PEDIATRIC DENTISTRY

Preclinical Laboratory Syllabus

and

Clinical Manual






This manual must be brought to all Pediatric
Dentistry rotations in the 3
rd
and 4
th
years.
2






























Revision March 2007


Dr. Robert Berson
Course director
Dr. Sharon Freudenberger
Lecturer
Dr. Clarice Law
Assistant Professor
3
INTRODUCTION

This manual is intended to serve as a guide in your preclinical lab course as well
as in your clinical experience. The information contained within will aid in your
understanding of the basic concepts necessary in the treatment of the child in the
primary, mixed and early permanent dentition.


MODULE 1

Restorative Projects:

1. Apply the principles of rubber dam application by properly placing a
rubber dam for restorative procedures.
2. Describe the morphological and histological differences between the
deciduous and permanent dentitions and how these differences require
modifications in the restorative procedure.
3. Apply the general principles of cavity design for the various classes of
caries in deciduous teeth by preparing and restoring typodont teeth.
4. Apply the principles of tooth and crown preparation for stainless steel
crowns by preparing and fitting typodont teeth.

Appliance Projects

1. Apply the principles of appliance construction by fabricating a lower
lingual holding arch (LLHA) space maintainer.


MODULE 2

1. Given a childs sample dental record, relate the data presented to
correlate medical and dental histories, oral examination, radiographic
findings, and model analysis: and formulate a preliminary treatment
plan giving proper consideration to the childs need for preventive,
restorative and orthodontic intervention.
2. Given a laboratory case, compute an arch length analysis, correlate
the information with other diagnostic aids available, and describe the
needs for dental intervention.
3. Identify the various occlusal patterns, arch forms, tooth arrangements,
and observable soft tissue irregularities that are depicted from a given
set of dental study casts.
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TABLE OF CONTENTS

RUBBER DAM APPLICATION ................................................................................................. 5
CLASS II CAVITY PREPS ........................................................................................................ 7
MANDIBULAR RIGHT 2
ND
PRIMARY MOLAR #T ................................................................. 8
MANDIBULAR RIGHT 1
ST
PRIMARY MOLAR #S ................................................................. 13
MAXILLARY LEFT 1
ST
PRIMRY MOLAR #I ............................................................................ 13
MANDIBULAR LEFT 1
ST
PERMENANT MOLAR #19 ............................................................ 15
MAXILLARY LEFT 2
ND
PRIMARY MOLAR #J ........................................................................ 16
MATRIX APPLICATION ............................................................................................................ 17
CLASS III CAVITY PREPS ....................................................................................................... 20
MANDIBULAR LEFT CUSPID #M ........................................................................................... 20
CLASS V CAVITY PREPS ....................................................................................................... 23
MAXILLARY LEFT LATERAL INCISOR #G ............................................................................ 23
STRIP CROWNS ...................................................................................................................... 24
MAXILLARY LEFT CENTRAL INCISOR #F ........................................................................... 25
STAINLESS STEEL CROWNS: #J AND #L .......................................................................... 27
LOWER LINGUAL HOLDING ARCH ....................................................................................... 34
PATIENT EXAMINATION & TREATMENT PLANNING ......................................................... 39
PROPHYLACTIC ANTIBIOTIC REGIMENS ........................................................................... 46
EXAMINATION CHECKLIST .................................................................................................... 49
OCCLUSION SUMMARY ......................................................................................................... 50
SUMMARY & TREATMENT PLAN .......................................................................................... 51
RADIOGRAPHIC GUIDELINES ............................................................................................... 53
MIXED DENTITION ANALYSIS ............................................................................................... 54
MOYERS MIXED DENTITION ANALYSIS WORKSHEET .................................................... 57
CLINICAL RESPONSIBILITIES ............................................................................................... 58
CARIES RISK ASSESSMENT TOOL (CAT) ........................................................................... 61
SAMPLE PATIENT QUESTIONNAIRES ................................................................................. 63
INJECTION PROCEDURE FOR THE PEDIATRIC PATIENT ............................................... 69
TECHNIQUE FOR FISSURE SEALANT ................................................................................. 73
ENDODONTIC TREATMENT OF PRIMARY TEETH ............................................................ 75
KNEE TO KNEE EXAM ............................................................................................................ 79
COMMON ANALGESICS ......................................................................................................... 81
COMMON PRESCRIPTIONS .................................................................................................. 82
BENEFITS OF FLUORIDE THERAPY .................................................................................... 84
MANAGEMENT OF DENTAL TRAUMA ................................................................................. 89
5
METHOD OF RUBBER DAM APPLICATION

Armamentarium

1. Rubber dam sheets, 5 X 5 or 6 X 6, pre-cut squares, medium or
light weight
2. U-shaped rubber dam frame.
3. Rubber dam clamp forceps
4. Rubber dam punch
5. Scissors
6. Dental floss and wooden wedges
7. Rubber dam clamps

Punching the dam

1. Place dam on Youngs frame, lightly stretch over four corner nubs.
2. Use appropriate size hole for a particular tooth.
3. Holes are punched to coincide with treated quadrant.
4. For a posterior tooth to be clamped, punch largest hole from an inked
horizontal line across the center of the dam (slightly below for
mandibular tooth and slightly above for a maxillary tooth). The punched
hole should be 1 ! inches from side of frame.
5. Additional holes, if needed, should be spaced 2-3 mm apart and
punched at a 45 degree angle toward the midline.
6. The number of teeth isolated is limited to the ones which are
necessary to accomplish the procedure.

Clamp selection and placement

1. Select the appropriate clamp.

a. W 14 A Ivory Partially erupted permanent molars
b. W 8 A Ivory Primary second molars or small permanent
molars
c. Ivory #4 with wings Primary second molars
d. 27 S. S. White Primary first molars; Small primary second
molars
e. 26 S. S. White Primary second molars; first permanent molars
f. 0 Ivory Permanent Incisors

2. Deliver clamp to tooth and gently push gingivally.
6
Placement

1. Carry dam and frame to mouth with tip of finger of each hand on
either side of hole.
2. Place hole over bow and spread downward with fingers; snap over
clamp.
3. Push additional rubber behind bow to minimize tension.
4. Stretch dam and expose remaining teeth.
5. Push dam through contacts and floss.
6. Reposition if necessary and secure dam to frame. Anchor dam with
floss, piece of rubber or wooden wedges.

Clinical Notes:

a. ALWAYS tie dental floss around bow of clamp prior to placing
clamp in patient.
b. NEVER leave child with rubber dam unattended.
c. NEVER leave anything in the mouth that is not visible to you at
all times (i.e. leaving cotton rolls under the rubber dam).

Dam removal

1. Cut ligated dental floss and interproximal septae
2. Be certain no part of rubber dam or floss remains.


7
Class II Preps. #T MO, #S DO, #I DO, #J MO
Restorations: #T Amalgam, #S Composite

Principles of Class II Cavity Preparation

Amalgam preparation:

The outline form for Class II restorations in primary molars can be seen in the
figures below:

Maxillary first and second primary molars (occlusal view).



Mandibular first and second primary molars (occlusal view).

The cavosurface margin should be placed out of stress-bearing areas and should
have no bevel. All internal angles should be slightly rounded. The buccolingual
walls should converge slightly in an occlusal direction. (Oblique ridges should not
be crossed unless they are undermined or are deeply fissured.)

The proximal box should be broader at the cervical portion than at the occlusal
portion. On primary molars there should be a distinct convergence of the buccal
and lingual walls of the proximal box. It is this convergence that supplies the
retention for the proximal box. The walls should parallel the respective buccal
and lingual surfaces, especially on the buccal surface, as a result of the distinct
bulge in the gingival third of the tooth.

The broad, flat contacts of primary molars necessitate comparatively greater
convergence for clearance into the embrasures.
The buccal, lingual, and gingival walls should all break contact with the adjacent
tooth, just enough to allow the tip of an explorer to pass. The wedge should be
just visible when contact is broken gingivally. This is equivalent to a 0.5 mm
clearance.

The buccal and lingual walls should create a 90-degree angle with the enamel.
The gingival wall should be flat, not beveled and all unsupported enamel should
8
be removed. Ideally the axial wall of the proximal box should be 0.5 mm into
dentin and should follow the same contour as the outer proximal contour of the
tooth. The mesiodistal width of the gingival seat should be 1 mm, which is
approximately equal to the width of the #330 bur.

It is essential that the isthmus nearest the proximal box be wide enough to
provide adequate bulk of amalgam. Just as in a Class I occlusal preparation, the
isthmus width should be one-third the intercuspal distance, plus or minus 0.5
mm.

Armamentarium

1. Typodont
2. Dental mirror
3. Explorer
4. Periodontal probe
5. Rubber dam equipment
6. Wedges
7. #330 bur, F.G., #1 and # ! round bur, finishing burs
8. Operative set, including instruments necessary to complete amalgam
and/or composite fillings i.e. condensers, hatchets, carvers, etc.
9. Articulating paper


Mandibular Right Second Primary Molar #T

Pertinent morphological features:

In general, the mandibular second primary molar is morphologically similar to the
first permanent molar. The primary molar is smaller in size and has more angular
(sharper) cusps. The mesial surface of the mandibular second primary molar
narrows toward the occlusal surface and is crossed by the mesial groove that
extends about one-third of the way from the occlusal surface toward the gingiva.
Contact with the first primary molar occurs just below the mesial groove. On the
distal surface contact with the first permanent molar is not as broad as the
contact of the mesial surface with the first primary molar. The distal surface is
smaller than the mesial surface and flattens toward the cervix.

Description of the lesion (Figure 1 and Figure 2)

In this example, it is assumed the incipient caries is present on the mesial
surface, just gingival to the contact area and in the occluso-lingual groove area.
9

Figure 1: A lesion shown from the distal surface. The lesion (black area) is gingival to the broad contact
area of the primary tooth (dotted line).

Figure 2: Mandibular right second primary molar with carious occlusal surface.


Description of the cavity preparation (Figure 3 and Figure 4)
.
Place rubber dam.
A wedge can be placed between #T and #S in order to prevent nicking the
adjacent tooth when preparing the proximal box.
The outline form should include retentive fissures but should be as conservative
as possible. Ideal pulpal floor depth is 0.5 mm into dentin (approximately 1.5 mm
from the enamel surface). The #330 bur is 1.5 mm and therefore an ideal tool for
gauging cavity depth.

The central groove of this tooth is prepared from the distal pit through the mesial
marginal ridge. The lingual and buccal grooves are also prepared to remove all
caries. The pulpal and axial wall depth is 1.25 to 1.5 mm. The isthmus ranges
from 1.0 to 1.25 mm. The converging buccal and lingual walls of the proximal box
curve smoothly into the occlusal portion of the preparation.



Figure 3: A Class II cavity preparation viewed from the proximal surface. Note the occlusal convergence of
proximal walls and that the gingival wall is slightly rounded and perpendicular to the long axis of the crown. .


Figure 4: Mandibular right second primary molar showing cavity preparation outline.



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Description of amalgam restoration:

Place a matrix band. (See page 17)
While holding the matrix band in place, insert a wedge between the matrix band
and the adjacent tooth, beneath the gingival seat of the preparation.
Triturate the amalgam. Add the amalgam to the preparation in single increments,
beginning with the proximal box.
Condense the amalgam into the corners of the proximal box and against the
matrix band to reestablish a tight proximal contact.
Carve the occlusal portion. The marginal ridge can be carved with the tip of an
explorer or with a Hollenback carver.
Remove the wedge and the matrix band.
Remove excess amalgam.
Gently floss the interproximal contact.
Burnish the restoration, and use a wet cotton pellet for final smoothing.
Remove rubber dam.
Check occlusion.




Figure 5: Back-to-back amalgam fillings. A. After placing matrix band (not seen in illustration) and
wedging, begin condensing the adjacent proximal boxes alternately. B. Continue condensing the amalgams
alternately until both preparations are slightly overfilled.

Composite preparation: (Figure 6)

The Class II composite preparation is generally the same as a Class II amalgam
preparation. The difference is, the composite preparation removes only enough
tooth structure to gain access to the proximal decay.

Start the preparation with a #330 bur located over the marginal ridge and direct
the bur gingivally. The occlusal outline form is dictated entirely by the extent of
the decay present. The cavosurface angles should be near 90 degrees. Do not
instrument the preparation with sharp internal line angles.

11

Figure 6: Modified Class II cavity preparations for composite restorations. Note the short bevel around the
preparations and small retentive grooves. A. Maxillary right second and first primary molars. B. Proximal
view C. Mandibular right first and second primary molars.

Description of composite restoration:

Place a matrix band. (See page 16)
While holding the matrix band in place, insert a wedge between the matrix band
and the adjacent tooth, beneath the gingival seat of the preparation.
Etch the preparation for 15 to 20 seconds
After etching, rinse and dry the preparation well.
Place a dentin-bonding agent in the preparation with a small brush.
Gently blow compressed air into the preparation to disperse a thin layer of
bonding agent evenly.
Polymerize the bonding agent.
With a plastic instrument or a pressure syringe, add the first layer of composite to
gingival portion of proximal. Do not exceed 4 mm thickness. Cure for 20 seconds.
Repeat procedure until proximal is filled. (Figure 7)
Complete occlusal composite build-up. Do not exceed 4 mm thickness. Cure for
20 seconds.
Remove matrix cure composite on buccal side for 20 seconds and lingual side for
20 seconds.
Use composite finishing burs to adjust occlusal surface anatomy.
Use a flame-shaped finishing bur to polish interproximal surfaces.
Remove rubber dam and floss interproximal areas.
Check occlusion.
12


Figure 7: Add first layer of composite to gingival portion of proximal. Do not exceed 4 mm thickness. Cure
20 seconds. Then add second layer of composite. Repeat procedure until proximal is filled


Figure 8: Complete composite build up. Remove matrix, cure composite on buccal side for 20 seconds and
lingual side for 20 seconds.




Figure 9: Use 12 sided finishing burs to adjust occlusal anatomy. Then use a flame-shaped finishing bur to
polish interproximal surfaces. Check occlusion and adjust premature contact spots with 12 sided finishing
burs.
13
Mandibular Right First Primary Molar #S

Pertinent morphological features:

The mesial surface of the mandibular first primary molar is quite flat from the
contact area to the cervical region. The well-developed cervical ridge is
especially prominent on the mesio-buccal surface and angles abruptly toward the
occlusal surface.
Description of the lesion:

For this example, it is assumed that there is incipient caries on the distal surface,
just gingival to the contact.

Description of the cavity preparation (Figure 10 and Figure 11):

Pulpal and axial depth on this first primary molar is 1.0 to 1.25 mm. The carious
central and distal pits are prepared as well as the central groove. The transverse
ridge is left intact. The isthmus is 1.25 to 1.5 mm wide.

Figure 10: Outline of a Class II cavity preparation in a mandibular right first primary molar.


Figure 11: Back to back Class II preparations in mandibular first and second primary molars.


Maxillary Left First Primary Molar #I

Pertinent morphologic features:

The maxillary first primary molar is characterized by a prominent and well
developed buccal-cervical ridge. The widest mesiodistal part of the crown is at
the contact area.

Contact with the primary second molar occurs in the occluso-lingual half of the
distal surface. The mesial surface is in contact with the primary canine on the
occluso-buccal third.

14
The large mesio-buccal pulp horn of the maxillary first primary molar is of special
concern in Class II mesial preparations.

Description of the lesion #I DO:

For this preparation, assume that incipient caries is present on the distal surface
of the tooth gingival to the contact.

Description of the cavity preparation (Figure 12 and Figure 13)

Pulpal wall depth on this first primary molar is 1.0 to 1.25 mm. No enamel should
remain on the pulpal wall. The entire central groove is prepared to a width of 1.0
to 1.25 mm. There is a slight extension (sometimes familiarly referred to as a
dovetail) into the fissured mesio-buccal groove. At least 1.25 mm of tooth
structure remains between the cavosurface margin of that extension and the
buccal surface.

The axial wall of the proximal box is the same depth as the pulpal wall (1.0 to
1.25 mm) at the gingival extension. As in all Class II cavity preparations for
incipient lesion, the buccal, lingual, and gingival walls are extended only so far as
to remove all caries and break contact with the adjacent second primary molar.
(The tip of an explorer should be able to just pass through sideways.) As in all
Class II preparations, the buccal and lingual walls converge occlusally,
paralleling the respective external surfaces of the tooth and flow smoothly into
the occlusal portion of the preparation. The gingival wall that is perpendicular to
the long axis of the crown is slightly concave.


Figure 12: Outline of a distal Class II cavity preparation on a maxillary first primary molar in contact with the
second primary molar.

Figure 13: Lingual view of a Class II cavity preparation in a primary first molar showing a pulpal and axial
wall depth of 1.0 1.25 mm.
15
Mandibular Left First Permanent Molar #19 (Figure 14)

Description of the lesion:
For this example it is assumed that there is a carious central pit. The caries
extends slightly into dentin.

Description of the cavity preparation:
Using # ", # ! or #1 round bur on the slow speed, remove caries.

Description of the PRR restoration:
Isolate tooth.
Etch tooth for 15-20 seconds.
Apply dentin bonding agent and air dry tooth.
Place a flowable composite resin in the central pit.
Apply a thin layer of flowable composite on the entire occlusal table.
Polymerize and adjust for occlusion.


Figure 14: A. The occlusal surface of a molar with a small area of decay in the central pit. B. A small bur
(no. " or ! round using slow speed) is used to remove the decay, which is confined to the enamel. C. A
filled sealant (S) is applied into the preparation and over all pits and fissures. This is a sealant procedure. D.
In this example, the caries extends into the dentin. A small bur (no. " or ! round) is used to remove decay.
E. A bonding agent (BA) and resin-based composite (CR) material are placed in the preparation. Then a
sealant (S) or flowable composite is applied over all remaining pits and fissures. This is a PRR procedure.
16
Maxillary Left Second Primary Molar #J

Pertinent morphologic features:

The crown of the maxillary second primary molar is approximately 0.5 mm larger
mesio-distally that the crown of the maxillary first primary molar. but the bucco-
lingual measurement of the second molar is often as much as 2 mm greater than
of the first molar. The mesial and distal surfaces of the second molar are also
relatively flat bucco-lingually, and they form especially broad contacts with the
first primary molar and first permanent molar. The mesial surface is also
characterized by the mesial groove that extends from the occlusal surface.

Description of the lesion

For this example it is assumed that the incipient caries is present on the mesial
surface, just gingival to the contact area, and on the occlusal surface in the
central pit near the buccal groove.

Description of the cavity preparation (Figure15)

The carious mesial pit and central pit of this tooth are prepared with an extension
into the non-coalesced buccal groove. Isthmus width on this second primary
molar is slightly greater than on the first primary molar (1.25 mm to just over 1.5
mm).

Depth of both the pulpal and axial walls on the second primary molar is 1.25 mm
to 1.5 mm. It is important to keep in mind the difference for axial depth on the first
and second primary molars, especially when preparing the two teeth back to
back as is common in treatment of children.


Figure 15: Maxillary first and second primary molars showing outline of Class II cavity preparation.
17
Matrix Application

Matrices must be placed for interproximal restorations to aid in restoring normal
contour and normal contact areas and to prevent extrusion of restorative
materials into gingival tissues. Both the contour and the large open area of the
proximal box of Class II preparations on primary teeth are of special concern in
adapting a matrix that is firm enough to sustain the pressure of condensation.

T-bands, sectional matrix, and AutoMatrix are commonly used in pediatric
dentistry. These types are more convenient when several cavity preparations are
being restored during the same appointment.

T-bands allows for multiple matrix placements.

Sectional-matrix allows for multiple matrix placements; is not circumferential.

AutoMatrix allows for multiple matrix placements; requires special tightening
and removing tools.

T-Band Matrix Procedures

T-bands are available in several sizes, contours and materials. A straight,
narrow, brass T-band will be sufficient in almost all pediatric restorative
procedures. (Figure 16)

Figure 16: T-band matrix strip.

Forming and Placing a T-band matrix:

1. SHAPE THE T-BAND INTO A CIRCLE AND ADJUST IT TO A SIZE
SLIGHTLY SMALLER THAN THE TOOTH.

With flat-nosed pliers bend up wings of the T-band (Figure 17)
Fold the band back on itself in the form of a circle and fold over the
extension wings of the T to make an adjustable loop.



Figure 17: Shaping a T-band.

18

2. ADJUST THE MATRIX TO THE TOOTH

With the sliding joint of the matrix over the tooth and the long end toward
the mesial, place the matrix over the tooth and seat it so that it extends
0.5 mm to 1.0 mm past the gingival cavosurface margin. Pull the tab end
and tighten the band around the tooth. Fold the tab distally back over the
joint (Fig. 18) to crease for size. Remove the band from the tooth. If the
original fit was not snug, decrease the circumference, and replace the
band on the tooth, and crease again.


Figure 18: T-band tab folded to form a crease.

3. TRIM THE MATRIX BAND TO SIZE.

Remove the band and flatten the fold with pliers back against the wings.
Cut the tab with the ends of the wings and round the corners.

4. RESEAT THE MATRIX BAND AND WEDGE IT

Replace the band on the tooth with the trimmed end directly distally. With
a good tight fit some resistance should be felt as the band is seated.
Select a wedge, trim if necessary, and insert.

Wedges

All matrices need to be wedged securely under the gingival margin to allow the band to
withstand the pressure of condensation and prevent flash at the gingival margin.

The slight separation provided by the wedge allows room for proper placement of the
matrix band and forceful condensations and ensures tight contact when the wedge is
removed.

Anatomically shaped wedges are available. (Figure 19) When triangular wedges are
used, it may be necessary to trim the apex to permit a snug fit against the band and
under the broad, flat, contact area typical of primary molar.

The wedge should be inserted from the larger embrasure usually the lingual on
primary molars or from the buccal if the proximal box has been opened up wider on that
side. During the insertion of the wedge, the matrix band should be secured.
19

Figure 19: Triangular wedges either trimmed or anatomically preformed.


Removing the T-Band matrix


1. OPEN THE JOINT OF THE MATRIX BAND.

After removing gross amalgam/composite excess from the proximal
area and the marginal ridge, but before carving either, open the joint
of the matrix band by raising the tab end with a spoon excavator or
plastic instrument and loosen the T wings (Figure 20).


Figure 20: Opening the T-band.

2. REMOVE THE MATRIX

Remove the wedge. The band may be removed by one of two methods.
Secure the restored marginal ridge area, if necessary. Then either cut
the band close to the restoration with a crown and bridge scissors and
pull buccally, or gently rock the band occlusally and/or lingually through
the contact. Replace the wedge to inhibit further hemorrhaging if
necessary

3. COMPLETE THE RESTORATIVE PROCEDURE
20
Class III: Cavity Preparation and Restorations

Principles of Cavity Preparation

The extremely small size of the primary anterior teeth, the very thin enamel and
weak incisal edge, and the proximity of the pulp to the surface must all be taken
into consideration when preparing Class III cavities.

Obtaining access to the lesion and providing adequate retention are the two
principal factors affecting the design of a Class III cavity preparation.

In any Class III cavity preparation for an incipient lesion the axial wall should be
just into dentin. Depth as measured from the cavosurface varies depending on
the tooth.
Mandibular canines 1.0 mm to a maximum of 1.25 mm
Maxillary incisors and canines 0.75 mm to 1.0 mm
Mandibular incisors 0.5 mm to 0.75 mm
A #1 round bur is appropriate for canines and maxillary incisors; a # ! round bur
is appropriate for the smaller mandibular incisors.
When access to the Class III lesion is from the proximal, low speed, using air
only is recommended for preparing the cavity.

Mandibular Left Canine #M

Pertinent Morphologic Features:

The mandibular primary canine is convex in the cervical third. On the mesial and
distal surfaces the height of contour is much nearer the cervix than the
permanent canine. Mandibular primary canines contact adjacent teeth near the
incisal third of the tooth. The incisal is highest at the apex of the cusp, and the
distal incisal edge is lower than the mesial aspect.

Generally, the pulp chamber follows the surface contour of the tooth. The enamel
layer is approximately 0.8 mm thick and, on the mesial and distal surfaces, tapes
as it nears the cervix. The distance from the pulp to the incisal surface is
approximately 3.3 mm at the apex and 2.3 mm on the mesial and distal aspects
of the incisal surface. To the mesial and distal surfaces this distance is
approximately 1.5 mm, and to the buccal and lingual surfaces, 2.3 mm.

Description of the lesion (Figure 21)

On the model for this preparation it is assumed there are extensive caries on the
distal surface just above the gingiva and below the contact approaching the
lingual surface. Loss of translucency in the proximal area is apparent.

21

Figure 21: Mandibular canine showing mesial and distal convex curvatures. A Class III caries lesion is
shown beneath the contact area.

Description of the cavity preparation (Figures 22)

The extensive caries on the distal surface of this tooth requires a disto-lingual
dovetail preparation. A #1 round bur or #330 bur is used, with access to the
lesion from the lingual.
The axial wall of the proximal is 1.0 mm to 1.25 mm from the cavosurface on the
canine (just into dentin on a natural tooth). When the caries is removed, all cavity
walls are established in sound tooth structure and just break contact with the
adjacent tooth.
The dovetail portion of the preparation is larger than the proximal portion (Figure
22). It is joined to the proximal portion by an isthmus that is similar to the isthmus
linking the occlusal and proximal portions of a Class II preparation.
The dovetail should always be prepared at the expense of the thicker gingival
enamel whether on the labial or lingual. The gingival wall of the dovetail should
follow the contour of the gingiva at a distance of no closer than 1.0 mm.
The inciso-gingival dimension of the canine dovetail (one-third to one-half the
incisal height of the crown) is between 1.5 and 2.0 mm, or slightly greater than
twice the diameter of the bur at the points of greatest dimension.
The mesial wall is parallel with the long axis of the anatomic crown. The mesio-
distal width of the dovetail is no greater than ! the mesio-distal width of the
tooth, as measured from the mesial cavosurface margin. Depth of the axial wall
in the dovetail on this tooth is 0.75 to 1.0 mm.
Place a short bevel (0.5 mm) at the cavo-surface margin.


Figure 22: Mandibular left primary canine showing a Class III preparation with a dovetail.

22

Figure 23: Transverse section of a mandibular primary canine showing Class III axial wall depth at both the
interproximal and dovetail area.

Description of restoration of Tooth #M

Clean and dry the preparation with water and compressed air.
Place a plastic or sectional metal matrix.
The matrix is placed interproximally and a wedge is inserted.
Etch the preparation for 15 to 20 seconds.
After etching, rinse and dry the preparation well.
Place a dentin-bonding agent in the preparation with a small brush.
Gently blow compressed air into the preparation to disperse a thin layer of
bonding agent evenly.
With a plastic instrument or a pressure syringe, place the composite in the
preparation.
Pull the matrix tightly around the cavity preparation with finger pressure and hold
until cured.
The preparation should be cured from both the buccal and lingual side.
Finish and polish after polymerization.
Gross finishing can be accomplished with fine-grit diamonds or with carbide
finishing burs.
A flame carbide bur is excellent for finishing the facial and interproximal
surfaces.
The lingual surface is best finished with a football shaped carbide finishing bur.
Final interproximal polishing of the restoration is completed with sandpaper
strips.
When finishing is completed, remove rubber dam and floss the interproximal
areas.
23
Class V: Cavity Preparations and Restorations

Principles of Cavity Preparation

A #330 bur is recommended for preparing Class V lesions.
On a primary tooth, the axial wall of an incipient lesion should be just into dentin
using the following as a measurement guide.

1.0 mm to 1.25 mm from the cavosurface of canines
0.75 mm to 1.0 mm on maxillary incisors
0.5 to 0.75 mm on mandibular incisors

The pulpal wall should be convex, parallel to the outer enamel surface.
The lateral walls are slightly flared near the proximal surfaces to prevent
undermining of enamel.
The final external outline is determined by the extent of decay.
Mechanical retention at the gingivoaxial and incisoaxial line angles can be
achieved with a #35 inverted cone bur or a ! round bur.
For resin based composites, a short bevel is placed around the entire
cavosurface margin.

Maxillary Left Lateral Incisor #G

Pertinent morphologic features:

All maxillary primary incisors have similar morphology, including an incisal edge
formed from one developmental lobe and a pronounced ridge. The pulp generally
conforms to the surface contour of the tooth. The enamel layer of the maxillary
lateral incisor is approximately 0.5 mm. The distance from the pulp to the incisal
surface is approximately 2.0 mm, 1.4 mm to the mesial and distal surfaces, and
1.4 to 1.9 mm to the buccal and lingual surfaces.

Description of the lesion (Figure 24):

It is assumed that on the tooth for this preparation, there is a small incipient
lesion just above the gingiva on the labial surface. The area appears slightly
decalcified and could be penetrated with an explorer.

Figure 24: Maxillary left lateral primary incisor with incipient carious lesion (left) and a transverse section
(right) showing the preparation (dotted line).

24
Description of the cavity preparation (Figure 25):

The preparation follows the shape of the carious lesion. Axial depth is 0.75 mm
to 1.0 mm.
The mesial and distal walls diverge when the mesial and distal walls of the
preparation are closer to the labial line angles.
Maximum dimensions of the cavity preparation should in no case be more than
0.5 mm greater than the carious lesion that was removed.
No retention grooves are required for this prep.


Figure 25: Maxillary left primary lateral incisor showing minimum preparation (left) contrasting with a
maximum preparation (right).

Description of restoration of Tooth #G

Etching, bonding, material placement, and finishing are similar to that described
for Class III restorations, except that no matrix is used.



The Composite Strip Crown

The composite strip crown is utilized to restore primary incisors for the following
indications:
1. Incisors with large interproximal lesions
2. Incisors that have received pulp therapy
3. Incisors that have been fractured
4. Incisors with multiple hypoplastic defects or developmental
disturbances
5. Discolored incisors
6. Incisors with small interproximal lesions that also demonstrate large
areas of decalcification

Armamentarium (in addition to above)

1. Strip crowns
2. #169L bur, #35 inverted cone
3. Scissors
25
Maxillary Left Central Incisor #F

Pertinent morphologic features:

See information given for tooth #G (page **)

Description of the lesion (Figure 26):

It is assumed that on the tooth for this preparation, there is extensive, deep
proximal decay.


Figure 26: Primary central incisor with extensive, deep proximal decay.

Description of preparation of Tooth #F:

Select the shade of resin to be used.
Place and ligate rubber dam.
Select a primary incisor celluloid crown with a mesiodistal width approximately
equal to the tooth being restored.
Reduce the incisal edge by 1.5 mm using a fine tapered diamond or #169L bur.
Reduce the interproximal surfaces by 0.5 to 1.0 mm (Figure 27). The reduction
should allow a crown form to slip over the tooth.
The interproximal walls should be parallel, and the gingival margin should have a
feather edge.
Reduce the facial surface by at least 1.0 mm and the lingual surface by at least
0.5 mm. Create a feather-edge gingival margin. Round all line angles.
Place a small undercut on the facial surface in the gingival one third of the tooth
with a #330 bur or a #35 inverted cone.


Figure 27: The proximal surfaces are sliced with a 169L bur to make the proximal surface free of the
adjoining tooth. The incisal surface is reduced 1 - 1 ! mm.

26

Figure 28: Composite Strip Crown preparation. A. Labial view. B. Proximal view. C. Incisal view. The
proximal slice should be parallel to the natural external contours of the tooth.

Description of restoration of Tooth #F:

Trim the selected crown form by cutting away excess material gingivally with
crown-and-bridge. Trial fit the crown.
Crown form should fit 1 mm below the gingival crest.
After the crown is fitted, punch a small hole in the lingual surface with an explorer
to allow for the escape of trapped air and filling material.
Etch the tooth for 15-20 seconds.
Rinse and dry the tooth, then apply a dentin bonding agent. Blow compressed air
on the tooth for a couple of seconds.
Fill the crown form approximately 2/3 full with a resin-based composite material
and seat onto the tooth.
While holding the crown in place, remove excess material with an explorer.
Polymerize the material from both buccal and lingual directions.
Peel the form from the tooth using an explorer.
Remove rubber dam and evaluate occlusion.
Finish with a flame carbide bur smoothing out any irregularities.
A football shaped bur may be used for final contouring of the lingual surface.
27
Stainless Steel Crown (SSC) #J, #L

The stainless steel crown remains one of the most useful restorations in Pediatric
Dentistry. Its ability to restore severely broken down teeth allows for teeth to be
retained, in instances when amalgam and composites would be sure to fail.
Full coverage should be used in all cases where a partial or complete pulp
removal has occurred.
Learning to place stainless steel crowns requires some skill and much practice. It
reverses your normal train of thought in that the tooth must be prepared to fit the
crown. Although rules are given for preparation and crown adaptation, they are
no substitute for analytical thought during tooth preparation and placement of the
crown.

Clinical note:
! A local anesthetic should be used even when the involved tooth is non-
vital, due to the potential for soft tissue trauma during tooth preparation.
! A rubber dam should be used for better visibility and patient control.
! Wedges may be placed in the interproximal for better tissue retraction and
to help avoid contact of the bur with adjacent teeth.

Armamentarium (in addition to above)

1. Stainless Steel Crowns
2. Football diamond
3. Crown scissors
4. Contouring pliers - # 114 ball-and-socket pliers
5. Crimping pliers - # 800-417 (Unitek)
6. Heatless stone
7. Rubber wheel
8. Glass ionomer cement (K-tac cem)

Steps for Preparation:

Check occlusion. Note the dental midline and the cusp-fossa relationship
bilaterally.
Place rubber dam to isolate the tooth and separate tooth from adjacent teeth
using wedges. (Figure 29)

Figure 29: Tooth at start of preparation

28
Reduce occlusal surface with the high speed handpiece using a #169L taper
fissure bur or a football diamond. Make depth cuts by cutting the occlusal
grooves to a depth of 1.0 1.5 mm, and extend through the buccal, lingual, and
proximal surfaces. (Figure 30)

Figure 30: Occlusal view of occlusal grooves cut for depth.

Next place the bur on its side and uniformly reduce the remaining occlusal
surface by 1.5 mm, maintaining the cuspal inclines of the crowns. (Figure 31)


Figure 31: Reduction of occlusal using cut grooves as depth guide.

Use a taper fissure bur or a thin, tapered diamond to cut through the contacts.
(Figure 32)


Figure 32: Completed mesial and distal slices should be straight and smooth.


Contact with adjacent tooth must be broken gingivally and buccolingually,
maintaining vertical walls with only a slight convergence in an occlusal direction.
The gingival proximal margin should have a feather-edge finish line. (Figure 33)


Figure 33: Occlusal and proximal reduction completed.



29
Buccolingual reduction is often limited to the occlusal one third of the tooth.
Further reduction may be necessary if there is a large mesiobuccal bulge. (Figure
34)


Figure 34: Excessive undercuts are reduced.

All angles of the preparation should be rounded to remove corners. (Figure 35,
Figure 36 and Figure 37)

Figure 35: The occlusal line angles are rounded.


Figure 36: The completed crown preparations (tooth # T on the left and teeth #I and #J on the right)
showing rounded line angles.




Figure 37: The mesial and distal contact points are cleared and a smooth taper from occlusal to gingival
should be obtained that is free from ledges or shoulders.
30
Selecting and seating the crown:

There are two commonly used types of SSCs:

1. Ni-Chro Ion
i. These are pretrimmed, precontoured and precrimped. They
are composed of a softer metal so that they can snap over
the prep without any alterations. If trimming of these crowns
become necessary, the precontour will be lost and the crown
will fit more loosely.

2. Unitek [3M]
i. These are pretrimmed, but they must be contoured and
crimped. They are primarily composed of chromium and
steel and are stronger than ion crowns.




Figure 38: Buccal view of two types of stainless steel crowns. On the left is a Ni-Chro Ion crown. The
lettering on the crown identifies it as a left mandibular first molar size 6. On the right is a Unitek [3M] crown.
Note how much longer the Unitek crown is, as well as its straight, noncontoured proximal surfaces.


Select the smallest crown that can be seated on the tooth. Start with #4 crown,
that is the most commonly used, and progress to a larger or smaller crown as
necessary. Seat the lingual first and apply pressure in a buccal direction so that
the crown slides over the buccal surface into the gingival sulcus

Slight resistance should be felt as the crown slips over the buccal bulge.
After seating the crown, check preliminary occlusal relationship by comparing
adjacent marginal ridge heights.

If the crown does not seat, occlusal reduction may be inadequate; the crown may
be too long, a gingival proximal ledge may exist; or contact may not have been
broken with the adjacent tooth.

31
An extensive area of gingival blanching around the crown indicates that the
crown is too long or is grossly over contoured. Ideally the crown should extend 1
mm into the gingival sulcus.

If the crown is too long, place the crown onto the preparation and lightly mark the
level of the gingival crest on the crown with a sharp instrument. (Figure 39)



Figure 39: Scoring a line at the gingival margin prior to final trimming and seating of the stainless steel
crown.



The crown is then removed and trimmed 1 mm below the mark with crown-and
bridge scissors or a heatless wheel on the low speed straight hand piece.

Contour and crimp the crown to form a tightly fitting crown.
Contouring involves bending the gingival one third of the crowns margins inward
to restore anatomic features of the natural crown and to reduce the marginal
circumference of the crown. This aids in ensuring a good fit.

Contouring is accomplished with a #114 ball-and-socket pliers.
Final adaptation of the crown is achieved by crimping the cervical margin 1 mm
circumferentially with a #800-417 pliers. (Figure 40)



Figure 40: A. #114 pliers are used for contouring. B. # 800-417 pliers are used for final crimping.
32
After contouring and crimping, resistance should be encountered when the crown
is seated. (Figure 41)



Figure 41: Mesio-distal cross section of crown (left) and bucco-lingual cross section of crown (right).

When removing the crown, a spoon excavator or amalgam carver can be used to
engage the gingival margin and dislodge the crown.

Remove rubber dam. Replace crown and check occlusion.

Final smoothing and polishing of the crown margin should be performed prior to
cementation. Use a heatless stone to thin the margin.
Rinse and dry the crown. Use glass ionomer cement, zinc phosphate or self-
curing resin to cement the crown. The crown is filled 2/3 with cement.
Dry the tooth with compressed air and seat the crown completely. Cement
should be expressed from all sides. Check centric occlusion prior to the cement
setting.

Remove excess cement from gingival sulcus with a sharp explorer. The
interproximal areas can be cleaned by tying a knot in a piece of dental floss and
drawing the floss through the interproximal region.

PROBLEMS SEATING THE CROWN?


Figure 42: Gingival ledge; contact is not broken.


! Inadequate occlusal reduction
! Inadequate reduction of buccal cervical bulge
! SSC too long
33
Clinical Note:

! CHOOSING A CROWN IN AREAS OF SPACE LOSS
! Rectangles vs. squares (mandibular 1
st
molars vs. maxillary 1
st
molars)
" Extensive distal caries on a mandibular or maxillary primary
1
st
molar will change its shape to look more like a square or
rectangle, respectively. (See figures below)
" When this happens, choose a primary 1
st
molar crown from
the opposite quadrant (opposite side, opposite quadrant).
" Note the space loss is due to mesial drift of the 2
nd
primary
molar.



Figure 43: Mandibular left 1
st
primary molar. Tooth structure distal to dotted line lost to extensive distal
caries would change the shape from a rectangle to a square.



Figure 44: Maxillary left 1
st
primary molar. If tooth structure distal to the dotted line is lost due to extensive
distal decay, a right mandibular 1
st
primary SSC crown is rotated to fit the preparation.
34
LOWER LINGUAL HOLDING ARCH

The lingual arch is basically a fixed orthodontic appliance, it is commonly
adapted for use as a holding arch and as a bilateral space maintainer. It is
especially useful for those young or physically and mentally compromised
patients who might not adapt well to a removable appliance (Figure 48).

The lingual holding arch is commonly used to prevent collapse of the lower
anterior teeth as is seen in patients with hyperactive lip and mentalis habits. As
well, a pontic may be added to the arch for replacement of a lost anterior tooth.
In orthodontic use, for example, the arch can be constructed to be activated for
tooth movement such as the expansion of the arch. Auxiliary wires may be
added to arch wire for individual tooth movements. When used as a space
maintainer, the lingual holding arch permits unhindered growth of the jaws and
alveolar bone, permits eruption of succedaneous and adjacent teeth and is
physiologic and inconspicuous.

CONSTRUCTION:

Band Placement and Adaptation:

1. Preformed bands are adapted and contoured to fit molar teeth, either the
second primary or the first permanent molars. Since the bands will support a fair
sized appliance they must be adapted very well with special attention paid to the
band engagement of the buccal and lingual undercuts to aid the mechanical
retention of the band.

2. Commercially pre-formed bands are available for each tooth group and in
several basic sizes within each group. For this exercise, the faculty has pre-
selected the proper size band that can be found in your laboratory kit. In general,
band selection consists of trial and error until a band is found that seems just
right to fit very snugly when properly contoured. A band that easily slides over
the tooth in the beginning selection process will usually be too large after proper
contouring and, if used, will require excessive cementation and incur the
possibility of decreased adhesion and early appliance breakdown.

3. The most important factor in band adaptation is the preliminary positioning of
the band. Examine the tooth and illustration in Figure 45. The buccal and lingual
surfaces are compound curves. It we mentally survey these surfaces on
mandibular molar teeth it can be seen that undercut areas are usually lower on
the buccal surface than on the lingual. The band is to be positioned so that is
extends into, and engages, these undercut areas. Thus, the band must be
positioned diagonally across the tooth to be lower on the buccal than on the
lingual.
If the band placed on a lower molar engages the buccal and lingual undercuts it
will fit snugly and not be easily displaced (Figure 46). If the band does not
engage the buccal and lingual undercuts it will be loose and easily displaced.
35

4. In clinical use, the band would be adapted directly to the patients tooth rather
than to a model. The pre-formed bands have also been partially contoured in the
manufacture process to be already lower on the buccal side than on the lingual.
In addition, a small V notch, or indentation, is usually found around the occlusal
rim of the band. This indentation is on the lingual occlusal ridge and is meant to
fit into the crevice formed by the junction of the two lingual cusps.

5. Using your laboratory typodont, push one of the pre-selected bands onto
either tooth 19 or tooth 30 keeping the occlusal height of the band just below the
interproximal marginal ridges of the tooth.

6. While holding the lingual surface in this position, push the band down buccally
using a serrated plugger, gold foil condenser or band seating instrument. The
buccal portion of the band should extend low enough to reach the buccal
undercuts.

7. The band is crimped in or rimmed in around the gingival circumference
using a pair of smooth jawed pliers. A contouring, or swaging, pliers is quite
useful for this purpose as well. The crimping in process provides for a tight
adaptation of the band into the buccal and lingual undercut areas. The band is
now ready for placement onto the tooth.

8. Place the band in position on the tooth using a band seating, or serrated
plugger and complete the band contour by burnishing the occlusal rim to adapt
snugly to the tooth. The finished band will have no open margins either around
the occlusal or lingual margins.

9. Complete the band construction for the lingual arch by repeating Steps 5
through 8 above and adapt a band to the antimere molar tooth (#19 or #30).

Making a Working Model:

10. A working model is used for the contouring of the lingual arch wire and its
attachment to the molar bands. Take an alginate impression of the typodont (or
patients arch) with the adapted molar bands in placed on the teeth. The
completed impression is removed and the bands are then removed from the
teeth.

11. Trim impression material that squeezed between the band and the tooth with
a carver until the impression of the edge of the band is clear all the way around.
Carefully reposition each molar band in its proper place in the impression.
Accurate positioning of the bands in the impression, and their fixation in place, is
absolutely necessary for a finished appliance that fits the typodont (or patient)
accurately. CARE is mandatory.

36
12. Place a bead of sticky wax on the inner lingual surface of each band is the
area where the lingual attachments, or the lingual arch wire, will be soldered.
The bead of wax should be sufficiently thick enough to provide an air space
between the working model and the band to facilitate heat transfer between the
band and wire, or attachment, during soldering. The wax should firmly hold the
band in place in the impression.

13. A working model is poured in yellow stone. Vibrate the stone while mixing
but not while pouring. The use of a vibrator is not recommended during pouring
for the vibration often shakes a band loose from its position in the impression and
results in a misplaced band on the working model. Instead, carefully add the
stone, in small portions, to each of the tooth areas avoiding air pockets as much
as possible. Gently vibrate the impression with a wiggling motion of the hand
alone. Complete the model build-up with stone and set it aside to harden. Do
not invert the impression but rather build up a sufficient amount of stone to serve
as a base. The impression, removed from the case, should reveal a working
model with a minimum of air holes and with the bands seated in their respective
proper positions. The lingual band wax may be carefully removed with an
explorer. Trim the stone to form a flat base.

Contouring the Arch Wire:

14. Figure 48 shows two sample lingual arch wires. Figure 48A is a simple arch
wire adapted from molar to molar beneath occlusal interference, touching the
lingual contours of most of the buccal teeth and resting on the cingulae above the
gingivae of most of the anterior teeth. It is the anterior teeth that resist the
anterior movement of the molar teeth. The arch is bent back and down from the
midpoint of the canine and then along the lingual-gingival margins of the buccal
teeth and then back up to the solder joint. This keeps the wire out of the
occlusion and free of the erupting premolars. The arch wire is soldered to the
molar bands and is cemented in place as a single unit.

Figure 48B is an arch wire similar to that in Figure 48A but has, in
addition, an Omega shaped loop (inverted) and contoured just anterior to each
band extending marginally into the lingual sulcus. The purpose of this loop is to
allow for some adjustment of the arch if necessary before cementation, or
importantly, for possible activation before cementation to apply tooth moving
forces to the molar teeth for uprighting the teeth in cases of space loss and molar
tipping. This arch is similarly cemented as a single unit after activation.

15. In this laboratory exercise, you will contour and solder the arch wire as in
Figure 48A using 0.036" diameter steel wire. It is a simple holding arch as is
frequently used to maintain the existing dental arch integrity at the time of
appliance placement.
37
16. The 0.036" steel arch wire can be contoured by starting at one molar band
and shaping the wire as it extends forward and returns to the molar band on the
other side, or it may be contoured by starting in the middle, in the lingual incisor
area, and extending the arch wire on each side back to the molar area. In either
technique, the arch wire should rest on the incisor cingulae above the gingivae.
It is not necessary for the arch wire extended distally to be contoured perfectly to
the shape of each tooth. Instead, it should contact the lingual surfaces of those
teeth that lie in the general shape of the arch as it would be represented in a
smooth contour. The distal end of the arch wire extends on each side over the
molar band to 1/2 to 3/4 the width of the band. The arch should be placed so as
not to interfere with occlusion or impinge on the gingivae.

17. After removal of any sharp edges from the distal ends of the arch wire, it is
positioned on the model and held in place by sticky wax covering a portion of the
anterior lingual wire and then plaster is placed over the wires, sticky wax and
teeth to secure the arch wire in place. The plaster should be kept away from the
area to be soldered. The arch wire adjacent to each band should be well
adapted to the band for proper soldering.

18. Gently heat the band-archwire joint to burn off any residual wax and to free
air space inside each band. Steel can only be soldered using fluoride flux. Flux
the joint well on both sides of the wire and direct the flame toward the inner
surface of the band while feeding solder externally to the band-archwire joint.

19. The appliance is removed from the working model and polished making sure
that there are no rough spots at either solder joint that may later irritate the
patients tongue. Polishing must not remove all of the solder that covers the
archwire because the solder bonds by physical forces, not chemical bonding.
The finished appliance is seated on the typodont by working each band
simultaneously, in steps, until both bands are seated properly and the archwire
rests in the predetermined position on the cingulae of the anterior teeth.




Figure 45: The buccal and lingual highlight contours Figure 46: Orthodontic band placed as to engage
of a mandibular posterior tooth when surveyed. undercut areas for retention. Band is placed higher
on lingual surface and lower on buccal surface.
38

Incorrect
not contoured
Correct
"Barrel" shaped

Figure 47: Band contour showing the difference between a non-contoured
cylinder (or band) and a precontoured band placed on a posterior tooth. The
non-contoured band will have gingival overhanging areas that impinge on the
tissues.


A B

Figure 48A and 48B: Lingual holding arches, with the arch wire soldered to
bands affixed to posterior molar teeth. The arch wire is contoured from side to
side and rests anteriorly on the cingulae of the anterior teeth. Extending
backward to the bands the arch wire dips down in the premolar area to avoid
occlusal interference and premolar development and eruption. Figure 167B
differs from Figure 167A in that an inverted omega loop is contoured anterior to
the molar band. This loop allows for adjustment of the arch wire where tooth
movement is desired.
39
PATIENT EXAMINATION & TREATMENT PLANNING

It can be said that a problem needs to be recognized to be diagnosed and that its
treatment depends upon the diagnosis. An accurate diagnosis depends upon (a)
a full written health history, (b) interviews to verify and support the history, (c) an
extra- and intraoral examination of the patient, and (d) obtaining additional
diagnostic aids such as x-rays, dental casts, laboratory tests, or consultations
with other health professionals.

Pages 39 to 45 are pages from the Dental Chart in Pediatric Dentistry at UCLA.
Included is the Pediatric Health Questionnaire filled out by the parent at the initial
visit to the clinic. From this, and from subsequent interviews with the parent to
discuss elements of the history, it can be determined that the patient is of good
general health or that there may be a need for consultation with the family
physician, hospital or health care facility.

It is important to determine the need for antibiotic support in any patient before
dental manipulation is initiated. Therefore, note the charts on the following
pages: 46 to 48.
40
41
42
43
44
45
46
PROPHYLACTIC ANTIBIOTIC REGIMENS

Dental procedures for which endocarditis prophylaxis is recommended
1

Dental extractions
Periodontal procedures including surgery, scaling, and root planing,
probing, and recall maintenance
Dental implant placement and reimplantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Subgingival placement of antibiotic fibers or strips
Initial placement of orthodontic bands but not brackets
Intraligamentary local anesthetic injections
Prophylactic cleaning of teeth or implants where bleeding is anticipated
1
Prophylaxis is recommended for patients with high- and moderate-risk cardiac
conditions

Dental procedures for which endocarditis prophylaxis in not recommended
Restorative dentistry (operative and prosthodontic) with or without
retraction cord
Local anesthetic injections (nonintraligamentary)
Intracanal endodontic treatment; post placement and buildup
Placement of rubber dam
Postoperative suture removal
Placement of removable prosthodontic or orthodontic appliances
Taking of oral impressions or oral radiographs
Fluoride treatments
Orthodontic appliance adjustment
Shedding of primary teeth
Clinical judgment may indicate antibiotic use in selected circumstances where
significant bleeding may occur

47








Prophylactic Regimens for Dental, Oral, Respiratory Tract
or Esophageal Procedures

SITUATION AGENT REGIMENT
A

Standard
general
prophylaxis
Amoxicillin
Adults: 2.0g;
Children: 50mg/kg orally one hour before
procedure
Unable to take
oral
medications
Ampicillin
Adults: 2.0g intramuscularly (IM) or
intravenously (IV);
Children: 50mg/kg IM or IV within 30
minutes (min) before procedure
Clindamycin
or
Adults: 600mg;
Children: 20mg/kg orally one hour before
procedure
Cephalexin
B

or
Cefadroxil
B
or
Adults: 2.0g;
Children: 50mg/kg orally one hour before
procedure
Allergic to
penicillin
Azithromycin
or
Clarithromycin
Adults: 500mg;
Children: 15mg/kg orally one hour before
procedure
Clindamycin
or
Adults: 600mg;
Children: 20mg/kg IV within 30 min before
procedure
Allergic to
penicillin and
unable to take
oral
medications
Cefazolin
B

Adults: 1.0g;
Children: 25mg/kg IM or IV within 30 min
before procedure

A
Total childrens dose should not exceed adult dose
B
Cephalosporins should not be used in individuals with immediate type hypersensitivity
reaction (urticaria, angiodema, or anaphylaxis) to penicillins

48








Cardiac Conditions Associated with Endocarditis

ENDOCARDITIS PROPHYLAXIS RECOMMENDED
Prosthetic cardiac valves, including bioprosthetic and homograft
valves
Previous bacterial endocarditis
Complex cyanotic congenital heart disease (e.g., single ventricle
states, transposition of the great arteries, tetralogy of Fallot)
High-risk
category
Surgically constructed systemic pulmonary shunts or conduits
Most other congenital cardiac malformations (other than above
and below)
Acquired valvar dysfunction (e.g., rheumatic heart disease)
Hypertrophic cardiomyopathy
Moderate-
risk
category
Mitral valve prolapse with valvar regurgitation and/or thickened
leaflets
ENDOCARDITIS PROPHYLAXIS NOT RECOMMENDED
Isolated secundum atrial septal defect
Surgical repair of atrial septal defect, ventricular septal defect, or
patent ductus arteriosus (without residual beyond 6 months)
Previous coronary artery bypass graft surgery
Mitral valve prolapse without valvar regurgitation
Physiologic, functional, or innocent heart murmurs
Previous Kawasaki disease without valvar dysfunction
Previous rheumatic fever without valvar dysfunction
Negligible-
risk
category
(no greater
risk than
the general
population)
Cardiac pacemakers (intravascular and epicardial) and implanted
defibrillators
49
EXAMINATION CHECKLIST

EXTRAORAL EXAMINATION

Cranium: Inspect for sore, flaking, inflammation, swelling and symmetry.

Neck: Thyroid gland palpate and inspect for swelling.
Musculature inspect and palpate for suppleness.
Lymph nodes palpate for lymphadenopathy.

Hair: Inspect for thickness, color, dryness and consistency.

Ears: Inspect for normal appearance, cartilaginous defects, pits and
and cutaneous lesions.

Eyes: Inspect for inflammation, deviation, ptosis, and exophthalmos.

Nose: Evaluate patency, note any discharge.

Perioral: Inspect for inflammation, scarring, eruption ulcerations.


SOFT TISSUE EVALUATION

Gingiva: Inspect for inflammation, bleeding and abscesses.

Mucosa: Inspect for inflammation, palate for swelling; inspect parotid duct
opening for function.

Pharynx: Inspect for inflammation, note gag reflex.

Tonsils: Inspect for size, inflammation.

Palate: Inspect and palpate for deviation and integrity.

Tongue: Inspect for inflammation, coating, observe range of motion, inspect
for atrophy, and deviation.

Lips: Inspect for chapping, ulcers, and cheilitis.
50
OCCLUSION SUMMARY

Examinations of the following conditions should be noted under each of the
following headings. Deviations from the ideal or norm should be noted. Those
that must be noted are starred (*), others are noted only as they occur or differ
from normal limits.

Alignment: *Tooth size-arch length discrepancy.
Space loss, alignment, rotations, missing or supernumerary
teeth, eruption abnormalities, ankylosis

Transverse
Relations: *Midline discrepancies (max and mand.), posterior crossbite.
Facial asymmetry, mandibular displacement, maxillary
midline diastema frenum

Vertical
Relations: *Overbite (%); openbite (mm); lip posture (open, closed)
tongue size, shape and position, lower face height


Anterior
Posterior *Overjet (mm), Cuspid relation Class I, II, III
Relations: *Molar relation Class I, II, III, or MS, DS, FTP
Profile (skeletal) convex, straight, concave
Lip posture (tight, loose, mentalis strain)
Tongue thrusting (swallowing)

Dental/
Family History *Home care; caries rate low, medium, high
Accidents trauma, speech defects, oral habits, speech
defects, family other requiring orthodontics

Patient
Compliance *Behavior precooperative, cooperative, anxious but
cooperative, etc. Willingness to accept appliances, braces,
frequent appointments


SUMMARY OF FINDINGS: Summarize problems noted in each area. The
instructor assigns the cases to the pre-doctoral or post-doctoral clinic for
continuing care and signs his/her name with the note. This may require an
orthodontic consultation.
51
SUMMARY & TREATMENT PLAN

Pages 40-45 are the pages in the dental chart where intraoral charting is recorded, an
outline of dental need is recorded and a treatment plan is developed from the data
obtained in the earlier examinations. The needs are to be assembled in a visit by visit
plan, or sequence of visits, to provide total care to the patient in the least possible
number of visits.

ADDITIONAL DIAGNOSTIC AIDS

X RAYS FOR PEDIATRIC PATIENTS

Initial films for all pediatric dentistry patients

1. New Patients:

Two (2) bitewing x-rays (largest size that fits) if the contacts are closed.

If contacts are open, do not take x-rays unless other reasons exist.

2. Recall Patients:

a. If patient has had previous caries, two (2) bite-wing x-rays (as above)
once each year.

b. If patient was caries free last exam, bitewing x-rays should be taken at 2
year intervals.

3. Special Circumstances:

a. Maxillary anterior occlusal x-ray (#2 of #3 (occlusal) film) at 6-8 years of
age (eruption patterns, missing and supernumerary teeth, eruption
problem, etc.).

b. Panoramic film: age 16-18 (3rd molar eruption).

c. Any film or combination of films deemed necessary by the dentist. For
example:

1. B/W or P/A in area of deep caries or abscess formation.

2. Cephalometric, F.M.S. (full mouth series), etc. for orthodontic
treatment.

3. In any area where pathology is suspected upon careful clinical
examination.

4. Films to locate position of tooth for surgery or orthodontics, etc.

5. Follow-up films in areas of pulpotomy or pulpectomy.
52
Clinical situations for which radiographs may be indicated include:

A. Positive historical findings:
1. Previous periodontal or endodontic therapy
2. History of pain or trauma
3. Familial history of dental anomalies
4. Postoperative evaluation of healing
5. Presence of implants

B. Positive clinical signs/symptoms:
1. Clinical evidence of periodontal disease
2. Large or deep restorations
3. Deep carious lesions
4. Malposed or clinically impacted teeth
5. Swelling
6. Evidence of facial trauma
7. Mobility of teeth
8. Presence of fistula or sinus tract
9. Clinically suspected sinus pathology
10. Growth abnormalities
11. Oral involvement in known or suspected systemic disease
12. Positive neurologic findings in the head and neck
13. Evidence of foreign objects
14. Pain and/or dysfunction of the temporomandibular joint
15. Facial symmetry
16. Abutment teeth for fixed or removable partial prosthesis
17. Unexplained bleeding
18. Unexplained sensitivity of teeth
19. Unusual eruption, spacing, or migration of teeth
20. Unusual tooth morphology, calcification or color
21. Missing teeth with unknown reason

C. Patients at high risk for caries may demonstrate any of the following:
1. High level of caries experience
2. History of recurrent caries
3. Existing restoration of poor quality
4. Poor oral hygiene
5. Inadequate fluoride exposure
6. Prolonged nursing (bottle or breast)
7. Diet with high sucrose frequency
8. Poor family dental health
9. Developmental enamel defects
10. Developmental disability
11. Xerostomia
12. Genetic abnormality of teeth
13. Many multisurface restorations
14. Chemo/radiation therapy
53
RADIOGRAPHIC GUIDELINES

54
MIXED DENTITION ANALYSIS:
DETERMINATION OF CROWDING OR SPACING

Orthodontic study models may be used to quantify the amount of crowding or
spacing present in any given arch. This is done by comparing the space
available with the space required for all of the teeth to fit. Space analysis
carried out in this way involves two major assumptions: 1) The anteriorposterior
position of the incisors is correct, and 2) The space available will not change
because of growth.

Quantifying Crowding/Spacing in the Adult Dentition

(space available) (space required) = crowding/spacing

A negative number indicates crowding: (e.g. 6.6mm is 6.6mm of
crowding)

A positive number indicates spacing: (e.g. +5.0mm is 5.0mm spacing)

Space available in the permanent dentition can be measured by dividing the
dental arch into four straight line segments. The measurements are taken from
the mesial of the first molar to the mesial of the canine and from the mesial of the
canine to the mesial of the central incisor (or midline in the case of a midline
diastema).



Space required in the permanent dentition is the sum of the mesiodistal widths
of all individual teeth measured from contact point to contact point.


55

Quantifying Crowding/Spacing in the Mixed Dentition

Patients often present for consultation and/or treatment during the mixed
dentition stage of occlusion. It is desirable to predict if any given patient may
later develop a problem with crowding or spacing. Since we are unable to
directly measure the size of the unerupted permanent teeth, we must estimate
their size. Proffit (Chapter 6) explains several methods of estimating the size of
permanent teeth including:

1. Measuring the permanent teeth on periapical films. This is then multiplied
by a correction factor that compensates for enlargement of the
radiographic image.

2. Estimates from proportionality tables. Proportionality estimations are
possible because there is good correlation between the size of the
mandibular incisors and the unerupted canines and premolars. Proffit
highlights two different proportionality methods including:

A. Tanaka and Johnson:

TANAKA AND JOHNSTON PREDICTION VALUES
+ 10.5mm =
Estimated width of mandibular canine
and premolars in one quadrant

One half of the
mesiodistal
width of the four
lower incisors + 11.0mm =
Estimated width of maxillary canine
and premolars in one quadrant

From Tanaka MM, Johnston LE: Am Dent Assoc 88:798, 1974.


B. Moyers Mixed Dentition Analysis: The Moyers Mixed Dentition Space
Analysis is the preferred method of prediction at the UCLA School of
Dentistry. It is a method of estimating arch length discrepancies in the
mixed dentition period and uses the same basic strategy of comparing
space available with space required.


Moyers Mixed Dentition Space Analysis Step by Step

Step 1: Calculate maxillary space available. We must know how much space is
available for the already erupted permanent incisors as well as the unerupted
permanent canines and premolars. This assumes that the treated arch will be
the same dimension as the current arch and that the incisor position will remain
unchanged.

56
Step 2: Calculate mandibular space available. As in step 1, we must know how
much space is available for the permanent teeth once they all erupt.

Step 3: Measure mandibular incisor width. Since these teeth are erupted, it is
most ideal to use the direct measurement of these teeth in mesiodistal width to
determine how much space they will require when in ideal alignment.

Step 4: Measure maxillary incisor width. Again, since these teeth are erupted,
we will use the actual measurement to determine how much space will be
needed to align them.

Step 5: Predict the widths of the unerupted canine and premolars. The summed
width of the mandibular incisors is used to estimate the space required for the
permanent canines and premolars in both the maxillary and mandibular arch.
This estimation is extrapolated from the probability chart created by R.E. Moyers.
This chart is designed to predict the sizes of unerupted canine and premolars in
one quadrant at a certainty level of 75%.

Step 6: Calculate space required. For both maxillary and mandibular arches,
add the actual measurements of incisors to the predicted widths of unerupted
canines and premolars to predict the space required for permanent teeth.

Step 7: Calculate arch length discrepancy. Subtract the predicted space
required from the space available in each arch to predict the arch length
discrepancy once the permanent teeth erupt.

Note:
The method used to measure space available is identical to that used for
adult dentition.
Space required in the posterior segments is provided by Step 5 and the
anterior space required is simply measured from the mesiodistal widths
of the four incisors.
As always, (space available) (space required) = crowding/spacing.
57

58
CLINICAL RESPONSIBILITIES

NEW PATIENTS
1) Introduce yourself and encourage the child and/or the parent to volunteer
information regarding the childs teeth.
2) If it is a new patient, review medical history and complete the yellow form
behind the medical questionnaire. Complete extraoral, intraoral
examinations and occlusion summary. See samples.
3) Determine the appropriate radiographs to be taken.
4) Get a start check and review the type and number of radiographs that will
be taken with the instructor.

INTRODUCTION TO DENTAL PROCEDURES

1) Orient the child to the chair and explain the purpose of todays visit. Use
Tell, show, and do.
2) Perform head and neck exam.
3) Initiate the oral examination with fingers, then a mouth mirror.
4) Chart teeth, do ortho evaluation. See sample.

CARIES EXAMINATION

1) Dry tooth with air syringe.
2) Examine each tooth surfaces for caries.
3) Note findings.
4) Prepare treatment plan in the order of greatest priority.

CARIES RISK ASSESSMENT

1) The American Academy of Pediatric Dentistry (AAPD) has determined that
caries-risk assessment is an essential part of clinical care for infants,
children and adolescents.
2) Use the AAPD Caries-risk assessment tool (CAT) to determine caries risk.
See page 61.
3) Note caries-risk assessment in the SOAP notes.

PROPHY AND FLUORIDE

1) Tell, show, and do regarding handpiece and prophy cup.
2) Remove deposits of plaque with a universal scaler, floss, and then polish
all tooth surfaces with rubber cup and prophy paste.
3) Explain to patient that you will be applying some fluoride tooth vitamins
to his/her teeth.
4) Encourage one last drink and/or rinse. Explain that the child will not be
able to eat or drink for ! hour.
59
5) Explain that fluoride is good for the teeth and not for the stomach. Fluoride
should not be swallowed. Demonstrate the use of the salvia ejector.
6) The use of fluoride trays is the preferred method of topical applications.
Both trays are placed in the mouth and the patient occludes on them. The
salvia ejector is placed in the mouth. The trays should remain in position
from 1-4 minutes. This depends how long the patient can tolerate the
procedure.
7) Try in the trays prior to filling them with fluoride. If it appears that the
patient cannot tolerate the trays, the following methods are possible:
a) One tray at a time.
b) Paint on with a cotton tip applicator
c) Brush on with a toothbrush

ORAL HYGIENE INSTRUCTION

1) Give a toothbrush and some floss to the child and ask the child to
demonstrate the way you usually brush and/or floss.
2) Assist the child in correct brushing and flossing techniques.
3) Parents with children 8 years of age and younger should be advised to
assist their child with brushing and flossing.

COMPLETION OF APPOINTMENT

1) Present case to instructor.
2) The final diagnosis and treatment plan is to be entered in ink only after
approval by instructor.
3) Give the child the toothbrush and floss and also a toy and/or sticker.
5) Discuss all your findings and treatment plans with the parent or guardian.
6) Make sure to ask the parent if they have any concerns or questions
regarding the diagnosis or treatment plan. Discuss your plan for the next
visit.

RECORD PROCEDURES

1) Use SOAP note format for chart entries.
2) Detail any instructions to a patient.
3) Note behavior of the child and what is to be done next visit.


NOTE: Accurate diagnosis and treatment planning depends upon:

! A full written health history
! Interviews to verify and support history
! An extra and intra oral examination of the patient
! Obtaining additional diagnostic aids such as x-rays, dental casts,
laboratory tests or consultations with other health professionals.

60
Review the Pediatric Health Questionnaire filled out by the parent at the initial
visit to the clinic. From this and from subsequent interviews with the parent to
discuss elements of the history, it can be determined that the patient is of good
health or that there may be a need for consultation with the family physician,
hospital or health facility.

It is important to determine the need for antibiotic support in any patient before
dental manipulation is initiated. See guidelines with regards to cardiac conditions
associated with endocarditis and the dental procedures that are listed needing
endocarditis prophylaxis.

RECALL PATIENTS

1) Seat the patient, review medical history, have parent sign a medical
history update, and determine if radiographs need to be taken.
2) Get a start check for prophy and fluoride treatment and confirm with the
instructor the number and type of radiographs to be taken if necessary.
3) Prepare the treatment plan in the order of greatest priority and present the
case to the instructor.

OPERATIVE PATIENTS

1) Seat the patient, review medical history, place most recent x-rays on the
viewbox and determine the operative procedure that has the highest priority.
2) Get a start check and confirm with the instructor the procedure you wish to
perform. Be prepared to explain your reasoning.
3) Give a short explanation as to how you are going to approach the procedure
and, if necessary, the amount of anesthesia that will be used.
4) High and low speed handpieces must be in the operatory prior to beginning
treatment.
5) The instructor needs to approve each of the following steps before the
student is permitted to proceed:
a. Rubber dam isolation
b. Ideal access preparation
c. Extension of cavity prep if necessary
d. Placement of matrix band and wedge if necessary
e. Final restoration prior to removing rubber dam
61
CARIES RISK ASSESSMENT TOOL (CAT)


62



63

64

65

66

67


68

69
INJECTION PROCEDURE FOR THE PEDIATRIC PATIENT

The control of pain during dental procedures is one of the most important factors
in child management.

Topical anesthetics, such as benzocaine, if used properly, produce surface
anesthesia of the mucous membrane and reduce or eliminate the discomfort of
the needle penetration. The best results behaviorally and physiologically is to use
the gel sparingly and apply to a dry mucosal surface for at least 2 minutes. Most
dissatisfaction with topical anesthetics results from prematurely injecting the
tissues.

There are occasions when it is more appropriate to proceed with the local
anesthetic injection without the benefit of topical anesthesia. This is
recommended for those patients in whom undesirable behavior is noted due to
the taste and/or numbing effect of the topical anesthetic. This occurs most often
in younger patients usually between the ages of 2-4.

A short (20 mm) or long (32 mm), 27 or 30 gauge needle may be used for most
Intraoral injections for children, including mandibular blocks. An extra short (10
mm), 30-gauge needle is appropriate for maxillary anterior injections.

LOCAL ANESTHETICS

Most dentists routinely use one or two local anesthetics agents. Be familiar with
the maximum allowable dosages for the size of the patient and the potential
undesirable effects of the agent. See charts below.


70


MOUTH PROPS

Mouth props can be used to help the child keep his mouth open sufficiently so
that dental treatment can be performed. There are several mouth props available
and of those evaluated, the scissors or Molt mouth prop serves the widest
variety of situations.

Molt mouth prop

PREPARATION FOR INJECTION

It is important to prepare the child to receive a local anesthetic. The choice of
words is extremely important. It should be explained to the child in terms that he
can understand and with phrases that will not upset him. For example, the
following comments can be used. Im going to put some sleepy juice on your
tooth, so that the tooth will go to sleep. Its going to feel kind of weird and funny.
71

If the child asks, will it hurt? a good answer would be: well, its going to feel
kind of weird; and you may feel a little pressure or pushing. Never tell the child it
is not going to hurt. The injection will feel uncomfortable (and may hurt a bit) and
hell never believe you again. You will have lost his trust. Try to keep away from
words like pinching, biting and stinging to describe the injection. These terms
should be avoided for fear of producing undesirable responses.

Dont use the word shot or injection. If the child comes in and says, Are you
going to give me a shot? A good answer would be, well we dont give shots like
you get at the doctors office. Its really different here, we put a special kind of
juice (or magic juice) near your tooth and it makes the tooth go to sleep.

The child should be allowed to look in the mirror following the injection, to see
that his face is not swollen or distorted.

The necessary local anesthetic armamentarium should be kept out of sight. It
should be place behind the patient where it is easily accessible to the dentist and
the assistant.

The injection procedure should proceed as a smooth act. If the child does
become upset, it is important to continue with the injection procedure. Dont stop.
It will be very difficult to reinject. Slowly inject the anesthetic. Rapid injections
tend to be more painful because of rapid tissue expansion. They also increase
the possibility of a toxic reaction if the solution is inadvertently deposited in a
blood vessel.

It is very important to explain to the parent before beginning dental treatment all
that is planned for that particular visit. Make sure to address any questions the
parent may have prior to beginning treatment.

During the injection, the assistant must be alert in order to anticipate abrupt
movements of the child. Often at the instant the needle penetrates the soft
tissues, the child will lift his arms up and it is at this time that the assistant must
block the childs arms.
72




As soon as the tip of the needle penetrates the tissue, a small amount of
anesthetic solution should be slowly and continuously expressed. The operator
should aspirate in order to determine the position of the needle point.

The operator can direct the operating light as to encourage the child to close his
eyes during the injection. If the childs behavior begins to deteriorate during the
injection, instruct the child to open his eyes and begin talking to him. Tell him the
funny feeling will go away soon, I am just going to count to 10 and then thats it.
Start counting and usually the child will start to calm down. Most children like
counting because it gives them the assurance that the procedure will end soon.

As soon as the syringe is removed, the child should have his mouth rinsed with
water. This will divert the childs attention away from what has just happened.
Discuss the funny feeling and caution the child about biting his tongue and lips.

When administering the local anesthetic and also when proceeding with the
treatment; try not to spend too much time explaining what it is and why it has to
be done. Your goal is to get the child in and out of the chair as quickly as
possible. Briefly explain what is to be done and do it. Distraction can be
accomplished by continuing a constant monologue with the child.

POSTOPERATIVE INSTRUCTIONS

Instruct the parent to remind the child not to bite or chew the lips, tongue and
cheek.
73
TECHNIQUE FOR FISSURE SEALANT


ISOLATE TOOTH

Rubber dam isolation is the ideal way to keep the tooth from salivary
contamination.

Cotton roll isolation with adequate suction to remove salvia from the operating
field is also acceptable.

CLEANSE TOOTH SURFACE

Use pumice slurry to cleanse the tooth surface.

Rinse the tooth thoroughly with copious amounts of water.

Some practitioners recommend cleaning the surface with 3% hydrogen peroxide
to remove additional debris from the fissures.

ACID-ETCH TOOTH SURFACE

Apply etching with a fine brush, or a minisponge to the tooth surface.

Exposure time varies from 15 to 30 seconds.

RINSE AND DRY-ETCHED TOOTH SURFACE

Rinse the etched tooth surface for 30 seconds.

Dry the tooth for at least 15 seconds.

If cotton roll isolation has been used, replace the cotton rolls at this time, making
certain that salivary contamination is not occurring.

If it is possible to avoid salivary/water contamination, application of a bonding
agent prior to sealant application may improve retention of sealant to the tooth.

If a dentin-bonding agent was placed, gently blow compressed air onto the tooth
to disperse a thin layer of bonding agent evenly.

APPLY SEALANT TO TOOTH SURFACE

Apply the sealant material to the tooth surface and allow the material to flow into
the pits and fissures.

Light cure sealant for 20-30 seconds.
74


EXPLORE THE SEALED TOOTH SURFACE

Explore the occlusion of the sealed tooth surface. Make sure there are no voids.

If voids are present reapply sealant.

Remove excess sealant material if necessary.

Pass dental floss between the contact regions to remove any inadvertently
placed sealant.

PERIODICALLY REEVALUATE AND REAPPLY SEALANT AS NECESSARY

The need for reapplication of sealants is highest during the first 6 months after
placement.
75
ENDODONTIC TREATMENT OF PRIMARY TEETH

The basic aim of endodontic therapy in children is the removal of infection and
chronic inflammation and thus the relief of associated pain. There are particular
considerations. The pulpal tissue of primary teeth usually become involved
earlier in the advancing carious lesion than in permanent teeth. Exposure occurs
more frequently during cavity preparation due to the enamel and dentin being
thinner and the extended pulp horns being relatively larger than in permanent
teeth.

VITAL PULPOTOMY TECHNIQUES

Pulpotomy is a procedure based on the idea that the radicular pulp tissue is
healthy or is capable of healing after amputation of the infected coronal pulp.

Pulpotomy is contraindicated when any of the following is present:

! Swelling (of pulpal origin)
! Fistula
! Pathologic mobility
! External root resorption
! Internal root resorption
! Periapical or interradicular radiolucency
! Pulp calcifications
! Excessive bleeding from radicular stumps

PULPOTOMY

1) Anesthetize and isolate tooth with rubber dam.
2) Remove all carious dentin to minimize bacterial contamination following
exposure.
3) After pulp is exposed, remove the roof of the chamber with a 330 fissure
bur.
4) Create a large enough access in order to remove all the coronal pulp
tissue. (See Figure 1.)
5) Having adequate access, use a large round bur in a slow speed
handpiece to amputate the coronal pulpal tissue. Be sure to use light
pressure to avoid perforation of the pulpal floor.
i. Note: a sharp spoon excavator may be used to remove
coronal pulp tissue.
6) Remove all debris from the pulp chamber with a spoon excavator.
7) Be sure to remove all coronal pulp tissue. Lateral tags of tissue left behind
when removing coronal pulp will continue to bleed when trying to control
hemorrhage.
8) If amputation has been of vital tissue, hemorrhage must be arrested at this
time with dry cotton pellets.
76
i. Excessive bleeding that persists in spite of cotton pellet
pressure may indicate that the inflammation has extended to
the radicular pulp.
ii. Such signs indicate that the tooth may need a two stage
pulpotomy, pulpectomy, or may need to be extracted.
9) Following hemostasis, place a cotton pellet slightly moistened with 1:5
dilution of Buckleys formacresol over the pulp stumps for 5 minutes.
10) Remove pellet. There should be very little or no hemorrhage present.
11) Place a base of IRM over the amputation site and condense to cover the
pulpal floor.
12) A second layer is then condensed to fill the access opening completely.
13) The final restoration ideally is a stainless steal crown to prevent
subsequent fracture of the weakened tooth.
14) If placement of the SSC is not possible at the same appointment, IRM
serves as an acceptable temporary restoration.




Fig. 1: Properly cut access





Fig. 2: Location and shape of the canal orifices of mandibular right 1
st
and 2
nd
primary molars



Fig. 3: Location and shape of the canal orifices of maxillary right 1
st
and 2
nd
primary molars
77
TWO-STAGE PULPOTOMY

A two-stage pulpotomy is indicated when hemorrhage is uncontrolled before
and/or after application of the formacresol. This technique fixes the coronal pulp
tissue, while some part of the radicular tissue remains vital.

1) Repeat pulpotomy steps 1-7.
2) Place a slightly moistened pellet of formacresol over the pulp stumps.
Formaldehyde vapor liberated from the cotton pellet permeates through
the pulpal space, producing fixation of the tissues.
3) Place an IRM temporary restoration. Make sure it is sealed well.
4) After 7-10 days the formacresol pellet should be removed:
i. Isolate the tooth.
ii. Remove formacresol pellet.
iii. If no hemorrhage is present, repeat pulpotomy steps 11-14.
iv. If hemorrhage is present, a pulpectomy is indicated.

PULPECTOMY

Pulpectomy is indicated when the pulp is either irreversibly inflamed or necrotic.
Although the technique is often considered difficult because of the complexity of
the root canals of primary teeth, clinical studies have shown a reasonable
prognosis. If the radicular pulp is necrotic, a two-stage procedure is preferred, but
if it is found to be irreversibly inflamed, a one-stage technique may be done.

ONE-STAGE PULPECTOMY

1) Repeat pulpotomy steps 1-7.
i. The access opening may need flaring to facilitate access of
the canals for broaches and files.
2) Root canals should be identified and a properly sized broach selected.
3) Use the broach gently to remove as much organic material as possible
from each canal.
4) Endodontic files are selected and adjusted to stop 2 mm short of the
radiographic apex of each canal.
i. This technique is intended to minimize the chance of
overinstumenting and causing periapical damage.
5) Sodium hypochlorite is used to irrigate to aid in removing debris.
i. The solution should be used very carefully and with no
excessive irrigation pressure to avoid forcing it into the
periapical tissues.
6) The canals are dried with paper points
7) Place a slightly moistened pellet of formacresol for 5 minutes.
8) Fill root canal with a thin mixture of ZOE paste using a lentulo mounted on
a slow speed handpiece or Vitapex can be packed in using a sterile
syringe.
9) Repeat pulpotomy steps 11-14.
78

TWO-STAGE PULPECTOMY

1) Repeat one-stage pulpectomy steps 1-6.
2) Place a slightly moistened pellet of formacresol and seal it in the pulp
chamber with an IRM restoration.
3) After 7-10 days, the formacresol pellet should be removed.
4) If the tooth is symptom-free, firm, and without a discharging sinus,
complete the restoration as noted in the one-stage pulpectomy.

Following any form of endodontic treatment, regular clinical and radiographic
reviews must be made of the tooth involved and its successor. If rarefaction of
the bone in the furcation area is seen, further pulpectomy may be possible, but
extraction is probably indicated. Radiographs should also be checked for
evidence of internal resorption which may progress to cause perforation of the
root.
79
KNEE TO KNEE EXAM

The child should be examined while sitting in the dental chair by himself. At times
a transitional period when the child sits on the parents lap may be appropriate.
More often if he is either too young or is unable to sit in the dental chair then a
knee to knee exam should be performed. The knee to knee exam allows the
dentist to examine the childs teeth with the caregivers assistance.

ARMAMENTARIUM

# Mirror
# Explorer
# Molt mouth prop (use if necessary)
# 2 X 2 Gauze (wipe teeth to remove plague)
# Toothbrush (use for toothbrush fluoride treatment and for OHI)
# Assistant (to chart for you)

HOW TO PERFORM A KNEE TO KNEE EXAM

1. Child sits on parents lap in a straddle position.
2. Parent leans the child back onto the dentists lap while the parent holds
the childs hands.
3. Dentist performs oral exam, OHI, prophy and/or toothbrush fluoride
treatment, while the parent controls the childs hands and legs.
4. The parent also has a perfect view of their childs mouth. The dentist can
take this opportunity to educate the parent. (Often the parent has never
really seen the posterior teeth.)


80
GOALS OF CHILDS FIRST ORAL EXAM

! Chart teeth
! Identify existing or potential problems.
! Assess caries risk.
" Note oral hygiene, diet, hypocalcified areas (white spots),
etc.
! Provide oral hygiene instructions and nutritional guidance.
! Perform prophy and/or toothbrush fluoride treatment
! Educate the parent and emphasize the importance of periodical exams.

81
COMMON ANALGESICS


ACETAMINOPHEN (TYLENOL)

Childrens dose: 15mg/kg/dose qid
Adult dose: 325-650mg q 4-6 h
Maximum dose: 4g/day

Forms: Drops: 100mg/ml
Susp: 160mg/5ml
Chew tab: 80mg
Tablet: 325mg and 500mg
Suppositories: 120mg and 650mg

Category: Analgesic, non-narcotic, antipyretic

Indications: Mild to moderate pain

Side effects: Rash, blood dyscrasias, hepatic necrosis with overdose,
renal injury with chronic use.


IBUPROFEN (MOTRIN)

Childrens dose: 5-10mg/kg/dose q 6-8 h
Maximum dose: 50mg/kg/24h
Adult dose: 400-600mg/dose q 4-6 h
Maximum dose: 2.4mg/day

Forms: Susp: 100mg/5ml
Tablets: 200mg, 300mg, 400mg

Category: Analgesic, non-narcotic, NSAID

Indications: Mild to moderate pain and inflammation

Side effects: Indigestion, nausea

Interactions: Increases levels of digoxin
82
COMMON PRESCRIPTIONS


DENTAL INFECTIONS

Amoxicillin: Dose: 20-40mg/kg/day PO div q 8h; Max dose: 875mg/dose

Rx: Amoxicillin 250mg/5ml
Disp: 150ml
Sig: Take one tsp (250mg) q 8h for 10 days.

Allergy to amoxicillin use:

Clindamycin: Dose: 10-30mg/kg PO daily div q6-8h

Rx: Clindaymycin 150mg
Disp: 30 tabs
Sig: Take one tablet (150mg) q 8h for 10 days. (Rx for patient weighing 25kg)

ANGULAR CHEILITUS

Rx: Triamcinolone and nystatin ointment (Mycolog II)
Disp: 15 g tube
Sig: Apply to affected area after each meal and at bedtime

APHTHOUS ULCER

Rx: Triamcinolone acetonide (Kenalog in Orabase)
Disp: 5 g tube
Sig: Dry lesion. Coat lesion with a thin film after each meal and at bedtime.

CANDIDIASIS

Rx: Nystatin suspension 100,000 units/ml
Disp: Infants: 125ml (Infant dose: 200,000 units qid)
Child/Adult: 300ml (Child/adult dose: 500,000 units qid)
Sig: Infants: 2 ml qid. Swab oral tissues and encourage swallowing.
Child/Adult: 5ml qid. Swish for two minutes and swallow.

Rx: Fluconazole susp. 40mg/ml or Fluconazole tablets 100mg (Diflucan)
Dose: 6mg/kg loading dose, then 3mg/kg qd for 13 days.
Sig: 1 dose qd for 14 days
Contraindications: Not for patients with renal or hepatic dysfunction.
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RECURRENT HERPES LABIALIS

Rx: Penciclovir cream (Denavir)
Disp: 5 g tube
Sig: Apply to affected area at first sign, then q 2h until lesion is gone.

MULTIPLE ORAL ULCERATIONS

Diphenhydramine (Benadryl) elixir 12.5 mg/5ml and Kaopectate
Mix equal parts by volume
Rinse with 5ml q 2h and spit out

Maalox can be used in place of Kaopectate

GINGIVITIS

Rx: Chlorhexidine gluconate mouthwash 0.12% (Peridex)
Disp: one bottle (16 oz)
Sig: Gargle with 5ml for 1 minute at bedtime.
Side effects: Increases calculus on teeth, altered taste sensation, tooth staining
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BENEFITS OF FLUORIDE THERAPY

Fluoride combats tooth decay in major ways:
! Reduction in enamel solubility
! Remineralization
! Interference with plaque microorganism metabolism
Community water fluoridation is the adjustment of fluoride in a water supply to an
optimal concentration between 0.7 to 1.2 ppm. Water fluoridation is especially
beneficial for poorer communities. It is safe, effective, low cost and non-
discriminatory and should be the major part of all caries preventive programs.
Since most of the fluoride that is absorbed is from ingested water, it is the most
efficient source of systemic fluoride.
Ninety-seven percent of the fluoride which is stored in the body is stored in bone
and teeth.
Aside from fluoridated water, there are several other means of fluoride therapy:
" Dentrifices
" Mouthrinses
" Gels/Foams
" Varnish
" Dietary Fluoride Supplements
DENTRIFICES
OTC TOOTHPASTE
" Most contain 0.1% (1000 ppm) fluoride = 1mg/g of fluoride as sodium
monofluorophosphate
" For children >2 years of age Use a pea-sized amount (approximately
0.25g) twice a day.
PRESCRIPTION STRENGTH DENTRIFICES
" PreviDent 5000 Plus or booster
" 1.1% (4,950 ppm) sodium fluoride toothpaste
" To be used once daily in place of regular toothpaste.
" It is well established that 1.1% sodium fluoride is safe and extraordinarily
effective in caries prevention.
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ppm sodium fluoride sodium monofluorophosphate
1500 0.32% 1.14%
1000 0.22% 0.76%
500 0.11% 0.38%
MOUTHRINSES
OTC MOUTHRINSES
" ACT, Fluorigard
" Solutions of 0.05% sodium fluoride (225 ppm) for daily
rinsing for children >6 years of age.
" Indication: incipient decay, low risk patients
PRESCRIPTION MOUTHRINSES
Prevident Dental Rinse 0.2%
" Indication: additional protection for children where there is no
fluoride in the water, useful during ortho treatment or for the
moderate risk patient
" Use 5ml/day: if swallowed = 1mg F/day
" Not strong enough for high caries risk patients
" Not to be swallowed by children when >3.0 ppm of fluoride in
the water
Gel Kam Oral Care Rinse
" 0.63% stannous fluoride (1512 ppm)
" Indication: moderate to high risk patients, reduces sensitivity
and protects root surface.
" For children >12 years old
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GELS/FOAMS
GEL/FOAM OF SODIUM FLUORIDE 0.9% (9000 ppm)=9mg/ml F/
GEL OF SODIUM FLUORIDE 1.23% (12,300ppm)=12.3 mg/ml F
" Indication: patients who are at high risk for caries, ortho
patients
" General application:
Trays should be tried in mouth as it may be
necessary to adapt tray
Patients should be seated upright and suction should
be used during the procedure.
Teeth should be air dried prior to application.
For caries prevention, cleaning or prophylaxis is not
necessary prior to application.
Fluoride should be applied from 1-4 minutes
depending on childs tolerance.
Young children are at risk for swallowing
Patients should not eat, drink, or rinse for 30 minutes
after application.
VARNISH
CAVITY SHIELD, DURAFLOR, DURAPHAT NaF 5% (22,500 ppm)
" Indication: Patients who are moderate to high risk for caries.
" General application:
Remove excess moisture from teeth with gauze or air.
Apply varnish as thin layer using disposable brush
The entire tooth surface must be treated
Avoid applying varnish to gingival areas because of
risk of allergy.
No drying is necessary after application because
varnish sets in a few seconds.
Varnish causes the teeth to appear yellowish. This will
wear off.
No rinsing, eating, or drinking for at least 30 minutes
after application.
Do not brush teeth that have been treated for 24
hours after application.
Children with high risk of caries, it is recommended
that fluoride varnish be applied every 3-6 months.
May be applied more often if necessary.
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DIETARY FLUORIDE SUPPLEMENTS
Dietary fluoride supplements come in tablet or liquid form including fluoride-
vitamin preparations.
Supplements are provided as sodium fluoride. One milligram of fluoride is
attained from 2.2 mg of sodium fluoride.
Indications: The use of fluoride supplements is indicated for children in non
fluoridated areas. See chart below.
DIETARY FLUORIDE SUPPLEMENT SCHEDULE
FLUORIDE ION LEVEL IN DRINKING WATER (ppm)
Age < 0.3 ppm 0.3-0.6 ppm > 0.6 ppm
Birth 6 months None None None
6 months 3years 0.25mg/day None None
3 6 years 0.5mg/day 0.25mg/day None
6 16 years 1mg/day 0.5mg/day None
* 1 part per million (ppm) = 1 milligram/liter (mg/L)
** 2.2 mg sodium fluoride contains 1 mg fluoride ion.
It is suggested that only children living in non-fluoridated areas use dietary
fluoride supplements between the ages of 6 months to 16 years.
If the fluoride level of the drinking water is not known, it should be tested. State
and local health departments can provide information on testing drinking water
for fluoride levels.
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SAFETY AND TOXICITY OF FLUORIDE
" Acute toxicity can occur from ingestion of excessive amounts
of fluoride.
" Nausea and vomiting are the usual result of acute toxicity.
" When prescribing fluoride supplements the total amount
should be within safe limits for an infant or toddler.
Thus there is a limit of 120 tablets of 2.2 mg NaF
which can be prescribed to a family at any given time.
Ingestion of the entire prescription would result in the
intake of 120 mg fluoride.
The lethal dosages are:
" 3 year old = 500mg
" 6 year old = 750mg
" 9 year old = 1000mg
o Symptoms may appear with 3-5mg/kg of
fluoride.
Should excessive amounts of fluoride be swallowed,
vomiting should be induced immediately.

FIRST AID FOR INGESTION OF FLUORIDE
! Induce vomiting
! Give milk or milk of magnesia (will bind fluoride temporarily)
! If possible, calculate dosage and call Poison Control Center 1-
800-825-2722

" Enamel fluorosis is a result of ingesting excessive amounts
of fluoride during tooth development.
" Various degrees of fluorosis, from barely noticeable whitish
opacities to severe pitting of the enamel surface and brown
staining.
" Fluorosis can only be produced during the relatively short
period of pre eruptive enamel development
The maxillary permanent incisors are the teeth which
are most important in protecting from fluorosis.
o The critical window for fluorosis in these teeth
is 18 to 24 months old.
o Enamel development is usually completed in
the maxillary incisors by age four
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MANAGEMENT OF DENTAL TRAUMA

It can be very distressing to see a child who has suffered trauma. Therefore it is
of utmost importance to have a systematic approach to avoid missing
information necessary for diagnosing and treatment planning.

It is highly recommended that a trauma assessment form is used to record data
and organize the management of care. (See attached sample of trauma sheet)

HISTORY

Questions that need to be asked regarding the immediate trauma:

# When, where and how did the trauma occur?
! Rule out child abuse.
# Were there any other injuries?
# Was there a period of unconsciousness, headache, amnesia, nausea or
vomiting? If so, how long?
! Rule out brain concussion or closed head injury.
# What initial treatment was given?
# Is there a disturbance in the bite?
# Is there sensitivity to cold and/or heat?

Questions that need to be asked regarding past medical history:

# Is there a history of cardiac disease?
" May necessitate use of antibiotic prophylactics.
# Is there a history of blood or seizure disorders?
# Any known allergies to medications?
# Is the patient taking any medications?
# What is the status of tetanus immunization?
# Any previous injuries to the dentition?

CLINICAL EXAM

# Palpate facial skeleton to rule out facial fractures.
# Note extra oral wounds, i.e. lip lacerations.
# Check for injuries to oral mucosa or gingiva.
# Palpate alveolus.
# Note any displacement of teeth or abnormalities of occlusion.
# Examine teeth for infractions and fractures.
# In case of crown fractures, note any pulp exposures and their size.
" Note reaction to pulp sensitivity tests (permanent teeth).
# Check for degree of mobility and percussion tone.
" Tenderness to percussion will indicate damage to PDL.
" High metallic tone implies the injured tooth is locked into bone.
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RADIOGRAPHIC EXAM

# Steep occlusal PA of the traumatized anterior region is adequate for most
lateral luxations, apical and mid-root fractures and alveolar fractures.
# The standard PA bisecting angle provides information about cervical root
fractures.
# A radiographic exam consisting of one steep occlusal exposure and three PA
bisecting exposures will provide sufficient information in determining extent of
trauma
# Must be able to assess:
" Stage of root development.
" Injuries to root and supporting structures.
# Take panoramic radiograph to rule out dento-alveolar, condylar, mandibular
and maxillary fractures.
# A soft tissue radiograph is indicated if there is a penetrating lip lesion.
" Place dental film between lips and dental arch and use 25% of normal
exposure time.

# If possible, take a photograph of the trauma. It is an excellent documentation
and can be used for treatment planning, legal claims or clinical research.

FOLLOW-UP

1 week Patients with replanted teeth. The splint should be removed at this time
to prevent ankylosis.

3 weeks A radiographic exam will show periapical radiolucency and possibly
some inflammation resorption. After luxation, the splint can be removed.

6 weeks Clinical and radiographic exam will show pulp necrosis in most cases
as well as inflammation root resorption.

2 and 6 months Optional for cases with questionable prognosis.

1 year Necessary for long term prognosis. In some cases, such as root
fractures, intrusions, and replanted teeth longer observation periods are
necessary
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