26.
A 12 yr old pt has avulsed an upper central incisor
just 20-min ago. The parent calls your surgery for
advice. What would be your instructions over the phone
and out line your management of the case?
9. Factors affecting long term prognosis of an avulsed
tooth? 40. Factors affecting the long-term prognosis of
an avulsed tooth.
An avulsed permanent tooth is one of the few real
emergency situations in dentistry.
INSTRUCTIONS TO BE GIVEN:
1)Advice the parent to stay calm and keep the patient calm.
2)Rule out any medical emergency
enquire about any loss of consciousness,
major injuries to other body parts and if any other injuries
that require suturing are present as the patient may require
medical attention .
3) Advise to find the tooth and pick it up by the crown (the
white part). Avoid touching the root to preserve the viable
Pdl cells. Ask if tooth is intact.
4) If the tooth is dirty, wash it briefly (10 seconds) under
cold running water and reposition it. Use cotton if required
Try to encourage the patient / parent to replant the tooth
until it is at the same level as the next one with firm, gentle
pressure.
Bite on a handkerchief to hold it in position, being careful
that it is not swallowed.
5)If this is not possible, place the tooth in a suitable storage
medium, e.g. a glass of milk or a special storage media, like
Hank's Balanced Salt Solution for avulsed teeth if
available. The tooth can also be transported in the mouth,
keeping it between the molars and the inside of the cheek.
Avoid storage in water to prevent dehydration.
6)Advice to come to the surgery as soon as possible.
Management of the patient after the arrival
Assuming as the patient is 12 years old the tooth is
expected to have fully developed root with closed apex.
1)Briefly take medical history: If child has any systemic
disease or is medically compromised (no implantation I
infective endocarditis)
Tetanus immunization status
2)Perform a quick clinical exam
-clean blood and debris
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-check for lacerations
-inspect the dentition
If tooth replanted prior to the patient's arrival at the
dental office or clinic:
Treatment
1)Leave the tooth in place.
2)Clean the area with water spray, saline, or
chlorhexidine
3)Suture gingival lacerations if present.
4)Verify normal position of the replanted tooth both
clinically and radiographically.
continue as below:
If tooth replanted prior to the patient's arrival at the
dental office or clinic
Give LA, if patient is in pain
1)Clean the tooth with saline, taking care not to handle
root surface. Adhering soft tissue not to be touched.
2) Irrigate the socket with saline.
3)Examine the alveolar socket. If there is a fracture of
the socket wall, reduce it with a suitable instrument.
4)Replant the tooth with gentle pressure.
5) Suture gingival lacerations if present.
Verify normal position of the replanted tooth both,
clinically and radiographically.
6)Apply a flexible splint for 7-10 days. It should be
passive and away from gingival tissues.
7)Administer systemic antibiotics. Tetracycline is the first
choice (Doxycycline 2x per day for 7 days at appropriate
dose for patient age and weight). The risk of discoloration
of permanent teeth must be considered before systemic
administration of tetracycline in young patients (In many
countries tetracycline is not recommended for patients
under 12 years of age).
In young patients Phenoxymethyl Penicillin (Pen V), at
appropriate dose for age and weight, is an alternative to
tetracycline.
8)Prescribe chlorhexidine mouthwash twice daily
9) If the avulsed tooth has been in contact with soil, and if
tetanus coverage is uncertain, refer to physician for a
tetanus booster.
10) Initiate root canal treatment 7-10 days after replantation
and before splint removal.
Patient instructions
1)Soft food for up to 2 weeks.
2) Brush teeth with a soft toothbrush after each meal.
3)Use a chlorhexidine (0.1 %) mouth rinse twice a day
Follow-up
Root canal treatment 7-10 days after replantation. Non
setting calcium hydroxide paste is used and sealed
obturation with G.P. is done after 6-12 months.
Splint removal and clinical and radiographic control after 2
weeks.
Clinical and radiographic control after 4 weeks, 3 months,
6 months, 1 year and then yearly thereafter for signs of
resorption.
Implants or FPD suggested at a later stage.
IF APEX WERE OPEN
Same as above
Patient follow up
1)If revascularization was possible, patient recalled to
check for signs of pulp necrosis.
2)radiographs takenat 4 weeks and monthly intervals for 4-
6 months-signs of resorption or loss of vitality
3)If that happens, immediate treatment with calcium
hydroxide.
Dressings replaced every month for 3 months and then
once in 3 months until radiographic calcific barrier seen.
Definitive root filling then placed.
MTA could also be placed instead of calcium hydroxide.
 stage of root development
 physiologic status of the periodontal ligament
 length of extra-oral time
Success compared with time shows:
less than 30 minutes - 90% success
30 to 90 minutes - 43% success
more than 90 minutes - 7 % success
Precautions.
 If possible the avulsed tooth should be stored in
milk or contact lens solution until replacement.
 Storage in tap water or saliva is not
recommended, since the hypotonic conditions
will result in rapid lysis of PDL cells.
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 The extra-oral time (EOT) the tooth is out of its
socket is critical to the success of the replantation
procedure.
 If tooth is replanted within 2 hours after avulsion
and stored in saliva, milk or Hank’s Balanced
Salt Solution the prognosis is good.
Also related to: 1. extra-alveolar time
2. dry-storage time
56. A 11 - yr old child has a class II div. I mat occlusion
he is a thumb sucker, discuss the causes and how u will
manage the malocclusion with mother of the patient?
Digit and Nonnutritive Sucking Behaviors.
Reasons for malocclusion and thumb sucking:
1) Many children suck their thumbs or fingers for short
periods during infancy or early childhood.
The habit may be considered normal during the first 2 years
of life, and oral changes reversible till he age of 6.
2) The main cause of the malocclusion is this habit of
persistent thumb sucking beyond the age of permanent
incisor eruption.
3) the reason behind the habit which could be social or
psychological should be investigated
4) Psychological counseling might be necessary as patient
might be unable to leave the habit though they may be
willing to do it.
5) Detailed discussion with the child's mother regarding the
patient's family history social behavior will give a better
idea of the underlying cause behind the persistent habit.
6) The child is asked to keep a daily record on a card of
each episode of thumb sucking and to call the dentist each
week and report on progress in stopping the habit.
7)Reassure the mother. Parents are often overanxious about
the habit and its possible effects.
This anxiety may result in nagging or punishment that often
creates a greater tension and intensification of the habit.
Explain that changes in the home environment and routine
are often necessary before the child can overcome the habit.
MANAGEMENT
*Take a detailed history of the patient
This should include:
1)frequency of habit
2)When habit was started
3)examination of occlusion
4)examination of extraoral structures.
5)examination of teeth for signs of caries or
gingivitis
*Lateral Cephalograms are taken with any other
radiographs that are required.
*study model impressions are made
*The following features might be present:
1)Anterior open bite
2)protrusion of upper incisor teeth
3)tongue thrusting that worsens the open bite
4)posterior crossbite due to overactivity of buccinators
5)lip trap(placement of lower lip below upper lip and short
hypotonic upper lip
6)convex profile with non competent lips
HABIT MANAGEMENT
1)CHEMICAL
Hot tasting, bitter flavoured preparations or distasteful
medications applied on thumb or fongers as reminders.
Useful for those in whom the habit isn’t firmly entrenched
2)MECHANICAL
Hawleys retainer with a palatal crib
application of adhesive tape on thumb
Bluegrass appliance: A modified, six-sided roller
machined from Teflon which permits
purchase of the tongue, is constructed to skip over a 0.
045-inch stainless steel wire that is soldered to molar
orthodontic bands
3)PSYCHOLOGICAL
Consultation might be required.
Child should be motivated and encouraged, not criticized.
MANAGEMENT OF MALOCCLUSION
Treatment is indicated if overjet is 6-9 mm or more
considerations in treatment planning
*growth spurt
*deviation of skeletal pattern from normal
*mandibular growth pattern-forward is favorable
*habit ceased before treatment begins
*space requirements are evaluated, whether teeth need to
be extracted or not
*detailed examination of study models and cephalograms
I GROWTH MODIFICATION
1)efforts are made to reduce maxillary growth, restrict
mandibular growth or both.
2)A headgear with facebow for maxillary prognathism
3)myofacial appliances such as activator or functional
regulator for mandibular deficiency correction are used
4)A combination of the two can be done.
5)The second phase of treatment is to align the arches with
fixed orthodontics.
II CAMOUFLAGE
1)Used when class II skeletal pattern is mild to
moderate,vertical facial proportions are good, arches are
well aligned
2)extraction of upper arch premolars and retract incisors
bodily
3)New treatment must not have a detrimental effect on the
facial profile.
4)Class II relation remains.
III.SURGERY
In the case that the growth spurt has completed,
orthognathic surgery will be required.
IV. Open bite or deep bite issues are addressed.
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59. Pit and fissure sealants?
The cariostatic properties of sealants are attributed to
the physical obstruction of the pits and grooves. This
prevents colonization of the pits and fissures with new
bacteria and also prevents the penetration of fermentable
carbohydrates to any bacteria remaining in the pits
and fissures, so that the remaining bacteria cannot
produce acid in cariogenic concentration.
Indicated Contraindicated
Recently erupted Caries free for 4 or more
years
Molar decreased caries risk
Deep narrow fissures Wide self cleansing p and f
patient high caries risk rampant caries or
interproximal
lesions are present
presence of incipient Occlusal surfaces that are
enamel caries. already carious
Uncooperative patients
Rx of primary molars is not normally recommended
Sealants can be classified by polymerization method (light-
or self-cure), resin system (Bis-GMA or urethane
diacrylate), colour (clear or tinted), and whether they are
filled or unfilled
TECHNIQUE
CLEANING
1)fissure cleansing with a rotating dry bristle
brush may be beneficial.
2)aluminum oxide air abrasion system
ISOLATION
1)The tooth (or quadrant of teeth) to be sealed is first
isolated.
2)Rubber dam isolation,Cotton rolls, absorbent
shields, and high-volume evacuation with compressed air
ETCHING
1)Microporosities in the enamel surface are created by the
acid-etching technique. This permits a low-viscosity resin
to be applied that penetrates the roughened surface and
produces a mechanical lock of resin tags when cured.
2)30% to 50% acid solutions or gels are now
recommended.
The etchant in solution should be placed on the enamel
with either a brush, small sponge, cotton pellet, or
applicator
3) The etchant should be placed widely across the surface
to be sealed so that there is no chance that resin placement
and polymerization will occur over a unetched enamel area.
4)If a solution is used, one should gently agitate and
replenish it
5) 20-second etching time is recommended.
6)Enamel rich with fluorhydroxyapatite may be resistant to
etching and may need to be exposed for longer periods.
Primary teeth may also sometimes be resistant to etching
and may require a longer etching time.
WASHING
1)thorough washing and drying of the etched tooth surface
2) The etched enamel is dried using a compressed air
stream that is free of oil contaminants.
3)The dry etched enamel should exhibit the characteristic
frosty appearance
APPLICATION OF SEALANT
Chemically Cured Sealant.
1)Precise mixing without vigorous agitation can help to
prevent the formation of air bubbles.
2)The addition of the catalyst to the base immediately
begins the polymerization of the material, and this
should be kept in mind so that no time is lost in carrying
the material to the etched and dried tooth.
3) Working time is limited with a chemically cured sealant.
Visible Light—Cured Sealant.
1)Material should be dispensed only when it is time to
place it on the tooth.
2)The working time is longer than with chemically cured
sealant.
3)The sealant is applied to the prepared surface in
moderation and then gently teased with a brush or probe
into the pits and grooves in thin sections
4) unpolymerized surface layer should be removed by
washing and drying the surface to avoid an unpleasant taste
Check the placement of the sealant with a probe, making
sure there are no voids, catches.
CHECK OF OCCLUSAL INTERFERENCES
1)Articulating paper should be used to check for occlusal
interferences and the occlusion adjusted if necessary
2)All centric stops should be on enamel.
3)excess sealant that may have flowed over the
marginal ridge or toward the cervical area should also
be removed.
REEVALUATION
It is important to recognize that sealed teeth should be
observed clinically at periodic recall visits to determine
the effectiveness of the sealant.
5% and 10% of sealants need to be repaired or replaced
yearly.
If a sealant is partially or completely lost, any discolored or
defective old sealant should be removed and the tooth
reevaluated.
Clinical Failures~
 Improper moisture control (rubber dam doesn’t fit
properly on partially erupted tooth)
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 Material mishandling (not refrigerated or properly
stored)
 Improper etch result (not long enough)
 Incomplete curing (lights not working well)
 Ineffective checking (placement after curing not well
checked)
60. Recommendations to a 3 yr old boy on fluoride
management?
24. What would b your recommendations to the parents
on fluoride therapy for a 3- year old boy?
129. A mother calls you and asks about toothpastes and
topical fluoride. She has a 7-year-old child and they do
not live in a fluoridated area. What is your advice?
1) Explain that fluoride is used to prevent dental decay, and
that it makes teeth more resistant to caries. Also, has an
antibacterial effect.
2)Factors that should be considered before committing to a
fluoride regimen
1.caries risk-high, medium,low
2.cariogenicity of the diet/oral clearance rate
3.patient age compliance
4.use of systemic and topical modalities
5.water fluoridation levels
6.existing medical conditions
7.Availability of fluoride modalities
3)The methods available are:
I)TOOTHPASTES
1)25% reduction in caries noted, greatest effect in
interproximal and smooth surface caries
2)conventional toothpastes=1000-1100 ppm (1 mg/g of
paste)
3)Added as sodium monofluorophosphate, stannous
fluoride
II) MOUTH RINSES
1)Supervised rinses reduce risk 20-50%
2)Daily and weekly rinses are available of APF(0.02%) and
NaF(100 ppm -1000ppm)
3)for :Orthodontic treatment patients, xerostomia, children
who cant brush adequately
4)Not for pre school children
III) VARNISHES
30% reduction of caries
For hypersensitive areas, newly erupted teeth amd
arresting early caries
TYPES:
1) Duraphat: stays for 12-48 hours on tooth
solution of natural varnishes-50 mg NaF/ml

2)Fluor protector: Silane fluoride varnish in polyurethane

lacquer. AVOID OVERUSAGE AND INGESTION.

Prophylaxis not necessary, but drying of tooth must

IV) CONCENTRATED GELS

1) APF gels: 1.23% fluoride=12300 ppm
mixture of NaF, HF and orthophosphoric acid
-only for professional use
2)NaF: Erosion, exposed dentin, carious dentin, porous
dentin
-stable, non irritating and non discolouring
3)snf2-for “at risk surfaces”
for root caries, post irradiation patients

V)SYSTEMIC FLUORIDES

1)tablets and drops

2)high risk caries individuals
3)chewed rather than swallowed
4)might increase risk of fluorosis

Ideal domestic water fluoride concentration for a child

6months to <4year child should be 0.25mg/L

Minimizing risk of fluorosis:

1.parent supervision while brushing

2.6year old and under ingest 30% of paste so the quantity

dispensed should be pea sized.

3.discourage swallowing toothpaste

4.if living in sufficiently fluoridated area , 400ppm fluoride

toothpaste to be used.

5. If fluoridated water is available, tablets (1 mg) are

available that can be used.

6. (For 2 to 7yrs age total fluoride intake should not

increase 0.07mg/kg)

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69.A 13 year old patient has rampant caries and
gingival swelling. What are the causes? How to prevent
them? What is your management?
109.Rampant caries.
Suddenly appearing widespread, rapidly burrowing type of
caries, resulting in early involvement of the pulp, and
affecting those teeth usually regarded as immune to decay.-
massler.
Signs and symptoms:
1)History of frequent replacement and/or new fillings or a
recent change in social or medical history or medication
use;
2) Multiple lesions at different stages of progression, from
early enamel decalcification to larger lesions and frank
cavitation
3) The dentinal base of cavities is usually soft and a
yellowish brown colour.
4) Lesions can develop anywhere often including surfaces
that are usually at low risk of caries
Rampant caries: On mandibular incisors interproximally
and cervically on other teeth
ECC: maxillary incisors, then molars.
5)Dentinal sensitivity from untreated carious lesions.
ETIOLOGY
1)In case of children, frequent bottle feedings and/or
prolonged bottle or breast feeding.
Putting child to sleep with a bottle
Pacifier coated with sweet substance
2)neglect and inadequate dental care.
3)emotional disturbances: An emotional disturbance may
initiate an unusual craving for sweets or the habit of
snacking, which in turn might influence the incidence of
dental caries.
4)Decreased saliva due to stress: noticeable salivary
deficiency is not an uncommon finding in tense, nervous,
or disturbed persons.
- medications (such as tranquilizers and sedatives)
-radiation therapy to the head and neck
5)an increase in refined carbohydrate consumption, or
from frequent exposure of the teeth
to erosive acids like carbonated beverages.
6) high susceptibility due anatomy, crowding, heredity
7)Dental appliances and restorations
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1. diagnose rampant caries
All investigations are performed including detailed history,
radiographs and extraoral and intraoral examination.
2. find the causes and assess, focus, teach, assist,
demonstrate, encourage and reinforce.
caries disclosing agent is preferred which can demonstrate
the caries involvement to the patient and the parent
3. preventive approach that is tailored for the individual
patient's needs
1)pit and fissure sealants, topical fluoride procedures, and
counselling patients to change to preventive dental
behaviours.
2) the daily at home use of a topical fluoride gel
in a custom tray for four minutes
3)daily brushing with a high fluoride concentration
dentifrice,
4)periodic use of a chlorhexidine rinse/gel to control
the levels of cariogenic flora
5)use of a fluoride varnish applied by a dental professional
twice weekly for at least one month.
6)monitor both compliance and clinical evidence of caries
in the months ahead.
Recall visits can scheduled every three months
7) Permanent restorative treatment should ideally not
commence until there is evidence of reduction in
caries activityn the form of syrup).
8) any emergency/painful teeth to be treated accordingly by
extraction or RCT.
9) -temporisation of existing caries until the oral hygiene is
stabilised and caries is controlled.
-permanent restorations once the condition is stabilised and
prevention of recurrence in future is confirmed.
Gingival swelling: could be either attributed to
1)poor oral hygiene favoring plaque deposition and causing
gingivitis or due to puberty related gingival swelling due to
hormonal imbalance
2)patient is on medication which causes gingival
overgrowth.
MANAGEMENT
1)Radiographs to assess damage and progression
2) Blood test to exclude dyscrasias
3)OHI and sc, rp
4)CHX
5)regular follow up

80.How do you manage a 2 1/2 year old child patient
who is visiting a dental clinic for the first time, and
what will you discuss with the parents?
Fears the child might face
1)the unknown
2)pain
3)new environment
4)new people
5)separation from parent
1)The first dental visit consists of a great deal of
preamble, a very short examination and some
follow-up with the parent.
2) Much of the preamble can be completed by the office
staff working at the front desk, who can help the parent to
fill out a health history and schedule the appointment for a
time when the child is least likely to be tired or hungry
3)A questionnaire about the child can be provided
including likes and dislikes, fears, personality, nicknames
4)Establish rapport with child and also parent.
Ask about:
-child visiting school? (for coping skills)
-parents feelings
-childs behavior at home
5)The dentist’s direct interaction with the patient
can usually be limited to about 5 minutes.
6)The best position for examining patients under 2 years of
age is the knee-to-knee position
-The parent and dentist sit in chairs facing one another with
their knees touching.
-The parent holds the child in his or her lap, with the child
facing the parent, and tilts the child’s head into the dentist’s
lap.
- This position allows the child to maintain eye contact with
the parent, while allowing the dentist access to the child’s
mouth.
The parent restrains the child’s hands, while the dentist
gently holds the head still and completes the examination.
-the child can also be asked to sit on a regular chair
or stand between parents knees
-The first examination is usually a visual exam
with a mirror; an explorer can be introduced
if there are any suspicious areas.
-controlled, calm and confident demeanour
-Use behavior management strategies:
*tell show do
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*voice control
*use of empathy
*provide a sense of control
*reinforcement of good behavior, ignore,discourage
bad behavior
*soft and hard rewards
*modeling
7)If the child is cooperative, a short tooth-brushing
demonstration can be given for the parent’s benefit.
8)Fluoride varnish may be applied if indicated.
9)The child is then allowed to play while the dentist
and parent discuss any issues that may have
been raised by the examination.
*If the child has a healthy mouth, this discussion is
usually limited to ways of keeping the mouth
healthy. *If dental caries were noted, the topic will
be possible causes and methods of treatment.
*If decay is found during the first dental visit,
the parent may have strong feelings of guilt.
Be supportive, by suggesting ways in which the
parent can help to treat and prevent further disease.
*3 day “diet diary” to be kept
10)Treatment should not be delayed until the child is
able to cooperate. a
11)The dental assistant also plays an essential role
in the first visit, spending most of the
appointment time speaking with the parent about
the child’s oral health and preparing and
reassuring the parent about the examination
12)refer if uncooperative or complicated.
Fears :0-6 months: Loss of support, loud noises.
7-12 months: Strangers, heights, sudden, unexpected and
looming objects.
1 year: Separation from parent, toilet, injury, strangers.
2 years: A multitude of sources, including loud noises
(vacuum cleaners, sirens/alarms, trucks and thunder),
animals, dark room, separation from parent, large objects or
machines, changes in personal environment, strange peers.
3 years: Masks, dark, animals, separation from parent.
4 years: Separation from parent, animals, dark, noises
(including at night).
5 years: Animals, ''bad'' people, dark, separation from
parent, bodily harm.
6 years: Supernatural beings (e.g., ghosts, witches, Darth
Vader), bodily injuries, thunder and lightning, dark,
sleeping or staying alone, separation from parent.
7-8 years: Supernatural beings, dark, media events (e.g.,
news reports on the threat of nuclear war or child
kidnapping), staying alone, bodily injury.
9-12 years: Tests and examinations in school, school
performances, bodily injury, physical appearance, thunder
and lightning, death, dark. Teens: Social performance,
sexuality.
100.Space maintainers.
Requirements:
1)maintain mesio distal space created by tooth
2)restore function as far as possible
3)prevent over eruption of opposing tooth
4)strong enough to withstand forces
5)no excessive stress on adjacent teeth
6)maintainence of oral hygiene permitted
7)must not restrict normal growth and development
Natural tooth is the best space maintainer.
MANAGEMENT
1)Evaluate the patient’s dental age and skeletal age if space
maintenance will be needed in the case of a lost primary
tooth.
Use radiographs to estimate root completion
2) If a broken down primary tooth is to be preserved,
proper pulpal therapy in conjunction with a restoration
would be needed.
3)According to need: removable or non removable
maintainer should be decided
REMOVABLE
Indications:esthetics of importance
Fixed cannot be used
CLP who require obturation
Multiple loss of deciduous teeth
Difficulty in adapting bands on half erupted
teeth
Contraindications:epileptic pts, allery to acrylic, less
cooperation
1)Acrylic partial dentures:
-can be adjusted to allow eruption
-masticatory function
-esthetics
2)Full dentures
-might be used to guide 1st molar to occlusion
3)Removable distal shoe space maintainer
-P.D. with distal shoe
Care to be taken that growth not hampered.
periodic check up for cracks or damage and irritation
Care t
FIXED
101.Tongue thrusting.
Tongue thrust is an oral habit pattern
related to the persistence of an infantile swallow
pattern during childhood and adolescence and
thereby produces an open bite and protrusion of the
anterior tooth segments
Types of tongue thrust 2,3
1. Physiologic This comprises of the normal
tongue thrust swallow of infancy
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1)Band and loop—
-prevents mesial migration of the primary second molar
after unilateral loss of the primary first molar
-easy and economical to make, takes little chair time, and
adjusts easily to accommodate the changing dentition
-does not restore chewing function and will not prevent the
continued eruption of the opposing teeth
2)Crown and loop
The stainless steel crown and loop maintainer may be
used if the posterior abutment tooth has extensive caries
and requires a crown restoration or if the abutment
tooth has had vital pulp therapy, or hypoplasia
3) Lingual arch
-maintains space after multiple primary teeth are
missing and the permanent incisors are erupted
- In the mixed dentition, a passive soldered lingual
arch is almost always the appliance of choice in the
mandibular arch
-prevents mesial drifting of molars and lingual collapse of
primary teeth
4)Distal shoe
-used when the primary second molar is lost prior to the
eruption of the permanent first molar
-influence the active eruption of the first permanent
molar in a distal direction
-modifications include crown and band appliances with a
distal intra gingival extension
5)Nance/transpalatal appliance (see Fig. 5–15):
-Used for bilateral loss of primary maxillary molars.
-Prevents mesial rotation and mesial drift of the permanent
maxillary molars.
-A thick wire that spans the palate
-Acrylic button on palate
-no contact with anteriors
6)Esthetic anterior space maintainer
-Plastic tooth on a lingual arch
7)Band and Bar(crown and bar)
2. Habitual The tongue thrust swallow is present
as a habit even after the correction of the
malocclusion.
3. Functional When the tongue thrust mechanism is an
adaptive behaviour developed to achieve an oral seal, it can
be grouped as functional.
4. Anatomic Persons having enlarged tongue can have an
anterior tongue posture.
Etiology
a. Genetic or heredity
E.g. hypertonic orbicularis oris activity.
b. Learned behavior ( habit ) : Tongue thrust
can be acquired as a habit. The following are
some of the predisposing factors that can lead
to tongue thrusting ;
1. Improper bottle feeding
2. Prolonged thumb sucking
3. Prolonged tonsillar and upper respiratory tract
infections.
4. Prolonged duration of tenderness of gum or
teeth
c.Maturational
i. Retained infantile swallow
The infantile swallow changes to a mature
swallow once the posterior deciduous teeth
start erupting.
The tongue thrust resulting from the retained infantile
swallow has poorest prognosis
ii.Functional adaptability: The tongue can protrude when
the incisors are missing.
Etiology
a. Mechanical restrictions : The presence of
certain conditions such as macroglossia,
constricted dental arches and enlarged
adenoids
b. Neurological disturbances affecting the
oro-facial region such as Hyposensitive
palate, moderate motor disability, disruption
of sensory control and coordination of
swallowing
c. Induction The other habits like thumb
sucking may result in anterior openbite. The
tongue thrusting may develop as a
compensatory mechanism
d. Psychogenic factors : Tongue thrust can
sometimes occur as a result of forced
discontinuation of other habits like thumb
sucking.
Tongue thrust can also be classified as simple
tongue thrust and complex tongue thrust.
1. SIMPLE TONGUE THRUST: (Anterior tongue
thrusting)
It is defined as tongue thrust with a teeth together swallow.
It is usually associated with the history of digit sucking.
Extra oral features 1. Usually dolichocephalic face.
2. Increased lower anterior facial height
3. Incompetent lips
4. Expresion less face
5.Speech problems like sibilant distortions and lisping
6.Abnormal mentalis muscle activity is seen
Intra oral features
1. Proclined, spaced and some times flared upper anteriors
resulting in increased overjet.
2. Retroclined or proclined lower anteriors
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depending upon the type of tongue thrust.
3. Presence of an anterior open bite.
4. Presence of posterior crossbites.
5. The simple tongue thrust is characterized by a
normal tooth contact during the swallowing act.
They exhibit good intercuspation of posterior
teeth in contrast to complex tongue thrust.
6. The tongue is thrust forward during swallowing to help
establish an anterior lip seal. At rest the tongue tip lies at a
lower level.
2. COMPLEX TONGUE THRUST: ( ANTERIOR
AND POSTERIOR TONGUE THRUST)
It is defined as tongue thrust with a teeth apart
swallow. It is usually associated with chronic
nasorespiratory distress, mouth breathing, tonsillitis, and
pharyngitis.
Features
The following features are seen :
1. Proclination of anterior teeth
2. Bimaxillary protrusion
3. This kind of tongue thrust is characterized
by a teeth apart swallow.
4. The anterior open bite can be diffuse or
absent.
5. Absence of temporal muscle constriction
during swallowing.
6. Patients with a complex tongue thrust
combine contractions of the lip, facial and
mentalis muscle.
7. The occlusion of teeth may be poor.
8. Posterior open bite in case of lateral tongue
thrust
9. Posterior crossbite
3.Lateral tongue thrust (posterior tongue
thrust) Some patients usually develop into a habit by
thrusting the tongue on to the lateral aspect.
Clinically lateral open bite can be seen.
It may be unilateral or bilateral and depends upon
V. Management of tongue thrust:
1)Age Tongue thrust often self-corrects by 8 or 9 years of
age by the time the permanent anterior teeth completely
erupt.
2) Treatment is generally not recommended when tongue
thrust is present without malocclusion or a speech problem.
3)If the tongue thrust is present with
Malocclusion but no speech problem orthodontic correction
of the malocclusion will usually eliminate the tongue
thrust.
4)If the tongue thrust is present along with
malocclusion and a speech problem, speech-and
orthodontic correction are needed.
5)The management of tongue thrust involves
interception of the habit
I. Training of correct swallow and posture of the tongue
a. Myofunctional exercises.
i.. The child is asked to place the tip of the tongue in the
rugae area for 5 minutes and is asked to swallow.
ii. The tongue tip against the palate can hold small
orthodontic elastics during swallowing. If the swallow is
correct the elastic will be retained in position.
iii. 4S exercises. This includes identifying the
spot by tongue, salivating, squeezing the
spot and swallowing.

The patient should practice the new swallowing

pattern at least 40 times a day.
121. significance of diet in caries activity
Holding a glass of water in one hand and facing a mirror,
the child takes a sip of water, closes the teeth into
occlusion, places the tip of the tongue against the incisive
papilla, and swallows.
This is repeated and each time is followed by the relaxation
of the muscles until the swallowing progresses
smoothly.
II. Appliances to guide the correct positioning of tongue
Once the patient is familiar with the new tongue
position an appliance is given for training the Part of keyes triad
correct positioning of the tongue.
*According to miller,
Pre orthodontic trainer/ Tongue trainer This
appliance aids in the correct positioning of the Dental decay is a chemico-parasitic process consisting of 2
tongue with the help of tongue tags. The tongue stages, the decalcification of enamel which results in its
guards prevent the tongue thrusting when in place total destruction and the decalcification of dentin in the
preliminary stage, followed by dissolution of the softened
III. Mechanotherapy residue.
fabricated to restrain anterior tongue movement during
The acid which affects this primary decalcificaton, is
swallowing with the objective of retraining the tongue to a
more posterior superior position in the oral cavity. derived from the fermentation of starches and sugar lodged
in the retaining centers of teeth.
Choice of appliance: The Acids formed mostly is Lactic acid which is formed
1. A well adapted soldered lingual arch wire through enzymatic breakdown of Sugars.
having short, sharp spurs can now be
inserted; protectively the tongue is withdrawn The various factors affecting diet are:
from the abnormal position and placed 1)Nature of the diet:
properly during swallowing
-a diet filled with roughage stimulates salivary stimulation
2. For cooperative patients oral screen can be
used. and clearance of debris stuck on tooth.
3. Removable appliance with tongue spurs or -Diet containing soft, sticky food does not have any such
spikes can also be used in cooperative action.
patients.
4. A fixed crib may be used along with fixed 2)Retention and clearance time
corrective appliance -Food that is less sticky or adherent has less cariogenic
. Removable appliance therapy
potential
A variety of modifications of Hawley's appliance
can be used to treat tongue thrust. -Stickiness is related to the adherence of food on the tooth.
eth. The acrylic The greater the clearance time, the greater chance of caries.
should be trimmed off from the gingival marginal -juices, cold drinks are less cariogenic than caramelized
area of the lingual surfaces of the maxillary sweets.
anteriors to allow the incisors to be move palatally.
b. Fixed Habit breaking appliance 3)Intake frequency
Bands are adopted on the first permanent molar frequent in between snacking increases caries
and a 0.040 inch stainless steel 'U'– shaped wire is adopted
susceptibility.
from one molar to another molar of the opposite side.
crib can be formed and soldered to the base.

STEPHENS CURVE

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Demineralisation of teeth starts at a critical pH of 5.2-5.5
This salivary pH change occurs immediately after eating
Frequent snacking increases the duration of time for which
pH remains below the critical pH, hence increases chances
of caries
Night- time bottle feeding, or prolonged use of a sippy cup,
can lead to early childhood caries. The flow of saliva is
decreased during sleep, so clearance of the sugary liquid
from the oral cavity is slowed down.
4) Chemical composition: Sucrose, which is a disaccharide
is more fermentable than polysaccharides like starch.
Refined sugars also contribute to dental caries by virtue of
being able to produce acids.
5)Protective elements
-considered to be food rich in calcium and phosphates
-reduce rate of dissolution of hydroxyapatite
-reduce fall in plaque pH
-enhance remineralisation
-modify composition of pellicle and plaque
-the presence of buffers in dairy products
the use of sugarless chewing gum, particularly gum
containing xylitol;
and the consumption of sugars as part of meals rather than
between meals) may reduce the risk of caries
-calcium, lectin, cocoa, cheese and other fat containing
products
6)Fluoride as dietary supplements or water greatly bring
down caries incidence
7)To reduce cariogenicity:
i)use sugar substitutes such as saccharine and aspartame
ii)based on a diet chart, sugars are reduced in diet with
decreased frequency, reduced stucky carb , increased
roughage.
Reduce frequency of consumption of sugar-containing
foods and drinks, especially between meals.
 Reduce frequency of consumption of fruit-based
drinks
 A few snack foods are safe (e.g. nuts and cheese),
but foods containing artificial sweeteners may be
less decay-producing.
 Foods containing starch and sugar in combination
(e.g. cakes, biscuits) and carbonated sugary
drinks are especially decay-producing.
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8)various studies have shown influence of diet
-patients with hereditary fructose intolerance
i)hopewood house study
ii)vipeholm study
iii)seventh day Adventist study
122. management of handicapped children.
-Children with disabilities may present challenges that
require special preparation before the dentist and office
staff can provide acceptable care.
-parental anxiety concerning the problems associated with a
child's disabilities frequently delays dental care until
significant oral disease has developed.
DENTAL ACCESS
1)In the dental operatory, doorways should be 4 inch
wider than normal.
Dental chairs should be adjustable for height to match
different wheelchair designs.
FIRST DENTAL VISIT
-Special attention should be given to obtaining
a thorough medical and dental history.
-The names and addresses of medical or dental personnel
who have previously treated the patient are necessary for
consultation purposes. Consultation with these specialists is
common and helps provide insight in case management
and planning.
-Drugs being taken currently which might cause
xerostomia.
-The first dental appointment is very important and
can set the stage for subsequent appointments.
- Schedule the patient at a designated time (early in the
day)
-allow sufficient time to talk with the parents and the
patient before initiating any dental care
RADIOGRAPHIC EXAMINATION
-Assistance from the parent and dental
auxiliaries and the use of immobilization devices may be
necessary to obtain the films.
-Delay radiography until the second visit
-For patients with limited ability to control film position,
intraoral films with bite-wing tabs are used for all bitewing
and periapical radiographs.
MANAGEMENT
- behavior management
- If patient cooperation cannot be obtained, the dentist must
consider alternatives such as treatment immobilization and
conscious sedation to allow performance of the necessary
dental procedures.
Partial or complete immobilization
-Pts who need help controlling their extremities, such as
infants or patients with certain neuromuscular disorders. -
Immobilization is also useful for managing combative,
resistant patients
- The parents, guardian, or patient (if an adult) must be
informed and must give consent, and the consent must be
documented, before immobilization is used.
The use of immobilization is indicated in the following
situations:
• A patient requires diagnosis or treatment and
cannot cooperate because of lack of maturity.
• A patient requires diagnosis or treatment and
cannot cooperate because of mental or physical
disabilities.
• A patient requires diagnosis or treatment and does
not cooperate after other behavior management
techniques have failed.
• The safety of the patient or practitioner would be
at risk without the use of protective
immobilization.
Immobilization is contraindicated for a cooperative
patient and a patient who cannot be safely immobilized
because of underlying medical or systemic conditions.
-The patient's record should display an informed
consent, the indications for use, the type of immobilization
used, and the duration of application.
The following are commonly used for immobilization:
Body
Papoose Board
Triangular sheet
Pedi-Wrap
Beanbag dental chair insert
Safety belt
Extra assistant
Extremities
Posey straps
Velcro straps
Towel and tape
Extra assistant
Head
Forearm-body support
Head positioner
Plastic bowl
Extra assistant
-Padded and wrapped tongue blades
-Rubber bite blocks that have floss attached for easy
retrieval if they become dislodged in the mouth.
CEREBRAL PALSY
Cerebral palsy is one of the primary handicapping
conditions of childhood.
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The importance of maintaining a calm, friendly,
and professional atmosphere cannot be overemphasized.
The following suggestions are offered to the clinician
as being of practical significance in treating a patient
with cerebral palsy:
1. Consider treating a patient who uses a wheelchair
in the wheelchair. Many patients express such a
preference, and it is frequently more practical for
the dentist. For a young patient, the wheelchair
may be tipped back into the dentist's lap.
2. If a patient is to be transferred to the dental chair,
ask about a preference for the mode of transfer. If
the patient has no preference, the two-person lift is
recommended.
3. Make an effort to stabilize the patient's head
throughout all phases of dental treatment.
4. Try to place and maintain the patient in the midline
of the dental chair, with arms and legs as close to
the body as feasible.
5. Keep the patient's back slightly elevated to minimize
difficulties in swallowing. (It is advisable not
to have the patient in a completely supine position.)
6. On placing the patient in the dental chair, determine
the patient's degree of comfort and assess the
position of the extremities. Do not force the limbs
into unnatural positions. Consider the use of
pillows, towels, and other measures for trunk and
limb support.
7. Use immobilization judiciously to control flailing
movements of the extremities.
8. For control of involuntary jaw movements, choose
from a variety of mouth props and finger splints.
Such appliances may also trigger the
strong gag reflex that many of these patients
possess.
9. To minimize startle reflex reactions, avoid presenting
stimuli such as abrupt movements, noises,
and lights without forewarning the patient.
10. Introduce intraoral stimuli slowly to avoid eliciting
a gag reflex or to make it less severe.
11. Consider the use of the rubber dam
12. Work efficiently and minimize patient time in the
chair to decrease fatigue of the involved muscles.
Predisposing conditions are as follows:
1. Periodontal disease. Periodontal disease occurs with
great frequency in persons with cerebral palsy.
Often the patient will not be physically able to
brush or floss adequately.
Diet may also be significant; children who have difficulty
chewing and swallowing tend to eat soft foods, which are
easily swallowed and are high in carbohydrates.
Patients with cerebral palsy who take phenytoin
to control seizure activity will generally have a
degree of gingival hyperplasia.
2. Malocclusions.
noticeable protrusion of the maxillary anterior teeth,
excessive overbite and overjet, open bites, and unilateral
crossbites.
Uncoordinated and uncontrolled movements of
jaws, lips, and tongue are observed with great
frequency in patients with cerebral palsy.
3. Bruxism. Bruxism is commonly observed in patients
with athetoid cerebral palsy.
Temporomandibular joint disorders may be sequelae of
this condition in adult patients.
4. Trauma. Persons with cerebral palsy are more
susceptible to trauma, particularly to the maxillary
anterior teeth.

-An effective preventive dentistry program is important for

a child with disabilities
-After the diagnosis the dentist should determine the
patient's needs, adequately communicate to the
parents and patient how such a program can be
effected.
-The parents (or the guardian) are initially responsible
for establishing good oral hygiene in the home.
Reinforcement of good home dental care is provided
-Home dental care should begin in infancy; the dentist
should teach the parents to gently cleanse the incisors
daily with a soft cloth or an infant toothbrush.
-For older children who are unwilling or physically unable
to cooperate, the dentist should teach the parent or
guardian correct toothbrushing techniques that safely
restrain the child when necessary.
-The brushing technique for patients with disabilities who
have fine or gross motor deficiencies limiting their ability
to brush should be effective and yet simple for the person
performing the brushing.
-Electric toothbrushes have also been used effectively by
children with disabilities. The vibration and noise tend to
desensitize the patient for future dental appointments if
followed by positive reinforcement.
FLUORIDE EXPOSURE
-The dentist should first determine the concentration of
fluoride in the patient's daily water supply. If the level of
fluoride is between 0.7 and 1 ppm, no supplementation
is normally required.
-accepted dentifrice containing a therapeutic fluoride
compound,Nightly application of a 0.4% stannous brush-on
gel ,rinsing with 0.05% sodium F mouthwash
-Pit and fissure sealants
-For a patient who requires dental work under general
anesthesia, deep occlusal pits and fissures should be
restored with amalgam or longwearing composites to
prevent further breakdown and decay.
-Patients with severe bruxism and interproximal
decay may need their teeth restored with stainless steel
crowns to increase the longevity of the restorations.
- certain patients can benefit from recall examinations
every 2, 3, or 4 months.
DIET AND NUTRITION
-should assess the diet by reviewing answers on a diet
survey with the parent
-conditions associated with difficulty in
swallowing, such as severe cerebral palsy, may require
that the patient be on a pureed diet.
-Patients with certain metabolic disturbances or syndromes,
such as phenylketonuria, diabetes have diets that restrict
specific foods or total caloric consumption.
-Any dietary recommendations should be made
individually
124. management of an 8 yr child needing nitrous oxide
NO is used for conscious sedation. documentationThe most
frequently used sedative agent.
1)Pre treatment documentation
-Each sedation procedure must be documented
-The reason to do so
-Informed consent from parent or guardian.
2)Instructions
-The pts diet should be evaluated before
-intake of food and liquids limited prior to treatment
-clear liquids stopped 2 hours before
(to decrease risk of aspiration)
-Adult guardian present throughout the procedure.
-Loose front opening clothes to be worn
3)Assesment
-Allergies, medications added respiratory effects when it is
given in combination with narcotics
or other CNS depressants.
-family diseases
-previous hospitalization
-weigt in kgs
-vital signs
-evaluation of airway patency
-Risk classification
-CONTRAINDICATIONS
nitrous oxide should be avoided in patients with
acute otitis media, severe behavioral
problems and emotional illness, uncooperativeness, fear
of "gas," claustrophobia, maxillofacial deformities that
prevent nasal hood placement, nasal obstruction
4) Equipment.
-The machine should be of the continuous-flow design,
with flowmeters capable of accurate regulation.
-A fail-safe mechanism that provides automatic shutdown
if oxygen falls below 25% and audible and visual alarms
that are activated by oxygen failure are important design
features.

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-There should be a flush lever for easy and immediate
flushing of the system with 100% oxygen.
-An efficient scavenger system is an important
component of any hose-mask system. The double-mask
type is the most efficient type of scavenger
-Nasal hoods should be of good design and should be
available in pediatric and adult sizes to ensure adequate
fit, which further reduces leakage
-sphygmomanometer and stethoscope available
-Emergency kit to be kept handy
5. Patient can talk, if applicable.
6. Patient can sit unaided
7. Patient can ambulate
8. If the child is very young or disabled, incapable of
the usually expected responses, the presedation
level of responsiveness or the level as close as
possible for that child has been achieved.
9. Responsible individual is available.

5)Technique.
-After a thorough inspection of the equipment, the mask
should be carefully placed over the nose.
-The delivery tubes are tightened behind the chair back in a
comfortable position.
-The bag is filled with 100% oxygen and delivered to the
patient for 2 or 3 minutes at an appropriate flow rate,
typically between 4 and 6 L per minute.
-With an appropriate flow rate, slight movement of the
mixing bag should be apparent with each inhalation and
exhalation.
-Once the proper flow rate is achieved, the nitrous oxide
can be introduced by slowly increasing the concentration at
increments of 10% to 20% to achieve the desired level.
-The operator should encourage the patient to breathe
through the nose with the mouth closed.

-The sensations are described as a floating, giddy feeling

with tingling of the digits. The eyes will take on a distant
gaze with sagging eyelids.
-When this state is reached, the local anesthetic may be
given.
-Once this is completed, the concentration can be reduced
to 30% nitrous oxide and 70% oxygen or lower.
-The patient can now be maintained and monitored, and the
contemplated procedure carried out.
-The dentist should communicate with the patient
throughout the procedure, paying particular attention to
the maintenance of an open, relaxed airway.
-An emesis basin should be readily available, and in the
event that vomiting does occur, the head should be rotated
to the side.
-Recovery can be achieved quickly by reverse titration.
-Once the sedation is reversed, the patient should be
allowed to breathe 100% oxygen for 3 to 5 minutes.
To prevent diffusion hypoxia
-The patient should be allowed to remain in the sitting
position for a brief period to ensure against dizziness on
standing.

Adverse Effects and Toxicity.

-Nausea and/or vomiting is the most common adverse
effect experienced with nitrous oxide sedation.
-Middle ear pressure will increase significantly,

Discharge criteria
1. Cardiovascular function is satisfactory and stable.
2. Airway patency is uncompromised and satisfactory.
3. Patient is easily arousable and protective reflexes
are intact.
4. State of hydration is adequate.

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