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Textbook of Pedodontics – Pediatric Dentistry by Shobha Tandon

TEXTBOOKOI
PEDODONTICS
ET w
Eg
..
,...............................................................
Khobha Tandon
K)ean
Frof. and Head
kept, of Pedodontics & Preventive Dentistry
fcollege of Dental Surgery
■MAHE, a deemed university)
l/lanipal
India.
Foreword by:
R. S. Nanda
fPreviews:
A. K. Munshi
Subba Reddy
CONTRIBUTORS
Nirmala Rao, bds, mds
Department of Oral Pathology,
College of Dental Surgery,
Manipal, MAHE
•
Usha Paul, BDS, MDS
Dept, of Pedodontics & Preventive
Dentistry
College of Dental Surgery, Manipal
■
■
Rakhee Goel, BDS, MDS
# 3 Mere Court, Chelford,
Macclesfield, Cheshire. SK11 9EB
■ Shyam Bhat, BDS, mds
Department of Pedodontics,
Yenopoya Dental College,
Mangalore.
«
Soni Stephen. BDS, MDS, FRACDS
Department of Children,s Dentistry,
United Dental Hospital of Sydney,
2 Chamers Street Surry Hills ,
NSW 2010
«
Nagesh Kumar G Rao, mbbs, md
Department of Forensic Dentistry,
Kasturba Medical College, Manipal
MAHE
■
Radhika Muppa, BDS, MDS
Former Assistant Professor,
College of Dental Surgery,
Manipal, MAHE
■ Amit Van'ka, bds, mds
Asssistant Professor,
Department of pedodontics,
Dental College,
Humnabad
CONTENTS
?
Foreword
Preview
Preview
Preface
Acknowledgements
SECTION 1 : CHILD AS A PATIENT
1J Introduction to pedodontics........ ................................
1
1.2 Case History, diagnosis and treatment planning..........................................................
6
1.3 Radiographic examination of pediatric dental patients............ ..................................... 19
1.4 Practice management.......................................
29
SECTION 2 : NORMAL GROWING CHILD
2.1 Stages of human growth and development (pre-natal).............. ........
2.2 Pedologic anatomy...........................
2.3 Stages of growth and development (post-natal).................
2.4 Growth assessment............ ............. ................ . —...........................................
36
......45
..60
.75
SECTION 3 : DEVELOPING DENTITION AND IT’S DISTURBANCES
3.1 Development of dentition ....?......
3.2 Common developmental disturbances of teeth............... ...... ....................................
3.3 Development of occlusion...................................
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND
V- «fiHAVIOURMANAGEMENT
4.1 Theories of child psychology..............
4.2 Emotional development...... .............................
4.3 Behavioural science and its application in pediatric dentistry ......
4.4 Pharmacological means of patient management..................................
4.5 Ephebodontics - Dentistry for adolescents.................................
i
85
97
106
121
..130
139
154
168
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD
5.1
5.2
5.3
5.4
Introduction ........................................................
Caries risk factors......................................................................
Early diagnosis of caries ................
Nursing caries and rampant caries .................
178
185
......196
..201
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL
6.1 Infants oral health care........................... ,............................................................................... 210
6.2 Parent counselling.................................................................................................................... 218
6.3 Diet counselling ...........
,224
.fi^KPit and fissure sealants.......................
233
6.5 Fluorides ...........
240
6.6 Methods on the horizon.....................................
267
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY
7.1' Introduction .........................................................................................
7.2 Principles and concepts of cavity preparation....... .........................
7.3 Procedures required for restoration........................
7.4 Modern restorative materials and techniques.....................
JZ/5 Semi-permanent restoration..........................................................
(Stainless steel and polycarbonate crowns)
SECTION 8 : PEDIATRIC ENDODONTICS
8.1 Objectives and diagnostic procedures......... ......................................
8.2 Treatment modalities ..........................................
273
278
283
...292
....314
328
335
SECTION 9 : DEVELOPING MALOCCLUSION AND IT’S MANAGEMENT
9.1 Incipient malocclusion....... .................................... ................................ ................ v..,....... 364
9.2 Orthodontic prevention............... ............................................................................. ?........... ,381
9.3 Early orthodontic interventions...................
402
9.4 Commonly occurring oral habits in children and their management.......................... ..
*
427
SECTION 10 : PEDIATRIC CONSIDERATIONS FOR ORAL SURGERY
10.1 Local anesthesia........................................
.....461
10.2Extraction ......................
471
10.3 Minor oral surgical procedures..............................................................
476
10.4 Oral and maxillo facial injuries in children............................................................................ 490
10.5 Commonly used drugs in children......................
526
SECTION 11 : DENTAL CARE FOR THE SPECIAL CHILD
11.1 Introduction .......................................................................................................................
535
11.2 Management of developmentally disabled child................................................................ 538
11.3 Management of medically compromised patients......................................
547
11.4 Cleft lip and palate....................................................................................................................574
11.5 Common craniofacial syndromes seen in children.................................................
591
11.6 Pediatric prosthodontics.......................................................................................................... 601
SECTION 12 : GENETICS IN PEDIATRIC DENTISTRY
12.1 Basic concepts in genetics......................................................................................................614
12.2 Chromosomal abnormalities......................................
622
12.3 Single gene disorders.......................................................................................................... 632
12.4 Genetic counselling.............................................................................................................. 638
12.5 Human gene therapy......................................................................................
643
12.6 Latest advances in genetics............................................................................................... 648
SECTION 13 : SOFT TISSUE ORAL LESIONS IN CHILDREN
13.1 Periodontal diseases ...............................................................................
13.2 Commonly seen other oral lesions..........................
654
675
SECTION 14 : ESSENTIAL RESEARCH METHODOLOGY,
EPIDEMIOLOGY AND BIOSTATISTICS
14.1 Research methodology..................................................
14.2Epidemiology and biostatistics .................
....687
691
SECTION 15 : FORENSIC PEDODONTICS
15.1 Introduction .................................... ...........................
15.2Child abuse............................
15.3 Bite marks...............................
15.4Dental age assessment............................................. ;................
....697
700
.706
713
APPENDIX
1. Clincial diagnosis of opacities of enamel..........................
.718
2. Causes of tooth discolouration .................
719
3. Causes of intra oral bleeding....... ......
.....................
..........
.720
4. Endocrine growth axis...................
721
5. Comparison of normal diagnostic values....................... *................................................ ..722
6. a. Chronology of permanent and deciduous dentition....................
..723
b. Chronology of deciduous dentition............................................
:............ I*?..... 724
7. Common abnormalities of deciduous dentition ..................................
725
8. Comparison of psychological theories................................................................................ 726
9. Stages of nursing-bottle caries..............................
727
1G. Comparison of conventional and recent model of caries management ....... :............ .727
11. Treatment protocol for nursing caries ...’.......................................................................... 728
12. Preventive protocol for dental caries...................................................................... .........729
13. a. Vaccination schedule (Indian Academy of Pediatrics) ...................
730
b. Vaccination schedule at KMC, Manipal..................................................... ’.............. 731
14. a. Effects of different fluoride concentrations on enamel formation ...............
732
b. Reports on slow release fluoride dental material^.................
732
c Reports on slow release fluoride in humans.........................................
733
15. Deans index.............................................................................................................
.733
16. Material guidance in pediatric dentistry............................................................................ 734
17. Relative characteristics for posterior restorations...................................................... ....734
18. Preventive protocol for periodontal diseases ..............................................
735
19. Major exanthemas in children ......
......73S
index........................................................................................................................................
SECTION - 1
Child as a Patient
1.1 Int rod uction to Pedodontics
Tandon S
Child is nature’s most benevolent creation. The child
i s not just a miniature adult but a dynamic organism
undergoing constant mental, physical and emotional
changes. Pedodontics is the branch of dentistry con
cerned with providing comprehensive dental care and
treatment for the child patient, making it the most
satisfying and rewarding type of dentistry. The
Pediatric dentist has the privilege of being entrusted
with the commencement ofa lifetime of optimal oral
health to the child patient
The word pedodontics is made of two words i.e. pedo
+dontics. Pedo is derived from "pais” which in Greek
means child, “dontics” stands for the study of the
tooth. It has become increasingly difficult to define
exact boundaries and limitations of pedodontics with
continuous development and advancements. There
fore, the need to acknowledge the definitions evolv
ingwithtimeis obligatory.
■ Stewart, Barber, Trimtman, Wei (1982):
“Pediatric dentistry? is the practice and teach
ing bf cbrnprehensive preventive and thera
peutic oral health care of child from birth
through adolescence. It is construed to include
care for special patients who demonstrate mental,
physical or emotional problems.”
« American Academy of Pediatric Dentistry (1985):
“Pediatric dentistry, also known as Pedodontics
and as Dentistry for adolescents and children,
is the area of dentistry concerned with pre
ventive and therapeutic oral health care for
children from birth through adolescence. It also
includes special care for special patients
beyond the age of adolescence who demon
strate mental, physical or emotional problems.”
■ Boucher’s Dental terminology’s (1993):
“Pedodontics is the branch of dentistry, that
includes having a child to accept dentistry,
prevention, detection, restoration of primary and
permanent dentition; applying preventive meas-
lence, intercepting and correcting various
areas of malocclusion.”
American Academy ofPediatric Dentistry (1999)
“Pediatric dentistry is an age-defined specialty
that provides both primary and comprehen
sive preventive and therapeutic oral health|^|^
for infants and children through
including those with special health care^^^g
TEXTBOOK OF PEDODONTICS
■ Thereto re with the experience of the Author:
"Pedodontics can be defined as a science
which deals with laying down the foundation
of healthy dentition and oro-facial complex
from the prenatal period through adolescence”
WORLD-WIDE HISTORY OF PEDODONTICS
1800 BC- Ancient Egypt
No caries in children’s teeth
1563-64 Eustachius
Described and showed illustrations of both primary
and permanent dentition
1737-Gerauldy
Writes about theories regarding tooth eruption and
exfoliation
1763- Joseph Hurlock
Publishes 1st book on children’s dentistiy
1764- Robert Bunon
‘"Father of Pedodontics” reiterates the importance
of deciduous dentition
1926 - Detroit Pedodontics Study Club
Dr. Samuel D. Harris - "Father of Children’s Den
tistry Organizations world-wide, starts the Detroit
Pedodontics Study Club
1927 - AAPDC
Detroit Study Club is now named the American
Academy for Promotion of Dentistry for Children
1940 - ASDC
American Academy for Promotion of Dentistiy for
Children renamed as the American Society of
Dentistiy for Children
1967- CDH
International Symposium on Child Dental Health is
conducted at London Hospital Medical College
1969- IADC
International Association of Dentistiy for Children
is established
1984 - AAPD
American Academy of Pedodontics is renamed to
the American Academy of Pediatric Dentistry
PEDODONTICS IN INDIA
In India (Table 1.1) the first Dental College, ‘"Calcutta
Dental College and Hospital” was started in the year
1920 by Dr. Rafiuddin Ahmed in his private chamber.
Dr. Ahmed, the Father of Dentistry7 in India is also
known as "The Grand Old Man of Dentistiy”. He is
credited with the first edition of "The Indian Dental
Journal” in October 1925, foundation of the “All In
dia Dental Association” in the year 1927, drafting
and passingof the Bengal Dentist Act in 1939, and
the passing of the Dentist Act in 1948.
Dentistry as a subject was introduced as a 2 years
diploma course to “Licentiate in Dental Science
(LDSc)”. It was changed to the 3yr. course in the
year 1926 and further modified to the present 4yr.
D.S. course in 1935.
B.
The foundation of Pedodontics was laid down in
Government Dental College, Amritsar, in 1950.
Pedodontics did not exist as an independent specialty
in the initial years.. of development of Dentistry in
India, but was includedas a mere one or two ques
tions inthe OperativeDentistry paper. Later it was
recognized as the section -B of the question pa per of
Orthodontics. In the year 1988 as per D.C.L rules it
got iWWe importance and was treated as a separate
Amritsar thertext to introduce this
K G.M.C. Lucknow (1967), PG.L
i^^toft<1978)andG.D.C.Bombay(1982). The fifth
^^^^sSionand first in south India wasthe C.O.D.S.
I^^pal in the year 1985 under Dr. Shobha Tandon.
SECTION 1 : CHILD AS A PATIENT |
Fig. 1.1 World-wide foundation of PedodonOc Societies.
Table 1.1: Evolution of Pedodontics in India.
1920 - Calcutta Dental College and Hospital
1 st Dental College started bv Dr. Rafiuddin Ahmed "Father of Dentistry in India”
1935-B.D.S.
Licentiate in Dental Science becomes Bachelor in Dental Suigeiy
1950 - Pedodontics is introduced
Government Pental College, Amritsar starts Pedodontics as a specialty
1978 - Pedodontics for Undergraduates
Pedodontics is introduced as a specialty in the undergraduate curriculum
wt
1979 - Indian Society of Pedodontics &
■'2:
The Association of Indian Pedodontists holds the 1st conference. Dr.B .R Vacher is
1made the “Father of Pedodontics in India”
1982- Affiliated to IADC
Indian Society of Pedodontics and Preventive Dentistry becomes an affiliate
■
member of IADC
4EW I TEXTBOOK OF PEDODONTICS
The Associati on of Indian Periodontists held its first
conference on the 24th of November 1979 where it
was first named as the Indian Society of Periodontia
(now Periodontics) and Preventive Dentistry Its con
stitution was drafted by Dr. Mrs. AmritTewari. Con
tributions made by Dr. B.R. Vacher, the Father of
Periodontics in India, was recalled and thus he was
unanimously made the life patron of the society.
MX. Gauba was elected first president of the soci
ety; Dr. Mrs. A Tewari the first General Secretary and
Dr. H.S.Chawla was the first editor of the journal. In
1982ISPPD became an affiliate member of I ADC, the
International Academy for Dentistry for Children.
DIFFERENCES BETWEEN THE CHILD AND THE
ADULT PATIENT
Hippocrates in the 5th Century B.C. talked about the
differences between the child and the adult. In the
4th Century A.D. Celsius recognized that the child
must be treated differently from adults. The discov
ery of childhood began around the 13 th century. (By
the Middle Ages, children started getting more at
tention especially as the heirs and sons of the ruling
houses and had belief not die while "teething’")..
Childhood compared to adulthood is a transitional
Stage characterized by many changes. Rapid changes
in childhood affect every aspect of dental care be
ginning from the first step of diagnosis till the peri
odic recall following treatment. A child differs from
an adult in various ways:
1 physical
2. emotional and psychological
3. consideration of behaviour
4. type of treatment (different dentition considerations)
5. dentist-patient relationship
6. parent-dentist relationship (Fig. 1.2)
SCOPE OF PEDODONTICS
In order to handle majority of the needs of the child,
the periodontist requires interaction with many
specialities (Fig. 1.3). The scope refers to the range
of activities considered in the practice of
Periodontics. In addition to be knowledgeable about
Fig. 1.2 Periodontic triangle
the dental needs of the child patient, basics in the
pediatric medicine, general and oral pathology,
growth and development and child psychology also
need to be known.
Changing trends in the scope of Pedodontics
In 1942 when Pediatric Dentistry was recognized as
a speciality, the common needèof the children were
restoration of the cari ous teeth, treatment of dental
pulp, and maintenance of tooth spaçe. Preventive
modalities of treatment were limited in practice. Di
agnostic techniques and materials for pediatric use
needed to be developed.
With the changing trends and development there
has been a tremendous increase in the scope of
pedodontics. Various factors responsible for this
change are:
■ Professional and public recognition of dental
health for the general well being of the child.
This indicates the increased knowledge in the
public sector regarding child dental health care.
■ Wide recognition of fluorides as the most effec
tive health agent in the prevention of dental
caries. This is gaining momentum even in India.
■ Introduction of high-speed technology in the
preparation of teeth requiring restoration.
■ Great improvement of various anesthetic agents
in clinical use.
SECTION 1 : CHILD AS A PATIENT |
Fig. 1.3 Scope of Periodontics
■
■
■
Introduction of *
system.of
the
sophisticated
plastics i.e. composites, ionomer cements,
compomer, pit and fissure sealants - what are now
popularly called "the invisible fillings”
Radical changes to control virulent infections in
any clinical content.'
Recognition of the child as an individual.
The present trends in Pediatric dentistry comprises of:
1. Preventive Dentistry
2. Public health dentistry
3. Child psychology and management
4. Clinicaldentistry
5. Preventive and Interceptive Orthodontics
6 Special care dentistry
7. Child abuse and neglect ( Forensic Pedodontics)
8. Genetics in Pediatric Dentistry.
Preventive practice has now become the dominant
branchin pedodontics.
The characteristic that differentiates the pediatric
dentist from the other dentists is the fact that he/
she provides comprehensive health in total to the
patient, prevents the onset of the disease right from
the beginning while considering the psychological
need of the child patient thus instills a fiositive atti
tude to dental health in future vears to come. With
the increasing range of activities one must realize
the need for knowledgeable and skilled practition
ers as the pedodontist
Self-Assessment
1. Define Pedodontics.
2. Who is the father ofdentistiy in India?
3. When was the American Academy of Periodontic
formed?
4. When and where was the first P.G. program in
pedodontics started?
5. What is the difference between a child and adult <
patient?
/JW"
6. What is the periodontic triangle?
j
.
7. What is the scope of pedodontics?
1.2 Case History, Diagnosis and
Treatment Planning
Tandon S
One can treat and cure only those diseases or signs
and symptoms .that are diagnosed in the first place.
This art and science of the patient evaluation is the
key to treatment planning.
A few terminologies need to be classified before go
ing on with the case history recording.
• Diagnosis - The determination of the nature of
the disease.
» Differential diagnosis * The process of listing
out two or more diseases, having similar signs
and symptoms of which only one could be attrib
uted to the patient’s suffering.
« Provisional diagnosis - A general diagnosis
based on clinical impression without any labora
tory investigations.
■
■
•
Final diagnosis - A confirmed diagnosis based
on all available data.
Symptom - Any morbid phenomenon or depar
ture from the normal in structure, function, or
sensation experienced by the patient and
indicative of a disease.
Sign - Any abnormality indicative of disease,
discovered on examination of the patient (an
objective symptom of a disease).
Accurate diagnosis can only be achieved by sys
tematic and methodical collection and evaluation of
data. Rarely does one come across diseases that have
just a single symptom or sign. Each component of
case evaluation has its own significance and should
HJbe allotted the same.
HISTORY
L Health history:
Health history is a structured format and must be
recorded as such. The interview conducted should
have a few guidelines to be followed such as:
« Various questions need to be asked depending
on the type of information needed. It may be
open-ended questions (encouraging a detailed
explanation) or close ended (specific 4 Yes’ or
4No’ answers). Leading questions are well
avoided.
■ To obtain history in infants and children, under
5 years of age, the parent or legal guardian is
interviewed.
■ The questionnaire should be accommodative
to the various problems encountered and not
stereotype.
■ Often, the symptoms are aptly described by
the patient and should be recorded in his own
words, (e.g. Doctor, I have a sudden ‘shooting’
type of pain).
■ The dentist should be an empathetic listener
for the patients may often pour out their
grievances to him/her and this will go a long
way in establishing a good rapport.
From the pedodontist’s point of view the dental
visit serves as a positive attitude instilling process
for further dental treatment. Thus behavior
shaping should be started from case history taking
and even before.
SECTION 1 : CHILD AS A PATIENT |
i
IL Vital statistics
It can be defined as a systematic approach to collect
and compile in numerical form the information
related to vital events. live births, deaths,
recognition, social structure and legislation.
Uses: It is essential to ■ Maintain records
■ To create administrative standard of health
activities
■ To direct or maintain control during execution
of programs.
■ To disseminate reliable i nformation on hea 1th
situation and programs.
1. Date: It records the time the patient reported
and can be referred back to during the follow
up visits.
2. Hospital numher/Case number: For the
purpose of maintaining a record, billing the
individual and for legal considerations (in view
of the Consumer Protection Act) one should
note the hospital number.
3. School and class : To know the economic
status, to communicate with the teacher. It also
helps in assessing the IQ of the child and to
establish effective communication at his own
IQ level.
Name: Name asking is a verbal communication
that establishes a rapport with the patient.
Further communication by means of the name
gives a sense of importance and acceptance.
(Nickname helps make the environment
informal).
5. Age : The chronological age (date of birth)
should be noted to compare with other ages
(dental, skeletal) so as to know whether growth
and development is normal in the child.
Certain diseases are known to occur
frequently at particular ages, which should
be kept in mind (e.g. primary herpes gingivost-
omatitis from 6 months to 6 years,
nursing caries is seen in the preschool age
group only). Depending on the age the
behaviour management'techniques also vary
and this should be kept in mind.
6. Sex : Girls mature faster than boys and
thus their treatment may be required earlier.
Some diseases are more common in females than
in males, e.g. anorexia is more common in
females while hemophilia may be found
exclusively in males. A combination of age and
sex can sometimes give an indication of the
occurrence of a disease, e.g. pubertal gingivitis
is commonly encountered in adolescent
females.
7. Race/Ethnic origin : Some diseases may be
common in certain races. Oral hygiene practices
may be common in some religions or races.
8. Address: Theaddress is used for all comnmnications sometimes even before the first visit.
By knowing the locality, along with the EHily
income and parents occupation, the socio
economic status can be assessed.
If the patient is coming from a far distance, the
appointments can be modified to complete
treatment in fewer visits.
Living area may indicate diseases endemic to
the particular areas.
9. Source of information : The source of infor
mation and relationship with à child should be
ascertained. The reliability of the information
BEI
provided may also need to be evaluated.
10. Source of referral: In multidisciplinary set
ups, day to day referrals are seen. The chief
complaint in these cases may be non-dental.
Thus stress on dental awareness arid
motivation may be needed.
■ In certain cases, just an opinion may be
required and the patient’s treatment can be
tfiWl I TEXTBOOK OF PEDODONTICS
'carried out only in consultation with
pediatrician or physician. The patient care
can be optimized by being in constant touch
with physician or pediatrician.
(e.g. Dental procedures may be performed
along with any. other general anesthesia
procedure in an uncooperative child).
1. Rh incompatibility: May result in the condition
termed 'erythroblastosis fetalis’. The sensitized
antibodies of the mother cross the placental
barrier and a immune reaction takes place. The
effects may be seen in the dentition, with wetb
described entities such as Hump’ on the tooth
and the characteristic blue-green discoloration.
III Chief complaint:
A detailed history of the same goes a long way in
establishing the diagnosis. Several factors need
to be evaluated regarding the chief complaint. For
example, the most common presenting illness can
be evaluated as:
1. The onset
2. The duration
3. The location
4. The quantity;- quality; severity; and frequency
of occurrence
5. Aggravating and relieving factors
6. Associated symptoms
2. Neonatorum Jaundice: The immature RBCs
in an infant are rapidly destroyed in the spleen.
The increased bilirubin cannot be sufficiently
cleared by the liver leading to a transient
jaundice’ in the child.
Medical History: History of any medical condi
tions should be asked, including recent hospita
lization, blood transfusions, etc.
IV Parent history:
A dental visit and the treatment performed would
point towards the attitudes of the parents. An
unpleasant experience may be transmitted
unknowingly to the child and it should be kept in
mind. Any genetic/inherited abnormalities should
be interviewed into.
V Prenatal history :
Prenatal history (mainly maternal) may disclose
information that can be linked to the present
condition (e.g. tetracycline stains on teeth) and
may indicate when an antibiotic can be
administered.
VI Birth History:
Suggests if any problems were encountered at
birth, as:
Other problems such as
Blue baby
Forceps delivery7
Any other problems
VIL Postnatal historv:
As discussed elsewhere, significance is attached
to the amount of time the child was breast fed,
bottle fed, if the bottle was misused, and the type
of nipple used etc. as given in the chart.
■ Vaccination status needs to be assessed along
with the present medical illness if any. Presence
of any habit/its duration, frequency# intensity
need to be evaluated.The behavioral status,
a general assessment as to whether the child is
cooperative or unco-operative and if any deeprooted problems are present, have to be found
out.
■ Any previous experience with the dentist and
what bearing it has on the present visit should
be noted.
■ Progress in school, how he interacts with other
children will indicate the development of the
child’s emotions.
Diet chart. A detailed diet history should be recorded.
The diet chart shows whether it is adequate. More
importantly it can indicate the cariogenicity of diet
(refer to diet counseling).
SECTION 1 : CHILD AS A PATIENT | CB
EXAMINATION
Gingiva: The normal gingiva in a child is different
from an adult. Inflammation of the gingiva and
accumulation of the plaque on the teeth are seen
by respective indices.
C Hard tissue evaluation
The teeth present have to be recorded so that the
dental age can be assessed along with the stage
of development of the dentition.
FDI scoring system : It is one of the commonly used
numbering system. Quadrants are allotted initial num
bers as:
Upper right
Upper left
Fig. 1.4 Knee to knee position of the Dentist and
the parent while examining the child.
A. The general examination and evaluation of the
patient begins with the first appearance of the
child and the parent themselves. A child hiding
behind the parent, child inquisitively looking at
the equipment, a smiling and laughing child, will
give a fair indication of the response to be ex
pected.
The build up of the child (whether normal for his
age), height, and posture while standing can also
be evaluated simultaneously.
The child, walking along with the parent should
be checked for the gait as well. Sometimes the
way the child walks can be associated with a par
ticular disease.
B. Local examination: Apart from the facial features
soft tissues need to be evaluated. (Fig. 1.4)
Skin/Lips: For presence of any sinus/fistula
Mucosa:. Any ulcerations, growths, Pallor of
mucosa may indicate anemia, yellowish discolouration - jaundice (rarely seen).
Systemic manifestations of diseases may be
present (Koplik’s spot as in early measles).
Nodes: Palpation of commonly involved lymph
nodes (sub mental and sub mandibular) shows
an acute or chronic infection.
Palate: The hard and soft palate may also show
manifestations of systemic diseases.
Primai}7
5
6
8
7
Upper right
Permanent
Upper left
1
2
4
3
Then the tooth in each quadrant is numbered as:
Primaiy:
555453 5251 616263,6465
858483 8281 7172737475
Permanent:
181716 151413 12 11 2122 23 2425 26 27 28
48 47 46 45 44 43 42 41 3132 33 34 35 36 37 38
Indices: The most commonly used indices are die
plaque index, gingival index and caries index:
Caries index: In pedodontics department, Manipal
we use the WHO criteria on each tooth surface.
Table 1.2)
■ Plaque Index (Silness and Loe, 1964)
Plaque has been defined as:
A specific, highly selective entity resulti^g^^^|t
sequential colonization of microorganw^J^^^/;
MTÏ> I TEXTBOOK OF PEDODONTICS
Table 1.2: WHO (1987) criteria for primary and permanent teeth.
Permanent tooth code
Condition/status
Primary tooth code
0
Sound
A
1
Decayed
B
2
Filled, with decay
C
3
Filled, no decay
D
4
Missing as a result of caries
E
5
Missing due to any other reason
-
6
Sealant, Varnish
F
7
Bridge abutment or special crown
G
8
Unerupted tooth
-
9
Excluded tooth
__________________________ :--------- -—. __ _______________ ,____
Surface of the teeth, soft tissues, restorations and
appliances. (Silness and Loe included materia alba
ànd debris under the plaque).
2
3
Rather than examine the whole dentition, a few4 In
dex teeth
*
are selected
Permanent Dentition - 16,12,24,36,32,44
Primary Dentition
- 55,52,64,75,72,84
In cases of mixed dentition, sometimes, depending
on the teeth present, the Index teeth may be as:
16,52,64,36,32,84, or such combinations where the
deciduous counterpart, if present is considered.
W Should both the primary and permanent teeth be
present, the permanent one is to be considered.
■ Should both be absent, the tooth distal to them
may be considered or only 5 teeth are considered.
• Each tooth is divided into 4 parts.
Scoring criteria
0 * No plaque in the gingival area
1 - A film of plaque adhering to tire free gingival
margin and adjacent area of the teeth. Only
running a probe across the teeth surface may
recognize the plaque.
- Moderate accumulation of soft deposits within
the gingival margin and/or adjacent tooth sur
face that can be seen with naked ejre.
- Abundance of soft matter within the gingival
pocket and/or on tire gingival margin and ad
jacent tooth surface.
*
Calculations
A. Plaque index for a tooth =
Add scores from 4 areas of tooth
4
B. Plaque index for a individual =
Add scores for each tooth
No. of teeth examined
Interpretation scale
0.0
- Excellent
0.1-0.9
- Good
1.0-1.9
- Fair
2.0-3.0
- Poor
SECTION 1 : CHILD AS A PATIENT I CXB
■ Gingival Index (Loe and Silness, 1967)
It has been developed for the purpose of assessing
the severity of gingivitis and its location in four pos
sible areas of an individua l tooth.
This probe detects pocket temperature differ
ences of 0.1 °C from a referenced subgingival
temperature
Higher temperature pockets a re signaled with a
red-emitting diode
Same teeth are examined as in plaque index
b) Fluoride Probe
- used to measure pocket depth
Each tooth is divided in to 4 parts
t Disto - facial papilla
2. Mid - facial papilla
3. Mesial facial papilla
4. Entire lingual gingival margin
Score Criteria
0 - Normal gingiva
1 - Mild inflammation, slight change in colour,
slight edema; No bleeding on probing
2 - Moderate inflammation, redness, edema, and
glazing; bleeding on probing
3 - Severe inflammation, marked redness and
edema, ulcerations, tendency to spontaneous
bleeding
Calculations
Gingival index score per tooth =
Total score
Advantages:
1. Constant probing force
2. Digital readout
3. High degree of accuracy
It is a computerised peridental probe consists
of a probe, handpiece, a digital readout, a foot
switch, a computer interface and a computer. *
c) Foster-Miller Probe:
Couples pocket depth determination with
detecting of CEJ from which clinical attaclunent
level is automatically detected.
d) Toronto Automated Probe:
To measure clinical attachment levels
Sulcus is probed with a Ni-Ti wire that is
extended under air pressure
4
Gingival index score for a person =
Total of all scores
No. of teeth examined
Interpretation
1. 0.1-1.0 Mild
2. 1.1-2.0 Moderate
3. 2.1-3.0 Severe
e) DNA Probe:
Helps to identify the organism associated with
periodontal disease.
It identifies species-specific sequences of
nucleic acids that make up DNA, thereby
permitting identification. The DNA library
includes probes for A.actinomycetumcomitans, P.gingivalis, B.intemiedius, C.rectus,
E.corrrodens, F.nucleatum andT.denticola.
ADVANCED DIAGNOSTIC AIDS
II. OTHER AIDS
Following diagnostic aids may be used as per the
need of patient.
PROBES
a) Perio temp probe
- helps to detect early inflammatory changes
in the gingiva by detecting temperature rise.
a) Xeroradiography: is an x-ray imaging system
that uses the xerographic copying process to
record images.
SOI I TEXTBOOK OF PEDODONTICS
b) CADIA: Computer Assisted Densitometric
Image Analysis system. A video camera meas
ures the light transmitted through a radiograph
and the signals from the camera are converted
into gray levels. The camera is interfaced with
an image processor and a computer that allows
storage and manipulation of images.
c) Computers: In diagnosis by computers, it is
necessary to store facts associated with symp
toms of patients with known diseases in field
of study. Computers help us by retention of
facts about many patients and selection of rel
evant facts to give a diagnosis. Computers
also help in comparati ve digital study of radio
graphs eg. Cephalograms.
Fig. 1.4a Use of computers in comparative
digital study of radiographs
d) Ultrasonics: The fundamental use of high fre
quency sonic vibrations is to define areas of
differing physical properties by reflection of
waves from the surfaces of adjacent areas of
tissues. Helps in defining the pulp anatomy,
shape of soft tissue neoplasms etc.
PHASES OF TREATMENT PLANNING
1. Systemic phase:
■ A patient with a medical disease background
may require the condition to be stabilized and
then dental treatment to be carried out. In
this respect the patient may have to be
referred to the physician or pediatrician as
required.
■
Keeping in mind the systemic condition, pre
medication (as in antibiotic prophylaxis,
sedation) needs to be given to the child, again
with the consent of the pediatrician or
physician.
2. Preventive phase:
Caries risk assessment (as described elsewhere)
Assessment for various preventive measures
(fluoride application, pit and fissure and sealant,
diet counseling).
3. Preparatory phase:
a) Behaviour management: The child’s behav
iour shaping should start right from the
reception itself.
b) O ral prophylaxis - It presents a clearer view
of the caries process which facilitate its
diagnosis. It also gives an idea whether the
patient will cooperate.
c) Caries control - Further progress of carious
lesions should be controlled. Sometimes
multiple lesions may need to be temprorized.
d) O rthodontic consultation - Minor orthodon
tic correction should be carried out before
evaluating the space maintenance program.
e) Oral surgery - Gross caries may necessitate
the removal of teeth.
f) Endodontic therapy - Sometimes, a tooth may
need to be saved with endodontic treatment.
Corrective phase:
a) Restorative dentistry - permanent fillings,
stainless steel crowns would be included
under this phase.
b) Prosthetic Rehabilitation - tooth replacement,
jacket crowns etc.
c) Early orthodontic intervention is to be car
ried out.
5. Maintenance phase:
Depending on the risk of the individual and his
oral hygiene status, a 3-6 month recall visit can
be established.
SECTION 1 : CHILD AS A PATIENT | ŒEB
FORMAT OF A CASE RECORD
DEPARTMENT OF PEDODONTICS AND PREVENTIVE DENTISTRY
COLLEGE OF DENTAL SURGERY, MANIPAL
DENTAL CASE SHEET
VITAL STATISTICS
Hospital No.:
Age :
STD:
Date :
Name :
School :
Pedo Reg. No.
Sex :
Examiner :
CHIEF COMPLAINT
History of Present illness :
Medical History:
Past Dental History :
Oral Hygienic Habits :
FREQUENCY
ORAL HABITS
DURATION
INTENSITY
Digit sucking
Nail biting/Lip biting
Tongue thrusting
Mouth breathing
Bruxism
Postural
DIET HISTORY
Time
Type of Food
Quantity
Method of
Preparation
Quantity of
Sugar Added
CEB I TEXTBOOK OF PEDODONTICS
CLINICAL EXAMINATION
GENERAL
Build:
Height:
Weight:
Gait:
Posture:
Body type:
Skin/Lips:
Mucosa:
Palate: \
Floor of Mouth:
Tongue:
Tonsi Is / Adenoids:
Examination of Head & Neck:
Shape of Head:
Facial form Facial Symmetry:
TMJ:
Lymph Nodes:
LOCAL EXAMINATION:
ORAL SOFT TISSUES:
Any other:
Oral Hard Tissue Examination:
Teeth present (FDI coding)
Caries Status:
DMFT/dinft
55
54
53
52
51
61
63
62
r
64
65
1
*
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
85
84
83
82
81
71
72
73
74
75
contd.
SECTION 1 : CHILD AS A PAT,'ENT |
Score
D=
M=
F=
DMFT =
d=
IB =
fdmft =
Oral hygiene
Plaque Index - Silness and Loe
B
D|
B
|M
dlZZJm
p
P
B
D|
IM
L
Score:
~
Comment:
Gingival Index = Loe and Silness
B
DI
IM
P
B
D|
|M
B
D|
|M
L
L
Score:
Occlusal Review:
Molar Relationship:
Primary.
Permanent:
«
Canine Relationship;
Over jet
mms
contd.
ffEB | TEXTBOOK OF PEDODONTICS
Over bite
nuns.
Midline
Normal / Deviated
Cross bite
Any other
Provisional Diagnosis
Lab Investigations if any:
Final Diagnosis:
TREATMENT PLAN:
Date
Treatment Done
Name of the Student
ASSESSMENT OF THE EFFECTIVENESS OF THE
COMPREHENSIVE TREATMENT PLAN
After completion of the scheduled treatment plan, it
is important to-assess all aspects of care provided
and the anticipated follow up programs. The clini
cian should always assess by the following queries
to himself.
1. Effectiveness of the preventive program:
■ Was the program appropriate?(for the age of
the patient and for the parent)
■ Was the program effective?
■
■
■
Sign, of Staff
Grade
Has the dental IQ improved? (of the child and
the parent)
Were the expectations reached?
How would you change the treatment plan
knowing the results achieved?
2. Evaluation of restorative care
■ Were the restorative techniques used success
ful?
■ Were the teeth restored as planned?
■ Were there any changes of major conse
quences?
SYSTEMIC APPROACH TO ORAL DIAGNOSTIC AND TREATMENT PLAN FOR A CHILD PATIENT
»1« I TEXTBOOK ÔF PEDODONTICS
■
■
What are the problems that could be antici
pated?
What would you like to do differently?
3. Evaluation on tooth guidance treatment
■ Was the case diagnosed properly?
■ Were the expected results achieved?
■ Is treatment complete?
■ Is the necessary follow-up care arranged?
4. Assess behavioral management approach used
■ Effective?
■ Appropriate for the chi Id?
■ Was the child’s behavior altered? Yes/No
5. Development of plan for the follow-up
« Establish proper referral
■ Establish recall( Time and treatment )
■ Establish home care program that will work
for the particular child and the parent.
S elf-Assessment
1. What do you understand by differential diagnosis?
2. How does the provisional diagnosis differ from
the final diagnosis?
3. What is vital statistics and its importance?
4. What are the factors needed to evaluate the chief
complaint?
5. Why is the recording of prenatal history impor
tant?
6. What is neonatorum jaundice?
7. Why should the extra oral examination be per
formed?
8. What is the FDI coding system?
9. Define an Index.
10. What are the different phases of a treatment plan?
11. What do you understand by recall?
1.3 Radiographie Examination of Pediatric
Dental Patients
John P, Tandon S
Radiographic examination plays a vital role in the
diagnosis and treatment planning of both children
and adults. It has to be stressed that radiographs
have an additional importance in the evaluation and
treatment planning of pediatric dental patients. A
complete examination of the dentition and associ
ated structures should include a radiographic sur
vey as well. In pediatric dental practice, radiographs
also play a significant role in the assessment of
growth and development. Radiographs, at the sim
plest level, help in the detection of dental caries and
at the most complex level, in the diagnosis of cysts,
tumours or any other ma jor craniofacial disorders.
The work of many scientists culminated in the dis
covery of X-rays by Roentgen on November 8,1895.
The then unknown and invisible rays were given the
name X-rays by Roentgen because of the simple fact
that the nature of these rays were not known at the
time of the discovery. However’ discovery of X-rays
changed the medical science rapidly, bringing in a
great revolution. X-rays have also been widely used
in dentistry and have a special place in pediatric den
tistry where the growing child with a developing den
tition needs to be assessed carefully.
Intra-oral films
Intra-oral films arc meant for positioning inside the
mouth during exposure. There are three types of
intraoral radiographic projections:
■ Intraora 1 periapical (ЮРА) radiographs
■ Bitewing radiographs
■ Occlusal radiographs
Size of intraoral films
(-------------
0
Types of radiographs:
The radiographs taken of a child patient can be
broadly grouped into two categories, intra-oral and
extra-oral radiographs. Accordingly, the film used in
pediatric dental practice for radiographic examina
tion can be grouped into:
i Intra-oral films
ii. Extra-oral films
Fig. 1.5 X-ray Films
| TEXTBOOK OF PEDODONTICS
■ Size 0 is used for bitewing and periapical radio
graphs of small children.
■ Size 1 is used for radiographing the anterior teeth
in adults. This film is not routinely used.
« Size 2 is the standard film used for anterior occlu
sal radiograph, periapical radiograph and bitewing
survey in mixed and permanent dentition.
Occlusal films have a size of57 x 76 nun and are taken
for visualizing the entire maxillary or mandibular
arches. (Fig. 1.5)
Extraoral films
Most of the extra-oral films are used in intensifying
screen-film combinations. The extra-oral films used
in dental practice vary in their sizes depending on
the individual projection for which they are employed.
• 1.5 x 7 inches films - these films are used for
temporomandibular joint (TMJ) views and lateral
oblique views.
• 8x10 inches films: These films are used for lateral
cephalograms, paranasal sinus veiw, etc.
« 6 x 12 inches film: These films are used for
orthopantomography.
Composition of films
A radiographic film is an image receptor system. On
exposure to x-rays, there is formation of an invisible
image or latent image which when chemically proc
essed transforms into a visible image which can be
viewed under trans-illumination.
An X-ray film consists of the following components.
1. Base: The base of x-ray film is made up of a poly
ester, polyethylene terepthalate. The base helps
in supporting the emulsion which gets chemi
cally activated when exposed to x-rays. The base
also provides rigidity to the film.
2, Adhesive layer: An adhesive layer is present over
the base to attach the film emulsion to the film
base.
3. Film emulsion: The film emulsion is the main
image receptor system of x-ray film, as this is
sensitive to both light and x-rays. The emulsion
mainly consists of silver bromide crystals with
some amount of silver iodide.
As it has already been mentioned, when the film is
exposed to x-rays, a latent image is formed in the film
which gets converted to a visible image only when
chemically processed.
For a radiograph to be of proper diagnostic quality, it
should be free from technical or processing errors
and it should give sufficient information pertaining
to the area radiographed or for which purpose the
radiographic projection is made.
Intraoral radiographs
As it has already been mentioned, there are three
types of intra-oral projections, intra-oral periapical
(ЮРА) radiographs, bitewing radiographs and oc
clusal radiographs.
Intraoral Periapical Radiographs (IOPA)
ЮРА radiographs are useful in the evaluation of teeth
and their associated structures. ЮРА radiograph can
be taken by using two techniques; short cone tech
nique or bisecting angle technique and long cone
technique or paralleling technique. Though the par
alleling technique provides an image of teeth with
minimal magnification, there is an inherent disadvan
tage of using this technique as special holders or
position indicating devices are required to take the
radiographs.
Paralleling technique cannot be employed in chil
dren with a shallow palate and a shallow floor of the
mouth. In small children, with primary dentition, size
0 film should be used. In older children or in situa
tions where a larger area has to be visualised, size 1
film should be used.
SECTION 1 : CHILD AS A PATIENT |
I
i
ï
Indication
Projections (Fig. 1.6)
The indications for taking periapical radiographs in
children are given below
■ To determine the status of the periapical region
in the deciduous and young permanent teeth.
■ In the evaluation of pulp treatment or endodon
tic treatment.
■ In the detection of developmental anomalies such
as supernumerary teeth, unerupted teeth or mal
formed teeth.
■ To identify any pathology involving the primary
teeth such as periapical pathology or internal
resorption.
■ To evaluate the status of the periodontal
ligament
• In the diagnosis of pulp calcification, root
resorption or root development
■ Ana lysis of space in mixed dentition
■ Diagnosis of traumatic injuries effecting
pathologic changes
For projection of the maxillary teeth, the head of the
patient should be kept upright. The vertical angula
tion used are:
For the anterior teeth
+50
For the premolars
+30
For the molars
+25
Technique
Obtaining Child's Co-operation for
Radiographs:
The following have been suggested for achieving
better co-operation from the child patient during the
radiographic procedure:
1. Acquaint the child with the dental X-ray machine
and explain the procedure to him. Use words the
child can understand.
2. Pre-set the timer and position the cone in the
approximate angulation prior to placing the film
when intra-oral radiographs are taken.
3. Obtain the confidence and the co-operation of
the child. Take the easiest film for the patient first
(e.g., upper anterior films).
4. Talk to the child so that you distract his attention
and establish rapport and confidence.
The film is positioned on the palatal aspect of the
teeth by using film holders. The tooth/teeth to be
radiographed should come in the center of the film.
The central x-ray beam is directed in such a way that
it liits the film almost perpendicularly. This principle
should be followed to prevent magnification of the
image and also to avoid a cone-cut appearance im
age formation.
For projection of mandibular teeth, the following ver
tical angulations are used.
For the anterior teeth
For the premolars
For the first and second molars
For the third molar
-20
-10
-5
For the lower anterior projection, the film is kept on
the floor of the mouth, on the lingual side of the
teeth. For the posterior projection, the film is kept on
the lingual sulcus. Care should be taken while taking
the radiographs of mandibular teeth to avoid soft
tissue trauma due to the sharp margins of the film.
The central x-ray beam is directed almost perpen
dicular to the film.
While employing the long cone technique, the cen
tral x-ray beam is directed perpendicular to the long
axis of the tooth and the long axis of the film, whereas,
while employing the short cone technique, the cen
tral x-ray beam is directed perpendicular to an imagi
nary bisector that bisects the angle formed by the
long axis of the tooth and the film.
Œ® 1 TEXTBOOK OF PEDODONTICS
Posterior teeth
MAXILLARY REGION
Horizontal plane
Central ray
Posterior teeth
Anterior teeth
MANDIBULAR REGION
•
J
Fig. 1.6 Angulation of X-ray tube for different regions of Oral Cavity.
Bitewing radiograph
■
Bitewing radiograph is a very usefid intrapral radio
graph, especially to detect incipient proximal caries.
Bitewing radiographs can be taken by using film sizes
No 0 or 1 for younger children and No.2 for older
children. The coronal portion of both the maxillary
and mandibular teeth of the required area can be visu
alized on the film.
■
■
Indications
•
•
•
•
Detection of interproximal caries with respect to
depth and relationship to pulp
Detection in incipient interproximal caries
Observation of boundaries of the pulp chamber
and the height of the pulp horns
Observation of primary resorption pattern
Observation of location and position of retained
primary roots
Observation of relationship of opposing teeth
Observation of location and position of
permanent tooth bud and its relationship, to
the primary root.
Bitewing radiographs can be taken with paper hold
ers to which a tab is attached. The central x-ray
'beam is directed between the contact points of the
teeth.
Occlusal radiographs
Occlusal radiographs are used in the evaluation of
the entire maxillary arch or mandibular arch. Occlu
sal radiograph are indicated in the localisation tech
nique (for example to determine the buccolingual
SECTION 1 : CHILD AS A PATIENT |
position of impacted teeth), to evaluate cortical plate
expansion, to evaluate fraction displacement, to
evaluate the maxillary sinus or submandibular sali
vary gland calculi. A larger film is used to cover the
larger area in one film.
Visualization of radiographs
Visualization of a radiograph requires a good source
of extraneous light. A thorough knowledge of the
basic anatomy and the radiographic appearance of
various osseous structures is very essential in the
proper interpretation of radiographs. Radiographs
should be examined in a quiet area that is free from
multiple extraneous stimuli.
2. The presence of residual primary roots.
3. The possibility of removal of a primary tooth
because of interference with the eruption of the
permanent tooth
4. Proper sequence of eruption
5. Evaluation of old restorations and detection of
recurrent lesions
6. In emergency situations, thé degree of pulpal
involvement, the amount of alveolar bone loss or
the presence of periapical pathosis is detected
7 Finally, in the ca se of traumatic injury, the possi
bility of a root fracture, and the type and area of
the fracture, are evaluated.
Recommended radiographic examination of
children and adolescents
Conditions and Areas routinely Evaluated
■ The degree and variation of calcification of the
teeth, and the size, shape, position and angula
tion of the unerupted teeth:
■ The presence or absence of teeth, including
anomalies in number, delayed eruption, or impac
tion.
■ Carious lesions and interproximal carious lesions
in particular. Incipient lesions on the facial and
lingual surfaces are not seen in a radiograph and
are more readily found with an explorer. Radio
graphic evidence of caries is seen only when sub
stantial amounts of decalcification has occurred
and a change in density is noted.
■ Degree and variation of root resorption of the
primary teeth, as well as the root development of
the permanent teeth.
• The presence of any periapical pathosis or bone
lesion
Conditions and Areas for Evaluation on Peri
odic Visits:
All previously mentioned areas and conditions are
and should be part ofa periodic examination. In addi
tion, the following should be evaluated:
1 Ectopic eruption.
Radiographs shoul d be taken judiciously and only
after thoroughly evaluating the patient clinically. The
following guidelines can be employed while advis
ing radiographs for a child patient or an adolescent
patient.
1. Child patient (before the eruption of the first
permanent tooth)
■ New patient: 2 bitewing projections of the
posterior region
■ Recall patients: Bitewing examination at 6
months interval.
Clinically no caries or no increased susceptibility to caries: Bitewing radiograph at 12 to
24 month intervals
■ Deep caries: SelectedIOPA radiograph
2 Child patient after the eruption of the first perma
nent tooth
■ New patient: Selected IOPA radiographs,
posterior bitewings, occlusal views, and OPG
■ Recall patient: Bitewing radiographs and
selected IOPA radiographs, if indicated.
■ Clinically no caries: Posterior bitewing radio
graphs
■ Deep caries: Selected IOPA radiograph
<EEB I TEXTBOOK OF PEDODONTICS
Adolescent (permanent dentition and before the
eruption of the third molars)
■ New patient: Posterior bitewing radiographs
and a selected 1OPA radiograph.
■ Recall patient: Posterior bitewing radiograph
at 6 to 12 month intervals.
■ Clinically no caries: Posterior bitewing radio
graphs
■ Deep caries: A selected ЮРА radiograph and
or bitewing radiograph.
3.
Extraoral and specialized radiographs
1. Rationale of panoramic radiograph (Fig. 1.8,1.9)
■ A panoramic radiograph or orthopanto
mogram (OPG) helps in the visualization of
both the maxilla and mandible together with
their associated structures in one film with
considerably less radiation exposure thana
routine full-mouth radiographic survey.
г
■
In panoramic radiography, the X-ray source
and the film rotate, with the result that the
structures that come within a “zone of image
layer' are clearly visualized, whereas the stru
ctures outside the image layer are blurred out.
■
With an advanced panoramic radiographic
system and by using panoramic scanography,
programs are available for imaging selected
anatomical areas such as the maxillary sinus,
nasal fossae, and so on.
■
Panoramic radiography is used in the evalua
tion of traumatic injuries as well as dental age
evaluation as it gives a good information
about the eruption status of the teeth,. OPG
can also be used for patient education.
2. Cephalometric radiography (Fig. 1.10,1.11)
Pediatric dentists, orthodontists, and maxillofa
cial surgeons, use cephalometric radiographs or
cephalograms for facial and jaw growth analysis.
Cephalometric radiographs are mainly used for
conventional cephalometric measurements and
cannot be used in case of evaluation of craniofa
cial anomalies.
Fig. 1.7 Cephalometric tracing on lateral Cephalogram.
SECTION 1 : CHILD AS A PATIENT | dklA
A typical tracing of lateral cephalogram with
planes and constructed points is shown in Fig. 1.7
Cephalometric radiographs can be traced manu
ally or can be digitized on a computer aided
software device and television based system.
3. Lateral oblique view
A lateral oblique view can be takèn by using a 5 x 7
inches screen film combination. Projections are
made separately for the right and left sides.
Lateral oblique view can be taxen either to visu
alize the body of the mandible or the ramus
region. This radiograph is of good use to identify
any pathology extending from the body of the
mandible to the ramus region.
4. Wrist radiography
Wrist radiography is taken for bone age estima
tion. In the radiography of the wrist, a plain film
of the left wrist is taken and the carpal and meta
carpal bones are studied for the degree of ossifica 
tion. Using Gruilich and Pyle scale, and compar
ing with the standard ossification patterns at
different stages, the degree of ossification is
. assessed. The skeletal age can be compared with
the Demirijian 'dental age', estimated from the
stage of crown and root development (maturity)
of premolars and molars .
5. Sialography
Sialography is a specialized radiographic
technique in which a dye or contrast medium is
introduced in a retrograde fashion into the duct
of the salivary gland and then a radiograph is
taken to study the pathology of the major
salivary glands. Mainly iodine-based contrast
agents are used. Sialography is contraindicated
in acute infection of the salivary glands. Sialog
raphy is mainly indicated in the case of stones
within the duct or Sjogren's syndrome.
6. Computerized tomography
Computerized tomography or CT is an advanced
radiographic system. An advantage of CT is its
high resolution. It is very helpful in the diagno
sis of disorders involving auditory ossicles,
neonatal maxillae and temporomandibular joint
(TMJ). CT provides a comprehensive view of
the dental arches, especially the positioning of
the supernumerary teeth, extent of cysts or
tumours. For easily identifiable problems, when
the conventional radiographs would suffice, it is
better to avoid CT.
TACT (tuned aperture computed tomography)
for the diagnosis of the external root resorption
* in which a new type of imaging digital radiographs
and subtraction radiographs are used. This has
an advantage over the current radiographic
modalities in viewing an object while decreasing
the superimposition of the overlying anatomical
strucutres.
7. Magnetic Resonance Imaging
Magnetic resonance imaging, popularly known
as MRI, is a non-invasive technique in which high
strength, static magnetic field pulsed radio waves
and switched gradient magnetic fields are used
to create an image. The magnetic resonance
signal is generated primarily from the hydrogen
nuclei of water and lipid molecules. MRI is widely
used to image the head, neck and the musculo
skeletal system. MRI is also a useful technique
in case of neoplasm ofthe maxilla and mandible,
study of the vascular structures and evaluation
of lymph nodes. MRI cannot distinguish between
benign and malignant neoplasms.
8. Ultrasound
Diagnostic ultrasound, which makes use of sound
waves to generate an image is cohimonly used in
obstetrics. Of late, ultrasound has found its
application indbe examination of the floor of the
mouth and salwaiy glands.
9. Postero-anteriarvieW
A postero-antenor view or PA view is taken with
a 8 x 10 inchesscreen film combination. As the
name implies, the central x-ray beam is directed
from behind aad through the skull. 4t is used to
I TEXTBOOK OF PEDODONTICS
Fig. 1.8 Orthopantomogram (an extraorai
radiograph)
Fig. 1.9 Taking of an O.P.G
Fig. 1.10 Patient position on Cephaiostat.
Fig. 1.11 Lateral Cephalogram (an extraoral
radiograph)
SECTION 1 •: CHILD AS A PATIENT | tfgfafc
evaluate the skull for any pathology, trauma or
developmental anomalies. It gives a good view
of the skull in the medio-lateral direction.
10. Paranasal sinus view " y
"
Paranasal sinus view or PNS view or Waters
projection is a variation of the PA view and is
mainly indicated in the visualization ofparanasal
sinuses, orbits and zygomaticofrontal sutures.
In this projection, the central x-ray beam enters
the skull tangentially to exit at the chin region.
This view is taken with a 8 x 10 inches screen film
combination.
11. Reverse - town projection
This radiograph is taken on a 8 x 10 inches screen
film combination. It is indicated in suspected cases
of condylar neck fractures. This radiograph is
taken in an open mouth position. This projection
is similar to the PNS view with the difference that
the head is tilted downward.
12. Submentovertexview
A submentovertex view is also taken with a 8 x 10
inches screen film combination. This radiograph
is taken by directing the central x-ray beam
through the floor of the mouth to exit at the
vertex of the skull. This radiograph helps in the
visualization of the condyles, sphenoid sinus and
curvature of the mandible.
13. Direct digital radiography (Fig. 1.12)
Direct digital radiography or digital intra-oral ra
diography is popularly called radio-visiography
(RVG). Though this technique makes use of the
x-ray machine, it differs from the conventional ra
diographic technique in that here an intensifying
screen charged coupled device (CCD) is used as
the.image receptor system. The signal from the
CCD is digitalized to form an image in the monitor.
In this technique the image is obtained immedi
ately and contrast enhancement is possible to
achieve better results. The image obtained can
also be stored in the computer for future refer
ence. It is also possible to obtain print outs from
the image recorded in the monitor.
Probable technical errors while taking
radiograph for a child patient:
In general there is no scientific difference in the tech
nique applied for the child and that for the adult pa
tient, but there is a high probability of technical er
rors while taking radiographs for the child patients.
These errors may distract or destroy the radiographs’
diagnostic value. The most commonly observed tech
nical errors are: .
■ Improper placement of films.
■ Cone cutting,
■ Incorrect horizontal angulation, for example in
case of interproximal caries this improper angula
tion showstheoverlappingof the contact area
and makes the diagnosis impossible.
■ Improper vertical angulation projects the cap of
the enamel of the crown over the interproximal
surface and obliterates the carious lesion
■ Over exposure due to defective devices.
■ A high exposure of the patient to radiation
because of repetition of taking X-rays due to an
uncooperative child '
Radiation hygiene measures:
Fig. 1.12 Radiovisuography.
It is imperative that the radiograph should be taken
by following proper radiation hygiene measures.
These measures are:
I TEXTBOOK OF PEDODONTICS
■
■
•
«
•
«
■
•
•
•
Proper registration of radiographic units
Proper maintenance of radiographic units
Training of personnel who are associated with
radiography
Dosage monitoring
Radiation protection of the child patients by us
ing lead apron with a thyroid collar.
Use of long lead-lined cylinders and cone posi
tioning devices
Use of electronically controlled exposure timer
Use of high speed films
Use of automatic processing machines that give
good consistent results
Employing proper technique to avoid the chances
of repeating the exposure.
■
Proper sterilization of objects used in radiogra
phy that can get contaminated by the patient’s
saliva.
Self-Assessment
1. Which sizes of films are used in children?
2. What are the intra-oral projections ?
3. What are the indications for using IOPA and bite
wing films in children ?
4. What are the advantages of an OPG ?
5. Name new techniques which can be utilized for a
radiographic diagnosis.
6. What measures will you adopt to make radio
graphic procedures more acceptable to children ?
7. Prepare a chart of angulations used for different
regions of the mouth.
I
1.4 Practice - Management
Tandon S, Paul U
The special developmental characteristics of the
pediatric patients and the important relationship
these patients establish with their parents, the prac
titioners and stciff members call for a unique environ
ment and establishment. Those who treat children
should periodically review various aspects of prac
tice management such as initial communication with
the parents, management of time, the child’s first visit
evaluation of guidance and education in home health
measures.
Each decision taken by a dentist that has a bearing
on office environment procedure or the assignment
of staff responsibility should be directed towards
the goals of rendering effective and pleasant service
for children.
A thorough oral examination, an accurate diagnosis
and effective treatment supported by preventive
measures are essential in the treatment of a child
patient. Emotional guidance is provided as needed,
and dental services are conducted in the most effiI cfent and pleasant manner commensurate with the
If i^bd’s behavior and parent’s attitudes.
>' ■ ■ . ■ V
f l. Initial communication with parents
| fAt the time the parents make an initial contact by
U=; telephone, the receptionist should project the den! OWstaff’s true interest in the child patient.
way to accomplish this is by offering correct
information in a friendly manner in response to
tiie inquiries. A friendly telephone voice con
veys a cordial feeling towards the parent
The receptionist should speak clearly in a natural
and well modulated tone and should converse in
an efficient but unhurried manner. The patient’s
full name and nickname, boththe parents’ names,
address and telephone number should be re
corded by the receptionist.
2. Dental clinic environment
The ideal office/clinic should be easy to approach
for self, staff and patients withampie car parking.
A dental office serving pediatric dental practi
tioner should consider the age range of the per
sons using the facilities. An attractive and com
fortable environment should be designed for both
children and parents. The interest of patients of
preschool age through the late teenage period
also need to be considered as well as the interest
of their parents. Therefore the decor of the re
ception and dental clinic requires careful plan
ning. Neutral colors, such as beige or light shades
of green or blue for the wall decor promote a tran
quil feeling and will permit the use of attractive
color accessories.
Decorations and accouterments depicting defi
nite settings meh as the circus, the outerspace,
or nursery rhymes add to the warmth and fantasy
of the office and tend to dispel fear. An aquarium
is always a source of entertainment and may be
placed either in the reception room or in the treat
ment room where it is visible to the child in the
chair (Fig. 1.13). Soothing, muffled music in the
reception room has a comforting effect on both
the parent and the patient and dispels the cold
ifcfiü I TEXTBOOK OF PEDODONTICS
ness often felt in a si lent room. Objects of inter
ests for all ages of children will provide an invit
ing atmosphere^ Children are attracted to books
or magazines. If adults are to bring children to
the dental office, reading material should be avail
able for them. Cookery books affefMtisy moth
ers interested in reading.
Selected toys, preferably of large size, including
building blocks, and wall attached activity centers
have proved to be main attractions for children of
all ages?
Certain dental drawings used in conjunction with
the different procedures undertaken in the clinic
can also be included and this has shown to alle
viate anxiety or fear of child patient (Fig. 1.14)
3. Management of time and appointment
■ To guide the parents in choosing the most
desirable hour for their child’s appointment the
receptionist must be prepared with informa
tion to justify the scheduling.
■ Morning appointments are preferable in a
young patient because the child will be fresh
and active. The length of the appointment
should be as short as possible (preferably less
thanTO min). Children should not be made to
wait top long in the reception area before the
dental procedure, as this wil 1 make them rest
less. There are certain other factors that affect
the child’s behavior,5which are under the con
trol of the dentist.
■ An appointment book should be well planned
and effectively designed with the layout for
the entire week. Longer appointments may be
scheduled first with shorter appointments
around the longer ones. A definite schedule
should be set for starting and finishing the
clinic.
4. Ancillary personnel
The efficient utilization ofchairside assistants is
extremely important in pedodontic practice be
cause:
■ It decreases the length of the dental appoint
ment thus aiding in child management.
■ The denti st practices more efficiently a nd more
rapidly thereby becoming more productive.
from the assistant decreases the number
of steps and movements necessary resulting
in less fatigue to the dentist. Statements re
garding the assistants’ role in periodontics are
generally limited to the need for this individual
to be a warm, caring person who must genu
inely portray a friendly attitude to the child.
(Stewart 1982). Finn (1973) has emphasized
that dental care of the handicapped child can
only be accomplished through the well coor
dinated teamwork of the dentist and his/her
auxiliary personnel.
5. Establishing a suitable record system
This must cover the medical history, chief com
plaints, investigation advised and carried out, di
agnosis plan and treatment plan, appointment
schedule, and fee chargeable and recovered. For
this computer and good software can have a re
markable use. It is legally mandatory for the den
tist to keep proper records. *
»
6. Establishing professional fees
■ The fees must be revised from time to time.
This can either be done by reference to the
schedules employed by other colleagues in the
locality or by applying the principles of cost
accountancy.
■ A rational method for determining the fee and
payment system should be followed with a few
important factors in mind such as the patient
work load, annual production hours, working
days per year, and the average monthly fore
cast per year.
7. Effective infection control measures
■ To protect the dentists’ self by using good
quality gloves, masks, protective eye glasses,
etc.
■ To protect the patients from cross contamina
tion by making sure that all the instruments
Fig. 1.13 Initial contact with the child.
Fig. 1.15 Patient sitting comfortably on
contoured dental chair.
Toooth brushing
Washing the mouth with
vacuum and 3 way syringe.
Cleaning the teeth with
brush in handpiece.
Drilling a vital tooth with air
turbine.
Infiltration anaesthesia by
injection.
Motivating patient towards oral
health.
Fig. 1.14 Portrayal of dental procedures to allay dental anxiety of children - KOYOT01988.
¡¡W W iK -
SECTION 1 : CHILD AS A PATIENT
ik» I TEXTBOOK OF PEDODONTICS
are properly sterilized. Thus infection control
should be given utmost importance.
8. Proper maintenance of clinic
The flooring, walls, ceilings and all the surfaces
of the equipment apdTnstruments and cabinets
* must be made of such materials so that they can
be very easily maintained clean.
9. Health education room :
Space should be allocated in the dental office
where the child and the parents can be given
proper instructions in preventive procedures. In
struction in oral hygiene procedures should be
explained fully and participation by the child
should be used until tooth brushing and flossing
become an established habit pattern. Dietary
counselling can also be given here. The dentist
should keep in touch with the current develop
ments; it is imperative that he participates in the
activities/deliberations of professional bodies.
10. Consultation with the parents:
■ During the consultation with the parents the
dentist may review the major diagnosis or may
elaborate on specific details such as the type
of infection, severity of dental caries, reasons
for pain, nature of oral defects, objectives of
guiding the developing occlusion and any oth
ers.
■ If consultation period is to be conducted effi
ciently, control of the parents’ conversation is
important.
■ If the parents are argumentators or demanding
or have a low level of dental information, the
dentist will require additional time and patience
to communicate the findings and propertreat
ment program.
11. Accountability
Dental profession is morally, ethically and legally
accountable to the patient in particular and the
society in general. In no way can we get out of
the obligation. This aspect has to be kept in mind
every time you treat a patient.
12. Consent
Consent, before any complicated diagnostic or
invasive procedures, anesthesia and surgery, is a
must except in rare circumstances such as life
threatening medical emergencies, on a court or
der or on request of the police. The consent
should be in local language and signed by the
parents or his close relatives or guardians.
NEVER DO IT
1. Never operate a patient without consent
2. Never lose your temper even on provocation
3. Don’t neglect updating your knowledge
through training courses/conferences etc. and
keep proof of it.
4. Never experiment on patients
5. Never forget your limitations
6. Never hesitate to refer the case if it cannot be
managed by you
7. Never give general anesthesia without an
anesthetist
8. Never use outdated medicines
9. Never resort to UNETHICAL practice
Right from diagnosing the incipient caries and
checking margins of restorations, a good vision
is critical in numerous aspects of clinical dentistry
13. Handling the Child in the Dental Chair (Fig. 1.15)
Selection of a dental contour chair has been found
to be most effective in children’s practice
■ The patient rests in a supine position with his
body parallel to the floor and feet slightly el
evated:
■ The assistant’s arm is held slightly above the
child’s chest, which affords a comforting feel
ing of security to him. The assistant sits across
the chair from the dentist completely.
■ The dentist operates in a sitting position on a
comfortable, contoured stool. All equipment
is conveniently located near the dentist and
the assistant; high and low speed handpiece,
suction, air and water syringes are mounted
on a bracket extending partially over the chair,
SECTION 1 : CHILD AS A PATIENT |
and well integrated instruction makes it possi
ble for these complements to be handed to the
dentist as needed.
■ Everything needed for any specific procedure
is within easy reach without leaving the chair,
c.g. the amalgamator is kept in a portable cabi
net nearby the chair.
■ All instruments are handed to and removed
from the dentist’s hand by the assistant.
■ The concept of ' four handed dentistry'7 im
plies that the assistant’s hands are constantly
employed in the treat ment of the child.
14. Sequence of procedures
After a thorough diagnosis of the problem is es
tablished, a sequence of appointments must be
incorporated. This area encompasses personal
preferences and individual treatment philoso
phies. However, there are certain guidelines,
which can be utilized.
Step one: Emergency procedures must be dealt
with immediately. This implies rendering only the
minimal necessary treatment to relieve pain and
or infection.
If possible, delay extraction or extensive pulpal
therapy provided that the pain can be relieved by
some other means.
Step two: A prevention plaque control program
should be introduced. This program includes
plaque identification and removal, diet counseling,
topical fluoride application and child parent edu
cation on home care arid oral hygiene practices.
The advantage of this approach is the opportu
nity to place emphasis upon prevention, devel
opment of rapport with the patient, evaluation of
patient behavior, and introduction of an initial trau
matic experience to the childpatient. The empha
sis on prevention should be reinforced at every
future appointment.
Step three: Restorative therapy usually begins
at the third visit. A procedure which is short and
simple should be selected first during this initial
appointment to allow the development of the pa
tient trust and confidence.
Step four: Following the completion of the re
storative phase of treatment, orthodontic and
prosthodontic care may be rendered if needed.
Although minor oral surgical procedures are ac
complished during the restorative phase of treat
ment, complex surgical endeavor should be de
layed until this phase.
Step five: No treatment plan is completed until
provision is made to provide a recall appointment
for evaluation and necessary follow-up care.
Special considerations while managing
the child
•
Direct physical contact with the child during all
procedures provides security to the child. It also
helps the doctor to better control the patient. Ob
servation of the patient’s hands during their
evaluation allows a critique for genetic anoma
lies, medically compromised signs of the systemic
etiology and specific oral habits.
■
Sight considerations are also a major part of doc
tor-patient transactions. The doctor should ap
proach small children at the eye level and talking
with child in the chair at eye level is helpful in
maintaining rapport. Instruments including sy
ringes, la rge bur blocks, or forceps should be kept
away from sight of the child to reduce his anxiety.
■
The senses of taste and smell are also important
considerations in treating a child patient The
, child can react rather adversely to the bitter taste
of local anaesthetic solutions or to the taste of
phosphoflouride solutions. Topical anesthetics,
topical fluorides, oral premedications. and impres
sion materials which are flavored for taste and
smell are of great benefit in the patients reception
of dental care. The hands and breath of the doc
tor and staff should not only be clean but also
relatively free of offensive odors.
I TEXTBOOK OF PEDODONTICS
Table 1.3: Attitudes of children towards dentistry.
Likes
Dislikes
■ An interesting waiting room with background
music
■ Be truthful, do not lie to the patient
■ To be called by the first name
■ Have everything ready before the child arrives
■ Educate both the child and the parent
■ Dentist to talk while working
■ To watch in a mirror while the dentist is working
■ To be told repeatedly that he or she is a
good patient
■ Allow the child to get into the dental chair
unassisted and adjust the chair for comfort
■ Giving the child a preview of what will occur
at the next appointment, and postoperative gift.
■
■
■
■
■
■
Attitudes of children towards dentistry are
given in Table 1.3
Essentials of Pedodontists’ attitude:
For a successful pedodontic practice, one should
have the following qualities in one’s own personal
ity or attitude projecting to a child patient.
» Self-confidence with a positive mental attitude.
* Goal orientation with clarity
» Patience while handling children
■ Gentle approach with tender, loving care.
■ Art of developing a friendly rapport.
« Cheerful and being honest with chi Idren
■ Sincere and emphathetic.
Î
.... Self-Assessment
;
JI
g
È
1. What are the objectives of practice management?
2. What is most desirable time for child patient ap
pointment?
3. Why should a suitable record system be maintained?
4. How should be the dental clinic environment for
children?
5. What is the rational method to determine the fee
structure?
6. What are the essentials of a pedodontist’s atti
tude?
■
■
■
■
Being kept waiting
Unattractive waiting room
Untruthfulness of a painful procedure
Being made fun of
Using fearprovoking words
Using undesirable mannerisms or facial
expression
Using words such as drill, sharp,
needle etc.
Scolding by the dentist
Being compared to other children
Adjusting the chair without consulting
the child
Further Suggested Reading For Section -1
1. AAPD; Guidelines for prescribing dental radio
graphs. Ped. Dent. Reference manual 21(5), 60,
1999-2000.
2. Bauden, J. W : The use of radiographs in pediatric
dentistry: The challenge of the eighties. Pediatric
Dentistry 3(2):455,1982.
,
3. Beoun L.R and Akerman, WY. Jr. : Intraoral or panoramic radiography? Dental clinics of North
America 28(1):47,1984.
‘
4. Bodner L., Sarnad H, Jacob B.Z. Computed tom
ography in pediatric oral and maxillofacial sur
gery. JDC. 32-38.1996.
5. Bragger U Pasquali L, Rylander H et al. Computer
assisted densitométrie image analysis in peri
odontal radiography to methodological study. J.
Clin. Periodontal 15:27,1988.
6. Caplan C M : Practice Expansion • The decision
making process and related strategies.
DCNA32(1), 1988.
7. Curcio R J : The art of the dental examination
DCNA 22(2), 209-28.1978
8. Curcio R J : The first phone call. DCNA 22(2) 197208,1978.
9. Fechtner L J; Mallin R J : Recall : The philosophy,
Methods and Results. DCNA 22(2),285-306,1978.
SECTION 1 : CHILD AS A PATIENT |
10. GelbierS: History of International Association of
Pediatric Dentistry, Part 6; Int. Jr. of Ped. Den.,
June, 6.2.143.1996.
11. Gelbier S.-History of the International associa
tion of Pediatric Dentistry. Part LNational and
society of dentistry for children; International
Journal of Pediatric Dentistry Dec., 4.4.281.1994.
12. Gelbier S.-History of the International Associa
tion of Pediatric Dentistry, Part 3 : Samuel D Harris
and some early pressure for International devel
opments; Int Jr. Of Ped. Den., 1'2.123,1995
13. Gibbs CH, Hirsch feld JW, Lee JG et al. Descrip
tion and clinical evaluation of a new computer
ised periodontal probe - the fluoride probe. J.
Clin. Periodontol 15:137, 1988
14. GrattBM, Sickles EA, Armitage GC. Use ofdental
xeroradiographs in periodontics comparison with
conventional radiographs. J. Periodontal 51:1,
1980:
15. Gupta S. Chada M.K. Sharma A. Assessment of
puberty growth spurts in boys and girls- a dental
radiographic method J- Indian Soc- Pedod-Prevdent 13(11), 4-9,1995.
16. Jeffcoat MK. Diagnosing periodontal disease.
New tools to solved old problems. J. In. Dent.
Asso 122:54,1999.
17. Kahn M A : The initial interview. DCNA 22(2),
231-242.1978.
18. Lewin B : Appointment Book Control: DCNA
22(2)307-312,1978.
19. MC Culloch CA, BirekP. Automated probe: Fu
turistic technology for diagnosis of periodontal
disease. Univ. Toronto Dent. J. 4:6,1991.
20. Me Donald- The dental literature: A reflection of
changesinDentistry for children: Jr. of Den for
Children, 253-254.1993.
21. Mittleman S J. Getting through to your patients:
Psychological jnotivation. DCNA32(1) 29*
1988.
34
22. Myers R.D. Dental radiology for children DCNA.
28(1)37-461984.
23. Norman H. Oslen- Four decades of change: Jr. of
Den. for Children, July-Oct, 253-254.1993.
24. Schwartz S H : Dental staff motivation, DCNA
32(1), 1988.
25. White and Tsantsouris. The use and abuse of
radiographs of the primary dentition. Quintes
sence Int’L Dent. Digest 59-62,1977.
26. White and Weissman, Relative discernment of
Lesions by Intra-oral and Panoramic Radiogra
phy 99 JADA 1117-1121,1977.
27. Zappa U. In vivo determination of radiographic
projection errors produced by novel film holder
and x ray beam manipulatorJ- Periodontol. 62( 1),
674-83;1991.
SECTION - 2
Normal Growing Child
2.1 Stages of Human Growth and
Development (Pre-natal)
The complexity of cranio-facial growth is of great
importance for a pedodontic understanding. Every
pedodontist should be an applied biologist and
should keep in mind the fact that the child is in a
dynamic, changing state and presents no static pic
ture. The fully developed cranio-facial skeleton rep
resents the sum of its separate parts, in which growth
is highly differentiated and occurs at different rates
and in different directions and is thus a complex con
cept. Growth and development can be divided into
three aspects.
We grow - increase in size, with a few exceptions
every dimension of the body gets larger with age
through the first two decades of life.
We grow up - changes in proportion, different areas
grow at different rates at different times.
We grow older - maturation
DEFINITION
Growth
Has been defined in many ways by different authors.
1. Growth may be defined as a developmental in
crease in mass, in other words it is a process that
leads to an increase in the physical size of cells,
tissues, organs or organisms as a whole (Stewart
1982).
2. Growth refers to an increase in size or number
(Proffit 1986).
3. Growth may be defined as the normal changes in
the amount of a living substance (Moyer 1988).
4. Growth is an increase in the size of a living being
or any of its parts, occurring in the process of
development (Stedman 1990).
5. Growth signifies an increase, expansion or exten
sion of any given tissue (Pinkham 1994).
Therefore, growth is not a random process. It is a
dynamic process with a stable pattern of changes
resulting in the increase in physical size and mass
during its course of development This can be pre
dicted with reasonable certainty.
Development
Growth is often used as a synonym for development.
In the biologic sense development is a process of
continuous changes occurring in a predetermined
order.
x
i
Development is an increase in complexity (Todd 1931)
Development is used to indicate an increase in the
skill and complexity of functions (Lowrey 1951).
1. Development is in complexity (Proffit 1986)
2. Development embraces other aspects of differ
entiation of form, but principally involves
changes of function, including those largely
shaped by interaction with the structural, emo
tional or social environment (Vaugham 1987).
3. Development refers to all the naturally occurring
unidirectional changes in the life of an individual
from its existence as a single cell to its elabora
tion as a multifunctional unit terminating in death
(Moyer 1988).
4. The act or process of natural progression from a
previous, lower or embryonic stage to a later, morecomplex, or adult stage (Stedman 1990).
SECTION 2 : NORMAL GROWING CHILD |
Primitive streak initiates the formation of
embryo.
Notochord is formed.
Embryonic disc is slightly curved as the
head and tail folds appear.
Paraxial mesoderm condenses from the
somites.
By the end of the 3rd wk primitive endothe
lial cells are formed which fuse into the
primitive heart tube.
Cardiovascular system is the first to reach
its functional stage.
Head forms 1/2 of the body length.
5. Development addresses the progressive evolu
tion of a tissue (Pinkham 1994).
Therefore, development comprises all the normal
sequential series of events which result in the
increased complexity or maturity in the course of
natural progression from a single cell to the multi
functionalorganism ending at death.
Prenatal period
The total period of prenatal life consists of forty
weeks and after 28 weeks. The fetus is considered
viable. The period of intra-uterine life can be divided
into two principle developing organs, the embryo
and the fetus.
TIME
PERIOD OF OVUM (Fig. 2.1)
0-1 wk
Secondary oocyte fuses with the sperm
within 24 hrs after ovulation forming the
zygote. The zygote undergoes cleavage
after 30 hrs to form the Morula and finally
the Blastocyte, which gets implanted in the
endometrium by 3-5 days
4 wk
(Fig.
2.6B)
Neural tube is formed
Embryonic disc assumes a C-shape as the
head, tail aid lateral folds form. (Fig. 2.5)
All major oxgans and systems of the body
start developing from the 3 germ layers.
Formation of the foregut, midgut and
hindgut takes place.
By die 24th day, 3 pairs of branchial arches
are present
Dental lamina too is formed.
On die 27di day the upper limb buds appear
Crown rumplengdi is 4-5 mm
5wk
(Fig.
2.6D)
Major development occurs in the head
region
4 branchial arches present
2nd pharyngeal arch overgrows the 3rd
and 4di arches to form cervical sinuses.
Upper limbs differentiate into hand plates.
Otic placodes and optic vesicles are seen.
Heart beat can be detected
ultrasonographically.
By the end of the 5th wk, 42-44 pairs of
somites are formed.
Lower limb buds appear.
Spontaneous movement of the embryo
such as twitching of the trunk and limbs
seen.
PERIOD OF EMBRYO (Fig. 2.2)
l-2wk
Embryonic period begins with the
pre-somite embryo.
Appearance of bilaminar embiyonk disc
consisting of the ectoderm and endoderm
Amniotic cavity and the yolk sac are
formed separated by the embryonic disc.
Prochordal plate is formed indicating
the fixture cranial region and the primi
tive mouth
3 wk
First missed menstrual period, (mother)
(Fig. 2.3, Morphogensis begins.
2.4)
Gastrulation results in the formation of the
intra-embryonic mesoderm thus forming
the trilaminar disc.
CEB
I TEXTBOOK OF PEDODONTICS
Polar body
Zona pellucida
- Blastomeres
ZYGOTE (24 Hrs.)
2 CELLED STAGE
Inner cell mass
Degenerating Zone
Blastocyst cavity
: Trophoblast
MORULA (72 Hrs.)
BLASTOCYST
Endothelial stroma
Inner cell mass
. Cystotrophoblast
Hypoblast
Uterine cavity
. IMPLANTED BLASTOCYST
(3rd to 5th day)
Fig. 2.1 Transformation of Zygote into Embryo.
*
SECTION 2 : NORMAL GROWING CHILD |
Syncitic trophoblast
Amniotic cavity
Bilaminar; Embyonic disc
Yolk sac
Fig. 2.2 Transverse section of the embryo.
Fig. 2.3 21 days old embryo
ME I TEXTBOOK OF PEDODONTICS
Oropharyngeal
membrane
Neural fold
Notochord
Primitive streak
17th Day
21st Day
Fig. 2.4 Dorsal view of embryonic disc-origin ally egg, then pear shaped and
finally slipper like.
2nd Week
6th to 7th Weeks
Fig. 2.5 Appearance of the head and tail folds.
SECTION 2 : NORMAL GROWING CHILD | CI*
Stómodium
A - 24th Day
Brachial
•arches
——
Heart prominence
Lens placode
Nasal placode
B - 28th Day
Stomodium
Nasal pit
C - 31st Day
Nasolacrimal
groove
D - 35th Day
Medial Nasal
Lateral promi
nence
1st Brachial
arch groove
E - 48th Day
F -14 Wks
Medial & lateral
nasal promine
nces merge with
each other and
with lateral nasal
prominences
Intermaxillary
segment
forming
philtrum
" of lip
—...
Fig. 2.6 A-F Development of face in intrauterine life.
,
| TEXTBOOK OF PEDODONTICS
6 wk
Formation of primitive nose, philtrum
and primary palate.
Development of auricular hillocks around
the facial groove.
Formation of retinal pigment in the eye.
Increase in head size which is more bent
over the heart prominence.
Embryo shows reflex response to touch.
Tooth buds of primary7 teeth develop.
Cranium to face ratio is 40:1
Crown ramp length is 21-23 mm.
7 wk
( Fig.
2.6E)
Eyelid formation begins. Midgut herniation
occurs Change of the blood supply to face
from the internal to external carotid artery7
and is characterized as the critical period.
8 wk
At the beginning of the 8th wk
Hands are short and webbed.
Eyes are open.
Tail still present but stubby.
Scalp vascular plexus occurs as a band
around the head.
By the end of the 8th week
Gross structure of the nervous system has
been established. Tail has disappeared.
Eyes unite by epithelial fusion.
Vascular plexus forms a band near the
vertex of the head.
Ovaries and testes are formed respectively
but the external genitalia are not yet dis
tinguishable.
Purposefill limb movements first occur but
are too slight to be felt by the mother till
about 17th wk.
12 wk
Erythropoiesis decreases in the liver and
begins in the spleen.
By the end of the 12th wk primary7 ossifica
tion centers appear in the skeleton espe
cially in the skull and long bones.
According to clinicians convenience the
1st wk to 12t,‘ wk mark the 1st trimester of
pregnancy. During this period the embryo
is sensitive to genetic, intra and extrauterine insults which could result in miscar
riage or termination of pregnancy. Various
deformities like deafness, mental retarda
tion, congenital heart diseases, cataract,
orofacial anomalies result from radiation,
infection, mechanical or psychological
trauma.
13-15
wk
(Fig.
2.6F)
Breathing & swallowing motions appear,
Crown calcification of primary' incisors and
1st molar begins.
Condyle, coronoid and the angle of
mandible become distinct.
17-20
wk
Primordial follicles form oogonia in the
ovaries.
Brown fat is formed which generates heat
for the infant.
1
Sucking reflex develops.
Calcification of canines and the second
molar begins.
Myelination of the nerves begins.
20 wk
Lanugo head and hair appear.
Skin is coated with vernix caseosa
This period is the usual lower limit of
foetal viability.
24 wk
Secretory epithelial cells secrete surfactant
in the lungs.
Histo differentiation of enamel organ and
dental lamina forms ameloblasts and
odontoblasts
Second trimester ends. This period is
relatively safe for dental treatment for the
mother.
PERIOD OF FETUS
*4 wk
Fetal period begins.
Crown rump length is 3cm weight 8gm.
This a period of rapid proliferation and
differentiation
10 wk
External genitalia distinguishable
SECTION 2 : NORMAL GROWING CHILD | €*EB
Table 2.1: Events taking place during embryonic period
Days
Length
Clinical Features
14-15
0.2 mm
Appearance of the primitive streak.
16-18
0.4 mm
Notochordal process appears.
Haemopoietic cells appear in the yolk sac
19-20
1-20mm
Intra embryonic mesoderm.
Primitive streak complete
Umbilical vessels and cranial neural folds form
20-21
2.0-3.0mm
Cranial neural folds develop.
Elevated embryonic bud.
Formation of primitive heart
22-23
3.0-3.5mm
Fusion of neural folds in cervical region.
Anterior and posterior neuropores open.
The first and second visceral arches formed
Heart tube begins to fold.
24-25
3.0-4.5mm
Cephalocaudal folding develops.
Cranial neuropore closes
Optic vesicles are formed and optic placodes appear
Formation of dental lamina
26-27
3.5-5.0mm
Caudal neuropore closed.
Upper limb buds appear
3rd pair of visceral arches are formed
28-30
4.0-6.0mm
4 visceral arch seen
Hindlimb buds appear
Optic vesicle and lens placode present
31-35
7.0-10.0mm
Forelimb pads paddle shaped.
Nasal pits seen.
Embryo C-shaped
35-42
9.0-14.0mm
Brain vesicles prominent.
Umbilical herniation present
External auricle visible
43-49
13.0-22.0mm
Pigmentation of retina seen.
Eyelids formed?
Maxillary swellings fuse with medial nasal swellings as upper lip
50-56
21.0-31.0mm
Limbs elongate with bending of the elbows and knees.
Face becomes human like, tail disappears.
.th
.
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tf № I TEXTBOOK OF PEDODONTICS
Third trimester begins.
Weight 900 g.
Length 25 cm
28 wk
Eyes begin to reopen.
Grasp reflex well developed.
Fetal head turns down.
Fetus weighs 1000 gm -1300 gms.
Length of fetus is 35 cm (14”).
30 wk
Fetus appears reddish and wizened since
skin is thin and there is relative absence of
subcutaneous fat
36-38 wk Fat develops rapidly resulting in red,
smooth, plump appearance This period is
devoted mainly to building up of tissues
and to preparing systems involved in the
transition from intrauterine to extrauterine
environment primarily the respiratory and
the cardiovascular systems
Hand forms 1/3 of the body length,
cranium to face ratio is 8:1.
Length is 45-50 cm (30 inches).
Weight is 3200 gm or 2.5 - 4.5 kg (5.5 to
10 lbs).
Head circumference 35 cm.
At the end of 3rd trimester there is
increased risk of hypoxia or its complica
tion to the foetus.
Patient should not be subjected to dental
treatment without taking utmost care
Self-Assessment
1. Defi ne growl h a nd development.
2. When does the first and second visceral arches
form?
3. When does the formation of dental lamina take
place?
4. What wi 11 be t he length of embryo when it is 20 to
21 days old?
5. When does face appear human like?
6. What is the significance of pre-natal period?
2.2 Pedologic Anatomy
Tandon S
A child may appear as a miniature adult to the lay
man but the details of the anatomy reveal that a child
is entirely different from an adult. The miracle of
growth and development are more evident here than
in the anatomical changes taking place in a growing
child. These changes vary progressively till puberty,
after which permanent features are established. The
knowledge of comparative anatomy of an adult and a
child is essential for the dentist for a correct diagno
sis and to recognize some of the developing charac
teristics of a child which may be mistaken for an ab
normality or a pathologic condition that may cause
concern to the parents of a child patient and also
mislead the clinician for a successfill treatment.
FETAL GROWTH CHANGES (Fig. 2.7a, b)
3rd month
5th month
At birth
Fig. 2.7b Prenatal changes upto birth
End of first month:
The head is less flexed and the neck longer and
clearly defined. The development of the face with
the formation of the upper lip and nostrils takes place.
The palate is still incompletely formed. Enamel or
gans are developed from dental lamina. The external
ears and eyelids are developing and limbs are form
ing. Skeletal and visceral tissues begin to form. Kid
neys begin to form with tubules; The backbone and
the vertebral canal form small buds that will develop
inner and upper extremities. Heart forms, starts beat
ing, and the body systems begin to form.
End of second month:.
Fig. 2;7a Stages of growth from, the end of the
third week to the end of eighth week in the utero
Eyes are far apart with eyelids fused, the nose is flat.
Ossification begins and limbs become distinct as
the upper and lower extremities. Digits are well
formed. Major blood vessels form. Many internal
organs continue to develop.
C33I I TEXTBOOK OF PEDODONTICS
End of third month:
cheesy covering over the skin. Fetal movement so
called‘quickening; can be seen
Eyes almost fully develop but eyelids still remain
fused. Bridge of nose develops and external ears are
formed. Ossification continues, nails develop. Head
flexion increases and the neck becomes proportion
ately larger. The umbilical protrusion of the gut is
reduced with a proportionate abdominal volume.
Heart beat is detectable.
Head becomes even less disproportionate to the rest
of the body. Eyelids separate and eyelashes form.
Skin is wrinkled and pink. Increase in the growth of
the cutaneous and subcutaneous tissues occurs.
End of fourth month:
End of seventh month:
Head is large in proportion to the rest of the body.
Face takes on human features and hair appears on
the head. Skin is bright pink. Many bones are ossi
fied and joints begin to form with continued devel
opment of the body systems. The eyes have moved
further into an anterior position but are still relatively
wide apart. The external ear is formed on the side of
the head and is no longer in the upper part of the
neck.
Head and the body become more proportionate. Skin
is wrinkled and pink. Eyebrow hairs and eyelashes
developed. The eyelids separate and the papillary
membrane separate. Body is more plump.
End of fifth month:
Head is less disproportionate to rest of the body.
Fine lanugo hairs covers the body. Rapid develop
ment of body systems takes place. Skin is bright
pink and sebaceous glands become active forming a
End of sixth month:
End of eight month:
Sub-cutaneous fat deposition takes place. Skin is
less wrinkled. Testes descend into the scrotum. Bones
of the head are soft.. There is a progressive loss of
lanugo, except for the hair on eyelids, eyebrows and
scalp. The bodily shape is more infantile. The tho
rax broadens relative to the head and the abdomen
also increases. The umbilicus is gradually centrally
located. Chances of survival are much greater by
this period.
Table 2.2: Growth of length and weight during fetal period.
Weeks
Months
9-12
3
5-8
10-45
13-16
4
9-14
60-200
17-20
5
15-19
250-450
21-24
6
20-23
500-820
25-28
7
24-27
900-1300
29-32
8
28-30
1400-2100
33-36
9
31-34
2200-2900
At birth
35-36
45-50
3400+
Crown-rump length (cm)
Weight (gm)
SECTION 2 : NORMAL GROWING CHJLD |
End of ninth month:
■
Additional sub-cutaneous fat accumulates. Lanugo
sheds. Nails extend to the tips of the fingers and
even beyond.
■
Growth of length and weight during fetal
period are given in Table 2.2
•
The sphenoid bone is made up of 3 parts (the
body, lesser and greater wings) at birth, which
fuse during the first year. Sinuses do not develop
in the sphenoid till the 5 year.
The ethmoid bone at birth is in 3 pieces (median
plate and a right and left labyrinth) which fuse by
the 5th or 6th year of life.
Each temporal bone consists of 4 parts which
completely fuse by puberty
Mastoid process is absent in the neonate, thus
the stylomastoid foramen lies superficial .
GENERAL POSTNATAL CHANGES IN DIMENSIONS
AND PROPORTIONS
■
Neonatal Skeleton
Body Proportions (Fig. 2.8)
The neonate has 270 bones as compared to an
adult who has 206 bones.
« The ratio between the calvarial and facial portion
is 8:1 at birth whereas it is 2.5:1 in an adult female
and 2:1 in an adult male.
■ Skull bones in the neonate are 45 (due to incom
plete ossification) and in the adult 22.
■ The frontal bone at birth is in 2 halves, which
fuses at 2 years.
« There are 2 parietal bones
« The occipital bone at birth consists of 4 pieces,
which fuse by 3-4 years of life.
The body proportions are a result of the differential
rates of growth of the cephalic and the caudal ends.
Massive changes in the body proportion occur from
the fetal life to adulthood.
■ Mid point: The mid-point of stature of a twe
month-old embryo is at the chest, closelo the chin
• At birth:This may shift tojust above the umbilici
■ In adult: It is at the pubic-symphysis region.
■ The length of the head doubles by adulthoo«
but the rest of the body grows still more, hence
birth 22% of the body area is coveredby the 1k«~.
■ This decreases to 13% at 12 years and only 10%
in an adult.
•
In utero
2 mo
5 mo
New born
2 yr
6 yr
12 yr
24 yr
<331 I TEXTBOOK OF PEDODONTICS
■
■
•
There is an axis of increased growth extending
from the head towards the feet. This increased
growth is the cephalo-caudai gradient.
The cephalo-caudai gradient can be observed in
the growth of the head. In the face, the mandible,
which is the farthest from the brain, grows more
as compared to the maxilla, which is closer.
I n t he early period of development, the cranium is
larger in relation to the face. Later, this propor
tion changes due to increased growth of the face.
Posture:
•
•
•
The neck is relatively short at birth and its mus
cles are not developed for supporting the head.
Functional development of these muscles begin
from two months onwards.
The Chest:
s
•3
1 ■
L
f ■
«
■ ■
■
The girth of the chest at birth is smaller than the
head circumference.
It becomes equal at two years and, by fifteen years
its ratio becomes 3: 2.
The final ratio in adults is 5:3.
The chest is rounded in the newborn.
Its final shape is attained by the time puberty is
reached.
Abdomen:
*
*
■
■
At this stage the abdomen is quite protuberant
but soft.
Ci rcumferencc of the abdomen is equa 1 to the chest
until two years.
After two years the abdominal circumference is
less than the chesf s.
Extremities:
■
At birth:
Legs arc short, arms long.
■
Arms:
Birth to 2 years - length increases by
6.75%
At 8 years - 50% longer than at two
years
By 16 to 18 years - slow growth,
increased development takes place
Thus an early maturer has shorter arms
than a late maturer
■
Legs:
At birth - short and curved
Birth to 2 years - length increases 40%
A lot of fat on the anedial aspect of
the foot gives the appearance of a flat
foot
6 years - straight, the knock-knee and
flat foot appearance gets corrected
8 years - 50% longer than at two years
Adolescence - 4 times longer than at birth
Early maturer - shorter legs than the
late maturer
The newborn is usually kept in a supine posture
but can be literally folded' to its most comfort
able posture i.e., the posture simulating the fetal
posture of partial flexion.
Mild lordosis and protuberance of the abdomen
is a common finding at 2-3 years of age, but this
disappears by 4 years.
The Neck:
•
■
The umbilicus of a newborn is shed-off around
the 12<}1 to 15th day.
The umbilicus is everted and in some cases umbilical hernia may be present.
CHANGES IN CRANIOFACIAL COMPLEX
The skeletal portion of craniofacial complex devel
ops as a blend of morphogenesis of primary skull
components.
1. The neurocranium: This consists of two parts
■ The desmocra nium which comprises the vault
of the skull or calvarium. It evolved in response
to need for protection of the brain and is formed
of the intra-membranous bone.
■ The chondrocranium forms the base of the
skull, which ossifies as a endochondral bone.
SECTION 2 . NORMAL GROWING CHILD I CEB
■
Fig. 2.9a Comparison between adult and
neonatal skull - Frontal view
i
Fig. 2.9b Lateral view
2. The viscerocramum is formed by the bones of
facial skeleton which develop by intramembranous ossification. This is derived from the
branchial arches
tMfhehsional changes in craniofacial
skeleton (Fig. 2.9a, b)
These changes can be appreciated even in intrauter
ine life.
■ Third month to birth:
The entire cranium becomes longer and wider in
its relation to height.
At birth:
Craniofacial skeleton undergoes between 30%
and 60% of its total growth.
Head makes up about a greater part of the total
bod\' length whereas in the adult it accounts for
about one-eighth of the total body height.
This change reflects the early development and
attainment of the final size of the head compared
with the rest of the body.
The remaining dimensional increase is not equal
in all parts of the cranium.
■ Afterbirth:
While the size ofthe cerebral cranium will increase
by about 50%. the facial skeleton will grow to
more than twice the original size.
Cranial circumference is an indicator of cranial
volume and therefore is often used in young in
fants fora rough measure of brain development.
■ By four years:
This growth is almost completed.
Cranial circumference thus increases from about
33 cm (at birth) to 50 cm at 3 years after which it
only increases by 6 cm.
■ Four years onwards:
Facial skeleton increases in all dimensions dur
ing postnatal growth period, tiie increase in height
being the greatest, (approximate!}7 200%).
In depth, the increase is somewhat smaller (ap
proximately 75%).
Increase in width is the smallest (approximately
15%).
The height of upper and lower face are highly
independent. The upper anterior face height
seems to be primarily correlated with cranial base
changes. Hie lower face height seems to be more
dependent on muscular function, environmental
factors interfering with the airway and the pos
ture of the head.
■ Because of the above changesdn the craniofacial
complex, general features of th^head and the face
arc observed to be different at different ages.
Head:
■ At birth:
The head circumference is around 35 ems (13.75
inches), (Fig. 2.10a)
I TEXTBOOK OF PEDODONTICS
»
•
•»
•
Head shape is rounded but sometimes it may get
molded during parturition as over-riding of the
parietal bone takes place when the head gets en
gaged in the birth canal.
Six months:
It increases to 44 cms
One year:
Head circumference may be more than the chest
circumference.
A total four inches increase takes place (2 inches
first 4 months and then 2 inches next 8 months)
By the end of the year head circumference be
comes equal to trunk dimension and the trunk's
may even exceed.
One vear onwards:
Between one to two years 4 inches increase takes
place.
At 10 years:
95% of total head growth completes with the width
of the head completed by 3 years while the length
of the head completes by 17-18 years.
Fontanelles: They bridge the gap between the
bones that limit them. They are made up of the
duramater, the primitive periosteum and the aponeu
rosis from inside outwards. (Fig. 2.10b)
Fontanelles present at birth are:
a) Anterior fontanelle, between the two parietal
bones and the frontal bone.
b) Posterior fontanelle, between the two parietal
bones and the occipital bone.
c) Sphenoid fontanelle, between the frontal, pari
etal, temporal and the sphenoid bone.
d) Mastoid fontanelle, between the parietal, occipi
tal and the temporal bone.
3. Anterior fontanelle serves as a landmark for with
drawal of blood for analysis from the superior
sagittal sinus.
4. Depressed level of fontanelle indicates dehydra
tion and increased level indicates an increased
intracranial pressure.
Closure time of fontanelle:
Anterior fontanelle (frontal): 18-24 months after
birth
■ Posterior fontanelle (occipital): 2 months after
birth
■ Anterolateral fontanelle (sphenoid) : 3 months af
ter birth (paired)
■ Posterolateral fontanelle (mastoid): begins to
close 1-2 months after birth, closure completely
by 12 months (paired)
■
Cranial synchondroses
Cranial synchondroses play an important role in
craniofacial growth.
Sphenoccipital: closes by 17-20 years
■ Sphenoethmoidal: closed by 2-4 years; may per
sist and fuse later in adolescence but is of little
importance in postnatal growth
■ Mid sphenoid: closes shortly after birth
Other synchondroses:
■ Intraoccipital
■ Sphenopetrosal
■ Petrooccipital
Craniotabes or soft skull due to paper-thin bones is
palpable in premature infants.
Clinical importance of fontanelles
Sutures of Cranium
1. Enables the fetal skull to modify its size and shape
as it passes through the birth canal and permits
rapid growth of the brain during infancy
2. Helps the physician to gauge the degree of brain
development by their state of closure.
1. Coronal suture: Between the frontal and parietal
bones
Closes: 24 years to 35 years of age
2. Sagittal suture: Between two parietal bone
Closes: 22 years - 30 years of age
SECTION 2 : NORMAL GROWING CHILD | C33
Measuring the height of new born child
Measuring the head circumference
of new born child
Fig. 2.10a
Metopic sutrue
Lateral view
Superior view
Fig. 2.10b Fontanelle and sutures ir> neonatal skull.
<SFB-| TEXTBOOK OF PEDODONTICS
3. Lambdoidal suture: Between two parietal and
occipital bone
Starts to close around 29 years of age.
4. Squamous sutures and lateral anteroposterior su
tures: between the squamous portion of the tem
poral bone and the parietal bone. The squamous
sutures closet late in life.
■
■
■
Face
■
•
•
•
■
■
■
At birth, the lower third and the middle third of
the face are underdeveloped due to the absence
of teeth.
The forehead is high and bulging.
The face of the newly born baby is round and
flat.
The eyes dominate and owing to the absence of
the root of the nose, appear to be widely sepa
rated.
After the onset of puberty the forehead flattens
and widens, lips thicken and the face acquires an
oval shape, mainly due to growth of the jaws.
The child's convex facial profile is straightened
out, owing to the more anterior position of the
jaws,
The development of chi n prominence and deeper
position of the eyes through growth of .the or
bital ridges and the ridge of the nose increases
this impression.
■
■
■
•
■
Mandible
■
■
Nasomaxillary Complex
■
•
•
■
The maxilla develops in the membranous tissue
at the end of the sixth fetal week
The maxilla proper is a result of a highly complex
growth pattern with many different components.
The maxilla is attached to the neurocranium di
rectly with the fronto-maxillary sutures and indi
rectly by means of various other facial structures
such as, the nasal, lacrimal and ethmoid bones,
the nasal septum including vomer, the palatine
bone and the zygomatic arch.
Most of the structures mentioned are joined to
gether in an edge-to-edge fashion.
During the early phase of fetal development the
sagittal interrelation of the jaws is characterized
by mandibular protrusion, which is gradually
reversed.
At birth the maxilla is placed more anteriorly giv
ing class II relationship of the jaws.
Later, in the course of post-natal development,
both maxilla and mandible with their.associated
soft tissues grow forward and downward and es
tablish a normal class I relationship.
Maxillary sinuses at birth are not well developed
and are present like slits.
Development of the orbita 1 cavities is practically
complete at birth.
Nasal cavity is located between the two orbits of
the eyes and its floor, is roughly level with their
bottoms.
The alveolar process can only be faintly dis
cerned and the palate has a weak transversal cur
vature.
The maxillary body is almost entirely filled with
the developing teeth.
Although still separated by a symphysis in the
midline, the two halves of the mandible fuse into
a single bone by the age of 1-2 years.
At birth
- The 2 rami are short
- Condylar development is minima 1
- A thin line of fibrocartilage and connective tis
sue exists at the midline of the symphysis to
separate the right and left mandibular bodies.
- The symphysial cartilage is replaced by bone
(Between 4 months of age and end of the 1st
year)
- Growth is quite general, with all surfaces show
ing bone apposition, especially at the alveolar
border, at the distal and superior surfaces of
the ramus, at the condyle, at the lower border
of the mandible and on its lateral surfaces.
SECTION 2 : NORMAL GROWING CHILD |
- The alveolar processes and the muscles are
poorly developed at this age, so that its basal
arch mainly determines the shape of the man
dible in the neonate.
- At birth the structure of mandible is shell like
with the 10 alveolar sockets for the develop
ing tooth gum.
- Of all the facial bones, the mandible shows not
only the largest amount of postnatal growth,
but also the largest individual variation in mor
phology.
- The position of the mandibular foramen
changes by remodeling, to a more superior
position from the occlusal plane as the child
matures into an adult.
- The foramen is below the occlusal plane in a
very young child, slightly at the occlusal plane
during the period of primary dentition. It aver
ages 7 mm above the occlusal plane in the adult.
- Angle of the mandible is more obtuse in young
children.
- Mental foramen is placed very close to the
border of the mandible in young children.
Temporomandibular joint
Three phases of development are seen in the intrau
terine life period (Velasco Merida et. al 1999)
■ Blastemic stage (7 to 8 weeks of development)
corresponds with the organization of the condyle
and articular disc and capsule.
■ Cavitation stage (9 to 11 weeks of development)
corresponds to the initial formation of inferiorjoint
cavity and then start of condylar chondrogenesis.
» Maturation stage (after 12 weeks of development)
Post natal changes in TMJ (Fig. 2.11)
»
■
At birth the articula r disc is flat and develops an
accentuated S-shaped profile as the articular tu
bercle develops.
Condylar cartilage is approximately 1.5mm thick
at birth but soon thins down to about 0.5mm. By
20 to 30 years of life, it is completely replaced by
endochondral ossification.
■
Mandibular condyle grows in a constant poste
rior, superior and lateral direction and attains a
mature contour by late mixed dentition period.
ORAL FEATURES OF THE NEONATE:
The edentulous arches of a child vary from an
edentulous adult.
The alveolar arches of an infant are called gum
pads which are firm and pink structures with a
definite form.
Each gumpad is divided into ten segments by
transverse grooves, and, of these, the groove be
tween the deciduous canine and the deciduous
first molar segments are prominent and called the
lateral sulci.
The upper gum pad (Fig. 2.12a): It is horseshoe
shaped and shows:
- Gingival groove - It is the groove-separating
the gum pad from the palate.
• Dental groove - It originates in the incisive
papilla region and extends backwards to touch
the gingival groove in the canine region and
then laterally to end in the molar region.
- Lateral sulcus -It is a deepened groove sepa
rating the canine and deciduous first molar
segments.
The lower gumpad: (Fig. 2.12b)
•- Differs from the upper.
- It is U-shaped, with its anterior portion everted
labially.
■ It also shows the gingival groove that demar
cates the lingual extent of the gumpads.
Mtci]
- Dental groove
running from the mandible back
wards, laterally to join the gingival groove in
the canine region.
“ Lateral sulcus - a deepened groove separating
the canine and deciduous first molar segments.
$
Relationship of gumpads (Fig. 2:12c)
At rest the gumpads are separated by the ton
lying over the lower gumpad.
There is no definite antero-posterior relatip
of the gumpads on occlusion, btft ?||||
J
C® I TEXTBOOK OF PEDODONTICS
Fig. 2.11 Development of mandible and the T.M.J.
gumpad being smaller, the lateral sulcus of the
lower gumpad lies distal to that of the upper.
There is a variable overjet with contact only in
the first molar segments.
During function the mandibular movements at this
stage are mainly vertical and to a very small ex
tent in the antero-posterior direction. Lateral
movements are absent.
During the .early phases of foetal development
the sagittal interrelationship of the jaws is char
acterized by a mandibular protrusion, which is
gradually reversed.
At birth the lower jaw is often situated posteriorly.
This relationship has some clinical significance
as disturbed post-natal forward growth of the
mandible may result in malocclusion.
Growth of gum pads
■
■
■
■
■
At birth the width of the gum pads are inadequate
to accommodate all the incisors.
The growth of gum pads is rapid in the first year
after birth.
Growth is more in a transverse direction and in
the labio-lingual direction.
Due to growth ,the segments of each gum-pad
become prominent.
Eruption of deciduous teeth commences at six
months of age.
Tongue
■
It is comparatively large in relation to the small
mouth.
SECTION 2 : NORMAL GROWING CHILD |
Medial incisor segment
Lateral incisor segment
Papilla
1st molar segment
Central incisor
Lateral incisor
Canine
Dental groove
■ 1st molar
Canine segment
Gingival groove
2nd molar
Fig. 2.12a Upper Gum Pad.
Fig. 2.12b Lower gum pads
Fig. 2.12c Gum pad relationship
<EEB I TEXTBOOK OF PEDODONTICS
■
■
The tongue is flat, thin and blunt tipped, prob
ably due to the short frenunu
The tongue, at this stage performs only one func
tion, i.e., acts as a piston while suckling.
O i HER EXTERNAL FEATURES OF A NEWLY
BORN CHILD:
Skin
■
Tonsils and Adenoids
■
■
«
At birth: The tonsils and adenoids are small in
size. Clusters of white-yellow follicles with ery
thematous borders may appear initially. A few
days after birth these may regress.
First few months:
The growth of tonsils and adenoids takes place
as the lymphoid tissue starts proliferating and
establishing function. This growth is more in the
presence of infection.
Six months to two years:
Maximum growth occurs as the primary physi
ological enlargement.
At six years:
The next hypertrophy, after a period of quies-
[
|
•
I
I
I
cence, occurs especia liy when the child is exposed
to infection at school. This is the secondary
physiological enlargement.
« At puberty:
The regression and atrophy of the nasopharyn
geal lymphoid tissue finally occurs by the time
the child attains puberty.
1
f
Buccal Pad of Fat (‘Corpus adiposum’ or
Bichat’s fat pad):
■
■
■
■
■
■
■
•
It is the child's reserve of energy. It is nothing
but the cheek prominence giving the infant a
chubby-cheek appearance. It is formed of a firm
encapsulated mass of fat lying between the sub
cutaneous fat and the muscles of the cheek.
Its exact role in suckling is not known. It probabty plays no role in suckling but it has been
found to regress once the suckling has ceased.
■
■
The ski n of a neonate is often reddish. Described
to be like that of a lobster, it shows various nor
mal variations.
A child may have an appearance of cyanosis due
to the thin skin and a high hemoglobin content of
the blood even when CO is high, while a deep
red purplish appearance may be the result of a
transient anoxia resulting from a closed glottis
prior to a vigorous cry. Cyanosis of hands and
feet also occurs upon exposure to cold.
The cause of acrocyanosis is an imbalance in
autonomous regulatory mechanism, and also, pe
ripheral vascular sluggishness. Another effect of
this is the ’Harlequin color change' (Harlequin
armour).
‘Mongolian Spots' are slate blue colored wellcircumscribed patches of pigmentation over the
back, buttocks and sometimes over the other parts
occurring in more than 50% of black infants and
occasionally in white infants,
Vernix caseosa, a whitish covering over the skin
formed by sebaceous secretion and exfoliated
epithelial cells around the end of the^fifth month
of gestation, may persist even after birth or may
be stained with the amniotic fluid contaminated
with meconium.
Deep red skin with fine, soft, immature, lanugo
hair is characteristic of a premature infant.
Post-term infants may show a whitish, peeling,
parchment like skin.
Erythema toxicum is a rash of w hitish, vesiculopustular papules w ith erythematous base that may
appear soon after birth, lasting for 1 week on the
trunk, face and extremities.
Pustular melanosis is a similar, benign vesiculopapular rash at birth in some blacks, around the
chin, back and extremities, palms and soles.
SECTION 2 : NORMAL GROWING CHILD |
Eyes
■
«
■
■
■
Size: The eyes of a neonate a re small at birth, the
size being one-third of the adult size. Maximal
growth occurs in the first year and continues at a
rapidly decelerating rate till three years, and fur
ther slows down till puberty.
Cornea: At birth, the cornea is relatively more
(10mm) and nearly fills the palpebral fissures. It
reaches an adult size (12mm) by two years. After
2 years, the posterior aspect of the eye grows,
giving the eyeballs their final spherical shape.
The Lens: The lens of a child is more or less
spherical and has greater refracting power.
Thefundus: It is less pigmented than the adult’s.
The fundus acquires its adult form by 4-6 months.
The retina: Has a fine peppery mottling. The pe
ripheral retina appears pale or grayish since the
peripheral vasculature is immature.
Nose
■
■
■
The nose of a neonate is small and flat with nar
row nostrils.
The bridge of the nose is depressed. Maximal
growth of the nasal cartilage occurs till puberty,
after which it attains its final form.
The hair within the nose becomes thicker around
puberty.
Lips
■
•
■
■
The 1 ips of a new-born are reddish pink, soft and
supple.
The midline of the upper lip has a small projec
tion * the labial tubercle (suckling callus), which
is said to disappear after the cessation of suck
ling.
Another feature of the lip similarly found to be
related to suckling is the abrupt separation of the
mucosa covering the inner aspect of the lips from
the outer aspect by a thin single line, parallel to
the free border of the lip.
It may undergo a slow transformation to form the
transition zone between the outer and inner as
pects after one year.
Ears
The ears of a child arc almost completely devel
oped.
■ The external auditory canal is short, straight and
fall of secretion.
■ The tympanic membrane has a dull gray translu
cency and the structures of the middle ear can be
easily studied through it.
■
REFLEXES PRESENTAT BIRTH:
1. Moro reflex: Any sudden movement of the neck
initiates this reflex. A satisfactory way of eliciting
the reflex is to pull the baby half-way to a sitting
position from the supine and suddenly let the
head fall back to a short distance. The reflex con
sists of a rapid abduction and extension of the
arms with the opening of hands. The arms then
come together as in an embrace.
Clinical importance: Its nature gives an indica
tion of the muscle tone. The response may be
asymmetrical if muscle tone is unequal on the two
sides, or if there is a weakness of an arm or an
injury to the humorous or clavicle. This reflex
usually disappears in 2 or 3 months.
2. Startle reflex: It is similar to moro reflex, but is
initiated by a sudden noise or any other stimulus.
In this reflex, the elbows are flexed and the hands
remain closed, there is less of the embrace, less
outward and inward movement of the arms.
Grasp reflex: When the baby’s palm is stimu
lated, the hand closes. There is also a correspond
ing plantar reflex. Both normally disappear by 24
months.
Walking/stepping reflex: When the sole of the
foot is pressed against the couch, the baby tries
to walk. It persists as voluntary standing.
•I
•■
Limb placement reflex: When the front of tl^ l||g
below the knee, or the arm below the.;^^^^^
.yâ
brought into contact with the edge.'
the child lifts the limbs over
-f
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'I
ME® 1 TEXTBOOK OF PEDODONTICS
6. Asymmetric tonic neck reflex: When the baby
is at rest and not crying, he lies at intervals with
his head on one side, the arm extended to the
same side, and often with a flexion of the contral
ateral knee. This reflex normally disappears after
2 or 3 months, but may persist in spastic children.
7. Rooting reflex and sucking: When the infants
cheek contacts the mother’s breast, the baby’s
mouth results in vigorous sucking movements
the baby rooting for milk. When corner of mouth
is touched, the lower lip is lowered, the tongue
moves towards the point stimulated. When the
linger slides away, the head turns to follow it.
When the center of upper lip is stimulated, the lip
elevates.
Swallowing begins around 12 1/2 weeks of in
trauterine life.
Full swallowing-and sucking is established around
32-36 weeks I.U life.
8. Gag reflex: It is seen at 18 1/2 weeks I.U life. In
the buccal cavity and pharynx, the ectoderm /
endoderm zone is towards the posterior third of
the tongue. Touching here elicits a gag reflex, a
protective reflex.
9. Nasal reflex
Stimulation of the face or nasal cavity with water
or local irritants produces apnea in neonates.
Breathing stops in expiration with laryngeal clo
sure and infants exhibit bradycardia and lower
ing of the cardiac output.
Blood flow to the skin, splanchnic areas, muscles
and kidney decreases, whereas the flow to the
heart and brain is protected. Midwives have for
many years blown on the face of neonates to in
duce the first breath.
10. Infantile swallow: Until tile primary molars erupt,
infant swallows with the jaws separated and the
tongue thrust forward using facial muscles (or
bicularis oris and buccinator). This is a non-conditional congenital reflex.
Acquired congenital reflex: After eruption of the
posterior primary teeth, from 18 months of age
onwards, the child tends to swallow with the teeth
brought together by the masticatory’ muscle ac
tion, without a tongue thrust.
11. Cry: It is a non conditioned reflex which accounts
for its lack of individual character and is of spo
radic nature. It starts as early as 21-29 weeks I.U
life.
12. Mastication: It is a conditioned reflex, learned ini
tially by irregular and poorly coordinated’ chew
ing movements. The proprioceptive responses of
the TMJ and the periodontal ligament of the
erupting dentition establishes a stabilized chew
ing pattern, aligned to the individual dental
intercuspation.
13. Blink reflex: Various stimuli provoke blinking.
Whether the child is awake or asleep, pupils of
the eye react to changes in the intensity of light.
14. Doll’s eye reflex: Through a complex mechanism,
infants hold fixation of faces, piovements or chang
ing intensity of light within their visual fields.
During the Ist week they are able to maintain these
fixations against passive movement of their bod
ies.
15. Babinski’s reflex: Stroking of the lateral surface
of the planter surface of the foot from the heel to
the toe results in flexion of the toe.
16. Parachute reflex: It appears at about 6-9 months
and persists thereafter. The reflex is elicited by
holding the child in ventral suspension and sud
denly7 lowering him to the couch. The arms ex
tend as a defensive reaction. In children with
cerebral palsy, the reflex may be absent or abnor
mal. It would be asymmetrical in spastic hemiple
gia.
17. Landau reflex: It is seen in vertical suspension,
with the head, spine and legs extended. If the
head is flexed, the hip knees and the elbows also
flex. It is normally present from 3 months and is
SECTION 2 : NORMAL GROWING CHILD |
difficult to elicit after 1 year. Absence of reflex
occurs in hypotonia, hypertonia or severe mental
abnormality.
18. Tendon reflexes: They are present in the neonate.
They are of great value for the diagnosis of cer
ebral palsy, for, in spastic children, the tendon
jerks are exaggerated.
19. Abdominal reflexes: They are also present in most
of the newborn babies.
Self Assessment
What is the period of embryo and foetus?
Which are the fontanelle and when do they close?
Which are the sutures and when do they close?
Explain how the moro’ reflex is elicited and what
is it’s clinical importance?
5. What are Gum pads? Give the features of the up
per gum pad.
6. What is the head circumference of the child at
birth.?
1.
2.
3.
4.
2.3 Stages of Human Growth and
Development (Post-natal)
Tandon S, Radhika M
Singes of post natal growth and development are
based on the average fluctuation in growth and de
velopment The followi ng developmental periods till
adulthood are generally considered.
Smiles on social contact.
Listens to voice and coos.
12 wk
POST NATAL PERIOD (Fig. 2.13a, b)
|
1-4 wk In prone position child 1 ies flexed and turns
Neonatal head from side to side, head sags on
period
ventral suspension.
16 wk
Motor response, grasp reflex are active.
Shows visual preference to human face.
Face is round and mandible small.
Abdomen is prominent with relatively
short extremities.
Criteria to assess premature newly
horn is born between the 28th to 37th week of 28 wk
gestation.
birth weight 2500 grams (51bs-81bs) or less.
birth length 47 cm (18 1/2 inches) or less.
head length below 11.5 cm (4 1/2 inches)
and
head circumference below 33 an (13 inches).
4 wk
Holds chin up.
Head lifted momentarily to the plane of
the body on ventral suspension.
Watches person, follows moving object.
Beginning to smile.
8 wk
Head sustained in plane of body on
ventral suspension.
40 wk
Lifts the head and chest.
Lifts head above plane of body on ventral
suspension.
Early head control with bobbing motion.
Makes defensive movements.
Listens to music.
Lifts head and chest, head in approximately
vertical axis.
Symmetric posture predominates, hands in
midline.
Enjoys sitting with full truncal support.
Laughs out loud.
1
Excited at sight of food.
Rolls over, crawls.
Sits briefly.
Reaches out for and grasps large objects.
Transfers objects from hand to hand
Polysyllabic vowel sounds formed
Prefers mother, babbles
Enjoys mirror
Sits up alone, without support.
Pulls to standing position; “cruises” or
walks holding on to furniture.
Grasps objects with the thumb and fore
finger; pokes at things with forefinger.
Repetitiveconsonantsounds (mama, dada).
Responds to sound of name.
Plays peek -a- boo, waves bye-bye.
SECTION 2 : NORMAL GROWING CHILD | 4CTB
Stands alone
Walks with support
Cruises
Pulls up
Creeps
Sits briefly
Transfers objects
Rolls over
Holds head
Turns head
Smiles
Regards
Birth
1
2
3
4
5
6
7
8
9
10 11
12 13 14
Age in Months
Fig. 2.13a Cephalo-caudal growth - Aldrich 1972.
Fig. 2.13b Normal Milestones in Development
New born: Prone
Supine
Ventral suspension
Puled to sit
Held sitting
NEWBORN
1 TEXTBOOK OF PEDODONTICS
Pulled to sit
Held sitting (Momentarily lifts head)
4 TO 6 WEEKS
Prone
Ventral suspension
Pulled to sit
4
Held sitting
10 T011 WEEKS
5TH MONTH
SECTION 2 : NORMAL GROWING CHILD |
Lifts head
Sits without being held
Transfers object from one
hand to other
Palmar grasp of cube
Held standing bears
full weight
6TH MONTH
Palm and thumb grasp
support
Forefinger and thumb grasp
Bear like crawl
Walks with hand held
1YEAR
I TEXTBOOK OF PEDODONTfCS
52 wk
Walks with one hand held, rises independ
ently takes several steps.
Releases object to other person on request
or gesture.
Increase in vocabulary by a few words,
besides ’mama. dada’.
Makes postural adjustments to dressing.
36 Mo
Rides tricycle.
.Stands momentarily on one foot.
Imitates a cross, copies a circle.
Knows age and sex.
Counts 3 objects correct 1\
48 Mo
Hops on one foot.
Uses scissors to cut out pictures.
Tells a story;
Plays with several children.
Goes to toilet alone.
60 Mo
Skips.
Dresses, undresses.
Asks questions about meaning of words
Domestic role-playing.
PRESCHOOL PERIOD
15 Mo
18 Mo
Walks alone, crawls upstairs.
Inserts pellet in bottle.
Jargon; follows simple commands, may
name a familiar object.
Indicates some desires or needs by point
ing; hugs parents.
Runs stiflly.
Walks up stairs with one hand held.
Explores drawers and waste baskets.
Imitates scribbling (vertical strokes).
Dumps pellet from bottle.
Vocabulary consists of about 10 words,
identifies one or more parts of the body.
Feeds self: seeks helps when in trouble.
24 Mo
Runs well; walks up and down the stairs
one step at a time.
Opens doors.
Jumps.
Circular scribbling.
Imitates horizontal stroke.
Puts 3 words together (subject, verb,
object).
Handles spoon well.
Helps to undress.
Listens to stories with pictures.
30 Mo
Goes upstairs with alternating feet.
Refers to self by pronoun T, knows full
name.
Helps put things away.
Pretends in play.
SCHOOL PERIOD (6-12 yrs)
6-10 yrs Steady growth until the pre-pubertal
growth spurts.
10-12 yrs Usual peak height velocity in girls.
13-14 yrs Usual peak height velocity in boys.
Lymphatic tissues are at their peak devel
opment during these years.
Girls reach their peak height velocities
earlier than boys on an average and have
a lower peak.
Growth rate declines after the peak height
velocity period to about the same as
during the infantile period
Average weight gain during this period =
3-3.5kg(71bs)
Average height gain during this period = 6
cm (2.5 inches)
PUBERTY AND ADOLESCENCE
There exits a considerable variability in the
chronologic ages in which this pubertal
period begins
SECTION 2 : NORMAL GROWING CHILD |
10 vrs
On an average it begins in female child.
12 «•vrs
Adolescence begins in male child.
13 vrs
Puberty coincides with development of
secondary sexual characteristics ie.
breasts in female child, pubic hair? voice
change in male child.
It is also marked by menarche in females.
The sooner the puberty occurs the sooner
the rate of growth declines and finally
stops.
In females maximum growth in height
occurs the year before the menarch.
There is an increase in the mass of muscles.
Redistribution of body fat.
Increase in skeletal growth.
Average height gain from 5 yrs to puberty
is +3 inches (annually) and by 13 years in
females is 63 inches while 62-65 inches in
mates.
Events of Puberty are given in Table 2.3
Predicting adult height and weight:
Boys
Giris
2 x height at 8 years = adult height
2 x height at 7 ’/2 years = adult height
Table 2.3: Events of Puberty
In males
In females
Onset of the height spurt
Major growth phases concern development
of adult female appearance.
Age of maximum spurt
Breast development.
Achievement of adult height
Changes in body contour.
Genital changes begin within one
year of beginning of accelerated
height growth
Genital development
At about 12 14 years there is increased
amount of androgen (17 ketosteroid)
found in urine
Height spurt usually 2 years earlier
than males 8 14 to 9 14 years)
Changes in pubic, auxiliary facial
and body hair begins
Secondary sex changes occur
shortly after this time
Height growth attains its maximum
velocity in the early genital and hair
change period
Menarche appears earlier than
the average age most likeiy due to
better health
Height spurt peaks at about 14 years
Sterile period of 3 years from menarche
until reproduction possible
Strength spurt peaks at end of
height spurt
Early sexual maturation is accompanied by
an advanced skeletal age compared to
chronological age
Voice change correlates with
skeletal age and occurs at about the
time of spermatogenesis
(14-16 years).
Early menarche - taller,
heavier and advanced developmentally
<îÏÏB I TEXTBOOK OF PEDODONTICS
(3 years to puberty slow gain in weight)
Body weight is probably the best index of nutrition
and growth
Predicting adult weight:
Boys 5 x weight at 2 years = adult weight
Girls 5 x weight at 1 V? years = adult weight
At different ages
Weight in Ihs
Birth
6-8 lbs
1 month
Regain birth weight
4 months
2 x birth weight
2-3 years
3 to 5 lbs yearly
5 years
5 x birth weight
Puberty
80 to 90 lbs
Age in years
DIFFERENTIAL GROWTH
Changes from birth to adulthood
Head
Trunk
Limbs, arms
Legs
•
■
■
■
2 x birth size
3 x birth size
4 x birth size
5 x birth size
Changes in body proportions occur due to asyn
chronous growth i.e. ' split growth”. Body parts
grow at their own rate and reach maturity inde
pendently, but in a coordinated fashion.
Generally, growth is more rapid in height than
weight. Hence, one "grows taller before growing
heavy”.
Less developed body parts grow more like mus
cles, lungs, bones, genitals increase approximately
twice the original size.
More developed body parts grow less like eyes,
brain, which complete development early.
Eye
Brain
Heart
Completes growth by 5 years
Completes growth by 10 years
Completes growth by 20 years
Fig. 2.14 Pattern of growth in Man-Tanner 1962
(Scammon’s curve)
Head
At birth 22% total body length
,
10 years 95% total head growth complete
15 years 98% total head growth complete
Width of the head complete by 3 years 1
Length of the head complete by 17-18 years
Scammon’s Growth Curve
Scammon’s growth curve indicates that growth rate
of different tissues are different at different ages. For
example, lymphatic tissue grows and reaches its maxi
mum growth rate at 10-12 yrs after which there is a
decline in growth rate. Genital organs reaches its peak
at the time of puberty (Fig. 2.14)
Growth Spurts
Growth does not take place uniformly at all times.
There seems to be periods when a sudden accelera
tion of growth occurs. This sudden increase in growth
is termed " growth spurt”
SECTION 2 : NORMAL GROWING CHILD |
■ Pubescent phase: Very rapid growth p hase.
■ Postpubescent phase: Decelerating height ve
locity. Finally, linear growth comes to a stop
with the fusion of the epiphyses.
Growth modification by means of functional and
orthodontic appliances elicit better response dur
ing growth spurts. Surgical correction involving
the maxilla and mandible should be carried out
only after cessation of the growth spurts.
The growth spurts in the prenatal period and the
infantile period differ in that they are more of a bio
physical process, involving the division of the cells.
On the other hand, the physiological alteration hi
hormonal secretion is believed to be the cause for
the accentuated growth associated with the pubertal
period. The timing of the growth spurts differ in boys
and girls.
Growth trends
cm/yr
By overlapping consequent Cephalograms, Tweed '
discerned a pattern of growth and termed it as
Growth trends'. He thus divided the individuals into
the following groups:
•
TVPEA
The maxilla and mandible grow together and thus
the ANB angle remains basically unchanged.
Should this be accompanied with a class 1 rela
tionship and in the mixed dentition does not ex
ceed 4.5°, no treatment is indicated. It is seen in
25 % of the cases.
■
TYPE A Sub-division
The maxilla is protruding with the ANB angle more
than 4.5. The treatment is to restrict the growth
ofthe maxilla while allowing the mandible to catch
up. The prognosis is good, but may sometimes
require the extraction of the premolars.
■
TYPEB
The maxilla and the mandible are found to grow
forwards and downwards with the growth of the
maxilla exceeding that of the mandible. This type
of growth trend has a poor prognosis asthe treiid
indicates that the point B will not catch up with
point A. Growth of the middle and lower face is
predominantly in the vatical direction.
■
TYPE B Subdivision
The ANB angle is large and continues to grow,
indicating an unfavourable growth trend,
Fig. 2.15 Growth in boys and girls (modified
from Bjork 1975)
The following are the timings of growth spurts (Fig.
2.15):
a. Just before birth
b. One year after birth
c. Mixed dentition growth spurt
• Boys : 8-11 yrs
■ Girls:7-9yrs
d
Adolescent growth spurt.
■ Boys : 14-16 yrs
• Giris: 11-13 yrs
The Adolescent growth spurt has been divided into
three phases:
■ Pre pubescent take offstage: Moderate increment in the height velocity.
<4:11 I TEXTBOOK OF PEDODONTICS
■
TYPEC
The maxilla and the mandible grow forwards and
downward with the mandible growing forward
more rapidly than the maxilla. The ANB angle is
seen to be decreasing w ith the mandible catching
up with the maxilla. This indicates a favourable
growth trend and treatment is not indicated until
the eruption of the canine.
«
TYPE C Subdivision
The mandible is found to be growing more for
ward as compared with the maxilla. With this the
mandibular incisors touch the lingual surface of
the maxillary incisors. Thus
1. either the mandibular incisors are tipped lin
gually or
2. maxillary incisors are tipped labially.
The prognosis is good and the mandibular inci
sors need to be retained from one cuspid to an
other.
Principles of bone growth and growth theories
L Any dimensional change in bone is restricted to
appositional growth on the external surface (pe
riosteum) and internal surface (endosteal) (Fig.
2.16a,b).
Resorption
Fig. 2.16b Diagramatic representation of the drift
and displacement (Chilander et al 1985)
2. Cartilage has the capacity for interstitial growth.
3. Continuous remodelling i.e. deposition of bone
on external bone surface (appositioned) and se
lective breaking down of bone on other surface
(resorptive) serves to maintain the shape and pro
portion of bone.
%
4. Remodelling leads to migration, known as drift
and movement, known as translation^ displace
ment.
A knowledge of these separate process in the bone
tissue movement is essential for a proper understand
ing of growth events and the effects of various forms
of treatment, e.g. an orthopedic force may prevent
normal growth through displacement, but need not
necessarily prevent drift continuing or even increas
ing to compensate for this absence of displacement
growth.
Enlow’s ‘V’ Principle
Fig. 2.16a Relocation of Maxillary Palate
(Enlow 1966)
Enlow has explained the significance of the interplay
between deposition and resorption for the shape of
various bones in the form of4 V’ shape. Deposition
on the internal surface of 4 V’ in the direction of
SECTION 2 : NORMAL GROWING CHILD |
led by thyroxin and steroids. Pubertal growth spurt,
is a primary function of the steroids and human
growth hormone Any increase in the above hormones
brings about an accelerated bone maturation.
Ossification and Ca4"* level in blood are interrelated.
While parathormone brings about increased osteo
clastic activity to compensate for decreased Ca++
blood level, calcitonin is responsible for enhancing
bone deposition.
In females, prolactin also brings about growth hor
mone like effects, though its primary effect is on breast
development.
GROWTH THEORIES: ASSUMPTIONS AND
CLINICAL IMPLICATIONS (See table 2.4)
Fig. 2.17 V-Principle of growth
(Chilander et al 1985).
POST NATAL DEVELOPMENT OF THE MAXILLA
(Fig. 2.18)
growth and absorption on the outer surface allows
the bone to retain its characteristic shape during
growth, is the growth of the head of the mandible
(Fig.2.17).
The mechanisms involved in the growth of the
nasomaxillaiy complex are the sutures, the nasal
septum, the periosteal and endosteal surfaces, and
the alveolar processes.
Physiology of growth
Growth of the maxilla, has two interrelated mecha
nisms, i.e.
1. the shift in position of the maxillary complex and
2. the enlargement of the maxillary complex itself..
Growth takes place due to the effect of the hormones
on the bone tissue. In one way or another, all the
hormones affect growth, with the growth hormones,
thyroxin, corticosteroids and insulin bringing about
changes in the growth rate and parathormone, vita
min D (and it’s various forms) and calcitonin affect
ing skeletal maturation and pubertal growth.
Growth hormone brings about changes in carbohydrate and lipid metabolism. It also stimulates
stomatomedin release, which causes cartilage growth.
Apart from growth hormone, insulin may also inciease
production of stomatomedin, while thyroxin can have
a modulating effect on it. Glucocorticoids, on the
other hand, are seen to suppress stomatomedin.
The effect of growth hormone is indirect (through
stomatomedin). Skeletal maturation is mainly control-
This mechanism can be assessed from three param
eters, the height, width and length.
Maxillary height
Maxillary height increases because of sutural growth
towards the frontal and zygomatic bones, and appo
sitional growth in the alveolar process. The nasal
floor is lowered by resorption while apposition oc
curs on the hard palate. Alveolar remodeling con
tributing to significant early vertical growth helps in
the attainment of width because of die divergence of
the alveolar processes. As they grow vertically, their
divergence increases the width.
COB I TEXTBOOK OF PEDODONTICS
Table 2.4: Growth Theories: Assumptions and Clinical Implications.
Theory
Assumption
Applications
Genetic
(Brodie, 1941)
■ The assumption was
that genes controlled
all aspects of growth.
■ The external factors have a significant,
modifying effect on it, thus reducing its effect
vastly. The inheritance that does take place
is polygenic in nature. For example the pre
disposition of an individual to class III
malocclusion.
Scott’s
Hypothesis
(1953)
• Cartilage grows actively,
bone later replaces it.
Thus cartilage has innate
growth potiential.
■ Transplantation and extir
pation experiments prove
that some innate potential
is evident though results
are equivocal.
■ Mandibular growth has been explained that the
condyles act as the diaphysis of a long bone
with growth occurring at both the ends. Recent
studies have proven that growth at the condyle
is mostly reactive and not of primary nature.
■ Maxillary growth can be explained due to the
translation of the nasomaxillary complex as
a unit
,
« Proliferation of sutural
connective tissue causes
appositional growth.
■ Genetic factor was
accepted.
■ Explains maxillary growth as the result of
pressure created by growth at the sutures.
■ Limitation being it could not explain.
- Lack of growth in suture transplantation.
- Growth occurs in cleft palate cases.
- Sutures respond to external influences.
Sutural
dominance
theory
(Sicher, 1955)
■ Membranous bones were
considered as growth
centers.
.
■ Several examples can be cited such as the
excessive growth of the cranial vaultMn cases
of Hydrocephalus.
Moss’s
Functional
theory
(1962)
« Functional matrices, which
can be further divided into
capsular and periosteal
matrices have the primary
control for the growth of
the craniofacial structures.
■ Bone responds to the
matrices in a passive
manner and does not
have any primary growth
potential
Van
Limborgh’s
theory
(1970)
■ Factors controlling skele ■
tal morphogenesis are:
1. Intrinsic genetic factors.
2. Local epigenetic factors.
3. General epigenetic
factors
4. Local environmental
■
factors
5. General environmental
factors.
.
1
Explains the interaction between the genetic
and environmental factors. Thus what may be
environment for the bone (muscle & soft tissue)
is in turn dependent on the growth and function
of the soft tissues. The growth of the muscle
and soft tissue has a genetic component
Even if there were genetic disposition, it is
polygenic, multifactorial in nature, thus pre-;
eluding any predictions of the facial dimensions
of children from the study of their parents.
contd.
I
SECTION 2 : NORMAL GROWING CHILD |
Theory
Assumption
Applications
Petrovic’s
Hypothesis
1974,
Cybernetics
■ Primary cartilage, in which
growth occurs by differenti
ation of chondroblasts,
can be modified with
factors which affect the
direction only and not the
amount of growth.
■ Secondary cartilage has a
direct cell multiplication
effect but more importantly
indirect effects also play
an important role.
■ It explains the mode of action of the functional
appliances directed at the condyle.
■ The upper arch acts as a mould into which the
lower arch adjusts itself, such that optimal
occlusion is established.
• Effect has been reported to be negligible.
Neurotropism ■ The nerve impulse
involving axoplasmic
(Work done by
transport has direct growth
Behrents 1976)
potential.
includes
■ It also has an indirect effect
epithelial
on the osteogenic growth
visceral and
by influencing soft tissue
muscular
growth.
components
Maxillary width
Growth in the median suture is more important than
appositional remodelling in the development of max
illary width.
Maxillary Length
Length increases in the maxilla after about the sec
ond year and this occurs by apposition in the maxil
lary tuberosity & by sutural growth toward the pala
tine bone. Surface resorption occurs anteriorly on
t he bony maxillary arch.
The postnatal growth of the maxilla parallels that of
the mandible in that forward & downward movement
of growing bone as a whole is a result of growth
which takes place in a posterior direction with corre
sponding repositioning of the entire bone in a for
ward direction.
The overall size of thé face increases by a series of
specific growth movements in several individual
areas which proceed away from each other, thereby
drawing out the dimensions of the maxilla in several
different directions. Thus it would be inporrect to
assume that growth occurs only in a forward and
downward direction.
As the maxillary complex is joined to the cranial base,
it naturally influences the development of maxilla.
There is no sharp line of demarcation between the
cranial and maxillary growth gradients. The position
of the maxilla is dependent on the growth at the
spheno-occipital and sphenoethmoidal synchon
droses.
Age changes in maxilla
At birth the transverse & anteroposterior diameters
of the maxilla are greater than the vertical diameter.
The frontal process is well marked but the body of
the bone consists of a little more than the alveolar
process. The tooth socket reaching almost to the
floor of the orbit. The maxillary sinus is a mere furrow
I TEXTBOOK OF PEDODONTICS
on the lateral wall of the nasal cavity. In the adult the
vertical diameter is greater owing to the development
of alveolar process and increase in size of the sinus.
rami and the alveolar ridges. These areas of bone
deposition account grossly for increase in the height,
length, and width of the mandible.
The palatine processes of the maxilla grow in a gen—------ orally downward direction by a combination of sur
face deposition on the entire oral side of the palatal
cortex with resorptive removal from the opposite na
sal side, as well as from periosteal labial surfaces of
the anterior maxillary arch.
At birth, the mandible generally consists of two
halves generally ossifying by 12 month of life. The
coronoid process is relatively large and projects well
above the condyle. The body has tooth buds, man
dibular canal running low' in the body.
Condylar growth (Fig. 2.19)
The premaxillary part of the maxilla grows in a down
ward direction. The surface orientation of this area is
such that a downward movement is brought about by
resorptive removal from the periosteal surface of the
labial cortex which faces away from the direction of
growth. The endosteal side of its cortex and the pe
riosteal surface of the lingual cortex receive new bone
deposits. This growth pattern also produces a slight
’’recession’* of the incisor area in a posterior direc
tion, a situation also present in the human mandible.
10 yrs.
Fig. 2.19 Vertical growth of the condyles.
(Bjork & Skieller 1972)
Fig. 2.18 Comparative growth of the upper and
lower jaw
POST-NATAL DEVELOPMENT OF MANDIBLE
(Fig. 2.18)
The main sites of post-natal mandibular growth are
at the condylar cartilage, posterior borders of the
The condylar cartilage of the mandible serves the
uniquely dual roles of an articular cartilage in the
TMJ, characterized by fibrocartilage surface layer,
and as a growth cartilage analogous to the epiphy
seal plate in a long bone. It would be wrong how
ever to accept this per se, as the condyle is not
considered the primary growth centre any more. Stud
ies that have evaluated the growth in cases of con
dylar fractures show that the growth of the mandi
ble may still continue in these cases.
SECTION 2 : NORMAL GROWING CHILD I C£B
Growth of the ramus
Change in the width
The mandible increases in width following the ‘V’
The ramus of the mandible lengthens by the growth
of the condylar cartilage and by the periosteal bone principle wherein bone deposition takes place on the
outer aspect of the mandible and resorption on the
formed at the posterior borders of the ramus.
inner aspect.
. The ramus increases in height by growth of con
dylar cartilage and by the bone deposited at the
base of the sigmoid notch, at the posterior bor , Age changes in mandible
der and at tip of coronoid process. The growth
of bone at the angle of the mandible leads to a ■ The body elongates especially behind the mental
foramen providing space for permanent molars.
change in mandibular angle from about 135 de
grees in the new born to about 100 degrees in ■ The mental foramen changes direction from ante
rior to posterosuperior and then almost horizon
the adult, although it is variable. The main in
tally, accommodating a changing direction ofthe
crease in height of the body is due to develop
emerging mental nerve. When teeth are present,
ment of alveolar bone.
the mental foramen is located midway between
■ The ramus is also translated posteriorly by
the upper and lower borders of the mandible.
resorption of the anterior border and deposition
on the posterior border [ which also creates space ■ The angle of the mandible diminishes with age.
■ During post-natal development, growth in man
for the permanent molars to erupt].
dibular width is completed, this is followed by
growth in length, and then in height. The growth
Thus the combination of condylar and ramus growth
in width including the dental arches completes
brings about:
before the adolescent growth spurt.
a) Backward transposition of the entire ramus,
thereby elongating the mandibular body.
Maxillo-mandibular relation
b) Displacement of mandibular body in an anterior
direction (in a downward and forward direction)
c) Vertical lengthening of the ramus as the mandible At birth the mandible tends to be retrognathic to the
maxilia, although the twojaws may be of equal size.
is displaced.
d) Movable articulation during these various growth This retrognathic condition is normally corrected
changes in the alveolar region above it creating
early in the postnalal life by rapid mandibular growth
and forward displacement to establish orthognathic
the submental concavity.
or an angle class I maxillomandibular relationship.
Alveolar process
This yet again conforms to the cephalocaudal gra
dient of growth pattern. Inadequate mandibular
The growth of the alveolar process is primarily re
growth results in angle class II, overgrowth of man
lated to the presence and eruption of the teeth as it is
dible produces angle class HI relation.
the increase in height and thickness.
Self-Assessment
Chin
The chin develops as a separate subunit of the man
dible. It is poorly developed in the infant and
achieves its prominence only during pubertal growth.
The resorption of the alveolar process above it a lso
accentuates the chin.
1. What are the growth spurts? In which age it is
seen and what is its significance?
2. What is cephalocaudal growth gradient?
3. What are growth trends?
4. Describe the physiology of growth
5. What is functional matrix theory?
CEB I TEXTBOOK OF PEDODOMT1CS
6. What is differential growth and Scammon’s
growth curve?
7. What is Enlow’s ‘ V’ principle?
8. What are the assumptions of 'petrovic’s hypoth
esis?
9 Which theory explains the interaction between
genetic and environmental factors?
10. What are the age changes take place in mandi
ble?
11. How does chin develop?
12. What maxillo-mandibular relationship exists at
birth?
4
2.4 Growth Assessment
Paul U. Tandon S
Craniofacial growth comprises the phenomena fall
ing within the scope of a number of disciplines and
occurring at several levels, including the molecular,
cellular tissue and organ levels. No specific method
can therefore be assigned to the study of these
events. In clinical pedodontics, however, data on
craniofacial growth usually serve to describe dimen
sional changes, relations between different bones
and growth mechanism. Some of the methods com
monly used for this purpose are described here.
1. Biometrics: is defined as the science of statisticalbiology, the collection and statistical analysis
of data regarding a living orga nism. Hie biometric
methods used for recording dimensional changes
in the cranium during growth are:
i) Longitudinal methods: These imply serial meas
urements in the same individual or population
over a long period of time. Their advantages
lie in the fact that individual patterns can be
defined and the variation within a group can
be analyzed, which is of special importance
when the individuals are to be compared with
standards or norms. These studies are expen
sive and time consuming, however, and the
dropout rate may be so high that statistical
significance of the observations is lost.
ii) Cross-sectional method: Groups of varying
ages or at varying stages in development are
examined only once. This method requires large
populations in order to yield statistical obser
vations, and it tends to mask or exclude indi
vidual variations, e.g. in the age of the puber
tal spurt.
iii) Semi longitudinal method: is sometimes used
in an attempt to reduce the aforesaid disad
vantages. Hiis means monitoring age-groups
or subgroups at different levels of develop
ment only forthat period which separates one
group from the next. Suitable selection criteria
are a prerequisite for obtaining representative
results with all these methods. However, when
studying facial dimensions, the importance of
race, sex, etc., must be taken into considera
tion.
2. Craniometry: The metric study of cranial dimensions in dry skulls is less suitable for descriptive
purpose where growth in children is concerned.
3. Somatometry: The metric evaluations of facial
dimensions, including soft tissues, is limited mainly
by lack of reliable methods for recording the data
and is therefdre used very little in pedodontics.
4. X-ray cephalometry: Enables longitudinal inves
tigations to be carried exit, and the information of
human craniofacial growth which has accumuläted during recent year is mainly based on this
technique. This method does not describe attirai
growth changes but usually depicts only how
the radiographic structure has changed in rela
tion to a certain reference structure. This prob
lem is because x-ray cephalometry describes
growth as a two dimensional phenomenon in
which growth of structures is simplified to
positional changes in a system of
The x-ray film does not distingui^^^^^^^g||
Æ5B I TEXTBOOK OF PEDODONTICS
changes in the position of a structure per se and
changes due to remodeling of its external sur
faces.
5. Metal indicators: The x-ray cephalometry can be
used to overcome the above mentioned problem
by implanting metal markers in a bone to act as a
reference point and changes in the external con
tours of the bone can be studied.
6. Superimposition: By taking a series of x-ray films
by using the above method to superimpose an
anatomical reference structures; the positional
changes can be studied.
7« Steriopairs images: In computer analysis
positional changes can be studied in a three di* mensional system.
8. Electromyography: Allows the action potentials
of the muscles of mastication to be correlated with
morphological data and normalization of muscle
function in the treatment of malocclusion. The
role of functional factors in craniofacial morpho
genesis is commonly accepted and has potential
to elucidate the important factors of hereditary
and environmental factors in the twin studies.
9. Animal experiments: are used to study specific
pathological conditions, malformations or ac
quired defects and events at the cellular level of
histological, histochemical and biochemical tech
nique. More detailed information on growth
changes thus can be obtained by the use of bone
labeling with the substances that are incorporated
into newly formed bone. Embiyological research
has been made possible due to these experiments.
10. Vital staining: Belchier (1736) stated that the
bones of animals who had eaten madder plant
were stained a red color due to alizarin, an essen
tial dye of the plant which was incorporated into
the bone. The bones contained a band of red
stain followed by an unstained band. The vital
staining method depicts the pattern of the post
natal bone deposition over an extended time pe
riod. It also gives the growth sites, the direction
and amounts of growth, as well as the timing and
relative duration of growth at different sites. Ali
zarin, and other vital dyes like procion and tetracj'dine are used extensively in hone research.
i
Normal
Deviation from normal
Fig. 2.20 Anthropometric measurements.
i
I
SECTION 2 : NORMAL GROWING CHILD |
L Radioisotopes: Radioisotopes of certain elements
and compounds are used as invivo markers for
studying bone growth. With injection the iso
topes, after a time get located within the growing
bones: Growth is measured by means of Geiger
counters or autoradiographic techniques.
An emitting isotope 99mTc is used to detect ar
eas of rapid bone growth in humans where bones
or sections of bones are placed against photo
graphic emulsions and then exposed by emission
of radiation from the radioactive substance.
2. Natural markers: There is a persistence of cer
tain developmental features of bone which are
used as natural markers. Trabaculae, nutrient
canals and lines of arrested growth can be used
for reference to study deposition, resorption and
remodeling.
3. Anthropometry: Various landmarks established
on dry skull are measured viewing individuals by
using soft tissue points overlying the bony land
marks. Farkas (1987) in his anthropometric stud
ies have provided new data for the human facial
proportions and change in time. (Fig. 2.20)
irowth assessment parameters
Why assessment should be done”?
: is done for:
Identification of grossly abnormal growth or even
pathological growth.
Recognition and diagnosis of any significant de
viation from normal growth.
Planning of orthodontic/orthopedic treatment
Determining efficacy of the treatment modality
’ rogman defines five ages >f childhood which may
e considered as growth assessment parameters in an
iterdisciplinary team evaluation of the patient with
arious types of short stature, endocrino/metabolic
isorders, syndrome identification and forensics.
, Chronologic age : The most commonly and easily
determined developmental age parameter is the
chronologic age, which is simply figured from the
child’s date of birth. Since each child has his own
characteristics growth time clock, i.e., there are
early, middle and late maturation chronological
age, neither accurate indicators of stage of devel
opment: nor it is a good predictor of growth po
tential.
2. Somatotypic age: In the overall assessment of a
child, a general body type which is also called as
somato type, is usually considered. Sheldon di
vides somatotype into three categories; ecto
morph, mesomorph and endomorph. The endo
morph is stocky, has-abundant subcutaneous fat
and has digestive viscera that are highly devel
oped; somatic structures are relatively underde
veloped. The mesomorph is upright, sturdy and
athletic; muscles; bones and connective tissue
predominate. The ectomoiph is tall, thin and frag
ile; his extremities are long and slender with mini
mal subcutaneous fat and muscle tissue. In gen
eral, the ectomorph is a late maturer (adolescent
growth spurt about 1 year after that of
mesomorphs), whereas an endomorph is anearly
maturer in terms of chronologic age. Although
somatotype may give a gestalt about the child’s
developmental pattern, it is not an accurate
predictor.
3. Height and weight age: Height has been consid
ered as an convenient determinant of develop
mental age. The standard growth commonly em
ployed to characterize a child’s height compared
to that of children of some chronological age is
used to assess developmental age. It is generally
seen that after age 2 each child tends to follow
the same percentile on the growth curve until the
puberty, when deviation may occur because bf
timing of the spurt differs among adolescents.
Since each child’s height is related to genetic and
environmental factors as well as to chronologic
age, it is clear that a single height measuremait is
limited as a predictor of developmental age. Not
all the children have same height at the same per
centile.
TEXTBOOK OF PEDODONTICS
Similarly weight standard curves have been con
structed. Although in the average child weight
may be correlated with height, it is clear that ab
normal variation in weight in otherwise normal
children limits the use of these curves as a sole
indication of developmental age.
4. Dental age
The simplest but least accurate dental age indica
tor involves recognizing teeth clinically present
and comparing them to the dental eruption charts.
But a wide variation of eruption time along with
environmental and local influences do not make
this a reliable parameter. Therefore, it is thought
that dental age should be replaced by a scale of
maturity, between immaturity and complete matu
rity, which can be expressed by a figure.
Gieiser and Hunt (1955): He was the first who ad
vocated the calcification of a tooth as a more mean
ingful indication of somatic maturation than its
clinical emergence. Whilethe emergence of a tooth
is a fleeting event and its exact time is very diffi
cult to determine, its calcification is a continuous
process, which can be assessed by permanent
records such as x-rays.
Demirjian (1973): A new approach has been
adopted which is based on absolute values, for
the lengths of the crowns or roots by using a new
technique ofpanoramic radiographs. Eight stages
of development, from calcification of the tip of
the cusp to the closure of the apex closure, were
designated by 0 (for no calcification) and letters
A to H, corresponding to the eight stages. Let
ters rather than numbers were selected so as not
to leave the false impression that each stage is
equidistant from other. Each stage was then given
a numerical score, according to the mathematical
technique by, the sum of which provides an esti
mate of an individual’s dental maturity on a 0 to
100 scale.
5. Sexual age:
With the onset of puberty, differential hormonal
action give characteristic body changes. Second
ary sexual characters like hair growth, accelera
tion of growth of genital organs and height spurt
occurs in males. In females, appearance of breast
buds and distribution of body fat with menarche
which follows the maximal height velocity is seen.
In females, the peak height velocity is a relatively
early event whereas in males it is a relatively late
event. The correlation of coefficient between the
age at menarche and skeletal age at 13 years is
0.85.
6. Facial age:
■ The ultimate goal of developmental growth
assessment of children is the facial age in or
der to identify where they are on their own
facial growth curve and use this as a predictor
.of future growth.
In addition to the developmental age assessment,
the most commonly used method of analysis be
tween the normal versus abnormal facial devel
opment is cephalometric analysis. Other meas
urements for assessing craniofacial developments
are:
1
Head circumference
Eye measurements
■ inner canthal
■ interpupillary
■ outer canthal
Ear length
Philtrum lengths
Width of the commissures
Change in facial proportions:
Increase in facial proportions are seen as:
1. General facial growth from infancy to adoles
cence and increase in size of dental arches.
2. Increase in size of the muscles of mastication
and facial expression.
3. Growth of alveolar processes of the maxilla and
the mandible with development and eruption
of deciduous and permanent dentition.
SECTION 2 : NORMAL GROWING CHILD |
4. I ncrease in maxilla size and growth of maxillary
sinus
5. Increase in mandible
6. Increase in size of nasal area and paranasal
sinuses.
7. Enlargements of orbits.
8. Expansion of ethmoid and sphenoid bones.
7. Skeletal age:
The assessment of skeletal maturation has been
used as an indicator of the developmental age Stanecu 1977.
Advantage:
1. A characteristic pattern of progression of os
sification can be identified i.e., each endochon
dral bone begins with a primary ossification
center which changes in shape, size and con
tour until the ultimate fusion.
2. Easily recognizable at ages of ossification
The hand and wrist radiograph is easily
radiographed with minimal radiation exposure
(Fig. 2.21a, b). The PA radiograph of the left
Fig. 2.21a Schematic representation of
hand wrist X-ray
hand and wrist has been chosen as a stand
ard. Dreizenetal 1957 stated that a 3 months
discrepancy occurred between the right and
left hand wrists in 13% and more than 6 months
in only 1.5%:
The radiograph of the hand and wrist of the child
is compared to the atlas standards with the same
sex and nearest age. The bones are assessed in a
regular order: Distal radius, Ulna, the carpels
(Capitate, hammate triqetral, lunate, scaphoid,
trapezium, trapezoid, psiform) metacarpals - the
proximal, middle, ilistal phalanges. Each center is
given a skeletal age. An overall average age is
then taken. The carpel bones are taken as a reli
able assessment parameter.
Tanner and Whitehouse et al (1975) gave a method
of scoring maturity of indi vidual bone to get the
skeletal age:
1. RUS (Radius Ulnar Short bones) score rates
the radius, ulna, metacarpels of the digits 1,3
and 5 proximal, middle and distal phalanges of
digits 1,3 and 5.
tfîhfc I TEXT BOOK OF PEDODONTICS
2. The carpel bone method score rates the carpel
bones. Here only 97% of the carpel score is
reached by 13 years in females age 11 in males.
3. The TW2 method scores all the bones. Each
growth center is given a maturity rating on a
scale of 8 (A to H) except the radius which has
9 (A to 1) "^ number is then given to each
center in an attempt to allow biologic variabil
ity. A total is got and this gives the overall
maturity rating.
8. Basal metabolic rate: There is a direct relation-,
ship between BMR (Basal Metabolic rate) and
growth. A mathematical expression can be de
veloped by means of which, it is possible to con
struct ideal curves of cumulative gain in height
and basal heat production from fetal stage to the
adulthood.
Factors affecting the physical growth
|
|
The regulation of growth in terms of rate, timing,
character as well as its ultimate form largely depend
on a combination and interaction of genetic and en
vironmental factors.
1. Genetic factors: The genes contained within the
nucleus of each cell are said to be necessary to
produce an entire organism and primarily respon
sible for orchestrating the phenomenon of nor
mal growth. A genetic control influences the size
of the organism to a great extent and the rate of
the onset of growth event Not all the genes are
active at birth.
• It is believed that size at birth relates to about
18% to the genome of the fetus, 20% to the
maternal genome, 3 2% maternal environmen
tal factors, and the remaining 20% to unknown
factors.
■ After birth infants growth rate is no longer
dependent on maternal factors but increas
ingly related to his own genetic makeup.
■ In 1 to 2 years post-natal shift has a significant
relationship to the genetic background of the
child, reflective of mid parental height.
■ During adolescence, growth correlates with the
parental size more strongly, being 0.7 to 18
years. Hence the size of the parents can be
considered as a best indicator of the eventual
predicted size of a newborn baby.
2. Extra cranial and intra cranial pressure:
Any factor affecting the physical growth is ex
pected to be associated with a profound and wide
spread effect on the size and shape of the cranial
vault.
« Artificially induced reshaping of the cranial
vault has been practiced in many cultures. The
baby’s skull is molded by wrapping it in a bond
age by using a cradle board. According to the
mythology of the Maya culture, the skull shape
symbolized the social class. Extra cranial me
chanical forces exerted during the period of
growth can effect the size and shape of the
part. It is observed that symmetrically deformed
skulls have significantly short cranial base and
the maxilla than underformed.
« The signs and symptoms related to increased
intra cranial pressure depend on the age of the
patient at the onset. During infancy rapid ven
tricular dilatation and increased cranial circum
ference results. If the raised pressure is
longstanding, sutural margins develop deep
interdigitation with spiky appearance. Later
when the sutures are closed, the volumetric
expansion in the neurocranium results in an
excessive resorption of the inner table of the
cranial vault. This manifestation is quite when
hydrocephaly occurs in conjunction with
pathologic sutural obliteration, as in Crouzon
and Apert syndrome, for instance.
SECTION 2 : NORMAL GROWING CHILD J
3. Nutrition: Lack of nutrition delays growth and
niay^ffcct size of parts, body proportions, body
chemistry, quality and texture of some tissues. It
may delay growth and the adolescent growth
spurt. For example, lodiacdcficient diet effect
the craniofacial growth in relation to all the di
mensions. Soft diet has been found to show re
tarded craniofacial growth in comparison to body
growth. The height, depth of the distal part of the
mandible were seen to be retarded during a study
of 3 weeks to 20 week of growth in male mice. As
the distal areas of both the craniofacial complex
and the mandible are closely related to jaw func
tion, growth retardation of this area could be ex
plained as the skeletal adaptation to the soft diet.
In children, during rather short periods of malnu
trition, they exhibit fine recuperative powers where
growth slows up and waits for a better time, and
with the return of good nutrition growth takes
place unusually fast until the genetically deter
mined curve is neared once more. This catch up
growth is seen in both sexes but females are bet
ter buffered against the effects of malnutrition.
4. Hormones: It is seen that 20 micrograms/kg b.w
of thyroxine injection daily for 28 days decreases
the length of the visccrocranium after 14 days,
whereas cranial base growth increases between
14 to 28 days. Thus, the craniofacial growth pat
tern is influenced by variation in the scrum level
of hormones. Similarly, anabolic steroids therapy
was found to significantly increase all measures
of the craniofacial complex. The low dose exhib
ited proportionate increases in most craniofacial
dimension, but the high dose produced overt
shape changes, notably a maxillomandibular, an
teroposterior jaw discrepancy due to maxillary
excess. About 20% increase in body weight was
noted with elongation of the maxillary and man
dibular incisors and an increase in depth of the
antegonial notch.
Hormones responsible for growth -
Group I
Hormones influencing skeletal growth bone:
1. Growth hormone (anterior pituitary)
2. Insulin (p cells of langerhans)
3. Thyrotropic hormone
Group II
Hormones responsible for ossification of long
bones:
1. Parathormone
GroupIU
Hormones responsible for pubertal growth
spurt
1. Androgens
2. Progesterone and oestrogen
Group IV
Prolactin hormone (anteriorpituitary)
5. Muscular functions: The close relation between
the muscles and the bone growth is seen due to
the fact that the muscles influence the growth
both as a tissue affecting the vascular supply
and as a force element. The importance of the
masticatory muscle function has been observed
in anthropologic studies, in which a low fre
quency of malocclusions was found in
populations with primitive living conditions. The
frequency of malformation seems to have in
creased since these populations came under the
influence of industrialized civilization. The in
creased loading of the jaw due to masticatory
muscle hyperfunction may lead to an increased
sutural growth and bone apposition resulting in
turn in an increased transverse growth of the
maxilla and broader base ofthe dental arches. Fur
thermore, an increase in the function of the mas
ticatory muscles is associated with the anterior
growth rotation pattern of the mandible and with
a well developed angular, coronoid and condylar
process. For example, wrestlers who are in gen
eral, characterized by a well developed muscular
| TEXTBOOK OF PEDODONTICS
system and have undergone heavy resistance
training, have wide and well developed dental
arches with a low frequency of malocclusion. The
excessive attrition observed on the teeth of the
medieval skulls indicated an extensive function
of the masticatory muscles. In contrast, the cranio
facial morphology was found to be deteriorated
in a group of patients with myotonic dystrophy.
The patients had a vertical growth pattern and a
high incidence of malocclusion such as distal oc
clusion, anterior open bite, lateral cross bite and
crowding. This group was characterized by a low
bite force level and a reduced masticatory
electromyographic activity.
(u Growth factors: Growth factors are peptides (pro
teins factors) that transmit signals within and be
tween cells and play a comprehensive role in the
modulation of tissue growth and development.
They were first discovered in early 1960 as growth
stimulants. These factors regulate cell activity
by a number of mechanisms such as mitogenic,
migration, differentiation and gene regulation,
which may occur simultaneously and in different
tissues w here the effects may be different depend
ing upon the condition. These factors have
greater significance in the treatment of oral and
dental conditions. For example, recently they
have been used to promote regeneration of sup
port tissues after a periodontal surgery; It is also
seen that a single application growth factors such
as bone morphogenic protein (BMP) around ex
traction socket implants increased osseous tis
sue formation.
7. Illness: Systemic disease has an effect oh child
growth. The usual minor illnesses do not show
much of an effect on growth. Serious prolonged
debilitating illnesses have a marked effect on
growth and growth processes.
8. Climate and seasonal effects: Those living in cold
climate usually have a greater proportion of adi
pose tissue. A large amount of skeletal varia
tions associated with ^variations in climate sea
sonal variations in the growth rate of children
and in weight of the newborns are present. There
is no direct effect of climate on the rate of growth.
9. Adult physique: Certain correlation between adult
physique and earlier developmental events
present e.g. tall women tend to mature later. Vari
ations in the rate of growth are associated with
differing somatotypes.
10. Socio-economic factors: These factors e.g. nutri
tion obviously play a role as a growth factor. Chil
dren living in favourable socio-economic condi
tions tend to be larger, display different types of
growth (height, weight ratio) and show a varia
tion in timing of growth. The lower the socio
class or socioeconomic status of the mother, the
smaller is the baby and subsequently the child.
11. Exercise: Exercise may be useful for development
of motor skills, for an increase in the muscle mass,
for the general well being and fitness but has no
favorable effect on the linear growth.
12. Family size and birth undey: There are differences
in the size of individuals, in their maturational lev
els of achievement and in their intel ligence that
can be correlated with the site of the family from
which they come. First bo rife usually weigh less
at birth, have less stature and a higher I.Q.
13. Secular trends: Size and maturational changes in
large populations can be shown to occur with
time, e.g., 15 years old boys are 5 inches taller
than 15 years olds of 50 years back. The average
onset of menarche has steadily become earlier.
When race, socio-economic levels, nutrition, cli
mate and other differences which lead to a change
in growth are called secular trends.
14. Psychological disturbance: Can lead to an inhibi
tion of growth by various methods. Children ex
periencing stressful conditions display an inhibi
tion of growth hormone. These may also happen
under less extreme conditions and thus amount
for lesser variations in individual growth.
SECTION 2 : NORMAL GROWING CHILD | <*EB
15. Maternal factors: Size of a full term infant is re
lated to the size of the mother. With adipose tis
sue development at 7 months IUL, there is an
increase weight gain the fetus fills the uterine cav
ity where the uterine size constraint is a factor for
the fetal growth. The role of placenta must also
be considered. The placenta grows by cell number
occurs till 35 weeks IUL after which increases in
cell size till 38-40 weeks. Thereafter, signs of de
terioration are seen in which a postmature infant
may become underweight for the length.
Incremental increase in height
Age
Birth
0-6 months
Increment
Height
20 inches
1 inch/month
26 inches
32 inches
1-7 years
1/2 inch/mbnth
3 inches/year
8-15 years
1 inches/year
62 inches
6-12 months
50 inches
Incremental increase in w eight
Age
Increment
Birth
-
Weight
0-4 months
4-12 months
2 Ibs/month
7 to 8 lbs
15 to 16 lbs
2 Ibs/month
23-24 lbs
1-2 years
2-10 years
1/2 Ibs/year
29-30 lbs
69-70 lbs
5 Ibs/year
Self-Assessment
i
2.
3.
4.
5.
What are the different growth assessment param
eters?
What are the methods of assessing the dental
age of the child?
Which are the measurements performed at birth
to assess the child?
What is dental age? How will you assess it?
What are the approximate heights of 2,5 and 10
yea r old children?
Further Suggested Reading For Section - 2
1. Bishara-SE; Jakobsen-JR; Treder-J; Nowak-A:
Arch width changes from 6 weeks to 45 years of
age. Am-J-Orthod-Dentofacial-Orthop. 111(4):
401-9,1997
2. Dahllof-G: Craniofacial growth in children treated
for malignant diseases.Acta-OdontoI-Scand.
56(6): 378-82,1998
3. Enlow et al : Handbook on facila growth. WB
Sunders company 1982
4. Frankenburgh WK et al: The Denver II: A major
revision and restandardization of Denver devel
opmental screening test. Pediatrics. .4.1411992
5. Friede-H: Growth sites and growth mechanisms
at risk in cleft lip and palate. Acta-Odontol-Scand.
56(6): 346-51,1998
6. Gosh S.: Second thoughts on growth monitoring.
IndianPediatr.:30.449,1993
7. Graber T.M. :Growth and Development. Orthodon
tics Principles and Practice. W.B. Saunders and
Company 1988
8. Illingworth R.S.: General development .the
neonatal child - some problems of early years and
their development Churchil Livingstone. 191,1991
9. Kjaer-I: Human prenatal craniofacial development
related to brain development under normal and
pathologic conditions. Acta-Odontol-Scand. 1995
Jun; 53(3): 135-43,1995
10. Moore K.L. Developing Human. WB Saunders
Co., 1992
11. Moyers Robert E.: Basic Concepts of Growth
and Development. Handbook of Orthodontics.
Year Book Medical Publishers. 1988
12. Nanda-SK: Growth patterns in subjects with long
and short faces [see comments]. Am-J-OrthodDentofacial-Orthop. 98(3): 247-58; 1990
13. Needleman Robert D.: Growth and development.
Textbook of Pediatrics. W.B. Saunders.30-67,1996
14. Ranly-DM: Early orofacial development. J-ClinPediatr-Dent. 22(|): 267-757,1998
15. Seow-WK: Effects of preterm birth on oral growth
and development Aust-Dent-J. 42(2): 85-91,1997
CE» I TEXTBOOK OF PEDODONTICS
15. Salzmann J A: Practice of Orthodontics JB
Lippincott compaly. 1966
16. Sejrsen-B; JakQbsen-J; Skovgaard-LT; Kjaer-I:
Growth in the external cranial base evaluated on
human dry skulls, using nerve canal openings as
references. Acta-Odontol-Sea nd. 55(6): 356-64,
1997
17. So-LL: Skeletal maturation of the hand and wrist
and its correlation with dental development AustOrthod-J. 15(1): 1-9,1997
18. Vargervik-K:Mandibular malformations: growth
characteristics and management in hemifacial mi
crosomia and Nager syndrome. Acta-OdontolScand. 56(6): 331-8 1998
19. Vinter-I; Krmpotic-Nemanic-J; Ivankovic-D;
Jalsovec-D: The influence of the dentition on the
shape of the mandible. Coll-Antropol. 21(2): 555604997
20. Wasserman E., Gromosch D.S.: Growth and de
velopment. Survey of clinical pediatrics. Me Graw
Hill International company. 1-39,1981
21. Williams P.L.: Embryology and development.
Gray’s Anatomy. 91,1995
SECTION - 3
Developing Dentition and
its Disturbances
3.1 Development of Dentition
Tandon S, ShayamBhat
Introduction
Stages of tooth evolution
The purpose of this chapter is to discuss the main
course of the normal development of human denti
tion, together with the concept of evolution of tooth
development, clinical features of the dentition and
the most common developmental disturbances.
Knowledge of the normal development of the denti
tion and an ability to detect deviation from the nor
mal are essential prerequisites for pedodontic diag
nosis and a treatment plan.
Graphically there are four stages of tooth evolution.
i) The reptilian stage (Haplodont)
ii) Early mammalian stage (Triconodont)
iii) Triangular stage (Tritubercular molars)
iv) Quadri tubercular molars
Definition
■
■
Dentition means a set of teeth
Teeth in the dental arch are used to designate the
natural teeth in position in their alveoli.
Evolutionary concept
During evolution several significant changes took
place in the jaws and teeth. When the Reptilian
evolved to mammalian, the dentition went from
“potyphydont” (many set of teeth) to “diphydont”
(only two sets of teeth) and then to "homodent” (all
of same teeth) to heterodent (different types of teeth
like incisor, canines, premolars and molars). There
also arose a necessity for the teeth and bones to
develop somewhat synchronously in order that the
function of occlusion.could be facilitated. Finally,
the number of cranial and facial bones has been re
duced by loss or fusion and the dental formula has
also undergone changes.
The Reptilian stage
This stage is represented by the simplest form of
tooth, the single cone type. It includes many teeth
in both jaws which limit jaw movement. Thus the
jaw movement is confined to that of a single hinge
movement.
*
Early mammalian stage
This stage exhibits three cusps in the line of devel
opment of the posterior teeth. The larger or anthro
pologically original cusp is centered with one smaller
cusp located anteriorly and another posteriorly.
. Tritubercular stage
According to the recognized theories explaining evo
lutionary tooth development, three triconodont limes
are changed to three cone shaped with the teeth still
by-passing each other more or less, when the jaw
opened or closed. These types are found in dogs
and other carnivorous animals.
Quadritubercular stage:
The next stage of development created a prQ^|bM
on the triangular form that finally occlud^^^^^g
antagonist of the opposingjaw Durii^^^^^n
tfiïSB i TEXTBOOK OF PEDODONTICS
an accommodation to the changes in the tooth form
and anatomy, the articulation of the jaws changed
accordingly.
The animals with dentition similar to that of humans
arc anthropoid apes. These include Chimpanzee,
Gibbon,Gorilla and Orangutan. The shapes of indi
vidual teeth in these animals are very close to their
counterparts in human mouth. Nevertheless, devel
opment of canines, arch form and jaw development
arc quite different.
Common evolutionary trends in the primates
1. There was shortening of the jaw due to the de
crease in the size of the olfactory organs, upright
body position and wide angle of the head to the
body.
2. There was decrease in the tooth size to be accom
modated in these jaws, with subsequent elimina
tion of some teeth from the dentition.
3. There was progressive shortening of the arch (in
front) and relative widening.
4. Canines reduced in size
5. Lower premolar crowns became more symmetri
cal from oval.
6. First molars became the dominant cheek teeth.
7. In the upper second and third molars, the
distolingual cusp reduced and often disappeared.
8. Third molars, which were larger than the first
molars, were reduced in size and often eliminated.
In modern man:
■
■
«
Characteristic of human dentition
Teeth of the vertebrates are characterized depending
upon:
■ Mode of attachment
■ Number of successive sets
■ Shape of teeth
L The way teeth are attached to the jaws.
a) Acrodont: Teeth attached to the jaw by a con
nective tissue.
b) Pleurodont: Teeth are set inside the jaws
c) Thecodont: Teeth are inserted in a bony socket
II. Depending on the number of teeth of successive
sets.
a) Polyphyodont: Teeth replaced throughout the
life, eg. shark.
b) Diphyodont: Two sets of teeth, eg. human be
ing.
c) Monophyodont: One set of teeth, eg. sheep,
goat.
III. According to type or shape of teeth
a) Homodont: A single type of teeth
b) Heterodont: Various types of teeth, eg. human
being.
Dental formula
Original formula of mammals was:
Permanent dentition:
r
13/3, C 1/1, PM4/4, M 3/3 J 11 x2 = 44 teeth
There is a decrease in the tooth-bearing portion
of the face. This decrease is partly due to a reduc
tion in tooth size.
In some primitive and pre historic human skulls
the second permanent molars usually succeeds
the 1st molar.
The occlusal length of the lower molars is reduced
in modern man and the ramus width is even more
reduced, less than the occlusal length of the lower
molars.
11
3 incisors, 1 canine, 4 premolars, 3 molars.
Deciduous dentition:
12/2, C 1/1, M 2/2
5x2 = 20 teeth
11
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
Pteient-dental formula: Teeth nuntber reduced in
Permanent dentition:
r
2
1
2
3
8
c —-PM—. M —
/■ 2
1
2
3
8
2 incisors, 1 canine, 2 premolars. 3 molars
Deciduous dentition:
1
2
. ;Q
C --- M
2
1
2
r
5
'S —
5
Origin of teeth
Theories: Each tooth whether primary or permanent
is believed to develop from theepithelial primary germ
cell: Varions theories regarding mammalian dentition
are reported.
!• The theory of concrescence: The mammalian den
tition was produced by the fusion of two or more
primitive conical teeth and each tubercle with its
corresponding root originated as a single tooth
oro-denial development, involve a scries of interac
tions not only between specific cell components, but
also between the different varieties of cells which
arise during organization of the various tissues
The formation of the primitive oral cavhy or
stomatodcum and the perforation of the buccopha
ryngeal membrane depend upon the contact between
the oral ectoderm and the pharyngeal ectoderm The
odontogenic epithelium is derived fiomthis ectoderm
It is believed that ectoderm, ecto-mesenchymc which
is contributed by the primitive streak through the
notochord and adjacent tissue and the mesoderm
arc involved in tooth formation. The inductive dif
ferentiation of the cell layers of a tooth germ results
from both cciodcrmal-ectomesenchymal and
cctomcscnchymal - mesodermal interaçtioiis.
Prenatal development
I n humans, odontogenic epithelium which is the all
iage of the dentitions, can be identified in 28-30 day
(ovulation age) embryo.
2. Theory of tritubercul v: Each of the mammalian
teeth was derived from a single reptilian tooth by
a secondary differentiation bf tubercles and roots.
This theory is widely accepted.
28-30 days The epithelium proliferates, giving the
appearance of epithelial thickening
located on the i nferior border of the maxillary process and the superior borders
ofthe mandibular arches in the area form
ing the lateral margins of the stomatodeum
3. Theory of multituberculy: The mammalian denti
tion is the result of reduction and condensation
of primitive tuberculate teeth.
30-32 days The odontogenic epithelium is 3-4 cell
thick, the cells being ovoid to cuboid
with little cytoplasm.
Tooth Development
32-34 days The mesenchyme immediately beneath
the odontogenic epithelium can be
distinguished from the adjacent mesen
chyme. The odontogenic epithelium
becomes invaginated relative to the
underlying mesenchyme and a dental
lamina from which individual tooth
buds arise.
In the developmental process specialized structures
such as teeth, differentiate as part of a closely inte
grated pattern of events. These progress from the
initial genetic potential of the fertilized ovum to be
influenced later by the prenatal and postnatal envi
ronment. The complex mechanisms, concerned with
i TEXTBOOK OF PEDODONTICS
4thweek
The formation of dental lamina
commences around and the tooth buds
for the deciduous teeth begin to form
about two weeks later. The dental lamina
marks out the position of the future
dental arches. The tooth buds for the
corresponding permanent teeth develop
from the same arch.
Stages of tooth bud development (Fig. 3.1)
1» Initiation:
« Phase of deciduous tooth - 5th month in utero
« Phase of permanent tooth - 6th month
■ Phase of accessional tooth - spaced from 4th
month in utero to 4-5 years
2. Proliferation
3. Histo-differentiation
4. Morpho-ditferentiation
5. Apposition
A tooth germ (tooth bud) consists of three parts: An
enamel organ, which is derived from the oral ectoderm,
a dental papilla and a dental sac, both of the latter
being derived from the mesenchyme. Each swelling
of the lamina which is destined to be a tooth germ
proliferates and differentiates, passing through
various histological and morphological differentia
A
Initiation
(Bud stage)
B
Proliferation
(Cap stage)
|
Morphodifferèntiation
Histodifferentiation
(Bell stage)
GROWTH
tion stages, namely bud, cap and bell stages. This
basic configuration of the future tooth crown is fixed
at the morphological differentiation stage. The
enamel organ produces the enamel by a process of
cell proliferation, cell differentiation and later miner
alization, and the dental papilla produces the dentin
and pulp of the tooth in a similar way. The dental sac
produces the cementum and the periodontal ligament.
Enamel formation ceases once the tooth crowns is
complete, but dentine formation continues with root
development. A layer of cementum is laid down on
the surface of the root dentine, and incorporates peri
odontal fibers that support the tooth through its at
tachment to the bony wall of the tooth socket. Once
histo-differentiation of the cells has progressed suf
ficiently far, mineralization commences. This occurs
in the deciduous teeth during the 14th intrauterine
week on average and begins with the central inci
sors. The permanent tooth buds appear in the fourth
and fifth intrauterine months, at about the same age
at which mineralization of the deciduous teeth com
mences. Mineralization of the permanent teeth is
initiated around the time of birth on average, begin
ning with the first permanent molar. Stages of tooth
development as classified by Nolla»can be referred
from Fig. 3.2
DEF
Apposition
(Before
(After
emergence) emergence)
CALCIFICATION
ERUPTION
Fig. 3.1 Life cycle of tooth. (Sharawig, Bhusary 1990).
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
10 - Apical end of root completed.
9 - Root almost completed.
8 - 2/3 of root completed.
7 -1/3 of root completed.
6 - Crown completed.
5 - Crown almost completed.
4 - 2/3 of crown completed.
3 - 1/3 of crown completed.
2 - Initial calcification.
1 - Abscence of crypt.
Fig. 3.2 Stages of tooth development (NoIla 1952)
d»> I TEXTBOOK OF PEDODONTICS
Chronology
An intimate relationship exists between tooth devel
opment and bone growth since teeth develop either
within a bony crypt or within a bony trough. Each
tooth passes through various progressive stages,
continually evolved with a physiologic process in
which histoïogïc, biochemical changes are simulta
neously taking place. The stages of development
are growth, calcification, eruption, attrition,
resorption and exfoliation.
Definition
first dental tissue laid down to the emergence of tooth
into the oral cavity and its completion of calcifica
tion (completion of root formation).
Deciduous dentition
Originally chronology for dentition is based on the
data of Logan and Kronfeld reportéd in 1933. Later, a
careful review of the data was done by various re
searchers like Massier and Shour in 1941, Moorrees
and Fanning and Hunt 1963, Kraus and Jordan in
1965, and Nystrom in 1977 etc.
ERUPTION STATUS OF DECIDUOUS TEETH IN IN
DIAN AND WHITE CHILDREN
Chronos - Time
Logos - Study
Therefore, chronology may be defined as the study
which deals with the timings of the various stages of
tooth development, starting with the initiation of the
Initiation of hard tissue development for all decidu
ous teeth occurs between 3.5 and 4.5 intrauterine
months. The crowns have been seen to get mineral
ized about halfway by birth and become folly formed
Table 3.1: Eruption status of deciduous teeth in Indian and white children
MAXILLARY ARCH
Teeth
South India
(Tandon 1998)
Male
Central India
(Kharbanda
1988)
Female Male
Female
North India
(Narinder
et al, 2000)
West Bengal
(Mukerji,
1973)
Male
Female
Male
Female
Western
Country (C.
data 1964-84)
Male
Female
9-12 i
12-14
Central Incisor
11-14 '10-14
10-14 10-14
9-11
9-11
10-12 10-13
7-9
Lateral Incisor
12-15 14-16
12-16 14-18
11-14
11-14
11-14
8-11
Canine
19-24 22-24
20-24 24-26
20-24 20-24
19-24 19-24
17-20 20-24
First molar
18-20 16-20
18-21
18-24
13-19 13-19
16-18 16-19
15-20 16-28
Second molar
28-36 26-32
26-32 20-36
20-30 20-30
29-32 29-32
23-36 30-32
12-15
MANDIBULAR ARCH
Central Incisor
10-12 10-12
10-12 10-13
7-9
7-9
10-12 10-13
7-9
6-6
Lateral Incisor
12-14 11-14
10-14 12-16
10-14
10-14
14-18
8-11
14-15
Canine
20-24 20-24
18-24 24-26
20-24 20-24
20-24 20-24
16-19 20-24
First molar
18-20 18-20
16-18
15-19
15-19
10-18 16-18
15-20 15-16
Second molar
26-30 26-32
26-32 26-32
20-30 20-30
29-32 29-32
20-26 30-32
18-12
15-20
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES | CD
during first 12 months of postnatal life. Root forma
tion continues and is completed after eruption, be
tween the ages of 1.5 and 3 years (for complete chro
nology, refer table 3.1). (Fig. 3.3)
Root completion
1 year
Eruption
Canines
and
6-12 months
incisors
4-6 months
Crown completion
relatively rapid under normal function, increases
whenever the velocity of the wear increases or
when the antagonist tooth is removed. Examples
of these teeth are the incisors of rodents and
lyomorphs.
Root completion
3 years
Eruption
3 years
Crown completion
Time requirement for - Time requirement for
development of priman7
development of perma
teeth.
nent teeth.
Fig. 3.3 Timing of Crown and Root Development
Clinical eruption. Eruption is derived from the Latin
word erumpere’ i.e., to break through. It is defined,
as the movement of the tooth from its position within
the jaws to its functional position in an occlusal plane,
in vertical/axial direction. Tooth eruption is intimately
associated with normal dentofacial growth and oc
clusal development, and the knowledge of eruption
is essential for a clinician to diagnose a dental prob
lem correctly, to plan his treatment successfully.
ii) Continuously extruding: Teeth stop forming once
root formation is complete. These teeth have a
well-defined anatomic crowns and root and are
usually associated with moderate occlusal wear.
The height of the clinical crown is maintained by
eruption of the tooth and apical migration of the
surrounding epithelial attachment, without simul
taneous deposition of the alveolar bone. As oc
clusal wear progresses, the tooth eventually loos
ens and exfoliates completely from its alveolar
housing. Examples are the check teeth of cattle
and sheep.
iii) Continuously invested teeth: Human teeth belong
to this type of eruption. These teeth also stop
forming after a predictable amount of root devel
opment has occurred and have distinct anatomic
crown and root structures, but the alveolar bone
remodels in response to eruption. With normal
attrition in the absence of periodontal disease,
the clinical crown shortens as the tooth erupts to
maintain vertical height and occlusal function and
brings the alveolar bone with it.
Stages of human tooth eruption
Human tooth eruption occurs in two major stages
which can be further divided into six phases.
Types of eruption
Three distinct types of teeth are differentiated by
their eruption pattern:
i) Continuously growing: Tooth formation ana erup
tion occur throughout the life. The dental tis
sues are formed from a proliferative base, and the
anatomic crown and root are very similar mor
phologically. Typically, these teeth have exten
sive wear. The eruption velocity, which is
1. Pre-emergence eruption:
During the early part of tooth formation, called
the follicular phase of eruption, the follicle en
larges concentrically in eveiy direction. It may
slightly move facially within the alveolar bone,
but there is little or no eruptive movement. The
tooth starts to enipt, and the pre-emergent spurt
phase of eruption begins, when crown formation
is complete and root development starts.
I TEXTBOOK OF PEDODONTICS
Theories of eruption:
■ Root growth theory
■ Constriction of pulp
« Pulp growth
■ Bone growth
« Tissue fluid pressure
■ Shrinkage of collagen
For a tooth to erupt intra-osseously, following
two factors are necessary:
■ The overlying tissue (bone, primary tooth root,
and gingiva) must resorb to provide an erup
tive path, and
■ A force must be generated to move the tooth
vertically. Resorption over the tooth seems to
be dependentonly on the presence of the coro
nal portion of the dental follicle.
The timing and development of the eruption path
way is independent of eruption pressure or even
the presence of a developing tooth.
Recent studies show that resorptive process may
be regulated by local growth factors such as trans
forming growth factor beta 1 (TGF-B1 ) and epi
dermal growth factor (EGF) produced within or
around the dental follicle. These growth factors
seem to chemoattract monocytes from the periph
eral blood vessels around the dental follicles. The
resorptive process begins with the formation of
osteoclasts from the coalescence of the
monocytes.
How the eruptive force is generated in the preemergent stage remains unclear. Although meta
bolic activity within the PDL probably plays an
important part, it is unlikely to be a source of the
pre-emergent eruptive force, because the major
ity of the principal periodontal fibers are sparsely
formed and incompletely linked with the alveolar
bone at this stage.
Deposition of the bone beneath the erupting tooth
is associated with eruption, but this seems to be
a result of eruption rather than its cause.
Vascular pressure has long been considered a lead
ing possibility but the pre-emergent eruption
mechanism remains an enigma.
2. Post emergent eruption
■ The post-emergent stage of eruption begins
with the prefunctional eruptive spurt, as the
tooth emerges through the gingiva and moves
into occlusal contact with its antimere. During
this phase, a tooth typically erupts about 4
nun in 14 weeks.
■ The juvenile occlusal equilibrium, circumpubertal eruptive spurt and adult occlusal equi
librium phases that follow are characterized by
a slower velocity of eruption.
■ After the teeth are in function, they continue
to erupt at the same rate as vertical growth of
the jaws unless there is occlusal wear or loss
at the opposing tooth, in which case additional
eruption occurs.
■ Throughout the post-emergent stage of erup
tion the PDL seems to be the major contributor
to the eruptive force. The principal fibers are
now well oriented and attached firmly to the
alveolar bone.
« The primary eruption mechanism is thought to
be either contraction of collagen As it matures
or (less likely) traction from contractile
fibroblasts.
■ Vascular effects similar to pre-emergent erup
tion may also contribute.
It seems reasonable to presume that forces op
posing the eruption mechanism control post-emer
gent eruption, analogues to the control of preemergent eruption by the resorption mechanism.
There are two points of evidence to support this
view:
i) in continuously erupting rodent incisors, the
rate of eruption slows as an erupting tooth
comes into function and
ii) in teeth of all types, if the opposing tooth is
removed, eruption occurs at a faster rate. Hu
man teeth wilt erupt beyond their normal posi
tion if the antagonist is removed.
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
Eruption rhythm
The circadian rhythm, in eruption is potentially sig
nificant in clinical practice. Studies indicate that cir
cadian rhythm exists during the pre-functional stage
of eruption of human teeth. The teeth intrude
transiently in conjunction with masticatory activity
and then erupt significantly overnight. The mean
daily eruption velocity was seen to be 71pm/day. It
is also believed that the effect on eruption of a su
pine position versus an upright position during the
night could be due to a change in intra-oral pressure
against the erupting tooth from either resting soft
tissue pressure (cheek and tongue) or functional
intraoral pressures (e.g. swallowing).
CLINICAL SIGNIFICANCE OF ERUPTION RHYTHM
i) Timing of eruption - controlling intervention. Ex
cessive eruption of the posterior teeth is a major
characteristic ofthe long face, and control of erup
tion during growth seems to be the key to suc
cessful treatment. The amount of force, its direc
tion, and the total hours of wear of the appliance
often are consideredthe most important clinical
factors that affect treatment outcome. If teeth
erupt primarily during the night with little or no
net eruption during the day, it is quite possible
that wearing an appliance (functional appliance,
bite blocks^ high pull head gear etc) is effective
during the night and early morning period when
the Eruption is most active is sufficient.
post-emergent eruption almost surely reflects a
rhythm in PDL activity7. The cellular activities of
periodontal fibroblasts have a periodicity similar
to eruption and orthodontic movements are also
related to cellular activity in PDL. Therefore, at
the time of treatment planning clinician should
explore fully this periodicity ofperiodontal cellu
lar activity for the control of pain and hyalinization or undermined resorption.
Teething
Teething is a term limited by common usage to erup
tion of primary dentition. Since the time of
Hippocrates (460-377 BC) teething is blamed for ail
ments such as fever; convulsions, bronchitis, otitis
media and diarrhea for causing 12% of the death in
children under four years. Complete opposite views
are also available. It is seen that these local and
systemic factors are associated with the disease
somewhere also and just as a coincidence appear
with teething.
Eruption of primary dentition usually begins in the
fifth or sixth month ofa child’s life. The appearance
of normal teeth is eagerly awaited by the parents
since it represents an important early milestone in
development. In mosteases eruption of teeth causes
no distress to the child or parents but sometimes the
process causes local irritation, which is usually mi
nor but which may be fewer enough to interfere with
the child’s sleep.
CONICAL FEATURES OF TEETHING
ii) Daily rhythm in skeletal growth: Ample evidence
demonstrates the skeletal growth requires an ad
equate level of HGH which increases in the night.
The rhythm in tooth eruption also reflects this
increase soon after the child goes to sleep. The
clinician should be aware that there is a rhythm in
skeletal growth and modification of treatment may
be more effective at the night than during the day.
Local signs:
■ Hyperemia or swelling of the mucosa overlying
the erupting teeth.
■ Patches of erythema on the cheeks
■ Flushing may also occur in the skin of the adja
cent cheek.
iii) Effect of tooth movement more generally: Be
cause eruption depends on metabolic activity
within the PDL, the rhythmicity associated with
Systemic signs:
■ General irritability and crying
« Loss of appetite
CEB I TEXTBOOK OF PEDODONTICS
■
■
■
■
■
■
•
Sleeplessness, restlessness
1 ncreased salivation and drooling
Insanity
Meningitis
Increased thirst
Circumoral rash
Cough
Associated problems:
Svstemic:
« Fever
■ Convulsions
■ Diarrhea
• Vomiting
a Bronchitis
■ Cholera
« Tetanus
■ Infantile paralysis
Local:
■ Eruption hematoma
« Erupt sequestrum
■ Ectopic eruption
■ Transmigration
« Transposition
Exfoliation
The physiologic process resulting in the elimination
of deciduous dentition is called exfoliation or shed
ding. This shedding or exfoliation is due to progres
sive resorption of the roots of the deciduous teeth
and their supporting tissue, the periodontal ligament.
In general, the pressure generated by the growing
and erupting permanent tooth dictates the pattern of
deciduous tooth resorption.
The first sign of root resorption is seen in the de
ciduous medial incisors and the first molars by the
age of 4-5 years. Resorption of the incisors begins
primarily on the lingual side with horizontal resorp
tion of the apical parts commencing at a la ter sta ge.
Root resorption in the deciduous molars starts from
the inner surfaces of the developing permanent tooth
germ.
Resorption of the deciduous incisors takes place
more rapidly (lasting 1.5-2 years on average) than
that of the canines and molars (2.5 - 5.7 years). The
permanent successor may be visible immediately af
ter exfoliation of a deciduous tooth, or there may be
a latent period of 0.1 to 0.5 years before the perma
nent successor erupts. The resorption process is
not continuous, but is interrupted by periods of rest
and periods of repair. This intermittent resorption
and repair explains the variation in mobility of the
deciduous teeth prior to exfoliation.
Premature loss of deciduous tooth has been found
to accelerate the clinical eruption of the subsequent
permanent tooth if the deciduous tooth is lost shortly
before normal tooth exfoliation time i.e., 1-2 years
before, whereas there is evidence both for and against
a retarding effect in the case of very early tooth loss
e. , 2-5 years before exfoliation. The explanation for
i.
this is that the dense fibrous connective tissue which
forms in place of the extracted deciduous may hinder
the eruption of its permanent successor.
Permanent teeth
Mineralization of the first permanent molar com
mences at birth on average, and is fallowed by the
other teeth (except third molars) in a given order
during the first 3.5 years of postnatal life.
■ The crown completion takes place at an age of
about 7 vears.
■ Mineralization ceases at an average age of 15-16
years with the completion of the roots of the sec
ond molars.
■ The respective mineralization stages for the third
molar are:
1. initiative at about 9 years
2. crown completion at about 13 years
3. root formation is completed arouod-2t) years
4. chronology of permanentteeth is presented in
table (refer table 3a&b in appendix).
■ The process from the initiation of crown minerali
zation to the closure of the root apex, takes from 8
to 14 years.
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
■
■
■
■
■
■
■
«
The development of the medial incisors is more
rapid and that of the canines and second molars
the slowest.
Root development alone takes on average from 6
to 7 years.
The mandibular teeth develop earlier than maxil
lary teeth.
A marked difference has been seen in tooth min
eralization, girls being ahead of half a year on
average, except in the case of the third molars.
The sex difference increases witli age and towards
the later formation stages.
Tooth eruption begins upon the completion of
crown formation and/or the beginning of root for
mation.
At the time of clinical eruption, root formation is
approximately three quarter complete.
There is always variations can be seen in the se
quence of eruption, the most frequent order is
mentioned in detail in section 3.3
Dental age
Dental age has been used for centuries as a param
eter for expressing biological maturity. It is of par
ticular interest to the pedodontists and orthodon
tists in planning of different types of malocclusions
in relation to maxillo-facial growth. It also plays a
great role in forensic odontology and pediatric en
docrinopathies.
Dental age is estimated by comparing the dental de
velopment status in a person of unknown age with
published dental developmental surveys.
The dental age of an individual as defined from the
radiographically observable tooth mineralization
stages, is a good index and can serve as one index of
biological age, having certain advantages over many
other such indices. Tooth formation can be defined
throughout the growth period from birth to adoles
cence, and tooth formation is less responsive to both
nutritional modification and hormonal disturbances
than many other developing tissues in the body.
Krogman believed that tooth formation age and the
monarch are best suited for the determination of the
biological developmental stage of the individual, as
they display the least variation.
Estimation of dental age
Different methods for the assessment of dental age
have been introduced.
1. Number of teeth erupted in the oral cavity or the
last tooth erupted. This method is rather rough,
however, as individual variations in eruption age
are extensive and endogenic and local factors may
affect tooth eruption.
2. Tooth formation stage of every tooth or of only
4-5 selected teeth may be recorded from a radio
graph, preferably orthopantamograph and corre
sponding age for each child. The tooth formation
age of the child is then obtained by calculating
the mean of the age estimates for the defined tooth
formation stage. The four teeth recommended
for this purpose:
a) from birth to 9 years: teeth 46,44,43,11
b) from I (» years onwards: teeth47,44,43,13
A tooth cannot be used, however, once it reaches
full maturity (the apex closed stage) as it no longer
gives any developmental information. Choice ofthe
teeth from the left side or rigid side does not make
any difference.
FACTORS AFFECTING DEVELOPMENT OF
DENTITION:
A. Systemic factors:
An accelerating effect: on the whole dentition is
very rare, but lias been reported to be due to:
■ Hyperthyroidism
« Hyper pitutarism
■ Turner’s syndrome
A retarding effect: Delayed eruption in both the
primary dentition and permanent dentition, but
more especially in the later has been attributed to
many diseases, syndromes and systemic factors,
the most common are:
<!ÏîB I TEXTBOOK OF PEDODONTICS
Hypopitutarism
■ Hypothyroidism
■ Cleidocranial dysostosis
■ Downs syndrome
■ Achondroplasia
« Hypovitaminosis (A and D)
• Amelogenesis imperfecta
■ Osteopetrosis
B. Local factors: Some local factors which may in
fluence the developing dentition are
■ Aberrant tooth position
■ Lack of space in the arch
i Very early loss of predecessor
« Ectopic eruption
■ Congenital absence of teeth
« Ankylosis of predecessor
■ Retained tooth or persisting deciduous root
remnants
• Arrested tooth formation (trauma)
■
■
■
■
Supernumerary tooth
Tumor
Cyst
Abnormal habit exerting muscular forces
S elf-Assessment
1. Classify developmental dentition periods.
2. What is natal and neonatal teeth?
3. What are the important considerations to be kept
while removing natal or neonatal teeth?
4. What is teething?
5. What is the chronology of deciduous and perma
nent dentition?
6. At what age maximum number of teeth are present?
7. How does exfoliation take place?
8. Name few associated local problems to teething.
9. What are the causes of delayed eruption?
10. What do you understand by dental age and how
will you assess it?
3.2 Common Developmental Disturbances
of teeth
Shyam Bhat, Tandon S
COMMON DEVELOPMENTAL DISTURBANCES
OFTEETH
Developmental disturbances in tooth eruption age,
size, shape, number and position are more comfhon
in the permanent dentition than in the deciduous
dentition. Heredity is believed to be most frequent
cause of these developmental disturbances. Com
monly occuring disturbances are discussed in table
3.2to3.5
Table 3.2: Common Developmental Disturbances of Teeth
Developmental Alteration of Number
Hypqdontia
Hyperdontia (Fig. 3.4a, b)
Definition
The developmental absence of multiple
teeth usually in association with systemic
manifestations (Stewart 1982).
An excess number of teeth when
compared to the normal dental
formula.
Etiology
Autosomal dominant with incomplete
penetrance.
Trauma, infection of the developing
tooth bud, radiation overdose,
glandular dysfunction, systemic
conditions such’ as rickets or syphilis,
German measles during pregnancy
and severe intrauterine disturbances.
Absence of appropriate dental lamina.
Recessive, autosomal or sex
linked.
■ Cleft lip and palate 28%
■ Cleidocranial dysplasia
■ Gardiner’s syndrome
Continued activity of the dental
lamina after the formation of the
normal number of tooth buds,
or result from complete division
of an early developing bud.
Clinical
features
Missing tooth: primary or permanent:
Other abnormalities include fusion,
ankylosis and short roots.
Syndromes: hereditary ectodermal
dysplasia.
Rudimentary or may be of normal
size.
Erupted or impacted. May cause
displacement of adjacent teeth.
Types include mesiodens,
supplemental tooth, para molar
and disto molar.
Treatment
Orthodontic closure of the space or a
prosthesis can be given.
Control of caries.
Crown recontouring.
Surgical removal
. Orthodontic alignment if needed.
1i
II
j
CEB I TEXTBOOK OF PEDODONTICS
Fig. 3.4a Palatally erupting supplemental teeth causing crowding.
Fig. 3.4b Labially erupting supplemental tooth.
Fig. 3.5 Microdontia involving single tooth (Right maxillary central incisor)
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
Table 3.3: Developmental alteration in the size of teeth
Microdontia (Fig. 3.5)
Macrodontia
Description
Teeth smaller than normal.
Teeth larger than normal.
Classification
■ True generalized microdontia. All
teeth are smaller than normal.
■ Relative generalized microdontia.
Normal or slightly smaller than
normal. Teeth are present in jaws
that are somewhat larger than normal.
■ Microdontia affecting a single tooth.
This is a rather common condition
most often affecting the maxillary
lateral incisor and the third molar.
• True generalized macrodontia.
« All teeth are larger than normal.
« Relative generalized macro
dontia. Here normal or slightly
larger than normal teeth are
present in smaller jaws.
■ Macrodontia affecting a single
tooth. This is occasionally seen
and is of unknown etiology.
Treatment
No specific treatment is indicated for
this condition.
No specific treatment is indicated
for this condition.
Table 3.4: Developmental alteration of shape
Anomalies
Definition
Etiology
Clinical features
Treatment
Gemination
Gemination can
be defined as
counting the bifid
crown as one
tooth, the normal
no. of teeth are
present and the
anomalous tooth
has probably only
one root canal.
(Levitas 1965)
A single tooth bud
divides resulting in
the formation of
tooth with the bifid
crown and a
common root and
root canal.
The normal no. of
teeth may be
present in the arch.
The tooth has two
crowns but only
one root canal.
Close monitoring
Fusion
Fusion can be
defined as an
incomplete
attempt of two
tooth buds to
fuse into one.
Union of two
normally reported
tooth buds with the
resultant formation
of a joined tooth
with confluence of
dentin: Some
physical force or
pressure is thou
ght to produce
contact between the
developing teeth &
their subsequent
fusion.
Two crowns
joined by enamel
or dentin but two
separate roots
or root canals.
May either be
complete or
incomplete.
Surgical division
and selected
shaping of
crown have been
tried.
contd.
<îtïï> I TEXTBOOK OF PEDODONTICS
Etiology
Anomalies
Definition
Concres
cence
Traumatic injury or
A form of fusion
which occurs after crowding of teeth
root formation,
with resorption of
has been£
_ the interdental bone
completed.
so that the two
roots are in appro
priate contact and
become fused by
the deposition
of the cementum.
Dens
evaginatus
A tubercle or
protuberance
from the involved
surface of the
affected tooth.
Clinical features
Treatment
Radiographically
it can be seen
that the roots of
two adjacent
teeth are fused
by cementum
whereas crowns
are separate.
No therapy unless
the union
interferes
with eruption when
surgical removal
of the tooth can
be considered.
May be due to the
The tubercle of
proliferation and
dens, evaginatus
évagination of part
appears as a
of the inner enamel pronounced
epithelium into the
elevation on the
stellate reticulum
occlusal surface of
of the enamel organ the posterior teeth
during development. and may occur in
Continued tooth
the form of a drop,
a pointed or
development
creates a tubercle
cylindrical cone.
of enamel and
In anterior teeth a
dentin containing
conically shaped
a horn of pulp
extension of the
cingulum is
tissue.
observed.
Talons cusp occurs
Talons cusp The talons cusp
during the morphois an uncommon
(Fig. 3.6)
differentiation stage
dental anomaly
of tooth develop
referring to an
ment It may occur
accessory cusp
as an outward
like structure
projecting from the folding of inner
enamel epithelial
cingulum area or
cells and transient
cementoenamel
focal hyperplasia
junction of the
of the peripheral
maxillary or
cells of the
mandibular
mesenchymal
anterior teeth.
dental papilla.
Appears as an
additonal cusp
that prominently
projects from the
palatal surface of
a primary or
permanent anterior
tooth and extends
at least half
distance from the
cementoenamel
junction to the
incisal edge.
Some talon cusps
are quite sharp
and spike like,
while others have
rounded and
smooth tips.
Removal of
enamel of the
tubercel and
placement of
calcium hydroxide
dressing to
stimulate the
odontoblasts to
produce reparative
dentin. If the dens
invaginatus
becomes pulpally
involved endo
dontic procedures
is the treatment of
choice.
If the talons cusp
interferes with
occlusion then it
should be
removed by
periodic grinding
of the cusp. If
deep fissures are
present between
the cusp and tooth
then it should be
sealed using pit
and fissure
sealant.
contd.
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
Fig. 3.6 Talon’s cusp present on right
maxillary lateral incisor’
Fig. 3.8a Types of amelogenesis imperfecta.
Hypoplastic amelogenesis imperfecta.
<!?!>
raph showing
Fig. 3.7 Ra
taurodontism.
Fig. 3.8b Hypomaturation amelogenesis
imperfecta.
Fig. 3.9 Dentinogenesis imperfecta showing severe attrition.
<ft>4 i TEXTBOOK OF PEDODONTICS
Anomalies
Definition
Etiology
Clinical features
Taurodonttsm
(Fig. 3.7)
Taurodontism is
the enlargement
of the body and
pulp chamber of a
multi rooted tooth
with apical dis
placement of the
pulpal floor and
bifurcation of the
roots. Neville
1994.
Genetically or
hereditary
transmitted. Error in
the function of the
Hertwig's epithelial
root sheath. The
epithelial sheath
begins to form
from the cervical
ring. This tends to
limit the pulp
mesenchymal
tissue by an apical
diaphragm.
The third molars
No special therapy
most affected
is required for
unilateral or
such a tooth.
bilateral single
tooth or at othertimes several
molars. A taurodont
I
has a long body
with short roots:
the pulp chamber
is elongated in theapico-occlusal
direction and lacks
constriction at the
cervix.
Dilacera
tion
Abnormal
angulation or
bend in the root
or less frequently
the crown of a
tooth.
An injury that
displaces the
calcified portion of
the tooth germ and
the remainder of the
tooth is formed at
an abnormal angle.
Secondary to the
presence of an
adjacent cyst, tumor,
or odontogenic
hamartoma.
The most frequent
involved teeth are
the permanent
maxillary incisors,
followed by the
mandibular
anterior dentition.
The abnormal
angulation may be
present anywhere
along the length
of the tooth.
Treatment
Grossly deformed
teeth require
surgical removal.
i
--------------------------- i----------------------------------
Table 3.5: Developmental alteration of structure.
Anomaly &
classificat
ion
I
I
Definition
Amelogene- Amelogenesis
sis imperfe imperfecta is a
cta (3.8a,b) group of here
ditary disorder
Type I
IA - hypopl characterized by
alteration of the
astic pitted
quantity and
autosomal
quality of enamel
dominant
IB - hypopl in humans and
is frequently
astic local
associated with a
autosomal
significant dental
dominant
IC - hypopl disease as stated
by Witkop and
astic local
Sauk 1976.
autosomal
_ .
Etiology
Clinical features
Treatment
Gene mutations in
the enamel matrix
produces one of the
following results:
Hypoplasia
Hypocalcification
Hypo maturation
isolated defect
with autosomal
dominant
autosomal
recessive and
x-linked inheritance
also occur.
■ Hypoplastic
The teeth lack
normal enamel
thickness.
Inadequate
deposition of
enamel matrix.
The enamel may
be pitted, have
horizontal or
vertical ridges.
■ Hypomaturation
Normal
deposition of
enamel matrix
« For poor esthe
tics: Primary
teeth restored
with glass
ionomer cement
and composite
veneer
■ Dentinal
sensitivity: Full
coverage with
stainless steel
crowns.
■ Dental caries:
Dietary advice,
fluonde therapy,
. ii________ ___________
I
contd
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
1
Anomaly &
classificat
ion
recessive
ID 7 hypoplastic
smooth
dominant.
IE - hypopl
astic
x-linked
dominant
IF - hypopl
astic
rough
autosomal
dominant
IG - Enamel
agenesis,
autosomal
recessive
Type 11
11A - hypom
aturation,
pigmented
autosomal
recessive
IIB - hypom
aturation,
x linked
recessive
IIC - snow
capped
teeth X
linked
HD - snow
capped
F teeth,
autosomal
j dominant.
Type HI
fitA - auto\ somal
dominant
j IIIB- auto; somal
recessive
Type IV
IV A- hypom
aturation
Definition
'S
Etiology
Clinical features
»
1
|
I
i
Treatment
Defective crystal
glass ionomer
structure miner
and composite
alisation. The affe
restorations,
stainless steel
cted teeth show
mottled, opaque
crowns.
white brown
■ Gingival
yellow discolora
inflammation
tion. The enamel
Increased
is softer than
preventive
normal & tends
oral health
care practices.
to chip from the
underlying dentin
• Hypocalcified
Enamel matrix
is laid down
appropriately
but no signicant minerali
zation occurs.
Enamel is
orange yellow at
eruption and
consists of
poorly calcified
matrix, which is
rapidly lost
leaving dentin
cores.
« Hypomaturation
hypoplastic with
taurodontism.
The enamel is
mottled yellow ~
brown; thin with
areas of hypomaturation.Molar teeth
have a taurodont
shape and other
teeth may have
enlarged ptrip
champers enamel
hypoplasia in
combination with
hypomaturation.
contd.
i
CED I TEXTBOOK OF PEDODONTICS
Anomaly &
classificat
ion
Definition
Etiology
hypoplastic
with taurodontism,
autosomal
dominant
IVB - hypo
plastic
hypomatu
ration with
taurodontism. auto
somal
dominant
■. ........................
Clinical features
Treatment
I__________
j
Dentinogenesis imperfecta (Fig 3.9)
Typel
Autosomal
dominant
Freq. 1 in
8-10,000
Type II
Autosomal
dominant
Freq. 1 in
1,25,000
Type III
Autosomal
dominant
Freq. 1 in
3,00,000
Type IV
Autosomal
recessive
Frequency
unknown
Dentinogenesis
imperfecta is a
hereditary develo
pmental disturba
nce of the dentin
that may be seen
alone or in conju
nction with the
systemic heredi
tary disorder
of the bone,
osteogenesis
imperfecta.
Genetically
inherited
disease.
Autosomal
dominant
« All the teeth in
The entire dentit
both the dentit
ion is at risk
ions are affected. because of the
The deciduous
numerous
teeth are affected problems. The
most severely
root canals
followed by the
Kbecome thread like.
Overlay dentures
permanent
■ The dentitions
placed on teeth
have a blue to
that ate covered
brown discolor
with fluoride
ation, often with
releasing glass
a distinctive
ionomer cement
translucence.
Preventive
■ Enamel
measures ought
frequently
to be undertaken
separates from
at the earliest.
the underlying
defective dentin.
■ The pulps are
usually
obliterated by
excess dentin
produciton.
contd.
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES | tfBEl
Anomaly &
classificat
ion
Clinical features
Etiology
Definition
Treatment
Regional odontodysplasia (Ghost teeth)
Regionaf "
odontodysplasia
is a localized
disorder of the
tissues of dental
origin resulting
in characteristic
ally bizarre
clinical and radioraphic
appearances.
*
Etiological factors
suggested include
a somatic mutation
affecting the dental
lamina in the area,
activation of latent
viruses, local
circulatory disorders,
pharmaco-therapy
during pregnancy,
neural disorders,
Rh incompatibi
lity or failure of
migration and
differentiation of
neural crest cells.
■ These teeth are
typically discol
ored yellow,
yellowish-brown
or brown.
■ The enamel of
both the primary
and permanent
teeth has been
reported to be
soft on probing.
■ Rough surface
texture.
■ Teeth affected
include perman
ent anterior
teeth.
■ Maxilla is pre
dominantly
involved than the
mandible.
« Occlusion,
drifting and over
eruption of
adjacent or
opposing teeth
may be found
where affected
teeth have failed
to erupt.
•
4
Self-Assessment
1. Wha t is the difference between fusion and concrescence?
2 What are ghost teeth?
3. What is the difference between Amelogenesis imperfecta and Dentinogenesis imperfecta.?
4. What is gemination?
5. . Classify microdontia,
6. What is the etiology of Talon Cusp?
7. What are the clinical features of Taurodontism?
8. What treatment is suggested for Dilaceration?
■
3.3 Development of Occlusion
Tandon S
Introduction
Periods of occlusal development
Development of occlusion is a genetically and envi
ronmentally conditioned process which shows a
great deal of individual variations, and consequently,
for the development of an acceptable occlusion,
quite a remarkable co-ordination of different events
is necessary. Failure in one part of the developmen
tal process may lead to anomalies, or else may be
compensated for by other developmental process.
The occlusion of the teeth may be divided into the
following developmental periods.
1. Predental jaw relationship (Neonate’s mouth)
2. The deciduous dentition
3. The mixed (transitional) dentition
4. The permanent dentition
In order to facilitate the understanding and compre
hension of the developmental process in the face, a
three-dimensional structure, this chapter is an attempt
to concentrate mainly on clinical features of devel
oping dentition and establishment of their relation
ship, because, the ultimate goal of the pediatric den
tist is to develop a perfect and healthy occlusion in
the permanent dentition by guiding the developing
occlusion.
Predentate refers to the period from birth to the erup
tion of the first deciduous teeth in the oral cavity. At
birth the alveolar arches, also called gum pads, are
horseshoe shaped in the maxilla and V-shaped in the
mandible. They are firm and pink in colour. These
gum pads develop in two parts.
■ Labial portion (differentiates first)
■ Lingual portion (differentiates later)
The term occlusion is derived from the Latin word,
“occlusio” defined as the relationship between all
the components of the masticatory system in normal
function, dysfunction and parafunction. An ideal
occlusion is the perfect interdigitation at the upper
and lower teeth, which is a result of developmental
process consisting of the main three events, jaw
growth, tooth formation and eruption.
Although the interrelation between the teeth essen
tially becomes established in childhood, it continues
to change to some extent throughout life. Thus the
occlusion is regarded as a dynamic rather than a static
interrelation between the facial structures.
PREDENTATE PERIOD
These two portions are separated from each other by
a dental groove which is the site of origin of the
dental lamina. (Refer chapter 2.2 pedologic anatomy
for details)
Longitudinal observations on occlusal development
suggest that the oral structural features of the new
born child do not seem to provide a reliable basis for
predicting the interaction between the teeth. At birth
distal relationship of the mandible to the maxilla makes
for this difference in the course of the first 3 -4 months.
The greater the anteroposterior dimension of the
gumpads, the greater the possibility of the child de
veloping malocclusion.
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
Precociously erupted teeth: Sometimes an infant
may be born with teeth which are precociously
erupted. If these teeth emerge before the first three
months of life, they are classified as premature teeth.
Those that are present at birth, are called natal teeth,
those that erupt during the neonatal period, from
birth to 30 days are designated neonatal teeth. Al
most 90% of these precociously erupted teeth are
primary teeth of which 85% are mandibular incisors
and 10% are supernumerary calcified structures fre
quently, referred to as predeciduous teeth. Natal
teeth appear more frequently than neonatal teeth (Fig.
3.10).
Etiology of neonatal and natal teeth: Superficial po
sition of tooth germ, increased rate of eruption due
to febrile incidents, hormonal stimulation and hered
ity. Eruption could be dependent on osteoclastic ac
tivity within area of the tooth germ.
Association with syndromes: These teeth are report
edly associated with syndromes like chondroectodermal dysplasia, Hallermann-StrcifT syndrome and
pachyonychia congenita, Ellisuan Creveland and,
Rigafede syndrome.
Incidence: The incidence of natal and neonatal teeth
has been estimated to be 1:1000 and 1:30000. It is
seen that 85% of natal or neonatal teeth arc man
dibular incisors, 11% are maxillary incisors, 3% man
dibular cuspids or molars and only 1% are maxillaiy
cuspids or molars.
The maxillary central mcisors erupt at 9 months of
age with spaces between them followed by the lateral
mcisors at the age of 1 year. By 1 to 1 1/2 years, the
first molars enipt, resulting in a vertically supported
occlusal contact between the two arches. The man
dibular canines erupt at 16 months and themaxillaiy
canines follow at around 18 months. By the age of 2
1/2 months to 3 years the full compliment of decidu
ous dentition is present.
During the first year of life the infant does not seem
to have a definite centric occlusal relationship or rest
position of the mandible. There is a limited anterio
posterior movement of the mandible but no lateral
movements. With the beginning of deciduous inci
sors eruption the alveolar mucosa presents an ap
pearance of having receded on the erupting teeth.
The primary incisors erupt into the anterior space of
the gum pads, thus accounting for the apparent
ovcrbitc. This overbite (usually in incisor region)
gets reduced as the posterior deciduous teeth come
into occlusion.
Clinical features of deciduous dentition
1. General characteristics
■ Both the dental arches are half round in shape
or ovoid
« Almost no curve of spee is present
■ Shallow cuspal interdigitation
■ Slight overjet and overbite
■ Vertical inclination of the incisors
■ Little or no crowding
DECIDUOUS ORPRIMARYbENTITION
At birth, the dental arches are small with a subse
quent crowding of tooth germs which are within the
jaw bone. This is overcome by increased jaw growth
and the buccal placement of tooth germs.
The mandibular incisors are the first teeth to erupt
into the oral cavity around six months after birth.
During this period there is increased anterior posi
tioning of the lowerjaw with relation to the upperjaw.
2. Spacing: Two types of dentition are
A Spaced dentition
Spaced dentition is supposed to be good as
spaces inbetween the teeth can be utilized for
adjustment ofpermanent successors which are
always larger in size compared to the decidu
ous teeth. These spaces present are of two
types:
■ Primate spaces (Fig. 3.11 and 3.13a):
These spaces are very prominent spaces
1 present in the primate species
in
CT>F> I TEXTBOOK OF PEDODONTICS
Fig. 3.10 Mandibular arch showing natal tooth
4
Fig. 3.11 Primate space and deciduous first molars in mesial step relation
Fig. 3.12 5 year old child showing physiolgoic spaces in upper and lower dentition
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
Fig. 3.13a Mesial step
Fig. 3.13b Distal step
Fig. 3.13c Flush terminal plane
Fig. 3.13a,b,c Mesial step (44%), Distal step (04%), Flush terminal (52%), (Tancfon, Sajid 2000)
human they exist between the upper lateral
incisors and the canines (present mesial to
maxillary deciduous canines) and lower
canines and first deciduous molars (present
distal to mandibular deciduous canines).
These spaces are also called as anthropoid
or simian spaces.
■ Physiologic/developmentai spaces
These spaces (Fig. 3.12) are present in
between the primary teeth and play an
important rôle in normal development of the
permanent dentition. The total space
present may vary from 0 to 8 mm with the
average4 nmi in the maxillary archand 1 to7
mm with the average of 3 mm in the man
dibular arch.
B. Non-spaced dentition
Primary teeth are present without any spaces
in between the teeth. This lack of space may
be due to the narrowness of the dental arches
or teeth are wider than usual. This type of den
tition usually indicates to crowding in devel
oping permanent dentition, but, it is not al
ways the case. It may depend on the individu
al’s growth of the jaws.
3. Occlusal relationship
Primary dentition develops quite independantly
of other morphologic process Le., there is little
relationship between primary tooth development
and skeletal maturation. This dentition is com
plete after the eruption of the second primary mo
lars, indicating that location for permanent teeth
in future has already been determined at this stage.
In other words, the dental arch circumference
(roughly half circular in shape) that connects the
most distal surfaces of the right and left second
primary molars should be preserved for the periîjSÏIf
TEXTBOOK OF PEDODONTICS
Primary molar relationship
The relationship of the distal surface of the max
illary and mandibular second primary molars is,
therefore, one of the key factors that influences
the future occlusion of the permanent dentition.
The posterior primary teeth occlude so that the
mandibular cusp articulates just ahead of its cor
responding maxillary cusp. The maxillary canine
occludes distal to the mandibular canine arid me
sial to the first molar. The maxillary first molar oc
cludes between the disto-occlusal aspect of the
first primary molar and the mesio-occlusal aspect
of the second molar in the mandible. The mesiolingual cusp of maxillary7 molars occludes in the
central fossa of the lower molars.
The mandibular second molar being somewhat
wider mesiodistally, gives rise, typically, to a flush
terminal plane at the end of the primary dentition.
As the distal surface of the second primary mo
lars guides the first permanent molars into occlu
sion, it is important to know how the upper and
lower deciduous molars are related to each other
(Fig. 3.16). The mesio-distal relation between the
distal surface of the upper and lower second pri
mary molars usually can be classified into the three
types:
i) Flush terminal or vertical plane type
The distal surface (Fig. 3.13c) of the upper
and lower teeth are in a straight plane (flush)
and therefore situated on the same vertical
plane. Usually it is a favourable relationship
to guide the permanent molars.
ii) Mesial step type (Fig. 3.11 and3.13a)
The distal surface of the lower molar is more
mesial to that of the upper. Invariably it is
favourable to guide the permanent molars into
a class I relationship.
iii) Distal step type (Fig & 13b)
The distal surface of the lower molar is more
distal to that of the upper. This relationship is
prognostically unfavourable as it guides the
permanent molars into distal occlusion.
The prevalence of various types of terminal planes:
Distribution Type
Present (%)
Bilateral
Flush terminal plane 59.1
(Vertical type)
Mesial step
19.1
Distal step
4.8
Unilateral
Flush terminal plane 9.1Mesial step
8.1
Distal step
iv) Anterior teeth relationship
Overbite: It is the distance which the incisal
edge of the maxillary incisors overlap vertically
past the incisal edge of the mandibular inci
sors. The average overbite in the primary den
tition is 2mm and is sometimes expressed in
terms of the percentage of the mandibular inci
sors crown covered.
Over jet: It is the horizontal distance between
the lingua! aspect of the maxillary7 incisors and
the labial aspect of the mandibular incisors,
when the teeth are in centric occlusion. The
average in primary dentition is 1-2 mm with a
normal range of 2-6 mnt At the age of 2 years
it is seen often to be 4 mm with
*
a fairly steady
decrease upto the age of five years. Concur
rently with the excessive wear of the primary
canines and molars, the whole lower dental
arch may7 move anteriorly, the incisors may
assume an edge-to-edge interrelationship by
the age of six years.
v) Canine relationship: The relationship of the
maxillary7 and mandibular deciduous canines
is one of the most stable in primary dentition.
It is classified as class I when mandibular ca
nine interdigitates in embrasure between the
maxillary7 lateral and canine and class II where
mandibular canine interdigitates distal to em
brasure.
vi) Arch dimensions (Fig. 3.14) The size of the
primary dental arch can be measured by the
dental arch width between the primary canines
and between the second primary molars.
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
Arch height
Arch length and circumference
The terms arch length and arch circumference are
often incorrectly used interchangeably
A small a mountof decrease takes place from the
eruption of the second molars until the eruption
of the first permanent molars due to the mesial
migration of the second primary molars, or the arch
can also be shortened due to interproximal caries.
Increase in the Iieight of the alveolar bone takes place
as it grows with time.
■ There is little or no increase in the arch height
during the period of the primary dentition
■ It is difficult to measure and is of theoretical value
The dental arch length can be measured from the
most labial surface of the primary central incisors to
the canines and to the second primary molars. Arch
circumference is determined by measuring the length
of the curved line passing over the buccal cusps or
the incisal edges of the teeth, from the distal surface
of the primary second molar around the arch to the
distal surface of the other primary molar.
Spaced dentition does not have any change in
the spaces present until the eruption of the per
manent molars.
■ Non-spaccd dentition does not show any devel
opment of spaces in the primary dentition.
■
■
Spaces
■
THE MIXED DENTITION PERIOD
The period during which both the primary and per
manent teeth are in the mouth together is known as
mixed dentition. The permanent teeth erupting in
place of previous deciduous teeth are the succèssional teeth, whereas those erupting posteriorly to
the primary teeth are called the accessional teeth.
Transition from the-primary to the
permanent dentition
C
C
Fig. 3.14 Arch dimension
«
Arch dimensions
A - Arch length
B1 - Bicanine diameter
B2 - Bimolar diameter
C - Arch perimeter / Arch circumference
■
«
Changes from 3 years to six years: Not many changes
take place till the eruption of the permanent teeth.
■
Arch width
■
■
The primary dentition does not show any sub
stantial increase in width across the alveolar arch.
Both maxillary and mandibular arches increase in
width by growing posteriorly to accommodate the
eruption of the permanent molars.
«
■
Calcification of the permanent dentition begins
between birth and three years of age. Second
premolars may not begin calcification until five
years of age.
*
Eruptive movement does not begin before crown
calcification is complete.
Enamel calcification is usually complete three to
four years before eruption into the oral cavity
(mandibular incisors are the exception).
Tooth crowns pierce the bony alveolar crest when
approximately 2/3 of root development is com
plete.
Teeth emerge into the oral cavity when approxi
mately 3 /4 of root development is complete.
Root development is complete approximately 2-3
years after eruption.
<ilk> I TEXTBOOK OF PEDODONTICS
Phases of mixed dentition can he divided into three
i) The first transitional period:
■ emergence of the first permanent molars
■ incisors transition
■ establishment of occlusion
ii) Intertransitional period:
■ containing both sets of dentition
■ four permanent incisors, left and right first per
manent molars
■ deciduous canines and deciduous first and
second molars
iii) Second transitional period:
■ emergence of bicuspids, cuspids and the sec
ond permanent molars.
■ establishment of occlusion
The important aspects of the mixed dentition are uti
lization of the arch perimeter which is used for align
ment of the permanent incisors and in the adaptive
occlusal changes that occur during the transition
from one dentition to the other.
THE FIRST TRANSITIONAL PERIOD (Fig. 3.15)
By the time of first permanent molars eruption any
initial spaces between the deciduous molars and ca
nines will generally have diminished or disappeared.
In both the jaws, the first permanent molars erupt
more or less in a perpendicular orientation to the
occlusal plane. They originate one above the other
in the ramus and come downward with the maxillary
permanent molars being accommodated by additions
at the tuberosity.
The antero posterior relation between the two op
posing first molars after eruption depends on:
■ their positions previously occupied within the
jaws
■ the sagittal relation between the maxilla and man
dible.
■ ratios of the mesiodistal crown dimensions of the
U/L deciduous molars.
■ The occlusal relationship is established by the
‘cone and funnel’ mechanism with the upper pala
tal cusp (cone) sliding into the lower occlusal
fossa (funnel).
Ideally, the eruption of the permanent molars into a
class I relationship is desired. Since the flush termi
nal relationship is more common in deciduous denti
tion, it is more common for the permanent molars to
erupt into an end-to-end relationship. The desired
class I relationship is established by the following
ways:
.
Fig. 3.15 Position of unerupted permanent teeth in relation to deciduous teeth
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES | CTEl
PRIMARY
PERMANENT
Class II
End - End
Class I
Class III
differential
> Forward growth
of mandible
DISTAL STEP
CLASS II
Fig. 3116 Occlusal relationships of primary and permanent molars
€ED i TEXTBOOK OF PEDODONTICS
a) Early mesial shift
If the deciduous dentition is spaced dentition
with flush terminal relationship of second decidu
ous molars, the eruptive force of the permanent
molars causes a closing of any existing spaces
between the ¡primary molars or primate spaces ef
fectively causing a decrease in arch length.
b) Late mesial shift
When no spaces exist, the erupting first perma
nent molar is not able to close spaces. In these
cases when the primary molar exfoliates the per
manent molar migrates mesially to use up the “Lee
way space” (the difference between the mesiodistal width of the primary canine, first and sec
ond molars and their permanent successors). This
averages 1.8 mm in the maxilla and 3.4 mm in the
mandible.
Initial
Occlusion
*Distal
23.3%
Cusp to Normal Mesial
26.7% 0.8%
Cusp
49.2%
Occlusion in
permanent
dentition
Class II
38.6%
Class 1 Class III
58.9% 2.5%
Fig. 3.17 Final establishment of permanent
molar relationship.
c) Primary molar guidance of permanent dentition
The primary second molar relationship can give
clues to the eventual permanent molar relation
ship. If the deciduous arches terminate in a
mesial step, the permanent molars may erupt di
rectly into a normal, angle class I occlusion (mean
ing that the mandibular first molar is half a cusp
mesial to its antagonist), in few cases it may de
velop into class III relationship. A definite distal
step guides the molars into distal relationship
which generally does hot improves with age, in
stead deteriorates. (Fig. 3.16 and 17)
INCISAL TRANSITION
The period of transition (ages 6 1/2 to 8 1/2) is critical
for the development of the dentition. During the
transition there are a number of factors that deter
mine the successful alignment of the permanent teeth
toward an ideal arch form.
a) Interdental spacing of primary incisors:
Interdental spacing averages 4 mm in the maxil
lary arch and 3 mm in the mandibular arch. The
amount of anterior spacing in the primary denti
tion is one of the first clinical observations made
in examining a young child. Lack of interdental
spacing must be considered a serious handicap
toward normal incisor alignment.
b) Inter canine arch width growth:
Only negligible amounts of growth occur from
three years (completion of primary dentition) to
6-7 years when the permanent mandibular inci
sors begin to erupt. Notable amount of growth
occurs with the eruption of the incisors and ca
nines.
Sex
Dental arch
Width increase
between 2-18 years
Males
Maxilla
Mandible
6 mm
4 mm
Females
Maxilla
Mandible
4.5 mm
4mm
c) Intercanine arch length increase:
When the permanent incisors erupt, they assume
a somewhat more anteriorly inclined position (la
bial inclination) than the deciduous incisors. This
position of the incisors averages 2.3 mm and re
sults in an increase in intercanine arch length of
approximately 3 mm without any change in
intercanine width. This makes another character
istic difference in tooth axis. The interincisal
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
angle between the maxillary and mandibular inci
sors is about 150° in primary dentition, whereas it
is about 123° in permanent dentition which makes
permanent dental arch circumference wider (Fig.
3.18)
~
in relation to the upper ones, which consequently
results in a change from a possible cusp-to cusp
molar relationship to a normal molar interrelation.
Fig. 3.18 Comparison of the angulation of the
permanent and primary teeth
Fig. 3.19a The size difference between the
primary molars and the permanent premolars
I) Favourable variations in the size ratio between
the primary and permanent teeth:
The permanent incisors are usually larger in total
width than the primary incisors they replace (the
difference is iiicisal 1 iajtnlity).
—
5 years
5 years
6 years
7 years
Permanent canine, premolars are usually smaller
in total width than primary canine and molar they
replace (the difference isjLeeway spaceLUHS3.19a, b).
The sum of the mesio.-distal width of the perma
nent lateral incisors is generally smaller thanbf
the primary lateral incisors by about 1 mm in the
maxilla and 3 mm in the mandible. This carries out
the smooth exchange of the lateral incisors.
The Leeway space, in addition to providing space
for the permanent canine, also allows the perma
nent molars to move mesially when the decidu
ous molars are replaced with the mesio-distally
smaller premolars. Moreover, the fact that the
Leeway space is greater in the mandible than in
the maxilla and facilitates a greater mesial
movement of the lower permanent molars
Fig. 3.19b Maxillary molar erupts into normal
occlusion after the mandibular first permanent
molar migrates mesially to obliterate the
mandibular diastema between primary first
molar & cuspid. (Baume, 1950)
CTF» I TEXTBOOK OF PEDODONTICS
BROADBENT PHENOMENON (Fig. 3.20)
(at age 5 1/2 years and 13 1/2 years)
School children tend to look unusual during the ex
change of their incisors, especially in the upper arch
when the permanent incisors erupt. These appear to
be much larger compared with the primaiy teeth with
their longitudinal axes-flared out like as an inverse
4 V’. As for the colour of the primaiy teeth, it is chalky
white, whereas permanent teeth tend to be more yel
lowish. Because of the pressure of erupting perma
nent canines in the developing roots of lateral inci
sors, the crowns of erupting incisors flare more later
ally producing diastema. Many parents worry about
these conditions. The transitional mal-alignment dur
ing the exchange period of the upper anterior teeth is
called as “the ugly duckling stage’’ (Broadbent in
1937). This phenomenon is self correcting and nor
mally, the incisors gradually straighten with the erup
tion of the lateral incisors and canines.
Spacing in deciduous
dentition
Crowding in permanent
dentition
<0 nun (crowding)
10 out of 10 children .
0mm
7 out of 10 children
0-3 nun
5 out of 10 children
3-6 mm
2 out of 10 children
>6 mm
0 out of 10 children
INTER TRANSITIONAL PERIOD
■
In the intertransitional period which lasts about
1.5 years, asymmetry in emergence and associ
ated differences in height levels and lengths of
clinical crowns of the corresponding left and right
teeth are made up.
■
Under the influence of the tongue, the mandibu
lar lateral incisors attain the proper sites within
the dental arch and their initial lingual location is
eliminated.
*
Fig. 3.20 7 year old child showing ugly
duckling stage
Sum of spaces in the mandibular deciduous denti
tion and corresponding probability of crowding in
the permanent dentition
■
Small rotations are corrected by the pressure ex
erted by the tongue and lips if the spatial condi
tions in the dental arches permit these movements.
«
There is wearing of deciduous teeth with attrition
of the cusp tips and occlusal morphology ap
proaching that of a plane.
■
The antero-posterior relation between 2 jaws is
not fixed in occlusion. A fixed intercusp relation
ship is absent. No interferences from the occlusal
contacts are present so the mandibular teeth at
tain a slightly more mesial position.
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
SECOND TRANSITIONAL PERIOD
■
■
•
At around 9 to 10 years of age, the second transi
tional period starts with shedding of the poste
rior teeth. The alignment of the erupting perma
nent teeth depends a lot on the order of exchange
of the lateral teeth which takes about one-andhalfyears to complete the exchange of all the lat
eral teeth.
After the eruption of incisors, there follows a
pause of about one to two years, and the next
tooth to erupt is the lower cuspid and the first
bicuspid at 9-10 years. The maxillary cuspid and
second bicuspid then erupt, at 11 to 12 years, and
the period is terminated by the appearance of the
second molars at 12 years.
Transition from the ugly duckling to a mature stage
of dentition is also called as prepubertal period.
This is correlative with the maturation of the child
as a whole.
■
During this period, the child tends to lose the
roundness of childhood and advances noticeably
toward adolescence.
■
The most common sequence of eruption of per
manent lateral teeth in the maxilla is 4-3-5 and in
the mandible 3-4-5. As mentioned previously,
because permanent canine is larger than the pri
mary canine, crowding is very con non immedi
ately after the exchange of the canines. This phe
nomenon is more prevalent in the mandible but
this crowding get alleviated after the exfoliation
of the second primary molar. If this sequence of
eruption is changed to 4-3-5 or 4-5-3, the Leeway
space will not be utilized as efficiently and in such
cases, the dentition will become crowded with
out the Leeway space helping to improve.
■
After the exchange of the lateral teeth has been
completed and dental arch upto the first molar is
established, the second permanent molars begin
to erupt. The dental arch length is reduced just
prior to eruption of the second molar by the me
sial force.
■ The arch circumference may also become short
ened than that of the primary dental arch by the
utilization of the leeway space with the exchange
of the second primary molar to the second premo
lar.
■ Therefore, it is quite possible that eruption of
second molar may accentuate the crowding if it
was already present in the dentition.
« Proximal carious lesions or early extraction of sec
ond primary molais, which are very common be
cause of high prevalence of caries for this tooth,
will cause further loss of dental arch space. This
space decreases substantially during the erup
tion period of the second permanent molar and
will significantly affect occlusal relationship.
■ In some cases the permanent molar erupts prior
to the second premolars. If the space after the
extraction ofthe second primaiy molar is not main
tained that space will be lost rapidly. A carefol
monitoring is required.
■
In the permanent dentition, the overbite and over
jet decrease throughout the second decade of
life probably due to relatively greater forward
growth of the mandible.
SELF-CORRECTING ANOMALIES (see below)
Definition
«
Anomaly is defined as marked deviation from
normal.
■
Selfcorrecting anomalies are the anomalies which
arise in the child’s developing dentition during
the period of transition from that of gum pads
stage to the onset of permanent period and get
corrected on their own without any dental treat
ment
I TEXTBOOK OF PEDODONTICS
Clinical considerations
and should be explained in brief the physiology
behind these transitional changes in the dentition.
Therefore, self correcting anomalies are part of de
veloping dentition and should not be considered as
The permanent dentition
any developmental or pathological abnormality. If
The permanent dentition is considered when all the
any apprehension on part of the parents (which is
often seen) the child should be removed promptly ^permanent teeth (all 28 teeth) are seen in the dental
correcting anomalies
1.
Pre-dentate period
a) Retrognathic mandible
b) Anterior open bite
c) Infantile swallowing pattern
II. Primary dentition
1) Anterior deep bite
2) Flush terminal plane
3) Spacing
4) Edge to Edge (due to attrition)
III. Mixed dentition
1) Anterior deep bite
2) Mandible anterior crowding
3) Ugly duckling stage
4) End-on relation
IV. Permanent Dentition
1) Overjet and overbite
Correction (Timing / Factors involved in)
Corrects with differential and forward growth
of the mandible.
Eruption of primary incisors
During the first year of life with introduction of
solid foods in diet.
Correct with:
■ Eruption of deciduous molars
■ Attrition of incisal edges
■ Forward and downward growth of mandible
(Early shift)
■ Eruption of the first permanent molar
■ (Late shift) Leeway space
■ Eruption of first permanent molar t
■ Eruption of permanent inciors
■
■
■
■
■
«
■
■
Proprioceptive response condition of patient
(with the eruption of first permanent molars
and premature contact of the pad of tissue
overlying them as natural bite opener)
Tongue pressure
Increase in intercanine width
Maxillary canine eruption
With eruption of first permanent molars
Late mesial shift in non spaced dentition
Decreases with eruption of all permanent
molars
Differential growth of mandible
SECTION 3 : DEVELOPING DENTITION AND ITS DISTURBANCES |
arches, often by the age of 12 to 14 years of age. The
established interrelationship between permanent
dental arches is by no means the final step in occlu
sal development. After the occlusion of the denti
tion has been established fairly minor changes re
lated to teeth take place in sagittal, transverse and
vertical interrelationship.
« Horizontal overbite decreases
■ Dental arches become shorter due to proximal wear
and often crowding develops in ‘mandibular inci
sor region by 14 years of age.
■ Vertical overbite decreases upto the age of 18
years by 0.5 mm.
■ The alveolar process may grow in height beyond
16 years of age.
■ Ox erjet decreases by 0.7 mm between 12 and 20
years of age.
■ Individual variations are considerable
■ The increase in the dental arches is generally not
continuous.
■ Functional variations influences the occlusal de
velopment.
« The most common sequence of eruption for de
ciduous teeth is: (The values for boys and girls
are combined)
Upper teeth
Lower teeth
Age in months
«
«
Most frequent sequence of eruption in the per
manent dentition (Fig. 3.21 ) is:
Upper teetliô
12
4
53
Lower teeth 1
6
2
34
57
8
6
8
10
12
20
7
8
Age in years
Self-Assessment
1. What is the period of gumpads and what are the
self conecting anomalies seen during this period?
2. What are the intraoral findings seen in a neonate?
3. What are the different types of deciduous denti
tion?
4. What are the different features of deciduous den
tition ?
5. What is flushterminal, mesial step and distal step?
6. What are the self correcting anomalies present
during the period of deciduous dentition?
7. What is the characteristic feature of first transi
tions period?
8. What is the characteristic feature of the second
transitional period?
9. What is the importance of first permanent molar?
10. What is the significance of early mesial shift and
late mesial shift?
~
11 . What is incisal liability?
12. What are the self correcting anomalies of mixed
dentition period?
13. What is the leeway space of the Nance?
14. What is intertransitional period?
15. What is conefunnel mechanism?
Further Suggested Reading For Section - 3
sequence
Fig. 3.21 Favourable eruption sequence.
1. Anton-SC: Developmental age and taxonomic affinity of the Mojokerto child, Java, Indonesia. AmJ-Phys-AnthropoL Apr, 102(4): 497-514,1997
I TEXTBOOK OF PEDODONTICS
2. Ash M.M.:Development of teeth, calcification,
and eruption. Wheelers Dental Anatomy and Oc
clusion. W.B. Saunders Company 1988
3. Bishara-SE; Khadivi-P; Jakobsen-JR: Changes in
tooth size-arch length relationships from the de
ciduous to the permanent dentition: a longitudi
nal studyAm-J-Orthod-Dentofacia 1-0rthop. Dec;
108(6): 607-13,1995
4. Gazi-Coklica-V; Muretic-Z; Brcic-R; Kern-J;
Milicic-A: Craniofacial parameters during growth
from the deciduous to permanent dentition—a
longitudinal study Eur-J-Orthod. 19(6): 681-9,1997
5. J-Clin-Pediatr-Dent. Spring; 21(3): 205-11,1997
6. Kieser-JA; Groeneveld-HT; Da-Silva-PC: Dental
asymmetry, maternal obesity, and smoking. Ant-JPhys-Anthropol. 102(1): 133-9,1997
7. Lewis-AB : Comparisons between dental and skel
etal ages. Angle-Orthod. 61(2): 87-92,1991
8. Manzi-G; Santandrea-E; Passarello-P:Dental size
and shape in the Roman imperial age: two exam
ples from the area of Rome. Am-J-PhysAnthropol. 102(4): 469-79,1997
9. Pahkala-R; Laine-T; Lammi-S: Developmental
stage of the dentition and speech sound produc
tion in a series of first-grade schoolchildren. JCraniofac-Genet-Dev-Biol. 11(3): 170-5,1991
10. Peretz-B; Nevis-N; Smith-P: Morphometric analy
sis of developing crowns of maxillary primary sec
ond molars and permanent first molars in
humans.Arch-Oral-Biol.'43(7): 525-33,1998
11. Rizzuti-N; Scotti-S: A case of hyperodpntia with
twenty-two supernumeraries: its surgical-ortho
dontic treatment. Am-J-Orthod-DentofacialOrthop. 111(5): 471-80,1997
12. Saleemi-MA; Hagg-U; Jalil-F; Zaman-S; Timing
of emergence of individual primary teeth. A prospective longitudinal study of Pakistani
children. Swed-Dent-J.; 18(3): 107-12,1994
13. Seow-WK: A study of the development of the
permanent dentition in very low birthweight
children.Pediatr-Dent. 18(5): 379-84,1996
14. Shapira-L; Tarazi-E; Rosen-L; Bimstein-E: The
relationship between alveolar bone height and
age in the primary dentition. A retrospective lon
gitudinal radiographic study. J-Clin-Periodontol.
22(5): 408-12,1995
15. To-EW: A study of natal teeth in Hong Kong
Chinese. Int-J-Pediatr-Dent 1(2): 73-6,1991
16. Tollaro-I; Baccetti-T; Franchi-L: Floating norms
for the assessment of craniofacial pattern in the
deciduous dentition.Eur-J-Orthod. 18(4): 359-65,
1996
17. Vedtofte-H; Andreasen-JO; Kjaer-I :Arrested
eruption of the permanent lowei second molarEurJ-Orthod. 21(1): 31-40,1999
18. Wölfel J.B., Schied R.C.: Primary Derttition. Den
tal Anatomy - Its Relevance to Dentistry. Williams
and Wilkins. 1997
.SECTION - 4.
Psychological Development
and Behaviour Management
4.1 Theories of Child Psychology
Tandon S
Introduction
Emotion
■ An effective state of consciousness in which joy,
sorrow, fear, hate or the likes are expressed.
■ A feeling or mood manifesting into motor or glan
dular activity.
Behaviour - is any change observed in the function
ing of the organism.
Behaviour management
■ The means by which dental health team effec
tively and efficiently performs treatment for a child
and simultaneously instills a positive denfajattitude in the child (Wright, 1975).
■ It can also be considered as an attempt to alter
the child’s behaviour and emotion in a beneficial
manner according to thelaws of society.
Psychological development is a dynamic process,
which begins at birth and proceeds in an ascending
order through a series of sequential stages manifest
ing into various characteristic behaviour. These
stages are governed by genetic, familial, cultural, in
terpersonal and interpsychic factors. The profes
sional dentist who deals with children and takes the
responsibility of their health care, is a parent surro
gate and can discharge certain aspects of the parent
care to the child, as do the physician and the teacher.
Therefore, a dental clinician needs to understand
several dimensions of child psychological develop
ment in order to relate effectively and to guide the
child patient. The clinician should know what emo
tional and social behaviour to expect from children in
different age groups, and also be able to communi . Importance of Child Psychology
cate on a level consistent with the child’s view of the
world.
■ To understand the chikfbetter.
■ To know the problem of psychological origin.
The aim of this discussion is to understand the vari ■ To deliver dental services in a jneaningful and
ous aspects of child psychology, applied to the den
effective manner.
tal situation for the successful management of the
■ To establish effective communication with the
cliild in dental clinic.
child and the parent.
■ To gain confidence of the child and of the parent.
Definitions
■ To teach the child and the parents importance of
primary and preventive care.
Psychology - is the science dealing with human na■ To have a better treatment planning and interac
ture, function and phenomenon of his soul in the main.
tion with other discipline.
/Child psychology - is the science that deals with the ■ To produce a comfortable environment for the
dental team to work on the patient
mental power or an interaction between the conscious
and subconscious element in a child. >
<FE> I TEXTBOOK OF PEDODONTICS
Theories of Child Psychology
Child psychology theories can be broadly classified
into two groups
1
Psychodynamic theories
- Psychosexual theory - Freud
- Psychosocial theory - Eric Erickson
- Cognitive theory - Piaget
fl. Behavioural theories
- Hierarchy of needs - Maslow
- Social Learning theory - Bandura
- Classicalcpnditioning - Pavlov
- Operant conditioning - Skinner
PSYCHOANALYTICAL THEORY
Sigmond Freud (1905) (Table 4.1)
|
I
I
I
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I
I
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f
|
with memory andjndgement. It is developed after
birth, expands with age_anditdelays, modifies
and controls Id impulses on a realistic level, (real
ity principle).
3. Super Ego: It is the prohibition learned from environment (more from parents and authorities). It
acts as a censor of acceptability of thoughts, feel
ings and behavior. It is determined by regulations
imposed upon the child by parents society, and
culture, (ethics & morals). It is the internalised
control which produces the feeling of shame and
guilt.
The expression of disôomfort as a result of conflict
between the three components of the psychic struc
ture is defined as anxiety.
Oedipus complex.
Sigmond Freud (1905) was the originator of psychoanalytical approach. Freud’s interest in development
arose from his desire to explain the disorders of per- Abung boys have a natural tendency to be attached
to the mother and they considertheir father astheir
sonality in adults. Freud thought the personality to
enemy. Hence they strive to imitate their father to
originate from biological roots, as a result of satisggtfTthe affection of the mother. Freud has also de
faction of a set of instincts of which sexual instinct
scribed oedipal complex as a desire to have sexual
was the most important. He described five psychorelation with the mother. The name of the oedipal
sexual stages. At each stage sexual energy is invested
complex comes from Greek mythology. Oedipus the
in a particular part called an erogenous zone.
King of Thebe, unwittingly slew his father and mar
¿"Psychic struciurejproposed by Freud in Psycho dyried his mother. The little boy adopts his father’s
manners, his attitudes and interests thinking that by
nami^Weory^composed of three parts
becoming like his father he can win his mother’s sexual
L Id: It is the basic structure of personality, which love.
serves as a reservoir of instincts or their mental
representative. It is present at birth, inyulse rid
den and strives for immediate pleasure and gratification. (pleasure principle).
2. Ego: It develops out of Id in the 2nd to 6th month
of life when the infant begins to distinguish be
tween itself and the outside world; it is the media
tion betweenId and super Ego. Unlike Id, Egois
governed by the reality principle. It is concerned
Electra complex
Similarly the young girls develop an attraction to
wards their father and they resent the mother being
close to the father. Freud has reported that little girls
have a comparable Electra complex to resolve this. In
Greek mythology, Electra helped her brother slay the
lover of their father Agemennou, in order to win her
father’s love.
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT | <FE1
Table 4.1: Freud’s Stages of Development
I
N
T
R
O
D
U
C
T
BIRTH
ORAL STAGE
ANAL STAGE
■ Is the 1st experience to
effect personality
development
■ In infants the oral
cavity is the site for
identifying needs.
■ It therefore serves as an
erogenous zone.
■ During this stage, maturation
of neuromuscular coritmP^ —occurs.
« Control over sphincters
particularly anal sphincter
results in increased voluntary
activity.
o
N
« This is a dependent _
■ Abrupt change at birth
stage since the infant
result in psycho
physiological emergency
is dependent on adults
for getting his oral
reactions (protective
needs fulfilled.
shell) similar to fear
and anxiety.
■ The characteristics are
observed in later life
during personality
development and depend
on child’s susceptibility
S
during this period.
T
h « If the neonate gets used
to the stimuli he is no.
c
longer anxious.
s
C
H
A
R
A
C
T
E
R
o
B
J
E
« Development of personal
autonomy and independence.
■ Child realizes his control
over his needs and practices
it with a sense of shame or
self-doubt.
■ The child realizes the
increasing voluntary control,
which provides him with the
sense of independence and
*
autonomy.
■ These reactions help the
child to learn some
adaptive mechanisms
against anxiety
generating stimuli.
■ Satisfaction of oral
desires e.g. suckling of
milk by mother, help in *
development of trust.
■ In later period of life
results in successful
achievements of needs.
■ Neonates who fail to
adapt to abrupt changes
get startled easily.
■ This results in a more
protective mechanism
which is maladaptive in
later life.
■ Anal eroticism and defenses
■ If child's needs are not
against it result in fixation on
adequately met in this
anal function.
stage the following
■ It is characterized by various
traits develop.
abnormal behaviours like:
Excessive optimism,
Disorderliness, Abstinence,
Narcissism, Pessimism,
Stubbornness, Willfulness,
Demandingness, Envy,
Frugality.
Jealousy.
T
V
E
S
P
A
T
H
O
L
0
G
contd.
<Eg> I TEXTBOOK OF PEDODONTICS
PhallicJitage
Latency Stage
Genital Stage
■ It is a transition
between the anal
stage and the
Phallic stage.
■ The stage begins
during the 3rc[year
of life till the 5th
year.
■ Resolution of any
defects occufsTn
this phase.
■ The phase ends jn
puberty.
■ Psychosexual
development"
extends from 11
to 13 yrs. tg_ _
young adulthood.
■ The child derives
pleasures from
exercising
control over the
urinary sphincter.
It is characterized by:
• Maturation of ego
tatesjjJace.
■ Oedipus complex
« Castration anxiety
■ There develops a
greater degree of
■ Penis envy
■ Electra^complex
control over
■ There is an increase in
instinctu.al impulses.
• Child gains better
genital masturbation,
sense of initiative &
accompained with
starts adapting to the
unusual fantasies
adverse environment.
about opposite sex.
Uretheral Stage
■ The objectives are « The child realizes the
sexual qualities with
similar to those of
out embarrassment.
anal stage.
• Resolution of the
stage in regulation of
drive impulse.
■ Loss of urethra
control results in
shame.
■ Competitiveness
• Ambition
■ Sense ofjdentity
develops.
■ Child has a matured
personality.
■ He can satisfy
genital potency
and realizes his
goals for
reproduction
and survival
■ The goal of this phase ■ Matures the
is the further develop
personality of the
ment of personality.
individual.
■ Consolidation of sex
■ Helps to separate
roles occurs.
from the depende
■ These result in
nce on parents.
maturation of ego
■ Their acceptance
and mastery over
of adult role,
skills.
functions with social
expectations and
cultural values.
■ If the above mentioned ■ Lack of inner control
or excessive inner
characteristics are
not resolved the
control result in a
pathological trait.
balance between male
and female roles
■ Lack results in an
immature behaviour
does not develop.
and decreased
development of skills.
■ Unresolved traits
from previous
phases are seen
in a modified
form.
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT | CTO
CLASSICAL CONDITIONING
Pavlov (1927)
Russian psychologist, Ivan Petrovich Pavlov was
one of the first to study conditioned reflexes expe ri
mentally
The crucial element of the conditioning is the rela
tion between the conditioned stimulus and the unconditioned stimulus. The more frequent the pairing
of the conditioned and unconditioned stimulus, the
stronger is the conditioning.
The principles involved in the process are:
1. Generalisation wherein the process of conditioning is evoked by a band of stimuli centered
around a specific conditioned stimulus. Thus a
test stimulus similar to training stimulus results
in a response, e.g. a child who has had a painful
experience with a doctor in a white coat always
associates any doctor in white coat with pain
2. Extinction of the conditioned behaviour results
if the association between the conditioned and
the unconditioned response is not reinforced, e.g.
in the above mentioned example subsequent vis
its to the doctor without any unpleasant experi
ences results in extinction of the fear.
3. Discrimination is the opposite of generalisation.
If the child is exposed to clinic settings which are
different to those associated with the painful ex
periences the child learns to discriminate between
the two clinics and even the generalised response
to any office will be extinguished.
The principles of classical conditioning can be used
in the following areas of animal and human behav
iour:
■ Developing goodJiabits
■ Breaking habits and elimination of conditioned
fear
■ Psychotherapy, to decondition emotional fear
■ Developing positivejattitiides
■ Teaching alphabets
MAHLERISJ'HEORY (1933)
This theoiy categorises the early childhood object
relations to understand personality development.
The period of childhood is thus divided into three
stages:
1. Normal autistic phase
2. Normal symbiotic phase
3. Separation individualisation phase
Normal autistic phase (0 -1 yrs)
■ It is a state of half - sleep, half - wakefulness.
■ This phase involves achievement of equilibrium
with the environment
I
Normal symbiotic phase (3-4 wks. to 4-5 mths.)
• The infant at this stage is slightly aware of the
caretaker but they both are still undifferentiated.
Separation individualisation process (5 to 36mths)
■ This phase is divided into 4 subphases (Table4.2)
1) Differentiation (5 - 10 mths)
2) Practicing period (10-16 mths)
3) Rapproachment (16 - 24 mths)
4) Consolidation and object constancy (24 - 36
mths)
OPERANT CONDITIONING
Skinner (1938)
J»The principles of operant conditioning arises from
the experimental work of Skinner. It has been considered as an extension of classical conditioning. Indi
viduals response is changed as a result of reinforce
ment or extinction ofprevious responses. Hence, sat
isfactory outcome will be repeated while unsatisfac
tory outcomes will diminish in frequency. According
to this theoiy, the consequence of behaviour itself
acts as a stimulus and affects future behaviour. Since
the behaviour acts upon the environment it is called
an operant. Skinner described four basic types of
operant conditioning distinguished by the type of
consequences:
<FIî> I TEXTBOOK OF PEDODONTICS
Table 4.2: Characteristic of Separation Individualisation Sub-Phases.
Differentiation
PracticingJ’eriod
Rapproacbement
Consolidation and
ObjectGonstancy
■ The infant
becomes alert
as cognitive and
neurological
maturation
occurs.
■ Characteristic
anxiety at this
period is stranger
anxiety.
« He differentiates
between self
and other.
■ Beginning of this
phase is marked
by upright
locomotion.
■ The child learns to
separate himself
from mother by
crawling.
« Separation anxiety
is present as the
child still requires
the mother for
safety.
■ The infant, now a
toddler is more
aware of the
physcial
separateness.
■ The child tries to
overcome this by
showing mother his
newly acquired skills.
■ The mother’s efforts to
help toddler are not
successful resulting
in temper tantrums.
■ Rapproachement crisis
develops as the child
wants to be soothed by
the mother but is unable
to accept her help.
■ This crisis is resolved
as the child’s skill
improves.
■ The child achieves a
definite sense of
individuality and is
able to cope up with
the mother’s absence.
■ He does not feel
uncomfortable on
being separated from
the mother since he
knows that she will
return.
■ He develops an
improved sense of
time and can tolerate
delay.
■
1. Positive reinforcement occurs if a pleasant con
sequence follows the response, e.g. a child re
warded for good behaviour following dental treat
ment.
2. Negative reinforcement involves removal of un
pleasant stimuli following a response, e.g. if the
parent gives in to the temper tantrums thrown by
the child, he reinforces this behaviour.
3. Omission refers to removal of the pleasant re
sponse after a particular response, e.g. if the child
misbehaves during the dentalprocedure, his-fa
vourite toy
for a short time result
ing in the omissionofthe undesirable behaviour.
4. Pimishmeiit
of an aversive
stimulus into à sîtuÎtfeBio decrease the undesir
able behaviour, eguBbfpalatalrake incorrec
tion of tongue thrusting habit.
Positive and negative reinforcements are the most
suitable types of operant conditioning for a dental
office while the other two types of operant condi
tioning should be used with caution. One mild form
of punishment that can be used for children is the
“voice control“.
COGNITIVE THEORY
Jean Piaget (1952)
Piaget formulated his theory on how children and
adolescents^think and acquire knowledge. He de
rived his theories from direct observation of children
by questioning them about their thinking. Accord
ing to Piaget, the environment does not shape child
behaviour but the child and adult actively seek to
understandthe environment. This process of adap
tation is made up of 3 functional variants -
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT | Ckfri
limitation concerns with observing, recognizg, taking up an object and relating it with earlier
periences or categories.
tions following adjustments in assimilated knowl
edge so that the facts fit better.
The sequence of development has been categorized
into 4 major stages (Table 4.3):
1) Sensorimotor stage (0 to 2 yrs)
. 2) Pre-operational stage (2 to 6 yrs)
3) Concrete operation stage (6 to 12 yrs)
4) Fonnaloperation stage (11 to 15 yrs)
xommodation accounts for changing concepts
d strategies as a result of new assimilated inrniation. Piaget calls the strategies and mental
tegories as 'schemes’.
|u ilib ration refers to changing basic assump
•le 4.3 : Sequence of development
isorimotor
Pre-Operational
Stage
Concrete Operation
Stage
Formal Operation
Stage
Every child is
>orn with certain
trategies for
iteracting with
he environment,
’hese primitive
•trategies mark
he beginning
•f the thinking
irocess.
‘he child does
iot yet have the
apacity to
epresent
•bjects or people
? himself
lentally.
<s maturation
•rogresses the
imple reflexes
•egin to be
oordinated e.g.
joking along
/¡th arm movelents resulting
r hand watching,
ly 10th mth, veri
ty of elementary
chemes develop
Jbject permanece develops in
ourse of co-ordlating actions &
9peated contacts
rith environment
■ Primitive strateg
ies change as the
child assimilates
new experiences
and accommod
ates original
strategies.
■ The child uses
symbols in
language and
play.
• He learns to
classify things
■ He solves
problems as a
result of intuitive
thinking but
cannot explain
why
« The thinking process
becomes logical.
« He develops the
ability to use
complex mental
operations such as
addition and
subtraction.
» The child is able to
understand others
point of view.
■ Concrete operations
develop based on
the level of under
standing achieved
so far.
■ The child now a
teenager is able to
think still more
abstractly.
w He can consider
a hypothetical
situation.
■ Uses inductive or
deductive logic to
make decisions
and solve problems.
■ He thinks of ideas
and has developed
a vast imagination.
*
1
I TEXTBOOK OF PEDODONTICS
HIERARCHY OF NEEDS
Masler (1954)
Masler believed in the self-actualisation theory, i.e.
the need to understand the totality of a person. He
gave forward the following thoughts
« The needs are arranged in a hierarchy and as one
general type of need is satisfied another higher
order need will emerge. The desires from most
basic biologic needs to the more psychological
ones become important only after basic needs
have been satisfied.
« Motivation is constantly required and is a never
ending, fluctuating complex present in almost all
organisms.
■ Pain avoidance, tension reduction and pleasure
act as sources of motivating behaviour.
Erickson described 8 stages of life cycle which are
marked by internal crises defined as the turning
points /periods.
Table 4.4 Comparison between Erickson’s and
Freud’s Psycholbgicâf stà^es.
""
Erickson concentrated on childjjgvelopmentcov^
ering the entire span of life cycle from infancy to
childhood through old age. UnlikeTreud, Erickson
emphasis the conscious self as much as unconscious
instincts. Despite differences, Freud and Erickson
share some important assumptions.
• Development depends upon child's instincts and
responses of those around him.
■ 11 n resolved is sues Trom early stages of life affect
person’s ability to deal with subsequent stages.
........—1
Age
Erickson’s Psychological
Stages
Freud’s
Psychological
Stages
0-1
Basic trust versus
mistrust - The infant forms
the first trusting relationship
with the caregiver.
Oral stage
2-3
Autonomy versus shame,
doubt - toddler begins to
push for independence.
Anal stage
4-5
Initiative versus guilt The child becomes more
assertive, resulting conflict
causes guilt.
Phallic stage
6-12
Industry versus
inferiority - The child must
learn basic cultural skills
such as school skills.
Latency stage
13-18 Identity versus role
confusion - The child a
teenager now must realize
who he is and what he
shall become.
PSYCHOSOCIAL THEORY
Eric Erickson (1963)
■■■■■■ -
19-25 Intimacy verus isolation The adult realizes the
need for one truly
intimate relationship.
26-50 Generativity versus
stagnation - The adult
rears children or performs
creative act failing which
stagnation occurs.
50+
Ego integrity versus
despair - The adult
integrates earlier stages
and achieves sense of
integrity.
Genital stage
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SOCIAL LEARNING THEORY
Bandura (1963)
Social learning theory is thought to be the most com
plete, clinically useful and theoretically a sophisti
cated form of behaviour therapy. As compared to
Operant and Classical conditioning this theory is:
■ Less r cductionistic
■ Provides more explanatory concepts
■ Encompasses a broader range of phenomena
process but requires cognitive factors and in
volves 4 processes which are:
- Attentional processes ~
- Retention processes
- Reproduction processes
- Motivational-processes
4 Self-re^alation - thisjvstem involves a process
of self-regulation, judgement and evaluation o
individual’s responses to his own behaviour.
Self Assessment
The learning of behaviour is affected by 4 principle
elements:
1. Antecedent determinants - the conditioning is af
fected if the person is aware of what is occurring.
2. Consequent determinants - Person’s perception
and expectancy (cognitive factors) determine be
haviour.
J^Moddling - Learning through observation elimi
nates the trial - error search. It is not an automatic
1.
2.
3.
4.
5.
6.
7.
What is psychic structure?
What is Oedipus complex?
What is Electra complex?
What is psychosocial theory?
What is Jean Piaget theory?
What is operant conditioning?
What is social learning theory?
4.2 Emotional Development
Tandon S
Emotion is a state of mental excitement characterised
by physiological, behavioural changes and altera
tions of feelings. Emotional expressiveness through
bodily movements, facial expressions and
vocalizations are within a human being reported to
be present in an infant through maturity.
Different Emotions at Different Stage of
Life are given in table 4.5
Physiology of Emotion
Development of emotions depends on maturation in
the nervous system and the endocrinal system. Dif
ferences in emotional responsiveness between chil
dren and adults appear to be partly due to cortical
immaturity and partly due to difference in endocrine
output.
• At birth cortex development is completed, frontal
lobe is immature and has little influence on the
functions of the lower parts of the brain resulting
in unbalanced emotions. Hence, emotional re
sponse of the child is quickly aroused but short
lived.
■ In 2 to 5 years and 11-12 years adrenal glands
gain weight rapidly and liberation of adrenaline
in blood is vigorous, as a result of which a
preschooler is highly emotional' and emotional
outbursts are prolonged too, giving rise to physi
ological signs of emotional disturbance.
■ As emotion subsides, parasympathetic energy
conserving system takes over and returns the or
ganisation to normal.
• Activities of the brain in certain regions, includ
ing hypothalamus and other parts of nervous
■
system, directly influence muscles and internal
organs to initiate body changes.
Indirectly stimulating adrenal hormones to other
body charges and prepare the body for fight or
flight response.
Characteristics of commonly seen emotions
in a child
L Distress or Cry:
■ At Birth: Primary emotion present at birth with
vigorous body expressions usually due to hun
ger, colic or any other internal cause.
■ At six month: It is greatly replaced by a milder
expression of fussing or vocalization.
■ During preschool: It is seen less, only for the
reasons of physical pain as he is thwarted by
his environment.
■ During school years: Pressure helps him to
outgrow the crying habit which decreases rap
idly. After this till 15 years crying occurs very
seldom.
■ In young adult: Ultimately it becomes a limited
quiet cry ing in private only for reasons of grief
or other intense emotions.
Different types of cry seen in children:
Sometimes, the different types of cries can be an
asset in diagnosing the behaviour of a child. Fol
lowing four types of crying are usually seen in
children (Elsbach, 1963).
1. Obstinate Crv:
■ The child throws a temper tantrum to
thwart dental treatment.
■ It is loud, high-pitched.
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Table 4.5: Different emotions at different stages of life.
Old age
Infancy
Maturity
Distress
Anxiety
Mature emotions
Grief
Startle
response
Fear
Shame
Anger
Disgust
Jealousy
Disappointment
Restlessness
Joy
Sensitiivity and control
Minimum differentiation
of response of esthetic
feeling
Wony
Self pity
Guilty feeling
Depression
Irritability
Boredom
Delight
Elation
Hopeful anticipation
Affection
Sex
■ Characterized as a siren like wail.
■ This form a belligerent cry, represents the
child’s external response to anxiety.
2. Frightened Cry
■ Usually accompanied by a torrent of tears.
■ Convulsive breath-catching sobs.
■ Usually the child emitting this type of cry
has been over-whelmed by the situation. *
3. Hurt Cry
■ May be loud, more frequently.
t
« Frequently accompanied by a s 111411
whimper.
■ Initially a child in discomfort shows a
single tear filling from the comer of the eye
and running down the child’s cheek with
out making any sound or resistance to the
treatment procedure.
4. Compensatory Cry
■ It is not a cry at all.
■ It is a sound that child makes to drown out
the noise for example a drill.
Mystical
Ecstasy
Possessive
Satisfaction
Benevolence
Sensuousness
■ Usually the ciy sound is slow, monotone.
■ It is a sort of coping mechanism to unpleas
ant auditory stimuli, finding himselfuncom
fortable in the situation.
IL Anger
Outburst of the emotion is caused by the child’s
lack of skill in handling the situation. Infants and
young children respond in anger in a direct and
primitive manner but as they develop the re
sponses become violent and more symbolic, for
example
■ 15 months children express anger by throwing
objects.
■ Two year olds attack other children with an
intention to hurt.
■ Four years old express their anger through beg
ging■ Five years old, have less expression of anger.
■ Six years old have a renewa l of violent meth
ods of expression of anger.
■ Seven year ones display less aggressiveness,
though kicking, throwing objects is observed.
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■ 8-9 years old’s anger is expressed through feel
ings. It becomes directed towards a single per
son.
■ 10 years old’s anger may become violent and
may be expressed physically.
■ 12 year olds express anger verbally.
■ 14 years olds may take out his anger on some
one else.
HL Fear
Fear is a reaction to a known danger (augmenting
the fight or flight response). Its source is the con
sciousness.
It may be defined as an unpleasant emotion or
effect consisting of psychophysiological changes
in response to realistic threat or danger to one’s
own experience.
Prevalence of Fear
«. Various studies have found the incidence of
dental fear to be 3-21%, depending on the age
of the child.
■ Girls have been reported to have more fears
than boys.
Several reasons suggested are
■ An inherent timidity in girls.
« Girls are encouraged to display fear while boys
are encouraged to hide it.
■ The fears have also been reported to increase
from infancy to young childhood. At the same
time, the type of fear varies at different ages
such as:
Development of fear
a. At birth:
■ This is a primary response acquired soon
after birth such as a startle response, how
ever, the newborn is unaware of the
stimulus.
■ With age he starts becoming aware of fear
producing stimuli and can adjust to the
isolated experience by resorting to flight if
he cannot solve the problem.
■ -Sometimes, the smells and sounds of equip
ment or even the appearance of dentist with
glasses and mask may be frightening.
h. Pre schooler(2-5 years)
■ Fear of animals or being left alone or aban
doned.
■ More apprehensive about failures, learns
to fear his prestige.
c Early schooler
Fear of the dark, staying alone. Shows fear of
supernatural powers like ghosts and witches,
imaginary objects and situations such as fear
of war, spies, beggars, etc.
d. Late schooler
■ By age of 9, fear of bodily injury may be
present.
• Fear of failure, not being liked, competition,
fear of punishment.
■ Fear of crowds, heights.
e. Adolescent
Fear of social rejection and fear of perform
ance (peer group pressures, academic pur
suits).
t
Fear of Dental Situation
It is observed that fearful patients usually report
a history of traumatic dental experiences. Unfa
vourable family attitudes and transmission of
these may also result in fear. Thus, various types
of fears can be observed in the clinic as:
L Innate fear (without stimuli or previous expe
rience): It is thus also dependent on the vul
nerability of the individual.
BL Subjective fear: Fears transmitted to the indi
vidual are termed subjective fears. They may
due to:
- Family experiences, peer (friends), informa
tion media (TV, papers, comics).
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ffl. Objective fear: Fears due to events, objects
and specific conditioning. Previous experience
(dental trauma) or generalization (medical ex
perience).
Fear Evoking Dental Stimuli
Various dental stimuli evoke fear. It is observed
that the most feared events in the dental clinic
can be ranked as:
■ Anaesthetic administration locally by injection.
■ Extraction.
« Sound of drill.
Factors Causing Dental Fear
An interaction of various factors occurs in the
existence of dental fear such.as:
1. Fear of pain or its anticipation.
2. A lack of trust or fear of betrayal.
3. Fear of loss of control.
4. Fear of the unknown.
5. Fear of intrusion.
Features of Fear
Fear is a package of reactions that tend to occur
together simultaneously or sequentially. About
70% children acquire dental fear at early age. This
emotion may present the following main two
expressions:
1. Tendency to freeze which reaches its extreme
in the form of death.
2. Startle, scream, run away from the scene of
danger, i.e. flight.
It turns, a shift from freeze reaction to flight.
I
Symptoms of Intense Fear:
■ Unpleasant feeling of terror.
« An urge to cry or hide.
■ Pounding of the heart.
■ Tense muscles.
■ Liability to startle
■ Dryness of the throat and mouth.
■ Sinking feeling.
■ Nauseous feeling.
■ Urge to urinate (very common in children).
■ Irritability.
■ Anger
■ Weakness
■ Sense of unreality.
Chronic fear leads to
—■
,
■ Tiredness.
■ Difficulty in sleeping and bad dream
■ Restlessness
■ Loss of appetite
■ Aggression
■ Avoidance of tension producing situation.
Physiological Sign of Fear
■ Pale sweaty skin.
■ Hair standing on end
■ Dilatation of pupils.
■ Rapid breathing.
■ Increased heart-rate.
■ Rising blood pressure.
■ Increased blood flow through muscles.
■ Contraction of the bladder and the rectum.
Biochemical Changes in Few Minutes
■ Secretion of adrenaline.
■ Secretion of noradrenaline.
■ Increase in free fatty and corticosteroids in
plasma.
Response to fear
It can be described at three level:
1. Intellectual levelz Where the child is reatty to
accept the situation and face the difficulties to
achieve results and benefits (usually seen at
adolescent age).
2. Emotional level: Usually the child shows the
fight or flight response, which acts as an in
stantaneous response (seen in school age).
3. Hedonic level: Usually reflected as self
centeredness, thereby accepting what is com
fortable and rejecting what is not without too
much concern for the outcome or nature of the
treatment (may be seen in a very young
<EE> | TEXTBOOK OF PEDODONTICS
children). It may be expressed through so
matic complains or chronic fatigue in the eld
erly group.
IV Anxiety
« Is an emotion similar to fear but arising with
out any objective source of danger.
« Is a reaction to unknown danger.
« It is often been defined as a state of unpleas
ant feeling combined with an associated feel
ing of impending doom or danger from within
rather than from without.
■ It is a learned process being in response to
one’s environment. As anxiety depends on
the ability to imagine, it develops later than
fear.
Sub-types of anxiety
Association
This is a process of classic conditioning whereby
previously neutral stimuli become the cause for
arousal and anxiety by pairing them with pain or
the negative experiences of others.
Attribution
Arousal in the biological sphere.
Appraisal
Here anxiety is concerned with cognition or the
way we think. It involves reconstruction of nega
tive experiences rather than positive happenings
that account for the arousal of anxiety.
first visit or the learning involved in dental anxi
ety may have been more indirect, depending upon
the experience of other people. Maternal anxiety
plays an important role in the chi Id’s anxiety level
determinant. A mother with higher anxiety, will
have a child usually showing a negative behav
iour as a result of his high level of anxiety.
Biological difference
Some people are ’more predisposed to become
more anxious or to learn about anxiety responses
than others due to the innate biological mecha
nism.
Types of anxiety7
Trait anxietv
Is a lifelong pattern of anxiety7 as a temperament
feature. These children are generally jittery, skit
tish, hypersensitive to stimuli.
State anxietv
Are acute situationally bound episodes of anxi
ety that do not persist beyond the provoking situ
ation.
Free floating anxiety
s
is a condition of persistently anxious mood in
which the cause of emotion is unknown and many
other thoughts or events trigger the anxiety.
Situational anxiety
Seen only to specific situations or objects.
Cause of Anxiety
Uncertainity
Fear of unknown is anxiety provoking. In dental
clinic, new patient’s anxiety can be due to the
uncertainity they feel about what awaits them af
ter initial first appointment Check up.
Previous learning
In such cases anxiety is present due to their pre
vious learning experiences of trauma during the
General anxiety
Where the individual experiences a chronic per
vasive feeling of anxiousness wha tever the exter
nal circumstances.
Anxiety Rating Scale
The patient’s anxiety can be evaluated through
the following scales:
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2 - Feeling scared but co-operates
3 - Feeling scared reluctant
to co-operative
Fig. 4.1 Anxiety Scale
4 - Feels very scared
un-cooperative, requires
physical restrains
CEE) I TEXTBOOK OF PJEDODONTICS
L Pictorial and Response Card
The scale evaluates the child’s fear in the den
tal set-up in different situations such as:
- appointment with the dentist
- waiting for his turn in the dentist’s office
- dental procedures
- lying on bed dreaming about the dentist, etc.
The scale gives 5 options graded 0 to 4, from
relaxed to panic behaviour depicted by vari
ous pictures (Fig. 4.1)
0- relaxed
1 - uneasy
2 - Feeling scared but cooperative
3 - feeling scared and uncooperative
4 - feeling ven’ scared, uncooperative, requires
physical restrain.
The child is shown pictures and encouraged
to represent his feelings.
Verbal Questions
The child is asked questions or given “sen
tence completion tasks” to verbalize his fear.
Negative or reluctant answers imply fear while
positive opinions imply non-fearful child.
K Questionnaire
Anxiety can also be evaluated by answers to
the questionnaire given to the child patient
and the parent. The questions help to deter
mine the attitude and experiences of both the
patient and parent.
V Phobia
■ Is an irrational fear resulting in the conscious
avoidance of a specific feared object, activity
or situation.
■ It may be defined as a persistent, excessive,
unreasonable fear of a specific object, activity
or situation that results in a compelling desire
to avoid the dreaded object.
Characteristics of phobia
■ Being out of proportion to the stimulus or situ
ation (not age appropriate).
■ Cannot be reasoned with
■ Being out of voluntary control
■ Persistent and unadaptable.
Types of Phobia
Shelhan (1982) divided'anxiety and phobia into
two major groups.
1. Exogenous (non-endogenous)
2. Endogenous
Non-endogenous:
This is a psychologically affected group who
involve a situation related anticipatory anxiety
symptoms such as:
■ Moist palms
■ Flattery stomach
■ Fine hand tremors
■ Shaky inside
■ Rapid heart beat
These are the symptoms seenwhen normal indi
viduals are stressed or threatened. The main cause
is in the external environment. It is an anxiety or
phobia due to a factor “to be produced from the
outside”. Thus, the individual can readily iden
tify the etiological agent.
Endogenous
This anxiety is present without any prior warning
or the presence of any detectable stress situa
tion. The cause is “to be produced from within”.
This type of anxiety has a more Severe cluster of
symptoms such as:
■ Light headedness or dizziness.
■ Difficulty in breathing
■ Parasthesia
■ Hyper-ventilation
■ Chest pain
■ Losing control
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT |
Other causes of Phobia
Based on the causative factor they can be
classified into three major categories:
L Simple Phobia
Is an isolated fear of a single object or situa
tion leading to avoidance of the object of tile
situation; The fear is irrational and excessive
but not always disabling. Some of the phobias
are:
Height
Acrophobia
Open space
Agoraphobia
Spider
Arachnophobia
People
Anthropophobia
Water
Aquaphobia (hydro)
Lightening
Astraphobia
Closed space
Claustrophobia
Dog
Cynophobia
Animals
Zoophobia
Darkness
Nyctophobia
Pyrophobia
Fire
Stranger
Xenophobia
■ Another common phobia is of darkness, a fear
experienced by children between the age of 4
and 6 years. This is most likely due to the
imagination of the child as to various creatures
lurking out in the dark.
« School phobia is an exaggerated fear of attend
ing school and occurs in all children peaking
around 11-12 years. A fearof the various ac
tivities connected to school such as new faces
and challenges, fear of leaving home.
■ In 12 years children of both sexes, previous
aversive dental experiences are more closely
related to dental phobia than general fear.
■ At adolescent period most children outgrow
their fear. Two phobias commonly seen are
fear of blushing and fear of being looked at.
FEAR ASSESSMENTS
The children’s Dental fear picture test
(Klingberg, 1994)
The children’s dental fear picture test (CDFP) con
sists of three different subtests:
■ The dental setting pictures (CDFP-DS)
■ The pointing pictures (CDFP-PP)
■ A sentence completion task (CDFP-SC)
2. Situational Phobia
Is popularly interpreted as a fear of open space,
but has wider implications. It usually refers to
a cluster of complaints. In addition to open or
crowded places they also fear public transport,
bridges, tunnels, being alone at home or being The dental setting pictures contain a set of ten picaway from home etc.
* tures (ISO A4 size papers) of animals in different
Characteristics
progressively more stress evoking dental care situa
Dizziness, loss of bladder control or bowel con tions. The pictures are presented to the child in nu
trol, cardiac distress.
4
merical order and the child is encouraged to tel l a
story about each picture. The following instructions
X Social Phobia
are given: Tell me a story about what is happening in
Is basically phobia due to the fear of being
the picture.
looked at and the concern about appearing
shameful or stupid in presence of others. Main
The cards depict the following themes:
types of social phobia are public speaking, fear
■ A baby bear brushing his teeth in the bathroom,
of eating, fearof blushing.
supervised by an adult bear.
Phobia in Childhood
■ A puppy and an adult dog walking in the street,
■ The most common phobia in childhood is the
one of the houses in the street accomodates a
fea r of animals. This usually comes on between
dental office.
the age of 2 and 4 and is gone before the age of ■ A baby lion and an adult lion in the dentist’s wait
10 years.
ing room.
ŒLJ I TEXTBOOK OF PEDODONTICS
■
■
«
«
■
■
■
A baby bear shaking hands with the dentist.
A baby cat sitting alone in the dental chair.
A bear lying in the dental chain opening his mouth
wide, and looking at the dental .instruments.
A dentist examining the teeth and holding instru
ments in the mouth of a puppy.
A dentist drilling a tooth of a puppy, dental as
sistant standing beside the chair.
A dentist giving a dental hygiene instruction to a
kitten.
A puppy being rewarded by the dentist after the
treatment.
The pointing pictures contain a set of five pictures
- (ISO A4 size papers) showing a (human) child in five
different dentally related situation.
« Just before going to the dentist
« The dentist examining the mouth
« The dentist giving an injection
■ The dentist drilling
■ Ly i ng in bed about to fa II asleep/dreaming about
dentists.
Each card shows two different reactions; one happy,
non-fcarful child, and one sad and fearful child. Four
rings of different sizes are situated below each pic
ture. representing four different feelings or answers
to'the picture: very happy and not the least afraid;
feeling very much afraid; feeling somewhat afraid;
feeling very very much afraid. Answers are given
verbally as well as by pointing to the ring represent
ing the child’s choice. The answers represent scores
ranging from 1 (veityliappy and not the least afraid)
to 4 (very much afraid). Thus, the test can give a
possible score rattgingfrQin 5 to 20.
The child is encouraged to give an answer on how
he or she would feel, being in the same situation as
the child in the picture. Each set of pictures is con
structed in two versions; one for boys and one for
girls.
The sentence completion task contains fifteen in
complete sentences, which are read to the child con
secutively. The child is instructed to complete the
sentences by saving the first word or words that
come to mind.
The above method can also be used with computer
aided hand mounted display of virtual realities.
Self-Assessment
What is the emotion present at birth?
Define fear?
What is imitative fear?
What is the difference between anxiety and pho
bia?
i
5. What are the different types of cries?
6. How does a two year old boy express his anger
-*
1.
2.
3.
4.
4.3 Behavioural Science and its Application
in Pediatric Dentistry
PaulU, TandonS
Introduction
Behavioural dentistry is an interdisciplinary science
which needs to be learned, practiced and reinforced
in the context of clinical care and within the commu
nity oral health care delivery system. The objectives
of this science is to develop in a dental practitioner
an understanding of the interpersonal, intrapersonal,
social forces that influence the patients behavior.
The clinician must acquire this knowledge to develop
appropriate behavioral skills with an improved qual
ity of communication and management of patients.
Behavioral dentistry also teaches to develop a rec
ognition and understanding that the body and mind
are not separate entities, and focuses on patients so
cial, emotional and physiological dental experiences.
Definitions
Behaviour: is an observable act, which can be de
scribed in similar ways by more than one person. It
is defined as any change observed in the function
ing ofan organism. Learning as related to behaviour
is a process in which past experience or practice re
sults in relatively permanent changes in an individu
al’s behaviour.
Behavioural science: is the science which deals with
the observation of behavioural habits of man and
lower animals in various physical and social envi
ronment including behaviour pedodontics, psychol
ogy, sociology and social anthropology.
Behavioural Pedodontics: It is a study of science which
helps to understand development of fear, anxiety and
anger as it applies to child in the dental situations.
Classification of child’s behaviour observed in
dental clinic (Table 4.6) —-
Wilson’s classification (1933)
a) Normal or bold: The child is brave enough to
face new situations, is co-operative, and friendly
with the dentist.
b) Tasteful or timid: The child is shy, but does not
interfere with the dental procedures.
c) Hysterical or rebellious: Child is influenced by
home environment - throws temper-tantrums and
is rebellious.
<5 Nervous or fearful: The child is tense and anx
ious, fears dentistry.
Frankel’s classification (1%2) (Frankel’s behaviour rating scale)
Rating
Behaviour
Refuses treatrnenf cries forcefully,
extremely negative behavior
associated with fear.
Reluctant to accept treatment and
displays evidence of slight
(-)
negativism
3. Positive Accepts treatment, but if the child has
a bad experience during treatment,
(+)
may become uncooperative
4. Definitely Unique behavior, looks forward to and
understands the importance of good
positive
preventive care
1. Definitely
negative.
(--)
2. Negative
<EH> I TEXTBOOK-OF PEDODONTICS
Table 4.6: Classification of child’s behaviour observed in dental clinic
Co-operativelsehavioT
Lacking co-operation
Disruptive behavior
■ Positive
■ Disabled physically
■ Seductive or demanding
■ Potentially cooperative ' J ■ Medically compromised
■ .Cooperative with
reservation (timid
child)
« Mentally disabled
Lampshire (1970)
1. Cchoperative: The child is physically and emo
tionally relaxed. Is co-operative throughout the
entire procedure.
2. Tense cooperative: The child is tensed, and co
operative at the same time.
3. Outwardly apprehensive: Avoids treatment ini
tially, usually hides behind the mother, avoids
looking or talking to the dentist. Eventually ac
cepts dental treatment.
4. Fearful: Requires considerable support so as to
overcome the fears of dental treatment.
5. Stubborn/Defiant: Passively resists treatment by
using techniques that have been successful in
other situations.
6. Hypermotive: The child is acutely agitated and
resorts to screaming kicking etc.
7. Handicapped: Physically/mentally, emotionally
handicapped.
8. Emotionally immature
Classification given by Wright (1975)
A Cooperative (Positive Behaviour)
a) Cooperative Behaviour
Child is cooperative, relaxed with minimal
apprehension.
■ Obsessive or resistant
■ Angry or aggressive
■ Somatizing behavior
■ Dissociation or psychotic
behavior
■ Depressed behavior
■ Addictive behavior (now-a-days
very common in adolescents)
- Drug abuse
- Eating disorder
b) Lacking cooperative ability
Usually seen in young child, (0-3 yrs.), disa
bled child, physical and mental handicap.
c) Potentially cooperative
Has the potential to cooperate, but because of
the inherent fears (subjective/objective) the
child does not cooperate.
B. Un-cooperative (Negative behaviour)
a) Uncontrolled/Hysterical/Incorrigible
Usually seen in:
<
- Preschool children at their first dental visit
- Temper tantrums i.e., physical lashing out
of legs and arms, loud crying and refuses
to cooperate with the dentist.
b) Defiant behavior/obstinate behavior
- This type can be seen in any age group.
- Usually in spoilt or stubborn children.
- These children can be made co-operative.
c) Tense co-operative
- These children are the borderline between
positive and negative behavior.
- Does not resist treatment but the child is
tensed at mind.
d) Timid behavior/shy
- Usually seen in a overprotective child at
the first visit
- Is shy but cooperative
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT I CSI
e) Whining type: Complaining type of behaviour
allows for treatment but complains through
out the procedure.
f) Stoic behavior: Seen in physically abused chil
dren. They are cooperative and passively ac
cept all treatment without any facial expres
sion.
Factors which affect child’s behaviour in the dental
office: (Table 4.7)
I. UNDER THE CONTROL OF THE DENTIST
1. Dental clinic:
■ Dental office should be warm and simulate a
homely environment Healthy communication
with the child should be^established. A pleas
ant environment helps the children to be relieved
of anxiety about the dental situation (Fig. 4.2).
■ The operating environment should be made
colorfuljand lively with posters. TV-and
\ridepgames and a separate waiting room for
the children is necessary and this should con
tain toys, for all age groups, story books and
comics.
• It should have a separate exit and an entry
door. Dental auxiliary should be kind to the
' children and should greet them with a smile.
■ Appointment time should always be short, i.e.
less than 30-min. Early morning appo^mtriiehts
Fig. 4.2 Developing rapport with the child patient.
are piWerable for younger children. Children
should not be kept waiting for too long in the
waiting area because they tend to become rest
less.
■ No long appointments are given to children
because of a trend towards deterioration of
behavior towards the end of the treatment pe
riod.
« Preparatioiiof theehild to the dental clinics
can be done by use oftelephone/letter/paniphlets. This decreases the anxiety of die child.
2. Effect of dentist’s activity and attitudes
The dentist should form a good impression on die
child. He/she should avoid jerky, and quick move-
Table 4.7: Factors which affect child’s behaviour in the dental office
Under the control of
the dentist
Out of control of the dentist
Under the control of die parents
Effect of dental office
environ nyent.
Growth and development
Home environment
Effect of dentist’s activity
and attitudes.
Nutritional factors
Family development and peer
influence
Dentist’s attire
Past dental experiences
Maternal behavior
Presence/absence of
parents in the operatory
Genetics
Presence of an older
sibling
School environment Socio
economic status.
Œ0> I TEXTBOOK OF PEDODONTICS
mcnts and should be fluent in his words and
actions.
Jenks (1964) has described six categories of ac
tivities by which the dentist can foster or enhance
cooperation in children. They are:
a. Data gathering and observation
b. Structuring
c. Extefnalization
d. Empathyand support
e. Flexible authority
f Educationandtraining
a. Data gathering and observation
This involves collecting the type of informa
tion about a childandhis parents that can be
obtained by a formal or informal office inter
view or by a written questionnaire. Observa
tion includes noting the behavior of the child
as he steps into the dental office during his
tory taking and while the dental procedure is
being carried out.
b< Structuring: Refers to establishing certain
guidelines of behavior set by the dentist and
his team to the child so that the child knows
what to expect and how to react. For example
the dentist explains to the child in a language
that he understands, the importance of the den
tal treatmehtahd~its purpose. He also pre
pares the child for each phase of the treatment
in advance.
c Extern alization : It is a process by which the
child’s attention isjocussed away from the
sensa^tions„jS5Q£iated wiHrihedental treat
ment. There are two components of externa lization:
- distraction
- involvement
The objective is to interest and involve the
child but at the same time not to let him into
verbal or motor discharges which might inter
fere with the necessary procedure.
d Empathy and support: Empathy is the capacity
to understand and to experience the feelings
of another without losing one’s own objectiv
ity. Dentists should noFbe totally engrossed
in the technical aspect of therapy. They must
have the sensitivity and capacity to respond
to the child’s feelings. He/she can achieve
this by the following examples:
- permitting the child to express their feel
ings without rejection
- communicating to the child that their
reactions are understood
- comforting the child when it is needed
- encouraging children when they show
acceptable behavior
- listening to the child’s comments when
they wish to talk.
e. Flexible authority: This includes compromises
made by the dentist to meet the needs of the
particular patient.
£ Education and training: The dentist should im
plement a program which both educates children and their parents as to what constitutes
good dental health and which stimulates them
to make the behavioral changed necessary to
achieve these goals.
3. Effect of dentist’s attire: If a chi Id has previously
experienced a stressful situation which includes
the presence of someone in white attire such as a
physician, the mere presence of a white clothed
individual would be sufficient to evoke a nega
tive behavior.
4. Presence or absence of parents in the operators:
This depends on the behavior of the child, parent
and dentist. Mother’s presence isessential for a
preschool child, handicappedchild etc. An older
child does not require mother’s presence because
of emotional independence of these children as
they grow older. Dentists are usually comfort
able and relaxed when parents are in the recep
tion room.
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT |
5. Presence of an older sibling: An older sibling
serves as a role model in a dental situation. This
again depends on the age of the patient. Presence
3f an older sibling has:
■ little effect on behavior of a 3 year old patient
i no effect in case of 5 year old patients
■ most noticeable effect among 4 year olds
OUT OF CONTROL OF THE DENTIST
L Growth and development
■ If therelslideficlenc}' in physical growth and
development or congenital malforh^tions, e.g.
cleft lip, as awareness^ of the deformity increases it leads to psychological trauma due
to rejection by the society.
■ Mental retardation, epilepsy, cerebral palsy etc.
.Here, the
make the child mentally handica]
child cannot react to the requirements of the
mother and the expectations_of the society.
Hence, there is a failure of cognitive develop
ment and therefore variations in the behavior
are encountered.
■ Also, a venr young child reacts very differ
ently and the same response may be trans
formed to a positive behavior, as the child
grovvsolde£^TIiusthcintellectual age of 3
years seems to be that point in developmental
progress that signifies a maturational readi
ness to accept dental treatment.
L Nutritional factors
■ Studies have shown that an increased intake
of sugarcausesan irritable behavior“
■ Hypogiy^nja causes a criminal behavior
■ Skipping breakfast leads to an impaired per
formance
■ Nutritional deficiency also affects the mile
stones of biological and cognitive develop
ment
>. Past medical and dental experiences
Any past unpleasant dental experience, prior hos
pitalization, surgicaHntervention, sickness, etc.,
are associated with a high degree of uncoopera
tive behavior. Therefore the emotional quality of
past visits rather than the number of visits is sig
nificant.
4. Genetics
« Genetics plays a very important role in psy
chological development.
■ This genetic influence is again modified tty the
environment i e.; there should be a constant
interaction between genetic programme ofthe
child and environment for the psychological
development of the child.
5. School environment
50% of the child’s development is affected by
school and thejetMim^5()%by the home envi
ronment. In the school, teachers and peers help
to influence the behavior of the younger children.
Also, seniors become role models to the juniors.
6. Socio-economic status
■ High socio-economic status child may develop
normally because the family can provide all
the necessary requirements to aid in a normal
psy chologic development. On the other hand,
this child may also become spoilt if he always
gets what he wants..
■ A low socio-economic status - child develops
resentment and is tensed as the child gets lit
tle attention and is often neglected. It also can
directly affect the child’s attitude towards the
value of dental health.
III. UNDER THE CONTROL OFTHE PARENTS
1. Home environment:
■ The home is the first school where a child
learns to behave. All the home individuals
influence the child’s behavio£ but none so
much as the mother, e.g. in case of a broken
home, the child may feel insecure, inferior,
apathic and depressed. Mother child relationship has been described as one-tailed. «
■ Postnatal behavior of the child d^»^ ^
the prenatal emotional status
tlte
«ED I TEXTBOOK OF PEDODONTICS
Maternal influences on personality development
2. Family development and peer influences:
Parental characteristics are viewed as unilateral in
■ Position of the child, status of the child in the
fluences on the developing child and is described as
family, parental attitudes can influence the
child’s behavior. Over indulgence by parents,
one tailed’. Most of the relevant mother-child relacan lead to a spoilt behavior in the child^who “ tionship fall into 2 broad category
a. Autonomy vs. control
may show sudden outbursts and temper tan
b. Hostility vs love
trums.
■ Internal family conflicts affect children’s
Mothers who allowed enough autonomy, and who
behavior. The child can sense disharmony in
expressed affection had children who were friendly,
the family and this can emotionally fnistrate
and cooperative. Punitive mothers and those who
the child.
ignored their children did not have sons who exhib
ited these positive behavioral features.
Sibling relationship influences child behavior
as follows:
Maternal attitude and child’s behavior
Older sibling
Mother’s
Child’s behavior
behavior
I
Sabotage younger child's
adaptiveness
Sibling
Rivalry
Misbehavior by the child in
the dental office
The younger child always tries to follow the model
of the older sibling and family members thus show
ing the same behavior of siblings.
3. Maternal behavior:
■ Maternal influence on the children’s
physical and emotional development begins
even before birth.
■ Somatic development of the foetus depends
on the nutritional status of the mother.
■ Neurohormonal system of mother transfers
emotion tp the foetus.
■ Postnatal behavior of the child is linked to pre
natal emotional status of the expectant mother,
e.g. Emotional stress during pregnancy can
lead to ail excessively active and irritable in
fant.
■ Agents such as
and
keratogenic/totipotentdrugsaffect the child’s
development if coiisumed durin^thepregna^. )
Overprotective
dominant
Shy, submissive, anxious
Over indulgent Aggressive, demanding, display
of temper tantrums
Rejecting
Usually well behaved, but may
be unable to cooperate, shy,
may cry easily
t
Aggressive, overactive, disobedient
Authoritarian
Evasive and dawdling
Under
affectionate
1. Overprotective mother
■ There is usually a close relationship between
the mother and the child: both physical & emo
tional interdependence from birth to 4 years.
« Exaggeration of this love and affection leads
to overprotection, which is harmful to the nor
mal psychological development of the child;
overprotection is seen in children whose moth
ers are ox er indulgent or dominating. They give
everything to the child so that the child is to
tally dependent.
Causes of oyerprotection:
a. Mothers who have conceived a child after a
long time.
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT |
b. Only child.
c. Sick child/handicapped child.
d. Financial reasonsfetc
Features of auoverprotection and dominance in
child
■ The overprotected child is not permitted to use
his own initiativeorniakedecisions forTiimself.
■ The mother takes active part in his social ac
tivities. The child does not leam to cope with
the problems and anxieties of life.
■ The child is submissive, shy, ajixious and fears
new situations, lacks in self-confidence. These
children may be co-operative but it may be dif
ficult to create a good rapport with the child.
They are polite, obedient, disciplined.
Management
■ Create self-confidence in the child
■ Familiarize the child with the clinic, and the
dentist’s auxiliaries
■ Tell-show-do technique
Z. Overp rotective - overindulgent mother
Features of the child:
■ The child is aggressive, demanding, display
temper tantrums, if their wishes are not met.
These children expect constant attention and
services.
■ They are used to getting their way at home
They are obstinate, stubborn, spoilt. These
children will try to dominate over the dentist
and demanding. They demonstrate angiy out
burst if their demands are not met with. These
children are well behaved and well adjusted
but the dentist will be unable to establish a
good rapport with the child.
J. Under affectionate mother
Here, the child is devoid of love and care. Under
affection varies from mild detachment to neglect
and this may begin during pregnancy or later in
childhood.
Features of the child:
The child appears to be well behaved and well
adjusted. They are shy and it is difficult to estab
lish a good rapport, and may be uncooperative to
dental treatment However, through affection and
love the child may be made to respond.
Causes for under affection
a) Unwanted child
b) Childbirth was not anticipated
c) Hampers the mother’s career and ambitions
d) Unhappy mother because of absent father due
to death, divorce etc. Lack of attention
e) Emotional problems
Rejecting mother
This may be in the form of physical violence or
verbal ridicule
Neglect manifests as:
a) Physical punishment, violence, especially in
the uneducated mothers. Battered baby syn
drome.
b) Refusal to spend time with the child
c) Refusal to spend money on the child
d) Neglect child’s health
e) Emotional and physical neglect
Features of the child
a) Ол ег reactive, revoltmg. aggressive, disobe
dient
b) Tries to gain attention of others by showing
overt behaviors
c) These children are constantly criticized,
nagged, tortured with displays of displeasure.
d) Lack of self-esteem
e) They are most difficult to deal in the clinic be
cause outwardly they are well behaved and
adjusted but are emotionally insecure.
Management
a) Develop confidence in the child by shoeing
love and care.
b) Meet their demands as soon as possibly
I TEXTBOOK OF PEDODONTICS
5. Authoritarian mother
The mother is very authoritarian and has^otcgrtain norms forlhe child to follow. This may vary
from physical abuse to verbal ridicule.
Behaviour modification: is defined as the attempt to
alter human behaviour and emotion in a beneficial
way and in accordance with the laws of learning.
Behaviourmanagement cobejJ^^
Features of the child:
a) Submission withresentment and later evasion
b) Evasive, dawdling child, obeys commands slowly
and with delay.
c) Parents are not supportive to the child and rather
criticize them. Therefore, these children are often
afraid of dentist and resist dental treatment.
d) The child shows a heightened avoidance gradi
ent and seeks to evade or delay the response.
Effects of maternal anxiety
a) Attitudes and experiences of one’s family in rela
tion to dentistry seem to be the most important
factor in determining how an individual will react
to dentistry.
b) People who come to thé dentist conditioned to
respond with tension and fear do so chiefly be
cause of the way dentistry is presented to them
in their homes.
c) The mother’s reaction to dental treatment has a
profound influence on the child’s attitude towards
dentistry. Highly anxious mothers may have their
children displaying negative and uncooperative
behaviors.
BEHAVIOUR MANAGEMENT
Definitions
Behaviour management: is defined as the means by
which thedcntal health team effectiveiv aiidjefîiciently performs dental treatment and thereby instills
a positive dental attitude (Wright 1975).
Behaviour shaping: is the procedure which slowly
develops behavior by reinforcing a successive ap
proximation of the desired behaviour untiTtHe desired behaviour comes into being.
■ Non pharmacological (Psychological Approach)
■ JPh^n^btowfl’"
Non-phannacological methods of behaviour manage
ment
1. Communication
2. Behaviour shaping (modification)
a) Desensitization
b) Modelling
c) Contingencymanagenient
3. Behaviour management
a) Audio analgesiab) Bibfeed back
c) Voice control
d) Hypnosise) Humorf) Coping.
g) Relaxation
h) Implosion therapy
\
i) Aversive conditioning
Pharmacological method of behaviour management
1. Pre-medication
a) Sedatives ahff hypnotics
b) Anti-anxiety drugs
c) Antihistamines
2. Conscious sedation
3. General anesthesia
Communicative management
■ Communicative management is universally used
in pediatric dentistry with both the co-operative
and uncooperative child (Chambers 1976).
■ It comprises the most fundamental form of be
haviour management in that it is the basis for es
tablishing a relationship with the child which may
allow a successful completion of dental proce
dures and at the same time, may help the child
develop positive attitudes towards dental care.
S
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT | <!TO
■
It is the means by which the dentist gets his point
across, making himself understood by the use of
words or expressions. One should always try to
establish communication from the first entry into
the reception area.
Sitting and speaking at the eye level allows for a
friendlier atmosphere.
■ Communication is a multisensory process, which
includes a transmitter, the spoken word is the me
dium and the pediatric patient is the reiver;
Types of communication:
a) Verbal communication is by speech
a) Nonverbal (multisensory communication) is by:
- Body language
- Smiling
- Eye contact
- Expression of feelings without speaking
- Showing concern
- By touching the child
- Giving him a pat
- Giving a hug
:) Both using verbal and non-verbal.
Use of euphemisms: Euphemisms are substitute
words, which can be used in the presence of chil
dren.
How to communicate?
■ Communication should be comfortable and reJææd.
i Language that is chosen should contain words
that express pleasantness, friendship and con
cern. Verbal effects are delineated through selec
tion of words and/or sounds, tone of voice and
voice infection (Korch 1972).
1 ^rt>al communication is best for younger children more than 3 years of age. Voice that is used
, shoulcTbeconstant and gentle. Tone of voice
can express empathy and firmness. Content of
the conversation should be such that from the
very beginning the dentist should make the child
feel that we are his well wishers. The conversa
tion should include asking the child’s name, age,
class and background
i The patient always prefers to be addressed by
his name.
i Compliment him about his appearance. Ask questions about his class,fris likes/dislikes. Commu
nication should be from a single source, either
between the dentist and the child or the child and
the dental assistant to avoid confusion. The child
is very sensitive to expression changes.
■
Choice of words, which is used by the dentist or
staff influence the emotional status of the child.
Therefore the use of euphemism7reframing is very
important while addressing to the child.
■ Anaesthetic solution is referred as water to put
the teeth to sleep.
Cariesls7elg®das a tooth bug
Rubberdam as a raincoat
■ Radiograph as tooth picture
Reframing: It is defined as taking a situation out
side the frame that up to that moment contained the
individual in différait conditions, and visualize
(reframe) it in a xwy acceptable to the person in
volved and with this reframing, such that both the
original threat and the threatened situation can be
safely abandoned <Beiyai Hill Peretz 1999).
The dental office/reception/waitingarea is a medium
of communication, which sends messages to the pa
tients. A friendly a
the child can be made Swi fortable with the environ
ment. In younger children, nonverbal communica
tion is more important.
Behaviour shaping
■ It involves the use of selected reinforces that
being learned will hopefully change a child’s
behavior from an inappropriate to an appropriate
form. This is based on the “stimulus-response”
theory. For example when a child enters the reception room and associates this with a previous
dental experience which was unpleasant, the
child’s’ internal responses would be fear and
ety while the external response would be crying.
<EE>"I TEXTBOOK OF PEDODONTICS
■
This is a step-by-step procedure to make the child
involved in dental therapy. When shaping the
behavior the dentist is teaching a child to be
have. These children needloTbe communicative
and cooperative to absorb information that may
be complex to them. Children cannot always grasp
the overall procedure with a single explanation.
Therefore it is necessary to divide the explana
tion for the procedure and consequently have to
be led through the procedure slowly; it is neces
sary to riiake all explanations at the child’s level
of understanding by an appropriate use of eu
phemisms.
Behaviour modification involves three techniques.
1. Desensitization
«“Joseph Wolpe (T975) used to remove fears and
tension in children who have had previous un
pleasant dental experience or negative
behavior.
« Desensitization is accomplished byjeaching
the child a competing response such as relaxa.tion and then introducing progressively more
threatening stimuli.
■ It is ah effective method for reducing a mala
daptive behavior.
• Systemic desensitization is effective because
the patient learns to substitute an appropriate
or adaptive emotional response (relaxation) for
an inappropriate or maladaptive response anxiety.
Method popularly used now-a-days for modifying
the behavior by desensitization in children is:
Tell ShowDotechnique (TSP) (Fig. 4.3a)
>^Addleslon 1959, introduced the concept of Tell,
Show, Do.
■ Tell and^show every step and instrument and
explain what is going to be done.
■ Continuously and in grades from the least fear
promoting object or procedure and move in
higher grades to more fearful objects.
■ By having verbal (tell) and nonverbal (show
and do) interactions, available, one can over-
come the many small dental related anxieties
of any chi ld.
Indications
a) Firstvigit '
b) Subsequent visits when i ntroducing new den
tal procedure
c) Fearful child
d) Apprehensive child because of information
received from parents/peers
TSD technique is applied as follows:
a) The dentist using the language that the child
can understand and tell the patient what is to
be done, it is presented slowly and repeatedly.
b) The dentist demonstrates the procedure to the
child using a mrfdel or himself and is done
slowly.
c) The dentist proceeds to do the dental proce
dure exactly as described.
This is effective in children more than 3 years of
age.
%
2. Modeling (Fig. 4.3b)
Introduced by Bandura (1969) developed from so
cial-learning principle procedure involves allow
ing a patienttoobserve one or more individuals
(models) w ho demonstrate a positive behavior in
a particular situation; Therefore the patient will
frequently’ imitiate the models behavior when placed
in a similar situation. Modeling can be done by:
aJJLive~models - siblings, parents of child etc.
bTFilmed models
c) Posters
. d) AudioyisuaLaids
Learning through modeling is effective when:
a) Observer is in a state of arousal.
b) When the model lias relatively more status and
prestige.
c) When there are positive consequences asso
ciated with models behavior.
■ Modeling technique seems to improve the
behavior of apprehensive children who
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT |
Fig. 4.3a Behaviour modification by
Tell Show Do Technique
Fig. 4.4 Involving the child in
watching his favourite program on
TV. fixed on ceiling at eye level
(which also serves as a distraction
technique)
Fig. 4.3b Behaviour modification by Modelling
Fig. 4.5 Hand over mouth technique
for aversive conditioning
CEE) I TEXTBOOK OF PEDODONTICS
■
have had no previous dental experience
(Klarman R1980).
An important advantage of live modeling
is that no additional equipment; personnel
or alterations in the dental routine are
required.
3. Contingency management
It is a method of modifying the behavior of childrenby presentation or withdrawal of reinforcers.
These reinforcers can be:
a) Positive reinforcer: is one whose contingent
presentation increases the frequency of
behavior (Hemy W Fields 1984).
b) Negative reinforcer: is one whose contingent
withdrawalincreases the frequency of behavior
(Stokes and Kenndy 1980). Negative reinforcer
is usually a termination of an aversive stimu
lus e.g.: withdrawal of the mother.
j
|
|
Types of reinforcements can be
a) Social: for e.g. praise, positive facial expression, physical contact by shaking hand, holding hand, and patting shoulder or back.
b) Material: may be given in the form of toys,
games. Sweets are not given - as reward since
it causes caries.
c) Activity reinforcers: Involving the child in
some activity like watching a TV show/special
programmes with him. For the benefit of con
tingency management-social reinforcers are the
most effective.
Behaviour management
• Behaviour management should go hand in hand
with the hand piece skills and knowledge of den
tal materials for the successful treatment of chil
dren. Disruptive behaviour can interfere signifi
cantly with providing quality dental care, result
ing in increased delivery time and risk of injury to
the child. Surveys of clinicians have found that
dentists consider the uncooperative child to be
among the most troublesome problems in clinical
practice. Recent findings suggest that nearly one
in four children (22%) seen by pediatric dentists
may present marked management problems.
■
■
Behaviour management methods in pediatric den
tistry are directed towards the goals of communi
cation and education. The relationship between
the dentist and the child is built through a dy
namic process of dialogue, facial expression, and
voice tone; all methods of delivering a message.
The goals of behaviour management are to
achieve good dental health in the child and to
help develop the child’s positive attitude towards
dental health.
Behaviour management is thus not an applica
tion of individual techniques created to deal with
the child, but rather a comprehensive methodol
ogy meant to develop a relationship between the
patient and the doctor which ultimately builds
trust and allays fears and anxieties.
Child can be managed by the following methods:
1. Audio analgesia: or" white noise” is a method of
reducing pain. This technique consists of pro
viding a sound stimulus of such intensify that
the patient finds it difficult to attend to anything
else (Gardner, Licklider, 1959). Auditory stimulus
such as pleasant music has been used to reduce
stress and also reduce the reaction to pain.
2. Biofeed back: involves the use of certain instrunientstodetect certain physiological processes
associated with fear (Buonomono, 1979).
For example if blood pressure is high the instru
ment gives stimulation and the subject is taught
to control the signals, therefore it is useful in anxi
ety and stress related disorders. Electroencepha
logram, electromyography can also be used in
bio-feed back.
3. Humor: helps to elevate the mood of the child,
which helps the child to relax. Functions of humor :
a) Social: forming and maintaining a relationship
b) Emotional: Anxiety relief in the child, parent
and doctor.
c) Informative: Transmits essential information in
a non-threatening way.
d) Motivation: It increases the interest and in
volvement of the child.
e) Cognitive: distraction from fearful stimuli
(Fig. 4.4).
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT |
4. Coping: It is the mechanism by which the child
copes up with the dental treatment.(It is defined
aisTliTcognitive and behavioral efforts made by
an ^dividual to master, tolerate or reduce stress
fill situations (Lazaue 1980). Patients under stress
prefer to draw comfort or reassurance from an
authority figure. Thus establishing a close or
trusting relationship with the doctor or nurse.
Coping effects may be of two types
a) Behavioural: are physical and-veibal activities
in which the child engages to overcome a
stressful situation.
b) Cognitive: The child may be silent and think
ing in his mind to keep calm. Cognitive coping
strategies can enable the children to:
■ Maintain realistic perspective on the events
at hand (reality-oriented working)
■ Perceive the situation as less threatening
(cognitive reappraisal)
■ Calms and reassures themselves that
everything will be all right (emotion regu
lating cognitions) (Sandra L Cuny (1988).
Signal system: This method is followed in our
clinic wherein as a part of coping, when it hurts,
we ask the child to raisejusjiand as suggested
byMusslemann 1991.
The normal coping mechanism utilized by den
tists to reduce pain and tension are friendliness,
support and reassurance.
5. Voice control
■ It is the modification of intensity and pitch of
one’s own voice in an attempt to dominate the
interaction between the dentist and the child.
■ Used in conjunction with some form of physi
cal restraints and hand-over-mouth exercise.
(HOME) is considered as acceptable by the
parents for nearly all-dental procedures (Henry
and Marilyn 1984).
« Change in tone from gentbLiafirm is effective
in gaining the child’s attention and reminding
him that the dentist is an authority figure to be
obeyed:
6. Relaxation This technique is used to reduce
stress and is based on the principle of elimination
of aiixietyRdaxation involves a series of basic
exercises, which may take several months to learn,
and which require the patient to practise at home
for at least 15 min per (fay.
7. Hypnosis: Hypnosis is an altered state of con
sciousness characterized by a heightened sug
gestibility to produce desirable behavioraTand
physiological changes. Hypnosis is one of the
most effective nonpharmacologic therapies that
can be used with children for a number of differ
ent procedures (Romanson, 1981). When used in
dentistry, it can be termed as hypnodontics
(Richardson 1980) or psychosomatic or sugges
tion therapy. Greatest benefit of hypnosis is to
reduce anxiety and pain.
8. Implosion therapy: Sudden flooding with a barrage of stimuli which have affected him adversely
and the child lias no other choice but to face the
stimuli until a negative response disappears. Im
plosion therapy mainly comprises of HOME, voice
control and physical restraints.
9. Aversive conditioning
Child who displays a negativebehavior and does
not respond to moderate behavior modification
technique falls into the category5
*7 of Frankel’s de
finitive negative behavior. Aversive conditioning
can be a safe and effective method of managing
extremely negative behavior. Those dentists who
contemplate using it should obtain parental con
sent prior to its use (Patricia P Hagan 1984). Two
common methods used in the clinical practice are
HOME and physical restraint:
A HOME (Hand over mouth exercise)
The behavior modification method of aversive
conditioning is also known as HOME. Introduced
by Evangeline Jordan 1920 (Fig. 4.5)
The purpose of HOME is to gain
a child so that communication canbe
<EF> | TEXTBOOK OF PEDODONTICS
Indications:
■ A healthy child who can understand but who
exhibits defiance and hysterical behavior dur
ing treatment.
■ 3.-6.ycaxsjOld^r
• A child who can understand simple .verbal com-
■ Children displaying uncontrollable behavior
Contraindications
■ Child under 3 years of age
■ Handicapped cluld/iinniature child, frightened
child
■« Physical,jnental and emotional handicap
Factors to be considered before applying HOME
technique
« HOME technique should not be used as a rou
tine procedure for the man'a^^iffpf the child.
« Inform’The’parents about the procedure.
« Consent of the parents is very important.
« Pediatric dentists should be aware of the
changing laws that govern inform consent
(Hagan 1984, Nash 1988, Scott 1991).
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Technique: After determining the child’s
behavior, the dentist firmly places his hand over^
the child’s mouth and behavioral expectations are
I
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calmly expfaineddoseto the child’s ear. When
the child’s verbal outburst is completely stopped
and the child indicates liis willingness to co-operate, the dentist removes his hand. Once the
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child co-operates, he should be complimented for
being quiet and praised for^good^ehayiorTlt
^-^shouid be noted that the child’s airway js not
restricted while performing the technique and the
whole procedure should not last for more than
20-30 sec.
Several variations of HOME
■ Hand over mouth with the airway unrestricted
« Handover mouth and the nose and the airway
restricted
• Towel held over the mouth only
■ Dry towel held over thenose and mouth
■ Wet towel held over the nose and mouth
HO MAR (airway restricted)
■ The advantagc behind airway restriction is that
the child will be quiet so as to breathe and the
screaming will decrease so that the doctor can
proceed.
■ Together witkTumdoyer mouth nostrils arc
pinched for 15 sec.
■ Bela nger 1993, believed that airway restrict ion
was the critical element and it should be
avoided.
B. Physical restraints: Last resort for handling un
cooperative patients or handicapped patients.
Restraints are usually needed for children who
are hypermotive. st ubborn or defiant (Kelly 1976).
The child is seated in the mother’s lap and one of
the mothers hand is placed on child’s forehead
while the other hand isglaced on both thc child’s
wrists. Physical restraints involve restriction of
movement of the child’s head, hands, feets or
body. Itcan be:
■ active - restraints performed by the dentist,
slalf or pa rentwithout the aid of a restraining
device.
« passive - with the aid of restraining device
i
Types of restraint:
a) For body
- Pedi wrap
-—
1
^Papoose board
- Sheets
- Beanbag with straps
- Towel and tapes
b) For extremities -Velcro straps
- Posey straps
- Towel and tape
c) For the head
- Head positioner
- Forearm body support
d) Mouth
-Mouthblocks
-Banded tongue blades
-Mouth props are used at the time of local
anesthesia to prevent child from closing
his mouth. Mouth props can also be used for:
- Physical/mental handicapped child.
- Young child who cannot keep the
mouth open for a long time.
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Child becoming extremely fatigued
because of long appointments and
frequently closes his mouth.
c) Others - Straps arc attached to dental unit to
restrain a child at the chest w aist and
legs. It is used mainly to control the
activity of mentally or physically
handicapped patients.
- Sheets: are also used to restrict
patient’s movements. This type of
restraint does not secure the child to
the dental chair unless an additional
sheet is used to tie around the
patient and the chair.
- Papoose board/Pedi wrap
Self-Assessment
1. Défi ne behavioural science?
2. What are the factors that influence the child’s
behaviour in the dental office?
3. What is timid behaviour?
4. What is Frankel s behaviour rating?
5: Wliat is the behaviour of a neglected child?
6. What are the causes of overprotection?
7. What is contingency management?
8. Differentiate between behaviour management and
behaviour modification,?
9. What is desensitization?
10. What is Tell Show Do approach?
11. What is audio analgesia / white noise?
12. Wliat is aversive conditioning?
13. Wliat is HOME technique?
14. What is stimulus-response theory?
15. What is hypnodontics?
16. What is voice control technique?
4.4 Pharmacologic Means of Patient
Management
Kevin Allen (late), Stephen S
The performance of painless procedures for the child
is one of the key factors in establishing a good rap
port. To this effect the use of pharmacologic means
has made dental treatment acceptable to a large
extent. These procedures can be carried out in the
normal circumstances with the help of behavior
shaping techniques.
In cases of disruptive behaviour, the use of behavior
management techniques can also be used. Unfortu
nately in some cases, it may not be possible either
due to the patient lacking cooperation or the sys
temic background of the patient demands that phar
macological means be used. The use of sedation,
relative analgesia or general anesthesia may be war
ranted in these cases, depending on the compliance
of the patient and the procedures required.
Terminologies
American Dental Association [1993] has defined as:
1. Conscious sedation - a minimally depressed level
of consciousness, that retains the patient's
ability to maintain an airway independently and
respond appropriately to physical stimulation and
verbal command.
2. Deep sedation - a controlled state of depressed
consciousness, accompanied by a partial loss of
protective reflexes, including inability to respond
purposefully to a verbal command.
3. General anesthesia - a controlled state of uncon
sciousness, accompanied by partial or complete
loss of protective reflexes, including inability to
maintain an airway independently and respond
purposefully to physical stimulation or verbal
command.
4. Ambulatory, outpatient or day care anesthesia
refers to the delivery of anesthetic care in which
patients are discharged home on the day of treat
ment.
SEDATION
The use of sedation is advocated in children lacking
cooperation for the short duration procedures. The
use of sedative agents can also be done in cases
where premedication is required as in cases of gen
eral anesthesia. This serves the purpose of making
the treatment more acceptable and less anxiety prone.
The various routes of commonly used sedatives have
been given in table 4.8
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Table 4.8: Sedation [Routes and Agents]
Routes of administration
Indications and benefits
Limitations and risks
1. Inhalation: [Nitrous
oxide]
■ Can be used for mild to
moderate.levels, of anxiety
■ Analgesia for brief, comfortable
procedures
■ Rapid onset and early
elimination and recovery
■ The duration of action can be
easily controlled
■ Agent has weak potency
■ It can be used to decrease
the anxiety levels, but not in
children with severe behavior
problems
■ Also cannot be used in
claustrophobic patients,
respiratory tract infections.
IL Oral [Several drugs
are used]
■ Can be used for preoperative “
sedation« Used for all levels of anxiety
■ Better acceptability and ease of.
administration
■ The incidence of ARD is less
■ Delayed onset of action .
coupled with unpredicatable
absorption
■ Depends on patient
compliance
■ Difficulty in dertermining
drug dosage
■ Trained personnel
proficient in management
of unconscious patient
required
A Hydroxyzine
[Vistaril]
[25 mg/5cc]
■ Mild sedative along with
antiemetic and anticholinergic
action
■ Potentiates narcotic and CNS
depressants
■ Better used in combination
with other agents
B. Promethazine
[Phenergan]
[12.5 mg/5cc,
2.5 mg/5cc]
■ Same as above
■ For mild levels of anxiety only
■ Better used in combination
Ç. Chloral hydrate
[Noctec]
[500 mg/5cc]
« For all levels of anxiety
■ Long working time
■ Believed to have *a wide range
of safety
■ Not recommended in
children below 6 years of age
■ Agitation common in the latent
period and as effects
dissipate
« No analgesia
■ Maximum dose not to exceed
1500 mg
D. Meperidine
[Demerol]
[50 mg/5cc]
■ Best used in combination for
1. Brief procedures with
promethazine or hydroxyzine
2. Longer procedures with
chloral hydrate
■ Poor oral absorption
■ Contraindicated in children with
COPD, Hypothyroid or liver
dysfunction
♦
confd.
I TEXTBOOK OF PEDODONTICS
Routes of administration
Indications and benefits
Limitations and risks
E. Diazepam [Valium]
[5 mg/5cc elixir,
2, 5, 10, 15 - mg
tablets]
■ Safe agent for mild to moderate
anxiety particularly in children
with cerebral palsy, mental
retardation
■ Children less than 6 years of age
■ Oral absorption equally good as
parenteral
■ Multiple doses required to
achieve sedation
■ Not effective in severe anxiety
when used alone
F. Triazolam [Halcion]
0.125, 0.25 mg tablets]
■ In addition has anticonvujgant
activity
■ Good oral absorption
■ Safety guidelines not fully
established
G. Chorpromazine
[Thorazine]
[10 mg/mlsyrup, 10,
25, 50, 100, 200
mg tablets]
■ Used in combination [Lytic
cocktail] with meperidine or
promethazine
■ Useful in severe behavioural
problems
■ Unpredicatable and less
studied
III. Intramuscular
■ Rapid onset of aciton
■ More reliable with little patient
compliance
■ Injection required and will not
be liked by children
■ May cause injury during
administration
■ Limited control over
reversibility
1. Ketamine
[Ketalar]
[10 and 50 mg/ml]
■ Dissociative anesthesia where
a cataleptic state can be induced
■ Potent analgesic
■ Potential for oral use
■ Safety of oral use not yet
established
2. Midazolam
[Versed]
[1 and 5 mg/ml]
■ Possesses hypnotic,
anticonvulsant and muscle
relaxant properties as well as
being antegrade amnesic and
anxiolytic
■ Greater potency as compared to
diazepam
■ Rapid onset of action
■ Little data for effective dose
in pediatric context
■ Used mainly for short
procedures.
IV. Intravenous
[commonly used is
Midazolam]
■ Most rapid onset of action
■ Permits titration and is easily
reversible
■ Maintains a line for emergency
drugs
■ feest for invasive procedures Of
short duration
« Requires extensive armament
arium, training [specially in
pediatric cases due to anatomic
and behavioural considerations]
■ Precautions to be taken in
significant hepatic or thyroid
disease.
■ Rectal, submucosal or subcutaneous are rarely used.
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT |
Fig. 4.6a Quantiflex for relative
analgesia.
CONCIOUS SEDATION [RELATIVE’ANALGESIA]
As a dentist, one must decide for oneself, what rep
resents acceptable behaviour. The judicious use of
conscious sedation has its place in dentistry, but it
can also be abused. Conscious sedation is useful
if long procedures are advocated for a nervous and
apprehensive child. But it does not approach the
problem of teaching the child to accept the dental
situation as an experience that he or she must meet
several times^a year for the rest of his or her life.
Thus it should be used in conjunction with the
psychologic means of behaviour management. What
really happens in relative analgesia is that the pa
tients threshold to pain, cold, warmth aid light touch
is raised. Thus, although the special senses may be
partly obtunded and a sensation numbness is de
scribed,superficial and deep reflexes remain active
and the sensorium remains clear (Fig. 4.6a, b).
Objectives
Benett [1978] has stated the objectives to be:
1. The patients mood should be altered.
Fig. 4.6 b Quantiftex for relative
analgesia.
2. Patient should be conscious, respond to verbal
stimuli.
3. Patient should be co-operative.
4. All protective reflexes intact.
5. Vital signs stable and normal.
6. Child’s pain threshold should be increased.
7. Amnesia should occur.
Indications
■
«
a
Patients who cannot cooperate or understand for
definitive treatment
~
Patient lacking cooperation because of lade of
psychological or emotional maturity
Patients with dental care requirements but are fear
ful and anxious
Contra-indications
Chronic obstructive pulmonary disorder [COPD],
pregnancy, myasthenia, epilepsy, obesity, bleed
ing disorders.
Uncooperative patients, unwilling, unaccompanied
Dental difficulties prolonged surgery, iris Tire» uate
personnel
I TEXTBOOK OF PEDODONTICS
Nitrous oxidé - O,X mixture for conscious sedation
Stages of anesthesia and conscious; sedation
This is the most widely used form of conscious se
dation using inhalation of the gases.
■ Roberts in 1990 has constructed a triad of ele
ments in relative analgesia (Inhalational) O2/N2O
gas mixtures (low to moderate as per the patient) .
• The three elements of importance stated were:
1. The administration of low to moderate con
centrations of nitrous-oxide, carefully titrated
to the patients need.
2. The patient is simultaneously subjected to a
steady flow of reassuring and semi-hypnotic
suggestion.
3. The use of equipment, such that it is not
possible toadminister 100% nitrous oxide ac
cidentally or deliberately.
The stages of anesthesia have been described by
several authors but the same may not always be
possible to delineate during the procedure. How
ever during conscious sedation it is important to
monitor the stages, since the contact with the
patient should be maintained at all times.
Pharmacology ofNf)
a. The patient at rest has tidal volume of 6-8 liters.
With anxiety this increases. Thus it is necessary
to establish flow rate as per the patients tidal
volume.
Capacity of the lungs
R at e/m inute
Tidal volume
Average tidal
volume/minute
Adults 12-16/m
500 cc
7 liters
Child 20-24/m
200-250CC
5 liters
Infant 25-30/m
100-175cc
3 liters
b. Nitrous oxide is carried in a simple solution in the
body and does not enter any chemical combina
tion i.e. its solubility in blood is extremely low.
Thus free state is high and a rapid equilibrium
between alveolar and arterial tension takes place,
and the onset as well as elimination occurs in a
few minutes.
c. It is a weak GA gas and cannot produce full gen
eral anesthesia on its own. But it is an excellent
analgesic.
Plane 1 - moderate sedation and analgesia
Achieved with concentrations of 5 -25% N2O (95 75%).
■ As the patient inhales, reassure that the symp
toms may not be felt. When the symptoms are
felt, specially in children the instructions have
to be adapted to the terminology understood.
Simultaneously, it is also important to use sug
gestion. For example, it important to connote a
floating, light feeling.
■ patient may sense dizziness.
■ Patient may feel tingling in the fingers, toes,
cheeks, tongue, back head or chest.
■ Marked sense of relaxation, the pain threshold is
raised.
\
■ Diminution of fear and anxiety occurs.
■ Hearing, vision also impaired but pupils are
normal and contract when a light is shown.
■ Perioral musculature is also relaxed.
■
Plane II- dissociation sedation and analgesia.
■
■
■
■
■
■
Concentrations of25-45%.
May or may not experience symptoms.
Psychological symptoms such as dissociation or
detachment are felt. A euphoric state, similar to
alcoholic intoxication (the laughing gas parties).
The patient is suffused by a warm wave and may
experience a slight humming or buzzing in the
ear, with a ‘floaty’ feeling.
Reduction in blink rate.
Patient has pleasant dreams and has a level of
psychosedation with a leg, hand sliding off the
chair.
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■
Patient is conscious and responds to questions,
with however a considerable mental effort in
volved in thinking.
Plane-IV: many develop beyond 65-85%
Light anesthesia - contact with patient lost.
NITROUS OXIDE HAZARDS
Plane-Ill: Total Anesthesia (Analgesia)
■
■
■
■
■
Achieved with 45-65% concentrations
Analgesia is complete. Patients may undergo
extraction procedure.
Marked amnesia develops.
Zone between analgesia and light anesthesia.
Federmesser has subdivided this into 3 planes.
a Lightest plane - state where a kaleidoscope
of images and thoughts are present
b. Somnolent state- where contact is still main
tained. If deeper planes are readied, nasal air
removed and the patient is asked to breathe
ambient air. He/she will return to lighter plane
in 15-20 seconds, or reduce to 10-15% N2O if
slower regression is desired. The open mouth
sign, where the patient has the ability to re
spond by keeping his mouth open by himself.
Thus never use mouth props, as this may not
enable to assess this sign.
c. Deepest plane - the patient carries put only
the simplest of commands only after repeated
several times.
Several hazards have been reported such as :
■ Forthe Patient
1. If enclosed spaces - contraindicated such as
pneumothorax.
2. Upper Respiratory Tract Infection,
3. Respective depression where respiration is on
CO2 drive, as O2 increase will diminish this drive
e.g. Bleomycin therapy -pulmonary fibrosis.
4. Pregnancy as spontaneous abortions may
occur.
5. Diffusion hypoxia, which can be avoided by
keeping the patient on 100% oxygen.
■
Patients/personnel
1. DNA synthesis affected - Vitamin B12 oxida
tion may be suppressed even with brief expo
sures (continuous inhalation of N2) of at least
6 hours.
2. Altered Hematopoesis, pernicious Anaemia.
Thus the procedure of concious sedation has
to be carried out with the maximum precau-
Table 4.9: Differences between Concious Sedation and General Anesthesia
♦
Concious Sedation
General Anesthesia
« At several visits the procedure may
be performed
<
« Patient is cooperative, but anxious and
fearful
■ Generally no extensive investigations are
required. No premedication is required
either.
■ Patient is conscious and contract is
maintained
■ Airway is maintained
■ No mortality
■ Recuperation period is 1-2 minutes
■ NPO not required
« Patient feels he is in control of the
situation
■ Generally a single sitting, once in a
lifetime procedure
« Patient is uncooperative
■ At least basic investigations are a
must. Premedication is also required
■ Ventilation is required
■ 99% success rate reported
■ Time consuming procedure
■ NPO strict
■ Patient cannot control the situation
<M>> | TEXTBOOK OF PEDODONT1CS
lions. The use of scavenging systems have
been advocated to reduce or eliminate nitrous
oxide.
■
■
Differences between concious sedation and gen
eral anaesthesia are given in table 4.9
■
GENERAL ANESTHÉSIA
■
Certain conditions or situations exist where the man
agement of the patient is difficult or impossible with
the psychological means alone. These patients gen
erally as a last resort and as a single sitting proce
dure may be managed by means of general anesthesia
(Fig. 4.7)
Chairside general anesthesia [day care, office or
ambulatory anesthesia]
■
indications for General Anaesthesia
■
Patients wherein local anesthesia is not effective
or the patient is allergic to it.
Patients who have sustained extensive orofacial
trauma.
Fearfiil, uncooperative, anxious patient with no
expectation that behaviour will improve.
Patients with dental needs who would other
wise receive comprehensive dental care eg: rural
areas.
Patients with certain physical, mental or medi
cally compromising condition
■
In the practice of pediatric dentistry, generally
ASA I or ASA II patients can be taken up for
chairside general anesthesia, where in the proce
dure may be taken up on an OPD basis, and pa
tient discharged the same day. However, depend
ing on the recover»7 from anesthesia, the patients
may sometimes have to make an overnight stay.
Our experience suggests that the three common
reasons for the use of general anesthesia are
handicapped or mentally retarded children, un
cooperative child, and inability to come for fre
quent visits.
,
’
« **
*
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» í**
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Reasons for administration of GA are given in
table 4.10
t
PREANESTHETIC EVALUATION AND PROCEDURES
Fig. 4.7 Dental procedure under chair side
general anaesthesia
The American Association of Pediatric Dentistry
[ 1985] has laid down the following guidelines for the
documentation to be done prior to treatment.
Table 4.10: Reasons for administation of GA
Group
No.
Reasons
Percentage
1
45
Handicapped/medically compromised
39.14 %
2
27
Uncooperative/lacking cooperative ability
23.48 %
3
43
Coming from far/inability for repeated visits
37'40 %
Tharian
and Tandon
(1995)
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT |
Instructions to parents
Cardiovascular systems
The practitioner should provide verbal and written
instructions to the parents. It should include expla
nation of potential/anticipated postoperative behav
iour and limitation of activities along with dietary
precautions. 24-hour contact number should be pro
vided.
1. Oxygen consumption is higher in a child than the
adult, resulting in higher metabolic rate. Thus
when apnea develops, hypoxemia develops more
rapidly.
Preoperative health assessment
It should be done within 2 weeks prior to the proce
dure, to be reviewed at the time of treatment. It should
include:
i.
Health history : a review of the medical informa
tion available should be performed. The patient
should be evaluated for
■ Histories of allergies/allergic reactions.
■ Current medications, including dose, time,
route and site of administration.
■ Diseases, disorders or abnormalities.
« Previous hospitalization.
■ Family history is also important and may act
as pointers.
2. Rather than stroke volume, cardiac output in the
child depends more on heart rate. Thus bradycar
dia is a much more serious sign.
Renal
The Glomerular Filteration Rate [GFR] is less in chil
dren. Thus the fluid electrolyte balance is delicately
maintained. For this purpose the various kidney dis
orders are to be ruled out.
Bleeding and other disorders
Are to be ruled out to prevent any complications,
GIT system for the refluxing and regurgitation phe
nomena, Endocrine and metabolic disorders to pre
vent exacerbation of the sa me.
SPECIAL CONDITIONS
it Review of systems: the respiratory and cardio
vascular systems are very important. The visuali
zation of larynx is important for laryngoscopy and
thus the Malampati classification is used for pre
dicting the larynx visible on the basis of how much
the tongue and soft palate can be seen.
PEDIATRIC CONSIDERATIONS
Respiratory systems
Pediatric airways are smaller than adult airways and
shaped differently. The trachea is shorter and the
narrowest part lies below vocal cords. Also the
tongue is relatively enlarged and posterior displace
ment of the tongue may cause complete airway ob
struction (also enlarged tonsil tissue). Lower airway
is more complaint and supported by less cartilage.
Thus airway obstruction is easier.
1. Diabetes and NPO considerations.
1. Attention deficit and hyperactivity disorder
[ADHD] Generally occurring in age 7 to 9 years,
when diagnosed may present with difficult *
pre
operative period. Also medications methyl
phenidate and clonidine may have interaction.
2. Mental retardation - biggest obstacle is history
as they are placed in care of someone other than
family
3. Down x syndrome - macroglossia and the airway
management is a problem.
4. Cerebral palsy ~ Stoetling and Durdorf [1993]
have reported that such patients have a propen
sity for gastroesophageal reflux and poor laryn-
lifîfrl | TEXTBOOK OF PEDODONTICS
geal and pharyngeal reflexes. Thus they are more
prone to aspiration. Also hypothermia may be a
problem.
5. Dentinogenesis imperfecta - loose teeth cause
concern during intubation. Besides, hyperther
mia may also be present.
Emergency
E -Emergency operation - any of the above class
operated as an emergency (e.g.II E would indicate an
ASA II patient being taken up as an-emergency
procedure)
Vital signs - pulse and BP to be recorded. Normal
paediatric vital signs are given in table 4.11
Risk assessment
In 1963 American Society of Anesthesiologists
[ASA]. Classification given is:-
: No organic, physiologic, biochemical or
psychiatric disturbance. The pathology
for which operation is to be performed is
localized and is not a systemic
disturbance.
Class II : Mild to moderate systemic disturbance
caused either by condition itself or by
other pathophysiological processes.
ClassIII / Severe systemic disturbance, even
though it may not be possible to define
the degree of disability with finality.
Class IV: Severe life threatening, not always
correctable by the operative procedure.
Class V : Moribund patient who has little chance
of survival but is submitted in despera
tion.
Class VI : Brain dead.
Class I
Laboratory testing - as mostly surgical procedures
are performed, the blood and urine picture is essen
tial.
Child’s physician - name and address of the child’s
physician
Rationale for sedation - briefly state the reason
for anesthesia.
Informed consent - written consent to be obtained.
Medications and instructions [Doctors orders]
a To parents
■ NPO instructions must be clearly written on
the order sheet. The most common reason
that a patient is disqualified for a scheduled
anaesthetic is that they have not complied
with the pre-operative nothing per oralinstruc
tions.
Table 4.11 : Normal paediatric vital signs
Respiratory Rate
Tidal Volume
" 100/67 + 25/23
24 + 6
112
94/55 •+RM» 14/9
23 + 5
270
Age
Heart Rate
Blood Pressure
3 years
101 + 15
5 years
r
90+10
1
12 years
70 + 17
109/58 + 16/9
19 + 5
480
Adult
77 + 5
122/75 + 30/20
12 + 3
575
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attention. Some sedatives specially the bar
biturates and the opiods have the disadvan
tage of causing nausea and vomiting. Also it
is contraindicated in patients with renal im
pairment and hepatic impairment.
The goal of pre-operative fasting is to decrease gastric acid volume and minimize the
pneumonitis that may result in the event the
patient aspirates gastric contents. (Latham
1999) NPO after midnight for 6-8 hours pre
operative (solids) while clear liquids may be
taken in healthy patients 2-3 hours pre-opera-
3. Anti-emetic - they are indicated only if patient
is highly prone to vomiting or sedatives have
been added in the premedication. Commonly
used is Hydroxyzine (Vistaril) or Metaclopromide. Also useful in reducing anxiety
and tension in younger children.
tive.
h To assistant
Premedication with a systemic background
■ Patients with Subacute Bacterial Endocarditis
- antibiotic prophylaxis is needed.
■ Patients with abscess - antibiotic therapy
Premedication in a normal child
The purpose of premedicating a child is:
.f
I
Objectives
1. To block unwanted autonomic reflexes.
2. To prevent excessive secretions.
3. To produce sedation and allay anxiety.
4. To facilitate induction of anesthesia and to
supplement and reduce the amount of the same
to be administered.
There is considerable deba te on the use of pre
medication in outpatients. However, a judi
cious use of the same is recommended.
Drugs used
L Anticholinergics - Drug used most commonly
is atropine. In recent times, Glycopyrrolate
[O.Olmg/kg IV] has also been found to be
very effective. The central effects are negligi
ble with greater drying effect as well as less
tachycardia than atropine.
2. Sedatives - These may be required in certain
cases where the patient may be apprehensive
about the procedure. Benzodiazepines and
Barbiturates have been commonly used for the
same. Davis [1988] has stated that chloral hydrate and Meperidine are the most commonly
used oral sedative agents. In recent times
Midazolam has also received considerable
Guidelines for premedication [Steward, 1983]
1. Infants under 1 year
Atropine ().02mg/kg -
i. v. at anesthesia.
i m., 30 minutes before
2. Healthy children 1-3 years of age
Atropine 0.02mgZkg - i.v. at anesthesia
i.m., 30 minutes before
3. Healthy children over 3 years of age
« Optimal psychological management.
« If indicated add 4mg/kg diazepam suspension.
■ Atropine 0.02mg/kg - i.v. at anesthesia
i.m., 30 minutes before
Other conditions
Certain other conditions exist where sedation may
be beneficial are:
4Mb.
■
Congestive Heart Disease
They benefit from sedation as to minimize oxy
*
gen consumption and demand on Cardiovascular
System during induction
■
Intracranial vascular malformations
Sedation to prevent dangerous hypertension
prior to or during anesthesia.
■ Mental retardation
Difficulty in induction of anesthesia. It. is also
helpful to allow parents to accompany during
induction.
<ïîE> I TEXTBOOK OF PEDODONTICS
PROCEDURE
Methods of administration : General Anesthesia can
be administered by using following types of circuits:
■ Open Method - where no rebreathing and noreservoir is present. _ ,
■ Semi Open - has à reservoir but no breathing.
■ Semi closed - reservoir and partial rebreathing.
■ Closed - reservoir and complete rebreathing.
Pre-Induction Consideration
■ C onnecto mask adapter
■ S uction
h Quick re-examination as children may develop
URTI or other infections overnight.
c.
Knowledge of the agents being used for the
various stages of anesthesia. Briefly they care
described in table 4.12
Protection
a Preparing Equipment - The anesthetist has to
check the equipment available. A brief check
list includes using the nemonic STATICS :
» S cope[laryngoscope]
■ T ube
■ A irway
■ T ape to fix the tube
■ I ntroducer stilet
Eye and corneal abrasions are prevented by closing
the eyes-with artificial tears and by also winding the
gauge over them. The mask should not be allowed
to creep up above the bridge of the nose.
Table 4.12: Commonly used parenteral anaesthetic agents
*
Benefical
Representative
Adverse effects
Drug family
agents
effects
■
■
■
«
■
Morphine
Fentanyl
Alfentanil
Sufentanil
Remifentanil
\ Clinical uses
■ Sedation
■ Analgesia
■ Euphoria
■ Respiratory
depression
■ Nausea
« Vomiting
■ Gastroparesis
■ Sedation
■ General
anaesthesia
■ Severe pain
managment
■ Diazepam
■ Midazolam
■ Triazolam
■ Sedation
« Anxiolysis
■ Amnesia
■ Respiratory
depression
■ Sedation
BARBITUR
ATES
■ Methohexital
» Thiopental
■ Loss of
consciousness
■ Respiratory
depression
■ Cardiovascular
depression
■ Induction of
general
anaesthesia
DISOPROPY
LPHENOL
■ Propofol
■ Respiratory
■ Sedation
■ Loss of
depression
consciousness ■ Cardiovascular
■ Rapid recovery
depression
■ Sedation
■ General
anaesthesia
OPOIDS
BENZO
DI AZEPI NES
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT Î
a Divinyl Ether - was used for induction by open
drop method. If used for more than 30 minutes
causes severe liver toxicity. Thus not used.
h Diethyl ether - Guedal *s stages are seen. Slow
induction, irritating to the respiratory mu
cosa, increased incidence of nausea and vom
iting - explosive. It has the advantage that there
is little CVS or respiratory7 depression. It also
maintains blood pressure.
c. Halogenated Hydrocarbons as a group show
following features:
1. Progressive reduction in the BP as
anesthesia (feepens.
2. Moderate to marked respiratory7 depression.
3. Produce cardiac arrythmias. due to
sensitization of the heart to endogenous
catecholamines.
4. Hepatotoxicity.
x Intravenous induction
« This is the preferred route for the induction of
anesthesia in adult patients. The maintenance
of anesthesia is, however not: preferred with
these agents.
■ The agent most commonly used is thiopenthl
sodium. The advantage is a rapid onset of ac
tion and also recovery time.
■ EMLA cream, a powerful topical agent is to
be applied for comfortable securing of the IV
line.
■ The preoxygenation concept, is that the pa
tient is to be kept on 100% oxygen 2-5 minutes
before induction.
In absence of
preoxygenation, during induction, the blood
oxygen saturation is seen to drop to levels of
.60% to 70% on induction with thiopental in
healthy patients breathing room air.
■ A few ml of Thiopental sodium (2.5%) is in
jected as a test dose.
■ 5% thiopental sodium injected rapidly is used,
but may lead to apnea. It is suggested that
2.5% every 15 seconds upto 0.5g (in avg.
male) with 0.2 to 0.25mg in children is given.
■ Too rapid induction can produce hiccuping
and involuntaiy muscle movement.
■ Rarely epileptiform conclusions may occur.
« It is inadvisable to administer thiopental as the
principle agent for operations lasting more than
1 hour or that more than 1g be given to a pa
tient.
Absolute contraindications for the use of thio
pental are:
■ Presence of respiratory obstruction.
■ Cardio vascular instability, shock.
■ Severe asthma or bronchospastic disease.
■ Porphyria.
b. Maintenance of anesthesia [Inhalation]
The maintenance of general anaesthesia is gen
erally by inhalation general anesthetics.
They can be classified as
1. \61atile
2. Gaseous.
Generally combined with nitrous oxide provides
excellent anesthesia and little nausea or vomiting is
encountered.
Masks for induction
a Shape of mask-for the children, induction is
generally carried out by the use of inhalatipn.
The shape of mask is modified to make it ac
ceptable to the children. E.g. balloon mask, Mickey
mouse with a wide open mouth.
h Scented masks - the use of scented masks to
disguise the odours of the inhalation agents in
cludes addition of drops of fruit extract on the
mask (Fig 4.8a).
«
Also vapourizing volatile fruit flavours into the
anaesthetic gas mixtures is acceptable.
Controlled ventilation and Assisted
ventilation
During the procedure, the anesthesiologist may
exert control over a patients breathing by two well
defined methods.
I TEXTBOOK OF PEDODONTICS
When conditions are judged to be proper, the exist
ence of the continuing neuro muscular block should
be determined by diagnostic tests. Neostigmine, in
a dose of 3()mg/kg is the most commonly used drug
for reversal.
Fluid electrolyte balance
The fluid electrolyte balance is maintained during
the procedure with an i.v. saline infusion, which is
continued even after the procedure is over.
Fig. 4.8a Different coloured fragnant nose tips
especially for children to give relative analgesia.
Fig. 4.8b Dr. Kevin Alien demonstrating relative
analgesia on child patient
■
•
Controlled ventilation- manual or mechanical ven
tilation in which the frequency of breathing is
determined by the ventilator according to pre
setcycling pattern without initiation by the pa
tient.
Assisted ventilation - where the patient initiates
inspiration and establishes frequency of breath
ing.
Reversal
Before attempting drug reversal, a satisfactory
physiologic state and ‘adequate recovery from the
effects of anaesthetic agents must prevail.
Postoperative period
■. Often it is essential to comfort the parents and
assure them that everything is normal. The
procedures performed should be explained to
the patient.
■i The patient is to be started off with clear fluids at
least 3 hours after the procedure is over. The
importance lies in the fact that the first fluid
administered may sometimes be associated
with vomiting. This is generally prevented by
adding anti emetics like metaclopromide into
the saline which is infused, over a period. Clear
fluids are then followed by milk and soft diet [
also taking into consideration the extraction sites].
■ The presence of any bleeding front the oral cav
ity, extra oral swelling should be checked for.
■ The patient can be started off with analgesics if
pain is present. If required antibiotics can also be
judiciously used.
■ The child should be evaluated for the various
systems such as the cardiovascular function,
whether the patient can independently maintain the airway which can be assessed by means
of various arousal and protective reflexes. The
recovery of the patient should be such that it is
aS close to the preoperative level as possible. This
applies particularly in children with cerebral palsy
or mental retardation where the responses ex
pected from a normal child cannot be elicited
even preoperatively. ■ The child should be monitored constantly and
should not be allowed to play in the ward as, the
patient may be disoriented for some time to come.
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT i € 6
■
The parents should be advised not to leave the
child unattended even for the next day.
Any instructions regarding the restorative pro
cedures performed should be given. The patient
may be recalled for a check up after 3 months for
review.
Self-Assessment
I. Define conscious sedation, deep sedation and
general anesthesia?
i
What are the objectives ofrelative analgesia?
What are the stages of anesthesia?
What are the drugs used for premedication?
What are the pediatric considerations for *general
anesthesia?
6. Enumerate the indications for general anesthesia.
7. What are the absolute contraindications for the
use of thiopented sodium?
2.
3.
4.
5.
4.5 Ephebodonties - Dentistry for Adolescents
GoelR
Introduction
Ephebos is the Greek noun referring to a youth en
tering manhood and from it is derived the word
ephebodonties, which encompasses total dentistry
for the individual undergoing the transition from
childhood to adulthood, ie., the period of life known
as adolescence.
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The word “adolescence” is derived from the Latin
“adolescere”, which is composed of the Latin words
“ad” or to, plus “oleve”, to grow, or “olere” to nourish.
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It is an in between age in our society and needs to be
understood as something independent of either childhood/adulthood. It is a time of enormous transition
and is certainly not of short duration. Hence, the
term teenager ( 13-19 years) has become synonymous
with the term adolescence in our society.
L Definition
Ephebodontics/adolescent dentistry is the science
of dentistry which deals with the children who are in
the process of growing up from childhood to man
hood or womenhood.
l
Medically adolescence can be considered as the pe
riod beginning with the appearance of the second
ary sex characters and terminating with the cessation of somatic growth.
Adolescence represents an extremely important time
in the dental care of the child patient. Prevention of
dental diseases is certainly one bf the pivotal con
cerns of the dentist who cares for adolescents. Ado
lescence marks a time in which the role of the parent
in the child’s dental home care needs to be mini
mized, and the responsibility of the adolescent for
managing his/her own oral health program must be
emphasized. The dentist must play a role in educat
ing and motivating such patients, for not only in
caries problem but also periodontal disease and its
unfortunate implications.
This chapter is an attempt to highlight the various
dental problems occurring in this group, ’and their
management since the dentist needs to be aware of
the different characteristics of the adolescent as they
relate to age.
Common dental problems observed
1. High caries attack rate
2. Pulp size
3. Partially erupted teeth which affect;
a) Placement of rubber dam
b) Placement and retention of rubber dam clamps
c) Taking impressions
d) Placement of matrix bands
e) Design of retainers
4. Gingival and periodontal problems
5. Congenitally missing teeth
6. Motivation for prevention
7. Traumatically injured teeth
8. Rapid changes in occlusion following removal of
teeth
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT I
9. Gingival recession
10. Esthetic results
11. Social behavior
12. High cost in cases of long standing dental ne-
Subtle changes observed
A. Physical changes
Body
Puberty is tlie landmark in physical development
when an individual becomes capable of sexual
reproduction. The advent of puberty is paralleled
by the development of genital tissue and sec
ondary sexual characteristics, such as, tlie devel
opment of hair in the area of the genitals.
The following changes are seen in the body of an
adolescent
■ It is a time when there is a increase in mass of
tlie muscles, a redistribution of body fat, and
an increase in the rate of skeletal growth.
■ There is a growth spurt assqciated with the
time of life.
■ Since males have a longer pre-growth spurt
maturation period, the total height of males
generally exceeds the height of females.
■ The earlier growth spurt of females also ac
counts for a period of time when mean height
of a group of young female adolescents may
exceed the mean height of the males.
■ It is important to realize also that in females
menarche serves as a signal that *
growth is
ending, but for males there is no such marker.
Craniofacial (Head and Neck)
During adolescence, subtle changes take place
in skeletal growth ofthe face and skull to give the
individual tlie final adult appearance.
« In adolescence the nose and tlie chin become
more prominent, the face increases in height
and and becomes prognathic.
■ The convex profile in tlie lip region of children
tends to be reduced by these growth changes.
■ The brow area becomes larger as a result of
pnuematization of tlie frontal sinuses and ap
position of the glabella.
■ By puberty, the sinuses are usually fully dealthough they may continue to en
large.
■ There is an average increase in the palatal vault
of approximately 10 urn frombirth through ado
lescence, but simultaneously tlie palate moves
downwards, as a result of appositional growth.
■ The growth of the jaws continues during this
period. This growth may be sufficient to de
velop room for the third molars. In many cases,
the growth is inadequate and these molars
become impacted.
■ Mandibular growth has taken place at the
condyles in the same mode as interstitial carti
lage growth. Such growth imparts an increase
in tlie vertical height of the ramus ofthe man
dible, and it also becomes more upright.
■ The whole face is a great deal longer vertically
and more sloping as a result of many changes
■ The adult facial skeleton is literally twice as
large as that of the newborn but that the brain
differs in size by only 50%.
• By completion of adolescence, the 27 bones
(15 single and 8 pairs, excludingtlie hyoid and
. ear bones) tliM originally made up the skull
have become 22 bones (06 single and 8 pairs
excluding the hyoid and ear bones) and are so
closely adapted that the skull can be consid
ered as a single bone.
B. Dental changes
■ All tlie permanent teeth generally will have
erupted by age 12, except possibly the four
second molars, which may erupt as late as age
13, and the thud molars, which usually erupt
between the ages of 17 and 21.
■ Except for the third molars the dentist should
be concerned about any unerupted permanent
tooth after age 13 and should examine the area
in question radiographically
<FZî> | TEXTBOOK OF PEDODONTICS
■ The roots of all the teeth are considered to
have been completed by-ageU6, except for
those of the third molars, which could achieve
completion as late as 25 years.
C Cognitive changes
The adolescent continues his or her cognitive
development and by the middle to late adoles
cence is capable of extremely sophisticated intel
lectual tasks. High ability at abstract thinking
allows the adolescent to deal with complex and
difficult vocational and educational challenges.
Formal operational thinking and the ability to store
information in the memory after perceiving it are
the hallmarks of the maturation of cognitive abil
ity of the adolescents. The new information avail
able to the adolescent, along with more sophisti
cated ways of analyzing this information, often
makes him/her appear to be a rebel, a complainer,
and an accuser.
The thoughts of adolescents are both introspec
tive, analytical and also egocentric. This dwell
ing upon one’s self makes an individual overly
self-conscious. Clothes, car, hairstyle, music
tastes and identity with certain people or groups
probably reflects the adolescent’s involvement
in self consciousness.
D. Emotional changes
The very rapid dramatic changes that happen to
adolescents can be paralleled with many emo
tional circumstances.. The self confidence and
personal identity of the adolescent may be com
promised if his/her feelings about body image are
wrong. The following issues are seen to have the
possibility of misinterpretation and anxiety for this
age group.
a) being attractive or unattractive
b) being loved/unloved
c) being strong/weak
d) being masçuline/feminine
E Social changes
Peers are very important social agents in large,
technological societies, in which children of thé
same age group are often kept together. The rela
tionships and dependencies upon parents starts
to decline and the importance of peers escalates.
The adolescent finds it difficult to share secrets,
thoughts and fantasies with his/her parents and
takes a close friend as his confidant. In such
cases, the peer is a valuable and useful audience.
At the same time an adolescent may tty drugs,
participate in criminal acts, or defy authority7, to
avoid rejection or ridicule from the peers.
Another important social change in the adoles
cent is an increase in the size and range of ac
quaintances. Children younger tend to limit their
friends to those in their neighbourhood, school
and perhaps church. Adolescents can, on the
other hand, have individual friends, belong to a
clique of friends and can. identify7 with larger
groups such as a football team. An adolescent’s
ability to sustain relationships with ail 3 groups
is indicative of good social skills .and that the
socialization process is going well.
The adolescent who gets along well with his/her
peer group seems to relate successfully with
adults. Those who do not get peer acceptance
seem to have more problems with adults and grow
up to have a variety of social and emotional diffi
culties.
The psychology of adolescence
As a psychosocial phase extending over a number
of years, adolescence is a developmental phenom
enon unique to man.
Personal Identity: The crucial problem of adoles
cence
The adolescent is faced with a major developmental
task of achieving a stable personal identity, which
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT I
will provide him with orienting concepts of what sort
of person he is, what his strengths and limitations
are, and how he can anticipate others response to
him. This requires the youngster to relinquish his
self-image and the role of childhood while not yet
being to fully embrace the role of an adult. The ado
lescent may need to give up and sometimes to ac
tively rebel against his dependent, submissive rela
tionship to his parents if he is to establish a healthy
personal identity of his own. This may give rise to an
emotional disorder rather specific to adolescence,
termed acute identity confusion. If mutual interac
tion between the parents and the child fails to de
velop it may give rise to a great confusion on the
part of the youth as to who or what he is, a subjec
tive feeling of unreality, an acute sense of isolation,
a loss of drive and sense of purpose, which makes
concentration impossible and disturbs the capacity
to appreciate time or to apply himself to practical
endeavors. Efforts to cope with the stresses of ado
lescence and to stave of acute identity confusion
may lead to a type of behavior highly distressing to
parents and to the adult society at large - the as
sumption of a “negative identity”.
he says he will do. He is orderly and persistent m
his work. He is very self-critical, sets high stand
ards for himself, sometimes doubts that he can
achieve his goals, but drives ahead until he ac
complishes what he lias set out to do. He is strongwilled and may be somewhat stubborn. Uc is said
to have a ‘strong’ personality.
2. Self adaptive person
The self-directed adolescent is in sharp contrast
to the second type of definitely healthy, adjusted
personality; the “adaptive person”. The adaptive
adolescent is friendly, vivacious, outgoing and,
though he does not strive for it as does the self
directedyouth, he accepts leadership and respon
sibility naturally and easily. The adaptive person
has a well developed sense of personal identity
and is quite aware of his relationship to others;
however, he seems in tune with society and is a
successfill conformist
Typical personality types: The adolescents can be
divided into the following personalities
3. The submissive person
He is one who continually calibrates and, hence,
insures his sense of identity in terms of the de
gree to w hich he meets the expectations of au
thority and the approval he receives for this. Con
sequently he feels more secure as a follower,
avoids conflicts, does not initiate action, and is
apt to be a relative nonentity. Though the sub
missive person may be docile and uncritical of an
authority he accepts, he is not submissive to eve
ryone; he may have ^strongly developed sense
of duty1*7 and may vigorously resist demands that
run counter to his principles. Nevertheless he
does not have a strong sense of his own identity.
1. The “self-directed” youth
They have a very well developed sense of self
and display those aspects of a strong personal
ity such as leadership and achievement, provid
ing a very different picture from the sociable, gre
garious teenager The self-directed person enjoys
a very good reputation, especially for responsi
bility and honesty. He is known as a conscien
tious person, who can be counted on to do what
4. The “defiant person”
This is an adolescent who is definitely unsuc
cessful in establishing a true sense of his own
identity and is defensive, counter-attacking
against a frustrating world by assuming a nega
tive identity. “The defiant person is openly hos
tile to society. He shows his hostility by doing
poor school work, refusing to conform to social
expectations. Because he has been neglected or
Therefore it can be seen that this is a period of life
during which a greater degree of inner turmoil and
unpredictability in behavior is considered more nor
mal than would be so at other times in life. For the
greatest number of adolescents the stresses of this ♦
period are coupled with vitality and exuberance which
makes life an exhilarating experience.
I TEXTBOOK OF PEDODONTICS
mistreated by society he bears a never-ending
grudge which prevents him from making any con
structive adjustment to his age mates, to his fam
ily, to school, or to a job. He is a definitely malad
justed individual.
5. The “unad justed person”
He shares with the defiant person an inability to
master the tasks required to establish a stable
sense of identity. However, the unadjusted per
son is not so openly hostile and attacking of so
ciety and is not apt to assume a negative identity,
though he is much more in danger of suffering
acute identity confusion. He is an anxious, inse
cure, unhappy youth in need of help.
seem important to be alert to particular attitudes
of the adolescent toward the teeth and the mouth
and the part these play in the young person’s
emerging body image. These attitudes may well
determine the adolescent’s degree of cooperation
in necessary dental treatment and in carrying out
good oral hygienE
Time and industry diffusion
■
Perhaps the most difficult task confronting many
adolescents concerns the need of the youth to
give up the child-like dependence or identifica
tion with the parents and to replace this with an
identification with his peers. For a number of
young people this engenders a painful feeling of
isolation and deprivation, and when the parents
resist this separation because of their own emo
tional needs, there may be the added distress of
conflict and antagonism between the parents and
the child.
■
The parents view this aimless, desultory
behaviour as “lazy” and they become angered
and dismayed as school work declines and home
chores are neglected. It is often when school
grades are perilously close to failure that the help
of the psychologist is sought.
■
It falls to the psychologist to convince the par
ents and the teachers that the young person is
not malingering when he complains that he can
not concentrate. He literally cannot concentrate,
he cannot marshal his resources, and he cannot
engender the energy and drive necessary for ef
fective action unti l he finds himself and gets his
bearings as a person with his own destiny in life.
The efforts of the parents to motivate him through
outside pressure and to expect him to exert him
self to gain their approval as he did during child
hood only increases his inability to come to grips
with his problems.
Emotional disturbances common to adoles
cents: Disturbance in body image
■
■
Whatever may be the personality of the adoles
cent, he must confront certain developmental
tasks. Among these the revision of the body
image and the accommodation to primary sexual
impulses and secondary sexual characteristics is
of major importance.
The changes in the body which are so evident to
others are also the source of great concern and
interest to the young person. Short stature in
boys, tallness and big bones in girls, failure in the
maturation of identifiable secondary sexual char
acteristics, all may cause alarm and defensive bel
ligerence or withdrawal within the young person.
Obesity and angular build can make a girl doubt
her femininity, while chubbiness or lack of mus
cular development can dismay a youth as to his
developing manhood.
«
Attitudes toward changing body image can have
a profound effect upon the adolescent’s care of
his body. These distorted attitudes toward the
body grade into actual psychosomatic disorders.
■
For the dentist, who is responsible for the care of
the teeth and the mouth of the adolescent, it would
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT |
veys the attitude to the adolescent that “any
thing goes”.
Negative identity
■
For the adolescent to embrace a negative identity
constitutes a maladaptive solution to his prob
lems. In certain circumstances, however, it ap
pears the only avenue open to him to escape the
acute identity contusion. When the demands and
the expectations for achievements placed on the
adolescent are so great he feels that he can never
measure up to them, he may be forced into a nega
tive identity. A young person may also be forced
into assuming a negative identity as a protective
measure when one of the parents insists on be
ing so much a part of his life that he is literally
suffocated in his efforts to establish his own in
dividuality7.
■
Unspoken competition between the parent and
the child evoked by the youth’f increasing physi
cal stature and independence may stimulate anxi
ety concerning loss of vigor and approaching age
for the parent.
■
Studies of adolescents who have been most suc
cessful in mastering the stresses of this period
indicate that the parent-child relationship is gen
erally one of mutual respect and trust in which
each one allows the other to live his own life with
out efforts at coercion or manipulation.
The three sub-stages of adolescence
Peer group influences: It is in his peer group that
the adolescent finds a base of acceptance and secu
rity from which to solidify his changing body image
and independence from the parents. To “belong” to
a group and to develop a language, mode of dress,
and behavior uniquely their own, which clearly sets
them off from adults, provides the adolescents with
a temporary refuge with others of their own kind for
making a transition from childhood to adulthood.
Parents influences: There may be no other time in
their child’s life which is as personally anxiety invok
ing and frustrating to the parent as is adolescence
and in certain instances it can lead to severe emo
tional disorder in a parent. The successful mastering
of the tasks of adolesceiioe requires a collaboration
between the adolescent and the parent in which the
parent provides the image of a mature adult provid
ing guidance and ultimate authority while allowing
the young person increasing independence in ques
tioning, revising, and finally establishing his own
beliefs and values.
■
Dictatorial, overbearing parents who allow little
freedom and independence to their adolescent
offspring can anticipate troublé;. Equally perni
cious, however, is the submissive parent who
cannot cope with adult responsibilities and con
Sub-stage
Characteristics
Early
adolescence
Middle
adolescence
Late
adolescence
Casting off of childhood role and
emergence into adolescence
Participation in teenage subculture
and peer group identity
Emergence of adult behavior
Special considerations during assessment
1. Rapid, unpredictable, and irregular skeletal and
dental growth.
2 The environmental challenges, with obstacles and
pitfalls. Drugs, smoking, sexually transmitted dis
eases, peer pressure, acne, more competitive edu
cation, career decisions, alcohol, family pressure
make up for some of the challenges facing to
day’s adolescent Dental professionals see trauma,
oral manifestations of sexual activity, hormonal
gingivitis, smokeless tobacco induced hyperkera
tosis, non compliance to dental recommendations,
and drug related behaviors.
3. Learning to cope, make decisions, and become
independent. Adolescence has always been atime
to make decisions, seek independence from familieS; deal with sexuality, and choose a career. The
I TEXTBOOK OF.PEDODONTICS
Table 4.13: Examination possible clinical findings in examination of the adolescent
Finding
Comment
Acne
Adolescent may be taking
antibiotics
Intra-oral evaluation
Mucosa
Generalized erythema
Effect of smoking, sexually
transmitted disease
Buccal mucosa
Erythema hyperkeratosis
Use of smokeless tobacco
Tongue
Coating, odor
Smoking, poor hygiene fungal
overgrowth from medication
Breath
Acetone, alcohol
Excessive dieting, alcohol abuse,
metabolic disorders (eg. Diabetes)
Gingiva
Inflammation
Pregnancy tumor
Hormonal change
Use of oral contraceptive
Pregnancy
Teeth
Erosion
Wear facets
Excessive stains
Discoloration
Bulimia
TMJ disorders, bruxtsum
Tobacco use
Existing pulpal pathosis from
trauma
Structure
Extra-oral evaluation
Skin
.
dentist often sees this turmoil in poor oral hy
giene compliance or refusal of treatment. The
missed appointment is just of many ways to say
“I am too involved in my search for self, my chang
ingvalues, and handling my environment to worry
about my teeth”.
Behavioural assessment
1. Sexual abuse: The young adolescent female or
male who has been sexually abused with oral pen
etration may exhibit reluctance in accepting den
tal care from a dentist of the same sex as the per
petrator. Aids in uncovering this situation are a
good history of previous compliance, behavioral
cues such as depression, and overt refusal of care
when oral contacts is made. Nonetheless, confirmation is difficult, since the abuse may be un
known to the parent or parents. It maybe the limit
of the dentist’s role to recommend counseling for
a child to uncover reasons for refusal of care with
the idea that intervention may uncover the cause.
j
1t
|
i
i
2. Rampant caries: Clinicians have noted that in ram
pant caries (more often in adolescent female) per
sonality problem manifestations can be varied,
with a girl cry ing silently or not saying a word
during the appointment. In some
cases,
*
treat
ment appointments can degenerate as the child
whimpers and finally loses composure. Time and
engagement in conversation are often the most
successful behavioral management keys in deal
ing with these adolescents. Dramatic changes in
behavior occurs with the dentist’s verbal rein
forcement of improved hygiene and provision of
even temporary esthetic anterior restorations that
allow the patient to smile and experience a more
positive self-image.
3. Extreme anxiety The behavioral management of
the child who exhibits extreme anxiety at the
thought of dental treatment can be achieved by
desensitization by psychological intervention.
Tools available to the dentist include non-invasive therapies at first, reinforcement of positive
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT |
accomplishments, positive peer interaction, and
involvement with a psychologist. The poorly
managed or unmanaged adolescent phobic may
become the adult dental phobic.
4. Anorexia nervosa;The treatment of the child with
an eating disorder can be difficult Experience
indicates that these patients, mostly females, will
develop dependency on a male authority figure.
They will also require a dentist’s full attention
during office visits and, unless counseled, will
demand time outside scheduled appointments.
5. Illicit drug use: Manifestations of drug inges
tion can be varied from a slight mental dissocia
tion or drifting to outright verbal aberrations or
extreme changes in personality.
Common adolescent behaviour problems
and suggested solutions
1. The adolescent is basically insecure and is often
unable to cope with many situations; eg dental
setting. There maybe weeping, crying, laughter,
squirming, and stoic silence all during a single
office visit and without an apparent reason. Be
kind and understanding, it will be highly appreci
ated.
2. Adolescents have varied interests; determine
what these are, and encourage discussion on
these issues. However, join the discussion ac
tively only if you are familiar with the topic; if
not, let the adolescent talk and inform you. Be
intelligent - considerable rapport with the patient
can be gained through discussion when handled
properly.
3. Adolescents tend to reject adult authority; how
ever, they are generally responsive to empathetic
guidance, because they are somewhat afraid of
the very independence they desire. Be firm but
kind; display authority7 in clinical matters, but do
not be authoritarian.
4. Adolescents are preoccupied with health matters
in general and appearance in particular. Use these
concerns as mechanisms for motivating the type
of behavior conducive to enhancing rapport and
improving oral health.
5. Frequently, adolescents regress to childlike
behavior in the dental office. This is a defense
mechanism to what is perceived as a traumatic or
unpleasant experience. Since this age group is
particularly sensitive to being treated as a child,
the dentist should adapt his treatment approach
appropriately. Be extremely careful not to cause
the patient obvious embarrassment.
6. Adolescents tend, to worry about many circum
stances; conditions in the home, parents, school,
social injustice, peer relationships, and world af
fairs constitute major concerns. Dentists should
encourage conversation on these matters to a
reasonable extent. Allow the patient to do most
of the talking.
7. Generally, a larger amount of food is consumed
over a 24 hour period during adolescence than at
any other time in the life cycle. This circumstance
provides the dentist with an opportunity3
*7 to moti
vate patients toward adequate nutritional intake
and proper dietary practices from the perspec
tives of obesity and oral health. Both of these
health conditions are vital concerns of adoles
cents. Maximize their potential in the dental set
tings.
The role of the dentist
■ The pedodontist should have a knowledge ofthe
crucial psychosocial tasks to be mastered that
will provide a framework for understanding the
problems facing the young person. The dentist,
acts as a parent surrogate and will take on certain
aspects of the parent for the adolescent, as do
the physician, teacher, and minister. However,
precisely because he is not the parent, the
I TEXTBOOK OF PEDODONTICS
«
•
«
«
dentist is afforded an opportunity to offer a mean
ingful adult relationship to the adolescent.
The dentist must perceive his young patient as a
unique individual deserving respect and capable
of independent action.
h is important not to involve the parents unnec
essarily in thé adolescent's treatment to the point
that he is excluded from all participation.
He should be given as much responsibility as
possible for making his own appointments, for
discussing the nature of his treatment, and for
carrying out, on his own, necessary prophylactic
and remedial procedures.
Educating the adolescent regarding the impor
tance of various procedures and the necessity of
adopting good oral hygiene practices serve as a
significant aid in the success of treatment.
Self-Assessment
L Define ephebodontics.
2. What are the commonly occurring dental prob
lems seen in these individuals?
3. When does the calcification of third molar com
plete?
4. What do you understand by a "defiant adoles
cent”?
5. What are the characteristics of a self directed
adolescent?
6. What is the identity confusion faced by the ado
lescent?
7. What is the role of the dentist in managing the
adolescent?
Further Suggested Reading For Section - 4
1. American Academy of Pediatric Dentistry : Guide
lines for the elective use of conscious sedation
and general anesthesia in pediatric patients
Pediatric Dentistry 7[4] 334-337,1985.
2. Ayer WA et al: Overcoming dental fear: Strate
gies for its prevention and Management. JADA,
107,18-27,1983.
3. Belanger GK, Ti|liss TSI: Behavior management
techniques in predoctoral and post doctoral
pediatric dentistry programs. J. of Dental'Education. 57,232-238,1993.
4. Carah WL et al: The dentist-patient relationship:
perceived dentist behavior that reduce patient
anxiety and increase satisfaction. JADA, 116,7276,1988.
5. Chapman HR, Kirby-tumer N. C. Dental fear in chil
dren a proposed model, BDJ 187,408-412,1999.
6. Collins V J : Principles of anesthesiology, general
and regional anesthesia. Vol. 1 *3 ed.Lea & Febiger
, Philadelphia, 1993.
7. Corah N. L, Gale E. N., Illig S. J. Assessment of a
dental anxiety scale, J Am Dent Assoc, 97:816819,1978
8. Gale. E. N. Fears of the Dental Situation. J Dent
Res, 51(4): 964-966,1972
9. Guthrie A. Separation Anxiety: an overview. Ped
Dent, 19(7):486-489,1997
10. Higgins S.M ; Anesthesia for periodontal sur
gery. Dental clinics of North America, 43 [2], 263287,1999.
11. Kuhn BR, Allen KD: Expanding child behavior
management technology in Pediatric dentistry, a
behavioral science perspective, Pediatric Den
tistry: 16, 13-17,1994.
t
12. KunbergG. Hwang P.C. Children 's dental fear pic
ture test (CDFP). A projection test for the assess
ment of child dental fear. J of dent Child. 89-96,
1994.
13. Lawrence SM et al: Parental attitudes toward
behavior management techniques used in
pediatric dentistry. Pediatric Dentistry. 13, 151155,1991.
14. Milgram P et al :Origin of childhood dental fear,
Behav. Res. Ther 33,313-319,1995
15. Parkin S. F. The assessment of two dental anxiety
rating scales for children. J Dent Child, 269-272,
1988
16. Peretz B, Gluck GM,: Reforming - re appraising an
old behavioral technique. The J. of Clinical
Pediatric Dentistry. 23,103-105,1999.
SECTION 4 : PSYCHOLOGICAL DEVELOPMENT AND BEHAVIOUR MANAGEMENT | CT»
17. Quality assurance criteria for pediatric dentistry:
Behavior Management, American Academy of
Pediatric Dentistry7 95, Ref. Manual, 1998-99
18. Roberts G J: Inhalation Sedation [Relative Anal
gesia ] with oxygen/Nitrous oxide gas mixtures: 2,
Practical techniques. Dental update; 17 [5], 190196,1990.
19. Rousset C., Lambin M., Manas E The ethological
method as a means for evaluating stress in chil
dren two to three years of age during
dentalexamination. J Dent Child ,99-106,1997
20. Saxen M.A; Wilson S; Paravecchio R: Anesthesia
for Pediatric Dentistry7. Dental Clinics.of North
America.43[2] 231-245,1999.
21. Scott D. S., Hirschman R. Psychological aspects
of dental anxiety7 in adults, J Am Dent Assoc,
104:27-31,1982
22. Sokel DJ, Sokel S, Sokel CK: A review of non
intensive therapies used to deal with anxiety and
pain in the dental office. JADA, 110,217-222,1985.
23. Steward D J Anticholinergic premedication for
infants and children. Can. Anesth-Soc-J, 30(4],
325-8,1983.
24. Ten Berge M, Hoogstraten J, Veerkamp J. S. J,
Prins P. J. M. The Dental Subscale of the Chil
dren’s fear Survey Schedule : a factor analytic
study in the Netherlands, Community Dent Oral
Epidem, 26:340-3,1998
25. Troutman K: Behavioral management ofthe men
tally retarded. DCNA, 21,62-636,1977.
26. Veerkamp J. S. J et al: Dental treatment for fearful
children using nitrous oxide. The parent’s point
* of view ASDC J dent Child, 59,115-119,1992.
27. Wein Stein P: The effect of dentist’s behaviors
on fear related behavior in children. JADA, 104,
32-38,1982.
28. Weiner A. A., SheehanD. V. Differentiating Anxi
ety - Panic Disorders From Psychologic Dental
Anxiety, DCNA, 32(4):823-840,1988
29. Weinstein P: Dentist’s responses to fear and non
fear related behaviours in children, JADA, 104,3840,1982.
SECTION - 5
Dental Caries in Early
Childhood.
5.1 Introduction
Tandon S
Dental caries is the most prevalent chronic disease
affecting the human race. In many ways it can be
considered a disease of modem times as the occur
rence of caries seems to be much higher in the last
few generations. It is said that once it occurs-the
scars persist throughout life evenlhough the lesion
is treated.
esthetic problem it poses. Systemic complications,
such as Subacute Bacterial Endocarditis have also
been documented to be associated with dental car
ies. The masticatory apparatus may also be affected
leading to difficulty in mastication and deglutition.
Therefore it is mandatory for the clinician to under
stand the magnitude of this problem and the risk
factors in the community to plan suitable preventive
measures. This chapter is an attempt to highlight the
current concept of caries, to enable the student to
detectit at an early stage with its underlying causa
tive factors in an individual and to implement timely,
effective health care services.
§
Definition
Fig. 5.1Upper dentition showing extensive caries
in a 314 years old child/
There are practically no geographic areas in the world
whose inhabitants do not exhibit some evidence of
dental caries. It affects persons of both sexes, in all
races, all socioeconomic strata and in every age group,
though some people may be more prone to it than
others. Though it may be argued that the disease is
notjifeth^
are far reaching. The cost involved in treating the
disease in terms of manpower and the hours spent is
enormous. Also, the excruciating pain experienced
by the patient can affect the patient as much as the
The word ‘CARIES’ is derived from the Latin word
meaning ‘rot’ or‘decay’. It is also akin to the Greek
word ‘ker’ for‘death’.
■ Ostrom[19^hasdefinedft^
or dentin dissolution that is caused by microbial
action at the tooth surface and is mediated by
physiochemical flow of water dissolved ions.
■ Hume [1993] states that caries is essentially a pro
gressive loss by acid dissolution of the apatite
[mineral] component ofthe enamel then the den
tin, or of the cementum then dentin.
interpretation of the carious process
■
The histopathologist may define caries in terms of
the stages of the lesion viewed microscopically.
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD |
■
■
■
The chemist describes the process in terms of the
interrelationship between pH, mineral flux, and
solubility at the tooth-saliva interface.
The microbiologist on the other hand defines car
ies in terms of the inter-actions involving oral bac
teria and the dental tissues.
Thus on a more broad basis, dental caries is a
multifactorial disease, which is the result of inter
action between the tooth [host] and the environ
ment around it including the bacteria, saliva and
diet of an individual.
Classification
Dental caries may be classified on the basis of three
factors:
A. Based on anatomic site
■ Occlusal (pit and fissure)
■ Smooth surface caries (proximal and cervical car
ies), which can be classified under crown caries.
■ Root caries is seen in older age groups. The pre
disposing factor for the occurrence appears to be
the recession of the gingival margin. (Table 5.1)
B. Based on the severity
■ Incipient caries
The early caries lesion, best seen on the
smooth surfaces of teeth, is visible as a4 white ♦
spot’. Histologically the lesion has an appar
entlyintact surface layer overlying subsurface
demineralization. Significantly many such le
sions can undergo remineralization and thus
the lesion per se is not an indication for re
storative treatment.
■ These white spot lesions may be confused ini
tially with white developmental defects of
enamel formation, which can be differentiated
------ by their position [away fromthe gingivM mar
gin], their shape [unrelated to plaque accumu
lation] and their symmetry [they usually af
fect the contralateral tooth] . Also on wetting,
the caries lesion disappears while the devel
opmental defect persists.
■ Occult caries:
Occult or hidden caries is used to describe
such lesion, which is hot clinically diagnosed
but detected, only on radiographs. The nature
of these lesions, their etiology and reasons as
to why they have eluded early clinical diagno
sis are still unclear. The prevalence of occult
caries has been reported to range from 0.8% in
premolars in 14-15 years to as high as 50% in
20 years olds (Seow 2000). It is believed that
bite wing and OPG radiographs along with
other noninvasive adjuncts like fiber optic tran
sillumination (FOTI), laser luminescence, elec
trical resistance method (ERM) are used for
diagnosing these occlusal lesions.
These lesions are’not associated with micro
organisms different to those found in other
carious lesions. These carious lesions seem to
increase with increasing age. Occult lesions
are usually seen with low caries rate which is
suggestive of increase fluoride exposure. It is
believed that increase fluoride exposure en
courages remineralization and slows down
progress of the caries in the pitand fissure
enamel while the cavitation continues in dentin,
and the lesions becomes maskedby a relatively
intact enamel surface. These hidden lesions
are called as fluoride bombs or iltioride
syndrome. Recently it is seen that occult car
ies may have its origin as pre-emptive defects
which are detectable only with the use of ra
diographs.
■ Cavitation
Once it reaches the dentinoenamel junction,
the caries process has the potential to spread
to the pulp along the dentinal tubules and also
spread in a lateral direction. Thus some amount
of seiisitivifymaybe associated with thistyfe
*
»it»:
of lesion. This may generally be accompanied
by cavitation and can be detected by the ra
diograph.
[ TEXTBOOK OF PEDODONTICS
C Based on progression
■ Arrested caries
With the shift in the oral conditions, even ad
vanced lesions may become arrested. Arrested
caries involving dentin shows a marked brown
pigmentation and induration of the lesion [ the
so called ‘eburnation ofdentin’].
D. Based on chronology
It has been stated that over a lifetime, caries inci
dence i.e. the number of new lesions occurring in
a year, shows three peaks-at the ages 4-8,11-19
and 55-65 years.
■ Recurrent/secondary caries
Recurrent caries is that occurring immediately
next to a restoration. It may be the result of
poor adaptation of a restoration, which allows
for a marginal leakage , or it may be due to
inadequate extension of the restoration. In ad
dition, caries may remain if there has not been
complete excavation of the original lesion,
which later may appear as a residual or recur
rent caries.
■ Radiation caries
Radiotherapy is frequently associated with
xerostomia due to decreased salivary secre
tion. This and other causes of decreased sali
vary secretion may lead to a rampant form of
caries, indicating the significance of saliva in
preventing caries.
Early childhood caries
« Early childhood caries would include two vari
ants: Nursing caries and rampant caries. The
difference primarily exists in involvement of
the teeth [ mandibular incisors] in the carious
process in rampant caries as opposed to nurs
ing caries.
■ Linear enamel caries (odontoclasia) is seen to
occur in the region of the neonatal line of the
maxillary anterior primaiy teeth. The line, which
represents a metabolic defect due to the trauma
of birth, may predispose to caries, leading to
gross destruction of the labial surfaces of the
teeth.
Teenage caries (adolescent caries)
■ This type of caries is a variant of rampant car
ies where the teeth generally considered im
mune to decay are involved. The caries is also
described to be of a rapidly burrowing type,
with a small enamel opening. The presence of
Table 5.1: Root caries based on the extent of lesion
Grade 1 (initial)
Grade 2 (shallow)
Grade 3 (cavitation)
a. Surface texture:
soft, can be
penetrated with
a dental explorer
b. No surface defect
c. Pigmentation:
variable, light tan
to brown
a. Surface texture:
soft, irregular,
rough, can be
penetrated with
a dental explorer.
b. Surface defect
(less than 0.50
mm in depth)
c. Pigmentation:
variable, tan to
dark brown
a. Surface texture:
a. Deeply penetrating
soft, can be penet
lesion with pulpal or
rated by dental
root canal involvement
explorer.
b. Pigmentation:
b. Penetrating lesion,
variable, brown to
cavitation present
dark brown.
(greater than 0.50
mm in depth) no
pulp involvement.
c. Pigmentation:
variable, light brown
to dark brown
Grade 4 (pulpal)
Billings
(1986)
SECTION' 5 : DENTAL CARIES IN EARLY CHILDHOOD |
a large pulp chamber adds to the woes, caus
ing early pulp involvement.
with the availabilty of refined carbohydrates has
influenced the diet to an extent that caries be
came highly prevalent. In fact, it is interesting to
note that Nearchos, Alexander the great’s admi
ral found in the Indus valley a rare and costly
Indian salt' that tastes like honey. Thus sugar
preparation spread from India to Persia and Ara
bia, presently known as the dental arch criminal.
Adult caries
■ With the recession of the gingiva and some
times decreased salivary function due to atro
phy, at the age of55-60 years, the third peak of
caries is observed. Root caries and cervical
caries are more commonly found in this group
Present status
EPIDEMIOLOGY OF DENTAL CARIES
■
■
To a great extent dental caries is a disease accom
panying advances in civilization. Its appearance
however can be traced back to the ancient times
where the disease has been found in the skulls of
human beings adopting the practice of agricul
ture. Thus caries has been found in the ape-man
and hominid type as well. A carious lesion has
also been described in the Pithecanthropus, the
Java man. The occasional occurrence of caries in
the Neanderthal skulls has also been reported.
The so called process of modernization has a tell
ing effect on the incidence of caries. The settling
down of populations in the urban areas coupled
The global epidemiology of caries can be seen to
exhibit three distinct patterns.
1. In the first group there is still scarcity of develop
ment and the infrastructure is relatively poor. The
mortality rate is quite high. The areas included in
this type of a population would be rural China,
Africa, South America and underdeveloped Asian
countries. In this state of affairs, the availability
of dental care is almost non-existent and the car
ies experience is higher in the cities than in the
rural areas.
2. It is found that in newly industrialized or the de
veloping countries there is evidence of increas-
SALIVA
"7 PLAQUE
CONTROL
DIET
FLUORIDE
- In water
- Toothpaste
- Varnish Gels
in school
-Improved
Nutrition
- Decreased
amount of
sugar
- Decreased
frequency
of sugar
- Antimicrobial
additives
-Bitterhome
care
- Batter
professional
care
- Chemical
control
- Antibiotics
changes in
microflora
- Changes in
properties
rate
- Buffer
capacity
- Immunoglob
ulin content
- Agglutinins
volume
Fig. 5.2 Reasons tor decline
materials
- Fissure
sealants
I TEXTBOOK OF PEDODONTICS
Table 5.2: Prevalence of dental cariés in children
Country
Age
Year
DMF
Decayed
Missing
Filled
Argentina
12
1961
1985
4.5
3.2
2.0
1.0
0.2
0.3
1.0
3.2
Australia
12
1954-55
1981
0.3
2.9
4.8
1.1
3.4
Bangladesh
12
1979
1984
3.0
1.5
3.0
1.4
0.1
0.1
0.0
0.0
Brazil
12
1965
1980
7,2
7.3
5.6
4.7
0.5
0.8
0.0
.0.8
Canada
12
1966-70
1984
11.1
3.3
3.2
0.5
1.0
0.5
1.0
1.6
China
12
1965
1985
0.1
0.4
0.4
0.0
0.0
Ethiopia
12
1983
1985
0.7
0.4
0.7
**
India
12
1965
1982
2.4
3.2
2.3
0.1
Kenya
12
1973
1985
1.7
0.2
1.4
.0.2
0.3
0.0
Nepal
12
1983-84
1986
0.2
0.5
0.5
0.9
0.0
0.0
0.0
..... 0.2.............
♦
*
0.0
South Africa
12
1978-79
1982
3.6
3.2
2.5
1.9
1.0
0.7
0.0
0.6
Sri Lanka
12
1978
1983
2.1
1.9
1.7
0.1
0.1
(Annual Statistics Mond 1987)
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD |
Table 5.3: Prevalence of dental caries in India
Author
Year
Age
Place
Prevalence of
caries (%)
Shourie K L
Kokil et al
Shegal
Shiek
Antia et al
Dutta
Tewari
Mishra et al
Sarkar
Dhar et al
Nagaraja Rao
Kapoor
Singh et al
Saimbi et al
Chopra et al
Vaish
Gauba
Navin and
Tandon
1941
1951
I960
1960
1962
1965
1977
1979
1979
1979
1980
1980
1981
1983
1983
1983
1986
1986
7-13
*
4-18
5-19
5-16
6-16
5-16
6-16
5-15
5-13
-
India
Gujarat
Bombay
Bombay
Bombay
Calcutta
Chandigarh
Behrampur
Calcutta
Hazratbal
Udupi
———————
55.50
68.7
90
30.9
2.57 (DMFT)
43.9
72.35
60.4
99
30.62
1.7 (DMF)
49.1
50.3
60.4
63.27 .
48.60
87.5
82
71.11
67.11
52.4
6.9
38.3
90.66
57.89 (Boys)
45.2 (Girls)
78.83
64.0
78-83
59.1
•
6-14
-
Jawadekar et al
Borle et al
Gangawar et al
Tandon & Paul
Gaikwad et al
1989
1990
1990
1992
1993
___ 7r.17_____
W
5-6
15-16
i
12
4-20
5-14
6-11
5-15
Damle
Ramësh et al
Singh et al
Gopinath et al
1994
1995
1997
1999
12-16 *
6-10
12-16
3-12
Patna
Lucknow
Bombay
Orissa
Punjab
Manipal
Sirur
Wardha
Lucknow
Manipal
Bombay
Nashik
Haryana
Thiruvallur
A
Table 5.4: Prevalence in preschool children
Author
Year
Navin & Tandon
Virjee et al
Ibrahim A
Sethi & Tandon
1986
1987
1992
1996
Place
Manipal
5 years
4-5 years
3-5 years
24-60 months Udupi
Prevalence
71.11%
65.0%
50%
65.5%
(19.44% Nursing caries)
(3.96% Rampant caries)
CED | TEXTBOOK OF PEDODONT1CS
ing rate of caries in the children and the adults as
well. These populous nations areJaced with con
sumerism and urbanization coupled with in
creased consumption of refined carbohydrates.
The dental care available is concentrated in the
urban areas and is involved more in CurafiveWhd
palliative services with the problems of the masses
still unaddressed. This pattern may be observed
in countries such as Taiwan, India, Chile, Uganda
and Thialand.
3. The third pattern is found in the developed coun
tries where the availability of dental services cou
pled with a more preventive and maintenance
approach has lead to a decrease in the DMFT
scores and greater number of retained teeth.
Suggested reasons for decline in caries are
given in Fig. 5.2
PREVALENCE OF DENTAL CARIES IN CHILDREN
(Table 5.2)
■
■
«
The DMFT figures were found to decline remark
ably at age 12 in most industrialized countries.
It was found that the countries, which fell in the
DMFT range of 1.8 - 3.0, were Hong - Kong, Thai
land; USA, Australia, Singapore, Nigeria, & the
United Kingdom. Similarly, in the range of 3.3 -4.8
they found New Zealand, France, Sweden, Neth
erlands, Ireland, Finland, Norway & Denmark.
Wall [1984] reported that nationally Australia was
observed to be rapidly approaching the WHO
target figure of 3 DMFT in the 12 yr. age groiip
[Common Wealth Department of Health, 1982 ]
PREVALENCE OF DENTAL CARIES IN INDIA
Dental caries in our country (Table 5.3) is consist
ently increasing in prevalence and severity especially
in children. Today according to a number of investi
gators, 70-80% are suffering from this disease. The
average number of decayed, missing and filled teeth
at the age of 15-16 years is about 4 in rural and 5 in
urban areas. Because these studies have recorded
point prevalence using no uniform criteria, cross
comparison of these studies has been difficult.
One of the earliest studies in epidemiology in dental
caries in India was carried out by Day et al [1940].
They examined 750 subjects from Lahore in the age
group of 5 -18 years & reported that the caries preva
lence was 94.04 %. Other studies, which have been
reported, are given in table.
The first National oral health survey was planned in
1984 by Indian Dental Association with the commit
ment to achieve WHO goals in our country. Region
wise distribution was found as:
■ In Northern states, an increase was noted at the
age of 5-6 years except for Punjab, where fluoride
tooth pastes and preventive programs may have
brought about the decline. In the permanent
dentition (15 years), however, the caries seems to
have declined.
■ In Eastern states, the urban areas (Calcutta) have
shown incline in both deciduous and permanent
dentition.
■ In Southern states, an incline in dental caries was
noted in both primary and permanent dentition.
A declining trend was. noted at Manipal
(Karnataka) again probably due to well organized
school health programs.
■ In urban areas of Western region (Bombay)
though slight decrease was noted^ it is well above
the WHO goal.
§
PREVALENCE IN PRESCHOOL CHILDREN
Very few studies are conducted in pre-schools of
our country. (Table 5.4)
Self-Assessment
1. Define dental caries.
2. What is odontoclasia or linear enamel caries ?
3. What is incipient caries? How do you clinically
differentiate between incipient caries and enamel
hypoplasia ?
4. What are recurrent and arrested caries?
5. What are the reasons for caries decline in devel
oping countries ?
6. What is the trend of caries in India ?
7. What is the average number of decayed, missing
and filled teeth in rural India ?
5.2 Caries Risk Factors
Tandon S, Vanka A
ETIOLOGY OF DENTAL CARIES:
at this stage and thus the role of microorganisms
was not highlighted.
Early theories
■
Parasitic (septic) theory
The role of microorganisms in the process of den
tal decay was substantiated by Leeuwenhoek
who found ‘animalcules’ from the scrapings of
his teeth even after maintaining meticulous oral
hygiene. But the mechanism as to why and how
they cause the destruction of the tooth was not
clear.
The legend of the -worm
Several early references to the decay process in?>
elude the ‘Legend of the worm’ where th$
Marshes created the worm, an equivalent of which
were also found in the Japanese and Chinese lit
erature. This theory also found acceptance in In
dia and Egypt and several remedies were directed
towards the 'worms’ such as fumigation, acupunc
ture etc.
I Miller 'schemico parasitic theory
ENDOGENOUS THEORIES
■
Humoral theory
The four humors that were thought to maintain
the body health included ‘blood, phlegm, blackbile *
**
and yellow bile’. All diseases including dental
caries were attributed to the imbalance between
these factors.
*
Vital theory
Hie tooth was thought to be the source and ori
gin of the disorder in that the process started
from the tooth within.
EXOGENOUS THEORIES
■
Chemical (acid) theory
The developments in the field of chemistry en
couraged the investigators to propose the role of
inorganic acids causing the decay process. Fermpntatinn wac fhniiaht fn bp n nnn-vifal nrnrpcc
(acidogenic theory)
Miller, the best known of the early investigators
of dental caries, published extensively on the re
sults of studies on caries in 18 89. He summarized
his theory as follows.
“Dental decay is a chemico parasitic process con
sisting of 2 stages, the decalcification of enamel,
which results in its tptal destruction & the decal
cification of dentin, as a preliminary stage, fol
lowed by desolution of softened residue. The acid
which affects this primary decalcification is de
rived from the fermentation of starches & sugar
lodged in the retaining centers of the teeth”.
The significance of Miller’s observation is that
he assigned an essential role to 3 factors in the
caries process:
1. the oral microorganisms in acid production &
proteolysis
2. the carbohydrate substrate,
3. the acid which causes dissolution of tooth
•_____1 _
<ETîï I TEXTBOOK OF PEDODONTICS
This theoiy has been accepted by the majority of
investigators in a form essentially unchanged
since its inception.
«
«
Proteolytic theory
The presence of pigmentation in the carious proc
ess combined with the fact that abundant organic
material is present on the tooth surface led
Gottlieb[1947] to propose this theory; This states
that the organic pathways are invaded first and
destroyed by proteolytic action.
Proteolysis - chelation theory
The proteolysis - chelation theory of dental car
ies, as proposed by Schatz et al [ 1955], states that
the bacterial attack on enamel, initiated by
keratinolytic microorganisms, results in a break
down of the protein & other organic components
of the enamel, chiefly " keratin'4. This results in
the formation of sùbstances, which may form
soluble chelates with the mineralized component
of the tooth and thereby decalcify the enamel at a
neutral or even alkaline pH.
OTHER THEORIES OF CARIES ETIOLOGY
•
•
Sulfatase theory:
Pincus [1950] advanced the sulfatase theory,
whereby bacterial sulfatase hydrolyzes the “mucoitin sulfate” of enamel and the “chondrotin
sulfate” of dentin producing sulfuric acid that in
term causes decalcification of dentinal tissues.
The concentration of sulfated polysaccharides
in enamel is very small and not readily accessible
as a substrate for enzymatic degradation. This is
a highly unlikely hypothesis for the degradation
of tooth enamel.
Complexing & phosphorylating theory:
[Lura, 1967]
According to this theoiy, the high bacterial utiliza
tion of phosphate in the plaque causes a local
disturbance in the phosphate equilibrium in the
plaque & the tooth enamel resulting in a loss of
inorganic phosphate from tooth enamel. Soluble
calcium -
complexing compounds produced by bacteria
cause further tooth disintegration. Saliva is an
abundant source of inorganic phosphate for bac
terial utilization. Hence it is highly improbable that
depletion of phosphate in the plaque by oral mi
crobial metabolism results in phosphate with
drawal from enamel.
■
Burch & Jackson hypothesis:
Based on the Burch’s theory of ‘auto-aggressive
theory of the cause of growth, disease and ag
ing’, Jackson and Burch [1970] suggest that genes
[partly inherited and partly as a result of muta
tions] determine whether or not a site on the tooth
is at risk. An abnormal mitotic control protein has
been proposed that causes disorders of the
odontoblasts as a random event that lead to
changes in the resistance of the enamel to acid
attack.
CURRENT CONCEPT
Caries is perceived to be a prolonged imbalance in
the oral cavity such that factors favouring deminer
alization overwhelm factors that favour
remineralization or healing of tissues. Therefore, to
understand the caries process, it is^necessary to
probe the reaction process that occurs at the sur
face.
■
Demineralization
The mineral content of tooth surface is hydrmtyápatite 4Ca{₽O4 }¿ { OH }2] which is in equilibrium
and neutral environment saturated with calcium
and phosphate. It is reactive to hydrogen ions at
the critical pH of 5.5 and below. H+ ions react
with the phosphate group in the aqueous envi
ronment immediately adjacent to the crystal sur
face with the conversion of phosphate to
hypophosphate by addition of hydrogen ions be
ing buffered at the same time. The hypophosphate
is not able to contribute to the normal hydroxya
patite equilibrium because it contains phosphate
not hypophosphate. Thus the hydroxyapatite
crystal dissolves and the process is termed dem
ineralization.
SECTION' 5 : DENTAL CARIES IN EARLY CHILDHOOD |
■
Remineralization
PRIMARY MECHANISM OF CARIES FORMATION
The demineralization can be reversed if the pH is
neutral and there are sufficient calcium and phos
phate ions in the immediate environment. Either
apatite dissolution can reach neutrality by buff
ering or the calcium and phosphate ions in saliva
can inhibit the process of dissolution through
the common ion effect. This enables rebuilding
of partly dissolved apatite crystals and is termed
remineralization.
In simple terms the caries process can be explained
as:
CARIOGENIC
BACTERIAL
ORGANIC
TOOTH
[McIntyre et al, 1998]
[IN PLAQUE]
+
5.5
5.0
4.5
3.5
4.0
Hydrogen ions Demineralization: FA and HA
dissolve
HA dissolves,
reacts with
phosphate ions FA forms in
presence of
in saliva and
fluoride
plaque
If H
* ions
Remineralization exhausted or
FA reforms
neutralized and
all ions retained.
6.8
6.0
5.5
HA - Hydroxyapatitie
5.0
4.5
4.0
3.5 >
FA - Fluorapatite
Primary factors responsible for dental caries:
■
Caries is truly a multifactorial disease. Interaction
between 3 primary factors is essential for the
initiation & progression of caries; [Keys, 1960]
1. a susceptible host tissue, the tooth ;
2. microflora with a cariogenic potential;
3. a suitable local substrate to meet the require
ments of the pathodontic flora.
■
Caries Tetralogy (Newbrun 1982) includes a fourth
factor, time to the still existing concept of Keyes,
depicting the significance of changes taking place
over a period (Fig. 5.3, 5.4).
MINERAL
— ORGANIC
ACIDS
— LOSS OF
ENAMEL
BACTERIAL
DEMINERALIZED
TOOTH
6.0
LOCAL
SUBSTRATE
ACIDS
6.8
+
PLAQUE
DEMINERALIZATION-REMINERALIZATION CYCLE
Critical pH
SUITABLE
+
(DENTIN)
PROTEOLYTIC
— CAVITATION
ENZYMES
1. THE TOOTH
The three aspects of the tooth to be-considered
are,
- Composition
- Morphologic characteristics
- Position
a Composition
The enamel composition varies according to
the inorganic content as well as the crystal
configuration and size, \fcrious trace elements
are also present in the enamel, notably fluo
ride and carbonate.
■ It is seen that the surface is more resistant
to caries than the subsurface enamel. It has
also been observed that the surface enamel
is highly mineralized and tends to accumu
late more quantities of fluoride, zinc, lead
and iron than the subsurface layer. The sur
face contains less carbonate, less water and
has more organic material than the subsur
face layer.
■ The fluoride content of enamel & (fentin
from sound teeth was found to be 410ppm
and 873 ppm respectively; but only 139 ppm
and 223 ppm respectively in carious teeth.
I TEXTBOOK OF PEDODONTICS
Fig. 5.3 Primary risk factors in caries.
TOOTH
PH
flora
Fluorides
Morphology
Nutrition
Trace Elements
Carbonate Level
Strep, mutans
(Substrate)
Oral Hygiene
Fluoride in Plaque
co
TOOTH
FLORA
CARIES
SUBSTRATE
SUBSTRATE
Oral Clearance
SALIVA
Oral Hygiene.
Detergency of Food
Frequency of Eating
Carbohydrate (type, concentration)
Fig. 5.4 Secondary risk factors in caries (Neubrun 1982).
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD |
h The morphology of the tooth
The presence of enamel hypoplasia has been
seen to predispose the tooth to the develop
ment of dental caries & that the more severely
the tooth is affected, the more extensive will
be the caries. A type of caries has been de
scribed to occur in the cases of Linear Enamel
Hypoplasia [LEH].
■ Presence of deep, narrow occlusal fissures
or buccal or lingual pits predisposes to
caries. Such fissures tend to trap food,
bacteria and debris, and since defects are
especially common in the base of fissures,
caries may rapidly develop in these areas.
c. Position
' Teeth which are malaligned, out of position,
rotated or otherwise not normally situated may
be difficult to cleanse & tend to favor the ac
cumulation of food & debris. This in a sus
ceptible person, would be sufficient to cause
caries. Besides, certain teeth and in each tooth,
certain surfaces are seen to be more suscepti
ble to the occurrence of caries.
2. ESSENTIALITY OF ORAL BACTERIA
There is now enough convincing evidence that
caries is an infectious disease. The carious lesion
develops as a result of a change in the ecosystem
at the tooth surface and one of the essential fac
tors responsible for this change is the shift in thé
microbial community. A sterile oral cavity of the
newly born child withiii a few hours ofbirth starts
getting invaded by a good number of bacteria
notably the species Streptococcus, Neisseria,
Actinomyces, Veillenella and Lactobacillus. They
colonize the oral environment These bacteria must
be able to stick to the receptor sites in the mouth
including the teeth, tongue, cheek, or find refuge
in the places such as interdental areas, where they
can resist the flow of saliva to develop a carious
lesion. Various studies have proved that:
■ Streptococcus mutans is the important patho
gen in initiation of caries and takes about 5-6
years to penetrate the enamel of 2.7mm thick
ness in a human tooth.
%
■ Other microorganisms like Lactobacillus
acidophillus, Lactobacillus cassi, Actinomy
ces and certain species of Streptococcus san
guis also have the ability to produce caries,
biit their caries activity is not comparable to
that of Streptococcus mutans.
■ All the microorganisms produce extracellular
polysaccharide from either glucose or sucrose
■ The number of lactobacillus increases only
after caries lesion has developed.
■ Microorganisms capable of destroying dentin
must not only possess the ability to produce
acid, and to survive in aciduric conditions, but
also be able to break down the protein struc
ture of the dentin.
Window of Infectivity
Carfield (1993) monitored oral cavity levels from
birth upto 5 years. He noted the initial acquisition
mutans S. and designated the time period as ‘win
dow of infectivity’. As the teeth' (primary teeth)
erupt in to the oral cavity they provide a virgin
habitate which enable MS to colonize the oral cav
ity avoiding competition with other indigenous bac
teria. Thus in the window period in deciduous teeth
the MS is established by 7-24 months of age and
may have difficulty in establishing later because it
would need to compete with other indigenous bac
teria.
Krass etal (1967) Edrman et al (1975) reported 2-6
yrs of age the child is less susceptible to acquiring
MS. The ‘Second Window Infectivity’ is present in
permanent dentition between 6-12 years of age
(Klock and Kroske (1977). 90% of teenager have
MS colonization while others found only 3% of
adults (mothers).
Davey and Rogers (1984) reported that children ac
quire additional strain of MS as they get older and
new teeth emerge but remain undetected since they
are present in low numbers.
3. THE ESSENTIALITY OFORALSUBSTRATE
The presence of readily fermentable carbohy
drates has been thought to be responsible for
I TEXTBOOK OF PEDODONTICS
this loss of caries immunity. The cariogenicity of
a dietary carbohydrate varies with the frequency
of ingestion, physical form, chemical composi
tion, route of administration & presence of other
food constituents.
more effective in its buffering action than
unstimulated saliva.
■ The critical pH at which demineralization starts
is about 5.2 to 5.5, depending on the calcium
and phosphate concentrations of the mixed
saliva.
■ The tooth that erupts into the oral cavity is
not fully matured. After erupting into the oral
cavity, it undergoes a process of ‘post-erup
tive maturation’. This makes the tooth less
prone to caries as compared to the immature
tooth. Though the exact mechanism is not fully
understood, saliva has been thought to play a
key role in this process.
■ Although saliva does bring about the deposi
tion of calcium phosphate, it does not have
unlimited potential. The calcium and phos
phate in the saliva exist in two forms:
ultrafilterable and non-ultrafilterable. The
ultrafilterable form has the potential to come
out of the solution and thus it may precipitate.
On the other hand, the non-ultrafilterable form
is bound to salivary proteins that prevent its
precipitation. These proteins consisting of
statherin and proline rich protiens.also inhibit
hydroxyapatite formation by blocking crystal
growth of calcium phosphate.
§
Essential cariogenic factors regarding the diet
■ The frequency of consumption of sugar-containing food is directly proportional to the car
ies experience
■ The frequency of in between meal snacks of
candies, cookies, chewing gum or carbonated
beverages play an important role in increasing
the caries rate.
■ Frequent ingestion of sucrose even with a rela
tively low concentration of 1.25 % wall cause a
drop in pH to between 4 and 5.
« A significant correlation exists between a high
sugar concentration in saliva with a prolonged
clearance time and caries activity.
■ Retentive, sticky, sweet foods with a little de
tergent or self cleaning properties may be po
tentially highly cariogenic.
« Monosaccharides & disaccharides are more
harmful as they are easily fermentable than
polysaccharides.
4. ENVIRONMENT
■ The integrity of the enamel environment is to
tally dependent on the composition and chemi
cal behavior of the surrounding fluids, con
sisting of saliva and/or the plaque fluid.
Important mechanisms of salivary factors related
to dental caries are given in table 5.5
PLAQUE
■
Saliva
• Under normal physiological conditions, the
saliva is supersaturated in terms of calcium and
phosphorous with respect to the enamel sur
face. This prevents the hydroxyapatite from
dissolving in the oral environment as long as
the pH of the environment is maintained.
« A pH drop, initially is countered by the buffer
ing action of the saliva due to the bicarbo
nates and the phosphates. Stimulated saliva,
with a higher bicarbonate content is said to be
■
■
More important in the carious process is the
plaque tooth interface
The mechanism of carbohydrate degradation to
form acids in the oral cavity by bacterial action
occurs through enzymatic breakdown of sugar.
The mere presence of acid in the oral cavity is of
far less significance than the localization of acid
upon the tooth surface. Dental plaque acts as a
reservoir for holding acids at a given point for
relatively long periods.
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD |
Table 5.5: Important mechanisms of salivary factors related to dental caries
Salivary
Factors
Effects on
Mineralization
Effects on
Bacteria
Effects on
Bacterial
Aggregation or
¿Adherence
Main buffer in saliva
Releases NH3
Releases NH,■w
Buffering factors
HCO,
Urea
Agrinine-rich
proteins
Antibacterial
factors
Lactoferrin
Binds to iron, also
inhibits indepen
dently of iron
Lysozyme
Hydrolyzes cell wall
polysaccharides
May promote
clearance
through
aggregation
Peroxidase
Produces OSCN,
inhibits glycolysis
Secretory IgA
Neutralizes toxins
and enzymes
Binds to bacterial
surface, prevents
adherence
Alpha amylase
Produces glucose
Indirectly
produces glucans
and maltose
Factors
affecting
mineralization
Histatins
Bind to hydro
xyapatite aid in
supersaturation
of saliva
Proline-rich
proteins
Cystatins
Bind to hydro
xyapatite aid in
supersaturaticn
of saliva
Some inhibition
of mutans
streptococci
♦
i
Bind to oral
bacteria-promote
adherence in
some cases
>
Bind to hydro
xyapatite aid in
supersaturation of
saliva
Statherin
Mucins
Role in
raising saliva or
Plaque pH
Bind to hydro
xyapatite aid in
Bind to oral
bacteria-promote
supersaturation
of saliva
adherence in
some cases
Provide physical
and chemical
barrier in enamel
pellicle
Aggregation and
clearance of oral
bacteria (MG2)
<FF> | TEXTBOOK.OF PEDODONTICS
■
Factors in plaque that may be responsible for the
initiation of caries aré:
a. The ability of the plaque to buffer the pH
changes caused by a carbohydrate exposure.
This is also related to the rate of and diffusion
or concentration of the lactic acid produced in
■
Otherfoods
■
the plaque.
b. The quantitative and qualitative changes in ,
the plaque microflora. Thus the presence of
streptococcus mutans, in higher levels [ cariogenic] as compared to more benign microor
ganisms [Actinomyces, Veilonella] will deter
■
mine the predisposition to caries.
OTHER FACTORS CAUSING CARIES
Several investigators have suggested that pre
natal deficiencies of protein, minerals and vita
mins predispose the infant to subsequent devel
opment of caries.
The vitamin content of diet
A high incidence of caries was observed in the
enamel hypoplasia developed due to vitamin de
ficiency'.
Infants with rampant caries who had no history
of using a nursing bottle were found to be strongly
associated with vitamin deficiency.
Heredity
The racial tendency for high caries or low caries
incidence appears to follow hereditary patterns.
■ Black children exhibited less dental caries than a
comparable group of white children.
• A high DMF father & a high DMF mother are
seen to produce an offspring with a high DMF
rate.
■ A greater resemblance between identical twins
than between fraternal twins with respect to caries incidence is also noted.
Chronic administration of syrups sweetened with
sucrose in children, leads to an increased inci
dence of caries in their deciduous as well as per
manent dentition.
■
I
j
J
|
|
f
Systemic conditions
■
>
A
The presence of a systemic disease or abnormal
ity may directly or indirectly [ as a side effect of
treatment] affect the incidence of dental caries.
Xerostomia caused due to a variety of factors
such as due to drugs, irradiation of the glands
and diabetes mellitus can cause an increase in
the incidence of dental caries. Similarly, other diseases such as cystic fibrosis and phenylketonu
ria, which require a specific diet regimes and life
styles may also affect the caries incidence.
Protein
■
■
Protein deficiency during dental development
leads to a delay in eruption & a greater suscepti
bility to caries.
Protein has also been seen to protect against dem
ineralization of enamel.
Trace elements
Trace elements like selenium, cadmium, lead, manga
nese and barium have been found to increase the
caries experience.
CARIES RISK ASSESSMENT
Dental caries is a biosocial disease that can be pre
vented if certain risk factors could be identified in
susceptible individuals or community The risk
groups or individuals for the purpose of caries con
trol are presented in Table 5.6
SECTION'5 : DENTAL CARIES IN EARLY CHILDHOOD |
Table 5.6: High and low risk child groups for the purpose of caries control
HIGH RISK CHILD
LOW RISK CfflLD
Social History
Low socioeconomic status
Middle class/upper class
High caries in siblings
Low caries in siblings
Poor dental awareness
Conscious of dental health
Motivation level low
Motivation level high
Medical History
Handicapped (poor manual control).
No medical problem, handicap or
Medical conditions predisposing to
salivary deficiency with normal birth.
xerostomia.
Long term cariogenic medicines
(syrups).
Traumatic delivery.
Dietary Habits
Frequent sugar intake (solid exposure
Sugar intake in limits.
>3, liquid exposure >5).
Refined carbohydrate intake.
Less
Pacifier habits/prolonged breast
No such history.
feeding.
Fluoride
Fluoride deficient.
Optimum water fluoride level.
No fluoride supplements, toothpaste
- Fluoride supplements (if required
indicated) toothpaste used.
Oral Hygiene
Poor oral hygiene with excessive
i
Oral hygiene fair.
9
plaque accumulation.
Saliva
Low buffering capacity.
High buffering capacity.
Streptococcus mutans count (more
than 105)
Streptococcus mutans count
Lactobacillus count (CFU) less than
less than 105
Lactobacillus count (CFU) less than
10,000/ml saliva
1000/ml saliva
CEE) I TEXTBOOK OF PEDODONTICS
Caries susceptibility and activity
■
The commonly used Dentocult test was devel
oped by Larmas [1975]. It consists of running
undiluted saliva over a dip slide coated with a
slightly modified Rogosa agar and the growth is
compared with a standard illustration. Correlation
of 65-90 % have been found between counts of
lactobacilli and caries experience. In this test, a
count of more than 10,000 colony forming unit
permli.eC.F.U./ml of saliva is considered high,
whereas a count of less than 1000 C.F.U./ml is
considered low.
■
Indications for the use of Dentocult-LB count.
a. For pre-selection of patients for yearly or half
yearly check-ups in communities.
b. It is an important educational aid for motiva
tion and dietary counseling among patients.
For this it is important to show the results to
the patients and explain what they mean.
c. Control of the efficacy of dietary counseling.
d. Sometimes a high, steady lactobacillus count
indicates medically compromised patients. For
example, diabetes mellitus predisposes the
subject to lactobacillus growth.
e. An unchanged DentociSt-LB value is a con
traindication for expensive bridges, oral im
plants or orthodontic treatment The test may
be considered an insurance for the dentist
aga inst accusations of malpractice.
Caries susceptibility refers to the number of new le
sions that may develop in an individual over a period
of time while caries activity suggests the number of
lesions that an individual has at the time of record
ing (new and old).
The caries susceptibility varies in different individu
als, in an individual in different teeth and also on the
different surfaces of each tooth. The susceptibility
of the teeth and surfaces in descending order is given
below.
Primary teeth: Second molar, First molar, Canine,
Lateral, Central.
Permanent teeth: First molars, Second molars, Up
per second bicuspids, Upper first bicuspids and lower
second bicuspids, Upper central and lateral, Upper
cuspids and lower first bicuspids, lower central and
lateral incisors and lower cuspids.
Surfaces in primary teeth: Occlusal, molar inteiproximal area, incisor interproximal areas.
Caries activity tests
Tests based on the estimation of the micro-organism
numbers have been developed and these have been
related to the caries activity. These tests aid the cli
nician in educating the patients regarding his or her
caries activity and thereby help in motivating them
in good oral hygiene practices.
Counts of lactobacilli
Counts of lactobacilli represent one of the earliest
and most widely used tests of caries activity. It was
observed in the 1920’s that high numbers of lactoba
cilli were found in subjects with abundant carious
lesions, and it was consequently believed that lacto
bacilli are the causes of caries.
Counts of Streptococci mutans
■
Numbers of mutans streptococci have been as
sessed in samples of plaque and saliva. The pres
ence of streptococcus mutans in the oral cavity
is an indicator of the cariogenic infection. One
diagnostic problem is the fact that caries is not a
specific infection. Thus there are many people
with mutans infection in their oral cavity without
any signs of a caries attack, while abundant car
ies lesions occur in patients without mutans in
fection. Thus the diagnostic value of mutans is
only Relative.
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD |
■
The Streptococcus /tnutans tests are useful for
the following purposes:
a. For the preselection of patients fór dental ex
amination. Like the lactobacilli test it is not
accurate enough for the final diagnosis.
b. For the demonstration of cariogenic infection.
c. For the evaluation of the effectiveness of any
mouthrinse medication, providing an objective
measure for the treatment.
d. For didactic purposes in health education'
e. For diagnosing mutans bearing parents in a
family before eruption of the child’s decidu
ous teeth.
■
The commercially available systems are:
1. MSBB method[Matsukubo et al{ 1981}, Showa
Yakuhin Co. Ltd. Tokyo, Japan]
2. Caries Screen SM [ Jordan et al {1987} Apo
Diagnostics, Toronto, Canada]
3. Strip mutans test [ Jenssén andBratthal {1989},
Orion diagnostica Espoo, Finland]
All three are based on the fact that bacitracin
inhibits the growth of all other oral strepto
cocci except mutans on the mitis salivaris me
dium
CARIOGRAM
«
Recently, a new method of illustrating the inter
action of factors contributing to the development
of caries has been introduced by Bratthall et al
[1999] called‘CARIOGRAM’.
■
A pie circle diagram is divided into 5 sectors, in ’
the foiling colours.
1. Green? Shows an estimation of the‘ chance to
avoid caries’
2. Dark Blue: ‘ Diet’ is based on a combination of
diet contents and diet frequency.
3. Red: ‘ Bacteria’ is based on a combination of
amount of plaque and mutans streptococci.
4. Light Blue sector: ‘Susceptibility ‘ is based on
a combination of fluoride program, saliva se
cretion and saliva buffer capacity.
5. Yellow sector: ‘Circumstances ‘is based on a
combination of past caries experience and re
lated diseases.
Self-Assessment
1. What is caries tetralogy ?
2. Which are the micro-organisms that are respon
sible for the initiation and progression of caries ?
3. Which are the secondary factors of caries ?
4. What is the concept of critical pH ?.
5. What is cariogram?
6. How will you differentiate between high and low
risk caries based on the streptococcus mutans
count.?
7. List out the theories on the etiology of dental
caries.
8. Which are the most susceptible and least sus
ceptible teeth affected by caries ?
5.3 Early Diagnosis of Caries
Tandon S, Vanka A
Traditionally caries has been diagnosed by the means
bf visual examination, tactile sensations and by use
of Radiographs. However, with the emphasis being
on prevention in the true sense, i.e primary preven
tion, it is not just enough to be able to diagnose the
relatively late lesion, as by the above methods. The
methods for the detection of caries can be used ei
ther clinically i.e. in vivo or they can be used purely
for research purposes i.e. in vitro. Though the meth
ods used for research can sometimes be applied clini
cally as well, the quantification of the demineraliza
tion requires a histological section of the tooth and
thus may not be viable clinically.
■
Slides have been used to gather information about
caries. With the use of slides, the pictures of the
posterior teeth tell us more about discolourations,
decalcifications and translucencies than can be
discerned by oral examination.
•
The use of temporary elective tooth separation
as a diagnostic aid in general practice has been
stated in both deciduous and permanent denti
tion with more lesions being revealed with the
separator technique than with clinical examina
tion alone (Fig. 5.5).
Tactile examination
£
METHODS OF CARIES DETECTION
Various methods used for caries detection are
mentioned in Table 5.7
«
The explorer and the floss to certain extent have
been used for the tactile examination of the tooth.
The explorer can be of different varieties such as:
1. Right angle probe [No. 6]
2. Back action probe [No. 17]
3. Shepherds crook [No.23]
4. Cow horn with curved ends [no.2]
«
Over the years the teachings of the use of ex
plorer have been:
Visual examination
The Visual examination of caries encompasses the
use of criteria such as detection of white spot,
discolouration and frank cavitation: Visual examina
tion on its own and without aids can be quite unreli
able.
Aids in the Visual diagnosis of caries
•
A magnification loupe may be used as an aid in
the process ofvisual examination. The loupes are
comfortable to wear, relatively inexpensive after
an initial breaking in period and freely available in
various magnifications from various opticians.
1924
Black
“Passing the explorer into pits —,
noting whether or not there is any
softening, and whether the instru
ment catches or enters at any point”
1956
Simon
“Recognize change or marginal
changes around a previously placed
restoration. This can be accomplished
with a mirror and explorer"
if
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD |
1982 Gilmore
1. &iape of the fissure
2. ^^rpness of the explorer
"Susceptible site can be entered by
the use of a small sharp explorer or if
3. Force of application
4. Path of explorer placement
enamel is rough, decalcified or opens
to the dentin”.
1985
Marzouk "Sharp explorer - pressing this tip
into pits and fissures will cause it to
Radiographs
penetrate the enamel and /or dentinal
caries cone, making a definitive diagno
Conventional
sis of caries".
1985 Sturdevant
“Defects are best detected when an
Though conventional radiographs [Bitewing and
ЮРА] are most frequently used for the detection
of caries, they are associated with drawbacks that
it presents a 2-D image of an object, may cause
overlapping of the teeth due to faulty angulation
, more so with the useof bisecting technique and
may also miss the initial lesion.
■
explorer provides tug back or resist
ance to removal".
The use of explorer condemned because
■
«
■
Sharp probe tips can cause physical damage to
small lesions with intact surfaces. The validity of
the same has been shown to be poor.
Probing may lead to fracture and cavitation in the
incipient lesion. Normal dental examinations with
an explorer may spread the organism in the mouth.
Mechanical binding of the explorer in the fissure
may be due to non-carious reasons, leading to
the feeling of catch. This may depend on factors
such as:
Advances
A. Digital Radiography' either with Charge coupled
device technology or Storage phosphor screen
technology has been used and is said to have
added advantages such as:
■ Less image resolution.
Table 5.7: Methods of caries detection
In vivo
In vitro
• •
1. Visual examination
2. Tactile examination
3. Radiographs-Conventional, Digital
and Xeroradiography
♦
4. Fiber optic transillumination.
5. Optical methods - Fluorescence, light
scattering
6. Electronic resistance measurements
7. Ultrasonics
8. Dyes
■ Single tooth measurements
1. Chemical analysis
2. Cross sectional microhardness testing
3. Polarized light rpicroscopy
4. Traditional transverse microradiography
(TMR)
5. Microprobe analysis
■
1.
2.
3.
4.
Methods for sequential measurements
on tooth slabs
Iodine absorbitometry
Longitudinal microradiogrpahy
Light scattering
Surface microhardness
........................ -v-p-r;;.. ■ T
■■ '■ ■ i
■'•••• ■ ...............
f
?
:
1
II
<l№> I TEXTBOOK OF PEDODONTICS
Fig. 5.5 Use of separators for detection of
proximal caries.
Fig- 5.6a Proximal caries in anterior teeth not
clearly seen by visual examinaiton.
Fig. 5.6b Caries disclosed by using
fibre optic transillumination on
the same teeth.
Fig. 5.7 Detecting initial caries with
diagnodent.
Fig. 5.8 Electronic conductance
measurement for caries detection.
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD | (ED
■
■
■
■
■
■
■
Less radiation required
The image detector is generally larger.
Detector life-span is unknown.
The image is immediately available
Hard copy image is less diagnostic
Image can be electronically transferred.
Image may be enhanced.
B. Xeroradiography has also been used with the ad
vantages of less radiation and edge enhancement
along with its wide latitude of exposure.
Fiber optic transillumination (FOTI)
The principle of transillumination is that there is a
different index of light transmission for decayed and
sound tooth. Since tooth decay has a lower index of
light transmission than the sound tooth structure, an
area of decay shows up as a darkened shadow that
follows the decay along the path of dentinal tubules.
■ The use of FOTI has been proved to be effective,
specially when used in the anterior region (Fig.
5.6a, b). The usage in the posterior region is as
sociated with some difficulty. It has been thus
advocated as an adjunct to visual and radio
graphic methods. Dyes have also been used for
the enhancement of visualization.
Fluorescence
«
The use of fluorescence for the detection of car
ies dates back 1929, when Benedict observed that
normal teeth fluoresce under ultraviolet illumina
tion and suggested that this fluorescence might
be useful in the determination of dental caries
when monochromatic light is used at350,410and
530nm on carious and non-carious teeth. In the
* carious lesions the emission spectra shifts to more
than 540nm, or the red range of the electromag
netic spectrum. The largest difference between
the carious and noncarious spectra is found at
600iun. They stated that when the enamel is illu
minated with light in the blue-green range the ob
servable fluorescence occurs in the green-yellow
range. They also stated that this difference seems
to be greyer in this range than the blue fluores
cence obtained in the ultraviolet excitation.
■
Recently it lias been found that when illuminated
with argohlaser light, the carious tissue has a
clinical appearance of a dark, fiery, orange-red
colour and is easily differentiated from sound
tooth structure. Decalcified areas appear as a dull,
opaque, orange colour.
■ DIAGNOdent: A new method of caries detection
is the DIAGNOdent [patented by Kn\fo,1999]
which is based on the principle of fluorescence.
This system has a range of -9 to 99 with [-9J being
the value where the tooth is the healthiest The
advantage lies in the early, precavitation stage of
caries detection. It is also useful in determining the
amount of carious involvement [decalcification]
in different areas of the same tooth (Fig.5.7)
Electronic resistance measurements
■ The low conductance of the tooth is primarily
caused by the enamel At locations where the
pore volume of the enamel is larger, the electrical
conductance increases considerably. Since the
conductanceof the tooth and the resistance are
inversely proportional, the increased conduct
ance or decreased resistance are indicative ofthe
presence of hypo and/or demineralization. The
increased pore volume is due to the formatiopof
microscopic cavities, which are filled with saliva
to form conductive pathways for electrical trans
mission (Fig. 5.8).
«
When a potential of less than one volt is applied,
the resistance of above 600 OOOohms indicates
that the tooth is caries free. A resistance below’
250000 ohms indicates that caries involving the
dentin is present.
■ Recently, site specific and surface specific meas
urements have been found to be useful in the
detection of caries in the precavitation stage as
well.
I TEXTBOOK OF PEDODONTICS
Ultrasonics
Ultrasonics is the use of sound waves for detection
and this offers considerable potential as a diagnos
tic instrument.
■ With the use of this instrumentation, sonic ve
locity and specific acoustic impedance can be de
termined for the dentin and enamel as well as for
the soft tissue and bone.
■
The velocity of sound on the enamel surfaces
has been found to be Vs= 3,143 121 m/s. Compar
ing with a radiographic and visual inspection, it
has been found that white spot lesions with no
radiolucencies or radiolucencies confined to the
enamel produced no detectable or weak surface
echoes. All sites with visible cavitation and
dentinal radiolucencies produced echoes with a
substantially higher amplitude.
Dyes
■
Various dyes have been used in the detection of
enamel caries [Calcein,Zyglo ZL-22],and dentin
caries [Fuschin,Acid redsystem,9-Aminoacridine].
Though the use of dyes for the detection of cari
ous dentin is used in the removal of the same,
concern has been expressed that the use of dyes
is associated with excessive removal of the dentin.
■
The use of the dye is based on the fact that in
creased porosity -through tlie development of
capillary like microvoids -is the earliest change in
the carious lesion. Very fluid solutions, that can
strongly wet the enamel can be used to deposit a
fluorescent material in these pores.
■
Other methods such as Micro-air abrasion, Infra
red camera, Tuned aperture computed tomogra
phy have also been developed for the detection
of caries.
Self Assessment
1.
2.
3.
4.
5.
What are clinical methods of diagnosing caries ?
What are caries detector dyes ?
What is caries activity and caries susceptibility ?
List out the newer methods of caries detection.
What are the reasons the Use of the explorer has
been condemned ?
5.4 Nursing Caries and Rampant Caries
Tandon S
Nursing caries is an unique pattern of dental caries
in very young children due to prolonged and im
proper feeding habits. Even as the first primary tooth
starts erupting, the oral environment can be condu
cive to the initiation of demineralization. Inspite of
the fact that dental caries is diminishing in our youth
there are still a large number of children with ad
vanced multiple carious lesions, victims of parental
ignorance of nursing caries which is a distinct clini
cal entity. Hence this chapter is aimed to review this
important clinical problem in depth to enable the stu
dents to extend the best possible care to the infants
and toddler.
■
1. Pathogenic microorganism
■
«
■
Terminologies and definitions are given in Table
5.8
Classification of early childhood caries are given
in Table 5.9
♦
■
Prevalence of Nursing Caries are given in Table
5.10
<
Etiologic agents in nursing caries
Bovine milk, milk formulas and human breast milk
have all been implicated in nursing caries because
of their lactose contents. Additional sweeteners
in the form ofjuices, honey dipped pacifier can
also cause this type of caries.
■ The basic mechanism of demineralization (Caries
initiation) is the same and the caries tetralogy is
the key in the whole process of nursing caries as
all the four variables, pathogenic microorganisms,
substrates, host factor (tooth) and time are es
sential in causing demineralization.
•
Nursing bottle can effectively block the salivary
access to the tooth surfaces, thereby increasing
the cariogenicity of the oral flora.
■
Streptococcus mutans is the principle organism
which colonizes the tooth after it erupts into the
oralcavity.
It is transmitted to the infant’s mouth primarily
through mother.
It is considereclmore virulent because of the fol
lowing reasons:
a. It colonizes the teeth
b. It produces large amount of acid
c. It produces large amount of extra cellular
polysaccharides which favor plaque formation.
It is seen that a child’s infection is nine times
greater when maternal salivary count of S.mutans
is greater than 100,000 colony forming units per
ni
S.mutans is more commonly evident in rapid and
smooth surface caries and less common in pit and
fissure caries.
2 SubMrate (Fermentable carbohydrate)
Carbohydrates are utilized by microorganisms to
form dextrans which
a. adhere organisms to tooth surface
b. cause organic acid to demineralize the tooth
In infants and toddler, the main sources of
fermentable carbohydrate are:
I TEXTBOOK OF PEDODONTICS
Table 5.8: Terminologies, and definitions
Terminologies
Author and Year
Definition
Nursing Caries
Winter et al, 1966
An unique pattern of dental decay in young
children duerto prolonged nursing habit.
Nursing Bottle Mouth
Kroll et al, 1967
A syndrome characterized by-a severe
caries pattern beginning with the maxillary
anterior teeth in a healthy bottle fed infant
or toddler.
Nursing Bottle Syndrome
Bottle-Propping Carres
Labial Caries
Comforter Caries
Shelton et al, 1977
A devastating condition that may render
young children dentally c.rippled.
Night Bottle Syndrome
Baby Bottle Caries,
Nursing Mouth
Dilley et al, 1980
A unique pattern of dental caries in young
children.
Baby Bottle Mouth
Nursing Mouth Decay
Groll, 1984
A very destructive carious process which
can affect infants and toddlers.
Nursing Bottle Caries
Tsamtsouris, 1986
Caries caused by a prolonged use of a bottle
filled with any liquid other than the water.
Baby Bottle Tooth
Decay
Mim Kelly et al, 1987
A caries caused by bottle feeding only not
by breast feeding.
Milk Bottle Syndrome
■ Infancy Caries
■ Soother Caries
■ Circular Caries
Ripa, 1988
A specific form of rampant decay of the
primary teeth of infants.
Tooth Cleaning Neglect
Moss, 1996
Baby bottle decay is renamed to shift the
emphasis away from the bottle to the need
for cleaning.
RIECDD (Rampant infant
and early childhood
dental decay)
Horowitz, 1998
It does define the age group affected by the
disease and the usual rapidity of its
development
Early Childhood Caries
Davies, 1998
A complex disease involving maxillary
primary incisors within a month after
eruption and spread rapidly to involve
other primary teeth.
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD |
Table 5.9: Classification of early childhood caries
Type IECC
(Mild to moderate)
■
■
Carious lesions involving the nwlars and incisors.
Seen in 2 to 5 years.
1
■
Cause is usually a combinaron of cariogenic semisolid
or solid food and lack of oral hygiene.
Number of affected teeth usually increases as the cariogenic
challenge persists.
■
Type II ECC
(Moderate to
severe)
«
■
■
■
■
Type III ECC
(Severe)
■
■
■
«
Labio-lingual carious lesion affecting the maxillary incisors
with or without molar caries, depending on age.
Seen soon after the first tooth erupts.
Unaffected mandibular incisors.
Cause is usually inappropriate use of feeding bottle or at
will breast feeding or combination of both, poor oral hygiene.
Unless controlled it may proceed to an advanced stage.
Carious lesions involve almost all the teeth, including
mandibular incisors.
Usually seen in 3 to 5 years of age.
Cause is a combination of factors and a poor oral hygiene.
Rampant in nature and involves immune tooth surfaces.
Table 5.10: Prevalence of Nursing Caries
Country
Year of publication
Prevalence percentage
England
1967-1982
3.1 to 12.0 %
United States
1976-1987
1.0 to 53.1 %
*
Canada
1982
3.2 %
Australia
1985
5.4 %
South Africa
1978 to 1981
3.1 to 12.2%
Indonesia
1979
48.0 %
India (Manipal)
1996
65.5 %
I TEXTBOOK OF PEDODONTICS
Fig. 5.9 The central incisors are affected
quickly while the parents are still waiting for
the eruption of lateral incisors.
Fig. 5.10 Mandibular (occlusal view): The teeth
are affected in accordance with eruption
pattern, but the mandibular incisors
remain intact.
Fig. 5.11 Maxilla (occlusal view): The maxillary
incisors simply fractured. The first and
second molars are seriously
affected.
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD |
■
■
■
■
■
■
Bovine milk or milk formulas
Human milk (breast feeding at will or on demand)
Fruit juices and other sweet liquids
Sweet syrups like vitamin preparations
Pacifiers dipped in honey or sugar solution
Chocolates or other sweets
3. Host
■
■
■
■
Teeth act as the host for the micro-organisms
Hypomineralisation or hypoplasia of the teeth
increases the susceptibility of the child to caries
Thin enamel in the primary teeth is one of the
reasons for early spread of lesions
Developmental grooves also may act as the plaque
retentive areas
4. Time
Jt is an important factor that determines caries
activity. More the time child sleeps with the bot
tle in the mouth, the higher is the risk of caries.
This is because the salivary flow and the swal
lowing reflex decrease, thus providing more time
for the accumulation of carbohydrates in the
mouth which are acted upon by microorganisms
to produce acid leading to caries.
Fig. 5.12 Nursing caries affecting cervical third
of the upper anterior teeth.
a. Maxillary central incisors: Facial, lingual, mesial
and distal surfaces.
b. Maxillary lateral incisors: Facial, lingual, mesial
and distal surfaces
c. Maxillary first molars: Facial, lingual and occlu
sal, prominent surfaces.
d. Maxillary canine and second molars: Facial, lin
gual and proximal surfaces.
e. Mandibular molars: At later stage
■
5. Other predisposing factors
■
■
■
■
■
■
Over indulgence of parents
Crowded homes
Child who has less sleep
Malnutrition
♦
Recently, it has been seen that salivary gland
function is impaired by iron deficiency and ex
cess of lead exposure, which makes the oral envi
ronment more caries susceptible.
Low birth-weight infants (less than 2500 g)
CLINICAL FEATURES
The intra-oral decay pattern of nursing caries is char
acteristic and pathognomonic of the conditions. It
affects the primary teeth in the following sequence
of involvement (Fig. 5.12):
Mandibular anterior teeth are usually spared be
cause of:
a. Protection by thetongue
b. Cleansing action of saliva due to presence of
the orifice ofthe duct of the sublingualglands
veiy close to lower incisors.
Progression of the lesion
Initially, a demineralized dull, white area is seen
along the gum line on the labial aspect of maxil
lary incisors, which is undetected by the parents.
■ These white lesions become cavities which in
volves the neck of the tooth in a ring like lesion.
■ Finally, the whole crown of the incisors is de
stroyed leaving behind brown black root stumps.
■ This unique pattern and unequal severity of the
lesions is due to three factors:
- Chronology of primary tooth eruption
- Duration of deleterious habits of feeding
- Muscular pattern ofthe infants sucking
•
€S3 I TEXTBOOK OF PEDODONTICS
Implications
■
■
■
The child who has nursing caries has an in
creased risk of developing caries even in the per
manent dentition.
The child with caries is also susceptible to other
health hazards.
The treatment of nursing caries may prove to be
financial burden for some parents.
Management
■
■
■
■
Aims
■
■
■
«
Management of existing emergency
Arrest and control of the carious process
1 nstitut ion of preventive procedures
Restoration and rehabilitation
Factors affecting management
■
■
■
Extent of the lesion
Age of the patient
Behavioral problems of the child due to young
age of the child
Treatment proper
It can be divided into three visits.
First visit
This phase of treatment constitutes treatment of the
lesion, identification of the cause for counseling of
the parent.
■ All lesions should be excavated and restored
■ Indirect pulp capping or pulp therapy proc dures
can be evaluated by further investigation.
« I f t he abscess i s present it can be treated through
drainage
■ X-rays are advised to assess the condition of the
succedaneous teeth.
■ Collection of saliva for determining the salivary
flow and viscosity.
« Also, the application of fluoride topically
Second visit
It should be scheduled one week after the first visit.
■ Analysis of diet chart and explanation of the dis
ease process of the child’s teeth should be un
dertaken by a simple equation.
■ Isolate the sugar factors from the diet chart and
control sugar exposure by intelligent use.
■ Reassess the restoration and redo if needed.
■ Caries activity tests can be started and repeated
at monthly intervals to monitor the success of
treatment.
Third and subsequent visits
■
■
«
■
■
The parent should be questioned about the child’s
feeding habits, specially regarding the use of
Restoring all grossly decayed teeth
Endodontic treatment
In case of unrestorable teeth extractions can be
done followed by spade maintenance.
Crowns can be given for grossly decayed or endodontically treated teeth.
Review and recall after every 3 months
Prevention
■
Parent counseling
«
nocturnal bottles, demand the breast feeding,
pacifiers dipped in sweetening agents.
The parents should be asked to try weaning the
child from using the bottle as a pacifier while in
bed.
In case of considerable emotional dependence
on the bottle, suggest the use of plain or fluori
dated water.
The parents should be instructed to clean the
child’s teeth after even7 feed.
Parents are advised to maintain a diet record of
the child for one week which include the time,
amount of food given to the child, the type of
food and the number of sugar exposures.
■
The main strategies for the prevention of nursing
caries should be to create awareness and alert
prospective parents and new parents about the
condition and its causes.
Information on nursing caries can be distributeä
to new parents through obstetricians or
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD I
Table 5.11: Nursing Caries Vs Rampant Caries
'■n"........ ^9
Age of occurrence
■ Seen in infants and toddlers.
■
Dentition involved
« Affects the primary dentition.
t
Etiology
« Several factors, primarily related to
improper feeding practices such as:
- Bottle feeding before sleep.
- Pacifiers dipped in honey/other
sweeteners.
- Prolonged at will, breast feeding.
Treatment
■ If detected in early stages, can be
managed by topical fluoride applications
and education.
♦
■ Directed toward maintenance of teeth till
the transition occurs.
Prevention
■ At the young age as the child is in
constant contact with the mother,
education of prospective and new
mothers is desired specifically.
...........
■ Acute, widespread caries with early
pulpal involvement of teeth which are
usually immune to decay. (Fig. 5.13)
Specific form of rampant caries.
Characteristic features
■ A specific pattern of involvement is seen.
The maxillary incisors followed by the
molars are involved.
■ Significantly, the mandibular incisors are
not involved.
"■■■
Rampant Caries
Nursing Caries
■
................
Seen at all ages, including adolescence.
■ Affects the primary and permanent
dentition.
Surfaces considered immunie to decay are .
involved. Thus, mandibular incisors ?re
affected.
■ Rapid appearance of new lesions and not
just years of chronic decay due to neglect
■
More multifactorial with all the essential
factors involved and not just feeding
practices.
■ Frequent snacks, excessive sticky refined
carbohydrate intake. .
■ Decreased salivary flow.
« Genetic background.
■
« With presence of multiple pulp exposures
would generally require pulp therapy.
• Long term, treatment may be requited when
permanent dentition is involved.
■
Dental Health Education at a mass level
involves people at all ages.
03 I TEXTBOOK10F PEDODONTICS
■
■
■
■
■
gynecologist, pediatricians, paramedical staff,
health workers and maternal and child health care
centers.
Sealing of all caries free pits and fissures
Professional fluoride programs
Use of antimicrobial therapy topically
.
Supervised home care should be taught
Systemic fluoride program if there is sub optimal
fluoride concentration in drinking water.
Parents should be educated
- how and when to feed the child during the
earliest stages of the child
- when and how to introduce solid foods
- breast feeding should be encouraged as hu
man breast milk is highly adapted to the hu
man infant and is almost a complete source of
all required nutrients.
Broadly based committees at governmental level
to address the i ssue of caries and the risk factors
in young children and how to recognize early signs
of the condition and promote early intervention.
3. What are the stages of nursing caries?
4. List out file key differences between nursing and
rampant caries.
5. What are the pre disposing factors of nursing
cari^?; ...
Further Suggested Reading For Section - 5
1. Al Ghanim NA, Adenubi JO, Wyne AH, Khan
■
NB. Caries prediction model in pre-school chil
dren in Riyadh, Saudi Arabia. Int J Pediatr Dent;
8:115-22.1998.
2. Alder M E: Intraoral digital radiography. Year
book of dentistry 105-96-18-2:478-480,1996.
3. Arnold L V: The radiographic detection of initial
carious lesions on the proximal surfaces of teeth.
Part 1. The influence ofexposure conditions. Oral
■
Surg Oral Med Oral Pathol.64:221-231,1987.
4. Bab I A; Feuerstien O; Gazit D: Ultrasonic detec
tor ofapproximal caries. Caries Res 31:322,1997.
5. Billings R J: Restoration of carious lesions of the
root. Gerodontology.5 :43-49[1986] cited in
Nursing Caries Vs Rampant Caries are given in
Newbum Ernest: Problems in caries diagnosis.
IntDent J.43:133-142,1993.
Table 5.11
Choksi Soli K: Detecting approximal dental car
ies with transillumination: A clinical evaluation.
J Am Dent Assoc. 125:1098-1102,1994.
Dowd. F J : Saliva and dental caries. DCNA
43(4),579-598,1999.
Ekstrand K V ; Qvist A ; Thylstrup O : Light
microscope study of the effect of probing in oc
clusal surfaces. Caries Res. 21:368-374,1987.
FusayamaT; Terachima S: Differentiation of two
layers of carious dentin by staining . J Dent
Res.51:866,1972.
Huysmans J M ; Verdonschot E H ; Rondel P :
Electrical conductance and electrode area on
Fig. 5.13 Rampant caries affecting teeth not
sound smooth enamel in extracted teeth. Caries
usually prone to decay.
Res 29:88-93,1995.
Self-Assessment
11. Lopex J: Xeroradiograpy in dentistry. J Am Dent
Assoc 92[1]: 106-110,1976.
1. Define Rampant caries.
12. Mitropoulos C: A comparison of fiber optic tran
2. What are the other terminologies of nursing
sillumination with bitewing radiographs. Br Dent
J.159[l]: 21-23,1985.
caries?
SECTION 5 : DENTAL CARIES IN EARLY CHILDHOOD | Œ)
13. Mouyen Francis; Benz Cristoph ;Sonnabend E
et.al: Presentation and physical evaluation of Ra
dio Visio Graphy Oral Surg Oral Med Oral Päthol.
68:238-42,1989.
14. Reisine S, Douglass JM. Psychosocial and
behavioral issues in early childhoodjarifö. Com
munity Dent Oral Epidemior.26:SuppI 1:3244.1998
15. Tinanoff LW. Introduction to the Early Child
hood Caries Conference: initial description and
current understanding. Community Dent Oral
Epidemiol;26:Suppl 1:5-7,1998
16. Wyne AH. Early childhood caries; nomenclature
and case definition, Community Dent Oral
Epidemiol;27:^3-5,1999.
SECTION - 6
Preventive Approach to
Caries Control
6.1 Infants Oral Health Care
Tandon S
introduction
The preventive and treatment protocol would be
guided by the risk group of the individual as out
lined in the Table 6.1.
preventive measures in its truest formi.e. 'primor
dial’ or 'primary’ prevention. Time and again, meas
ures initiated before the onset of the disease have
proven to be effective.
Why infant oral health care?
The caries preventive program needs an individual
ized approach which can and should be started right
fromfhe prenatal period through infancy to adoles
cence and even further. It thus includes measures
such as:
«
•
•
•
■
infants oral health care
parent counseling, diet counseling
fluoride programs
pit and fissure sealants and
other methods on the horizon.
INFANT ORAL HEALTH CARE
While the industrialized countries may claim of a re
duction in the caries incidence, developing coun
tries such as India still face an uphill task, as the
caries incidence is still on the increase (not with
standing the goals of WHO). In an attempt to strike
at the root of the problem, Infant Oral Health Care is
an invaluable foundation step. While assessment as
to the risk of the infant developing oral diseases in
later life, may not be entirely accurate, a general policy
will go a long way in reducing the incidence of the
same. What better timing exists, than to initiate the
■
Oral mucosa is the first in the human body where
microorganisms are seen to be established soon
after the birth within 6 to 8 hours in an infant who
may be considered as a child who'has not yet
reached the age of one year.
§
L Oral cavity of the infant is invaded by a variety of
microorganisms but most of them are transient.
Streptococcus is found to be consistently present
within few hours after birth,
2. The eruption of teeth is an event that brings about
a qualitative and quantitative change in the
microflora. The colonization of the 'Pioneer Bac
teria’ is a special process, which then gives a
substrate to attach the 'Secondary Invaders’.
Oral health care measures at this stage prevents
the colonization by the secondary and generally
more pathogenic microorganisms.
1. Infectious diseases of the oral t avity: It has been
proven that streptococcus mutans, a primary
causative factor in the initiation of caries, is trans
mitted from the mother to the infant. These gather
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL | WÜ
Table 6.1: Modalities of treatment based on risk assessment
HIGH RISK GROUP
LOW RISK GROUP
Professional
Therapy
Home Care
« Oral prophylaxis
■ Complete rehabilitation
of all carious lesions.
■ Antimicrobial therapy
(chlorhexidine gel)
« Pit and fissure sealants
(specially in young
permanent teeth)
■ Topical fluoride
appliations (preferably
varnish)
« Diet modification
■ Dental health education
A more frequent recall
and review program
(every 3 months)
■ Supervised home care
(use of disclosing agents
for patient motivation)
■ Home fluoride application
« Sustained release of
fluoride tablets.
■ Self gel applications
■ Fluoride dentifrice (if not
in use, above 4 years)
■ Salivary substitutes (in
case of xerostomia)
■ Chewing gum with
anticariogenic properties.
....
/
a foothold in the mouth immediately after the erup
tion of teeth.
With a weaning of the diet and adoption of a cariogenic diet, caries may develop in the oral cavity
and cause severe and rapid destruction of the
hard tissues if left unchecked. The diet, particu
larly drinks with low pH, has the potential to cause
erosion.
Nursing bottle caries has been found to be preva
lent in the population due to faulty feeding prac
tices by the mothers.
2. Traumatic injuries: With lack of motor coordina
tion, trauma to the developing primary dentition,
may also occur.
3. Habits: Such as thumb sucking usually have their
inception at this age and may persist to cause
..
.....
professional
Therapy
Home
Care
■ Annual
topical
application
■ Regular recall
for 6 months.
■ Dental health
education
■ Fluoride
dentifrice
(if not in use)
4. Child abuse and Neglect may also be detected.
5. Handicapped children, cleft lip, palate cases'and
other such children requiring special attention,
may do so right frontbirth.
6. Problems of speech, language would require early
detection.
To all these problems, the traditional approach has
been to treat the effects of the disease. By delineat
ing an infant oral health policy, one may not have to
encounter the disease process or its effects.
Thus Nowak (1997) has stated that “the goal of the
first oral supervision visit is to assess the risk for
dental disease, initiate a preventive program, pro
vide anticipating guidance and decide on the periodicity of subsequent visits”.
I TEXTBOOK OF PEDODONTICS
How to proceed for infant oral health care?
As in the evaluation of any case, a proper history
coupled with a vigilant assessment including knowl
edge of what is normal and what is not at this age is
This in turn brings us to the queries of the par
ents as to when do the teeth erupt. The age at
which teeth erupt varies greatly between children
and a difference of 6-12 months can be considered normal.
essential.
L History: A detailed history involving the prena
tal, birth and post natal periodsis necessary. De
mographic details of the parents including the
socioeconomic status need to be evaluated.
Grindefford (1995) has stated that one of the fac
tors which is a significant predictor of early car
ies development is socio-demographic factors
(importantly, the mother’s education).
2. Examination: A deQtjst should not be blinded by
the necessity to do a dental examination only. ‘ A
general assessment would provide an insight to
systemic problems, if any. Once satisfied that the
infant is in apparently normal health, a thorough
oral examination is warranted.
j
I
■
|
|
|
3. Risk assessment is carried out by noting down
various factors. These include dietary factors,
amount of the plaque present on the teeth present
|
and feeding practices. This should be followed
by customization of a preventive protocol, rather
than generalization.
j -e: :
4. Any therapy, restorative procedure or prophylactic measures needed should be instituted.
.
1 Role
of dentist
.......
$ ■■ ■:
I-The dentist is a valuable source of information, on a
i one to one basis or in small gatherings. On a larger
; scale, the dental association can be involved in teachJfling the masses.
< The timing of first visit - The dentist is well placed
to decide as to when the child should visit the
H dental operatory. With the benefits of a compre
hensive preventive program well documented, the
first dental visit should be within the first six
I months ofthe eruption ofthe first primary tooth.
Age
Teeth erupted
6-10 months
Bottom front teeth then top front
or side bottom front teeth
9-13 months
Top front teeth
13-19 months
First molars, then canines,
then second molar
2 14 - 3 years
All the teeth
Since the parent encounters eruption of teeth for
the first time, the signs of teething should be made
aware to the parent. Various home remedies may
be traditionally carried out in these circumstances,
such as rubbing honey over the gums. Such prac
tices predisposing to caries should be strictly dis
couraged. Symptomatic treatment such as teeth
ing toys or hard sugar free rusks are however
acceptable.
b. Feeding practices: From nutritional point of view,
breast milk has several systemic and immunologic
advantages over proprietary formulas. Thus the
importance of breast feeding cannot be over em
phasized.
However, on the flip side, prolonged and at will
breast feeding, beyond the stipulated weaning
time of the child, specially throughout the night
and sometimes throughout the day, has been as
sociated with nursing caries;
Breast feeding Vs Bottle feeding is given in
Table 6.2
Importance of weaning
Weaning is a process of expanding the diet to in
clude foods and drinks other than breast milk or milk
formulae.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
i
Table 6.2: Breast feeding Vs Bottle feeding
Breast Feed ing
s
£
Bottle Feeding
Functions:
■
■
■
It stimulates the muscles around the
mouth and tongue activity for normal
growth of the teeth and jaws
Breast feeding allows milk flow on
demand
It allows gravity working correctly oh
the muscles involved in swallowing
■ Muscles don’t have to work hard, hence
normal growth of the teeth and jaws may
get affected
■ Milk flows from the bottle in a continuous
flow thus does not allow muscles to work.
■ Bottle feeding while lying on their back
keeps the tongue in a unnatural forward
position to keep from drowning
Nutrition:
a
a
a
a
Milk is more nutritious as it is a complete
source of all required nutrients
Easily digestable
Higher percentage of lactoalbumin rich in
sulfur containing amino acids
Higher percentage of certain vitamins like
vitamin C and D are present
a
a
a
It may not provide, complete nutrition as
some children are not able to digest it
easily because of the nature of its fat
Percentage is less
Do not have sufficient amount
Immunologic
a
Colostrum rich in certain antibodies like
IgA and contains maternal macrophages
which protect the child against infections
a
It lacks this natural defence against
infection
a
Does not contain colostrum
No control on overfeeding and gain more
weight during the first year of life, which
is not desirable
More common
Incidence is high
Others'
■
a
a
a
■
Colostrum may contain a gut control factor
and stimulate growth of Gl tract
Infant controls own intake and reduces
possibility of feeding
Reduced risks of the ear and respiratory •
infections
Decreased incidence of deleterious habits
Weaning brings about the introduction of a more
sophisticated diet and includes infant foods as
well. It is suggested that vegetables be intro
duced before fruits so that the infant develops a
habit to accept the vegetables, while the sweeter
fruits are naturally welcomed.
Bottle feeding: Often, parents who are too busy
to deal with the crying child, try to quieten the
child by using the bottle containing milk or other
sweetened drinks as a pacifier. This, when given
frequently to the child before and during sleep
a
a
a
nursing caries. In this respect, the sugars taken
nis
before sleep, when little saliva deansing a
present, should be assessed and highlighted to.
the parents. A simple schematic representation,
of the carious process, with the acid production
destroying the teeth should be explained.
Some important tips on Bottle feeding
Parents should be instructed to:
■ Provide more attention to the child
■ Remove the bottle immediately after feeding
■ Substitute the milk or non-sweetened juices with
nloin
wofpr
I 'TEXTBOOK OF PEDODONTICS
■
■
■
«
•
w
Encourage your baby to stay in upright position
with a bottle
Use a bottle with a nipple that has a small hole to
enable the infant to work with his muscles activ
ity to get the milk from bottle (Fig. 6.1)
Introduce a cup to drink as soon as possible
Bottle feeding be allowed atintervals
It should not be used as a pacifier
Give water after feeding with the bottle and clean
the mouth soon after feeding
This cleaning activity should be preferably performed
after every meal or at least once in a day. Besides the
maintenance of good oral hygiene at this age, this
routine also goes a long way in establishing a prac
tice to be followed in the years to come.
The parents should be advised to thus take care of
the gum pads and teeth as they erupt, till the time
where the child develops sufficient neuro muscular
control to brush his/her teeth.
iii. Pacifiers: Several disadvantages have been
found with the use of pacifiers (Fig. 6.2a,b) such
as:
■ those dipped in honey or sugars can cause
increased caries
■ malocclusion
■ unhygienic conditions leading to infections
and GIT disorders
D. Anticipateiw guidance
Nowak (1995) describes anticipatory guidance as a
proactive, developmentally based counseling tech
nique that focuses on the needs of a child at each
stage of life.
Edwall's physiologic
pacifier.
Edward’s functional
nursing nipple.
Fig. 6.2a
Nuk sugar
(cross sectional view)
Fig. 6.1 Difference betweenNuk sugar and
Conventional Nipple.
Primary pacifier
Secondary pacifier
Fig. 6.2b
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL | FIFl
What it effectively means is that one should not get
disheartened, for many times a patient may lack co
operation at this young age. Providing an insight
into the development of a child will involve the par
ent, with a much more focussed strategy. Also, at
every stage it is essential that the dentist takes into
consideration the various milestones of dental de
velopment. Such anticipatory guidance can make the
parents more at ease during childhood dental visit,
these pointers are also essentials inpreventing many
of the possible dental problems children would oth
erwise often face.
E Oral hygiene practices
Many parents would not be even aware of the fact
that oral hygiene practices can be essential at this
age.
A thorough intra oral examination may reveal the
plaque on the tooth surfaces and food debris as well.
In such cases and in all other cases as well if the
child has been brought early, the proper technique
for positionBg and tooth cleaning should be dem
onstrated.
i
Gum pads: The cleaning of gum pads can be
started as early as within the first week of birth.
Cleaning infants mouth (Fig. 6.3a, 3b)
The parents can be instructed to:
« Lay the baby down with his/her head in your
lap and feet pointing away
« Open the baby’s mouth and slide the forefin
ger inside along the cheek and press down on
the back side lower gum pad.
■ Take a small gauze (2” x 2”) between thumb
and forefinger and wipe vigorously over the
ridge of the baby’s top and bottom jaws.
■ Nowadays specially designed for infants tooth
brushes, finger cots and wipes are available,
which can also be used.
« Use adequate pressure just to remove the film
that covers the child’s gum pad.
■ Clean at least every day twice after morning
and last feed in the night.
■ Spend at least two to three minutes in cleaning.
Fig. 6.3a Upper gum pad in infant
Fig. 6.3b Lower gum pad in infant
being cleaned with wet gauze
being cleaned with wet gauze.
Q© I TEXTBOOK OF PEDODONTICS
ii. Teeth: The positioning of the infant, depending
on whether one or both the parents are involved
in the procedure should be first demonstrated and
then supervised by the dentist.
■
Weaning foods free of, or low in non-milk extrin
sic sugars be recommended to the mothers.
■
Depending on the amount of fluoride present in
community water, and the requirements of the
child, a fluoride supplementafiofiprogram can be
instituted.
■
Pediatrician should be made aware of the dentist
population in Iris vicinity for the purpose of refer
ral. This in cases of large multi-specialty centers
is easily done, but in smaller places with dental
centers spread over a larger area may be difficult.
While performing these procedures care should
be taken that the child is supported at all finies
and the movements are slow and careful, so as to
not cause any injury and address the problem in
that light, not just keep reinforcing a particular
set of instructions.
Role of pediatricians
■
The pediatricians or prima ry care physicians treat
infants and monitor the growth and development
of children. They are thus usually the first health
care providers and can act to evaluate their oral
health status.
«
In this respect, they can be the forebearers in
providing information to the parents as they are
more often in contact with the child and parents.
The dentist should establish a contact with
pediatrician and formulate a policy regarding den
tal health for the infant.
«
Following topics needed to be discussed
- Tooth eruption
- Preventive oral hygiene
- Orofacial development
- Fluoridation
- Diet
*
•
Johnson (1997) has also discussed the interac
tion with the pediatrician at the time of weaning.
When the child is 10 months old, the assertive
ness of the child may make the parents to give in
by giving a sleep time bottle. A solution sug
gested is the gradual dilution of the liquid. Thus
1 week
1/3 bottle water
2nd week
2/3 bottle water
3rd week
only water
Role of other personnel
Nurses, midwives do not always manage the care of
the neonate beyond the first few weeks of life, but
they can be assets in providing guidance and refer
ral if anticipated at the time of the newborn screen
ing. They can provide information about immuniza
tion, accident prevention and dental health.
■ The need for commencement of tooth brushing
or cleaning with gauze as soon as the first tooth
erupts can be emphasized through prenatal
classes by the gynecologist or obstetrician.
■ Neonatalogists can also play a significant role by
advising and counseling the parents regarding
any congenital defect, such as cleft lip and pal
ate, regarding the dental and the overall health
aspect of the child.
■ Importance of breast feeding can be emphasized
by these medical personnel.
■ Mothers can be informed about the transmission
of antibiotics via breast milk and their effect of
dental health.
■ Importance of the mother’s own oral hygiene is
equally important as poor oral health of the mother
can affect the health of the fetus and the new
born. Poor maternal periodontal health has been
found to increase the potential for pre-mature low
birth weight of babies. High caries level in the
mother can result in an equally high level in the
child.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL 1 6D
Guidelines to parents
Children are our most precious resource. Their opti
mal oral health should be provided not only on a
therapeutic but also on a preventive basis early in
life itself. Parents should be educated at the earliest
possible time by not only the dentist but also the
general practitioner in order for to provide them a
disease free environment.
1. The parents should bring their child for his/her
first dental visit early, at least by the time the baby
is 6 months of age.
2. Breast feed the baby but do not indulge at will.
3. Avoid frequent use of the bottle with sugared
milk or drinks as this can lead to nursing bottle
caries. Instead, give the child more attention.
4. Do not put the child to bed with the bottle or at
the breast but take the bottle away immediately
after feeding.
5. Dilute the milk gradually in the bottle and end
with plain water.
6. Feeding should be supervised at all times.
7. Start the child on semi-solid foods by 5-6 months
and reduce the use of bottle or breast feeding.
8. Do not use pacifiers or dummies dipped in honey
or other sugar items.
9. Avoid extended use of sugared medicines such
as syrups.
Clean thrums and later teeth with a cloth or soft
brush after every meal or before sleep.
Parents should brush or clean their baby’s gums/
teeth everyday till the child is old enough to man
age himself.
12. Contact the dentist immediately if there is any
accident or trauma to the baby 's teeth.
13. Parents should know about the benefits of fluo
ride and its proper use such as that used in infant
formulas and dentifrices.
14. Half- yearly visit to the dentist should be routine.
Self-Assessment
1. What are the reasons for starting oral health care
in the infants?
2. What do you understand by the colonization of
pioneer bacteria?
3. When does the oral cavity get invaded with the
microorganism?
4. What is ‘anticipatory guidance’?
5. What is the role of the pediatrician in infant’s oral
health care?
6. List out the differences between breast and bot
tle feeding?
7. How are the gum pads of the infant cleaned?
8. Summarize the various measures involved in im
parting oral health care to infants?
6.2 Parent Counselling
Tandon S
When we consider the tremendous backlog of unmet
dental needs and ever-increasing demand for care, it
becomes obvious that dental disease, can not be
controlled by treatment alone. It can be managed
only through prevention, especially in children.
Health education is thus basic to prevention.
Parents serve as role models and children are influ
enced early in life by their varying opinions. In the
dental setting the cooperation of the child is directly
related to the opinion and anxieties of the maternal
figure. Thus to change the children’s dental behavior
effectively, dental health educators and professional
need to target the mothers and educate them to be
come models of proper dental health practices.
■
■
Obtaining the cooperation of a child patient, es
tablishing a good rapport with the child and also
using effective techniques of behavior manage
ment
Educating the parents about various dental prob
lems and diseases and their sequelae and how
they can be prevented with accurate preventive
measures if recognized earlier.
IFWE ARETO HAVE A GOOD CHILD PATIENT WE MUST
FIRST EDUCATE THE PARENTS. A DENTIST WHO FAILS
TO DO SO IS NOT USING EVERY MEANS AVAILABLE TO
HIM IN MANAGEMENT OF THE CHILD.
INSTRUCTIONS TO THE PARENT
«
Definition
Parent counselling can be defined as educating the
parents regarding the child’s oral health status, opti
mal health care and informing them about the pre
vention of potential dental diseases
Purpose
The purpose of parent counselling in pediatric den
tistry involves:
• Discussion of emotional problems of children,
particularly in relation to dental treatment.
■ To offer the dentist an insight into parental influ
ences which may produce unnecessary anxieties.
■ Knowing about the attitude of parents towards
behaviour management techniques used during
dental treatment of children.
Inform the parents:
■ Not to voice their own personal fears in front of
the child.
■ Never to use dentistry as a threat of punishment.
■ To familiarize their child to dentistry by taking the
child to the dentist. This helps in making the
child accustomed to the dental office and to get
acquainted to the dentist.
■ About the home environment and importance of
moderate parental attitudes in building well-ad
justed children. Regular dental care helps in pre
serving the teeth and also in formation of good
dental patients.
■ Never to shame, scold or ridicule the child to over
come the fear of dental treatment.
■ Not to promise the child what the dentist is or not
going to do.
SECTION 6 : PREVENTIVE ^PpRdACH TO CARIES CONTROL |
■
■
■
s
Not to bribe their child to go to the dentist.
To convey to the child in a casual manner that
they have been invited to visit the dentist.
To commit the child to dentist’s care in the office
and should not enter the treatment room unless
requested by the dentist.
---Occasional display of courage by the parent’s in
dental matters will build courage in the child.
EDUCATION OF PARENTS IN VARIOUS ASPECTS
OF DENTISTRY
Preventing dental diseasefrom conception to
3 years of age:
a
A large number of children experience a dental
disease before 3 years of age. Nursing caries is
particularly a devastating form of caries frequently
seen in this age group. Thus, it is important to
educate the parents so they can make appropri
ate decisions regarding the management oftheir
infants and toddlers oral health.
PARENTS EDUCATION GUIDELINES FOR INFANTS
AND TODDLERS are given in Table 6.3
Prenatal counseling: Parents should be educated
regarding:
a. Dental development of their child.
b. The dental disease process.
c. Appropriate feeding practices emphasizing the
hazards of improper bottle and breast-feeding. 4
d. Oral hygiene measures appropriate for infants and
toddlers.
e. Expectant parents can also be told regarding the
mother’s health during pregnancy and the potentiat detrimental effects that poor health and un
healthy habits may have on their child’s dental
development.
f. Also in pregnancy the food need increases to
meet the special physiological changes in the
body to support the growth of the foetus and
facilitate normal labour.
Why are the p rimary teeth important?
a
Primary teeth act like the foundation stone for
permanent teeth.
■ They maintain proper space for the permanent
teeth to occupy.
■ These teeth help in normal growth ofjaw height
and give shape to the face, just like in older indi
viduals whose face looks completely collapsed
when they take out their denture.
■ Teeth provide a sense of self worth by contribut
ing to one’s appearance.
8 Primary teeth certainly help in the first step of
grinding of food, once the infants start eating
solid food.
Preventing dental diseasefrom 3 to 6 years ofage
Children in this age group frequently exhibit gingivi
tis and may experience rampant decay. The rampant
decay is often a sequelae to nursing caries initiated
during the first 3 years of life or extensive caries may
develop as a result of eating patterns initiated after
weaning.
1. Diet: Pa rents are educated about the role of diet
and their ill-effect on initiation of caries.
*.
nil
8 - The frequency of exposure is the most impor

tant factor in development of dental caries.
■ The rate at which sugar is cleared from the oral
cavity is also the important factor in the cariogenic potential of a food. The sticky reten
tive items such as chocolates, toffees have
• When the exposures are too frequent or the
sugar is retained too long, the net result is dis
solution of tooth structure and formation of a
cariouslesion.
* Food items that can be recommended as relamilk, sugarlessgum, and raw vegetables. Items
to be particularly avoided include sugared gum,
tfFÏÏÏ I TEXTBOOK OF PEDODONTICS
Table 6.3: Parent's education guidelines for infants and toddlers
Dentist’s action
Content area
Oral development
Gum padg.to^ompletion of primary
dentition.
Establishment of occlusion.
Discuss the patterns of eruption.
Discuss the myths about unhygienic habits
practised during teething.
Educate the parents about teething facts.
Discuss oral stimulator.
Discuss the importance of primary teeth.
Discuss bruxism and its ills.
Fluorides
Importance of topical and systemic
fluorides.
Recommendation against topical fluoride use
till 3 yrs. of age.
Assess the fluoride status.
Discuss the fluoride supplements if needed.
Professional application of fluoride begins at the
age of 3 yrs. when swallowing can be controlled.
Oral hygiene/health
Clean the gum pads with a soft clean cloth after
each feeding.
Instruct the parents about the use of a soft brush and
pea size toothpaste.
Brushing technique taught to the parents.
Educate the parents about the importance and need
of periodic dental visits.
\
Care of gum pads.
Mouth cleaning techniques
Periodicity of dental visit.
Habits
Review pacifier use and safety and hygiene issues.
Non-nutritional sucking.
Pacifier use.
Thumb-sucking.
Discuss the ill effects of thumb sucking to the
dentofacial structures.
Nutrition and diet
Discuss the proper feeding practices & use of the bottle.
Role the child’s food plays in his growth and
developement.
Discuss how frequent sugar intake results in initiation
of caries.
Baby bottle tooth decay pattern.
Importance of diet.
Injury and prevention
Oral trauma
Immediate referral to the dentist as an injury to, the
teeth of young child can have serious and long-term
consequences.
Use of baby walker when infant begins to learn to walk.
Use of car seat or the child should be in mother’s lap.
Child should not be left alone for a long time.
Discuss the electric cord & safety measures to be taken.
Home child proofing
(Also see Chapter on Infant Health
Care)
. I
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
■ The most important dietary advice is to limit
the number of carbohydrate exposures per day
rather than to limit the total amount of carbo
hydrate consumed.
(Also see chapter on Diet Counselling).
2. Oral hygiene
■ The 3 to 6 year olds require parental assist
ance to achieve effective plaque removal.
■ Parents should be instructed to brush for the
child at least once a day, and to clean between
any teeth that are in contact with each other
with dental floss. Bedtime is the ideal time to
establish this routine because the salivary flow
rate slows during sleep. Thus natural protec
tive mechanisms are reduced.
■ Additionalbrushingsmaybeperformedbythe
child unaided.
3. Fluorides
■ Fluoride consumption should be investigated
and supplemented if appropriate.
■ The use of fluoride containing toothpaste
(once daily) should be carefully monitored.
Parents should be instructed to dispense only
a pea-sized amount for their child. The child
should brush under the supervision of the
parent so that they can monitor to ensure ex
pectoration. Other times the child can brush
with non-fluoridated toothpaste.
■ Professional application of high concentration
fluoride gels is usually begun at the age of
3yrs. when swallowing can be controlled.
4. Professional dental care
« The parents are educated that in small primary
teeth, caries progresses at a high rate. Also,
because of rapid developmental changes, the
timings of the visits can be critical for initiat
ing preventive measures.
■ Semiannual dental visits should begin at the
age of 3yrs. and continue throughout child
hood and adolescence.
Prevention ofdental diseasefrom 6 to 12
years ofage:
Eruption of the first permanent molar at about the
age of 6yrs. is a milestone requiring preventive ac
tion. Parents are educated about the importance of
the first permanent molar. They are told how the vari
ous preventive measures taken at this stage can pre
vent the progression of caries.
L Sealants
« The most effective aid for preventing pit and
fissure decay is professionally applied seal
ants. Most children benefit from the applica
tion of sealants to their permanent molars
whichallows them to maintain a caries free den
tition into adulthood.
2. Diet
« Children of school age are developing some
autonomy in eating habits. They often make
their own food choices at school and may pur
chase snack items. Parents are instructed to
monitor the dietary practices, especially for
children who experience smooth surface decay
3. Fluorides
■ As the child develops control over swallow
ing, topical fluorides canbe safely used and at
this age they begin to assume an important
role in prevention.
■ Regular use of toothpaste(twice-daily fluori
dated toothpaste) is recommended for its abra
sive action in removal of the plaque as well as
fluoride exposure. By the age of 6yrs. most
patients are capable of expectorating but par
ents should monitor it.
4. Oral hygiene
« Parents need to remain active in supervising
the home care practices of 6 -12 year old.
■ During this age span a transition can be made
from care provided by the parent to supervised
self-care.
I TEXTBOOK OF PEDODONTICS
« By the age of 10 most children are capable of
fine motor coordination necessary for adequate
tooth brushing and begin to assume responsi
bility for daily flossing. Parents should con
tinue to monitor brushing and flossing fre
quency and adequacy.
5. Habits:
« Education about any oral habits if it is present.
■ Also educate the parents about transitional
changes in the developing dentition and the
importance of primary and permanent denti
tion.
Prevention of dental disease in the adolescent:
■
Prevention of dental caries continues to be an
oral health priority during adolescence and pre
vention of periodontal disease becomes a special
concern. This is a very unique age group. At the
stage of adolescence the main processes utilized
are:
a. Rejection of many parental values.
b. The beginning of independent struggle and
c. The testing out types of behavioral
experimentations.
Parents are educated that they should tackle the child
at this stage very diplomatically. The child should be
given enough emotional support from the family and
his various habits should be monitored by the par
ents. The parents should have a friendly approach.
1. Oral hygiene
■ The adolescent patient possesses the fine
motor skills necessary for adequate tooth
brushing and flossing, but problems in com
pliance are likely to be encountered.
■ For periodontal health it is necessary to re
move the plaque from all areas of the tooth
that contact the gingiva. Dental floss can be
used to effectively remove the interproximal
plaque.
2.
Diet
■ In patients with a high caries rate, rampant den
tal decay may result in an extensive damage to
the dentition. It is usually associated with poor
oral hygiene practices and a high frequency of
sugar consumption.
■ Progress of lesions can be hdted^ith an ap
propriate diet control and an aggressive topi
cal fluoride therapy.
3. Fluorides
■ Systemic fluorides are no longer of benefit af
ter the last permanent tooth erupts at about
age of 13yrs.,except for patients who have func
tional third molars.
■ Topical fluorides are the most effective pre
ventive measure for the patients who experi
ence smooth surface caries.
■ Use of fluoride containing dentifrices regularly( thrice daily) provides an economical and
effective fluoride source.
4. Orthodontics:
■ Many patients undergo orthodontic treatment
during adolescence. These patients are at a
high risk for both gingivitis and the resultant
gingival hyperplasia ánd for dental caries
around and under the appliance or braces.
■ Topical fluoride therapy is indicated to pre
vent decay.
■ A thorough removal of the plaque from the
gingival areas should be performed to prevent
gingivitis and periodontitis.
5. Smokeless tobacco
■ Peer pressure and advertising exert pressure
on children and adolescent to establish a habit
that may result in addiction and ultimately in
duce oral cancer.
■ Evidence of tobacco use, such as shreds of
tobacco present in the oral cavity or localized
hyperkeratosis should be a signal to initiate
efforts to motivate the patients to discontinue
the habit.
■ Parents should be instructed/counselled not
to nag or punish the adolescent as it might
further entrench the habit.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
Parents should assess why the adolescent got
the habit?
a) Is it because of peer pressure/influence?
b) Is it because of home environment?
c) Is it because of bad company?
d) How long he has been using tobacco?
■
The dentist being an authority in clinical matters
along with parents support should start the
counselling.
The adolescents are preoccupied with health matter
in general and appearance in particular. This concern
can be used as a mechanism for motivation to dis
continue the habit.
Preventing dental injuries:
An injury to the teeth of a young child can have
serious and long-term consequences that may lead
to discoloration, malformation and even the loss of
teeth. Such consequences can have a considerable
emotional impact on the children.
■ If during the trauma to the orofacial structure
tooth is avulsed, the parents should be instructed
to keep the avulsed tooth under the tongue of
child or to store the tooth in milk or saline. The
survival of replanted avulsed tooth will be en
hanced if avulsed tooth is stored in some media *
prior to replantation.
■ Parents are advised to immediately contact the
dentist, as in nearly all situations of dental inju
GPEb
ries the prognosis worsens. The unfavorable con
sequences are more likely to occur with delay in
treatment of the injury.
• However, the best approach is to take active meas
ures to prevent injuries.
■ Most injuries to the primary teeth occur within
toddlers 12 to 30 months of age. For measures to
be taken to prevent the injury in this age group
refer chapter on Infant Oral Health Care.
■ Another major cause of dental injuries in children
is falls during play. Children who engage in con
tact sports are at the greatest risk of dental inju
ries. Athletic mouth protectors(mouth guards) sig
nificantly reduce dental injuries.
In order to achieve maximum effective results, pre
ventive efforts should be initiated early in the life of
the child. Althoughmost children experience dental
disease, a mouth free of caries and periodontal dis
ease is a potentially attainable goal for all children
when they use currently available techniques.
Self-Assessment
1. Define parent counselling?
2. What is the purpose of parent counselling ?
3. What are the topics which need to be discussed
with the parents?
4. What is the significance of prenatal counselling?
5. Who influences more an adolescent to develop
the habit of smokeless tobacco ?
6.3 Diet Counselling
’•i
Tandon S
Introduction
It has become increasingly evident that dietary
counselling is the most neglected of all preventive
measures suggested by the researchers in terms of
daily diet on the level of health as well as the suscep
tibility to a wide variety of diseases including oral
cavity. The dental practitioner is faced with a wide
variety of patients and the clinician must accept each
individual as he or she is, and be prepared to adapt
his or her technique to the specific needs of that
individual. At times the clinician must teach the pa
tient about diet, health and cause and prevention of
disease. Successful diet counselling depends on the
ability of the clinician to make the patient see the
problem clearly and thereby work upon the solution.
Definiton
Nutrition: The sum processes concerned in the
growth, maintenance and repair of living body as a
whole or its constituent parts. (Oxford Dental Dic
tionary)
« Science of food and its relationships to health. It
is concerned primarily with the part played by the
nutrients in body growth, development and
maintenance. (WHO 1971)
Food: Any substance which when taken into the body
of an organ may be used either to supply energy or
to build a tissue. (Oxford Dental Dictionary)
■ Anything that is eaten, drunk or absorbed for
maintenance of life, growth and repair of the
tissues.(Nizel 1989).
Diet: referred to as food and drink regularly
consumed. (Oxford Dental Dictionary)
■ Total oral intake of a substance that provides nour
ishment and energy.(Nizel 1989)
Balanced diet: one which contains varieties of foods
in such quantities and proportion that the need for
energy, amino acids, vitamins, fats, carbohydrates
and other nutrients is adequately met for maintain
ing health, vitality and general well-being and also
makes provision for a short duration of leanness.
(Chauliac 1984)
HOW OUR FOOD AFFECTS HEALTH?
*
The food that we eat affects our body in 2 way
Systemic effect: depends on their content of nutri
ents and includes the influence of such nutrients on
general health, growth and development, cell renewal,
ability of the tissues to repair and resistance to dis
ease.
Local effect: consists of what food can do to the
tissues or their environment because of their mere
presence in such an environment. In dentistry, most
local effects result from the interaction between food
residues and oral bacteria, which leads to plaque for
mation. The metabolites from the plaque bacteria have
effects on the soft and hard oral tissues.
CLASSES OF NUTRIENTS
The classes of nutrients necessary for the growth of
the child are:
SECTION 6 : PREVENTIVE APPROAClfï^ARIES CONTROL |
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Energy providing carbohydrates and lipids.
Tissue building protein.
Regulator vitamins and minerals
Water comprising 55 to 65% of the total body
weight
3ASIC FOOD GROUPS (Table 6.4, 5,6)
/arious nutrients play an important role in growth
md development. However, terms like protein, calium, riboflavin (Vit. B2), etc. have little meaning to
he layman and must be translated into the languages
>f foods. Eg. The mother should be asked to buy
nilk, which contains carbohydrates, proteins, cal:ium and riboflavin.
i The basic five food groups are called foundation
foods. Consuming these foods in the quantity
recommended will provide from 75 to 100%ofthe
recommended dietary allowances (RDA). The five
food groups are, however, low in calories and for
this reason additional food are recommended, e.g.
fats and oils such as butter,vegetable oil,sugars.
)IET AND DENTAL CARIES
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The patients diet and dental caries activity are
related. From the dietetic view point,dental car
ies is widely accepted as being caused by the
ingestion of fermentable carbohydrates, particu
larly sucrose.
Fermentable carbohydrates and more specifically
sucrose are rarely eaten as such. They are eaten
as components of foods that contain other ingre
dients and have different texhires
The cariogenic potential of foods containing su
crose depends on many variables such as the
ability to:
- Be retained by teeth.
- Form acids.
- Dissolve enamel.
- Neutralize or buffer acids.
Certain characteristics of sucrose containing
foods or conditions surrounding their consump
tion are more important in terms of cariogenidty
<
and retentive sucrose containing foods are more
cariogenic than sugar containing foods that are
liquid and non-retentive.
■ The frequency and time of ingestion of foods are
also important. The sucrose containing food be
comes more dangerous if it is eaten more fre
quently. Food eaten at meals produces less car
ies than the same eaten between meals does.
■ In decreasing order of cariogenidty, the food are
grouped as:
- Adherent, sucrose-containing foods eaten fre
quently between meals.
- Adherent, sucrose-containing foods eaten
duringmeals.
- Non-retentive(liquid)sucrose-containing bev
erages consumed frequently between meals.
- Non-retentive(liquid)sucrose-containing
foods consumed during meals
PROPOSED DIET COUNSELLING PROGRAM
Objectives of diet counselling program for the den
tal office comprise:
The correction of diet imbalances that could ef
fect the patient’s general health and sometimes is
also reflected in his oral health.
■ The modification of dietary habits, particularly
the ingestion of sucrose containing foods in
forms, amounts and circumstances that promote
caries formation.
■
The proposed program is based on a step by step
progression through:
■
Interview, where diet diary forms are introduced
with a brief discussion of the purpose of diet
A 24 hour diet record is prepared to get an idea of
food the child is consuming.
■ A six days diet diary is advised to be prepared by
the patient
■ Complete records of six days diet diary are
analyzed regarding the balanced and unbalanced
diet.
■ Isolating the sugar factors.
■
€35 I TEXTBOOK OF PEDODONTICS
Table 6.4: Food groups with proteins and calories per serving
Amount in
grams
In terms of
servings
(approx.)
Grams/Servings
(approx.)
(grams)
In standard
cup
(approx.)
Protein
Calories
370 gm
70 gm
4
2
90 gm
35 gm
1/3 cup
1/3 cup
10 gm
6 gm
325
128
Green leafy
vegetables
125 gm
2
60 gm
6 bundles
4 gm
25
Other
vegetables
75 gm
2
35 gm
2.0 gm
24
Roots and
Tubers
75 gm
2
35 gm
0.5 gm
40 (rava)
40 gm
1
40 gm
0.3 gm
I
34
3.2 gm
4
63
4.0 gm
4.0 gm
62
52
6.2 gm
87
Food
group
Cereals
Cereals
Pulses
Vegetable
Fruits
Fruits
Milk
Milk & milk
product
200 ml
2
100 ml
30 gm
30 gm
small
50 gm
large
1
30 gm
40 gm
40 gm
3 tbsp
3 tbsp
Rice
-
Wheat flour
- 150 gm
Rava
-
Pufees
- 220 gm
Ragi flour
- 150 gm
14 cup
Meat
Meat, fish
and egg
Others
Fats/oils
Sugar
One preet cup:
5 gm
5 gm
250gm
150gm
1 tabs
1 tabs
48
20
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL | FFH
Table 6.5: Daily food plan for different age groups
Daily food
plan
Toddler
S - gms
Pre-school
S - gms
School
S - gms
Adolescent
S - gms
Adult
S - gms
Pregnant
Women
S - gms
2 1/3 - 90
1 14 - 35
2 - 200
2-60
3-250
2-70
4-350
2-70
5 1/3 - 475
2 ’/4 - 80
414.-400
2-70
14-60
14 - 40
1/4-75
2 14-150
2 - 120
214 - 150
14-30
1-40
2-70
2-75
5-175
5-175
1-30
1-40
1-50
2-75
1-30
1-35
1 14 - 150ml
2 14 - 250ml
2 - 200ml
•2 - 200ml
2 - 200ml
3 14 - 325
1r30
1-50
1-30
1-30
1-30
1 - 30
1-30
1-30
1 - 30
7 tsp - 35
2 tsp - 30
234 tsp - 40
214 tsp - 40
7 tsp - 35
2 tsp - 30
Cereals
Cereals
Pulses
Vegetable
Green leafy
vegetables
Other
vegetables
roots and
Tubers
-
Fruits
Fruits
Milk
Milk & milk
product
Meat
Meat & fish
Egg
Others
Fats/oils
Sugar
S
Gms
tsp
4 tsp - 20
4 tsp - 20
5 tsp - 25
2 tsp-30
• 2 tsp-30
. 2 tsp - 30
- Servings
- grams
- tea spoon
i
Table 6.6: Daily caloric & protein for different age groups
Toddler
Preschool
School
Adolescent
Adult
Pregnant
Women
fÿlloriç
require
ment
1200 - 1500
1500
1800
2500
2800
2800
№^■•^^ein
redire\ihpnt
18 -20 gms
22 gms
33 gms
50 gms
55 gms
100 gms
€EE> i TEXTBOOK OF PEDODONTICS
■
■
■
«
Educating the patients in the role of sugar in the
decay process.
The consumption of acceptable substitutes in
stead of more cariogenic foods.
The recognition of practical limitations to imme
diate success.
Provision of continous positive reinforcement.
Where should the counselling take place?
counselling as well as most patient education should
take place in a consultation type of room/office, not
in the dental operator?. Distractions and anxiety pro
ducing instruments may break down communication
between the patient and the counsellor in the dental
operatory.
Who shold give counselling?
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The counsellor should possess dental and nutrition
knowledge as a result of professional education and
training. These best-qualified professionals are:
■ Dentist
« Dental hygienist
■ Nutritionist
■
DIETARY COUNSELLING
First appointment: Before counsellinga child or his
mother, determine what the child is eating. In a 15 to
20 minutes appointment the diet diary forms are in
troduced with a brief discussion of the purpose of
diet counseling such as, explain to the patient
■ That we are looking for possible dietary causes
of the caries problem of the patient. So that we
can reduce the risk of future caries by dietary
means.
■ What beneficial outcome could be available for
him in better oral health and appearance and pos
sibly improved health in general.
Here it is important:
■
■
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Who should receive counselling?
To adolescents group, direct communication and
diet counselling should be performed.
■
Not to be judgmental about the patient’s re
sponses as otherwise he may tend to present his
best side.
Not to emphasize the role of sucrose-containing
foods before the diet diary is completed, for oth
erwise the patient may tend to present an ideal
rather than real diet.
The patient should not be patronised or lectured.
If
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■
Ideally all children brought to dental care need to
be counselled.
|
•
The child under the age of 6yrs. is almost com
pletely dependent upon the parent usually the
mother for his or her food supply and subsequent
food habit development. Therefore the dentist
must counsel the mother in an effort to prepare
her for an important role as an educator and model.
Elementary school child: as the cliild matures and
develops more control over food selection, more
efforts can be directed in educating him with the
parent as the observer.
Counselling should be at an elementary level and
should not exceed 45 minutes. Several sessions
of 20 minutes may be preferable to one long ses
sion.
■
■
DIET DIARY (Table 6.7a)
■
Please record every food item consumed solid,
liquid, during 6 consecutive days. Record food
consumed at mealtime, between meals, at soda
fountain or while watching a movie, picture or
television. Also record candies, chewing gum,
cough drops or syrups.
■
The approximate amount in household measures
such as 1 cup,2 table spoon(T),l tea spoon(t).
■
The kind of food and how it was prepared, such
as baked chicken raw apple, cooked cereal, etc.
«
Additions to food in cooking or at the table: but
ter, sugar, cream, etc.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL J
Table 6.7a: Diet diary of the patient for a week
Patient’s Name:
Day
Breakfast
Amount Food .
Lunch
Amount Food
Dinner
Amount Food
Between meals
Amount Food
1.
2.
3.
4.
5.
6.
List of foods containing sugar (Table 6.7b)
ISOLATE THE SUGAR FACTORS
Foods containing sugar in solution.
Soft drinks, soda pop,powdered drink mixes,
fruit drinks.
Sweetened condensed milk, syrups.
Sweetened sauces such as chocolate,
butterscotch.
Chocolate milk,hot chocolate, cocoa.
Milk shakes, malts.
■ The patient should be aided in identification of
those foods which are likely to cause oral dis
eases; the time when they are most harmful and
also those which are most nutritious and least
cariogenic (Table 6.7b)
Solid retentivefoods containing sugar.
Cakes, doughnuts, cookies, candy bars,
brownies, chocolates.
Pastries, pudding, muffins, sweet rolls, pies.
Sugar-containing cereals, sugar-coated gum.
Dried fruits such as raisins, dates, apricots.
Fruit cooked in sugar.
fcecream, jams jellies, marmalades.
Sugar-containing chewing gum, caramels,
bftihdns.
Hariliaridy, mints, lollipops, jellybeans.
Fro^lB^honey.
Cough drops,syrups.
■ The interviewer and the patient together code the
record by any two different colours, for eg. red
Xs for harmful choices and time and by blue Xs
for good choices and meal pattern.
*
* In addition to these foods, some medicines such
as cough syrups,antacids (both liquid and tab
lets) contain variable amounts of sucrose.
■ Taking this as a game can motivate the child. He
is asked to count the number of red Xs which are
harmful for his teeth Next, ask the child which Xs
marked food he can eliminate. Have him write them
in appropriate spaces in his workbook. Tell him
that he should be able to reduce number of red
Xs when he comes next. When the child comes
with a reduced number of red Xs, he should be
praised for his effort (Table 6.8).
| TEXTBOOK OF PEDODONTICS
Table 6.8: Sample recording
First day:
Patient’s name:
Age:
Sugars in solution
Time
7.30 am
Form of food
Breakfast
10.30 am Snack
12.30 pm Lunch
3idly-X
1 glass milk (2t
.sugar added) - X
3 cookies - X
1 coke (small
glass) - X
2 chapaties - X
1 cup vegetables —X
1 cup rice - X
1 doughnut sugar
coated - X
1.30 pm
Snack
1 pastry (small) - X
1 cream filled cup
cake - X
6.00 pm
Snack
1 candy bar
(large) - X
7.30 pm
Dinner
2 chapaties - X
1 cup vegetable -- X
1 cup dhal - X
9.00 pm
Snack
1 cup caramel - X
1 glass chocolate
mild - X
Solid retentive food
containing sugar
During
meals
1
Between
meals
1
At bed
time
1
During
meals
1
Between
meals
4
At bed
time
1
y
‘X’ Total No. of exposures - 9
■
■
The cariogenic potential of a patient’s diet is
evaluated by determining the total number of ex
posures to sucrose-containing foods during 6
consecutive days.
Exposure is defined as eating the food at one time
and is not related to the amount of food sucrose
ingested.
Grand total, time of exposure to acid = (total expo
sure X 20 minutes)
(This time is based on Stephan’s curve that the pH of
the plaque drops and remains below a critical level at
which enamel decalcification can occur for an aver
age of 20 minutes after the introduction of sucrose
into the mouth).
EDUCATE THE PATIENT IN THE ROLE OF SUGAR IN
DECAY PROCESS
■
The plaque that forms in the teeth every day con
tains bacteria(germs).These bacteria change the
sugar present in food into acids.
SUGAR (in food) + PLAQUE / BACTERIA (germs) =
TOOTH +ACID = DECAY
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
The grand total of time of exposure to acid is used
here, to give the patient a roughidea of the risk that
his diet is imposing on his teeth.
DETERMINE THE ADEQUACY OF DIET
Determine the number of servings of food in each
of the basic five food groups and compare this
with the recommended number of servings. (Re
fer Table 6.4, 5, 6)
■
List of substitutes (Table 6.9)
Peanuts, walnuts,peacans.almonds,other types
of nuts.
Popcorn, corn chips, potato chips, whole wheat
biscuits, unsweetened,dry cereals.
Cold cuts of meats (unsweetened).
Cubes of cheese.
Pizza, toasts.
Fresh fruits, salads.
Vegetables such as carrot slices, celery sticks,
cucumber slices.
Baked potatoes, fried potatoes.
Hamburgers, hot dogs.
Unsweetened fruit juices, freshly squeezed
fruit juices.
Sugarless chewing gum.
Sandwiches.
Katz and other researchers in 1981, suggested •
that nuts and cheese tend to diminish the pH in
plaque after the ingestion of acetic foods orthose
containing sugar.
The list of substitutes should be formed by the
joint efforts of the demist and the patient. The
dentist should propose
substitutes and also
ask what substitutes the patient will be willing to
accept.
It is not fair to cut down all the sugar from the
child diet. Intelligent use of sugar must be there
and that is:
- Use sugared food during meal time and
- Food consumption followed by appropriate
oral hygiene measures.
■ Sometimes a compromise may benecessaiy. It is
better to go from a very cariogenic to a less cariogenic than to obtain nothing.
RECALL VISITS
During the next months at regular intervals, die
dentist should evaluate the patient’s progress and
provide psychological reinforcement.
■ Evaluations are made by means of:
- The patient’s comments.
• New diet diaries.
- Susceptibility tests such as snyder tests and
• Clinicaljudgement
■ Reinforcement is provided by praising the pa
tient’s efforts. Point out the improvements made
in the diet as well as in the test results and the
absence of new caries lesions.
■ Emphasis should be placed on making the pa
tient folly aware of the benefits derived from the
program and that the benefits are the product of
the patient’s own efforts.
■
PATIENTS WITH HIGH CARIES ACTIVITY DIET
BUBEST SUBSTITUTES FOR FOOD ITEMS
For such a patient counseling should be part of pre
ventive procedure and it should include:
substitutes should be reasonable, which are
acceptable to the dentists in terms of lesser
Immediate removal of all carious tissue and place
ment of ZnOE (temporary) restorations.
■ Topical fluoride applications.
« Plaque control instructions
■ Home use of fluoride containing dentifrices and
mouth rinses.
cariogenicity as well as to the patient as far as
tasteand preferences are concerned.
Food guide for children is illustrated in Fig. 6.4
■
summary of exposures to fermentable car?
determine the dietary changes that are
g ^^^^^Wed for better dental health.
t
I TEXTBOOK OF PEDODONTICS
S - Servings
Fig. 6.4 Food guide for children.
Self-Assessment
Define food, nutrition, diet and balanced diet.
Which are the basic food groups ? Give their Rec
ommended dietary allowances in children.
3 Prepare a diet chart such that the sugar expo
sures can be highlighted ?
4 What are the steps in conducting diet counseling
for a high risk caries child ?
1
2
6.4 Pit and Fissure Sealants
Bali RK, Batía R, Tandon S
Introduction
The high susceptibility of pit and fissures to caries
presents a major dental problem and provides the
rationale for caries control of these areas. While oc
clusal surfaces represent approximately 10% of the
enamel surface at risk, they account for almost 50%
of the caries in human dentition.
Caries of Pit and Fissure
n
■
■
■
and characteristically form a triangular or cone
shaped lesion with its apex at the outer surface
and its base towards DEJ. Pit and fissures pro
duces greater cavitation than the proximal smooth
surface caries.
With this understanding of the onset of occlusal
caries, the eradication of pit and fissures would
eliminate them as caries opportunity sites thus pre
venting the disease.
HISTORY
The caries process, particularly in the first and
second molars, usually starts soon after eruption.
It is usually rapid and can often result in loss of Milestones of pit and fissure sealant
the tooth. The very presence of pits and fissure Methods aimed at eliminating pit and fissure have
may be the single most important factor in deter been tried since the early 1920’s.
mining the presence of caries in these sites.
Hyatt(1923)
Proposed technique called prophylactic
However at the turn of century, Black (1897) noted ------- —
~ odontotomy. This technique Consisted of"
that pit and fissure don’t cause caries process.
tilling the fissures with silver or copper
oxy-phosphate cement as soon as the
They instead provide a sanctuary to those agents,
teeth eri$ted Ihto the oral cavity. Later
which cause caries. They permit the entrance of
when they are fully erupted, preparing a
microorganisms and food into this sheltered,
small occlusal cavity and filling it with
warm, moist, richly provided incubator and the *
amalgam.
dental plaque can be expected to form here.
Bodecker
ProposetHechnique called fissure eradiIn a caries susceptible person, when carbohy ~(1929)
cation. This technique involved mechanidrates in food comes in contact with the plaque,
T^aTeradication of fissures in order to
transform deep, retentive fissures into
acidogemc bacteria in the plaque create acid. This
cleansable areas.
acid damages the enamel walls of the pit and fis
sures and caries results. The enamel in the bot
Bunocore
Advocated the filling of pit and fissure
with bonded resin. He observed that
tom of the pit and fissures may be very thin, so ~
after treatment of the enamel with a con
that early dentin involvement frequently occurs.
centrated phosphoric add solution (85%)
In occlusal pit and fissures the form of caries le
for 30 seconds, attachment of acrylic
sion is different from that of smooth surface le
resin to the tooth surface is greatly
increased.
sion. Caries follows the direction of enamel rods
taUb I TEXTBOOK OF PEDODONTICS
Mid1960’s
First materials used experimentally as
sealants were based on cynoacrylates
but they were never marketed.
Bowen
(1965)
Reported BIS-GMA material development
The basis of BIS-GMA resin is the reac
tion product of bisphenol A and glycidyI-
■
■
methacrylate.
BIS-GMA is the base resin to most of the current
commercial sealants. Urethane dimethacrylate and
other dimethacrylates resins are also used in the seal
ant materials.
■
■
Definitions
The shallow, wide V and U shaped fissures tend
to be self-cleansing.and somewhat caries resist
ant.
Deep, narrow I shaped fissures are quite con
stricted and resemble a bottleneck. They have a
narrow slit like opening with a larger base as it
extends towards the dentino enamel junction.
These caries susceptible, I shaped fissures may
also have a number of different branches.
Similarly, K shaped fissures are also very suscep
tible to caries.
Usually non-invasive technique is recommended
for U and V shaped fissures and invasive tech
nique for I and K type fissures.
Pit:^ItJs defined as a small pinpoint depression lo-„
PIT AND FISSURE SEALANTS
cated at the junction of de\?elo.piiicntahgroeves'Of at
terminals of those grooves. The central pit describes
Fissure sealants are defined whereby pits and fis
a landmark in the central fossae of the molars where
sures that occur principally on the occlusal surfaces
developmental grooves join (Ash, 1993).
of the molar and premolar teeth are occluded by ap
Fissure: It is defined as deep clefts between adjoin- plication of fluid materials, which are then polymer
ized. Currently used methods are based on the prin
ing cusps.^They provide areas for retention of caries
ciple that the adhesion of acrylic and composite resin
producing agents. These defects occur on occlusal
to enamel is greatly increased if surfaces are first
surfaces of the molars and premolars, with tortuous
etched withan acid. The acids used are oftwo main
configurations that are difficult to assess from the
surfaces. These areas are impossible to keep clean types: those that polymerize after mixing two compo
nents and those that polymerize only after exposure
and highly susceptible to advancement of the cari
to an appropriate light source.
ous lesion. (Orbans, 1990)
MORPHOLOGY OF FISSURES
Effectiveness of sealants
Pits and fissures are enamel faults, narrow shafts or
cracks of some length whose blind ends are directed
more or less towards the dentino-enamel junction.
These differ from grooves that are shallow linear de
pressions formed tty the perfect joining of the differ
ent lobes.
For sealant to be effective, first of all it must be re
tained. Whether or not a sealant is retained is de
pendant upon the:
1. Technique of application.
2. The type of sealant material.
3. The morphology of the tooth surface to which it
is applied.
Nango (1960) in a study of crown sections described
Classification of Pit and Fissure Sealants
four principal types of fissures, based on the alpha
betical description of shape.
V type
Utype
I type
Ktype
Mitchell and Gordon (1990) stated that the sealants
can be differentiated in the following ways:
1. Polymerization methods
a Self activation (mixing two components)
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL I
b. Uglg^Uvamii:-------|
Hl
•Ilf
light
- Second generation: Self cure
- Third generation: Visible light
- Fourth generation: Fluoride releasing
6-7 years of age for the first permanent molar.
11-13 years of age for th^second permanent molars
and the premolars.
■
The approach that considers only selected pa
tients for sealants has been discussed by
Simonsen in 1983. He recommended triaging pa
tients into thrje groups:
Group 1: Caries-free patients judged at no risk
to decay.
Group 2: Patients judged to be at moderate risk
to decay.
Group 3: Patients with rampant caries at a high
risk to decay
Sealing of teeth in group 2 patients is done, but
not in group 1 and 3.
«
Most realistic approach for deciding which crite
ria should be used in selecting patients for seal
ant application is to judge clinically. Clinical judge
ment is done to select the teeth that are most
likely to decay based on:
1. Age
2. Oral hygiene
3. Familial mid individual history of dental caries
4. Fluoride environment and history
5. Dietary habits
6. Tooth tyrpe and morphology
SIlMS Resin systems
BIS-GMA—...' _ „.
||t
■ Urethane acn late
Vt^ii^tilted and unfilled
-,-^iear sealants have been shown to have betH
ter flow characteristics than tinted or opaque,
Bljl '
but this can be an advantage or disadvantage
depending on the position of the tooth to be
sealed. Although the retention rates of the two
types are similar, colored sealants are more
easily appreciated by the patient and moni
tored by the dentist at subsequent recalls.
■ The sealant is applied in a viscous liquid state
that enters the micropores, which have been
enlarged through acid conditioning. Then the
resin hardens because of either a self-harden
ing catalyst or application of a light source.
The extensions of the hardened resin that have
penetrated and filled the pores are called tags.
Requisites of an efficient sealant as (Brauer, 1978):
1. A viscosity allowing penetration into deep and
narrow fissures even in the maxillary teeth.
X Adequate working time.
3
i cure.
*
«M» and prolonged adhesion to the enamel.
5 tow sorption and solubility. -—
uiiiauu
IllfW/fCariostatic action.
l^^rañges for sealant application
T^iyearsofagefor the primary molar sealant appli
cation.
Indications
Clinical judgement is the decidingfactor in the place
ment of sealants.
■ Newly erupted both primary molars and perma
nent bicuspids ami molars with complete reces
sion of pericoronal operculum and with open and/
or sticky grooves and fissures.
■ Stained pits and fissures with minimum decalcifi
cation or opacification and no softness at the base
of fissures.
■ The tooth in question should have erupted less
than 4 years ago.
I TEXTBOOK OF PEDODONTICS
Fig. 6.5 Clinical guidelines for application of fissure sealants (Fig. 6.6a, b, c)
Patient’s selection
■ Child with extensive caries in primary teeth:
- Seal all the first permanent molars.
■ Children with special needs. For eg.
- Medically compromised.
- Mentally or physically handicapped.
- From a disadvantaged social background.
Tooth selection
■ Child with occlusal caries on one of the first
permanent molar.
- Seal the remaining sound first permanent
molars.
■ Occlusal caries affecting one or more first
permanent molars
- Need to seal the second permanent molar
as soon as they have erupted sufficiently.
■ Tooth should be sealed within 2 yrs. of eruption.
Do not seal if:
Pit and fissure have
remained caries-free
for 4 yrs. or longer.
The tooth can not be
isolated.
Caries on proximal
surface of tooth.
I
Doubt about the integrity of an occlusal surface
on clinical examination.
I
I
Take bite wing radiograph
I
I
If no sign of dentin
involvement
I
Seal the surface as
preventive measures
Recall: Evaluate sealed
teeth for sealant integrity
and retention and caries
progression.
I_______
I
Early dentin
involvement suspected
I
Investigate the fissures
using small burs
Place a minimal composite
restoration incorporating a
fissure sealant to protect the
rest of the occlusal surface.
Extensive caries discovered on
investigation
I
Standard dental restoration
should be inserted
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL I &&
Fig. 6.6a Occlusal fissure of the first molar tooth is
suspect because the patient has recently established a caries rate.
Fig. 6.6b Preparing the enamel surface for
fissure sealant.
Fig. 6.6c The same patient showing fissure seal about
2 year after placement.
I TEXTBOOK OF PEDODONTICS
Contraindications
«
•
«
»
»
Individual with no previous caries experience and
well coalesced pit and fissures. Monitor if the
individual and the teeth are not at risk.
Radiographic or clinical evidence of caries on the
proximal surface of the tooth should not be
sealed.
Wide and self-cleansable pit and fissures.
Tooth that can not be isolated or partially erupted
tooth.
Pit and fissures that have remained carious free
for 4 years or longer.
Fig. 6.7a S.E.M. picture of a freshly etched enamel
showing a typical porous surface pattern.
TECHNIQUE OF APPLICATION
1. Cleaning: the surface of the tooth selected for
sealant placement should be cleaned first with a
shiny of pumice and water. It is important that
neither a prophy paste nor a paste containing
fluoride be usedrns they will compromise the acid
etching procedure and therefore the sealant’s ef
fectiveness.
2. Washing and drying: immediately following clean
ing, the tooth is washed with water and air-dried.
3. Etching: occlusal surface is then etched with a
30-50% solution of phosphoric acid liquid or gel
for 60 seconds (Fig. 6.7a, b)
« Etching produces microscopic porosities in the
enamel. The resin extends into these micro
scopic porosities and forms tags which attach
it firmly to the tooth surface.
**■ With different etch times, no quantitative dif
ferences in the surface morphology of ena mel
are observed. (Tandonet. al.. 1989). This shows
that the retentive character of the etched sur
face is similar for different etch times. Thus, a
short etch time of 15 sec. is satisfactoiy for
primary enamel and is also sufficient to pro
duce the required etch pattern for the strong
binding of sealants.
Adhesive or resin
Conditioned surface
Original
surface*
Adhesive or resin
•Non-conditioned surface
Fig. 6.7b Microstructure of enamel.
4. Washing and drying: following etching, the tooth
surface is washed with water for 30 seconds to
remove all the etchant, then air-dried. A property
etched tooth surface has a dull frosted appearance.
■ After etching the tooth the surface should re
main dry and free of any moisture contamina
tion until the resin is applied and cured. The
tooth can usually be kept diy with cotton rolls
and suction. If not, then a rubber dam must be
used.
■ If the surface becomes contaminated, it must
be re-etched for an additional 10 seconds.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL | fEEi
5. Application of material: care must be taken when
applying the material to avoid incorporating air
bubbles
6. Curing: material is cured according to the manu
facturer’s directions. Once the material has been
ftilly cured, it is carefully examined with an ex
plorer to make certain that
■ all pits and fissures are covered.
■ all excessive material has been removed.
■ material is firmly adherent to the enamel surface.
7. Recall: along with other forms of dental care, the
sealants should be thoroughly checked at sub
sequent recall appointments to ensure:
« it is still firmly adherent, and
■ no sealant material has been lost (Fig. 6.5c).
If it is necessary, that the sealant material should be
added at this time.
Sealants have been shown to be safe, efficient and
effective methods of preventing pit and fissure car
ies ami as such should be used by all dental person
nel for prevention of ravages of dental caries.
Self-Assessment
1
.
Define pits and fissures.w
2 Classify the pits and fissures seen in the tooth.
3 What considerations should be considered be
fore the application of the sealants?
4 Briefly describe the procedure of application of
the sealant.
6*5
Fluorides
Tandon S
The Fluoride element is the most electronegative el
ement, which never exists in free state in nature but
combined chemically with other elements as fluoride
compound. It has not only notable chemical quali
ties but also physiological properties of great impor
tance for human health and well being. Its selective
effect on the hard tissues of the body attributes sig
nificantly to prevention and control of dental caries.
Fluorine word is derived from the Russian word “flor”
which comes from “floris” meaning destruction in
Greek and from Latin word fluor” means to flow since
it was used as a flux. Fluoride apparently is ubiqui
tous in its distribution and is the 13th among the
trace elements in order of abundance in the earth’s
crust. It is a highly reactive anion with an atomic
weight of 19 and atomic number of 9. Fluoride is
widely distributed in the biosphere; is present in the
lithosphere, hydrosphere, atmosphere and in all liv
ing organisms. It enters into the atmosphere by vol
canic action and entrainment of the soil and water
vapours due to the action of the wind. It returns to
the earth by deposition as dust or in rain, snow and
fog. It comes to the hydrosphere by leaching from
the soil and minerals in to the ground.
Fluoride in the environment is depicted in Fig. 6.8a
History
The history of fluoride is more than hundred years
old. The first hint of possible connection of fluoride
and dental health was given by Sir James CrichtonBrowne in 1892. He suggested the probable cause of
dental caries as a change in bread, which did not
have bran or husky part of wheat containing fluo
rine. Since then numerous studies have confirmed it
as an essential micronutrient for the optimum forma
tion of the crystalline structure in mineralized tissues
such as bone and teeth. The crystalline structure of
the enamel formed under the influence of fluoride
becomes morphologically and chemically better
suited to withstand the odontolytic microorganisms.
The milestone studies are discussed in Table 6.10
MECHANISM OF ACTION (Fig. 6.8b)
Fluoride’s role in decreasing theprevalence of caries
has been well accepted for many years. However, the
beliefs about fluoride have changed. It is now deter
mined that the presence of fluoride in and on enamel
surface is the key to the effectiveness of fluoride.
Fluoride is incorporated through out the tooth crown
formation during development. To understand the
cariostatic effect of fluoride it is necessary to know
the enamel structure and the process of deminerali
zation.
Enamel structure: Enamel consists of apatite like crys
tals, which are primarily carbonate ions. These crys
tals are arranged in rod like structures, having hy
droxyl ions, which run parallel to the long axis. There
are numerous atomic scale structural imperfections
within the enamel crystals, as well as the spaces be
tween the rods. These structural imperfections, as
well as inclusions such as carbonates and magne
sium within in the enamel crystals increase the acid
solubility of the crystals. Since carbonate accounts
for five percent of human enamel it is often
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
Fig 6 8a Fluoride in the environment
I
-3
r
I
In Lithosphere
In Bioshphere
In Hydrosphere
In Atmosphere
t
t
t
Ground water
Ambient air
(0Ä6 mg/m3)
t
t
t
Rocks Minerals
(> 50)
t
Earth, Crust
(300 ppm)
Plants (2 - 20 mg/g)
I
Lake water
(150 mg/kg)
Leafy vegetables
(11 -26 mg)
t
t
f
Soil
(500 ppm)
Animal Feed
Sea water
(15 -18 mg)
t
Through technology
(0.05 - 1.8 micrograms/
m3) à
1
Ground lofty
mountains
I
Rain water
Volcano
Table 6.10: Milestones studies of fluoride
Year and Investigation
Discovery or Report
1901, Dr. Frederick
McKay
■ Permanent stains present on the teeth of the local inhabitant of
Colorado Spring, U.S.A., known as ‘Colorado Stains’ noticed.
■ Stains characterised by minute white flecks, yellow or brown spots
scattered all over the surface of the tooth were termed as mottled
enamel (most obviously and unmistakably defective enamel).
1902, Dr. J. M. Eager
■ Described similar stains seen on the teeth of certain Italian emigrants
embarking at Naples as “denti di chiaie”.
1916, Dr. Green
Vardmin Black
« Supported McKay work with histologic evidence reporting it as an “an
endemic imperfection of the enamel of the teeth”
1918, Dr. O. E. Martin
Dr. F. McKay
« Britton in 1898 had changed its water supply from shallow well to a
deep drilled artesian well. All those who had passed through child
hood before the change of water had normal teeth and who grown
after this had mottled enamel. Thus, it was concluded that some
*
mysterious
element in water was present.
1925, Dr. F. McKay
■ Change of wgter supply from spring water of the Great salt lake of
Oakley, Idaho city showed no brown stains in children who were born
after change of the water supply.
1928, Dr. McKay
Dr. Gromer Kempt
■ Similar observation found in Bauxite where changed water supply (in
1909) from a shallow well to foot well resulted in children with badly
stained teeth. They found that no mottling occurred in the people who
grew upon Bauxite water prior to 1909.
4
coM.
I TEXTBOOK OF PEDODONTICS
Year and Investigation
Discovery or Report
1931, Mr. H. V. Churchill
■ A spectrographic analysis of Bauxite city water showed the presence
of fluoride at the level of 13.7 ppm.
1933, Dr. H. Trendley
Dean
■ Shoe Leather Survey conducted in 97 localities with the help of ques
tionnaire with the aim to find out minimal thresh hold of fluoride, the
level at which it began to blemish the teeth.
1939, Dean and McKay
■ Came out with the most conclusive and direct proof that fluoride in
domestic water is primary cause of human mottled enamel (dental
fluorosis)
1939, Dr. H. Trendly
Dean
■ Hypothesis showing the inverse relationship between endemic dental
fluorosis and dental caries emerged with survey of four Illinois cities.
Table 6.11 : Caries inhibitory effect through water fluoridation
1944 - 1959
Francis Arnold,
Philip Jay and
John Knutson
> GRAND RAPIDS-MUSKEGON STUDY (water fluoridation) Grand
Rapids as experimental town and sodium fluoride was added to
water at 1 ppm and Muskegon as control.
■ First crucial step proved caries reduction from 12.48 to 6.22 DMF
indicating that previously observed inverse relationship of fluoride in
water and dental caries was a cause and effect relationship.
1945 - 1955
David et al.
■ NEWBURGH-KINGSTON STUDY - 10-year study.
Newburgh children showed caries decline from 23.5 to 13.9% after
water fluoridation.
1967 (1946-1960)
Dr. J. R. Blayney,
T N. Hill,
S. O. Zimmerman
■ EVANSTON-OAK PARK STUDY-14-year study.
Fluoridation in Evanston showed a 40% reduction of caries.
1951 Hutton et al.
1965 Brown and
Poplove
■ CANADIAN STUDY (Brantford, Sarnia and Stratford)
Stratford with a naturally present 1.3 ppm fluoride in water was auxiliary
control. After 17 years of fluoridation, Brantford showed a 50% reduc
tion in caries.
Fluoride inhibits smooth surface caries
1961, Backer Dirks
et al.
■ DUTCH STUDY (Tiel-Culemborg)
Tiel was fluoridated at the level of 1.1 ppm. Culemborg with 0.10 ppm
served as a control. 13 years study showed 88% reduction in smooth
surface caries and 43% in pit and fissure caries.
1965, Ludwig
• NEW ZEALAND STUDY
Study carried out in Hastings from 1954 to 1964 showed a DMF
decline from 5.48 to 2.46 with reduction of approximal caries by 69%
and occlusal caries by 49%.
1969, World Health
Organization
■ Recommended first time 1 ppm fluoride in drinking water for a practica
ble and effective public health measure.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
referred to as carbonate apatite. Enamel is the hard
est body tissue and contains 85% of mineral by vol
ume. The remaining 15% consists of water, protein
and lipids in spaces between the enamel crystals and
the rods. These act as diffusion channels fbr fluo
ride, minerals and acids.
The action of fluoride^n the enamel surface can be
divided into the following:
■
Fluoride incorporation in enamel
Incorporation of fluoride into enamel throughout
development is not a principal mechanism of
cariostatic effect. It is believed that pre-eruptive
exposure to fluoride may produce teeth more re
sistant to caries by making pits and fissures shal
lower. but post eruptive exposure of fluoride too
has a significant role in it.
■ Pre-eruptive incorporation
Fluoride gets incorporated in the fluid filled sac,
which surrounds the developing tooth. It then
enters the developing enameL Highest concen
tration of fluoride is seen in enamel crown located
at or near the tooth surface.
■
A
Fluoride continues to enter the enamel surface,
causing crystals to change from predominantly
carbonated apatite and hydroxyapatite to fluora
patite (FAP) and fluorhydroxyapatite (FHAP)
cry stals. These fluoride rich crystals are less acid
soluble than the original enamel apatite.
An apatite crystal.
B. Relationship between hydroxyl and
calcium ions.
C. Fluoride lends stability to hydroxyl column
and apatite lattice.
■
Open circles: Calcium
Grey circles: Oxygen
Black circles: Hydrogen
Fig. 6.8b Mechanism of action of fluoride
(Ekstrand 1988)
Post-eruptive incorporation
Remineralization of acid dissolved enamel
Minerals of tooth enamel are continuously in ex
change with the minerals of saliva and thus the
balance is maintained. This equilibrium can get
disturbed with the organic acids produced by the
metabolism of fermentable carbohydrates by the
microorganisms. This leads to a drop in pH of the
plaque on the enamel surface and in the
sub-surface. Minerals, particularly calcium and
phosphate leave the dissolved enamel in their
I TEXTBOOK OF PEDODONTICS
ionic form and enter the plaque fluid. This proc
ess is called as “demineralization”. This gets re
versed with the factors like fluoride and is termed
“remineralization”. The surface and sub-surface
of the enamel absorb and hold minerals and fluo
ride, which are present in the plaque fluid and
enhance the regrowth of the partially dissolved
crystals. Fluoride’s ability to facilitate the
remineralization process is presently believed to
be more significant than its inhibition of deminer
alization. The regrowth by fluoride incorporation
chemically forms new crystals that are larger and
more acid resistant and contain a higher concen
tration of fluoride. This explains why the “white
spot” i.e. incipient lesions which have been ar
rested or healed due to fluoride application are
considerably less reactive to further acid chal
lenge than the adjacent unaffected enamel.
White spot (Incipient caries)
The high concentration of minerals and fluoride at
the surface layer of the enamel and the loss of miner
als diffract light, creating an opacity that appears
clinically as a white spot. Although the white spot is
generally recognized as the first clinical evidence of
developing caries, the caries initiates much earlier. In
the presence of fluoride the spot becomes smooth
and shiny, but in the absence of fluoride it appears
rough and chalky. The surface of the white spot
should not be probed too hard, though it appears
intact because it is mineral deficient and weak layers
may break and form cavitation. Therefore, this intact
incipient lesion should be treated with topical fluo
ride and allowed to remineralize.
INHIBITING DEMINERALIZATION
It is believed that demineralization is slowed down
with the continuous exposure of fluoride and a
stronger acid challenge is required to demineralize
the enamel crystals. As discussed in incorporation
ef fluoride into enamel structure, it is seen that a
maximum fluoride concentration is in first formed
enamel, near the incisal edge and steeply decreases
towards the more recently formed cervical region.
Thus in younger children enamel is much more sus
ceptible to demineralization around the neck of the
tooth. This can be inhibited with the topical applica
tion of fluoride. In older children the concentration
of fluoride is inverted. The active role of fluoride in
the caries process, thus, recommends that the clini
cian should follow the rationale for semiannual fluo
ride application which is rested on the following two
basic premises:
■ Increase the fluoride content in enamel to as high
as possible in a short time.
■ Prevent the formation ofcalcium fluoride and other
fluoride precipitates that are more soluble than
fluoridated hydroxyapatite.
Effect of fluoride during pH - cycling:
In the oral environment there is a continual cycling
of pH change resulting from acid challenge and neutralizationby saliva. Itis believed that fluoride present
in oral fluid can range from undetectable to 20ppm,
depending on the individual cs recent exposure to
fluoride. When this fluoride containing enamel crys
tals get embodied in pellicle on the enamel surface,
its ability to resist transfer of minerals out of enamel
is improved. This hypothesis demonstrates the sub
tle but critical interaction between saliva, enamel and
fluoride.Fluoride inhibits plaque formation
Plaque is a reservoir for fluoride and approximately
2% of the fluoride in plaque is present as a free ion. It
was seen that fluoride can not cross the cell wall and
the membrane in ionized forms, but can rapidly travel
through the cell wall and into cariogenic bacteria in
the form ofhydroxyfluoride (HF). Hydrogen and fluo
ride ions combine as the bacteria produce acid dur
ing the metabolism of fermentable carbohydrates.
Hence, the acid helps in the fall of pH and a portion
of the fluoride ion in the plaque fluid then combines
with hydrogen ions and rapidly diffuses in the cell
effectively drawing more HF from the outside, and
so on.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL | 00
In a clinical trial of 6 - 1 lyrs olds low fluoride
containing (289ppm) dentifrices have shown to
have similar effect on primary and permanent (fen
tition in reducing the caries increment of high fluo
ride (900ppm) dentifrice (Tandon and Paul 1996)
6. Teeth irradiated
switched Nd-YAG laser at
50mJ followed by fltwide application have shown
maximum resistance to the artificially induced
caries. (Altai and Tandon 1996)
5.
H+ +FBacterial ceil
pH 7
H+ +F-
HF
pH 4
H+ +F-
HF
Once inside the bacterial cell, HF dissociates again,
acidifying the cell and releasing fluoride ions, which
interfere with essential enzyme (enolase) activity,
thereby inhibiting bacterial metabolism and inhibit
ing plaque formation against the progression of den
tal caries.
Role of low7 fluoride in oral environment
Brown and Coworker (1996) predicted that low con
centration of fluoride could enhance remineralization.
Since fluoride ion is most effective at enamel saliva
interface it is believed that it is beneficialto provide
a continuous supply of fluoride ions at that inter
face. It provides and maintains caries inactive state.
The study conducted in pedodontic department of
Manipal with a low fluoride level showed the follow
ing results:
L 0.4% APF provide equally effective protection in
enamel against acid attack in a vitro study as that
of 1.23%APF (Tandon and Tissy 1988)
2. The lower concentration of 0.4mg NaF in a sus
tained release tablets has shown no difference
with that of a high concentration of200mg NaF in
reducing dental caries (Shyama and Tandon, 1991)
3. Fluoride dentifrices containing lbw concentration
of 175ppm NaF is found to increase the
microhardness of the enamel. This takes place
slowly and steadily as compared to high concen
tration of 300, 700 and lOOOppm, respectively
(Tandon et al 1992)
4. A continuous uptake of low fluoride of 289ppm
toothpaste by the enamel was seen and a signifi
cant difference was observed in 12 weeks as com
pared to the high concentration (900ppm) of fluo
ride in dentifrices/ Sandra and Tandon 1994)
FLUORIDE METABOLOSM
Source of fluoride
The principal source of human fluoride ingestion is
water.
■ It is present in nearly all ground water, though
concentration in water supply is very small
■ It is also derived from plants, marine animals and
even dust particles
■ Fluoride content varies in different types of food,
like
a. Certain types of fishes, dried mackerel and
dried salmon contain a large amount of fluo
ride i.e. 84.5 ppm
b. Potatoes give 6.4 ppm
c. Tea contains an average of 97 ppm
GENERAL SURVEY OF DIETARY ITEMS FOR FLUO
RIDE CONTENT: (Tandon & Thomas 1989) Theaverage fluoride content in the commonly consumed
dietary items are given in Table 6.12,13,14.
THE CHEMISTRY OF FLUORIDE
Chemically fluoride is so violently reactive that it
rarely or never occurs in nature^s elemental fluo
rine. Its atomic weight is 19.0 and it exists chemically
in the form of fluorides, chiefly as:
■ Fluorspar (CaF2)
■ Fluorapatite (Ca10(PO4)6F2)
■
Cryolite (Na^AlF^)
Berndt and Stearns (1972) viewed that, the
crystallographic unit cell for apatite contains 10
calcium, 6 phosphate and 2 fluoride ions. The ionic
| TEXTBOOK OF PEDODONTICS
Table 6.12: Average fluoride content of commonly used cold beverages
Name/brand of drink
Fluoride content in ppm
Fluoride content in 200 ml
Thums up
0.233
46
Frooti (mango, orange,
appy)
0.165 - 0.202
33-40
Orange juice
0.100
20
Sugar cane juice
0.085
17
Tender coconut water
0.083
17
Butter milk
0.108
22
Table 6.13: Average fluoride content of commonly used hot beverages
Fluoride content in ppm
Approx,
fluoride
content in 1
cup of coffee/
tea (200 ml)
with milk &
sugar (micro >
gms)
Quantity of
coffee
powder/tea
leaves used
Coffee/tea
without milk
and sugar
Coffee/tea
with milk
and sugar
1 tsp
0.192
0.174
34
1 tsp
0.175 - 0.185
0.164-0.171
32 - 34
Local-Kelagur
CTC tea
leaves
1 tsp
1.710
1.54
200
Commercial
tea (Brooke
Bond, Lipton
green label,
Taj Mahal)
1 tsp
1.00 - 1.19
0.928 - 1.11
190 - 222
Brand of tea
and coffee
, used
Local coffee
(Panduranga)
Commercial
coffee
(Nescafe
& Bru)
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL | @3)
Table 6.14: Average fluoride content of commonly used food items
Items
Dry wt of substance
(gms)
Fluoride in 100gm
sample (micrograms)
M__
Fluoride (ppm) in
dry wt of substance
1
Cereals group
Raw rice
Wheat
Rava (sogee)
Jowar (millet)
Ragi
Corn flour
9.00
8.90
8.80
8.90
9.10
9.00
0.42
0.53
0.51
0.64
0.79
1.52
38
47
45
57
72
137
9.20
9.20
8.60
8.90
1.17
0.89
0.77
0.72
107
82
67
64
2.70
2.80
1.50
0.70
0.75
4.20
1.34
1.55
3.04
1.59
1.83
0.91
36
2.50
1.80
2.70
1.40
1.03
1.30
1.10
2.38
1.56
2.21
0.98
0.86
1.14
0.54
Pulses group
Black gram dhal
Sambar dhal
Green gram flour
Green peas
Roots and tubers
Onion
Potato
Carrot
Beetroot
Ra'dish
Ginger
Vegetables group
Beans
Tomato
Brinjal (local)
Cucumber
Ladies finger
Green chillies
Pumpkin
•
'
59
28
60
14
9
15
6
Leafy vegetables
Cabbage
Spinach
Coriander leaves
2.10
1.50
1.50
2.14
3.84
2.40
45
58
36
contd.
I TEXTBOOK OF PEDODONTICS
Items
Dry wt of substance
(gms)
Fluoride (ppm) in
dry wt. of substance
Fluoride in 100gm
sample (micrograms)
Fruits
Orange
Pineapple
Green grapes
Banana
Apple
Guava
0.86
1.40
1.04
2.46
1.30
1.70
^1.03
1.03
0.55
0.39
0.32
0.43
9
14
6
10
4
7
4.60
4.10
3.80
2.20
0.92
4.62
1.17
1.80
42
189
45
40
2.10
8.20
0.58
165.44
12
135.70
2.60
9.30
8.00
9.60
075
0.86
1.52
0.73
0.43
0.75
22
M42
58
41
54
Animal foods
Chicken
Whole egg
Pork
Mutton
Sea foods
Fresh water fish
Dried sea fish
Miscellaneous
Coconut
Common salt
Jaggery
Sugar
Tamarind
structure of apatite readily permits the substitution
of other ions of the same charge. Since the calcium,
phosphate or fluoride are approximately of the same
size, when substitutes exists, they maintain the size
of the unit cell.
■
■
ABSORPTION OF FLUORIDE
•
■
It is readily absorbed into the body. Absorption
occurs mainly in the stomach, is passive in na
ture and no active transport mechanism is in
volved.
It can also occur from the lungs by inhalation of
fluoride dust and gases.
i
A third and very rare route of absorption is
through the skin. It may occur when hydrogen
fluoride is applied to the skin. However, the re
sulting bum is more serious than the fluoride ab
sorbed.
It is believed that soluble fluoride in drinking water
would be absorbed nearly completely regardless
of fluoride in the water supply. The absorption of
fluoride from food depends on thé solubility of
inorganic fluorides in the diet and its calcium con
tent. If calcium or aluminum compounds are
added, fluorine absorption is reduced.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
EXCRETION OF FLUORIDE
Fluoride is excreted in urine, lost through sweat and
excreted in feaces. It occurs in traces in milk, saliva,
hair, and tears. The principal route of fluoride excre
tion is via the urine and urinary fluoride level is re
garded as one of the best indices of fluoride intake.
The very rapid rate of excretion is one of the most
protective factors in severe poisoning.
Spencer et al. (1978) reported that the kidney is the
main pathway of fluoride excretion with an average
fluoride intake of 3.9mg/day. Urinary fluoride is 30
percent of fluoride intake in renal patients and 50 to
60 percent in normal person. The faecal fluoride is
low. The antacid aluminum hydroxide is commonly
used to decrease the serum phosphorus level and
inhibits the internal absorption of fluoride.
STORAGE OF FLUORIDE
Fluoride is stored in the hard tissue of the body. The
extent of fluoride uptake in different parts of the skel
eton and dentition depends upon the amount in
gested and absorbed, the duration of fluoride expo
sure and the type, region and metabolic activity of
the tissue concerned.
UPTAKE OF FLUORIDE IN BODY TISSUE
It slightly alters the chemical composition of bone
and teeth minerals. The carbonate and citrate con
tents are lowered and magnesium level remains un
changed
■
The ions present in the crystal surface might mi
grate slowly into vacant spaces in the crystal in
terior during recrystallization.
Fluoride in bone
t
Fluoride ions are able to enter the hydroxyapatite
lattice. The fluoride concentration in living human
bone builds up slowly with age. The distribution of
fluoride within bone is not uniform. It is the highest
in the areas of most active growth.
Fluoride in enamel and dentin
Fluoride uptake in dental tissues also increases with
age and with increasing concentration in water. It is
considerably lower in the enamel and the dentin than
that found in the bone of the same individual. After
the tooth has folly formed, fluoride is chiefly incor
porated at tissue surface. The highest fluoride in den
tin is found adjacent to odontoblastic layer. Mahajan
and Sidnu (1981) found less resorption of the roots
of the teeth that are treated with fluoride.
Fluoride in blood
Approxiriiately three-quarters of the total blood fluo
ride is in plasma and one-quarter in red blood cells.
The regulation of plasma fluoride concentration is
due to a large volume of extracellular body fluid,
which dilutes absorbed fluoride by deposition of fluo
ride in the skeleton and by excretion in urine.
Fluoride in plaque
Three-stage mechanism takes place for the entry of
the ion into the apatite lattice as follows:
■ Fluoride ion exchange with one of the ion or po
larized molecules present in the loosely integrated
shell.
■ Second stage involves the exchange of fluoride
in the hydration shell with anion group at the
surface of apatite crystal. Ionic exchange occurs
between fluoride ion and hydroxyl and bicarbo
nate groups and also fluoride ions already present
in the crystals.
Dental plaque is the main storage source in the oral
cavity. Its concentration in plaque is many times
higher than in saliva, especially gingival crevicular
fluid where it is 10 to 20% more than plasma concen
tration of fluoride.
Fluoride in placenta andfoetus
Evidence concerning the extent of placental transfer
in human has been conflicting. Higher fluoride values
f&ifo i TEXTBOOK OF PEDODONTICS
are present in maternal blood and the placenta tissue
of pregnant women living in the areas, where drinking
water contains Ippm than those of non-fluoridated area.
Fluoride in saliva
ft is seen that fluoride from ingested food, water and
supplements returns to the mouth in saliva in suffi
cient quantities. Most children have oral fluid fluo
ride levels ranging from 0.01 to 0. Ippm, with the av
erage concentration falling in the range of 0.02 to
0.03ppm. A recent study concluded that a difference
of only 0.02ppm of fluoride in oral fluid might indi
cate why one child is caries active while another is
caries resistant.
MODE OF FLUORIDE ADMINISTRATION (Fig. 6.9)
SYSTEMIC FLUORIDE
Fluoride after the ingestion can get absorbed and
incorporated into developing enamel and can ben
efit teeth before eruption. It also benefits the teeth
after their eruption, when it returns to mouth in sa
liva and gingival exudate.
COMMUNITY WATER FLUORIDATION
Community water fluoridation in the process of
adjusting the amount of fluoride in a community
water supply to an optimum level for the preven
tion of dental caries.
■ The effect of fluoride in drinking water on dental
caries has been the subject of research com- /
menced decades before. Studies have shown that
the adjustment of fluoride concentration in drink
ing water to the optimal level of Ippm is associ
ated with a marked decrease in dental caries. The
world health organization recognized these facts
by its resolutions in 1969 and 1975, in which it is
stated that water fluoridation application should
be the corner stone of national health policies for
prevention of caries.
■ The recommended daily dosage of fluoride for
children above 3 years of age is Img. This can be
obtained by drinking one liter of water with a con
centration of Ippm fluoride ion. Since the amount
of water consumed will vary with temperature,
the fluoride ion concentration considered opti
mal for a particular locality is predicted upon the
average of the maximum dally temperature.
■
Fig. 6.9 : Mode of fluoride administration
Fluoride Administration
Topical
Systemic
”3
Water fluoridation
School water fluoridation
Milk fluoridation
■
■
■
Dietary fluoride
Salt fluoride
Fluoride in sugar
•
Dietary fluoride — fluoride drops
supplements
— fluoride drops with vitamins
— fluoride tablets/lozenges
— fluoride tablets with vitamins
— fluoride sustained release
— fluoride devices
i— fluoride rinse fluoride solution
Professional
Self
application
application
— fluoride solution
— varnish
— foam
*— gels
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
Fluoride compounds in community water
Sodium fluoride was the first compound used in a
controlled fluoridation program. Owing largely to its
low cost, sodium silico fluoride replaced sodium fluo
ride as the chemical most often used to fluoridate
water. There has been an increased use,fof
hydrofluorsilicic acids as the fluoride ion source.
RECOMMENDED LEVEL OF FLUORIDE IN WATER
(WHO 1971)
■
Concentration 0.7 to I .^pm
Depending upon a community mean maximum daily
temperature:
■ Cold climate 1.2ppm
■ Summer season or temperate climate 0.7ppm
BENEFITS OF WATER FLUORIDATION
CALCULATION OF OPTIMUM LEVEL OF FLUORIDE
Cariostatic effects of water fluoridation ill children
are not limited to permanent dentition but also ex
tended to primary dentition as well.
■ This method is preferred since some tooth sur
faces receive greater protection against caries
than other. For example smooth surfaces of teeth,
especially proximal surface, derive maximum pro
tection than do pit and fissures on the occlusal
surface.
« Water fluoridation have both pre-eruptive and
post-eruptive effects
■ Fluoridated drinking water not only acts systemically during tooth formation to make dental
enamel more resistant to dental decay, but also
lias topical effect through the release in saliva
after ingestion.
« Fluoride in saliva through the systemic mode re
mains elevated for an extended period, provides
protection against demineralization, and facilitates
remineralization.
■ It changes the morphology of occlusal surfaces,
by making pit and fissures more shallow and self
cleansing.
■ Fluoridation of community water is the least ex
pensive and most effective way to provide fldoride to a large group of people.
■ If there is a question regarding the fluoride con
centration, which is not an additive but is natu
rally present to some degree in water, the local
authority of health can test samples and can pro
vide accurate information.
! ■ Beverages bottled in fluoridated areas or other
such products may pass on the beneficial effects
i
to fluoride deficient/deprived population. This is
(
termed ‘Diffusion’ or cHalo’ effect.
ppm fluoride=0.34 IE
E=0.38 + 0.0062 X temp, in °F
(E is estimated water intake)
RECENT RECOMMENDATIONS (WH01994)
In view of the increased concern about the toxic ef
fect of fluoride through systemic ingestion, espe
cially about opacities of developing dentition, WHO
lias recommended optimum level of fluoride in drink
ing water as: 0.5 to 1.0 ppm.
Table 6.15 Percentage caries reduction with differ
ent methods
Method of fluoride
administration
Average %
reduction of caries
■ Community water
fluoridation
50-60%
■ Salt water fluoridation
40%
■ Dietary supplements
50-85%
■ Fluoride dentifrices
20-30%
« Professional applied
topical fluoride
30-40%
■ Self applied topical
application
20-50%
SCHOOL WATER FLUORIDATION
■
School water fluoridation is the adjustment of the
fluoride concentration of a school’s water supply
for caries prevention.
| TEXTBOOK OF PEDODONTICS
■
After observing the beneficial effects of commu
nity water fluoridation, an alternative method for
supplying systemic fluoride for children was de
cided. School water was fluoridated to provide
maximum cariostatic effect in developing teeth.
Since children spend only 6 to 8 hours in school,
concentration of fluoride 4 to 6 times more than
that designated for community water, was recom
mended. For instance, in Elk lake, Pennsylvania
the school water supply wa s fluoridated at 5ppm
and in five years there was a reduction of 28.6%
seen in caries. After 10 years of school water fluori
dation, the children who attend school continu
ously had 39 percent less decayed, missing and
filled teeth than did their counter parts. Similarly
several hundred of rural schools in the United
States and few schools in Brazil and Thailand prac
tice school water fluoridation.
calendar year. They also allow7 supplementation to
begin at birth, so that maximum protection can be
afforded to both primary and permanent teeth.
Dietary fluoride supplements are administered in the
following forms:
1) Fluoridated milk
2) Fluoridated salt
3) Fluoride in sugar
4) Fluoride in citrus beverages
5) Fluoride drops
6) Fluoride drops with vitamins
7) Fluoride tablets/lozenges
8) Fluoride tablets with vitamin
9) Fluoride oral rinse supplements
Fluoridated milk
Milk fluoridation is suggested as an alternative to
water fluoridation for caries prevention, Jolan
Banoczy et al. (1984) undertook a longitudinal study
to see the effect of milk consumption in 3 to 9 years
old children with homogenous living condition. Chil
dren were given 200ml milk daily, fluoridated with
0.4mg of fluoride for preschoolers (3 to 5 years old) ;
and 0.75mg fbr schoolers (6 to 9 years old) for 300 i
days in a year. Caries increment was seen consider
ably less in the second year and the third year com
pared to the first year.
«
Advantages and disadvantages
■ Results of several school water fluoridation pro
grams indicate that it can be an effective public
health measure to reduce dental caries in commu
nities where fluoridation of water supply is not
possible.
• This method has some disadvantages also. Most
of children are 5 to 6 years old upon starting
school; at this age their dental development pre
cludes the fluoride from school water fluorida
tion and will not provide pre-eruptive contact to
the primary teeth. It allows only limited pre-eruptive protective benefits to the primary teeth.
■ Another disadvantage is intermittent fluoride ex
posure of children. Most children who attend
school for 5 to 6 hours are actually in school less
than 180 days during a year and do not receive
complete effect of fluoride.
Disadvantages
Although most of the studies have shown evidence
of protection from caries, milk is not an ideal vehicle
for fluoride delivery because of the following reasons:
■ It provides only a limited exposure to children, as
consumption of milk tends to decline with in
crease in age.
■ Absorption is slow as compared to water fluori
dation.
DIETARY FLUORIDE SUPPLEMENTATIONS
Fluoridated salt
Though a school based program assures that par
ticipating children are regularly receiving their fluo
ride supplements, the time of exposure to the devel
oping dentition is not at the maximum level. In com
munity water fluoridation they receive an advantage
of being able to administer the fluoride for the entire
The addition of fluoride to table salt is a feasible way
to deliver systemic fluoride, particularly in countries
that lack a widespread municipal water system. Fluori
dated salt has been sold in Switzerland for many
years. France and a few countries in Western Hemi
sphere have introduced salt fluoridation in recent
years. Wespi (1961) first promoted the use of table
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
Table 6.16: Recommended dietary fluoride supplements (Revised schedule, 1999).
Age in years
Concentration of fluoride in drinkj|^ water in ppm
< 0.3 ppm
0.3 to 0.6 ppm
> 0.6 ppm
Birth to 6 months
None
None
None
6 months to 3 years
0.25 mg/day
None
None
3 to 6 years
0.50 mg/day
None
None
6 to 16 years
1.00 mg/day
None
None
salt as a vehicle for fluoride in the mid 1940s. Initially
supplementation was 90mgF/kg of salt. Recently it
has been recommended in the range of 200 to 250
mgF/kg salt. Commonly used salts are potassium fluo
ride (250 mg/kg) and sodium fluoride (225 mg/kg). All
over the world only five countris (Belgium, France,
Germany, Spain and Switzerland) have specific poli
cies of use of salt fluoridation. A sixth, Hungaiy, is
presently contemplating a recommendation (Banting
1999).
Advantages and disadvantages
Salt fluoridation holds a great promise for under
developed countries and countries like India where
water fluoridation is not feasible due to a limited cen
tral water supply and not accessible to a majority of
the community. Salt is the vehicle, which is not ex
pensive and is used almost in all the houses. Fluo
ride supplied in salt is usually ingested with meals
hence absorption is relatively slow.
4
Fluoride in sugar
■
■
Several studies have shown that adding fluoride
to sugar and sugar products has potential to re
duce the cariogenic effect of sugar or fermentable
carbohydrates among population groups, espe
cially where it is impractical to use other fluoride
vehicles. 42% reduction in caries was observed
in a 3 year clinical trial. (Luoma et al. 1979)
In Manipal department of pedodontics too, a clini
cal trial conducted with fluoridated sugar rinse in
children has shown a high potential in control
ling caries risk factors like salivary pH and
S.mutans count compared to the control group.
(Tandon 1994, unpublished data)
Disadvantages
It is believed that the marketing of cariologically harm
less fluoridated sucrose products would increase the
general consumption of sucrose and thus will pro
mote a nutritional imbalance. Further more, one type
of fluoridated sugary product may not reach all those
needing the fluoride supplements.
Fluoride in citrus beverages
Citrus beverages may also be considered as a poten
tial vehicle for the administration of fluoride as di
etary supplements. (Galon et al. 1983)
Prescribed fluoride supplements. [Tablets, drops, vi
tamins etc.]
Fluoride supplements are prescribed by the practi
tioner for children living in areas with a suboptimal
level of fluoride in the drinking water. Recently, the
recommendations of American Academy of Pediatric
Dentistry [AAPD] and the American Academy of
Pediatrics [AAP] have been revised by qualified
health care providers as given in Table 6.16
Precautions to be considered
■
Before prescribing a fluoride supplement for a
child, a physician or dentist should know the
child’s ace.
<%%> I TEXTBOOK OF PEDODONTICS
■
The concentration of fluoride in the child’s
‘primary source” of drinking water.
Generally infants are given fluoride drops with or
without vitamins, which are directly placed in the
mouth or added as foods. Fluoride tablets are geh-~
erally prescribed after a child has a full comple
ment of the primaiy teeth. The effectiveness of
fluoride drops or tablets is neither enhanced nor
reduced by adding vitamins. However, there may
be increased compliance as a separate route is
avoided when fluoride is prescribed in vitamins.
Prenatal fluoride supplements
deeply into enamel. These ions tend to provide only
local protection.
PROFESSIONAL APPLICATION
When fluoride is applied to an enamel surface it dif
fuses inward by way of the less dense inter prismatic
spaces to a depth related to its concentration, the
treatment time, pH and the type of fluoride agent Fluo
ride agent should not be swallowed while applied.
Procedure to be followed:
To reduce the likelihood of ingestion of fluoride dur
ing a professionally applied topical application, the
following procedures should be kept in mind.
« Seat the patient in an up right position
« Use trays with absorptive liners
■ Limit the amount of the agent, for example during
gel application, the gel is placed in the tray to no
more than 2 5 ml (one-half of a teaspoon)
■ Use suction during and after treatment
■ Have the patient expectorate thoroughly after the
trays are removed.
Prior to 1966, fluoride was prescribed in prenatal sup
plements for potential caries prevention in teeth
where development begins in intrauterine life and at
birflt There was a belief that fluoride would cross
the placental barrier and get acquired by the devel
oping teeth sufficiently to provide caries protection.
; Legros et al [1983] reported that prenatal fluoride
| protect the teeth by:
| a. By affecting the morphology of teeth, promoting
the formation of smooth teeth with shallow
grooves and fissures.
Commonly used agents in clinics for topical
i b. Enamel shows less depth of etching and is comapplications are discussed in Tables 6.17-18,
19*
j
posed of more densely placed enamel rods with
|
more mineralized apatite crystals and with a slightly
|
better crystallinity.
?
f c. Recently, another school of thought is that di, etary fluoride supplements to pregnant women
can not be recommended because there is no con
clusive evidence that it reduces dental caries in
the teeth of their offspring.
Fluorideoral rinse supplements
Fluoride oral rinse supplements provide both a sys
temic and topical effect. The patient swishes the so
lution producing a topical effect, and then swallows
the solution, providing a later systemic effect.
TOPICAL APPLICATIONS (Fig. 6.10)
Fig. 6.10 Various topical fluoride products.
Topical fluorides are directly applied to the erupted
teefli. Fluoride ions in such agents do not penetrate
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
Table 6.17: Commonly us-ed-fluoride agents in clinics
_____________________ SOLUTION__________
g________
8% SnF2 (19,360 ppm)
Amount
2% NaF (9,040 ppm) pH-7
Method of
preparation
* To prepare 2% Na F, dissolve
* ‘O’ No. gelatin capsules are priorly
filled with 0.8 gm, powdered SNF2
20 gms of NaF powder in 1 liter of
distilled water in a plastic bottle.
and are stored in airtight plastic
containers.
* NaF should always be stored in
plastic bottles. If. stored in glass
*. To prepare 8% SNF2, content of one
containers, the *F of the solution can
capsule is dissolved in 10ml of
react with the silica of glass forming
distilled water in a plastic container
and then shaken.
SiF2 reducing the-availability
of free active fluoride
* SnF2 solution is to be prepared just
for anticaries action.
before each application.
Technique of
application
Knutson and Feldman technique
(1948)
* Clean and polish the teeth in only
the first of four applications.
* Isolate the upper and opposing
lower quadrant with cotton rolls.
* Dry the teeth thoroughly.
* Apply the 2% NaF with cotton rolls
applicators and allow it to dry on
the teeth for about 4 minutes.
* NaF is applied once because once
a layer of CaF2 (dorhinant product
of reaction) gets formed it interferes
with further diffusion of F to react
with hydroxyapatitie. This is called
choking off phenomenon.
* Instruct the patient to avoid eating,
drinking for 30 minutes.
Muhler (1957) technique.
* Do a thorough prophylaxis.
* Isolate a quadrant with cotton rolls
arid dry the teeth.
* Apply the freshly prepared 8% SNF2
continuously to the teeth with cotton,
applicators.
* Reapply the solution to the tooth
every 15-30 sec. So that the teeth
are kept moist with the solution for
4 minutes.
* Instruct the patient not to eat, drink
or rinse for 30 minutes. This, helps
in prolonging the availability of F
to react with the tooth surfaces.
,No. of
application
per year
* Second, third and fourth applications are done at weekly Interval.
* Application is recommended at 3,
*7, 11 and 13 years.
* Once per year.
Advantages
* Chemically stable
* Acceptable taste because of
neutral pH.
* Non-irritating to the gingiva.
* Does not discolor the teeth.
* Cheap and inexpensive.
* The rapid penetration of tin and
fluoride within 30 seconds.
* Highly insoluble tin-fluoro
phosphate complex forms on
enamel surface that is more
resistant to decay than enamel.
✓
contd.
I TEXTBOOK OF PEDODONTICS
Amount
2% NaF (9,040 ppm) pH-7
8% SNF2 (19,360 ppm)
Disadvantages
* Patient has to make four visits to
the dentist within a relatively short
time.
* Unstable in aqueous solutions and
should be prepared fresh for each
patient.
* Its naturally low pH (2.1 to 2.3) is
rather astringent and the solution
has a metallic taste.
* It may cause gingival irritation,
particularly to the dehydrated and
diseased gingival tissue.
* Produce discoloration of the teeth
particularly in hypocalcified areas.
* Causes staining on the margins of
restoration.
Mechanism of aciton: NaF
Ca10 (PO4)6 (OH)2 + 20 F —± 10 CaF2 + 6PO4~ + 2OH
CaF2 + 2Ca5 (PO4)3 OH
2Ca5 (PO4)3 F + Ca (OH)2
Mechanism of action: SnF2
Low concentration:
H
Ca5 (PO4)3 OH + 2SnF —> 2CaF2 + Sn2 (OH)PO4 + Ca3 (PO4)2
;£
j
V
High concentration.
5
f
I
Ca. (POX OH + 16SnF, —► CaF, + 2Sn,F.PO. + Sn7(OH)PO„ + 4CaF,(SnR),'
5 ' 4'3
2
2
3 3 4 2' '4
2' 3'2 e
2Ca5(PO4)3 OH + CaF2 —► 2Ca5(PO4)3F + Ca (OH)2
Table 6.18:
SOLUTION
GEL
Amount
1.23% F APF (12,300 ppm) pH - 3.0
23% F APF (12,300 ppm) pH - 4 - 5
Method of
preparation
* To prepare APF solution dissolve
20 gms of NaF in 1 liter of 0.1 M
phosphoric acid.
* To this add 50% hydro fluoride
acid to adjust the pH at 3.0 and *F
concentration at 1.23%.
* To prepare $ gel, a gelling agent
methylcellulose or hydroxyethyl
cellulose is to be added to the
solution and the pH is adjusted
between 4-5.
contd.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
SOLUTION
__________ A____________________________
.
Technique of
applicaton
Brudevold technique (1963)
* Do a thorough prophylaxis and
isolate a quadrant with cotton rolls.
* APF solution is continuously and
repeatedly applied with cotton
applicators.
* Keep the teeth moist for 4 minutes.
* Pass the floss through each
interproximal embrasure to
ensure wetting of these surfaces.
* Repeat the procedure for
remaining quadrant.
* Instruct the patient not to eat, drink
or rinse for 30 minutes.
* Do a thorough prophylaxis and dry
the teeth.
* Fill the U/L tray with APF gel.
* Insert the U/L trays simultaneously
into the mouth and have the patient
bite down tightly for 4 minutes.
* Thixotropic gel displays a high
viscosity at low shear rates and a
very tow viscosity at higher shear
rates. The clinical importance of
this is that the gel thins out under
biting forces and more easily
penetrates between the teeth.
Conversely, when it is not under
stress it remains in the tray and
does not tend to run down the
patient’s throat.
* Instruct the patient not to eat, drink
or rinse for 30 minutes.
No^ of applica
tion per year
* Semiannual
* Semiannual
Advantages
* Fluoride uptake following the
applicaton of APF solution is
greatly accelerated whereas that
following NaF is much slower.
50% more effective than NaF.
* APF solution is cheap, can be
prepared easily.
* It is stable with a long shelf-life,
when stored in an opaque plastic.
bottle.
i
* Acceptable by the child due to
^flavoured taste.
* Easy to apply as with gel fluoride
comes in constant contact with
teeth so re-appxlication is not
required.
* Can be self-applied.
* Thixotropic property.
* Caries reduction more than when
compared to APF solution.
Disadvantages
* Teeth must be kept wet with the
solution for 4 minutes.
* APF solution is acidic, sour and
bitter in taste so necessitates the
use of suction.
* Can cause irritation to inflammed
gingival tissue and to the open
carious lesion thus, it should be
applied only after restoration of all
carious teeth.
Mechanism of action: APF
J?ja5 (PO4)3OH + 4H+
5Ca++ + 3HPO4" + H2O (dehydration and shrinkage)
Ca++ + HPO4~
(hydrolysis)
\ z
1
Ca.HPO4.2H2O (DCPD)
SCaklPO
9H n * r-
(Di calcium phosphate dihydrate) (Intermediate product)
--------r o /Dfi \ C a OUDH - X TU+X OU n
| TEXTBOOK OF PEDODONTICS
Table 6.19:
*
VARNISH
FOAM
Amount
Bifuoride 12 (2.71% NaF, 2.92% CaF2)
0.92% F (9200 ppm) pH - 4.5
Method of
preparation
* Commercially available
(discovered by Schmidt in 1964)
* Commercially available
Technique of
application
* Do the thorough prophylaxis and
dry the teeth (do not use cotton for
isolation as varnish is sticky and
tend to stick to cotton)
* Drop the varnish onto the brush
or foam pellet.
* Paint the varnish thinly first on
the lower arch (as saliva collects
more rapidly on it) and then on
upper arch starting from the
proximal surfaces. Layers, which
are too thick, separate too easily
* Instruct the patient:
a. Not to rinse or drink anything
at ail for that day.
b. Not to eat solid for that day.
c. Take liquid and semisolids
till next morning.
d. Not to brush that day.
z
f
f
No. of applica
tions per year
Semiannual application
Semiannual application
Advantages
* Forms a watertight protective film
insulating against thermal and
chemical influences.
* With correct application and proper
mouth hygiene varnish remains
in place for several days. During
this time fluorides act on the
treated surface.
* It is less dense than gel and is able
to flow better, allowing a free movement
of the fluoride ion on the tooth
surface and interproximal areas.
* Total density by weight is less than
gel application. This reduces the
risk of ingestion and systemic
toxicity of fluoride.
. Disadvantages
* Patient compliance is required.
* Retention on to the tooth surface
is less as no polymers are added.
* Other varnish preparation: Duraphat (Germany), Fluorprotector (Lichenstein), Fluoritop (India)
Mechanism of action: Varnish
10Ca5(PO4)3OH + 10F-
6Ca5(PO4)3F + 2CaF2 + 6Ca3(PO4)2 + 10OH
2Ca5(PO4)3OH + CaF2
2Ca5(PO4)3F + Ca (OH)2
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL I
Otherfluoride applications (by the professional)
1. Fluoride impregnated prophylaxis paste and cup
The temperature of enamel surface is raised dur
ing a prophylaxis because of the friction between
the prophylaxis cup and the tooth. High tempera
ture enhances the uptake from fluoride contain
ing prophylaxis paste or solutions (Putt et al 1978).
It is therefore reasoned that if a fluoride impreg
nated prophylaxis cup or paste are developed,
fluoride would be released under optional condi
tions. Laboratory evidence have also confirmed
that prophylaxis cup made from a blend of ther
moplastic resins and impregnated with sodium
fluoride and stannous fluoride will increase the
fluoride content of enamel. When fluoride con
taining prophylaxis pastes are used, the effects
were generally found to be similar whether a con
ventional or fluoride impregnated prophylaxis cup
was used (Stookey and Statiman, 1976)
2. Iontophoresis
It is based on a theory that small electric current
will help to drive fluoride ion further into the
dental enamel, producing the desired effect, re
duced enamel solubility, increased fluorapatite for
mation, reduced dentine sensitivity and even steri
lization of root canals.
3. Dental materials containing fluoride
Several studies were conducted to see the
cariostatic effect of dental materials containing
fluoride and a highly significantly fluoride up
take by enamel was recorded that was placed in
contact with the materials.
■ Carboxylate cements are now used more ex
tensively for cementation of crowns and or
thodontic bands.
■ Fluoride in amalgams have also been tried.
Jerman (1970) added 1.5% of stannous fluo
ride to silver amalgam alloy and noted that the
enamel surface placed in contact with this al
loy showed a significant reduction in enamel
acid solubility.
■ Fluoride containing varnish and sealants were
considered of potential value in Pedodontic
practice. A poly^ethane based material con
taining 10% sodium monofluorophosphate
commercially available as “Expoxylite 9070” has
shown 36.6% less carious surface on first per
manent molar.
■ Glass ionomers are the recent innovation which
seem to dominate the other materials because
of their fluoride leaching property.
SELF APPLIED TOPICAL APPLICATIONS
Fluoride Dentifrices
Fluoride containing tooth pastes now account for
approximately 85% ofdentifrices market in the world,
especially in the USA. The Council on Dental Thera
peutics of the American Dental Association currently
recognises few caries preventive dentifrices with
ADA seal acceptance. They all contain between 1,000
and 1,500 ppm fluoride formulated from either so
dium fluoride or sodium mono-fluorphosphate and
none contains stannous fluoride.
Advantages
/
Because fluoride dentifrices usually are used regu
larly two or three times a day, they provide a frequent
source of fluoride in low concentration that can in
hibit demineralization and enhance remineralization.
Availability
Fluoride dentifrices are available and recommended
for the people of all ages whether they live in fluori
dated or non-fluoridated areas.
Precautions to be considered
Preschool age children should be supervised
while brushing to avoid ingestion of excessive
amount of paste.
■ Only a dab or pea- size amount ofdentifnoeshould
be used by six years of age or below.
■
Îflîïïl | TEXTBOOK OF PEDODONTICS
■
■
A ribbon of dentifrice that covers the bristles of
an adult-sized toothbrush contains about one
gram of dentifrice. Swallowing the amount of fluo
ride which is present in this toothpaste should be
avoided.
At least one brushing with fluoride tooth paste
should be done just before bed time, placing fluo
ride in the mouth prior to a period of low salivary
flow thus prolonging fluoride availability (Table
6.20)
Table 6.20 Use of fluoride tooth pastes
Child age
Recommendations for use of fluori
de tooth paste
Below 4
years
Fluoride tooth paste is not recomm
ended
4 to 6
years
Brushing once daily with fluoridated
toothpaste and other two times with
a non-fluoridated toothpaste.
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u
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■
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kj
6 to 12
years
Brushing twice, daily with fluoridated
toothpaste and once with a non
fluoridated toothpaste.
Above
12 years
Brushing three times with fluoride
toothpaste.
■ ■ t
n
£
fluoride Impregnated Dental Floss
mal surfaces receive the benefit of additional fluo
ride dental flossing, this may increase its value as a
caries preventive aid.
Gillings (1973) utilizing sodium fluoride and stannous
fluoride successfully developed and patented sev
eral formulas of fluoride of fluoridated dental floss.
Because of the unknown sample size and the lack of
clinical size and date, no definitive conclusions about
this cariostatic effect could be made.
Fluoride rinses
Fluoride mouth rinses for school based health
programs or in home are currently popular as a
simple way to expose teeth to fluoride frequently.
The early trial with neutral sodium fluoride, acidu
lated phosphate fluoride and stannous fluoride rinse
proved to reduce caries by 20 to 50 percent.
Amount of Fluoride in Self Applied Fluoride
Rinses are given in Table 6.21
z.
Usually non-prescribed fluoride mouth rinses con
tain 0.05% NaF (about 225 ppm). They should be
swished vigorously once a day for bne minute and
expectorated. Prescription fluoride rinses generally
contain 0.2%. NaF (about 900 ppm). They are de
signed to be used under supervision, once a week
for one minute.
Dental floss is an essential part in the plaque control
intheinterproximal enamel surface. Iftheinteiproxi-
Table 6.21 : Amount of fluoride in self applied fluoride rinses
Program
Agent
Home
0.05% NaF
Daily
0.044% APF
School
Frequency
Fluoride
Concentration
Volume used
Amont of
fluoride
0.023%
10 ml
2.3 mg
Daily
0.02%
10 ml
2.0 mg
0.01% Snf2
Daily
0.024%
10 ml
2.4 mg
0.2% Naf
Weekly
0.09%
10 ml
9.0 mg
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
Precautions to be considered:Children under five
years and some handicapped children may swallow
the rinse rather than spit it, hence mouth rinses are
not recommended for them.
70kg or about 1.0 to X0 gm sodium fluoride for a
child of 15 kg. Amount less than this, however, can
cause:
■ Nausea
■ Writing
Sustained release fluoride
Constant exposure of teeth to low levels of fluoride
has been found to be more effective in reducing car
ies by remineralization of incipient carious lesions.
The objective of sustained release fluoride is to pro
vide a regular release of fluoride slowly intra-orally
fora longer period.
A number ofdental materials containing fluoride have
been develop as cements, acrylics and resin while
intra-oral devices used are copolymer membrane
beads and glass pellets. (Refer appendix 14b, c)
FLUORIDE TOXICITY
Accumulated evidence from numerous studies shows
that the prolonged use of fluoride at recommended
levels does not produce harmful physiological ef
fects in human. Dental fluorosis which has been
found to be true in individuals consuming drinking
water containing upto 8-0 ppm fluoride, about eight
times the recommended amount. In India many of the
states have been identified with some circumscribed
areas of high fluoride level and are marked as en
demic fluoride belts (Fig. 6.11). These areas are hav
ing ground water with more than 4.00 ppm.
*
Dental fluorosis occurs in human being consuming
water containing 2.0 mg/lit or more of fluoride par
ticularly during first eight year of life. Skeletal
fluorosis can occur if water contains more than 4
ppm fluoride and is consumed regularly.
Acute Toxicity
Ingestion of an acute fatal dose of fluoride is very
rare. The amount of 35 to 70 mgF/kg body, weight of
soluble fluoride is to be lethal. This is equivalent to 5
» Diffuse abdominal pain
■ Diarrhoea
■ Excess salivation
■ Thirst
■ Muscle tremors
Treatment
■ Vomiting should be induced with a syrup of ipeac
or digital or mechanical by stimulation of tongue
or throat.
a Subsequent effects should be made to decrease
the absorption offluoride by administering fluoride binding liquids like warm water, Calcium hy
droxide liquid, antacid containing aluminum or
magnesium hydroxide or milk.
a The affected individual should be hospitalized
and stomach should be thoroughly washed with
additional lime water
a At the sigp of a muscle tremor calcium gluconate
should be administered intravenously, along with
saline to prevent a shock
Chronic toxicity
Chronic toxicity is due to a long term ingestion of a
smaller amount of fluoride which usually effect the
hard tissue and kidney.
Table 6.22 Chronic toxicity effects of excessive fluo
ride ingestion
Effect
Dosage
Duration
Dental
fluorosis
2 time optimal
Until 5 years
(Excluding third
molars)
Skeletal
fluorosis
10-25 mg/day
10-20 years.
Kidney
a
5-10 mg/day
6-12 months
Fig. 6.11
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
Table 6.23a Lethal and safe dosages of fluoride
for a 70kg adult
*
Methods
■ Certainly Lethal Dose (CLD)
1 mg/L, which is suitable for health in drinking water,
depends on the materials and methods used.
Defluoridation methods using organic or inorganic
substances nowdays are available.
5-10 gm NaF
or
32- 64 mg F/kg
■ Safely Tolerated Dose (STD) = % CLD
1.25-2.5 gm NaF
or.
8-16 mg F/kg
Table 6.23b CLD’s & STD’s of fluoride of selected
ages*
Age
2
4
6
8
10
12
14
16
18
Weight (lbs)°
22
29
37
45
53
64
83
92
95
CLD (mg)
STD (mg)
320
422
538
655
771
931
1,206
1,338
1,382
80
1Ô6
135
164
193
233
301
334
346
* 3rd percentile of the normal age-specific weight distri
bution.
Table 6.24 Common signs and symptoms of
acute fluoride toxicity*
■
■
■
•
■
Low dosages
High dosages
Nausea
Vomiting
Hypersalivation
Abdominal pain
Diarrhea
■ Convulsions
■ Cardiac arrhythmias
■ Comatose
* Stanley and Herschel (1984)
DEFLUORIDATION
Defluoridation is a scientific means to improve the
quality of water with high fluoride concentration by
adjusting the optimum level in drinking water
f
To reduce the fluoride concentration to less than
1.
Adsorption and ion exchange method
Some substances adsorb fluoride ion by the sur
face, arid it canbxchange its negative ions such
as OH
* group for fluoride ions. Thus the concen
tration of fluoride in water decreases. This proc
ess depends on suitable conditions like pH, tem
perature, flow rate, grain size of the material. Some
of the commonly used materials are:
Activated Alumina (Al? O3), Fluidized Activated
Alumina, Activated Bauxite (Hydrate of A1 (OH)3),
Zeolite (NaO2. A12O3), n SiO3x H2O, Tricalcium
phosphate (Ca 3(P04)2orTCP), Superphosphate
(COHPOj-bCaSOJ,Activated bone char (Ca10
(PO4)8 OH2).Magnesite(MgOO3)
^Activated Carbon, Palan Carbon, Charcoal, Clay
and Soil, Bricks.
2. Precipita/ion Method
In a high pH condition, co^recipitatipn of sev
eral elements in water with fluoride ions forms
fluoride salts. Sometimes, it may cause
flocculation if the substance used is Aluminium
ions. Thus, the fluoride concentration in water
decreases. A well known substance of this group
is Alum, which is used in water supply systems
and water treatment. These substances include:
Alum(KAl(SO4)2.12H.O), AlumandJimgfCaO)
Lime Softening (Ca (OH)2), Calcium chloride (Ca
CI?)
3. Methods based on membrane separation
In the industrialized world 'reverse osmosis* pipcess is well known. All elements in water get <|L
minishedafter filtration. This method is claimed
to be the best water purification process avail
able. This method seems to be expensive for de
veloping countries as 30% of raw water is lost in
the process.
I TEXTBOOK OF PEDODONTICS
INDIAN TECHNOLOGY FOR DEFLUORIDATION
■
Nalgonda Technique
■
■
■
This technique first developed in India in 1975, is the
most simplest, the least expensive and the easiest to.
operate of all the other methods of defluoridation.
Using Lime and Alum
National Environmental Engineering Research Insti
tute (NEERI), Nagpur has been involved in
defluoridation research since 1960 s. One of their
work which could be successfully transferred from
laboratory to the field and implemented in Nalgonda
Technique. The first community plant for removal of
fluoride from drinking water was constructed in the
district of Nalgonda in Andhra Pradesh., in the town
of Kathri, thus the name of the technology.
Procedure
Raw water is mixed with adequate lime and alum. The
amount of lime depends on the alkalinity of the raw
water. If the raw water has adequate alkalinity, the
lime addition is not required. Alum solution, is added
after theaddition of lime, stirred gently for 10 min
utes and the flocs formed are allowed to settle. This
process of floc formation, and setting requires an
hour.
~~
The chemicals are same as those used in a
muncipal urban water supply.
It is cost effective.
Designs are flexible to use at different location.
Defluoridation meets with standard laid down by
the Bureau of Indian Standard (fluoride content
less than Img/L).
Combined Nalgonda and Calcined Magnesite
technique
In Tanzania the calcined magnesite technique and
Nalgonda technique both were introduced as a flow
system of a pilot plant for experiments in 1985 and
completed in 1990. In this plant the Nalgonda tech
nique was passed through a filter bed consisting of
calcined magnesite granules. Fluoride was absorbed
by the calcined magnesite granules thus further re
ducing fluoride concentration. However, there was a
rise in pH over 10.0 and the treatment water needed
adjustment before being drunk. This method is found
impractical for rural regions as calcined magnesite
needs to be regenerated.
Prasanti technology
i
In Indian villages this method of utilizing Activated
Alumina is found to be most popular and cost effec
tive material for defluoridation. It originated as a re
sult of research carried out by the Bio-Science, De
partment of Satya Sai University for Higher Learning
Domestic use
in Prasant Nilayam, Anathapur District, Andhra
Pradesh, at which 25 community defluoridation plant
were constructed, each serving 200-400 people in
In rural areas this method is advised for domestic
use of defluoridation of drinking water as required.
location and have been functioning since 1998. Be
The advice is given to mix water with lime and ahimiru sides the community plants, approximately 500 do
a closed big vessel and leave it overnight so that
mestic defluoridation filters are being used by peo
next morning the clean supernatant is decanted for ple living in endemic area.
use and is safé for tansumption
Other materials tried in India
Advantages of Nalgonda Technology
■ Fish bone charcoal
■ This method can be used both at domestic and
Researches of the University of Roorkee suggested
community levels.
practical application of Fish bone charcoal as a
« Operations are possible manually.
comparatively cheaper and mix effective materials.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
■
Drumstick plant (Moringa Cleifera)
Was also, used as an alternative to defluoridate
drinking water as it is easily accessible (could be
seen in the house hold of rural and Urban) and it
has been widely used tb reduce water turbidity
because of its excellent coagulating and clarify
ing properties. The defluoridation efficiency of
the seeds of drumstick could possibly be due to
calcium and magnesium levels in the plants.
■
Askali - extract mycetial biomass
Researchers from Osmania University,
Hyderabad, have demonstrated the ability of this
material from Aspergillus riger to bind fluoride
from fluoride containing water but the mechanism
is still not clear.
-
■
Clay Minerals
Two fluoride sorption Clay materials :
montmoslloniteKSF, Kaolin and a Silty Clay Sedi
ment Series (used in making pottery) were tried
for defluoridation.
■
Tricalcium Phosphate (TCP)
The TCP may be able to produce a complex chemi
cal reacting mechanism in defluoridation which
needs energy.
Self-Assessment
1.
2.
3.
4.
5.
6.
7.
What is fluoride?
What are Colorado stains?
What do you mean by the term mottling ?
Who are Mckay and Martin ?
What are the causes of mottling?
*
WhowasDr. H.V Churchill?
Who conducted the shoe leather survey and
where it was done?
8. Who is called the father of fluorides in dentistry?
9. What was the recommendation for fluoride in
drinking water for its caries prevention?
10. What are the sources of fluorides?
11. What is the plasma half-life of fluoride?
12. List out the systemic and topical actions of fluo
rides
13. What is anti-enzymatic action of topical fluorides?
14. How fluoride renders the enamel more resistant
to acid dissolution through systemic action?
15. How does fluoride bring about remineralization
of incipient caries?
16. Name the modes of administration of fluorides?
17. Who introduced topical application of NaF in
dentistry ?
18. What is the technique of application of 2% NaF
called as ?
19. How much of fluoride solution is required for topi
cal application of full mouth?
20. What is the choking-off effect?
21. What is the method of preparation of 2% NaF
solution?
22. What is fittydent?
23. Instructions to be given after NaF application ?
24. What is the technique of application of stannous
fluoride called as?
25. What are byproducts released after SnF applica
tion?
26. Which is the byproduct that makes the tooth
stronger to acid dissolution?
27. What is the frequency of 8% SnF application ?
28. What is APF and what is the technique of appli
cation called as?
29. What is the difference between APF gel and APF
solution?
30. WhatisDCPD?
31. What do you mean by thixotropic property?
32. What are the commonly used fluoride varnishes?
33. What are the composition ofcommonly used fluo
ride varnishes?
34. What are the technique of application ofduraphat,
fluorprotector and Bifluoride -12 ?
35. What are the advantages of fluoride varnish?
36. Name some fluoride mouth rinses.
37. Name the fluoride containing dentifrice in the
Indian market?
38. What is tiie a
dentifrice?
39. What is the mechanism of action of sodium
monofluorophosphate?
40. List the recommendations for use of fluoridated
tooth paste in children.
€03 I TEXTBOOK OF PEDODONTICS
41. Define fluoridation and defluoridation.
42. When was the water fluoridation started and in
which cities?
43. Name the milestone studies in water fluoridation
44. What is the optimum level of fluoride in water?
45. What are the types of water fluoridation?
46. What are the endemic fluoride areas in India?
47. Why is water fluoridation is not effective in India?
48. Who introduced milk and salt fluoridation ?
49. Why salt fluoridation is a viable method of sys
temic fluoride ingestion?
50. What are fluoride drops?
51. What are fluoride tablets?
52. Name some commercially available fluoride tablets?
53. What is the daily dose of fluoride tablets?
54. What are the two types of fluoride toxicity?
55. What are the clinical features of fluoride toxicity?
56. What are GLD and STD for fluorides?
57. What are the emergency treatments for acute fluo
ride toxicity ?
58. Name the defluoridation methods.
59. What are anion and cation exchange resins?
60. What is the Nalgonda technique?
6.6 Methods on the Horizon
Tandon S
A lot of research has been directed towards efforts
to develop methods to prevent caries, which have
ranged from simple to highly sophisticated tech
niques. These current approaches are still under trial,
and based on three prong-strategies.
1. Combating caries inducing micro-organisms
2. Increasing tooth resistance against acid attack
3. Modifying cariogenic diet ingredients
1. Antiplaque agents.
The role of plaque in the formation of dental car
ies is well documented. Thus anti bacterial and
anti adherence agents are being tested as a plaque
building blockers.
■ The enzyme glucosyltranferase [GTE] may be
inhibited by the use of analogues of sucrose
interfering with glucan synthesis.
■ In the recent times some plant and fungal prod
ucts that alter the adhesion of cell surface
glucans are also being identified. In this con
text, cheaper modalities that are accessible to
the masses are being tested in the form of in
digenous products. Rajesh et al [1997] tested
the efficacy of Mango leaf, Neem leaf and Tea
K
extracts and found that all the three products
i
were effective in reducing the plaque forma
tion as well as the streptococcus mutans count.
■ The antibacterial products may have the draw
back of being rapidly eliminated from the oral
cavity and for this purpose, Controlled Release
Devices [CRD] or polymers are being used to
increase the substantivity in the oral cavity.
2. Altering surface morphology/Increasing tooth
resistance
A so called ‘surface active polymeric agents for
surface adhesive binding has been developed
by Bowen et al [1995] comprising of application
in 2 stages for increasing tooth resistance to den
tal decay.
■ Monomer which would have a chemical bond
followed by
« A polymeric top coat which would enhance
durability and esthetics.
■ Tooth resistance is improved using two steps
procedure by enhancing the fluoride uptake in
enamel. This method involves initial applica
tion of an acidified calcium phoshate solution
followed by suitable fluoride solution. Such a
two component system can be used as a pro
fessional topical application or self applied
mouth rinse or alternately using chewing gum
of an amorphous calcium phosphate ( ACP)
and tooth paste containing fluoride.
3. Lasers
■ CO2 lasers can be used to alter the tooth sur
face of enamel and make it less prone to caries.
Concern however exists regarding the depth
control and optimum irradiation conditions.
Pits and fissures and root surfaces may be the
areas targeted by the lasers.
4. Benign microorganisms/ Replacement therapy
• Using the ‘Use a thorn to draw a thorn ‘phi
losophy, an approach would be to supersede
the cariogenic bacteria by more benign ones.
| TEXTBOOK OF PEDODONTICS
■ The dominant acid [lactic acid] produced by
S. mutans is controlled by a gene which can be
mutated.
■ Genetic engineering provides a better alterna
tive producing inactivated forms and then clon
ing it, for example, a new approach is being
used to transfer the genes from bacteria that
naturally produces enzymes such as mutanase
which degrades the extra-cellular sticky poly
mers involved in plaque adhesion and build
up into bacteria such as streptococcus
gordoni.
■ An attempt to transfer arginine diminase gene,
which produces base in S sanguis, into S
mutans , to counter its acidogenic potential
has been made.
5. SAP (Self assembling polypeptides)
Preliminary reports have suggested the use of
self assembling polypeptides [Strafford et al 1999]
for augmentating host resistance. These may be
useful in promoting enamel remineralization, pre
sumably as a result of their nucleating potential.
Following incubation in the mineralizing solution,
large crystal deposits were found within the SAP.
These protective peptides are used as pacifiers
for young children to help modify the bacterial
flora againt baby bottle caries. These peptides
have also been used in mouth rinses and denti
frices.
6. Chewing gums
« A novel technique involves the use of chew-'
ing gums after meals in order to counter the
pH drop that occurs with the intake of sugar.
Various sugar free gums have been tried out,
with additions such as xylitol, lactitol and Urea.
■ A clinical trial conducted by Gopinath and
Tandon [1996] compared the plaque pH change
in the groups using urea, fluoride and sugars.
The results indicated that the chewing gum
containing urea showed the highest pH fol
lowed by fluoride and sugar. Thus the study
concluded that chewing gum containing thera
peutic agents such as urea may be recom
mended in high risk caries children.
7. Tooth friendly sweets
Use of noncariogenic sweeteners have proved to
be excellent measures in the control of caries. A
short term plaque study was undertaken by
Tandon et al (1997) to evaluate effect of lactitol 4O (b- Galactosy) -D-glucitol on plaque by incor
porating it as a sweetener in biscuits. Significant
reduction was found in plaque formation, carbo
hydrate content, increase in calcium, phosphate
and protein with lactitol when compared with the
control.
8. Microdentistry
Here treatment begins before conditions arise. It
enables the use of a microscope to detect condi
tions invisible to the naked eye. This can again
be used as an educational and motivational tool
by helping the patient observe his own oral con
ditions. For example, letting the patient see the
microorganisms in the plaque
9. Teledentistiy
It is the provision of dental care where the patient
and provider are not physically ip the same loca
tion. This is a relatively new field of study, which
can also be used as an adjunct iit providing pre
ventive home care advices.
10. Indigenous products
Recently a lot of emphasis has been placed on
the utilization of the rich natural resources present
in India. In this context studies have been con
ducted on the use of various products such as
Mango leaf, Neem and Tea. These have been
found to have antiplaque and anticariogenic po
tential.
CARIES VACCINE
Preventive dentistry has taken long strides in the
direction of eliminating dental diseases. In this
*Wïg
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL | €EE)
|ptfae; caries vaccine has generated a good
sm. This modality of treatment can
t the occurrence of caries on a large scale.
îtion
a suspension of
_^^^fcdor killed micro-organisms administered for
^^^^^vention, amelioration or treatment of infocJ^Ssdiseases’. [Stedman’s dictionary, 1990].
S|^|||g'<oicept of a vaccine can be visualized primarily
the recognition of mutans streptococci as the
key microorganisms in the development of caries.
Thus efforts have been directed at preventing its
colonization in the oral cavity
How it works
The basis of a vaccine is that it keeps the patient in a
state of readiness such that in case an infection does
occur, the immune response [i.e. the secondary im
mune response] which is more rapid and effective
can be mounted. Thus during the first response, both
B and T lymphocytes form memory cells that later
"remember6 the earlier attack and respond muchbet-
The main immunoglobulin in saliva, as in any other
secretions in the body, is the secretory IgA. On the
other hand the IgG is present in very low concentra
tions. The significance of antibodies in the protec
tion against dental caries lies in that, the presence of
|levels of antibodies in the gingival fluid has
J^n correlated with low levels of caries. Also the 1"
J^B^hocytes, in caries free subjects, have been found
to possessT lymphocytes with greater potential for
W antigenic stimulation with S. mutans than caries
juries ofadministration.
In general, two schools of research have evolved.
One concerned with IgG and systemic vaccination
using a cell wall constituent of S. mutans, while the
other with the oral route of vaccination and stimula
tion of IgA.
The various routes that have been tried out include:
L Oral route
t
Systemic route
Active gingivo-salivary route
Active immunization
Oral route
The oral route of administration has concentrated
on stimulation of the secretory IgA antibodies
via the common mucosal system [consisting of
MALT and GALT], which is activated in the spe
cial cells of the intestinal tract.
For the colonization of streptococcus mutans in
oral cavity, the enzyme Glucosyltransferase is of
paramount importance. Thus several studies have
been carried out using it
The disadvantages associated with the oral route
of delivery is the rapid breakdown of the protiens
or peptides. But it also considered safer than the
systemic route due to the concern of cross reac
tivity to the streptococcal antigens.
2. Systemicroute
Subcutaneous administration of S.mutans has
been tried out in monkeys and it elicited predomi
nantly IgG, IgM and IgA antibodies. These were
found to enter the oral cavity through the gingival
crevicular fluid.
3. Active gingivo-salivary route.
There has been some concern expressed regard
ing the side effects of using these vaccines with
the other routes, hi order to limit these potential
side effects, and to localize the immune response,
the gingival crevicular fluid has been used as the
route of administration. Apart from the IgG, it
also associated with increased IgA levels.
The various modalities tried out were:
■ Direct injection oflyzozyme into rabbit gingiva
which has elicited local antibody forming cell
response.
| TEXTBOOK OF PEDODONTICS
■ BrusliingliveS.mutansontotliegingivaofrhesus monkeys[ which failed to induce antibody
formation]
■ Using smaller molecular weight streptococci
antigen, which resulted in better performance,
probably due to better penetration.
tively target the cells to where it should reach.
These liposomes are closed vesicles with
bilayered phospholipid membrane. The effi
cacy using liposomes has been found to in
crease two fold in a rat model. In humans in
creased IgA Antibodies have been found.
4. A dive immunization:
Various new approaches have been tried out in
order to overcome the existing disadvantages.
■ Passive immunization
As the name suggests, passive immunization
involves passive or external supplementation
of the antibodies. This carries the disadvan
tage of repeated applications as the immunity
conferred is temporary.
■ Synthetic peptides:
Any antigen derived from animals or humans
has the potential for hypersensitivity reaction.
The chemically synthesized peptides hold an
advantage in that this reactivity can be
avoided. This has also been found enhance
the immune response. In humans synthetic
peptides elicited both IgG and T-cell prolifera
tive response, and the antibodies were both
anti-peptide and anti-native.
The synthetic peptides give antibodies not
only in the gingival crevicular fluid but also in
the saliva. The synthetic peptide used is de
rived from the Glucosyl tranferase enzyme. [Pu
rified water soluble and insoluble].
■ Coupling with cholera toxin subunits
It has been found that coupling of the protein
with nontoxic unit of the cholera toxin was ef
fective in suppressing the colonization of strep
tococcus mutans. This approach was tried out
as the cholera toxin effectively binds to the
lymphoid cells and functions as an excellent
adjuvant. The intra-oral route of administrationwas tried outfKatz, 1993].
■ Fusing with salmonella
The avirulent strains of salmonella is an effec
tive vaccine vector so that fusion using
recombinant techniques have been used.
■ Liposomes
These have used in the delivery of several,
particularly anticancer, drugs so as to effec
Several approaches tried out are:
■ Monoclonal antibodies
Monoclonal antibodies to the S.mutans cell
surface antigen I/II has been investigated. The
topical application in human subjects brought
a marked reduction in the implanted strepto
coccus mutans. Thus by bypassing the sys
tem less concern exists about the potential
side effects.
■ Bovine milk and whey
Systemic immunization of cows with a vaccine
using whole mutans streptococci lead to the
bovine milk and whey containing IgG
antibodies.This was then added to the diet of
a rat model. The immune whey brought a re
duction in the caries level.
This whey was also used in a mouth rinse by
Filler et al[l 991 ]. This resulted in lower per
centage of streptococcus mutans of plaque .
■ Egg-yolk antibodies
The novel concept of using hen egg-yolk anti
bodies against the cell associated glucosyl
transferase of S. mutans was introduced by
Hamada [1990]. Vaccines used were formalinkilled whole cells and cell associated glucosyl
transferase in the other. Caries reduction has
been found with both these treatments.
SECTION 6 : PREVENTIVE APPROACH TO CARIES CONTROL |
• Transgenic plants
Latest in these developments in passive im
munization is the use of trangenic plants to
give the antibodies. They have the advantages
that:
- The genetic material can be easily ex
changed.
- It is possible to manipulate the antibody
structure so that while the specificity of the
antibody is maintained, the constant region
can be modified to adapt to the human con
ditions, thus avoiding cross reactivity.
- Large scale production is possible as it
would be quite cheap.
■ An apple a day keeps the tooth doctor away
Researchers are working on ways, to inject a
peptide - a fragment of a protein that blocks
the bacterium streptococcus mutans which
causes tooth decay into the fruit so that cavi
ties and painful visits to the dentist could be
come a thing of the past.
British scientists at Guys Hospital in London
have already isolated a gene and the peptide
that prevents the bacterium from sticking to
the teeth. Professor David James (2000), a plant
biotechnologist at the Horticulture Research
International in Southern England, is trying to
find ways to deliver the peptide into the mouth'
through apples or strawberries.
Though some difficulties are being faced
*
at
the present, caries vaccine is certainly a very
vibrant issue. The potential implications are
enormous and should be pursued with the same
vigor as before.
Further Suggested Reading For Section - 6
1. Banting D W: International fluoride supplement
recommendations . Community Dent. Oral
Epidemiol .27,57-61,1999
2. Barcoiiey Linda S.,Parental influence on child pref
erence of a dentist,JDC, March-April, 101-9,1986.
3. Bardsen A; Bjdlvatn K : Risk factors in the de
velopment of dental fluorosis. Clin Oral Investig.
2,155-60,1998
4. Basil G., The cariogenicity of snack food and con
fections, JADA, W. 90,121-132,1975.
5. Bibby B.G., Enamel demineralization by snack
foods, JDR, Vol. 54,881-890,1975.
6. Brambilla E et al: Caries prevention during preg
nancy : Results of a 30-month study. J Am . Dent
Assoc. 129,871-877,1998.
7. British Paedodontic Society: A Policy Document
for Fissure Sealants, BDJ, ,42-3,1987.
8 Chad Lee,Teaching parents at WIC clinics to ex
amine their high ride babies,JDC, 347-9,1994.
9. Feigal RJ, Sealants and preventive restorations;
review of effectiveness and clinical changes for
improvement. PedDent. 20(2),85-92,1998.
10. Gawronsky T.H, Effects of dietary sucrose levels
on extracellular polysaccharide metabolism of
dental plaque, JDR, Vol. 54,881-890,1975.
11. Geopfaerd S. J: An infant oral health program: the
first 18 months Pediatr. Dent. 9(1):8-12,1987
12. Griffen Ann L. .Preventive oral health care for the
infant,child and adolescent,Pediatric Oral Health,
Oct,1209-1226,1991.
13. Holt RD, Maynihan PJ.: The weaning diet and
dental health. Br. Dent. J. 181:254-258,1996
14. Infant oral health care: Pediatr. Dent. Special Is
sue: Reference Manual 18(6):25,1996-97
15. Jensen M.E.: diet and dental caries, DCNA.43(4),
615-634,1999.
16. Johnsen K., Siegel M: Resources for improving
the oral health of maternal and child populations.
J. Pub. Health Dent 50 Special (6):418-26,1990
17. LimebackH., Introduction to the conference. Com
munity Dent. Oral Epidem, 27,27-30,1999
18. Long M.H., Hsai L.S.: The role of the CNM in
newborn management J. Nurse, Midwideiy.
1992,37 (suppl) :8S-17S, 1992
19. Meiers J.C., Management of the questionable
carious fissure: invasive Vs noninyasive
techniques,JADA, W. 108,64-70,1984.
20. Mitchell L. and Gordon P.H., Fissure sealant- Re
cent development, Dental Update, vol.7,299-301,
1990.
| TEXTBOOK OF PEDODONTICS
21. Moore C.E., Pit and fissure sealants; one more
time, J AD A, Vol.54,729-30,1988.
22. Newbrun E and others. Comparison of dietary
habits and dental health of subjects with fruc
tose intolerance and control subjects, J AD A, Vol.
101,619-626, Oct 1980.
23. Nowak A. J., Casamassimo P.S.: Using anticipa
tor}' guidance to provide early dental interven
tion. J. Am. Dent. Assoc. 126-1156-63,1995
24. Ripa L. W., The current status of pit and fissure
sealants, J CanndDent Assn, No. 5,367-77,1985.
25. Rock W P ; Sabieha A M: The relationship be
tween reported toothpaste usage in infancy and
fluorosis of permanent incisors . Br. Dent. J .
183,165-170,1997
26. Schneider Howard S.,Parental education leads to
preventive dental treatment for patients under age
of 4yrs,JDC, Jan-Feb,33-7,1993.
27. Sethi B., Tandon S: Caries pattern in preschool
children J.J.D.A. 67:141-145,1996
28. Simon Katz, A diet counseling programme, JADA,
Vol. 102,840-845,1981.
29. Slavkin H.G. : First encounters; Transmission of
infectious oral diseases from mother to child.
J.A.D.A. 128:773-778,1997
30. Stephen K W et al: Effect of fluoridated salt in
take in infancy: a blind caries and fluorosis study
in 8th grade Hungarian pupils. Community Dent
Oral Epidemiol.27,210-215,1999
31. Tandon S., Kumari R., Udupa S., The effect of
etch time on the bond strength of a sealant and
on etch pattern in primary and permanent enamel,
JDC, Vol. 56, 186-90,1989.
32. Tandon Shobha,Infant oral health care,Kerala
dental journal. Vol 20,No. 4,115-122,1997.
33. Tewari A., Gauba K., Goyal A.: Evaluation of the
change in the knowledge of community regard
ing infant dental care subsequent to intervention
strategies through existing health monpower in
rural areas of Haryana (India) Ind. Soc. Pedo. Prev.
Dent. 12:29-34,1994
34. Warren D P ; Chan. J P : Topical fluorides ; effi
cacy, administration and safety. 45,134-40(1997]
35. Warren J J; Levy S M: A review of fluoride den
tifrice related to dental fluorosis . Ped Dent
21,265-271,1999
36. Workshop on guidelines for sealant use: Recom
mendations, Journal of public health dentistry,
Vol.55.No.5,special issue,263-73, 1995.
I
SECTION - 7
Pediatric Restorative
Dentistry
7.1 Introduction
Mount G J
Introduction
There is no doubt that prevention is better than cure
and this is never more so than in relation to restora
tive dentistry for children. The problems multiply rap
idly when a young patient begins to show signs of
active caries and, in view of the small size of the
tooth crowns, it is essential that treatment be under
taken at the earliest possible moment. The cause and
progress of the disease is discussed in some detail
elsewhere in this book so the contents of this chap
ter will be confined mainly to methods of treatment
for teeth which have already been damaged by the
disease.
In the past, operative procedures were predicted
upon the notion that it was essential to remove all of
the tooth structure that had been demineralised by
caries on the grounds that it was not possible to heal
it. It was also assumed that there were some parts of
the crown of a tooth which were more susceptible to
caries than others and once a lesion had commenced,
it was essential to remove the entire surface to pre
vent any recurrence. The end result of these theories
was that a classification of cavities was developed
to fulfil the requirements and specific cavity designs
were dictated based upon rather mechanical con
cepts. As the restorative materials available at that
time were entirely neutral, showed no biological ac
tivity and did not adhere to tooth structure, the cavi
ties designed to accept a restoration were geometric
and precise, included mechanical interlocking devices
and paid little attention to the extent of the actual
lesion.
On the basis of the recent concept of caries which is
discussed elsewhere it is now apparent that it is pos
sible to remineralize and heal a carious lesion, to at
least some degree, so complete removal of extensive
areas of natural tooth structure is no longer required.
It addition there are now tooth coloured restorative
materials which will adhere very effectively to natu
ral tooth structure so that mechanical interlocking
designs for retention are not necessary either. These
materials will be discussed in detail in the next sec
tion and it will become apparent that it is now possi
ble to think again about how to deal with active car
ies providing that the primary step always is modifi
cation of the bacterial flora, which is the essential
cause.
Deciduous teeth are endowed with the task of per
forming a variety of fonctions such as:
■ Help in speech and mastication
■ Promoting an esthetic appearance
■ Maintenance of arch length
■ Maintaining a healthy oral environment free of
pain
Therefore, in short these functions help in contribut
ing to the health of the child as a whole and a clinty
cian needs to know the art of restoring and preserv
ing these teeth until their normal exfoliation. Before
going to the procedures concerned with cavity prepa
ration and restoration, it is essential to have a thor
ough knowledge regarding the morphology of pri
mary teeth as well as the differences between the
primary and permanent teeth.
I TEXTBOOK OF PEDODONTICS
Morphologic differences between Primary and Permanent Teeth
The anatomy of the primary teeth resembles in general that of corresponding permanent teeth expect for
special functional adaptations necessitated by the smaller jaw of the child (Table 7.1). There is one major
exception that mandibular first deciduous molar does not resemble any other teeth.
Table 7.1: Morphologic differences between Pimary and Permanent Teeth
' Primary Teeth
Permanent Teeth
The Crown:
■ Lighter in colour, bluish white (milky white)
■ Darker in colour, grayish or yellowish white.
also called as milk teeth as its refractive
index is same as milk i.e, 1.
■ Quration of deciduous dentition^ j
■ Duration of permanent dentition:
^6 months to 5 % years.
(f
6 years onwards.
■ Number of teeth: 32
■ Number of teeth: 20
2 incisors, 1 canine, 2 premolars,
2 incisors, 1 canine., 2 molars
3 molaras (eight teeth in each quadrant)
(five teeth in each quadrant)
» ^Smaller in all dimension. Exposed aíéh is
« Larger in dimensions.
about one-half that of the permanent teeth.
■ The crowns are wider in their mesjo-distal
■ The crowns of anterior teeth are larger in
cervico-occlusal dimesnion than the mesiodimension in relation to the ceryico- fyjp’
occlusal height. This gives a cup^shaged
distal. This gives a longer appearance to
appearance to anterior teeth and squat
M permanent anterior teeth. %
shaped appearance to molars.
■ Cuspids are slender and tenate be more
■ Cuspids are less conical.
*
conical, c&b&t df■ The cervical ridges are more pronounced^■ - ■ The cervical ridges are flatter.
especially on the~ buccal aspect of first
primary molar.
G
<
*
d
■ There is less convergence of buccal and
■ Buccal and lingiial surfaces of molars,
especially the first molars, converge towards
lingual surface of molars towards occlusal
surface.
occlusal surface so that they have^ narrow
y
q O'.
occlusal table in a bucco-lingual plane.9W!A
■ The occlusal plane is relatively flats»
* ? ■ The occlusal'plane has more curved contour/
■ Molars are more bulbous and are sharply
They have less constriction of neck,
constricted (bell shaped) cervically.
The enamel is thinner and has a more
■ The enamel is thicker and has a thickness
consistent depth of about 1 mm thickness
of about 2-3 mm.
throughout the entire crown.
B^The contact areas between molars are
■ The contact point between permanent molars
broader, flatter, and sjtuated! gingivally.
is situated occlusally.
■ The enamel rods at the cervical slppe^J p .
The enamel rods are oriented gingivally.
r-j
occlusally from the DEJ. ■ The supplemental grooves are more.
% The supplemental grooves are less'
__________________________________ /,________________ c________ Z.
1
contd.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
■ Mammelons present on incisal edges of newly
erupted incisor teeth (Fig. 7.1b). a
■ Mammelons absent
(Fig. 7.1a)
Fig. 7.1a Mammelons are absent in~
decidous teeth.
Fig. 7.1b Mammelons are present on
newly erupted central incisors.
■ First molar is larger in dimension than second
molar.
■ First molar is smaller in dimension than
second molar.
The root:
zU4^
, ■ TFtle roots are larger and more slender in
'
comparison to crown size. % 7 !
■ Furcation is more towards cejvical area so
that root trunk is smaller. - 4
7 CA^C
■ The roots are narrower mesio-distally.
■ At the cervical region, the roots of the
primary molars flare outward and continue
to flare as they approach the apices to
accommodate permanent molars. -> %T
■ Undergo physiologic resorption during
shedding of primary teeth.
'!
V
■ The roots are shorter and bulbous in
comparison to crown.
■ Placement of furcation is apical thus the root
trunk is larger.
■ The roots are broader mesio-distally.
■ Marked flaring of roots is absent
•
r,T
.
'ty-J
. r^r
■'
:
:
<
■
'7
■ Physiologic resorption is absent.
The pulp: The pulp chamber anatomy in both primary and permanent teeth closely approximates
the surface shape of the crown.
■ Pulp chamber larger in relation to crown *
,
size.
/.iW__
w Pulpal outline follows the DEJ more closely..
I The pulp horns are closer to the outer ''/ ?
surface. Mesial pulp horn extends to a
closer approximation of surface than does
the distal pulp horns.
High degree of cellularity and vascularity
in tissue (at least in stages prior to
advanced physiologic resorption of roots) f
■ High potential for repair.
■ Pulp chamber smaller in relation to crown
size.
Pulpal outline follows DEJ less closely.
■ The pulp horns are comparatively away from
the outer surface.
■z Comparatively less degree of cellularity and
(■; Vascularity in tissue.
• Comparatvely less potential for repair.
contd.
I TEXTBOOK OF PEDODONTICS
■ Comparatively less tooth structure.
■ Greater thickness of dentin over the pulpal
wall at the occlusal fossa of molars.
■ Root canals are more ribbon like (Hibbard
and Ireland 1957). The radicular pulp
follows a thin, tortuous and branching path.
■ Floor of pulp chamber is porous. Accessory
canals in primary pulp chamber floor leads
directly into inter-radicular furcation.
■ More tooth structure protecting for repair.
« Comparatively lesser thickness of dentin over
the pulpal wall at the occlusal fossa of molars.
■ Root canals are well defined with less
branching.
.
■ Floor of pulp chamber does not have any
accessory canal.
Histolgoic differences
■ Roots have enlarged apical foramens. Thus,
the abundant blood supply demonstrates
a more typical inflammatory response.
■ Incidence of reparative dentin formation
beneath carious lesion is more extensive
and more irregular
■ Pulp nerve fibers pass to the odontoblastic
area, where they terminate as free nerve
endings.
■ Density of innervation is less because of
which primary teeth are less sensitive to
operative procedure. Neural tissue is the
first to degenerate when root resorption
begins.
■ Localization of infection and inflammation
is poorer in pulp.
Mineral content
■ Enamel and dentine are less mineralized
(inorganic content is less).
■ Neonatal lines present (both in enamel
and dentin)
■ Enamel: bands of Retzius are less common,
this may be partly responsible for. bluish
white color of enamel.
■ Dentin: dentinal tubules are less regular.
■ Dentin thickness is half that of permanent
teeth. As a result dentin forming cells are
functionally active by approximately 360 days.
• Interglobular dentin is absent.
« Dentin is usually less dense. This difference
can be observed clinically by resistance
offered to the cutting of the bur. The dentin
is cut more easily and also abrades more
rapidly.
■ Foramens are restricted. Thus reduced blood
supply favours calcific response and healing by
calcific scarring.
■ Reparative dentin formation is less.
« Pulp nerve fibers terminate mainly among the
odontoblasts and even beyong the predentin.
■ Density of innervation is more.
■ Infection and inflammation ip pulp is localized.
i
t
■ Enamel and dentin are more mineralized.
■ Neonatal lines seen only in first permanent
molar (as the mineralization takes place at birth)
■ Bands of Retzius are more common.
«
■ Dentinal tubules are more regular.
■ Dentin forming cells are functionally acitve
by 700 days.
■ Interglobular dentin present just beneath the
homogenous and well calcified mantle layer
of dentin.
■ The dentin is difficult to cut.
contd.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
« Periodontal structure: the cementum is
very thin and of the primary type. Secondary
cementum is characteristically absent
■ Alveolar atrophy is rare.
■ Gingivitis (gingival inflammation) is
generally absent in healthy child. Similarly,
recession is infrequent.
Self-Assessment
1. List out the functions of deciduous teeth?
2. What are the anatomic differences between the
primary and permanent teeth?
3. How does the primary and permanent tooth differ
in terms of localization of infection?
■ The secondary cementum is present.
■ Alveolar atrophy occurs.
« Gingivitis is common in adult.
i
7.2 Principles and Concepts of
Cavity Preparation
Mount G J, Tandon S
Various classifications for cavity preparations have
been advocated. The more relevant classification
pertaining to primary teeth and young permanent
teeth are discussed below.
Class n lesions
They are found on the proximal surfaces of the bi
cuspids and molars.
Class III lesions
Lesions found on the proximal surfaces of anterior
teeth that do not involve or necessitate the removal
of the incisal angle.
A. Black’s classification (Fig. 7.2):
Class IV lesions
Lesions found on the proximal surfaces of anterior
teeth that involve the incisal angle.
Class I
Class IV
Class fl
Class V
Class III
Class VI
Fig. 7.2 Types of cavities
Class I lesion
Lesions that begin in the structural defects of teeth
such as pits, fissures and defective grooves.
Locations include
■ Occlusal surface of molars and premolars
■ Occlusal two thirds of buccal and lingual surfaces
of molars and
« Lingual surfaces of anterior tooth
Class V lesions
Lesions that are found at the gingiva! third of the
facial and lingual surfaces of the anterior and poste
rior teeth.
Class VI (Simon’s modification)
Lesions involving cuspal tips and incisal edges of
teeth.
B. Other modifications
■ Charbeneu’s modification
a. Class II: Cavities on single proximal surface of
bicuspids and molars.
b. Class VI: Cavities on both mesial and distal
proximal surfaces of posterior teeth that will
share a common occlusal isthmus.
c. Lingual surfaces of upper anterior teeth
d. Any other unusually located pit or fissure in
volved with decay.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY | ffEl
conservative approach to the preservation of
natural tooth structure. This system is designed
to utilize the healing capacity of enamel and
dentin (Table 7.2a).
■ Sturdevant’s classification
Feature
A cavity involving only one
tooth surface
Compound cavity A cavity involving two sur
faces of a tooth
Complex cavity
A cavity that involves more
than two surfaces of a tooth
Cavity
Simple cavity
■ Finn’s modification of Blacks’ cavity prepa
ration for primary teeth
Class I: Cavities involving the pits and fissures
of the molar teeth and the buccal and
lingual pits of all teeth.
Class II: Cavities involving proximal surface of
molar teeth with access established
from the occlusal surface.
Class III: Cavities involving proximal surfaces of
,
anterior teeth which may or may not
involve a labial or a lingual extension.
Class IV: A restoration of the proximal surface
of an anterior tooth which involves the
restoration of an incisal angle.
Class V: Cavities present on the cervical third
of all teeth, including proximal surface
where the marginal ridge is not
included in the cavity preparation.
The three sites of carious lesions:
Site 1
Site 2
Site3
The four sizes of carious lesions:
Size 1
Size 2
Size3
C Baume’s classification
a Pit and fissure cavities
b. Smooth surface cavities
D. Classification by Mount and Hume [1998]
This new system defines the extent and complex
ity of a cavity and at the same time encourages a
Pits, fissures and enamel defects on occlu
sal surfaces of posterior teeth or other
smooth surfaces.
Proximal enamel immediately below areas
in contact with adjacent teeth.
The cervical one-third of the crown or,
following gingival recession, the exposed
root.
Size 4
Minimal involvement of dentin just beyond
trea tment by remineralization alone.
Moderate involvement of dentin. Following
cavity preparation, remaining enamel is
sound, well supported by dentin and not
likely to fail under normal occlusal load. The
remaining tooth structure is sufficiently
strong to support the restoration.
The cavity is enlarged beyond moderate.
The remaining tooth structure is weakened
to the extent that cusps or incisal edges are
split, or are likely to fail or left exposed to
occlusal or incisal load. The cavity needs to
be further enlarged so that the restoration
can be designed to provide support and
protection to the remaining tooth structure.
Extensive caries with bulk loss of tooth
structure has already occurred.
Table 7.2a: Classification by Mount and Hume.
Site
Size
Minimal 1
Moderate 2
Enlarged 3
Extensive 4
Pit/fissure 1
1.1
1.2
1.3
1.4
Contact area 2
2.1
2.2
2.3
Cervical 3
3.1
3.2
3.3
2.4
3.4
I TEXTBOOK OF PEDODONTICS
Principles of ca vity preparation
Conventional concept (Black’s concept)
Dr. G.V. Black has described the concept of “exten
sion for prevention” for cavity preparation. His ba
sic idea was to prevent the recurrence of caries by
placing the margins of restorations along self-cleans
ing areas.
■ Incisors and canines: In these teeth the margins
of the proximal cavities are placed beyond the
contact area.
« Molars and premolars: The contact between the
adjacent tooth is broken. Occlusal step occupies
the entire middle third of the tooth buccolingually
Buccal groove and other sharp grooves are in
cluded in the preparation
■ Gingival third cavities: Cervical margin placed
subgingivally and the mesiodistal extension
placed in self cleansing areas
I. Outline form
The locations that the peripheries of the completed
tooth preparation will occupy on tooth surfaces. It
can be:
• Internal outline form
■ External outline form
Features
1.
2.
3.
4.
5.
6.
7.
8.
9.
Extend cavity margins to sound tooth structure
Include all the fissures ’
Extend outline form to provide sufficient access
Cavity margins should be placed in self-cleansable
areas
The pulpal floor and axial wall should have an
average depth of 0.5 mm into the dentin.
Margins should be extended to include all defec
tive enamel
0.2 - 0.3 mm clearance from the adjacent tooth
while preparing the proximal box in class II cavi
ties.
Margins of the cavity preparation should not be
in contact with the opposing tooth.
If less than 0.5mm of the tooth structure exists
between two carious surfaces, then they should
be joined.
Factors influencing outline form
a. Embrasure area
b. Contact with opposing tooth
c. Caries index of the individual: High caries index;
more tooth structure is included in the outline
d. Position of the tooth in the arch
e. Masticatory forces influencing mesio distal ex
tension
f. Convexity of the tooth
g. Extent of the carious lesion
h. Proximity of the lesion to other defects in enamel
I Esthetic consideration
j. Partial edentulism
k Restorative material to be used
I Existing restorations
II. Resistance form
It is the shape given to the cavity to enable the tooth
as well as the restoration to withstand the stresses
of mastication to which it is subjected.
Features
1. Flat pulpal and gingival walls, the formation of
these walls perpendicular to pcclusal forces.
2. Utilizing box form of cavity preparation
3. Cavity prepared in such a way that strong cusp
and ridge areas remain with adéquat^ dentin sup
port
4. Rounded internal line angles to avoid stress con
centrations.
5. Butt joint between the tooth and restoration
6. Removal of unsupported enamel
7. 90 degree cavo-surface angle
8. Adequate bulk of the restorative material
9. Adequate depth and width of the cavity
10. Reverse curve in the case of class II cavities, when
the proximal outline becomes offset
buccolingually.
11. Gingival cavosuface bevel given in the case of
permanent teeth.
12. The width of the cavity should not be more than
l/4th - l/5th the intercuspal distance.
13. The pulpal floor should be 0.5mm below the
dentino-enamel junction.
14. The cavity wall should be divergent occlusally at
the marginal ridge areas.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY I
III. Retention form
ft is comprised of those factors of cavity design that
prevent the restoration from being displaced.
Features
1. Parallel or an inverse taper of 5 degree under the
triangular ridges of cuspal areas in the case of
class I and class II cavities.
2. Retention cores and grooves as used in class III
and Class V cavities.
3. Occlusal dovetail in the case of proximo occlusal
cavities where only one proximal surface is in
volved.
4. Pins placed into the dentin
5. Acid etching of the ena mel
6. The proximal box of class II design is divergent
gingivally to contribute to the retention form.
IV. Convenience form
It includes shaping the cavity to facilitate access for
instrumentation, for condensation, adaptation and
finishing.
Features
1. Modifications of cavosurface margins for ease of
placement of restorative material.
2. Extension of buccal and lingual walls for visibil
ity and access to deeper portions of the cavity.
3. The proximal lesion can be instrumented from the
facial, or lingual embrasures in a tooth with wide,
accessible embrasures and intact marginal ridges.
V. Removal of any remaining infected
dentin
In the case of a small carious lesion, the infected
dentin would be completely removed as the abdve
mentioned principles are achieved. However, when
a large carious lesion exists, some amount of infected
dentin still remains inspite of following the above
procedures. In such cases the infected dentin has to
be removed.
VI. Finishing the enamel walls
It is the further development of specific cavosurface
design and degree of smoothness that will bring about
the maximum effectiveness of the restorative mate
rial being used.
Purpose
1. To place the margins on sound tooth structure
2. To have smooth walls and rounded angles
3. To facilitate placement and finishing of the re
storative material.
4. Placement of taper or bevel for the appropriate
restorative material.
VII. Cleansing of the cavity
The operating field should be kept clean and ad
equately isolated by the use of rubberdam, cotton
rolls, and high vacuum evacuation equipment.
Conditioning of the cavity may be done in certain
cases like bonding systems for amalgam and com
posite restorations.
Recent Concept
Cavity preparation for operative procedures now no
longer adhere to Black’s concept of ‘Extension for
prevention’. Increased knowledge of preventive
methods, advanced techniques, and improved re
storative materials render the clinician to follow both
conservative and preventive criteria which can be
met by the present day dentistry based on the princi
ple of‘Constriction with Conservation’.
The following principles should be considered while
’preparing a cavity according to the recent concept:
■ Cavity designs should be dictated under the site
and extent of the lesion and not by any precon
ceived notion of mechanical interlocking patterns.
■ Should not be in expectation of extending the
cavity out to a “caries free” area.
■ The first choice of a restorative material should
be one that displays some degree of biological
activity and will therefore assist in the process of
remineralization and healing of remaining tooth
structure.
■ Only that part of the tooth crown that is irretriev
ably degenerated and broken down should be
removed and the remainder even though
demineralized and softened, should be retained
and remineralized
■ The first function ofthe restoration will be to elimi
nate any surface cavitation that has resulted from
caries because, in the continuing presence of de
fects on the surface, it will not be possible to
completely control plaque accumulation.
I TEXTBOOK OF PEDODÓNTICS
Martin et al (2000) have applied the term 'minimal
intervention’,'minimally invasive’ or 'preservative
dentistry’ to above concept. This approach en
tails a departure from the traditional surgical
method to the elimination of caries lesion which
is in the inner halt of enamel, at the dentino enamel
junction, and slightly into dentine but with little
or no cavitation. Minimal intervention is therefore
based on 'biological’ or ‘therapeutic’ approach
with following principles.
- Remineralization of early lesions
- Reduction in cariogenic bacteria
- Repair rather than replacement of defective
restorations
- Disease control
S elf-Assessment
1. What are the components of Black’s classifica
tion?
2. List out the principles of cavity preparation.
3. Give the newer classification based on site and
size.
4. How does the recent concept differ from Black’s
cavity preparation?
Table 7.2b Iatrogenic factors affecting dental pulp
Depth of cavity
preparation
■ Increased rate of collagen turn over
■ Odontoblastic cell damage
■ Protein synthesis inhibition
Minimum 2 mm remaining dentin thickness
essential for pulp protection
Speed of rotation
■ Low speed result in increased vibrations
■ Increased heat generation
Speed greater than 1.5 to 2.5 lakh rpm
safest with coolants
Heat generated
« Greater than 46° C leads to stasis
and thrombosis of blood
■ Greater than 55° C leads to necrosis
Avoid heat generation by adequate use
of coolants
Pressure
■ Increased pressure leads to
displacement of odontoblastic nuclei
into tubules
Low speed maximum pressure is less
than 4 ounces.
High speed max. is less than 1 ounces
Dehydration
■ Displacement of cell/nuclei into tubule
■ Pulpal edema
■ Increased permeability of dentin to irritants
Avoid excessive drying of cut tdoth
structure
*
■ Increased heat generated with
abrasives
■ Steel burs produce more heat than carbide
Use carbide burs with coolants for cavity
preparations
. Size of burs
■ Large size of burs have increased heat
generation.
« Reduced access for coolants
• More loss of tooth structure
Medium/small sized burs preferred
Coolants
(Air spray)
■ Air spray leads to desiccation of dentin
Water spray is preferred as it reduce
heat and washes away debris
Vibrations
“REBOUND RESPONSE”
■ Pulpal edema
• Fibrosis of pulp tissue
■ Changes in ground substances
• Reduction in predentin formation
Avoid use of low speed which increases
vibrations
Pins
» Microfractures of dentin
» Undetected pulp exposures
Cautious use of pins where indicated
Extensiveness
■ Increases heat generation
Avoid cutting excessive tooth structure
Polishing of
restorations
» Increased heat due to friction
Polishing must be done in wet field
Orthodontic
treatment
• Interference with apical blood vessels
leading to disruption of blood supply and
nutrition to odontoblasts
■ Severe cases-necrosis of pulp
Forces must be limited to less than
50-70 gms
Nature of cutting
instruments
i
7.3 Procedures Required for Restoration
Mount G J, Sajida B, Tandon S
1. Isolation
2. Cavity preparation
3. Placement of matrices
4. Material placement
ISOLATION
The oral environment needs to be adequately con
trolled to prevent it from interfering wSth the execu
tion of any dental procedure. This control is attained
through isolation.
A. Fluid absorbents
The isolation can be achieved by absorption of sali
vary secretions. These can be used for short periods
when absolute dryness is not required. E.g. examina
tion, polishing fluoride application.
Various materials that can be used for this purpose
are:
■ Cotton rolls
■ Gauze or throat shields
■ Absorbent paper
Need for isolation in Pedodontics
1. Increased salivation in child patient
2. Excessive tongue movements
3. Short attention span which requires shorter du
ration of treatment and therefore better isolation
techniques.
4. Decreased danger of aspiration of foreign parti
cles
5. Convenience to the operator since it improves
visibility
6. Improved properties of restorative material
7. Isolation techniques help in behavior manage
ment. This especially holds good for use of rub
berdam.
‘Cotton rolls (Fig. 7.3)
î
Various means of isolation
A. Fluid absorbents
B. Saliva ejectors
C Rubber dam
D. Use of matrices during restorative procedures
suction tip
•
Cotton rolls are available in different diameters,
cut to variant lengths and have plain or woven
surfaces.
I TEXTBOOK OF PEDODONTICS
■
■
■
These are stabilized and held sublingually with
specific holders or with an anchoring rubber dam
clamp.
They can be applied without holders, over or lat
eral to salivary glands orifices.
Cotton rolls provide the advantage of slightly
retracting the cheeks aiding invisibility and ac
cess.
Gauze of throat shields
■ It is used in pieces of 2” x 2" or larger
■ These are better suited for large areas than cot
ton rolls
■ They are better tolerated by delicate tissues and
have less adherence to dry tissues compared to
cotton.
Absorbent paper pads
9 These are of different shapes to fit various loca
tions in mouth.
■ They are more absorbent than any of the above
absorbents.
B. Saliva ejectors and high volume evacu
ating equipment
4. It should not interfere with instrumentation
5. It needs to be used with other adjuncts like cot
ton rolls and gauze
Advantages
■ It provides an adequate dry field along with the
advantage of washed field.
■ There is no dehydration of oral tissues
■ Precious metals sucked can be recovered
Precautions
Care should be taken to avoid cross contamination.
Thus,
1. The saliva ejector should be disinfected after each
use.
2. Disposable tips are preferred.
3. The child patient is cautioned not to close his
mouth to hold the tip since it may cause backflow
of contaminated solutions into his mouth as a
result of pressure changes.
C. Rubber dam
Rubber dam, which is usually la tex rubber, is one of
the most effective means of isolating teeth. It was
developed by Barnum [1864]. >
t
Saliva ejectors prevent pooling of saliva in the floor
of the mouth. High volume evacuating equipment
removes solid debris along with water unlike the sa
liva ejector.
Types
■ Metallic - are autoclavable and have rubber tip
to avoid irritating the delicate tissues on the floor
of mouth.
9 Plastic - are disposable and inexpensive
Requirements
1. The tip should alwaysbe moulded to face back
wards with a slight upward curvature.
2. The floor of the mouth under the tip should be
covered with gauze to prevent injury to soft tis
sue.
3. It should not traumatize the lip or cheek mucosa.
Rationale
é
1. Maintains clean, visible field
2. Patient protection - prevents aspiration of for
eign bodies.
3. Clinician protection
4. Reduces risk of cross-contamination especially
to the root canal system.
5. Retracts and protects soft tissues
6. Increases efficacy by minimizing patient conver
sation and need for frequent rinsing.
7. Application of medicaments without the fear of
dilution.
8. Improved properties of restorative materials
9. Psychological benefit to the patient
Contraindications
1. A child with upper respiratory tract infection,
congestion of nasal passage or other nasal ob
struction.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY | fEEl
2. Presence of some fixed orthodontic appliance
ci 3Arecently erupted tooth that does not retain a
■ ■?Oisnts-with allergy to latex.
* --O'■ ’
S?
HF fie rubber dam should not obstruct patient’s airt
way and thus should not cover his nose.
Holes should be prepared in rubber dam for paSi i^&s with upper respiratory tract obstruction,
lii^^^tietits with allergy to latex, latex free rubber
should be used. Rubber dam napkin can be
used to prevent the latex rubber dam from con
tacting the patient’s tissues.
Armamentarium
1. Rubber dam sheet
2. Rubber dam frame
3. Rubber dam punch
4. Rubber dam forceps
5. Waxed dental floss
6. Scissors
7. Rubber dam napkin
8. Lubricants
9. Clamps
Rubber dam has a shiny and a dull surface. The dull
surface is kept facing occlusally since it is less re
flective.
Rubber dam frame
■ Plastic frame eg:
Star visi frame
Nygard - Ostby (Fig. 7.5)
Quick Dam or Handidam frame (has built
in plastic frame) (Fig. 7.6)
■ Metal frames e.g. Young frame
Rubber dam punch
It aids in punching holes corresponding to teeth
size on the rubber dam sheet.
Lubricants
Water soluble lubricants are applied in the area of
punched holes for easier placement of the dam e.g.
shaving cream or soap slurry.
Clamps: These are made up of shiny or dull stainless
steel and consist of a bow and 2 jaws. They aid in
anchoring the dam to the tooth and in soft tissue
retraction
Types ofclamps (Fig. 7.4)
■ Winged
Rubber dam is available in various thicknesses as ■ Wingless
thin, flat latex sheets.
■ Serrated
■ thin
0.15 mm
■ Clamps with jaws inclined cervically to engage
■ medium
0.20 mm
erupting tooth or severely broken down tooth.
» heavy
0.25 mm
* ■ Clamps with cndo-illuminator system to illuminate
■ extra-heavy
0.30 mm
pulp chamber and canal orifices.
■ special heavy 0.35 mm
Rubber dam sheet
It is available as rolls or prefabricated size i.e., 5” x 5“
or 6 ” x 6” while non latex rubber dam is available only
in 6” x6” size.
The dam is manufactured in various colours. Darker
colour offers better visual contrast but the lighter
colour provides the advantage of naturally illuminat
ing tlie operating field and allows easier placement
of film below the dam
Winged clamp
Wingless clamp
Fig. 7.4 Types of Clamps
€39 I TEXTBOOK OF PEDODONTICS
Fig. 7.7a Isolation of anterior teeth with
rubber dam
Fig. 7.7b Rubber dam is an effective means
of isolation
Fig. 7.8 Different techniques of tying dental floss to the clamp.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY | @8
Common rubber dam clamps for pediatric use
1. Partially erupted permanent molar -454A, 8A Ivory
2. Fully erupted permanent molar -14,8 Ivory
3. Second primary molar - 26,27, S. S. White, 3 Ivory
4 Firstprimary molar, bicuspid, permanent canine 2,2A Ivory
5. Primary incisors and canine - 0 Ivory
a retracts the tissues better than thin type and
b. is easier to place than heavier type
■ The dam is then punched.
- F
a. In primary dentition rubber dam is routinely
placed over c, d, e (Fig. 7.10)
Procedure of rubber dam placement (Fig. 7.7a, 7b)
1. Selection and preparation of the rubber dam.v
2.
3.
4.
5.
6.
Decide the tooth to be clamped
Select a clamp
Introduce the materials to the child
Tie a length of floss to the clamp (Fig. 7.8)
Place the clamp, rubber dam and frame (Fig. 7.9)
Fig. 7.10 A method of punching holes in
Rubber Dam
Fig. 7.9 Placement of Rubber Dam Clamp
7; Slip a napkin near the rubber dam and spread it
over the face.
8. Place protective coating of cocoa butter/petrolatum/varnish over silicate or GIC restorations to
prevent dehydration.
9 Adapt and slip a saliva ejector tip between the
rubber and napkin on the non-operating side.
Selection and preparation of the rubber dam
■ Heavy and extra heavy dams are used for restora
tive procedures while medium is considered ideal
for endodontic purposes since it
For the maxillary arch
The first hole is punched for ‘e’ in the midline of
rubber dam 1.25” (3.5 cms) from the upper border.
The second hole punched for ‘d’ is one hole
smaller in size, 4 to 5 cm away and at an angle of
40 degree vertical towards the dentist
The third hole for ‘c’ is punched a size smaller
hnd again 4-5 cm from d forming an angle of 40
degree to the vertical.
For the mandibular arch
Similar procedure is followed for the mandibular
arch with the hole for c punched 1.75” (4.5cm)
from the upppr border in midline.
€30 I TEXTBOOK OF PEDODONTICS
Second hole is punched one hole smaller in size,
4-5 mm away at an angle 40 degree to the vertical
towards the dentist.
■
■
Advantages of this method
- The dam is centered on thequadrant being
worked on.
- Nasal obstruction is avoided
- Holes can be punched in absence cf the tem
plate
■
b. Ready made templates:
These can also be used for marking the areas of
teeth to be punched.
Methods of placement
a. The bow of the clamp is positioned through the
hole in the dam and the rubber is placed over the
wings of the clamp.
The clamp is stretched and placed on the tooth
along with dam which is teased under the wings
of clamp. The dam is then attached to the frame.
b. Wingless clamp is placed on the tooth and dam is
stretched over the clamped tooth.
- Tliis allows the clinician to see the area of tooth
being clamped.
- Variation to this method would be to place the
rubber dam first followed by clamp and frame.
c. Split dam technique
This is used to isolate anterior teeth without the
use of clamp. This is useful in cases of insuffi
cient crown structures eg. horizontally fractured
tooth.
Additional isolation Aids
Moisture control, retraction and access are the main
aims of isolation. Apart from aforementioned tech
niques other alternatives to provide isolation are:
• Retraction cord
It is usually used for cervical lesions when the
use of rubber dam is impractical or inappropriate.
They can be used with non-caustic styptics to
control sulcular seepage or hemorrhage.
Mirror and evacuator tip
These help in retraction of oral soft tissues^ spe
cially in absence of rubber dam.
Mouth prop
Mouth prop benefits both operator and the pa
tient. They maintain mouth opening during vari
ous procedures and prevent muscle fatigue in pa
tients.
Drugs
Antisialagogues can be used to decrease exces
sive salivation eg. Atropine.
Local anesthesia is known to decrease pain. This
in addition to the vaso-constrictor in it brings
about a reduction in salivation.
Modifications of Cavity Preparation in Primary
Teeth
All the principles of cavity preparation of permanent
teeth also hold good for the primary teeth. However,
a few factors have to be taken into consideration
while restoring the primary teeth. These include:
■ The smaller tooth dimension of the deciduous
dentition
« The thin ena mel coveri ng the teeth t
■ Broad contact areas
■ Proximity of the pulp chamber to outer tooth sur
■
face
Narrow occlusal table
Class I cavities
■ Due to the narrow occlusal table present the isth
mus should not be more than l/3rd the intercuspal
distance in the case of a small carious lesion.
■ The depth should not be more than 0.5 mm into
the dentin.
■ The pulpal floor should be flat. Any remaining
caries lesion should be removed using round bus.
■ Use of preventive resin restoration is advocated
rather than the conventional cavity preparation
which includes all pits and fissures.
Class II cavities
« Due to the presence of broad contact areas, the
gingival floor of the proximal box should be wide
so as to place the margins in self cleansing areas.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
The box should however converge occlusally
with the buccal and lingual wall paralleling the
external tooth surface.
■ The walls of the proximal box should meet the
occlusal walls in a straight line to avoid any weak
points.
■ The walls of proximal shoiiEinot be flared as it
■
■
■
■
■
■
■
■
■
■
■
would lead to unsupported enamel.
The isthmus should have just adequate width that
is it should not exceed 1/3 id the intercuspal width
in primary molars.
The axiopulpal line angle must be either rounded,
tunneled or grooved for sufficient bulk of the res
toration.
The strength of amalgam at the isthmus area can
be increased by an adequate depth of the prepa
ration.
Retention can be improved by a ‘U’ shaped re
tention groove along the amelodentinal junction
ofthe proximal box.
When the cavity margins exceeded that of an ideal
preparation particularly in the case of a mandibu
lar first primary molar, it is recommended that an
overlay of the distobuccal cusp be prepared.
The weakened cusp is reduced to the level of the
pulpal floor of the occlusal preparation.
Mesiodistally the cusp should not be reduced
more than l/3rd the crown’s mesiodistal length.
Since the enamel rods, at the cervical area of the
tooth, are oriented occlusally the gingival seat
should not be beveled, rather should follow the
enamel rod inclination.
If the depth of the lesion is farther gingivally, the
axial wall should follow the contour of the exter
nal surface. This will prevent pulp exposure from
occurring.
Care should be taken to avoid the mesiobuccal
pulp horn in the case of small first molars. Since
the contact with the canine is a point contact, the
proximal box extension and the gingival flare can
be minimized.
The proximal box should allow the passage of a n
explorer tip between its margins and adjacent
tooth in all three directions, buccally, gingivally
and lingually.
Class III cavity
■ When the contact is open, the outline is triangu
lar with base towards the gingival aspect of the
cavity
■ Gingival cavity wall is inclined occlusally to par
allel the enamel rod direction.
■ Retention pits can be placed at the axiobucco
gingival and axio linguo gingival point angles.
■ A dovetail may be placed in the middle one third
ofthe lingual surface of the tooth. This helps in
gaining access to the carious lesion and in facili
tating retention ofthe restoration.
Young permanent first molars
■
■
■
«
■
■
The following special morphological considera
tions should be kept in mind while preparing a
cavity in a young permanent first molar
The first permanent molars erupt between the
ages of five and six years and, as this is an age
group wherein caries is a common problem, these
are often the first of the permanent teeth to be
come carious.
The result of various developmental interference
will often result in failure of the enamel to unite
completely and smoothly in the middle of the oc
clusal surface and there will be the potential for
faults and defects in the occlusal enamel, even
before eruption.
The occl usal surface of any tooth is particularly
susceptible for plaque accumulation within a defect because of the heavy pressure to which this
surface is subject to during mastication. Such fis
sures can be as far as 1.5 to 2mm deep into the
enamel and it is possible for them to penetrate
right through to dentin.
They may range in width from 100 to 500pmand
will often be wide at the entry, narrow down to
less than 200 pm in the middle and then open
wider again at the dentin.
In many cases the fissures are made up of a series
of pits of considerable depths rather than one
continuous fissure.
The result of this convoluted anatomy may be
compaction of bacteria laden plaque into the
depths of the fissure leading to active deminerali-
I TEXTBOOK OF PEDODONTICS
zatiort down the walls and into dentin with mini
mal visible evidence on the.occlusal surface. In
communities that have systemic fluoridation the
enamel is often very hard and does not break
down until it is severely undermined. This means
that carie? Jhát has progressed through to the
dentin can progress all the way to pulpal involve
ment without any visible breakdown on the oc
clusal surface.
• The enamel rods within a fissure are not always
as regular in pattern as those elsewhere around
the crown of a tooth. Those at the shoulder
around the entiy to a fissure are often gnarled
and irregular and will not always accept a regular
etch pattern. In the depths of a fissure there may
be a layer of enamel rods lying parallel to the sur
face rather than at right angles.
■ There is the likelihood of a carious lesion on the
distal of the deciduous second molar extending
some damage on to the mesial of the adjacent
permanent tooth. The carious lesion may become
visible and available for treatment at the time the
deciduous tooth is exfoliated.
Kinetic Cavity Preparation
Kinetic cavity preparations (KCP), which used fine
particles'of powder fired at high speed in a control
led manner instead of the traditional high and low
speed drills. Advantages of this technique are that
no vibrations or pain sensation, and also no need for
anesthesia in most cases. This truly allows us to o
multiple quadrant dentistry so as to decrease the
number of patient visits, and better time utilization.
MATRICES USED FOR RESTORING THE TOOTH
Matricing is the procedure whereby a temporary wall
is created opposite to axial walls, surrounding areas
of tooth structure that were lost during preparation.
Objectives
The matrix should achieve the following functions:
• Displace the gingiva and rubber dam away from
the cavity margins. This improves the accessibil
ity during the restorative procedures.
■
■
■
Assure diyness and non-contamination of the
operating field.
Provide shape to the restoration during setting
of the restorative material.
Maintain shape during hardening of the restora
tion.
Types (Fig. 7.11)
Fig. 7.11 Different matrices and retainers - on left
metallic matrix bands with retainers; on right
celluloid matrix bands
1. Matrices for Class I cavity ^compound cavity)
■ Double banded Tofilemire
2. Matrices for Class II
■ SinglebandedTofilemire
« Ivory matrix No. 1
■ Ivory matrix No. 8
■ Black’s matrices
■ Soldered band or seamless copper band matrix
■ Anatomical matrix
■ Auto-matrix
■ S-shaped matrix band
■ T-shaped matrix band
3. Matrices for a cavity preparation for amalgam on
distal of cuspid
■ S shaped matrix
■. Tofilemire
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
4. Matrices for Class III for tooth coloured restora
tions
■ Transparent celluloid strips
5. Matrices for Class IV for tooth coloured restorations
■ Celluloid strips
■ Aluminum foil (non-light cure)
■ Transparent crown form matrices
■ Anatomic matrix
■ Modified S shaped band of copper, tin,
aluminum foil (non-light cure)
6. Matrices for Class V amalgam restorations
■ Window matrix
■ S shaped matrix
7 Matrices for Class V tooth coloured restorations
■ Anatomic matrix (non-light cure)
■ Aluminum or copper collars (non-light cure)
■ Celluloid strips (light cure)
X. Sectional matrix with G-rings (retainers) for pos
terior composites (Fig 7.12a. 12b )
Fig. 7.i2a Sectional matrix bands on left with
retaining G-rings on right
Self Assessment
1. What are the morphological and histological dif
ferences between deciduous and permanent
teeth?
2. What is the recent concept of cavity preparation
and how does it differ from Black’s concept?
3. What is Finn’s classification of cavities?
4. What are the basic principles in the preparation
of cavity in primaiy teeth?
5. What is the difference between resistance and
retention?
6. What are the commonest causes of Class II amal
gam failures in primaiy I molars?
7. What are the specific modifications of class II
cavities in primary molar?
8. What should be the width of the isthmus in de
ciduous teeth?
9. Where should be the placement of the gingival
seat in a class II cavily?
1(1 What are the different matrices used in
Pedodontics?
11. What is a rubberdam?
12. What is a quickdam?
Fig. 7.12b G-rings in place with sectional
matrix
7.4 Modern Restorative Materials
and Techniques
Mount G J, Hien Ngo, Byrant R W
In view of the limited life span of the deciduous teeth
it is normal to utilize one of the plastic restorative
materials which are placed directly into the cavity
This will include the first molars because of the diffi
culties which will be encountered in trying to place
restorations such as gold inlays or gold foils in a
patient of tender years (Fig. 7.13af b, c) (Fig. 7.14a
b, c).
Requirement of an ideal restorative material
■ Restoration of aesthetics.
■ Maintenance of the physical strength of the
crown
» Preserving the anatomy of the occlusal surface
and thus preserving the interrelationship with the
opposing and adjacent teeth.
■ Prevention of further ingress of bacteria or their
by-products into the micro space between the
restoration and the tooth.
■ Long term adhesion between the restoration and
the tooth to ensure complete isolation.
GLASSIONOMER
This materialwas developed by Wilson et al in the
early 1970s. It can be used as a luting cement for
indirect restorations, a lining under another restora
tive material, or a restoration in its own right.
Advantages
« It is a tooth coloured material.
a It will adhere directly to both enamel and dentin
through an ion exchange mechanism
• It is biologically active, as it is capable of releas
ing fluoride, calcium and phosphate ions.
Disadvantage
Its physical properties are not sufficient to enable it
to withstand heavy occlusal loads in large restora
tions.
Classification
The following is the accepted classification-
Type I-luting
Cementation of crowns, bridges and
orthodontic devices
Powder: liquid ratio approximately 1.5.1
Radio-opaque
\
Type O - restorative
Type II. 1 restorative aesthetic
All types of aesthetic restorations
Auto- cure or resin modified
Powder: liquid ratio 3:1 or greater
Radiopaque - generally
High physical properties
Type II. 2 restorative
Restorations under high occlusal load
Auto- cure or resin modified
Powder: liquid ratio 3: l orgreatei
Radioopaque
Used as a dentin substitute or interim
restoration
Type III - lining or base
Simple lining under a metallic restoration
Powder: liquid ratio 1.5:1 only
Auto cure
Radiopaque
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
Fig. 7.13a Occlusal shoulder showing little sign
of demineralization with obvious caries begining
in the depths of fissures and entering the dentin
Fig. 7.14a Full mouth rehabilitation - pre
treatment showing upper teeth
Fig. 7.13b S.E.M. picture of similar fissure in
a molar tooth reveals a small degree of demine
ralization at the base of fissure
Fig. 7.14b Fun mouth rehabilitation - pre
treatment showing teeth in occlusion
Fig. 7.13c Same fissure at higher magnifi
cation reveals the presence of layer of enamel
which appears to have no rod formation at all
Fig. 7.14c Full mouth rehabilitation - post
treatment
I TEXTBOOK OF PEDODONTICS
High strength base for lamination technique
Powder: liquid ratio 3:1 or greater
Constituents
PoWer
The powderw®essentially a calcium fluoroalu
minosilicate glass. It is possible to substitute the
calcium with strontium and the percentage of fluo
ride in the formula can also be varied. Phosphate can
be added to decrease the melting temperature and
modify the setting characteristics. Fine colloidal sil
ver can be sintered to the particles and amalgam al
loy particles can be added to thé mix in an attempt to
enhance the properties.
Liquid
The liquid is essentially a poly alkenoic acid. The
usual acid is a 40-55% solution of 2:1 polyacrylic or
itaconic acid copolymer in water or a copolymer of
maleic acid and poly acrylic acid. The use of copoly
mers improves storage. The inclusion of tartaric acid
will retain the working time so that the mix will be
clinically workable.
Modified glass ionomer cements
“Anhydrous”
In this modification the liquid is delivered in a freeze
dried form that is then incorporated into the powder.
The liquid to be used is clean water only and this
may enhance shelflife and facilitate mixing. Another
alternative is to use a dilute tartaric acid as the liquid
with dehydrated pofyacrylic acid included in the pow
der These alternatives make it possible to use a
polyacrylic acid with higher molecular weight thus
improving physical properties.
The term anhydrous is actually a misnomer as it is
not possible for ion transfer to occur, in any material,
in the absence of water.
Resin modified
These are materials which have a small quantity of a
resin into the liquid formula. Less than 1.0% of
photoinitiators are allowed for the setting reaction
to be initiated by light of the correct wavelength^
The advantages include early resistance to water
uptake in the newly set cement as well as enhanced
translucency. The resin utilized in these materials i,s
hydroxyethylmethacrylate (HEMA) and it is incor
porated into the liquid in about 15-25% so as to have
a powder liquid ratio of about 3:1. setting reaction
Compomer
This is the term developed by the manufacturer with
a claim to incorporate some of the properties of a
glass ionomer with a composite resin. A compomer
is a composite resin that uses an ionomer glass which
is the major constituent of a glass ionomer as the
filler. There is also a small quantity of a dehydrated
polyalkenoic acid incorporated with the filler parti
cles.
The filler particle is held within an anhydrous resin
matrix and there is complete absence of water. Hence
there can be no ion exchange, acid/ base setting re
action and the material initially remains inert. The
setting reaction is light activated and there can be
no acid base reaction until there has been a degree of
water uptake into the restoration. Following water
uptake there will be an ion exchange? between the
glass and the rehydrated polyalkenoic acid followed
by a low grade fluoride release, but this will be nei
ther sustained nor at a higher level. Since fluoride
uptake cannot take place a compomer cannot be re
garded as a fluoride reservoir.
The most significant difference between the two
materials is the absence of an ion exchange adhe
sion. The adhesive system used with a compomer is
based on the acid etch/ min bond system found
with all composite resins.
Finally the percentage filler content is relatively low
compared to the hybrid composite resins, both the
water uptake and the wear factor are relatively high.
Setting reaction for glass ionomers (Fig. 7.15a, b)
The setting reaction has been described as an acid
base reaction. The surface of all the glass particles is
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
Fig. 7.15a A diagrammatic representation of
the acid/base setting reaction of the glass
ionomer materials as well as ion exchange
union occuring with tooth structure
Fig. 7.15b A diagrammatic representation of
setting reaction of glass ionomer
Fig. 7.16 S.E.M. picture of a glass ionomer
restoration adjacent to tooth structure showing
presence of relatively large porosities
Fig. 7.17 S.E.M picture of smear layer left on
the surface of tooth after cavity preparation
Fig. 7.18a S.E.M picture showing the surface
of dentin following a ten second application of
a 10% polyacrylic acid
Fig. 7.18b S.E.M picture showing similar dentin
surface following etching with a 37% ortho
phosphoric acid for 15 second
FETfr | TEXTBOOK OF PEDODONTICS
softened by the polyacrylic acid and both calcium
and aluminium ions are released through the proton
attack. Calcium ions react first and form calcium
polyacrylate chains followed a little later by a similar
reaction with the aluminium ions. The calcium poly
acrylate chains are rather fragile and soluble in water
and therefore require protection if they are to be re
tained. The formation of polyacrylate chains will
progress quite rapidly following the initial setting
reaction. These chains are strong and insoluble in
water and form the main body of the restoration. Both
the calcium and aluminium ions will cross-link as the
reaction progresses and forms a rather porous net
work.
A further ion exchange reaction occurs as part of the
setting process where there will be a silica hydrogel
formed on the surface of the glass particles. There
will be a gradient of ions formed about one third of
the way into the glass to the extent that the glass
and the matrix become chemically bound and can be
regarded as a single mass (Fig. 7.16).
Setting reaction of resin modified
The setting reaction of resin modified glass ionomers
is very similar with regards to the acid base reaction
though at a slightly slower pace. The usual ionomer
salt hydrogel will form along with a poly HEMA ma
trix with the possibility of multiple cross linking be
tween the two matrices. The setting reaction of poly
HEMA matrix will be stimulated by light activation
subsequently an oxidation/ reduction reaction will
continue to progress through any remaining
unreacted resin chains so that in die long run the
entire restoration will be set. This has been desig
nated as a “tri cure setting reaction”.
The setting rate depends on the following factors:
■ Temperature ofthe mixing slab: The lower the tem
perature of the mixing slab, the longer the work
ing time and vise versa. However the temperature
should always be above the dew point.
■ Powder liquid ratio. The higher the powder con
tent the higher the physical properties. However,
care should be taken to ensure that the materials
are properly dispensed before mixing.
Setting reaction of compomer
[WI
There are essentially two^difierent
systems for initi
ating polymerization in a composite resin. The origi
nal materials were all chemically activated however
they exhibited an undesirable colour shift. Subse
quently a system for light activation was developed
and this has proven to be relatively colour stable. It
is also possible to combine the two systems.
Method of using glass ionomer
Hand mixing
Divide the dispensed powder into two equal parts.
Gently spread the liquid drop a little over the glass
slab. Roll the first half of the powder into the liquid
and incorporate the two together rapidly. This is com
pleted in 10 seconds and the rest of the powder is
brought into the mix. No attempt should be made to
tty and dissolve the powder into the liquid. It is only
necessary to wet the surface pf each particle so that
ion release can occur leading to the initiation of the
acid/base setting reaction. The final mix should be
completed within 25- 30 seconds.
Conditioning the cavity
Following completion of any cavity preparation there
will be a smear layer left on the surface of the floor
and walls (Fig. 7.17). This will consist of tooth de
bris, bacterial plaque, pellicle and other debris and if
left in place may interfere with the development of
the ion exchange adhesion layer. It is therefore nec
essary to remove this before placing the restoration.
■ For this purpose a 10 % percent poly acrylic acid
is applied and allowed to remain in place for 10
seconds only (Fig. 7.18a, b). The surface energy
of the cavity walls and floor is modified so that
the high surface energy newly mixed cement will
adapt better to the low surface energy cavity
walls.
■ The cavity should be washed thoroughly and
dried lightly and the cement flowed into place
SECTION 7 : PEDIATRIC RESTORATIVE DENTIStRY | @9
■
immediately. Do not over dry the cavity, as the
glass ionomer is a water based material and may
lose physical properties if dehydrated through a
lack of water.
It is important to note that conditioning and etch
ing are two different entities. A cavity for restora
tion with glass ionomer should always be condi
tioned but the enamel margin of the cavity to be
restored with composite resin must always be
etched.
Ion exchange adhesion
One of the greatest hazards in restorative dentistry
is microleakage between a restoration and the cavity
walls or floor. As long as they are present bacteria
and their toxins will cause a continuing inflammation
within the pulp tissue so elimination of micro leakage
is essential. The union between glass ionomer and
tooth structure arises as a result of an exchange of
ions. When the newly mixed cement is adapted to
either enamel or dentin there will still be a quantity of
free polyalkenoic acid within the cement. Because of
its low pH the acid will attack the tooth surface and
release calcium and phosphate ions which will be
free to mix with the matrix of the cement Further re
lease of ions buffers the reaction and a new material
containing ions from both the cement and the tooth
will begin to form and set at the interface. The new
material will be firmly attached to both sides of the
union and will be stronger and more resistant to acid
attack than either the tooth structure or the cement.
Some degree ofbond is also developed between glass ♦
ionomer and the collagen fibres of the dentin. This
arises through either hydrogen bonding or metallic
ion bridging between the carboxyl groups on the
poly acid in the cement and the collagen fibres in
tooth structure.
The strength of this ion enriched material has to be
properly assessed. Failure of the union will be cohe
sive in either the tooth or the cement rather than
adhesive at the interface. Therefore.it is important to
understand the term bond strength in relation to the
glass ionomers.
Water balance
■ As a water based material, glass ionomer is al
ways susceptible to both water loss and water
uptake.
■ All types of glass ionomer will lose wateriftyxposed to dehydration for longer than a few min
utes.
■ The type II. 1 cement remains susceptible to wa
ter uptake for at least one hour and up to 24 hours
after placement and if it is not properly protected
it will lose both translucency and physical prop
erties.
■ The most effective method for early protection is
to paint over the newly set restoration a low vis
cosity, light activated, resin enamel bond immedi
ately after removing the matrix. Light activate the
bond before releasing the restoration to the envi
ronment. This will ensure stability within the ce
ment for the first onerhour during which time the
calcium polyacrylate chains can complete their
formation and the aluminium poly aciylate chains
will then become dominant.
■ It must be noted that all glass ionomers may lose
water for periods between two weeks and six
months after placement because not all water is
. fully bound within that period. The resin-modi
fied forms of glass ionomer were developed to
overcome this problem however they also remain
susceptible to dehydration for some time after
placement so they also should be sealed.
Biocompatibility
• The glass ionomers show a high degree of com
patibility with living tissues. The polyalkenoic
acids used as the Equid are mild adds with a high
molecular weight and a long complex chain for
mation. This makes it difficult fortheacid to per
meate through dentin tubules and even if it do&s
it will not produce a vigorous reaction,
■ Another reason for the relatively high
biocompatibility is the presence of free fluoride
ions within the set cement. Bacteria such as Strep
tococcus mutans is unable to thrive in the pres
ence of fluoride so theie will generally be a low
accumulation of plaque on the surface of a glass
ionomer.
I TEXTBOOK OF PEDODONTICS
■
Again in the absence of bacteria the pulp shows
an ability to recover rapidly and defend itself from
inflammation. It is possible to place a glass
ionomer directly over a mechanically exposed
pulp and expect to find secondary dentin forma
tion in immediate apposition to the cement.
Ion release
Glass ionomers show a steady release of flouride
ions throughout its life span without in any way af
fecting the physical properties of the restoration. The
fluoride ion remains free of the matrix formation so
that, immediately following placement, there will be a
generous flow that will reduce steadily over the next
month or thereabout. The level will then settle to a
steady flow amounting to a level of about 10 ppm in
the ambient saliva. If the ambient level is raised sub
stantially for brief periods, such as during a topical
fluoride application, then fluoride ions will return to
the restoration. This means that the restoration can
be regarded as a fluoride reservoir.
It has also been shown recently that a similar ex
change of calcium and phosphate ions can occur in
much the same way. Clinical evidence also suggests
that there is a degree of remineralisation under a glass
ionomer restoration and it is assumed that the re
lease of all three ions has a positive bearing on this
activity.
Limitations
■ Resistance ¿0 fracture is one of the main limita
tions to the use of glass ionomer. It is generally
quite satisfactory for a one surface lesion but a
two surface lesion is always at risk. Resistance to
^TMtfture also depends on the particle size of the
powder and particle size distribution.
■ Improvements to enhance strength of glass
ionomer will have to be. of chemical origin or
through the elimin ation of microporosities.
■ Resistance to abrasion and wear is a little below
that of composite resin.
■ They also remain susceptible to dehydration
throughout lifespan so patients with a dry mouth
should not have their teeth restored with glass
ionomer.
COMPOSITE RESINS
Apart from the glass ionomers, the only other mate
rial that has the ability to restore aesthetics and to
develop and maintain adhesion in the oral environ
ment, is the composite resin. However their ability to
adhere long term to tooth structure is limited to
enamel only.
%
i
History of composite resins is given in Table
7.3
Table 7.3: History of composite resins
Late
1930s
■ First mention of the methyl methacrylates.
Kramer and
McLean
1949
« Published several papers on a number of materials in this
category.
Buonocore
1954
• Development of a micro mechanical adhesion to enamel
simply by acid etching the enamel for up to one minute
rather than applying a thin coat of a very low viscosity resin.
Bowen
1960s
■ Proved the value of including a variety of fillers.
■ Also modified the resin formula from a relatively simple
methyl methacrylate to a far more complex bisphenol-A
diglycidyl dimethacrylate and the modern concept of 'filled'
or ‘composite resin’ was generated.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
Classification
Based on filler particle size and size distribution Lutz
and Phillips (1983)
■
■
■
Initiator system to activate the setting mechanism
Stabilisers (inhibitors)
Pigments (colouring agents)
^Wptions in composite resins
Based upon the forgoing information there have been
lypel: macro filled composttowtin
This type is also known as conventional or tradi further variations developed in the composite resin
range based largely upon the filler particles and their
tional. Because of the relatively large particle size,
this group exhibits a pattern of unacceptable wear size distribution.
both of itself and of the opposing tooth.
Flowable
The term flowable has been developed to indicate a
Type 2: micro filled composite resin
The fillers in this material are amorphous silica parti composite resin which is relatively simple to place
into a cavity in contrast to the standard hybrid matecles of 0.04 mm average diameter. With such small
filler particles they are translucent and highly aes
Such a flowable material is manly used in the case of
thetic but high filler loading is difficult to achieve.
The wear resistance is low and they cannot sustain a a deciduous tooth. The flowablity of the composite
resin is improved by reducing the filler content
high filler loading.
Type 3: hybrid composite resin
These are also known as small particle composites.
They contain a combination of macrofiller particles
with a proportion of microfiller particles and are prob
ably the most commonly used composite resins. The
main variation is in the proportion and distribution
ofthe various particle sizes because this will control
the ability to fill the resin and increase the percent
age loading.
Constituents
The chemistry and setting reaction of a composite
resin is very complex so there are a number of differ
ent chemicals and materials incorporated, each with
a specific function and the proportion is likely to
vary from one manufacturer to another.
« An organic resin component that forms the ma
trix e.g. BisGMA
■ Inorganic filler: These may be
a. Macro fillers with a particle size of about 5-30
mm e.g. glass, quartz, ceramic etc.
b. Micro fillers with a particle size of 0.04 mm e.g.
amorphous silica.
■ Coupling agent applied to the particles to unite
the filler to the resin silane.
Packable
Another term has been introduced to differentiate a
material from a standard hybrid composite resin and
that is the term packable. The difference is achieved
by varying the particle size and size distribution
though the water uptake and the wear factor will re
main standard and acceptable. The main difference
will be in the feel of the material when being placed
into the cavity. The material will be less likely to stick
to the packing instrument and be withdrawn from the
cavity during placement.
Chemically activated systems
These materials are marketed as two paste or powder/liquid systems. One part will contain an initiator,
benzoyl peroxide, the other part contains a tertiary
aromatic amine accelerator and combination of two
parts will yield free radicals. These radicals initiate
polymerisation of the resin.
Visible light activated systems
Single paste, visible light activated composite resin
systems contain a two component initiator system,
comprising a dik clone and a tertiary amine. The photosensitive diketone, usually 0.2-0.7%
camphoroquinone, absorbs the radiant energy of
*E>I TEXTBOOK OF PEDODONTICS
wavelength approximately 470 mh. At the appropri
ate stage of excitation, the diketone combine with
the amine to form a complex that breaks down to
release free radicals that then initiate polymerisation
of the resin.
«
Other systems
Dual activated composites have both a light acti
vated and a chemically activated initiation system
and are packaged as two pastes. The light activation
mechanism is used to initiate polymerization and the
chemical activation is relied upon to continue and
complete the setting reaction.
PROPERTIES OF COMPOSITE RESINS
Polymerization
The actual chemistry of the setting reaction is rea
sonably complex but is typical of all resin
polymerization. In a chemically activated composite
resin, the reaction takes place almost uniformly
throughout the bulk of the material. In the light activated systems, the depth to which activation will
ccur is dependent on a number of factors. It is important to note that much of the resin not activated
initially by the light at the time of curing will remain
unset.
In both systems a significant proportion of the meth
acrylate groups remain unreacted even after some
hours. The quantity of unreacted methacrylate groups
f will be influenced by the concentration of the differ
ent monomers. Most of the chemistry of the setting
reaction and the consequent contraction will take
.'|U'Withinthe first few seconds during light acti
vation and the remainder will be complete within two
jj| days.
> Water sorption andsolubility
| Water sorption is higher for micro filled resins and
H for hybrid and macrofilled resins. A minimum amount
* of water sorption is essential to a newly placed com
posite resin because it will bring^bout a degree of
expansion and help to counteract setting reaction.
\feriation in the water sorption and solubility of
different composite resin is associated with the type
and amount of monomers and diluents.
The degree of polymerization will also have a bear
ing so that, if the curing time is reduced by 25% there
will be a 2 fold increase in sorption and a 4 to 6 fold
increase in solubility. Both the long term durability
of the restoration and its colour stability will be seri
ously affected by inadequate polymerization.
Rapid thermal changes may also cause break down
of the silane coating and in micro filled composites.
The bond between the prepolymerized particles and
the matrix is a potential site for hydrolytic failure.
Polymerization contraction
The resin matrix in a composite resin is highly sub
ject to a setting contraction whether it is light acti
vated or auto cured. The problems and risks are less
in restoring deciduous teeth because the cavities are
relatively small and it is therefore somewhat easier to
get light activation to penetrate the relatively short
distance to the base of the restoration.
As the material sets first in proximity to the activator
light the contraction will be towaMs the light, thus
tending to pull the resin away from the cavity walls
and floor.
*
With chemically activated composites the contrac
tion develops more slowly and evenly with a ten
dency to draw towards the center of the restoration.
The polymerization contraction with either material
has a substantial impact on adaptation to dentin,
marginal adaptation and marginal seal. Ina large cav
ity with weakened cusps there is a tendency for cusp
deformation leading to post-restoration sensitivity
and even fracture at the base of a cusp.
Wear
Clinical wear of the composite resin remains one of
the main weaknesses in its use as a restoration on
load bearing surfaces.
Regardless of the material, clinical wear is associ
ated with a roughening of the surface of the restora
tion, due in part to scratching of microfilled compos
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
ites and partly due to loss of particles and frictional
contact in the case of macro filled composites. The
slightly greater resistance to wear of a heavily filled
micro filled composite is consistent with the greater
resistance to sliding wear shown by this material.
Therefore it is desirable to use the most heavily filled
material available regardless of possible difficulty in
clinical handling.
CLINICAL STEPS (Fig. 7.19a, 19b)
Etching and bonding
An essential prerequisite for the micro-mechanical
attachment is that the enamel should be etched with
37% orthophosphoric acid to demineralize the enamel
toadepthof 20 to 30 pm and render it porous. Avery
low viscosity unfilled resin is then flowed over the
surface and allowed to soak in to the porosities for
about 30 seconds before it is light activated. Com
posite resin is then built over the resin bond.
Injuvenile enamel there is less mineral and more or
ganic collagen present and therefore the etch pat
tern is quite different There will be more waterpresent
because of the presence of dentin tubules and their
direct access to the pulp and the amount of fluid flow
will only be enhanced following acid etchingbeoause
it will lead to opening and funneling of the tubules.
In a deciduous tooth even a small cavity will be rela
tively close to the pulp and therefore there will be a
greater density of tubules on the floor of the cavity
and a relatively greater fluid flow.
The goal of a resin dentin bonding agent is to attach
composite resin to healthy dentin and to seal the
dentin tubules against the entry ofbacteria and their
toxins. Hus will avoid post restoration sensitivity
caries and loss of restoration. Bonding to dentin re
quires the removal of all demineralized affected den
tin and this is not always desirable, particularly in a
deciduous tooth where there will be little enough
dentin remaining above the pulp and an exposure is
undesirable. It is possible through the use of glass
ionomer to remineralize some ofthe dentin and this is
the preferred method of sealinga cavity in a decidu
ous tooth.
Prerequisites for etching
First, the enamel at the cavity margin must be fully
mineralized and soundly based on healthy dentin.
Also there must be no micro cracks present on the
tooth. The best union will be developed at the ends
of the enamel rods rather than along the long sides
so it is desirable to develop a reasonably long bevel
at the cavo- surface margin.
Principles to successful resin-dentin bonding
■ Dentin should be etched to remove smear layer
and dentin tubule plugs
Fig. 7.19a Esthetic restoration for localised
enamel hypoplasia
Fig. 7.19b Teeth* restored esthetically by
veneering
€ЕЭ I TEXTBOOK OF PEDODONTICS
Etching should be sufficient to demineralize the
surface layer of both inter and intratubular dentin
leaving collagen fibres exposed dnd available for
a mechanical interlock with the resin
» The spçgàçe should be thoroughly washed to re
move all remaining etchant
a The surface should remain wet but not flooded
a
Apply a hydrophilic primer containing acetone,
or similar to guide and facilitate penetration of
the resin adhesive around the exposed collagen
fibers.
a Finally apply the resin adhesive and cure before
Applying composite resin.
»
Delivery and placement
The chemical cure and the dual cure materials will be
packaged as a paste/ paste system or a powder/ liq
uid system. Always follow' the manufacturers’ in
structions in detail and stay within the time param
eters so as not to go beyond the working time.
Tri ensure complete adaptation to the cavity floor it
is desirable to place the freshly mixed material into
the disposable syringe and then tamp the material
into the cavity with a small plastic sponge.
The light activated materials will always be delivered
in light proof carpules or syringes which have been
loaded under vacuum. This means that they are free
of porosity at the time of delivery7.
Placement must be undertaken with care and atten
tion to detail with particular reference to the depth of
cure available through a curing light. The efficiency
of the light must be checked periodically to ensure
that the lower layers are also cured adequately.
incremental build up
Due to the problems posed by light activation of
composite resins, it is essential to be prepared to
undertake incremental build up of any restoration
deeper than about 2.0 mm. Incremental placement
means placement of the composite in small quanti
ties in selected areas of the cavity and then directing
the light activating unit in such a way that, while
curing, the resin will shrink.towards thé tooth struc
ture rather than away from it. As it is not possible to
excessively light activate any composite resin it is
recommended that the increments be as small as pos
sible and that the light activator be applied from many
positions during build up. However the position and
direction of the first application of the light is critical
to the over-all success of the restoration.
Depth of cure
In view7 of the often limited access to the oral envi
ronment in a child patient the depth of cure of a com
posite resin is quite significant. It is imperative that
the activator light be placed within 1-2 mm of the
surface of the newly placed restoration otherwise
the depth of cure will be limited.
Failure to light activate the composite resin to the
full depth of the restoration has important implica
tions for the success and longevity of the restora
tion.
Factors to be considered while curing.
« The degree of cure will decrease with increasing
depth
■ Increased time of exposure to the light will in
crease depth of cure.
1
■ The more heavily filled the resin and the larger
the particle size, the greater depth of cure. Micro
filled resins will cure to a depth of 2-3 mm only
while hybrid resins may cure to a depth of 4-5
mm
■ Lighter the shade of the material the greater the
depth of cure and the greater the translucency
the deeper the cure.
■ Light activator units vary in their light outputs
over time as well as with power fluctuations. The
efficiency7 of each unit should be checked fre
quently
■ The tip of the light source should be placed as
close as possible to the restoration and should
never be more than 4 mm away.
■ The depth of cure should be measured from the
face of the activator light.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
■
Curing through tooth structure will reduce the
depth of cure to the same extent as if curing
through a composite resin of similar opacity.
Limitations of composite resins
■ Both the resin and the fillers used are anhydrous
and completely inert. However some of the minor
constituents such as HEMA, have been identi
fied as allergens and pose a potential risk. It has
been shown to be identifiable in the pulp tissue
in certain circumstances and care should be exer
cised in its use.
■ Any unreacted polymer chains may be an irritant
to the pulp and lead to post- insertion sensitivity.
■ The tissue cells respond less favourably to com
posite resin than they do to glass ionomer and it
has been postulated that incomplete cure of the
resin is the prime cause of this.
Clinical considerations
Clinical placement techniques are probably the most
significant factors in success or failure.
In pediatric dentistry a restoration will not be ex
pected to last for more than a few years so a limited
amount of wear can be tolerated. However a rela
tively large setting shrinkage will be undesirable.
Aesthetics and fracture resistance will not be of great
significance but the ability to bond effectively to
both the enamel and dentin will be relevant. There
will often be a relatively short concentration span
from the patient as well as limited access to the oral
cavity so simplicity ofplacement techniques will be
important There is often a clear choice between com
posite resin and glass ionomer and the operator must
be aware of the relevant properties of both so that a
logical decision can be made.
AMALGAM (Fig. 7.20)
The remaining plastic restorative material of value in
the restoration of deciduous teeth is amalgam. This
remains the most reliable and inexpensive material of
all. There have been a number of scare campaigns
over the recent years suggesting that amalgam is not
Fig. 7.20 A traditional amalgam restoration tn
the distal of deciduous fir&t molar
biocompatible and it has even suggested that it is
carcinogenic. There is no convincing evidence at all
for these claims and there has been adequate support for its continuing use from all the prime scien
tific authorities throughout the world.
Types of dental amalgam alloy
I. a. High copper alloy;
Copper content more than 12%
b. Low copper alloy;
Copper content less than 6%
c. Gallium alloy
IL based on particle shape and type
a Lathe cut; irregularly shaped filings produced
by cutting an ingot of alloy on a lathe.
b. Spherical partide; produced by atomisingthe
alloy, whilst still liquid into a stream of inert
III. based on zinc content
a. Zinc containing; alloys with more than 0.01%
zinc.
b. Zinc free; alloys with less than 0.01% zinc
IV “y2content”
Amalgams may be described as y2 containing and
y2 free.
| TEXTBOOK OF PEDODONTICS
Table 7.4: Constituents
Com position of low copper
amalgam alloys (Weight %)
Composition of high copper
amalgam alloys (Weight %)
■ Silver
68-70%
■ Silver
40-60%
• Tin
26-28%
- Tin
27-30%
2-4%
« Copper
13-30%
• Zinc
0-2%
■ Zinc
0-2%
■ Mercury
0-3%
■ Mercury.
0-3%
■ Copper
:
a. Low copper amalgams contain the Sn-Hg
phase which is called the y2 phase to distin
guish it from the y phases of the Ag-Sn and
Ag-Hg alloy systems.
b. Within several hours after amalgamation, all
correctly manipulated high-copper amalgams
are y2 - free.
Constituents (Table 7.4)
Amalgams that contain zinc appear to exhibit a lower
rate of marginal failure'underclinical loading but they
tend to exhibit excessive delayed expansion if con
taminated with moisture during placement. A number
of elements, such as indium, palladium, and platinum,
may be included in the alloy.in minor quantities.
Packability
This refers to the resistance offered by the amalgam
to the forces of condensation used in placing the
amalgam. It varies according to the size and propor
tional distribution of lathe- cut or spherical particles.
Amalgams containing only spherical particles are
relatively easy to pack.
Trituration
The object of trituratibn is to completely wet the en
tire surface of all the alloy particles with the mercury,
to bring about the process known as amalgamation.
Amalgamators are made to work at different speeds
and the action should be checked periodically The
efficiency can be tested with a trial mix. The freshly
mixed mass is dropped on to the bench from a height
of approximately 30cm. If the mix is diy and crumbles,
the trituration time should be increased. A well mixed
amalgam should stay together when dropped on the
bench but should be a little flattened and retain a wet
gloss on the surface. It is better to slightly over tritu
rate than to under triturate an amalgam because
greatly extended trituration may reduce plasticity;
shorten working time and increase final contraction.
Condensation
This refers to incremental placement of the amalgam
into the prepared cavity and compression of each
increment into the other increments tolform a con
tinuous homogenous mass that is well adapted to all
the margins, walls and line angles. It is best carried
out using hand instruments with a smooth flat face
that can deliver reasonable force, per unit area, to
the amalgam and compress the layers together. Me
chanical condensers are available and reduce the need
for application of load. However there is an undesir
able generation of heat and mercury vapour. Ultra
sonic condensation has been suggested but it is not
recommended because^t allows the release of con
siderable quantities of mercury vapour into the am
bient atmosphere with a consequent risk to the op
erators.
Placement andfinishing
Following trituration the amalgam should be con
densed into the cavity within four minutes. It can
then be burnished towards the margins and carved
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
to an approximate occlusal form. At a subsequent
appointment any necessary final adjustment can be
carried out to the occlusal and proximal surfaces.
Structure ofthe set amalgam
Provided the minimal amount of mercury, commen
surate with complete amalgamation, is incorporated
initially, and then proper condensation techniques
are carried out, approximately 35-50%of the final vol
ume of the set amalgam will consist of unreacted
portions of alloy particles, held together by the y
phase matrix.
Moisture contamination
It is essential to keep the amalgam completely free
from moisture contamination during the entire place
ment procedures following trituration. The cavity
must be completely dry and free of gingival seepage
or haemorrhage. Inclusion of water will lead to in
crease in corrosion and tarnish with a reduction of physical properties. A zinc containing amalgam will
develop a delayed expansion.
Marginal sealing and bonding
This means that a newly placed amalgam will be sub
ject to a degree of microleakage and it is desirable to
take steps to overcome this. There are two alterna
tives available for this:
1. Copal varnish. This has been used for many years
and provides an immediate seal that will last for a
limited time only. It is recommended that it be
placed in two applications of a very thin coat and
the vehicle be allowed to evaporate briefly.
2. Resin bond. There has been a move lately to re
place die copal varnish with an unfilled resin bond
such as those used as an enamel bonding agent
with composite resin. The theory behind this is
that the resin bond will develop some degree of
union with enamel and dentin on one side and
amalgam on the other side and thereby both seal
the margin as well as strengthen the tooth crown
and compensate to some degree for the destruc
tion caused by cavity preparation. A bond with a
very low viscosity should be used and placed
carefully in a single layer, taking care to not allow
it to puddle in the comers. It should then be light
activated before placing the amalgam so that it
will not be incorporated in the amalgam during
condensation.
Limitations
The biocompatibility of amalgam has been the sub
ject of extensive investigation, particularly in rela
tion to the presence of mercury. Mercury in dental
amalgam may pose threats to the health of patients,
to the health of dental care providers and to the en
vironment.
Alternative to amalgam
In view of the mercury presented in amalgam a mer
cury free alloy has been suggested. This is gallium.
Certain drawbacks ofdental amalgam, noticeably that
of potential mercury poisoning have lead to the
development of newer materials. One such material
is gallium alloy, a mercury free metallic substitute to
silver amalgam. A study was conducted in our de
partmentusing gallium alloy as a restorative material
in pediatric patients and it has shown encouraging
results.
LINING MATERIALS
placea fining material on the floor of a cavity prior to
placement of the finaliestoration. There have beep a
number of reasons for their use including sedation
of a preexisting pulpal inflammation as well as pre
vention of further irritationfrom sudden te
change.
The materials used in the past and the reasons for
their use can be listed as follows-
Zinc phosphate cement: This was used exten
strong enough to accept the load imparted to the
dentin by condensation of an amalgam r
tion. It was accepted that there was no the
€E0 I TEXTBOOK OF PEDODONTICS
pulp. Its use was continued for a long time be
cause it was expected that an additional layer of
this cement would protect other weaker lining
materials that became popular, from disturbance
during condensation of aipalgam. It is regarded
as out of date at this time.
2. Zinc oxide *
.
eugenol
This became popular be
cause the anti bacterial properties of eugenol were
recognised as well as the sedative effectiveness
of zinc oxide. It is used as a temporary sedative
dressing over a large cavity with an inflamed pulp
beneath. It is effective because it provides a seal
around the periphery of a cavity simply because
bacteria cannot penetrate past the eugenol. Fast
setting types were developed to allow this to be
used alone as a lining but, as it is relatively weak,
it does not offer support for an amalgam restora
tion placed over the top.
3. Calcium *
.
hydroxide
This was introduced as a
lining because of its antibacterial properties as
well as the theory that the excess calcium ions
present in the cement would be available to the
pulp and would encourage remineralization within
the pulp chamber. The fact that it is very alkaline
with a pH 13 ensured the inability of bacteria to
thrive in its presence and this helps to stabilise
conditions on the floor of a cavity. If placed too
close to the pulp it will cause necrosis of the sub
jacent soft tissue but, in the absence of bacteria,
the pulp is likely to survive beyond the necrotic
area. It will then lay down a calcific barrier a short
distance away and it was this which lead to the
assumption that it was calcium ions from the lin
ing which prornoted the repair. It has recently been
shown that calciùni ions do not transfer from the
lining to the pulp but the conditions developed
by its presence allow the pulp to carry out its
own repair process.
4. Glass ionomer: This is now the material of choice
for lining a cavity because it is an effective barrier
to temperature change and also provides an ion
exchange adhesion that is the most effective
barrier to microleakage of bacteria under a resto
ration.
RECENT MODIFICATIONS IN RESTORATIONS
PREVENTIVE RESIN RESTORATION
With the advent of newer restorative materials the
ideology of sealing for prevention of fissure caries
rather than ‘the cavity extension for prevention’ came
into practice.
Preventive resin restoration utilizes the invasive and
non-invasive treatment of borderline or question
able caries. The resin placed in the carious areas and
adjacent caries susceptible areas, seal them from the
oral environment and provide a valuable treatment
alternative to conventional restorations like amalgam.
Types of carious surfaces treated
Three types of preventive resin restorations are per
formed depending upon the carious lesion.
1. Group A: Deep pit and fissure susceptible to car
ies.
■ The preparation size is very small
■ Unfilled resin or sealant is used to restore the
preparations of carious lesions involving
round bur of size Vi or less.
1
2. Group B: Minimal exploratory carious lesion
■ Since the caries can be explored the prepara
tion needs to be extended
■ Preparation size is by size 2 round bur
■ The restoration requires some filler to the un
filled resin
3. Group C: Isolated carious lesion
■ The caries is very definite and requires con
siderable preparation
■ Larger size bur is used following which a small
bevel is placed at cavo-surface margin
■ Unfilled resin layer followed by filled compos
ite is introduced into the preparation
Steps of placement:
The steps are the same as for the placement of resin
restoration.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY | CTO
Technique
Placement of preventive resin restoration utilizes prin
ciples of acid etch technique similar to those of seal
ant placement with the exception of caries removal
from isolated pits and fissures.
Clinical perspective
Preventive resin restoration has shown to improve
the long term health of teeth.
Materials like glass ionomer cement have been tried
as glass ionomer rest a seaf to incorporate their
various advantages which are:
■ Fluoride release benefits and
a True adhesion to enamel and dentin
However they have inherent disadvantages such as
a Technique sensitivity and
a Poor wear resistance which makes unsuitable as
restorations in occlusal contact.
Advantages of preventive resin restoration (Fig. 7.21 )
1. Minimal cavity preparation required thus prevents
unnecessary removal of healthy tooth structure
for retention.
2. Seals caries thereby halting the destruction of
tooth e.g. Teeth with pit and fissure, dens
evaginatus.
3. Loss of the restoration and subsequent replace
ment proves to be less invasive than that for con
ventional restoration like amalgam.
Conventional restqrgtjon leading to
gross tooth loss
Precaution
Early loss of preventive resin restorations similar to
pit and fissure sealant has been attributed to insuffi
cient etching. Thus it is very important to maintain
excellent isolation from salivary and moisture con
tamination for the long term success of preventive
resin restorations.
A.R. T RESTORATIONS
The placement of a restoration in a large occlusal
cavity can be done by means of art technique or
Atraumatic Restorative Treatment. Once the bacte
rial involvement is eliminated and further ingress pre
vented it is possible for the tooth structure to heal.
In the past a paste of zinc oxide and eugenol was
used to provide the seal and the anti caries activity.
Unfortunately it was too weak and subject to water
uptake and subsequent degeneration. In recent times
it has been realised that glass ionomer will perform
exactly the same way and will also last much longer
in the oral environment.
History
A group in Zimbabwe and another in Thailand be
gan experimentation to check longevity and effi
ciency and their results were so encouraging that
the system has been adopted by the WHO and is
being promoted world wide as a useful technique for
communities that lack regular dental facilities.
Preventive resin restoration with
minimal tooth loss
Fig. 7.21 Molar life cycle with conventional and PRR.
CTTÎfr I TEXTBOOK OF PEDODONTICS
Method
LAMINATION TECHNIQUES
In this technique there will be only hand instruments
available to open and clean the lesion and the re
storative materials will be hand mixed. A small selec
tion of hand instruments has been designed to suit
the system. There is a type of hatchet with multiple
blades to assist in opening through the enamel and
provide immediate access to the lesion. There is a
group of spoon excavators suitable for cleaning the
walls and it is expected that the floor will be left alone
as far as possible. It is only necessary to clean the
cavity to the extent the walls are clear of the infected
layer so that the ion exchange adhesion can be de
veloped. Aise X’
is a neei^ t0 create sufficient
room for asubstantial thickness of glass ionomer so
that it will withstand occlusal load. The glass ionomer
is provided as a powder and liquid ready for hand
mixing. A conditioner is used prior to the placement
of the cement. At the stage of placement, following
cavity preparation an additional drop of liquid is
placed in one corner of the mixing slab and once
isolation has been achieved this liquid is picked up
on a wet cotton pellet and placed into the cavity as
the conditioning agent. It is wiped around the cavity
and then immediately washed out using one or more
wet cotton pellets. This will remove debris and ex
cess polyacrylic acid and prepare the cavity walls for
the ion exchange adhesion. Dry the cavity with fur
ther cotton pellets and prepare to mix the cement.
There is a very significant relationship between the
composite resins and glass ionomers and the most
important factor isthat they can be successfully com
bined so that the strength of one can adequately
compensate for the weakness of the other. Both are
acceptably aesthetic but composite resin, with present
techniques, will not bond adequately long term to
dentin. This applies particularly in deciduous teeth
and must be regarded as a significant weakness. On
the other hand glass ionomer lacks fracture strength
to the extent that it is limited in its ability to restore a
marginal ridge which is under occlusal load. But with
a little care the two materials can be united to the
extent that they make a very useful combination and
can thus offer sufficient longevity for the average
restoration of reasonable dimension.
The mix should be thick and it should be placed in
the cavity and the gloved finger used as a matrix.
Thefinger can remain in place until the initial set has
occurred finis ensuring that the restoration remains
dry for that period of time. Cover the cement with
varnish to keep the cement free from contamination
till final setting takes place.
Adjust the occlusion using spoon excavators. This
technique has now been in extensive use in develop
ing countries for several years and the success rate
justifies its continuing use.
The technique for construction of a laminated resto
ration involves the use of a fast setting high strength
glass ionomer as a base, or dentin substitute, wili
allow for the development pf a sound ion exchange
union between the dentin arid the restoration. Place
ment of the most wear resistant composite resin over
this will provide an enamel replacement that is aes
thetic and long lasting.
Clinical technique (Fig. 7.22a, b, c)
Prepare a conservative cavity such that the adhe
sive materials can support the undermined enamel.
Condition the cavity, in preparation for the place
ment of glass ionomer. For a proximal lesion place a
short length of mylar strip as a matrix and support it
gently with a wooden wedge. Place the glass ionomer
and tap it gently into place to ensure good adapta
tion of the cement to the floor of the cavity so that
will.be free of porosity Allow the glass ionomer to
set or if a resin modified material is being used, apply
the activator light from different positions for at least
40 seconds.
The cavity can then be redesigned as a composite
resin cavity taking into account the relative flexibil-
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
Fig. 7.22a Occlusal fissure on lower molar
opened conservatively with a very fine tapered
diamond bur and conditioned for 10 seconds
with 10% poly acrylic acid
Fig. 7.23a A patient presented with mild
symptoms in lower second molar tooth.
Illustration shows fissures involved with a
degree of demineralisation
Fig. 7.22b The illustration shows the glass
ionomer being painted prior to light
activation
Fig. 7.23b A cavity has been opened to com
plete the exploration of the lesion. The affected
dentin on the pulpal floor has not been cleaned
as it is expected to heal
Fig. 7.22c The same patient showing restora
tion immediately after light activation
Fig. 7.23c A cavity conditioned with 10%
polyacrylic acid, an throughly washed and
lightly dried
€J© | TEXTBOOK OF PEDODONTICS
Fig. 7.23d The centre cavity has been restored
with resin modified glass ionomer built
incrementally and each section light-activated
for 20 seconds
Fig. 7.23e The area to be restored with com
posite resin is etched with 37% ortho-phos
phoric acid for 15 seconds
i
Fig. 7.23f The glass ionomer has been lami
nated with a hybrid composite in the area that
will bear the heaviest occlusal load
Fig. 7.23g A radiograph of finished restoration
Fig. 7.23h Same restoration showing the
comparison with amalgam placed in the first
molar tooth some years ago
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY J
i ty of this material along with its ability to unite with
the glass ionomer. The cavity must be atleast 2.0 mm
deep, all enamel margins should be exposed so that
the full micromechanical attachment of composite
resin to enamel is available. If the proximal box is so
deep that there is no enamel at the gingival margin
then leave the proximal Moor as glass ionomer only.
Having prepared the cavity both the enamel and the
glass ionomer should be etched with 37%
orthophosphoric acid for 15 seconds only. Wash the
cavity thoroughly and dry lightly. Now paint the en
tire cavity with a light coat of a resin enamel bond
and light activate it. The matrix system can now be
repositioned as required and wedged tightly into
place. The composite resin can now be built incre
mentally taking care to add no more than 3.0mm in
depth in any increment. Light activate each incre
ment for at least 40 seconds and over build a little to
allow for loss of bulk duringcontouring and polish
ing. Following final contouring light activate once
more for at least 40 seconds to ensure a complete
cure in depth (Fig. 7.23a, b, c, d, e, f, g, h).
The lamination technique can be utilised for the rein
forcement of any material that is regarded as insuffi
ciently strong for a given situation.
DESIGNING FOR PROXIMAL LESIONS
Plaque accumulates readily immediately below the
contact area between any two teeth, anteriors as well
as posteriors. In the absence of good plaque control
and regulation of refined carbohydrate intake the pH
interproximally will fluctuate frequently to levels well
below pH 5.5 and regular attacks of deminearalisation
may occur. There will be no occlusal load on these
lesions so plaque will not be forced into the develop
ing cavitation as happens on the occlusal surface,
so progress through tooth structure may be quite
slow. In the absence of cavitation there is always a
chance that the lesion can be healed through
remineralisation so the current recommendation is to
keep an early lesion under careful observation be
fore proceeding to surgical intervention.
On the other hand the anatomy of the deciduous
tooth suggests that intervention should be under
taken early rather than later because of the risk of
pulpal involvement. At the same time there are con
siderable risks involved in cutting a cavity in certain
areas, particularly in the proximal surfaces of decidu
ous molars in which the mesiobuccal pulp horn is
often very close to the surface. So the risk/benefit
ratio will need to be assessed in may cases before a
treatment plan is finally formulated.
Having decided on the need to prepare a cavity there
are at least three alternatives available.
Tunnel cavitv
If the cavity is very small aid more than 2.5 mm from
the crest of the marginal ridge, it is possible to de
velop a so called tunnel type cavity. This involves
approaching the dentin lesion from the occlusal fossa
just medial to the marginal ridge using a small ta
pered diamond cylinder at intermediate high speed
under air water spray. Aim diagonally towards the
lesion and develop a small access cavity. Having
located the lesion upright the same bur and move it
cautiously into the marginal ridge and lean it to the
buccal and then to the lingual to develop a triangular
entiy tunnel into the carious dentin.
Once the lesion has been identified use a small round
bur at low speed to carefully clean the gingival floor,
the buccal wall and the lingual wall but leave the
pulpal wall untouched. Hie inner wall of the proximal
enamel can now be explored carefully for signs of
cavitation. If the wall is intact there is no need to
break through to the external surface because the
enamel will most certainly heal in the short term; In
the presence of cavitaion lightly debride the walls of
the enamel cavity with a very small chisel to clean
fragile enamel prisms. The cavity is now reatty for
restoration and the preferred material is a glass
ionomer. It can be syringed and tamped into place
and bn the assumption that there are clean wlls
around the full circumference of the cavity, these will
be a complete seal and the potential for
remineralization of the pulpal wall if required (Fig.
7.24a, b).
Q0 I TEXTBOOK OF PEDODONTICS
Fig, 7.24a Tunnel cavity preparation in upper
second molar and slot cavity preparation
in the first molar
Fig. 7.24b The cavities were restored with resin
modified glass ionomer
Fig. 7.25a A cavity prepared on second molar
dictated by carious lesion
Fig. 7.25b A short length of mylar strip has
been pre formed to shape and is gently
supported by a wooden wedge
Fig. 7.25c Glass ionomer has been syringed
into the conditioned cavity and tamped on to
the floor and axial wall to ensure good
adaptation
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY | ÎCTÊV
Internal preparation (Partial or blind tunnel)
If the approximal enamel in relation to the lesion is
demineralised but not cavitated, it is not necessary
to break through the enamel because it is likely that,
- With good preventive follow up, it can be
remineralised.
Slot cavity/Minibox restoration
The next alternative could be the preferred design
for the small proximal lesion in all deciduous teeth. It
has been loosely titled slot or box cavity and in
volves approaching the lesion through the crest or
outer surface of the marginal ridge. Entry should be
very conservative in the beginning and it should be
extended only as dictated by the extent of the lesion.
Confine the cavity to the extent of the caries only
and retain as much tooth structure as possible. The
restorative material of choice is the glass ionomer.
As there will be a greater exposure to occlusal load
with this design there will be a greater need to con
sider the advantages of lamination with composite
resin (Fig. 7.25a, b, c)
Proximal approach
The third potential approach to the proximal lesion
becomes possible only if the adjacent tooth is miss
ing or else has a fairly extensive cavity already pre
pared in it This will allow a direct access to the le
sion and can lead to a very conservative cavity with
no involvement of the marginal ridge at all. Remove
only the completely broken down enamel sufficient
to allow access to the dentin, use a small round bur
to clean the walls but leave the axial walls alone. Use
a radioopaque restorative material because it will need
to be visible to another operator who may other wise
mistake it for a carious lesion.
The advantages of above preparations in comparsion
with conventional Class II preparation are:
it is conservative, maintains marginal ridge which
contributes to conserve the tooth strength.
■ Prevent the risk for iatrogenic damage to the ad
jacent approximal surface is minimised.
■ A normal contact area is maintained
■
SMART MATERIALS
While the quest for the ‘ideal restorative material’
goes on a newer generation of materials are being
released. These materials, though some may not be
commercially available, have the potentiai to replace
the currently used ones.
that support the remaining tooth structure to theex
tent that cavity preparation can be doneinthe most
conservative way. Some of these materials arc
‘biomimetic’ in nature, wherein there may beproperties that ‘mimic’ natural tooth substance such as
enamel or dentine better and one step further in die
concept of tissue regeneration, wherein the tissues
can be regrowri in the oral cavity. Along these lines
BRAX -1 gene has been isolated, which is thought
to be responsible for the control on enamel growth.
Even the current developments in existing materials,
notably composite and GIC, can also be applied to
make the materials ‘smarter’. To overcome some of
their deficiencies by use of CAD/CAM can make
designing of cavity preparation much easier and more
adaptable to each tooth, rather than a generalized
approach
Self-Assessment
1. Whatisresin modified glass ionomer?
2. What is the setting reaction for glass ionomer
cement?
3. What is ion exchange adhesion?
4.
5. What is the difference between conditioning and
etching?
6. What is meant by a smear layer?
7. What are the pre requisites for etching?
8. What is ‘zinc free’ alloy?
9. What is amalgam?
10. What is the indication of ART?
11. What are the merits and demerits oftunnel cavity
preparation?
1|||
12. What is slot cavity?
7.5 Semipermanent Restorations
Mount G J, Batra R, Tandon S
The alarming rate of failure for extensive class 2 res
torations in primary molars and class 3 in primary
anterior teeth has compelled the researchers to dis
cover the semipermanent restorations The
polycarbonate crowns and the stainless crowns are
one of these moderately recent advances. The semi
permanent restorations are recominended to restore
the lost tooth structure and stabilize it with these
prefabricated crowns..
POLYCARBONATE CROWNS
In pedodontic practiceJhe most common lesion in
anterior teeth is likely to be the result of nursing
bottle caries. These lesions will occur beginning on
t he labial face of all anteriors and they progress rap
idly as a diffused demineralisation of the entire sur
face of all existing teeth. The best that can be offered
at this time is the stabilisation of the lesion without
much in the way of a complete rebuild of the coronal
anatomy. It is suggested that the first step should be
to develop a clean periphery around the lesion using
a smallround bur whilst leaving the central portion
of the affected dentin intact and undisturbed for fear
of producing a pulp exposure. Tins will make it pos
sible to develop the ion exchange with glass ionomer
and allow development of an effective seal.
Polycarbonate crowns are temporary crowns which
can be given as fixed prosthesis to deciduous
anteerior teeth which will get exfoliated in future.
These are contraindicated in:
•
■
■
severe bruxism
deep bite
excessive abrasion
Polycarbonate crowns are designed to provide vari
ous advantages:
■ they save time
■ are easy to trim and
■ can be easily adjusted with pliers
Technique for construction (Fig. 7.26a, b.c):
1. Crown is selected according to mesiodistal width
and cervico-mesial length of the tooth while keep
ing in mind the shade of the tooth.
2. The tooth is reduced by about 0.5 mm to allow
space for the crown form labio-Iingually.
3. Mesio distally the reduction removes the contacts.
4. 1 -2 mm of incisal reduction is carried out
5. Crown is selectively ground at gingival aspect
6. It is then lined with acrylic or composite material
7 The preparation and the surrounding gingiva is
lubricated with water or saliva and the crown is
then seated. As the acrylic starts to set the crown
is removed from the preparation and reseated a
number of times. This dissipates the heat during
polymerization and prevents blocking into under
cuts.
8. The margins are trimmed and finished and the
crown is cemented with luting acrylic cement.
Blanching of gingival tissues should be checked
to avoid over extension into the sulcus.
STAINLESS STEEL CROWN
Stainless steel crown is a semi-permanent restora
tion used in the primary and young permanent teeth.
It was introduced as chrome-steel crown by
Humphrey in 1950, which proved to be a favour to
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
31^
Fig. 7.26a Polycarbonate crown for anterior
teeth (Courtesy: 3M Product)
Fig. 7.27 Crown forms - Aluminium crowns on
left and 3M stainless steel crowns on right
Fig. 7.26b Cervical crimping of polycarbonate
crown to improve the adaptation
(Courtesy: 3M Product)
Fig. 7.28a Caries is excavated before the
placement of stainless steel crown
Fig. 7.26c Cementation of polycarbonate crown
on left central incisor
Fig. 7.28b Stainless steel crown in place
following cementation
! TEXTBOOK OF PEDODONTICS
clinical pediatric dental practice. Now it is commonly
called stainless steel crown.
The requirement of stainless steel crown is more fre
quently found in deciduous dentition than in perma
nent dentition because of 2 reasons:.
* First in a relatively small deciduous teeth ne
glected caries can destroy the tooth’s integrity
faster than in the larger teeth of the permanent
dentition.
■ Second the deciduous teeth pulp is larger than
permanent pulp in relation to it dentin and enamel
envelope. Thus it is difficult to make the dentinal
stump for a gold casting or to use a pin system of
retention for more extensive amalgam restoration.
Thus, stainless steel crown is an efficient and reli
able method of restoration of deciduous dentition. It
is also a most advantageous system of restoration
because of its retention and resistance.
Advantages
« These crowns are far superior to multisurface
amalgam restorations with respect to both life
span and replacement also and a most advanta
geous system of restoration because of its reten
tion and resistance.
■ They are acceptable to both the patient and the
dentist.
« They are also more cost effective because of com
paratively simple procedures involved in restor
ing even severely affected primary molars.
Objectives
Objectives of using stainless steel crown restoration
are:
• to achieve biologically compatible, masticatorily
competent and clinically acceptable restoration.
■ to maintain the form and function and where pos
sible, the vitality of the tooth should be main
tained.
DIFFERENT TYPES OF STAINLESS STEEL CROWNS
■ Un trimmed crowns (eg. Rocky mountain) these
crowns are neither trimmed nor contoured, require
lot of adaptation, thus are time consuming.
■
Pretrimmed crowns (eg.Unitek stainless steel
crowns,3M Co.,st. paul,MN;and Denvo
crowns,Denvo Co. Arcadia,CA).
These crowns have straight, non-contoured sides
but are festooned to follow a line parallel to the
gingival crest. They still require contouring and
some trimming.
■
Precontoured crowns (eg.Ni-Chro Ion crowns
and Unitek stainless steel crowns,3M
Co.,stpaul,MN).
These crowns are festooned and are also
precontoured though a minimal amount of
festooning and trimming may be necessary. (Ta
ble 7.27)
COMPOSITION
■
Stainless steel crowns (18-8)Austentic type of
alloy is used. For example Rocky mountain and
Unitek.
17-19% ciiromium
10-13% nickel'
67% iron and
4% minor elements.
*
The austentic types provide the best corrosion
resistance of all the stainless steel.
$
■
Nickel-base crowns They are Inconel 600 type
of alloy.
72% nickel
14% chromium
6-10% Fe
0.04% carbon
0.35% manganese and
0.2% silicon.
These alloys have good formability and ductility
necessary for clinical adaptation of crowns an 1 wear
resistance to resist opposing occlusal forces. The
metallurgical characteristics ofNi-Chrome crown al
lows these crowns to be fully shaped and strain hard
ened without a defect during manufacture.
INDICATIONS
■
Extensive decay in primary and young^permanent teeth (Fig. 7.28a, b)
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY | flQ
For instance, developing class 5 lesion is a sign
of poor oral hygiene and cariogenic diet When
this occurs in the preschool age child who also
has class 2 lesion in the same tooth, the stainless
steel crown is indicated particularly in the first
primarymolar.
Primary teeth with caries on 3 or more surfaces or
where caries extends beyond the anatomic line an
gles. For example caries on mesial surface ofthe max
illary and mandibular first molar. The proximity ofthe
pulp on the mesial side make placement of an accept
able amalgam restoration difficult.
Primary incisors with class 4 lesions occuring mesially and distally, along with a class 5 lesion on the
same tooth i.e. the primary anterior teeth that are
extensively decayed from the nursing bottle syn
drome.
■ For teeth deformed by developmental defects or
anomalies:
Stichas enamel dysplasias or dentinogenesis im
perfecta.
'
s
■
For teeth with hypoplastic defects:
r
They may be more susceptible to caries because
retention of the plaque occurs in hypoplastic de
fects. In the placement of stainless steel crowns
on hypoplastic teeth, treatment may involve the
crowning of the teeth in all 4 quadrants (often all
posterior teeth). Thus there is a danger of alter
ing the vertical dimension by impinging on the
freeway space. So the crowns should be fitted
quadrant wise. Only when the previous crown is
cemented then proceed with preparation of the
tooth in the next quadrant.
■
As an abutment:
For a space maintainer or prosthetic .appliance,
for example a restoration for a first primaiy molar
when it is tobe the abutment for a distal extension
appliance.
■
Temporary restoration of a fractured tooth
■
In severe cases of bruxism:
The teeth may be soab reded that stainless steel
crowns are required to restore the interarch verti
cal dimension and prevent traumatic pulpal expo
sure.
i.
>
In the mixed dentition phase, the stainless steel
crown adapted to the primaiy molars will assist in
preventingundue wear ofthe first permanentmb-
■
If extensive abrasions have already resulted in a
loss of the vertical dimension, then a slight (less
then 2mm) opening of the bite is acceptable. If
the bite is opened more than 2mm,it will result in
tenderness of the treated tooth and possibly in
an adverse pulp response.
■ Following die pulp therapy
^Tnbbfliffieprimary and permanent teeth as pulp
therapy leaves the treated tooth more brittle be
cause of fluid loss, it is likely to fracture.
■
Asa preventive restoration
If the patient has a high susceptibility to caries
manifesting it either by numerous gross carious
lesions or by rampant caries and in a handicapped
child whose lack of oral hygiene may encourage
further decay.
Single tooth crossbite:
In case wherFalbwer mandibular incisor lias been
previously displaced labially, a reversed stainless
steel crown or a banded metal incline on the
inlocked incisor with a guide plane at a 45 degree
angle to the occlusion plane can be used. With
the use of stainless steel crown correction oc
curs in lto2 weeks.
For replacing prematurelylost anterior teeth:
Double stainless steel crowns on abutment teeth
can be used for replacing the lost maxillary ante
rior teeth.
Factors To Be Considered In Pre-Operative
Evaluation
■
Dental age of the patient
This is recorded by the root development of the
underlying tooth. When a primary tooth can be
expected to exfoliate within 2 years of restore-
CTEl I TEXTBOOK OF PEDODONTICS
t io it, amalgam restoration can be done. However,
failure of extensive amalgam restoration in the pri
mary teeth can be frustrating. This can be over
come by an initial placement of stainless steel
crown.
■
Co-operation of the patient
If the patient is uncooperative, whether it is due
to age(i.e <3yrs.) or due to negative behavior. If
the child is stubborn and does not want to coop
erate, first a positive behavior has to be instilled.
If child is unable to co-operate because of age(i.e
<3yrs ) then a chair side GA may have to be con
sidered. In this case, since it is difficult to check
the correct occlusion so it is always better to keep
the stainless steel crown at the level or slightly
below the level of the adjacent tooth. So that the
child does not have disturbed occlusal due to
premature contact.
■
Motivation of the parents
Whether the parents are willing to come for den
tal visits for the follow-up.
•
Medically compromised/disabled children
For example in children with a heart problem,
prophylaxis has to be taken as in tooth reduction,
-subgingival procedure is done or in poor general
condition of the child chair side GA has to be
taken into account.
CLINICAL PROCEDURE
■
Evaluate the preoperative occlusion
a. Take the alginate impression of U/L dental arch
of the patient.
b. Pour the cast in the dental stone. *
c. Note the dental midline and the cusp fossa
relationship bilaterally.
■
Selection of crown
The correct size crown may be selected prior to
the tooth preparation by the M-D dimensions of
the tooth to be restored, and a Boley gauge can
be used for this purpose
If the crown is not selected before the tooth re
duction, after the tooth reduction it can be
selected as a trial and error procedure which
approximates the M-D width of thé crown. The
smallest crown that completely covers the prepa
ration should be chosen.
To produce steel crown margins of similar shapes,
examine the contours of the buccal and lingual
marginal gingivae (Fig. 7.30a,b).
■ Buccal and lingual marginal gingivae of the
second primaiy molar resembles smiles with
greatest occlusal-gingival height of the clini
cal tooth crown about midway on the buccal
and lingual surfaces.
■ Buccal marginal gingivae of the most mandibu
lar first primary molar and many maxillary first
molars is similar to a stretched out "S’, having
greatest occlusal-gingival height located at the
mesiobuccal.
■ The contour of the lingual marginal gingivae
of all the first primaiy molars resembles smile.
« The occlusal-gingival height is located about
midway in bucco-lingual direction.
■ Tooth preparation
L. A should be administered.
Isolation
Isolation has to be done with ¿otton rolls, which are
held in position by cotton roll retainer. Use of rubber
dam for isolation is mandatory. When it is not possi
ble to use rubber dam, as in case of terminal teeth in
arch, a gauze oral screen should be used to prevent
the possible aspiration of a crown form.
Remove the decay
Decay is removed with a large round bur in a slow
speed handpiece or with a spoon excavator.
Fig. 7.30a,b (a) Proxmial marginal gingival
tissues of second deciduous molar appears to
frown and (b) Buccal surface appears to smile
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
After caries removal and pulp therapy, if necessary,
the previously carious area can be built up with a
quick setting reinforced ZnOE cement and/or zinc
oxyphosphate cement.
and occlusolingual line angles are rounded by hold
ing the bur at a 30-45° angle to the occlusal surface
and moving it in a mesio-distal direction.
RECOMMENDATIONS FOR PREPARATION
Steps in reduction
The aims of tooth reduction are:
a to provide sufficient space for the steel crown.
■ to remove the caries.
a
to leave sufficient tooth for retention of the
crown.
Occlusal reduction (Fig. 7.31a)
A 69L OR 169L bur is used to reduce the occlusal
surface by 1.5 to 2.Omm,following the cuspal outline
and maintaining the original contour of the cusps.
Reduction of occlusal surface can be judged by com
parison with the marginal ridges of the adjacent teeth.
Proximal slices (Fig. 7.31b)
Place the wooden wedges in the interproximal em
brasures. The wedges separate the adjacent teeth,
thus minimize the risk of damaging the tooth enamel.
The bur (69L or 169L) is moved B-L across the proxi
mal surface, beginning at the marginal ridges and at
an angle (10 degree) slightly convergent to occlusal
surface. The depth of slice should be sufficient to
break contact with the adjacent tooth and it should
develop a finish-line below any existing caries. Prepa
ration should be taken gingivally far enough to avoid
the development of the ledge, whi h would make it
difficult to seat the crown properly (Fig. 7.31c). Be
cause of cervical constriction of the primary tooth,
adequate depth of the proximal preparation will res|^|ri^^ther edge finish line.
^^®^^Wthe buccal and lingual surface is either
very minimal. Natural undercuts of
dBOOri^ce^'assists the retention of the stainless
However; in some cases; as the first
piiiif iholar, it is necessary to reduce the large buc
calbulge.
Round all the line angles
Using a side of the bur or diamond, the occlusobuccal
«
How much occlusal reduction should be done?
Though various views have been expressed re
garding the occlusal reduction it is found that
about 1.5-2mm of reduction have to be done to
obtain occlusal clearance. However as much of
the tooth structure as possible must be left for
retention.
■
Which su rface should be reduced first, proxi
mal or occlusal?
If the proximal reduction is done at the initial step,
even with utilization ofwedged rubber dam, some
a mount of gingival bleeding will occur. If blood
gets on the preparation, it will make the diagnosis
ofvery small pulp exposure difficult.
Thus the best plan is to reduce the occlusal as
the initial step, removing any caries as part of
that step. Next perform the necessary pulp therapy
then proceed with proximal surface reduction.
■
Considerations for retention capability of the
crown
It is not only mechanical preparation which is re
quired for the retention but the cementing me
dium also plays an important role for the reten
tion of stainless steel crown.
■
Special recommendations for preparation of
tooth
One has to concentrate on making the stainless
steel crown more physiologically acceptable to
the gingiva as it is seen in our clinical practice
and also that cement increases the retentive
capacity of all types of preparations. Reducing
supragingival bulge with reduction extending
0.5mm below7 the gingival crest helps to obtain an
acceptable gingival response.
I TEXTBOOK OF PEDODONTICS
Fig. 7.31a Preparation of tooth to receive
stainless steel crown - 1.0 to 1.5 mm occlusal
reduction
Fig. 7.32 Contouring done at middle 1/3rd of
crown to produce belling effect
Fig. 7.31b Mesial and distal contact points
are cleared
Fig. 7.33 Crimping done at cervical 1/3rd of
crown to aid in tight marginal fit
Fig. 7.31c Cross-section showing crown
margin located approximately 1 mm
subgingivally
Fig. 7.34 Stainless steel crown in place.
Excess cement is removed using explorer and
knotted dental floss
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
It is especially significant when the Ion crowns
are used because of hardness and difficulty of
manipulating the nickel steel. When the softer
metal crowns(Rocky-mountain) are used, rnaintainingthe cervical bulge may be the preparation
of choice.
EVALUATION CRITERIA FORTOOTH PREPARATION
■
■
■
■
■
■
■
The occlusal clearance is 1.5 to 2mm.
The proximal slices converge toward the occlusal
and lingual, following the normal proximal con
tour.
An explorer can be passed between the prepared
tooth and the proximal tooth at the gingival mar
gin of preparation.
The buccal and lingual surface are reduced at least
0.5mm with the reduction ending in a feather edge,
0.5 to 1mminto the gingival sulcus.
The buccal and lingual surfaces converge slightly
towards the occlusal.
All the point and line angles in the preparation
are rounded and smoothed.
The occlusal third of buccal and lingual surfaces
are gently rounded.
INITIAL ADAPTATION OF CROWN
Two principles related to stainless steel crown length
and crown margin shapes that are based on an un
derstanding of the tooth morphology and gingival
tissue contours were presented by Spedding(1984).
•
The crown should be of a correct length and its
margins can be adapted closely to the tooth. This
can be achieved when the finished crown is cor
rectly seated on the prepared tooth vith its oc
clusal surface in the occlusal plane and its mar
gins placed just apical to the marginal gingival
crests.
After the correct size crown is placed on the pre
pared tooth, the crown height can be reduced by
removing about 1mm of the crown initially with a
crown and bridge scissors or with a corborundum
wheel on a slow speed straight handpiece, which
shapes the margins simultaneously.
■
For shapingthe ciown margins, mark 3 light points
on the metal at the mesiobuccal, buccal and
distobuccal and at the mesiolingual, lingual and
distolingual surfaces at the crest of respective
marginal gingiva without compressing the mar
ginal gingiva. These marks on the metal corre
sponds to the greatest diameter of the tooth. Fi
nal finished margins are placed approximately 1mm
below these marks. The correctly shaped finished
crown margins are parallel to the contours of the
marginal gingiva of the tooth, about 1.0mm into
the gingival crevice.
SEATING THE CROWN
Now the crown is tried on the preparation by seating
the lingual first and applying pressure in a buccal
direction so that the crown slides over the buccal
surface into the gingival sulcus. Resistance should
be felt as the crown slip over the buccal bulge.
Each time the crown is placed on the tooth, gingival
tissue should be carefully examined so that the mar
gins are in the gingival sulcus. They shouldnot com
press and produce blanching of the marginal gingival
tissue.
CROWN CONTOURING (Fig. 7.32)
Initial crown contouring is performed witha 114plier
(ball and socket pliers)in the middle l/3rd ofthe crown
to produce a belling effect. This will give the crown a
more even curvature. Contouring of proximal metal
surface is not done with these pliers as they are al
ready in contact with the adjacent teeth. Though,
occasionally the #112(Abell) pliers are used to con
tour a proximal surface to establish correct contact.
Adaptation of the gingival 1/3 rd of the crown is done
with the 137 Gordan pliers.
I TEXTBOOK OF PEDODONTICS
CROWN CRIMPING (Fig. 7.33)
Any marked gingival crimping of the crown can also
be done with Unitek 800-412 pliers. The tight mar
ginal fit aids in:
■ mechanical retention of the crown.
• protection of the cement from exposure to oral
fluids.
» maintenance of gingival health.
During the trial fitting and cementation, the crown
should be placed from lingual and rolled towards
buccal surface. In this way, maximum undercut
on the buccal surface is more easily covered.
CHECKING THE FINAL ADAPTATION OF
THE CROWN
•
■
■
■
«
•
«
•
The crown must snap into place. Should not be
able to be removed with finger pressure.
The crown should fit so tightly that there is no
rocking on the tooth. Moderate occlusal displace
ment forces at the margin do not displace the
crown.
The properly seated crown will correspond to the
marginal ridge height of the adjacent tooth and is
not rotated on the tooth.
Crown is in proper occlusion and should not in
terfere with the eruption of the teeth.
There should not be any high points when
checked with an articulating paper.
The crown margin extends about 1 mm gingival to
gingival crest.
No opening exists between the crown and the
tooth at the cervical margins. Crown margins
closely adapted to the tooth and should not cause
gingival irritation.
Restoration enables the patient to maintain oral
hygiene.
FINISHING AND POLISHING
Accumulation of the plaque and inflammation of
gingiva is commonly seen in practice of restorative
dentistry due to rough and unpolished restoration.
To avoid these complications, the crown should be
polished prior to cementation with a rubber wheel to
remove all scratches.
Procedure ofpolishing
While polishing the crown, margin should be blunt
since knife edge finish produces sharp ends which
act as areas of plaque retention. A broad stone wheel
should run slowly, in light brushing strokes, across
the margins towards the center of the crown. This
will draw the metal closer to the tooth without reduc
ing the crown height and thus improves the adapta
tion of crown.
A wire brush can be used to polish the margins to a
high shine. To give a fine lustre to crown, Rouge,
whiting or a fine polishing material can be used.
RADIOGRAPHIC CONFIRMATION OF THE
GINGIVAL FIT
Before cementation, a bite wing is taken to verify
proximal marginal integrity. If the crown is too long,
there is still an opportunity to reduce the length. If it
is too shorty then add an orthodontic band or adap
tation of another crown is indicated.
CEMENTATION (Fig. 7.34)
f
Stainless steel crown should be cemented only on
clean dry tooth. Isolation of teeth with cotton rolls is
recommended.
■ Rinse and dry the crown inside and out and pre
pare to cement it. A ZnPO4,polycarboxylate or
GIC is preferred.
« If ZnPO4 is used, 2 coats of cavity varnish should
be applied on vital tooth before cementation and
cement should be of consistency so that it strings
about 1 1/2 inches from mixing pad with the
spatula. Cement is filled in approximately 2/3rd of
crown, with all inner surface covered.
■ Seat the crown completely on dried tooth surface
preparation. Final placement should follow an
established path of insertion of the crown. Ce
ment should be expressed around all margins. To
ensure complete seating of the crown, handle of
mirror or band pusher may be used.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
Before the cement sets, ask the patient to close
into centric occlusion by applying pressure
through a cotton roll and confirm that the occlu
sion has not been altered.
■ ZnPO4, cement can be easily removed with an
explorer or scaler. After the polycarboxylate ce
ment is partially set, it will reach a rubbery con
sistency. Excess cement should be removed at
this stage with a explorer tip. The interproximal
areas can be cleaned by passing the dental floss
through these areas.
■ Rinse the oral cavity and before dismissing the
patient reexamine the occlusion and the soft tis
sues.
■
Among all the cements used for cementation the GICs
are quite new and very promising. Cementing Stain
less steel crown with GIC have some benefits. These
cements have comparable strengths as ZnPO4, re
lease fluoride as do the silicophosphates chelate or
bond to the tooth structure and compatible to the
pulp as do the polycarboxylates. But the response to
GIC was characterized by gingival enlargement and
sulcular bleeding with no tooth sensitivity. The rea
son for this is unknown. It could be due to excess
material in the gingival sulcus. Hence the most ver
satile, retentive and least irritating cement available
at present time appears to be polycarboxylate.
SPECIAL CONSIDERATIONS FOR STAINLESS
STEEL CROWNS
Quadrant dentistry
When the quadrant dentistry is practiced, stainless
steel crowns are to be placed on the adjacent teeth.
Few points which are to be considered here are(Nash
1981):
■ prepare the occlusal reduction of one tooth com
pletely before beginning the occlusal reduction
of the other tooth as their is tendency to under
reduce both ,when reduction on both the teeth is
done simultaneously.
• reduce the adjacent proximal surface of the teeth
being restored more than when only one tooth is
restored. The greater reduction will ease the place
ment of the crowns and interproximal approxima
tion. (Fig. 7.35a,b)
■ both crown should be trimmed, contoured and
prepared for cementation simultaneously to al
low for adjustments in the interproxtmalspaces
and establish proper contact areas.
To get these adjustments, adapt and seat the crown
on the most distal tooth first and proceed mesially.
Crowns in areas of space loss (Me Evoy 1977)
When there is an extensive and long standing caries,
the primary teeth shift into the interproximal contact
areas. As a result the crown required to fit over the
B-L dimensions will be too wide a M-D to be placed
and the crown selected to fit over the M-D space will
be too small in cirumference.
■ Select a larger crown which will fit over the tooth’s
greatest convexity
■ Reduce the M-D width by grasping die marginal
ridges of the crown with Howe utility pliers and
squeezing the crown.
« Recontour the proximal,buccal and lingual walls
of the crown with theNo. 137 or No. 114 pliers.
■ Do the additional reduction of buccal and lingual
surface of tooth and select a smaller crown, if this
crown is difficult to place.
Preparing a Stainless steel crown adjacent to a
class H amalgam (Mc Evoy 1985)
■ Place the rubber dam.
■ Crown reduction is completed and the crown is
adapted.
■ Next a matrix band and wedges are placed. Amal
gam is inserted and carved.
■ With the matrix band in place, the crown is re
moved safely without fracturing the amalgam.
■ Then remove the matrix band and the final carv
ing of amalgam is done, .as there is good visibility
and access to the proximal box area.
■ Now complete die crown adaptation and cement
the crown.
The advantage of this approach is that, because
the crown and clas& II amalgams are prepared and
restored concurrently better restorations may
r TEXTBOOK OF PEDODONTICS
The crown is tried on the tooth and amount of
overlapping necessary is marked on the crown.
The overlapped edges are then spot welded. The
crown js polished with a rubber wheel and fine
abrasives. '
■
The oversized tooth or the undersized c rown
Separate the edges as needed and weld a piece of
0.004 inch orthodontic band material across the
cut surface. After contouring, apply the solder to
fill any microscopic deficiency in seal. Polish the
soldered crown.
■
Deep subgingival caries
One approach is to complete the indicated pulp
treatment and then restore the cavity preparation
with silver amalgam.
Fig. 7.35a Buccal marginal gingival tissues of
second deciduous molar appears to ‘smile’
and first deciduous is 'streched-out S’
Now the silver amalgam is considered substitute
for the tooth structure. The proximal areas are
sliced as in a routine crown preparation. Stain
less steel crown is adapted with amalgam substi
tutes for tooth structure at the interproximal fin
ish line. If the subgingival caries occurs
interproximally, the unfestooned Rocky moun
tain crown will be deep enough to coyer the prepa
ration.
Fig. 7.35b Proximal reduction is more when 2
adjacent crowns has to be placed than a
single crown
Another method is to solder an extension on in
terproximal areas of the crown.
result and it helps to overcome the nuisance of
placing 2 rubber dams.
STAINLESS STEEL CROWN MODIFICATION
■
In 1971 ,Mink and Hill reported several ways of modi
fy! ng the stainless steel crown when the crowns are
either too large or too short.
■
Undersized tooth or the oversized crown
This commonly occurs when due to a long stand
ing interproximal caries,space loss has occurred.
To reduce the crown circumference ,a cut is made
up of the buccal surface to the occlusal surface.
The cut edges are re-approximated to overlap one
another making the crown circumference smaller.
The open contact
If the closed contact area (except for the primate
space)is not established, it will result in food pack
ing, increased plaque retention and subsequently
gingivitis.
This problem can be solved by selection of a larger
crown or exaggerated interproximal contour can
be obtained with a 112 (ball and socket)plier to
establish a close contact. Interproximal contour
can also be build by addition of a solder.
■
Open faced stainless steel crowns
The-stainless steel crown can be modified in
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
anterior teeth by a open faced stainless steel
crown, which is simply a stainless steel crown
with the labial surface trimmed away to leave a
crown perimeter which is then restored with a resin
veneering. (Croll 1998)
„_
This has 2 advantages- esthetic are often improved.
- tooth structure is accessible for pulp testing.
COMPLICATIONS
Common complications that can arise with stainless
steel crown preparation are:
■
Interproximal ledge ____ —
Sledge will be produced instead of a shoulder
free interproximal slice, if the angulation of the
tapered fissure bur is incorrect. Failure to remove
this ledge will result in difficulty in seating the
crown.
When the adjacent tooth is partially erupted and
the contact area is poorly established, the inter
proximal slice is difficult to prepare. To clear the
contact area, extensive subgingival tooth reduc
tion is requi red which may result in formation of a
ledge or damaging the erupting tooth. In such a
case, it may be wise to delay crowning until con
tact areas are properly established.
« Crown tilt_
-—Complete lingual or buccal wall may be destructed
by caries or improper use of cutting instrument.
This may result in finished crown tilting toward
the deficient side. Placement of restoration prior
to crowning provides a support to prevent crown
tilt, the alloy acting as a core. The clinical signifi
cance of crown tilting is minimal unless it occurs
on young permanent molars where supra-eruption of the opponent tooth may occur.
■
Poor margins,
When the crown is poorly adapted, its marginal
integrity is reduced. Recurrent caries may occur
around open margins.
Chances of plaque retention and subsequent gin
givitis increases with marginal discrepancy. The
tolerant potential ofyoung periodontal ligament
tissues is very high to an extreme amount of zinc
phosphate cement pushed into lingual sulcus
during the cementation procedure. The foreign
body was incorporated without any signs of gin
givitis and discomfort to the patient
Tnhalatjnnorjiigestinn nf cr
To prevent such mishaps, the rubber dam should
remain in place until cementation. It prevents ac
cidental swallowing or aspiration of a crown.
Sometimes sudden movement may result in in
halation or ingestion of the crown.
- If this occurs, attempt can be made to remove
the crown by holding the child upside down
as soon as possible.
- If this is unsuccessful, medical referral should
be done for an immediate chest X-ray.
- If the crown is in bronchi or lung, medical consultation will probably result in an attempt to
remove it by bronchoscopy.
- The presence of cough reflex in the conscious
child wil l reduce the chances of inhalation and
ingestion of the crown is more likely. Inges
tion is of less consequence as the crown will
usually pass uneventfully through the alimen
tary tract within 5-10 days. But it should be
diagnosed by absence of the crown on a chest
radiograph.
Self-Assessment
1. What is the use of polycarboxylate crowns?
2. What are the indications of stainless steel crowns?
3. What are the different types of stainless steel
crowns?
4. What are the modifications of stainless steel
crowns?
5. How much of occlusal reduction should be done?
6. Which surface should be reduced first, occlusal
or proximal?
7. What is snap fit’ of a crown?
| TEXTBOOK OF PEDODONTICS
8. What are the complication's associated with stain
less steel crowns?
Further Suggested Reading For Section - 7
1. Akinmade AO, Nicholson JW. Review - GI^ss
ionomer cements as adhesives. Part I. Fundamen
tal aspects and their clinical relevance. Journal of
Material Science in Medicine. 4,95-101,1993
2. Bonella E, White SM. Fatigue of resin bonded
amalgam restorations. Oper. Dent., 21,122-126,
1996
3. Bortolozzi CF, Pimenta LAF. Evaluation of the
compressive strength of teeth with Class II con
servative restorations. Ji Dent. Res. (Abstr.97)
77;1155,1998
4. Browning WD, Denninson JB. A survey of fail
ure modes in composite resin restorations. Oper.
Dent. 21;160-166,1996
5. Bryant RW, Hodge K-LV. A clinical evaluation of
posterior composite resin restorations. Austral
ian Dental Journal, 39177-81,1994
6. Clemens A,.Full Jerry, D.Walker, Jimmy
R.Pinkham,stainless steel crowns for deciduous
molars, JADA 89:360-364,August 1974.
7. Croll T. P, Primary incisor restoration using resinveneered stainless steel crowns, ASDC-J-DentChild;65,89-95,March-April 1998.
8. Dawson AS, Makinson OF, An alternate philoso
phy and some new treatment modalities in opera
tive dentistry, Part II, Australian Dental Journal,
32;205-10,1992
9. Frenken JE, Makoni F, Sithole WD, Hackenitz.
Three year survial of one surface ART restora
tions and glass ioniser sealants in a school oral
health program in Zimbabwe. Caries Res. 32:119126,1998
10. Frenken JE, Makoni F, Sithole WD. Atraumatic
restorative treatment and glass-ionomer sealants
in a school oral health programme in Zimbabwe:
Evaluation after 1 year. Caries Res. 30:428-433,
1996
11. Friedman MJ. New light curing options for com
posite resin restorations. Compend. Contin. Educ.
Dent. 20:122-135,1999
12. Greener EH. Amalgam - yesterday, today and to
morrow. Operative Dentistry. 4;24-35,1979
13. Hamid A, Hume WR. The effect of dentin thick
ness on diffusion of resin monomers in vitro. Jour
nal of Oral Rehabilitation. 24;20r25,1997
14. Hilton TJ. Cavity sealers, liners and bases; cur
rent philosophies and indications for use. Oper.
Dent. 21:134-146,1996
15. Hollist NO. Clamp usage when applying rubber
dam.BrDent J,27;184(12):579,1998
16. Hume WR, Gerzina TM. Bioavailability of com
ponents of resin-based materials which are ap
plied to teeth. Critical Reviews of Oral Biology
and Medicine. 7; 172-179,1996
17. Hunt PR. Micro conservative restorations for
approximal carious lesions. Journal of the Ameri
can Dental Association. 120;37-40, Î990
18. J. American Academy of Pediatric dentistry,Special
Issue,Ref.Manual. Vol.2.1,106,1999-00
19. Marshall K. Rubber dm: Br' Dent J, 184(5);218-9,
1998
20. Martin J. Tyas, Kenneth J. A, JoE Frencken,
Graham J. Mount, Minimal intervention dentistry
- a review, Int. Dent. J. 50:1:141,2000
21. Mc.Evoy Susan A.,A new tech, sequence for
approximating a stainless steel crowp and a class
II amalgam. J.Pedo,9;250-256,1985.
22. McLean JW, Nicholson JW, Wilson AD. Proposed
nomenclature for glass-ionomer dental cements
and related materials. Guest editorial, Quintes
sence International, 25:587-589,1994
23. McLean JW. Dentinal bonding agents versus
glass-ionomer cements. Quintessence Interna
tional. 25;659-667,1996
24. McMaster DR. House RC, Anderson MH, Pelleu
GB. The effect of slot preparation length on the
transverse strength of slot retained restorations.
Journal of Prosthetic Dentistry. 67;472-477,1992
25. Mount GJ, Hume WR. A revised classification of
carious lesions by site and size. Quint. Inter.,
28;301-303,1997
26. Mount GJ, Hume WR. Preservation and restora
tion of tooth structure. Mosby International, Lon
don, 1998.
SECTION 7 : PEDIATRIC RESTORATIVE DENTISTRY |
)
\
j
|
27: Mount GJ, Makinson OF, Peters MCRB. The
strength of auto-cured and light cured materials.
The shear punch test. Aust. Dent. J., 41 ;118-23,
1996
28. Mount GJ. Clinical performance of glassionomers. Biomaterials. 19:573-579,1998
29. Mount GJ. Clinical placement of modem glass
ionomer cements. Quintessence International.
24; 107-111,1993
\
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i
£
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i
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30. Mount GJ. The use of amalgam to protect remaining tooth structure. New Zealand Dental Journal,
73:15-20,1977
*
31. Nash,David A.,The nickel-chromium crown for
restoring post. Primary .teeth, J AD A, Vol. 102:4449,Jan., 1981
|
J
i
32. Ngo H, Marino V, Mount GJ. Calcium, Strontium,
Aluminium, sodium and fluoride release from four
glass-ionomers. J. Dent. Res. 77, Abstr. 75, page
641,1998.
33. Ngq H, Mount GJ, Peters MCRB. A study of
(
f
'
glass-ionomer cement and its interface with the
enamel and dentin using a low-temperture, high
resolution scanning electron microscope tech
nique. Quint Int 28;63-69,1997
34. Olmez A, Oztas N, Basak F, Erdal S. Comparison
of the resin-dentin interface in priniaiy and permanent teeth. J. Clinical Pediatric Dent. 22:293 298,1998
35. Pashley DH. Clinical correlations of dentine struc
ture and function. J. Prosth. Dent 66;777-781,1991
36. Protocols for clinical pediatric dentistry, Vol.4;80,
Annual 1996.
37. Robert H.Speeding, Two principles to produce
well adapted stainless steel crown, DCNA,
157,Jan. 1984.
38. Savide N.L.Caputo and Luke L.S; The effect of
tooth perforation on retention of stainless steel
crowns, J.Dent. Child, 46;25,1979.
39. Simonsen RJ. Cost effectiveness of pit and fis
sure sealant at 10 years. Quintessence Interna
tional, 20;75-84,1989
40. Strand GV, Nordbo H, Tveit AB, Espilid I,
Wikstrand K, Eide GE. A three year clinical study
of tunnel restorations. Eur. J. Oral Sci. 104;384-89,
1996
41. Strand GV, Tveit AB. Gjeidet NR Marginal ridge
strength of tunnel prepared teeth restored with
various adhesive filling materials. In press.
42. Van Meerbeck B, Peumans M, Verschueren M,
Gladys S, Braem M, Lambrechts P, Vanherle G.
Clinical status of ten adhesive systems. Journal
of Dental Research. 73,1690-1702,1995
43. Whitehouse RL. Dosages of inter patient cross
contamination from saliva ejector suck back. J Can
Dent Assoc. Jun 62(6):499-500,1996
44 Willems G, Lambrechts P, Braem M, Celis JP,
Vanherle G. A classification of dental composites
according to their morphological and mechanical
characteristics. Dental Materials, 8;310-319,1992
SECTION - 8
Pedia tric Endodontics
8.1 Objectives and Diagnostic Procedures
Gopinath V R, Tandon S
Introduction
Pediatric endodontics is a relatively new terminol
ogy, which deals with the management of pulpally
involved teeth in children. The pulp therapy in chil
dren is still a subject of controversy due to mainly
the lack of efficacious medicaments and skill, which
requires a lot of patience on the part of the operator
in handling this group of patients. Despite increased
awareness regarding the importance of deciduous
teeth and emphasis on the prevention of dental car
ies, pre-mature loss of primary and young permanent
teeth continues to be common in dental practice.
Therefore, this chapter highlights the dynamics of
dental pulp, its pathologies affecting it with clinical
features and its diagnostic procedures. It also dis
cusses in detail about the various treatment modalities,
the primary objective of which is to preserve the tooth.
Factors Influencing Appropriate Pulp Therapy
It is desirable to attempt to maintain the vitality of
the pulp of a tooth affected or infected by caries,
traumatic injury or other causes. However, a tooth
can remain functional without a vital pulp. It is pos
sible to reduce pulp autolysis or eliminate it entirely
without significantly compromising the function of
tooth. The successful pulp therapy is predictive upon
the acquisition and analysis of appropriate diagnos
tic data.
Treatment planning should include:
■ Is the child a reasonable patient?
Consider the value of the involved tooth in rela
tion to the child’s overall development and abil
ity to co-operate in the dental chair.
■
Is the child medically fit?
Medical histoiy is of great importance as, those
children who are more susceptible to infection
like children with congenital heart disease or
immuno-suppressed patients or children with
poor healing potentials (diabetes) wifi always be
questionable cases for a successful pulp therapy.
■
Is the tooth restorable?
A tooth with extensive caries leading to gross
destructi on of the coronal portion or a tooth which
has caries penetrating the floor of the pulp cham
ber is unrestorable.
■
Is it necessary to keep the tooth?
The amount of root remaining and the extent of
bone loss that has occurred in the supporting
structure will have a significant bearing on pre
serving thé tooth.
■
Are parents co-operative and do they understand
the importance of treatment options?
Parents’ consent in accepting the treatment and
preventive program, including periodic evalua
tion should always be given prior consideration.
SECTION 8 : PEDIATRIC ENDODONTICS |
Goals of Pulp Therapy
The primary objective of pulp treatment is to main
tain the integrity and health of oral tissues. This
may be achieved by keeping the following goals in
the mind:
■ to allow a tooth to remain in the oral cavity in a
non-pathological state
■ to maintain the arch length and tooth space
■ to restore a tooth to its functionally efficient form
■ to present the development of aberrant habits
and speech abnormality
■ to maintain the child’s esthetics and thereby pre
vent any psychological trauma
Prior To Any Treatment Option A Sound Knowl
edge About The Dynamics Of Physiology And Pa
thology Regarding Pulp Is Mandatory For A Suc
cessful Clinician
Pulp Physiology
Dental pulp may be defined as a special organ with a
-unique environment of the unyielding dentin sur
rounding a resistant, resilient soft tissue of mesen
chymal origin reinforced with a ground substance. It
has a close relationship between its peripheral cells,
the odontoblasts and dentin therapy making it a func
tional entity, sometimes referred to as the pulp den
tin complex.
The dental pulp has a high circulatory force because
of the fluid interchange between capillaries and tis
sue, which maintain a hydrostatic pressure within
this non-compliant chamber. This pressure is called
as intra pulpal pressure, which is normally 10 mm of
Hg and varies with each arterial pulse. The pulp does
not have a consistent effective collateral circulation,
even though the teeth have accessory canals. Hence,
a pulpal injury irrespective of different causes is fre
quently irreversible and painful.
Nerve fibers responsible for transmitting pain are A
delta (fast pain) and polymodal fibers (slow pain).
Histology
The pulp is described as having two regions, central
and peripheral zones.
■
Central pulp zone: The main body of the pulp
occupies this area, which contains a core of loose
connective tissue (stroma) bearing large nerves
and blood vessels and branch out to supply to
outer pulp layers. Outlining the central zone is an
area that is richly populated with undifferentiated
mesenchymal cells (reserve cells) and fibroblasts,
and is referred to as the cell rich zone. The princi
ple extra cellular components are ground sub
stance and collagen.
■ Peripheral zone: Peripheral to the central area is
the sub-dentinoblastic region of the pulp or zone
of Weil. This appears as a cell free zone which
may diminish in size or temporarily disappear.
Plexuses of capillaries and small nerve fibers
ramify in this layer deep to the odontoblastic layer.
The nerve fibers do not have their outer wrap
ping (myelin sheath) and terminate into naked,
free fibers as dendrites (free nerve endings), act
ing as specific receptors for pain. On account of
these free nerve endings, pulp demonstrates pain
as the only sensation irrespective of the stimu
lus.
Structural Elements of the pulp are given in Table
8.1
Histopathology and Clinical Symptoms
■ Normal:
A normal tooth is asymptomatic and exhibits a
mild to moderate transient response to thermal
and electric pulpal stimuli, the response subsides
almost immediately where such stimuli are re
moved. The tooth and its attachment apparatus
do not cause a painful response when percussed
or palpated. Radiographs usually reveal aclearly
delineated canal that tapers toward the apex. There
is no evidence of canal calcification and the lamina
dura is intact.
330
I TEXTBOOK OF PEDODONTICS
Table 8.1 : Structural elements of the pulp
Cellular Components
Cell
Location
Function
1. Fibroblast
Throughout the cell rich zone
Produces matrix and collagen
2. Reserve cell
Capillaries and cell rich zone
Pleuripotent
3. Histiocyte
Connective tissue
Phagocytosis
4. Odontoblast
First cell type as pulp is
approached from the dentin
Glycoprotein synthesis
(predentin matrix)
Extracellular Components
Components
Distribution
Function
1. Fibres
Throughout
Provides support for structural
elements
2. Ground
substances
Makes up the bulk of the pulp
Gel like medium in which all
elements are placed.
3. Nerve fibres
(A-delta and C)
Transmit pain impulses only
(because of the presence of
free nerve endings only)
4. Arterioles,
venules and
lymphatics
•
The diseases of the pulp can be classified as:
1. Hyperemia
- reversible
- irreversible
2. Pulpitis
- Acute pulpitis
- Chronic ulcerative pulpitis
- Chronic hyperplastic pulpitis
3. Pulp degeneration
- Calcific
- Fibrous
- Atrophic
- Internal resorption
4. Necrosis of pulp
Painful pulpitis
Painful pulpitis is a clinically detectable inflamma
tory response of the pulpal connective tissue to an
irritant. The exudative (acute) force is hyperactive
and the painful symptoms are indicative of an
intrapulpal pressure increase that has surpassed the
threshold limits of pain fibers.
Reversible pulpitis:
■ The pulp is inflamed to the extent that thermal
stimuli cause a quick, sharp, hypersensitive re
sponse that subsides as soon as the stimulus is
removed; otherwise the tooth is asymptomatic.
Any irritant that can affect the pulp may cause
reversible pulpitis, e.g. caries.
■ Reversible pulpitis is not a disease but merely a
symptom. If the cause can be removed, the pulp
should revert to an uninflamed state and the symp
tom should subside. A reversible pulpitis can be
clinically distinguished from a symptomatic irre
versible pulpitis by two methods.
SECTION 8 : PEDIATRIC ENDODONTICS |
1. Pain in reversible pulpitis subsides almost imme
diately after the stimulus is removed while in an
irreversible pulpitis there is a sharp painful re
sponse to thermal stimuli and the pain lingers
even after the stimulus is removed.
2. With a reversible pulpitis there is ho spontane
ous pain as there often is with a symptomatic
irreversible pulpitis.
Irreversible pulpitis
Irreversible pulpitis may be acute, subacute or
chronic; it may be partial or total. The pulp may be
infected or sterile. Clinically, the acutely inflamed pulp
is thought to be symptomatic and the chronically
inflamed pulp asymptomatic. With pulpal inflamma
tion there is an exudate, if the exudate can be vented
out to relieve pain that accompanies edema, the tooth
may remain quiescent. Conversely, if the exudate that
is being continuously formed remains within the hard
confines of the root canal, pain will probably occur.
Symptomatic irreversible pulpitis
Characterized by spontaneous intermittent or con
tinuous paroxysms of pain. “Spontaneous” means
that no stimulus is evident. Sudden temperature
changes induce prolonged episodes of pain. There
may be a prolonged painful response to cold (i.e.
remaining after the stimulus is removed) that can be
relieved by heat, and painful response to heat which
is relieved by cold. Continuous spontaneous pain
may occur merely by a change in posture (eg, when
the patient lies down or bends over). Pain from the
symptomatic irreversible pulpitis tends to be moder
ate to severe, depending on the severity of inflam
mation. It may be sharp or dull, localized or referred
(eg., referred from the mandibular molar towards the
ear or up to the temporal area), intermittent or con
stant.
Asymptomatic irreversible pulpitis
Asymptomatic irreversible pulpitis may develop on
the conversion of a symptomatic irreversible pulpitis
into a quiescent state, probably because the inflam
matory exudate was quickly vented. This can be due
to any type of injury, but it is usually caused by a
€EE>
large carious exposure or by a previous traumatic
injury that resulted in a painless pulp exposure of
long duration.
Hyperplastic pulpitis
One form of asymptomatic irreversible pulpitis is a
reddish cauliflower-like overgrowth of pulp tissue
through and around a carious exposure. This is at
tributed to a low-grade chronic irritation and to the
increased vascularity ofthe pulp that is characteris
tically found in young people.
Internal resorption
The asymptomatic irreversible pulpitis can also be
present in the form of internal resorption. This is
characterized by the presence of chronic inflamma
tory cells in the granulation tissue. It is diagnosed
by radiographs.
Necrosis
Necrosis, death of the pulp, may result from untreated
irreversible pulpitis or may occur immediately after a
traumatic injury that disrupts the blood supply to
the pulp. The necrotic remnants maybe liquefied or
coagulated. Regardless of the type of necrosis, the
endodontic treatment is the same.
Diagnostic Procedures
Before initiating treatment, one must first assemble
all the information regarding signs, symptoms and
history. That information is then combined with re
sults from the clinical examination and test to obtain
the diagnosis. A diagnostician must have a Working
knowledge of examination procedures - percussion,
palpation, probing and pulp testing; a knowledge of
pathosis, itsradiographicandclinicalmanifestation;
an awareness of the various modalities of treatment;
and above all, a questioning mind. A methodical and
disciplined approach, along with a good measure of
patience, will help establish an accurate diagnosis.
History
Recollecting is the first step towards establishing a
diagnosis. A complete history will net determinetieatment but may influence modification in endMrt"* irk-
€33 I TEXTBOOK OF PEDODONTICS
treatment modalities, especially if there have been
any changes in the patient’s health status.
lesions, discolorations and other obvious abnormali
ties associated with the teeth should be noted.
Detailed history ofpain
Children are not good historians. Their symptoms
are often misleading because of their apprehension
and parent involvement. It is not uncommon to see a
child with a large carious lesion in the primary tooth
with no complaint and sometimes without any deep
lesion the child will complain of pain due to fear.
Therefore, a detailed history of the pain should be
evaluated with very simple, subjective questions like:
1. Do you have any discomfort on eating ice cream
or drinking hot soup?
.2. What happens when you eat anything sweet like
a candy bar?
3. Does your tooth bother you at the night when
you go to sleep?
4. How long does the pain last?
5. Does your tooth jump when you hit it with tooth
brush or spoon?
6. How often do you get this pain?
Coronal Evaluation
Done by using a mouth mirror and explorer and pos
sibly a fiber optic light source. The dentist carefully
and thoroughly examines the suspected tooth or
teeth for caries, defective restoration, discoloration,
enamel loss or defects that allow direct passage of
stimuli to the pulp. Vertical and horizontal fractures
are located by transillumination.
The above questions are an attempt to see if the
tooth is influenced by any thermal, chemical stimuli
or percussion. Spontaneous pain at night indicates
trouble. These questions may give a clue as to
whether a tooth is mildly inflammed, chronically
inflammed or necrotic.
External Examination
The child must be examined for localized swelling,
changes in colour or bruises, abrasions, cuts or scars
and similar signs of disease, trauma or previous treat
ment. The extraoral examination includes the face,
lips, and neck, which may need to be palpated if the
patient reports soreness. Enlarged lymph nodes are
of importance in denoting the spread of inflamma
tion.
Intraoral Examination
Examination of oral vestibules, buccal and lingual
mucosa, palatal soft tissues for localized swelling
and sinus tract or color changes is carried out.
Finally, as part of the general inspection, carious
Pulpal Evaluation
The clinical condition of the pulp can be evaluated
by thermal stimuli, percussion, palpation and vitality
tests. The various method of pulpal evaluation, pro
vide information which can be used with the child’s
history and radiograph to establish diagnosis.
Conventional Pulp Testing Methods are given in
Table 8.2
Newer methods
■
Laser Doppler Flowmetry
The laser doppler flowmetei; developed in the
1970s to measure the velocity of red blood cells
in capillaries, is a noninvasive, objective, pain
less alternative to traditional neural - stimulation
methods, and therefore a promiring test for young
children. The flowmeter produced regular signal
fluctuations for vital teeth. Nonvital teeth showed
no such synchronous signal but produced irregu
lar fluctuations or veiy steep spike traces that
were attributed to a movement artifact. This in
strument has demonstrated its value for ongoing
assessment of post - traumatized permanent inci
sors.
■
Pulse oximetry in evaluation of vitality
Since pulp vitality is purely a function of vascu
lar health, a vital pulp with an intact vasculature
may test nonvital if only its neural component is
injured as in a recently traumatized tooth. For elec
tric and thermal testing to be effective, the pulp
must have a sufficient number of mature neurons.
SECTION 8 : PEDIATRIC ENDODONTICS |
Table 8.2: Conventional Pulp Testing
Method
Technique/Material
1. Thermal
- Cold
- Heat
■
Ethyl chloride, ice, air
blast, hot water, heated
gutta percha (used for
location of symtomatic
tooth).
■ Lingering pain: Irreversible pulpitis
■ Hypersensitivity or subsiding pain:
Reversible pulpitis.
2. Electric
■
Instrument such as
odontometer
(Fig. 8.1)
« Higher current required (nonvital or
chronic inhammation)
■ Lower current required (acute pulpitis)
Unreliable in:
Children
Recently traumatized teeth
Multirooted teeth
3. Percussion
«
Vertical
■
Lateral
■ Apical periodontitis
(Irreversible pulpitis if due to caries)
■ Lateral periodontal space inflartimation
4. Radiograph
IOPA
Fig. 8.1 Odontometer for pulp testing.
However, both primary and immature permanent
teeth may not exhibit full alpha myelinated axon
innervation until 4-5 years after eruption. This
reduced number of pain receptors makes them
less responsive to stimuli. Considering all these
limitations, present pulp testing with thermal and
electric methods cannot be considered reliable
vitality tests for children.
Symptom/lnterpretation
• Furcation involvement
■ Thickening of the PDI space: Indicates
periapical infection (usually accompained
with irreversible pulpitis)
A direct measurement of pulp circulation is the
only real measure of pulp vitality. Pulp oximetry is
a completely objective test, requiring no subjec
tive response from the patient, that directly meas. ures blood oxygen saturation levels. To deter
mine oxygen saturation, the pulse oximeter meas
ures and compares amplitudes of the ratios of
transmitted infra-red with red light This ratio var
ies with relative fractions of oxygen saturated to
unsaturated hemoglobin and used to calculate
oxygen saturation. These characteristics infer that
die pulse oximeter is also capable of evaluating
the blood vasculature status within a tooth and
therefore pulp vitality.
The dependence on a pulsatile blood flow ap
pears to be a disadvantage of the use of the pulse
oximeter.
■ Dual wavelength spectrometry
This measures blood oxygenation change within
| TEXTBOOK OF PEDODONTICS
the capillary bed of dental tissue and thus not
dependent on a pulsatile blood flow.
■
Hughes probeye camera:
This is used in detecting temperature change as
small as 0. Io C hence been used to measure pulp
vitality7 experimentally.
Self-Assessment
1. What is dental pulp and what is so special about
it?
2. What are the important factors to be considered
for planning pulp therapy?
3. What are the primaiy objectives of pulp therapy?
4. What is the Zone of Weil?
5. What are the functions of dental pulp?
6. What is meant by the util ity of pulp?
7. How will you differentiate clinically reversible
pulpitis and symptomatic irreversible pulpitis?
8. Why electrical pulp tester is unreliable in chil
dren?
8.2 Treatment Modalities
Tandon S, Gopinath V K
INDIRECT PULP CAPPING THERAPY
■
■
Definition: The procedure involving a tooth with
a deep carious lesion where carious dentin re
moval is left incomplete, and the decay process is
treated with a biocompatible material for some time
in order to avoid pulp tissue exposure is termed
indirect pulp capping.
A radiopaque base is placed over the remaining
affected dentin to stimulate healing and repair.
The tooth then is restored with a material that
seals the involved dentin from the oral environ
ment.
Justifications:
■ Reduction of hyperemia in pulp.
■ Remineralization of carious or precarious dentin.
■ Reduction of anaerobic bacteria.
■ Formation of reparative dentin.
■ Pulp vitality maintained.
■ Continued normal root closure in immature per
manent teeth.
Indication and contraindications and objec
tives of indirect and direct pulp are given in
table. 8.3 and 8.4 respectively
Procedure (Fig. 8.2)
■
Indirect pulp therapy is utilized when pulpal in
flammation has been judged to be minimal and
complete removal of caries would probably cause
a pulp exposure. Careful diagnosis of the pulpal
status is completed before the treatment is initi
ated.
The tooth is anesthetized and isolated with rub
ber dam. All the caries except that immediately
overlying the pulp is removed. Care must be taken
to eliminate all the caries at the dentin - enamel
junction. If there is a communication of the caries
with the oral cavity, the carious process will con
tinue, resulting in failure of treatment.
Care must also be taken while removing the car
ies to avoid exposure of the pulp. The use of a
large round bur is best to remove the caries. The
utilization of a spoon excavator when approach
ing the pulp may cause an exposure by removal
of a large segment of decay and hence should be
used cautiously. Not all undermined enamel is
removed, for it will help to retain the temporary
restoration.
After all the caries, except that just overlying the
pulp, has been removed, a sedative filling of ei
ther zinc oxide - eugenol (ZOE) or calcium hy
droxide is placed over the remaining carious den
tin and areas of deep excavation. The tooth may
then be restored with ZOE or amalgam (Fig-1). If
the remaining tooth structure is insufficientto
retain the temporary filling, a stainless steel band
or temporary crown must be adapted to the tooth
to maintain the dressing within the tooth.
I TEXTBOOK OF PEDODONTICS
Table 8.3: Indications and contraindications of pulp capping
INDIRECT PULP CAPPING
DIRECT PULP CAPPING
^Indications
» Ideally, used when pulpal inflammation
has been judged to be minimal and
complete removal of caries would cause
a pulp exposure.
Indications
■ Small mechanical exposures less than
1mm which is surrounded by sound
dentin.
■ Light red bleeding from the exposure
site that can be controlled by cotton
pellet.
■ Traumatic exposures in a dry, clean
field, which report to the dental office
within 24 hours.
Contraindications
■ Any signs of pulpal or periapical
pathology.
« Soft leathery dentin covering a very large
area of the cavity, in a non restorable
tooth.
Contraindications
■ Pain at night.
■ Spontaneous pain
■ Tooth mobility
■ Thickening of Periodontal membrane
■ Intraradicular radiolucency
■ Excess bleeding at the exposure site
■ Purulent or serous exudate
Table 8.4: Objectives of indirect and direct pulp capping
INDIRECT PULP CAPPING
■ The restorative material should seal
completely the involved dentin from the
/ oral environment.
* The vitality of the tooth should be
preserved.
■ No prolonged post-treatment signs or
symptoms of sensitivity, pain or
swelling should be evident.
• The pulp should respond favourably
and tertiary dentin or reparative dentin
should be formed, as evidenced by
radiographic evaluation (1.5 microns/day
after 30 days of pulp capping).
■ There should be no evidence of internal
resorption or other pathologic changes.
DIRECT PULP CAPPING
The vitality of the tooth should be
maintained.
■ No prolonged post - treatment signs or
symptoms of sensitivity, pain, or
swelling should be evident.
■ Pulp healing and tertiary dentin
formation should result.
■ There should be no pathologic
changes.
■
SECTION 8 : PEDIATRIC ENDODONTICS |
Amalgam
Remaining
caries
A - The pulp will be exposed if all the caries is removed.
B - All decay is eliminated except that just overlying the pulp. Calcium hydroxide ZOE is placed over the remaining caries.
C - The tooih is sealed with amalgam.
Fig. 8.2 Indirect pulp therapy.
Fig. 8.3 Dentinal barrier formed following indirect pulp capping
on deciduous second molar.
| TEXTBOOK OF PEDODONTICS
«
If this preliminary caries removal is successful,
the inflammation will be resolved and deposition
of reparative dentin beneath the caries will allow
subsequent eradication of the remaining caries
without pulpal exposure.
•
The sedative dressing to be used in indirect pulp
therapy may be either calcium hydroxide or ZOE.
«
The treated tooth is reentered in 6 to 8 weeks, and
the remaining caries is excavated. The rate of re
parative dentin deposition has been shown to
average 1.4 microns per day following cavity
preparations in the dentin of human teeth. The
rate of reparative dentinformation decreases mark
edly after 48 days.
•
«
procedure of pulpal protection with adequate base
is, of course, mandatory before placement of per
manent restorations.
■
The reentry restorative procedure is still ques
tionable. Research has shown that carious den
tinwill remineralize with the initial restoration. If
the restoration has a good margin and at the re
call visit a layer of secondary dentin is evident,
reentry is not necessary (Fig. 8.3).
Infected Vs Affected Dentin is given in Table 8.5
■
If the initial treatment was successful, when the
tooth is reentered the caries will appear to be ar
rested. The color will have changed from deep
red rose to light gray or light brown. The texture
will have changed from spongy and wet to hard,
and the caries will appear dehydrated. Practically
all bacteria are destroyed under ZOE and calcium
hydroxide dressing sealed in deep carious lesions.
DIRECT PULP CAPPING
Definition: The procedure in which the small ex
posure of the pulp, encountered
■ During cavity preparation or
■ Followingatraumatic injury or
■ due to caries, with a sound surrounding den
tin, is dressed with an appropriate
biocompatible radiopaque base in contact with
the exposed pulp tissue prior to placing a res
toration is termed as a direct pulp capping.
■>
•
Following removal of the remaining caries, the
tooth maybe permanently restored. The usual**
Direct pulp capping in Primary teeth
Traditionally, direct pulp capping in the primary
teeth has been viewed with skepticism. The rea
sons cited were, the abundant blood supply and
Table 8.5: Infected Vs Affected dentin
Infected dentin
Affected dentin
Highly demineralized
Unremineralizable
Superficial layer
Lacking sensation
Stained by 0.5% fuschin or 1.0% acid
red solution in 0.2% propylene glycol
■ Ultrastructure: Intertubular dentin
greatly demineralized, with irregularly
scattered crystals.
Presence of deteriorated collagen
fibers that have only indistinct cross
bands and no interbands.
■ Should be excavated.
■
■
■
■
■
Intermediately demineralized
Remineralizable
Deeper layer
Sensitive
Does not stain
■
Ultrastructure: Inter-tubular dentin
partially demineralized, but apatitie
crystals bound like fringes to the sound
collagen fibers with distinct cross bands
and interbands.
■
Should be left to remineralize.
■
■
■
■
•
SECTION 8 : PEDIATRIC ENDODONTICS |
tin chips. In addition, microorganisms may be
forced into the tissue. The resulting inflammatory
reaction can be so severe as to cause a failure.
a consequent faster inflammatoiy response, and
poorer localization of infection.
Limitation in Primary Teeth:
Reasons for limitation of direct pulp capping in carijus exposure is as follows.
■ Internal resorption.
■ Calcification.
i Chronic pulp inflammation.
i Necrosis.
■ Intraradicular involvement.
Recently however, animal studies have suggested
that healing of the pulp may take place even in
the presence of inflammation. Several studies
have found varying success rates (Table 8.6).
»
Procedure:
When pulp capping is done, care must be exer
cised while removing the deep carious dentin over
the exposure site to keep to a minimum the push
ing of dentin chips into the remaining pulp cham
ber. Studies have shown decreased success when
dentin fragments are forced into the underlying
pulp tissue. Inflammatory reaction and formation
of dentin matrix are stimulated around these den
■
Staining carious lesions was proposed many years
ago by Fusayama to allow differentiation of
remineralizable and non-remineralizable dentin.
These harmless dyes demonstrate nonremineralizable dentin. Parts ofthe tooth that stain
should be removed. Any tooth structure that
does not stain can remain, since this soft dentin
will remineralize. Examples ofsome brands are CariD Test (Gresco products Inc), Caries Detector (J
Morita USA Inc), Caries Finder (Danville Engi
neering) and Sable Seek (ultra dent products). This
method will limit the removal of decay to nonremineralizable dentin during direct and indirect
pulp capping.
■
Location of the pulp exposure is an important
consideration in the prognosis. If the exposure
occurs on the axial wall of the pulp, with pulp
tissue coronal to the exposure site, this tissue
may be deprived of its blood supply and undergo
necrosis, causing a failure. Then, a pulpotomy or
pulpectomy should be performed rather than a
pulp cap.
Table 8.6: Success rate in direct pulp capping using different materials (Primary Teeth)
Year
Author
1963
Sawusch
1970
Weine
1971
Jepperson
1977
Schroder et al
1984
Garcia Godoy
1984
1987
Filling material
Observation period
Success%
Dycal
10-63 months
80
8-19
Dycal
18.6 months
90
2-7
Ca(OH)2 paste
1-7 years
78
Ca(OH)2 paste
12 months
83
4-9
ZOE & FC
18 months
96
Jerrel et al
6-10
Dycal
7-63 days
95
Turner
6-10
Life
63 days
22
Age
Dycal
33
Ca(OH)2
85
«El» I TEXTBOOK OF PEDODONTICS
■
«
Flush out dentinal debris and control bleeding at
the exposure site. No clot should form on the ex
posed site. The pulp-capping agent should come
in contact with the vital pulp tissue. Marginal seal
over the pulp-capping procedure is of prime im
portance since it presents ingress of bacteria and
reinfection. Healing and the formation of sec
ondary dentin are inherent properties of the pulp.
Factors promoting healing are conditions of the
pulp at the time of amputation, removal of irri
tants, and proper postoperative care such as
proper sealing of the margins.
After pulpal injury, reparative dentin is formed as
part of the repair process. Although formation of
a dentin bridge has been used as one of the crite
ria for judging successful pulp capping, bridge
formation can occur in the teeth with irreversible
inflammation. Moreover, successful pulp capping
has been reported without the presence of a re
parative dentin bridge over the exposure site.
Salierit features ofsuccessful pulp capping:
« Maintenance of pulp vitality.
• Lack of undue sensitivity or pain.
• Minimum inflammatory response.
• Lack of internal resorption and iritraradicular pathosis.
Pulp capping agents
Many materials and drugs have been employed as
pulp capping agents. Materials, medicaments, anti
septics, anti-inflammatory agents, antibiotics and
enzymes have been utilized as pulp-capping agents;
but calcium hydroxide is generally accepted as the
material of choice for pulp capping.
■
Calcium hydroxide (Table 8.7)
Herma/?[1930] introduced calcium hydroxide for
pulp capping. In 1938 Teuscher and Zander intro
duced calcium hydroxide in the United States.
They histologically confirmed complete dentinal
bridging with healthy radicular pulp under cal
cium hydroxide dressings.
When calcium hydroxide is applied directly to pulp
tissue, there is necrosis of the adjacent pulp tis
sue and an inflammation of the contiguous tis
sue. Dentin bridge formation occurs at the junc
tion of the necrotic tissue and the vital inflamed
tissue. Although calcium hydroxide work effec
tively, the exact mechanism is not understood.
Compounds of similar alkalinity (pH of 11) cause
liquefaction necrosis when applied to the pulp
tissue. Beneath the region of necrosis, cells of
the underlying pulp tissue differentiate into
odontoblasts and elaborate dentin matrix.
Table 8.7: Calcium hydroxide: advantages and disadvantages
Advantages
•
■
•
■
Initially bactericidal then bacteriostatic
Promotes healing and repair
High pH stimulates fibroblasts
Neutralizes low pH of acids
■
•
■
Stops internal resorption
Inexpensive and easy to use
Parti cl esm ay obturate open tubules
Disadvantages
■
Does not exclusively stimulate dentinogenesis.
■ Does exclusively stimulate reparative dentin.
■ Associated with primary tooth resorption
■ May dissolve after one year with cavo surface
■
■
dissolution
May degrade during acid etching
Degrades upon tooth flexure
■
■
Marginal failure with amalgam condensation
Does not adhere to the dentin or resin restoration
Cox and Suzuki, 1994
SECTION 8 : PEDIATRIC ENDODONTICS I
Commercially available compounds ofcalcium hy
droxide in a modified form are known to be less
alkaline and thus less caustic on the pulp. The
reactions to Dycal, Prisma VLC Dycal, Life and
Nu-cap have been shown to be similar The chemi
cally altered tissue created by application of these
compounds is resorbed first, then the bridge is
formed in contact with the capping material.
It was postulated that calcium would diffuse from
a calcium hydroxide^ressing into the pulp and
participate in the formation of a reparative (fentin.
Experiments with radioactive ions, however, have
shown that calcium ions from the calcium hydrox
ide do not enter into the formation of new dentin.
Radioactive calcium ions injected intravenously
were identified in the dentin bridge. Thus, it was
established that calcium for the dentin bridge
comes from the blood stream.
Isobutyl cyanoacrylate
It has been reported to be an excellent pulp -cap
ping agent because of its hemostatic and bacte
riostatic properties; at the same time it causes
less inflammation than calcium hydroxide. How
ever, it cannot be regarded as an adequate thera
peutic alternative to calcium hydroxide since it
does not produce a continuous barrier of a re
parative dentin following application to the ex
posed pulp tissue.
Resin bonding agents (Hybridization)
In the recent years, research has supported the
use of resin bonding agents on potentially heal
able exposed pulps. Supeibond C & B and clearfil
liner bond system have been observed to induce
a secondary dentin formation when used as a di
rect pulp capping agent. Studies have supported
using 4-methacryloxyethyl trimellitate anhydride
(4 - META) bond (Amalgam bond, Parkell) on ex
posed pulp.
cess rate of 89% when compared to calcium hy
droxide which gave a success rate of 68% only.
■
Other materials
Several other materials used as pulp capping
agents have included antibiotics, corticosteroids,
polycarboxylate cements, dentin, albumin, acid
and alkaline phosphatase, chondroitin sulfate,
chondroitin sulfate and collagen, calcium - eug
enol cement, calcitonin, barium and strontium hy
droxide, native enriched collagen solution and
hydroxyapatite.
PULPOTOMY
Definition: pulpotomy can be defined as the com
plete removal of the coronal portion of the dental
pulp, followed by placement of a suitable dressing or
medicament that will promote healing and preserve
vitality of the tooth [Finn, 19950
PRIMARY TOOTH VITAL PULPOTOMY.
Pediatric dentists still consider pulp therapy particu
larly the vital pulpotomy to be controversial. While
pulpotomy therapy evolved slowly over the first 50
years, the pace of change since the 1960s has con
tinued to accelerate dramatically.
■
Pulpotomy therapy can be classified according
to the following treatment objectives as devitali
zation (mummification, cauterization), preserva
tion (minimal devitalization, noninductiveX or
regeneration (inductive, reparative].
PULPOTOMY
I. VITAL PULPOTOMY TECHNIQUE
1. Devitalization
■ Single sitting
■ Two stage
Laser
Andreas Moritz (1998) evaluated the effect of CO2
laser on direct pulp capping and reported a sue
1. Formocresol
2. Electrosurgery
3. Laser
1. Gysi Triopaste
2. Easlick’s
Formaldehyde
€2E) I TEXTBOOK OF PEDODONTICS
3. Paraform devitalising
paste
2. Preservation
1. Glutaraldehyde
2. Ferric sulphate
3. Regeneration
1. Bone morphogénetiç
protein.
■
Radiographic interpretation can give some clues
as to the extent of the carious lesion, status of the
lamina dura, presence of abnormal resorptive proc
esses or interradicular rarefaction’s, which can
give an indirect clue to the relative presence or
absence of inflammation that may exist.
A. DEVITALIZATION (Single sitting):
II. NON-VITAL PULPOTOMY
(Mortal pulpotomy)
1. Beechwood cresol
2. Formocresol
Indication and contraindication for
pulpotomy
Indication:
1. Vital tooth with healthy periodontium.
2. Pain, if present, is neither spontaneous nor per
sistent.
3. Tooth which is restorable.
4. The tooth that possesses at least 2/3rd of its root
length.
5. Hemorrhage from the amputation site is pale red
and easy tojcontrol.
6. In mixed dentition stage primary tooth is prefer-.
able to a space maintainer.
Contraindication
1. Evidence of internal resorption.
2. Presenceof interradicularbone loss.3. Existence of abscesses~or fistula in relation to the
teeth.
4. Radiographic signs of calcific globules seen in
the pulp chamber.
5. Caries penetrating the floor of the pulp chamber.
6. Tooth close to naturafexfoliation.Diagnostic consideration:
■ Examination of the literature shows overwhelm
ing evidence of the importance of performing the
pulpotomy on teeth in which inflammation has
been confined to the coronal pulp when radicular
pulp is free of inflammation. Teeth selected ac
cording to these criteria will have a successful
prognosis.
1. Formocresol pulpotomy technique:
■ The formocresol pulpotomy technique was
first advocated by Sweet [1930]. He used a
multiple sitting technique , which has been
subsequently modified to either a single or two
stage technique.
■ Formocresol is a solution of 19% formalde
hyde, 35% cresol in a vehicle of 15% glycerine
and water. To prepare a 1:5 concentration of
this formula, first thoroughly mix 3 parts of glyc
erin with 1 part of distilled water, then add 4
parts of this preparation to 1 part Buckley’s
formocresol, and thoroughly mix again.
Mechanism of action
■ The proposed mechanism of action of formal
dehyde is that it prevents tissue autolysis by
bonding to protein. In particular, the chemical
binding is thought to be peptide groups of
certain side chain amino acid groups. This is a
reversible process and is accomplished with
out changing the basic overall structure of the
protein molecules.
Procedure (Fig. 8.4a, b, c)
■ In the pulpotomy procedure, the tooth should
first be anesthetized and isolated with rubber
dam. A surgically clean technique should be
used throughout the procedure. All remaining
dental caries should be removed, and the over
hanging enamel should be planed back to pro
vide a good access to the coronal pulp.
■ The entire roof of the pulp chamber should be
removed with a bur. No overhanging dentin
SECTION 8 : PEDIATRIC ENDODONTICS
A. Cariously involved primary
molar
C. Placement of a cotton pellet
moistened with formocresol.
B. Access cavity and removal of
coronal pulp tissue
D. Pulp chamber filled with ZOE and crown is
buildup with glass-ionomer before placement
of stainless steel crown.
Fig. 8.4a Method of performing a Pulpotomÿ.
Fig. 8.4b Pulpotomy on deciduous molar pre treatment
Fig. 8.4c Pulpotomy on deciduous molar post treatment
€НЭ I TEXTBOOK OF PEDODONTICS
from the roof of the pulp chamber should
remain. A sharp discoid spoon excavator may
be used to amputate the coronal pulp. The pulp
stump should be cleanly excised with no tag
of the tissue extending to the floor of the pulp
chamber.
■ The pulp chamber should then be irrigated
with a light flow of water from the water sy
ringe and evacuated. Moist cotton pellets
should be placed in the pulp chamber and al
lowed to remain over the pulp stump until a
clot forms.
« If the hemorrhage is controlled readily and the
pulp stump appears normal, it may be assumed
that the pulp tissue in the canals is uninflamed
hence it is safe to proceed with the pulpotomy.
The pulp chamber is dried with a sterile cotton
pellet Next, a pellet of cotton moistened with
1:5 concentration of Buckley’s formocresol and
blotted on a sterile gauze to remove the ex
cess, is placed in contact with the pulp stump
and allowed to remain for 5 minutes. The pel
lets are then removed and the pulp chamber is
dried with new cotton pellets.
«
A thick paste consisting of zinc oxide and
eugenol is prepared and placed over the pulp
stump. A zinc poly carboxy late cement is
placed over the paste and the tooth is restored
with stainless steel crown.
DEVITALISATION PULPOTOMY
(Two stage):
This is a two stage procedure involving the use
of paraformaldehyde to fix the entire coronal and
radicular pulp tissue. The medicaments used to
devitalize the exposed primaiy pulp are similar, in
that they contain some formalin or paraformal
dehyde. The medicaments used have a devitaliz
ing, mummifying and bactericidal action.
■ The formula of each agent used are as follows:
1. Gysi Triopaste:
2. Easlicks
Paraformaldehyde
paste:
3. Paraform
Devitalizing
Paste:
Tricresol 10ml
Cresol 20ml
Glycerin 4ml
Paraformaldehyde 20ml
Zinc Oxide 60gm
Paraformaldehyde 1gm
Procaine base 0.03gm
Powdered asbestos
0.05gm
Petroleum Jelly 125gm
Carimine to colour
Paraformaldehyde 1gm
Lignocaine O.Oógm
Propylene glycol 0.50ml
Carbowax 1500 1.30gm
Carmine to Colour
Technique
First appointment
Step I:
- Preparation of instruments and materials.
- Isolation of the affected teeth with rubber dam.
- Preparation of the cavity.
- Excavation of the deep caries dentin.
Step II:
- When pulp exposure is encountered during
excavation of deep caries, ensure that the ex
posed site is free of debris. Ideally, enlarge the
exposure with a round bur. Prepare a cotton
pellet large enough to cover the exposure but
small enough to clear the cavity margin. Incor
porate the paraformaldehyde paste into the pel
let, and place it over the exposure, Seal the
tooth for 1 to 2 weeks. Formaldehyde gas lib
erated from the paraformaldehyde permeates
through the coronal and radicular pulp, fixing
the tissues.
Second Appointment:
- On the second appointment, pulpotomy is car
ried out with the help of local anesthesia. The
roof of the pulp chamber is removed and
SECTION 8 : PEDIATRIC ENDODONTICS
cleaned with saline and dried with a cotton pel
let. The pulp chamber is filled with antiseptic
paste and the tooth is restored. Note that on
the second appointment, after removal of
dressing if the pulp is found to be vital, repeat
the dressing for one more week or do a vital
pulpotomy under local anesthesia.
MORTAL PULPOTOMY (NON-VITAL PULPOTOMY)
Ideally, a non-vital tooth should be treated by pulpec
tomy and root canal filling. However, pulpectomy of
a primary molar may sometime be impracticable due
to non-negotiable root canals and also due to limited
patient’s cooperation. Hence, a two stage pulpotomy
technique is advocated.
Selection Criteria:
■ History of spontaneous pain.
■ Swelling, redness or soreness of mucosa.
■ Tooth mobility.
■ Tenderness to percussion.
■ Radiographic evidence of pathological root re
sorption or periradicularbone destruction.
■ Pulp at the exposed site does not bleed.
Now-a-days the tooth with the above mentioned se
lection criteria is considered for pulpectomy rather
than Mortal pulpotomy
First Appointment
In the first appointment the necrotic coronal pulp is
removed. The pulp chamber is irrigated with saline
and dried with cotton pellet, infected radicular pulp
is treated with a strong antiseptic solution such as
beechwood cresol. Dip the pellet in beechwood
cresol and remove the excess by damping it on a
sterile cotton and place it in the pulp chamber over
the radicular pulp. Seal the cavity with a temporary
cement for one or two weeks.
Second Appointment
During the second appointment isolate the tooth and
remove the temporary dressing and the pellet con
taining beechwood cresol. Note that if the symp
toms persist or if there is no signs of resolution of
the sinus, a decision must be made either to repeat
the treatment or to extract the tooth. If there are no
symptoms the pulp chamber can be filled with a anti
septic paste. While filling the pulp chamber the anti
septic paste can be firmly pushed into the root ca
nals with cotton pellets. The tooth can be restored
with stainless steel crown.
1. Minute pulpotomy
■ Garcia Godoy, Novakovic, Carvajal have sug
gested that a shorter application time (1 minute)
may be adequate and perhaps superior to the
recommended 5 minutes.
Clinical & Radiographic Evaluation:
1. Absence of pain, fistula, abscess & mobility.
2. Absence of periradicular or periapical pathol
ogy3. Absence of internal or external resorption.
Histologic Evaluation:
Massler and Mansokhani described the tissue
reaction to formocresol as a progressive fixation
followed by degeneration. Three distinct zones
noted between 7 to 14 days are as follows.
1. Broad acidophilic zone of fixation.
2. Broad pale staining zone of atrophy.
3. Broad zone of inflammatory cell.
A progressive apical movement of these zones
was described with only an acidophilic zone left
at the end of a year
Formocresol toxicity:
The toxic properties of formocresol reported are;
■ Permanent tooth hypoplasia
■ Systemic distribution
« Antigenicity
■ Mutagenicity and carcinogenicity
■ Occurrence of dermatitis and pharyngitis
2. Electrosurgical pulpotomy (Mack and Dean,
1993)
It is a non-chemical devitalization, whereas mum
mification eliminates pulp infection and vitality
with chemical crosslinking and denaturation. Etectrocauteiy carbonizes and heat denatures the pulp
and bacterial contamination. Electrosurgery does
Г TEXTBOOK OF PEDODONTICS
little to improve on the formocresol pulpotomy
but does not use any chemicals.
After amputation of the coronal pulp, the pulp
stumps are cauterized through this method. After
completion, the pulp chamber is filled with zinc
oxide and eugenol paste. The tooth is restored
with a stainless steel crown.
3. Laser Pulpotomy
In an effort to find a more biologically acceptable
and effective alternative to formocresol, other
agents and techniques have been examined. Nonpharmacologic hemostatic techniques for the pul
potomy procedure, such as electrosurgeiy and
laser therapy have been suggested. Jeng-fen Liu
et al in 1999 studied the effect on Nd: YAG laser
for pulpotomy in primary teeth and noted 100%
success with no signs or symptoms, and only
one tooth had internahroot resorption at the sixmonth follow up visit.
1. Glutaraldehyde
Glutaraldehyde introduced by Kopel (1979) has
received attention in the recent years as an alter
native to formocresol for pulpotomy in primary
teeth in view of its superior fixative properties,
self-limiting penetration, low antigenticity, low tox
icity and elimination of cresol. The histologic pic
ture of a glutaraldehyde treated pulp shows ini
tial zone of fixation that does not migrate apically.
The tissue adjoining the fixed zone has the cellu
lar details found in normal pulp tissues The clini
cal success rate when glutaraldehyde was not
overzealously blotted from the pellet before use
was high (Table 8.8).
■
In vitro, antimicrobial and cytotoxic concentra
tions of glutaraldehyde and formocresol showed
an effective antimicrobial activity at a concentra
tion of 3.125% glutaraldehyde and 0.75%
formocresol. Thus gluturaldehyde was seen to
exert a less cytotoxic effect on the immediate and
surrounding tissues when used as a pulpotomy
agent.
■
The cytotoxic effect of glutaraldehyde and for
maldehyde was studied, in relation to the time of
exposure and concentration. Cytotoxic effects of
formaldehyde occurred over a narrow concentra
tion range from non-toxic to maximally toxic, and
the range was little affected by the time of expo
sure. In contrast, glutaraldehyde exerted its effect
over a wider concentration range, and a longer ex
posure time were necessary for maximal toxicity.
B. PRESERVATION
Included in this category are chemicals which in
duce minimal insult to the tissue. While not capable
of initiating an inductive process, they helped to
conserve vitality of the radicular pulp. Chemicals in
cluded under this section are glutaraldehyde and fer
ric sulfate, which have an obvious effect on the su
perficial tissue but differ from formocresol and elec
trosurgery by virtue of their properties, actions and
rationale for use.
Table 8.8: Clinical studies with Glutaraldehyde
Investigators
Clinical success
Radiographic
Duration (in months)
Guillaría (1989)
96
96
12
Prakash et al (1989)
100
100
6
Fuks et al (1991)
96
82
25
Garcia godoy (1991)
100
98
42
Tsai et al (1993)
98
78.7
36
Alacam (1996)
96
92
12
SECTION 8 : PEDIATRIC ENDODONTICS | €ZB
■
exposed dentin pulp of four adult miniature pigs
was seen to cause a substantial amount of hard
tissue formation (osteodentin and tubular den
tin) thereby completely bridged the delect. Hence,
hop-1 is a collagen carrier matrix which appeared
to be a suitable bio-active capping agent.
Gluteraldehyde application in 2 to 5% concentra
tion was advocated safe for clinical success.
2. Ferric sulfate
This npnaldehyde hemostatic compound was
proposed on the theory that it might prevent prob
lems encountered with clot formation and thereby
minimize the chances for inflammation and inter
nal resorption. Ferric sulfate forms a metal-pro
tein clot a t the surface of the pulp stump and this
acts as a barrier to irritating components of the
sub-base. If true, the ferric sulfate may function
solely in a passive manner.
C. REGENERATION
An ideal pulpotomy treatment should leave the
radicular pulp vital, healthy and completely enclosed
within an odontoblast lined dentin chamber. In this
situation, the tissue would be isolated from noxious
restorative materials in the chamber, thereby dimin
ishing the chance of internal resorption. Addition
ally, the odontoclasts of the uninflamed pulp could
enter into the exfoliative process at the appropriate
time. Implied in this scenario is the induction of re
parative dentin formation by the pulpotomy agent.
■ Unlike the other two categories for pulp treat
ment, the rationale for developing this field of
regeneration is actually based on sound biologic
principles.
«
This exciting new era was founded when Urist
(1965) concluded that the bone matrix contains a
factor capable of autoinduction and named this
factor bone morphogenetic protein (BMP). Only
recently, with the techniques of molecular biol
ogy we now know that there is a family of pro
teins that has bone inductive properties and BMP
is a generic term for this family.
«
The effect of recombinant human BMP-2 and
BMP-4 when capped with inactivated (fentin ma
trix on an amputated canine pulp have been seen
to imply that recombinant human BMP2 and BMP
4 induce differentiation of adult pulp cell into
odontoblast. The recombinant human osteogenic
protein 1 (hop-1) when placed on artificially
■
We will be entering a new era, when commercially
available recombinant human BMPs will be made
available for experimentation and clinical trials. A
combination of BMPs may be necessary to en
sure maximal and predictable reparative dentino
genesis, but there are details to be determined in
logical steps. If this material is proved to be fruit
ful in human clinical trial this product could be an
ideal material of choice for vital tooth pulpotomy
in primary teeth.
Pulpotomy with commonly used materials
is given in Table 8.9
PULPECTOMY IN PRIMARY TEETH
(Fig. 8.5a, b, c,d,e)
^Pulpectomy involves removal of the roof and con
tents of the pulp chamber in order to gain access to
the root canals which are debrided, enlarged and dis
infected. The canals are filled with resorbable mate
rial. Indications and contraindictions of pulpectomy
in primary teeth are given in table 8.10.
Objectives:
■ Following the treatment, the infectious process
should resolve.
■ There should be radiographic evidence of a stcessfiil filling without gross over-extension or
underfilling.
■ The treatment should permit resorption of the
primary root structures and filling materials at the
appropriate time to permit normal eruption of succedaneous tooth.
■ There should be no radiographic evidence of fur
ther breakdown of the supporting tissues
■ Treatment should alleviate and prevent further
sensitivity, pain or swelling.
■ There should be no internal or external root re
sorption or other pathology.
€E0 I TEXTBOOK OF PEDODONTICS
Table 8.9: Pulpotomy with commonly used materials
Formocresol
Calcium Hydroxide
Glutaraldehyde
■ Tissue fixation is evident
■ Calcium bridge formation
• Better and non reversible
■ Potent germicides—
■ Vital tissue remains at the
■ Germicidal activity
fixation of the tissues.
■ Vital pulp remains.
■ Excellent antimicrobial ----- -
apex.
■ Reported clinical success
■ Reported clinical success
« Pulp tissue remains vital1___
about 95% after 2 years.
■ Histological success 35%
■ Histological success .70%
■ Associated with internal
to be 65%
■ Reported clinical success
resorption in deciduous
after 2 years.
« Reported toxicity and
periapical leakage due to
teeth.
98-100%
« Comparitively less
.dystrophic calcification^
■ Less pulpal necrosis
« Bridging may make further
the smaller molecule size.
endodontic treatment
complicated.
1
Table 8.10: Deciduous tooth pulpectomv
Contraindications
Indications
■ Systemic conditions
^«.Strategically important tooth, (e. a:
molar where the permanent first
■ Lack of patient cooperation
■ Excessive mobility
molar has not erupted)
■ Non-restorable
. . . tooth
in case of the deciduous second
.... ■ Irreversible pulpitis
■ Minimal periapical changes with
. sufficient bone support
■ At least 2/3 rd of the root length
available
■ Internal resorption withoutany
obvious perforation
.......... —\-----
I
*
SECTION 8 : PEDIATRIC ENDODONTICS | €EE>
Fig. 8.5a Pulpectomy in deciduous
anterior tooth - pretreatment
Fig. 8.5b Pulpectomy in deciduous
anterior tooth - post-treatment
following obturation
Fig. 8.5c Pulpectomy in deciduous
molar tooth - Pretreatment
Fig. 8.5d Check X-ray
Fig. 8.5e Pulpectomy in deciduous ‘
molar tooth - Post obturation
€E0 r TEXTBOOK OF PEDODONTICS
TECHNIQUE (Fig. 8.6A-F)
■
Primary Molars
The primary molars normally have the same
number of roots and positions of the roots as the
corresponding permanent molars. The maxillary
molars have three roots, two facial and one pala
tal; the mandibular have two roots, mesial and
distal. The roots of the primary molars are long
slender compared with the crown length and
width, and they diverge to allow fona permanent
tooth bud formation.
■
Maxillaryfirst primary molars
The maxillary7 first primary molars have from two
to four canals that roughly correspond to the ex
terior root form with much variation. The palatal
root is often round; it is often longer than the two
facial roots. Bifurcation of the mesial-facial root
into two canals occurs in approximately 75% of
the maxillary7 first primary7 molar.
Access opening for pulpectomy in
primary teeth
Primary Root Canal Anatomy
?
To complete endodontic treatment on primary teeth
successfully, the clinician must have a thorough
knowledge of tile anatomy of the primary root canal
systems and the variations that normally exist.
■
Primary anteriors
The form and shape of the root canals of the pri
mary anterior teeth resemble the form and shape
of the exteriors of tjie teeth.
«
Maxillary incisors
The root canals of the primary maxillary central
and lateral incisors are almost round but some
what compressed. Normally, these teeth have one
canal without a bifurcation. Apical ramifications
or accessory7 canals and lateral canals are rare
but do occur.
«
■
Mandibular incisors
The root canals of the primary7 mandibular central
and lateral incisors are flattened on the mesial
and distal surfaces and sometimes grooved,
pointing to an eventual division into two canals.
The presence of two canals is seen less than 10%
of the time. Occasionally, lateral or accessory ca
nals are observed.
Maxillary and Mandibular Canines
The root canals of the maxillary and mandibular
canines correspond to the exterior root shape, a
rounded triangular shape with the base toward
the facial surface. Sometimes, the lumen of the
root canals is compressed in the mesial-distal di
rection. Bifurcation of the canal does not nor
mally occur. Lateral canals and accessory canals
are rare.
■ Maxillary second primary molars:
The maxillary7 primary molar has two to five ca
nals, roughly corresponding to the exterior root
shape. The mesial-facial root usually bifurcates
or contains two distinct canals. This occurs in
approximately 85% to 95% of the maxillary sec
ond primary molars.
■ Mandibularfirst primary molars:
The mandibular first primary molar usually has
three canals, roughly corresponding to the exter
nal root anatomy but may have two to four ca
nals. It is reported that approximately 75% of the
mesial roots contain two canals, whereas only
25% of the distal roots contain more than one
canal.
■ Mandibular secondprimary molars
The mandibular second primary molar may have
two to five canals but usually has three. The me
sial root has two canals approximately 85% of the
time, whereas the distal root contains more than
one canal only in 25% of the times.
SECTION 8 : PEDIATRIC ENDODONTICS |
A. Access opening
B. Use an endodontic file to remove
the infected pulp
C. Dry the canals with cotton pellets
and paper points
D. Obturate the canals with ZOE
mixture
E. Apply constant pressure to the
ZOE mixture
F. An alternative method using a
moist cotton pellet to condense the
mixture
Fig. 8.6 Pulpectomy on primary teeth
&& I TEXTBOOK OF PEDODONTICS
Access opening for primary anterior teeth:
Access opening for endodontic treatment on primary
or permanent anterior teeth have traditionally been
through the lingual surface. This continues to be the
surface of choice except for the maxillary primary in
cisors. Because of the problems associated with the
discoloration of endodontically treated primary inci
sors, it has been recommended to use a facial ap
proach followed by an acid etch composite restora
tion to improve aesthetics.
Canal Cleaning And Shaping:
Isolation (Fig. 8.7)
■’ Use of the rubber dam is essential in any endo
dontic procedure as it is the best method of iso
lating the tooth from the oral cavity. First intro
duced by Barnum (1864), it is useful in providing
a clean, dry and sterilizable field. (Refer isolation)
The anatomy of maxillary primary incisors is such
that access may successfully be made from the facial
surface. The only variation to the opening is more
extension to the incisal edge than with the normal
lingual access in order to give as straight an approach
as possible into the root canal.
Access openingfor primary posterior teeth:
Access opening into the posterior primary root canalsare essentially the same as those for the perma
nent teeth.
Important differences between the primary and per
manent teeth are the:
• Length and the bulbous shape of the crowns
■ A very thin dentinal wall at the pulpal floor and
the root.
« The depth necessary7 to penetrate into the pulp
chamber is quite less than that in the permanent
teeth.
■ Likewise, the distance from the occlusal surface
to the pulp floor of the pulp chamber is much less
than in permanent teeth. In the primary molars,
care must be taken not to grind on the pulpal
floor since perforation is likely.
When the root of the pulp chamber is perforated and
the pulp chamber is identified, the entire roof should
be removed with a bur. Since the crown of the pri
mary teeth are more bulbous, less extension towards
the exterior of the tooth is necessary to uncover the
openings of the root canals than in the permanent
teeth.
Fig. 8.7 Isolated primary maxillary first molar
during pulpectomy
Debridement
■
\
Canal cleaning and shaping is one of the most
important phases of primary endoddntic therapy.
The main objective of the chemica l - mechanical
preparation of the primary tooth is debridement
of the canals. Although an apical taper to the
canals is desirable, it is not necessary to have an
exact shape to the canals. The biomechanical
preparation in the primary7 teeth can be said to be
different enough to warrant the following con
siderations:
1. Relative pulpectomy'. Due to the tortuous
course of the canal coupled with the numer
ous accessory canals, the complete removal
of pulp in the primary teeth may often be diffi
cult , if not impossible. Thus, all such proce
dures can be regarded as partial pulpectomy
procedures.
SECTION 8 : PEDIATRIC ENDODONTICS |
2. Selective filling'. Resorption in the primary
teeth may have started at thetime of treatment.
Also, the slender roots, with thin apical ends
may predispose the tooth to a root fracture in
cases of excessive preparation. Thus the pro
cedure of selective filing of the canals should
be followed.
the pulp chamber with temporary cement. At a
subsequent appointment the canal is reentered.
As long as the patient is free of all sighs and
symptoms of inflammation, the canals are again
irrigated w ith sodium hypochlorite and dried pre
paratory to filling.
FILLING OFTHE PRIMARY ROOT CANALS
It is important to establish the working length to
prevent over extension through the apical
foramen. It is suggested that the working length
be shortened, 2 or 3mm short of the radiographic
root length, especially in the teeth showing signs
of apical root resorption.
Instruments should be gently curved to help
negotiate canals. This helps in maintaining the
original shape of the canal and thus lessens the
risk of perforation. Shaping of the canals proceeds
in much the same manner as is done to receive a
gutta-percha filling. The canals are enlarged sev
eral file sizes past the first file that fit snugly into
the canal, with a minimum size of 30 to 35.
ROOT FILLING MATERIALS
Developmental, anatomic and physiologic differ
ences between the primary and permanent teeth calls
for differences in the criteria for root canal filling ma
terials. The ideal requirements of a root-filling materi
als for the primary teeth are as follows.
Ideal requirements:
■ Resorb a t a similar rate as the primary root.
■ Should beTSrmiess to the periapical tissues and
to the permanent tooth germ; resorb readily if
pressed beyond the apex.
■ It should have a stable disinfecting power.
■ It should be inserted easily into the root canal
and be removed easily if necessary)
■ Should adhere to the walls of the canal and should
not shrink.
■ It should not be soluble in water.
■ Be radiopaque and not discolour the tooth.
No material currently available meets all these cri
teria. The filling material most commonly used for
primary pulp canals are_Zinc_feide^=^g@ad^
paste, iodoform paste and calcium hydroxide.
Since many of the pulpal ramification cannot be
reached mechanically, copious irrigation during
cleaning and shaping must be maintained. Debri
dement of the primary root canal is more often
accomplished by chemical means than mechani
cal means. The use of sodium hypochlorite to
digest organic debris and RC-prep to produce
effervescence must play an important part in re
moval of the tissue from the inaccessible area of
the root canal system.
ZINC OXIDE - EUGENOL PASTE
If the inflammation is beyond the coronal pulp
with only inter radicular but no periapical radiolucency, a single visit pulpectomy is preferred. On
the cither hand, if the pulp is necrotic with peri
apical involvement, filling procedure is delayed
until a later time. After canal debridement, the ca
nals are again copiously flushed with sodium hy
pochlorite and are then dried with sterile paper
points; a pellet of cotton is barely moistened with
camphorated parachlorophenol and sealed into
Zinc oxide - eugenol paste (ZOE) is probably the
most commonly used filling material for primaiy teeth.
Camp in 1984 introduced the endodontic pressure
syringe to overcome the problem of underfilling, a
relatively common finding when thick mixes ofZOE
are employed. Under-filling, however, is frequently
clinically acceptable. Overfilling, on the other hand,
may cause a mild foreign body reaction. Another
disadvantage of ZOE paste is the difference between
its rate of resorption and that of the tooth root.
€E2) I TEXTBOOK OF PEDODONTICS
radioopaque. For these reasons, the calcium hy
droxide - iodoform mixture can be considered to
be a nearly ideal primary tooth filling material.
Other preparation with a similar composition is
available mthe United States with the trade name
ofEndoflas (Sanlon Laboratories, A. A 7523 Cali,
Colombia S. A).
IODOFORM PASTE
Several authors have reported the use of KRI paste,
It resorbs rapidly and has no undesirable effects on
succedaneous teeth when used as a pulp canal medi
cament in abscessed primary teeth. FurtheyKRIpaste
that extrudes into the periapical tissue is rapidly re
placed with anormal tissue. It is also found to have a
long lasting bactericidal potential. Since iodoform
paste does not set into a hard mass, it can be re
moved if retreatment is required. KRI was found to
have a success rate of 84% as compared to ZOE,
which showed a success rate of only 65%.
*
A paste developed by Maisto has been used
clinically for many years, and good results have
been reported with its use. This paste has the
same composition as the KRI paste with addi
tions.
Composition of commonly used root canal mate
rials are given in Table 8.11 for primary teeth
CALCIUM HYDROXIDE
»
t W-
This material is generally not used in pulp therapy
for primary teeth. However, several clinical and
histopathologic investigations of calcium hydrox
ideand iodoform mixture (Vitapex, Neo Dental
Chemical Products Co. Tokyo) have been pub
lished by Fuchino and Nishino (1980). This mate
rial was found to be easy to apply and resorbs at
a ¿lightly faster rate than that of the root. It has
no Toxic effects on permanent successor and is
«
Chawla et al (1998) carried out apilot study in the
mandibular primary molars using calcium hydrox
ide paste as a root canal filling material and found
it to be a success.
■
We have also observed almost a 100% clinical
success in 10 endodontically treated primary
molars which were filled with vitapex (calcium
hydroxidised idoform).
GUTTA PERCHA
Since gutta percha is not a resorbable material its
use is contraindicated in the primary teeth.
Comparison of materials used for pulpectomy
in primary teeth is given inTable 8.12
Obturation techniques
■ Several techniques have been used fpr the filling
of materials into the deciduous teeth canals.
1. The primary teeth with their larger canals can
be filled with the thin mix coating the walls of
tire canal with the help of a reamer in a anti
clock wise direction while taking it out slowly
followed by the placement of the thicker mix
which is then pushed manually.
* i’
le 8.11: Composition of commonly used root canal materials for primary teeth
Walkhoff paste
KRI paste
Maisto paste
Vitapex (Fig. 8.8)
■ Parachlorophenol
■ Camphor
■ Menthol
■ Iodoform 80.8%
■ Camphor 4.86%
■ Parachlorophenol
2.025%
■
■
■
■
Zinc Oxide 14 gms
Iodoform 42 gm
Thymol 2 gm
Chlorophenol
Camphor 3cc
■ Lanolin 0.50 gms
« Calcium hydroxide
■ Iodoform
■ Oily
additives
■ Menthol 1.215%
SECTION 8 : PEDIATRIC ENDODONTICS |
Fig. 8.8 Vitapex material for obturating root
canals in primary teeth
Fig. 8.9 Lentulo spiral used to obturate
root canals
Fig. 8.10 Endodontic instrument holder
Fig. 8.11 Over obturation seen following ZOE
obturation of mandibular second
molar (Distal Root)
J TEXTBOOK OF PEDODONTICS
Table 8.12: Comparison of materials used for'pulpectomy in primary teeth
Properties
ZOE
Ca[OH]2with
Iodoform
*
[VITAPEX]
KRI
paste
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
1. Resorbs at the same rate as the tooth.
2. Harmless
3. Overfill resorbs
4. Antiseptic
5. Easily applied
6. Adheres to the wall
7. Easily removed
8. Radiopaque
Y
Y
Y
9. No discolouration
Y
Y
Y
Y-Yes
*Vitapex - Neo Dental Chemical Products Co. Ltd., Tokyo, Japan (2000)
2. Pastes can also beifilled by means of a Lentulo
spiral mounted on the micromotor hand piece.
The direction of rotation needs to be checked
for the material to properly flow into the canal.
(Figs. 8.9, 8.10).
chamber to seal over the ZOE canal filling. The
primary tooth is restored with a stainless steel
crown.
FOLLOW-UP AFTER PRIMARY PULPECTOMY
I
■
The rate of success following^rimary pulpectomy
is high. However, these teeth should pe periodi
cally checked for success of the treaXipent and to
intercept any problem associated with failure.
While resorbing normally without interference
with eruption of the permanent tooth, the primary
tooth should remain asymptomatic, firm in the al
veolus, and free from pathosis. If evidence of
pathosis is detected, extraction and conventional
space maintenance are recommended.
«
It has been pointed out that pulpally treated pri
mary teeth may occasionally present a problem
of overretention. After normal physiologic resorp
tion of the root reaches the pulp chamber, the
large amount of ZOE present may impair the re
sorption and lead to prolonged retention of the
crown. Treatment usually consist of simple re
moval of the crown and allowing the permanent
tooth to erupt
3. The endodontic pressure syringe is also effec
tive for placing the ZOE into the canals. The
Vitapex system also uses a syringe with the
material in it. The syringe is introduced upto
1/5 the distance from the apex of the canal and
the material is slowly injected as the syringe is
withdrawn from the canal.
«
■
Regardless of the method adopted to fill the ca
nals, care should be used to prevent extrusion of
the materials into the periapical tissues. The ad
equacy of the obturation is checked by radio
graphs. In the event a small amount of the ZOE is
inadvertently forced through the apical foramen,
it is left alone since the material is resorbable (Fig.
8.11).
When the canals are satisfactorily obturated, a
fast - set temporary cement is placed in the pulp
SECTION 8 : PEDIATRIC ENDODONTICS |
YOUNG PERMANENT TOOTH
APEXIFICATION AND APEXOGENISIS (Table 8.13)
Endodontic management of infected or non vital of
young permanent tooth with a wide-open blunder
buss apex has long presented a challenge. An imma
ture permanent tooth is defined as one where the
apex can be considered to be open.
Problem oftreating immature incisor with a necrotic
pulp
The anatomy of the non-vital immature incisor
presents several problems.
1. There is an open apex hence no hard tissue stop
against which gutta percha can be packed.
2. The open apex of the root canal tends to be
shaped like a blunderbuss making it difficult to
obturate the apex with root filling material.
3. Apicectomy is not advisable because the walls
of the immature roots are likely to fracture when
sealing the root apex.
■
Root canal treatment of these teeth requires a root
end closure technique to form a complete calcific
barrier at the apex of the tooth, against which a
GP root filling can be condensed without the pos
sibility of sealant or GP going through the apex
into the periapical tissues.
APEXIFICATION
Indications
This procedure is indicated for nonvital permanent
teeth with incompletely formed roots.
Objectives
This procedure should induce root end closure at
the apices of immature roots, as evidenced by peri
odic radiographic evaluation. Post treatment, adverse
clinical signs or symptoms such as a prolonged sen
sitivity, pain, or swelling should not be evident There
should be no evidence of abnormal canal calcifica
tion or internal or external root resorption, lateral root
pathosis, or breakdown of periradicular supporting
tissues during or following treatment.
Adaterials
A number of materials and procedures have been rec
ommended for apexification procedure: antisepticand
antibiotic paste (as reported by Frank), Zinc oxide
Table 8.13: Apexogenesis and Apexification
APEXOGENESIS
■ It is the physiologic process
of root development in vital
infected tooth.
« Normal or pulp tissue with
minimal inflammation is
present:
1. Completely (direct pulp
capping)
2. In the radicular portion
(pulpotomy)
■ Normal root end development
takes place.
^APEXIFICATION (Fig. 8.12a, b. C, d)
• It is the method of inducing
the development of root apex
in an immature pulpless tooth
by formation of osteocementum
or other bone like tissue.
■ Indicated in cases where there
is no normal pulp tissue i.e.,
where the pulp has undergone
irreversible pulpal necrosis.
■ Normal root development takes
place rarely. More commonly,
calcific barrier is formed clinically,
on a radiograph or both.
<cFF> I TEXTBOOK OF PEDODONTICS
f r*
Fig. 8.12a Apexification pretreatment
showing open apex
Fig. 8.12b Calcium hydroxide placed
in the pulp chamber following
removal of pulp
Fig. 8.12c Check X-ray - Apical
constriction formed by 12-13 months
Fig. 8.12d Post-treatment obturated
with gutta percha
SECTION 8 : PEDIATRIC ENDODONTICS 1
A. Immature tooth with periradicular
disease
B. Working length measured
Ç. The canal is filled with calcium hydroxide
Fig. 8.13 Apexification
359J
I TEXTBOOK OF PEDODONTICS
and metacresylacetate-camphorated para-chlorophqnol, tricalcium phosphate, collagen-calcium phos
phate gel, resorbable tricalcium phosphate, ceramic,
calcium hydroxide, empty canals and even no treat
ment at all.
•
Calcium hydrô^3^ ^:
This is available in many forms and is the most
widely used and tested material. Dry powder can
be packed into the canal; powder can be mixed
with water; or powder can be mixed with intracanal
medicaments or with methyl cellulose. Recently,
calcium hydroxide points (58% calcium hydrox
ide, 42% guttapercha and colouring agent) have
also been used. There seems little justification,
however, for mixing the powder with an intracanal
medicament. Most medications are clearly cyto
toxic. The antibacterial effect is provided by cal
cium hydroxide.
Procedure
’Frank in 1966 was one of the first to describe the
clinical methods using calcium hydroxide paste and
camphorated monochorophenol (CMCP), to stimu
late root closure.
The procedure for apexfication is as follows (Fig 8.13):
1. The tooth is isolated with rubber dam, and ac
cess is gained into the pulp chamber.
2. Using large reamers and files, remove the debris
from the coronal half of the pulp and establish
the file length radiographically.
3. Clean the canal, irrigate it and then dry it with a
paper point. Repeated gentle use of sodium hy
pochlorite assists debris removal.
4 Seal a pellet of CMCP in the pulp chamber with a
provisional restorative material.
5. On recall, in 1 to 3 weeks, remove the restoration
and clean the canal.
6. Take care to avoid any instrumentation of the walls
of the dentin near the apex.
7. Mix a paste of calcium hydroxide and CMCP on a
glass slab. Cany the paste to the canal and force
it into the apex with a large plugger or coneshaped instrument. The objective is to fill the ca
nal completely. Obtain a radiograph to check the
accuracy of the root canal filling.
8. On a 6 month recall, you should see radiographic
evidence of an apical closure. Weine, 1976 noted
five alternatives evident at this time.
■ No apparent apical closure, but a resistance
point when a file is inserted.
■ Radiographic evidence of a calcified bridge at
the apex.
■ Apical closure without canal space changes.
■ Normal continuance of apical closure.
■ Increased radiographic evidence of resolution
of apical pathology.
9. When you have accomplished apical closure, the
root canal filling is completed.
10. If apexification has not been completed, repeat
the cleaning and insertion of a calcium hydroxide
and CMCP paste.
Treatment Evaluations:
« The first evaluation of the apexification proce
dure may be done after 3 months. Radiographs
may show hard tissue deposition, but such evi
dence is not considered reliable. It is necessary
to test the quality of the apical barrier with a size
35 file. If the file easily penetrates, so too will the
obturation material It will therefore be necessary7
to continue the apexfication by reapplying cal
cium hydroxide.
■
If the 3 months radiograph shows little or no api
cal changes, reschedule the patient for another 3
months recall. There is no need to change the
calcium hydroxide if it appears to occupy the root
canal space adequately, and if the coronal temporaiy seal appears satisfactoiy. Any question about
either condition requires replacement of both the
calcium hydroxide and the coronal seal. Shalini
Gupta et al in 1999 reported a continuing root
formation in a carious non-vital and immature
mandibular second premolar after a single visit
calcium hydroxide apexification treatment. An
apical hard tissue barrier was formed, accompa
nied by a separate, mesioapically growing root,
in 7 months post treatment. Treatment was con
cluded with gutta percha root canal restoration.
The success of this single visit apexification treat
SECTION 8 : PEDIATRIC ENDODONTICS |
ment supports the contention thatfrequent chang
ing of the calcium hydroxide dressing is not al
ways required to induce an apical closure.
■
The follow-up evaluation is repeated even 3
months until successful apical bridging has oc
curred .This may take as little as 3 months or as
long as ayear or more, depending on the degree
of apical destruction and the ability of the apical
tissue tb repair.
Obturation of the root canal
Because the root canal wall does not change during
apexification, the shape of the canal will remain the
same after the apical barrier has formed, namely a
reverse taper. These canals are probably best suited
for obturation by a thermoplasticized technique. (Fig
8.14a, b, c).
Fig. 8.14a Root canal treatment in permanent
first molar - pre treatment
Recall andfollow-up
A routine recall evaluation should be performed to
determine the outcome of the root canal procedure.
Teeth treated in this manner are more likely to de
velop root fractures due to the thin root canal avails.
Therefore, the more developed the teeth before
apexification, the better their prognosis.
Alternative to conventional apexification
■ A primary objective in endodontic therapy is the
complete obturation of the root canal space. A
good apical stop is an essential factor in achiev
ing this goal. It effectively confines the filling
material to the canal space and allows the appli
cation of adequate condensation forces to yield
ait acceptably dense filling. Immature pulpless
teeth present special problems in adherence to
this objectives. These teeth have parallel or di
vergent walls in the apical third which make a
normal development of an apical stop impossi
ble. This leads to an inability to confine the filling
material to the canal space.
■
Mineral trioxide aggregate or MTA, is a new ma
terial developed for endodontics that appears to
be a significant improvement over other materials
Fig. 8,14c Post-obturation
I TEXTBOOK OF PEDODONTICS
for procedures in bone. It is the first restorative
material that consistently allows for the
overgrowth of cementum, and it may facilitate the
regeneration of the periodontal ligament.
m
Schwartz et al [1999] reported the lise of MTA
as:
1. First appointment - Calcium hydroxide was
used and the tooth was temporized
2. Second appointment! 3 weeks later] - The tooth
still had a sinus tract
3. Third appointment - The sinus was healed. A
thick mix of MTA and saline was introduced
into the canal, and left to set overnight. The
next day the tooth was obturated with gutta
percha. The tooth was found to be asympto
matic with normal periapical structure at 9 and
20 months recall .
Self-Assessment
1 What role do the radiographs play in the man
agement of deep caries?
Z Give the objectives, indications, contra indica
tions of indirect pulp capping?
3. Describe the treatment procedure for pulpotomy
and pulpectomy?
4. What is the difference between the infected and
affected dentin?
5. What are the materials used for indirect pulp cap
ping, direct pulp capping, pulpotomy and pulpec
tomy?
6. What are the reasons for the relative low success
rate of direct pulp capping in primary teeth?
7. What are the differences between formocresol and
glutaraldehyde pulpotomy?
8. What is mortal pulpotomy?
9. What are the materials used for obturation of pri
mary teeth?
10. What is the difference between apexogenesis and
apexification?
Further Suggested Reading For Section - 8
1. Berger IE. Pulp tissue reaction to formocresol
and zinc oxide-eugenol. J.Dentchild: 13; 32,1965
2. Cappuccino C.C & Sheehan R.F. The biology of
the dental pulp. In text book of oral biology. Edi
tion by J.H. Shaw, E.A Sweeney, C.C Cappuccino
and S.M. Meller. Philadelphia, WB. Saunder &
Co., 1978.
3. Chawla H.S. etal. Calcium hydroxide as a root ca
nal filling material in primaiy teeth- A pilot study.
J. Indian Soc Pedo PrevDent: 16(3); 90-91,1998
4. Curt Goho. Pulse oximetry evaluation of vitality
in primaiy and immature permanent teeth. Pediatr
Dent-: 21 (2); 125-127,1999
5. Ehrenreich D.W A comparison of the effect of
Zinc oxide and eugenol and calcium hydroxide
on carious dentin in human primar/ molar. J. Dent
Child: 35; 451,1968
6. Eliyahu Mass. Endodontic treatment of infected
primaiy teeth using Maisto’s paste. J. Dent Child:
56:117,1989
7. Fei A,Udin R.D Johnson R. A clinical study of
ferric sulfate as a pulpotomy agent in primary
teeth. Pediatr Dent: 13; 327-332,1991
8. Garcia-godoy et al, Pulpal response to different
application time of formocresol. J.Pedod: 6; 170193,1982
9. Gideon Holán & Anna B Fuks. Comparison of
pulpectomies using ZOE and KRI paste in pri
mary molar. Pediatr Dent: 15(6); 403,1993
10. Glass R.L & Zander H. A. Pulp healing. J. Dent
Res: 28; 97,1949
11. Sun HW et al. Cytotoxicity of glutaraldehyde and
formadehyde in relation to time of exposed and
concentration. Pediatr Dent: 12; 3^)3-307,1990
12. Jeng-Fen Liu, Liang-Ru-Chen, Shou-Yee Chao.
Laser pulpotomy of primary teeth. Pediatr Dent:
21(2); 128-129,1999
13. Kopel H.M¡. etaíl The effects of glutaraldehyde
on primary pulp tissue following coronal ampu
tation, an m vivo histologic study. J.Dent.Child:
47; 425-430,1980
SECTION 8 : PEDIATRIC ENDODONTICS |
14. Machido Y. Root canal therapy in deciduous teeth.
Jap Dent Assoc J: 36; 796-802,1983
15. Mack R.B, Dean J. A. Electrosurgical pulpotomy:
a retrospective human study. J.Dent.Child: 60; 107114,1993
16. Mack R.B, Halterman C.W. Labial pulpectomy
access followed by esthetic composite resin res
toration for non-vital maxillary deciduous inci
sors. J. Am Dent Assoc: 100; 374,1980
17. Mount G. J. Some physical and biological proper
ties of glass ionomer cement. Int. Dent. J. 45;135140,1995
18. Mesic N - Par etal. Clinical and histological exami
nation of young permanent teeth after vital am
putation of the pulp. Acta Stomatologica
Croatica: 24; 253-262,1990
19. Nakashima .M. Induction of dentin formation on
canine amputated pulp by recombinant human
bone morphogenetic proteins (BMP)2 & 4. J. Dent.
Res: 73(9); 1515-1522,1994
20. Nevins A etal. Induction of hard issue into
pulpless open apex teeth using collagen calcium
phosphate gel.. JOE: 4; 76,1978
21. Nishino M etal. Clinico-roentgenographical study
of iodoform-calcium hydroxide root canal filling
aterial Vitapex in deciduous teeth. Jap. J.
Pedodont: 18; 20-24,1980
22. Olgart L, Gazelius B, Lindh- Stromberg. U. Laser
Doppler flowmetry in assessing, vitality in luxated
permanent teeth. IntEndod J: 21; 300-306,1988
23. Roberts S.G & Brilliant J.D. Tricalcium phosphate
as an adjunct to apical closure in pulpless pennanent teeth. JOE: 1;263,1975
24. S.D Hill etal. Comparison of antimicrobial and
cytotoxic effects of gluteraldehyde and
formocresol. Oral Surg Oral Med Oral Pathol: 71;
89-95,1991
25. Stewart D. J and Kramer IRH. Effects of calcium
hydroxide on the unexposed pulp. J. Dent Res:
37; 758,1958
26. Tomeck C.D, Smith J, Grindall P. Biologic effects
of endodontic procedures on developing incisor
teeth. Effect of pulp injury and oral contamina
tion. Oral Surg: 35; 378,1973
27. Tsai TP, Su H.L, Tseng L.H. Glutaraldehyde prepa
rations and pulpotomy in primaty molar. Oral Surg
Oral Med Oral Pathol: 76; 346-350,1993
28. Wilkerson M, Hill S, Arcoria C. Effect of the or
gan laser on primaiy tooth pulpotomies in swine.
J. Clin Las Med & Suf: 14; 37-42,1996
29. Suneda YT et al. A histopathological study of di
rect pulp capping with adhesive resins. Oper Dent:
20; 223-229,1995
30. Zander H. A. Reaction of the pulp to calcium hy
droxide. J. Dent Res: 18; 373,1939
SECTION - 9
Developing Malocclusion
and its Management
9.1 Incipient Malocclusion
Tandon S
Introduction
Incipient malocclusion
The responsibility of early detection and manage
ment of developing malocclusion rests with the
pedodontists, because they see the patient at a very
young age and at various intervals like preschool
age, school age and the teenage period. Many ir
regularities or deviations from the normal may be
observed while they just begin to exist and they are
diagnosed early. This chapter is aimed to discuss
principles of diagnosis of incipient malocclusion
which is sometimes present as early as in predentate
period, deciduous dentition or mixed dentition. The
diagnosis of these deviations is of prime importance
for a dental practitioner to prevent before they start
to come into existence or to refer such problems to
the concerned specialist for the timely intervention
to minimize the corrective treatment
A incipient malocclusion may be defined as a con
dition which shows atendency ip develop into a
deviation from the normal dentofacial or occlusal
relationship. }
Types of incipient malocclusion (Table 9.1)
The early recognition of such problems requires the
knowledge of what is normal and also classifying
both normal and abnormal for a successful plan
ning of preventive or interceptive treatmerft. There
fore, a cursory examination is required at the first
visit to collect information, classify occlusion, or
ganize the facts gathered and reach a tentative di
agnosis. This provides a basis for a more definitive
treatment plan, and a line of action to prevent ini
tial occlusal problems to develop into malocclusion.
definitions
Concept of diagnosing incipient malocclusion
Incipient: Beginning to exist or coming to exist
ence.
Diagnosis is the study and interpretation of data
concerning a clinical problem in order to determine
the presence or absence of an abnormality.
Malocclusion: Such malposition and contact of
maxillaiy and mandibular teeth as to interfere with
the highest efficiency during excursive movements
ofjaws which are essential for mastication and nor
mal functions.
The traditional approach in diagnosing a normal
occlusion was to view the normal occlusion as fa
vourable, functional and acceptable esthetically, but
the modem concept is entirely changed. It is now
mainly stressing on prevention oriented early de
tection of problems.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Table 9.1: Types of incipient maloclusion
Dental
Skeletal
Dento-skeletal
Involving tooth or a group of teeth
Example:
i) Crowding in deciduous dentition
ii) Rotation of teeth interfering with
mastication
iii) Dental caries causing mesiodistal spacelogs
iv) Space loss with a premature loss
of deciduous teeth
v) Anterior and posterior cross bite.
When mandible or maxilla
are in abnormal réíatign to
4 each other or to the anterior
cranial base.
Example:
1 ncipien£problemjuxuxs
during growth of the individual
i) Developing mandibular
. growth in class III relation
ii) Maxilla developingjn...
class ÍI relation
Combination of both
Example:
i) Deficient mandibular
growth with lower
anterior crowding.
Recently Graber (1994) expressed his view regard
ing the diagnosis ' the goal of the diagnostic proc
ess is to produce a list of all the patient’s problems
and to state them clearly and concisely” which seem
to be a very simple way of detecting deviation espe
cia lly related to the incipient one.
Incipient malocclusion is the result of a develop
mental process, not pathologic, and the objective
signs typically measured by the dentist are morpho
logic characteristics rather than the physiologic
measurements of function used by the physician to
treat an illness. Therefore, a clinician must keep in
mind that orthodontic diagnosis is based on the
symptoms of impaired functions and/or psychologi
cal acceptance that has let the patient to seek treat
ment, not the morphological signs per se.
The growth of the child is not static in nature and is
constantly under dynamic changes from birth until
the early stage of teenage. It is thus, essential to
obtain a good rapport between the dentist, the child
and parent and it should be made clear that a nor
mal occlusion may not develop always. The parent
should be made to understand how things can go
wrong, and how much easier it is to prevent and
intercept the incipient problems rather than correct
them at a later date.
ESSENTIALS OF DIAGNOSIS
I. GENERAL EVALUATION
Initial patient contact:
Data collection starts with the first encounter with
the patient and/or parent. First contact may be via
die telephone - one gets to know the patient’s age,
source of referral, parents awareness, etc. It can
also reveal whether the parents’ orientation is pri
marily cosmetic or whether their greatest concern
is with function and oral health, in the first inter
view when one questions “What problem concerns
you the most”?
Chief complaint:
There are two logical reasons for concern about the
alignment and occlusion of teeth, impaired
dentofacial esthetics that can lead to psychological
problems, and impaired function. It is important to
establish their relative importance to the patient.
The dentist may or may not agree with the patient’s
assessment - that judgement'comes later. At this
stage, the objective is to find out what is important
to the patient.
Medical history:
Orthodontic problems are almost always the culmi
nation of a developmental process, not the resum e#
ÆSŒI I TEXTBOOK OF PEDODONTICS
a pathologic process. A careful medical history is
needed to provide a proper background for under
standing the patient’s overall situation and to evalu
ate specific orthodontically related concerns.
Dental history
Can evaluate any problems plus the patients atti
tude towards dental treatment.
Can also question the parents, whether they have
had any orthodontic treatment before. This will shed
some light on the possible hereditary component of
the child’s problem and it provides an insight into
how much, the parents already know about his type
of treatment.
Genetic history
A genetic history can begin with an inquiry as to
whether any siblings have required orthodontic
treatment and a discussion about the nature of their
problems. Inquiries should also be made into
whether the parents/close relatives have had ortho
dontic treatment, which may indicate the child’s pre
disposition towards malocclusion.
When examining, be alert to facial characteristics
that might be associated with a craniofacial syn
drome.
Social-behavioural history
This information may be difficult to obtain, as par
ents are often reluctant to speak about a child’s emo
tional problems. Questions on progress in school
should be made. If the child is slow or has a learn
ing disability it may be better to, whenever possi
ble, to reduce the patient’s responsibility in cartying out treatment, e.g. a fixed rather than a remov
able appliance is preferable.
Attempt to elicit the patient’s feelings of self worth.
If facial protrusion is the problem, how does it af
fect the child’s self evaluation? Do the children in
school call the child by funny names that relate to
the appearance? Does the family focus, inadvert
ently, on one or more of the child’s facial features?
Age:
Chronological age recorded, certain treatment
changes occur at certain ages that are normal for
that age, thus knowing the age helps identify and
anticipate this condition. Growth modification pro
cedures using functional and orthopedic appliances
are carried out during the growth period. Surgical
procedures are carried out after growth cessation.
Sex:
Growth spurts are different in males and females.
Females usually precede males in the onset of growth
spurts at puberty and termination of growth.
Prenatal history:
Information on condition of the mother during preg
nancy (drugs like thalidomide and German mea
sles can result in congenital deformities of the child).
Information on the type of delivery (forceps deliv
ery predispose to TMJ injuries which can manifest
as marked mandibular growth retardation).
Family history:
Skeletal class II/III malocclusions are inherited.
II. STRUCTURAL ASSESSMENT
£
Extra oral examination:
A. General health, body type, and posture
1. Physical growth status:
It is important to judge the general physical
development in relation to the amount of
growth that has occurred and the potential of
future growth that remains. This is achieved
by recording height and weight of the child.
2. Body type
Ectomorphic, mesomorphic and endomorphic
have certain implications regarding somatic
growth and development.
B. Facial features:
1. Facial type (mesofacial, brachyfacial and
dolicofacial).
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
. Shape of the head (dolicocephalic, mesocephalic
and brachycephalic) (Fig. 9.1)
Profile analysis (anteroposterior and vertical re
lationship) (Fig. 9.2)
a) protruded/retruded mandible
b) prbtfudedfretruded maxilla
c) relationship of maxilla and mandible to cra
nial structures.
Lip posture at rest (colour size, mentolabial sul
cus) (Fig. 9.3)
. Relative symmetry of facial structures
(Fig. 9.4a, b, c)
a) size and shape of nose
b) chin button size and contour
ntra Oral Examination:
) Jaw relationship
- Ant-post relationship (overjet) (Fig. 9.5)
- Vertical relationship (ovefbite) (Fig. 9.6)
- Lateral relationship (crossbite)
- Position of the upper and lower lips with re
spect to maxillary and mandibular incisors
during mastication, deglutition, respiration
and speech.
- Tongue position and pressures exerted dur
ing functional movements.
III. FUNCTIONAL ASSESSMENT
Respiration
Mouth breathing or interference with nasal respi
ration have important effects on craniofacial growth.
Methods of examination
1. Study the patient’s breathing unobserved. Nasal
- breathers usually show the lips touching lightly
during relaxed breathing, whereas mouth breathers keep the lips apart.
2. Ask the patient to close the lips and take a deep
breath through the nose:
Nasal breathers normally demonstrate a good re
flex control of alar muscles and control the size
and shape of the external nares, they dilate the
externalnares on inspiration. MoutfibreaffiSST'
even though they are capable of breathing
through the nose, A) not change the size and
shape of the external nares and occasionally even
contract the nasal orifices during inspiration.
) Open mouth examination of the teeth
- Number of teeth present and absent
- Identification of teeth present
- Record any abnormality of size, shape/position
- Restorative status
- Tooth to bone ratio
- Oral hygiene
- Centric occlusion, molar and canine relation
ship
3. Mirror test: A double sided mirror is held be_ - tween the nose and the mouth. Fogging on the
- Overjet and over bite
nasal side of the mirror indicates nasal breath
- Midline
ing while fogging towards the oral side indicates
) Soft tissue appraisal
mouth breathing.
- Gingiva (color, texture, hypertrophy)
- Labial frenum, upper and lower
Cotton test: (Butterfly test): A butterfly shaped
- Tongue size, shape, posture
piece of cotton is placed over the upper lip be
low the nostrils. If the cotton flutters down it
- Palate, tonsils, adenoids
indicates nasal breathing. This test can be u^ed
- Vestibular mucosa
-• Lip morphology, color, texture, and charac
to detect an unilateral nasal blocking.
ter of tissue, hypotonic, flaccid, hypertonic,
.J. Water test: The patient is asked to fill his mouth
functionless, redundant, short, long etc).
with water and retain it for a period of time.
- Clicking, crepitus or popping of TMJ
While nasal breathers accomplish this with ease,
- Excessive mobility of individual teeth
mouth breathers find the task difficult
TEXTBOOK OF PEDODONTICS
A. Mesocephalic
B. Brachycephalic
C. Dolicocephalic
Fig. 9.1 Shape of Head.
A convex profile indicates
cl. II malocclusion usually
from a mandible that is placed
too far posteriorly.
A Straight
profile (Normal
profile)
Fig. 9.2 Facial profiles
A concave profile indicates
cl. Ill malocclusion which may
be due to the maxilla too far
back or the mandible too
forward.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Competent lips
Incompetent lips
Assessment of mentolabial sulcus
Normal - No contraction of muscle
Hyperactive - Puckering of chin
Assessment of nasolabial angle
Normal angle - 110°
Prognathic maxilla - < 110°
Retrognathic maxilla - > 110°
Fig. 9.3
A. Symmetric face
B. Asymmetric face
Fig. 9.4a Symmetry of face
J
{SO) | TEXTBOOK OF PEDODONTICS
Natural head position while facingthe examiner
Intercanthal distance is about
equal to alar nasal base width
Thirds of the face are roughly
equal in vertical dimension
Mouth is as wide as the distance
from right to left medial limbus
Fig. 9.4b Normal facial proportions.
A. Upper apical zone
B. Upper coronal zone
C. Lower apical zone
D. Lower coronal zone
Fig. 9.4c Relationship of facial zones.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT
Fig. 9.5 Assessment of anterior posterior jaw relationship with ‘A’ and ‘B’ points
Normal - The hand is at an even level
Prognathism - The middle finger is ahead of index finger, hand points downward
Retrognathism - Index finger is ahead with hand pointing upward
Fig. 9.6 Assessment of the vertical facial height with the angle formed between
lower border of mandible and the Frankfort horizontal plane
I TEXTBOOK OF PEDODONTICS
Differential Diagnosis
1. Nasal breathers: lips touch lightly at rest, nares
dilate on command inspiration.
2. Mouth breathers: Lips are parted at rest, nares
maintain size/contact on command inspiration
with the lips held together.
Speech difficulties indicating dental problems
(Bell 1980) are given in Table 9.2 .
Differential diagnosis of swallowing types are
illustrated in Table 9.3
Occlusal interference.
In various positions (centric or eccentric), there may "
be occlusal interferences, leading to a deviated path
of closure and consequently forcing an imbalance
of musculature. This may in turn have a potential
for affecting future growth and imbalance in cranio-
Table 9.2: Speech difficulties indicating dental problems
Dental problems
Speech Sound
Type
Zs/ZzZ
Sibilant
ZtZ ZdZ
Lir
ZfZ ZvZ
Linguodental
ZthZ ZchZ ZshZ
voiced or
voiceless
Linguodental
fricative
Distortion related to severe openbite, missing
incisors.
ZIZ
Linguo
alveolar
continuant
Distortion related to tongue tie.
jo
Lisp related to large gap between
incisors or missing incisors, openbite.
Difference in production related to alveolar
stop irregular incisors (especially lingual
• position of max incisors or supernumerary
teeth; tongue tie).
Distortion related to excessive protrusion of
mandible fricative.
£
Table 9.3: Differential diagnosis of swallowing types
Swallowing
Tongue thrusting
Signs and symptoms
infantile
Mature
Simple
Complex
Retained
infantile
swallowing
Tongue between teeth
Endogenous
Mandibular stabilization
by facial contractions
Teeth-together swallow
Lip and mentalis
contractions
Enlarged tonsils and
adenoids or history of
low gag reflex threshold
Yes
Yes
No
No
Yes
No
Yes
No
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Ño
No
Yes
No
Yes
No
Yes
Yes
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT I G&
facial skeleton as well as distorting the form of al
veolar arches. For example, pseudo class III due to
functional disturbance in occlusion, bilateral cross
bite appearing as unilateral cross bite due to func
tional adaptation. These problems may also have an
impact on TMJ growth and normal function.
Recent methods of orthodontic evaluation:
1) RMO’S Jiffy orthodontic evaluation
2) PorDios (purpose on request digitizer Input-Out
put system) is an IBM compatible system.
3) Dentofacial planner
4) Quick ceph image
5) Digigraph (synthesis of wider imaging, comp
tech, and 3 D sonic digitizing).
POTENTIAL PROBLEMS OF INCIPIENT
MALOCCLUSION
In the present era, dentistry is prevention oriented
and the child in the first year of life is a most desir
able patient to recognize the potential problems of
incipient malocclusion. Following details may be
able to elicit some of the anticipated incipient
malocclusions.
I. Predentate period:
a) Types of delivery: It is observed that the method
of delivery at the time of birth is of serious con
cern for a dentist.
■ A high incidence of crossbite is seen in a
group of children who were bom with for
ceps delivery.
■ An increased asymmetric molar occlusion was
observed with traumatic breach delivery.
■ A tendency for abnormal dental arch dimen
sion, larger height of the maxilla and greater
length of the mandibular arch was observed
to occur as a result of forceps delivery.
■ Fewer bilaterally stable occlusions, corre
sponding more asymmetric molar and canine
occlusions and a tendency for the asymmet
ric occlusion were found in the difficult
forceps deli ven’ group. The children also had
a tendency for a narrower shape of arch, sug
gesting early constructive forces.
b) Preterm birth (Gestational age under 37
weeks):
Prematurely bom infants are subjected to a vari
ety of metabolic stresses and exhibit a higher
prevalence of oral dental disturbances than nor
mal full term infants. These developing prob
lems can be prevented if timely care is provided
to the infant
Following may be considered as an index to de
veloping probable malocclusion problems.
Palatal grooves and cleft formation:
■ A prolonged orotracheal intubation of infants
is seen to be associated with airway damage,
palatal groove formation, defective primary
incisors and an acquired cleft palate.
Primary incisor defects
■ Intubated infants exhibit a fourfold increase
in primary incisor defects, which occur in ap
proximately 85% cases. Nearly 2/3Td of tire
maxillary incisors affected are located to the
left of the midline, corresponding to the
greater prevalence of right handed intubation
technique.
Alveolar ridge groove formation
Greenberg and Nowak (1984) reported 47.6%
incidence of palatal/alveolar ridge groove for
mation with orotracheal intubation in preterm
infants for a period of 1 to 62 days. Incidence of
palatal groove formation increased to 87.5% in
infants who were intubated 15 days or more. This
palatal grooving can be prevented with the use
of an intraoral derice that prevents tire endo tra
cheal tube from directly pressing on the palate.
Delayed eruption of primary teeth:
Fadavi (1992) noticed delayed eruption in pre
mature infants.
Viscardi (1994) found that first primary teeth
erupts at the usual chronologic age in healthy
premature infants, but eruption may be delayed
in premature infants who require a prolonged f
y
' -'S'-
tfcYZI | TEXTBOOK OF PEDODONTICS
mechanical ventilation for neonatal illness/or
who experience inadequate nutrition.
c) Neonatal jaw relationship
Although upper and lower gum pads touch
throughout much of tire arch circumference, in
no way is a precise bite or jaw relationship yet
seen. Generally, the forward relationship of the
maxillary gumpad seen at birth gets corrected
itself with the growth of mandible. But, an an
terior open bite associated with it may not be a
transient relationship. It is seen that 2% of all
neonates have an anterior openbite relationship.
The oral habit also has a definite influence on
the infant’s gumpads, resulting in a significant
increase in the incidence of anterior openbite re
lationship by the age of 4 months. Sometimes, it
may remain with the tongue thrust habit at a
later stage also.
d) Infantile swallowing
During the normal infantile swallow the tongue
lies between the gumpads and the mandible is
stabilized by an obvious contraction of the fa
cial muscles. The buccinator muscles is particu
larly strong in infantile swallow as it is during
nursing. The normal infantile swallow is seen
in the neonate and gradually disappears with the
eruption of the incisors in the primary dentition.
It, therefore, is less often seen in the dental ex
amination of children. The cessation of the in
fantile swallowing and the appearance of the ma
ture swallowing pattern is not a simple on and
off phenomenon. Sometimes, they are an inter
mix of primary dentition and mixed dentition
swallowing pattern is as transitional swallow
causing an open bite. Therefore, this transition
of swallowing should be observed carefully.
e) Retained infantile swallowing
This is seen due to persistent presence of this
swallowing reflex even after the arrival of per
manent teeth. There is a demonstration of very
strong contraction of the lips and facial muscu
lature. One thrusts the tongue strongly between
the teeth in front and on both sides, particularly
noticeable are the contractions of the buccinator
muscle. Such patients may have the following in
dications to developing incipient mal-occlusion.
■ Inexpressive faces, since the 7th cranial nerve
muscles are not being used for the delicate
purpose of facial expression but rather for the
ma ssive effort of stabilizing the mandible dur
ing the swallow7.
■ Serious difficulties in mastication, for ordi
narily they occlude only on one molar in each
quadrant.
■ Their gag threshold is typically low.
■ These children may restrict to themselves to
a soft diet and frankly stating they do not en
joy eating.
■ Mastication often occurs between the tongue
tip and palate because of the inadequacy of
occlusal contact.
f) Inadequate breast feeding
It is observed that in children whose mothers
have introduced an early weaning and w7ho had
vety short breast feeding, a low impact muscu
lar activity interfered with the normal develop
ment of alveolar ridges, hard palate and hence
lead to posterior cross bite in primaiy dentition.
Karjalainen (1999) has also suggested that early
introduction of bottle feeding is an indication of
low muscular activity which may result into de
veloping malocclusion problems.
Therefore, early diagnosis of such potential prob
lems may be of great help to the dental practi
tioner to guide the child and intervene to break
the habit. Sometimes, a prognosis for condition
ing of such a primitive reflex is very poor. It may
be associated with skeletal craniofacial develop
mental syndromes and/or neural deficits for
w hich dentist may be the first to recognize the
problem to refer the case timely.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
II. Deciduous dentition
The main value of observing children during the
deciduous dentition is to prevent and intercept
malocclusion.
Crowding or overlapped teeth in the primary denti
tion may occur, although it is rare. True crowding
in the primary dentition almost always guarantees
a crowded permanent dentition.
Serial examinations, cephalograms, lateral jaw and
intra oral radiographs and casts must be taken in
order to record dentofacial maturation progress.
Diagnostic records should be obtained at the fol
lowing intervals:
1. Before the permanent mandibular incisors be
gin to erupt (age 5).
2. After the permanent maxillary incisors begin to
erupt (age 6.5).
3. After the permanent maxillary lateral incisors
begin to erupt (age 7.5 to 8).
Dental arches
A child’s primary dentition without spacing results
in crowding of the permanent dentition in almost
40% cases. Therefore, spacing is desirable in the
primary dentition (Fig. 9.7).
Spacing in
deciduous dentition
Chances of crowding
in permanent dentition
Crowding
No spaces
Below 3 mm total
spacing
3-6 mm
Over 6 mm
10 in 10
7 In 10
5 in 10
2 in 10
None
(Leighton 1971)
Crowding of isolated teeth, however, is sometimes
indicative of a sucking habit. Lower anterior teeth
can be tipped lingually into a crowded position as a
result of constant pressure from a finger.
Transverse relationship
One should look out for any midline discrepancies
and posterior plane. A large midline discrepancy is
unusual in the early primary dentition, and one
should be suspicious of a mandibular shift, which is
often indicative of a posterior crossbite.
It is important to check that the mandible is in
centric relationship because a bilateral cr
ite
will appear to be unilateral, if the mandible drifts
laterally into maximum intercuspation. Thechild
shifts the jaw because the teeth do not fit well
together and the bite is uncomfortable.
«
A true unilateral crossbite that is due to unilat
eral maxillary constriction in the primary denti
tion is rare but can occur.
■
Maxillary constriction in primary dentition may
be due to an active thumb sucking habit, although
there are many cases in which the origin of the
crossbite is undetermined. In a small number of
cases, the mandibular shift is due to an interfer-
Fig. 9.7 Mild crowding in the lower anteriors
Although the presence of primate and developmen
tal spacing does not ensure that the permanent den
tition will erupt without crowding, these spaces usu
ally alleviate some crowding.
GEt I TEXTBOOK OF PEDODONTICS
ence caused by the primary canines (selective
removal of enamel in both arches eliminates the
interference and the lateral shift into crossbite).
«
Anterior crossbite may occur due to over retained
primaiy teeth.
u
A crossbite in the primary dentition usually will
be present in the perma nent dentition, and if cor
rected in primaiy dentition it may not reappear
in the permanent dentition. Untreated functional
posterior crossbite gradually brings about a com
pensatory structural change of the mandible and
sometimes of the condyle.
Vertical dimension
Overbite: is approximately 2 mm in the primaiy
dentition. Anterior openbite is usually indicative of
a sucking habit in this age group.
If the patient and the parent deny the existence of a
sucking habit, further investigation into the cause
of the open bite is needed. Skeletal malocclusion
condylar fracture, and degenerative diseases such
as juvenile rheumatoid arthritis may account for the
openbite and should be investigated.
Overjet: Excessive overjet in the primary dentition
is usually due to a non-nutritive sucking habit or to
a skeletal mismatch between upper and lower jaws.
■
If the patient’s eruption pattern deviates from
the normal sequence and there are differences
between the contralateral sides of the mouth, fur
ther investigation is warranted to determine
whether the teeth are missing or are impeded
from erupting.
■
If a tooth is missing (often maxillaiy lateral in
cisors) or prevented from erupting, it could be
an indication of the development of an incipient
malocclusion.
■
A missing primary molar could lead to discrep
ancies in arch length at a later date (i.e, during
eruption of the permanent 1st molar). Similarly
with an impacted primary tooth.
Habits:
Thumb and finger sucking, pacifier habits, lip hab
its, tongue thrust, mouthbreathing, nail biting, bruxism and self-mutilation are some habits that can be
seen during the primaiy dentition period.
Thumb sucking (4 to 6 hrs/day) pan cause
• anterior openbite
■ facial movement of the upper incisor and lin
gual movement of the lower incisors.
■ maxillary constriction.
Changes that occur during the primaiy dentition
are okay so long as the habit extinguishes itself prior
to eruption of the permanent teeth.
Delay of eruption
■
Children with delayed dental eruption may ei
ther have a veiy slow but normal sequence of
eruption or some isolated eruption problem.
«
To distinguish the eruption sequence of the child,
it is compared with the normal sequence of erup
tion and the eruption pattern on the right side is
compared with that on the left.
«
If the sequence seems appropriate, dental devel
opment is slow (probably).
Primary dentition terminus
By 3 years of age the occlusion of the 20 primary
teeth is usually established and the relationship of
the distal terminal planes of the second primaiy mo
lar teeth is represented by one of the three planes,
straight flush terminal plane, mesial and distal step.
These primary molar relationships again can give
us an insight into the future permanent molar rela
tionships and whether any malocclusion will de
velop or not.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Table 9.4: Second primary molars relationship indicative of
developing occlusion
Primary terminal plane
49% mesial step
37% flush terminal
14% distal step
Initial permanent
1st molar occlusion
1% class III
27% class I
49% end on
23% class II
Second primary molars relationship indicative of
developing occlusion (Table 9.4)
Second molar relationship in non spaced decidu
ous dentition
Mesial step: When the distal surface of the man
dibular second molar is mesial to that of the maxil
lary second molar it may develop to class III molar
relationship in permanent dentition which depends
on:
Magnitude of Leeway space
Magnitude of Mesial step
Differential growth of jaw-s
Distal step: When the distal surface of mandibular
second molar is distal to that of maxillary second
molar, a class II molar relationship is attained by
the permanent molars. This relationship will not
be able to get changed even with the utilization of
Leeway space or differential growth of mandible.
Molar relationship in non-spaced mandibular and
spaced maxillary deciduous arch
■ A poor combination which is accompanied by a
distal step in primary1 dentition leading to distoocclusion immediately after the eruption of per
manent first molar.
■ If the flush terminal plane exists, but maxillary
first permanent molar erupts prior to the first
permanent mandibular molar, it w ill close the
spaces in maxillary arch and develop into distoocclusion.
Changes of developing malocclusion
« The likelihood of developing a class I perma
nent dentition relationship is greatest when a
Final occlusion
3% class III
59% class I
39% class II
mild mesial step terminus exists during the pri
mary dentition stage.
• Chances are very good but less predictable that
a class I will develop from a flush terminal plane.
■ The opportunity for a class I developing from a
distal step terminus is virtually non existent
Impacted primary teeth
Prolonged impaction of primary incisors is unusual.
In history of trauma they may be present but usu
ally reerupt again and do not remain impacted.
These impacted teeth can cause a delay in the erup
tion of the permanent tooth.
Congenital absence of primary teeth:
Hypodontia of primary teeth (incisors), is usually
associated with agenesis of the corresponding per
manent incisor in children w'hen early extraction
or tooth avulsion takes place.
The likely rationale fortheir observation is that the
successional tooth buds of permanent incisors develop just lingual to the buds of their primaiy pred
ecessor and therefore it is very likely to be impaired
by an abortive development of the primary incisor
tooth bud.
Infected Primarv teeth:
The close association of an infected apex to an
unerupted tooth may cause the unerupted perma
nent tooth to become ankylosed. The process fol
lows the irritation of the follicular/periodontal tis
sue resulting from chronic infection. In the
unerupted tooth, enamel is protected by enamel epi-
€H3 I TEXTBOOK OF PEDODONTICS
thelium. The enamel epithelium may disintegrate
as a result of infection (or trauma), the enamel may
subsequently be resorbed, and bone or coronal ccmentum may be deposited in its place. The result is
a solid fixation of the tooth in its uncrupted posi
tion. Malocclusion can be initiated by the child w hen
he favours one side of his jaw to avoid chewing on
carious teeth.
Retained primary teeth: (Fig. 9.8a, b)
Retained mandibular incisors cause permanent lat
eral incisors to erupt lingually. Retained maxillary
Fig. 9.8a Lingually erupting mandibular central
incisors due to retained primary teeth.
incisors cause permanent lateral incisors to erupt
in crossbite. At the time of eruption of permanent
incisors, if the primary teeth show no sign of exfo
liation (check on a xray) and then extract to pre
vent development of a malocclusion. u ..
Maxillary primaiy canine can cause labial/lingual
eruption or impaction of permanent canine.
Ankylosis of primary teeth
■ Primaiy teeth, particularly molars, may become
ankylosed (fused) to the alveolar process and
their eruption is prevented. Primary teeth are
more likely to get ankylosed in the lower arch
twice as often as the upper one.
• Ankylosis can lead to malocclusion because
when it occurs late in the resorption of the pri
mary roots, even then it can interfere with the
eruption of the underlying permanent tooth.
■ Henderson (1979) pointed out that ankylosis
should be considered as an interruption in the
rhythm of eruption.
■ Nagan (1990) suggested that ankylosed tooth that
has failed to erupt or is submerged well below
the occlusal plane of the adjacent tooth should
be extracted and be replaced with a suitable space
maintainer as it may cause supra eruption of the
opposing tooth and space loss by tipping of the
adjacent teeth.
Loss of primary tooth
If the primary tooth is lost and the crown of its suc
cessor tooth is completed (Nolla’s stage 6) and root
formation has begun, then the permanent succes
sors will be accelerated in its eruption. On the other
hand if the crown of a successor tooth is not com
pleted at the time of loss of the primary tooth, the
eruption of the permanent tooth will be delayed be
yond its normal eruption time. Therefore, antici
pated problem and their management should be as
sessed accordingly.
1
Fig. 9.8b Properly aligned permanent cenuat
incisor after primary teeth extraction and
proximal stripping.
Premature loss of primary teeth
Primary teeth act as space maintainers for the per
manent teeth. Proper timing of the exchange of
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
primary with permanent teeth is an important fac
tor in tire proper disposition of the permanent teeth
in the dental arch. The effects of an early loss of a
primary:^qqth-may be as follows:
- “ Shorteningof arch length.
- Tipping of the adjacent permanent teeth
- Supraeruption of the opposite tooth
Factors influencing mesial/distal drift:
Degree of crowding
- It is directly related to the rate and extent of drift.
- In an uncrowded arch there may be little or no
movement of teeth but in a crowded arch adja
cent teeth quickly move into the spaces provided
by the extraction of teeth.
Tooth extracted
■ Loss of 2nd primary7 molar allows mesial drift
of the 1st permanent molars, especially if it is
unerupted; however a center line shift occurs
only in very7 crowded arches.
■ In contrast, extraction of a primary7 canine, al
lows permanent incisors to drift distally, but me
sial drift of teeth is minimal.
■ Extraction of a primary 1st molar allows some
mesial and distal drift to occur.
■ Relative amount of mesial and distal drift of teeth
is expected following extraction of a primary tooth.
Primary tooth
extracted
2nd molar
1st molar
Canine
Age of patient
The earlier a primary tooth is extracted, the greater
the opportunity7 for drifting of teeth, but overeruption
of opposing teeth may limit movement.
If a primary molar is extracted before eruption of
the permanent 1st molar, mesial drift of the latter is
inevitable, even in arches that are not crowded.
Important considerations
Therefore, the extraction of a primary tooth can have
profound effects on the developing permanent den
tition. A tooth should never be extracted before first
assessing its likely effects and then plan treatment
to prevent or eliminate those effects.
Since an important factor that determines drifting
of teeth is the degree of crowding in the arch, it is
essential to assess this before appropriate treatment
can be planned.
Gingival conditions
The gingival conditions should also be considered
from the point of view of a developing malocclusion.
■ Generalized prepubertal periodontitis: In the pri
mary teeth prepubertal gingivitis may show root
resorption with clefting and inflammation ofthe
gingiva, rapid destruction of the alveolar bone
and a premature loss of the primary teeth that
may affect the eruption and drifting of perma
nent teeth and lead to a malocclusion.
■ Children with hypophosphatasia may show pre
mature exfoliation of their primary teeth (due to
failure of anchorage of periodontal fibers) which
may affect alignment of the permanent teeth
which are known to be normal on eruption,
■ Loss of attachment with breakdown of alveolar
bone, exposure of root, tooth mobility and pre
mature tooth loss may occur in dentin dyspla
sia, juvenile periodontitis, papillon leferve syn
drome, leukemia, neutropenia, scurvy, diabetes,
hypophosphatasia, mercury toxicity and radia
tion.
Supernumerary teeth
Counting of teeth will reveal the presence of super
numerary teeth. Approximately, 0.3% of children
have extra teeth in the primary dentition.
Functional relationships and TMJ
There is a possible or potential functional element
in every7 malocclusion. The patients usual occhisal
position may be due to occlusal interferences in the
Î TEXTBOOK OF PEDODONTICS
««deviated path of closure. Any interference may
prompt a reflex shifting of mandible during closure
to an occlusal position dictated by cusps and forc
ing an imbalance of musculature.
Such
malocclusions may be termed as functional
malocclusions.
They arc important because of their potential for
affecting future growth and imbalance in craniofa
cial skeleton as well as distorting the form of the
alveolar arches.
Ectopic eruption:
The situation where the erupting permanent tooth
causes resorption of primary tooth due to improper
direction of eruption can be termed as ectopic erup
tion. This condition is more commonly seen during
the eruption of the upper first permanent molar
wherein the deciduous second molar roots are
resorbed. The other region where this may be ob
served is the mandibular anterior teeth.
Self-Assessment
1. What does the word incipient indicate?
2. What is the rationale of incipient malocclusion?
3. Name some of the incipient malocclusion con
ditions?
4. What is ectopic eruption and how does it lead to
the malocclusion problem?
5. What are the important steps in early diagnosis
of incipient malocclusion problems?
6. What is retained infantile swallow and what will
happen if it is not checked on time?
7. What arc the different facial forms?
8. List out the various anomalies in predentate, pri
mary dentition and mixed dentition?
9.2 Orthodontie Prevention
Shetty N., Tandon S
Introduction
In the quest for providing optimal dental care, the
age-old maxim of ‘prevention is better than cure’
holds true. In this endeavor the Pedodontist is most
evenly poised to carry the mantle of providing the
required services.
■
B. Interceptive orthodontics
■
The American Association of Orthodontists
(1969) defined interceptive orthodontics as that
phase of science and art of orthodontics employed
to recognize and eliminate the potential irregu
larities and malpositions in the developing
dentofacial complex.
■
Profitt and Ackerman [1980] have defined it as
the elimination of existing interferences with the
key factors involved in development of denti
tion.
For the preventive approach to be truly effective it
needs to apply at its earliest i.e. at the primary pre
vention level. However this may not always be pos
sible and the treatment provided early in the progress
of the problem may also limit the damage caused or
sometimes even revert ft back to normal.
Thus the key difference between ‘Prevention’ and
Interception’ lies primarily in the matter of tim
ing. This chapter presents a brief preview as to the
modalities of treatment for the clinician, which can
go a long way in preventing the development of
malocclusions or at least minimizing them.
Definitions
We prefer to define preventive orthodontics as a
comprehensive monitoring of the developing
dentition in a child and applying suitable meas
ures to guide it to normal occlusion.
■ Our clinical experience defines Interceptive or
thodontics as an early intervention in the devel
oping dentition to minimize the developing
malocclusion or eliminate the potential factors
interfering with normal occlusion.
A, Preventive orthodontics
■
Graber [ 1966] has defined preventive orthodon
tics as the action taken to p? ¿serve theintegrity7
of what appears to be normal occlusion at a spe• cifictime’?)
■
Profitt and Ackerman [1980] have defined it as
prevention of potential interference with occlu
sal development.
"'Importance of deciduous dentition
No other factor plays a more significant role in
preventive and interceptive orthodontics than the
preservation of the deciduous dentition till its
normal time of exfoliation. The deciduous teeth
provide a ‘mold’ for the proper growth of jaws,
so that the permanent teeth may have an adequate
space for aligning themselves.
l-TEXTBOOK OF PEDODONTICS
Premature loss of a deciduous tooth or a group
of teeth may lead to the following wide range of
implications .
•
Space loss: The premature loss of the deciduous
tooth will lead to the imbalance of forces main
taining the tooth in the mouth, leading to an un
controlled force causing space loss. Also, the
guidance of the first permanent molar is a prime
consideration, for the deciduous dentition.
•
Speech: Specially, primary7 anterior teeth have
a role to play in the development of speech ar
ticulation in children. Premature loss may lead
to abnormal tongue position as well.
•
Esthetics: A child may feel ashamed to smile
or laugh with his peers because of embarrass
ment.
«
Psychological effect: The child may sometimes
have a more withdrawn attitude due to the
anaesthetic appearance.
» -Mastication: It may lead to loss of masticatory
efficiency and hence improper assimilation of
food. Thus general health gets affected.
_Growth stimulation: for the development of
dentofacial structures will be absent.
Rao (1998) has stated premature tooth loss may lead
to certain specific effects such as: Changes in dental arch length and occlusion
, ■ Misarticulation of consonants in speech
Development of oral habits
■ Psychological trauma.
A Pedodontist frequently comes across such cases,
assesses its effect and thus has a profound effect on
the future dental and may be psychological status
of an individual.
Preventive measures to be considered
(Role of Pedodontist)
A pedodontist is often the first person to encounter
the above mentioned effects of premature loss of
deciduous teeth. Thus it is essential on the part of
the pedodontist to take early measures in prevent
ing the profound effects on future developing den
tition, psychology and personality of the child. The
following tiniety measures should be instituted.
A. Parent education:
~"Pedodontists are largely responsible for the pre
vention in orthodontics. They first see the child
patient. This provides the best opportunity to
educate the parents to the realization that de
ciduous teeth are fully as important as the per
manent ones, arid insomeTSpect^^xiT rriore
so. An investment in their early care will be of
immediate benefit to the child as well as be of
priceless value later.
In this age where the opportunity exists to start
care for the child even before birth, the role of
antenatal diagnosis and education cannot be de
nied.
£
Genetic counselling involves the determination
of the risk of an individual acquiring a particu
lar disease existing in the family tree and advis
ing the parents as the potential problems that
may arise. For example, the growth of the jaws,
the mandible in particular, has been seen to fol
low a genetic trend.
B. Caries control:
Dental caries of the deciduous teeth, when ne
glected or when not given proper dental care is'
the principal cause of malocclusion of the per
manent dentition. Thus, all measures that play
a role in cariesprevention and treatment play a
major, albeit indirect, role in preventive ortho
dontics.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
L^Tri this context Nutritional_jand_ Diet
Counselling, Fluoride applications and water
fluoridation, pit and fissure sealants play an
important role. Tertiary preventive measures
such as the pulpectomy procedures also in their
own way manage to maintain the tooth in the
arch for the required time and prevent space
loss.
C. Maintenance oftootitshedding time table
A difference of more than 3 months in shedding
and eruption in one quadrant, compared to oth
ers, should be viewed with suspicion and inves
tigated thoroughly.
D. Maintenance of dental arch integrity
Preventive orthodontics to a large extent is re
sponsible for the maintenance of arch integrity,
most commonly following the premature loss of
a deciduous tooth.
E. Other measures
Many other factors like care of the deciduous
teeth, maintenance of occlusal equilibration if
there is any functional reason, extraction of su
pernumerary tooth, ankylosed tooth, monitoring
of incipient malocclusion are important part of
preventive orthodontics in Pediatric dental prac
tice apart from space management.
SPACE LOSS
In the arch, every tooth is like a unit, which is main
tained in place by a host of factors and also it, in
turn, maintains the arch integrity. Should there be
any imbalance of the forces acting on the tooth, the
opposing unrestricted force causes a movement of
tooth/teeth.
E.g.: a) In cases where proximal contact is lost due
to caries or even loss of a tooth as a whole, the me
sial component of force (generally) is unbalanced
and may cause mesial drifting, more so during the
eruption of the first permanent molar.
Nature and prevalence ofspace loss
While recording the prevalence of space loss or clo
sure the following observations are recorded by most
of the clinicians.
■ Incidence of premature loss of deciduous
molars
■ Rate of space closure
■ Time of space closure
■ Amount of space closure
■ Direction of space closure.
A. Premature loss of deciduous molars
Majority of reports indicate that frequently the
premature extraction of the deciduous molars
will cause crowding of teeth due to space loss
associated with either rotation, tipping or bod
ily movement. We have also observed that by
the age of 7-8 years, almost 50-60 % children
start showing mutilated occlusion due to the early
loss of primary teeth. The maximum number of
cases were due to caries of deciduous molars. (Ta
ble 9.4a, b).
B. Rate and Time of space closure
■ Unger (1938) proposed that the earlier a tooth
is lost the greater the initia l rate of space loss.
■ Seward (1965) found that a continual rate of
closure 13 mm. per year in the maxilla ex
isted and all individuals demonstrated space
loss. In the mandible, the mean rate of clo
sure was 1.0 mm per year, with individuals
varying widely in the timing of closure.
« Northway (1984) has stated that more space
was lost in the first year following an extrac
tion than in successive years. The rate of space
loss in maxilla is age related. Thus at the age
of 6 years: total space loss is 4.1mm, 7 years:
2.1mm and at an older age, <L5mm. In the
mandible, there was no relation between age
and the amount of space loss. Average loss
was from 2.6 to 3.2 mm in 4 years (Table 9.4c)
I TEXTBOOK OF PEDODONTICS
NATURE AND PREVALENCE OF SPACE LOSS
Table 4a: The percentage of malocclusions due to the premature
extraction of deciduous molars
1
Lyons
1924
65%
2
Brandhorst
1932
20%
3
Willets
1933
28%
4
Tandon
1985
50%
Table 4b: Prevalence of premature loss of deciduous molars
Authors
Age
0/
/0
Year
1
Brandhorst
N.A
37%
1932
2
Pringle
6 yrs
70%
1937
3
Charbeneau
7-8 yrs
35%
1950
4
Foster
4 yrs
11%
1958
5
Simons
N.A
15%
1972
6
Pedersen
8 yrs
50%
1978
7.
Tandon et al
7-8 yrs
48%
1987
Northway (1984)
Table 4c: Unilateral space loss due to premature extraction
MANDIBLE
MAXILLA
D
E
D+E
D
E
D+E
2.3
2.5
2.3
1.4
1.4
1.3
- M
- F
0.1
-
4.2
2.1
•
-
1.9
-
2.7
2.9
-
“Breakspeary (1961)
0.8
2.2
2.0
0.7
1.7
1.3
Ronnerman and
Thilander (1977)
0.5 1.4
3.7 4.5
1.7
6.83.1
2.1
Rao and Sarkar (1999]
1.11
2.05
2.58
0.40
1.23
Liu (1949)
Jarvis (1952)-
-
1.38.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT I
C Amount of space closure
Several studies have found that the maximum
space loss occurred in the maxillary region due
tu the premature loss of the second deciduous
molars.
■ Contrary to the other reports space loss in our
patients was found to be maximum in the man
dible with the total space loss being more than
2.5 mm.
D. Direction of space closure
There has been a generalization of the direction
of space closure.
« Earlier studies have reported that maxillary7
extraction sites close primarily by mesial
movement of posterior teeth, and mandibular
extraction sites by distal migration of ante
rior teeth.
■ Based on Kronfeld’s theory7 that neutral areas
are located between the bicuspids in maxilla
and just mesial to the first molar in mandi
ble, the teeth anterior to the neutral area «re
expected to erupt to the distal, while the distal
teeth migrate forward.
■ North way et al (1984) stated that for both
arches, the greatest space loss occurred as a
result of the molar movement forward towards
mesial.
E. Effect of caries
It has been reported that in both the arches, se
vere caries resuhs in a space loss of about 1mm. In our patients, the Ioss~3ue to caries, was”
observed to be from 1.5 to 2.5mm
INDIVIDUAL TOOTH LOSS
A. Maxillary first primary molar loss:
Though measurements of D+E show not much
arch length loss after premature loss of D /D, in
these cases the incidence of canine (permanent)
being blocked out from the normal alignment is
high.
Sequelae
■ The primary canine shows a distal shift in
the 1st year (if at all)
■ The deciduous second and the permanent first
molars shift mesially depending on age and
duration of absence
■ The first premolar is mesially directed along
the mesial surface of the second molar
■ The permanent canine has no place and is
blocked out of the arch.
B. Maxillary second primary molar loss:
Sequelae
« The molar shifts mesially. It was observed that
if the extractions were performed prior to the
emergence of the first molars, it resulted in a
permanent space loss, more in the upper.than
lower.
■ The second most deleterious period has been
found to be after emergence of the second
molar but before the emergence of the first
bicuspid.
■ The period of emergence of the second molar
is thought to be crucial, as distal to the first
molar a growth centre exists.
■ The cuspid and the first deciduous molar shift
distally.
« The first bicuspid generally erupts first and
erupts into this space distally, sometimes even
causing impaction of the second bicuspid.
C. Maxillary first and second molars loss:
Under these circumstances, a host of factors ex
ist and the outcome depends on the interaction
between them.
D. Mandibular tooth loss
The effect of mandibular extractions tends to be
similar for all the 3 situations i.e - D loss, E loss
and D + E loss
■ The permanent molar tips forward. If D is
lost, the E may tip as well.
Îtfcfcl J TEXTBOOK OF PEDODONTICS
■ The developmental orientation of bicuspid
tooth buds is an important variable and so is
the sequence of eruption.
■ In severe cases again, the second bicuspid has
got a maximum chance of being impacted due
to lack of space.
E. Anterior region
■ Most studies agree that the loss of the ante
rior teeth are rarely associated with any space
loss, especially so when the primary canines
have already erupted.
■ The premature loss of canine on one side of
the arch, in the mandibular region, is associ
ated with the shift of the midline in the same
direction.
«
There is a linguo - distal inclination of the
teeth, causing a collapse of the anteriors lin
gually, apart from closure of the space and
shift of midline, [Barber, 1987].
VARIABLES INFLUENCING SPACE CONTROL
PROGRAMS
———
•
Most growth studies are in general agreement
that once the primary dentition has been estab
lished, the arch length i.e. the measurement from
the distal surface of the second primary molar
around the arch to a similar position on the op
posing side is constant until the permanent den
tition is established. The preservation of the
same in the primary and mixed dentition is of
utmost importance, for it allows the dental units
to 'fit’ into their relative positions. Wright and
Kennedy (1978) have discussed the following key
variables and their importance.
J^-Oral musculaturejind habits (Fig. 9.9)
■ "Maxillary arch - Anterior teeth may be
proclined and thus arch length or perimeter
is increased. Thus clinician should check and
evaluate where the teeth should be as well as
where they are at the initial examination.
■ Mandibular - In case where mandibular cus
pid is extracted, an abnormally strong mentalis musculature may cause distal drifting of
the lateral incisor, shift of midline and a deep
ening of the bite.
2. Timelapsedsinceext faction
The time elapsed since extraction must be con
sidered, as a maximum space lossLwill occur in
the first six months. Thus when a choice exists,
appliances must be placed immediately follow
ing extraction.
3. Dental age, Eruption pattern & Bony covering
Decisions are to be based upon the normsüssôciated with dental age rather than chronological
age.
■ Eruption patterns may also vary and thus may
impede the placement of the appliance as
such. Also, ectopic eruption and root resorp
tion (atypical) may also delay or hasten exfo
liation time.
■ Eruption of the first molar causes a bodily
space loss in maxillary and tipping in man
dibular arch. It is observed that space in man
dibular arch is difficult to regain.
■ In cases where a tooth has been lost due to
infection the overlying bone may not be a good
guideline to follow. In such situations, the
amount of root formation should also be con
sidered (3/4 of root development).
4. Available space .
Though space loss may occur after the tooth has
exfoliated prematurely, it might sometimes be
present before due to interproximal caries. Thus,
the amount of space available and required
should be measured and thus space maintenance
/regaining should be instituted.
5. Interdigitation
Increased cuspal height along with proper in
terdigitation will help to stabilize the occlusion.
Thus, it has been postulated that these factors may
help prevent the space loss.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
2
Lip
force
force
6.6 g/cm2
10.0 g/cm2
(Large variability)
buccinator
11.6 g/cm2
Fig. 9.9 Balance of forces
6. Anomalies^
These may hamper the eruption of the teeth such
as the supernumerary tooth and thus it is essen
tial that a complete radiographic survey be done
before the selection of the appliance.
7. Sequence of eruption
A situationmayansewhere the second decidu
ous molar is lost prematurely and the eruption
of the second molar is taking place. Though
other factors may not warrant space mainte
nance, it may be required for this purpose.
CLINICAL ASSESSMENT FOR SPACE
MANAGEMENT
Clinical assessment can be carried out following the
guidelines laid down recently by the American
Academy of Pediatric Dentistry.
1. Intra-oral examination to:
a. Assess the overall oral health status
b. Determine the status of patient’s occlusion
2. Facial analysis
a. Determine the asymmetric growth patterns
and or lateral deviations of the mandible
b. Determine dental, skeletal growth
c. Dental and skeletal (occlusal) abnormalities.
3. Functional assessment
a. Functional factors
b. Habits
c. Detect TMJ dysfunction
Apart from above guidelines, the following factors
should also be considered before deciding the treat
ment plan such as:
■ Position of incisors. This gives an indication as
to the amount of space actually present.
| TEXTBOOK OF PEDODONTICS
■
«
■
■
Crowding: This would indicate 1 mm minimum
requirement
Depth of curve of Spee: The correction of 1mm depth on either side of the arch yields a 1
mm linear space per side.
Midlines: Shift of the midline may require ad
ditional space.
Leeway space: Whether it is maintained I re
gained depends on the arch - length analysis
done.
Space discrepancy analysis
Any space management measures should be carried
out only after a space discrepancy analysis is done
for which the two factors to be considered are:
1. Space required <
2. Space available
It can either be done by a radiographic method or
on study model or combination of both. Though sev
eral authors have recommended different analysis,
we suggest that at least two of the following be per
formed rather than rely on a single analysis.
A. Arch perimeter or Moyer’s analysis
The perimeter of the arch is measured from the
mesial surface of one permanent molar around
to the mesial surface of the opposite molar. The
arch can be measured in 4 - 6 segments.
« ,Size of unerupted teeth: A special case in*volves computation of the size of unerupted
teeth, either from radiographs or by ratios
based upon correlations between the sizes of
permanent teeth. The Moyers analysis is the
most commonly used mixed dentition analy
sis.
B. Radiographic method:
It requires clear x-ray films of the unerupted teeth
and of the overlying primary æeth. The enlarge
ment ratio for each unerupted permanent tooth
is computed by measuring the nearest erupted
tooth first in the mouth and then in the radio
graph.
■ The equation used is:
Erupted tooth size in the mouth
Erupted tooth size in X-ray -
Unerupted
x tooth size
in X-ray
- Correct tooth size
C. Hixon and Oldfather have suggested a method,
which has been stated to be the most accurate. It
involves the following measurements.
Sum of the maximum mesio - distal diameter of
one permanent central incisor and one lateral
incisor, with the diameter of the unerupted first
and second bicuspids measured on the radio
graph taken by the paralleling technique (using
a 16-inch cone). The following prediction chart
can be used:
Measured value
23mm
24
25
26
27
28
29
30
Estimated tooth size
18.4mm
19.0
19.7
i 20.3
*21.0 ,
21.6
22.3 *
22.9
D. Tanaka and Johnson used the following meas
urement:
■ Half the Mesio-distal width of 4 lower inci
sors +10.5 « Mandibular 3+4+5 in one quad
rant.
■ Half the Mesio-distal width of 4 lower inci
sors + 11.0 = Maxillary 3+4+5 in one quad
rant
SPACE MAINTENANCE AND MANAGEMENT
By tradition and repetition, preventive orthodon
tics is to many people limited to the procedurei
implied by the term space maintenance. Thus it if
important to place in proper perspective tin
terms space maintenance and management.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
■
Space maintenance can be defined as the provisïôïïofaïïappliance (active or passive) which
is concerned only with the control of space loss
without taking into consideration, measures to
supervise the development of dentition.
■
Space management (control) includes measures
that diagnose and prevent/intercept situations,
so as to guide the development of dentition and
occlusion.
SPACE MAINTAINERS
■
Space maintainers can be defined as appliances
used to maintain space or regain minor amounts
of space lost, so as to guide the unerupted tooth
into a proper position in the arch.
Ideal requirements:
The space maintainers used should meet the fol
lowing conditions.
■ Maintain the desired mesiodistal dimension of
the space (intra-arch space maintenance)
. ■ Should not interfere with the vertical eruption
of the adjacent teeth I inter arch space mainte- /
nance]
■ Should not interfere with the eruption of the per
manent teeth
._■« Provide mesiodistal space opening when it is re
quired.
■ Maintain individual functional movement of
teeth.
« Modifiability: Anticipation of future modifica
tions is essential.
« Limitations: Loss of the 1st primary molar be
fore eruption of the second premolar while us
ing the band and loop.
■ Cost: Directly bonded are the best as time is
saved.. As laboratory time increases, labour
charges increases.
CLASSIFICATION OF SPACE MAINTAINERS
>
REMOVABLE
Passive
Active
Functional
Non-functional
------------------- ►
FIXEl)
;
Bonded
Banded
;
■
Passive
Active
1
Functional
Factors governing the selection of appliance:
■ Patientcooperation: With removable appliances,
greater cooperation is required as compared to
the fixed appliances.
■ Appliance integrity: In general all types of ap
pliances suffer breakage. But as per Wright and
Kennedy [1968] the mandibular removable ap
pliance is the most susceptible to breakage and
that the integrity of fixed appliances is better.
■ Maintenance: The length of time and the pro
jected maintenance should be considered.
Wrought partial
Cast partial
Non-functional
Band and loop
Lingual arch
Distal shoe space maintainer
Nance palatal arch
Transpalatal arch
Prefabricated space
maintainer (3D)
Bonded space maintained
^ETt> I TEXTBOOK OF PEDODONTICS
FIXED SPACE MAINTAINER
■
Construction of space maintainer
The fixed space maintainer generally are constituted
of the following components:
a. Band
b. Loqp/archwire
c. Solder joint _
d. Auxiliaries
■
Band: The band forms an important part of the con
struction of the various fixed appliances. Several
bands are employed such as:
1. Loop bands
a. Precious metal (first introduced by Johnson)
b. Chrome alloy bands.
2. Tailored bands
a. Precious metal
b. Chrome alloy.
3. Preformed seamless bands
a. Chrome alloy/precious metal which are
adopted, festooned and stretched to fit.
«
A range of preformed bands from 1-32 depend
ing on the mesiodistal width of the tooth for the
maxillary and mandibular arch are available
commercially.
Band material: Depending on the tooth to be
banded, they can be classified as:
■ Anterior teeth
0.003 by 0.125 by 2 inches
• Bicuspids
0.004 by 0.150 by 2 inches
■ Molar region
0.005 by 0.180 by 2 inches
(deciduous)
• Molar region
0.006 by 0.180 by 2 inches
(permanent)
Technique for band construction
Every band should possess a few ideal criteria such
that ■ It should fit the contours of the tooth as closely
as possible, thereby enhancing the placement of
the attachment in relationship to the tooth.
■
■
■
Should not extend subgingivally any more than
necessaiy
Band material should resist deformation under
stresses in the mouth.
Resist tarnish
Inherent springiness
Cause no occlusal interference
Steps in band formation
A. Separation
B. Band fitting [band pinching]
C. Welding
D. Soldering
A. Separation: Adequate separation of the teeth is
an essential prerequisite for any banding tech
nique.
Methods
■ Brass wire - 0.015 inch - 0.020-inch soft brass
wire. It works well in young patients with
thick periodontal membrane, but can be quite
painful.
■ Elastic threads - These prqyide a gentle force
over a prolonged period and are painless at
the time of insertion.
£
B. Band formation: Various techniques of band for
mation are known. These can be:
a. Direct formation
b. Preformed bands
c. Indirect band technique
Direct formation of the band in the mouth in
volves:
i) Band pinching
■ The band strips are first contoured in an
inciso - gingival or occluso - gingival
direction using the Johnson’s contouring
pliers. The ends of the strip of the band
material are welded and then a loop is
made for the reception of Howlett band
forming pliers. This contoured strip is
located on the tooth in the desired posi
tion (Fig. 9.12, 13, 14)
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Fig. 9.10 Pliers for band pinching and crown adaptation
I TEXTBOOK OF PEDODONTICS
iii) Trimming
This involves reducing on the buccal and lin
gual side if required. This primarily adjusts
the occluso-cervical length of the band.
Fig. 9.11 Band forming pliers - anterior band
forming plier on the left side and posterior
band forming plier on tie right
■
■
■
■
■
The bands should be pinched on the cuspal
area and not on the groove areas. This is
because, it is difficult to adapt a double
thickness of the band in the groove areas.
The upper molar band is usually pulled
from the palatal side, whereas the lower
molar band is pulled from buccal side.
The seam of the upper band will be kept
at the mesioloingual line angle whereas
for the lower, at the mesiobuccal line angle.
The two edges of the seam should be
parallel to each other so that the band rests
uniformly on the tooth surface.
In cases where a sufficient clinical crown
is available, the peak band - forming
pliers may be employed on the teeth.
These are available as right and left.
ii) Festooning
■
This constitutes the countouring of the
band in order to follow the gingival
margin proximally. The level of the band
at the marginal ridge is also adjusted in
the process.
« The distal side may require more trimming
because of the lower position of the
marginal ridge as well as due to the raised
position of the gingiva (especially during
eruption of the distal tooth) (Fig. 9.15)
iv) Folded flap method
■ After the formation of the seam, the
excess is cut off, leaving a small remnant
The band is then returned to the toothand
the small remnant is folded neatly against
the lingual surface of die tooth.
■ This should be done directly on the tooth;
otherwise the band will be made smaller
during the process of folding over the tag.
The folded over remnant is then spot
welded. The band may sometimes require
crimping to produce a rolled retentive edge
to the band.
■ The occlusal margins of a completely
seated band should be slightly below the
proximal ridges (1-mm).
■ Gingival margins should extend 0.5 to
1.0 mm into the gingival sulcus (Owen et
al 1984). A better criterion is to check
clinically for the blanching and relieve the
areas where it is seen.
■ Buccally it should be just below the level
where the opposing cusps touch the
grooves.
■ Lingually, it should be placed just below
the deepest portion of the lingual devel
opmental groove.
A partially indirect technique involves the con
struction of the bands and then taking impres
sions to form the appliance on the cast. Atotally
indirect technique is where the bands are also
constructed on the cast. This is useful as it pro
vides a more efficient and faster method.
C. Welding: Welding is the process during which a
portion of the metal being joined is melted and
flowed together. Bands are generally joined by
welding. Electric spot welding is carried out with
electric current being forced to flow through a
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Fig. 9.12 Welded band material with eyelet
Fig. 9.13 Howlett band forming plier engaging
fie welded band material
Fig. 9.14 Contoured strip placed on tooth
Fig. 9.15 Band showing the festooning
icEEl I TEXTBOOK OF PEDODONTICS
- Where loop is welded to the crown
- Where the band is adapted over the crown and
the loop is soldered to it.
limited area on the materials to be welded. The
resistance of the materials to electric current gen
erates an intense localized heat and brings about
fusion of the two surfaces.
D. Soldering: It is the process by which the two
metals are joined together by an intermediary
metal of a lower fusion temperature. The most
common solder used is the silver solder contain
ing silver, zinc, copper and tin.
Flux is used to increase the flow and prevent
oxidation. The solder is applied to the joint after
which finishing is done with a green stone, while
polishing with a rouge.
I. BAND AND LOOP (Fixed, non functional, pas
sive space maintainer)
Construction
The larger tooth, the second deciduous molar, is used
for anchorage of the appliance. A loop (0.030 inch
to 0.035 inch) is soldered to the band and spans the
edentulous space to contact the abutment tooth be
low the contact point. The loop is contoured to rest
on the tissue on both sides of the ridge, with an
opening in the loop sufficient to permit the erup
tion of the cusps of the underlying permanent tooth.
The loop should contact the mesial abutment at the
contact point (Barbar, 1982). If it is constructed
below it, the chances of it slipping gingivally are
high. (Fig. 9.16).
Modifications
1. The loop can be made only on one side, but it is
less stable (Meyers).
2. Sometimes an occlusal rest is given on the tooth.
This modification is to overcome the disadvan
tage of the appliance slipping gingivally. But this
may hamper the proper eruption of the tooth to
its occlusal plane (Wright and Kennedy, 1978).
3
Crown - loop: Where abutment requires a crown
this appliance may be used. Two techniques can
be used -
4. Reverse i.e. Banding the first primary molar for
guidance. This appliance has been used in cases
where the second molar is lost before the erup
tion of the first permanent molar(Gellin 1990)
5. A cast crown with a tube on the canine and a
cast crown with a bar and post can be cemented
on the molar, such that the post fits the tube.
6. Techniques for constructing a functional vari
ant of space maintainer, either by direct or indi
rect technique have also been described.
II. LINGUAL ARCH SPACE MAINTAINER (Fixed,
nonfunctional,passive mandibular arch appli
ance)
■
They belong to those group of space control ap
pliances which not only contiol anteroposterior
movements but also are capable of controlling
and preventing an arch perimeter distortion, by
controlling the lingual collapse of single tooth
or segments of the arch.
*
■
The lingual arch in essence consists of a round
stainless steel or precious alloy wire, 0.32 to 0.40
inches in diameter closely adapted to the lin
gual surfaces of the teeth and anchored to bands
on the first permanent molars. Rarely, second
deciduous molars may also be used. The means
used to anchor the archwire to the bands will
define whether the lingual arch is of a remov
able or fixed type (Fig. 9.17a, b, c, d).
Removable lingual arch
■ It has precision made vertical posts soldered at
right angles to distal extensions, which fit pre
cision - made tubes on the lingual surfaces of
the molar bands and are held together by means
of lock wire.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT
Fig. 9.16 Space maintained for missing
primary first molars using the crown and loop
on left side, band and loop on the right
Fig. 9.17a Pre-formed lingual arches
Fig. 9.17b Fixed lingual arch space maintainer
with banded first first permanent molars
Fig. 9.17c Lingual arch with ‘U’-loop
Fig. 9.17d Modified lingual arch
I TEXTBOOK OF PEDODONTICS
■
«
More used for active movement when tipping of
the molar is less than 5 degrees as it allows for
an easy removal and adjustment.
Lingual tubes are placed in the center of the lin
gual surfecepftjbiehand anterio-posteriorly and
aligned with the lingual groove, such that they
are parallel to the long axis of the tooth and at
right angles to the occlusal margin.
Modifications of removable lingual arch
a) Auxiliary springs can be incorporated to bring
about minor individual tooth movements.
t>) Loop lingual archwire: used as 2 loops or 1 loop
mesial to the first permanent molar. It is used
for limited tooth movements i.e. either
posteriorly or even buccal movement of the tooth.
c) Lingual Horizontal tube: This is used, as the ver
tical tube on the unaffected side will provide a
greater resistance to its movement than on the
affected side.
d) Ellis loop lingual archwires: These are preformed
arch wires. Along with this, Ellis Vertical lin
gual tubes are used. It has the advantage that it
is time saving. Since it is preformed, possible
fracture points are reduced to a minimum.
Ifixed lingual arch
This is soldered or welded to the band. It is used
mostly where an active tooth movement is not
planned. The addition of canine ‘spurs’ distal to
the deciduous cuspids, is a simple modification that
helps to maintain a anterio-posterior length at both
ends of the arch.
Idngual arch construction
■ The wire should be made to contact the cingula
of the mandibular incisors slightly above the
gingival papillae. The wire should also lie in
the gingival third of the primary molar, while
extending posteriorly to rest passively on and
parallel to the middle third of the molar
bands[Kapala, 1985]
• In case of edentulous ridge, the wire is curved
down to the lingual approximately 1 mm away
from the soft tissue.
The wire should maintain a 3 - 4 mm contact
with the lingual surface of the band to provide
for a long solder joint
■ Konstantinos et al (1998) have suggested that
in the canine region 2 omega bends need to be
given. This is to prevent interference between
the arch wire and the cuspids, which migrate
distally into the primate spaces.
■ In the original design by Hotz, 2-inch adjust
ment loops are given so as to allow for some
adjustment ofthe length. They may also be used
for regaining space.
■
Passivation
The lingual archwire should be completely passive.
This is done by heating the wire to a dull brownish
appearance, while keeping the wire gently in place
on the cingula with an old instrument.
III. DISTAL SHOE SPACE MAINTAINER
(Intra-alveolar, Eruption guidance appliance)
«
The fixed distal shoe space maintainer, was first
reported by Willets (1932). The appliance is con
structed when there is a premature loss of the
second primary molar, prior to the eruption of
the first permanent molar. This wai a cast gold
appliance and soon fell into disfavour due to the
increased cost.
■
The commonly used one is that described by
Roche [1942], a crown or band and bar appli
ance. The major difference between the two ap
pliances in the gingival extension. The Roche
variety had a ‘V’ shaped gingival extension while
the Willets one had a bar type (Fig. 9.18a,b,c,d)
Classification
1. Fixed
i) Functional
Advantage - durable, maintains occlusion, can
be used after removal of extension.
Disadvantage - costly, time consuming, diffi
cult construction and adjustment.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Fig. 9.18b Modified distal shoe
Fig. 9.18c Distal shoe placed intraorally
Fig. 9.18d Radiographic view of distal shoe
Fig. 9.19 Nance space holding applicance to
maintain space for maxillary pre-molars
Fig. 9.20 Trans palatal arch - upper fixed
bilateral space maintainer
I TEXTBOOK OF PEDODONTICS
ii) Non-functional
Advantage - easy fabrication, low cost and
single abutment.
Disadvantage - more breakage chance, less
retentive and new appliance required after
eruption of tooth.
2. Removable
Criteria for appliance fabrication
A. In the lower arch, the contact area of the distal
extension should have a slight lingual position
over the crest of the alveolar ridge. By contrast,
the area of distal extension of the maxillary ap
pliance should be slightly facial. This is impor
tant to prevent rotation of tooth and appliance.
B. Width
If no adequate width is provided, the tooth may
slip. It should be approximately the width of
the contact area.
C. Length of the distal extension:
■ Ideally, measure the second molar before ex
traction and remove the same from model.
« If the second molar is already missing, a rec
ommended practice is to measure on a radio
graph, the distance between distal surface of
first primary molar to the first permanent
molar. This carries the disadvantage of the
appliance being over extended, especially in
the maxillary arch as the molar erupts from a
more distal direction to swing mesially.
• Thus the best way is to measure M- D width
of the second primary molar on opposite side.
D. Depth ofgingival extension
The gingival extension of the appliance should
be constructed to extend 1 mm below the mar
ginal ridge so as to just ‘capture’ the mesial
marginal ridge of the tooth
Special considerations:
a) For the functional type if cast gold appliance is
used, better to use 2 abutments, as it is func
tional. But with space between the canine and
the 1st molar, this may not be possible. Thus a
groove placed in the mesiofacial surface with a
691 bur will aid in developing retention.
b) For non-functional as it is not able to establish
the occlusion, the first molarmay tip over the
plane, at the time of eruption.
IV. NANCE ARCH or NANCE SPACE HOLDING
APPLIANCE (Fixed, nonfunctional, passive,
maxillary arch appliance)
■
Discussing the limitations of the orthodontic
treatment, Nance (1947) described the ‘preven
tive lingual wire’. It consists of bands on the
upper molars, with the arch wire extending for
ward into the vault.
Construction (Fig. 9.19)
■ The acrylic button is present on the slope of the
palate and provides an excellent resistance
against forward movement (U loop). The wire
should extend from the lingual of bands to the
deepest and most anterior point in the middle of
hard palate.
■ ‘U’ bend is given in the wiw for the retention of
the acrylic 1 -2 mm away from the soft tissue.
V. TRANSPALATAL ARCH (TPA)
(Fixed, non-functional, passive appliance)
It is used in the maxillary arch. The arch is sol
dered to both sides, straight, without a button and
without touching the palate. (Fig. 9.20)
■ The basis of the appliance is that the migration
and rotation is caused by rotation around the lin
gual root By preventing this, space loss is pre
vented by the appliance. Also, it is thought that
one molar will provide some stability to it’s an
timere. However, cross arch anchorage can be
used if onty one of the primary molars is lost
and both the permanent molars are erupted.
BONDED SPACE MAINTAINERS
1) These were suggested by Palmer (1979) as they
would be helpful in reducing the time for appli
ance construction.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT | icSEl
- upper right + lower left and
- upper left + lower right
■ A triangular mesh pad is adapted to the me
sial surface of distal abu tment and to the distal
surface of anterior abutment. For additional
retention, the mesh can be contoured to ex
tend onto a small area of the lingual and buc
cal aspects.
■ The space maintainer tube is welded on the
post mesh, while the wire with the correct
length is welded anteriorly.
■ A vacuum molded template is then formed
over the space maintainer. After removal of
the template, the appliance is cleaned and
bonded.
2) A variation was suggested by Artum and
Marstander (1983). They found a round,
multistrand orthodontic wire 0.032 inch diam
eter to be more satisfactory4*7 than an ordinary
round wire. They also used an autopolymerizing
composite resin.
3) A new universal space maintainer has been sug
gested by Athanasios (1984).
It consists of a solid steel foil pad bases and 2
sections
a) Round retainer wire
b) Stainless steel tubing.
Only 2 variations - left and right - are sufficient.
The pads can be used for direct bonding after
the wire length is marked and the excess is cut.
Advantages stated are:
1. Easy, fast and economical to produce
2. No bands or impressions are necessary
3. It can be completed in one appointment
4. Can be used for posterior spaces of any length
5 Possibilities of decalcification and periodon
tal damage is decreased.
6 Can be used on partially erupted teeth and is
esthetic.
4) A 3D instant space maintainer which is patented
by Rocky Mountain has been described by
Wilson and Wilson[1984]. It is pre-fabricated
and available in 2 forms.
■ The .030" truchrome construction is said to
resist distortion. The 3Dpost - tube provides
a secure fit. It also allows to be tightened with
a slight adjustment. The bar position is ad
justed to the first bicuspid just below the con
tact point Features include an instant plug in
and removal, secure lock in, resist deforma
tion, removable for hygiene, can be used for
space regaining, time and cost - saving and
can also be converted to a functional space
maintainer.
5) Modified bonded space maintainer
■ Coican (1992) has presented a case report
where the conventional band and loop was
contraindicated because the first molar was
partially erupted. A removable appliance was
rejected due to lack of retention, short clini
cal crowns and the patient’s age. A second
molar bracket was bonded to the buccal sur
face of the erupting first molar. A full size
rectangular wire segment is used to span the
edentulous space and provide light contact
against the deciduous first molar.
■ Liegeois et al [1999] have also described a
modified bonded space maintainer. Slots and
occlusal shores are prepared on the primary
teeth and a sanitary pontic is placed in the
edentulous area to make it functional. The
alloy used is chrome cobalt.
DISADVANTAGES OF THE FIXED SPACE
MAINTAINERS
Maximum failures are encountered with the
placement of lingual arches.
■ Cement loss and solder failure are found to be
high in all appliances.
■ Tissue lesions are high with the band and loop.
■ Another important disadvantage is the eruption
interference caused by lingual arch in a few cases.
■
Management by fixed space maintainers illus
trated in Table 9.5
Table 9.5: Management by fixed space maintainers
■f
Appliance
Indications
Contraindications
Limitations/Disadvantages
1. Band
and
loop
1. Premature loss of any
primary first molar.
2- Where the unerupted
premolar is more than
2 years from clinical
eruption and root
. length is less than 1/2
Extreme crowding or
space loss
High caries activity
1. Seldom used for space
loss of more than one tooth.
2. Nonfunctional
3. Migration of the loop
gingivaily (semi fixed)
4. Loss of E before eruption
of 4
' \ -*L~
>'
2. Lingual
arch
wires
T. Bilateral loss of posterior 1 .Before the eruption of
1. Loss of cementatibn and
teeth (rarely used in
the mandibular incisors
solder are most commonly
. primary dentition)
(can be modified)
associated with this
2. Minor movement of the
appliance.
anterior teeth.
2. May cause untoward
3. Maintenance of leeway
movement
space.
4. Space regaining
3. Distal
shoe
space
mainta
iner
Early loss or removal of the 1. Inadequate abutments 1. Over extension causes
due to multiple loss
injury to the permanent
second primary molar prior
2. Poor patient/parent
tooth bud i.e., second
to the eruption of the first
premolar.
permanent_molar is the
cooperation
3. Congenitally
2. If under extended, it
prime indication.
missing first molar
may allow the molar to
In the maxillary arch with
tip into the space or over
4. Medical conditions such
bilateral space loss, 2
as blood dyscrasias,
the band.
appliances may be used.
CHD, Rh: fever,
3. Prevents complete epithedi^b^tes or generalized
lialization of the extraction
socket.
?
debilitation
4. Ronnermann and Thiiander
(1979) have discussed the
path of eruption and stated
that the drifting takes palce
only after eruption through
the bony covering. The
lower first molar normally
erupts occlusalward to
contact first the distal crown
surface and uses that butt
ress for uprighting. Isolated
cases should be considered
ectopic eruption.
4. Nance
palatal
arch
1. Bilateral loss of the
deciduous molars.
2. Combined with a habit
breaking appliance
(on the acrylic button)
1. Palatal lesions
2. If either of the molars
has not erupted
1. May cause tissue hyper
plasia and infection due to
poor oral hygiene.
5. Trans
palatal
arch
1. Best in cases where
unilateral loss of space
is seen.
1. Bilateral loss
1. May cause both the molars
to tip together.
V'"
-,
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT I
REMOVABLE SPACE MAINTAINERS
Indications:
1) When premature loss of primary molars takes
place and space maintenance with restoration of
masticatory fonction is impdæhf.
2) In cas® Where supra-eruption has already taken
place, a non-fonctional one may be used.
3) In the anterior region, premature loss may have
deleterious effects on speech and esthetics. For
this purpose, replacement of the anterior teeth
may be done by R.P.D.
4) When a multipletpoth loss is seen, where fixed
appliances may not serve the purpose.
5) When permanent molars have not erupted,aremovable guiding plane may also be used.
6) In high-risk caries child, maintenance is poor
. j and fixed appliances are contraindicated. The
key disadvantage of all removable appliances lies
in the heavy dependence on patient compliance.
■
Fig. 9.21a Functional removable space
maintainer - upper arch
In a majority of clinical conditions, a removable,
partial denture, with an acrylic denture base,
wrought wire clasp and artificial teeth will serve
the purpose. Rarely, in cases of prolonged use,
a cast, chrome - cobalt alloy framework may be
considered. (Fig. 9.21a, b)
Classification:
A simple classification that includes the various
clinical situations in which removable appliances
may be given in the primary/mixed dentition are:
I
- Unilateral Maxillary posterior
II
- Unilateral Mandibular posterior
III
- Bilateral Maxillary posterior
IV
- Bilateral mandibular posterior
V
- Bilateral maxillary anterior and. Posterior
VI
- Bilateral mandibular anterior posterior
VII - Primary/permanent anterior r
VIII - Complete primary teeth loss.
Demerits:
1. It depends entirely on patient co-operation and
compliance.
2. It may be lost or can be broken by the patient.
3. The lateral jaw growth may be restricted, if clasps
are incorporated.
Fig. 9.21b Functional removable space
maintainer lower arch
4. It may irritate the underlying soft tissues.
5. It may not maintain space during the eruption
of the tooth.
Self Assessment
1. Define preventive orthodontics
2. What are the common procedures done in pre
ventive orthodontics?
3. Define space maintainer, space maintenance and
space management
4. Classify space maintainers and give the indica
tions, advantages and disadvantages of the same
5. What factors are considered before instituting a
space maintainer program?
6. Write short notes on
a. Willet’s appliance
b. Band and loop space maintainer
c. Proximal stripping
9.3 Early Orthodontic Interventions
J
Mehta S, Vanka A, Tandon S
Introduction
Early orthodontic intervention by the pediatric den
tist is a highly controversial issue generated by a
section of specialists. Though comprehensive treat
ment may be required at a later date, the need for
early intervention cannot be denied. The problem
can be prevented from occurring in the first place
or it's complexity can be reduced to an extent that
the further procedures are simplified. Clinical ex
periences of various Pedodontists show that empha
sis should be placed on guidance of growth, early
interception of developing malocclusion and elimi
nation of the first symptom.
Reasons for earlv interventions
Several reasons that favour early intervention are:
■ It does not impede normal growth of the denti
tion rather it helps in facilitating the guidance
of developing occlusion.
■ Crowding progressively gets worse if not inter
vened, early, with the secondary effects being
more complicated than primary problem.
■ Premature loss of primary teeth if not prevented,
can cause asymmetry of the arch form, with com
plex mechanics required to treat this problem
later. (Fig. 9.22a, b)
• Rotated teeth if not corrected early and left for
long duration may also affect stability of correc
tion later. (Fig. 9.23a, b, c)
• Early intervention also allows for more favour
able condylar position and growth by unloading
the mandible in cases of developing class III
relations. Thus, use of devices such as utility arch
wire , can reduce the complexity of the treat
ment at a later date. It can be considered a su
pervised neglect on the part of specialists if in
cipient malocclusions are not resolved as soon
as they are seen in the developing dentition
(Carpezza ,1997)
■ The early occlusal guidance trains the tongue to
act like a functional appliance and produces
unique arch development.
« Majority of the class II problems which are of
ten 3.5 mm or less in molar relation if treated
early can be corrected within-^ 6-8 months.’
« Clinical studies have shown the ‘Andrews six
keys to normal occlusion" can be more consist
ently attained with early intervention than late
treatment.
« Extraction of permanent teeth can be reduced
with early intervention and hence more
esthetically accepted profile is achieved.
■ Non compliance of adolescent years can be
avoided with early treatment.
■ Children and patient’s support is overwhelming
as functionally and esthetically accepted occlu
sion can be achieved before the traditional start
ing time for late orthodontic treatment.
Benefits of early diagnosis and treatment:
a) The possibility' of achieving better results?
b) Some forms of treatment can only be done at an
early age.
c) Early treatment of serious deleterious habits is
easier than treatment after years of habit rein
forcements.
~
4*
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Fig. 9.22a Radiograph showing unilateral
space loss
Fig. 9.22b Radiograph showing bilateral
space loss
Fig. 9.23a Derotation of maxillary left central
incisor by semi fixed appliance, a) Banded
central incisor
Fig. 9.23b Derotation of maxillary left central
incisor by semifixed appliance, b) Use of
elastics for derotation
Fig. 9.23c Derptated central incisor
Cßö I TEXTBOOK OF PEDODONTICS
d) Psychologic advantage to early treatment in some
children.
Difficulties in early treatment:
Before starting treatment, however, one must evalu
ate the drawbacks such as:
1. Misperceptions exist about the goals of early
treatment
2. Improper early treatment can be harmful
3. Diphasic treatment may lengthen the chronologi
cal treatment time.
4. Early diagnosis and treatment planning are more
tentative during active growth and tricky to pre
dict whereas when growth diminishes the fac
tors of malocclusion are clearly seen.
efficient orthodontic treatment. Following condi
tions may need a thorough evaluation with an early
intervention.
a) Loss of primary teeth endangering available
space in the arch,
b) Closure of space due to premature loss of de
ciduous teeth. The lost space in the arch must
be regained
c) Malpositions of teeth that interfere with normal
development of occlusal function, faulty pattern
of eruption, mandibular closure or endanger the
health of teeth.
d) Supernumerary teeth that may cause
malocclusions (Fig. 24a, b).
Conditions that need early intervention:
In Primary dentition:
a) Anterior and posterior crossbite
b) Cases in which teeth have been lost due to car
ies and loss of space may result.
c) Unduly r^^ned primary incisors which inter
fere withformal eruption of permanent incisors.
d) Malpositioned teeth which interfere with nor
mal occlusal function or induce faulty pattern of
mandible closure.
e) All habits or malfunctions which may distort
growth.
Fig. 9.24a Mesiodens resulting in midline
diastema
Contra-indications to early intervention:
a) There is no assurance that treatment results will
be sustained.
b) A better result can be achieved with less effort
at another time.
c) Social immaturity of the child makes treatment
impracticable.
d) Patient unwilling to co-operate for treatment.
In Mixed dentition period:
The mixed dentition period is the time of the great
est opportunity for occlusal guidance and intercep
tion of malocclusion. At this time, the dentist has
the greatest challenges and finest opportunities for
Fig. 9.24b Diastema resolving following
extraction of mesiodens
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
e) Crossbites of permanent teeth.
f) Malocclusions resulting from deleterious hab
its.
g) Oligodontia - if closure of space is preferable to
prosthesis.
h) Localized spacing between the maxillary cen
tral incisors for which orthodontic treatment is
indicated.
i) Neutro occlusion with extreme labio version of
maxillary teeth.
j) Class II (disto occlusion) cases of functional type
k) Class II (disto occlusion) of dental type
l) Class II (disto occlusion) cases of skeletal cases
m) Space supervision problems.
n) All malocclusions accompanied by extremely
large teeth. If serial extraction is to be under
taken, treatment must be instituted in mixeddentition.
o) Gross inadequacies of disharmonies of apical
bases.
to the development of occlusal disharmonies. How
ever, when the space is progressively lost, as we
have discussed in space closures following early loss
ofjprnnary teeth, the therapy should be considered
to regain it so that additional disharmonies do not
develop. Then the regained space is maintained.
These problems can be either completely eliminated
by the preventive measures or can be corrected in
their inception before they cause irreparable dam
age.
Diagnosis
For regaining space or any movement of teeth, the
most important procedure is diagnosis. Attention,
limited to the segment id which the tooth is miss
ing, is a frequent cause of the failure in attempting
to regain space. Considérations for treatment should
include;
■ The alignment and space needs ofthe other teeth
in the arch,
■ The relationships of teeth to the denture base,
■ The transverse and sagittal denial relationships,
■ The vertical relationships, aid
■ The profile of the soft tissue
The various diagnostic aids necessary are study
models, radiographs of all the periapical struc
turés, clinical assessment of facial symmetry and
proportions, and possibly cephalometric analy
sis.
INTERCEPTIVE ORTHODONTICS
Dental and skeletal relation
Hie concept of interceptive orthodontics revolves
around the minor problems present during devel
opment Of dentition, which if left untreated mayin
creasein terms of complexity and be, consequently
difficult to treat at a later date. Thus (he procedures
are instituted once the problem is detected? albeit at
an early stage. It may thus be considered at the
secondary level of prevention.
The common problems, which can be intercepted,
would be space regaining, crowding, crossbites,
midline diastemas, and orthopedic guidance
REGAINING THE SPACE
------
Space maintenance is necessary in early loss of pos
terior primary teeth because early loss contributes
Clinically we have to make quick assessments
to determine unfavourable skeletal patterns or
dental malocclusions. Thus, clinical assessment
should rule out the presence of a dental or skeletal class II, class III, openbite or dosed bite re
lationship.
Certain variations in class I malocclusion may
also exist in which simple measures at refin
ing space should not be the only consideration.
Dentil alignment considerations that affect thé
regaining of фасе include estimation of rota
tion, slipped contacts, and fecial-lingual dis
placement of teeth frorii arch circumference.
Assessment of the soft tissue profile will help to
identify cases in which a relative protruriotipr
retorsion of the central alveolar structures’dééis
complicate evaluation of available space,
| TEXTBOOK OF PEDODONTICS
Radiographs and study models
Radiographs and study models will aid significantly
in assessing space needs and consideration of tooth
alignment. It is important to recognize whether
teeth have moved bodily into the space or have
tipped axially, because forces applied to tip teeth
back into a proper alignment are easier to manage
than forces required to move the teeth bodily.
Visualizing the proximity of adjacent erupting teeth
(especially second molars) and estimating their po
tential impact on the teeth that have crowded the
space should also be done. Radiographs of the peri
apical structures are necessary.
Mixed dentition analysis
Moyer’s mixed dentition analysis will give an esti
mate of the amount of the space to be regained. It is
however safer to do at least another analysis [Tanaka
and Johnson] to confirm the exact amount of space
loss that has taken place. Sometimes even if there
is a loss bf space, one may need only to maintain
the space if it is sufficient for the permanent succes
sors to erupt into good alignment.
Ànchorage considerations
When appliances are used to reposition the first per
manent molars, there will be reciprocal force ex
erted to thé teeth and the supporting tissues ante
rior to the space, and the result may be an undesir
able flaring of the anterior teeth. Thus if favourable
conditions exists, an attempt to regain space is cer
tainly indicated. Several fixed and removable ap
pliances for space regaining procedures have
evolved for thé tipping of the first molars. However, the distal movement other than minimal tip
ping can most satisfactorily be achieved by head
gearappliance.
Construction: A molar band is fitted to the first
permanent molar. Molar tubes are soldered or spot
welded in a horizontal position both buccally and
lingually to the band. Impressions will be taken
with alginate.
A stainless steel wire which is slightly smaller than
the tube size is selected and bent into a ‘U’ shape.
The base of the ‘U’ should contain a reverse bend
to contact the distal surface of the first premolar.
As the wire comes out of the tube it should aim
toward the first premolar at a point just below the
greatest distal convexity of the first premolar. A
stop should be placed on both arms where the
straight part meets the bend of the wire. A spaced
coil spring is selected which will slide on the wire
and is cut about 2 to 3 mm. longer than the distance
from the anterior stop to the molar tube. The band
is cemented with the coil springs compressed.
Gerber space maintainer (Fig. 9.25)
This type of appliance may be fabricated directly in
the mouth during one relatively short appointment
and requires no lab work. A
assembly, which
may be welded of soldered in place with silver sol
der and fluoride flux is fitted in the tribe, the appli
ance placed and wire section extended to contact
the tooth mesial to the edentulous area.
FIXED SPACE REGAINERS
Open coil space regainer
A reciprocal active fixed regainer can be used to
good advantage in the mandibular arch when the
first premolar has erupted into the oral cavity.
Fig. 9.25 Space regainer to regain space due to
early loss of 74, 75 teeth
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT | CEd
The length of the push coil springs is established
by placing the band-tube-wire assembly in the
mouth, extending the wire to the desired length, in
contact with the mesial tooth and measuring the
distance bet^en the tube stops on the wire and the
end of the "LT tube. To this distance, add the'amount
of space needed in the regainer, plus 1 to 2 mm, to
ensure spring activation and cut springs to this
length. The springs are compressed enough to al
low the assembly to fit the edentulous area.
Hotzlingual arch (Fig. 9.26)
Another method for moving the molar distally uti
lizes the looped Hotz lingual arch. This is appro
priate in a situation where the lower first perma
nent molar has drifted mesially, but the premolar or
.cuspid has not drifted distally But there must be xray evidence that there is sufficient space between
the first molar and the developing second molar.
maintainer, since it facilitates frequent removal
of the arch for the purpose of activation.
Sectional arch technique
K sectional arch technique can also be used to re
gain the lost arch length. Upto 4 millimeters of space
can be regained In an effective and efficient manncr by the method described. It can be used in the
cases where the second molar is erupted.
Lip bumper/plumper (Fig. 9.27a, b)
The appliance is most easily used for the space re
gaining procedures in which bilateral movement is
desired. It consists of a heavy labial arch wire over
Fig. 9.27a Lip bumper to distalize molars and to
align lower incisor, by relieving lip pressure and
allowing guidance under tongue pressure, a) Pre
treatment witt) appliance in place
Fig. 9.26 Lingual arch space maintainer with
U-loop to regain space loss in the 74 .region
■
■
■
Anchorage for the movement is achieved as the
arch contacts all the teeth. Besides, spurs across
the canines can also be used to the same effect.
After adjustment, the posts in the passive posi
tion should be approximately 1 mm distal to their
passive positions over the lumen of their tubes.
The arch is then forced forward and the posts
slipped down into place.
As mentioned earlier, it is advantageous to use
the removable type of lingual arch space
Fig. 9.27b Post treatment
CHi) I TEXTBOOK OF PEDODONTICS
which an acrylic flange is prepared in the anterior
region such that it does not contact the lower
anteriors. Instead, it is used to relieve the lip pres
sure. This pressure can be used to distalize the mo
lars by:
1. Incorporating loops in the arch wire just before
it enters the buccal tube.
2. Utilizing a coil spring.
It can also be used unilaterally.
Anterior space regainer
A technique described is the use of an anterior space
regainer utilizing direct bonding. To the lateral in
cisors was attached labial tubes. A 0.014” round wire
was then inserted in an open coil spring and
activated. [Bayardo (1986)]
REMOVABLE SPACE REGAINERS
Several designs of space maintainers have been de
scribed. The correct selection of the appliance de
pends on the case, particularly the compliance of
the patient.
Free end loop space regainer
It utilizes a labial archwire for stability and reten
tion, with a back-action loop spring constructed of
No. 0.025 wire. The base of the appliance is made
of acrylic resin. Movement of the permanent molar
is achieved by activating the free end of the wire
loop at specific intervals of time.
Split saddle/split block space regainer
It is also called split saddle space regainer. It dif
fers from the free end spring type in that the fiinctional part of the appliance consists of an acrylic
block that is split buccolingually and joined by
No.0.025 wire in the form of a buccal and a lingual
loop. The appliance is activated by periodic spread
ing of the loops. The activator block is split with a
disk after the appliance has been processed.
Sling shot space regainer
This consists of a wire elastic holder with hooks
instead of a wire spring that transmits a force against
the molar to
r be distalized. This is called sling shot
appliance, since the distalizing force is produced
by the elastic stretched on the middle of the lingual
surface of the molar to be moved. The other is ar
ranged in the same position on the buccal surface
of the molar. The elastic caiibechanged once each
day.
Jack screw
It is another type of removable appliance used for
space regaining which will incorporate an expan
sion screw in the edentulous space. Space is opened
by expanding the plates anteroposteriorly.
CROWDING
Crowding is a common problem encountered at vari
ous stages of development and in varying degrees
of severity. Crowding in the mandibular region may
be seen in the early mixed dentition and is a find
ing of importance for the Pedodontist.
In the pre-eruption stage of the incisors, crowding
is seen to be present There exists a situation called
‘incisor liability’ where the permanent incisors be
ing larger than their deciduous counterparts, may
have an impact on the crowding.
a) In the maxillary arch, the laterals ate more palatally placed.
b) In the mandibular arch, the teeth may be lin
gually placed accompanied by some amount of
rotation.
Will crowding resolve on its own?
This is dependent on several factors such as 1. Interdental spacing - the eruption of the per- ’
manent incisors brings about the lateral shift of
the deciduous canines so as to align themselves.
Should interdental spacing be absent, this shift
is not possible and may decrease the chances of
a better alignment. Thus, Leighton’s prediction
of permanent teeth crowding based on presence
or absence of interdental spacing can be a good
predictor.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
2. Intercanine arch width - the intercanine arch
width increase can also help in resolving the
incisal crowding. The intercanine width in
creases to about 6mm in maxilla and about 4mm
in mandible from 2 years of age to maturity.
Hagberg (1994) has used this measurement and
predicted that an intercanine distance of 28 mm
or more shows little risk of crowding, while that
less than 26 mm may be associated with some
crowding upto 10 years of age at least.
3. Inclinations of the permanent incisors - the
more forward inclination of the permanent inci
sors may help increase the arch circumference.
4. Ratio of the size between the permanent and pri
mary teeth will give an indication as to whether
adequate space will be available or not.
Considering the above factors and keeping in mind
goals of interceptive orthodontics being to make
adequate space available at tine right time, observa
tion or intervention may be required.
Options in the management of crowding
The various options that exist in the management
of crowding are:
1) Observe
2) Disk primary teeth
3) Extraction of teeth
4) Referral
1. Observation
In cases where spacing exists in the primary den
tition with the incisor position having an addi
tional space creating effect, crowding (less than
2 mm) will in most cases correct themselves with
normal dentition and occlusion establishment
(apart from late incisor crowding). Concomi
tantly, if a space analysis, coupled with the meas
urement of intercanine width shows a favour
able situation, the patient should be kept under
observation.
2. Disking ofprimary teeth'. (Fig. 9.28)
The primary teeth may sometimes prevent the
incisors from aligning themselves. If the space
required is not more than 3-4 mm, the grinding/
disking the mesial surfaces of the canines will
help to align the incisors.
Fig. 9.28 Proximal stripper can be used for
better control over proximal stripping
Disking may either becarried put either by means
of a169L bur or a disking stri|’ In cases where
minimal disking is required, the strip may be
preferred for better control The disked surfaces
need to be protected with a fluoride application.
Once space is made available, the teeth may
spontaneously correct themselves by tongue pres
sure. Should the laterals be locked behind the
centrals, however, modification of the lingual
arch (withauxiliaiy springs) may be used to align
the incisors. Should an adequate space not be
provided by disking the canines, the primary mo
lars may be disked later.
3. Extraction of teeth
The extraction of teeth in order to create space
is a well established procedure. The most recyiiVi ’s ex
traction, timely extraction and Wilkinson
traction.
Serial extraction
Though the concept was initiated way back by
Bunon (1743) the catchy term serial extraction
was coined by Kjellgren (1929) and was popu
larised by Nance (1940), who has been called
the 'father of serial extraction’ philosophy in the
US. The extraction of teeth is often carried but
СЮ I TEXTBOOK OF PEDODONTICS
without proper diagnostic aids or further com
prehensive orthodontic correction is not taken
into consideration. Thus the term/Guidance of
eruption ‘[11012,1970 ] would sound more ap
propriate.
Definition
Serial extraction can be defined asjthe correctly
timed, planned removal of certain deciduous and
permanent teethm mixed dentition cases with dento
alveolar disproportion i.e., teeth to supporting bone
imbalance in order to:
a) Alleviate crowding of the incisor teeth for ex
ample to provide space for spontaneous align
ment of incisors, when the lateral incisors are
erupted at 7-8 years, deciduous canines may be
extracted
b) Allow unerupted teeth to guide themselves into
improved positions. For example, deciduous first
molar is extracted to speed eruption of first
premolar, when root development of the first
premolar is halfway.
c) Lessen the period of active appliance therapy or
eliminate it.
Indicationsfor serial extraction
1) Class I with anterior crowding (space discrep
ancy 10mm or more)
2) Lingual eruption of the lateral incisors
3) Midline shift potential due to unilateral canine
loss
4) Crowded arches accompanied with extreme
proclination
5) Abnormal primaiy canine root resorption
4) Lack of developmental spacing
7) ¿ Anomalies such as ankylosis, ectopic eruption
Contraindications
1) Mild to moderate crowding (about 8 mm or less)
2) Congenital absence of teeth providing space
3) Where extensive caries of permanent first mo
lars requires their removal.
4) Accompanying deep or openbites without cor
rection
5) Severe class IL III of dental/skeletal origin
4) Cleft lip and palate cases
Assessment - It includes
■ Clinical examination
■ Occlusion study (models)
« X-rays - ЮРА, OPG, cephalograms with cepha
lometric tracings
■ Mixed dentition analysis
■ Facial photographs
Rules to be followed:
1) There must be class I molar relationship bilater
ally
2) The facial-skeletal relation must be balanced
anterior-posteriorly, vertically and mesio distally.
3) Discrepancy should be at least 5 mm in all quad
rants
4) Dental midline should coincide
5) There must be neither openbite nor deepbite
Procedure and rationale
Several sequences of treatment have been advocated
with the most common ones being those of Dewel
and Tweed.
■
Dewel [ 1978 ]: The sequence proposed by
Dewel is the extraction of CD4
A. Extraction of deciduous canines - the decidu
ous canine space is utilized for aligning the
crowded incisors. The resorption of the canine
by a lateral incisor can provide an indication to
the same (Age 8.5 years).
B. Extraction of the first deciduous molars - At
the age of 8.5 years, the unerupted permanent
premolar will not have reached 1/2 root length.
Once this happens (at about 9 1/2 yearsV Же
deciduous first molar may be extracted to pro
mote the eruption of the first premolar. At this
stage, it would 3d well to note that the incisor
crowding may have got resolved. Should the
eruption sequence be unfavourable, with the ca
nine erupting before the premolar, enucleation
can be carried out. The extraction of the second
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
deciduous molar with the placement of a lingual
arch is another alternative, wherein the first
premolar is encouraged to shift distally. At a later
date, once the canines erupt the first premolars
are removed.
It is important that before extracting the first
premolars, a reassessment of the existing prob
lem is made.
■
Tweed (1966) proposed the extraction sequence
as DC4:
a) At 8 year of age, all the deciduous first molars
are extracted. The deciduous canines are main
tained to hamper the eruption of permanentjcanines.
Thus mechanotherapy and retention may be
unavoidable.
2) It may be used only selectively in class II
malocclusions.
3) Psychological trauma and lack of the patient co
operation may affect the future dental treatment.
4) Caries may affect the second premolars, neces
sitating their removal.
5) Impacted canines-even after removal of premo
lar, the canine may remain impacted.
Timely extraction: (Fig. 9.29a, b)
This is similar to serial extractions wherein se
quential removal of deciduous teeth is carried
out, but differs in that no permanent teeth are
removed. The term Timely extraction has been
recommended by Stemm [1973].
*b) After the premolars (crowns) are through the al
veolar bone, the premolars along with the de
ciduous canines are extracted.
■
Dale (1985) has proposed the same technique in
cases of alveolodental protrusion. Here after ex
traction of the premolar and canine, no effort is
made to prevent the lingual movement of teeth.
Advantages of serial extraction procedure
The key advantage in serial extraction lies in the
fact that by timely extraction of the teeth, further
appliance therapy is minimized or eliminated. It will
also reduce the complexity of treatment need.
Fig. 9.29a Timely extraction a} Pre-treatment
Disadvantages of serial extraction procedure
1) Unfortunately, quite too often the serial extrac
tion procedure will have to be followed by fixed
appliance therapy. This is particularly so in cases
of Class I with crowding, where the procedure
is accompanied by
a) Relatively deep oveibite
b) Distoaxial inclination of the canines and
mesioaxial inclination of the second
premolars. This has been termed as ditching.
Fig. 9.29b Post-treatment
I TEXTBOOK OF PEDODONTICS
Timed extractions have been advocated in cases
where:
a) There is a gingival recession due to labial posi
tioning of the lower incisors, coupled with an
inadequacy of dental arch length.
b) There is ectopic eruption of the lateral incisors
or the first permanent molars. Apart from the
locking of the tooth below the deciduous coun
terpart (especially in maxillary molar), space loss
may also be present.
Hie plain removal of the canines will cause lateral
and lingual shift ofthe mandibular incisors. Though
this will help in repositioning, it may create arch
length deficiency where none existed before and thus
should be accompanied by space maintenance to
preserve the alignment. The best indication to use
the so called timed extractions of primary teeth
would be when the crowding is 4-9 mm. This is
because the alignment of the incisors after the per
manent canines have erupted is a difficult task.
•
•
Incisor extraction
Occasionally, extraction of an incisor tooth may
give a good result. This can be done in cases
where the jaws are narrow and the teeth are fanned
out laterally. Any pathology of the lateral inci
sors, where it cannot be saved or if it is excluded
from the arch, may favour its extraction.
Wilkinson’s extractions
While serial extractions are primarily indicated
in cases where the crowding exists in the ante
rior region for relief of crowding in the posterior
teeth segments, the first molar extractions can
be carried out
The criteria to be evaluated would thus be quite
similar to serial extractions. The dental age of
an individual needs to be assessed. For the sec
ond molar to assume a normal relationship, the
first molar should be extracted preferably before
eruption of the second molar (especially in the
mandibular arch). Before extracting the first mo
lars, the inclination of the second premolar
should be evaluated, as it may incline further
distally & get impacted below the second molar.
CROSS BITE
■
An anterior crossbite is an abnormal labiolingual
relationship between one or more maxillary and
mandibular anterior teeth while a posterior
crossbite is an abnormal buccolingual relation
ship of a tooth or teeth in the maxilla or mandi
ble, or both, when the two dental arches are
brought into a centric occlusion
Classification
Cross bite
J
Anterior
Posterior
I
I
Unilateral
Bilateral
I
I
True
Functional
Combination of above
Anterior Vs Posterior cross bite is depicted in Ta
ble 9.6
The modalities of treatment for anterior cross bite
A differential diagnosis must be made to determine
whether the problem is of skeletal or dental origin.
The prognosis is much better if a plain dental prob
lem exists.
Other factors that need to be evaluated are:
■ Axial inclinations of the upper and lower inci
sors
■ The absolute size of the mandible and maxilla
and their relationship to each other and to cra
nial base.
■ Profile of the patient'
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT | CIO
Table 9.6: Anterior Vs Posterior cross bite
Anterior cross bite
Posterior cross bite
1. Traumatic injuries to the primary
1. Ectopic eruption of the permanent
Etiology:
dentition that cause a lingual dis
first molar.
*
It can be dental,
placement of the permanent tooth
2. Prolonged thumb or finger sucking.
skeletal or a
bud.
3. Prolonged retention of primary
combination
teeth.
2. Supernumerary tooth.
of the two.
4. Occlusal interferences.
3. An inadequacy of arch length
causing the lingual deflection of the 5. Skeletal: They may be caused due to:
a) Deficient lateral growth of the
permanent tooth during eruption.
maxilla as seen in deft palate
4. AJiabit of biting the upper lip.
repair.
5. A repaired cleft lip.
b) Increased growth of mandible or
6. A functional cross bite caused due
to premature tooth contact during
c) Combination of both.
centric closure.
7. Skeletal: An anterior cross bite of
skeletal origin generally results from
an excessive abnormal mandibular
growth that produces a true class
III malocclusion. It has got a genetic
background.
■
■
■
The molar and cuspid occlusion
The extent of root formation (if root formation
is not complete lighter forces to be applied)
Adequate mesiodistal space should be available
Sufficient overbite for retention purpose
Corrective measures and appliances
a) Occlusal equilibration: Correction of a pseudo
class III anterior crossbite may require only the
removal of premature tooth contacts by incisal
grinding of the maxillary and mandibular incisors.
b) Tongue blade therapy: It is ideally suited for
cases where a simple one tooth anterior dental
crossbite exists, with the teeth in the early stages
of eruption. Using the lower incisor as the ful
crum, the locked tooth can be pushed out by plac
ing the tongue blade 45 degrees behind the tooth.
It should be used 1-2 hours daily for 10-14 days
• (Fig. 9.30d).
c) Lower inclined plane: This was introduced by
Catalan. Treatment of dental anterior crossbite
involving one or two teeth may be accomplished
by using a cemented lower acrylic inclined plane.
The inclined plane should be contoured and pol
ished at a 45-degree angle to the long axis ofthe
lower incisor teeth prior to cementation. The
steeper the angle, greater the force applied (Fig.
9.31a, b, c).
It lias the disadvantage that:
■ the possibility of opening the bite by wearing
it longer than two or three weeks.
■ exact amount of labial movement is unpre
dictable and uncontrollable.
\
d) Stainless steel crown: A reverse stainless steel
crown is best suited for single tooth crossbites
in which the lower mandibular incisor has been
previously displaced labially.
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Fig. 9.30a Left central incisor in cross-bite Pre-treatment
Fig. 9.30b Post-treatment
Fig. 9.30c 2’ - spring for correcting anterior
cross bite
Fig. 9.30d Tongue blade therapy for correcting
developing anterior cross
bite
*
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Fig. 9.31a Lower inclined plane to correct
anterior cross bite with 21, 22.
teeth in cross bite
Fig. 9.31b Lower inclined plane in place
Fig. 9.31c Corrected bite
Fig. 9.32a Correction of anterior segmental
cross bite. Pre-treatment
i
/
Fig. 9.32b Appliance placed to open the
bite in order to correct the cross bite
Fig. 9.32c Post-treatment
Cí£> i TEXTBOOK OF PEDODONTICS
e) Composite inclines: Another simple technique
is to build up a composite incline on the lower
teeth directly in the patient’s mouth. Croll [ 1999]
has suggested the use of a bonded compomer
dope based on the assumption that a compomer
having lessstrengththan a composite can be eas
ily removedwhen desired.
■
■
The midline should be checked to determine if
unilateral mandibular shift is present.
A facebow transfer may sometimes confirm the
functional shift, however, by observing the pa
tient closing from rest into centric occlusion, a
lateral deviation can be frequently observed.
Corrective measures and appliances
f) Removable Hawley appliance: A maxillary
Hawley appliance with Z springs incorporated
into the acrylic resin is usefid in the correction
of a dental anterior crossbite involving'single or
more than one tooth. Retention can be obtained
by the use ofball clasps, Adams or C type clasps.
Movement of the inlocked incisors is accom
plished by activating the springs 1.5 mm to 2
mm every one or two weeks. Patients are in
structed to wear the appliance 24 hours a day. If
the bite is deeper than normal, or if correction is
taking longer than expected, then a slight open
ing of the bite may be desirable by means of a
bite plane (Fig. 9.30a, b, c and 9.32a, b, c).
g) fixed appliances: Lingual arch may sometimes
be indicated in case of space control programs.
Auxiliary springs can be used along with the lin
gual or palatal arches for the purpose of correct
ing the crossbites.
Modalities for the Correction of Posterior
crossbite
The important consideration is to determine whether
the crossbite is unilateral or bilateral, and which
has got a functional component to it. Following
points can be considered in differential diagnosis:
• Study models using a wax bite can be an asset to
diagnosis. It also helps in detecting abnormal
inclination of teeth, symmetry of the dental
arches to certain extent the growth pattern.
« Cephalometric analysis will show gross skeletal
abnormalities.
• An occlusal radiograph can also be taken preoperatively to compare with the post-operative
x-ray.
a) Occlusal equilibration: A dental bilateral lin
gual crossbite in the primary or mixed dentition
may be simply corrected by removing occlusal
interferences, usually in the cuspid areas. How
ever, this may sometimes need to be accompa
nied by some appliance.
b) Removable W-arch appliance: This appliance
should be limited to only bilateral dental crossbite
conditions because of the reciprocal action. Cau
tion should be exercised since a precise control
of the force being applied to the teeth is difficult.
c) Cross elastic appliance: Cross elastic therapy is
useful in correction of dental unilateral crossbite
involving one or two teeth. Bands are adapted
and cemented to the teeth involved. A hook or
button spot is welded to the bands. The two teeth
are engaged by means of an elastic. Reciprocal
movement of both the upper and lower teeth oc
curs. The disadvantages are patient cooperation
and increased armamentarium (Fig. 9.33a, b, c).
d) Removable Hawley appliance: A removable
maxillary Hawley appliance with an offset
jackscrew embedded in the acrylic resin, may be
useful in the correction of two teeth unilateral
dental crossbite. The appliance offers good con
trol of the amount and direction of force being
applied to the teeth. The activation of the screw
is done at 1/4 turn every week (Fig. 9.34a, b, c).
When the crossbite is corrected, the appliance
should be worn in passive retention for an addi
tional three to six months as a retentive applianee.
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Fig. 9.33a Maxillary molar in lingual
cross bite
Fig. 9.34a Complete posterior and left central
incisor in cross bite
Fig. 9.33b Correction utilizing interarch
elastics
Fig. 9.34b Correction with appliance incorpo
rating screw and Z-spring
Fig. 9.33c Post-treatment
Fig. 9.34c Post-treatment
Table 9.7: Midline Diastema
*
Etiology
Treatment plan
1. Normal developing dentition
[Ugly Duckling Stage]
■ Resolves by itself with the eruption of the
permanent canines.
■ Spontaneous closure seems to occur with
less frequency in ,
a) Generalized spacing
b) Initial diaste&atf&more than 3 mm.
2. Familial incidence
■ Appliance therapy
3. Parafunctional habits
• Flaccid lips and a poor muscle tone
• Tongue thrust (simple) may Cause
anterior open bite and diastema
• Thumb/digit sucking over a prolonged
period
i) Correction of the habits has been known to
spontaneously correct the diastema
within limits.
ii) In cases of excessive diastema, correction
of the diastema can be simultaneously
carried out with the habit breaking appliance.
4. Tooth size discrepancies
a) Excessive anterior vertical overlap
b) Excessive vertical maxillary alveolar
growth. Retrognathic mandible or a
prognathic mandible.
■ First intrusion of the maxillary incisors,
followed by retraction of the incisors
to close the diastema.
■ If however cephalogram indicates an
excessively long lower face or a Class III
growth trend, functional therapy may be
the treatment of choice.
5. Frenum attachments
■ Generally advocated that the diastema
should be closed as far as possible before
going in for frenectomy. The reason cited
is that should the surgery be performed
before, the surgical scar tissue maintains
the diastema.
%
(xMesio-distal angulation of teeth
■ The correction of the crown angulation
(tipping) will close the diastema. *
7. Tooth anomalies (supernumerary tooth,
peg shaped laterals, absence of laterals).
■ Supemumerary:Removal of the super
numerary followed by a closure of the
diastema is done.
■ Peg shaped laterals: The diastema can be
corrected orthodontically followed by esthetic
restoration of the peg shaped laterals.
■ Absence of laterals:
i) The space for the missing laterals, if
detected early, may initially be maintained
and at later date replaced with fixed
prosthesis.
ii) Another option is to orthodontically move the
canines into the space of the missing
laterals, followed by a careful recontouring
of the cuspid and the first bicuspid (if
required) to simulate the lateral and
cuspid respectively.
8. Pathological (Juvenile periodontitis)
■ Systemic phase [if required ] followed by
appliance therapy
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Skeletal correction: It may be carried out in two
forms:
a) Slow palatal expansion
b) Rapid palatal expansion
The various appliances used are:
- Minnesota expander
- Hyrax jackscrew
- Fixed split palate acrylic appliance
MAXILLARY MIDLINE DIASTEMAS
Maxillary midline diastemas are one of the com
mon complaints encountered. It has been defined
as a space greater than 0.5 mm between the proxi
mal surfaces of adjacent teeth. The incidence of di
astema varies both culturally, racially and with age.
Fig. 9.35a Diastema correction of lower
incisors using elastics
Midline diastema, etiology and treatment plan
are illustrated in Table 9.7
Appliance therapy for the correction of diastema
The correction of diastema can be carried out by
various fixed or removable appliances. The principie applied here is of reciprocal anchorage (in fixed).
The types of movement are either bodily or more
commonly by tipping. (Fig. 9.35a, b, c, d).
Removable appliances
a) An active plate can be utilized for this purpose.
The plate incorporates palatal finger springs
passing between the central and lateral, such that
the loop is opposite to the direction of move
ment. A modified cantilever spring may be used
to the >ame effect.
b) A split labial bow is a modification which can
be utilized to close the diastema. It may be ac
companied by the disadvantage that space may
be created between the laterals.
c) In cases where there is an increased overjet ac
companying the diastema, a Hawleys plate with
an active labial low can be used to retract the
incisors and thus close the space.
Fig. 9.35b Post-treatment
Inherent in the use of removable appliances is
the drawback that only tipping movements can
be achieved. For optimum angulation of the teeth,
a further correction is required.
Fixed appliances
a) A stainless steel band with a bracket or more
commonly a bracket may be banded to the tooth
and elastics utilized to bring.the centrals towards
each other. Tubes may be welded and an archwire
used, so that the teeth may slide. In this case
more control can be achieved over movement
b) For a more esthetic treatment, a lingual button
may be bonded and an elastic applied. Even these
CSS I TEXTBOOK OF PEDODONTICS
Fig. 9.35c Diastema correction of upper
incisors using arch wire
Fig. 9.35d Post-treatment
Fig. 9.36a Myofunctional appliance and
their modifications
Fig. 9.36b Appliance showing orthodontic
prevention and interception
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
may bring about only a tipping movement, and
not true bodily movement.
c) For the purpose of bodily movement of the teeth,
it is suggested that an Edgewise bracket with a
simple looped partial arclwiiemade from a rec
tangular wire be tied under ffie^ehsion into both
has been termed hybrid appliance. The three basic
components included are:
b
brackets.
Retention
In order to prevent a relapse, a long term retention
is required in these cases. A small multistranded
wire may be used lingually and held in place by
means of composite.
• Linguo-facial muscle balance - shields or
screens. The equilibrium theory of tooth posi
tion states that over time tooth movement occurs in response to any alterationhuthe
homeostatic relationship existing betweenthe
forces from the tongue on one side and the lips
and cheeks on the other. The vestibular shields
and lip pads of the functional regulator hold the
lips and cheeks away from the teeth, thereby dis
rupting the equilibrium and permitting an un
opposed buccal movement of the teeth.
FUNCTIONAL JAW ORTHOPAEDICS
In achieving dentofacial effects, fixed orthodontic
appliances generate mechanical forces that are trans
mitted to teeth. In functional orthodontic appli
ances, the neuromuscular activity is tapped to alter
stresses on teeth and jaw bones.
■
Definitions
■ Frankel (1974) A functional appliance can be
defined as a removable or fixed appliance which
favourably changes the soft tissue environment.
b
Mills (1991 j: A functional appliance can be de
fined as a removable or fixed appliance which
changes the position of the mandible so as to
transmit forces generated by the stretching of
the muscles, fascia and/or periosteum, through
the acrylic and wirework to the dentition and
the underlying skeletal structures.
Classification:
Functional appliances can be removable or fixed and
can also be classified as: (Fig. 9.36a)
- tooth borne passive - eg. bionator
- tooth borne active - eg. Clark twin block
- tissue borne, eg. Frankel functional regulator
The appliances have also been classified, depend
ing upon the components used. Such an appliance
Eruption - biteplanes. These may be anterior,
flat, or inclined and constructed out of either
acrylic or wire. They act by encouraging a dif
ferential eruption of teeth and by removing
intercuspal interferences.
Mandibular repositioning - construction or
working bite. All functional appliances are con
structed to a ‘construction’ or ‘working’ bite.
Such registrations are based on theassumption
that, by displacing the mandible from its rest
position and stretching the muscles attachedto
it, reflex activity will restore the mandible to a
posture determined by the unstretched muscles.
Indications
Use bf functional appliances alone
Some patients can be treated by use of functional
appliances only, so that an acceptable occlusion can
be established. These cases generally have a mild
skeletal discrepancy, proclined upper incisors and
no dental crowding.
Use of functional appliances in combination with
fixed appliance
This is used most commonly to improve the
anteroposterior relationship before starting the fixed
appliance treatment. In particular, they are extremely
| TEXTBOOK OF PEDODONTICS
useful in Class II cases and go a long way in reduc
ing the amount of a comprehensive fixed therapy
required. It may also reduce the need for
orthognathic surgery7 at later date.
Interccptive treatment
Early intervention with functional appliances may
be indicated when one wishes to utilize their growth
enhancing effect. In addition, (hey are extremely
effective at reducing the relative prominence of the
proclined upper incisors, which are particularly sus
ceptible to dentoalveolar trauma.
Rationale for use
The theoretical basis behind the functional appli
ance therapy is that a new pattern of function within
the orofacial system (i.e., in the tongue, lips or
muscles of mastication), directed by the appliance,
leads to the development of a new' morphologic pat
tern (i.e, an altered dental or skeletal relationship).
Evidence for these theories come from both animal
experimentation and human cephalometric studies.
Effects on the dento-skeletal complex
The skeletal, dentoalveolar and soft-tissue effects
of these appliances have been reviewed by Dare and
Nixon (1999).
Skeletal effects
Il has been reported that growth takes place at the
condyles during the growth of the mandible by
means of a functional therapy. Some amount of
growth restriction of the maxilla has also been re
ported recently.
Dentoalveolar effects
The dentoalveolar effects of functional appliances
include:
• inhibition of the downward and forward erup
tion of the maxillary teeth;
■ retrod i nation of the upper incisors
■ proclination of the lower incisors
■ lower labial segment intrusion; and
■ leveling of the curve of Spee and tipping of the
occlusal plane.
Effects on soft tissues
These include:
■ removal of the lip trap and improved lip compe
tence
■ removal of adaptive tongue activity
■ lowering of the rest positidí üfTlie mandible;
and
■ removal of soft-t issue pressures from the cheeks
and lips.
COMMON APPLIANCES IN USE
Activators (Fig. 9.37a, b, c, d)
The "monobloc", designed by Robin (1902), was
the first reported functional appliance. This was
modified by Andresen in 1936 and later termed ac
tivator in 1957.
Indications
Partial or total correction of Class II div I, Class II
div II, Class III, open bites in a mixed and early
permanent dentition. A typical indication would be
Class II div I with deep bite.
'4
Contraindication
It is not advisable to use the appliance in cases of
crowding or where individual tooth movements are
required.
Bite registration
Based on the amount of horizontal and vertical open
ing
a) Schwarz (1956) suggests the optimal is a half of
the individuals maximum range.
b) Woodside (1977) states that mandible registered
in a position protruded 3.0mm distal to the most
protrusive position that the patient can achieve.
As a general rule the horizontal advancement is kept
edge to edge or 2 mm less than the maximum pro
trusion. Vertical opening is kept 5 mm posteriorly.
It is also advocated that in cases where the overjet
is more than 10 mm, a stage-wise advancement is
to be carried out.
SECTION 9: DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Fig. 9.37a Class H div. 1 malocclusion
with a retruded mandible
Fig. 9.37b Correction with activator therapy
Fig. 9.37c Post-treatment photograph showing
molars in Class I relationship
Fig. 9.37d Post-treatment photograph
showing change in profile
I TEXTBOOK OF PEDODONTICS
Duration of use
In general, an overjet of 8mm may require 10-12
months of wear. Though originally designed as a
night wear appliance only, the time taken for cor
rection may be reduced if the patient compliance is
good and the patient can wear for more than 14
hours a day.
Several modifications have been suggested for the
activator, which can be used for a variety of situa
tions.
Bionator
Originally designed by Balters in 1964, these have
been termed ‘open activators’ in view of their re
duced bulk. Three basic types of bionators have been
used as per their indications. They are
• The standard appliance is used in cases of a de
ficient mandible and is made up of an acrylic
flange extending posteriorly. The palatal bar with
a loop [ to control tongue position] and the modi
fied labial bow[ with buccal extensions, that re
duce the muscle forces] are used. With selective
trimming, desired eruption of the teeth can be
achieved.
■ The open bite appliance, which is used to in
hibit any abnormal posture or function of the
tongue.
■ The reversed/class III appliance, which is used
to stimulate the growth of the under developed
maxilla. The loop of the palatal bar is in the
opposite direction and the trimming differs in
that some acrylic is left between the teeth. The
maximum benefit is obtained when the appli
ance is worn day and night
Clark twin block
This type of appliance was introduced by Clark in
1988, and consists of upper and lower removable
plates with acrylic hooks trimmed at an angle of 70
degrees with a midline expansion screw in the up
per plate to allow a simultaneous expansion. They
were originally designed for high angle cases and
are often constructed with an attachment inserted
into the upper block for high-pull headgear.
Frankel functional regulator
The functional regulator is the only true tissue-bome
appliance; however, wirework does extend onto the
occlusal surfaces of the maxillary canines and the
first permanent molars. Much of the appliance is
located in the vestibule and the appliance is said to
work by altering both mandibular posture and the
contour with the dentition. This appliance can be
used to enhance dental eruption as well as correct
anteroposterior and lateral arch discrepancies.
Frankel advocates advancing the mandible 2 to 3
mm every 4 to 5 months, and notching the maxil
lary teeth to aid retention.
Horse shoe appliance
The horse shoe appliance is used for the correction
of class III molar relationship. Originally developed
by Schwarz (1997), the appliance has the advan
tages that it is easy to construct, and it does not
allow for the eruption of teeth due to the presence
of acrylic resin over the upper and lower teeth.
Head gear
In cases where a skeletal overgrowth is present in
the maxillary arch, extra-oral foVce may be required
to restrict the growth of the maxilla. The most
commonly used appliance for this purpose is the
head gear appliance.
A significant factor for the success of the head gear
appliance is the determination of whether it is the
maxillary overgrowth that is the problem [and if it
is, how much] or if the mandible is lacking in growth
(and if it will catch up).
The forces applied are through the teeth. These
forces have a horizontal and vertical component.
Should these forces be improperly applied, as in
where there is an excess of the vertical component,
it may lead to molar extrusion. This may not only
harm the molar but has the undesirable effect of
impeding mandibular growth as well.
Anchorage for the appliance is derived from vari
ous regions [cervical, occipital, parietal regions].
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
As with all the removable appliances, the patient s
cooperation is of paramount importance.
Specifications for use
K duration of 12-16 hours a day is the minimum
requirement for an effect to occshb^Qisnerally a force
of 400 gms on either side is applied.
Pendulum Appliance
This appliance has also been termed as non-com
pliance therapy for molar distalization. The pendu
lum applicance is a hybrid that uses a larger Nance
acrylic button in the palate for anchorage along with
0.032 TMA springs that deliver a light continuous
force to upper first molar. This appliance produces
a broad swinging arc or pendulum of force from
midline of palate to the upper molars.
Fig. 9.38a Skeletal Class III malocclusion
intercepted using a chin cap
This is mostly used in the patient with Class 1 skel
etal relationship and Class II dental malocclusion.
Chin cap (Fig. 9.38a, b, c)
It is used in cases of excessive grow th of the mandi
ble. The use and efficacy of the chin cap is not ac
cepted by all the clinicians, but can be considered a
valuable aid.
Two philosophies exist to its use. They are concerned
with the direction of force applied.
1. They are used such that the force is applied
through the condyle. Though animal experi
ments may have substantiated this, clinical find
ings are disappointing. This could, in part, be
attributed to the basic difference in the mecha
nism of growth of the maxilla and the mandi
ble.
2. They are used with the forces directed below’ the
condyle. The effect is that the chin is rotated
downward and backward which is caused by the
rotation of the mandible. This type of an appli
ance is ideal in cases with short vertical height.
The pre-orthodontic trainer
The starting (blue) trainer imparts only a light force
on the teeth, then after 6-8 months the firmer (pink)
Fig. 9.38b Chin cap in frontal view
Fig. 9.38c Chin can in lateral view
I TEXTBOOK OF PEDODONTICS
trainer, which imparts a much higher force on the
malaligned anterior teeth, is implemented. This is
the principle behind the straight wire technique,
starting with a light wire then progressing to a firmer
wire as the teeth come into a better alignment.
When to treat?
Several factors should be taken into consideration
before deciding to go ahead with the appliance
therapy.
■ The best time to start the functional therapy is
in the late mixed dentition. Thus several func
tional appliances- for example, the medium
opening activator for an early reduction of a deep
overbite as well as for sagittal correction can be
used in this period. Rather than a generaliza
tion, girls and boys, along with early maturers
should be assessed individually.
• Advantage can be taken of the pubertal growth
spurt so that this active growth phase can be
harnessed to optimize the amount of growth re
straining effect or growth enhancing effect.
■ In the maxilla, generally the growth needs to be
retarded and thus if the growth spurt is not over
even after appliance therapy, some amount of
growth may lead to a recurrence of the problem.
In the mandible on the other hand the growth
needs to be enhanced by taking the help of the
growth spurt. However, as the growth spurt
measured by a longitudinal monitoring of stat
ure, cannot be predicted with any great clinical
accuracy, some authors have questioned the use
of this appliance.
•
Yang [1997] has suggested the use of a Horse
shoe appliance for the treatment of Class III
malocclusion., originally suggested by Schwarz
[1966]. It consists of 2 separate plates for the
upper arch and lower arch, and has the advan
tages of easy construction, and prevents extru
sion and individual movements ofteeth as it cov
ers the whole of upper and lower dentition.
Limitations and complications offunctional
appliances
They can be listed out as:
■ Discomfort, as both the upper and lower teeth
are joined together.
■ It mainly depends on the patient’s compliance.
■ It can be used only if a favourable horizontal
growth pattern is present in cases of Class II cor
rection.
■ It has to be removed during mastication, par
ticularly when strongest forces are applied.
■ It may interfere with speech
■ Treatment is often increased - the two-stage treat
ment may prolong treatment by upto 18 months.
■ Laboratory and technical resources are required
for construction and adjustment
■ High cost
Self-Assessment
1. Define interceptivo orthodontics
2. What are the common procedures done in inter
ceptivo orthodontics?
3. What is serial extraction? Discuss in detail the
methods, indications, advantages and disadvan
tages of serial extraction
4. Write short notes on:
a. space regainer
b. management of developing cross bite
c. Rationale for interceptivo orthodontics
d. Mixed dentition analysis
5. What is non-compliance therapy for distalization
of molars?
9.4 Commonly Occuring Oral Habits
in Children and their Management
I
Tandon S, Sajida B, Bhat M,
Oral habits maybe a part of normal development; a
symptom with a deep rooted psychological basis or
may be the result of abnormal facial growth. A wide
array of oral habits has been a subject under discus
sion for many years. Digit sucking, lip and nail bit
ing, bruxism, mouth breathing, tongue thrusting etc.
may be considered as some of the common habits
seen in children. These habits bring about harmful
unbalanced pressures to bear upon the immature,
highly malleable alveolar ridges, the potential
changes in position of teeth, and occlusions, which
may become decidedly abnormal if these habits are
continued for a long time. The data on the etiology,
age of onset, self-correction and treatment
modalities for the various habits differ greatly. Hence
for a successful management of the habit, an un
derstanding of the dental implications and mani
festations of the habit should be pursued. One of
the most valuable sendees that can be rendered as
part of the interceptive orthodontic procedures is
elimination of the abnormal habits before they can
cause any damage to the developing dentition. Since
the pedodontist is at an advantage in that he can
see the child during the period that the habit is de
veloping, he gets the opportunity to examine the
child before the detrimental effect of the habit mani
fests itself as derangement in occlusion and unfa
vourable esthetics.
Definitions
Dorland (1957): habit can be defined as a fixed or
constant practice established by frequent repetition.
Buttersworth (1961): defined a habit as a frequent
or constant practice or acquired tendency, which has
been fixed by frequent repetition.
Mathewson (1982): Oral habits are learned pat
terns of muscular contractions.
With our clinical experience we have defined a habit
as a settled tendency in response to a specific cause
resulting from repeated learning.
Classification
We have attempted to classify the commonly ob
served oral habits in our practice based on their
causative factors (Refer flow chart 9.1).
Development of habit
The newborn develops some instincts, which are
composed of elementary reflexes. An instinct is one
where the pattern and order are inherited, while in
a habit the pattern and order are acquired if con
stantly repeated during the lifetime of an individual.
At the beginning the infant makes an effort by fre
quent learning and practice, later on the muscles
start responding more readily. At the outset it takes
a long time for the impulses to pass along the affer
ent nerves to the brain and back along the efferent
nerves to the muscles involved. It has been stated
that unconscious mental pattern of childhood
develops from five sources namely instinct, insuffi
cient or in correct outlet to energy, pain or
discomfort, abnormal physical size of parts, imitation
of or imposition of others.
СЕЭ I TEXTBOOK OF PEDODONTICS
Flow chart 9.1 Oral habits can be classified as:
Non-obsessive
(easily learned and dropped)
Obsessive
(deep rooted)
;
Intentional
or
Meaningful,
e.g. Nail biting,
Digit sucking,
Lip biting.
Masochistic
or
Self-inflicting
injurious habit
e.g. Gingival
stripping
Unintentional
or
Empty, e.g.
Abnormal pillowing,
Chin propping
Functional Habits
e.g. Mouth breathing,
Tongue thrusting,
Bruxism
Author
James (1923)
Kingsley (1958)
Morris and
Bohanna
(1969)
Classifi
cation
a. Useful habits
b. Harmful
habits
a. Functional oral
habits.
b. Muscular habits
c. Combined ones
a. Empty habits I. a. Compulsive
a. Pressure
habits non b. Meaningful
habits
pressure
habits
b. Non-compuhabits
Isive habits
b. Biting
JI.a. Primary
habits
habits
b. Secondary
' habits
THUMB SUCKING
_
Thumb sucking is a habit of concern to specialists
in various fields, such-as psychiatrists, psycholo
gists, pediatricians, pediatric dentists, orthodontists,
speech therapists and plastic surgeons. Despite ex
tensive research considerable controversy still ex
ists regarding sucking habits.
Thumb sucking and finger sucking can more gen
erally be termed as digit sucking. A broader cat
egory of sucking habits includes any form of
nonnutritive sucking that involves pacifiers, hair, etc.
Definition
Thumb sucking can be defined as placement of the
thumb into various depths into the mouth (Fig.
9.39a, b)
Klein (1971)
Finn (1987)
Classification
Based on our clinical observation, thumb sucking
can be classified:
1. Normal Thumb Sucking
The thumb sucking habit is considered normal
during the first and second year of life. Such a
habit is usually seen to disappear as the child
matures. The habit at this age does not generate
any malocclusion.
2. Abnormal Thumb Sucking
When thumb-sucking habit persists beyond the
preschool period then it could be considered as
an abnormal habit. If the habit is not controlled
. or treated during this stage, it may cause delete
rious effects to the dentofacial structures.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT |
Cffi)
Fig. 9.39a Finger sucking
Fig. 9.39b Thumb sucking
This can again be divided into:
a. Psychological
The habit may have a deep-rooted emotional
factor involved and may be associated with
insecurities, neglect or loneliness experienced
by the child.
Type B: This type is seen in almost 13-24% of the
children wherein the thumb is placed into the oral
cavity7 without touching the vault of the palate, while
at the same time maxillary and mandibular anteriors
contact is maintained.
b. Habitual
The habit does not have a psychological bear
ing, however the child performs the act out of
habit. The habit is a cause for concern due to
its potential to cause malocclusion.
Sucking habits can also be classified as:
a. Nutritive sucking habits
eg. Breast feeding, bottle feeding
b. Non-nutritive sucking habits (NNS habits)
eg. Thumb or fmger sucking, pacifier sucking
[O’ Brien, 1996]
Subtelny (1973) : has graded thumb sucking into 4
types:
Type A: This type is seen in almost 50% of the chil
dren, where in whole digit is placed inside the mouth
with the pad of the thumb pressing over the palate,
while at the same time maxillary and mandibular
anteriors contact is present.
Type C: This type is seen in almost 18% of the chil
dren where in the thumb is placed into the mouth
just beyond the first joint and contacts the hard pal
ate and only the maxillary incisors, but there is no
contact with the mandibular incisors.
Type D: This type is seen in almost 6% of the chil
dren wherein very little portion of the thumb is
placed into the mouth.
Johnson (1993): Classified NNS habits based on
factors that influence the severity of the habit (Ta
ble 9.8).
The Sucking Reflex
The process of sucking is a reflex occurring in the
oral stage of development and is seen even at 29
weeks of i.u., and may disappear during normal
growth between the ages of 1 and 3 1/2 years. It is
the first co-ordinated muscular activity of ^■ in
fant. It is important for meeting both psyc
cal
CEß) I TEXTBOOK OF PEDODONTICS
Table 9.8: Classification of NNS habits.
Level
Description
Level 1 (+/-)
Boys or Girls of any chronological age with a habit that occurs during sleep.
Level ll(+/-)
Boys below age 8 with a habit that occurs at one setting during waking hours.
Level lll(+/-)
Boys under age 8 years with a habit that occurs at multiple settings during
waking hours.
Level IV(+/-)
Girls below age 8 or a boy over 8 years with a habit that occurs at one setting
during waking hours.
Level V (+/-)
Girls under age 8 years or a boy over age 8 years with a habit that occurs
across multiple settings during waking hours.
Level VI (+/-)
Girls over age 8 years with a habit during waking hours.
(+/-) designates willingness of the parents to participate in treatment.
and nutritive needs during feeding and apart from
seeking nutritional satisfaction they also experience
pleasurable stimuli from lips, tongue and oral mu
cosa and learn to associate these with enjoyable sen
sations such as fondling, closeness of a parent. Ba
bies who are restricted from sucking due to a dis
ease or other factors become restless and irritable.
This deprivation may motivate the infant to suck
the thumb or finger for additional gratification.
Finger and tongue thrusting habits are normal for
the first year and half of life and will disappear spon
taneously by the second year with proper attention
to nursing. If it continues beyond 3 years,
malocclusion will result.
Influence of different variables on incidence and
prevalence of thumb sucking habit is given in
Table 9,9
Theories
Various theories have been proposed by psycholo
gists to explain noil-nutritive digital sucking
■
Classical Freudian theory (1905)
The psychoanalytical theory holds that this origi
nal response arises from an inherent psychosexual drive suggesting that digit sucking is a
pleasurable erotic stimulation of the lips and
mouth. One of the concepts of thumb sucking
brought about by this theory is that humans pos
ses a biologic sucking drive. An infant associ
ates sucking with pleasurable feelings such as
hunger, satiety and being held. These events will
be replaced in later life by transferring the suck
ing action to the most suitable object available,
namely the thumb or fingers.
*
■
The learning theory: Davidson (1967)
This theory advocates that non-nutritive suck
ing stems from an adaptive response. The infant
associates sucking with such pleasurable feel
ings as hunger. These events are recalled by suck
ing the suitable objects available mainly thumb
or finger.
■
Oral drive theory: Sears and Wise (1982)
They suggested that the strength of the oral drive
is in part a function of how long a child contin
ues to feed by sucking. Thus, thumb sucking is
the result of prolongation of nursing;' and not
the frustration of weaning. This theory agrees
with Freud’s theory that sucking increases the
erotogenesis of the mouth.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT I ¿jklB
Table 9.9: Influence of different variables on incidence and prevalence of thumb sucking habit
Variables
Relationsh ips
Study
Age
No evidence of thumb sucking in neonates.
2- 5 years - 17.3%
upto 7 years - 45%
Levin and Kaye 1964
Singhal and Bhatia 1988
Garathini et al 1990
Relatively low incidence in preschool children.
Traisman and Traisman,
Robert, Brazelton
1956-1958
Even distribution in school going children except in
six years or older children who were engaged in
slight sucking habit.
Backlund 1963
No correlation in gender in neonates.
Levin and Kaye 1964
In infants and children no significant difference
between boys and girls.
Traisman and Traisman
1958
Even distribution among boys and girls in school
going children
Backlund 1963
Race
Significantly low incidence found in Negroid races.
Brenchley 1992
Pacifier
Related to low incidence of thumb sucking at 5 years
Ravn 1976
Feeding
methods
Increase incidence in a low duration breast feeding
Longer feeding leads to habit
Significant relationship between duration and
intensity of thumb sucking and amount of time
spent in feeding sessions
Levy 1928
Gender
Robert 1944
Yarrow 1954
Siblings
No correlation between level of the habit and number
of siblings with the habit.
Larsson et al. 1971
Parental
status
High incidence among children of professionals
Popovich and Thompson 1973
No incidence of thumb sucking
Dahlborg, Qwen and
Moghall 1969.
CE9 I TEXTBOOK OF PEDÔDONTICS
Non-nutritive
Frustration
Fig. 9.40 Etiology of different sucking habits
■
Johnson and Larson (1993)
They believed that it is a combination of psy
choanalytic and learning theories which explains
that all children posses an inherent biologic drive
for sucking. The rooting and placing reflexes are
merely a means of expression of this drive. En
vironmental factors also may contribute to this
sucking drive to nonnutritive sources such as
thumb or fingers. (Fig. 9.40)
Maintenance of the habit
Most children would cease digit sucking early in
their developmental process by the age of three to
four years. But an acute increase in the child's level
of stress or anxiety due to some underlying
psychologic or emotional disturbances can account
for continuation of a digit sucking habit, with con
version of ah empty habit into a meaningful stress
réduction response. Therefore, direct therapy has
been linked to unfavourable results, such as symp
tom substitution. This makes it very clear that be
fore initiating treatment try to grasp the possible
psychologic disturbances, whereas with a learned
habit it follows that direct and aggressive treatment
of the habit would not place the patient at risk for
symptom substitution.
Causative factors
«
Parent’s occupation
This can be related to the socioeconomic status
of the family. Families living in high socioeco
nomic status are blessed with ample sources of
nourishment. The mother is in a better position
to feed the baby and within a short time the ba
by's hunger is satisfied. Mothers belonging to
the low socio-economic group is unable to pro
vide the infant with sufficient breast milk. Hence,
in the process the infant suckles intensively for
a long time to get the required nourishment,
thereby also exhausting the sucking urge. The
development of a sucking habit is said to be as a
way of rechanneling the surplus sucking urge.
This theory explains the increase in incidence
of thumb sucking in industrialised areas when
compared to rural areas. The African children
needed to suck intensively for a long time to get
sufficient nourishment. Thus they exhausted the
whole of their sucking urge.
■
Working mother
The sucking habit is commonly observed to be
present in children with working parents. Such
children brought up in the hands of a caretaker
may have feelings of insecurity. Therefore, they
use their thumb to obtain a secure feeling.
■
Number of siblings
The development of the habit can be indirectly
related to the number of siblings. As the number
increases the attention meted out by the parents
to the child gets divided. A child neglected by
the parents may attempt to compensate his feelings of insecurity by means of this
habit.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT I
Order of birth of the child
It has been noticed that the later the sibling rank
of a child, the greater the chance of having an
oral habit. It has been speculated that to some
extent siblings imitate one another in sucking
Social adjustment and stress
Digit sucking has also been proposed as an
emotion based behaviour related to difficulty with
social adjustment or with stress. Although suck
ing for psychological satisfaction as well as for
food is considered normal in infancy, digit suck
ing in older children has been told to be associ
ated with abnormal psychological development.
The psychological effects may be compounded
by the emotional impact of peer pressure and
punitive and scolding parents.
Feeding practices
Various controversies exist in this regard as to
the influence of feeding modes to the develop
ment of the habit. Thumb sucking is seen to be
more frequent among breast-fed children. Yet
abrupt wdaning from the bottle or breast has also
been hypothesized to contribute to acquiring an
oral habit A negative relation is also seen be
tween breast-feeding and the development of
dummy or finger sucking.
Age °f
child
The time of appearance of digit sucking habit has
significance.
In the neonate’. Insecurities are related to
primitive demands as hunger.
During the firstfew weeks of life’. Related to
feeding problems.
During the eruption of the primary molar. It
may be used as a teething device.
Still later. Children use the habit for the re
leases of emotional tensions with which they
are unable to cope, taking refuge in regress
ing to an infantile behaviour pattern.
In spite of contrasting views regarding the
etiology there is some agreement that if the habit
continues beyond the age of 6-7 months it is
difficult to break it until the child is 4-5 years.
Thus it was suggested that the habit should be
viewed by the clinician as a behavioural pattern
of multivariate nature. Thumb sucking may be
gin for one reason and be sustained by other fac
tors at different ages.
Diagnosis of digital habits
■ History
Determine the psychological component in
volved
Question regarding the frequency, intensity
and duration of the habit
Enquire the feeding patterns, parental care of
the child.
The presence of other habits should be evalu
ated.
The diagnosis of a digit habit can also be obvi
ous when the child is actively performing the
habit. However, during a dental appointment a
child may seldom indulge in his habit.
■ Extraoral examination
Various key areas to be noted include the fol
lowing:
The digits (Fig. 9.41)
Digits that are involved in the habit will ap
pear reddened, exceptionally clean, chapped
Fig. 9.41 Callus formation on the thumb as a
result of thumb sucking
| TEXTBOOK OF PEDODONTICS
and with a short fingernail i.e. a clean dishpan
thumb. Fibrous roughened callus may be
present on the superior aspect of the finger
The habit is also known to cause deformation
of the finger.
Lips
Upper lip may be short and hypotonic. Note
the position of lips at rest whether they are
held together or apart. The position of the lips
during swallowing should also be observed.
Chronic thumb suckers are frequently char
acterized by a short, hypotonic upper lip. Rela
tive tensions of the upper and lower lips also
plays a role during swallowing. Upper lip
passive or incompetent during swallowing.
Lower lip is hyperactive and this leads to a
further increase in the proclination of upper
anteriors due to its thrust on these teeth.
■
Intra oral examination
Tongue
Examine the oral cavity for correct size and
position of the tongue at rest, tongue action
duringswallowing.
Dento alveolar structures
Individuals with severe finger or thumb suck
ing habits, where the digit applied an ante
rior superior vector to the upper dentition and
palate, will have flared and proclined maxil
lary anteriors with diastemas and retroclined
mandibular anteriors (Fig. 9.42).
Facial form analysis
Check for mandibular retrusion, maxillary
protrusion, high mandibular plane angle, and
profile.
When swallowing, the patient is observed for
presence of a facial grimace or an excessive
mentalis muscle contraction, a normal place
ment of the tongue against the teeth and pal
ate and whether the pa ttern of speech of the
child is essentially normal. Facial profile is
either straight or convex.
Other features
Features caused due to the presence of other
habits along with thumb sucking. Associated
symptoms that should be watched for during
the initial examination are habitual mouth
breathing and tongue thrust swallow, particu
larly in children with anterior openbite. Ac
tive thumb suckers also have a higher inci
dence of middle ear infections and frequently
have enlarged tonsils accompanied by mouth
breathing. Features of secondaiy habits have
to be noted.
Fig. 9.42 Forces acting on teeth while thumb
sucking
Other intraoral symptoms will include a high
probability of buccal crossbite, particularly in
those children who suck their digits with a
pronounced constriction of their buccal mus
culature and a tendency to narrow palates.
Observe the symmetry of incisal position of
upper central and lateral incisors. Asymmetry
indicates that the child sucks the right or left
thumb or finger by preference. Measure di
mensions of over-jet and open bite if present.
Gingiva
Look for evidence of mouth breathing;
gumline etching, decayed or excessive stain
ing on the labial surface of the upper central
and lateral incisors.
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT I <№>
Clinical Findings
A digit sucking habit can present without ill effects.
However various malocclusions can occur in the pri
mary and permanent dentitions.
■
Constriction ofmaxillary arch
This may be because of the failure of the maxil
lary arch to develop in width due to an altera
tion in the balance between cheek and tongue
pressures. If the thumb is placed between the
teeth, the tongue must be lowered, which de
creases pressure by the tongue against the lin
gual surfaces of the upper posterior teeth. At the
same time, cheek pressure against the teeth is
increased as the buccinator muscle contracts dur
ing sucking. Cheek pressures are greatest at the
corners of the mouth and this probably explains
why the maxillary arch tends to become 4V’ shaped with more constriction across the canines
than the molars.
■
Posterior cross bite
This occurs as a consequence of constriction of
the maxillary arch. The unbalanced muscle
forces on the maxilla exerted by the cheek mus
cles are unmet by the pressure from the lingual
musculature which are normally present. While
this results in a maxillary constriction, there is
no restriction to the mandibular growth eventu
ally leading to a cross bite.
The type of malocclusion produced by digit suck
ing is dependent on a number of variables (Nanda
1989)
1. Position of the digit
2. Associated orofacial muscle contractions
3. Mandibular position during sucking
4. Facial skeletal pattern
5. Intensity, frequency and duration of force ap
plied.
Commonly observed clinical problems
■
■
Maxillary anterior proclination and mandibu
lar retroclination
When a child places a thumb or finger between
the teeth, it is usually placed at an angle so that
it presses lingually against the lower incisors and
labially against the upper incisors. This direct
pressure is responsible for the displacement of
the incisors. There can be variation depending
on which teeth are affected, how much, which
teeth are contacted, and the number of hours per
day of sucking and the magnitude of pressure.
Intermittent vigorous sucking does not cause as
much malocclusion as that seen in a habit of 6
hours or more, especially as seen in children who
sleep with the thumb or finger between the teeth
all night long.
The anterior open bite
This type of malocclusion arises due to a combi
nation of factors
1. Interference with normal eruption of incisors
due to an interposed thumb.
2. Excessive eruption of posterior teeth due to
separation of the jaws, which alters the verti
cal equilibrium on the posterior teeth, 1mm
of elongation posteriorly opens the bite by
about 2mm anteriorly
Dentofacial changes associated with prolonged
nutritive sucking habits are given in Table 9.10
Prevention
■ Motive based Approach
The etiology of thumb sucking focusses on a pre
dominant psychological background. It’s preven
tion should be directed towards the motive be
hind the habit Histoiy serves as an important
tool for diagnosing the etiology, whether the
habit is meaningful or empty
■
Child’s engagement invarious activities
Parents when questioned may reveal that the
child practices the habit when bored and left to
himself or it could be just before he goes to ^fjp<
In such cases, the parents can be c<
keeping the child engaged in various
* |
:,'S
■ '■
S-
СЕЭ I TEXTBOOK OF PEDODONTICS
Table 9.10: Dentofacial changes associated with prolonged nutritive sucking habits
Effects on the maxilla
Increased proclination of the maxillary incisors
Increased maxillary arch length
Increased anterior placement of apical base of the maxilla
Increased SNA
Increased clinical crown length of the maxillary incisors
Increased counterclockwise rotation of the occlusal plane
Decreased SN to ANS-PNS angle
Decreased palatal arch width
Increased atypical root resorption in primary central incisors
Increased trauma to maxillary central incisors
Effects on the mandible
Increased proclination of mandibular incisors
increased mandibular intermolar distance
Increased distal position of B point.
Effects on the interarch
relationship
Decreased maxillary and mandibular Incisal angle
Increased overjet
Decreased overbite
Increased posterior cross-bite
Increased unilateral and bilateral Class II occlusion
Effects on lip placement
and function
Increased lip incompetence
Increased lower-lip function under the maxillary incisors
Effects on tongue
placements and function
Increased tongue thrust
Increased lip to tongue resting position
Increased lower tongue position
Other effects
Risk to psychologic health
K
Increased risk of poisoning
Increased deformation of digits
Increased risk of speech defects, especially lisping
*
(Johnson and Larson 1993)
This gives little chance for the child to practice
the habit. The child can be encouraged to follow
his hobbies of interest such as painting or en
gaging in outdoor activities with his fellow
mates. These measures can be followed when the
parents are working.
Parent’s involvement in prevention
When the parents are at home they should be
advised to spend ample time with the child so as
to put away his feeling of insecurity. At night
this can again be reinforced by playing soothing
music or by telling good bedtime stories till the
child falls asleep.
■
Duration of breast feeding
Care should be taken w7hen feeding infants in
that the duration of feeding should be adequate
so as to enable the child to exhaust his sucking
urge and feel completelly satisfied.
«
Mothers presence and attention during bottle
feeding
Bottle-fed babies should be held by the mother
and enough attention should be given in the proc
ess. This will promote a close emotional union
between the mother and the baby similar to that
seen in breast-feeding.
SECTION 9: DEVELOPING MALOCCLUSION AND ITS MANAGEMENT J
■
■
Use of a Physiological nipple
A physiological nipple should be used for bot
tle-feeding and the size and number of the hole
should be standardized to regulate a slow and
steady flow of the milk.
Use of a dummy or pacifier
Acquiring a digit sucking habit can be prevented
by encouraging the baby to suck a dummy in
stead. If the child has already found his thumb
or fingers, it will not be easy to introduce the
dummy. Because not all babies start to suck their
thumbs, it is only necessaiy to offer a dummy to
a child whose behaviour indicates an urgent de
sire to suck a digit or dummy. Dummies are easier
to dispense with at an earlier age than is digit
sucking.
digit sucking continues after 6 years or into
mixed dentition, the malocclusion will not selfcorrect.
■
Motivation of the child to stop the habit
It is also important to assess the maturity of the
child in response to new situations and to ob
serve the child’s reactions to any suggestion. The
treatment approach for the digit sucking habit
should deal directly with the child. The first
ingredient needed to stop the habit is the child’s
desire to stop.
■
Parental concern regarding the habit
If the parent is unable to cope with the situation
positively then both the parent and the child
should be dealt with during treatment. The par
ents should become silent partners. It is impor
tant that the child should not be embarrassed or
criticized, rather help should be offered to deal
with this difficult liabit. Negative reinforcements
in the form of threats, nagging and ridicule
would only entrench the habit.
■
Otherfactors
Self-correction again depends on the severity of
the malocclusion, anatomic variation in the
perioral soft tissue, and the presence of other oral
habits, such as tongue thrusting, mouth breath
ing and lip biting habits.
Treatment considerations
■
Psychological status of the child
Diagnosis and management of any psychologi
cal problem should be planned before treatment
of any potential or present dental problem. The
frequency, duration and intensity of the oral liabit
are important in evaluating the psychological
status of the child. The events that precede the
habit such as the use of a security blanket, the
dependency on a favourite toy; problems with
sleep, nightmares, nervousness and anxiousness
will yield information concerning the possible
psychological stimuli of the habit. If the oral
habit was associated with an emotional problem
this would suggest the need for psychological
consultation.
» Age factor
If the child desists with the finger sucking habit
within the first three years of life, the damage
incurred such as open bite, is temporary provided
the child’s occlusion is normal. No treatment is
provided in this age group. If a malocclusion is
caused by digit sucking and the habit is discon
tinued between the age of 4 and 5 years, self
correction of the habit can be expected. When
Treatment
The treatment plan can be broadly divided into the
following:
1. Psychological therapy
« Screen the patient for the underlying psycho
logical disturbances that sustain a thumb suck
ing habit Once psychological dependence is
suspected, the child is referred to profession
als for counselling.
■ Thumb sucking children between the ages of
4 and 8 years of age need only reassurance,
positive reinforcement and friendly remind
ers.
I TEXTBOOK OF PEDODONTICS
« Awareness of the habit can be accomplished
by emphasizing the positive aspects of habit
cessation. Various aids are employed to bring
the habit under the notice of the child such as
study models, mirrors, etc.
« Children and parents are informed about ex
isting dentofacial deformities and the long
term risks of a sustained habit. Patients should
be presented with positive mental and visual
images of the dentofacial ideals expected from
habit cessation and subsequent orthodontic
treatment.
■ During the treatment adequate emotional sup
port and concern should be provided to the
child by the parents.
■ Destructive approaches in the form of nag
ging, shamming and belittling ought to be
strictly avoided.
• Constant reassurance and encouragement
should be provided to the patient to gain his
confidence.
• The use of positive behaviour modification
techniques and even hypnosis has been effec
tive in digit habit therapy. When the habit is
discontinued, the child can be rewarded with
a favourite new toy or special outing.
■ Dunlop’s beta hypothesis: He believed that if
a subject can be forced to concentrate on the
performa nce of the act at the time he practises
it, he can learn to stop performing the act.
Forced purposeful repetition of a habit
eventually associates it with unpleasant reac
tions and the habit is abandoned. The child
should be asked to sit in front of a mirror and
asked to suck his thumb, observing himself
as he indulges in the habit.
2.
Reminder therapy
This can be divided into the following:
• Extra oral approaches (Fig. 9.43a, b)
It employs hot tasting, bitter flavoured prepa
rations or distastefill agents that are applied
to finger or thumbs. For example, Cayenne
pepper, quinine, asafoetida. This is effective
only when the habit is not firmly entrenched.
Fig. 9.43a Thumb sucking habit
Fig. 9.43b Thumb sucking habit corrected with
thumb cap
Thermoplastic thumb post was devised by
Allen in 1991 where a thermoplastic mate
rial was placed on the offending digit. A total
of 6 weeks of treatment time was required for
elimination of habit.
■ Intraoral appproaches
Various orthodontic appliances are employed
to attenuate and eventually break the habit.
Removable appliances used may be palatal
crib, rakes, palatal arch, lingual spurs.
Hawley’s retainer with and without spurs.
Fixed appliances such as upper lingual tongue
screens appear to be more effective in break-
SECTION 9 : DEVELOPING MALOCCLUSION AND ITS MANAGEMENT | gRIjl
ing these habits. If the child has made appre-.
ciable changes in his habit by 3 months, the
appliances can be safely removed for a test
ing period. If gross signs of anxiety are
aroused e.g. bed wetting, bad dreams, etc, the
appliance should be removed.
3. Mechanotherapy
Fixed intra-oral anti thumb sucking appliance
Most effective mechanical deterrent to thumb
sucking is an intraoral appliance attached to the
upper teeth by means of bands fitted to the pri
mary second molars or the first permanent mo
lar. A lingual arch forms the base of the appli
ance to which are added interlacing wires in the
anterior portion in the area of the anterior part
of the hard palate. It works by preventing the
patient from putting the palmer surface of the
thumb in contact with the palatal gingiva,
thereby robbing the pleasure of sucking.
Blue grass appliance
Haskell (1991) introduced this appliance, for
children with a continued thumb sucking habit,
which is affecting the mixed or permanent den
tition. It consists of a modified six sided roller
machined from Teflon to permit purchase of the
tongue. This is slipped over a 0.045 stainless
steel wire soldered to molar orthodontic bands.
This appliance is placed for 3-6 months. Instruc
tions are given to turn the roller instead of suck
ing the digit. Digit sucking is often seen to stop
immediately.
Quad helix
This appliance prevents the thumb from being
inserted and also corrects the malocclusion by
expanding the arch.
TONGUE THRUSTING
In embryonic life, the developing tongue is consid
ered disproportionately large in comparison to the
developing mandible and it fills the embryonic na
sal cavity.
The lower jaw of the infant is usually behind the
upper jaw. Vertically a space is present between the
gum pads. During the infantile swallow the tongue
is between the gumpads in close apposition with
lips and its contraction plus those of the facial mus
cles help to stabilize the mandible. The mandibular
elevators show a minimal activity.
During the latter half of the first year of life, sev
eral maturational events occur that alter the func
tioning of the orofacial musculature. With the ar
rival of incisors the tongue assumes a refracted pos
ture and initiates the learning of mastication. As
soon as bilateral posterior occlusion is established,
true chewing motions are seen to start and the learn
ing of the mature swallow begins. Gradually the fifth
cranial muscles assume the role of mandibular
stabilization during the swallow. The muscles of fa
cia t expression begin to learn the delicate and
.complicated functions of speech and facial
expression.If the transition of infantile to mature
swallow does nottake place with the eruption ofteeth,
then it leads to what is known as the tongue thrust
swallow.
Definitions
■
Brauer - 1965 A tongue thrust was said to be
present if the tongue was observed thrusting be
tween, and the teeth did not close in centric oc
clusion during deglutition.
■
Tulley 1969 - States tongue thrust as the for
ward movement of the tongue tip between the
teeth to meet the tower lip during deglutition
and in sounds of speech, so that the tongue be
come

Textbook of Pedodontics – Pediatric Dentistry by Shobha Tandon

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