Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Lobes
-lobes are primary centers of ossification in tooth development
-lobes separated by developmental grooves in post. teeth and by developmental depression in ant. teeth
-all anterior teeth have 4 lobes (3 facial and 1 cingulum)
-premolars have 4 lobes (3 buccal and one lingual); mand. 2PM has 5 lobes (3 buccal, 2 lingual)
-1st molars have 5 lobes (1 for each cusp)
-2nd molars have 4 lobes (one for each cusp)
-3rd molars have at least 4 lobes
Angle’s Occlusion
1) Class I: max. 1M MB cusp fits into mand. 1M buccal groove
- mesial slope of max. canine coincides with the distal slope of mand. canine
2) Class II: max. 1M MB cusp mesial to mand. 1M buccal groove
- mesial slope of max. canine lies distal to the distal slope of mand. canine
3) Class III: max. 1M MB cusp distal to mand. 1M buccal groove
- mesial slope of max. canine lies distal to the distal slope of mand. canine
Anomalies of Shape
1) Dens evaginatus: extra cusp (talon cusp in incisors)
-extra cusp has enamel, dentin, and pulp so must be careful in restorative procedures
2) Dens invaginatus (dens in dente): caused by invagination of inner enamel epithelium
-termed “tooth within a tooth”
-most common in permt max. lateral incisors
-if enamel and dentin not formed correctly within defect, a direct communication with pulp can occur
-treated w/ small restoration or sealant to prevent pulpal involvement
3) Taurodontism: long vertical pulp chambers and short roots
4) Dilaceration: bent/twisted root occurring as result of intrusive or displacement injury to primary predecessor
-dilaceration also common in congenital ichthyosis
Anomalies of Structure
1) Enamel hypoplasia: refers to deficiency in QUANTITY of enamel
-no interproximal contact btw teeth
-causes: 1) genetic: amelogenesis imperfecta
2) environmental: systemic dx (fever), fluorosis, nutritional defic. (vit A, C, D, Ca, Ph)
2) Enamel hypocalcification: refers to deficiency in QUALITY of enamel
-also has genetic and environmental causes
3) Amelogenesis imperfect (AI): related to enamel only and dependent on stage of enamel formation (enamel
hypoplasia)
-normal root and pulp morphology
1) Type I: Hypoplastic (inadequate QUANTITY of enamel)
2) Type II: Hypomaturation (inadequate MATURATION of enamel)
3) Type III: Hypocalcified (inadequate QUALITY/mineralization of enamel
4) Dentinogenesis imperfect (DI): predentin matrix is defective, resulting in amorphic, atubular dentin
-teeth are reddish-brown to gray color
-slender roots
-small or absent pulp chambers/canals
1) Type I: osteogenesis imperfecta, blue sclera, hearing loss
2) Type II: no osteogenesis imperfecta (most common type)
3) Type III (Brandywine type): multiple periapical radiolucencies
5) Dentin dysplasia
-Shield type I: Normal anatomy. Short, pointed roots. Absent pulp chambers/canals. Multiple periapical
radiolucencies
-Shield type II: Primary teeth similar to DI. Permanent teeth have pulp stones, thistle tube shaped
chambers, no periapical radiolucencies
Behavior Management – the means by which the dental health team effectively and efficiently performed treatment
for a child and at the same time instills a positive dental attitude.
Behavior Shaping – the procedure which slowly develops behavior by reinforcing a successive approximation of
desired behavior until desired behavior comes into being.
Behavior Modification – the attempt to alter human behavior and emotion in a beneficial manner according to laws
of modern learning theory.
Aversive Conditioning
-psychological strategy that uses some form of negative stimulus w/ purpose of extinguishing or improving negative
behavior
-indicated for children over 3 yrs of age that are momentarily uncontrolled or defiant
-not indicated for children under 3 yrs, timid, tense-cooperative, or lack cooperative ability (mentally challenged)
-several variations of aversive conditioning exist:
a) voice control (use firm tones)
b) hand-over-mouth exercise (HOME)
-aversive conditioning should always be followed by positive reinforcement for improved behavior
-communication w/ parent before and after aversive conditioning is a necessity
-aversive conditioning exposes dentist to liability so parental informed consent should be obtained prior to use
Topical Anesthetics
-a good, long-lasting benzocaine topical is recommended
-benzocaine has rapid onset
-dry the mucosa w/ gauze first, then apply topical for minimum of 30 seconds
Conscious Sedation
-minimally depressed level of consciousness that retains pt’s ability to independently and continuously maintain an
airway and respond appropriately to physical stimulation or verbal commands
-inhalation route is most frequently used route for sedation in pedo (N20)
Signs of Saturation
1) Continuously reminding child to keep mouth open
2) No response to questions
3) Agitation
4) Sweating
5) Nausea
6) Unconsciousness
Diffusion Hypoxia
-when NO is discontinued, there is a high outpouring of NO from tissues into lung, which dilutes available oxygen
in lungs
-can be prevented by giving 100% oxygen for 3-5 minutes following nitrous oxide procedure
Pulp Capping
1) Indirect pulp cap
a) Indications: pt is symptom free, no radiologic evidence of pathology, and minimal caries in area that
would cause pulp exposure if removed
b) Procedure: remove caries except that right on pulp; place CaOH and base, restore tooth, re-enter in 6-8
weeks to remove rest of caries
2) Direct pulp cap
a) Indications: small pinpoint exposure that is non-carious and symptom free
b) Procedure: place CaOH over pulp exposure and restore tooth
Pulpotomy
-coronal removal of vital pulp tissue
1) Indications
a) vital primary tooth w/ carious exposure
b) clinical signs of normal pulp canal (no swelling, drainage, or pathologic mobility, no symptoms)
c) tooth is restorable
2) Procedure
a) Remove superficial and lateral decay
b) Remove roof of pulp chamber
c) Remove coronal pulp w/ #4 round bur in slow speed w/ light pressure
d) Place dry cotton pellets to arrest pulpal bleeding
e) Five minute formocresol application
-if hemorrhage can’t b stopped, consider pulpectomy or 2-visit pulpotomy
f) Build up in ZOE and place stainless steel crown
3) Medicaments
a) Formocresol: most commonly used medicament for pulpotomies
-consists of 35% cresol, 19% formalin in glycerine solution
-formocresol may be toxic
-acts by direct contact
b) Ferric sulfate
-success rates comparable to formocresol and is less toxic
c) MTA
-have shown higher success rates than formocresol
Pulpectomy
-complete removal of all remaining pulp tissue
1) Indications
a) Necrotic or chronically inflamed pulp in tooth that is strategically located
b) Normal supporting bone
2) Contraindications
a) Non-restorable tooth
b) Internal or external root resorption
c) Tooth doesn’t have accessible canals (primary 1st molars)
d) Significant bone loss
3) Procedure
a) Remove coronal pulp, irrigate chamber w/ NaHClO, remove radicular pulp w/ small file
b) Obtain working length and enlarge canal 3 file sizes
c) Fill canal w/ ZOE by using syringe and condensing
d) Build up tooth in ZOE and place SSC
-if there is LINGUAL ectopic eruption of permt incisors, giving double row of teeth, you can let primary incisors
exfoliate if mobile or else you should extract them
-the permt incisors will move labially once this is done
-there can be LATERAL ectopic eruption where central incisors erupt into lateral incisor position, causing early
exfoliation of a primary lateral
-this can result in midline deviation so other primary lateral should be extracted
Gingivitis
-very common in children and treated w/ improved oral hygiene
-parental participation needed in oral hygiene in children under 8 yrs old due to lack of manual dexterity
-parental supervision may be needed in children over 8 yrs due to lack of interest or understanding of consequences
-common conditions in children can aggravate gingivitis:
a) mouth breathing c) erupting teeth
b) crowded teeth d) braces
Puberty Gingivitis
-characterized by enlarged, bulbous interproximal gingival tissue on labial aspects of anterior teeth
-treatment involves improved OH, removing local irritants, and nutrition counseling
Tetanus Coverage
1) Uncovered children: give antitoxin (tetanus immune human globulin)
2) Children w/ previous coverage but outdated: toxoid booster
3) Active immunization: no need for booster
-active immunization includes:
a) 3 injxns of diphtheria, pertussis, and tetanus (DPT) vaccine during first year
b) booster at 1.5 and 3 yrs
c) booster at 6 yrs and then every 4-5 yrs
Lateral Luxation
-displacement in axial direction
-torn PDL w/ contusion or fx of bone
-nontender and nonmobile
-txt: allow passive repositioning if possible, but if not then actively reposition and splint for 1-2 wks
-active repositioned tooth will more likely have necrosis than passively repositioned
Intrusion
-apical displacement into alveolar bone
-unless it is determined that the root of intruded primary tooth is impinging on permt successor, it is left alone in
hopes it will re-erupt on its own
-should be extracted if endangering permt tooth
-tooth should be x-rayed
Extrusion
-partial displacement of tooth out of socket axially
-the greater the distance from normal position, the greater chance of severing apical vasculature and pulpal necrosis
-tooth can be repositioned and splinted for 7-14 days
-endo txt should be done to prevent pulpal necrosis which can cause problems in permt tooth
Fractures
1) Enamel only: smooth enamel and check vitality at 1, 2, 6 months due to possibility of concussion
2) Enamel and dentin: smooth edges and restore; check vitality at 1, 2, 6 months
3) Enamel, dentin, and pulp:
a) vital pulp: pulpotomy
b) necrotic pulp w/o internal/external resorption: pulpectomy
c) Necrotic pulp w/ resorption: extraction
Avulsion
-replanting primary teeth has poor prognosis
-can be considered if within 30 minutes
-if replanted, splint, recommend soft diet, give antibiotics, and follow w/ pulpectomy
-antibiotics following replantation:
a) doxycycline
b) Pen VK (if susceptible to tetracycline staining in permt teeth)
-PRIMARY TEETH SHOULD NOT BE REPLANTED
Ellis Classification
1) Class I: involves little or no dentin
-enameloplasty or bonding
2) Class II: involves dentin but not pulp
-CaOH or GI
3) Class III: involves pulp
-pulp therapy and restoration
4) Class IV: loss of entire crown
-pulpectomy and SSC
5) Class V: teeth avulsed
6) Class VI: fracture of root w/ or w/o loss of crown
7) Class VII: displacement of tooth w/ or w/o loss of crown
8) Class VIII: fracture of crown en masse
9) Class IX: traumatic injuries to primary dentition
Root Fracture
-root fractures in primary teeth are rare due to malleable bone surrounding roots
a) Fracture in apical half: splint or no txt if mobility minimal
-fxs in apical 1/3 most likely to undergo repair
b) Fracture in coronal half: rigid splint or extraction
Splinting
-use stainless steel ortho wire which must be passive (not putting pressure on teeth)
-fix to teeth w/ composite
-long-term splinting of primary teeth increases risk of ankylosis and should be avoided
Fluoride Facts
1) Food and Nutrition Board recommends public water supplies be fluoridated when levels are significantly below
0.7 mg/L
2) Fluoride intake of 20-40 mg/day can inhibit enzyme phosphatase
-phosphatase needed for calcium utilization in tissues (bones and teeth)
3) Fluoride intake of 40-70 mg/day can cause heartburn and pain in extremities
4) Fluoride can displace calcium in body, as well as calcium displacing fluoride (calcium treats fluoride toxicity)
5) Topical fluoride does not cause fluorosis, only systemic
6) School water fluoridation is 4.5x city water
7) Greatest conc. of fluoride at outermost enamel layer
8) Proximal and smooth surfaces benefit most from fluoride
9) Fluoride excreted by kidney
10) Toothpaste contains 1100 ppm fluoride (1% F-)
Types of Fluoride
1) 2% Sodium fluoride (NaF): neutral pH (~9), acceptable taste, no adverse effects on restorations
2) 8% stannous fluoride (SnF2): nonstable, bad taste, stains restoration margins
-pH of 2 (acidic)
3) 1.23% acidulated phosphate fluoride (APF): acceptable taste, can cause etching of porcelain and composites
-pH of 3 (acidic)
Fluorosis (Mottling)
-enamel hypoplasia char. by chalky white spots or brown staining and pitting of teeth from increased fluoride levels
affecting enamel matrix formation and calcification
-excessive fluoride impairs ameloblastic fxn
-severity increases w/ increasing amt of fluoride (low-dose, long-term excess)
-children living in temp. zones where water supply contains higher content of fluoride are most affected
-is irreversible condition
Thumb-Sucking Habits
-common up to age 3
-risk of malocclusion= time/day habit performed x duration of habit (weeks, months) x intensity of habit
-effects of thumb-sucking:
1) increased overjet (proclined max. anteriors and retroclined mand. anteriors)
2) anterior open bite (supraeruption of posterior teeth)
3) posterior crossbite (tongue not positioned btw max. alveolus and cheek constriction)
4) class II malocclusion
-txt: recommended intervention at age 5-6 yrs if child still has habit
Teething
-symptoms: rise in temp, drooling, diarrhea, dehydration, and loss of appetite
-symptoms can be reduced by using chilled teething rings w/ possible use of topical anesthetics and non-aspirin
analgesics
Cleft Palate
-combined cleft lip and palate more common than cleft palate alone
-isolated cleft palate more common in females
-4 classes:
1) Class I: only soft palate
2) Class II: soft and hard palates but not alveolar process
3) Class III: soft and hard palate and involves alveolar process on one side of premaxilla
4) Class IV: soft palate and continues through alveolus on both sides of premaxilla
Cleft Lip
-more common in males
-more common on left side than right
-4 classes:
1) Class I: unilateral notching of vermilion not extending to lip
2) Class II: unilateral notching that extends into lip but not to floor of nose
3) Class III: unilateral notching that extends into floor of nose
4) Class IV: any bilateral clefting of lip
Clefting-Associated Syndromes
1) Stickler’s syndrome
2) Van der Woude’s syndrome
3) DiGeorge syndrome
Growth Facts
1) At age 6, child’s head is 90% of its adult size
-brain and neural tissues are fully developed at age 6
2) At birth, jaw is large enough to accommodate all primary teeth
3) At birth, width of face has reached greatest percentage of its adult size
4) At birth, palate is pretty flat
5) From age 6-12, lymph tissue is 200% of its adult mass
Neuroblastoma
-most common malignant tumor in neonates
Down Syndrome
-has high incidence of perio dx but low incidence of caries
-other characteristics:
1) hypoplasia of midface
2) prognathic class III occlusion w/ open bite
3) macroglossia
4) mouth breathers