left teeth fro' a %i'ilar &o%ition in front of the &atient, exce&t that the &atient*% 'outh i% at a height +u%t belo, the o&erator*% elbo,( When re'o$ing teeth fro' the lo,er right the righthanded o&erator %tand% behind the &atient ,ith the chair a% lo, a% &o%%ible to allo, good $i%ion( When &erfor'ing extraction% in the %u&ine &atient under general anae%the%ia the &atient*% 'outh i% u%ually at a le$el +u%t belo, the o&erator*% elbo,( Once again, lo,er right teeth are re'o$ed fro' behind, ,ith all other% being extracted by the o&erator %tanding in front of the &atient( )t doe% %a$e ti'e during general anae%the%ia if teeth can be re'o$ed a'bidextrou%ly a% all teeth can be extracted ,ith the o&erator %tanding in front of the &atient( The re'o$al of &ri'ary teeth ,ith the non-do'inant hand i% not difficult to 'a%ter and i% a u%eful %/ill to acBuire( T%e non-Cor=in! %and The %ection% belo, de%cribe the in%tru'ent% and techniBue u%ed by the o&erator*% ,or/ing hand( The *non-,or/ing* hand al%o ha% i'&ortant role% to &lay ;6ig( =:( =<G =( )t retract% %oft ti%%ue% to allo, $i%ibility and acce%%( ( )t &rotect% the ti%%ue% if the in%tru'ent %li&%( @( )t &ro$ide% re%i%tance to the extraction force on the 'andible to &re$ent di%location( A( )t &ro$ide% *feel* to the o&erator during the extraction and gi$e% infor'ation about re%i%tance to re'o$al( &rder o+ e9tra"tion When &erfor'ing 'ulti&le extraction% in all Buadrant% of the 'outh ;e%&ecially if under general anae%the%ia< the order of extraction i% a% follo,%G =( Sy'&to'atic teeth are extracted before *balancing extraction%* on the o&&o%ite %ide( ( 3o,er teeth are extracted before u&&er teeth ;to eli'inate bleeding interfering ,ith the %urgical field<( @( )f there are %y'&to'atic teeth in all Buadrant% right-handed o&erator% %hould begin ,ith lo,er right extraction%( Thi% 'ini'i5e% the nu'ber of change% of &o%ition of the %urgeon, ,hich ,ill reduce general anae%thetic ti'e(

(PPER PRI7ARY AND PER7ANENT ANTERI&RS When the%e teeth are in a nor'al &o%ition in the dental arch they %hould be re'o$ed by a&&lying the force&% bea/% to the root and then u%ing cloc/,i%e and anticloc/,i%e rotation% about the long axi% ;the action one ,ould e'&loy ,hen u%ing a %cre,dri$er<( )n older children %o'e additional buccal ex&an%ion 'ay be reBuired for the re'o$al of the &er'anent u&&er canine( When re'o$ing &ri'ary u&&er anterior%, u&&er &ri'ary anterior or u&&er &ri'ary root force&% are u%edH for the &er'anent 'axillary anterior% u&&er %traight force&% are e'&loyed( Mal&o%itioned &er'anent u&&er anterior% are freBuently encountered and 'odification% to techniBue 'u%t be e'&loyed( 3abially &laced u&&er lateral inci%or% and canine% ha$e $ery little buccal %u&&ort and are ea%ily re'o$ed, either by u%ing %traight force&% a&&lied 'e%ially and di%tally and u%ing a %light rotatory 'o$e'ent a% de%cribed earlier or by the u%e of ele$ator%( The 'o%t u%eful ele$ator% under the%e circu'%tance% are the %traight and cur$ed War,ic/ 7a'e% and Cou&land%( The %traight ele$ator% are a&&lied along the length of the 'e%ial and di%tal %urface% of the root and directed in a rotatory 'anner to,ard% the a&ex ;6ig( =:( <( The 'e%iobuccal and di%tobuccal %urface% are u%ed alternately, although in 'any in%tance% the tooth ,ill be ele$ated after a&&lication to only one of the%e %urface%( When the cur$ed War,ic/ 7a'e% ele$ator% are u%ed, the right-%ided War,ic/ 7a'e% i% &o%itioned on the 'e%iobuccal %urface of u&&er right teeth and the di%tobuccal %urface of u&&er left teeth, and then rotated to,ard% the 'id-line of the tooth( The left-%ided in%tru'ent i% u%ed on the o&&o%ite root %urface in a %i'ilar fa%hion( "alatally &o%itioned lateral inci%or% and canine% are u%ually not acce%%ible ,ith force&% and thu% ele$ator% are u%ed a% de%cribed abo$e, ,ith the exce&tion that they are a&&lied on the &alato'e%ial and &alatodi%tal %urface%( When the cur$ed ele$ator% are u%ed the right-%ided in%tru'ent i% a&&lied di%tally on the right %ide and 'e%ially on the left %ide( (PPER PRI7ARY 7&*ARS The%e teeth di%&lay the 'o%t ,idely %&layed root% found in either dentition and thu% con%iderable ex&an%ion of the %oc/et i% reBuired( #&&er &ri'ary 'olar force&% are u%ed and a&&lied to the root%( The initial 'o$e'ent after a&&lication of the force&% i% &alatal, to ex&and the %oc/et in thi% direction( The tooth i% then %ub+ected to a continuou% bucally directed force, ,hich re%ult% in deli$ery( Occa%ionally, buccal 'o$e'ent i% not adeBuately obtained due to gro%% carie% on the &alatal a%&ect cau%ing %li&&age of the force&% bea/ on the &alatal %ide during buccal ex&an%ion( Thi% 'ay be o$erco'e by co'&leting the extraction by continued &alatal ex&an%ion, the ela%tic bone of younger &atient% allo,ing thi% to be &erfor'ed( (PPER PRE7&*ARS The t,o-rooted, u&&er fir%t &re'olar i% be%t re'o$ed by buccal ex&an%ion u%ing u&&er &re'olar force&%( The u&&er %econd &re'olar i% often %ingle rooted and, although buccal ex&an%ion ,ith &re'olar force&% %hould be atte'&ted in the fir%t in%tance, thi% tooth can al%o be %ub+ected to a rotation about it% long axi% to effect deli$ery( "alatally di%&laced u&&er &re'olar% are difficult to re'o$e ,ith force&%( The u%e of ele$ator% in a 'anner %i'ilar to that de%cribed for &alatally &laced canine% i% &referred(

(PPER PER7ANENT 7&*ARS The%e teeth are re'o$ed u%ing left and right u&&er 'olar force&%( 6ollo,ing a&&lication of the force&% to the root% of the tooth ;the &ointed bea/ being dri$en to,ard% the buccal root bifurcation< the tooth i% deli$ered by ex&anding the %oc/et in a buccal direction( The u%e of &alatal ex&an%ion i% not a% %ucce%%ful in the re'o$al of &er'anent 'olar%, but it 'ay be ,orth atte'&ting if buccal ex&an%ion fail% to deli$er the tooth( The &roble' ,ith &alatal ex&an%ion ,hen extracting &er'anent 'olar% i% that it can cau%e fracture of the &alatal root, ,hich i% u%ually the 'o%t clo%ely a%%ociated ,ith the 'axillary antru'( *&8ER PRI7ARY ANTERI&RS The%e teeth are extracted in the %a'e 'anner a% their u&&er counter&art%, in that, rotation about the long axi% u%ing lo,er &ri'ary anterior or root force&% i% e'&loyed( *&8ER PER7ANENT ANTERI&RS "er'anent lo,er inci%or% are not readily re'o$ed by rotation a% their root% are thin 'e%iodi%tally and rotation i% li/ely to cau%e root fracture( The 'o%t effecti$e 'ethod of re'o$al i% to a&&ly lo,er root force&% and ex&and the %oc/et labially( "er'anent lo,er canine% 'ay be deli$ered by a rotatory 'o$e'ent about the long axi% or by buccal ex&an%ion( 3abially di%&laced lo,er canine% are re'o$ed in a 'anner %i'ilar to that de%cribed for buccally &laced u&&er anterior%( Me%ial and di%tal a&&lication of force&% or %traight ele$ator% are u%ed( Straight ele$ator% are u%ed on lo,er inci%or% that are labially &laced( The &o%ition of lingually &laced lo,er anterior% nor'ally &reclude% the u%e of force&% and %traight ele$ator% a&&lied 'e%ially and di%tally %hould be e'&loyed( *&8ER PRI7ARY 7&*ARS The%e teeth are re'o$ed by buccolingual ex&an%ion of the %oc/et( They can be extracted u%ing either lo,er &ri'ary 'olar or lo,er &ri'ary root force&%( 3o,er &ri'ary 'olar force&% are %i'ilar in de%ign to the &er'anent 'olar force&%( They ha$e t,o &ointed bea/% ,hich engage the bifurcation( 3o,er &ri'ary root force&% are u%ed by a&&lying the bea/% to the 'e%ial root of the &ri'ary 'olar( 3o,er fir%t &ri'ary 'olar% are u%ually 'ore ea%ily re'o$ed ,ith lo,er &ri'ary root force&%( 0fter a&&lication of the force&% a %'all lingual 'o$e'ent i% follo,ed by a continuou% buccal force, ,hich deli$er% the tooth( *&8ER PRE7&*ARS When the%e teeth are fully eru&ted in the arch of the young &atient they are u%ually %i'&ly re'o$ed by a rotatory 'o$e'ent around the long axi% of the root u%ing lo,er &re'olar force&%( Mal&o%itioned lo,er %econd &re'olar% are nor'ally lingually &o%itioned and can be difficult to re'o$e ,ith lo,er force&%( When lingually &laced, lo,er &re'olar% 'ay be extracted u%ing %traight ele$ator% a&&lied 'e%ially, lingually, and di%tally( 0lternati$ely, it i% often &o%%ible to a&&ly the bea/% of u&&er fine root force&% 'e%ially and di%tally to the cro,n of the lingually &laced tooth ,hen the force&% are directed fro' the o&&o%ite %ide of the +a,( Gentle rotation of the tooth ,ith the force&% 'ay then effect re'o$al( *&8ER PER7ANENT 7&*ARS T,o de%ign% of force&% are u%ed to extract lo,er 'olar teeth( The lo,er 'olar force&% ha$e t,o &ointed bea/% that are a&&lied in the region of the bifurcation buccally and

lingually( Once a&&lied the force&% are u%ed to 'o$e the tooth in a buccal direction to ex&and the buccal cortical &late( When buccal ex&an%ion i% not %ufficient to deli$er the tooth then the force&% %hould be 'o$ed in a figure-of-eight fa%hion to ex&and the %oc/et lingually a% ,ell a% buccally, and thi% i% generally %ucce%%ful( 0 different techniBue i% u%ed ,ith force&% of the co,horn de%ign( The%e force&% ha$e t,o bea/% that ta&er to a &oint( The &oint% are a&&lied to the bifurcation of the lo,er 'olar in a 'anner identical to that de%cribed abo$e( The next 'o$e'ent i% to %Buee5e the force&% handle% together, ,hich re%ult% in the bea/% a&&roaching one another at the ba%e of the bifurcation( The only ,ay the bea/% can a&&roach each other i% by di%&lacing the tooth in an occlu%al direction re%ulting in extraction of the tooth( 4oth the 'ethod% are %ucce%%ful in re'o$ing &er'anent 'olar teeth in children and the choice of techniBue de&end% 'ainly on the &reference of the o&erator( 7ana!ement o+ ,-ried teet% 4uried teeth ;including %u&ernu'erarie%< are treated in children for %e$eral rea%on%G ;=< %y'&to'atic ;e(g( &ain<H ; < radiogra&hic %ign% of &athology ;e(g( dentigerou% cy%t for'ation<H ;@< &art of an orthodontic treat'ent &lan( )f buried teeth are %y'&to'le%%, ha$e no a%%ociated &athology, and are not cau%ing orthodontic &roble'% ;either by their ab%ence or in &re$enting the orthodontic 'o$e'ent of eru&ted teeth< they %hould be left alone( Such teeth %hould be /e&t under clinical and radiogra&hic re$ie, %o that any de$elo&ing &athology 'ay be detected and treated( )n ca%e% ,here uneru&ted teeth are to be re'o$ed the fir%t %te& in 'anage'ent i% to locali5e the buried tooth by clinical exa'ination and radiogra&hic techniBue%( 0 nu'ber of radiogra&hic $ie,% 'ay be u%edG ;=< &arallax &eria&ical%H ; < ortho&anto'ogra'H ;@< occlu%al $ie,%H ;A< true lateral facial bone%( )n &ractice, &arallax &eria&ical% and an ortho&anto'ogra' are u%ually %ufficient( The &eria&ical fil'% ,ill hel& to e%tabli%h the buccolingual &o%ition of the buried tooth in relation to the eru&ted dentition( The ortho&anto'ogra' ,ill %u&&ly infor'ation concerning the o$erall %ha&e of the tooth, it% relation%hi& to neighbouring %tructure% ;%uch a% the antru', inferior al$eolar ner$e canal, other uneru&ted teeth<, and the extent of any a%%ociated &athology( Once the tooth ha% been located and the difficulty of re'o$al and &atient co-o&eration a%%e%%ed then the 'ethod of anae%the%ia %hould be deter'ined( E9tra"tion o+ ,-ried teet% When re'o$ing buried dental ti%%ue in children it i% i'&erati$e to ha$e an excellent $ie, of the o&erati$e field( Thi% i% e%&ecially i'&ortant ,hen re'o$ing uneru&ted teeth or %u&ernu'erarie% clo%ely a%%ociated ,ith other uneru&ted teeth that are to be retained( )n the%e circu'%tance% the tooth of intere%t and it% uneru&ted neighbour%

'u%t be clearly identified( F*AP DESI6N 6la&% %houldG be 'uco&erio%tealH be cut at >9 to boneH ha$e a good blood %u&&lyH a$oid da'age to i'&ortant %tructure%H allo, atrau'atic reflectionH &ro$ide adeBuate acce%% and $i%ibilityH and &er'it rea&&o%ition of the ,ound 'argin% o$er %ound bone( F*APS F&R ;(CCA**Y P*ACED TEET5 T,o de%ign% of fla& 'ay be u%ed for the re'o$al of buccally &laced teeth( The fir%t of the%e include% the gingi$al 'argin a% the hori5ontal co'&onent and a $ertical relief inci%ion into the de&th of the buccal %ulcu% ;6ig( =:( @ ;a<-;g<<( )t allo,% good ex&o%ure, ea%y orientation, can be readily extended and, for the 'o%t &art the ,ound edge ,ill be re&laced o$er %ound bone at the end of the &rocedure( )f thi% de%ign i% u%ed in the 'andible in the region of the 'ental fora'en care 'u%t be ta/en to en%ure that the $ertical relief i% at lea%t one tooth in front of the fora'en ;,hich ,ill ha$e been locali5ed fro' the ortho&anto'ogra'<( The only &roble' ,ith thi% ty&e of fla& i% that it 'ay di%ru&t the gingi$al contour, but thi% i% not a 'a+or long-ter' &roble' in the child( The %econd de%ign of fla& for buccally &laced teeth i% a %e'ilunar inci%ion( 0t lea%t : '' of attached gingi$a %hould be 'aintained at the narro,e%t &oint to en%ure a good blood %u&&ly to the 'arginal gingi$ae( Thi% fla& doe% not &ro$ide %uch good ex&o%ure or orientation a% the &re$iou% de%ign, and it i% ea%y at the end of %urgery to be left ,ith a large &art of the ,ound 'argin o$er a bony defect( Thi% can lead to ,ound brea/do,n( F*APS F&R PA*ATA**YB*IN6(A**Y P*ACED TEET5 "alatally &o%itioned teeth are be%t re'o$ed $ia an inci%ion that follo,% the &alatal gingi$al 'argin ;6ig( =:( A ;a<-;g<<( Such an inci%ion 'aintain% the integrity of the greater &alatine ner$e% and blood $e%%el%( )t i% often &o%%ible to rai%e thi% fla& ,ithout %acrificing the neuro$a%cular bundle that lea$e% the inci%i$e fora'en( Thi% bundle ,ill %tretch to a certain degreeH ho,e$er, if acce%% de'and% it %hould be cut( Thi% rarely re%ult% in any &o%to&erati$e co'&lication%( The extent of the &alatal gingi$al inci%ion de&end% u&on the %urgery in$ol$ed( 0 fla& extending bet,een the 'e%ial a%&ect of both fir%t &er'anent 'olar% i% not unu%ual for the re'o$al of bilateral i'&acted 'axillary canine%( S'aller fla&% 'ay be %ufficient to re'o$e &alatally &laced teeth or %u&ernu'erarie% near the 'id-line( )n the lo,er +a, adeBuate acce%% to the lingual %ide i% obtained by rai%ing the lingual gingi$a and reflected 'uco%a $ia an inci%ion run around the lingual gingi$al 'argin( ;&NE RE7&)A* When ,or/ing clo%e to buried teeth that are to be retained it i% e%%ential that bone i% re'o$ed ,ith care( Thi% 'ay be carried out u%ing a hand&iece and bur $ery %lo,ly( The u%e of chi%el% ,ith hand &re%%ure ;'allet% are not u%ed unle%% ,or/ing under general anae%the%ia and are %eldo' reBuired in children< i% 'uch %afer becau%e thi% i%

unli/ely to da'age coronal ti%%ue( T&&T5 RE7&)A* Once %ufficient bone ha% been re'o$ed to allo, identification of the tooth to be extracted and ex&o%ure of the greate%t dia'eter of it% cro,n, the tooth %hould be ele$ated( )f thi% i% li/ely to &roduce undue &re%%ure on neighbouring eru&ted or buried teeth then the tooth %hould be di$ided u%ing a hand&iece and bur and re'o$ed in &art%( Mandibular teeth that are i'&acted ,ithin the line of the arch are be%t re'o$ed by the %o-called *bro/en in%tru'ent techniBue*, in ,hich &re%%ure i% a&&lied fro' one %ide of the tooth ;e(g( u%ing a %traight War,ic/ 7a'e% ele$ator< to force it out of the other %ide( S(T(RIN6 Re%orbable %uture% %hould be u%ed in children ,hene$er &o%%ibleG @D9 or AD9 %oftgut i% ideal( DISC5AR6E 0ny bleeding %hould be arre%ted before the &atient i% allo,ed to lea$e the %urgery( The &atient and &arent %hould recei$e in%truction% on %i'&le 'ethod% of hae'orrhage control( The &atient i% encouraged to 'aintain good oral hygiene and 'ay be gi$en an anti%e&tic 'outh,a%h( The &roble' of %elf-inflicted trau'a in anae%theti5ed area% i% %tre%%ed at thi% %tage( PAIN RE*IEF Si'&le analge%ic% are u%ually reBuired, but a%&irin 'u%t be a$oided in tho%e under = year% of age due to it% a%%ociation ,ith Reye*% %yndro'e( "araceta'ol elixir ;= 9 'gD: 'l four ti'e% daily for tho%e under ! year% of ageH :9 'gD: 'l four ti'e% daily for children aged !-= year%< i% ideal( The &atient i% gi$en a re$ie, a&&oint'ent but %hould return %ooner if there are any &roble'% ,ith bleeding, exce%%i$e &ain, or %,elling( 0 tele&hone nu'ber for contact in an e'ergency 'u%t be &ro$ided( RE)IE8 The &atient %hould be re$ie,ed = ,ee/ after %urgery, at ,hich %tage re%orbable %uture% 'ay ha$e di%a&&eared( The %urgical %ite %hould be exa'ined for undue %,elling, the area of local anae%the%ia exa'ined for e$idence of %elf-inflicted trau'a, and the &atient Bue%tioned about any re%idual altered %en%ation( )t i% often nece%%ary to reinforce good oral hygiene at thi% %tage( P&STE'TRACTI&N PR&;*E7S 6ortunately, &o%textraction &roble'% are rare in children( Dry %oc/et doe% not %ee' to occur after the re'o$al of &ri'ary teeth but it can affect older children follo,ing &er'anent 'olar extraction%, although the incidence i% not a% great a% in adult%( 3ocal 'ea%ure% %uch a% irrigation and dre%%ing ,ith a %edati$e &ac/, &lu% the &re%cri&tion of an analge%ic are %ufficient( "o%to&erati$e hae'orrhage i% an occa%ional &roble' ,ith children and can be i'&re%%i$e follo,ing 'ulti&le extraction% under general anae%the%ia( #%ually &re%%ure a&&lied ,ith gau5e or a hand/erchief i% effecti$e( )f not, %uture% ,ith or ,ithout hae'o%tatic gau5e 'u%t be u%ed( Se$ere blood lo%% i% $ery rare, but if thi% occur% it i% i'&ortant to exclude a %y%te'ic cau%e to en%ure %ub%eBuent treat'ent can be &erfor'ed %afely(

Fi!. /5.2/ The non-,or/ing hand %u&&ort% the tooth for extraction and reflect% the %oft ti%%ue%( Fi!. /5.22 #%e of a Cou&land ele$ator to deli$er a buccally &laced u&&er canine( Fi!. /5.23 ;a< #%e of a buccal fla& to re'o$e eru&ted TC, totally %ub'erged TD, infraoccluded TE, and uneru&ted TA( ;4y /ind &er'i%%ion of Dental Update(< ;b< The buccal fla& i% rai%ed( ;4y /ind &er'i%%ion of Dental Update(< ;c< 4one i% re'o$ed ,ith a chi%el follo,ing re'o$al of TC7( ;4y /ind &er'i%%ion of Dental Update(< ;d< Totally %ub'erged TD i% identified by occlu%al a'alga'( ;4y /ind &er'i%%ion of Dental Update(< ;e< TD Re'o$ed and TA located( ;4y /ind &er'i%%ion of Dental Update(< ;f< TA re'o$ed( ;4y /ind &er'i%%ion of Dental Update(< ;g< Wound Clo%ure( ;4y /ind &er'i%%ion of Dental Update(< Fi!. /5.20 ;a< "re-o&erati$e $ie, &rior to re'o$al of &alatal %u&ernu'erary ;F C40DC< in a > year old child $ia a %'all &alatal fla&( ;4y /ind &er'i%%ion of Dental Update(< ;b< #neru&ted =T and %u&ernu'erary ob$iou% on radiogra&h( ;c< Eru&ted teeth extracted and &alatal gingi$al 'argin being inci%ed( ;4y /ind &er'i%%ion of Dental Update(< ;d< S'all &alatal fla& rai%ed( ;4y /ind &er'i%%ion of Dental Update(< ;e< =T and %u&ernu'erary identified after bone re'o$ed( ;4y /ind &er'i%%ion of Dental Update(< ;f< =T re'ain( ;4y /ind &er'i%%ion of Dental Update(< ;g< Wound clo%ure( ;4y /ind &er'i%%ion of Dental Update(< /5.5.3 S-r!i"al aid# to ort%odonti"# S-r!i"al e9 o#-re o+ teet% The ex&o%ure of buried teeth 'ay in$ol$e either the extraction of eru&ted teeth or the re'o$al of buried dental ele'ent%, but in %o'e ca%e% all that i% reBuired i% exci%ion of o$erlying %oft ti%%ue( )f the tooth can be ex&o%ed adeBuately through a collar of attached gingi$a then the &rocedure i% Buite %i'&leG =( Eru&ted &ri'ary &redece%%or% 'ay be extracted( ( 0 fla& i% rai%ed in the 'anner de%cribed abo$e( @( 0ny uneru&ted %u&ernu'erarie% or buried teeth are extracted( A( The bony i'&action i% relie$ed and the ,ide%t dia'eter of the cro,n ex&o%ed( 0t thi% %tage it 'ay be &o%%ible to &lace an orthodontic brac/et to aid eru&tion, although thi% i% by no 'ean% e%%ential( :( 0 &ac/, for exa'&le, Whitehead*% $arni%h on =D -inch ;about =( : c'< or =DA-inch ;about 9(!@ c'< ribbon gau5e or a &eriodontal dre%%ing, i% then &laced around the tooth and the fla& re&laced around the &ac/( )t i% not al,ay% nece%%ary to %acrifice %oft ti%%ue if the tooth i% ex&o%ed, and the &ac/ can be &laced $ia &ri'ary tooth %oc/et%( 0lternati$ely it i% &o%%ible in %o'e ca%e% ;%uch a% the ex&o%ure of a &alatally &laced canine< to incor&orate a &eriodontal &ac/ on to the acrylic of an u&&er re'o$able orthodontic a&&liance to 'aintain ex&o%ure during healing( !( The u%e of non-re%orbable %uture% to 'aintain the &ac/ i% reco''ended, although other &art% of the inci%ion can be clo%ed ,ith re%orbable %uture%(

?( )n ca%e% in ,hich the re'o$al of %oft ti%%ue fro' the &alate or cre%t of the ridge i% all that i% reBuired to ex&o%e a tooth then it i% unnece%%ary to rai%e a full fla&( 0ll that i% needed i% to %acrifice the o$erlying ti%%ue and &ac/ the ,ound ;6ig( =:( : ;a< and ;b<<( Occa%ionally thi% can cau%e exce%%i$e bleeding in the &alate( Thi% i% controlled by &a%%ing a non-re%orbable %uture acro%% the full thic/ne%% of the &alatal 'uco&erio%teu' +u%t &o%terior to the ,ound edge to ligate the greater &alatine artery( C( When an uneru&ted tooth, cla%%ically a canine, i% &al&able high in the buccal %ulcu% under reflected 'uco%a it %hould not be ex&o%ed by %acrificing the o$erlying %oft ti%%ue( Thi% ,ould re%ult in the cer$ical collar of the tooth being %urrounded by non/eratini5ed 'uco%a( To o$erco'e thi% &roble' a fla& containing /eratini5ed gingi$a 'u%t be rai%ed coronal to the i'&acted tooth, bone re'o$ed if nece%%ary, and the fla& re&laced in a 'ore a&ical &o%ition to allo, a collar of attached gingi$a around the tooth at eru&tion( >( The &ac/ and any re'aining non-re%orbable %uture% %hould be re'o$ed after ?-=9 day%( ;ondin! o+ ort%odonti" a lian"e# to -ner- ted teet%

When it i% i'&o%%ible to re&o%ition a fla& a&ically around an uneru&ted tooth an alternati$e i% to bond either a gold chain or a 'agnet to the buried tooth ;6ig( =:( ! ;a< and ;b<<( When &erfor'ing thi% techniBue the tooth i% locali5ed a% de%cribed abo$e and the gold chain or 'agnet attached to the tooth u%ing co'&o%ite re%in and a bonding agent( When a gold chain ha% been attached ;6ig( =:( ! ;a<< the chain i% brought through the edge% of the ,ound in the area of natural eru&tion of the tooth( The free end of the chain i% then either bonded to an eru&ted tooth or %utured to the 'uco%a during the healing &eriod before orthodontic acti$ation( When a 'agnet i% u%ed ;6ig( =:( ! ;b<< the %oft ti%%ue% are relocated in their original &o%ition and %utured( 0 'agnet ,ith the o&&o%ite &olarity i% incor&orated ,ithin a re'o$able a&&liance and thi% i% &laced o$er the ,ound to a&&ly the 'agnetic force( S-r!i"al an"%ora!e Occa%ionally there i% in%ufficient eru&ted dentition to allo, orthodontic anchorage( Thi% i% e%&ecially the ca%e for the &atient ,ith hy&odontia ;Cha&ter =@<( Extraoral anchorage 'ay be e'&loyed in %uch ca%e%( 0nother techniBue i% to &ro$ide anchorage by the &ro$i%ion of i'&lant%( Standard dental i'&lant% are not nor'ally u%ed in children a% they act a% an/ylo%ed teeth and 'ay di%turb the gro,th of the +a,% ;%ee belo,<( Orthodontic i'&lant%, ho,e$er, 'ay be &laced, for exa'&le, in the 'idline of the &alate ;6ig( =:( ?<( Orthodontic a&&liance% can then be attached to the%e i'&lant%, ,hich are re'o$ed at the end of treat'ent( Fi!. /5.25 ;a< Ex&o%ure of &alatal canine by ti%%ue %acrifice( ;4y /ind &er'i%%ion of Dental Update(< ;b< Ribbon gau5e &ac/ %utured in defect( ;4y /ind &er'i%%ion of Dental Update(< Fi!. /5.21 ;a< Gold chain bonded to uneru&ted 'axillary &er'anent canine( The free end of the chain ,ill be bonded to the eru&ted 'axillary &er'anent inci%or follo,ing fla& re&lace'ent( ;b< Magnet bonded to uneru&ted lo,er %econd

&re'olar tooth follo,ing bone re'o$al( 6ollo,ing fla& re&lace'ent an acrylic %&lint containing the 'agnet ,ith the o&&o%ite &ole ,ill be &o%itioned o$er the 'uco%a( Fi!. /5.22 0n orthodontic i'&lant &laced in the 'id-line of the &alate and u%ed to &ro$ide anchorage( ;)'age /indly %u&&lied by Strau'ann 3td(< /5.5.0 A i"al #-r!er$ 0&icecto'y i% rarely &erfor'ed in children( 0% ,ith adult &atient% the be%t treat'ent for &ul&al &athology i% nor'ally con$entional endodontic thera&y( 1o,e$er, there are %o'e indication% for the techniBue, 'o%t co''only teeth ,ith intran%igent o&en a&ice%( 0 nu'ber of different fla& de%ign% 'ay be u%ed( The be%t i% the triangular fla& in$ol$ing the gingi$al 'argin and $ertical relief inci%ion de%cribed abo$e for the re'o$al of buccally &laced buried teeth( "rinci&ally thi% i% becau%e the extent of a&ical &athology i% often 'ore exten%i$e in children than i% %ugge%ted radiogra&hically, and u%e of the %e'ilunar fla& can lead to &art% of the inci%ion being left o$er a bony defect at the end of %urgery( Te"%niA-e The %urgical techniBue i% identical to that u%ed in adult% but there are a nu'ber of &oint% of difference ,hen &lacing the a&ical %eal( )n teeth ,ith i''ature o&en a&ice% through-and-through root filling% are un%ati%factory a% the a&ex 'ay be ,ider than the bul/ of the canal, thu% %o'e for' of retrograde re%toration i% reBuired( )t i% often difficult to %ecure undercut% at the a&ex ,hen dealing ,ith a tooth that ha% an o&en a&ex, but thi% can be o$erco'e by &lacing a large retrograde filling and relying on 'ulti&le 'icro%co&ic undercut% to %ecure it( /5.5.5 C$#t# inter+erin! Cit% er- tion Eru&tion and dentigerou% cy%t% can interfere ,ith the eru&tion of teeth( Eru&tion cy%t% in the young child are %i'&ly inci%ed ;,hen occluding teeth are &re%ent thi% can be achie$ed by the &atient the'%el$e% on biting<( Dentigerou% cy%t% 'ay be 'ar%u&iali5ed to the oral 'uco%al lining follo,ing the re'o$al of any o$erlying &ri'ary &redece%%or and the &er'anent tooth allo,ed to eru&t( So'e authoritie% ad$ocate 'ore aggre%%i$e treat'ent in$ol$ing enucleation of the cy%t ;,ith or ,ithout re'o$al of the tooth< to en%ure that e&ithelial re'nant% are not left behind( 6i%%ural cy%t% ;%uch a% the na%o&alatine cy%t< are rare in childrenH ,hen found they %hould be enucleated( /5.5.1 Treatment o+ a"-te oro+a"ial in+e"tion 0t thi% &oint it i% rele$ant to di%cu%% the treat'ent of orofacial infection( The 'a+or cau%e of thi% condition i% dental in origin( The 'inor oral %urgical treat'ent% di%cu%%ed abo$e 'ay all be e'&loyed to definiti$ely treat the %ource of an orofacial infection( 0lternati$ely, con%er$ati$e treat'ent% %uch a% endodontic thera&y 'ay be a&&ro&riate( 0 ra&idly %&reading extraoral infection, ho,e$er, i% a %urgical e'ergency( Thi% 'erit% i''ediate treat'ent and 'ay reBuire ad'i%%ion for in-&atient 'anage'ent( T,o area% of extraoral %&read are of %&ecial i'&ortance( The%e are the %ub'andibular region and the angle bet,een the eye and no%e( S,elling in the

%ub'andibular region ari%ing fro' &o%terior 'andibular teeth can re%ult in the floor of the 'outh being rai%ed( Thi% can cau%e a &hy%ical ob%truction to breathing and %&read fro' thi% region to the &ara&haryngeal %&ace% 'ay further ob%truct the air,ay( The ad$ance fro' dy%&hagia to dy%&noea can be ra&id( 0 %ub'andibular %,elling %hould be deco'&re%%ed a% a 'atter of urgency in children( 0 child ,ith rai%ing of the floor of the 'outh reBuire% i''ediate ad'i%%ion to ho%&ital( The fact that tri%'u% i% in$ariably an a%%ociated feature 'a/e% ex&ert anae%thetic hel& e%%ential for %afe 'anage'ent( )nfection in$ol$ing the angle bet,een eye and no%e ;6ig( =:( C< ha% the &otential to %&read intracranially and &roduce a ca$ernou% %inu% thro'bo%i%( Thi% i% a &otentially life-threatening co'&lication( The angular $ein% of the orbit ;,hich ha$e no $al$e%< connect the ca$ernou% %inu% to the face, and if the nor'al extracranial flo, i% ob%tructed due to &re%%ure fro' the extraoral infection then infected 'aterial can enter the %inu% by re$er%e flo,( To &re$ent thi% co'&lication, infection in thi% area ;,hich ari%e% fro' u&&er anterior teeth, e%&ecially the canine%< 'u%t be treated ex&editiou%ly( The &rinci&le% of the treat'ent of acute infection are toG ;=< re'o$e the cau%eH ; < in%titute drainageH ;@< &re$ent %&readH and ;A< re%tore function( )n addition, analge%ia and adeBuate hydration 'u%t be 'aintained( Re'o$al of the cau%e i% e%%ential to cure an orofacial infection ari%ing fro' a dental %ource( Thi% u%ually 'ean% extraction or endodontic thera&y( )n%titution of drainage and &re$ention of %&read are %u&&orti$e treat'ent%they are not definiti$e cure%( Drainage 'ay be obtained during the re'o$al of the cau%e, for exa'&le, a dental extraction, or 'ay &recede definiti$e treat'ent if thi% 'a/e% 'anage'ent ea%ier, for exa'&le, inci%ion and drainage of a %ub'andibular ab%ce%%( Drainage 'ay be intra or extraoral( When an extraoral inci%ion i% 'ade it i% 'ade in a %/in crea%e &arallel to the direction of the facial ner$e( )n the %ub'andibular region the inci%ion i% 'ade 'ore than one finger*% breadth belo, the angle of the 'andible to a$oid the 'andibular branch( Once %/in ha% been inci%ed the di%%ection i% carried out bluntly until the infection ha% been located( 3ocule% of infection are then ru&tured u%ing blunt di%%ection and a drain %ecured to the external %urface( De&ending on the a'ount of drainage the drain i% %ecured for A-AC h%( 0ny &u% %hould be %ent for culture and %en%iti$ity te%ting to the 'icrobiology laboratory( "re$ention of %&read 'ay be achie$ed %urgically or by the u%e of antibiotic%( )n %e$ere ca%e% intra$enou% antibiotic% ,ill be u%ed( The antibiotic of choice in children i% a &enicillin( )t i% i'&ortant to re'e'ber that acute infection% are &ainful and that analge%ic%, a% ,ell a% antibiotic%, %hould be &re%cribed( The u%e of &araceta'ol elixir i% u%ually %ufficient( Si'ilarly, it i% i'&ortant that a child %uffering fro' an acute infection i% adeBuately hydrated( )f the infection ha% re%tricted the inta/e of oral fluid% due to dy%&hagia then ad'i%%ion to ho%&ital for intra$enou% fluid re&lace'ent i% reBuired( Fi!. /5.23 )nfection in thi% region can %&read intracranially( ;4y /ind &er'i%%ion of Dental Update(<

/5.5.2 A-totran# lantation o+ teet% Re&lantation of an a$ul%ed tooth due to trau'a ha% been di%cu%%ed in Cha&ter = ( )n thi% %ection autotran%&lantation of teeth i% di%cu%%ed( 0utotran%&lantation of teeth in children 'ay be con%idered a% a treat'ent for the follo,ingG ;=< re&o%itioning of an ecto&ic toothH ; < re&lace'ent of an unre%torable tooth ,ith a redundant 'e'ber of the dentition( The ecto&ic tooth 'o%t co''only re&o%itioned by %urgical 'ean% i% the uneru&ted, &alatally &laced, u&&er &er'anent canine( 0n exa'&le of u%ing autotran%&lantation a% a 'ean% of tooth re&lace'ent i% the %ub%titution of an u&&er inci%or that i% undergoing re%or&tion by a &re'olar tooth %cheduled for extraction a% &art of an orthodontic treat'ent &lan ;6ig( =:( > ;a<-;+<<( The 'anage'ent regi'en for both treat'ent% i% %i'ilar and i% a% follo,%G ;=< a%%e%%'ent of donor tooth and reci&ient %iteH ; < atrau'atic extraction of donor toothH ;@< &re&aration of reci&ient %iteH ;A< tran%&lantationH ;:< %&linting of tran%&lanted toothH ;!< root treat'ent of tran%&lanted tooth( )n addition, ,hen autotran%&lantation i% u%ed to re&lace a tooth in the arch %o'e coronal &re&aration and orthodontic 'o$e'ent of the donor tooth 'ay be reBuired( Tran%&lantation %urgery i% u%ually &erfor'ed under antibiotic &ro&hylaxi% ;either oral or intra$enou% a'oxicillin ;a'oxycillin<<, a% the u%e of %y%te'ic antibiotic% ha% been %ho,n to decrea%e the incidence of root re%or&tion( A##e##ment o+ donor toot% and re"i ient #ite The tooth to be tran%&lanted ha% to be a&&rai%ed clinically and radiogra&hically &rior to %urgery( The cro,n of an eru&ted tooth can be a%%e%%ed for carie% and it% di'en%ion% 'ea%ured( Root %tatu% and %ha&e ,ill be deter'ined u%ing &eria&ical radiogra&h%( Donor teeth %hould ha$e an o&en a&ex ,ith at lea%t three-Buarter% of the root for'ed( The 'or&hology of uneru&ted teeth for tran%&lantation can only be deter'ined radiogra&hically( Teeth ,ith %e$ere root cur$ature are un%uitable for tran%&lantation a% it i% unli/ely they can be re'o$ed intact ,ithout trau'a( )n addition, the &roduction of a donor %ite %uitable for a dilacerated tooth 'ay be difficult to &roduce ,ithout da'aging neighbouring $ital teeth( )t i% i'&ortant to e$aluate the reci&ient %ite both clinically and radiogra&hically( The %&ace a$ailable for the tran%&lanted tooth 'u%t be a%%e%%ed in both the hori5ontal and $ertical di'en%ion%( )t 'ay be nece%%ary to create %ufficient %&ace u%ing &reo&erati$e orthodontic%( "eria&ical radiogra&h% ,ill alert the clinician to the &re%ence of any bony &athology or retained dental re'nant% at the reci&ient %ite( Atra-mati" e9tra"tion o+ donor toot%

)t i% e%%ential to re'o$e the donor tooth u%ing 'ini'al trau'a and a$oiding contact ,ith the root %urface( Da'age to the root %urface ,ill lead to re%or&tion or an/ylo%i%( Thu% ,hen re'o$ing an eru&ted tooth for tran%&lantation the u%ual rule% concerning the a&&lication of force&% bea/% to the root %urface do not a&&ly( The bea/% are &o%itioned on the cro,n( "rior to the a&&lication of the force&% a %cal&el %hould be run around the gingi$al 'argin to the cre%t of the ridge to %e$er gingi$al attach'ent%( When an uneru&ted tooth i% being u%ed a% a donor great care 'u%t be exerci%ed during it% re'o$al( The entire cro,n 'u%t be ex&o%ed( 0% 'entioned earlier, bone re'o$al ,ith hand chi%el% i% le%% li/ely to da'age the donor than the u%e of a bur( Once the cro,n ha% been ex&o%ed ele$ator% or force&% ;again confined to the cro,n< are u%ed to extract the tooth a% gently a% &o%%ible( When the tooth ha% been extracted it %hould be gently re&laced into it% %oc/et and 'aintained there until the reci&ient %ite i% &re&ared( Thi% i% to en%ure that a %ati%factory tooth i% obtained before reci&ient %ite %urgery i% &erfor'ed( Pre aration o+ t%e re"i ient #ite The reci&ient %ite 'ay or 'ay not contain a tooth( 6ollo,ing extraction of the tooth at the reci&ient %ite the %oc/et i% enlarged, if nece%%ary, u%ing either a chi%el or a bur ;an i'&lant bur i% ideal<( So'e o&erator% reco''end that the %oc/et i% enlarged follo,ing fla& rai%ing by re'o$ing the buccal &late of bone, ,hich i% %tored in %aline &rior to being re&laced ,ith the cortical %urface again%t the root( )t i% thought that thi% 'ight decrea%e the incidence of an/ylo%i%( Tran# lantation Once the %oc/et ha% been &re&ared the donor tooth i% gently &laced in it% ne, &o%ition( The occlu%ion i% a%%e%%ed to en%ure that it i% not trau'atic to the tran%&lanted tooth, and the gingi$al 'argin i% held around the tooth ,ith a hori5ontal 'attre%% %uture( S lintin! t%e tran# lanted toot% The donor tooth %hould be %&linted at the ti'e of tran%&lantation( )t i% i'&ortant to %tre%% that rigid %&linting %hould not be e'&loyed a% thi% 'ay lead to an/ylo%i%( 0 %i'&le %&lint u%ing orthodontic ,ire bonded to the tooth and it% neighbour% ,ith co'&o%ite re%in i% %ufficient( )t i% e%%ential that %&linting i% not 'aintained for too long a &eriod a% thi% 'ay al%o lead to an/ylo%i%@ ,ee/% i% the 'axi'u' length of ti'e, indeed in %o'e ca%e% the %&lint can be re'o$ed in = ,ee/( Root treatment o+ tran# lanted toot% The &ul& of the tran%&lanted tooth i% extir&ated after -@ ,ee/% and the root canal filled ,ith non-%etting calciu' hydroxide( The calciu' hydroxide i% re&laced ,ith gutta &ercha at around !-= 'onth%* &o%t-tran%&lant a% long a% there i% no e$idence of root re%or&tion( FolloC-- o+ tran# lanted teet% 0t the ti'e of di%charge the &atient %hould be gi$en an anti%e&tic 'outh,a%h to

'aintain good hygiene in the %urgical %ite( The fir%t re$ie, i% in = ,ee/, at ,hich %tage %uture% are re'o$ed( )t 'ay be &o%%ible to re'o$e the %&lint at thi% %tage( The next re$ie, i% at -@ ,ee/% for %&lint re'o$al and endodontic treat'ent( 0 &eria&ical fil' %hould be ta/en at thi% %tage( 6urther re$ie,% %hould be underta/en at @ and ! 'onth% and then annually( Coronal re%ha&ing can be &erfor'ed at any %tage( &rt%odonti" mo.ement o+ tran# lanted teet% Tran%&lanted teeth can be 'o$ed orthodontically( Thi% %hould begin @ 'onth% follo,ing tran%&lantation and be co'&leted ,ithin > 'onth% of the tran%&lant( Fi!. /5.24 ;a< D= for extraction to be re&laced by &art of an orthodontic treat'ent &lan( ;b< )nci%ion of ;c< and ;d< Extraction of ,hich i% to be re'o$ed a% gingi$al attach'ent(

u%ing cotton roll to &rotect root( ;e< Extracted to D= %oc/et(

( ;f< Widening of D= %oc/et ,ith chi%el( ;g< Tran%&lantation of ;h< Suturing and %&linting of at @ 'onth%( /5.1 I7P*ANT&*&6Y

( ;i< and ;+< 3abial and occlu%al $ie,% of

The u%e of i'&lant% for orthodontic anchorage ,a% 'entioned abo$e( The u%e of dental i'&lant% a% &ro%the%e% in children i% contraindicated exce&t under circu'%tance% ,here %e$ere &%ychological %tre%% 'erit% %uch treat'ent( There are three rea%on% for a$oiding i'&lant% in young &atient%G =( The i'&lant doe% not 'o$e ,ith the gro,ing al$eolu%it act% a% an an/ylo%ed tooth( Thu% i'&lant% %hould not be &laced until $ertical gro,th of the +a,% i% $irtually co'&lete ;around =C year% of age<( The exce&tion to thi% rule i% the lo,er intercanine region ,hich can recei$e i'&lant% earlier in exce&tional ca%e% of hy&odontia, for exa'&le, X-lin/ed ectoder'al dy%&la%ia( ( )'&lant% can interfere ,ith nor'al gro,th of the +a,%( @( .oung bone doe% not beha$e in the %a'e ,ay a% 'ature bone( Due to %Bua%hing and cru%hing, the axi% of an in%erted i'&lant 'ay de$iate ,idely fro' the axi% of ta&( )n addition, the u%e of teeth for autotran%&lantation i% often a $iable alternati$e in young &atient%( /5.2 S&FT TISS(E S(R6ERY /5.2.0 Introd-"tion The follo,ing %hort %yno&%i% co$er% the i'&ortant functional and orthodontic &roble'% in the child and adole%cent(

/5.2./ *a,ial +rena 0 &ro'inent 'id-line frenu' in the 'axilla 'ay be &re%ent in a%%ociation ,ith a dia%te'a( Whether or not the frenu' i% the cau%e of the dia%te'a i% o&en to Bue%tion a% a fle%hy frenu' doe% not al,ay% &roduce an ae%thetic defect( -e$erthele%%, the exci%ion of a 'id-line 'axillary frenu' i% often reBue%ted a% &art of an orthodontic treat'ent &lan( Thi% &rocedure i% $ery %i'&ly &erfor'ed under local anae%the%ia ;6ig( =:(@9 ;a<-;d<<( 4efore %urgery a radiogra&h of the u&&er inci%or area %hould be ta/en to eli'inate other &o%%ible cau%e% of a 'id-line dia%te'a ;%uch a% a 'e%ioden%<( 0 'id-line 'axillary frenu' %hould not be re'o$ed before the &er'anent canine% ha$e eru&ted, a% the %&ace 'ay clo%e %&ontaneou%ly ,hen the%e teeth a&&ear( Surgical re'o$al i% achie$ed by di%%ecting the 'id-line ti%%ue $ia inci%ion% &arallel to the frenu' fro' the labial 'uco%a, at a &oint beyond the &ro'inent fibrou% ti%%ue, through the interdental %&ace to &alatal 'uco%a( The &art of the inci%ion in attached gingi$a i% 'uco&erio%teal( The %urface of the ex&o%ed bone in the interdental %&ace %hould be curetted or gently burred to re'o$e re%idual fibrou% attach'ent%( "ri'ary clo%ure of the labial &art of the inci%ion i% achie$ed by %uturing, and the defect in attached gingi$a i% co$ered by either a &eriodontal dre%%ing ;Coe-"ac/< or ribbon gau5e %oa/ed in Whitehead*% $arni%h, ,hich i% held in &lace by %uture%( The &ac/ i% re'o$ed ?-=9 day% after %urgery( Fi!. /5.30 ;a< "atient for u&&er 'id-line labial fraenecto'y( ;b< )nci%ion% &arallel to fraenu'( ;c< Defect at end of re'o$al( ;d< Wound clo%ure ,ith re%orbable %uture% in reflected 'uco%a and %il/ %uture holding &ac/ interdentally( /5.2.2 *in!-al +rena 0 &ro'inent lingual frenu' %hould be exci%ed if it i% interfering ,ith %&eech or oral hygiene( Thi% i% %i'&ly &erfor'ed under local anae%the%ia( The frenu' i% held by a &air of hae'o%tatic force&%, a triangular %ection of ti%%ue i% re'o$ed, and the ,ound end% %utured( /5.2.3 7-"o"ele# Mucocele% are co''on in the %econd decade of life, although they occa%ionally occur in younger children including the ne,born( )f the%e le%ion% cau%e functional or e'otional &roble'% they %hould be exci%ed, but if there i% no di%turbance re'o$al 'ay be delayed until the child i% older( 0n inci%ion i% 'ade next to the le%ion, ,hich i% re'o$ed by a blunt di%%ection under the e&itheliu'( )n$ariably a nu'ber of 'inor %ali$ary gland% are ob$iou% during %urgery ;they often a&&ear li/e a bunch of gra&e% around the 'ucocele<( The%e %hould be re'o$ed in $ie, of the fact that 'ucocele% are &roduced a% a re%ult of trau'a( 0ny ob$iou% dental cau%e of trau'a, for exa'&le, a %har& tooth, %hould be re'edied( One ty&e of 'ucocele that i% be%t referred for %&eciali%t treat'ent i% that found in the floor of the 'outh, the %o-called *ranula* ;6ig( =:(C<( Thi% le%ion i% often 'ore exten%i$e than i% at fir%t a&&arent and co'&lete cure occa%ionally in$ol$e% re'o$ing the %ublingual gland( /5.2.0 In"i#ional ,io #$

)nci%ional bio&%ie% are &erfor'ed to confir' a diagno%i% by re'o$ing &art of a le%ion( )t i% &referable that the %urgeon ,ho i% going to treat the le%ion &erfor'% the inci%ional bio&%y and therefore thi% &rocedure i% be%t &erfor'ed by an oral %urgeon( /5.2.5 E9"i#ion ,io #ie# o+ non-atta"%ed m-"o#a S'all le%ion% of the oral 'uco%a are re'o$ed by exci%ional bio&%y, ,hich in$ol$e% the re'o$al of an elli&%e of ti%%ue including the le%ion( The long axi% of the elli&%e i% 'ade &arallel to the direction of 'u%cle &ull, and it i% be%t to hold the %&eci'en ,ith a %uture &a%%ed under it to a$oid cru%hing, ,hich could render the %&eci'en u%ele%% for hi%tological exa'ination ;6ig( =:(@=<( 0ll ti%%ue %urgically re'o$ed %hould be &laced in a %olution of =9L for'al %aline ;not in ,ater< and tran%&orted to the laboratory for hi%tological exa'ination( 3e%ion% that are ob$iou%ly benign and are not interfering ,ith function or cau%ing e'otional di%tre%% can be left in the young child and re'o$ed, if nece%%ary, at a later date ;6ig( =:(@ ;a< and ;b<<( Fi!. /5.3/ 3i& le%ion held by %uture( ;4y /ind &er'i%%ion of Dental Update(< Fi!. /5.32 ;a< and ;b< 3u'& related to eru&ting T?( and $ie, = ,ee/ laterthe lu'& ha% di%a&&eared and the T? ha% eru&tedno treat'ent ,a% gi$en( ;4y /ind &er'i%%ion of Dental Update(< /5.2.1 E9"i#ion ,io #$ o+ atta"%ed !in!i.aB alate The%e &rocedure% lea$e a defect that i% not readily treated by &ri'ary clo%ure( 6ollo,ing the bio&%y it i% u%eful to lay a hae'o%tatic 'aterial o$er the defect to arre%t bleeding and then to co$er the area either by a &eriodontal dre%%ing or by %ecuring a Whitehead*% $arni%h, ribbon-gau5e &ac/ in the defect ,ith non-re%orbable %uture%( /5.2.2 S-t-rin! Re%orbable %uture% %hould be u%ed to clo%e %oft ti%%ue ,ound% in children ,hene$er &o%%ibleH ho,e$er, in 'obile %tructure% %uch a% the tongue and li& the%e 'ay be lo%t %hortly after %urgery a% their /not% 'ay be le%% %ecure than tho%e obtained ,ith blac/ %il/( To o$erco'e thi% &roble' it i% u%eful to bury /not% by ta/ing the fir%t bite of ti%%ue fro' ,ithin the ,ound rather than fro' the 'uco%al %urface( The %econd bite begin% on the 'uco%al %urface of the o&&o%ite ,ound edge( Thi% en%ure% that the /not di%a&&ear% into the ,ound ,hen it i% tied ;6ig( =:(@@<( Fi!. /5.33 Sa'e &atient a% in 6ig( =:(@9 %ho,ing buried /not% ,ith %oft-gut %uture%( ;4y /ind &er'i%%ion of Dental Update(< /5.3 S(77ARY Thi% cha&ter ha% con%ideredG ;=< &athological condition% of the oral and &erioral %tructure% in childrenH ; < dental extraction% in childrenH ;@< 'inor oral %urgical &rocedure% that can be &erfor'ed ,ithout in-&atient

anae%thetic facilitie% in healthy childrenH ;A< the 'anage'ent of acute %&reading infection fro' a dental focu% in children( /5.4 F(RT5ER READIN6 0ndrea%en, 7( O( ;=>> <( "tlas of replantation and transplantation of teeth( Mediglobe, 6ribourg, S,it5erland( ;" ,eautifully illustrated guide to tooth transplantation(< Gorlin, R( 7(, Cohen, M( M(, and 1enne/a', R( C( M( ; 99=<( #yndromes of the head and nec% ;Ath edn<( Oxford #ni$er%ity "re%%, Oxford( ;" valua,le reference text(< Soa'e% 7( 8( and Southa' 7( C( ; 99:<( 8ral pathology ;Ath edn<( Oxford #ni$er%ity "re%%, Oxford( ;" comprehensive oral pathology text(< /5./0 REFERENCES Cole, 4( O( )(, Sha,, 0( 7(, 1ob%on, R( S(, -unn, 7( 1(, Welbury, R( R(, Meechan, 7( G(, and 7e&%on, -( 7( 0( ; 99@<( The role of 'agnet% in the 'anage'ent of uneru&ted teeth in children and adole%cent%( International +ournal of Paediatric Dentistry, /3, 9A-?( Meechan, 7( G(, Carter, -( E(, Gilgra%%, T(, 1ob%on, R( S(, 7e&%on, -( 7( 0(, -ohl, 6( S(, -unn, 7( 1( ; 99@<( )nterdi%ci&linary 'anage'ent of hy&odontiaG oral %urgery 'anage'ent( $ritish Dentist +ournal, /40, A @-?( Scully, C( M(, Welbury, R( R(, 6lait5, C(, de 0l'eira, O( C( ; 99 <( 8rofacial health and disease in children and adolescents( Martin Dunit5, 3ondon( Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

/1. 7edi"al di#a,ilit$ - ( - Hosey and ) ) 4el,ury /1./ INTR&D(CTI&N /1./.0 &.er.ieC There are 'any general 'edical condition% that can directly affect the &ro$i%ion of dental care and %o'e ,here the con%eBuence% of dental di%ea%e, or e$en dental treat'ent, can be life-threatening( 0n increa%ing nu'ber of children ,ho no, %ur$i$e ,ith co'&lex 'edical &roble'% due to i'&ro$e'ent% in 'edical care &re%ent difficultie% in oral 'anage'ent( Dental di%ea%e can ha$e gra$e con%eBuence% and %o rigorou% &re$ention i% &ara'ount( The decline in childhood 'ortality ha% led to

increa%ing e'&ha%i% on 'aintaining and enhancing the Buality of the child*% life and en%uring that children reach adult life a% &hy%ically, intellectually, and e'otionally healthy a% &o%%ible( Dental care can &lay an i'&ortant &art in enhancing thi% Buality of life( )ndeed, 'anage'ent ,ithin the &ri'ary dental %er$ice% hel&% to *nor'ali5e* life for the%e children ,ho a&&reciate attending along ,ith their fa'ily e$en though %o'eti'e% they 'ight %till reBuire %&eciali%t ex&erti%e( E$en though the infant 'ortality rate% ;death% under = year of age< ha$e declined dra'atically in the #nited 2ingdo', the death rate% are %till higher in the fir%t year of life than in any other %ingle year belo, the age of :: in 'ale% and !9 in fe'ale%( The rate% are highe%t for the $ery young( The 'ain cau%e% of death in the neonatal &eriod ;the fir%t A ,ee/% of life< are a%%ociated ,ith &re'aturity ;o$er A9L< and by congenital 'alfor'ation% ;@9L<( )n the re'ainder of the fir%t year, ho,e$er, the 'ain cau%e% of death occur at ho'e and often nothing abnor'al or %u%&iciou% i% found ;S#D)%udden unex&ected death in infancy and S)DS%udden infant death %yndro'e<( 0lthough the unex&ected death of a child o$er = year of age i% rare, a fe, infant% %till %uccu'b to re%&iratory and other infecti$e di%ea%e% ;e(g( 'eningiti%<, congenital 'alfor'ation%, and accident%( /1././ T%e medi"al %i#tor$ 0ll &atient% %hould ha$e an accurate 'edical hi%tory ta/en before any dental treat'ent i% underta/en( Thi% i% i'&ortant for %e$eral rea%on%G =( To identify any 'edical &roble'% that 'ight reBuire 'odification of dental treat'ent( ( To &rioriti5e children ,ho reBuire inten%i$e &re$enti$e dental care( @( To identify tho%e reBuiring &ro&hylactic antibiotic co$er for &otentially %e&tic dental &rocedure%( A( To chec/ ,hether the child i% recei$ing any 'edication that could re%ult in ad$er%e interaction;%< ,ith drug% or treat'ent ad'ini%tered by the denti%t( Thi% ,ould include &a%t 'edication that could ha$e had an effect on dental de$elo&'ent( :( To identify %y%te'ic di%ea%e that could affect other &atient% or dental &er%onnelH thi% i% u%ually related to cro%%-infection &otential( !( To e%tabli%h good ra&&ort and effecti$e co''unication ,ith the child and their &arent%( ?( To deter'ine the fa'ily and %ocial circu'%tance%, ,hether other %ibling% are affected by the %a'e or %i'ilar condition and the ability of the &arent% to co&e ,ith attendance for dental a&&oint'ent% gi$en the added burden of 'edical a&&oint'ent% and their ,i%h to en%ure adeBuate continued %chooling( C( To facilitate co''unication ,ith 'edical colleague%( >( To %ati%fy 'edico-legal reBuire'ent%(

Many dental &ractitioner% u%e %tandard Bue%tionnaire% to obtain a 'edical hi%toryH it ha% been found that one of the 'o%t effecti$e 'ethod% i% to u%e a Bue%tionnaire follo,ed by a &ertinent &er%onal inter$ie, ,ith the child and their &arent or guardian( >e$ Point# 2ey 'edical Bue%tion%a%/ aboutG cardio$a%cular di%order%H bleeding di%order%H re%&iratoryDche%t &roble'%H e&ile&%yH he&atiti%D+aundiceH diabete%H ho%&itali5ation or ho%&ital in$e%tigation for any rea%onH &re$iou% general anae%thetic ex&erienceDany further general anae%thetic &rocedure% &lannedJ allergie%H illne%% in other fa'ily 'e'ber%H 'edication( /1./.2 T%e !eneral e9amination General ob%er$ation of the child i% in$aluable and can &ro$ide $ital infor'ation( The child*% de'eanour i% i'&ortant in a%%e%%ing their &otential co-o&eration for dental treat'ent, but a%%e%%'ent of general out,ard a&&earance can al%o be hel&ful in deter'ining their %tate of health( 0n i'&re%%ion of height ;are they a% tall a% their &eer%J< and ,eight ;undernouri%hed or obe%eJ< can gi$e clue% not only about nutrition but al%o %o'atic gro,th and dental de$elo&'ent( 8i%ually acce%%ible area%, %uch a% %/in and nail%, can re$eal cyano%i%, +aundice, and &etechiae fro' bleeding di%order%( The hand% &articularly are ,orthy of in%&ection and can al%o %ho, alteration% in the fingernail% %uch a% finger-clubbing fro' chronic cardio&ul'onary di%order%, a% ,ell a% infection% and %&linter hae'orrhage%( O$erall %ha&e and %y''etry of the face 'ay be %ignificant and there 'ay be characteri%tic facie% that are diagno%tic of %o'e congenital abnor'alitie% and %yndro'e%( /1.2 CARDI&)ASC(*AR DIS&RDERS /1.2.0 Introd-"tion The%e can be di$ided into t,o 'ain grou&%G congenital heart di%ea%e ;exi%ting before or at birth<H and tho%e di%order% that are acBuired after birth( Congenital heart di%ea%e occur% in a&&roxi'ately C children in e$ery =999 li$e birth%( There i% a ,ide %&ectru' of %e$erity, but -@ of the%e children ,ill be %y'&to'atic in the fir%t year of life( /1.2./ Con!enital %eart de+e"t# The cau%e i% rarely /no,n in indi$idual ca%e% but 'ultifactorial inheritance &attern%

are 'ainly re%&on%ible( Se$eral chro'o%o'al abnor'alitie%, %uch a% Do,n %yndro'e, are a%%ociated ,ith %e$ere congenital heart di%ea%e but the%e re&re%ent fe,er than :L of the total( The 'ain ty&e% of congenital condition% are %ho,n in Table =!(=( )n 'o%t in%tance% there i% a co'bination of genetic and en$iron'ental influence%, including infection%, during the %econd 'onth of &regnancy( Many defect% are %light and cau%e little di%ability, but a child ,ith 'ore %e$ere defect% 'ay &re%ent ,ith breathle%%ne%% on exertion, tiring ea%ily, and %uffer fro' recurrent re%&iratory infection%( Tho%e children ,ith %e$ere defect% %uch a% tetralogy of 6allot and $al$ular defect%, including &ul'onary atre%ia and tricu%&id atre%ia, ,ill ha$e cyano%i%, finger-clubbing, and 'ay ha$e delayed gro,th and de$elo&'ent ;6ig%( =!(=, =!( , and =!(@<( Characteri%tically, the%e children ,ill a%%u'e a %Buatting &o%ition to relie$e their dy%&noea ;breathle%%ne%%< on exertion( 5eart m-rm-r# The incidence of congenital heart di%ea%e i% falling, affecting ?-C infant% &er =999( Many &arent% ,ill re&ort that their child either ha%, or had, a *heart 'ur'ur*( The%e 'ay only be di%co$ered at a routine exa'ination, although they occur in o$er @9L of all children( Mo%t of the%e 'ur'ur% are functional or innocent and not a%%ociated ,ith %ignificant abnor'alitie%, but are the re%ult of nor'al blood turbulence ,ithin the heart( )nnocent 'ur'ur% are heard 'o%t freBuently fro' @-? year% of age( )n a %'all 'inority of ca%e% a heart 'ur'ur indicate% the &re%ence of a cardiac abnor'ality cau%ing the turbulence( )f the denti%t i% in any doubt about the %ignificance of a 'ur'ur, then a cardiological o&inion %hould be %ought( -or'ally contact ,ith the child*% 'edical &ractitioner ,ill clarify the %ituation( )nnocent 'ur'ur% do not reBuire any %&ecial &recaution% or treat'ent( )entri"-lar #e tal de+e"t# ()SD) The%e are the 'o%t co''on of the cardiac 'alfor'ation%( S'all defect% are a%y'&to'atic and 'ay be found during a routine &hy%ical exa'ination( 3arge defect% ,ith exce%%i$e &ul'onary blood flo, are re%&on%ible for %y'&to'% of breathle%%ne%%, feeding difficultie%, and &oor gro,th( 4et,een @9L and :9L of the %'all defect% clo%e %&ontaneou%ly, u%ually ,ithin the fir%t year of life( 3arger defect% are u%ually clo%ed %urgically in the %econd year of life, but defect% in$ol$ing other cardiac %tructure% 'ay reBuire co'&lex %urgery or e$en tran%&lantation( Atrial #e tal de+e"t# (ASD) The%e are not a% co''on a% the 8SD in children, but are &ro&ortionately 'ore %ignificant in adult% and 'ore freBuent in fe'ale%( 0n i%olated &atent fora'en o$ale i% of no clinical %ignificance and not con%idered to be an 0SD( E$en an extre'ely large 0SD rarely &roduce% heart failure in children, but %y'&to'% u%ually a&&ear in the third decade( Surgery i% u%ually carried out before %chool age( P-lmonar$ #teno#i# With 'ild to 'oderate %teno%i% of the &ul'onary $al$e there are u%ually no %y'&to'%, but exerci%e intolerance and cyano%i% 'ay occur if thi% i% %e$ere(

Treat'ent i% reBuired for the 'oderate to %e$ere for'%H relief of thi% ob%truction i% no, carried out in 'a+ority of children by balloon dilatation rather than %urgery( Patent d-"t-# arterio#-# During fetal life 'o%t of the &ul'onary arterial blood i% %hunted through the ductu% arterio%u% into the aorta, thu% by&a%%ing the lung%( 6unctional clo%ure of the ductu% arterio%u% u%ually occur% at birth( 8irtually all &reter' babie% ,eighing le%% than =(?: /g ha$e a &atent ductu% arterio%u% in the fir%t A h of life but thi% u%ually clo%e% %&ontaneou%ly( Ductu% arterio%u% &atency i% 'ediated by &ro%taglandin%, and the ad'ini%tration of inhibitor% of &ro%taglandin %ynthe%i%, %uch a% indo'ethacin, i% effecti$e in clo%ing the ductu% in a %ignificant nu'ber of babie%( Surgical ligation, ho,e$er, i% a %afe and effecti$e bac/-u& if indo'ethacin i% contraindicated or ha% not been %ucce%%ful( Tetralo!$ o+ Fallot Thi% cla%%ically con%i%t% of the co'bination ofG ;=< an ob%truction to right $entricular outflo, ;&ul'onary %teno%i%<H ; < 8SDH ;@< dextro&o%ition of the aortaH ;A< right $entricular hy&ertro&hy( Cyano%i% i% one of the 'o%t ob$iou% %ign% of thi% condition but it 'ay not be &re%ent at birth( 0% the child gro,%, ho,e$er, the ob%truction to blood flo, i% further exaggerated( The oral 'ucou% 'e'brane% and nail-bed% are often the fir%t &lace% to %ho, %ign% of cyano%i%( Gro,th and de$elo&'ent 'ay be 'ar/edly delayed in %e$ere untreated tetralogy of 6allot and &uberty i% delayed( Early 'edical 'anage'ent in$ol$e% the u%e of &ro%taglandin% %o that adeBuate &ul'onary blood flo, can occur until %urgical inter$ention can be carried out( )nitially, a %hunt &rocedure ;u%ually the 4laloc/-Tau%%ig %hunt< i% &erfor'ed to ana%to'o%e the %ubcla$ian artery to the ho'olateral branch of the &ul'onary artery( 3ater in childhood, total %urgical correction i% underta/en but the 'ortality rate fro' thi% &rocedure i% :-=9L( Fi!. /1./ Thi% %ho,% the hand of a boy ,ith Do,n %yndro'e and 6allot*% tetralogy( The cyano%i% and finger-clubbing a%%ociated ,ith hi% %e$ere cardiac di%ea%e are ob$iou%( Fi!. /1.2 Cyano%i% affecting the li&% in a boy ,ith 6allot*% tetralogy( The 'ucou% 'e'brane% a&&ear blui%h( Fi!. /1.3 Central cyano%i% affecting the tongue of the boy %ho,n in 6ig( =!( ( /1.2.2 A"A-ired "ardio.a#"-lar di#ea#e R%e-mati" +e.er Rheu'atic fe$er follo,% a grou& 0 %tre&tococcal infection of the u&&er re%&iratory tract, e%&ecially in de$elo&ing countrie%, and 'ay occur at all age% but u%ually bet,een : and =: year%( En$iron'ental factor%, %uch a% o$ercro,ding, &ro'ote the

tran%'i%%ion of %tre&tococcal infection% and the incidence of rheu'atic fe$er i% higher a'ong lo,er %ocio-econo'ic grou&%( The clinical on%et i% u%ually acute and occur% @ ,ee/% after a %ore throat( 7oint &ain% are co''on and of a characteri%tic 'igratory &olyarthralgia or &olyarthriti%( Carditi% i% the 'o%t %eriou% 'anife%tation, occurring in A9-:9L of initial attac/%, e%&ecially in young children( 6e$er i% u%ually &re%ent, but in an in%idiou% on%et of the condition it 'ay be lo, grade( Mo%t of the carditi% re%ol$e% exce&t the le%ion% on the cu%&% of the heart $al$e% ,hich beco'e fibro%ed and %tenotic( Rheu'atic heart di%ea%e i% the 'o%t i'&ortant 'anife%tation of rheu'atic fe$er and 'ay affect 'itral, aortic, tricu%&id, and &ul'onary $al$e%( Di#ea#e# o+ t%e m$o"ardi-m and eri"ardi-m Ma+or di%ea%e% in$ol$ing the 'yocardiu' and &ericardiu' include bacterial infection% %uch a%G di&htheria and ty&hoidH tuberculou%, fungal, and &ara%itic infection%H rheu'atoid arthriti%H %y%te'ic lu&u% erythe'ato%u%H urae'iaH thala%%ae'iaH hy&erthyroidi%'H neuro'u%cular di%ea%e%, %uch a%, 'u%cular dy%tro&hyH and glycogen %torage di%ea%e%( They are relati$ely rare in children in de$elo&ed countrie%( &t%er "ardio.a#"-lar ro,lem# There are %e$eral other i'&ortant condition% that are co''on in adult% but not in children( The%e include coronary artery di%ea%e ;i%chae'ic heart di%ea%e<, cardiac arrhyth'ia%, and hy&erten%ion( )n children, %econdary hy&erten%ion i% 'ore co''on than e%%ential hy&erten%ion and i% a%%ociated ,ith renal abnor'alitie% in ?:-C9L of tho%e affected( /1.2.3 Dental "are +or "%ildren Cit% "ardio.a#"-lar di#order# The 'o%t i'&ortant con%ideration in &lanning dental care for children ,ith cardio$a%cular di%order% i% the &re$ention of dental di%ea%e( 0% %oon a% a child i% diagno%ed a% ha$ing a %ignificant cardiac &roble' they %hould be referred for dental e$aluation and an aggre%%i$e &re$enti$e regi'en co''enced to include dietary coun%elling, fluoride thera&y, fi%%ure %ealant%, and oral hygiene in%truction( Regular 'onitoring, both clinically and radiogra&hically, ,ith reinforce'ent of the &re$enti$e ad$ice i% e%%ential( 0cti$e dental di%ea%e %hould be treated before cardiac %urgery i% underta/en( Treatment lannin! )f the child and &arent;%< are %een in infancy and effecti$e &re$enti$e dental &rocedure% are in%tituted, then, theoretically, o&erati$e denti%try %hould be unnece%%ary( )n &ractice, the %ituation 'ay be $ery different( )f in$a%i$e o&erati$e &rocedure% are reBuired then antibiotic &ro&hylaxi% ,ill be nece%%ary, ,hich influence% treat'ent &lanning( )deally, treat'ent in children %hould be carried out during %hort a&&oint'ent% %o that co-o&eration i% 'axi'i5ed( 1o,e$er, if &ro&hylactic antibiotic% are reBuired it i% i'&ortant to carry out a% 'uch treat'ent a% &o%%ible under each co$er but thi% ha% to be balanced again%t the %tre%% of longer a&&oint'ent%( )f 'ulti&le a&&oint'ent% ,ith &ro&hylaxi% are reBuired, then A ,ee/% %hould be allo,ed bet,een a&&oint'ent% ,hen &enicillin i% u%ed to allo, &enicillinre%i%tant organi%'% to di%a&&ear fro' the oral flora though alternating ,ith non-

&enicillin antibiotic% can circu'$ent thi%( Other &roble'% 'ay include &rolonged bleeding follo,ing %caling or %urgical &rocedure% due to thro'bocyto&enia and anticoagulant 'edication( )t i% e%%ential to chec/ the &latelet count and &rothro'bin ti'e if dental extraction% are &lanned( The &atient*% &rothro'bin ti'e i% co'&ared ,ith nor'al and called the international nor'ali5ed ratio ;)-R<( -o child ,ith %y'&to'atic cardiac &roble'% %hould ha$e any routine dental &rocedure% until detail% of the condition ha$e been obtained and the &atient*% &hy%ician con%ulted( Anti,ioti" ro %$la9i# 0ntibiotic &ro&hylaxi% i% nece%%ary for 'o%t congenital cardiac 'alfor'ation%( The cardiac condition% that reBuire antibiotic &ro&hylaxi% for dental &rocedure% are li%ted in Table =!( ( Dento gingi$al 'ani&ulati$e &rocedure% that are li/ely to induce an increa%e in the le$el of bacteria in the blood reBuire antibiotic &ro&hylaxi% to &re$ent the de$elo&'ent of endocarditi%( The &rocedure% are %ho,n in Table =!(@( The%e include extraction%, %caling, %urgery in$ol$ing gingi$al ti%%ue%, and re%torati$e &rocedure% ,here the gingi$al 'argin% are li/ely to be trau'ati5ed either during ca$ity &re&aration or during 'atrix band, ,edge, or rubber da' &lace'ent( Endodontic treat'ent %hould only be carried out on teeth ,here there i% a $ery high &robability of %ucce%%( Thi% i% u%ually confined to &er'anent inci%or teeth ,ith %traight canal% and clo%ed a&ice% and i% carried out a% a %ingle-$i%it &rocedure under a&&ro&riate antibiotic co$er( 0ntibacterial &ro&hylaxi% reco''endation% are con%tantly u&dated ;Table% =!(A and =!(:< and re$i%ed a% ne, %cientific e$idence and drug% beco'e a$ailable( The late%t 4riti%h Cardiac Society guideline% and the $ritish 6ational 1ormulary %hould be chec/ed( The 'edication %hould be ta/en under %u&er$i%ion( There i% %till %o'e contro$er%y o$er ,hich condition% do or do not reBuire &ro&hylactic antibiotic thera&y( )f any doubt exi%t% then the &aediatrician or cardiologi%t %hould be con%ulted before in$a%i$e dental &rocedure% are underta/en( 0t the ti'e of ,riting thi% ne, edition, the 4riti%h Cardiac Society ha$e &ubli%hed ne, guideline%( The%e ha$e not yet been ,idely ado&ted ,ithin the dental &rofe%%ion and they differ fro' the current 4-6 ; 99A<( Reader% are ad$i%ed to read the late%t edition% of the 4-6 and to read the re'ainder of thi% %ection in that context( There i% a three-%te& a&&roach to the u%e and choice of antibiotic &ro&hylaxi%( =( 0%%e%%'ent of cardiac ri%/ ;Table =!( < 0ntibiotic &ro&hylaxi% i% reBuired only in 'oderate or high ri%/( ( 0%%e%%'ent of the ri%/ of %ignificant bacterae'ia a%%ociated ,ith the dento-gingi$al 'ani&ulati$e &rocedure ;Table =!(@< )f the detail of the &lanned dental &rocedure in$ol$e% a dento-gingi$al 'ani&ulati$e &rocedure that ,ill cau%e a %ignificant bacterae'ia then antibiotic &ro&hylaxi% i% needed( @( 0%%e%%'ent of antibiotic &ro&hylaxi% regi'enG choice, do%age, and 'ode of

ad'ini%tration ;Table% =!(A and =!(:< The choice of regi'en i% deter'ined by the u%e of anae%the%ia and analge%ia( 6or 'ulti&le $i%it% of treat'ent under local anae%the%ia a &eriod of = 'onth %hould ela&%e before a %econd do%e of the %a'e antibiotic i% gi$en( 0lternating the %eBuence of antibiotic bet,een $i%it% ;e(g( &enicillin then clinda'ycin< can be u%ed to o$erco'e thi% need to ,ait = 'onth before the next $i%it( The need for general anae%the%ia or intra$enou% %edation reBuire% a 'odification of the drug regi'en &articularly in regard to do%age( Tho%e &atient% ,ith highe%t ri%/ of infecti$e endocarditi%, for exa'&le, &ro%thetic heart $al$e% or &re$iou% infecti$e endocarditi%( ;=< -ot allergic al%o reBuire genta'ycin and &o%to&erati$e a'oxicillinH ; < "enicillin allergicreBuire $anco'ycin and genta'ycin( Children ,ho ha$e had correcti$e %urgery for a &atent ductu% arterio%u% and tho%e ,ho ha$e recei$ed a heart-lung tran%&lant are con%idered to ha$e nor'al heart% and only reBuire &ro&hylactic antibiotic% for the initial ! 'onth% follo,ing %urgery( Tho%e ,ho had an atrial %e&tal defect corrected u%ing a catheter-ba%ed &rocedure reBuire &ro&hylactic antibiotic% for = 'onth% follo,ing %urgery( If in dou,t; contact the child?s cardiologistD >e$ Point# 0ntibiotic &ro&hylaxi% con%ideration%G 0%%e%%'ent of cardiac ri%/, 0%%e%%'ent of the ri%/ of %ignificant bacterae'ia a%%ociated ,ith the dento-gingi$al 'ani&ulati$e &rocedure, 0%%e%%'ent of antibiotic &ro&hylaxi% regi'enG choice, do%age, and 'ode of ad'ini%tration( /1.3 DIS&RDERS &F T5E ;*&&D /1.3./ ;leedin! di#order# The blood i% in a dyna'ic eBuilibriu' bet,een fluidity and coagulation, but the hae'o%tatic 'echani%' i% 'ore co'&lex than +u%t alteration% in thi% eBuilibriu'( )t in$ol$e% local reaction% of the blood $e%%el%, &latelet acti$itie%, and the interaction of %&ecific coagulation factor% that circulate in the blood( )n early childhood 'any of the bleeding di%order% ha$e a genetic bac/ground but ,ith increa%ing age 'ore beco'e iatrogenicu%ually due to anticoagulant 'edication( "atient% ,ho ha$e had cardiac %urgery for %o'e congenital abnor'ality, tho%e ,ho ha$e had a recent 'yocardial infarction, and tho%e ,ho ha$e had cerebro$a%cular accident% 'ay all be recei$ing long-ter' anticoagulant thera&y( Table =!(! gi$e% a cla%%ification of bleeding di%order% ba%ed on di%order% of coagulation, bleeding &roble'% due to decrea%ed nu'ber% of &latelet%, and di%order% of bleeding ,here there are nor'al nu'ber% of &latelet%( Many of the%e condition% are $ery rare and ,ill not be con%idered further( 5aemo %ilia 1ae'o&hilia 0 i% an X-lin/ed, rece%%i$ely inherited condition cau%ed by a deficiency

of factor 8)))( The degree of %e$erity i% $ery $aried but tend% to be con%i%tent ,ithin the %a'e fa'ily( Children ,ith o$er :L of nor'al le$el% of circulating factor 8))) 'ay lead nor'al li$e%, tho%e ,ith bet,een =L and :L are 'oderately to %e$erely affected by 'inor trau'a, etc(, ,hile tho%e ,ith under =L ha$e 'ulti&le bleed% into +oint% ;hae'arthro%e%< and 'ay be %e$erely &hy%ically handica&&ed a% a re%ult( Ob$iou%ly, &re$ention of trau'a to tho%e ,ho ha$e thi% condition i% extre'ely i'&ortant, but the a$ailability of factor 8))) concentrate% ha% re$olutioni5ed the Buality of life of hae'o&hiliac%( #nfortunately, %o'e of the%e blood re&lace'ent &roduct% ha$e been conta'inated in the &a%t ,ith he&atiti% and hu'an i''unodeficiency $iru% ;1)8< and, therefore, cro%%-infection control i% a high &riority( )t ,a% found that a nu'ber of &atient% ,ho ,ere thought to be hae'o&hiliac% did not re%&ond to re&lace'ent ,ith factor 8))) ;antihae'o&hiliac globulin< but ,ere deficient in another factorfactor )X( Thi% i% /no,n a% Chri%t'a% di%ea%e or hae'o&hilia 4( Thi% i% al%o tran%'itted a% an X-lin/ed rece%%i$e trait ,ith a ,ide range of clinical %e$erity, but fe'ale carrier% of thi% condition al%o ha$e a tendency to bleed( >e$ Point# 6actor 8))) le$elG > :L'ildH =-:L'oderate to %e$ereH <=L%e$ere( )on 8ille,rand?# di#ea#e Thi% i% a do'inantly inherited, co'&lex, and $ariable condition characteri5ed by a $a%cular abnor'ality of large irregular ca&illarie%, defecti$e &latelet% that do not adhere to each other, and decrea%ed le$el% of factor 8)))( Co''on clinical 'anife%tation% are no%e bleed% and %&ontaneou% gingi$al hae'orrhage( 8on Willebrand*% di%ea%e i% the 'o%t co''on inherited bleeding di%order affecting, N= in e$ery =999 indi$idual% in the #nited State% and the #nited 2ingdo'( T%rom,o"$to enia Thi% i% cau%ed by a reduction in the nu'ber% of circulating &latelet% in the blood%trea'( -or'al le$el% are bet,een =:9 and A99 =9>Dl( The &latelet count %hould be at lea%t :9 =9>Dl before %urgery i% atte'&ted( Clinical %ign% are &etechial hae'orrhage% into the %/in and 'ucou% 'e'brane% ,ith hae'ate'e%i% ;blood in the $o'it<, hae'aturia ;blood in the urine<, and 'elaena ;blood in the faece%<( )n children the u%ual cau%e% of thro'bocyto&enia are idio&athic, an acute i''une re%&on%e u%ually follo,ing an u&&er re%&iratory tract infection, leu/ae'ic infiltration of the bone 'arro,, or follo,ing the ad'ini%tration of $ariou% drug%( >e$ Point# Genetic coagulation di%order%G hae'o&hilia 0 ;factor 8)))<C9L

hae'o&hilia 4 ;factor )X<=@L factor X)!L 4leeding di%order%G hae'o&hilia 0= G 9,999 $on Willebrand*% di%ea%e= G =999 /1.3.2 Dental mana!ement o+ ,leedin! di#order# 0 good hi%tory i% the be%t %creening de$ice, but a bleeding tendency 'ay only beco'e 'anife%t after a %urgical &rocedure or trau'a( Effecti$e co''unication ,ith the child*% &hy%ician or hae'atologi%t i% i'&ortant, not only to e%tabli%h the aetiology of any bleeding tendency but al%o to liai%e o$er any nece%%ary 'edical treat'ent that i% reBuired to re&lace reduced le$el% of clotting factor%( The corner%tone of dental care i% &re$ention and regular re$ie, %o that if di%ea%e doe% occur it can be treated at an early %tage( 3ocal anae%thetic infiltration% or intraliga'entou% in+ection% are unli/ely to cau%e &roble'% if gi$en carefully( Regional anae%the%ia, %uch a% an inferior dental bloc/, i% contraindicated a% bleeding in the &terygo'andibular region ,hich 'ay re%ult in a%&hyxia( "ul& treat'ent of &ri'ary 'olar teeth 'ay be reBuired to a$oid extraction%( Mo%t &ri'ary teeth exfoliate %&ontaneou%ly ,ith little hae'orrhageH ho,e$er, occa%ionally ,hen they are $ery 'obile, the %oft ti%%ue% de$elo& an infla''atory hy&er&la%tic re%&on%e and bleeding 'ay be a &roble'( )n the%e %ituation% extraction 'ay be nece%%ary ,ith the a&&ro&riate hae'atological re&lace'ent thera&y( 1o,e$er, if dental extraction% or %urgery do beco'e nece%%ary then the &atient% are u%ually be%t 'anaged in the ho%&ital %ituation( 5aemo %ilia 0deBuate re&lace'ent and careful 'onitoring of factor 8))) and factor )X le$el% are reBuired( Thi% i% u%ually done ,ith fre%h-fro5en &la%'a or free5e-dried concentrate( "atient% ,ith 'ild to 'oderate hae'o&hilia 0 can often be 'anaged on an out-&atient ba%i% u%ing re&lace'ent thera&y or DD08" ;= de%a'ino-C, darginine $a%o&re%%inH al%o /no,n a% de%'o&re%%in< ,hich %ti'ulate% the relea%e of factor 8)))( 0ntifibrinolytic agent% %uch a% E0C0 ;e&%ilon-a'inoca&roic acid<, and tranexa'ic acid are al%o gi$en to &re$ent ly%i% of the clot( They al%o %ignificantly reduce the reBuire'ent for re&lace'ent of factor 8)))( Medication% containing non-%teroidal, anti-infla''atory drug% ;-S0)D%< or a%&irin %hould not be gi$en ;a%&irin %hould not be gi$en any,ay to a child under =! year% becau%e of the ri%/ of de$elo&ing Reye*% %yndro'e<( )on 8ille,rand?# di#ea#e 6actor 8))) concentrate% are not u%ually effecti$e, but DD08" i% u%ed in co'bination ,ith E0C0 or tranexa'ic acid( "atient% ,ith 'ore %e$ere ty&e% of $on Willebrand*% di%ea%e ,ill reBuire fre%h-fro5en &la%'a or a cryo&reci&itate re&lace'ent( T%rom,o"$to enia The &latelet count %hould be at lea%t :9=9>Dl before %urgery i% atte'&ted and continuou% infu%ion of &latelet% 'ay be reBuired( )n children ,ith the idio&athic for'

of thi% condition, &redni%olone ;A 'gD/g &er day for = ,ee/, gi$en orally< ,ill increa%e the &latelet count to o$er :9=9>Dl ,ithin AC h in about >9L of ca%e%( The nece%%ary treat'ent can then be carried out( /1.3.3 ;lood d$#"ra#ia# There are %e$eral relati$ely co''on di%order% of the red and ,hite blood cell% that 'ay influence dental care in the child( Many of the%e condition% al%o gi$e ri%e to abnor'al bleeding but, in addition, 'ay lead to delayed healing, infection, or 'uco%al ulceration( 0n outline cla%%ification i% gi$en in Table =!(?( Red ,lood "ell di#order#E anaemia When there i% a reduction in the red blood cell $olu'e or hae'oglobin concentration, the oxygen carrying ca&acity of the blood i% lo,ered( 0nae'ia i% not a %&ecific di%ea%e but a %y'&to' of an underlying di%order( Children ,ith anae'ia 'ay be $ery &ale ;exa'ine the nail-bed%, con+uncti$a, and oral 'ucou% 'e'brane%<( They 'ay al%o be tired, li%tle%%, and breathle%%( IR&N-DEFICIENCY ANAE7IA Thi% 'ay re%ult fro' chronic blood lo%%, &o%%ibly a% a re%ult of hae'orrhagic di%order%, but in children it i% 'ore co''only due to dietary deficiency or 'alab%or&tion( 8ita'in 4= and folic acid are al%o needed for the 'aturation of red blood cell% in the bone 'arro,( 6*(C&SE 1-P5&SP5ATE DE5YDR&6ENASE (6-1-PD) DEFICIENCY Thi% en5y'e i% needed in the hexo%e 'ono&ho%&hate %hunt &ath,ay( )n deficiency the accu'ulation of oxidant% in the red blood cell% cau%e% their hae'oly%i% and 'ay re%ult in +aundice, &al&itation%, dy%&noea, and di55ine%%( Drug% %uch a% a%&irin, &henacetin, and a%corbic acid, a% ,ell a% infection%, 'ay &reci&itate hae'oly%i%( 0% the gene for G-!-"D i% located on the X-chro'o%o'e it i% inherited a% a %ex-lin/ed condition( There are 'any $ariant% of the condition and it i% co''on in certain ethnic grou&%H for exa'&le, ty&e 0 i% found in ==L of 0'erican blac/ &eo&le and G-!-"D MED i% relati$ely co''on in ethnic grou&% of Mediterranean origin( SIC>*E-CE** ANAE7IA Thi% i% an inherited auto%o'al-rece%%i$e di%order that re%ult% in the %ub%titution of a %ingle a'ino acid in the hae'oglobin chain( Sic/le-cell trait i% the hetero5ygou% %tate in ,hich the affected indi$idual carrie% one gene for hae'oglobin S( 0&&roxi'ately, =9L of 0'erican 4lac/ children and u& to :L of Central 0frican 4lac/ children carry the trait( Sic/le-cell anaemia i% the ho'o5ygou% %tate, ,ith affected gene% fro' both &arent%( The red blood cell% containing hae'oglobin S ha$e a life of only @9-!9 day% and beco'e clu'&ed together under certain condition%, thu% bloc/ing %'all blood $e%%el% and leading to &ain and necro%i%( 0ffected children 'ay be &ale, tired, ,ea/, and breathle%%( They 'ay co'&lain of &ainful +oint% and %,elling of the hand% and feet( There tend% to be a failure to thri$e and gro,th retardation ,ith an increa%ed %u%ce&tibility to infection( 3ater &roble'% include renal function i'&air'ent and retinal and con+uncti$al da'age( T5A*ASSAE7IA

Thi% i% another inherited di%order of hae'oglobin %ynthe%i% and 'ay occur a% a hetero5ygou% trait or ho'o5ygou% thala%%ae'ia 'a+or( )t occur% &articularly in Mediterranean countrie% and in the Middle-Ea%tern 0rab countrie%( )t re%ult%, li/e %ic/le-cell anae'ia, in a %e$ere &rogre%%i$e hae'olytic anae'ia( Regular blood tran%fu%ion% are nece%%ary to 'aintain the hae'oglobin le$el abo$e =9 gDdl( )f treat'ent i% inadeBuate then hy&ertro&hy of erythro&oietic ti%%ue occur% and thi% re%ult% in 'a%%i$e ex&an%ion of the 'arro, of the facial and %/ull bone% &roducing 'axillary hy&er&la%ia and &rotru%ion of the 'iddle third of the face( Dental mana!ement o+ anaemia 0ll anae'ic children ha$e a greater tendency to bleed after in$a%i$e dental &rocedure%( Therefore, any %ign% or %y'&to'% %ugge%ti$e of anae'ia %hould be in$e%tigated( The hae'oglobin le$el and hae'atocrit are %i'&le te%t% u%ed for %creening, and a ,hite blood cell and &latelet count %hould al%o be obtained( )f the%e re$eal any abnor'alitie% then further, 'ore co'&lex, te%t% 'ay need to be underta/en( )deally, the underlying defect %hould be corrected before e'bar/ing on a cour%e of routine dental care( 0 fa'ily hi%tory of condition% %uch a% %ic/le-cell anae'ia and thala%%ae'ia i% %ignificant and all 4lac/ &atient% %hould be te%ted routinely for %ic/le-cell di%ea%e &rior to a general anae%thetic( Sic/le-cell cri%e% occur due to inadeBuate oxygenation and, if &o%%ible, general anae%thetic% %hould be a$oided in &reference to the u%e of local anae%the%ia( >e$ Point# Sic/le-cell di%ea%eG 0ll 4lac/ &atient% %hould be %creened &rior to general anae%the%ia( 8%ite ,lood "ell di#order#E le-=aemia 3eu/ae'ia i% a 'alignant &roliferation of ,hite blood cell%( )t i% the 'o%t co''on for' of childhood cancer, accounting for about one-third of ne, ca%e% of cancer diagno%ed each year( 0cute ly'&hocytic leu/ae'ia account% for ?:L of ca%e% ,ith a &ea/ incidence at A year% of age( The general clinical feature% of all ty&e% of leu/ae'ia are %i'ilar a% all in$ol$e a %e$ere di%ru&tion of bone 'arro, function%( S&ecific clinical and laboratory feature% differ, ho,e$er, and there are con%iderable difference% in re%&on%e to thera&y and long-ter' &rogno%i%( 0cute leu/ae'ia ha% a %udden on%et but the initial %y'&to'% are u%ually non-%&ecific ,ith anorexia, irritability, and lethargy( "rogre%%i$e failure of the bone 'arro, lead% to &allor, bleeding, and fe$er, ,hich are u%ually the %y'&to'% that lead to diagno%tic in$e%tigation( The bleeding tendency i% often %ho,n in the oral 'uco%a ;6ig( =!(A< and there 'ay al%o be infecti$e le%ion% of the 'outh and throat( The dental &ractitioner 'ay, therefore, be the fir%t to diagno%e the condition ;6ig( =!(:<( 4one &ain and arthralgia are al%o i'&ortant &re%enting co'&laint% in about one-Buarter of children( On initial hae'atological exa'ination 'o%t &atient% ,ill ha$e anae'ia and thro'bocyto&enia( 0 %ignificant &ro&ortion ,ill ha$e ,hite blood cell count% of le%% than @999D''@ and about 9L ,ill ha$e count% greater than :9,999D''@( The

diagno%i% of leu/ae'ia can be %u%&ected on %eeing bla%t cell% on the blood %'ear confir'ed on bone 'arro, bio&%y, ,hich ,ill %ho, re&lace'ent by leu/ae'ic ly'&hobla%t%( The treat'ent $arie% ,ith the clinical ri%/ feature%H children under year% and o$er =9 year% ,ith an initial ,hite blood cell count of o$er =99,999D''@ and central ner$ou% %y%te' in$ol$e'ent ;leu/ae'ic cell% in the cerebro%&inal fluid< ha$e the ,or%t &rogno%i%( The ba%ic treat'ent co'&onent% areG =( Induction of remission( To re'o$e abnor'al cell% fro' the blood and bone 'arro,( Drug% u%edG $incri%tine and &redni%one( ( Prophylactic treatment to central nervous system( Drug% u%edG intrathecal 'ethotrexate &lu% irradiation of central ner$ou% %y%te'( @( Consolidation( Drug% u%edG cyto%ine arabino%ide &lu% a%&aragina%e( A( (aintenance( Drug% u%edG 'ethotrexate &lu% 'erca&to&urine for a&&roxi'ately year%( :( )elapse( )f rela&%e occur% then bone 'arro, tran%&lantation can be con%idered( On thi% regi'en o$er ?9L of children no, %ur$i$e and can be regarded a% cured( >e$ Point# Childhood leu/ae'iaG ?:L i% acute ly'&hocytic leu/ae'iaH &ea/ incidence at A year% of ageH denti%t% can hel& early diagno%i%, alerted by 'uco%al hae'orrhage, and 'outh and throat infection%( Dental mana!ement o+ le-=aemia )n co''on ,ith other 'edically co'&ro'i%ing condition%, children ,ith leu/ae'ia are categori5ed a% ha$ing a high ri%/ of dental carie%( Therefore, &re$ention i% e%%ential( #nle%% there i% a dental e'ergency no electi$e o&erati$e dental treat'ent %hould be carried out until the child i% in re'i%%ion( The drug regi'en u%ed to induce re'i%%ion ha% nu'erou% %ide-effect%, including nau%ea and $o'iting, re$er%ible alo&ecia ;hair lo%%<, neuro&athy, and, 'o%t i'&ortantly fro' a dental &oint of $ie,, oral ulceration ;'uco%iti%<( )t can be extre'ely difficult to carry out nor'al 'outh care for children at thi% %tage and 'any ha$e difficulty ,ith toothbru%hing due to acute nau%ea( S,abbing the 'outh ,ith chlorhexidine 'outh,a%h and the routine u%e of antifungal agent% are e%%ential( 3ocal anae%the%ia &re&aration% %uch a% :L lignocaine ;lidocaine< oint'ent, 9L fla$oured ben5ocaine, or ben5yda'ine hydrochloride ;Diffla'< a&&lied before 'ealti'e% can hel& to reduce the &ain fro' ulceration or 'uco%iti%( The u%e of antibiotic &a%te or &a%tille% and ice chi&% can al%o be hel&ful( Once the leu/ae'ia i% in re'i%%ion, and after con%ultation ,ith the child*% &hy%ician, routine dental care can be underta/en ,ith the follo,ing ad+u%t'ent%G =( )f in$a%i$e &rocedure% are &lanned then current hae'atological infor'ation i%

reBuired to a%%e%% bleeding ri%/%( ( "ro&hylactic antibiotic thera&y to &re$ent &o%to&erati$e infection %hould be con%idered( Thi% i% gi$en if the functional neutro&hil count i% de&re%%ed( @( Children ,ho are i''uno%u&&re%%ed are al%o at ri%/ of fungal and $iral infection%( 6ungal infection% %hould be treated aggre%%i$ely ,ith a'&hotericin 4, ny%tatin, or flucona5ole, and her&etic infection% ,ith to&ical andDor %y%te'ic acyclo$ir( A( Regional bloc/ anae%the%ia 'ay be contraindicated due to the ri%/ of dee& hae'orrhage( !( Oral &re$enti$e care i% i'&ortant( 0 ty&ical &rotocol 'ight includeG 4hile in hospital Epaediatric dentistry specialistF= Relief of 'uco%iti%G Diffla' 'outh,a%h, to&ical anae%the%ia, antibiotic &a%tille%, ice chi&%( Eli'ination of bacterial &laBueG chlorhexidine 'outh,a%h 9(= LH &o$idone iodine to&ical a&&lication( -y%tatin :99,999 unit% *%,i%h and %,allo,*( To&ical fluoride thera&y( Manual &laBue re'o$alG toothbru%hing in%truction if &latelet count i% greater than 9=9>DlH *foa' on a %tic/* ,ith chlorhexidine if &latelet count i% le%% than 9=9>Dl( "t home Eprimary care providerF= Oral %ur$eillance( To&ical fluoride thera&y( 6i%%ure %ealant%( Diet ad$ice( Toothbru%hing in%truction( "re%cri&tion of antifungal% if reBuired( >e$ Point# Oral %ide-effect% of che'othera&yG 'uco%iti%, oral ulcerationH infection ;leuco&enia<H hae'orrhage ;thro'bocyto&enia<( Oral &ro&hylaxi% during che'othera&yG oral hygieneH &ain relief for 'uco%iti%H fluoride%H chlorhexidineH antifungal%(

Fi!. /1.0 Thi% @-year-old child ,a% brought to the dental %urgery ,ith %&ontaneou% bleeding fro' hi% gu'%( 1e had recently had %e$eral no%ebleed% and had beco'e $ery lethargic( 1i% %/in and 'uco%a ,ere $ery &ale( 1ae'atological in$e%tigation %ho,ed acute ly'&hocytic leu/ae'ia( Fi!. /1.5 Oral a&&earance of a &atient ,ith acute 'yeloid leu/ae'ia, ,ith infiltration of the gingi$ae and %&ontaneou% bleeding( Thi% oral &re%entation and ty&e of leu/ae'ia i% le%% co''on than the ly'&hocytic ty&e %ho,n in 6ig( =!(A( ;Courte%y of Wolfe "ubli%hing(<( /1.0 RESPIRAT&RY DIS&RDERS /1.0.0 Introd-"tion There are age-related di%ea%e &attern% a% far a% the re%&iratory %y%te' i% concernedH the%e &attern% are al%o affected by %ex, race, %ea%on of the year, geogra&hy, and en$iron'ental and %ocio-econo'ic condition%( 6or exa'&le, the relati$ely %hort eu%tachian tube in infant% and young children allo,% ea%y acce%% to a%cending infection% fro' the &harynx( Cy%tic fibro%i% largely affect% Cauca%ian%, ,herea% lung infection% and infarction% a%%ociated ,ith %ic/le-cell di%ea%e occur al'o%t exclu%i$ely in 4lac/ children( Sea%onal $ariation in the incidence of re%&iratory tract infection% and a%th'a are Buite 'ar/ed and certain infection% ha$e a ,ell-defined geogra&hical di%tribution( The freBuency of bronchiti% 'ay not be $ery different bet,een %ocioecono'ic grou&%, but the %e$erity 'ay reflect difference% in nutritional %tatu% and &erha&% the a$ailability of 'edical care( /1.0./ A#t%ma 0%th'a i% a diffu%e ob%tructi$e lung di%ea%e that cau%e% breathle%%ne%%, coughing, and ,hee5ing( )t i% a%%ociated ,ith hy&erreacti$ity of the air,ay% to a $ariety of %ti'uli and a high degree of re$er%ibility of the ob%tructi$e &roce%%( 0%th'a i% a leading cau%e of chronic illne%% in childhood( "re$alence data are conflicting, but at lea%t =9L of children ,ill, at %o'e ti'e, ha$e %ign% and %y'&to'% co'&atible ,ith a diagno%i% of a%th'a( There i% 'ounting recent e$idence to %ugge%t that the &re$alence i% increa%ing( 4efore &uberty a&&roxi'ately t,ice a% 'any boy% a% girl% ,ill %uffer fro' a%th'a, thereafter, the %ex incidence i% %i'ilar( 0bout half the children ,ho are affected ,ill be $irtually free of %y'&to'% by the ti'e they beco'e adult%( The aetiology i% &oorly under%tood but it i% a co'&lex di%order in$ol$ing i''unological, infectiou%, bioche'ical, genetic, and &%ychological factor%( 0cute e&i%ode% of coughing and ,hee5ing are often &reci&itated by ex&o%ure to allergen% and irritant%, %uch a% cold air or noxiou% fu'e% and e'otional %tre%%( Drug thera&y i% no, the 'ain%tay of treat'ent both &ro&hylactically and during acute exacerbation%( Dental mana!ement o+ a#t%ma Dental treat'ent it%elf can cau%e e'otional %tre%%, ,hich 'ay &reci&itate an attac/( Routine dental care ,ith local anae%the%ia i% not u%ually a &roble'H if in doubt, in$ite the child to ta/e a &uff of their inhaler before co''encing( Steroid inhaler% for a%th'a do not generally cau%e adrenal %u&&re%%ion and in%ufficiency( 1o,e$er, there i% recent e$idence that %o'e of the ne,er generation of %teroid inhaler% 'ay cau%e %u&&re%%ion( )f in doubt contact the child*% &hy%ician(

General anae%the%ia for %e$ere a%th'atic% u%ually reBuire% in-&atient ho%&ital ad'i%%ion( Recently, a %tudy ha% been &ubli%hed lin/ing dental ero%ion ,ith a%th'a( Thi% 'ay be due to an increa%ed li/elihood of ga%tro-oe%o&hageal reflux in &eo&le ,ith a%th'a or to acidic long-ter' 'edication or to the increa%ed con%u'&tion of ero%i$e be$erage% due to *drying* of the oral 'uco%a by inhaler%( >e$ Point# Of rele$ence to the dental 'anage'ent of a%th'aG Ero%ion due to refluxH increa%e con%u'&tion of acidic be$erage%( General anae%the%ia 'ay reBuire in-&atient ad'i%%ion( The ne, generation of %teroid inhaler% 'ay cau%e adrenal %u&&re%%ion( /1.0.2 C$#ti" +i,ro#i# Cy%tic fibro%i% i% an auto%o'al-rece%%i$e 'ulti%y%te' di%order &redo'inantly of the exocrine gland%( Thic/ $i%cid 'ucu% i% &roduced, &articularly in the lung%, ,hich lead% to chronic ob%truction and infection of the air,ay% and to 'alab%or&tion( )t i% the 'o%t co''on genetic condition in Cauca%ian%, ,ith a&&roxi'ately :L of the &o&ulation being carrier% and = in 999 of li$e birth% affected( The abnor'al gene ha% been located on the long ar' of chro'o%o'e ?( The clinical 'anife%tation% of the condition are $ariable and %o'e &atient% re'ain a%y'&to'atic for long &eriod%( Coughing i% the 'o%t con%tant %y'&to' of &ul'onary in$ol$e'ent and thi% 'ay lead to recurrent re%&iratory infection% and bronchioliti%( Sufferer% often undergo regular &hy%iothera&y to clear che%t %ecretion%( 3ung di%ea%e &rogre%%e% leading to exerci%e intolerance and %hortne%% of breath ;6ig( =!(!<( More than C:L of affected children %ho, e$idence of 'alab%or&tion due to exocrine &ancreatic in%ufficiency( Sy'&to'% include freBuent, bul/y, grea%y %tool% and a failure to thri$e de%&ite a large food inta/e( Dental mana!ement o+ "$#ti" +i,ro#i# There are re&ort% of decrea%ed carie% &re$alence attributable not only to the long ter' u%e of antibiotic% and &ancreatic en5y'e %u&&le'ent% but al%o to increa%ed %ali$ary buffering( -e$erthele%%, the%e children %uffer fro' delayed dental de$elo&'entH 'ore co''only ha$e ena'el o&acitie% and are 'ore &rone to calculu%( Moreo$er, they need to ha$e a $ery high calorific inta/e and 'ay ha$e freBuent refined carbohydrate %nac/%( 0% %uch, children ,ith cy%tic fibro%i% are an i'&ortant &riority grou& for dental health education and care( General anae%thetic% %hould be a$oided in $ie, of the &ul'onary in$ol$e'ent( 0 %ignificant &ro&ortion of affected children al%o ha$e cirrho%i% of the li$er, ,ith re%ultant clotting defect% and a liability to hae'orrhage follo,ing %urgical &rocedure%( Children ,ith cy%tic fibro%i% %o'eti'e% %till 'ay be &re%cribed tetracycline to &re$ent che%t infection%, a% a re%ult of the de$elo&'ent of

'ulti&le antibiotic %en%iti$itie%, e$en though it cau%e% intrin%ic dental %taining ;6ig( =!(?<( Fi!. /1.1 Thi% boy ha% cy%tic fibro%i% and %ho,% a *barrel che%t* defor'ity due to re%&iratory infection%( Coincidentally, he al%o ha% a defor'ity of the cla$icle%( ;Courte%y of Wolfe "ubli%hing(< Fi!. /1.2 Tetracycline ,a% ad'ini%tered o$er a &rolonged &eriod to thi% &atient ,ho ha% cy%tic fibro%i%( Thi% ha% re%ulted in it% incor&oration into the 'ineral 'atrix ,ith 'ar/ed di%colorationalternati$e antibiotic% are no, u%ed( Recent i'&ro$e'ent% in the 'anage'ent of &eo&le ,ith cy%tic fibro%i% ha$e 'eant that an increa%ing nu'ber are not 'aintained on long-ter' antibiotic &ro&hylaxi%( /1.5 C&N)(*SI)E DIS&RDERS /1.5./ Fe,rile "on.-l#ion# Con$ul%ion% are co''onH about :L of children ha$e had one or 'ore con$ul%ion% and accurate diagno%i% of the aetiology i% $ery i'&ortant( The $a%t 'a+ority of the%e are febrile con$ul%ion% and are a%%ociated ,ith illne%%e% that cau%e high fe$er late in infancy %uch a% otiti% 'edia( The %ei5ure% are u%ually tonic-clonic ,ith lo%% of con%ciou%ne%% follo,ed by %u%tained 'u%cle contraction%( Re%&iration 'ay be i'&aired, ,hich 'ay lead to cyano%i%( The teeth are often fir'ly clenched ,ith &o%%ible tongue and li&-biting( There 'ay al%o be a lo%% of bladder and bo,el control( Thi% tonic &ha%e i% follo,ed by the clonic &ha%e of inter'ittent 'u%cular contraction( The duration i% al,ay% le%% than =: 'in( The%e con$ul%ion% u%ually occur early in the illne%% during the &eriod of ra&id te'&erature ri%e and 'ay be the fir%t indication that the child i% ill( )t i% 'o%t i'&ortant to eli'inate the &o%%ibility of central ner$ou% %y%te' infectionH therefore exa'ination of the cerebro%&inal fluid i% e%%ential if there i% &er%i%tent dro,%ine%% follo,ing the attac/( /1.5.2 E ile #$ )t 'ay be difficult to differentiate the%e %i'&le febrile con$ul%ion% fro' e&ile&%y but it i% e%%ential that thi% diagno%i% i% 'ade a% the thera&y, &rogno%i%, and i'&lication% differ enor'ou%ly( Table =!(C gi$e% a li%t of condition% that are co''only a%%ociated ,ith recurrent %ei5ure%( E&ile&%y i% not a di%ea%e in it%elf but a ter' a&&lied to recurrent %ei5ure%, either of un/no,n origin ;idio&athic e&ile&%y< or due to congenital or acBuired brain le%ion% ;%econdary e&ile&%y<( )t affect% about 9(:- L of the &o&ulation( Medical 'anage'ent u%ually con%i%t% of long-ter' anticon$ul%ant drug thera&y( The choice of drug de&end% on the %ei5ure ty&e, but the do%age need% to control the %ei5ure% ,ith 'ini'al %ide effect%( -e, generation anti-e&ile&tic drug% ha$e beco'e a$ailable, for exa'&le, 3a'otrigine, Gaba&entin, Oxcarba5e&ine, Tiagabine, and To&ira'ate but e$en the%e are not ,ithout &roble'%, for exa'&le, hy&erexcitability, di55ine%%, de&re%%ion, ,eight lo%%, and abdo'inal &roble'%( The 'o%t fa'iliar anti-e&ile&tic drug% are Sodiu' 8al&roate, "henytion, and Carba'a5e&ine( Dental mana!ement o+ e ile #$ )f &o%%ible, any liBuid anti-e&ile&tic 'edication %hould be %ugar-free ;6ig( =!(C<(

Sodiu' 8al&roate i% not a%%ociated ,ith gingi$al enlarge'ent and li/e Carba'a5e&ine, 3a'otrigine, and Oxcarba5e&ine i% a$ailable a% a %ugar-free liBuid( "henytoin re%ult% in gingi$al enlarge'ent in about half of &atient%( The child ,ith good control of %ei5ure% need% a 'ini'u' of re%triction%, although the &o%%ibility of an attac/ occurring in the dental chair %hould be con%idered( 0 $ery high %tandard of oral hygiene i% reBuired to 'ini'i5e the de$elo&'ent of gingi$al enlarge'ent and gingi$al %urgery %hould ne$er be conte'&lated unle%% the oral hygiene i% good( Trau'a to anterior teeth i% often encountered in &eo&le ,ith e&ile&%y ,ho 'ay ha$e freBuent, un&redictable fall%( Rei'&lantation of a$ul%ed teeth i% u%ually contraindicated in tho%e ,ith %e$ere learning difficultie%( )f &ro%the%e% are reBuired then they %hould be ,ell retained ,ith cla%&% and unli/ely to brea/ or be inhaled during %ub%eBuent attac/%( >e$ Point# E&ile&%yG 9(:-=L of the &o&ulationH gingi$al enlarge'ent ,ith &henytoinH chec/ that any liBuid 'edication i% %ugar-free( Fi!. /1.3 Thi% @-year-old child ,ith e&ile&%y ha% ra'&ant carie% of the &ri'ary dentition, ,ith a %o'e,hat unu%ual di%tribution of a&&roxi'al le%ion% in both u&&er and lo,er inci%or% a% ,ell a% 'olar%( The child had been on long-ter', %ucro%e-ba%ed 'edication but ha% no, changed to the %ugar-free %odiu' $al&roate liBuid( ;Courte%y of Wolfe "ubli%hing(< /1.1 7ETA;&*IC AND END&CRINE DIS&RDERS /1.1./ Dia,ete# mellit-# Diabete% i% the 'o%t co''on endocrineD'etabolic di%order of childhood and i% due to the deficiency of in%ulin and abnor'al 'etaboli%' of carbohydrate, &rotein, and fat( Ty&e ) diabete% 'ellitu% i% in%ulin-de&endent ;)DDM< and u%ually of +u$enile on%et( )t i% age-related ,ith &ea/% of &re%entation bet,een : and ? year% and at &uberty( The &re$alence of diabete% in %chool-age children i% a&&roxi'ately &er =999( 0lthough there i% a genetic &redi%&o%ition, there 'ay ,ell be a triggering effect fro' $iral infection% in the aetiology of diabete%( The clinical 'anife%tation% are &olydi&%ia ;increa%ed thir%t<, &olyuria ;increa%ed urination<, &oly&hagia ;increa%ed a&&etite<, and ,eight lo%%( There 'ay be an in%idiou% on%et of lethargy, ,ea/ne%%, and ,eight lo%%( The diagno%i% i% de&endent on the de'on%tration of hy&erglycae'ia in a%%ociation ,ith gluco%uria( The ai'% of treat'ent are to control the %y'&to'%, &re$ent acute 'etabolic cri%e% of hy&o- and hy&erglycae'ia, and to 'aintain nor'al gro,th and body ,eight, ,ith an acti$e life-%tyle( )f there i% good control of blood %ugar le$el% ,ith in%ulin thera&y and nutritional 'anage'ent, then diabetic co'&lication% are 'ini'i5ed( One of the 'a+or ha5ard% of in%ulin treat'ent i% the de$elo&'ent of hy&oglycae'ia( )t i% u%ually of ra&id on%et ;unli/e hy&erglycae'ia< ,ith %,eating, &al&itation%, a&&rehen%ion, and tre'bling( Thi% &rogre%%e% to 'ental confu%ion, dro,%ine%%, and co'a( 1y&oglycae'ia in a diabetic child indicate% too 'uch in%ulin relati$e to food inta/e and energy ex&enditure( 6or an acute e&i%ode a carbohydratecontaining %nac/ or drin/ %hould be gi$en( 0nother &roble', &articularly in adole%cent%, i% the &%ychological ad+u%t'ent to the conditionH the rebelliou% teenage

year% 'ay lead to non-co'&liance ,ith in%ulin thera&y and nutritional 'anage'ent( Many of the%e &roble'% can be a$erted by %uitable education and coun%elling( Dental mana!ement o+ dia,ete# The ,ell-controlled diabetic child ,ith no %eriou% co'&lication% can ha$e any dental treat'ent but %hould recei$e &re$enti$e care a% a &riority( #ncontrolled diabete% can re%ult in $aried &roble'%, ,hich 'ainly relate to fluid i'balance, an altered re%&on%e to infection, &o%%ible increa%ed gluco%e concentration% in %ali$a, and 'icro$a%cular change%( There 'ay be decrea%ed %ali$ary flo,, and an increa%ed incidence of dental carie% ha% been re&orted in uncontrolled young diabetic%( There i% al%o ,elldocu'ented e$idence of increa%ed &eriodontal &roble'% and %u%ce&tibility to infection%, &articularly ,ith Candida %&( Dental a&&oint'ent% %hould be arranged at ti'e% ,hen the blood %ugar le$el% are ,ell controlledH u%ually a good ti'e i% in the 'orning i''ediately follo,ing their in%ulin in+ection and a nor'al brea/fa%t( General anae%thetic% are a &roble' becau%e of the &re-anae%thetic fa%ting that i% reBuired, and %o the%e are nor'ally carried out on an in-&atient ba%i% to enable the in%ulin and carbohydrate balance to be %tabili5ed intra$enou%ly( /1.1.2 Adrenal in#-++i"ien"$ There are a nu'ber of %yndro'e% a%%ociated ,ith adrenal in%ufficiency, %uch a% 0ddi%on*% di%ea%e and Cu%hing*% %yndro'e( 1o,e$er, &roble'% in the dental 'anage'ent of &atient% ,ith %teroid in%ufficiency are 'ore li/ely to occur in children ,ho are being &re%cribed %teroid thera&y for other 'edical condition%H for exa'&le, in the %u&&re%%ion of infla''atory and allergic di%order%, acute leu/ae'ia, and to &re$ent acute tran%&lant re+ection( )n children, the ri%/% of ta/ing cortico%teroid% are greater than in adult% and they %hould only be u%ed ,hen %&ecifically indicated, in 'ini'al do%age, and for the %horte%t &o%%ible ti'e( )f a child ha% adrenal in%ufficiency andDor i% recei$ing %teroid thera&y, then any infection or %tre%% 'ay &reci&itate an adrenal cri%i%( 6or routine re%torati$e treat'ent no additional %teroid %u&&le'entation i% u%ually nece%%ary( 1o,e$er, if extraction% under local anae%the%ia or 'ore exten%i$e &rocedure% are &lanned andDor if the &atient i% &articularly a&&rehen%i$e, then the oral %teroid do%age %hould be increa%ed( General anae%the%ia %hould not be carried out on an out-&atient ba%i%( Con%ultation ,ith the child*% &hy%ician i% nece%%ary before &re%cribing %teroid%, and anae%theti%t% 'u%t be a,are of %uch 'edication in order to a$oid a &reci&itou% fall in blood &re%%ure during anae%the%ia or in the i''ediate &o%to&erati$e &eriod( /1.1.3 &t%er di#order# Many other 'etabolic and endocrine di%order% occur in children but the%e are rare e$ent%( /1.1.3./ T%$roid di#ea#e Thyroid di%ea%e 'ay &re%ent in early adole%cence, although it i% generally 'ore co''on in adult%( Dental 'anage'ent %hould &re%ent no &roble'% if the thyrotoxic &atient i% 'edically ,ell controlledH ho,e$er, liai%on ,ith the &hy%ician% i% i'&ortant(

/1.1.3.2 Renal di#order# -e&hrotic %yndro'e i% a condition ,here &rotein lea/% fro' the blood into urine $ia the glo'eruli of the /idney re%ulting in hy&o&roteinae'ia and generali5ed oede'a( 3eft untreated, %ufferer% ,ould die of infection% but fortunately the 'a+ority re%&ond to treat'ent u%ing cortico%teroid%, u%ually &redni%olone( The /idney undergoe% a co'&lex de$elo&'ental and 'igratory &roce%% leading to a high freBuency of congenital ano'alie%, %uch a% &olycy%tic di%ea%e and unilocular cy%t%( 0cute &yelone&hriti% i% 'ore co''on ,hen there i% a congenital abnor'ality &re%ent and %o, e$en though it i% %i'&ly treated ,ith antibiotic%, children often undergo further 'edical in$e%tigation% to rule out congenital abnor'ality( Therefore, children ,ith renal &roble'% are li/ely to be, or ha$e been, under %&eciali%t 'edical care( 6ro' a dental $ie,&oint, children ,ith reduced renal function, or 'ore i'&ortantly, &rogre%%i$e renal failure need extra con%ideration ,hen &re%cribing drug%( Such children 'ayG fail to excrete a drug or it% 'etabolite%, be 'ore %en%iti$e to the drug*% effectH be le%% tolerant of %ide effect%H and %a'e drug% 'ay e$en be le%% effecti$e( Exa'&le% of drug% ,here caution %hould be exerci%ed by the denti%t includeG 'ida5ola' and other ben5odia5e&ine%, chloral hydrate, -S0)D%, 6lucona5ole and co-tri'oxa5de( The 4-6 %hould al,ay% be con%ulted( /1.2 NE&P*ASTIC DIS&RDERS There are a&&roxi'ately = 99 ne, ca%e% of childhood cancer each year in the #nited 2ingdo'( Child cancer &atient% largely reflect the child &o&ulation in general and a% %uch, re&re%ent a cro%%-%ection of the &o&ulation( Cancer cau%e% 'ore childhood death% bet,een the age% of = and =: year% than any other di%ea%e, but i% %till con%iderably behind trau'a a% the 'o%t co''on rea%on for 'ortality( The incidence of 'alignant tu'our% in children under =: year% of age in de$elo&ed countrie% i% e%ti'ated to be in the region of = in =9,999 children &er year but the 'ortality rate i% high, at bet,een @9L and A9L( 0lthough leu/ae'ia i% the 'o%t co''on for' of childhood cancer, tu'our% of the central ner$ou% %y%te' and neural cre%t cell% and ly'&ho'a% al%o for' a %ignificant &ro&ortion ;Table =!(><( "rogno%i% $arie% ,ith the ty&e of tu'our, the %tage at ,hich it ,a% diagno%ed, and u&on the adeBuacy of treat'ent( Ma+or ad$ance% ha$e been 'ade in the treat'ent of childhood 'alignancy in the la%t fe, decade%, largely a% a re%ult of ad$ance% in che'othera&y and bone'arro, tran%&lantation( Dental mana!ement o+ "%ildren Cit% "an"er The children 'ay ha$e untreated carie% and, %ince 'any are under : year% of age, and 'ay not ha$e had a &re$iou% dental exa'ination( The oral %ide-effect% of cancer treat'ent are %ho,n in Table =!(=9 but can be categori5ed into ;=< i''ediate and ; < long ter'( The i''ediate &roble'% include 'uco%iti% ;oral ulceration< and exacerbation% of co''on oral di%ea%e% that 'ay beco'e life threatening and are u%ually 'anaged by &aediatric denti%try %&eciali%t% in liai%on ,ith their 'edical colleague%( Child cancer %ur$i$or% later &re%ent ,ith long-ter' &roble'% relating toG gro,thH &uberty, and re&roductionH cardiacH thyroidH cogniti$e deficitH and %ocial function( Oral and dental de$elo&'ent can al%o be i'&eded and %&eciali%t ad$ice 'ight again be reBuired( De%&ite thi%, the introduction of a %hared care arrange'ent

bet,een the &ri'ary dental &ractitioner and the &aediatric %&eciali%t ,hen the child i% in re'i%%ion i% $ital to en%ure continued &re$enti$e thera&y and good oral health ,hile at the %a'e ti'e *nor'ali5ing* care( >e$ Point# Children ,ith cancer need the co'bined care of &ri'ary and %&eciali%t dental %er$ice%H There are i''ediate and long-ter' effect% of cancer treat'entH Di%ea%e &re$ention i% $ital( /1.3 &R6AN TRANSP*ANTATI&N /1.3.0 Introd-"tion 2idney, heart, bone 'arro,, li$er, and &ancrea% tran%&lantation are no, routine &rocedure%( Mo%t li$er tran%&lant% in children occur becau%e of biliary atre%ia( 4one 'arro, tran%&lant% are the treat'ent of choice for children ,ith a&la%tic anae'ia, tho%e ,ho fail con$entional thera&y for leu/ae'ia, and for %o'e i''une deficiency di%order%( 0lthough children ,ith end-%tage renal di%ea%e can be /e&t ali$e by hae'odialy%i%, their Buality of life i% con%iderably i'&ro$ed by /idney tran%&lantation( Children ,ho reBuire organ tran%&lantation are con%idered to be at a high carie% ri%/ and %o &re$ention i% i'&ortant( /1.3./ Pretran# lant treatment lannin! 0ny candidate for organ tran%&lantation %hould be referred for %&eciali%t dental e$aluation( Whene$er &o%%ible, acti$e dental di%ea%e %hould be treated before the tran%&lant &rocedure and any teeth ,ith doubtful &rogno%e% extracted( Thi% 'ay &re%ent difficultie% a% 'any &retran%&lant &atient% can be %eriou%ly ill and ha$e $ariou% a%%ociated 'edical &roble'%( Moreo$er, %o'e children ,ill be &laced on a high carbohydrate ;cariogenic< diet, for exa'&le, *'axi+ul*, to *build-the'-u&* in &re&aration for %urgery and %o the dental tea' ,ill need to ado&t a &rag'atic a&&roach to ad$ice relating to %ugar inta/e and freBuency during thi% ti'e, %ince the child*% 'edical ,ell being 'u%t ta/e &riority( Children undergoing bone 'arro, tran%&lantation are &rone to infection, bleeding, and delayed healing due to leuco&enia and thro'bocyto&enia( 1o,e$er, the 'a+ority of children a,aiting li$er tran%&lantation due to biliary atre%ia are of a $ery young age and ha$e not ex&erienced dental carie%, though their teeth 'ay ha$e intrin%ic green %taining due to bili$erdin de&o%ition in the de$elo&ing dental ti%%ue%( Thi% i% a ti'e ,hen inten%i$e oral hygiene in%truction and &re$enti$e ad$ice and thera&y are of &ara'ount i'&ortance in hel&ing to 'ini'i5e later &otential oral &roble'%( 4efore any in$a%i$e dental &rocedure% are underta/en, con%ultation ,ith the child*% &hy%ician i% $ital in order to e%tabli%h the extent of the organ dy%function and it% re&ercu%%ion%( "ro&hylactic antibiotic% ,ill &robably be reBuired in &atient% ,ith cardiac &roble'% and de&re%%ed ,hite blood cell count%( 0ny %ignificant alteration% in bleeding ti'e% andDor coagulation %tatu% 'u%t be chec/ed( There are al%o certain drug% that %hould be a$oided in&atient% ,ith end-%tage li$er or /idney di%ea%e( /1.3.2 Immediate o#t-tran# lant eriod

Drug% &re%cribed to &re$ent graft re+ection ha$e %e$eral %ide-effect%( 05athio&rine re%ult% in leuco&enia, thro'bocyto&enia, and anae'iaH hence, children in thi% i''ediate &o%t-tran%&lant &ha%e 'ay be e$en 'ore &rone to infection% and hae'orrhage than before( Cyclo%&orin ;6eoral< and Tacroli'u% are largely re&lacing a5athio&rine but the%e 'ay cau%e %e$ere /idney and li$er change% leading to hy&erten%ion and bleeding &roble'%( Cyclo%&orin i% al%o a%%ociated ,ith gingi$al enlarge'ent( Steroid% are &re%cribed at thi% ti'e ,ith the ri%/ of adrenal %u&&re%%ion( 6ull %u&&orti$e dental care i% reBuired and children co'&lain of nau%ea and 'ay de$elo& %e$ere oral ulceration( Routine oral hygiene &rocedure% can beco'e difficult but the u%e of chlorhexidine a% a 'outh,a%h, %&ray, or on a di%&o%able %&onge, together ,ith local anae%thetic &re&aration% i% hel&ful( /1.3.3 Sta,le o#t-tran# lant eriod Once healing ha% occurred and any acute graft re+ection been brought under control then routine dental treat'ent can be underta/en( Reinforce'ent of all &re$enti$e ad$ice and liai%on ,ith the child*% dietitian 'ay be hel&ful a% 'any &atient% are %till on high carbohydrate %u&&le'entation( Steroid thera&y i% di%continued in children ,ith li$er tran%&lant% after @ 'onth% but 'ay be continued for longer &eriod% than thi% in tho%e ,ith other organ tran%&lant%( 0ntifungal &ro&hylaxi% i% u%ually gi$en in the fir%t fe, 'onth% after tran%&lantation to &re$ent oral candidal infection%( Dental &roble'%, a&art fro' oral ulceration and tho%e a%%ociated ,ith i''uno%u&&re%%ion and bleeding tendencie%, include delayed eru&tion and exfoliation of &ri'ary teeth and ecto&ic eru&tion of &er'anent teeth( The%e are related to the gingi$al o$ergro,th a%%ociated ,ith cyclo%&orin and nifedi&ine 'edication ;6ig( =!(><( >e$ Point# Tran%&lant i''uno%u&&re%%ionG leuco&eniaH thro'bocyto&eniaH gingi$al enlarge'ent( Fi!. /1.4 The%e gro%%ly hy&er&la%tic gingi$ae are a%%ociated ,ith cyclo%&orin and nifedi&ine 'edication in thi% ==-year-old boy ,ho ha% had a /idney tran%&lant( Thi% co'bination of drug% i% reBuired to &re$ent re+ection and to control hi% blood &re%%ure( /1.4 S(77ARY )n all children ,ho are 'edically co'&ro'i%ed the dental tea' can not only &lay a $ital &art in the o$erall 'edical 'anage'ent but al%o in hel&ing the%e children and their &arent% ad+u%t to nor'al life follo,ing reco$ery( Oral care i% extre'ely i'&ortant in enhancing the Buality of life by reducing the 'orbidity and 'ortality of oral condition%, and by allo,ing the child to eat ,ithout &ain and %o gain o&ti'al nutrient inta/e( "re$enti$e care %hould be the corner%tone of any oral care &rogra''e( Since 'any children tra$el long di%tance% to regional and %u&ra-regional unit%, %hared care bet,een the ho%&ital &aediatric denti%try %&eciali%t and the &ri'ary care &ro$ider can facilitate the child*% reintegration into their local co''unity and a$oid lo%t %chooling(

=( 0n increa%ing nu'ber of children ,ith co'&lex 'edical &roble'% no, %ur$i$e due to i'&ro$e'ent% in 'edical care, and &re%ent difficultie% in oral 'anage'ent( ( 0n accurate, detailed 'edical hi%tory 'u%t be obtained for all children before any dental treat'ent i% underta/en( @( 0n aggre%%i$e &re$enti$e regi'en i% reBuired for all children ,ith %ignificant 'edical &roble'%H thi% 'u%t enco'&a%% dietary coun%elling, %uitable fluoride thera&y, fi%%ure %ealant a&&lication%, and oral hygiene in%truction( A( Congenital heart di%ea%e i% 'ore co''on in children than acBuired condition%( Many of the%e 'alfor'ation% reBuire &ro&hylactic antibiotic% &rior to carrying out any in$a%i$e dental &rocedure%( :( Children ,ith bleeding di%order%, %uch a% hae'o&hilia, thro'bocyto&enic &ur&ura, and 8on Willebrand*% di%ea%e, 'u%t be hae'atologically in$e%tigated &rior to dental treat'ent( 1ae'atological re&lace'ent thera&y 'ay be reBuired before o&erati$e treat'ent( !( Children ,ith anae'ia, ,hether fro' iron deficiency or fro' %uch inherited condition% a% %ic/le-cell anae'ia or thala%%ae'ia, re&re%ent general anae%thetic ri%/% in &articular( ?( 3eu/ae'ia i% the 'o%t co''on for' of childhood cancer and the fir%t di%%e'inated cancer to re%&ond co'&letely to che'othera&y in a %ignificant nu'ber of children( Dental 'anage'ent of affected children need% to con%ider their hae'atological %tatu% a% ,ell a% their i''unoco'&ro'i%ed condition( C( 0%th'a i% a leading cau%e of chronic illne%% in childhoodH %e$ere a%th'atic% 'ay be on %y%te'ic %teroid thera&y, ,hich ha% i'&lication% for dental care( >( Con$ul%ion% are co''on in children, occurring in a&&roxi'ately :L, but 'any of the%e are a%%ociated ,ith e&i%ode% of high fe$er in the child and not ,ith e&ile&%y( =9( Diabete% 'ellitu% i% the 'o%t co''on endocrineD'etabolic di%order of childhoodH if there i% good control of blood %ugar le$el% ,ith in%ulin thera&y and nutritional 'anage'ent, then diabetic co'&lication% are 'ini'i5ed and dental care %hould be routine( ==( Organ tran%&lantation in children i% no, being increa%ingly underta/enH there are 'any %ide effect% of drug control of i''uno%u&&re%%ion that affect treat'ent &lanning and oral care( = ( The &artici&ation of the dental tea' in the o$erall 'anage'ent of children ,ith 'edical &roble'% can %ignificantly hel& to enhance the Buality of lifeH &re$enti$e care %hould be the corner%tone of dental 'anage'ent( /1./0 F(RT5ER READIN6 4ehr'an, R( E( and 8aughan, 8( C( ; 99@<( 6elson text,oo% of pediatrics ;=?th edn<(

W( 4( Saunder%, "hiladel&hia, " 0( ;-he standard paediatric ?,i,le?@ a huge amount of information a,out all types of medical pro,lems in children < Gorlin, R( 7(, Cohen, M( M(, and 3e$in, 3( S( ; 99=<( #yndromes of the head and nec% ;Ath edn<( Oxford #ni$er%ity "re%%, Oxford( ;-he authoritative pu,lication on this su,9ect with erudite lists of references < Grundy, M( C(, Sha,, 3(, and 1a'ilton, D( 8( ;=>>@<( "n illustrated guide to dental care of the medically compromised patient( Wolfe, 3ondon( ;$asic information on a wider range of su,9ects than can ,e covered in the present chapter and with practical information on dental care < 3ittle, 7( W( and 6alace, D( 0( ; 99 <( Dental management of the medically compromised patient ;!th edn<( Mo%by .ear 4oo/, St 3oui%, MO( ;Comprehensive information ,ut with very helpful summaries on potential pro,lems related to dental care < Scully, C( and Ca,%on, R( 0( ; 99A<( (edical pro,lems in dentistry Churchill 3i$ing%tone, Edinburgh( ;:th edn<( ;-he most comprehensive account of how to cope with medical pro,lems(< Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

/2. C%ild%ood im airment and di#a,ilit$ - + H 6unn /2./ INTR&D(CTI&N 0n i'&air'ent beco'e% a di%ability for a child only if he or %he i% unable to carry out

the nor'al acti$itie% of hi% or her &eer grou&( 6or exa'&le, a child ,ho ha% bro/en an ar' i% te'&orarily *di%abled* by not being able to eat and ,rite in the nor'al ,ay( 1o,e$er, for %o'e children i'&air'ent i% a &er'anent feature in their li$e%, although it 'ay beco'e a di%ability only if they are unable to ta/e &art in e$eryday acti$itie%, %uch a% co''unicating ,ith other%, cli'bing %tair%, and toothbru%hing( One definition that hel&% to clarify ,hich children are *di%abled*, for the &ur&o%e% of &ro$iding dental care, i% a% follo,%G *dentally di%abled* refer% to &atient% ,ho ha$e %o'e gro%% condition or deficit in their oral ca$itie%, ,hich nece%%itate% %&ecial dental treat'ent for exa'&le, a cleft of the li& and &alate( 4y contra%t, children ,ho are *di%abled for denti%try* are tho%e ,ho ha$e a &hy%ical andDor intellectual or e'otional condition that 'ay &re$ent the' fro' being treated in a routine 'anner( There are a nu'ber of rea%on% ,hy children ,ith di%abilitie% 'erit %&ecial con%ideration for dental careG =( The oral health of %o'e children ,ith di%abilitie% i% different fro' that of their nor'al &eer%, for exa'&le, the greater &re$alence of &eriodontal di%ea%e in &eo&le ,ith Do,n %yndro'e and of tooth,ear in tho%e ,ith cerebral &al%y( ( The &re$ention of dental di%ea%e in di%abled children need% to be a higher &riority than for %o-called nor'al &eer% becau%e dental di%ea%e, it% %eBuelae, or it% treat'ent, 'ay be life-threatening, for exa'&le, the ri%/ of infecti$e endocarditi% fro' oral organi%'% in children ,ith congenital heart defect% ;6ig( =?(=<( @( Treat'ent &lanning and the &ro$i%ion of dental care 'ay need to be 'odified in $ie, of the &atient*% ca&abilitie%, li/ely future co-o&eration, and ho'e care, for exa'&le, the fea%ibility of &ro$iding a re%in-bonded bridge for a teenager ,ith cerebral &al%y, &oorly controlled e&ile&%y, and inadeBuate ho'e oral care( )n the light of the%e con%ideration%, do %uch children need %&ecial dental careJ Mo%t of the %tudie% ,hich ha$e been underta/en on di%abled children ha$e indicated that the 'a+ority can in fact be treated in a dental %urgery in the nor'al ,ay, together ,ith the re%t of their fa'ily( >e$ Point# The need for %&ecial dental care ari%e% becau%e ofG difference% in dental di%ea%e &re$alenceH dental di%ea%eDtreat'ent 'ay be life-threateningH the 'odification% reBuired to treat'ent &lan%H the need for %&ecial facilitie%H treat'ent 'ay be ti'e-con%u'ing( Thi% nor'ality i% de%irable, &ro$ided the di%abled &er%on actually recei$e% good dental care( The e$idence fro' 'any %tudie% i% that, although the o$erall carie% ex&erience i% %i'ilar bet,een di%abled children and their %o-called nor'al conte'&orarie%, the ty&e of treat'ent they ha$e ex&erienced i% differentG di%abled children ha$e %i'ilar le$el% of untreated decay, but 'ore 'i%%ing teeth and fe,er re%tored teeth( 0 'inority of children ,ith co'&lex di%abilitie% need %&ecial facilitie%, u%ually only a$ailable in dental or general ho%&ital%, or fro' %&eciali5ed co''unity

dental clinic%( What is needed by all &atient% ,ith di%abilitie% i% a $ery aggre%%i$e a&&roach to the &re$ention of dental di%ea%e( 4ecau%e of the &otential for dental di%ea%e, or it% treat'ent, to di%able an i'&aired child, &riority 'u%t be gi$en to &re$enti$e dental care for %uch indi$idual% fro' a $ery young age( Children ,ith a %ignificant degree of i'&air'ent are ter'ed *children ,ith %&ecial educational need%* or *children ,ith learning difficultie%*( The%e ter'%, u%ed %ynony'ou%ly, enco'&a%% a ,ide $ariety of i'&air'ent%, but three 'ain area% intellectual, &hy%ical, and %en%ory i'&air'ent%&redo'inate and ,ill no, be con%idered in 'ore detail( )t i% i'&ortant to %tre%%, ho,e$er, that i'&air'ent doe% not al,ay% &re%ent a% a di%crete entityH in any &o&ulation of affected children, at lea%t a Buarter of the grou& ,ill be 'ulti&ly i'&aired, 'a/ing it difficult to a%%ign a *label* to that child*% i'&air'ent( Medical co'&ro'i%e, con%idered in 'ore detail in Cha&ter =!, 'ay al%o be i'&o%ed on the%e i'&air'ent%( The ,ay in ,hich %o'e of the%e &re%ent to a denti%t are gi$en belo,, together ,ith the dental 'anage'ent i%%ue% rele$ant to each( Many of the i%%ue% rai%ed are, of cour%e, co''on to a nu'ber of i'&air'ent%( Fi!. /2./ 0 =@-year-old boy ,ith Do,n %yndro'e and gro%% carie%, ,ho ,a% &re$ented fro' going on a co'bined heart and lung a% ,ell a% a renal tran%&lant regi%ter becau%e of hi% dental di%ea%e( /2.2 INTE**ECT(A* I7PAIR7ENT /2.2.0 Introd-"tion The cau%e% of intellectual i'&air'ent are nu'erou% and for 'any children a cau%e for their di%ability 'ay ne$er be identified( 0&&roxi'ately, : &er =999 of the child &o&ulation are affected, and the 'a+ority, a% ,ith other i'&air'ent%, ,ill be 'ale%( Children ,ith intellectual i'&air'ent can be di$ided broadly into tho%e ,ho are either 'entally retarded or ha$e a learning difficulty( The%e are broad grou&%, often ,ithout a ,ell-defined aetiology or con%i%tent &re%enting feature%, but there are t,o di%tinct %ubgrou&% ,here the cau%e i% /no,n and the feature% are ,ell de%cribed, na'ely Do,n and 6ragile X %yndro'e%( )ntellectual i'&air'ent 'ay be &re%ent in %o'e children ,ith cerebral &al%y and tho%e ,ho ha$e %uffered birth anoxia, and %e$ere infection%, for exa'&le, 'eningiti% and rubella( )ntellectual i'&air'ent i% al%o a feature of auti%', 'icroce&haly, and 'etabolic di%order% ;e(g( &henyl-/etonuria<, and 'ay al%o be acBuired after %ignificant trau'a( -ot e$ery condition ,ill ha$e %&ecific dental feature% li/e Do,n %yndro'e, but an under%tanding of the underlying i'&air'ent ,ill hel& the denti%t &lan treat'ent 'ore effecti$ely( Mental retardation, &er$a%i$e de$elo&'ental di%order% ;auti%' and %chi5o&hrenia<, learning di%abilitie%, dy%lexia, attention-deficit di%order%, and hy&eracti$ity are all contro$er%ial categorie% ,ho%e definition and &roce%%e% of a%%e%%'ent are not uni$er%ally agreed( >e$ Point# Cla%%ification of children ,ith i'&air'ent% intellectually i'&aired'entally retarded, learning difficultie%H &hy%ically i'&airedde$elo&'ental, degenerati$eH

 %en%ory i'&air'entH 'edically co'&ro'i%edH co'bination of i'&air'ent%( 7ental retardation Thi% i% %o'eti'e% called 'ental handica&, 'ental %ubnor'ality, or 'ental deficiency( )t i% a general category characteri5ed by lo, intelligence, failure of ada&tation, and early age of on%et( 3o, general intelligence i% the 'ain characteri%tic( 0ffected children are %lo, in their general 'ental de$elo&'ent and they 'ay ha$e difficultie% in attention, &erce&tion, 'e'ory, and thin/ing( They 'ay be %tronger in %o'e %/ill% than other%, for exa'&le, 'u%ic and co'&uting, but generally they are of lo, intellectual attain'ent( Children ,ith lo, intelligence are not called 'entally retarded unle%% they al%o ha$e %o'e &roble' in ada&tation( That i%, they are unli/ely to be able to li$e inde&endently and ,ill al,ay% de&end ina&&ro&riately on other% a% a %ource of inco'e and %u&&ort for daily li$ing( 0ccording to )K le$el%, fi$e le$el% are traditionally de%cribed( The %i'&licity of the cla%%ification i% %o'e,hat illu%ory ,ith great indi$idual difference% a'ong &eo&le ,ith 'ental retardation( >e$ Point# )ntellectual i'&air'ent 'ay occur inG cerebral &al%yH birth anoxiaH %e$ere infection%H auti%'H 'icroce&halyH 'etabolic di%order%H 'a+or trau'aH %o'e %yndro'e%( DoCn #$ndrome Do,n %yndro'e i% a chro'o%o'al di%order, tri%o'y =, ,ith di%tinct clinical feature%( The &re$alence i% a&&roxi'ately = in !99 birth% but there i% $ariation ,ith 'aternal age, %o that at A9 year% of age the incidence i% about = in A9 birth%( 1o,e$er, the nu'ber% %een in any one country ,ill $ary de&ending on the &re$ailing attitude to,ard% &renatal %creening and ter'ination( The general &hy%ical feature% a%%ociated ,ith Do,n %yndro'e are a greater &redi%&o%ition to cardiac defect%, leu/ae'ia of the 'yeloid ty&e, infecti$e he&atiti% infection ;e%&ecially in in%titutionali5ed 'ale%<, although 'o%t children ,ill ha$e been $accinated again%t $iral for'%( Coeliac di%ea%e a% ,ell a% thyroid di%order% are al%o clinical feature% of thi% condition( )ncrea%ingly, a for' of early de'entia, entitled di%integrati$e di%order i% being recogni5ed in adole%cent% ,ith Do,n %yndro'e( The feature% %een are of a &rogre%%i$e lo%% of %/ill%, both cogniti$e and &hy%ical and ha$e ob$iou% rele$ance in denti%try becau%e of the i'&act on &er%onal oral care( 8arying degree% of 'ental retardation occur, and u&&er re%&iratory tract infection% and an inability to ,ith%tand infection% generally are co''on( "hy%ically, &redo'inant feature% are a rounded, %'all face ,ith an under-de$elo&ed 'id-face

;6ig( =?( <, e%&ecially of the na%al bridge, an u&,ard %lant of the eye% ,ith &ro'inent e&icanthic fold%, %Buint%, cataract%, and 4ru%hfield %&ot% on the iri%( The hand% of children ,ith Do,n %yndro'e are %tubby ,ith a &ronounced tran%$er%e &al'ar crea%e( )ntraorally the tongue i% large, &rotruding, and %o'eti'e% hea$ily fi%%ured ;6ig( =?(@<( The &alate 'ay be high $aulted and narro,( There i% u%ually a delay in the exfoliation of &ri'ary teeth and in the eru&tion of &er'anent teeth, ,hile %o'e teeth 'ay be congenitally 'i%%ing( Teeth that eru&t are often 'icrodont andDor hy&o&la%tic ;6ig( =?(A<( There i% a high &re$alence of &eriodontal di%ea%e in the anterior al$eolar %eg'ent%, e%&ecially in the 'andible( Thi% i% &robably due to i'&aired &hagocyte function in neutro&hil% and 'onocyte%, co'bined ,ith &oor oral hygiene( Other factor% i'&licated in the &atho&hy%iology of the exten%i$e infla''ation %een in Do,n %yndro'e &atient% are enhanced "GE &roduction and increa%ed acti$ity of &la%'inogen acti$ator%, and thu% collagena%e acti$ity( >e$ Point# Oral and dental feature% in Do,n %yndro'eG 'id-face hy&o&la%iaH large, fi%%ured tongueH narro,, high-$aulted &alateH delay in exfoliationDeru&tionH congenitally ab%ent teethH 'icrodontDhy&o&la%tic teethH Fra!ile ' #$ndrome -ext to Do,n %yndro'e thi% i% the 'o%t co''on cau%e of 'ental retardation( Thi% di%order i% largely under-diagno%edH and &eo&le ,ho ha$e been cla%%ified a% ha$ing *'ental handica& of un/no,n origin*, e%&ecially if they are 'ale, &robably ha$e 6ragile X %yndro'e( The condition i% of &articular %ignificance becau%e a high &ro&ortion of affected indi$idual% ha$e congenital heart defect%, u%ually 'itral $al$e &rola&%e, that 'ay reBuire antibiotic &ro&hylaxi%( 0lthough 'ale% are &redo'inantly affected, 'ilder $er%ion% of the di%ability 'ay be %een in fe'ale%( Per.a#i.e de.elo mental di#order# Thi% grou& enco'&a%%e% auti%' and childhood %chi5o&hrenia( The for'er i% characteri5ed by it% early on%et, u%ually before @9 'onth% of age, ,herea% childhood %chi5o&hrenia &re%ent% later( They are condition% that re&re%ent &rofound ada&ti$e &roble'% in thin/ing, language, and %ocial relation%hi&%( 0uti%' in &articular ha% the di%tincti$e feature of re%tricted and %tereoty&ical beha$iour &attern%( Mo%t children %core belo, nor'al on )K te%ting and thu% ex&erience %ignificant de$elo&'ental delay( The 'ore %e$erely delayed children %ee' obli$iou% to their &arent% or carer%, ex&re%% the'%el$e% 'ini'ally, %ho, a lo, le$el of intere%t in ex&loring ob+ect%, a$oid %ound%, and engage in rituali%tic beha$iour( Children ,ith 0%&erger*% %yndro'e di%&lay %o'e of the feature% of auti%' but 'ay al%o &o%%e%% a le$el of %/ill in %o'e area% ,ell abo$e the a$erage for their &eer%( The%e feature% need to be ta/en into con%ideration ,hen atte'&ting dental care, and underline% the &articular i'&ortance of accli'ati5ation and fa'iliarity of routine

;ritual%< a% &art of that &roce%%( The cau%e% of auti%' are un/no,n but are thought to be &renatal and not %ocial in origin( Much intere%t ,a% generated in a &o%%ible lin/ ,ith MMR $accine a% a &o%%ible aetiological factor but thi% e$idence ha% %ince been di%credited( 0 'a+or 'alfor'ation in the cerebellu' ha% recently been i'&licated a% a &o%%ible cau%ati$e factor( The &re$alence of auti%' range% fro' 9(9@L to 9(=L ,ith fluctuation% that 'ay &oint to an en$iron'ental cau%e( *earnin! di++i"-ltie# 3earning difficulty i% a%%ociated ,ith dy%lexia, 'ini'al brain da'age, attentiondeficit di%order, and hy&eracti$ity( 0ll the%e categorie% are contro$er%ial, 'ainly becau%e they ha$e been o$erextended( 1i%torically, a child ,ith a learning difficulty ha% been defined a% one ,ho%e &erfor'ance in one acade'ic area i% 'ore than year% behind the child*% ability( Thu% the i'&air'ent i% re%tricted in it% range and there i% a di%cre&ancy bet,een acade'ic &erfor'ance and te%ted general ability( )n the%e t,o ,ay% a learning difficulty differ% fro' 'ental retardation becau%e the latter i% characteri5ed by general delay and acade'ic &erfor'ance i% u%ually at the le$el ex&ected fro' ability( )n &ractice, learning difficulty ha% been u%ed to characteri5e any child ,ith a learning &roble' ,ho cannot be labeled 'entally retarded, no 'atter ho, broad the range of i'&air'ent or the di%cre&ancy fro' the te%ted ability le$el( Thi% o$erexten%ion of the definition ha% not only increa%ed the a&&arent &re$alence of learning di%ability but ha% al%o 'ade the ,hole area rather confu%ing( )n general, the &re$alence of learning difficultie% i% e%ti'ated on a$erage to be about A(:L( There i% o$erla& bet,een learning difficultie% and other &roble'%, for exa'&le, higher le$el% of cla%%roo' beha$ioural &roble'% and an increa%ed ri%/ of delinBuency( )n &art, thi% account% for the greater &redo'inance of 'ale% in grou&% ,ith intellectual i'&air'ent a% they are 'ore li/ely than fe'ale% to be di%ru&ti$e at %chool and thu% be referred for a%%e%%'ent by educational &%ychologi%t%( D$#le9ia Thi% ,idely di%cu%%ed for' of learning di%ability i% a %&ecific &roble' ,ith cognition( The broade%t definition of dy%lexia include% tho%e children ,ho%e reading %/ill% are delayed for any rea%on, and it i% u%ually a%%ociated ,ith a nu'ber of cogniti$e deficit%( "re$alence $arie% fro' @L to =!L de&ending on the breadth of the definition and the country( 6or exa'&le, &re$alence rate% are higher in the #nited State% than they are in )taly, &erha&% due to the co'&lexity of the Engli%h language a% co'&ared ,ith )talianI 7inimal ,rain dama!e Thi% category of i'&air'ent i% u%ed to de%cribe the child ,ho ha% 'inor neurological %ign%, ,hich are often tran%itory( They are not reliable &redictor% of future beha$ioural and educational &roble'%(

Attention di#order and %$ era"ti.it$ The%e di%order% are often confu%ed ,ith one another( Children ,ho cannot %it %till are thought to be inattenti$e to their le%%on% in %chool( 0 child ,ho doe% not &ay attention oftenG fail% to fini%h acti$itie%H act% &re'aturely or redundantlyH infreBuently react% to reBue%t% and Bue%tion%H ha% difficultie% ,ith ta%/% that reBuire fine di%cri'ination, %u%tained $igilance, or co'&lex organi5ationH and i'&ro$e% 'ar/edly ,hen %u&er$i%ed inten%i$ely( 0 child ,ho i% hy&eracti$eG engage% in exce%%i$e %tanding u&, ,al/ing, running, and cli'bingH doe% not re'ain %eated for long during ta%/%H freBuently 'a/e% redundant 'o$e'ent%H %hift% exce%%i$ely fro' one acti$ity to anotherH andDor often %tart% tal/ing, a%/ing, or 'a/ing reBue%t%( Thi% ele$ated acti$ity le$el ex&re%%e% it%elf differently at different age%( )nattenti$e, hy&eracti$e children are di%turbing to their &arent%, other children, and to &rofe%%ional% li/e teacher%, doctor%, and denti%t%( They are often +udged to be beha$iourally di%turbed( The $ariation in definition, age, %ex, %ource of the data, and cultural factor% &roduce% &re$alence e%ti'ate% of u& to @:L( 1o,e$er, 'o%t e%ti'ate% are under >L for boy% and e$en le%% for girl%( Emotional and ,e%a.io-ral di#order# There are 'any 'anife%tation% of e'otional di%orderG fear, anxiety, %hyne%%, aggre%%i$e, de%tructi$e or chronically di%obedient beha$iour, theft, a%%ociating ,ith bad co'&anion%, and truancy( When &arent% or teacher% belie$e that the%e &roble'% interfere ,ith the child*% %ociali5ation, they are often referred for &rofe%%ional hel&( )n con%idering the &re$alence of e'otional or beha$ioural di%order%, account ha% to be ta/en of the $ery co''on, %ee'ingly identical, beha$iour of nor'al children( Eating di%order%, ,hich 'ay be of concern to denti%t% becau%e of %elf in+uriou% beha$iour a% ,ell a% dental ero%ion, are i'&ortant in the &re%chool &eriod and, in different ,ay%, in adole%cence( Fi!. /2.2 3ateral $ie, of a Do,n %yndro'e child, to %ho, 'id-face hy&o&la%ia( Fi!. /2.3 The &rotruberant, fi%%ured tongue of an adole%cent ,ith Do,n %yndro'e( Fi!. /2.0 0 Do,n %yndro'e &atient ,ith 'ar/ed dental hy&o&la%ia, conical teeth, and hy&odontia( /2.2./ 6eneral "on#ideration# A""e## to "are Segregated %&ecial education and in%titution%, e%&ecially in rural area%, ,ere characteri%tic of %er$ice% for di%abled children until after the Second World War( During the =>:9% there ,a% a 'o$e to,ard% normali>ing the li$e% of *handica&&ed* children( Thi% 'o$e'ent %et about 'a/ing 'a+or change% in the li$e% of affected children and adult% but cannot yet be con%idered a% co'&letely %ucce%%ful( The 'o$e to nor'ali5ation ca'e about largely for ideological, legal, and &robably in %o'e countrie% for financial rea%on%( The &hilo%o&hy of thi% 'o$e'ent, ,hich originated in S,eden, centered on the idea

that an i'&aired &er%on %hould li$e in an en$iron'ent a% near nor'al a% &o%%ible( Thi% in$ol$ed re%iding in ho'e-li/e re%idence% and attending %chool%, ,or/ &lace%, and recreational &rogra''e% that ,ere &art of the co''unity( On the ba%i% of thi% ideology, 'any 'ildly i'&aired &eo&le ,ere 'o$ed out of long-%tay in%titution% into co''unity ho'e%( Thi% 'o$e'ent ,a% fo%tered by the belief that in%titutionali5ation retarded e'otional and cogniti$e gro,th( De-in%titutionali5ation ,ould al%o reduce the %tate*% ex&en%e in 'aintaining i'&aired &eo&le, and the onu% ,ould be %hifted to &arent%, &ri$ate charitie%, and local authoritie%( Conte'&orary conce&t% ,ithin thi% 'o$e'ent are e'bodied in %ocial role $alori5ationthat i%, the conce&t of %ocial de$aluation of ,hich %ocial exclu%ion, for ,hate$er rea%on, i% +u%t one a%&ect( While 'o%t &eo&le ,ould agree ,ith the &rinci&le of nor'ali5ation, inadeBuate funding ha% &roduced a le%% than %ati%factory alternati$e in co''unity care and di%a%trou% con%eBuence% for %o'e 'entally ill &eo&le and tho%e ,ith ,ho' they interact( While 'any children and adult% ,ith i'&air'ent% ,ere re%ident in long-%tay in%titution% the &ro$i%ion of dental %er$ice% ,a% relati$ely efficient( With the 'o$e to nor'ali5ation, children ,ere often returned to &arent%Dguardian% or hou%ed by %ocial %er$ice% in ho'e% in the local co''unity, thereby &lacing an additional burden on the%e fa'ilie% or carer% to organi5e dental care( 0long%ide thi% &rogra''e ha% been the 'o$e to integrate a% 'any children a% &o%%ible into 'ain%trea' education( Thi% 'ay 'ean that the%e children are not a% readily identifiable a% ,a% the ca%e ,hen they attended *%&ecial %chool%* and thu% 'ay 'i%% out on the o&&ortunity to recei$e the &rioriti5ed dental care they need( 6or teenager%, it ha% beco'e a&&arent that %o'e 'anager% of the adult training centre% that they attend feel that, a% &art of nor'ali5ation, their client% %hould recei$e *nor'al* dental care, that i%, fro' a general dental &ractitioner( Thi% ,ould be de%irable, &ro$ided general dental &ractitioner% ,ere ha&&y to &ro$ide thi% %er$ice( The e$idence to date i% that thi% i% not generally the ca%e( )n the 'eanti'e, teenager% and young adult% could lo%e out by not continuing to recei$e the %&ecial dental %er$ice% that the &ublically funded %er$ice ha% been able to offer, %i'&ly becau%e it i% felt by their ad$ocate% that thi% run% contrary to the &hilo%o&hy of *nor'ali5ation*( Con#ent +or dental "are 0 treat'ent &lan for a child ;le%% than =! year% of age in 'o%t +uri%diction%< reBuire% the con%ent of a &arent before e'bar/ing u&on acti$e treat'ent( Thi% i% often by i'&lied con%entH that i%, the &arent bring% the child to the %urgery and the child %it% in the chair, the i'&lication being that the &arent ha% con%ented to treat'ent( Thi% i% no different to the %cenario ,ith an i'&aired child( The #nited -ation% Con$ention on the Child reBuire% that children*% right% are &rotected and in thi% context, cogni5ance ta/en of the child*% $ie,% on ,hether they ,i%h treat'ent to be carried out( 0% ,ith any &atient, be%t intere%t% 'u%t be &rotected( Difficulty ari%e% in adole%cent% ,ith an intellectual i'&air'ent ,ho are o$er the age of con%ent( )n thi% %ituation &arent% or carer% are unable to gi$e a $alid con%ent on their charge*% behalf( That i%, an adult cannot con%ent for treat'ent on behalf of another adult( Denti%t% ,ould be ,ell ad$i%ed to obtain a %econd o&inion on their treat'ent &lan before e'bar/ing on dental care for an i'&aired young &er%on ,ho i% +udged to be inca&able of gi$ing their o,n $alid, that i%, infor'ed, con%ent( Thi% i% &articularly the ca%e ,here dental care under general anae%the%ia i% being conte'&lated( )t i% &rudent, al%o, to di%cu%% the

&ro&o%ed treat'ent &lan and to obtain the agree'ent for the care that i% being %ugge%ted fro' tho%e ,ho ha$e an intere%t in the &atient( There ,ill be occa%ion% ,hen it ,ill not be &o%%ible to ea%ily underta/e an exa'ination for a child or adole%cent ,ith a &rofound learning di%ability( )n tho%e circu'%tance%, a deci%ion ha% to be 'ade a% to ,hether %o'e for' of &hy%ical inter$ention, &re$iou%ly ter'ed re%traint, 'ay need to be u%ed( The clinician 'u%t decide, on the ba%i% of a nu'ber of factor%, ,hat i% the be%t ,ay for,ard( 0t all ti'e%, a% &art of the denti%t*% duty of care, %he or he 'u%t act in the &atient*% be%t intere%t in reaching a deci%ion a% to ,hether to u%e %o'e for' of &hy%ical inter$ention( Thi% deci%ion 'u%t be ta/en in the light of a nu'ber of factor%, 'odified after Schu'an and 4ebau and incor&orated into the 4riti%h Society of Di%ability and Oral 1ealth*% "olicy Docu'ent on "hy%ical )nter$ention% ;htt&GDD,,,(b%dh(org< a% follo,%G >e$ Point# "hy%ical inter$ention% Mini'u' to be effecti$e( Clearly docu'ented ty&eDrea%on( Only e'&loyed by trained %taff( 4eneficial for indi$idual to co'&lete treat'ent( -ot %een a% &uni%h'entDfor con$enience( -ot li/ely to cau%e &hy%ical trau'a( -ot li/ely to cau%e 'ore than 'ini'al &%ychological trau'a( 0 'ean% of a$oiding 'ore %e$ere re%traint ;e(g( G0<( To control in$oluntary 'o$e'ent%( To a$oid in+ury to %elf, other%( 0greed ,ith other% clo%e to &atient( /2.2.2 &ral %ealt% Dental "arie# )n the ab%ence of targeted &re$enti$e and treat'ent &rogra''e%, children ,ith i'&air'ent% fare le%% ,ell than their nor'al &eer%( While o$erall di%ea%e ex&erience a% 'ea%ured u%ing the d'fDDM6 index ;decayed, 'i%%ing, filled &ri'aryD&er'anent teeth< i% %i'ilar, for the child ,ith i'&air'ent% there i% often 'ore untreated decay, 'ore 'i%%ing, and fe,er filled teeth( Early %tudie% &oint to a reduced &re$alence of dental carie% in children ,ith Do,n %yndro'e, but thi% feature 'ay be attributable 'ore to the later eru&tion of teeth relati$e to a control grou& of unaffected children %o that the teeth are *at ri%/* in the 'outh for a %horter &eriod( The relati$e 'icrodontiaD%&acing %een in young &eo&le ,ith Do,n %yndro'e 'ay al%o be a contributory factor in thi% %u&&o%ed reduction in dental di%ea%e &re$alence( Periodontal di#ea#e The &eriodontal %tatu% of children ,ho are intellectually i'&aired 'ay be co'&ro'i%ed by their inability to co'&rehend and thu% co'&ly ,ith oral hygiene 'ea%ure%( )n the%e children &eriodontal di%ea%e i% 'ore &re$alent, &o%%ibly a% a re%ult of an altered i''une %tate ;Cha&ter ==(<( 0l'o%t uni$er%ally, &laBue and gingi$iti%

indice% %core% are higher in children ,ith i'&air'ent%( 7alo""l-#ion There are no %tudie% that deal %&ecifically ,ith the &roble'% of 'alocclu%ion in intellectually i'&aired children( 1o,e$er, in &ubli%hed data on general dental health, the nu'ber of orthodontic ano'alie% i% freBuently higher becau%e 'any re'ain untreated( )n Do,n %yndro'e the relati$e 'id-face hy&o&la%ia contribute% to the &%eudo%/eletal cla%% ))) relation%hi& and thi%, in co'bination ,ith the narro,, high$aulted &alate &roduce% buccal cro%%-bite% ;6ig( =?( <( &t%er oral de+e"t# One feature of note i% the &re$alence of ena'el defect% often cau%ed by the aetiological agent that &roduced the i'&air'ent( )t i% &o%%ible that denti%t% could &lay a &art not only in the diagno%i% of %o'e di%abilitie%, for exa'&le, coeliac di%ea%e ;6ig( =?(:<, but al%o in the ti'ing of the in%ult that led to the i'&air'ent( Teeth &ro$ide a good chronological record of the ti'ing of %e$ere %y%te'ic u&%et% ;Cha&ter =@<( Fi!. /2.5 Chronological hy&o&la%ia in a child ,ith coeliac di%ea%e( /2.2.3 & erati.e ro"ed-re# Children ,ho are intellectually i'&aired 'ay be able to co-o&erate for dental treat'ent, but their ability to acce&t %&ecific &rocedure% %uch a% the u%e of local anae%thetic and high %&eed in%tru'ent% ,ill de&end on their degree of under%tanding and le$el of 'aturity( )%olation 'ay be difficult due to a large tongue and &oor control of 'o$e'ent, and in the%e %ituation% it 'ay be nece%%ary to co'&ro'i%e on the treat'ent a&&roach( )n fi%%ure %ealing it 'ay be 'ore &racticable to u%e a gla%% iono'er ce'ent, &rotected by occlu%al ad+u%t'ent ,ax or a glo$ed finger during the %etting &ha%e, rather than to %truggle ,ith all the %tage% of a&&lying a con$entional re%in %ealant ;6ig( =?(!<( 1u'an clinical trial% are no, under,ay in both the #nited 2ingdo' and the #nited State% to in$e%tigate the u%e of intraoral fluoride-relea%ing de$ice%( The%e are %'all dia'eter gla%% bead% that are attached by co'&o%ite re%in, to the buccal %urface of a tooth ;Cha&ter !<( The de$ice di%%ol$e% %lo,ly in %ali$a, relea%ing fluoride a% it doe% %o( Tho%e currently on trial ha$e continued to ele$ate %ali$ary fluoride le$el% for u& to year%( Whether the relea%ed fluoride i% eBuitably di%tributed around the 'outh i% not yet /no,n( The &lace'ent, and retention in situ, of the gla%% bead% in %uch children 'ay be a challenge( Dura&hat fluoride $arni%h ;:L %odiu' fluoride M ,!99 &(&('( fluoride, Colgate< i% an al'o%t ideal &re$enti$e agent for children ,ith &oor tolerance of dental &rocedure%( The a'ber-coloured &olyurethane-ba%ed 'aterial i% a&&lied to the tooth %urface%, &referably dry, although the $arni%h i% ,ater tolerant, and the re%ulting adherent fil' %lo,ly relea%e% fluoride ;6ig( =?(?<( The exerci%e %hould be re&eated u& to four ti'e% a year de&ending on carie% ri%/( 0 reduction of carie% in &er'anent teeth of bet,een @9L and ! L ha% been re&orted u%ing Dura&hat TM $arni%h( Recour%e to one or other for'% of con%ciou% %edation 'ay be indicated for a child

,ith i'&air'ent% ,ho find% it difficult to co-o&erate for dental care( 1o,e$er, a degree of co'&liance i% nece%%ary in order to retain the na%al hood for the deli$ery of nitrou% oxideDoxygen for inhalation %edation;6ig( =?(C< a% it i% for the in%ertion of a cannula for intra$enou% %edation( 1o,e$er, )8 %edation i% not u%ually indicated for children although the drug u%ed 'o%t co''only in the #nited 2ingdo', Mida5ola', can be gi$en orally although again, the outco'e 'ay not be &redictable( 6or %o'e &atient% general anae%the%ia ,ill be nece%%ary to &ro$ide adeBuate dental care ;6ig( =?(><( Thi% facility i% not ,idely a$ailable and often 'ean% con%iderable di%ru&tion for the fa'ily becau%e of the di%tance in$ol$ed in tra$elling to %&eciali%t centre%( 0dditionally, the child 'ay be un%ettled by the ,hole &roce%% of being %tar$ed, loo/ed after by %trange &er%onnel, being anae%theti5ed, and then ,a/ing u& ,ith a %ore throat and &erha&% a 'outh full of blood( There i% e$idence that thi% ex&erience i% only in the %hort-ter' 'e'ory a% 'any &arent% co''ent on ho, 'uch better their child i% in ter'% of beha$iour, %lee&ing &attern%, and eating after the i''ediate &o%to&erati$e &eriod( Treat'ent &lanning for dental care under general anae%the%ia ha% to be 'ore radical( The o&&ortunity to reduce a *high* re%toration or to re$ie, a doubtful tooth i% not nece%%arily a$ailable ,ithout recour%e to another general anae%thetic( Radiogra&hy i% an i'&ortant aid in theatre, e%&ecially for the &atient ,ho i% totally unco-o&erati$e in the dental chair( )t i% &articularly i'&ortant for detecting other,i%e hidden &athology and for early ena'el le%ion%( The latter cannot nor'ally be left in the ho&e that they ,ill re'inerali5e by &re$enti$e 'ean%( Si'ilarly, the chance% of re%toration failure can be reduced by the u%e of &ul&oto'y techniBue% and &refor'ed 'etal cro,n%( Mo%t for'% of treat'ent can be carried out under general anae%the%ia &ro$ided there i% %ufficient o&erating ti'e and the &atient*% general condition &er'it% it( Succe%% i% de&endent u&on careful &re-anae%thetic a%%e%%'ent by denti%t and anae%theti%t( 0&&ro&riate &erio&erati$e care in theatre, for exa'&le, %teroid or antibiotic co$er, and the bac/-u& of in-&atient facilitie% ,here 'edically or %ocially indicated, are $ital to a %ucce%%ful outco'e( "atient% ,ith Do,n %yndro'e 'ay ha$e altlanto-axial +oint in%tability and ,ill need extra care in 'o$ing fro' trolley to theatre table a% ,ell a% during the reco$ery &ha%e( >e$ Point# "re-anae%thetic a%%e%%'enti'&ortant feature%G accurate 'edical hi%toryH &re$iou% anae%thetic hi%toryH %ignificant air,ay difficultie%H need for &re'edicationH tran%&ort arrange'ent%H ho'e care( Fi!. /2.1 Gla%% iono'er ce'ent fi%%ure %ealant( Fi!. /2.2 6luoride $arni%h on &ri'ary 'olar% in a child ,ith a 'ixed ly'&hDhae'angio'a and a learning di%ability(

Fi!. /2.3 0 &arent of a boy ,ith crebral &al%y a%%i%ting in the deli$ery of nitrou% oxide %edation for routine %caling( Fi!. /2.4 Dental treat'ent under day-%tay general anae%the%ia for a child ,ith i'&air'ent%( /2.2.0 5ome "are &ral %$!iene There i% little to be gained in e'bar/ing on elaborate treat'ent &lan% including ad$anced re%torati$e ,or/ ,hen it ,ill not be 'aintained by regular oral hygiene 'ea%ure% at ho'e( "arent% or carer% need %&ecific ad$ice and &ractical hel& in the be%t ,ay to care for their child*% 'outh( Great reliance i% thu% &laced on the &arent or carer ,ho 'u%t be acti$ely in$ol$ed in oral hygiene in%truction and gi$en &o%iti$e %ugge%tion% for 'odification% to the %tandard techniBue%( Exa'&le% include ad$ice on the ,ay to &o%ition a child ;a bean bag can be hel&ful<, in order to clean their 'outh 'ore efficiently and le%% trau'atically( 0nother aid i% the u%e of a &ro& %uch a% a toothbru%h handle to gain acce%% to tooth %urface% on the other %ide of the 'outh( Modification of exi%ting, often $ery narro,-handled toothbru%he% or the u%e of %&ecially 'odified bru%h head% can be hel&ful ;6ig( =?(=9<( Carer% 'ay be concerned about being bitten ,hen they atte'&t to clean a child*% 'outh, in %ituation% ,hen toothbru%hing i% a battle( )n the%e circu'%tance%, u%e of an infadent bru%h ;6ig( =?(==<, ,ith bri%tle% incor&orated onto the end of a &la%tic-ty&e 'aterial that fit% o$er the end of a finger, %i'ilar to a finger-%tall, can o$erco'e the%e &roble'% and en%ure adeBuate tooth cleaning( 6or %o'e children, the 'echanical re'o$al of &laBue can be 'ore readily acco'&li%hed u%ing a &o,ered toothbru%h( Once the child ha% beco'e accu%to'ed to the %en%ation, re%ult% can be better than by con$entional toothbru%hing( Che'ical agent% are effecti$e in reducing &laBue in the %hort ter', but not enough i% /no,n about the effect% of their long-ter' u%age( Many children find the ta%te of 9( L chlorhexidine gluconate, either a% a gel or %olution, un&alatable and &arent% or carer% are unha&&y about the extrin%ic bro,n %taining( Many &atient% ,ith i'&air'ent% 'ay be unable to u%e a 'outh,a%h correctly and either %,allo, or %&it out anything di%ta%teful( 0n alternati$e techniBue i% to o&t for chair%ide a&&lication of chlorhexidene a% a $arni%h( Originally intended for treating dentine hy&er%en%iti$ity, a&&lication of the $arni%h ha% been %ho,n to reduce the incidence of both gingi$al %ign% and dental carie%( So'e %chool% for children ,ith %&ecial educational need% &ro$ide toothbru%he% for their &u&il% during their learning of &er%onal hygiene %/ill%( 1o,e$er, %u&er$i%ing %taff 'ay be una,are of the be%t 'ethod of 'outh cleaning, ,hich 'ay be 'ore de&endent on their o,n &erce&tion% of oral health and the &ercei$ed difficulty than any other factor ;6ig( =?(= <( Toothbru%hing can be taught in the %a'e ,ay a% other %/ill%, but it reBuire% ti'e for the indi$idual a% ,ell a% co''it'ent on the &art of the regular carer to en%ure that all area% of the 'outh are being cleaned each ti'e( 1o,e$er, 'any di%abled children are

intolerant not only of toothbru%hing but al%o of tooth&a%te and they 'ay gag ,hen tooth&a%te, ,hich they cannot %,allo, becau%e of &oor reflexe%, i% introduced into the 'outh( Tooth&a%te al%o ob%cure% the $ie, for the carer during toothbru%hing and they cannot al,ay% be %ure that the tooth %urface% are clean( )n the%e circu'%tance%, ,here tooth&a%te i% unacce&table to the child, &arent% or carer% %hould atte'&t to clean around the 'outh ,ith a &iece of gau5e 'oi%tened in a 9( L chlorhexidine gluconate %olution or a toothbru%h di&&ed in fluoride 'outhrin%e ;9(9:L %odiu' fluoride if u%ed on a daily ba%i%<( 0lternati$ely, chlorhexidine in gel for' or fluoride tooth&a%te can be rubbed a% $igorou%ly a% &o%%ible around the tooth %urface% u%ing a finger( Since chlorhexidene i% inacti$ated by the traditional foa'ing agent% in tooth&a%te%, the for'er %hould be u%ed at a different ti'e of the day to the latter( Children ,ho are tube-fed for %o'e or all of their nutrient inta/e %till need oral care( They ,ill freBuently accu'ulate %ignificant Buantitie% of calculu%, ,hich, if detached 'ight be inhaled( Regular 'outh cleaning and the u%e of a *tartar control* tooth&a%te are nece%%ary ;6ig( =?(=@<( Diet More %e$erely i'&aired children 'ay ha$e ,ell-regulated eating ti'e% and a reduced li/elihood of %nac/ing( The food con%u'ed 'ay be %e'i-%olid or e$en liBuidi5ed, but tho%e food% ,hich are ea%ily reduced to thi% for' are often dentally unde%irable( )n the%e circu'%tance% the denti%t %hould offer ad$ice on li'iting the nu'ber of inta/e% of food, &ro$ided it confor'% to the child*% general nutritional and dietary need%( 6or %o'e children e%tabli%hing a nor'al eating routine ,hile *gro,ing u&* beco'e% a battlefield and i'&aired children are no exce&tion to thi%( )t i% often ea%ier for &arent% to *gi$e in* to a child and allo, the' to eat a li'ited $ariety of un%uitable food% freBuently( Thi% ,ill be +u%tified by &arent% %aying they are de%&erate to get the child to eat %o'ething, and %o bi%cuit%, and other %nac/% high in non-'il/ extrin%ic %ugar%, beco'e the nor'( Thi% &attern i% further endor%ed in %o'e children ,ith i'&air'ent% ,here ,eight gain i% &ara'ount and the dental i'&lication% are %econdary, if indeed they are e$en con%idered( Drin/% can al%o be a difficult area, &articularly the u%e of %,eetened bottle% for an extended &eriod in a child*% life( )t i% not unco''on for children of year% of age or older %till to be u%ing a bottle containing 'il/, often for na&%, la%t thing at night before going to bed and e$en during the night( Thi% i% an extre'ely difficult habit to brea/, but the 'o%t %ucce%%ful a&&roach ha% been to ad$i%e the &arent gradually to dilute the content% ,ith ,ater o$er a &eriod of ,ee/%, until e$entually the child i% drin/ing ,ater only( Thi% not only eli'inate% the unde%irable habit but al%o gi$e% the &arent of the child, ,ho i% able to be toilet trained, %o'e &ro%&ect of getting the child dry and out of na&&ie% o$ernight( 6or a nu'ber of children ,ith i'&air'ent%, the u%e of %,eetened 'edication ha% led to an increa%e in dental carie% ;6ig( =?(=A<( )n the &a%t thi% ha% ari%en becau%e of a lac/ of %ugar%-free alternati$e%( 1o,e$er, ,ith the &har'aceutical indu%try*% greater a,arene%% it i% often only due to ignorance a'ong the 'edical &rofe%%ion that %uch out'oded &re%cribing continue%( So'e children ,ill be ta/ing 'edication a% di%&er%ible tablet% or in an effer$e%cent for', %o'e of ,hich, ,ith chronic u%e, 'ay &redi%&o%e to dental ero%ion(

0nother con%ideration i% %&oiling( 6or any &arent the birth of a child ,ho i% i'&aired in %o'e ,ay, i% a %hoc/( Month% of eager antici&ation are follo,ed by di%belief, anger, denial, fru%tration, and guilt( "arent% ha$e to grie$e for the nor'al child they ,ill ne$er ha$e, before co'ing to ter'% ,ith their ne, re%&on%ibilitie%( "arent% continue to feel guiltyH 'aybe their child ha% an i'&air'ent becau%e of %o'ething they ha$e done, or %o'ething they %hould not ha$e done( Either ,ay, they 'ay atte'&t to a%%uage that guilt by %&oiling the child( Thi% 'ay ta/e the for' of ea%y to eat %,eet food%, ,hich are thought to be &lea%urable and are ,elco'ed by the child ,ith a &oor a&&etite, thu% co'&ounding the &roble' of &oor eating( "oor eating habit% re%ulting in oral di%ea%e need to be tac/led together ,ith the &aediatrician and dietician, a% ,ell a% the &arent% or caregi$er%( >e$ Point# General dietary ad$iceG Re%trict %,eet food%Ddrin/% to 'ealti'e%( 3i'it %,eetened food%Ddrin/% to three ti'e% a day( 2ee& food and drin/% clear of bedti'e by about an hour( Re'e'ber that carbonated drin/%, and %o'e 'edicine% are ero%i$e to teeth( 0%/ for %ugar%-free 'edicine%( Fl-oride# Many %&ecial 'il/ for'ula% and food %u&&le'ent%, a% ,ell a% containing non-'il/ extrin%ic %ugar% to boo%t the child*% calorie inta/e, in %o'e ca%e% al%o ha$e Buite %ub%tantial a'ount% of fluoride( )t i% ,i%e therefore to chec/ the diet carefully before ad$ocating the u%e of fluoride %u&&le'ent% for %uch children( Where dental carie% i% &otentially a real &roble' and in the ab%ence of any other for' of %y%te'ic fluoride%, then the daily fluoride %u&&le'ent regi'en of 9( : 'g fro' ! 'onth% of age, follo,ed by an increa%e to 9(: 'g at @ year% of age, and then =(9 'g fro' ! to =! year% of age i% to be ad$ocated( Once the concentration of fluoride in the local ,ater %u&&ly i% /no,n fro' the ,ater co'&any, fluoride %u&&le'ent% can be &re%cribed by the general dental &ractitioner if indicated, either a% dro&% for the younger child or tablet% for the &re%chool child( )t i% li/ely that %o'e children ,ith i'&air'ent% ,ill ne$er co&e ,ith fluoride tablet% and ha$e to re'ain on dro&%( 0% long a% the &arent i% gi$en ,ritten in%truction% to o$errule the &re%cribing %chedule gi$en for younger children on the label of the bottle, there i% no rea%on ,hy older children %hould not be &re%cribed fluoride dro&%( The denti%t %hould al%o ad$i%e on the a&&ro&riate fluoride tooth&a%te to be u%ed in con+unction ,ith fluoride %u&&le'entation or ,ater fluoridation( Each ca%e %hould be con%idered indi$idually ta/ing into account the relati$e ri%/% and benefit% that 'ay occur( "ara'ount i% con%ideration of the ri%/ of de$elo&ing dental carie% $er%u% the &otential for ena'el o&acitie% in the &er'anent dentition( 0% a guideline, if the ri%/ of carie% i% 'ini'al, and if the diet i% rea%onably ,ell controlled and ho'e oral care i% generally good, then it i% %en%ible to %ugge%t the u%e of a &ea-%i5ed a'ount of tooth&a%te containing a&&roxi'ately :99-!99 &(&('( of fluoride for the child under ! year% of age, &ro$ided that tooth&a%te can be u%ed %ucce%%fully( Older children, in the %a'e %ituation %hould u%e a tooth&a%te containing bet,een =999 and =:99 &(&('( of fluoride, a% the ri%/ of ena'el o&acitie% on anterior teeth i% non-exi%tent and thi%

for'ulation ,ill &ro$ide o&ti'al &rotection again%t carie%( )n the child ,here the de$elo&'ent of dental di%ea%e ,ould &o%e a real ha5ard to their general health, and ,here ho'e care in ter'% of oral hygiene and diet i% &oorly controlled, it i% ad$i%able to confer 'axi'u' &rotection by reco''ending the u%e of a tooth&a%te containing =999-=:99 &(&('( of fluoride, e$en during the &re%chool year%( 4ecau%e of the inability of 'any di%abled children to hold %olution% in their 'outh% or to ex&ectorate, fluoride 'outh,a%he% are contraindicatedH ho,e$er, they can be u%ed on a toothbru%h ;di&&ed< ,here tooth&a%te i% not ,ell tolerated, to 'i'ic the a'ount of to&ical fluoride recei$ed fro' tooth&a%te( >e$ Point# 6luoride ad$iceG %u&&le'ent% to gi$e o&ti'al carie% &rotectionH fluoride 'outh,a%h on a toothbru%h in%tead of &a%te in ca%e% of &a%te intoleranceH lo, carie% ri%/G :99-!99 &(&('( of fluoride &a%te ;<! year%<, =999-=:99 &(&('( of fluoride &a%te ;>! year%<H high carie% ri%/G =999-=:99 &(&('( of fluoride &a%te ;&ea-%i5ed a'ount< fro' the ti'e of tooth eru&tion on,ard%( Fi!. /2./0 0 *%u&erbru%h* in u%e in a child ,ith cerebral &al%y( Fi!. /2.// 0n infadent bru%h for u%e ,ith a &atient ,ho i% uncoo&erati$e for oral hygiene 'ea%ure%( Fi!. /2./2 Staff in a %&ecial %chool bru%hing the teeth of a child ,ith an i'&air'ent( Fi!. /2./3 3oo%e calculu% de&o%it% in a child ,ith chro'o%o'e A&-%yndro'e( Fi!. /2./0 The dental effect% of freBuent 'edication in a child ,ith a cleft of the li& and &alate( /2.3 P5YSICA* I7PAIR7ENT CERE;RA* PA*SY /2.3.0 Introd-"tion The co''on &hy%ical i'&air'ent% the denti%t ,ill encounter areG developmental neuro'u%cular di%order%, for exa'&le, cerebral &al%y, %&ina bifida, %colio%i%, and o%teogene%i% i'&erfectaH and degenerative neuro'u%cular di%order%, for exa'&le, 'u%cular dy%tro&hy and +u$enile for'% of arthriti%( )ncluded in thi% general category of &hy%ical i'&air'ent are children ,ith cleft% of the li& andDor &alate ;Cha&ter =A<, ,here there 'ay ,ell be an a%%ociated %yndro'e in u& to =>L of ca%e%( /2.3./ 6eneral "on#ideration# Cerebral &al%y occur% in =- children &er =999 of %chool age, a figure ,hich ha% been relati$ely %table becau%e of the i'&ro$ed Buality of %ur$i$al of &re'ature babie%( Thi% i% a grou& of non-&rogre%%i$e neuro'u%cular di%order% cau%ed by brain da'age, ,hich can be &re-, &eri-, or &o%tnatal in origin, and i% cla%%ified according to the ty&e of 'otor defectG

=( #pasticityi'&aired ability to control $oluntary 'o$e'ent%( There i% the a&&earance of %e$ere 'u%cle %tiffne%% and the &lanned 'o$e'ent of an affected li'b re%ult% in a hy&otonic tendon reflex, e%&ecially ,ith ra&id 'o$e'ent%( S&a%ticity occur% in about :9L of ca%e% of cerebral &al%y( ( "thetosisuncontrolled, %lo, t,i%ting, and ,rithing 'o$e'ent%, ,hich are freBuent and in$oluntary and occur in o$er =!L of ca%e%( @( )igidityre%i%tance to &a%%i$e 'o$e'ent, ,hich 'ay be o$erco'e by %udden action( )t i% unco''on and the 'a+ority of the%e children are intellectually i'&aired( A( "taxiadi%turbance of eBuilibriu' a% ,ell a% difficulty in gra%&ing ob+ect%( )t i% al%o unco''on( :( Hypotoniaall 'u%cle% are flaccid ,ith decrea%ed function( !( (ixeda co'bination of the abo$e( The la%t : year% ha% %een a change in the &ro&ortion of the different %ubty&e%( 6or exa'&le, ,ith the decrea%e in /ernicteru% ;neonatal +aundice<, there ha% been a fall in the athetoid for', but the %&a%tic for', a%%ociated ,ith &re'aturity, ha% increa%ed( 0n affected child 'ay be 'ono&legic ,ith only one li'b affected ;6ig( =?(=:< or ha$e all four li'b% affected ;Buadri&legia<( )n addition, they 'ay be di%abled by other i'&air'ent% %uch a% con$ul%ion%, intellectual i'&air'ent, %en%ory di%order%, e'otional di%order%, %&eech and co''unication defect%, and a &oorly de$elo&ed %,allo,ing and cough reflex( Fi!. /2./5 Mono&legia of the right ar' in a child ,ith cerebral &al%y and a congenital heart defect( /2.3.2 &ral %ealt% The oral and dental feature% that 'ay be %een in children ,ith cerebral &al%y areG ;=< &oor oral hygiene, increa%ed &eriodontal di%ea%e, and drug-induced gingi$al enlarge'entH ; < 'alocclu%ion ;increa%ed &re$alence of %/eletal cla%% )) ,ith anterior o&en-bite<H ;@< a tendency to bruxi%'H ;A< tongue thru%t and 'outh breathingH ;:< an increa%e in carie% &re$alenceH ;!< increa%ed &re$alence of anterior trau'aH ;?< ena'el hy&o&la%iaH ;C< heightened gag reflex and &eri-oral %en%iti$ityH ;>< droolingH ;=9< decrea%ed &arotid flo, rate( 0lthough not confined to children ,ith cerebral &al%y, ga%tric reflux i% relati$ely

co''on ;6ig( =?(=!<( There 'ay be an ob$iou% aetiology, for exa'&le, a hiatu% hernia, but Buite often a cau%e for the ero%ion cannot be identified ;Cha&ter =9<( Fi!. /2./1 "alatal ero%ion on 'axillary inci%or% in a child ,ith cerebral &al%y( /2.3.3 & erati.e ro"ed-re# Children ,ho are %e$erely &hy%ically i'&aired ,ill &robably be brought to the dental %urgery in a ,heelchair or be carried( Care i% reBuired in the handling of %uch &atient% ;%ee Section =?(A(=<( >e$ Point# Oral feature% in cerebral &al%yG gingi$al hy&er&la%iaH increa%ed carie% &re$alenceH 'alocclu%ionH dental trau'aH ena'el hy&o&la%iaH heightened gag reflexH dental ero%ion and abra%ion ;bruxi%'<( 0ltered gag and cough reflexe% 'ay co'&licate the deli$ery of dental care or the &ro$i%ion of &ro%the%e%, a% ,ell a% adding to the &atient*% anxiety( "lentiful rea%%urance, efficient %uction and %/illed a%%i%tance are $ital to %ucce%% in the%e %ituation%( )'&aired $entilation 'ay acco'&any %colio%i% and beco'e% an e$en 'ore i'&ortant con%ideration if &rocedure% in$ol$ing a general anae%thetic are conte'&lated( Children ,ho %&end long &eriod% in one &o%ition 'ay be &redi%&o%ed to &re%%ure %ore%, therefore lengthy &rocedure% in the dental chair ,ithout a brea/ are be%t a$oided( 1y&o&la%tic teeth can be $ery %en%iti$e, &articularly to extre'e cold( "atient% can ex&erience acute di%co'fort during tooth &re&aration or ultra%onic %caling ;e$en ,hen the affected teeth are di%tant fro' the o&erating %ite<, 'erely fro' the cold &roduced by high $olu'e a%&iration( The u%e of a de%en%iti5ing agent li/e Dura&hat fluoride $arni%h or fi%%ure %ealing the %y'&to'atic %urface can be hel&ful if a re%toration i% not indicated( 1y&o&la%tic ena'el doe% not ha$e the %a'e ordered &ri%' %tructure a% nor'al ena'el and, de%&ite acid etching, 'ay not &ro$ide o&ti'u' retention for con$entional re%in%( )n thi% %ituation, gla%% iono'er ce'ent% 'ay be a 'ore %uitable alternati$e( So'e le%% %e$erely di%abled children ,ill ha$e little or no intellectual i'&air'ent but ,ill ha$e a degree of %&a%ticity or rigidity( Thi% 'ay &re$ent the' fro' co-o&erating fully ,ith dental &rocedure%, de%&ite their ,illingne%% to do %o, and they 'ay be hel&ed by nitrou% oxide %edation ;Cha&ter A<( Such %edation 'ay al%o hel& di'ini%h an exaggerated gag reflex( /2.3.0 5ome "are

&ral %$!iene "hy%ical i'&air'ent 'ay hinder oral hygiene &rocedure% and for the child ,ho ha% gingi$al enlarge'ent the &roble' 'ay be co'&ounded( Mo%t children reBuire hel& ,ith bru%hing until they are ? year% or older, but for the child ,ith &hy%ical li'itation% thi% 'ay be a &er'anent co''it'ent on the &art of carer%( 3i'ited or bi5arre 'u%cle 'o$e'ent% &re$ent nor'al 'outh clearing and food i% often left i'&acted in the $ault of the &alate( Thi% i% readily re'o$ed ,ith the end of a toothbru%h handle or a %&oon handle, but carer% need to be a,are of the &otential for thi%, other,i%e food re%idue% 'ay be left in the oral ca$ity for day%( "o,ered toothbru%he% 'ay be hel&ful for a child ,ith li'ited dexterity, not only becau%e of the relati$e efficiency of cleaning but al%o becau%e of the larger %i5e of the handle of 'o%t of the%e bru%he%( When nor'al li'b 'o$e'ent i% i'&aired or ab%ent andDor nor'al %&eech i% i'&o%%ible, the 'outh a%%u'e% an e$en greater i'&ortance a% a 'ean% of holding 'outh%tic/% to gra%& &en% or to o&erate a $ariety of eBui&'ent( )t i% $ital the dentition i% 'aintained to the highe%t %tandard a% the %ucce%%ful u%e of %uch 'outh%tic/% i% reliant on ha$ing a good occlu%al table for balanced contact ;6ig( =?(=?<( Children ,ith cerebral &al%y, e%&ecially ,here there i% acco'&anying intellectual i'&air'ent, ,ill on occa%ion ado&t a habit of %elf-'utilation by che,ing %oft ti%%ue% around the 'outh ;6ig( =?(=C<( Thi% can be triggered by teething, although often no cau%e 'ay be found( )t i% di%tre%%ing for the &arent% a% the child i% ob$iou%ly in &ain fro' the ulcerated area% and 'ay refu%e all food and drin/, but there i% little they can do to brea/ the habit( )t 'ay be hel&ful to di%cu%% the child*% 'edication ,ith their &hy%ician a% the &re%cri&tion of a drug to reduce 'u%cle tonu%, ,hich can be an exacerbating factor in thi% %ituation, could be con%idered( There are a nu'ber of %olution% to the &roble' de&ending on the cau%e and the %e$erity of the condition( )n a child ,ho i% eru&ting &ri'ary teeth it 'ay be &o%%ible to fit an occlu%al %&lint, &ro$ided that %ufficient teeth are a$ailable for retention( 6abrication of the %&lint 'ay nece%%itate a %hort general anae%thetic for i'&re%%ionta/ing( 0lternati$ely, addition of gla%% iono'er ce'ent to the occlu%al %urface% of the &ri'ary 'olar%, to o&en the occlu%ion and &re$ent the teeth contacting the %oft ti%%ue%, 'ay be %ucce%%ful( )f only anterior &ri'ary teeth are &re%ent then co'&o%ition, 'oulded o$er the offending tooth %urface% a% a te'&orary %&lint, 'ay brea/ the habit and allo, healing ;6ig( =?(=> ;a< and ;b<<( )f the &roble' i% 'ore %e$ere and a %&lint i% not fea%ible, it i% %en%ible to extract the &ri'ary teeth in$ol$ed( )n the &er'anent dentition, rounding-off the &ointed or %har& tooth %urface% andDor fitting a %&lint i% u%ually %ucce%%ful( During the acute &ha%e the u%e of a to&ical analge%ic %uch a% 9(=:L ben5yda'ine hydrochloride ;Diffla'< in %&ray for' increa%e% 'outh co'fort &rior to eatingH and 9( L chlorhexidine gluconate %olution ;Cor%odyl< %,abbed around the 'outh or a&&lied a% a gel on a finger &ro'ote% 'ore ra&id healing by /ee&ing the area clean( En%uring that the child ha% &lenty of fluid% i% of &ara'ount i'&ortance a% %'all, debilitated children ra&idly beco'e dehydrated( The other area of concern to &arent% and carer% i% drooling( 6or %o'e di%abled children thi% can be exce%%i$e, although %urgery to di$ert the %ub'andibular flo, 'ore &o%teriorly 'ay alle$iate the &roble'( 1o,e$er, thi% i% not al,ay% %ucce%%ful and carrie% the ri%/ of increa%ing carie% &re$alence a% a re%ult of the greatly

di'ini%hed %ali$ary $olu'e( The u%e of acrylic training &late% that encourage the for'ation of an oral %eal a% ,ell a% &ro'oting a 'ore acti$e %,allo,ing 'echani%' %o that %ali$a doe% not &ool in an o&en 'outh 'ay be hel&ful ;6ig( =?( 9<( Concurrent ,or/ ,ith %&eech and language thera&i%t% ,ill hel& ,ith the nece%%ary thera&y that i% funda'ental to the %ucce%% of %uch treat'ent( 0necdotal ca%e re&ort% %u&&ort the u%e of the%e &late%, but fe, %tudie% ha$e been &ubli%hed that gi$e ob+ecti$e data on their %ucce%%( 1o,e$er, one relati$ely non-inter$entional 'ethod of reducing %ali$a flo, i% the u%e of hyo%cine hydrobro'ide, a drug ,hich bloc/% &ara%y'&athetic tran%'i%%ion to the %ali$ary gland%( )t i% a&&lied a% a &atch behind the ear and changed e$ery three day%( Diet Con%ideration% on dietary a%&ect% ha$e been co$ered in the %ection on intellectual i'&air'ent ;Section =?( (A<( So'e children, becau%e of a failure to thri$e, ,ill be fed through a ga%tro%to'y %ite( )f the child i% exclu%i$ely fed $ia thi% route, they ,ill tend to accu'ulate large de&o%it% of calculu%( The%e need to be re'o$ed fro' %urface% ad+acent to the gingi$al 'argin% in &articular( Thi% can be difficult unle%% there i% good coo&eration fro' the &atientH an i'&aired air,ay 'a/e% the %afe re'o$al of %uch de&o%it% ha5ardou%, ,ith the ri%/ of inhalation of calculu%( The ga%tro%to'y %ite can be u%eful al%o for %edati$e drug%, e%&ecially bitter intra$enou% %edation drug% that 'ight other,i%e not be tolerated orally( 1o,e$er, %uch %edation &rocedure% need to be carried out in %&eciali%t unit%( Fi!. /2./2 0 'odified &en holder for a child ,ith arthrogry&ho%i%( Fi!. /2./3 Self-'utilation in a child ,ith cerebral &al%y( Fi!. /2./4 ;a< and ;b< Trau'atic %elf-'utilation in a boy ,ith cerebral &al%ybefore and after the u%e of a co'&o%ition *%&lint* to &rotect the trau'ati5ed area( Fi!. /2.20 0 &alatal training &late de%igned to i'&ro$e li& and tongue &o%ture( /2.0 P5YSICA* I7PAIR7ENT SPINA ;IFIDA /2.0.0 Introd-"tion S&ina bifida occur% a% a re%ult of non-fu%ion of one or 'ore &o%terior $ertebral arche%, ,ith or ,ithout &rotru%ion of %o'e or all of the content% of the %&inal canal( )t 'ay be acco'&anied by hydroce&halu% in u& to >:L of ca%e%( )t i% e%ti'ated that in :9-!9L of affected children the defect i% inherited and that en$iron'ental agent% 'ay be re%&on%ible for the re'ainder( )n the #nited 2ingdo' the incidence i% (: &er =999 birth% and, unli/e other 'alfor'ation%, i% co''oner in fe'ale%( 0 Buarter of children ,ill al%o ha$e e&ile&%y and about a third ,ill ha$e %o'e degree of intellectual i'&air'ent( /2.0./ 6eneral "on#ideration# Children ,ith %&ina bifida ,ill, unle%% the defect i% %light, %&end 'uch of their ti'e

confined to a ,heelchair ;6ig( =?( =< and be incontinent( #rinary tract infection% are co''on and the child 'ay be on freBuent cour%e% of antibiotic%( 1ydroce&halu%, unle%% arre%ted, i% treated by the in%ertion of a %hunt ;fitted ,ith a S&it5-1olter $al$e< to drain fluid fro' the $entricle% into either the %u&erior $ena ca$a or 'ore u%ually the &eritoneu'( )t i% i'&ortant to &rotect the $enou% %hunt fro' bloc/age, ,hich 'ay ari%e fro' a bacterae'ia of oral origin, other,i%e intracranial &re%%ure ,ill increa%e, cau%ing con$ul%ion%( 0lthough o&inion i% di$ided on the nece%%ity to co$er in$a%i$e dental &rocedure% in children ,ho ha$e a %hunt, tho%e erring on the %ide of caution ,ill u%e the %a'e &ro&hylaxi% regi'en a% in cardiac di%ea%e ;Cha&ter =!<( 1o,e$er, there i% no indication for antibiotic &ro&hylaxi% if the %hunt i% a $entriculo-&eritoneal one( Children ,ho are confined to a ,heelchair for 'uch of the ti'e ,ill need to be treated either in their chair or tran%ferred carefully to the dental chair( There are co''ercially a$ailable chair ada&tation% to acco''odate a &atient in their ,heelchair ;6ig( =?( <( The%e are hel&ful if the child i% too hea$y to tran%fer ea%ily to the dental chair or if the &rocedure i% 'ore ea%ily acco'&li%hed for the o&erator and &atient in thi% &o%ition( Sha&ed body %u&&ort%, ,hich are e%%entially 'odification% of a bean bag, are al%o a$ailable for u%e in the dental chair for any &atient ,ith a &hy%ical di%ability ,ho cannot other,i%e be co'fortably acco''odated( The%e %u&&ort% contain a 'aterial that allo,% the' to 'ould to the body %ha&e of the &atient and be re'oulded for %ub%eBuent &atient% ;6ig( =?( @<( Fi!. /2.2/ 0 girl ,ith %&ina bifida,heelchair-aided( Fi!. /2.22 0 cu%to'i5ed floor in%ert to acco''odate a &atient*% ,heelchair ;courte%y of Dr 0li%tair 4ole%, -ational Rehabilitation 1o%&ital, )reland<( Fi!. /2.23 Dental chair ,ith 'oulded cu%hion %u&&ort% ;courte%y of Dr 4itte 0hlborg, Mun-1-Center, S,eden<( /2.0.2 &ral %ealt% and o erati.e ro"ed-re# There i% little in the dental literature to %ugge%t that the oralDdental health of children ,ith %&ina bifida i% different fro' other children ,ith i'&air'ent%( The %a'e &rinci&le% of treat'ent a&&ly to the%e children a% to other% ,ho are i'&aired, na'ely aggre%%i$e &re$ention and early inter$ention ,ith a radical a&&roach if dental treat'ent under general anae%the%ia i% reBuired( /2.0.3 5ome "are The i%%ue% rele$ant to %&ina bifida ha$e been co$ered in the a&&ro&riate %ection% under intellectual and &hy%ical i'&air'ent( /2.5 P5YSICA* I7PAIR7ENT 7(SC(*AR DYSTR&P5Y /2.5.0 Introd-"tion Mu%cular dy%tro&hy i% a grou& of 'u%cle di%ea%e% ,hich &re%ent a% &rogre%%i$e atro&hy and ,ea/ne%% of %/eletal 'u%cle% ,ith re%ultant di%ability and defor'ity( The 'u%cle fibre% degenerate and are re&laced by fatty and fibrou% ti%%ue( The di%ea%e i%

e$entually fatal a% a re%ult of recurrent re%&iratory infection%( "re$alence rate% in children are of the order of A &er =99,999 children( /2.5./ 6eneral "on#ideration# The child ,ith 'u%cular dy%tro&hy ,ill initially be 'obile but a% the di%ea%e &rogre%%e%, they ,ill beco'e reliant on a ,heelchair to 'o$e around( 0 re%&irator ,ill be nece%%ary in the later %tage% of the di%ea%e and &atient% are then confined to ho'e or to re%idential care( There are a nu'ber of $ariant% of the di%ea%e ,ith different %ign% and %y'&to'%( Male% are exclu%i$ely affected in the Duchenne-ty&e, ,hile facial 'u%culature i% al,ay% affected in the fa%cio%ca&ulohu'eral-ty&e, but rarely in other for'%( /2.5.2 &ral %ealt% The oralDdental effect% of the di%ea%e are nu'erou% and includeG ,ea/ne%% of the facial 'u%cle%H &oor oral hygiene %econdary to the general inability to &ro$ide oral %elf-careH increa%ed dental decayH increa%ed &otential for &eriodontal di%ea%eH 'alocclu%ion %econdary to decrea%ed facial 'u%cle tone ,hile retaining tongue functionH decrea%ed &rotecti$e reflexe% and reduced ability to %,allo, or clear %ecretion% fro' the oro&harynx, thu% increa%ing the &otential for a%&iration( /2.5.3 & erati.e ro"ed-re# Con%ideration need% to be gi$en to ,heelchair tran%fer techniBue% and &adding a% ,ell a% the length of a&&oint'ent% ;%ee abo$e<( The u%e of %edation and general anae%the%ia 'ay need to be a$oided due to the decrea%e in re%&iratory function and the ri%/ of &o%t-anae%thetic co'&lication%( 6reBuent recall i% i'&ortant, ,ith a&&lication% of to&ical fluoride% and anti&laBue agent% ;9( L chlorhexidine gluconate<( There are no contraindication% to dental treat'ent, ,ith the exce&tion of orthodontic% becau%e of the changing 'u%cle force%( 0% a con%eBuence of tooth 'o$e'ent %een a% &art of the di%ea%e, and the li/ely de$elo&'ent of anterior or &o%terior o&en-bite%, &ro%thetic a&&liance% 'ay beco'e non-functional( /2.5.0 5ome "are 0&&ro&riate %u&&ort and training need% to be gi$en to the &arent or carer %o that in the later %tage% of the di%ea%e, ,hen contact ,ith dental %er$ice% 'ay be difficult, adeBuate &laBue control can be 'aintained( Dental treat'ent 'ay need to be &ro$ided ,ithin the ho'e en$iron'ent, although thi% ,ill u%ually be at the %tage ,hen the &atient ha% reached adulthood( )t i% i'&ortant that e$ery effort i% 'ade to o&ti'i5e oral function and facial a&&earance and thereby encourage a &o%iti$e %elf-i'age( /2.1 &T5ER 7(SC(*&S>E*ETA* I7PAIR7ENTS

There are a $ariety of other defect%, %o'e degenerati$e and %o'e de$elo&'ental, ,hich al%o affect childrenH ho,e$er, the%e are relati$ely rare and unli/ely to be encountered regularly in &racticefor exa'&le, o%teogene%i% i'&erfecta, +u$enile arthriti%, and 'ulti&le %clero%i%( When &atient% &re%ent ,ith %uch di%abilitie% there 'ay be %ignificant oral %ign%, for exa'&le, in rheu'atoid arthriti% there i% an increa%ed incidence of S+ogren*% %yndro'e ;autoi''une< and anae'ia ;%econdary to anti-infla''atory and %teroid 'edication<( 0ggre%%i$e &re$ention i% $ital to &re$ent dental di%ea%e( /2.2 ;*INDNESS AND )IS(A* I7PAIR7ENT /2.2.0 Introd-"tion 8i%ual i'&air'ent% $ary fro' total blindne%% to %ight li'itation% of %i5e, colour, di%tance, and %ha&e( The &re$alence i% in the order of @ &er =999 children( /2.2./ &ral %ealt% The oral and dental health of children ,ith a $i%ual i'&air'ent i% no different fro' the nor'al &o&ulation and ,ith good ho'e care thi% can be 'aintained( )n the #nited 2ingdo' 'any children are educated in boarding %chool% and their %u&er$i%ion, ,ith regard to &er%onal hygiene and diet ;re%traint fro' bet,een-'eal %nac/ing<, often 'ean% that their oral health i% good( /2.2.2 & erati.e ro"ed-re# Con%ideration %hould be gi$en to the de%ign and for'at of ,ritten 'aterial a$ailable for u%e by &atient% ,ho 'ay be $i%ually i'&aired, for exa'&le, in%truction% for the ,earing of orthodontic a&&liance% and diet hi%tory %heet%( 1ighly %tyli5ed ty&e %hould be a$oided and a 'ix of u&&er and lo,er ca%e %hould be u%ed( 3etter% %hould be at lea%t one-eighth of an inch high ;about @ ''H =A &oint< and be on uncoated ;nonglare< &a&er( The be%t contra%t for ea%e of reading i% blac/ ty&e on ,hite or off-,hite &a&er( )t i% i'&ortant to a%%i%t the $i%ually i'&aired &er%on according to their indi$idual need%( "atient% ,ith a %ight defect ob+ect to being forcefully guided around by a nur%e or denti%t ,ho i% enthu%ia%tic to hel&( Many %ight-i'&aired &atient% ,ill ha$e an increa%ed %en%iti$ity to bright light% and &erha&% touch( The o&erating light %hould therefore be u%ed ,ith caution and the latter %hould be utili5ed to enhance the &atient%* &erce&tion of ,hat i% being doneH for exa'&le, being allo,ed to feel the in%tru'ent% and the dental chair( )t i% not unu%ual for &eo&le to %hout at tho%e ,ith a $i%ual i'&air'ent( Sight-i'&aired children are not u%ually deaf a% ,ell and %hould therefore be addre%%ed in a nor'al $oice( )t i% i'&ortant to the &atient, and not only tho%e ,ith $i%ual i'&air'ent%, that con$er%ation i% addre%%ed to the' and not to the &er%on ,ith the'the %o-called *Doe% he ta/e %ugarJ* a&&roach( 4ecau%e $i%ion i% i'&aired and the %en%e of touch 'ay be heightened, it can be %tartling %uddenly to feel a cold 'irror in your 'outh ,ithout ,arning( 0 *tell-feel-then-do* a&&roach i% i'&ortant for the%e children ,ho 'ay be unner$ed by contact ,ithout fore,arning( With the%e con%ideration% in 'ind,

there are no area% of dental treat'ent that are un%uitable for the child ,ith a $i%ual i'&air'ent, &ro$ided that they, or their &arent or carer, can 'aintain an adeBuate %tandard of oral hygiene( )n%ertion of orthodontic a&&liance% 'ay initially be difficult and techniBue% li/e flo%%ing ta/e ti'e to 'a%ter( /2.3 DEAFNESS AND 5EARIN6 I7PAIR7ENT /2.3.0 Introd-"tion 3o%% of hearing i% an i'&air'ent acBuired by 'any ,ith increa%ing age( 1o,e$er, %o'e children are born ,ith either a &artial or total lo%% of hearing and thi% can occur in i%olation or in co'bination ,ith other i'&air'ent%, for exa'&le, rubella %yndro'e ;auditory, $i%ual, intellectual, and cardiac defect%<( The &re$alence i% @ &er =999 children( /2.3./ 6eneral "on#ideration# "atient% ,ho ha$e hearing i'&air'ent 'ay be fearful, or e$en ho%tile, becau%e they feel they are not going to under%tand ,hat i% being a%/ed of the'( The child 'ay not hear ,hat ha% been %aid but &retend% they ha$e done %o to a$oid e'barra%%'ent( )n thi% %ituation $i%ual aid% a%%u'e an e$en greater i'&ortance( )t i% i'&ortant for o&ti'i5ing hearing that all extraneou% bac/ground noi%e i% re'o$ed ,hen co''unicating ,ith the hearing-i'&aired child( "i&ed 'u%ic in the %urgery, noi%e fro' the rece&tion area, a% ,ell a% internal noi%e% fro' a%&irator% and %ca$enging %y%te'% %hould be reduced or eli'inated( Many deaf or hearing-i'&aired children ,ill ,ear aid% ;6ig( =?( A< to enable the' to &ic/ u& 'ore %ound%, and older children 'ay ha$e beco'e %/illed not only in li&reading but al%o in %igning( 1o,e$er, there i% no, a trend to,ard% di%couraging the u%e of %igning and to &o%iti$ely encourage a child to acBuire %o'e %&eech, utili5ing any re%idual $ocal &otential( Fi!. /2.20 0 child ,ith Willia'*% %yndro'e ,earing hearing aid%( /2.3.2 &ral %ealt% There i% a &aucity of data concerning the oral health of children ,ith hearing i'&air'ent( 0% ,ith $i%ually i'&aired children, re%idence a,ay fro' ho'e in %&ecial boarding %chool% %o'eti'e% 'ean% that eating &attern% are 'ore de%irable dentally, ,ith le%% o&&ortunity for bet,een-'eal %nac/ing co'&ared to day &u&il%( Su&er$i%ion of oral hygiene 'ea%ure% can al%o be better in children li$ing in in%titution% and i% reflected in their oral hygiene %core%, but thi% i% $ery $ariable( 3i/e 'any other i'&aired children, hearing-i'&aired &atient% are initially ,ary of &o,ered toothbru%he% becau%e of the %en%ation they &roduce intraorally( 4ut, although the%e bru%he% ha$e not been %ho,n to be better in ter'% of &laBue re'o$al than a ,ell'ani&ulated 'anual bru%h, in children &articularly, the no$elty a%&ect 'ay be a 'oti$ating factor to u%e thi% ty&e of bru%h to greater benefit( /2.3.3 & erati.e ro"ed-re#

6or tho%e children ,ho can li&-read it i% nece%%ary to %it ,ell in front of the child, ,ith good lighting to the o&erator*% face( 4oth denti%t and a%%i%tant %hould 'o$e their li&% clearly during %&eech and a$oid the te'&tation to %hout( Ma%/% are therefore to be &ut to one %ide and bearded o&erator% %hould en%ure that facial hair doe% not ob%cure clear $i%uali5ation of li& 'o$e'entI 0 co''ent a% to the be%t hearing %ide %hould be in%erted in the &atient*% note% %o that %taff are a,are of thi% at each $i%it( Children ,earing hearing de$ice% 'ay be di%turbed by the high-&itched noi%e &roduced by hand&iece% and ultra%onic %caler%( Thi% 'ay 'a/e the' le%% co-o&erati$e and le%% a'enable to treat'ent( Si'ilarly, the conduction of $ibration% fro' the hand&iece and bur% $ia bone i% 'ore di%turbing for the hearing-i'&aired child( 0fter initial co''unication% are co'&lete it 'ay be ad$i%able to %ugge%t that the hearing de$ice i% re'o$ed or turned off and only re-in%erted on co'&letion of the dental treat'ent in ti'e for final in%truction%( 8ery young children often ha$e difficulty /ee&ing the aid% in &lace %i'&ly becau%e of the %i5e of the i''ature &innae( Thi% i% e%&ecially %o ,hen lying %u&ine in the dental chair( /2.4 S(77ARY =( Children ,ith i'&air'ent% &re%ent the dental tea' ,ith the challenge of ada&ting fa'iliar %/ill% to ne, %ituation%( ( To 'eet thi% challenge effecti$ely ,e need to re-exa'ine %o'e of the %tereoty&e% of i'&air'ent ,e carry in our o,n 'ind%( @( 0n i'&air'ent beco'e% a di%ability by $irtue of other &eo&le*% attitude%, the thing% ,e do or do not do, the facilitie% ,e do not offer, a% ,ell a% the &hy%ical barrier% the en$iron'ent inter&o%e%( A( Oral and dental health are little different bet,een children ,ith i'&air'ent% and other%( What i% different i% the ty&e of treat'ent &ro$ided, ,ith 'ore 'i%%ing teeth and fe,er filled teeth in &o&ulation% ,ith i'&air'ent%( :( So'e children ha$e %&ecific oral condition% a% a re%ult of their i'&air'ent, for exa'&le, &eriodontal di%ea%e in Do,n %yndro'e( !( 0 degree of co''on-%en%e, a ,illingne%% to be flexible, a% ,ell a% a ,or/ing fa'iliarity ,ith the co''oner 'edical condition% and their i'&lication% for oral and dental health, are 'o%t of ,hat a general dental &ractitioner reBuire% to &ro$ide dental care for the child ,ith i'&air'ent% in hi% or her co''unity( /2./0 F(RT5ER READIN6 -unn, 7( 1( ; 999<( Disa,ility and oral care( 6D) World Dental "re%% 3td(, 3ondon( ;" comprehensive coverage of aspects of oral and dental care for people with disa,ilities(< -unn, 7( 1( ; 99@<( "re$enting childhood i'&air'ent( )n -he prevention of oral disease ;Ath edn<( ;ed%( 7( 7( Murray, 7( 1( -unn, and 7( G( Steele<, &&( 99-=!( Oxford

Medical "ublication%, Oxford( ;" more comprehensive review of preventive aspects of oralCdental care(< Shu'an, S( 2(, 4ebeau, M( 7( ;=>>A<( Ethical i%%ue% in nur%ing ho'e careG &ractice guideline% for difficult %ituation%( S&ec Care Dent, /1, =?9-?( ;Covers criteria for the safe use of physical intervention(< Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy

/2. C%ild%ood im airment and di#a,ilit$ - + H 6unn /2./ INTR&D(CTI&N 0n i'&air'ent beco'e% a di%ability for a child only if he or %he i% unable to carry out the nor'al acti$itie% of hi% or her &eer grou&( 6or exa'&le, a child ,ho ha% bro/en an ar' i% te'&orarily *di%abled* by not being able to eat and ,rite in the nor'al ,ay( 1o,e$er, for %o'e children i'&air'ent i% a &er'anent feature in their li$e%, although it 'ay beco'e a di%ability only if they are unable to ta/e &art in e$eryday acti$itie%, %uch a% co''unicating ,ith other%, cli'bing %tair%, and toothbru%hing( One definition that hel&% to clarify ,hich children are *di%abled*, for the &ur&o%e% of &ro$iding dental care, i% a% follo,%G *dentally di%abled* refer% to &atient% ,ho ha$e %o'e gro%% condition or deficit in their oral ca$itie%, ,hich nece%%itate% %&ecial dental treat'ent for exa'&le, a cleft of the li& and &alate( 4y contra%t, children ,ho are *di%abled for denti%try* are tho%e ,ho ha$e a &hy%ical andDor intellectual or e'otional condition that 'ay &re$ent the' fro' being treated in a routine 'anner( There are a nu'ber of rea%on% ,hy children ,ith di%abilitie% 'erit %&ecial con%ideration for dental careG =( The oral health of %o'e children ,ith di%abilitie% i% different fro' that of their nor'al &eer%, for exa'&le, the greater &re$alence of &eriodontal di%ea%e in &eo&le ,ith Do,n %yndro'e and of tooth,ear in tho%e ,ith cerebral &al%y( ( The &re$ention of dental di%ea%e in di%abled children need% to be a higher &riority than for %o-called nor'al &eer% becau%e dental di%ea%e, it% %eBuelae, or it% treat'ent, 'ay be life-threatening, for exa'&le, the ri%/ of infecti$e endocarditi% fro' oral organi%'% in children ,ith congenital heart defect% ;6ig( =?(=<( @( Treat'ent &lanning and the &ro$i%ion of dental care 'ay need to be 'odified in $ie, of the &atient*% ca&abilitie%, li/ely future co-o&eration, and ho'e care, for exa'&le, the fea%ibility of &ro$iding a re%in-bonded bridge for a teenager ,ith cerebral &al%y, &oorly controlled e&ile&%y, and inadeBuate ho'e oral care( )n the light of the%e con%ideration%, do %uch children need %&ecial dental careJ Mo%t of the %tudie% ,hich ha$e been underta/en on di%abled children ha$e indicated that the 'a+ority can in fact be treated in a dental %urgery in the nor'al ,ay, together ,ith the re%t of their fa'ily( >e$ Point# The need for %&ecial dental care ari%e% becau%e ofG difference% in dental di%ea%e &re$alenceH dental di%ea%eDtreat'ent 'ay be life-threateningH the 'odification% reBuired to treat'ent &lan%H the need for %&ecial facilitie%H treat'ent 'ay be ti'e-con%u'ing(

Thi% nor'ality i% de%irable, &ro$ided the di%abled &er%on actually recei$e% good dental care( The e$idence fro' 'any %tudie% i% that, although the o$erall carie% ex&erience i% %i'ilar bet,een di%abled children and their %o-called nor'al conte'&orarie%, the ty&e of treat'ent they ha$e ex&erienced i% differentG di%abled children ha$e %i'ilar le$el% of untreated decay, but 'ore 'i%%ing teeth and fe,er re%tored teeth( 0 'inority of children ,ith co'&lex di%abilitie% need %&ecial facilitie%, u%ually only a$ailable in dental or general ho%&ital%, or fro' %&eciali5ed co''unity dental clinic%( What is needed by all &atient% ,ith di%abilitie% i% a $ery aggre%%i$e a&&roach to the &re$ention of dental di%ea%e( 4ecau%e of the &otential for dental di%ea%e, or it% treat'ent, to di%able an i'&aired child, &riority 'u%t be gi$en to &re$enti$e dental care for %uch indi$idual% fro' a $ery young age( Children ,ith a %ignificant degree of i'&air'ent are ter'ed *children ,ith %&ecial educational need%* or *children ,ith learning difficultie%*( The%e ter'%, u%ed %ynony'ou%ly, enco'&a%% a ,ide $ariety of i'&air'ent%, but three 'ain area% intellectual, &hy%ical, and %en%ory i'&air'ent%&redo'inate and ,ill no, be con%idered in 'ore detail( )t i% i'&ortant to %tre%%, ho,e$er, that i'&air'ent doe% not al,ay% &re%ent a% a di%crete entityH in any &o&ulation of affected children, at lea%t a Buarter of the grou& ,ill be 'ulti&ly i'&aired, 'a/ing it difficult to a%%ign a *label* to that child*% i'&air'ent( Medical co'&ro'i%e, con%idered in 'ore detail in Cha&ter =!, 'ay al%o be i'&o%ed on the%e i'&air'ent%( The ,ay in ,hich %o'e of the%e &re%ent to a denti%t are gi$en belo,, together ,ith the dental 'anage'ent i%%ue% rele$ant to each( Many of the i%%ue% rai%ed are, of cour%e, co''on to a nu'ber of i'&air'ent%( Fi!. /2./ 0 =@-year-old boy ,ith Do,n %yndro'e and gro%% carie%, ,ho ,a% &re$ented fro' going on a co'bined heart and lung a% ,ell a% a renal tran%&lant regi%ter becau%e of hi% dental di%ea%e( /2.2 INTE**ECT(A* I7PAIR7ENT /2.2.0 Introd-"tion The cau%e% of intellectual i'&air'ent are nu'erou% and for 'any children a cau%e for their di%ability 'ay ne$er be identified( 0&&roxi'ately, : &er =999 of the child &o&ulation are affected, and the 'a+ority, a% ,ith other i'&air'ent%, ,ill be 'ale%( Children ,ith intellectual i'&air'ent can be di$ided broadly into tho%e ,ho are either 'entally retarded or ha$e a learning difficulty( The%e are broad grou&%, often ,ithout a ,ell-defined aetiology or con%i%tent &re%enting feature%, but there are t,o di%tinct %ubgrou&% ,here the cau%e i% /no,n and the feature% are ,ell de%cribed, na'ely Do,n and 6ragile X %yndro'e%( )ntellectual i'&air'ent 'ay be &re%ent in %o'e children ,ith cerebral &al%y and tho%e ,ho ha$e %uffered birth anoxia, and %e$ere infection%, for exa'&le, 'eningiti% and rubella( )ntellectual i'&air'ent i% al%o a feature of auti%', 'icroce&haly, and 'etabolic di%order% ;e(g( &henyl-/etonuria<, and 'ay al%o be acBuired after %ignificant trau'a( -ot e$ery condition ,ill ha$e %&ecific dental feature% li/e Do,n %yndro'e, but an under%tanding of the underlying i'&air'ent ,ill hel& the denti%t &lan treat'ent 'ore effecti$ely( Mental retardation, &er$a%i$e de$elo&'ental di%order% ;auti%' and %chi5o&hrenia<, learning di%abilitie%, dy%lexia, attention-deficit di%order%, and hy&eracti$ity are all

contro$er%ial categorie% ,ho%e definition and &roce%%e% of a%%e%%'ent are not uni$er%ally agreed( >e$ Point# Cla%%ification of children ,ith i'&air'ent% intellectually i'&aired'entally retarded, learning difficultie%H &hy%ically i'&airedde$elo&'ental, degenerati$eH %en%ory i'&air'entH 'edically co'&ro'i%edH co'bination of i'&air'ent%( 7ental retardation Thi% i% %o'eti'e% called 'ental handica&, 'ental %ubnor'ality, or 'ental deficiency( )t i% a general category characteri5ed by lo, intelligence, failure of ada&tation, and early age of on%et( 3o, general intelligence i% the 'ain characteri%tic( 0ffected children are %lo, in their general 'ental de$elo&'ent and they 'ay ha$e difficultie% in attention, &erce&tion, 'e'ory, and thin/ing( They 'ay be %tronger in %o'e %/ill% than other%, for exa'&le, 'u%ic and co'&uting, but generally they are of lo, intellectual attain'ent( Children ,ith lo, intelligence are not called 'entally retarded unle%% they al%o ha$e %o'e &roble' in ada&tation( That i%, they are unli/ely to be able to li$e inde&endently and ,ill al,ay% de&end ina&&ro&riately on other% a% a %ource of inco'e and %u&&ort for daily li$ing( 0ccording to )K le$el%, fi$e le$el% are traditionally de%cribed( The %i'&licity of the cla%%ification i% %o'e,hat illu%ory ,ith great indi$idual difference% a'ong &eo&le ,ith 'ental retardation( >e$ Point# )ntellectual i'&air'ent 'ay occur inG cerebral &al%yH birth anoxiaH %e$ere infection%H auti%'H 'icroce&halyH 'etabolic di%order%H 'a+or trau'aH %o'e %yndro'e%( DoCn #$ndrome Do,n %yndro'e i% a chro'o%o'al di%order, tri%o'y =, ,ith di%tinct clinical feature%( The &re$alence i% a&&roxi'ately = in !99 birth% but there i% $ariation ,ith 'aternal age, %o that at A9 year% of age the incidence i% about = in A9 birth%( 1o,e$er, the nu'ber% %een in any one country ,ill $ary de&ending on the &re$ailing attitude to,ard% &renatal %creening and ter'ination( The general &hy%ical feature% a%%ociated ,ith Do,n %yndro'e are a greater &redi%&o%ition to cardiac defect%, leu/ae'ia of the 'yeloid ty&e, infecti$e he&atiti% infection ;e%&ecially in in%titutionali5ed 'ale%<, although 'o%t children ,ill ha$e been $accinated again%t $iral for'%( Coeliac di%ea%e a% ,ell a% thyroid di%order% are al%o clinical feature% of thi% condition( )ncrea%ingly, a

for' of early de'entia, entitled di%integrati$e di%order i% being recogni5ed in adole%cent% ,ith Do,n %yndro'e( The feature% %een are of a &rogre%%i$e lo%% of %/ill%, both cogniti$e and &hy%ical and ha$e ob$iou% rele$ance in denti%try becau%e of the i'&act on &er%onal oral care( 8arying degree% of 'ental retardation occur, and u&&er re%&iratory tract infection% and an inability to ,ith%tand infection% generally are co''on( "hy%ically, &redo'inant feature% are a rounded, %'all face ,ith an under-de$elo&ed 'id-face ;6ig( =?( <, e%&ecially of the na%al bridge, an u&,ard %lant of the eye% ,ith &ro'inent e&icanthic fold%, %Buint%, cataract%, and 4ru%hfield %&ot% on the iri%( The hand% of children ,ith Do,n %yndro'e are %tubby ,ith a &ronounced tran%$er%e &al'ar crea%e( )ntraorally the tongue i% large, &rotruding, and %o'eti'e% hea$ily fi%%ured ;6ig( =?(@<( The &alate 'ay be high $aulted and narro,( There i% u%ually a delay in the exfoliation of &ri'ary teeth and in the eru&tion of &er'anent teeth, ,hile %o'e teeth 'ay be congenitally 'i%%ing( Teeth that eru&t are often 'icrodont andDor hy&o&la%tic ;6ig( =?(A<( There i% a high &re$alence of &eriodontal di%ea%e in the anterior al$eolar %eg'ent%, e%&ecially in the 'andible( Thi% i% &robably due to i'&aired &hagocyte function in neutro&hil% and 'onocyte%, co'bined ,ith &oor oral hygiene( Other factor% i'&licated in the &atho&hy%iology of the exten%i$e infla''ation %een in Do,n %yndro'e &atient% are enhanced "GE &roduction and increa%ed acti$ity of &la%'inogen acti$ator%, and thu% collagena%e acti$ity( >e$ Point# Oral and dental feature% in Do,n %yndro'eG 'id-face hy&o&la%iaH large, fi%%ured tongueH narro,, high-$aulted &alateH delay in exfoliationDeru&tionH congenitally ab%ent teethH 'icrodontDhy&o&la%tic teethH Fra!ile ' #$ndrome -ext to Do,n %yndro'e thi% i% the 'o%t co''on cau%e of 'ental retardation( Thi% di%order i% largely under-diagno%edH and &eo&le ,ho ha$e been cla%%ified a% ha$ing *'ental handica& of un/no,n origin*, e%&ecially if they are 'ale, &robably ha$e 6ragile X %yndro'e( The condition i% of &articular %ignificance becau%e a high &ro&ortion of affected indi$idual% ha$e congenital heart defect%, u%ually 'itral $al$e &rola&%e, that 'ay reBuire antibiotic &ro&hylaxi%( 0lthough 'ale% are &redo'inantly affected, 'ilder $er%ion% of the di%ability 'ay be %een in fe'ale%( Per.a#i.e de.elo mental di#order# Thi% grou& enco'&a%%e% auti%' and childhood %chi5o&hrenia( The for'er i% characteri5ed by it% early on%et, u%ually before @9 'onth% of age, ,herea% childhood %chi5o&hrenia &re%ent% later( They are condition% that re&re%ent &rofound ada&ti$e &roble'% in thin/ing, language, and %ocial relation%hi&%( 0uti%' in &articular ha% the di%tincti$e feature of re%tricted and %tereoty&ical beha$iour &attern%( Mo%t children %core belo, nor'al on )K te%ting and thu% ex&erience %ignificant de$elo&'ental

delay( The 'ore %e$erely delayed children %ee' obli$iou% to their &arent% or carer%, ex&re%% the'%el$e% 'ini'ally, %ho, a lo, le$el of intere%t in ex&loring ob+ect%, a$oid %ound%, and engage in rituali%tic beha$iour( Children ,ith 0%&erger*% %yndro'e di%&lay %o'e of the feature% of auti%' but 'ay al%o &o%%e%% a le$el of %/ill in %o'e area% ,ell abo$e the a$erage for their &eer%( The%e feature% need to be ta/en into con%ideration ,hen atte'&ting dental care, and underline% the &articular i'&ortance of accli'ati5ation and fa'iliarity of routine ;ritual%< a% &art of that &roce%%( The cau%e% of auti%' are un/no,n but are thought to be &renatal and not %ocial in origin( Much intere%t ,a% generated in a &o%%ible lin/ ,ith MMR $accine a% a &o%%ible aetiological factor but thi% e$idence ha% %ince been di%credited( 0 'a+or 'alfor'ation in the cerebellu' ha% recently been i'&licated a% a &o%%ible cau%ati$e factor( The &re$alence of auti%' range% fro' 9(9@L to 9(=L ,ith fluctuation% that 'ay &oint to an en$iron'ental cau%e( *earnin! di++i"-ltie# 3earning difficulty i% a%%ociated ,ith dy%lexia, 'ini'al brain da'age, attentiondeficit di%order, and hy&eracti$ity( 0ll the%e categorie% are contro$er%ial, 'ainly becau%e they ha$e been o$erextended( 1i%torically, a child ,ith a learning difficulty ha% been defined a% one ,ho%e &erfor'ance in one acade'ic area i% 'ore than year% behind the child*% ability( Thu% the i'&air'ent i% re%tricted in it% range and there i% a di%cre&ancy bet,een acade'ic &erfor'ance and te%ted general ability( )n the%e t,o ,ay% a learning difficulty differ% fro' 'ental retardation becau%e the latter i% characteri5ed by general delay and acade'ic &erfor'ance i% u%ually at the le$el ex&ected fro' ability( )n &ractice, learning difficulty ha% been u%ed to characteri5e any child ,ith a learning &roble' ,ho cannot be labeled 'entally retarded, no 'atter ho, broad the range of i'&air'ent or the di%cre&ancy fro' the te%ted ability le$el( Thi% o$erexten%ion of the definition ha% not only increa%ed the a&&arent &re$alence of learning di%ability but ha% al%o 'ade the ,hole area rather confu%ing( )n general, the &re$alence of learning difficultie% i% e%ti'ated on a$erage to be about A(:L( There i% o$erla& bet,een learning difficultie% and other &roble'%, for exa'&le, higher le$el% of cla%%roo' beha$ioural &roble'% and an increa%ed ri%/ of delinBuency( )n &art, thi% account% for the greater &redo'inance of 'ale% in grou&% ,ith intellectual i'&air'ent a% they are 'ore li/ely than fe'ale% to be di%ru&ti$e at %chool and thu% be referred for a%%e%%'ent by educational &%ychologi%t%( D$#le9ia Thi% ,idely di%cu%%ed for' of learning di%ability i% a %&ecific &roble' ,ith cognition( The broade%t definition of dy%lexia include% tho%e children ,ho%e reading %/ill% are delayed for any rea%on, and it i% u%ually a%%ociated ,ith a nu'ber of cogniti$e deficit%( "re$alence $arie% fro' @L to =!L de&ending on the breadth of the definition and the country( 6or exa'&le, &re$alence rate% are higher in the #nited State% than they are in )taly, &erha&% due to the co'&lexity of the Engli%h language a% co'&ared

,ith )talianI 7inimal ,rain dama!e Thi% category of i'&air'ent i% u%ed to de%cribe the child ,ho ha% 'inor neurological %ign%, ,hich are often tran%itory( They are not reliable &redictor% of future beha$ioural and educational &roble'%( Attention di#order and %$ era"ti.it$ The%e di%order% are often confu%ed ,ith one another( Children ,ho cannot %it %till are thought to be inattenti$e to their le%%on% in %chool( 0 child ,ho doe% not &ay attention oftenG fail% to fini%h acti$itie%H act% &re'aturely or redundantlyH infreBuently react% to reBue%t% and Bue%tion%H ha% difficultie% ,ith ta%/% that reBuire fine di%cri'ination, %u%tained $igilance, or co'&lex organi5ationH and i'&ro$e% 'ar/edly ,hen %u&er$i%ed inten%i$ely( 0 child ,ho i% hy&eracti$eG engage% in exce%%i$e %tanding u&, ,al/ing, running, and cli'bingH doe% not re'ain %eated for long during ta%/%H freBuently 'a/e% redundant 'o$e'ent%H %hift% exce%%i$ely fro' one acti$ity to anotherH andDor often %tart% tal/ing, a%/ing, or 'a/ing reBue%t%( Thi% ele$ated acti$ity le$el ex&re%%e% it%elf differently at different age%( )nattenti$e, hy&eracti$e children are di%turbing to their &arent%, other children, and to &rofe%%ional% li/e teacher%, doctor%, and denti%t%( They are often +udged to be beha$iourally di%turbed( The $ariation in definition, age, %ex, %ource of the data, and cultural factor% &roduce% &re$alence e%ti'ate% of u& to @:L( 1o,e$er, 'o%t e%ti'ate% are under >L for boy% and e$en le%% for girl%( Emotional and ,e%a.io-ral di#order# There are 'any 'anife%tation% of e'otional di%orderG fear, anxiety, %hyne%%, aggre%%i$e, de%tructi$e or chronically di%obedient beha$iour, theft, a%%ociating ,ith bad co'&anion%, and truancy( When &arent% or teacher% belie$e that the%e &roble'% interfere ,ith the child*% %ociali5ation, they are often referred for &rofe%%ional hel&( )n con%idering the &re$alence of e'otional or beha$ioural di%order%, account ha% to be ta/en of the $ery co''on, %ee'ingly identical, beha$iour of nor'al children( Eating di%order%, ,hich 'ay be of concern to denti%t% becau%e of %elf in+uriou% beha$iour a% ,ell a% dental ero%ion, are i'&ortant in the &re%chool &eriod and, in different ,ay%, in adole%cence( Fi!. /2.2 3ateral $ie, of a Do,n %yndro'e child, to %ho, 'id-face hy&o&la%ia( Fi!. /2.3 The &rotruberant, fi%%ured tongue of an adole%cent ,ith Do,n %yndro'e( Fi!. /2.0 0 Do,n %yndro'e &atient ,ith 'ar/ed dental hy&o&la%ia, conical teeth, and hy&odontia( /2.2./ 6eneral "on#ideration# A""e## to "are Segregated %&ecial education and in%titution%, e%&ecially in rural area%, ,ere

characteri%tic of %er$ice% for di%abled children until after the Second World War( During the =>:9% there ,a% a 'o$e to,ard% normali>ing the li$e% of *handica&&ed* children( Thi% 'o$e'ent %et about 'a/ing 'a+or change% in the li$e% of affected children and adult% but cannot yet be con%idered a% co'&letely %ucce%%ful( The 'o$e to nor'ali5ation ca'e about largely for ideological, legal, and &robably in %o'e countrie% for financial rea%on%( The &hilo%o&hy of thi% 'o$e'ent, ,hich originated in S,eden, centered on the idea that an i'&aired &er%on %hould li$e in an en$iron'ent a% near nor'al a% &o%%ible( Thi% in$ol$ed re%iding in ho'e-li/e re%idence% and attending %chool%, ,or/ &lace%, and recreational &rogra''e% that ,ere &art of the co''unity( On the ba%i% of thi% ideology, 'any 'ildly i'&aired &eo&le ,ere 'o$ed out of long-%tay in%titution% into co''unity ho'e%( Thi% 'o$e'ent ,a% fo%tered by the belief that in%titutionali5ation retarded e'otional and cogniti$e gro,th( De-in%titutionali5ation ,ould al%o reduce the %tate*% ex&en%e in 'aintaining i'&aired &eo&le, and the onu% ,ould be %hifted to &arent%, &ri$ate charitie%, and local authoritie%( Conte'&orary conce&t% ,ithin thi% 'o$e'ent are e'bodied in %ocial role $alori5ationthat i%, the conce&t of %ocial de$aluation of ,hich %ocial exclu%ion, for ,hate$er rea%on, i% +u%t one a%&ect( While 'o%t &eo&le ,ould agree ,ith the &rinci&le of nor'ali5ation, inadeBuate funding ha% &roduced a le%% than %ati%factory alternati$e in co''unity care and di%a%trou% con%eBuence% for %o'e 'entally ill &eo&le and tho%e ,ith ,ho' they interact( While 'any children and adult% ,ith i'&air'ent% ,ere re%ident in long-%tay in%titution% the &ro$i%ion of dental %er$ice% ,a% relati$ely efficient( With the 'o$e to nor'ali5ation, children ,ere often returned to &arent%Dguardian% or hou%ed by %ocial %er$ice% in ho'e% in the local co''unity, thereby &lacing an additional burden on the%e fa'ilie% or carer% to organi5e dental care( 0long%ide thi% &rogra''e ha% been the 'o$e to integrate a% 'any children a% &o%%ible into 'ain%trea' education( Thi% 'ay 'ean that the%e children are not a% readily identifiable a% ,a% the ca%e ,hen they attended *%&ecial %chool%* and thu% 'ay 'i%% out on the o&&ortunity to recei$e the &rioriti5ed dental care they need( 6or teenager%, it ha% beco'e a&&arent that %o'e 'anager% of the adult training centre% that they attend feel that, a% &art of nor'ali5ation, their client% %hould recei$e *nor'al* dental care, that i%, fro' a general dental &ractitioner( Thi% ,ould be de%irable, &ro$ided general dental &ractitioner% ,ere ha&&y to &ro$ide thi% %er$ice( The e$idence to date i% that thi% i% not generally the ca%e( )n the 'eanti'e, teenager% and young adult% could lo%e out by not continuing to recei$e the %&ecial dental %er$ice% that the &ublically funded %er$ice ha% been able to offer, %i'&ly becau%e it i% felt by their ad$ocate% that thi% run% contrary to the &hilo%o&hy of *nor'ali5ation*( Con#ent +or dental "are 0 treat'ent &lan for a child ;le%% than =! year% of age in 'o%t +uri%diction%< reBuire% the con%ent of a &arent before e'bar/ing u&on acti$e treat'ent( Thi% i% often by i'&lied con%entH that i%, the &arent bring% the child to the %urgery and the child %it% in the chair, the i'&lication being that the &arent ha% con%ented to treat'ent( Thi% i% no different to the %cenario ,ith an i'&aired child( The #nited -ation% Con$ention on the Child reBuire% that children*% right% are &rotected and in thi% context, cogni5ance ta/en of the child*% $ie,% on ,hether they ,i%h treat'ent to be carried out( 0% ,ith

any &atient, be%t intere%t% 'u%t be &rotected( Difficulty ari%e% in adole%cent% ,ith an intellectual i'&air'ent ,ho are o$er the age of con%ent( )n thi% %ituation &arent% or carer% are unable to gi$e a $alid con%ent on their charge*% behalf( That i%, an adult cannot con%ent for treat'ent on behalf of another adult( Denti%t% ,ould be ,ell ad$i%ed to obtain a %econd o&inion on their treat'ent &lan before e'bar/ing on dental care for an i'&aired young &er%on ,ho i% +udged to be inca&able of gi$ing their o,n $alid, that i%, infor'ed, con%ent( Thi% i% &articularly the ca%e ,here dental care under general anae%the%ia i% being conte'&lated( )t i% &rudent, al%o, to di%cu%% the &ro&o%ed treat'ent &lan and to obtain the agree'ent for the care that i% being %ugge%ted fro' tho%e ,ho ha$e an intere%t in the &atient( There ,ill be occa%ion% ,hen it ,ill not be &o%%ible to ea%ily underta/e an exa'ination for a child or adole%cent ,ith a &rofound learning di%ability( )n tho%e circu'%tance%, a deci%ion ha% to be 'ade a% to ,hether %o'e for' of &hy%ical inter$ention, &re$iou%ly ter'ed re%traint, 'ay need to be u%ed( The clinician 'u%t decide, on the ba%i% of a nu'ber of factor%, ,hat i% the be%t ,ay for,ard( 0t all ti'e%, a% &art of the denti%t*% duty of care, %he or he 'u%t act in the &atient*% be%t intere%t in reaching a deci%ion a% to ,hether to u%e %o'e for' of &hy%ical inter$ention( Thi% deci%ion 'u%t be ta/en in the light of a nu'ber of factor%, 'odified after Schu'an and 4ebau and incor&orated into the 4riti%h Society of Di%ability and Oral 1ealth*% "olicy Docu'ent on "hy%ical )nter$ention% ;htt&GDD,,,(b%dh(org< a% follo,%G >e$ Point# "hy%ical inter$ention% Mini'u' to be effecti$e( Clearly docu'ented ty&eDrea%on( Only e'&loyed by trained %taff( 4eneficial for indi$idual to co'&lete treat'ent( -ot %een a% &uni%h'entDfor con$enience( -ot li/ely to cau%e &hy%ical trau'a( -ot li/ely to cau%e 'ore than 'ini'al &%ychological trau'a( 0 'ean% of a$oiding 'ore %e$ere re%traint ;e(g( G0<( To control in$oluntary 'o$e'ent%( To a$oid in+ury to %elf, other%( 0greed ,ith other% clo%e to &atient( /2.2.2 &ral %ealt% Dental "arie# )n the ab%ence of targeted &re$enti$e and treat'ent &rogra''e%, children ,ith i'&air'ent% fare le%% ,ell than their nor'al &eer%( While o$erall di%ea%e ex&erience a% 'ea%ured u%ing the d'fDDM6 index ;decayed, 'i%%ing, filled &ri'aryD&er'anent teeth< i% %i'ilar, for the child ,ith i'&air'ent% there i% often 'ore untreated decay, 'ore 'i%%ing, and fe,er filled teeth( Early %tudie% &oint to a reduced &re$alence of dental carie% in children ,ith Do,n %yndro'e, but thi% feature 'ay be attributable 'ore to the later eru&tion of teeth relati$e to a control grou& of unaffected children %o that the teeth are *at ri%/* in the 'outh for a %horter &eriod( The relati$e 'icrodontiaD%&acing %een in young &eo&le ,ith Do,n %yndro'e 'ay al%o be a

contributory factor in thi% %u&&o%ed reduction in dental di%ea%e &re$alence( Periodontal di#ea#e The &eriodontal %tatu% of children ,ho are intellectually i'&aired 'ay be co'&ro'i%ed by their inability to co'&rehend and thu% co'&ly ,ith oral hygiene 'ea%ure%( )n the%e children &eriodontal di%ea%e i% 'ore &re$alent, &o%%ibly a% a re%ult of an altered i''une %tate ;Cha&ter ==(<( 0l'o%t uni$er%ally, &laBue and gingi$iti% indice% %core% are higher in children ,ith i'&air'ent%( 7alo""l-#ion There are no %tudie% that deal %&ecifically ,ith the &roble'% of 'alocclu%ion in intellectually i'&aired children( 1o,e$er, in &ubli%hed data on general dental health, the nu'ber of orthodontic ano'alie% i% freBuently higher becau%e 'any re'ain untreated( )n Do,n %yndro'e the relati$e 'id-face hy&o&la%ia contribute% to the &%eudo%/eletal cla%% ))) relation%hi& and thi%, in co'bination ,ith the narro,, high$aulted &alate &roduce% buccal cro%%-bite% ;6ig( =?( <( &t%er oral de+e"t# One feature of note i% the &re$alence of ena'el defect% often cau%ed by the aetiological agent that &roduced the i'&air'ent( )t i% &o%%ible that denti%t% could &lay a &art not only in the diagno%i% of %o'e di%abilitie%, for exa'&le, coeliac di%ea%e ;6ig( =?(:<, but al%o in the ti'ing of the in%ult that led to the i'&air'ent( Teeth &ro$ide a good chronological record of the ti'ing of %e$ere %y%te'ic u&%et% ;Cha&ter =@<( Fi!. /2.5 Chronological hy&o&la%ia in a child ,ith coeliac di%ea%e( /2.2.3 & erati.e ro"ed-re# Children ,ho are intellectually i'&aired 'ay be able to co-o&erate for dental treat'ent, but their ability to acce&t %&ecific &rocedure% %uch a% the u%e of local anae%thetic and high %&eed in%tru'ent% ,ill de&end on their degree of under%tanding and le$el of 'aturity( )%olation 'ay be difficult due to a large tongue and &oor control of 'o$e'ent, and in the%e %ituation% it 'ay be nece%%ary to co'&ro'i%e on the treat'ent a&&roach( )n fi%%ure %ealing it 'ay be 'ore &racticable to u%e a gla%% iono'er ce'ent, &rotected by occlu%al ad+u%t'ent ,ax or a glo$ed finger during the %etting &ha%e, rather than to %truggle ,ith all the %tage% of a&&lying a con$entional re%in %ealant ;6ig( =?(!<( 1u'an clinical trial% are no, under,ay in both the #nited 2ingdo' and the #nited State% to in$e%tigate the u%e of intraoral fluoride-relea%ing de$ice%( The%e are %'all dia'eter gla%% bead% that are attached by co'&o%ite re%in, to the buccal %urface of a tooth ;Cha&ter !<( The de$ice di%%ol$e% %lo,ly in %ali$a, relea%ing fluoride a% it doe% %o( Tho%e currently on trial ha$e continued to ele$ate %ali$ary fluoride le$el% for u& to year%( Whether the relea%ed fluoride i% eBuitably di%tributed around the 'outh i% not yet /no,n( The &lace'ent, and retention in situ, of the gla%% bead% in %uch children 'ay be a challenge( Dura&hat fluoride $arni%h ;:L %odiu' fluoride M ,!99 &(&('( fluoride, Colgate< i%

an al'o%t ideal &re$enti$e agent for children ,ith &oor tolerance of dental &rocedure%( The a'ber-coloured &olyurethane-ba%ed 'aterial i% a&&lied to the tooth %urface%, &referably dry, although the $arni%h i% ,ater tolerant, and the re%ulting adherent fil' %lo,ly relea%e% fluoride ;6ig( =?(?<( The exerci%e %hould be re&eated u& to four ti'e% a year de&ending on carie% ri%/( 0 reduction of carie% in &er'anent teeth of bet,een @9L and ! L ha% been re&orted u%ing Dura&hat TM $arni%h( Recour%e to one or other for'% of con%ciou% %edation 'ay be indicated for a child ,ith i'&air'ent% ,ho find% it difficult to co-o&erate for dental care( 1o,e$er, a degree of co'&liance i% nece%%ary in order to retain the na%al hood for the deli$ery of nitrou% oxideDoxygen for inhalation %edation;6ig( =?(C< a% it i% for the in%ertion of a cannula for intra$enou% %edation( 1o,e$er, )8 %edation i% not u%ually indicated for children although the drug u%ed 'o%t co''only in the #nited 2ingdo', Mida5ola', can be gi$en orally although again, the outco'e 'ay not be &redictable( 6or %o'e &atient% general anae%the%ia ,ill be nece%%ary to &ro$ide adeBuate dental care ;6ig( =?(><( Thi% facility i% not ,idely a$ailable and often 'ean% con%iderable di%ru&tion for the fa'ily becau%e of the di%tance in$ol$ed in tra$elling to %&eciali%t centre%( 0dditionally, the child 'ay be un%ettled by the ,hole &roce%% of being %tar$ed, loo/ed after by %trange &er%onnel, being anae%theti5ed, and then ,a/ing u& ,ith a %ore throat and &erha&% a 'outh full of blood( There i% e$idence that thi% ex&erience i% only in the %hort-ter' 'e'ory a% 'any &arent% co''ent on ho, 'uch better their child i% in ter'% of beha$iour, %lee&ing &attern%, and eating after the i''ediate &o%to&erati$e &eriod( Treat'ent &lanning for dental care under general anae%the%ia ha% to be 'ore radical( The o&&ortunity to reduce a *high* re%toration or to re$ie, a doubtful tooth i% not nece%%arily a$ailable ,ithout recour%e to another general anae%thetic( Radiogra&hy i% an i'&ortant aid in theatre, e%&ecially for the &atient ,ho i% totally unco-o&erati$e in the dental chair( )t i% &articularly i'&ortant for detecting other,i%e hidden &athology and for early ena'el le%ion%( The latter cannot nor'ally be left in the ho&e that they ,ill re'inerali5e by &re$enti$e 'ean%( Si'ilarly, the chance% of re%toration failure can be reduced by the u%e of &ul&oto'y techniBue% and &refor'ed 'etal cro,n%( Mo%t for'% of treat'ent can be carried out under general anae%the%ia &ro$ided there i% %ufficient o&erating ti'e and the &atient*% general condition &er'it% it( Succe%% i% de&endent u&on careful &re-anae%thetic a%%e%%'ent by denti%t and anae%theti%t( 0&&ro&riate &erio&erati$e care in theatre, for exa'&le, %teroid or antibiotic co$er, and the bac/-u& of in-&atient facilitie% ,here 'edically or %ocially indicated, are $ital to a %ucce%%ful outco'e( "atient% ,ith Do,n %yndro'e 'ay ha$e altlanto-axial +oint in%tability and ,ill need extra care in 'o$ing fro' trolley to theatre table a% ,ell a% during the reco$ery &ha%e( >e$ Point# "re-anae%thetic a%%e%%'enti'&ortant feature%G accurate 'edical hi%toryH &re$iou% anae%thetic hi%toryH %ignificant air,ay difficultie%H need for &re'edicationH

 tran%&ort arrange'ent%H ho'e care( Fi!. /2.1 Gla%% iono'er ce'ent fi%%ure %ealant( Fi!. /2.2 6luoride $arni%h on &ri'ary 'olar% in a child ,ith a 'ixed ly'&hDhae'angio'a and a learning di%ability( Fi!. /2.3 0 &arent of a boy ,ith crebral &al%y a%%i%ting in the deli$ery of nitrou% oxide %edation for routine %caling( Fi!. /2.4 Dental treat'ent under day-%tay general anae%the%ia for a child ,ith i'&air'ent%( /2.2.0 5ome "are &ral %$!iene There i% little to be gained in e'bar/ing on elaborate treat'ent &lan% including ad$anced re%torati$e ,or/ ,hen it ,ill not be 'aintained by regular oral hygiene 'ea%ure% at ho'e( "arent% or carer% need %&ecific ad$ice and &ractical hel& in the be%t ,ay to care for their child*% 'outh( Great reliance i% thu% &laced on the &arent or carer ,ho 'u%t be acti$ely in$ol$ed in oral hygiene in%truction and gi$en &o%iti$e %ugge%tion% for 'odification% to the %tandard techniBue%( Exa'&le% include ad$ice on the ,ay to &o%ition a child ;a bean bag can be hel&ful<, in order to clean their 'outh 'ore efficiently and le%% trau'atically( 0nother aid i% the u%e of a &ro& %uch a% a toothbru%h handle to gain acce%% to tooth %urface% on the other %ide of the 'outh( Modification of exi%ting, often $ery narro,-handled toothbru%he% or the u%e of %&ecially 'odified bru%h head% can be hel&ful ;6ig( =?(=9<( Carer% 'ay be concerned about being bitten ,hen they atte'&t to clean a child*% 'outh, in %ituation% ,hen toothbru%hing i% a battle( )n the%e circu'%tance%, u%e of an infadent bru%h ;6ig( =?(==<, ,ith bri%tle% incor&orated onto the end of a &la%tic-ty&e 'aterial that fit% o$er the end of a finger, %i'ilar to a finger-%tall, can o$erco'e the%e &roble'% and en%ure adeBuate tooth cleaning( 6or %o'e children, the 'echanical re'o$al of &laBue can be 'ore readily acco'&li%hed u%ing a &o,ered toothbru%h( Once the child ha% beco'e accu%to'ed to the %en%ation, re%ult% can be better than by con$entional toothbru%hing( Che'ical agent% are effecti$e in reducing &laBue in the %hort ter', but not enough i% /no,n about the effect% of their long-ter' u%age( Many children find the ta%te of 9( L chlorhexidine gluconate, either a% a gel or %olution, un&alatable and &arent% or carer% are unha&&y about the extrin%ic bro,n %taining( Many &atient% ,ith i'&air'ent% 'ay be unable to u%e a 'outh,a%h correctly and either %,allo, or %&it out anything di%ta%teful( 0n alternati$e techniBue i% to o&t for chair%ide a&&lication of chlorhexidene a% a $arni%h( Originally intended for treating dentine hy&er%en%iti$ity, a&&lication of the $arni%h ha% been %ho,n to reduce the incidence of both gingi$al %ign% and dental carie%( So'e %chool% for children ,ith %&ecial educational need% &ro$ide toothbru%he% for their &u&il% during their learning of &er%onal hygiene %/ill%( 1o,e$er, %u&er$i%ing

%taff 'ay be una,are of the be%t 'ethod of 'outh cleaning, ,hich 'ay be 'ore de&endent on their o,n &erce&tion% of oral health and the &ercei$ed difficulty than any other factor ;6ig( =?(= <( Toothbru%hing can be taught in the %a'e ,ay a% other %/ill%, but it reBuire% ti'e for the indi$idual a% ,ell a% co''it'ent on the &art of the regular carer to en%ure that all area% of the 'outh are being cleaned each ti'e( 1o,e$er, 'any di%abled children are intolerant not only of toothbru%hing but al%o of tooth&a%te and they 'ay gag ,hen tooth&a%te, ,hich they cannot %,allo, becau%e of &oor reflexe%, i% introduced into the 'outh( Tooth&a%te al%o ob%cure% the $ie, for the carer during toothbru%hing and they cannot al,ay% be %ure that the tooth %urface% are clean( )n the%e circu'%tance%, ,here tooth&a%te i% unacce&table to the child, &arent% or carer% %hould atte'&t to clean around the 'outh ,ith a &iece of gau5e 'oi%tened in a 9( L chlorhexidine gluconate %olution or a toothbru%h di&&ed in fluoride 'outhrin%e ;9(9:L %odiu' fluoride if u%ed on a daily ba%i%<( 0lternati$ely, chlorhexidine in gel for' or fluoride tooth&a%te can be rubbed a% $igorou%ly a% &o%%ible around the tooth %urface% u%ing a finger( Since chlorhexidene i% inacti$ated by the traditional foa'ing agent% in tooth&a%te%, the for'er %hould be u%ed at a different ti'e of the day to the latter( Children ,ho are tube-fed for %o'e or all of their nutrient inta/e %till need oral care( They ,ill freBuently accu'ulate %ignificant Buantitie% of calculu%, ,hich, if detached 'ight be inhaled( Regular 'outh cleaning and the u%e of a *tartar control* tooth&a%te are nece%%ary ;6ig( =?(=@<( Diet More %e$erely i'&aired children 'ay ha$e ,ell-regulated eating ti'e% and a reduced li/elihood of %nac/ing( The food con%u'ed 'ay be %e'i-%olid or e$en liBuidi5ed, but tho%e food% ,hich are ea%ily reduced to thi% for' are often dentally unde%irable( )n the%e circu'%tance% the denti%t %hould offer ad$ice on li'iting the nu'ber of inta/e% of food, &ro$ided it confor'% to the child*% general nutritional and dietary need%( 6or %o'e children e%tabli%hing a nor'al eating routine ,hile *gro,ing u&* beco'e% a battlefield and i'&aired children are no exce&tion to thi%( )t i% often ea%ier for &arent% to *gi$e in* to a child and allo, the' to eat a li'ited $ariety of un%uitable food% freBuently( Thi% ,ill be +u%tified by &arent% %aying they are de%&erate to get the child to eat %o'ething, and %o bi%cuit%, and other %nac/% high in non-'il/ extrin%ic %ugar%, beco'e the nor'( Thi% &attern i% further endor%ed in %o'e children ,ith i'&air'ent% ,here ,eight gain i% &ara'ount and the dental i'&lication% are %econdary, if indeed they are e$en con%idered( Drin/% can al%o be a difficult area, &articularly the u%e of %,eetened bottle% for an extended &eriod in a child*% life( )t i% not unco''on for children of year% of age or older %till to be u%ing a bottle containing 'il/, often for na&%, la%t thing at night before going to bed and e$en during the night( Thi% i% an extre'ely difficult habit to brea/, but the 'o%t %ucce%%ful a&&roach ha% been to ad$i%e the &arent gradually to dilute the content% ,ith ,ater o$er a &eriod of ,ee/%, until e$entually the child i% drin/ing ,ater only( Thi% not only eli'inate% the unde%irable habit but al%o gi$e% the &arent of the child, ,ho i% able to be toilet trained, %o'e &ro%&ect of getting the child dry and out of na&&ie% o$ernight( 6or a nu'ber of children ,ith i'&air'ent%, the u%e of %,eetened 'edication ha% led

to an increa%e in dental carie% ;6ig( =?(=A<( )n the &a%t thi% ha% ari%en becau%e of a lac/ of %ugar%-free alternati$e%( 1o,e$er, ,ith the &har'aceutical indu%try*% greater a,arene%% it i% often only due to ignorance a'ong the 'edical &rofe%%ion that %uch out'oded &re%cribing continue%( So'e children ,ill be ta/ing 'edication a% di%&er%ible tablet% or in an effer$e%cent for', %o'e of ,hich, ,ith chronic u%e, 'ay &redi%&o%e to dental ero%ion( 0nother con%ideration i% %&oiling( 6or any &arent the birth of a child ,ho i% i'&aired in %o'e ,ay, i% a %hoc/( Month% of eager antici&ation are follo,ed by di%belief, anger, denial, fru%tration, and guilt( "arent% ha$e to grie$e for the nor'al child they ,ill ne$er ha$e, before co'ing to ter'% ,ith their ne, re%&on%ibilitie%( "arent% continue to feel guiltyH 'aybe their child ha% an i'&air'ent becau%e of %o'ething they ha$e done, or %o'ething they %hould not ha$e done( Either ,ay, they 'ay atte'&t to a%%uage that guilt by %&oiling the child( Thi% 'ay ta/e the for' of ea%y to eat %,eet food%, ,hich are thought to be &lea%urable and are ,elco'ed by the child ,ith a &oor a&&etite, thu% co'&ounding the &roble' of &oor eating( "oor eating habit% re%ulting in oral di%ea%e need to be tac/led together ,ith the &aediatrician and dietician, a% ,ell a% the &arent% or caregi$er%( >e$ Point# General dietary ad$iceG Re%trict %,eet food%Ddrin/% to 'ealti'e%( 3i'it %,eetened food%Ddrin/% to three ti'e% a day( 2ee& food and drin/% clear of bedti'e by about an hour( Re'e'ber that carbonated drin/%, and %o'e 'edicine% are ero%i$e to teeth( 0%/ for %ugar%-free 'edicine%( Fl-oride# Many %&ecial 'il/ for'ula% and food %u&&le'ent%, a% ,ell a% containing non-'il/ extrin%ic %ugar% to boo%t the child*% calorie inta/e, in %o'e ca%e% al%o ha$e Buite %ub%tantial a'ount% of fluoride( )t i% ,i%e therefore to chec/ the diet carefully before ad$ocating the u%e of fluoride %u&&le'ent% for %uch children( Where dental carie% i% &otentially a real &roble' and in the ab%ence of any other for' of %y%te'ic fluoride%, then the daily fluoride %u&&le'ent regi'en of 9( : 'g fro' ! 'onth% of age, follo,ed by an increa%e to 9(: 'g at @ year% of age, and then =(9 'g fro' ! to =! year% of age i% to be ad$ocated( Once the concentration of fluoride in the local ,ater %u&&ly i% /no,n fro' the ,ater co'&any, fluoride %u&&le'ent% can be &re%cribed by the general dental &ractitioner if indicated, either a% dro&% for the younger child or tablet% for the &re%chool child( )t i% li/ely that %o'e children ,ith i'&air'ent% ,ill ne$er co&e ,ith fluoride tablet% and ha$e to re'ain on dro&%( 0% long a% the &arent i% gi$en ,ritten in%truction% to o$errule the &re%cribing %chedule gi$en for younger children on the label of the bottle, there i% no rea%on ,hy older children %hould not be &re%cribed fluoride dro&%( The denti%t %hould al%o ad$i%e on the a&&ro&riate fluoride tooth&a%te to be u%ed in con+unction ,ith fluoride %u&&le'entation or ,ater fluoridation( Each ca%e %hould be con%idered indi$idually ta/ing into account the relati$e ri%/% and benefit% that 'ay occur( "ara'ount i% con%ideration of the ri%/ of de$elo&ing dental carie% $er%u% the

&otential for ena'el o&acitie% in the &er'anent dentition( 0% a guideline, if the ri%/ of carie% i% 'ini'al, and if the diet i% rea%onably ,ell controlled and ho'e oral care i% generally good, then it i% %en%ible to %ugge%t the u%e of a &ea-%i5ed a'ount of tooth&a%te containing a&&roxi'ately :99-!99 &(&('( of fluoride for the child under ! year% of age, &ro$ided that tooth&a%te can be u%ed %ucce%%fully( Older children, in the %a'e %ituation %hould u%e a tooth&a%te containing bet,een =999 and =:99 &(&('( of fluoride, a% the ri%/ of ena'el o&acitie% on anterior teeth i% non-exi%tent and thi% for'ulation ,ill &ro$ide o&ti'al &rotection again%t carie%( )n the child ,here the de$elo&'ent of dental di%ea%e ,ould &o%e a real ha5ard to their general health, and ,here ho'e care in ter'% of oral hygiene and diet i% &oorly controlled, it i% ad$i%able to confer 'axi'u' &rotection by reco''ending the u%e of a tooth&a%te containing =999-=:99 &(&('( of fluoride, e$en during the &re%chool year%( 4ecau%e of the inability of 'any di%abled children to hold %olution% in their 'outh% or to ex&ectorate, fluoride 'outh,a%he% are contraindicatedH ho,e$er, they can be u%ed on a toothbru%h ;di&&ed< ,here tooth&a%te i% not ,ell tolerated, to 'i'ic the a'ount of to&ical fluoride recei$ed fro' tooth&a%te( >e$ Point# 6luoride ad$iceG %u&&le'ent% to gi$e o&ti'al carie% &rotectionH fluoride 'outh,a%h on a toothbru%h in%tead of &a%te in ca%e% of &a%te intoleranceH lo, carie% ri%/G :99-!99 &(&('( of fluoride &a%te ;<! year%<, =999-=:99 &(&('( of fluoride &a%te ;>! year%<H high carie% ri%/G =999-=:99 &(&('( of fluoride &a%te ;&ea-%i5ed a'ount< fro' the ti'e of tooth eru&tion on,ard%( Fi!. /2./0 0 *%u&erbru%h* in u%e in a child ,ith cerebral &al%y( Fi!. /2.// 0n infadent bru%h for u%e ,ith a &atient ,ho i% uncoo&erati$e for oral hygiene 'ea%ure%( Fi!. /2./2 Staff in a %&ecial %chool bru%hing the teeth of a child ,ith an i'&air'ent( Fi!. /2./3 3oo%e calculu% de&o%it% in a child ,ith chro'o%o'e A&-%yndro'e( Fi!. /2./0 The dental effect% of freBuent 'edication in a child ,ith a cleft of the li& and &alate( /2.3 P5YSICA* I7PAIR7ENT CERE;RA* PA*SY /2.3.0 Introd-"tion The co''on &hy%ical i'&air'ent% the denti%t ,ill encounter areG developmental neuro'u%cular di%order%, for exa'&le, cerebral &al%y, %&ina bifida, %colio%i%, and o%teogene%i% i'&erfectaH and degenerative neuro'u%cular di%order%, for exa'&le, 'u%cular dy%tro&hy and +u$enile for'% of arthriti%( )ncluded in thi% general category of &hy%ical i'&air'ent are children ,ith cleft% of the li& andDor &alate ;Cha&ter =A<, ,here there 'ay ,ell be an a%%ociated %yndro'e in u& to =>L of ca%e%(

/2.3./ 6eneral "on#ideration# Cerebral &al%y occur% in =- children &er =999 of %chool age, a figure ,hich ha% been relati$ely %table becau%e of the i'&ro$ed Buality of %ur$i$al of &re'ature babie%( Thi% i% a grou& of non-&rogre%%i$e neuro'u%cular di%order% cau%ed by brain da'age, ,hich can be &re-, &eri-, or &o%tnatal in origin, and i% cla%%ified according to the ty&e of 'otor defectG =( #pasticityi'&aired ability to control $oluntary 'o$e'ent%( There i% the a&&earance of %e$ere 'u%cle %tiffne%% and the &lanned 'o$e'ent of an affected li'b re%ult% in a hy&otonic tendon reflex, e%&ecially ,ith ra&id 'o$e'ent%( S&a%ticity occur% in about :9L of ca%e% of cerebral &al%y( ( "thetosisuncontrolled, %lo, t,i%ting, and ,rithing 'o$e'ent%, ,hich are freBuent and in$oluntary and occur in o$er =!L of ca%e%( @( )igidityre%i%tance to &a%%i$e 'o$e'ent, ,hich 'ay be o$erco'e by %udden action( )t i% unco''on and the 'a+ority of the%e children are intellectually i'&aired( A( "taxiadi%turbance of eBuilibriu' a% ,ell a% difficulty in gra%&ing ob+ect%( )t i% al%o unco''on( :( Hypotoniaall 'u%cle% are flaccid ,ith decrea%ed function( !( (ixeda co'bination of the abo$e( The la%t : year% ha% %een a change in the &ro&ortion of the different %ubty&e%( 6or exa'&le, ,ith the decrea%e in /ernicteru% ;neonatal +aundice<, there ha% been a fall in the athetoid for', but the %&a%tic for', a%%ociated ,ith &re'aturity, ha% increa%ed( 0n affected child 'ay be 'ono&legic ,ith only one li'b affected ;6ig( =?(=:< or ha$e all four li'b% affected ;Buadri&legia<( )n addition, they 'ay be di%abled by other i'&air'ent% %uch a% con$ul%ion%, intellectual i'&air'ent, %en%ory di%order%, e'otional di%order%, %&eech and co''unication defect%, and a &oorly de$elo&ed %,allo,ing and cough reflex( Fi!. /2./5 Mono&legia of the right ar' in a child ,ith cerebral &al%y and a congenital heart defect( /2.3.2 &ral %ealt% The oral and dental feature% that 'ay be %een in children ,ith cerebral &al%y areG ;=< &oor oral hygiene, increa%ed &eriodontal di%ea%e, and drug-induced gingi$al enlarge'entH ; < 'alocclu%ion ;increa%ed &re$alence of %/eletal cla%% )) ,ith anterior o&en-bite<H ;@< a tendency to bruxi%'H ;A< tongue thru%t and 'outh breathingH ;:< an increa%e in carie% &re$alenceH ;!< increa%ed &re$alence of anterior trau'aH

;?< ena'el hy&o&la%iaH ;C< heightened gag reflex and &eri-oral %en%iti$ityH ;>< droolingH ;=9< decrea%ed &arotid flo, rate( 0lthough not confined to children ,ith cerebral &al%y, ga%tric reflux i% relati$ely co''on ;6ig( =?(=!<( There 'ay be an ob$iou% aetiology, for exa'&le, a hiatu% hernia, but Buite often a cau%e for the ero%ion cannot be identified ;Cha&ter =9<( Fi!. /2./1 "alatal ero%ion on 'axillary inci%or% in a child ,ith cerebral &al%y( /2.3.3 & erati.e ro"ed-re# Children ,ho are %e$erely &hy%ically i'&aired ,ill &robably be brought to the dental %urgery in a ,heelchair or be carried( Care i% reBuired in the handling of %uch &atient% ;%ee Section =?(A(=<( >e$ Point# Oral feature% in cerebral &al%yG gingi$al hy&er&la%iaH increa%ed carie% &re$alenceH 'alocclu%ionH dental trau'aH ena'el hy&o&la%iaH heightened gag reflexH dental ero%ion and abra%ion ;bruxi%'<( 0ltered gag and cough reflexe% 'ay co'&licate the deli$ery of dental care or the &ro$i%ion of &ro%the%e%, a% ,ell a% adding to the &atient*% anxiety( "lentiful rea%%urance, efficient %uction and %/illed a%%i%tance are $ital to %ucce%% in the%e %ituation%( )'&aired $entilation 'ay acco'&any %colio%i% and beco'e% an e$en 'ore i'&ortant con%ideration if &rocedure% in$ol$ing a general anae%thetic are conte'&lated( Children ,ho %&end long &eriod% in one &o%ition 'ay be &redi%&o%ed to &re%%ure %ore%, therefore lengthy &rocedure% in the dental chair ,ithout a brea/ are be%t a$oided( 1y&o&la%tic teeth can be $ery %en%iti$e, &articularly to extre'e cold( "atient% can ex&erience acute di%co'fort during tooth &re&aration or ultra%onic %caling ;e$en ,hen the affected teeth are di%tant fro' the o&erating %ite<, 'erely fro' the cold &roduced by high $olu'e a%&iration( The u%e of a de%en%iti5ing agent li/e Dura&hat fluoride $arni%h or fi%%ure %ealing the %y'&to'atic %urface can be hel&ful if a re%toration i% not indicated( 1y&o&la%tic ena'el doe% not ha$e the %a'e ordered &ri%' %tructure a% nor'al ena'el and, de%&ite acid etching, 'ay not &ro$ide o&ti'u' retention for con$entional re%in%( )n thi% %ituation, gla%% iono'er ce'ent% 'ay be a 'ore %uitable alternati$e( So'e le%% %e$erely di%abled children ,ill ha$e little or no intellectual i'&air'ent but ,ill ha$e a degree of %&a%ticity or rigidity( Thi% 'ay &re$ent the' fro' co-o&erating

fully ,ith dental &rocedure%, de%&ite their ,illingne%% to do %o, and they 'ay be hel&ed by nitrou% oxide %edation ;Cha&ter A<( Such %edation 'ay al%o hel& di'ini%h an exaggerated gag reflex( /2.3.0 5ome "are &ral %$!iene "hy%ical i'&air'ent 'ay hinder oral hygiene &rocedure% and for the child ,ho ha% gingi$al enlarge'ent the &roble' 'ay be co'&ounded( Mo%t children reBuire hel& ,ith bru%hing until they are ? year% or older, but for the child ,ith &hy%ical li'itation% thi% 'ay be a &er'anent co''it'ent on the &art of carer%( 3i'ited or bi5arre 'u%cle 'o$e'ent% &re$ent nor'al 'outh clearing and food i% often left i'&acted in the $ault of the &alate( Thi% i% readily re'o$ed ,ith the end of a toothbru%h handle or a %&oon handle, but carer% need to be a,are of the &otential for thi%, other,i%e food re%idue% 'ay be left in the oral ca$ity for day%( "o,ered toothbru%he% 'ay be hel&ful for a child ,ith li'ited dexterity, not only becau%e of the relati$e efficiency of cleaning but al%o becau%e of the larger %i5e of the handle of 'o%t of the%e bru%he%( When nor'al li'b 'o$e'ent i% i'&aired or ab%ent andDor nor'al %&eech i% i'&o%%ible, the 'outh a%%u'e% an e$en greater i'&ortance a% a 'ean% of holding 'outh%tic/% to gra%& &en% or to o&erate a $ariety of eBui&'ent( )t i% $ital the dentition i% 'aintained to the highe%t %tandard a% the %ucce%%ful u%e of %uch 'outh%tic/% i% reliant on ha$ing a good occlu%al table for balanced contact ;6ig( =?(=?<( Children ,ith cerebral &al%y, e%&ecially ,here there i% acco'&anying intellectual i'&air'ent, ,ill on occa%ion ado&t a habit of %elf-'utilation by che,ing %oft ti%%ue% around the 'outh ;6ig( =?(=C<( Thi% can be triggered by teething, although often no cau%e 'ay be found( )t i% di%tre%%ing for the &arent% a% the child i% ob$iou%ly in &ain fro' the ulcerated area% and 'ay refu%e all food and drin/, but there i% little they can do to brea/ the habit( )t 'ay be hel&ful to di%cu%% the child*% 'edication ,ith their &hy%ician a% the &re%cri&tion of a drug to reduce 'u%cle tonu%, ,hich can be an exacerbating factor in thi% %ituation, could be con%idered( There are a nu'ber of %olution% to the &roble' de&ending on the cau%e and the %e$erity of the condition( )n a child ,ho i% eru&ting &ri'ary teeth it 'ay be &o%%ible to fit an occlu%al %&lint, &ro$ided that %ufficient teeth are a$ailable for retention( 6abrication of the %&lint 'ay nece%%itate a %hort general anae%thetic for i'&re%%ionta/ing( 0lternati$ely, addition of gla%% iono'er ce'ent to the occlu%al %urface% of the &ri'ary 'olar%, to o&en the occlu%ion and &re$ent the teeth contacting the %oft ti%%ue%, 'ay be %ucce%%ful( )f only anterior &ri'ary teeth are &re%ent then co'&o%ition, 'oulded o$er the offending tooth %urface% a% a te'&orary %&lint, 'ay brea/ the habit and allo, healing ;6ig( =?(=> ;a< and ;b<<( )f the &roble' i% 'ore %e$ere and a %&lint i% not fea%ible, it i% %en%ible to extract the &ri'ary teeth in$ol$ed( )n the &er'anent dentition, rounding-off the &ointed or %har& tooth %urface% andDor fitting a %&lint i% u%ually %ucce%%ful( During the acute &ha%e the u%e of a to&ical analge%ic %uch a% 9(=:L ben5yda'ine hydrochloride ;Diffla'< in %&ray for' increa%e% 'outh co'fort &rior to eatingH and 9( L chlorhexidine gluconate %olution ;Cor%odyl< %,abbed around the 'outh or a&&lied a% a gel on a finger &ro'ote% 'ore ra&id healing by /ee&ing the area clean( En%uring that the child ha% &lenty of fluid% i% of &ara'ount

i'&ortance a% %'all, debilitated children ra&idly beco'e dehydrated( The other area of concern to &arent% and carer% i% drooling( 6or %o'e di%abled children thi% can be exce%%i$e, although %urgery to di$ert the %ub'andibular flo, 'ore &o%teriorly 'ay alle$iate the &roble'( 1o,e$er, thi% i% not al,ay% %ucce%%ful and carrie% the ri%/ of increa%ing carie% &re$alence a% a re%ult of the greatly di'ini%hed %ali$ary $olu'e( The u%e of acrylic training &late% that encourage the for'ation of an oral %eal a% ,ell a% &ro'oting a 'ore acti$e %,allo,ing 'echani%' %o that %ali$a doe% not &ool in an o&en 'outh 'ay be hel&ful ;6ig( =?( 9<( Concurrent ,or/ ,ith %&eech and language thera&i%t% ,ill hel& ,ith the nece%%ary thera&y that i% funda'ental to the %ucce%% of %uch treat'ent( 0necdotal ca%e re&ort% %u&&ort the u%e of the%e &late%, but fe, %tudie% ha$e been &ubli%hed that gi$e ob+ecti$e data on their %ucce%%( 1o,e$er, one relati$ely non-inter$entional 'ethod of reducing %ali$a flo, i% the u%e of hyo%cine hydrobro'ide, a drug ,hich bloc/% &ara%y'&athetic tran%'i%%ion to the %ali$ary gland%( )t i% a&&lied a% a &atch behind the ear and changed e$ery three day%( Diet Con%ideration% on dietary a%&ect% ha$e been co$ered in the %ection on intellectual i'&air'ent ;Section =?( (A<( So'e children, becau%e of a failure to thri$e, ,ill be fed through a ga%tro%to'y %ite( )f the child i% exclu%i$ely fed $ia thi% route, they ,ill tend to accu'ulate large de&o%it% of calculu%( The%e need to be re'o$ed fro' %urface% ad+acent to the gingi$al 'argin% in &articular( Thi% can be difficult unle%% there i% good coo&eration fro' the &atientH an i'&aired air,ay 'a/e% the %afe re'o$al of %uch de&o%it% ha5ardou%, ,ith the ri%/ of inhalation of calculu%( The ga%tro%to'y %ite can be u%eful al%o for %edati$e drug%, e%&ecially bitter intra$enou% %edation drug% that 'ight other,i%e not be tolerated orally( 1o,e$er, %uch %edation &rocedure% need to be carried out in %&eciali%t unit%( Fi!. /2./2 0 'odified &en holder for a child ,ith arthrogry&ho%i%( Fi!. /2./3 Self-'utilation in a child ,ith cerebral &al%y( Fi!. /2./4 ;a< and ;b< Trau'atic %elf-'utilation in a boy ,ith cerebral &al%ybefore and after the u%e of a co'&o%ition *%&lint* to &rotect the trau'ati5ed area( Fi!. /2.20 0 &alatal training &late de%igned to i'&ro$e li& and tongue &o%ture( /2.0 P5YSICA* I7PAIR7ENT SPINA ;IFIDA /2.0.0 Introd-"tion S&ina bifida occur% a% a re%ult of non-fu%ion of one or 'ore &o%terior $ertebral arche%, ,ith or ,ithout &rotru%ion of %o'e or all of the content% of the %&inal canal( )t 'ay be acco'&anied by hydroce&halu% in u& to >:L of ca%e%( )t i% e%ti'ated that in :9-!9L of affected children the defect i% inherited and that en$iron'ental agent% 'ay be re%&on%ible for the re'ainder( )n the #nited 2ingdo' the incidence i% (: &er =999 birth% and, unli/e other 'alfor'ation%, i% co''oner in fe'ale%( 0 Buarter of children

,ill al%o ha$e e&ile&%y and about a third ,ill ha$e %o'e degree of intellectual i'&air'ent( /2.0./ 6eneral "on#ideration# Children ,ith %&ina bifida ,ill, unle%% the defect i% %light, %&end 'uch of their ti'e confined to a ,heelchair ;6ig( =?( =< and be incontinent( #rinary tract infection% are co''on and the child 'ay be on freBuent cour%e% of antibiotic%( 1ydroce&halu%, unle%% arre%ted, i% treated by the in%ertion of a %hunt ;fitted ,ith a S&it5-1olter $al$e< to drain fluid fro' the $entricle% into either the %u&erior $ena ca$a or 'ore u%ually the &eritoneu'( )t i% i'&ortant to &rotect the $enou% %hunt fro' bloc/age, ,hich 'ay ari%e fro' a bacterae'ia of oral origin, other,i%e intracranial &re%%ure ,ill increa%e, cau%ing con$ul%ion%( 0lthough o&inion i% di$ided on the nece%%ity to co$er in$a%i$e dental &rocedure% in children ,ho ha$e a %hunt, tho%e erring on the %ide of caution ,ill u%e the %a'e &ro&hylaxi% regi'en a% in cardiac di%ea%e ;Cha&ter =!<( 1o,e$er, there i% no indication for antibiotic &ro&hylaxi% if the %hunt i% a $entriculo-&eritoneal one( Children ,ho are confined to a ,heelchair for 'uch of the ti'e ,ill need to be treated either in their chair or tran%ferred carefully to the dental chair( There are co''ercially a$ailable chair ada&tation% to acco''odate a &atient in their ,heelchair ;6ig( =?( <( The%e are hel&ful if the child i% too hea$y to tran%fer ea%ily to the dental chair or if the &rocedure i% 'ore ea%ily acco'&li%hed for the o&erator and &atient in thi% &o%ition( Sha&ed body %u&&ort%, ,hich are e%%entially 'odification% of a bean bag, are al%o a$ailable for u%e in the dental chair for any &atient ,ith a &hy%ical di%ability ,ho cannot other,i%e be co'fortably acco''odated( The%e %u&&ort% contain a 'aterial that allo,% the' to 'ould to the body %ha&e of the &atient and be re'oulded for %ub%eBuent &atient% ;6ig( =?( @<( Fi!. /2.2/ 0 girl ,ith %&ina bifida,heelchair-aided( Fi!. /2.22 0 cu%to'i5ed floor in%ert to acco''odate a &atient*% ,heelchair ;courte%y of Dr 0li%tair 4ole%, -ational Rehabilitation 1o%&ital, )reland<( Fi!. /2.23 Dental chair ,ith 'oulded cu%hion %u&&ort% ;courte%y of Dr 4itte 0hlborg, Mun-1-Center, S,eden<( /2.0.2 &ral %ealt% and o erati.e ro"ed-re# There i% little in the dental literature to %ugge%t that the oralDdental health of children ,ith %&ina bifida i% different fro' other children ,ith i'&air'ent%( The %a'e &rinci&le% of treat'ent a&&ly to the%e children a% to other% ,ho are i'&aired, na'ely aggre%%i$e &re$ention and early inter$ention ,ith a radical a&&roach if dental treat'ent under general anae%the%ia i% reBuired( /2.0.3 5ome "are The i%%ue% rele$ant to %&ina bifida ha$e been co$ered in the a&&ro&riate %ection% under intellectual and &hy%ical i'&air'ent( /2.5 P5YSICA* I7PAIR7ENT 7(SC(*AR DYSTR&P5Y

/2.5.0 Introd-"tion Mu%cular dy%tro&hy i% a grou& of 'u%cle di%ea%e% ,hich &re%ent a% &rogre%%i$e atro&hy and ,ea/ne%% of %/eletal 'u%cle% ,ith re%ultant di%ability and defor'ity( The 'u%cle fibre% degenerate and are re&laced by fatty and fibrou% ti%%ue( The di%ea%e i% e$entually fatal a% a re%ult of recurrent re%&iratory infection%( "re$alence rate% in children are of the order of A &er =99,999 children( /2.5./ 6eneral "on#ideration# The child ,ith 'u%cular dy%tro&hy ,ill initially be 'obile but a% the di%ea%e &rogre%%e%, they ,ill beco'e reliant on a ,heelchair to 'o$e around( 0 re%&irator ,ill be nece%%ary in the later %tage% of the di%ea%e and &atient% are then confined to ho'e or to re%idential care( There are a nu'ber of $ariant% of the di%ea%e ,ith different %ign% and %y'&to'%( Male% are exclu%i$ely affected in the Duchenne-ty&e, ,hile facial 'u%culature i% al,ay% affected in the fa%cio%ca&ulohu'eral-ty&e, but rarely in other for'%( /2.5.2 &ral %ealt% The oralDdental effect% of the di%ea%e are nu'erou% and includeG ,ea/ne%% of the facial 'u%cle%H &oor oral hygiene %econdary to the general inability to &ro$ide oral %elf-careH increa%ed dental decayH increa%ed &otential for &eriodontal di%ea%eH 'alocclu%ion %econdary to decrea%ed facial 'u%cle tone ,hile retaining tongue functionH decrea%ed &rotecti$e reflexe% and reduced ability to %,allo, or clear %ecretion% fro' the oro&harynx, thu% increa%ing the &otential for a%&iration( /2.5.3 & erati.e ro"ed-re# Con%ideration need% to be gi$en to ,heelchair tran%fer techniBue% and &adding a% ,ell a% the length of a&&oint'ent% ;%ee abo$e<( The u%e of %edation and general anae%the%ia 'ay need to be a$oided due to the decrea%e in re%&iratory function and the ri%/ of &o%t-anae%thetic co'&lication%( 6reBuent recall i% i'&ortant, ,ith a&&lication% of to&ical fluoride% and anti&laBue agent% ;9( L chlorhexidine gluconate<( There are no contraindication% to dental treat'ent, ,ith the exce&tion of orthodontic% becau%e of the changing 'u%cle force%( 0% a con%eBuence of tooth 'o$e'ent %een a% &art of the di%ea%e, and the li/ely de$elo&'ent of anterior or &o%terior o&en-bite%, &ro%thetic a&&liance% 'ay beco'e non-functional( /2.5.0 5ome "are 0&&ro&riate %u&&ort and training need% to be gi$en to the &arent or carer %o that in the later %tage% of the di%ea%e, ,hen contact ,ith dental %er$ice% 'ay be difficult, adeBuate &laBue control can be 'aintained( Dental treat'ent 'ay need to be &ro$ided

,ithin the ho'e en$iron'ent, although thi% ,ill u%ually be at the %tage ,hen the &atient ha% reached adulthood( )t i% i'&ortant that e$ery effort i% 'ade to o&ti'i5e oral function and facial a&&earance and thereby encourage a &o%iti$e %elf-i'age( /2.1 &T5ER 7(SC(*&S>E*ETA* I7PAIR7ENTS There are a $ariety of other defect%, %o'e degenerati$e and %o'e de$elo&'ental, ,hich al%o affect childrenH ho,e$er, the%e are relati$ely rare and unli/ely to be encountered regularly in &racticefor exa'&le, o%teogene%i% i'&erfecta, +u$enile arthriti%, and 'ulti&le %clero%i%( When &atient% &re%ent ,ith %uch di%abilitie% there 'ay be %ignificant oral %ign%, for exa'&le, in rheu'atoid arthriti% there i% an increa%ed incidence of S+ogren*% %yndro'e ;autoi''une< and anae'ia ;%econdary to anti-infla''atory and %teroid 'edication<( 0ggre%%i$e &re$ention i% $ital to &re$ent dental di%ea%e( /2.2 ;*INDNESS AND )IS(A* I7PAIR7ENT /2.2.0 Introd-"tion 8i%ual i'&air'ent% $ary fro' total blindne%% to %ight li'itation% of %i5e, colour, di%tance, and %ha&e( The &re$alence i% in the order of @ &er =999 children( /2.2./ &ral %ealt% The oral and dental health of children ,ith a $i%ual i'&air'ent i% no different fro' the nor'al &o&ulation and ,ith good ho'e care thi% can be 'aintained( )n the #nited 2ingdo' 'any children are educated in boarding %chool% and their %u&er$i%ion, ,ith regard to &er%onal hygiene and diet ;re%traint fro' bet,een-'eal %nac/ing<, often 'ean% that their oral health i% good( /2.2.2 & erati.e ro"ed-re# Con%ideration %hould be gi$en to the de%ign and for'at of ,ritten 'aterial a$ailable for u%e by &atient% ,ho 'ay be $i%ually i'&aired, for exa'&le, in%truction% for the ,earing of orthodontic a&&liance% and diet hi%tory %heet%( 1ighly %tyli5ed ty&e %hould be a$oided and a 'ix of u&&er and lo,er ca%e %hould be u%ed( 3etter% %hould be at lea%t one-eighth of an inch high ;about @ ''H =A &oint< and be on uncoated ;nonglare< &a&er( The be%t contra%t for ea%e of reading i% blac/ ty&e on ,hite or off-,hite &a&er( )t i% i'&ortant to a%%i%t the $i%ually i'&aired &er%on according to their indi$idual need%( "atient% ,ith a %ight defect ob+ect to being forcefully guided around by a nur%e or denti%t ,ho i% enthu%ia%tic to hel&( Many %ight-i'&aired &atient% ,ill ha$e an increa%ed %en%iti$ity to bright light% and &erha&% touch( The o&erating light %hould therefore be u%ed ,ith caution and the latter %hould be utili5ed to enhance the &atient%* &erce&tion of ,hat i% being doneH for exa'&le, being allo,ed to feel the in%tru'ent% and the dental chair( )t i% not unu%ual for &eo&le to %hout at tho%e ,ith a $i%ual i'&air'ent( Sight-i'&aired children are not u%ually deaf a% ,ell and %hould therefore be addre%%ed in a nor'al

$oice( )t i% i'&ortant to the &atient, and not only tho%e ,ith $i%ual i'&air'ent%, that con$er%ation i% addre%%ed to the' and not to the &er%on ,ith the'the %o-called *Doe% he ta/e %ugarJ* a&&roach( 4ecau%e $i%ion i% i'&aired and the %en%e of touch 'ay be heightened, it can be %tartling %uddenly to feel a cold 'irror in your 'outh ,ithout ,arning( 0 *tell-feel-then-do* a&&roach i% i'&ortant for the%e children ,ho 'ay be unner$ed by contact ,ithout fore,arning( With the%e con%ideration% in 'ind, there are no area% of dental treat'ent that are un%uitable for the child ,ith a $i%ual i'&air'ent, &ro$ided that they, or their &arent or carer, can 'aintain an adeBuate %tandard of oral hygiene( )n%ertion of orthodontic a&&liance% 'ay initially be difficult and techniBue% li/e flo%%ing ta/e ti'e to 'a%ter( /2.3 DEAFNESS AND 5EARIN6 I7PAIR7ENT /2.3.0 Introd-"tion 3o%% of hearing i% an i'&air'ent acBuired by 'any ,ith increa%ing age( 1o,e$er, %o'e children are born ,ith either a &artial or total lo%% of hearing and thi% can occur in i%olation or in co'bination ,ith other i'&air'ent%, for exa'&le, rubella %yndro'e ;auditory, $i%ual, intellectual, and cardiac defect%<( The &re$alence i% @ &er =999 children( /2.3./ 6eneral "on#ideration# "atient% ,ho ha$e hearing i'&air'ent 'ay be fearful, or e$en ho%tile, becau%e they feel they are not going to under%tand ,hat i% being a%/ed of the'( The child 'ay not hear ,hat ha% been %aid but &retend% they ha$e done %o to a$oid e'barra%%'ent( )n thi% %ituation $i%ual aid% a%%u'e an e$en greater i'&ortance( )t i% i'&ortant for o&ti'i5ing hearing that all extraneou% bac/ground noi%e i% re'o$ed ,hen co''unicating ,ith the hearing-i'&aired child( "i&ed 'u%ic in the %urgery, noi%e fro' the rece&tion area, a% ,ell a% internal noi%e% fro' a%&irator% and %ca$enging %y%te'% %hould be reduced or eli'inated( Many deaf or hearing-i'&aired children ,ill ,ear aid% ;6ig( =?( A< to enable the' to &ic/ u& 'ore %ound%, and older children 'ay ha$e beco'e %/illed not only in li&reading but al%o in %igning( 1o,e$er, there i% no, a trend to,ard% di%couraging the u%e of %igning and to &o%iti$ely encourage a child to acBuire %o'e %&eech, utili5ing any re%idual $ocal &otential( Fi!. /2.20 0 child ,ith Willia'*% %yndro'e ,earing hearing aid%( /2.3.2 &ral %ealt% There i% a &aucity of data concerning the oral health of children ,ith hearing i'&air'ent( 0% ,ith $i%ually i'&aired children, re%idence a,ay fro' ho'e in %&ecial boarding %chool% %o'eti'e% 'ean% that eating &attern% are 'ore de%irable dentally, ,ith le%% o&&ortunity for bet,een-'eal %nac/ing co'&ared to day &u&il%( Su&er$i%ion of oral hygiene 'ea%ure% can al%o be better in children li$ing in in%titution% and i% reflected in their oral hygiene %core%, but thi% i% $ery $ariable( 3i/e 'any other i'&aired children, hearing-i'&aired &atient% are initially ,ary of &o,ered

toothbru%he% becau%e of the %en%ation they &roduce intraorally( 4ut, although the%e bru%he% ha$e not been %ho,n to be better in ter'% of &laBue re'o$al than a ,ell'ani&ulated 'anual bru%h, in children &articularly, the no$elty a%&ect 'ay be a 'oti$ating factor to u%e thi% ty&e of bru%h to greater benefit( /2.3.3 & erati.e ro"ed-re# 6or tho%e children ,ho can li&-read it i% nece%%ary to %it ,ell in front of the child, ,ith good lighting to the o&erator*% face( 4oth denti%t and a%%i%tant %hould 'o$e their li&% clearly during %&eech and a$oid the te'&tation to %hout( Ma%/% are therefore to be &ut to one %ide and bearded o&erator% %hould en%ure that facial hair doe% not ob%cure clear $i%uali5ation of li& 'o$e'entI 0 co''ent a% to the be%t hearing %ide %hould be in%erted in the &atient*% note% %o that %taff are a,are of thi% at each $i%it( Children ,earing hearing de$ice% 'ay be di%turbed by the high-&itched noi%e &roduced by hand&iece% and ultra%onic %caler%( Thi% 'ay 'a/e the' le%% co-o&erati$e and le%% a'enable to treat'ent( Si'ilarly, the conduction of $ibration% fro' the hand&iece and bur% $ia bone i% 'ore di%turbing for the hearing-i'&aired child( 0fter initial co''unication% are co'&lete it 'ay be ad$i%able to %ugge%t that the hearing de$ice i% re'o$ed or turned off and only re-in%erted on co'&letion of the dental treat'ent in ti'e for final in%truction%( 8ery young children often ha$e difficulty /ee&ing the aid% in &lace %i'&ly becau%e of the %i5e of the i''ature &innae( Thi% i% e%&ecially %o ,hen lying %u&ine in the dental chair( /2.4 S(77ARY =( Children ,ith i'&air'ent% &re%ent the dental tea' ,ith the challenge of ada&ting fa'iliar %/ill% to ne, %ituation%( ( To 'eet thi% challenge effecti$ely ,e need to re-exa'ine %o'e of the %tereoty&e% of i'&air'ent ,e carry in our o,n 'ind%( @( 0n i'&air'ent beco'e% a di%ability by $irtue of other &eo&le*% attitude%, the thing% ,e do or do not do, the facilitie% ,e do not offer, a% ,ell a% the &hy%ical barrier% the en$iron'ent inter&o%e%( A( Oral and dental health are little different bet,een children ,ith i'&air'ent% and other%( What i% different i% the ty&e of treat'ent &ro$ided, ,ith 'ore 'i%%ing teeth and fe,er filled teeth in &o&ulation% ,ith i'&air'ent%( :( So'e children ha$e %&ecific oral condition% a% a re%ult of their i'&air'ent, for exa'&le, &eriodontal di%ea%e in Do,n %yndro'e( !( 0 degree of co''on-%en%e, a ,illingne%% to be flexible, a% ,ell a% a ,or/ing fa'iliarity ,ith the co''oner 'edical condition% and their i'&lication% for oral and dental health, are 'o%t of ,hat a general dental &ractitioner reBuire% to &ro$ide dental care for the child ,ith i'&air'ent% in hi% or her co''unity( /2./0 F(RT5ER READIN6

-unn, 7( 1( ; 999<( Disa,ility and oral care( 6D) World Dental "re%% 3td(, 3ondon( ;" comprehensive coverage of aspects of oral and dental care for people with disa,ilities(< -unn, 7( 1( ; 99@<( "re$enting childhood i'&air'ent( )n -he prevention of oral disease ;Ath edn<( ;ed%( 7( 7( Murray, 7( 1( -unn, and 7( G( Steele<, &&( 99-=!( Oxford Medical "ublication%, Oxford( ;" more comprehensive review of preventive aspects of oralCdental care(< Shu'an, S( 2(, 4ebeau, M( 7( ;=>>A<( Ethical i%%ue% in nur%ing ho'e careG &ractice guideline% for difficult %ituation%( S&ec Care Dent, /1, =?9-?( ;Covers criteria for the safe use of physical intervention(< Co&yright E 99: Oxford #ni$er%ity "re%%, 99:( 0ll right% re%er$ed( ;FD-< Sho, D 1ide 4ibliogra&hy