Академический Документы
Профессиональный Документы
Культура Документы
OPGD 804-04
2002 Sophomore Spring Semester
University of Louisville School of Dentistry
Orthodontic, Pediatric and Geriatric Dentistry
Faculty
Dr. Guy M. Furnish, Course Director
Dr. Kim Hansford
2
3
TABLE OF CONTENTS
Course Schedule________________________________________________________ 5
Course Description______________________________________________________ 6
Topic: Development of the Dentition (Freshman Spring) ____________________ 10
Dental Development Review Questions_____________________________________ 18
Topic: Examination, Diagnosis and Treatment Planning______________________ 22
Objectives ________________________________________________________________ 22
Slide Notes for Examination and Diagnosis _____________________________________ 24
Topic: Pediatric Dental Radiology and Radiographic Interpretation ___________ 34
Objectives ________________________________________________________________ 34
Slide Notes for Pediatric Oral Radiographic Technique __________________________ 35
Slide Notes for Radiographic Interpretation ____________________________________ 42
Panoramic Dental Radiology_________________________________________________ 55
Topic: Local Anesthesia & N
2
0-0
2
Inhalation Sedation ______________________ 61
Lecture Notes for Local Anesthetic Injections and Child Management ______________ 63
Maximum Dosage of Lidocaine with Epinephrine 1:100,000 ______________________ 66
Slide Notes for Local Anesthesia______________________________________________ 68
Lecture Notes for Nitrous Oxide-Oxygen Inhalation _____________________________ 74
Selection and Management of the Child Patient _________________________________ 74
Introduction ____________________________________________________________________ 74
Benefits to the Patient: ____________________________________________________________ 74
Benefits to the Dentist: ____________________________________________________________ 75
Characteristics __________________________________________________________________ 75
Contraindications ________________________________________________________________ 76
Equipment______________________________________________________________________ 76
Introducing N
2
0-0
2
to the Child _____________________________________________________ 77
Technique of Initial Administration __________________________________________________ 77
Topic: Sealants and the Preventive Resin Restoration (PRR) ___________________ 79
Objectives ________________________________________________________________ 79
Lecture Notes for Preventive Dentistry, Sealants and Preventive Resin Restorations __ 81
Patient Record___________________________________________________________________ 81
Plaque Control __________________________________________________________________ 81
Diet Control ____________________________________________________________________ 81
Toothbrush vs. Rubber Cup Prophylaxis ______________________________________________ 81
Sealants________________________________________________________________________ 82
Supplemental Fluoride ____________________________________________________________ 82
Alternatives to Community Fluoridation ______________________________________________ 83
Practical Considerations of Supplementation___________________________________________ 83
Topical Fluoride Therapy __________________________________________________________ 84
Office Therapy __________________________________________________________________ 85
4
Home Therapy __________________________________________________________________ 86
Sample Fluoride Gel Prescription____________________________________________________ 86
Fluoride Recommendations for Orthodontic Patients_____________________________________ 86
Safety _________________________________________________________________________ 88
Safety with Topically Applied Fluoride _______________________________________________ 90
Safety with Home Fluoride_________________________________________________________ 90
Topic: Pediatric Restorative Dentistry _____________________________________ 91
Topic: Pulp Therapy for the Primary Dentition and Young Permanent Teeth _____ 93
Objectives ________________________________________________________________ 93
Lecture Notes for Treatment of Deep Caries, Vital Pulp Exposure, and Pulpless Teeth in
the Child and Adolescent ____________________________________________________ 95
Diagnostic Aids _________________________________________________________________ 95
Evaluation of Treatment Prognosis before Pulp Therapy__________________________________ 97
Vital Pulp Therapy - Treatment of the Deep Carious Lesion - Indirect Pulp Cap _______________ 98
Direct Pulp Cap ________________________________________________________________ 102
Vital Pulp Therapy ______________________________________________________________ 104
Summary of Pulpotomy Studies ____________________________________________________ 107
Non-Vital Pulp Therapy - Pulpectomy_______________________________________________ 108
Non-Vital Pulp Therapy - Apexification _____________________________________________ 112
Past Examples Of Midterm & Final Exams ________________________________ 114
5
COURSE SCHEDULE
Pediatric Dentistry I - OPGD 804-04
Sophomore Spring 2002
Fridays - 1:00 P.M. - Room 103
DATE LECTURE TITLE SPEAKER
January 4 Course Introduction Furnish
Examination & Diagnosis Furnish
January 11 Examination & Diagnosis Furnish
January 18 Examination & Diagnosis Furnish
January 25 Pediatric Oral Radiology Furnish
February 1 Pediatric Oral Radiographic Interpretation Furnish
February 8 Pediatric Oral Radiographic Interpretation Furnish
February 15 Pediatric Oral Radiographic Interpretation Furnish
February 22 M I D T E R M
March 1 Local Anesthesia and N
2
0-0
2
Inhalation Sedation Hansford
March 8 Prevention, Sealants and PRRs Hansford
March 15 Restorative Dentistry Furnish
March 22 Pediatric Pulp Therapy I Furnish
March 29 Pediatric Pulp Therapy II Furnish
April 5 S P R I N G B R E A K Furnish
April 12 Sample Cases/Treatment Planning Furnish
April 19 F I N A L
April 26 Finals Week
6
COURSE DESCRIPTION
1. Course Title: Pediatric Dentistry I - OPGD 804-04
[1 credit hour]
2. Time and Location: Friday afternoons from 1:00 to 1:50 p.m. (Room 103)
3. Faculty: Dr. Guy Furnish (Course Director)
Dr. Kim Hansford
4. Office Hours and Information About Course Director:
Guy M. Furnish, DMD
Associate Professor, Pediatric Dentistry
Office room number: 306B
University telephone number: 852-5126
Office hours: posted on office door
Home telephone number: 451-1580
Department secretaries: Roxie Williams and Evelyn Tanner
Room 319 [852-5124]
5. Required Text: Pediatric Dentistry, Infancy Through Adolescence, 3rd Edition, J. R.
Pinkham, W. B. Saunders Co., Philadelphia, 1999. This text is used for junior courses as
well.
6. Course Content:
You have just completed a lecture and laboratory course designed to acquaint students
with basic psychomotor skills pertinent to contemporary pediatric dentistry. Exercises on
alginate impressions, diagnostic casts, amalgam restorations and stainless steel crowns
were included. The Orthodontic Laboratory Course taken concurrently and other
orthodontic courses in the near future will address psychomotor skills in arch length and
cephalometric analysis and fabrication of appliances commonly employed to manage the
developing occlusion, such as space maintainers, space retainers, crossbite correction
appliances, oral habit appliances and Hawley appliances.
This lecture course presents a brief introduction to the Pediatric Dentistry Clinic designed
to give the basic knowledge and clinical skills necessary for management of the simplest
and most basic pediatric patient needs. This will include an introduction to the Pediatric
Dentistry Clinic and its forms, procedure, treatment planning and case presentation
pertinent to dentistry for children, pediatric oral radiology, operative dentistry, preventive
techniques and theories, pulp therapy and an overview of what to expect encountering the
personality of the child patient. This course directly contributes to the attainment of
skills listed under ULSD Major Competencies 2, 5, 7, 9, 10, 12, and 14.
It is the first of two lecture courses designed to fulfill the Curriculum Guidelines for
Predoctoral Pediatric Dentistry developed by the Section of Pediatric Dentistry of the
American Association of Dental Schools. Objectives are given for each lecture as an aid
7
in preparing for examinations. An excellent required text is utilized in this course and
throughout the remaining pediatric dentistry courses given in your junior year. Buy it.
You wont be sorry.
After reviewing suggestions for improving this course obtained from last year's students,
the Department has decided to make a few changes in the format of the course.
Unfortunately, moving the class to another time slot, not after lunch or right before clinic
was not possible.
This year, in an attempt to make the class period more stimulating, we are changing from
a strict lecture/slide format to one that is more interactive. There are pre-class reading
assignment responsibilities. Each week you will be given a reading assignment that must
be read prior to class time. During class you will be quizzed, either orally or in writing,
on the material contained in the reading assignment. You will also be called upon at
random to respond to questions concerning pertinent patient examples presented in a
format that is similar to the format of the case analysis section of the Part II National
Boards.
7. Grading/Remediation:
Students will be evaluated on attendance, quizzes, a midterm and a final examination.
You will be responsible for material covered in all classes and handouts and assigned
readings from the required text that should be brought to class. Testable material will be
compatible with the objectives as outlined in the course description.
A one-hour midterm examination will count 30% of the final course grade and a one-hour
plus cumulative final examination will count 50%. Quizzes will be given most weeks and
will count 20% of your grade.
Quizzes 20%
Midterm 30%
Final 50%
The lectures offered in this course contain visual information we feel is necessary for the
student to successfully complete his or her clinical assignment. Attendance will be
recorded off quizzes or by student signature on the class roster distributed from the start
of the lecture until 15 minutes after the hour. Punctual attendance for lectures is expected.
More than one unexcused absence will result in a drop of one letter grade.
The course grading scale is as follows:
A 90 to 100
B 80 to 89
C 70 to 79
F 0 to 69
All scores on examinations will be adjusted such that test items that were clearly
negatively discriminating are eliminated.
8
In the event of a failing grade, the student will have to perform satisfactorily on a written
make-up examination within two weeks of the end of the semester. The highest course
grade attainable will be a "C," regardless of your performance on the make-up exam.
Satisfactory performance on the make-up exam will raise that student's grade to a "C.
Double failures, in the absence of extenuating circumstances, will require repetition of
the course.
8. Unethical Behavior:
The Department of Orthodontic, Pediatric and Geriatric Dentistry takes a grim view and
an aggressive stance on cheating and other unethical behavior. Students accused of a
breach of ethical conduct will be reported in accordance with "The Code of Professional
Responsibility and the Bylaws of the Student Review Council of the University of
Louisville School of Dentistry (the official document given to all students). In any
hearing resulting from such an accusation, the department's recommendations will
usually range from a course failure with no available mechanism to make up the grade
(until the full course is successfully completed the following year) to dismissal from
school with the etiology of the dismissal clearly and permanently stated on school
records.
9. Reading Assignments Covered on Quizzes:
DATE CHAPTER AND PAGES TOTAL PAGES
January 4
First 2 pages of Growth and Development handouts and
Sophomore Preclinical Course alloy and stainless steel
preps
January 11
Chapter 1 (3-11) Pediatric Dentistry
Chapter 12 (139-183) Dynamics of Change Birth to 3
Chapter 13 (184-193) Infant/Toddler Exam
64
January 18 Chapter 17 (251-264) Dynamics of Change Age 3-6
Chapter 18 (265-286) Exam/Diag./Tx. Planning, 3-6
36
January 25
Chapter 29 (427-444) Dynamics of Change Age 6-12
Chapter 30 (446-474) Exam/Diag./Tx. Planning, 6-12
Chapter 36 (579-592) Dynamics of Change-Adolescence
Chapter 37 (594-617) Exam/Diag. & Tx. Planning/General
Orthodontics-Adolescence
84
February 1
Chapter 18 (280-284) All previously read.
Chapter 30 (469-474) All previously read.
Chapter 37 (607-610) All previously read.
15
February 8 &
15
Same as February 4
February 22 Midterm - All of the above
9
March 1 Chapter 5 (69-73) Pediatric Physiology
Chapter 6 (74-83) Nonpharmacologic Issues/Pain Control
Chapter 7 (85-91) Pain and Anxiety Control/Pain
Perception Control
Chapter 28 (411-417) Local Anesthesia
29
March 8 Chapter 32 (481-517) The Acid-Etch
Technique/Sealants/PRR
37
March 15 Chapter 20 (296-308) Dental Materials
Chapter 21 (309-339) Restorative Dentistry for the Primary
Dentition
44
March 22 Chapter 22 (341-354) Pulp Therapy for Primary Dentition
Chapter 33 (522-530) Pulp Therapy for Young Permanent
Teeth
23
March 29 Same as March 24
April 5 Spring Break
April 12 Chapters 14, 19, 31, 38 Prevention of Dental Disease 36
April 19 Final Exam - All of the above
10
TOPIC: DEVELOPMENT OF THE DENTITION
(FRESHMAN SPRING)
Objectives:
Students should be able to:
l. Identify the extent of development of the primary and permanent dentition at each of the
following times:
6 weeks in utero
Dental lamina begins as invaginations of the oral ectoderm; gives rise to the deciduous
tooth buds at 6 weeks in utero.
14-18 weeks in utero
Calcification of all primary teeth begins in the following order: centrals, 1
st
molars,
laterals, canines, 2
nd
molars
Birth
primary centrals, laterals, crowns nearly complete
primary canines l/3 crown completion
primary 1
st
molars 3/4 crown completion
primary 2
nd
molars l/4 crown completion with occlusal calcification incomplete
permanent 1
st
molars may show calcification
3 to 5 months
all permanent anterior teeth (centrals, laterals and canines) begin calcification with the
exception of maxillary laterals that begin at 10 to 12 months
6 to 8 months
first primary tooth erupts (mandibular central incisor)
2 1/2 years
all primary teeth erupted (2 l/2 years)
1
st
premolars begin calcification
3 years
primary teeth in occlusion, apices closed
2
nd
premolars and permanent 2
nd
molars begin calcification
permanent 1
st
molar crown complete
11
4 5 years
permanent central and lateral crowns completed
6 years
first permanent tooth erupts (mandibular central or first molar)
7 years
crowns of all permanent teeth are completed except 3
rd
molars (remember that 14
weeks in utero to 7 years of age is critical calcification time for esthetics)
6 8 years
early mixed dentition
Permanent 1
st
molars, central and lateral incisors erupt
8 years
Permanent 2
nd
molar crowns completed
8 - 10 years
middle mixed dentition
lower canines erupt at 9 -10 and all first premolars erupt
3
rd
molars begin calcification
10 13 years
late mixed dentition
2
nd
premolars, upper canines, 2
nd
molars erupt
apexogenesis of permanent incisors and first molars at approximately age 10
Note: The patients chronological age is of less value than the patients dental age when
supervising the developing dentition. Root development is the best guide to dental age.
Apexogenesis ages are an important consideration when planning endodontic
treatment.
17 21 years
eruption of 3
rd
molars
2. Identify the normal eruption sequence and eruption age in months of the primary dentition.
centrals (6 - 8)
laterals (7 - 9)
1
st
molars (12 14)
canines (16 18)
2
nd
molars (20 24)
12-month-old has 12 teeth, 16-month-old has 16 teeth, 2-year-old has 20
3. Define the terms natal and neonatal teeth.
Natal teeth are present at birth; neonatal teeth erupt within 30 days after birth.
12
4. Identify the characteristics of the normal primary dentition.
Ovoid arch
No curve of Spee - flat occlusal plane
Shallow cuspal interdigitation with slight overbite and overjet
Primary incisors stand more upright than their permanent successors
Little crowding - usually interdental spacing (see #5)
Terminal plane relationship (see #10): straight or flush 50% (most common), mesial step
25% (most ideal), distal step 25%
5. Identify the two morphological arch forms of the primary dentition.
There is normally spacing between all the anterior primary teeth. This is often a concern of
the parents who miss the adult looking (lack of spacing) smile. However, while spacing may
not be pretty, it is normal and desirable.
Type I -- spaced (generalized interdental spacing -- primate spaces)
Type II -- unspaced (no generalized interdental spacing -- no primate spaces)
No spacing appears interdentally as the child gets older if the child never had spaces.
The more spacing there is the less chance of later crowding.
A primary dentition with no spaces is quite likely to have crowding later. If there is
crowding in the primary dentition, rest assured there will be crowding in the permanent
dentition.
6. Define the term primate spaces.
Spaces found between maxillary canines and laterals and the mandibular canines and 1
st
molars in the primary dentition.
7. Differentiate between accessional and successional teeth.
Accessional teeth erupt distal to the primary dentition. Successional teeth replace teeth in the
primary dentition.
13
8. Identify the normal eruption sequence and eruption age in years of the permanent dentition.
Sequence of permanent tooth eruption: maxillary arch 6-1-2-4-5-3-7
mandibular arch 6-1-2-3-4-5-7
Age of permanent tooth eruption in years:
maxillary arch mandibular arch
1
st
molars 6-7 1
st
molars 6-7
centrals 7-8 centrals 6-7
laterals 8-9 laterals 7-8
1
st
premolars 10-11 canines 9-10
2
nd
premolars 10-12 1
st
premolars 10-12
canines 11-12 2
nd
premolars 11-12
2
nd
molars 12-13 2
nd
molars 11-13
3
rd
molars 17-21 3
rd
molars 17-21
9. Identify the characteristics of the transition from primary to permanent dentition.
There is an increase in the incidence of malocclusion with minor crowding.
Slight mandibular anterior crowding is normal at age 7 to 8, when the permanent incisors
and first molars have erupted but the primary canines and molars are retained.
This crowding is later relieved by a slight increase in bicanine width, labial positioning of
the permanent incisors relative to the primary incisors, and a slight distal and buccal
repositioning of the canines as the lateral incisors erupt.
There is a decrease in both arch length and arch circumference in the transition to the
permanent dentition. Between 10 and 13 years of age the maxillary arch circumference
decreases 1-2 mm and the mandibular arch decreases 3-4 mm.
Bimolar width increases 4 mm in the maxillary arch up until age 10 and decreases slightly in
the mandibular arch.
Perhaps the main point to remember is that after age 3, there is no significant skeletal growth
in the front of the jaws. Therefore, growth will not overcome any significant early crowding
and the crowding will persists into the permanent dentition. That is why crowding of the
incisorsthe most common form of Angles Class I malocclusionis by far the most
prevalent form of malocclusion.
14
10. Identify a distal step, mesial step, and a straight (flush) terminal plane relationship of the
second primary molars and their impact on the position of the first permanent molars in the
mixed dentition.
These primary molar relationships determine the position of the permanent first molars. Note
that the word distal in distal step refers specifically to the distal surface of the lower
primary second molar being distal to the distal surface of the upper second primary molar.
The flush terminal plane relationship, shown in the middle left, is the normal relationship in
the primary dentition. When the first permanent molars first erupt, their relationship is
determined by that of the primary molars. The molar relationship tends to shift at the time
the second primary molars are lost and the adolescent growth spurt occurs, as shown by the
arrows. If leeway space is inadequate and there is no differential forward growth of the
mandible, the change will be that shown in the top line. With available leeway space but
without good growth, the change will be that shown by the dotted line. With good growth
and a shift of the molars, the change shown by the bottom double line can be expected. One
can see that distal steps lead to Class II relationships, flush terminal planes usually lead to
Class I relationships but can lead to a Class II. Mesial steps nearly always lead to a Class I
but can lead to a Class III depending on the patients growth pattern.
15
11. Define " leeway space" and identify its significance.
Leeway space is the difference in mesial-distal dimension of the primary canine, 1st and 2nd
molar, and the permanent canine, 1st and 2nd premolars in each quadrant. It is used to
permit relief of permanent incisor crowding, mild amounts of which are usually present after
incisor eruption. It also provides for a late mesial shift of the first permanent molars when
necessary. Nance determined leeway space to be .9 mm in the maxillary arch and 1.7 mm in
the mandibular arch. Moyer determined it to be 1.3 mm in the maxillary arch and 3.1 mm in
the mandibular arch.
12. Identify how the arch forms (spaced and unspaced) and mesial and flush terminal planes can
occur in various combinations in different children and result eventually in proper Class I
occlusions.
A 5-year-old with a spaced dentition with mandibular primate spaces and a flush terminal
plane relationship will undergo an "early mesial shift" closing the primate spaces and
become a Class I molar relationship at age 6 to 7.
A 5-year-old with an unspaced dentition with no primate spaces and a flush terminal plane
will undergo a "late mesial shift" utilizing the leeway space and become a class I molar
relationship at age 10 to 13.
"Early mesial shift" denotes the closing of mandibular primate spaces on eruption of
permanent 1st molars. "Late mesial shift" denotes the closing of the leeway spaces by the
mesial drifting of the permanent 1st molars on loss of the primary 2nd molars.
Flush terminal plane
mandibular primate space
Early mesial shift
closing primate space
at 6-8 yrs. of age
Class I molars
5 yrs. of age
Late mesial shift
utilizing leeway space
10-13 yrs. of age
Flush terminal plane
no mandibular primate space
16
17
13. Identity the "ugly duckling" stage and its significance.
Frequently, the maxillary incisors erupt into the oral cavity with a strong distal inclination of
their crowns. This is because as the lateral incisors erupt, the canines higher up are literally
sliding down the distal surfaces of the developing roots of the lateral incisors. This tends to
force the apices of these roots toward the midline, while the crowns tend to flare laterally.
As the canines continue to erupt, however, there is an autonomous straightening up of the
lateral incisors. The temporary spacing that often occurs between the crowns of the centrals
and laterals is usually closed (if no greater than 2mm) as the canines erupt into complete
occlusion. This is a most hazardous time to place appliances due to the chance of damaging
the apices of the maxillary laterals and the possibility of deflecting the permanent canines
from their normal path of eruption.
Illustrations and references: Contemporary Orthodontics. 3rd edition, William R. Proffit, C.
V. Mosby Co.
18
DENTAL DEVELOPMENT REVIEW QUESTIONS
1. There is no other organ of the human body that takes so long to attain its ultimate
morphology as the ________________.
2. There are six histogenic events or stages that participate in the progressive development
of the teeth. These are initiation (bud stage), ________________ (cap stage),
__________________, ________________(bell stage), ______________, and
________________.
3. The first sign of human tooth development is seen during the __________ week of
embryonic life.
4. Interference with the stage of _______________________ may result in extra cusps or
roots, suppression of cusps or roots, fusion, or gemination.
5. Peg-shaped teeth, micro or macrodontia, dens-in-dente, Hutchinsons incisors, Mulberry
molars, or dilaceration could occur due to disturbances in the stage of
______________________________.
6. Interference during the stage of _________________________ may result in
amelogenesis imperfecta or osteogenesis imperfecta.
7. Missing or extra teeth could be the result of interference in the
____________________________ stage.
8. Hypocalcification may be the result of interference in the
______________________________ stage of tooth development.
9. Hypoplasia may be the result of interference in the __________________________ stage
of tooth development.
10. Calcification of all primary teeth begins between _____ to _____ months in utero.
11. Enamel deposition is completed in all the primary teeth before birth.
True or False? (circle)
12. The crowns of all primary teeth have usually completed calcification by one year of age.
True or False? (circle)
13. The average eruption sequence and eruption age of the primary teeth
is as follows:
____________________ (_________ to _________ months)
____________________ (_________ to _________ months)
____________________ (_________ to _________ months)
____________________ (_________ to _________ months)
____________________ (_________ to _________ months)
19
14. Mandibular teeth usually precede their maxillary counterpart in eruption.
True or False? (circle)
15. Inclusion cysts are relatively common in newborn infants.
True or False? (circle)
16. Match the following:
A. Bohn's nodules B. Dental lamina cyst C. Epstein's pearls
________ inclusion cysts found along the mid-palatine raphe
________ inclusion cysts found along the buccal and lingual aspects of the dental
ridges
________ found along the crest of the alveolar ridges in newborns
17. When encountering natal or neonatal teeth, you must decide if the teeth are
_____________________________ prior to deciding on treatment.
18. A bluish-purple elevated area of tissue that has developed on the gum pad a few weeks
prior to the eruption of a tooth is called a ____________________. Treatment is
unnecessary.
19. A. _______________________________
B. _______________________________
C. _______________________________
D. _______________________________
20. Spacing in the primary dentition ranges from 0 to 10 mm in the maxillary arch, with an
average of ______mm. The range in the mandibular arch is 0 to 6 mm, with a mean of by
______mm.
21. Ideal overbite in the primary dentition is _______ mm.
Ideal overbite in the permanent dentition is______ mm.
Ideal overjet in the primary dentition is _______ mm.
Ideal overjet in the permanent dentition is _______mm.
22. The relationship of the maxillary and mandibular primary canines is one of the most
stable throughout the primary dentition. It is the best indication of the actual relationship
of the maxilla to the mandible. True or False? (circle)
23. If the terminal plane relationship of the primary molars is a mesial step, the first
permanent molars will probably erupt into a Class ______ relationship
24. If the terminal plane relationship of the primary molars is a distal step, the first permanent
molars will erupt into a Class ______ relationship.
25. In a spaced dentition with second primary molars displaying a flush terminal plane, the
eruptive force of the first permanent molars will tend to close the spaces. With the
20
_______________ spaces located mesial to the maxillary primary canines and distal to
the mandibular primary canines, the shifting of the mandibular primary molars to allow a
Class I molar relationship is favored. This is referred to as the
________________________________.
21
26. The ________________________________ refers to a mesial shifting of the first
permanent molar into a Class I relationship following the loss of the second primary
molar. This relationship is possible due to a size differential between the primary
posterior teeth and their permanent successors and has been termed by Nance as
_______________________________.
27. The four average maxillary permanent incisors are 7.6 mm larger than the primary
incisors they replace. The four mandibular permanent incisors are 6.0 mm larger than the
primary incisors they replace. This inverse size differential has been termed
___________________________________.
28. With luck, a combination of four factors, either singular or in combination, allows larger
permanent teeth to fit into the arch without crowding. They are:
1.______________________________________________________________
2.______________________________________________________________
3.______________________________________________________________
4.______________________________________________________________
29. Broadbent has referred to the period from the eruption of the maxillary lateral incisors to
the eruption of the maxillary canines as the ____________________ stage. This is often
a time of patient and parental concern over anterior esthetics.
30. Permanent first molar root formation is completed by age _____.
Permanent mandibular incisor root formation is completed by age _____.
Permanent maxillary incisor root formation is competed by age _____.
31. Fill in the eruption ages of the following permanent teeth:
A. Mandibular canine _____ to _____ years
B. Maxillary first premolar _____ to _____ years
C. Mandibular first premolar _____ to _____ years
D. Maxillary second premolar _____ to _____ years
E. Mandibular second premolar _____ to _____ years
F. Maxillary canine _____ to _____ years
G. Mandibular second molar _____ to _____ years
H. Maxillary second molar _____ to _____ years
32. A childs blood pressure increases with age. A 3- to 5-year-old has an average blood
pressure of 100 / 60. A childs pulse and respiration rates decrease with age. A 3-year-old
has an average pulse of approximately 105 and a respiration rate of 30 / min. A 5-year-
old has an average pulse of approximately 100 and a respiration of 26 / min.
33. Cleft lip is caused by a disruption of the developmental process in the 4
th
to 7
th
weeks of
fetal development. Cleft palate develops in the 8
th
to 12
th
intrauterine week. The
mandibular symphysis is fused by the childs first birthday.
22
TOPIC: EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING
Reading Assignment
Pediatric Dentistry, Infancy Through Adolescence, 3
rd
Ed., Pinkham,
Orientation to the text (pp. ix, and x)
Chapters 1 (pp. 3-11)
Section I (pp. 139-140)
Chapter 12 (pp. 141-183)
Chapter 13 (184-193)
Section II (p. 251)
Chapter 17 (pp. 253-264)
Chapter 18 (pp. 265-286)
Section III (pp. 427-428)
Chapter 29 (pp. 429-444)
Chapter 30 (pp. 446-474)
Section IV (p. 579)
Chapter 36 (pp. 581-592)
Chapter 37 (pp. 594-617)
Objectives
Upon completion of the reading assignment and attendance at class lecture, the student
should be able to:
1. describe the physical changes (body, craniofacial and dental) taking place from
conception through adolescence;
2. describe the cognitive changes taking place from birth through adolescence;
3. describe the emotional changes taking place from birth through adolescence;
4. describe the social changes taking place from birth through adolescence;
5. describe the epidemiology and mechanisms of dental disease as it affects children from
birth through adolescence;
6. describe the objectives of the infant and toddler examinations;
7. describe the steps of the infant examination;
8. describe the emergency examination;
9. describe the management of electrical burns of the mouth;
10. describe the clinical implications of pre-term birth;
23
11. describe the role of the dental personnel in introducing the child to dentistry;
12. describe the role of the parent in introducing the child to dentistry;
13. describe proper methods for separating a reluctant child from his/her parent;
14. describe the need for honesty in dealing with the child patient;
15. describe the purpose of a systematic approach to the examination and the components of
the physical assessment of a child patient;
16. describe the purpose for the medical and dental history questions appropriate for
children;
17. identify normal and abnormal in the child's mouth;
18. describe the rationale and method for entering progress notes in the pediatric dental
record;
19. identify factors that affect treatment decisions;
20. describe the rationale for sequencing treatments; and
21. describe a general systemic approach to treatment planning.
24
Slide Notes for Examination and Diagnosis
1. The initial diagnosis begins with a telephone call from the parent. Your impression of the
child begins in the waiting room. Does the child hide behind Mom. Does the child cower
or like the place. Don't confront the child with too bold an approach. Things that you
should notice; stature, gait, speech, fast, slow, alertness. Smile. Compliment something,
nice clothes, shoes, haircut, etc. Use a slow approach, a pleasant approach. Don't loom
over the child. Talk to the child, be at ease, take your time, be prepared, have everything
ready. Re-read your manual and review the chart beforehand. Know what you are going
to do, and you won't fumble as much.
. The child can tell if you are under stress. If you are, the child is also. Stand back, look
and talk. Does the child give you eye contact? Is the child bright, alert, confident, scared,
anxious, or evasive? This lets you know if you can approach the child and at what speed.
2. The parents will have filled out the first two pages of the chart before you see the child
on the first visit. Pay careful attention to the health history and the past dental history.
3. Most children will greet you with a smile. This is a new experience for them. If there is a
significant item noted in the medical history, a medical consult would have to be obtained
before any treatment can be accomplished. If a consult has been obtained, it will be in the
pocket of the chart. Look in the pocket of each chart to see if there is a medical consult
form.
4. Children usually like some physical contact. If they will accept it, hold a hand, touch an
arm or shoulder when complimenting. "Hey, you are doing a good job! Thank you."
Praise goes a long way. You may be the only person to ever thank them. Smile. Smell
good. Be compassionate.
5. Everybody is somebody. We all like to be noticed, feel important, succeed. Use this
information to your benefit. Compliment the child about his clothes. Ask about pets,
brothers and sisters. Everybody likes to succeed. Get the child on your side. A good
assistant is invaluable.
6. If the child is anxious or afraid, you have to go slower. Talk softly and be assuring. Tell
the child what you are going to do. It's easy, we're going to have some fun today."
7. How does the child perceive you? Does he have bright eyes and a smile or a cold stare
and distrust? Use your personality and intuition. Get the child on your side.
8. A drawing from one of Dr. Walker's patients. This child saw the dentist as a bloodshot-
eyed, big person with a bloody drill, approaching a small scared child. Do you trust
anybody in your mouth? Put yourself in their shoes.
9. If the child is anxious, or quiet and you want to get something started, ask if she has a
hand. Looking at a hand is not threatening. Turn it over and look at the other side. "Do
you have another one?" Look at it. "You really have some hands there, young lady." Now
I'm going to look at your lips. Look and write something down.
25
10. On the initial visit and on recall, the child should be weighed and measured for height.
This is a non-threatening way to get started. Talk to the child. Ask questions. Break the
ice.
11. Hey, have you ever had your arm pumped up?" Check for nodes, look around, and dont
miss anything.
12. Recheck the chart. If the child is old enough, ask about health history. Fill out the rest of
the chart - the preventive page.
13. The oral exam begins with the fingers. Im going to look at your front teeth. If the child
won't open, push the lips apart and say "very good, that's a nice job." Write something
down, be casual. Say "open" and look again. Great!" Usually you get a little more done
each time. In and out. If the child is anxious, many in and outs are better than one long
look. Get the child used to following directions. Don't let them talk on and on and thus
evade the procedure. Say "open" and back up, praise the child. Look at soft tissue first,
then the occlusion. Does the child have any oral habits?
After face, lips and all other soft tissue has been accounted for, look at the teeth. Check
for position, number, color and caries. What radiographs will be necessary for further
information?
14. This is a nice looking lower arch of a child between three to five years of age. There are
ten teeth in each arch in the primary dentition - incisors, canines and molars - no
premolars. When primate spaces are present, they are distal to the lower canines and
mesial to the upper canines. You like to see primate spaces because they add additional
room for the larger permanent incisors. Dry the teeth with short bursts of air.
Demonstrate the air away from the patient first, then on the childs hand and finally in
their mouth - a short burst. Talk while you are doing the exam. Don't ask for permission
saying May I look at your teeth? If the child says no - then what are you going to do?
Don't ask for permission - make declarative statements. Get in the chair so we can get
started. Let's go take some pictures. Open.
Tell the child what you are going to do. "I am going to count your teeth." Count out loud.
"Hey, you really have a lot of teeth. Did you know you have 20 teeth?" The upper arch is
ovoid. Look at the color of the tissue. This is a healthy looking mouth.
15. Class I primary dentition. Mesial step. Upper central is wider than the lower central.
Upper central touches lower central and lateral. Upper lateral touches lower lateral and
canine. This is what you want to see - each tooth in each arch touches two teeth in the
opposing arch. You also want to see generalized spacing in the primary dentition.
A Class II primary dentition. In a Class II dentition, the upper arch is generally the
offender and is more forward with a resulting horizontal overjet. Now the teeth will not
interdigitate when in occlusion but will occlude one on one.
16. Both slides depict Class II primary dentitions. The one on the left has a large overjet but a
near normal overbite. The slide on the right has a large open-bite but a near normal
overjet. This is caused by two different habits. On the left - thumb. On the right - tongue.
26
17. Class III primary dentition. This is usually a genetic pattern. Look at the parents. The
lower arch is usually the offender in Class III malocclusion. It grows out from under the
upper arch.
18. Prominent chin of a Class III dentition.
Mixed dentition (both primary and permanent teeth present), with a maxillary
constriction resulting in a unilateral convenience cross-bite. If it were a simple unilateral
cross-bite, the upper and lower centrals would line up.
19. A 7-year-old with caries in the distal of both lower 1st primary molars. You can see the
caries appears deep. Don't bury an explorer in the caries - it will hurt the child
unnecessarily and you won't learn anything new. Lower 1st permanent molars will
usually come in 6 months before the upper 1st permanent molars. The upper centrals will
line up on their own if there is no habit and no excessive crowding.
20. Anterior view of the same child. Normal pigmentation.
Fill out the caries chart the best you can before radiographs are taken. In this manner we
can best prescribe what radiographs to take.
21. After the charting has been finished up to this point - call an instructor over. The
instructor will review the chart, the patient and then indicate which radiographs are
needed to finish the exam.
22. Protect the child with a lead apron and a collar
Show the child the film and the machine. Explain that you are taking a picture of her
teeth and she will have to be very still.
23. If a panoramic film is indicated, you or an assistant will take it.
24. This is a nice bitewing of a three-year-old. A permanent molar is developing in the lower
corner of the film behind the 2nd primary molar. There is spacing between the teeth and
this is good in the primary dentition. No caries present.
Panorex of a 3-year-old. Look for symmetry. Count the teeth. 10 primary teeth in each
arch. The developing permanent canines are the lowest teeth in the lower arch and the
highest teeth in the upper arch. Get used to finding these teeth first when looking at a
Panorex of the mixed dentition. From these teeth you ought to be able to name the rest of
the teeth.
25. The interview and counseling portion of the visit is best accomplished prior to the
examination of the infant or toddler. When you are examining an infant, know what you
are looking for. Youll take a short, loud look. The infant will cry as soon as you place
him on his back and put your finger in his mouth. Use gauze to wipe saliva out of the
way. Get a good long look and then give the child back to mom. Then talk about it, it will
be quieter.
27
If you want to demonstrate to the parent - an exam or brushing technique place two chairs
facing each other - knee to knee. The infant is on his back with his head in your lap, the
heel of your hands on the infants cheeks. Mom has the infant's legs under her elbows and
holds the infant's wrists. Do what you need to do and get it over with and the infant back
up in vertical position.
26. This is the lower arch of a 6 1/2-year-old. It has nice ovoid form, 6-year molars are in,
and the tissue color looks good. The exam should be painless. If you don't dry the teeth
before using an explorer and the caries entrance is the same size as the explorer -
hydraulic pressure can be generated if you forcibly push the explorer in the hole. This
increased pressure can cause a lot of pain. If the teeth were dry before doing the same
exam - no problem and you can see so much better.
This is a good-looking ovoid upper arch. The upper teeth usually come in about 6 months
after the corresponding lower teeth.
27. This is a bitewing of an 8-year-old. Get used to looking at developing permanent teeth for
a guide to the age of the child.
This is a Panorex of a 7-year-old with a missing permanent premolar. Always look for
symmetry and count the teeth.
28. This is an 8-year-old with a prominent frenum. Don't do any treatment for the frenum at
this age. Wait until the upper permanent canines erupt. They usually squeeze the centrals
together and solve the problem. In any event, wait before treatment.
The upper arch of the same patient.
29. This is the lower arch of the same 8-year-old. Look for symmetry. The lower right 1st
permanent molar may be trapped at an angle behind the 2nd primary molar - ectopic
eruption. This will have to be dealt with. Take a radiograph and find out.
Nice looking permanent dentition. This was an orthodontic case - molar bands are still in
place.
30. Class I permanent dentition. Look at the interdigitation - each tooth contacts two teeth in
the opposing arch.
Panorex of a 14-year-old with a fractured central incisor.
31. This is a Panorex of an 8-year-old with a prematurely missing lower right primary canine.
Crowding caused this problem - a shifting of all anterior teeth toward the missing canine
spot. Notice also that the upper left lateral resorbed the root of the primary canine next to
it . This is also a sign of crowding - the resorption of two primary teeth by one permanent
tooth.
28
31. This is a Panorex of an 8-year-old with space loss caused by caries and loss of primary
teeth. There is also a congenitally missing upper left permanent premolar. Look for
symmetry. Count the teeth. Find the permanent canines first.
32. Thumbs up - everyone wants to succeed and be noticed. Use this to your benefit. Most
patient want to help you. This child has crowded lower anterior teeth. It may be an ortho
problem. How old is this child? Probably around 8.
33. If you need to get an impression of a patient, know what you are looking for. You won't
get it if you don't know what you are after. This is a good impression and an excellent set
of models.
34. Bacteria and the pellicle remaining on the tooth cause green stain. It houses the bad guys
and can cause demineralization of the tooth. The easiest way to remove it is to dry the
teeth and paint them with iodine. It kills the bacteria and the stain is easier to remove.
You may have to paint it on more than once. Don't splatter it.
Bacteria also cause Black stain but it causes no harm. It just looks bad. It is usually
associated with a caries-free mouth. It needs to be removed for esthetics.
35. There is a lot of caries here. Pain is not always present even though there is a hyperplastic
pulp in a lower primary molar. In all of this disaster the permanent teeth are lined up in
good fashion. Don't punch holes in this, you can see that it is bad. Get radiographs to
finish the diagnosis.
The upper arch of this 9-year-old is not as bad as the lower. These caries can be managed.
Keep the arch intact if possible to allow room for the permanent teeth.
36. This is a 4-year-old child with nursing caries. Taking a bottle to bed at night and falling
asleep with whatever is in the bottle pooled around the teeth usually causes this. This
continual onslaught will destroy most of the upper anterior teeth. The teeth usually spared
are the lower anteriors, which are protected by the tongue. When the child is asleep the
saliva flow is shut way down. The buffering action by the saliva is reduced and whatever
caries potential is in the liquid will be enhanced. Water in the bottle at night is OK -
anything else can be disastrous.
Another nursing caries child with an erupting permanent central pushed off course by an
abscessed primary central incisor. The tooth is erupting into buccal mucosa and will not
have any attached gingiva. This will have to be taken care of later with a periodontal
procedure.
37. Restorations are the best space maintainers. You have to watch band and loops space
maintainers. Cuspids will distalize with the eruption of the permanent laterals. You may
have to remove the band and loop and place a lingual arch.
Be able to read radiographs. Know the difference between primary and permanent teeth.
Be able to recognize pulp treatment and steel crowns. Look at the developing teeth to see
if the child is on schedule in his eruption pattern.
29
38. This 5-year-old girl has been up all night with an abscess. She is tired, has sad eyes, and
would like help. She may be skeptical. She has pain now and doesn't want any additional
pain. Can you examine her without adding to her discomfort? Ask if she wants help. Tell
her what you are going to do. Do all of your looking as gently as possible. Get a
radiograph of the area. Either extract the tooth today or put her on antibiotics and wait 5
days and then extract. You must keep in constant contact with the parent to make sure the
infection doesnt progress into a cellulitis if you choose this course of action. If the
gumboil pops, the pressure will be gone and the pain may go away. When the tissue heals
over the opening again, the pressure will build up and the pain will return. Explain this to
the child and the parents. They may think if there is no pain everything will be alright.
39. An abscess of a permanent tooth will show at the apex on a radiograph. On a primary
molar it is in the bi- or tri-furcation area. The floor of the pulp chamber of a primary
tooth is porous and the by-products of an abscess will go right through the floor.
An 8-year-old with both permanent upper laterals in cross-bite. This has to be treated
before the upper cuspids come down and trap the laterals. Treat these right away.
40. Bruxism and attrition are common in children. They usually grow out of it when they get
their permanent teeth. The pulp chambers have filled up with reparative dentin. The
parents are concerned but there is nothing you can do about it.
41. Ankyloglossia (tongue-tie) is not a severe problem. Most parents are concerned because
of the appearance and what they think may go wrong with speech. If the child is past 2
years of age the correction of the situation will usually not help change any speech
patterns but it will help the looks.
This ankyloglossia case should be treated because of the damage being done to the tissue
between the central incisors.
42. The lower arch of this 5-year-old has a few problems. When the stainless steel crowns
were placed a salivary duct was irritated and closed up. A ranula resulted but opened up
on its own within a few days, otherwise surgery would have been required. There is an
abscessed lower left 1st primary molar that will need a pulpectomy and a crown or
extraction and a band and loop. The facials of the lower canines have caries. This weak
spot on the facial of upper and lower primary canines is common. I think it is caused by
the position of the developing primary canine being pushed up against the facial bony
plate of the alveolus while it is in the crypt.
This is an upper arch of an 8-year-old with Dilantin hyperplasia. Spend a lot of time with
this type of patient in developing good oral hygiene habits. If
the tissue grows over the biting surfaces, periodontal surgery will be needed.
43. Internal resorption of a primary molar on a 10-year-old. By the time you see it like this, it
is too late. The thin root has been perforated. A pulpectomy has to be done early if it is to
30
be successful. In this case you could leave the tooth in place (it is causing no harm) and it
may hold space long enough for the premolar to erupt without space loss.
An occlusal film of an 8-year-old with a cleft palate. They may have missing teeth or
extra teeth in the area of the cleft. They need treatment like everybody else. You would
like to retain arch length in the cleft area. Don't be befuddled by a radiograph in front of a
patient. Do your homework prior to explaining the situation to the child or the parent..
44. This is an occlusal radiograph of a 2-year-old who has had trauma. Both primary centrals
will have to be removed. There is also a mesiodens present that will have to be removed
to allow for the proper eruption of the upper centrals. If the mesiodens were near the apex
of the developing permanent centrals you would postpone its removal until the centrals
had erupted.
A ray of a central with dens-in-dente that should be restored. This mesiodens should not
be removed before the permanent centrals have erupted and the apexes have closed.
45. An occlusal radiograph of a 3-year-old with calcific metamorphosis. This is a response to
pulpal irritation - trauma in this case. The only problem with this - it may not resorb at
the same rate as its partner and will have to be extracted. Keep an eye on it to assure both
permanent centrals erupt at the same time.
Radiograph of an ankylosed primary molar in an 8-year-old. It is below the occlusal
plane and this can result in some space loss as other teeth tip over it. The crown may be
built up with composite or a stainless steel crown placed. If the tooth is removed a space
maintainer should be placed.
46. Gemination of a primary lateral in a 3-year-old. The crown tends to split into 2 crowns.
There is 1 root and 1 root canal. The crown is wider than normal and will take up more
room in the arch. There is usually the right amount of teeth in the arch. Look for possible
problems with the permanent successor.
Ray of a the geminated primary lateral. The pulp chamber is much wider than normal.
The permanent lateral looks OK
.
47. Ray of fused primary incisors. There are 2 roots and 2 pulp canals. In the mouth these
teeth can sometimes look like gemination. But if you count the odd looking tooth as one
unit, there will be one less tooth in the arch than normal. Look at the radiograph and you
can make a decision.
Ray of a 9-year-old child. When this child was 3 years old, he traumatized his upper
central. They went to a pediatrician. She said it was just a baby tooth and it would be OK.
This was their first dental visit and they only came because they suspected something was
wrong because he still had a baby tooth in the front of his mouth. The primary tooth
abscessed soon after the accident. You can tell this because there was no secondary
dentin formation in the primary central. The resulting lesion caused the permanent central
31
to deviate from its proper course and then cease developing altogether. There has been
space loss and the midline has shifted. The permanent central has to be extracted. There is
a large defect in the area. Orthodontics will be needed to correct the spacing problem. A
costly mistake because "it was only a baby tooth."
48. This mesiodens should have been removed early on, it was low in the arch and impeded
the permanent centrals from erupting into their proper position. It is easy to remove but
the centrals will now have to be moved orthodontically to align the roots. It would have
been self-correcting if the mesiodens had been removed early in the game.
49. This 13-year-old boy has enamel dysplasia due to a disturbance during enamel formation.
His brother had the same kind of malformation. We couldn't trace anything that could
have caused this much damage. These teeth can be restored with acid-etch composites.
The canine on the right slide has been restored. A senior dental student here at U of L
restored all the teeth and published the case in the Journal of the American Dental
Association.
50. Hypoplasia. This was easy to restore with the acid-etch technique. There was virtually no
caries in this patient, who had a lot of allergies.
Amelogenesis in a 4-year-old. Primary and permanent teeth are affected. What little
enamel he had has chipped away. This patient needs stainless steel crowns to maintain
space and also to maintain vertical dimension.
51. The upper arch and the occlusion of this same amelogenesis patient. He had an abscess of
his upper central. The supporting structure was so destroyed that the tooth had to be
removed.
If stainless steel crowns aren't placed soon, vertical dimension will be lost.
52. Panorex of the amelogenesis case. The bulbous enamel of normal teeth did not form and
the teeth look like square pegs. There is no width to the teeth. The permanent teeth are
also involved in amelogenesis imperfecta.
The same patient with stainless steel crowns. There was little or no preparation required
on these teeth before the crowns were placed.
53. Same amelogenesis patient. Notice how the bite has been opened.
Another amelogenesis patient with bands and composite used to restore the canines.
54. Full mouth and Panorex of the amelogenesis imperfecta patient. Permanent anteriors
were coming in and were very sensitive. Bands were cemented in place until complete
eruption and a more esthetic restoration could be placed. Notice the lower right 1st
permanent molar. It is in bad shape now. You can get behind in a hurry with this type of
patient. Keep your eyes open.
32
55. Dentinogenesis imperfecta in a 4-year-old child. The teeth are amber in color, iridescent.
Enamel is normal but not attached well to the dentin. It will chip away easily. These teeth
will need to be covered with stainless steel crowns just like the amelogenesis case. The
permanent teeth will be affected also.
56. Dentinogenesis imperfecta - teeth in occlusion before and after treatment. Vertical
dimension has been regained.
57. Congenitally missing teeth in a 5-year-old. When upper permanent laterals are missing
the permanent centrals sometimes are missing a lobe and are skinnier than normal. This
compounds the problem of esthetically restoring the mouth. This child will need dental
treatment over an extended period of time. Space management is a must. If this patient
has children they will have a good chance of having missing teeth also.
58. The same patient with a lower partial for space maintenance and esthetics.
59.-62. Ectodermal dysplasia. These patients have fair complexions, sparse hair, saddle nose,
little or no eyebrows, and may be missing fingernails and sweat glands. There are a lot of
these people in the state of Washington. They have missing teeth and cone shaped teeth.
If they are missing primary teeth, there will not be a permanent successor. This child had
4 primary upper anteriors and 2 lower canines. The same number of permanent teeth was
also present. All other teeth were missing. Overlay dentures are one answer to achieve
function and esthetics. If there are congenitally missing teeth, there will be no alveolar
bone in the area, just basal bone. If they don't have sweat glands, they have trouble in the
summer time, they heat up in a hurry. Maybe that's why a lot of them are in the mild
climate of Washington.
63. A common problem in the mixed dentition is ectopic eruption. Instead of the 1st
permanent molar sliding up the enamel of the 2nd primary molar like the tooth in the
lower left slide, it will approach at a more acute angle and hit the root of the 2nd primary
molar. It will then start resorbing the dentin and then get hung up under the enamel. This
is the case with the molars in the upper left of the radiograph and also on the radiograph
on the right. If no treatment is attempted, the permanent molar may be hung up for years
or resorption may go on to completion and the primary molar will be lost prematurely,
resulting in space loss. There are two modes of treatment. Push the permanent molar
distally and retain the primary molar or extract the primary molar and then push the
permanent molar distally and hold it in place with a space maintainer.
64. Habits. A thumb sucking habit will usually cause a symmetrical defect. A class II
malocclusion with a large overjet and overbite and a constricted upper arch resulting in a
cross-bite. The lower anterior teeth will be tilted to the lingual, increasing the overjet.
The upper and lower teeth will not interdigitate anymore, they will hit one on one.
65. Enlarged tonsils and adenoids can cause abnormal breathing patterns resulting in
unwanted tooth movement. If the child is a mouth breather, the lips and cheek muscles do
not perform their job and the teeth will find a new equilibrium.
33
66. Two cephalographs showing before and after pictures of a patient with enlarged
adenoids. Controversy - Dr. Peter Vig says the amount of airflow is determined by nares
opening, not the airway in the adenoid area. You have to correct the cause of the problem
before correcting the problem or the teeth will go right back to their original position
when you remove your appliance.
67. A constricted upper arch in a 7-year-old resulting in a convenience crossbite. When the
child occludes, the teeth hit end on and this doesn't feel good so the child shifts the lower
jaw to one side or the other, ending up in a cross-bite. You can tell there was a lateral
movement of the lower jaw by looking at the midline - it doesn't coincide. Have the child
open and close and watch the movement.
A lip sucking habit can also cause a malocclusion. In all the habits we have seen, if they
are mild and are discontinued before major movements have occurred - the occlusion will
remain normal. The cases I have shown are fairly severe. Habits cause trouble by the
length of time and the energy involved in the habit.
68. After you have gathered all the information about this patient, write on a paper towel all
the procedures that have to be accomplished to put this patient in good shape. This is a
draft of your treatment plan. Call an instructor over and we will work with you in
finalizing the plan.
69. After the treatment plan is okayed, copy it in the chart. Write in the procedure codes and
the clinic fees. The parent will want to know - how many visits and how much will it cost
me. Write the procedures in groups of what can be accomplished on each visit. Try to
complete all the work in each quadrant to minimize having to repeat the same injections.
Tell the parent approximately how many visit there will be. The instructor will OK the
plan at this time but will not sign it until the parent agrees to the plan and signs it.
70. Present the treatment plan to the parent either out in the waiting room or if is quiet in the
clinic, you can bring them back. Answer any and all questions at this time.
71. One of the first items on the treatment plan is usually a PHP. Make all notations about the
preventive procedures on page 5 of the chart.
72. Explain the prophy procedure to the patient if they haven't had one before. Show the
patient the rubber cup and the suction apparatus before you start. You can have the
patient by the sink during the fluoride treatment if you wish.
73. After all procedures are finished for the day, call an instructor over and get checked off.
Have your progress notes, and grade sheet filled in properly. Make sure all radiographs
are mounted and dated.
Return the patient to the parents and explain what was accomplished and what to expect
on the next visit. Compliment the child in front of the parents. You will get better
compliance from the child with repeated compliments during treatment.
74. If your patient comes in like this child on the left, try to have him leave like the child on
the right.
34
TOPIC: PEDIATRIC DENTAL RADIOLOGY AND RADIOGRAPHIC
INTERPRETATION
Reading Assignment
Pediatric Dentistry, Infancy Through Adolescence, 3
rd
Ed., Pinkham
Chapter 18 (pp. 280-284),
Chapter 30 (pp. 469-474),
Chapter 37 (pp. 607-610)
Objectives
Upon completion of the reading assignment and attendance at class lecture, the student
should be able to:
1. describe possible difficulties in obtaining radiographs from children;
2. describe some patient management techniques for overcoming these difficulties;
3. describe how the guardian may be employed to obtain necessary radiographs;
4. describe how aids such as film holders, tape, etc. may be used to facilitate radiograph
making;
5. describe four measures that should be taken to ensure radiation hygiene;
6. describe the views of and the techniques for producing a preschool radiographic series;
7. describe three ways to make the taking of bitewing radiographs more acceptable to the
patient;
8. describe the views of and the techniques for producing a mixed dentition radiographic
series;
9. describe how to determine whether two or four bitewing radiographs will be sufficient for
diagnosis in the mixed dentition;
10. identify the structures reproduced in a routine panoramic radiograph;
11. describe the radiographs that would be appropriate for diagnosing injuries following
trauma to the teeth, face or head;
12. identify common pathology or anomalies in children by how they present on radiographs;
and
13. describe the guidelines of the Academy of Pediatric Dentistry concerning indications for
radiographs on children and adolescents.
35
Slide Notes for Pediatric Oral Radiographic Technique
1. Title: Pediatric Oral Radiology
Clinical slide of maxillary anterior occlusal technique
2. Parental concern must be addressed.
Risks to patients if radiographs are not taken: irreversible damage, compromised
treatment, increased risk of failure, and more costly care.
3. Indications for radiographs: clinical evidence of injury, disease (caries), pulpal pathosis,
delayed or accelerated eruption or exfoliation, swelling, hemorrhage, pain, or ulceration
4. High-yield criteria for exposing radiographs in asymptomatic children: In the primary
dentition, take posterior bitewings if proximal contacts closed and the child is cooperative
to determine presence of interproximal caries.
High-yield criteria are meant to identify patients who are most likely to benefit from
radiographs.
5. In the early transitional dentition (permanent first molars erupted) take anterior occlusal
radiographs to detect supernumerary teeth or missing teeth. An exam that includes all
tooth-bearing areas is recommended at this time to detect pathoses and proximal caries,
and to aid in the early diagnosis of developmental anomalies. This may consist of
posterior bitewings and one of the following: a. posterior periapical radiographs or, b.
panoramic radiograph or, c. lateral jaw 45-degree projections.
In the early permanent dentition (postpubertal; late adolescence) radiographs are made to
evaluate the same tissues as in the early transitional dentition and to evaluate the position
and development of the third molars. This examination should be made within two years
of the eruption of the permanent second molars. The practitioner who is providing the
orthodontic diagnosis and/or treatment may prescribe a cephalometric radiograph.
6. Risk of dental caries is classified as either high or low. A high risk to dental caries is
associated with; poor oral hygiene, fluoride deficiency, prolonged nursing,, high
carbohydrate diet, poor family dental health, developmental enamel defects,
developmental disability and acute or chronic medical problem, or genetic abnormality.
The child with a high risk should have bitewing radiographs made as soon as posterior
primary teeth are in proximal contact. The age of the patient is not an important variable,
If interproximal caries are detected and restored, follow-up radiographs are indicated
semi-annually until the child is caries-free and classified as having a low risk of dental
caries.
7.-10. A child with a low risk of dental caries may be defined as a normal, healthy,
asymptomatic patient exposed to optimal levels of fluoride, performing daily preventive
techniques and consuming a diet low in cariogenicity. The low risk patient with closed
proximal contacts should have posterior bitewing radiographs made. If no caries are
found, then radiographs may be made every 12 to 18 months if primary teeth are in
36
contact, or up to 24 months if permanent teeth are in contact. Bitewing radiographs may
be made more frequently if the child enters the high-risk category. The more rapid
progression in primary teeth should be considered in determining the time interval
between bitewing radiographs.
Exposing radiographs to document treatment result, when not needed to establish the
presence of pathosis or aid in establishing a diagnosis, is considered unnecessary and an
unwarranted exposure of the child to ionizing radiation. These recommendations are an
attempt to fulfill the professions obligation to establish guidelines for the optimal use of
diagnostic radiography with minimal radiation exposure.
11. Film Size - #O, #1, #2, Occlusal
Comparison of film sizes
12.. Appropriate Radiographic Surveys (Blank)
13. Eight Film Series - 2 anterior occlusals, 2 posterior bitewings, 4 posterior periapicals
Example of eight film series
14. Panoramic Film - Posterior Bitewings
Panolipse of an 8-year-old
15. Anterior maxillary occlusal film showing periapical lesion above right primary central,
impeding eruption
Panoramic film of 5-year-old
16. Mesiodens (clinical and radiograph) - one of many reasons for taking radiograph.
Mesiodens between two centrals - should have been removed before centrals erupted.
Tough to treat now.
17. Clinical slide of darkened F with calcific metamorphosis
Radiograph of same patient showing the chamber and canal filling in
18. Introducing the Child to Intraoral Radiology
Walking with child patient to x-ray room - talk to child, make a game of it - a new
experience - you are looking for cooperation.
19. Use Tell - Show - Do; tell the child using camera analogy; show the child a film packet,
unexposed and exposed; and do a dry run
Dry run desensitizes the child and determines the childs ability to sit still
20. 3 to 6 year old - may have difficulty cooperating. Radiographs can be delayed until
cooperation can be managed
Check all settings and position the tube before the film to allow for short attention span
and gagging.
21. Do easiest procedures first.
Do anterior occlusal films before bitewings and periapicals
37
22. Place apron and collar on patient - don't take films without lead protection.
23. Clinical picture demonstrating proper angulation for maxillary occlusal - 60.
Radiograph of 4-year-old - should be able to see primaries and developing permanent
teeth..
24. Important! When you push the button you are looking at the patient.
Were Not Shooting A Movie
25. If You Cant Get The Child To Hold Still - Dont Expose The Child
Blurred Film
26. A panoramic film is a good aid in the diagnosis of structures in the oral area. A typical
Panorex set up with a child patient in the chair. This Panorex of a 3-year-old
demonstrates development you would expect at this age.
27. Clinical picture demonstrating proper angulation for lower occlusal film. Tilt head back
(chin up) + 30 and angle the tube up at a -30. Or use -15