Pedodontics

1.Early-Dental Intervention

Introduction

Until recently pediatric dentistry involved treating children for their first dental visit at age three. The reason for the delay of treatment was not the absence of caries but the lack of child's cooperation.

Today there is a new direction in treating children's dental needs. We are not waiting till the problem appears but instead we are trying to prevent the dental disease. We must remember that caries destruction (nursing caries or baby-bottle caries are now known as early childhood caries ECC) in a three-year old is initiated well before this age. Habits such as healthy-dietary choices and preventive behaviors are established early in life. Therefore, efforts to prevent dental disease must begin during infancy. Our goal is to produce a caries-free generation. This can only be done with early-dental intervention.

A child's first dental visit should occur within 6 months of the eruption of the first primary tooth (approximately 12 months of age). This will allow the dentist to evaluate the infant's oral health via examination and history taking of pre- and postnatal factors. With this information the dentist will be able to determine the child's risk of dental disease and thus intercept possible problems such as early childhood caries. Counseling and use of anticipatory guidance will prevent pediatric oral disease.

Anticipatory guidance is a system of education that focuses on the age-appropriate needs of a child. Traditionally we were using the same unidirectional caries prevention message for each patient. Today the practitioner is developing a treatment plan that is developmentally relevant and geared for that child's particular stage of life. Early intervention will initiate a relationship between the child, parent and dental care giver. This sets the foreground for early identification of risk, evaluation of oral development, fluoride management, counseling of oral habits, prevention of oral injuries, and modification of dietary and oral hygiene behaviors. This timely family motivation and tailored preventive program will give the child an opportunity for good oral health throughout life.

Assessment

Early-dental intervention should include the following:

History

The following health questionnaire (Table 1) could be sent to the parent and brought back on the day of the appointment.

Prenatal, Perinatal and Postnatal History

Health and developmental history covers pre-, peri-, and postnatal information. These facts will explain dental abnormalities that occur in the primary dentition. It is important to obtain this information early in childhood since the parent might forget the details as the child grows older. Events that might have an effect on the primary dentition include high-risk pregnancies, administration of tetracycline during pregnancy, pre-term or low-birth-weight (LBW less than 2500 gm) infants and high fever during childhood (frequent otitis media).

It is important to understand the clinical implications of pre-term and LBW infants. Enamel hypoplasia and other mineralization defects in primary dentition seen in these children may be caused by neonatal hypocalcemia during the enamel mineralization process. In addition pre-term infants may need intubation due to their medical status. The intubation procedure itself causes injury to the developing incisors. The longer the orotracheal tube is in place the more likely these infants will have associated problems such as airway damage, palatal groove formation, defective primary incisors, and acquired cleft palate. The dentist must keep in mind that LBW infants can experience respiratory distress syndrome or develop bronchopulmonary dysplasia. This places them at high risk for respiratory infections and wheezing. These symptoms cause problems for the child in the dental office.

Development History

Knowledge of the child's developmental milestones allows the dentist to assess the patient's dental growth. Eruption of the first tooth provides information as to the child's future dental development. If a child is a "late bloomer" it will not be surprising that the child will have a slower dental developmental pattern.

Medical History

An accurate medical history is crucial for treating any patient. The dental practitioner must not only take note of the precautions that must be taken because of a patient's particular medical history but also advise the patient on how to have better dental quality of life despite the medical issue. For instance, a child with frequent otitis media probably has been exposed to many types of antibiotics that contain high concentrations of sucrose. It is the dentist's obligation to recommend dietary management and tooth cleaning procedures so as to prevent future problems.

Dental History

Answers to the questions on the history of fluoride intake, dental trauma, oral hygiene habits, oral or dental symptoms and current infant-oral-health care provide information to formulate dental management recommendations.

Feeding History

Feeding history includes information such as, whether the child is breast- or bottle-fed, frequency and duration of feedings, nighttime feedings, contents of bottle, and pacifier use. This information will aid in the discussion of diet's influence on dental caries and recommendations on healthy feeding practices.

Table 1. Health and Developmental History Questionnaire

Prenatal

1. Pregnancy complications

If so, describe: –––––––––––––––––––––––––––––––––––––––––

Perinatal

2. Premature or low-birth weight
3. Birth complications

Postnatal

4. Hospitalizations
5. Medications:
   If so, describe: –––––––––––––––––––––––––––––––––––––––––
6. Allergies (medications or anesthetic)
   If yes, list them :–––––––––––––––––––––––––––––––––––––––––
7. Immunizations up to date
8. Disability
9. Chronic illness

Develop and Medical History

10. Developmental milestones within correct time-span (speech, motor skills, socialization)
11. First baby tooth
    How old was the baby when the first tooth appeared? –––––––––––––––––
12. Anemia
13. Asthma
14. Bleeding excessively from cut or extraction
15. Cardiac problems (heart murmur)
16. Diabetes
17. Eye disorders
18. Frequent ear infections
19. Immune-system disorders (HIV)
20. Kidney problems
21. Liver problems
22. Malignancies or leukemia
23. Nervousness or apprehension
24. Psychiatric care/ emotional problems
25. Rheumatic fever
26. Sinus problems
27. Thyroid disorders
28. Tonsillitis
29. Ulcer or colitis
30. Any current medical treatment or problem not listed above –––––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––––––––

Dental History

31. Fluoride supplements
32. Water supply fluorinated
33. Toothpaste use
34. Texture of toothbrush
35. Frequency of brushing
36. Dental floss
37. Bad breath
38. Mouth breathing
39. Oral habits: thumb-sucking, fingernail biting, cheek-biting, pacifier
40. Grinding
41. Traumatic injury to the mouth or teeth
42. Teeth sensitive to cold, heat, sweets, pressure
43. Swelling or lumps in the mouth
44. Frequent blisters on the lips or mouth
45. Pain around the ear

Feeding History

46. Breast fed
47. Bottle fed
48. Frequency, amount, content, nighttime feeding:
    –––––––––––––––––––––––––––––––––––––––––––––––––––––––
49. Solid food
50. Snacking Frequency, content:
    ––––––––––––––––––––––––––––––––––––––––––––––––––––––––
51. Feeding problems

Examination

Clinical inspection of oral structures may be completed either through traditional or parent-assisted (knee-to-knee) methodology. Considering that the patient is an infant or toddler it is important to provide a non-threatening environment for the dental exam. It is not crucial for the child to be evaluated in the dental chair. The knee-to-knee exam is done when the dentist and parent sit facing each other. The patient's head is gently placed on the dentist's lap while the child's legs are wrappedaround the parent's waist. This position allows the parent to gently restrain the child's hands and legs while providing the child with parental reassurance. The dentist will then have good visualization of the patient's head, face and mouth.

It is important to explain to the parent prior to the exam that it is normal for a child under the age of three to fuss, cry and not cooperate in a dental setting. The parent is already aware that children do not always cooperate in a pediatrician's office or when they get a haircut. It is the same with the dentist. Once the parent is informed as to what and how the exam will be done and reassured that the child is comfortable, the parent will understand that the dentist is simply providing important medical and dental intervention. Then the patient's resistance to the exam will not stop the practitioner or parent from continuing the evaluation and the dentist will be able to provide the child with the needed service.

While examining a child the dentist is not just looking for caries and periodontal disease but growth and development. Once the patient is positioned comfortably an extra-oral exam is done first.

Extraoral examination includes:

	Evaluate head and neck for abnormalities (size, shape and symmetry)
	Orthodontic facial type
	Lymph nodes (cervical, submandibular, occipital)
	Eyes, ears, TMJ, nose, lips and mouth
	Facial bruising rule out child abuse
	Speech and language assessment

Once the extra-oral exam is completed the dentist continues with the intraoral exam.

Intraoral examination includes:

	Evaluate the soft tissues for any pathologic processes (cysts, epulis, submucous clefts, ulcerations)
	Oropharynx and tonsils
	Periodontal status and oral hygiene level
	Dentition (molar relationship, overjet/bite, midline, cross-bite, crowding/spacing, hypo/hyperdontia, hypoplastic or hypocalcified enamel, caries)

Caries-Risk Assessment

Caries-risk assessment is an important step in determining a patient's treatment plan in early-dental intervention. There are different factors that may play a role in a child developing dental caries. The following list of factors should be discussed with the parents in order to provide them with information and understanding about the child's caries process and determining a preventive program.

Caries-Risk Factors:

Social

- Mother's and sibling's caries experience
- Primary care-giver
- Family dynamic (tension/integrity, recent migration, language barrier, divorce)
- Health beliefs (ethnic and cultural diversity)
- Income/education (can have an impact on access to dental care)

Medical

- Medical conditions
- Medications

Dental

- Past caries experience
- Past treatment experience
- Dental development
- Tooth alignment and integrity
- Current dental status

Environment

- Oral hygiene
- Diet/ bottle usage
- Topical-fluoride usage
- Systemic-fluoride usage

Biological Variables

- Salivary secretion rate and buffering capacity
- Lesion appearance (presentation, amount per year)
- Decalcification
- Streptococci levels (High levels are found in very young children with caries risk.)

Once all of the above information is obtained then a dentist can determine what level of risk the child has for caries.

Low risk of disease

- Caries present

- Fluoridation in community water

- Good family history (healthy diet, good-oral hygiene, helpful care-givers, dentally healthy siblings)

Moderate risk of disease

- One or two new lesions per year

High risk or future high risk of disease

- Three or more new lesions per year

- Orthodontic treatment

- Medically compromised children

- Frequent hospitalizations and illness

- Social-risk factors

Anticipatory Guidance

Anticipatory guidance is a method of providing information that is tailored for an individual patient at his or her stage of life. The counseling will cover important issues ranging from discussion of developmental milestones, nutrition and feeding information, oral hygiene and caries-prevention techniques, fluoride information, trauma prevention, and a review of habits.

Table 2: Anticipatory Guidance
Age	Dental Guidance
Birth through 6 months	At this stage first tooth may have erupted. Dentist should discuss appropriate use of the nursing bottle and danger of bottle caries. Further discussion should include teething, mouthing objects, non-nutritive sucking, what happens at baby dental visits, and s. mutans transmission.
12 months	Review with the parent pattern of teeth eruption for the next 6 months. Provide nutrition and feeding information; encourage discontinuation of the bottle and use of tippy cup; inquire about sugar consumption; and the risk of caries and prevention methods. Demonstrate for the parent the use of toothbrush and dentifrice. Review changes in diet related to fluoride and sugar consumption.
18 months	Review anticipated tooth eruption for the next 6 months. Discuss with the parent nutrition and snacking habits. Inquire about child's compliance with oral hygiene procedures.
2 years	Review occlusion and related concepts of crowding, spacing and space loss, overbite and overjet.
5 years	Discuss exfoliation of teeth; eruption patterns and problems that may occur. Review dental trauma and medical emergencies that may occur at play or at school, and management procedures.
6 years	Discuss eruption of 6-year molars; occlusion; orthodontics and periodontal diseases. Extended discussion of dental caries and management. Sufficiency of fluoride intake. Introduce the benefits of dental sealants.
Adolescence	"Ugly duckling" stage of development. Dental development, facial growth and changes in appearance. Orthodontics. Sealants for the second molars.

Source: Novak A, Casa Massimo: Using anticipatory guidance to provide early-dental intervention. JADA 126: 1156-1163, 1995.

Pinkhma JR, Pediatric Dentistry Infancy Through Adolescence. Philadelphia: W.B. Saunders Company; 1994.

Diet Modification

Diet is an issue that needs tremendous attention since it is one of the most important factors in determining a child's caries-risk. This discussion should start at the first dental visit preferably just when the child's first tooth has erupted. This way habits have not been established. The parent should be informed of early childhood caries that is not limited to the bottle but could also be caused by breast-feeding. Contents in the bottle such as milk and water have better nutritive and less cariogenic effects than orange or apple juice. If juices are preferred then offer the option of dilution. Be aware that out of ignorance and tradition parents might add sugar or honey to the bottle because they believe this is healthier for the child. Explain that this is contraindicated for good oral health. It is important to review the need to stop the bottle and wean at an appropriate age. If that is not possible then advise the parent to clean the toddler's teeth frequently, check if the fluoride intake is optimal, and introduce the child to the "sippy" cup. It should be noted that the bottle should not be used as a pacifier. Frequency, duration, and night bottle or breast-feeding should be in balance with the child's food intake, and not carried to one or the other extreme.

Considering today's fast pace, an adolescent's daily diet might not be as healthy as we would like it to be. Review with the child specifically what he or she eats during the day when not supervised by the parent. You will be surprised to hear that the child might have swapped the turkey sandwich mom prepared for four Oreo cookies and a fruit roll-up. It will be beneficial to educate the child about the consequences of his choices. It is important not to just set rules for the child but also give the child options. Since fermentable carbohydrates stick to the teeth and dissolve more slowly they cause more damage. Therefore, instead of potato chips choose strawberries, kiwi or even chocolate as long as they brush, rinse or chew sugarless gum afterwards. Snacking between meals should be discouraged but if it occurs it should be done with wise choices. Soft drinks are extremely erosive; therefore, alternatives such as chocolate milk, apple juice (with moderation) or ice tea should be given. Parents should be careful about giving rewards as sweets. If this is done try to limit it to mealtime. Although foods are labeled `no added sugar' they may still contain high levels of natural sugars. A dentist has a duty to educate a parent and patient with sound dietary advice that is focused on positive alternatives. This education establishes good-dietary habits early in the child's life and promote healthy development and dental well-being for years to come.

Fluoride Supplementation and Oral Hygiene Counseling

Fluoride has several mechanisms of action. These include tooth resistance to demineralization, remineralization enhancement and reduction of cariogenic effect of plaque. Fluoride can be effective either systemically or topically. Systemic benefits are available through community water fluoridation, food consumption, fluoride supplements, mouth rinses that are meant to be swallowed. Topical benefits are available from toothpastes or other more concentrated forms that are prescribed or professionally applied.

The dentist will determine which form of fluoride should be administered depending upon the child's age, caries history and risk and access to fluoridated water. Children who do not have access to optimally fluoridated water should be given fluoride supplements. Even if the child has received a prescription for supplements from the pediatrician it should still be checked since guidelines do change. Table 3 shows the daily dosage schedule for fluoride supplementation that has been recommended by the ADA and AAP. Notice that supplementation does not begin until the child is six months of age.

Table 3. Fluoride Supplementation Regimen
Age	Concentration
	<0.3	0.3-0.6	>0.6
6 months < 3 years
3 years < 6 years	0.50	.25	0
6 to at least 16 yr	1.00	.50	.25

Even children who live in fluoridated areas need to be supervised because they may receive too little or excessive amounts of fluoride. In particular, infants whose primary intake is breast milk are deficient in fluoride intake because breast milk contains only trace amounts of fluoride. On the other hand infants who are formula fed may receive excessive amounts of fluoride. Depending on where the formula was manufactured it may contain fluoride which may be excessive when prepared with fluoridated water. Dentists should inquire if bottled water is the main source of fluid intake since there is great variability in the fluoride content in bottled water.

Besides the professionally applied fluoride or prescription toothpaste, dentifrice will constitute the only topical application of fluoride in children up to age three. Parents of children under the age of three must be instructed to supervise brushing and place a pea- size toothpaste onto the toothbrush since the child may not have mastered the ability of expectorating. If not properly supervised, over a period of time this intake could cause fluorosis.

Children who are at high risk of developing caries or have had a history of severe caries may receive a prescription for concentrated topical fluoride for home use. The dentist is responsible to educate the parent of appropriate storage of these products so as to prevent accidental ingestion.

As discussed, dietary management and optimal fluoride intake are part of the preventive program but we must not forget the importance of good oral hygiene. If this is taught early then a lifelong positive habit will be established. The child may have the dexterity to accomplish good dental home care at the age of eight but until then the parent should supervise. Therefore, the dentist should suggest to the parent effective ways to accomplish this responsibility.

Initially, when the patient is an infant it would be convenient to perform oral hygiene for him or her on the changing table as this will provide a place with good lighting and height. When the child is older the knee-to-knee position will be easier especially if he or she is resistant. The parent should be encouraged to be persistent since a systematic routine of at least brushing twice a day will teach the child of importance. As children reach the independent age of two they want to brush on their own. The parent should still supervise and check if plaque has been fully removed.

A soft-bristled brush should be used to clean all surfaces of the teeth in the upper and lower jaws, angling the toothbrush forty-five degrees to the gingival margin. Flossing is introduced if the interproximal surfaces of the primary molars have closed contacts, since then they become more at risk for caries. In this situation if the child does not have the dexterity to floss the parent should help. A commercial floss holder may be helpful.

A preventive measure that will aid in the child's oral hygiene is placement of sealants. Sealants placed on teeth with especially deep grooves prevent food impaction in those areas and thus the production of carious lesions. This restoration should be introduced to the parent as an option.

Non-Nutritive Habits and Trauma Prevention

Non-nutritive habits are normal during infancy. These habits are related to the rooting and sucking reflexes that appear at birth. The rooting reflex occurs when an infant comes in contact with an object that touches his cheek or lips. The baby will then automatically turn towards this object be it the mother's breast or a pacifier. This reflex should disappear at around 7 months of age. The sucking reflex is essential for nursing or bottle feeding. This reflex disappears once feeding is established since then the reflex is not needed to obtain nourishment. This occurs at approximately one year of age.

If the thumb/digit sucking or pacifier habit persists after the age of three dental malformation will begin with possible skeletal malformation. If the habit is stopped after the age of three but prior to permanent incisor teeth eruption (between age 5-7) then malocclusion may self-correct. However, the dentist should stress to the parent that although the malformation may improve without active treatment if the habit is not stopped prior to age 3 it will be more difficult for the child to get rid of this comfortable habit. Once the permanent incisors erupt, the habit will produce malocclusion (Table 4) in the anterior area of the mouth. This will impact the child socially, psychologically and functionally.

Table 4. Malocclusion Due to Non-Nutritive Habits

	Anterior open bite
	Upper incisor protrusion (increased overjet)
	Lower incisor possibly displaced
	Anterior tongue thrust

Anterior and/or Posterior Cross-Bite

If the child already has a pacifier habit, the following precautions should be implemented:

	To ensure the child's safety the pacifier should never be attached to a string around his neck because this can cause injury or strangulation.
	Check on the box that the pacifier is approved by the consumer product commission since then it will follow specific requirements (e.g., one-piece construction, nontoxic).
	The child should not walk or run with the pacifier in the mouth since falling with it may cause soft- and hard-tissue damage.
	Parents should be discouraged to place honey or sugar on the pacifier since this will increase caries-risk.
	Once the child is asleep attempt to remove the pacifier.

Since non-nutritive sucking is normal at an early age active intervention is discouraged under age three. Between the ages of three to five "gentle persuasion" and "positive reinforcement" are encouraged to prevent prolonging of the habit. Luckily, majority of children cease the habit on their own. However, if the habit does not cease by the age of 5 or 6 then treatment is indicated. Success of treatment is usually correlated to the patient's desire to stop the habit. If the patients have the desire to stop they may just need some mechanical device to "remind" them to remove the digit or object from the mouth. Such devices include adhesive tape or a chemical (hot-tasting, bitter-flavored liquid) placed on the digit. If the habit occurs mostly at night, another option is to gently wrap an ace bandage around a magazine that is placed on the elbow of the arm that has the finger habit. This will prevent the arm from bending when the child is asleep and does not have control over his or her movements. The most effective device would be an intraoral fixed appliance such as a Hawley with a palatal bar or a crib or bluegrass appliance.

Trauma Injuries

Trauma to one's child is emotionally challenging to a parent. If there is a way to prevent these emergencies from occurring, or educating the parent as to what should be done under these circumstances, then a great medical service has been rendered. Most injuries to the primary dentition occur when infants begin to walk (age 1-2). Since they do not have the coordination to protect themselves from their falls the dentist should suggest to the parents to remove coffee tables or other objects that may cause harm. Child-proofing the home will also include covering plug outlets, removal of open electrical extension cord, etc. Car accidents are another major cause of dental injuries to children. Review of child safety should include the need for a car seat or booster, even when driving for a short errand.

The dentist should be aware of oral signs showing child abuse since this is a serious cause of dental injuries to young children. Signs of abuse are labial frenum tears, injuries in various stages of healing, repeated injuries, and injuries whose clinical presentation is not consistent with the history presented by the parents. As the child grows older he or she will become more active in sports. This is when the dentist should encourage the use of helmets and professionally fabricated mouth guards. The child with a large overjet is extremely prone to injury. These devices prevent sports-related orofacial trauma, such as jaw fractures, neck injuries, concussions and tooth avulsions or fractures. If a soft-tissue injury occurs, a clean slightly wet (to prevent adhesion to the wound) gauze should be placed with gentle pressure to obtain hemostasis until the injury is evaluated. If avulsion to a permanent tooth occurs the parent should be advised to try to find the tooth and place it in either Hank's solution (if available), saliva, water or milk and come immediately to the dentist's office for evaluation. They should be warned not to reimplant an avulsed primary tooth since this could damage the succedaneous tooth.

It is the dentist's obligation to provide early-dental intervention to prevent dental disease. With the use of anticipatory guidance the dental practitioner could educate and direct the parent and child to a path of good oral health from infancy to adulthood.

References

1. Thomas A, Chess S. Temperament and development. New York: Brunner/Mazel; 197
2. Badalaty MM, Houpt MI, Koenigsberg SR, Maxwell KC, DesJardins PJ: A comparison of chloral hydrate and diazepam sedation in young children. Pediatr Dent 12:33-37, 1990.
3. American Academy of Pediatric Dentistry. The Handbook. American Academy of Pediatric Dentistry, Chicago: 1996.
4. Cameron A, Widmer R. Handbook of Pediatric Dentistry: London: Mosby-Wolfe; 1997.
5. Malamed SF. Sedation, A Guide to Patient Management 2nd edition, St. Louis. CV Mosby Co.,1989.
6. Pinkham JR, Pediatric Dentistry Infancy Through Adolescence. Philadelphia: W.B. Saunders Company; 1994.
7. Pinkham JR, An analysis of the phenomenon of increased parental participation during the child's dental experience. J Dent Child 58(6):458-463,1991.
8. Stewart RE, Barber TK, Troutman KC, Wei SHY: Pediatric Dentistry: Scientific foundations and clinical practice, St. Louis: CV Mosby Co., 1981.
9. Winer GA: A review and analysis of children's fearful behavior in dental settings, Child Dev 53:1111-1133, 1982.
10. Wright GZ, Starkey PE, Gardner DE. Child Management in Dentistry. Bristol: IOP Publishing Limited; 1987.

2.Behavior Management of a

Child In a Dental Setting

Today dentistry is oriented toward prevention. It was previously thought that a child's first dental visit should occur at the age of three when the child is expected to be more cooperative with dental treatment. This wisdom is no longer accepted. Dental disease could begin earlier and effective prevention could be implemented early in life. Dentistry for children may be a challenge but it is possible if a strategy for managing a child is established. There is a variety of behavior management techniques that allow a dentist to provide effective dental treatment to children as young as one year old.

It is important to ensure positive dental experience for children. Research has shown that the way adults feel toward dental treatment correlates to their early-dental experiences. Therefore, the dentist will need to be knowledgeable about non-pharmacological and pharmacological techniques. But prior to choosing a particular technique the dentist should be aware that an important factor in achieving cooperative behavior is based on open communication between the dentist and parents. If the parents understand and agree to the management style used by the dentist the outcome of the dental appointment will be satisfactory to everyone. The practitioner will need to balance a child's behavior with parents' expectations.

Depending on a child's personality type the dentist will use different approaches to treat him or her. Thomas and Chess have categorized children into three types by temperament as shown in Table 5 below:

Table 5. Different Types of Child Temperaments

1. Easy

	Positive in mood
	Bodily functions are regular
	Adaptable and flexible
	Reaction to stress low or moderate intensity

2. Body Functions

	Body functions are irregular (slow development of daily pattern for sleeping, eating and having bowel movements)
	Reaction to stress high intensity

3. Slow to Warm Up

	Shy disposition
	Reaction to stress–low intensity
	Change is difficult (negative to change, slow to adapt)

A child with an easy temperament will display a positive approach to handle the dental appointment. On the other hand, a difficult child will withdraw, have an intense reaction at the first dental visit, and have a hard time adapting to change during the experience. A slow-to-warm-up child will also withdraw and will have a negative reaction to change. Approximately 65% of children could be placed into one of these three categories; the rest would have a combination of these traits.

A dentist should be aware that there are certain times during a dental visit that cause additional anxiety to a child. With this knowledge the practitioner could anticipate disruptive behavior. It is documented that the three most feared points during a dental procedure are the "needle," application of the rubber dam and high-speed handpiece sound during tooth preparation. In addition to the above-mentioned critical moments of a dental appointment we will describe other experiences below:

First Impression

In order to promote positive reactions in children the surrounding environment should be age appropriate. The waiting room should have safe toys, books for the children and magazines for the parents. When greeting a child for the first time try not to wear a mask or surgical garb. The operatory room could have stimulating visual distracters, such as stuffed animals hanging from the operatory light, puppets or childlike posters on the wall. The dental staff should transmit positive, confident and comfortable attitude to the child.

Separation From the Parent

Under the age of three a child usually does better with a parent in the room. Let the parent take the lead in this respect. Over the age of three most children do not need their parents to be present during the appointment. Dentists should decide if they find having the parent in the room helpful or bothersome. We must keep in mind that in this litigious society of today it may be beneficial to have a parent in the room especially with a difficult management case. The parent may feel more secure with the dentist's patient management choices if the parent can observe the child's behavior. On the other hand, if the dentist has a preference to the contrary it should be discussed prior to the first treatment visit. There may be some instances in which if a parent is present in the room it may heighten the child's reactions during treatment. Children often like to portray themselves as victims and anxious parents fearful of dentistry themselves may assume the role of rescuers too quickly. This starts in the child a vicious cycle of heightened fear responses. Sometimes an agreement should be made with the parent that if the child misbehaves then the parent would be asked to leave the operatory.

Getting into the Chair

We take this part of the procedure for granted. For the child with an easy temperament getting into the dental chair will be quite easy and should be praised. However, for the child with a difficult or slow-to-warm-up temperament getting into the dental chair may symbolize the beginning of a new unfamiliar challenge. Therefore, some children may need extra assistance, or even require an "airplane ride" into the chair.

The Injection and the Dental Procedure

The injection is the most feared part of the dental experience. This may be due to "acquired fears" often passed on to the children by their siblings, parents, and friends, vividly describing their frightening experience with the needle. Children also get a "learned fear" from their own difficult experience either at a physician's office or at a hospital. We must be sensitive to these feelings and try to make the injection as inconspicuous as possible. We can place the child in a position of control by giving the child a chance to choose from various fun flavors of topical anesthetics. The dentist should judge the child's attention span and agitation and determine if application of topical anesthetic should be skipped due to the additional waiting time it would require.

It is best not to use the term injection or needle, but instead call it "sleepy juice." It is not recommended to lie about the needle. The procedure could be briefly explained to the child so that the child would not be surprised. For example, one can say to the child, "I am going to wiggle your lip while I sing to you your favorite song. I'll give you some sleepy juice that will make your tooth go to sleep." The best way to build trust with children is to answer their questions honestly. If they ask if it will hurt explain to them that it will feel like a pinch or a mosquito bite. There is a product on the market that provides local anesthesia through a device that looks like a pen instead of a syringe. The benefit is that children do not fear its appearance and when administered they don't feel the injection since it is pressure monitored. The only problem is that it takes longer to administer the anesthetic. The dentist should train the staff to manage a child who is resistant to the injection. A dental assistant could restrain the patient's arms so that the child does not grab the dentist's hands, which could cause injury to the child or staff.

Providing a comfortable environment prior to starting the injection or the procedure will lessen a child's extraneous fears. Be careful of bright lights, loud noises, and sudden movements. These small details could change the entire outcome of the appointment. Before starting anything try to develop trust with the child. Having the patience to do this in the middle of the day after just completing roundhouse prep on the previous patient may be difficult. But investing the time to do this may save you a lot of anxiety in the long run. Introduce the child to some instruments that will be used. For instance, the air-water syringe ("the water squirter,") the suction ("the straw,") the explorer ("the counter.") Try not to place all the instruments on the bracket table in front of the patient; this may be too overwhelming and will only increase the amount of questions the child has for you. When passing instruments from the assistant to the dentist, be careful not to do this over the patient's face but preferably over the chest. The overhead light could be quite blinding for children of three years of age; give them a choice of sunglasses they could wear while sitting on their very own "beach chair." If a child is afraid of loud noises (and you cannot afford virtual reality glasses or television in every operatory) a simple Walkman could be given to the child to drown out the surrounding noises.

At the end of the first appointment the dentist or dental assistant should tell the child as to what would be done and used at the next treatment appointment. This way the child will not have to hold in all the questions and fears for the coming days and weeks prior to the procedure date. Another benefit is that a trained professional honestly informs the patient as to what would be done. Otherwise, we take the risk that parents may unintentionally disregard the child's questions or, worse yet, answer them incorrectly due to their own lack of information or fear.

Depending on what would be done at the treatment appointment is what should be told. Surprisingly, the materials and applicators used to dispense these materials (e.g., etch needle dispenser, cement, bonding agent) could cause more fear in a child than the instruments themselves.

It is advised to use a rubber dam in pediatric patients. A rubber dam provides better visualization, protection of oral soft tissues, moisture control, and prevention of aspiration of foreign bodies. If it is used, then explain to the child that a "raincoat" will be placed on the teeth so that only the teeth that need to be fixed will get wet. The raincoat has a ring that keeps the raincoat in place. This ring sometimes feels a little tight but this way we know that the raincoat fits just right. The high-speed handpiece (without a bur) should be run for a second so that the child becomes familiar with the sound it makes and realizes that it just squirts water. The low-speed handpiece should be run slowly with a round bur and gently placed on the dentist's thumb to show that it doesn't hurt but it just feels bumpy or tickles. The child will appreciate having all this explained and might even surprise you when the child comes in for the next appointment and tells you exactly what needs to be done instead of crying about each part of the procedure.

Return to the Parent

Although this is not a feared moment of the dental appointment it is a critical moment. Children who have behaved throughout the procedure, or who were resistant initially and calmed down towards the end may inexplicably burst out crying after the whole procedure is finished. This is a normal reaction. All the anxiety and fear that were controlled during the appointment are finally released at the end. The child should still be rewarded for the good behavior. If the parents were present during the procedure they will understand this sudden release of tension and anxiety by the child. However, this reaction should be explained to the parents prior to the appointment so that they will not have doubts as to what the dentist has done. Always inform and discuss with the parents at the conclusion of the appointment what was done and what will be done; ask them to monitor the child if anesthesia was administered to prevent self-injury; inform them if the child will have any discomfort; and give post-op instructions, if needed.

Nonpharmacological Behavioral Methods

There are several behavioral methods that could be used to decrease the anxiety children have during a dental appointment. Which one to use depends on the patient's temperament, developmental age, and the dentist's relationship with the child.

Tell-Show-Do

In this method before anything is done the procedure is explained in a language the child understands, thus substituting words for instruments and procedures. Then it is demonstrated through simulation. Finally, the procedure is started. The "telling" and "showing" could be done simultaneously. For example, before doing an exam on the patient the dentist could explain and demonstrate on a doll how they (the dentist and the child together) can look at the doll's teeth through the "mirror" and use the "counter" (back end of explorer) to count her teeth. Then the procedure could be started on the patient.

Positive Reinforcement

A reward that is either verbal or tangible is given for a desired behavior. It is important to focus on something good that the child had done even if the appointment was difficult. This way the child will not be totally embarrassed but will have an accomplishment to be proud of which they will try to repeat at the next session. Children always react positively to praise.

Distraction

Distraction is a method of taking away the attention from an uncomfortable thought or uncooperative behavior and directing it toward something else. The injection is generally the most feared part of the dental procedure. This is the time I find distraction to be most effective. Besides wiggling the patient's cheek or lip during administration of anesthesia the child could be exposed to a repertoire of children's songs sung in a ridiculous and funny way. Believe me, not only is the patient distracted but so are the parents and siblings that are in the room. Humor is a playful method of distraction that is often effective.

Fading

This method involves patient holding something that will help the patient cooperate during the appointment and then slowly removing that object (or person) once the patient feels comfortable. This method is used more with adolescents in order to build their confidence and overcome their fear.

Systematic Desensitization

This method involves initially presenting situations or instruments that evoke little anxiety and then gradually bringing in more fear-provoking stimuli. This way the dentist could build the child's confidence through accomplishments and trust. We do not want to overwhelm the child. Gradual presentation of events from least to most fearful is recommended. If a child has an extensive treatment plan (and the patient is not symptomatic) then jumping to do an extraction on the first or second visit will prevent the child from cooperating at future operative appointments. Planning accordingly will save the dentist time and aggravation. It is preferable to do treatment in this order exam, cleaning and fluoride, radiographs, sealants, operative, extractions.

Voice Control

Voice control should not be misconstrued as a method of screaming. In fact whispering into a child's ear with a firm voice or communicating with the child in a tone that relays the message that the dentist is in charge will provide a more favorable response. This technique must be used immediately when uncooperative behavior begins because once the inappropriate behavior is out of control it will not work as well.

Restraints

When using any form of restraint we must always keep the following factors in mind. The restraints must be safe, time limiting and not used as a form of punishment. Consent from the parent beyond the general consent is recommended. The restraint is advised in cases where the child's uncooperative behavior may cause injury to the child or staff during the dental treatment. Since the only other alternative for unmanageable patients would involve drugs or general anesthesia this method is preferred because there is little risk of harm to the child.

There are children who are cooperative but are simply unable to keep their mouths open. There are jaw stabilization devices such as taped tongue blades, McKesson mouth props and soft-mouth ratchets that could assist in mouth management.

Wrist restraints or assisted hand control by staff or a parent are most beneficial for children who are not resistant to treatment but just don't have control over their movements (e.g., CP, MR.) By using this method, treatment is easier to complete. The child is then saved from needing to be treated under general anesthesia during routine periodic dental visit.

Patient stabilization is important for the uncooperative patient in order to prevent undue harm and to allow clear visualization of the oral cavity and provide best medical care. The patient could be stabilized with a sheet, papoose board (Olympic Medical Corporation, Seattle, Wash.), papoose board with head-stability attachment or patient's head held by a parent. If the parent is willing to help and the child is small enough, then the parent should sit in the patient's chair, holding the child in the lap, wrapping legs around the child's legs and restraining the child's arms. If the parent is not mentally or physically able to do this then this is not an option.

Pharmacological Behavioral Methods

Most pediatric dental patients could be managed by the methods described above. However, there are children that will need pharmacological intervention to provide dental care. These candidates include those that are resistant to treatment and also children that due to their behavior may cause harm to themselves or staff; included are patients with a medical problem or a handicapping condition. Another group of children who may need pharmacological intervention consists of those with an extensive treatment plan.

Often children who are cooperative initially become uncooperative when they have to return several times for operative procedures. At this point pharmacological intervention does not work as effectively as if implemented initially. Thus we must look at the full picture and consider future complications that may arise. Remember, children's dental experiences affect their perception of dental treatment in adulthood.

Before discussing routes of administration for various medications in the management of pain and anxiety in pediatric patients we must understand the levels of sedation we could obtain in a young patient. It is important to know the fundamental differences because of potential overlap.

Conscious Sedation

	Minimally depressed level of consciousness
	Independently maintain patent airway
	Respond to physical or verbal stimuli

Deep Sedation

	Controlled state of depressed consciousness or unconsciousness
	Partial or complete loss of ability to maintain patent airway
	Partial or complete loss of ability to respond to stimuli

General Anesthesia

	Controlled state of unconsciousness
	Complete loss of ability to maintain patent airway
	Complete loss of ability to respond to stimuli

It is important to understand the distinctions between conscious sedation, deep sedation and general anesthesia when sedating pediatric patients. Under conscious sedation the patient is able to maintain a patent airway and respond appropriately. However, under deep sedation and general anesthesia the patient is unable to maintain a patent airway independently, and is, therefore, at higher risk of cardiovascular and respiratory complications. Therefore, those dentists who want to use the modality of deep sedation or general anesthesia must undertake this in a hospital setting. The topic of deep sedation and general anesthesia is beyond the scope of this course. If an office conscious sedation mode of treatment is preferred the practitioner should be vigilant as to the special guidelines that must be followed.

Conscious Sedation

One should follow specific guidelines while administering conscious sedation to a pediatric patient in the dental office under the safest environment. The safety standards stress two important areas. The office personnel that must be present during the procedure include the dentist and the assistant. The assistant should be trained in resuscitation measures and should have the capability to monitor physiologic parameters. Continuous monitoring by a trained individual is essential. The pulse oximeter is the equipment of choice to use. It will obtain information on the status of the patient's oxygenation by measuring oxyhemoglobin.

In addition to monitoring the office should be equipped with positive pressure oxygen and high-speed suction. Easy access to backup emergency service is necessary. Prevention is the key to success.

The dentist should have a thorough knowledge of the medications to be used, their maximum doses and contraindications. The maximum recommended dose (MRD) should be calculated by weight and should never be exceeded.

It is essential to obtain a thorough medical history and complete a physical assessment. This information will allow the practitioner to determine if the patient is a candidate for conscious sedation.

History

	Medications (steroids, bronchodilators, OTC depressants)
	Previous sedations complications (vomiting, allergic reactions)
	Hospitalizations
	Family history (malignant hyperthermia)
	Diseases
	Cardiovascular
	Pulmonary

- asthma, croup, allergies

- sleep apnea (airway problem)

Premie on ventilator (bronchopulmonary dysplasia)

- central nervous system

	Liver
	Kidney

Physical Assessment

	Vital signs: HR, RR, BP
	Vital statistics: age and weight
	Physical condition
	Gait, wheelchair, coordination
	Airway
	Mouth breather, nasal speech
	Syndromes of head and neck (mid-facial hypoplasia)
	Obesity

ASA Status (Class 1 or 2 is acceptable for conscious sedation)

	Class 1 Healthy patient
	Class 2 Mild to moderate systemic disease without significant limitation
	Class 3 Severe systemic disturbance with physical limitations
	Class 4 Life-threatening systemic disorder
	Class 5 Moribund patient not expected to survive >24 hours

Routes of Administration

Inhalation

Nitrous oxide is helpful with children who are anxious but cooperative or those with short-attention span. The uncooperative children might not allow the mask to be placed on their nose. Children who have upper respiratory obstruction or who cannot understand that they must breathe through their nose are poor candidates for nitrous oxide. There are some patients who feel nauseous or excited from it. Therefore, the practitioner should evaluate acceptability of each patient to nitrous oxide.

The benefit of nitrous oxide is that its dose could easily be controlled (titration capability) and has rapid onset and recovery time. It lacks serious adverse effects because it is inert and nontoxic.

It is important to calibrate equipment annually and check the delivery system. The system must have a fail-safe feature to prevent administration of pure nitrogen when the oxygen tank is empty. A scavenger system is essential to prevent exposure of trace levels of nitrous oxide to dental office personnel.

The dentist must introduce the nosepiece and prepare the child to the feelings they will experience. Today nosepieces are available with different flavors and colors that are pleasant to children. It could be explained to the children, " You'll be able to choose a `Mickey Mouse' nose and Mickey is going to play a game with you. You and Mickey are going to close your mouth and breathe the sweet-smelling magic air through your nose. Then you'll feel like you're flying and your hands and feet will feel like someone is tickling you."

Oral

As opposed to needles, the advantage of administering medication through the oral route is that it is more accepted by the child, especially if the medication tastes good and is given in low volume. However, if the child is uncooperative in drinking the drug the child may cause spillage or vomiting of the medication. Adding more medication after the initial dose is spilled is not recommended since the practitioner will not have a way to determine how much medication needs to be replaced. Thus certainty of effect becomes questionable. Once the drug is administered it is not titratable and its effect becomes unpredictable.

It is advisable to give the medication in the office under proper supervision. When scheduling a sedation appointment the practitioner must keep in mind that oral administration has the longest time of onset than any other route. Allocate additional 45 minutes prior to the beginning of the treatment. Absorption of the medication orally is variable from patient to patient. Thus the effect of the medication may range from agitation to proper sedation.

All these factors must be kept in mind. If the medication is calculated by weight for each individual patient and is not combined with other medications, then the oral route of sedation is very safe.

Intramuscular

Little patient cooperation is required in order to administer intramuscular injection. With IM route of administration the full dose is given with certainty. Absorption of the drug is dependent on the location it is deposited. If the medication is injected in a deep muscle absorption is faster than the oral route. If the drug was deposited between muscle layers then absorption will be unpredictable. As with the oral route of administration, the drug cannot be titrated safely. The practitioner must be careful to minimize the possibility of tissue trauma at the injection site. It should be stressed to the parent that although the child may be resistant to intramuscular sedation due to the fear of the needle, the benefit is that the injection is absorbed faster and is technically easier to administer.

Intravenous

The intravenous route of administration is very predictable and easily titratable (thus reversible) due to the fact that the drug is injected directly into the blood stream. There is no question of absorption time. A small initial test dose can be given to check for any allergic reaction to the drug. The benefit of this route of administration is that in case of an emergency intravenous access has already been established.

Intravenous access and maintenance is difficult in children, particularly those who are overweight. There are potential complications at the venipuncture site which include bleeding, hematoma or thrombophlebitis. Due to the fact that medications could be directly injected into the bloodstream there is an increased potential for complications to occur very rapidly, requiring the highest level of monitoring.

Medications Used For Conscious Sedation

1.Sedative-Hypnotics

The principal effect is sedation and sleepiness. It does not decrease anxiety or give analgesia. As the amount of medication is increased, hypnosis, and at a higher level general anesthesia and coma, could occur. Sedative-hypnotics site of primary effect is the reticular activating system. This is the area of the brain that maintains consciousness. There are two categories of sedative-hypnotics.

A. Barbiturates

	Pentobarbital, secobarbital, methohexital
	Since these drugs are rapid acting the difference between mild sedation dose and general anesthesia dose is small — they are not used for conscious sedation.

B. Nonbarbiturate Hypnotics

Chloral Hydrate

- Most common sedative agent in pediatric dentistry

- Minimal cardiovascular or respiratory effect

- Bitter tasting management problem

- Gastric irritability may cause vomiting (when antiemetic given dosage levels must be adjusted to prevent potentiation)

2. Antianxiety Agents

The principal effect is to remove anxiety. The primary site of action is the limbic system. This is the area of emotions. As doses increase the drug will affect the reticular activating system which produces sedation. Most antianxiety medications have a safer therapeutic index because the range between the dose that produces the desired effect and the one which produces unconsciousness is large.

A. Benzodiazepines (used more for adults)

- Diazepam (Valium)

- Minimal cardiovascular and respiratory effect

- Reversal agent (Flumazenil)

Midazolam (Versed)

- Respiratory depression side effect

- 3-4 potency of diazepam

- Reversal agent (Reversed)

B. Antihistamines

Hydroxyzine (Atarax, Vistaril) Diphenhydramine (Benadryl)

- Possess both antianxiety and sedative-hypnotic properties

- Bronchodilator

- When used alone these drugs are not very effective for conscious sedation; thus used as potentiating agents or as antiemetic

3. Narcotics

Narcotics are used for analgesia and/or to potentiate the effects of sedative-hypnotics or antianxiety agents. The primary site of action is the opioid receptors of the central nervous system. Narcotics should not be used if sedation is desired. Narcotics should be used with extreme caution for conscious sedation since they can produce respiratory depression.

Meperidine (Demerol)

- CNS, CV, respiratory depression
- Reversal agent (Naloxone)

Preparation For Conscious Sedation

Informed consent must be obtained prior to a conscious sedation session. The diagnosis, treatment options including the option of no treatment, and risks involved should be explained to the parents in a language they can understand. The consent should be in writing and with witnesses.

Verbal and written instructions should be given to the parents prior to the procedure explaining dietary precautions and postoperative care. It should be stressed that no food or liquids should be given to the child after midnight. Parents should be careful of children unintentionally sneaking in food because they are hungry. I had a case where a child ate 3 cookies in the car on the way to the office for a sedation procedure. These cookies were left in the car the night before and the child found them without the parents knowing.

Monitoring

Monitoring is the key to the success of any sedation procedure. It ensures patient safety and provides the ability to recognize potential problems early. The practitioner must adhere to the prevailing standard of patient care in the local community. The more sedated the patients the more crucial it is to monitor them.

Monitoring will include evaluating and documenting the patients' level of consciousness, and airway (respiratory system) and cardiovascular systems. The level of consciousness is determined by the patients' response to stimuli. Is the patient able to have a conversation and control body and eye movements? Monitoring a patient's airway involves keeping the chin elevated, repositioning the head if there is snoring, checking chest movement and patient color. Armamentarium of a pulse oximeter allows the practitioner to monitor oxygen saturation. The pre-tracheal stethoscope allows for evaluation of respiratory sounds and rate. To monitor the cardiovascular system a stethoscope is needed; either manual or automatic devices are needed to measure heart rate and blood pressure. It's important to have the right fitting cuff to obtain the correct reading.

Documentation is necessary for medicolegal reasons. The record must include: pretreatment history, informed consent, sedation written instructions, weight and baseline vital signs. During the sedation procedure it is important to have continuous documentation of vitals and medications administered, including nitrous levels.

Behavior Management of a Child In a Dental Setting
Upon discharge the clinician must evaluate the patient's vital signs and the patient's ability to maintain an airway. Is the patient able to talk, walk and recognize the surroundings? The patient should always be discharged with written post-op instructions in the care of a guardian.

There is a wide range of treatment modalities to choose from in order to deliver the best dental care for the youngest and even most difficult patient. With the knowledge of these behavior management techniques dental practitioners would be in a better position to either choose to use them in their own practice or refer them to the appropriate health-care team.

References

1. Thomas A, Chess S. Temperament and development. New York: Brunner/Mazel; 1977.
2. American Academy of Pediatric Dentistry. The Handbook. American Academy of Pediatric Dentistry, Chicago: 1996.
3. Cameron A, Widmer R. Handbook of Pediatric Dentistry: London: Mosby-Wolfe; 1997.
4. Malamed SF. Sedation, A Guide to Patient Management 2nd edition, St. Louis. CV Mosby Co.,1989.
5. Pinkham JR, Pediatric Dentistry Infancy Through Adolescence. Philadelphia: W.B. Saunders Company; 1994.
6. Pinkham JR, An analysis of the phenomenon of increased parental participation during the child's dental experience. J Dent Child 58(6):458-463,1991.
7. Stewart RE, Barber TK, Troutman KC, Wei SHY: Pediatric Dentistry: Scientific foundations and clinical practice, St. Louis: CV Mosby Co., 1981.

3.Endodontic Treatment in Primary and Young-Permanent Dentition

Dentists should provide methods of caries prevention to their patients. However, once a patient's dental health has deteriorated to severe caries with pulpally involved teeth we should educate the patient as to the importance of maintaining the natural dentition with endodontic treatment instead of the faster method of extraction. By doing so we could prevent problems with occlusion, aesthetics, phonetics or function.

In order to obtain an accurate diagnosis and to determine if a tooth is treatable we should collect facts about the patient's medical history, behavior and dental information (e.g., history of pain, clinical and radiographic examinations, etc.)

Medical History

A child's medical history should be reviewed thoroughly before instituting "just endodontic" treatment. Certain medical histories will contraindicate or indicate the decision to retain the tooth with endodontic therapy.

Indications

	Bleeding disorder: Simple dental problems could compromise a child's medical management. Endodontic treatment could be safely carried out and could prevent further progression of dental disease. Endodontic treatment is preferable to extractions in order to avoid the need for platelet transfusion. Avoid block anesthesia to prevent hematoma from occurring.
	Coagulopathies: If this type of patient is not treated with root-canal treatment then the teeth in question would probably need extractions or risk producing an infection in the future. Under those conditions the patient would then need to be treated in a hospital in conjunction with a hematology team.

Keep in mind that endodontic treatment could be done without factor-cover if block anesthesia is not administered. Due to the risk of hematoma with a block anesthesia a hematologist would then need to be consulted.

Hypodontia: The aim in treating a patient with congenitally missing teeth is to maintain carious teeth with endodontic treatment so as to prevent any further loss of dentition.

Contraindications:

	Congenital cardiac disease: Endodontic treatment is contraindicated in patients with congenital cardiac disease if antibiotic prophylaxis is not taken. This would place the patient at higher risk of developing bacterial endocarditis. Therefore, it is important to obtain medical history prior to treatment.
	Diabetes: If the diabetes is not controlled then healing is delayed. This increases the chance for endodontic treatment to have a poor prognosis. To minimize the risk of infection postoperative antibiotics are recommended
	Immunodeficiency: Since a dental infection could be life threatening to an immunocompromised patient, endodontic treatment is not the first choice of treatment. Once a treatment plan is chosen consultation with the physician to determine the patient's immune status, medications, and the need for antibiotic prophylaxis should be discussed.

Behavioral Factors

When treating children, their behavior will influence the plan of treatment. Factors to look at include:

	behavior at previous treatment
	attendance history
	parental cooperation

A child may present with multiple carious teeth that could be saved with endodontic treatment and stainless steel crowns. However, the patient was uncooperative for simple procedures and the parents declined treatment to be done with sedation. The only other option is extraction and space maintenance if indicated. This is an example where behavioral factors could change a preferred treatment plan.

Dental Factors

History of pain

It is difficult to obtain an accurate history of pain from children since they may not be able to verbalize what they are feeling or localize the area of pain. In addition, these children may be used to pain since they have had severely carious teeth from a young age and do not realize that this is abnormal. Moreover, physiologically pain in children may not be a part of the history since a draining parulis may have formed from the grossly carious teeth which would relieve the pressure that causes pain.

The different presentations of pain will aid in determining if the pulp is treatable. A history of duration, frequency and location of pain should be documented.

There are two main types of dental pain.

A. Provoked Reversible

i.If stimulated by thermal, chemical or mechanical irritants, the pain lessens or stops when stimulus is removed.

ii.Intermittent pain

B. Spontaneous ز Irreversible

i.Constant, nocturnal throbbing pain.

Clinical examination

Signs of pulpal pathosis:

	swelling and redness of vestibule
	grossly carious teeth with paruli
	missing or fractured restorations (possible pulp involvement)

Exam should include:

Soft tissue examination

1. Extraoral review lymphadenopathy could be caused by dental infection but URI and otitis media should also be ruled out.
2. Intraoral feeling fluctuation in a swollen mucobuccal fold could be the sign of an acute dentoalveolar abscess that has not reached the exterior as of yet.

Hard tissue examination

	Mobility is indicative of pulpal involvement but one must be careful to compare mobility of suspected tooth to its antimere so as not to misdiagnose an exfoliating tooth for a pathologic one.
	Percussion is the most reliable test in primary teeth. This test could be done gently with the back end of a dental mirror. Electric-pulp testing (EPT) and heat/cold sensitivity tests do not provide accurate data in primary dentition since children may confuse where the source of pain is emanating from. In addition these tests tend to increase disruptive behavior in an apprehensive child.

Future considerations

Once a diagnosis has been reached the dentist should evaluate if the tooth should be saved as an individual tooth and relative to the whole mouth.

	Restorability Is there a gross coronal breakdown or has the caries extended to the pulp floor rendering the tooth unrestorable?
	Large infection An acute odontogenic infection of a primary tooth needs to be extracted. The pus cannot be drained through a primary tooth. The same is true of a primary tooth with large periapical pathology.
	Orthodontic Before the first permanent molar erupts it is desirable to maintain a pulpally involved second-primary molar to prevent space loss. In this situation a pulpectomy should be attempted although it has a poorer prognosis.
	Oligodontia A primary molar should be preserved for as long as possible if its permanent successor is congenitally missing. The tooth will maintain the bone level till the patient is old enough for implants, prosthetics and/or orthodontics.

Keep in mind that the pulp clinical presentation dictates treatment options:

Hemorrhagic vital pulpotomy

Endodontic Treatment in Primary and Young-Permanent Dentition

Necrotic ز nonvital ز pulpectomy (poor prognosis)

Radiographic examination

Radiographs are valuable in determining the diagnosis and prognosis of the tooth in question. The following could be evaluated on a radiograph:

	Depth of caries or restorations in relation to the pulp.
	Pulpal changes failing pulpotomy or pulpectomy, pulp obliteration, pulp stones
	Irradicular pathology radiolucencies of primary teeth usually present at the furcation area, not at the apex. This is due to accessory canals on the pulp floor.
	Root resorption

- Internal inflammation of vital pulp within the root canal;
- External inflammation of nonvital pulp affecting the root or surrounding bone.

Periapical pathology (PAP) PAP + root resorption = poor prognosis.

Endodontic Treatment in Primary Dentition

Vital Pulp Therapy

	Indirect Pulp. This treatment modality is not recommended in primary dentition. Indirect pulp treatment is recommended on permanent dentition that has deep carious lesion near the pulp but has no signs or symptoms of pulp degeneration. If there is a 75% chance of exposure with complete caries removal then this treatment is attempted. In order to maintain pulp vitality and to avoid the need for root canal treatment removal of all the caries is delayed. A medicament of either calcium hydroxide or zinc oxide eugenol paste is placed and the cavity is sealed properly. Bacteria will then remain in the deeper dentin layers and be inactivated and carious dentin will re-mineralize. After 6-8 weeks the tooth is reentered for removal of remaining caries and placement of permanent restoration. Some practitioners do not reenter the tooth for final caries removal but instead place final restoration if the patient is asymptomatic after 6-8 weeks. It is important to follow up and have radiographs taken to evaluate the status of the tooth.
	It is preferable to know the pulp status of primary teeth by removing all caries so as to prevent the need for a two-step procedure (IPT) or additional treatment due to infection (if IPT is unsuccessful). This way we are not subjecting the child to extra dental work or discomfort.
	Direct Pulp. This treatment modality is not successful in primary dentition. The direct pulp procedure in primary teeth results in internal resorption or abscess. Failure of the direct-pulp capping procedure in primary teeth could be due to the high cellular content of the pulp. Direct- pulp capping is indicated on permanent teeth with mechanical, carious or traumatic pinpoint pulp exposures. The tooth must be asymptomatic and free of oral contaminants. Calcium hydroxide (bactericide) placement used to be the common practice due to its properties of stimulating the formation of dentin, which helps to maintain pulp vitality. It has become more common and successful to skip this step and continue with the restoration.
	Pulpotomy. This procedure has been shown to be 70-99% successful on primary teeth depending on the study. The purpose of the pulpotomy is to allow the radicular pulp tissue to heal after the carious coronal pulp is removed. This procedure allows for healthy supporting tissues to maintain arch form and prevent harm to the permanent dentition.
	Pulpotomy contraindicated:

	Swelling or fistula
	Mobility
	External or internal resorption
	Interradicular or periapical radiolucency
	More than 1/3 root resorption
	Pulp calcifications
	Nonvital (necrotic) pulp tissue (excessive bleeding, dry, odor)
	History of nocturnal or spontaneous pain, tender to percussion or palpation

Pulpotomy indicated:

	Radiograph caries extends more than 2/3 through dentin (marginal ridge grossly destroyed)
	Mechanical or carious pulp exposure
	Reversible pulpitis (inflammation limited to coronal pulp)
	History of provoked pain by heat, cold, sweets or air that is reduced or disappears when removed

There are several pharmacologic medicaments and non-pharmacologic techniques used for the pulpotomy procedure in order to fix or stimulate repair of the remaining vital radicular pulp.

The properties of an ideal medicament or technique should include:

	Nontoxic (no harm to pulp or other structures)
	Bactericidal
	Promote healing of radicular pulp
	Allow physiologic root resorption to occur
	Long-term clinical success

Pharmacologic medicaments:

A. Formocresol (Fixative)

	Ingredients - formaldehyde, cresol, glycerol, and water (1/5 dilution)
	Mode of action

- bacteriocidal
- fixation inhibits bacterial growth.

Contraindications

- Short-term success high but long-term success is 70%

- Toxic to cells

- Mutagenic and carcinogenic potential

- Histologic failure of radicular pulp: fixation (coronal third), chronic inflammation (mid-third) and vital tissue (only at apical third)

- Exfoliation accelerated

- Time of application It used to be recommended to place formocresol for 5 minutes; however, one minute produces less inflammation and still kills most organisms.

B. Glutaraldehyde (Fixative)

Mode of action

- Bacteriocidal
- Fixation with minimal systemic distribution
- Less toxic because of less penetration into the tissues

Contraindications

- Short-term success rate is good.
- Long-term success rate does not match formocresol success.

C. Ferric Sulfate (Astringent) hemostatic agent

D. Vitapex

Iodoform and calcium hydroxide (bacteriostatic)

E. Maisto's paste

Iodoform and parachlorophenol and camphor-menthol

F. Ledermix

Dimethylchlorotetracycline and triamcinolone

Non-pharmacologic techniques:

A. Electrosurgery

Mode of action

- electrofulguration or electrocautery or electrodesiccation

- advantages–quick, hemostasis (good visibility), no systemic effect

Contraindications

- Excess heat production destroys tissue

- Persistent inflammation

- Formocresol still has higher success rate

B. Lasers

	Advantages–quick, hemostasis, decreased bacterial count
	Disadvantages– same as electrosurgery

C. Pressure pulpotomy

	Mode of action – pressure produces hemostasis
	This technique does not use a medicament that could potentially be toxic or a heat source that presents problem of chronic inflammation.
	Since a medicament is not used the health of the pulp tissue is not masked. If hemostasis is not obtained it is clear that a pulpectomy or extraction should be instituted instead of the pulpotomy.
	Long-term studies indicate 87-93% success.

Pulpotomy procedure:

1. Preoperative radiograph evaluated; local anesthesia administered; rubber dam placement to aid in isolation and child behavior.
2. Removal of caries and endodontic access using a No. 330 bur on high-speed handpiece.
3. The coronal pulp is removed with slow-speed handpiece 6 or 8 round bur. Care should be taken not to perforate pulpal floor.
4. If hemorrhage continues, evaluate if there are tags of pulpal tissue remaining under ledges of dentin. Then cotton pellets under pressure should be placed over radicular pulp orifices for a few minutes. Local anesthetic should not be used as a hemostatic agent since this will mask the true condition of the pulp. If excessive bleeding continues then this may indicate that the radicular pulp is inflamed and necrotic and then a pulpectomy or extraction would be needed.
5. If there is hemostasis or slight bleeding then the chosen medicament or technique discussed above could be implemented.
6. Fill with zinc-oxide eugenol dressing (IRM).
7. Final restoration; preferably a stainless-steel crown should be placed at the same visit.

Nonvital Pulp Therapy

Pulpectomy. The pulpectomy procedure has been shown to have an 80-85% success rate. The parent should still be informed that the tooth has a guarded prognosis. Postoperatively the patient will be monitored for resolution of symptoms, infective process and whether internal or external resorption does not occur. The purpose of this treatment is to maintain a primary tooth that would have otherwise been lost to infection. This procedure allows for maintenance of space and function with the natural dentition.

Pulpectomy contraindicated:

	Root resorption present
	Large intraoral swelling
	Extraoral swelling
	Fluctuant swelling

If these circumstances exist pulpectomy is not the treatment of choice; instead extraction and antibiotics (if necessary) are indicated. It is impossible to achieve complete drainage through a primary tooth due to the presence of extremely thin pulpal canals. One must keep in mind that a swelling may present in between two primary teeth and thus it may be difficult to determine which tooth is responsible for the presentation. In such a case both teeth should be extracted to prevent systemic involvement, and a secondary procedure for the child if the tooth becomes symptomatic.

Pulpectomy indicated:

	Irreversible pulpitis spontaneous, nocturnal pain not relieved by analgesics
	Necrotic pulp hyperemic, dry, foul odor
	Abscessed (in limited cases e.g., small intraoral swelling)
	Irradicular pathology
	Space maintenance (e.g., primary 2nd molar with unerupted 6-yr molar)
	Adequate root remaining
	Cooperative patient

Pulpectomy obturant should have:

	Antibacterial
	Biocompatible
	Easily inserted and removed
	Radiopaque
	Resorbable (harmless to adjacent tooth, but if material extends beyond apex and then resorbs at the same rate as the primary root)
	Not impeding eruption of permanent tooth

Medicaments:

1. Zinc Oxide-Eugenol Paste. This material is used most commonly in the United States. However, it does have problems with biocompatibility and, if overfilled, the paste will be resorbed slower than the tooth.
2. Iodoform Paste (Maisto's Paste, Kri-1 Paste). The ingredients included in this paste are iodoform, camphor, parachlorophenol, menthol. This paste has a bactericidal effect and has the advantage of resorbability and replacement of healthy tissue if extruded past the apex.
3. Calcium Hydroxide or Vitapex (Calcium Hydroxide and Iodoform). This material allows for faster resorbability than of the roots, no ill effects to the permanent tooth, is radiopaque and easy to apply. These materials are more commonly used.

Pulpectomy procedure:

1. A diagnostic radiograph with root apices visible should be taken. Anesthesia administered since there still might be vital tissue at the apices. Rubber dam will allow for isolation and easier behavior management.
2. The access opening will be slightly more flared than in a pulpotomy to allow accessibility with broaches and files. This is implemented first by a high-speed bur to remove all caries, and once close to the pulp floor a slow speed is used with a large round bur to gain access to the canals.
3. Once the orifices of the roots are visible the chambers are debrided with a broach and endodontic files that are measured at 1-2 mm short of the radiographic apex. Care must be taken not to over instrument so as to prevent damage to the permanent tooth bud. Periodically irrigate the canals with no pressure using normal saline, anesthetic or sodium hypochlorite solution to dissolve organic material. The canals are dried with appropriate paper points.
4. Fill with obturant (see list above)

	Large canals (anterior) Thin mixture is placed on the walls of the canal.
	Thick mixture is then condensed gently with either endodontic plugger or amalgam condenser.
	Small canals (posterior) Use of anesthetic or tuberculin syringe could facilitate in the placement of medicament in the canals.
	The canal is then closed with Zinc Oxide Eugenol (IRM).
	After 6-8 weeks when postoperative radiograph indicates that signs and symptoms have improved then a permanent restoration should be placed. Restoration of a pulpectomized tooth in the anterior region could be done as either a composite (not recommended since more likely to fracture), strip crown or stainless steel crown with white facing depending on the amount of tooth structure remaining and parent preference. In the posterior region a stainless steel crown is the restoration of choice.

Endodontic Treatment in Young-Permanent Dentition

There is a difference between mature-permanent teeth and young-permanent teeth. The apex of a mature tooth has completely closed whereas a young-permanent tooth is still developing and is in the process of apical root closure. This process may take 2-3 years after the tooth erupts. Therefore, treatment of young dentition will combine both techniques used in the primary and secondary dentition. The goal of treating young-permanent teeth is to promote closure of the apex or at the very least to obtain atypical apical closure. This will ensure favorable crown-to-root ratio and allow root-canal procedure to be completed when indicated.

The young-permanent dentition attributes pulpal degeneration to either:

1. Deep caries–usually affects posterior teeth (permanent 1st molars)

2. Trauma–usually affects anterior teeth (maxillary incisors)

As discussed above, in order to make an accurate diagnosis in the primary dentition as well as the young-permanent dentition, information regarding medical history, behavioral factors and dental development must be obtained. To prevent repetition of material the following information will cover what is different in endodontic treatment for the young-permanent dentition.

Dental Factors

History of trauma

When dealing with trauma to a young-permanent tooth time is an important detail to consider. The longer the pulp is exposed the greater the likelihood for infection and pulp degeneration.

Longer time of pulp exposure

- apexogenesis, apexification

Shorter time of pulp exposure

- direct pulp cap

Clinical Factors

Caries The clinical presentation of caries in the young-permanent dentition could be misleading. A small lesion in enamel may actually be so advanced that it has reached the pulp through poorly coalesced pit, fissure or hypoplastic enamel. To determine the extent of the lesion the practitioner should evaluate radiographs, note the patient's sensitivity to probing with an explorer; the final option is clinical excavation.

Trauma Fractures are classified as follows:

	Ellis class I fracture in enamel
	Ellis class II fracture in enamel and dentin
	Ellis class III fracture in enamel, dentin and pulp
	Ellis class IV root fractures

Trauma could occur as concussion, mobility, intrusion, extrusion and lateral luxation or avulsion. Treatment for these types of injuries is beyond the scope of this book.

Diagnostic tests - Young-permanent dentition has open apices and therefore incomplete nervous innervation. Thus electric-pulp testing could be misleading. However, electric- pulp test should still be done to obtain a baseline and a reference for comparison in the future.

Other factors to consider:

Stage of root development

- Is there a favorable prognosis if apexogenesis or apexification is implemented?

Crown status

- Is the tooth restorable? Will the tooth need endless restorative treatment in the future?

Orthodontic

- Is the tooth crucial in the arch?

Radiographic exam

Periapical radiographs are essential for evaluating the pulp status of traumatized or deeply carious young-permanent teeth. A periapical radiograph of the antimere for comparison or different views of the affected tooth to rule out fractures is helpful.

Vital Pulp Therapy

	Indirect pulp. This has been discussed above.
	Direct pulp. This procedure would be indicated in the following situations:

1. Carious exposure (small)

i.Asymptomatic

- no pain or redness or swelling.

ii.Radiograph

- no sign of pulp degeneration or periapical area.

iii.Clinically

- controllable bleeding at exposure site.

iv.A temporary restoration is placed till success is insured at which time a permanent restoration is placed.

2. Mechanical exposure (small)
3. The operative procedure is done under rubber dam isolation thus preventing bacterial invasion.
4. A final restoration is usually placed since success is likely. Caries or trauma is not a source of exposure.
5. Trauma (coronal fracture with pulp exposure Ellis class III)

i.pulp exposure <2 mm and injury occurred in the past few hours; direct pulp cap

ii.pulp exposure >2 mm or injury occurred more than a few hours (micro absesses develop in the pulp) apexogenesis

iii.A composite bandage is placed to prevent additional manipulation of an already traumatized tooth. If a final restoration is placed the child may not return for the indicated follow-up visits.

If this procedure is undertaken the risks and benefits should be explained to the parents with the understanding that problems may arise in the future; therefore, careful monitoring is important.

• Pulpotomy. Although this procedure is clinically successful on primary teeth the same is not the case with young- or mature-permanent teeth. Over time deterioration occurs and if calcium hydroxide had been used then a bridge may have formed over the pulp stumps, preventing future root-canal treatment. This procedure should only be attempted if behavioral or socioeconomic constraints prevent conventional endodontic treatment.
• Apexogenesis. Apexogenesis is indicated on immature permanent vital teeth in the following situations:

	Large (> 2 mm) or long standing (>few hours) mechanical or traumatic pulp exposure
	Coronal pulp infected
	The goal in this procedure is to maintain viability of the pulp in the root to allow apical closure (apexogenesis). A radiopaque "bridge" will form at the apex. The benefits of apical closure is that the root will be longer and thus resist fracture and, when RCT is implemented it would be easier to obtain an apical stop to a closed apex as opposed to a large open apex.

Apexogenesis procedure:

1. Radiograph (confirming no periapical pathology) and local anesthesia.
2. Rubber dam isolation.
3. High-speed round bur to remove infected pulp until vital tissue is reached. The pulp is rinsed. Hemorrhage is normal as long as it is minimal and of usual color. Hemostasis is obtained with slight pressure.
4. Non-setting calcium hydroxide (Pulpdent) is placed on the vital tissue (making sure it is not on a blood clot), and then a temporary restoration is placed.
5. A permanent restoration is placed once success is evident. Success is evaluated on 3-6 month follow-up visits, which include pulp vitality tests, radiographs to check for "bridge" formation and continued root development.
6. After the apex is closed conventional root-canal treatment is recommended to prevent future canal obliteration.

Non-Vital Pulp Therapy

Apexification. Apexification is indicated on immature-permanent teeth with:

	Necrotic (nonvital) pulp
	Periapical pathology

- radiograph or clinical

The goal in this procedure is to build an apical hard tissue barrier across the large open apex of the tooth.

Apexification procedure:

1. Local anesthesia.
2. Rubber dam isolation.
3. Endo access with extirpation of necrotic pulp tissue using broaches and files. Instrumentation is done 1 mm short of the radiographic apex and should be implemented gently to prevent fracture from pressure on the short-rooted tooth. Irrigation with sodium hypochlorite, sterile saline or local anesthetic will remove necrotic tissue.
4. Non-setting calcium hydroxide is placed in the canal. To facilitate placement to the apical portion of the root a sterile cotton pellet could be used to transfer the material. A temporary restoration should be placed in the interim.
5. Since the calcium hydroxide washes out it should be changed every 2-3 months.
6. It takes between 6 to 18 months for a calcific bridge to form. Radiographs and gentle probing within the tooth will determine if the bridge is present. Once there is an apical barrier conventional root-canal treatment with gutta percha obturation should be completed very carefully and gently so as not to disturb the bridge.

References

1. Kennedy DB, Kapala JT: The dental pulp: Biological consideration of protection and treatment. In Braham RL, Morris E (eds): Textbook of Pediatric Dentistry. Baltimore, Williams & Wilkins, 1985.
2. American Academy of Pediatric Dentistry: Guidelines for Pulp Therapy for Primary and Young Permanent Teeth Reference Manual 1996.
3. Pinkham JR: Pediatric Dentistry Infancy through Adolescence. Philadelphia, WB Saunders, 1994.
4. Cameron A, Widmer R: Handbook of Pediatric Dentistry. London, Mosby, 1997.
5. Seltzer S, Bender IB: The Dental Pulp 3rd ed. Philadelphia, Lippincott, 1984.
6. Avram DC, Pulver F: Pulpotomy medicaments for vital primary teeth: Surveys to determine use and attitudes in pediatric dental practice and in dental schools throughout the world. J Dent Child 56:426-434, 1989.
7. Camp JH: Pulp therapy for primary and young-permanent teeth. Dent Clin North Am 28:651-668, 1984.
8. Weine FS, Endodontic Therapy. St Louis. CV Mosby Co.,1989.

4.Gingival and Periodontal

Diseases In Children

We may be under the impression that children do not develop serious gingival or periodontal problems. This is incorrect. As practitioners we must be informed and educated on gingival and periodontal diseases that may affect children so as to provide best dental and medical care, and apply measures to prevent further destruction.

In order to treat a periodontal problem we must be able to differentiate between normal and abnormal periodontium. We must keep in mind that normal periodontium in children is different than that in adults.

Child Gingiva

	Redder (due to increased vascular supply)
	Flabbier (due to decreased fiber content)
	No stippling (less rete attachment)
	PDL less density and wider
	Flatter interdental papillae

Child Bone

	Few trabeculae
	Larger marrow spaces
	Less calcification
	More blood supply and lymphatic drainage
	Flatter at alveolar crest

Child Teeth

	Spacing (allows for better oral hygiene)
	Short crowns (less occlusal force)

Spaced roots (less occlusal force)

Anatomic

A. Gingival Recession (Local)

Most common gingival recession occurs to the lower anterior teeth possibly due to a buccally positioned incisor. This area could be difficult to clean, contributing further to the periodontal problem. This may produce a mucogingival defect.

B. Mucogingival Defect

As discussed above, this defect occurs in children mostly due to a buccally positioned lower incisor erupting through a band of attached gingival. The pocket depth will exceed the width of attached keratinized gingiva. Periodontal treatment, if indicated, should only be started after orthodontic treatment is complete.

C. High Labial Frenum Attachment

This condition could make gingival recession and mucogingival defects worse. A high labial frenum attachment in the maxilla could create cosmetic problems. Surgical options include a frenectomy (to reposition the frenum attachment) or a gingival graft (to produce good anatomic contours that are easier to keep clean.) However, any type of surgery should only be done once orthodontic treatment is finished.

Gingival Overgrowth

A. Drug-induced

Gingival enlargement may be caused by several types of medications. Phenytoin is an anti-epileptic; Cyclosporin is an anti-rejection medication used for children undergoing transplantation; Nifedipine is a calcium channel blocker used to control hypertension. The gingival enlargement starts at the interdental papillae and marginal gingiva and could progress to cover the crowns of the teeth. If the medications are stopped the condition regresses; however, consultation with the physician may allow an alternate drug to be used. Maintenance of oral hygiene is essential. Chlorhexidine is helpful. Gingivectomy is an option if the overgrown tissue impedes in tooth eruption or aesthetics.

B. Hereditary Gingival Fibromatosis

Fibromatosis may be genetic (autosomal dominant) or idiopathic. It appears as generalized firm nodular enlargements of the gingiva, which affects both the primary and secondary dentition. Gingivectomy is required to maintain good oral hygiene and prevent problems of delayed eruption and displacement of teeth.

C. Mouth-breathing Gingivitis

The upper anterior region is the most common area for mouth-breathing gingivitis. Mouth breathing affects changes to the gingiva through surface dehydration. It should be noted that we should not only treat the gingivitis with root planing and scaling and oral hygiene instruction but also treat the cause. Refer the child for an ENT consultation to evaluate the cause of the mouth-breathing problem. Does the child have a large adenoid or tonsils or is it a skeletal issue that should be evaluated by an orthodontist? If the source of the problem is not solved, this type of gingivitis will certainly recur even with periodontal treatment.

Gingival Disease

A. Gingivitis

The clinical features of gingivitis include gingival inflammation and no bone loss. The process is reversible. Gingivitis is not a common condition in the primary dentition; however, it does become more prevalent during puberty. Its etiology ranges from plaque accumulation to local factors. Local factors include calculus, orthodontic appliances, eruption, mouth breathing and crowding. The problem may be corrected after the offending agent (plaque or orthodontic appliance) is removed, cleansed or adjusted. The child may need an orthodontic consultation if mouth breathing or crowding is the source of the problem.

B. Inflammatory Enlargement

The clinical features of inflammatory enlargement include bluish red, soft, bleeding gingiva with ballooning interdental papilla and/or marginal gingiva. This condition may be generalized or localized. The causes could be chronic exposure to plaque, orthodontic appliances or mouth breathing. Treatment includes plaque removal; gingivectomy, if required; and appliance adjustment, if necessary.

C. Gingival Abscess

Gingival abscess is described as a localized, painful lesion of marginal gingival or interdental papilla. The cause may be from a foreign object such as a popcorn or fingernail being embedded in gingiva. Relief is obtained after removal of the offending agent and debridement.

D. Pericoronitis

Pericoronitis is an inflammation, swelling or a traumatized pericoronal flap usually affecting erupting third molars. Causes include food impaction, trauma or stress. Symptoms include pain, possible swelling and limited jaw closure. The treatment depends on how severe the case is. Treatment options are irrigation, saline rinses, reduction of opposing tooth, extraction of functionless tooth, and antibiotics.

E. Acute Necrotizing Ulcerative Gingivitis (ANUG, Trench mouth or Vincent's infection)

ANUG clinical features include malodor, painful gingivitis with punched out gingival lesions with white pseudomembrane and gingival necrosis. The patient may have symptoms of lymphadenopathy, malaise and low-grade fever. The factors attributing to this condition include stress, malnutrition, immunosuppression. Peak incidence occurs in late teens and twenties. Effective dental treatment includes debridement, irrigation, chlorhexidine, antibiotics for systemic involvement, NSAIDS for pain and emphasis on good dental care.

Early-Onset Periodontitis

Localized and General Prepubertal Periodontitis (LPP or GPP).

LPP or GPP affect children between the ages of six and twelve. Attachment and bone loss occurs around primary teeth and may also affect the deciduous teeth. LPP may progress to LJP (localized juvenile periodontitis). Causes for this condition include leukocyte chemotactic defect (LCD), immune problem, or cementum defect. LPP is associated with Actinobacillus actinomycetemcomitans (Aa) type of bacteria. Antibiotic treatment includes penicillin, erythromycin or tetracyclines. Dental management may start with scaling and root planing but may still end with extraction of affected primary teeth.

B. Localized Juvenile Periodontitis (LJP)

LJP manifests itself with extremely rapid localized bone loss to the permanent incisors and molars. The rate of bone loss is four times faster than in adult periodontitis. Surprisingly, there is little plaque or inflammation apparent. Children in the age range between 10-15 years are at the greatest risk for LJP. They may have a previous history of LPP. This condition is caused by either Actinobacillus actinomycetemcomitans organism, a leukocyte chemotactic defect (immune defect) or it could be genetic in nature. If this disease is not treated it could lead to severe bone loss, tooth movement and exfoliation of permanent teeth. Treatment involves a combination of root planing and scaling, periodontal surgery, antibiotics (metronidazole which could be used in combination with amoxicillin or tetracycline) and, if necessary, tooth extraction. If treating with tetracycline the child should be older than the age of eight. It is important to have frequent follow-up visits to test if the microbe has been eradicated and to prevent recurrence, which is more likely to occur in children.

C. Generalized Juvenile Periodontitis

Generalized juvenile periodontitis occurs in persons under the age of thirty, with probably a previous history of LJP. The clinical feature includes generalized bone loss in the permanent dentition. The management for this condition is the same as for LJP.

Adult-Onset Periodontitis

Adult-onset periodontitis does not affect only the adult population but also affects twenty percent of 14-17-year old. This type of periodontitis presents itself in teens with attachment loss of at least 2 mm in one or more sites. Fortunately, periodontitis could be arrested with proper treatment of oral hygiene instruction and maintenance, scaling and root planing and correction of local contributory factors. It is crucial to stress to these adolescents that they play a vital role in maintaining their oral health and if their problem with adult-onset periodontitis is not treated, it could result in the need for extensive periodontal and surgical care when reaching adulthood.

Systemic Diseases

A. Acute Leukemia

Leukemia is a malignancy of the blood due to a proliferation of white blood cells. Around 50% of childhood cancers are acute leukemia and tumors of the central nervous system. Various groups of acute leukemia are differentiated by the type of cell that is excessively proliferating in the bone marrow.

1. Acute myeloid leukemia (AML)

- 20% of acute childhood leukemia

- gingiva appears edematous, bluish red, hyperplastic (due to infiltration of leukemic cells)

2. Acute lymphoblastic leukemia (ALL)

- 80% of acute childhood leukemia

- petechia or mucosal ulceration may be present

Flags must go up when you treat a child that presents with gingival enlargement, excessive bleeding, petechia or ulcerations with no specific etiology or resolution. Leukemia must be ruled out with a CBC.

3. Chediak-Higashi syndrome. This is an autosomal recessive syndrome that results from defective neutrophils which causes oculocutaneous albinism, photophobia, peripheral neuropathy and sepsis. Due to severe periodontal disease teeth are shed easily. Most children die by the age of 10. To improve these patients' quality of life dental care should be implemented that will prevent further infection and discomfort.

B. Down syndrome

There is a high prevalence of periodontal disease in Down syndrome individuals. Those who are under 30 years of age have 60-100% prevalence for periodontal disease. The etiology of periodontitis may be from a PMN chemotactic defect or T-cell maturation defect or poor-blood supply to the gingiva. This condition could also occur in the primary dentition and usually affects the lower incisors. Over 30% of Down syndrome children have congenital heart defects. Thus you must remember to prescribe prophylactic antibiotics when necessary.

C. HIV Gingivitis or Periodontitis

The HIV infection affects the immune system by decreasing the amount of CD4 lymphocytes present. There is a variety of disorders that affect children with HIV. The most common lesions for children are HIV gingivitis, candidiasis and parotid swelling; for adolescents they are HIV periodontitis, candidiasis, aphthous ulcers and xerostomia.

Children with HIV are immunocompromised; therefore, a dental infection could be life threatening. Infected patients usually have atypical presentations for common infections.

1. HIV gingivitis

- characterized by a linear erythematous appearance of the buccal gingival margins

- spontaneous bleeding and petechiae

- Tx improved oral hygiene and chlorhexidine

2. HIV periodontitis

- deep pain

- spontaneous bleeding and severe erythema

- interproximal necrosis and cratering (worse than ANUG)

- reduced T4:T8 ratios

- Tx - metronidazole (similar to ANUG)

D. Hypophosphatasia

Hypophosphatasia is a genetic metabolic disease that could present itself with premature loss of the primary dentition, abnormal cementum, pulp chambers that are abnormally large. These characteristics make the dentition look like "ghost teeth." The adult teeth are not usually affected. Systemically there are features of severe bone abnormalities that could cause infant death. The metabolic disorder is due to a deficiency of alkaline phosphatase and an increase in urinary excretion of phosphoethanolamine. There are four groups of hypophosphatasia.

1. Congenital

- 75% mortality rate

2. Infantile

- appears within the first 6 months of life

- 50% mortality rate

- renal calcinosis, cranial synostosis

- premature loss of teeth

3. Childhood

- begins between 6-24 months of life

- long-bone abnormalities

- first sign of illness

- premature loss of anterior primary teeth with minimal gingival inflammation

4. Adult

- bone pain

- pathologic fractures

- childhood history of rickets

The earlier the symptoms appear the more severe the disease. We could do a great service to these children by identifying the clinical features of premature loss of primary teeth and referring them to a pediatric endocrinologist for further investigation to rule out hypophosphotasia.

E. Insulin-Dependent Diabetes Mellitus ( IDDM type 1)

Diabetes is a disorder caused by destruction of the insulin-producing beta cells in the pancreas as a result of virus, toxin or autoimmunity. Insulin production is reduced, thus preventing sufficient breakdown of blood glucose. Blood glucose levels must be maintained to prevent hyperglycemia and ketoacidosis. This form of diabetes is usually controlled with the administration of insulin.

Periodontal disease is a complication of IDDM. Patients with uncontrolled IDDM type 1 have an increased risk and earlier onset of periodontitis, xerostomia, and recurrent intraoral periodontal abscesses. Postoperative healing time increases as does the likelihood of postsurgical infection.

Thus management of an uncontrolled diabetic should be done with caution and consultation with a physician. Certainly, surgery should be avoided in these patients till the diabetes is controlled. The controlled IDDM patient should be given morning appointments (reduces stress level), advised to take usual insulin dosage and eat a meal before the appointment (to prevent hypoglycemia), and, if needed, given prophylactic antibiotics (to reduce risk of infection). The dentist should have a source of glucose in the office if symptoms of insulin reaction occur.

F. Langerhans Cell Histiocytosis (Histiocytosis X, Hand-Schuller-Christian)

Histiocytosis is a disorder of a proliferation of Langerhans cells. There are three categories of which Hand-Schuller-Christian disease has the most periodontal involvement.

1. Eosinophilic Granuloma

- older children and adults

- localized lesions to bone ("punched out" lesions)

- dental intraoral mass or swelling, pain, gingivitis, and loose teeth; lesions involve posterior mandible

2. Letterer-Siwe Disease

- Infants

- Skin and visceral lesions (necrotic and ulcerated gingiva, also involves spleen, nodes, liver, lungs, bone marrow)

3. Hand-Schuller-Christian

- younger children (ages 2-5 years)

- triad

- skull lesions, diabetes insipidus, exophthalmos

- involvement of gingiva and mandible, thus resulting in premature loss of teeth (usually all four quadrants involved)

- destruction of lamina dura results in the appearance of "floating teeth" on dental x-rays

Treatment of histiocytosis X could involve surgery, radiation and chemotherapy. If dental treatment is indicated and a patient is under chemotherapy it is important to monitor blood counts and clinical status. Toxicity from chemotherapy could cause complications. Oral lesions are treated with conservative excision and curettage. Extraction of compromised teeth would be needed to control oral lesions.

G. Leukocyte Adhesion Defect (LAD)

LAD is an autosomal recessive defect involving a decrease in the number of leukocyte surface glycoprotein. This causes reduced resistance to infection. Therefore, these children have frequent respiratory, skin, ear, and soft-tissue bacterial infections. Oral manifestations include ulceration, cellulitis, gingival inflammation, periodontitis and premature loss of primary teeth. Periodontitis presents itself in the form of generalized prepubertal periodontitis and is usually refractory to treatment.

H. Neutropenia

Neutropenia is a condition where there is a decrease in neutrophils, causing the patient to be susceptible to infection. The periodontal symptoms include ulcerations, recurrent soft-tissue infections, bone loss causing early loss of deciduous teeth and periodontal disease in permanent dentition. Treatment involves early preventative care, chlorhexidine rinse, and elective extraction of primary teeth.

I. Papillon-LeFe'vre Syndrome

This autosomal recessive syndrome has two features that are pathognomonic for this condition: Hyperkeratosis of the palms and feet and continuous exfoliation of both primary and adult dentition due to periodontal disease. The primary teeth do not resorb but are shed with their roots prior to the permanent teeth erupting. The permanent teeth are then also prematurely lost. A actinomycetemcomitans is associated with this neutrophil defect and thus metronidazole and chlorhexidine is given to delay the exfoliation of teeth. Full dentures are fabricated to allow function, speech and aesthetics.

J. Self-mutilation

Conditions with self-mutilation:

	Congenital Indifference to Pain Syndrome (autosomal recessive)
	Lesch-Nyhan Syndrome (X-Linked)
	Peripheral Sensory Neuropathies

These children don't feel the pain and thus inflict trauma to the gingiva, lips, tongue or mucosa either using fingers, objects or simply by biting or chewing. Auto avulsion has also been documented. These cases are difficult to maintain. Treatment options include grinding of sharp teeth cusps, composite occlusal table buildups, and acrylic splints. In severe cases elective extractions may be necessary. It has been documented that alternative therapies such as therapeutic touch has been successful in mitigating the self- injurious behavior.

References

1. American Academy of Pediatric Dentistry. The Handbook. Chicago, American Academy of Pediatric Dentistry, 1996.
2. Bhat M: Periodontal health of 14-17 year old US school children. J Public Health Dent 51:5-11m 1991.
3. Cameron A, Widmer R. Handbook of Pediatric Dentistry, London: Mosby-Wolfe, 1997.
4. Carranza FA, Glickman's Clinical Periodontology 6th edition. Philadelphia, WB Saunders Co., 1984.
5. Pinkham JR, Pediatric Dentistry Infancy Through Adolescence. Philadelphia: WB Saunders Co., 1994.
6. Ranney RR, Debski BF, Tew IG: Pathogenesis of gingivitis and periodontal disease in children and young adults. Pediatr Dent 3:89,1981.
7. Romer M, Dougherty N, Fruchter M. Alternative therapies in treatment of oral self injurious behavior: a case report. J of Special Care Dent 18(2):66-69, 1998.

5.Dental Anomalies

As pediatric or general dentists it is important to be able to diagnose and treat dental anomalies. If these problems are diagnosed early then appropriate advice, prognosis and potential risk could be explained. In some cases genetic consultation would be beneficial in order to provide information as to what to expect for future generations. Diagnosing dental anomalies provides a great service to the children because then the issues of aesthetics, dental function, occlusion, treatment for pain are all addressed in proper context.

Stewart and Prescott (1976) categorized dental anomalies in terms of abnormalities in tooth number, size, shape, and color. This method allows the anomalies to be related to the stages of tooth development during which the problem occurred.

Before describing the dental anomalies we must first review the dental developmental stages of a tooth unit from initiation to eruption. At approximately 6 weeks in utero dental lamina differentiates from the basal layer of oral epithelium. In addition to the primary teeth, dental lamina is also produced for the future permanent dentition.

Three Phases For Initiation

Primary dentition 2^nd month in utero

Succedaneous dentition 5^th month in utero

Accessional dentition

1^st molar 4^thmonth in utero

2^nd molar 1 year of age

3^rd molar 4-5 years of age

It is from the dental lamina that tooth buds arise. Tooth buds are comprised of enamel organ , dental papilla and dental sac. The ectodermal tissue provides the ameloblasts that form enamel and the mesoderm develops dentinoblasts that form dentin and pulp. The tooth bud follows a specific life cycle of seven histologic stages (from initiation through eruption) during which morphologic developmental stages (from dental lamina, bud, cap, bell, and hertwig root sheath) occur.

1. Initiation

This stage begins at 6 weeks in utero when the basal layer of the oral epithelium expands. The basal layer is what separates the ectoderm (epithelium) above from the mesoderm. At ten sites (future tooth germs) along the basement membrane (the row of cells above the basal layer) in both the maxilla and mandible cells start to multiply faster than the surrounding cells.

Problems in this stage lead to anomalies of tooth number.

2. Proliferation

Proliferation continues the expansion of the tooth bud (bud stage). When the tooth germs epithelial cells continue to multiply; they take on the form of a cap (cap stage). The cap is comprised of:

mesenchyme which will form à dental sacà cementum and PDL;

dental papilla à pulp and dentin

stellate reticulum of the dental organ à enamel

Problems in this stage lead to anomalies of number, size, proportion and twinning.

3. Histodifferentiation

	The cells in the tooth germ begin to differ histologically. The differentiation of the odontoblasts occurs before that of the ameloblast. The cap begins to change its shape to a bell (bell stage).
	Problems in this stage lead to anomalies of enamel and dentin .

4. Morphodifferentiation

The histological cells (ameloblasts, odontoblasts, cementoblast) begin to organize to develop various tissues of enamel, dentin, pulp, cementum, and PDL. This stage is called the advanced bell stage.

Problems that arise at this stage lead to anomalies of size and shape.

1. Apposition

	The special tissues now deposit layers of enamel and dentin.
	Problems in this stage lead to anomalies of enamel, dentin and cementum.

6. Calcification

Calcification occurs through the precipitation of inorganic calcium salts, thus hardening the matrix (enamel and dentin) that was formed earlier. This process takes a long period of time and begins at the cusp tip or incisal edge of the tooth. The lines of retzius (or neonatal line in primary teeth) are incremental lines that could be found in the cross section of a crown. These lines represent the developmental pattern of a tooth and, therefore, if irregularities are found then systemic disturbances are at fault. During the birth process the fetus sustains enough insult to cause a growth change that is reflected dentally as the neonatal line or ring.

Problems in this stage lead to anomalies of mineralization of enamel and dentin.

7. Eruption

When the crown has been completely formed the inner and outer epithelia continue to grow without the stellate reticulum. This structure is now called the Hertwig's root sheath . The Hertwig's root sheath determines the shape of the root and the eruption of the tooth.

1. Number

Hyperdontia. Supernumerary teeth occur more frequently in males than in females (2:1), have a higher incidence in the permanent dentition (5 times more common) than in the primary dentition, and are located 90% of the time in the maxilla. The most common supernumerary tooth is the mesiodens which occurs in the palatal midline.

Supernumerary teeth are classified as follows:

	Supplemental = duplication of normal anatomy of teeth
	Rudimentary = duplication of dysmorphic teeth (conical, tuberculate, molariform)
	Syndromes that demonstrate hyperdontia:
	Cleidocranial dysplasia
	Delayed exfoliation of primary teeth
	Delayed eruption of permanent teeth
	Lack of cementum
	Hypoplasia of clavicles and midface
	Gardner's syndrome Delayed eruption
	Osteomas, Odontomas
	Epidermoid cysts and intestinal polyps
	Cleft lip or palate Excess (or deficiency of) number of teeth
	Crouzon's disease Hypoplastic midface, craniosynostosis, exophthalmos (Craniofacial dysostosis)
	Down's syndrome Mental retardation, brachycephaly
	Hallermann-Streiff syndrome Delayed exfoliation of primary teeth
	High palatal vault
	Mandibular hypoplasia
	Oral-Facial-Digital syndrome Median pseudocleft of upper lip
	Cleft tongue
	Cleft palate
	Multiple hyperplastic frenum with clefts
	Sturge-Weber syndrome Seizures, portwine stain of face, calcified meninges

Management of conditions that involve supernumerary teeth depends on the shape and position of these teeth. Conical teeth erupt and are easily extracted. Tubercular or inverted conical teeth would need oral surgery. It is important to remove the supernumerary teeth so as not to impede the path of eruption of the permanent teeth and to prevent ectopic eruption from occurring. We must not forget to rule out the differential diagnosis of compound odontoma which has the morphology of teeth.

The treatment is dependent upon the patient's age at the time the supernumerary teeth are discovered. Before the of age ten if the unerupted central incisor is upright then the supernumerary tooth is surgically removed and the permanent tooth erupts normally. If the child is over the age of ten, or if the central incisor is maligned, then the tooth needs surgical exposure and the orthodontist will decide if bonding of brackets or chains is indicated so as to assist in traction.

The following will describe the management of syndromes with supernumerary teeth. Please keep in mind that the treatment is provided by a multi-task team involving physicians, geneticists, psychologists, and, of course, all necessary dental specialists. The dental treatment may involve some or all of the following steps that are implemented at appropriate stages depending on the child's age:

	Referral to cleft palate team
	Removal of over-retained primary teeth
	Surgical removal of supernumerary teeth, pathology
	Surgical exposure of permanent teeth
	Orthodontics/Orthognathic surgery

Hypodontia (Oligodontia) Congenital absence of teeth occurs more often in females than in males (1.4:1), and occurs almost 10 times more often in the permanent dentition than in the primary dentition. There is a significant correlation between missing primary and missing permanent successor teeth. The most common missing teeth are the last teeth in each group (i.e., lateral incisor, second premolar, and third molar) with the frequency occurring in the following order: third molar, mandibular 2nd premolar, maxillary lateral, maxillary 2nd premolar.

Syndromes that demonstrate hypodontia:

	Ectodermal dysplasia Conical crowns, maxillary hypoplasia
	Aplasia of sebaceous glands and sparse hair
	Chondroectodermal dysplasia Conical crowns, premature teeth (25%)
	(Ellis-van Creveld) Enamel hypoplasia, absent maxillary sulcus
	Polydactyly, dwarfism, ectodermal dysplasia (hidrotic)
	Cleft lip or palate Hypodontia occurs adjacent to the cleft
	Crouzon's disease See above
	Down Syndrome See above
	Hallermann-Streiff syndrome See above
	Incontinentia pigmenti Conical crowns, premature teeth, delayed eruption
	Pigmented macules, alopecia, mental retardation
	Orofaciodigital syndrome See above
	Reiger's syndrome Delayed eruption
	Midface hypoplasia
	Seckel syndrome Facial hypoplasia
	Low-set lobeless ears
	Microcephaly, dwarfism

The goal in treating these patients is to provide function (mastication and maintaining the vertical dimension), speech and aesthetics. This can begin as young as 2-3 years of age. At this age children are more aware of their appearances compared to the appearances of their peers and are more likely to accept treatment. Also at this time, all of the primary dentition will have erupted and thus dentures will not need to be redone for another 4-5 years. Treatment options may include composite build-ups of conical teeth, partial dentures (conventional or over-dentures), orthodontics (to close spaces), surgery (exposing impacted teeth), and implants. Implants are not recommended for growing children. However, children with conditions such as ectodermal dysplasia do not develop alveolar bone where teeth are absent; thus the implants will not retard alveolar growth or change the eruptive path of distally positioned tooth buds since they are congenitally missing.

2. Size

Microdontia.Presentation of a tooth smaller than its normal size could occur as a singular occurrence or in a generalized form. The singular form usually occurs as maxillary peg-shaped laterals or maxillary third molars. The teeth affected are most often the same teeth that are congenitally missing. Microdontic maxillary lateral incisors occur more often in the permanent dentition (2%) than in the primary dentition (<.5%). It is more common in females.

There are two generalized forms:

True generalized microdontia

- All of the teeth are smaller than their normal size. This is rare but could occur in pituitary dwarfism.

Generalized relative microdontia

- The teeth are smaller in relation to the larger-than-normal mandible and maxilla.

Management of these cases includes porcelain crowns and composite build-ups to improve aesthetics. This is difficult since these teeth have a narrower emergence profile at the cervical margin. Thus, the practitioner must be careful as to how large he builds up the tooth to prevent an overhang at the gingival margin.

A trial wax build-up would allow the dentist to evaluate if orthodontics would be necessary to obtain optimal results prosthetically. Prior to any treatment the microdontic teeth need a periodontal evaluation and measurement of their root-to-crown ratio. This information might dissuade the dentist from restoring these teeth at that time and reevaluate in the future for implants after exfoliation.

Conditions with microdontia:

	Chondroectodermal dysplasia See above
	Ectodermal dysplasia See above
	Hemifacial microsomia Results from hematoma of stapedial artery in-utero
	Leads to less blood supply (growth) to half (hemi) of face causing microdontia to affected side
	Down syndrome Peg laterals

Macrodontia. Presentation of a tooth larger than its normal size could occur as a singular occurrence or in a generalized form. Macrodontia is unknown in the primary dentition but may occur in the permanent dentition (1%).

The generalized forms of macrodontia:

True generalized macrodontia

- occurs due to a hormonal imbalance such as pituitary gigantism

- all the teeth are larger than normal teeth

Generalized relative macrodontia

- the teeth are larger with respect to the smaller mandible and maxilla

Management of these cases includes reducing tooth size with stripping. If there is only one tooth that is enlarged then the antimere could be built up with composite as long as the final result would be aesthetically pleasing. As a last resort, extraction and replacement of the tooth prosthetically could be attempted.

Conditions with macrodontia:

	Hemifacial hypertrophy Caused by either vascular or neurogenic abnormalities
	Teeth develop and erupt more rapidly on affected side
	Otodental syndrome Macrodontia affects posterior teeth
	Molar fusion

Twinning. Twinning presents itself as a structure similar to two conjoined teeth. Keep in mind that if there is a "double tooth" in the primary dentition there is a chance to have a missing tooth in the permanent dentition or retarded eruption of the permanent successor. Twinning can appear in different forms such as fusion, gemination, or concrescence.

1. Fusion

Fusion, gemination and concrescence have an incidence of .5-2.5% and somewhat higher in the primary dentition. Gemination occurs when there is a union at the dentinal area of two-tooth germs. Therefore, when counting the dentition there will be a one-unit reduction of the number of teeth. But if the tooth is fused to a supernumerary tooth then the number of teeth will be normal. They usually appear with two separate canals. Management of fused teeth includes caries prevention and aesthetics. Since these teeth appear with a groove on the buccal and a notch in the incisal it is advisable to place a sealant to prevent future complications. In the permanent dentition the fused teeth could be separated with endodontic, orthodontic or restorative treatment to reshape and realign the teeth.

ii. Gemination

Gemination occurs when there is an incomplete division of one-tooth germ. When counting, the dentition will have an extra crown (as long as there is a normal complement of teeth.) They appear as a bifid crown with a single root and pulp chamber. Management includes caries prevention as described above. It is not possible to separate the tooth since it has only one canal. Therefore, extraction, prosthetic replacement and possible orthodontics are other treatments of choice if the tooth becomes symptomatic or is aesthetically displeasing.

iii. Concresence

Concresence is the joining of two teeth by cementum only. It occurs after root development from trauma or crowding. If the tooth is symptomatic then endodontic or surgical consultation should be advised with future prosthetic treatment.

1. Size and Shape

Dens invaginatus (dens in dente, tooth within a tooth). Dens invaginatus is a developmental invagination of inner enamel epithelium resulting with the cingulum pit of the tooth having a thin enamel layer between the pulp and the oral cavity. Having such a small barrier between the invaginated portion and the oral environment causes caries involvement and possible pulp necroses. This anomaly occurs at an incidence in the permanent dentition of 1-7.7% and in the primary dentition at .1%. It occurs more often in males than in females and mostly affects the maxillary lateral or first premolar.

If the tooth has recently erupted and is caries-free then the palatal surface should be sealed. The endodontist should be consulted to evaluate if the case is favorable for root-canal treatment. If the internal anatomy is not negotiable for root-canal treatment then extraction and prosthetics may be indicated.

Dens evaginatus. Dens evaginatus is a developmental evagination of the inner enamel epithelium resulting with an extra cusp which contains pulp tissue. It occurs in the central groove or ridge of a posterior tooth (usually lower premolar) or in the cingulum area of incisors. This anomaly occurs at an incidence of 1-4.3% in the permanent dentition and is almost unknown in the primary dentition. The syndrome associated with this anomaly is lobodontia which has characteristics of "wolf teeth" and fang-like cusps.

Prior to a tooth erupting into full occlusion it is recommended that prophylactically the tubercle be recountoured by supporting its sides with composite to produce a central ridge. If the tubercle has been fractured or abraded then a pulp exposure occurs. This usually occurs soon after eruption at which point the apex of the root has not closed. The treatment would include either an apexification or apexogenesis or extraction. An orthodontist and prosthodontist should be consulted.

Taurodontism. Taurodont teeth have enlarged pulp chambers, long crowns and short roots. The incidence ranges from .5-5% in the population.

Taurodontism is found in the following:

	Amelogenesis imperfecta Type IV, enamel hypoplasia and hypomaturation
	Mottled yellow teeth
	Down's syndrome See above
	Ectodermal dysplasia See above
	Klinefelter's syndrome Taurodontism in 30%, bimaxillary prognathism
	Mental retardation, small cranial dimension
	Oral-facial-digital syndrome See above
	Trichodento-osseous syndrome Taurodonts have periapical radiopacities
	High pulp horns prone to exposures
	Delayed eruption
	Dolichocephalic with Sclerotic bones, coarse hair frontal bossing

Dilaceration. Dilaceration is described as an abnormal bend of the root that occurs during its development. The etiology for this condition is usually trauma to the primary dentition (i.e., intrusion.)

Dilaceration is a consistent finding in:

	Congenital ichthyosis Delayed eruption
	Hyperkeratosis of knees and elbows, scaly skin

4. Structure Enamel

Amelogenesis imperfecta (AI). Amelogenesis imperfecta is an inherited enamel defect with incidence ranging from 1:14,000, 1:8000, to 1:4000. AI is categorized into four major types: (hypoplastic, hypomaturation, hypoplastic or hypomaturation with taurodontism, and hypocalcification) with a total of 14 subgroups. The inheritance patterns could either be autosomal dominant, autosomal recessive, or x-linked. The unique feature of AI is that it is an enamel defect that has distinct patterns of inheritance and it occurs separately from any syndrome, metabolic or systemic condition.

A. Hypoplastic

During the histodifferentiation stage of tooth development there is inadequate amount of enamel formed due to the absence of inner enamel epithelium in the enamel organ differentiating into ameloblasts. A majority of the cases are of the hypoplastic type.

Both dentitions are affected

- Enamel insufficient quantity

- Anterior open bite (60% of cases)

Hypomaturation

This type of defect occurs due to a defect in the enamel matrix apposition.

- Enamel normal thickness (quantity)

- Enamel – soft, porous, brown (quality)

3. Hypocalcified

This type of defect occurs during the calcification stage of enamel formation.

- Enamel – normal thickness (quantity)

- Enamel – soft, poorly calcified enamel fractures (quality) exposing dentin (unaesthetic)

- Anterior open bite (60% of cases)

- High calculus formation

- Delay in eruption

D. Hypoplastic or hypomaturation with taurodontism

This type of defect occurs during both apposition and histodifferentiation stages of tooth development.

- Enamel – mottled yellow-brown color with pits

- Taurodont molars

Management of AI includes all or some of the following suggestions. In order to preserve vertical dimension and to restore the dentition to function stainless steel crowns are recommended until late adolescence at which time definitive treatment with PFMs could be started. If there are small hypoplastic teeth then over dentures could be fabricated. To obtain aesthetics for the anterior teeth it is possible to bond composite (veneers are preferable) to hypoplastic and hypomineralized enamel. To correct anterior open bite in hypoplastic forms orthodontic or orthognathic surgery may be necessary. The parents should be referred to genetic counseling that would provide relevant information they need.

Enamel hypoplasia. This is a defect in enamel quantity where the enamel has a break in surface continuity. Enamel hypoplasia could result from either local or systemic causes.

A. Local

Enamel hypoplasia may occur from local causes such as infection, iatrogenic surgery, over retained primary teeth or trauma.

B. Systemic

The systemic causes for enamel hypoplasia include:

Asthma fluorosis > 2 ppm/day

- 10% chance of fluorosis

Infections

- rubella embryopathy {primary dentition}

- syphilis {permanent dentition}

Hutchinson's incisors, mulberry molars

- cytomegalovirus

	Neonatal hypocalcemia
	Neurologic defects

- cerebral palsy

Prematurity

- disruption of ameloblastic matrix activity or mineralization

Radiation

- same as prematurity

Vitamin deficiencies

- A, C, D, Ca,P

	Syndromes or chromosome defects
	Down syndrome
	Epidermolysis bullosa Lesch-Nyhan syndrome
	Fanconi syndrome Sturge-Weber syndrome
	Hurler syndrome Treacher-Collins syndrome
	Hunter syndrome Trichodento-osseous syndrome
	Hypoparathyroidism Vitamin dependent ricket

5. Structure (Dentin)

Dentinogenesis imperfecta (DI). Dentinogenesis imperfecta is an inherited autosomal dominant dentin disorder that has an incidence of 1:8000. DI is divided into three groups: Shields Type 1, Type 2 and Type 3. DI may or may not be associated with osteogenesis imperfecta (OI); therefore, if a child presents with DI, blue sclera and a history of bone fractures then OI should be ruled out.

A. Shields Type

1. Osteogenesis imperfecta {Bones brittle, bowing of limbs, bitemporal bossing}

	Blue sclera, impaired hearing
	Primary dentition

- affected more than permanent

Permanent dentition

- affects central incisors and 6's

	Pulps obliterated, bulbous crowns, narrow roots
	Amber tooth color, periapical radiolucencies

B. Shields Type 2. No OI

	Primary and permanent dentition affected equally
	Same characteristics as DI-1 with no OI

C. Shields Type 3. Rare, found in Brandywine population

	Shell-like teeth with pulp exposures
	Bell-shaped crowns

Management of DI is the same as AI since they both have the same goals in mind, which are to preserve function, vertical dimension and provide aesthetic appeal.

Dentin dysplasia ("rootless teeth"). Dentin dysplasia is an autosomal dominant inherited dentin disorder. This anomaly has been classified into two types:

A. Shields Type 1

Primary and permanent dentitions

- normal crown morphology

- short constricted roots or rootless

§ absent pulp chambers

§ periapical radiolucencies

B. Shields Type 2

Primary dentition

- amber color

Permanent dentition

- normal crown morphology

§ x-ray- thistle tube pulps w/ stone

§ no periapical radiolucencies

Odontodysplasia ("ghost teeth") Odontodysplasia is an anomaly of tooth development with unknown etiology. Both the primary and permanent dentition are affected. Soon after or prior to the primary teeth erupting the patient presents with abscess. The classic presentation of "ghost teeth" is due to the shell-like crowns (thin layer of poorly calcified enamel and dentin), calcified pulps with shortened roots.

Management in these cases is difficult since restoration with stainless steel crowns or composite is not successful. The affected teeth would then require extraction and prosthetic replacement to restore aesthetics and function.

The following is a list of conditions that have dentin anomalies related to systemic abnormalities:

Vitamin D resistant rickets

- Impaired renal reabsorption of P

	Hypoparathyroidism
	Pseudohypoparathyroidism
	Albright's hereditary osteodystrophy

- MR, short stature

Ehlers-Danlos syndrome

- hyperelastic skin and mucosa

6. Structure (Cementum)

Dental anomalies involving cementum only are not common. The following conditions have histologically defective cementum.

Cleidocranial dysplasia. For more details of this condition, refer to section above that discusses hyperdontia. This condition is also related to cementum defects since the teeth are deficient in cellular cementum.

Epidermolysis bullosa. This is an inherited vesiculo-bullous disease of the skin and mucous membranes. This condition displays poorly calcified acellular cementum and overproduction of cellular cementum.

Hypophosphatasia. Due to low serum alkaline phosphatase levels bone fails to mineralize properly. The clinical features include osteoporosis, bone fragility and premature loss of primary incisors (before 18 months of age). The teeth are lost early due to the failure of cementum to form. Bone and dentin are also affected. Therefore, as explained before this is not an exclusive cementum defect.

References

1. Witkop CJ Jr: Amelogenesis imperfecta, dentinogenesis imperfecta and dentinal dysplasia revisited: Problems in classification . J Oral Pathol 17:547-553,1988.
2. American Academy of Pediatric Dentistry. The Handbook. Chicago, American Academy of Pediatric Dentistry; 1996.
3. Bhaskar SN. Orban's Oral Histology and Embryology: St. Louis, CV Mosby Co.; 1986.
4. Cameron A, Widmer R. Handbook of Pediatric Dentistry, London: Mosby-Wolfe; 1997.
5. Pinkham JR. Pediatric Dentistry Infancy Through Adolescence, Philadelphia: WB Saunders Co.;1994.
6. Stewart RE, Prescott GH: Oral Facial Genetics, St. Louis, CV Mosby Co., 1976.