2011 @dentallib M S Muthu, N Sivakumar Pediatric Dentistry, Principles [PDF]

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Pediatric Dentistry Principles and Practice SECOND EDITION EDITORS



MS Muthu, MDS, PhD Professor and Head, Department of Pediatric Dentistry, Saveetha Dental College, Chennai 600 077, Tamil Nadu, INDIA



N Sivakumar, MDS, FICD Professor and Head, Dept of Pediatric Dentistry, Narayana Dental College and Hospital, Nellore 524 003, Andhra, Pradesh, INDIA



ELSEVIER A division of Reed Elsevier India Private Limited



Table of Contents Cover image Title page Copyright DEDICATED TO Contributors Foreword Preface to the Second Edition Preface to the First Edition Acknowledgements Brief Contents



Section I: Pediatric Dentistry: Fundamentals Chapter 1: Introduction to Pediatric Dentistry Role of a Pediatric Dentist and Pediatric Dentistry Chapter 2: History Taking, Examination, Diagnosis and Treatment Planning in Pediatric Dentistry History Taking (Fig. 2.1) Examination Diagnosis Treatment Planning Chapter 3: Chronology and Morphology of Primary and Permanent Teeth Chronology and Eruption of Human Dentition Nolla’s Stages of Tooth Development (Nolla 1952) Morphology of Primary Teeth Morphology of Individual Primary Teeth Chapter 4: Teeth Identification Teeth Identification Systems Teeth Identification Exercise



Section II: Growth and Development: Changes in the Dentofacial Structures Chapter 5: Growth and Development Fundamentals of Growth and Development Chapter 6: Development of Dentition and Occlusion Development of Teeth Eruption and Shedding of Teeth Clinical Problems During Eruption of Teeth Developmental Anomalies of Teeth Development of Occlusion



Section III: Psychology, Behavior and Behavior Guidance Chapter 7: Child Psychology Freud’s Psychodynamic Theory Erikson’s Psychosocial Theory or Theory of Personality Development Jean Piaget’s Cognitive Theory (Fig. 7.5) Classical Conditioning by Ivan Pavlov (1903)



Operant Conditioning by BF Skinner Observational Learning by Albert Bandura Separation-Individuation Theory by Margaret S Mahler Theory of Hierarchy of Needs by Abraham Maslow (Fig. 7.9) Anxiety and Fear Mental and Emotional Development (Maturation) with Age and Fears Stone and Church Classification of Child Development Chapter 8: Behavior Guidance Behavior of Children in Dental Setting Factors/Variables Influencing Behavior of Children Behavior Management Chapter 9: Pharmacological Behavior Management History of Sedation and Anesthesia Basic Concepts of Sedation and General Anesthesia Goals of Sedation and Anesthesia General Guidelines Sedation General Anesthesia



Section IV: Preventive Dentistry Chapter 10: First Dental Visit Viewpoints from Different Countries Regarding First Dental Visit Goals of a First Dental Visit Preparation of the Child for the First Dental Visit First Dental Visit Chapter 11: Principles of Preventive Dentistry Preventive Measures Chapter 12: Infant Oral Health and Anticipatory Guidance Risk Assessment Caries Assessment Tool Infant Oral Health Infant Examination Dental Home Anticipatory Guidance Responsibility of Non-dental Professionals Regarding Infant Oral Health Care Chapter 13: Fluorides and Their Role in Pediatric Preventive Dentistry



Systemic Fluorides Topical Fluorides Fluoride Toxicity Chapter 14: Plaque Control Measures in Pediatric Dentistry Current Hypotheses on the Role of Plaque Bacteria in the Etiology of Dental Diseases Mechanical Plaque Control Chemical Plaque Control Chapter 15: Dental Health Education and School Dental Health Programs Dental Health and General Health Dental Health Education Learning and Teaching Aids for Oral Health Education Successfully Conducted School Dental Health Programs in Western Countries



Section V: Dental Caries Chapter 16: Caries Risk Assessment and Caries Activity Tests Caries Risk Assessment Caries Activity Tests



Chapter 17: Dental Caries Etiology of Dental Caries Clinical Classification of Dental Caries Histopathology of Dental Caries Epidemiology of Dental Caries Rampant Caries Sugar Substitutes Caries Vaccine Chapter 18: Early Childhood Caries Etiology of Early Childhood Caries Clinical Features of Early Childhood Caries Management of Early Childhood Caries Preventive Measures Chapter 19: Role of Diet and Nutrition Role of Nutrition in Dental Development Role of Diet in Dental Caries Food Guide Pyramid Diet Counseling Diet Diary (Table 19.2)



Dietary Counseling in the Dental Practice Role of Diet in Periodontal Disease Chapter 20: Recent Advances in Diagnosis of Caries Conventional Methods Non-conventional Methods Non-conventional Methods in Use



Section VI: Restorative Dentistry and Endodontics Chapter 21: Pit and Fissure Sealants and Preventive Resin Restorations Pit and Fissure Sealants Preventive Resin Restorations (Fig. 21.4) Chapter 22: Atraumatic Restorative Treatment Principles of ART Chapter 23: Pediatric Operative Dentistry Diagnosis of Child’s Treatment Needs and Planning by Visits Principles of Cavity Preparation Fundamentals of Cavity Preparation in Primary Teeth



Chapter 24: Pulp Therapy Pulp–Dentin Complex Classification of Disease of Pulpal and Periapical Tissues Deep Caries Management Other Pulp Therapy Procedures Chapter 25: Crowns in Pediatric Dentistry



Section VII: Injuries to the Teeth: Prevention and its Management Chapter 26: Traumatic Injuries of Teeth and Supporting Structures Etiology of Trauma to Teeth and Supporting Structures History Taking and Examination for Traumatized Patient Classification of Injuries to Teeth and Supporting Structures Treatment Planning Chapter 27: Sports Dentistry for Children and Adolescents Epidemiology and Prevalence of Sports-related Traumatic Injuries Prevention of Sports-related Traumatic Injuries Management of Sport-related Injuries



Section VIII: Pediatric Orthodontics Chapter 28: Preventive and Interceptive Orthodontics Diagnosis and Treatment Planning Classification of Malocclusion Management of Crowding Chapter 29: Space Maintainers and Regainers Space Maintainers Space Regainers Chapter 30: Oral Habits Classification of Habits General Etiology of Oral Habits Fundamentals in Management of Oral Habits



Section IX: Children with Special Health Care Needs and Medical Emergencies Chapter 31: Dental Care for Children with Special Needs Fundamentals of Management



Chapter 32: Management of Medically Compromised Children Chapter 33: Cleft Lip and Palate Management Chapter 34: Medical Emergencies Emergency Management



Section X: Interdisciplinary Pediatric Dentistry Chapter 35: Oral Surgical Considerations and Local Anesthesia Fundamentals of Nerve Supply to Primary Teeth Fundamentals of Local Anesthetics Use of Topical Anesthetics Indications and Contraindications for Extraction of Primary Teeth Chapter 36: Prosthodontic Considerations for Children and Adolescents Restoration of Single Tooth Restoration of Multiple Teeth Concerns Regarding Growth and Development in a Growing Patient Chapter 37: Pediatrie Oral and Maxillofacial Pathology and Treatment Considerations



Benign Tumors of Soft Tissue (Fig. 37.1) Reactive Lesions Bone Pathology (Fig. 37.2) Non-odontogenic Cysts Odontogenic Cysts Odontogenic Tumors (Fig. 37.5) Malignant Tumors of Connective Tissue Origin (Fig. 37.6) Chapter 38: Gingival and Periodontal Diseases in Children Normal Gingiva and Periodontium Gingival Diseases and Mucogingival Defects Periodontal Diseases Systemic Disorders Associated with Periodontitis Chapter 39: Forensic Odontology



Section XI: Miscellaneous Chapter 40: Dental Materials Used in Pediatric Dentistry Glass Ionomer Cements Zinc Oxide Eugenol (ZOE)



Alginate (Irreversible Hydrocolloid) Chapter 41: Radiology Introduction to Radiation Physics Fundamentals of Imaging Techniques Chapter 42: Indices Used in Pediatric Dentistry Indices Chapter 43: Genetic Aspects of Dental Anomalies Fundamentals of Genetics Chapter 44: Antimicrobials and Analgesics Used in Pediatric Dentistry Antibiotics Analgesics Prescription Writing Calculation of Drug Dosage Chapter 45: Child Abuse and Neglect Child Abuse Child Neglect Chapter 46: Pediatrie Dentistry: Practice Management



Internal Environment of Dental Office Practice Management Excellent Customer Service Chapter 47: Essential Pediatrics for Pediatric Dentist General Examination Immunization Schedule in Children (Recommended by Indian Academy of Pediatrics) Glossary Index



Copyright Pediatric Dentistry: Principles and Practice, 2/e Muthu and Sivakumar ELSEVIER A division of Reed Elsevier India Private Limited Mosby, Saunders, Churchill Livingstone, Butterworth Heinemann and Hanley & Belfus are the Health Science imprints of Elsevier. © 2009, 2011 Elsevier First Edition 2009 Second Edition 2011 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means—electronic or mechanical, including photocopy, recording, or any information storage and retrieval system—without permission in writing from the publisher. ISBN: 978-81-312-2818-0 Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and the duration of administration, and the contraindications. It is the responsibility of the practitioners, relying on their own experience and knowledge of the patient, and to take diagnoses, to determine dosages and the best



treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Authors assume any liability for any injury and/or damage to persons or property arising out or related to any use of the material contained in this book. Please consult full prescribing information before issuing prescription for any product mentioned in this publication. The Publisher Published by Elsevier, a division of Reed Elsevier India Private Limited Registered Office: 622, Indraprakash Building, 21 Barakhamba Road, New Delhi-110 001 Corporate Office: 14th Floor, Building No. 10B, DLF Cyber City, Phase II, Gurgaon-122 002, Haryana, India Publishing Manager: Ritu Sharma Commissioning Editor: Nimisha Goswami Managing Editor (Development): Anand K Jha Copy Editor: Saroj K Sahu Manager-Publishing Operations: Sunil Kumar Production Executive: Arvind Booni Cover Designer: Raman Kumar Typeset by Chitra Computers, New Delhi Printed and bound at Rakmo Press Pvt. Ltd., Okhla, New Delhi.



DEDICATED TO J Krishnamurti (and his books) and Latha Rajinikanth (for her book Chinna Chiru Manithargal) for inspiring me to choose Pediatric Dentistry as my career



—MS Muthu My Parents, my teachers and students who are the motivation for what I am today —N Sivakumar



Contributors Abinash Mohapatra MDS, Vice Principal, Hi Tech Dental College and Hospital, Bhubaneshwar - 751 025 A Victor Samuel MDS, Senior Lecturer, Dept of Pediatric Dentistry, Saveetha Dental College, Velappanchavadi, Chennai - 600 077 B Ajay Reginald MDS, Professor of Oral Pathology, Narayana Dental College and Hospital, Nellore - 524 003 D Jayaraj MDS, Senior Lecturer, Dept of Pediatric and Preventive Dentistry, Indira Gandhi Institute of Dental Sciences, Sree Balaji Vidyapeeth University, Pillaiyarkuppam, Puducherry - 607 402 EMG Subramanian MDS, Reader, Dept of Pediatric Dentistry, Ultra’s Best Science Dental College, Madurai - 625 104 G Deepa MDS, Reader, Dept of Pediatric Dentistry, Saveetha Dental College, Velappanchavadi, Chennai - 600 077 J Jeevarathan MDS, Reader, Dept of Pediatric Dentistry, Balaji Dental College, Pallikaranai, Chennai - 600 100 J Mohammed Farzan MDS, Reader, Dept of Pediatric Dentistry, Sri Ramachandra Dental College, Porur, Chennai - 600 116 K Rekhalakshmi MDS, Senior Lecturer, Dept of Pediatric Dentistry, Narayana Dental College and Hospital, Nellore - 524 003 M Y Padmanabhan MDS, Senior Lecturer, Dept of Pediatric Dentistry, Sri Ramakrishna Dental College and Hospital, Coimbatore 641 006 Priya Sampath BDS, Tutor, Dept of Pediatric Dentistry, Meenakshi Ammal Dental College, Chennai - 600 095



Sankalp Taparia MDS, Consultant Pediatric Dentist, HAPPY 2TH, Pediatric Care Clinic, 7, Deodar Street, Kolkata - 700 019 Sharath Asokan MDS, MS, MPhil, PhD, Reader, Dept of Pediatric Dentistry, Meenakshi Ammal Dental College, Chennai - 600 095 Steven JL Rodrigues MDS, Professor, Dept of Pediatric Dentistry, Saveetha Dental College, Velappanchavadi, Chennai - 600 077 SVSG Nirmala MDS, Professor, Dept of Pediatric Dentistry, Narayana Dental College and Hospital, Nellore - 524 003



Foreword The specialty of Pediatric Dentistry has grown significantly in the last two decades. At least most of the cities in India, have a Pediatric Dentist now. A decade ago it is a rare phenomenon to see a Pediatric Dentist. In this country of 1 billion people, it is said that 25% of this population are children. No part of this country has the benefit of water fluoridation. One can imagine the extent of dental disease in children of this country. This specialty is a very important field of dentistry, where lack of training at the undergraduate level can hamper a general dentist’s ability to provide the highest quality care to children. Hence a comprehensive book which can help students apply the principles of child psychology and behavior management is needed. It can help students and more general dentists to incorporate these principles in practice. The book is written in a reader friendly manner, important aspects are highlighted appropriately. Definitions are given as a separate section of this book, with Self-assessment Questions at the end of each chapter. This will greatly help the undergraduate students during the time of examinations. Topics like Teeth Identification, Sports Dentistry and Drugs Used in Pediatric Dentistry are unique about this book. In our country, we do not have the privilege of having nitrous oxide and oxygen at every practice. Hence, more indigenous techniques to manage our children are necessary. This book by Dr MS Muthu and Dr N Sivakumar, will definitely show the way for these things. I knew them as colleagues and have seen the harmony in them when they were with me in Meenakshi Ammal Dental College. They had tremendous understanding between them and running the department in a very efficient way. I knew that they were working on



this book for quiet some time. Now finally, it is time for its release. I believe that this book will give the undergraduate students a sound foundation in Pediatric Dentistry. E Munirathnam Naidu, MDS, University, Chennai, INDIA



Former Vice Chancellor, Meenakshi



Preface to the Second Edition We came up with the first edition of Pediatric Dentistry: Principles and Practice three years back and we are thankful to all our readers for their overwhelming response, feedback and valuable suggestions for the betterment of this book. We knew many books do not come for a second edition so early. We are glad that we are given a chance to add value to the book by incorporating all the suggestions from our valuable readers. Thanks to the publishers for having a futuristic approach towards this book. When we look back at working on the first edition; it was a nightmare. We thought the revision would be a cake walk. In fact it was more tedious than the first edition. However we have worked hard in order to come up with the best for our readers. We have added 6 new chapters to this edition. However, in the process of revising the book it was a constant endeavor from our side to maintain the balance between the content and the explanatory part as well. We did not want a book to be too elaborate and make it extremely difficult for the UG student to grasp important aspects of Pediatric Dentistry. It was greatly appreciated as a well balanced undergraduate book and good start up book for the passionate postgraduate student of the specialty of Pediatric Dentistry. In the second edition we have also divided the content into various sections. These sections are thoroughly mapped up with the second edition of the book MCQs in Pediatric Dentistry which came out recently with almost around 1500 chapter wise MCQs in pediatric dentistry. This division will help the reader orient towards the content in a better way. The chapters on Child Psychology, Behavior Guidance, Teeth Identification, Traumatic Injuries to the Teeth and Supporting



Structures, Antibiotics and Analgesics used in Pediatric Dentistry were greatly appreciated. I sincerely urge the readers to look into the extensively revised chapters on History Taking (Chapter 2), Pharmacological Behavior Management (Chapter 9), Early Childhood Caries (Chapter 18), Indices (Chapter 42) and Pediatric Dentistry: Practice Management (Chapter 46). These chapters have been updated to date. History Taking chapter has been greatly modified with the inputs from Dr Steven Rodrigues (one of the greatest Pediatric Dentists we have ever met). The chapters on History taking (Chapter 2) and a new chapter on First Dental Visit (Chapter 10) will be a hallmark of this edition as the content given is so unique to any Pediatric Dentistry textbook across the globe. These chapters reveal the involvement of the contributors’ interest and continuous learning from treating children exclusively for around the last 13-15 years. Pharmacological Behavior Management chapter has been completely revamped with extensive revision with the help of Dr Padmanabhan from Coimbatore. Early Childhood Caries chapter is added with quality of life information and the current preventive measures being researched and practiced in the most developed nations. The newly introduced indices like ‘PUFA” and “ICDAS” system have also been included in the Indices chapter. Pediatric Dentistry: Practice Management chapter has been added with more evidence for successful exclusive pediatric dental centers across the country with more information of customer care and new dental practice management software etc. Abraham Maslow said, “Musician must make music, Artist must draw and the Singers must sing to reach “Self-actualization”. We believe that Pediatric Dentists must Treat Children (only) to reach ‘Self-actualization”. This subject is much more than a branch of dentistry. It is a separate science dealing with the youngest minds. As the authors we are confident that this book will inspire you in some way, somehow to be a passionate Pediatric Dentist. We hope that readers will find this book useful. We look forward to valuable comments, criticism, and suggestions of the readers to improve this book in the subsequent editions.



MS [email protected] and N [email protected]



Preface to the First Edition We thought that we shall write a textbook for students few years back. Then we questioned ourselves on what authority we are writing this textbook? There were many questions in our mind. Can we write this textbook with the present level of experience as Pediatric Dentists? How much time it will take to finish this project? If we write this book, who will recommend this book? In spite of many doubts and questions we started on this venture almost 30 months ago. One of us has 15 years of experience teaching Pediatric Dentistry and the other has been treating exclusively children for the last 11 years and teaching for the last 9 years. Is this experience enough to write a textbook? We do not know! But as teachers and practitioners we have been continuously learning from our experiences with students and patients. We believe Pediatric Dentistry is a great field. We don’t believe in ‘beating’ Pediatric Dentistry, but believe in ‘talking’ Pediatric Dentistry. We have learnt and have tremendous faith in our behavior management techniques. Some of our students are examples for it. We have shared everything we have known with our students. We have never kept any technique or simple short cuts for ourselves. We were happy when some of our students were more capable than us in certain areas. We continuously encouraged their strengths and were grateful that we could be a stepping stone for some of our excellent postgraduate students of the Department of Pediatric Dentistry. We strongly believe in the following saying by Henry Adams. “A teacher affects eternity; he can never tell where his influence stops”. Time will tell the influence of us in the long run. We as teachers have appreciated and encouraged our students selflessly. Because of these traits we continue to become better



teachers as days go by. During this journey we have learnt many things. We thought this book will help us to share these things which we have learnt over a period of time with our colleagues, faculties, students and patients. We have mentioned in this book some strategies that were used effectively by us in handling children in our practice as well as in the institutions where we belong now or belonged earlier. We have tried our best to put as much information as possible for an undergraduate student, at the same time it can serve as good start guide to postgraduate students. We have tried to integrate the syllabi recommended by the Dental Council of India, as well as from various universities across the country into this book. Definitely the Pediatric Dentistry books by McDonald, Pinkham, Stewart and Barber, Stephen Wei, Finn, Mathewson and Braham, Morris have served as guides for us to write many of our chapters. However, Practice of Pediatric Dentistry in the West and in our country is different. We believe more in non-pharmacological behavior management techniques. The western countries use nitrous oxide, oxygen in more than 50% of its patients. Hence, we have modified certain techniques and approaches as it is applicable in our country. We hope that readers will find this book useful. We look forward to the valuable comments, criticism, and suggestions of the readers to improve this book in the subsequent editions. MS [email protected] and N [email protected]



Acknowledgements “Develop an attitude of gratitude, and give thanks for everything that happens to you, knowing that every step forward is a step toward achieving something bigger and better than your current situation.” —Brian Tracy As the quote says, one has to have an attitude to show gratitude continuously. Though this book has both of our names as editors, there were many people who made this possible. First of all, we would like to thank the Publishers, Elsevier for their trust in us that we would be able to complete this work. We thank Ms Ritu Sharma, Mr Anand K Jha, Nimisha and their team for being patient with us. We also like to thank Dr SVSG Nirmala, Dr Steven Rodrigues, Dr Sharath Asokan, Dr EMG Subramanian, Dr Jeevarathan, Dr Priya Mahesh, Dr Mohammed Farzan, Dr Abinash Mohapatra, Dr Padmanabhan, Dr Rekhalakshmi, Dr Jayaraj, Dr Deepa and Dr Sankalp Taparia for their contributions. MS MUTHU I would like to thank my colleagues in my Department at Saveetha Dental College, Dr Steven, Dr Deepa, Dr Sujatha, Dr Victor, Dr Harini (Former), Dr Zakriya for always ready to help me with any academic work. We are building a dream team here in terms of teaching, learning and living. I should thank all my Postgraduate students for being there and trying hard to run with me towards the dream department. I would like to thank my former colleagues Dr V Rathnaprabhu,



Professor and Head, Dr Venkatachalapathy, Dr Roshan, Dr Deepti Amarlal and Dr Prabhakaran for handling the departmental responsibilities whenever I was away for this work while I was working at Meenakshi Ammal Dental College. Thanks are due to Dr Sivapathasundharam and Dr Kavitha (from Department of Oral Pathology) for their histological pictures for the chapter on Pediatric Oral and Maxillofacial Pathology and treatment considerations, Dr Harshavardhan from the Department of Oral Medicine for contributing pictures for the chapter and Dr Venkatachalapathy and Dr Manikandan (OMFS) for contributing images for the chapter on Cleft Lip and Palate Management. My sincere thanks to our Principal, Dr Jayakumar, and Vice Principal, Dr Ambalavanan for allowing my absences in the department (occasionally) because of this book. My sincere thanks are also due to the former postgraduate students Dr Phanibabu, Dr Preethi Sharma, Dr Brindha, Dr Senthil and Dr Bhavani for their help in preparing the manuscript, being a model for some of the photographs taken in the department and sharing some of their clinical photographs. I would also like to thank two of my former postgraduate students for their valuable contribution — Dr Rekka for correcting few of the chapters and giving valuable and sincere inputs and Dr Shifa for her tireless efforts in getting, clicking, reclicking and organizing many of the images for this book as well as for suggesting the sources from where we can get appropriate images for this book. She has contributed many of the quotes at the beginning of each chapter after searching for hours on the internet. My undergraduate students from my previous institution Kirthana Devaji Rao and Indumathy also deserve special thanks for drawing the pencil diagrams for chapters on oral hygiene measures, and child psychology and behavior management. I furthermore, like to thank Dr SG Damle and Dr SG Sujan, Dr Adesh Kakade and Dr Bhavsar for making me a Pediatric Dentist. The learning in the Department of Pediatric Dentistry between the years 1997-1999 was priceless. The exclusive Pediatric Practitioners of Mumbai, Dr Ujwal Kontham



(my friend and colleague), Dr Meenakshi Kher, Dr Sanchali and Dr Rupali needs a special mention for their clinic pictures and being a role model for my Practice in Chennai. Dr Karthik Venkatraghavan (Bangalore) Sankalp (Kolkata), Jayaraj (Puducherry), Dr Aruna Mohan, Dr Sakthivel, Dr Deepti, Dr Roshan (All from Chennai), Dr Uma (Salem), Dr Sukhdeep Singh (Noida), Dr Harsh Vyas and Dr Ashwin (Mumbai) should also be thanked for the images of his practice and website. A teacher I respect for his sincerity, commitment, straightforwardness, and the ability to work hard untiringly is Dr Munirathnam Naidu. I am grateful; I came across him and learned so much from him; how an administrator should be. Though I have not spent great amount of time with him, but the few hours or few days (in total) I have interacted with him during his tenure in Meenakshi Ammal Dental College is priceless. The staff nurses of my department Rani, Eswari, and Sheela deserve appreciation for running across the department numerous times for making Xerox and print-outs of chapters. My maid’s daughter Kavitha who has crossed the roads from my clinic for the same purpose should be thanked. I would like to thank the doctors who worked with me in my private practice (Pedo Planet) Dr Jude, Dr Aishwarya Chatterjee, Dr Mathavi, Dr Vidhya, Dr Amuthavalli, and Dr Charanya for helping me proofread the chapters. I would like to thank my wife Muthu Prathibha (with Aradhana Sarayu inside for few months and outside for few months) and sisterin-law Jeyashree for their efforts in checking the language of many chapters. I should also thank my wife for the hundreds of hours she has sacrificed, as I was engaged in this work for more than 30 months. Thanks to my family members, Dad, Mom, uncle (Saras Kathiresan), brother (Ganesh), sister-in-law (Anu), sister (Vasanthi), brother-in-law (Srinivasan), sister-in-law (Gayatri), and her husband (Vikram) for their concern over me during this process. If I have not mentioned any of them who have contributed for this book in some way, it is purely accidental. I have listed some of the



books that were useful for us in writing this book. 1. Dentistry for the Child and Adolescent by McDonald 2. Clinical Pedodontics by Finn 3. Fundamentals of Pediatric Dentistry by Mathewson 4. Textbook of Pediatric Dentistry by Braham and Morris 5. Pediatric Dentistry: Scientific Foundations and Clinical Practice by Ray Stewart, Thomas Barber, Kenneth Troutman and Stephen Wei 6. Pediatric Dentistry: Infancy through Adolescence by J R Pinkham 7. Pediatric Dentistry: Total Patient Care by Stephen Wei Other books and the journals consulted are mentioned as Suggested Reading. N SIVAKUMAR Most of those mentioned by Dr Muthu who were my former colleagues and students from Meenakshi Ammal Dental College, Chennai or my present colleagues at Narayana Dental College, Nellore deserve my acknowledgements too. My sincere thanks to all my undergraduate teachers at Government Dental College, Hyderabad who taught me during 1983-1988 with special mention to Dr S Hamid Abu Talib who sowed seeds of Pedodontics in my mind and my postgraduate teachers Dr Shobha Tandon, Dr A R Prabhakar and Dr P Sudha at College of Dental Surgery, Manipal during my postgraduate studies from 1989-1991. A special mention to those who inspired me during my PG days; Dr Thresiamma Joseph, Dr VV Subba Reddy, Dr SG Damle and Dr AK Munshi in the specialty of Pedodontics and Dr MK Manjunath, former Professor of Conservative Dentistry and Endodontics at Manipal to name a few. No words can convey my gratitude to Dr E Munirathnam Naidu, my former Principal, Meenakshi Ammal Dental College, Chennai, who was also our Vice Chancellor when I left Meenakshi University. He is a friend, philosopher, guide and a role model in every way.



My special thanks to my parents Sri Sudarsanam Naidu and Smt Vanajakshamma, especially my mother who has been my inspiration to studies and for all the sacrifices they have done right from my childhood to see what I am today. I should thank my wife Bharathi and two daughters Sai Lavanya and Usha who have shown lot of patience and unconditional love in all these years of my academic and administrative work and having had little time to spare for them.



Brief Contents Contributors vii Foreword ix Preface xi Acknowledgements xiii Section I: Pediatric Dentistry: Fundamentals Chapter 1. Introduction to Pediatric Dentistry 3 Chapter 2. History Taking, Examination, Diagnosis and Treatment Planning in Pediatric Dentistry 7 Chapter 3. Chronology and Morphology of Primary and Permanent Teeth 19 Chapter 4. Teeth Identification 35 Section II: Growth and Development: Changes in the Dentofacial Structures Chapter 5. Growth and Development 45 Chapter 6. Development of Dentition and Occlusion 57 Section III: Psychology, Behavior and Behavior Guidance Chapter 7. Child Psychology 71 Chapter 8. Behavior Guidance 91 Chapter 9. Pharmacological Behavior Management 113 Section IV: Preventive Dentistry Chapter 10. First Dental Visit 131 Chapter 11. Principles of Preventive Dentistry 137 Chapter 12. Infant Oral Health and Anticipatory Guidance 141 Chapter 13. Fluorides and Their Role in Pediatric Preventive Dentistry 149 Chapter 14. Plaque Control Measures in Pediatric Dentistry 163



Chapter 15. Dental Health Education and School Dental Health Programs 173 Section V: Dental Caries Chapter 16. Caries Risk Assessment and Caries Activity Tests 183 Chapter 17. Dental Caries 195 Chapter 18. Early Childhood Caries 209 Chapter 19. Role of Diet and Nutrition 219 Chapter 20. Recent Advances in Diagnosis of Caries 229 Section VI: Restorative Dentistry and Endodontics Chapter 21. Pit and Fissure Sealants and Preventive Resin Restorations 241 Chapter 22. Atraumatic Restorative Treatment 249 Chapter 23. Pediatric Operative Dentistry 253 Chapter 24. Pulp Therapy 269 Chapter 25. Crowns in Pediatric Dentistry 291 Section VII: Injuries to the Teeth: Prevention and its Management Chapter 26. Traumatic Injuries of Teeth and Supporting Structures 305 Chapter 27. Sports Dentistry for Children and Adolescents 327 Section VIII: Pediatric Orthodontics Chapter 28. Preventive and Interceptive Orthodontics 335 Chapter 29. Space Maintainers and Regainers 349 Chapter 30. Oral Habits 365 Section IX: Children with Special Health Care Needs and Medical Emergencies Chapter 31. Dental Care for Children with Special Needs 385 Chapter 32. Management of Medically Compromised Children 393 Chapter 33. Cleft Lip and Palate Management 403 Chapter 34. Medical Emergencies 411



Section X: Interdisciplinary Pediatric Dentistry Chapter 35. Oral Surgical Considerations and Local Anesthesia 423 Chapter 36. Prosthodontic Considerations for Children and Adolescents 433 Chapter 37. Pediatric Oral and Maxillofacial Pathology and Treatment Considerations 443 Chapter 38. Gingival and Periodontal Diseases in Children 455 Chapter 39. Forensic Odontology 467 Section XI: Miscellaneous Chapter 40. Dental Materials Used in Pediatric Dentistry 475 Chapter 41. Radiology 479 Chapter 42. Indices Used in Pediatric Dentistry 491 Chapter 43. Genetic Aspects of Dental Anomalies 505 Chapter 44. Antimicrobials and Analgesics Used in Pediatric Dentistry 511 Chapter 45. Child Abuse and Neglect 519 Chapter 46. Pediatric Dentistry: Practice Management 529 Chapter 47. Essential Pediatrics for Pediatric Dentist 539 Glossary 545 Index 551



SECTION I



Pediatric Dentistry: Fundamentals OUTLINE Chapter 1: Introduction to Pediatric Dentistry Chapter 2: History Taking, Examination, Diagnosis and Treatment Planning in Pediatric Dentistry Chapter 3: Chronology and Morphology of Primary and Permanent Teeth Chapter 4: Teeth Identification



CHAPTER 1



Introduction to Pediatric Dentistry MS Muthu and N Sivakumar



CHAPTER OUTLINE Introduction Role of a Pediatric Dentist and Pediatric Dentistry Aims and objectives Scope of pedodontics Comprehensive or total patient care Differences between pediatric dentistry and other specialties Differences between child and adult patient Characteristics of an ideal pedodontist Suggested Reading Self-assessment Questions



“You can learn many things from children. How much patience you have, for instance.” —Franklin P Jones



Introduction “Pediatric dentistry is the practice and teaching of comprehensive, preventive and therapeutic oral healthcare of child from birth through adolescence. It is construed to include care for adult patients who demonstrate mental, physical or emotional problems.” —Stewart, Barber, Troutman and Wei, 1982 “Pediatric dentistry is an age-defined specialty that provides both



primary and comprehensive preventive and therapeutic oral healthcare for infants and children through adolescence, including those with special healthcare needs.” —American Academy of Pediatric Dentistry These definitions indicate the shift in Pediatric Dentistry from its extraction oriented beginnings towards prevention. Pediatric dentistry in India is still a developing field. It has its roots in the middle of the 20th century and has grown to the present state from there on. “Baby teeth don’t deserve care because you lose them anyway”- is a notion that still exists in the minds of majority of people in India. The gradually increasing number of pediatric dentists across the country may slowly change this trend. When dentistry was treatment oriented in developed nations, age was a consideration because of behavioral reasons and the inability of the clinician and the child patient to communicate. For these reasons, the first dental visit was kept on or after the third birthday. However, with the advancements in preventive dentistry and pharmacological behavior management techniques, it is recommended now to initiate the first dental visit on or before the first birthday. This chapter highlights the role of a pediatric dentist and the scope, aims and objectives of pediatric dentistry.



Role of a Pediatric Dentist and Pediatric Dentistry A pediatric dentist must extend himself to comprehend the needs of the children and their parents. He must spend time and effort teaching parents and children in his practice and in his community, the value of preserving the primary and permanent teeth. He must pass on to the parents the information regarding the ideal time and manner in which the children’s teeth should receive restorative care. Lack of awareness among the people of the community cannot be an excuse for not providing high quality pediatric dental care. In fact, one of the primary responsibilities of a practicing pediatric dentist is to create that awareness which does not exist in that area. However,



handling children with tender loving care is the ultimate goal of a pediatric dentist. The role of a pediatric dentist is aptly described by the axiom given below “Every child has a fundamental right to his/her total oral health and we have an obligation to fulfill this faith.” —Indian Society of Pedodontics and Preventive Dentistry (ISPPD) Pediatric dentistry differs in many ways from the other branches of dentistry which treat adult patients. As pediatric dentists, we have to develop a relationship with the parent/caretaker and the child, give comfort by allaying fears about dentistry and relieve pain and agony of dental problems of the child physically and emotionally. Study of psychological development of children and application of various behavior management techniques based on the psychological makeup and the emotional status of children is very much a part of contemporary pediatric dentistry. It is important to know that there are different modalities of treatment to primary and young permanent dentition compared to that of permanent dentition. We have to apply prevention oriented treatment planning. Children come from diverse backgrounds with different behaviors. The child may present a behavior that can be due to numerous subjective and objective experiences which he/she had undergone during his/her growing period. Most of the behaviors would have been positively or negatively reinforced over a long period of time by parents or caretakers. Hence the child may try to exhibit a similar behavior in the dental office environment also. “Healthy habits are inculcated in infancy and childhood as the child learns to imitate people around.” These factors should be borne in mind when we handle children and try to cultivate good oral hygiene, dietary and health habits.



Aims and Objectives of Pedodontics



Pedodontics, as a field or specialty of dentistry, has the following aims and objectives: • To create not only a good dental patient but also a good citizen of tomorrow • To instill a positive attitude and behavior towards dentistry • To introduce and implement principles of preventive dentistry from birth including parental guidance and counseling • Early diagnosis and treatment • Restore the lost tooth structure to maintain harmony between the hard and soft tissues • Occlusal guidance and early treatment of developing malocclusion • Management of children with special needs



Scope of Pedodontics Scope of pedodontics refers to the range of activities that are observed in the practice of pedodontics. Initially, pediatric dentistry was limited to the restoration of carious teeth, treatment of dental pulp or extractions and space maintenance. Practice oriented towards prevention was limited. Conversely, recent days have seen a remarkable change in the scope of pedodontics with the field becoming more prevention oriented. It may be due to various factors like: • Increased knowledge in the public regarding child dental health care • Advent of various sophisticated materials and agents for prevention and treatment of dental diseases • Improvement in technology of dental care delivery systems • Improvement in various anesthetic agents for clinical use • Radical changes to control virulent infections • Most importantly, recognition of the child as an individual Thus the scope of contemporary pedodontics includes:



• Child psychology and behavior management • Communication and parental involvement in delivery of care • Prenatal, natal and infant oral health considerations • Restorative dentistry and endodontics • Supervision of orofacial growth and development, preventive and interceptive orthodontics • Oral medicine and radiology • Pediatric medicine and surgery • Cariology and immunology • Preventive and public health dentistry • Care of the patients with special health care needs • Sedation, pharmacological management, and hospital dentistry • Child abuse and neglect (Forensic Pedodontics) • Genetics related to Pedodontics, etc.



Comprehensive or Total Patient Care Most often parents come to the dental office with a chief complaint and expect it to be treated. However, as a Pediatric dentist, we are supposed to treat the child as a whole rather than give solutions to a particular complaint. Hence, comprehensive care aims at: • Recognition of the child patient as a whole, not just treating a tooth but with the view of treating a child with dental problem. • Giving comprehensive treatment plan for the child after thorough history taking, complete examination and delivery of care not just for the chief complaint. • Maintenance of patient records for professional, ethical and legal needs. • Informed written consent with an explanation on the diagnosis, treatment planning, behavior management technique used and the prognosis to the parent or the legal guardian should be obtained. • Establishment of the database including history, examination,



diagnostic aids, diagnosis and treatment planning. • Delivery of dental care including education about dental diseases and their preventive aspects, behavior management, growth supervision, guidance of developing occlusion, restorative treatment, management of soft tissue and surgical problems.



Differences between Pediatric Dentistry and other Specialties It is well recognized that diagnosis of a child’s needs is different from that of the adult. Enumerated below are some differences between pediatric dentistry and other specialties. • Child progresses from infant to adult with alterations in anatomy and physiology. Slowly the child grows from a dependant state to an independent state; in other words selfcenteredness of infancy through stages to a concern for and attention to the needs of others. • Pediatric dentistry provides the opportunity to practice true prevention, whereas adult preventive programs do not prevent disease, but merely prevent its recurrence. • The dentist–patient relationship is triangular in pediatric dentistry. The pediatric dentist has to consider the patient and the parent when planning or providing dental care to the child. • The health care process must address the behavioral needs of the child in conjunction with dental and other oral health needs of the child. • Child is constantly changing and the health care needs also change with time. This fact has to be kept in mind while managing children.



Differences between Child and Adult Patient Understanding the differences between a child and adult patient is



essential. The differences are related to: • Physical development • Emotional and psychological development • Behavioral aspects of children • Dynamics of change in the dentition with differences in treatment of primary, young permanent to the permanent dentition • Dentist–patient relationship • Parent–dentist relationship Handling these factors is described later in Chapter 7 Child Psychology and Chapter 8 Behavior Guidance.



Characteristics of an Ideal Pedodontist (Fig. 1.1) The most important characteristic of a good pedodontist or a dentist, who handles children, is to have lots of patience.



FIGURE 1.1 Characteristics of an ideal pedodontist.



This trait serves as the foundation for all other required characteristics. The second most important requirement is empathy towards children. The difference between sympathy and empathy should not be misunderstood. Empathy is defined as ‘the ability to identify with and understand somebody else’s feelings or difficulties’. When we interact with children with empathy and patience, we will be able to identify their fear and slowly help them come out of it. The third important attribute is kindness towards children, which helps the dentist to establish a mutually trustworthy relationship. This helps them to look forward for their dental visits. They also tend to develop a positive attitude towards dentistry (Fig. 1.1). Apart from patience, empathy and kindness, a good pedodontist should have the following qualities: • Self-confidence and positive mental attitude • Goal orientation with clarity



• Flexibility in handling children • Cheerfulness with a gentle approach and tender loving care (TLC) • Art of developing a friendly rapport with children • Sincerity and honesty As we go through this journey, we realize that practicing pediatric dentistry is less stressful than any other specialty of dentistry because once we do the treatment properly; rarely do you see them with any complaints pertaining to the treatment rendered. Further the treatment procedures carried out in children have more predictable outcomes than adult dentistry. Childhood is precious. It characterizes innocence and fearlessness. However, when it comes to dental treatment and meeting doctors, it creates ripples in the child’s mind. If we have unconditional love and patience, this journey is going to be a marvelous one and we can make a world of difference in their minds about dentistry. As pediatric dentists, we have the greatest opportunity of interacting with the most innocent minds every day. This keeps us more vibrant and younger in spite of time. Detailed discussion about setting up a pediatric dental clinic and management of an exclusive pediatric dental practice is discussed in Chapter 46 Pediatric Dentistry: Practice Management.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Define pediatric dentistry. Discuss the aims, objectives and scope of pediatric dentistry. 2. Discuss the aims, objectives and scope of Pediatric dentistry and add a note on the setting up of pediatric dental practice.



Short Notes



1. Definitions of pediatric dentistry 2. Aims and objectives of pediatric dentistry 3. Scope of pediatric dentistry 4. Differences between pedodontics and the other specialties 5. Comprehensive pediatric dental care 6. Ideal characteristics of a pedodontist



SUGGESTED READING 1. Album, MM. Pedodontics, its scope and future. J Prev Dent. 1976; 3(6):6. [8–11]. 2. American Academy of Pediatric Dentistry Reference Manual 2006–2007. Pediatric Dentistry 28 7 2006 or ref. to website:. www.aapd.org 3. American Dental Association Commission on Dental Accreditation, Accreditation standards for advanced specialty education programs in Pediatric Dentistry. Chicago, Ill, 2000. 4. Andlaw, RJ, Rock, WP. A Manual of Paediatric Dentistry, 4th edn. Edinburgh: Churchill Livingstone; 1998. 5. Braham, RL, Morris, ME. Textbook of Pediatric Dentistry, 2nd edn. New Delhi: CBS Publishers; 1990. 6. Stewart RE, Barber TK, Troutman KC, Wei SHY, eds. Pediatric Dentistry: Scientifc Foundations and Clinical Practice. St. Louis:



Mosby, 1982. 7. Wright, GZ. Behavior Management in Dentistry for Children. Philadelphia: Saunders; 1975.



CHAPTER 2



History Taking, Examination, Diagnosis and Treatment Planning in Pediatric Dentistry Steven JL Rodrigues, N Sivakumar and MS Muthu



CHAPTER OUTLINE Introduction Initial contact with the parent History Taking Fundamentals of information gathering Chief Complaint History of present illness Past medical history Systems review Medications/treatment history Examination Diagnosis Treatment Planning Clinical examination form for pediatric dentistry Suggested Reading Self-assessment Questions



“God gave you ears, eyes and hands; use them on the patient in that order.” —William Kelsey Fry (1889–1963)



Introduction Children are different from adults in terms of physical, emotional and psychological maturation and childhood is the most significant period of growth and development. These dynamics of change will demand



specific skills in management, examination, diagnosis and treatment planning which are different from managing adult patients. The tell-show-do (TSD) technique of behavior management which involves explanation, demonstration and completion of what was told and shown, may be employed in history taking, examination and diagnosis in children. A complete medical history inclusive of the prenatal, natal and postnatal history along with a review of systems must be recorded. A brief past dental history, personal history, family history, diet history and oral hygiene history must also be noted. The major complaints should be recorded as described by the patients. The symptoms are the subjective evidences of the disease or condition as perceived by the child or the parent. The objective evidence of the disease is obtained by signs elicited by the dentist. The decision whether to rely on the child or the parent’s perception depends on the age, emotional status and intelligence level of the child at the time of the visit. No leading questions should be asked. The parent or the child is simply asked to describe the problem as fully as possible. The description of the chief complaint should include the reason for seeking dental care and any previous attempt at solving the problem. It is important to resolve the chief complaint, if possible, in the first visit. After complete examination of the oral cavity and related structures, a treatment plan is developed and is discussed with the parent or caretaker and the child. This will include the current problem list, problems anticipated in the future as a holistic comprehensive oral health program. Establishment of good communication is very important in dealing with young children. One must show genuine interest about the likes and dislikes of the children in day-to-day life. Making a note of the hobbies of children and mentioning them during the next appointment will help. In dealing with children, patient management has an equal importance as the competence and technical efficiency in dental treatment.



Initial Contact with Parents The parent contacts either personally or by telephone seeking an appointment for the child. The receptionist must show warmth and concern in the approach and should communicate clearly while offering the appointment. The responses of the dental office staff should assure the parents that our chief concern is towards the wellbeing of the child. The receptionist should record the necessary initial information about the child patient in the patient information form. This includes the name, age, sex, contact address and telephone numbers, nick name or pet name and the name with which the child likes to be addressed. It also includes the problem for which the appointment is sought.



Establishing a rapport • Good body language • Warm reception—greet the patient and parent(s) when they enter • Establish eye contact • Lean forward while talking while maintaining a reasonable distance • Facial expressions must reflect the mood of the conversation • Inform the patient from time to time why you are seeking the information



Definitions History: History can be defined as a planned professional conversation between the dentist and the patient, which allows the patient to communicate his symptoms, feelings and fears so that the nature of the patient’s suspected illness and mental attitudes may be determined. Case history is the least understood and the most undervalued prerequisite in the scientific approach in managing a patient. It allows an intelligent approach to diagnosis, helps establish successful



dentist–patient relationship, utilizes the patient’s knowledge or experience along with that of the clinician and helps understand the patient’s wishes and expectations. Examination: The examination can give a snapshot of the abnormalities detectable at that particular time whereas the history indicates how it happened and the chronology of its development. The examinations may confirm what the patient has told the dentist during the history taking. Symptom: Symptom is defined as any bodily change that is perceptible to the patient (it is subjective). Symptoms may vary from patient to patient; that which is perceived as discomfort by few may be excruciating pain to others. Sign: Sign is any bodily change which is perceptible to a trained observer (it is objective).



History Taking (Fig. 2.1) Fundamentals of Information Gathering The process of history taking is time intensive and it must begin as the patient enters the operatory. It is preferable to conduct the patient interviewing in a comfortable non-clinical setting. It must be organized and systematic. It should be standardized and consistent. It should be complete and accurate.



FIGURE 2.1 Case history recording — both the parent and patient are interviewed.



• Questions must be asked in a relaxed, casual, nonaggressive and non-threatening manner. The questions should have a definite outline or direction. The clinician has to be very patient, slow/unhurried, show concern and interest in what the patient is saying. He/she should be emphatic, must not express surprise or shock while recording the history. He/she must speak with the patient and not at or down. The clinician should be quietly reassuring in his/her approach, should not rush and must not interrupt when the patient is talking. Above all, he/she must “BE A GOOD LISTENER”. The person who records the history may have to rephrase the question in case the patient does not understand the question and should never have a preconceived idea of what the problem is as it may cloud one’s judgment.



Biographical data • Name • Nick name • Age • Chronological age • Dental age • Date of birth • Gender • Address • Phone no (Res, Office, Mobile) • E-mail address • Languages spoken (preferred mode for communication) • Class • School attended • Favorite subject • Favorite teacher • Favorite activity • Likes • Dislikes • Fears • Phobias • Person accompanying the child (If it is parent … their occupation) • Pediatrician • Dentist • Referred by • Any special notes/medical alerts • Initial behavioral assessment • Temperament Note: In the biographical information, details about the child’s favorite teacher, favorite activity, school, likes and dislikes can be gathered both from the patient and their parents. Informations of this sort are unique about history taking in pediatric patients. This



information can facilitate interesting conversations between the patient and the pediatric dentist. This helps the pediatric dentist to become more than a dentist and become a friend with whom the child patient can interact fearlessly. This also helps the pediatric patient to bond with his/her dentist which is major factor in providing dental care to children.



Chief Complaint The chief complaint is the symptom or symptoms in the patient’s (parent’s) own words. It is subjective in nature and related to an abnormal/uncomfortable feeling or condition. There may be more than one symptom. The symptoms are recorded in the order in which they appear. If there are no symptoms, then the reasons to visit the clinic are to be found and enumerated. Note: Words of caution • Young patients may not be able to express exactly what they feel. • Older patients may want to be helpful. • Fear may cause the child to disguise a problem. • There may be a psychological element to the problem.



History of Present Illness It is the chronological account of the patient’s chief complaint(s) and related to symptoms from the time of onset to the time of presentation at the dental setting. It may be qualitative or quantitative. (Qualitative means — pain can be described as sharp, lancinating, dull, throbbing; Quantitative — lasts for three hours and had occurred every day for the last seven days). Questions to be asked: PAIN: • When did it start? • How did it start?



• What is the character and nature? • What is the duration? • What is the location? • What are the aggravating or relieving factors? • Is it associated with any other activity?



Past Medical History Prenatal history • Any history of miscarriages/abortions? • Any infections during pregnancy? • Any history of trauma during pregnancy? • Any history of alcohol intake during pregnancy? • Any history of smoking? • Drug intake during pregnancy? • Any dental problems during pregnancy?



Natal history • Was the child born premature/term/post-term? • History of uncontrolled diabetes? • History of eclampsia? • Any history of fetal distress? • Type of delivery? • Did the child cry at birth? • Blue/yellow baby? • Apgar score (if available) • Did your child have teeth in the mouth at birth? • Any other deformities noticed at birth? • Birth weight • Crown-rump length • Head circumference



Postnatal history



• Did the child have normal milestones (rolling over, crawling, standing, talking, walking) • Immunization status of the child as of today? • Did any teeth erupt in the oral cavity in the first 30 days? • When did the milk teeth start erupting? • Did your child have or was exposed to the following infections? (Chickenpox, measles, mumps, recurrent upper respiratory infections, recurrent sore throat, recurrent ear infections) • Any history of hospitalizations? • If yes then, (Reasons for hospitalizations, name of the hospital, date of admission, date of discharge, discharge summary)



Systems Review Growth and development • Any physical problems with growth? • Difficulty in focussing or being attentive? • Whether the child is extremely nervous? • Ability to communicate? • Whether the child has ever been counseled/counseling being considered in the near future



Central nervous system • History of (H/O) headaches, seizures, frequent spells of fainting • Hearing difficulty • Sighting difficulty • Smelling difficulty • Tasting difficulty • Any H/O head injuries in the past



Cardiovascular system



• H/O breathlessness (on standing/exertion) • H/O turning blue on exertion • H/O squatting • H/O previous surgeries (or recommended in the future)



Hematopoietic system • Does your child bruise easily, have frequent nose bleeds or bleed excessively (more than the normal time) from small cuts? • Is your child more susceptible to infections than other children? • Does/did your child have recurrent bouts of fever? • Does/did your child have H/O swollen glands?



Blood transfusions • Has your child ever received blood transfusions? • If yes then why, when and the source of blood. • Were repeated transfusions required? • If yes then why, frequency and the source of blood.



Respiratory system • Any H/O shortness of breath/difficulty in breathing. • Any H/O wheezing. • Any H/O chronic upper respiratory tract infection. • Any H/O lung infections/pneumonia. • Any H/O evening rise of temperature, unexplained weight loss, night sweats.



Gastrointestinal system • Any H/O reflux.



• Any H/O frequent/recurrent stomach aches. • Any H/O frequent diarrhoea. • Any H/O unintended weight loss. • Any H/O hepatitis or jaundice.



Genitourinary system • Any H/O difficulty passing urine? • Any H/O pain in the back?(flanks) which may or may not radiate to the naval? • Any H/O swelling of the face/extremities (especially early in the morning) • Any H/O recurrent urinary tract infections? • Any H/O hematuria?



Endocrine system • H/O diabetes? • H/O any deficiency/excess in any hormones?



Allergies • Any H/O allergy to food or things in the environment? • Any H/O allergy to any kind of medications? • If yes then, when did it occur?; what caused it?; how was it managed?; did it require hospitalization?



Medications/Treatment History • Is your child taking any prescription or non-prescription medications? • Has your child received chemotherapy or is it planned in the near future? • Has your child ever received radiation therapy, is it planned in



the future?



Past dental history The following information may be gathered from the parent and child: • At what age did the first milk tooth start erupting? • Were there any problems associated with the eruption of the milk teeth? • Were there any problems associated with replacement/falling of milk teeth and eruption of the permanent teeth? • Did your child ever experience any toothache in the past? • Did your child ever have any traumatic injury in the region of mouth, teeth or jaws in the past? • Did your child ever visit dentist in the past? • Yes/no (besides no—first dental visit) • If yes, then when did he visit the dentist? why did he visit the dentist? • Was any dental treatment/emergency care was done at this visit? • Was any dental treatment carried out at subsequent visit? • What was the experience of the child at the dentist like? • Did the child look forward to his dental visits?



Personal history • Was your child breast fed/bottle fed or both? • If breast fed, then till what age? • If bottle fed, then till what age? • Contents of the bottle • Timing of the feeds • Frequency of the feeding • Did the child fall asleep while being fed? • At what age did weaning begin?



• At what age was the child started on a semi-solid/solid diet? • Did your child ever use a pacifier? If yes, then what type and how long? • Is your child frequently on medications? If yes, then What is the medication being prescribed for? Since when is your child taking medication? For what duration does he have to take it? • Bladder habits • Bowel habits • Nap and nap timings • Sleep patterns



Diet history • How would you describe your child apatite? • Would you say your child is a fussy eater? • Would you say your child’s diet is a balanced diet? • Does your child prefer food that is sweeter to taste? • Does your child prefer a soft/pureed diet? • Does your child prefer juices/carbonated beverages over water? • Is your child fond of snacking between meals? If yes, then what does he prefer to snack on? How frequently does he snack in a single day? • In your opinion does your child eats sweets very often? • What kind of sweets does your child prefer? • How many times on an average in a day does your child eat sweets?



Oral hygiene history • When did you begin cleaning your child’s mouth? • Who is responsible for cleaning your child’s teeth? • If the child his/her teeth on their own, is it



supervised/unsupervised? • What does your child use to clean his/her teeth? (finger/tooth brush/ any other) • If tooth brush, then type, size and bristles? • How is it cleaned and stored? • How frequently is the tooth brush changed? • Does the child use tooth powder/toothpaste or any other agent to clean his teeth? • If toothpaste, then is the toothpaste fluoridated? • If tooth brushing is assisted, • Who brushes the child’s teeth? • What brushing technique does the parent use? • For how long are the teeth brushed? • Is dental floss used? • Is the mouthwash being used by the child?



Behavioral history How would you describe your child’s temperament/personality? • Is your child outgoing and friendly or would you describe him as being reserved and slow to warm up? • Would your child be described as focused, a go-getter, and an achiever? • Is your child laid back and needs to be pushed, coaxed and encouraged to get anything done? • Would you describe your child as being of a sad disposition? • Does your child bounce back from a difficult or bad situation? • Does your child enjoy going to school? • Does your child mix around and make friends easily? • How does your child react to (a) a new situation, (b) new people, (c) a stressful difficult situation? • What according to you are your child’s coping mechanisms?



Habits



Dental habits Does the child have any of the following habits? • Finger/thumb sucking • Nail biting • Lip biting/sucking • Tongue thrusting • Mouth breathing • Bruxism/teeth grinding If yes, then what is the frequency, intensity, duration and observable clinical manifestations?



Non-dental habits • Has the child had any exposure to substances like tobacco/alcohol/glue and other organic solvents?



Family history • Is your family joint or a nuclear family? • How many members are there in your family? • Who is responsible for decision making in the family? • How are the relationships within the family? • How are the relationships with the neighbors/friends? • Is there any history of hereditary diseases in the family? • Was any family member exposed to tuberculosis? The following questions may be asked especially if there is a history of the child repeatedly falling sick. • What is the kind of house that you all live in? • Does the house have adequate ventilation? • Are the sanitation facilities adequate in the house?



• Has the area you all live in been reported as endemic for any disease? Note: The following question may be asked on completion of the history taking to obviate the possibility of any question being missed by the dentist or any information that may not have been provided by the parent/caretaker that might be critical or important to the outcome of treatment of the child. IS THERE ANYTHING I HAVE NOT ASKED YOU ABOUT OR YOU HAVE NOT TOLD ME THAT YOU THINK I SHOULD KNOW THAT WOULD HELP ME TREAT YOUR CHILD TO THE BEST OF MY ABILITIES?



Examination General examination: The examination of the child begins with observation as the child walks into the clinic. These observations may include a. physical stature of the child, b. facial and body proportions, c. posture and d. gait. Changes noticed in any of the above mentioned observations from the normal for that age may indicate growth disturbance (dwarfism/gigantism), neuromuscular disorder (polio/cerebral palsy), a CNS disorder (cyst/tumor in the brain), orthopedic problem(bony defect/fracture/bony disorder), the state of mind (depression, low self esteem) or it simply may be bad footwear. Head: Size, shape and symmetry of the head should be evaluated (hydrocephalus, microcephaly, sleeping on the side). Hair: Color (kwashiorkor, marasmus), texture, sparse or full growth (ectodermal dysplasia). Eyes: Check for gross vision (acuity), filled of vision, exophthalmos,



hypo- or hypertelorism, conjunctivitis, icterus and pallor. Ears: Gross hearing or any other type of deformity, discharge from the ear. Nose: Olfactory capability, patency of nasal airway, obvious gross deviation of nasal septum, polyps, hypertrophy of the nasal turbinates, tenderness over sinuses and allergic rhinitis. Neck: Skin, enlarged obvious, cervical lymph nodes and draining sinus, range of movements of the neck. Skin: Color and texture to be evaluated. Look for inflammation, scarring, eruptions, ulcerations and dryness of skin. Nails: Spooning, clubbing, yellow discoloration, cyanosis and evidence of nail biting. Extraoral examination: Shape of the head: (a) Dolicocephalic, (b) mesocephalic, (c) brachycephalic Facial form: (a) Leptoprosopic, (b) mesoprosopic, (c) euryprosopic Facial symmetry: (a) Symmetrical, (b) asymmetrical Lateral profile: (a) Convex, (b) straight, (c) concave Facial divergence: (a) Anterior divergent, (b) posterior divergent, (c) straight Lips: (a) Competent, (b) incompetent, (c) potentially competent Upper lip: (a) Normal, (b) short, (c) everted, (d) protrusive, (e) repaired Lower lip: (a) Normal, (b) short, (c) everted, (d) protrusive, (e) repaired Mouth opening: (a) Normal, (b) restricted TMJ: (a) Normal, (b) clicking, (c) pain, (d) mandibular deviation on opening, (e) mandibular deviation on closing Muscle of mastication: (a) Temporalis, (b) masseter Lymph node examination: Speech: (a) Normal, (b) problems in articulation, (c) phonation, (d) rhythm, (e) symbolization Swallowing: (a) Infantile swallow, (b) mature/adult swallow Breathing: (a) Nasal, (b) oral Any other findings in the orofacial region (draining sinus,



angular cheilitis, any skin lesions). Intraoral examination: It includes information about any soft tissue-related lesions/conditions and hard tissue examination. Hard tissue examination includes problems related to jaw bones and teeth. The teeth should be recorded in FDI system for easy understanding and communication. Information regarding eruption status to assess dental age, primary and secondary dentition present, decayed, missed and filled teeth present and the oral hygiene status is included. Soft tissue examination: • Lips • Labial mucosa • Buccal mucosa • Soft palate • Hard palate • Tongue (dorsal, ventral surface) • Floor of the mouth • Openings of the salivary glands (Stensen’s, Wharton’s, Bartholin’s) • Tonsils (palatine/pharyngeal/lingual) • Frenum (upper labial/buccal, lower labial/buccal, lingual) • Gingiva (color, contour, consistency, shape, position, bleeding on probing, presence of deposits) • Any other findings Hard tissue examination • Teeth present • Chronological age/dental age • Carious teeth (DMFT, dmft, DMFS, dmfs, PUFA, pufa) • Oral hygiene (good, fair, poor-inferred from the OHI simplified) Occlusal examination: It includes primary molar relationship, permanent molar relationship, primary/permanent canine



relationship, overjet and overbite relationships, diastemas and any crowding present. • Spaced dentition/closed dentition • Primary molar relationship (right, left) • Permanent molar relationship (right, left) • Permanent canine relationship (right, left) • Overbite (deep bite, open bite) • Overjet (crossbite—anterior, posterior) • Midline (maxilla, mandible) • Midline diastema • Crowding • Rotation • Missing teeth • Arch form Any other findings: This includes the findings not related to the chief complaint like the developmental disturbances of teeth in terms of size, shape or number, fractured or discolored teeth, impacted teeth, submerged teeth which were not reported by the patient or parent. Summary of the findings: All positive/relevant information/findings from case history and clinical examination are summarized to facilitate a differential/provisional diagnosis.



Diagnosis Provisional diagnosis: It is a tentative diagnosis which is not fully worked out, concluded or agreed upon. This is based on the medical and dental history taken and also the clinical examination findings and is used till the final diagnosis is worked out based on the investigations. Differential diagnosis: Differential diagnosis is the process of identifying a condition by differentiating all pathologic processes or conditions that may produce similar lesions or findings. It is otherwise



termed as distinguishing between diseases of similar character by comparing their signs and symptoms. All the investigations (including radiologic or laboratory) will aid in the process of differential diagnosis. Investigations: Investigations that may be carried out to aid in arriving at a provisional or final diagnosis from a differential diagnosis may include the following. Laboratory: Laboratory investigations like complete blood picture, urine tests or histopathology are carried out to aid in differential diagnosis. This may be augmented by other specialized tests like liver function tests, renal function tests may be needed under certain circumstances. Radiographs: Intraoral periapical, bitewing, occlusal (maxillary/mandibular), lateral oblique, lateral cephalogram, orthopantomogram, PA mandible, PNS, sialography may be needed. Occasionally advanced imaging techniques like Spiral CT, ConeBeam CT, MRI may be needed. Others: Caries risk assessment, vitality testing, salivary flow assessment, tests for mouth breathing, etc. Final diagnosis: This is the diagnosis that is arrived at after all the data have been collected, analyzed and subjected to logical thought. Treatment may be necessary in some instances before the final diagnosis is made. The diagnosis may be categorized under the following headings: medical, behavior, growth, oral hygiene, caries risk, restorative, endodontic, orthodontic, surgical and any other.



Treatment Planning Treatment planning is a stepwise, rational, evidence-based ordered sequence in which the treatment necessary for the child’s well being will be carried out. No such thing as an ideal treatment plan. We must customize care according to the needs of the child. There is no fixed treatment plan. The treatment plan may change in the process of being executed depending on the new needs that may arise. We cannot have a single treatment plan. Alternate treatment plans may need to be



available while taking into consideration the following factors: 1. The emergency needs of the child (trauma/dentoalveolar abscess/cellulitis) 2. The medical history (leukemia, hemophilia) 3. The age of the child (longevity of care required, behavioral assessment—cooperative, lacking cooperative ability, potentially cooperative) 4. Socioeconomic status (affordability of care) 5. Distance from treatment facility (access to care) 6. Parental attitudes towards dentistry (positive or negative) 7. Level of motivation of parents (desire or lack of desire for dental care) 8. Educational status of parent (importance of care for milk teeth) 9. Present and future dental needs of the child (proximal disking vs composite restoration on mesial aspect of second deciduous molar) 10. Prognosis of tooth in concern (whether the tooth can be brought into function) 11. Anticipated benefits for the child and parent (tangible and non-tangible) 12. Limitations of time, resources and manpower 13. The need and importance of preventive care 14. Requirement for expanded, holistic care that not only meets the dental needs of the child but also takes care of his emotional and psychological well being The treatment planning may be executed in the following order. Immediate phase: It refers to attending to the immediate needs of the patient, physically and emotionally. Relieving the pain and mental agony of the patient and parent is the primary concern for any dentist. Attending to the traumatic injuries, deep carious lesions which need immediate attention are some examples for the same along with prescription of analgesics, anxiolytics, antibiotics, etc. In case of routine dental visits without emergencies, the immediate phase is



omitted. Systemic phase: It includes referral to medical specialist/family physician in case of medical conditions to be treated or advice to be taken before dental procedures like prophylactic antibiotics for prevention of subacute bacterial endocarditis (SABE). Preparatory phase: It includes preventive measures like oral health education, oral prophylaxis, fluorides and/or fissure sealant application and premedication given for the patient management. Corrective phase: It includes step by step planning of all the restorative, endodontic, surgical, orthodontic and prosthetic rehabilitation procedures. Maintenance phase: It includes the instructions given for the maintenance after the dental procedures are completed, recall schedules, etc.



Clinical Examination Form for Pediatric Dentistry



CONCLUSION This chapter outlines a specific and systematic approach of history-taking. Detailed evaluation of trauma, preventive and interceptive orthodontic assessments are explained in Chapters 24 and 26, respectively. Various tooth-numbering systems are dealt within detail in Chapter 4. The remaining chapters in this book will help the student augment their diagnosing and management skills in order to provide oral health services to children and adolescents.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Role of history taking in pediatric dentistry. 2. What are the different steps/phases in treatment plan?



Short Notes 1. Importance of past dental history 2. Importance of medical history in pediatric dentistry 3. Role of personal history in children



SUGGESTED READING 1. Kerr, DA, Ash, MM, Millard, HD. Oral Diagnosis, 3rd edn. St Louis: Mosby; 1970. 2. McDonald, RE, Avery, DR, Dean, JA, Examination of the mouth and other relevant structures. Dentistry for the Child and Adolescent 8th edn. Mosby, St Louis, 2004. 1– 22. 3. Wei, SHY, et al, Examination, diagnosis and treatment planning: Pediatric Dentistry: Total Patient Care. Lea and Febiger, Philadelphia, 1988. 101–114.



CHAPTER 3



Chronology and Morphology of Primary and Permanent Teeth MS Muthu and N Sivakumar



CHAPTER OUTLINE Introduction Chronology and Eruption of Human Dentition Importance of learning chronology Summary of chronology Nolla’s Stages of Tooth Development Morphology of Primary Teeth Morphology of Individual Primary Teeth Maxillary central incisors Maxillary lateral incisors Maxillary canines Maxillary first primary molars Maxillary second primary molars Mandibular central incisors Mandibular lateral incisors Mandibular canines Mandibular first molars Mandibular second molars Functions of primary teeth Clinical significance of morphology of primary teeth Conclusion Suggested Reading Self-assessment Questions



“In all things of nature, there is something of the marvelous.”



—Aristotle



Introduction One of the areas in which we observe the precision and uniqueness of nature is in the morphology of teeth in different species. Humans have two sets of teeth — one set of teeth when the jaw is small and another set as the jaw grows. Each tooth has a predetermined and programed shape and location to form. The process of tooth development is a series of events taking place simultaneously in harmony with various other processes. This chapter is primarily aimed at providing a brief overview of tooth development and a detailed description of morphology of primary teeth and differences between primary and permanent teeth.



Chronology and Eruption of Human Dentition The history of chronological studies demonstrates the difficulty in obtaining adequate documentation of the source of the data being presented. Tables 3.1 and 3.2 give the details of the chronology of human dentition as given by various authors. One of the earliest of widely used table is by Logan and Kronfeld. Later this was revised by Lunt and Law in 1974. Both the tables are presented here for the reader’s benefit. A summary of the development of primary and permanent tooth is given in Chapter 6 for the reader to assimilate this information. Table 3.1 Chronology of human dentition by Logan and Kronfeld (1933)



Tooth



Hard tissue formation begins



Amount of enamel at birth



Enamel Eruption completed



Root completed



PRIMARY Maxillary Central incisor



4 months in utero



Five-sixths



1.5 months



7.5 months 18 months



Lateral incisor



4.5 months in utero



Two-thirds



2.5 months



9 months



24 months



Cuspid



5 months in utero



One-third



9 months



18 months



39 months



First molar



5 months in utero



Cusps united



6 months



14 months



30 months



Second molar



6 months in utero



Cusp tips still isolated



11 months



24 months



36 months



Central incisor



4.5 months in utero



Three-fifths



2.5 months



6 months



18 months



Lateral incisor



4.4 months in utero



Three-fifths



3 months



7 months



18 months



Cuspid



5 months in utero



One-third



9 months



16 months



39 months



First molar



5 months in utero



Cusps united



5.5 months



12 months



27 months



Second molar



6 months in utero



Cusp tips still isolated



10 months



20 months



36 months



Mandibular



PERMANENT Maxillary Central incisor



3–4 months



4–5 yrs



7–8 yrs



10 yrs



Lateral incisor



10–12 months



4–5 yrs



8–9 yrs



11 yrs



Cuspid



4–5 months



6–7 yrs



11–12 yrs



13–15 yrs



First 1.5 – 1.75 yrs bicuspid



5–6 yrs



10–11 yrs



12–13 yrs



Second 2–2.25 yrs bicuspid



6–7 yrs



10–12 yrs



12–14 yrs



First molar



First molar



Second molar



2.5 – 3 yrs



Sometimes a trace



Third molar 7–9 yrs



2.5 – 3 yrs



6–7 yrs



9–10 yrs



7–8 yrs



12–13 yrs



14–16 yrs



12–16 yrs



17–21 yrs



18–25 yrs



Mandibular Central incisor



3–4 months



4–5 yrs



6–7 yrs



9 yrs



Lateral incisor



3–4 months



4–5 yrs



7–8 yrs



10 yrs



Cuspid



4–5 months



6–7 yrs



9–10 yrs



12–14 yrs



First 1.75 – 2 yrs bicuspid



5–6 yrs



10–12 yrs



12–13 yrs



Second 2.25 – 2.5 yrs bicuspid



6–7 yrs



11–12 yrs



13–14 yrs



2.5 – 3 yrs



6–7 yrs



9–10 yrs



7–8 yrs



11–13 yrs



14–15 yrs



12–16 yrs



17–21 yrs



18–25 yrs



First molar



At birth



Second molar



2.5 – 3 yrs



Sometimes a trace



Third molar 8–10 yrs



Table 3.2 Chronology of human dentition by Lunt and Law (1974)



Tooth



Hard tissue formation begins



Amount of enamel at birth



Enamel Eruption completed



Root completed



PRIMARY Maxillary Central incisor



14(13–16) wk in utero



Five-sixths



1.5 months



10(8–12) 1.5 yrs months



Lateral incisor



16(14.7–16.5) wk in utero



Two-thirds



2.5 months



11(9–13) 2 yrs months



Canine



17(15–18) wk in utero



First molar 15.5(14.5–17) wk in utero



One-third



9 months



19(16–22) 3.25 yrs months



Cusps united



6 months



16(13–19) 2.5 yrs mos( ) 16(14–18) mos( )



Second molar



19(16–23.5) wk in utero



Cusps united



11 months



29(25–33) 3 yrs months



Central incisor



14(13–16) wk in utero



Three-fifths



2.5 months



8(6–10) 1.5 yrs months



Lateral incisor



16(14.75-) wk in utero



Three-fifths



3 months



13(10–16) 1.5 yrs months



Canine



17(16-) wk in utero



One-third



9 months



20(17–23) 3.25 yrs months



First molar 15.5(14.5–17) wk in utero



Cusps united



5.5 months



16(14–18) 2.25 yrs months



Second molar



Cusps united



10 months



27(23–31) 3 yrs mos( )



Mandibular



18(17–19.5) wk in utero



27(24–30) mos( )



Importance of Learning Chronology Learning the chronology and eruption of teeth is very much important for a student learning pedodontics. Knowledge on dates of crown completion, eruption and root completion of teeth will help the student or clinician in the following stages: • Determination of dental age and identification of teeth during initial examination. • Identification of developmental anomalies and their probable age of occurrence, e.g. nutritional disturbances or drugs affecting the teeth, pre- or postnatal. • Changing treatment strategies based on the developmental



status of the teeth, like young permanent teeth with large pulp chambers and incomplete root development. • Planning the preventive and interceptive orthodontic procedures based on the dental development.



Summary of Chronology Primary teeth The hard tissue formation of primary teeth starts as early as the 4th month of intrauterine life. By the 6th month of intrauterine life, hard tissue formation of all the primary teeth would start. At birth, enamel formation of primary teeth is at various stages. Enamel formation of all the primary teeth is completed by 11 months (maxillary second molar) of age. The eruption of primary teeth starts by 6 months after birth and by 24 months of age (2 yrs), all the primary teeth are present in the mouth. Generally, the mandibular teeth erupt earlier than the maxillary teeth. The root formation of primary teeth is usually completed by 10–23 months after their eruption; the least for the incisors and the longest for the canines. Sequence of eruption: Sequence of eruption of primary teeth is A, B, D, C, E (teeth mentioned in Palmer notation) whereas sequence of calcification is A, D, B, C, E.



Permanent teeth The hard tissue formation of permanent teeth starts as early as 3–4 months after birth. However, it is reported that the beginning of calcification of first permanent molars starts at birth. Enamel formation of all the permanent teeth is completed by the age of 8 years except the third molars which takes place by 12–16 years. Hence tetracycline or any other drug, which can cross the placenta and intrinsically discolor the tooth should not be used until this age (8 years). The eruption of permanent teeth starts by 6–7 years and is completed by 12–13 years except the third molars that may erupt by 17–21 years. Generally, the root formation of most of the permanent teeth is usually completed by 2 years after the eruption of the teeth.



However, the canines and permanent molars may take 3–4 years after eruption. Sequence of eruption: Favorable sequence of eruption of permanent teeth in mandible is 6/1, 2, 3, 4, 5, 7 whereas in maxilla it is 6/1, 2, 4, 5, 3, 7. Here the sequence is more important than timing to prevent any abnormalities in eruption which results in malocclusion. Approximate time difference between crown completion to eruption and root completion can be assessed from the following diagram as it will be easy to remember eruption dates based on which one can assess the crown completion or root completion dates. Figure 3.1 shows that the primary incisors’ crown completion occurs 4 to 6 months before eruption date, whereas the same is 6 to 12 months for primary canines and molars. Root completion will occur one year after eruption for all primary teeth. For permanent teeth, the crown completion time is approximately 3 years before eruption and the root completion is approximately 3 years after eruption.



FIGURE 3.1 Root completion of primary and permanent teeth.



Nolla’s Stages of Tooth Development (Nolla 1952) In 1952, Nolla has given an arbitrary description of tooth formation divided into eleven stages (Fig. 3.2). These are numbered as A to K or 0 to 10. This is useful in dental age estimation for medicolegal or forensic purposes. Important stages to remember are stage 2 (initial calcification) and stages 6 and 9 (the time teeth begin eruptive movements). Mean stage of calcification for each tooth is shown in terms of the 10 stages of calcification (Table 3.3). Table 3.3 Mean stages of calcification for each teeth Norms for maturation of permanent teeth in boys Age Mandibular teeth (growth stage) (Years)



Maxillary teeth (growth stage)



3



5.2



4.5



3.2



2.6



1.1



5.0



0.7



...... 4.3



3.4



3.0



2.0



1.0



4.2



4



6.5



5.7



4.2



3.5



2.2



6.2



2.0



...... 5.4



4.5



3.9



3.0



2.0



5.3



5



7.5



6.8



5.1



4.4



3.3



7.0



3.0



...... 6.4



5.5



4.8



4.0



3.0



6.4



6



8.2



7.7



5.9



5.2



4.3



7.7



4.0



...... 7.3



6.4



5.6



4.9



4.0



7.4



7



8.8



8.5



6.7



6.0



5.3



8.4



5.0



0.8



8.2



7.2



6.3



5.7



4.9



8.2



8



9.3



9.1



7.4



6.8



6.2



9.0



5.9



1.4



8.8



8.0



7.0



6.5



5.8



8.9



9



9.7



9.5



8.0



7.5



7.0



9.5



6.7



1.8



9.4



8.7



7.7



7.2



6.6



9.4



10



10.0 9.8



8.6



8.2



7.7



9.8



7.4



2.0



9.7



9.3



8.4



7.9



7.3



9.7



11



......



......



9.1



8.8



8.3



9.9



7.9



2.7



9.95 9.7



8.8



8.6



8.0



9.8



12



......



......



9.6



9.4



8.9



......



8.4



3.5



......



9.95 9.2



9.2



8.7



......



13



......



......



9.8



9.7



9.4



......



8.9



7.5



......



......



9.6



9.6



9.3



......



14



......



......



......



10.0 9.7



......



9.3



5.3



......



......



9.8



9.8



9.6



......



15



......



......



......



......



10.0 ......



9.7



6.2



......



......



9.9



9.9



9.9



......



16 ½



......



......



......



......



......



10.0 7.3



......



......



......



......



......



......



......



17



......



......



......



......



......



......



......



7.6



......



......



......



......



......



......



Norms for maturation of permanent teeth in girls Age Mandibular teeth (growth stage) (Years)



Maxillary teeth (growth stage)



1



2



3



4



5



6



7



8



5.3



4.7



3.4



2.9



1.7



5.0



1.6



4



6.6



6.0



4.4



3.9



2.8



6.2



5



7.6



7.2



5.4



4.9



3.8



6



8.5



8.1



6.3



5.8



7



9.3



8.9



7.2



8



9.8



9.5



9



10.0 9.9



10



2



3



4



5



6



...... 4.3



3.7



3.3



2.6



2.0



4.5



2.8



...... 5.4



4.8



4.3



3.6



3.0



5.7



7.3



3.9



...... 6.5



5.8



5.3



4.6



4.0



6.9



4.8



8.1



5.0



...... 7.4



6.7



6.2



5.6



4.9



7.9



6.7



5.7



8.7



5.9



1.8



8.3



7.6



7.0



6.5



5.8



8.7



8.0



7.5



6.6



9.3



6.7



2.1



9.0



8.4



7.8



7.3



6.6



9.3



8.7



8.3



7.4



9.7



7.4



2.3



9.6



9.1



8.5



8.1



7.4



9.7



......



10.0 9.2



8.9



8.1



10.0 8.1



3.2



10.0 9.6



9.1



8.7



8.1



10.0



11



......



......



9.7



9.4



8.6



......



8.6



3.7



......



10.0 9.5



9.3



8.7



......



12



......



......



10.0 9.7



9.1



......



9.1



4.7



......



......



9.8



9.7



9.3



......



13



......



......



......



10.0 9.4



......



9.5



5.8



......



......



10.0 10.0 9.7



......



14



......



......



......



......



9.7



......



9.7



6.5



......



......



......



......



10.0 ......



15



......



......



......



......



10.0 ......



9.8



6.9



......



......



......



......



......



......



16



......



......



......



......



......



......



10.0 7.5



......



......



......



......



......



......



17



......



......



......



......



......



......



......



......



......



......



......



......



......



*Source:



8.0



1



Nolla, in RE Moyers, Handbook of Orthodontics, 4/e [Chicago, Year Book Publishers, 1988], p 111; and Viken Sassouni: Dentofacial Radiography in Forensic Dentistry, J Dent Res Supplement to No 1, Vol 42, 1963.



FIGURE 3.2 Nolla’s stages of calcification: Nolla’s eleven stages of calcification:* Compare the radiograph with the drawings and give the tooth a value accordingly. Then transfer the value to Nolla’s tables to derive the age. 0 = Absence of crypt; 1 = Presence of crypt; 2 = Initial calcification; 3 = One-thirds of crown completed; 4 = Twothirds of crown completed; 5 = Crown almost completed; 6 = Crown formation completed; 7 = One-third of root completed; 8 = Two-thirds of root completed; 9 = Root almost completed, open apex; 10 = Apical end of root completed. (Source: Nolla, in Moyers RE, Handbook of Orthodontics, 4/e [Chicago, Year Book Publishers, 1988], p 111; and Viken Sassouni, Dentofacial



Radiography in Forensic Dentistry, J Dent Res Supplement to No 1, Vol 42, 1963.).



Morphology of Primary Teeth Importance Understanding the morphology of teeth is essential for various reasons (Box 3.1). Box 3.1



Importance of morphology of



primary teeth 1. Knowledge about morphology helps to understand and design the cavity preparations on teeth for restorations 2. It helps to execute the pulpal procedures like pulpotomy and pulpectomy carefully by predetermining the access into the pulp chambers 3. It helps to understand the variations in morphology and root canal anatomy to determine the treatment during atypical situations 4. It helps to understand the variation in the progress and susceptibility of caries on various tooth surfaces 5. It helps to understand the occlusion 6. It helps to do the extraction of teeth 7. It helps to plan the tooth preparation for various forms of crowns 8. It helps in identification of teeth during initial examination of the patient



Morphology of Individual Primary Teeth



Maxillary Central Incisors (Fig. 3.3) Development The maxillary central incisor hard tissue formation begins at 4 months in utero. Enamel formation is completed by 1.5 months after birth. At birth, five-sixths of enamel formation is completed. The central incisor erupts into the oral cavity by 7–8 months. The root formation continues till 18 months.



FIGURE 3.3 Morphology of maxillary central incisor.



Morphology Crown: Maxillary central incisor has five surfaces namely, labial, lingual, mesial, distal and incisal. Labial surface: The crown is longer mesiodistally than incisocervically. The labial surface is either flat or convex in all directions. The mesial border of the crown is convex from the incisal edge towards the cervical third from where it converges rapidly towards the long axis. The distal surface has a uniformly convex appearance from the incisal edge to the cervical border. As the crown is longer mesiodistally, the incisal edge is also proportionately long joining the mesial surface at an acute angle and the distal surface at a



more rounded obtuse angle (Fig. 3.3A). Lingual surface: This surface shows well-developed marginal ridges and a cingulum. The cingulum divides the lingual concavity into mesial and distal fossa. The cingulum is convex and occupies almost one-third of the surface (Fig. 3.3B). Mesial and distal surfaces: Both the surfaces are markedly convex labiolingually. They have a pronounced cervical ridge. The contact areas with the adjacent teeth are broad, extending from the incisal one-third to the gingival third (Fig. 3.3C). Incisal surface: The incisal edge is nearly straight. The incisal edge joins the mesial surface at an acute angle and the distal surface at an obtuse angle (Fig. 3.3D). Root: The root is single and conical in shape. It has a rounded apex. The mesial surface of the root exhibits a developmental groove. Pulp cavity: The central incisor has two or three small pulp horns projecting towards the incisal edge. The incisal edge is 2.3 mm from the pulp horn on the mesial aspect and 2.4 mm from the pulp horn on the distal aspect. On both the mesial and distal aspects, the pulp is approximately 1.2 mm from the dentinoenamel junction. The pulp cavity of the tooth follows the general external outline of the tooth. There is no demarcation of the pulp cavity into a separate pulp chamber and root canal. Both the pulp chamber and the canal are relatively larger compared to their successors. The pulp canal tapers evenly till the apical foramen.



Maxillary Lateral Incisors (Fig. 3.4) Development The hard tissue formation for this incisor begins at 4.5 months in utero. At birth, two-thirds of enamel formation is completed. Enamel formation is completed by 2.5 months after birth. The tooth usually erupts into the oral cavity by 9 months of age. Root formation continues till the second year after birth.



FIGURE 3.4 Morphology of maxillary lateral incisor.



Morphology Crown: The crown has five surfaces similar to that of central incisor, namely, labial, lingual, mesial, distal and incisal. Labial surface: The maxillary lateral incisor is smaller than the central incisor. The labial surface is almost flat or slightly convex in all directions. The distal incisal angle is rounded. The mesial border of the labial surface is initially convex at the mesiolabial incisal angle subsequently straightening and converging towards the long axis. The distal border is evenly convex from the incisal to cervical border (Fig. 3.4A). Lingual surface: Lingual surface has a less prominent cingulum compared to the central incisor. The mesial and distal marginal ridges are also less pronounced than the central incisor. The cingulum does not extend into the lingual concavity which is shallower than the central incisor (Fig. 3.4B). Mesial and distal surfaces: The mesial and distal surfaces are convex; the mesial surface being slightly longer and more convex than the distal surface (Fig. 3.4C). Incisal surface: The incisal edge is wider labiolingually and more convex mesiodistally (Fig. 3.4D).



Root: It has a single long root, somewhat flattened on mesial and distal surfaces. A gradually tapering apex is present. Usually, the apex is deflected distally. Pulp cavity: The pulp cavity generally conforms to the external surface of the tooth. There is no distinct demarcation of the pulp chamber and the canal. The pulp chamber is smaller than the central incisor. The distance from the incisal edge to the pulp is 2.6 mm. From the mesial and distal aspects, the pulp is 0.9 mm from the DEJ.



Maxillary Canines (Fig. 3.5) Development Hard tissue formation begins at 5 months in utero and one-third of enamel is formed at birth. Enamel completion takes place by 9 months after birth and the tooth erupts into the oral cavity by approximately 18 months. Root completion takes place by 3 years and 3 months.



FIGURE 3.5 Morphology of maxillary canine.



Morphology



Crown: This is the largest of the primary anterior teeth. This tooth is best described as being long and sharp. The crown is constricted at the cementoenamel junction. Labial surface: The labial surface is irregularly convex and presents three lobes—the central, the mesial and the distal. The central lobe is the most prominent. The next prominent lobe is the distal and then the mesial. The labial surface also exhibits two developmental grooves namely mesiolabial and distolabial which are of equal depth and mark the boundaries of the three lobes (Fig. 3.5A). Lingual surface: The most prominent lingual ridge extends from the apex of the cusp to the cingulum. The cingulum is not as prominent as in the central and lateral incisors. A well-defined groove separates the cingulum from the mesial and distal marginal ridges (Fig. 3.5B). Mesial and distal surfaces: The mesial and distal surfaces are convex, with convex labial borders and concave lingual borders. The tooth is broader labiolingually than any of the incisors (Fig. 3.5C). Incisal surface: The incisal border is divided into two portions by the tip of the cusp—mesial and distal. The mesial portion begins at the mesiolabioincisal angle where it is initially convex and subsequently becomes concave in the region of the mesiolabial developmental groove, only to become convex, once more, near the tip of the cusp. The distal portion of the incisal border is convex from the tip of the cusp to its junction with the distal border. Although the tip of the cusp is situated in the center line of the tooth, the mesial portion of the incisal edge is longer (Fig. 3.5D). Root: The root is relatively long and large and is more than twice the length of the crown. It is somewhat flattened on both the mesial and distal surfaces. The root apex is often defected towards the distal and labial. Pulp cavity: The pulp cavity conforms to the general surface contour of the tooth. There are three pulp horns—mesial, central and distal. The central horn is the longest and the mesial the shortest. The central pulp horn is 3.2 mm from the DEJ at the incisal edge. The pulp canal of the maxillary cuspid shows a marked constriction to the apical third of the root.



Maxillary First Primary Molar (Fig. 3.6) Development Hard tissue formation begins at 5 months in the intrauterine life. The cusps are united at birth and the enamel formation is completed by 6 months after birth. The tooth erupts at 14 months of age and the root completion takes place by 2.5 years.



FIGURE 3.6 Morphology of maxillary first primary molar.



Morphology Crown: Maxillary first primary molar poses the greatest problem of all the primary teeth from a descriptive viewpoint. This tooth presents with five well-defined surfaces, namely, the buccal, lingual, mesial, distal and occlusal. Buccal surface: The buccal surface is convex in all directions with the greatest convexity occlusogingivally at the cervical ridge, which is very prominently developed. The buccal surface is divided by a poorly defined buccal groove which is situated distal to the center of the tooth making the mesiobuccal cusp larger than the distobuccal one. This mesiobuccal cusp extends further cervically and hence has a longer and more prominent cervico-occlusal diameter. There is a welldeveloped buccal ridge on this cusp which extends from the tip of the cusp to the cervical margin (Fig. 3.6 A). Lingual surface: The entire lingual surface generally is made up of one definite mesiolingual cusp which is more rounded. The shorter diameter of the lingual cusp as compared to the diameter of the two



combined buccal cusps, leads to a narrower lingual diameter (Fig. 3.6 B). Mesial surface: The mesial surface is greater in diameter at the cervical border than at the occlusal. Contact with the primary cuspid is in the form of a small circular area on the occlusobuccal third of the tooth (Fig. 3.6 C). Distal surface: This surface is narrower than the mesial surface. It is wider cervically than occlusally. The marginal ridge is fairly well developed. Contact with the primary second molar is broad and is in the shape of an inverted crescent in the occlusolingual half of the distal surface. Occlusal surface: The greatest dimension of the crown of this tooth is at the mesiodistal contact areas and from these areas the crown converges cervically. The occlusal surface presents a longer buccal margin than a lingual one. This surface is made up of three cusps— mesiobuccal, distobuccal and the mesiolingual. The mesiobuccal cusp is the most prominent (largest and sharpest) and occupies the major portion of the bucco-occlusal surface. In some teeth, the distobuccal cusp may be poorly developed or absent completely. The lingual portion of the occlusal surface is formed by the mesiolingual cusp. Some lingual cusps are crescent-shaped, others are bisected by a lingual groove which may set off a small distolingual cusp. This surface has three pits—central, mesial and distal. The central pit is found in the central portion of the occlusal surface and forms the hub of the three primary grooves—the buccal groove, which extends buccally on to the buccal surface; mesial groove, which extends mesially to the mesial pit and distal groove, which traverses to the distal pit. The mesial pit is the deepest and best defined. In preparation of occlusal portions of class II cavities, it is not necessary to include the distal pit in the outline form of the mesial preparations (Fig. 3.6 D). Root: This tooth has three roots—a mesiobuccal, a distobuccal and a palatal. These roots are long, slender and widely spread. A characteristic of all primary molars is that the furcation of the roots begins at the cementoenamel junction. The palatal root is the longest



and diverges in palatal direction. The distobuccal root is the shortest. Pulp cavity: This tooth generally has three root canals corresponding to the three roots. Variations in the root canal anatomy are not uncommon and may have anastomoses and branchings. The pulp chamber has three or four pulp horns corresponding to the cusps. Mesiobuccal pulp horn is the largest of all. This pulp horn is situated 1.8 mm from the cusp tip. The occlusal view of the pulp chamber follows the general surface contour of the tooth and resembles somewhat a triangle with rounded corners.



Maxillary Second Primary Molar (Fig. 3.7) Development Maxillary primary second molars are the last primary teeth to erupt. The hard tissue formation begins at 6 months in the intrauterine life. At birth, the cusps of the teeth are not yet united. By 11 months of age, enamel formation of the tooth is completed and it erupts into the mouth by 24 months. Root completion takes place by 3 years of life.



FIGURE 3.7 Morphology of maxillary second primary molar.



Morphology Crown: The crown as a whole resembles the maxillary permanent first molar having the same pit, groove and cuspal arrangement. However, the crown differs in being smaller and angular and in converging more towards the occlusal. The crown is trapezoidal in outline. The



size of this tooth is intermediate between the smaller first primary molar and the larger first permanent molar. The enamel thickness is usually 1.2 mm uniformly on the tooth. Buccal surface: This surface presents a well-defined cervical ridge extending the entire diameter of the buccal surface. However, this is less prominent than those found on the first primary molars. The buccal surface is divided by the buccal groove into a mesiobuccal and a distobuccal cusp, the mesiobuccal cusp being the larger (Fig. 3.7A). Lingual surface: The lingual surface is divided by the lingual groove into a mesiolingual and a distolingual cusp where the mesiolingual cusp is higher and larger. A fifth cusp, when present, occupies the mesiolingual area at the middle third of the crown. It is frequently referred to as Carabelli’s cusp (Fig. 3.7B). Mesial surface: This surface presents with a fairly high marginal ridge which is indented by the mesial groove extending from the occlusal surface. This surface forms a broad contact with the first primary molar in the form of an inverted crescent (Fig. 3.7C). Distal surface: Contact with the first permanent molar is in the form of an inverted crescent with the convexity towards the occlusal surface. Occlusal surface: Occlusal surface resembles the occlusal surface of first permanent molars. There are four well-defined cusps and a smaller, sometimes absent, fifth cusp. The mesiolingual cusp is the largest and the mesiobuccal cusp is the second largest in size. The distobuccal is third in size, but has a very prominent lingual ridge with a slight mesial inclination. The mesiolingual cusp joins the distobuccal cusp through the oblique ridge which is an outstanding characteristic of the tooth. The distolingual cusp is the smallest of the four and is separated from the mesiolingual cusp by a marked distolingual groove. The occlusal surface has three pits in which the central pit is the large and deep. The distal pit is deep and flanked by well-defined triangular grooves. The mesial pit is shallow. Because of the prominent oblique ridge, cavity preparation is usually confined to the area on either side of the ridge and does not cross the ridge unless it is undermined or carious or additional area is needed for retention



(Fig. 3.7D). Root: This tooth has three roots, namely, mesiobuccal, distobuccal and palatal roots. Though they resemble the permanent molar, they are thinner and flare more as they approach the apex. This divergence helps to accommodate the developing premolar. Distobuccal root is the shortest and narrowest and the palatal being the longest and largest. Pulp cavity: The three root canals correspond to the three roots. The pulp chamber confines to the general outline of the tooth and has four pulpal horns. A fifth horn projecting from the lingual aspect of the mesiolingual horn may be present. The mesiobuccal pulp horn is the largest. This horn is usually 2.8 mm from the DEJ. The distolingual pulp horn is the smallest and shortest.



Mandibular Central Incisors (Fig. 3.8) Development The hard tissue formation for central incisors starts at 4.5 months in the intrauterine life. Three-fifths of enamel is formed at birth and the enamel formation is completed by 2.5 months of age. This is the first tooth to erupt in an infant’s mouth by the age of 6 months. The root formation is completed by 1.5 years.



FIGURE 3.8



Morphology of mandibular central incisor.



Morphology Crown: The mandibular primary incisors are narrow and are the smallest incisors in the mouth. The central incisor is smaller and narrower than lateral incisor and also the smallest of the primary teeth. This tooth is smaller than lateral incisor in all dimensions except labiolingually. Labial surface: This surface is convex in all directions. The mesial and distal borders are relatively straight and converge with the long axis in a gentle taper. No developmental grooves are seen on this surface (Fig. 3.8A). Lingual surface: Lingual surface corresponds closely to the labial, with the exception that the mesial and distal borders show a marked constriction in the cervical region, producing a narrow, tapered, lingual surface at the cervical line. This surface presents with marginal ridges and a cingulum. The cingulum occupies the cervical third of the lingual surface (Fig. 3.8B). Mesial and distal surfaces: The mesial and distal surfaces are convex labiolingually and less so incisocervically. Contact with adjacent teeth is on the incisal third of the proximal surfaces (Fig. 3.8C). Incisal surface: This surface is straight and bisects the tooth labiolingually (Fig. 3.8D). Root: The root is straight with a gradual convergence toward the apex. It is approximately twice the length of the crown. It is slightly flattened on its mesial and distal aspects and tapers towards the apex. Pulp cavity: The pulp cavity conforms to the general surface contour of the tooth. The pulp chamber is widest mesiodistally at the roof of the chamber. The pulp canal is oval in appearance and tapers towards the apex. There is definite demarcation between the chamber and canal in the central incisor. The pulp is approximately 2.6 mm from the incisal edge. The distance to the pulp is 1.7 mm from the distal enamel surface and 1 mm from the mesial surface.



Mandibular Lateral Incisors (Fig. 3.9) Development The beginning of hard tissue formation is similar to that of central incisor (4.5 months in utero). Enamel formation is completed by 3 months of age and at birth only three-fifths of enamel formation is completed. Root formation is completed by 18 months. The tooth erupts into the mouth by 7 months of age.



FIGURE 3.9



Morphology of mandibular lateral incisor.



Morphology Crown: The mandibular primary lateral incisor more closely resembles the maxillary primary lateral incisor than it does with regard to the mandibular primary central incisor. This is distinguished from the mandibular central incisor by the distal incisal angle, which is more rounded. The outline of the lateral incisor is similar to central incisor but is somewhat larger in all dimensions except labiolingually. Labial surface: Labial surface is convex in all directions and does not have any developmental grooves (Fig. 3.9A). Lingual surface: The lingual surface is similar to that of primary mandibular central incisor (Fig. 3.9B).



Mesial and distal surfaces: Contact with adjacent teeth is on the incisal third of the proximal surfaces (Fig. 3.9C). Incisal surface: The incisal edge slopes towards the distal aspect of the tooth. This is one of the differentiating factors from the central incisor (Fig. 3.9D). Root: The root is longer and tapers toward the apex. Pulp cavity: This conforms to the general surface contour of the tooth. The chamber is widest mesiodistally at the roof of the chamber. The demarcation between the chamber and the canal is not well defined as the central incisor. The pulp dimensions are somewhat smaller than the central incisor.



Mandibular Canines (Fig. 3.10) Development Hard tissue formation begins in the 5th month of intrauterine life and one-third of enamel formation is completed at birth. Enamel formation is completed by 9 months of age and the tooth erupts into the oral cavity by 16 months. Root completion takes place by 3 years and 3 months.



FIGURE 3.10



Morphology of mandibular canine.



Morphology Crown: The mandibular canine is a long narrow tooth, much smaller than the primary maxillary canine. This gives the mandibular canine a slender appearance, in contrast to the bulbous appearance of the maxillary canine. The crown is not as large labiolingually as its maxillary component. Labial surface: This surface is convex in all directions. This tooth has a prominent central lobe which terminates incisally in the labial portion of the cusp and extends cervically to the cervical ridge. The greatest variation in the outline form when compared with maxillary canine is observed from the labial surface. The distal cusp slope is longer than the mesial slope in case of the mandibular canine, whereas the opposite is true for the maxillary cuspid. This makes the intercuspation possible during mastication (Fig. 3.10A). Lingual surface: This is formed by three ridges—lingual, mesial marginal and distal marginal. Lingual ridge aids in the formation of the apex and extends along the length of the lingual surface, fusing with the cingulum at the cervical third. The marginal ridges are less prominent than the maxillary canine. Distal marginal ridge is slightly longer than the mesial. The cingulum is narrow because of the convergence of the proximal surfaces as they approach the lingual surface (Fig. 3.10B). Mesial and distal surfaces: The mesial and distal surfaces are convex in the cervical third, but the mesial surface may become concave as it approaches the cervical ridge, because of the thickness of the marginal ridges. Contact with adjacent teeth is on the incisal third of the tooth (Fig. 3.10C). Incisal surface: This surface is highest at the apex of the cusp and proceeds cervically both mesially and distally. The distal incisal edge is longer and intercuspates with the mesioincisal edge of the upper cuspid (Fig. 3.10D). Root: The root tapers to a sharp apex. It has a broader labial than lingual diameter. The mesial and distal surfaces are flattened. The root



is longer in proportion to the crown length when compared with the maxillary cuspid. The root may be as much as 2 mm shorter than that of the maxillary canine. Pulp cavity: The pulp cavity conforms to the general surface contour of the tooth. There is no differentiation between the pulp chamber and the root canal. The root canal terminates with an abrupt constriction at the apical foramen. The pulp is 3 mm from the DEJ at the incisal edge. There is 1.8 mm distance from the pulp to the mesial and distal DEJ.



Mandibular First Molars (Fig. 3.11) Development Hard tissue formation starts by the 5th month of intrauterine life and at birth, the cusps of the teeth are united. Enamel formation is completed by 5.5 months after birth and the tooth erupts into the oral cavity by 12 months. Root formation is completed by 2 years and 3 months.



FIGURE 3.11



Morphology of mandibular first molar.



Morphology Crown: Mandibular primary first molar is far more constant in its anatomical form than is the maxillary primary first molar. Unlike the other primary tooth, the first primary molar does not resemble any of



the permanent teeth. The two prominent features of this tooth are the deep central pit and the marked buccogingival ridge. This ridge reaches its greatest curvature at the mesiobuccal angle, where it is also most prominent. Buccal surface: The two distinct buccal cusps have no evidence of a developmental groove (occasionally a buccal depression is seen) between them. The mesial cusp is larger than the distal one. This surface presents with a well-developed cervical ridge which extends across the buccal surface just above the neck of the tooth but is more pronounced on the mesiobuccal (Fig. 3.11A). Lingual surface: This surface is traversed by a lingual groove which divides the lingual surface into a larger mesiolingual and a smaller distolingual cusp (Fig. 3.11B). Mesial surface: This surface is flat in all aspects (Fig. 3.11C). Distal surface: The distal surface is convex in all aspects. Occlusal surface: The occlusal surface may be rhomboidal in shape. It consistently presents with four cusps—mesiobuccal, distobuccal, mesiolingual, and distolingual. When viewed as a whole, the mesial half of the crown is larger than the distal half. There are three pits located on the occlusal surface namely, the central pit, mesial pit and the distal pit. The central pit is the deepest and all these pits are connected by the central developmental groove (Fig. 3.11D). Root: The roots resemble those of mandibular permanent molar. There is a trunk which bifurcates into a mesial and a distal branch. The mesial and distal branches are characteristically divergent from one another with the mesial root being more divergent. The long slender roots spread considerably at the apical third, extending beyond the outline of the crown. Pulp cavity: Pulp cavity is formed by the pulp chamber and the pulp canals. There are four pulp horns, the largest being the mesiobuccal pulp horn which forms a considerable portion of the pulp chamber. The mesiolingual pulp horn is the third in size but second in height. It is long and pointed. The floor of the pulp chamber is arched in the mesiodistal direction, sloping towards the orifices of the mesial and distal canals. Two canals lie in the mesial root and one canal lies



in the distal root. The root canal is broad buccolingually and fine mesiodistally.



Mandibular Second Molars (Fig. 3.12) Development The hard tissue formation begins at 6 months in utero and at birth the cusp tips are isolated. Enamel formation is completed by 10 months of age and the tooth erupts into the oral cavity by 20 months. The root formation is completed by 3 years.



FIGURE 3.12



Morphology of mandibular second molar.



Morphology Crown: This tooth resembles the mandibular first permanent molar as it has the same pit and groove pattern and is a five-cusped tooth. Buccal surface: The buccal surface is divided into three cusps by a mesiobuccal and distobuccal developmental groove; they are a distal cusp, a mesiobuccal cusp and a distobuccal cusp in the ascending order of size. However, the difference in size is insignificant. These three cusps coalesce into a well-developed cervical ridge which extends along the entire width of the buccal surface just above the neck of the tooth (Fig. 3.12A). Lingual surface: The two cusps of almost equal size are evident on the lingual surface and are divided by a short lingual groove. They are



the mesiolingual and the distolingual cusps. The cusps are of equal height (Fig. 3.12B). Mesial surface: The mesial surface is generally convex and flattens considerably cervically. The contact with the first primary molar is broad and is in the shape of an inverted crescent just below the notch of the mesial groove (Fig. 3.12C). Distal surface: The distal surface is generally convex, flattens somewhat buccolingually as it approaches the cervical border. It is smaller than the mesial surface. Contact with the first permanent molar is not as broad as contact on the mesial surface, being in the form of a round contact just buccal and cervical to the distal groove. Occlusal surface: The primary second molar, when viewed from the occlusal surface, appears rectangular with a slight distal convergence of the crown. There are five cusps, three on the buccal and two on the lingual surface. The buccal cusps are mesiobuccal, distobuccal and distal. The lingual cusps are the mesiolingual and distolingual. The largest cusp is the distobuccal. One difference between the crown of the primary molar and that of the first permanent molar is in the distobuccal cusp; the distal cusp of the first permanent molar is smaller than the other two buccal cusps. The enamel is uniformly 1.2 mm thick. There are three pits on the surface of which the central pit is the deepest and best defined, followed by the mesial pit and the least well-defined distal pit. The mesial marginal ridge is developed to a greater extent than the distal marginal ridge (Fig. 3.12D). Root: There is a trunk which bifurcates, a short distance from the buccal and lingual borders to form a mesial and a distal branch. These branches of the root system tend to be more divergent than those of primary first molar. They extend mesially and distally so that the distance between the two branches may exceed the mesiodistal diameter of the crown which allows for the developing succedaneous tooth. The mesial root is wide buccolingually and flattened mesiodistally containing two root canals. The distal root resembles that of the mesial with the exception that it is not as long and the buccal and lingual surfaces of the distal root converge towards a sharper apex than do those of the mesial root.



Pulp cavity: The coronal pulp has five pulp horns. The mesiobuccal and mesiolingual pulp horns are almost of equal height; distobuccal and distolingual pulp horns are also approximately equal in height but are only approximately two-thirds the height of the two mesial pulp horns. The mesiobuccal pulp horn extends 2.8 mm from the DEJ, while the distobuccal pulp horn is 3.1 mm from the DEJ. The floor of the pulp chamber is arched in a mesiodistal direction sloping towards the orifices of the mesial and distal pulp canals. The mesial canals may have a common orifice in the floor of the pulp chamber. This orifice is wide buccolingually and located in the pulpal floor close to the mesial wall. The canal soon divides into a mesiobuccal canal and a distobuccal canal. The mesiobuccal canal is the largest and the longest of the two. They both taper gradually as they approach the apex. The distal root canal is roughly oval, being wider buccolingually as it leaves the pulp chamber. The canal remains wide as it extends through the root branch, but it is constricted in the center which may, in some teeth, become occluded. The canal converges gradually to the apical foramen.



Measurements of individual primary teeth Measurements of primary teeth are given in Table 3.4. Table 3.4 Dimensions of primary teeth (in mm) Overall length Crown length Root length M-D diameter L-L diameter PRIMARY Maxillary Central incisor 16



6



10



6.5



5



Lateral incisor



15.8



5.6



11.4



5.1



4



Cuspid



19



6.5



13.5



7



7



First molar



15.2



5.7



11.7



7.3



8.5



Second molar



17.5



5.7



11.7



8.2



10



Second molar



17.5



5.7



11.7



8.2



10



Central incisor 14



5



9



4.2



4



Lateral incisor



15



5.2



10



4.1



4



Cuspid



17.5



6



11.5



5



4.8



First molar



15.8



6



9.8



7.7



7



Second molar



18.8



5.5



11.3



9.9



8.7



Mandibular



Functions of Primary Teeth The various functions of primary teeth are given below.



Mastication The primary incisors help to tear the food and the molars help to chew them thoroughly which in turn helps in digestion of food. Children with untreated decayed primary teeth tend to eat less or avoid hard and chewable food substances. This results in poor general health of a child leading to frequent illnesses and need for constant medical supervision. Hence, a set of healthy primary teeth and their preservation till its exfoliation time is very essential.



Esthetics and appearance Normal primary anterior teeth are very essential for children in their growing years. It has a tremendous influence on their self-image. Properly aligned anterior teeth provide a child with a sense of wellbeing and a positive self-image. Children with fractured, discolored or decayed anterior teeth are shown to be poor performers in the school (Slack and Jones). Children who are younger than 4 or 5 years do not express these difficulties adequately at home. They tend to be shy and introvert. As the peer influence is very high among school going children where they come across each other on a daily basis, appropriate importance has to be given for primary anterior teeth.



Speech Ability to use the teeth for pronunciation is acquired entirely with the aid of the primary dentition. Early and accidental loss of primary anterior teeth may lead to difficulty in pronouncing the sounds ‘f’, ‘v’, ‘s’, ‘z’ and ‘th’. Even after the permanent teeth erupt, difficulty in pronouncing ‘s’, ‘z’ may persist. In most instances, with complete eruption of the permanent incisors, the difficulty is self-correcting.



Maintenance of space The primary teeth are nature’s space maintainers and the best. Each primary tooth maintains the space for the succedaneous teeth.



Growth of jaws The presence of primary teeth helps the alveolar bone to grow and maintain it. In children who have congenitally missing teeth (i.e. ectodermal dysplasia), the absence of teeth results in the loss of the height of the arches. Table 3.5 and Figure 3.13 describe the differences between primary and permanent teeth. Table 3.5 Differences between primary and permanent teeth (Fig. 13.3) Based on



Primary teeth



Permanent teeth



Size



a. Primary teeth are smaller in dimensions b. Primary teeth are wider mesiodistally in relation to the occlusocervical height



a. They are larger in size than primary teeth b. The anterior teeth are wider occlusocervically than mesiodistally



Shape



a. The cervical ridges are more pronounced (IV) b. They have a narrow occlusal table. This is the result of the occlusal convergence of the buccal and lingual



a. The cervical ridges are not very prominent b. The occlusal table is broader as the buccal and lingual surfaces do not



surfaces of the molars c. Cervical constriction is prominent (V) d. Mamelons are absent



converge like primary teeth c. The cervical constriction is not prominent d. Mamelons are present in young permanent tooth



Number



a. They are 20 in number (incisors, molars and canines)



a. They are 32 in number (incisors, molars, premolars, canines)



Color



a. They are lighter (white) in color (known as milk teeth) because of the refractive index of milk and enamel are the same (refractive index-1)



a. Yellowish white in color



Contact area



a. They have a broader contact area rather than a point. These areas are located gingivally



a. They have contact points between the teeth and are located occlusally



Pulp



a. The pulp chambers are large (II) b. Pulpal horns are located at a higher level especially the mesial pulp horns (III) c. The root canals are narrow and tortuous d. The floor of the chamber has many accessory canals (reason for early furcation involvement in primary molars) e. The pulp is highly vascular and has high potential for repair



a. Pulp chambers are small b. Pulpal horns are relatively away from the outer enamel surface c The root canals are wider and do not have extensive branching d. The floor of the pulp chamber does not have many accessory canals e. The pulp is not highly vascular and the potential for defense is less comparing to primary tooth



Roots



a. Roots of primary anterior teeth are narrower mesiodistally b. Roots are longer and more slender in comparison to the crown size (VII) c. The flaring of the roots is more (VIII) d. The flaring continues further in the apical third (to accommodate the developing tooth germ) e. Undergo physiologic resorption



a. Roots of permanent teeth are wider mesiodistally b. Roots are shorter in comparison to the size of the crown c. The roots do not flare at the cervical region d. The roots do not flare in the apical third



e. Do not undergo physiologic resorption Histological



a. The thickness of enamel and dentin is less (I) b. Enamel and dentin are less mineralized c. The direction of enamel rods slope occlusally in the cervical region (VI)



a. The thickness of enamel and dentin is more b. Enamel and dentin are more mineralized c. The direction of enamel rods slope gingivally or horizontally



FIGURE 3.13 Differences between primary and permanent teeth.



Clinical Significance of Morphology of Primary



Teeth As mentioned earlier, understanding the morphology of primary teeth and applying it appropriately in clinical situations is of paramount importance. The authors have enumerated certain clinical applications of morphology of primary teeth. These are below: 1. Generally, the thickness of enamel and dentin is less in primary teeth. Hence, the spread of caries from enamel to pulp can be faster in primary teeth, e.g. the distance from the mesial surface of primary maxillary lateral incisor to the pulp is only 0.9 mm. 2. Even in posterior primary teeth, the distance from the external surface of the tooth to pulp is less in the proximal region. Hence, any proximal caries in primary teeth must be radiographed and the extent of pulpal involvement must be assessed. 3. The pulp horns are very highly placed in primary teeth, e.g. the tip of the mesiobuccal pulp horn of a mandibular first primary molar is almost at the DEJ. It also has a deep central pit. Hence, caries on the mesial pit in a mandibular fisrt primary molar should be treated with caution. Aggressive removal of caries can lead to pulp exposure. 4. The prominent buccal cervical ridge on a mandibular first primary molar may provide some resistance for placement of a stainless steel crown. Reducing this cervical ridge alone may be sufficient at times for placement of a stainless steel crown. 5. During cavity preparation, the oblique ridge in maxillary second primary molar should be preserved unless undermined by caries. Breaking this ridge can weaken the tooth to a great extent and may lead to fracture of the tooth into buccal and palatal half, if there is any undue stress on the tooth. 6. Conical roots of primary anterior teeth facilitate easy removal. However, the flared roots of primary molar removal dictate the tooth to be removed with care. 7. Applications related to operative dentistry, specific to each



tooth will be dealt in Chapter 23.



CONCLUSION Knowledge in chronology of teeth helps the student in identifying the dental age of the child along with identification of teeth and their treatment needs. Description of primary teeth gives enough evidence that each tooth has a function to perform. The incisors are designed to produce shearing action and used for biting and cutting. The canines are designed for tearing and holding food. The molars are for grinding and mixing the food with oral fluids. An intact set of teeth will serve the individual to eat better. Understanding the morphology is essential to reproduce them whenever they are damaged.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Describe in detail the morphology of mandibular first primary molar. 2. Describe the differences between primary and permanent teeth.



Short Notes 1. Importance of understanding the chronology of teeth 2. Nolla’s stages of tooth development 3. Cusp of Carabelli 4. Oblique ridge 5. Morphodifferentiation 6. Functions of primary teeth 7. Importance of morphology of primary teeth 8. Occlusal anatomy of mandibular second primary molar



SUGGESTED READING 1. Arnim, SS, Doyle, MP. Dentin dimensions of primary teeth. J Dent Child. 1959; 26:191. 2. Ash, MM, Nelson, SJ. Wheelers Dental Anatomy, Physiology and Occlusion, 8th edn. Philadelphia: Saunders; 2003. 3. Barker, BC, et al. Anatomy of root canals. IV– deciduous teeth. Aust Dent J. 1975; 20:101. 4. Bhaskar, SN. Orban’s Oral Histology and Embryology, 11th edn. St Louis: Mosby; 1991. 5. Kiran K et al. Morphologic dimensions of primary teeth of children from Chennai and Hyderabad. Unpublished data. 2005. 6. Kramer, WS, Ireland, RI. Measurements of the primary teeth. J Dent Child. 1959; 26:252. 7. Kraus, BS. Calcification of the human deciduous teeth. J Am Dent Assoc. 1959; 59:1028. 8. Kraus, BS, Jordan, RE. Human Dentition before Birth. Philadelphia: Lea and Febiger; 1965. 9. Logan, WHG, Kronfeld, R. Development of the human jaws and surrounding structures from birth to the age of 15 years. J Am Dent Assoc. 1933; 20:379–427. 10. Lunt, RC, Law, DB. A review of the chronology of calcification of deciduous teeth. J Am Dent Assoc. 1974; 89:599–606.



11. Mathewson, RJ, Primosch, RE. Fundamentals of Pediatric Dentistry, 3rd edn. Chicago: Quintessence; 1995. 12. Moyers, RE. Handbook of Orthodontics, 4th edn. St Louis: Mosby; 1988. 13. Nolla, CM. The development of the permanent teeth. J Dent Child. 1960; 27:254. 14. Puddhikarant, P, Rapp, R. Radiographic anatomy of pulpal chambers of primary molars. Pediatr Dent. 1983; 5:25–29. 15. Russman, SA, A study of pulp chamber anatomy in the deciduous dentition Thesis. University of Michigan, Ann Arbor, June, 1947. 16. Schour, I, Massler, M. Studies in tooth development: the growth pattern of human teeth. J Am Dent Assoc. 1940; 27:1778–1793. 17. Schour, I, McCall, JO. Chronology of the human dentition. In: Orban B, ed. Oral Histology and Embryology. St Louis: Mosby; 1944:240. 18. Slack, GL, Jones, JM. Psychological effect of fractured incisors. Br Dent J. 1955; 99:386–388. 19. Smith, CE. Cellular and chemical events during enamel maturation. Crit Rev Oral Biol Med. 1998; 9:128–161. 20. The Handbook of Pediatric Dentistry:



American Academy of Pediatric Dentistry, 1999. 21. Wheeler, RC. A Textbook of Dental Anatomy and Physiology, 5th edn. Philadelphia: Saunders; 1974. 22. Zeiss, RC, Nuckolls, J. Dental Anatomy. St Louis: Mosby; 1949.



CHAPTER 4



Teeth Identification MS Muthu and N Sivakumar



CHAPTER OUTLINE Introduction Teeth Identification Systems FDI system Universal system Symbolic system or Palmer or Zsigmondy/Palmer notation Teeth Identification Exercise Guidelines for identification of teeth Conclusion Suggested Reading Self-assessment Questions



“Be sure you positively identify your target before you pull the trigger.” —Tom Flynn



Introduction Appropriate identification and recording of the primary and permanent teeth may be a difficult challenging exercise for an undergraduate student who is unfamiliar with mixed dentition. Knowledge about the different teeth identification systems, eruption sequence, exfoliation pattern of primary teeth, developmental anomalies of teeth and morphology of primary, permanent teeth can help them do this exercise easily. The morphology of primary and permanent teeth was dealt in Chapter 3. This chapter deals primarily with the identification systems and some guidelines which can help



the student to perform this exercise better.



Teeth Identification Systems FDI System This system was proposed by Federation Dentaire Internationale (FDI). This is a two digit numbering system. The first digit represents the quadrant and the second digit represents the individual tooth. The jaw is divided into four quadrants namely maxillary right and left and mandibular left and right. These quadrants are denoted with the numbers 1, 2, 3 and 4 for permanent teeth and 5, 6, 7 and 8 for primary teeth, respectively. The teeth are numbered in each quadrant from 1 to 8 for permanent teeth and 1 to 5 for primary teeth starting from the central incisor towards the distal. The two digits in this system are pronounced separately, e.g. in the expression 14: 1 denotes – maxillary right, 4 – denotes the fourth tooth in the arch from midline, i.e. first premolar and it is pronounced as one-four. In the expression 65 in primary teeth: 6 denotes – maxillary left, 5 denotes the fifth (last) tooth in the quadrant from midline, i.e. second primary molar and it is pronounced as six-five. FDI has also specified that the tooth charting system should fulfill the following basic requirements: 1. The system should be simple and easy to understand, teach and use. 2. It should be easy to pronounce in conversation and dictation. 3. It should be adaptable and should fit in the standard charts used in practice. 4. It should be easy to translate into a computer input. 5. It should be easily communicable.



The permanent teeth can be identified and charted as:



18



17



16



15



14



13



12



11



21



22



23



24



25



26



27



28



48



47



46



45



44



43



42



41



31



32



33



34



35



36



37



38



The primary teeth can be identified and charted as: 55



54



53



52



51



61



62



63



64



65



85



84



83



82



81



71



72



73



74



75



Universal System This system uses the numbers 1 to 32 for recording permanent teeth. It starts from maxillary right third molar as 1 and progresses around the arch to the maxillary left third molar which is identified as 16. Number 17 is mandibular left third molar and around the arch to the mandibular right third molar which is 32. The primary teeth are identified by the first 20 letters of the alphabet from A through T. A denotes the maxillary right second primary molar and progresses around the arch to the maxillary left primary second molar which is identified as J. K is mandibular left second primary molar and progresses to T which is mandibular right second primary molar. Permanent teeth 1



2



3



4



5



6



7



8



9



10



11



12



13



14



15



16



32



31



30



29



28



27



26



25



24



23



22



21



20



19



18



17



Universal System Primary teeth A



B



C



D



E



F



G



H



I



J



T



S



R



Q



P



O



N



M



L



K



Symbolic System or Palmer or Zsigmondy/Palmer Notation



This symbolic system for the permanent dentition was introduced by Adolph Zsigmondy of Vienna in 1861 and then modified for the primary dentition in 1874. Palmer published this system in 1870. This system is often mentioned as Palmer notation system in the United States and less commonly as the Zsigmondy/Palmer notation system. This system describes the permanent teeth as a four quadrant symbolic system. Beginning with the central incisors, the teeth are numbered 1 through 8 in each arch. The primary teeth are numbered from A to E, where the A is central incisor and the E is second primary molar. All three notation systems are depicted in Figure 4.1A, B.



FIGURE 4.1A Summary of all systems—permanent teeth.



FIGURE 4.1B Summary of all systems—primary teeth.



Permanent teeth 8



7



6



5



4



3



2



1



1



2



3



4



5



6



7



8



8



7



6



5



4



3



2



1



1



2



3



4



5



6



7



8



Symbolic system or Palmer notation



Primary teeth E



D



C



B



A



A



B



C



D



E



E



D



C



B



A



A



B



C



D



E



Teeth Identification Exercise This following system is being advocated in the departments of both the editors of the book, and it appears to be very useful in training the undergraduate stunts to identify the teeth properly. During their initial clinical postings at the Department of Pediatric Dentistry, the undergraduate students have their clinical records which has a teeth identification exercise section. A page from the section is given here for better understanding of the system (Table 4.1). Table 4.1 Teeth identification exercise S. No.



Name of the Teeth Total number of Wrong Age Sex signature patient identification teeth present identification



1. 2.



A patient with either primary, mixed or permanent dentition is allotted to the student for identification of the teeth present in the mouth. He/she is expected to record the teeth present in the mouth in the notebook and discuss with one of the faculty. The faculty discusses the identification and explains if there is any incorrect identification. The wrong identification column helps the student to keep track of his/her mistakes. It is commonly observed that the student finds it difficult to differentiate between the primary and permanent canines, primary molars and premolars. A student is expected to do a minimum number of teeth identification exercises before he starts treating the patients. This system has helped the students to differentiate between the primary and permanent teeth



easily.



Guidelines for Identification of Teeth If a student finds it difficult to identify a particular tooth, he is asked to assess and thoroughly evaluate the following factors one by one to come to a conclusion (Box 4.1). Box 4.1



Guidelines for teeth identification



1. Size and shape of the teeth 2. Color of the teeth 3. Presence of mamelons (lobed incisal edge/developmental grooves) 4. Eruption status of the teeth 5. Eruption sequence of the teeth 6. Chronological age of the patient 7. Mobility of teeth 8. Eruption status of teeth in the opposing quadrant/ arch 9. Previous history of extraction 10. Presence of wear facets



Size and shape of teeth (Fig. 4.2) The size of the primary teeth is smaller (Fig. 4.2 A, B) compared to their succedaneous teeth except for the primary molars where they are larger than premolars. Hence a smaller size tooth usually indicates a primary tooth. Occasionally, one may encounter a peg lateral which looks smaller and this may confuse a student to identify it as a primary tooth. Under such circumstances, the assessment of the other factors like chronological age, mobility and eruption status of the tooth will help them to identify the tooth correctly. Fusion and gemination of primary tooth in a six-year-old child can create an illusion of a permanent tooth because of its larger size.



FIGURE 4.2 Differences in size in primary (A) and permanent (B) teeth.



The mandibular second primary molar resembles the mandibular first permanent molar (Fig. 4.3), not the succedaneous second premolar. Maxillary primary second molar resembles maxillary first permanent molar. Mandibular first primary molar and maxillary first primary molar do not resemble any permanent tooth. Knowledge about the cuspal anatomy of primary molars and premolars is essential and it helps a student to identify the teeth correctly.



FIGURE 4.3 Resemblance of first permanent molars to second primary molars.



Color of teeth Generally, primary teeth are whiter in color in comparison to the permanent teeth. This may also sometimes aid in identification of teeth correctly.



Presence of mamelons (developmental grooves) (Fig. 4.4) Mamelons are developmental grooves present on the incisal edges of a newly erupted incisor. These are seen in permanent teeth because the enamel formation in permanent teeth occurs in lobes (Fig. 4.4A, B). These lobes fuse together to form the labial and lingual surfaces of teeth. The lines of fusion are seen as grooves on the incisal edge of newly erupted incisor which are called mamelons. These grooves wear off as the age advances unless the teeth are in crossbite or out of occlusion. Hence presence of mamelons is an indication that they are young permanent incisors. The mamelons are not seen in primary incisors as the enamel formation takes place from a single lobe.



FIGURE 4.4 Mamelons on young permanent tooth.



Eruption status of teeth All the primary teeth are present in a child’s mouth by the age of 3 years. Hence, any newly erupting tooth found in a child, more than 5 years of age has to be a permanent tooth. Observing the extent of crown that has come out of the gingival (whether it is partially erupted or completely erupted) and correlating it with the chronology



of eruption gives a clue to correct identification (Fig. 4.5).



FIGURE 4.5 Erupting permanent tooth.



Eruption sequence of teeth The sequence of eruption of teeth can vary with individuals. The favorable sequence observed for permanent teeth in the maxilla is as follows: 6, 1, 2, 4, 5, 3, 7, 8 (first molar, central incisor, lateral incisor, first premolar, second premolar, canine, second molar and third molar). The favorable sequence observed for permanent teeth in the mandible is as follows: 6, 1, 2, 3, 4, 5, 7, 8 (first molar, central incisor, lateral incisor, canine, first premolar, second premolar, second molar, and third molar). In primary teeth, the normal eruption sequence observed in both maxilla and mandible is:



A, B, D, C, E (central incisor, lateral incisor, first primary molar, canine, second primary molar). Knowing the sequence correctly can further help the students identify the teeth properly.



Chronological age of patient Generally, the undergraduate students tend to relate the eruption of teeth to the chronological age of the child, as they are familiar with the eruption schedule from the first year of the dental school. However, there is always variation in the chronological age and the eruption of teeth, e.g. not every premolar erupts between 10 and 12 years. If a chronically infected primary second molar (due to caries and abscess formation) is extracted by the age of 8 years, it can lead to accelerated eruption of second premolar by 8.5 or 9 years of age.



Mobility of teeth Mobility of a tooth indicates that it is a primary tooth. Hence checking any tooth in doubt for its mobility can give a clue to the student.



Eruption status of teeth in opposing quadrant/arch Generally, the eruption of teeth is bilaterally symmetrical. Hence, observing the eruption status of the opposing quadrant or comparing the eruption status of teeth in both the quadrants can give a hint about the tooth in question.



Previous history of extraction Previous history of extraction can lead to either accelerated or delayed eruption of the succedaneous permanent teeth. Occasionally, when a chronically infected primary molar with destruction of bone covering the unerupted permanent tooth (premolar) is extracted, it accelerates the eruption of a premolar at an age as early as 7 years (Fig. 4.6). However, a delay in eruption of premolar can be observed, if the



extraction of primary molar (without sepsis) has taken place at an early age like 6 years. A brief history of previous extraction will indicate that the tooth which was removed was a primary tooth and the tooth which is present is a prematurely erupted permanent tooth.



FIGURE 4.6 Premolar erupted at the age of 6 years even before the eruption of first permanent molar.



Presence of wear facets (Fig. 4.7) This particular factor can be a good clue for identification of a canine. The primary canines erupt into the mouth by the age of 2 years. In a patient aged 6 years or more, the canines may have wear facets on the incisal edge because of the occlusal wear (Fig. 4.7). However, a newly erupting permanent canine may not have any wear facets even by the age of 13 or 14 years. Observation of wear facets can eliminate the risk of identifying the canine incorrectly.



FIGURE 4.7 Wear facets on primary canine.



CONCLUSION The teeth identification exercise followed in a systematic way has resulted in lesser number of mistakes committed by our students over the years. When the above mentioned factors are carefully evaluated by students, the chances for incorrect identification becomes almost negligible. Having a minimum requirement on the number of identification exercises to be performed during the undergraduate training program can definitely help students to master this exercise.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Describe the various tooth notation systems. Write the advantages and disadvantages of each system. 2. What are different factors that should be considered while identifying a tooth?



Short Notes 1. FDI system 2. Universal system 3. Palmer notation 4. Mamelons and wear facets as factors for teeth identification



SUGGESTED READING



1. Ash, MM, Nelson, SJ, Wheeler’s Dental Anatomy, Physiology and Occlusion 8th edn. Saunders, St Louis, 2005. 1–28. 2. Black, GV. Descriptive Anatomy of the Human Teeth, 4th edn. Philadelphia: SS White Dental Manufacturing; 1902. 3. Lyons, H. Committee adopts official method for the symbolic designation of teeth. J Am Dent Assoc. 1947; 34:647. 4. McDonald, RE, David, RA. Development and morphology of primary teeth. In: McDonald RE, David RA, Dean JA, et al, eds. Dentistry for the Child and Adolescent. 8th edn. St Louis: Mosby; 2004:50–58. 5. Peck, S, Peck, L. A time for change of tooth numbering systems. J Dent Educ. 1993; 57:643.



SECTION II



Growth and Development: Changes in the Dentofacial Structures OUTLINE Chapter 5: Growth and Development Chapter 6: Development of Dentition and Occlusion



CHAPTER 5



Growth and Development A Victor Samuel, Abinash Mohapatra, MS Muthu and N Sivakumar



CHAPTER OUTLINE Introduction Definitions Fundamentals of Growth and Development Prenatal growth Postnatal growth Factors affecting growth and development Theories of growth and development Basic concepts of human and craniofacial growth Development of maxilla Development of mandible Differential growth Krogman’s ages of childhood Growth markers Growth spurts and differential growth Growth assessment methods Importance of Study of Growth and Development in Pedodontics Conclusion Suggested Reading Self-assessment Questions



“All change is not growth, as all movement is not forward.” —Ellen Glasgow



Introduction The organization and complexity of growth and development are nowhere more evident than in the changes that take place in the head and face. The fertilized cell begins to expand by the process of mitosis, which takes place within the first 24–36 hours after fertilization. First observable growth of the face occurs during the fourth week of intrauterine life. The time from conception to birth is described in three phases — the period of the ovum, the period of the embryo and the period of the fetus. This entire process is automated to highest order of perfection resulting in a newborn life. This chapter will focus on the concepts of growth and development pertaining to the craniofacial structures.



Definitions Growth According to: • Stewart, 1982: Growth may be defined as developmental increase in mass. In other words, it is a process that leads to an increase in the physical size of the cells, tissue organs or organisms as a whole. • Proffit, 1986: Growth refers to an increase in size or numbers. • Stedman, 1990: Growth is an increase in size of a living being or any of its parts, occurring in the process of development. • Pinkham, 1994: Growth signifies an increase, expansion of any given tissue.



Development According to: • Todd (1931): Development is an increase in complexity. • Moyers (1988): Development refers to all the naturally occurring unidirectional changes in the life of an individual



from its existence as a single cell to its elaboration as a multifunctional unit terminating in death. • Stedman (1990): Development refers to the act or process of natural progression from previous, lower or embryonic stage to a later, more complex adult stage. • Pinkham (1994): Development addresses the progressive evolution of a tissue.



Differentiation Differentiation is the change from generalized cells or tissues to more specialized kinds during development. In other words, it is the change in quality or kind. Maturation: Maturation is defined as the qualitative changes that occur with age. Translocation: Translocation is a change in position, e.g. the chin point is translocated (moved) downward and forward far more than any growth at the chin itself.



Fundamentals of Growth and Development Growth is basically an anatomic phenomenon and quantitative in nature. By definition, growth may occur by both an increase in cell size and an increase in cell number. Initially, the large egg subdivides into multiple cells of ordinary size. This multiplication alone does not result in growth and no significant growth occurs during this time. The most common means by which growth is achieved are through protoplasmic synthesis and simple incorporation of water within the confines of the cell. The other method by which growth occurs is by intercellular deposition of substances. Development is basically a physiologic phenomenon and qualitative in nature. It is the process of a cell becoming more and more specific to an organ or a specialized tissue. Though growth and development are defined separately they are integrated and continue



after birth for many years.



Prenatal Growth Prenatal growth from conception to birth is usually divided into three periods.



Period of ovum (0–2 weeks) This period is from fertilization to implantation. This period lasts until the dividing ovum or blastocyst becomes attached to the wall of the uterus. It is usually for 10–14 days.



Embryonal period (2–8 weeks) This period is characterized by differentiation of tissues and formation of organs. Body size and weight is low at the end of this period (7.5 cm/14 g). Water content is high and mineralization of bones and teeth has not yet started. During the first trimester, the embryo is vulnerable to teratogenic influences. A 1-month-old embryo has no real face but the beginning of development of face gets started. The five mesenchymal elevations (Fig. 5.1) constitute the initial features of the face. These include frontonasal process, two maxillary processes and two mandibular processes. The frontonasal process is a downward proliferation of mesenchyme of developing brain. Maxillary and mandibular processes arise from the first branchial arch. These processes grow in different ways and form the face.



FIGURE 5.1 Embryo with branchial arches.



Primordial oral cavity (stomadeum) is seen as a shallow depression bounded by the frontonasal process and by the maxillary and mandibular processes. The floor of the stomodeum is formed by the buccopharyngeal membrane. During 5th week, nasal placodes invaginate to form nasal pits and the edges of each pit rise above the surface and are referred to as medial raised edge and lateral raised edge. Each maxillary process moves toward the midline and joins with the frontonasal process. During this time, a shelf like process develops on the medial side of each maxillary process. These two palatal processes move toward the midline where they fuse and form the



hard palate. This palatal fusion is normally completed by the 8th intrauterine week. The cartilaginous skeleton of the first branchial arch, known as Meckel’s cartilage, provides a form for the development of mandible. Muscles of mastication and the trigeminal nerve are derived from the first branchial arch. In the embryonic period, the cranial end of the embryo grows rapidly than the other end resulting in the head constituting nearly half of the total body size at the end of the embryonic period.



Fetal period (8—40 weeks) Before the fetal period, the embryo has acquired all of its morphologic characteristics. The fetal period is characterized by osseous development. This period is also characterized by accumulation of subcutaneous fat, increase in muscle mass and reduced water content. During this period, accumulation of calcium due to mineralization of bones and teeth is important. The calcium content increases from 5 to 30 g. The dominance of the head growth is not maintained in the fetal period. The eyeballs grow rapidly during this time contributing to the widening of the face (Fig. 5.2). Nasal septum is said to have considerable influence in determining the facial form. The expansion of the eyeballs, the brain and spheno-occipital synchondroses result in the separation of the facial sutures. In the fetal period, maxilla is more developed than the mandible in contrast to the embryonic period where the mandible is larger than the maxilla. At birth, the mandible tends to be retrognathic to the maxilla. Rapid and extensive growth takes place during the rest of the fetal period. Major remodeling of the early facial skeleton occurs throughout the remaining fetal period and the bones enlarge in all directions from their respective ossification centers. Remodeling starts when the definitive form of each of the individual bones of the face and cranium is attained.



FIGURE 5.2 Embryo with nasal placodes and maxillary processes.



Postnatal Growth Postnatal growth and development begin at birth and terminate when adult maturity is attained and/or growth ceases. The first year of life is characterized by rapid growth in which most children undergo a 50% increase in length and almost a 200% increase in weight. In the entire human lifespan, the maximum amount of growth takes place during



the first year of life. After the first year, the growth rate tapers and the height and weight increases remain predictable all the way to adolescence. As the body changes and matures, the infant is able to afford sophisticated movements. By age 2, a child can run, climb, walk and kick a ball. By the end of second year, the growth of the brain has attained 75% of its adult weight. At birth, the bones that form the cranium are not fused and are separated by membrane filled spaces called fontanellae (Fig. 5.3). The face appears fat and the lower jaw seems underdeveloped and receded. The growth of the cranial vault is complete before that of the maxilla and the maxillary growth is completed before the mandibular growth which explains the cephalocaudal growth gradient. Prenatal and postnatal growths of mandible and maxilla are dealt separately in this chapter.



FIGURE 5.3 Fontanellae of an infant’s skull.



Factors Affecting Growth and Development Various factors can influence the growth and development of a human being in the prenatal and postnatal periods. Those factors are: 1. Hereditary factors 2. Nutrition 3. Illness 4. Race 5. Socioeconomic factors 6. Family size and birth order 7. Secular trends 8. Climate and seasonal changes 9. Physiological disturbances 10. Exercise 11. Maternal factors Hereditary factors: Heredity controls both, the end result and rate of progress toward the end result. Body height is determined by several genes (polygenic action) derived from both parents. Generally, tall parents will have tall children and short parents will produce short children. Nutrition: Sufficient intake of nutritious food is essential for normal growth and development. Inadequate intake of nutritious food delays growth. Malnutrition involves deficiency in calories and required food elements. Starvation alters the composition of the body. In starvation, the protein in the body is not accumulated, instead gets consumed so that the cell mass of the body is reduced. Fat is consumed and depleted. A sufficient diet includes an adequate supply of protein. Nine amino acids are essential for growth; absence of any one results in disordered growth. Calcium, phosphorus, magnesium and fluorides are essential for proper bone growth and tooth formation. Illness: Growth impairment (height as well as weight) is typical in children with chronic diseases of the gastrointestinal tract, kidneys, vascular system, etc. The diet may be adequate, but malabsorption (as



in celiac disease) may reduce the internal supply of nutrients. The effects of disease on growth are similar to those of malnutrition. After an illness, a catch up growth period usually brings the child back to the predetermined growth curve. Race: There is considerable evidence that children today are growing faster than they grew in the past. There are various factors like nutrition and environment that may lead to difference in growth in different races but, there is sufficient evidence to suggest that race by itself has a role to play in the growth process. Dietary pattern varies across the races which will affect the nutrition which in turn affects the growth and development. Socioeconomic factors: Children who live in favorable socioeconomic condition tend to grow bigger than the others. Malnutrition is a well-known cause of growth retardation in many developing countries and may also have been the cause of lower height in the past. Family size and birth order: In families, there will always exist a difference between the various members of a family with respect to their individual sizes, maturation level and intelligence. Evidence suggests that usually the first born children weigh less at birth, have less stature and higher IQ. Secular trends: Size and maturational changes in a large population can be shown to occur with time. As mentioned earlier, there is considerable evidence that children today are growing faster than they grew in the past. The adolescent height spurt occurs earlier now, but not more accentuated when compared to the past. Early in the 20th century, men reached their final height at 25 years of age. Now final height is reached at about 20 years of age. Secular change has been more marked in children than in total adult height. Climate and seasonal changes: Growth in height is faster in the spring than in the autumn. On the contrary, weight growth proceeds faster in the autumn than in the spring. There is evidence that growth and eruption of teeth is greater at night than in daytime. The reason for these differences is probably related to fluctuation in hormone release.



Physiological disturbances: A balanced hormone production is needed for optimal growth. Most importants are the growth hormone from the pituitary gland, sex hormones from the testicles/ovaries and the thyroid hormone. If growth hormone is not secreted sufficiently during childhood, it results in dwarfism. The effect of overproduction of growth hormone is gigantism. Lack of sex hormones results in absence of pubertal growth spurt but (eunuchism), because of the extended growth period, final stature may be above normal. If the production of sex hormones starts too early (pubertas praecox), height will be above normal during childhood, but the final height will be below normal. The thyroid hormones regulate the general metabolism. In cases of hypothyroidism, there will be a significant reduction in skeletal growth. Exercise: There is a general opinion that individuals who perform regular physical exercises grow bigger than the persons who do not involve much in physical activity. Individuals who exercise regularly will be fit and develop muscle mass. However, there is no correlation between the increase in muscle mass and the linear growth. Maternal factors: The size of a full-term infant correlates well with the size of the mother. At about 7 months of gestation, the fetus fills out the uterine cavity to the extent that the uterine size constraint becomes a factor in later fetal growth. Uterine constraint is presumably greater during the first pregnancy.



Theories of growth and development Various hypotheses have been put forth by several investigators regarding skull growth. Few of them have been briefly discussed below. 1. Genetic theory by Van Limborgh: This theory was proposed by Van Limborgh. It indicates that intrinsic genetic factors are the major concern, with modeling, resorptive and depository alterations, changes under the influence of muscles and other environmental factors. 2. Sutural dominance theory by Sicher: Sicher ascribed equal



values to all osteogenic tissues, cartilages, sutures (Fig. 5.4) and periosteum. However, this theory is referred as sutural dominance theory, because proliferation of connective tissue and its replacement by bone in the sutures was considered as the primary factor in bone growth.



FIGURE 5.4



Sutures of skull.



3. Cartilaginous theory by Scott: According to Scott, the intrinsic growth controlling factors are present in the cartilage and in the periosteum with the sutures being only secondary and dependent on extrasutural influence. Scott suggested that



cartilaginous parts of the skull must be recognized as primary centers of growth with the nasal septum being a major contributor in maxillary growth. 4. Functional matrix theory by Melvin Moss: This is the most widely accepted theory of craniofacial growth. The functional matrix concept attempts to comprehend the relationship between form and function. It comprises of two constituents: 1. Skeletal unit 2. Functional matrix This states that the form function and organization of skeletal component is always secondary and compensatory to the non-skeletal unit. Skeletal unit comprises of all microskeletal and macroskeletal components. Functional unit comprises of soft tissues, spaces and organs.



Skeletal unit All skeletal tissues associated with a single function are called the skeletal unit. The skeletal unit may be comprised of bone, cartilage and tendinous tissue. When a bone is comprised of several contiguous skeletal units, they are termed as microskeletal units. The maxilla and mandible are comprised of a number of such microskeletal units. When adjoining portions of a number of neighboring bones are united to function as a single cranial component, it is called a macroskeletal unit. The entire endocranial surface of the calvarium is an example of macroskeletal unit.



Functional matrix The functional matrix consists of muscles, glands, nerves, vessels, fat, teeth and the functioning spaces. The functional matrix is divided into two: 1. Periosteal matrix 2. Capsular matrix



Periosteal matrix: They act directly and actively upon their related skeletal units. Alterations in their functional demands produce a secondary compensatory transformation of the size and/or shape of their skeletal units. Such transformations were brought about by the interrelated processes of bone deposition and resorption. The periosteal matrix includes the muscles, blood vessels, glands, etc. These tissues act directly on their related skeletal units thereby bringing about a transformation in their size and shape. This transformation, due to the action of periosteal matrices, is brought about by bone deposition and resorption. Capsular matrix: They act indirectly and passively on their related skeletal units producing a secondary compensatory translation in space. These alterations in spatial position of skeletal unit are brought about by the expansion of the orofacial capsule within which the facial bones arise, grow and are maintained. The facial skeletal units are passively and secondarily moved in space as their enveloping capsule is expanded. The neurocranial capsule and the orofacial capsule are examples of capsular matrices. Each of these capsules is an envelope which contains a series of functional cranial component (skeletal units and related functional matrix) which as a whole is sandwiched between two covering layers. In the neurocranial capsule, the cover consists of the skin dura mater whereas in the orofacial capsule the skin and mucosa form the covering.



Basic Concepts of Human and Craniofacial Growth The basic concepts of human and craniofacial growth are described by Donald J Ferguson in “Dentistry for the Child and Adolescent”. The concepts are summarized below.



Basic concepts of growth 1. Growth disposition is similar for all individuals.



2. Different body parts increase in length at different rates. 3. The overall potential for growth is determined primarily by intrinsic or genetic factors. 4. The extent to which an individual attains his or her potential for growth is determined predominantly by extrinsic or environmental factors.



Craniofacial growth principles 1. The basic types and functioning spaces that comprise the head and face are subject to growth timing differences. 2. Growth of primary cartilage and functioning spaces has a directing influence on the craniofacial pattern change. 3. Mandibular condylar cartilage, craniofacial sutures and appositional resorptive bone changes facilitate pattern growth of the head and face. 4. Growth of the face and head tends to demonstrate relative equivalency.



Basic concepts of craniofacial growth 1. Different parts of the craniofacial complex grow at different times. 2. Differences in growth size, direction, velocity and timing are observed among individuals. 3. The faces and heads of no two humans are exactly the same.



Development of Maxilla The development of maxilla postnatally occurs entirely intramembranous ossification. Growth occurs in two ways: 1. Apposition of bone at the sutures that connect maxilla to the cranium and cranial base 2. Surface remodeling



by



Postnatal development of nasomaxillary complex is attained by growth observed at sutures, nasal septum and alveolar process. The growth mechanism is produced by (Fig. 5.5):



FIGURE 5.5 Schematic diagram showing drift and displacement.



1. Displacement 2. Growth at sutures 3. Surface remodeling (drift)



Displacement Displacement is movement away from a certain position or place. This displacement can occur by two ways:



1. Priary displacement 2. Secondary displacement 1. Primary displacement: Primary displacement is when there is a displacement of a bone in conjunction with its own growth. It is initiated by the sum of the expansive forces of the soft tissue (e.g. maxillary tuberosity). 2. Secondary displacement: Movement of bone is not directly related to its own enlargement but by the growth of the other bones and their soft tissues (e.g. cranial growth causing forward and downward growth of maxilla).



Growth at sutures Important sites of growth in the maxilla are the frontomaxillary sutures, the zygomaticotemporal sutures and the pterygopalatine sutures. These sutures are all parallel to each other and growth at these sites has the effect of moving the maxillary complex in a downwards and forward direction. There is also some growth in the median palatine suture and there is downward divergence of the pterygoid processes.



Drift Deposition occurs on the side facing the direction of growth and resorption on the surface facing away from direction of bone growth.



Cortical drift Drift and displacement occur together and complement each other (i.e. they move in the same direction) or they may take place in contrasting directions.



Summary The growth pattern of the face requires that it grows “out from under the cranium”. It means that the maxilla must move through growth, a



considerable distance downward and forward relative to the cranium and cranial base. As the downward and forward movements occur, the space that would otherwise open up at the sutures is filled in by the proliferation of bone at these locations. Bone apposition occurs at both the sides of the suture. The posterior border of the maxilla is free and bone is added to this surface, creating additional space for erupting permanent teeth. As the maxilla grows downward and forward, its front surfaces are remodeled and bone is removed from most of the anterior surface. The overall growth changes are results of both, a downward and forward translation of the maxilla and a surface remodeling (Fig. 5.6). The whole bony nasomaxillary complex is moving downward and forward relative to the cranium, being translated in space. It is not necessary that remodeling changes oppose the direction of translation. In some places, the effect is additive and in others it is opposite to each other. For example in the alveolar process region, the anterior part of the alveolar process is a resorptive area, so removal of bone from this area negates some amount of forward movement of maxilla. But on the roof of the mouth, bone is removed on the nasal side and added in the oral side resulting in downward and forward movements of the palate.



FIGURE 5.6 Schematic diagram of maxilla showing areas of resorption and apposition.



Growth dimensions — palate During prenatal life, there is greater appositional growth in the alveolar margin resulting in greater palatal length than the width. The length increases usually takes place between 7 and 18 weeks in the intrauterine life. At birth, the appositional growth in the maxillary tuberosity equals the difference that existed prenatally (lengdi = width). Postnatally, the appositional growth on the lateral side of the maxilla results in increased width of the palate comparing to its length.



Development of Mandible Prenatal growth of mandible At 6th week, a single ossification center for each half of mandible arises at bifurcation of the inferior alveolar nerve. The development of a slender cartilage rod during the second month serves as a precursor of mandibular mesenchyme which forms around it and is responsible for mandibular growth activity. This cartilage is called Meckel’s



cartilage. Bone begins to develop lateral to Meckel’s cartilage during the 7th week and continues until the posterior aspect is covered with bone. Between 10th and 14th weeks, secondary accessory cartilages appear. These include head of the condyle, part of coronoid process and mental protuberance. The secondary condylar cartilage grows interstitially and appositionally and in the 14th week, the first evidence of endochondral bone formation is seen. There is a marked increase in mandibular growth between the 8th and 12th weeks of fetal life. This brings changes in mandibular position and form. Ossification stops at the point which will later become the mandibular lingula and the remaining part of the Meckel’s cartilage continues on its own to form the sphenomandibular ligament and the spinous process of the sphenoid. Ossification in the downward proliferating condylar cartilage does not appear until the 4th or 5th month of life.



Fate of Meckel’s cartilage Meckel’s cartilage disappears by the 24th week of intrauterine life. Dorsal end of it ossifies to form the malleus and incus. A part of the cartilage transforms into sphenomandibular ligament and anterior malleolar ligament. Its ventral end forms accessory endochondral ossicles.



Postnatal growth of mandible Development of mandible takes place by both endochondral and membranous ossifications. Though the condylar cartilage is different from epiphyseal cartilage, endochondral replacement does occur here. All the other areas of mandible grow by direct surface apposition and remodeling. The actual growth occurs at the mandibular condyle and the posterior surface of the ramus translating the mandible downward and forward. The body of the mandible grows longer by appositional growth at the posterior surface of the ramus and simultaneous removal of bone from the anterior surface of the ramus (Fig. 5.7). In other words, the length increases by movement of the ramus away



from the chin. Due to the continuous remodeling, what was the posterior surface at one time becomes the center at a later date and eventually may become the anterior surface as remodeling proceeds.



FIGURE 5.7 Schematic diagram of mandible showing areas of resorption and apposition.



Parts of the mandible derived from intramembranous ossification are: 1. Whole body of mandible except the anterior part 2. Ramus of mandible as far as mandibular foramen Parts of the mandible derived from endochondral ossification are: 1. Anterior portion of the mandible (symphysis) 2. Part of ramus above the mandibular foramen 3. Coronoid process 4. Condylar process “The human mandible has no one design for life. Rather it adapts and



remodels through the seven stages of life, from the slim arbiter of things to come in the infant, through a powerful dentate machine and even weapon in the full flesh of maturity, to the pencil thin, porcelain like problem that we struggle to repair in the adversity of old age.” —DE Poswillo, 1988



Differential Growth The human body does not grow at the same rate throughout life. Different organs grow at different rates to a different amount and at different times. This is termed as differential growth. Two important aspects of growth which help us to understand the concepts of differential growth are: 1. Scammon’s growth curve 2. Cephalocaudal gradient of growth.



Scammon’s growth curve (Fig. 5.8) Different tissues in body grow at different times and at different rates. Scammon divided the tissues into four types:



FIGURE 5.8 Graph showing Scammon’s curve.



1. Lymphoid 2. Neural 3. Somatic (‘S’-shaped growth) 4. Genital



The growth of lymphoid tissues increases after birth. It reaches its 100% growth by 7 years and 200% by 10 years and thereafter regresses in size. Neural growth attains its 90% growth by the age of 7 years. Growth of genital and somatic tissues is accelerated during puberty.



Cephalocaudal gradient of growth Cephalocaudal gradient of growth simply means that there is an axis of gradient of growth extending from head towards feet.



Krogman’s Ages of Childhood 1. Chronological age 2. Biological age: a. Morphologic age (height, weight, age) b. Skeletal age c. Dental age d. Circumpubertal age 3. Behavioral age 4. Mental age 5. Self-concept age The behavioral, mental and self-concept ages are important in the overall developmental evaluation of growth pattern. 1. Chronological age: It is the most commonly and easily determined developmental age parameter which is simply figured out from the child’s date of birth. Each child has its own characteristic growth time clock. Time clock is affected by disease, metabolic, endocrine development and environmental factors. It is neither an accurate indicator of stage of development nor it is a good predictor of growth potential. 2. Somatotypic age: It includes overall assessment of the child. It gives developmental pattern of the child but not an accurate scale to predict age. Scheldon classifies individuals based on



the somatotype into three age categories (Fig. 5.9).



(A) Ectomorphic, (B) endomorphic and (C) mesomorphic individuals. FIGURE 5.9



a. Ectomorph: Ectomorph individuals are tall, thin and fragile with long and slender extremities having minimal subcutaneous fat and muscle tissue. These individuals are late maturers. b. Mesomorph: Mesomorph individuals are upright, sturdy and athletic in nature. In their body muscles, bones and connective tissue predominate. c. Endomorph: Endomorph is stocky having abundant subcutaneous fat and highly developed digestive viscera. Their somatic structures are relatively under developed. These individuals are early maturers.



Growth Markers The developmental status of a child is usually assessed in relation to events that take place during the progress of growth. Thus chronological age, sexual maturational characteristics, dental development (dental age), height and weight measurements and skeletal age are some of the biological indicators that have been used to identify the stages of growth. Chronological age: Chronological age is often not sufficient for assessing the developmental stage and somatic maturity of the patient, so that the biological age has to be determined. Biological age: The biological age is determined from the skeletal, dental and morphologic age and onset of puberty. Morphologic age: Morphologic age is based on the height. A child’s height can be compared with those of his same age group and other age groups to determine where he/she stands in comparison to others. Height is useful as a maturity indicator from late infancy to early adulthood. Dental age: Dental age has been based on two different methods of assessment. 1. Tooth eruption age 2. Tooth mineralization stage Sexual age: Sexual age refers to the development of secondary sexual characteristics. This type of indicator is useful only for adolescent growth. Skeletal age: Skeletal age assessment is often made with the help of hand—wrist radiograph which can be considered the ‘biological clock’. Nine developmental stages are there according to Bjork (1972), Grave and Brown (1976). The ossification events are localized in the area of the phalanges, carpal bones and radius (Fig. 5.10). Leonard S Fishman (1982) outlined four stages of bone maturation found at six anatomical sites located on the thumb, 3rd finger, 5th finger and radius. Eleven skeletal maturity indicators are found in these six



anatomic sites.



FIGURE 5.10 Hand–wrist radiography.



Epiphysis as wide as diaphysis • Third finger—proximal phalanx • Third finger—middle phalanx • Fifth finger—middle phalanx Ossification: Adductor sesamoid of thumb Capping of epiphysis



• Third finger—distal phalanx • Third finger—middle phalanx • Fifth finger—middle phalanx Fusion of epiphysis and diaphysis • Third finger—distal phalanx • Third finger—proximal phalanx • Third finger—middle phalanx • Radius Dental age: Demirjian’s method of dental age determination is based on the stage of mineralization. Demirjian et al, in 1973, divided tooth mineralization into nine stages (Fig. 5.11).



FIGURE 5.11 Demirjian’s schematic diagram of stages of tooth development.



1. Tooth germ without signs of calcification. 2. Calcification of single occlusal points without fusion of different calcification. 3. Fusion of mineralization points. The contour of the occlusal



surface is recognizable. 4. Calcification of the crown is complete; beginning of dentin deposits. 5. Crown formation is complete up to the cementoenamel junction. 6. Root length shorter than crown height. 7. Root length larger than crown height. 8. Root formation finished. Apical foramen still open. 9. Apical foramen is closed.



Growth Spurts and Differential Growth Growth does not always take place uniformly at all times. There seems to be periods when a sudden acceleration of growth occurs. This sudden increase in growth is termed as “growth spurt”. The physiological alteration in hormonal secretion is believed to be the cause for such accentuated growth. The timing of growth spurt differs in boys and girls. Causes: • Prebirth—cell division • Postbirth—hormones Timings of growth spurts: 1. Just before birth. 2. One year after birth. 3. Mixed dentition growth spurt: Boys— 8–11 years; girls— 7–9 years 4. Prepubertal growth spurt/adolescent growth spurt: Boys— 14– 16 years; girls— 11–13 years. Prepubertal growth spurt/adolescent growth spurt has been divided into three phases:



a. Prepubertal take off stage—moderate increment in the height velocity. b. Pubescent phase—very rapid growth phase. c. Post-pubescent phase—decelerating height velocity finally, linear growth comes to a stop with fusion of the epiphyses. Clinical application: Growth modifications by means of functional and orthopedic appliances elicit better response during growth spurts. Surgical corrections involving maxilla and mandible should be carried out only after cessation of the growth spurts.



Growth Assessment Methods Biometrics: It is the science of statistical biology, collection and analysis of data regarding a living organism. The biometric methods used for recording dimensional changes in the cranium during growth are: 1. Longitudinal methods 2. Cross-sectional method 3. Semilongitudinal method Craniometry: This method considers the cranial dimensions of dry skulls. Somatometry: Somatometry is a study of soft tissues and is not a reliable method. X-ray cephalometry: This method depicts only the radiographic structural changes in relation to a certain reference structure. Metal indicators: In this method, metal markers are implanted in a bone to act as a reference point and changes in the external contour of the bone is studied. Superimposition: In this, a series of X-ray films are taken at different time periods and used for studying positional changes. Stereopairs images: In this, positional changes can be studied in a three-dimensional system. Electromyography: Electromyography allows the action potential of



the muscles of mastication to be correlated with morphological data and normalization of muscle function in the treatment of malocclusion. Vital staining: The vital staining method depicts the pattern of the postnatal bone deposition over an extended time period. It gives direction and amounts of growth to the growth sites as well as the timing and relative duration of growth at different sites. Radioisotopes: In this method, radioisotopes are injected and growth is measured by means of autoradiographic techniques. Natural markers: Trabeculae, nutrient canals and lines of arrested growths can be used as a reference to study deposition, resorption and remodeling. Anthropometry: Various landmarks on the dry skull are measured by viewing individuals by using soft tissue points overlying the bony landmarks.



Importance of Study of Growth and Development in Pedodontics • Knowledge of normal human growth is essential for the recognition of abnormal or pathologic growth. • Estimation of growth potential is necessary for orthodontic, surgical, orthognathic and orthopedic corrections of dentofacial disharmony to achieve a stable functional and an esthetic result. • The study of growth in children is done to assess the health and nutrition of children living in a nation. • The study of growth in children is done to compare the growth of an individual child with the growth of a large sample of other children. This is important for health education professionals and parents who care for growing children. • Growth rate may be the best indicator of the physical and psychologic well being of children. • To know the growth spurt period and to use the



myofunctional appliances appropriately.



CONCLUSION A harmonious growth among the various parts of the craniofacial skeleton will result in balanced growth. Thorough understanding of the growth and development of the facial structure at various stages of development will facilitate the differentiation of normal growth and development from the abnormal.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Define growth and development. Explain the prenatal and postnatal growth of mandible. 2. Growth and development of mandible. 3. Growth site versus growth centre. 4. What are the clinical applications of functional matrix theory in dentistry? 5. What are the constraints of functional matrix theory? 6. What are the two complementary concepts that are included in update of functional matrix hypothesis?



Short Notes 1. Growth spurts 2. Dental age 3. Scammon’s growth curve 4. Meckel’s cartilage 5. Skeletal age 6. Growth of maxilla 7. Growth assessment methods 8. Krogman’s ages of childhood 9. Fate of Meckel’s cartilage



10. Functional matrix theory 11. Van Limborgh theory of growth 12. Petrovic theory of growth 13. Growth markers 14. Growth deficiency and its clinical implications



SUGGESTED READING 1. Braham, RL, Morris, ME. Textbook of Pediatric Dentistry, 2nd edn. Delhi: CBS Publishers; 1980. 2. Enlow, DH. Handbook of Facial Growth. Philadelphia: Saunders; 1975. 3. Finn, SB. Clinical Pedodontics, 4th edn. Philadelphia: Saunders; 1991. 4. Graber, TM. Orthodontics: Principles and Practice, 3rd edn. Philadelphia: Saunders; 1992. 5. Pinkham, JR, et al. Pediatric Dentistry: Infancy through Adolescence, 4th edn. New Delhi: Elsevier; 2005. 6. McDonald, RE, Avery, DR, Dean, JA. Dentistry for the Child and Adolescent, 8th edn. St Louis: Mosby; 2004. 7. Stephen, HYW. Pediatric Dentistry: Total Patient Care. Philadelphia: Lea and Febiger; 1988. 8. Stewart, RE, Barber, TK, Troutman, KC, et al.



Pediatric Dentistry: Scientific Foundations and Clinical Practice. St Louis: Mosby; 1982. 9. Profift, WR, Fields, HW. Contemporary Orthodontics, 2nd edn. St Louis: Mosby; 1993. 10. Koch, G, Poulsen, S. Pediatric Dentistry: A Clinical Approach. Copenhagen: Munksgaard; 2001.



CHAPTER 6



Development of Dentition and Occlusion N Sivakumar and MS Muthu



CHAPTER OUTLINE Introduction Development of Teeth Morphological developmental stages Histophysiological developmental stages Eruption and Shedding of Teeth Eruption Shedding of teeth Clinical Problems during Eruption of Teeth Teething Natal and neonatal teeth Dental lamina cysts, Epstein’s pearls and Bohn’s nodules Factors affecting development of dentition Developmental Anomalies of Teeth Development of Occlusion Gum pads Primary dentition stage Mixed dentition stage Permanent dentition stage Conclusion Suggested Reading Self-assessment Questions



“Adam and Eve had many advantages, but the principal one was that they escaped teething.”



—Franklin P Jones



Introduction The purpose of this chapter is not only to discuss extensively on the developmental stages of teeth but also to describe the salient aspects of them with an emphasis on the clinical importance of learning development of dentition and occlusion in pediatric dentistry. The authors suggest the students to read the textbooks on Dental Anatomy and Histology, Oral Pathology as well as Orthodontics for a detailed knowledge on development of teeth, developmental disturbances of teeth and factors affecting development of occlusion. The present day scenario of the integrated teaching highlights the importance of learning the basic sciences and allied sciences subjects for application in clinical dentistry. The students are expected to learn the normal development of dentition and occlusion and be in a position to identify any abnormality or deviation from normalcy.



Development of Teeth Tooth development is a dynamic process and goes through various stages of formation. It begins from the differentiation of the oral ectoderm to dental lamina formation by invaginations in the epithelium as described below in detail. The tooth development progresses in the following stages (AAPD).



Morphological Developmental Stages • Dental lamina • Bud stage • Cap stage • Bell stage • Advanced bell stage • Hertwig’s epithelial root sheath • Enamel pearls



• Formation of enamel and dentin matrices



Histophysiological Development Stages (Fig. 6.1)



FIGURE 6.1 Various stages of tooth development (From Orban’s Oral Histology and Embryology, Elsevier).



• Initiation • Proliferation • Histodifferentiation • Morphodifferentiation • Apposition • Calcification (mineralization) and maturation.



Dental lamina Mammalian teeth develop from two types of cells—stomodeal ectoderm, which forms ameloblasts and cranial neural crest-derived (ecto) mesenchyme cells, which form odontoblasts and cementoblasts. These two cell types juxtaposed in the developing oral cavity, interact to control the entire process of tooth initiation, morphogenesis and cytodifferentiation. Dental lamina begins at 6 weeks of intrauterine life and tooth buds



arise from the lamina. Initiation of primary teeth is seen from second month in utero, successor teeth (teeth erupting in place of primary teeth) from 5 months in utero and initiation of accessory teeth (permanent teeth that erupt distal to primary dentition) from 4 months in utero for first permanent molars and one year after birth for second permanent molars. The enamel of teeth is derived from the ectoderm and the mesoderm provides the anlagen for the dentin, pulp and periodontal tissues. Neural crest cells are responsible for tissues like bone, cartilage, dentin and dermis but not the enamel which is derived from the stomodeal ectoderm. The tooth bud consists of enamel organ, dental papilla and dental sac.



Initiation (bud stage) The first sign of tooth development can be observed as early as the 6th week of intrauterine life. An epithelial thickening in the region of the future dental arch is formed by proliferation of cells from the basal layer of oral epithelium. This extends along the entire margin of the jaws and is termed as the primordium of the ectodermal portion of the teeth which results in dental lamina. Ten round or ovoid swellings occur in each jaw during the same time in the positions due to be occupied by the primary dentition. The entire primary dentition and permanent molars arise from the dental lamina. The permanent incisors, canines and premolars develop from the buds of their predecessors.



Proliferation (cap) stage The method of proliferation of cells continues in the cap stage. A cap is formed as a result of uneven growth in different parts of the bud. A shallow invagination appears on the deep surface of the bud, with the peripheral cells of the cap later forming the outer and inner enamel epithelium.



Histodifferentiation and morphodifferentiation



(bell) stages The epithelium continues to invaginate and gets deeper until the enamel organ assumes the shape of a bell. There is differentiation of the cells in the dental papilla into odontoblasts and the cells of the inner enamel epithelium into ameloblasts. The histodifferentiation marks the end of proliferation as the cells lose the capacity to multiply. This stage is the predecessor of apposition stage. In the morphodifferentiation stage, the formative cells are arranged to outline the shape and size of the tooth, the process that occurs before matrix deposition. The morphology of the tooth gets established when the inner enamel epithelium is arranged such that the margin between it and the odontoblasts delineates the future dentinoenamel junction. Mammalian tooth morphogenesis must be controlled by either ectodermally derived cells and/or ectomesenchymally derived cells, since these are the only cell types that form teeth. Current evidence suggests that the information for generation of an incisor or a molar tooth is inherent in the ectomesenchyme, whereas the establishment and actual mechanics of using this information are carried out by ectodermally derived cells of the enamel knot. Spatial domains of homeobox genes are established in the ectomesenchyme and provide the positional information (odontogenic homeobox code) for the specification of tooth shape. Two possible mechanisms of the highly restricted domains of ectomesenchymal gene expression regulation are: 1. Neural crest cells contain a prepattern, and 2. Neural crest cells respond to positional signals from the oral epithelium.



Apposition stage A layer-like deposition of a nonvital extracellular secretion in the form of a tissue matrix results in apposition. This tissue matrix is deposited by the formative cells, ameloblasts and the odontoblasts that line up



along the future dentinoenamel and dentinocemental junctions at morphodifferentiation stage. The enamel and the dentin matrix are deposited by these cells according to a definite pattern and rate. The formative cells begin their act at specific sites referred to as growth centers as soon as the dentinoenamel junction is accomplished.



Calcification and maturation Matrix deposition is followed by calcification or mineralization which involves the precipitation of inorganic calcium salts within the deposited matrix. The process begins with a nidus around which further precipitation occurs. The nidus increases in size by addition of concentric laminations. These individual calcospherites approximate and fuse with each other to form a homogenously mineralized layer of tissue matrix. If the calcification process is disturbed, there is a lack of fusion of the calcospherites. These deficiencies are not identified easily in enamel but in the dentin they are evident as interglobular dentin.



Eruption and Shedding of Teeth Eruption Tooth eruption has been defined as the movement of a tooth from its site of development within the alveolar process to its functional position in the oral cavity. (Massler and Schour 1941) Eruption literally means ‘to come out’. But it is not restricted to just coming out, as it includes movement of tooth right from the time of its initiation, till it is lost. Thus it is a continuous process involving complex series of movements. The process of tooth eruption can be conveniently, even if arbitrarily, divided into three phases: 1. Pre-eruptive 2. Eruptive/prefunctional 3. Posteruptive/functional eruptive



Pre-eruptive phase It is preparatory to eruptive phases. It consists of movements of the tooth germ within the alveolar process before root formation. During this phase, the growing tooth moves in various directions to maintain their position in expanding jaws. This is accomplished by both bodily and eccentric movements. Bodily movement is a shift of the entire tooth germ, which causes bone resorption in the direction of tooth movement and bone apposition from behind. These movements occur continuously as the jaws grow. Eccentric growth refers to relative growth in one part of the tooth, while rest of the tooth remains constant. These movements relate to the adjustments that each crown must make in relation to its neighbor, and to the jaws as they increase in width, height and length. The primary teeth in the alveolar process move in occlusal and facial direction or in the direction of the growth of the face. At the same time, there is some mesial and distal movements. The permanent teeth also move within the jaws to adjust their position within the jaws. Even during the crown formation, there will be small pre-eruptive gyratory movements of the tooth.



Eruptive/prefunctional phase Eruptive phase starts after crown formation is completed and the root begins to form. It is an active eruption process moving the tooth towards its functioning position. This has warranted many to believe that the growing root pushes the tooth into the oral cavity but has not been proved otherwise. It can again be divided arbitrarily into three stages: 1. Intraosseous eruption 2. Mucosal penetration 3. Preocclusal eruption Intraosseous eruption: The histological events of bone resorption along a predetermined path for individual teeth form the intraosseous phase of eruption. For some permanent teeth, this phase involves



journey through the space occupied by the roots of primary teeth. Following this phase, the tooth passes through its bony crypt and enters and breaks through the supraosseous soft tissue structure exposing itself to the oral environment. After that, the tooth begins to move to attain its functional position in the oral cavity by coming in contact with its antagonist.



Posteruptive/functional eruptive phase When the occlusal plane is approached, the rapid phase of eruption comes to a halt. Initial events after reaching occlusal plane include consolidation of periodontal support for the tooth and closure of root apex. Later eruption will proceed at a slower rate to maintain the vertical dimension of face and for compensation of occlusal attrition. Also as the jaws continue to grow, the teeth need to accommodate themselves till the growth seizes. This involves the bone remodeling that takes place by increase in height of the alveolar process and also the thickness of the bone around the socket. Not only these movements, but also the teeth move in mesial direction to compensate for the interproximal wear. Thus once the tooth is in its functional position, it needs to withstand many forces. All these come under the posteruptive or the functional phase.



Theories of eruption Numerous theories of tooth eruption have been put forward. These involved almost all the tissues in or near an erupting tooth. However, none of them alone can account for the journey of a tooth, thus concluding that eruption is a multifactorial mechanism where a series of synchronous and well orchestrated events are responsible for eruption to occur. Factors like bone remodeling, root formation, hydrostatic pressure, dental follicle and the formation of periodontal ligament (PDL) are the many factors that can influence the mechanism of tooth eruption.



Shedding of Teeth



The primary teeth are small and fewer to fit the small jaws of infant. Because the teeth once formed cannot increase in size, it follows that the primary teeth must be shed to be replaced by permanent teeth. Shedding is the exfoliation of the primary teeth caused by physiologic resorption of their roots and its supporting structures. This mechanism is brought about by the pressure exerted by the underlying tooth and also the activation of the osteoclastic and odontoclastic cells. As hard tissue resorption takes place the tooth loses its attachment apparatus of the periodontal ligament. The developing musculature of the oral structures and increasing masticatory load on the primary dentition also influence and further weaken the dentition and aid in exfoliation. Unlike eruption, shedding is not a continuous process but has periods of activity and quiescence, and ultimately the periods of active resorption prevail, resulting in shedding of primary dentition.



Clinical Problems During Eruption of Teeth Teething The term ‘teething’ literally means, ‘eruption of primary teeth’. Increased salivation, putting fingers in the mouth, diarrhea, fever, convulsions, acute herpetic gingivostomatitis, photophobia, blinking eyes, vomiting, neuralgia, severe headache, cold, weight loss, toxemia, tonsillitis, paralysis, cholera, meningitis, tetanus, even death have been attributed to eruption. In 19th century, infant mortality has been attributed to teething. It was proved that no evidence exists of teething causing fever, convulsions, bronchitis or diarrhea and all other conditions mentioned. Teething neither increases the incidence of infection nor the erythrocyte sedimentation rate (ESR) or white blood cell (WBC) counts. It does not cause fever. Any fever that shows more than 101° F temperature is not attributed to teething. Teething does not cause anger, sleep disturbance or rubbing of cheek or ear as mentioned by



lay people. It does cause day-time restlessness, increase in amount of finger sucking, drooling or rubbing of gums and possibly loss of appetite. One-third of children only show pronounced change in mucosa with small hemorrhage. Eruption of teeth is a normal physiological process, the fever or other infections are considered coincidental.



Management Inflammation of tissues over erupting teeth results in pain temporarily. Removal of tissue covering over the erupting teeth is not recommended. Nontoxic unbreakable teething toys or rings are advised. Solid silicone-based teething rings are superior to their liquid-filled counterparts, as the potentially irritant contents may leak, if they are damaged and they cannot be sterilized. Temporary pain relief is provided by the pressure produced by chewing the teething ring, preferably chilled one. Pacifiers can also be used for this purpose. Teething rings should be attached to the infants clothing and not tied around the neck, as strangulation could result. Hard, nonsweetened rusks, made from flour and wheat germ with no sugar or sweetener can also be attached on to the infant’s clothing. Alternative nonpharmacological holistic therapies (acupressure, aromatherapy, massage and homeopathy) have been suggested as giving relief from the symptoms of teething. Nonirritating topical anesthetics, some systemic analgesics and antipyretics can be advised to give relief from pain and fever. The child may be referred to a pediatrician or family physician in case of any systemic disturbances and fever with temperature more than 101°F.



Natal and Neonatal Teeth The natal and neonatal teeth are also termed as premature teeth or predeciduous dentition. These teeth erupt prior to 3 months of age. Natal teeth are present at birth and neonatal teeth erupt within the first 30 days of life.



These teeth commonly occur in pairs, mostly in the lower anterior region. The natal to neonatal teeth ratio is 3:1 with the incidence as 1 in 2000 to 3500. Ninety percent of these teeth are true primary teeth, others are supernumerary. Etiology of natal and neonatal teeth is unknown, but superficially positioned tooth bud may be a reason and most of these teeth are poorly formed. Natal and neonatal teeth may be associated with Riga-Fede disease in which trauma to tongue during feeding is observed. These may also be observed in chondroectodermal dysplasia. Structures to bear in mind during examination are dental lamina cysts, Bohn’s nodules, Epstein‘s pearls in the differential diagnosis of natal and neonatal teeth.



Management Radiographs can be taken to confirm the root length of the teeth in question. Teeth with little mobility become firm over time and with eruption of adjacent teeth. Extraction is indicated in case of sharp incisal edge causing injury to tongue or loosely attached teeth to prevent aspiration. If breastfeeding is painful for the mother, then the use of breast pump or bottle feeding is recommended. Extraction is not indicated in this condition as infant seems to sense mother’s discomfort and learns to avoid causing it. If extraction is decided, it should be delayed until the 10th day postpartum, in order to avoid hemorrhage because of possible deficiency of vitamin K in the infant.



Dental Lamina Cysts, Epstein’s Pearls and Bohn’s Nodules Dental lamina cysts are found on the crest of the maxillary and mandibular dental ridges and originate from the remnants of the dental lamina. Epstein’s pearls are formed along the midpalatine raphe and are considered to be remnants of epithelial tissue trapped



along the raphe as the fetus grows. Bohn’s nodules are formed along the buccal and lingual aspects of the dental ridges and on the palate away from the raphe, considered as remnants of mucous gland tissue and are histologically different from Epstein’s pearls.



Problems in eruption • Eruption hematoma • Pericoronitis • Eruption sequestrum • Ectopic eruptions (Fig. 6.2 A, B)



FIGURE 6.2



Ectopic eruption.



• Transpositions (Fig. 6.3)



FIGURE 6.3



Transposition of canine.



Factors Affecting Development of Dentition Local factors



• Lack of space in the arch • Early loss of primary tooth • Ankylosed primary teeth, retained roots • Trauma to primary dentition • Ectopic eruptions • Congenital absence of teeth • Supernumerary teeth • Cysts/tumors of jaws • Abnormal musculature



Systemic factors Acceleration of eruption • Hyperthyroidism • Hyperpituitarism • Turner’s syndrome Delayed eruption • Hypopituitarism • Hypothyroidism • Down’s syndrome • Cleidocranial dysostosis • Hypovitaminosis A and D



Developmental Anomalies of Teeth Due to the disturbances that occur at different stages of development of dentition, various anomalies of development appear which are discussed below. Initiation or bud stage: Anomalies of number occur if there is any disturbance in the initiation or bud stage. They are hyperdontia, hypodontia (oligodontia) or anodontia. Proliferation or cap stage: Anomalies of size like microdontia and



macrodontia occur due to disturbances in proliferation or cap stage. They are twinning/conjoined teeth including gemination, fusion (Fig. 6.4), conation and concrescence.



FIGURE 6.4 Fusion of tooth.



Morphodifferentiation stage: Anomalies of size and shape occur due to disturbances in morphodifferentiation stage. This includes dens in dente, dens evaginatus, talon cusp, taurodontism and dilacerations. Histodifferentiation or bell stage: Anomalies of structure will occur in this stage. This includes amelogenesis imperfecta (AI) type I: hypoplastic and dentinogenesis imperfecta: shields type I, II and III. Apposition stage: Anomalies of structure in enamel, dentin and cementum occur due to disturbances in apposition stage. In enamel: AI types II and IV, hypomaturation type, acquired enamel hypoplasia due to systemic and local causes.



In dentin: Dentin dysplasia – two types (shields), regional odontodysplasia – ‘ghost teeth’ and other conditions with dentin abnormalities. In cementum: Anomalies of cementum as in hypophosphatasia, epidermolysis bullosa, cleidocranial dysplasia. Calcification stage: Anomalies of structure also occur due to disturbances in calcification stage of teeth. In enamel: Hypocalcification occurs as in amelogenesis imperfecta type III – hypocalcified and enamel fluorosis. In dentin: Sclerotic dentin results.



Development of Occlusion Ideally, the occlusion develops from primary dentition through mixed (transitional) dentition to the permanent, with a sequence of events occurring in orderly and timely fashion leading to functionally stable and esthetic occlusion. If the sequence is disturbed due to any factor, malocclusion will result. Corrective measures are needed to prevent or minimize the malocclusion with passive space maintenance or active tooth guidance as will be needed. Development of occlusion can be studied under the following stages: • Gum pads • Primary dentition stage • Mixed dentition stage • Permanent dentition stage



Gum Pads The gum pads are alveolar arches or the edentulous arches of an infant (Fig. 6.5). They are firm and pink structures, divided into ten segments by transverse grooves. The groove between primary canine and first molar segments is prominent, termed as lateral sulcus. Upper



gum pad is horseshoe-shaped and the lower gum pad is ‘U’ shaped and everted labially in the anterior portion.



FIGURE 6.5 Gum pads.



In upper arch, the gingival groove separates gum pad from palate. The dental groove extends from incisive papilla backwards to touch gingival groove in the canine region and ends laterally in molar region. In the lower arch, the gingival groove demarcates lingual extent of the gum pad. The dental groove extends from mandible backwards, laterally to join gingival groove in the canine region. At rest, the gum pads are separated by tongue, which will be lying



over the lower gum pad. There will be variable overjet with contact only in first molar segments. Only anteroposterior movements are seen in gum pads with no lateral movements. The gum pads initially show class II type of relationship, with upper gum pad forwardly placed compared to lower one. This is termed as one of the self-correcting anomalies, that gets corrected with growth of the jaws as age advances. Rapid growth of the gum pads is seen in the first year of life, which is more in transverse and labiolingual direction and the segments become more prominent with growth.



Primary Dentition Stage Features of primary dentition General characteristics of the primary dentition according to Baume are as follows: • Arches are half round or ovoid • Flat or no curve of Spee • Shallow cuspal interdigitation • Vertical inclination of teeth (90°) • Slight overjet or overbite • Little or no crowding. Primary dentition is of spaced or closed (nonspaced) type (Fig. 6.6A, B). Spaced dentition has interdental spacing and primate spaces. Interdental spaces are physiologic or developmental spaces which will be 0 to 8 mm (average 4 mm) in maxilla; 1 to 7 mm (average 3 mm) in mandible. This spacing is otherwise termed as primary spacing.



FIGURE 6.6 (A) Spaced and (B) closed primary dentition.



Primate spaces (Fig. 6.7) are the spaces present mesial to maxillary



canines and distal to mandibular canines in the primary dentition. These are otherwise termed as anthropoid spaces or simian spaces. These spaces are helpful in other primates with longer or larger canines to occlude in the opposing jaws.



FIGURE 6.7 Primate spaces.



Primary molar relationship (Fig. 6.8) The meaning of primary molar relationship is the relation between upper and lower second primary molars. Here the key of occlusion is presumed as the distal surface of the upper primary second molar. It can be one of the three types—flush or straight terminal plane (76%), mesial step (14%), distal step (10%).



FIGURE 6.8 Diagram showing primary molar relationship.



Flush or straight terminal plane: If the distal surfaces of both upper and lower primary second molars are in one line with each other when the primary teeth are in occlusion, it is termed as flush terminal plane occlusion. Mesial step: If the distal surface of the lower primary molar is mesial to the distal surface of the upper second primary molar in occlusion, it is termed as mesial step occlusion. Distal step: If the distal surface of the lower primary molar is distal to the distal surface of the upper second primary molar in occlusion, it is termed as distal step occlusion. Mesial step is the ideal relationship which routinely guides the first permanent molars into class I relationship. Distal step guides the permanent molars into abnormal class II relationship. Straight terminal plane which is the more frequent primary molar relationship guides the first permanent molars into either class I or class II depending on many factors and this should be closely monitored by a clinician.



Anterior teeth relationship In the anterior segment includes the four primary incisors and their relationship with each other. Primary incisors are almost upright when compared to the angulated permanent incisors. Overbite: It is the vertical overlap of the maxillary and mandibular incisors in occlusion. This can be measured and recorded in millimeters or percentage of the total height of the mandibular incisor crown. This is approximately 2 mm in primary dentition. Overbite



increases from primary dentition to the permanent (Fig. 6.9).



FIGURE 6.9 Recording overjet and overbite in a patient.



Overjet: It is the horizontal overlap of the maxillary and mandibular incisors in occlusion. This is measured in millimeters. In normal occlusion, there is little or no overjet. It is more helpful to describe the overjet as ideal, deficient, or excessive rather than in millimeters (Fig. 6.9). Canine relationship: It can be of three types, viz. class I, class II and class III in both primary and permanent dentition corresponding to the permanent molar relationship. According to Baume, not much change is observed in dental arch dimensions in primary dentition in majority of the cases, and Franke described reduction in arch length after natural exfoliation of primary teeth.



Mixed Dentition Stage The posterior teeth tend to move forward which reduces arch length. Moorrees has shown that arch length decreases 2 to 3 mm between 10 and 14 years, during the exchange of primary molars with premolars. He also demonstrated that arch circumference is reduced up to 3.5 and 4.5 mm in mandible respectively for boys and girls in mixed dentition period. Mixed dentition period can be studied under three stages: 1. First or early transitional stage 2. Intertransitional period stage 3. Second or late transitional stage



Early transitional stage (Fig. 6.10) Early transitional stage spans between 6 to 8 years of life and is marked with the emergence of first permanent molars. This will correspond with or followed by exchange or transition of incisors with central incisors and also lateral incisors in some cases. Establishment of occlusion occurs with permanent central incisors, first molars and primary laterals, canines and molars. Early mesial shift of mandibular first permanent molar occurs in this stage.



FIGURE 6.10 Future permanent molar relationship based on primary molar relationship.



Early mesial shift: It occurs in spaced dentition with flush/straight terminal plane primary second molar occlusion. The eruptive force of first permanent molars closes the spaces distal to primary canines decreasing the arch length. Incisal liability: It refers to the difference between the amount of space needed for the permanent incisors and the amount of space available for them. This results in crowding of permanent incisors in the mandibular arch (sometimes in maxillary arch too) at age 8 to 9. There are different mechanisms by which this incisal liability gets compensated. They are: • Utilization of interdental spacing or the spaces between the primary incisors and canines in spaced dentition. • Increase in the arch width or intercanine width changes leading to more outward positioning of canines after eruption. This accounts for a space of about 2 mm. • Arch length changes; labial inclination and positioning of permanent incisors in a larger arc compared to upright primary incisors. This contributes to additional 1 to 2 mm space. • Repositioning of the canines in the mandibular arch slightly back into the primate spaces along with the widening of arch accounting for another extra-millimeter of space. Secondary spacing: It is observed in closed primary dentition. When the permanent mandibular laterals emerge, they push the primary canines laterally creating a space. This was termed as secondary spacing by Baume. Secondary spacing can also occur during the eruption of permanent central incisors.



Intertransitional stage



This stage consists of equal number of both sets of dentition. It will have 12 permanent teeth consisting of 8 incisors and 4 molars plus 12 primary teeth consisting of 4 canines and 8 primary molars with four permanent incisors left and right first permanent molars plus primary canines and primary molars in each jaw. Secondary spacing, the space created by the emergence of permanent lateral incisors in both maxilla and mandible is also observed in this period.



Late transitional stage This stage includes emergence of permanent canines, premolars and second permanent molars and establishment of permanent occlusion. Ugly duckling stage or Broadbent phenomenon (Fig. 6.11), intercanine width changes, exchange of primary canines and molars with their permanent counterparts and late mesial shift occurs in this stage.



FIGURE 6.11 Ugly duckling stage.



Ugly duckling stage or Broadbent phenomenon (Fig. 6.11): This refers to the appearance of diastema in the midline of the maxilla with fared incisors during the eruption of the permanent incisors and



canines. Permanent incisors are larger and develop in a more restricted area compared to their primary counterparts. There is an inclination in the eruptive paths of the permanent incisors giving a flared appearance. Flaring of incisors can also occur due to the pressure exerted by the crowns of the erupting canines over the roots of the incisors. The permanent canines are the last permanent teeth to erupt mesial to first permanent molars. The crowns of the canines exert a mesial component of force on the incisor crowns as they erupt into the oral cavity which is often adequate to straighten the incisors and close the diastemas. Secondary spacing: It is observed in closed primary dentition. When the permanent mandibular laterals emerge, they push the primary canines laterally creating a space. This was termed as secondary spacing by Baume. Secondary spacing can also occur during the eruption of permanent central incisors. Intercanine width increase: It occurs during the eruption of incisors. If the primary canines are reduced in size or extracted, the secondary spacing and intercanine width changes do not occur. Late mesial shift: It occurs in closed primary dentition with flush terminal plane, erupting first molars cannot shift mesially until the exchange of C, D and E with 3, 4 and 5. The combined width of primary canine and primary molars is more than the combined width of permanent canine and premolars. The difference in their mesiodistal widths, the ‘leeway space of Nance’ is utilized by the first permanent molars to shift mesially to establish class I relationship. Amount of leeway space is 1.8 mm in maxilla, 3.4 mm in mandible according to Nance; 2.6 mm in maxilla, 6.2 mm in mandible according to Lo and Moyers. Direction of eruption of first permanent molars: It varies in the maxilla and mandible. In mandible, the first permanent molar continues to erupt in a mesial and lingual direction until it comes in contact with the distal surface of the primary second molar and then erupts into the oral cavity against it. In maxilla, the direction of eruption of first permanent molar initially is buccal and distal until it comes in contact with the buccal tissues, then swings mesially until it



comes in contact with the distal surface of the primary second molar and erupts into occlusion. Primary second molar vs permanent first molar: The occlusion of the first permanent molars depends on the primary second molar relationship and whether the dentition is spaced resulting in shift of teeth or minimal growth differential or forward growth of mandible. Factors affecting the establishment of normal posterior occlusion: • Extensive interproximal caries • Premature extraction of primary teeth before the eruption of first permanent molars • Ectopic eruption of maxillary first molars • The above conditions lead to reduction in arch length, crowding and abnormal molar relationship. Self-correcting anomalies: Self-correcting anomalies are grouped as transient malocclusion. These are not true malocclusions but mimic malocclusion during the normal development of dentition and occlusion. They do not need any corrective measures, but get corrected themselves as they pass through the developmental stages They are as given in Table 6.1. Table 6.1 Self-correcting anomalies Stage of Self-correcting development anomaly Gum pads



Correction will occur due to



(a) Retrognathic mandible



(a) Differential and forward growth of the mandible



(b) Anterior open bite



(b) Eruption of primary incisors



(c) Infantile swallow



(c) Weaning of liquid to solid food



Primary dentition



(a) Anterior deep bite (b) Straight terminal plane occlusion



Mixed dentition



(a) Eruption of primary molars, attrition of incisal edges and forward and downward growth of mandible (b) Early mesial shift



(c) Primary spacing



(c) Eruption of permanent teeth



(a) Mandibular anterior crowding



(a) Secondary spacing, intercanine width increase, tongue pressure (b) Maxillary canine eruption



(b) Ugly duckling stage



(c) Late mesial shift



(c) End-on relation of first permanent molar Permanent dentition



Overjet and overbite Eruption of all permanent teeth and differential growth of mandible



Permanent Dentition Stage Permanent occlusion is said to be ideal, if the following six keys philosophy by Andrews is followed. 1. Proper molar relationship: The distal surface of the distobuccal cusp of the upper first permanent molar occludes with the mesial surface of the mesiobuccal cusp of the lower second permanent molar. 2. Proper crown angulation (mesiodistal tip): The gingival portion of each crown is distal to the incisal portion and varies with each tooth type. 3. Proper crown inclination (labiolingual, buccolingual): Anterior teeth (incisors) are at a sufficient angulation to prevent over eruption. Upper posterior teeth — lingual tip is constant and similar



from 3 to 5 and increased in the molars. Lower posterior teeth — lingual tip increases progressively from the canines to the molar. 4. No rotations. 5. Tight contacts. 6. Flat occlusal plane. The permanent teeth occlusion is observed for the proper anterior and posterior teeth relationship. Overjet and overbite of incisors, canine relationship which can be class I, II, or III and permanent molar relationship which can be again Class I, II or III.



CONCLUSION The process of development of occlusion from infancy through adolescence is a continuous and dynamic process. Many events occur during this phase and proper diagnosis and intervention can lead to prevention of malalignment. The changes that occur during this phase may progress normally within acceptable ranges of variation or they may be adversely affected by deleterious environmental influences. With well established early orthodontic procedures, the severity of malalignment can be reduced to a great extent. Establishment of a functional and esthetically acceptable adult occlusion, which is a major goal of children dentistry, can be achieved with intelligent interpretation of problems encountered during this phase and correcting it.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Self-correcting anomalies or transient malocclusion. 2. Enumerate different developmental anomalies at different histophysiological stages of tooth development.



Short Notes 1. Natal and neonatal teeth 2. Ugly duckling stage 3. Early and late mesial shift 4. Leeway space of Nance 5. Gum pads 6. Epstein’s pearls and Bohn’s nodules 7. Terminal plane relationship 8. Spacing in primary dentition 9. Primate spaces 10. Eruption of teeth 11. Shedding of teeth 12. Andrew’s six keys of occlusion 13. Secondary spacing 14. Incisal liability 15. Canine relationship 16. Clinical problems during eruption of teeth 17. Gum pads



SUGGESTED READING 1. Berkovitz BK. How teeth erupt. Dent Update 206–210, 1990. 2. Graber, TM, Vanarsdall, RL, Jr., Vig, KWL. Orthodontics: Current Principles and Techniques, 4th edn. St Louis: Mosby; 2005. 3. Logan, WHG, Kronfeld, R. Development of the human jaws and surrounding structures from birth to the age of fifteen years. J Am Dent Assoc. 1933; 20(3):379–427.



4. Mathewson, RJ, Primosch, RE. Fundamentals of Pediatric Dentistry, 3rd edn. Chicago: Quintessence; 1995. 5. McIntyre, GT, McIntyre, GM. Teething troubles. British Dent J. 2002; 192(5):251–255. 6. Moyers, RE. Handbook of Orthodontics, 4th edn. St Louis: Mosby; 1988. 7. Proceedings of the International Meeting on Signaling Mechanisms in Dentin Development, Regeneration, and Repair: from Bench to Clinic November 10–11, 2000. Thessaloniki, Greece: Advances in Dental Research; 2001. 8. Sharpe, PT. Homeobox genes and orofacial development. Connect Tissue Res. 1995; 32:17– 25. 9. Sharpe, PT. Neural crest and tooth morphogenesis. Adv Dent Res. 2001; 15:4–7. 10. Stewart RE, Barber TK, Troutman KC, Wei SHY, eds. Pediatric Dentistry: Scientific Foundations and Clinical Practice. Mosby: St. Louis, 1982 87–134. 11. Ten Cate, AR, Oral histology: Development, structure and function 5th ed. Mosby Company, 1998. 268–285. 12. The Handbook of Pediatric Dentistry: American Academy of Pediatric Dentistry, 1999.



13. Tracy, WE, et al. Analysis of dentin pathogenesis in vitamin D resistant rickets. Oral Surg. 1971; 32:38.



SECTION III



Psychology, Behavior and Behavior Guidance OUTLINE Chapter 7: Child Psychology Chapter 8: Behavior Guidance Chapter 9: Pharmacological Behavior Management



CHAPTER 7



Child Psychology N Sivakumar and MS Muthu



CHAPTER OUTLINE Introduction Freud’s Psychodynamic Theory Erikson’s Psychosocial Theory Jean Piaget’s Cognitive Theory Classical Conditioning Operant Conditioning Observational Learning Separation–Individuation Theory Theory of Hierarchy of Needs Anxiety and Fear Mental and Emotional Development (Maturation) with Age and Fears Stone and Church Classification of Child Development Suggested Reading Self-assessment Questions



“It is with children that we have the best chance of studying the development of logical knowledge, mathematical knowledge, physical knowledge, and so forth.” —Jean Piaget



Introduction Child psychology is the science that deals with the study of child’s mind and its functions. It is also defined as the science that deals with the mental power or the interaction between the conscious and subconscious elements in a child. Guidance of a child’s behavior in the dental office is an essential prerequisite to complete dental care. The concept of treating the patient with a dental problem, not just the tooth should be operative with all the patients, more so with children. Mistakes made by the dentists are often hidden by the stoic nature of the adult patient or by subsequent failure of the patient to return. The effects of mistakes made with child dental patients have to be faced immediately and also when the child has to return unwillingly or forcibly with the parent in the subsequent visits. An important aspect of treating the child patient, which is different from treating adult, is the intimate involvement of the parent in the relationship, which completes the pedodontic treatment triangle (Fig. 7.1) that includes the dentist, the child patient and the parent.



FIGURE 7.1 Pedodontic treatment triangle (GZ Wright, 1975).



Child is at the apex of the triangle indicating the importance of child in pediatric dentistry. The arrows on the triangle indicate communication in both the directions, e.g. child to dentist or dentist to child. Since many of the child’s attitudes towards society, likewise towards dental care are learned from parents, it is necessary to educate the parents in making the dental experience for the child a favorable one. Recently society is added to the center of the triangle as the child management strategies we employ should be acceptable to the society.



Importance of Child Psychology • Know the child patients better



• Understand the behavior problems psychologically • Deliver dental services in a meaningful and effective way • Establish effective communication and gain the confidence of the child and the parent • Produce a comfortable environment for the dental team to work on the patient • Teach the parent and the child, the importance of primary and preventive care



To treat a child successfully or to manage a child in a dental setting, one should have sufficient knowledge on psychological development, personality development and development of anxiety and fear at different stages of childhood. There are different theories on psychology which have an application in pediatric dentistry (Box 7.1). Box 7.1



Theories on psychology for



pediatric dentistry Theories on emotional development • Psychoanalytic theory or psychosexual theory by Sigmund Freud • Psychosocial theory or Erikson’s model of personality development Theory on cognitive development • Cognitive development theory by Jean Piaget Theories on learning and development of behavior • Classical conditioning by Ivan Pavlov



• Operant conditioning by BF Skinner • Observational learning (modeling) by Albert Bandura Other relevant theories • Separation-individuation theory of child development by Margaret S Mahler • Theory of hierarchy of needs by Abraham Maslow



The following topics are also discussed in this chapter: • Anxiety and fear in children • Mental and emotional development with age • Stone and Church’s classification of child development.



Freud’s Psychodynamic Theory According to Freud, what humans do, why they do it, what and how humans are largely determined during the first few years of life during which the person develops characteristic ways of dealing with internal (sexual) drives and conflicts. Differences in personality originate from difference in childhood sexual experiences.



Structure of Personality The structure of personality is composed of three mental structures (Figs. 7.2, 7.3), the id, the ego and the superego. What a person thinks, feels and does is a function of the actions and interactions of these three hypothetical structures called psychic triad, each of these structures developing at a different time.



FIGURE 7.2 Mental structures of personality.



FIGURE 7.3 Iceberg phenomenon explaining id, ego and superego.



Id (instinctual drives) The id is that portion of the mind that contains the unconscious drives for pleasure and destruction. The id strives for immediate satisfaction of its drives. There are two ways by which the id tries to achieve reduction of tension. They are: 1. Reflex action 2. Primary process thinking Reflex action: It is a simple response that occurs reflexively to stimulus (hunger) in the environment, e.g. child’s sucking on a nipple



which reduces tension and quietens the aroused and unhappy child. Primary process thinking: It is creation of a fantasy about an object or behavior to reduce tension and satisfy the id’s drives, e.g. the child might fantasize about nursing in order to partially reduce tension of hunger. Hence the id can be defined as “the inherited reservoir of unorganized drives, is mostly unconscious, is governed by the pleasure-pain principle, aims at immediate satisfaction of libidinal urges, is immoral, is illogical and lacks unity of purpose”.



Ego Primary process thinking alone cannot ensure the survival of the child. Imagination of feeding is pleasurable, but it does not satisfy nutritional requirements. This is the time when this second mental structure ego develops. The ego is the conscious and reality-oriented portion of the mind. It is conscious of what happens in the child’s world by perceiving the difference between the child and the external environment. It is also responsible for the child’s capacity for self-awareness. It helps the id to obtain real rather than imaginary satisfaction. It follows the reality principle rather than the pleasure principle. To follow the reality principle, the ego uses the secondary process thinking or realistic thinking rather than simple fantasy or primary process thinking. Although it is more realistic than the id, the ego derives all its energy from the unconscious drives of the id and exists only to find the effective ways of satisfying those drives. Hence, ego can be defined as the integrating or mediating part of personality, which develops out of interaction of id and environment. It has perception of both the internal and the external world.



Superego The superego develops during the phallic period. It contains moral principles and values that have been acquired from the child’s parents



and society. It has also been termed as the policeman of the three, monitoring the ‘right’ and ‘wrong’. It contains two subparts: 1. Conscience 2. Ego ideal Conscience: It contains moral prohibitions against certain behaviors, especially those expressing the sexual and aggressive drives of the id. Ego ideal: It is the image of what one ideally can be and how one ought to behave. Hence superego can be defined as the internal part of the individual that makes value judgments. It acts as the individual’s conscience and is idealistic. To understand the psychic triad, the author uses the following example in his lectures, Let us imagine a situation of an examination hall where a group of students are writing an exam. The examination is monitored by an invigilator. One of the students is planning to copy (from a piece of paper which he brought inside the hall) without the knowledge of the invigilator. In this situation: The ‘Id’ says go ahead and copy. Don’t bother about anything. Id simply wants its desire to be fulfilled (working on ‘pleasure principle’, wants immediate gratification of desires). Ego comes into action and checks whether the invigilator is watching. Ego says whenever the invigilator is not watching; you can copy from the paper. But don’t copy when he is watching (working on the reality principle, carefully fulfilling id’s impulses) so that you will not be caught for copying. But the ‘superego’ says ‘don’t copy’. It is wrong to copy during an examination (moral values, acts as a policeman). Eventually what happens is which component of the personality overrides the situation. Id wins if the student copies during the examination. Superego wins if he realizes that copying during examination is incorrect. This kind of interaction between id, ego and superego continues to



take place in a child’s and everybody’s life everyday. What we choose to be depends on various influences and the circumstances we are in.



Erogenous Zones Freud believed that at different ages of life, human beings feel tension most intensely in different areas of body. These areas require pleasure-producing stimulation to reduce or eliminate the tension. These areas are termed as erogenous zones.



Concept of Fixation The desires of the id changes from age to age. However, some individuals never lose their desire of a particular kind of gratification, such as oral stimulation. This is called fixation. Fixation thus is a failure of the development in which the individual continues to seek a particular kind of gratification even after he/she has passed through the stage in which that kind of pleasure is normally sought. Cause of fixation: When a child is extremely frustrated in the pursuit of pleasure or overgratified by it, the person becomes continuously concerned with obtaining that pleasure.



Development of Personality Freud divided the development of personality into five stages: 1. The oral stage (birth to 18 months) 2. The anal stage (18 months to 3 or 4 years) 3. The phallic stage (3 or 4 to 6 years) 4. The latency stage (6 to 11 years) 5. The genital stage (11 years onwards)



Oral stage



During the first 18 months of life, mouth is the most sensitive zone. The mouth experiences the most tension and requires the tension reducing stimulation. Nursing — eating, as well as mouth movement, includes biting, sucking, even on thumb or pacifier or keeping objects in the mouth is the means by which the tension in and around the mouth is reduced. Care related to feeding from parents is important in this stage. Either insufficient or forceful feeding can result in fixation in this stage. Symptoms of oral fixation: The symptoms of oral fixation are smoking, drinking, chewing habits of gums, pens, pencils, etc., nailbiting, overeating, sarcasm (the biting personality) and verbal hostility. Abundant oral stimulation may result in an oral passive individual. Symptoms are: 1. Complete dependency on others 2. Not taking any initiative on their own 3. Having a very laid back attitude 4. In the habit of procrastinating Lack of oral stimulation may result in an oral aggressive individual who is characterized by being envious, jealous, aggressive in relationships, tries to grab all the time and often exploits others.



Anal stage The child enters the anal stage around 18 months of age, when the locus of gratification shifts to the anal region, either from movement or withholding the movement of the bowels. They also discover their ability to control such movements. This is the age of toilet training and parents want to control when, where and how to eliminate the feces. A child’s pleasure in retaining or eliminating feces at his/her choice of time and place can lead to conflict with parents. Symptoms of anal fixation: Anal expulsive personality shows excessive sloppiness, disorganized, reckless, careless and defiant behavior. They may also be vain, pompous and conceited. Anal



retentive personality shows obsessively cleanly and orderliness and intolerance of those who are not clean and orderly. They also are meticulous in everything they do and can be miserly withholding, obstinate, conforming and passively aggressive. They may from time to time display behavior that may be described as being selfish and self-centred.



Phallic stage At about the age of 3 to 4 years, the child enters phallic stage during which the genitals become the most sensitive area, and the child derives pleasure by manipulating them. Again development conflicts with parents as they try to curb this behavior. Oedipus and Electra complexes mark this stage. This is probably the most challenging stage in a person’s psychosexual development. Freud proposed that children develop a feeling of attraction towards the parent of the opposite sex and a related wish, to eliminate the parent of the opposite sex, whom they envy and fear as they stand as a rival for the affection of the opposite sex parent. In boys, this situation is called the Oedipus complex, named after the young man in a Greek myth who killed his father and married his mother, unaware of their true identities. In girls, it is called the Electra complex. Boys, in the midst of their Oedipus complex, often experience intense castration anxiety, that comes from the fear of punishment from the fathers for their desire for the mothers. Girls’ Electra complex involves penis envy. That is, according to Freud, the girl believes that she once had a penis but that it was removed. In order to compensate for its loss, the girl wants to have a child by her father. The ego fears the consequences of expressing them and realizes that these drives cannot be satisfied directly. The child who successfully resolves this conflict learns to control envy and hostility and begins to identify with and model after the parent of the same sex, through which the ego obtains partial satisfaction. Boys try to imitate the father; girls try to imitate the mother. This process is known as identification. The specific aspect of identification with parents is



adopting their values and morals. This forms the third part of the personality, the superego. When the oedipal conflict is resolved and superego is formed, the child is ready to move into the next developmental stage. Symptoms of phallic fixation: Weak or confused sexual identity (may be considered the root cause of homosexuality) may also be afraid of or incapable of close love or intimacy. For males, anxiety and guilty about sex, fear of castration, and narcissism or selfishness. For females, sense of envy and inferiority.



Latency stage This period extends through late childhood to puberty. Children may learn about the social environment around them, other people, culture, values and their own skills, capacities and interests. There is little pressure from the id and little internal conflict and this latency lasts for 5–6 years, till puberty upon which they become capable of reproduction and the sexuality is reawakened.



Genital stage When the young person reaches puberty or sexual maturation, he or she enters the genital stage during which the person feels strong and adult sexual interests and desires for the first time. This may also be a renewal of old oedipal sexual and aggressive feelings. This stage does not cause any fixation. According to Freud, if people experience difficulties at this stage, it will be due to the damage from the earlier oral, anal and phallic stages. These people come into this last stage of development with fixations from earlier stages. For example, attractions to the opposite sex can be a source of anxiety at this stage if the person has not successfully resolved the Oedipal (or Electra) conflict at the phallic stage. From this point on the ego has to work hard to balance the demands of the id for sexual gratification with the conscience and ego ideal of superego. The adult’s personality reflects how well the ego manages to do this.



Erikson’s Psychosocial Theory or Theory of Personality Development According to Erik Erikson, there are eight (psychological) stages (Fig. 7.4) in the human life cycle, sequence of which is set by the nature. The first five stages are extended from birth through adolescence (Table 7.1). Stages 6 to 8 are young adult, adult and late adult which are not related to pediatric dentistry and hence are not discussed in this textbook. Each stage is characterized by a different psychological ‘crisis’, which should be resolved by the individual before the individual can move on to the next stage. These stages are: Table 7.1 Erikson’s stages of psychosocial development (birth to adolescence) Stage



Psychosocial crisis



Significant social relationships



Favorable outcome



First year



Basic trust vs mistrust



Mother or mother’s substitute



Trust and optimism



2 to 3 years



Autonomy vs shame and doubt



Parents



A sense of self-control and adequacy



4 to 6 years



Initiative vs guilt



Basic family



Purpose and direction, ability to initiate one’s activities



6 to 11 years Industry vs inferiority



Neighborhood, school



Competition in intellectual, social and physical skills



Adolescence Identity vs role confusion



Peer groups and out groups, models of leadership



An integrated image of oneself as unique person



FIGURE 7.4 Erikson’s psychosocial stages.



SUMMARY 1. Development of basic trust (birth to 18 months): Basic trust vs mistrust – oral sensory stage 2. Development of autonomy (18 months to 3 years): Autonomy vs shame and doubt – muscular anal stage 3. Development of initiative (3 to 6 years): Initiative vs guilt – locomotor genital stage 4. Mastery of skills (6 to 11 years): Industry vs inferiority – latency stage 5. Development of personal identity (12 to 17 years): Identity vs role confusion – adolescence stage



Oral Sensory Stage (Basic Trust vs Mistrust) This stage corresponds to the oral stage of Freud or infancy. The psychosocial crisis in this period involves basic trust at one extreme and mistrust at the other. Infants depend on parents or caretakers for food, warmth or affection and trust them for it. The infant’s needs should be met as and when they arise and discomforts removed promptly. If this is done and the infants are cuddled, fondled, played with and talked to with consistence in care, they develop a sense of trust towards the world as a safe place and towards people as helpful and dependable. The caretaker should know whether the child is crying because of



hunger or any other reason and should refrain from using feeding as answer whenever the child cries. For example, if the child is uncomfortable in wet nappy, it should be changed. However, if the care is inconsistent, inadequate and rejecting, a basic mistrust is fostered. Fear and suspicion develops towards the world in general and people in particular which continues through later stages of development. The basic fear of this stage is fear of abandonment. The tight bond between parent and the child in this early stage of emotional development is reflected in a strong sense of separation anxiety in the child when separated from the parent. Dental treatment at an early age is preferably done in the parent’s presence and if possible while the child is being held by one of the parents. At later ages, a child who never developed a sense of basic trust is likely to be an extremely frightened and uncooperative patient who needs special effort to establish trust and rapport with the dentist and staff.



Muscular Anal Stage (Autonomy vs Shame or Doubt) This stage corresponds to the anal stage of Freud or toddler stage. The emerging autonomy (independence) builds on the child’s motor and mental abilities. The child takes pride (I am! Look at me) in new accomplishments and wants to do everything for him as he learns to eat, walk, talk, use the toilet, etc. If the parents recognize the young child’s capabilities, allow him to develop at his own pace and reassure when he makes mistakes, then a sense of self-control of muscles, impulses and the environment is developed, which will contribute to the confidence needed to cope with future situations that require choice, control and independence. However, when the caretakers are overprotective or impatient and do everything for the child, they reinforce a sense of shame and doubt. Rushing the child occasionally is not a problem but when caretaking is continuously overprotective and criticism of accidents (wetting, soiling, spilling or breaking) is harsh the child develops an excessive



sense of doubt in his or her abilities to control the world and the self. The child who passes through this stage with a sense of autonomy is well prepared to be autonomous in later stages of life. Principal anxiety or fear of this period is fear of loss of love and fear of separation. To obtain cooperation from the patient is to have the child to think that whatever the dentist wants to do was his or her own choice. For a 2-year-old seeking autonomy, it is all right to say “open your mouth if you want to” but it is almost unacceptable for the dentist to do it. Hence, it is better to offer the child reasonable choices whenever possible. A child who is afraid of the situation will be unwilling for separation from parent. Simple procedures also should be done in presence of the parent. Complex procedures may require sedation or general anesthesia.



Locomotor Genital Stage (Initiative vs Guilt) This stage corresponds to the phallic stage of Freud. The child can initiate motor activities and no longer merely responds to or imitates the other children. He/she will have a sense of taking risks as safe behavior and say “I will try”. It holds true for language and motor activities. He/she now must learn achieving a balance between the eagerness for adventure and responsibility and learning to control impulses and childhood fantasies. Whether the child leaves this stage with a sense of initiative or guilt depends on how the parents respond to self-initiated activities. If parents are encouraging, but consistent in discipline, children will learn to accept without guilt, that certain things are not allowed, but at the same time will not feel shame when using their imagination and engaging in fantasy. Initiative is also reinforced when parents answer their questions (intellectual initiative). On the other hand, if the child is made to feel that certain activity is bad, that the questions are a nuisance and that the play is silly and stupid, then the child may develop a sense of guilt over self-initiated activities in general. The primary fear of this stage is fear of bodily injury. For most children, the first visit to the dentist comes during this stage of



initiative. Visit to the dentist should be constructed as an adventure in which the child can experience success. Success in coping with the anxiety of visiting the dentist can help develop a greater sense of accomplishment. On the other hand, if the child is poorly managed, the dental visit can result in a sense of guilt that accompanies failure. Initial appointment with parental presence and with little treatment is important in getting the dental experience a good start. After the initial experience, the child at this stage can usually tolerate being separated from the parent for the treatment and is likely to behave better, so that the independence rather than the dependence is reinforced. The child at this stage is curious about the surroundings, e.g. the dental office and wants to learn about the things found there.



Latency Stage (Industry vs Inferiority) This stage corresponds to the latency period of Freud or elementary and middle school years (6 to 11 years). Children develop feelings that they can make things, use tools and acquire skills and a sense of “I am capable.” This is a period of shift from home to peer groups. Capabilities in this period are pleasure in intellectual stimulation, seeking success, deductive reasoning, playing take-turn games and obedience to rules that are required for the above games. When the children are encouraged and allowed to finish the efforts to make, do or build practical things and are praised and rewarded for the results, a sense of industry and competence is enhanced. If the parents see the efforts of the children in making and doing things as ‘mischief or making a mess’, it will develop a sense of inferiority in the children’s minds. Also constant failure at academic level leads to inferiority. Principal anxiety of this stage is superego anxiety created by the child’s own internal standards. Behavioral guidance is done in this stage by clearly outlining the child, what to do or how to behave and then reinforcing it positively. Because of the child’s drive for a sense of industry and accomplishment, cooperation with treatment can be obtained. They like to get attention of the peer groups and motivated by the facts that can be noticed by the peers, e.g. improved



appearance by dental treatment rather than properly aligned teeth or chewing efficiency.



Adolescence Stage (Identity vs Role Confusion) This stage corresponds to the genital stages of Freud, i.e. adolescence, spanning from 12 to 18 years. According to Erikson, adolescent integrates the healthy resolutions of all the previous conflicts. Those who have dealt the previous stages positively are ready for the ‘identity crisis’ of this stage which is the single most significant conflict. Maturation is seen mentally as well as physiologically. They are ready to plan for their future. They experience new ways of looking at and thinking about the world. Adolescents become capable of constructing theories and philosophies designed to bring all the varied and conflicting aspects of society into a working, harmonious and peaceful whole. In a single word, the adolescent is an impatient idealist who believes that it is as easy to realize an ideal, as it is to imagine it. Erikson believes that the new interpersonal dimension that emerges during this period has to do with a sense of ego identity at the positive end and a sense of role confusion at the negative end in which the adolescent is unable to make decisions and choices, especially about vocation, sexual orientation and his role in life and society in general. The authority of the parents and others is usually rejected in this stage for establishing one’s own identity and members of the peer group become important role models. At the same time, some separation from the peer group is necessary to establish one’s own uniqueness and value. The inability to separate can lead to a poor sense of direction for the future, confusion regarding one’s place in society and low self-esteem. A typical adolescent feels that the health problems are concerns of somebody else and neglects his own health concerns.



Jean Piaget’s Cognitive Theory (Fig. 7.5)



Cognitive development involves changes in cognitive processes and abilities. Cognition refers to knowing and understanding. This involves the following key concepts:



FIGURE 7.5 Piaget’s cognitive stages.



• Schemas • Assimilation • Accommodation • Equilibration



Schemas A schema describes both the mental and physical actions involved in knowing and understanding. Schemas are categories of knowledge that help us to interpret and understand the world. According to Piaget, schema includes both a category of knowledge and the process of obtaining that knowledge. With experience, the new information is used to modify, add to or change previously existing schemas. For example, a child may have a schema about a type of animal, such as a cow. If the child’s sole experience has been with white cows, a child might believe that all cows are white and have four legs. Suppose when the child encounters a black cow, the child will take in this new information, modifying the



previously existing schema to include this new information.



Assimilation The process of taking in new information into the previously existing schemas is known as assimilation. The process is somewhat subjective, because we tend to modify experience or information to fit in with our pre-existing beliefs. As mentioned above, seeing a white cow and labeling it as ‘cow’ is an example of assimilating the animal into the child’s cow schema.



Accommodation Another part of adaptation involves changing or altering our existing schemas in light of new information, which is known as accommodation. Accommodation involves altering existing schemas or ideas as a result of new information or new experiences. New schemas may also be developed during this process. In the example given above, seeing at black cow and accepting it into the cow schema is an example of accommodation. In brief, assimilation means the utilization of the external environment by the subject to integrate knowledge into the prior internal structures. Accommodation means modification of prior knowledge structure when properties of the environment do not fit into the internal structures.



Equilibration Piaget believed that children try to balance between assimilation and accommodation, which is achieved through a mechanism called equilibration. As children progress through the stages of cognitive development, it is important to maintain a balance between applying previous knowledge (assimilation) and changing behavior to account for new knowledge (accommodation). Equilibration helps explain how children are able to move from one stage of thought into the next. According to Piaget, there are four distinctive periods of cognitive development (Fig. 7.5) under two broad categories:



1. Sensorimotor period (18 months to 2 years) 2. Period of conceptual intelligence (2 years and above) a. Preoperational period (2 to 7 years) i. Preconceptual stage (2 to 4 years) ii. Intuitive stage (4 to 7 years) b. Period of concrete operations (7 to 11 years) c. Period of formal operations (11 years and beyond)



Sensorimotor Period It lasts from birth to approximately 2 years of age. Object permanence, primitive beginning of symbolic thought and animism are the hallmarks of this stage. During this stage, infants understand their environment by physically manipulating the world around them. Children utilize the skills and abilities they were born with, such as looking, sucking, grasping and listening and learn literally by pushing, banging and poking at things. Piaget recommended that this physical exploration of the environment is cognitively productive and not just aimless play. Knowledge of the world is limited to sensory perceptions and motor activities. Behavior is limited to simple motor responses to sensory stimuli. Frequent interaction with objects leads eventually to the development of object permanence (Fig. 7.6), the concept notion that an object continues to exist even after it disappears from view. During second year, children are capable of discovering a hidden object even after it has been removed from one hiding place to another.



FIGURE 7.6 Concept of object permanence (sensorimotor period).



Symbolic thought is developed towards the end of this stage, which is the capacity to construct a mental representation of an object–a symbol, pretending that one object is another, e.g. a spoon for a racing car. Animism is imparting life to inanimate objects, like furniture, wall and floor or doors, etc. and if the child gets hurt by those objects, the child will feel happy by hitting them or if the caretaker or parent hits them.



Period of Conceptual intelligence Period of conceptual intelligence starts from 2 years of age that includes preoperational stage, period of concrete operations and the period of formal operations.



Preoperational period By the end of sensorimotor period, the 2-year-old child is not surprised by any of the events around him. Animism and symbolic thought are seen. Most children can remember past events, engage in imaginary play and begin to use language effectively. But young children still demonstrate thought processes that are dramatically different than those of the adults, they do not understand concrete logic and cannot mentally manipulate information. Egocentrism, centration, irreversibility and lack of conservation are the hallmarks of this stage. Conservation is Piaget’s term for the awareness that physical quantities remain constant in spite of their changes in their shape or appearance. In the early stages of conceptual intelligence (2 to 7 years), the child’s world is ego centered or has limited ability to share another person’s viewpoint—egocentrism. His view of the world is animistic or artificialistic and he cannot distinguish what is real from what is not real. The description of pain presented by the child during this stage reflects the developmental level. He may, for example, feel that the dentist or the assistant is the cause of



the pain because that person was present at the time of painful experience. Another example is, if he hurts himself by bumping against a door, he may hit the door as he feels that it gets hurt or will be happy if the caretaker or parent slams at the door. Animism means ‘imparting life to inanimate objects’. A 2 to 7-year-old child’s thought is also centered only on one salient aspect of the problem or one feature of a multifaceted experience is emphasized in the child’s perception, which is known as centration. For instance, a 3-year-old child may identify a series of pictures as cow, if each of the animals has horns like cow and, in fact, that is what the child has centered on in his recognition of a cow. A child can center on a salient aspect of a dental appointment. Obviously, centering on painless things like ‘counting the teeth’ or ‘cleansing the teeth’ is better than centering on painful things like tooth extractions, needles, etc. A 5-year-old child may think that a sandwich cut into four pieces contains more to eat than the same sandwich cut into two pieces. There are definite limitations to preoperational child’s reasoning skills. When a child is shown equal amount of water in two beakers and each one is poured into two glasses, of which one is short and wide, the other is narrow and taller the preoperational child thinks that the taller glass contains more water even if he is shown that the same quantity is being poured in both (Fig. 7.7). They are influenced by what they see. Because the water level is higher in the tall glass, it must contain more water. This is termed as lack of conservation.



FIGURE 7.7 Concept of conservation (concrete operational period).



Another aspect of this stage is irreversibility, which is the inability to envision reversing an action. They cannot think about what will happen if the water were to be poured back from the glasses into the original beaker.



Concrete operational period (Fig. 7.7) A 7-year-old child becomes capable of logical reasoning (use of inductive logic not deductive logic), the period during which the child begins to understand logical concepts. The child no longer makes judgments solely on the basis of how things appear. They develop the qualities of reversibility and decentration. But there are limitations in child’s reasoning in the concrete operational period. Children reason logically when the problem is displayed before them. In the presence of objects that can be viewed and sometimes manipulated, they demonstrate a practical, concrete form of intelligence. The child’s thinking is more stable and reasonable, and he can understand many relationships with the cause and effect. With his knowledge he can understand that specific procedures caused pain. At the end of this stage and the beginning of the formal operational period, a child is able to express his pain like an adult would.



Formal operational period (Fig. 7.8)



People acquire new reasoning skills or formal operational thinking. The essence of thought is to reason hypothetically, to consider beforehand all the possible solutions to a problem. Unlike concrete operational child, formal operational child can reason about what could be as well as what actually is. Skills such as logical thought (deductive logic), deductive reasoning and systematic planning also emerge during this stage. The thinking will be abstract, systematic, logical and reflective. Instead of solely relying on past experiences, they begin to consider possible outcomes and consequences of actions. This type of thinking is important in long-term planning.



FIGURE 7.8 Classical conditioning by Ivan Pavlov.



The adolescents feel that they are constantly ‘in stage’, being observed and criticized by those around them. This phenomenon has been called the ‘imaginary audience’ by David Elkind. The imaginary audience has powerful influence on young adolescents, making them quite self-conscious and particularly susceptible to peer influences. The notion that ‘others care about my appearance and feelings as much as I do’ leads adolescents to think that they are unique, special individuals. As a result of this thought, a second phenomenon



emerges called the ‘personal fable’ by Elkind. This concept holds that because I’m unique, I’m not subject to consequences others will experience. The personal fable is a powerful motivator that allows us to cope in a dangerous world. Both these factors can also result in a dysfunctional behavior and foolhardy risk taking. At the beginning of the formal operational period, a child is able to express his feelings of pain like an adult would.



Classical Conditioning by Ivan Pavlov (1903) “Next time there’s a revolution, get up earlier.” —Ivan Pavlov Learning that results from association or pairing of two stimuli in the environment is referred to as learning by association or classical conditioning. Classical conditioning is a type of learning in which a stimulus acquires the capacity to evoke a response that was originally evoked by another stimulus (Fig. 7.8). Presentation of food to a hungry animal along with some other stimulus like ringing a bell is done repeatedly. Auditory stimulus of ringing the bell will become associated with the food presentation stimulus. The unconditioned stimulus is a stimulus that evokes an unconditioned response without previous conditioning. The unconditioned response is an unlearned reaction to an unconditioned stimulus that occurs without previous conditioning. Unconditioned means unlearned, untaught, pre-existing and this connection was already present before we started messing around with the hungry animal or the child or the spouse. The conditioned stimulus is a previously neutral stimulus that has, through conditioning, acquired the capacity to evoke a conditioned response. Presentation of food is unconditioned stimulus (unconditioned means



unlearned) and salivation is the unconditioned response. Here ringing of bell is the neutral stimulus. Over a period of time, neutral stimulus of ringing of bell will become conditioned stimulus and salivation becomes conditioned response.



Process of Classical Conditioning Classical conditioning will include the following processes of acquisition, generalization, discrimination, extinction and spontaneous recovery. Acquisition: Learning a new response or forming a new response tendency due to conditioning. Generalization: Stimuli similar to the original conditioned stimulus also evoke a conditioned response. Discrimination: Learning to discriminate or learning to respond to only certain stimuli but not to respond to others. Extinction: The conditioned response gradually disappears when the unconditioned stimulus is removed. Spontaneous recovery: The reappearance of an extinguished response after a period of nonexposure to the extinguished stimulus.



Example of classical conditioning White coats, hospital atmosphere, etc. (neutral stimuli—(NS) associated with pain, fear (unconditioned response) producing procedures (unconditioned stimulus) will produce fear (conditioned response) in future, even when not associated with original unconditioned stimulus. Here, the ‘neutral stimulus will become conditioned stimulus’. With repetition, there will be reinforcement of the unconditioned response (fear).



Treatment techniques based on classical conditioning Counterconditioning — reducing a conditioned response (e.g. anxiety) by establishing an incompatible response (relaxation) to the same



conditioned stimulus (e. g. an injection). Wolpe developed a treatment program for anxiety that was based on the principles of counterconditioning. Anxiety symptoms could be reduced (or inhibited) when the stimuli to the anxiety were presented in a graded order and systematically paired with a relaxation response —systematic desensitization.



Operant Conditioning by BF Skinner “Operant conditioning shapes behavior as a sculptor shapes a lump of clay.” —BF Skinner The term “Operant” refers to the notion that humans learn from operating on their environment. We behave, then note the consequences and use them to modulate future behavior. Operant conditioning involves exploratory or goal-seeking actions and their consequences. It is also known as ‘instrumental conditioning’. In 1930s, Skinner believed that an organism ‘operates’ on the environment instead of simply reacting to stimuli and encounters a special kind of stimulus, called ‘reinforcing stimulus’ or a reinforcer. This special stimulus has the effect of increasing the operant, the behavior occurring just before the reinforcer. Learning that occurs when an organism associates its behavior with the consequences or results of that behavior and the nature of the consequences modifies the organism’s tendency to repeat the behavior in the future. The consequences can be one of the three, i.e. reinforcement, omission or punishment. Reinforcement will increase the probability that the desirable behavior will recur. Omission or punishment will decrease the probability that the undesirable behavior recur. Presentation of a pleasant stimulus to increase the probability of behavior (repetition) is termed as positive reinforcement or reward. Withdrawal of an unpleasant stimulus to increase the probability of



behavior is termed as negative reinforcement or escape. Withdrawal of a pleasant stimulus to decrease the probability of behavior is termed as omission or time out. Presentation of an unpleasant stimulus to decrease the probability of behavior is termed as punishment.



Process of Operant Conditioning The process of operant conditioning includes acquisition and shaping along with extinction, generalization and discrimination mentioned under classical conditioning. Acquisition: This is the formation of a new response tendency. Shaping: This involves reinforcement of the behavior that is increasingly similar to the desired behavior until finally the desired behavior occurs or reinforcement of closer and closer approximation of a desired response. The others are extinction, generalization and discrimination. In pediatric dental practice, it is equally important to reinforce the behavior which is desirable and also not to reinforce those which are not desired. Contingency management (CM), the systematic reinforcement of desired behaviors and the withholding of reinforcement or punishment of undesired behaviors, is an effective strategy of Behavior Management of Children based on Operant Conditioning by Skinner.



Observational Learning by Albert Bandura “Most human behavior is learned by observation through modeling.” —Albert Bandura Acquisition of behavior through imitation of the behavior of others (models) is observational learning. Two distinct changes in



observational learning are acquisition of behavior by observing it and the actual performance of that behavior. Children are capable of acquiring almost any behavior that they observe closely and that is not too complex for them to perform at their level of physical development. Observational learning has two components, viz. acquisition and performance and is governed by four interrelated processes.



Observational learning process The process of observational learning includes four processes namely, attention, retention, reproduction and motivational processes. Attention process: To learn through observation, one must pay attention to another person’s behavior and its consequences so as to repeat the same if required. Retention process: One must store a mental representation of what has been witnessed or observed in their memory. Reproduction process: It is the ability to reproduce the response by converting the stored mental images into overt behavior. Motivational process: One is unlikely to reproduce an observed response unless motivated to do so.



Factors affecting observational learning The following three factors will affect or influence the observational learning process. Acquisition versus performance: Bandura distinguishes between acquisition of a learned response and the performance of that response. He maintains that reinforcement affects which responses are actually performed than which responses are actually acquired. Characteristics of a role model: If they are liked and respected, they are more likely to be imitated, e.g. parents, siblings, peers, favorite cartoon character, film stars, models based on the age of the child. Expected consequences of the behavior: Children observing other people getting rewarded for positive behavior are likely to behave positively. Children observing an older sibling defying and being



punished are less likely to defy. This is otherwise known as vicarious learning. Modeling, a behavior management technique is based on this theory of observational learning by Albert Bandura.



Separation-Individuation Theory by Margaret S Mahler Margaret Mahler assumed that the “psychological birth is not simultaneous to the biological birth.” She observed that disturbed children could work with a therapist and succeeded in a group setting, but that psychotic children need one-on-one help. Her main interest was in normal childhood development, but spent much of her time with psychiatric children and how they arrive at the “self”. Mahler’s theory for the developmental phase is as follows.



Normal autistic phase (birth to 4 weeks) 1. The infant is oblivious to everything. 2. State of half-asleep, half-awake. 3. Major task of this phase is to achieve homeostatic equilibrium with the environment.



Normal symbiotic phase (4 weeks to 5 months) 1. He/ she begins to recognize others in his/her universe, not separate beings, but as extensions to him/herself. 2. Social smile is characteristic (2 to 4 months).



Separation-individuation phase This consists of four subphases that overlap over the next 5 to 36 months. It is during the critical subphases that psyche is shaped and lays the foundation how the individual interprets and responds to



information in his reality. The first 3 years of life are critical in determining personality and mental health. The subphases are: First subphase: Differentiation (5 to 10 months) 1. Process of hatching from autistic shell, i.e. developing alertness, sensorium that reflects cognitive and emotional maturation. 2. Beginning of comparative scanning, i.e. comparing mother with the other. 3. Characteristic anxiety: Stranger anxiety, which involves curiosity and fear (most prevalent around 8 months). Second subphase: Practicing (10 to 16 months) 1. Beginning of this is marked by upright locomotion – child has new perspective and also mood of elation. 2. Mother is used as home base. 3. Characteristic anxiety of this subphase is separation anxiety. Third subphase: Rapprochement (16 to 24 months) 1. Infant is now a toddler, more aware of physical separateness, which dampens the mood of elation. 2. Child tries to bridge the gap between himself and mother, concretely seen as bringing objects to mother. 3. Mother’s efforts to help toddler often not perceived as helpful, temper tantrums are typical – terrible twos. 4. Characteristic event is rapprochement crisis where the child wants to be soothed by the mother yet not able to accept her help. 5. Symbol of rapprochement: Child standing on threshold of door not knowing which way to turn in helpless frustration. 6. Resolution of crisis occurs as the child’s skills improve and the child is able to get gratification from doing things himself.



Fourth subphase: Object constancy (24 to 36 months) 1. Child is able to cope with mother’s absence and engage substitutes. 2. Child begins to feel comfortable even in the mother’s absence by knowing she will return. 3. Gradual internalization of image of mother as reliable and stable. 4. Through increasing verbal skills and better sense of time, child can tolerate delay and endure separations. Disturbances in attachment and problems in separation-individuation may reflect in abnormal infant/ child behavior.



Theory of Hierarchy of Needs by Abraham Maslow (Fig. 7.9)



FIGURE 7.9 Hierarchy of needs by Abraham Maslow.



“What a man can be, he must be.” —Abraham Maslow Abraham Maslow studied successful people rather than people with psychological problems unlike most of the earlier psychologists and determined that almost everyone wants to be happy and loving, but they have definite needs that must be met with before they can act



unselfishly. Most of the earlier psychologists studied people with psychological problems. Abraham Maslow studied successful people and decided that almost everyone wants to be happy and loving, but they have specific needs that must be met with before they can act unselfishly. Humans are motivated by unsatisfied needs and that certain lower needs need to be satisfied before higher needs can be satisfied. Maslow said that most of the people want more than they have. Once a person has met their most basic needs, they then develop higher needs. Maslow said, “as one desire is satisfied, another pops up in its place.” Maslow created a hierarchy of needs as a pyramid with 5 needs. 1. Physiological needs: These are basic needs, such as food and water along with air, sleep, clothing, etc. and must be satisfied before other needs. If they are not fulfilled, people will direct all their energy and resources towards satisfying them. Biological necessities such as food, water, oxygen, sleep, sex, etc. are the important needs because a person would feel sickness, irritation, pain, discomfort, etc. or may even die if they were not fulfilled. 2. Safety needs: Both physical and psychological safeties are necessary to meet these needs. These are protection, stability, pain avoidance, etc. Maslow believed that children need safety more than adults when they feel afraid. Safety needs are mostly psychological in nature which can be safety and security of a home and family. However, if a family is dysfunctional, i.e. with an abusive husband or in-laws, a female cannot move to the next level because she is always worried about her safety. Love and belongingness have to wait until she is no longer wince in fear. Many in our society cry out for law and order because they do not feel safe enough to go for a walk in their neighborhood. 3. Love and belonging needs: These needs are also termed as social needs that include affection, acceptance and inclusion



which are the need to be accepted by and integrated in groups and the need for affection from parents, peers and other loved ones. This is to escape loneliness and isolation, to give and receive love and also for a feeling of belonging. 4. Esteem needs: This includes self-respect and self-esteem which are the needs to be respected, to have self-respect and to respect others. Humans include the need to be competent, to achieve, to be successful and to be open and independent. In addition, esteem needs include the desire to be acknowledged and appreciated for their achievements. 5. Self-actualization needs: Maslow considered that a very small group of people reach a level called self-actualization, where all of their needs are met. Maslow described self-actualization as a person’s finding their ‘passion or mission’. He said, “a musician must make music, an artist must paint and a poet must write”. Many will be confused self-actualization with fame or fortune, but often this is not the same. While rich or famous people might reach self-actualization, many psychologists believe that most people who have reached the highest level of happiness are unknown beyond their circle of family and friends. Civilization develops when people reach a particular level in Maslow’s hierarchy. Once people meet their physiological needs and they feel safe, they begin to develop a culture and an advanced culture or society.



Application of Maslow’s hierarchy of needs theory to pediatric dentistry Similar to the other theories, this may not have a direct bearing on the child’s behavior in pediatric dentistry. The parental psychology and attitudes, according to Maslow is based on the hierarchy and their socioeconomical status might have an influence on the child’s oral and dental health and their behavior in the dental setting.



Anxiety and Fear Anxiety is one of the primary emotions acquired soon after birth. It is a personality trait and is an apprehension, tension or uneasiness that stems from anticipation of danger, the source of which is largely unknown or unrecognized. Fear is an emotional response to a consciously recognized and usually external threat or danger. It is a primitive response developed to protect the individual from harm and self-destruction. There are two types of fear: 1. Objective fear 2. Subjective fear



Objective Fear This type of fear is acquired objectively or produced by direct physical stimulation of the sense organs (seen, felt, smelt or contacted) but not of parental origin, which are disagreeable and unpleasant in nature. Fear from previous unpleasant contact with dentistry or unrelated experiences like repeated hospitalization leading to fear of uniform worn by the dental team or even characteristic smell of hospital or clinic, drugs or chemicals associated with unpleasantness arouse fear.



Subjective Fear This type of fear is based on the feelings and attitudes described to the child by others though the child does not have that experience personally. The subjective fears are imitative, suggestive or imaginative. Suggestive fears are acquired by imitation of observing others. These imitative fears are transmitted while displayed by others (parents) and acquired by the child without being aware of it. They are generally recurrent, deep seated and are difficult to eradicate. Displayed feeling on parent’s face creates more impression than verbal suggestions. Even a tight clenching of the child’s hand in dental



office while undergoing dental treatment creates fear in child’s mind about dental treatment. These fears are also developed through friends and playmates, by reading books and periodicals, watching media and theatre and depend on repetition. Imaginative fears are based on the child’s capacity of imagination; they become more intense with age and mental development.



Value of Fear Fear lowers the threshold of pain so that any pain produced during dental treatment becomes magnified. Fear has safety value when given proper direction and control. As fear producing stimuli can cause actual harm to the child, fear is a protective mechanism for selfprotection. The nature of fear can be utilized to keep the child away from dangerous situation of either social or physical nature. If the child does not fear punishment or parental disfavor, his behavior may make him a threat to society. Proper training of the child by parent should not be in the direction of eradicating fear, but rather in that of channeling it toward dangers that really exist and away from situations where no danger lies. The child should be taught that the dental office is not a place to fear. Dentistry should not be employed as a threat or punishment. Using it in this manner creates fear of dentistry or dentist. On the other hand, if the child has become attached to the dentist, fear of loss of his approval may have some value in motivating the child for dental treatment.



Assessment of Fear and Anxiety in Children There are some scales for assessment of fear and anxiety in children and adolescents which include the following.



Children’s fear survey schedule (CFSS)



The children’s fear survey schedule is used to assess a range of general fears in children. A dental subscale has been devised (CFSSDS) from this, that consists of 15 items rated on a five-point scale, ranging from 1 (not afraid) to 5 (very afraid). These scale scores are calculated by summing up the item scores; the total score may range from 15 to 75. Scores which are above 38 indicate significant dental fear. Both the full-scale and dental subscale are internally consistent. The CFSS-DS has been found to discriminate between children who do or do not display dental fear and/or behavioral problems during dental treatment.



Facial image scale Facial image scale (Fig. 7.10) comprises a row of 5 faces ranging from very happy to very unhappy. The children were asked to point at which face they felt most like at that moment. The scale is scored by giving a value of 1 to the most positive affect face and 5 to the most negative affect face.



FIGURE 7.10 Facial image scale.



Venham’s picture scale (Fig. 7.11) Venham’s picture scale consists of a series of eight-paired drawings of a child. Each pair consists of a child in a non-fearful pose and a fearful pose (i.e. running away). The respondent (child patient) is asked to indicate, for each pair, which picture more accurately reflects his or her feelings at me time. Scores are determined by summing up the number of instances in which the child selects the high-fear stimulus.



Unfortunately, there is not much published information about the reliability and validity of this scale.



FIGURE 7.11 Venham’s picture scale.



Venham’s anxiety and behavior rating scales These two scales assess the anxiety and uncooperative behavior of children in the dental setting. Both scales consist of five behaviorally defined categories ranging from 0 to 5, with higher scores indicating greater levels of anxiety or lack of cooperation. The criteria used to assign the scores are described by Venham and colleagues. Using the method of paired comparisons, they were able to ascertain that the points on the scale can be treated as interval data. A high degree of inter-rater reliability was found for both scales, even for untrained observers.



Adolescents’ fear of dental treatment cognitive inventory This scale measures the thoughts and ideas an adolescent may have during dental treatment. It is unique among the children’s scales in that it focuses solely on the cognitive manifestations of the fear. It is a 23-item scale, with a 5-point response format with scores range from 23 (no fear) to 115 (high fear). The scale has been cited only in its original development study. Despite the advantages of assessing the cognitive dimensions of anxiety, there is insufficient evidence to support the usefulness of this scale.



Behavior profile rating scale Behavior profile rating scale consists of 27 uncooperative behaviors considered to be related to dental anxiety. The behavior of the child in the dental setting is observed for 3-minute intervals throughout the 30-minute consultation and each item is scored, if the behavior occurs at the point of observation. An overall score is calculated on the basis of the frequency of each behavior, together with a weighting for the severity of the behavior (i.e. kicking is perceived to be more severe than oral complaints). The scale has adequate inter-rater reliability, given adequate training of observers. The face validity of the scale is high and it has been found to distinguish between children referred



for behavioral management of uncooperative behavior in the dental setting and a control group of children. As with many behavioral measures, use of this scale is likely to be time consuming.



Mental and Emotional Development (Maturation) with Age and Fears Birth to two years It is the infancy stage corresponding to oral stage of Freud and Erikson’s trust vs mistrust. First form of fear or anxiety is seen in this stage, i.e. fear of strangers other than the immediate family members. Fear developed from the conflict of basic trust vs mistrust also may be seen.



Two-year-old Vocabulary is limited to 12–1000 words. They are in precooperative stage of lacking cooperative ability. Solitary play is preferred, as child has not yet learned to play with other children. The child is too young to be reached with words alone and must handle and touch objects in order to grasp their meaning fully. Fears or anxieties of this age group are fear of falling, sudden jerky movements, bright lights, separation from the parents and fear of strangers.



Three-year-old Communication is easier. Child has great desire to talk and often enjoys telling stories. Fear of this age group is fear of strangers.



Four-year-old Children of this age generally listen to explanations with interest and normally responsive to verbal directions. They usually have lively minds and may be great talkers, although they tend to exaggerate in



their conversation. In some situations, they may be defiant. There is increased ability to evaluate fear-producing stimulations. Intelligent children display more fear, may be because of greater awareness of the danger and reluctance to accept verbal assurance without proof. Fears of this age group are fear of falling, fear of noise and fear of strangers are lessoned. Fear of bodily injury is present. Prick of hypodermic needle or sight of blood produces increased response disproportionate to that of pain.



Five-year-old This is the age of readiness to accept group activities and community experience. If prepared properly by the parents, there is little fear of separation. Children of this age are proud of their possessions. Comments about clothes, toys, etc. can be effective. Fantasy also plays very important role. It serves as a buffer for emotional problems. Children will combat on imaginative level, things they fear in reality. By doing so, the children not only gain comfort but also develop the courage and poise to meet the real situation. Children will do with pleasure in fantasy what they dislike to do in reality. They make believe play of going to the dentist and having the teeth worked on might help in dispelling undue subjective fears of a child.



Six to twelve-year-old Children of this age group learn from outside world and become increasingly independent of their parents. These are the years in which closely-knit groups and gangs are formed. These are important years of learning, as to how to get along with other people and to abide by the rules of the society (reasoning). Child can usually resolve fears of dental procedures, if the dentist explains and reasons well. Child has also learnt to tolerate unpleasant situations and has marked desires to be obedient, carrying frustrations



well. The child develops considerable emotional control. However, the child objects to people making light of his suffering, bullying, injustice or ridiculing whether it is from a friend or a dentist.



Teenage Girls especially become concerned about their appearance. They like to be as attractive as possible. This interest in cosmetics can be used as a motivating factor for seeking dental attention. To satisfy their ego, they will be willing to cooperate. Knowledge about the fears in each age group will be useful and is applied in dealing with the children in pediatric dentistry.



Stone and Church Classification of Child Development Stone and Church (1975) classified the child development into five different stages. Some of the stages may not be applicable to the present day children, where they are put into schools very early in their childhood. 1. Infant – 15 months 2. Toddler – 15 months to 2 years 3. Preschooler – 2 to 6 years 4. Middle years child – 6 to 11 years 5. Adolescent – 11 to 18 years



Infant The 15-month period of infancy corresponds to the oral stage of Freud, the stage of trust vs mistrust of Erikson and sensorimotor period of Piaget. This is the period in which the baby learns about the world it is placed, whether it is a good and acceptable place or a locus



of hurt. The baby advances from relative helplessness to a positive, ambulatory toddler. At about 6 months of age, the infant begins teething and chews on anything that is in close proximity to them and minor illness may begin to appear as maternal antibody protection starts disappearing. The first form of fear, referred to as stranger anxiety (to persons outside the accustomed environment) is seen. Another source of anxiety for the infant is due to the concept of trust vs mistrust. The mistrust when the infant’s needs are not adequately met, leads to fear and distrust. Infant and parent both have an influence over each other. The parental attitudes and their effect on children are discussed in Chapter 8 Behavior Guidance. Training of the infant in regularity will give the infant their first lesson in character building. When parents abuse the child because of their personal problems, the child is likely to become retarded and intellectually substandard.



Toddler This stage represents 15 months to 2 years of age. Toddler is still very much a little one, taking one or two naps daily and yet is developing un-baby like skills, rapidly developing in cognitive and verbal skills and also in self-awareness. Cooperative behavior and reasoning power are not observed. The child is capable of perceiving why dental measures need to be accomplished or realizing the need for cooperative behavior in the dental office. Toddler is a child developing and growing in knowledge and motor skills but still is an immature individual.



Preschooler Children of 2 to 6 years of age or the preschoolers ‘show’ their ‘personality’ whose behavior pattern is easily observed. Their behavior is influenced and shaped to a considerable extent by their immediate environment.



They are more skilled in the usage of words and symbols and more effective in interpersonal communication. They expand their circle to people outside their family. Belligerence and kindness co-exist with them. They expand their circle to people outside the family. Aggression and sympathy coexist with them. They adapt the behavior of familiar individuals like parents and other family members in facial expressions, mannerisms and gestures and also communication. Fantasy, pretension and storytelling by older people like grandparents are accepted as facts. They create imaginary friends and circumstances. Their emotional conditions are often made apparent by drawings. Self-awareness is observed and fears about real and unreal things as a result of this are seen. Time frame is not workable and meaningless for preschooler below 5 years. They will not have logic on space, which is observed as exaggeration in drawing. Causal relations change sequentially with the increase in overall knowledge, intelligence and thinking. At first their thinking is animistic, assuming that all things have life, followed by artificiality that all circumstances and things are human creations. Then they develop more realistic thinking with time.



Middle Years Child Child of 6 to 12 years age or middle years period is rather a peaceful period of time compared to the active (hustle bustle) nature of a preschooler. This is the time of “loose tooth” and the time for moderately rapid physical growth. This is the time for reaching out of independent identity, peer groups and sexual growth latency, time for getting punished when disobedient and a time for imaginary and realistic fears. Thinking becomes logical and reversible. The children learn conversations and can now reflect, reason and understand logical relationships.



Adolescent Children from age 12 to adulthood or a pause in the cycle of life as they are no longer children but not yet adults. Early development is marked by pubescence. Preadolescent period is marked by physical growth spurt, maturation of secondary sexual characteristics and changes in body proportions. Girls are initially ahead of boys but boys later catching up. Sexual maturation is marked by first menses in girls and presence of live spermatozoa in the urine for boys. The main characteristic of issue is the identification of child for this new role. A change in morphological and emotional characteristics is seen. Self-awareness becomes intensified and results in a new push for independence. The children direct increasingly towards peer groups with less family supervision and restraint and more privileges. They are concerned about peer status and independent self but still welcome intervention into problems over which they have questionable control. They want to be popular and selective about friends and things. Note: Fears at different age groups and general management strategies are mentioned under Erikson’s psychosocial theory, mental and emotional development with age and Stone and Church classification. However, readers can look into the next chapter for the behavior management strategies and correlate the information.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Enumerate the different theories of child psychology and explain Jean Piaget’s cognitive theory. 2. Critically evaluate Freud’s psychosexual theory and Erikson’s psychosocial theory. 3. Enumerate the psychology of a 5-year old child. 4. Stone and Church classification of child development.



5. What are the possible ways of assessing fear and anxiety in children and how far they are reliable? 6. How will you apply classical conditioning and observational learning theories to the fear of a child in dental setup?



Short Notes 1. Define child psychology and enumerate the importance of child psychology 2. Pedodontic treatment triangle 3. Id, ego and superego 4. Concept of fixation 5. Freud’s psychosexual theory 6. Erikson’s stages of personality development 7. Preoperational child 8. Classical conditioning 9. Reinforcement 10. Anxiety vs fear 11. Subjective vs objective fear 12. Fear, anxiety and phobia 13. Concept of centration 14. Modifications of pedodontic treatment triangle 15. Separation individuation theory



SUGGESTED READING 1. Bandura, A. Social Foundations of Thought and Action: A Social-cognitive Theory. Englewood Cliffs: Prentice-Hall; 1986. 2. Bandura, A. Social Learning Theory. Englewood Cliffs: Prentice-Hall; 1977.



3. Chambers, DW. Managing anxieties of young dental patients. J Dent Child. 1970; 37:363–373. 4. Crider, AB, Goethals, GA, Kavanaugh, RD, et al. Psychology, 3rd edn. Scott: Foresman and Company; 1983. 5. Decker, JD, Nathan, BR. Behavior Modeling Training: Principles and Applications. New York: Praeger; 1985. 6. Erikson, EHSchlein S, ed. A Way of Looking at Things – Selected papers from 1930 – 1980. New York: WW Norton, 1987. 7. Erikson, EH. Childhood and Society. New York: Norton Publishers; 1963. 8. Hofling, CK. Textbook of Psychiatry, 2nd Edn. Philadelphia: Lippincott; 1968. 9. Kanfer, FH, Goldstein, AP. Helping People Change. New York: Pergamon Press; 1986. 10. Mahler, MS, Pine, F, Bergman, A. The Psychological Birth of the Human Infant. New York: Basic Books; 1975. 11. Maslow, A. Motivation and Personality, 2nd edn. New York: Harper and Row; 1970. 12. Maslow, A. Towards a Psychology of Being. Princeton: Van Nostrand; 1962. 13. Newton, JT, Buck, DJ. Anxiety and pain measures in dentistry: a guide to their quality and application. J Am Dent Assoc. 131, 2000.



14. Piaget, J. The Language and Thought of the Child. New York: Harcourt; 1926. 15. Skinner, BF. Science and Human Behavior. New York: MacMillan; 1953. 16. Skinner, BF. The Behavior of Organisms: An Experimental Analysis. New York: AppletonCentury-Crofts; 1938. 17. Stone, LJ, Church, J. Childhood and Adolescence, 3rd edn. New York: Random House Inc; 1975. 18. Troutman, KC. Behavior of children in the dental office, Update. Pediat Dent. 1988; 1:1–4. [6–8]. 19. Wadsworth, BJ. Piaget’s Theory of Cognitive and Affective Development. New York: Longman; 1989. 20. Wayne W. Psychology: Themes and Variations (2nd edn). Briefer Version. Brookes/Cole Publishing Company (Pavlov). 21. Weiten, W. Psychology: Themes and Variations, Briefer Version, 5th edn. Belmont: Wadsworth/Thomson Learning; 2001. 22. Wright, GZ. Behavior Management in Dentistry for Children. Philadelphia: Saunders; 1975.



CHAPTER 8



Behavior Guidance N Sivakumar and MS Muthu



CHAPTER OUTLINE Introduction Definitions Behavior of Children in Dental Setting Frankl’s behavior rating scale Sarnat’s behavior rating scale Wright’s classification of cooperativeness of children in dental office Lampshire’s classification of behavior Factors/Variables Influencing Behavior of Children Factors under the control of the dentist Factors under the control of the parents Other factors influencing behavior Behavior Management Behavior management strategies Fundamentals of behavior management Communication with children Behavior management techniques Conclusion Suggested Reading Self-assessment Questions



“Each kid has a different level of expertise and some of them are very raw and inexperienced and some are incredibly mature and experienced. So you just have to go with what they are rather than have some abstract technique that you’re going to try to apply to them.”



—David Cronenberg



Introduction The approach towards children in the recent times has changed dramatically in the society, followed by a transformation in medical and hospital pediatric care. Dental profession has been slower in incorporating sound child-friendly approaches into dental care though, many changes have been brought into pediatric dental practice. Involvement of parents in the dental operatory is one such change. Expanded communication to ensure informed consent for treatment as well as consent for type of management approaches to children is the standard of present day pediatric dental practice. Enhancing the skills of all dentists and staff members in the techniques of nonpharmacological child management will be an essential factor for the future, since policies on sedation are becoming more complex. Behavior modification and management techniques gain more importance, along with better communication skills of the dental team. Emphasis must be placed on early and timely intervention, parental involvement, effective communication, cultural competence and the ‘medical/dental home’ concept (refer Chapter 18 on Infant Oral Health and Anticipatory Guidance) as methods to reduce negative dental attitudes and behaviors of children (Fig. 8.1).



FIGURE 8.1 A poster in an exclusive pediatric dental practice in India.



“Although operative dentistry may be perfect, the appointment is a failure, if the patient departs in tears.” —Mc Elroy, 1895 As early as 1895, McElroy gave the above statement highlighting the importance of successful management of children in the dental office so that they come back cheerfully with a positive attitude towards dentistry for the next visit. We as dental practitioners should recognize and treat childhood dental diseases that are within the knowledge and skills acquired in dental schools. Safe and effective treatment of childhood dental problems often requires modification of the child’s behavior.



Definitions “Behavior management” has been the traditional term that describes the effort by families, caregivers, therapists, and also dentists to control disruptive behaviors of people with special needs during daily activities or clinical treatment. Advocates have tried to help others understand that “no one likes to be managed” and that such



terminology stigmatizes or dehumanizes the individual. Through life experience every human grows, learns, and benefits from many sources of support and guidance in order to function in social and family settings. Thus, the American Academy of Pediatric Dentistry (AAPD) has recently changed its terminology from “behavior management” to “behavioral guidance” Behavior guidance: Behavior guidance is a continuum of individualized interaction involving the dentist and patient directed toward communication and education “which ultimately builds trust and allays fear and anxiety”. Behavioral support: This term is used to describe a collaborative philosophy that is person-centered in that it considers the individual, evaluates their environment and support resources, and attempts to plan how challenging behavior can best be moderated. Behavior: It is an observable act or any change in the functioning of an organism. Behavior management: It is defined as a means by which the dental health team effectively and efficiently performs dental treatment and thereby instills a positive dental attitude. Behavior shaping: It is the procedure, which develops behavior by reinforcing a successive approximation of the desired behavior until the desired behavior comes into being. It is otherwise defined as a procedure of reinforcing behaviors that are increasingly similar to the desired behavior until finally the desired behavior occurs. Behavior modification: It is defined as an attempt to alter human behavior and emotion in a beneficial way and in accordance with the laws of learning. Behavioral guidance: It is a continuum of interaction involving the dentist, the dental team, the patient and the parent directed towards communication and education. Behavioral pedodontics: It is the study of science that helps to understand development of fear, anxiety and associated acts as applied to the child in dental situation. To understand the behavior of children in a dental setting and to manage the same effectively and efficiently, sound knowledge of the



psychological basis of development of children, different types of behavior of children in dental setting and factors affecting the behavior of children are needed. The psychological basis was discussed in Chapter 7 on Child Psychology and the rest is dealt in this chapter.



Behavior of Children in Dental Setting A number of systems have been developed for classification of behavior of children in dental setting. Understanding these systems will be more than useful not just for academics but also in day to day pediatric dental patient behavior recording, child management and research in pedodontics. Some of the useful scales and classifications are given below. • Frankl’s behavior rating scale • Sarnat’s behavior rating scale • Wright’s classification of cooperative behavior of children in dental office • Lampshire’s classification of behavior



Frankl’s Behavior Rating Scale Frankl et al (1962) introduced this behavior rating instrument referred to as Frankl rating scale. It is one of the most widely used and reliable tools developed for behavior rating of children in dental setting for dental institutions as well as private practice in pediatric dentistry. This scale consists of four ratings numbered from 1 to 4, each defining a specific behavior as follows. Rating 1: Definitely negative. Refusal of treatment, crying forcefully, fearful or any other overt evidence of extreme negativism. Rating 2: Negative. Reluctant to accept treatment, uncooperative, some evidence of negative attitude but not pronounced, i.e. sullen,



withdrawn. Rating 3: Positive. Acceptance of treatment; at times cautious, willingness to comply with the dentist, at times with reservation but patient follows the dentist’s directions cooperatively. Rating 4: Definitely positive. Good rapport with the dentist, interested in the dental procedures, laughing and enjoying the situation. Rating 1 may include immature, uncontrollable or defiant behaviors as discussed later in this chapter. Rating 2 may include immature, timid and whining type of behaviors or fears due to family or peer influences. Rating 3 may include tense cooperative, whining or timid type of behaviors.



Wright’s modification of Frankl’s behavior rating scale (1975) Modifcation is mentioned within the brackets. • Rating 1: Definitely negative (– –) • Rating 2: Negative (–) • Rating 3: Positive (+) • Rating 4: Definitely positive (+ +) Example usage: • First visit for initial examination: (–) → (+) TSD (with TSD technique) • Preventive dental procedure: (+) → (+ +) with fluoride varnish application • Restoration with class II amalgam on 74: (+)→ (–) L. A. (with L. A. injection) To differentiate between preoperative and postoperative behaviors, arrow mark is used along with the factor influencing that change.



Sarnat’s Behavior Scale



Sarnat et al described a behavior rating scale for children in dental situation with 5 types of behavior as follows. 1. Active cooperation: Smiles, offers information, initiates light conversation, gives positive responses. 2. Passive cooperation: Indifferent, but obedient, follow instructions, quiet. 3. Neutral, indifferent: Needs convincing, mild crying, follows instructions under pressure. 4. Opposed, disturbs work: Seizes hands of the dentist, not relaxed, sits and stands alternatively. 5. Completely uncooperative, strongly opposed: Cries, refuses to sit or enter the dental office.



Wright’s Classification of Cooperativeness of Children in Dental Office (1975) Wright’s classification of children’s cooperative behavior is under the following categories: • Cooperative children • Children lacking cooperative ability • Potentially cooperative children 1. Uncontrolled behavior 2. Defiant behavior 3. Timid behavior 4. Tense cooperative behavior 5. Whining behavior.



Cooperative children Most of the children whom we see in day to day practice fall under this category. They show minimal apprehension and are reasonably relaxed. These children usually have good rapport with the dentist and the dental team. They show interest in the dental procedures and often enjoy the situation. The dentist can work effectively and efficiently with these children as they follow the guidelines



established, perform within the framework provided and present reasonable level of cooperation.



Children lacking cooperative ability Children lacking cooperative ability are in total contrast to the cooperative children as they lack the ability to cooperate because of their mental and physical immaturity due to age or some special condition. This includes two groups of children — one being very young who are emotionally immature because of age (less than 2½ years). These children can pose a major behavior problem and are often referred to as ‘pre-cooperative’ children or children in precooperative stage. The second group includes children with specific debilitating or handicapping conditions with mental and physical deficiencies. The severity of the condition will not allow them to cooperate like normal children of their same age. These are called ‘special children’ and the number of these children you see in dental office is increasing recently.



Potentially cooperative children These children are otherwise termed as ‘behavior problem’ children. They differ from the children lacking cooperative ability because they have the ability to cooperate but they do not. This can be because of objective/subjective fears or any other factor which can influence behavior of children in dental setting. The behavior of these children can be modified by different techniques as discussed later in this chapter and they can become cooperative children.



1. Uncontrolled behavior This type of behavior is seen in a young child of age 3 to 6 years. The reaction is seen in the form of a tantrum, which may begin at the reception area or even before the child enters the dental clinic. This



behavior is also known as incorrigible. It is characterized by tears, loud cry, physical lashing out, flailing of hands and legs. All are suggestive of a state of acute anxiety or fear. These children are termed as hypermotive by Lampshire. School age children tend to model their behavior on adults or other older children. Uncontrolled and immature behavior is not seen in older children, but if it is seen there will be deep rooted reasons for it and these children may reveal adjustment problems in other settings. Immediate measures to manage when uncontrolled behavior is seen are removal of the child from the reception area, as soon as possible before it starts a chain reaction in other children. Second, the child’s flailing must be stabilized to avoid physical injury to the child and the dental team. Finally, communication should be established, to make it possible to explain about the procedures. Most children who can comprehend the situation can have their behavior controlled.



2. Defiant behavior This behavior is typical of the elementary school years but can be observed in other age groups also. Defiant behavior is controlled to an extent and is distinguished by “I don’t want to’, ‘I don’t need to’, or ‘I won’t” type of reply. They protest as they would do at home when they were brought to the dental office against their wish. These children are often referred to as ‘stubborn’ or ‘spoiled’. They frequently become highly cooperative after establishment of guidelines for their behavior and gaining their confidence. Defiance can be passive as seen in older children approaching adolescence. Failure of communication results when the dentist tries to involve the child in the dental procedure and the youngster refuses to respond verbally. He may avoid eye contact and also reject the situation by clenching his teeth when an intraoral examination is attempted. Passive resistance is often observed in older children approaching adolescence. They have the freedom to express their likes and dislikes at home and when brought to the dental office unwillingly their selfimage is affected and they rebel.



Passive resistance can pose difficult behavior problems. The dentist has to use firmness and avoid struggling. An attempt should be made to understand them and try to relate to them. If they express dislike for dentistry, tell them that dentistry is not inherently pleasant. When they say I do not like needles, agree that they are not fun. One has to be honest and eventually the conversation is directed to other topics. Then the consequences of neglecting the dental problems and a mature view of dental fears are discussed. Once their negative attitudes are modified to a willing or willing to try frame of mind, many behavior management techniques can be used to overcome their negative attitudes.



3. Timid behavior (Fig. 8.2) Timidity is milder when compared to uncontrolled and defiant behaviors but when managed incorrectly they may become uncontrolled. The timid child may hide behind a parent but usually offers no physical resistance during the separation procedure. Some may pause or hesitate when given directions. They may sob or whimper out but not cry hysterically. They lift their hands occasionally to cry but withhold tears. Reasons for timidity can be overprotective home environment, living in isolated areas without any contact with strangers. They are often overawed by strangers and strange situations.



FIGURE 8.2 Timid behavior.



These children need to gain self-confidence and confidence in the dentist and they must be carefully led and handled through the dental situation. Timid children are highly anxious and do not always hear or comprehend the instructions. The dental team has to recognize this and repeat often the guidelines for behavior or the instructions for maintenance and follow-up.



4. Tense cooperative behavior The behavior of these children is termed borderline. They accept the



treatment and cooperate but are extremely tense, which is typical of these children. The tension is often revealed by the body language. The child patient’s eyes may follow the movements of both the dentist and the dental assistant. A tremor in the voice heard when they speak, perspiration on the palms of the hands or the eye brows are some features of tense cooperative behavior. A busy or unobservant dentist might fail to see the problem as these children control their emotions. These children are easily mismanaged because they accept treatment. They may grow up accepting dentistry but with the development of an attitude which is detrimental to the future dental health voicing the dislike out of proportion to what they experience personally.



5. Whining behavior Whining can be seen in timid or tense-cooperative children. Since whining plays the prominent role in their behavior, it is described as a separate entity. They allow the dentist to perform the procedure but whine throughout despite encouragements. They frequently complain of pain. Whining can be a compensatory mechanism to control their fear. The cry is controlled, constant and not particularly loud, often without any tears. Continuous whining can be a source of irritation and frustration to those involved in the treatment and great patience is required in dealing with whining children. The whining can be used as a compensatory mechanism by the child sometimes to avoid listening to the sounds of dentistry for which they are afraid off. If this can be recognized the child can be distracted from those noises or sounds by giving them headphones with good soothing music. Good sound proofing of the dental operatory also helps to an extent along with some visual clips to distract the attention of the child.



Lampshire’s Classification of Behavior (1970) 1. Cooperative: Physically and emotionally relaxed children who are cooperative throughout the dental appointment.



2. Tense cooperative: The children are tensed but they will be cooperative for the dental procedures as described in Wright’s classification. 3. Outwardly apprehensive: These children avoid treatment initially, hide behind the mother and avoid looking at or talking to dentist. They eventually accept the treatment. 4. Fearful: These are afraid of the dental procedures and require considerable support to overcome the fear of dental treatment. 5. Stubborn/defiant: Passively resists treatment using techniques that have been successful in other situations like at home. 6. Hypermotive: These children are agitated and resort to screaming and kicking, etc. 7. Handicapped: This includes physically or mentally and emotionally handicapped. 8. Emotionally immature: Children who are under 2.5 to 3 years of age.



Factors/Variables Influencing Behavior of Children • Factors under control of dentist • Factors under control of parent • Other factors that influence behavior



Factors Under Control of Dentist • Dental office environment • Dentist’s activity, attitudes and attire • Scheduling of appointments • Presence/absence of parent or older sibling in the operatory • Substantial reinforcement



Dental office environment Dental office environment should be warm and give a homely feeling. Pleasant environment relieves the anxiety of children about the dental situation. The operating environment should be made colorful and lively with posters and toys (Fig. 8.3), and a separate waiting room for the children is necessary and this should contain TV and video games, toys, storybooks and comics. It should have a separate exit and entry door. Dental auxiliaries should be kind to the children and should greet them with caring attitude and smile. Establishing a separate recreational or play area (Fig. 8.4) will encourage them to leave the parents aside and will facilitate separation when the child is transferred to the dental operatory.



FIGURE 8.3 An operatory in an exclusive pediatric dental practice in India.



FIGURE 8.4 Play area inside an exclusive pediatric dental practice in Chennai, India.



The operatory should be designed to minimize potentially negative visual stimuli. The less it looks like a clinic, the less likely the physical appearance of the office is to increase the anxiety levels. Color is very significant for youngsters and bright colors are preferred to pastels. They are also aware of the sounds and this clearly has implication in the use of dental equipment. So good sound insulation is essential and carpeting the area further reduces sound levels. The tones of the voice of dentist and staff can either instill or discourage confidence. The type of background music may also be of influence. Pleasant odors of the clinic are definitely noticed positively by children. The smell of medications, such as eugenol or formaldehyde can be unpleasant for many children. Instruments which are fear provoking should be kept at inconspicuous places. It is preferable to place equipment behind the patient and the use of prepared trays is especially helpful, since the time required to prepare for each patient is reduced. This allows a



greater period of time for orientation and encourages a more relaxed pace at each visit. Cleanliness and neatness are important to children, just as they affect adult attitudes. They reflect on the individual who administer the facility, therefore encourage or discourage the confidence.



Effect of dentist’s activity, attitude and attire The points discussed later in this topic in fundamentals of behavior management give an idea on the activities and attitude of the dentist as he/she should form a good impression on the child. He should avoid sudden, jerky movements and should be fluent in his words and actions. If a child has previously experienced a stressful situation, which includes the presence of someone in white attire such as a physician, the mere presence of white clothed individual would be sufficient to evoke a negative behavior. The attire worn by dentists may vary from white gown to jackets, to a shirt and tie or an open necked shirt. Less formal attire will have a beneficial effect on some children.



Scheduling of appointments Consideration should be given to scheduling of appointments for youngsters. If they are accustomed to a nap or meals at a given time a day, then this time should be avoided, or irritability may result. Some children prefer to skip school for dental appointments rather than losing their play time. So some appointments can be scheduled during the school hours as preferred by them as a management technique. Early appointments are preferable. Appointment time should be short, i.e. less than 30 min. Children should not be kept waiting for too long in the waiting area because they tend to become restless. Long appointments can result in deterioration of behavior towards the end of the treatment period. Preparation of the child to the dental clinics can be done by use of telephone/letters/pamphlets. This decreases the anxiety of child.



Presence/absence of parents/sibling in operatory (Fig. 8.5) Until recently, the parent involvement in the operatory is minimal; in fact many dentists actively discouraged it with some exceptions. Starkey has been one of the strong advocates of separation of the child from the parent during dental treatment for the following reasons:



FIGURE 8.5 Parental presence in the operatory.



• The parent often repeats orders which creates annoyance for both the child patient and the dentist. • The parent injects orders forming a barrier to the establishment of communication and rapport between child and the dentist. • The dentist will be unable to use voice control in the presence of parent as he/she might be offended.



• The child has to divide attention between the parent and the dentist and the dentist has to divide attention between the parent and the child. Mother’s presence in the operatory is essential for a preschool child, handicapped child, etc. An older child does not require mother’s presence because of emotional independence of these children, as they grow older. Recent trends show that parental presence can be used as a communication and a reassurance for the parent and the child. There are advantages to parental presence. Data from past studies suggest: • No increase in negative patient behavior with parents present. • Great parental interest in accompanying their child. • Improvements in patient management and anxiety reduction in medicine and dentistry when parents are effectively involved. Box 8.1 describes the advantages of parental presence during procedures in dentistry for children. Box 8.1



Advantages of parental presence



during procedures in dentistry for children • Parents prefer to accompany children in stressful situations. • Parents view the reality of dentist’s excellent care. • Parents see proof of the dentist’s hard work and caring approach. • Parents are not left imagining regarding the dentist’s interaction with their child. • Parents feel a part of the process of decision-making and care. • Health care messages can be delivered simultaneously to child and parent.



• Dental care delivered can be described simultaneously to child and parent. • Communication time is reduced by decreased need for repeated messages. • Parents can reinforce dental health messages at home. • Dentists can get rapid informed consent for changes in treatment or management. • Dentists can get rapid feedback on parent’s attitude and beliefs. • Very young children can get appropriate physical and psychological support. • Patient behavior and anxiety reduction can be improved.



An older sibling serves as a role model in a dental situation. This again depends on the age of the patient. Presence of an older sibling has little effect in the behavior of 3-year-old, no effect in the case of 5year-old and most noticeable effect in the 4-year-old.



Substantial reinforcement Reward or gift giving practice after successful completion of an appointment will help in reinforcement of a positive dental attitude in children. Keeping some tooth brushes, small toys, cartoon character stickers, etc. in the clinic that can be given as a token of appreciation and love are examples for this. One should differentiate a reward from that of a bribe. ‘Reward’ is in recognition of good behavior after completion of an operation, without a previously implied promise whereas ‘bribe’ is promised to induce a desired behavior. Gift giving can have spectacular results as these gifts provide a pleasant reminder of the dental appointment. Many children who are tense during the dental procedures suddenly come alive on completion and scamper for a gift.



Factors Under Control of Parents



Parents shape the children’s behavior right from their birth selectively encouraging or discouraging certain behaviors and positively reinforcing desirable behaviors. The children’s behavior can be affected by many factors which are related to or under the control of the parents like: • Home environment • Family and peer influences • Maternal anxiety • Parental attitudes



Home environment The home is the first school where a child learns to behave. The behavior of the child is influenced by the mother. In the case of a broken home, the child may feel insecure, inferior, apathic and depressed. Mother—child relationship has been described as one tailed. Children learn good values and positive attitudes, if they are cared to and talked to and when more time is spent with them. Retired grand parents in the family and non-working parent can play a major role in this as we see the present day children are left in daycare because of both parents working.



Family and peer influences Position of the child and status of the child in the family can influence the child’s behavior. Over protection/over indulgence by parents can lead to a spoilt behavior in the child who may show sudden outbursts and temper tantrums. Internal family conflicts affect children’s behavior. The child can sense disharmony in the family and this can frustrate the child. The younger child always tries to follow the model of the older sibling. School aged children will try to model on the friends and peers for their attitudes and behavior when they try to move away from the influence of parents.



Maternal behavior/anxiety



Maternal influence on the child’s mental, physical and emotional development begins even before birth. Somatic development of the fetus depends on the nutritional status of the mother. Neurohormonal system of mother transfers emotion to the fetus. Postnatal behavior of the child is linked to the prenatal emotional status of the expectant mother, e.g. emotional stress during pregnancy can lead to an excessively active and irritable infant. Anxieties and fears of mother about dentistry may be passively transmitted to an observant child at home or when the mother is undergoing dental treatment in the presence of the child. Maternal influences on personality development (Fig. 8.6). The mother—child relationship falls into one of the two categories:



FIGURE 8.6 Maternal influences on personality development.



1. Autonomy vs control 2. Hostility vs love



Mothers who allowed enough autonomy and who expressed affection had children who were friendly and cooperative and those who ignored their children did not have children who exhibited these positive behavioral features. ‘Bell’ termed the parent-child relationship as ‘one-tailed’; since parental characteristics are viewed as having a unilateral influence on those developing in the child. According to the ‘one-tailed’ theory, many of the child characteristics including his personality, behavior and reaction to stressful situations are the direct product of various parental — especially maternal — characteristics. The behavior of mothers who participated in the Berkley growth study was rated according to the attitudes depicted in the Schaefer model. The mother’s attitudes were then correlated with the behavior of their sons. It was found that loving mothers tended to have calm, happy sons, while hostile mothers had sons who were excitable and unhappy. The dental implications of the effects of maternal attitudes in moulding the child’s personalities are apparent, as a friendly cooperative child will probably also exhibit these traits in the dental office.



Parental attitudes Over protection: The usual feeling mothers have for their children is one of love and affection which is a pre-requisite for the healthy emotional development of the child. An exaggeration of this attitude namely, ‘over protection’ can be potentially harmful to the child’s development. Several possible factors may provide the stimulus, for maternal overprotection. The causes for this may be a history of previous miscarriages, or a long delay in conception, death of the other sibling, or if the mother is aware she cannot have any more children. A serious illness or a handicapping situation may also warrant over protectiveness. Another possible cause is parental absence through death or divorce. There are several signs that help to identify an overprotective mother. She gives excessive care to the child in terms of feeding, dressing and bathing after the child passes the usual age of parental



care. She is constantly involved in the child’s daily activities and may not allow him to take the ordinary risks at play and shows excessive concern regarding the child’s medical and dental problems. The overprotective mother retards the normal psychological maturation of the child and the behavior that the child displays depends on whether the maternal over protection is coupled with ‘dominance’ or with ‘overindulgence’. The dominant over protective mother is associated with a submissive child exhibiting extreme shyness and anxiety. The submissive child will usually be a co-operative dental patient; although establishing a rapport or a casual communication may be difficult. The overindulgent overprotective mother is associated with an aggressive and demanding child who expects constant attention and service. Denying their wishes result in temper tantrums or physical assault. The aggressive child will usually not be anxious in a new or unfamiliar environment such as the dental office. However, he may expect or demand the dentist attention. Overindulgence: Overindulgence may be associated with overprotection or it may be the dominant maternal trait. Over indulgent parents and grandparents give the child what ever he might want, as far as financially possible, including toys, candies and clothes, and they usually place very little restraint upon their child’s behavior. His emotional development is impeded, keeping him on the infantile, dependent state in which crying or temper tantrums will produce the behavior from his parents that he demands. He is usually incapable of amusing himself and he keeps the adults around him busy for him. These children expect “to get their own way” in the dental office and they may show bursts of temper when they cannot control the dental situation the way they control situations at home. Under affection: Under affection may vary from mild detachment to indifference, to neglect. Under affection may begin during pregnancy or it may develop later in childhood. A mother may become less emotionally supportive of her child due to her outside interests or employment or simply because the child is unwanted.



Children experiencing maternal under affection are usually well behaved and outwardly appear to be well adjusted. However, they tend to be unsure of their decision-making capacities. Since they have not learned to experience love and affection at home, emotional contact and support with them is difficult. A dentist may find that they easily cry, are shy, are unable or unwilling to co-operate. These children will respond to a surrogate, such as a dentist or a dental assistant, who will give them emotional support and needed affection. Rejection: Acceptance vs. rejection is one of the most significant of family influences. Maternal rejections may arise under many circumstances in which the child is unwanted. For example, the child may be rejected because of an unstable and unhappy marriage, because the birth was not anticipated, and the child’s presence interferes with the mother’s career or other ambitions, or because the mother herself is immature or emotionally unstable. The mother’s behavior is characterized by neglect of the child, severe punishment, ragging and resistance to spending time with or money on the child. When the maternal rejection is overt, the child usually lacks a feeling of belonging or worthiness. He may show extreme anxiety and be aggressive, over active and disobedient. He will usually resort to any behavior to gain attention. These children will usually be difficult dental patients who require considerable behavior modification by the dentist. At its extreme, this attitude can lead to the ‘battered child syndrome’. The abuse and neglect can be both emotional and physical; both are destructive to the normal development of children. In these cases, the dentist’s role must obviously go beyond that of the dental treatment of the child and should include awareness of the problem of maltreatment and a proper reporting mechanism to social or legal authorities. Authoritarianism: The authoritarian parent chooses techniques for controlling child behavior that may be termed ‘non-love oriented’. Discipline often takes the form of physical punishment or verbal ridicule. The authoritarian mother will insist that the child should conform to her setof norms and will expand much effort to train the child along these lines.



The usual response of a child to an authoritarian mother is submission coupled with resentment and evasion. While the child will not directly disobey a command, he has a heightened ‘avoidance – gradient’ and will seek to evade or delay response. Overanxiety: This attitude is characterized by undue concern for the child, usually as a result of a previous tragedy. It can be associated with overprotection, overindulgence or over-affection. The children of overanxious parents may be shy, timid and fearful. They generally are good dental patients but difficulty in overcoming their fears may be encountered. Overidentification: This attitude occurs in parents who try to relive their own lives in those of the children. Whatever they could not do or achieve in their lives, they expect their children to fulfill the same. If the child fails to respond favorably they get disappointed and it is displayed to the child. An observant child senses the parental disappointment and has the feelings of guilt, mirrored as shyness, retirement and unsureness.



Other Factors Influencing Behavior • Growth and development • Nutritional factors • Socioeconomic status • Awareness of dental problems • Past medical/dental history • School environment



Growth and development Deficiency in growth and development due to any congenital problems like any syndromes or cleft lip/palate leads to rejection or excessive sympathy by the society. This along with excessive concern by the parents might affect the psychological development and



behavior of the child which in turn will influence their behavior in dental office. Younger children may not be able to perform according to the expectations of the dentist because of their level of physical and motor development.



Nutritional factors Nutritional deficiency may influence the overall physical and cognitive development of the child which in turn affects the behavior. Children who come for dental appointments skipping a meal or those who are hungry during the appointment may not perform up to the expectations.



Socioeconomic status Children from high socioeconomic background may develop normally as they are provided with all the necessary needs for normal physical and psychological development which leads to positive attitudes. On the other hand, stubborn, defiant or spoilt kids are also seen because of excessive pampering and giving what ever they need. Children from low socioeconomic status may develop resentment or are tensed as the child gets neglected most often and gets little attention from the parents. This in turn affects their attitude towards dental health.



Awareness of dental problems Children, who are aware that they have a dental problem whether it is a serious one or a simple esthetic concern, tend to show negative behavior in their first dental visit. This can be due to a result of apprehension transmitted to the child by the parent or may be due to the feeling of shyness to show the teeth to the dentist which might result in avoidance of opening the mouth initially.



Past medical/dental history



Children with positive medical experiences are more likely to be cooperative dental patients. Those with negative medical experiences are more likely to be uncooperative dental patients. The emotional quality of the medical visit is important than the number of visits to a pediatrician or physician. Pain experienced in the previous medical appointments or hospital is an important consideration in the child’s medical history as well as how the child has reacted to that painful experience. Past dental history with painful and fear producing experiences also evoke negative responses in the future dental appointments unless their behavior is shaped or modified.



School environment Children who have passed through preschool years with negative attitudes might change to positive frame of mind because of the care and concern shown by a good caring teacher. They also can get influenced by the peers and seniors in terms of their attitudes towards life and also dentistry.



Behavior Management Behavior management is a continuum of interaction with a child/parent directed toward communication and education. Thus the principles of behavior management are communication and education with empathy, coaching and listening. Goals of behavior management are to establish communication, alleviate fear and anxiety, deliver quality dental care, so that the child considers the dentist trustworthy and develops a positive attitude towards oral/dental health. Behavior management is the means by which the dental team effectively and efficiently performs dental treatment and there by instills a positive dental attitude (Wright GZ, 1975). Behavior shaping is that procedure which very slowly develops behavior by reinforcing successive approximations of the desired



behavior until the desired behavior comes to being. It is otherwise defined as a procedure of reinforcing behaviors that are increasingly similar to the desired behavior until finally the desired behavior occurs.



Behavior Management Strategies Behavior management strategies include the pre-appointment behavior modification procedures using the principles of learning theory like modeling. The goal is to keep the first dental visit as pleasant as possible to develop a positive attitude in the child towards dentistry. Behavior management techniques are discussed later in this topic. Pre-appointment letters are sent to the parents on preparing their children for the first dental visit experience (Box 8.2). Parents are advised to construct the visit to dental clinic as an adventure in which the children can gain success. Dental visits should not be pictured as punishments for their wrong doings at home. Parents and other family members should not talk bad about dental experiences in front of children. An example of the pre-appointment letter is given in Box 8.2. Box 8.2



Pre-appointment letter



First Dental Visit Dear Mrs Vasanthi, I came to know that you have taken an appointment with us at Pedo Planet – Pediatric Dental Center for your child. I appreciate your effort and interest in your child’s dental health. At Pedo Planet, we give lot of importance to a child’s first dental visit. We try to keep this appointment as an introductory appointment and make it very pleasant for your child. As parents we appreciate you, if you can tell your child about the appointment as an opportunity to meet new people and environment where he will be taught to keep his teeth healthy. Kindly avoid making any negative comments or using threatening phrases (like injections, extraction of



teeth, etc.) about the appointment. Generally, in the first appointment, we examine the teeth and may take X-rays, if necessary. Sometimes we may provide him with a fluoride coating. This will be an interesting experience for your child. We have a team of doctors, who enjoy working with children and know how to work with them. We believe in prevention to a great extent. Good general health begins with good dental health. We will discuss in this regard in the forthcoming appointment. Thanking for choosing us as your pediatric dental care providers. I am looking forward to meet you and your child. Sincerely, Dr MS Muthu, MDS Behavior management strategies also include the attitudes and integrity of the dental team, communication with children, behavior shaping and management methods and other practical considerations.



Fundamentals of Behavior Management Definition of behavior management includes effective and efficient delivery of high quality dental care. However, this depends on how well the entire dental team conduct themselves during a pediatric dental appointment. These include: • Positive approach • Team attitude • Organization • Truthfulness • Tolerance • Flexibility



Positive approach The attitude or the expectations of the dentist can affect the outcome of the dental appointment. Children will respond successfully to the



guidelines and positive statements of the dentist. Thoughtless questions and remarks will not be effective. It is important to anticipate success always to obtain success with children, not the anticipation of failure.



Team attitude Compassion, warmth and interest can be conveyed to children without a spoken word. A pleasant smile tells them that you care for them. Children respond well to friendly attitude, which can be conveyed immediately through a casual greeting. They can be made to feel comfortable by the use of nicknames that like to be addressed. Their nickname and their interests can be noted in their case records for future to initiate conversation which demonstrates a friendly and caring attitude.



Organization Organization of the plans like who will receive the new patient, who will deal with the patients who create disturbance in waiting room or reception area, who will receive the child from the parent, etc. are very important. Each dental office or pediatric dentistry department has its own plans and the entire dental team should know this in advance along with a well organized and detailed treatment plan. Such plans will increase the efficiency and contribute to successful pediatric dental patient-staff relationships. Delay and indecisiveness can lead to apprehension in young patients



Truthfulness Most children see things as black or white contrary to the adults. The grey shades in between are difficult for them to perceive. For them, the dental health team is either truthful or not. Truthfulness is an extremely important factor in building trust and it is a fundamental rule in dealing with children. So the dental team should be truthful in explaining the children about the procedures to be done, but in a non-



threatening manner and also outlining what is expected of them for successful completion of the appointment.



Tolerance Tolerance levels vary from person to person and time to time. Tolerance refers to the ability of the dentist to cope with misbehavior while maintaining composure. It is very important in dealing with children. An upsetting experience away from dental office also can affect the clinician’s mood in the dental office. Some dentists will be in a better frame of mind in the mornings and some improve the coping abilities as the day progresses. The appointments of ‘behavior problem’ children are booked accordingly. Learning to recognize the factors that overtax the tolerance levels of the dentist and the dental team is an important fundamental, since it prevents loss of selfcontrol.



Flexibility Flexibility is also a fundamental skill in pediatric dental care. The dental team must be prepared to change the plans from time to time because children are children, lacking in maturity sometimes. A proposed treatment may have to be shortened, a planned two-visit treatment may have to be finished in one visit, materials or instruments selected or operating position may have to be changed. Thus the dentist and the dental team must show flexibility as the situation demands.



Communication with Children Effective communication is an important factor in dealing with children as discussed in many places in this topic. The following are some guidelines not rules which can be modified or improvised as demanded by the situation. • Establishment of communication



• Establishment of communicator • Message clarity • Voice control • Multisensory communication • Problem ownership • Active listening • Appropriate responses



Establishment of communication The first objective of successful management of a young dental patient is to establish communication. There are many ways of initiating a verbal communication based on the age of the child. Involving the child in conversation will relax the child and enables the dentist to learn about the patient. Verbal communication with young children is best initiated with complementary comments about their dress or interests followed by some questions that elicit an answer other than yes or no.



Establishment of communicator The dental team must be aware of their roles and who should be communicating with the child at different areas of the dental clinic. The communication should be from single source always to avoid confusion to the child and an undesirable response. Initially, the receptionist greets the child and parent and makes them seated. The dental assistant talks to the child from reception room to the operatory and during the preparation of the child in the dental chair. When the dentist arrives, the dental assistant takes a more passive role, since the child can listen to only one person at a time. If the parent has to be present in the operatory he or she has to be given prior instructions as to not to give any instructions to the child unless it is warranted and asked by the dentist.



Message clarity Communication is a complex multisensory process including a transmitter, a medium and a receiver, the transmitter is the dentist, medium is the spoken word and the receiver is the child (Fig. 8.7). The message should be understood in the same way by the sender and receiver.



FIGURE 8.7 Diagram depicting transmitter, medium and receiver.



Euphemisms or word substitutes are like second language for pediatric dentists. These are used to explain about instruments or procedures to improve the clarity of the message to young patients. Generalized words like doctor are not used until the child learns discrimination, e.g. dentist from pediatrician/physician. Some examples of word substitutes are given in the Table 8.1. Table 8.1 Euphemisms Dental terminology



Word substitute (euphemism)



Mouth mirror and probe



Tooth counting objects



X-ray film



Photograph for tooth



X-ray machine



Photo camera for teeth



Micromotor handpiece



Motor cycle



Air rotor handpiece



Whistle/tooth shower



3-way syringe



Air and water pistol or gun



Suction



Vacuum cleaner



Alginate



Pudding or ice cream



Sealant



Tooth paint



Rubber dam



Rain coat



Rubber dam frame



Rain coat rack



Local anesthetic



Sleep medicine for tooth, magic water



Examination of teeth



Counting teeth



Composite or GIC



Tooth color cement



Communication can be verbal or nonverbal. Verbal communication is by speech. Nonverbal communication is by body language, smiling, eye contact, showing concern, touching the child, giving him a hug and expression of feelings without speaking.



Voice control Reference to voice control is seen in many places in dentistry especially in management of pediatric dental patients. It is very difficult to describe this effective management tool with words. One has to witness this being used to understand better. Sudden and firm commands are given to gain the attention of the child and to stop from doing unwanted things. Monotonous, soothing conversation will function like music set to a mood. Voice control will be more effective when used in conjunction with other communicative techniques. Loud commands are use to reduce disruptive behaviors. A sudden command of “stop crying and pay attention to me” may be an initial measure for further communication. Use of a foreign language other than the mother tongue of the child would be equally effective in stopping a disruptive behavior that is preventing communication. It is described in detail later in this



chapter.



Multisensory communication Multisensory communication, i.e. nonverbal means of communication is very effective in management of children. Body contact like simple act of placing the dentist’s hand on the child’s shoulder conveys a feeling of warmth, security and friendship. This type of approach helps children to relax, especially those 7 to 10 years age. Eye contact is also important and a child who avoids it is not fully prepared to cooperate. Rapid heart beat or pulse rate and beads of perspiration on the forehead will give an indication of nervousness of the child. Sitting and speaking to children at eye level gives a feeling of friendlier and less authoritative communication.



Problem ownership In difficult situations of management, the dentists should not forget the fact that they are dealing with children. One should not use ‘you’ messages, which will carry an impression that the child is wrong. If ‘I’ messages are used, that means dentist is taking the responsibility of the situation. For example, one has to use ‘I can’t fill your tooth if you don’t open the mouth’ rather than ‘you must open your mouth’.



Active listening Listening is important in the treatment of children. Listening to the spoken word is important for older children (verbal communication) than the nonverbal communication. The patient is stimulated to express his feelings and the dentist does the same as a necessary process in communication.



Appropriate responses The response of the dentist should be appropriate for the situation in communicating with children. It depends largely on the extent and nature of the relationship with the child, the age of the child and the



motivational level of the child’s behavior. An inappropriate response will be a dentist displaying displeasure extremely with an anxious young child on the first dental visit when there is little time to establish a good rapport. Once the dentist and the child get familiar with each other and then if the child displays unacceptable behavior, the dentist can express disapproval without losing self-control which will be an appropriate response.



Behavior Management Techniques There are many behavior management techniques mentioned in literature. Some of them are given in Table 8.2. Table 8.2 Behavior management techniques A. According to AAPD, 1999 1. Traditional behavior management a. Tell-show-do b. Distraction c. TLC, gentle speaking d. Modeling e. Positive reinforcement f. Voice control 2. Aversive behavior management a. Voice control b. Hold and go c. Restraining (medical immobilization) d. Hand over mouth exercise (HOME), hand over mouth with airway restricted (HOMAR) 3. Pharmacological management a. Conscious sedation b. Deep sedation c. General anesthesia B. According to AAPD Guidelines, 2002–03 I Basic behavior management 1. Communicative management a. Voice control



b. Nonverbal communication c. Tell-show-do d. Positive reinforcement e. Distraction 2. Parental presence or absence 3. Nitrous oxide/oxygen inhalation sedation II Advanced behavior management 1. Hand over mouth exercise 2. Medical immobilization 3. Sedation 4. General anesthesia



All techniques other than traditional or communicative management techniques need informed written consent from parent/guardian beyond the general consent. For ease of learning, the behavior management techniques can be classified as: • Pharmacological methods • Non-pharmacological methods



Pharmacological methods of behavior management 1. Premedication: a. Sedatives and hypnotics b. Anti-anxiety drugs c. Antihistaminics 2. Conscious sedation 3. General anesthesia Pharmacological behavior management techniques are discussed in Chapter 9 in this textbook.



Nonpharmacological behavior management techniques 1. Communication 2. Behavior shaping (modification) a. Tell-show-do b. Modeling c. Contingency management d. Retraining e. Parental presence/absence f. Systematic desensitization g. Voice control h. Protective stabilization (formerly medical immobilization or restraining) i. Hand over mouth excercise (HOME) Pediatric dentistry, as a specialty, has been a leading advocate for excellence in communication with children—‘communicative management’ is a phrase often used. Now, these communicative strategies include parents as well. These management tools include verbal and nonverbal communication, the old ‘tell-show-do’ technique, modeling, distraction, positive reinforcement, flexibility, foreshadowing visualization, relaxation and the presence of parents. Dental health professionals who have experience with children use strategies that will work and these strategies do work. Explaining new and strange procedures to children always helps them understand and cope. The rapport that can be developed with children in a few minutes of careful talk and play pays great dividends of trust. Trust leads to decreased patient anxiety, which leads to decreased pain perception and pain response (Fig. 8.8). A skilled practitioner’s use of dialogue, expression and tone of voice leads to success with children but to an untrained observer, the results often look like magic.



FIGURE 8.8



Relationship cycle in child management.



Unfortunately, many of the strategies used for long successfully by pediatric health care providers are not well understood in dentistry. In fact, many methods and phrases commonly used by dentists lead to negative outcomes in relating to children. There are bad patient behaviors that are iatrogenic, e.g. children developing an aversion towards dentistry because many dentists treating children lack knowledge, skill or attention to the vital performance of providing and ensuring profound local anesthesia. Most of them are uncomfortable with their skills and avoid giving children local anesthesia. Therefore, it is essential that dentists who treat children learn what works with kids and how to use the magnificent strategies available, so that dental care for children can be a more enjoyable experience for all those involved. For this vision to become a reality, many more dental professionals will need to be aware of and skilled in the communication management methods advocated by the American Academy of Pediatric Dentistry.



1. Communication Communication (i.e. imparting or interchange of thoughts, opinions or information) may be accomplished by a number of means but, in the dental setting, it is affected primarily through dialogue, tone of voice, facial expression and body language. The four ‘essential ingredients’ of communication are: 1. The sender or transmitter 2. The message, including the facial expression and body language of the sender 3. The context or setting in which the message is sent 4. The receiver The transmitter is the dentist, message or medium is the spoken word, and the receiver is the child. For successful communication to take place, all 4 elements must be present and consistent. Without consistency, there may be a poor ‘fit’ between the intended message and what is understood. The dentist, therefore, must have a basic understanding of the cognitive development of children so, through appropriate vocabulary, messages consistent with the receiver’s intellectual development can be sent. Communication may be impaired when the sender’s expression and body language are not consistent with the intended message. When body language conveys uncertainty, anxiety or urgency, the dentist cannot effectively communicate confidence in his/her clinical skills. The message should be understood in the same way by the sender and receiver. Euphemisms or second language is used. Generalized words (doctor) are not used until the child learns discrimination, e.g. dentist from pediatrician/physician.



2. Behavior shaping (modification) Tell-show-do (TSD) technique (Fig. 8.9): Addleston in 1959



introduced this technique which encompasses several concepts from the learning theory and has been a cornerstone of the behavior management. It may be used with any patient.



FIGURE 8.9



Picture showing tell-show-do.



It is a technique of behavior shaping which uses a series of successive approximations. It should be used routinely by all the members of the dental team working on children. TSD is used synonymous with behavior shaping in the literature. Objectives • Teach the patient important aspects of the dental visit; familiarization of dental setting • Shape the patient’s response to procedures through desensitization and well-described expectations. TSD technique includes verbal explanations at the patient’s



understanding level (tell) appropriately using second language or word substitutes wherever necessary, demonstration of the visual, auditory, olfactory and tactile aspects of the procedure in a nonthreatening fashion (show) and completion of the procedure without deviating from what was explained and demonstrated (do). While working intraorally, the child should be shown as much of the procedure as possible. Any deviation from that of originally explained or demonstrated can affect the relation between the child and the dentist. So honesty is required, to achieve positive attitude of children in future. Modeling (imitation) (Fig. 8.10): Children are capable of acquiring almost any behavior that they observe closely and that is not too complex for them to perform at their level of physical development. Modeling is learning by imitation based on observational learning theory by Albert Bandura, 1969. Goal of modeling is to have the patient reproduce the behavior exhibited by the model.



FIGURE 8.10



Modeling.



Models: Model is a provider of information about a behavior by performing that for the observer. Models can be live or filmed models. A ‘good’ model must be similar to the observer. Live models can be coping or mastery models. Modeling effectiveness can also be increased by using a ‘coping’ model. For dentally anxious children, it has been found ‘coping’ models are more effective than ‘mastery’ models. A coping model would express their fears and difficulty with the modeling situation, whereas the mastery model would show ‘mastery’ over the modeling situation. “Coping models typically present complex behaviors in small steps as they overcome difficulties similar to those to be experienced by the observer.” The “mastery model would not express or show any fear or difficulty with the modeling”. Stages and requirements of modeling: Two stages of modeling are acquisition and performance and the four requirements are attention, retention, motoric reproduction, reinforcement and motivation which were discussed under observational learning theory in the Chapter 7 on Child Psychology. Factors affecting modeling • Observer’s state of arousal. • Characteristics of the model, i.e. a model with social and demographic characteristics similar to the dentally anxious child or model with some pride and regard; liked or respected by the child based on his/her age, e.g. favorite movie or cartoon stars, role models in the society. • Expected consequences of the performance (reward or punishment). Learning by observing the consequences of a behavior is termed ‘vicarious learning’. Merits of modeling • Stimulation of new barriers



• Facilitation of behavior in a more appropriate manner • Disinhibition of inappropriate behavior due to fear • Extinction of fears Contingency management: This technique is based on the operant conditioning theory of BF Skinner. It is a method of modifying behavior by presentation or withdrawal of the reinforcers. These reinforcers are the pleasant or unpleasant stimuli mentioned in the operant conditioning theory in child psychology. Contingency management includes: • Reinforcement Positive reinforcement Negative reinforcement • Omission/time out • Punishment Reinforcement: It is a method of increasing the probability (frequency) of a desired behavior by presentation of a pleasant stimulus or withdrawal of an aversive or unpleasant stimulus. Here the stimulus is termed as reinforcer. Positive reinforcement (Fig.8.11): It is done through the presentation of a reinforcer in appreciation, after a successful completion of a dental appointment by the child. This will increase the frequency of the same behavior in future appointments. The reinforcers used can be one of the following:



FIGURE 8.11 of the month.



Certificate as a token of appreciation–patient



1. Social: In the form of a pat on the back or shoulder, shaking hand, hugging the child or verbal praise in the presence of parent for which the child will be happy. 2. Material: In the form of gifts like toothbrush kits, drawing kits, favorite cartoon stickers or toys appropriate for their age. 3. Activity: In the form of allowing the child to perform his/her choice of activity like watching a favorite TV show or movie or playing his favorite instrument for sometime or games of interest. Remember, these are rewards for the child which are given after the procedure, not bribes as they are not offered or promised in anticipation of a cooperative behavior before starting the procedure. Negative reinforcement: It is done by withdrawal of the aversive stimulus to increase the frequency of a positive behavior in the future appointments. Example for this withdrawal of handpiece if the child



is afraid of the noise of that and using hand instruments so that the child will accept dental treatment in the next appointment. Omission or time out: It is the means of increasing the probability (frequency) of a desired behavior by withdrawal of or threatening to withdraw a pleasant stimulus. Example is warning or threatening the child that you will send the mother outside the operatory, if the child is not cooperating for the procedure. Punishment: It is the means of increasing the frequency of a desired behavior by the presentation of an aversive stimulus. Examples can be the use of voice control, protective stabilization or handover mouth exercise. Retraining: This technique is used for a child with previous bad dental experience or with negative behavior due to other reasons. This is similar to that of behavior shaping. It is designed to fabricate positive values to replace the negative behavior. The causes for the negative attitudes are to be established before using retraining. There are three main approaches for retraining procedure as follows: Avoidance: If a 3-year-old patient who underwent a bad dental experience recently, presents with a deep caries lesion, it might be possible to avoid extensive pulp therapy at this time by doing an indirect pulp capping. This allows for the final treatment to be delayed and performed at a more appropriate time until the child’s expectancies have been revised and he has been retrained. De-emphasis and substitution: If the child is afraid of a particular instrument or technique or does not like the taste of a material, it may be changed and substituted with another suitable one, if possible. The child can be given different materials to choose from, which makes him feel that you have recognized his dislike and also that you are prepared to help him. If an instrument cannot be avoided or substituted, the child can be told that you understand the problem and it will be used as minimum as possible. Distraction: Distraction is the technique of diverting the patient’s attention from what may be perceived as an unpleasant procedure.



Giving the patient a short break during a stressful procedure can be an effective use of distraction. When the above two methods cannot be used, distraction or diversion will be an effective method. When the child is uncomfortable with certain dental procedures distraction can be done in the form of story telling, counting the number of teeth loudly and repetitive statements of encouragements, asking the child to recollect a favorite joke or a movie or using audio visual aids. It can be a useful technique for administration of local anesthetic. Parental presence/absence: The presence or absence of the parent sometimes can be used to gain cooperation for treatment. A wide diversity exists in practitioner philosophy and parental attitude regarding parents’ presence or absence during pediatric dental treatment. Parenting styles have evolved in recent decades. Practitioners are faced with challenges from an increasing number of children who many times are ill-equipped with the coping skills and the selfdiscipline necessary to deal with new experiences in the dental office. Frequently, parental expectations for the child’s behavior are unrealistic, while expectations for the dentist who guides their behavior are great. Practitioners agree that good communication is important among the dentist, patient and parent. Practitioners also are united in the fact that effective communication between the dentist and the child is paramount and requires focus on the part of both parties. Children’s responses to their parents’ presence or absence can range from very beneficial to very detrimental. Each practitioner has the responsibility to determine the communication and support methods that best optimize the treatment setting recognizing his/her own skills, the abilities of the particular child and the desires of the specific parent involved. The objectives of parental presence/absence are to: • Gain the patient’s attention and improve compliance. • Avert negative or avoidance behaviors. • Establish appropriate dentist–child roles. • Enhance effective communication among the dentist, child and



parent. • Minimize anxiety and achieve a positive dental experience. Indications: May be used with any patient. Contraindications: Parents who are unwilling or unable to extend effective support (when asked). Systematic desensitization: Systematic desensitization was introduced by Joseph Wolpe (1952), has two important elements: 1. Gradational exposure of the child to his/her fear. 2. Induced state of incompatibility to his or her fear. This technique was used for patients with psychiatric problems regarding some fears. The therapist creates a list of steps arranged as a hierarchy from the least to the most stressful: • The patient, while in a state of deep relaxation, is exposed one step at a time, each step presented repeatedly until there is no evidence of stress or antagonism on the patient’s part. • On satisfactory completion of the hierarchy procedure, the patient is desensitized to the predominant fear. In a dental situation, the procedures needed for the child from the initial appointment to the final appointment are arranged in a hierarchy from the least painful/fearful ones (procedures needing local anesthesia like pulp therapy and extractions). When the child gets gradational exposure to these procedures they will be ready to take the next level procedure without much apprehension. • Tell-show-do or retraining can be part of desensitization procedure. Voice control: Voice control is a type of aversive conditioning behavior management technique. This technique is used to control a child who is crying loudly and uncontrollably. The dentist acts as if he is very angry and not happy with the child and raises his voice to a



high pitch and tells the child to stop crying and a mention is made that it is not a place where he can play around or keep crying. This is usually carried out on children of 3–6 years. Most often the children seeing the dentist’s unhappiness become quiet and start listening to the dentist’s instructions. If this technique fails, the dentist may have to carry out HOME to establish communication with the child. It is also found that more than the high pitched voice, the dentist’s facial expressions bring out the desired response from children. Hence the face should express the unhappiness of the situation. This is perceived by the child and will make him respond positively to the situation. Objectives • Gain the attention and compliance. • Avert negative and avoidance behavior. • Establish appropriate adult–child roles. Used appropriately, this is one of the effective behavior management techniques to control a child exhibiting temper tantrums or defiant behavior. If this technique is used on a child at the end of the appointment, the dentist makes a sincere attempt to talk to the child and explains that this happened because he/she did not listen to him initially. This helps the dentist to establish a relationship with the child and shows that if the child obeys the dentist’s command, it will be a pleasant experience and such strategies will not be applied to him. In the author’s experience, children experiencing either voice control or HOME (discussed later) become very cooperative later on and turn to be the best patients thereafter. Always a written consent or an explanation of this technique to the parents prior to its use will help the parents understand the need of these techniques. If not explained prior to use, the parent may feel that the dentist is not patient enough with his child. Protective stabilization (medical immobilization or treatment immobilization or restraining): The use of any type of protective



stabilization in the treatment of infants, children, adolescents or persons with special health care needs is a topic that concerns health care providers, care givers and the public. Protective stabilization (restraining) is defined as the restriction of patient’s freedom of movement, with or without the patient’s permission, to decrease risk of injury while allowing safe completion of treatment. The restriction may involve another human(s), a patient stabilization device or a combination thereof. The use of protective stabilization has the potential to produce serious consequences, such as physical or psychological harm, loss of dignity, violation of a patient’s rights and even death. Because of the associated risks and possible consequences of use, the dentist is encouraged to evaluate thoroughly its use on each patient and possible alternatives. Partial or complete stabilization of the patient sometimes is necessary to protect the patient, practitioner, staff or the parent from injury while providing dental care. Protective stabilization can be performed by the dentist, staff or parent with or without the aid of a restrictive device. The dentist should always use the least restrictive, but safe and effective and protective stabilization. The use of a mouth prop in a compliant child is not considered protective stabilization. The need to diagnose, treat and to protect the patient, practitioner, staff and parent should be considered for the use of protective stabilization. Points to consider • Other alternative modalities • Dental needs of the patient • The effect on quality of dental care • Patient’s emotional development • Patient’s physical considerations Protective stabilization, with or without a restrictive device, performed by the dental team requires informed consent from a parent. Informed consent must be obtained and documented in the



patient’s record prior to use of protective stabilization. Due to the possible aversive nature of the technique, informed consent also should be obtained prior to a parent performing protective stabilization during dental procedures. Furthermore, when appropriate, an explanation to the patient regarding the need for restraint, with an opportunity for the patient to respond, should occur. In the event of an unanticipated reaction to dental treatment, it is incumbent upon the practitioner to protect the patient and staff from harm. Following immediate intervention to assure safety, if techniques must be altered to continue delivery of care, the dentist must have informed consent for the alternative methods. The patient’s record should include: • Informed consent • Type of stabilization used • Indication for stabilization • The duration of application of stabilization • Frequency of stabilization evaluation and safety adjustments • Behavior evaluation/rating during stabilization Objectives • Reduce or eliminate untoward movement • Protect patient and dental staff from injury • Facilitate delivery of quality dental treatment Indications • Patient requiring immediate diagnosis/limited treatment and cannot cooperate due to lack of maturity, mental or physical disability • When patient or dentist would be at the risk without the protective use of immobilization



Contraindications • A cooperative patient • Patient who cannot be immobilized safely due to associated medical conditions • Patients who have experienced previous physical or psychological trauma from protective stabilization (unless no other alternatives are available). • Nonsedated patients with nonemergent treatment requiring lengthy appointments Precautions • Tightness and duration of the stabilization must be monitored and reassessed at regular intervals • Stabilization around extremities or the chest must not actively restrict circulation or respiration • Stabilization should be terminated as soon as possible in a patient who is experiencing severe stress or hysterics to prevent possible physical or psychological trauma Types of restraints • Oral: Mouth props, padded wrapped tongue blades, rubber/plastic bite blocks • Body: Papoose board, triangular sheet, Pediwrap, bean bag dental chair insert, safety belt, extra-assistant • Extremities: Posey strap, velcro straps, towel/tape, extraassistant • Head: Forearm support, head positioner, plastic bowl, extraassistant Pediwrap: Reinforced nylon meshsheet with velcro closures available in small, medium and large sizes which is placed on prepositioned chair.



Child is placed on the wrap and velcro fastners are put on chest followed by arms and legs to avoid movements. Papoose board (Fig. 8.12): Secures child against a rigid base with three pairs of canvas straps or single strap for very young child. Velcro system is easy to close and adjusting by pressing or peel apart fasteners.



FIGURE 8.12 Papoose board.



• Restrains even the most uncooperative patients. Hand over mouth exercise — HOME (Fig. 8.13): Hand over mouth



exercise was introduced by Dr Evangeline Jordan. It is not widely used in recent times because of its legal implications. However, many dentists use this efficiently to control a child who is crying uncontrollably. It is used as a last resort when all the other management techniques have failed and to gain the attention of the child so that communication can be established and cooperation is obtained for safe course of treatment. It was called emotional surprise therapy by Lampshire and as aversive conditioning by Kramer.



FIGURE 8.13 Hand over mouth exercise.



Objectives • To gain the attention of child enabling communication so that behavioral expectations can be explained • To eliminate inappropriate avoidance responses to dental treatment



• To ensure child’s safety in the delivery of quality dental treatment • To establish appropriate learned responses Indications: A healthy child who is able to understand and cooperate and exhibits defiant, hysterical avoidance behavior. Contraindications • When the child is in pre-cooperative period where communication is not possible • When the child is mentally and physically challenged • When the child is a mouth breather due to obstructive causes • When the parental consent cannot be obtained • When the dentist is emotionally unstable Technique: The best description of this technique was given by Levitas in 1974. It is described as it is carried out on a child. The details of the technique are given in Box 8.3. Box 8.3



Best description of HOME



technique given by Levitas I place my hand over the child’s mouth to muffle the noise. I bring my face close to his and talk directly into his ear. “If you want me to take my hand away, you should stop screaming and listen to me. I only want to talk to you and look at your teeth.” After a few seconds, this is repeated, and I add, “Are you ready for me to remove my hand”? Almost invariably there is a nodding of the head. With a final word of caution to be quiet, the hand is removed. As it leaves the face, there may be another wail with the garbled request, “I want my mommy.” Immediately the hand is replaced. The admonition to stop screaming is repeated, and I add, “You want your mommy?” Once again the head bobs. And then I say, “All right, but you must be quiet, and I will bring her in as soon as I



am finished. O.K.?” Again the nod – and the hand is slowly lowered. My assistant is always present during HOME to help restrain flailing arms and legs so that no one is physically injured. By restraining the child he can be made aware of the fact that his undesirable coping strategies are not necessary or useful. While the child is composing herself, I begin to talk – about his clothes, about his freckles, about his pets, about almost anything and no reference is made to what has gone before. As far as I am concerned, that is done and over. If there is an attempt on the part of the child to start again, a gentle but firm reminder that the hand will be replaced is usually enough to make him reconsider. It is sometimes difficult to convey HOME with the written word, for voice control and modulation are essential for HOME to be most effective. This technique is usually very effective in the age group of 3–6 years. Modifications for hand over the mouth technique are hand over the mouth with airway restriction/restricted (HOMAR) and towel over mouth. If airway is restricted by closing the mouth and nose with the hand, then it is hand over mouth with airway restriction (HOMAR) and if towel is used for closing the mouth, it is known as towel over mouth technique.



CONCLUSION Having tremendous amount of patience is essential to be a successful pediatric dentist. This one trait in the dentist can win the trust of many parents and children and help the dentist establish a long-term relationship with them. It also helps to understand the child and the situation better and choose an appropriate strategy to handle them. A student who regularly interacts with children unknowingly learns many behavior management strategies. However, knowing the different behavior management strategies as explained above is very essential before treating children. As time passes by, choosing the right behavior management techniques becomes simple and natural for a pediatric dentist who treats



children on a regular basis. General dentists who are not thorough with these strategies can always refer the uncooperative children to a pediatric dentist who can approach them better and may be able to instill a positive dental attitude in them.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Define behavior management and behavior modification. Explain the fundamentals of behavior management and describe the management strategies used on a preschooler who shows happy hustle-bustle behavior in the reception area. 2. Explain the different behavior management techniques used in managing a child in the dental office with application of the child psychology theories.



Short Notes 1. Frankl’s behavior rating scale 2. Wright’s classification of cooperative behavior 3. Factors controlling behavior of a child 4. Multisensory communication 5. Aversive management techniques 6. Modeling 7. Contingency management 8. Retraining 9. Systematic desensitization 10. Tell-show-do 11. HOME 12. Voice control 13. Parenting attitudes 14. Importance of scheduling appointments in pediatric dental



practice



SUGGESTED READING 1. American Academy of Pediatric Dentistry Handbook, 1999. 2. American Academy of Pediatric Dentistry Reference Manual 2006 – 2007. Pediatric Dentistry 28 7 2006 or ref. to website. www.aapd.org 3. American Academy of Pediatric Dentistry Reference Manual. Guideline on behavior guidance for the pediatric dental patient, Reference Manual 2006–2007. Pediatric Dent. 2006; 28(7):97–111. 4. Do, Catherine: Applying the social learning theory to children with dental anxiety. J Contemp Dent Pract 5 1 2004:1–8. (At www.thejcdp.com) 5. Fenlon, WL, Dabbs, AR, Curzon, ME. Parental presence during treatment of the child patient: a study with British parents. Br Dent J. 1993; 174:23–28. 6. Figel, RJ. Guiding and managing the child dental patient: a fresh look at old pedagogy. J Dent Educat. 2001; 13:69–77. 7. Frankl, SN, Shiere, FR, Fogels, HR. Should the



parent remain in the operatory? J Dent Child. 1962; 29:150–163. 8. Lampshire, EL, Control of pain and discomfortGoldman H, et al, eds. Current Therapy in Dentistry Vol IV. Mosby, St Louis, 1970. 489–525. 9. Levitas, TC. HOME – Hand over mouth exercise. J Dent Child. 1974; 41:178. 10. Lyons, RA. Understanding basic behavioral support techniques. Spec Care Dentist. 2009; 29(1):39–50. 11. Mathewson, RJ, Primosch, RE. Fundamentals of Pediatric Dentistry, 3rd edn. Chicago: Quintessence; 1995. 12. McDonald, RE, Avery, DR, Dean, JA. Dentistry for the Child and Adolescent, 8th edn. St. Louis: Mosby; 2004. 13. McElroy, CM Dentistry for Children, Californian Dental Assoc Trans 1895; 85 14. Rimm, DC, Masters, JC. Behavior Therapy: Techniques and Empirical Findings. New York: Academic Press; 1974. 15. Sarnat, H, Peri, JN, Nitzan, P, Perlberg, A. Factors which influence cooperation between dentist and child. J Dent Educ. 1972; 36:9–15. 16. Starkey, PE. Training office personal to manage children. In: Wright GZ, ed. Behavior



Management in Dentistry for Children. Philadelphia: Saunders, 1975. 17. Venham, LL. The effect of mother’s presence on the child’s response to dental treatment. J Dent Child. 1979; 46:51–57. 18. Wright, GZ. Nonpharmacological Management of Children’s behaviors. In: Mc Donald RE, Avery DR, Dean JA, eds. Dentistry for the Child and Adolescent. 8th edn. St. Louis: Mosby; 2004:34. 19. Wright, GZ, Starkey, PE, Gardner, DE. Managing Children’s Behavior in the Dental Office. St. Louis: Mosby; 1983.



CHAPTER 9



Pharmacological Behavior Management MY Padmanabhan, MS Muthu and N SivaKumar



CHAPTER OUTLINE Introduction History of Sedation and Anesthesia Safety of anesthetic agents Uniqueness of pediatric patients Informed consent Basic Concept of Sedation and General Anesthesia Goals of Sedation and Anesthesia General Guidelines Selection of candidates Sedation Techniques General Anesthesia Maintenance Completion of procedure Recent advances in sedation Conclusion Suggested Reading Self-assessment Questions



“Primum nor curarum - first do no harm”.



Introduction The mind of a child is a blank slate on which experience writes its lessons. Negative dental experiences are major causes of long-



standing fear and anxiety towards dental treatment. Conventional behavior management techniques can allay these unwanted physiological responses in majority of the pediatric patients, but a significant proportion of children still offer a challenge to the pediatric dentist. The essence of providing dental care to the pediatric patient does not merely involve a ‘drill and fill’ procedure, but dwells around the ability of the dentist to guide the apprehensive child comfortably through the dental treatment. The child who requires dental treatment is frequently not capable of cooperative behavior. Under such circumstances, performing technically complex dental treatment on young children becomes very difficult. Most of the dental materials are technique sensitive and performing certain procedures in an uncooperative child is almost impossible, without compromising the quality of the procedure. It is also important in clinical pediatric dentistry to provide dental care without inflicting psychological trauma to children. Although many behavior management techniques exist, most of these techniques are often unsuccessful or inappropriate to overcome the anxiety of extremely fearful and very young children (less than 3 years old). These techniques can also involve a significant amount of time, during which the patient’s dental condition may deteriorate. In such situations, pharmacologic management may be the treatment of choice. Sedation and analgesia for pediatric dental procedures performed within the dental office and in hospital environment are becoming more frequent due to tremendous pressure on health care measures to be more predictable, cost-effective and ‘productive’. The aim of this chapter is to describe conscious sedation and general anesthesia procedures in detail and the agents used for sedation and general anesthesia. A brief history of the discovery of anesthesia is also given in the beginning of this chapter.



History of Sedation and Anesthesia The history of sedation dates back to the ancient times when Egyptians had used various narcotic agents and the Chinese



employed Hashish, a preparation of cannabis composed of compressed trichomes with psychoactive properties similar to marijuana, for its analgesic and sedative effect. European physicians did their best to relieve their patients’ pain, through sedation, most often through the judicious use of opium or, after 1680, through Laudanum, the mixture of opium in sherry introduced by Thomas Sydenham (1624–1689). Henry Hill Hickman (1800–1830) was a general practitioner from Shropshire, England, who in 1824 explored methods of painless surgery on animals using both carbon dioxide and nitrous oxide gases. The credit for the advent of sedation in dentistry goes to Horace Wells, who propagated the technique of utilizing nitrous oxide for dental extractions. Wells had earlier been one of the stage-volunteers who tried inhaling nitrous oxide during a demonstration by Professor Gardner Quincy Colton (1814–1998) at Union Hall in Hartford, Connecticut. The next day Wells submitted himself to the extraction of one of his own molars by fellow dentist Dr John Riggs. Colton administered the nitrous oxide. Almost insensible, Wells felt no more than a pinprick. With the help of his former colleague Morton, Wells was ready for a public demonstration. Unfortunately, during the public demonstration at Massachusetts General Hospital that Wells staged to publicise his discovery, the patient stirred and cried out. He had been under-anaesthetised; the gasbag was withdrawn too soon. The reaction of Wells’ audience, a class of irreverent medical students, was scornful. There was laughter and cries of ‘humbug’. Wells was mortified and in the rest of his short life, it seems he never really recovered from the humiliation. On Friday, October 16, 1846 Dr. William Thomas Green Morton, a dentist from Harford, Connecticut, and Dr. Well’s partner, administered ether to Mr. Gilbert Abbott for the removal of a tumor by the well-known surgeon Dr. John C. Warren at Massachusetts General Hospital. The surgery which was a great success was considered as a milestone in the field of sedation and anesthesia. Morton tried to patent this anesthetic under the name of Letheon but soon gave up his intentions to widespread insistence



that his discovery be free for all humankind. Nitrous oxide was not used until 1863, when Colton reintroduced the gas into dentistry. He subsequently developed Colton dental institutes—which specializes in dental extractions under nitrous oxide anesthesia. In 1868, Andrews, an American physician, introduced the combined use of nitrous oxide and oxygen inhalation. The first successful intravenous agent—hexobarbital—was introduced in 1932 by Weese in Germany. Thiopental, synthesized that same year, was first used in medicine by Lundy in 1934. Jorgensen is often considered to be the father of intravenous conscious sedation in dentistry. Jorgensen and Leffngwell from the University of Loma Linda developed a technique named as Jorgensen or Loma Linda technique, which uses multiple agents—pentobarbital, meperidine and scopolamine—carefully titrated to defined end points. Thereafter many drugs have been introduced to produce varying levels of central nervous system depression—diazepam, ketamine, fentanyl and midazolam to name a few.



Safety of Anesthetic Agents Considering the number of patients treated under general anesthesia and conscious sedation the record of safety and efficacy of the anesthetic agents is truly remarkable. D’Eramo E reported in 1992, that the average incidence of mortality for patients undergoing dental office anesthesia is about 1 in 3,00,000. A review by Keenan RL in 1994 revealed, a rate of 1 to 2 deaths per 10,000 anesthetics used for anesthesia to different patients in hospitals. Although the exact rates vary according to the study cited, it is generally agreed upon the safety of anesthesia as performed by competent practitioners according to established standards of care.



Uniqueness of Pediatric Patient Anatomic and physiologic differences There are several anatomic and physiologic differences between the adult and the child. The differences in the pulmonary and



cardiovascular systems are of greatest interest to the anesthesiologists. The differences in respiratory system make the child more susceptible to respiratory failure faster. The important differences are enumerated below: 1. The basal metabolic rate is high in children leading to greater oxygen consumption. Hence, when apnea or inadequate ventilation occurs, hypoxia develops faster in children. 2. The enlarged tongue when displaced posteriorly along with the larger tonsils in children can lead to respiratory obstruction. 3. Airways of children are smaller and shaped in a funnel form, with the narrowest part of the trachea lying below the vocal cords in contrast to the tubular form of larynx found in adults. 4. The lower airway of infants and children are easily obstructed by mucus, edema and pus. 5. In children, the cardiac output and oxygen demand is high but with limited oxygen reserve. Hence, compromised oxygen delivery can rapidly result in dysrhythmias and cardiac arrest.



Behavioral characteristics Some of the behavioral characteristics of children cannot be controlled by the clinician, yet they often can have a significant impact on the outcome of clinical treatment. Few such characteristics described by Saxen MA et al in 1999 are enumerated below: 1. Child’s age 2. Cognitive development 3. Degree and expression of fear and anxiety 4. Child temperament



Informed Consent Obtaining informed consent before any sedation or general anesthesia procedure is essential. This should be obtained from the parent or a



legal guardian of the child before the procedure. The parent or legal guardian should be given clear, concise explanation about the need for the procedure and the possible sequelae, in terms that are familiar to them. The consent form should form a separate part of the hospital records. A sample consent form used here is given in Box 9.1. Box 9.1



Sample consent form



DEPARTMENT OF PEDIATRIC DENTISTRY Meenakshi Ammal Dental College, Maduravoyal CONSENT FOR TREATMENT UNDER GENERAL ANESTHESIA By signing this form, I agree that Dr ________________ his or her associates, members of the department of Pediatric Dentistry and appropriately licensed personnel of Meenakshi Ammal Dental College, may perform the following operations or procedure. I understand that Meenakshi Ammal Dental College provides educational training for healthcare professionals and agree that residents and students may assist the procedure on my son/daughter. PROCEDURE: Any necessary dental treatment under general anesthesia, including x-rays, prophylaxis, periodontal therapy, restorations, extractions, pulpal therapy, space maintainers, fluoride treatment and photographs. EXCEPTIONS, IF ANY: ____________________________________ • I acknowledge that I have had an opportunity to discuss with Dr. ________ my son’s/daughter’s condition, the planned operation or procedure, its purpose and nature, reasonable alternatives, possible consequences of remaining untreated, risks, benefits and possible consequences. • The procedure stated above is the one planned by my dentist at this time. I realize that the dentist will not be able to anticipate or explain all the possible risks and complications which could occur. I agree that additional procedures may be performed if



my dentist believes that they become necessary during this procedure. • I understand there are no guarantees that this procedure will be successful and that an undesirable result does not necessarily mean that an error was made. • During this procedure I also consent to have any anesthetics given to my son/daughter that the anesthesiologist or the physicians performing the procedure believe are needed. I realize that there are medical risks associated with the anesthesia. • If I am scheduled to receive blood or blood products, my dentist has advised me of the risk and alternative therapies available. If it becomes medically necessary for my son/daughter to receive blood or blood products, I agree to be transfused and accept the related risks. • I agree to the disposal of any tissue, organ or body part removed during surgery. I agree that any material removed during surgery may be used for research purposes. • I give my permission for pictures to be taken for educational purposes as long as the identity is not made known. ___________________________________________ Signature Name & Relation: ____________________________________ Date: ________________ Time: _________________ AM/PM ________________ Signature of Dentist obtaining consent



Basic Concepts of Sedation and General Anesthesia For all practical purposes, it is beneficial to categorize the patient based on the level of consciousness, patency of airway and ability to self-ventilate rather than the techniques (route of administration) employed. The American Society of Anesthesiologists’ proposed a



system for classifying sedation practices based on the level of consciousness, which was adopted by American Academy of Pediatric Dentistry. The levels of sedation as proposed by this system of classification are as follows. Minimal sedation (formerly anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Though cognitive functions and coordination may be impaired, ventilatory and cardiovascular functions remain unaffected. Moderate sedation (formerly conscious sedation or sedation/analgesia) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. The sedated patient may respond purposely to verbal commands (like “open your mouth”) which may or may not be accompanied by light tactile stimulation (light tap), however, eliciting a verbal response to commands may not occur spontaneously. The patient is still in an interactive state where age appropriate responses (such as crying, in case of young children) may be expected. With moderate sedation, no intervention is required to maintain a patent airway and spontaneous ventilation is adequate. If the patient is not making spontaneous efforts to breathe, then the patient should be considered to be deeply sedated. Cardiovascular function is usually maintained. This is the preferred level of sedation for performing dental procedures in a dental office. Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. There may be partial or complete loss of protective airway reflexes and the ability to independently maintain ventilatory function may be impaired. General anesthesia is a drug-induced loss of consciousness during which patients are not aroused, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired because of depressed spontaneous ventilation or druginduced depression of neuromuscular function. Hence, skilled assistance is usually required to maintain a patent airway, and



positive-pressure ventilation. Cardiovascular function may be impaired. The characteristics of different types of sedation has been summarized as in Table 9.1. Table 9.1 Levels of sedation Minimal sedation



Status



Moderate sedation/Conscious Deep sedation sedation



General anesthesia



Responsiveness Normal to Purposeful to verbal verbal or light tactile stimulation stimulation



Purposeful to repeated or painful stimulation



No response to painful stimulation



Arirway



Maintained



Maintained



May need Often needs intervention intervention



Ventilation



Normal



Adequate



May need assistance



Often needs assistance



Cardiovascular



Normal



Maintained



Usually maintained



Usually maintained



Goals of Sedation and Anesthesia The foremost goal is to optimize patient safety by minimizing complications. The goals of sedation in the pediatric patient for diagnostic and therapeutic procedures are to: • Guard the patient’s safety and welfare • Minimize physical discomfort and pain • Control anxiety, minimize psychological trauma, and maximize the potential for amnesia • Control behavior and/or movement to allow the safe completion of the procedure • Return the patient to a state in which safe discharge from



medical supervision, as determined by recognized criteria is possible.



General Guidelines Selection of Candidates Medical history: A comprehensive medical history which gives due consideration to the presence of any medical conditions that can place the child at increased risk of respiratory or cardiovascular depression during sedation or anestheisa should be taken. Evaluations of previous medical consultations or reports by itself can reveal majority of underlying medical problems, the rest of which can be diagnosed by appropriate physical examination and laboratory tests. Physical status: The American Society of Anesthesiologists (ASA) maintains a graded physical status classification as a useful tool for assessing a patient’s appropriateness for procedural sedation (Table 9.2). Patients in ASA class I and II are considered appropriate candidates for minimal, moderate or deep sedation and in-office anesthesia for dental procedures. ASA class III patients can be treated under ambulatory anesthesia, provided their medical conditions were stable for at least 3 months. ASA class IV patients are best managed in a hospital setting after appropriate medical consultations. Table 9.2 ASA physical status classification Grade



Physical status



Class I



A normally healthy patient



Class II



A patient with mild systemic disease (e.g. controlled reactive airway disease)



Class III



A patient with severe systemic disease (e.g. a child who is actively wheezing)



Class IV



A patient with severe systemic disease that is a constant threat to life (e.g. a child with status asthmatics)



Class V



A moribund patient who is not expected to survive without the operation (e.g. a



patient with severe cardiomyopathy requiring heart transplantation)



Airway assessment: A directed physical examination to assess the airway should be performed prior to any procedure under sedation. Presence of active upper and lower respiratory tract illnesses, potentially difficult airways (as in patients with short necks, small mandibles, large tongues or trismus), severe tonsillar hypertrophy and obesity increase the patient’s risk for experiencing adverse events during sedation or in-office anesthesia and are encouraged to consult with appropriate subspecialists and/or an anesthesiologist prior to sedation. Presence of caretaker: The pediatric patient needs to be accompanied to and from the treatment facility by a parent, legal guardian or other responsible person. It is preferable to have 2 accompanying persons, if one of them would be driving the vehicle to transport the child following sedation. This is particularly important for infants and toddlers transported in car safety seats, who are at risk of resedation after discharge because of residual prolonged drug effects with the potential for airway obstruction. Children who cannot be taken care of by a responsible adult during the early post-discharge period ( 0.7 ppm



Birth to 6 months



Not recommended



Not recommended



Not recommended



6 months to 3 years



0.25 mg



Not recommended



Not recommended



3 to 6 years



0.5 mg



0.25 mg



Not recommended



6 to 16 years



1 mg



0.5 mg



Not recommended



Topical Fluorides Definition Topical fluorides are those fluoride containing agents which are applied to the tooth surfaces in regular intervals in order to prevent the development of caries. They exert an anticaries effect by increasing the concentration of fluoride in the outermost surface of the enamel. Topical fluorides can be administered either by a professional person in the dental office at regular intervals or by the individual themselves by self-administration on a daily basis. Professionally applied topical fluorides have relatively large amount of fluoride when compared to self-administered topical fluorides.



Professionally Administered Topical Fluoride



Professionally administered topical fluoride agents are: 1. 2% Sodium fluoride 2. 8% Stannous fluoride 3. 1.23% Acidulated phosphate fluoride 4. Fluoride varnishes 5. Intra-oral fluoride releasing devices



Sodium Fluoride (2%) Sodium fluoride was developed by Knutson et al in 1947. It has a neutral pH of 7 and the available fluoride in ppm is 9040.



Preparation Sodium fluoride (2%) is prepared by dissolving 20 g of sodium fluoride powder in one liter of distilled water. The prepared 2% sodium fluoride is always stored in plastic bottles.



Application: Knutson technique First thorough oral prophylaxis is done. The teeth are isolated with cotton rolls. Sodium fluoride is applied using cotton applicators. It is applied only once due to formation of CaF2, which prevents further diffusion of F− ions. This is called choking off phenomenon. The patient should refrain from eating and drinking for next 30 minutes.



Number of applications Each application is done for about four minutes. Four applications are done at weekly intervals. Four applications each at the ages of 3, 7, 11 and 13 years (Table 13.2) which corresponds to primary dentition, eruption of first permanent molars and permanent incisors, eruption of premolars and permanent canines and eruption of second molars. Table 13.2



Sodium fluoride application 2% sodium fluoride application schedule



3 years of age



7 years of age



11 years of age



13 years of age



First week Second week Third week Fourth week



Mechanism of action When 2% sodium fluoride is applied topically, it interacts with the hydroxyapatite crystals of the surface enamel to form calcium fluoride (CaF2). This formed calcium fluoride is the dominant product and thus interferes with further diffusion of fluoride. Hence sodium fluoride is applied only once and further applications serve no purpose due to this reason. The calcium fluoride thus formed further reacts with the hydroxyapatite to form fluoridated hydroxyapatite. Thus the fluoride content of the surface enamel is enhanced and in turn enables the tooth to resist cariogenic attacks.



Advantages 1. Chemically stable 2. Acceptable taste 3. Non-irritating to gingiva 4. Does not discolor teeth 5. Inexpensive



Disadvantage Four visits for four consecutive weeks by the patient is needed for every course of application which is difficult from the patient and parent’s view.



Stannous Fluoride (8%) Stannous fluoride (8%) solution has a pH of 2.1 to 2.3. The concentration of fluoride in 8% stannous fluoride is 19360 ppm.



Preparation Stannous fluoride powder (0.8 g) is premeasured and stored in gelatine capsules. Whenever the patient arrives, a fresh solution of stannous fluoride is prepared. While preparing the solution, the powder and the water are mixed only in a plastic container. The solution is made fresh by mixing the 0.8 g of stannous fluoride powder with 10 ml of distilled water. Stannous fluoride is always freshly prepared and the powder is always stored in air tight capsules as it is highly unstable. The tin component of stannous fluoride is highly reactive and gets oxidised easily to its stannic form, thus reducing the anticaries efficacy of the product.



Application: Muhler technique (1957) The first step is performing a thorough oral prophylaxis. The teeth are isolated and stannous fluoride is applied using cotton applicators. The applied surfaces of the teeth have to be kept moist for 4 minutes. This is obtained by reapplication every 15 to 30 seconds. As mentioned earlier, the patient should refrain from eating or drinking for next 30 minutes. The number of applications required is once per year.



Mechanism of action When stannous fluoride reacts with hydroxyapatite of the dental enamel, the fluoride as well as the tin combines with it to form a crystalline product known as stannous trifluoro phosphate (Sn3F3PO4). This stannous trifluorophosphate is highly resistant to decay. When stannous fluoride reacts with hydroxyapatite, 4 end products are formed:



a. Stannous trifluorophosphate b. Tin hydroxyphosphate c. Calcium trifuorostannate d. Calcium fluoride. At low concentration, stannous trifluorophosphate and tin hydroxyphosphate are formed. At very high concentration, stannous trifluorophosphate and calcium trifluorostannate are formed. It is essential to observe formation of stannous trifluorophosphates which have the anticariogenic effects in both high and low concentration. Calcium trifluorostannate which is formed during high concentrations is also believed to have anticaries action. Additionally, calcium fluoride is formed in small amounts as one of the end products at both low and high concentrations. This calcium fluoride again combines with hydroxyapatite to form fluorhydroxyapatite. Tin hydroxyphosphate gets dissolved in the oral fluids and gives the metallic taste when stannous fluoride is applied. At low concentration: 1. Stannous fluoride + hydroxyapatite → stannous trifluorophosphates (anticariogenic) + tin hydroxyphosphate (metallic taste) + calcium fluoride 2. Calcium fluoride + hydroxyapatite → fluorhydroxyapatite (anticariogenic) At high concentration: 1. Stannous fluoride + hydroxyapatite → stannous trifluorophosphates (anticariogenic) + calcium trifluorostannate (anticariogenic) + calcium fluoride 2. Calcium fluoride + hydroxyapatite → fluorhydroxyapatite (anticariogenic)



Advantages



1. Rapid penetration of tin and fluoride within 30 seconds. 2. The tin-trifluorophosphate complex formed on the enamel surface is more resistant to decay than enamel itself.



Disadvantages 1. Highly unstable 2. Has a metallic taste 3. Causes gingival irritation 4. Discoloration of teeth 5. Staining of margins of restorations



Acidulated Phosphate Fluoride (1.23%) Acidulated phosphate fluoride is simply an acidified sodium fluoride with phosphoric acid in order to gain more depth of fluoride penetration when applied on the tooth. It can be applied either as a solution or gel. The pH of APF solution is 3 and APF gel is 4 to 5. The fluoride concentration is 12,300 ppm.



Preparation Acidulated phosphate fluoride solution is prepared by dissolving 20 g of sodium fluoride in one liter of 0.1M phosphoric acid. In order to adjust the pH to 3 and fluoride concentration at 1.23%, 50% hydrofluoric acid is added to this. A gelling agent methylcellulose or hydroxyethylcellulose is added to the solution and pH is adjusted at 4–5 in order to make a gel.



Application After performing oral prophylaxis, the teeth are isolated with cotton rolls. The solution is applied using cotton applicators continuously to keep the teeth moist for 4 minutes. Floss is passed through interproximal embrassure. The gel form of APF is applied using trays. The tray is inserted and the patient is asked to bite tightly for 4



minutes. The gel thins out under the biting force because of its thixotropic nature. Salivary ejectors are used during this application. Patient should not eat or drink for next 30 minutes. The recommended number of applications per year is twice.



Mechanism of action When APF is applied initially, it leads to dehydration and shrinkage in volume of hydroxyapatite crystals, which on further hydrolysis forms an intermediate product called dicalcium phosphate dihydrate (DCPD). This DCPD is highly reactive with fluoride and starts forming immediately when APF is applied. Fluoride penetrates more deeply to form fluorapatite.



Advantages APF solution: 1. Fluoride uptake is greater 2. 50% more effective than NaF 3. Stable, long shelf-life when stored in opaque plastic bottle 4. Inexpensive 5. Easy to prepare APF gel: 1. Flavored taste hence highly acceptable 2. Easy to apply 3. Reapplication not required 4. Can be self-applied 5. Caries reduction more than APF solution



Disadvantages APF solution:



1. Solution is acidic, sour and bitter in taste 2. Teeth must be kept moist for 4 minutes with solution 3. Prolonged exposure of composite restorations results in loss of material and surface roughening APF gel: 1. Can cause irritation to inflamed gingival tissue 2. Can cause irritation to open carious lesions, hence restoration of all carious teeth before application



Fluoride Varnishes Fluoride varnishes are developed in order to increase the retention of topical fluoride on to the enamel for a longer period of time. Thus the reaction time of fluoride with the enamel is also increased thereby providing an improved cariostatic action. Duraphat: This fluoride varnish contains sodium fluoride. It contains 22,600 ppm of fluoride. The varnish form is made by the alcoholic solution of natural varnishes. Since it is in varnish form, it sets very rapidly in the presence of moisture when applied. It remains on to the applied tooth surface for up to the next 12 hours after application. Fluorprotector: This product contains 2% difluorosilane. It contains 7000 ppm of fluoride. The varnish form is made by polyurethane lacquer which is dissolved in chloroform. It is available as 1 ml ampoules. Each ampoule contains 6.21 mg of fluoride. Fluorprotector varnish sets rapidly than duraphat. Varnish application procedure: After thorough oral prophylaxis, the tooth is dried and varnish is applied over all the teeth surfaces. Cotton rolls are not used for isolation as the varnish sticks to it. Patient is instructed not to close the mouth and to remain with the mouth wide open for 4 minutes for the varnish to dry. Patients are asked to refrain from eating or drinking for one hour.



Intraoral Fluoride Releasing Devices Intraoral fluoride releasing devices are those which release a predetermined quantity of fluoride inside the mouth over a long period when attached on to the tooth surfaces. It basically consists of a rate controlling membrane inside which a central depot of fluoride containing plastic copolymer matrix is embedded. The rate at which the fluoride ions are released into the oral cavity from the matrix core is controlled by the copolymer membrane. A typical intraoral fluoride releasing device can release about 0.02 to 0.2 ppm of fluoride for a period 3 to 4 months at a stretch. These devises are of use to those who have impaired salivary secretions and those with special health care needs who are unable to maintain routine oral hygiene.



Self-Administered Topical Fluorides Fluoride Dentifrices (Fig. 13.2) Fluoride containing dentifrices can be classified according to the fluoride content as:



FIGURE 13.2 Fluoride dentifrices (Courtesy: Colgate Palmolive Ltd, India).



1. High potency fluoride dentifrices (>1000 ppm) 2. Low potency fluoride dentifrices ( 4.6



Inactive



4.6–4.5



Mildly active



4.4–4.2



Active



4.1 and less



Very active



The swab test is advantageous over the Snyder’s test, as no



collection of saliva is necessary. Therefore, it is particularly valuable in evaluating caries activity in very young children. However, the swab test is not widely used now.



5. Dip slide methods A specially designed dip slide of plastic is coated with LBS agar. Undiluted, paraffin stimulated saliva is flowed over the agar surface. The amount of saliva inoculated on the dip slide is relatively constant in spite of the method of inoculation. The plastic slide holders are positioned vertically with a slight tilt to assure both agar surfaces are wetted with saliva. Excessive saliva is allowed to drain on to a clean absorbent paper. The slide is then placed into a sterile tube, which is tightly closed and incubated at 35°C for 4 days. It is then removed and the colony density is determined by comparing it with a model chart that is provided. The lactobacilli will form transparent or white colonies. Readings of more than 10000 colonies per ml of saliva are considered high, whereas the readings of less than 1000 colony counts are considered low. Any result between 1000 and 10000 is considered medium. All agar surfaces indicated as negative at the time of examination should be carefully re-examined with reflected light for the appearance of colonies.



Based on Streptococcus mutans S. mutans may constitute less than 1% of the total flora of plaques. These concentrations can be extremely variable. S. mutans tends to be located at specific sites only; salivary counts neither pinpoint to its location on teeth nor estimate its degree of infection at a given site. Principle: The tests measure the number of S. mutans colonyforming units per unit volume of saliva. Culturing plaque samples from discrete sites such as occlusal tissues and proximal areas is an ideal method for the purpose of quantifying the S. mutans that have colonized on teeth. However, this is not practical and hence salivary samples may be used as a workable alternative. Incubation on a selective Streptococcus medium known as mitus—salivarius agar



(MSA) with the high concentration of sucrose (20%) and 0.2 µ bacitracin per millilitre (MSB) suppresses the growth of most non-S. mutans colonies.



a. Streptococcus mutans count tests The number of S. mutans in human’s saliva has been proposed as a reliable indicator of caries activity. In the quantitative evaluation of the number of S. mutans colony forming units, a serial dilution is accomplished, using 1 ml of saliva specimen. One ml aliquots of these serial dilutions are then plated using conventional mitis salivarius agar with the addition of sucrose and bacitracin. This is followed by an incubation period of 4 days, at which time the CFUs are counted. A threshold value of 2.5×106 CFU/ml of saliva has been suggested to select children considered to be at a high caries risk.



b. Dip Slide Method for S. mutans This method is very similar to that of dip slide method for lactobacilli. Undiluted paraffin-stimulated saliva is poured on a special plastic slide that is coated with mitis salivarius agar, containing 20% sucrose. The agar surface is thoroughly moistened and the excess saliva is allowed to drain off. Two discs containing 5 µg of bacitracin are placed on the agar, 20 mm apart. The slide is then tightly screwed into a cover tube and incubated at 37°C for 48 hours in a sealed jar. The scoring is done as follows: 1. Low: Colonies are discrete and could be readily counted at 15× magnification with the total count of CFU inside the inhibition zone less than 200. 2. Medium: The colonies are discrete and the number in the zone of inhibition is more than 200 at 32×. 3. High: The colonies are tiny and almost completely or totally cover the inhibition zone, with the number of colonies uncountable, when using a 32× magnification.



S. mutans tests using mitis salivarius medium with bacitracin are very good in identifying children with low caries increments. Positive scores do not correlate well with high caries increments. The tests are economical and suitable for mass screening to identify low-risk population who do not require preventive treatment.



Based on Both S. mutans and Lactobacilli Advanced dip slide methods of S. mutans and lactobacilli (dentocult and Strip mutans) (Fig. 16.6) S. mutans in saliva: S. mutans level in saliva is done using Dentocult SM (Orion Diagnostica, Finland), following the instructions of the manufacturer (Fig. 16.6). A disk impregnated with bacitracin is dropped inside the tube that contains selective culture media for S. mutans. To sample saliva, the strip is rotated 10 times on the surface of the tongue and put it into the tube with media and incubated at 37°C for 48 hours. The results of the strip were compared with the chart of the manufacturer (Fig. 16.7). The data were coded as follows:



FIGURE 16.6 Components of Dentocult and Strip Mutans kit.



FIGURE 16.7 Scoring chart for S. mutans.



• Code 0 & 1 — 105 106



Lactobacillus levels in saliva – dentocult LB



Dentocult method is a simple and highly practical method for estimating salivary levels of Lactobacillus and other aciduric microorganisms. It was introduced by Larmas in 1975. This method makes use of a self-contained kit with a shelf life of at least 1 year. This simplified, prepackaged selective culture system is easily adapted for office use and does not require special equipment.



Method Undiluted paraffin-stimulated saliva is poured over a plastic slide that is coated with LBS agar on both sides. Excess saliva is allowed to drain off and the slide is placed into a sterile tube. The tube which is tightly closed is incubated at 35°C to 37°C for 4 days. At the end of four days, the colony density on the slide is not counted, but is compared with a model chart and classified as about 1000, 10,000, 100,000 or 1,000,000 aciduric organisms/ml of saliva. • Code 0–103 mfc/ml • Code 1–104 mfc/ml • Code 2–105 mfc/ml • Code 3–106 mfc/ml



Older Methods Enamel solubility test It is same as Fosdick dissolution test. This test is not generally suited for office procedures. It is based on the fact that when glucose is added to saliva containing powdered enamel, organic acids are formed. These in turn decalcify the enamel resulting in an increase in the amount of soluble calcium in the saliva-glucose enamel mixture. The extent of increased calcium is supposedly a direct measure of the degree of caries susceptibility.



Salivary reductase test



Rapp in 1962, claimed that this test measures the activity of the reductase enzyme present in salivary bacteria. Principle involved: The reductase enzyme is involved in the formation of products dangerous to the tooth surface. The test measures the rate at which an indicator molecule diazoresorcinol, changes from blue to red to colorless or leukoform on reduction by the mixed salivary flora. Procedure: A kit is available under the trade name Treatex. 5 ml of stimulated saliva is collected in a plastic container with paraffin wax stimulation. The sample is then mixed with the dye diazoresorcinol which colors the saliva blue. As the dye is reduced, the color changes and the caries conduciveness reading are taken after 15 minutes. No incubation is needed. The results are interpreted as given in Table 16.4. Table 16.4 Interpretation of salivary reductase test: results Color change



Caries conduciveness



Blue in 15 minutes



Nonconducive



Orchid in 15 minutes



Slightly conducive



Red in 15 minutes



Moderately conducive



Red immediately on mixing



Highly conducive



Colorless in 15 minutes



Extremely conducive



Buffer capacity test: Buffer capacity can be quantitated using either a pH meter or color indicators. The test measures the number of milliliters of acid required to lower the pH of saliva through an arbitrary pH interval, such as from pH 7.0 to 6.0 or the amount of acid or base required to bring color indicators to their end point. Procedure: 10 ml of stimulated saliva is collected under oil at least 1 hour after eating. 5 ml of this is taken in a beaker. The pH of the saliva is adjusted to 7.0 by addition of lactic acid or base. The level of lactic



acid in the graduated cylinder is re-recorded. Lactic acid is then added to the sample until a pH of 6.0 is reached. The number of milliliters of lactic acid needed to reduce pH from 7.0 to 6.0 is a measure of buffer capacity. This number can be converted to milliequivalents per liter. There is an inverse relationship between buffering capacity of saliva and caries activity. The saliva of individuals whose mouth contains a considerable number of carious lesions frequently has a lower acid buffering capacity. This test, however, does not correlate adequately with caries activity.



Fosdick calcium dissolution test Principle: This test measures the milligrams of powdered enamel dissolved in 4 hours by acid formed when the patient’s saliva is mixed with glucose and powdered enamel. Procedure: 25 ml of stimulated saliva is collected, part of which is analyzed for calcium content. The rest is placed in an 8-inch sterile test tube with about 0.1 g of powdered human enamel. The tube is sealed and shaken for 4 hours at body temperature with test tube agitation equipment. After agitation, it is again analyzed for calcium content. The amount of enamel dissolution increases as the caries activity increases.



Drawbacks • Time required—4 hours • Not simple • Complex equipment needed • Personnel must be trained • High cost



Dewar test Principle: It is similar to the Fosdick calcium dissolution test except that the final pH after 4 hours is measured instead of the amount of calcium dissolved.



Caries Risk Test This test was described by Edelstein and Tinanoff and by Weinberger and Wright. This was initially thought to distinguish the caries competent child from the caries-incompetent child, both of whom appear caries free on examination. However, the accuracy of this test has not proved as helpful as anticipated.



Basic limitation of caries activity tests None of these tests are highly reliable indicators of expected/future caries increments because these tests measure only a single parameter.



CONCLUSION While the dental profession has made great strides in reducing the amount of caries in population through the wide application of fluoride, there remains a significant amount of work to be done in the area of risk assessment and its application to practice. Newer techniques and methods will be available in the future to assess the risk of an individual for caries and take appropriate preventive measures. This will help us to manage the disease rather than treating the effects.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Caries activity tests. 2. Define risk. Describe the clinical implications of caries risk assessment. Write about the dip slide methods in caries activity tests.



Short Notes 1. Snyder’s test



2. Alban’s test 3. Diagnodent 4. Cariogram 5. Cariostat 6. Quantitative light-induced fluorescence 7. Advantages and disadvantages of caries activity tests 8. Dentocult and Streptococcus mutans



SUGGESTED READING 1. Alaluusua, S, et al. Slide scoring method for estimation of Streptococcus mutans level in saliva. Swed Dent J. 1980; 4:81–86. 2. Alban, A. An improved Snyder test. J Dent Res. 1970; 49:641. 3. Ali, YA, Chandranee, NJ, Wadher, BJ, Khan, A, Khan, ZH. Relationship between caries status, colony forming units (CFU) of Streptococcus mutans and Snyder caries activity test. J Indian Soc Pedo Prev Dent. 1998; 16(2):56– 60. 4. Anderson, M. Risk assessment and epidemiology of dental caries: review of the literature. Pediatr Dent. 2002; 24:377–385. 5. Akyuz, S, et al. Dental caries and cariostat test in preschool children. J Marmara Univ Dent Fac. 1997; 2(4):616–620. 6. Barber, LR, Wilkins, EM. Evidence-based



prevention, management and monitoring dental caries. J Dent Hyg. 2002; 76(4):270–275. 7. Berg, JH. The marketplace for new caries management products: dental caries detection and caries management by risk assessment. BMC Oral Health. 2006; 6(suppl 1):S6. 8. Bratthall, D, Petersson, GH. Cariogram - a multifactorial risk assessment model for a multifactorial disease. 2005; 33:256–264. 9. Carlos, JP, Opening statements and orientationBibby BG, Shern RJ, eds. Proceedings on Methods of Caries Prediction 1978 1–2. [Spec Supp, Microbiology Abst]. 10. Crossner, CG, Hagberg, C. A clinical and microbiological evaluation of the dentocult dip-slide method. Swed Dent J. 1977; 1:85–94. 11. Crossner, CG. Salivary Lactobacillus counts in the prediction of caries activity. Community Dent Oral Epidemiol. 1981; 9:182–190. 12. Finn, SB, Clinical Pedodontics 4th edn. Saunders, Philadelphia, 1991. 518–536. 13. Galaviz, LAA, et al. Caries risk in children: determined by levels of mutans streptococci and Lactobacillus. J Clin Pediatr Dent. 2005; 29(4):329–334. 14. Green, GE, Weisenstein, PR. Salivary and plaquelactobacilli in the progression of



human dental caries. J Dent Res. 1959; 38:951– 960. 15. Hadley, FP. A quantitative method for estimating Bacillus acidophilus in saliva. J Dent Res. 1933; 13:415–428. 16. Klock, B, A comparison of different methods for prediction of caries activityBibby BG, Shern RJ, eds. Proceedings on Methods of Caries Prediction 1978 17–20. [Spec Supp, Microbiology Abst]. 17. Larmas, M. A new dip-slide method for counting of salivary lactobacilli. Proc Finn Dent Soc. 1975; 71:31–35. 18. Larmas, M. Saliva and dental caries: diagnostic tests for normal dental practice. Int Dent J. 1992; 42(4):199–208. 19. Newbrun. E. Caries activity tests. In: Cariology. 3rd edition. Quintessence Publishing Co, Inc. 1273-289, 989. 20. Nikiforuk G. Monitoring caries activity. In: Understanding dental caries- 2 Prevention basic and clinical aspects. Karger Publishing Co: 225-241. 21. Nishimura, M, et al. Assessment of the caries activity test (Cariostat) based on the infection levels of mutans streptococci and lactobacilli in 2-13 years old children’s dental plaque. J



Dent Child. 1998; 65(4):248–251. 22. Parkins, FM, Previous caries prediction testsBibby BG, Shern RJ, eds. Proceedings on Methods of Caries Prediction 1978 5–11. [Spec Supp, Microbiology Abst]. 23. Rapp, GW. A fifteen minute caries test. Illinois Dent J. 1962; 31:290–295. 24. Rodriguez, FE. Quantitative incidence of Lactobacillus acidophilus in the oral cavity as a presumptive index of susceptibility to dental caries. J Am Dent Assoc. 1931; 18:2118–2135. 25. Sandy, CE, Bulate, L. The salivary lactobacillus count as an index of caries activity. Aust J Dent. 1950; 54:18–26. 26. Snyder, ML. A simple colorimetric method for the estimation of relative numbers of lactobacilli in the saliva. J Dent Res. 1940; 19:349–355. 27. Snyder, ML. Laboratory methods in the clinical evaluation of caries activity. J Am Dent Assoc. 1951; 42:400–413. 28. Snyder, ML, et al. Evaluation of laboratory tests for estimation of caries activity. J Am Dent Assoc. 1962; 65:30–45. 29. Tinanoff, N, Douglass, JM. Clinical decision making for caries management in children. Pediatr Dent. 2002; 24(5):386–392.



30. Tsubouchi, J, et al. A longitudinal assessment of predictive value of a caries activity test in young children. J Dent Child. 1995; 62(1):34– 37.



CHAPTER 17



Dental Caries MS Muthu and N Sivakumar



CHAPTER OUTLINE Introduction Definition Etiology of Dental Caries Dental plaque and dental caries Theories Stephan curve Role of saliva in dental caries Socioeconomic factors Hereditary factors Clinical Classification of Dental Caries According to location According to rapidity According to whether lesion is a new one or not Based on extent of damage Histopathology of Dental Caries Enamel caries Dentinal caries Epidemiology of Dental Caries Caries in the primary dentition Caries in the mixed dentition Caries in the permanent dentition Bilateral caries experience Rampant Caries Sugar Substitutes Fundamentals of artificial sweeteners Caries Vaccine Suggested Reading



Self-assessment Questions



“The disease is painless; it’s the cure that hurts.” —Katherine Whitehorn



Introduction Dental caries remains as one of the most widespread diseases of mankind. It is the single most common chronic childhood disease. It is five times more common than asthma and seven times more common than hay fever. Nowadays, all experts on dental caries agree that it is a multifactorial disease and also an infectious and communicable disease. Although there are effective ways for prevention of this disease, the unmet needs remain large in developing and developed nations. This chapter discusses the etiology of dental caries, histopathology of its spread and its pattern of occurrence in primary and permanent dentition. The various caries diagnostic methods and preventive measures are discussed in Chapter 16 on Caries Risk Assessment and Caries Activity Tests.



Definition Dental caries is a microbial disease of the calcified tissues of the teeth characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth. Caries is a biofilm (plaque)-induced acid demineralization of enamel or dentin, mediated by saliva—American Academy of Pediatric Dentistry.



Etiology of Dental Caries Dental Plaque and Dental Caries



Dental plaque plays a major role in the etiology of both periodontal disease and dental caries. Dental plaque is primarily composed of bacteria and lesser amounts of bacterial extracellular products, food debris and desquamated epithelial cells. The major determinant of plaque formation is the ability of certain microorganisms to adhere to the tooth surface. This characteristic is a major factor influencing smooth surface caries. In contrast to plaque on smooth surface, the ability of bacteria to adhere is not a requisite for fissure caries. Acid production by the oral microorganisms within dental plaque is the most important determinant in pathogenesis of dental caries. Simple sugars are easily converted by microorganisms to lactic acid. Demineralization of enamel is a result of concentration of hydrogen ions present at the tooth surface and the amount of time for which enamel is exposed to low pH conditions. Apart from the acids, cariogenic microorganisms like S. mutans produce large quantities of water insoluble glucan from sucrose. In addition to a role in bacterial attachment, the insoluble extracellular polysaccharides are also believed to act as a barrier to the diffusion of acids away from the tooth and to the transport of salivary buffers into the plaque. For dental caries to occur, it is recognized to require a host (tooth), a dietary substrate (refined carbohydrates), aciduric bacteria (microorganisms). Given time, the interaction of cariogenic microorganisms and fermentable carbohydrates (sucrose) may induce demineralization, which can progress to loss of tooth structure/cavitation. These three factors form the Keyes triad in the etiology of dental caries (Fig. 17.1) and are discussed in detail below.



FIGURE 17.1 Keyes triad of dental caries.



Dietary factor The role of the diet deserves special consideration because of the often observed differences in caries incidence of various populations who subsist on dissimilar diets. 1. The physical nature of the diet has been suggested as one factor responsible for the difference in caries experience between individuals. The diet of the primitive man consisted of raw unrefined foods containing a great deal of roughage, which cleanses the teeth of adherent debris during the usual masticatory movements. In the modern diet, soft and refined



foods tend to cling tenaciously to the teeth and are not removed because of the general lack of roughness. The reduction of mastication due to the softness of diet also augments the clinging of food. Toffee and caramel adhere tenaciously to the tooth surface. 2. The carbohydrate content of the diet has been almost universally accepted as one of the most important factors in the dental caries process. Sucrose is said to be the arch criminal of dental caries because of its susceptibility of conversion to acids by oral microorganisms. 3. Animal studies have proven the fact that frequency of intake plays a major role in etiology of dental caries. Individuals with more frequent intake of carbohydrates are more prone for dental caries than the individuals taking the same quantity in a lesser frequency. Hence it can be said that “the most important thing is not what we eat; but how we eat”.



Host factor Carbohydrates and microorganisms may be considered as attack forces in caries etiology. Salivary secretion may be considered an environmental force, capable of enhancing or detracting from the process and the enamel may be viewed as a resistance force. Susceptibility of tooth can be attributed to certain physical and chemical changes in the enamel. These could be factors such as surface imperfections (hypoplasia, deep pits and fissures) that favor the accumulation of carbohydrates and microorganisms. Alterations in the tooth composition that predispose to destruction by cariogenic agents may occur prior to the eruption of teeth.



Microbial factor Studies by Orland and Fitzgerald have demonstrated that dental caries will not occur in the absence of microorganisms. Animals maintained in a germ free environment did not develop caries even when fed a high carbohydrate diet. However, dental caries did



develop in these animals when they were inoculated with microorganisms from caries-active animals and then fed cariogenic diets. Streptococcus mutans has been implicated as one of the major and most virulent of the caries producing organisms. Streptococcus mutans is both acidogenic (acid producing) and aciduric (survives in acidic environment). The other microorganisms attributed in etiology of dental caries are Lactobacillus acidophilus and Streptococcus sobrinus. These microorganisms convert the fermentable carbohydrates into acids which in turn dissolves the tooth structure.



Theories The etiology of dental caries is considered to be a complex problem complicated by many indirect factors which obscure the direct cause or causes. A number of theories of caries etiology exist. Some theories related to the etiology of caries, which have evolved through years of investigation and research will be discussed here.



Acidogenic theory (chemico-parasitic theory) (Fig. 17.2) WD Miller, probably the best known of the early investigators of dental caries, published extensively on the results of studies on dental caries since 1882. Miller based his ideas on a series of experiments carried out in the laboratories of the famous German microbiologist Robert Koch. He made the significant observation that many microorganisms could produce acid from the fermentation of sugar. He showed that a number of oral microorganisms had this property and that lactic acid was one of the major acids formed. He further showed that extracted human teeth could be demineralized by incubating them in a mixture of bread or sugar with human saliva. These findings were published in the book ‘The Microorganisms of Human Mouth’.



FIGURE 17.2 Acidogenic theory.



In essence, the theory proposes that acids are produced at or near the tooth surface by bacterial fermentation of dietary carbohydrates (Fig. 17.2). The acids so formed are responsible for the dissolution of the apatite crystals which forms the bulk of the enamel. The acids are held in close proximity to the tooth surface by dental plaque which also serves to protect the acids from the washing and buffering effects of saliva. Bacteriologic studies have helped clarify the role of different microorganisms in the etiology of dental caries. Two major microorganisms which are intimately associated with dental caries are Streptococcus mutans and Lactobacillus acidophilus. It has also been reported that Streptococcus mutans is related to the initiation of dental caries and Lactobacillus acidophilus is responsible for the progression of caries. Actinomyces species are also reported to be related to root caries formation.



Proteolysis theory This theory was proposed by Gottlieb in 1944. This theory states that proteolytic enzymes liberated by oral bacteria could destroy the organic matrix of enamel, resulting in a loosening of the apatite crystals with their eventual loss, and collapse of the tissue (Fig. 17.3). This can be compared to the mortar softening and weakening in an old brick wall, the mortar being the organic matrix and the bricks representing the apatite crystals. Hence the initial attack on enamel might be proteolytic rather than by acid. Frisbie in 1944 and Pincus in 1949 extended the concept by proposing that sulfates of Gramnegative bacilli hydrolyzed the sulfated mucosubstances of the matrix, liberating sulfuric acid, which then dissolved the mineral. Limitations of this theory are:



FIGURE 17.3 Proteolysis theory.



1. Areas of enamel with a relatively high organic content, such as tufts and lamellae do not show a greater susceptibility to caries. 2. It was not possible to simulate caries with proteolytic agents. 3. While there is no doubt that a wide variety of proteolytic enzymes are produced by dental plaque, they are more likely related to initiation of periodontal disease. However, once enamel is collapsed and a cavity is formed, microorganisms can enter the tissue. Proteolysis will then play a significant role in tissue destruction especially in the dentin and cementum.



Proteolysis–chelation theory This theory was proposed by Schatz and Martin in 1955. The word chelation is derived from chelas—claw. Chelation is a process involving the complexing of a metallic ion to a complex substance through a coordinate covalent bond which results in a highly stable, poorly dissociated or weakly ionized compound. Chelates can be formed at neutral or alkaline pH values, the theory suggests the



possibility that demineralization of enamel could arise without acid formation. The proteolysis-chelation theory of dental caries states that the bacterial attack on the enamel, initiated by keratinolytic microorganisms, results in a breakdown of the protein and other organic components of enamel, chiefly keratin (Fig. 17.4). This results in the formation of substances which may form soluble chelates with the mineralized components of the tooth and thereby decalcify the enamel at a neutral or even alkaline pH. Enamel also contains other organic components besides keratin, such as mucopolysaccharides, lipid and citrate which may be susceptible to bacterial attack and act as chelators. The proteolysis–chelation theory also states that both the organic and inorganic portions of enamel are attacked simultaneously. Later research suggested that saliva and plaque do not contain substances in sufficient concentrations to chelate calcium in detectable amounts from enamel.



FIGURE 17.4 Proteolysis–chelation theory.



Autoimmunity theory Burch and Jackson proposed this theory in 1966. This theory is related



to Burch’s theory of the cause of growth, disease and aging in which the incidence of many diseases follow a mathematical pattern of random events. The random event which the theory requires is a mutation in a cell concerned with the regulation of growth by synthesizing and releasing into the circulation a protein. Burch calls this protein a mitotic control protein (MCP) effective on highly specific targets such as a group of cells in one tissue. The authors of this theory quote studies of caries in twins which showed them that an individual inherits a genetic predisposition to caries. They suggested that genes, partly inherited and partly as a result of mutations, determine whether a site on a tooth is at risk. In dental caries, the odontoblasts are the target cells and when the mutation occurs, an abnormal MCP is produced, leading to disorders of the odontoblasts under its control. This in turn leads to changes in the resistance of the enamel to acid attack (Fig. 17.5).



FIGURE 17.5 Autoimmunity theory.



The limitation of this theory is that it is based on analysis of epidemiologic data. It is doubtful whether data collected during routine clinical examinations are sufficiently accurate for



mathematical analysis.



Sucrose–chelation theory Eggers-Lura suggested that sucrose itself and not the acid derived from it could cause the dissolution of enamel by forming unionized calcium saccharates. The theory is that calcium saccharates and calcium complexing intermediaries require inorganic phosphate which is subsequently removed from the enamel by phosphorylating enzymes (Fig. 17.6). Later, investigations failed to confirm this concept of caries formation.



FIGURE 17.6 Sucrose–chelation theory.



Stephan Curve Acidogenic bacteria in dental plaque can rapidly metabolize certain carbohydrates to acids. In the mouth, the resultant change in plaque pH over time is called a Stephan curve. During rest, the pH is fairly constant although inter-subject differences between individuals and between sites in one individual are found. Following exposure to fermentable refined carbohydrates, the pH reduces rapidly to reach a minimum in 5–20 minutes. However, this returns to its starting value within 30–60 minutes. Stephan showed that within 2–4 minutes after rinsing with a solution of glucose or sucrose, plaque pH was reduced from approximately 6.5 to about 5.5 and gradually returned to the original pH value in 40 minutes or so. Plotted graphically, this is known as the Stephan curve after the Swedish dental scientist who



first brought this into prominence (Fig. 17.7).



FIGURE 17.7 Stephan curve.



Role of Saliva in Dental Caries The fact that the teeth are in constant contact with and bathed by the saliva would suggest that this environmental agent could profoundly influence the state of oral health of a person. The complex nature of saliva and the great variation in composition makes it difficult to establish the factors that may directly influence dental health. The composition of stimulated and unstimulated saliva varies and is not particularly meaningful unless the exact conditions under which the saliva was collected are described. Flow rate of saliva is an important factor in caries etiology. Individuals with greater salivary flow develop less number of carious lesions than individuals with lesser salivary secretion. It is well



known that in those instances in which normal salivary flow is greatly diminished, e.g. as the result of radiation therapy—rampant tooth decay may ensue. The importance of this possibility is easily demonstrated in rodents. The total amount of saliva secreted during sleep is negligible. As diminished salivary flow favors caries activity, the process of tooth decay should be accelerated during nonwaking hours. During this period, the mechanical clearance of carbohydrates and microorganisms would be minimal. The concentration of inorganic calcium and phosphorus shows considerable variation depending on the rate of flow. The calcium and phosphorus in saliva is incorporated into the demineralized enamel surface under appropriate conditions. It is reported that the calcium and phosphorus content of saliva is low in caries active persons. There are numerous other inorganic components of saliva such as sodium, magnesium, potassium, carbonate, fluoride and chloride. Some of the organic constituents of saliva like ammonia, urea have been reported to decrease the caries incidence. Buffering capacity of saliva has a tremendous influence on the carious process. The buffering capacity of saliva is primarily due to the presence of bicarbonate. The other buffer of significance is phosphate. Individuals having salivary secretion with good buffering capacity could neutralize some of the acids that play an etiologic role in tooth decay resulting in lesser caries. The presence of lysozyme, immunoglobulins and other antibacterial substances in saliva may also play a role in caries formation. However, the exact manner in which these mechanisms work needs further research.



Socioeconomic Factors Since the socioeconomic conditions in various communities differ widely, knowledge of the possible relationship of these factors to dental caries in children is advisable. Children living in the communities with higher economic levels had better access to dental care and had fewer lost teeth, but the total caries experience was unaffected by the level of dental care available. Though there are



conflicting reports in this area, it appears that socioeconomic conditions may affect the caries prevalence in the primary dentition more so than in the permanent dentition. The Surgeon General’s report from United States noted that children and adolescents living in poverty suffer twice as much tooth decay as their more affluent peers and that their disease is more likely to go untreated. It is also mentioned that although continuing reduction of dental caries in permanent teeth have been achieved, caries prevalence in primary teeth has stabilized or possibly increased. However, the available data confirms that economically poor children are at high risk for dental caries.



Hereditary Factors It is clear from many dietary studies that variation in susceptibility to dental caries exists even under identical, controlled conditions. This implies that because of genetic differences certain environmental influences are potentially more cariogenic for some people than for others. This is not to say that dental caries is an inherited disease; however, genetic influences may modify the overt expression of this disease in the individual. Most authors agree that genetic influences on dental caries are relatively minor in comparison with the overall effect of environmental factors. This is supported by the fact that children acquire their dietary habits, oral hygiene habits and oral microflora from their parents. This makes dental caries more an environmental disease rather than a hereditary disease. However, the authors are of opinion that genetics may play a major role than what is thought of today. Their views are based on the fact that children from some of the rural or remote parts of India when examined seemed to have less dental decay or remain caries free. They have access to cheapest, stickiest toffees and chocolates and rarely do they perform proper oral hygiene measures. In spite of these detrimental environmental influences, they remain decay free beyond permanent dentition. Probably their teeth are less susceptible for dental caries because of inherent resistance. To summarize,



susceptibility to dental caries is influenced to a significant but minor degree by heredity. This genetic control is undoubtedly multifactorial in nature and such a polygenic background strongly implies considerable environmental influence. Specific types of dental caries susceptibility representing the extremes of variation (caries free state or rampant caries state) of this trait may ultimately prove to be monogenic traits, but at present the evidence is insufficient for a clear statement of such inheritance. More research in the coming years with advanced molecular techniques will elucidate this critical question.



Clinical Classification of Dental Caries Dental caries can be classified clinically in a number of ways depending upon the clinical features. 1. According to location: • Pit and fissure caries • Smooth surface caries • Root caries 2. According to rapidity with which it progresses: • Acute dental caries • Chronic dental caries 3. According to whether lesion is a new one or not: • Primary caries • Secondary caries 4. Based on extent of damage: • Incipient caries • Occult caries



According to Location Pit and fissure caries These are the caries that occur on the pits and fissures of premolars and molars and on the lingual surface of incisors and canines. These are the most susceptible surfaces of tooth to develop caries. Deep pits



and fissures favor food retention and are difficult to clean by routine brushing. Hence they provide a favorable environment for the oral microorganisms to thrive and convert the carbohydrates to acids continuously, leading to demineralization of the enamel. The spread of caries through a pit or fissure and from a smooth surface is different, which is discussed in the next section on histopathology. Most of the pit and fissure caries develop with a narrow penetration point and develop a large cavitation with overhanging enamel. The lateral spread of the caries at the dentinoenamel junction (explained in histopathology) as well as penetration into the dentin along the dentinal tubules may be extensive without fracturing away the overhanging enamel. Thus there may be a large carious lesion with only a tiny point of opening (Fig. 17.8).



FIGURE 17.8 Schematic diagram showing progress of pit and fissure caries.



Smooth surface caries



This type of caries is the one which develops on the proximal surfaces of teeth or on the gingival third of the buccal and lingual surfaces. This type of caries is entirely dependent upon the development of recognizable plaque for the initiation of caries. This ensures further retention of carbohydrates and microorganisms on the tooth surface and subsequent production of acids to initiate the caries process. Proximal caries usually begins just below the contact point and appears in the early stage as a faint white opacity of enamel (Fig. 17.9).



FIGURE 17.9 Schematic diagram showing progress of smooth surface caries.



Root caries Root caries is otherwise called root surface caries or caries of cementum. It is defined as a soft progressive lesion that is found anywhere on the root surface that has lost connective tissue attachment and is exposed to the oral environment. The



microorganisms involved in root caries are different from those involved in coronal caries. Microorganisms appear to invade the cementum either along Sharpey’s fibers or between bundles of fibers, in a manner comparable to invasion along dentinal tubules.



According to Rapidity with which it Progresses Acute dental caries This type of caries runs a rapid clinical course and results in early pulp involvement by the carious process. It occurs most often in children and young adolescents because the dentinal tubules are large and open and show no sclerosis. The process is so rapid that there is little or no time for deposition of secondary dentin. Early childhood caries caused by prolonged bottle feeding and on demand breastfeeding can be categorized into a form of acute dental caries. Early childhood caries is dealt in Chapter 18.



Chronic dental caries This form of caries progresses slowly and tends to involve the pulp much later than acute dental caries. It is seen most commonly in adults. The entrance to the lesion is almost invariably larger than that of acute caries. Because of this there is not only less food retention but also greater cleansing by saliva. The slow progress of the lesion often allows deposition of secondary dentin.



According to Whether Lesion is a New One or Not Primary caries Primary caries is the one which is occurring on the tooth for the first time. It can be any of the above mentioned type of caries.



Secondary caries This type of caries occurs beneath or adjacent to an existing restoration. This is most often due to inadequate caries removal prior



to filling or because of poor margins of restoration leading to leakage (Fig. 17.10). This allows both the bacteria and the substrate (carbohydrate) to enter and produce acids below or adjacent to the restorations leading to secondary caries.



FIGURE 17.10 Secondary caries around a filling.



Based on Extent of Damage Incipient caries These are often called white spot lesions (Fig. 17.11). Clinically, the surface of the lesion is intact and there is subsurface demineralization. If the environment is favorable, these lesions can undergo remineralization. These lesions can be differentiated from developmental defects by wetting the lesion. On wetting, these white spot lesions disappear; but the developmental defect persists. They



can be diagnosed with a good bitewing radiograph.



FIGURE 17.11 White spot lesions.



The physiochemical process of white spot lesions was difficult to understand until the Moreno model (Fig. 17.12) was described. In this model, acids formed by cariogenic bacteria dissolve the surface as well as subsurface enamel. The calcium and phosphate ions from the subsurface dissolution diffuse outward toward the surface and reprecipitate on the surface making the enamel surface appear unaltered. Hence, the surface enamel is in a type of chemical equilibrium with mineral being lost into the plaque due to low pH, but being remineralized from the ions diffusing out from the subsurface lesion. If the oral environment is maintained in a cariogenic state eventually the rate of transfer from the surface enamel into plaque becomes greater than the rate of precipitation and the surface enamel collapses.



FIGURE 17.12 Moreno model.



Occult caries Occult caries is used to describe a type of caries which is clinically not detected but seen on a radiograph. They are associated with pre-



eruptive defects of enamel (which occurs even before the tooth comes into the oral cavity) and seen only on radiographs. It is believed that increased fluoride exposure encourages remineralization of the surface layer; but the cavitation continues in the dentin and the lesion is masked by an intact surface layer. These hidden lesions are called fluoride bombs or fluoride syndrome.



Histopathology of Dental Caries Histopathological investigations have elucidated the progress of caries in different tissues. For ease of understanding, the histopathology is discussed will be considered under the following headings: 1. Enamel caries 2. Dentinal caries



Enamel Caries The spread of caries in enamel varies for smooth surface caries and pit and fissure caries. In smooth surface caries, the earliest manifestation is the appearance beneath dental plaque an area of decalcification which resembles a chalky white area. This is called incipient caries. At this stage, histologically, there is usually a loss of interprismatic or interrod substance of enamel with increased prominence of rods. In some instances, it consists of only roughening of rods. Another change in early enamel caries is the accentuation of the incremental lines of Retzius. As this process advances and involves deeper layers of enamel, it forms a triangular or a cone-shaped lesion with the base toward the surface of the tooth. Pit and fissure caries have a different pattern of progression. Often the enamel in the bottom of the pit is very thin, so that early dentin involvement occurs. On the other hand, some pits and fissures are shallow and have a relatively thick layer of enamel covering their base. When caries occurs here, it follows the direction of enamel rods and characteristically forms a triangular cone-shaped lesion with its



apex at the outer surface and its base towards the dentinoenamel junction. It should be noted that the general shape of the lesion here is just opposite of that occurring on smooth surface caries. This results in greater number of dentinal tubules being involved when the caries reaches the dentinoenamel junction, causing greater cavitation with pit and fissure caries than smooth surface caries (Fig. 17.13).



FIGURE 17.13 Histopathology of enamel caries.



Dentinal Caries (Fig. 17.14) Once caries reaches the dentin, it progresses through the open dentinal tubules. The speed at which various microorganisms travel depends upon a number of factors. Once microorganisms penetrate farther and farther into the dentinal tubules, they are separated more and more from the carbohydrate substrate upon which the bacteria responsible for the initiation of the disease depend. The high protein content of the dentin would favor the growth of those microorganisms which have the ability to utilize this protein for metabolism. Thus proteolytic organisms would appear to predominate in deeper caries of the dentin, while acidogenic forms are prominent in early caries. This substantiates the hypothesis that initiation and progression of dental caries are two distinct processes. As the carious lesion progresses towards the pulp, it tends to assume the shape of a triangle with the apex toward the pulp and the base toward the enamel.



FIGURE 17.14 Histopathology of dentinal caries.



Epidemiology of Dental Caries The prevalence and incidence of a disease refers to the number of individuals showing evidence of that disease either at one point in time (prevalence) or the change in the extent over a period of time (incidence). Dental caries is measured in terms of decayed, missing and filled teeth or surfaces (DMFT or DMFS) for permanent teeth using capital letters. Dental caries in primary teeth is measured as decayed, extracted (or indicated for extraction) and filled teeth or surfaces using lower case letters (deft or defs).



Caries in Primary Dentition Caries in children aged less than 3 years tend to involve the occlusal



surfaces of primary molars. In these children, posterior contacts may not close until the age of 3 years which may explain this observation. However, once posterior contacts close, the prevalence of interproximal caries increases. Secondly, primary molars have more occlusal lesions than first primary molars; likewise the mandibular molars have more than the maxillary because of the depth and anatomy of the occlusal fissures. The labial and lingual surfaces of primary incisors never decay, except in cases of early childhood caries or nursing caries. Mandibular primary incisors seldom decay, probably because of the spacing that occurs in the area, protection of the tongue (while bottle feeding) and their close proximity to the ducts of the submandibular salivary gland, which means that they benefit from the diluting and buffering properties of saliva.



Caries in Mixed Dentition The newly erupted first permanent molars have areas that are susceptible to plaque retention and subsequent development of caries. These are the occlusal surfaces in permanent molars, the lingual developmental pit and groove in maxillary permanent molars and the buccal developmental groove in mandibular permanent molars. Probably because of the depth, mandibular permanent molars decay more frequently than maxillary permanent molars. It is shown that the best predictor of caries in the permanent molars is the level of caries in the primary dentition. In addition to these areas, closing of proximal contacts may result in the development of proximal lesions. The effect of fluoride has brought about a marked decline in the number of interproximal lesions in the mixed and young permanent dentition. This has occurred in both fluoridated and non-fluoridated communities and confirms the belief that occlusal pit and fissure caries is least influenced by fluoride.



Caries in Early Permanent Dentition Various studies suggest that there is an unnecessarily high incidence of caries in the young permanent dentition. The order of susceptibility



of teeth to caries in early permanent dentition is, first permanent molars (most susceptible), second permanent molars, premolars, maxillary anterior teeth, canine and mandibular incisors (least susceptible). There is often a bilateral symmetry of caries attack in children which is discussed below. The occlusal surfaces of recently erupted second molar and premolar are susceptible to caries by virtue of their morphology. There are more occlusal than interproximal lesions in the 12–13 years old due to the recent eruption and of lack of establishment of proximal contacts on second molars and premolars. However, after the age 13 years, there is an increased percentage of interproximal caries compared to occlusal caries.



Bilateral Caries Experience The tendency for dental caries to occur bilaterally is a generally appreciated phenomenon. Based on studies which investigated bilateral caries experience, the following conclusions can be drawn: 1. It is said that 3 out of 4 cases in which dental caries occurs in a posterior tooth, the comparable tooth in the opposite arch will also be involved. 2. In 4 out of 5 cases, caries will be on the same surface.



Rampant Caries Rampant caries is defined as a “suddenly appearing, widespread, rapidly burrowing type of caries, resulting in early involvement of the pulp and affecting those teeth usually regarded as immune to ordinary decay”. (Massler, 1945). Winter et al in 1966 described it as a lesion of acute onset involving many or all of the erupted teeth, rapidly destroying the coronal tissue, often on surfaces normally immune to decay and leading to early involvement of the dental pulp. The mechanism of decay process in rampant caries is similar to other types of caries explained above. However, it can occur suddenly



in teeth that were previously sound for many years. Its sudden onset suggests that an overwhelming imbalance of the oral environment has occurred and some factors in the caries process seem to accelerate it so that it becomes uncontrollable. This type of rampant caries is seen in young teenagers though it is observed in children and adults (Fig. 17.15A, B). It is often associated with emotional disturbances. According to McDonald, some of the factors which may predispose an individual to rampant caries are as follows:



FIGURE 17.15 Rampant caries.



1. Repressed emotions and fears 2. A traumatic school experience 3. Dissatisfaction with achievement 4. Rebellion against a home situation 5. Continuous general tension and anxiety. Such emotional disturbances may create an unusual craving for sweets or the habit of snacking which in turn might influence the incidence of dental caries. A noticeable decrease in salivary flow is observed in individuals with emotional disturbance which can increase their risk for caries. Radiation therapy for any tumor of head and neck also can lead to decreased salivary flow leading to rampant caries.



Sugar Substitutes Artificial sweeteners are called sugar-substitutes. There are two kinds of sweeteners—nutritive and non-nutritive. Nutritive sweeteners provide some calories; non-nutritive sweeteners typically provide zero calories. The ideal sweetener should provide sweetness, with no unpleasant after-taste, have little or no calories, not be carcinogenic or mutagenic, be economical to produce and should not be degraded by heat when cooked.



Fundamentals of Artificial Sweeteners I. Nutritive sweeteners As stated above, the terms ‘nutritive’ and ‘non-nutritive’ denote a difference in the amount of energy provided by sweeteners. Nutritive sweeteners include sugar sweeteners (e.g. refined sugars, high fructose corn syrup, crystalline fructose, glucose, dextrose, corn sweeteners, honey, lactose, maltose, various syrups, invert sugars, concentrated fruit juice) and reduced-energy polyols or sugar alcohols (e.g. sorbitol, mannitol, xylitol, isomalt, and hydrogenated starch hydrolysates).



a. Sugar sweeteners: Most sugar sweeteners used as replacements for sugar contain about the same calories as sugar. So although there may be some differences in the way we metabolize sugar and nutritive sweeteners like sucrose and fructose, there is no obvious weight loss benefit. b. Polyols/sugar alcohols: Polyols offer less energy; and offer potential health benefits (e.g. reduced glycemic response and reduced dental caries risk). The polyols sorbitol, mannitol, and xylitol are found in plant products such as fruits and berries. All polyols are absorbed slowly and incompletely from the intestine, therefore, an excessive load may cause diarrhea. If polyols were completely absorbed, then like sugar they would provide the usual 4 calories per gram. The FDA allows these nutritive sweeteners to be labeled as having fewer calories per gram than other nutritive sweeteners.



Approved nutritive sweeteners 1. Monosaccharide polyols or novel sugars Sorbitol: Sorbitol is a sugar alcohol that occurs naturally in many fruits and berries. It is produced commercially from glucose, but is expensive to manufacture. Sorbitol is often used as a ‘bulk’ sweetener in a variety of food substances such as chewing gum, chocolates and confectioneries. It is half as sweet as sucrose and is considered noncariogenic, although in solution it can be fermented slowly by mutans streptococci. Sorbitol has been shown to be cariogenic with prolonged use by patients with reduced salivary gland function. Sorbitol is not easily metabolized or absorbed from the gastrointestinal tract and can cause diarrhea, if ingested in large quantities. Sorbitol gives 2.6 cal/g energy. Generally recognized as Safe (GRAS) —label must warn about a laxative effect. It is 50–70% as sweet as sucrose; some individuals experience a laxative effect from a load of > 50 gm. Mannitol: It gives 1.6 cal/g energy. Approved food additive; the label must warn about a laxative effect. It is 50–70% as sweet as sucrose; some individuals experience a laxative effect from a load of >



20 gm. Xylitol: Xylitol was discovered in wood chips in 1890 and in wheat and oat straw in 1891. It is a non-fermentable, pleasant tasting, noncariogenic polyol derived from pentose sugar xylose and is relatively expensive to manufacture. Xylitol is as sweet as sucrose and was approved as safe for use in humans in 1986. It is used primarily in chewing gum and possesses approximately the same sweetness potency as sucrose. Studies have suggested that the regular use of xylitol containing chewing gum reduces the amount of dental plaque as well as increase saliva flow. A significant reduction in caries incidence has been reported in caries active age groups when xylitol containing gum was chewed regularly. Recently, xylitol has been credited in reducing the transmission of cariogenic bacteria from mother to infant and has been shown to have bactericidal qualities. The FDA has not yet approved additional uses of xylitol as a sweetener. However, numerous European studies have established the safety for human consumption. An additional reported benefit of chewing gum containing xylitol is reduced ear infection in young children at day-care centers. It gives 2.4 cal/g energy. It is an approved food additive used in foods for special dietary use.



2. Disaccharide polyols or novel sugars Isomalt: It gives 2 cal/g energy, 45–65% as sweet as sucrose and used as a bulking agent. Lactitol: It gives 2 cal/g energy, 30–40% as sweet as sucrose and used as a bulking agent. Maltitol: It gives 2.1 cal/g energy, 90% as sweet as sucrose and used as a bulking agent. Trehalose: It gives 4 cal/g energy. It is 45% as sweet as sucrose.



3. Polysaccharide polyols HSH (hydrogenated starch hydrolysates): It gives 3 cal/ g energy and 25–50% as sweet as sucrose (depending on the monosaccharide



composition).



II. Non-nutritive sweeteners Non-nutritive artificial sweeteners are intensely sweet—between 200 and 700 times sweeter than sugar. They add sweetness to foods for people (like diabetics) who need to limit their intake of sugar. They contain little or no calories or glycemic response (impact on blood sugar levels). The United States lead the world in consumption of high-intensity sweeteners, consuming approximately 50% of the world demand. Non-nutritive sweeteners may assist in weight management, control of blood glucose and prevention of dental caries. But most non-nutritive sweeteners come with health warnings because of the lack of clinical tests on their long-term use. FDA has approved four non-nutritive sweeteners and regulates them as food additives—saccharin, aspartame, acesulfame potassium (or acesulfame-K) and sucralose. Nutritive sweeteners provide a sweet taste and a source of energy; non-nutritive sweeteners are sweet without energy. The ideal agent should provide sweetness, but with no unpleasant after-taste, have little or no calories, not be carcinogenic or mutagenic, be economical to produce, and should not be degraded by heat when cooked.



Non-nutritive sweetening agents or noncaloric sweeteners The US Food and Drug Administration (FDA) approved non-caloric sweeteners to date are aspartame, acesulfame potassium, saccharin, sucralose and neotame. Non-nutritive sweeteners offer no energy (or insignificant energy in the case of aspartame) and, because they sweeten with little volume, they can also be referred to as highintensity sweeteners. 1. Aspartame (Nutrasweet, Equal, Sugar Twin): Aspartame (Equal) is a dipeptide methyl ester, discovered in 1965 and is approximately 200 times sweeter than sucrose. Aspartame was approved in 1981 for limited use as a sweetener in the US, and extended to a larger market



in 1983. Its nutritive value is 4 cal/g energy. Aspartame is the most widely used non-cariogenic artificial sweetener. Its primary use is in diet, soft drinks, yogurt, puddings, gelatin and snack foods. Aspartame has been shown to have a protective effect against some mycotoxins and is claimed to be safe for use by type 2 diabetics. Mycotoxins are toxic metabolic products of some fungi and can result in mycotoxicosis in humans. Mycotoxins can be found in contaminated cereals and foods obtained from animals that ingested a mycotoxin contained diet. Oral ingestion of 6 mg/kg of aspartame has been reported to reduce the number of sickle cells in the blood of patients with homogenous sickle cell anemia. There have been concerns raised relative to toxic effects on growth, glucose homeostasis and liver functions with long-term usage. People with phenylketonuria should avoid aspartame as they cannot metabolize phenylalanine, a component of aspartame. 2. Acesulfame potassium or acesulfame K (Sunett, Sweet and Safe, Sweet One): Acesulfame potassium, a non-nutritive product, was approved by the FDA in 1988 for use as a sweetener in dry food products. In 1994, yogurt, refrigerated desserts, syrups and baked goods were added to the approved list. The use of acesulfame potassium is approved for use in foods, beverages, cosmetics and pharmaceuticals in more than 30 countries. Although considered safe for consumption by humans there have been some health issues raised relative to dose-dependent cytogenetic toxicity. Acesulfame K is approved as a general-purpose sweetener 200 times sweeter than sucrose; non-cariogenic and produces no glycemic response; synergizes the sweetening power of nutritive and nonnutritive sweeteners; sweetening power is not reduced with heating. Its nutritive value is zero calories. 3. Saccharin: Saccharin is 200 to 700 times sweeter than sucrose and is the oldest of the artificial sweeteners used in the United States. It is non-cariogenic and non-caloric and is available in liquid and tablet forms as a tabletop sweetener but has a slightly bitter after-taste. In



1970, saccharin was identified as a potential bladder carcinogen. A warning label is required on all food products in the US that contain saccharin. It is approved as a sweetener for beverages and as a tabletop sweetener in foods with specific maximum amounts allowed and 200– 700 times sweeter than sucrose; non-cariogenic and produces no glycemic response; synergizes the sweetening power of nutritive and non-nutritive sweeteners; sweetening power is not reduced with heating and has a nutritive value of zero calories. 4. Sucralose (splenda): Sucralose is a non-nutritive, noncaloric trichlorinated derivative of sucrose. It is not metabolized by the body and has been shown to be non-cariogenic. Sucralose is widely used throughout the world in many food products such as tea and coffee sweetener, carbonated and non-carbonated beverages, baked goods, chewing gum and frozen desserts. No health concerns have been reported with sucralose. Sucralose is approved as a general-purpose sweetener. It is 600 times sweeter than sucrose; non-cariogenic and produces no glycemic response; sweetening power is not reduced with heating. Nutritive value is zero calories. 5. Neotame: Neotame is approved as general-purpose sweetener. It is 8,000 times sweeter than sucrose; non-cariogenic and produces no glycemic response; sweetening power is not reduced with heating. This sweetener does provide energy; however, because of the intense sweetness, the amount of energy derived from it is negligible. Nutritive value is zero calories.



Caries Vaccine A vaccine is defined as ‘a suspension of attenuated or killed microorganisms administered for the prevention, amelioration or treatment of infectious diseases’. A vaccine to prevent the disease of dental caries has been an anticipated scientific breakthrough since 1940s even though the etiological agents were thought to be lactobacilli. With the recognition



of mutans streptococci (Streptococcus mutans and Streptococcus sobrinus and their relatives) as the key organisms in the dental caries process, the method of immunization specially targeted at neutralizing S. mutans has been a thrust in caries vaccine research. The efforts have thus been directed against colonization of these organisms in the oral cavity. Considerable progress has been made in elucidating the factors involved in their pathogenic activity, culminating recently in the sequencing of the entire S. mutans genome. Likewise, enormous strides have been made in comprehending the workings of the mucosal immune system by which secretory IgA (SIgA) antibodies are generated in saliva and other secretions. The mechanisms of action of salivary IgA antibodies against mutans streptococci include interference with their sucrose-independent and sucrose-dependent attachment to and accumulation on, tooth surfaces, as well as possible inhibition of their metabolic activities. The goal of immunizing infants and young children against colonization by mutans streptococci and hence diminishing the development of caries might be accomplished by applying new strategies of mucosal vaccination that would induce salivary IgA antibodies without the complications of parenteral injection. The most recent research is directed towards a greater understanding of the immune system and specifically of the immune responses to mutans streptococci. The route of administration of the vaccine is usually mucosal absorption by intraoral or intranasal tissues. Active immunization: Enteric coated capsules filled with crude S.mutans GS-5 GTF antigen preparation in lysosomes were used to immunize adults. Parotid salivary IgA antibody responses were induced with this application. This delayed the colonization of S.mutans in the oral cavity. Mucosal immunization with dental caries vaccines could be protective, especially in pediatric populations where mutans streptococci is not yet a permanent member of the dental biofilm. Passive immunization: Passive antibody administration has also been examined for effects on indigenous mutans streptococci.



Strategies include, development of antibodies to mutans streptococcal antigens in cow’s milk and hen’s eggs, and the genetic engineering of human like S-IgA antibodies in plants. Mouth rinses containing bovine milk or hen egg yolk IgY antibody to S.mutans cells led to modest short-term decreases in the numbers of indigenous mutans streptococci in saliva or dental plaque. Elaborate discussion on caries vaccine is beyond the scope of this textbook. Hence readers are suggested to refer to appropriate resources for the same.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Define dental caries. Classify types of caries and describe the role of plaque in caries formation. 2. Enumerate the theories on dental caries. Write about the acidogenic theory. 3. Sugar substitutes. 4. Caries vaccine.



Short Notes 1. Rampant caries 2. Acidogenic theory 3. Proteolysis-chelation theory 4. White spot lesion and Moreno’s model 5. Aspartame 6. Xylitol 7. Occult caries or fluoride bomb 8. Pit and fissure caries 9. Smooth surface caries 10. Secondary caries 11. Root caries 12. Stephan’s curve



13. Autoimmunity theory of caries formation



SUGGESTED READING 1. Braham, RL, Morris, ME. Textbook of Pediatric Dentistry, 2nd edn. New Delhi: CBS Publishers; 1980. 2. Edgar, WM, Mullane, DMO. Saliva and Oral Health, 2nd edn. London: British Dental Association; 1996. 3. Finn, SB. Clinical Pedodontics, 4th edn. Philadelphia: Saunders; 1991. 4. Fitzgerald, RJ, et al. Dental caries in gnotobiotic rats infected with a variety of Lactobacillus acidophilus.. Arch Oral Biol. 1966; 11:473–476. 5. Kennedy, DB, et al. Pediatric Operative Dentistry, 4th edn. Great Britain: Wright; 1996. 6. McDonald, RE, Avery, DR, Dean, JA. Dentistry for the Child and Adolescent, 8th edn. St. Louis: Mosby; 2004. 7. Moreno, EC, Zahradnik, RT. Chemistry of enamel subsurface demineralization in vitro. J Dent Res. 1974; 53:226. 8. Orland, FJ. Bacteriology of dental caries: formal discussion. J Dent Res. 1964; 43:1045– 1047.



9. Stephan, RM. Changes in the hydrogen ion concentration on tooth surfaces and in carious lesions. J Am Dent Assoc. 1940; 27:718. 10. Stephen, HYW. Pediatric Dentistry: Total Patient Care. Philadelphia: Lea and Febiger; 1988. 11. Stewart, RE, Barber, TK, Troutman, KC, et al. Pediatric Dentistry: Scientific Foundations and Clinical Practice. St. Louis: Mosby; 1982. 12. Tandon, S. Textbook of Pedodontics, 2nd edn. Hyderabad: Paras Publishing; 2003.



CHAPTER 18



Early Childhood Caries MS Muthu and N Sivakumar



CHAPTER OUTLINE Introduction Definition Overview Etiology of Early Childhood Caries Associated risk factors Window of infectivity and fidelity of transmission of Streptococcus mutans Clinical Features of Early Childhood Caries Stages of early childhood caries Management of Early Childhood Caries Very mild Mild Moderate and severe Authors’ view on benefits of treatment under general anesthesia Preventive Measures Quality of life of children with early childhood caries Risk factors for dental caries in young children Conclusion Suggested Reading Self-assessment Questions



“In my ideal world, no child would suffer.”



—Clay Aiken



Introduction Centers for disease control and prevention stated in their 1996 bulletin that, “Of all the infectious diseases that affect humans, dental caries may be the most prevalent. Early childhood caries is the most recent nomenclature for a particular pattern of caries in young children. Unlike caries in the permanent dentition, early childhood caries preferentially affects the primary anterior teeth. It has been previously termed as ‘nursing caries’ or ‘baby bottle tooth decay’. Although a general caries decline is evident, early childhood caries is still the major threat to oral health of infants and toddlers. The first carious lesion in a tooth means the beginning of a long series of operative procedures unless the caries is controlled.



Definition Though the literature does not provide a universally accepted definition for early childhood caries (ECC), American Academy of Pediatric Dentistry (AAPD) defines it as “the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces” in any primary tooth in a child 71 months of age or younger. In children younger than 3 years of age, any sign of smooth surface caries is indicative of severe early childhood caries (S-ECC). From ages 3 through 5, one or more cavitated, missing (due to caries) or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of >4 (age 3), >5 (age 4), or >6 (age 5) surfaces constitutes S-ECC.



Overview Dental caries is an infectious and transmissible disease that is strongly modified by diet with saliva as a critical regulator. The causative factors and mechanisms involved in ECC are basically the same as



other types of coronal caries but ECC is a serious public health problem, prevalent in low socioeconomic groups and also in the general population. It can be a particularly virulent form of caries observed soon after tooth eruption, beginning on smooth surfaces, progressing rapidly and leaving a lasting detrimental impact on the dentition. Children experiencing caries as infants or toddlers have a much greater probability of subsequent caries in both the primary and permanent dentitions. ECC does besides affecting the teeth has consequences that lead to more widespread health issues. Infants with ECC grow at a slower pace than caries-free infants. Some young children with ECC may be severely underweight because of associated pain and the disinclination to eat. Caries is the result of an ecologic imbalance in the oral cavity that can be described as a three-step event (Fig. 18.1). The first step involves the colonization of mutans streptococci and establishment of a cariogenic flora. A prolonged exposure to carbohydrates enhances further accumulation of aciduric bacteria (mutans streptococci, lactobacilli, etc.) to pathogenic levels in the second step. In the third step, this ecologic shift creates a long-term low-pH environment that can demineralise the tooth enamel rapidly.



FIGURE 18.1 Three-step event of ecologic imbalance.



Etiology of Early Childhood Caries The three primary individual factors responsible for dental caries are: 1. Cariogenic microorganisms (microbial or agent factor)



2. Suitable (cariogenic) substrate (dietary factor) 3. Susceptible tooth (host factor).



Microbial factor (agent factor) The main microorganisms implicated in caries are the Streptococcus mutans (MS) and Streptococcus sobrinus. These pathogens can colonize the tooth surface and produce acids at a faster speed than the capacity of neutralization in an environment below the critical pH value (less than 5.5), which results in the destruction of the tooth enamel. The major reservoir of mutans streptococci is the oral cavity and infant infection depends on the level of maternal infection or on the person in closer contact with him or her. Horizontal transmission also has been described in nursery facilities of day care centers and within families. These bacteria need nondesquamative surfaces to colonize because their numbers increase with the number of erupted teeth and with age. In the period known as ‘window of infectivity’ which corresponds to the eruption of lower primary incisors (6 months) and upper primary molars (24 months), the acquisition of streptococci increases. Other microorganisms such as lactobacilli are associated with progression of an established lesion and not with the initiation of caries itself.



Cariogenic substrate (dietary factor) Sucrose is the most important cariogenic food and the most widely used. It turns noncariogenic and anticariogenic foods into cariogenic ones. Other sugars involved in cariogenesis are glucose and fructose found in honey and fruit. A simple exposure to cariogenic food would not be a risk factor for dental caries, but the frequent and prolonged contact of these substances with teeth would. A sucrose rich diet facilitates the initial establishment of mutans streptococci in plaque and a prolonged exposure to carbohydrates enhances further accumulation of aciduric bacteria, such as mutans streptococci, lactobacilli to pathogenic levels.



Susceptible tooth (host factor) The following factors contribute to the susceptibility of the tooth for dental caries: 1. Immature posteruptive enamel 2. Presence of enamel defects like hypoplasia 3. Morphology and genetic characteristics of the tooth in relation to its size, surface, depth of fossae and fissures, etc. Among the host factors, saliva is the major defense system against caries. It buffers the acids produced by the bacteria and mechanically removes the food remnants and bacteria from the mouth. It functions as a mineral reservoir for calcium and phosphate, necessary for enamel remineralization. It also contains antibacterial substances like IgA, etc. Situations that decrease salivary flow and consequently its buffering capacity, as occurs while infants are sleeping, increase the tooth susceptibility to caries.



Window of Infectivity and Fidelity of Transmission of Streptococcus Mutans Longitudinal studies have shown that mutans streptococci colonise the oral cavity of infants sometime after the emergence of their first set of teeth. Typically, this happens during a period called ‘window of infectivity’ which is from 7 to 24 months, i.e. the period during which the primary teeth emerge. By 24 months, all the primary teeth are present. Because mutans streptococci are poor colonizers of tooth surfaces in comparison to other oral bacteria, its window of infectivity relies on the newly emerged, virgin teeth to gain an initial colonization. A second window may open when permanent teeth erupt by 6 years, but the source may be from reservoirs established in the primary dentition. The time for colonization in infants varies depending on environmental factors, such as diet, level of exposure from other infected individuals and tooth composition. Mutans streptococci readily colonise on hypoplastic teeth because of their



surface roughness. Ultimately, the source for mutans streptococci is usually, but not always from the mother. DNA fingerprinting shows that infant’s genotypes of mutans streptococci match their mothers in more than 70% of cases. In early childhood, several factors that are unique for that age group which predispose an infant to the risk of ECC are given in Box 18.1. Box 18.1



Risk factors which predispose an



infant to ECC 1. Early colonization of mutans streptococci 2. Lack of oral hygiene routines 3. Sugars in drinks, milk and infant formulas at bedtime or during naptime 4. High frequency of sugar consumption from drinks and solid food 5. Nursing bottles, pacifiers and sucking habits 6. Prolonged feeding pattern 7. Low salivary flow at night 8. Newly erupted, immature teeth 9. Immature specific and nonspecific defense system 10. High prevalence of hypoplastic defects in primary dentition 11. Medical conditions 12. Parental education 13. Socioeconomic status 14. Siblings



Knowledge of the complex interaction of such risk factors and risk indicators is essential for the complete understanding of ECC and the benefits of preventive measures. A ‘caries assessment tool’ (CAT) is described in Chapter 12 on Infant Oral Health and Anticipatory Guidance which helps the practitioner to assess the risk of the child considering the above listed factors.



Clinical Features of Early Childhood Caries Early childhood caries can develop as soon as teeth erupt. Cavities may be visible as early as 10 months of age. It typically presents in children as white lines or spots on the maxillary incisors, which are among the first teeth to erupt and least protected by saliva. These white lines or spots are usually seen along the gum line of the incisors. These white areas will rapidly breakdown into yellow brown cavities, if left untreated. These cavities are discolored to brown or black from stains in foods and drinks. Caries progresses from decalcification of upper primary incisors to primary molars and canines, if not controlled. While the four upper incisors are the most severely affected by ECC, lower incisors remain intact because they are protected by the tongue and moistened by the saliva from submandibular salivary glands. The distribution of ECC follows the sequence of eruption. If left untreated, the decay of the maxillary incisors eventually continues to such an extent that the crowns are weakened and fractured. This process may be so rapid that the parents often perceive the teeth as defected from the moment of eruption. As discussed earlier, enamel defects may predispose to early caries.



Stages of Early Childhood Caries The stages of early childhood caries described by Harris and Garcia Godoy in 1999 are given Box 18.2. Box 18.2



Stages of ECC



1. Very mild (Fig. 18.2): Clinical appearance shows slight demineralization usually at gingival crest and no cavitation.



FIGURE 18.2



Very mild form of early childhood caries.



2. Mild (Fig. 18.3): Clinical appearance shows demineralization in gingival third of tooth and moderate cavitation.



FIGURE 18.3



Mild form of early childhood caries.



3. Moderate (Fig. 18.4): Clinical appearance shows frank cavitation on multiple tooth surfaces.



FIGURE 18.4



Moderate form of early childhood caries.



4. Severe (Fig. 18.5 A, B): Clinical appearance consists of widespread destruction of tooth and partial to complete loss of clinical crown.



FIGURE 18.5



Severe form of early childhood caries.



Management of Early Childhood Caries Managing ECC is a challenging and an arduous task for even a trained pediatric dentist. Children aged 3 years and below are categorized by Wright as ‘children who lack cooperative ability’. Hence treatment for ECC in such situations may need pharmacological management like sedation, general anesthesia, etc.



Very Mild (Fig. 18.2) When the clinical appearance do not show any cavitation on the teeth surfaces, it is possible to arrest the process by active preventive measures. The clinical appearance of the white spot lesions and the role of plaque in demineralization of tooth surfaces are explained to the parents. The possibility of developing a full blown ECC, if appropriate preventive measures are not taken, is also put forward to them. The consequences of severe ECC are described to them with the possibility of an intervention in the hospital under general anesthesia. Counseling regarding diet, oral hygiene measures, fluoride adequacy and the need for frequent recall to monitor the progress of the ECC are explained to them. Regarding diet, the importance of frequency of refined carbohydrates intake is explained and the need to clean the infant’s teeth after every meal or intake is stressed. The need for assistance in performing oral hygiene measures (mother or father brushing the child’s teeth) is also emphasized. Systemic fluorides are given, if necessary, in the form of drops or tablets depending upon the age and the other sources of fluoride intake for the child. If proper care is taken by the parents and the professional advice is followed meticulously, this process of very mild ECC can be arrested at that stage itself.



Mild (Fig. 18.3) Children or infants with mild ECC need intervention of the carious process by a dentist who can handle children and infants. Children less than 3 or 3.5 years are too young to cooperate for any dental



procedure. Most of these children cannot tolerate a high-speed (airotor) drill being used in their mouth. The moment they hear the sound of a high-speed airotor or the water spray they become uncooperative. Hence caries removal can be attempted by a slowspeed (micromotor) and restorations can be attempted in the dental office setting. If the child does not cooperate for the procedure, then treatment under general anesthesia can be recommended and carried out. Controlling the active caries process at this stage will prevent an extensive and invasive treatment with multiple pulp therapies and crowns at a later stage under general anesthesia. In many developing countries, where referral to a specialist is not widely practiced, such patients are not given appropriate treatment by a general dentist. Most parents of these patients would have met a dentist at this stage of ECC, where they were advised against any treatment stating that these are milk teeth and they will be replaced. Unfortunately, these children are left untreated and not referred to the right sources also.



Moderate and Severe (Figs. 18.4, 18.5) Children with moderate and severe ECC may need pharmacological intervention. Children with multiple decayed teeth (decay involving multiple surfaces of a single tooth), with deep caries lesions on the posteriors need multiple appointments and many local anesthetic injections to carry out pulp therapy and stainless steel crowns in a regular dental setting. Children of even 4–6 years also, may become uncooperative after the initial visits with injections, etc. The author feels that whenever a need for multiple dental procedures like pulp therapy and stainless steel crowns and deep caries management coexist in a single child, treatment under general anesthesia can provide the highest quality of dental care for them. However, the benefits and the risk involved should be weighed for each patient and a decision should be taken accordingly. Children with S-ECC usually present with multiple decayed teeth at various stages of progression. Some teeth may need restorations while some may need stainless steel crowns with or without pulp therapy, etc. Indications and contraindications for pulpotomy, pulpectomy,



pulp capping and stainless steel crowns are discussed in Chapters 24 and 25 on Pulp therapy. Hence treatment planning for such children depends on the extension of decay, number of teeth involved, age of the child, risk for future caries, parental attitudes towards oral health, cost of the treatment and availability of the specialist and facilities.



Authors’ View on Benefits of Treatment under General Anesthesia 1. The anterior decayed teeth can be pulpectomised and strip crowns or anterior stainless steel crowns can be placed. This improves the esthetics for a young child and makes a tremendous difference among the peer group. Slack and Jones have reported that untreated/discolored/fractured anterior teeth in children tend to affect the progress of such children in school. Composite restorations can be carried out comfortably to the highest quality as the child is sleeping. 2. Once the posterior teeth with deep cavities are treated and restored with crowns, the eating pattern of the infant improves to a great extent. Children start eating chewable food substances and vegetables which improves their general health. They can gradually switch over from refined food substances to a better dietary pattern after the treatment (Figs. 18.6, 18.7).



Case 1. Pre- and post-treatment pictures of child with severe early childhood caries treated under general anesthesia. FIGURE 18.6



(A-C) Pre-treatment pictures of severe early childhood caries and (D-F) post-treatment pictures of severe early childhood caries. FIGURE 18.7



3. As the active caries lesions are arrested, the microbial population of the mouth decreases gradually over a period of time which, in turn decreases the risk of new cavities on newly erupting primary or permanent dentition. 4. As the sensitive tooth surfaces are covered and the carious teeth are restored, the child can allow or perform better oral hygiene practices like brushing, etc. 5. As the entire treatment is carried out in one visit under general anesthesia, the child will not have any unpleasant dental experience. 6. Behavior of some children improves after a hospitalization procedure.



Preventive Measures Preventive measures can be categorized into community-based measures, professional measures and home care methods. Community-based measures are community water fluoridation, school water fluoridation and education programs organized at the community level. Professional measures are steps taken at the dental office by a dentist to prevent ECC. These measures include teaching



appropriate oral hygiene measures, regular fluoride application, recall visits, etc. Home care methods are efforts taken by the parents in relation to dietary habits, feeding habits, oral hygiene measures, etc. Prevention of transmission of mutans streptococci from mothers with high counts of mutans streptococci can be achieved by use of xylitol containing chewing gum after birth. Studies have shown significantly lower dmf index in children whose mothers have used xylitol chewing gum from 3–24 months after delivery. Dental health education to improve the habits of parents or caregivers by increasing their knowledge about early childhood caries must be promoted. Educational programs are highly recommended and provided for high-risk groups and high-risk communities. Wherever possible, preventive oral health information should be provided to expectant mothers during prenatal education programs. Poor dietary habits and lack of adequate oral hygiene in terms of heavy plaque accumulation are without doubt key factors in caries development in early childhood. Proper infant oral hygiene practices should be taught to the parents and caregivers by the dentists. Oral hygiene habits established at the age of 1 year can be maintained throughout early childhood. Detailed description of the infant and early childhood oral hygiene measures were discussed in the Chapter 12 on Infant Oral Health and Anticipatory Guidance. The concept of anticaries mechanisms of fluoride has changed since late 1980s. Systemic effects have been downgraded and the current view is that fluoride has to be present in the plaque fluid during the caries challenge slowing down the dissolution of enamel and supporting the precipitation of crystals back into the tooth structure. Apart from water fluoridation, the use of fluoride tablets and fluoride varnishes seem to be the most suitable fluoride regimens for the infant. Fluoride toothpaste is the most common vehicle to apply fluoride to the teeth and should be recommended to all infants. The children can start using fluoridated dentifrice at 1–1.5 years of age. Because small children usually swallow 30% of the paste, it is important to limit the amount to the size of a pea. Younger children can use fluoride dentifrices with at least 500 ppm of fluoride in it.



Quality of Life of Children With Early Childhood Caries Quality of life (QoL) subsumes two distinct domains in research. One is health-related quality of life (HRQoL); the other nonhealth or environment-based quality of life. HRQoL encompasses domains of life directly affected by changes in health, i.e. aspects of life that improve when a physician successfully treats a patient. Oral healthrelated quality of life is pertaining to the effects of oral diseases on the functioning of patients. Early childhood caries affects many young children around the world. ECC is an infectious disease and if left untreated, may result in systemic consequences. Several studies have addressed the effects that ECC has on a child’s and their family’s quality of life (QoL). Quality of life factors frequently associated with poor oral health were: 1. Toothaches 2. Having trouble eating certain foods 3. Missing school 4. Difficulty to brush the teeth 5. Frequent episodes of fever, cough and cold 6. Poor self-image The flow chart (Fig. 18.8) explains the vicious cycle of ECC in children leading to poor quality of life for them.



FIGURE 18.8 Vicious cycle of ECC.



Research studies also have investigated the potential positive effect of treatment intervention on QoL for children with severe caries. These studies demonstrate improved oral health-related QoL following treatment under general anesthesia. One to four weeks following treatment under general anesthesia, children were reported to have better perceived quality of life. Parents have reported overall improvements in their child’s health, reduction in pain, improved ability to eat and improved ability to sleep. Parents of children seeking emergency dental care reported that 19% of the children experienced interference with play, 32% with school, 50% with sleeping and 86% with eating. Hence ECC has a tremendous, but often invisible, impact on society and the health care system. Recognition of its pervasiveness likely will drive oral health planning for the foreseeable future.



Risk Factors for Dental Caries in Young Children



It is well known that the etiological factors in dental caries formation are the diet, bacteria and susceptible tooth. However, in young children, bacterial flora and host defense systems are in the process of being developed, tooth surfaces are newly erupted and may show hypoplastic defects and their parents must negotiate the dietary transition through breast/bottle feeding, first solids and childhood tastes. Thus it is thought that there may be unique risk factors for caries in infants and young children. An extensive review by Rebecca Harris (2004) enumerates a total of 106 risk factors significantly associated with ECC. These could be grouped into 20 demographic factors, 29 dietary factors, 15 factors related to breast/bottle feeding, 9 factors related to oral hygiene habits, 4 related to oral bacterial flora and 29 related to other factors such as parental oral health and enamel hypoplasia. Early childhood caries is more commonly found in children who live in poverty or in poor economic conditions who belong to ethical and racial minorities, born to single mothers, of parents with low educational level, especially of illiterate mothers. In this population, prenatal and perinatal malnutrition can cause enamel hypoplasia; oral hygiene is usually poor; exposure to fluorine is usually insufficient and there is a greater preference for sugary foods. Malnutrition may cause enamel hypoplasia and it may lead to reduced salivary secretion and low buffering capacity. Low birth weight, including preterm births predisposes to high levels of streptococcal colonization in addition to favoring the development of enamel hypoplasia and salivary disorders. The severity of ECC can increase with the severity of bronchial asthma, having as major cause the use of drugs which reduce salivary secretion, in addition to the fact that powder inhalers and oral medications contain sugar in their formulation. Baby bottles predispose to ECC because their nipple blocks the access of saliva to the upper incisors, whereas lower incisors are close to the main salivary glands and are protected from liquid contents by the bottle, nipple and the tongue. The use of baby bottles during the night is associated with reduction in salivary flow, which would cause



stagnation and prolonged exposure to fermentable carbohydrates. Additionally it has been demonstrated that infants with ECC sleep less at night, wake up more frequently and receive more bottle feedings as a way to manage their sleep problems. Early childhood caries can be associated with breastfeeding when the consumption pattern has certain characteristics such as ad libitum nocturnal breastfeeding (at will breastfeeding or on demand breastfeeding) large number of breastfeedings a day, prolonged breastfeeding and mainly frequent breastfeeding during the night, resulting in accumulation of milk on the teeth which when combined with reduced salivary flow and lack of oral hygiene may produce tooth decay. The presence of high levels of ECC, despite a reduction in permanent dentition caries through fluoridation of water and use of fluoridated toothpastes, begs for a broader look at social and behavioral factors that correlate with this form of the disease. FisherOwens and colleagues proposed a model for pediatric oral disease that superimposes child, family and community factors over the classic Keyes biological model to indicate the influence of these nonbiological factors on caries initiation.



Newer methods of preventive measures for early childhood caries 1. Glycyrrhiza uralensis (the licorice plant): Extract Glycyrrhizol A from the licorice plant has been shown to kill cariogenic bacteria at a high rate better than triclosan. Studies have shown significant reduction of S. mutans counts after using lollipops with Glycyrrhizol A. 2. Specifically-targeted antimicrobial peptides (STAMPs): An antimicrobial product has been developed that is selective only for S. mutans. This product is called specifically-targeted antimicrobial peptides (STAMPs) and it contains a speciesspecific targeting domain molecule fused with a wide spectrum antimicrobial domain molecule. The result is that



only the specific bacteria of interest is targeted. Once the fused molecule attaches to the S. mutans bacterium, the antimicrobial domain kills the bacterium almost instantly, without affecting any of the hundreds of non-cariogenic oral bacteria. These are being developed as a commercial product. 3. 1.0% flavored chlorhexidine gel: 1.0% Flavored chlorhexidine gel has been developed that can be used on a toothbrush. It was found to cause a significant reduction of S. mutans levels in 3–4 years old children using once a month dosing schedule. 4. Silver diamine fluoride (SDF): SDF could be very useful to delay caries progression until children are older and can have their caries restored without the need for general anesthesia.



CONCLUSION The authors’ opinion is that an appropriate early first dental visit and following the principles of anticipatory guidance provided by a pediatric dentist is the best way to prevent early childhood caries. In most of the developing countries, this information is not available even in urban areas to the expectant mothers and parents. Referral to an appropriate specialist is not practiced widely in these countries and hence most of the children are denied dental care in spite of their visit to a practicing dentist at an early age. Many children are affected by early childhood caries because of lack of information on appropriate feeding practices. As many parents in developing countries cannot afford a hospital-based care for their children’s teeth, prevention holds the key for this public health issue and any incidence of early childhood caries is a failure of the oral health care system.



SELF-ASSESSMENT QUESTIONS Essay Type Define early childhood caries. Describe management of severe early childhood caries.



the



etiology



and



Short Notes 1. Definition and classification of early childhood caries 2. Window of infectivity 3. Etiology of early childhood caries 4. Stages of early childhood caries 5. Clinical features of early childhood caries



SUGGESTED READING 1. Acs, G, Lodolini, G, Kaminshy, S, Cisneros, GJ. Effect of nursing caries on body weight in pediatric population. Pediatr Dent. 1992; 14:302–305. 2. American Academy of Pediatric Dentistry. Clinical guidelines on infant oral health care. Pediatr Dent. 2003; 25(7):54. 3. American Dental Association - Council in Access, Prevention and Interprofessional Relations. Panel report - Symposium on Early Childhood Caries in American Indian and Alaska Native Children, November 2009. 4. Berkowitz, RJ. Etiology of nursing caries: a microbiologic perspective. J Public Health Dent. 1996; 56:51–54. 5. Casamassimo, P, et al. Beyond the dmft - The human and economic cost of early childhood caries. J Am Dent Assoc. 2009; 140(6):650–657.



6. Caufield, PW, Cutter, GR, Dasanayake, AP. Initial acquisition of mutans streptococci by infants: evidence for a discrete window of infectivity. J Dent Res. 1993; 72:37–45. 7. Caufield, PW. Dental caries: a transmissible and infectious disease revisited—a position paper. Pediatr Dent. 1997; 19:491–498. 8. Caufield, PW, Mitchell, JD, Ruby, Y, et al. Alabama antimicrobial restorative treatment (AART): a novel approach to prevention and treatment of dental caries. J Dent Res. 2000; 79(abstract):593. 9. Cunnion, DT, et al. Pediatric oral healthrelated quality of life improvement after treatment of early childhood caries: a prospective multisite study. J Dent Child. 2010; 77(1):4–11. 10. Drury, TF, et al. Diagnosing and reporting early childhood caries for research purposes. J Pub Health Dent. 1999; 59:192–197. 11. Edelstein, B, et al. Experience and policy implications of children presenting with dental emergencies to US Pediatric dentistry training programs. Pediatr Dent. 2006; 28(5):431–437. 12. Fisher-Owens, SA, et al. Influences on children’s oral health: a conceptual model.



Pediatrics. 2007; 120(3):e510–e520. 13. Harris, R, et al. Risk factors for dental caries in young children: a systematic review of the literature. Comm Dent Health. 2004; 21(S):71– 85. 14. Helfenstein, V, Steiner, M, Marthaler, TM. Caries prediction on the basis of past caries including precavity lesions. Caries Res. 1991; 25:372–376. 15. Horowitz, HS. Research issues in early childhood caries. Comm Dent Oral Epidemiol. 1998; 26(suppl):67–81. 16. Ismail, AI. Prevention of early childhood caries. Comm Dent Oral Epidemiol. 1998; 26(suppl):49–61. 17. Ismail, AI, Sohn, W. A systematic review of clinical diagnostic criteria of early childhood caries. J Public Health Dent. 1999; 59:171–191. 18. Kaste, LM, et al. An evaluation of NHANES III estimates of early childhood caries. J Public Health Dent. 1999; 59:198–200. 19. Kohler, B, Bratthall, D, Krasse, B. Preventive measures in mothers influence the establishment of the bacterium of Streptococcus mutans in their infants. Arch Oral Biol. 1983; 28:225–231. 20. Li, Y, Caufield, PW. The fidelity of initial



acquisition of mutans streptococci by infants from their mothers. J Dent Res. 1995; 74:681– 685. 21. Proceedings. Conference on early childhood caries, Bethesda, Md Oct 1997. Comm Dent Oral Epidemiol. 26(suppl), 1998. 22. Seow, WK, Humphrys, D, Tudehope, DI. Increased prevalence of developmental dental defects in low birth weight children: a controlled study. Pediatr Dent. 1987; 9:221– 225. 23. Seow, WK. Biological mechanisms of early childhood caries. Comm Dent Oral Epidemiol. 1998; 26(suppl):8–27. 24. Tinnanoff, N. Introduction to early childhood caries conference: initial description and current understanding. Comm Dent Oral Epidemiol. 1998; 26(suppl):5–7. 25. Twetman, S, Garcia-Godoy, F, Goepferd, SJ. Infant oral health. Dent Clin North Am. 2000; 44(3):487–505. 26. van Houte, J. Role of microorganisms in caries etiology. J Dent Res. 1994; 73:672.



CHAPTER 19



Role of Diet and Nutrition MS Muthu, N Sivakumar and SVSG Nirmala



CHAPTER OUTLINE Introduction Role of Nutrition in Dental Development Impaired dental development Role of Diet in Dental Caries Effect of diet and nutrition before and after eruption Role of dietary sugars Role of fresh fruit and fruit products Role of milk, cheese and other factors Role of trace elements Food Guide Pyramid Diet Counseling Role of Diet in Periodontal Disease Nutrition and Dental Health Suggested Reading Self-assessment Questions



“The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.” —Thomas Edison



Introduction



The worldwide distribution of severity of dental caries has changed in recent years with a marked fall in incidence of dental caries in many developed countries. This is mainly due to the widespread use of fluorides. In developing countries, there is a rise in dental caries, paralleling their rise in sugar consumption. However, the irony is in some developing countries, dental caries occurs in affluent communities with good basic nutrition, while it is rare in communities with the lowest nutritional standards. The focus of this chapter is to provide an overall view of nutrition and diet on dental development and its role in dental diseases.



Role of Nutrition in Dental Development Development of tooth bud begins in intrauterine life and continues until early adolescent years. During this period, many factors can affect dental development. Some of these effects are permanent and irreversible. The stage of tooth development which is interrupted will depend on the time of insult; therefore teeth provide a good record of developmental disturbances. Nutritional deficiencies or excesses are just one among the many causes of defects in tooth development.



Impaired Dental Development Defects of dental development can range from the total absence of teeth to complicated dental malformations. It can range from aberrations in size, shape and number of teeth, but since nutrition has little or no influence on these gross abnormalities, they will not be considered further here. Instead, defects of dental enamel, which are commonly seen and of practical importance are discussed here. A wide range of causes of developmental defects of dental enamel have been identified. Pindborg in 1982 proposed a classification which divided the causes broadly into: 1. Generalized or systemic 2. Local or intraoral causes.



Table 19.1 illustrates the classification given by Pindborg. Table 19.1 Pindborg classification of developmental defects of enamel Systemic causes Genetically determined



Amelogenesis imperfecta



Chromosomal abnormalities



Trisomy 21



Congenital defects



Heart disease



Inborn errors of metabolism



Phenylketonuria



Neonatal disturbances



Premature birth, hypocalcemia, hemolytic anemia



Infectious diseases



Rubella



Allergies



Asthma



Neurological disturbances



Tuberous sclerosis



Endocrinopathies



Hypoparathyroidism, diabetes mellitus



Nutritional deficiencies



Vitamins, proteins, minerals



Nephropathies



Nephrotic syndrome



Enteropathies



Nonspecific diarrhea, celiac disease



Intoxications



Tetracyclines, vitamin D, fluoride, other minerals



Local causes Trauma



Falls, surgery



Irradiation



Radiotherapy



Local infection



Periapical infections of deciduous teeth



A review of the literature in this topic indicates that the two most common relevant nutritional causes of impaired dental development are: 1. Hypocalcemia 2. Excessive fluoride ingestion.



Hypocalcemia Hypocalcemia has many causes, hormonal as well as nutritional. Diarrheal diseases in infancy and early childhood are likely to be important factors in underdeveloped communities especially, leading to hypocalcemia and subsequently, to dental hypoplasia. Vitamin D deficiency could also be a factor in producing hypoplasia in some individuals. Childhood or exanthematous fevers have been suggested as causes of enamel hypoplasia (Fig. 19.1). A trend was observed for increasing severity of asthma and low birth weight infants to be associated with opacities and hypoplastic lesions.



FIGURE 19.1 Enamel hypoplasia.



There is one well-recognized defect of dental development children living in communities in which malnourishment widespread—linear enamel hypoplasia. This occurs principally deciduous incisor teeth and high prevalences have been reported



in is in in



many countries. Nikiforuk and Fraser in 1981 have proposed a unifying concept for the etiology of enamel hypoplasia. They noted that strong associations between the prevalence of acute diarrheal disease and enamel hypoplasia and hypothesized that chronic diarrhea causes malnutrition, resulting in hypocalcemia which can lead to linear enamel hypoplasia. May Mellanby who did much of the work on the influence of vitamins on development of teeth was one of the pioneers in this field. She has observed that deficiency of vitamin D can lead to enamel hypoplasia.



Excessive fluoride ingestion Use of fluorides in various forms has been the most important way of controlling dental caries. There can be no doubt with regard to the great ability of fluoride to prevent the progression of dental caries and it is now widely available for use in a number of vehicles. In many regions of the world, the level of fluoride in drinking water is excessive. Some parts of the world which have excessive fluoride in water are: 1. Southern states of the USA 2. East Africa 3. Areas by the Rift Valley 4. Middle East countries 5. Indian subcontinent 6. Some parts of south east Asia including Japan. Consuming water with high concentrations of fluoride can cause varying degrees of fluorosis (Fig. 19.2). This can lead to mottling of enamel. This can be prevented by appropriate defluoridation methods which are discussed in Chapter 13 on Fluorides and their Role in Pediatric Preventive Dentistry.



FIGURE 19.2 Enamel fluorosis.



Role of Diet in Dental Caries After second World War, advice about healthy eating often urged mothers to give their young children diet rich in calcium and vitamin D. It was expected to help the formation of strong healthy bones and teeth and the resultant strong teeth would be less likely to decay. Although this is sound advice as far as the skeleton is concerned, there has been little evidence to substantiate that good nutrition early in life helps to prevent dental decay by a systemic effect. This does not mean that good nutrition should be discouraged; it merely reflects the current view that diet has a much greater effect locally in the mouth on erupted teeth than it does pre-eruptively, while the teeth are forming. It is similar to the view about fluorides and its systemic effects which were later proved to have only topical effect.



Effect of Diet and Nutrition before and after



Eruption In relation to the pre-eruptive effects, the following elements have also been studied extensively. 1. Malnutrition 2. Vitamin D 3. Calcium to phosphorus ratio 4. Vitamin A 5. Vitamin C 6. Protein 7. Fluoride 8. Sugar consumption. The following discussion will briefly review the role of above mentioned entities on teeth. Two theories were proposed whereby malnutrition during tooth development could make tooth more susceptible to caries and they may also act together in some situations. The first theory proposed by Mellanby states that malnutrition causes defectively formed teeth. The second theory was proposed by Alvarez and Navia in 1989, that eruption of teeth is delayed in malnourished children. Vitamin A is said to have a major role in maintenance of epithelial tissues. Its effect on salivary gland results in more caries on rats fed with vitamin A deficient diet. Protein deficiency is said to cause defective formation of teeth increasing the susceptibility to caries. Decreased consumption of sugar during and after two World Wars has resulted in decrease in dental caries experience in many countries. Initially, it was thought that use of fluoride in water and other systemic modes tend to get incorporated into the developing enamel and make them resistant to decay. However, there is no strong evidence for this hypothesis and it is believed now, that fluoride in any form has only topical effect. Fluoride ingested through water or tablets tends to get absorbed into the circulation which is secreted through saliva and helps in remineralization of the demineralized tooth structure, thereby producing only topical effect. Hence, it can be said that diet can affect the structure of teeth and



their future susceptibility to dental caries and of all these dietary influences, fluoride is likely to be the most important. At an optimum dose, fluoride markedly decreases the development of dental caries, while at high doses it has an adverse effect on tooth structure. Most of the caries preventive effects of fluoride are post-eruptive.



Role of Dietary Sugars Sucrose is said to have a major role in the etiology of dental caries. There is a wealth of information on the relationship between dietary sugars and development of dental caries. Various observational human studies, interventional human studies and animal experiments have proven the role of sugars and their frequency of intake to have tremendous influence on dental caries formation. Some of the milestone observational studies like Hopewood House study and Seventh Day Adventists study have played a crucial role in determining the role of dietary sugars in dental caries etiology. In these observational studies, the relationship between the disease (dental caries) and possible causative and confounding factors (sugar consumption, frequency of consumption) were observed. In interventional studies like Vipelholm studies and Turku sugar studies, diets of groups of people were purposefully altered and the effect of this intervention observed. There is vast amount of data on the role of sugar consumption in diet and the frequency of its consumption on dental caries. Hence, it is wise to cut down on both the frequency of consumption of sugar as well as the total amount of sugar consumed. Role of sugar substitutes or non-calorific sweeteners is discussed in Chapter 17.



Role of Fresh Fruit and Fruit Products It is generally agreed that, consumption of fresh fruits and fruit products improve general health. Literature reveals three aspects of this area which have been widely researched and published. The role of fruits and vegetables, secondly dried fruit and thirdly fruit juices have been studied extensively. Describing these studies is not the



purpose of this chapter and a summary of these research findings are given below. Fresh fruits, dried fruit and fruit juices are capable of causing dental caries in humans. However, the pattern varies in individuals as explained below. 1. Sugary, fruit flavored drinks should not be used as a comforter in young children to induce sleep or during sleep. 2. Fresh fruits appear to be of low cariogenicity. Citrus fruits have not been associated with the development of dental caries. Large consumption of apples and grapes can result in dental caries, but such high consumption is outside usual levels in most countries. 3. High consumption of fruit juices can cause dental erosion.



Role of Milk, Cheese and other Factors Human milk and cow’s milk contain about 7 g/100 g and 4.8 g/100 g of lactose, respectively. These amounts are sufficient to classify milk as a cariogenic substance. But the presence of calcium and phosphate in milk can prevent dissolution of enamel and milk may have other protective factors as well. Hence, consumption of milk can be caries promoting or caries inhibiting depending on how the milk is consumed. The frequency, duration of the exposure and addition of sugar (sucrose) to it are important in tilting the see-saw in the direction of health or disease. Casein is a phosphoprotein present in milk and has been considered to be one of the ingredients responsible for caries protective effect. Now there is a product in the market using casein as a primary ingredient called ‘Tooth Mousse” (Fig.19.3). It has CPP-ACP which is said to remineralize white spot lesions.



FIGURE 19.3 Tooth Mousse—CPP-ACP (Courtesy: GC Asia Dental Pvt Ltd).



Research has shown that cheese is not only noncariogenic but also has anticaries properties. Cheese is said to: 1. Increase the stimulation of salivary flow with its favorable properties 2. Raising the calcium concentration in plaque 3. Increasing the amount of basic substances in plaque 4. Adsorption of protein such as casein to the enamel surface thereby physically slowing the caries process. Hence, it can be summarized that milk contains factors which are sufficient, in almost all circumstances to counteract any cariogenic potential of lactose in milk. These factors are calcium, casein, phosphorus and fats. As mentioned earlier, the major determinants which increases the risk is the way milk is given and addition of sugars to it. Cheese is very likely to be caries-protective in nature.



Role of Trace Elements Elements which are known to have a role in metabolic processes of higher animals and whose daily requirement by humans is less than 100 mg are known as trace elements. Fluorine is a trace element, and it has been already discussed in detail. The quantity of information available about other trace elements and their role in dental caries is negligible in comparison to fluorides. The trace elements which are studied for their relationship with caries are: 1. Molybdenum 2. Selenium 3. Strontium 4. Lithium Sorting out the effect of one element is very difficult as geographical areas which contain high levels of one element probably also contain high levels of other elements. However, studies on various elements have not shown any significant and meaningful associations with caries etiology.



Food Guide Pyramid Food guide pyramid was given by the National Academy of Sciences and the US Department of Agriculture. This pyramid (Fig. 19.4) categorizes food into the following groups:



FIGURE 19.4 Food guide pyramid.



1. Grain group 2. Vegetable group 3. Fruit group



4. Milk group 5. Meat group 6. Others. Foods in the five basic groups are not included in the fermentable carbohydrates unless free sugar is added during their preparation. The pyramid shows a range of servings for each food group. The number of servings that are right for an individual depends on how many calories he needs. This depends on his or her age, sex, size and activity level. Almost everyone should have at least the lowest number of servings in these ranges. As per the recommendations of National Academy of Sciences, calorie requirements are as follows: • 2800 calories is about right for teenage boys, many active men and some very active women. The purpose of limiting a diet to the basic five food groups is twofold. An adequate diet is fundamental to general good health and is of course essential during tooth development. In addition, it is a well-established fact that if children and adults closely follow the recommended diet and consume a diet rich in protein, fresh fruit and vegetables, the appetite for snacks between meals will be decreased.



Diet Counseling Fundamentals Since dietary habits are so personal, dietary advice must be personalized, if it is to be successful. Such advice is, however, full of pitfalls and needs to be approached in a systematic and pragmatic way. We do not eat food simply to satisfy our physiological needs. There is a range of psychological, social, economic and cultural factors which also influence our intake of food. Hence giving dietary advice successfully therefore depends on far more than providing knowledge. It requires sensitive understanding of the role of the food



in society and its significance for the individual patient. It must be understood that to change eating habits is one of the most difficult changes in behavior to achieve. Also it should be remembered that the patient’s receptivity to advice varies with their mood and sense of urgency. For example, dietary advice to a kid after a dental extraction may result in hearty agreement and promises which are not realistic. The substance of the advice may not be absorbed or remembered accurately. In general, the solid and retentive sucrose containing foods are more cariogenic than sugar containing foods that are liquid and nonretentive. Food eaten at meals produces less caries than the same eaten between meals does. In decreasing order of cariogenicity, the foods are grouped as: • Adherent, sucrose-containing foods eaten frequently between meals. • Adherent, sucrose-containing foods eaten during meals. • Nonretentive (liquid) sucrose-containing beverages consumed frequently between meals. • Nonretentive (liquid) sucrose-containing foods consumed during meals.



Proposed Diet Counseling Program Objectives of diet counseling program for the dental office comprise: • The correction of diet imbalances. • The modification of dietary habits. The proposed program is based on a step by step progression through: • Interview, where diet diary forms are introduced. • A 24-hour diet record is prepared. • A 6 days diet diary is advised to be prepared by the patient. • Complete records of 6 days diet diary are analyzed regarding



the balanced and unbalanced diet. • Isolating the sugar factors. • Educating the patients in the role of sugar in the decay process. • The consumption of acceptable substitutes. • The recognition of practical limitations of immediate success. • Provision of continuous positive reinforcement.



Where should the counseling take place? It should take place in a consultation type of room/office, but not in the dental operatory.



Who should give counseling? The best-qualified professionals are: • Dentists • Dental hygienists • Nutritionists



Who should receive counseling? • Ideally all children brought for dental care. • Parents of the child: for children under the age 6 years, who is dependent upon the parent, usually the mother, for his or her food supply and subsequent food habit development. • Elementary school child—as the child matures and develops more control over food selection. • To adolescents group. Note: The duration of the counseling should not exceed 45 minutes.



It is important



• Not to be judgmental about the patient’s responses. • Not to emphasize the role of sucrose containing foods; otherwise the patient may tend to present an ideal rather than real diet. • The patient should not be patronized or lectured.



Diet Diary (Table 19.2) Table 19.2 24-hour diet dairy Day:........................... Patient’s Name:.................................................................... Age/sex:................................... Time/Meal consumed/Food consumed 7.30 am



Breakfast



3 idly – X 1 glass milk (2tsp. sugar added) –X



10.30 am



Snack



12.30 pm



Form of food Sugar in solution



Sugar exposures During meals



1



3 cookies – X 1 coke (small glass) –X



Between meals



1



Lunch



2 chapatis – X 1 cup vegetables – X 1 cup rice - X 1 doughnut sugar coated – X



At bedtime



1



1.30 pm 6.00 pm



Snack Snack



1 pastry (small)-X Solid retentive food 1 cream filled cup containing sugar cake – X 1 candy bar (large) – X



During meals



1



7.30 pm



Dinner



2 chapatis – X 1 cup vegetable – X 1 cup dhal – X



Between meals



4



9.00 pm



Snack



1 cup caramel – X



At bedtime



1



1 glass chocolate milk – X (X Total no. of exposures—9)



• Recording every food item consumed (solids, liquids) during 6 consecutive days. • Recording food consumed at mealtime, between meals, at soda fountain or while watching a movie, picture or television. • Also record candies, chewing gum, cough drops or syrups. • The approximate amount is mentioned in household measures such as 1 cup, 2 table spoon (T), 1 tea spoon (t). • The kind of food and how it was prepared, such as baked chicken, raw apple, cooked cereal, etc. • Additions to food in cooking or at the table—butter, sugar, cream, etc.



List of Foods Containing Sugar Foods containing sugar in solution • Soft drinks, soda pop, powdered drink mixes, fruit drinks • Sweetened sauces such as chocolate, butterscotch • Chocolate milk, hot chocolate, cocoa • Milk shakes, malts Solid retentive foods containing sugar • Cakes, doughnuts • Cookies, candy bars, brownies, chocolates • Pastries, pudding, muffins, sweet rolls, pies • Sugar containing cereals, sugar coated gum • Dried fruits such as raisins, dates, apricots • Fruit cooked in sugar



• Ice cream, jams, Jellies, marmalades • Sugar containing chewing gum, caramels



Isolate the sugar factors • Aided in identification of those foods which are likely to cause oral diseases. • The interviewer and the patient together code the record by any two different colors, e.g. red Xs for harmful choices and time and by blue Xs for good choices and meal pattern. • Asked to count the number of red Xs which are harmful for the teeth. • Next, ask the child which Xs marked food he can eliminate. • Tell him that he should be able to reduce number of red Xs when he comes next. • When the child comes with a reduced number of red Xs, he should be praised for his effort. • The cariogenic potential of a patient’s diet is evaluated by determining the total number of exposures to sucrosecontaining foods during 6 consecutive days. • Exposure is defined as eating the food at one time and is not related to the amount of food sucrose ingested. Grand total, time of exposure to acid = (total exposure × 20 minutes) (This time is based on Stephan curve that the pH of the plaque drops and remains below a critical level at which enamel decalcification can occur for an average of 20 minutes after introduction of sucrose into the mouth.)



Educate the patient on the role of sugar in decay process The plaque that forms on the teeth every day contains bacteria



(germs). These bacteria change the sugar present in food into acids.



Sugar (in food) + Plaque/bacteria (germs) = Acid Tooth + Acid = Decay Sugar (in food) + Plaque/bacteria (germs) = Acid Tooth + Acid = Decay Suggested substitutes for food items • The substitutes should be reasonable. • The list of substitutes should be formed by the joint efforts of the dentist and the patient. • It is not fair to cut down all the sugar from the child diet. Intelligent use of sugar must be there and that is: Sugared food should be consumed during meal time and Food consumption should be followed by appropriate oral hygiene measures. • Sometimes a compromise may be necessary A list of habits to be discouraged and encouraged is used as a guide. Table 19.3 gives a brief description of such habits and it is adapted from the book on Nutrition and Dental Health by Rugg-Gunn. Table 19.3 Suggestions for good dietary habits Habits to be encouraged



Habits to be discouraged



1. Consumption of breakfast



1. Frequent eating of sugary foods



2. Not skipping meals



2. Frequent drinking of sugary drinks



3. Not eating just before bedtime



3. Children refusing to eat meal but demanding



sweet as substitute 4. Confining sweet eating to very few occasions per week Foods



4. Adults using confectionery as a bribe or as an easy option to cope with children Other habits



1. Use of wholemeal bread



1. Drinking alcohol due to stress



2. Use low sugar breakfast and not adding sugar



2. Prominence of fatty foods, e.g. fries, fried food



3. Eating potatoes



3. Use of excessive salts



4. Eating fresh fruit or vegetables as snacks 5. Not taking sugar in drinks 6. Using artificial sweeteners and sugar free products 7. A varied diet and food from all important food groups



Recall visits • Evaluating the patient’s progress • Providing psychological reinforcement • Evaluations are made by means of: The patient’s comments New diet diaries Susceptibility tests such as Snyder tests and clinical judgment • Reinforcement is provided by praising the patient’s/parent’s efforts. • Emphasis should be placed on making the patient fully aware of the benefits.



Dietary Counseling in the Dental Practice



In the day-to-day practice of dentistry, dentists must provide certain patients with sound preventive recommendations that include diet and dental caries. There is currently a slow shift in attitude amongst the dental professionals towards the adoption of a medical model rather than the sample restoration of the cavities. Several methods can be used in the dental setting to assess the diet of selected dental patients. Diet histories, 24-hour diet recall, dietary records and food frequency questionnaires have a role in this evaluation of diet and dental caries. Ask the patient for a 24-hour diet recall and make recommendations to the patient. Usually, the recall is done randomly, and it may be repeated as many as four times to establish dietary patterns that have large day to day variations. The dietary records or food diary approach needs to be carefully explained to the patient so that everything consumed during the examination time is documented accurately. A 3- to 7-day period is usually used in the dental setting, although 4-day records are quite commonly used. In most busy offices, food frequency questionnaires with 50 to 150 food items are used to have the patient mark use of the foods on a scale ranging from never to several times per day. The frequency questionnaire is commonly used because it is inexpensive, time for uncomplicated and requires little time for, staff to complete. The dietary assessment can be done immediately and feedback can be provided during the same visit to the patient. This method may be used during screening sessions and educational tours and the more expensive and complicated assessments can be reserved for the specific high caries risk patients.



Role of Diet in Periodontal Disease Although periodontal disease is the main cause of tooth loss in the world, in developed nations, it may be dental caries. While the progression of dental caries is often accompanied by pain, periodontal disease can develop slowly over years, without symptoms. Factors which are concerned with the pathogenesis of periodontal disease



which may be influenced by diet and nutrition are: 1. Dental plaque 2. Epithelial integrity 3. Immune response 4. Collagen formation and repair 5. Bone formation and repair 6. Food consistency (whether it is fibrous or soft). Numerous studies have been carried out to assess the role of various dietary components in periodontal disease. Various components that have been studied extensively so far include proteins, sugars, fiber and food consistency, calcium, phosphorus, vitamin D, fluoride, fat, iron, magnesium, trace elements other than fluoride, vitamin A, folic acid, vitamin C and vitamin E. As the periodontal tissues are comprised of epithelium, collagen fibers, blood vessels, other connective tissue elements, cementum and bone, it would be surprising if nutritional deficiencies did not adversely affect these tissues. There is strong evidence for such damage in animals but less evidence for such damage in humans. Only in cases of severe vitamin C deficiency, periodontal tissues are really affected. Hence to summarize, the periodontal tissues will benefit when nutrition is adequate, but dietary supplementation of nutrients mentioned above in what are commonly accepted as adequate levels does not seem to improve periodontal health further. So, by far the most important way of maintaining periodontal health is through regular, and thorough physical removal of plaque with good oral hygiene practices.



Nutrition and Dental Health The information above has given an indication of the role of good nutrition in relation to good dental health. The greatest threat to the dental health of children comes from the excessive use of sugars in various forms. Confectionery, soft drinks, biscuits, cakes and table sugar are the major sources of sugar in children and should be considered as the targets for dietary advice. Of particular concern in



the infant and young child is the addition of sugar to milk feeds and the frequent and prolonged use of sugary drinks often used as comforters during their sleep time. Hypocalcemia in infancy can cause hypoplasia and inadequate levels of vitamin D can increase the risk of dental caries. Fluoride has a well-established role in the prevention of dental caries and the sensible use of fluorides should be encouraged. Children with special needs may need a different diet. Dentists should discuss the care of such patients with their medical and dietetic colleagues. Appropriate nutrition can play a major role in good dental health.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Define enamel hypoplasia. Classify causes of enamel hypoplasia. Discuss various factors involved in enamel hypoplasia. 2. Nutrition and dental health.



Short Notes 1. Pre-eruptive effects of diet on teeth 2. Food guide pyramid 3. Role of milk and milk products in caries prevention 4. Casein 5. Diet counseling 6. Enamel hypoplasia 7. Food, diet, nutrition 8. Diet history/diet diary 9. Trace elements and dental caries



SUGGESTED READING 1. Alvarez, JO, Navia, JM. Nutritional status, tooth eruption and dental caries: a review. Am J Clin Nutr. 1989; 49:417–426. 2. Donald, J. Forrester, Mark, L. Wagner, James, Fleming. Pediatric Dental Medicine, 6th Ed. Philadelphia: Lea & Febiger; 1981. 3. McDonald, RE, Avery, DR, Dean, JA. Dentistry for the Child and Adolescent, 8th edn. St. Louis: Mosby; 2004. 4. Mellanby, M. An experimental study of the influence of diet on teeth formation. Lancet. 1918; ii:767–770. 5. Mellanby, M, Coumoulos, H. The improved dentition of 5-year-old London school children. Br Med J. 1944; i:837–840. 6. Mellanby, M, Martin, WJ. Dental structure and disease in some 5-year-old Indian school children compared with the same group in London. Arch Oral Biol. 1962; 7:733–750. 7. Nikiforuk, G, Fraser, D. The etiology of enamel hypoplasia–a unifying concept. J Pediatr. 1981; 98:888–893. 8. Nizel, AE, Papas, AS, Dietary counseling for the prevention and control of dental caries. Nutrition in Clinical Dentistry 3rd Ed. WB Saunders, Philadelphia, 1989. 277–308.



9. Pindborg, JJ. Aetiology of developmental enamel defects not related to fluorosis. Int Dent J. 1982; 32:123–134. 10. Rugg-Gunn, AJ. Nutrition and Dental Health. Oxford: Oxford Univeristy Press; 1993.



CHAPTER 20



Recent Advances in Diagnosis of Caries K Rekhalakshmi and N Sivakumar



CHAPTER OUTLINE Introduction Conventional Methods Visual examination Tactile examination Radiographs Non-conventional Methods Requirements for non-conventional methods Pediatric significance Non-conventional Methods in use Digital radiography Digital subtraction radiography Dyes Transillumination Fluorescence Electrical conductance Ultrasonics Conclusion Suggested Reading Self-assessment Questions



“Diagnosis is not the end, but the beginning of practice”. —Martin H Fischer



Introduction Dental practitioners worldwide use visual examination together with



the dental explorer to decide if an occlusal surface is in need of restoration or if preventive management is required. However, accurate diagnosis of the occlusal surface is difficult due to anatomical nature of the fissures and the likelihood of caries being initiated on the fissure walls and base which make it difficult to detect with probing alone. Histological studies show that only a small proportion of occlusal caries can be discovered by visual inspection and probing. Hence, the diagnosis of caries is a challenge in Dentistry. However at present, dentists have several options at their disposal for the clinical diagnosis of dental caries. This chapter is primarily aimed at providing a brief overview of the conventional and non-conventional methods that can be employed in diagnosis of dental caries.



Conventional Methods Traditionally, dentists have relied mostly on the following methods for caries detection. 1. Visual examination 2. Tactile sensation 3. Radiography



Visual Examination It is completely subjective with low reproducibility, but the following criteria can be used to help in examination.



Ekstrand criteria The visual inspection can be performed using air/water spray. 0: Slight or no change in enamel translucency after prolonged air drying 1: Opacity or discoloration hardly visible on wet surface, but distinctly visible after air drying 1a: Opacity (brown) hardly visible on the wet surface, but



distinctly visible after air drying (>5 s) 2: Opacity or discoloration distinctly visible without air drying 2a: Opacity (brown) distinctly visible without air drying 3: Localized enamel breakdown on opaque or discolored enamel and/or grayish discoloration from underlying dentin 4: Cavitations in opaque or discolored enamel exposing dentin Lussi criteria 0: Caries free 1: Caries extending up to halfway through the enamel 2: Caries extending in the inner half of the enamel 3: Caries in the outer half of the dentin 4: Caries in the inner half of the dentin



ICDAS International Caries Detection and Assessment System (ICDAS) was proposed to reduce subjectivity, increase sensitivity and monitor the lesions at an early stage and evaluate activity. It is meant to be a unifying set of predominantly visual criteria that can be used to describe the characteristics of clean, dry teeth at both the enamel and dentinal caries level and to assess caries activity. In 2003, the ICDAS-I was devised based on the principle that the visual examination should be carried out on clean, plaque-free teeth, with carefully drying of the lesion/surface to identify early lesions. ICDAS I: 0: Sound tooth surface 1: First visual change in enamel 2: Distinct visual change in enamel 3: Microcavitation 4: Underlying dark shadow from dentin with or without cavitation 5: Distinct cavity with visible dentin 6: Extensive distinct cavity with visible dentin



Later, in 2005, these criteria were modified and the ICDAS-II was created at the ICDAS workshop in Baltimore. The improvement included an exchange of codes to ensure that the system would reflect increased severity. ICDAS II: 0: Sound tooth surface: No evidence of caries after prolonged air drying (5 s). 1: First visual change in enamel: Opacity or discoloration (white or brown) is visible at the entrance to the pit or fissure after prolonged air drying, which is not or hardly seen on a wet surface. 2: Distinct visual change in enamel: Opacity or discoloration distinctly visible at the entrance to the pit and fissure when wet, lesion must still be visible when dry. 3: Localized enamel breakdown due to caries with no visible dentin or underlying shadow: Opacity or discoloration wider than the natural fissure/fossa when wet and after prolonged air drying. 4: Underlying dark shadow from dentin ± localized enamel breakdown. 5: Distinct cavity with visible dentin: Visual evidence of demineralization and dentin exposed. 6: Extensive distinct cavity with visible dentin and more than half of the surface involved. These criteria are being used in several clinical research studies. Preliminary data from ongoing studies and recently completed studies indicate that ICDAS is repeatable and has good sensitivity and specificity. A detailed description of the ICDAS system is given in the Chapter 42 “Indices used in Pediatric Dentistry”.



Tactile Examination It involves usage of the dental explorer, to determine the presence of a loss of continuity or breaks in the enamel and assess the softness or



resilience of the enamel. But, the use of an explorer to detect caries has been studied extensively. Probing with an explorer into pits and fissures will reveal a “catch” only if the diameter of the defect accommodates its tip. There is also a consensus that using an explorer to forcefully probe the suspected carious pits and fissures does not add to diagnostic yield and may be damaging. Because the reversal of the carious process depends on an intact surface layer of the lesion, the typical use of the dental explorer to probe the suspicious areas often results in the rupture of the surface layer covering early lesions. Hence the use of dental explorer to probe the enamel is no longer recommended. More appropriate strategies involve using explorers to remove plaque to permit visual inspection of pits and fissures and lightly assess surface hardness.



Radiographs Usage of intraoral periapical radiographs (IOPA) is a traditional method in diagnosing carious lesions. But they do not always reveal the presence of occlusal lesions because of the amount of healthy tooth structure surrounding the lesion, the small size of many lesions and the variables in radiographic quality as related to radiographic exposure and development. Lesions located on interproximal tooth surfaces have generally been detected with the use of bitewing radiographs. But they detect only advanced lesions.



Non-conventional Methods Requirement for non-conventional Methods It is apparent that conventional methods for the detection of dental caries do not fulfil the criteria for an ideal caries detection method, as they rely on subjective interpretation and are insensitive to early caries detection. Thus carious lesions are diagnosed at a welladvanced stage, involving one-third or more of the thickness of enamel. As a result, it is often necessary to restore the lesion rather than attempt alternative measures to reverse or arrest the lesion.



Hence there is a requirement for non-conventional methods and more innovative strategies, for the assessment of carious lesions.



Pediatric Significance Because of the thinness, low mineral content and greater porosity of primary enamel than permanent enamel, the requirement for other methods is more in primary teeth. Significance also exists for young permanent teeth where the thickness of dentin will be less. The widespread use and availability of fluoride has changed the behavior of carious lesions dramatically. The resulting slower progression of carious lesions has afforded the dental profession the opportunity to diagnosis and manage caries at an early stage and this has led to renewed interest by researchers, clinicians and manufacturers of diagnostic tools in caries. Recent years have seen an increase in research activity surrounding diagnostic methods, particularly in the assessment of early caries lesions. Increased desire of dental professionals and patients for a more conservative restorative procedures as well as the implementation of measures to control and reverse the carious process led to significant efforts to develop technologies for the early detection of dental caries.



Non-conventional Methods in Use Digital Radiography Direct digital radiography provides a number of advantages when compared to the conventional film. These include contrast and edge enhancement, image enlargement, lower radiation dose, image compression and automated image analysis. Digital radiology encompasses all the techniques that produce digital (or computerized) images, as opposed to conventional radiology that uses X-ray film. There are three main techniques in capturing images, used in intraoral digital radiology:



1. Film scanners 2. Intraoral phosphor plates 3. Intraoral digital sensors Intraoral digital sensors are most commonly used. A digital intraoral sensor is based on an ‘imager’, or a silicon chip that permits the acquisition of an image. Such a chip is constituted of a myriad of pixels, each pixel capturing a small quantity of light and converting this light into electricity. There are several technologies that are used to produce images. The two major ones are CCD (charged-coupled device) and CMOS (complementary metal-oxide semiconductor). They both convert photons into electrons. Radiovisiography (RVG) is a charged-coupled device with a digital sensor. The main advantages of digital intraoral radiography systems are that they result in few errors in the image and environmental problems, since there is no use of chemicals. They also save time and reduce radiation dose to the patient because the receptors are more sensitive to radiation. These advantages are significant when dealing with children. It is possible to improve images using image enhancement facilities; this could prove interesting for use with impatient children. But according to a review done by Wenzel (2006), more radiographs will be taken with a digital system compared to conventional radiographs, as there can be difficulties with positioning the sensors, leading to re-exposures.



Digital Subtraction Radiography For years, dentistry has dealt with the problem of no quantitative measures to determine the success of a particular treatment. When evaluating bone, changes can be masked by disparities in projection geometry. Digital subtraction radiography is a technique that allows us to determine quantitative changes in radiographs. The premise is quite simple. A radiographic image is generated before a particular treatment is performed. At some time after the treatment, another image is generated. The two images are digitized and compared on a



pixel-by-pixel basis. The resultant image shows only the changes that have occurred and ‘subtracts’ those components of the image that are unchanged. This can be used in diagnosis of secondary caries or recurrent caries under already existing restorations.



Dyes Tactile and visual criteria are normally used to render a cavity cariesfree and the idea of a diagnostic aid that would differentiate infected dentin was considered desirable. As early as 1940, Gomori used silver nitrate to stain caries lesions. Other investigators examined the value of 8-hydroxyquinoline in the detection of early caries (Konikoff and Lyles, 1966). Fluorescein dye has been used in the detection of caries lesions by use of ultraviolet illumination (Hefferren et al., 1971). A solution of basic fuchsin in propylene glycol has been used both in the diagnosis and treatment of caries lesions (Fusayama, 1979, 1980). A technique using a basic fuchsin red stain was suggested to aid in the differentiation of the two layers of carious dentin. Because of potential carcinogenicity, the basic fuchsin stain was subsequently replaced by another dye, acid red solution. Products based on acid red 52 are marketed by a number of manufacturers, e.g. Caries Detector, Kuraray, Osaka, Japan. Many clinicians also have had good success with acid reds 50, 51, 54, and other commercially available caries detectors. Propylene glycol based Caries Finder™(Fig 20.1) is available in red and easy-to-see green, 10 ml bottles or 1 g syringe (red formulation only). Some caries detection products contain a red and blue disodium disclosing solution (e.g. Cari-D-Tect, Gresco Products, Stafford, Texas). These products stain infected caries dark blue to bluish-green.



FIGURE 20.1 Caries Finder™ (Courtesy: Danville Materials, California, USA).



Principle involved Caries-detecting stains differentiate mineralized from demineralized dentin in both vital and nonvital teeth. Outer carious dentin is stainable because of the irreversible breakdown of collagen crosslinking which loosens the collagen fibers. Inner carious dentin and normal dentin are not stained because their collagen fibers are undisturbed and dense. It is now clearly established that these dyes do not stain bacteria but instead stain the organic matrix of less mineralized dentin. The lack of specificity of caries-detector dyes was confirmed in 1994 by Yip and others, who correlated the location of dye-stainable dentin with mineral density. The dyes neither stained bacteria nor delineated the bacterial front but did stain collagen associated with less mineralized



organic matrix. Dye staining and bacterial penetration are independent phenomena and this fact significantly limits the usefulness of these dyes for diagnostic purposes. Most clinical investigations have concluded that conventional tactile and visual criteria are the most satisfactory ones in assessment of caries status during cavity preparation and that subsequent use of a caries-detector dye could result in unnecessary removal of sound tooth tissue. Dyestainable status is not a good predictor for the presence or absence of bacteria in dentin and lacks the necessary specificity for the accurate detection of carious dentin. The value of using dyes for carious enamel detection has proven even more dubious than for dentin. Many, such as procion dyes, produce irreversible staining, which would be clinically unacceptable.



Modifications • Caries detector dyes are composed of two components — a dye and a solvent mostly made of propylene glycol. It is believed that solvents with low molecular weight are able to penetrate deeper into permeable tissues as compared to those with high molecular weight. Based on this effect, a new caries detector dye, Caries Check (CC), containing 1% acid red in polypropylene glycol has been recently introduced. The high molecular weight of the solvent in Caries Check compared with propylene glycol present in routine dyes was claimed to prevent over-penetration of the dye into porous dentin tissues, inhibiting unnecessary dentin removal. • Dye-enhanced transillumination and dye-enhanced laser fluorescence have been significantly effective in diagnosing artificial incipient lesions.



Transillumination Principle involved Transillumination works best with longer wavelengths of light in



the yellow and orange range, because they have higher penetration properties. Blue light used for curing is the least effective, owing to decreased penetration and increased scattering. Transillumination works best when a small light source is used in a dark field. The optimal approach is to turn the operatory light away and use an incandescent yellow-to-white light source about 1 mm wide. It is a good method of detecting proximal decay in the anterior teeth. It is less effective in detecting decay in premolars and molars.



Transillumination devices 1. Composite curing lamps 2. Fiberoptic handpieces 3. FOTI and DIFOTITM 1. Composite curing lamps: Some composite curing lamps have filtered tips that change the wavelength of light to yellow-orange so that the lamp can be used for transillumination. 2. Fiberoptic handpieces (Fig. 20.2): An easy-to-use alternative is the fiberoptics built into handpieces.



FIGURE 20.2 Fiberoptic hand piece (Courtesy: Dentex, KAB Dental, USA).



3. Fiberoptic transillumination (FOTI): Fiberoptic Transillumination is a classic diagnostic aid which has never gained wide acceptance. It offers an alternative method of diagnosis that can be used to supplement the clinical examination. It is a simple, noninvasive, painless procedure that can be used repeatedly with no risk



to the patient. A narrow beam of bright white light is directed across areas of contact between approximal surfaces and the disruption of crystal structure, which occurs in demineralisation, deflects the light beam and produces shadows. The procedure has been validated histologically and has levels of sensitivity and specificity that exceed those of radiographs. FOTI instrument provides an intense light beam that is transmitted through a fiberoptic cable to a specially designed probe to permit the use of transillumination on the proximal surfaces of the teeth. • DIFOTI® (digital imaging fiberoptic transillumination) takes advantage of advances in computer technology. The visually observed images are captured using a digitally charged coupled device (CCD) camera and sent to computer for analysis using dedicated logarithms. It instantly creates highresolution digital images of occlusal, interproximal and smooth surfaces, but it is as good as radiography for detection of caries on the interproximal surfaces (Fig. 20.3). More information about DIFOTI is discussed in Chapter 16 on Caries Risk Assessment and Caries Risk Activity Tests.



FIGURE 20.3 DIFOTI® (Courtesy: Electro-Optical Sciences Inc. New York, United States).



Fluorescence Principle involved Fluorescence can be used for caries detection because of the difference in fluorescence observed between sound and demineralized enamel, which is greater when the enamel is illuminated by light in the blue-green range (488 nanometers).



Fluorescence devices • QLF (QLF-clin, Inspektor Research Systems BV, Amsterdam, Netherlands), which uses an arc lamp with a 290 to 450 nm wavelength. • DIAGNOdent (KaVo Dental, Lake Zurich), which uses IR light and has a 655 nm wavelength. • Soprolife • Fluorescence spectrophotometer, which uses several wavelengths, is an approach that has been investigated but has not yet been developed commercially.



QLF (Fig. 20.4) The QLF™ (Quantitative light fluorescence) clinical system is a portable intraoral camera device connected to a computer with which initial enamel caries lesions on the lingual, buccal and occlusal areas of tooth elements in vivo can be quantified longitudinally in time with respect to lesion depth and lesion size. The teeth will be illuminated with blue light and the images captured with a yellow filter.



FIGURE 20.4 QLF™ (Courtesy: Inspektor Research Systems BV, Amsterdam, Netherlands).



This methodology began with the observation in 1978 by a dental scientist in Sweden that the use of a laser light of selected wavelength markedly enhanced the visibility of early noncavitated lesions. Subsequent investigations by this group confirmed the value of this approach for the early detection of caries clinically. Numerous studies confirmed the correlation between the amount of observed fluorescence and the mineral content of the lesions and made possible the development of a system that could truly assess the changes in either progression or recession of carious lesions. To facilitate use in clinical practice, a small portable system QLF™, was developed in which the laser source was replaced by a regular light source and filter system. The light illuminating the tooth is transported through a light filled light guide. The fluorescent filtered images are captured using a color CCD camera. Data are collected, stored and analyzed by customised software. QLF method has undergone several developments with respect to both software and hardware. Numerous investigations have demonstrated the practical usefulness of QLF for early detection of dental caries on occlusal and smooth tooth surfaces as well as quantification of lesion changes related to treatment procedures and environmental factors such as oral hygiene. The only significant limitation to this instrument is its inability to detect or monitor interproximal lesions. More information about QLF is discussed in Chapter 16 on Caries Risk Assessment and Caries Risk Activity Tests.



DIAGNOdent (Infrared LASER Fluorescence) A portable device DIAGNOdent™ (Kavo, Bibberach, Germany) (Fig. 20.5 A and B) has been introduced, in which fluorescence alterations of carious enamel are expressed as readings on a scale from 0 to 99. This instrument was developed for the detection of occlusal and



smooth surfaces. It uses a diode laser light source and a fiberoptic cable that transmits the light to a hand-held probe with a fiber-optic eye in the tip. The light is absorbed and induces infrared fluorescence by organic and inorganic materials. The emitted fluorescence is collected at the probe tip, transmitted through ascending fibers, processed and presented on a display window as an integer between 0 and 99. Increased fluorescence reflects carious tooth substance. The bacterial metabolites, particularly porphyrins, have been found to be responsible for the fluorescence. The instrument is very good at indicating the presence of deeper lesions in enamel or into dentin that may not be apparent yet on radiographs but is unable to reliably indicate the depth of a dentinal lesion. It appears to be particularly useful for confirming the presence of occlusal caries. Instrument readings higher than 20 or 25 reflect the likely presence of caries and higher readings generally reflect more extensive lesion progression, although a linear relation does not seem to appear between the readings and the extent of the lesions. More information about Diagnodent is discussed in Chapter 16 on Caries Risk Assessment and Caries Risk Activity Tests.



FIGURE 20.5A DIAGNOdent™ (Courtesy: Kavo, Bibberach, Germany).



FIGURE 20.5B Working principle of DIAGNOdent™.



• DIAGNOdent pen (Fig. 20.6) is a hand-held laser caries detection aid that provides the same high detection accuracy



as DIAGNOdent.



FIGURE 20.6



DIAGNOdent pen (Kavo, Bibberach, Germany).



Soprolife (Fig. 20.7) The blue LED emits light at 450 nm. It does not emit ultraviolet light. This wavelength excites the dentin which, in reaction, reflects a light signal named fluorescence. The spectrum (color) of the fluorescence signal is green when the dentin is healthy and dark red, when the dentin is infected.



FIGURE 20.7 Soprolife (Acteon group, North America).



Electrical Conductance Principle involved As a tooth gets demineralized in the caries process, the loss of mineral leads to increased porosity in the tooth structure. This porosity is filled with fluid from the oral environment which contains many ions. Increased ionic content in the pores leads to increased electrical conductivity, or, conversely, increased porosity leads to decreased electrical resistance or impedance. Many studies were performed to adapt the principle of the electrical conductance property to the dental laboratory and clinical situations. These used many prototypes as well as commercially marketed caries detection machines, of which, not all are available today. The electric resistance value of any given area of a tooth depends on the local porosity, the amount of liquid present, the temperature, the mobility of the liquid and the ion concentration of the liquid. To avoid the influence of saliva, these techniques involve drying the tooth surface using a standardized airflow procedure. Interpreting the measurements is relatively complex since there is no standard representing the different levels of caries.



Devices Using the Electrical Conductance Property • The modified AC Ohmmeter • Vanguard Electronic Caries Detector (Massachusetts Manufacturing Corp., Cambridge, Mass., USA) • Caries Meter L (G-C International Corp., Leuven, Belgium)



• ECM I, II, III and IV (LODE Diagnostic, Groningen, The Netherlands) • Modified Electrochemical Impedance Spectroscopy (EIS) • Electrical Impedance Tomography (EIT) The concept of examining teeth for caries using an electrical signal is not new; reports in the literature from the UK date from the 1950s. Perhaps the most significant early device for use in everyday practice was the ‘Vanguard’ fixed frequency electrical caries monitor designed in the US in the 1970s; this showed very encouraging diagnostic performance when evaluated in the 1980s. In the early 1980s, a Japanese device was also available commercially as the ‘Caries Meter L’. These devices were not available widely and were, to an extent, before their time. A Dutch meat-processing Company, Lode, produced a close copy of the Vanguard device in the 1990s as the ECM (electronic caries monitor). Once again, the caries detection performance was very encouraging and superior to alternatives available at that time. A major technological advance came in 1996 when Nature Medicine reported the first use of multiple electrical frequencies using a method known as the AC impedance spectroscopy technique (ACIST) being applied to caries detection in the laboratory setting. The use of variable frequencies allowed a major step forward in characterizing the status of the dental hard tissues more accurately and being able to differentiate both health and disease more clearly. Its principal advantage over single (fixed) frequency measurements is that, since materials have different electrical responses at different frequencies, it can help to determine more accurately the various parameters which demonstrate these differences. Although these breakthroughs laid the foundation for a clinical device, it took many years of work to move from a large computer-driven, mains powered, laboratory stack of instrumentation to a regulatory-approved, battery-powered handheld device. Thus CarieScan Pro™ device came into market. CarieScan Pro™ (Fig. 20.8): It is an easy to use clinical device produced by a Scottish company. It is a miniaturized technology,



which has been tested with clinicians in a number of formats to produce a clinically useful and easy to use aid to caries detection and monitoring. It also eliminates the problem of variation in the performance of reusable tips after autoclaving as this contains single use sensor tips, as it has been found that consecutive sterilization of probes in autoclave alters readings, downgrading their performance.



FIGURE 20.8 CarieScan Pro™ (Courtesy: CarieScan Ltd, The Technology Park, Dundee, UK).



Ultrasonics Principle involved The use of ultrasound to detect dental caries has been proposed for the past 30 years. The technique has received renewed interest at various times. Ultrasound waves have a frequency of >20,000 Hz. Sound waves have all the usual properties of waves, in that they may be reflected, scattered, refracted or absorbed. The relative ability of a medium to transmit sound depends on its mechanical properties, such as elasticity, density and the wavelength of the sound. Thus ultrasound may be a quick and reliable tool for the detection of dental caries in enamel.



Portable ultrasonic device and algorithms The apparatus generates longitudinal ultrasound waves that may be applied to any accessible surface of a tooth. The reflected ultrasound pulse echoes are collected and correlated with the incident pulse. The ultrasound pulse echoes from the front and rear surface of a dental cavity, may be distinguished from other echoes and provided in visual display to inform as to the size and location of the cavity. Surface lesions exposed to ultrasonic surface waves create ultrasonic surface wave reflections, which may be received at the transmitter/receiver, thereby detecting the presence of a cavity. Ultrasonic surface waves are capable of only limited penetration into the tooth and therefore, are unable to detect deeply penetrating caries or to determine the size of the caries.



Other Methods The other methods that can also be employed in the diagnosis of caries are magnifying loupes or intraoral camera magnification, LED



mouth mirrors, xeroradiography, air abrasion, optical coherence tomography, multiphoton imaging, infrared thermography and terahertz pulse imaging.



CONCLUSION Every caries detection tool will have its own advantages and disadvantages. Therefore, their performance threshold and the operator’s influence on performance must be considered. Not all methods accurately detect early lesions and false positives and false negatives may occur. Majority of the non-conventional methods are not cost-effective, which happens to be the major limitation in their usage. Detecting early lesions in combination with assessing the activity status is essential for establishing the prognosis and threshold required for preventive intervention. No single test is perfect; but clinicians who use a combination of diagnostic measures and a sound clinical judgment can routinely achieve more accurate assessment of disease process.



SELF-ASSESSMENT QUESTIONS Essay Type Enumerate different methods used in diagnosis of dental caries. Write briefly about the recent developments.



Short Notes 1. DIAGNOdent 2. FOTI and DIFOTI 3. Digital radiography 4. Dyes in caries diagnosis 5. ICDAS criteria



SUGGESTED READING 1. da Silva, PRD, Marques, MM, Steagall, W, Jr., Mendes, FM, Lascala, CA. Accuracy of direct digital radiography for detecting occlusal caries in primary teeth compared with conventional radiography and visual inspection: an in vitro study. Dentomaxillofacial Radiology. 2010; 39:362–367. 2. Diniz, MB, Rodrigues, JA, Hug, I, Cordeiro, RCL, Lussi, A. Reproducibility and accuracy of the ICDAS-II for occlusal caries detection. Community Dent Oral Epidemiol. 2009; 37:399– 404. 3. Dove, SB. Radiographic diagnosis of dental caries. J Dent Edu. 2001; 65(10):985–990. 4. Gakenheimer, DC. The efficacy of a computerized caries detector in intraoral digital radiography. J Am Dent Assoc. 2002; 133:883–890. 5. Hall, A, Girkin, JM. A review of potential new diagnostic modalities for caries lesions. J Dent Res. 2004; 83(Spec Iss C):C89–C94. 6. Kavvadia, K, Lagouvardos, P. Clinical performance of a diode laser fluorescence device for the detection of occlusal caries in primary teeth. Int J PaedDent. 2008; 18:197– 204.



7. Longbottom, C, Huysmans, M. Electrical measurements for use in caries clinical trials. J Dent Res. 2004; 83(Spec Iss C):C76–C79. 8. McDonald, RE, Avery, DR, Dean, JA. Dentistry for the Child and Adolescent, 8th ed. St. Louis: Mosby; 2004. 9. O’brien, WJ, Vazquez, L, Johnston, WM. The detection of incipient caries with tracer dyes. J Dent Res. 1989; 68(2):157–158. 10. Pitts, NB. How electrical caries detection and monitoring with caries can help deliver modern caries management. Oral Health. 2010; 34–43. 11. Stookey, GK, González-Cabezas, C. Emerging methods of caries diagnosis. Journal Dent Edu. 2001; 65(10):1001–1006.



SECTION VI



Restorative Dentistry and Endodontics OUTLINE Chapter 21: Pit and Fissure Sealants and Preventive Resin Restorations Chapter 22: Atraumatic Restorative Treatment Chapter 23: Pediatric Operative Dentistry Chapter 24: Pulp Therapy Chapter 25: Crowns in Pediatric Dentistry



CHAPTER 21



Pit and Fissure Sealants and Preventive Resin Restorations EMG Subramanian, MS Muthu and N Sivakumar



CHAPTER OUTLINE Introduction History of prevention of pit and fissure caries Pit and Fissure Sealants Types of fissures Cariostatic properties of sealants Types of sealants Selection of patient Role of etching while placing pit and fissure sealants Technique of pit and fissure sealant application Glass ionomer based sealants Role of bonding agents in sealant placement Reasons for sealant failure Preventive Resin Restorations Placement technique Conclusion Suggested Reading Self-assessment Questions



“It is a wise man’s part, rather to avoid sickness, than to wish for medicines.” —Thomas More



Introduction Caries of the occlusal surfaces of permanent and primary dentition



continues to be a problem for children, with newly erupted permanent molars at risk, owing to the presence of pits and fissures. These areas are susceptible for initiation of dental caries because of their tortuous invaginations and irregularities where bacteria and food get mechanically retained. Even a toothbrush bristle cannot penetrate and mechanically clean the depths of these pits and fissures. Although only 12.5% of all tooth surfaces are occlusal, these surfaces present more than two-thirds of the total caries experienced by the children. The most effective way to prevent pit and fissure caries is by effective sealing using material called pit and fissure sealants. A susceptible tooth, cariogenic bacteria and suitable substrate for the bacteria to form acids are all necessary for dental caries to occur. All the preventive programs against caries aim against these factors. Pit and fissure sealants aim against all the three factors in one way or other. They act by the physical obstruction of pits and fissures, which prevents colonization of the pits and fissures with new bacteria. Sealants also prevent entry of fermentable carbohydrates into the pits and fissures so that any remaining bacteria cannot produce acid in cariogenic concentration thus protecting the tooth against caries. They are an effective means of preventing pit and fissure caries which substantially reduce dental caries in population beyond that achieved by fluorides and other preventive measures. Simonsen in his book Clinical Applications of the Acid Etch Technique described pit and fissure sealant as a material that is introduced into the occlusal pits and fissures of caries susceptible teeth, thus forming a micromechanically bonded, protective layer cutting access of caries producing bacteria from their source of nutrients. A pit is defined as a small pin point depression located at the junction of developmental grooves and at terminals of those grooves. A fissure is defined as deep clefts between adjoining cusps. These defects occur on occlusal surfaces of molars and premolars, with tortuous configurations that are difficult to access from the surfaces.



History of Prevention of Pit and Fissure Caries (Table 21.1)



In the history of prevention of caries, there were both conservative and invasive attempts by various authors. Among the authors who attempted to find conservative means of treating occlusal pits and fissures, Wilson in 1895 used zinc phosphate cement and Kline and Knutson in 1942 used ammonical silver nitrate to seal pits and fissures. Bodecker in 1929 proposed enamel fissure eradication which involves mechanical eradication of narrow, deep inaccessible fissures into shallow wide cleanable areas. However, the prophylactic odontotomy, introduced by Hyatt in 1923, an invasive operative procedure, remained the treatment of choice for many clinicians well into the 1970s. This included filling the pits and fissures with silver or copper oxyphosphate cements as soon as the teeth erupt into oral cavity and small occlusal cavities are prepared when the teeth fully erupt into oral cavity and filled with silver amalgam. Later, Buonocore in 1955 described the technique of acid etching as a method of increasing the adhesion of resin materials and this marked the start of a revolution in the clinical practice of Dentistry. Cyanoacrylates were the first materials to be used as sealants but it was never marketed. Bis-GMA resin introduced by Bowen in 1965 is the component of the basic resin to most of the current sealants. Glass ionomers are used as interim sealants for primary molars that are difficult to isolate and partially erupted first permanent molars that are at the risk of developing decay. Once the permanent molar is fully erupted, the glass ionomer cements can be replaced with regular sealants. Table 21.1 Summary of the history of sealing pits and fissures Author



Year



Technique



Wilson



1895



Zinc phosphate to seal the fissures



Hyatt



1923



Prophylactic odontotomy



Bodecker



1929



Fissure eradication



Kline and Knutson



1942



Ammonical silver nitrate to seal the fissures



Pit and Fissure Sealants Pit and fissure sealants are defined as thin plastic coatings placed on the occlusal surfaces of posterior teeth to form a mechanical barrier between tooth structure and the oral environment. The reviews of Eklund and Ismail in 1950s, 1960s and 1970s revealed that 70% of all molar occlusal surfaces would become carious within 10 years of emergence into the oral cavity. A high percentage of these occlusal lesions occurred in the first 3 years after eruption. These early caries data supported Council of Dental Research policy that sealants should be universally applied, principally to molar teeth within 3 or 4 years of eruption. However, the current perspective is that sealants should be directed to those teeth judged at risk for caries, not directed to all teeth with pits or fissures.



Types of Fissures Fissures extend from enamel towards dentinoenamel junction in different shapes. There are four different types of fissures based on the alphabetical description of shape. They are I, K, U and V types. U and V type fissures are usually shallow and wide, tend to be selfcleansable and are caries resistant. I and K-shaped fissures are susceptible to caries. ‘I’-shaped ones are narrow and deep; constricted like bottle neck (Fig. 21.1). They have a narrow slit-like opening and a large base towards the dentinoenamel junction.



FIGURE 21.1 Schematic diagram of a deep fissure.



Cariostatic Properties of Sealants It is attributed to the physical obstruction of pits and fissures which prevents colonization of the pits and fissures with new bacterium and prevention of fermentable carbohydrates to gain access into pits and fissures so that any remaining bacterium cannot produce acid in cariogenic concentration. Many clinical studies have reported on the success of pit and fissure sealants with respect to caries reduction which is attributed to decrease in bacterial counts.



Advantages of pit and fissure sealants • Placement of sealant is a noninvasive procedure. • Sealants will prevent occurrence of fissure caries. • Fluoride releasing sealants confer protection on adjoining areas.



• Sealants can be used at community level for prevention of caries. • It is easy to apply. • Extensive armamentarium not required.



Types of Sealants Based on type of activation Based on the type of activation, pit and fissure sealants can be classified as: 1. Self-activation 2. External energy activation Self-activation type: It is known as chemical cure type with two components, one containing tertiary amine (activator) and the other benzoyl peroxide. When these two components are mixed, the reaction produces free radicals which initiate polymerization. It has a minimum working time of 60–90 seconds. External energy activation: In the external energy activation category, UV light was used as external source of energy in the earlier days which is no longer used because of its health hazards primarily to the eyes. The present day sealants are visible light curing sealants which have diketones and aromatic ketones, which are sensitive to blue light with a wavelength of 470 nm. The advantage of external energy activation is its increased working time as it starts polymerizing only after exposing to light.



Based on appearance Based on appearance, pit and fissure sealants are classified as transparent or opaque. Opaque materials can either be tooth-colored or white and transparent sealants are clear, pink or amber-colored. Clear and tooth-colored materials are esthetic but are difficult to detect on recall examinations.



Based on filler Sealants are classified based on the filler content as filled or unfilled. Recent advances include fluoride-releasing sealants and sealants with light-activated coloring agents that allow for color change during or after polymerization. However, the fluoride-releasing sealant has not shown superiority to regular sealants. Glass ionomer sealants available have been shown to be ineffective as pit and fissure sealants, but could be used as transitional sealants (in partially erupted molars).



Requisites for an efficient sealant Brauer in 1978 suggested the following prerequisites for a sealant to be effective (Box 21.1). Box 21.1



Prerequisites for a sealant to be



effective — suggested by Brauer 1. Viscosity allowing penetration into deep and narrow fissures even in maxillary teeth 2. Adequate working time 3. Rapid cure 4. Good and prolonged adhesion to enamel 5. Low sorption and solubility 6. Resistance to wear 7. Minimum irritation to tissues 8. Cariostatic action



Selection of Patient Based on caries risk Simonsen in 1983 divided patients into three groups: Group 1:



Caries free patients judged to be with no risk of decay.



Group 2:



Patients judged to be at moderate risk of decay.



Group 3:



Patients with rampant caries at a high risk of decay.



Good professional judgment should be used in the selection of teeth and patients. The use of pit and fissure sealants is contraindicated when interproximal lesions and rampant caries are present. Occlusal surfaces that are already carious with dentin involvement require a restoration. Hence, sealing of teeth is indicated in group 2 and not in groups 1 and 3.



Based on clinical judgment The clinical judgment is done to select teeth that are most likely to decay based on: • Age of the patient • Oral hygiene • Familial and individual history of dental caries • Tooth type and morphology • Dietary habits • Fluoride environment and history After the assessment of the above-mentioned parameters, decision is taken regarding the placement of pit and fissure sealants.



Based on age • 3 to 4 years of age—for primary molars • 6 to 7 years of age—for first permanent molars • 11 to 13 years of age—for second permanent molars and premolars. In children with extensive caries in primary dentition and children with special healthcare needs, all the permanent molars must be sealed as soon as they erupt sufficiently. Children with one of the first



permanent molars carious, sealing all the remaining permanent molars and the second permanent molars as soon as they erupt sufficiently or within 2 years after eruption, is essential. Table 21.2 summarizes the indications and contraindications for placement of pit and fissure sealants. Table 21.2 Indications and contraindications for pit and fissure sealants Criteria



Seal



Do not seal



Tooth age



Recently erupted teeth



Partially erupted teeth, teeth that are caries free for 4 or more than 4 years



Tooth type



Molar



Premolar, except when caries risk is high



Occlusal Deep, narrow retentive pits and morphology fissures



Shallow, wide self-cleansing pits and fissures



Status of proximal surface



Sound



Carious



Isolation



Teeth that can be isolated



Teeth that cannot be isolated



General caries activity



Low or moderate caries activity (many occlusal and few proximal lesions)



High or no caries activity (many proximal and few occlusal lesions)



Role of Etching while Placing Pit and Fissure Sealants Normal enamel consists of hydroxyapatite crystals that are arranged in prisms with their rods arranged perpendicular to the surface of the tooth. The enamel surface is usually in a low-energy, weakly reactive and hydrophobic state. However, it becomes a high energy, strongly reactive and hydrophilic surface after etching. This high energy state provides for the rapid attraction of the sealant to the etched enamel



surface. But because it is hydrophilic, it starts attracting saliva that is supersaturated with minerals and etching becomes difficult, if contamination occurs. Hence isolation is very important especially after etching before placing the sealant for any composite restoration.



Difference between etching primary and permanent teeth Initially, it was believed that enamel of primary teeth requires additional etching time due to the occurrence of prismless enamel. Prismless enamel is the product of reduced functional activity during the terminal stages of amelogenesis that results in lack of enamel rod formation during the last 25 µm of enamel formation. It was later found that this prismless enamel is present only in the cervical area of the teeth and extra etching of primary teeth enamel is not required.



Technique of Pit and Fissure Sealant Application The procedure of sealant application is carried out meticulously with proper isolation. Among the steps outlined below, certain steps are more critical than others and particular care must be exercised at these steps to avoid failure. All resin-based dental materials are very sensitive to moisture contamination and this remains the common cause for sealant failure. The steps involved in application of sealant are: 1. Cleansing: Oral prophylaxis with prophy paste is performed. Rinse thoroughly and dry the tooth with a jet of air. 2. Centric stop registration: Articulating paper is used to record the centric stops. If excess sealant flows into these areas, it can cause occlusal interference leading to failure of the sealant. In case of partially erupted tooth, this step can be omitted. 3. Isolation: The tooth is isolated with cotton rolls and saliva ejector. 4. Etching of the tooth surface: Etching with 35–37% Ophosphoric acid is carried out for 15 seconds for both primary



and permanent teeth enamel (Fig. 21.2).



FIGURE 21.2



Schematic diagram of etched enamel surface.



5. Washing and drying: Etchant is removed with a continuous jet of water for at least 30 seconds. Inadequate removal of the acid gel can lead to lack of retention of sealant. If saliva contamination occurs, acid etching is repeated. An etched enamel should appear chalky white after washing and drying. 6. Application of bonding agent 7. Application and evaluation of the sealant: A thin coat of sealant is applied, such that it does not flow into the centric stops. Light curing is done for a duration recommended by the manufacturer of the sealant (Fig. 21.3).



FIGURE 21.3



Placement of sealants.



8. Adjustment and finishing: Check occlusion with an articulating paper and gross excess is removed with a finishing diamond bur. 9. Recall and review: Patient is asked to report for regular recalls. If the sealant is lost completely or partially, it should be replaced.



Glass Ionomer Based Sealants As reported by Berg (2002) in his review on glass ionomer cements, it must be noted that resin-based sealants are the most effective materials for pit and fissures so far. Resin sealants, work exceptionally well, and serve their function for many years when placed properly. Their limitation clinically is the difficulty often encountered in relation to handling. To use a resin sealant, the tooth must be properly isolated and avoidance of contamination throughout the procedure must be guaranteed. Contamination can result in failure of the resin sealant. Glass ionomers offer an alternative to resin sealants, and should be



considered for use as a pit and fissure sealant in certain situations. If it is determined due to clinical considerations, that resin sealants cannot be used, then glass ionomer cement should be considered. Particular clinical situations where the use of glass ionomers as sealant materials might be most useful include: 1. Precooperative children with primary molars having deeply pitted or fissured surfaces, but are difficult to isolate. 2. Permanent first or second molars that are not yet fully emerged into the oral cavity. 3. Situations where a transitional sealant can be considered prior to the placement of a resin sealant. Three other considerations need to be identified regarding the use of glass ionomer materials as pit and fissure sealants for children. They are: 1. The physical properties of glass ionomer materials 2. The formulation of glass ionomer selected for the procedure 3. The longevity of glass ionomer sealants Glass ionomers when used as sealants, have been shown to exhibit a high frequency of fracture within the pits and fissures, although the glass ionomer material has tended to remain within the depths of the fissures as a result of their inherent ability to chemically bond to tooth structure allowing a sealing effect to be in place in most cases. For the primary dentition, there are some scenarios where the longevity of glass ionomer as a sealant, particularly when formulated as a resin-modified glass ionomer, is adequate to allow survival until the eventual exfoliation of the tooth.



Fuji VII It is a special resin free glass ionomer surface protector which can be applied quickly and easily as soon as the tooth erupts (even in



partially erupted molar). It coats, occludes pits, fissures and the tooth surface protecting them from acid attack and the development of caries. It adheres chemically in the presence of moisture to both enamel and dentin, so it can be used to protect molars from the moment of eruption. The chemical adhesion is via ion exchange direct to tooth structure which means acid etching or a bonding agent is not required. Hence, it can be applied in less time. The pink color of this sealant facilitates placement and margin identification. It also acts as a reminder of its temporary nature and helps to decide recall dates for maintenance, if needed. It has six times higher fluoride release than any other glass ionomer and far more than any resin sealant. It is also radiopaque and biocompatible to soft tissues.



Role of Bonding Agent in Sealant Placement Success with pit and fissure sealants is quite dependent on the technique. While there is no guarantee that a sealant will survive on any particular surface for a specified period of time, studies have shown that correctly placed sealants are likely to be retained over a period of years rather than months or weeks. Hence increasing sealant retention is the key to caries prevention. Bonding agents have been recommended to increase the sealant retention. Bonding agents have shown to reduce microleakage, improve bond strength and enhance the vertical penetration of the sealant. However, research regarding this is controversial. Recently, research has shown the usefulness of self-etching adhesive prior to the application of fissure sealant in significantly reducing microleakage. Detailed discussion regarding the controversies associated with the placement of bonding agents during sealants placement is beyond the scope of this chapter. However, to conclude, the authors prefer to use bonding agents while placing the sealants.



Reasons for Sealant Failure • Sealants are lost most frequently from the lingual surfaces of



maxillary molars and buccal surfaces of mandibular molars as these areas are shallow and etching becomes insufficient. • Insufficient isolation and moisture control allows incorporation of air bubbles into the sealant material. • Incomplete removal of debris from the pits and fissures before etching.



Preventive Resin Restorations (Fig. 21.4) The preventive resin restoration is the conservative answer to the ‘extension for prevention’ philosophy of class I cavity preparation because it prevents pit and fissure caries at the expense of weakening the tooth structure. In other words, the preventive resin restoration is a natural extension of the use of occlusal sealants. It integrates the preventive approach of occlusal sealant therapy for caries susceptible pits and fissures with therapeutic restoration of incipient caries that occurs on the same occlusal surface with composite resins. This technique provides the most conservative approach in treating incipient occlusal caries with minimal tooth preparation and prevention of future caries formation through sealant placement.



FIGURE 21.4 Preventive resin restorations.



There are three types of preventive resin restorations as determined by the exploratory preparation based on the extent and depth of the caries lesion. These are type A, B and C (Simonsen, 1978). Most clinical situations are not to be classified according to type until exploratory preparation is completed by the operator to determine the extent of the lesion. Classification according to type is necessary so as to determine the type of restorative material to be selected. Type A: This comprises suspicious pits and fissures where caries removal is limited to enamel only. A slow-speed round bur is used to remove any decalcified enamel and local anesthesia is not required. Type B: This comprises incipient lesion in dentin that is small and confined. Type C: This is characterized by the need for greater exploratory preparation in dentin. This would require local anesthesia and placement of a liner like calcium hydroxide over the exposed dentin. Initially, Simonsen advocated an unfilled resin for type A, a diluted composite resin (a combination of unfilled bonding agent and filled resins) for type B and a filled composite resin for type C. The greater



retention of diluted composite resin was attributed to the greater wear resistance of filled resin particles; whereas the dilution with unfilled resin provided the viscosity necessary to flow. With the advent of wear resistant (filled), light-activated, radiopaque composite resin systems for posterior teeth, these new generation of materials will enhance the success of preventive resin restorations.



Placement Technique Armamentarium • Local anesthesia (optional) • Rubber dam or cotton rolls • Cotton pellets • Burs—slow-speed no. 1/4, 1/2 round, white finishing stone, high-speed no. 330, carbide fluted finishing • Etching gel (tooth conditioner) • Sealant • Applicator • Bonding agent • Calcium hydroxide liner • Polymerization unit (visible light) • Composite resin (filled) • Plastic (teflon) instrument or condenser • Marking paper



Type A restoration • Clean the surface of the tooth • Isolate with cotton rolls or preferably rubber dam • Remove decalcified pits and fissures with a slow-speed 1/4 or 1/2 round bur (the caries must be limited to enamel to be classified as type A; do not attempt to place the retentive area in the preparation)



• Place acid etching gel all over the occlusal surface for 20 to 60 seconds • Wash (20 seconds) and dry (10 seconds) the surface • Apply the sealant carefully, avoid air entrapment (voids) in the preparation site • Polymerize with visible light-curing light for 20 seconds or according to manufacturer’s instructions • Adjust the occlusion, if needed, with finishing burs



Type B restoration These are indicated when exploratory removal of caries has included dentin to a slight extent. After prophylaxis of the surface and placement of rubber dam (local anesthesia is optional), follow the procedural steps given for type A to complete the restoration.



Type C restoration Repeat all the steps listed for type B restoration, since type C restoration is, by definition, larger and deeper; add additional polymerization time (30 seconds). In most cases, local anesthesia will also be required. A base or sub-base may be needed before the placement of the final restoration.



CONCLUSION Resin sealants, placed by appropriately trained personnel are safe, effective yet underused in preventing pit and fissure caries on at-risk surfaces. Effectiveness of sealants is increased with proper isolation techniques and appropriate follow-up and resealing whenever necessary. Unfilled sealants perform better than filled sealants. Colored or clear sealant is a matter of personal preference. However, it has been shown that the ability to assess retention properly in colored sealants is much less error prone than with clear sealants. Many large-scale community-based sealant programs have already produced convincing evidences that such programs can be inexpensive and highly efficacious, even in a public health setting.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Classify pit and fissure sealants. Explain the technique of application of sealant. 2. Define pit and fissures. Write the indications and contraindications for use of pit and fissure sealants. Write about preventive resin restorations.



Short Notes 1. History of fissure sealants 2. Prophylactic odontotomy 3. Fissure eradication 4. Technique of sealant placement 5. Acid etching 6. Preventive resin restorations (PRR) 7. Indications and contraindications for placement of sealants



SUGGESTED READING 1. Asselin, ME, et al. Marginal microleakage of a sealant applied to permanent enamel: evaluation of 3 application protocols. Pediatr Dent. 2008; 30:29–33. 2. Berg, JH. Glass ionomer cements. Pediatr Dent. 2002; 24:430–438. 3. Bodecker, CF. Eradication of enamel fissures. Dent Items. 1929; 51:859–866.



4. Buonocore, MG. A simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Res. 1955; 34:849–853. 5. Carlos, JP, Gittelsohn, AM. Longitudinal studies of the natural history of caries. II - a life-table study of caries incidence in the permanent teeth. Arch Oral Biol. 1965; 10:739– 751. 6. Council on Dental Research. Costeffectiveness of sealants in private practice and standards for use in prepaid dental care. J Am Dent Assoc. 1985; 110:103. 7. Eklund, SA, Ismail, AI. Time of development of occlusal and proximal lesions; implications for fissure sealants. J Pub Health Dent. 1986; 46:114–121. 8. Feigal, RJ. The use of pit and fissure sealants. Pediatr Dent. 2002; 24(5):415–421. 9. Hardison, JR. The use of pit and fissure sealants in community public health programmes in Tennessee. J Public Health Dent. 1983; 43:233. 10. Hyatt, TP. Prophylactic odontotomy: the cutting into the tooth for the prevention of disease. Dent Cosmos. 1923; 65:234–241. 11. Kline, H, Knutson, JW. Studies on dental caries



XIII— effect of ammoniacal silver nitrate on caries in the first permanent molar. J Am Dent, Assoc. 1942; 29:1420–1426. 12. Lewis, MH. Sealants for community programs. Can Dent Assoc J. 1985; 5:841. 13. Mascarenhas, AK, et al. Effectiveness of primer and bond in sealant retention and caries prevention. Pediatr Dent. 2008; 30:25–28. 14. Mitchell, L, Gordon, PH. Fissure sealant — recent development. Dental Update. 1990; 7:201–299. 15. Reid, DB, Grainger, RM. Variations in the caries susceptibility of children’s teeth. Hum Biol. 1955; 27:1. 16. Simonsen, RJ, Pit and fissure sealants. Clinical Applications of the Acid Etch Technique 1st edn. Quintessence Publishing, Chicago, 1978. 19–42. 17. Simonsen, RJ. Pit and fissure sealant — review of the literature. Pediatr Dent. 2002; 24(5):314– 393. 18. Wilson, IP. Preventive dentistry. Dent Dig. 1895; 1:70–72.



CHAPTER 22



Atraumatic Restorative Treatment Sharath Asokan



CHAPTER OUTLINE Introduction Principles of ART Success of ART ART and ITR Suggested Reading Self-assessment Questions



Introduction Dental caries is the most widespread oral disease in the world, yet it tends to go untreated in under-served communities in both developing and industrialized countries. These under-served populations mainly receive extractions when they seek for dental care; they do not receive fillings for cavities when they get to see a dentist. The World Health Organization actively promotes atraumatic restorative treatment (ART) as a viable approach to meet the need for treatment of dental caries. ART is a method of caries management introduced by the World Health Organization. It was developed primarily for use in the Third World countries where skilled dental man power and facilities are limited and the population is high. ART is used in situations where classical restorative care cannot be delivered. The purpose is to prevent tooth decay from worsening until more definitive care can be delivered or until care is no longer necessary owing to the exfoliation of a primary tooth. ART results in the reduction of bacterial mass through the removal of carious tooth structure and the remineralization of affected (not infected) dentin.



ART employs simple but effective techniques of hand instrumentation and slow-speed rotary preparation. ART uses manual excavation of dental caries, eliminates the need for anesthesia and use of expensive equipment and restores the cavity with glass ionomer, an adhesive material that bonds to the tooth structure and releases fluoride as it stimulates remineralization. It uses materials with low technique sensitivity, which is important for young children, who have short attention spans. Further, ART is noninvasive, which makes it highly acceptable to patients. But in deciding whether to use ART, the severity of dental caries must be considered. On a tooth-by-tooth basis, the lesions chosen for ART should be circumscribed by healthy enamel and should involve only dentin that is not close to the dental pulp. The tooth may have exhibited reversible pain or sensitivity, but it should be vital and ideally, have no symptoms suggesting involvement of the pulp. Finally, ART requires frequent follow-up and should be confined to teeth that have a reasonable remaining functional lifespan to make the cost and effort worthwhile. ART can be accomplished using the knee-to-knee technique, but this is recommended primarily when only one tooth is involved. It is preferable to place the child in the dental chair, if possible.



Principles of ART The two main principles of ART are: • Removing carious tooth tissues using hand instruments only • Restoring the cavity with a restorative material that sticks to the tooth. Generally, ART is performed using glass-ionomer as the restorative material. Reasons for using hand instruments rather than electric rotating handpieces are (Fig. 22.1):



FIGURE 22.1 Alternative restorative technique.



• It makes restorative care accessible for population groups who are living in remote areas and may be without access to electricity. • The use of a biological approach, which requires minimal cavity preparation that conserves sound tooth tissues and causes less trauma to the teeth. • The low cost of hand instruments compared to electrically driven dental equipment. • The limitation of pain that reduces the need for local anesthesia to a minimum and reduces psychological trauma to patients. • Simplified infection control. Hand instruments can easily be cleaned and sterilized after every patient. The reasons for using glass ionomer are: • Glass ionomer cements have a chemical bond to both enamel and dentin, hence, the need to cut sound tooth tissue to prepare the cavity is reduced. • Fluoride is released from the restoration to prevent and arrest caries. • It is rather similar to hard oral tissues and does not inflame the pulp or gingiva. ART can be applied when: • There is a cavity involving the dentin • That cavity is accessible to hand instruments ART should not be used when:



• There is presence of abscess or fistula near the carious tooth. • The pulp of the tooth is exposed. • Teeth have been painful for a long time and there may be chronic inflammation of the pulp. • There is an obvious carious cavity, but the opening is inaccessible to hand instruments. • There are clear signs of a cavity, for example in a proximal surface, but the cavity cannot be entered from the proximal nor the occlusal directions



Success of ART Based on studies already conducted, ART can certainly be used with confidence in one-surface cavities particularly in permanent teeth. For example, results of field studies in Thailand and Zimbabwe have shown that 71% and 85% of the one-surface ART restorations respectively are in good shape after 3 years. It is expected that ART will perform equally well in one-surface cavities in primary teeth. Unfortunately, limited information is available at the moment to support this assumption. In primary teeth, ART restorations do not need to stay in place for long since these teeth will eventually be replaced by permanent teeth. The maximum time a restoration needs to remain in a primary tooth is about 6 years. ART restorations can help maintain a natural tooth eruption pattern and avoid disturbances in the positions of permanent teeth. Success of ART in multiple-surface cavities very much depends on the size of the cavity and the restorative material used. Small to medium size multiple-surface cavities can be confidently treated with ART. Restorations placed in large cavities may not stay in place for a long time. This is because the glass ionomers currently available are not strong enough for this application. However, glassionomers with improved qualities are being developed. We can expect improved materials appropriate for use in large size cavities to be available in the future. As ART does not require electrical driven dental equipment, carious cavities can be treated almost everywhere. ART can be applied, not



only in the dental clinic, but also in institutions for home-bound, physically and mentally handicapped people, in remote areas and in schools. It is certainly patient friendly and makes the provision of oral care much easier to patients who are nervous or fearful. ART needs to be considered as a preventive and treatment modality for caries in communities with limited access to dentists.



ART and ITR The term atraumatic restorative treatment was replaced by alternative restorative treatment (ART) and now a broader terminology interim therapeutic restorations (ITR) is used. Atraumatic/Alternative Restorative technique (ART) has been endorsed by the World Health Organization as a means of restoring and preventing caries in populations with little access to traditional dental care. In many countries, practitioners provide treatment in non-traditional settings that restrict restorative care to placement of provisional restorations. Since circumstances do not allow for follow-up care, ART mistakenly has been interpreted as a definitive restoration. ITR utilizes similar techniques but has different therapeutic goals. ITR may be used to restore and prevent further decalcification and caries in young patients, uncooperative patients or patients with special health care needs or when traditional cavity preparation and/or placement of traditional dental restorations are not feasible and need to be postponed. Additionally, ITR may be used for stepwise excavation in children with multiple open carious lesions prior to definitive restoration of the teeth. The use of ITR has been shown to reduce the levels of cariogenic oral bacteria (e.g. mutans streptococci, lactobacilli) in the oral cavity. The ITR procedure involves removal of caries using hand or slowspeed rotary instruments with caution not to expose the pulp. Leakage of the restoration can be minimized with maximum caries removal from the periphery of the lesion. Following preparation, the tooth is restored with an adhesive restorative material such as selfsetting or resin-modified glass ionomer cement. ITR has the greatest success when applied to single surface or small 2 surface restorations.



Inadequate cavity preparation with subsequent lack of retention and insufficient bulk can lead to failure. Follow-up care with topical fluorides and oral hygiene instructions may improve the treatment outcome in high caries-risk dental populations.



SELF-ASSESSMENT QUESTIONS Essay Type Atraumatic restorative treatment



SUGGESTED READING 1. American Academy of Pediatric Dentistry. Policy on Interim Therapeutic Restorations. Reference Manual. 2010-2011; 32(6):10–11. 2. Barmes, DE. Foreword: Proceedings of the international association of dental research symposium on minimal intervention techniques for dental caries. J Public Health Dent. 1996; 56(3 special issue):131. 3. Berg, JH. Glass ionomer cements. Pediatr Dent. 2002; 24(5):430–437. 4. Castro, A, Feigal, RF. Microleakage of a new improved glass ionomer material in primary and permanent teeth. Pediatr Dent. 2002; 24(1):23–27. 5. Croll, TP, Nicholson, JW. Glass ionomer cements in pediatric dentistry: Review of the literature. Pediatr Dent. 2002; 24(5):423–429.



6. Grossman, ES, Mickenautsch, S. Microscope observations of ART excavated cavities and restorations. South African Dent J. 2002; 57(9):359–363. 7. Lo, ECM, Holmgren, CJ. Provision of atraumatic restorative treatment (ART) restorations to Chinese preschool children: A 30-month evaluation. International J Paediatr Dent. 2001; 11(1):3–10. 8. Manual for ART. http://www.dhin.nl/art_manual___main.htm (Accessed on 18/06/11). 9. Naty, Lopez, Sara, Simpser-Rafalin, Peter, Berthold. Atraumatic Restorative treatment for prevention and treatment of caries in an underserved community. Am J Public Health. 2005; 95(8):1338–1339. 10. Yip, HK, Smales, RJ, Ngo, HC, Tay, FR, Chu, F. Selection of restorative materials for the atraumatic restorative treatment (ART) approach: A review. Spec Care Dent. 2001; 21(6):216–221.



CHAPTER 23



Pediatric Operative Dentistry MS Muthu, N Sivakumar and K Rekhalakshmi



CHAPTER OUTLINE Introduction Diagnosis of Child’s Treatment Needs and Planning by Visits Behavior management Control of pain and discomfort Isolation of the operating field Quadrant dentistry Uses of four-handed dentistry techniques Preference of handpieces for operative care Modification of instruments for primary teeth Morphologic considerations in cavity preparation of primary teeth Principles of Cavity Preparation Classification of caries Traditional vs minimal interventional cavity design Choice of the restorative material Principles of operative dentistry Fundamentals of Cavity Preparation in Primary Teeth Cavity preparations Matrix bands Willett inlay preparation Interim therapeutic restorations (IRT) and alternative restorative treatment (ART) Restoration of diastemas Suggested Reading Self-assessment Questions



“Although operative dentistry may be perfect, the appointment is a failure if the patient departs in tears.” —Mc Elroy, 1895



Introduction One of the major goals of a practicing pediatric dentist is to preserve the integrity of the primary teeth so that normal function is maintained and normal exfoliation ensues. Retaining the primary teeth in a healthy state helps the child to eat better, maintain space for the permanent teeth, have positive self-image and provide a favorable environment to newly erupting permanent teeth. Having a caries free dentition paves way for reduced caries risk in the future. This also contributes to the child’s general health. Though morphologically, primary teeth resemble permanent teeth the restorative procedures need to be modified for primary teeth. Undoubtedly, some of the restorative decisions are difficult to make. Child’s well-being is kept as the highest priority during treatment planning. Children who have experienced dental caries will need preventive care as well as restoration of diseased teeth. Hence, they need a properly drawn-out treatment plan. The philosophy of focusing entirely on prevention and delaying the restoration is not an appropriate way of treatment planning. Treating children with diseased teeth solely with topical fluoride, diet analysis and oral hygiene measures does little good when broken down teeth and abscesses are present. This chapter gives practically oriented guidelines specifically for performing operative procedures in children.



Diagnosis of Child’s Treatment Needs and Planning by Visits When the child first enters the dental office, the child’s behavior and their relationship to the caretaker is observed. Past dental experiences



such as previous restorations, extractions and use of local anesthesia are recorded. Children who have not experienced restorative dentistry in the past but who now need treatment will need an introduction to clinical dentistry. This encompasses a sequenced approach of ‘tellshow-do’ gradually introducing the methods to be used; topical and local anesthesia, rubber dam placement, rotary instruments and completion of a restoration. In the first dental visit, an attempt is made to simply orient the child to the operatory and the dental office. In this visit, no restorative care is carried out other than temporary fillings or placement of dressings. If the child is very cooperative and the dentist has time, some simple restorative procedures can be carried out. Procedures should be carried out from simple restorative procedures to start with and gradually the dentist should proceed with more invasive pulp therapy and extractions. A treatment plan should be written out by visits. An ideal approach for a new child patient will be as follows: 1. First visit: Initial examination, history taking and radiographs and treatment planning by visits. 2. Second visit: Review of oral hygiene, diet counseling, oral prophylaxis, topical fluoride application (By this time, the dentist would have established a rapport with the child and an assessment of his or her behavior is made. Any need for pharmacological management in the future visits can also be determined). 3. Third visit: Operative dentistry under local anesthesia, pulp therapy. Though this kind of approach is the ideal way, in developing countries like India, where most dental treatment is sought only when there is pain or other symptom, a change in this approach may be necessary. However, nothing in pediatric dentistry is rigidly laid down; the practicing pediatric dentist should be flexible to modify or change the approach whenever necessary.



Behavior Management The objective of the dentist should be to lead a child through a pleasant dental experience so that he/she becomes a good dental patient, develops positive dental attitude and accepts treatment gracefully. Dentists who are constantly evaluating their techniques of behavior management will be able to provide the highest standards of care because the success of the treatment procedures depends in part upon the ability to manage the child. If routine behavior management techniques fail, use of pharmacological agents should be considered. Indifferent behavior of children cannot be an excuse for providing substandard care. If a general dentist cannot handle a child, he/she should refer the child to a nearby pediatric dentist, keeping in mind the child’s dental health. Often the authors are encountered with general dentists asking for ways to manage a difficult child in their practice. For this, the author’s reply is as follows: “There are no fixed or rigid rules on behavior management, because the child and the practitioner are individuals and their personal communication and interaction will be unique. The trust established between them cannot be judged. However, dentists should talk to children in terms that they can understand and once communication is established the dentist should use ‘tell-show-do’ approach. If unsuccessful, the dentist should refer these children to pediatric dentists.” Anticipating the child’s emotions, will allow the dentist to explain the procedure to be performed and the sensations child should expect. Good behaviors are positively reinforced and negative behaviors are calmly discouraged or ignored. A set of working rules should be established early and rigidly enforced so that the child knows the limits of acceptable behavior. Treatments should not be postponed because of inappropriate behavior of child. If this happens, children learn to escape by behaving inappropriately. Occasionally, a dentist may be faced by a defiant child, who will try to defy the dentist’s commands. Under such circumstances, appropriate behavior management techniques should be employed and the child needs to realize early ‘who is the boss there’. A pediatric dentist should be



child-like, not childish. When defiant children are managed appropriately, they become the best of the patients later on because the dentist would have been the first person to control their defiant behavior. Detailed management techniques are discussed in Chapter 9 on Behavior Management.



Control of Pain and Discomfort Caries excavation or removal can cause pain and discomfort in children. Hence, appropriate local anesthesia should be administered before deep caries excavation. If the pain is not controlled, even a child with positive behavior can become negative towards dental treatment. Children are routinely scared by parents with injections and needles (by doctors), hence the dentist may find it difficult to convince the child for local anesthesia. However, taking efforts to learn a good method of obtaining local anesthesia (like the TeDiE technique, discussed in the Chapter 35 on Oral Surgical Considerations and Local Anesthesia) will be of great use in treating children. Appropriate use of topical anesthetics is greatly recommended by the authors.



Isolation of the Operating Field The goals of operating field isolation are moisture control, retraction and harm prevention. Local anesthesia is also important in moisture control.



Goals of isolation Moisture control: Operative dentistry cannot be executed properly unless the moisture in the mouth is controlled. Moisture control refers to excluding sulcular fluid, saliva and gingival bleeding from the operating field. It also refers to preventing the handpiece spray and restorative debris from being swallowed or aspirated by the patient. Local anesthesia: Use of these agents reduces salivation, apparently because the patient is more comfortable, less anxious and less



sensitive to oral stimuli, thus reducing salivary flow. Retraction and access: This provides maximal exposure of the operating site and usually involves maintaining an open mouth and depressing or retracting the gingival tissue, tongue, lips and cheek. Harm prevention: An axiom taught to every member of health profession is ‘Do no harm,’ and an important consideration of isolation is preventing the patient from being harmed during the operation.



Types of isolation 1. Rubber dam isolation 2. Cotton roll isolation and cellulose wafers 3. Throat shields 4. High volume evacuators and saliva ejectors 5. Retraction cord 6. Mirror and evacuator tip retraction 7. Mouth props



1 Rubber dam isolation Rubber dam was introduced by SC Barnum in 1864. It maintains a clean operating field during restorative procedures. The advantages of using rubber dam regularly are: • It increases the visibility and accessibility to the dentist. • It maintains isolation of the teeth, provides a dry field and effectively retracts the tongue and cheeks away from the field of operation. • It saves time. • It reduces the chances of injury to soft tissues. • It also prevents any aspiration or ingestion of dental instruments or materials. • It produces a calming effect in children as they feel that their teeth are isolated from the rest of the body.



• It protects the patients from any bad taste of the materials used. • It helps the dentist to educate the parents when treating children by showing what was done to their kid. Armamentarium (Fig. 23.1):



FIGURE 23.1 Components of rubber dam kit.



1. Rubber dam sheet 2. Rubber dam punch 3. Rubber dam clamps 4. Rubber dam forceps 5. Rubber dam frame (Young’s frame) 6. Dental floss 7. A fat blade instrument



8. Scissors 9. Petroleum jelly 10. Wedges or tooth pick 11. Template Placement and removal of rubber dam (Figs. 23.2, 23.3): First the appropriate clamp is chosen. Unless the clamp is firmly anchored to the tooth, the tension of the stretched rubber will easily dislodge it. Therefore, the proper selection of a clamp is of utmost importance. It is recommended that the clamp be tried on the tooth before the rubber dam is placed to ascertain that the clamp can be securely seated and will not be easily dislodged by the probing tongue, lip, or cheek musculature. An 18-inch length of dental floss should be doubled and securely fastened to the bow of the clamp.



FIGURE 23.2 Rubber dam placement technique—method one.



FIGURE 23.3 Rubber dam placement technique—method 2: Clamp with sheet and frame as one unit.



The floss will enable us to retrieve the clamp, if it is dislodged. The appropriate clamp is taken with a rubber dam forceps and placed on the tooth to be clamped. Then a rubber dam sheet (mostly 5×5 inch sheets of medium latex) is kept on a template where the appropriate holes are marked and punched with a rubber dam punch. The holes are lubricated with petroleum jelly. The sheet is stretched with the index finger of both the hands spreading the hole and placed over the clamp. The sheet is stretched over other teeth which need to be exposed. Place the Young’s frame and stretch the dam on to it. A wedge is placed between the contacts of the most anteriorly isolated tooth. The first step in removing the rubber dam is removal of wedges and then with forceps, the clamp is removed with the frame as a unit. When a quadrant of restorations in the primary dentition is planned and no pulp therapy is anticipated, Croll recommends the ‘slit-dam method.’ One long opening is made in the dam and the entire quadrant is isolated without interseptal dam material between the



teeth.



2 Cotton roll isolation and cellulose wafers Absorbants, such as cotton rolls and cellulose wafers can also provide isolation. Absorbants are isolation alternatives when rubber dam application is impractical or impossible. Using a saliva ejector in conjunction with absorbants may further abate salivary flow. Several commercial devices for holding cotton rolls in position are available. It is generally necessary to remove the holding appliance from the mouth to change the cotton rolls. This is inconvenient and time consuming; consequently they are not often used. An advantage of cotton roll holders is that they might slightly retract the cheeks and tongue from the teeth, which enhances access and visibility. Placing a medium sized cotton roll in the facial vestibule isolates the maxillary teeth. Placing a medium-sized cotton roll in the vestibule and a larger one between the teeth and the tongue isolates the mandibular teeth. While placement of a cotton roll in the facial vestibule is simple, placement on the lingual of mandibular teeth is more difficult. Lingual placement is facilitated by holding the mesial end of the cotton roll with operative pliers and positioning the cotton roll over the desired location. Use the index finger of other hand to push the cotton roll gingivally while twisting the cotton roll with the operative pliers towards the lingual of the teeth. Cellulose wafers may be used to retract the cheek and provide additional absorbancy. When removing cotton rolls or cellulose wafers, it may be necessary to moisten them using the air-water syringe to prevent inadvertent removal of the epithelium from the cheeks, floor of the mouth, or lips.



3 Throat shields When the rubber dam is not being used, throat shields are indicated when there is danger of aspirating or swallowing small objects. This is particularly important when treating teeth in the maxillary arch. A gauze sponge, unfolded and spread over the tongue and the posterior part of the mouth is helpful in recovering small objects, should it be



dropped accidentally during treatment.



4 High-volume evacuators and saliva ejectors High-volume evacuators are preferred for suctioning water and debris from the mouth because saliva ejectors remove water slowly and have little capacity for picking up solids. The tip of the saliva ejector should be smooth and made from a nonirritating material. Disposable, inexpensive plastic ejectors that may be shaped by bending with the fingers are preferable because of improved infection control. A Svedopter is a helpful device that serves both as a saliva ejector and a tongue retractor.



5 Retraction cord Retraction cord may help restrict excess restorative material from entering the gingival sulcus and provide better access for contouring and finishing the restorative material. The diameter of the cord should be selected such that it is gently inserted into gingival sulcus, producing lateral displacement (a few tenths of a millimeter) of the free gingiva (opening the sulcus) without blanching it (caused by ischemia due to pressure). The objective is to obtain minimal yet sufficient lateral displacement of free gingiva and not to force it apically. The cord may be moistened with a noncaustic styptic before insertion, if bleeding of the fragile tissue is anticipated.



6 Mirror and evacuator tip retraction A secondary function of the mirror and evacuation tip is to retract the cheek, lip and tongue.



7 Mouth props It can be of potential aid for a lengthy appointment on posterior teeth. A mouth prop should establish and maintain suitable mouth opening, thereby relieving the patient’s muscles of this task, which often



produces fatigue and sometimes pain. The ideal characteristics of a mouth prop are as follows: • It should be adaptable to all mouths. • It should be capable of being easily positioned and removed, with no patient discomfort. • It should be capable of being easily adjusted, if necessary, to provide the proper mouth opening or improve its position in the mouth. • It should be stable once applied. • It should be either sterilizable or disposable. Mouth props of different designs and different materials are available. They are generally available either as block type or ratchet type. Although the ratchet type is adjustable, its size and cost are disadvantages. The convenience and cost of the block type commend it for use in most operative procedures.



Drugs The use of drugs to control salivation is rarely indicated. The operator should be familiar with the indications, contraindications and side effects.



Quadrant Dentistry Practicing quadrant dentistry reduces the number of visits and also the number of times local anesthesia is used. Using a rubber dam, a whole quadrant of the dentition is isolated and all the work in that quadrant is completed in one visit. This might include pulp therapy with stainless steel crowns on two primary molars as well as two restorations of first permanent molar and canine. This can be effectively carried out by an experienced pediatric dentist in 60 minutes. Reducing the number of visits also decreases the cost to the parents. Though this type of practice is not common in countries like India, many dentists are now slowly moving towards practicing



quadrant dentistry.



Uses of Four-handed Dentistry Techniques (Fig. 23.4) The use of four-handed dentistry can aid dentists in providing more efficient care and also promotes comfort and sense of well-being in his/her child patients. Administering local anesthesia can be done easily with four-handed dentistry than with the older techniques. Minor movement of children can be easily controlled, if they try to move suddenly during a critical procedure. Dentist’s positional fatigue can be markedly reduced by practicing four-handed dentistry routinely.



FIGURE 23.4 Four-handed dentistry.



Preference of Handpieces for Operative Care High speed With the present wide use of air-driven handpieces, the dentist has his choice of rotary speeds of up to 4,00,000 rpm. Using carbide burs



at high speeds with air-water spray playing continuously on the tooth being prepared, decay may be removed and cavities can be shaped, with less trauma for the patient and less time expended by the operator. The tactile sense needed to skillfully use the air-driven handpieces is one which only practice can help develop. Many similarities remain, however, when low and high speed operations are compared. Carbide burs and diamond points must be sharp and clean. Above all they must not be worn to a point at which they produce more heat than the air-water spray can easily dissipate. The time saved by using sharp instruments and the increased comfort to the patient are well worth the cost of more frequent replacement.



Low speed For some children, the high-pitched whine of the airotor is extremely disturbing and it is helpful to have the quiet low speed contra-angle available as an alternative. In spite of increased bone conduction vibration, this handpiece was more acceptable for this small group of children. Many dentists feel that the final depths of decay in a cavity should be eradicated using only slow speed. The noise of an airotor and the water spray can be extremely disturbing to a young child (less than 3 years of age). The authors routinely use slow-speed contra-angle handpiece on young children (2.5 to 3.5 years of age) who sit on the dental chair without their parents. The slow speed handpiece can first be tried on their nails so that they can feel the vibration associated with it. Use of slow-speed is highly recommended for providing restorative care for anterior teeth in young children as use of high-speed airotor may spray water into their nostrils. This makes them restless and the dentist may have to discontinue the procedure. The use of an instrument called ‘Uni Grip’ (Fig. 23.5) where a high-speed airotor bur can be attached to a slowspeed handpiece is useful. Soft caries can be effectively removed with slow speed or a sharp excavator. In older age group, routine use of high-speed airotor is recommended to carry out the procedure quickly and efficiently.



FIGURE 23.5 Uni grip.



Modification of Instruments for Primary Teeth Although most dentists experienced in treating children would agree that there is now a broader choice of all instruments and materials used in pedodontic work than ever before, the careful dentist might still wish to modify a few of his instruments specially for primary teeth. It has been suggested that in using a one-to-one mix in amalgam a small 0.8 mm condenser should be used. This is a necessity in children’s smaller amalgam preparations. With this as a starting point, the following suggestions are made for amalgam restorations: • Grind down and polish all amalgam condensers so that they fit the more convergent cavity forms in primary molars. • Sharpen a sickle-shaped blunted explorer to trim overhangs before amalgam hardens. • Remove as much as 3 mm of length from the noncutting end of a carbide bur to make it shorter for children’s smaller mouths. This can be done with a separating disk and the end can be polished with an abrasive rubber wheel. • Constantly check to be sure of the sharpness of all instruments, especially burs, enamel hatchets, chisels and hoes, caries excavators and all amalgam carvers. This will enable each dentist to produce the excellent results his training has



prepared him to accomplish.



Morphologic Considerations in Cavity Preparation of Primary Teeth Principles of cavity preparation for primary teeth differ from that of permanent teeth. Morphology of primary teeth is responsible for these differences and they are discussed in relation to their clinical significance.



Shape of the crown Generally, the size of the primary teeth is smaller but more bulbous than permanent teeth. The crowns are wider mesiodistally than occlusogingivally. The occlusal table is narrow because of the occlusal convergence of buccal and lingual surfaces (Fig. 23.6). This is more pronounced in first primary molar than second primary molar. This automatically reduces the buccolingual dimensions of the occlusal part of any class I or II cavity to prevent weakening of cusps. In class II preparations, the isthmus is narrow exactly at a point where strength is needed to withstand the forces of occlusion.



FIGURE 23.6 Narrow occlusal table of primary teeth.



The thickness of enamel and dentin is thin in primary teeth so the pulp is proportionately larger (Fig. 23.7). The clinical significance of this entity is—caries can progress to the pulp faster if not diagnosed early, smaller burs needs to be used, sufficient bulk of restorative material is to be placed without exposing the pulp to provide retention. One has to keep in mind the distance between the mesial surface of the mandibular first primary molar and the pulp may be as little as 1.6 mm.



FIGURE 23.7 Enamel and dentin thickness in primary teeth.



The sharp constriction at the neck of primary teeth necessitates special care in the formation of gingival floor during class II preparation. This is discussed under the contact areas below.



Contact Areas (Fig. 23.8) Contact areas between primary molars are broad, fatter and situated farther gingivally than those of permanent teeth. The clinical significance of this factor is:



FIGURE 23.8 Contact areas between primary teeth.



1. Interproximal caries need to be extensive before they are clinically observable, so one has to rely on bitewing radiographs for its early diagnosis. 2. Buccal and lingual margins of proximal box in class II restorations should extend towards the embrasure to make them accessible for self-cleansing. 3. As the proximal caries starts below the contact area, gingival seat must be taken below the contact area.



Enamel rod inclination (Fig. 23.9) The inclination of enamel rods of primary molars in the gingival one-



third is towards the occlusal surface. Hence, there is no need for beveling the gingival seat in primary molars, which is done routinely to remove the unsupported enamel rods in permanent teeth. This is because of the apical or horizontal inclination of enamel rods in permanent molars.



FIGURE 23.9 Enamel rod inclination.



Pulp morphology The pulp horns in primary teeth are more prominent than that of permanent teeth. Mainly the first primary molar has an occlusal ridge of enamel below which is a pulp horn (Fig. 23.10). This horn is very fine and may extend to the dentinoenamel junction. Hence, there is considerable risk when a cavity preparation is attempted on the first



primary molar. The depth of the cavity in class I and II restorations should be kept to a minimum to prevent inadvertent pulp exposures.



FIGURE 23.10 Highly placed pulp horns in primary teeth.



Principles of Cavity Preparation Classifications of Caries (Cavities) Black’s classification Classification of tooth preparations according to the anatomical areas involved as well as by the associated type of treatment was presented by Black.



Class I:



All pit and fissure restorations. They are assigned to three groups: • Restorations on occlusal surface of premolars and molars • Restorations on occlusal two-thirds of facial and lingual surfaces of molars • Restorations on lingual surface of maxillary incisors



Class II:



Restorations on proximal surfaces of posterior teeth.



Class III: Restorations on the proximal surfaces of anterior teeth that do not involve the incisal angle. Class IV: Restorations on the proximal surfaces of anterior teeth that do involve the incisal angle. Class V:



Restorations on the gingival third of the facial or lingual surfaces of all teeth.



Class VI: Restorations on the incisal edge of anterior teeth or the occlusal cusp heights of posterior teeth.



Black separated the proximal lesion into anterior and posterior and the anterior lesion into one further division on the basis that the groups required a different type of treatment.



Finn’s modification of Black’s classification The classification in permanent teeth originated by Black has been modified slightly and applied to primary teeth. These modifications can be outlined as follows: Class I:



Those pits and fissures on the occlusal surfaces of the molar teeth and the buccal and lingual pits of all teeth.



Class II:



All proximal surfaces of molar teeth with access established from the occlusal surface.



Class III: All proximal surfaces of anterior teeth which may or may not involve a labial or lingual extension. Class IV: A restoration of the proximal surface of an anterior tooth which involves the incisal angle. Class V:



On the cervical third of all teeth, including the proximal surface where the marginal ridge is not included in the cavity preparation (spot filling).



Mount and Hume classification This classification is designed to simplify the identification of lesions and to define their complexity as they enlarge and is expected to provide benefits for the profession and their patients. Three sites of carious lesions: Carious lesions occur in three sites on the crown or root of a tooth, that is, in those areas subject to the accumulation of plaque. These are: Site 1: Pits, fissures and enamel defects on occlusal surfaces of posterior teeth or other smooth surfaces, such as cingulum pits on anteriors. Site 2: Approximal enamel immediately below areas in contact with adjacent teeth. Site 3: The cervical one-third of the crown or following gingival recession, the exposed root. It is regarded as logical to classify lesions by these sites and then to grade them by size according to the extent of progress. Four sizes of carious lesions (Table 23.1): Table 23.1 Cavity classification Size Site



Minimal 1



Moderate 2



Enlarged 3



Extensive 4



Pit and fissure 1



1.1



1.2



1.3



1.4



Contact area 2



2.1



2.2



2.3



2.4



Cervical area 3



3.1



3.2



3.3



3.4



Size 1: Minimal involvement of dentin just beyond treatment by remineralization alone. Size 2: Moderate involvement of dentin. Following cavity preparation, the remaining enamel is sound, well supported by dentine and not likely to fail under normal occlusal load. That is, the remaining tooth structure is sufficiently strong to support the restoration.



Size 3: The cavity is enlarged beyond moderate. The remaining tooth structure is weakened to the extent that cusps or incisal edges are split or are likely to fail, if left exposed to occlusal or incisal load. The cavity needs to be further enlarged so that the restoration can be designed to provide support and protection to the remaining tooth structure. Size 4: Extensive caries with bulk loss of tooth structure has already occurred. Black’s classification did not allow for the size 1 lesion in either site 1 or site 2 because of the absence of adhesive restorative materials and to a certain degree, equipment limitations. It is suggested that there are a number of other advantages to be derived from adoption of the proposed classification. A number system such as this can be readily and accurately utilized for record keeping on a computer. Even though there are additional numbers involved, the system represents a simplification of the Black classification and is therefore easier to learn.



Traditional vs Minimal Interventional Cavity Design In traditional preparations, cavities were designed without the present understanding of the action of the fluoride ion and in the presence of restorative materials which had no inherent therapeutic properties, were subject to microleakage and were often not esthetic. Also, in the absence of adhesive restorative materials, it was regarded as essential to remove all unsupported enamel regardless of its location. More importantly, it was often necessary to remove additional sound tooth structure just to make room for the restorative material thus defeating one of the prime purposes of restoration—the preservation of remaining tooth structure. Black suggested that it was necessary: • To remove tooth structure to gain access and visibility • To remove all traces of affected dentin from the floor of the



cavity • To make room for the insertion of the restorative material itself • To provide mechanical interlocking retentive designs and • To extend the cavity to ‘self-cleansing’ areas to avoid recurrent caries. The result was that, by today’s standards, completed cavities for all restorations were large. In his designs, Black showed commendable respect for remaining tooth structure as well as occlusal and proximal anatomy, but it was necessary to sacrifice relatively extensive areas of enamel to achieve his goals. Other far more effective methods of dealing with a carious lesion are now available. With modern understanding of adhesion and remineralization, it is no longer necessary to remove all unsupported demineralized enamel around the cavity margin, the concept of ‘selfcleansing’ areas has been discarded and removal of all affected dentin from the axial or pulpal wall of the cavity is strictly contraindicated because of the potential for remineralization and healing.



Choice of the Restorative Material The common restorative materials used in pediatric dentistry are composite and other resin systems, glass ionomers, silver amalgam alloys and stainless steel alloys. Composite resins, glass ionomers or some combination of the two are being used progressively more and silver amalgam progressively less in pediatric restorative dentistry. Many pediatric dentistry practices do not use silver amalgam at all; instead, some forms of composite resin and/or glass ionomer are used. These materials have bonding capability. Glass ionomers may be considered pharmacologically therapeutic because they release fluoride over time; they also have minimal shrinkage during setting. Composite resins possess durability and superior esthetic qualities. When managed properly, both materials are capable of providing superior marginal sealing at the tooth—restorative material interface. The manufacturers of these materials have also combined them in an effort to join the primary advantages of each type of material.



Berg has suggested to think of these materials and their combinations on a continuum, with glass ionomer on the left, composite resin on the right and the combined materials somewhere in between depending on the relative amounts of each material in the mix. Two major categories on the continuum are described as ‘resin modified glass ionomer’ (or ‘hybrid ionomer’ or ‘light cured glass ionomer’) and ‘compomers’ (or ‘polyacid modified composite resin’ or ‘glass ionomer-modified composite resin’). A fifth formulation has been added on the right side of the continuum in the form of ‘flowable composite resin.’ Berg points out that knowing the particular strengths and weaknesses of each type of material on the continuum will enhance the clinician’s ability to make the best choices for each individual restorative situation.’ Despite its declining use, silver amalgam remains one of the most durable and cost-effective restorative materials. Success in using this filling material depends on adherence to certain principles of cavity preparation that do not always apply when materials on the glass ionomer—composite resin continuum are used. Some renewed interest in silver amalgam has occurred because of the development of ‘bonded amalgams.’ Bonded amalgams are silver amalgam restorations that have been condensed into etched cavity preparations lined with a dentin-bonding agent and some material on the glass ionomer–composite resin continuum. Bonded amalgams require considerable extra effort and expense to place when compared to conventional amalgam restorations. In general, the use of bonded amalgams seems difficult to justify for the routine restoration of primary teeth because traditional silver amalgam should provide comparable quality more efficiently and cost-effectively in most situations. The decision to use a particular material depends on many other things. What the dentist decides to do may hinge on his total knowledge of the primary dentition as well as his ability to manage the child. Some factors that should be considered are:



• Age of the child • Degree of carious involvement • Time of normal exfoliation • Developmental status of the dentition • Caries risk assessment • Patient’s oral hygiene • Anticipated parental compliance and likelihood of timely recall • Patient’s ability to cooperate for treatment



Principles of Operative Dentistry Black outlined an certain principles permanent teeth recommended that be followed:



approach to cavity preparation and identified that should be followed. Both primary and lend themselves to these principles. It is during cavity preparation the following sequence



• Gain access • Establish outline form • Eliminate caries • Establish resistance and retention form • Refine and debride the cavity The above steps blend together and therefore cannot really be considered as separate activities, particularly with the use of highspeed cutting instruments. These principles are proposed for amalgam restorations and not for adhesive restorations.



Fundamentals of Cavity Preparation in Primary Teeth Traditionally, the most important goal of restorative dentistry was to remove caries thoroughly before the restoration. However, for class I lesions, the traditional treatment has been replaced with conservative



caries excavation and restoration using a combination of bonding restorative, fluoride releasing and sealant materials. In all cavity preparations, a flat pulpal floor is recommended. The axiopulpal line angle in class II preparations should be beveled or rounded to reduce stress concentration and increase the bulk of the material. The buccal, lingual and gingival margins of the cavity preparation should be brought to self-cleansible areas.



Cavity Preparations The cavity preparations for amalgam restoration and composites differ significantly. Also the involved tooth determines the shape of the cavity preparation. The following discussion on different cavity preparation is described toothwise under each category of cavity preparation.



Class I (Fig. 23.11) Class I caries is the one which involves the pits and fissures of the occlusal surfaces of the molar teeth and the buccal and lingual pits of all teeth.



FIGURE 23.11 Class I—primary molars.



1 First primary molars Cavity preparation for amalgam restoration: The cavity preparation is started with a round bur and once the caries is removed, outline is defined with a straight fissure bur. For removal of soft caries, a sharp spoon excavator is used. Outline form should be dovetailed, including all susceptible grooves and fissures, areas of caries, and developmental grooves (without breaking the central ridge). The occlusal portion is usually extended about one-half the way across on



the primary molars. The outline form should be composed of smoothly following curves and arcs. The central ridge is not broken unless it is undermined by caries. If two pit cavities exist on the mesial and distal pit; they are prepared as two independent cavities without breaking the central ridge. The ideal depth of the cavity is 0.5 mm into the dentin. This is approximately 1.5 mm from the enamel surface. The width of the cavity should be one-quarter to one-third of the intercuspal width. All internal line angles should be rounded. The walls of cavity preparation converge slightly with the greatest width at the pulpal floor. Cavosurface margins should be sharp. If the cavity is deep, a calcium hydroxide or a glass ionomer base is used to protect the pulp, over which amalgam restoration is placed. Cavity preparation for composites: Caries is removed as conservatively as possible and the preparation is extended to include all susceptible grooves and fissures (without breaking the central ridge). Cavity need not be extended into dentin unless the caries is found to extend already into the dentin. The entire preparation of the tooth can be completed with round and fissure burs. If the cavity preparation is deep, a suitable base is placed before acid etching. Then appropriate composites are used after application of bonding agents. Other methods of restorations like pit and fissure sealants and preventive resin restorations are discussed in Chapter 21 on Pit and Fissure Sealants and Preventive Resin Restorations. Caution: The mesial pulp horn projects almost into the dentinoenamel junction. The depth of the cavity should be as shallow as possible to prevent inadvertent pulp exposure.



2 Second primary molars Cavity preparation for amalgam restoration: The principles mentioned for the first primary molars are applicable to second primary molars also, except for the following: 1. In mandibular second primary molar, the cavity is extended throughout the occlusal surface including all susceptible grooves and fissures.



2. Preparation in maxillary second primary molar includes only the nearest occlusal pit. The transverse ridge is not included unless undermined with caries. The distal preparation is done in the same manner. Cavity preparation for composites: Preparation mentioned for composites for first primary molars are followed for second primary molars too. The extension of cavity preparation in mandibular second primary molar includes the entire occlusal surface, whereas in maxillary second primary molars the mesial and distal pits are prepared separately without breaking the transverse ridge.



Class II (Fig. 23.12) Class II lesions occur after the primary molars contacts are established. Once contacts are established, taking of bitewings should not be delayed in the hope of detecting the lesion clinically, either by exploration or by observation of grey discoloration of the marginal ridge. Early diagnosis of class II lesions enables the clinician to prepare a conservative cavity. The authors are of opinion that if the class II cavity becomes larger than the minimal classical dimensions then the tooth would be better served by a stainless steel crown. When a child is young (say, 4 or 5 years or less than that) and longevity of a class II restoration on a primary molar is questionable, a stainless steel crown is advised considering the duration for which primary molars has to stay in the oral cavity.



FIGURE 23.12 Class II—primary molars.



Traditional class II cavity preparation consists of three components: a. Occlusal extension b. Proximal box c. Isthmus



The main concern is the preservation of tooth structure to leave the tooth as strong as possible. Occlusal extension: Caries is removed with a round bur and ideal depth is 0.5 mm into dentinoenamel junction. The buccal and lingual walls are prepared with occlusal convergence. The cavity outline is extended into all the susceptible grooves and fissures. The buccal and lingual walls should be at right angles to the surface of the tooth and in the direction of enamel rods. The pulpal floor should be flat mesiodistally. The idea of the dovetail lock cut at the opposite end of the occlusal part to the proximal box is outdated. The purpose of dovetail is to increase retention. It becomes unnecessary, when the fissures and grooves are included in the cavity preparation. Removing tooth structure to produce a lock would only serve to weaken the tooth unnecessarily. Proximal box: Buccal and lingual walls of proximal box should have an occlusal convergence and approximately follow the buccal and lingual surfaces of the tooth. This provides for increased retention and also extends the preparation into self-cleansing areas. There is no need to bevel the gingival seat in primary molars as the enamel rods are inclined occlusally. Axiopulpal line angle should be rounded to prevent stress concentration and to add bulk of material into the restoration. Isthmus: The width of the isthmus should be approximately onethird of interocclusal distance. Increasing the depth of the cavity will aid in better retention of restoration than the width. Increasing the width unnecessarily removes sound tooth structure. Isthmus fracture seems to occur only when there is a premature contact from the opposing tooth. Reduction of high points with articulating paper is of paramount importance while doing class II restorations. Modifications of class II preparation like slot preparation, tunnel preparations are used when conservative preparations are needed. Such preparations are used when proximal caries is not involving the occlusal surface.



Class III



Caries involving the proximal surfaces of anterior teeth without involving the incisal angle are known as class III lesions. If the caries process involves the incisal angle, it is categorized as class IV lesion. If the carious lesions on the proximal surfaces of anterior primary teeth have not advanced into dentin, a small conventional class III cavity may be prepared and restored with glass ionomer cements or composite resins. Class III restorations require the use of celluloid matrix strip. In mandibular incisors, the retention of filling in a class III situation is questionable. Hence a process called ‘disking’ to open the proximal contacts and to remove most if not all of the cavitation followed by topical treatments with fluoride varnish, will often suffice. The following discussion describes cavity preparation on primary maxillary incisors, canines and mandibular canines. Primary (maxillary) incisors: The class III preparation is carried out by two ways: 1. Class III with open contacts: If the contact areas are open between the incisors, the cavity can be prepared directly. There is no need for a dovetail lock to enhance access and retention. The outline of the cavity is prepared with a round or pearshaped bur, to a triangular outline with the base of the triangle at the gingival aspect of the cavity. The labial and palatal cavity walls should parallel the external surfaces of the tooth to meet at the apex of the triangle. Cavity depth should be 1– 1.5 mm and retention grooves can be placed along the dentinoenamel junction with a small round bur. 2. Class III with closed contacts: To access the caries, an indirect approach should be carried out. Some clinicians advocate a palatal dovetail to facilitate access to interproximal caries and to aid in retention of the restoration. With present bonding agents, composite resins can be used without dovetail. When a dovetail is given, the dovetail extends up to the middle of the tooth. Considering the esthetics, dovetail is placed in the palatal side for maxillary teeth.



Primary canines (Figs. 23.13, 23.14): When there is a distal cavity in the canine, a palatal (maxillary) or facial (mandibular) lock aids in retention of the restoration. Because of the occlusion, it is recommended that where a dovetail lock is used it should be a palatal lock for the maxillary canine and a facial lock for the mandibular canine. The retentive lock should be in the middle third of the crown, not crossing the midline.



FIGURE 23.13 Class III—primary canines.



FIGURE 23.14 Class III, IV—primary canines.



Class IV When caries involves the incisal angle, use of strip crowns, anterior stainless steel crowns, open faced stainless steel crowns or veneered stainless steel crowns is recommended. The indications for full coverage of incisors as described by Waggoner are: 1. Incisors with large interproximal lesions 2. Pulpotomized or pulpectomized incisors 3. Fractured incisors which have lost an appreciable amount of



tooth structure 4. Hypoplastic incisors due to developmental disturbances 5. Discolored incisors 6. Incisors with small interproximal lesions that also demonstrate large areas of cervical decalcification. Detailed description of the use of these crowns is discussed in the Chapter 25 on Crowns in Pediatric Dentistry.



Class V (Fig. 23.15) Class V lesion occurs on the gingival one-third of the tooth. Its etiology can be directly related to poor oral hygiene, since this area is accessible to toothbrush. Dietary habits, such as sucking mints and chewing gums can also be an etiological factor. The initial decalcification is caused by the breakdown of foods containing fermentable carbohydrates held in close proximity to the buccal/labial surfaces of teeth for long periods.



FIGURE 23.15 Class V cavity in primary teeth.



Outline form should be limited to the carious lesions and any adjacent decalcified areas. Decalcified areas and carious defects occurring 2 mm apart should be included in the cavity outline as extension for prevention, rather than as separate lesions. A gently curved outline which is kidney-shaped is acceptable for a class V lesion. A round bur is used to prepare the cavity and an inverted cone bur can be used to flatten the floor of the preparation. Any remaining caries can be removed with a slow-speed round bur or spoon excavator. Fluoride releasing cement or composites can be used to fill the cavity.



Matrix Bands The first step in space management in pediatric dentistry is maintaining arch length by properly contoured restorations. The



restorations on carious teeth should restore their original dimensions and contour whenever possible. The margins of restorations should not retain food debris, plaque and bacteria so that they will not be detrimental to gingival health or encourage recurrent caries. This can be achieved with proper use of matrices for class II and class III restorations. Matrices used in primary dentition should be compatible with the size of the primary molar. It should have enough stability to withstand the pressures of condensation and retention to resist any effort of the child to dislodge it. The best results are obtained when the matrices are contoured and wedged. A wooden or plastic wedge is used to prevent any gingival overhang of the restoration. Correctly placed wedge holds the band closely to the tooth surface in the cervical region and they are inserted from the buccal or lingual side. Occasionally, two wedges are placed one from the buccal and the other from the lingual side. Commonly used matrices are: 1. Spot-welded orthodontic band 2. T-bands 3. Tofflemire or Siqveland 4. Sectional matrices (Palodent) 5. Celluloid matrices



Spot-welded orthodontic band (Fig. 23.16) A 40 mm long orthodontic band material is spot-welded to form a loop larger than the average sized primary molar. This loop is placed on the tooth and a Howe plier is used to draw the loop tight, buccally. It is removed and spot-welded to maintain this accurately adapted contour. Excess band material is cut with scissors. Following cavity preparation, the band is placed on the tooth and contoured. Wedges are placed, if necessary. After the filling, the band is removed in a buccolingual direction.



FIGURE 23.16 Matrices—spot-welded orthodontic band.



T-bands (Fig. 23.17) T-bands can be purchased in different sizes or can be made with orthodontic band material using a spot welder. The short arms of the ‘T’ are folded over to form a loop; the free end is passed through the loop, ensuring that it is on the buccal side of the band and freely sliding. The band is placed on the tooth so that it passes below the level of the gingival seat of the proximal box. A plier is used to tighten the arms. Once tightened, it is maintained by bending the free sliding arm back on itself. Excess band material is cut with scissors. The advantage of T-bands is that it is thin and an MO and DO on adjacent teeth can be carried out simultaneously.



FIGURE 23.17 Matrices—T-band.



Tofflemire and Siqveland (Fig. 23.18) The advantage of Tofflemire is that the band can be removed in a



buccolingual direction which prevents marginal ridge fracture. The disadvantages include an additional bulk in the child’s mouth, which may rest against lip, cheek and tongue. The additional tactile stimuli increase salivation. The retaining arms may annoy the child because of which he or she will dislodge the band before placement of alloy into the cavity.



FIGURE 23.18 Matrices—Tofflemire.



Sectional matrices The sectional matrices are easy to use and precontoured to maintain proximal contacts. They are used with G rings.



Celluloid matrices A wedged celluloid matrix is advised for anterior teeth resin restorations.



Willett Inlay Preparation When a filling on a primary molar will not have longevity, these inlays can be considered. These inlays are prepared on primary molars and are expensive because of the laboratory cost involved. However, these inlays can be prepared fast with little chair time that can compensate for some of the laboratory cost. Preparation of tooth involves slicing the proximal area or areas with a safe-sided disk at slow speed. The slicing is done at right angles to the occlusal plane of the tooth and carrying it just below the free margin of gingiva and laterally into self-cleansing areas. With a tapering fissure bur, a trench



cut is made through the enamel beginning one-third up the buccal groove, extending over the occlusal surface and down through the lingual surface. The trench cut ends in a feather edge at the gingiva third and follows the contour of the tooth. From the central trench, a similar cut is made to connect with the proximal slice. The walls must be parallel and all undercuts are removed to permit the wax pattern to separate freely and without distortion. Casting is carried out with base metals or gold. After the advent of SS crowns, these inlays are not practiced widely in pediatric dentistry.



Interim Therapeutic Restorations (ITR) and Alternative Restorative Treatment (ART) The two applications of glass ionomers where fluoride release has advantages are interim therapeutic restorations (ITR) and alternative restorative treatment (ART).



Interim therapeutic restorations (ITR) This may be used in very young patients, uncooperative patients or patients with special health care needs for whom traditional cavity preparation and/or placement of traditional dental restorations are not feasible or need to be postponed. Additionally, ITR may be used for caries control in children with multiple open carious lesions, prior to definitive restoration of the teeth.



Alternative restorative treatment (ART) Formerly known as atraumatic restorative treatment, this technique was developed for restoration of teeth in underdeveloped countries (see Fig. 22.1). This technique is used widely in countries that do not have electricity or access to sophisticated dental equipment. It is also recognized by American Academy of Pediatric Dentistry as a useful technique in the treatment and management of dental caries and adopted a policy on ART in 2001. The above techniques use only hand instruments like sharp spoon



excavators to remove decay and filling is done with fluoride-releasing glass ionomer cements. These methods may prevent pain and preserve teeth in these individuals. The advantages of these techniques are: 1. The noise and vibration of dental handpieces are not present. 2. It can be carried out even in knee-to-knee position. 3. Need for acid etching and high velocity suction is eliminated. 4. Local anesthesia is often not necessary. 5. Fluoride-releasing materials prevent further decay.



Restoration of Diastemas Midline diastemas are spaces seen between the incisors. Nowadays, these spaces are closed with newer composite materials. This method of diastema closure is inexpensive, reversible and nondestructive compared to the older full coverage restorations. Careful evaluation and treatment planning is essential for this procedure. The use of diagnostic study casts is highly recommended for treatment planning. A diagnostic wax-up of the proposed restorative treatment is helpful in visualizing the end result. Important pretreatment considerations include: 1. The size and location of the space or spaces 2. The size and the shape of the teeth to be restored 3. Age of child Generally, composite resins are added to the teeth on both sides of the space following the routine steps in composite restoration. One must also keep in mind the length and width of the tooth. If the width becomes greater, those teeth will appear more ‘square’ causing an unpleasant result. If the length is increased, chances for fracture of the tooth are more. However, light reflections can be used to create illusions. For some patients, partial diastema closure is done so that the teeth do not become abnormally large. Using these techniques even peg laterals can be modified to normal-shaped incisors.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Rubber dam. 2. Morphological differences between primary and permanent teeth and its applicability in restorative dentistry for children. 3. Class II cavity preparation in primary molars.



Short Notes 1. Quadrant dentistry 2. Indications for full coverage restorations for primary incisors 3. Techniques of application of rubber dam 4. Depth vs width of cavity preparation 5. Alternative restorative treatment 6. Willet inlay 7. Matrices 8. Diastema closure 9. Class V cavity preparation 10. Class III cavity preparation in maxillary canine 11. Isthmus 12. Proximal box in class II cavity preparation



SUGGESTED READING 1. Braham, RL, Morris, ME. Textbook of Pediatric Dentistry, 2nd edn. New Delhi: CBS Publishers; 1980. 2. Finn, SB. Clinical Pedodontics, 4th edn. Philadelphia: Saunders; 1991.



3. Guidelines on Pediatric restorative dentistry. American Academy of Pediatric Dentistry Reference Manual 2009-2010. Pediatric Dent 31(6): 172–178 4. Kennedy, DB, et al. Pediatric Operative Dentistry, 4th edn. Bristol: John Wright; 1996. 5. McDonald, RE, Avery, DR, Dean, JA. Dentistry for the Child and Adolescent, 8th edn. St. Louis: Mosby; 2004. 6. Mount, GJ, Hume, WR. A new cavity classification. Aust Dent J. 1998; 43(3):153–159. 7. Roberson TM, Heymann HO, Swift EJ, eds. Sturdevant’s Art and Science of Operative Dentistry, 4th Edition, St. Louis: Mosby, 2002. 8. Stephen, HY Wei. Pediatric Dentistry: Total Patient Care. Philadelphia: Lea and Febiger; 1988. 9. Stewart, RE, Barber, TK, Troutman, KC, et al. Pediatric Dentistry: Scientific Foundations and Clinical Practice. St. Louis: Mosby; 1982. 10. Wheeler, RC. Textbook of Dental Anatomy and Physiology. Philadelphia: Saunders; 1965. 11. Wright, GZ, et al. Child Management in Dentistry, 2nd edn. Oxford: ButterworthHeinemann; 1983.



CHAPTER 24



Pulp Therapy Sankalp Taparia, MS Muthu and N Sivakumar



CHAPTER OUTLINE Introduction Pulp–Dentin Complex Anatomical differences Histological considerations Etiology of pulpal diseases Diagnosis of pulpal status Clinical examination Medical factors determining, whether a primary tooth should be saved Evaluation of prognosis before pulp therapy Classification of Diseases of Pulpal and Periapical Tissues Deep Caries Management Indirect pulp therapy Other Pulp Therapy Procedures Direct pulp capping Calcium hydroxide Corticosteroids and antibiotics (ledermix) Pulpotomy Pulpotomy for young permanent teeth (apexogenesis) Pulpectomy Various obturating materials Apexification Follow-up of pulp treated tooth Pulp revascularization Conclusion Suggested Reading



Self-assessment Questions



“When you realize the value of all life, you dwell less on what is past and concentrate more on the preservation of the future.” —Dian Fossey



Introduction Significant changes have occurred in pediatric endodontics over the past 50 years. Prior to the early 1900’s, extraction of primary and permanent teeth was the order of the day. Tremendous amount of research into progression of dental caries and pulpal pathology have resulted in definite guidelines for endodontics in primary teeth. This chapter deals with the preservation of primary and young permanent teeth with pulpal involvement. The objective of pulp therapy is preservation of the tooth in a healthy state, functioning as integral part of the dentition. Treatment of pulpally inflamed primary and permanent teeth in children presents a unique challenge to the dental clinician. Pulp diagnosis in the child patient is imprecise as clinical symptoms do not correlate well with the histologic pulp status. Age and behaviour can compromise the reliability of pain as an indicator of the extent of pulpal inflammation. Dental treatment of primary teeth must satisfy different goals than permanent teeth. Primary teeth have a limited lifespan and it is often possible to treat primary teeth only once. The main goal of pulp therapy for primary teeth is to maintain an intact dental arch, a healthy periodontium and vitality of the dental pulp when possible. Currently accepted endodontic therapy for primary teeth can be divided into two categories— vital pulp therapy and root canal therapy.



Pulp–Dentin Complex The dentin–pulp complex acts anatomically and functionally as a unit and is essential to consider the unique properties of each component in detail for better understanding. Dentin is a mineralized tissue that surrounds the dental pulp and processes of the odontoblasts. It contains predominantly hydroxyapatite crystals and type I collagen. The collagen fibrils form the framework for hydroxyapatite crystals. The dentinal tubules run from the dentinoenamel junction and converge on one another toward the pulp of the tooth. The convergence of the tubules and their increased diameter toward the pulp is responsible for an increase in dentin permeability near the pulp. The permeability of the dentin allows for both outward pulpal fluid flow and inward diffusion of chemical and bacterial products. The thickness of dentin remaining between prepared surfaces and the pulp is the critical variable in determining whether dentin can protect the pulp. The dental pulp consists of loose connective tissue that occupies the central part of the tooth. It contains the cells, fibers, vessels, ground substance and interstitial fluid quite similar to that of other connective tissues. Tissue pressure in the pulp is the result of vascular pressure and is normally about 15 cm H2O. This was previously reported by Van Hassel as 5–14 mm Hg and when it gets around 35 mm Hg, pulpal damage is irreversible. More detailed description of the pulp is given below in the histological considerations. Pulp is derived from the cephalic neural crest. The dental papilla, from which the pulp arises, develops as ectomesenchymal cell proliferation and condenses adjacent to the dental lamina at the sites where the teeth will develop. Pulp formation starts on the 8th week of the intrauterine life in the region of incisors. First there is proliferation and condensation of mesenchymal elements known as dental papilla. The epithelial elements proliferate rapidly and assume a bell shape and enclose the future pulp tissue. Maturation of the dental papilla progressively moves apically, beginning at the tooth’s most coronal level and on its



apex. By the time a tooth erupts, the pulp within could be arbitrarily termed as ‘mature’. Along with development, pulp becomes vascular and star-shaped fibroblasts develop.



Anatomical Differences Anatomical differences between the pulp chambers and root canals of primary and permanent teeth are enumerated: 1. Pulps of primary teeth are proportionately larger and the pulp horns extend closer to the outer surfaces of the cusps than in permanent teeth. 2. The thickness of dentin which protects the primary pulp tissue is less than that of permanent teeth. Mesial pulp horn of maxillary 1st primary molar is about 1.8 mm from the outer enamel surface and mandibular pulp horn is only about 1.6 mm. 3. An increased number of accessory canals and foramina as well as porosity in pulpal floors of primary teeth have been noted in comparison with permanent teeth. 94% of all primary molars have accessory foramina (2004 Dammaschke et al) concluding that accessory canals might contribute to furcation bone resorption when molars have pulpal inflammation. 4. The roots of primary teeth are longer and slender. 5. Primary root canals are more ribbon-like and have multiple pulp filaments within their numerous accessory canals. 6. Roots of primary teeth flare outward from the cervical part to a greater degree than permanent teeth. 7. The roots of primary anterior teeth are narrower mesiodistally than permanent anterior teeth. All these factors make extirpation of pulp filaments from primary teeth more difficult and cumbersome. Hence all the above mentioned factors have to be considered while performing pulp therapy in primary teeth.



Histological Considerations Pulp is a highly vascular connective tissue with considerable healing potential. The features that distinguish pulp tissue from other connective tissues are: 1. Presence of odontoblasts 2. Absence of histamine releasing mast cells 3. Tissue confinement in a hard cavity with little collateral circulation 4. Vascular access limited to the root apex The pulp of a primary tooth is histologically similar to that of permanent tooth. The overall response of the tooth to injury such as dental caries represents the complex interplay between injury, defence and regenerative processes. Pulp is broadly categorized into central and peripheral zones. The peripheral zone is outlined by the odontoblast cells. The layer below these odontoblasts is called as the subodontoblastic layer or the cell free zone of Weil. This cell free zone is made of plexuses of capillaries and small nerve fibers. The next layer termed the cell-rich zone contains fibroblasts and undifferentiated cells, which sustain the population of odontoblasts by proliferation and differentiation. These zones vary in their prominence from tooth to tooth and from area to area in the pulp of the same tooth. These zones tend to become increasingly prominent as the pulp ages. Both of these zones are less constant and less prominent near the root apex. Rapp and associates stated that the density of the innervation of the primary tooth is not as great as that of the permanent tooth and may be the reason why primary teeth are less sensitive to operative procedures. They agree, however, that as the primary teeth resorb, there is a degeneration of neural elements as with other pulp cells. Neural tissue is the first to degenerate when root resorption begins, just as it is the last tissue to mature when the pulp develops.



Etiology of Pulpal Diseases 1. Physical—mechanical, thermal, electrical 2. Chemical—acids, monomer, etc. 3. Bacterial—toxins, direct, anachorectic 4. Traumatic injuries



Diagnosis of Pulpal Status It is difficult, if not impossible, to determine clinically the histologic status of the pulp. However, with thorough clinical and radiographic assessment, it is possible to determine whether the tooth is treatable or not. It is imperative to select the appropriate treatment for a tooth for its long-term prognosis.



Clinical Examination Diagnosing the status of pulp begins with a thorough history of pain and swelling. Eliciting an accurate history may be difficult in young children, as they are too young to narrate properly. Hence, the astute clinician should have the ability to ask right questions and also to identify whether the child is telling the truth. Occasionally, children may hide the exact history to avoid any treatment during the visit; hence they may say the tooth is not hurting. Being aware of our limitations, the clinician must distinguish between two types of dental pain—provoked and spontaneous. Provoked pain: It is stimulated by thermal, chemical or mechanical irritants (sweet, hot or cold foods or liquids) and is reduced or eliminated when the noxious stimulus is removed. This sign frequently indicates dentin sensitivity due to a deep carious lesion or a faulty restoration. The pulp is in a transitional state in most cases and the condition is usually reversible, indicating a reversible pulpitis diagnosis. Sometimes this type of pain is also felt due to the soreness around a primary tooth nearing exfoliation or erupting permanent teeth. Spontaneous pain: It is a throbbing, constant pain that may keep



the patient awake at night. This extensive degenerative change extending into the root canals points towards an irreversible pulpitis diagnosis. Similar kind of spontaneous, throbbing pain can be observed when the dental papilla is inflamed due to food impaction. This condition may cause bone destruction and the pulp in these cases can be treated and the symptoms disappear with proper restoration of the tooth and re-establishment of an adequate contact point. It is important to do a thorough clinical examination in a pediatric patient. Pulpal pathology in primary teeth is often painless and symptomless. Only clinical finding may be the presence of a gumboil or a fistulous tract on the attached gingiva adjacent to the corresponding decayed tooth or redness and swelling of the vestibulum. It is often left undiagnosed in the anterior primary teeth region. To avoid this ‘lift the lip examination’ (Fig. 24.1) must be performed, whenever there are decayed or traumatized anterior primary teeth. In addition, attention must be paid to the missing or fractured restorations or carious marginal breakdown because these may also be indicators of pulp involvement.



FIGURE 24.1 Lift the lip examination.



Palpation, assessment of tooth mobility and sensitivity to percussion are helpful diagnostic tools. Fluctuation, felt by palpating a swollen mucobuccal fold may be representative of an acute dentoalveolar abscess prior to externalization. Bone destruction following a chronic abscess can also be detected by palpation. Comparison of mobility with the contralateral tooth is of particular importance. Significant variation in mobility may help the clinician in suspecting pulpal involvement or the presence of a necrotic pulp. Careful interpretation is needed to differentiate between pathological mobility and normal physiological pre-shedding mobility. Tenderness to percussion is an important clinical finding indicating the periapical status of the tooth (acute apical periodontitis). The critical thing in eliciting this finding on a pediatric patient is to be careful while percussing an acutely inflamed tooth. The authors suggest and practice using the index finger to percuss an acutely inflamed tooth. It is also suggested to be ‘very gentle’ while doing this; as this test itself can cause severe pain and make a very young



child resisting further examination or treatment.



Size of exposure In deep caries management, the size of the pulp exposure, the appearance of the pulp and amount of bleeding are important clinical observations in diagnosing the status of the pulp. The most favorable condition for a vital pulp therapy is a small pin point exposure surrounded by sound dentin. A large exposure results when a large mass of leathery dentin is removed with a sharp spoon excavator. It is often associated with a watery exudate or pus indicating advance pulpal degeneration. Most often such tooth may need a pulpectomy or extraction.



Importance of radiographic assessment A brief description from the textbook on ‘Oral Radiology: Principles and Interpretation’ of the viewing conditions and systematic radiographic examination is given below: “The first step in radiographic image analysis is to use a systematic approach to identify all the normal anatomy present in an image or set of images. A profound knowledge of the variation of normal appearance is required to recognize an abnormal appearance. In short, the image analysis can proceed from examining the bone, the supporting structures of each tooth and then the tooth itself. Ideal viewing conditions should exist for viewing a radiograph properly. Some of the ideal viewing conditions are reduction in the ambient light in the viewing room, mounting the film in a film holder, masking the viewing box to eliminate all light from the periphery of the film, using a magnifying glass for examination (Fig. 24.2).”



FIGURE 24.2 Radiographic assessment using magnifying glass.



As mentioned above, a thorough radiographic assessment of teeth is very essential to determine the extent of decay and the status of the periapical region of a tooth with deep caries. It shows any widening of periodontal space or any radiolucency or opacity in the periapical region and in the surrounding region. The proximity of the caries to the pulp can be diagnosed better with a bitewing radiograph than a periapical radiograph (Fig. 24.3). However, what often appears to be a barrier of secondary dentin protecting the pulp may be actually an irregularly calcified mass of carious material. Any form of internal resorption present in the coronal or apical portions usually indicates extensive inflammation, is unlikely that the pulp will respond well to treatment due to the presence of a perforation. Pathologic bone and root resorption occurring in the bifurcation or trifurcation areas are signs of advanced pulpal pathosis that has spread into the periapical tissues and is usually treatable only with extraction.



FIGURE 24.3 Radiograph with caries involving pulp.



Pulp vitality testing Accurate measurement of the vitality of the tooth is the need of the hour, in particular, to establish the vitality of normal teeth to that of traumatized teeth or affected by dental caries. Existing methods such as the electric pulp tester, thermal testing and other methods are inaccurate which led to better invention of devices such as pulse oximeter, laser Doppler flowmetry and many more in the process for diagnosing pulpal vitality. They are as follows. Electric pulp testing (Fig. 24.4): Before doing electric pulp testing procedure, the procedure must be explained to the patient. An apprehensive or confused patient may give erratic responses. To perform electric pulp testing, one must follow a standard procedure. First dry the teeth to be tested and isolate them with cotton rolls. Cover the tip of the electrode with toothpaste or a similar electrical conductor. To complete the circuit, a ground attachment may be clipped on patient’s lip. Then slowly the electric current is passed through the tooth using the control in the pulp tester. A record must be made of the results of each tooth tested. For multirooted tooth, one may have to place the electrode on more than one crown location.



FIGURE 24.4 Electric pulp testing.



Thermal tests: Two types of thermal tests are available, cold and hot stimuli. Neither is totally reliable in all cases, but both can provide useful information in many cases of pulpal involvement. When using cold stimulus, one must try to determine if the effect of stimulus



application produces a lingering effect or if the pain subsides immediately on removal of the stimulus from the tooth. In testing, if the pain lingers, that is taken as evidence for irreversible pulpitis. If pain subsides immediately after stimulus removal, hypersensitivity or reversible pulpitis is the more likely diagnosis. Cold testing can be made with an air blast, a cold drink, an ice stick, ethyl chloride or fluorimethane spray or a carbon dioxide ‘ice stick’. Hot testing can be made with a stick of heated gutta-percha (Fig. 24.5) or hot water. Baseplate gutta-percha is warmed and formed into a cone, applied to a warm instrument, reheated and applied to the moistened tooth. The tooth is moistened, so that gutta-percha will not adhere to it. If the patient is complaining of a severe toothache, one must be ready to apply cold immediately following a dramatic response to heat. In case of hot water, the tooth is isolated with a rubber dam, so that the hot water will flow around the tooth. The electric pulp tester has been in use for more than a century now and has provided a great degree of reliability for mature teeth. Its shortcomings in young permanent teeth and in cases of trauma are also well known.



FIGURE 24.5 Thermal pulp testing—hot gutta-percha.



True assessment of pulpal blood flow: The tooth, compared to other sensory organs, is relatively late in maturing. Neural development for sight and smell is almost entirely prenatal. Taste organs have continued development postnatally. The tooth is functional for a relatively long period before neural development nears completion. Nerve fibers entering the teeth have been identified histologically as myelinated (A-fibers) and unmyelinated (C-fibers). Myelinated nerve fibers do not reach their maximum number until the apex of the tooth nears completion. The fibers continue to increase in number up to 5 years posteruption. This fits the clinical impression that the newly erupted healthy permanent teeth have great variability in their pulpal sensitivity and are therefore less reliable in assessing vitality. In order to investigate the vasculature of the dental pulp and its architecture, a wide variety of approaches have been used by many researchers, but with conflicting results. Recent advances in the alternative diagnostic techniques for pulp vitality centre on the



determination of the pulpal blood flow. Direct measurement of the pulpal circulation is the real measure of its vitality. Laser Doppler flowmetry, dual wavelength spectrophotometry and Pulse Oximetry all establish the same by a non-invasive subjective method as compared to the traditional objective techniques like electric pulp tester or thermal testing. Cholesteric liquid crystals have been used to show the difference in tooth temperature between the vital and necrotic pulps. Vital pulps tend to be hotter whereas necrotic pulps are cooler. Laser Doppler flow meter has also been shown to measure pulpal blood flow thereby assessing the vitality of the tooth. Hughes probe eye camera which is capable of detecting very small temperature changes, has been used to measure pulp vitality experimentally. This equipment is capable of detecting temperature changes as small as 0.1°C. Pulse oximeter probes (Fig. 24.6) have been modified to assess pulp vitality on a tooth. They tend to assess the oxygen saturation of a tooth and thereby indicating the status of the pulp.



FIGURE 24.6 Pulse oximeter probe.



Test cavity: This procedure involves slow removal of enamel and dentin through an existing restoration, using a small round bur to test vitality of the tooth. Once the bur reaches the dentinoenamel junction, patient perceives sensitivity or sharp pain indicating the vitality of the tooth. This procedure is used as a last resort when the other tests are inconclusive. In spite of the various modalities of pulp vitality assessments, one has to use the results of these tests, information cautiously in children. Generally, children tend to be anxious, about the dental appointments. Many a times, they can give false positive or negative information for this kind of testing, to avoid any dental treatment. However, the true assessment of pulp blood flow using any of the methods mentioned above can be very useful in children. Also one should remember a young permanent tooth and a recently traumatized tooth may not give a reliable response to vitality testing in children.



Medical Factors Determining, whether a Primary Tooth should be Saved Contraindications • Patient with congenital cardiac defects • Immunosuppressed patients • Patients who do not have proper wound healing, that is, those with uncontrolled diabetes or patients being treated for cancer • Patients with severe medical conditions who must be treated under general anesthesia where the risk of treatment failure and the need for a second general anesthesia must be minimized Medical conditions where it is advisable to perform pulp therapy in order to avoid extraction of a tooth: • Bleeding and coagulation disorders like hemophilia • Hypodontia in the permanent dentition, where a primary tooth is expected to remain as long as possible or for the life of the patient



Evaluation of Prognosis before Pulp Therapy • Patient and parent co-operation and motivation • A patient who has previously failed to comply with dental treatment



(A) Missing 2nd premolar with decayed 85 (B) Pulpotomy + stainless steel crown on 85. FIGURE 24.7



• Patient’s family background precludes pulp therapy, that is, unfavorable attitude towards dental treatment • Oral health and hygiene status of patient and parent desire in maintenance of oral hygiene • Caries activity and overall prognosis • Stage of dental development • Difficulty in pulp canal instrumentation • Space management considerations • Considerations for balanced and compensated extractions • Treatment cost considerations



Classification of Disease of Pulpal and Periapical Tissues Diseases of Pulp and Periapical Tissues by WHO K04 Diseases of pulp and periapical tissues K04.0 Pulpitis K04.00 Initial (hyperaemia) K04.01 Acute K04.02 Suppurative pulpal abscess K04.03 Chronic K04.04 Chronic, ulcerative K04.05 Chronic, hyperplastic pulpal polyp K04.08 Other specified pulpitis K04.09 Pulpitis, unspecified K04.1 Necrosis of pulp Pulpal gangrene K04.2 Pulp degeneration



Denticles Pulpal calcification Pulpal stones K04.3 Abnormal hard tissue formation in pulp K04.3X Secondary or irregular dentine Excludes: pulpal calcifications (K04.2) pulpal stones (K04.2) K04.4 Acute apical periodontitis of pulpal origin Acute apical periodontitis NOS K04.5 Chronic apical periodontitis Apical granuloma K04.6 Periapical abscess with sinus Includes: Dental or dentoalveolar abscess with sinus Periodontal abscess of pulpal origin K04.60 Sinus to maxillary antrum K04.61 Sinus to nasal cavity K04.62 Sinus to oral cavity K04.63 Sinus to skin K04.69 Periapical abscess with sinus, unspecified K04.7 Periapical abscess without sinus Dental abscess without sinus Dentoalveolar abscess without sinus Periodontal abscess of pulpal origin without sinus Periapical abscess with no reference to sinus



K04.8 Radicular cyst Includes: Cyst • Apical periodontal • Periapical K04.80 Apical and lateral K04.81 Residual K04.82 lnflammatory paradental Excludes: developmental lateral periodontal cyst (K09.04) K04.89 Radicular cyst, unspecified K04.9 Other and unspecified diseases of pulp and periapical tissues Clinical classification of status of the pulp and root canal conditions proposed by Abbott (2004): Clinically normal pulp (based on clinical examination and test results) Reversible pulpitis • Acute • Chronic Irreversible pulpitis • Acute • Chronic Necrobiosis (part of pulp necrotic and infected; the rest is irreversibly inflamed) Pulp necrosis • No signs of infection • Infected



Pulpless, infected root canal system Degenerative changes • Atrophy • Pulp canal calcification either partial or total • Hyperplasia • Internal resorption (surface, inflammatory, replacement) Previous root canal treatment • No signs of infection • Infected • Technical standard (based on radiographic standard either adequate or inadequate) • Other problems – perforation, missed canals, fractured instrument, etc.



Deep Caries Management Indirect Pulp Therapy Definition “Indirect pulp capping (Fig. 24.8) is defined as a procedure in which a material is placed on a thin partition of remaining carious dentin that, if removed, might expose the pulp.” OR “Indirect pulp therapy is defined as application of a medicament over a thin layer of remaining carious dentin, after deep excavation with no exposure of the pulp.”



FIGURE 24.8 Indirect pulp capping.



Indirect pulp therapy (IPT) is recommended for teeth that have deep carious lesions approximating the pulp but no signs and symptoms of pulp degeneration. It is performed on a lesion where it is anticipated that the pulp would be exposed when the caries is excavated completely. Pulp has an excellent healing potential and the basic principle behind this procedure is to stimulate the pulp to generate reparative dentin beneath the carious lesion. This results in the arrest of caries progression and preservation of the vitality of the non-exposed pulp. Pierre Fauchard was the first clinician to document the concept of indirect pulp capping in the 18th century.



Indications • Mild discomfort from chemical or thermal stimuli • Absence of spontaneous or nocturnal pain • Large carious lesion radiographically close to the pulp but without any lymphadenopathy • Normal appearance of adjacent gingiva • Normal color of the tooth • Normal lamina dura and periodontal ligament space without any periradicular or furcal radiolucency.



Contraindications • Sharp continuous pain, persisting after the withdrawal of the stimulus • Nocturnal pain • Excessive tooth mobility • Tenderness on percussion • Parulis in gingiva adjacent to the tooth • Discolored tooth • Large carious lesion with obvious radiographic pulp exposure • Interrupted lamina dura with widened periodontal ligament space • Peri-radicular or inter-radicular (furcal) radiolucency • Pulpal calcifications • Soft leathery dentin covering a very large area in the cavity, in a non-restorable tooth.



Diagnosis Reversible pulpits.



Technique This technique has been attempted from time to time since the year



1866 when Atkinson reported leaving softened dentin over a vital pulp and soaking it with cresoate. Often the dentin became hardened. Currently, in this technique, the deepest layer of the remaining carious dentin is covered with a biocompatible material to prevent pulp exposure and additional trauma to the tooth. This results in deposition of tertiary dentin, which increases the distance between affected dentin and the pulp. It also helps in the deposition of peritubular (sclerotic) dentin, which decreases dentin permeability. It is important to remove carious tissue completely from the dentinoenamel junction and from the lateral walls of the cavity in order to achieve optimal seal between the tooth and the restorative material and thereby prevent microleakage. The dilemma faced is always “as to how much caries to be left behind?” The carious tissue that should remain at the end of the cavity preparation is the quantity that, if removed, would result in evident exposure. The most infected portion of the caries is removed leaving the less infected demineralized dentin. Clinically, it is difficult to determine whether an area is infected carious lesion or a bacteriafree demineralized zone. The best clinical marker is the quality of the dentin—soft, leathery, mushy dentin should be removed and hard discolored dentin can be left behind to be covered with a calcium hydroxide liner as the indirect pulp therapy agent. The ultimate objective of this is to preserve pulp vitality by: • Arresting the carious process; • Promoting dentin sclerosis (by reducing permeability); • Stimulating the formation of tertiary dentin; and • Remineralizing the carious dentin. Calcium hydroxide (Dycal, Dentsply Caulk, Milford, DE, USA) and zinc-oxide-eugenol (ZOE) are the two most commonly used indirect pulp therapy agents. Recent studies indicate that the use of glass ionomer cement (GIC) as a biocompatible material for this procedure has proved beneficial and results in remineralization. The use of alternate materials for the procedure like dentin bonding agents have



shown poor bond strengths and not ideally suited for IPT. Recent research towards the use of bioactive molecules like enamel matrix protein (Emodogain) or TGF-β have been utilised experimentally to stimulate tertiary dentin formation but they have not been used clinically as yet. Interestingly, a study by Falster et al (2002) has concluded that the protection of the pulp, with indirect pulp treatment with an adhesive resin, is as effective as the use of a traditional calcium hydroxide liner when placed under a single surface resin restoration (composite). In addition, they stated that after removing deep caries in primary tooth and establishing a good seal, the tooth’s innate abilities are more important to the success than the use of calcium hydroxide. A lot of studies have compared indirect pulp therapy with formocresol pulpotomy and have proven that IPT has a higher longterm success (average success rate of 97% when the case selection has been right) as compared to formocresol pulpotomy (average success rate of 75%) over a period of 42–47 months. In addition, almost all studies indicate that formocresol pulpotomized teeth exfoliate earlier as compared to the normal exfoliation time of IPT treated teeth. It seems the success of indirect pulp treatment depends on a number of important criteria: • No symptoms or symptoms consistent with reversible pulpits • Absence of clinical or radiographic lesions such as internal or external root resorption or furcation radiolucency • Complete removal of caries on all the walls of the preparation leaving behind only a small amount of caries in the area where there would be an exposure • Placement of a restoration that provides excellent seal to prevent recontamination from bacteria All these improve the tooth’s innate capabilities to remineralise the dentin and heal the pulp. Table 24.1



Affected dentin vs infected dentin Affected dentin



Infected dentin



Intermediately mineralized



Highly demineralized



Remineralizable



Unremineralizable



Deeper layer



Superficial layer



Sensitive



Lacking sensation



Does not stain



Stained by 0.5% fuschin or 1.0% acid red solution in 0.2% propylene glycol



Should be left to remineralize



Should be excavated



ULTRASTRUCTURE: Intertubular dentin partially demineralized, but apatite crystals bound like fringes to the sound collagen fibers with distinct cross-bands and interbands



ULTRASTRUCTURE: Intertubular dentin greatly demineralized, with irregularly scattered crystals. Presence of deteriorated collagen fibers that have only indistinct cross-bands and no interbands



Other Pulp Therapy Procedures Direct Pulp Capping (Fig. 24.9) Definition



FIGURE 24.9 Direct pulp capping.



“Direct pulp capping is defined as the treatment of an exposed vital pulp by sealing the pulpal wound with a dental material placed directly on a mechanical or traumatic exposure to facilitate the formation of reparative dentin and maintenance of the vital pulp.” OR



“Direct pulp capping is defined as 1 mm2. or less than 1 mm2. exposure due to mechanical exposure during cavity preparation or caries or trauma left behind with a sound surrounding dentin and dressed with a biocompatible radiopaque base in contact with the exposed pulp and should heal the tissue and deposit the reparative dentin prior to placing the restoration.” Phillip Phaff, who placed gold foil against an exposed pulp with the intention of promoting pulpal healing was the first one to document vital pulp therapy. Direct pulp cap is a treatment option for teeth with traumatic or mechanical pulp exposures (inadvertently exposed during an operative procedure). It should be attempted only when the pulp is vital and does not show any signs or have any symptoms of irreversible pulpitis. A calcium hydroxide medicament is placed over the exposure site to stimulate dentin formation and thus ‘heal’ the wound and maintain the vitality of the pulp. MTA (mineral trioxide aggregate) can also be used as an alternative material and the tooth can receive a permanent restoration on the same appointment. An important criterion for the case selection in these cases, in addition to absence of pain, is either no bleeding from the exposure site or bleeding in an amount that would be considered normal in the absence of a hyperemic or inflamed pulp. In spite of the recommendation from the American Academy of Pediatric Dentistry, direct pulp capping is not a common procedure for most pediatric dentists. The procedure, however, is recommended for immature permanent teeth. In primary dentition, the probable reason for the failure of the treatment is due to the high cellular content of the primary pulp tissue resulting in internal resorption or an acute dentoalveolar abscess. It has been believed that the undifferentiated mesenchymal cells may differentiate into odontoclasts, leading to internal resorption. It is a procedure indicated for pinpoint-sized mechanical exposure or traumatic pulp exposure. DPC of a carious pulp exposure is NOT recommended. Ideally, the procedure should be performed under a rubber dam to prevent any salivary bacterial contamination of the pulp.



Some research has gone into the use of dentin bonding agents for direct pulp capping based on the rationale that if an effective, permanent seal against bacterial invasion can be provided it will lead to pulp healing. It has been received with some skepticism and present recommendation is against the use of acidic agents and adhesive resins for this procedure. However, this treatment could be recommended for exposed primary pulps in older children 1 to 2 years prior to normal exfoliation. In these children, a failure of treatment would not imply the need for space maintainer following extraction, as it would in younger children. There have been a variety of materials used for DPC: • Calcium hydroxide • Zinc oxide eugenol • Corticosteroids and antibiotics • Polycarboxylate cements • Tricalcium phosphate cement • Cyanoacrylate • Collagen • 4 META (4, methacryl oxyethyl trimellitate anhydride) • MTA (mineral trioxide aggregate)



Calcium hydroxide First used for pulp capping by Hermann in 1930. In an alkaline medium, enzyme phosphatase is active in releasing inorganic phosphate from the blood, thus precipitating calcium phosphate. Pure calcium hydroxide has a pH of 11. Commercially, Dycal is the most commonly used in India. Other products are Pulpdent and Hydrex (MPC). Histological changes: Pulp in direct contact with calcium hydroxide (alkaline pH) becomes necrotic after 24 hours. Necrotic layer is separated from healthy tissue by a deep staining basophilic material—calcium proteinate. Partially calcified fibrous tissue lined by odontoblasts is seen below the calcium proteinate zone in 14 days. A



zone of new dentin is observed within 28 days. Dycal: Introduced in 1962 by L.D. Caulk Co. Two paste system. Calcium hydroxide consists of a base (titanium dioxide in glycol salicylate and pigment) and a catalyst (calcium hydroxide and zinc oxide in ethyl-toluene sulfonamide) and it has a pH of 7 (neutral). It attains its final compressive strength of 1100 psi in about 7 minutes. The histological changes vary with Dycal because of the neutral pH. Pulp in direct contact with the material undergoes necrosis. This necrosed tissue is removed by macrophages. Granulation tissue is seen in the layer. Odontoblasts are seen differentiating in the granulation tissue and form dentin. The dentin formed is in contact with the Dycal making it difficult to visualize the dentin bridge from the radiopaque material.



Zinc oxide Eugenol Eugenol: 4-allyl-2-methoxyphenol. This is obtained primarily from the oil of clove. It is extracted from the oil by treatment with sodium hydroxide. Ether is added to the resultant solution to remove the other components. The separated eugenol is then treated with hydrochloric acid and washed until a purified preparation is obtained. Zinc oxide: It is produced by exposing a zinc mineral to high temperature; the liberated volatile zinc is then oxidized to form zinc oxide, which is insoluble in water and considered to be a mild astringent and antiseptic. IRM (L.D. Caulk Co.): Intermediate restorative material (IRM) or reinforced zinc oxide eugenol. 10 to 40% finely divided natural or synthetic resin (e.g. pine resin, polymethyl methacrylate, polystyrene or polycarbonate) along with zinc oxide and eugenol.



Corticosteroids and antibiotics (ledermix) ® Powder: • Dimethyl chlortetracycline hydrochloride • Triamcinolone acetonide



• Zinc oxide • Calcium hydroxide Liquid: Eugenol and rectified oil of turpentine



Pulpotomy (Fig. 24.10) Definition “Pulpotomy is defined as the surgical removal of the entire coronal portion of the pulp presumed to be partially or totally inflamed and quite possibly infected at the amputation site, followed by placement of suitable medicament either to heal or preserve (fixation) the remaining vital radicular pulp within the canals, under aseptic conditions.”



FIGURE 24.10 Pulpotomy.



Pulpotomy is a procedure for teeth with healthy pulps or teeth with symptoms of reversible pulpitis and deep caries where carious pulp exposure is encountered. Radiographically, the tooth should not show signs of pathological resorption or radiolucency. It is based on the rationale that radicular pulp tissue is healthy or is capable of healing after surgical amputation of the affected or infected coronal pulp.



Historical review Formocresol was introduced by Buckley in 1904, used a mixture of equal parts of formalin and tricresol to treat necrotic or ‘putrescent’ pulps. In the 1930s, Sweet developed a multi-appointment pulpotomy procedure that became very popular and is the predecessor to the currently used single visit pulpotomy. He had started with five appointments which were later reduced to three. By the year 1955, he had shown a clinical success rate of 97% in 16,551 cases. It was, however, reported that nearly half of the primary teeth exfoliated earlier. Doyle et al (1962) reduced it to two visits, complete devitalization. Berger (1965) recommended the one-appointment, 5minute protocol, resulting in partial devitalization. Venham (1967) gave the 15 sec protocol, but it’s not preferred. Loos and Han in 1971 reported comparable tissue fixations with 1:4 or 1 in 5 dilution as will full strength. The current technique followed is the use of diluted Buckley’s formocresol technique for 5 minutes in a single visit.



Indications 1. Vital teeth with pulp exposures larger than those considered suitable for pulp capping. 2. The tooth is free of radicular pulpitis. 3. Pain if present, is neither spontaneous nor persistent. 4. The tooth is restorable. 5. The tooth possesses at least two-thirds of its root length. 6. There is no evidence of internal resorption.



7. No inter-radicular bone loss. 8. No abscesses or fistulas exist. 9. The hemorrhage from the amputation site is pale red and easy to control. 10. Recommended for young permanent teeth with incompletely formed apices and cariously exposed pulps that give evidence of extensive coronal tissue inflammation.



Contraindications 1. Root resorption exceeds more than one-third of the root length. 2. The tooth crown is nonrestorable. 3. Highly viscous, sluggish or absent hemorrhage is observed at the radicular canal orifices. 4. Marked tenderness to percussion. 5. Mobility with locally aggravated gingivitis associated with partial or total radicular pulp necrosis exists. 6. Radiolucency exists in the furcal or periradicular areas. 7. Persistent toothaches and coronal pus.



Diagnosis Irreversible pulpits (limited to the coronal pulp)



Technique After achieving adequate anesthesia and rubber dam placement, all the superficial caries should be removed before pulpal exposure to minimize bacterial contamination following exposure. The roof of the pulp chamber should be removed by joining the pulp horns with bur cuts using a no. 330 bur on a high-speed water-cooled turbine. The coronal pulp is then amputated using either a sharp spoon excavator or a slowly revolving round bur leaving an intact vital radicular pulp. This procedure should be carried out carefully to prevent further damage to the pulp and perforation to the pulpal floor. Carefully remove all tissue; tags of tissue remaining under ledges of dentin may



continue to bleed, masking the actual status of the radicular pulp stumps and thus obscuring a correct diagnosis. Following coronal pulp amputation, one or more cotton pellets should be placed over each amputation site and pressure should be applied for a few minutes. When the cotton pellets are removed, hemostasis should be apparent, although a minor amount of wound bleeding may be evident. Excessive bleeding that persists in spite of cotton pellet pressure and a deep purple color of tissue may indicate inflammation has extended to the radicular pulp. Such signs indicate that the tooth is not a good candidate for pulpotomy and pulpectomy or extraction should be considered as a treatment option. No intrapulpal anesthesia or any hemostatic agent should be used to control the bleeding, as this bleeding is the only indicator of the radicular pulp status. Following hemostasis, a cotton pellet dipped in Buckley’s formocresol solution (one-fifth dilution or full strength) is placed over the pulp stumps for 5 minutes. A base of zinc oxide eugenol is placed over the amputation site and lightly condensed to cover the pulpal floor. A second layer is then condensed to fill the access opening completely. The final restoration should, preferably, be a stainless steel crown.



Formocresol The formocresol used in this technique is to be diluted in the clinic as the commercially available solutions are all full strength solutions. Unknowingly, many clinicians use full strength formocresol thinking they are using a diluted product, even though the diluted product is not available commercially. The formocresol used in the technique may be obtained under the trade name Buckley’s formocresol (Roth, Chicago, IL). Composition: Commercially available Buckley’s formula contains 35% cresol, 19% formalin in a vehicle of glycerine and water at a pH of approximately 5.1. The glycerine is added to prevent polymerization of formaldehyde to paraformaldehyde. Another commercial product Sultan brand, however, contains 48.5% cresol 48.5% formaldehyde and 3% glycerine.



Preparation of dilute formocresol solution: To dilute this to onefifth strength, thoroughly mix three parts of glycerine with one part of distilled water. Add these four parts to one part of concentrated commercial formocresol compound. Histology: In spite of histologic studies that showed formalin, cresol, and paraformaldehyde to be connective tissue irritants, it was recognised early that formocresol is an efficient bactericide. It was also found to have the ability to prevent tissue autolysis by the complex chemical binding of formaldehyde with protein. Massler and Mansukhani (1959) conducted a detailed histologic investigation and found that fixation of the tissue under the medicament was apparent. After a 7-14 day application, the pulp developed three distinctive zones: 1. A broad eosinophilic zone of fixation 2. A broad pale-staining zone with poor cellular definition 3. A zone of inflammation diffusing apically into normal pulp tissue After 60 days, the remaining tissue was believed to be completely fixed, appearing as a strand of eosinophilic fibrous tissue. Controversy regarding the use of formocresol: The medicament, though highly successful for the procedure, has been a subject of controversy since the last two decades. It has been under the scanner after two critical reviews by Ranly, 1984 and Garcia-Godoy 1986. A number of studies have been conducted that have questioned the postoperative effect of formocresol pulpotomy on the primary teeth, and also the succedaneous premolars, mostly without concrete evidence. Formocresol has been found to be cytotoxic to pulp tissues. Formocresol and formaldehyde have been found to be more cytotoxic than cresol. The response of the pulp tissue appears to be time and concentration dependent. The more dilute the concentration the less the toxicity, and lesser the inflammatory response. In June 2004, International Agency for Research on Cancer (IARC) classified formocresol as carcinogenic to humans, leaving the profession to look



for other viable alternatives to formocresol. In addition, they state that there is strong but insufficient evidence that formaldehyde is a causative agent for leukemia. However, the debate still goes on regarding the safety and use of formocresol in dentistry. Clinical and radiographic success of formocresol pulpotomy: Literature is full of studies related to the clinical and radiographic success of formocresol pulpotomies and most studies report a clinical success rate ranging from 85–95% over a period of 24–52 months but when the radiographic results are clubbed along with the clinical success, the rate drops to 74–88% over the same period. The major reason for the radiographic problem is pulp canal obliteration and internal resorption. Pulpotomy is considered a failure, if one or more of the following clinical or radiographic pathologic signs exist—pain, swelling, fistula, periapical or inter-radicular radiolucency and pathologic internal or external root resorption. Signs of failure can be seen radiographically long before they are expressed clinically. The other major area of research is the increased success rate of teeth with stainless steel crowns as the permanent restoration as compared to amalgam. Pulpotomized primary molars can be successfully be restored with one surface amalgam, if their natural exfoliation is expected within not more than 2 years. For all other cases, including multi-surface restorations stainless steel crowns are the treatment of choice. Indirect pulp capping has also been compared to pulpotomy and here indirect pulp capping has a success rate that is significantly higher than formocresol pulpotomy for deep caries management. Overall success rate of indirect pulp capping is 93% compared to 74% for formocresol pulpotomy and about 38% of the teeth exfoliated prematurely for pulpotomy treated tooth, which is a major concern in this treatment option, compared to the normal exfoliation time for almost all indirect pulp capping teeth. Alternate materials to formocresol: Ranly classified the various procedures and medicaments reported in literature according to treatment objectives as follows:



1. Devitalization: First approach to be used with the intention of ‘mummifying’ the radicular pulp tissue. It involved the original two-sitting formocresol pulpotomy, which resulted in complete devitalization of the radicular pulp. Also included were the 5-minute Buckley’s formocresol and 1:5 diluted formocresol techniques. 2. Preservation: It involves medicaments and techniques that provide minimal insult to the orifice tissue and maintain the vitality and normal histologic appearance of the entire radicular pulp. Pharmacotherapeutic agents included in this category are corticosteroids, glutaraldehyde and ferric sulfate. Non-pharmacotherapeutic techniques in this category include electrosurgical and laser pulpotomies. 3. Remineralization: Agents that have cell-inductive capacity to either replace lost cells or induce existent cells to differentiate into hard tissue-forming elements. Historically, calcium hydroxide was the first medicament to be used in a ‘regenerative’ capacity. Recently, its regenerative capacity has been questioned owing to the fact that calcium hydroxide tissue response is more reactive than inductive. Examples of true cell-inductive agents include transforming growth factorβ (TGF-β) in the form of bone morphogenetic proteins (BMP), freeze-dried bone and mineral trioxide aggregate (MTA). These materials are more representative of the regeneration category and provide the direction for future research in vital pulp therapy.



Glutaraldehyde In 1975, ‘s-Gravenmade and Dankert et al proposed that 2% glutaraldehyde could be an alternative pulpotomy fixative medicament. It was stated that it has better fixative properties with true crosslinking, the larger molecule size than formaldehyde will prevent it to diffuse out of the apical foramen, effective disinfecting properties and also has a low mutagenicity. It has lower cytotoxicity compared to formocresol, no damage to the erupted permanent teeth.



After extensive research, it was found that the success rate was low compared to formocresol pulpotomies and a potential drawback is the shelf life of the product. It appears that it is not the ideal material to replace formocresol.



Ferric sulfate Landau and Johnson in the late 1980s started the use of ferric sulfate (an astringent) as a pulp medicament in monkey’s teeth. Fei et al conducted the first clinical study in primary teeth. Fuks compared the two medicaments and reported similar success rates for dilute formocresol and 15.5% ferric sulfate for a period of 34 months. Even ferric sulfate causes early exfoliation of the treated teeth and has the same radiographic signs of failure like calcific metamorphosis and internal resorption.



Mineral trioxide aggregate It has been only recently recommended as a pulp capping agent in primary teeth. First published clinical trials began in 2001 animal studies in 2003–2004. Both white and gray MTA and regular and white Portland cements were tested as pulpotomy agents. A number of human studies have demonstrated better success rates than formocresol over 6–74 months. Pulp canal obliteration is a common finding but the inhibitory factor in the use of this material is its exorbitant cost. Only time will tell whether MTA will replace the gold standard, as the most commonly used pulp medicament and set a new standard of its own.



Electrosurgery Controlled energy in the form of electrosurgical heat application to the pulp stumps at the canal orifice site has been proposed as an alternate to the more traditional pharmacotherapeutic techniques, particularly those using formocresol. Numerous researchers have tried this as an alternate to formocresol pulpotomy but none could prove that it is



superior to formocresol pulpotomy.



Lasers Lasers have been suggested for a number of procedures in dentistry including pulpotomy. Nd:YAG, Diode, CO2, Argon, Er:YAG lasers all have been tried as an alternate to formocresol pulpotomy with similar or slightly lower success rates than the gold standard. As lasers become more common in dentistry, dentists owning a laser can use this as an alternate to pulpotomies in children in their practices.



Freeze-dried bone This product has been tested as a pulp capping agent in monkeys which showed favourable results in 6-week samples showing vital teeth in all the samples and dentin bridge formation in 87.5% of the teeth. The 6-month sample showed 83.5% remained vital and all teeth having a dentin bridge. However, it was suggested that the material be evaluated on larger sample sizes for longer periods of time and also human research is warranted.



Pulpotomy for Young Permanent Teeth (Apexogenesis) Definition “Apexogenesis is defined as the vital pulpotomy procedure undertaken for young permanent teeth with calcium hydroxide which lays down a dentinal bridge thereby allowing the radicular portion of the pulp for root elongation/lengthening.” Diagnosis in young permanent teeth varies greatly from that of completely formed permanent teeth. Most diagnostic aids used for fully formed permanent teeth for conventional endodontic therapy have little or no value in primary or immature permanent teeth. Most of our treatment plans vary according to the stage of development of the tooth root. According to Orban, tooth root’s development begins



after enamel and dentin formation has reached the cementoenamel junction. In permanent teeth, root formation is not completed until 1–4 years after the tooth erupts into the oral cavity. The immature teeth imply incomplete formation of one-third of the root apex or it may appear as a funnel-shaped or blunderbuss canal which is a challenge for the endodontist to allow the healing of the apical portion of the root in both vital and nonvital teeth. The faciolingual width of most roots and canals is greater than the mesiodistal width thereby causing the difficulty in determining apical closure of the roots. The X-ray beam is exposed in the faciolingual plane, but the radiograph is read mesiodistally. Apart from the single-rooted maxillary central and lateral incisors and a few single canal lower premolars radiographs cannot determine apical closure. Canal obturation for incompletely formed roots and open apices present a unique problem while using the conventional endodontic techniques. In such cases, the treatment objective is to maximize the opportunity for apical development and root closure, by apexogenesis and enhance continual root dentin formation. This can only be achieved, if the radicular pulp tissue is maintained in a healthy, infection free-state and this is the main principle behind treating such teeth with the pulpotomy technique. In vital young permanent teeth, the medicament of choice has been calcium hydroxide although formocresol has also been suggested as an alternative material. Pulpal inflammation which is superficial and unlikely to extend beyond the canal orifices, with good healing potential, should be treated by a full pulpotomy. When the root canals have developed thick dentinal walls and the apices are closed a full pulpectomy can be performed. Calcium hydroxide was thought to be the more biologically acceptable material than formocresol in the 1940s and 1950s due to the fact that it promoted reparative dentin bridge formation and pulp vitality was maintained. It was a concept introduced by Teuscher and Zander in 1938, describing this as a ‘vital pulp therapy’ technique. The histological studies showed that the pulp tissue adjacent to the calcium hydroxide initially got necrotized due to the high pH of pure calcium hydroxide (11–12) accompanied by an acute inflammatory



changes in the underlying pulp tissue. After 4 weeks, a fresh odontoblastic layer was formed followed by dentin bridge formation. It was later demonstrated that 3 zones were formed about 4–9 days later: (a) coagulation necrosis, (b) deep-staining basophilic areas with varied osteodentin and (c) relatively normal pulp tissue, slightly hyperemic, underlying an odontoblastic layer. Formocresol pulpotomy was extremely successful in primary teeth leading to the hypothesis that it can be used in young permanent teeth also. It was researched upon extensively and histological reports suggested that canal calcifications occurred, along with continued apical closure and partial bridging was also noted. Inflammatory areas were replaced with connective tissue. It was observed for 14 to 33 months by Trask in 43 teeth reporting a success rate of 42 teeth. He considered it to be a temporizing treatment only and not a substitute to future endodontic therapy, which was advisable at a later date on root completion. Intracanal calcifications were reported by many researchers as a problem in formocresol pulpotomy, thereby causing difficulty in negotiation of canals, if left untreated by endodontic therapy after root completion. The most recent material with promising results has undoubtedly been MTA (mineral trioxide aggregate). It was developed by Torabinejad at the Loma Linda University, California, USA as a material for lateral root perforation repair. Over the years, the material is slowly becoming one of the most versatile medicaments to be used in endodontic therapy. It is being effectively used as an apical barrier forming material in immature vital and nonvital permanent teeth, as a pulpotomy medicament in both primary and permanent dentition, pulp capping agent for young permanent teeth and also as a repair material for perforation and restorative defects.



Composition and properties MTA materials are a mixture of refined Portland cement and bismuth oxide and are reported to contain trace amounts of SiO2, CaO, MgO, K2SO4, and Na2SO4. The major component, Portland cement, is a



mixture of dicalcium silicate, tricalcium silicate, tricalcium aluminate, gypsum and tetracalcium aluminoferrate. Bismuth oxide has been added to provide radiopacity greater than that of dentin. Up to 2002, only one MTA (grey MTA) was available but in that year a white MTA was introduced ProRoot MTA (Dentsply, Endodontics, Tulsa, Ok, USA) to address esthetic concerns. The MTA powder is mixed with the supplied sterile water in the ratio of 3:1 (powder: liquid ratio) and it is recommended that a moist cotton pellet is placed temporarily over the material till the following appointment. Upon hydration, the material forms a colloidal gel that solidifies to a hard structure in approximately 3–4 hours (setting time of this material). Moisture assists this setting and this hydrated MTA has an initial pH of 10.2 which rises to 12.5 (3 hours after mixing). The disadvantages of this materials include the difficulty in manipulation of this material, difficulty in storage and also the high prohibitive cost of this material (1 g of this material approximately costs Rs 2500).



Technique This procedure allows continuation of physiological root closure by retaining the radicular pulp tissue. This is usually achieved with a calcium hydroxide pulpotomy. After the coronal pulp is removed, calcium hydroxide is placed over the remaining vital radicular pulp tissue and the access opening is sealed with a permanent filling material. Periodic clinical and radiographical follow-up is carried out to monitor the root formation. If this procedure fails, apexification may have to be carried out.



Cvek pulpotomy or partial pulpotomy Cvek has shown that, in exposures resulting from traumatic exposures, pulpal changes are characterized by a proliferative response, with inflammation extending only a few millimetres into the pulp. When the hyperplastic tissue is removed, healthy pulp is seen. In cases with carious exposure, it might be necessary to remove tissue to a greater depth in order to reach noninflamed pulp. Cutting of the



tissue with a diamond bur using high speed with water cooling is the best method. After pulp amputation, saline is used for irrigation and the hemorrhage is controlled with cotton pellets. A dressing of calcium hydroxide is gently placed on the amputation site. Care should be taken not to push the material into the pulp. An entrance filling with GIC or composite is done. Recently MTA has been used to carry out these procedures. Follow-up • Apical development is monitored by comparison with the preoperative radiograph (IOPA). • Formation of calcific bridge, continued apical development, absence of internal resorption and periapical radiolucency are evidences of success. • Often there is linear calcification along the length of the root canal after formation of a calcific bridge called as calcific metamorphosis and is pathological rather than physiological. • Many clinicians are content to call this nature’s efforts at root filling. • Microscopic evaluation reveals that pulp remnants slowly become nonvital through self-strangulation. • One school of thought favors leaving the tooth well alone and allowing sclerosis of the root canal. • On the other hand, bacteria might migrate into these root canal spaces and periapical pathology might result. • Once the canal calcifies to a great extent, it may be impossible to negotiate it with instruments, even the use of chelating agents like EDTA (ethylene diaminetetra-acetic acid) might not help. • Calcium hydroxide pulpotomy can thus be considered as the 1st stage of treatment for vital, cariously or traumatically exposed, permanent teeth with incompletely formed apices and the aim to permit normal closure. • The 2nd stage treatment should be the conventional root canal therapy, once the apices are closed.



• The state of apical development and the speed of calcific metamorphosis will decide the exact timing of RCT.



Pulpectomy (Fig. 24.11) Definition “Pulpectomy involves removal of the non-vital cariously exposed roof of the pulp chamber and contents of the chamber in order to gain access to the root canals which are debrided, enlarged and disinfected followed by the obturation with the resorbable material.”



FIGURE 24.11 Pulpectomy.



The pulpectomy procedure is indicated in teeth that show evidence of chronic inflammation (irreversible pulpitis) or necrosis of the radicular pulp or when a tooth has been planned for a pulpotomy and excessive hemorrhage (hyperemia) is encountered at the time of



treatment. Many pediatric dentists prefer pulpectomy for primary anteriors even if the tooth could be treated only by pulpotomy (having reversible pulpitis) because of the belief that a complete obturation of the canal is preferable to partial obturation whenever possible. Most negative attitudes towards primary teeth complete pulpectomy have been based on the difficulty in cleaning and shaping the bizarre and tortuous canal anatomy of these teeth. It was especially true for primary molars with their resorbing and open apices. Removal of abscessed teeth has been suggested by a few because of their potential to create developmental defects on their successors. In addition to this, behavior management problems that occur in children have surely added to the reluctance of some dentists to perform root canal treatment in primary teeth. In spite of these objections, successful root canal obturations have been carried out. The goal of pulpectomy procedure is to eliminate the bacteria and the contaminated pulp tissue from the canal. In primary teeth, more emphasis has been given on chemical means in conjunction with limited mechanical debridement to disinfect and remove necrotic pulp remnants from the ‘so called inaccessible canals’ rather than the conventional ‘shaping’ of the canals.



Indications 1. Primary tooth with irreversibly inflamed pulp and having not more than one-third of root resorbed 2. Primary tooth with an abscess, or sinus opening 3. Traumatized primary anterior tooth with a fracture/caries involving the pulp irreversibly 4. Alveolar bone free of pathologic resorption 5. Internal resorption in teeth with no visible perforation 6. Presence of pus at the exposure site or in the pulp chamber 7. Pulpless primary teeth without permanent successor 8. Pulpless primary second molars before the eruption of the permanent first molars



9. Children suffering from hemophilia 10. Teeth next to the line of a palatal cleft 11. Primary molars supporting orthodontic appliances 12. Handicapped children where monitoring of space maintainers or continuous supervision is not possible 13. Primary molars where arch length is deficient 14. Pulpless primary anterior teeth when speech, crowded arches or esthetics is a factor



Contraindications 1. A primary tooth with a irreversibly inflamed pulp with excessive root resorption involving more than two-thirds of the root 2. Tooth with internal resorption 3. Primary tooth with excessive mobility 4. Primary tooth with deep caries and a large radiolucency with the possibility of affecting/damaging the succedaneous tooth 5. A nonrestorable tooth 6. Teeth with mechanical or carious perforations of the floor of the pulp chamber 7. Primary teeth with underlying dentigerous or follicular cysts 8. Young patients with systemic illnesses such as congenital or rheumatic heart disease, hepatitis or leukemia and children on long-term corticosteroid therapy or those who are immunocompromised



Diagnosis Irreversible pulpitis



Technique The child with necrotic primary tooth can present with varied clinical signs and symptoms ranging from being absolutely asymptomatic to an acutely or chronically abscessed, mobile and painful, teeth with



swollen periodontal tissues. In the latter case, the child may be fairly apprehensive and irritable, making relief of pain and swelling a top priority. In cases of non-draining alveolar abscess and cellulitis from odontogenic origin, antibiotic therapy using first or second generation penicillins for a period of 5 to 7 days must be the first line of treatment. Canal instrumentation can be implemented at the next appointment helping the child also in allaying his/her apprehension. After securing profound anesthesia and placement of the rubber dam for isolation, all caries is removed with a slow-speed round bur or a sharp spoon excavator. The pulp chamber is carefully opened to relieve any pressure from the infected pulp, with a high-speed bur. The access preparation is made by joining all the pulp horns with a bur. Remove the roof of the chamber and the coronal pulp with a lowspeed round bur or a sharp spoon excavator. The access opening is refined to make a straight line access with slight flaring to allow ease of insertion of the files.



1 Access openings Primary anterior teeth: Access openings for endodontic treatment on primary or permanent anterior teeth have traditionally been through the lingual surface. This remains the surface of choice except for the primary maxillary incisors where the recommended approach is to use the facial surface followed by an acid etched composite restoration to improve esthetics (Cohen). The anatomy of the primary incisors is such that access opening can be successfully made from the facial surface with more extension to the incisal edge than with the normal lingual access to give a straight line access to the root canal. Primary posterior teeth: The access openings are essentially similar to the permanent teeth. Some of the differences are: a. The length of the crown is short. b. Primary teeth have very thin dentinal walls in the root canals and the floor. c. The depth necessary to penetrate into the pulp chamber is much less than that in the permanent teeth, also the distance



from the occlusal surface to the pulpal floor is much less than permanent teeth. The author uses the following useful analogy to make the new graduate student understand the three-dimensional nature of the pulp chamber and the need to be cautious when making an access opening of the primary molars. The tooth is compared to a building with basement, first (ground), second and third floors. The basement represents the root portion of the tooth. The pulp chamber is represented by the ground or first floor. Second floor contributes the dentin and the third floor represents the enamel. The roof of the first floor is synonymous with the roof of the pulp chamber and the floor of the first floor represents the floor of the pulp chamber from where the root canals originate. When access opening is made the bur penetrates the enamel and dentin (i.e. the third and second floors) and enters the chamber by penetrating the roof of the first floor. Attempt should be made to remove the entire roof of the pulp chamber (i.e. the roof of the first floor) to facilitate access to all the root canal orifices and also to access the necrotic pulp tissue and the infected dentinal walls immediately below the roof of the chamber. This can be achieved with a straight fissure bur or a round diamond bur. As mentioned above, the distance from the occlusal surface to the pulpal floor is much less in primary teeth. Hence, the dentist or the dental student should be careful while doing this, not to touch the floor of the pulp chamber with the bur while deroofing as it may cause a perforation of the floor.



2 Working length determination The working length of the root canals is determined from a radiograph with an endodontic file inside the canal. The authors recommend the use of the frequency dependent apex locators which can help in locating the end of the root canal correctly. To prevent overextension through the apical foramen, it is advisable to shorten the working length to 2–3 mm short of the radiographic length especially in teeth exhibiting signs of apical root resorption. After the



correct length is established, set all smaller files (Hedstroem files or Kfiles) to this length for cleaning and shaping the canals.



3 Pulp extirpation and preparation of canals After the working length determination, the pulp tissue is extirpated with broaches and Hedstroem or K files. Because of greater flexibility, nickel-titanium (NiTi) instruments are recommended rather than stainless steel instruments. Occasionally, when the pulp has undergone a fibrous degeneration, it comes out enmasse with a barbed broach. Avoid excessive cleaning and shaping as it may lead to lateral wall perforations or floor perforations. The purpose of filling is to remove the pulp tissue from the canals to create space for the primary teeth obturating material. Frequent irrigation with sodium hypochlorite or sterile normal saline will aid the pulp extirpation procedure. Copious irrigation also helps to clean the pulpal ramifications which cannot be reached mechanically. The canals are usually enlarged from the 15 no. file to 25 or 30 no. file. This debridement helps to remove the necrotic or infected dentin from the root canal walls. Shaping of the canals proceeds in much the same manner as is done to receive a gutta-percha filling. Care must be taken to avoid over instrumentation through the apical foramen which can possibly injure the permanent tooth germ. The scientific data available on the use of rotary instruments in primary teeth is sparse. More research is needed in this area of pediatric endodontics.



4 Obturation techniques Obturation of primary teeth is done with a resorbable material which will give way for the erupting permanent tooth. Ideal requirements of a root filling material for primary teeth are: 1. Resorbable 2. Antiseptic 3. Non-inflammatory 4. Non-irritating to the underlying permanent tooth germ



5. Radiopaque 6. Easily inserted 7. Easily removed 8. Should not discolor the tooth No material that is currently available meets all these criteria. Calcium hydroxide with iodoform comes closest to the ideal obturating material. Nonresorbable materials such as gutta-percha or silver points are contraindicated as they will not enhance the primary root physiologic resorptive process. Obturation using freshly mixed zinc oxide eugenol: 1. Using reamer (Fig. 24.12): After the pulp extirpation is complete, the canal is dried with paper points. A thin mix of zinc oxide eugenol is made. The consistency is considered ideal, if the material can fall on its own weight when taken with a cement spatula. Then a no. 15 or a no. 20 reamer is taken, with which the mixed zinc oxide eugenol is taken into the root canals. Then the following techniques are employed to fill the canals:



FIGURE 24.12



Obturation technique using reamer.



a. First the reamer is rotated clockwise inside the canals for 10–15 rotations keeping in mind not to extend beyond the working length. This is done simultaneously with tilting the reamer on all directions inside the canal. This procedure facilitates the entry of zinc oxide eugenol inside the canal. b. Secondly, the reamer is moved vertically up and down 10–15 times, simultaneously tilting the reamer in all directions horizontally. This facilitates the lateral condensation and coating of the canal walls with zinc oxide eugenol. c. Thirdly, the reamer is withdrawn anticlockwise from the canal which allows the zinc oxide eugenol to leave the reamer and stay inside the canal. This procedure is repeated at least 5 times for each canal. In case of maxillary primary molars, it may be wise to repeat this process at least 7–8 times for each canal. 2. Using wet cotton: In this method, first, zinc oxide-eugenol is



mixed as mentioned above and taken into the root canal with a file or reamer. Then a small wet cotton pellet (squeezed thoroughly) is taken and used to condense the material inside the canal from the chamber. This procedure is repeated 5-8 times. It is also advised to apply pressure using the cotton pellet towards each canal separately, i.e. the direction of the pressure with wet cotton pellet should be directed for individual canals. The drawback of this method is the lack of control over the extrusion of the material. 3. Using lentulo spirals: In this method, the zinc oxide eugenol is taken inside the canal with either a hand lentulo or an enginedriven lentulo spiral. Obturation using injectable syringes: After the canal is dried thoroughly, the syringe loaded with the obturating material is taken inside the canal and the material is extruded slowly, continuously withdrawing the syringe from the canal. This method is a simpler and faster method for obturating the root canals of primary teeth. The materials used with this technique are: a. Metapex (calcium hydroxide and iodoform paste) b. Vitapex (calcium hydroxide and iodoform paste) c. Calcicur (calcium hydroxide paste) Endodontic pressure syringe (Fig. 24.13): Endodontic pressure syringe was designed by Greenberg and Katz. It consists of an internally threaded barrel with a threaded hub, a threaded plunger, threaded needle and a small wrench. Using this syringe, a very thick mix of zinc oxide eugenol can be forced through an extremely narrow gauge needle. This instrument is unique in that it allows effective placement of filling material into the apical portion first. Accordingly, none of the sealer is lost in the access cavity, at the orifice of the canals, or along the walls of the coronal portion of the canal.



FIGURE 24.13 Endodontic pressure syringe (Courtesy: Pulp Dent Corporation, USA).



The flexibility of the needle allows them to be bent to reach the apex, of even inaccessible posterior teeth. Other methods: Jiffy tube: The regular mix of zinc oxide eugenol is backloaded into the tube. Then the tube tip is placed into the canal orifice and the material expressed into the canal with a downward squeezing motion until the orifice appeared visibly filled. Tuberculin syringe: This syringe is loaded with a thin mix of zinc oxide eugenol and the material was expressed into the canal by slow finger pressure on the plunger until the canal was visibly filled at the orifice. Figure 24.13 depicts the preoperative and postoperative radiographs of pulpectomy.



Various Obturating Materials 1. Unreinforced zinc oxide eugenol



2. Calcium hydroxide (calcicure) 3. Calcium hydroxide with iodoform (Vitapex, Neo-Dental International Inc., Federal Way, WA or Metapex, MetaBiomed Co. Ltd., Korea) 4. Kri paste (a mixture of p-chlorophenol, camphor, menthol and iodoform) 5. Walkhoff paste (parachlorophenol, camphor, menthol) 6. Maisto paste (zinc oxide, iodoform, thymol, chlorophenol, camphor, lanolin)



Apexification (Figs. 24.14–24.17) Definition “Apexification is defined as chemically induced root formation by calcium hydroxide or CMCP in nonvital immature, blunderbuss canals of young permanent teeth.”



FIGURE 24.14 Preoperative and postoperative radiographs of pulpectomy.



FIGURE 24.15 Radiograph of maxillary central incisor with open apex.



FIGURE 24.16 Radiograph of maxillary central incisor with MTA apical plug.



FIGURE 24.17 Central incisor with MTA plug and obturated with GP.



Endodontic management of a young pulpless permanent tooth with a wide open blunderbuss apex has long been presented a challenge to dentistry. Prior to the introduction of the apical barrier techniques, the usual approach was surgical. In the pulpless tooth with an incompletely formed apex, the thin dentinal walls made it difficult to



achieve an apical seal. The material which is used very successfully for inducing a apical barrier is calcium hydroxide. The use of calcium hydroxide for apexification in pulpless tooth was first reported by Kaiser in 1964. Since then it has become the most widely used material to promote apexification. One of the most recently popularized materials for this purpose is mineral trioxide aggregate (MTA).



Technique Most often the tooth is nonvital and the pulp is necrosed. Hence use of local anesthesia may not be necessary. However, these procedures are performed under rubber dam, local anesthesia can be given. 1. Obtain adequate anesthesia 2. Apply rubber dam 3. Make an access opening following the objective of access opening 4. Pulp extirpation is carried out after length determination 5. Canals are irrigated with a suitable irrigant (the authors prefer saline) 6. Canals are dried 7. Injectable calcium hydroxide in injected inside the canal (Pulpdent or calcicure) 8. Entrance filling done with a cement with good sealing ability (GIC) 9. Radiograph is taken to check the intracanal calcium hydroxide 10. Periodic recall is scheduled (2 weeks, 3 months and 6 months) Usually it takes around 6 months for barrier to form. Once the barrier formation is confirmed clinically (by passing an endodontic instrument) obturation of the tooth is done with gutta-percha. A postendodontic jacket crown is done or an interim composite restoration is done depending on the age of the patient. Recently, a single visit apexification has become popular with the advent of MTA. This material can be mixed and placed at the open



apex with special carriers. It usually sets within 4 hours and then the obturation with gutta-percha can be carried out on the next day.



Follow-up of Pulp Treated Tooth All pulpally treated teeth should be monitored regularly. A clinical and radiographic assessment should be made every 6 months. Any following abnormalities should be acted on: 1. Excessive mobility 2. Persistence of pain 3. Presence of swelling 4. Development of a sinus or a fistula on the gingiva adjacent to the tooth 5. Persistent tenderness to percussion 6. Persistence of radiolucency either furcal or periapical



Pulp Revascularization Pulp necrosis of an immature permanent tooth from caries or trauma arrests further root development and leaves the tooth within, weak walls that are prone to fracture. Endodontic treatment of such a tooth is difficult because the thin walls do not forgive much mechanical instrumentation and the open apex is impossible to seal with conventional methods of lateral condensation or thermoplasticized techniques. The traditional treatment for these teeth is long-term application of calcium hydroxide to induce apexification (an apical hard tissue barrier). More recent treatments have been used as an artificial barrier of MTA. Both of these techniques are followed by a traditional root filling, but they do not increase the fracture resistance of the walls. Root-wall strengthening with composite resin have been advocated, but they may limit the possibility of RCT, if need arises in the future. In this situation, the necrotic uninfected pulp acts as scaffold for the ingrowth of new tissue from the periapical area. The absence of bacteria is important for successful revascularization because the new



tissue will stop at the level it meets bacteria in the canal space. Extrapolating from this information, it is hypothesized that disinfection of a necrotic-infected immature permanent tooth with apical periodontitis may render it to the same starting point as a necrotic uninfected avulsed immature permanent teeth (necrotic due to severance of vascular supply but uninfected by bacteria). The effective antibiotic combination for killing common endodontic pathogens in vivo and in vitro is metronidazole, minocycline and ciprofloxacin.



Technique An access cavity is prepared under LA and rubber dam isolation. A sterile endodontic hand file is used to disrupt the pulp tissue from the canal spaces, without removing it from the canals. A needle is placed within 1 mm of apex and the canals are slowly flushed with 10 ml of 5.25% of NaOCl. The canals are dried with paper points and the antibiotic mixture is prepared into a creamy consistency and spun down into the canal with the lentulo spiral instrument to a depth of 8 mm into the canal. The access cavity is closed with 4 mm of Cavit. After 4 weeks, if the patient is asymptomatic, reporting of no pain, under the same aseptic conditions, the access cavity is re-entered. The canals are again flushed with 10 ml of 5.25% of NaOCl. The canals should appear clean with signs of inflammatory exudate. An explorer is introduced into the canal space until the vital tissue is felt at a depth of 15 mm into the canal space. An explorer is used to irritate the tissue gently to create some bleeding into the canal. The bleeding is stopped at a level of 3 mm below the level of CEJ and left for 15 minutes so that the blood would clot at that level. After confirming the blood clot to approx. 3 mm apical to the CEJ, MTA is carefully placed over the blood clot, followed by a wet cotton pellet and Cavit. Two weeks later, if the patient is asymptomatic, the Cavit and the cotton pellet are replaced with bonded resin restoration. The patient should be scheduled for recall examination. At the 2-year follow-up, the closure of apex and thickenings of dentinal walls become obvious.



CONCLUSION The need for restorative dentistry is most likely diminishing in the developed nations because of the widespread use of topical and systemic fluorides and sealants. Though endodontists are trained to perform excellent pulp therapy for adults, providing pulp therapy for children still remains to be the domain of pediatric dentists because of the behavior challenges. With newer techniques and materials, pulp therapy in primary teeth is becoming more and more as a definite procedure with excellent prognosis for the treated tooth.



SELF-ASSESSMENT QUESTIONS Essay Type 1. Define pulpotomy. Enumerate the indications and contraindications for polpotomy. Write in detail formocresol pulpotomy procedure. 2. Write the indications and contraindications for pulpectomy in primary teeth. Elaborate on the root canal obturation materials and techniques used for primary teeth.



Short Notes 1. Direct pulp capping 2. Indirect pulp capping 3. Calcium hydroxide 4. Formocresol 5. Apexification vs apexogenesis 6. Indications and contraindications for pulpectomy in primary teeth 7. Pulp vitality testin



SUGGESTED READING 1. Abbott, PV, Yu, C. A clinical classification of the status of pulp and the root canal system. Aust Dent J Endodontic supplement. 2007; 52(1):S17–S31. 2. Cohen, S, Burns, RC. Pathways of the Pulp, 4th edn. New Delhi: Elsevier; 1990. 3. Cvek, M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod. 1978; 4:232. 4. Cvek, M. Treatment of non-vital permanent incisors with calcium hydroxide. Odontol Rev. 1972; 23:27. 5. Gopikrishna, V, Pradeep, G, Venkateshbabu, N. Assessment of pulpal vitality: A review. Int J of Pediatr Dent. 2009; 19:3–15. 6. Guideline of pulp therapy for primary and young permanent teeth [Special Reference Manual]. Pediatr Dent. 2010-11; 32(36):194–201. 7. Ingle, JI, Bakland, LK, Baumgartner. Endodontics, 6th Edition. BC Decker; 2008. 8. Journal of Endodontics. Pulp Symposium. 34(75), July 2008. 9. Kaiser JH. Presentation to the American Association of Endodontists Meeting,



Washington DC, April, 1964. 10. Kenneth M Hargreaves, Stephen Cohen, Pathways of the Pulp (9th Edition), 2007. 11. King, Whorter, Seale. Concentration of formocresol used by pediatric dentists in primary tooth pulpotomy. Ped Dent. 2002; 24(2):157–159. 12. McDonald, RE, Avery, DR, Dean, JA. Dentistry for the Child and Adolescent, 8th edn. St. Louis: Elsevier; 2004. 13. Patchett, Cl, Srinivasan, V, Waterhouse, P. Is there life after Buckley’s Formocresol? Part II – Development of a protocol for the management of extensive caries in the primary molar. International Journal of Pediatric Dentistry. 2006; 16:199–206. 14. Pinkham, Casamassismo, Fields, McTigue, Nowak. Pediatric Dentistry infancy through adolescence, 4th Edition. Elsevier; 2005. 15. Rajendran, R, Sivapathasundharam, B. Shafer’s Textbook of Oral Pathology, 6th Edition. Elsevier; 2009. 16. Rapp, R, et al. The distribution of nerves in human primary teeth. Anat Rec. 1967; 159:89. 17. Ranly, Dm. Pulpotomy therapy in primary teeth: new modalities for old rationales: A review. Ped Dent. 1994; 16(6):403–409.



[Nov/Dec]. 18. Roberts, HW, Toth, JM, Berzins, DW, Charlton, DG. Mineral trioxide aggregate material use in endodontic treatment: A review of the literature. Dental Materials. 2008; 24:149–164. 19. Sathorn, C, Parashos, P, Messer, H. Antibacterial efficacy of calcium hydroxide intracanal dressing. A systematic review and meta-analysis. International Endodontic Journal. 2007; 40:2–10. 20. Sidney, B Finn. Clinical Pedodontics, 4th Edition. W.B. Saunders; 2000. 21. Srinivasan, V, Patchett, Cl, Waterhouse, P. Is there life after Buckley’s Formocresol? Part I – A narrative review of alternative interventions and materials. International Journal of Pediatric Dentistry. 2006; 16:117–127. 22. Srinivasan, V, Waterhouse, P, Whitworth, J. Mineral Trioxide Aggregate in pediatric dentistry. Int J of Pediatr Dent. 2009; 19:34–37. 23. Stephen, HY Wei. Pediatric Dentistry: Total Patient Care. Philadelphia: Lea and Febiger; 1988. 24. Stewart, RE, Barber, TK, Troutman, KC, et al. Pediatric Dentistry: Scientific Foundations and Clinical Practice. St. Louis: Mosby; 1982. 25. Van Hassell, HJ, Natkin, E. Induction of root



end closure. J Dent Child. 1970; 37:57. 26. White, SC, Pharoah, MJ. Oral Radiology: Principles and Interpretation, 5th edn. New Delhi: Elsevier; 2004.



CHAPTER 25



Crowns in Pediatric Dentistry J Jeevarathan, MS Muthu and N Sivakumar



CHAPTER OUTLINE Introduction Classification Indications Contraindications Advantages Armamentarium Tooth preparation Crown selection Crown seating Adapting the crown Finishing Cementation Clinical modifications Full coronal restoration for anterior teeth Conclusion Suggested Reading Self-assessment Questions



“You have Ferrari in cars, Harley-Davidson in bikes and Stainless Steel Crowns in Pediatric Dentistry.”



Introduction Dental caries is one of the most common infections affecting the teeth of children. Restoration of these is very important so as to re-establish the lost function like esthetics, mastication and speech. The restoration that is placed should have the same lifespan as that remaining for the



tooth and should also protect the remaining tooth structure. Even though the primary teeth are a temporary dentition with known life expectancies, the clinician should select the best choice of restorative materials. The most commonly used materials are amalgam and composite resins which require a reasonably intact tooth with sufficient structure to support the material. This requirement is more frequently found in the permanent dentition than in the deciduous dentition. In the small deciduous teeth, neglected caries can destroy the tooth integrity faster than that in the larger permanent teeth and moreover the deciduous pulp is larger than the permanent pulp in relation to its dentin and enamel envelope. In these situations, the clinician’s best choice is stainless steel crowns, which were introduced by Humphrey in the year 1950. These stainless steel crowns are semipermanent restorations used to overcome a wide range of problems encountered in pediatric dentistry on both primary and permanent teeth.



Classification Based on composition Prefabricated metal crowns can be divided into permanent and temporary crowns for primary teeth. The prefabricated metal crowns are made from stainless steel or nickel-base alloys and the temporary crowns are made of aluminum and tin-base alloys. 1. Stainless steel crown (Unitek and Rocky Mountain crowns) (Fig. 25.1): These alloys are made of authentic steels with the nominal composition of 17–19% chromium, 9–13% nickel and 0.08–0.12% carbon. These alloys have good formability and ductility necessary for the clinical adaptation of crowns and have adequate hardness and wear resistance to resist opposing occlusal forces.



FIGURE 25.1



Stainless steel crowns.



2. Nickel-base crowns (Ion Ni-chro from 3M) (Fig. 25.2): These



are an Iconel type of alloy with the following nominal composition—76% nickel, 15.5% chromium, 8% iron, 0.04% carbon and 0.35% manganese. These crowns are strain hardened during manufacturing and have formability and ductility so necessary for the clinical manipulation.



FIGURE 25.2



Uncontoured/untrimmed crowns.



3. Tin-base crowns: They have a nominal composition of 96% of tin and 4% of silver. They are readily adaptable but are not as permanent as above crowns. 4. Aluminum-base crowns: These are made of aluminum alloys containing 1.2% manganese, 10% magnesium, 0.7% iron, 0.3% silicon and 0.25% copper. Even though they are readily adaptable, their clinical durability is less.



Based on morphology 1. Uncontoured/untrimmed crowns (Unitek) (Fig. 25.2): They were first developed crowns whose sides are straight and longer. Nowadays, they are used only in deep interproximal



lesions. 2. Pretrimmed crowns (Unitek stainless steel crowns, 3M, De novo crowns): The crowns are of normal length of the tooth, sides are straight but shorter when compared to untrimmed crowns. They are not contoured. Need for trimming is minimal when compared to untrimmed crowns. Contouring and crimping is required. 3. Precontoured crowns (Ni-chro ion crowns and Unitek): They are similar to pretrimmed crowns in height of the crowns but they are more rounded in the gingival margin and they simulate the normal appearance of the tooth (Fig. 25.3).



FIGURE 25.3



Nickel-base crowns.



Clinical availability The crowns are available clinically in different sizes for both primary and permanent molar teeth individually. They are available from size 2 to 7.



Indications 1. Extensive carious lesions: a. Insufficient tooth surface to retain an amalgam or composite resin filling. b. Tooth with caries involving three or more surfaces (Fig. 25.4).



Indications for SS crowns— multisurface caries. FIGURE 25.4



c. Children with rampant caries d. As a preventive measure in children who are in high caries risk group like handicapped children, etc. 2. In teeth with developmental defects like amelogenesis imperfecta (Fig. 25.5), dentinogenesis imperfecta to prevent the loss of vertical dimension.



FIGURE 25.5



imperfecta.



Indications for SS crowns—amelogenesis



3. Following pulpal therapy in primary and young permanent teeth where full crown is contraindicated (Figs. 25.6, 25.7).



Indications for SS crowns—post-endodontic restoration (pulpotomy). FIGURE 25.6



Indications for SS crowns—post-endodontic restoration (pulpectomy). FIGURE 25.7



4. Severe bruxism patients where there will be excessive wear of primary dentition and on permanent teeth to prevent damage to its occlusal surface. 5. As abutments for: a. Space maintainer when indicated (Fig. 25.8)



Indications for SS crowns— abutments for space maintainers. FIGURE 25.8



b. Distal shoe appliance c. Fixed habit breaking appliances d. Fixed prosthetic appliances e. Extracoronal restoration in abutments for removable prosthesis. 6. In fractured primary anterior teeth. 7. Anterior single tooth crossbite correction.



Contraindications 1. Imminent exfoliating primary teeth. 2. In anterior teeth where esthetics is of more concern. 3. Patients allergic to nickel.



Advantages Stainless steel crowns have two major advantages over an amalgam restoration. They are: 1. Stainless steel crowns are superior in longevity when compared to the class-II amalgam restoration as they can withstand fracture, and need not be repeated. Braff proved this in 1975, which reviewed 75 patients to compare success rates of class-II amalgam restoration and stainless steel crowns. Nearly 88.7% of amalgam restoration needed retreatment whereas only 30.03% of stainless steel crowns needed retreatment. Economics and time favor stainless steel crowns. Dawson et al in 1981 and Einwag and Dunninger in 1996 have said that stainless steel crowns have longer lifespan than multisurface amalgam restorations. Levering and Messer in 1988 studied the lifespan of stainless steel crowns and class-II restorations. Crowns placed in children 4 years of age and younger have a success rate twice that of amalgam for each year up to 10 years of service. This is also apparent in children older than 4 years. When a choice exists between a class-II



amalgam and a crown in a child younger than 4 years, the likelihood of failure of amalgam is twice that of stainless steel crowns. Mink and Bennet in 1968 have said that stainless steel crowns are much better in long term for children with high caries rate because the possibility of recurrent caries is eliminated. 2. Stainless steel crowns were found to be more cost-effective when compared to multisurface amalgam restorations. In 1988, Messer and Levering have shown in their cost comparison studies that amalgam replaced by crown is more costlier than a direct crown on the tooth initially. 3. According to Full et al 1974, ease of delivery, less chair-side time and economy of cost are other advantages.



Armamentarium (Fig. 25.9): Tooth preparation Burs:



FIGURE 25.9 Armamentarium.



• 69 or 169 liter bur for tooth reduction • No. 1/2 round bur for marking on the stainless steel crown.



Crown adaptation Pliers: • The no. 114 (wide) and 115 (medium) Johnson pliers are used for general contouring of the stainless steel crown. • Crimper no. 800–417 is used to crimp the last 1–2 mm of the gingival margin. • The Abel ball-and-socket plier no. 112 can be used to produce contact points. • Gordon plier no. 137 is used to contour the cervical margin. • Crown and bridge scissors.



Tooth Preparation (Fig. 25.10) Before starting a tooth preparation, anesthesia should be given and occlusal assessment should be done. The three steps in tooth preparation are occlusal, proximal reduction and roundening of line angles.



FIGURE 25.10 Stainless steel crown preparation.



Occlusal preparation According to Nash in 1981, 69 or 169 liter bur is used to reduce the occlusal surface by 1.5 to 2.0 mm following the cuspal outline and maintaining the original contour of the cusp. The amount of occlusal reduction varies with authors, but the above is indicated for the present clinically available nickel—chromium crowns. Humphrey in 1950 recommended that the cusp be reduced, if necessary and the four sides of the tooth were reduced but preserving as much tooth structure as possible. Rapp in 1966 has given a simplified tooth preparation for stainless steel crowns where the height of the tooth is reduced such that only 4 mm of tooth structure is available from gingival margin. Mink and Bennet in 1968 suggested a uniform reduction of 1 to 1.5 mm of occlusal reduction after making a 1 mm groove with the bur for guidance. Troutman in 1976 said that a uniform occlusal reduction of 1 mm is sufficient. He reduced the supragingival bulge, extending 0.5 mm below the gingival crest. Kennedy in 1976 had said that the occlusal surface can be reduced to 1.5 to 2 mm. Occlusal preparation is done before the proximal reduction, as the chances of gingival bleeding due to proximal reduction can be a hindrance in diagnosing the bleeding from the pulp.



Proximal reduction Wooden wedges are used in the interproximal embrasures to reduce the risk of damage to the adjacent tooth enamel. The bur is swept buccolingually across the proximal surface, beginning at the marginal ridge and at an angle slightly convergent to the occlusal surface. The bur should follow a path tangential to the proximal surface and the depth of the slice should be sufficient to break the contact with the adjacent teeth and produce a knife-edge finish line. Care must be taken to extend the preparation gingivally far enough to avoid the development of a ledge, which would make it difficult to seat the crown properly. The sufficient reduction is checked by passing an explorer through the interproximal aspect at the gingival portion.



Roundening line angles All line angles created by the occlusal preparation and proximal reductions are rounded. Moving the bur at an angle of 45° rounds the occlusobuccal and lingual surfaces. The other line angles are slightly rounded into the proximal preparation to avoid any sharp margins.



Crown Selection (Fig. 25.11) The three main considerations in selecting the crown are adequate— mesiodistal diameter, light resistance to seating and proper occlusal height. The correct size crown may be selected:



FIGURE 25.11 Crown selection.



1. Prior to tooth preparation by measuring the mesiodistal dimension of the tooth to be restored using a Boley gauge



2. It can also be selected after the preparation of the tooth 3. Trial and error method. Crowns are manufactured such that the length is proportional to the mesiodistal and circumferential measurements. It is generally advisable to select a medium-size crown such as a no. 4 and progress to a larger or a smaller crown as required. A crown selected should be somewhat larger than the tooth to which it is being adapted. The most common sizes used are the size 4 or 5. The correct crown will approximate the mesiodistal width and the circumference of the tooth, having been placed with some resistance and yet completely enveloping the tooth at the cervical aspect.



Crown Seating The selected crown is placed on the lingual side and rotated to the buccal side. The crown should fit loosely with 2–3 mm of excess on the gingival side. The marking should be done on the gingival margin with a scaler or points can be made with the no. ½ slow-speed round bur. From this mark, the excess length of the crown beyond 1 mm can be cut using scissors or trimming using heatless stone. A properlyseated crown will correspond to the marginal ridge height of the adjacent teeth and is not rotated on the tooth.



Adapting the Crown As the nickel—chromium crowns are pretrimmed and contoured, only few adjustments are needed. Adaptation is very important to the gingival health of the supporting tooth. Poorly-adapted crowns will serve as a collection area for bacteria and can cause recurrent caries. The various pliers used for this are no. 114 (wide) and 115 (medium) Johnson pliers to contour the gingival edges to tighten the fit of the crown. Nowadays, the crown crimper no. 800–417 is used to crimp the last 1–2 mm of the gingival margin. This may produce a scalloped margin, which can be smoothened by drawing the crown while squeezing the plier. The Abel ball-and-socket plier can be used to



produce contact points. Gordon plier no. 137 is used to contour the cervical margin. During this time: a. The crown must snap into the place, which cannot be removed with finger pressure. b. It must fit snugly against the tooth. c. There is no blanching or cutting of gingiva. d. The margin of the crown is 1 mm into the sulcus and should closely engage the tooth structure on all surfaces. e. The occlusion should be normal without any interference and the contact with the adjacent tooth, if present, should be reestablished. In 1984, Spedding gave two principles for obtaining optimal adaptation of stainless steel crowns to primary molars. They are: 1. Crown length 2. Shape of crown’s margin As said earlier, the crown margin should just be into the sulcus engaging the undercut. The outline of the crown margin should follow the gingival margin of the tooth. For the second primary molar, it should resemble smiles on the buccal and lingual margins. The buccal marginal gingiva of the first primary molar has a different outline due to the mesiobuccal bulge. It will be like the letter S that is stretched out. The contour on the lingual gingival margin of all first primary molar resembles smiles. The proximal contour of all primary molars resembles frown, as the occlusogingival height is shortest at midpoint buccolingually. While trimming the crown, the shape of the margin should be kept in mind. Contouring and crimping the crown margin help to get a tight fit around the crown. A tight marginal fit aids in mechanical retention of the crown, protection of the cement from oral fluids and maintenance of gingival health.



Finishing After adaptation, the crown margin should be trimmed using green stone in counterclockwise direction at 45° angle. This will help to achieve what is called a minicrimp. Then the rubber wheel is used to smoothen it after which the crown is polished using Tripoli/iron oxide.



Cementation Selection of the cement is mainly depends on the status of the pulp. While cementing a crown on a vital tooth cavity, varnish should be routinely used. The most commonly used cement is the glass ionomer cement. Mathewson in 1975 said that the retention of stainless steel crowns is due to cementing medium used rather than the mechanical adaptation. Savide et al in 1979 have done a study to compare the retention capabilities in five different types of tooth preparation. He concluded that the non-cemented preparations demonstrated only little mechanical retention but that following cementation the retentive values of all preparations improved greatly. After cementation, the excess cement in the interproximal surfaces is removed using the floss with a knot and drawing it through. Cement should be expressed around all the crown margins; this ensures that all the spaces between crown and tooth have been completely filled by the cement.



Clinical Modifications Adjacent stainless steel crowns (Nash, 1981) The various steps to be followed are to reduce the occlusal reduction of one tooth completely before reducing the other. If both the teeth are reduced side-by-side, there are chances of under reduction. There should be sufficient reduction on the proximal aspect producing approximately 1.5 mm at the gingival level. Both crowns should be trimmed, contoured and prepared for cementation simultaneously. It is advisable to place the posterior crown first. The



sequence of cementation of crowns should follow the same sequence as that when the crowns were placed for final trial fitting. While establishing the broad contact point, Howe plier no. 110 is used (Fig. 25.12).



FIGURE 25.12 Adjacent stainless steel crowns.



Adjacent stainless steel and class-II amalgam restoration When a stainless steel crown and an adjacent class-II amalgam restoration are to be done in one appointment, first the stainless steel crown is completed and then, the class-II restoration should be done. The stainless steel crown is used as a guide in reproducing the anatomy and morphology of the silver amalgam restoration.



Adjacent stainless steel crowns with arch length loss (Mc Evoy, 1977) In cases where there is space loss due to long-standing caries in the



adjacent teeth, the crown should be reduced to a smaller size. One crown of normal size can be used and the other crown should be smaller. For this a primary maxillary first molar from the opposite side will fit a primary mandibular first molar. This is because the maxillary first molar is narrower in size. Howe pliers can be used to flatten the contacts of the crowns and for the alignment of the adjacent crown while cementation.



Adjusting tooth circumferences (Fig. 25.13) (Mink and Hill, 1971) Undersized tooth or oversized steel crown: The oversized crown is placed on the tooth and cut is done either on the buccal or lingual surface using the scissors. Squeeze the crown to overlap the cut edges and retry the crown on the tooth. Adapt the crown, check the extension of the crown margin into the gingival area and then scratch a line on the overlapped edges. This will help to reposition the edges, if they are displaced while removing. Spot weld the overlapped edges, solder the edges and polish them.



FIGURE 25.13 Modifications of stainless steel crowns.



Oversized tooth or undersized steel crown: If the crown available is undersize then, cut on the buccal or lingual or both the sides. Try the crown on to the tooth. Use an orthodontic 0.004 inch thickness band material to weld it over the cut part on one side and the other side is left alone. Trim the excess band near the gingival surface. Use no. 114 plier to adapt the band material to the crown contour. Retry the crown and scratch the band material where it overlaps the crown. Remove the crown and reposition the scratched part and spot-weld, solder the edges and polish them. Adjusting crown length (Mink and Hill, 1971): The crown should extend just 1 mm into the gingival sulcus. Excess will result in blanching of the gingiva. In cases of deep carious lesions, the crown will be short to cover this area and provide adequate seal. This can be overcome by welding a small strip of 0.004 inch band material to the crown in the area of inadequacy. The band material is trimmed and adapted to the appropriate length and contour. The margin between the band and the crown is reduced and blended with a rubber wheel and polished with fine abrasives, leaving a smooth almost imperceptible juncture. Decrease in tooth circumference (Nash, 1981): In cases of proximal caries, the adjacent teeth usually drift and result in loss of space. When this occurs the crown required to fit will be too wide mesiodistally to be placed or when seated it will be rotated. A crown selected to fit the available mesiodistal space will be too small in circumference. In this case, a larger crown is selected and by grasping the marginal ridge of the crown with Howe pliers and crown is squeezed, such that mesiodistal size is reduced. Care must be taken to prevent the collapse of the walls by placing an insert that will maintain the crown shape.



Full Coronal Restoration for Anterior Teeth Full coronal restoration of carious primary incisors may be indicated



in/when: 1. Multisurface caries 2. Incisal edge is involved 3. Extensive cervical decalcification 4. Pulpal therapy is indicated 5. High caries risk patients 6. Child behavior makes moisture control difficult for class-III restoration. The crowns that are available for restoring primary incisors can be placed into two categories: 1. Those that are preformed and held on to the tooth by luting cement: a. Stainless steel crowns b. Facial cutout stainless steel crowns c. Resin-veneered stainless steel crowns d. Polycarbonate crowns 2. Those that are bonded to the tooth: a. Strip crowns/celluloid crowns b. Pedo jacket crowns c. New millennium crowns d. Art glass crowns Crowns of many types are available for maxillary incisors and canines but no such crowns are available for mandibular incisors.



Stainless steel crowns (anterior) Preformed stainless steel crowns are the most durable and reliable for restoring severely fractured primary incisors. Croll described that stainless steel crowns are easy to place, fracture-proof, wear resistant and attached firmly to the tooth until exfoliation. The main disadvantage is the unsightly silver metallic appearance. It is the



fastest crown that can be placed and a well-crimped cemented crown is very retentive. As the population becomes more conscious of esthetics, these stainless steel crowns have become less desirable for anterior teeth (Fig. 25.14).



FIGURE 25.14 Anterior stainless steel crowns.



Facial cutout stainless steel crowns This is otherwise referred to as ‘open-face steel crown’ in which a window preparation is done on to the cemented stainless steel crown and over which composite material is placed. This technique is a dramatic improvement over the plain metallic appearance of stainless steel crown. The disadvantage of this crown is that some amount of metal margins is visible. Placement of this crown takes a longer time as it is a two-step procedure: (i) crown placement, and (ii) composite placement. Complete moisture control is necessary during composite



placement. The durability is good like steel crowns but the facings can fracture.



Resin-veneered stainless steel crowns (Fig. 25.15) Prefabricated resin-veneered crowns are available in which the composite resin and thermoplastics are bound to the metal. The advantages of these crowns are that an esthetically pleasing result can be obtained with relatively short operating time but occasionally the veneer can fracture. Additionally when moisture control is difficult and the resin crowns cannot be placed, it is a good alternative. Other problems with these pre-veneered crowns are that crimping can fracture veneers and they are expensive. The fractured veneers can be repaired but their durability is not long lasting. There are 4 brands of this prefabricated stainless steel crowns available. They are Kindercrowns, Whiter Biter crowns–II, Nusmile and Cheng crowns. More recently, a new resin-veneered Dura-crown is introduced which has labial gingival margin crimped and resin adapted to the gingival edge of the anterior aspect of the crown.



FIGURE 25.15 Veneered stainless steel crowns.



Polycarbonate crowns (Fig. 25.16) Polycarbonate crowns are heat-moulded acrylic resins used to restore anterior teeth. These do not resist strong abrasive forces, leading to occasional fracture and debonding or dislodgement. These are contraindicated:



FIGURE 25.16 Polycarbonate crowns.



• When there is inadequate spacing between teeth • Crowding of anterior • Deep overbite is present • Bruxism habit • When there is evidence of abrasion in the anterior teeth.



There are three clinical problems with these crowns. They may fracture alone or along with the cement or they may dislodge leaving the cementing medium on the tooth. These can be corrected by placement of cervical rotation groove in the tooth and a lingual vent in the crown.



Strip crowns (Fig. 25.17) Celluloid crowns are a popular method of restoring primary anterior teeth. These crowns provide superior esthetics than other forms of anterior coronal coverage restorations and the ease of repair, if the crown gets chipped or fractured. The procedure is very technique sensitive, which includes tooth preparation, good moisture and hemorrhage control, adhesive application and placement of crowns filled with resin composite (Fig. 25.18). This crown relies on adhesion to dentin and enamel for retention. If a lot of tooth structure is absent, the longevity of the crown is jeopardized.



FIGURE 25.17 Strip crowns.



FIGURE 25.18 Strip crowns technique.



Tooth preparation: The tooth preparation includes 1 mm on the incisal and proximal surfaces, which taper to follow the pulpal outline with shoulder as the finish line. Reduce the labial and lingual surfaces approximately 1/4 mm to remove aprismatic enamel. Finish the gingival margin subgingivally to a feather edge preparation. Avoid removing excessive amounts of enamel on the labial and lingual surfaces. Select a crown and try in the prepared tooth. The crown is pierced with a sharp explorer at the mesial or distal incisal angle to create a core vent for the escape of any air bubbles entrapped in the crown. Care should be taken not to damage the proximal seams of the crown. Following vent preparation, sharp-curved scissors should be used to trim the crown gingival margins. The crown is filled with the resin material and inserted on the tooth. The excess material is removed with an explorer and polymerized. After this the strip crown is peeled off with a sharp, hand-held instrument such as cleoid/discoid carver (Fig. 25.18A-C).



Pedo jacket crowns This is also bonded to the tooth and is handled similarly to a celluloid crown; only the jacket is made of a tooth-colored copolyester material. The crown is filled with resin material and left on the tooth after polymerization instead of being removed as the celluloid crown form.



New millennium crowns This crown is similar in form to the pedo jacket and strip crown except that it is made of a laboratory-enhanced composite resin material. Like other crowns, this is also filled with resin material and bonded to the tooth.



Art glass crowns



Art glass is the current material advocated for restoring primary teeth. It contains bifunctional and new multifunctional methacrylates forming a cross-linked three-dimensional polymer. Even though it has less filler content compared to conventional composites, they provide better durability and esthetics than composite strip crowns. They are available only in one shade and 6 sizes for central, lateral and cuspid teeth.



CONCLUSION Full coronal restorations always offer an outstanding alternative to any restorative material used in primary teeth. Stainless steel crowns are cost effective, provide increased durability and longevity, less chair-side time and above all their full coverage prevent any future development of new caries. Strong consideration should be given to the use of stainless steel crowns in children whenever possible.



SELF-ASSESSMENT QUESTIONS Essay Type Stainless steel crowns.



Short Notes 1. Classification of stainless steel crowns 2. Indications and advantages of stainless steel crowns 3. Strip crowns 4. Tooth preparation for stainless steel crown 5. Bonded full coronal restoration for anterior teeth 6. Resin-veneered stainless steel crowns



SUGGESTED READING



1. Braff, MH. A comparison between stainless steel crowns and multisurface amalgams in primary molars. J Dent Child. 1975; 42:74. 2. Croll, TP, Epstein, DW, Castaldi, CR. Marginal adaptation of stainless steel crowns. Pediatr Dent. 2003; 25:2452–2490. 3. Dawson, LR, Simon, JF, Taylor, PP. Use of amalgam and stainless steel restoration for primary molars. J Dent Child. 1981; 48:420–422. 4. Einwag, J, Dunninger, P. Stainless steel crown versus multisurface amalgam restoration: an 8-year longitudinal study. Quintess Int. 1996; 22:321–323. 5. Full, CA, Walker, JD, Pinkham, JR. Stainless steel crown for deciduous molars. J Am Dent Assoc. 1974; 89:360–364. 6. Grosso, FC. Primary anterior strip crowns: a new approach. J Pedol. 1987; 1:182–186. 7. Lee, JK. Restoration of primary anterior teeth: review of the literature. Pediatr Dent. 2002; 24:506–510. 8. Levering, NJ, Messer, LB. The durability of primary molar restorations—III: costs associated with placement and replacement. Pediatr Dent. 1988; 10:86–93. 9. McEvoy, SA. Approximating stainless steel crowns in space loss quadrants. J Dent Child.



1977; 44:105. 10. Messer, LB, Levering, NJ. The durability of primary molar restorations—II: observations and predictions of success of stainless steel crowns. Pediatr Dent. 1988; 10:81–85. 11. Mink, JR, Hill, CJ. Modification of the stainless steel crown for primary teeth. J Dent Child. 1971. 12. Nash, DA. The nickel-chromium fro restoring posterior primary teeth. J Am Dent Assc. 1981; 102:44–49. 13. Seale, SN. The use of stainless steel crowns. Pediatr Dent. 2002; 24:501–505. 14. Spedding, RH. Two principles for improving the adaptation of stainless steel crowns to primary molars. Dent Clin North Am. 1984; 28:157–175. 15. Waggoner, WF. Restoring primary anterior teeth. Pediatr Dent. 2002; 24:511–516.



SECTION VII



Injuries to the Teeth: Prevention and its Management OUTLINE Chapter 26: Traumatic Injuries of Teeth and Supporting Structures Chapter 27: Sports Dentistry for Children and Adolescents



CHAPTER 26



Traumatic Injuries of Teeth and Supporting Structures N Sivakumar and MS Muthu



CHAPTER OUTLINE Introduction Etiology of Trauma to Teeth and Supporting Structures Prevalence of injuries Factors affecting dental trauma Complications of dental injuries to primary teeth Complications of dental injuries to permanent teeth History Taking and Examination of a Traumatized Patient History of trauma Clinical examination Investigations Classification of Injuries to Teeth and Supporting Structures Numerical classification Descriptive classification Treatment Planning Soft tissue Primary dentition Crown fractures Permanent dentition Splinting Instructions to parents First-aid information to public Preventive measures Conclusion Suggested Reading



Self-assessment Questions



“Never underestimate a child’s ability to get into more trouble.” —Martin Mull



Introduction Injury to a young child’s teeth and face is a traumatic experience for the child and the parents. It is not only traumatic in the physical sense but also in an emotional and psychological sense. Under such circumstances, the distress suffered by the child and parent must be managed before the damaged tissues can be evaluated. In addition, other injuries of more significance should be ruled out prior to dental treatment. Quality and timeliness of initial care is the need of the hour and importance of endodontic considerations for the injured teeth is borne in mind. A good history of the event, as well as medical history, must be taken in concert with a clinical evaluation of the child’s neurologic status and physical assessment.



Etiology of Trauma to Teeth and Supporting Structures The maxillary incisors are the most frequently injured teeth in the primary and permanent dentition. Primary or permanent molars are rarely injured and when injury occurs it is usually due to indirect trauma (i.e. blows to the underside of the chin causing the mandible to close forcefully against the maxilla). Many of the accidents that affect the primary teeth occur during the first 3 years. During this period of growth and development, the child is gradually moving from a state of total dependence with respect to movement to one of independence and stability as he or she learns to sit up, bend over, crawl, kneel,



stand, walk and run. Any or all of these stages of motor development brings with it the hazard of accidental injury. In the primary dentition, luxation injuries (described later) are more common than fractures due to the cancellous nature of the bone in young children and to the lower root/crown ratio in comparison with that of permanent teeth. Falls during play activities account for most of the injuries to young permanent teeth. Children engaging in contact sports are at greatest risk for dental injury. In the teenage years, automobile accidents cause a significant number of dental injuries primarily when the occupants are not wearing the seat belts. Children with class II div. 1 malocclusion are more prone for injuries because of the prominent maxillary incisors. In children with seizures, a sudden episode can cause a fall and lead to injuries to permanent teeth. In contrast to the primary dentition, permanent teeth suffer crown fractures more frequently than luxation injuries. The dense alveolar bone is responsible for this phenomenon. Another serious but often overlooked cause of dental injuries is due to child abuse. Almost 50% of the children who are abused suffer injuries to the head and neck. The common etiological factors for trauma to the teeth and the supporting structures are given in Box 26.1. Box 26.1



Common etiological factors for



trauma to teeth and supporting structures • Falls as infant or toddler • Falls and collisions in school age • Bicycle, motorcycle injuries • Contact sports • Road traffic accidents • Mental retardation • Epilepsy • Non-accidental injuries (child abuse)



Prevalence of Injuries The exact number of children who sustain injuries to their teeth each year is unknown. However, the incidence judged by the number of such injuries seen in clinics and private dental offices, must be high. Studies in different countries have reported a wide range of prevalence for different kind of injuries. There is voluminous amount of literature available in this context and describing them is out of the scope of this chapter. A brief summary of the prevalence of injuries to the teeth and supporting structures is described below. • Trauma to primary dentition is common, many times unnoticed as they are minor and a child who is involved in busy play or other activity may not remember minor injuries and report to parents. • Most usual age of occurrence is 1 to 2 years as they try to stand up and walk because of lack of control on motor movements. • 28% of 5-year olds would have experienced some kind of injury to the teeth and supporting structures. • Most injuries are luxation type as bone is resilient in primary dentition (injury is primarily to the supporting structures). • For injuries of permanent dentition, school age is the common age. • 20% of 12-year-olds had experienced some kind of trauma. • More of crown fractures compared to root fractures. • Boys to girls ratio is said to be 2:1 but not many studies supporting this fact are available. The prevalence may be more in boys because of their physical activity. • Prevalence of injuries is more in maxillary central incisors followed by maxillary laterals, mandibular centrals and laterals.



Factors Affecting Dental Trauma Predisposing factors for dental trauma



• Age of the child, with children of 1.5 years due to falls when they learn to stand and walk because of lack of development of neuromuscular coordination and 8–11 years, which is school age with increased physical activity and contact sports. • Occlusion with increased overjet (greater than 4 mm) is termed as accident prone profile as seen in class II division 1 and class I type 2 malocclusion. • Developmental defects of teeth and dental caries which will weaken the tooth structure, in turn affecting the resistance of tooth to fracture. • Mental retardation and epilepsy might result in falls of children resulting in trauma to the teeth.



Mechanical factors affecting dental trauma Mechanical factors affecting dental trauma are given in Box 26.2. Box 26.2



Mechanical factors affecting dental



trauma • Shape of the impacting object • Velocity of the impacting object • Mass of the impacting object • Direction of impact • Type of impact—direct or indirect



The type of damage varies with the shape of the impacting object. If the object is sharp, the energy from this spreads only to limited area, which favors mostly crown fractures with minimum displacement. On the other hand, if the object is blunt, the energy spreads from the crown region to the apical region causing luxation. The energy of impact depends on the mass and velocity of the



striking object. The impacting object can be with high velocity and low mass like gunshot injury or low velocity and high mass like striking the tooth against the ground. Usually the low velocity impact causes more damage to the supporting structures where as tooth fractures are less common. In high velocity impact, crown fractures are more common than injury to supporting structures, as the energy is not transmitted to them. The fracture line of the tooth depends on the direction from which the impact occurs. If the impact is from frontal aspect then the fractures can be horizontal, horizontal fractures at the neck of the tooth, oblique crown–root fractures or oblique root fractures. If the impact is in the axial direction of tooth, it may result in luxation injuries. Direct trauma is one in which the tooth comes in direct impact with the striking object. In indirect trauma, the tooth does not come in direct contact but the force transmitted from the impact will injure the tooth. Usually, direct trauma causes crown or crown–root fracture in the anterior tooth whereas indirect trauma causes fractures in the posterior teeth or even jaw fractures. The example of direct trauma is tooth struck against the table, whereas for indirect trauma it is a fall causing injury to chin, which could cause fracture of tooth and the condyle. Direct trauma: It occurs when the tooth itself is struck, e.g. against a table or chair. Indirect trauma: It is seen when the lower dental arch is forcefully closed against the upper as by a blow to the chin in a fight or a fall.



Complications of Dental Injuries to Primary Teeth The sequelae of dental trauma on primary teeth can vary from no sequelae to severe financial burden it causes to the family involved. They are: • Different injuries of teeth involving crown, root or whole tooth as described later • Failure to continue eruption



• Color changes or discoloration—slight, moderate or severe which can be transient or permanent • Infection and abscess • Loss of space in the dental arch • Ankylosis • Injury to developing permanent tooth • Abnormal exfoliation • Financial costs for maintaining dental arch space or restoration.



Sequelae of trauma to primary teeth on developing permanent teeth (Fig. 26.1) The primary teeth because of their close proximity to the permanent tooth buds, any injury to it can be transmitted to the permanent tooth buds. The damage to the permanent tooth has varied clinical presentations, depending on the timing and the extent of the injury to the primary tooth and subsequently to the permanent tooth. These clinical presentations are enumerated in Box 26.3. Box 26.3



Various clinical presentations for



damage of permanent tooth 1. White or yellow-brown discoloration of enamel—Turner’s tooth (hypocalcification, due to pH changes because of periapical inflammation) 2. White or yellow-brown discoloration enamel hypoplasia (horizontal indentation encircling tooth, defective enamel matrix formation, result of intrusion at age 2) 3. Crown dilaceration (3% cases, when 1/2 crown is formed) 4. Odontoma-like malformations 5. Root dilaceration or lateral root angulation 6. Vestibular root angulation 7. Root duplication or bifid root



8. Partial or complete arrest of root formation 9. Sequestration of permanent tooth germs 10. Disturbance in eruption 11. Partial reduplication 12. Disturbances in eruption



FIGURE 26.1 (A) Diagram showing the possibility of permanent tooth germ damage due to injury to the primary incisor. (B) Radiograph showing dilacerated permanent incisor crown due to injury to the primary dentition.



Hence, it is essential that the parents should be warned of the possibility of damage to the permanent teeth, if the child has suffered trauma to the primary dentition.



Complications of Dental Injuries to Permanent Teeth Injury to the permanent teeth can lead to any of the following complications: • Color changes • Infection and abscess • Loss of space in the dental arch • Loss of alveolar bone support • Ankylosis • Resorption of root structure • Abnormal root development • Financial costs of potential root canal, periodontal, restorative or prosthetic therapy.



History Taking and Examination for Traumatized Patient Visual examination or inspection of the patient starts the moment, the patient enters the clinic. The general condition of the patient gives an idea about any systemic, neurological involvement.



History of Trauma



Obtaining adequate medical and dental history is essential to arrive at a proper diagnosis and determine appropriate treatment measures. The examining dentist should be alert because, with the confusion of a young injured child entering the office and disrupting the day’s schedule, the potential to forget to gather important historical information is great. Hence, a detailed trauma assessment form should be used to record data thoroughly. In history taking, when, where and how of the injury is to be considered seriously. This information, the authors would like to call it as ‘the trauma triad’—a triad of three important questions with reference to the episode of trauma (Box 26.4). Box 26.4



The trauma triad



• WHEN the accident happened. This gives an indication of whether the treatment was sought immediately or not. Time interval between injury and treatment may significantly affect prognosis in case of pulp exposure, displacement and avulsion type of injuries. Delay in seeking advice also may give an indication of neglect on the child by the caretaker. • WHERE it happened. The place of injury, whether a play ground which is not clean, classroom or home where the surroundings may be clean. This is done to consider tetanus protection and also medicolegal implications, if it is involving any other places because of accidents, assaults, etc. and also to retrieve the teeth or their fragments form the site of injury. • HOW the accident happened. This may give an indication of other injuries, like soft tissue injuries, etc. Consideration to be given for non-accidental injury (see later) and also for medicolegal implications.



History of previous trauma also should be taken into consideration, which gives an idea of whether the child is prone for frequent injuries.



Medical history Routine data on the patient’s general health is essential before attempting to treat the dental injury. Questioning about the following conditions is mandatory to obtain a proper medical history: • Bleeding disorders • Cardiac disease, rheumatic fever • Epilepsy • Allergies—specifically to penicillin • Anti-tetanus protection—date of booster • Did trauma cause loss of consciousness, amnesia, drowsiness, vomiting or headache? • History of taking any medication, to avoid overdosage of some medicines being already taken.



Initial neurologic assessment Neurological assessment is the most important part of the evaluation of the child with traumatic injuries, which should be done before any prolonged examination and dental treatment is initiated. Croll et al pointed out that a triad of symptoms, viz. irritability, vomiting and lethargy is seen in children with head injuries, with or without loss of consciousness. These symptoms usually reduce within 48 to 72 hours. The following things are to be done for appropriate neurologic assessment: • Check any unusual communication or motor functions • Look for normal respiration without obstruction of the airway or danger of aspiration • Replant avulsed teeth as indicated (if the traumatic episode involves avulsion) • Obtain a medical history and information on the accident • Determine blood pressure and pulse • Examine for rhinorrhea or otorrhea • Evaluate function of the eyes—is diplopia or nystagmus



apparent? Are pupillary activity and movement of the eyes normal? • Evaluate movement of the neck for pain or limitation • Examine the sensitivity of the facial skin for paresthesia or anesthesia • Confirm normal vocal functions • Confirm patient’s ability to protrude the tongue • Confirm hearing (tinnitus or vertigo) • Evaluate sense of smell • Ensure follow-up evaluation



Non-accidental injuries (NAI) or child abuse and neglect These are not injuries due to accidents, but inflicted by people who are responsible for the care of the children for different reasons. A child is considered to be abused if he or she is treated in a way that is unacceptable in a given culture at a given time. Reported cases are far less in number than the actual numbers and it is now recognized as an international issue with widespread prevalence. Identification of nonaccidental injuries due to child abuse and neglect, its management and the dentist’s role, etc. are discussed in Chapter 45 on Child Abuse and Neglect.



Past dental history Information regarding past dental history will reveal history of any previous trauma, the frequency of dental visits and the type of treatment they undertook. The type of anesthetics used and drugs prescribed during the treatment can be determined from their records. The cooperativeness of the patient and any untoward complications, if occurred can be noted from their records.



Clinical Examination Once appropriate medical and dental history is obtained, the dentist



can begin the clinical examination. It is very tempting to focus immediately on a fractured or displaced tooth and thus miss other important injuries. Hence a disciplined approach to complete a clinical examination is needed to arrive at an appropriate diagnosis. Assessment of the behavior of child and parental attitudes towards the child and dentistry should a part of the routine before examining any child.



Extraoral examination • Assessment of any asymmetry of the face due to injuries to facial skeleton or due to any swelling. • Palpation of facial skeleton for any noticeable fractures, deviations, etc. • Observation of symptoms and signs that gives an idea of fractures of facial bones. • Recording of any extraoral wounds/bruising like lacerations, contusions, and abrasions. • Recording of paresthesia of any part of the face in case of suspicion of nerve damage.



Intraoral examination • Evaluation of any bleeding sites, swellings, and lacerations of the oral mucosa or gingival tissues. In case of lacerations, decide whether suturing is necessary? In case of poor visibility of the site due to blood clots, it should be cleaned by gauze and saline, not with air spray. • Examine for general condition of mouth which includes dental caries, oral hygiene and periodontal status. • Examine tooth crowns for—presence and extent of fractures, pulp exposures, changes of color. • Record displacement of teeth. • Rapid orthodontic assessment including abnormalities in the



alignment of teeth (occlusion) and any oral habits? • Abnormal mobility of teeth or alveolar segments? • Percussion.



Investigations Pulp tests To evaluate the injury thoroughly, vitality testing of teeth must be performed. A positive response indicates that the pulp is alive, whereas a negative response indicates pulp death. Following a traumatic injury, the tooth may be in a state of shock and can give a false response. Hence, the reading after the injury should not be taken as the only reading; further testing should be performed on subsequent visits. Some of the commonly employed methods of vitality testing and the newer techniques are given in Box 26.5. Box 26.5



Commonly employed methods and



newer techniques of vitality testing • Thermal stimulation (ethyl chloride, ice, carbon dioxide snow [– 78 to 108°F], heated gutta-percha) • Electric pulp testing • Mechanical stimulation—test cavity (usually the last resort) • Laser Doppler flowmetry • Pulse oximetry



Radiographs • Extraoral views—to exclude facial fractures • Intraoral—use standard paralleling devices, if possible.



Use of radiographs: The radiographs are taken to assess or record: • Root fracture—two radiographs to determine the plane of the fracture line • State of the apex—the dental age may not coincide with chronological age • Size of pulp, proximity of the pulp to the fractured end • Periapical rarefactions, periodontal injuries • Baseline for comparison with future radiographs. For soft tissue damage, consider soft tissue radiographs—pieces of tooth may be embedded in the lips. If part of the tooth remains unaccounted for, arrange for chest radiography. The soft tissue radiographs are taken with half of the exposure time, when compared to that of regular radiographs.



Photographic documentation Photographs of the dental injury are necessary for follow-up, insurance liabilities and for medicolegal implications. Photographs of tooth fragments or foreign bodies embedded in soft tissues are necessary to avoid legal litigations regarding healing. Photographs of the injury before and after treatment will be a good source for educating the parent and child. Photographs in the horizontal and vertical or axial plane will accurately reveal displacement of tooth.



Classification of Injuries to Teeth and Supporting Structures Traumatic injuries can affect either the tooth or its supporting structures or both. For the tooth, it can be to the crown, the root or both. Hence the basis for the classification is: Traumatic injury can be to the:



1. Tooth 2. Supporting structures 3. Both In tooth: 1. Crown 2. Root 3. Both A definitive and descriptive type of classification is necessary which should offer a simplified interpretation of the type of injury. The classification should be accurate, easily understandable, communicable and universally acceptable as it provides information for treatment decisions and also in cases of medicolegal importance. Many authors gave numerous classifications for trauma to anterior teeth and their supporting structures based on various factors like etiology, anatomy, pathology and therapy. But only some were universally accepted. Broadly, the classifications can be divided into: 1. Numerical classification a. WHO classification, 1978 b. WHO classification, 1992 2. Descriptive classification a. Ellis and Davey classification 1960 b. Andreasen’s classification 1981 c. Stephen Wei classification Some of the classifications which are of clinical and academic importance are discussed.



Numerical Classification 1 WHO classification, 1978 The World Health Organization has adopted a system of



classification in its application of international classification of diseases to dentistry and stomatology in 1978. Every injury has a code number, which are as follows: a. Injuries to hard dental tissues and pulp: • Enamel fracture—873.60 • Crown fracture without pulpal involvement—873.61 • Crown fracture with pulpal involvement—873.62 • Root fracture—873.63 • Crown–root fracture without pulpal involvement— 873.64 • Crown–root fracture with pulpal involvement— 873.64 b. Injuries to periodontal tissues: • Luxation—873.66 • Concussion—873.66 • Subluxation—873.66 • Lateral luxation—873.66 • Intrusion/extrusion—873.67 • Avulsion—873.68 • Others—873.69



2 WHO classification, 1992 According to the International Classification of Diseases (1992) by World Health Organization, the code numbers are changed as follows: a. Injuries to hard dental tissues and pulp: • Enamel infraction—N 502.50 • Enamel fracture—N 502.50 • Crown fracture without pulpal involvement—N 502.51 • Crown fracture with pulpal involvement—N 502.52 • Root fracture—N 502.53 • Crown–root fracture without pulpal involvement—N 502.54



• Crown–root fracture with pulpal involvement—N 502.54 b. Injuries to periodontal tissues: • Concussion—N 503.20 • Subluxation—N 503.20 • Extrusive luxation—N 503.20 • Lateral luxation—N 503.20 • Intrusion—N 503.21 • Avulsion—N 503.22 c. Injuries to the supporting bone: • Communition of the mandibular (N 502.60) or maxillary (N 502.40) alveolar socket • Fracture of the mandibular (N 502.60) or maxillary (N 502.40) alveolar socket wall • Fracture of the mandibular (N 502.60) or maxillary (N 502.40) alveolar process • Fracture of mandible (N 502.61) or maxilla (N 502.42) d. Injuries to gingiva or oral mucosa: • Laceration of gingiva or oral mucosa (S 01.50) • Contusion of gingiva or oral mucosa (S 00.50) • Abrasion of gingiva or oral mucosa (S 00.50) WHO has modified its classification based on Application of the International Classification of Diseases to Dentistry and Stomatology (1995), by substituting ‘S’ in place of ‘N 5’. For example, the number for root fracture is S02.53 instead of N 502.53.



Descriptive Classification 1 Classification by Ellis and Davey (1960) Class 1:



Simple fracture of the crown involving little or no dentin



Class 2:



Fracture of the crown involving considerable dentin but not exposing dental pulp



Class 3:



Extensive fracture of the crown involving considerable dentin and exposing



dental pulp Class 4:



The traumatized teeth that become nonvital with or without loss of crown structure



Class 5:



Teeth lost as a result of trauma (avulsion)



Class 6:



Fracture of root with or without loss of crown structure



Class 7:



Displacement of the tooth without fracture of crown or root



Class 8:



Fracture of crown en mass and its replacement



Class 9:



Injuries to primary dentition



2 Andreasen’s classification a. Injuries to hard dental tissues and pulp: • Class I:



Enamel infraction



• Class II:



Enamel fracture



• Class III:



Enamel–dentin fracture



• Class IV:



Complicated crown fracture



• Class V:



Uncomplicated crown–root fracture



• Class VI:



Complicated crown–root fracture



• Class VII:



Root fracture



b. Injuries to periodontal tissues: • Concussion • Subluxation • Extrusive luxation • Intrusive luxation • Lateral luxation • Avulsion



3 Stephen Wei classification



a. Injuries to the tooth: Crown: Crack or craze without loss of structure which can be horizontal or vertical • Fracture of crown involving enamel, enamel–dentin or enamel–dentin–pulp, which can be horizontal, vertical or oblique • Fracture of crown, root and cementum—with or without pulp involvement. Root: Apical, middle or cervical third root fractures which can be horizontal or oblique. Whole tooth: • Concussion • Subluxation • Displacement or luxation Intrusion Extrusion Labial displacement Lingual/palatal displacement Lateral displacement • Avulsion b. Injuries to supporting bone: • Fracture of alveolar socket—intrusion causing crushing injury to bony socket • Fracture of socket wall labially or lingually/palatally • Fracture of the alveolar process • Fracture of the maxilla • Fracture of the mandible



Treatment Planning



Soft Tissues Soft tissue injuries (Fig. 26.2) are common in trauma to the primary dentition causing displacement of tooth/teeth. Lips often cushion the teeth during a fall, and may be bruised or lacerated by the impact of teeth against tissue. The upper and lower lips, frenum, tongue, and vestibular mucosa should be examined carefully for laceration; if laceration is present, check for any foreign body impaction, such as a tooth fragment or gravel. Swelling and bruising of the lips are common findings after oral trauma, even in the absence of laceration.



FIGURE 26.2 Soft tissue injury.



A child who falls while holding an object in his mouth—most commonly, a stick, pencil or pen, straw, pacifier, or a toothbrush— often suffers an impalement injury of the oropharynx. Most impalement injuries heal spontaneously, but the wound should be explored for possible foreign bodies and a prophylactic antibiotic should be prescribed to avoid infectious complications.



The injured area is often obscured by blood and the area should be cleaned up either by irrigating or wiping the area with water or normal saline, in order to carry out a full assessment. If there is significant soft tissue injury, the soft tissues should be sutured under local anesthesia for cooperative child and general anesthesia for an uncooperative child. If the soft tissue injury is severe or site of trauma is dirty, antibiotic coverage for 5 days may be necessary and patients’ anti-tetanus status should be evaluated. A recall after 7–10 days is practical to check healing and for suture removal. Soft tissue injuries can be one of the following: 1. Laceration: A shallow or deep wound in the mucosa resulting from a tear and is usually produced by a sharp object. 2. Contusion: A bruise is usually produced by impact with a blunt object and not accompanied by a break in the mucosa usually causing submucosal hemorrhage. 3. Abrasion: A superficial wound produced by rubbing or scraping of the mucosa leaving a raw bleeding surface.



Primary Dentition Hard tissues Injuries to the primary teeth irrespective of their severity can have devastating prognosis. Hence, a complete diagnostic work as described before should precede all the treatments. Displacement is the most common type of injury with crown or root fractures being rare. Examination should be done as soon as possible to assess the extent of damage. Even a blow could cause severance of neurovascular bundle at the apex leading to pulp necrosis. Any such sequelae can threaten the developing permanent tooth buds, the reason why diagnostic follow-up examinations after treatment should occur for all injuries to primary teeth. The primary objective of treating injured primary teeth is to prevent injury to the permanent successor and then to save the primary teeth, if it is not damaging the successor. The dentist should aim at restoring



the tooth and esthetics; if possible, with the least amount of active treatment compatible with the child’s cooperation. Before restoring or treating the hard tissue injury, one should decide whether to save the tooth or not, based on the following considerations: • Risk of damage to the underlying permanent tooth/teeth • The time of exfoliation of injured primary tooth • The clinical symptoms and radiographic sequelae after injury • Patient cooperation for treatment • Parent’s cooperation for review to assess vitality of the injured tooth and other pathology. Trauma often results in discoloration, either yellow or blue-black. Yellow indicates calcific reaction and calcification of complete root canal (endogenous root canal). Blue-black indicates degeneration of pulp. Discolored and/or nonvital teeth: Even if symptomless, these teeth require radiographic and clinical follow-up. If there is evidence of periapical involvement, pulpectomy procedure or extraction should be considered as there is risk of damage to permanent successors.



Crown Fractures (Fig. 26.3) Enamel infraction (Ellis-Davey, class IX) Enamel infraction is defined as an incomplete fracture (crack) of the enamel without loss of tooth substance. This can be detected by the use of transillumination or staining of teeth with disclosing solution will often reveal the fracture line. The infractions appear as a vertical or horizontal crack or craze on the tooth. The injury does not require any initial therapy but the injured tooth should be periodically evaluated for the possible sequelae of trauma as explained before.



FIGURE 26.3 Crown fractures—primary teeth.



Enamel fracture (Ellis Davey, class IX) Enamel fracture is an uncomplicated crown fracture in which the loss of tooth structure is confined only to enamel. These fractures can be diagnosed by visual examination and by probing. The fracture line can be horizontal, vertical or even oblique. If the fracture involves a small chip, the rough jagged tooth edge should be smoothened to prevent irritation to tongue and lip. If needed, a fluoride varnish like Duraphat or Bifuorid 12 can be applied. A larger enamel fracture can be restored by composite restoration.



Enamel and dentin fractures (Ellis Davey, class IX)



It is uncomplicated crown fracture with tissue loss confined to enamel and dentin without involving the pulp. These types of injuries with exposed dentinal tubules require an immediate temporary restoration or protective covering, in addition to the complete diagnostic procedure. Radiographic examination of these teeth will reveal the size of pulp chamber and its proximity to the fracture line, the stage of root development and the degree of root resorption. The injured teeth will show pulpal hyperemia and the immediate treatment should aim in restricting further trauma to the pulp by mechanical, thermal or chemical insults or irritants. The exposed dentinal tubules should be sealed using a hard setting calcium hydroxide or glass ionomer lining with composite restoration. This will prevent any further injury to the pulp and also encourage secondary dentin formation. If the fracture involves loss of considerable amount of hard tissue, the treatment of these fractures depends on whether the fragment is recovered or not. If the fragment is recovered then fragment reattachment can be done. If fragment cannot be recovered, composite restoration can be done. If there is extensive loss of tooth structure and the fragment is not recovered then the afflicted tooth should be restored with various full coronal coverage restorations like: • Stainless steel crown • Open-faced (facial cut-out) stainless steel crown • Resin-veneered stainless steel crown • Polycarbonate crown • Strip crowns/ celluloid form crowns • Art glass crowns. The esthetic restorative procedures of anterior teeth are described in Chapter 25 on Crowns in Pediatric Dentistry.



Treatment summary 1. Smoothening of the rough edges 2. Fluoride application



3. Composite restoration



Enamel–dentin fracture with pulp involvement (Ellis Davey, class IX) This is otherwise termed as complicated crown fracture. The treatment options for crown fractures with pulp exposure in the primary dentition traditionally consist of direct pulp capping, pulpotomy, pulpectomy and extraction. Mostly these injured teeth are usually extracted due to poor cooperation of the child patient or the complications of retaining the primary tooth. Various treatment options currently undertaken for these fractures are: • Direct pulp capping • Partial pulpotomy • Cervical pulpotomy • Pulpectomy • Apexification (few case reports are there on primary tooth apexification) • Extraction Before initiating any treatment, the following factors to be considered: • Time lapsed from injury and the amount of pulpal exposure • The stage of root development • The amount of root resorption • Vitality of the pulp If the child is very young, one may have to undertake the treatment under general anesthesia. Pulp therapy and the extraction procedures are discussed in Chapter 24 on Pulp Therapy.



Treatment summary 1. Direct pulp capping 2. Partial pulpotomy 3. Cervical pulpotomy 4. Pulpectomy 5. Extraction



Root fractures (Ellis Davey, class IX) Root fractures are rare in primary dentition because of: a. Resiliency of bone b. Short root length c. Physiologic resorption Diagnosis is entirely dependant on radiographic examination and radiograph serves as a baseline record for comparison at later visits. Root fractures (Fig. 26.4) occasionally escape radiographic detection immediately after injury, while radiographs exposed later clearly reveal the fracture. This is due to the development of either hemorrhage or granulation tissue between fragments or due to resorption at the fracture line that is part of healing process. Diagnosis of root fracture in primary dentition with radiograph presents special problem due to superimposition of permanent teeth, which often makes detection of the fracture near the apex difficult.



FIGURE 26.4 Root fractures–primary teeth.



Management of root fracture in primary dentition depends on the level of fracture. The best prognosis is for fractures in the apical onethird of the root. Most of these teeth maintain their vitality and are minimally mobile. The tooth including the apical fragment will resorb normally and should be monitored periodically with radiographs. Fractures that occur in the middle/cervical third of the root indicate extraction. A gentle attempt should be made to dislodge the apical root fragment. If it cannot be easily extracted, it should be left and monitored with radiographs in order to avoid iatrogenic trauma to permanent tooth germ. Primary teeth with root fractures without dislocation may be preserved and normal shedding of injured teeth is anticipated.



Splinting is not necessary in such occasions. Simple fractures in the middle third of the root can be stabilized with splint for a period of not more than 3 weeks to promote ‘cementum callus’ union. Primary teeth with root fracture and severe dislocation of coronal fragments should generally be removed, as pulp necrosis is likely to develop.



Treatment summary 1. Apical one-third—monitored periodically 2. Middle third—stabilized with splint (occasionally extraction) 3. Cervical third—extraction



Crown–root fracture (Ellis Davey, class IX) (Fig. 26.5) These fractures account for very small percentage in primary dentition and are mainly due to indirect trauma, i.e. injury to the chin during fall resulting in these fractures in molars. Crown–root fractures in incisors are very rare and are mainly due to direct trauma. Displacement of the coronal fragment is often minimal because of the tight gingival collar on primary teeth. The fracture line is usually single but multiple fractures can occur. The patient complaint may be pain on mastication or when biting forcefully on occlusion or even severe sensitivity. Otherwise the tooth will be asymptomatic. Standard radiographic examination of crown–root fracture seldom contributes to the clinical diagnosis as the oblique fracture line is almost perpendicular to the central beam. However, it acts as a baseline record.



FIGURE 26.5 Crown–root fractures–primary teeth.



These fractures can be complicated when pulp is exposed and uncomplicated when it is not exposed. In uncomplicated crown root fracture, the exposed dentinal tubules will be highly sensitive and



they may pave way for the entry of microorganisms into the pulp. Hence, these teeth have to be restored with full coronal coverage restorations mostly stainless steel crowns. In complicated crown-root fractures, the fracture line can be either in the buccolingual or mesiodistal direction involving the pulp. Hence for these teeth, either pulpotomy or pulpectomy has to be carried out. The fractured parts can be united with the latest composite materials. But finally a stainless steel crown to prevent any further fracture and reinfection. If the fracture line extends far below, the gingiva involving more amount of root then the tooth has to be extracted.



Treatment summary 1. Uncomplicated—full coronal coverage restorations (SS crowns) 2. Complicated—pulpotomy or pulpectomy and stainless steel crown



Concussion (Ellis Davey, class IX) Concussion is an injury to the tooth supporting structure without displacement or mobility but with marked reaction to percussion in horizontal and vertical directions. This often goes unreported due to the minor nature resulting from little or no bleeding and the reluctance of the parent to take the child to the dentist for injuries that appear inconsequential. Radiographically, these teeth may show widening of the periodontal ligament space. Apart from clinical and radiographic follow-up, concussion injuries in primary dentition usually require no treatment. Slight reduction of the enamel surface may alleviate the discomfort felt from functional contacts. Teeth that have sustained such an injury show minute hemorrhages in the periodontal ligament. These teeth would have received the least amount of trauma, but may demonstrate the poorest prognosis at follow-up evaluation that is one



reason for continued surveillance. Parents are instructed to give the child a soft diet and progress back to the normal foods according to the child’s tolerance.



Treatment summary 1. Periodic follow-up 2. Soft diet



Subluxation (Ellis Davey, class IX) Subluxation is defined as evidence of abnormal movement in horizontal and/or vertical direction with sensitivity to percussion and occlusal forces. There is usually clinical evidence of hemorrhage around the gingival margin indicating damage to the periodontal ligament. Treatment of subluxated teeth mainly depends on: • The amount of root resorption (physiologic) • Injuries to the adjacent teeth Most often, this entity does not require any treatment. Other treatment options are relieving the occlusion, occasionally splinting and occlusal relief and extraction.



Treatment summary 1. No treatment 2. Relieving occlusion 3. Splinting and relieving occlusion 4. Extraction



Luxation (Ellis Davey, class IX) (Fig. 26.6)



Intrusion: Intrusion is the displacement of tooth into the alveolar bone. Intrusion of primary incisors occurs under the age of 4 years. This is due to elasticity of the bone and also the full length of the root. Intrusion is always associated with soft tissue injuries of which contusion of the lower lip and the chin is frequent.



FIGURE 26.6 Crown fractures—showing fracture of enamel, enamel and dentin, enamel, dentin and with pulp involvement.



Intrusions can be divided into three grades based on visual examination: • Grade I representing mild partial intrusion with more than 50% of the crown visible • Grade II representing moderate partial intrusion with less than 50% of the crown visible • Grade III representing severe or complete intrusion of the crown. Bleeding may be noticed around the tooth, which is not usually mobile or sensitive to palpation. Percussion may reveal a metallic sound but tenderness to percussion is a rare finding. In case of partial intrusion, the orientation of displacement can be identified easily.



• Labial crown orientation indicates a palatal intrusion of the root toward the permanent tooth germ. • Palatal crown inclination indicates a buccal intrusion of the root away from the successor tooth germ. Grade III type intrusions may be located buccal to the cortical plate or in the nasal cavity sometimes. Crushing or compression of the alveolar bone is associated with intrusive injury, detected by gentle palpation of the mucosa in the traumatized area. In this situation, the tooth and the cortical plate move as a single unit. Periapical and occlusal radiographs are adequate to diagnose an intruded incisor, which will appear submerged in the bone with the absence of periodontal ligament space. The occlusal image determines the direction of intrusion by evaluating the dimension of the intruded incisor. • A palatally intruded tooth moves away from the source hence it appears elongated. • A labially intruded incisor moves closer to the source hence appear foreshortened on the image. • An extraoral lateral radiograph will help in determining the proximity of the intruded incisor root apex to the succeeding permanent tooth germ and fracture of labial cortical plate. Thus direction of the apex can be determined by one or more of the following signs: • Inclination of the crown • Palpation of soft tissue above the affected teeth • Presence of submucosal hemorrhage • Imaging with periapical and lateral radiographs. Management mainly depends on the direction and severity of the intrusion and the presence of alveolar bone fracture. If the root of the primary incisor is forced towards the labial bone then spontaneous re-



eruption is anticipated within 1 to 6 months. In addition to orientation, the degree of intrusion plays an important role in the management as spontaneous re-eruption is anticipated only when the intrusion is mild. Also, digit sucking habit may prevent the intruded teeth from re-eruption. Extraction is indicated in cases of: • Moderate or severe intrusion of the tooth • Palatally directed root which may contact with or invades the follicle of the permanent tooth germ • Buccal cortical plate perforation • Tooth positioned buccal to the cortical plate • Bone fracture was present • Signs of re-eruption not evident after 4 to 8 weeks, that may indicate ankylosis of the intruded tooth • Infection of the tooth. In those cases where extraction is not indicated, one must be aware of the risk of infection due to impaction of bacterial plaque at the site of trauma. Signs of infection include swelling, spontaneous bleeding, abscess formation and fever. In these cases, the traumatized incisor must be removed and antibiotic therapy instituted.



Treatment summary 1. Wait and watch for spontaneous re-eruption 2. Extraction—if permanent tooth injury is suspected



Extrusive and lateral: Extrusion is the partial displacement of tooth out of the socket. Extruded teeth might have occlusal interference with the opposing tooth. Lateral luxation includes teeth that are displaced in a direction other than axial direction. The various treatment options are no treatment, repositioning and extraction. Palatal luxation is the



most common one pushing the root apex labially and away from the developing tooth germ. Periapical radiographs of palatally luxated teeth appear as foreshortened images with wide periapical radiolucent area indicating the apices of the primary teeth were pushed labially away from the permanent successors. If the displacement is minimal, they can be left without any treatment but periodic monitoring should be done. If they are interfering with occlusion, repositioning can be done with thumb and finger followed by splinting. If the palatal displacement is so severe such that the injured teeth are in crossbite on centric occlusion, then these teeth are to be splinted after repositioning for 2 weeks. If improvement is not seen within 2 weeks, extraction is indicated. Repositioning should not be attempted and extraction is the treatment of choice, if: • Any chances of damage to the underlying permanent tooth germ is anticipated. • Injured tooth is nearing time for exfoliation.



Treatment summary 1. Repositioning and splinting 2. Extraction



Avulsion (Ellis Davey, class IX) Avulsion is the total or complete displacement of the tooth out of the socket otherwise referred to as exarticulation. The avulsion in primary dentition occurs mainly by falling against hard objects. The maxillary incisors are most commonly affected but there are reports of avulsion of first primary molars in literature. Avulsions that occur more than 2 years before the date of exfoliation may result in a delay of up to 2 years in the eruption of successor tooth. The first and most important step is to ask the parents to locate the avulsed tooth or



teeth. If not located, radiographs should be taken to rule out intrusion, displacement into soft tissues, chances of aspiration or ingestion and root fracture. The question to replant these primary teeth is a debate and controversy in the literature. Many authors uniformly caution against replantation of avulsed primary teeth due to possible damage to successor, while there are some case reports suggesting replantation of primary incisors. The main benefit of primary incisor replantation may be maintenance of a normal anterior dentition which may relieve parental guilt or concerns that a child’s self-esteem and social acceptance will be compromised by premature loss of primary incisors. Kinoshita et al had recommended the following criteria for replantation of avulsed primary teeth. They are: • A fairly short time after avulsion • Brought in wet condition • Little possibility of secondary infection after replantation. If the above criteria are fulfilled, the tooth can be replanted and splinted for 7 to 10 days. Parents who urge the dentist to replant the teeth should be informed about the additional procedures and the possible outcome. The signs of failed replanted tooth include the signs of discoloration in the crown, tooth mobility, appearance of radiolucent area near the tooth apex and external root resorption. Undergraduate students are cautioned to use the above mentioned information on replantation of primary teeth. Many authors and teachers believe replantation of avulsed primary tooth is CONTRAINDICATED.



Permanent Dentition Hard tissues Two questions that must be asked for any dental injuries involving permanent teeth regarding management:



• Is it possible to save the tooth? If the answer is Yes! • Is it desirable to save the tooth? The major factors that reduce the prognosis of treatment are: • Severe mobility • A root fracture in the coronal third of the root • A coronal fracture extending subgingivally • A nonvital tooth with an open apex Even if the long-term prognosis seems poor, it may be desirable to keep the tooth as a maintainer of space and alveolar bone. General condition of the mouth and attitude of the patient and the parent towards dentistry and dental treatment are to be considered. Orthodontic consideration, e.g. increased overjet, gross incisor crowding and any serious medical conditions, mental or physical handicap can also affect the management. Crown fractures (Fig. 26.7) Generally, the prognosis of crown fractures appears to depend primarily upon the presence of associated periodontal ligament injury and secondarily upon the extent of dentin exposed and the age of the pulp exposure.



FIGURE 26.7 (A-E) Crown fractures—permanent teeth: fragment reattachment.



1. Enamel infraction: The injury does not require any initial therapy but the injured tooth should be periodically evaluated for the possible sequelae of trauma.



2 Enamel fractures (Ellis Davey, class I) For simple enamel fractures, generally no treatment is required. Smoothening of the edges of the fractured crown with fine disks or stone is done to prevent irritation to soft tissues. This is followed by application of a fluoride varnish. Follow-up is done for sensibility of pulp.



Treatment summary 1. Selective grinding of teeth 2. Fluoride application 3. Composite restoration



3 Enamel and dentin fractures (Ellis Davey, class II) Pulp protection and esthetics are the main concerns. Hard setting calcium hydroxide (e.g. dycal, life) is placed over the exposed dentin as a part of indirect pulp capping. Calcium hydroxide can be stabilized by an open-faced stainless steel crown or orthodontic band. A composite or glass ionomer bandage (dressing) initially followed by a definitive composite restoration using strip crowns or polycarbonate crowns also can be used for esthetics. The pulp sensibility should be monitored regularly. Early treatment improves the chance of maintaining pulp vitality. Initial follow-up is after 3 months and



thereafter at 6 monthly intervals. Pulp capping procedure is discussed in Chapter 24 on Pulp Therapy. Fragment reattachment: Fragment reattachment can be done for Ellis class II and III or uncomplicated and complicated fractures of crown. The procedure includes reattachment of the fractured tooth fragment which was retrieved by the patient/parent or by the dentist from the soft tissues. Procedure: It is done under local anesthesia with rubber dam isolation. Calcium hydroxide dressing is given to the dentin portion over the pulp. Preparation of the fragment and the attachment site is done for taking the composite resin restoration. The fragment of the tooth can be attached to a piece of sticky wax to facilitate handling of the fragment. It is followed by acid etching; bonding and attachment of the fragment with chemical cure or light cure composite resins. Finally, finishing and polishing of the attachment area is done with finishing burs and disks.



Treatment summary 1. Indirect pulp capping 2. Composite restoration with strip crowns or polycarbonate crowns 3. Fragment reattachment



4 Enamel–dentin fracture involving pulp (Ellis Davey, class III) Any fracture exposing the pulp is a challenge for the clinician in management. The factors that influence the management of crown fractures with pulp exposure are: • Vitality of the pulp • Size of pulp exposure • Time elapsed since exposure



• Stage of development of root apex and • Restorability of the fractured crown Objectives of treating pulp exposed teeth are: • To retain the tooth • To maintain vitality if possible, to allow apex closure • To ensure apex maturity by chemical means If the color of the exposed pulp is bright red in color, it may be assumed that the apical circulation is intact. If the exposed pulp appears cyanosed that may indicate a compromised apical circulation. Closed apex: In case of closed apex, the procedure is extirpation of pulp and conventional endodontic treatment. Consideration is given for calcium hydroxide therapy for 6/12 months before definitive root filling. Open (immature) apex: Treatment of open or immature apex varies based on the vitality of the tooth. Vital tooth: Direct pulp capping or pulpotomy with calcium hydroxide is performed based on the amount of pulp exposure to allow apexogenesis. Nonvital tooth: In case of nonvital tooth, induction of root end closure or apexification is done with calcium hydroxide and CMCP. Apexogenesis and apexification procedures are discussed in Chapter 24 on Pulp Therapy.



Treatment summary 1. Direct pulp capping 2. Composite restoration 3. Fragment reattachment (Fig. 26.7A-E) 4. Cvek pulpotomy 5. Calcium hydroxide pulpotomy (apexogenesis) 6. Apexification 7. Root canal treatment



Crown fractures of posterior teeth: These fractures particularly occur secondary to a hard blow under the chin. Fractures of permanent posteriors are restorative challenges to the clinician. Full coverage with stainless steel crown can be done, followed by cast or ceramic crowns after the establishment of full occlusion of the involved and adjacent teeth.



5 Crown root fracture (Fig. 26.8) In case of crown root fracture, the treatment varies based on different factors:



FIGURE 26.8 Surgical extrusion of the tooth and its rehabilitation as a management option for crown root fracture of an incisor.



• Extraction is the choice, if oblique line extends beyond onethird of the clinical root length. • Uncomplicated crown root fracture (without pulp involvement): Treatment is done to retain the tooth, if fracture line extends only about 2 mm below the marginal base level. Pulp capping with calcium hydroxide and light cure composite resin or fragment reattachment. • Complicated crown–root fracture (with pulp involvement): If it is an immature tooth with open apex, vitality of the tooth is checked: For vital tooth, pulpotomy is done for apexogenesis If it is nonvital, apexifcation is done followed by root canal treatment and light cure composite or fragment reattachment. In case of closed apex, pulpectomy and root canal treatment followed by fragment reattachment or light cure composite restoration. The criteria for success of treatment in fractures involving pulp of permanent teeth include: • Completion of root development in immature or young permanent teeth. • Presence or absence of clinical signs like pain, mobility and fistula. • Presence or absence of any radiographic signs of pathology like, periapical radiolucency indicating bone or root resorption.



Treatment summary 1. Pulp capping with composite restoration/fragment reattachment 2. Pulpotomy and apexogenesis 3. Pulpectomy and apexification 4. Removal of the coronal fragment and supragingival restoration 5. Removal of the coronal fragment supplemented by gingivectomy and/or osteotomy 6. Removal of the coronal fragment and surgical or orthodontic extrusion of the root 7. Extraction



6 Root fractures (Ellis Davey, class VI) (Fig. 26.9) Root fractures are relatively uncommon in permanent dentition. They usually account for