Professional Documents
Culture Documents
Pediatric Dentistry
Pediatric Dentistry
Nikolaos Kotsanos
Haim Sarnat
Kitae Park Editors
Pediatric
Dentistry
Textbooks in Contemporary Dentistry
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This textbook series presents the most recent advances in all fields of dentistry, with the aim of bridging the
gap between basic science and clinical practice. It will equip readers with an excellent knowledge of how to
provide optimal care reflecting current understanding and utilizing the latest materials and techniques. Each
volume is written by internationally respected experts in the field who ensure that information is conveyed in
a concise, consistent, and readily intelligible manner with the aid of a wealth of informative illustrations.
Textbooks in Contemporary Dentistry will be especially valuable for advanced students, practitioners in the
early stages of their career, and university instructors.
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Nikolaos Kotsanos • Haim Sarnat • Kitae Park
Editors
Pediatric Dentistry
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Editors
Nikolaos Kotsanos Haim Sarnat
Department of Paediatric Dentistry Department of Pediatric Dentistry, School
Aristotle University of Thessaloniki of Dental Medicine
Thessaloniki Tel Aviv University
Greece Tel Aviv
Israel
Kitae Park
Institute of Oral Health Science
Samsung Medical Center, School of Medicine
Sungkyunkwan University
Seoul
Korea (Republic of)
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
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V
Contents
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1 1
Contents
References – 9
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2 N. Kotsanos et al.
theoretical courses, included clinical training. Thus, by ative, in maintaining carious primary teeth or the space
the end of World War II, pediatric dentistry was already from their premature loss. As for available restorative
a separate discipline. materials, the approach could not be primarily aesthetic
Before then, local anesthesia was neither standard- at a time that only few children had access or happily
ized nor as efficient as nowadays. Behavior management accepted orthodontic treatment (. Fig. 1.2).
and guidance was during the third quarter of the twen- Preventive dentistry and its teaching acquired its
tieth century progressively based on knowledge and decisive role in that third quarter of the twentieth cen-
principles of child psychology, when the concomitant tury [4], mainly connected to oral hygiene measures for
evolution of the latter allowed for it. The progress of dental decay. Artificial fluoridation of drinking water
dental science and research and the emphasis on psycho- was established in some countries, starting with the
logical and behavioral aspects have had a great impact in USA, and the global spread of the use of fluoridated
changing the image of dentistry for children and adults toothpaste significantly reduced caries in children. This
alike. The development of post graduate programs had was at first in industrialized countries, where fluoride
centered in a more total patient care approach in pediat- toothpaste consumption has come to be today around
ric dentistry [3]. The dental treatment was mainly restor- 300 ml per person (three normal size tubes). The effec-
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Pediatric Dentistry: Past, Present, and Future
3 1
tiveness of brushing in dental and gingival health has the twentieth century saw a shift from mainly restorative
since been connected with a healthy mouth and a bright to preventive, cosmetic, and orthodontic procedures in
smile in modern culture (. Fig. 1.3).
children and adolescents [5, 6], which continues to date.
The acid etching of enamel, which was first described
in 1955, was a further breakthrough. It proved to be the
decisive technology for the continuous improvement of Overview
composite resins. Mainly these were the aesthetic restor- Milestones of pediatric dentistry in the twentieth century
ative materials contributing to a more conservative (from beginning to end):
approach in restoring carious teeth including sealing 1. Epidemiological recording of dental caries docu-
vulnerable fissures for caries reduction. Thus, the end of ments extent.
2. Pediatric dentistry textbooks get published.
3. Effective formulated local anesthesia is introduced.
4. Postgraduate pediatric dentistry programs are
developed.
5. Communicative behavior management is widely
taught.
6. Topical fluorides prevail and major caries decrease
is evidenced in children.
7. Etching the enamel boosts fissure sealing and com-
posite as restorative.
8. The rights of the child concept are adopted.
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4 N. Kotsanos et al.
posed a physical as well as a social problem for children be relatively low in many emerging Asian countries, even
and adults in the industrialized countries. Implementing though, for the most part, carious and periodontal needs
preventive programs achieved some caries reduction in remain there largely unmet [16]. Notwithstanding the
the child population after that time. For example, the diversity of dental caries reports in the various parts of
mean dmfs (sum of decayed, missing, and filled primary Africa, caries does not seem to be among the prime fac-
tooth surfaces) of 4-year-olds in southern Sweden was tors influencing oral health-related quality of life [17].
reduced from 8 to 2 between 1967 and 1980 [9]. At the Regarding restorative needs, a decrease of multi-
same trend, 70% of the Danish 5-year-olds in 1998 were surface cavities, endodontic treatment needs, and place-
caries-free, while the mean DMFS (same index for per- ment of preformed metal crowns in primary teeth has
manent teeth) of 12-year-olds was reduced to 1.5 [10]. been noted in university pediatric dentistry clinics of
Similar reductions had been observed in the USA in the countries showing significant caries decline. Though
1970s. The average DMFS of children aged 5–17 years these are still widely performed there today, the most
decreased from 7.1 to 4.8 with a dramatic decrease in the frequent recipients are those socioeconomically worse
number of extracted first permanent molars [11]. It was and minorities like immigrants [18–20]. Before, caries
remarkable that this trend was irrespective of systemic indices were high because dental caries, by affecting the
ways of fluoride use (. Fig. 1.5).
majority of children in the early and mid-twentieth cen-
In other parts of the world this improvement came tury, was considered a disease of modernization; there
somewhat delayed. In Italy, for example, a report for was a higher prevalence in developed countries and in
preschool children showed caries decline in the last individuals with higher socioeconomic status. In the
decade of the past century [12]. In China this seemed late twentieth and the twenty-first century, this pattern
to occur in the first decade of the current century, while of caries prevalence and severity changed in developing
.. Fig. 1.5 Tooth decay Tooth Decay Trends in Fluoridated and Non-Fluoridated
(DMFT) trends of 12-year-olds Countries
in fluoridated and non-fluori- WHO data on DMFT in 12 year olds*
dated countries. (Accessed at
7 https://fluoridealert.org/
Ice
lan
studies/caries01) d
8 Ne
wZ
eal
an Ital
d y
Non-Fiuoridated**
Decayed, Missing of Filled Teeth (DMFT)
Jap Fluoridated
6 an
Aus
t rali
a
4
Belgium
United Sta Irela
nd
tes
2
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Pediatric Dentistry: Past, Present, and Future
5 1
.. Fig. 1.6 The changing DMFT
pattern of caries incidence in 5
12-year-olds in developed and Developed countries All countries Developing countries
developing countries during the
last two decades of the twentieth
century and beyond [15] 4
0
1980 1981 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
ditions, which can impact on their oral health and usu- Consequently, it is very likely that the gingival health
ally require increased and/or special services for dental has improved [32]. Regarding orthodontics, it seems
and periodontal disease. Studies of special care needs now attractive, considering the large increase of accep-
children show much higher prevalence of caries com- tance and frequency of children under orthodontic
pared to children in the general population. In two stud- treatment (. Fig. 1.7). While it has a positive impact
ies reporting on disabled children in Kuwait and children on the oral health-related quality of life of adolescents
with autism in South Africa, the teeth most affected [33], treatment requirements – compliance to treatment,
were the first permanent molars and their periodontal long duration, costs – pose a burden to many population
and restorative needs were mostly unmet [30, 31]. groups.
Although there is little longitudinal data on the his- Dental auxiliary personnel were introduced several
tory of oral diseases/conditions other than caries, there decades ago in industrialized countries for various rea-
has been some progress in the prevalence and treatment sons including the reduction of costs, which are higher
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6 N. Kotsanos et al.
for dental education than any other health profession. 1.2.1 rends in Pediatric Dentistry
T
1 One such example was in Australia’s health-care system in the Future
in the mid-1960s, in trying to address the then difficult-
to-meet treatment needs for child dental disease. Today, Future trends for the practice of pediatric dentistry
oral health therapists and hygienists comprise one quar- based on research advances may include the following:
ter of the dental workforce providing fissure sealants, 1. Predominance of prevention of dental caries by early
restorations and primary tooth extractions, oral health identifying high caries risk, informing and engaging
instruction, fluoride applications, scale and cleans, parents, promoting oral health care at home, use of
and some periodontal services [34]. Thus, much of the fluoride and other prevention technologies, applica-
less complex dental treatment needs are not provided tion of fissure sealants, and establishment of efficient
by dentists themselves, and this, along with the caries recall system.
decline, means that their involvement with restorative 2. Increased intervention in orthodontic anomalies and
procedures has decreased significantly. smile aesthetics, which already are of high interest
Lastly, upcoming social changes bring about other among parents and children.
issues. As many families nowadays have limited free 3. Improved accessibility and dental care for people
time, either because both parents are occupied at work or with disabilities, alongside with extending the dental
because they escort children in several organized extra- neglect concept to them.
curricular activities (. Fig. 1.8), they become more selec-
4. Increased use of new technology dental equipment
tive in search of high-quality services for their children. (e.g., evolution of laser devices [36], sophisticated
Even though restorative procedures show reduction, the electronic anesthesia techniques that increase effi-
emphasis on quality and the increase in preventive, cos- ciency and acceptance by children, etc.).
metic, and orthodontic services compensate for it. 5. Therapeutic approaches based on the principles of
Τhe recent pandemic of airborne Covid-19 with preventive dentistry including minimally invasive
even asymptomatic carriers spreading the disease has operative approaches lead to painless and often
challenged dentistry among other health professions. pleasant dental procedures for children. This
Concerns regarding dentists’ and patients’ safety dur- improved dentist’s image will further reduce phobic
ing the outbreaks limited dental care to emergencies young adults.
compromising preventive appointments. Among other 6. Exclusive use of tooth-colored materials with ever-
impacts [35], the aerosols produced in several dental improving bonding and with emphasis on safety
procedures imposed a higher level of protection than (lack of toxicity), while these principles increasingly
before, necessitating the use of FFP2/FFP3 masks and apply to preformed crowns.
other protective gear. The production of successful vac- 7. Molecular biology and engineering bring potential
cines has somewhat eased fears for dental visits, but applications in the dental practice with regeneration
the risk of similar viral future threats calls for constant of dental tissue by the stem cell technology.
alertness. 8. Better understanding the microbiome of the human
body and its environment will allow development of
preventive health measures for oral and general
health.
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Pediatric Dentistry: Past, Present, and Future
7 1
and it is the most widely ratified human rights treaty cause for suspecting neglect. The American Academy of
(about 200 countries currently). Its purpose is to defend Pediatric Dentistry defines dental neglect as “the willful
children’s rights and protect them from exploitation
failure of parent or guardian to seek and follow through
phenomena, violence, and abuse. Oral health is not spe- with treatment necessary to ensure a level of oral heath
cifically mentioned but is nevertheless implied under essential for adequate function and freedom from pain
general health and wellbeing. The reference to health and infection” [42].
rights in articles 23–25 briefly includes:
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8 N. Kotsanos et al.
1. Good dental knowledge, in prevention of oral dis- 55 Support training programs, advising accreditation
1 eases, restoring dental cavities, wear and various boards, and sponsoring programs to enhance success
defects, pulp treatment, dental materials, oral sur- throughout their career
gery, preventive orthodontics, and certain principles 55 Be competitive in pursuing and advancing collabora-
of prosthetic dentistry tive research
2. Basic knowledge of pediatrics, anesthesiology, gen-
eral medicine and oral pathology, growth and devel- Engagement with pediatric dentistry ascribes the prac-
opment, as well as nutrition ticing dentist with an additional important social role
3. Knowledge of mental, emotional development, and as an educator, trainer, and protector of the vulnerable
child psychological issues, because each child groups, often in collaboration with the pediatrician and
requires different management, depending on age, many other clinicians and scientists. Along with prog-
maturity, and other physical abilities ress in recognizing children’s rights, this is still important
because access to care remains a serious public health
It is apparent, however, that the dentist has an obliga- problem, even in population sections of industrialized
tion to recognize the limits of his/her knowledge either countries. This role includes:
in dental/medical or in the behavior management
skills. In cases where the patient’s needs exceed those 55 Dynamic interventions for impoverished, neglected,
limits, the dentist must refer the patient to a special- or abused children
ist pediatric dentist. Moreover, the level of dental care 55 Undertaking interventions on preventing of dental
provided to the child should be of quality that can be caries, which remains a plague for certain groups of
certified. Dental care and treatment options should unprivileged child populations, by individual or col-
not be empirical or even based only on expert opin- laborative voluntary activities (. Fig. 1.10)
ion. Today it is evidence-based as far as possible, which 55 Counseling parents and children on obesity, an epi-
means knowledge that comes from randomized control demic of our time, discussing healthy eating habits
trials, systematic reviews, and meta-analyses. Research and regular exercise
today is deemed to fill the gaps in the documentation
of knowledge in pediatric dentistry, as in other fields
of medicine.
Pediatric dentistry has widely expanded its content,
due to the recognition of the importance of child oral
health and its effect on normal physical and psychologi-
cal development. Its effective practice requires the pedi-
atric dentist to collaborate with various other pediatric
specialties. The extensive level of education in pediatric
dentistry is not possible to be integrated in undergradu-
ate dental programs and it is taught in postgraduate spe-
cialization programs. These, according to the principles
of international bodies of pediatric dentistry [43–45],
aim to specialize the trainee in all aspects in order to be
able to:
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Pediatric Dentistry: Past, Present, and Future
9 1
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s12903-018-0632-1.
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32. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-
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Evans G, et al. Trends in oral health status: United States, 1988-
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1994 and 1999-2004. Vital Health Stat. 2007;11(248):1–92.
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33. Ferrando-Magraner E, García-Sanz V, Bellot-Arcís C, Mon-
past 25 years. Indian J Dent Res. 2018;29(3):323–8. https://doi.
tiel-Company JM, Almerich-Silla JM, Paredes- Gallardo
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V. Oral health-related quality of life of adolescents after orth-
15. Petersen PE (2003) The World Oral Health Report 2003. www.
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Accessed on 21/14/2020.
34. Teusner DN, Satur J, Gardner SP, Amarasena N, Brennan
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35. Campagnaro R, Collet GO, Andrade MP, Salles JPDSL, Calvo
17. Malele-Kolisa Y, Yengopal V, Igumbor J, Nqcobo CB, Rale-
Fracasso ML, et al. COVID-19 pandemic and pediatric dentistry:
phenya TRD. Systematic review of factors influencing oral
fear, eating habits and parent’s oral health perceptions. Child
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36. American Academy of Pediatric Dentistry. Policy on the use
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39. Chen KJ, Gao SS, Duangthip D, Lo ECM, Chu CH. Prevalence 42. American Academy of Pediatric Dentistry. Definition of dental
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Contents
References – 22
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12 T. Coolidge et al.
Helping children develop positive attitudes about den- Senso- Preopera- Concrete Formal operational
rimotor tional operational (hypothetical/
tists and oral health is an effective strategy to ensure that
abstract thinking)
these patients continue to have positive attitudes about
dentists and oral health throughout their lives. This
long-term goal involves developing a relationship with
the child and his/her parents that fosters trust, as well with that physical maturation and result in the devel-
as providing those dental services that result in promot- opment of cognitive abilities, i.e., interaction between
ing oral health in keeping children healthy throughout genetic and environmental features [1], and result in
their childhood. In our opinion, many of the difficulties qualitatively different ways of thinking or behaving as
dentists encounter while trying to provide dental care to they develop.
young children are a result of focusing on the short-term These new ways can be identified as occurring at
goal of completing a particular dental procedure, rather distinct times, or stages, during a child’s development.
than keeping this long-term goal in mind. A strong This concept alone will serve the pediatric dentist well.
background in child cognitive development will pro- Piaget’s stage model of cognitive development provides
vide clinicians with tools helpful for accomplishing both clinicians with the structure with which to understand
short- and long-term goals when working with children. the thought processes of pediatric patients. Piaget stated
The Swiss psychologist Jean Piaget studied the that children go through four different stages of cognitive
development of children’s thought processes for nearly development (. Table 2.1) [2].
Case Study
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Child Cognitive Development: Building Positive Attitudes toward Dentists and Oral Health
13 2
schema (“kitty”). It also further refines the child’s schema
for “doggie.” According to Piaget, the child has accommo-
dated the “doggie” schema to include the new information.
The general processes of assimilation and accommo-
dation are facilitated by the child’s growing understand-
ing of what constitutes a prototypical example of the
schema. For example, the child learns that the prototypic
zebra has white and black stripes, while the prototypic
.. Fig. 2.2 Piaget’s early sensorimotor stage
horse does not. In various cultures, prototypic men and
women may wear different clothes and/or have differ-
ent hairstyles. Similarly, although they are both objects
The sensorimotor stage begins at birth and lasts until which one can shelter inside of, prototypic houses differ
approximately the child’s second birthday. Children are from prototypic tree forts.
born with reflexes (e.g., sucking), can see and hear, and This raises the issue of what a prototypic dentist is
explore and learn about their worlds through their senses like. For some adults, the prototypic dentist is someone
and their ability to move (. Fig. 2.2). This means that
wearing a white coat who helps people have good oral
they understand their world through what they can sense health. For other adults, the dentist is someone frighten-
and physically interact with. One frequent way of learn- ing who causes pain inside one’s mouth. Dentists and
ing about objects during this stage is to put them in one’s parents can each work to influence the child to develop
mouth. Other ways to learn about objects and the world a positive prototypic schema for dentists. The pediat-
around include looking and handling things with one’s fin- ric dentist and the parents can help the child learn the
gers. Some fascinating research has demonstrated that new- schemata for “dentist,” “visiting the dentist” and “oral
borns can mimic adults who are sticking out their tongues hygiene” even before his or her first dental visit by post-
or making other facial gestures, indicating that mimicry is ing current pictures of the dentist, the waiting room,
another method of sensorimotor exploration [3]. and the pediatric operatory on the practice’s website, so
Especially during the first year of life, the sensorimo- that parents can show their children who the dentist is
tor child does not have a fully developed, individuated and what the dental office looks like. The website can
sense of self. That is, she does not consider herself to also suggest appropriate pictures about children’s dental
be a completely separate person from her caregivers. appointments and oral home care for parent and child
This is why physical contact with caregivers is soothing, to look at together. These pictures can provide infor-
while physical separation from them can be stressful. In mation about what a dentist does and how to maintain
addition, children of this age are only concerned with good oral health through behaviors at home. These prin-
what they can sense in the present moment. The clini- ciples also apply for older children.
cian needs to remember how a child thinks at this stage: The photographs posted on the practice’s website can
“out of sight, out of mind.” help children notice that the dentist and other personnel
Piaget believed that children begin to construct are smiling. “Smiling” is likely to be part of children’s
schemata or concepts – ideas about how the world works – schemata of “good people” or “nice people.” Another
during this stage. Schemata are mental representations photograph might show the dentist using a large toy
about the world and include different kinds of objects, toothbrush to “brush” the teeth of a plush alligator,
individuals, actions, descriptors or properties, and abstrac- which can cue the parent to say: “Look, the dentist is
tions [4]. For example, parents point out a dog and say: cleaning Mr. Alligator’s teeth! That helps him keep his
“Look, honey, see the doggie!” Eventually, the child points teeth nice and strong!” Since “nice” and “strong” are
to a different dog and says: “Doggie!” It seems that the positive qualities, this conveys that dentists are helpful
child has learned that certain objects are “doggies.” In people, as well as that brushing is related to the health of
Piaget’s terms, the child has used assimilation to apply one’s teeth. Dentists can provide parents with descrip-
the “doggie” schema to a new object. However, it is not tions of what the dental philosophy of the practice is,
uncommon for children to point to a different animal (say, what will happen at a dental appointment to pass on to
a cat) and say “Doggie!” From the adult’s point of view, the child, and additional information designed to help
the child is incorrect to assign a cat to the concept of “dog- ensure that the parent provides information about how
gie.” The parent may say, “No, honey, that is a kitty,” and a dentist is helpful to children.
provide some information about why the object is a cat While infants use their vision to begin to build sche-
and not a dog. This starts the process of developing a new mata of concrete objects that they can see, such as dogs,
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14 T. Coolidge et al.
snack may be served. At another point, the children are out that children can become afraid of the dentist by
expected to lie down and take a nap, or at least lie qui- simply hearing another person say something such as:
etly. Later, the parent will come back, the child will be “Dentists! I hate them! They hurt you!” However, if the
helped to put on his/her coat, and then parent and child child has developed complex, positive schemata and
will return home. scripts for dentists and dental visits, he or she is much
Here, too, dentists can help by providing parents with less likely to be influenced by these negative statements
suggestions for how to describe the script for “going to from others.
the dentist.” When children first visit the dental office, Revisiting the vignette of 15-month-old Sally, kick-
they try to understand this new experience in light of ing and crying are normal behaviors for a child of her
what they already know. When the new experiences do age – and perhaps up to a year older than her – so it
not fit with their current schemata and scripts, the child would be a mistake to conclude that she is an unruly
is more likely to respond with uncertainty, feelings of child (. Fig. 2.3). The initial kicking provides her
being overwhelmed, or fear. If the clinician can pro- developing brain with information about the object
vide detailed pictures or other visual examples on his/ which she is sitting on. Closing her eyes, looking away
her website of what will happen during an initial den- from the dentist’s face, and crying are signs of being
tal visit, the parent and child can use this information overwhelmed. The increased kicking is another sign of
to help the child develop new schemata and a script for
“going to the dentist.” As a result, he or she will become
more relaxed and will behave more positively on the first
and future visits.
Eye Catcher
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Child Cognitive Development: Building Positive Attitudes toward Dentists and Oral Health
15 2
distress. There are a number of reasons why she might
be feeling this way. First, it is her first dental visit, so she with the clinician and the examination is successfully
is working hard to figure out who this new person is and completed. When Alex arrives home, his father asks
what this new experience is all about. Second, she has “How was your dental visit?” Despite learning that
been put into a pediatric dental chair where she is sepa- he has healthy teeth and having had an otherwise
rated from her mother. Third, unless she has seen his/her unremarkable clinical visit, Alex breaks into tears
photograph ahead of time, she is now being approached and tells his father all about how he got hurt. Now,
by a stranger. These combined are probably more than here is the problem with memory: as time passes, Alex
she can tolerate. Examining Sally in a parent-supported may remember the fear he experienced at the dentist
(as well as restrained) position (7 Fig. 5.15a, b) is much
office, but that memory has become detached from
less stressful, because in that position she can maintain the source of the fear. In other words, he is likely to
physical contact with her mother/father, which should associate his fear with the dentist and the entire expe-
be soothing to her. This position also allows her parent rience, rather than with the brief surprise and pain he
to lean in, so that Sally can be reassured by seeing his/ experienced when he hopped up into the chair.
her familiar face, thus satisfying the central need that
young children have for physical parental touch and
reassurance during the sensorimotor and early preop- In addition to Piaget’s stage theory, psychologists soon
erational stages. found that children’s social environment also had a pro-
Another cause for Sally’s distress is that the source found influence on their cognitive development. Lev
of control has shifted from herself to the stranger/den- Vygotsky, a contemporary of Piaget, believed that cul-
tist. Before the crying began, Sally was putting the toy ture and, specifically, the social environment of a child
keys in her mouth and taking them back out again, a provide a tremendous contribution to cognitive develop-
typical behavior for children in this stage, who learn a ment. Of interest to the pediatric dentist is Vygotsky’s
great deal about the world by putting things inside their belief that children have skills that allow them to learn
mouths. Notice that Sally was controlling when the keys from others. Vygotsky identified what he called the
went inside and outside, and her tongue, inner cheeks, zone of proximal development (ZPD) as the difference
and lips were exploring the keys as she moved them. between skills the child has already acquired on his own
Contrast this with the dentist’s attempt to start an oral and what he would be capable of doing with some assis-
exam by putting a mirror inside her mouth: suddenly, tance (or what is sometimes called “scaffolding”) from
someone else – a stranger – is controlling what gets put older siblings or adults [5]. Dentists, too, can help chil-
inside her mouth, how it moves around, and when it is dren learn new information by utilizing the concept of
removed. the ZPD and move the child’s cognitive development
Observations of children under 2 years of age receiv- forward. For example, if a child opens his mouth only
ing dental care indicated that, when the caretakers were slightly, the dentist can say: “Nice job, Tommy! Right
attentive to their children, the children were less dis- now I can see your front teeth. If you open your mouth
tressed. The difficulty arises from the broad definition of really wide, then I can see the rest of your teeth, too.”
being “attentive.” While the physical contact of a mother- Tommy is likely to open his mouth more widely, having
supported exam may be important, it is not necessarily learned how this allows the dentist to see more of his
sufficient. The lack of control and/or understanding of teeth.
being separate from the caregiver is distressing. Even if As children progress to the preoperational stage
the parent is physically present in the operatory, if he/she toward 2 years of age, they increasingly use symbols to
is distracted – perhaps by being in conversation with the represent their world. During this time, language skills
dental assistant or checking his/her phone for texts – the are developing rapidly, and children are acquiring an
child is more likely to become distressed. increasing number of mental images and schemata. What
this tells the clinician is that children can now engage in
games of make believe or pretend play. While a child
2.1.2 Preoperational Stage in this stage has not yet developed an understanding of
basic mental operations, two very important skills have
Case Study
emerged: representing simple concepts (i.e., children can
tell whether two things are the same or different) and
When 4-year-old Alex enters the operatory, he hops he/she is beginning to understand the concepts of time.
up into the chair, slips, and bangs his chin on the Children can now think about the concept of yesterday
metal tray table. He sheds a few tears and is quickly (the past) and soon (the future). These skills allow them
calmed by his mother. However, Alex remains appre- to begin to anticipate the consequences of their behav-
hensive the entire visit even though he cooperates iors. Further, compared with infants, children in the pre-
operational stage are learning to control their impulses,
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16 T. Coolidge et al.
and thus they have more coping resources. Adults can Just as the parents help the child understand who
take advantage of the concept of the zone of proximal a dentist is and the upcoming dental visit by talking
development to help children develop coping resources. about what will happen, the dentist should talk to chil-
2 dren during the dental appointment itself, explaining
what he or she is doing and why he/she is doing it (“I
Case Study am counting your teeth to see how many you have”).
While it may be amusing to the child to experience other
Sammy walked slowly into the operatory and then
novel aspects of the dental office, such as feeling his/
stood hiding behind his mother. Sammy had been to
her body recline and return to a sitting position as the
the dentist once before, just after his first birthday,
back of a pediatric dental chair is lowered and raised,
but he had no memory of that event. Now he was
or fun to experience the water being squirted into his or
4 years old. His mother gently tried to coax him into
her mouth and then suctioned out by the “straw,” prob-
the chair, but he was very hesitant. She lifted him up
ably the most important behavior for the dentist is to
into the chair, and he immediately drew his knees to
talk to the child about what he/she is doing – and why –
his chest and put his head down.
before, during, and after any procedures or activities.
I introduce myself and tell Sammy that I want to
The descriptions and explanations serve two purposes.
take a look at his teeth to count them. Sammy doesn’t
First, they provide rationales for the child to help him/
look at me or respond. I go on to say that, to do this, I
her understand what is going on. Thus, they explain to
need him to lie flat in the chair and to open his mouth
the child what is happening, which is reassuring and can
for me. I suggest to him that perhaps he could pretend
help prevent the child’s imagination from incorrectly
he was a statue, and lie still. While Sammy is listening
assuming that something bad or dangerous is occurring
to me, he remains folded up in his little ball position.
in this new situation. Second, the information that is
Mom then says to Sammy: “Sammy, Melanie comes
conveyed helps the child develop the schemata related
to Dr. Dentist so he can keep her teeth healthy. She told
to dentists and oral health.
me that when she ‘lies still like a statue’ and opens her
In addition, clinicians need to remember that preop-
mouth really wide, it makes the Doctor’s job easier.”
erational children do not yet have the cognitive capaci-
I knew that Melanie was Sammy’s older sister,
ties of older children. For example, think about the
because she is my patient, too, but, since I had already
directions you may give to a child patient during an
asked Sammy to “lie still like a statue,” I had my
appointment. Do you ask the child to open wide? Then
doubts that his mother’s statement would work. I was
close. Then open wide, then close. Now, perhaps you
surprised and happy to watch Sammy uncurl himself,
want to check the bite after a new filling, so you ask the
put his hands at his side, and open his mouth! At
child to open his mouth and grind his teeth backward
the end of my exam, I complimented Sammy for his
and forward then side to side. Very young children will
excellent ability to lie still like a statue. Sammy said
not be able to inhibit the well-rehearsed sequence of
that lying still like a statue worked for Melanie, so he
opening and closing their mouths and switch to the new
trusted that it would work for him, too. His mother
grind backward and forward, side to side task.
went on to say: “Sammy really adores Melanie.” He
If tell-show-do (described in 7 Chap. 5) is used with
was unable to relate to pretend play as I had hoped,
preoperational children, the dentist should only refer to
but, because of the example that his older sister had
one step or action at a time. This is because children at
set, he developed a successful coping mechanism with
this stage cannot remember a series of things very well.
a gentle nudge from his mother, based on the concept
For example, if the dentist said “I need you to open your
of the zone of proximal development.
mouth very wide, and turn your head toward me, and
be very still,” the child may remember the initial action
that the dentist described (open mouth wide), or the last
At the same time, children in the preoperational stage action described (be very still), but not all three. (In Sect.
have difficulty viewing the world from someone else’s 2.2.1 of this chapter, we point out that, in general, mem-
perspective. This egocentrism means that children ory tends to be strongest for the initial experience, due
believe that other people perceive things in the same way to the primacy effect, and the last experience, due to the
as they do. From the child’s point of view, whatever he recency effect. The same is true for hearing a list or series
or she is seeing, hearing, or experiencing, the p
arent/sib- of words or descriptions. The issue with preoperational
ling/dentist must also be experiencing. In other words, children is that they are not able to remember all of the
the child cannot “put himself/herself in another’s shoes.” contents of the list or series that are in between the first
For example, in the previous scenario Sammy acted as if and last items as older children can.)
the dentist couldn’t see him or know that he was in the One of the best illustrations of how children in the
operatory, because he couldn’t see the dentist when he preoperational stage think differently from adoles-
was hiding behind his mother. cents and adults can be seen in the children’s failure
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Child Cognitive Development: Building Positive Attitudes toward Dentists and Oral Health
17 2
to understand the principle of conservation. The clas- 2.1.3 Concrete Operational Stage
sic example is to show a young child two glasses of the
same size and shape, each filled to the same height with Case Study
water. The child can compare the two glasses and tell
you whether the amount of water in the glasses is the Six-year-old Carlos hops up in the operatory chair
same or different (in this case, she will tell you that it is with great energy and confidence. After a quick exam-
the same). Then, you can take a taller, thinner glass and ination and a confirmation from the x-rays, I show
have the child watch you as you pour the water from Carlos the weakness on the enamel on his lower molar.
one of the first two glasses into this differently shaped – When he asks, “How did that happen?” I explain about
taller and thinner – glass. Then, when you ask the child the decay while also including behavioral steps he can
whether the two glasses of water have the same amount take to prevent the further breakdown of his tooth.
of water in them, or a different amount, she will confi- Carlos is now old enough to understand the concept
dently tell you that they are different, and, in particular, of reversibility such that he understands that, by skip-
that the tall glass has more water in it. When you ask her ping teeth brushing before he went to bed this past
why, she will explain that the taller glass has more water year, his enamel has weakened and the harmful bacte-
because the water level is higher! ria in his mouth have multiplied and are attacking his
This failure to understand that matter remains the tooth. Carlos can now perform basic mental opera-
same despite the change in height (i.e., the failure to tions, thus quickly calculating the effect his poor oral
understand conservation) extends to other changes in care may have on the rest of his teeth. As Carlos is
appearance (e.g., two lines of ten pennies each are “the now able to look at situations from a perspective out-
same” as long as the two lines have the same length. side of his own (i.e., is much less egocentric than the
However, once the pennies are spread out in one of the preoperational child), he is able to understand what I
lines, then that line has “more” pennies in it.). and his parents see. (For example, unlike 4-year-old
Why does the child fail to understand conservation? Sammy, Carlos knows that the dentist could see him,
Piaget said that children may only be able to focus on or know that he was in the room, even if he tried to
one aspect of a situation at a time. Thus, in the example hide behind his mother.)
of water, the child can only focus on the height of the I tell Carlos to imagine his teeth are like the bricks
two glasses – without also being able to focus on the on the side of my office building. Sometimes ivy and
width of the glasses, or the fact that the volume of water moss start growing on the bricks and you might even
must be the same even though it has been poured into a think they make it look nice. But, when we pull the
taller glass, because the child saw the adult pouring the plants off of the brick, some of that hard brick goes
water from the old container into the new one. On the with the plants. The brick on the building still looks
other hand, an older child is not fooled by the increased good, but it is now weaker. When this happens over
height and will be able to tell you that the amount of a period of years, eventually the bricks are no lon-
water is still the same. If you ask how he knows this, he ger hard and strong and in some cases crumble and
can say something such as: “You just poured the water need to be removed. I explain to Carlos that this is
into a new glass. If you pour it back again, you will see like his teeth and sugar. His teeth are like the bricks,
that it is the same amount as before.” The older child is all polished and strong, and the pleasing to look at
referring to the process of reversibility. ivy is like the raisins and lollipops he is so fond of. It
This means that dentists should not expect a child in doesn’t happen overnight, but eventually, if the sugar
the preoperational stage to be able to think about men- is allowed to stick to the teeth without being removed
tally reversing actions. For example, the following state- every night, the enamel on his teeth, like the brick,
ment cannot be understood by preoperational children: will weaken and crumble.
“If you had done a better job brushing, the tooth bugs My story is met with a blank stare from Carlos,
would not have become stuck to your teeth.” who says that his teeth don’t have ivy and moss grow-
On the other hand, the dentist can take advantage of ing on them! Children at Carlos’ stage of cognitive
the fact that the preoperational child is likely to attribute development have trouble with hypothetical and
lifelike qualities to inanimate objects and natural events, abstract reasoning. Any directions that start with
a process called “animism.” Thus, children of this age “imagine” or “let’s pretend…” are doomed as children
respond well to statements such as: “Let’s let your tooth at this stage understand concrete concepts and have
rest on Mister Pillow” or “The super straw will suck up not yet developed the skill to think in the abstract.
all of the extra water.”
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18 T. Coolidge et al.
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Child Cognitive Development: Building Positive Attitudes toward Dentists and Oral Health
19 2
Case Study
Eye Catcher
One of us (TC) observed a teen as she underwent a
Sample Revised Iowa Dental Control Index items:
restoration. The observer noticed that the teen was
Desired Control:
moving her feet in a deliberate way on the chair (while
55 To what degree would you like control over what
taking care not to jostle herself), and asked the teen
will happen to you in the dental chair?
about this once the treatment was completed. Sitting
upright, the patient explained that she had been anx-
Predicted Control:
ious about whether she would be able to handle the
55 Do you feel you have control of what will happen
discomfort of the injections and the length of time
to you in the dental chair?
that the treatment would take. She went on to say
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20 T. Coolidge et al.
Eye Catcher his father – focused on this initial experience. This dem-
onstrates the power of the primacy effect. However, if
55 Sample Child Dental Control Assessment Items: the dentist (and/or parent) had found ways to use some
2 55
55
I want the dentist to tell me what will happen.
I want the dentist to answer my questions.
of the behaviors described below, Alex would have been
better able to put the initial experience in context.
55 I want the dentist to tell me how long things will Important behaviors for the dentist who wants to
last. prevent the development of dental fear:
55 Have the child repeat the information that you want
him/her to remember. You can ask the child “What
did you learn today?”, as well as “What are you going
2.2 sing Memory Principles to Help
U to tell your dad [i.e., the parent who was not in the
Prevent the Development of Fear operatory with the child during the visit] about your
trip to the dentist today?”
Returning to 4-year-old Alex, who banged his chin at 55 Have the child talk about what she learned and how
his dental appointment, let us focus on what dentists can well she did today, because this helps to ensure that
do to prevent children from developing dental fear. This she remembers these positive aspects.
is particularly important given that we want children to 55 If the child refers to “negative” behavior, reframe
return for routine dental care on a regular basis, and it this in a truthful way to put it in perspective, and
is possible that children may also need to undergo some include a reference to some aspect of positive behav-
appointments that involve restorations or other inva- ior that you noticed. For example, if the child says “I
sive treatments. Unfortunately, the negative memory cried, it hurt,” you can reply: “Yes, it’s true that you
from one appointment may impact a child’s behavior did cry when you got the shot, and I am sorry that it
on subsequent visits [22]. Given the pervasive negative hurt you. But you only cried for a minute or two, and
valence surrounding dental appointments in our culture then you were able to lie very still and that helped me
(how often has one heard “It was like pulling teeth” or finish the work quickly. Overall, you really did well
“Ugh, I’d rather have a root canal”), children may have today!”
heightened anxiety and arrive at their first dental visit 55 After walking the child back out to the waiting room,
prepared to experience something awful. Some research be sure that she overhears you tell her parent what a
focuses on restructuring memory of visits or procedures good job she did today.
so as to prevent negative memories growing with the 55 Focus on simple, salient facts while suggesting
passage of time [23–25]. important ideas peripherally. Suppose the main
General memory principles help guide the restruc- important idea that you want the child to under-
turing procedure followed in cognitive intervention [23]. stand is: “Make sure you cover your teeth with
These include: toothpaste every time you brush.” To make that
Use the primacy effect concept identified by memory message salient, talk about how “the fluoride in
researchers. We have already recommended that dental the toothpaste kills the bacteria that eat your tooth
offices offer stimuli (e.g., photos of the dentist and the enamel. When you cover your teeth with toothpaste,
dental office on the practice website) and previsit activi- you are protecting them.”
ties (e.g., books for parents and children to look through) 55 Children (and adults) find it easier to remember infor-
to help prepare children for their initial visit. Dentists mation if it is associated with them. For example, the
also need to ensure that the initial visit – and the initial dentist should talk to the child during the appoint-
aspects of that visit – is as positive as possible. These ment about how well he is helping. The dentist can
initial experiences are likely to be strongly remembered, say: “Thank you for lying nice and still.” “Thank you
as they are the primary experiences that the child has. for letting me know that you need a little break now.”
When children form their first impression of their visit, “You know how to open your mouth really wide!”
they will use that information as a lens through which
they experience and interpret all subsequent informa- In addition to ensuring that the beginning of the dental
tion, and have additional time to explore, think about, encounter is positive (primacy effect concept), accord-
and analyze this initial information. This results in a ing to the recency effect concept the last experiences
strong encoding and thus a stronger recall. at the dental office are also central to the child’s mem-
Since 4-year-old Alex had a painful experience at ory of the visit. In other words, the dentist needs to
the onset of his dental appointment, it is not surpris- ensure that these last experiences are positive. The end
ing that his memory of the visit – as he described it to of the appointment provides an excellent opportunity
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Child Cognitive Development: Building Positive Attitudes toward Dentists and Oral Health
21 2
to reinforce concepts first introduced, and any positive Eye Catcher
behaviors exhibited. Remind children how they helped
the dentist take care of their teeth. The dentist can say: Sample BIS item: “I feel worried when I think I have
“You really helped me today! You sat nice and still, done poorly at something important.”
you opened your mouth really wide, which made my Sample BAS item: “When I want something I usu-
job so much easier. You also followed my directions ally go all out to get it.”
really well. You know, you helped me so much today,
and that made my job so much easier.” Always praise
the child for something positive, even if the appointment
Given the seeming paradox between understanding
was difficult. For example, even the child who cries dur-
the reasoning behind, say, suggestions to brush but at
ing the entire examination can be told what a great job
the same time not brushing, dentists are likely to find
he did opening his mouth very wide when the dentist
the results of one study team intriguing. In several
asked so that the dentist could see his teeth much more
studies, Sherman, Updegraff, and Mann [28] experi-
easily.
mented with the wording of the messages they created
To illustrate the power of the last experiences of
to learn whether they were successful in motivating
a dental visit, imagine the memory that this young
college students to change an oral behavior. First,
patient – observed at the end of an appointment which
they created two messages about flossing. One was
included a restoration – will have of his dental visit:
gain-oriented (“Great Breath, Healthy Gums Only a
The father heard his son crying in the operatory and
Floss Away”) and referred to the benefits of flossing,
came to the doorway. When he saw his child in the den-
while the other was loss-oriented (“Floss Now and
tal chair, extremely upset, he said: “Ahhh, now I know
Avoid Bad Breath and Gum Disease”) and referred
what to do to punish you in the future. Next time you
to the downsides of not flossing. Importantly, the
misbehave I’m going to bring you back here!”
same information was included in both messages. For
example, the gain-oriented message included the state-
ment that “flossing your teeth daily removes particles
2.3 ailoring Oral Messages
T of food in the mouth, avoiding bacteria, which pro-
to the Individual Patient motes great breath,” while the loss-oriented message
included the same information, but worded differ-
Dentists (and other dental personnel) often find them- ently: “If you don’t floss your teeth daily, particles of
selves wanting to give information or advice to their food remain in the mouth, collecting bacteria, which
patients and/or the parents of their patients. Sometimes causes bad breath.”
they feel frustrated when their advice doesn’t seem to be The team recruited college students and measured
heeded. We would like to offer some suggestions about their relative preferences for approaching (to receive
how to tailor the information in specific ways, which a reward) or avoiding (to avoid punishment) with the
have been found to be more effective in terms of result- BIS/BAS scale. The researchers postulated that the stu-
ing in actual behavior change. dents who were higher on BIS would respond more to a
Of note, individuals are motivated both by the prom- message focused on losses, while the students who were
ise of receiving rewards and the risk or threat of receiv- higher on BAS would respond more to a message focused
ing punishment, although some individuals are more on gains. The students were then randomly assigned to
motivated by one of these two possibilities [26]. An indi- receive either the gain or the loss message. After they read
vidual’s relative preference for one of these two possi- the message, they received individual packets of dental
bilities can be assessed by the BIS/BAS Scale [26], where floss. After a week, the students were asked how many
BIS is short for the “behavioral inhibition system” (i.e., packets they still had. The results were that students who
that which operates to reduce the risk of receiving pun- had received the message which was congruent with their
ishment) and BAS is short for the “behavioral activa- motivational style flossed significantly more than the stu-
tion system” (i.e., that which operates to increase the dents who had received the message which was incongru-
likelihood of receiving rewards). A 10-year longitudinal ent with their motivational style [28].
study found that adolescents’ endorsement of the BIS The take-away message is that the dentist who spe-
items increased with age [27], indicating that inhibition cifically tailors his/her description of the outcome of a
tendencies increase with experience and maturation. desired behavior (e.g., more frequent dental visits, such
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22 T. Coolidge et al.
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Child Cognitive Development: Building Positive Attitudes toward Dentists and Oral Health
23 2
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Smith TA, Weinstein P, Milgrom P. The child dental control got my shot! Influencing children’s reports about a visit to their
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tural differences. Eur J Paediatr Dent. 2005;6:35–43. 26. Carver CS, White TL. Behavioral inhibition, behavioral acti-
22. Quas JA, Bauer A, Boyce WT. Physiological reactivity, social vation, and affective responses to impending reward and pun-
support, and memory in early childhood. Child Dev. 2004;75: ishment: the BIS/BAS scales. J Pers Soc Psychol. 1994;67:
797–814. 319–33.
23. Pickrell JE, Heima M, Weinstein P, Coolidge T, Coldwell SE, 27. Almy B, Kuskowski M, Malone SM, Myers E, Luciana M. A
Skaret E, Castillo J, Milgrom P. Using memory restructur- longitudinal analysis of adolescent decision-making with the
ing strategy to enhance dental behaviour. I J Paediatr Dent. Iowa gambling task. Dev Psychol. 2018;54:689–702.
2007;17:439–48. 28. Sherman DK, Updegraff JA, Mann T. (2008). Improving oral
24. Chen E, Zeltzer LK, Craske MG, Katz ER. Alteration of mem- health behavior: a social psychological approach. J Am Dent
ory in the reduction of children’s distress during repeated aver- Assoc. 2008;139:1382–7.
sive medical procedures. J Consult Clin Psych. 1999;67:481–90.
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25 3
Contents
3.3 Puberty – 34
3.3.1 Disorders of Puberty – 34
References – 35
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26 P. Triantafyllou and S. Roberts
Growth and development in addition to onset and pro- and sex steroids is essential for fetal growth. Thyroid hor-
gression of puberty are important topics in the field mones are very important for growth after birth but do
of pediatrics and that of pediatric dentistry. Growth is not seem to be essential during fetal period given that the
the term which is referred to children’s linear growth, growth of newborns with athyreosis is unaffected. Male
whereas development is referred to cognitive and emo- fetus starts to produce testosterone at tenth fetal week.
tional maturation and milestones’ achievement written Elevated testosterone levels perinatally drive to a higher
3 in 7 Chap. 2.
weight and less adipose tissue of male newborns [1–5].
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Pediatric Body Growth
27 3
without shoes. For children from birth to 2 years of age, child’s adult height potential can be estimated by cal-
supine length should be measured, and it requires two culating midparental (MPH) or target, height. Having
persons to obtain a reliable measurement. The one holds measured parents’ heights, the target height is occur-
child’s head and the other straightens the legs. Over the ring by calculating mean parental height and adding or
age of 2 a stadiometer should be used to measure height subtracting 6.5 cm for male or female child, respectively.
in standing position without shoes. Measurements Two standard deviations for the calculated target height
should be plotted on standardized growth charts [3, 5]. is approximately ±10 cm [1].
Standardized growth charts can be obtained from either
national surveys or the World Health Organization 3.1.2.4 Bone Age
website (. Figs. 3.1 and 3.2). For patients who have tri-
Linear growth depends on skeletal maturation which
somy 21, Turner syndrome, Klinefelter syndrome, and in normal children follows an orderly development.
achondroplasia, specific growth charts are available that Skeletal maturation depends on the appearance of
should be used [3]. In every growth chart there are five epiphyseal centers, the length of long bones, and the
curves usually referred to third, 15th, 50th, 85th, and fusion of the epiphyses that marks the cease of growth.
97th percentile. For instance, when the height of a child Estrogen fuses the growth plate in both girls and boys.
is plotted on the 15th percentile, it means that 15% of Bone age is a method of assessing skeletal maturation
children matched for age and gender are shorter and by comparing left hand and wrist radiograph with
85% taller than that child. To evaluate weight gain, it is given age-appropriate standard radiographs of healthy
preferable to use BMI (body mass index) growth charts children (. Fig. 3.4). There are two main methods for
according to which children are categorized as under- the evaluation of bone age: a) the most widely used
weight, normal, overweight, or obese. In children less Greulich and Pyle hand standards and b) the Tanner
than 2 years, weight-for-length is used instead of BMI. and Whitehouse method mainly used in Great Britain
Moreover, head circumference, arm span, upper seg- [1, 6–10]. Retarded bone age may be seen in hypothy-
ment/lower segment ratio, and sitting height are body roidism, growth hormone deficiency, Cushing’s syn-
proportion measurements that can be considered for drome, chronic malnutrition, and underlying chronic
growth evaluation if there is a clinical concern for short disease. Advanced bone age results from hyperthyroid-
or tall stature, falloff in growth velocity, or an underly- ism, precocious puberty, androgen excess, or obesity.
ing syndrome. Furthermore, bone age, in addition to child’s height
at a specific moment, can be used for prediction of
3.1.2.2 Growth Velocity final height, commonly performed using the Bayley-
Normal growth is assessed by growth velocity. It is Pinneau method [9, 10]. Height predictions must be
calculated by the difference of two measurements in a used in caution in children with abnormal growth pat-
time interval of 6–12 months. Shorter intervals such as terns and/or underlying pathology that may impact
3 months may lead to inaccurate evaluation of growth. growth.
There are specific charts for growth velocity (. Fig. 3.3).
for a child growing at the tenth percentile if parents are method is considered relatively accurate (± 1 year) for
healthy and their height is also at the tenth percentile finding dental maturity of single children, although
and the child has a normal growth velocity for age. By there may be an overestimation in puberty [11]. Dental
contrast, if the parents are very tall, even if this child’s age, despite being considered more reliable than erup-
height is in normal range, it is short for the genetic tion age of the teeth, does not show a high correlation
potential and needs further investigation. Therefore, the with bone age [12].
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28 P. Triantafyllou and S. Roberts
a Height-for-age BOYS
5 to 19 years (percentiles)
3 180
85th
180
50th
170 170
15th
3rd
160 160
Height (cm)
150 150
140 140
130 130
120 120
110 110
b Height-for-age GIRLS
5 to 19 years (percentiles)
180 180
97th
50th
160 160
15th
140 140
130 130
120 120
110 110
100 100
Months 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9
Years 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (completed months and years)
2007 WHO Reference
.. Fig. 3.1 Height for age WHO curves from fifth to 19th year of age of children. Frequently used percentiles are marked at the right side.
a. Boys. b. Girls
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Pediatric Body Growth
29 3
a Weight-for-age BOYS
5 to 10 years (percentiles)
45 45
97th
40 40
85th
35 35
50th
Weight (kg)
30 30
15th
25 25
3rd
20 20
15 15
Months 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9
Y e a rs 5 6 7 8 9 10
Age (completed months and years)
2007 WHO Reference
b Weight-for-age GIRLS
5 to 10 years (percentiles)
97th
45 45
40 40
85th
35 35
Weight (kg)
50th
30 30
15th
25 25
3rd
20 20
15 15
Months 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9
Y e a rs 5 6 7 8 9 10
Age (completed months and years)
2007 WHO Reference
.. Fig. 3.2 Weight for age WHO curves from fifth to tenth year of age of children. Frequently used percentiles are marked at the right side.
a. Boys. b. Girls
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30 P. Triantafyllou and S. Roberts
22
9 3.2 Growth Disorders
20 Boys 8
Girls 3.2.1 I ntrauterine Growth Retardation
18 7
and Small for Gestational Age
16
Centimetres per year
6 Newborns
a b
Overview
55 Intrauterine growth retardation – newborn growth
did not achieve genetic potential
55 Small for gestational age – newborn’s weight and/or
length < third or tenth percentile for gestational
age.
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Pediatric Body Growth
31 3
Height-for-age BOYS
5 to 19 years (percentiles)
85th
180 180
50th
170 170
15th
Mean
parental
3rd
160 160
Height (cm)
150 150
140 140
130 130
120 120
110 110
Months
100 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 100
Y ears 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (completed months and years )
2007 WHO Reference
.. Fig. 3.6 Growth chart of a boy with familial short stature (below 3rd percentile)
Height-for-age BOYS
5 to 19 years (percentiles)
85th
180 180
50th
170 170
15th Mean
parental
3rd height
160 160
Height (cm)
150 150
140 140
130 130
120 120
110 110
Months
100 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 100
Y ears 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (completed months and years )
2007 WHO Reference
.. Fig. 3.7 Growth chart of a boy with constitutional delay of growth at puberty
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32 P. Triantafyllou and S. Roberts
hormone action despite normal secretion is rare. Short Moreover, children with homocystinuria are character-
stature may be one of the main features of chromosomal ized by tall stature [3, 6, 16].
or genetic syndromes such as Turner syndrome, trisomy Endocrine disorders such as congenital adrenal
21 or Noonan syndrome, Russell-Silver syndrome, or hyperplasia, hyperthyroidism, and precocious puberty
Seckel syndrome, respectively (. Figs. 3.8 and 3.9).
may result to linear growth acceleration. Nevertheless,
Additionally, skeletal dysplasias or disproportional parallel skeletal maturation results to early epiphyseal
growth may result on short stature (. Table 3.1), like
closure and compromised final height. Extremely rarely
achondroplasia (. Fig. 3.10), spinal epiphyseal dyspla-
tall stature is caused by excessive growth hormone secre-
sia, or SHOX deficiency [3, 6, 14, 15]. tion most commonly due to pituitary adenomas.
Height-for-age BOYS
5 to 19 years (percentiles)
85th
180 180
50th Mean
parental
height
170 170
15th
3rd
160 160
Height (cm)
150 150
140 140
130 130
120 120
110 110
GH
Months
100 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 100
Y ears 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (completed months and years )
2007 WHO Reference
.. Fig. 3.8 Growth chart of a boy with growth hormone deficiency before and after treatment with growth hormone (GH)
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Pediatric Body Growth
33 3
.. Fig. 3.9 a Child with short stature for chronological age due to growth hormone deficiency. b The accompanying reduced bone growth
contributes to intense crowding of both dental arches. (Courtesy of Dr. I. Manoukakis)
HV height velocity
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34 P. Triantafyllou and S. Roberts
HV height velocity
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Pediatric Body Growth
35 3
defect. The earlier the age of onset, the more likely it is 7. Greulich WW, Pyle SI. Radiographic atlas of skeletal develop-
to find an organic cause [18–21, 23, 25]. ment of the hand and wrist. 2nd ed. Stanford, CA: Stanford
University Press; 1959.
Precocious puberty is distinguished as central or 8. Tanner JM, Whitehouse RH, Marshall WA, Healy MJR, Gold-
gonadotropin-dependent and peripheral or gonadotropin- stein NH. Assessment of skeletal maturity and prediction of
independent. Central precocious puberty is caused by adult height (TW2 method). 2nd ed. London: Academic Press;
activation of hypothalamic-pituitary-gonadal axis, and it 1975.
is more common in girls. In the majority of cases it is idio- 9. Martin DD, Wit JM, Hochberg Z, Sävendahl L, Van Rijn
RR, Fricke O, et al. The use of bone age in clinical prac-
pathic and rarely there is a central nervous system defect tice - part 1. Horm Res Paediatr. 2011;76:1–9. https://doi.
(tumor, inflammation, trauma, radiotherapy, or hydro- org/10.1159/000329372.
cephalous). In contrast, in peripheral precocious puberty 10. Martin DD, Wit JM, Hochberg Z, van Rijn RR, Fricke O, Werther
sex steroids’ production is autonomous mainly due to G, et al. The use of bone age in clinical practice - part 2. Horm
hormone-producing tumors or McCune-Albright syn- Res Paediatr. 2011;76:10–6. https://doi.org/10.1159/000329374.
11. Liversidge HM. The assessment and interpretation of Demir-
drome. Central precocious puberty is treated with GnRH jian, Goldstein and Tanner's dental maturity. Ann Hum Biol.
analogue in order to prevent early epiphyseal closure with 2012;39:412–31.
compromise in final height and to alleviate psychologi- 12. Yan-Vergnes W, Vergnes JN, Dumoncel J, Baron P, Marchal-
cal distress. In cases of peripheral precocious puberty, the Sixou C, Braga J. Asynchronous dentofacial development and
management is etiological (surgery in tumors, cortisone dental crowding: a cross-sectional study in a contemporary
sample of children in France. J Physiol Anthropol. 2013;32:22.
replacement in congenital adrenal hyperplasia) [18–25]. https://doi.org/10.1186/1880-6805-32-22.
13. Claris O, Beltrand J, Levy-Marchal C. Consequences of intra-
uterine growth and early neonatal catch-up growth. Semin Peri-
3.3.1.2 Delayed Puberty natol. 2010;34:207–10.
Delayed puberty is considered the absence of breast 14. Wit JM, Oostdijk W, Losekoot M, van Duyvenvoorde HA,
enlargement by the age of 13 years in girls or the absence Ruivenkamp CA, Kant SG. Mechanisms in endocrinol-
of testes’ enlargement (≥4 ml) by the age of 14 years ogy: novel genetic causes of short stature. Eur J Endocrinol.
2016;174:R145–73.
in boys [23, 27, 29, 30]. Delayed puberty is more com-
15. Argente J. Challenges in the Management of Short Stature.
mon in boys and more often it is constitutional with a Horm Res Paediatr. 2016;85:2–10.
history of delayed puberty in a parent or an older sib- 16. Baron J, Sävendahl L, De Luca F, Dauber A, Phillip M, Wit JM,
ling. Children with constitutional delay of growth and Nilsson O. Short and tall stature: a new paradigm emerges. Nat
puberty are usually shorter for their age with delayed Rev Endocrinol. 2015;11:735–46.
17. Davies JH, Cheetham T. Investigation and management of tall
bone age. However, bone age prediction is in line with
stature. Arch Dis Child. 2014;99:772–7.
MPH; if predicted height is shorter, this is more worri- 18. Dattani MT, Hindmarsh PC. Normal and abnormal puberty. In:
some for underlying pathology. Their final height is usu- Clinical pediatric endocrinology. Blackwell; 2005. p. 183–210.
ally normal as they have additional time for prepubertal 19. Bordini B, Rosenfield RI. Normal pubertal development: part I:
growth [30]. the endocrine basis of puberty. Pediatr in Rev. 2011;32:223–9.
20. Bordini B, Rosenfield RI. Normal pubertal development: part
Constitutional delay of puberty has to be distin-
II: clinical aspects of puberty. Pediatr in Rev. 2011;32:281–92.
guished by underlying pathology such as permanent 21. Bourguignon JP, Juul A. Normal puberty in a developmental
central defect (hypothalamic/pituitary hormone defi- perspective. Endocr Dev. 2012;22:11–23.
ciency), primary gonadal failure, underlying chronic dis- 22. Nussey S, Whitehead S. Chapter 6: gonad. In: endocrinology: an
ease, or chromosomal disorders (Klinefelter syndrome integrated approach. Oxford: BIOS Scientific Publishers; 2001.
23. Lee PA. Puberty and its disorders. In: Lifshitz F, editor. Pediatric
in boys or Turner syndrome in girls). [23–27, 29, 30]
endocrinology. 4th ed. New York; 2003. p. 211–38.
24. Abreu AP, Kaiser UB. Pubertal development and regulation.
Lancet Diabetes Endocrinol. 2016;4:254–64.
References 25. Latronico AC, Brito VN, Carel JC. Causes, diagnosis, and treat-
ment of central precocious puberty. Lancet Diabetes Endocri-
1 . Weintraub B. Growth Pediatric Rev. 2011;32:404–6. nol. 2016;4:265–74.
2. Rosenbloom AL. Physiology of growth. Ann Nestle. 2007;65:97– 26. Abitbol L, Zborovski S, Palmert MR. Evaluation of delayed
108. puberty: what diagnostic tests should be performed in the seem-
3. Patel L, Clayton PE. Normal and disordered growth. In: Brook ingly otherwise well adolescent? Arch Dis Child. 2016;101:
C, Clayton P, Brown R, editors. Clinical pediatric endocrinology. 767–71.
5th ed. Blackwell; 2005. 27. Fenichel P. Delayed puberty. Endocr Dev. 2012;22:138–59.
4. Juul A, Kreiborg S, Main KM. Growth and pubertal develop- 28. Abreu AP, Dauber A, Macedo DB, Noel SD, Brito VN, Gill
ment. Ch. 2. In: Koch G, Poulsen S, editors. Pediatric dentistry: JC, et al. Central precocious puberty caused by mutations in the
a clinical approach. 2nd ed. Wiley-Blackwell; 2009. imprinted gene MKRN3. NEJM. 2013;368(26):2467–75.
5. Wales J. Growth and puberty. Ch 10. In: Lissauer T, Clayten 29. Kaplowitz PB. Delayed puberty. Pediatr Rev. 2010;31:189–95.
G, editors. Illustrated Textbook of Paediatrics. 2nd ed. Mosby; 30. Harrington J, Palmert MR. Clinical review: distinguishing con-
2003. stitutional delay of growth and puberty from isolated hypo-
6. Lifshitz F, Botero D. Worrisome growth. In: Lifshitz F, editor. gonadotropic hypogonadism: critical appraisal of available
Pediatric endocrinology. 4th ed. New York; 2003. p. 1–46. diagnostic tests. J Clin Endocrinol Metab. 2012;97:3056–67.
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37 4
Contents
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4.7 Special Issues with Adolescents – 50
4.7.1 espond to Requests for Privacy – 51
R
4.7.2 Adolescents May Resist Going to the Dentist – 51
References – 58
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Child Dental Fear, Communication and Cooperation
39 4
4.1 Child Misbehavior a
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40 T. Coolidge and N. Kotsanos
4.2 Fear Definitions and Prevalence extreme or irrational – which may lead to actively avoid-
ing the situation [5, 6]. Children may not be able to rec-
ognize their dental phobia as being irrational. Also, we
Definition recommend that dentists not use active avoidance as a
The Definition of Pain criterion for determining if children are phobic about
The International Association for the Study of dentistry, because younger children, especially, may not
Pain defines pain as follows: be able to avoid going to dental appointments. It may
4
»» An unpleasant sensory and emotional experi- be more appropriate to call children phobic if they react
to an upcoming treatment with dread or need special
ence associated with actual or potential tissue
accommodations (such as a pediatric dentist who special-
damage, or described in terms of such tissue
izes in treating fearful children) to endure treatment [7].
damage…. Pain is always subjective….Many
For the remainder of this chapter, for simplicity’s
people report pain in the absence of tissue dam-
sake we will use the term “dental fear” to refer to dental
age or any pathophysiological cause; usually this
fear, dental anxiety, and dental phobia.
happens for psychological reasons. There is usu-
Researchers estimate that dental fear occurs in 5 to
ally no way to distinguish their psychological
20 percent of children and adolescents [8]; when studies
experience from that due to tissue damage if we
from a number of samples were compared, the research-
take the subjective report. If they regard their
ers estimated that 9 percent of children and adoles-
experience as pain, and if they report it in the
cents had dental fear [7]. Dental fear is more common
same ways as pain caused by tissue damage, it
in younger children [7, 9]. As 7 Chap. 2 describes, as
should be accepted as pain [4].
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Child Dental Fear, Communication and Cooperation
41 4
fear also misbehaved [15]. We believe that dentists who Classical Conditioning
treat children are already alert to the possibility that the
child patient may misbehave and/or have dental fear,
because these make providing dental treatment more
Unconditioned Unconditioned
challenging. An additional reason for alertness is related Stimulus Response
to the potential ability of the dentist to make a positive
difference in the oral health of their patients, due to two
factors. First, children referred because of misbehavior Meat Salivation
and/or fear are more likely to have caries, compared
with their better-behaved peers [3]. Second, longitudinal
research indicates that having caries in childhood pre- Conditioned Conditioned
dicts having caries in adulthood [16]. Thus, the dentist Stimulus Response
who keeps concepts about dental fear and misbehavior
in mind as he or she works with pediatric patients may
Ring bell Salivation
be able to help patients minimize caries during their
childhood and thereby also reduce the risk of caries in
Without any conditioning, the dog automatically salivates
their adulthood.
when it sees the meat. If you ring a bell when you present the
meat, eventually the dog will salivate when it hears the bell.
The dog has been conditioned to respond to the bell.
4.3 Etiologies of Dental Fear
.. Fig. 4.2 Classical conditioning
4.3.1 Classical Conditioning
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42 T. Coolidge and N. Kotsanos
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Child Dental Fear, Communication and Cooperation
43 4
4.3.4 eelings of Helplessness and Loss
F
of Control
The etiology of dental fear includes helplessness
and loss of control5 and also lack of trust (or fear of
betrayal) [25] as important factors in the child’s develop-
ment of dental fear. Adults with greater preferences for
being in control in the dental setting, but lowered per-
ceptions that they actually had control in that setting,
were at greater risk for having dental fear [26]. Children
8–10 years of age with greater dental fear stated that
they wanted to have more ways of controlling what hap-
pened to them at the dentist [27], while 11–15-year-olds
with greater dental fear also preferred to have more ways
of controlling their experiences at the dentist [28]. Thus,
lack of trust and loss of control constructs may be con-
sidered “cognitive” in the sense that they involve assess-
ments of the dental situation.
Tip
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44 T. Coolidge and N. Kotsanos
4.3.7 Temperament
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Child Dental Fear, Communication and Cooperation
45 4
appointment for the extraction). On the other hand, One study found that children raised by permissive
other children may experience heightened anxiety upon families were more likely to need protective stabilization
hearing the news, in which case it would be preferable and parental separation during treatment, compared
to wait until the appointment for the extraction to let with children from authoritarian or authoritative fam-
the child know [39]. ilies [44]. Another study by this team found that chil-
dren of permissive and authoritarian families displayed
more negative behavior and were rated as being more
4.3.8 arenting Style and Other Parenting
P anxious during treatment, compared with children from
Factors authoritative families [1]. Of note is that these latter chil-
dren scored highest on a measure of “effortful control,”
Baumrind [40] described three parenting styles, each which is related to the ability to control one’s behaviors.
characterized by a combination of high vs. low tenden- Parenting style may also be related to the prevalence
cies to dominate or control their children and high vs. of caries. Howenstein et al. [42] found that 80% of the
low displays of warmth directed toward their children. children of authoritative parents had no caries at their
Authoritarian parents exert high control over their chil- initial dental visit, compared with only 3% of the chil-
dren and display low levels of warmth, authoritative dren of permissive parents and 9% of the children of
parents also exert high control but display higher lev- authoritarian parents.
els of warmth, while permissive parents exert little con- Another study examined the roles that psychologi-
trol and display high levels of warmth. A fourth style, cally intrusive behaviors on the part of the parent (or
termed neglectful, was proposed characterized by low parents) may play in the development of dental fear [45].
control and low warmth [41] (. Fig. 4.9).
This term refers to parental behaviors that are character-
Among children whose behavior did not require ized by the child’s experiences of pressure to disavow his/
referral to a specialist, those who had authoritarian par- her own sensations and perceptions in favor of what the
ents had significantly higher dental fear scores [10]. In parent asserts. Examples include parents who deny the
a sample of young children, most (93%) of the children existence of the child’s pain, reject the child’s attempts to
whose parents were authoritative behaved cooperatively express his or her own views when they differ from those
during an initial dental visit. By contrast, only about of the parent, shame or ridicule the child, or vacillate
half of the children of permissive (58%) and authori- between being over- and under-protective of the child.
tarian (45%) parents behaved cooperatively [42]. In one These result in a child who is vulnerable to feeling a lack
sample, mothers who were authoritative were found to of control in situations, because he/she hasn’t had the
have higher emotional intelligence than mothers who developmentally appropriate experiences of successfully
were authoritarian or permissive. While parenting style managing unusual stimuli and experiences [ 45]. These
was not related to the children’s behavior in the dental children are at greater risk for displaying negative behav-
setting, higher levels of emotional intelligence in the iors [46]. Unfortunately, there is also evidence that the
mother was predictive of greater cooperation in the child’s negative behaviors are likely to elicit additional
child [43]. intrusive behaviors from the parent, which perpetuates
the child’s tendency to engage in negative behaviors
because he/she child has not been allowed to develop the
Control capacity to feel in control [47].
High Low Parenting today may be harder than it was a gen-
eration or so ago [48]. Parents are less likely to provide
the high control of the authoritative and authoritar-
ian parenting styles, replaced by greater indulgence –
Low
Authoritarian Neglectful
or even neglect – seen in the permissive and neglectful
parenting styles [49, 50]. More parents focus on verbal
Warmth
Authoritative Permissive
to children and/or increased requests for pharmaco-
logical interventions [50]. In two observational samples,
the majority (67–70%) of permissive parents intervened
Parenting Styles
during the appointment to have the dentist stop the
treatment of their child, compared with none of the
.. Fig. 4.9 Four parenting styles authoritarian or authoritative parents [1, 44].
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46 T. Coolidge and N. Kotsanos
Eye Catcher
This approach has been tested in several random-
One of the most powerful techniques for develop- ized clinical trials with children at higher risk for early
ing a strong dentist-parent alliance is drawn from childhood caries. In one sample, at 12 and 24 months
the principles of motivational interviewing, a set of after the discussion with the parents, the children
communication guidelines designed to help individu- whose parents were in the motivational interviewing
als change their behavior [51]. After the initial pleas- group had significantly fewer caries, compared with
antries with the parents who are bringing you a new those who received more traditional oral health edu-
4 child patient for the first time, you can ask the parent cation [52, 53].
“What is your dental wish for Johnny?”
Our experience has been that most parents say
things such as “I hope he doesn’t ever have tooth-
ache,” “I’d like her teeth to be pretty,” “I want his 4.3.9 Parental Dental Fear
teeth to be nice and strong,” etc.
Notice that, for each of these goals, the same com- Children whose parents are afraid of the dentist are at
bination of good oral care practices at home, coupled higher risk of developing fear themselves, [54] and the
with frequent checkups with you, will maximize the relationship between parental and child fear is generally
odds that the goal will be reached. In other words, stronger for younger children [55]. Mothers who are den-
you as the dentist have the same goal as the parent tally fearful are less likely to go to a dentist themselves at
does. least once a year, as well as less likely to have taken their
You can reinforce the parent’s goal: “OK, so your child to a dentist in the first 3 years of life [56]. Children
wish is that Johnny never has a toothache. That’s a of fearful parents who avoided taking them to a dentist
great goal!” Then remind the parent of the goal later were at increased risk of having caries and of displaying
on, when you discuss oral home care (“Not letting misbehavior at a dental visit at age 5 [3]. It would be wise
Johnny fall asleep with a juice bottle is an important for the pediatric dentist to routinely ask if a parent (or
way to prevent cavities and toothache”), coming back other caretaker) is afraid of dentists or dental treatment,
to the dentist for regular checkups (“Regular check- as well as whether he/she goes to the dentist regularly.
ups help me find any problems early on, another
important way to prevent toothaches”), and so on.
You can also write the goal down in the child’s chart, 4.4 Measuring Dental Fear
so that you can refer to it at the beginning of subse-
quent visits. Now you have created a bond between There are several ways of assessing children’s dental fear,
yourself and the parent: you are working together to including self-report measures (questionnaires) that the
reach a common goal. child completes, questionnaires about dental fear that
Motivational interviewing counselors often offer parents or others complete about, or on behalf of, the
their clients a “menu” of options, each of which is child, and behavioral rating scales used by observers
designed to help them reach their goal. Similarly, you to rate children’s behaviors, such as crying or resisting
can offer the parent a “menu” of options, all of which treatment, that are assumed to indicate that the child is
are designed to meet the parent’s goal for the child. afraid. For objective quantitative estimate some physi-
You can say: ological changes can be evaluated, like the heart rate,
“Here’s a list of things that other parents have breath rate, and palms sweating. The more recent mea-
done to help their children reach their goal of not surement of hormones cortisol and α-amylase in the
having toothache.” [Examples: “Don’t give her a bot- saliva for the estimation of dental stress has not shown
tle with juice in it when it’s time for sleeping”; “After to be advantageous compared to changes in heart rate,
he eats, wipe his teeth with a clean cloth”, “Don’t which remains an immediate and easier procedure [57].
put honey in her bottle of milk”.] “Which of these
do you think you could try?” This allows the parent
to answer something such as: “I think I can just give 4.4.1 Self-Report Measures
him a bottle with water when I put him down for his
nap.” You can reinforce the parent’s choice (“That’s Perhaps the most commonly used self-report measure is
a great option”) and then troubleshoot if necessary the Children’s Fear Schedule Survey – Dental Subscale
(“I remember you told me that Grandma often gives [58]. This measure consists of a list of 15 items or
your child a bottle with juice when it’s time for a nap. descriptions of things that a child might encounter in
How could you make sure that this doesn’t happen?”). the dental setting, as well as a few items which refer to a
medical encounter. Each item is answered on a 5-point
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Child Dental Fear, Communication and Cooperation
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Below are some things that you might be afraid of. Not afraid A little A fair Pretty much Very afraid
Circle the number that best represents how you feel at all afraid amount afraid
1. Dentists 1 2 3 4 5
2. Doctors 1 2 3 4 5
3. Injections (shots) 1 2 3 4 5
4. Having someone examine your mouth 1 2 3 4 5
5. Having to open your mouth 1 2 3 4 5
6. Having a stranger touch you 1 2 3 4 5
7. Having somebody look at you 1 2 3 4 5
8. The dentist drilling 1 2 3 4 5
9. The sight of the dentist drilling 1 2 3 4 5
10. The noise of the dentist drilling 1 2 3 4 5
11. Having somebody put instruments in your mouth 1 2 3 4 5
12. Choking 1 2 3 4 5
13. Having to go to the hospital 1 2 3 4 5
14. People in white uniforms 1 2 3 4 5
15. Having the nurse clean your teeth 1 2 3 4 5
scale, ranging from “Not afraid at all” to “Very afraid” 4.4.2 Behavior Rating Scale
(. Table 4.1). The individual item scores are summed;
the total score may range from 15 to 75, with higher The most commonly used behavior rating scale is the
scores indicating greater dental fear. Frankl scale [67]. Children are rated on a 4-point scale
The CFSS-DS has been found to have good reliabil- according to their behavior in the dental office, ranging
ity and validity [59, 60], although some authors have from definitely negative (e.g., crying forcefully) to defi-
pointed out that some of the items do not specifically nitely positive (e.g., laughing). The ratings may be made
relate to pediatric dentistry (e.g., “Having to go to the at different points during the dental encounter (e.g.,
hospital”) and/or may not be highly related to pediat- entry into operatory, getting into the chair, accepting
ric dentistry today (“People in white uniforms”) [61]. the dental bib, etc., through to include behavior during
Initially created in English, the measure has now been treatment and behavior at the end of the encounter), or
translated and validated in a number of additional the dentist may simply notice what the child’s worst rat-
languages. ing was during the encounter (. Table 4.2).
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48 T. Coolidge and N. Kotsanos
which increases the chances that stimuli will be experi- may ask a child to use a graphic scale to rate any dis-
enced as painful [5, 68]. Psychological methods of reduc- comfort or pain that he or she is feeling (. Fig. 4.10).
ing fear and anxiety primarily raise the pain tolerance It is important that the dentist immediately notice
level, rather than affecting the pain threshold [69]. In that the child is in pain and stop, provide more anesthe-
addition, being able to handle discomfort in the dental sia, or find a different way to provide treatment that is
situation presupposes that one can control one’s anxiety. pain-free, in order to prevent the classically conditioned
Careful attention to children is required when there development of fear. In an adult with a long history
is a possibility that they may experience pain, because of safe, pain-free dental experiences, there is a smaller
4 children differ in their awareness of, and reactions to, chance that a negative dental experience will result in
pain. Children under the age of 3 or 4 may have a hard fear. Since children have not had the chance to experi-
time communicating when they experience painful ence such a long history of pain-free dental encounters,
stimuli [70]. Older children, who typically have better if a dentist lacks sensitivity or knowledge of proper
self-discipline and know more ways to cope with what child guidance to deal with a child in pain, this may cre-
might be stressful for their younger peers, may be able ate cooperation problems because the child has no other
to remain quiet and restrict their movements even in effective ways of communicating that he or she is in pain
circumstances when they feel some pain. However, it other than to rely on more primitive methods, such as
is important for the dentist not to assume that a quiet, shouting, kicking, or thrashing about – which, in turn,
immobile child does not feel discomfort. The dentist make dental treatment more difficult [72].
1 Definitely negative − Refuses treatment, cries forcefully, fearfulness, or any other overt evidence of
extreme negativism
2 Negative − Reluctance to accept treatment, uncooperative behavior, and some evidence of
negative attitude that is not pronounced
3 Positive + Acceptance of treatment, cautious behavior at times, willingness to comply
with the dentist, at times with reservation, but patient follows the dentist’s
directions cooperatively
4 Definitely positive ++ Good rapport with the dentist, interest in the dental procedures, laughter and
enjoyment
.. Fig. 4.10 Wong-Baker face scale [71] for children 3 to 17 years old (above) and self-report Likert scale (below)
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Child Dental Fear, Communication and Cooperation
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4.5.1 roviding Children with Information
P 4.5.3 I mpact of Treatment Aspects
about What Will Happen on the Child’s Sense of Loss of Control
One way of reducing anxiety and addressing a ten- Children may experience a sense of loss of control with
dency to worry to the point of having catastrophic certain aspects of dental treatment, including when
ideas about what will happen is to provide children dental tools that cause pain are in their mouths and the
with more information about what will happen during children believe that they cannot end the painful stim-
their visit. This could be done in the form of a pam- uli themselves [76]. If the child believes that he/she is
phlet or video that shows children undergoing exams, going to feel pain that is greater than he/she can bear
radiographs, restorations, and the like. The dentist can (i.e., greater than his/her level of pain tolerance) without
also allow children time to explore being in the chair in having any way to control or end the pain, the result is
various positions, touch some of the instruments, see likely to be fear.
his/her own teeth in the mirror, and so on. The dentist Speech is typically more difficult when the patient is
can also tell the children what the different steps in the undergoing dental procedures, due to the dental dam,
treatment are going to be, how long each will take, and instruments in the mouth, and the like. Being unable to
especially what the child is likely to feel during each speak easily may also cause the child to feel a lack of
step [73]. control. The signal we mentioned earlier (raising the left
arm to signal pain) can also be taught to the child to use
in case he or she wants to communicate something to the
4.5.2 ental Visits that Do Not Involve
D dentist, and its understanding tested, especially for the
Invasive Procedures case of local anesthesia administration.
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50 T. Coolidge and N. Kotsanos
and their level of emotional maturity. During a dental 4.6.3 herapeutic Management of Fear
T
visit, most children over the age of 3 are able to manage (Desensitization)
any anxiety and, if they have proper guidance from the
dentist, behave cooperatively. However, some children The methodical introduction of children to dentistry is
have not yet developed appropriate ways of coping and accomplished through various techniques of behavioral
therefore may respond to the strangeness or stressful- configuration through which the appearance of anxiety
ness of the dental appointment instinctively, such as and fear is prevented or reduced drastically (discussed
by crying or attempting to withdraw. Also, consistent in 7 Chap. 5). However, when anxiety or fear is already
4
with the descriptions of parenting styles and/or intru- established, the dentist needs to use desensitization [82].
siveness above, when parental discipline is lacking or It is important that the patient remain calm while the
is overly strict, children’s coping abilities are usually dentist gradually introduces stimuli which are related to
decreased [79]. what the patient is afraid of. This is accomplished by
establishing with the patient what the least fearful stim-
uli are and presenting these first. As long as the patient
4.6.2 Child Crying and Coping Behavior remains calm, the dentist can then gradually move on to
more fearful stimuli. This approach results in a break-
Furthermore, the child’s reactions to pain will vary ing of the classically conditioned relationship between
depending on his/her background, including cultural the conditioned stimulus (e.g., dental stimuli) and the
background [80]. Children frequently refer to their social conditioned response (e.g., fear), so that the child may
environment for clues about how to respond to stimuli. now experience the stimulus more calmly [5]. Some den-
For example, the child notices how others respond to tists may prefer to refer a child to a psychologist for the
his/her crying and may modify his/her behavior accord- desensitization. The advantages of the dentist himself/
ingly: Is crying accepted, or is the child supposed to herself carrying out the treatment are that the child
“toughen up” and withstand the uncomfortable stimu- develops a trusting relationship with the person who will
lus stoically? When is it appropriate to ask for help? then be carrying out the dental treatment, and the child
Here, the dentist’s first job is to determine the cause of becomes familiar with the operatory and dental tools
the crying. Even stubborn, hysterical crying has a cause: that will be used in that treatment.
this kind of crying reveals how anxious the child is in the As described in 7 Chap. 5, this same technique of
dental situation, which perhaps is a new one to the child gradual introduction of dental stimuli is used to prevent
and certainly is a threatening one. The dentist needs to children from developing dental fear. As a preventive
respond with empathy as well as calmness, to help the method, it becomes part of behavioral guidance.
child feel safe and become able to cooperate. On the
other hand, crying that is the result of painful stimuli
reveals that there has not been enough local anesthesia.
Regardless of the cause, dentists who work with children 4.7 Special Issues with Adolescents
need to be able to respond to crying without losing their
self-control [81]. As they mature, adolescents increasingly prefer to make
As we have seen, crying may be one response to the their own choices. While their parents are still the ones
stress of the dental situation. Adults and children alike who have the legal power to provide consent for dental
use some kind of strategy to deal with anxiety, which treatment, the dentist should ask the adolescent what
can manifest anywhere on a continuum between com- he or she would prefer to do and try, if possible, to be
plete self-control (positive, cooperative behavior) to guided by the adolescent’s preference.
complete rejection (negative, uncooperative behavior).
The dentist should evaluate a new pediatric patient’s Case Study
behavior carefully, to gain information about how well
this particular child is able to cope. Facial expressions, We had treated an adolescent for dental fear as a child
crying, complaints, and body language all provide and encountered him again as an adolescent when he
diagnostic cues. A quick and practical way to estimate was undergoing orthodontia. Although his mother
and record a child’s behavior during the dental proce- rolled her eyes as her son was describing this, we were
dure is through the use of the Frankl scale, described happy to see – literally – that the orthodontist had
earlier. It is useful to keep records of the child’s behav- accepted the adolescent’s requests for orange and
ior during dental visits so that the dentist can prepare black wires as Halloween neared, and red and green
for the possible behavior of the child in subsequent wires around Christmas.
appointments.
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Child Dental Fear, Communication and Cooperation
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4.7.1 Respond to Requests for Privacy “They will criticize me for not taking better care of my
teeth”). We have heard adolescents say things such as:
Adolescents are also more likely to want to keep certain “I know I should go to the dentist – and I need to go to
things from their parents. For example, a dentist may the dentist – but I am too afraid to go.” This kind of
notice increased enamel erosion in an adolescent female, description reveals the ambivalence that fearful adoles-
and ask her about it. The patient might reveal that she is cents may experience about going to the dentist.
pregnant or bulimic – and beg the dentist not to tell her The strength of the undesirable aspect – the avoid-
parents. Another adolescent might admit to using drugs, ance aspect – becomes stronger as the individual comes
and similarly say that he doesn’t want his parents to find closer to the ambivalent situation. For example, it
out. The dentist must delicately manage these kinds of may be easy enough to contact a dentist to make an
requests while still respecting the law, which typically appointment which will occur at some (distant) time
says that parents (or legal guardians) must give consent, in the future. However, as the day of the appointment
and which often is interpreted to mean that parents have draws closer, the ambivalent individual becomes more
the right to know information about their child that is fearful about what might happen at the appointment,
relevant to medical treatment. There are exceptions to and, as this avoidance aspect becomes stronger than the
these generalities. For example, in Washington state, approach aspect, the individual is increasingly likely to
USA, minors may give consent for emergency treatment cancel the appointment (or not show up) [5].
if the parents are not available; in addition, minors may To help counter the strength of the avoidance side,
receive birth control, mental health treatment, substance the dentist can use the motivational interviewing tech-
abuse treatment, and other services without parental nique described earlier. The dentist can ask something
consent. These exceptions will vary by laws applicable to such as “If I could perform a dental miracle for you,
where the dentist’s practice is located. what would it be?” and respond accordingly: “That is
a wonderful goal! I can help you with that goal. I will
make sure to check .............. every time you come, to
4.7.2 dolescents May Resist Going
A make sure that you are making progress toward your
to the Dentist goal.” The purpose is not only to help the adolescent
believe that the dentist is “on his/her side” but also to
As children become adolescents, they are increasingly stress the positive reasons for coming to see the dentist.
able to influence – or even decide – whether they will go This can help “tip the balance” so that the ambivalent
to a dentist for regular checkups. They may also be at adolescent comes for his/her appointments.
increased risk for caries as their parents are no longer In general, individuals vary with regard to whether
closely involved in monitoring diet or oral home care they are more likely to approach, or avoid, uncertain sit-
[83]. Some adolescents who have a dentist that they can uations. Sherman and colleagues [86] found that college
go to will avoid going for dental care; these adolescents students who read messages about flossing their teeth
are more likely to have caries, as well as more advanced which were framed to be consistent with their general
caries, compared with their peers who do go for check- approach vs. avoidance motivational style were more
ups [83, 84]. likely to floss, compared with those whose messages
Unlike the younger child who is usually brought to were inconsistent with their motivational style.
the dentist by his/her parents, adolescents are increas-
ingly likely to make their own decisions about making Eye Catcher
and keeping appointments for dental checkups as they
gain more autonomy. If they are fearful, they may well Earlier, we described asking a parent what his/her
be operating according to the cycle of fear, as described dental wish was for the child. You may recall that,
earlier. An additional model of going or not going to a in our hypothetical responses, two parents requested
dentist is useful to consider, reflecting the ambivalence things they would like their children to have or to
that some adolescents (and adults) may feel about den- attain (“I’d like her teeth to be pretty”; “I want his
tal appointments if they are afraid. Dollard and Miller teeth to be nice and strong”), while one requested
[85] described the approach-avoidance conflict that something he/she hoped would NOT have (“I hope he
a person will encounter if some situation has both an doesn’t ever have toothache”). One could say that the
attractive (approach) and an undesirable (avoidance) first two wishes were “approach” ones, while the third
aspect to it. For fearful adolescents, dental care may one was an “avoidance” wish. Similarly, the dentist
well have an attractive (approach) aspect (“I will get the treating an adolescent could ask him/her what his/her
tooth fixed”; “I will get my teeth cleaned”), as well as an dental wish, or dental miracle is – and listen to learn
undesirable (avoidance) aspect (“I will experience pain”;
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52 T. Coolidge and N. Kotsanos
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Child Dental Fear, Communication and Cooperation
53 4
school was related to greater accuracy in interpreting
these communications [89]. If the pediatric dentist is
unsure of how he or she is expressing these nonver-
bal aspects of communication, he/she may want to
have someone observe some of his/her interactions,
to provide feedback. Alternatively, he/she may decide
to record some interactions to be able to review them
afterward.
Overview
Nonverbal communication summarized:
Voice: A calm and reassuring tone inspires confi-
dence.
Expression: A smile is a powerful tool, especially in
the first dentist-patient interaction.
Eyes: Visual contact confirms that there is dentist-
child communication.
Hand gestures: Avoid curt or sudden movements,
which can startle the child.
Body posture: A large height contrast between the
dentist and the child patient can be frightening for the
patient.
Place: A relaxing atmosphere in the dental office,
with child-friendly features and decorative aspects, can
help reduce fear. .. Fig. 4.12 Dental terminology is often incomprehensible to
parents
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54 T. Coolidge and N. Kotsanos
comprehensible. Instructions should be given in a way tion about tailoring oral health messages to adolescents,
that describes what the dentist would like the child to to help encourage (or convince) them to develop good
do [91]. Children younger than about 10 have a hard oral care habits.
time understanding reversibility and therefore don’t
understand the concept of brushing their teeth to
reduce plaque levels [87]. 4.8.5 Providing Written Information
Children do not understand verbal descriptions of
conditionals, or causal relationships, until about ages 11 Two other points are also relevant [17]:
to 13. If the dentist says to a child who has not reached Some information can be given to the child before
this ability “If you are good, I will give you a present,” the appointment, so that there is time for the child
the child is likely to conclude that he or she is going to to prepare mentally for what will happen during the
get a present. Because “being good” is abstract, the child appointment. Usually, only a small amount of informa-
also will not know what it is that the dentist is referring tion given at the dentist’s office is remembered by the
to. Thus, the intended purpose of the dentist’s statement child, especially when there is anxiety about the dental
is lost. For this reason, small gifts for good cooperation procedure.
should only be given as a reward at the end of the proce- Important information and directions (e.g., for home
dure and not earlier (. Fig. 4.13).
oral care practices that will help minimize the develop-
It isn’t until the child reaches formal operational ment of decay) should be given to the parents in writing,
thought, beginning around age 11, that the child is as otherwise they may forget much of the information
capable of understanding conditionals and engaging in after leaving the office.
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Child Dental Fear, Communication and Cooperation
55 4
Dental Office Logo 55 Give your child fluoride mouthwash to swish around
Dear Parents, his/her teeth once or twice a day, at a different time
Your child’s good oral health, like many other child from brushing with the toothpaste.
health needs, depends primarily on you. As indicated 55 Keep sugared or starchy snacking (such as potato
by published studies, the fillings needed for restoring chips, candy, etc.) to a minimum. When these types of
your child’s decayed teeth will last only if you follow materials are on the teeth, they hasten the process
the specific oral health program that you and I have dis- that causes decay.
cussed. It is a program designed to prevent dental
decay, which means that it will also help to ensure that Other studies demonstrate the importance of bringing
your child’s permanent teeth will be healthy when they your child back regularly for follow-ups with the dentist.
come in. You can think of the oral health program as a The dentist can monitor your child’s oral health and make
prescription to follow for healthy teeth. (Note: The any recommendations for changes to your child’s oral
dentist can substitute the parents’ dental wish for their health program. Depending on your child, these follow-up
child, as described in the Eyecatcher about Motiva- visits may be scheduled every 6 months or more frequently.
tional Interviewing, in place of the generic “for healthy We will contact you when it is time to schedule the next
teeth.”) Please contact us if you have any questions follow-up appointment. (Of course, if you see changes in
about the program. your child’s teeth, or have any questions, feel free to con-
55 Depending on your child’s age and manual dexter- tact us before the next follow-up appointment.) This is
ity, you will brush your child’s teeth or carefully proven to help the success of the preventive program.
supervise your child as he/she brushes his/her own We are more than happy to help you help your child
teeth. Pay particular attention to the back teeth, maintain good oral health!
and cleaning in between the teeth. Use a fluoridated Yours sincerely,
toothpaste. ………………….
more empathic the dentist will be able to be [93]. Expressing desires or fear, or even anger, is normal, while
The attitude and behavior of the dentist can influence continuous whining or movement needs calm manage-
the child’s anxiety and thereby his/her behavior. Dentists ment. When the dentist finds himself/herself in difficult
who used reinforcement, asked how the child was feel- situations and/or feels pressured by a lack of time, he/
ing, or provided specific instructions were more likely she becomes irritated and is more likely to deliver nega-
to find that children cooperated, while dentists who tive messages, such as “Stop moving/crying right now!”,
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56 T. Coolidge and N. Kotsanos
.. Table 4.3 Examples of empathic communications to the fearful child and their corresponding effects
Empathic communication to the child Possible thoughts of the Explanation of impact to child behavior
child in response
You seem unhappy or embarrassed. You seem to Maybe they understand If the child is shy and/or resistant, he/she can learn
mean that you didn’t want to come here how badly I feel. from our words. If he/she is crying, he/she can stop.
I wish you did not need to be here. Surely you Perhaps it is not so strange It’s not necessary to show his/her feelings by crying
want to go home right away that I feel this way because he/she senses that his/her feelings are
4 I wish we never needed to have to do some received and accepted by the dentist
things that you do not want
Sometimes even grown-ups do not want to go to
the dentist
You think we will do things that might hurt you? Hmm, I’ll be able to The dentist shows he/she understands how the
We will simply count your teeth, take a couple manage. It won’t take long child feels, while explaining what will happen next,
of pictures, and then you are free to leave before I can leave thus decreasing the child’s fear of the unknown
I am sorry for this noisy jerk you feel on your I am doing all right The dentist’s verbal descriptions of what the child
tooth. Thank you for trying not to move so that feels, the dentist’s positive reinforcement, and the
we can be done sooner dentist’s explanation all reduce the child’s worry
to the child. These negative messages may temporarily a positive feeling about dentistry) was associated with a
result in the cessation of uncooperative behavior, but significant reduction in anxiety among children in the
the effect is not long-lasting, the child’s sense of trust waiting room, compared with seeing photographs of
in the dentist is reduced, and his/her fear is increased neutral, non-dental stimuli. Dentists can help parents
[96]. It is better to convey information about how the simulate these findings by encouraging them to look at
child’s behavior is interfering with the treatment, such the office website before the initial appointment, so that
as calmly saying “Unfortunately, I can’t finish as quickly they and their children can see photographs of the den-
as I would like to if you are moving/if you close your tal office that show smiling children. Other photographs
mouth.” When dentists ask children if anything hurts, could show the smiling receptionist, dentist, assistant,
provide specific positive reinforcement (“You are doing and any other primary personnel that the child is going
a great job keeping your hands in your lap”), or pro- to meet, the waiting room, the operatory with the den-
vide direction, children are more likely to cooperate; on tal chair, and the like. This allows the parent and child
the other hand, delivering put-downs (“Don’t act like a to spend some preparatory time at home talking about
baby”), setting rules, or trying to coerce the child results what the child is likely to notice during the visit. In addi-
in more uncooperative behaviors [91]. tion, as described previously, if possible an introductory
visit to the dental office – when no dental procedures are
carried out – can be helpful in ensuring that the initial
experiences with the dentist and the office are positive.
4.9 he Influence of the Dental
T
Environment
4.9.2 ave Welcoming Reception, Staff
H
4.9.1 rovide Positive Stimuli before
P and Waiting Areas
the Initial Visit
The reception and waiting area creates a strong impres-
A child’s first visit to a dental office will be characterized sion (and the initial impression for children who aren’t
by new stimuli, such as odors, sounds, and sights. The able to view the office website photographs in advance),
multitude of unfamiliar stimuli and experiences may in large part because it reflects the personality of the
overwhelm the child, who may respond with anxiety and dental office and therefore provides clues to the child
begin to cling closer to his/her parent. The American and parent about what kind of people they are likely
Academy of Pediatric Dentistry [70] recommends that to encounter in the office and what is likely to happen
child patients be exposed to “positive pre-visit imagery” during the appointment itself (. Fig. 4.14). Pleasant
(p. 189), based on Fox and Newton [97], who found that surroundings, attractive use of color, and gentle music
seeing photographs of children smiling as they sat in a help create a positive mood and are attractive to the
dental chair (and other photographs designed to convey child, thus reducing anxiety. Compliance with ADA
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Child Dental Fear, Communication and Cooperation
57 4
a a
unforeseen delays, office personnel should apologize Dental receptionists often greet children and their
to the parent and child and keep them informed of parents as they arrive at the dental office and make the
how much longer the wait is likely to be. The dentist follow-up appointments as families leave. They may also
might consider ensuring that new child patients and/or be the individuals with whom parents have their first
younger patients be appointed for the first time slot of interaction with, as they call to seek the initial appoint-
the day and/or the first time slot after the lunch break ment for the child. Subsequently, parents and children
when possible, as a way of ensuring that these appoint- will also have interactions with the dentist, dental assis-
ments start on time. tants, and others during dental procedures. Therefore,
As a rule of thumb, children who are at the office the dentist must ensure that all of the office staff are
for the first time and who are sitting still without being skilled in communicating with pediatric patients and
occupied by some activity may become worried about their families.
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Child Dental Fear, Communication and Cooperation
59 4
41. Lamborn SD, Mounts NS, Steinberg L, Dornbusch SM. Pat- 60. Porritt J, Buchanan H, Hall M, Gilchrist F, Marshman Z. Assess-
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42. Howenstein J, Kumar A, Casamasimo PS, McTigue D, Coury assess child dental anxiety. Int J Paed Dent. 2002;12:47–52.
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ton DC: American Psychological Association, 2002; pp. 235–262. with the child in the operatory? J Dent Child. 1962;29:
47. Eisenberg N, Taylor ZE, Widaman KF, Spinrad TL. External- 150–63.
izing symptoms, effortful control, and intrusive parenting: a test 68. Rhudy JL, Meagher MW. Fear and anxiety: divergent effects on
of bidirectional longitudinal relations during early childhood. human pain thresholds. Pain. 2000;84:65–75.
Dev Psychopathol. 2015;27:953–68. 69. Baldwin WC, Weisenberg M. Effect of psychologic factors on
48. Long N. The changing nature of parenting in America. Ped reactions to pain. In: Ripa LR, Barenie JA, editors. Manage-
Dent. 2004;2:121–4. ment of dental behavior in children. Littleton MA: PSG Pub-
49. Casamassimo PS, Wilson S, Gross L. Effects of changing
lishing Company; 1979. p. 41–60.
U.S. parenting styles on dental practice: perceptions of diplo- 70. American Academy of pediatric dentistry. Guideline on
mats of the American Board of Pediatric Dentistry. Ped Dent. behavior guidance for the pediatric dental patient. 2016;38:
2002;24:18–22. 185–98.
50. Law CS. The impact of changing parental styles on the advance- 71. Wong DL, Baker CM. Pain in children: comparison of assess-
ment of pediatric oral health. CDA J. 2007:192–7. ment scales. Pediatr Nurs. 1988;14:9–17.
51. Miller WR, Rollnick S. Motivational interviewing: preparing 72. Versloot J, Craig KD. The communication of pain in paediatric
people for change. 2nd ed. New York, NY: Guildford Press; dentistry. Eur Arch Paediatr Dent. 2009;10:61–6.
2002. 73. Ripa LR. Attitudinal and environmental influences on children’s
52. Weinstein P, Harrison R, Benton T. Motivating parents to pre- behavior in the dental situation. In: Ripa LR, Barenie JA, edi-
vent caries in their young children: one-year findings. J Am Dent tors. Management of dental behavior in children. Littleton MA
Assoc. 2004;135:731–8. PSG; 1979. p. 27–40.
53. Weinstein P, Harrison R, Benton T. Motivating mothers to pre- 74. Nicolas E, Bessadet M, Collado V, Carrasco P, Rogerleroi V,
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54. Coric A, Banozic A, Klaric M, Vukojevic K, Puljak L. Dental 75. Rantavuori K, Zerman N, Ferro R, Lahti S. Relationship
fear and anxiety in older children: an association with parental between children’s first dental visit and their dental anxiety in
dental anxiety and effective pain coping strategies. J Pain Res. the Veneto region of Italy. Acta Odont Scand. 2002:297–300.
2014;7:515–21. 76. Seligman MEP. Helplessness: on depression, development and
55. Themessl-Huber M, Freeman R, Humphris G, MacGillivray S, death. San Francisco CA: W.H. Freeman; 1975.
Terzi N. Empirical evidence of the relationship between paren- 77. Sherman JJ, Cramer A. Measurement of changes in empathy
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International J Paed Dent. 2010;20:83–101. 78. Tsiantou D, Lazaridou D, Coolidge T, Arapostathis KN, Kot-
56. Heima M, Heaton L, Gunzler D, Morris N. A mediation analy- sanos N. Psychometric properties of the Greek version of the
sis study: the influence of mothers’ dental anxiety on children’s Toronto composite empathy scale in Greek dental students. Eur
dental utilization among low-income African Americans. 2017. J Dent Educ. 2013;17:208–17.
Comm Dent Oral Epi. 2017;45:506–11. 79. Zabin MA, Melamed BG. Relationship between parental dis-
57. Arhakis A, Menexes G, Coolidge T, Kalfas S. Heart rate, sali- cipline and children’s ability to cope with stress. J Beh Assess.
vary α-amylase activity, and cooperative behavior in previously 1980;2:17–38.
naïve children receiving dental local anesthesia. Pediatr Dent. 80. Folayan MO, Idenehn EE, Ojo OO. The modulating effect of
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1982;49:432–6. learned resourcefulness and coping with crying in pediatric den-
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83. Coolidge T, Heima M, Johnson EK, Weinstein P. The dental 91. Weinstein P, Getz T, Ratener P, Domoto P. The effect of den-
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84. Skaret E, Raadal M, Berg E, Kvale G. Dental anxiety and dental 92. Elkind D. Egocentrism in adolescence. Child Dev. 1967;38:
avoidance among 12 to 18 year olds in Norway. Eur J Oral Sci. 1025–34.
1999;107:422–8. 93. Hojat M. Empathy in patient care: antecedents, development,
85. Dollard J, Miller N. Personality and psychotherapy. New York: measurement, and outcomes. New York: Springer; 2007.
McGraw Hill; 1950. 94. Weinstein P, Getz T, Ratener P, Domoto P. Dentists’ responses
86. Sherman DK, Mann T, Updegraff JA. Approach/avoidance
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motivation: understanding the congruency effect. Motiv Emot. Assoc. 1982;104:38–40.
4 2006;30:165–9. 95. Welly A, Lang H, Welly D, Kropp P. Impact of dental atmo-
87. Chambers DW. Communicating with the young dental patient. J sphere and behaviour of the dentist on children’s cooperation.
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61 5
Behavior Guidance
and Communicative
Management
Travis Nelson and Nikolaos Kotsanos
Contents
References – 77
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62 T. Nelson and N. Kotsanos
patient and parent/caretaker [2]. Specific behavior guid- tance in the effective implementation of these tech-
ance techniques have been developed by combining niques. By mastering these techniques, practitioners can
5 similar stimulus-response pairs. Combining these man- successfully care for the majority of children using basic
non-pharmacologic approaches.
agement techniques allows the clinician to provide the
best patient experience in the shortest possible time. The Contemporary care of children is contingent on
aim of these interactions is to alleviate fear and anxi- empathetic practice of dentistry. Organizations like
ety, while promoting an understanding of the processes the AAPD recognize that fostering the emotional
required to achieve and maintain oral health. development of the child is as important as mainte-
nance of their oral health. Guidelines published by the
AAPD reflect the profession’s value of caring for the
child as a whole [2]. Similarly, the European Academy
Overview
of Pediatric Dentistry (EAPD) provides a framework
An evaluation of the child’s cooperative potential is
for compassionate care of children in its official pub-
essential for treatment planning. Children can be clas-
lications and editorials [5]. This approach is child-cen-
sified into the following three groups according to their
tered, taking into account the experience and opinions
ability to cooperate for dental treatment [1–3]:
of the patient and the family. It establishes a thera-
1. Cooperative.
peutic relationship in which the patient’s needs are
2. Potentially cooperative (e.g., shy, tense, fearful,
respected in the context of the family’s feelings and
strong willed, emotionally immature, phobic, with
opinions [6–8].
mild mental/motor impairment).
In many countries, the clinician may combine purely
3. Unable to cooperate (e.g., younger than 2.5–3 years,
communicative techniques with pharmacological ones,
severely mentally impaired).
i.e., minimal inhalation sedation with nitrous oxide
or minimal to moderate procedural sedation [2, 5].
Incorporating non-pharmacologic behavior guidance
techniques generally improves the patient experience
5.1.1 lassification of Behavior Guidance
C and quality of a sedation visit. Protective stabilization,
and Management Techniques sedation (except for nitrous oxide inhalation), and gen-
eral anesthesia are referred to as advanced behavior
Most textbooks [1, 3, 4] and the American Academy management techniques by AAPD [2]. This means that
of Pediatric Dentistry (AAPD) guidelines have struc- specific training is required to use these techniques [7].
tured behavior guidance and management into indi- Good training and experience are certainly required to
vidual techniques, grouped and classified in a more or develop effective communicative behavior guidance too.
less similar fashion. Broadly following the frequently Individual techniques are described in this chapter, while
updated AAPD guidelines [2], these techniques can pharmacological techniques are described separately in
be divided into basic and advanced approach strate- 7 Chap. 8.
gies.
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Behavior Guidance and Communicative Management
63 5
societally accepted, it must always be remembered that
they must be integrated into an individualized behavior
guidance approach for each child. Consequently, behav-
ior guidance is as much an art as it is a science [2].
5.2.1 Tell-Show-Do
TSD Technique
.. Fig. 5.2 The entire dental team should use the same terminology
3. Do: perform the procedure in the child’s mouth with patients. (Redesigned from Chadwick & Hosey [4])
exactly as demonstrated to the child.
During the second step (show) the child is shown
dental instruments and materials that have an unusual
In the first step of TSD (tell), it is important to use appearance, smell, or taste. This provides a multisensory
language that does not provoke anxiety and is easily experience that prepares the child for the dental proce-
understood by the child. This increases the patient’s dure. This is often enhanced by providing the child with
understanding and builds trust. For consistency it is a handheld mirror, allowing them to watch the procedure
important that all members of the dental team agree being performed during the third step (do) (. Fig. 5.3).
upon and use the same child-friendly terminology TSD is most effective when each step is very basic and is
(. Fig. 5.2). Consider the following examples of child- repeated until the child grasps the concept. This allows
55 Suction (→ vacuum cleaner). TSD is particularly useful with children who are in
55 Rubber dam (→ raincoat). Piaget’s preoperational stage of cognitive development,
55 Mouth prop (→ tooth chair). i.e., up to 6 to 7 years of age (see 7 Chap. 2). It is less
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64 T. Nelson and N. Kotsanos
.. Fig. 5.3 A patient observing the dental procedure in a hand mirror previous traumatic dental and medical experiences may
have more difficulty overcoming their fears, so progress
toward acceptance may be slower than with patients
who simply fear the unknown [2].
TSD is predicated on honesty. Its effectiveness is
undermined if the practitioner lies to the child or doesn’t
follow through with the procedure exactly as described.
Dentists can fall into this trap when parents have prom-
ised the child something that is not realistic, or by prom-
ising unrealistic things themselves. When a child asks
directly, “Will you give me a shot?”, he is indicating that
he has heard children receive injections at the dentist.
“No” is the wrong answer to this question. The dentist
can tactfully combine tell-show-do with other techniques,
such as distraction. For example, she could perhaps say
“in children we use sleepy jelly. Can you smell it? After
the jelly we use 5 drops of sleepy juice. We’ll count them.”
Local anesthesia is perhaps the only dental procedure not
introduced routinely by dentists in the tell-show-do man-
ner. This potentially prevents a negative reaction caused
by the child viewing the needle before the injection.
.. Fig. 5.4 Patient distressed by lip numbness from local anesthe- When appropriately modified, tell-show-do is very
sia. Explaining the “sleepy lip” sensation before administration may useful with children who have mild to moderate dis-
prevent this reaction abilities. For example, with hearing-impaired patients
2. Have child sit on dental chair and begin with a toothbrush or dental mirror
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Behavior Guidance and Communicative Management
65 5
“show” may be emphasized more than “tell.” Speak
clearly, slowly, and in front of the patient. This allows
for lip-reading. It is also useful to have the parent func-
tion as an interpreter for patient requests. Avoid sud-
den noises and complex commands when working with
vision-impaired children. Allow the patient extra time
to touch and feel instruments. Children with severe
intellectual disability may have challenges responding
to basic behavioral techniques, but many can be suc-
cessfully treated in this manner if provided with addi-
tional time and a consistent treatment approach. Show
patients and families respect by avoiding language that
stigmatizes the patient, and always refer to the patient
using people-first language (e.g., child with Down syn-
drome, not Down syndrome child) [12].
.. Fig. 5.6 The patient holds a toy that emits a sound when a but-
ton is pressed. This allows them to pause the procedure and provides
a sense of control
5.2.2 Providing Control
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66 T. Nelson and N. Kotsanos
concerns (“What are you worried about today?”). Then sweets so often” or “you need to do a better job brush-
he proceeds to tell the patient how the dental team will ing your teeth” are not likely to generate positive results.
address their concern (“We will use sleepy juice to make Instead, use messaging like “your teeth will stay healthy if
sure it doesn’t hurt when we clean your tooth.”). Finally, you drink juice during mealtimes instead of throughout
he asks if the patient understands the explanation and the day.” When providing brushing instruction, it is also
if there are any additional concerns. The key feature of very helpful to praise the child’s brushing efforts while
this approach is alleviating anxiety by honing in on and actively demonstrating brushing techniques in a mirror.
addressing specific patient concerns [2]. In addition to verbal and nonverbal praise, the dentist
may present the child with a small gift. Simple prizes such
as colorful stickers and small toys are very well received
5.2.4 Positive Reinforcement by children (7 Fig. 4.12). Providing the gift at the end
5
voice or praise by the dentist or staff. dental treatment members of the dental team can
55 Nonverbal communication, such as facial expres- stimulate the imagination by telling stories, referenc-
sions, a pat on shoulder, or a high-five*. ing patient hobbies (computer games, sports, or other
55 Small prizes or gifts at the end of the visit. personal activities), and engaging the child through par-
ticipatory activities like holding a mirror. This can be a
*Touching the patient may be subject to Covid-19 pan- good relationship building exercise, but there is little evi-
demic restrictions or similar polices. dence that focusing on non-dental issues is effective in
When a child encounters a painful stimulus and reducing dental fear [13]. On the other hand, TV, head-
appropriately raises his hand, he is reinforced in two phones with music, and other audiovisual technologies
ways: (1) negative reinforcement as the painful stimulus are becoming very common in offices that care for chil-
is removed and (2) positive reinforcement as the dentist dren [15, 16]. Virtual reality devices are a very immersive
praises him for following instructions. In turn, praise
increases the patient’s self-esteem and feelings of accep-
tance. The amount of praise from the dental team and
parents should be proportional to the effort. It is often
advantageous to reserve the greatest praise for the end
of a dental visit.
Providing clear instructions and specific requests
improves child behavior. On the contrary, critical ques-
tions like “can’t you keep your mouth open wide?” are
not productive in managing child behavior [13]. Instead,
look for opportunities to reinforce positive behavior. We
can provide positive reinforcement throughout the visit
by praising the child for staying calm and still, keeping
their mouth open, and even for being a good listener.
Gentle words from the provider offer positive reinforce-
ment in themselves. The calm effect provides the child
with a sense of well-being and safety.
It is also most effective to put a positive spin on patient
education and oral health messages. Criticizing patients .. Fig. 5.8 A child engaging in creative activity (drawing) in the
and parents with statements like “you really shouldn’t eat waiting room
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Behavior Guidance and Communicative Management
67 5
form of distraction, and some findings suggest that distraction. During the administration of local anesthe-
patients who use them may even experience lower levels sia, most children are fairly anxious and their minds are
of procedural pain [17–19] (. Fig. 5.9).
fully focused on the syringe. If the dentist informs the
Another technique that can be used with success patient that she will slowly count (e.g., five “drops”) and
is providing the patient with breaks when they display does accordingly, the child is not only distracted, but is
cooperative behavior (contingent distraction) [1]. It is given a time frame for the procedure (time structuring).
important to recognize that distraction does not work in It is critical to recognize that distraction simply supports
the absence of communication. In fact, very stimulating a child’s cooperation and is not an alternative to insuf-
forms of distraction such as television and video games ficient local anesthesia. In fact, obtaining excellent local
may interfere with communication and make treatment anesthesia is perhaps the most critical step in facilitating
more challenging. good patient behavior.
Distraction can be passive or participatory. Asking
the patient to count the number of local anesthesia
drops that the dentist administers or participate in 5.2.6 Modeling
breathing exercises is an example of participatory dis-
traction. A trick, such as shaking of the patient’s lip dur- Modeling focuses on shaping behavior using the prin-
ing local anesthesia administration, is considered passive ciples of learning theory and imitation. Studies have
shown that it can enhance cooperation [20, 21]. Modeling
is similar to the TSD technique, where an observing
a
child is “shown” a cooperative patient who models good
behavior (. Fig. 5.10). The interaction may be live or
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68 T. Nelson and N. Kotsanos
tionships common with adult patients. Parents can also Parent presence may therefore prove useful during new
interfere with the child’s ability to concentrate on dental experiences because separation anxiety is not added to
procedures and may try inappropriately to be support- the novelty of the unknown environment. Very nervous
ive with phrases like “don’t be afraid” or “did it hurt?”. children may cling to the parent, as this imparts a feeling
While they may be well-intentioned, those messages of safety [28]. Many are used to their parent comforting
increase distress in the patient and frequently make them when they are distressed, so they reflexively seek
treatment more challenging. Most pediatric practitio- parental protection and avoid the dental examination
ners recognize that parents are most effective when they and/or treatment (7 Fig. 4.8). While this may appear to
function as silent supporters of their child. be a negative reaction, some have suggested that paren-
Three or more decades ago pediatric dentists tal presence can be leveraged as a reward for coopera-
allowed parents to be present during the child’s visit tion in initially noncooperative children [7, 29, 30].
much less frequently than they do today. Progressively, In such cases we can reach out to the child before
dentists are more accepting of parental presence, even he becomes completely uncommunicative with an empa-
during restorative sessions [24, 25]. Smaller family sizes, thetic message like:
changes in child-rearing practices, and parent emotional
needs have led many parents to expect greater involve-
»» I know that you want to show your mother what a good
listener you can be today. She will stay right here with
ment in the dental visit. Parents who remain in the wait-
us as long as you are able to listen to me. If you don’t
ing area may be concerned about their child’s ability
open wide, that shows us that you aren’t listening. That
to cooperate and the dentist’s skills to manage them.
means she will need to leave until you focus on what I
This is particularly true during the first appointment
am asking. I would like to have her stay here with us.
(. Fig. 5.11). Over subsequent visits parents may have
Are you ready to show her how well you can open and
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Behavior Guidance and Communicative Management
69 5
parent to leave the room [29]. Typically this approach and reduces crying. The act of breathing relaxes the
quickly facilitates cooperation in preschoolers and early child and helps regulate the autonomic nervous system.
school-age children. This technique is most effective when the dentist dem-
onstrates how the child should breathe by taking deep
breaths with her 4–5 times. Asking the child to relax her
5.2.9 Other Complementary Techniques muscles while breathing also helps relieve tension and
reduces anxiety [14].
Depending on the training and preferences of the practi-
tioner, other complementary strategies may be employed zz Hypnosis
in addition to these basic strategies. Combining distraction, relaxation, and monotone
speech can create a hypnotic state that reduces stress and
zz Time structuring pain. Approximately one third of patients are receptive
Young children have a short attention span. Typically, to these techniques, but there are limited reports about
it is better to present procedures in “steps” rather than the effects of hypnosis in pediatric dentistry [4, 31, 32].
minutes. The dentist gains the child’s confidence and While there is some limited evidence to show effective-
cooperation by explaining the basic steps involved in ness, a systematic review suggested that there is not yet
the visit, i.e., local anesthesia, rubber dam placement, enough support to broadly endorse the benefits of hyp-
caries removal, matrix band and wedge placement, nosis in the dental office [33].
restoration placement, light curing, etc. in a way she
can easily understand. Structuring time in this way zz Sound Analgesia
allows her to understand when the session is nearing Soft melodic sounds or higher-volume rhythmic music
an end [14]. played through speakers or headphones is a form of
distraction known as sound analgesia. These techniques
zz Guided Imagery have been used with fair results to improve child behav-
Children will often begin a sentence with “I don’t like ior for short, potentially painful, procedures such as
...” or “I don’t want to ....” It is helpful to understand local anesthesia [34]. While not well documented in the
that the child may raise concerns like this to assert his dental literature, adult patients under laboratory pain
feelings about the procedure. These types of statements conditions experienced distraction and increased self-
do not necessarily mean that the patient will not do what control while listening to music [35].
is asked of him. Instead, these observations may be the
product of the child’s imagination. He may be wishing zz Humor
for something that he understands may not actually Laughter reduces the body’s stress reaction and con-
occur. It can be helpful to respond to these observations tributes to feelings of well-being. Humor is also regu-
with statements like, “It would be nice not having to....” larly used in the education sector as a useful tool for
This demonstrates an appreciation for the child’s active maintaining student interest and causing relaxation.
imagination and empathy for his feelings. In most cases, Consequently, humor is employed often in medical and
children understand that what is asked of them needs dental settings. Members of the dental team can employ
to be done. If we request cooperation calmly and con- this technique by telling age-appropriate jokes, invent-
fidently, they often respond favorably [15]. The child’s ing rhymes, giving dental instruments funny names,
imagination is probably most active around the age of and making playful gestures [1]. As with all techniques,
4–5 years. We can leverage this in our interaction with authenticity is important and success is contingent on
the patient. The clinician can guide the patient’s visit the clinician’s temperament.
with phrases like “Imagine that you are in space” or “...
pretend that you are Batman (or another character the zz Memory Restructuring
child likes) being brave for the dentist.” This type of Children frequently navigate difficult dental visits with-
guided imagery is based on principles of hypnosis and out tears; however, that is not always the case. When the
can be a powerful adjunctive technique [1]. patient has a negative experience, it can help to restruc-
ture her memory of the visit. Successful implementation
zz Directed Breathing of this technique involves enhancing positive associa-
Directed breathing is one of the most powerful ways tions and minimizing negative aspects of the visit. After
to reestablish a fearful patient’s focus. A crying child is treatment is complete, the dentist may engage in a car-
often too distracted by her distress to respond to direc- ing conversation with the child and parent. He should
tions. Instructing a fussy child to take deep, rhythmi- verbally praise the child for some aspect of the visit that
cal breaths directs her attention on something concrete she performed well. For example, the dentist might say,
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70 T. Nelson and N. Kotsanos
ask that the parent praise them at home later that day in -And with this (air/water syringe) Anna, we blow a
the presence of other family members. Memory restruc- little wind on the teeth…sending a light stream of air
turing has been demonstrated to be effective at reducing onto her hand as you are holding it...this cleans and
dental fear and improving behavior at subsequent treat- dries them so that I can see really well. Now open big like
ment visits [2, 36]. a lion so that I can count your teeth like we practiced.
Anna opens her mouth.
zz The Use of Rubber Dam and Accessories -Ah, thank you for opening so wide Anna (positive
Instrumentation used in pediatric dentistry to provide reinforcement). What a nice healthy mouth! You begin
high-quality restorative outcomes (i.e., by maintain- the dental examination, counting teeth and dictating
ing a clean, dry field) contributes indirectly to overall findings to your assistant.
treatment results by improving patient behavior. Many 55 Restorative Treatment
children with dental behavior management problems
perform better after a rubber dam and a mouth prop Alex is a healthy 5-year-old boy. He needs restoration
are placed (. Fig. 5.12). This creates a perception of a
of his two left mandibular primary molars. You have
barrier between the child and the technical procedures. successfully administered a mandibular block, anes-
The mouth prop also allows the patient to relax with- thetizing the inferior alveolar nerve (see 7 Chap. 7).
out having to focus on keeping his mouth open. Treating - You explain to him. Alex, now that your teeth are
patients in the supine position with a dental assistant sleeping on this side, I will cover them with this raincoat
present reduces treatment time and improves safety (rubber dam). That way no more icky tastes will get on
when the assistant holds the child’s hands during specific your tongue, and no water or little bugs will stay in your
aspects of the dental visit. Children with disabilities and mouth. Do you want to feel it? See, it’s soft and made of
strong gag reflexes may require alternative positioning rubber!
for comfort and cooperation [37].
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Behavior Guidance and Communicative Management
71 5
5.3 Advanced Behavior Guidance
He touches it.
- This little ring (rubber dam clamp) will hold it in Children may show a variety of negative behaviors
place like a button. If it bothers you at all, raise this hand in the dental office, including a strong attachment to
again. OK? their parents, avoiding eye contact, expressing strong
- This tooth chair (mouth prop) makes it easy to will, refusal to cooperate, and fight/flight reactions.
keep your mouth open. Now open wide please. That’s Fortunately, many children who display these behaviors
great, thank you! can be treated successfully using the right combination
The small size Molt mouth prop is inserted, not to of basic techniques. On the other hand, those strategies
pry the teeth apart, but to help the mouth stay open are ineffective with some patients. Attempting to pro-
(. Fig. 5.13). Alex can watch this process in the mir-
vide dental care for children who are unable to cooper-
ror, satisfying his curiosity and focusing his attention ate with basic behavior guidance techniques can result in
on the procedure. poor outcomes and frustration for the child, parent, and
- Alex, anything that falls onto the raincoat will be dentist (. Fig. 5.14). In these situations clinicians with
sucked up by this small vacuum cleaner (high-volume advanced training may consider use of protective sta-
suction). I will clean the little hole in your tooth with this bilization, procedural sedation, and general anesthesia
metal brush (diamond bur). Then I will fill it with little (GA) [2]. For the purposes of this chapter, we have lim-
putty and we will be all done. ited our discussion to non-pharmacological techniques.
You showed your patient the cylindrical diamond
bur and let him feel it on a finger nail (on a high-speed
hand piece but at very low speed). That will put him at 5.3.1 Protective Stabilization
ease and reduce concerns about the unknown. You also
gave the patient control by allowing him to raise his Active Immobilization Operative dental care requires
hand to pause the appointment if he experiences pain. good control of the field and the child’s movements. In
- Everything OK Alex? specific situations, safe treatment requires parents or
He nods in agreement. members of the dental team to actively hold the child’s
- Okay, let’s do it. Would you like to listen with head- hands, limbs, or head for brief periods of time. This is
phones while watching this cartoon on the screen? known as active immobilization. This is particularly com-
*Depending on the experience and the tempera- mon with young, precooperative children. Examples
ment of the pediatric dentist, steps may vary in content include:
and speed.
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72 T. Nelson and N. Kotsanos
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Behavior Guidance and Communicative Management
73 5
cial needs who cannot cooperate willingly for dental a
examination. Most typically, passive immobilization
devices consist of padded boards with fabric fasteners
for securing hands and legs to the body. These devices
are manufactured in various sizes and are intended to
limit movement and prevent accidental injury from den-
tal instruments (. Fig. 5.17). Care should be taken to
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74 T. Nelson and N. Kotsanos
a
Short Preference List of Behavior Guidance
Techniques
The management of the child’s behavior may include
the following techniques:
55 Always:
1. Approach with empathy and provide control.
2. Tell-show-do suited to child’s age.
3. Reinforce positive behavior.
55 Possibly:
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Behavior Guidance and Communicative Management
75 5
simply drying teeth with air [ 44]. When indicated for a
procedure, good local anesthesia significantly reduces
gagging and helps prevent nausea/vomiting. It is rec-
ommended that patients in whom the gag reflex is
anticipated arrive to the dental visit with an empty
stomach. This reduces nausea and limits vomiting. An
upright chair position is also recommended. If there is
.. Fig. 5.20 Drawing by a 6-year-old while awaiting treatment no immediate need for restorative dentistry, instructing
the parent to assist the patient with brushing the molar
lingual surfaces for several weeks may help desensitize
sensitive areas (. Fig. 5.21). For children who need
exercises may also be very helpful. to child-rearing practices. For example, when parents
The gag reflex is often encountered when exposing are uninvolved and assign parenting responsibilities to
radiographs, taking maxillary impressions, placing a other caretakers, the parent-child bond may be weak.
rubber dam, providing fissure sealants, and on occasion These children may not feel a sense of security from
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76 T. Nelson and N. Kotsanos
will the parent be the only party consenting for care? seen a movement toward common guidelines between
55 Is advanced behavior guidance indicated, and if so the International, American, and European Pediatric
what are the potential consequences? Dentistry associations.
55 Has the parent been fully informed of their treat- Studies demonstrate that when provided with ade-
ment options? quate explanations, most parents accept communicative
55 Have cultural background, economics, and parent techniques like tell-show-do and positive reinforcement.
preferences been considered? Techniques that involve voice control and use of a “bite
rest” mouth prop are reasonably well accepted, but more
For adult dental care, consent is implied when the patient aversive techniques like “hand over mouth” and passive
sits in the dental chair to receive treatment. With children, stabilization receive low acceptance [39, 49]. While these
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Behavior Guidance and Communicative Management
77 5
techniques are generally not seen as desirable by many par- 3. Ripa L, Barenie J. Management of dental behavior in children.
ents, those with uncooperative children are more willing to Littleton, Mass.: PSG Publishing Co; 1979.
4. Chadwick B, Hosey M. Child taming: how to manage children in
agree to the use of more aversive techniques if the rationale dental practice. London: Quintessence; 2003.
for use is well explained [40, 50]. Acceptance of sedation 5. Ten Berg M. Dental fear in children: clinical consequences. Sug-
and general anesthesia varies widely depending on culture gested behaviour management strategies in treating children
and the healthcare and legal system of each country. It is with dental fear. Eur Arch Paediatr Dent. 2008;9(Suppl 1):41–6.
always very important to provide detailed informed con- 6. Nelson T. The continuum of behavior guidance. Dent Clin N
Am. 2013;57(1):129–43.
sent before implementing pharmacological techniques [50]. 7. Townsend JA. Behavior guidance of the pediatric dental patient.
Ch.23. In: Casamassimo PS, Fields Jr HW, Mc Tigue DJ, Nowak
Types of Consent Consent is an essential component of AJ, editors. Pediatric dentistry. Infancy through adolescence. 5th
healthcare delivery. Specifics of informed consent are gov- ed. Elsevier Saunders: St. Louis; 2013.
erned by the laws of individual countries. Consent may be 8. Addleston H. Child patient training: fortnightly review of the
chicago dental society; 1959. p. 7–9–27–9.
implied – as when a parent observes the dental team per- 9. Raseena KT, Jeeva PP, Kumar A, Balachandran D, Anil A,
forming an examination – or it may be expressed in oral Ramesh R. A comparative study of tell-show-do technique with
or written form [50]. Written documentation offers the and without the aid of a virtual tool in the behavior manage-
dentist better legal protection than oral or implied con- ment of 6-9-year-old children: a nonrandomized, clinical trial.
sent. Written consent provides evidence of the consent J Indian Soc Pedod Prev Dent. 2020;38(4):393–9. https://doi.
org/10.4103/JISPPD.JISPPD_280_20.
process, which may decrease liability that stems from mis- 10. Radhakrishna S, Srinivasan I, Setty JV, Murali Krishna DR,
communication. In the case of oral consent, the presence Melwani A, Hegde KM. Comparison of three behavior modifi-
of a witness is recommended (e.g., the dental assistant), cation techniques for management of anxious children aged 4–8
and records should be kept in patient’s file. Written con- years. J Dent Anesth Pain Med. 2019;19(1):29–36. https://doi.
sent should be procedure specific, as risks differ for restor- org/10.17245/jdapm.2019.19.1.29.
11. Kharouba J, Peretz B, Blumer S. The effect of television distrac-
ative procedures, extractions, protective stabilization, and tion versus tell-show-do as behavioral management techniques
sedation or general anesthesia [50]. In all cases, the laws of in children undergoing dental treatments. Quintessence Int.
the country supersede any consent arranged between the 2020;51(6):486–94. https://doi.org/10.3290/j.qi.a44366.
family and the dentist. In situations where a patient suf- 12. Communicating with and about people with disabilities: Centers
fers harm, responsibility is often ascribed to the dentist if for Disease Control. https://www.cdc.gov/ncbddd/disability-
andhealth/materials/factsheets/fs-communicating-with-people.
there is no evidence that informed consent was obtained html.
before a procedure [51]. The consent process is also an 13. Weinstein P, Getz T, Ratener P, Domoto P. The effect of den-
important opportunity for the dentist to discuss the child’s tists' behaviors on fear-related behaviors in children. J Am Dent
care and develop trust and rapport with families. Assoc. 1982;104(1):32–8.
14. Milgrom P, Weinstein P, Getz T. Treating fearful dental patients.
A patient management handbook. 2nd ed. Seattle: University
Clinician Temperament and Training Success in behavior
of Washington Continuing Dental Education; 1995. p. 167–70.
guidance relies on the experience, skill, and temperament 231–36, 313, 16
of the individual practitioner. Some clinicians are more 15. Ram D, Shapira J, Holan G, et al. Audiovisual video eyeglass
comfortable with advanced behavioral strategies such as distraction during dental treatment in children. Quintessence
sedation and protective stabilization. Others may not have Int. 2010;41(8):673–9.
16. Prabhakar AR, Marwah N, Raju OS. A comparison between
had training in pharmacologic techniques and thus tend audio and audiovisual distraction techniques in managing anx-
to rely more on communicative behavior management. ious pediatric dental patients. J Indian Soc Pedod Prev Dent.
Regardless of the clinician’s approach, it is critical that she 2007;25(4):177–82.
develop a strong working knowledge of the wide variety 17. Asl Aminabadi N, Erfanparast L, Sohrabi A, Ghertasi Oskouei
of behavior guidance techniques. This allows her to imple- S, Naghili A. The impact of virtual reality distraction on pain
and anxiety during dental treatment in 4-6 year-old children: a
ment strategies that are most likely to be successful in her randomized controlled clinical trial. J Dent Res Dent Clin Dent
hands. Prospects. 2012;6(4):117–24.
18. Morris LD, Louw QA, Grimmer-Somers K. The effectiveness
of virtual reality on reducing pain and anxiety in burn injury
patients: a systematic review. Clin J Pain. 2009;25(9):815–26.
References 19. Khandelwal D, Kalra N, Tyagi R, Khatri A, Gupta K. Control of
anxiety in pediatric patients using "tell show do" method and audio-
1. Wright G, Kupietzky A. In: Wright G, Kupietzky A, editors. visual distraction. J Contemp Dent Pract. 2018;19(9):1058–64.
Non-pharmacologic approaches in behavior management. 2nd 20. Karekar P, Bijle MN, Walimbe H. Effect of three behavior
ed. Behavior management in dentistry for children; 2014. guidance techniques on anxiety indicators of children undergo-
2. American Academy of Pediatric Dentistry. Behavior guidance ing diagnosis and preventive dental care. J Clin Pediatr Dent.
for the pediatric dental patient. The Reference Manual of Pedi- 2019;43(3):167–72. https://doi.org/10.17796/1053-4625-43.3.4.
atric Dentistry. Chicago, Ill: American Academy of Pediatric 21. Farhat-McHayleh N, Harfouche A, Souaid P. Techniques for
Dentistry; 2020. p. 292–310. managing behaviour in pediatric dentistry: comparative study of
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live modelling and tell-show-do based on children's heart rates dental fear in 4-12-year-old children in a dental setting. Int J
during treatment. J Can Dent Assoc. 2009;75(4):283. Paediatr Dent. 2018; https://doi.org/10.1111/ipd.12445.
22. Greenbaum PE, Turner C, Cook EW 3rd, Melamed BG. Den- 38. Sacheti A, Ng MW, Ramos-Gomez F. Infant oral health is the
tists' voice control: effects on children's disruptive and affective current standard of care. J Mass Dent Soc. 2012;61(3):22–7.
behavior. Health Psychol. 1990;9(5):546–58. 39. Boka V, Arapostathis K, Vretos N, Kotsanos N. Parental accep-
23. Wells MH, Dormois LD, Townsend JA. Behavior guidance: that tance of behaviour-management techniques used in paediatric
was then but this is now. Gen Dent. 2018;66(6):39–45. dentistry and its relation to parental dental anxiety and experi-
24. Adair S, Waller J, Schafer T, Rockman R. A survey of mem- ence. Eur Arch Paediatr Dent. 2014;15(5):333–9.
bers of the american academy of pediatric dentistry on their 40. Eaton JJ, McTigue DJ, Fields HW Jr, Beck M. Attitudes of
use of behavior management techniques. Pediat Dentist. contemporary parents toward behavior management techniques
2004:159–66. used in. Pediatr Dent. 2005;27(2):107–13.
25. Ramos ME, Kao JY, Houpt M. Attitudes of pediatric dentists 41. Frankel RI. The papoose board and mothers' attitudes following
toward parental presence during dental treatment of children. J its use. Pediatr Dent. 1991;13(5):284–8.
5 N J Dent Assoc. 2010;81(3):32–7. 42. Roberts JF, Curzon ME, Koch G, Martens LC. Review: behav-
26. Crossley ML, Joshi G. An investigation of paediatric dentists' iour management techniques in paediatric dentistry. Eur Arch
attitudes towards parental accompaniment and behavioural man- Paediatr Dent. 2010;11(4):166–74.
agement techniques in the UK. Br Dent J. 2002;192(9):517–21. 43. Nelson T, Chim A, Sheller BL, Mc Kinney CM, Scott JM. Pre-
27. Cassidy J, Shaver P, editors. Handbook of attachment theory, dicting successful dental examinations for children with autism
research and clinical application. New York: Guilford Press; 1999. spectrum disorder in the context of a dental desensitization pro-
28. Frankl S, Shiere F, Fogels H. Should the parent remain with the gram. J Am Dent Assoc. 2017;
child in the dental operatory? J Dent Children. 1962:150–63. 44. Katsouda M, Coolidge T, Simos G, Kotsanos N, Arapostathis
29. Kotsanos N, Coolidge T, Velonis D, Arapostathis KN. A form of KN. Factors associated with gagging during radiographic and
‘parental presence/absence’ (PPA) technique for the child patient intraoral photographic examinations in 4-12-year-old children.
with dental behaviour management problems. Eur Arch Paediatr Eur Arch Paediatr Dent. 2020; https://doi.org/10.1007/s40368-
Dent England. 2009:90–2. 020-00535-9.
30. McWhorter AG, Townsend JA. Behavior symposium work-
45. Gustafsson A, Arnrup K, Broberg AG, Bodin L, Berggren
shop a report - current guidelines/revision. Pediatr Dent. U. Psychosocial concomitants to dental fear and behaviour man-
2014;36(2):152–3. agement problems. Int J Paediatr Dent. 2007;17(6):449–59.
31. Oberoi J, Panda A, Garg I. Effect of hypnosis during Adminis- 46. Salim NA, ElSa'aideh BB, Maayta WA, Hassona YM. Dental
tration of Local Anesthesia in six- to 16-year-old children. Pedi- services provided to Syrian refugee children in Jordan: a retro-
atr Dent. 2016;38(2):112–5. spective study. Spec Care Dentist. 2020;40(3):260–6. https://doi.
32. Peretz B, Bercovich R, Blumer S. Using elements of hypnosis org/10.1111/scd.12460.
prior to or during pediatric dental treatment. Pediatr Dent. 47. Raskin SE, Tranby EP, Ludwig S, Okunev I, Frantsve-Hawley
2013;35(1):33–6. J, Boynes S. Survival of silver diamine fluoride among patients
33. Al-Harasi S, Ashley PF, Moles DR, Parekh S, Walters V. Hyp- treated in community dental clinics: a naturalistic study. BMC
nosis for children undergoing dental treatment. Cochrane Data- Oral Health. 2021;21(1):35. https://doi.org/10.1186/s12903-020-
base Syst Rev. 2010;(8):Cd007154. 01379-x.
34. Aitken JC, Wilson S, Coury D, Moursi AM. The effect of music 48. Law CS, Karp JM. Behavior guidance symposium workshop B
distraction on pain, anxiety and behavior in pediatric dental report - training implications. Pediatr Dent. 2014;36(2):154–7.
patients. Pediatr Dent. 2002;24(2):114–8. 49. Alammouri M. The attitude of parents toward behavior man-
35. Mitchell LA, MacDonald RA, Brodie EE. A comparison of the agement techniques in pediatric dentistry. J Clin Pediatr Dent.
effects of preferred music, arithmetic and humour on cold pres- 2006;30(4):310–3.
sor pain. Eur J Pain. 2006;10(4):343–51. 50. American Academy of Pediatric Dentistry. Informed consent.
36. Pickrell JE, Heima M, Weinstein P, et al. Using memory restruc- The reference manual of pediatric dentistry. Chicago, Ill.: Amer-
turing strategy to enhance dental behaviour. Int J Paediatr Dent. ican Academy of Pediatric Dentistry; 2020, p. 470–355. Guide-
2007;17(6):439–48. line on Informed Consent. Pediatr Dent 2015;37(5):95–7.
37. Katsouda M, Tollili C, Coolidge T, Simos G, Kotsanos N,
51. Sheller B. Challenges of managing child behavior in the 21st cen-
Arapostathis KN. Gagging prevalence and its association with tury dental setting. Pediatr Dent. 2004;26(2):111–3.
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79 6
Examination, Diagnosis,
and Treatment Plan
Implementation
Stergios Arizos, Johan K. M. Aps, and Konstantinos N. Arapostathis
Contents
References – 109
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80 S. Arizos et al.
6.1 Examination and Diagnostic Process nication with the young patient by demonstrating our
interest before he/she sits in the dental chair. An impor-
The dental examination of the young patient is a com- tant question is reason for the visit (e.g., routine checkup,
plex process, quite different from the equivalent in an emergency because of trauma, pain, etc.). Thus, one can
adult. It is not merely a simple oral checkup but a pro- avoid overlooking the prime reason of the visit, let’s say,
cess of collecting, analyzing, and evaluating data (medi- for example, an ectopic eruption of a tooth, and focus
cal, dental, social, personal, motor skills, cognitive and instead on the need for pit and fissure sealants. A com-
learning skills, etc.). This process, while identifying any plete medical and dental history of a patient includes
dental problems (diagnosis), will reveal the child’s per- the familial and social history.
sonality and family background in the scope of best
meeting the oral needs (treatment plan) of every young 6.1.1.1 Family and Social History
patient. Taking the family and the social history of the child is
a natural seamless procedure providing a picture of the
6 close family and the broad social environment of the
Eye Catcher child. By means of an informal conversation about the
family (e.g., double or single parent, number of siblings,
The main element that differentiates the examination
place of residence (urban, rural), kind of school the child
of a child to that of an adult is that the child needs a
attends, verbal communication skills and level, possible
special approach by the examining dentist (behavior
extracurricular activities), important information is col-
guidance). Most often a child is not capable or unwill-
lected. The parents’ – or guardians’ – education level,
ing to provide accurate information about the back-
often somehow drawn by their profession, may offer
ground of a dental problem. Nor can he/she provide
insight into ease of communication about their child’s
information about the medical history. All the neces-
oral health and oral home care. Their occupation and
sary information will be provided by the child’s par-
the child’s social security number are useful for writing
ent or guardian who is obliged by law to accompany
prescriptions and for applying for financial coverage by
the child to the dentist. Still this information is sub-
a social security or health insurance agent. Asking such
jective and needs to be treated critically by the clini-
questions may often be perceived as indiscretion on the
cian because oftentimes it may be distorted by overly
part of the dentist; a relevant document may for that
anxious parents under emotional stress or others who
reason be available in the waiting area.
underreport their child’s complaints.
6.1.1.2 Medical History
Taking a detailed medical history is paramount as some
The actual symptoms will come to light during the pathological conditions may be predisposing factors for
examination process, which need be properly structured oral health and thus affect the treatment plan or explain
in stages orderly and clearly succeeding one another. manifest dental defects. Information relating to preg-
For example, discussing the child’s main complaint nancy and delivery, weight of the infant at birth, pre-
with the parents/guardians at the same time with clini- maturity and corresponding intubation, as well as days
cal examination is incorrect. Even worse, history taking spent in an incubator should all be recorded. Equally
while struggling to convince a child to sit in the dental important is the investigation of infection during the
chair may lead to failure. Mistakes like these increase neonatal period and infancy, while compliance to the
the probability of a wrong diagnosis. The stages of the immunization program should also be confirmed.
diagnostic process are the following: Particular attention is needed in recording possible
syndromes and other congenital anomalies with a special
55 History taking. emphasis on congenital heart disease or heart surgery
55 Clinical examination. that can be ground for developing bacterial endocardi-
55 Radiographic examination (if needed). tis. Parents often report the presence of a heart murmur
without being able to provide further details. In such
cases, further investigation of the condition by refer-
6.1.1 History Taking ring the child to a pediatrician or pediatric cardiologist
is necessary to determine the nature of the murmur and
History taking begins with the collection and record- whether antibiotic coverage for certain dental treat-
ing of personal data of the young patient and this has ments or a modified treatment plan is warranted.
some extra significance. Except that it is a practice’s legal Patients with diabetes (type I) or children with chronic
obligation to keep records with patients’ data, knowing respiratory diseases (e.g., asthma) need s ometimes spe-
name, etc. aids in establishing a good way of commu- cial treatment, so it is important that the severity of these
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Examination, Diagnosis, and Treatment Plan Implementation
81 6
conditions is further investigated. Chronic use of drugs which the dentist comes in physical contact with the
(e.g., corticosteroids) may often require modification of young patient.
drug level before dental treatment, always by consult- Essentially, the examination begins long before the
ing the child’s attending physician. Highly detailed log- young patient seats in the dental chair, when the his-
ging is needed in patients with a history of neoplasia tory forms are being filled in or, in cases of children
or transplants. It therefore becomes obvious that taking with intensely fearful disposition, just by observing their
the medical history is a vital process for treatment plan- behavior in the waiting room. So, relative to the child’s
ning and its overlooking may lead to situations that can age, the dentist can assess his/her physical growth and
end up being life threatening. An example of a medical gather information on maturity from the child’s mov-
history form is shown in . Fig. 6.1.
ing, behaving, talking, and his/her facial expressions.
The observation of appearance and behavior may give
6.1.1.3 Dental History hints for possible disorders and syndromes that require
The aim of dental history taking is, first, to investigate any further investigation through the medical history.
previous dental experience, in order to check the degree The dentist can, besides assessing the oral cavity, have
of familiarity of the child with the dental environment. a quick look at the child’s eyes, and at other exposed
Any previous dental treatment, along with administra- parts of the body, such as hands and legs, for various
tion of local anesthesia, the time elapsed since the child’s signs that may be related to the patient’s general health,
last visit to the dentist, and whether this was pleasant or including possible signs of physical abuse. These include
unpleasant to the patient, should also be recorded. An bite marks, burns, abrasions, and bruises in different
attempt is made to highlight any problems that existed in stages of healing, which are located in parts of the body
the past, and detect any underlying fears toward dental that normally do not get traumatized. Irritation signs
treatment, both on the side of the parent and the child. and hyperplastic areas at the fingers may also provide
This will aid in adopting a suitable approach strategy useful information about the existence of a bad habit,
that will effectively address all the possible previous neg- such as digit sucking, while nails’ shape and color (curva-
ative experiences. Moreover, the history of any previous ture, cyanosis) may advocate a congenital heart disease.
facial or dental injuries also needs to be checked, along
with any treatment that was provided. 6.1.2.1 Extraoral Examination
In case pain is the reason for the dental visit, a pain As soon as the young patient takes his/her place in the
history is next taken. This includes the assessment of dental chair, the dentist proceeds to an assessment of
several characteristics such as the localization of pain the facial structures, looking for anomalies that are typi-
(soft tissue, tooth, maxillary, or mandibular), its nature cal for a syndrome (e.g., hypertelorism, forehead height,
(acute, dull, spontaneous, or provoked), and its duration. etc.). The structure and the height of the lips as well
At this point caution is advisable, as children, especially as the tone of both the labial and parietal muscles are
the ones below age 6 years, can rarely provide reliable checked and assessed. Palpation of the neck and the
information about pain characteristics, unless the pain submandibular triangle follows, in checking for pres-
is acute, recent, and so intense as to make them change ence of enlarged or sensitive lymph nodes (. Figs. 6.2
their habits. Pain details are a vital element for diagno- and 6.3).
sis. Parents can usually provide such details as well as The examination of the temporomandibular joint
whether they have administered any analgesics (see also (TMJ) is also important. Palpation of the condyle head
7 Chap. 14 for emergencies). Finally, the dental his-
area during mouth opening and closing is followed by
tory should include the child’s oral hygiene (frequency checking maximum mouth opening together with any
of tooth brushing, use of fluoride toothpaste, any other divergence of the mandible [1] (see also 7 Chap. 19).
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82 S. Arizos et al.
MEDICAL HISTORY
Please answer the following questions about your child's medical history. Existing medical conditions and medications that can directly affect a dental treatment.
Your answers will help us to provide your child better care. If you do not understand a question, please ask your dentist.
Does your child have a history of: Does your child have a history of:
Rheumatic fever..............................................
6 Anemia..........................................................
Bleeding disorders......................................
Penicillin............................................................
Other antibiotics.................................................
Other drugs......................................................
Does your child have a history of: Has your child ever been:
Jaundice............................................................. Hospitalized.......................................
Diabetes............................................................
Has your child: Has your child recently taken any medication?
Bronchitis………………………………………… ..................................................................
Pneumonia…………………………………………
Has your child or another member of your family ever had problems after a general anesthesia?
Has your child visited a pediatrician or another specialist during the last year? If so, please
specify......................................................................................................................
Is there anything else related to your child that you believe is important for a better approach and treatment by us? ................................
................................................................................................................................ better
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Examination, Diagnosis, and Treatment Plan Implementation
83 6
6.1.2.4 Examination of Periodontal Tissues
The examination of the periodontal tissues starts by
checking the degree of gingival inflammation and
the presence of calculus. Gingivitis is very common
throughout childhood. Gingival health and oral hygiene
are closely related and assessed by the gingival index
(GI) and plaque index (PI), respectively. The use of a
periodontal probe for examining specific teeth for gingi-
val attachment loss should start soon after the eruption
of first permanent molars [3], so that any periodontal
problems are detected early and appropriately treated
[4] (see also 7 Chap. 15). This examination is of even
hyperplastic or short labial frenula, as well as gingival The recording of dental carious lesions should be done
recessions. in detail and systematically, preferably with the aid of a
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84 S. Arizos et al.
Extraoral examination
Profile: ………………………………………………………………………………………………
TMJ: ………………………………………………………………………………………………..
6
Intraoral examination
Dental chart
.. Fig. 6.3 Part of an oral examination form. Its format may depend on the computer dental software
during examination of the teeth for time-saving reasons. Additional important elements of a patient’s dental
record are also intraoral and extraoral photographs, as
6.1.2.6 Examination of Dental Occlusion well as impressions for the construction of plaster model
The dental occlusion is a main component for the devel- casts, if needed (or digital impressions as is increasingly
opment of functional orofacial structures as well as done nowadays). Taking intraoral photographs may be
aesthetics. Therefore, during dental examination, molar useful to record and refer special conditions of hard
relationship in the primary dentition, and first perma- and soft oral tissues. They can be repeated as often as
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Examination, Diagnosis, and Treatment Plan Implementation
85 6
.. Fig. 6.4 Examination of dental surfaces after they are dried with
the air syringe of the dental unit
b
.. Fig. 6.5 Dark stain on the primary teeth in a 20-month-old tod- .. Fig. 6.6 a. Occlusal and cervical caries lesions in the primary
dler molars of a 7-year-old reviewed every 6 months. b After the applica-
tion of fluoride varnish at caries risk sites only
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86 S. Arizos et al.
ries a potential stochastic biological risk (the so-called listen to the machine while it is doing a dummy run
stochastic effects of the linear non-threshold model) (without the child or anyone else being irradiated)
[16–17]. Proper justification of the use of radiographs, (. Fig. 6.8).
pathology, or more bone spread pathology), and the the parallel technique and the bisecting angle technique
treatment planning and that radiographs should only in the maxilla (. Fig. 6.9). This requires some practice
be taken after a thorough history taking and an intra- as elongation or foreshortening of the image is possible
oral exam. Moreover, the radiographic exam should if one uses the wrong angle and the primary X-ray beam
be based on a patient individual basis, meaning there is not aimed perpendicular at the imaginary bisecting
is no such thing as routine radiography (. Table 6.1).
line. In fact, occlusal and oblique occlusal radiographs
It is justifiable to take radiographs to evaluate trauma, use the bisecting angle too. It is obvious that the bisect-
healing, treatment, or development of the dentition and ing angle technique is only to be used when the paral-
the tooth bearing tissues, as long as the ALARA (as lel technique is not possible, for whatever reason (e.g.,
low as reasonably achievable) principle is respected and severe gagging reflex or image detector is too large for
applied. In . Table 6.2 the decision criteria for dental
the child) [23]. . Fig. 6.10 shows examples of good and
radiographic examination are summarized relative to bad images with both techniques. It is obvious that the
the information collected from the social, medical, and age of the patient and the cooperation play an impor-
dental history, as well as during the clinical examination. tant part in the outcome of the image quality and hence
It is obvious that taking good quality radiographs is often the diagnostic yield.
not always as easy in pediatric patients, as patients need
to be cooperative enough to comply with the technical
aspects of the radiographic procedure. As retakes imply Image Detectors
higher patient radiation doses, one has to assess which Image detectors can be analog film, photostimulable
radiographic techniques (e.g., occlusal versus periapi- phosphor storage plates (PSPP), or solid state sensors
cal radiography) shall be used in each individual case (. Fig. 6.11). The latter are either charged coupled
(. Fig. 6.7).
devices (CCD) or complementary metal oxide semicon-
As for all steps in the treatment with children, one ductors (CMOS). These are, compared to the other two
has to explain at the individual child’s cognitive level image detectors, bulkier and therefore not always easily
what is going to happen and how it will be achieved. In tolerated by children. Both PSPP and solid state sensors
order to make them understand better why they have are digital image detectors. The PSPP resemble analog
to put the image detector in their mouth or why they film physically and are therefore often easier to use in
have to stand still for a panoramic radiograph, it is use- children. However, the PSPP are vulnerable to damaging
ful to show them a radiograph of another patient. This due to biting, bending, or sharp objects scratching the
will help them understand the process. Also explain surface (. Fig. 6.12), whereas the solid state sensors are
well what sounds the child will hear or just let the child not. Artifacts on the PSPP will be reproduced every time
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Examination, Diagnosis, and Treatment Plan Implementation
87 6
Type of encounter Child with only a primary Child with a Adolescent with Adult, dentate or Adult,
dentition mixed dentition permanent partially edentulous completely
dentition edentulous
Recall patient1 with no Posterior bitewing radiographs at 12- to 24-month Posterior Posterior bitewing Not
clinical caries and no intervals if proximal surfaces cannot be clinically bitewing radiographs at applicable
increased risk for assessed radiographs at 24- to 36-month
caries2 18- to 36-month intervals
intervals
Recall patient1 with Posterior bitewing radiographs at 6- to 12-month intervals if proximal Posterior bitewing Not
clinical caries or at surfaces cannot be clinically assessed radiographs at applicable
increased risk for 6- to 18-month
caries2 intervals
Recall patient1 with An “individualized” radiographic exam, which may consist of, but is not limited to, selected Not
periodontal disease periapical radiographs and bitewing radiographs, based on the clinician’s judgment applicable
Patient for monitoring Clinical and professional judgment will determine the need for Usually not indicated
of growth and radiographic examination and which type of radiographic examination
development of the is preferable
dentomaxillofacial
complex
Patient with other Clinical and professional judgment will determine the need for radiographic examination and which type of
circumstances including, radiographic examination is preferable
but not limited to,
proposed or existing
implants, pathology,
restorative or endodon-
tic needs, treated
periodontal disease, and
caries remineralization
1Clinical situations for which radiographs may be indicated include, but are not limited to, previous periodontal or endodontic treat-
ment, history of pain or trauma, familial history of dental anomalies, postoperative evaluation of healing (incl. Implant placement),
monitoring of remineralization, presence of dental implants, clinical evidence of periodontal disease, large or deep restorations, clini-
cally deep caries lesions, impacted and malpositioned teeth, presence of a sinus tract (fistula), clinically suspected sinus pathology,
growth abnormalities, known or suspected systemic disease with oro-dental implications, positive neurological findings in head and
neck, evidence of foreign objects in the dentomaxillofacial complex, pain, dysfunction or trauma to the temporomandibular joint,
facial asymmetry, abutment teeth for partial removable or fixed prosthesis, unexplained bleeding, dental sensitivity, swelling, morphol-
ogy, mobility, eruption, exfoliation and absence of teeth, and extensive dental erosion
2Factors increasing the risk for caries may include, but are not limited to, high level of caries experience or demineralizations, recurrent
caries, high titers of cariogenic bacteria, existing restoration(s) of poor quality, poor oral hygiene, inadequate exposure to fluoride,
prolonged breastfeeding or bottle-feeding (especially nocturnal), frequent high sucrose content in diet, poor family dental health,
enamel defects, disability, hyposalivation, genetic abnormality affecting the teeth, many multisurface restorations, history of radio-
therapy and/or chemotherapy, eating disorder, substance abuse (alcohol, drugs), and irregular dental care
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.. Fig. 6.9 Illustration of the
parallel technique (top) and the
bisecting angle technique
(bottom): the X-ray beam is
directed perpendicular at the
image detector, which is placed
parallel to the teeth, and the
X-ray beam is directed perpen-
dicular at the imaginary
bisecting angle (red line) between
the long axis of the tooth (green
line) and the long axis of the
image detector (yellow line)
does not cause higher radiation doses than a colleague of image detector and may even require a brand spe-
who uses digital image detectors, as the exposure times, cific holder (e.g., Rinn XCP-Ora®). If paper tabs (e.g.,
which are needed to acquire good quality diagnostic Rinn ® bitewing loops) or foam tabs (e.g., Disposable
images, are the same. XCP® biteblock) are used to position the phosphor
storage plate or the solid state sensor in the patient’s
Image Detector Holders mouth, there is no extraoral aid to help one aim per-
Image detector holders provide good positioning of pendicular at the image detector. It is obvious that
the image detector inside the patient’s mouth and at the overlap between approximal surfaces is more common
same time enable accurate aiming of the X-ray source if one does use these. When using the Snap-A-Ray®
to ensure the parallel technique is respected. One of the Xtra Film and phosphor plate holder, or the Eezee-
most used image detector holders are Rinn® XCP and Grip®, one has the same issues. For the solid state sen-
Hawe Neos® (. Fig. 6.14). They also provide protec-
sors, the Snap-A-Ray ® DS exists, which is adapted to
tion of the image detector and its stability inside the hold the solid state sensor and which can be equipped
patient’s mouth. The size and shape and model of the with a metal rod and a ring to aid extraoral X-ray beam
image detector holders have to be paired with the type aiming (. Fig. 6.15).
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.. Fig. 6.11 Digital image detectors for intraoral radiography: example of a photostimulable phosphor storage plate (left) and example of
a solid state sensor (right)
Collimation and Protective Aprons or Shields ment, is essential to obtain good quality radiographs.
Collimation of the X-ray beam is important to It is not true that the use of a rectangular versus a
reduce the radiation dose and to reduce the scat- circular collimator causes more retakes [30–33]. In the
tered radiation. When using a rectangular collimator case of children, it is our duty to keep the radiation
(. Fig. 6.16), one will reduce the patient’s radiation
dose as low as possible; hence, one should promote
dose with at least 50%. The use of a good image detec- and support the use of rectangular collimation in
tor holder, which allows accurate X-ray beam align- pediatric dentistry.
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.. Fig. 6.12 Three examples of images made with a damaged photostimulable phosphor storage plate and an image of a damaged plate
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Examination, Diagnosis, and Treatment Plan Implementation
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.. Fig. 6.16 Rectangular collimators for intraoral radiography reduce the patient’s radiation dose by 50%
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94 S. Arizos et al.
.. Fig. 6.19 Examples of extraoral bitewing radiographs taken with Planmeca® panoramic machines. (Courtesy of Mr. James Hughes,
Planmeca®, USA)
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Examination, Diagnosis, and Treatment Plan Implementation
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intervals between radiographic examination reviews for
.. Table 6.3 Intervals of bitewing radiographic examination
reviews according to the protocol of the European Academy
low caries risk patients (up to one proximal caries lesion
of Paediatric Dentistry (EAPD) [22] without any other indication of high caries risk) and
high caries risk patients (with proximal caries lesion in
Age Caries risk
enamel and/or in dentin). The corresponding protocol
Low High
of EAPD is shown in . Table 6.3.
This preference of the European Academy of Paediatric It is indicated for the diagnosis and assessment of any
Dentistry was based on findings of epidemiological pulpal or periapical pathology, dental anatomy, root
surveys that have demonstrated that, even in popula- resorption, tooth exfoliation, dental trauma, eruption,
tions with low caries index, more than 1/3 of the chil- and periodontal problems and, in general, for the diag-
dren in the abovementioned age groups had proximal nosis of problems associated with a single tooth or a
caries lesions that were missed during clinical examina- small area of the oral cavity (. Fig. 6.20). Periapical
tion [40–42]. Both Academies recommend similar time radiographs taken from two different horizontal or ver-
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96 S. Arizos et al.
tical angles can be used to identify the position of teeth to close one eye and hold your index and middle fin-
in three dimensions. This is called the parallax technique ger up in front of you so you can see only one finger.
or the buccal object rule. The first radiograph is taken Then move your head to the left or the right. The finger
perpendicular at the tooth of interest. Then a second that came in your field of view in which you turned your
radiograph is taken with the image detector in the same head is the middle finger, which is further away than
position, but the X-ray source coming either more from your index finger. Your index finger will always move in
the mesial or more from the distal. If the object of inter- the opposite direction in your field of view. Solid state
est in the projection moved in the same direction as the sensors are an advantage when using the parallax tech-
one the X-ray source was moved in, then the object is nique as one can leave the image detector in the patient’s
located more lingual or palatal. The opposite holds for mouth and only adjust the X-ray beam’s angle, which
objects located on the buccal. One can remember the is impossible with PSPP (. Fig. 6.21). The plate sizes
following mnemonic: “SLOB” which stands for “same are the same with the ones used in bitewing radiographs
lingual opposite buccal.” An easy to remember trick is (. Figs. 6.22 and 6.23).
6
a b
.. Fig. 6.21 Illustration of the parallax technique (SLOB rule, same supernumerary tooth appears to be moving in the opposite direction
lingual opposite buccal). a To identify the exact location of the than in which the X-ray machine was moved; hence, the supernumer-
impacted maxillary canine, two periapical radiographs are taken ary tooth is positioned labial to the central incisor. The dentifrice
from a different horizontal angle. The projection of the canine moved tubes below explain the principle: the image in the middle shows only
in the same direction in which the X-ray machine was moved, which one green labeled tube, but if one moves to the left or to the right
implies the canine is positioned palatally. In this case the canine is. b (change in horizontal angle), the red labeled tube is revealed. The red
To identify the position of the supernumerary tooth that overlaps in labeled tube moved in the same direction as your head moved in. The
its projection with the left central maxillary incisor, one takes two green labeled tube at the front moved in the opposite direction in
periapical radiographs from two different horizontal angles. The your field of view (SLOB or same lingual, opposite buccal)
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97 6
a b
.. Fig. 6.22 a Periapical radiograph investigating the infra-occluded second primary molar with a conventional size 0 plate. b Periapical
radiograph with a size 0 digital sensor. Periapical lesion of first primary molar and its surrounding tissues are well displayed
Occlusal (Standard and Oblique) Radiography raphy fails or is impossible (. Figs. 6.24 and 6.25). In
The standard occlusal radiograph is ideal to image the orthodontia the standard upper occlusal radiograph is
anterior mandibular or maxillary teeth. For the man- often used to follow up with rapid maxillary expansion.
dible, the image detector is placed on the occlusal plane In cases where the aim is the diagnosis of pathologic
with the child sitting upright (occlusal plane is now par- conditions located in the anterior region of the jaws, an
allel to the floor) and the X-ray beam aimed 45 degrees occlusal radiograph of the mandible or the maxilla can
upward through the tip of the chin (. Fig. 6.24). For
be used, as an alternative or supplement to a periapical
the maxilla, the image detector is also placed on the one (. Fig. 6.27). It is clear that the use of solid state
occlusal plane with the child sitting upright, but the sensors is a little more complicated in occlusal radi-
X-ray beam aiming 65 degrees downward through the ography, but not impossible, especially in the primary
bridge of the nose (. Fig. 6.25). These views provide a
dentition.
periapical view of all four incisors and sometimes also Oblique occlusal radiographs can be used to image
of the adjacent canines. In . Fig. 6.26 it is shown how
primary molars, premolars, and permanent molars in
one can protect phosphor plates during occlusal radiog- case a periapical radiograph is impossible for the child
raphy. The use of two wooden tongue depressors taped to handle. For the mandible, the image detector, prefer-
around the plate is simple and cheap. In young children, ably a phosphor storage plate, is placed on the occlusal
a size 2 plate can be used with the long axis transverse in plane with the child sitting upright so the occlusal plane
the patient’s mouth. If two wooden tongue depressors is parallel to the floor. The child is then asked to turn
are taped around the plate, and the child is sitting on the the head in the opposite direction and the X-ray beam
parent’s lap, the parent can hold the wooden spatulas to is aimed at a 30 degree angle upward through the apices
stabilize the plate and the patient, and it provides also of the teeth one wishes to visualize. The reason for the
the radiographer with information about the tilting of head turning to the opposite side is because otherwise
the occlusal plane. The parent in this case should also the shoulders are in the way of the X-ray machine.
wear a protective apron. It is an easy technique in case For the maxilla, the child is sitting upright and the
of dental trauma, a mesiodens, or suspected periapical image detector is placed on the occlusal plane, which is
pathology when the above-described periapical radiog- to be held parallel to the floor. The X-ray beam is then
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98 S. Arizos et al.
b c
a
d
e f g
.. Fig. 6.24 Standard occlusal radiograph of the maxilla and the after dental trauma. h shows the application of this technique with a
mandible. a Illustration of how the X-ray machine has to be posi- size 2 solid state sensor used with the long axis transverse in the
tioned for both the upper standard occlusal (65 degree downward patient’s mouth to diagnose the tooth apices in the case of an early
angle) as well as the 45 degree mandibular occlusal radiograph. b is childhood caries. h is an illustration of a 45 degree angle, while i is an
an illustration of a standard upper occlusal radiograph of the entire true occlusal view of the mandible with the X-ray source placed per-
maxillary arch. c is an illustration of the technique used to image pendicular at the occlusal plane, which is a view used to investigate
only the anterior teeth. d shows that the technique can also be used the contours of the mandible and the floor of the mouth. j is an
with smaller size 2 films as well. e is an illustration of the technique illustration of a size 2 solid state sensor used with its widest dimen-
to identify supernumerary and malformed teeth (solid state sensor sions transverse in the mouth to investigate the eruption pattern of
size 2 was used here), while in f it is used to check the tooth apices the mandibular incisors
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Examination, Diagnosis, and Treatment Plan Implementation
99 6
h i j
.. Fig. 6.24 (continued)
a b c
d e
.. Fig. 6.25 Examples of oblique occlusal radiographs taken on lateral maxillary incisor. d is a view of the first quadrant, showing
patients with special needs. a is a view of the third quadrant, show- the missing first primary molar and the developing first right premo-
ing osteitis around the roots of the severely decayed first primary lar. Also notice the bite and bending marks on this phosphor plate. e
molar. b shows severe root resorption of the right lateral maxillary is also of the first quadrant and shows the compromised eruption of
incisor. c is a view of the first quadrant, showing the erupting right the second premolar
aimed 60 to 65 degrees downward through the apices of well tolerated. This radiograph replaces the periapical
the teeth one wishes to visualize. . Figure 6.25 shows
ones of anterior teeth in young patients. In older chil-
examples of this technique, which can be used as an dren, always according to the size of the mouth and
alternative in case intraoral parallel technique is not fea- its opening, the size 4 radiographic plate (57x76 mm),
sible in a patient. In young children (primary dentition), which is also available as a SPP plate, is usually used
only the size 2 radiographic plate is, in most situations, (. Fig. 6.13). The use of a size 4 plate, if possible, is for-
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100 S. Arizos et al.
a b
c d
.. Fig. 6.27 Occlusal radiographs. a. Mandibular radiograph with radiograph for the delayed eruption of left permanent incisor with a
a size 4 plate, investigating delayed eruption of the permanent size 2 plate. d. Maxillary radiograph investigating the ossification of
canine. b. Maxillary radiograph for the examination of the anterior the median maxillary suture after rapid maxillary expansion (con-
region of the primary dentition, with a size 2 plate. c. Maxillary ventional size 4 plate)
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.. Fig. 6.28 Panoramic
radiograph of a child in the
mixed dentition. The image at
the top shows a well-collimated
panoramic radiograph of a
10-year-old patient. For the
image at the bottom, the adult
settings were used on a
4-year-old patient, and as such it
is not well collimated and shows
far too much of the orbits
images and distortions, inherent to the technique, are the radiation dose but also to accommodate the focal
always present (. Fig. 6.28). Especially in orthodontics
trough. There are panoramic machines that can scan
lateral and frontal cephalometric radiographs are com- faster than the traditional 18 seconds (e.g., Morita®
mon imaging modalities. Correct patient positioning is Veraviewepocs). These fast scans cause a lesser patient
also crucial to retain adequate diagnostic yield. Cone radiation dose (dose and time are linearly related). A
beam computed tomography (CBCT) is an imaging faster scan can also be an advantage if the patient can-
modality that provides three-dimensional images of the not stand still for 18 seconds.
hard tissues. CBCT comes in different field of view sizes, A panoramic radiograph is a valuable tool for the
but the field of view should always be as close as pos- diagnosis of pathologic conditions or developmental
sible to the area of interest. The latter is important for disorders in the primary, mixed, and permanent denti-
patient dose limitations. It needs to be emphasized that tion. For instance, several conditions such as impacted
patients must be able to understand the instructions and teeth, ectopic eruption of teeth, mandibular fractures
must be able to stand or sit still long enough to obtain (especially condylar), and cysts and tumors of the jaws
high-quality images. Another extraoral radiographic can easily be detected. However, panoramic radio-
technique, the oblique lateral radiograph, requires large- graphs are not very helpful in the diagnosis of caries
sized PSPP in rigid cassettes and allows one to take lesions [43–45]. Guidelines issued by the EAPD and
two-dimensional images of the jaws if patients cannot the AAPD regarding the use of panoramic radiographs
cope with intraoral radiography requirements or with in children and adolescents vary only in phrasing.
relatively long exposures required for panoramic radi- According to EAPD guidelines, panoramic radiographs
ography. The latter technique will be described below. should be taken only when findings, during the clinical
or the intraoral radiographic examination, cannot be
Panoramic Radiography explained when compared with normal oral anatomic
Paramount in panoramic radiography is the position- structures. They should not be used in asymptom-
ing of the patient. Since there is no standardization in atic children and adolescents [22]. On the other hand,
panoramic radiography machines, the manufacturer’s AAPD guidelines propose the use of panoramic radio-
guidelines are to be followed accurately. Instructions dif- graphs according to the specific needs of every patient
fer between manufacturers. For children it is important [20]. It all comes down to justification of the exposure
to use the child modus of the machine in order to reduce on a patient individual basis (. Fig. 6.29).
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102 S. Arizos et al.
b c
.. Fig. 6.29 a. Panoramic radiograph reveals two supernumeraries appear moving in the same direction with the X-ray machine; there-
obstructing eruption of central incisors. b, c. Two periapical radio- fore, they lie behind (palatally) the unerupted central incisors
graphs taken with a different angulation, where supernumeraries
Medical CT (computed tomography) and CBCT are not It is clear that for CBCT patients also need to be able to
the same, although often both are called CT. Medical CT understand what will happen and that they have to be able
uses a fan-shaped beam that is spiraled around the patient to stay still long enough, because motion artifacts are det-
several times with the patient in supine position, whereas rimental for image quality and diagnostic yield [48–51].
CBCT uses a cone-shaped beam that revolves around Although guidelines are clear that CBCT should
an upright sitting or standing patient only once. Both not be used for caries detection, in 2014 Ertas et al.
imaging modalities produce three-dimensional images. published that for deep occlusal caries lesions CBCT
Medical CT, however, is calibrated and uses so- called scored better than other radiographic techniques [52].
Hounsfield units to identify tissue, air, and fluids in the The exposure of the young and developing patient to
scans, which makes this imaging modality fit for hard and the radiation required for a CBCT, which is considerably
soft tissue diagnosis, whereas CBCT can only be used for higher than in other conventional techniques, justifies its
teeth and bone diagnostic purposes. Unfortunately, CBCT use only in well-considered individual cases.
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.. Fig. 6.30 Example of a small field of view (diameter 5 cm and sors. Clockwise the images represent the axial (caudal), the
height 5.5 cm) cone beam CT image taken on a child for two super- parasagittal view (profile), the three-dimensional reconstruction of
numerary teeth positioned palatal of the two central maxillary inci- the volume, and the coronal view (frontal)
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104 S. Arizos et al.
.. Fig. 6.31 Example of a cone beam CT image taken at the maxil- crown complicated fracture in a maxillary left permanent incisor
lary anterior teeth on a 10-year-old child for the diagnosis of a root-
a b
.. Fig. 6.32 a, b. Oblique lateral radiography explained in pictures tic spectrum disorder, who appeared to have an ameloblastic fibroma
(X-ray beam parallel to the occlusal plane and oblique to the image coronally to the mandibular right first permanent molar, displacing
detector, which is held against the nose and cheek). c. An example of both molars and preventing their eruption
the resulting radiographic image of an 11-year-old boy with an autis-
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2. Be in the best interest of the patient’s restorative
needs:
55 It should aim to restoring teeth with biocompat-
ible/bioactive materials.
55 Primary tooth restorations should be aimed to
last until normal tooth exfoliation.
3. Ensure proper growth and development of the occlu-
sion:
55 Monitoring and preventing occlusal discrepancies.
55 Coordinating with other specialties – e.g., ortho-
dontics, surgery, speech therapists, etc.
4. Appreciate parameters, such as:
55 The patient’s maturity or possible disabilities.
55 The family and social background for feedback
and compliance with treatment plan require-
ments. .. Fig. 6.33 Radiographic findings are demonstrated to parents
avoiding dental terminology in an effort that they appreciate their
child’s dental needs
The treatment plan is recorded in the patient’s chart in
a coded way that saves time and facilitates future refer-
ence. The next step is to obtain approval (consent) from standable language, avoiding the excessive use of dental
the patient’s parents or guardians. terminology, and putting the emphasis on the long-term
benefits of child’s oral health and aesthetics rather than
the financial aspects of treatment. New future needs
6.2.1 resentation of the Treatment Plan
P may be connected with compliance to home care mea-
to Parents sures while own responsibilities for restorative mishaps
should be undertaken. The current situation should
A comprehensive treatment plan that includes priorities, not be dramatized by over-criticizing the parents for it.
alternatives, and consequences if no treatment is per- Explanations for the causes and positive attitudes for
formed should be presented to parents, based on exist- maintaining oral health lead to better informed and
ing guidelines. An honest approach helps establishing a active parents and children [53]. Motivational interview-
good relationship for parent and child. Demonstrating ing techniques described in 7 Chap. 4 are also useful in
the patient’s needs using visual educational facili- encouraging parents to actively support their children.
tates explanations to parents and increases acceptance
chances. Examples of such means are demonstrations
in-mouth, by intraoral camera, on a model of a child’s Eye Catcher
dentition, as well as by pointing any findings on intra-
There may be times that a thorough presentation is
oral, panoramic, or other radiographs (. Fig. 6.33).
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106 S. Arizos et al.
be brief, not getting into unnecessary details and at the Ideally, oral hygiene is performed to the child and
same time encouraging the child to express questions demonstrated to the parent/guardian during the first visit.
directly to the dentist. For instance, if local anesthesia This except for the educational value has the benefit of
is about to be used in a following visit, questions by examining the child’s coping ability for future treatment
stressed parents should be answered beforehand, allow- and making a first positive contact (. Table 6.4). An
ing the dentist to focus on the child. Description of a exception would be an emergency treatment. The same
procedure that is about to begin to parents may stress a holds true for radiological examination. Its omission may
child waiting for the dentist to start working in his/her result in an incomplete diagnosis and, hence, incomplete
mouth. treatment plan (. Fig. 6.35), while accepting radio-
In order to ensure compliance with the preventive graphic examination is a good indicator of the child’s
program and acceptance of the applied behavior man- ability and readiness to cope with restorative treatment.
agement techniques, the dentist should establish a certain Another factor may be the existing dental health-care
relationship with the child and the parent or guardian: system. In different countries, and even within the same
6 a so-called treatment alliance [53, 54], which is based on country, provision of dental health care for its young
mutual trust. The proportion of responsibility between
the child and the parent regarding the compliance with
the preventive program changes as the child grows. The .. Table 6.4 The first two visits of a treatment plan that
responsibility for oral hygiene is often left entirely to the includes restorative treatment
child, even from a very young age (. Fig. 6.34), in a
.. Fig. 6.34 The responsibility of oral hygiene for a 3-year-old child .. Fig. 6.35 Inadequate restorative treatment performed a year ago
belongs to the parents in the absence of radiographic examination
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Examination, Diagnosis, and Treatment Plan Implementation
107 6
citizens may vary and not cover the entire spectrum of
needs. In many countries, there are national insurance
schemes providing very limited dental care for children,
and this severely affects implementing comprehensive
pediatric dental treatment. In other cases, children with
cooperation problems are referred from remote areas to
pediatric dentists, quite often with emergencies. Ideally,
the first visit ends with treatment planning after a thor-
ough examination and provision of a risk-based preven-
tive program, while quadrant restorative treatment is left
for the second or, if so decided, a later visit. Emergencies
however impose restorative treatment to start right away
in the first visit. Otherwise, considerations of time sav-
ing on behalf of the parent by cutting short the time
.. Fig. 6.36 A multiple-chair pediatric dental office with a theme
allowed for proper behavior guidance or by overload-
decoration and several work positions for auxiliary personnel
ing restorative work in the scope of reducing appoint-
ments may not be in the best interest of the young dental
patient. beginning of treatment. Avoiding any injection pain,
In cases of full-mouth restorative needs, their schedul- especially in stressed patients, makes the acceptance of
ing and execution per quadrant or sextant is preferable local anesthesia easier.
for efficiency reasons on the dentist’s part, for reducing
the administrations of local anesthesia, and for mini- Eye Catcher
mizing commuting for parents. A study showed that the
child’s stress before and after the administration of local Many times, in cases of vulnerable children who are
anesthesia by training pediatric dentists was reduced unready to cooperate, flexibility in treatment plan-
only at the fourth restorative visit [55]. Regarding the ning is necessary. Instead of an ideal quadrant den-
sequence of treatment, there has been advice to start or tistry treatment, a more conservative approach, often
to finish the treatment at a quadrant with mild restor- referred to as stabilization [53], combined with an
ative requirements for easier acceptance or for improving anti-caries agent like sodium diamine fluoride, is to be
the child’s memories, respectively. The choice of jaw for preferred. The arrest of active caries lesions by use of
the first restorative session, due to the different type of preventive measures and application of glass ionomer
local anesthesia required (local infiltration versus inferior cements in some cavities until their final restoration,
dental nerve block), is in the discretion of the operator often referred to as “alternative” or “interim” restor-
depending on individual skills and experience or may be ative treatment [56], is preferable in cases with low aes-
left to the child’s preference for increasing acceptance. thetic demands (. Figs. 6.37 and 6.38). This strategy
Extractions of primary teeth, as well as minor surgical is particularly useful in precooperative children below
operations, may be incorporated into quadrant works. the age of 3 or even in fearful potentially cooperative
The content and speed of executing the treatment ones at the beginning of their dental experience, if
plan and the productivity in pediatric dentistry in general there are no pain or inflammation emergencies. Thus,
also depend on the way the provided services are orga- children with similar clinical problems may follow dif-
nized. In industrialized countries, the dental team usually ferent treatment plans based on their level of readiness
consists of dental assistants, other dental auxiliary per- for acceptance of treatment. During the evaluation
sonnel with enhanced role (hygienists, dental therapists), process, acclimatization of the child continues with the
and office staff (. Fig. 6.36). Many routine dental tasks,
provision of preventive, nonoperative care. Unless par-
such as preventive work and follow-ups, are performed by ents are able to comply with the preventive program,
this personnel, while in other societies these are consid- perfect restorations alone in a child’s mouth, as further
ered part of the (pediatric) dentist’s duties. explained in 7 Chap. 12, do not guarantee a long-term
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108 S. Arizos et al.
a c d
6 b e f
.. Fig. 6.37 a. Severe neglect of a mouth of a 9.5-year-old boy pre- are evident in the panoramic radiograph. c–f. Clinical condition of
senting with dental phobia and intense gag reflex during his first den- his molars
tal visit. Occlusal views were impossible to take. b. His dental needs
a b c
d e
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Examination, Diagnosis, and Treatment Plan Implementation
109 6
remaining 20%, a referral to a specialist pediatric dentist If these simple rules are followed, a harmonious rela-
would be preferable, in order to receive the comprehen- tionship is established between colleagues, and, most
sive care that they needed. Such patients may be: importantly, high-quality dental care is provided to the
child patient.
55 Very young children below the age of 3, with severe
forms of early childhood caries, possibly requiring
treatment under general anesthesia. References
55 Children with developmental dysplasias or syn-
dromes, such as clefts, ectodermal dysplasia, etc. 1. Pérez RE. Temporomandibular disorders in children. In: Harfin
J, Satravaha S, Faltin Jr K, editors. Clinical cases in early orth-
55 Children with serious medical problems, such as
odontic treatment. Cham: Springer; 2017.
heart or renal disease. 2. Kana A, Markou I, Arhakis A, Kotsanos N. Natal and Neonatal
55 Children or adolescents with impairments (emo- teeth: a systematic review of prevalence and management. Eur J
tional or physical) undermining the quality of the Paediatr Dent. 2013;14(1):27–32.
proposed dental treatment. 3. Clerehugh V, Tugnait A. Diagnosis and management of peri-
odontal diseases in children and adolescents. Periodontol 2000.
55 Uncooperative children with severe anxiety or phobia.
2001;26:146–68.
4. Califano JV. Research science and therapy committee American
The American Academy of Pediatric Dentistry Academy of periodontology. Periodontal diseases of children
(AAPD) declares that it is unethical to ignore a dis- and adolescents. J Periodontol. 2003;74(11):1696–704.
ease because of age, behavior, or a disability [58]. Thus, 5. Baelum V. What is the appropriate caries diagnosis? Acta Odon-
tol Scand. 2010:65–79.
dentists have the moral obligation to refer the patients
6. Brouwer F, Askar H, Paris S, Schwendicke F. Detecting second-
whose needs are beyond their capabilities. The time of ary caries lesions: a systematic review and meta-analysis. J Dent
referral is very important. The pediatric dental office Res. 2016:143–51.
staff is trained and the environment designed appro- 7. Lara-Capi C, Cagetti MG, Linstrom P, Lai G, Cocco F, Simark-
priately for child patients with demanding treatment Mattsson, Campus G. Digital transillumination in caries detec-
tion versus radiographic and clinical methods: an in vivo study.
needs. The identification of referral cases must be done
Dentaomaxillofacial Radiol. 2017: 20160417.
promptly, before the application of unsuitable behavior 8. Kuenisch J, Soechtig F, Pitchika V, Laubender R, Neuhaus
management techniques or prior to the child’s expo- KW, Lussi A, Hickel R. In vivo validation of near-infrared light
sure to repeated unpleasant stimuli. When the latter is transillumination for interproximal dentin caries detection. Clin
allowed to occur, it creates fear, even phobia, conse- Oral Invest. 2016:821–9.
9. Chen X, Zhan JY, Lu HX, et al. Factors associated with black
quently making the addressed pediatric dentist’s task
tooth stain in Chinese preschool children. Clin Oral Invest.
considerably more difficult. 2014;18:2059. https://doi.org/10.1007/s00784-013-1184-z.
If a general practitioner refers a patient to an endo- 10. Kanellis MJ. Orthodontic treatment in the primary dentition. In:
dontist, this is usually to provide treatment needed Bishara SE, editor. Textbook of orthodontics. Philadelphia: Pa,
for a specific tooth. After its completion, the patient Saunders; 2001. p. 248–56.
11. American Academy of Pediatric Dentistry. Guideline on man-
returns to the referring dentist. In the case of pediat-
agement of the developing dentition and occlusion in pediatric
ric dentistry, it is considerably different, as patients are dentistry. Reference manual 17/18, Pediatric Dent. 39(6):334–47.
usually being referred for comprehensive dental care 12. Li Y, Wang W. Predicting caries in permanent teeth from car-
and less often for a specific procedure prescribed by the ies in primary teeth: an eight-year cohort study. J Dent Res.
referring practitioner. This referral, in most cases, has 2002;81(8):561–6.
13. Helfenstein V, Steiner M, Marthaler TM. Caries prediction on
the same characteristics of a referral to an orthodon-
the basis of past caries including precavity lesions. Caries Res.
tist. Follow-up of the patient can either be performed 1991;25(5):372–6.
by the specialist or the general practitioner. The choice 14. American Academy of Pediatric Dentistry. Periodicity of Exam-
may depend on the patient’s age, the parent’s desires, ination, Preventive Dental Services, Anticipatory Guidance/
or the referring dentist’s desires. The procedure is the Counseling, and Oral Treatment for Infants, Children, and Ado-
lescents. Reference Manual 2018/19, 40 (No. 6); 194–204.
following:
15. Tan EH, Batchelor P, Sheiham A. A reassessment of recall fre-
quency intervals for screening in low caries incidence popula-
55 If a dentist proposes that a child should preferably tions. Int Dent J. 2006;56(5):277–82.
be referred to a pediatric dentist, parental consent is 16. White SC, Mallaya SM. Update on the biological effects of ion-
needed. izing radiation, relative dose factors and radiation hygiene. Aust
Dent J. 2012;57(1 Suppl):2–8.
55 In case of an emergency, the referring practitioner
17. Whaites E, Drage N. The biological effects and risks associated
should notify the pediatric dentist accordingly, pre- with X-rays. In: Whaites E, Drage N, editors. Essentials of den-
venting disruption of his or her schedule and con- tal radiography and radiology. 5th ed. Churchill Livingstone;
tributing to the best treatment for the patient. 2013. p. 65–78.
55 Radiographs and other relevant information should 18. Hoogeveen RC, Hazenoot B, Sanderink GCH, Berkhout WER.
The value of thyroid shielding in intraoral radiography. Dento-
be forwarded to the pediatric dentist.
maxillofacial Radiol. 2016:20150407.
55 The pediatric dentist, in turn, should thank the refer- 19. Sansare KP, Khanna V. Karjodkar. Utility of thyroid collars
ring practitioner, explaining the case management in cephalometric radiography. Dentomaxillofacial radiology.
and outcome. 2011:471–5.
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111 7
Contents
References – 127
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112 K. N. Arapostathis and J.-L. Sixou
Prevention and controlling of pain during dental treat- ing with keratinized mucosa [9, 11, 12]. Cooling sprays,
ment is one of the most important parameters in the although being efficient, should not be used, especially
dentist’s attempt to provide for his/her patients a com- in young children. Cold liquid can flow down the throat.
plete and quality-based dental treatment. Especially Furthermore, sudden arrival of the cold can frighten the
when the patients are children, successfully achieving a child.
high level of cooperation, building trust, preventing the
rise of dental phobia, and establishing a positive attitude
toward the dental act are definitively connected with the 7.1.2 Injectors and Needles
minimization of discomfort and even complete absence
of pain while at the dentist [1–4]. Many studies have The carpule syringe is the most commonly used syringe
arrived at the conclusion that the main causes of den- in adult and pediatric dentistry. It is made of metal or
tal phobia and avoidance of dental treatment are early plastic; mostly stainless steel can be sterilized and fea-
painful or otherwise negative dental experiences [3–7]. tures the ability to perform suction. Plastic devices seem
Painless dental treatment is achieved when the patient’s to be preferred by children [13]. When using it in child
fear and anxiety is controlled and is combined with the patients, there are various innovative ways in which
7 effective administering of anesthesia. syringes can be presented (. Fig. 7.1). There are also
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Local Anesthesia in Pediatric Dentistry
113 7
.. Fig. 7.2 From top to bottom: 37 mm needle (extra long) with
25 G lumen. 22 mm (short) and 27 G needle, recommended for infe-
or 1:200,000. Mepivacaine possesses a slight vasodilat-
rior alveolar nerve block in child patients. 22 mm (short) and 30 G ing ability and in some ways, it can be argued, causes
lumen needle. 10 mm (extra short) and 30 G needle, recommended minor scale vasoconstriction [9]. This ability renders it
for local infiltration anesthesia in child patients. The arrows on the the anesthetic of choice when use of a vasoconstrictor
plastic piece of each needle indicate the bevel side of the tip is not suggested or contraindicated, such as when per-
forming minor, short-term dental work on very young
intraosseous anesthesia, while 22–25 mm needles are children. The duration of effective pulpal anesthesia is
suggested when performing inferior alveolar nerve block short (20–30 min), but the quick relief from the unpleas-
in child patients [11, 15–17] (. Fig. 7.2). It has been
ant numbing sensation of the neighboring soft tissue in
discovered that needle length does not correlate with infiltration techniques in free mucosa is in fact an asset.
discomfort during insertion, while needle point condi- Articaine is available in a 4% solution with vasocon-
tion does directly correlate with experienced pain. There strictor 1:80,00, 1:100,000, 1:200,000, or 1:400,000. It
also seems to be conflicting evidence in relation to needle possesses increased intratissue infiltration but is contra-
diameter. As a result of these findings, the use of dif- indicated in patients with cardiac or respiratory condi-
ferent needles for different types of insertion is advised, tions and can even cause methemoglobinemia in high
especially in the case of palatal anesthesia [16, 18–20]. doses. A high level of caution is required to avoid exceed-
When injecting in attached mucosa (palatal mucosa, ing the maximum permissible dosage of anesthetic solu-
attached gingiva), the flat part of the bevel at the tip of tion in child patients [10, 21–23]. The exact dose of
the needle should be sought to come into parallel con- anesthetic solution is frequently not calculated based on
tact with the periosteum for better and painless penetra- the child’s weight, causing cases of overdose and toxic-
tion in gingiva and injection of the anesthetic solution. ity as a result. The unique physiology of the child’s body
For this reason, needles have an indication for their (reduced ability for renal clearance and variations in
correct orientation. Some needles have a double bevel relation to metabolism, gastrointestinal flora, and serum
to allow better penetration within bone in intraosseous proteins) requires administering smaller doses of local
techniques (. Fig. 7.2).
anesthetic to avoid dangerous toxic reactions from the
circulatory and central nervous system [3, 9, 10, 22, 23].
The maximum permissible dose for each anesthetic solu-
7.1.3 Types of Local Anesthetics – Dosage tion is presented in . Table 7.2.
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114 K. N. Arapostathis and J.-L. Sixou
.. Table 7.2 Maximum permissible dose of anesthetic solutions per each kg of body weight (1 cartridge = 1.8 ml) [3, 22]
7 Maximum
Dose
300 mg 8.3 300 mg 5.5 500 mg 6.9
able and efficient for routine treatments in children [24, 7.1.7 ocal Anesthesia Using Alternative
L
25]. The addition of epinephrine lowers the pH of the Kinds of Injectors
solution. It has been found that the lower pH of the
anesthetic solution increases discomfort during injec- These are appliances that differ from traditional syringe
tion, and thus, epinephrine-free solutions are preferred, anesthesia or do not use needles. The most common of
when the length and type of dental treatment allow these are: computer-controlled administering of anes-
it [26, 27]. Felypressin and norepinephrine are other thesia (C-CLAD), computer-controlled administering
vasoconstrictors available. of anesthesia and needle rotation, and needleless jet
injector anesthesia.
anesthetic to remain close to the injection point [19]. C-CLAD injectors (The Wand-STA™, Sleeper One™,
The ideal speed of injection is 1 ml/min, and for no rea- CCS™, Dentapen™) allow good support points.
son should it ever exceed 1.8 ml/min [9, 28]. While in Injection is controlled by the use of an electronic
one study it appears that the rate of injecting the anes- device. It allows a drop-by-drop delivery during the first
thetic did not reduce the effectiveness or cause coopera- seconds of injection which is very difficult to perform
tion problems in children aged 5–6 [28], rapid injection using traditional syringes [32]. Another characteristic
of anesthetic causes some degree of pain [29]. Use of is that injection is continuous and stable or increases
computer-controlled injectors may be a way to help con- slowly after the first seconds: it therefore avoids pulses
trol the speed of injection and therefore lower the intra- of anesthetics that are associated to high intratissular
tissular pressure related to injection. pressure around the needle and therefore to pain. Using
C-CLAD devices takes more time than regular anes-
thesia and comes at a higher cost, so much as to initial
7.1.6 Temperature of Injected Solution purchase as to buying specific consumables for one of
them (The Wand-STA™). The different appearance of
The temperature of the anesthetic does not seem to cor- the needle and syringe, when pen-shaped, appears to
relate with pain experienced when it is above 15 °C. It reduce fear and pain in patients [13]. Although a sig-
is suggested that anesthetic solutions be preserved at nificant difference in pain levels was found in adults,
ambient temperature, somewhere consequently not too results are more ambiguous in children in usual infil-
hot or cold [26, 29–31]. tration techniques [33–35]. Recent literature reviews
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Local Anesthesia in Pediatric Dentistry
115 7
mucosa of the alveolar process, slightly more cervi-
cally than where the apex of the tooth is calculated to
be. This technique yields successful anesthetic results in
regions where the device can be placed vertically to the
alveolar process (e.g., anterior teeth). However, there are
conflicting results as to the acceptance of the device by
child patients [6, 45]. It could prove to be very useful
in patients who have a fear of needles (aichmophobia/
belonephobia).
dence to conclude [39, 40]. The levels of dental phobia, reduces the chances of swallowing even small amounts
proper communication with the patient, and appropri- of the anesthetic, reducing the chance of a toxic reac-
ate presentation of the device are the most important tion, which is a possibility [46].
factors in influencing acceptance and cooperation with
the dentist. Two studies indicate that low-anxious chil-
dren receiving local anesthesia with the Wand™ dis- 7.2.2 ain Local Anesthesia Techniques
M
play less pain-related behavior signs than low-anxious
children receiving local anesthesia with the traditional
with Infiltration in Free Mucosa
syringe, while no differences are found in anxious chil-
dren whatever the kind of injector used (with or with- Eye Catcher
out electronic assistance) [41, 42]. C-CLAD injectors
The techniques of administering local anesthesia to
have shown promising results in lowering pain in chil-
children are essentially similar to those for adults. The
dren during mandibular nerve blocks and intraliga-
differences are basically related to their craniofacial
mental injection [43, 44] and during palatal injections
complex size and density. This has implications on
(see further).
both the length and the gauge of needle selection.
7.1.7.2 nesthesia without Use
A
of Needle – Jet Anesthetic Technique There are two basic differences in the craniofacial com-
With jet injection technique, the anesthetic is forwarded plex of children when compared to adults:
through pressure to the tissues without using a needle. 1. Anesthetic effectiveness is easier in child patients, as
The Injex™ device is a representative example of this the jawbones are less dense, allowing faster and bet-
technique and used even in non-dental medical work ter diffusion of the anesthetic solution [1].
(. Fig. 7.4). A certain preparative process is required
2. The smaller size of oral structures in children,
before performing anesthesia unlike traditional meth- depending on their age, dictates a smaller depth of
ods, while the device and its consumables come at an needle penetration in mucosal tissues in traditional
increased price. The device is applied vertically to the infiltration techniques and allows access to the
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116 K. N. Arapostathis and J.-L. Sixou
a b
7 c d
.. Fig. 7.4 a–c. Injex needleless jet injection syringe with necessary components to prepare administering local anesthesia. d. Position of
application
mandible from a modified position in the following (c) The mental foramen in children is a little closer
cases [9]: to the first primary molar, and the injection point
(a) The inner mandibular foramen in children is for the anesthetic solution is chosen between the
found at the height of the occlusal plane and not two mandibular primary molars (. Figs. 7.7
on the ramus, age does not seem to make any dif- 7.2.2.1 Local Infiltration Anesthesia
ference. The syringe is positioned above the pri- Local infiltration anesthesia has the same indications in
mary molars, with direction from the opposite children as it does in adults. It is traditionally considered
half, at a 10-degree downward angle. Needle as the anesthesia of choice for teeth, the periodontal tis-
penetration depth is about 15 mm and depends sue, and palate in the maxilla and for the incisors and
on the mandible’s size [11, 29]. surrounding periodontal tissue in the mandible. If this is
(b) In buccal nerve block anesthesia, injection takes performed in an inflamed area, its action may be delayed
place upward and buccally from the last tooth on or suspended [3]. In the maxilla, local infiltration anes-
the arch, using an amount less than 0.5 ml, thesia on the target tooth is preferred over superior alve-
depending on age. This should always be done in olar nerve block (. Figs. 7.9 and 7.10). An exception
child patients for tooth extraction in case of infil- can be made in cases of permanent molars whose apices
tration technique. To place the dental dam clamp are covered by thick and/or fat zygomatic bone, or in the
without discomfort, an even smaller amount can case when the molar nerves are combined with branches
be injected at the depth of the gingivodental sul- of palatine nerve [11]. Additional palatal anesthesia is
cus [29]. suggested as a supplementary procedure in pulpoto-
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Local Anesthesia in Pediatric Dentistry
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118 K. N. Arapostathis and J.-L. Sixou
75
b
7 35
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Local Anesthesia in Pediatric Dentistry
119 7
7.2.3.1 nterior Middle Superior Alveolar
A is performed halfway between the midpalatine raphe
Nerve Block (AMSA) and the crest of the free gingival margin at the premolar
The AMSA injection aims at anesthetizing maxillary level. After diffusion within the bone through nutrient
teeth and palatal tissues extending from the central inci- canals, the anesthetic solution is supposed to anesthe-
sor to the buccal root of the first molar mesially. Most of tize branches of anterior and middle superior alveolar
the time, teeth anesthetized range from the lateral inci- nerves and also areas covered by the greater palatine and
sor to the second premolar or primary molar. Injection nasopalatine nerves. Computer-controlled injection has
been shown to induce less pain in children compared to
injection with traditional syringes [51, 52].
a b
.. Fig. 7.11 Palatal anesthesia with initial buccal approach. toward the palatal surface. c. New insertion of the needle with pala-
a. Insertion of the needle horizontally, in the interdental papilla. tal infiltration will follow
b. The anesthetic is injected gradually as the needle penetrates
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120 K. N. Arapostathis and J.-L. Sixou
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Local Anesthesia in Pediatric Dentistry
121 7
a b c
.. Fig. 7.14 Transcortical anesthesia using a C-CLAD injector of the anesthetic solution. b. Second step: The needle is in contact with
(Sleeper One™). a. First step: Gingival anesthesia. The needle (9 mm the cortical plate (90° angle). c. Third step: After passing through the
long, 30 G) is inserted with shallow angle with the flat part of the bevel cortical plate (in this case without needle rotation), the anesthetic solu-
facing the gingival surface. The tip of the needle can be seen in subsur- tion can be injected. Computer control allows low injection speed and
face situation as well as the whitening of gingiva due to the spreading therefore low intratissue pressure and decreased risk of pain
is more adapted to children than devices in which rota- Contraindications for intraligamental anesthesia are
tion is based on drilling (Stabident™, X-Tip™). Slow children at high infectious risk because of the 96.6% rate
injection is recommended. Computer-controlled devices of bacteremia associated to ILA [62, 63], acute peri-
with or without needle rotation are well adapted to IO odontal inflammation, and teeth with partly developed
injections. Prospective studies performed with the Quick roots. When applied to primary teeth, concern has been
Sleeper™ or Sleeper One™ devices have shown a 92% raised as to the formation of the succedaneous tooth
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122 K. N. Arapostathis and J.-L. Sixou
painless and effective administering of anesthesia is the the child that as a “good helper.” he should have his
most important parameter concerning patients in pedi- mouth open, not move his head, and, should he feel
atric dentistry. The word “painless” has both physical pain, raise his hand (the one at the assistant’s side).
and psychological meanings. Painless administering is (c) Applying topical anesthetic.
possible from a technical standpoint, meaning correct Application of topical anesthetic takes place as dis-
application of topical anesthesia, use of the appropri- cussed above (. Fig. 7.5). This contributes to the
ate needle, slow injection of the anesthetic solution, and patient feeling as slight pain as possible upon needle
limiting the amount of needle insertions [1]. This too insertion, but requires slow and steady injection of
however depends on various other parameters, such as the anesthetic as the needle bores deeper.
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Local Anesthesia in Pediatric Dentistry
123 7
7.3.2 Administration of Local Anesthesia (b) Good preparation.
The syringe and its components can be assembled out-
Administering local anesthesia can be painless and side the child patient’s field of vision. Alternatively,
effective assuming three basic conditions are met. the dentist can ask for the child’s “help,” calling the
(a) Working position for the clinician/patient/assistant. carpule, e.g., a pen or a spaceship, the needle a straw,
The child patient should always be in the supine posi- and the cartridge as a magical potion. As previously
tion, so that the dentist has a good field of vision and described, plastic devices, especially pen-shaped, are
can hold the head (. Fig. 7.17). This is combined
preferred by children [13]. The dentist may decide
with limiting the child’s view of the dental tools and to show the syringe and needle with or without its
anesthetic devices [11]. The dentist places the child’s cap, based on the experiences, temperament, and
head in a suitable position and the assistant hands maturity of the child. For instance, in a child with
the prepared uncapped carpule syringe carefully so negative experience, who insists on the idea that he’s
that it’s out of his field of vision. Immediately after, getting injected, the needle could be presented as a
as injection of the anesthetic begins, the assistant metal straw, and a small portion be dripped onto,
can remove through suction the remaining anes- e.g., the child’s nail, as a demonstration. Once the
thetic which flows undesirably into the mouth, so patient sees through the mirror a drop fall onto his
that the bitter taste does not cause vexation. At tooth, to confirm that it does not hurt, the mirror
the same time, he/she is ready to control instinctual
movement of the child due to pain (. Fig. 7.18).
.. Fig. 7.18 a. The assistant hands over the syringe to the dentist
away from the child’s field of vision, having first removed the needle
.. Fig. 7.17 a, b. Administering of anesthesia. The patient is in the cap. b. The assistant remains prepared to control the child’s instinc-
supine position, so that the dentist has a good field of vision and can tual movement as the dentist administers inferior alveolar nerve
hold the head block anesthesia
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124 K. N. Arapostathis and J.-L. Sixou
a a
b
7 b
from the mucosa, the next insertion is not painful. In conclusion, for reasons of brevity, it is preferred
To reduce the child’s discomfort when the needle is to emphasize the following, instead of getting into com-
inserted, pressure on the area can be applied. Other plicated explanations about the injection:
tricks effective to distracting the child are rubbing
the palate externally or creating a minor jolt [10]. 55 Keeping the mouth opened well.
Following anesthesia, in most of infiltration 55 Focusing on the child’s ability to raise his hand.
techniques, a scared young child may be surprised 55 Warning about the consequent, post-anesthetic sense
and feel anxious, burst into tears, and considerably of numbness in infiltration techniques.
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Local Anesthesia in Pediatric Dentistry
125 7
Eye Catcher 7.4.1.4 Cheek, Lip, or Tongue Injury
Biting, due to lack of understanding of the anes-
Palatal techniques, ILA, and IO injections are not thetic phenomenon, is quite common in children and
associated with soft tissue numbness (lips, cheeks, patients with mental difficulties, especially in buccal
tongue) and therefore with soft tissues self-biting. infiltration and inferior alveolar nerve block anesthesia
However, each of them may lead to anxiety and pain (. Fig. 7.21). This injury is accompanied by swelling
during needle penetration and injection of the anes- and pain. In open rupturing trauma, some topical anti-
thetic solution. Needle rotation in IO injections in septic like 2% chlorhexidine is required to avoid super-
children above the age of 7 may be surprising for the infection [9]. As a preventative measure, children and
patients. Good preparation of the patient is therefore parents should be informed that biting, scratching, or
required. rubbing the anesthetized soft tissues should be avoided.
The application of a cotton bud between the tissues and
the dental arches to remind the patient is also suggested.
The risk of biting is decreased or absent in palatal tech-
7.4 Complications of Local Anesthesia niques (AMSA, P-ASA) and in intraosseous techniques.
Local anesthesia complications may happen locally, at 7.4.1.5 Edema
the point where the anesthetic was applied, or systemi- An edema can be caused by needle trauma or a local
cally [9, 10, 21–23, 66]. infection. It usually causes pain, malfunction, and even
The amount and type of administered local anes- appearance problems. Sometimes, if the problem is
thetic as well as potential unwanted reactions should be acute enough, it may cause obstruction of the airways.
noted in the patient’s file. An edema caused by injury is a minor issue that recedes
within a few days without need for therapy [9].
In rare instances, in infiltration techniques, prolonged vasoconstriction of small blood vessels in that area. The
anesthesia relating to burrowing of the nerve by the skin usually returns to its normal color during the ses-
needle (felt as an electric shock in the neural region) or sion. On rare occasions, this might manifest on the ipsi-
hemorrhaging around the nerve can occur [3]. This usu- lateral portion of the face, in which case the child and
ally recedes within 2 months. the parents should be put at ease.
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126 K. N. Arapostathis and J.-L. Sixou
a b
7
c d
.. Fig. 7.21 a. Lower lip injury due to biting, 2 days following infe- open rupture trauma from 2 weeks past. d. Abrasions caused by
rior alveolar nerve block. b. The extent of the same edema. c. Cre- scratching anesthetized area, 3 days after procedure
ation of gingival tissue in another child, following acute biting and
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Local Anesthesia in Pediatric Dentistry
127 7
techniques and pharmacologic agents. Eur Arch Paediatr Dent.
a
2017;18(5):323–9.
5. Arapostathis KN, Coolidge T, Emmanuil D, Kotsanos N. Reli-
ability and validity of the Greek version of the Children’s
fear survey schedule – dental subscale. Int J Peadiatr Dent.
2008;18(5):374–9.
6. Saravia ME, Bush JP. The needleless syringe: efficacy of anes-
thesia and patient preference in children dental patients. J Clin
Pediatr Dent. 1991;15(2):109–12.
7. Munshi AK, Hegde A, Bashir N. Clinical evaluation of the
efficacy of anesthesia and patient preference using the needle-
less jet syringe in pediatric dental practice. J Clin Pediatr Dent.
2001;25(2):131–6.
8. McDonald RE, Avery DR, Dean JA, Jones JE: Local anesthe-
sia and pain control for the child and adolescent, In: Dean JA,
Avery DR, MacDonald RE, editors. Dentistry for the child and
adolescent. 9th ed., Ch. 13. Mosby: Elsevier; 2011.
9. Malamed SF. Handbook of local anesthesia. 6th ed. St Louis:
b Elsevier Mosby; 2013.
10. Kühnisch J, Daubländer M, Klingberg G, Dougall A, Spyrido-
nos Loizides M, Stratigaki E, Amar JL, Anttonen V, Duggal M,
Gizani S. Best clinical practice guidance for local analgesia in
paediatric dentistry: an EAPD policy document. Eur Arch Pae-
diatr Dent. 2017;18(5):313–21.
11. Fayle SA, Duggal ΜS. Local Analgesia. In: Duggal ΜS, et al.
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12. Meechan JR, Robb ND, Seymour RA. Pain and anxiety control
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13. Kuşcu OO, Akyuz S. Children’s preferences concerning the phys-
ical appearance of dental injectors. J Dent Child. 2006;73(2):
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14. Davis MJ, Vogel LD. Local anesthetic safety in pediatric patients.
N Y State Dent J. 1996;62(2):32–5.
15. Kohli K, Ngan P, Crout R, Linscott CC. A survey of local and
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16. Fuller NP, Menke RA, Meyers WJ. Perception of pain to three
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17. Sixou JL, Barbosa-Rogier ME. Efficacy of intraosseous injec-
tions of anesthetic in children and adolescents. Oral Surg Oral
.. Fig. 7.22 a. Whitish region on the cheek due to vasomotor disor- Med Oral Pathol Oral Radiol Endod. 2008;106(2):173–8.
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tration in the respective maxillary primary molars. b. A more topical anesthetics for pain caused by needle sticks and scaling
generalized case, 30 minutes after inferior alveolar nerve block. and root planing. J Periodontol. 2001;72(4):479–84.
Anesthetic solution used: 2% lidocaine with epinephrine 1:80,000 19. Flanagan T, Wahl MJ, Schmitt MM, Wahl JA. Size doesn’t
matter: needle gauge and injection pain. Gen Dent. 2007;55(3):
216–7.
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2009. meier L, Daubländer M. Epinephrine-reduced articaine solution
3. American Academy of Pediatric Dentistry. Use of local anes- (1:400,000) in paediatric dentistry: a multicentre non-interven-
thesia for pediatric dental patients. Reference Manual 2017/18; tional clinical trial. Eur Arch Paediatr Dent. 2013;14(2):89–95.
39(6). 25. Sixou JL, Marie-Cousin A. Intraosseous anaesthesia in children
4. Klingberg G, Ridell K, Brogårdh-Roth S, Vall M, Berlin
with 4% articaine and epinephrine 1:400,000 using computer-
H. Local analgesia in paediatric dentistry: a systematic review of assisted systems. Eur Arch Paediatr Dent. 2015;16(6):477–81.
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26. Oikarinen VJ, Ylipaavalniemi P, Evers H. Pain and tempera- 43. Palm AM, Kirkegaard U, Poulsen S. The wand versus tradi-
ture sensations related to local analgesia. Int J Oral Surg. tional injection for mandibular nerve block in children and
1975;4(4):151–6. adolescents: perceived pain and time of onset. Pediatr Dent.
27. Meechan JG, Day PF. A comparison of intraoral injection dis- 2004;26(6):481–4.
comfort produced by plain and epinephrine-containing lidocaine 44. Baghlaf K, Alamoudi N, Elashiry E, Farsi N, El Derwi DA,
local anesthetic solutions: a randomized, double-blind, split- Abdullah AM. The pain-related behavior and pain perception
mouth, volunteer investigation. Anesth Prog. 2002;49(2):44–8. associated with computerized anesthesia in pulpotomies of man-
28. Maragakis GM, Musselman RJ. The time used to adminis-
dibular primary molars: a randomized controlled trial. Quintes-
ter local anesthesia to 5 and 6 year olds. J Clin Pediatr Dent. sence Int. 2015;46(9):799–806.
1996;20(4):321–3. 45. Arapostathis KN, Dabarakis NN, Coolidge T, et al. Compari-
29. Wilson S. Local anesthesia and oral surgery in children. In: son of acceptance, preference, and efficacy between jet injection
Casamassino PS, Fields HW, McTigue DJ, Nowak AJ. Pediatric INJEX and local infiltration anesthesia in 6 to 11 year old dental
dentistry. Infancy through adolescence. 5th ed., Ch. 28. St Louis: patients. Anesth Prog. 2010;57(1):3–12.
Elsevier Saunders; 2013. 46. Bittmann S, Krüger C. Benzocaine-induced methaemoglobinae-
30. Rood JP. Some anatomical and physiological causes of failure to mia: a case study. Br J Nurs. 2011;20(3):168–70.
achieve mandibular analgesia. Br J Oral Surg. 1977;15(1):75–82. 47. Benham NR. The cephalometric position of the mandibular
31. Ram D, Hermida LB, Peretz B. A comparison of warmed and foramen with age. J Dent Child. 1976;43(4):233–7.
room-temperature anesthetic for local anesthesia in children. 48. Wright GZ, Weinberger SJ, Martin R, Plotzke O. The effective-
7 Pediatr Dent. 2002;24(4):333–6.
32. Tzafalia M, Sixou JL. Administration of anesthetics using metal
ness of infiltration anesthesia in the mandibular primary molar
region. Pediatr Dent. 1991;13:278–83.
syringes. An ex vivo study. Anesth Prog. 2011;58(2):61–5. 49. Oulis C.J, Vadiakas G, Vassilopoulou A. The effectiveness of
33. Rosenberg ES. A computer-controlled anesthetic delivery system mandibular infiltration compared to mandibular block anaes-
in a periodontal practice: patient satisfaction and acceptance. J thesia in children. Pediatr Dent. 1996;18(4):301–305.
Esthet Restor Dent. 2002;14(1):39–46. 50. Yu F, Xiao Y, Liu H, Wu F, Lou F, Chen D, Bai M, et al. Evalu-
34. Sumer M, Misir F, Koyuturk AE. Comparison of the wand with ation of three block anesthesia methods for pain management
a conventional technique. Oral Surg Oral Med Oral Pathol Oral during mandibular third molar extraction: a meta-analysis. Sci
Radiol Endod. 2006;101(6):e106–9. Rep. 2017:20;7:40987.
35. Tahmassebi JF, Nikolaou M, Duggal MS. A comparison of pain 51. Jälevik B, Klingberg G. Pain sensation and injection techniques
and anxiety associated with the administration of maxillary in maxillary dento-alveolar surgery procedures in children--a
local analgesia with wand and conventional technique. Eur Arch comparison between conventional and computerized injection
Paediatr Dent. 2009;10(2):77–82. techniques (the wand). Swed Dent J. 2014;38(2):67.
36. Libonati A, Nardi R, Gallusi G, Angotti V, Caruso S, Coniglione 52. Feda M, Al Amoudi N, Sharaf A, Hanno A, Farsi N, Masoud
F, Marzo G, Mattei A, Tecco S, Paglia L. Pain and anxiety asso- I, Almushyt A. A comparative study of children's pain reac-
ciated with computer-controlled local Anaesthesia: systematic tions and perceptions to AMSA injection using CCLAD ver-
review and meta-analysis of cross-over studies. Eur J Paediatr sus traditional injections. J Clin Pediatr Dent. 2010;34(3):
Dent. 2018;19(4):324–32. 217–22.
37. Pozos-Guillén A, Loredo-Cruz E, Esparza-Villalpando V, Mar- 53. Allen KD, Kotill D, Larzelere RE, Hutfless S, Beraghi S. Com-
tínez-Rider R, Noyola-Frías M, Garrocho-Rangel A. Pain and parison of a computerized anaesthesia device with a tradi-
anxiety levels using conventional versus computer-controlled tional syringe in preschool children. Pediatr Dent. 2002;24:
local anesthetic Systems in Pediatric Patients: a Meta-analysis. J 315–20.
Clin Pediatr Dent. 2020;44(6):371–99. 54. Ram D, Kassirer J. Assessment of a palatal approach-anterior
38. Smolarek PC, Wambier LM, Rodrigues Chibinski AC. Does superior alveolar (P-ASA) nerve block with the wand® in paedi-
computerized anesthesia reduce pain during local anesthesia in atric dental patients. Int J Paediatr Dent. 2006;16:348–51.
pediatric patients for dental treatment? A systematic review and 55. Woodmansey K. Intraseptal anesthesia: a review of a relevant
meta-analysis. Int J Paediatr Dent. 2020;30(2):118–35. injection technique. Gen Dent. 2005;53(6):418–20.
39. Carugo N, Paglia L, Re D. Pain perception using a computer- 56. Sixou JL, Marie-Cousin A, Huet A, Hingant B, Robert JC. Pain
controlled anaesthetic delivery system in paediatric dentistry: assessment by children and adolescents during intraosseous
a review. Carugo N, Paglia L, Re D. Eur J Paediatr Dent. anaesthesia using a computerized system (QuickSleeper). Int J
2020;21(3):180–2. Paediatr Dent. 2009;19:360–6.
40. Monteiro J, Tanday A, Ashley PF, Parekh S, Alamri H. Interven- 57. Cabasse C, Marie-Cousin A, Huet A, Sixou JL. Computer-
tions for increasing acceptance of local anaesthetic in children assisted intraosseous anaesthesia for MIH teeth. A preliminary
and adolescents having dental treatment. Cochrane Database study. Odont Stomatol Trop. 2015;38:5–9.
System Rev. 2020;2:CD011024. 58. Smaïl-Faugeron V, Muller-Bolla M, Sixou JL, Courson F. Eval-
41. Versloot J, Veerkamp JS, Hoogstraten J. Pain behaviour and dis- uation of intraosseous versus conventional infiltration anaes-
tress in children during two sequential dental visits: comparing thesia in pediatric oral healthcare: combined split-mouth and
a computerised anaesthesia delivery system and a traditional parallel-arm randomized controlled trial. Int J Paediatr Dent.
syringe. Br Dent J. 2008;205(1):E2. 2019;29(5):573–84.
42. Kuscu OO, Akyuz S. Is it the injection device or the anxiety 59. Garfunkel AA, Kaufman E, Marmary Y, Galili D. Intraliga-
experienced that causes pain during dental local anaesthesia? Int mentary--intraosseous anesthesia. A radiographic demonstra-
J Paediatr Dent. 2008;18(2):139–45. tion. Int J Oral Surg. 1983;12(5):334–9.
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60. Sharaf AA. Evaluation of mandibular infiltration versus
procedures in children. Oral Microbiol Immunol. 2009;24(3):
block anesthesia in pediatric dentistry. ASDC J Dent Child. 177–82.
1997;64:276–81. 64. Ashkenazi et al. Effect of computerized delivery intraligamental
61. Brannstrom M, Lindskog S, Nordenvall KJ. Enamel hypoplasia injection in primary molars on their corresponding permanent
in permanent teeth induced by periodontal ligament anesthesia tooth buds. Int J Paediatr Dent. 2010;20:270–5.
of primary teeth. J Am Dent Assoc. 1984;109(5):735–6. 65. Gray M. Local analgesia in paedodontics. Br Dent J.
62. Roberts GJ, Simmons NB, Longhurst P, Hewitt PB. Bacterae- 1994;177(10):366.
mia following local anaesthetic injections in children. Br Dent J. 66. Ram D, Peretz B. Reactions of children to maxillary infiltration
1998;185(6):295–8. and mandibular block injections. Pediatr Dent. 2001;23:343–6.
63. Sonbol H, Spratt D, Roberts GJ, Lucas VS. Prevalence, inten-
sity and identity of bacteraemia following conservative dental
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131 8
Pharmacologic Behavior
Management (Sedation –
General Anesthesia)
Dimitrios Velonis, Dimitrios Emmanouil, and Keira P. Mason
Contents
References – 151
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132 D. Velonis et al.
dentist to apply restrictive behavioral management In minimal sedation patients respond to verbal com-
techniques and this was preferred for reducing seda- mands, while respiratory and circulatory functions are
tion needs. Today, however, the majority of pediatric unaffected and reflexes are mildly reduced.
dentists refrain from restrictive methods in favor of
pharmacologic behavioral management. Following this
8 increased use of sedation and general anesthesia (GA),
such training has become a critical component of the
curriculum of postgraduate pediatric dentistry training
programs [1].
Eye Catcher
.. Table 8.1 Level of CNS sedation [2] (older terms appear in parentheses)
Level of sedation
Minimal sedation Moderate sedation (conscious Deep sedation General anesthesia
(anxiolysis) sedation)
Patient Pt. responds to Pt. responds to verbal or light Pt. responds only after repeated No pt. response even to
response to verbal stimuli tactile stimuli (e.g., touch), eyes or painful stimuli, difficult to painful stimuli
stimuli usually closed arouse
Breathing – Not affected Adequate Potentially inadequate Usually inadequate
Airway No intervention needed Intervention may be needed Intervention needed
Cardiovascular Not affected Usually adequate Usually adequate Potentially inadequate
function
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Pharmacologic Behavior Management (Sedation – General Anesthesia)
133 8
In moderate sedation, patients respond to verbal lation have not been established [10]. Greece prohibits
commands. There is minimal risk of airway compromise, the use of oral or nitrous oxide sedation by dentists in
and cardiovascular functions are usually unaffected. a dental practice setting. The Association for Dental
In deep sedation there is partial or total loss of pro- Education in Europe (ΑDΕΕ) has issued sedation guide-
tective reflexes, and patients are not easily aroused but lines for dental graduates from European dental schools
will respond to persistent verbal or painful stimuli. [11]. According to these guidelines, every dental gradu-
Spontaneous breathing may be compromised and open ate should have a minimum background on pharma-
airway support may be needed. Cardiovascular function cologic behavioral management of both children and
is usually stable; however, the risks during deep sedation adults. A recent resolution of the European Dentists
are similar to those of general anesthesia. Council used an evidence-based approach to propose
In general anesthesia protective reflexes are com- the training and use requirements for nitrous oxide in
pletely lost and patients require airway support. dental practices. In order to comply with European
Cardiovascular function is affected and physiologic guidelines and for achieving conformity, it is upon the
monitoring is needed. dental schools and continued education providers to
The most important element of the new guidelines provide such training and upon the legislators to pro-
is the introduction of the term “rescue.” Transition vide the legal framework.
from one stage of sedation to the next is always pos- Preferences by dentists and acceptance by patients
sible; therefore, all personnel must be appropriately and their parents also vary across the globe. For exam-
trained and certified to prevent and treat complications, ple, in many dental offices in the USA and Canada, cer-
and decrease, or reverse the sedation if needed. Adverse tified dentists or dentists-anesthesiologists administer
and unfortunate incidents have been reported in several deep sedation for potentially difficult and painful proce-
countries during dental sedation, even at doses which dures, such as impacted third molar extractions.
were deemed within safe dosing limits [3, 4]. Several In contrast, deep sedation is not used in dental offices
associations, the American Academy of Pediatric in the UK, as it is considered equivalent to general
Dentistry included, have now updated guidelines. [2, 4] anesthesia. Differences also exist for the preferred route
of administration (. Fig. 8.2). While rectal administra-
Sedation Acceptance and Preferences in Different tion of midazolam is not the method of choice in the
Countries In the United States (USA), sedation has UK and the USA, it is widely used in the Scandinavian
been used for dental procedures for many years. 82% of countries. The use of restraints during sedation is also
pediatric dentists, members of the American Academy of not uniformally accepted nor adopted worldwide. The
Pediatric Dentistry, reported using sedation in more than use of papoose board and wrap is still used during seda-
10% of their patients [5]. Nitrous oxide/oxygen inhala- tion in the USA and is generally accepted by parents
tion sedation is used widely by 3/4 of pediatric dentists and approved by the AAPD, but it is legally forbidden
and more than half of general dentists [5, 6]. Similar to in the UK and Scandinavian countries [8, 12].
findings in the USA, 75% of pediatric dentists worldwide
reported using nitrous oxide/oxygen inhalation sedation
alone or in combination with other drugs [7]. The same
sample of pediatric dentists estimated that 10–20% of
children could benefit from pharmacologic behavioral
management. In some dental schools, these sedation tech-
niques are a component of the undergraduate dental cur-
riculum [6].
In Europe there is a lack of uniformity in sedation
training and teaching. In Sweden, nitrous oxide/oxy-
gen sedation has been used since 1979. Appropriately
trained dentists administer the sedatives (most often
oral or rectal midazolam) and nitrous oxide/oxygen
inhalation sedation to patients classified as ASA I and
ASA II [8]. In the United Kingdom (UK), 28% of the
National Health Service (NHS) dentists reported using
sedation [9]. In Italy, sedation is administered by a
trained dentist or anesthesiologist, but comprehensive .. Fig. 8.2 Oral administration of midazolam mixed with juice by
training and certification requirements as well as legis- needleless syringe (courtesy of Dr. J. Veerkamp)
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Pharmacologic Behavior Management (Sedation – General Anesthesia)
141 8
the gas flow with the tidal volume. Total liters flow per be associated with an increased risk of adverse events
minute (L/min) is adjusted depending on the size and [34]. For safety reasons, the dentist should always be
age of the child. The reservoir bag should be approxi- accompanied by assisting personnel. At least one staff
mately 2/3 full. Children aged 2–3 years (14 kg weight) member must be present in the treatment room at all
may be started with a flow under 3 L/min, increasing times during the administration of nitrous oxide and the
the flow to 4 L/min at age 4 (20 kg), to 5 L/min at age 6 patient should never be left unattended.
(28 kg), and almost 6 L/min above 10 years old (>40 kg) Generally, N2O should not be used as a substitute
[21]. Children need to be instructed to breathe properly. for local anesthesia. N2O actually anesthetizes the soft
Observing the movement of the reservoir bag is essential tissues, creates minimal discomfort from the injection,
to monitor breathing. and is highly recommended. However, to avoid any local
Once the volume of gas flow has been established anesthesia discomfort, some clinicians take advantage
(about 2–3 minutes of oxygen), titration of gases for of the N2O analgesic properties and perform minor
sedation commences. procedures, like class I cavity restorations, without local
The use of the rubber dam also helps with proper anesthesia [35].
breathing. Once the dam is in place, mouth breathing is
difficult and nasal breathing is easier (. Fig. 8.7).
8.2.1.3 Monitoring
There are two methods to initially administer nitrous Clinical observation of the patient’s responsiveness,
oxide to children: color, respiratory rate, and rhythm is adequate monitor-
(a) Standard Titration Technique ing for N2O/O2 sedation. Answering questions provides
an indication that the patient is breathing. No other
The standard titration technique (also known as slow monitoring is required except in cases that an additional
titration technique or slow induction technique) is used pharmacologic agent is used [4].
by many dentists for adults and older children. The tech-
nique begins slowly with 100% oxygen. After 2–3 min- 8.2.1.4 Contraindications
utes, gases are adjusted to approximately 20% N2O and N2O/O2 sedation cannot be used to control the behavior
80% oxygen. Every 1–2 min, the gas ratio is altered. The of hysterical or defiant children with whom the dentist
N2O level is increased about 10% and the oxygen flow cannot communicate. These children will not accept a
is lowered concomitantly. The total gas flow, which was nasal mask or cooperate adequately in order to inhale
established at the outset, is maintained. Often, gas is the nitrous oxide.
titrated near a 1:1 ratio for the injection and rubber dam Common cold, upper respiratory infections (URI) or
procedures and then decreased to about 30%. At the end bronchitis, allergies, hay fever, and any condition which
of the procedure, 100% oxygen should be delivered for might lead to nasal blockage and prevent a child from
at least 3–5 minutes. This is specifically important while sufficiently inhaling N2O, are also contraindications.
treating children as they de-saturate rapidly [4]. As N2O Administering N2O to a child with a middle ear infec-
is 34 times more soluble than nitrogen in blood, diffu- tion may cause a painful increase in middle ear pressure
sion hypoxia may occur. The patient may be discharged and result in a ruptured eardrum. To patients with bowel
when returning to normal (pre-sedation) levels of con- obstruction, it may lead to expansion of gas with readily
sciousness and has regained normal speech and gait [32]. apparent adverse consequences. Other areas of trapped
(b) Rapid Induction Technique gas may not be so clinically apparent; patients who have
undergone recent retinal surgery may have intraocular
An alternative method for N2O administration is the gas that may expand during N2O administration, lead-
rapid induction technique [33]. Similar to the standard ing to intraocular hypertension and irreversible loss of
titration technique, rapid induction begins with oxygen. vision [36].
After 1–2 minutes, the gas is delivered at 50% N2O and N2O can be safely administered to patients with
50% oxygen. It is maintained at this level for 5–10 min- bronchial asthma and other forms of chronic obstruc-
utes, and once injections have been given and a rubber tive pulmonary disease (COPD), because it is nonirritat-
dam placed, the N2O level is decreased and the oxygen ing to the bronchial and pulmonary tissues. Increased
is increased. This technique is most appropriate for stress can lead to an asthmatic attack; therefore, nitrous
the very young child or the highly anxious patient as it sedation can be helpful. Exception is a small subset
allows the clinician to deal with the behavior faster. of patients with severe pulmonary disease who utilize
During nitrous oxide/oxygen analgesia/anxiolysis, hypoxic drive (lack of oxygen) to stimulate breathing,
the concentration of N2O should not routinely exceed rather than the normal mechanisms mediated by carbon
50%. At concentrations greater than 50%, N2O may dioxide accumulation. These patients reflect a relative
cause deep sedation which in general has been found to contraindication to the use of N2O.
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142 D. Velonis et al.
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Pharmacologic Behavior Management (Sedation – General Anesthesia)
143 8
8.2.2 Moderate Sedation with Other Drugs all benzodiazepines, exerts its clinical effect by bind-
ing to the GABA receptor complex which facilitates
Sedative drugs may be administered by oral, inhala- the action of the inhibitory neurotransmitter gamma-
tion, rectal, submucosal, intramuscular, or intravenous aminobutyric acid [44]. It is most commonly adminis-
routes. Oral sedation is regarded by many dentists to tered to children orally at a dose 0.3–1 mg/kg (usually
be the simplest and most convenient sedation method 0.5 mg/kg) or rectally (0.3–0.4 mg/kg) with a maximum
for managing the un-cooperative child patient. It is easy dose of 10–12 mg. Intravenous and intramuscular dose
to administer and there is no need for nasal hood or is usually 0.2 mg/kg. It is administered for minimal or
injection. conscious sedation or for short-term diagnostic pro-
cedures. A suitable volume of the injectable form may
8.2.2.1 Benzodiazepines be mixed with sweetened juice to improve the flavor,
Benzodiazepines are the most widely used drugs for for oral administration at the corresponding dosage
minimal/moderate sedation. Most commonly used ben- (. Fig. 8.9). Midazolam is rapidly absorbed in the gas-
zodiazepines are midazolam and at a lesser degree diaz- trointestinal tract and produces its peak effect in 30 min
epam [15, 20]. They have sedative-hypnotic, anxiolytic, with a short half-life of 1.5 h. This makes it a desirable
amnesic, and anticonvulsant effects. Their mechanism drug for short procedures [45]. The anterograde and ret-
of action is inhibitory activation of the GABA receptor rograde amnesia after midazolam is another advantage
complex, similar to N2O. of midazolam [46]. This has been questioned because
Diazepam (Valium), used to be a very common oral the amnesic effect mainly affects explicit memory, but
sedation agent but due to its slow onset of action (1 hour) leaves implicit memory intact.
and long period of elimination (50% in 24–48 hours), There are issues though with inter-individual varia-
has been substituted by midazolam [43]. tion of effects and its elimination that are highly dose-
Midazolam is today the most popular water-soluble dependent as well as post-procedure agitation, which
fast and short-acting benzodiazepine. Midazolam, like occurs in 17% of pediatric patients pre-medicated with
d e
Cl
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144 D. Velonis et al.
midazolam (0.3–0.5 mg/kg) [47]. Because of the possibility 8.2.2.2 Other Drugs and Combination
of paradoxical reactions to midazolam, personnel must be Antihistamines such as hydroxyzine and promethazine
trained to reverse midazolam sedation by administration have a mild sedative effect along with antiemetic prop-
of flumazenil, a benzodiazepine antagonist. The dosage is erties and are historically reported to have been used
0.01 mg/kg weight preferably intravenously, but can also either alone or in combination with other drugs and
be administered intramuscularly or submucosally. N2O [20].
Clinical Case Presentation – Comprehensive Dental Treatment Under Sedation with a Combination of Oral
and Inhaled Drugs in a Pediatric Hospital-Based Dental Clinic
A 4-year-9-month-old patient presented for emergency weight was 12 kg. He had no known drug or food aller-
treatment with lower right quadrant swelling and bloody gies and was hospitalized 1 year prior for 4 days for pneu-
exudate from his tooth for 1 week. He had already been monia and dehydration. He reportedly ate very little
placed on oral antibiotics by the pediatrician. Clinical food, which was limited to juice and pizza topping.
and radiographic exam revealed dentoalveolar abscess A comprehensive treatment plan was designed to
associated with his mandibular first right primary molar address his dental treatment needs. Completion of the
8 (. Fig. 8.10). As the patient had had a negative experi-
treatment plan can be viewed in . Fig. 8.10 and took
ence with dental treatment in the year prior and did not place in 11 appointments over a 7-month period. He
cooperate for the treatment plan before, he was planned would only cooperate for radiographic exam under seda-
for emergency extraction of this tooth on the same day tion. Following the initial emergency tooth extraction
with oral midazolam (5 mg) and nitrous oxide sedation. under sedation and passive restraint, restorative treat-
Informed consent for the procedure, passive restraint, ment of teeth of upper left quadrant was done under
and the sedation were obtained. Preoperative assessment Valium, Vistaril, and nitrous oxide sedation, and all other
and nil per os (NPO) status were confirmed and recorded. restorative sessions were completed with nitrous oxide
His medical history was significant for failure-to-thrive, sedation alone. No sedation was needed for band fitting,
mild intermittent asthma (cold and exercise induced), taking alginate impressions, and for cementation of the
gastroesophageal regurgitation disease, and mild anemia space maintainers.
for which he was on medications. On his last complete The prognosis for this child in general is good. His
blood count (CBC), hemoglobin (Hg) was 11.3 g/dl. His oral hygiene improved dramatically. Arch space was man-
.. Fig. 8.10 Comprehensive dental treatment under sedation showing caries disease status and progress of dental treatment
with a combination of oral and inhaled drugs in a pediatric over a 7-month period. In the right, intraoral photographs at
hospital-based dental clinic. In the left, periapical radiographs the recall visit after completion of the treatment plan
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Pharmacologic Behavior Management (Sedation – General Anesthesia)
145 8
aged adequately. The prognosis was guarded for pulpoto- completed, albeit with modifications, but in the end the
mized mandibular first left primary molar that showed child’s behavior was successfully modified. Although
root resorption and had to be monitored. He no longer treatment in one visit under GA should be considered
had complaints from his mouth and his eating habits had and presented in such extensive cases, parental informed
also improved to include more food groups. Gradually consent is the decisive point. Treatment under GA may or
his behavior and cooperation improved. He was Frankl 4 may not improve behavior [48–50]. This child was treated
at the last recall. He also did very well at that time for between 2003 and 2004. At that time esthetic posterior
intraoral photographs and radiographs without sedation. crowns were not as developed or widely used, and diaze-
He had gained almost 8 kg in 1.5 years. pam (but also opioids and chloral hydrate) was used
Overall evaluation. This was a challenging case that more than nowadays. The authors present this case also
illustrates the differences in treating this child in several to point out that during the last 10–15 years procedural
visits with sedation in the office, as opposed to complet- sedation for dental treatment utilizes more often mid-
ing all dental treatment in one session under general azolam and nitrous oxide sedation instead of diazepam
anesthesia. It took 7 months for the treatment plan to be and opioids, and that polypharmacy is to be avoided.
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able to have a duplicate set of instruments and equip- .. Fig. 8.12 Dental unit and portable x-ray unit, prepared before
ment as reserve. the procedure
emotionally challenging. Preparation of the child and and 8.14). A nasal or oral intubation is preferable for
parent by the dental and medical team is very impor- dental treatment; a laryngeal mask is usually not com-
tant. A rule of thumb is that when children fall asleep patible with the access needed for safe dental treatment
crying, they awake the same way [53]. Most anesthesi- (. Fig. 8.15). The usual mixture of anesthetic gases is
ologists prefer that the parent accompany the child into comprised of N2O, Ο2, and sevoflurane. The dental team
the operating room until induction of anesthesia, reduc- during induction is on standby and ready to approach
ing separation anxiety for both the parent and the child with the dental equipment and proper adjustment of the
[46, 53]. A study suggests that parental presence during operating bed [54].
induction of GA is helpful only with a calm parent and
an anxious child, and not helpful when both parent and 8.3.2.3 Dental Treatment
child are both either calm or anxious [54]. After the anesthesiologist secures the patient’s airway
Many anesthesiologists use pre-induction sedation and gives approval, the dentist(s) can proceed with tak-
with midazolam or ketamine, administered 15–20 min- ing dental radiographs if required (. Fig. 8.16). The
utes prior to separation from parents for maximum dentist and a sterile assistant prepare the patient for the
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Pharmacologic Behavior Management (Sedation – General Anesthesia)
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.. Fig. 8.13 a. Induction of general anesthesia with inhalation of .. Fig. 8.14 a. Administration of anesthetic gases to child in
anesthetic gases. b. Child falling asleep . Fig. 8.11 and b. assisted ventilation with the bag valve. Child is
dental treatment, and the perioral area is cleansed with methodically executed, usually by quadrant. The mouth
a sterile 10 × 10cm gauze soaked in povidone iodine, fol- is kept open with the use of a mouth prop (. Fig. 8.17).
lowed by one soaked in sterile water or saline solution. Minor oral surgical procedures can also be per-
The patient’s head is draped with folded sterile towels, formed. Dental extractions preferably could be sup-
typically clamped together with towel clips (mosquitos) plemented with local anesthesia [51, 55]. The dentist
or hemostatic forceps, leaving a triangular space around must inform the anesthesiologist about the time, type,
the mouth. The throat pack is then placed tightly into route, and quantity of local anesthetic to be used (pre-
the pharyngeal space behind the soft palate and around emptive analgesia) and should regularly communicate
the tube. The time and presence of throat pack place- information on progress of the procedure and expected
ment are recorded. This throat pack prevents escape time of completion. When all restorative and surgical
of materials into the pharynx, or trachea, and should procedures have been completed, fluoride varnish is
be inspected continuously during the procedure and applied to all teeth. The oral cavity and the pharynx
kept as clean and dry as possible by the assistant with are thoroughly inspected for foreign bodies. The throat
the suction. With the throat pack in place, a thorough pack is carefully removed and the time recorded.
intraoral and dental exam and procedure can be per- Following extubation, the patient is then transferred
formed. Intraoral examination findings are recorded, to the post-anesthesia care unit (PACU), where recovery
and together with the radiographs (if taken), a final from the GA is monitored. The parents are reunited with
treatment plan is formulated. The treatment plan is their child and are discharged after specific criteria are met.
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Pharmacologic Behavior Management (Sedation – General Anesthesia)
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a b
c d
e f
.. Fig. 8.17 a. Placement of a throat pack. b. Comprehensive oral tube is notable. e, f. Advantages of working under GA, isolation of
exam. The mouth is kept open with the use of a mouth prop. c. two quadrants
Restorative treatment with rubber dam isolation. d. Nasotracheal
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150 D. Velonis et al.
Because of the extensive restorative needs of the patient and The dental prognosis is fair. Caries control with
the lack of ability for cooperation in the dental clinic, it was parental education and participation was initiated,
decided that the oral rehabilitation be performed under dietary modifications, fluoride application at home and
GA. All stages of family preparation and preoperative exam- the dental office, and behavioral management to promote
ination were completed as described in previous paragraphs. future cooperation without adjuvant medications.
a b
c d
e f
.. Fig. 8.18 Dental treatment in the OR of a 20-month-old still unerupted) including PMC placement on maxillary first
boy with severe early childhood caries (ECC). a. Starting an IV primary molars. d. Short lingual frenum (ankyloglossia). e. Lin-
line. b. Oral tracheal intubation. Nasal tracheal intubation was gual frenectomy. f. Immediate postoperative view after extrac-
not possible due to anatomic restrictions. c. Restorative treat- tion of maxillary incisors and fluoride varnish application
ment without rubber dam isolation (second primary molars are
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Pharmacologic Behavior Management (Sedation – General Anesthesia)
151 8
8.4 afety Concerns About Sedation or
S References
General Anesthesia
1. Casamassimo PS, Wilson S, Gross L. Effects of changing U.S.
parenting styles on dental practice. Pediatr Dent. 2001;24:18–22.
During the past 15 to 20 years, a significant number of 2. American Society of Anesthesiologists. Practice guidelines for
adverse events and deaths have been reported in children sedation and analgesia by non-anesthesiologists. Anesthesiol-
2–17 years old who received dental treatment under ogy. 2002;96:1004–17.
sedation or general anesthesia. This has sparked a grow- 3. Coté CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey
C. Adverse sedation events in pediatrics: a critical incident anal-
ing concern of the public about the safety of such pro-
ysis of contributing factors. Pediatrics. 2000;105:805–14.
cedures. Recent articles like the one that appeared in the 4. Coté CJ, Wilson S. Guidelines for monitoring and Management
NY Times [57] highlight these issues and propose a set of Pediatric Patients before, during, and after sedation for diag-
of important questions that the parents should ask the nostic and therapeutic procedures: update 2016. Pediatr Dent.
dentist prior to any treatment plan that includes seda- 2016;38:13–39.
5. Houpt M. Project USAP 2000--use of sedative agents by
tion or GA.
pediatric dentists: a 15-year follow-up survey. Pediatr Dent.
One study presented 95 cases that developed serious 2002;24:289–94.
complications following sedation for dental or other 6. Adair SM, Rockman RA, Schafer TE, Waller JL. Survey of
medical treatment and reported that in 57% of the cases behavior management teaching in pediatric dentistry advanced
there was permanent brain damage or death. In these education programs. Pediatr Dent. 2002;26:151–8.
7. Wilson S, Alcaino EA. Survey on sedation in paediatric den-
cases, the etiology was overdose of sedatives or anesthet-
tistry: a global perspective. Int J Paediatr Dent. 2011;21(5):
ics and polypharmacy, i.e., use of multiple drugs with 321–32.
or without nitrous oxide/oxygen at the same time [58]. 8. Klingberg G. Pharmacological approach to the management of
Other causes were taking sedatives at home before treat- dental anxiety in children--comments from a Scandinavian point
ment, medications administered by staff without proper of view. Int J Paediatr Dent. 2002;12:357–8.
9. Morgan CL, Skelly AM. Conscious sedation services provided in
training and experience, premature discharge, and the
secondary care for restorative dentistry in the UK: a survey. Br
choice of drugs with narrow therapeutic range (chloral Dent J. 2005;198:631–5; discussion 625.
hydrate, phenobarbital, promethazine). An important 10. Zanette G, Robb N, Facco E, Zanette L, Manani G. Sedation in
observation in this study was that adverse events were dentistry: current sedation practice in Italy. Eur J Anaesthesiol.
noted even in cases where the right choice of drugs and 2007;24:198–200.
11. Plasschaert AJM, Holbrook WP, Delap E, Martinez C, Walms-
dosage has been made, at the fault of insufficient moni-
ley AD. Association for Dental Education in Europe. Profile
toring or emergency management. and competences for the European dentist. Eur J Dent Educ.
Another study estimated that the risk of death fol- 2005;9:98–107.
lowing intravenous administration of sedative medica- 12. Chadwick BL, Hosey MT. Child taming: how to manage chil-
tions is 1 in 300.000 [59]. Regarding GA, death risk was dren in dental practice. Series: Quintessentials of dental practice,
Vol. 9. 2nd ed. United Kingdom: Quintessence Publishing; 2017.
higher before 1980 (estimated at 1:5000), that is, before
13. Integrated National Board Dental Examination (INBDE).
the wide use of pulse oximetry and capnography. More https://www.ada.org/en/jcnde/inbde. Accessed 10 Jan 2019.
recently, death risk with GA was estimated by some 14. American Society of Anesthesiologists. Standards and Guide-
investigators at 1 in 100,000 cases for Europe, USA, and lines. ASA physical status (2014). https://www.asahq.org/
Australia [60]. Parental acceptance for treatment under standards-a nd-g uidelines/asa-p hysical-s tatus-c lassification-
system. Accessed 9 Jan 2019.
GA seems to be also culture related (higher in the USA
15. American Academy of Pediatric Dentistry. Guideline for Moni-
[61], low in Jordan and Greece [62, 63]). toring and Management of Pediatric Patients During and After
In conclusion, those that deliver dental treatment Sedation for Diagnostic and Therapeutic Procedures. 2018–2019.
under sedation or GA must have proper training and Pediatr Dent. Reference Manual. 2018;40:6.
certification and strictly adhere to all guidelines and 16. Green SM, Krauss BS, Mason KP. Reevaluating fasting for pro-
cedural sedation. JAMA Pediatr. 2018;172:622.
recommendations with respect to procedure selection,
17. American Academy of Pediatric Dentistry. Guideline on use
drug selection, risk assessment, and choice of sedation of nitrous oxide for pediatric dental patients. Pediatr Dent.
or anesthetic technique. Procedural sedation is a vital 2016;39(6):273–7.
part of the behavior management continuum. Every 18. Kupietzky A, Tal E, Shapira J, Ram D. Fasting state and epi-
day thousands of children are sedated safely all over sodes of vomiting in children receiving nitrous oxide for dental
treatment. Pediatr Dent. 2008;30:414–9.
the world. Still in weighing the option to use procedural
19. Hosey MT. UK National Clinical Guidelines in pediatric den-
sedation, we must strive to achieve a standard of “zero tistry. Managing anxious children: the use of conscious sedation
tolerance” for adverse outcomes. in paediatric dentistry. Int J Paediatr Dent. 2002;12:359–72.
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20. Hallonsten A-L, Jensen B, Raadal M, Veerkamp J, Hosey MT, oxide in a hospital-based pediatric dental clinic: a pilot study. J
Poulsen S. EAPD Guidelines on Sedation in Paediatric Den- Can Dent Assoc. 2007;73:615.
tistry. https://www.eapd.eu. 2005. 42. Gupta K, Emmanouli D, Sethi A. 2021. Use of nitrous oxide-
21. Emmanouil D, Kupietzky A. Nitrous oxide/oxygen inhala-
oxygen inhalation sedation in the COVID-19 era. Int J Paedi-
tion sedation in children. In: Wright GZ, Kupietzky A, editors. atr Dent. 2021. Letter to the editor. E-pub ahead of print DOI:
Behavioral management in dentistry for children. Chichester, https://doi.org/10.1111/ipd.12745.
UK: John Wiley & Sons; 2014. p. 145–58. 43. Creedon RL, Dock M. Pharmacological Management of patient
22. Wright AJ. History of anesthesia: early use of nitrous oxide. Bull behavior. In: Mc Donald RE, Avery DR, editors. Dentistry for
Anesth Hist. 1999;17:10–1. the Child and Adolescent. 8th ed. St. Louis.: Mosby; 2004.
23. Jevtović-Todorović V, Todorović SM, Mennerick S, Powell S, p. 297–324.
Dikranian K, Benshoff N, Zorumski CF, Olney JW. Nitrous 44. Blumer JL. Clinical pharmacology of midazolam in infants and
oxide (laughing gas) is an NMDA antagonist, neuroprotectant children. Clin Pharmacokinet. 1998;35:37–47.
and neurotoxin. Nat Med. 1998;4:460–3. 45. Bhatnagar S, Das UM, Bhatnagar G. Comparison of oral mid-
24. Emmanouil DE, Quock RM. Advances in understanding the azolam with oral tramadol, triclofos and zolpidem in the seda-
actions of nitrous oxide. Anesth Prog. 2007;54:9–18. tion of pediatric dental patients: an in vivo study. J Indian Soc
25. Hornbein TF, Eger EI, Winter PM, Smith G, Wetstone D, Smith Pedod Prev Dent. 2012;30:109–14.
KH. The minimum alveolar concentration of nitrous oxide in 46. Kain ZN, Hofstadter MB, Mayes LC, Krivutza DM, Alexander
man. Anesth Analg. 1982;61:553–6. G, Wang SM, Reznick JS. Midazolam: effects on amnesia and
26. Guedel AE. Inhalation anesthesia—a fundamental guide. The anxiety in children. Anesthesiology. 2000;93:676–84.
Macmillan Company; 1937. 47. Dahmani S, Brasher C, Stany I, Golmard J, Skhiri A, Bruneau B,
27. Langa H. Relative analgesia in dental practice; inhalation anal- Nivoche Y, Constant I, Murat I. Premedication with clonidine is
8 gesia with nitrous oxide. Saunders. 1968;
28. Gillman MA, Lichtigfeld FJ. Pharmacology of psychotropic
superior to benzodiazepines. A meta analysis of published stud-
ies. Acta Anaesthesiol Scand. 2010;54:397–402.
analgesic nitrous oxide as a multipotent opioid agonist. Int J 48. Cantekin K, Yildirim MD, Cantekin I. Assessing change in
Neurosci. 1994;76:5–12. quality of life and dental anxiety in young children following
29. Roberts GJ. Inhalation sedation (relative analgesia) with oxy- dental rehabilitation under general anesthesia. Pediatr Dent.
gen/nitrous oxide gas mixtures: 1. Principles Dent Update. 2014;36(1):12E–7E.
1990;17:139–42, 145–6. 49. Fuhrer CT, Weddell JA, Sanders BJ, Jones JE, Dean JA, Tom-
30. Galeotti A, Garret Bernardin A, D’Antò V, Ferrazzano GF, Gentile lin A. Effect on behavior of dental treatment rendered under
T, Viarani V, Cassabgi G, Cantile T. Inhalation conscious sedation conscious sedation and general anesthesia in pediatric patients.
with nitrous oxide and oxygen as alternative to general anesthesia Pediatr Dent. 2009;31(7):492–7.
in Precooperative, fearful, and disabled pediatric dental patients: a 50. Kupietzky A. Blumenstyk. A comparing the behavior of chil-
large survey on 688 working sessions. Biomed Res Int. 2016:1–6. dren treated using general anesthesia with those treated using
31. Clark MS, Brunick AL. Handbook of nitrous oxide and oxygen conscious sedation. ASDC J Dent Child. 1998;65(2):122–7.
sedation. 3rd ed. St. Louis: Mosby; 2008. 51. Gazal G, Bowman R, Worthington HV, Mackie IC. A double-
32. Jastak JT, Orendurff D. Recovery from nitrous sedation. Anesth blind randomized controlled trial investigating the effectiveness
Prog. 1975;22:113–6. of topical bupivacaine in reducing distress in children follow-
33. Simon JFJ, Vogelsberg GM. Behavior management in dentistry ing extractions under general anaesthesia. Int J Paediatr Dent.
for children. In: Wright GZ, editor. . Philadelphia: W.B. Saun- 2004;14:425–31.
ders Co.; 1975. p. 177–96. 52. Rashewsky S, Parameswaran A, Sloane C, Ferguson F, Epstein
34. Babl FE, Oakley E, Seaman C, Barnett P, Sharwood LN. High-con- R. Time and cost analysis: pediatric dental rehabilitation with
centration nitrous oxide for procedural sedation in children: adverse general anesthesia in the office and the hospital settings. Anesth
events and depth of sedation. Pediatrics. 2008;121:e528–32. Prog. 2012;59:147–53.
35. Hammond NI, Full CA. Nitrous oxide analgesia and children’s 53. Zuckerberg AL. Perioperative approach to children. Pediatr Clin
perception of pain. Pediatr Dent. 1984;6:238–42. N Am. 1994;41:15–29.
36. Lockwood AJ, Yang YF. Nitrous oxide inhalation anaesthesia in 54. Kain ZN, Caldwell-Andrews AA, Maranets I, Nelson W, Mayes
the presence of intraocular gas can cause irreversible blindness. LC. Predicting which child-parent pair will benefit from paren-
Br Dent J. 2008;204:247–8. tal presence during induction of anesthesia: a decision-making
37. Flippo TS, Holder WD. Neurologic degeneration associated
approach. Anesth Analg. 2006;102:81–4.
with nitrous oxide anesthesia in patients with vitamin B12 defi- 55. Anand P, Wilson R, Sheehy EC. Intraligamental analgesia for
ciency. Arch Surg. 1993;128:1391–5. post-operative pain control in children having dental extractions
38. Onody P, Gil P, Hennequin M. Safety of inhalation of a 50% under general anaesthesia. Eur J Paediatr Dent. 2005;6:10–5.
nitrous oxide/oxygen premix. Drug Saf. 2006;29:633–40. 56. American Academy of Pediatric Dentistry (2012) Policy on
39. Rowland AS, Baird DD, Weinberg CR, Shore DL, Shy CM, Pediatric Pain Management. Pediatr Dent Reference Manual.
Wilcox AJ. Reduced fertility among women employed as dental 2016;39(6):99–101.
assistants exposed to high levels of nitrous oxide. N Engl J Med. 57. Saint Louis C. 2017. Should Kids Be Sedated for Dental Work?
1992;327:993–7. New York Times https://www.nytimes.com/2017/08/24/well/fam-
40. Henry RJ, Primosch RE. Courts FJ the effects of various dental ily/should-kids-be-sedated-for-dental-work.html. Accessed 10
procedures and patient behaviors upon nitrous oxide scavenger Jan 2019.
effectiveness. Pediatr Dent. 1992;14(1):19–25. 58. Coté CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey
41. Freilich MM, Alexander L, Sándor GKB, Judd P. Effectiveness C. Adverse sedation events in pediatrics: analysis of medications
of 2 scavenger mask systems for reducing exposure to nitrous used for sedation. Pediatrics. 2000;106:633–44.
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59. Vaughan GG, Jarnigan TK, Montgomery MT. Morbidity and 62. Alammouri M. The attitude of parents toward behavior man-
mortality associated with the pharmacologic management of agement techniques in pediatric dentistry. J Clin Pediatr Dent.
pain and anxiety. Compendium. 1993;14:752, 754–6, 758. 2006;30:310–3.
60. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Hel- 63. Boka V, Arapostathis K, Vretos N, Kotsanos N. Parental accep-
sinki declaration on patient safety in Anaesthesiology. Eur J tance of behaviour-management techniques used in paediatric
Anaesthesiol. 2010;27:592–7. dentistry and its relation to parental dental anxiety and experi-
61. Eaton JJ, McTigue DJ, Fields HW. Beck M attitudes of contem- ence. Eur Arch Paediatr Dent. 2014;15:333–9.
porary parents toward behavior management techniques used in
pediatric dentistry. Pediatr Dent. 2005;27(2):107–13.
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155 9
Growth of the Craniofacial
Complex
Fernando Pugliese, Anastasios A. Zafeiriadis, and Mark G. Hans
Contents
References – 175
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9.1 Introduction
ate size of the forehead becomes reduced. As the whole face expands, the frontal, maxillary, and
The childhood face appears quite broad. As develop- ethmoidal sinuses enlarge significantly. The mandible of
ment continues, vertical facial growth overtakes expan- the young child is still quite small in actual size, but also
sion in width to a marked extent, so that a relatively proportionately, relative to the upper jaw and the face in
narrower facial proportion characterizes the adult [2]. general, as it normally lags behind the maxilla in early
The nasal bridge is quite low in the child resulting in a growth. However, it will usually grow twice as much as
“pug nose.” It develops to a greater or lesser extent in the maxilla during puberty allowing it to “catch up” to
different facial types to become more prominent in most the maxilla in young adulthood. So it is sometimes dif-
adults. The eyes of the infant seem quite wide-set with ficult to predict during early childhood possible maloc-
a broad-appearing nasal bridge separating them. This clusions that might or might not become fully expressed
is because the nasal bridge is so low, and also because during later development. The chin is poorly formed in
much of the width of the bridge has already been the infant and gradually becomes more prominent year
attained in the infant. by year, because of remodeling changes that take place.
The infant and young child have a nose that pro- The young child’s mandible appears to be pointed as it
trudes very little with a short vertical dimension. The is wide, short, and more “V”-shaped. In the adult, the
shape and size of the infantile nose, however, give little entire lower jaw becomes more anatomically diverse.
indication as to what will happen to it during subse- The development of the chin, together with massive
quent growth. The lower part of the nose in the adult growth in the lateral areas of each ramus, expansion
is proportionately much wider and a great deal more of the masticatory musculature, and flaring of the
prominent. In the adult, the midface has become greatly gonial regions, leads the whole lower face to take an
expanded, and the nasal floor has descended well below “U”-shaped configuration, resulting in a considerably
the orbital floor. This change is quite marked because of more full appearance. In the infant and young child, the
the enormous enlargement of the nasal chambers. Note gonial region lies well inside (medial to) the cheekbone.
also the close proximity of the young child’s maxillary In the adult, the posterior-inferior corner of the man-
arch and orbit, in contrast to their positions in the adult dible extends laterally out to the cheekbone or nearly so.
(. Fig. 9.1).
This gives the posterior part of the jaw a square appear-
While the cheekbone is prominent in early child- ance (. Fig. 9.2).
hood, it is nonetheless quite diminutive and fragile com- The ramus of the adult mandible is much longer ver-
pared with that of the adult. The malar process and the tically. It is also more upright at the junction between the
inferior part of the zygoma enlarge considerably during corpus and the ramus. Increases in vertical height of the
childhood growth, even though the actual growth is in rami accommodate the vertical expansion of the nasal
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Growth of the Craniofacial Complex
157 9
is occupied by a vast magazine of unerupted teeth hid-
den to the eyes [4]. The thin covering and supporting
bone of the jaws is a much less commanding feature of
the young face.
>>Important
55 The growth of the brain slows considerably after
about the third or fourth years of childhood, but
the facial bones continue to enlarge markedly for
many years.
55 As development continues, vertical facial growth
overtakes expansion in width to a marked extent,
.. Fig. 9.2 Square appearance of the posterior part of the jaw. so that a relatively narrower facial proportion
(From Enlow and Hans [3] with permission) characterizes the adult.
55 The mandible of the young child is still quite small
in absolute size, but also proportionately, rela-
region and the eruption of the upper and lower perma- tive to the upper jaw and the face in general, as it
nent teeth. The premaxillary region normally protrudes normally lags behind the maxilla in early growth.
beyond the mandible in the infant and young child and However, it will usually grow twice as much as the
lies in line with, or forward of, the bony tip of the nose. maxilla during puberty allowing it to “catch up”
This gives a prominent appearance to the upper jaw and to the maxilla in young adulthood.
lip. In subsequent facial development, however, the nose
becomes much more protrusive, and the tip of the nasal
bone comes to lie well ahead of the basal bone of the 9.2 renatal Facial Growth
P
premaxilla. and Development
The anterior surface of the bony maxillary arch in
the infant has a vertically convex topography in contrast The “head” of a 4-week-old human embryo is mostly
to the concave contour of this region in the adult. The just a brain covered by a thin sheet of ectoderm and
adult maxillary alveolar bone is noticeably more pro- mesoderm. The location of the mouth is marked by a
trusive and proportionately more massive (in conjunc- tiny depression, the stomodeum. The eyes have already
tion with the permanent dentition). The whole face, begun to form by a thickening of the surface ectoderm
vertically, is longer and more sloping as a result of the (the future lens), which meets an out-pouching from the
changes outlined above. At birth, the overall length of brain (the future retina). The eyes are still located at the
the cranium is approximately 60–65% complete, and it sides of the head, however (. Fig. 9.3). As the brain con-
increases rapidly. By 5 years old, it reaches about 90% tinues to grow and expand, the eyes rotate toward each
of its full size. In addition, much of the adult width other and toward the midline of the future face. This
of the cranium is attained by the first or second year. reduces the interorbital dimension, but only relatively,
In the newborn, six fontanelles (“soft spots”) are pres- as everything is actually increasing in size (. Fig. 9.4).
ent between the bones of the skull roof. They become As the whole head expands, the thin membrane that
covered at different times, but all have been reduced covers the stomodeum soon ruptures, and the pharynx
to sutures by the 18th month. In the child, the slender opens to the outside. The pharynx is the anterior-most
neck below a relatively large cranium, particularly in the segment of the endodermally lined, embryonic gut. Its
occipital region, gives a characteristic youthful appear- lumen is bounded on the right and left sides by the pha-
ance to the whole head. This gradually disappears (to a ryngeal (or visceral) arches. Between the arches are the
greater or lesser extent) until about puberty, when the pharyngeal clefts on the outside and the pouches on the
expansion of the neck muscles and other soft tissues inside. Where each cleft meets its pouch, a mesoder-
causes a proportionate decrease in the prominence of mally reinforced contact between ectoderm and endo-
the head relative to neck circumference, less noticeably derm occurs. All these arches and some of the clefts and
in females. pouches develop into specific adult structures in the face,
The external appearance of the baby’s face hides the head, and neck. The tissues in each arch develop into
truly striking enormity of the dental battery developing specific muscles, bones, and cartilages, and the arrange-
within it. When a crown tip first erupts, the parent natu- ment in the adult is carried forward from the pattern
rally believes that the process is just beginning and that that exists in the embryo. Each arch has a specific cranial
the tooth is only a tiny, but newsworthy, addition to the nerve which services the structures deriving from that
pink mouth. They do not realize that the whole midface particular arch (. Fig. 9.5).
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158 F. Pugliese et al.
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Growth of the Craniofacial Complex
159 9
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160 F. Pugliese et al.
so years of age, these surfaces characteristically become and lining the surface of a bone is actually carried out
resorptive. Through fetal life and the early part of child- by the membranes and other surrounding tissues rather
hood, however, they remain depository, as the bony than by the hard part of the bone.
maxillary and mandibular arches must expand sagit- All the various resorptive or depository growth fields
tally to accommodate the dentition [3]. Sometime before throughout a bone do not have the same rate of growth
about 5 or 6 years of age, however, the outer surfaces activity. Some fields grow much more rapidly, or to a
of the forward part of both the maxilla and mandible much greater extent, than others. Fields that have some
become resorptive. Subsequent lengthening of the bony special significance or noteworthy role in the growth
arch then proceeds only posteriorly. The characteristic process are often termed growth sites, such as the man-
postnatal resorptive fields in the anterior parts of the dibular condyle (. Fig. 9.11). During remodeling, the
arches develop in conjunction with their continuing ver- extent of bone deposition usually slightly exceeds that
tical growth (. Fig. 9.9).
of resorption so that the regional parts of a bone gradu-
ally enlarge as they remodel.
Remodeling is a basic part of the growth process
9.3 Concepts of the Growth Process as the “drift” moves each regional part from one loca-
tion to another as the whole bone enlarges. This calls
Bones grow by adding new bone tissue on one side for sequential remodeling changes in the shape and size
of a bony cortex toward the direction of progressive of each region. The ramus, for example, moves progres-
growth and undergoing resorption on the other side. sively posteriorly by a combination of deposition and
This growth process is termed “drift.” The outside and resorption. The whole ramus is thus relocated posteri-
inside surfaces of a bone are completely blanketed by a orly, and the posterior part of the lengthening corpus
mosaic-like pattern of “growth fields.” The outside sur- becomes relocated into the area previously occupied
face, however, is not all depository, as one might pre- by the ramus. This progressive, sequential movement
sume. About half of the periosteal surface of a whole of component parts as a bone enlarges is termed “area
bone has a characteristic arrangement of resorptive relocation” (. Fig. 9.12).
fields; a characteristic pattern of depository fields covers The same deposition and resorption which produce
the remainder. If a given periosteal area has a resorp- the overall growth enlargement of a whole bone carry
tive type of field, the opposite (endosteal) surface of out relocation and remodeling at the same time. Growth
that same area has a depository field and vice versa and remodeling are, in fact, inseparable parts of the same
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Growth of the Craniofacial Complex
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.. Fig. 9.13 Palate inferiorly relocated. (From Enlow and Hans [3]
.. Fig. 9.11 Mandibular condyle as a growth site. (From Enlow and with permission)
Hans [3] with permission)
contact with the cranium. The whole maxillary region is
displaced downward and forward away from the cranium
by the expansive growth of the soft tissues in the mid-
facial region. Displacement triggers new bone growth at
the various sutural contact surfaces between the naso-
maxillary composite and the cranial floor. Displacement
thus produces downward and forward growth by bone
deposition simultaneously taking place in an opposite
upward and backward direction (. Fig. 9.15).
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162 F. Pugliese et al.
.. Fig. 9.14 Displacement (or translation) process. (From Enlow and Hans [3] with permission)
9.4 Bone and Cartilage and it also grows interstitially by cell divisions of chon-
drocytes and by increases in the intercellular matrix.
Because of the unique nature of its intercellular matrix, Together with the noncalcified matrix, and the absence of
cartilage is a rigid and firm tissue, but it is not hard. vessels, these various features combine to allow the car-
Cartilage provides three basic functions. It gives flexible tilage to function and to grow in areas of direct pressure
support in appropriate anatomic places (the nasal tip, [7]. Because it can exist without a covering membrane, it
ear lobe, thoracic cage, tracheal rings); it is a pressure- is suited to articular surfaces, synchondroses, and epiph-
tolerant tissue located in specific skeletal areas where yseal plates; because it can expand interstitially, carti-
direct compression occurs (such as articular surfaces lage can thereby grow even without a membrane. As its
of joints); and it functions as a “growth cartilage” matrix is noncalcified, diffusion of substances can take
in conjunction with certain enlarging bones (e.g., a place through it and cell divisions are possible. Because
synchondrosis, condylar cartilage, epiphyseal plate). there are no vessels to press closed, cartilage is pressure-
adapted and can grow where compression exists because
of its noncalcified, interstitial expansion features.
Eye Catcher Unlike cartilage, which is usually under compres-
sion, bone is tension-adapted [8]. Bone must have a
Cartilage is a nonvascular connective tissue that is
vascular, osteogenic covering soft tissue, and it can only
normally noncalcified. Vascularization and calcifica-
grow appositionally. Bone cannot grow directly in heavy
tion, however, are involved as steps in the replacement
pressure areas as its growth is dependent upon a sen-
of cartilage tissue by bone tissue in a normal embryo-
sitive, vascular membrane. Bone needs a membrane in
logic process called endochondral bone formation.
order to support its internal vascular system, which in
turn is essential because the matrix is calcified and will
not allow diffusion of oxygen and other substances to
Cartilage usually has a perichondrium, but it can exist and from cells. Once an osteocyte is encased in a calci-
without this covering membrane. Cartilage grows appo- fied matrix, it cannot grow by cell division, meaning that
sitionally by the activity of its chondrogenic membrane, a bone cannot grow interstitially.
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Growth of the Craniofacial Complex
163 9
.. Fig. 9.15 Downward and forward maxillary displacement. (From Enlow and Hans [3] with permission)
In terms of embryologic origin, bones are formed and remodeling process. The whole membrane, as a
intramembranously (directly from mesenchymal stem sheet, undergoes extensive fibrous changes in order to
cells) in tension areas and endochondrally (formed first sustain constant connections with the bone by means of
in cartilage then converted to bone) in pressure areas. collagenous fiber continuity from the membrane into the
“Growth cartilages” take part in the latter ossification matrix of the bone. As fibers in the membrane become
process. They provide for the linear growth of a bone enclosed within the new bone deposits, the membrane-
toward the direction of pressure. As interstitial carti- produced fibers become incorporated as bone fibers.
lage expansion provides pressure-adapted growth on the This is accompanied by fibrous remodeling within the
pressure side of the cartilage plate, an equal amount of membrane to provide continuity between membrane
cartilage is removed and replaced by bone on the other and bone fibers. The membrane grows outward rather
side. The remainder of the bone, including all its cortical than just backing off as bone is laid down by it. The
plates, grows by membranous ossification in conjunc- movements of muscle attachments along remodel-
tion with the periosteal and endosteal membranes. ing surfaces of bones and the insertion of muscles on
The membranes associated with bone (periosteum, resorptive bone surfaces are also carried out by this
sutures, periodontium) have their own internal growth membrane remodeling and relinkage process.
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164 F. Pugliese et al.
The structure, dimensions, angles, and placement of the chondral (medullary fine-cancellous) bone is laid down
various facial parts are affected by the size, shape, and by the endosteum within each bone. Compact cortical
growth of the basicranium. The neural side of the cranial (intramembranous) bone is formed around this core
floor requires an entirely different mode of development of endochondral bone tissue. The interior of the sphe-
compared to the calvaria because of its topographic noid bone eventually becomes hollowed to form the siz-
complexity and the tight curvatures of its fossae. The able sphenoidal sinus, which is formed secondarily and
endocranial surface of the basicranium is characteristi- enlarges progressively.
cally resorptive in most areas, because of the multiple Disturbances in synchondrosal growth, such as
directions of enlargement and the complex magnitude of achondroplasia, result in significant shortening of the
remodeling required. Fossa enlargement is accomplished cranial base, while growth of the calvaria and mandible
by direct remodeling, involving deposition on the outside is largely unaffected [10]. Normal basicranial growth
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Growth of the Craniofacial Complex
165 9
>>Important
55 As the brain expands, the separate bones of the
calvaria are correspondingly passively displaced
in outward directions, through the soft tissue stro-
mata attached to them.
55 Three synchondroses are operative during the
fetal and early postnatal periods: the intersphe-
noidal, the sphenoethmoidal, and the spheno-
occipital synchondrosis.
55 The spheno-occipital synchondrosis ceases growth
activity at about 12–15 years of age. Its presence
provides for the elongation of the midline portion
of the cranial floor by endochondral ossification.
depends on genetically coded biologic processes occur- the backward-facing periosteal surface of the tuberos-
ring within the cartilage cells of the synchondrosis. ity receives continuing deposits of new bone as long as
However, although there is some intrinsic growth capac- growth in this part of the face proceeds. The arch also
ity in the basicranium, extrinsic control factors are also widens, and the lateral surface is, similarly, depository.
required. In contrast, the calvaria largely depend on the The endosteal side of the cortex within the interior of
growth of the brain and its surrounding endocranial the tuberosity (the maxillary sinus) is resorptive. The
and ectocranial matrix for growth control. cortex thus relocates progressively posteriorly and also,
As the middle and anterior cranial fossae become to a lesser extent, in a lateral direction with the maxillary
enlarged, the nasomaxillary complex is carried along sinus increasing in size as a result.
anteriorly with the floor of the anterior cranial fossa
from which it is suspended. At about 5 or 6 years of age,
frontal lobe growth and anterior cranial fossa expansion
are largely complete [11]. Therefore, any further develop-
mental protrusion of the forehead is a result of thickening
of the frontal bone and enlargement of the frontal sinus
within it. The temporal lobe and middle fossa, however,
continue to enlarge for several more years, and ongoing
expansion of each temporal lobe continues to displace
the frontal lobe forward, with this, in turn, causing ten-
sion in the osteogenic suture systems between these two
areas. The anterior fossae and the maxillary complex are
carried anteriorly by the frontal lobes, which are moved
forward because of temporal lobe enlargement behind
them. Each anterior cranial fossa enlarges in conjunc-
tion with the expansion of the frontal lobes. Wherever
sutures are present, they contribute to the increase in
the circumference of the bones involved. Thus, the sphe-
nofrontal, frontotemporal, sphenoethmoidal, fronto-
ethmoidal, and frontozygomatic sutures all participate
in a closely coordinated, traction-adapted bone growth
response to brain and other soft tissue enlargements.
The bones all become primarily displaced “away” from .. Fig. 9.17 Maxillary tuberosity remodeling. (From Enlow and
each other as a consequence. Hans [3] with permission)
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166 F. Pugliese et al.
Eye Catcher
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Growth of the Craniofacial Complex
167 9
.. Fig. 9.20 Ethmomaxillary complex downward displacement. (From Moyers and Enlow [14] with permission)
9.6.3 Downward Maxillary Displacement associated soft tissues, and all of the alveolar sockets as
the entire maxilla is displaced downward as a unit [15].
The primary displacement of the whole ethmomaxil-
lary complex in an inferior direction (. Fig. 9.20) is
>>Important
accompanied by simultaneous remodeling (resorption 55 The maxillary tuberosity is a major “site” of max-
and deposition) in all areas, inside and out, throughout illary growth. It is growth in this area that creates
the entire nasomaxillary region. New bone is added at space for eruption of the molar teeth.
the frontomaxillary, zygotemporal, zygosphenoidal, 55 The whole maxilla undergoes a simultaneous
zygomaxillary, ethmomaxillary, ethmofrontal, naso- process of primary displacement in anterior and
maxillary, nasofrontal, frontolacrimal, palatine, and inferior directions as it grows and lengthens pos-
vomerine sutures resulting in displacement of the bones. teriorly and superiorly.
As the bones of the ethmomaxillary region are dis-
placed downward by the expanding soft tissues, sutural
bone growth takes place at the same time in response to 9.7 Growth of the Mandible
this, thus enlarging the bones as the soft tissues continue
to develop. 9.7.1 The Ramus
The downward movement of the teeth is accom-
plished by a vertical drift of each tooth in its own In terms of anatomy, the significance of the ramus of
alveolar socket as the socket itself also drifts inferi- the mandible is mostly that it provides an attachment
orly with it in lock-step by deposition and resorption. base for masticatory muscles, which, of course, com-
Simultaneously, there is a passive carrying of the maxil- prises a basic function. However, the critical remodel-
lary dental arch as a whole, the palate and bony arch, all ing and adjustments in ramus alignment, vertical length,
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168 F. Pugliese et al.
and anteroposterior breadth also provide an ever- 9.7.3 The Mandibular Condyle
changing fit with the growing maxilla and the limitless
structural variations of the face. Of course, it is not the This is an anatomic part of special interest because it
bony ramus itself that does this job, but its osteogenic, forms the articulation for the mandible and as such
chondrogenic, and fibrogenic connective tissues receiv- determines, at least in part, the relationship between the
ing local input control signals that produce its adjustive upper and lower teeth. Although the majority of the
shape and size through time. mandible is formed by intramembranous ossification,
The ramus is remodeled in a generally postero- the portion of the bony mandible that is derived from
superior manner while the mandible as a whole becomes condylar cartilage is endochondral in origin. During
displaced anteriorly and inferiorly, allowing posterior mandibular development, the condyle functions as a
lengthening of the corpus and dental arch. The posterior regional field of growth that provides an adaptation for
development of the mandibular bony arch simultane- its own localized growth circumstances, just as all the
ously proceeds by remodeling into the region previously other regional fields accommodate their own particular
occupied by the ramus. What was formerly ramus is con- localized growth conditions.
verted into what then becomes the mandibular corpus, The condylar growth mechanism itself is a clear-
which is thereby lengthened by this remodeling process. cut process. As seen in . Fig. 9.22, the endochondral
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Growth of the Craniofacial Complex
169 9
pressure-tolerant articular contact and has a multidi- 9.7.4 Ramus Uprighting
mensional growth capacity in response to ever-changing,
developmental conditions. Depending on where in the The ramus normally becomes more vertically aligned
condylar cartilage mitotic divisions occur, that part of during its development. As long as it is actively growing
the condyle (and ramus) thereby proliferates more verti- in a posterior direction, this is accomplished by greater
cally or more posteriorly, as determined by input signals amounts of bone addition on the inferior part of the pos-
that are related to both the demands of the dynamic and terior border than on the superior part (. Fig. 9.23). A
static articulation of the teeth and the architectonic pat- correspondingly greater amount of matching resorption
tern of “fitting” among the multitude of craniofacial on the anterior border takes place inferiorly rather than
parts. superiorly. A “remodeling” rotation of ramus alignment
The rate and directions of condylar growth are thus occurs. Condylar growth becomes directed in a
presumably subject to the influence of extracondylar more vertical course along with the rest of the ramus.
agents, including intrinsic and extrinsic biomechani- Vertical lengthening of the ramus continues to take
cal forces and physiologic inductors, e.g., functional place after horizontal ramus growth slows or ceases.
movement of the mandible. One hypothesis is that This is to match the continuing vertical growth of the
increased amounts of pressure on the cartilage serve to midface. To achieve this, condylar growth may become
inhibit the rate of cell division and proliferation, while more vertically directed, and a different pattern of ramus
decreased amounts of pressure appear to stimulate and remodeling can also become operative (. Fig. 9.24).
accelerate growth. Moreover, the nature of the condy- The direction of deposition and resorption reverses. A
lar stimulus is more complex than simple forces acting forward growth direction can then occur in some indi-
directly on the condyle; rather, nerve-muscle-connec- viduals on the anterior border in the upper part of the
tive tissue pathways are involved, and the changes coronoid process. Resorption takes place on the upper
utilize a composite of such tissue responses and chain part of the posterior border. A posterior direction of
feedbacks with the condyle as well as the other parts remodeling takes place in the lower part of the poste-
of the mandible also participating. Sensory nerve rior border. The result is a more upright alignment and a
input from the periodontal membranes and from the longer vertical dimension of the ramus without a mate-
soft tissue matrix throughout the face picks up stimuli rial increase in breadth. This remodeling change, when it
that are passed on via motor nerves to muscles that, in occurs, appears to be more marked when the backward
turn, alter the displacement and the positioning of the relocation of the ramus, to provide for corpus lengthen-
mandible, which then affects the course of growth and ing, has decreased. There are probably other relation-
remodeling by the condyle and all other areas of the ships involved as well, including different facial and
growing mandible. headform types, although the biologic basis is presently
The condyle, of course, plays an important role not fully understood.
in mandibular growth [17]. It is directly involved as a The ramus undergoes a remodeling alteration in
unique regional growth site; it provides indispensable which its angle becomes changed in order to retain
latitude for adaptive growth; it provides movable articu- constant positional relationships between the upper
lation; it is pressure tolerant and provides a means for
bone growth (endochondral) in a situation in which
ordinary periosteal (intramembranous) growth would
not be possible. It is not just the condyle, however, that
participates as the key component; the whole ramus is
directly involved. The ramus bridges the pharyngeal
compartment and places the mandibular arch in an
occlusal position with the maxillary arch. The horizon-
tal breadth of the ramus determines the anteroposterior
position of the lower arch, and the height of the ramus
accommodates the vertical dimension and growth of
both the nasal and masticatory components of the mid-
face. The dimensions and morphology of the ramus are
directly involved in the attachments of the masticatory
muscles, and the ramus must accommodate their growth
.. Fig. 9.23 The ramus normally becomes more vertically aligned
and size. It is the growth and development of the whole during its development, with greater amounts of bone additions on
ramus, not merely the condyle, that accomplishes these the inferior part of the posterior border than on the superior part.
multiple and basic ends. (From Enlow and Hans [3] with permission)
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170 F. Pugliese et al.
and lower arches. Otherwise, development among all .. Fig. 9.25 Lateral cephalometric x-ray
the diverse parts involved at different times, to differ-
ent degrees, and in different directions would result in 9.8 Cephalometrics
a marked misfit between the upper and lower jaws. The
composite of vertical growth changes of the mandibular Broadbent et al. [18] published a landmark paper describ-
dentoalveolar arch, the ramus, and the middle cranial ing the invention of a new kind of oriented radiograph
fossae must match the composite of vertical nasomaxil- of the human skull. This radiograph was unique in one
lary growth changes to achieve a continuing facial bal- important way. It was a standardized lateral and frontal
ance. Any differential will lead to a displacement type of view of the human skull. The standards set forth in this
mandibular rotation, either downward and backward or paper remain in use today. The evaluation of physiologi-
forward and upward. Normal variations of facial type cal growth and its variants, together with its possible
and headform pattern are a common basis for such diversions, similarly with the base of the skull and the
mandibular rotations. anatomical structures of the viscerocranium, depends
heavily upon the design and analysis of a cephalometric
>>Important x-ray [19]. The most commonly used type for the evalu-
55 The lingual tuberosity is a major site of growth ation of the sagittal and vertical relationships of the
for the mandible just as the maxillary tuberosity anatomical structures of the craniofacial complex is the
is a major site of growth for the upper bony arch. lateral cephalometric x-ray (. Fig. 9.25). The frontal
55 Although the majority of the mandible is formed x-ray, which evaluates the relationships on a lateral axis,
by intramembranous ossification, the portion of is rarely used.
the bony mandible derived from condylar carti- Today, cephalometrics, the detailed analysis of
lage is endochondral in origin. cephalograms, the standardized x-rays, is used in three
55 The horizontal breadth of the ramus determines important ways by practitioners interested in facial
the anteroposterior position of the lower arch, growth. First, it allows longitudinal study of facial
and the height of the ramus accommodates the growth both in the absence and presence of orthodon-
vertical dimension and growth of both the nasal tic treatment. Second, it provides a vocabulary of
and masticatory components of the midface. terms to describe the morphology of the human face
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Growth of the Craniofacial Complex
171 9
and jaws, and third, it provides five pieces of informa- The practitioner needs to know if the anatomic features
tion useful for orthodontic diagnosis and treatment of the patient are normal or abnormal with respect to
planning. These five elements that all orthodontists these parameters. The plan for treatment then follows.
derive from a combination of the clinical examination For the analysis of a cephalometric x-ray, guiding points
and the lateral cephalometric radiograph are as fol- are placed on drawings of anatomical elements that are
lows: displayed in the cephalometric x-ray [19, 20]. This process
can be down by hand on special transparent paper or dig-
itally with the help of computer software (. Fig. 9.26).
.. Fig. 9.26 Digital tracing of a cephalometric x-ray prepared with Viewbox® cephalometric software (dHAL Software, Kifisia, Greece)
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172 F. Pugliese et al.
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Growth of the Craniofacial Complex
173 9
factors combine to place the upper and lower teeth in lies mesially to the normal position. This is largely a
such a way that: skeletally based type of occlusal variation.
1. There is no undue amount of overjet. There is a developmental and structural relationship
2. All the teeth interdigitate perfectly, cusps fitting the among these separate systems of classification (shape of
grooves of antagonist teeth. the whole skull, the facial profile, and occlusion) [21].
3. There is no undue amount of overbite; the maxillary In individuals with a dolichocephalic head form,
front teeth do not overlap and cover the mandibular the brain is horizontally long and relatively narrow.
front teeth by more than about one-third the crown This sets up a cranial base that is flatter, as the flexure
height of the lower incisors. between the medial and anterior cranial floors is more
4. The maxillary canine is about one-half tooth width open. The whole nasomaxillary complex is thus placed
distal to the mandibular canine. in a more protrusive position relative to the mandible
5. The mesiobuccal cusp of the maxillary first molar because of the horizontally longer cranial floor. It is
occludes with the mesiobuccal groove of the man- also lowered relative to the mandibular condyle, causing
dibular first molar (approx. One-half cusp behind). a downward and backward rotation of the entire man-
The overall mandibular arch length is shorter than dible. Finally, the occlusal plane becomes rotated into
maxillary arch length in the normal occlusion and a downward-inclined alignment. These factors result in
the more posterior positioning of the maxillary a tendency toward mandibular retrusion and a Class II
molars accommodates the larger size of the upper molar relationship. The profile tends to be retrognathic
incisors. Normal differences also exist in root align- (. Figs. 9.27, 9.28). However, compensatory changes
ment, the incisor roots tip lingually, the canine roots may sometimes affect this.
tip distally, and the molar and premolar roots are Individuals with a brachycephalic head form have
essentially vertical. a rounder and wider brain. This sets up a cranial base
that is more upright and has a more closed flexure,
The majority of the population, in fact, does not have which decreases the effective horizontal dimension of
“normal” dentition. Most have a kind of malocclusion the middle cranial fossa. The result is a relative retrusion
which falls into one of the three general categories. This of the nasomaxilla and a more forward relative place-
system was first devised by Edward Angle and is thus ment of the entire mandible. This causes a greater ten-
called the Angle Classification [29]. The Class I maloc- dency toward a prognathic profile and a Class III molar
clusion is the least severe type, and it mainly involves relationship. The occlusal plane as well as the ramus
dental variations from the ideal. The molar relation- of the mandible may be aligned upward, but various
ship is normal, and disharmonies usually concern the
crowding of anterior teeth. The profile is usually good,
although a few millimeters of retrognathia may nor-
mally be present. Overjet is not excessive. A variation of
the Class I occlusion involves “bimaxillary protrusion”:
proclination of both the upper and lower incisor regions.
This gives a noticeably “full” appearance to the mouth.
The Class II malocclusion is skeletally as well as den-
tally based. The various bones cause a positioning of the
teeth in such a way that a “Class II molar relationship”
exists. The maxillary first molar lies either directly over
or in front of the mandibular first molar, rather than
slightly behind, where it should be. In the most common
variety (Division 1) of the Class II type of malocclusion,
the maxillary incisors are protrusive with excessive over-
jet, and the profile is distinctly retrognathic. In another
variety (Division 2), however, overjet is not pronounced,
but a deep bite with palatally inclined incisors is pres-
ent, and sometimes the lateral maxillary incisors seem
to flare outward.
.. Fig. 9.27 Dolichocephalic head form, causing a downward and
The Class III malocclusion is characterized by a backward rotating of the mandible, resulting in a tendency toward
marked protrusion of the mandible, a prognathic profile, mandibular retrusion and a Class II molar relationship. (From
and a molar relationship in which the lower first molar Enlow and Hans [3] with permission)
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174 F. Pugliese et al.
.. Fig. 9.28 Dolichocephalic
head form. (From Enlow and
Hans [3] with permission)
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Growth of the Craniofacial Complex
175 9
.. Fig. 9.30 Brachycephalic
head form. (From Enlow and
Hans [3] with permission)
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177 10
Contents
References – 205
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178 A. Arhakis et al.
10.1 The Physiology of Tooth Eruption .. Table 10.1 Median age of eruption (Md) with one
standard deviation (S.D.) in months of primary teeth based
Eruption is the emergence of teeth from their devel- on a study carried out in n = 1988 Caucasian Arab children
opment position in the bone to the functional occlu- in Jordan [3]
sal position in the dental arch. This axial movement is Tooth Female
Male
divided into three phases: pre-eruptive phase, eruptive
Md S.D. Md S.D.
phase, and functional phase [1].
55 Pre-eruptive phase is observed before the beginning Maxilla
of root formation, during which the tooth germ Central incisor 10.5 0.7 10.6 0.6
moves within the tooth crypt.
Lateral incisor 12.9 0.6 13.1 0.6
55 The eruptive phase begins when the root starts to
form, while the tooth germ undergoes intraosseous Canine 20.6 0.6 19.8 0.7
and supraosseous movement until it enters the oral First molar 15.5 0.8 15.5 0.6
cavity and ends when tooth reaches occlusal plane.
Second molar 27.7 0.6 27.2 0.6
At this phase there are two substages: the first is the
intraosseous phase, followed by the extraosseous/ Mandible
preocclusal phase which starts after tooth penetra- Central incisor 8.3 0.9 8.1 0.7
tion through the alveolar process. At the end of this Lateral incisor 14.6 0.4 13.9 0.5
phase stabilization of periodontal tooth support
takes place, while root formation continues. Canine 20.9 0.6 19.8 0.8
First molar 16.1 0.8 15.8 0.6
The functional phase is the third and final phase, in which Second molar 27.7 0.5 27.2 0.6
10 the teeth move to maintain their positions of functional
occlusion and move toward the occlusal plane for some
time after reaching the initial occlusal contacts [1].
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
179 10
eruption time in the permanent dentition shows more be taken on account. Tooth eruption delay of several
pronounced variation compared to primary dentition, months in respect to its timely erupted symmetrical one
normally ranging 6–18 months. The first to erupt per- in either jaw could be related to pathology and should
manent teeth have the minimum standard deviation of be checked radiographically (e.g., tooth impaction,
their mean eruption time, whereas the later erupting odontoma, etc.). For example, an 11-year-old child
ones maxillary canines, premolars, and second perma- that had the mandibular left first premolar erupted 6
nent molars have the maximal [4, 5]. months before the contralateral tooth should have a
Following the normal distribution of eruption times radiographic examination if there is no mobility in the
both for primary and permanent teeth, one or two stan- predecessor primary molar.
dard deviations are indicative of normality, as the range
is significant. For example, a clear medical and family
history for a 12-month-old boy with no erupted teeth, 10.1.2 Mechanism of Tooth Eruption
who has a bulky alveolar ridge indicative of presence
of unerupted teeth, should be simply monitored clini- Tooth eruption has caused many historical discussions.
cally. If there is a thin, potentially edentulous alveolar Various theories and opinions have been proposed
ridge or the child is older, radiological examination and about the mechanism of tοοth eruption, such as the
then general medical examination are recommended theory of hydrostatic pressure in vessels and/or tissues
(. Fig. 10.1). Symmetrical teeth usually erupt almost
[6], a theory of the role of the periodontal ligament in
simultaneously, but other possible local factors should the eruption process [7], a theory of mobility/contrac-
tion of periodontal ligament fibroblasts [8], a theory
of root formation [6], and the bone remodeling theory
[9]. According to the prevailing opinion the dental fol-
a
licle has an important role in tooth eruption. Surgical
removal of the follicle has been shown to inhibit the
eruption process. Removing the coronal portion of den-
tal follicle causes disorder of bone resorption coronally
without affecting the bone deposition in the apical por-
tion, whereas the removal of the apical portion of the
follicle reduces bone formation apically but does not
inhibit the bone resorption process coronally [10]. If the
tooth germ is replaced with an artificial tooth in an oth-
b
erwise intact dental follicle, the artificial tooth still moves
toward the eruption position [9, 11]. These data suggest
that the dental follicle contributes to the eruption pro-
cess during the intraosseous phase, but does not explain
the continued extraosseous phase of eruption. After
the emergence of the crown of the tooth through the
alveolar bone, the enamel organ degenerates, becomes
thinner, and is known as reduced enamel epithelium
(. Fig. 10.2). The fusion of the reduced enamel epithe-
c
lium with the epithelium of the oral mucosa allows the
penetration of the erupting tooth without causing trau-
matic discontinuity of the oral mucosa [12].
The influence of innervation on tooth eruption
has been evaluated in experimental studies through an
epithelial-mesenchymal interaction with the epithelial
rests of Malassez [13, 14]. Kjær proposed a new eruption
mechanism based on previous work, stating that the eti-
ology behind the eruption process is that an innervation-
provoked pressure in the apical part of the tooth results
in an eruption that requires continuous adaptation from
the periodontal membrane and the active movement of
.. Fig. 10.1 a By clinical evaluation, a 3-year-old girl is suspected
to have congenital absence of maxillary lateral incisors. b Radio- the crown follicle, destroying overlying bone tissue [15].
graphic assessment reveals delayed development and eruption of lat- This attributes the process to the membrane covering
eral incisors. c Their full eruption at the age of 4.5 years the apical part of the tooth root, the periodontal mem-
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180 A. Arhakis et al.
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
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that did not confirm the association of these symptoms
with the tooth eruption, concluding that these can be
attributed to coexisting reasons, not related with tooth
eruption [25]. An increase in body temperature up to
37.5 °C, with an absence of other clinical symptoms,
may be associated with teething. Nevertheless, higher
body temperature is not associated with tooth erup-
tion and the responsible reason should be detected by a
pediatrician [26]. Many parents report various teething
symptoms of their children, the most common of which
is oral pain.
Eye Catcher
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182 A. Arhakis et al.
Ibuprofen
structure of the enamel prisms, early eruption appears
to inhibit the normal maturation of enamel resulting in
Usual oral dosage: a tendency for abrasion and staining, as pigments enter
10 Infants and children <50 kg: 4–10 mg/kg/dose every 6–8 hours
as needed (maximum single dose 400 mg; maximum dose 40
the porous enamel texture [30]. Natal and neonatal
teeth are found in healthy neonates, but have also been
mg/kg/24 hours)
observed in 50 different syndromes [28].
Alternative dosing based on age of child Two of the most common complications associated
Age Weight Dosage with (neo)natal incisors are injury of the mother’s nip-
ple and the Riga-Fede syndrome. During breastfeeding,
lbs kg mg3
the tongue of the infant embraces the mother’s areola,
6–11 months 6–11 2.7–5 40 passing out of the alveolar crest or even out of his lips.
4–11 months 12–17 5.1–7.7 80 The infants’ suckling incorrectly, possibly in order to
avoid the painful stimulus from the tooth to the lower
1–2 years 18–23 7.8–10.5 120
surface of the tongue, creates a condition that injures
2–3 years 24–35 10.6–15.9 160 the nipple and areola of mother’s breast and making
breastfeeding painful for the mother [26]. Riga-Fede
syndrome manifests as self-injury of the top or bottom
surface of the tongue of the infant. The lesion begins
of the child and parents. Before the administration of as a simple ulcer (see 7 Chap. 20, 7 Fig. 20.7) which
systemic therapy, i.e., analgesic/anti-inflammatory, the can develop into a bulky, fibrous mass with clinical
pediatrician should exclude other medical conditions, presentation of ulcerative granuloma. The problems
not related to teething [27] (. Table 10.3).
in breastfeeding in both cases can lead to disturbances
in nutrition, reduced weight gain, and inhibition of
infant’s growth [31].
10.3 Disturbances in Tooth Eruption
Eye Catcher
10.3.1 Premature Tooth Eruption: Neonatal
Teeth Natal and neonatal teeth should not be extracted
unless they are supernumerary (requires radiographi-
According to . Table 10.1, the mandibular primary
cal confirmation) or if they create any problems for
central incisors may erupt early, e.g., at 5 months of age, the mother or the infant. In some cases, smoothening
and the eruption is considered normal. However, there of the incisal edge may prevent tongue ulceration [32].
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a b
c d
.. Fig. 10.4 a Prenatal tooth in a newborn baby. b Eruption of a neonatal mandibular incisor. c, d Neonatal tooth that needed to be
extracted appears with immature and thin hard tissues
in which there is a delay in both physical and dental For this reason, the eruption disorder also occurs in areas
development often cause delay in the emergence of the with no supernumerary teeth [37]. People with tricho-
primary and permanent dentition. Delayed eruption is dento-osseous syndrome have normal height but also
observed in at least 150 different syndromes [34]. exhibit disorders in bone remodeling (sclerotic lesions)
One often overlooked but quite common cause for with reduced osteoclastic activity. Tooth eruption may
failure of eruption is a so-called primary failure of be delayed in the permanent dentition, often leading to
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184 A. Arhakis et al.
tooth impaction [38]. Hypoplastic enamel defects are 10.3.2.2 Localized Delay in Tooth Eruption
also observed (see 7 Chap. 17). In cases with pycnodys-
Very early loss of primary teeth due to severe carious
ostosis, individuals exhibit short stature and short limbs. lesions or trauma of the anterior teeth is a common
The skeleton, including the craniofacial complex, shows cause of delayed eruption of the permanent successor.
osteopetrosis and brittleness. The increased density of Mainly in the case of trauma, this is likely to occur due
the jaw bones in combination with the intense crowding to the creation of more fibrous (scar) connective tissue
causes inhibition of tooth eruption of the permanent during healing. On the other hand, early eruption of the
dentition and other anomalies [39]. Hypohidrotic ecto- permanent successor is usual, after severe inflammatory
dermal dysplasia is mainly characterized by oligodontia; alveolar osteolysis of microbial etiology (following a
however, cases of generalized delayed eruption have also septic pulp) of the primary predecessor (. Fig. 10.8).
been reported [40]. In cases of profound delay, regardless of the cause, the
Children with cleidocranial dysplasia, tricho-dento- treatment plan may include surgical exposure and wait-
osseous syndrome, and pycnodysostosis, who exhibit ing for either self or orthodontically assisted eruption
great eruption delay, should be closely monitored from (. Fig. 10.9). Another relatively common cause of
an early age. The treatment is especially complicated delayed tooth eruption in healthy children is supernu-
and is based on surgical extractions of supernumerary merary teeth. Αdditionally, the presence of odontomas
teeth and exposing and assisting eruption of unerupted is almost always related to inhibition of the eruption
teeth as part of a long-lasting orthodontic treatment. of permanent teeth and orthodontic anomalies (see
Delayed eruption and impaction of permanent teeth 7 Chap. 17).
are observed in the absence of syndromes, sometimes Ankylosis of primary teeth, due to trauma in anterior
related with systemic diseases. Probably these conditions teeth or due to poorly understood reasons in posterior
are related to osteoblast/osteoclast malfunction mecha- teeth, may cause delayed eruption of the permanent suc-
10 nisms that have not been clarified (. Figs. 10.6 and 10.7).
cessor. Crown or root dilaceration and partial or com-
Terms used include ‘primary failure of eruption’, usually plete inhibition of root formation as consequences to
referring to single teeth in the molar area, and ‘tooth erup- trauma or inflammation of primary teeth may delay or
tion delay’. The therapeutic approach may be simply mon- inhibit the eruption of permanent incisors [41]. Differ-
itoring or, in some cases, similar to the above mentioned. ent types of cysts in the anterior or posterior region may
b
c
a
d e f
.. Fig. 10.5 a Initial examination of cleidocranial dysplasia in a the chief complaint. e Greatly delayed dental age and supernumerary
13-year-old boy. b Confirmation of hypoplastic clavicles in chest maxillary incisors. f Surgical exposure and extraction of two super-
radiograph. c Open sagittal suture of the skull and lack of nasal numerary and orthodontic tractions of permanent teeth in the den-
bone in anteroposterior cephalometric radiograph. d Occlusion class tal arch. (Courtesy of Dr. O. Kolokitha)
III and a small maxilla and long delayed tooth eruption, which was
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
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a b
.. Fig. 10.6 a Teeth of an 11-year-old boy with free medical history. b His panoramic radiograph shows characteristics of ‘tooth develop-
ment and eruption delay’ and ‘primary failure of eruption’ of the mandibular first molars
a b
c d
.. Fig. 10.7 a Delayed eruption of permanent teeth in an 8-year- child at age 11. Slight overeruption of the mandibular first perma-
old boy with a medical history of hydrocephalus. b Enlarged follicles nent molars 3 years after their surgical exposure. Late unassisted
of mandibular first permanent molars and possible minute folli- eruption of the opposing maxillary molars
cles of second molars in the panoramic radiograph. c, d The same
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186 A. Arhakis et al.
also inhibit normal eruption of the permanent teeth. the anterior region of the maxilla. It may cause tooth
Most commonly dentigerous and midline cysts, which impaction and root dilacerations and is treated with
appear radiographically as radiolucent lesions with a enucleation. When antineoplastic radiation is insti-
well-defined cortex, are treated usually either with enu- tuted in the craniofacial region for malignant tumors,
cleation or marsupialization [42] (. Fig. 10.10). Rarely
it may produce dental anomalies of permanent teeth
multiple dentigerous cysts with impacted teeth related to such as root formation arrest which may affect tooth
syndromes are encountered (. Fig. 10.11).
eruption [43]. Anterior teeth eruption delay may have
The presence of a benign or malignant tumor could a psychological impact due to esthetics. A profound
cause a delay in the eruption of permanent teeth. The delay in maxillary anterior teeth eruption may be
adenomatoid odontogenic tumor is a benign, epithe- accelerated with surgical removal of the overlying con-
lial, well-defined, single spaced tumor with a small nective tissue, while even a simple incision may suffice
central radiopaque nucleus. It is mainly located in at times. Surgical treatment is however rarely necessary
a b
10
c
.. Fig. 10.9 a Delayed eruption of mandibular left first permanent radiograph shows the first permanent molar in traction process 3
molar in an 8.5-year-old girl probably related to ‘primary failure of years later. The eruption failure had resulted in sharp bends of the
eruption’ [36]. b Clinical appearance after the decision for orthodon- root apices, when in close contact with the lower border of the man-
tic traction. c Surgical exposure of mandibular left second premolar dible. e Successful outcome after laborious traction and the overall
and first permanent molar for the traction of the premolar in the 4-year orthodontic treatment with extraction of two maxillary pre-
dental arch (traction of the molar will follow). d New panoramic molars. (Courtesy of Dr. I. Manoukakis)
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a b
c d
.. Fig. 10.10 a A midline cyst in the mandible of a 4.5-year-old sors at the age of 6 years. The hypoplastic labial area of the right
boy. b Ten months after enucleation of the cyst under general anes- permanent central incisor suggests early trauma (at the age of 1 year)
thesia. c, d Complete bone healing and eruption of the central inci- as a possible cause of the cyst, although there was no anamnesis
.. Fig. 10.11 Rare case of an 18-year-old girl with a phenotype of and a hypoplastic supernumerary in the left coronoid process (cour-
cleidocranial dysplasia and impaction of left maxillary canine, mul- tesy of Dr. S. Dalampiras)
tiple dentigerous cysts of premolars and molars even in the sinuses,
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188 A. Arhakis et al.
or bilateral, occurs with much greater frequency in the The maxillary permanent canines often find inad-
maxilla than in the mandible (10:1). The main cause of equate space as they usually erupt last (except perhaps
this disturbance is the disharmony of dental/osseous for the second molars), and this often leads to erup-
growth in the area. The ectopic tooth has pronounced tion delays. Moreover, they may occasionally follow an
proximal inclination with its proximo-occlusal crevice almost horizontal path of eruption becoming subject
entrapped at the disto-cervical constriction of the to impaction (frequency 1.5–2%) [45]. This should be
crown of the second primary molar, having resulted in suspected when the canines cannot be palpated labially
its pathological root absorption distally. Diagnosis is approximately 1.5 years before their normal eruption
confirmed radiologically. In many cases the eruption time or when there is a gross asymmetry in their eruption
path is spontaneously corrected and the root resorp- time (. Fig. 10.15). Impaction may be confirmed with
10 a b c
.. Fig. 10.12 a Delayed eruption of maxillary right permanent cen- lateral incisors were left to self-erupt. c Eruption and good alignment
tral incisor in an 8-year-old boy. b The radiograph does not reveal of all incisors 2 years later
any obstacle to its eruption. Maxillary right permanent central and
.. Fig. 10.13 Case of ectopic eruption of maxillary first molars in an 8-year-old boy which has self-corrected bilaterally. Distal cervical
resorptions of maxillary second primary molars occurred before self-correction
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
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.. Fig. 10.14 a Bite-wing
radiograph of a spacious a c
right-side primary dentition in a
4-year-old boy. b At age 6 years
an ectopic eruption of the
maxillary first permanent molar
is observed, along with severe
root resorption of the adjacent
second primary molar. c The
patient re-appeared 6 years later
with consequential palatal
eruption of the maxillary left
second premolar with significant b
drift of maxillary left first
premolar and first permanent
molar
a b
.. Fig.10.15 a Panoramic radiograph of a 14-year-old girl with alveolar bone in the canine region before their normal eruption time,
three impacted permanent canines, which require surgical exposure radiologic examination, and extraction of primary predecessors was
and orthodontic traction in the dental arch. b Early palpation of likely to have facilitated their proper eruption
a panoramic radiograph, and surgery with orthodontic case of palatal eruption. The treatment usually includes
traction is undertaken as described in 7 Chap. 11.
extraction of the primary predecessor and crossbite cor-
Eruption of permanent anterior teeth can be diverted rection if needed. Less often, maxillary central incisors
as a result of crowding, local inflammation, or dental erupt labially at a higher position (. Fig. 10.16).
trauma of the primary predecessor or due to the presence On the contrary, lingual eruption of mandibular
of a mesiodens or odontoma. Ectopic eruption of the max- permanent incisors is much more frequent and is associ-
illary permanent incisor usually occurs palatally and often ated with resorption limited to the lingual root surface
causes an anterior crossbite. Parents should be informed of primary predecessors and their prolonged stay in the
during the routine recalls being observant of the eruption dental arch. Since these are the first permanent teeth to
position of maxillary incisors and seek early treatment in erupt, this condition alerts parents. The extraction of
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190 A. Arhakis et al.
.. Fig. 10.16 a Ahead of time appearance of left permanent central resorption of the primary predecessor seen in the radiographic
incisor in a labial ectopic location in a 7-year-old girl. b This, together image, suggests inflammation due to old lateral laxation trauma as
with the severe discoloration, inclination, and lack of apical root the cause for the anomalous eruption path of the permanent incisor
ment of the ectopic incisors. In cases of anterior crowd- dimensional—radiograph by the absence of periodontal
ing, extraction of adjacent primary anterior teeth is not space, depending on the extent and location of patho-
recommended because this simply postpones crowding logical findings, i.e., mesial or distal part of the root
until the adjacent permanent teeth erupt. as opposed to buccal or lingual. Very often, ankylosis
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
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.. Fig. 10.18 a, b Bilateral transposition of permanent maxillary lateral incisors and canines in a 12-year old girl
a
b
c d
.. Fig. 10.19 a Radiographic image of bilateral ankylosis and sub- posite build-up of the right and extraction of the left second primary
mergence of mandibular second primary molars in a 13-year-old molar. d Further submergence of the primary molar build-up is seen
boy. There is no permanent successor of his right one. b Clinical view 3 more years later
of occlusion at the right side. c Ideal occlusion 24 months after com-
is located in the furcation area in both primary and 10.3.3.3 Eruption Cysts
permanent molars (. Fig. 10.20). With conventional
Their appearance on the alveolar ridge is related to the
radiographs, the replacement resorption is often not vis- rupture of the dental follicle, shortly before primary or
ible; however, this can be seen on CBCT. In early anky- permanent teeth eruption. They are exhibited as soft,
losed primary molars, the crown is so infraoccluded that relatively translucent, single bluish swellings, contain-
it may become submerged into the gingiva or even the ing serous fluid and blood with inflammatory elements
alveolar bone (. Fig. 10.21). In this case, extraction is
(. Fig. 10.22). They are more frequently seen in the
the treatment of choice. This may be done under local maxilla [49]. The diagnosis is clinical, while therapeu-
anesthesia depending on patient cooperation. Many of tic intervention usually is not necessary as the condition
these cases also require interceptive orthodontics (see is self-resolved after tooth eruption. At times, biting
7 Chap. 11).
trauma by the opposing teeth causes discomfort to the
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192 A. Arhakis et al.
a b
10
.. Fig. 10.20 a Extracted ankylosed primary molar. b Radiograph of the molar tooth section shows replacement resorption in the furcation
area. This is a very common location for molar ankylosis in both primary and permanent dentition. (b: courtesy of Dr. H. Luder)
child. In this case, incision of the cyst after local anes- in order to reduce the possibility of infection in case
thesia is an effective treatment, while in case of recur- of biting trauma to the operculum. Treatment includes
rence some authors suggest marsupialization or surgical washing with chlorhexidine solution 0.2%, which may
removal [50]. be more efficacious if administered under the operculum
with a syringe. In more extensive inflammation, systemic
10.3.3.4 Inflammation Related to Eruption antibiotic administration and analgesics are necessary.
of Teeth In some cases the follicle of a slowly erupting per-
The eruption of permanent teeth may infrequently be manent tooth can develop into a cyst. This occurs
accompanied with local soft tissue inflammation. This quite often and is usually resolved spontaneously
inflammation is either purely periodontal as the pressure if there is an opening toward the oral cavity. If the
of the erupting teeth causes local disturbances of the tooth itself obturates the opening, a lateral cyst can
periodontal ligament (. Fig. 10.23) or a consequence
develop. This may need a surgical exposure/marsupi-
of pulpal necrosis due to external resorption of a pri- alization of the cyst, and a drain must be placed until
mary adjacent tooth (. Fig. 10.24). In the latter case,
there is an epithelial connection between the gingiva
extraction of the necrotic primary tooth may be indi- and the epithelium of the cyst. These cysts often look
cated. More common is pericoronitis of the last molar to like lateral periodontal defects. A scaling of the root
erupt (. Fig. 10.25). For the prevention of pericoronitis,
surface is contraindicated and would interfere with
proper brushing is indicated during the eruption stage, complete healing (. Fig. 10.26) [51].
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
193 10
a b
c d
.. Fig. 10.21 a The mandibular right second primary molar is clinically absent in a 4-year-old boy. b Εxtensive ankylosis and absence of the
periodontal space is evident radiographically in the mesial root. c Occlusal clinical view 8 months later. d Radiographically, the follicle of the
second premolar may be seen located distally of the roots of the ankylosed primary molar. e Patient had moved and appeared again 4 years
later. f Severe inclination of the mandibular right first permanent molar is observed in the OPG, requiring orthodontic uprighting, following
the extraction of the submerged ankylosed second primary molar
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194 A. Arhakis et al.
a b c
.. Fig. 10.24 a Periodontal inflammation and fistula buccal to an radiograph shows external resorption of the lateral. c. Its extraction
erupting maxillary right permanent central incisor with vital pulp. reveals the extent of resorption with pulp necrosis, apparently from
The adjacent primary lateral incisor is sensitive to percussion. b The previous pressure during eruption of the permanent central incisor
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.. Fig. 10.25 a Inflammation accompanied by pain and buccal edema in a 6-year-old girl. b Pericoronitis of the erupting mandibular left
first permanent molar probably related to biting the operculum
.. Fig. 10.26 Buccal bifurcation cyst on a slowly erupting mandib- CBCT image, an opening lateral of its crown is visible. This orifice is
ular right first molar. Clinically the symptoms were like a pericoroni- needed to be opened surgically for cyst marsupialization
tis with a hard swelling buccal to the tooth on palpation. In the
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196 A. Arhakis et al.
tion of the supporting alveolar bone. If the perma- such as neutropenia and leukemia are also associated
nent successor is absent, the root of the primary tooth with periodontal disease in children, probably because
is resorbed very slowly and it may take many years of failure of the defense mechanism against periopatho-
or several decades (. Fig. 10.27). The etiology for
genic bacteria [54]. Early loss of primary teeth is
this intermediate condition is unknown. There are the most common oral finding in hypophosphatasia
various data on the differences between the “normal” (. Fig. 10.29) [55]. In Chediak-Higashi syndrome there
root resorption of primary teeth without successors is a severe immune deficiency with periodontal disease
and the prevention of root resorption in permanent of primary dentition. Early shedding of primary teeth is
teeth. For example, there are differences in the cells also observed in Langerhans histiocytosis [56].
of the periodontal ligament, which are degraded by
metalloproteinase activity that precedes the root sur-
face resorption. Similar cells of primary teeth produce 10.4.2 Extraction and Surgical Techniques
10 more collagenase compared to those of permanent Related to Eruption
teeth and have a pronounced reaction to certain cyto-
kines such as L1a and TNF-A [52]. 10.4.2.1 Extraction of Primary Teeth
When tooth extraction is planned, this should be after
careful clinical and radiographic considerations. The
principles of extraction include expansion of the bony
socket, use of a lever and fulcrum, and insertion of a
wedge. Conical roots should be extracted using rota-
tional movement and a buccally directed movement for
removal from the socket. In multi-rooted teeth, a figure
eight movement to expand the socket should be started.
The final path of removal is toward the buccal aspect
as bone is thinner. In case of primary teeth with frag-
ile crowns or subgingival fractures after dental trauma,
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
197 10
a b
.. Fig. 10.29 a 3½-year-old patient with early tooth loss. b Lost finished. The patient was then referred to a hospital where hypophos-
teeth as collected by the mother. She reported that the teeth fell out phatasia was confirmed
spontaneously with almost no bleeding. Root formation is not even
a b c
d e f
.. Fig. 10.30 Extraction of maxillary primary central incisors with pulling motion. c Inadequate cervical grasp of the central incisor
severe cervical carious lesions undermining the crown, septic pulp leads to its coronal fracture. d, e Twisting motion of the more sub-
necrosis, and fistulae. a Good subgingival grasping of the right cen- gingivally grasped root. f The two extracted teeth
tral incisor with appropriate forceps. b Easy extraction in a twisting/
use of an elevator to lever and luxate the tooth or root perform routine maintenance of instruments. Careful
fragment from its socket and a firm grip of the forceps debridement of socket should follow the use of eleva-
is needed. An elevator will help in loosening soft tissue tors especially if bone has been fractured when used as
attachment from the tooth, luxation of teeth from the a fulcrum.
surrounding bone before the application of dental for- Anterior primary tooth extraction is a relatively easy
ceps, expansion of alveolar bone or socket, and removal procedure, because of their single conical roots. The
of broken, fractured, or retained roots or dental frag- tooth is firmly grasped, as subgingivally as possible, with
ments from their sockets. It is important to avoid exces- the appropriate forceps for primary teeth and extracted
sive forces, support the instrument to prevent injury to by combined twisting/rotation and pulling motion
adjacent structures, protect major structures, provide (. Fig. 10.30). Elevators are useful when tooth crown
adequate lighting, use a proper and stable fulcrum, and destruction goes subgingivally. Movements of the crown
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198 A. Arhakis et al.
.. Fig. 10.31 Bisection of the tooth in buccal-lingual direction effected with a long cylindrical diamond-coated bur and completed with an
elevator that is inserted into the deep cut produced
toward buccal should be avoided during the extraction of the crown. Therefore, after mandibular block anes-
10 in order not to force the apex of the primary tooth in thesia and additional buccal infiltration, bisection of
direction of the successor tooth and cause damage on the tooth is often the preferred approach, based on
its developing crown. For the same reason, it is not indi- the radiographic image. A long diamond bur is placed
cated to perform a curettage of the extraction alveolus. in a buccal-lingual direction, producing a deep groove,
Granulation tissue in this area is a reaction on the infec- where an elevator may be inserted to complete the bisec-
tion and will disappear spontaneously when the source tion (. Fig. 10.31). Removal of the two parts is then
of infection is eliminated. an easy and less stress bearing. Additionally, since the
The extraction of second primary molars with no ankylosis is often in the furcation area, the proposed
significant root resorption, especially the mandibular approach is very useful because the ankylosed area is
ones, can be very challenging and may result in loss of often removed by the bur. Extreme caution should be
child’s cooperation. This is because the mesio- distal taken to avoid injuries to the successor, which is a pos-
dimension of the roots is considerably larger than that sibility if diligence is not practiced.
Managing Ankylosed Primary Molars [57]. In this case, extraction, after adequate local anesthe-
Sometimes early ankylosed primary molars do not follow sia, is the treatment of choice. The crown of the tooth is
the eruption pattern of the adjacent teeth, and it is pos- captured with the appropriate forceps and, if needed,
sible for their crown to be submerged into the gums or with the simultaneous grip of alveolar bone cervically. In
even the alveolar bone. Conservative monitoring of most cases, where ankylosis is located in the furcation
ankylosed primary molars is recommended. The clinician area, it is useful to move the ankylosed tooth slowly in a
should consider extraction if the permanent successor bucco-lingual direction until it is disengaged by causing
has an altered path of eruption, if the ankylosed primary alveolar expansion. Less frequently, where the ankylosis
molar is severely infraoccluded with the adjacent teeth is at the root, root fractures are very likely and sometimes
tipping to prevent the successor from erupting, or both. the root will need to be extracted using a bur or by raising
The ankylosed molar often exfoliates spontaneously a surgical flap. If elevators are used to luxate ankylosed
within 6 months; however, when exfoliation is more teeth, great caution must be taken not to luxate a recently
delayed, arch-length loss, occlusal disturbance, hooked erupting neighboring tooth due to its short root and
roots, or impaction of permanent successors may occur therefore weak anchorage in the alveolar bone [58].
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
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10.4.2.2 Extraction of Structures Impeding mond or steel bur in order to preserve the surrounding
Tooth Eruption bone or teeth (. Fig. 10.32). Apparently, a multidisci-
In cases where primary or permanent teeth do not erupt plinary team including a pediatric dentist, orthodontist,
into the oral cavity, it is necessary to radiographically oral surgeon, and a periodontist in some cases can be
exclude or confirm the presence of obstacles such as involved [59].
odontomas, supernumerary teeth, or other structures. Odontomas present a severe obstacle for erupting
In the anterior region mesiodentes are quite common, teeth and they should be removed completely. Surgical
but supernumerary teeth can occur in most areas of removal (by enucleation) using a minimally invasive sur-
the dentition. If one or more obstacles are visible, it is gical technique to remove the least amount of bone tis-
important to do a proper localization of these structures sue through a mucoperiosteal flap is indicated. In case
by either a series of x-rays with different angulations or of odontomas, this may reveal a number of calcified
a CBCT. The topographic relation to all other structures small structures looking like teeth (compound odon-
must be evaluated carefully in order to plan the surgical toma) or lesions of complex odontomas with or without
removal with the least collateral damage. Ideally, they mineralized structures showing a tooth-like appearance.
should be removed when permanent teeth adjacent to Bone is removed using a low-speed dental hand-drill
the lesion exhibit about one half of their root develop- and a tungsten carbide bur until the odontoma or crown
ment to ensure no harm occurs to the normal perma- of mesiodens is exposed. In cases of compound odon-
nent teeth or interference with their eruption. Usually a tomas it is preferable to remove them together with the
flap must be raised and the structures need to be exposed intact follicle around them to make sure that all com-
by selective ostectomy with a round bur. In many cases ponents are removed and not a single little “tooth” is
it proves to be useful to dissect the crown from the left behind. Otherwise this could pose again a problem
root of an impacted tooth to be extracted with a dia- for the eruption of other teeth (. Fig. 10.33). Adjacent
a b
c d
.. Fig. 10.32 a Clinically missing maxillary right central incisor. b the first tooth to be removed with an elevator. d After further ostec-
The radiograph shows two mesiodentes, one of them horizontally. c tomy, the horizontal mesiodens was located and sectioned in two
After a flap was raised, slight ostectomy with a round bur allowed parts prior to extraction
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200 A. Arhakis et al.
a b
c d
10
.. Fig. 10.33 a Clinically missing maxillary right primary canine. b fully rinsed and inspected. d Overview of the extracted hard-tissue
Radiograph shows cloud-like radio-opaque structures. c After a flap bodies, some of them resembling tiny teeth, others more like com-
was raised and an ostectomy with a round bur, the follicle was plex odontomas
opened, the tooth-like structures were removed, and the alveola care-
teeth are seldom harmed by the excision since they are 10.5 Transplantation of Teeth
usually separated from the lesion by a septum of bone.
The patient can be treated under local anesthesia, 10.5.1 Extraction and Re-implantation
without any premedication depending on the patient’s of Permanent Teeth
behavior. The wound is carefully irrigated with physi-
ological solution and cleaned with a sterile dressing; the
After extraction or loss of a tooth, options that exist
flap repositioned and sutured with 3.0 absorbable suture
for the extraction space in a growing child may include
material [60].
replacement with a removable prosthesis, orthodontic
It has been suggested that specimens should be sent
space closure, use of the extraction space orthodonti-
for microscopic and histologic examination. Patient
cally to relieve crowding, or tooth replacement by auto-
care is specifically related to maintenance of proper
transplantation. Autotransplantation is related to the
oral hygiene including 0.2% digluconate chlorhexidine
transfer of a tooth from its alveolus to another site in the
prescription, ingestion of cold, soft meals, refrain-
same person. It is used for replacement of congenitally
ing from physical exercise/excessive physical activity
missing teeth or teeth lost due to trauma and dental dis-
during the next 48 hours, antibiotics, and pain man-
ease or those with poor prognosis after re-implantation
agement, in addition to careful future clinical and
or revascularization procedures. The recipient site may
radiographical follow-up. Later orthodontic traction
be either an extraction site or a surgically prepared
might be needed in order to guide any impacted teeth
alveolus. A donor tooth chosen for autotransplantation
into their position, especially if they have completed
should be of limited value in the dentition, e.g., a third
root formation [59].
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
201 10
molar, a premolar in a crowded arch, or a supplemental untouched, and is transplanted to the recipient area
tooth. Some tilting of the distal tooth could still occur without extraoral storage. If partial healing of a previ-
due to the size discrepancy between donor and recipi- ously extracted tooth socket had occurred, the recipi-
ent teeth (e.g., permanent molar and premolar) [61]. ent site can be prepared with a round bur. The created
Especially in cases with little space and therefore nec- alveolus should be larger than the tooth, which allows
essary orthodontic treatment, this procedure may be a the tooth to be placed without contact with the bone. If
very valid option to replace teeth and preserve esthetics the tooth is pressed against the bone, ankylosis is more
and alveolar bone. likely to occur. Once a transplanted tooth is put in place,
If it is desired to achieve revascularization of a it needs to be fixed in position. To prevent ankylosis and
transplanted tooth, the apex needs to have an opening favor revascularization, it is necessary that the splint
of at least 2 mm and the root length should be ¾ of the allows a physiological mobility. Alternatively, the tooth
expected length. If revascularization is successful, most can also be kept in place with a suture, which can be
pulp chambers will show obliteration with time, which removed after 1 week. Another important factor is the
is not a complication but a visible sign of vital tissue gingiva around a transplanted tooth: the tooth should
inside the tooth (. Fig. 10.34). Teeth with an already
be positioned in a way that allows the gingiva to cover
closed apex can also be transplanted, but because revas- the entire root surface. A tight gingival seal around
cularization is highly unlikely, a root canal treatment the tooth improves the prognosis. For this reason, it is
is necessary. This can be done orthograde prior to the often advisable to put a tooth away from the occlusion,
transplantation or retrograde during the procedure [62]. if beforehand there was an anchylosed tooth that kept
Autotransplantation is performed under local anes- the gingiva apically. Although a transplanted tooth can
thesia, and mucoperiosteal flaps are simultaneously generate bone growth, it is generally wise to implant it
raised in the donor and recipient areas. The most impor- in the bone and move it afterward orthodontically to its
tant factor for success is the extraction of the tooth to desired position. The patient is prescribed chlorhexidine
be transplanted. The donor tooth should be carefully rinse and amoxicillin for 1 week and then, clinically and
and gently extracted using a forceps (avoiding exces- radiographically reviewed at 1 week, 1 month, 3 months,
sive pressure), keeping the radicular part intact and and then every 6 months [63].
a b c
d e f
.. Fig. 10.34 a Radiography of agenesis of mandibular second pre- agenesis site. b Image immediately after transplantation. c–e Growth
molar. Because maxillary premolar extractions were necessary for of alveolar bone and root. f Increase in root length and pulp oblit-
the orthodontic treatment, it was decided to transplant one at the eration are seen after 2 years
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202 A. Arhakis et al.
Eye Catcher
factor; an apical foramen diameter greater than 1 mm
In cases of transplantations of premolars from the decreases the risk of pulpal necrosis after transplan-
maxilla into the mandible, it may be useful to implant tation, and root resorption is more frequent in trans-
the tooth in a rotated position (. Figs. 10.34 and
planted teeth with mature root development than in
10.35), because in this way the often narrow oro- teeth with immature roots [65]. On the other hand, teeth
buccal dimension of the alveolar ridge allows it better in the early stages of root development show less post-
to find enough room for the transplant, still preserv- transplant root growth than those with more mature
ing the buccal and lingual corticalis. Furthermore, roots but incompletely formed apices [66] as there is
this approach also allows often a better gingival seal a possibility of no additional root growth after trans-
after the extraction of a primary molar in that area. plantation. Transplantation of a fully formed root will
require adequate endodontic therapy to ensure high sur-
vival rates [61].
Upon follow-up, radiographic examination of the auto-
transplanted tooth should reveal continued root growth,
no signs of root resorption, and intact lamina dura. 10.5.2 Transplantation of Teeth Anteriorly
Also, there can be partial pulp obliteration in the trans-
planted tooth. The final crown-to-root ratio should be After traumatic loss of anterior teeth (avulsion or after
less than 1. Clinically, the tooth should respond posi- replacement resorption), their replacement poses diffi-
tively to ethyl chloride test and no periodontal lesions culties in adolescence. Implants are strictly contraindi-
present. Andreasen and others reported the long-term cated because they behave as ankylosed teeth and don’t
prognosis of autotransplanted premolars after 13 years, follow or even impair the growth of the alveolar ridge.
10 with 95% and 98% survival rates for teeth with incom- Transplants can be a biological alternative. Usually pre-
plete and complete root formation, respectively [62]. molars are chosen; however, they only become available
There are several factors to ensure a successful auto- in orthodontic cases with inadequate space indicating
transplantation; the donor tooth should preferably have extractions. Primary canines may be an alternative as
at least three quarters of the root formed, and it is nec- they can be extracted without long-term disadvantages.
essary to have an atraumatic technique to preserve an If premolars are used to replace incisors, they need to
intact periodontal ligament and Hertwig’s root sheath in be re-formed by a composite buildup and sometimes the
the donor tooth [64]. Pulp survival is also an important palatal cusp needs to be reduced (. Fig. 10.36).
a b
.. Fig. 10.35 a Clinical image immediately after transplantation of a rotated way to facilitate healing of a larger alveolus b After orth-
maxillary second premolar to the mandibular left side. In the right odontic rotation of the two second premolars, the clinical aspect is
side, second premolar is also a transplant that has been implanted in unsuspicious. Tooth mobility is normal
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
203 10
a b
c d
.. Fig. 10.36 a Transplanted premolar in the place of an ankylosed The palatal cusp was left in place and does not bother the patient. c
maxillary central incisor. Clinical view 2 weeks after transplantation. 6 years after transplantation the composite reconstruction was dis-
For optimal gingival adaptation, the tooth had to be positioned in colored and needs to be replaced. d Radiographically obliteration
the same location as the ankylosed tooth and then moved orthodon- was evident. There is no visible resorption, which corresponds with
tically to its ideal position. b After reconstruction with composite. the normal clinical mobility
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204 A. Arhakis et al.
a b
c d
10
.. Fig. 10.37 a Ankylosed maxillary right central incisor. Mobiliza- extract the tooth, resect the apical part, and put a retro-post prior to
tion and subsequent orthodontic forces did not result in healing of replantation in a more coronal position. c Clinical view 5 years after
the periodontal ligament and re-ankylosis was evident. b Radio- replantation. Mobility was normal. d Its radiographic image shows
graphically the replacement resorption was unclear. It was decided to no signs of resorption and normal periodontal space
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Tooth Eruption, Shedding, Extraction and Related Surgical Issues
205 10
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41. Sennhenn-Kirchner S, Jacobs HG. Traumatic injuries to the pri- patients with Papillon-Lefèvre syndrome. J Am Acad Dermatol.
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bone cyst and delayed eruption of permanent mandibular inci- dental disorders. Arch Pediatr. 2017;24:5S80–4. https://doi.
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Dent. 2011;12:275–7. 56. Kumar A, Masamatti SS, Virdi MS. Periodontal diseases
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characteristics and occurrence in growing children. Angle ary retention in the primary dentition. ASDC J Dent Child.
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sample. Eur J Paediatr Dent. 2014;15:258–64. 61. Mendes RA, Rocha G. Mandibular third molar autotransplan-
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10 48. Kurol J, Magnusson BC. Infraocclusion of primary molars: a 62. Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O. A long-
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49. Nagaveni NB, Umashankara KV, Radhika NB, Maj Satisha survival and pulp healing subsequent to transplantation. Eur J
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report of 24 new cases. J Clin Pediatr Dent. 2004;28:183–6. teeth: is there a role? Br J Orthod. 1998;25:275–82. https://doi.
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52. Harokopakis-Hajishengallis E. Physiologic root resorption in 66. Andreasen JO, Paulsen HU, Yu Z, Bayer T. A long-term study
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53. Ullbro C, Crossner CG, Nederfors T, Alfadley A, Thestrup-
Pedersen K. Dermatologic and oral findings in a cohort of 47
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207 11
Orthodontic Knowledge
and Practice for the
Pediatric Dentist
Kitae Park, Anastasios A. Zafeiriadis, and Nikolaos Kotsanos
Contents
References – 244
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208 K. Park et al.
It is not an important consideration whether pediat- I, and Class III malocclusion, respectively. By conduct-
ric dentists would perform orthodontic treatment on ing oral examination with such estimation, pediatric
their own or refer their patient to an orthodontist. This dentists can understand the big picture of characteristics
should be a pediatric dentist’s own decision. With all of each patient. Following the full eruption of the first
their patients, however, being growing children and ado- permanent molars, patients with convex or concave pro-
lescents, they are dealing with problems related to dental file are labeled as Class II or Class III malocclusion with
eruption and facial growth. Therefore, it is essential for skeletal discrepancy of the maxilla and mandible. In this
them to have good orthodontic knowledge that would case, suitable orthopedic treatment would be needed to
help make a strategic decision, even while performing begin at some point before skeletal growth is completed.
restorative treatment, e.g., deciding to save a badly cari- Patients with straight profile, on the other hand, are con-
ous primary molar by restoring it. sidered that the relationship between the maxilla and
the mandible is within normal range. Age for possible
orthodontic treatment would consequently not be criti-
cal, and, in some cases, it might be of advantage to start
11.1 General Perspectives in Orthodontic treatment after skeletal growth is completed. Decisions
Management of Children are therefore dependent on patient’s sagittal relation.
and Adolescents When a transverse discrepancy of the maxilla and man-
dible exists, treatment would have to begin while skeletal
In most cases, no sophisticated techniques are required growth is still in progress. This holds true even in the pres-
to solve simple orthodontic problems. It is more impor- ence of a straight profile, because this discrepancy is still
tant for pediatric dentists to have a broad understanding considered a skeletal problem that requires orthopedic
of children’s orthodontic growth pattern, i.e., be able to treatment. A briefing for determining each malocclusion
predict how children’s faces would grow up in the future, treatment on the basis of the three different profiles is
rather than focusing on orthodontic techniques. Further, given below.
to analyze orthodontic aspects, they should look to rec-
11 ognize the pediatric patients’ overall orthodontic profile 11.1.1.1 Straight Profile
rather than focusing merely on their dental problems. A patient with a straight profile is considered as hav-
ing no skeletal discrepancy between the maxilla and
the mandible (as long as there is no transverse discrep-
11.1.1 Profile Evaluation ancy), and accordingly no orthopedic treatment would
be required. Therefore, age for orthodontic procedure is
How can we identify differences between orthopedic and less critical. However, early treatment should be consid-
orthodontic problems? The differences are easily identi- ered, if this straight profile patient has at least one of the
fied by examining the patient’s face (i.e., profile) rather following findings:
than looking into their mouth (. Fig. 11.1).
1. Localized anterior crossbite causing traumatic
occlusion
Orthodontic vs. Orthopedic Treatment Localized anterior crossbite can cause lateral or forward
functional deviation of the mandible and sometimes
Orthopedic treatment is to correct skeletal dishar-
lead to traumatic occlusion that would result in gingival
mony between the maxilla and mandible, while orth-
recession of the lower anterior teeth (. Fig. 11.2). Gin-
odontic treatment is to align the maxillary and/or
gival recession caused by traumatic occlusion should
mandibular teeth by moving them. It is, therefore, rec-
be treated promptly upon detection, because it would
ommended that orthopedic treatment be performed
worsen at a rapid rate unless the ectopically driven tooth
at some point before skeletal growth is completed,
is corrected. On the other hand, localized anterior cross-
whereas there is no age limitation on provision of
bite, which does not cause mandibular functional devia-
orthodontic treatment. Thus, discerning orthodontic
tion or traumatic occlusion, is occasionally treated with
from orthopedic problems would provide good crite-
a comprehensive orthodontic treatment approach after
ria to determine the appropriate age for each patient’s
all the permanent teeth are fully erupted.
treatment.
2. Localized severe rotation of the anterior teeth that
causes esthetic problem
Generally, at age 4–5 years, after the primary dentition Severe rotation of the anterior teeth can be caused by
is fully completed, children are to be distinguished based arch length discrepancy or an impacted supernumer-
on the convexity of their facial profile, that is to say they ary tooth. The resulting esthetic problem may have a
can be divided into convex, straight, and concave profile negative psychological impact on children, and there-
types, which would later be estimated as Class II, Class fore, treatment is recommended as early as possible
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Orthodontic Knowledge and Practice for the Pediatric Dentist
209 11
Orthopedic
Convex
treatment
Facial profile
Concave
Orthodontic
treatment
Straight
.. Fig. 11.1 Understanding the big picture of orthodontic characteristics of each patient by profile evaluation
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210 K. Park et al.
.. Fig. 11.2 Localized anterior crossbite can cause lateral or matic occlusion from anterior crossbite. b The traumatic occlusion
forward functional deviation of the mandible and sometimes lead to was removed by correcting anterior crossbite
traumatic occlusion. a Gingival dehiscence has occurred by trau-
a b
11
.. Fig. 11.3 Because esthetic problem of severe rotation of the anterior teeth can psychologically have negative effect on the children, it is
recommended for them to have treatment as early as possible. a Before treatment. b After treatment
12% of canine impactions were accompanied by lateral may vary from person to person, and accordingly bian-
incisor root resorption [3, 4]. Therefore, it is important for nual clinical or radiographic examination would be rec-
the pediatric dentist to suspect and diagnose impaction ommended. There also has been preventive treatment for
of the maxillary permanent canine and perform an early canine impaction using maxillary expansion, which has
treatment to prevent it, in collaboration with the ortho- proven effective [10, 11]. Yet another approach has been
dontist when necessary. That is, a radiographic examina- proposed to increase the effect by combining maxillary
tion should be implemented by age of 8 or 9 in the case expansion with wire appliances to additionally force the
of absence of canine bulge. Panoramic radiographs show root of the adjacent lateral incisor mesially [12].
that the canine and lateral incisor are overlapped until 6 or 5. Transverse discrepancy
7 years of age in most cases, and the canine tends to incline
distally after 8 years of age [8], having more vertical erup- If a child has transverse discrepancy between the maxilla
tion path after 9 years of age. Localization analysis using and the mandible, he/she is supposed to have a skeletal
panoramic radiographs showed that the distance between discrepancy and need an orthodontic procedure (mainly
the canine cusp tip and the occlusal plane was most useful orthopedic treatment) although he/she has a straight
in predicting the possibility of canine impaction, and this profile. It is recommended to begin the treatment as early
could be detected as early as 8 years of age [9]. as possible, because the generalized posterior crossbite
For the treatment of eruption disturbance of the per- causing mandible deviation may lead to permanent
manent canine, Ericson and Kurol suggests that primary facial asymmetry while growing up (. Fig. 11.6). Poste-
canine extraction improves the eruption path of the per- rior crossbite involving only one or two teeth not caus-
manent canine, if the canine has enough eruption space ing mandibular functional deviation would not need an
and is not accompanied with root resorption of the adja- immediate treatment. Kanomi et al. conducted a CBCT
cent lateral incisor [4] (. Fig. 11.5). However, the effect
study on the effect of rapid maxillary expansion (RME)
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a b
c d
.. Fig. 11.4 a Mesial drift of ectopically erupted maxillary first molars using Nance button anchorage. c Nance holding arch was
permanent molars following the loss of the second primary molars. used for the retention. d Both the maxillary second premolars
b Fixed appliance has been used to distalize both the first permanent erupted well into the spaces created by orthodontic treatment
a b
.. Fig. 11.5 a Radiographic signs (eruption angulation path and tion path was improved. c Ectopic eruption of the permanent canine
downward eruption progress) were found on the upper left canine. b was fully corrected naturally
In 6 months after extraction of the upper left primary canine, erup-
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212 K. Park et al.
a b c
.. Fig. 11.6 a Left-side unilateral posterior crossbite causing man- expansion. c Mandibular functional deviation is corrected by maxil-
dibular functional deviation to the left side. b Upper removable lary expansion
expansion appliance with median screw was used to make maxillary
with children aged 6 to 15. They reported that either treatment can be implemented even in the early mixed
bonded expander (McNamara-type RME) or banded dentition stage. Likewise, if the patient does not long
expander (Hyrax-type RME) was an effective treatment for treatment for her/his condition in spite of compara-
option, but expansion efficiency decreased with age [13]. tively severe maxillary protrusion, one-phase treatment
can be undertaken in the late mixed dentition stage or at
11.1.1.2 Convex Profile growth peak (. Fig. 11.7). Proffit reported that “Early
A patient whose profile is convex is considered as Class II treatment for most Class II children is no more effective,
malocclusion, which refers to sagittal maxilla-mandible and considerably less efficient, than later 1-stage treat-
discrepancy. That is to say, patients with convex profile ment during adolescence” but also described that “Class
have either prognathic maxilla or retrognathic mandible, II clinical trial results do not mean early Class II treat-
or a combination of both. In the case of Class II maloc- ment is never indicated” [17].
11 clusion, orthopedic treatment is required at some point
while skeletal growth is in progress.
Conditions for Two-Phase Treatment
well as severity of malocclusion, as many studies have trates a patient who had a successful result of phase I
shown. Thus, if the patient is psychologically distressed orthopedic treatment performed at a relatively late age,
about severe maxillary protrusion, phase 1 orthopedic showed a favorable growth pattern, and kept the good
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.. Fig. 11.7 Flowchart for
Class II malocclusion in Class II malocclusion
children. It is desirable to
implement two-phase treatment
only when Class II malocclusion Full step class II molar
is severe enough to correspond Selection criteria 7 mm OJ
with selection criteria. However, Severe convex profile
if the patient is psychologically
distressed about severe maxillary
Yes No
protrusion, phase 1 orthopedic
treatment can be considered even
One
in the early mixed dentition stage Pt’s Desire phase
Yes No
With pt’s Desire
Two One
phases phase
Two phase treatment can
be considered
orthopedic correction until his physical growth ended. a number of studies of growth pattern prediction after
When orthopedic correction is successfully done, the facemask treatment, accurate predictions of patient’s
patient can be categorized as Class I malocclusion and growth patterns are not likely to be possible [19–21]. In
will be allowed to choose when to resume the follow-up the case of Class III malocclusion, therefore, it is impor-
treatment any time he/she feels ready. tant to predict various possible outcomes, establish a
treatment plan for each outcome, and inform the out-
11.1.1.3 Concave Profile comes and plans to the patient and/or parents before the
A patient whose profile is concave is considered as Class treatment is started. In the same context, when growth
III malocclusion, which refers to sagittal discrepancy is about to end soon, the condition can be predicted in
between the maxilla and the mandible. That is to say, three ways followed by each related treatment plan as
patients with concave profile have either retrognathic follows (. Fig. 11.10):
maxilla or prognathic mandible, or a combination of 1. In case that good profile and occlusion are main-
both. In the case of Class III malocclusion, just as in tained as the result of favorable growth:
Class II, orthodontic procedure including orthopedic 55 Final orthodontic treatment would be recom-
treatment is required at some point while skeletal growth mended to improve esthetic or achieve functional
is in progress. perfection, or no further treatment would have to
While a localized anterior crossbite caused by a den- be performed depending on patient’s satisfaction.
tal problem can simply be treated using a removable 2. In case that facial profile and occlusion are accept-
orthodontic appliance, Class III malocclusion of skel- able because Class III growth pattern is not severe:
etal origin is generally treated with orthopedic treatment 55 Compensation treatment would be recommended
methods using facemask or functional appliances, such when skeletal growth is completed, but facial pro-
as a Frankel appliance. However, patients with concave file would not be improved because orthopedic
profile with midface deficiency are generally recom- treatment is not included.
mended to use facemask that can improve the facial pro- 3. In case that Class III growth pattern is severe, clearly
file by maxillary protraction (. Fig. 11.9). It has been
showing a concave profile, and anterior crossbite
suggested that such functional appliances have dental seems not to be able to be improved by orthodontic
effect rather than orthopedic effect [18]. treatment:
Facemask can be used for pediatric patients from the 55 Orthognathic surgery would be applied only if
primary dentition around 5 years of age until the late the patient and parents want to undergo the pro-
mixed dentition, but mostly in the early mixed dentition cedure.
around 7–8 years of age. Patients are generally able to
obtain the desired result of maxillary protraction within Likewise, in the cases of Class III malocclusion treat-
a year, leading to noticeable improvement of facial pro- ment, patient’s growth patterns tend to play a more
file. However, facemask cannot completely improve the important part than the treatment itself, and success or
Class III traits. Thus, if potential Class III traits are failure of the treatment tends to depend on the final
strongly predicted, the mandible would possibly grow result. Regardless of the result, however, it would be
more than the maxilla, leading to anterior crossbite or one of the predictions made prior to the treatment,
profile change into concave. Although there have been and accordingly every one of the results should not be
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.. Fig. 11.8 Later-state phase I treatment of Class II malocclusion. oramic and cephalometric radiographs. Patient is in permanent den-
a Severe overjet, convex profile, and Class II molar relationship in an tition state and can be categorized as Class I malocclusion. e
11-year, 1-month-old boy. b Pretreatment panoramic and cephalo- Photographs in 4-year retention. Posttreatment results are well
metric radiographs showing late mixed dentition state and Class II maintained. f Cephalometric and panoramic radiographs in 4-year
characteristics. c Posttreatment photographs showing improved retention. Phase I orthopedic correction is still well maintained
facial profile, overjet, and molar relationship. d Posttreatment pan-
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c
.. Fig. 11.8 (continued)
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.. Fig. 11.8 (continued)
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Skeletal
Orthopedic tx
Dental
.. Fig. 11.9 Profile evaluation can be a good-decision process to orthopedic treatment methods using facemask or functional appli-
diagnose Class III malocclusion if it is skeletal origin or dental. ances, such as Frankel appliance, etc. However, patients with concave
Localized anterior crossbite caused by dental problem can simply be profile with midface deficiency are generally recommended to use
treated using removable orthodontic appliance, while Class III mal- facemask that can improve the facial profile by maxillary protraction
occlusion resulted from skeletal origin is generally treated with
Three conditions at
growth completion
Final
orthodontic
treatment
Orthognatic
Surgery
.. Fig. 11.10 Using facemask treatment, patients with Class III predicted, the mandible would possibly grow more than the maxilla,
malocclusion are generally able to obtain desired result of maxillary leading to anterior crossbite or profile change into concave. When
protraction within a year, leading to noticeable improvement of growth is about to end, the condition can be predicted in three ways
facial profile and occlusion. However, facemask cannot completely followed by each related treatment plan
improve the Class III traits. If potential Class III traits are strongly
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218 K. Park et al.
regarded as a failure. Although there have been vari- 11.2 Age-Specific Perspectives
ous prediction models of treatment result, each of them in Orthodontic Management
does not provide an accurate growth pattern because
of Children and Adolescents
they are all based on retrospective studies [19–21].
Thus, it is critical to inform about various possible
Preventive orthodontics can be useful in primary as well as
results, and even a surgical option in the worst case, to
in mixed dentition. The dental clinician has to be aware of
the patient and parents prior to Class III malocclusion
what things to observe and look out for during all stages
treatment.
of dental development and also be prepared to diagnose
One of the reasons why early orthopedic treatment
and decide when the use of preventive orthodontics would
is implemented for Class III malocclusion, although
prove effective. This section addresses the most common
an optimal result is not always guaranteed, is that the
problems arising in the development of the occlusion
psychological aspect should be considered, same as in
during primary and mixed dentition and their potential
Class II malocclusion cases. For example, if the patient
effects on the permanent dentition, as well as the recom-
reaches middle or high school years without orthopedic
mended actions for their prevention and/or correction.
treatment for concave profile and anterior crossbite was
generally established at age 7–9, he/she will have more
chances to experience a psychological problem because
11.2.1 Intervention in the Primary
of his/her own appearance.
Dentition
11.1.2 Concluding Remarks on Profile In the primary dentition, it is possible for abnormali-
Evaluation ties to appear in the dental and skeletal relations of
the arches. However, no serious intervention is usually
Most parents want to know how their child would grow needed at such an early age [23]. Having said that, there
up in terms of face and tooth appearance. Patients with have only been a relatively few clinical research papers
11 Class III malocclusion have the distinguishing cephalo- dealing with this age range, and their recommendations
metric features of this malocclusion type since being in are based on expert opinion rather than documenta-
the primary dentition [22]. Pediatric dentists can make tion. Where early orthodontic intervention is considered
a relatively simple prediction by observing the child’s pertinent, the possibility of comprehensive orthodontic
profile. This can be done easily and relatively accurately, treatment in the permanent dentition should be taken
and the dentist can draw up a comprehensive layout into account. If such a future need is foreseen, the cost/
showing how the malocclusion would develop. Pediatric benefit for intervening at such a young age should be
dentists tend to primarily be interested in caries preven- examined. The child’s ability to cooperate should also
tion and treatment. However, they would not be able to be taken into account, as well as the possible burnout
provide the best treatment or might even give unneces- effects of a lengthy course of treatment. During the
sary treatment, if they do not observe patient’s appear- child’s dental examination, the type and extent of poten-
ance by just concentrating on intraoral examination. tial abnormalities should be observed and recorded.
For example, when a patient has canine impaction, a These can be classified into the following categories.
dentist might only consider how to perform forced erup-
tion as the first thing. In this case as well, however, pro- 11.2.1.1 Arch Space Anomalies
file evaluation should be the priority in order to make a Crowded or widely spaced teeth are frequently observed
comprehensive treatment plan. . Figure 11.11 depicts
in the primary dentition. Except for the normal primate
that a patient with lip protrusion can have totally differ- spaces, widely spaced teeth and generalized spacing are
ent treatment procedure. That is, a four first premolar a normal characteristic of the primary dentition, pro-
extraction approach can be chosen, but extracting the gressively more so toward the late primary dentition as a
impacted canine instead of the premolar would have result of slow jaw growth in all directions (. Fig. 11.13).
a much less copious and yet esthetically similar effect. Generalized spacing and primate spaces are useful for
On the other hand, it would be desirable to save the the future arrangement of the significantly wider ante-
impacted canine of a patient with straight profile. In rior successor permanent teeth and consequently require
the same context, the canine of the patient shown in no intervention. In the case of crowding, intervention
. Fig. 11.12 was saved through autotransplantation,
is not necessary either, but this situation does require
and such a treatment method was worth undergoing in frequent monitoring of the developing dentition as it is
spite of some treatment failure possibilities. In conclu- likely that the crowding will be worse after the eruption
sion, using profile evaluation would play a key role to of the permanent teeth [24].
establish an overall treatment plan that leads to the best In the anterior region, the early loss of one or all inci-
possible results for pediatric patients. sors does not necessarily lead to loss of space, especially
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219 11
.. Fig. 11.11 a In the panoramic radiograph, horizontal impaction tion orthodontic treatment. c, d In this patient, the upper left canine
of the upper left canine is shown. In cephalometric radiograph, was extracted instead of the first premolar for the spot of canine
flared upper and lower incisors causing lip protrusion are shown. b impaction, which would have similar effect with one of extraction
Lateral facial photograph is showing lip protrusion, and therefore, orthodontic treatment. In the final result, good facial profile is
this patient can be a good candidate for four first premolar extrac- achieved by sacrificing the impacted canine
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220 K. Park et al.
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.. Fig. 11.11 (continued)
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.. Fig. 11.12 a In the panoramic radiograph, similar horizontal arches with good facial profile. c, d In this patient, impacted canine
impaction of the upper left canine is shown. In cephalometric radio- was saved by autotransplantation, and in the final result, good facial
graph, good inclination of the upper and lower incisors is shown. b profile is maintained. For this patient, autotransplantation was
Facial and intraoral photographs are showing fairly well-aligned worth undergoing in spite of its probability of treatment failure
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.. Fig. 11.12 (continued)
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.. Fig. 11.14 One year after the loss of the primary central incisor.
Tilting of the lateral incisor has not affected total arch length with
canine relationship remaining stable
observed, making the space look narrower, but this has adequate eruption of the first permanent molar, replace-
no effect on total arch length (. Fig. 11.14). If one or ment of the “distal shoe” with, e.g., a “band and loop”
more primary incisors are lost before canine occlusion, is required. The paradigm shift on caries control nowa-
which occurs at about the age of 2, no suggestions for days, as well as the level of technical difficulty of these
space maintenance have been proposed; the child’s inabil- early interventions, has made them less popular among
ity to cooperate constitutes a prohibitive factor anyway. pediatric dentists. Alternatively, space regaining may
In the case of the first primary molar loss, a space- be pursued after the first permanent molar completes
maintaining device should be applied, preferably of a eruption, following a mixed dentition space analysis.
fixed type, as this is likely to be much better tolerated by However, considering the difficulty of distalizing the
the young patient. In unilateral loss, the classic “band lower first permanent molar compared to the upper first
and loop” is preferred (. Fig. 11.15), although simpler permanent molar, using the distal shoe may still be an
appliances can be used, requiring less technical prepara- option in the lower arch.
tion. Such a device may be comprised of a suitably bent Fitting fixed appliances requires appropriate seating
stainless steel wire bonded to the etched enamel of the and removing instruments such as band-removing pliers.
adjacent teeth with composite resin (. Fig. 11.15d). The Band decementation or solder failure may occur in all
0.28′ (0.7 mm) diameter offers minimal elasticity, allowing fixed appliances, as well as detachment in those bonded
independent tooth movement for preventing its debond- with composite. Patients should be given instructions,
ing. This has shown success empirically, but no evidence and parents should be informed about the potential
exists as yet regarding its longevity. For bilateral loss in need for immediate repair.
the mandible, two independent “band and loop” appli-
ances may be cemented at the second primary molars. 11.2.1.2 Occlusal Anomalies
In the cases with at least two permanent lower incisors At the Vertical Plane
erupted, which already indicates a very early mixed den- Anterior open bite is commonly observed in the primary
tition, a lingual holding arch can be used (. Fig. 11.16). dentition, and most of the time, it is only dentoalveolar,
For bilateral loss in the maxilla, a Nance appliance was resulting from harmful oral habits, such as the use of the
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224 K. Park et al.
a b
c d
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.. Fig. 11.15 a Band and loop on the cast. The wire is almost in mary and permanent molars are necessary for selecting the proper
contact with the gums to minimize masticatory stress load and is band size. d Another type of unilateral space maintainer made chair
temporarily fixed to the lower second primary molar band with wax. side by 0.7 mm wire bonded with resin composite to the primary
b The appliance is cemented to an upper second primary molar. c canine and second molar. It is shown here when its removal is due
Commercially available sets of bands for each quadrant of the pri- because of eruption of the succeeding first premolar
At the Sagittal Plane
Anteroposterior discrepancies in the relationship of
the molars, as well as that of the anterior teeth, belong
to this category. In the anterior teeth, overjet may be
.. Fig. 11.16 Lingual holding arch cemented on the second pri- increased, but when negative, it is called a crossbite. The
mary molars. It is shown here while the first premolars are erupting relationship of the distal surface of the maxillary second
and its removal is due
to that of the mandibular second primary molar guides
the future occlusal relationship of the first permanent
thumb or a pacifier as a comforter. Treatment in these molars. In normal occlusion, the distal surfaces of the
cases is focused on the discontinuation of the habit. maxillary second primary molars are nearly on the same
The open bite automatically regresses or fully corrects vertical line or about 1 mm distally to the occluding
itself, as the muscular balance between the tongue, the mandibular ones (ideal relationship) (. Fig. 11.20).
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.. Fig. 11.17 a Recent loss of the upper right primary lateral incisor and canine due to trauma. b A modified Nance appliance is cemented
to the second primary molars, with the addition of an artificial lateral for esthetical purposes
Eye Catcher Distal step occlusion of the second primary molars is fre-
quently observed, in combination with increased overjet
Disorders at the anteroposterior/sagittal plane, of the anterior teeth (. Fig. 11.21). This abnormality
although they are more of a problem in the mixed den- usually has a skeletal basis but can also be related to
tition, may be observed in the primary dentition. Using harmful oral habits. This is something that can be diag-
primary molar relationship information alone for pre- nosed based on clinical history and examination. Usu-
dicting the relationship of jaws and dental arches in the ally, these occlusal relationships of the primary molars
permanent dentition is not always safe, and the relation- carry on to the permanent dentition, being indicators of
ship between the primary canines may be more helpful an Angle Class II malocclusion development. However,
in assessing disorders at the sagittal plane [25]. More orthodontic treatment is infrequently justified at such an
importantly, these occlusal examinations always should early age, as explained in 7 Sect. 11.1 of this chapter.
be based on careful evaluation of facial profile, because Less common in Caucasians and more so in East
the big picture of the skeletal pattern of the patient can Asians is the opposite disorder – called mesial step
be assumed accurately from facial evaluation. occlusion – in combination with anterior crossbite, i.e.,
occlusion of the upper anterior teeth lingually to the
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226 K. Park et al.
a b
c d
.. Fig. 11.19 Disorders on the vertical plane. a, b Severe anterior open bite from thumb-sucking at 3 years of age. c Six months after habit
11 cessation. d Full self-correction 18 months later
.. Fig. 11.21 The primary dentition with distal step occlusal rela-
.. Fig. 11.20 Normal occlusal relationships between the second tionship of the second primary molars and canines. There is a mod-
molars and canines in the primary dentition erate horizontal protrusion. This is a disorder in the sagittal
(anteroposterior) plane
respective lower teeth (. Fig. 11.22). The treatment
is usually long term. If the abnormality is combined instead may not be effective to correct anterior cross-
with a functional disorder, it should be corrected at this bite in the primary dentition. Correction of an anterior
age. Correction of multiple tooth anterior crossbite is crossbite is maintained by the occlusion itself. However,
rarely successful through selective grinding, but there is regular follow-ups are needed, since there is a tendency
insufficient documentation to definitively indicate the for relapse in the permanent anterior teeth in a fair num-
best treatment in these cases [27]. ber of cases.
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At the Transverse Plane treat posterior crossbite occlusion early, since in many
Disorders of this category include posterior crossbite cases it is self-corrected with eruption of the permanent
(unilateral or bilateral), i.e., abnormalities in the bucco- molars and premolars. If further occlusal abnormali-
lingual relations of the posterior teeth, mainly related ties are foreseen, they may all be corrected later by a full
to a narrower maxillary dental arch. These discrepan- orthodontic treatment.
cies, if not treated at the appropriate time, may lead to a Correction of posterior crossbite is usually recom-
multitude of complications in the permanent dentition, mended in cases where there is lateral shift of the man-
such as severe dental wear, periodontal distraction, and dible, and, at the maximum intercuspation of the two
even skeletal problems like facial asymmetry. There is arches, there is notable midline deviation. In the absence
insufficient documentation in the literature whether to of deviation with only dentoalveolar crossbite, treat-
ment is postponed until after the eruption of the first
permanent molars. The simple treatment possible is the
selective relief of tooth cusps interfering with normal
occlusion. This usually involves reverse inclined cusp
reduction of the upper and lower canines and leveling
the cusps of the primary molars in crossbite [28, 29]
(. Figs. 11.24 and 11.25).
a b
c d
.. Fig. 11.23 a Anterior crossbite. b Unsuccessful correction attempt with the use of an inclined plane. c Palatal bite plate with expansion
screw after 1 month’s use. d At the 6-month follow-up, a stable correction of the abnormality is observed
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228 K. Park et al.
Apart from crossbite, there is also a much rarer occlu- cause related to the basal bone of the jaws and require
sal abnormality characterized by severe discrepancy jaw monitoring for the appropriate orthodontic intervention.
b c
11
.. Fig. 11.24 a Posterior crossbite (right side) at the age of 6 years, with functional shift and midline deviation. b, c Before and after reduc-
ing the interfering cusps of involved the primary teeth
a b
.. Fig. 11.25 a Posterior crossbite at age 4 years with canine interference during lateral functional shift. Grinding of the maxillary and
mandibular right primary canines and molars was undertaken at this stage. b Occlusal relationship at age 10 with no further treatment
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a b
.. Fig. 11.26 a Functional posterior crossbite at 6 years of age as tion of a quad-helix after the eruption of the maxillary first perma-
the only occlusal abnormality. b One visit grinding of the left maxil- nent molars is shown here after reactivation of the anterior part. d
lary and mandibular primary teeth (under local anesthesia) failed to Overtreatment, better seen in the permanent molars, is necessary for
solve the problem in the following 6 months. c An 8-month applica- preventing relapse
.. Fig. 11.27 Telescopic occlusion in the primary dentition. a Unilateral. b Bilateral. Tartar presence in the maxillary second primary
molars is probably related to impaired masticatory function
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230 K. Park et al.
Apart from primary crowding, space loss due to posterior primary tooth is lost, the need for a space main-
advanced dental caries or premature loss of a primary molar, taining/regaining appliance should be examined. As most
resulting to mesial drift of the first permanent molar, may of space loss – adjacent tooth drifting – occurs within the
lead to secondary crowding (. Fig. 11.28). It is thus neces-
first months after a premature primary molar extraction,
sary to maintain the primary teeth intact or restore them to space maintenance should be considered without delay.
their normal size, also for occlusion purposes. Retention of In many cases, maintaining space after premature
the second primary molars, in particular, aids in maintain- loss of the primary molars is important for preventing
ing stability of the entire dental arch length [30]. When a crowding of the permanent teeth (. Fig. 11.29). There
.. Fig. 11.29 a Neglect in maintaining space after premature loss of the primary molars. b The panoramic radiograph shows the mesial drift
of all permanent molars and lack of space for the permanent maxillary canines and mandibular second premolar eruption
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231 11
by two Adams clasps, usually anchoring the appli- a fixed appliance made up of two bands cemented to
ance on the first permanent molars, and a labial wire the first permanent molars and connected by an 0.036′
arch, resting on the labial surface of the anterior teeth (0.9 mm) diameter wire arch that is passively applied to
(. Fig. 11.32). The mandibular lingual holding arch is
the gingival third of the lingual surface of the permanent
incisors (. Fig. 11.33). For the maxilla, a transpalatal
.. Fig. 11.31 a Neglect in maintaining space after early loss of both mandibular permanent molar rendering the placing a space-
the left mandibular primary molars. b Overeruption of the maxillary maintainer obsolete
second primary molar is preventing any further mesial drift of the
.. Fig. 11.32 Removable Hawley appliance a For the maxilla. b For the mandible. The added screw has resulted in regaining the space lost
by premature extraction of the second primary molar
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232 K. Park et al.
wire arch that goes around the anterior area and in the appliance can be used, e.g., one that includes brack-
tubes. The lower lip muscle tone results in distalizing ets, tubes, partial archwire, and springs (. Fig. 11.34).
(or rather uprighting) the molars. This process may be Removable devices, such as the Hawley appliance, may
accelerated by incorporating coil springs in the device. also be used in combination with a jackscrew or finger
For isolated unilateral space problems, a sectional fixed springs [34] (. Fig. 11.35).
a b
.. Fig. 11.33 a Loss of the second primary molars. Lingual holding arch wire rests passively on the gingival third of lower anterior teeth
lingual surface. b Transpalatal arch with loop for activation of the 0.36′ (0.9 mm) diameter wire
11
.. Fig. 11.34 a Lower lip bumper for space regaining for the man- lis). b Space regaining for a second premolar with the use of spring
dibular left canine and first premolar (courtesy of Prof. N. Topouze- in a partial wire arch from the canine to first permanent molar
.. Fig. 11.35 a Dual-purpose removable appliance for space maintenance (right side) and space regaining (left side, fitted with jackscrew).
b Activating the screw for space regaining
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11.2.2.2 Mixed Dentition Analysis One method of mixed dentition analysis is to calcu-
late the width of the unerupted permanent teeth from
Eye Catcher
an undistorted X-ray image. For this reason, periapical
X-rays are preferred over panoramic ones, especially
The goal of mixed dentition analysis is to predict the
when calculating canine tooth width [35]. This tech-
width of the unerupted permanent teeth and calcu-
nique can be used for both jaws and all ethnic groups.
late whether these will fit in the available space, so
Precision of measurement depends on X-ray quality
that an early diagnosis of potential problems in the
including correct exposure angles. Correcting the X-ray
dental arches is allowed. Indications for preventive or
magnification is required, and this can be achieved by
interceptive orthodontic treatment may thus be early
comparing the width of a primary molar tooth in the
recognized and treatment decisions made, as well as
X-ray with its real width (clinical or on a plaster cast)
whether orthodontic consultation is necessary.
using the ratio [35]:
Other methods of analysis include those that use den- mixed dentition analyses tend to be reliable, if they are
tal ratio charts, since these are simple to use and do applied to the same ethnic groups from which the pre-
not require X-rays. They are based on the analogy of dicted values arose. They should be, however, avoided
permanent mandibular incisor width to the canines if the radiographic examination reveals shape- and size-
and premolars. Moyer’s mixed dentition analysis [36] related abnormalities of the permanent teeth.
uses the sum of the four permanent mandibular incisor
width to predict the summed width of the maxillary or 11.2.2.3 Dental Spacing
mandibular permanent canine with the first and second Spaces may be seen between any teeth, while in the
premolar in each side. Estimated values are presented mixed dentition this phenomenon is usually found
in . Table 11.1. Estimations are based on the width
between the two central incisors (diastema). The den-
of the mandibular rather than the maxillary incisors tist does not need to close this until the lateral incisors
because of the increased size variability of the upper and canines have all erupted. In the majority of cases,
laterals. The width of expected permanent teeth was the horizontal forces exerted during the eruption of
calculated based on a sample of Caucasian children, these teeth close the diastema, and there is no need for
to which the method holds greater precision. Moyer’s treatment. However, should the condition persist, the
analysis tends to overestimate the size of permanent possibility of an existing supernumerary (mesiodens)
teeth [35]. or odontoma causing the abnormality should be inves-
The Tanaka and Johnston analysis [37] also uses tigated (. Fig. 11.36). In these cases, the mesiodens
the width of the mandibular incisors for calculating the is extracted, and then, the diastema may be closed
width of the canines and premolars. This method is pre- spontaneously without any treatment. If the diastema
sented in . Table 11.2. This method also has a tendency
remains after 6 months, orthodontic space closure may
to overestimate predicted tooth size but is particularly be needed. This can be achieved through the use of a
easy to use, since it can be memorized and applied with- removable Hawley appliance with springs pushing the
out the use of charts [35]. Other methods, such as the two central incisors mesially at the midline or by fixed
Staley and Kerber analysis, [38] use both radiographs for partial appliance, i.e., brackets on the incisors for pull-
width of the teeth and prediction charts. In conclusion, ing them close with elastic forces (. Fig. 11.37).
.. Table 11.1 Predicted values of the sum of permanent canine and premolars width of one side with Moyer’s analysis (confidence
level 75%) [36]
Mandibular incisors 19.5 20 20.5 21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26 26.5 27 27.5 28 28.5 29
Canine Maxilla 20.6 20.9 21.2 21.3 21.8 22.0 22.3 22.6 22.9 23.1 23.4 23.7 24.0 24.2 24.5 24.8 25.0 25.3 25.6 25.9
plus
premolars Mandible 20.1 20.4 20.7 21.0 21.3 21.6 21.9 22.2 22.5 22.8 23.1 23.4 23.7 24.0 24.3 24.6 24.8 25.1 25.4 25.7
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234 K. Park et al.
Sum of mandibular + 11 mm = predicted width of maxillary Evaluation of occlusion should be performed, so that
incisor width canine and premolars per side potential interventions decided in the form of full orth-
2 + 10.5 mm = predicted width of mandib- odontic treatment [25]. Sometimes other consequences
ular canine and premolars per side may be present already, such as periodontal trauma.
In this anomaly too, its skeletal nature should be
11
.. Fig. 11.36 a Midline diastema caused by the presence of an erupted mesiodens. b X-ray shows the presence of another unerupted
mesiodens
.. Fig. 11.37 a A large midline diastema of the maxillary incisors. b Space closed with two brackets and elastic forces
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Orthodontic Knowledge and Practice for the Pediatric Dentist
235 11
.. Fig. 11.38 A severe form of skeletal anterior open bite. Four years later without treatment, the open bite has increased
.. Fig. 11.39 a A young patient’s mixed dentition with severe anterior deep bite (at proclined position). b This vertical plane anomaly con-
tributes to labial periodontal trauma of the mandibular central incisors
At the Sagittal Plane
These anomalies manifest with consequences in the pro-
traction of the anterior teeth (overjet). If the first per-
manent molar relationship is of an Angle Class II or
Class III malocclusion, it is most likely that this will have
respective consequences in the horizontal protraction
of the anterior teeth. Increased overjet in the maxillary
anterior region may be caused by forward relocation of
the anterior maxillary alveolar process and backward
relocation of the anterior mandibular alveolar process,
by increased labial inclination of the maxillary inci-
sors and increased lingual inclination of the mandibu-
lar incisors, and by maxillary prognathism, mandibular
retrognathism, or a combination of any of those fac-
.. Fig. 11.40 Class II occlusal relationship with severe overjet in
tors (. Fig. 11.40). Causes for the anterior dentoalve-
the mixed dentition (Angle Class II). This is a disorder on the sagittal
olar divergence can be various harmful oral habits, but plane
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236 K. Park et al.
the cause of a generalized anomaly, especially when it building an inclined plane with resin-modified glass
includes the basal base, is probably skeletal and should ionomer cement placed on the corresponding mandib-
be further investigated through lateral cephalometric ular incisors corrects the crossbite within 2–3 weeks. Its
radiographs. removal is performed with great care to avoid incisal
enamel fractures. Mild cases of anterior crossbite in
early mixed dentition can potentially be solved by sim-
Eye Catcher ply raising the bite for 2–3 weeks, thus allowing inci-
sor alignment by involuntary pressure of the tongue
It has been suggested that early orthodontic treatment (. Fig. 11.42).
in the mixed dentition of children with severe overjet When anterior crossbite is found in all the ante-
could reduce the risk of maxillary incisor fracture. rior teeth, correct and timely diagnosis is required, to
However, there was also a report that no significant determine if the problem is skeletal or merely func-
difference was shown in incisor fracture as a result tional in nature. Skeletal-related anterior crossbite
of dental trauma in children who had at least 7 mm (skeletal Angle Class III) is the disharmony of the jaw-
overjet corrected by early treatment, in comparison bones at the sagittal plane, while a narrow maxilla may
to other children for whom treatment had been post- coexist, indicative of a width problem of the jaw basal
poned until the permanent dentition [40]. The early bones. In this anomaly, the anterior teeth may occlude
treatment with fixed appliances of a Class II maloc- directly into crossbite without forward sliding of the
clusion in patients with severe overjet is not often mandible (. Fig. 11.43). In the anterior crossbite of
selected by the orthodontist, because orthodontic functional cause, the anterior teeth are in a scissors
treatment requires a longer treatment time this way, position, being forced to fall into crossbite for a stable
possibly exhausting the child’s tolerance and coopera- occlusion. In general, sagittal plane occlusal anoma-
tion. If, however, other personal patient reasons exist, lies require correct diagnosis and often full orthodon-
e.g., risky athletic activities, low self-esteem because tic treatment; therefore, orthodontic consultation is
of dental esthetics, etc., early intervention for overjet advisable.
11 correction may be justified.
At the Transversal Plane
Posterior crossbite in isolated teeth due to dentoalveolar
The opposite commonly seen anomaly in the mixed reasons is usually caused by diverging eruption of per-
dentition at the sagittal plane is the anterior cross- manent teeth and is frequently observed in the mixed
bite. This can be simply of dentoalveolar etiology dentition. Unilateral or bilateral posterior crossbite with
and may involve one or more anterior maxillary inci- midline shift due to functional mandibular deviation
sors in lingual occlusion with the mandibular ones. is also common in occurrence. In functional posterior
These cases are treated as described in the primary crossbite, there is always a lateral sliding element. The
dentition with a removable Hawley appliance with most common cause is a disharmony in dental arch
springs (. Fig. 11.41). In the case of a single tooth,
width, with coexisting prominent cusps of the primary
.. Fig. 11.41 a Neglected anterior crossbite of the maxillary left permanent central incisor. b Correction is attempted with a removable
Hawley appliance with Z-shaped spring and acrylic cover of the occlusal surfaces of the posterior teeth for occlusal relief
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Orthodontic Knowledge and Practice for the Pediatric Dentist
237 11
a b
.. Fig. 11.43 Severe crossbite with apparent skeletal characteristics of Angle Class III molar relationship
canines, causing a lateral shift of the mandible, which the skull. Orthodontic consultation is advisable in these
can be combined with functional anterior crossbite. cases.
Correction of crossbite in these cases is necessary and
can be achieved through the use of fixed or removable 11.2.2.5 Tooth Number and Eruption-Related
appliances, as described earlier in the primary dentition, Anomalies
following the selective grinding of the primary teeth General information on tooth eruption disorders is pro-
involved [41]. Furthermore, skeletal-related crossbite can vided in 7 Chap. 10. This section will only discuss them
also occur related to size abnormalities in the maxilla in relation to the aligning of the dentition through orth-
or the mandible, reflecting asymmetries at the base of odontic means.
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238 K. Park et al.
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Orthodontic Knowledge and Practice for the Pediatric Dentist
239 11
a b
.. Fig. 11.45 a Severe ectopic eruption of both maxillary first per- further assisted by newly inserted rubber rings. c Complete eruption
manent molars. Orthodontic brackets bonded on their erupted part, in 14 weeks. If the second primary molar root resorption later leads
and spring bearing elastic wire is directly bonded on the three adja- to their premature loss, space maintenance may be needed
cent primary teeth for each side. b Corrected eruption in 8 weeks
a b c
.. Fig. 11.46 a Ectopic eruption of a maxillary first permanent leukemia. b The primary molar was lost, leading to severe lack of
molar with complete root resorption of the adjacent second primary space. c Regaining is attempted using a Hawley appliance, fitted with
molar in a girl aged 7 years with a history of acute lymphoblastic a jackscrew
abnormalities with multiple supernumerary teeth, such orthodontic advice is useful for deciding the best suited
as cleidocranial dysplasia (CCD), may prove extremely solution. Building the crown height of a primary molar
difficult and should be treated by a specialized ortho- with severe infraocclusion prevents further diversion of
dontist in cooperation with a maxillofacial surgeon [48]. the adjacent teeth (7 Fig. 10.21). Monitoring should
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240 K. Park et al.
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Orthodontic Knowledge and Practice for the Pediatric Dentist
241 11
a b
a b
c d e
.. Fig. 11.50 a, b Eruption failure of the maxillary left central inci- with correct occlusion of the incisor. The high cervical gingival line
sor is due to a mesiodens in a 9-year-old girl. c, d Its surgical removal with reduced attached gingival requires gingivoplasty
followed by orthodontic traction of the permanent incisor. e Result
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242 K. Park et al.
mainly aiming to prevent tongue thrust during swallow- be painless, and its use should not expose the mouth to
ing (. Fig. 11.52). A fixed habit cessation appliance
potential injuries.
bypasses the issue of compliance, but it is only advised
in cases where the child wants to stop the habit [51]. It 11.2.3.2 The Position of the Tongue at
consists of two bands cemented to the molars and a wire Swallowing
arch with grid that obstructs thumb entry into the mouth Abnormal positioning of the tongue while swallow-
(. Fig. 11.53). It must not interfere with occlusion and
ing has in the past been referred to as infantile swal-
low, reverse swallow, or tongue thrust and has been
associated with the emergence of anterior open bite. It
is natural for infants to swallow with the mouth open,
that is without occluding, with the tongue positioned
between any teeth present and not coming into contact
with the palate. Upon completion of the primary den-
tition, infantile swallowing is replaced by adult swal-
lowing patterns, during which the tongue movement is
more complex. There are cases however where infantile
swallow persists and the tongue protrudes through the
anterior teeth, causing anterior open bite and/or other
dental abnormalities [52]. In the case of preexisting
open bite, the abnormal position of the tongue when
swallowing might be an adaptive movement, and the
problem that originally caused the open bite should be
addressed first.
Tongue thrusting may be quite prevalent in the mixed
.. Fig. 11.51 Severe infraocclusion of the second permanent molar
dentition, up to 40% in some communities [53, 54]. In
11 in an adult. Its ankylosis has occurred in childhood, possibly by
trauma to its periodontium during extraction of the adjacent first many cases, tongue thrusting can be related to breath-
permanent molar ing disorders, namely, tonsil hypertrophy and chronic
a b
c d
.. Fig. 11.52 a Severe anomaly at the vertical plane (open bite) due to prolonged use of pacifier. b, c Commercial appliance and its use after
habit cessation for prevention of tongue thrust. d Very significant improvement in occlusion after 6 months
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243 11
a b
c d
.. Fig. 11.53 a Anterior open bite through persistent harmful sucking of thumb in the primary and mixed dentition. b Treatment by fixed
appliance for habit cessation. c, d Intermediate and final result before any further orthodontic intervention
mouth breathing. The participation of the tongue in occlusal problems, while referral to an otolaryngologist
this functional imbalance of the oral musculature can at the same time is considered pertinent so potential
lead to the creation or increase of Angle Class II mal- problems can be diagnosed and the method and time of
occlusion. The first treatment step for this disorder is action decided upon.
orofacial-myofunctional therapy. Specifically, the young
patient should perform normal swallowing exercises at 11.2.3.4 Nail-Biting
regular periods of time throughout the day. An appli- Nail-biting is a rare habit before ages 3–6 years. It has
ance that obstructs tongue thrusting, similar to the type been suggested that this habit is related to stress and
used to stop thumb-sucking, could also be used. low self-esteem and that its frequency increases around
puberty. Chronic nail-biting does not cause disorders
11.2.3.3 Mouth Breathing in occlusion but is considered responsible for the wear-
Mouth breathing and its relation to the emergence of ing of incisal edges and the appearance of small enamel
orthodontic abnormalities is a complex issue, because cracks, particularly in the maxillary incisors. Wire appli-
it is hard to distinguish between exclusively mouth ances have been proposed to help onychophagic young
breathers and nose breathers in the various studies. It is persons manage their chronic habit [56]. Some children
believed that all people go through phases of nose and have the habit of biting pencils and other objects which,
mouth breathing during the day [55]. There is a weak if of a chronic nature, may have some effect on the posi-
correlation between mouth breathing and the existence tion of the involved teeth.
of abnormalities that, together, constitute the so-called
“adenoid faces” (. Fig. 11.54). Characteristics include
11.2.3.5 Lip Sucking
an oblong face with an increased lower anterior height, Sucking of the lip is easy to discern, since the lips and
short or toneless lip, and maxillary/mandibular inci- some of the perioral skin of children who have this
sor protraction. The existence of the aforementioned habit are red and appear inflamed. Although this habit
abnormalities does not automatically justify surgi- does not have serious consequences for the teeth, it can
cal intervention in the adenoids or the nasal conchae, contribute to the maintaining of a preexisting occlusal
since these characteristics can appear without the coex- abnormality, especially if this habit takes place often, is
istence of mouth breathing [52]. In this case, the goal done intensely, and lasts long. Sucking of the lower lip
of orthodontic treatment should be addressing patient’s and its interference while swallowing may increase labial
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244 K. Park et al.
11
.. Fig. 11.55 Occlusal anomaly with excessive overjet and overbite. Folding due to interference of the lower lip of the same patient while
the teeth are in occlusion at swallowing
inclination of the maxillary incisors as well as lingual 4. Ngo CTT, Fishman LS, Rossouw PE, Wang H, Said O. Correla-
inclination of the mandibular incisors, thus contributing tion between panoramic radiography and cone-beam computed
tomography in assessing maxillary impacted canines. Angle
to increased anterior overjet (. Fig. 11.55).
Orthod. 2018 Jul;88(4):384–9. https://doi.org/10.2319/103117-
739.1.
5. Jung YH, Liang H, Benson BW, Flint DJ, Cho BH. The assess-
ment of impacted maxillary canine position with panoramic
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reducing overjet and open bite associated with thumb sucking scope. 1990;100:89–93.
habit. Minerva Stomatol. 2011;60(7–8):333–8. 56. Marouane O, Ghorbel M, Nahdi M, Necibi A, Douki N. New
52. Christensen JR, Fields HW, Adair SM. Oral habits. Ch. 26. In: approach to managing onychophagia. Case Rep Dent.
Casamassimo PS, Fields Jr HW, McTigue DJ, Nowak AJ, edi- 2016;2016:5475462. https://doi.org/10.1155/2016/5475462.
tors. Pediatric dentistry. Infancy through adolescence. 5th ed.
Philadelphia: Elsevier, St. Louis; 2013. p. 385–92.
11
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Contents
References – 277
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248 N. Kotsanos et al.
adherence of mature dental plaque (intraoral biofilm) The enamel surface zone however is not critically
to a tooth surface is required. Dental plaque harbors affected because de- and remineralization cycles pre-
a plethora of microorganisms (bacteria) on the tooth serve it while chemical dissolution progresses into
surface (host). These microorganisms thrive on ferment- deeper enamel. This is primarily owed to its continuous
able carbohydrates (substrate), producing organic acids repair by redeposition of dissolved mineral from deeper
which in turn influence plaque in terms of its acidogenic enamel and/or from the biofilm reservoir when plaque
and acidophile synthesis. This is known as the “ecologi- pH rises again above the critical level [4] (. Fig. 12.2).
cal plaque hypothesis.” [2]. Later, only after the carious lesion front has advanced
The composition and metabolic activity of microor- into the dentin, the relatively intact but insufficiently
ganisms in the biofilm, by the duration over which acids supported surface zone collapses, resulting in a cavi-
remain on the tooth-plaque interface, affect the min- tated lesion (. Fig. 12.3). Thus, during the early stage,
eral balance of the hard tissues with their liquid envi- caries affecting the enamel is a physicochemical process
ronment toward de- or remineralization. Contributing (demineralization), whereas cavitation is a late stage that
factors include thickness/maturation of dental plaque, is caused by mechanical stresses.
frequency of exposure to fermentable carbohydrates Demineralization tends to follow anatomical path-
12 (pH drops), developmentally defective dental tissues, ways, enamel prisms, and dentinal tubules (. Figs. 12.3
reduced salivary flow and buffer capacity, and inad- and 12.4). If responsible caries risk factors have not
equate exposure to fluoride. Such factors may prolong been addressed prior to cavitation, caries progression
the effects of the acids responsible for tilting the balance toward the dentin includes proteolytic processes tak-
toward demineralization and create active disease condi- ing place in the presence of higher pH levels than those
tions. It is accepted that caries is a multifactorial disease, required for demineralization. Effective biofilm removal
in which many environmental, genetic, and behavioral from inaccessible cavities is not possible through every-
risk factors interact [3]. Arresting the caries process day oral hygiene practices; therefore caries progression
(remineralization) can be achieved by controlling some becomes difficult to control. Exceptions may be shallow
or most of the factors responsible for its activity. cavitated lesions in accessible tooth surfaces (e.g., buc-
cal surfaces); these may be easily arrested by rigorous
plaque removal. Otherwise, restoring the tooth anatomy
with a biocompatible material allows again adequate
Overview cleaning of all tooth surfaces.
The following factors are important determinants of
caries activity and progression: 12.1.1.2 Caries Microbiology
55 Fermenting bacteria – mature (thick) dental plaque According to the “ecological plaque hypothesis,” plaque
55 Diet – frequent exposure to fermentable carbohy- is a structurally and functionally organized biofilm [2].
drates It is formed in an orderly way, and, in a healthy mouth,
55 Dental enamel – e.g., developmentally prone to it remains relatively stable (in a state of microbial
breakdown or hypoplastic homeostasis) containing low amounts of potentially
55 Chemotherapeutic agents – e.g., exposure to fluo- pathogenic species of microorganisms. In an active dis-
ride ease state, a shift occurs whereby acid-producing and
55 Host defense – e.g., saliva buffering capacity, acid-tolerant microorganisms become dominant in the
unspecified genetically mediated plaque. Many microorganisms, in particular Streptococci
55 Socioeconomic factors – affecting behavior, priori- and Lactobacilli, but also Diphtheroids, some fungi, and
ties, means Staphylococcus can produce enough acids to demineral-
ize hard dental tissues. Streptococcus mutans, which has
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Dental Caries Prevention in Children and Adolescents
249 12
a
.. Fig. 12.1 a A proximal caries lesion in a mandibular first permanent molar seen after the extraction of the second primary molar. b Col-
lapsing of the superficial enamel zone allows retention of plaque in the small cavity
a b
.. Fig. 12.2 a Microradiograph of an enamel section with a small caries lesion with relatively intact surface zone. b Mapping of mineral loss
percentages in the various zones in the same lesion.
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250 N. Kotsanos et al.
Socioeconomic Status
.. Fig. 12.4 a Transmission electron microscope view of trans- Children living in poverty have twice the rate of dental
versely cut carious enamel which shows dissolution of crystals inside caries compared to children living in more affluent fami-
the prisms. ×3,000. b Image of cut carious dentin by the same tech-
lies. This disparity in caries rates continues through until
nique shows the demineralized collagen fibers and the presence of
bacteria in the enlarged dentinal tubules. ×5,000 adulthood, although the differences dissipate in older age
groups [13]. There is also evidence that children of minor-
ity groups experience higher caries rates and unmet treat-
ment needs compared to national average [14]. Moreover,
in many areas of the world, minority children are more
likely to lack dental insurance coverage.
reduced, in the absence of effective toothbrushing prior to orthodontic treatment are in greatest risk dur-
ing treatment. They require intense supervision for
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Dental Caries Prevention in Children and Adolescents
251 12
a b
.. Fig. 12.6 a First permanent molar with MIH showing break- average oral hygiene habits. He is likely the beneficiary of protective
down of brittle enamel that is prone to caries formation. b The car- hereditary salivary factors, good tooth anatomy, and lack of dental
ies-free dental arch of a 21-year-old who has a cariogenic diet and arch crowding
b c
.. Fig. 12.7 a Primary caries lesions detected immediately after out proper oral hygiene. c. Same patient as in b. Demineralized
removal of orthodontic brackets from the upper lateral incisors and enamel around the removed orthodontic brackets shows through the
canines. b Unusual caries presentation at the incisal edges of the transparent retainer in maxillary anterior teeth
lower incisors due to orthodontic retainers worn for two years with-
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252 N. Kotsanos et al.
.. Fig. 12.8 Severely defective restorations on primary and perma- 12.1.3 Clinical Manifestation of Caries
nent molars. They were placed without the benefit of a radiographic
evaluation In childhood and adolescence, dental caries almost
always initiates on enamel surfaces, as root surfaces are
12.1.2 Epidemiology and Treatment Needs not normally exposed in the oral cavity. The partially
demineralized primary enamel lesion appears opaque
A number of researchers have found that children of white because the refractive index of the salivary con-
lower-income families are more likely to have early tent of its pores (water RI = 1.33) differs from that of
childhood caries [20, 21]. For example, only 10% of 3- sound enamel (RI = 1.62). By drying the lesion with the
to 6-year-olds enrolled in private kindergartens experi- air syringe (air RI = 1.0), the contrast with surrounding
12 enced dental caries with an average dmfs index of 0.4, normal, translucent, enamel increases. Further, in case
compared to 23% and 1.3 respective caries values of of active carious lesions in areas of plaque retention and
those enrolled in state-funded kindergartens [20]. Other reduced salivary flow, the white surface remains opaque
family stressors, such as divorce, having a parent in jail, by the prevailing demineralization. If the plaque is not
and exposure to neighborhood violence, have also been frequently supplied with carbohydrates or the lesion
predictive of caries; furthermore, greater numbers of surface is kept plaque-free, it becomes glossy due to
stressors are associated with increased risks for caries or prevailing remineralization. More often in occlusal pits
other dental problems [21]. Therefore, emphasizing the and fissures, influx of organic substances from saliva
impressive generalized decrease in caries rates of chil- and protein denaturation makes these initial lesions or,
dren in the industrialized world, i.e., for 12-year-olds sometimes the advanced too, appears stained very dark
between now and several decades ago, should not take (. Fig. 12.9).
the focus away from the extent and severity of this per-
sistent disease of childhood in some societal strata or
in less privileged countries worldwide. Control of dental
caries in young children remains an intractable problem, Overview
despite the great progress in scientific knowledge about Demineralized enamel surfaces (early carious lesions)
prevention. Families, especially those of low socioeco- are commonly found in areas of plaque retention and
nomic status lack knowledge or motivation. Pediatric reduced salivary flow:
dentists should closely monitor children of low-income 1. Pit, fissures, or other anatomical defects of enamel
families and families experiencing other stressors, as 2. Cervical smooth surface areas of teeth
well as counsel families on sound oral health practices, 3. Proximal surfaces, between gingival crest and the
to try to minimize the development of caries in these contact areas
at-risk children.
Although preventive measures in most countries, either
in home care or professionally applied, have contributed In the primary dentition, dental caries may initially show
to caries reduction in children, a significant number of a certain pattern, affecting primarily one of the surface
children in industrialized countries require restorative categories shown in the overview box, and later spread
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Dental Caries Prevention in Children and Adolescents
253 12
a b
c d e
.. Fig. 12.9 Early caries in clinical terms, a in pits and fissures of area (ε), coinciding with the areas of plaque retention, e erythrosine-
primary molars, b at the cervical third of labial surfaces of mixed dyed dental plaque on the pits and fissures of a first permanent
dentition anterior teeth, c in the proximal surface of a second pri- molar after brushing explains why these sites are prone to caries
mary molar. d Demineralization is around and below the contact
to more categories. The diagnosis of early dentinal caries malfunction may occur as a side effect of head and neck
affecting proximal surfaces of both the primary and per- radiotherapy. In all these forms of rapidly progressing
manent dentitions is possible from bitewing radiographs. caries, caries activity is at its highest.
There are some predisposing factors which can critically
affect the clinical pattern of caries. Most common in the 12.1.3.2 Arrested Caries
permanent teeth are developmental defects such as MIH Small carious lesions are easy to arrest, primarily with
and gross plaque retention around orthodontic brackets effective plaque removal. In some cases of advanced
(. Figs. 12.6 and 12.7). Hypomineralized second pri-
chiefly occlusal cavitated lesions, more often in primary
mary molars (HSPM) is another common factor in the molars, arrest may come as a natural phenomenon. The
primary dentition, leading to atypical carious cavities enamel walls may break down resulting to an opened cav-
and atypical restorations (see 7 Chap. 17). ity exposing the carious dentin to the oral environment
and thus presenting an opportunity to become arrested.
12.1.3.1 Severe Forms of Active Caries Demineralized dentin becomes ebony hard and very
Sometimes the de−/remineralization balance shifts dark in color by wear/remineralization (. Fig. 12.11).
intensely toward demineralization resulting in the rapid The discoloration is owed to protein denaturation of the
progression of caries. This rampant form of caries may partially demineralized dentin along with further degra-
be equated with dental cleaning neglect and depending dation of exogenous organic matter absorbed into the
on the patient’s age is an own responsibility or such of porous dental tissues. Darkening of the enamel or the
the parent/guardian. Rapidly progressing caries may dentin generally indicates a very slow mineral loss pro-
appear at any age. S-ECC is a term used for the preschool cedure or caries arrest.
age, [24] it is quite widespread in lower socioeconomic Restoration of primary teeth with arrested carious
populations, and its treatment is discussed in the next lesions may not be necessary except for the purpose
chapter. Rapidly progressing caries during adolescence of improving aesthetics. Having said that, caution is
(. Fig. 12.10) is of particular concern. The diet of the
required as caries active proximal surfaces may coexist.
adolescents with often excessive soft drink consump- Small, arrested carious lesions are much more common
tion, at a time when parental control weakens and peer in the pits and fissures of molars and their dark color
influence increases, may intensify the carious challenge aids diagnosis. These require close follow-up because
especially when they abstain from oral hygiene. Another they might not be fully arrested and in such cases, restor-
aggressive form of caries caused by severe salivary gland ative treatment is necessary (. Fig. 12.9e).
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254 N. Kotsanos et al.
12.1.4 Caries Diagnosis and Record Keeping i.e., hard dental tissue distraction, pain, and presence of
dentoalveolar inflammation.
It becomes apparent that dental caries is a chronic In the past decades, there has been increased inter-
disease, usually progressive in nature. Historically, est in etiologically treating dental diseases. In the twen-
treatment of dental caries has been synonymous with tieth century caries was being recorded using an index
surgical treatment (restorative treatment, prosthet- known as DMF (decayed, missing, filled, tooth or sur-
ics, dental materials, implants). This, by itself, did not faces). In the beginning of the current century, atten-
address the disease process but merely its symptoms, tion became focused on documenting and monitoring
of initial caries lesions of enamel. Introduced in 2005,
the “International Caries Detection and Assessment
a System” (ICDAS) [25] is an index that was developed
to include recording of early caries of enamel and
clinically visible dentin caries, by stage of progression.
Particular attention was paid to recording and manage-
ment of discolored enamel fissures, including treatment
options based on disease activity. The treatment and
follow-up of caries was therefore based on a system with
relatively standardized diagnostic criteria. Another sim-
ilarly detailed caries classification system is the “Nyvad”
visual-tactile classification system devised to enable the
detection of the activity and severity of caries lesions
with special focus on low caries populations [26]. On the
b other end, as most caries in developing countries remains
untreated, there is an index to evaluate the clinical con-
sequences in oral structures. This PUFA index records
severely decayed teeth with visible pulpal involvement
(P/p), ulceration caused by dislocated tooth fragments
12 (U/u), fistula (F/f), and abscess (A/a) [27].
>>Important
The International Caries Detection and Assessment
System (ICDAS) advantages:
55 Monitoring of the progression and arrest of cari-
ous lesions
55 Assessment of the effectiveness of treatment and
.. Fig. 12.10 a Severe early childhood caries. b Very high caries
disease management approaches
activity in a young adolescent, manifesting also as initial caries
(demineralization) in the interproximal surfaces of mandibular per- 55 May be used in both clinical and epidemiological
manent incisors caries research
a b c
.. Fig. 12.11 a Arrested caries in primary incisors. b Arrested carious “open cavity” in a second primary molar (possibly predisposed by
primary molar hypomineralization) planned to be restored based on patient’s request. c After its restoration with composite
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Dental Caries Prevention in Children and Adolescents
255 12
12.1.4.1 Diagnostic Techniques, Tools, later in this chapter. Monitoring disease progression is
and Appliances usually coded, e.g. by categorizing radiolucent lesion
Three basic diagnostic means have traditionally been in depth as confined to the
use in dentistry for the detection of early caries lesions. 55 D1: enamel
1. Direct Visualization 55 D2: outer third of the dentin
55 D3: middle third of the dentin
In most cases, direct visual observation is the basic diag- 55 D4: inner third of the dentin
nostic technique. Adequate diagnosis is only possible
on tooth surfaces that are accessible, dried, and free
of plaque. Additional aids may be necessary to ensure 12.1.4.2 Relationship of Clinical,
accurate diagnosis. Proximal surfaces of tooth surfaces Radiographic, and Histological
that are in contact cannot be visualized directly, unless Examinations
a suitable orthodontic elastic ring is inserted for a few Nonoperative diagnostic methods do not allow for
days pushing teeth apart for 1 mm or so. accurate assessment of the depth of caries lesions and,
2. Tactile Sensation in general, the clinical examination is the least accurate.
The actual depth could be evaluated only by a histologi-
Mainly on occlusal surfaces, tactile sensation with an cal examination of the hard tissues. Their relationship is
explorer can contribute to diagnosis in deep pit and fis- shown in . Fig. 12.14. Newer methods and techniques
sures and assure the need for sealing them. However, are continuously investigated for improved diagnostic
exerting pressure by a sharp explorer, a favorable prac- sensitivity. Thus far, new technologies have only acces-
tice of the past, imposes the risk of breaking undermined sory role in clinical practice [28].
demineralized enamel surface (ICDAS II grade 2 or 3)
and causing an iatrogenic microcavity (. Fig. 12.12).
12.1.4.3 Detection of Early Caries
Although a blunt probe has been suggested, [25] a sharp Not uncommonly, occlusal caries may have extended
explorer used with caution may at times be useful, just well into dentin despite the presence of an apparently
as it is in plaque removal from deep pits and fissures intact overlying enamel surface. This condition of “hid-
prior to their sealing. den caries” poses a diagnostic difficulty. It is thought
3. Radiographic Examination that the widespread access to fluoride often promotes the
preservation of the surface enamel over subsurface cari-
The radiographic examination of caries provides infor- ous lesions. In fact, the philosophy of arresting the pro-
mation on the presence and depth of lesions of the proxi- gression of early carious lesions is based on the necessity
mal and occlusal surfaces (. Fig. 12.13). The sensitivity
of preserving an intact surface over the partially demin-
of the radiographic technique should be considered for eralized “body of the lesion” (. Fig. 12.15). The thick-
a diagnosis that is as accurate as possible, as explained ness of the surface zone and even the depth of carious
lesion are probably positively influenced by the preserva-
tion of the original enamel surface (. Fig. 12.16). This
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256 N. Kotsanos et al.
a b
c d
.. Fig. 12.13 a, b Bitewing radiographs of a 5-year-old child with tion from the same patient at 15 years of age. Caries lesions D1 in the
caries on proximal surfaces of the primary molars. D1 lesion in the distal of lower left second and right first premolars, D2 in the distal
mesial of lower right second molar, D2 in the distal of lower right of upper right first premolar and mesial of upper right first molar,
first molar and the mesial of upper left second molar, D3 in the distal D3 in the distal of upper left second premolar, and D4 in the distal
of upper right first molar, and D4 in the distal of upper and lower of upper left first premolar. Some surfaces present with superimposi-
left first and mesial of lower left second molars (with pulpal involve- tions. In both sets, occlusal caries lesions are not detected radio-
ment in the lower left molars). c, d Bitewings of the permanent denti- graphically
12
12.1.4.4 Alternative Diagnostic Technologies accessible smooth surfaces. An optical fiber carries
for Carious Lesions light from a diode laser of 655 nm wavelength to the
Digital Image Fiber-Optic Trans-illumination dental surface under testing (. Fig. 12.18). The latter
(DIFOTI) absorbs the light; the organic and inorganic elements are
Diagnosis of caries is possible with use of an intense stimulated to produce infrared fluorescence. The sub-
light beam transmitted through optical fibers to ante- stances emitting fluorescence are porphyrins (bacterial
rior or posterior teeth at a buccolingual dimension. In metabolic products). The fluorescence is transferred to
a few European countries, fiber-optic trans-illumination another optical fiber back into the device resulting in a
has been used in place of bitewing radiography for more numerical display from 0 to 99. Values above
20 indicate
than three decades. Several studies have concluded the existence of decayed hard tissue.
that this technique shows the same efficacy compared Several in vitro and in vivo studies show sig-
to the clinical examination. This technology has been nificant sensitivity in caries detection by the
advanced with the introduction of a digital display. The DIAGNOdent (KaVo Dental Co) and VistaProof
observed image is recorded by a charge-coupled device (Durr Dental) systems. They demonstrate very good
(CCD) technology digital camera which is then sent to reproducibility of measurements on the occlusal
a computer for analysis (. Fig. 12.17). DIFOTI has a
surface. The measurements are influenced by several
similar sensitivity to conventional radiographs, but lags factors including:
behind in assessing the depth of the lesion into dentin 55 Enamel dehydration from persistent air drying
[30, 31]. It is a relatively new technique which has not yet 55 Presence of calculus, plaque, or discolorations
undergone sufficient clinical research testing. 55 Presence of pit and fissure sealants [32]
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257 12
a b c
d e
.. Fig. 12.14 a Periapical radiograph (taken in vitro) of a premolar Both could not be clinically detectable (in situ). d In longitudinally
which has been extracted for orthodontic reasons. On the left proxi- splitting the tooth the extent of the two lesions is visible. The front
mal surface, a radiolucency is observed on the outer half of enamel of the cavitated lesion is well into the dentin e The front of the white
and slightly in the underlined dentine (D2). On the other proximal spot is limited in the enamel. The observed cracks in the dentin are
surface there are no findings. b The former exhibits a minor break- due to dehydration
down of the superficial enamel c The latter presents a white spot.
lesions and its slow speed for image analysis. Therefore, which is divided into multiple picture elements (pix-
QLF cannot be recommended for routine use in the den- els). Upon exposure to radiation, electric charges cor-
tal office setting. At present, cost/benefit ratio data are responding to energy-bearing photons hitting the sensor
lacking for both DIFOTI and QLF technologies. are generated in each pixel. The analog signal, once
converted to digital, is shown on the computer screen in
Digital Radiography various shades of gray [36]. In pediatric dentistry, there
The effort to reduce the emitted Röntgen radiation are two significant disadvantages to the CCD technol-
led to the adoption of the most sensitive conventional ogy: the thickness the CCD sensors, their cord, and their
radiographic F speed film which demonstrated high high cost.
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258 N. Kotsanos et al.
a b
c d
.. Fig. 12.15 a Low magnification of a scanning electron micro- izing microscope showing the ending of six striae of Retzius at the
scope photomicrograph showing perikymata and enamel rod ends respective six perikymata on enamel surface. d Similarly cut enamel
seen on the enamel surface of a newly erupted premolar crown. b section with artificially created small caries lesion imbibed in water
Part of A is further magnified to show the evident discontinuity of (R.I. =1.33). The 6-lobe pattern of subsurface demineralization is
12 the surface at a perikyma (arrows) which may represent weak points probably related to entry points at the merging of six perikymata
in caries attack. c Longitudinal section of sound enamel in the polar-
b c
.. Fig. 12.16 a Microradiograph of enamel cut perpendicularly to artificial carious created in one half of a 3rd molar which has been
the long axis of the tooth with an artificial “carious” enamel lesion surgically extracted from an adolescent before full enamel matura-
imitating the natural caries lesion. In the right part (flattened) the tion was accomplished. c Prior exposure of the other half tooth to a
surface zone of enamel had beforehand been ground away. The mineralizing solution (enriched with Ca++ and PO4---) before the
lesion surface zone in this part is much thinner and the depth of artificial caries formation favors development of a much smaller
demineralization much greater than in the left part with original lesion and well-remineralized enamel surface zone (b, c: sections in
enamel. b Absence of adequately remineralized surface zone in an water are observed in polarizing microscope)
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Dental Caries Prevention in Children and Adolescents
259 12
a b The number of electrons is proportional to the intensity
of radiation. The plate is scanned in a reader machine
(. Fig. 12.22) and the electrons emit light at a particu-
>>Important
Digital radiography has many advantages over the con-
ventional radiography film:
c 55 Reduction of radiation dose
55 Direct image production
55 Avoidance of film and developer liquids
55 Reduction of time and cost
55 Ability to edit and enhance the image
55 Compatibility with keeping only electronic patient
records
55 Ease of duplication for copies to accompany referrals
thin as the conventional radiographic films. They are additional data to be entered, such as saliva and intra-
cordless and flexible (not quite as much as films) com- oral microflora, and includes the following ten factors
pared to CCD sensors (. Fig. 12.21). These features
with different weight upon the final risk level:
make their use more child-friendly and therefore pref- 1. Presence of caries lesions
erable in pediatric dentistry. They are somewhat more 2. Medical condition and medications
sensitive than CCD, resulting to even less radiation dose 3. Salivary Lactobacilli and mutans Streptococci
for the patient. Image formation is different in SPP tech- counts
nology. The SPP plate has no pixels but rather the ability 4. Diet content
to reliably store an image for up to 10 minutes [37] in the 5. Number of between meal snacks
following way. Electrons activated by radiation photons 6. Plaque amounts
remain trapped for some time at higher energy layers. 7. Use of fluoride supplements
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260 N. Kotsanos et al.
a b
.. Fig. 12.19 a Image by QLF system of early caries on occlusal surface of molar. b QLF handpiece and laptop
a b
.. Fig. 12.20 a Front side of two different size CCD plates with ceramic base. b Backside
12
a b
.. Fig. 12.21 a SPP plates (at left) have similar size with the conven-
tional radiographic films No. 0 and 2 (at right). b Backside of SPP .. Fig. 12.22 An SPP plate is inserted for scanning (Digora, Soredex,
plates KaVo Dental)
have been conducted in children, either in the primary appear to be a prognostic factor for dental caries [40].
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Dental Caries Prevention in Children and Adolescents
261 12
Therefore, the presence of the black stain may be predic-
tive of low caries risk in childhood. The esthetic prob-
lem can be addressed by polishing the enamel with a
rotary ibrush and tooth polishing paste assisted by using
ultrasound tips in inaccessible to brush areas. Older chil-
dren may accept air-powder abrasive systems. Effective
toothbrushing may substantially prevent the formation
of black stain.
It should be mentioned that other types of extrin-
sic black stain may at times be observed on children’s
.. Fig. 12.23 Screenshot of the Cariogram pie graph teeth, such as from an iron supplement (. Fig. 12.24d).
so for children in the primary dentition [41]. Designed investigated at present. Its removal is as easy as ordinary
in the last part of the past century, i.e., before the era dental plaque, unlike the black stain which requires pro-
developmental tooth anomalies like MIH and HSPM fessional cleaning.
have been closely associated with caries, it does not list
12.1.5.3 The Treatment Strategy of Caries
them in the risk factors.
Primary prevention requires taking measures to promote
>>Important the nonoccurrence of a disease. Management strategies
Risk factors for the prediction of future caries gener- of dental caries has the same basic purpose to control
ally include the progression of the disease as early as possible, before
55 A higher dmfs or DMFS index than average for it leads to localized demineralization and subsequent
the child’s age cavitation. Traditionally, for the dental profession and
55 The presence of demineralized enamel areas (pre- the public alike, restoring carious cavities has been
cavitated caries lesions) synonymous with caries treatment, while measures for
55 High levels of mutans Streptococci in saliva maintaining a healthy dentition were considered pre-
55 Developmental defects of enamel vention. Thus, professional efforts to address caries as
55 Low socioeconomic status an infectious disease have focused more on restorative
55 A diet that is high in sugar content (surgical) and less on therapeutic (etiological) treatment.
55 Presence of orthodontic or other dental appli- The understanding of dental caries etiology and
ances of the role of therapeutic agents such as fluoride led
to interventions offered at the very early stages of
12.1.5.2 Presence of Extrinsic Black Stains possible caries development, before the occurrence of
The presence of black stains on the tooth surfaces is clinically detectable demineralization. Presently, treat-
inversely associated with caries risk, both in the pri- ment interventions of dental caries include effective
mary and the permanent teeth [42]. This however has communication (i.e., oral hygiene education by motiva-
only been studied in children and there is not any lon- tional interviewing and self-management) and clinical
gitudinal data. Its formation is significantly reduced measures aimed at preventing or controlling (healing)
in the permanent dentition compared to the primary of primary caries lesions. Although tooth repair with
dentition (. Fig. 12.24). Prevalence has reported to be
restorative materials and endodontic and prosthetic
from 2.4 up to 16%. Its microflora consists mainly from procedures (described in 7 Chapters 13 and 14) will
Actinomyces, differing to cariogenic plaque dominated remain important to dentistry, these procedures merely
by Streptococci and Lactobacilli. This possibly explains treat the symptoms of the disease and not the disease
the lower caries prevalence of children with black stain. itself [3].
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262 N. Kotsanos et al.
a b
c d
.. Fig. 12.24 Black stain a In a 20-month-old child b In a 13-year-old adolescent. c Coexistence of black stain and caries in the primary
teeth of early mixed dentition. d Mild black stain as a result of long consumption of iron supplementation by a preschooler
>>Important
Prevention and control of dental caries in children and
adolescents include four parallel strategies:
1. Enhancement of tooth resistance to caries with
fluorides and other remineralization agents
2. Effective mechanical removal of the biofilm
3. Pit and fissure sealants in caries susceptible tooth
sites
.. Fig. 12.25 Orange plaque (biofilm) on first permanent and pri- 4. Controlling exposure to fermentable carbohydrates
mary molars
Beyond the third strategy which remains the responsi-
bility of the dental clinician, all other strategies require
12.2 Therapeutic Measures for Caries effective engagement and motivation of the patient and
Control family with the clinician’s guidance toward behavioral
changes that would lead to caries control. These strate-
The prevention of dental disease is perfectly interwoven gies will now be explained in greater detail.
with the provision of comprehensive dental care to chil-
dren and is an essential part of the practice philosophy
of pediatric dentistry. Prevention concerns all oral dis- 12.2.1 Fluorides and Medicinal Means
eases, abnormalities of occlusion, and possible injuries.
12.2.1.1 Fluoride
Preventive measures for optimal occlusion and function of
the dental arches, periodontal diseases, and dental trauma Mechanism of Action
in children and adolescents are covered in their respective By 1942, Dean et al. [43] observed the following findings
chapters. In this chapter, only those measures related to in conjunction with fluoride in drinking water:
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55 Low caries indices associated with high fluoride con- resecretion in saliva, which then enriches the dental
centrations plaque.
55 Increased “mottling” (fluorosis) of teeth associated
with higher concentrations of fluoride Systemic Fluoride
55 A fluoride concentration of 1 part per million (ppm) Water Fluoridation
in drinking water provided the best result of maxi- Water fluoridation is a systematic method of fluoride
mum caries reduction without mottling delivery on a community level. Three hundred million
people around the world drink fluoridated water, with
Based mainly on these findings, a fluoridation program 1.0 ppm to be the optimal concentration of fluoride.
of drinking water was begun for the prevention of den- During the second half of the twentieth century, more
tal caries at the community level in the United States. than 113 studies in 23 countries had already been pub-
This was followed by many epidemiological, laboratory, lished showing an approximately 50% caries reduction
and clinical studies to elucidate the mechanism of fluo- [45]. In the United States, the cost of fluoridation of
ride action and the most effective ways for its implemen- drinking water is 10 cents to 1.5 USD per person per
tation. It was long believed that its incorporation into year, in inverse proportion to the size of the commu-
the enamel during its formation offered increased resis- nity. Despite being an inexpensive and effective method
tance to dental caries but was later shown by artificial of caries prevention, there is some public opposition to
caries formation in vitro that enamel fluoride content adding fluoride to drinking water. Most European coun-
was of lower importance [3]. At the same time, the claim tries have not adopted it, although its use is supported
that the transformation of hydroxyl- to fluorapatite (by by the European Academy of Paediatric Dentistry [46].
replacement of OH− with F− ions) was responsible for
increased caries resistance became disproved, since only Milk Fluoridation
a very small percentage of mineral volume underwent It has been used in some countries, mainly in indoor
such transformation. childcare centers such as boarding schools and kinder-
The current understanding is that the presence gartens. In a randomized control clinical trial of 6-year-
of fluoride at the tooth-plaque interface is impor- old children, those who consumed fluoridated milk from
tant (. Fig. 12.26). During de- and remineralization
the age of three years showed 76.4% lower DMFT and
activities, only a minimal amount of fluoride favors the 31.3% lower dmft indices in comparison to the control
equilibrium to be tipped toward remineralization. In group [47]. Fluoride concentration in milk is usually
addition, after a topical application of fluoride, CaF2 2.5–5.0 mg F/L. [48] Milk fluoridation has limited appli-
crystals are formed on tooth surfaces which are respon- cations. Its use could be part of community health pro-
sible for the sustained pH-controlled release of fluoride. grams in target groups with high caries prevalence and
It is therefore accepted that the anticaries effect of fluo- low compliance for toothbrushing [46].
ride is mainly topical [44]. Even when fluoride is avail-
able through a systemic route, such as from drinking Salt Fluoridation
fluoridated water, its effects are mainly topical through Fluoridated salt is available in over 30 countries around
the world, e.g., Switzerland, Germany, France, and
Costa Rica. As a caries preventive measure, it is con-
sidered quite effective, but its effectiveness has not been
well documented. Moreover, its usefulness in children,
particularly those of young age, is very limited as chil-
dren generally follow a diet low in salt [48].
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264 N. Kotsanos et al.
American Dental Association fluoride supplementation usually ranges from 1000 to 1450 ppm (. Fig.12.27).
schedule is based on the fluoride concentration of drink- Toothpastes with 5000 ppm F are specifically targeted
ing water and the age of the child [50]. to special care patients, high caries risk adolescents, and
those with fixed orthodontic appliances, yet without
Topical Fluorides sound evidence for superior effectiveness [53].
Home Use In addition to fluoride and other possibly antimicro-
Toothpaste bial substances, toothpastes contain mainly two types
Over-the-counter fluoridated toothpaste is the most of active ingredients to enhance brushing effectiveness,
effective vehicle of fluoride exposure. Fluoridated tooth- abrasives and surfactant factors to improve tooth and
paste may be the most important preventive measure plaque wetting. The main concern of fluoride toothpaste
that is responsible for the dramatic reduction in caries use in young children is the risk of fluorosis – usually
levels in developed countries since the 1970s. Its role in mild in appearance – that is caused by chronic swallow-
preventing tooth decay has been documented by numer- ing [54]. Considering the child’s caries vs. fluorosis risk,
ous studies [51, 52] to be effective in reducing caries rates advice should be based on recommendations on the fluo-
by 21%–28% compared to non-fluoride toothpaste. ride concentration and amount of toothpaste according
Fluoride is contained in toothpaste either in the form to age (. Table 12.1). Because of the continued high car-
of inorganic salts such as sodium fluoride (NaF), stan- ies rates and the difficulty in predicting caries risk in tod-
nous fluoride (SnF2), and monofluorophosphate fluo- dlers, the American Dental Association recommended
ride (MFP) or in the form of organic compounds such as caregivers to start brushing children’s teeth at eruption
amine fluoride (NF4−) which theoretically offers greater of the first tooth and with no more than a smear or a rice
availability of free fluoride ions. Fluoride concentration grain size of fluoridated toothpaste twice a day [55, 56].
Fluoride Rinses
a Fluoride rinses usually contain NaF in different concen-
trations, ranging from 225 ppm (or less) to 800–900 ppm
fluoride. They are aimed at high-risk children, and the
high F rinses are recommended for less frequent use,
12 e.g., weekly. Because of the risk of swallowing, it would
not be recommended for preschoolers. Efficacy of fluo-
ride rinses in preventing caries is better documented for
permanent teeth [46].
Professional Application
Fluoride Gels and Varnishes
Fluoride gels contain 12,300 ppm fluoride either as
acidulated phosphate fluoride (APF) at pH 2.3 or as
b
.. Table 12.1 Recommended use of fluoride toothpastes in
children [46]
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Dental Caries Prevention in Children and Adolescents
265 12
a b
.. Fig. 12.28 Disposable fluoride treatment trays: a. for primary dentition filled with APF foam. b. for mixed dentition with APF gel
(1.23%)
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266 N. Kotsanos et al.
a b
.. Fig. 12.30 Caries of the maxillary left primary first molar a before SDF application and b after SDF application
Over a 30-month follow-up, SDF had 48% higher suc- or from public supply. Infants who consume formula
cess rate in caries lesion arrest compared to the controls. that is prepared with fluoridated water are at risk of
The AAPD guidelines [63] endorsed the use of SDF for developing fluorosis in their permanent teeth, espe-
the arrest of cavitated carious lesions in primary teeth as cially if such formula is consumed around the age of
12 part of a comprehensive caries management program. 2 years. Fluoride chewing gums containing 0.25 mg
Additionally, until more evidence becomes available, fluoride per piece are available. In addition, some
close monitoring based on patient’s disease activity and foods, such as fish and tea, have considerable fluoride
caries risk level is recommended. concentration.
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Dental Caries Prevention in Children and Adolescents
267 12
55 8 ml of APF gel (12,300 ppm F) mean caries rate compared with the sole use of fluori-
55 4.4 ml fluoride varnish (22,600 ppm F) dated toothpaste [68].
Probiotics
The rise in microbial strains that have become resistant
to antibiotics has recently led to a search for alternative
methods of preventing dental caries. Bacteriotherapy,
which aims to significantly displace pathogenic microor-
ganisms with harmless ones, has attracted the attention
of both researchers and food manufacturers resulting in
.. Fig. 12.31 Casein phosphopeptide-amorphous calcium phos- the introduction of the so-called probiotics. Some pro-
phate (CPP-ACP, Recaldent, GC) in creamy form biotics contain species of Lactobacilli, Bifidobacteria,
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268 N. Kotsanos et al.
12.2.2.1 Toothbrushing
Toothbrushing is a socially acceptable practice for
b
plaque removal for all age groups. Parents frequently
have questions regarding toothbrushing in terms of the
actual technique, frequency and duration, type of brush
(shape and size of head or handle, bristle hardness, elec-
tric versus manual), and toothpaste (amount and con-
centration of fluoride) to use.
flora. Probiotics are also available in other forms, such ticipation of parents is considered necessary for the most
as tablets (. Fig. 12.32). The benefits of probiotics do
posterior teeth until the age of 7–8 years, because relative
not currently seem to be sustainable in altering the oral manual dexterity skills in most children are underdevel-
flora if their administration is not continuous. There are oped until then. Parental supervision of brushing for sev-
some encouraging results regarding their antimicrobial eral more years is recommended.
properties but effects on dental caries have not been Toothbrush bristles should be made of nylon with
documented [74]. soft rounded edges to reach the interdental areas while
being gentle to the gingival tissues. Electric toothbrushes
are increasingly used nowadays having typically a round
12.2.2 Dental Plaque Removal head aiming to brush teeth one by one (. Fig. 12.34).
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Dental Caries Prevention in Children and Adolescents
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Timing, Frequency, and Duration of Brushing
a
Since dental plaque begins to form on tooth surfaces with
the emergence of the first tooth in the oral cavity, tooth
cleaning should start as soon as the teeth erupt. At first,
the use of a piece of gauze is sufficient for plaque removal
from the first primary incisors. When many incisors are
erupted, and no later than the eruption of the first primary
molars, use of a toothbrush is a necessity (. Fig. 12.35).
Eye Catcher
a b
.. Fig.12.34 a Hand toothbrushes, infant size (far right) to adolescent and adult size (left). b Recent technology electrical toothbrush
(Oral-B iO) working with microvibrations
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270 N. Kotsanos et al.
a a
b
b
to accomplish, and its use in children could start after The depth and morphology of pits and fissures of occlu-
contacts are established between the primary molars. sal surfaces, especially in recently erupted teeth, do not
This is more important for caries risk children, provided allow for effective plaque removal with the toothbrush
risk can be estimated. Educating high-risk early ado- (. Fig. 12.38). With mature plaque behaving as a closed
lescents in the correct use of dental floss seems a good ecosystem allowing for reduced saliva and fluoride
practice. access, teeth with deep pits and fissures are particularly
Interdental brushes are the alternative solution of vulnerable and often become carious within a short time
plaque removal from interdental areas (. Fig. 12.37).
after their eruption [81]. Although the occlusal surfaces
Thin-sized such brushes are intended for daily use by represent only one-tenth of the total tooth surfaces in
adolescents at risk for dental caries or periodontal dis- the oral cavity, they may account for nearly 50% of the
ease. For added benefit, fluoride toothpaste or gel should cavitated lesions in children aged 6–12 years. A study
be added to the brush before applied to each interdental found that caries incidence on the occlusal surfaces of
space or combining interdental brushing with ordinary permanent molars peak approximately two years after
brushing for practical purposes. they begin to erupt [82].
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Dental Caries Prevention in Children and Adolescents
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a a
.. Fig 12.38 a The pit and fissure system of a molar occlusal sur-
face by low magnification scanning electron microscopy. b Stagnant
.. Fig.12.37 a Different thin interdental brushes and suggested
plaque disclosed with erythrosine on a partially erupted first perma-
fluoride gel. b Demonstration of interdental brush use
nent molar
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272 N. Kotsanos et al.
a a b
b c
c d
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Dental Caries Prevention in Children and Adolescents
273 12
year from beginning of eruption to full occlusion. Partially the salivary glands for saliva production, and its own
erupted teeth are more difficult to clean well, and there is ability to resist pH decrease (buffering capacity). The
practically no self-cleaning while the tooth is out of occlu- most important factor is the total time that plaque pH
sion. Therefore, this period of partial eruption carries the remains low, which is directly related to the frequency
highest caries risk for the occlusal surfaces of molars [81] of food intake [93]. The greater the number of meals
(. Fig. 12.38b). A resin sealant may be placed as soon as
and snacks, the longer pH at plaque/enamel interface
possible once the occlusal table is fully erupted. Until then, remains low, thus favoring demineralization of the den-
a glass ionomer sealant may be placed if those tooth sur- tal tissues (. Fig. 12.42).
faces considered as high risk [87]. Alternatively, rigorous Sugars in the diet is an important component of car-
brushing at home combined with topical fluoride applica- ies risk. Epidemiological studies such as the Vipeholm
tion on these surfaces every 3 months has been shown to be study [92] however, although extremely valuable, were
effective in reducing caries development [88]. conducted before the time of fluoride. A review of find-
Satisfactory sealant retention rates 53% after ten and ings shows that despite increases in sugar consumption,
35% and fifteen years have been reported [89]. Sealant communities that adopted frequent toothbrushing with
effectiveness for caries prevention varies between 83% in fluoride toothpaste experienced a significant decrease
the first year to 53% fifteen years after their initial place- in dental caries rates [94]. Therefore, proper preventive
ment [90]. The retention rates of either conventional or measures of oral hygiene along with use of fluorides
resin-modified glass ionomer sealants are substantially may mitigate the effect of the diet on dental caries, and
lower than those of resin sealants [87, 91]. Yet, it seems the contemporary view is that dental caries is primarily
that the anticaries action of glass ionomer sealants is owed to tooth cleaning neglect.
extended for a period after their loss, possibly due to the Nevertheless, parents and their children should
fluoride release from the small remnants of the material be advised to adopt a balanced and healthy diet and
in the fissures. avoid snacks that favor the development of caries
(. Fig. 12.43). A useful tool for assessing a young
and, when consumed at high frequency between meals, to assist in providing customized dietary counseling,
contribute to a significant increase in caries rates. Liquid and they have been met however with only partial suc-
carbohydrates, such as in soft drinks, sugar containing cess and sometimes without success at all [95]. This is
juices, or other drinks, etc., are also highly cariogenic one of the reasons they are not part of everyday prac-
but to a lesser extent, due to shorter oral clearance time tice of general practitioners, although other reasons
compared to the solid carbohydrates. like perceived financial and time constraints play a role
Sugar (sucrose) is the most implicated carbohydrate [96]. Anyway, between meal snacks may need to be con-
in terms of acid production in the plaque. However, trolled, with the number of meals plus snacks during the
glucose and fructose are also metabolized by microor- day ideally being five (three main meals and two snacks).
ganisms which can lead to acid production. Nowadays, It is important to emphasize avoiding harmful habits,
in conjunction with the use of many different types of e.g., the use of bottle or at will breastfeeding during the
sweeteners and syrups by the food industry, a simple night or the use of a sweetened pacifier, which are sig-
recommendation for reducing sugar intakes by children nificant risk factors for S-ECC [97].
is not enough. Consumption of foods such as bananas, In addition to its association with dental caries,
grapes, and other fruits, white bread, sugared cereals frequent consumption of sugar containing drinks and
(especially popular for children’s breakfast), pasta, pota- between meal snacks has also been linked with over-
toes, and even milk can all lead to acid production under weight and obesity [98]. Obesity has reached epidemic
certain conditions and to a drop in plaque pH below the proportions worldwide. In the United States, obe-
critical value of 5.5 for dissolving hydroxyapatite. sity rates had quadrupled in children aged 6–11 and
Therefore, sugar concentration is not necessarily almost doubled in adolescents aged 12–19 in a period
considered to be the most important factor for caries of 25 years [99], and a 2016 publication estimated the
development. Other important factors that influence percentage of obese children aged 2–19 years to be 17%
the cariogenicity of a food item is its ability to adhere [100]. In some epidemiological studies of preschoolers,
to tooth surfaces (affecting oral clearance), the rate at a positive relationship between overweight and obese
which it dissolves in saliva, its capacity to stimulate children has been found with their caries index [101].
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274 N. Kotsanos et al.
a 8.0
7.0
Plaque pH
6.0
Critical pH*
8.0
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Hours
breakfast coffee lunch sweet tea biscuit dinner coffee coffee
sweet sweet sweet
b 8.0
7.0
Plaque pH
6.0
Critical pH*
8.0
12 8
breakfast
9 10 11
coffee
12 13
lunch
14 15 16
tea
17 18 19
dinner
20 21 22 23
coffee
24 Hours
.. Fig. 12.42 Stephan curves with continuous recording of PH in contents leads to fewer pH drop episodes boosting remineralization
the plaque/enamel interface during a day. a Meals and multiple (Licensed under the Creative Commons Attribution-Share Alike 4.0
snacking prolong pH remaining below critical value and therefore International license, by Lolim95, Wikipedia commons)
increase caries risk. b Decreasing between meal snacking and sugar
Several other health risks associated with overweight dental care team is to not only help to educate the
and obesity in childhood include type II diabetes, car- patient and parents or family about disease etiology
diovascular diseases (hypertension, high cholesterol, but also to provide coaching and support to enable
and dyslipidemia), psychological stress (depression and the family to make lifestyle changes as improving
low self-esteem), respiratory disease (obstructive sleep oral hygiene practices, dietary habits, and fluoride use
apnea and asthma), and orthopedic (vlaisopodia and [103]. Traditional approaches involve the dental care
slipped capital femoral epiphysis) and liver function team telling the patient what to do. A close partnership
(steatohepatitis) [102]. or collaboration between an informed and engaged
patient and family and a proactive dental care pro-
vider is necessary in order for the patient to make suc-
12.2.5 Patient Motivation and Recalls cessful sustainable changes to improve their caries risk
[104]. A significant challenge is to determine how to
12.2.5.1 Patient Motivation help patients increase their motivation to make behav-
Dental caries is a chronic disease that is significantly ior changes. This is particularly important at turbulent
influenced by social and behavioral factors. When times. In a relevant longitudinal study of adolescents
patients have active caries, the disease process will in Brazil, for example, the frequency of toothbrushing,
progress unless the risk factors that are responsible the use of dental services, and the self-perceived need
for the disease are addressed. Effective control of the for dental treatment significantly decreased in com-
disease requires patient self-management of the etio- parison to immediately before the recent pandemic of
logical factors. An important role of the professional CoVid-19 [105].
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Dental Caries Prevention in Children and Adolescents
275 12
.. Fig. 12.43 Pyramid of Harvard School of Public Health for cor- hsph.h arvard.e du/nutritionsource/healthy-e ating-p yramid/.
rect frequency per kind of diet intakes. It must be accompanied by Accessed on March 20, 2021
sufficient intake of liquid and daily physical exercise. 7 https://www.
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276 N. Kotsanos et al.
12
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Dental Caries Prevention in Children and Adolescents
277 12
commitment to goals [106]. Motivation can be and often there is active caries disease with rapidly evolving lesions
is influenced by the health-care provider. What providers (cavities or “white spots”), the first step is to arrest them
do or say can make patients more or less likely to change or at least reduce their rate of progression. This requires
their behaviors. A key element of helping patients make the education of the preventive program, coaching and
positive behavior changes is a strong partnership while at support to establish self-management goals, as well as
the same time honoring their autonomy. Engagement and ultimately the long-term ability of the child or parent to
trust can be created by focusing on desires, goals, hope, make sustainable changes to improve their caries risk.
and positive expectations and for the patient’s oral health. This poses a challenging task to the clinician.
Asking open-ended questions can help patients elicit With advances in technology, traditional commu-
“change talk.” Motivational interviewing training is avail- nication methods such as reminders by post have been
able, and practice is important to improve the skills needed replaced by cell phone text messages, social network
to help patients improve their motivation for change. messages, e-mails, etc. It is a good practice to remind
patients and/or parents of the benefits of compliance
12.2.5.2 Recall Visit with follow-ups. Most dental records software programs
automatically update and support the follow-up system.
Overview In the absence of an automated electronic practice man-
During follow-up recall visits, patients should receive agement system, the basic demographic and contact
as a part of their ongoing caries disease prevention and information of each patient could be entered in a simple
management program: electronic file corresponding to the appropriate follow-
55 Reevaluation of caries risk factors up month based on the caries risk of the patient. If the
–– Assessment of patient compliance to pro- patient responds, a new recall is set in the appropriate
posed preventive measures and reactivation month. Some incentives might enhance patient motiva-
as needed tion or parent compliance with follow-up visits, e.g., a
–– Revisiting of self-management goals and low-cost policy for follow-ups, granting a new tooth-
reaffirming those goals or establishing new brush for improved oral hygiene, praising the child, or
goals granting small gifts if there are no treatment needs.
55 Clinical examination to assess for new/recurrent
caries and the status of preventive or restorative
treatments, e.g., fissure sealants, restorations, pulp References
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171–5. 41. Tellez M, Gomez J, Pretty I, Ellwood R, Ismail AI. Evidence
21. Kumar S, Tadakamadla J, Zinner-Gembeck MJ, Kroon J, Lalloo on existing caries risk assessment systems: are they predictive
R, Johnson NW. Parenting practices and children’s dental car- of future caries? Community Dent Oral Epidemiol. 2013;41(1):
ies experience: a structural equation modelling approach. 2017. 67–78.
Community Dent Oral Epidemiol. 2017;45(6):552–8. 42. de Rezende VS, Fonseca-Silva T, Drumond CL, Ramos-Jorge
22. Bolin AK. Children's dental health in Europe. An epidemiologi- ML, Paiva SM, Vieira-Andrade RG. Do patients with extrinsic
cal investigation of 5- and 12-year-old children from eight EU black tooth stains have a lower dental caries experience? a sys-
countries. Swed Dent J Suppl. 1997;122:1–88. tematic review and meta-analysis. Caries Res. 2019;53(6):617–27.
23. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and https://doi.org/10.1159/000500476.
sealant prevalence in children and adolescents in the United 43. Dean HTAF, Elvove E. Domestic water and dental caries. Public
States. NCHS. Data Brief. 2011-2012;2015(191):1–8. Health Report (US). 1942;57:1155–79.
24. Policy on Early Childhood Caries (ECC): classifications, conse- 44. Buzalaf MA, Pessan JP, Honório HM, ten Cate JM. Mecha-
quences, and preventive strategies. Pediatr Dent. 2016;38(6):52–4. nisms of action of fluoride for caries control. Monogr Oral Sci.
25. Honkala E, Runnel R, Honkala S, Olak J, Vahlberg T, Saag 2011;22:97–114. https://doi.org/10.1159/000325151.
M, et al. Measuring dental caries in the mixed dentition by 45. Murray JJ. Efficacy of preventive agents for dental caries. Sys-
ICDAS. Int J Dent. 2011;2011:150424. temic fluorides: water fluoridation. Caries Res. 1993;27(Suppl
26. Nyvad B, Baelum V. Nyvad criteria for caries lesion activity and 1):2–8.
severity assessment: a validated approach for clinical manage- 46. Toumba KJ, Twetman S, Splieth C, Parnell C, van Loveren C,
ment and research. Caries Res. 2018;52(5):397–405. https://doi. Lygidakis NΑ. Guidelines on the use of fluoride for caries pre-
org/10.1159/000480522. vention in children: an updated EAPD policy document. Eur
27. Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van Arch Paediatr Dent. 2019;20(6):507–16. https://doi.org/10.1007/
Palenstein Helderman W. PUFA – an index of clinical conse- s40368-019-00464-2.
quences of untreated dental caries. Community Dent Oral Epi- 47. Maslak EEAI, Kchmizova TG, Litovkina LS, Luneva N. The
demiol. 2010;38(1):77–82. effect of a milk fluoridation project in Volgograd. Caries Res.
28. Chawla N, Messer LB, Adams GG, Manton DJ. An in vitro 2004;38(4):377.
comparison of detection methods for approximal carious lesions 48. Espelid I. Caries preventive effect of fluoride in milk, salt and
in primary molars. Caries Res. 2012;46(2):161–9. tablets: a literature review. Eur Arch Paediatr Dent. 2009;10(3):
29. Kotsanos N, Darling AI. Influence of posteruptive age of
149–56.
enamel on its susceptibility to artificial caries. Caries Res. 49. Poulsen S, Gadegaard E, Mortensen B. Cariostatic effect of daily
1991;25(4):241–50. use of a fluoride-containing lozenge compared to fortnightly
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rinses with 0.2% sodium fluoride. Caries Res. 1981;15(3): 70. Petersson LG, Magnusson K, Andersson H, Deierborg G, Twet-
236–42. man S. Effect of semi-annual applications of a chlorhexidine/
50. Rozier RG, Adair S, Graham F, Iafolla T, Kingman A, Kohn fluoride varnish mixture on approximal caries incidence in
W, et al. Evidence-based clinical recommendations on the pre- schoolchildren. A three-year radiographic study. Eur J Oral Sci.
scription of dietary fluoride supplements for caries prevention: a 1998;106(2 Pt 1):623–7.
report of the American Dental Association Council on Scientific 71. Maruniak J, Clark WB, Walker CB, Magnusson I, Marks RG,
Affairs. J Am Dent Assoc. 2010;141(12):1480–9. Taylor M, et al. The effect of 3 mouthrinses on plaque and gin-
51. Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride tooth- givitis development. J Clin Periodontol. 1992;19(1):19–23.
pastes for preventing dental caries in children and adolescents. 72. Thorild I, Lindau B, Twetman S. Caries in 4-year-old children
Cochrane Database Syst Rev. 2003;1:CD002278. after maternal chewing of gums containing combinations of xyli-
52. Twetman S. Caries prevention with fluoride toothpaste in chil- tol, sorbitol, chlorhexidine and fluoride. Eur Arch Paediatr Dent.
dren: an update. Eur Arch Paediatr Dent. 2009;10(3):162–7. 2006;7(4):241–5.
53. Pretty IA. High fluoride concentration toothpastes for children 73. Thorild I, Lindau B, Twetman S. Long-term effect of maternal
and adolescents. Caries Res. 2016;50(Suppl 1):9–14. xylitol exposure on their children's caries prevalence. Eur Arch
54. Mascarenhas AK, Burt BA. Fluorosis risk from early expo- Paediatr Dent. 2012;13(6):305–7.
sure to fluoride toothpaste. Community Dent Oral Epidemiol. 74. Twetman S. Are we ready for caries prevention through bacterio-
1998;26(4):241–8. therapy? Braz Oral Res. 2012;26(Suppl 1):64–70.
55. American Dental Association Council on Scientific A. Fluo- 75. Bernardi S, Karygianni L, Filippi A, Anderson AC, Zürcher A,
ride toothpaste use for young children. J Am Dent Assoc. Hellwig E, et al. Combining culture and culture-independent
2014;145(2):190–1. methods reveals new microbial composition of halitosis patients'
56. Guideline on Perinatal and Infant Oral Health Care. Pediatr tongue biofilm. Microbiology. 2020;9(2):e958. https://doi.
Dent. 2016;38(5):54–8. org/10.1002/mbo3.958.
57. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride gels for 76. Higuchi T, Suzuki N, Nakaya S, Omagari S, Yoneda M, Hanioka
preventing dental caries in children and adolescents. Cochrane T, et al. Effects of Lactobacillus salivarius WB21 combined with
Database Syst Rev. 2002;2:CD002280. green tea catechins on dental caries, periodontitis, and oral mal-
58. Moyer VA. US preventive services task force. Prevention of den- odor. Arch Oral Biol. 2019;98:243–7. https://doi.org/10.1016/j.
tal caries in children from birth through age 5 years: US Preven- archoralbio.2018.11.027.
tive Services Task Force recommendation statement. Pediatrics. 77. Ceyhan D, Akdik C, Kirzioglu Z. An educational programme
2014;133(6):1102–11. designed for the evaluation of effectiveness of two tooth brush-
59. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride var- ing techniques in preschool children. Eur J Paediatr Dent.
nishes for preventing dental caries in children and adolescents. 2018;19(3):181–6. https://doi.org/10.23804/ejpd.2018.19.03.03.
Cochrane Database Syst Rev. 2002;3:CD002279. 78. Taschner M, Rumi K, Master AS, Wei J, Strate J, Pelka M. Com-
60. Stebbins E. What value has Argenti Nitras as a therapeutic agent paring efficacy of plaque removal using professionally applied
in dentistry? Int Dent J. 1891;12(10):661–71. manual and power toothbrushes in 4- to 7-year-old children.
61. Nishino M, Yoshida S, Sobue S, Kato J, Nishida M. Effect of Pediatr Dent. 2012;34(1):61–5.
topically applied ammoniacal silver fluoride on dental caries in 79. Sharma A, Arora R, Kenchappa M, Bhayya DP, Singh D. Clini-
children. J Osaka Univ Dent Sch. 1969;9:149–55. cal evaluation of the plaque-removing ability of four different
62. Ng MW, Sulyanto RS. Chronic disease management of car- toothbrushes in visually impaired children. Oral Health Prev
ies in children and the role of silver diamine fluoride. CDA. Dent. 2012;10(3):219–24.
2018;46(1):23–34. 80. Creeth JE, Gallagher A, Sowinski J, Bowman J, Barrett K, Lowe
63. Crystal YO, Marghalani AA, Ureles SD, Wright JT, Sulyanto S, et al. The effect of brushing time and dentifrice on dental
R, Divaris K, et al. Use of silver diamine fluoride for den- plaque removal in vivo. J Dent Hyg. 2009;83(3):111–6.
tal caries management in children and adolescents, including 81. Carvalho JC, Ekstrand KR, Thylstrup A. Dental plaque and
those with special health care needs. Pediatr Dent. 2017;39(5): caries on occlusal surfaces of first permanent molars in relation
135–45. to stage of eruption. J Dent Res. 1989;68(5):773–9.
64. Whitford GM. Fluoride in dental products: safety consider-
82. Harkane T, Larmas MA, Virtanen JI, Arjas E. Applying modern
ations. J Dent Res. 1987;66(5):1056–60. survival analysis methods to longitudinal dental caries studies. J
65. Evans RW, Darvell BW. Refining the estimate of the critical Dent Res. 2002;81(2):144–8.
period for susceptibility to enamel fluorosis in human maxillary 83. Wegehaupt F, Jorge F, Attin T, Tauböck T. Influence of short-
central incisors. J Public Health Dent. 1995;55(4):238–49. ened light-curing duration on the potential of resin-based
66. Tavener JA, Davies GM, Davies RM, Ellwood RP. The preva- surface sealants to prevent Erosion. Oral Health Prev Dent.
lence and severity of fluorosis in children who received tooth- 2017;15(1):79–87. https://doi.org/10.3290/j.ohpd.a37717.
paste containing either 440 or 1,450 ppm F from the age of 12 84. Lygidakis NA, Oulis KI. A comparison of Fluroshield
months in deprived and less deprived communities. Caries Res. with Delton fissure sealant: four year results. Pediatr Dent.
2006;40(1):66–72. 1999;21(7):429–31.
67. Cochrane NJ, Saranathan S, Cai F, Cross KJ, Reynolds
85. Lygidakis NA, Oulis KI, Christodoulidis A. Evaluation of fis-
EC. Enamel subsurface lesion remineralisation with casein phos- sure sealants retention following four different isolation and
phopeptide stabilised solutions of calcium, phosphate and fluo- surface preparation techniques: four years clinical trial. J Clin
ride. Caries Res. 2008;42(2):88–97. Pediatr Dent. 1994;19(1):23–5.
68. Sitthisettapong T, Phantumvanit P, Huebner C, Derouen
86. Papageorgiou SN, Dimitraki D, Kotsanos N, Bekes K, van Waes
T. Effect of CPP-ACP paste on dental caries in primary teeth: a H. Performance of pit and fissure sealants according to tooth
randomized trial. J Dent Res. 2012;91(9):847–52. characteristics: a systematic review and meta-analysis. J Dent.
69. Fennis-le YL, Verdonschot EH, Burgersdijk RC, Konig KG, 2017;66:8–17.
van’t Hof MA. Effect of 6-monthly applications of chlorhexi- 87. Antonson SA, Antonson DE, Brener S, Crutchfield J, Larumbe
dine varnish on incidence of occlusal caries in permanent J, Michaud C, et al. Twenty-four month clinical evaluation of fis-
molars: a 3-year study. J Dent. 1998;26(3):233–8. sure sealants on partially erupted permanent first molars: glass
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ionomer versus resin-based sealant. J Am Dent Assoc. 2012;143(2): 99. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin
115–22. LR, Flegal KM. Prevalence of overweight and obesity among
88. Carvalho JC, Thylstrup A, Ekstrand KR. Results after 3 years of US children, adolescents, and adults, 1999- 2002. JAMA.
non-operative occlusal caries treatment of erupting permanent first 2004;291(23):2847–50.
molars. Community Dent Oral Epidemiol. 1992;20(4):187–92. 100. Ogden CL, Carroll MD, Lawman HG, Fryar CD, et al. Trends
89. Romcke RG, Lewis DW, Maze BD, Vickerson RA. Retention in obesity prevalence among children and adolescents in the
and maintenance of fissure sealants over 10 years. J Can Dent United States, 1988-1994 through 2013-2014. JAMA. 2016 Jun
Assoc. 1990;56(3):235–7. 7;315(21):2292–9. https://doi.org/10.1001/jama.2016.6361.
90. Simonsen RJ. Retention and effectiveness of dental sealant after 101. Pikramenou V, Dimitraki D, Zoumpoulakis M, Verykouki E,
15 years. J Am Dent Assoc. 1991;122(10):34–42. Kotsanos N. Association between dental caries and body mass
91. Raadal M, Utkilen AB, Nilsen OL. Fissure sealing with a in preschool children. Eur Arch Paediatr Dent. 2016;17(3):171–
light-cured resin-reinforced glass-ionomer cement (Vitre- 5. https://doi.org/10.1007/s40368-016-0222-3.
bond) compared with a resin sealant. Int J Paediatr Dent. 102. Krebs NF, Jacobson MS, American Academy of Pediatrics
1996;6(4):235–9. Committee on N. Prevention of pediatric overweight and obe-
92. Gustafsson BE, Quensel CE, Lanke LS, Lundqvist C, Grahnen sity. Pediatrics. 2003;112(2):424–30.
H, Bonow BE, et al. The Vipeholm dental caries study; the effect 103. Ng MW, Fida Z. Dental hygienist-led chronic disease manage-
of different levels of carbohydrate intake on caries activity in ment system to control early childhood caries. J Evid Based
436 individuals observed for five years. Acta Odontol Scand. Dent Pract. 2016;16(Suppl):20–33. https://doi.org/10.1016/j.
1954;11(3–4):232–64. jebdp.2016.01.015.
93. Bowen WH. The Stephan curve revisited. Odontology.
104. Edelstein BL, Ng MW. Chronic disease management strategies
2013;101(1):2–8. https://doi.org/10.1007/s10266-012-0092-z. of early childhood caries: support from the medical and dental
94. van Loveren C, Duggal MS. The role of diet in caries prevention. literature. Pediatr Dent. 2015;37(3):281–7.
Int Dent J. 2001;51(6 Suppl 1):399–406. 105. Brondani B, Knorst JK, Tomazoni F, Dutra Cósta M, Vargas
95. Evans D. Some evidence that one-to-one dietary interventions AW, Noronha TG, Mendes FM, Ardenghi TM. Effect of the
in the dental setting can change behaviour. Evid Based Dent. COVID-19 pandemic on behavioral and psychosocial factors
2012;13(2):42. related to oral health in adolescents: a cohort study. Int J Pae-
96. Arheiam A, Brown SL, Burnside G, Higham SM, Albadri S, diatr Dent. 2021. https://doi.org/10.1111/ipd.12784.
Harris RV. The use of diet diaries in general dental practice in 106. Borrelli B, Tooley EM, Scott-Sheldon LA. Motivational inter-
England. Community Dent Health. 2016;33(4):267–73. https:// viewing for parent-child health interventions: a systematic review
doi.org/10.1922/CDH_3928Arheiam07. and meta-analysis. Pediatr Dent. 2015;37(3):254–65.
97. Feldens CA, Giugliani ER, Vigo A, Vitolo MR. Early feed- 107. Patel S, Bay RC, Glick M. A systematic review of dental recall
ing practices and severe early childhood caries in four-year-old intervals and incidence of dental caries. J Am Dent Assoc.
12 children from southern Brazil: a birth cohort study. Caries Res.
2010;44(5):445–52.
2010;141(5):527–39.
108. Ramos-Gomez FJ, Crystal YO, Ng MW, Crall JJ, Feather-
98. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened bev- stone JD. Pediatric dental care: prevention and management
erages and weight gain: a systematic review. Am J Clin Nutr. protocols based on caries risk assessment. J Calif Dent Assoc.
2006;84(2):274–88. 2010;38(10):746–61.
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Contents
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13.6.7 reformed Crowns – 307
P
13.6.8 Veneers and Prosthetic Appliances – 308
References – 311
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Restorative dental needs of children and adolescents (S-ECC) may have any pattern of insult, affecting ante-
arise primarily as a consequence of dental caries. rior and/or posterior primary teeth. Poorly informed
Secondly, they arise from dental trauma, developmental parents are often surprised by how soon caries develops
dental anomalies (more often molar incisor hypominer- in their child’s new teeth, before good oral hygiene, fluo-
alization) including tooth aplasias, and, less frequently, ride, and other preventive measures are established.
erosive dental wear. As explained in the introductory One particular form of S-ECC, formerly referred
7 Chap. 1, there are data for increasing number of
to as “baby bottle syndrome,” is characterized by car-
unmet needs with decreasing child age. Among other ies affecting mainly the maxillary primary incisors and
reasons, this is apparently associated with the less-than- first molars. This pattern is attributed to the sequence
optimal dental education in pediatric dentistry in most of eruption and therefore the exposure time of each
societies in the past. tooth to the cariogenic challenge [2]. The absence of
During transition from infancy to early childhood, proper oral hygiene and fluorides together with unsuit-
adolescence, and adulthood, restorative philosophy and able dietary habits are deemed to be the cause. However,
choice of techniques/materials need to suit the changing presence of severe developmental dental defects (e.g.,
conditions of the growing child, e.g., the type of den- primary molar hypomineralization or hypoplasia) are
titions (primary or permanent) with their anatomical known to promote this advancing form of caries [3,
differences and functional duration. Moreover, differ- 4]. These dietary habits most often include allowing
ent preventive principals and strategies may be suitable the baby to go to sleep with a bottle containing milk
according to the patient’s caries risk and age group in or other liquids with fermentable sugars, i.e., during the
order to achieve optimum results. All these factors affect period when salivary flow is minimal, thus depriving
the treatment plan, and for this reason the caries man- teeth from its protective properties. This S-ECC form
agement is presented in this chapter by age group. may also occur as a result of prolonged breastfeeding
at will during the night, usually while the infant sleeps
with mother [5] (. Fig. 13.1). Breastfeeding is known
13.1 Age up to 3 Years to promote physical and emotional health; its ad libitum
use (i.e., during sleep), however, after the first teeth erupt
This age group is characterized by the eruption of the is discouraged, as is bottle use when the child is able to
entire primary dentition and the process of establish- use a glass, i.e., after age 12 to 18 months [1].
ing functional occlusion. At the same time, although Bottle-feeding-associated S-ECC first challenges the
the child cognitive development is rapid, it is still below labial surfaces of the maxillary incisors, which benefit
the level required to fully, and consistently, cooperate less by the protective effect of saliva. It subsequently
with the dentist for restorative treatment. Therefore, it extends to adjacent surfaces such as palatal and inter-
is utmost important to identify these preschoolers with proximal, as well as the occlusal and other surfaces of
high caries risk so that preventive advices and practices the maxillary primary molars. The mandibular anterior
can be given by educating them and, more crucially, teeth remain without obvious damage until much later,
guiding parents to comply with their implementation. probably because of saliva protection and less contact
with the liquid intakes (. Fig. 13.2). If the deleterious
Definition
The American Academy of Pediatric Dentistry
(AAPD) defines early childhood caries as “the pres-
ence of one or more decayed (non-cavitated or cavi-
tated lesions), missing (due to caries), or filled tooth
surfaces in any primary tooth in a child under the age
of six.” Furthermore, if this occurs before the age of
3 years, or if there are at least 4, 5, or 6 carious cavi-
ties at age 3, 4, or 5 years, respectively, the disease is
categorized as severe early childhood caries [1].
.. Fig. 13.1 S-ESS in the form of nursing caries with advanced cer-
Early childhood caries (ECC) may affect any primary vical lesions in the maxillary incisors due to prolonged breast feeding
teeth, more often molars. Severe early childhood caries at will and absence of oral hygiene with fluoride
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284 N. Kotsanos and F. Wong
first dental examination for babies before the their first unless there are urgent needs due to pulpal inflammation
birthday, so that parents are adequately informed and and pain, a biological (etiological) approach focusing to
motivated on time [8] (see 7 Chap. 6).
the conversion of active caries lesions to inactive should
be preferred, at least until cooperation of the child may
13.1.1.2 Treatment and Restorations allow definite restorations possible in the dental office.
With early diagnosis and implementation of therapeutic This approach may include [8, 9]:
measures, ECC lesions can be arrested and, with ongo- 55 Effective oral hygiene with fluoride toothpaste
ing eruption of teeth, remain inactive and require no 55 Discontinuing cariogenic diet habits
restoration, except for esthetic purposes (. Fig. 13.3).
55 Frequent checkups at the dental office with fluoride
The greatest difficulty in restoring heavily carious teeth varnish application or perhaps other antimicrobial
is insufficient cooperation of children under 3 years. agents (e.g., silver diamine fluoride)
More specifically, addressing their restorative needs in
the dental office without sedation is hindered by: If this therapeutic target is met, the certainly more
55 The negative reaction of children fearing unknown demanding dental restoration sessions can be post-
individuals in a stressful situation poned to age 3 years or older [9] (. Fig. 13.4). Effec-
55 The intense instinctive refusal of treatment even in tive counseling of the dental professionals by avoiding
the least painful stimulus judgmental remarks to the family is very important
55 The difficulty to maintain cooperation for a long because the success of nonsurgical caries management
time during extensive restorations depends on parental motivation, compliance, and coop-
eration. Indeed, keeping frequent, initially monthly or
In countries where in-office sedation is not possible with- bimonthly, appointments is critical due to the all too
out an anesthesiologist present, dental rehabilitation is often seen inadequate compliance.
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Restoration of Carious Hard Dental Tissues
285 13
a a
b
b
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286 N. Kotsanos and F. Wong
The widespread use of adhesive materials nowadays the restorative material, any of the three abovemen-
has reduced this need and has resulted to removing tioned types of materials may be used. When, how-
less healthy tooth substance. Such materials include ever, a significant part of the restoration is exposed
resin composites and their acid modified hybrids (com- to heavy occlusal loads, a composite is preferred –
pomers) as well as RMGIC [11]. with prior GIC coating in deep cavities – to better
resist the abrasive forces (. Fig. 13.9).
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Restoration of Carious Hard Dental Tissues
287 13
a b a b
the adjacent tooth is missing, is made by occlusal is preferred. RMGIC has also shown success, albeit
access with a cylindrical diamond bur cutting in a with considerable occlusal wear in large cavities [16]. An
buccolingual direction, within the limits of the open sandwich approach has also been used in primary
intended size of the proximal box. This need not molars by covering the RMGIC material with a com-
reach so-called self-cleaning proximal areas, at least posite layer (. Fig. 13.12), in order to take advantage
for patients with daily oral hygiene, fluoride, and of each material properties [17]. However, its efficacy is
regular recalls. The high injury rates of the neighbor- less well-documented than it is for permanent teeth [18].
ing enamel of the adjacent tooth necessitate its pro-
tection by:
1. Securing a sectional metal matrix in the interden- 13.2.2 Preformed Metal Crowns (PMC)
tal space with a wooden wedge during box prepa-
ration (. Fig. 13.10)
Although standard (small) class II cavities in primary
2. Removal of unsupported enamel by hand chisels molars restored by pediatric dentists with RMGIC [19]
to avoid such risk or composite [17] could last as long as PMCs, neither of
these materials has adequate evidence of good survival
The bulk of the softened dentin can easily be removed for sizeable restorations. The good survival reported
with a spoon excavator. Peripheral dentin needs to be on properly fitted PMCs is irrespective of size of cari-
thoroughly removed to allow adequate bonding and ous destruction of the primary molars [19]. The main
prevent microleakage that may lead to secondary caries drawback of the PMCs seems to be their esthetics, so
development. This is succeeded by a round steel bur of the this disadvantage should be adequately explained to
proper size (usually No. 4 or 5) at low speed. Both these the parents to accept their use. The esthetic problem is
traditional ways, and their combination works faster and overcome by choosing tooth-colored crowns, which are
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288 N. Kotsanos and F. Wong
is impossible, sometimes tricks like using opposite side with an explorer tip. Proximal preparation is done with
PMCs of the other jaw can be tried. appropriate care to avoid injury to the adjacent surfaces
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Restoration of Carious Hard Dental Tissues
289 13
a a b
c
b
Eye Catcher
.. Fig. 13.14 a Contouring and crimping PMC pliers. b Contouring The “Hall technique” is proposed for placing PMCs
a PMC. c Crimping the cervical edge. d PMCs for first (left) and sec- in carious primary molars with neither tooth prepa-
ond primary molars (right). The first and third PMC from left are not ration nor caries removal [ 21, 22]. Its advocates sup-
festooned (older generation) always requiring adjustments by pliers port that the PMC can be pushed into place without
local anesthesia; the occlusion can easily be tolerated
in contact. All line angles are rounded. The appropri- by the child and adapted within several days. As this
ate size crown is selected by a trial-and-error procedure, technique is proposed as simple and easy to use, it
and in case the tooth size is between crown sizes, an is gaining acceptability by both general practitioners
additional circumferential reduction eases seating the [23] and parents [24]. It has also been shown that the
smaller size. The slight elastic deformation of these longevity of PMCs placed by the Hall technique is as
thin metal crowns allows for a snap fit with their pre- good as that of conventional approaches with equal
contoured shape usually needing no other adjustment. success rates of 95% over an observational period of
The tight cervical adaptation means mechanical reten- 77 months [25].
tion of the crown and better respect to gingival health.
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290 N. Kotsanos and F. Wong
a b c d
e f g h
.. Fig. 13.16 a Restorative needs of a 4-year-old. b Following reha- image. f After cementing the veneered PMC. Notice its esthetic dif-
bilitation, a veneered PMC is requested by parents for maxillary ference with the mandibular PMC. g, h Occlusal view and radio-
right first primary molar. c, d, e Crown preparation and radiographic graph at the 6-month follow-up
molar. b Fitting the similar size PMC is feasible option of a full zirconia crown. Supply of the respective
sets of crowns is required for selecting the appropriate
13.2.3 Restoring Anterior Primary Teeth size. After removing the decayed and additional tooth
tissue to enable fitting of the crown, this is cemented
Caries in the proximal contact surfaces of anterior with a GIC. In the absence of a set of those preformed
primary teeth suggests high-caries activity and the crowns, a second option is building the tooth up with
need to implement an appropriate preventive program. composite by using celluloid strip crowns [26]. When
Common locations are the distal surface of the canines there is no sufficient cervical enamel for retention of
and the mesial of upper incisors. In any case, a class the composite material, provided that the teeth have
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Restoration of Carious Hard Dental Tissues
291 13
previously been endodontically treated, it is possible to shedding of primary incisors. However, the longevity of
enhance retention either by fabricating a short stainless these options is not as yet supported by clinical studies.
steel wire post (. Fig. 13.19) or by a composite post
a b c
d e f
.. Fig. 13.19 a Occlusal radiograph after endodontic treatment of maxillary right primary central incisor. b Custom-made wire post and
strip crown. c, d Securing the post with a fast-setting ZOE cement and, supragingivally, with composite. e After placing the composite filled
strip crown, excess composite flows cervically. f Final restoration after trimming excess material
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292 N. Kotsanos and F. Wong
Topical fluoridation
Fissure sealing
13
target for preventive/therapeutic interventions in this softened dentin before placing a restoration, because
age, effected with the application of sealants that are the marginal integrity cannot be guaranteed in the long
described in 7 Chap. 12. Small carious lesions in the
run. Leaving affected (relatively hard) stained dentin in
pits and fissures may be treated by minimal composite deep cavities is considered a safe practice [33]. The buc-
restorations combined with sealing non-carious fissures. cal surface of mandibular first molars and the palatal
It is common today for the benefit of communication, surface of maxillary ones should be carefully followed
to refer to sealants when the fissure system is healthy or up as developmental deep pits are often exposed in these
has minimal (non-cavitated) enamel demineralization, surfaces by ongoing eruption. This requires placement
while preventive resin restoration (PRR) implies that a of a sealant or, if missed, a PRR or typical composite
carious fissure requires limited dentin removal restored restoration may be needed later (7 Fig. 12.41). The sec-
by small amount of composite [29]. These preventive ond permanent molars may also be similarly vulnerable
restorations are also referred to as ultraconservative or during eruption at the late mixed to early permanent
minimally invasive [30]. dentition period. All fissure sealants should be periodi-
cally reexamined for defects and repaired with PRRs if
13.3.1.1 Preventive Resin Restoration (PRR) need be. Diagnostic criteria for selecting a sealant or a
Sealants not only prevent the onset of fissure caries but PRR are schematically shown in . Fig. 13.20.
may even lead to arrest of dentinal caries. Sealed radio- The PRR philosophy has been explained earlier in
graphically verified and active occlusal caries became the primary molars. Its placing procedure is as follows:
inactive and did not progress [31, 32]. The significance of after plaque removal just as with sealant placement, a
these findings is that good marginal seal stops substrate minimum preparation of pits and fissures may be made
penetration to underlying dentin caries bacteria turning for improved access with a tapered or a small diameter
them inactive. Despite the scientific value of these stud- (0.5–0.8 mm) round diamond. The extent of demineral-
ies, however, it remains good practice to remove infected ized enamel and dentin dictates possible further cavity
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Restoration of Carious Hard Dental Tissues
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a b a b
c d
.. Fig. 13.22 a hard tissue cutting laser device (Er, Cr: YSGG). b
Occlusal cavity preparation of a severely hypomineralized mandibu-
lar primary second molar without local anesthesia. (Courtesy of Dr.
K. Arapostathis)
.. Fig. 13.21 a Aiming to restore a mildly carious first permanent
molar with PRR. b Caries removal leads to one of the cavities being performed in the same manner preferring incremental
relatively large for PRR. c Etched enamel following a GIC base in placement of composite (. Fig. 13.23).
the deep cavity. d After adhesive and composite placement, the resto-
ration is completed with sealing non-carious fissures
years, many studies have advocated its usefulness [35, significantly weaken the mesio-occlusal marginal ridge.
36]. There are several laser device types; those pre- Otherwise, a standard class II cavity is prepared for a
ferred for cutting hard tissues are primarily of the composite or an amalgam restoration, a procedure pre-
erbium type, at two wavelengths, Er,Cr: YSGG at sented in restoration types for the next age group.
2.780 nm and Er:YAG at 2.940 nm (. Fig. 13.22).
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294 N. Kotsanos and F. Wong
b c d e
.. Fig. 13.23 a Bite wing radiograph showing a deep cavity of man- of the relatively hard dentine. c After a GIC base where appropriate.
dibular left second permanent molar. b Preparation of various sizes d Etching the beveled enamel. e The finished composite restorations
in the second premolar and the two molar cavities without removal
Other common needs for esthetic restorations of or ozone has shown dramatic reduction in residual bac-
permanent incisors in this age group are crown frac- teria [39], and this may be especially useful in case of
13 tures, due to trauma, and developmental anomalies of partial caries removal before restorations are placed.
the hard dental tissues. These are covered in the respec-
tive 7 Chaps. 16 and 17. In all cases, permanent restora-
tions are made with composite with the aid of a suitable 13.4 Age 12 to 18 Years
celluloid matrix, strip crown, or incisal angle mold as
described in the textbooks of restorative dentistry. 13.4.1 Proximal and Smooth Surface Caries
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295 13
a b
.. Fig. 13.24 a While preparing the disto-occlusal surface of the preparation, it was restored with composite before placing RMGIC
second primary molar, a small cavity is discovered in the mesial sur- restorations to primary molars
face of the permanent molar. b Following a conservative class V
was from 1.5 to 2 times slower, but in nearly half of possible to diagnose clinically, using a separating rubber
them, lesions had not progressed in 4 years. Newly ring to achieve a temporary interdental space of 1 mm in
erupted teeth may be more caries susceptible, before a few days could assist diagnosis. Restorative treatment
their enamel completes its posteruptive maturation, as in questionable interproximal caries should therefore be
previously had shown by in vitro data [41]. Generally, undertaken only if cavitation is diagnosed by visual or
there were no consistent differences in the rate of pro- tactile means or by monitoring radiographs, showing
gression between premolars versus molars or between progressing outer dentinal radiolucencies.
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296 N. Kotsanos and F. Wong
a b a b
c c
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a b
.. Fig. 13.27 Maxillary incisors before a and after b resin infiltration of cervical enamel demineralized during orthodontic treatment.
(Courtesy Dr. A. Kavvadia)
Eye Catcher
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298 N. Kotsanos and F. Wong
c
.. Fig. 13.30 Image of the past without the use of rubber dam
13
55 Significantly aiding child cooperative behavior after .. Fig. 13.31 The rubber dam greatly reduces contamination dur-
local anesthesia administration. ing pulp treatments
55 Improving visibility and access to the working field
by retracting and protecting adjacent soft tissues
(. Fig. 13.30).
instruments, debris from amalgam removal, irriga-
55 Enabling quadrant dentistry. tion liquids, etc. [52]
55 Providing optimum moisture control with suction 55 Contributing to dental staff safety by significantly
use [50]. reducing infected aerosols when coupled with high-
55 Contributing to an aseptic environment in endodon- volume suction to about 90–99% [53]. *
tic treatments [51] (. Fig. 13.31).
55 In minimal sedation sessions, it minimizes mouth emis-
55 Contributing to patient safety by preventing inges- sions of and exposure of dental personnel to nitrous
tion/aspiration of foreign bodies, such as small oxide with efficient mask and exhaust system [54].
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Restoration of Carious Hard Dental Tissues
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a c
.. Fig. 13.32 a Accessories for rubber dam use in children from top 8A, 14 (for fully erupted molars), 14A. Middle row second primary
anticlockwise: hole punch, clamp forceps, rubber dam elastic sheet molars: No. 27 W, 12A, 13A. Bottom row for permanent incisors:
and metal frame, floss tied clamp, and scissors. b Commonly used No. 2. c Securing the rubber dam sheet for isolation of anterior teeth
clamps in pediatric dentistry. Upper row for permanent molars: No. with a floss loop and a piece of elastic cord (WedjetsR)
On the other hand, the disadvantages of rubber dam 55 No. 12A and 13A for second primary molars and
include: possibly 27 W (mandible)
55 Occasional difficulties in placing the clamp especially Wingless (W) clamps are available in addition
to partially erupted teeth. to those with wings. The latter, being more popu-
55 The possibility of it coming off if it is not tightly lar, are necessary for fitting the rubber dam if one
secured. prefers the one-step technique (see below). It is
55 The need for gingival anesthesia, in case local anes- advisable to tie dental floss to the clamp bow and
thesia is not necessary otherwise. secure it to the frame after clump placement in
55 Difficulty in placement to patients with severe gag case the clamp pops off the tooth. In isolating
reflex. anterior teeth, smaller-size clamps (e.g., No.2) can
55 The difficulty of some child patients to swallow their be placed bilaterally or, alternatively, the dam
saliva. may be secured by tight loops of dental floss or
55 Possible temporary injury to periodontal tissues. stabilized by elastic cords between teeth
55 Extended time required for the placement. This can (. Fig. 13.32c).
be minimized if the dam system is prepared by an 2. Rubber dam sheet. The latex or latex- free sheet is
assistant and placed in one step. available in a variety of colors, odors, and flavors to
please young patients. Darker colors increase contrast
* The importance of using rubber dam was especially with teeth. Medium thickness with dimensions 5 x 5
emphasized during the CoVid-19 pandemic. inches (12.5 x 12.5 mm) is most suitable for children.
In very young children, its first use needs additional 3. The dam punch. Single- or multiple-size hole punches
explanation time by tell-show-do and appropriate non- are available. In everyday practice, small holes are
technical vocabulary. Most of the above disadvantages rarely used.
are in the dentist’s control and can be minimized with 4. The dam frame. The frame keeps the elastic relatively
experience. stretched after placement. It is available in metal or
plastic. The metal pins tend to secure the dam better
in the long run.
13.5.1 Equipment 5. The clamp forceps. Available types have undercut
ends for securely transferring the clamp to the tooth.
The accessories needed for placing a rubber dam to a Care is needed at removing forceps not to destabilize
child’s mouth include [55] (. Fig. 13.32):
the clamp.
1. Clamps. A stable clamp needs to be touching the 6. Scissors. This is optional for cutting away the rubber
tooth cervix at four points. The most commonly used dam part if it covers the patient’s nose. It may also be
clamps in children are: useful to poor nasal breathers for cutting a hole in
55 No. 14 and 14A for permanent molars and pos- the working side of the sheet to allow for mouth
sibly 7A and W8A breathing.
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300 N. Kotsanos and F. Wong
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a b
.. Fig. 13.34 One step placement of the rubber dam a Forceps in clamp as it is engaged in the rubber dam. The elastic sheet is not exces-
sively stretched in the up-down direction. b Placing the rubber dam in the maxillary left second primary molar
a b c
.. Fig. 13.35 Examples of self-retained retractors. a OptiView™ (Kerr) b OptraGate (Ivoclar Vivadent). c Metal cotton roll holder for
mixed dentition mandibular posterior teeth
and the adult than in young children, exerting higher of excessively large proximal cavities, special pressure
occlusal load on restorations. Young permanent teeth rings are available to improve contacts at the buccal and
differ to more mature teeth in pulp chamber size and lingual aspects of the cavity outline (. Fig. 13.37). In
have implications in their risk for pulp exposure. They anterior teeth, celluloid straight or angle matrices or
are also in a continuous eruption phase affecting the cer- strip crowns could be used depending on cavity type and
vical border of restorations. size.
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302 N. Kotsanos and F. Wong
a
13 a b
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Some bonding agents contain water aiming to rehydrate 13.6.4 Glass-Ionomer Cements
collagen for improving bonding [62].
Bonding agents are under constant development to Glass-ionomer cements (GIC) were introduced in den-
improve their properties and inhibit long-term bond tistry in 1970. Although this name prevailed, the cor-
deterioration, e.g., by adding cross-linkers to neutral- rect name in chemical terms is polyalkenoate cements.
ize the endogenous matrix metalloproteinases (MMPs), The base is alumino-fluoro-silicate calcium (or stron-
which degrade the demineralized collagen dentin matrix tium) glass powder. Mixing with water-soluble polyalke-
[63, 64]. They are going through successive generations noic acid produces an acid-base reaction. The reaction
becoming more user-friendly, with application stages releases fluoride ions at a high peak, which decreases sig-
reduced to two or even to one step. nificantly after a few days [66]. The Ca and then Al ions
The steps for bonding application are: form bridges with carboxyl groups of the acid and the
1. Apply the etchant – phosphoric acid 32–37% cement changes from a gelatinous stage to solid within
(pH 0.1–0.4) – to enamel for 15–30 sec. It is also several minutes (. Fig. 13.39). Other acidic compo-
applied to dentin for 5–8 sec to remove the smear nents are added, such as itaconic and polymaleic acids,
layer and demineralize the cut dentin surface (inter- to improve the acid-base reaction, and tartaric acid is
and peritubular) to open the lumen of dentinal added to accelerate the setting time [67].
tubules and free collagen fiber ends. Achieving differ- At the initial reaction stage (2–5 min after mixing), the
ent etching times for enamel and dentin presents acid is neutralized by Ca and Sr ions to form respective
with some difficulty. For better control, it is recom- salts. The formation of Al complexes at the end step stabi-
mended that the acid is in colored gel form so that lizes the final structure (5–10 min after mixing). The setting
can be selectively placed first in enamel. process continues to be very sensitive to water because this
2. After thorough rinsing of the etchant and careful may lead to leaching of Al ions and not allow the cement
drying (full drying of enamel and gentle air-drying
on dentin are again challenging), a primer is applied
to modify the dentin surface from hydrophilic to a
hydrophobic, i.e., compatible with the adhesive agent
and the composite [57].
3. The bonding agent is spread on dentin and enamel
with excess liquid being blown away gently. After pho-
topolymerization, a portion of composite is applied
and polymerized for incrementally built restorations.
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304 N. Kotsanos and F. Wong
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Restoration of Carious Hard Dental Tissues
305 13
Furthermore, there are so-called hybrid and microhybrid
composites with a variety of particles of average size 1–3
and 0.2–0.7 μm, respectively, which were most commonly
used before the appearance of nanofilled ones.
The particles are usually irregular in shape and are
retained in the resin body with the aid of coupling agents.
Lately mono- or biphosphate methacrylate is preferably
used to give better spatial dispersion of particles due to its
electrically charged phosphate groups [81]. Large particle
size usually contributes to better mechanical strength of
the material. However, very small (nano) particles allow
higher filler content to increase strength and reduce
polymerization shrinkage by decreasing the resin content.
.. Fig. 13.42 In vitro fluoride release graph shows superiority of a Also, the polishability and esthetics are improved. The
RMGIC (Vitremer, 3 M ESPE) over other materials. Low-level hybrid resins are produced to take advantages of these
release continues and is shortly but significantly increased by combined properties. The high-content medium/low-
“recharging” the material with a fluoride rinse solution on the 51st
size particles have shown to have better wear resistance.
day
Though they achieve lower shrinkage (range 1–4.5%),
they should nevertheless still be placed by incremental
technique in large cavities. To decrease shrinkage and pre-
a b vent microleakage, polymerization can start with a lower
intensity curing light or aimed at the material through the
enamel wall [82]. Flowable composites have lower particle
content than hybrid ones. They are mainly used as liners
or as restoratives in minute cavities like the PRRs.
Before the era of dentin adhesives, evidence for
the survival of old composite restorations in primary
molars was poor compared to other materials [83].
Contemporary composites, however, have significantly
improved properties [10, 82]. When esthetics is impor-
tant, the composite is the material of choice for direct
restorations to all permanent and the anterior pri-
mary teeth. For primary teeth, special whiter shades
.. Fig. 13.43 a, b Marginal fractures of unsupported enamel 2 and are available in the market (. Fig. 13.4). Due to its
2.5 years, respectively, after mandibular first primary molar restora- micromechanical retention properties, the composite
tions. In both cases, there is no secondary caries of the exposed den-
tin, which is attributed to the fluoride release from the material.
allows dental tissue preservation with conservative cav-
Monitoring – instead of restoration replacement – is an option ity preparations, while the resin content, unlike amal-
gam, allows for restoration repair. It, however, requires
more controlled placement conditions, particularly as
regards to isolation from moisture. Thus, rubber dam
13.6.5 Resin-Based Composites
use becomes more critical than with other materials. The
composite can also be combined with RMGIC as previ-
There are many resin composite products in the dental
ously mentioned (. Figs. 13.12 and 13.44).
market. Features, such as esthetics and polishing abil-
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306 N. Kotsanos and F. Wong
a b
in composites and bonding agents. Their light intensity,
ideally around 1000 mW/cm2 for fast curing, should be
checked periodically with appropriate radiometer and
include a “soft-start” mode of low light intensity for
reducing shrinkage stress [85]. Lately, a blue diode laser
(445 nm) has been tried for composite photopolymeriza-
tion with comparable efficacy to an LED unit [86].
Although it is thought that the presence of eugenol
prevents resin composite polymerization, quick setting
c d ZOE cements do not appear to decrease the compos-
ite bond strength with dentin [87]. Nevertheless, ZOE
should still be avoided in anterior teeth under composite
as it may cause staining compromising restoration color.
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Restoration of Carious Hard Dental Tissues
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PRRs. There are a few studies showing possible BPA a b
associations with the immune system or the neuropsy-
chological development of children [93, 94]. Hence, it
is a potential health hazard warranting further investi-
gation. BPA-free composites have appeared in the den-
tal market as the AAPD recommends avoiding BPA
containing composites during pregnancy and proposes
measures for reducing potential exposure. These include
removal of the unpolymerized residual monomer from
the surface of sealants or composite restorations imme-
diately after placement by rubbing with rotary brush
and pumice powder, meticulous wiping with a cotton
roll, and copious rinsing with a water syringe [10]. The
use of rubber dam and high-volume suction also limit
possible exposure to BPA.
.. Fig. 13.46 a Class I amalgam restorations in maxillary primary
molars. b Class II amalgam restoration in mandibular first primary
13.6.6 Dental Amalgam molar. The second primary molar with incipient occlusal caries
received a sealant instead of a class I amalgam
PMCs for primary molar teeth [96]. If it is preferred for cedure is easily completed in one visit, it is the method of
class II cavities, the width and depth of preparation at choice for such cases [21, 99], and they are also favored
cavity isthmus should be at least 1.2–1.5 mm. This fea- when restoring teeth of high-caries children under
ture adversely affects its use because it contravenes the general anesthesia in order to reduce later needs. The
modern views of minimally invasive dentistry on pre- basically stainless steel marketed PMCs (. Figs. 13.13
ecology are important selection criteria, although com- CA, USA) have additional internal grooves (ZirLock®)
mercial reasons may also play an important role to the to increase their retention. Due to high strength of the
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308 N. Kotsanos and F. Wong
a b c
.. Fig. 13.47 Mandibular right primary first molar restored with a NuSmile zirconium crown. a preparation. b Try-in crown. c The cemented
zirconium crown
tion can be provided. In the primary dentition, the amount of acrylic resin is bonded to the 0.36′ (0.9 mm)
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Restoration of Carious Hard Dental Tissues
309 13
a a
b
b
.. Fig. 13.49 a Four acrylic primary incisors added in a modified .. Fig. 13.50 Resin-bonded bridge in late adolescence replaces an
Nance appliance to replace the lost natural teeth. b Note the exten- earlier loss of the upper right central incisor due to trauma. a Labial
sion of wire and acrylic in the midline palate to provide space main- view. b Palatal aspect. (Courtesy of Dr. P. Gerasimou)
tenance because of concomitant loss of both first primary molars
due to severe ECC
wear resistance of some materials in large restorations,
such as RMGIC, will result in time to altered outline
stainless steel wire to support the teeth (. Fig. 13.49).
form occlusally in relation to the surrounding enamel
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310 N. Kotsanos and F. Wong
a a b
.. Fig. 13.51 a Tissue healing following the loss of two central and
one lateral permanent incisors of an 11-year-old girl with posterior 13.7.2 Improving the Dental Materials
cross bite. b Her panoramic radiograph. c Palatal acrylic plate with
an expansion screw and three acrylic replacement teeth. d Crossbite The present restoration failure rates because of sec-
correction and esthetic result in the 12-month follow-up. Close mon-
itoring until implant prosthesis at the end of adolescence is indicated
ondary caries suggest that there is still much room for
improvement in current restorative materials and, in
addition to improving adhesive and mechanical prop-
secondary caries is often related to lack of recognizing
erties, focus has been also in improving the biological
and removing all primary carious dentin from the cav-
profile of restorative materials [109]. Despite the proven
ity peripheral walls from the start. This frequent find-
protection exerted by the various fluoride vehicles used
ing in young patients may be related to cooperation
in caries prevention, the limited fluoride penetration in
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Restoration of Carious Hard Dental Tissues
311 13
plaque restricts its protective effect in difficult to access Other approaches aim to increase to significant levels
areas [110]. Consequently, the survival of restorations the fluoride release ability of composites, just as it natu-
could be significantly improved with materials having rally occurs with GIC. All these remain tested in vitro
bacteriocidal properties, better dental tissue adhesion, so far. One similar attempt is to incorporate MgAl and
and remineralizing properties. The relevant additives CaAl containing hydroxides in experimental compos-
should not adversely affect the mechanical properties of ites to render them fluoride rechargeable [118]. Other
those materials. There is extensive research on agents, attempts include the development of a bioactive glass
such as silver, zinc oxide, calcium fluoride, quaternary composite adhesive for orthodontics that shows long
ammonium, polyethylene amines, bioactive glass, and time release in acidic environment of ions F, Ca, and
nano(fluor)hydroxyapatite, to be incorporated into com- PO4 ions with a potential to prevent formation and pro-
posites – as well as to bonding agents – which are cur- gression of early carious lesions around the brackets
rently the most widely used esthetic dental restoratives. [119]. Research continues and it is possible that future
This chapter concludes with a brief update of research tooth-colored restorative materials may also have caries
progress for novel restorative biomaterials with possible preventive properties, but these need to be tried clini-
future applications in pediatric dentistry. cally to verify whether they increase restoration survival.
Silver (Ag) compounds have a wide range of antimi-
crobial applications. Ag reacts with sulfhydrylic groups
of proteins preventing the unraveling and replication
of bacterial DNA, thus inhibiting their cell wall syn- References
thesis and cell division [111]. Low Ag concentrations
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(0.5–1.0%) in the form of nanofillers in a test CR exhib- childhood caries (ECC): classifications, consequences, and pre-
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microscope (SEM) fewer colonies of mutans streptococci after a
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34. Bekes K (ed). Pit and fissure sealants. Springer, 2018
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2011;12(3):170–5. 36. Olivi G, Genovese MD. Laser restorative dentistry in children
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Contents
References – 342
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317 14
a b
.. Fig. 14.2 a The very deep carious lesions in two mandibular respective pulp horns. b Due to pulp proximity in the first molar,
primary molars along with reported short duration provoked pain the pulp was close to exposure after careful removal of the infected
suggest bacterial infiltration and inflammatory reaction, mainly at dentin
55 Proper diagnosis, with an emphasis on recognizing as already mentioned, the fact that pain is not reported
emergency cases does not exclude pulp inflammation in either primary
55 Alleviating any anxiety affecting the parents or the or permanent teeth. It remains possible that children
child with pulpless primary teeth, even some with a fistula,
55 Alleviating the child’s pain (avoiding extraction, if may not have a pain history, and their parents may con-
possible) firm this. Children’s active lives and the low significance
attributed by many parents to primary teeth may result
The presence of pain may be associated with an inflam- in paying little attention to such matters. This often
mation of pulpal, periapical, or periodontal etiology. results in the dentist having a rather difficult task when
Pain history and characteristics determine whether trying to elicit an accurate pain history from the child
the case is an emergency. An accurate history taking and their parents.
includes possible pain-evoking stimuli, its location, It is very important for arriving at correct diagno-
intensity, duration, and frequency, as well as the factors sis and treatment to make a distinction between two
that alleviate or exacerbate it. Such questions are often types of dental pain. Evoked pain is generated by vari-
difficult to be answered, particularly by preschool age ous thermal, chemical, osmotic, or/and mechanical
children, and some information needs to be taken from stimuli and declines or disappears with the removal of
the parent, albeit with some reservations as to its accu- the stimulus. It should be noted that pain caused by
racy [7]. Many children are prone to giving false answers thermal stimuli to primary teeth is not as common as
so as to avoid dental treatment they are afraid of, and in permanent dentition. A history of toothache caused
this is a typical phenomenon. For example, a fright- exclusively by evoked stimuli does not necessarily mean
ened child, after a sleepless night with toothache, when nonreversible lesion to the pulp, whereas it is difficult
finally faced with the dentist, may anticipate the likeli- to accurately connect pain features with the extent of
hood of a painful intervention; so they may report they pulpal inflammation [2]. The tooth usually presents a
have no pain. On the other hand, some parents, possibly carious cavity, in which food enters during mastica-
somewhat negligent for not responding in good time, tion, and one or more of the stimuli mentioned above
may play down a child’s prior symptoms. Furthermore, causes pulpal pain. The absence of a contact point in
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318 A. Arhakis et al.
lus; it occurs outside meal times, frequently in the Extraoral edema appears in the form of cellulitis
evening [7]. In primary teeth such pain has been corre- extending to the inter-muscle spaces of the face or
lated with extensive inflammation throughout the pulp neck, often leading to intense local lymphadenitis. In
tissue, both in the chamber and in the root canal(s), the mandible, this usually appears as a result of sep-
where there may also be internal resorption. Therefore, tic pulp necrosis in the first or second primary molar
this is a nonreversible condition [8]. The child usually or that in permanent molars of older children and
avoids bringing any solid or liquid food into contact adolescents. In the maxilla, the inflammatory spread
with the teeth on the painful side. The responsible tooth of septic necrosis of the pulp of first primary molar
may present significant clinical symptoms, such as pain may extend to the child’s eye socket (. Fig. 14.5).
on occlusion, or signs such as tenderness on pressure, The drainage of the extraoral edema follows the route
often in conjunction with mobility. Although there may of least resistance; pus drainage through the skin,
be no additional radiographic pathologic signs as yet, as sometimes encountered in permanent teeth, is an
the expansion of periodontal space, often visible in the exceptionally rare phenomenon for primary molars. If
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Pulp Therapy in Pediatric Dentistry
319 14
.. Fig. 14.4 a The frequent
a b
finding of a fistula, relatively
closer to the (restored) maxillary
primary canine rather than the
responsible first primary molar,
raises a diagnostic issue. b The
radiograph reveals that the cause
is septic pulp necrosis of the
molar
a b
.. Fig. 14.5 a Spread of the edema with redness and a reduced Spread of osseous inflammation to the suborbital region due to sep-
capacity to open the mouth caused by dentoalveolar inflammation tic necrosis of the maxillary right first primary molar
of the mandibular right second primary molar in an 8-year-old. b
necessary, appropriate antimicrobial administration has risen slightly in its alveolus. Upon occlusion, pain
(see below), either alone or with calcium hydroxide is often felt in that case. Percussion testing may be very
root canal treatment, leads the edema to recession in a painful, and make anxious children more frightened
matter of days [10]. of dentists. When deemed necessary, exercising mild
pressure on the tooth with a finger is sufficient.
Mobility
Pathologic mobility of primary teeth is accompanied Vitality Tests
by radiographic findings. Mobility caused by edema is The value of pulp vitality testing using electrical or ther-
related to non-vital pulp and can be treated with root mal stimuli, although high in permanent teeth, has dubi-
canal treatment. The outcome of the latter does not ous reliability in primary teeth. The subjective response
depend on the extent of pathologic mobility [8]. is often further influenced by the child’s anxiety or fear.
Furthermore, painful stimuli will negatively affect the
Percussion cooperation of a frightened child. Some new painless
Pain caused by pressure on a tooth indicates that sup- techniques have been adapted for use in dental prac-
porting periodontal tissues are inflamed and radiogra- tice, such as measuring pulpal blood flow using Laser
phy may depict a periradical space increase if the tooth Doppler Flowmetry [11]. Its use has extended to include
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320 A. Arhakis et al.
young permanent teeth in diagnosing the vitality (hemo- Root Canal Obliteration
dynamic function) of their pulp. Such techniques have The intense production of tertiary dentin leading to a
yet to gain ground in broader clinical applications. drastic reduction of pulp tissue indicates pulp reaction
under chronic carious lesions or trauma. The resulting
14.1.1.4 Radiographic Examination pulp obliteration mainly involves anterior primary teeth
Absolute prerequisite for correct diagnosis and treat- following injury and root canals of posterior primary
ment of pulp pathology is appropriate and recent teeth following pulpotomy (. Fig. 14.6) [12, 13]. While
radiographic examination. Panoramic or other extra- tooth monitoring becomes necessary, it does not imply
oral radiographs are unsuitable for diagnosing pulp or treatment failure.
the supporting bone pathology, as already described in
7 Chap. 6. Intraoral periapical or bite wings providing
Internal Root Resorption
images of the molar furcation area have significantly Internal resorption may be visible radiographically when
higher diagnostic value concerning carious lesions, the it involves the mesial and/or distal aspects of root canals
pulp and the periodontal condition. They provide infor- while, if at initial stages it involves the lingual or buccal
mation on: sides, it may not be diagnosed. Therefore, when treating
55 Proximity to the pulp in cases of deep carious lesions a symptomatic pulp, preexisted resorption foci cannot be
55 Adequacy of restorative work excluded [14]. The presence of internal resorption follow-
55 Success or failure of pulpotomy or pulpectomy out- ing pulp capping or pulpotomy is an indication of chronic
come [12] pulp inflammation, i.e., treatment failure. Although suc-
cessful root canal treatment cases have been presented
The commonest radiographic findings related to pulp (. Fig. 14.7), in the absence of sufficient documentation
Bone Radiolucency
Radiolucencies in primary molars resulting from pulp
infection almost always appear at the bifurcation area,
b
unlike permanent molars which mostly develop periapical
lesions. This has been attributed to the presence of many
accessory root canals in the bifurcation dentin of primary
molars [16] (. Fig. 14.9). Radiolucency starts by thicken-
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Pulp Therapy in Pediatric Dentistry
321 14
.. Fig. 14.7 a Radiograph of
a b
an emergency pulpotomy per-
formed 4 weeks ago in a 4-year-
old girl (diagnostic radiographs
were then not possible due to
intense gag reflex). Internal
resorption in the distal root of
the mandibular second primary
molar and onset of furcation
bone resorption are seen; there
was probably a misdiagnosed
pulp condition. b Further prog-
ress of internal root resorption c d
after 2 weeks. c A root canal
treatment was undertaken and
completed at 8 weeks. d Success-
ful outcome of treatment at the
30 months follow-up
pulp condition expected depending on diagnostic find- appointments helps accommodate for possible emer-
ings is presented in . Table 14.1.
gencies. If there is no emergency, this may be used to
deflate possible delays of prior sessions or for staff
relaxation and communication. This is particularly
Diagnosis During Intervention
useful for the first day of the working week, because
All too often the final diagnosis and treatment deci- chances for an emergency add up at weekend holidays.
sion cannot be made before direct observation and When there is an emergency case, the clinician is called
immediate assessment of the pulp tissue following its on to:
exposure. Both the size of exposure and the nature of 1. Minimize possible distress of small children often
the fluid excreted from the specific point are of diag- unaccustomed with the dental environment
nostic value [8]. Large exposed sites are not consid- 2. Perform necessary examinations for correct diagno-
ered appropriate for direct pulp capping in primary sis and emergency treatment for patient relief
teeth [18]. Quick hemorrhage control signifies partial 3. Book a new full clinical/radiographic examination
inflammation and indicates a case for pulpotomy. session for total care by enrolling the patient in the
Intense hemorrhage (or suppurated blood flow) is his- regular dental practice schedule
tologically related to inflammation extending into the
root canals of primary teeth. In this case, pulpectomy Following the diagnosis, a treatment decision is reached
is indicated, but not without prior radiographic for either preserving or extracting the tooth, after the
examination [8, 12]. informed consent of parents. If it is about a permanent
Continuous hemorrhage from root canal entries tooth, it is useful to have an orthodontic evaluation.
for more than a few minutes is a sign of hyperemic Emergency cases involving painful inflamed primary
inflammatory root pulp. If vasoconstrictors are teeth because of caries almost invariably concern molars.
injected directly into the root canals (e.g., local anes- On the relatively few occasions the emergency case
thetic with epinephrine), this intervention in the concerns carious anterior primary maxillary teeth, the
hemostatic capacity of the pulp deprives us of the inflammation will have already spread to the periapical
possibility of determining the extent of the inflamma- tissues.
tion. In cases of evoked pain to a primary molar, con-
servative treatment may be performed. Emergency
treatment involves painless removal of some soft den-
14.1.2 Management of Pulp-Related tin with a spoon excavator, if possible, and temporarily
sealing cavity with GIC. If the clinician’s available time
Emergency and the child’s cooperation allow, radiographic exami-
nation and definite treatment by appropriate pulp ther-
When a child arrives as an emergency in a busy den-
apy may be preferred in this initial session; otherwise, a
tal surgery, it disrupts its smooth operation. A break
new appointment may be arranged.
of, e.g., 30 minutes at some point between scheduled
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322 A. Arhakis et al.
a b c
.. Fig. 14.8 a Major furcation bone resorption accompanied by period, but a wait-and-see approach was chosen. c After 3 years,
probable (missed) small external resorption of the adjacent distal a pathology-related deflection in the path of premolar eruption
root of mandibular second primary molar. b Root canal treatment together with lack of resorption of the primary molar roots are
did not lead to resolution of furcation pathology after a 5-month observed
14
If there is spontaneous pain in a primary molar, as is
often the case, definite treatment requires pulpectomy or
extraction, based on the radiographic image and other
factors described below. The dentist must be determined
to apply effective local anesthesia and be familiar with
this procedure in the case of an anxious or even fright-
ened child. Otherwise, it is better to refer the child to
a pediatric dentist, considering the consequences of a
failed, possibly painful, unscheduled session primarily on
the future cooperation of the child and secondarily on the
rest of the clinician’s daily schedule. Emergency interven-
tions may include means of pain control by anti-inflam-
matory/antimicrobial administering in cases of extensive
inflammation (. Fig. 14.5) or even drilling the tooth for
.. Fig. 14.10 Radiographic examination of deep cavity of a first immediate drainage, antiseptic irrigation, and temporary
mandibular primary molar reveals periodontal space thickening in filling. There is no need to expose a localized abscess of
the furcation area along with internal root resorption (arrows) a primary tooth for pus drainage, because these usually
recede shortly if prior instructions are followed.
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Pulp Therapy in Pediatric Dentistry
323 14
.. Table 14.1 Symptoms and signs in various pulp conditions of primary teeth
Diagnostic findings Partial chronic pulpitis Total chronic pulpitis Partial/total pulp necrosis
Mobility (pathologic) + +
Edema +
Tenderness on percussion/pressure + +/?
Vitality testing > >
Pain /? (evoked) + (spontaneous) +/
Intense hemorrhage on exposure +
Radiographic findings /+ +
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324 A. Arhakis et al.
14
c d
.. Fig. 14.11 a Persistent right submandibular edema after difuse furcation bony lesion suggests the first primary molar as
9-day hospitalization of a 5-year-old. b The tongue presents the responsible tooth (please disregard the dark thick artefact
fungal infection secondary to long chemotherapeutic treatment. line above its pulp chamber). d The annual follow-up radiograph
c Radiograph reveals deep, back-to-back, restorations of man- confirms the successful outcome of the root canal treatment
dibular right primary molars with residual carious dentin. A
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Pulp Therapy in Pediatric Dentistry
325 14
the bacteria of nutrients. The carious process is thus the acceptance of sealing the soft infected dentin of pri-
interrupted and any carious dentin that remains hard- mary molars under a PMC placed by the Hall technique.
ens (remineralizes) [7]. Following IPC, the pulp-dentin Attention should be paid to fully removing carious
complex is preserved by activating the reparative pulp dentin located at the peripheral cavity walls and, partic-
mechanism for secondary dentin apposition [21]. ularly, the cervical one where most mistakes occur. The
restorative material must be seated on healthy dental
14.2.1.1 Technique tissues (. Fig. 14.10). Otherwise, existing leakage risks
The tooth is anesthetized and isolated with rubber dam. caries progression. The use of a round bur (usually Νο.
All carious dentin is removed except for that very close 4 or 5) at very low rotation speed provides quite a good
to the pulp, which, if removed, might lead to pulp expo- sense of the hardness of deep dentin to be removed, in the
sure. This requires familiarization of the clinician with effort to avoid pulp exposure. On the contrary, the use of
the pulp chamber shape and dimensions of primary teeth a hand excavator, although very useful at initial removal
and with the radiographic image of deep primary molar of gross carious dentin, when approaching the pulp is
caries. The risk of exposure is much higher approaching more likely to result in its exposure. For the same reason,
the primary tooth pulp horns, whether from the axial or the use of the dental probe to sense the dentin hardness
the supra-pulpal cavity wall (. Fig. 14.12). While it is
should be completely avoided, contrary to an old view
generally advised that following caries excavation only for checking if all carious dentin is removed. The ART
hard and discolored dentin remains, in fast-progressing technique (discussed in 7 Chap. 13) for removing cari-
active lesions no dentin with such characteristics is often ous dentin using only hand instruments (usually without
found. This increases the risk of unnecessary pulp expo- local anesthesia) is another form of IPC [22].
sures. All these apply to anterior teeth as well. The prop-
erties of lining materials such as (RM)GIC allow for 14.2.1.2 Materials
minimal remnants of soft dentin surrounding the pulpal If the pulp is healthy or with signs of reversible pulpitis,
horn [20]. These materials seem to possibly satisfy the it is sufficient to cover the pulpal cavity wall with conven-
need for both an indirect capping material and a filling tional GIC or RMGIC [23]. Other biocompatible mate-
material according to a clinical study [9], an approach rials may be used like a quick-setting calcium hydroxide
that also reduces chair time. The same principal governs or ZOE. The latter was formerly used as temporary fill-
ing material in the so-called stepwise excavation [20].
a For primary teeth in general, reentry to the cavity is not
recommended and IPC and restoration are better com-
pleted in one session. Although there is a view that lining
the deep cavity with calcium hydroxide is advantageous
due to the initially high pH, what seems to be impor-
tant is the tight seal from bacteria rather than the type of
material used to cover the pulpal wall of the cavity [21].
14.2.1.3 Effectiveness
IPC success rates of 83–96% have been reported for pri-
b c
mary teeth that present no signs or symptoms of non-
reversible pulpitis [23]. IPC using preferably calcium
hydroxide and GIC is taught as the technique of choice
at 70% and 83% of American and British dental schools,
respectively [24]. IPC has the same indications as pulp-
otomy in primary molars with deep carious lesions with-
out pulp exposure [25] and may therefore be preferred
over pulpotomy, since their success is similar [26].
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326 A. Arhakis et al.
not risk a DPC without using a rubber dam. With extra Calcium Hydroxide
careful carious dentin removal, there may be cases that Pure calcium hydroxide (Ca[OH]2) has been, and still is,
exposure is borderline with no bleeding (. Fig. 14.13).
the gold standard. Its water mixture provides good dis-
Following DPC, the pulp is expected to preserve its infection, because of high pΗ [12], and prevents micro-
vitality and “defend itself ” by reparative dentin deposi- bial growth; it has a superficial caustic effect to the pulp
tion. This technique may be selected ideally for small tissue and is very soluble (it does not set). This is why
carious pulp exposure cases in permanent teeth with an it is also employed in the form of quick-setting cement
open apex. If we suspect that the inflammation extends with the addition of salicylate esters (commercial
to a large part of the pulp chamber, treatment failure brands, e.g., Dycal, Life, etc.); this increases mechani-
and full-blown pulpitis are probable. In primary teeth, cal stability and easier handling (it sets very soon). As
DPC may be selected based on strict criteria indicat- a cement has much lower pH [9] which may explain the
ing absence of pulp inflammation, i.e., in clinical terms, lower success rates when compared with pure calcium
absence of spontaneous or continuous pain of pulpal hydroxide in direct pulp capping. The pulp reacts form-
origin and limited self-contained hemorrhage after min- ing ideally a “bridge” of hard tissue, preserving pulp
imal pulp exposure [17, 25]. The documentation of such vitality. The quality of this “bridge” has been studied
instructions is however low, based on a few old studies in permanent teeth and shown to be less solid than the
and expert opinions; more recently, randomized con- one formed with the use of ΜΤΑ [29], allegedly because
trolled clinical trials with contemporary pulp capping the latter bonds much better with dentin and remains
materials support DPC as an option in carious primary stable in the long-term, thus preventing microbial leak-
molars, with success rates comparable to pulpotomy [18, age. Nevertheless, calcium hydroxide is still the most
27]. user-friendly and affordable material [30].
Instead of direct capping per se in cases of carious
primary teeth, some authors have adopted partial pulp- Mineral Trioxide Aggregate (MTA)
otomy with calcium hydroxide or MTA (. Fig. 14.14).
The basic ingredients of ΜΤΑ is a mixture of dical-
In performing it, about 2 mm of pulp – the part con- cium and tricalcium silicate and tricalcium aluminate,
sidered to be inflamed – is removed using a high-speed 20% bismuth oxide added for radio-opaqueness and,
diamond bur. This variation has produced success rates in smaller amounts, and iron and magnesium oxides. It
75% after 3 years [28]. Since it is a preferred option in has found various dental applications as final root canal
pulp exposures of traumatized permanent teeth, it is sealer, in direct pulp capping and pulpotomy, root pen-
described in 7 Chap. 16.
etration, and apical plugs [30, 31]. Less documentation
is available for the similar material Portland cement [32].
14.2.2.1 Technique When the powder form is mixed with water, it becomes
14 colloidal and hardens within about three hours; its pH
DPC procedure requires ideal conditions. Gross cari-
ous dentin removal at pulpal walls and cavity prepa- is 12.5, similar to that of pure calcium hydroxide. The
ration must have been completed before exposure main product of the reaction of these cements with
occurs. Thus, the most dentin infected with bacteria water is calcium hydroxide, which explains their similar
will have already been removed. If uncontrollable effect on the pulp. ΜΤΑ setting is accelerated in a humid
hemorrhage is observed at minimal primary tooth environment; this is why, after placing it at the exposure
pulp exposure, extensive inflammation is present and site, dump cotton wool is temporized in the cavity, with
other pulp treatment options are chosen among those the final restoration placed the following day. This is
presented below [20]. If there is little hemorrhage a disadvantage in clinical practice but some studies of
leading soon to spontaneous hemostasis, possibly one visit for MTA application and restoration in pri-
aided with a short light dressing with a cotton pellet mary teeth have shown good results [28]. ΜΤΑ strength
dump in saline, DPC is possible. After gently drying is at least equivalent to that of ΖΟΕ and other similar
the pulpal wall, the minimally exposed primary tooth cements. Disadvantages are its relatively high cost and
pulp may be covered under no pressure with calcium the necessity to be packaged in single doses because
hydroxide (Ca[OH]2) or mineral trioxide aggregate atmospheric humidity degrades it, thus other packaging
paste (ΜΤΑ), before placing a PMC or a well-sealed forms have appeared (. Fig. 14.16).
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Pulp Therapy in Pediatric Dentistry
327 14
a b
c d
.. Fig. 14.13 a Extremely deep cavities in both mandibular primary in both molars after extra careful carious dentin removal at pulpal
molars, radiographically in contact with the pulp cavity, and pos- walls. Caries removal was complete at axial and cervical walls. d The
sible furcation involvement of the first one. There was history of only finished restorations with RMGIC after calcium hydroxide cover of
provoked pain. b Occlusal aspect of oversize class II cavity prepara- exposure site on both molars. e Follow-up radiograph at 30 months
tions. c Wide borderline pulp exposure with no bleeding was evident shows pulp treatment success and healthy bone furcation
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328 A. Arhakis et al.
14.2.3.1 Technique
After local anesthesia administration and rubber
dam placement, carious dentin is fully removed from
the cavity walls using a Νο. 4 or 5 round bur at a low
speed handpiece. Thus, additional bacterial contami-
.. Fig. 14.14 a Radiographic image of mandibular second primary nation when the pulp is exposed is prevented. If the
molar of a 6-year-old boy referring recent, short-duration, evoked pulp is exposed, the supra-pulpal wall of the crown
14 pain (its apical distal root resorption seems unrelated). b Partial
pulpotomy with MTA and placement of a PMC was preferred along
chamber is removed using a cylindrical diamond bur
with restoring the first molar. c Progressive root canal obliteration is on a high-speed handpiece with water spray. The bur
observed under the MTA at 2-year recall follows the outline of the crown chamber, as defined
by the pulp horns, starting from the exposure point
(. Fig. 14.17).
direct pulp capping is a reliable long-term option for The pulp segment in the crown chamber may be
carious primary teeth as well, it should only be chosen amputated using a new (sharp) sterilized excavator or a
in the light of the precautions listed above [18, 30]. new round No. 4–6 bur on a low speed handpiece. The
pulp is amputated at the root canals entries, a procedure
requiring familiarity with their topography. Ample rins-
14.2.3 Primary Molar Pulpotomy ing of the pulp chamber with saline solution helps pre-
vent the entry of infected dentin debris into root canals.
Pulpotomy is the excision and removal of the inflamed The entire crown pulp must be carefully removed as any
crown pulp segment. The healthy radical segment inflamed remnants continue to bleed impeding diagnosis
remains and is covered with some material so as to pro- and making it impossible to visually examine the root
mote healing at the dissection point with the generation canal entries. Root pulp hemorrhage is controlled by
of hard tissue, thus allowing the radical pulp to preserve placing a cotton wool plug impregnated with saline for
its vitality. In cases of anterior teeth, partial pulpotomy 3 minutes (. Fig. 14.18). The tooth is considered suit-
or pulpectomy is preferred over pulpotomy because able for pulpotomy only when hemorrhage stops after
there is no abrupt narrowing of the pulp chamber in its that. Placing a cotton wool plug impregnated with 5%
transition to the radical pulp. sodium hypochlorite solution for 1 minute may help in
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Pulp Therapy in Pediatric Dentistry
329 14
.. Fig. 14.15 a Radiograph
a b
of carious primary teeth. b
Pulp exposure of maxillary
second primary molar after
spontaneous hemostasis. c
The 2-year follow-up radio-
graph after DPC with ΜΤΑ
and IPC of maxillary and
mandibular second primary
molars, respectively, shows
the success of both pulp
treatments. d, e Clinical view
of the restorations
c d e
a b c
.. Fig. 14.16 a Individual packaging of white ΜΤΑ (ProRoot, Dentsply, and Angelus) in power sachets and distilled water. b White ΜΤΑ
(Medcem GmbH) with powder in capsules. c Allegedly less sensitive to moisture white ΜΤΑ (NuSmile)
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330 A. Arhakis et al.
a b c
.. Fig. 14.17 a A cylindrical diamond bur has been used to cut to be detached. b Cotton wool dumped in formocresol is pressed in
away supra-pulpal dentin of a mandibular second primary molar the pulp chamber after careful inflamed pulp remnants. c The pulpal
with a large distal carious cavity. The supra-pulpal-dentin is ready chamber with complete hemostasis
a b c
d e
14
.. Fig. 14.18 a Series of pulpotomy actions following radiographic pulp and placement of cotton wool plug impregnated with saline
examination, local anesthesia, and rubber dam isolation. a Hyper- solution for 3 minutes. d Hemostasis is controlled. e Filling the pulp
plastic pulpitis of mandibular left second primary molar. b Cavity chamber with quick-setting ZOE preparation following capping of
preparation with removal of supra-pulpal dentin with pear-shaped pulp stumps with MTA
diamond at high speed under water cooling. c Amputation of crown
than other materials [40–42]. Their mode of action was obliteration is a frequent finding, but this does not seem
explained earlier in DPC. A small quantity of 1–2 mm to be clinically significant (. Fig. 14.14). Success rates
thickness is placed at root canal entries. The absence of are over 95% for 1- to 2.5-year follow-up period, [20,
internal root resorption, biocompatibility, and capac- 43, 44], although lower rates have been reported when
ity to induce “dentin bridge” creation has increased placed by pediatric dentistry trainees (Dimitraki et al.
MTA preference for pulpotomies. Some root canal 2019) [18].
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Pulp Therapy in Pediatric Dentistry
331 14
Formocresol Other Techniques and Medications
Formocresol was the most popular primary tooth pulp- A different approach is electrosurgery to cauterize the
otomy and reference material for more than 70 years. pulp, leaving a clot at radical pulp stumps. A retrospec-
In the new century, there has been renewed reflection tive study reported high clinical and radiographic suc-
to the cytotoxicity and potential mutagenic action of cess rates (96% and 84%, respectively) (Lin et al. 2014).
the formaldehyde (19%) it contains, which has caused Additionally, various laser methods have been assessed
concern in the scientific community, leading to recom- on animals and in dental praxis, such as Nd:YAG,
mendations for stopping its use [25]. Dilution of formo- Er:YAG, carbon dioxide laser, laser diode, and argon
cresol with glycerine, at a ratio of 1:5, was found to be laser [50, 51]. Data so far do not support the general
as effective [43], and this has been employed more fre- adoption of laser and electric surgery techniques for pri-
quently in recent decades to mitigate the undesirable mary molar pulpotomy.
effects of formaldehyde. Formocresol is a potent anti-
septic that does not promote dentinogenesis but causes
fibrous degeneration and fixation, under the site of pulp 14.2.4 Pulpectomy/Root Canal Treatment
amputation. Despite animal studies eliciting its nega- of Primary Teeth
tive effects, formocresol has remained clinically accept-
able [45], and its use was until recently taught at dental Pulpectomy means the full removal of pulpal tissue.
schools in the USA and Europe. Success rates have been Following chemical and mild mechanical processing of
reported in the order of 80–90%, close to those for ΜΤΑ root canals, these are filled with a biocompatible mate-
[39, 46, 47]. rial to prevent any bacteria remaining within them. Root
canal treatment is indicated when there are signs and
Ferric Sulfate symptoms of chronic pulpitis or necrotic pulp (pulpless
When this coagulating agent comes into contact with tooth) without radiographically apparent internal or
blood, a ferric ion and protein complex is formed in the external pathologic root resorption. Local pus presence
form of a membrane mechanically covering vessels and is not a contraindication as it can be managed by end-
inducing hemostasis. This complex covers the root canal odontic drainage. Contraindications to root canal treat-
amputated pulp preventing clot formation (Srinivasan ment leave extraction as the alternative (. Fig. 14.19).
et al. 2006) [46]. This 15-second impregnation with fer- Extraction is preferred for primary teeth with extensive
ric sulfate (. Fig. 14.17b) is followed by mild irrigation
crown destruction that cannot be restored even with a
of the crown chamber with water and light drying with PMC. When, in mixed dentition, the roots of a primary
a moist cotton wool pellet. A ZOE cover of root canal molar have been resorbed, either naturally or pathologi-
entries is succeeded by the permanent restoration. A wide cally, to the degree that there is no furcation bone up to
range of ferric sulfate success is reported (43–97%) which the permanent successor tooth crown, the primary molar
is lower than those of MTA [17, 48]. Ferric sulfate has extraction is preferred and there is no need to maintain
no systemic toxic action. In the “post-formocresol era,” space [3]. When space maintenance is an issue, preserv-
it remains a popular medication in primary tooth pulp- ing the primary tooth in the dentition is significant espe-
otomy [24, 49]. cially before the first permanent molars erupt [25].
a b
.. Fig. 14.19 a External and internal resorption of mesial roots of on top of the successor’s crown, indicating the need for space main-
mandibular second primary molar and major furcation bone resorp- tenance. b, c Radiographic and clinical view with space maintainer in
tion in an 8-year-old boy call for its extraction. Some bone is visible place after 3.5 years, respectively
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332 A. Arhakis et al.
Anatomical Features of Primary Molar Roots acceptable by the child. Removing the supra-pulpal
dentin is done as for pulpotomy, but the axial walls
The shape and form of root canals in anterior teeth may deviate more if necessary for easy access of root
are simple. In molars, however, many variations of canal filing and rinsing [54]. Every canal entry has to
their basic anatomy exist, emphasizing the impor- be located and the canal tissue remnants removed by
tance of the clinician being familiar with the mor- appropriately sized Hedstroem or K files. The buccal
phology of root canals to ensure successful root canal root canals of maxillary primary molars (particularly
treatment. Maxillary and mandibular primary molars the distal one) and the lingual root canals of man-
sometimes exhibit more than the usual three root dibular primary molars are usually thinner, and pulp
canals. In the mandible, a network of thin accessory extirpation or debridement usually starts with files Νο.
canals is usually found between buccal and lingual 25–35 [54, 55]. The length of files preferred for primary
aspect of the second molar distal root. In about one molar teeth is 21 mm since this, except for being suf-
quarter of second molars in both jaws, there is a very ficiently long, facilitates working in the smaller open-
wide root canal dividing before the apex (. Figs. 14.20
ing of a child’s mouth (. Fig. 14.22). If satisfactory
and 14.21) [ 52, 53]. Primary molar roots present con- opening of the mouth is not possible, some authors rec-
siderable curvature embracing the successor tooth ommend permanently bending a file (. Fig. 14.23). In
germ, so that care is needed to avoid perforating order to avoid files penetrating the apex, the working
them. The furcation lesions found almost exclusively length is set at 2–3 mm shorter than the actual one [54,
in primary molars with inflamed/necrotic pulps signi- 55].
fies that mechanical debridement should focus in the Root canals are disinfected with 5% sodium hypo-
cervical half of the roots, thus reaching their apical chlorite or chlorhexidine under continuous suction for
part with files being purposeless most of the time. removing organic residues, while mildly filing slightly
short to apex [54]. In pulpitis not extending further
than the root canals, endodontic treatment may be com-
pleted in one session, while in pulpless (septic) teeth or
14.2.4.1 Technique if inflammation extends to the alveolar bone, treatment
In the first session it is necessary to administer local completion requires more than one session [17]. Two ses-
anesthesia to avoid any pain during pulpectomy and/ sions usually suffice, with root canals cleaned as above in
or debridement. It also makes the rubber dam more the first session, dried with paper points and filled with
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Pulp Therapy in Pediatric Dentistry
333 14
a b c d
palatal
mesial
mesial
distal distal
.. Fig. 14.21 3-D models of second primary molars [52] (by per- resorption. c Mandibular molar with a single, wide root canal in the
mission). a Maxillary molar with auxiliary root canal in the apical distal root. d Mandibular molar with bifurcated root canal in the
half of mesiobuccal root. b Maxillary molar with early canal ter- middle and apical thirds of the distal root
mination in the palatal root, possibly the result of external root
b c
d e f
.. Fig. 14.22 a Periapical radiograph in this 5-year-old boy shows Hedstroem file) is done under rinsing with NaOCl. d Final restora-
moderate furcation bone resorption of mandibular right sec- tion of the cavity followed the filling of root canals with ZOE at
ond primary molar with deep occlusal cavity involving the pulp. b the next session. e Post-op radiograph. f The 3-year follow-up radio-
After inferior alveolar nerve block anesthesia, the rubber dam was graph confirms the successful treatment outcome. Some resorption
placed. c Mild filing of mesiobuccal root (with 21 mm length, No.25 of the inner wall of the mesial root is without clinical significance
calcium hydroxide with the help of a lentulo spiral or 14.2.4.2 Root Canal Filling Materials
high pressure syringe and temporized [56]. In the second and Effectiveness
session, 10–14 days later, rinsing is repeated and, if there The differences in growth/development, anatomy, and
is no exudate or other signs of inflammation, the root physiology between primary and permanent teeth
canals are dried by paper points and carefully filled with impose changes also in the criteria for root canal fill-
an appropriate paste (see types below). The pulp cham- ing materials. The ideal material for primary teeth
ber is then filled with a quick-setting ZOE preparation should.
[57, 58], a post-op radiograph taken, and final restora- 55 Be absorbable at a rate comparable to the rate of
tion or PMC placed. root resorption
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334 A. Arhakis et al.
93%) [10]. The fact that, in the case of primary teeth, of partial or total necrosis.
less strict radiographic success criteria may be applied in
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Pulp Therapy in Pediatric Dentistry
335 14
.. Fig. 14.24 a Hemorrhagic
pulp exposed while preparing a b
occlusal cavity in a young per-
manent molar with spontaneous
pain history indicates nonrevers-
ible pulpitis. b. Septic carious
dentin with pulp abscess (hema-
toxylin/eosin stain, By permis-
sion [64])
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336 A. Arhakis et al.
Another approach is to complete tooth restoration One such is a calcium silicate cement (Biodentine™,
in one session by stepwise excavation, just as is done for Septodont, France), which appears to promote equally
primary teeth (. Fig. 14.26). This does not offer the
dense reparative dentin as that produced by ΜΤΑ [69]
possibility to confirm the reversibility of pulp inflam- (. Fig. 14.27). In the past, adhesive dentin agents were
mation securing a safer prognosis. In choosing the best experimentally used in contact with the exposed pulp,
option, all the relevant factors for the individual patient but they did not meet with success. This supports the
must be considered on a case-by-case basis, because view that besides hermetically sealing the cavity from
long-term prognosis in the relevant literature does not bacteria, the capping material should promote repara-
favor either of the two options [67]. tive dentin formation.
When a small carious exposure of healthy or, more
likely, reversibly inflamed pulp occurs, and after pos-
14.3.2 Direct Pulp Capping sible hemorrhage is controlled, the capping material of
choice is placed over the exposure without pressure. If
Evidence on the suitability of carious permanent teeth it is a quick-setting calcium hydroxide, it is then coated
for DPC, as well as the relevant clinical procedure, with a GIC followed by a sound restoration to fully pre-
do not differ from that presented for primary teeth. vent microleakage. If the choice is MTA, it should be
Traditionally, the material of choice has been calcium covered with a dump cotton pellet before the tooth is
hydroxide, while the more recent so-called Bioactive temporarily filled. It takes a few hours for the MTA to
Endodontic Cements have shown excellent results [68]. set, so cotton is removed and final restoration placed at
a b
14 .. Fig. 14.26 a Deep occlusal carious lesion of mandibular first permanent molar. b Indirect pulp capping with quick-setting calcium
hydroxide, GIC lining and final composite restoration in one session appears to be successful at the 6-month review
c d
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Pulp Therapy in Pediatric Dentistry
337 14
a b
.. Fig. 14.28 a Deep carious lesion of a mandibular first perma- directly capped with Biodentine™ cement. b This radiograph was
nent molar without a history of spontaneous pain. Despite the effort taken 4 months later, before placing a permanent restoration. The
toward indirect pulp capping, exposure occurred, and the pulp was tooth was asymptomatic
a later time. If the material is Biodentine™ cement, it 14.3.3 Partial Pulpotomy and Cervical
can be left as a temporary filling material for up to 6 Pulpotomy
months or be coated after its 12-minute setting time with
the permanent restoration (. Fig. 14.28) [70]. Direct
In partial pulpotomy only the superficially inflamed
capping is considered successful if the pulp survives pulp next to exposure site is removed, and the healthy
and the radiograph confirms the deposition of repara- pulp is covered with any biological material listed above
tive dentin at the exposure site. Furthermore, in teeth for DPC. It is considered the treatment of choice for
with an open apex, success is confirmed when the root permanent incisors with crown fractures that expose the
continues developing and apex formation is completed pulp; for a description of the procedure see 7 Chap. 16.
with vital pulp with no more than reversible pulpitis Wide acceptance of DPC and partial pulpotomy in
are selected, and a sound procedure is followed, studies young permanent teeth affected by caries has restricted
show that DPC of permanent teeth shows success rate the choice of cervical (deep) pulpotomy exclusively to
of 73% for over 3 years follow-up [72] or even 80% for cases when hemorrhage can only be controlled at the
6 years follow-up [73]. In a specialist endodontic private level of pulp stumps at the entries to root canals. Even
practice, success rates at 9 years follow-up of 98% for then, it is meaningful to choose this procedure only in
young teeth with mature apex have been reported, which immature teeth so that apices may be completed, while
rose to 100% in the 15 teeth with immature apices [38]. in mature teeth full pulpectomy and root canal treat-
ment should be preferred [77]. Once again, the capping
Eye Catcher materials of choice for deep pulpotomy are MTA or
calcium hydroxide (. Fig. 14.30). A theoretical disad-
Various bioactive molecules are being investigated, vantage of the technique, in case of failure, may be the
including growth factors and molecules of extracel- difficulty to access root canals for further treatment due
lular enamel or dentin matrix. These are considered to possible formation of a hard tissue bridge under the
capable of activating the endogenous stem or ances- capping material.
tor cells, enhancing the local regenerative potential.
Animal studies have shown that the use of bioactive
molecules in pulp capping produced a thicker layer of 14.3.4 Root Canal Treatment of Immature
homogenous reparative dentin, while research contin- Carious Teeth
ues in the quest whether carious dentin is capable of
repair [74]. For example, collagen infiltrated with The detailed procedures of endodontic procedures of
hydroxyapatite and silicon nanoparticles provided mature teeth can be found in textbooks of endodon-
scaffolding for increased crystal formation toward tology. In this part of a pediatric dentistry book, the
carious dentin remineralization, if environmental emphasis is given to the treatment of irreversible pulpal
conditions were favorable [75]. inflammation or pulp necrosis, with or without apical
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338 A. Arhakis et al.
14
a c
d e
.. Fig. 14.30 a An emergency case of immature carious first per- pulpotomy. c Radiographic image with temporary filling. d Contin-
manent molar with extensive crown pulp inflammation. b Hemosta- ued apexogenesis is seen at the 6-month review. A preformed metal
sis and placement of MTA at root pulp stamps following cervical crown had been placed. e Clinical occlusal view
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Pulp Therapy in Pediatric Dentistry
339 14
antisepsis [80]. The access cavity of the tooth is sealed plug consists in completing the endodontic treatment
with a temporary restoration which should be at least of an immature tooth soon, by sealing the open apex
3 mm thick. The goal of the apexification treatment is to and still promoting the hard tissue barrier formation in
promote healing of the periapical tissues and the forma- the next 6 to 18 months as in the traditional technique
tion of an apical hard tissue barrier which will act as a (. Fig. 14.32). The MTA’s very hard consistency, how-
stop for a future endodontic obturation. The apical bar- ever, does not forgive mistakes.
rier is achieved within a period which ranges from 6 to This procedure can be followed both in traumatized
18 months (average 12 months), during which the canal teeth and in teeth with carious pulp necrosis. If the
may need calcium hydroxide refilling two or three times tooth is necrotic, local anesthesia may not be necessary,
because of gradual resorption at its apical portion [81]. except for a minimal amount to numb the gingiva for
The need, however, to change calcium hydroxide during clamp placing. MTA apexification may be performed
the apexification is debated. After the clinical procedure using also alternative bioactive cements [79]. Successful
is completed, the patient will be followed at 1 week, 1 apical barrier formation, following the placement of an
month (for symptoms), and then every six months with MTA apical plug in 22 pulpless immature permanent
a clinical and radiographic evaluation. The formation incisors, was as high as 95% [82]. For posterior carious
of the apical barrier is confirmed radiographically. The permanent teeth with open apices, there have been only
roots are permanently filled with gutta-percha (best if case reports [83, 84].
thermoplasticized) and root canal sealer (. Fig. 14.31).
with adhesive techniques. According to some authors, of symptoms, three weeks later, the tooth is reopened,
the treatment can be also completed in one appoint- using an anesthetic solution without vasoconstrictor,
ment, without waiting for the MTA to set. The patient is the canal is rinsed, and bleeding is induced by pushing
checked for symptoms after one week and followed-up an endodontic file passed the working length [85]. When
clinically and radiographically to monitor the mineral- a coagulum is formed, the coronal portion of the root is
ized barrier. The advantage of using a preformed apical sealed with MTA or other bioactive endodontic cement,
a b c
.. Fig. 14.31 a Radiograph of a heavily carious and abscessed and ongoing healing of the periapical tissues. c Three-year follow-up
mandibular first permanent molar with large diffused periapical radiograph of the tooth with preformed metal crown showing com-
radiolucency at immature distal root. b Obturation of the canals plete healing, resorption of the extruded material, and intact lamina
with gutta-percha following the temporary calcium hydroxide fill dura [84] (By permission)
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340 A. Arhakis et al.
c d
a b c
14
.. Fig. 14.33 a Periapical radiograph showing the mandibular per- 6-months recall: the tooth is asymptomatic and the bone lesion is
manent right first molar of a 7-year-old boy, affected by deep caries healing. c 18 months recall: the tooth is still asymptomatic, periapi-
and showing signs of apical periodontitis at the apex of the distal cal tissues look healthy, the root canal walls appear thickened, and
root. The tooth did not respond to sensitivity test. Tooth revascu- the apical opening narrowed, but the root has not increased its length
larization treatment was attempted using triple antibiotic paste. b
and the tooth is hermetically restored. By this procedure thicker dentinal walls and consequently more fracture-
the stem cells from the papilla should be able to migrate resistant roots [86, 87]. Histopathology reports have
and use the coagulum as a scaffold, and growth factors shown that the endodontically grown tissue was mostly
are released from the dentinal walls. The migration of of periodontal origin being cementum bone-like and
stem cells should recreate the pulp tissue. So far, the fibrous connective tissue [78, 88]. The revascularization
clinical cases studied have shown success in achieving mechanism, the type of tissue coming in contact with
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Pulp Therapy in Pediatric Dentistry
341 14
a b c
d e f
.. Fig. 14.34 a Partial pulpotomy with white MTA in an 8-year-old The patient however complained of localized crown discoloration at
girl, of the immature maxillary right central incisor having suffered the fracture line, which becomes more evident as enamel and den-
a complicated crown fracture. b The 3-month radiographic follow- tin are progressively removed. f The discoloration was related to the
up shows the reattachment of the fragment with composite resin. c MTA. Most of it was removed and cavity restored with opaque and
Successful outcome after 5 years, with some canal obliteration. d, e enamel-colored composite resin
pulpal walls, and the long-term clinical consequences even in conservative pulp treatments of permanent inci-
are therefore still under investigation. sors (. Fig. 14.34). Discoloration related to endodontic
Finally, several experimental animal studies and treatment has always been an aesthetic problem, aris-
recent limited trials in humans indicate that stem cell ing in pulpless teeth before or after treatment. Before
treatment may play a significant role in the future of treatment, it is caused by the degeneration of necrotic
dentistry. The first applications will most probably con- pulp tissues due to patient neglect for seeking treatment.
cern the pulp and periodontal tissues, after the possible After endodontic treatment, it stems from inadequate
epigenetic stability of populations emerging from stem treatment procedures allowing leakage, for example,
cell cultures has been investigated. What have also to be an unsuitable access shape to pulp chamber allowing
determined are the protocols to test regenerated dental for degenerating pulp remnants to remain unnoticed.
tissues before they are clinically used to ensure desirabil- Restoring normal color by internal bleaching may be
ity of shape, size, and color [89]. achieved following the procedure described below.
After radiographic examination of the tooth and
placement of the rubber dam, the filling is removed
14.3.5 Restoring the Color of Discolored and unobstructed lingual approach to the pulp cavity is
Teeth achieved. The pulp contents are removed up to a few
millimeters beyond the clinical cervix; using a round
Since gray MTA has been considered responsible for the bur at a low speed, discolored dentin is removed in so
discoloration due to its ferric oxide content, white MTA far that tooth strength is not compromised. A thin layer
has been developed and marketed, particularly for use of cement, e.g., white GIC, is cervically placed so as to
with anterior teeth. Despite the use of white MTA, how- prevent microleakage of the bleaching agent into the
ever, in 5 of the 22 anterior teeth receiving root canal root or the periodontium through the dentinal tubules.
treatment in a clinical study of children of an average age The dentin is etched internally and then cleaned of fatty
of 10 years, some crown discoloration was observed [82]. ingredients with an acetone impregnated cotton wool
It has indeed been observed after the use of white MTA pellet.
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342 A. Arhakis et al.
a b c d
.. Fig. 14.35 a-d Gradual color restoration in four sessions of a discolored maxillary right central permanent incisor that had received root
canal treatment. (Courtesy of Dr. P. Beltes)
The cavity is filled up to the dentin borders with a 9. Kotsanos N, Arizos S. Evaluation of a resin modified glass
dense paste produced by mixing sodium perborate pow- ionomer serving both as indirect pulp therapy and as restor-
ative material for primary molars. Eur Arch Paediatr Dent.
der with 3% hydrogen peroxide. The enamel walls are 2011;12:170–5.
cleaned and a temporary restoration, e.g., RMGIC, 10. Ballesio I, Campanella V, Gallusi G, Marzo G. Chemical and
offers a hermetic seal [90]. If necessary, the process is pharmacological shaping of necrotic primary teeth. Eur J Paedi-
repeated. In the last session, the cavity and tooth are atr Dent. 2002;3:133–40.
thoroughly rinsed with water, due to a risk of chemical 11. Roeykens H, De Moor R. The use of laser Doppler flowmetry in
paediatric dentistry. Eur Arch Paediatr Dent. 2011;12:85–9.
damage to the gingiva and of external cervical resorp- 12. Fuks AB. Vital pulp therapy with new materials for primary
tion of the root by the bleaching agents. Then cavity is teeth: new directions and treatment perspectives. Pediatr Dent.
wiped with cotton wetted with chloroform and restored 2008;30:211–9.
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bleaching effect) after etching and bonding. If every techniques in primary molars: a long-term follow-up. J Endod.
2008;34:950–5. https://doi.org/10.1016/j.joen.2008.05.009.
stage is performed with care, the outcome is good and 14. Alaluusua S, Veerkamp J, Declerck D. Policy document for the
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(. Fig. 14.35) [91].
15. Peretz B, Nisan S, Herteanu L, Blumer S. Root resorption pat-
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63. Hargreaves KM, Giesler T, Henry M, Wang Y. Regenera-
Eur J Oral Sci. 2010;118:290–7. https://doi.org/10.1111/j.1600--
tion potential of the young permanent tooth: what does the 0722.2010.00731.x.
future hold? J Endod. 2008;34:S51–6. https://doi.org/10.1016/j. 78. Simon SR, Tomson PL, Berdal A. Regenerative endodontics:
joen.2008.02.032. regeneration or repair? J Endod. 2014;40:S70–5. https://doi.
64. Slootweg PJ. Dental pathology, Ch. 8. In: Disorders of the den- org/10.1016/j.joen.2014.01.024.
tal pulp. 2nd ed. Springer-Verlag; 2013. 79. Harlamb SC. Management of incompletely developed teeth
65. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or
requiring root canal treatment. Aust Dent J. 2016;61(Suppl
ultraconservative removal of decayed tissue in unfilled teeth. 1):95–106. https://doi.org/10.1111/adj.12401.
Cochrane Database Syst Rev. 2006;3:CD003808. https://doi. 80. Hasselgren G, Olsson B, Cvek M. Effects of calcium hydroxide
org/10.1002/14651858.CD003808.pub2. and sodium hypochlorite on the dissolution of necrotic porcine
66. Hayashi M, Fujitani M, Yamaki C, Momoi Y. Ways of enhanc- muscle tissue. J Endod. 1988;14:125–7. https://doi.org/10.1016/
ing pulp preservation by stepwise excavation- a systematic S0099-2399(88)80212-7.
14 review. J Dent. 2011;39:95–107. https://doi.org/10.1016/j.
jdent.2010.10.012.
81. Deepti A, Shifa S, Muthu MS, RathnaPrabhu V. Apical closure
of immature molar roots: a rare case report. Int J Clin Pediatr
67. Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treat- Dent. 2008;1:54–7.
ment of deep carious lesions by complete excavation or par- 82. Moore A, Howley MF, O'Connell AC. Treatment of open apex
tial removal: a critical review. J Am Dent Assoc. 2008;139: teeth using two types of white mineral trioxide aggregate after ini-
705–12. tial dressing with calcium hydroxide in children. Dent Traumatol.
68. Parinyaprom N, Nirunsittirat A, Chuveera P, Na Lampang S, 2011;27:166–73. https://doi.org/10.1111/j.1600-9657.2011.00984.x.
Srisuwan T, Sastraruji T, et al. Outcomes of direct pulp capping 83. Woelber JP, Bruder M, Tennert C, Wrbas KT. Assessment of
by using either ProRoot mineral trioxide aggregate or biodentine endodontic treatment of c-shaped root canals. Swiss Dent J.
in permanent teeth with carious pulp exposure in 6- to 18-year-old 2014;124:11–5.
patients: a randomized controlled trial. J Endod. 2018;44:341–8. 84. Musale PK, Kothare S. Non-surgical endodontic manage-
https://doi.org/10.1016/j.joen.2017.10.012. Epub 2017 Dec 21 ment of immature permanent mandibular first molar: a 3 year
69. Tran XV, Gorin C, Willig C, Baroukh B, Pellat B, Decup F, follow-up. Eur Arch Paediatr Dent. 2018;19:373–7. https://doi.
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on pulp repair. J Dent Res. 2012;91:1166–71. https://doi. 85. Cotti E, Mereu M, Lusso D. Regenerative treatment of an
org/10.1177/0022034512460833. immature, traumatized tooth with apical periodontitis: report
70. Rajasekharan S, Martens LC, Cauwels RGEC, Anthonappa RP, of a case. J Endod. 2008;34:611–6. https://doi.org/10.1016/j.
Verbeeck RMH. Biodentine™ material characteristics and clini- joen.2008.02.029.
cal applications: a 3 year literature review and update. Eur Arch 86. Cehreli ZC, Isbitiren B, Sara S, Erbas G. Regenerative
Paediatr Dent. 2018;19:1–22. https://doi.org/10.1007/s40368- endodontic treatment (revascularization) of immature
018-0328-x. necrotic molars medicated with calcium hydroxide: a case
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series. J Endod. 2011;37:1327–30. https://doi.org/10.1016/j. 89. Mitsiadis TA, Papagerakis P. Regenerated teeth: the future
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83. https://doi.org/10.1016/j.joen.2013.04.032.
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347 15
Periodontal Diseases
in Children and Adolescents
Aikaterini-Elisavet Doufexi and Frank Nichols
Contents
References – 360
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348 A.-E. Doufexi and F. Nichols
Children and adolescents commonly present with peri- Gingivitis presents with the same clinical findings in chil-
odontal diseases. The dental clinician should be aware dren and adults: gingival redness, edema of free gingi-
of and be able to diagnose and timely treat such diseases vae, bleeding on probing, and often loss of stippling [2].
for the following reasons: [1] The gingival margin becomes rounded due to edema and
1. The prevalence of periodontal disease in children bleeds upon any mechanical challenge (. Fig. 15.1). If
and adolescents is high. gingivitis is left untreated, the gingival tissue can become
2. Superficial or localized periodontal lesions in chil- more fibrous and the interdental papillae may appear
dren may lead to more severe and generalized peri- hyperplastic, thereby increasing the depth of the gingi-
odontal diseases in adulthood. val crevice [2]. This leads to pocket development without
3. There is strong evidence for an association between loss of attachment (“pseudo-pocket”).
general-systemic diseases and periodontal diseases. Epidemiological data indicate that in children aged
4. Families at high risk for periodontal disease (e.g., 4–9 years, gingivitis occurs at rates of 40–60%. Its
due to predisposing genetic factors) can be identified prevalence increases with age [3]. Approximately 82%
early and placed into individualized prevention pro- of teenagers suffer from gingivitis in the USA, while
grams and more vigilant treatment. in various other countries teenagers show a similar or
5. The prevention and treatment of most forms of peri- higher prevalence [4, 5]. Experimental gingivitis studies
odontal disease is straightforward and effective. after discontinuation of oral hygiene showed that longer
time was required for its appearance in children than in
adults [6–9]. The bleeding index (GI, gingival index) in
Eye Catcher
various age groups (children, adolescents, adults), with
The most common periodontal disease in children similar plaque index scores, was also found to increase
and adolescents is gingivitis. Common in youth are with age [7]. The different inflammatory responses in
also mucogingival problems, gingival hyperplasias, various age groups could be partially attributed to dif-
and necrotizing ulcerative gingivitis/periodontitis. ferent levels of hormones, particularly in females.
Periodontal attachment loss occurs infrequently in The inflammatory response of the gingiva to plaque
children, but when it does, it is usually aggressive. accumulation is typically more severe around erupting
Severe periodontal attachment loss in children and permanent teeth and is frequently termed “eruption
adolescents should raise concern for an underlying gingivitis.” [10] The main reason is simply related to
systemic disease of genetic predisposition. the substantially greater bacterial load due to ineffec-
tive oral hygiene in the tooth eruption sites. Access to
and cleaning of the tooth eruption area with the brush
requires more time and effort. Another reason might
15.1 Diseases Restricted to Gingiva
be that degenerative changes in the attached epithelium
undergoing remodeling at the eruption site may lead to
15.1.1 Gingivitis
15 a diminished immune response with an altered ability to
mount a suitable inflammatory response [10].
15.1.1.1 Definition, Epidemiology,
and Clinical Findings 15.1.1.2 Microbiological and Histological
Chronic gingivitis is a reversible disease of periodontal Findings
tissues with signs and symptoms of gingival inflamma- Although the signs and symptoms of gingivitis in chil-
tion without attachment loss. Under the general title dren are less pronounced than in adults, the microbiota
“gingivitis,” we could describe three different forms: is generally similar and is characterized by elevated
(a) Acute or chronic gingivitis of exclusively microbial levels of subgingival Prevotella sp., Actinomyces sp.,
etiology. Capnocytophaga sp., Leptotrichia sp., and Selenomonas
(b) Gingivitis in which the inflammatory reaction is modi- sp. [11–13]. Histologically, gingivitis in children is char-
fied by hormones, specifically gonadotrophins (elevated acterized by ulceration of the epithelium of the gingival
estrogen and/or progesterone levels in puberty, during sulcus and infiltration of the underlying connective tissue
pregnancy, and when taking oral contraceptives). by inflammatory cells [2]. Dominant cells in the region
(c) Gingivitis secondary to drug-induced gingival of gingival inflammation are T lymphocytes in contrast
hyperplasia. to adult gingivitis where B lymphocytes predominate.
The total number of leukocytes in the sulcus is generally
The primary etiologic factor associated with these forms reduced in children compared to adult gingivitis [2, 14,
of gingivitis is dental plaque on tooth surfaces of chil- 15]. Moreover, elevated estrogen and progesterone levels
dren. Other factors may be important predisposing in adolescents may contribute to increased vascularity
factors that complicate the development of the inflam- and a more pronounced inflammatory response of gin-
matory process, i.e., by differentiating host response. gival tissue to bacterial plaque [2, 11, 16].
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Periodontal Diseases in Children and Adolescents
349 15
a b
c d
.. Fig. 15.1 a. A seven-year-old boy with chronic generalized gingi- bleeding upon plaque removal are educational to the child. d. Clini-
vitis manifested by edema of free gingivae. b. Heavy plaque deposits cal appearance 6 weeks after the treatment of gingivitis (oral hygiene
due to the absence of oral hygiene are evident to the naked eye. c. instructions, removal of deposits). Tooth crowns appear longer, due
Plaque disclosure with fuchsine dye and demonstrating spontaneous in part to the resolution of edema
5. Fixed orthodontic appliances (. Fig. 15.3). .. Fig. 15.2 A girl 14 years of age scheduled for orthodontic treat-
ment. Ineffective oral hygiene and tooth crowding contributed to
On the other hand, factors that affect host defense localized gingivitis (edema of free gingivae). Arrows indicate the
localized gingival recession, consistent with ectopic (labial) tooth
responses may include: positioning
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350 A.-E. Doufexi and F. Nichols
a a
b
b
occur in adults. It was reported, for example, that, out of gesterone) receptors as investigated immunohistochemi-
27 cases with a median age of 13 years, three were patients cally. No etiologic relationship has been established.
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Periodontal Diseases in Children and Adolescents
351 15
a b
.. Fig. 15.5 a. Clinical image of localized juvenile spongiotic gin- Histological picture of LJSGH. The epithelium demonstrates hyper-
gival hyperplasia (LJSGH) in a 10-year-old boy extending full width plasia, spongiosis, and exocytosis. A dense mixed inflammatory cell
in the attached gingiva of the right central and only in the free infiltrate is seen in the underlying connective tissue. (Courtesy of Dr.
gingiva of the left central incisor (courtesy of Dr. R. Steffens). b. N. Nikitakis)
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352 A.-E. Doufexi and F. Nichols
vectomy) [22]. It should be noted that, in 40% of these Neurofibromatosis type I, also termed von
patients, recurrence of hyperplasia after gingivectomy Recklinghausen’s disease, is an inherited disease with
appears 18 months after surgical treatment, which is varying expression, depending on the type of mutation
frequently associated with gingival inflammation due to that causes it (see 7 Chap. 21). Intraorally, gingival
15 poor compliance [21, 22]. Surgical interventions should hyperplasia may present with tooth impaction, orth-
necessarily be followed by frequent and meticulous odontic anomalies, high plaque and caries indices, and
maintenance therapy. periodontal attachment loss.
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Periodontal Diseases in Children and Adolescents
353 15
a e f g
c
h i j
.. Fig. 15.8 a–d. Clinical appearance of congenital fibrous gin- interdental papillae between the maxillary central and lateral inci-
gival hyperplasia in a 10-year-old girl. The patient presents with sors, which have clinical signs of chronic inflammation, i.e., smooth,
“pseudo-pockets” and swollen gingivae composed of fibrous tissue, red, and spongy texture. e–j. The radiographic images show normal
especially in the upper and lower anterior regions. Exceptions are the bone levels in the hyperplastic anterior region
bacteria and dysfunction of the immune system. Retrospective studies in patients with localized aggres-
sive periodontitis show that attachment loss in the
primary teeth can precede that in the teeth of the
15.2.1 Chronic Periodontitis in Children permanent dentition [30]. In contrast, generalized
and Adolescents aggressive periodontitis is determined by recording
attachment loss in three or more teeth other than
Chronic periodontitis occurs not only in adults but molars or incisors [11]. Some clinicians and periodon-
also in children and adolescents. Briefly, the clinical tal researchers believe that localized aggressive peri-
signs include rapid attachment loss and severe gingival odontitis is not a precursor disease to other forms of
inflammation and may show a familial aggregation [11, periodontitis, while others maintain that it can evolve
23] (. Fig. 15.9). Secondary features include defects
into generalized aggressive periodontitis [11, 31, 32]
in phagocytosis and excessive activity of macrophages/ (. Figs. 15.11 and 15.12). The incidence of aggressive
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354 A.-E. Doufexi and F. Nichols
a1 a2 a3
b1 b2 b3
c1 c2 c3
c4
.. Fig. 15.9 Three African-American sisters present with character- significant periodontal destruction around the maxillary central
istics of aggressive periodontitis, such as severe periodontal lesions, incisors, which can account for their significant buccal displacement.
loss of teeth due to periodontal disease at a young age, periodon- Radiographic evidence indicates also the advanced periodontal
tal destruction in incisors and molars, and genetic predisposition. lesions around the first maxillary molars. c1–4. The youngest girl
a1–3. The oldest girl of the family (19 years old) has already lost a of the family shows significant loss of the attachment between the
central incisor and a first lower molar due to periodontal disease. upper central incisors with the characteristic loss of papilla. By con-
The lower molar has been replaced with a fixed partial denture. Dur- trast, there is no loss of periodontal attachment in the lower incisors.
ing periodontal surgery advanced intraosseous periodontal lesions According to the dental history, both parents lost their teeth due to
were detected in the mandibular molar region of the contralateral periodontal disease. Overall, the pediatric dentist should collaborate
side. b1–3. The middle sister (17 years old) has already shown buc- with a periodontist in the diagnosis, prevention, and treatment of
cal displacement of the upper central incisors. Radiographs showed aggressive periodontitis in children
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Periodontal Diseases in Children and Adolescents
355 15
a b c
d e
.. Fig. 15.11 a. 9-year-old boy with localized aggressive periodon- radiographic examination reveals significant bone loss on the molars
titis. A. Acute hyperplastic inflammatory lesion is seen in the gin- as well. e. Five years after baseline examination, the periodontitis
giva of the maxillary and mandibular molars. b, c. The radiographic has progressed significantly with the maxillary right second premo-
examination reveals significant alveolar bone loss in the central max- lar having a hopeless prognosis. (Courtesy of Drs. N. Kotsanos and
illary and the lateral mandibular incisors. d. Eighteen months later, A. Gofa)
are Porphyromonas gingivalis (P.g.), Peptostreptococcus A.a., the IgG2 antibody produced against A.a. is spe-
micros, Campylobacter rectus, and Tannerella forsythia. cific for the high molecular weight lipopolysaccharide
The Aggregatibacter (formerly Actinobacillus) acti- (HMWLPS) generated by A.a. [11]. Production of IgG2
nomycetemcomitans (A.a.) is also a periopathogenic antibodies against A.a. appears to be protective against
bacterium and is frequently recovered as a substantial aggressive periodontitis [11, 41, 42] since patients with
percentage of the flora at localized periodontitis sites. higher concentrations of IgG2 show less attachment
Among the five different serotypes of A.a. isolated, sero- loss compared to patients with lower titers of IgG2.
type b has been associated with aggressive and chronic The immune response in young patients with chronic
periodontitis and serotype c with periodontal health. periodontitis is determined by other factors as well. For
However, a single subgingival organism has not been example, the levels of IgG2 in serum are influenced by
implicated as the causative organism for localized peri- genetic and environmental factors. Specifically, high
odontitis [4, 11, 12, 38–40] levels of serum IgG2 have been detected in Blacks with
Both localized and generalized periodontitis in chil- aggressive periodontitis, while low levels of IgG2 are
dren and adolescents are characterized by dysfunction of typically observed in subjects with a smoking history
the immune system. Patients show polymorphonuclear [11]
leukocyte dysfunction and impaired immunoglobin pro-
duction (immunoglobins come from B lymphocytes). 15.2.1.2 Treatment
For both localized and generalized periodontitis, poly- As mentioned before, aggressive periodontitis is prob-
morphonuclear leukocytes typically show impaired ably caused by either a specialized subgingival flora or a
chemotaxis (although this is not universal) and reduced dysfunctional immune reaction to the subgingival flora.
GP-110 expression, which is a glycoprotein found on the Thus, the treatment of aggressive periodontitis aims to
neutrophil cell surface and acts as a receptor of chemo- reduce the microbial load and to strengthen host defense
tactic factors. The IgG immunoglobulins are classified mechanisms [11].
into four isotype classes (IgG1–4). After infection with
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356 A.-E. Doufexi and F. Nichols
c d
Eye Catcher been used with successful results, especially in the cases
of resistant to tetracyclines A.a. Administration of met-
The antimicrobial therapeutic approach for chronic ronidazole (250 mg) in combination with amoxicillin
periodontitis in children and adolescents is similar to (375 mg 3 times daily for 7 days) may be more effective
the classical periodontal disease management proto- in eradicating (or substantially reducing) the A.a. and
col, i.e., the combination of the following: P.g. in most patients with rapid progression of periodon-
(a) Conventional debridement treatment with root titis [2, 11, 48]. The same antibiotic regimen can be used
scaling and planing. in the cases of generalized periodontitis. Use of alter-
(b) Surgical treatment. native antibiotics may be required in patients who do
(c) Local or general administration of antibiotics not respond to conventional antibiotic therapy. In this
(antimicrobials) [11]. case, laboratory techniques, such as bacterial culture,
polymerase chain reaction (PCR) detection of genetic
products, ELISA, or DNA probes, can be used to detect
The treatment of chronic periodontitis requires eradi- periopathogenic bacteria or that resist conventional
cation of the biofilm by root scaling and planing and antibiotic treatment [11].
typically includes surgical intervention and the admin-
istration of antibiotics (. Fig. 15.13). Indeed studies
15
indicate that levels of A.a. were significantly reduced 15.2.2 Periodontitis Associated
only after periodontal surgery, while the conservative with Systemic Disease
treatment with the administration of antibiotics does
not significantly reduce the levels of A.a. [3, 11, 42, 43]. Periodontal disease associated with systemic disease may
Since in most cases of periodontitis other periopatho- be a manifestation of these diseases. Examples include:
genic bacteria are detected besides A.a., administra- 1. Papillon-Lefèvre syndrome (7 Fig. 10.29)
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Periodontal Diseases in Children and Adolescents
357 15
a
b
c d e
.. Fig. 15.13 a. A 5-year-old boy with no systemic diseases who scaling and planing and systemic antibiotics. c–e. Eighteen months
was diagnosed with aggressive periodontitis shows significant clini- after treatment completion, the patient presents with periodontal
cal signs of acute gingival inflammation (edema and loss of stippling health. The patient complied with frequent recall appointments.
appearance). b. Radiographic examination reveals significant attach- Orthodontic treatment will be initiated in the future for the posterior
ment loss in deciduous molars. The patient was treated with root crossbite. (Courtesy of Drs. N. Kotsanos and D. Apatzidou)
underlying bone by transformed leukocytes. Children subgingival plaque of diabetic children with periodontitis
with leukemia might have fever, bleeding disorders, and [55]. Therefore, children with type I diabetes are at higher
malaise. Gingivitis signs and symptoms in children with risk of developing destructive periodontal disease.
leukemia will be recurrent, if the systemic disease is not A significant correlation is also reported between
treated. Periodontal disease associated with systemic dis- body fat index and the presence of periodontitis in
eases in children and adolescents typically shows severe children and adolescents [56]. The authors conclude
symptoms, including severe inflammation, ulceration, that a healthy diet and physical activity may be factors
rapid bone loss, tooth mobility, and tooth loss. For fur- that inhibit the onset and progression of periodontitis.
ther reading on the relationship between systemic dis- The mechanism linking obesity with periodontitis may
eases and periodontal disease, the reader is directed to involve elevated levels of cytokines including IL-8 and
Williams and Paquette [49], while other diseases, such as TNF-α in crevicular fluid of obese patients that might
neutropenia, histiocytosis X, HIV infection, and leuke- contribute to periodontal destruction. However, there
mia, are further described in 7 Chaps. 20 and 21.
are some common predisposing factors for obesity and
periodontitis, such as unhealthy diet and low socioeco-
nomic status. Therefore, it appears that the two diseases
15.2.3 Diabetes Mellitus and Periodontal are associated not only through common biological
Disease mechanisms but also through common risk factors.
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358 A.-E. Doufexi and F. Nichols
calculus, oral hygiene instructions, administration of factors responsible for the genesis of recession can also
metronidazole or penicillin if there are other systemic help to prevent failure of mucogingival surgery.
symptoms, and frequent recall appointments. If the
patient is a smoker, he/she should be informed about
the role of nicotine to gingival tissue responses and 15.3.2 Frenum Pull
referred for smoking cessation therapy. Scaling using
ultrasound has proven to be very efficient and leads to Another common finding in children is frenum pull
rapid relief of symptoms. It is also recommended to between the maxillary central incisors accompanied by
use a soft toothbrush, at least in the initial phase of diastema (. Fig. 15.17). In most cases there is no reason
therapy, because of severe pain with each contact of for immediate treatment until eruption of permanent
the gingiva, and mouthwashes with 1.5% hydrogen per- incisors and canines, when usually the diastema closes
oxide or 0.2% chlorhexidine can cause significant burn- spontaneously. If the patient elects to have orthodontic
ing sensation. treatment, surgical incision or excision of the frenum is
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Periodontal Diseases in Children and Adolescents
359 15
a b
.. Fig. 15.15 a, b. A 4-year-old boy presented for dental caries scratching his gingiva with his nails. Treatment will include gingival
treatment. Clinical examination revealed extensive gingival reces- recession as well as management of underlying stress. (Courtesy of
sion in the area of the maxillary lateral incisors. The child confessed Dr. Arhakis)
in the frenectomy area might cause aesthetic concerns erative children it may be performed under local anes-
due to different thickness and color between the graft thesia with cautious placement of a few sutures due to
and the adjacent gingiva. Moreover, a frenectomy can the vascularity of the floor of the mouth. It has recently
be accompanied with a lateral sliding flap by which pri- been reported that frenectomy can be done by the use of
mary closure can be achieved over the site where the fre- diode, Nd:YAG, or CO2 laser, a method associated with
num was previously located [60, 61]. less postoperative pain and discomfort and also better
The ankyloglossia (tongue-tie) is a malformation healing compared to traditional surgical techniques.
characterized by high attachment of a short lingual The laser excision technique is simple and efficient, read-
frenum, occurring at a frequency of about 1.5–4.5%. ily achieves the required frenum release with minimal
The short lingual frenum limits the tongue movement bleeding, and can be accomplished without anesthesia
anteriorly and superiorly in the mouth, limiting its even in infants with severe ankyloglossia.
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360 A.-E. Doufexi and F. Nichols
a b
c d
.. Fig. 15.17 a, b. Frenum pulls on the upper lip in the primary and d. Medium ankyloglossia in a 7-year-old girl. The patient did not
permanent dentitions, respectively. Frenum excision is better post- undergo surgical treatment, since her speech was not impaired.
poned until after orthodontic treatment. c. The high frenum attach- (Courtesy of Dr. N. Kotsanos)
ment can impair plaque control and promote gingival inflammation.
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Periodontal Diseases in Children and Adolescents
361 15
23. Armitage GC. Development of a classification system for peri- odontitis in high-risk patients. J Periodontol. 1992;63:
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odontitis: progression of attachment loss during 6 years. J J Paediatr Dent. 2018;19:119–26.
Periodontol. 1996;67:968–75. 51. Lalla E, Cheng B, Lal S, Kaplan S, Softness B, Greenberg E,
32. Gunsolley JC, Califano JV, Koertge TE, Burmeister JA,
Goland RS. Lamster IB:119-126. Diabetes mellitus promotes
Cooper LC, Schenkein HA. Longitudinal assessment of early periodontal destruction in children. J Clin Periodontol.
onset periodontitis. J Periodontol. 1995;66:321–8. 2007;34:294–8.
33. Albandar JM, Brown LJ, Brunelle JA, Löe H. Gingival state 52. Sadeghi R, Taleghani F, Mohammadi S, Zohri Z. The effect of
and dental calculus in early-onset periodontitis. J Periodontol. diabetes mellitus type I on periodontal and dental status. J Clin
1996;67:953–9. Diagn Res. 2017;11(7):ZC14–7.
34. Araujo M. Localized juvenile periodontitis or localized aggres- 53.
Sbordone L, Ramaglia L, Barone A, Ciaglia RN, Iacono
sive periodontitis. J Mas Soc Summer. 2002;51:14–8. VJ. Periodontal status and subgingival microbiota of insulin-
35. Butler JH. A familial pattern of juvenile periodontitis (peri- dependent juvenile diabetics: a 3-year longitudinal study. J
odontosis). J Periodontol. 1969;40:115–8. Periodontol. 1998;69(2):120–8.
36. Newman MG, Socransky SS. Predominant cultivable microbi- 54. Al-Zahrani MS, Bissada NF, Borawskit EA. Obesity and peri-
ota in periodontosis. J PeriodontalRes. 1977;12:120–8. odontal disease in young, middle-aged and older adults. J
37. Slots J. Subgingival microflora and periodontal disease. J Clin Periodontol. 2003;74:610–5.
Periodontol. 1979;6:351–82. 55. Kieser JA, Thomson WM, Koopu P, Quick AN. Oral piercing
38. Asikainen S, Lai CH, Alaluusua S, Slots J. Distribution of and oral trauma in a New Zealand sample. Dent Traumatol.
Actinobacillus actinomycetemcomitans serotypes in periodon- 2005;21:254–7.
tal health and disease. Oral Microbiol Immunol. 1991;6: 56.
Campbell A, Moore A, Williams E, Stephens J, Tatakis
115–8. DN. Tongue piercing: impact of time and barbell length on lin-
39. Han NM, Xiao XR, Zhang LS, Ri XQ, Zhang JZ, Tong YH, gual gingival recession and tooth chipping. J Periodontol.
et al. Bacteriological study of juvenile periodontitis in China. J 2002;73:289–97.
Periodontal Res. 1991;26:409–14. 57. Kamble A, Shah P, Velani PR, Jadhav G. Laser-assisted multi-
40. Moore WE, Moore LV. The bacteria of periodontal diseases. disciplinary approach for closure and prevention of relapse of
Periodontol. 2000. 1994;5:66–77. midline diastema. Indian J Dent Res. 2017;28:461–4.
41. Califano JV, Gunsolley JC, Nakashima K, Schenkein HA,
58. Koora K, Muthu MS, Rathna PV. Spontaneous closure of mid-
Wilson ME, Tew JG. Influence of anti-Actinobacillus actino- line diastema following frenectomy. J Indian Soc Pedod Prev
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ity of generalized early-onset periodontitis. Infect Immun. 59. Suter VG, Heinzmann AE, Grossen J, Sculean A, Bornstein
1996;64:3908–10. MM. Does the maxillary midline diastema close after frenec-
42. Califano JV, Pace BE, Gunsolley JC, Schenkein HA, Lally ET, tomy? Quintessence Int. 2014;45(1):57–66.
Tew JG. Antibody reactive with Actinobacillus actinomycetem- 60. Horton CE, Crawford HH, Adamson JE, Ashbell TS. Tongue-
comitans leukotoxin in early-onset periodontitis patients. Oral tie. Cleft Palate J. 1969;6:8–23.
Microbiol Immunol. 1997;12:20–6. 61. Suter GA, Bornstein M. Ankyloglossia: facts and myths in
43. Albandar JM. Aggressive periodontitis: case definition and
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diagnostic criteria. Periodontol 2000. 2014;65:13–26. Review. 62. American Academy of Pediatric Dentistry. Policy on the use of
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363 16
Dentoalveolar Trauma
of Children and Adolescents
Cecilia Bourguignon, Aristidis Arhakis, Asgeir Sigurdsson,
and Nikolaos Kotsanos
Contents
References – 409
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364 C. Bourguignon et al.
Application of international classification of diseases to is often accompanied by alveolar bone fracture, which
dentistry and stomatology. Later, JO and FM Andreasen is discussed in the subchapter on this topic. There may
suggested some adjustments in the classification, which also be maxillary or mandibular trauma, most often
include the groups below [1]. occurring at the mandibular condyles. Oral injuries
Injuries to the hard dental tissues and the pulp: are common among teenagers, usually after a fight
55 Incomplete enamel fracture. Fracture without (. Fig. 16.3), but may also be a component of more
enamel loss (enamel infraction) serious non-oral injuries, for example, those occurring
55 Complete enamel fracture. Loss confined to the at motor accidents. Whether mandibular/maxillary frac-
enamel tures should be treated simply by splinting or if surgical
55 Crown fracture (enamel/dentin), no pulp exposure; correction is necessary lies beyond the scope of a pediat-
also known as uncomplicated crown fracture
16 55 Crown fracture (enamel/dentin), pulp exposed; also
ric dentistry textbook, and readers are referred to other
sources, e.g., maxillofacial surgery literature.
known as complicated crown fracture
55 Crown/Root fracture with or without pulp exposure
55 Root fracture; no enamel involvement Eye Catcher
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Dentoalveolar Trauma of Children and Adolescents
365 16
Number of Accidents
a b 25
22
21 21
20 19
17
15
10
5
5
2
1
0
.. Fig. 16.2 a Upper lip edema a few hours after a 2-year-old tod- up to 1 up to 2 up to 3 up to 4 up to 5 up to 6 up to 7 up to 8
dler had fallen. b Intraoral view of the dentoalveolar trauma
.. Fig. 16.4 Age distribution of 106 successive patient arrivals with
200 traumatized primary teeth at University of Gottingen Dental
Clinic, Germany [3]
most frequently between the ages of 2 and 5 years dental trauma, but there are cases of multiple dental
and about 80–85% of them are caused by falls [3, 4] traumas as well [4, 7].
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366 C. Bourguignon et al.
a b c d
.. Fig. 16.5 a Crown-root fracture with pulp exposure of a man- and placement of a stainless-steel crown after removal of the frac-
dibular primary first molar after blow to the chin. b Radiographic tured fragment rather than tooth extraction. Regular monitoring of
image of the crown-root fracture. c, d Treatment involved pulpotomy the tooth is necessary
a b
Dental trauma distribution
60 90
Permanent teeth
16 50
80
Primary teeth
70
NUMBER OF PATIENTS
40 60
Males Females
50
30
40
20 30
20
10
10
0 0
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 >40 Assault Bike Fall MVA Other Play Sport Work
AGE GROUPS (YEARS) CAUSE OF INJURY
.. Fig. 16.7 A sample of 323 Australian individuals who sought do not become apparent prior to school age. b Causes of traumatized
treatment for dental trauma [4]. a Distribution of patients according primary and permanent teeth (MVA motor vehicle accident)
to age and gender. Prevalence differences between males and females
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Dentoalveolar Trauma of Children and Adolescents
367 16
interference or impact on fixed surfaces of reduced
.. Table 16.1 Distribution of frequency of permanent
hardness mainly causes luxation injuries. The outcome
incisors dental trauma
is, of course, dependent on the force of the impact. The
Lam, Abbott Roberts and most common predisposing factor is increased over-
et al. 2008 [4] Longhurst 1996 [9] jet with protrusion of maxillary incisors. It has been
reported that an increase from 0–3 mm to 3–6 mm
Upper central incisors 63% 73% leads to twice as many trauma rates, while if protru-
Upper lateral incisors 18% 18% sion exceeds 6 mm, incidence triples [14] (. Fig. 16.9).
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368 C. Bourguignon et al.
.. Fig. 16.9 a Face of an 8-year-old with increased risk of dental 16.1.4.3 Extraoral Examination
trauma due to overjet of maxillary central incisors >10 mm. b, c The patient is checked for the presence of abrasions,
A 7-year-old girl with epilepsy. There is a 15 mm maxillary perma-
nent central incisor overjet with deep bite. Previous trauma caused
edemas, bruising, hematomas (particularly in the con-
an enamel-dentin fracture. A sinus tract is now evident labially to the junctivas), and hemorrhagic foci. Facial bones should be
right central incisor palpated to locate any abnormalities that might lead to
fracture diagnosis. If the edema or pain does not allow
direct palpation, appropriate radiographs should be
and or behavioral changes/unexplained irritation can taken. The patient is to be asked to open and close his/
be also signs [19]. Therefore, it is essential to do at least her mouth so as to identify whether there is limitation or
some rudimentary CNS evaluation prior to any further deviation in the mandibular movement and to diagnose
treatment is rendered. If there are any signs of brain condyle fractures (e.g., temporomandibular disorders,
injury, the patient needs to be referred immediately to see 7 Chap. 19, 7 Fig. 19.4).
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Dentoalveolar Trauma of Children and Adolescents
369 16
16.1.4.5 Radiographic Examination
It is imperative that radiographs should be taken, depend-
ing on the tooth and the type of trauma, so that clear con-
clusions may be drawn concerning the presence or absence
of a root fracture, the potential displacement of the injured
tooth, the periapical and periodontal condition, the stage
of root development, and, in the case of a primary tooth,
its relation to its permanent successor [22]. Since maxil-
lary central incisors are most frequently affected teeth, the
IADT (International Association of Dental Traumatology)
recommends that three periapical radiographs be taken
with different horizontal angulations, plus an occlusal
radiograph [21]. Radiographic examination is imperative
in certain reviewing checks, based on the protocols rec-
ommended, because, in the long run, this is a fundamen-
tal criterion of a successful or unsuccessful outcome. For
example, halting of normal pulp space width reduction in
young teeth or discovery of a periradicular radiolucency
or of a pathologic external root resorption on primary or
permanent teeth confirms pulp tissue necrosis and infec-
tion. This is explained by the diffusion of necrotic/septic
material from the root canal through the apex and dentinal
tubules. In these situations, endodontic treatment needs to .. Fig. 16.10 Positioning a young child on the parent’s lap, while
be started as soon as possible. the parent is holding between fingers a No. 2 biting plate, for taking
a radiograph of the anterior primary teeth
Radiographic examination of primary teeth in very
young children who cannot cooperate is performed
with them sitting on the parent’s lap while the parent is
holding a No. 2 biting conventional or phosphor plate
(. Fig. 16.10). In cases of crown fractures and wounds
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370 C. Bourguignon et al.
b c zz Follow-up
No follow-up is necessary in the case of infractions. In
an enamel-dentin fracture without pulp exposure, clini-
cal recall should be performed at 6–8 weeks after the
injury [23] (See also . Table 16.2).
zz Treatment
16.2 Dental Trauma to Primary Teeth Treatment recommended for pulp exposure includes
pulpotomy, either partial or complete, and root canal
Before describing trauma to erupted teeth, one needs to treatment, provided the patient is capable of cooperat-
refer first to the fact that children who had to undergo ing. When the two techniques were used for primary
orotracheal intubation for various reasons (premature incisors with caries, success rates showed no signifi-
delivery, corrective surgical treatment, etc.) are more cant difference [28]. The fractured crown is then recon-
likely to present dental abnormalities. Such abnor- structed using composite resin (. Fig. 16.13). If there
malities are considered to be resulting from trauma to is no hemorrhage from a recent trauma (within a few
the alveolar process caused by the metal laryngoscope hours), the pulp may be covered immediately. In cases
during intubation at a time when the development/cal- of patients incapable of cooperating, extraction might
cification of anterior maxillary primary teeth is taking be necessary [23, 29].
place (. Fig. 16.12). There is evidence of analogous
zz Treatment zz Treatment
In limited fractures, which do not significantly affect If pulp exposure cannot be clinically or radiographi-
esthetics, it is preferable to grind sharp enamel borders cally excluded, the two components have to be
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Dentoalveolar Trauma of Children and Adolescents
371 16
.. Table 16.2 IADT recommended clinical and radiographic follow-up scheme on dental trauma of primary teeth [23]
Enamel fracture
Enamel-dentine fracture c+rb
Crown fracture with pulp exposure c+rb c+rb c+r
Crown-root fracture c+rb c+rb c+r
Root fracture:
Without crown part displacement c+rb c+rb c+rb c+rb
Extraction of crown part c+rb c+rb
Concussion – Subluxationb c+rb c+rb c+rb
Lateral luxation c+rs+rb s+rb c+rs+rb c+rs+rb c+rs+rb c+rb
Intrusive luxation c+rb c+rb c+rb c+rb
Extrusive luxation c+rb c+rb c+rb c+rb
Avulsion c+rb c+rb
Alveolar bone fracture c+rb c+r+s c+rb c+r c+rb
c clinical examination, r radiographic examination, s splint removal, rs review if repositioned and splinted
aAnnually until exfoliation
bRadiographs are only indicated where clinical findings are suggestive of pathosis
a b c
.. Fig. 16.13 a Clinical and radiographic image of crown fractures both central incisors with composite resin. c Twelve months after
to both maxillary primary central incisors in a 3-year-old child. the initial injury no pathologic findings are observed (courtesy Dr.
The left central presents with extensive pulp exposure. b Images G. Vadiakas)
after pulpotomy of the left central incisor and crown buildup of
separated. If the pulp is not exposed, remove the mov- frequent finding, the treatment of choice is extraction
able part of the tooth and, if feasible, reconstruct the [29, 30] (. Fig. 16.14).
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372 C. Bourguignon et al.
zz Treatment
If the coronal fragment is not displaced and is immo-
bile, no treatment is necessary [23]. If it is slightly mobile
.. Fig. 16.15 a Radiographic imaging of horizontal root fracture
and if the child is cooperative, splinting with wire and of a maxillary primary right central incisor. b The ensuing edema
composite resin may be recommended. Parents need to
16 be informed that after the splint is removed, the tooth
results in extrusion of the coronal fragment from the socket. c Root
canal treatment of the coronal fragment up to the fracture line;
may become mobile and may fall out after some time, incisal crown reduction was done to avoid traumatic occlusion.
d At 12 months follow-up, the apical fragment has been normally
especially if a new trauma occurs. In cases when the
resorbed, while there is also root canal obliteration of the left central
crown part has been displaced and prevents occlusion, incisor. Follow-up is necessary
or when a root fracture is accompanied by alveolar bone
trauma, the treatment of choice is to extract the coro-
nal fragment and leave in situ the apical fragment. To 16.2.2 Luxation Injuries to Primary Teeth
prevent trauma to the permanent successor germ, the
16.2.2.1 Concussion
apical fragment is allowed to be normally resorbed [23,
29] (. Fig. 16.15).
This is encountered in about 11% of primary dentition
trauma [6]. There is no clinical movement, mobility of
zz Follow-up the tooth, or significant hemorrhage from the gingival
If the coronal fragment has been splinted, the case sulcus, because there is no significant periodontal liga-
should be reviewed in a week. The splint should be left ment rupturing. However, there is pain on percussion.
in place for 4 weeks. Clinical recalls are performed after Radiographically, the periodontium presents no patho-
6–8 weeks and 1 year has passed after the injury. Regular logic post-traumatic finding [23]. Due to mild symptoms,
annual clinical recall suffices until the permanent tooth such cases are often missed by parents who only visit the
erupts (see also . Table 16.2).
dentist if signs/symptoms, like discoloration, appear [31].
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Dentoalveolar Trauma of Children and Adolescents
373 16
zz Treatment, Follow-up splinting, is an option [23]. However, repositioning a
The tooth should remain under observation, with clini- laterally displaced primary tooth carries a higher risk
cal recall at 1 and 6–8 weeks after the injury [23]. of pulp necrosis [32]. Furthermore, due to their age
and fear following the injury, young patients are often
16.2.2.2 Subluxation (Loosening) noncooperative. To avoid another possible injury to
This is quite a frequent phenomenon and concerns permanent successors, it is preferable not to attempt
about 1/3 of dental trauma to primary dentition [6]. The to reposition a laterally displaced primary tooth. It
tooth injured has not been displaced but has become is recommended that it should be left to return natu-
mobile due to partial periodontal ligament rupture. This rally to its position with the help of tongue pressure
mobility might be mild to medium, horizontal, or verti- [31]. In cases of minor occlusal interference, selective
cal in direction. The gingival sulcus often presents lim- grinding is recommended. Extraction is considered
ited hemorrhage. In the radiograph, periodontal tissues when the crown has been significantly displaced labi-
appear normal [23]. ally causing significant occlusal interference and in
neglected cases of such trauma when there is often
zz Treatment perforation in the vestibular alveolar bone plate
If the patient is cooperative, when mobility exceeds 2 mm (. Fig. 16.17) [23].
a b c d
.. Fig. 16.16 a Lateral laxation of maxillary primary left central successfully attempted in this cooperative 3-year-old and tooth
incisor seen the next day of the accident. b Palatal displacement is splinted rigidly. d At the 6-month recall, the tooth was free of signs
emphatically shown in the occlusal radiograph. c Because of trau- and symptoms
matic occlusion, tooth repositioning under local anesthesia was
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374 C. Bourguignon et al.
zz Follow-up
Clinical recalls take place at 1 week, 6–8 weeks,
6 months, and after 1 year. Regular annual clinical recall
suffices until the permanent tooth erupts [23] (see also
. Table 16.2).
16
a b
.. Fig. 16.18 a Multiple intrusion of three maxillary incisors and after having fractured the alveolar plate. The nasal spine is visible
avulsion of the fourth one in a 26-month-old. b The parents per- more superiorly. The trace drawing indicates the previous tooth and
ceived two incisors as lost. c Extraoral radiograph of another intru- bone plate positions (stippled lines) in relation to intruded positions
sive incident shows both central incisor apices in labial displacement (continuous lines)
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Dentoalveolar Trauma of Children and Adolescents
375 16
a b c d
.. Fig. 16.19 a Intrusion of maxillary primary left central incisor after orthodontic alignment was undertaken when age 3 years at
(after 24 hours) in a 16-month-old boy. b Spontaneous re-eruption parents’ request. Pulp obliteration indicates pulp remained vital. d
with 45° rotation in 8 weeks. c Radiograph of the tooth with reten- Clinical view at age 6 years
tion (splinting with the right central incisor) at 4-year follow-up,
zz Follow-up
Clinical recalls take place at 1 week, 6–8 weeks, and after
1 year. Regular annual clinical recall suffices until the
permanent tooth erupts [23] (see also . Table 16.2).
16.2.2.6 Avulsion
Avulsion means the tooth is completely out of its socket .. Fig. 16.20 a Dentition after avulsed maxillary primary left cen-
and its prevalence represents 5–18% of displacement tral incisor. b Parents brought the avulsed primary tooth only to be
informed that its replantation is not recommended
trauma. About 90% of avulsed teeth are primary max-
illary incisors [6]. Radiography confirms that the tooth
was not intruded. It is good to search for the avulsed zz Follow-up
tooth, because there is also a risk that the tooth went It is necessary to perform clinical review at 6–8 weeks.
accidentally into the respiratory tract. Symptoms in such Further follow-up at 6 years of age is indicated to
cases are coughing, tachypnea, and high temperature monitor eruption of the permanent tooth [23] (see also
[23]. . Table 16.2).
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376 C. Bourguignon et al.
16 16.2.3.1 Pulpitis
Pulpitis is the initial reaction of the pulp in cases of
direct tooth injury such as in fractures or in cases of
b
luxation injuries. Pulpitis may be fully reversed or lead
to pulp degeneration and necrosis without any pain or
symptoms. Teeth with reversible pulpitis may be sen-
sitive to concussion. However, pulpitis may be due to
bacterial contamination, whether the fracture exposes
the pulp or not, whereupon septic pulp necrosis ensues
with signs of periapical inflammation. In such cases root
canal treatment becomes necessary, or, if there is no
patient cooperation, the tooth has to be extracted [29].
16.2.3.2 Discoloration of the Traumatized .. Fig. 16.22 a The dark brown-gray shade of symptomless max-
Tooth illary primary right central incisor indicates pulp necrosis. b The
radiograph shows small apical radiolucency and a larger one at
Discoloration appears in almost half of primary tooth asymptomatic left central incisor, which has a slightly wider root
trauma cases [5]. It is common for the pulp capillaries canal than its right counterpart. Follow-ups are necessary to deter-
to bleed following trauma. Blood elements enter the mine if treatment becomes necessary
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Dentoalveolar Trauma of Children and Adolescents
377 16
a
discoloration, as well as radiographic findings, such as
periapical lesion and pathologic root resorption.
16.2.3.3 Pulp Canal Obliteration tized primary teeth are the maxillary incisors, the per-
manent teeth mostly suffering such consequences are
It is usually discovered clinically by the yellowish color of
their homologous successor teeth. Regarding enamel
the crown of such teeth. The pulp chamber and root canals
defects, these are more frequently found in the labial
become significantly stenotic by mineralized dentin like
surface because this surface is close to the apex of pri-
tissue formed at fast rate (. Fig. 16.23). This phenome-
mary incisors.
non is quite frequent and appears in 52% of intruded teeth
[33]. Pulpal necrosis has been observed in only 10% of
primary teeth with pulp space obliteration within 3 years
[35]. Therefore, prognosis should be considered favorable, Traumatic injuries to primary teeth may affect the
and these teeth do not need root canal treatment if there is underlying permanent successors by any of the follow-
no periapical lesion shown in the radiograph and no clini- ing mechanisms:
cal signs of pulp necrosis and infection. 55 Direct physical damage (. Fig. 16.24)
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Dentoalveolar Trauma of Children and Adolescents
379 16
16.2.4.3 Crown Dilaceration rotation during the descent may lead to vestibular root
Such dysplastic defects are due to primary tooth impact appearance [38]. The decision depends on the crown
onto the germ of the permanent successor tooth, result- integrity and the severity of dilaceration. If the tooth
ing to a bend at the developing cervical part, which is erupts on its own, its position in the dentition is assessed
softer in relation to the already mineralized crown [36, along with the possibility of correcting the crown shape
37]. In a report of anterior permanent teeth with dysplas- using composite resin.
tic defects related to primary tooth trauma, dilaceration
was found in 25% of the cases [37]. Crown angulation 16.2.4.4 Other Rare Developmental Disorders
varies depending on the developmental phase and the Rare dysplasias of successor permanent teeth are
germ location at the time of injury, as well as on the reported as follows [36, 37]:
direction of the trauma-causing force. The crown of 55 Odontoma-type dysplasia (. Fig. 16.26)
teeth remain impacted. About 3% of trauma cases to 55 Partial or complete interruption of root develop-
primary dentition lead to such abnormalities [36]. It is ment continuity
inferred that the accidents occur earlier than age 5 years, 55 Permanent tooth germ necrosis
i.e., when more than half or all the permanent crown has
developed. Most commonly correlated trauma cases are Types of trauma most often correlated with these spe-
extrusive and intrusive laxations of predecessor primary cific abnormalities are intrusive and extrusive laxations
teeth [37]. of primary teeth [37].
zz Treatment zz Treatment
As soon as dilaceration is discovered, it is followed up In some cases, such as lateral root bending, dysplastic
using lateral extraoral radiographic examination and permanent teeth do erupt. If possible, orthodontic trac-
probably other auxiliary radiographs, like CBCT. If the tion is applied to the dentition if certain teeth erupted,
tooth does not erupt, a decision about extraction and to temporarily conserve alveolar osseous mass until
orthodontic correction of the diastema or orthodonti- more permanent treatment is possible. In the remaining
cally guiding the tooth to occlusion must be made. If cases, however, extraction and correction of the space is
the latter solution is chosen, attention is necessary in recommended to allow future prosthetic restoration [36,
the case of intense tooth dilaceration, because crown 37].
a b c
d e f
.. Fig. 16.26 a Radiographic image of dysplastic unerupted four dysplasia. e, f Patient aged now 12 years is under orthodontic treat-
maxillary permanent incisors in an 8-year-old boy with a history ment, while the right central with dysplastic crown has been tempo-
of severe trauma at age 9 months. A “wait and see” approach was rarily built up, the left central and right lateral have been extracted
adopted. b He returned 1 year later with left-side labial edema. c, as untreatable, and the left lateral was endodontically treated. Final
d The partially erupted left lateral already had septic pulp, prob- esthetic/prosthetic rehabilitation will follow orthodontic treatment
ably due to pulp communication with the oral environment due to as a multidisciplinary approach case
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380 C. Bourguignon et al.
a b a
b
c d
Following trauma to anterior primary teeth, there are tion is recommended [41]. Response to pulpal sensitivity
often disorders observed in the time or path of per- tests is normal. In case of severe infractions, etching and
manent successor tooth eruption (see 7 Chap. 10).
sealing with bonding resin should be considered; other-
Delayed permanent tooth eruption was noted in 1/3 of wise, no treatment is required.
primary tooth trauma cases [39]. It is reported that this
may last up to 1 year and adversely influence occlusion zz Follow-up
in the mixed dentition. A permanent tooth may often be Clinical and radiographic recalls are not necessary in
at crossbite along with delayed presence of the primary the cases of sole infractions [21] (see also . Table 16.3).
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Dentoalveolar Trauma of Children and Adolescents
381 16
.. Table 16.3 Follow-up table for fractured permanent teeth, according to IADT Guidelines 2020 [21]
Enamel infraction
Complete enamel c+r c+r
fracture
Enamel-dentine fracture c+r c+r
without pulp exposure
Enamel-dentine fracture c+r c+r c+r c+r
with pulp exposure
Crown-root fractures c+r c+r c+r c+r c+r c+r
Root fracture c+r+s c+r c+r+s* c+r c+r c+r
This follow-up regimen is recommended when there is no luxation injury associated to the fracture at the time of trauma. If a con-
comitant luxation injury occurred, the luxation follow-up regimen prevails (please look . Table 16.4)
zz Treatment a
Treatment, depending on fragment size and patient’s
esthetic requirements, may comprise grinding to
improve incisal edge appearance or crown reconstruc-
tion using tooth fragment if available or composite resin
(. Fig. 16.29).
zz Follow-up
Clinical and radiographic recalls as well as vitality tests b
should be performed at 6–8 weeks and 1 year after the
injury [41, 21] (see also . Table 16.3). Pulpal necrosis
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382 C. Bourguignon et al.
Isolating with a double lip retractor is not sufficient, [46–48]. The technique involved is described as follows.
since breathing vapors contaminate the etched surfaces The crown fragment should be kept moist or be rehy-
and compromise adhesion. Local anesthesia is not drated in water for at least 15 minutes before it is bonded
always necessary, since even if a thin dentin wall remains, [49]. This improves bonding quality and strength. A
it may be covered with a base such as glass ionomer length of adhesive wax may be added to the incisal edge
cement (GIC) and blowing or rinsing the tooth causes of the broken fragment so as to facilitate manipulations.
no pain any more [21]. According to some authors, bev- It has been suggested that the enamel on both fractured
eling broken enamel reinforces retention and improves surfaces be beveled prior to reattachment, but this may
esthetic result. Following rubber dam placement, dentin prevent optimal coaptation of the two fragments. The
coverage if needed, etching, and the application of an enamel of both fragments is then etched and the adhe-
adhesive, the composite resin (CR) should be applied sive applied. By placing and light curing a minimal
using a celluloid partial or full strip crown, depending quantity of composite resin between the two edges, the
on whether the fracture is angular or almost horizontal, broken piece is accurately repositioned. Any gaps left
respectively (. Figs. 16.30 and 16.31).
are filled and the fracture line is reinforced with more
A more elaborate composite resin buildup may be composite resin. In the last three decades, this restora-
made by taking a silicone impression and pouring a tion type has been in use (. Fig. 16.32); some authors
plaster model which is sent to a lab technician who will have reported on technique details. For example, bev-
reconstruct the tooth and fabricate a “silicone key” or a eling of the fracture line did not seem to increase the
mouth-guard. The clinician will then use one of those as strength of the restoration [46]; however, it aids in mask-
a palatal matrix to gradually add layers of enamel and ing the fracture line. Adding composite resin on the frac-
dentin composite in different shades and forms trying ture line did not increase bond strength when compared
to mimic a natural tooth. Finishing and polishing are to using solely the adhesive on its own [48]. No sound
essential steps to obtain a good tooth-composite inter- clinical data regarding time endurance as compared to
face and an esthetically pleasing restoration [21]. solely composite resin reconstruction techniques have
If the broken fragment is found intact, it is an been reported. Rubber dam isolation should always be
interesting esthetic option to consider bonding it back used in restorative procedures, even if there is no pulp
a b c
16
.. Fig. 16.30 a Clinical view of enamel-dentine oblique crown fractures on three maxillary permanent incisors of a 9-year-old child. b, c
Clinical and radiographic view after the crown buildup was made using composite resin. (Courtesy Dr. G. Vadiakas)
a b c d
.. Fig. 16.31 a Enamel-dentine crown fracture without pulp expo- tooth followed etching and bonding. All was done under rubber dam
sure on mandibular permanent right lateral incisor after covering the isolation, which is now removed for finishing the restoration. d One-
dentin with GIC and enamel beveling. b Appropriate size strip crown year recall
filled with composite. c Placement of strip crown on the fractured
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Dentoalveolar Trauma of Children and Adolescents
383 16
a b c d
.. Fig. 16.32 Reattachment of a fractured crown fragment in a fragment using a non-radiopaque composite available at early 1990s.
9-year-old girl. a Oblique enamel-dentine crown fracture on maxil- d Recall of the adult patient 14 years later with no other interven-
lary permanent left central incisor. b, c Reattachment of the tooth tion. A slight shade change of the composite can be detected
a
exposure, to avoid saliva and breathing humidity con-
tamination (. Fig. 16.33).
zz Follow-up
Clinical examinations including vitality testing and
periapical radiographs need to be repeated at 6–8 weeks
and 1 year following the injury. Pulpal necrosis has been
shown to occur in 9% of such traumas [50], but this rate
also depends on how soon after trauma the pulp was b
protected. If trauma to periodontal tissues happened
as well, pulpal necrosis likelihood rises to 28% [51–
53]. The presence of a periapical radiolucency or root
development interruption of young permanent incisors
means that the pulp became necrotic and infected. This
makes root canal treatment imperative [21] (see also
. Table 16.3).
16.3.1.4 Enamel-Dentine Fracture with Pulp .. Fig. 16.33 a, b Rubber dam isolation improves adhesion of com-
posite buildups. There are several ways to apply the rubber dam:
Exposure (Complicated Crown placing the clamps away, as shown here, is one of them. Alterna-
Fracture) tively, dental floss can be knotted on each tooth. WedjetsR can also
These crown fractures are also called “complicated frac- be used interdentally. Direct clamping of an immature incisor is not
recommended due to the high risk of fracture of these fragile teeth
tures.” The pulp is exposed to the oral environment and
bacterial contamination starts immediately. That’s why
treatment should be provided the soonest possible. development. Root canal treatment should thus be
avoided. Treatment depends on root formation stage
zz Diagnosis and degree of pulpal inflammation. Such treatment
Crown fracture with pulp exposure does not automati- options include the following: (1) direct pulp capping,
cally cause pain, but sensitivity to hot and cold stimuli, (2) partial pulpotomy, (3) cervical pulpotomy, or (4)
as well as low intensity pain during mastication [21]. The root canal treatment. The first three treatment types
scale of pulp exposure and the time interval between are described below, while for root canal treatment,
injury and treatment are parameters with a direct effect the reader is invited to look in this chapter in section
on the inflammatory reaction extending into the pulp. “Endodontic Management of Injured Teeth.” All these
At the initial examination, pulp sensibility tests are treatment options should always be carried out under
unreliable and pulp vitality can be perceived visually. rubber dam isolation.
Radiographic examination is imperative, similar to the
previous types of trauma, so as to exclude the possibility Direct pulp capping The success rate of this procedure is
of root fracture and to confirm apex status [21]. lower than Cvek’s partial pulpotomy; therefore, direct
pulp capping is not frequently recommended [54, 55].
zz Treatment Ideal clinical prerequisite conditions for direct pulp cover
The aim of pulpal treatment is to maintain pulp vital- are to observe a vital pulp where the pulp exposure is lim-
ity to allow immature teeth to complete their root ited (up to about 1 mm) and for the intervention to take
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384 C. Bourguignon et al.
place soon after the trauma (up to several hours). Besides, needed before its widespread use can be safely recom-
the pulp should be free of inflammation owed to another mended.
cause, e.g., deep caries. Technique steps are: 55 When Ca(OH)2 is used as the pulp dressing material,
55 Local anesthesia without vasoconstrictor. it should be covered hermetically. Glass ionomer
55 Tooth isolation with rubber dam. cements seem to provide an adequate marginal seal
55 Cleaning of tooth surfaces and disinfection of before the tooth is restored with composite resin [58].
tooth and rubber dam with iodine, chlorhexidine, or
sodium hypochlorite.
55 Rinsing and disinfection of the pulpal exposure with Partial pulpotomy In cases of more extensive pulp expo-
saline solution, chlorhexidine, or sodium hypochlorite. sure and delayed arrival at the surgery (up to 2 days fol-
Blood clot presence reduces the likelihood of heal- lowing the injury), partial pulpotomy is preferred (Cvek
ing, either by preventing direct contact of therapeutic technique) in order to remove the inflamed portion of the
agents with pulp tissue or because the space left after pulp first [54]. The aim is to obtain a dentin bridge forma-
its decomposition is inviting bacterial presence [56]. tion below the cover material. The technique is recom-
55 Once hemostasis is obtained, calcium hydroxide (CH) mended for either mature or immature teeth. After
powder mixed with saline or anesthetic solution to the anesthesia and rubber dam isolation, the technique steps
consistency of a paste is applied; this remains the gold are the same as described above for direct pulp capping;
standard for pulp coverage. Alternatively, ΜΤΑ® has however, an additional step is required, the partial ampu-
been used in the recent past years and has been shown tation of the pulp before the placement of the capping
to favor dentin bridge formation and pulp vitality material [21] (. Fig. 16.34).
maintenance as well. However, MTA, whether gray or The amputation is done as follows:
white, has been shown to create tooth discoloration, 55 A small reservoir of approximately 2 mm deep is
and its use is not recommended anymore for pulp created by amputation of the exposed pulp with a
capping [21, 57], especially in anterior teeth. Bioden- high-speed sterile bur under copious water spray. A
tine®, a new bioceramic cement, seems to be a prom- diamond causes less damage than a low-speed bur or
ising material for pulp capping, but more studies are an excavator (. Fig. 16.35a) [59, 60].
a b c
16
d e
.. Fig. 16.34 a The maxillary permanent left central incisor of an of the rubber dam, the exposed pulp is excised to about 2 mm deep,
8-year-old boy presents a horizontal crown fracture with pulp expo- Ca(OH)2 paste is applied on the remaining pulp, and GIC covers the
sure. The right one presents an oblique crown fracture without pulp paste and the exposed dentin of both teeth. d The final crown build-
exposure. b The radiographic examination shows that the incisors ups with composite resin. e Post-op radiographic image. (Courtesy
have open apices. c View of the pulp exposure. Following placement Dr. G. Vadiakas)
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Dentoalveolar Trauma of Children and Adolescents
385 16
a 3–4 days. This is sometimes indicated for teeth that have
also suffered other injuries as well [54]. The technique is
the same as partial pulpotomy; however, pulp amputation
is done at the cervical level of the tooth.
zz Follow-up
In all three treatment modalities described above to
tackle exposed vital pulps, clinical and radiographic
examinations, in combination with sensibility testing, are
.. Fig. 16.35 Cvek’s partial pulpotomy. a A small reservoir, almost important and should be repeated on follow-up visits at
a box of approximately 2 mm, is created by amputation of the 6–8 weeks, 3 months, 6 months, and 1 year following the
exposed pulp with a high-speed sterile bur under copious water spray. injury [21] (see also . Table 16.3). Clinically, it should
A diamond causes less pulp damage than a low-speed bur or an exca- be confirmed that there is no pain or apical inflammation
vator. b After obtaining hemostasis, the pulp is covered with a thick
and that the crown color is normal. Radiographs should
calcium hydroxide paste (mixture of calcium hydroxide powder with
saline or anesthetic solution). A hermetic seal covering the calcium confirm continuing root development (. Figs. 16.36
hydroxide should then be placed before fragment bonding or com- and 16.37). If a periapical radiolucency appears, root
posite buildup. Please note rubber dam isolation during treatment canal treatment should be performed.
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386 C. Bourguignon et al.
zz Treatment
a b
Prior to attempting any treatment, a decision must be
made on whether the remaining tooth structure will be
mechanically strong enough to support a future restora-
tion. If not so, it is wise to consider the possibility of
submerging the root, rather than attempting to extrude
it to create restorable margins. Options for treating this
type of fracture are discussed below:
Eye Catcher
on the labial surface and ends 2–5 mm subgingivally in consuming when compared to the surgical approach,
the palatal aspect. In this case, radiographic diagnosis since it usually takes 5 weeks to obtain 2–3 mm extrusion,
presents some difficulties. If the crown component is as well as at least another 8–10 weeks of splinting to retain
retained in place by periodontal fibers, it may present the tooth in its new position [65, 66]. The depth of the
a wide range of mobility levels, depending on how far fracture line is important because the crown/root ratio fol-
subgingivally its palatal border lies. There is usually a lowing extrusion should be at least 1:1 after crown recon-
pulp exposure. More rarely, the fracture line may be struction. Since there is concomitant displacement of the
almost parallel to the longitudinal tooth axis. bone and periodontal tissues along with the tooth move-
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Dentoalveolar Trauma of Children and Adolescents
387 16
a b c d
.. Fig. 16.38 Crown-Root fracture. Surgical extrusion of the repositioning of the tooth in a more coronal position in order to cre-
tooth. a Radiographic view of the crown-root fracture of a maxil- ate restorable margins. Root canal treatment was finalized, and the
lary permanent right central incisor in an 11-year-old boy. A previ- crown was buildup with composite. d Radiographic view at 9-year
ous dentist had started the endodontic treatment and had placed a follow-up. The tooth is still functioning and asymptomatic and no
radiopaque paste inside the canal. b Clinical view of the tooth after pathologic signs are present. Due to coronal repositioning, its tooth
removal of the temporary filling. The fracture line extends subgingi- apex is located more coronally compared to the left central incisor
vally well below the crestal bone level. c Clinical view after surgical
c d
a b
.. Fig. 16.39 Crown-root fracture of 11-year-old boy is candidate fails to document the course of this fracture line. d One angle of the
for orthodontic traction. a Clinical image of maxillary permanent cone beam tomographic scans reveals the fracture line to end mesi-
right central incisor after emergency treatment. b A mobile mesio- ally at crestal bone level (arrow)
palatal fragment is apparent (arrow). c The periapical radiograph
ment, lateral fiberotomy has to be performed every been proposed [70] (please see the “Replacement
7–10 days during the orthodontic traction period. Resorption (Ankylosis)” section later in this chapter).
Alternatively, bone and gum remodeling may be per- Retaining the root contributes toward maintaining alveo-
formed in a single procedure at the end of orthodontic lar crest volume so that it may be removed as late as pos-
traction. sible after puberty, only if necessary and when the timing
of implant placement is deemed appropriate [71]. A mid-
Surgical extrusion of the tooth This is an intentional par- term prosthetic appliance will have to be made for the
tial avulsion so that the root is repositioned to a more patient. Allowing the root to remain submerged and
coronal position to allow fracture margins to lie at the placement of a Maryland bonded bridge is also a very
level of the gingiva (. Fig. 16.38). Following splinting in
good option for these patients.
the new position, the tooth should receive root canal
treatment. Prognosis is good, but there is 5% possibility zz Follow-up
for the root to resorb within 3 years [67] or, according to Clinical and radiographic examinations, in conjunc-
other authors, 12% in 4 years [68, 69]. tion with vitality testing, are important and should be
repeated at 1 week, 6–8 weeks, 3 months, 6 months,
Extraction Finally, there is the option of extracting the and then yearly for at least 5 years [21] (see also
tooth if none of the solutions above is suitable. Prosthetic . Table 16.3).
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388 C. Bourguignon et al.
most often involved are maxillary central incisors, at It is also likely that the radiograph does not reveal
a rate of 75%. In young patients, whose permanent a root fracture immediately after the injury, but at a
incisors are immature and at various eruption stages, later point in time. This is most probably due to either
root fracture is a rather rare event [72]. Socket elas- hemorrhage or granulomatous tissue formation at the
ticity probably makes such teeth more susceptible fracture line, which gradually displaces the coronal
to displacement and avulsion rather than root frac- fragment incisally [73]. Additionally, depending on the
ture. Root fractures may be horizontal (transverse), direction of the radiograph beam, some root fractures
oblique, or vertical (longitudinal). The latter often may be undetectable. That’s why, according to IADT,
appears in mature teeth with an intraradicular post radiographic assessment comprises taking three periapi-
and prognosis is bad. Horizontal and oblique frac- cal radiographs from different angles, plus an occlusal
tures are more frequent and are distinguished into radiograph [21].
simple and multiple ones. Simple ones have a better Cone beam computerized tomography (CBCT)
prognosis. They are distinguished into apical third, examination is also extremely helpful to diagnose the
middle third, and cervical third fractures of the root. true extent of root fractures. The real trajectory of frac-
Prognosis is worse in cervical to middle third frac- ture lines is usually undetectable in a single periapical
tures due to less periodontal support during their radiograph (. Fig. 16.40).
they may be erroneously diagnosed as tooth loos- Repositioning is performed under local anesthesia and
ening (subluxation) or lateral displacement (lateral confirmed through radiographic examination. Splinting
luxation) since clinical characteristics are the same. is performed, for instance, with a passive twist flex wire
Furthermore, they may be missed, due to the pres- and composite resin on the labial surface of affected and
ence of a more visible dental trauma, such as a crown adjacent teeth. The splint should be semiflexible and
fracture. Involved teeth might be sensitive to percus- passive, without applying forces on the teeth. Splinting
sion and palpation, and the coronal fragment may be should remain for about 4 weeks but may stay up to
slightly displaced lingually, labially, and/or incisally 4 months if the fracture is located at the cervical third
(. Fig. 16.40) [65].
of the root [21].
a b c
16
.. Fig. 16.40 a Periapical radiographic view of maxillary perma- takes a vertical direction downward to the alveolar bone crest pala-
nent right central incisor presenting a horizontal middle third root tally. There is a chance that the fracture may heal. Before the advent
fracture. b The cone beam coronal view shows the same. c However, of cone beam examination, many oblique root fractures were misdi-
the cone beam sagittal view reveals that the fracture line is oblique agnosed as “horizontal” and healed
and more complex: from the labial, it starts horizontally but then
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Dentoalveolar Trauma of Children and Adolescents
389 16
Eye Catcher The protocol for clinical and radiographic recalls of
fractured permanent teeth is summarized further in
Four types of reactions have been described following . Table 16.3.
4. Interposition of granulation tissue between the vital in almost all cases [75, 79]. As with every fracture
fragments. This failure to heal is related to pulpal type, a negative response to sensibility testing does not
necrosis and infection of the coronal fragment. necessarily indicate pulp necrosis. The degree of disloca-
Clinically, the tooth is sensitive to horizontal or ver- tion of the coronal fragment is one of the most impor-
tical percussion, while an abscess is likely to appear tant factors influencing prognosis, and reapproximating
at the fracture level. Radiographically, the fracture the two halves is key to pulpal healing [77].
line widens, there is lamina dura loss, and there are
alveolar bone radiolucencies at the fracture level.
16.3.2 Luxation Injuries to Permanent Teeth
a b c
d e f
.. Fig. 16.41 a Root fracture in the middle third with extrusive Five weeks later root canal treatment of the coronal fragment was
and lateral luxation of maxillary permanent left central incisor in initiated due to pain symptoms. e At the 3-year follow-up, the tooth
a 12-year-old boy (closed apex). b, c The tooth was repositioned, remains asymptomatic with normal mobility but with crown 1 mm
and a semiflexible wire passive splint was bonded with composite. shorter. f Healing has occurred by bone tissue between the frag-
Incisal edge was ground by 1 mm to avoid occlusal interference. d ments. Note the canal obliteration of the apical fragment
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390 C. Bourguignon et al.
.. Table 16.4 Follow-up table for luxation injuries of permanent teeth, according to IADT Guidelines 2020 [21]
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Dentoalveolar Trauma of Children and Adolescents
391 16
a b c
.. Fig. 16.42 a, b Lateral luxation of right lateral with subluxation primary canine, and carefully etching available teeth on either side
of right central incisor in a 10-year-old girl. c Emergency manage- for splinting with flexible orthodontic wire and composite resin
ment consisted of repositioning the lateral, removing the very mobile
tioned ideally during the first 12 hours after the injury, ferent reports of laterally luxated teeth surviving. One
under local anesthesia, − buccal and/or palatal – or study reports that immature teeth present low rates of
after infraorbital nerve block [84]. To disengage a pulp necrosis (9%), while mature teeth present high rates
locked apex, it is pressed from the buccal, using a fin- (77%) [80].
ger with simultaneous mild pull of the tooth crown
incisally, which also achieves concurrent reduction 16.3.2.4 Intrusive Luxation
of any alveolar bone fracture that may be present Intrusive luxation occurs due to axial force applied to
(. Fig. 16.42). Tooth splinting should be semiflex-
the tooth’s incisal edge. This is considered to be the most
ible and performed with a passive wire retained on the serious trauma type, since it is associated with extensive
labial tooth surfaces using small amounts of composite lesions of the pulp, periodontal cells, and cementum
resin for dental/gingival hygiene. The purpose of splint- and often with alveolar bone plate fracture [87]. It is a
ing is to maintain the tooth in position, while allowing traumatic lesion of particularly bad prognosis, particu-
physiologic mobility. This has been shown to improve larly if the patient did not comply with proper treatment
periodontal healing and be helpful in the prevention of (. Fig. 16.43).
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392 C. Bourguignon et al.
a b
c d
.. Fig. 16.43 Consequences of a neglected intrusion case. a Serious The right central incisor did not re-erupt and produces an ankylotic
trauma to an 8-year-old girl at the playground swing, with intrusion sound on percussion, while the left lateral incisor presents a fistula.
of all 4 maxillary permanent incisors and severe lateral luxation of d Root development continued in the right lateral and left central
many primary teeth. b Same patient 8 weeks later. Partial re-eruption incisors, but not in the other two incisors. Prognosis for right central
of the incisors (more limited for the right central one, which is also incisor is bad, especially that its presence is impeding anterior alveo-
rotated). c Patient reappearance 20 months after the initial injury. lar bone growth. Family compliance is needed to improve prognosis
a b c
d e
16
.. Fig. 16.44 a Intrusion and non-complicated crown fracture of re-eruption occurred, but only partially. e Outcome 12 months later,
a maxillary permanent left central incisor in an 8-year-old. b Pala- after repositioning the left central incisor by orthodontic means and
tal view. c Radiographic view (open apex). d Six months monitor- stabilization splinting over a 3-month period
ing after pulp protection with glass ionomer cement. Spontaneous
happen within 3 months [88, 89]. Given that about If the intrusion is severe, more than 7 mm, the IADT
2/3 of such teeth become necrotic during this waiting Guidelines recommend to reposition the tooth either
period, the teeth need to be monitored so that necrosis surgically or orthodontically. It has also been proposed
may be diagnosed in good time [86, 90]. If within a few that a mild attempt to disengage the tooth using a tooth
weeks there is no sign of re-eruption, the tooth is repo- extraction forceps should be made immediately after the
sitioned using orthodontic means [21] (. Fig. 16.44). injury [21].
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Dentoalveolar Trauma of Children and Adolescents
393 16
zz Mature teeth and 12 months, and every year for 5 years [21] (see also
If the tooth is intruded less than 3 mm, it is worth trying . Table 16.4). Healing is complex due to the high likeli-
to wait for spontaneous re-eruption. If after 2–4 weeks hood of pulp necrosis and external tooth resorptions,
there is no sign that re eruption is on its way, surgical both replacement and inflammatory. After follow-up
or orthodontic repositioning is indicated. If the mature of many years, it was confirmed that the pulp became
tooth is intruded more than 7 mm, surgical reposition- necrotic in 2/3 of intruded permanent teeth with open
ing is recommended by the IADT Guidelines [21]. The apex and in 98–100% of those with a closed apex [89].
figures below show orthodontic (. Fig. 16.45) and sur-
a b c
.. Fig. 16.45 Orthodontic repositioning of intruded teeth. a Severe c Completion of root canal treatment. d Crown buildups with com-
intrusion of both maxillary central incisors, concomitant with exten- posite resin and alignment of incisors using fixed orthodontic appli-
sive crown fracture in a 14-year-old adolescent from a bike accident. ances. Clinical and radiographic follow-ups will continue. (Courtesy
b Starting orthodontic repositioning with traction of central incisors. of Dr. G Vadiakas)
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394 C. Bourguignon et al.
a b c
d e f
.. Fig. 16.46 Surgical repositioning of intruded teeth. a, b Severe root cementum with the forceps. d Splinting with orthodontic wire
intrusion of maxillary permanent right central incisor, moderate and composite resin and suturing of interdental gingival papillae. e
intrusion of left central incisor, fracture to their crowns, and con- Esthetic restorations with composite resin following root canal treat-
comitant fracture of the alveolar bone plate in a 10-year-old girl. ment of the two central incisors. Soft tissues healed well. f 4-year
Teeth are quite mature. c Immediate surgical repositioning of central follow-up radiographic image without signs of root resorption or
incisors with forceps. Caution should be taken not to damage the other pathologic findings. (Courtesy of Dr. G Vadiakas)
of recent trauma, the blood clot will spread out from the on the stage of root development. In immature teeth,
apical region of the socket. In extrusions neglected for pulpal necrosis rates are 9%, while in mature teeth, rates
several days, the blood clot has become organized. Some reported are 55–98% [80, 91].
authors recommend orthodontic intrusion of those The protocol for clinical and radiographic recalls in
teeth if they are mature. If, however, the tooth is severely cases of luxated permanent teeth is summarized in this
interfering with occlusion, it may be extracted and repo- chapter, in the 7 Sect. 16.3.4, in . Table 16.4.
and composite resin, ensues for 2 weeks to allow time This type of trauma appears more frequently among
for periodontal ligament healing. The patient is given young individuals, when the apex has not yet fully devel-
the same instructions as those given for intrusion injury. oped and the alveolar bone is more resilient. The aim
Continuous monitoring of the tooth is necessary of emergency treatment is to replant the avulsed tooth
so that any root resorption may be noticed. In cases as soon as possible, ideally within minutes, at the site of
of immature teeth, pulp space revascularization is con- the accident. Parents, sport coaches, and the population
firmed if root development continues. In mature and in general should be instructed to do so [24]. If debris
immature teeth, continuous negative reaction to pulp are present on the root surface, they should be gently
sensibility testing, presence of apical radiolucency, removed by rinsing the tooth in water, milk, or saline
swelling, or fistula indicates pulpal necrosis, whereupon prior to replantation. No wiping or scraping should be
root canal treatment is indicated. done, since they damage the cementum and periodontal
ligament cells covering the root surface. The combina-
zz Follow-up, prognosis tion of the three parameters presented below determines
Following clinical and radiographic examination the treatment of choice as well as the prognosis.
2 weeks after the injury, the splint is removed. Recall fol- 55 Root development stage: Spontaneous pulp space
lows the protocol applied for luxation injuries [21] (see revascularization is considered unlikely in the case
also . Table 16.4). Tooth preservation rates are high fol-
of a replanted mature tooth (closed apex). In a
lowing extrusion injuries, while pulpal survival depends tooth with open apex, the likelihood of pulp space
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Dentoalveolar Trauma of Children and Adolescents
395 16
a b c
d e f
.. Fig. 16.47 Extrusive luxation with delayed repositioning. a A immediately replanted and splinted for 2 weeks. e Signs of pulp canal
17-year-old girl presents 6 days after extrusive luxation of maxil- obliteration on both teeth at the 8 months recall. f Reconstruction of
lary permanent right central incisor, with crown fracture of this and the crowns with composite resin at this stage, although this should
the left lateral incisor. There is significant occlusion interference. b have been carried out earlier in order to cover the exposed dentin.
Radiograph shows that the teeth are mature (closed apex). The apical Follow-up continues in case of root canal treatment need and signs
socket space probably contains an organized clot. c, d The extruded of root resorption
incisor is extracted and, after the blood clot is curetted away, is
revascularization and, consequently, of the root –– Hank’s Balanced Salt Solution (HBSS) is an iso-
continuing development is higher, particularly if tonic solution with a neutral pH, which contains
the root surface is treated with tetracyclines, such ingredients necessary for cellular metabolism and
as doxycycline or minocycline, prior to replantation is suitable for cell culture [99].
[92, 93]. –– Viaspan solution is used in medicine for preserv-
55 Time the tooth remained out of the socket: The lon- ing organs to be transplanted; therefore, it is ideal
ger the tooth remains outside its socket, the higher for preserving teeth [100]. However, neither of
the likelihood of periodontal cell necrosis due to these two solutions are readily available.
desiccation. Consequently, the sooner replantation –– Dentosafe® and Save-A-Tooth® are kits that con-
takes place, the more favorable the results [94–98]. tain a medium for the preservation of avulsed teeth.
If the extra-alveolar dry time is less than about They are a cell culture medium that contains min-
15 minutes, periodontal tissues may well heal. If eral salts, amino acids, vitamins, and glucose [101].
the tooth remains outside its socket for more than –– Milk is a good medium for PDL preservation and
an hour, even in humid environment, healing is is readily available. It has the appropriate osmotic
impaired and any therapeutic intervention aims at properties, neutral pH, and nutrients and no toxic
limiting the phenomenon of replacement resorp- ingredients. Low-fat milk seems to be most suit-
tion [95]. able as compared to full fat and low temperature
55 Tooth preservation medium: A preservation medium possibly improves cell survival [101, 102].
may decelerate the destruction of periodontal cells –– Other media. Saliva is less suitable than milk,
caused by dehydration. because it is more hypotonic, but it is always read-
–– An extra-alveolar dry environment (air) soon ily available. Saline solution is preferable to water,
causes necrosis of periodontal fibers resulting in which is the most hypotonic and causes quicker
root resorption [95]. cell lysis [103].
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396 C. Bourguignon et al.
Mature Teeth (Closed Apex) (please look further down in this chapter).
The tooth has already been replanted The proper posi-
tion of the replanted tooth is verified clinically and radio- The tooth remained outside the socket up to 60 minutes in a
graphically. The area is thoroughly rinsed and any gingival favorable medium The process followed is the same as
lacerations are sutured. The tooth is cleaned and splinted for closed apices, with the administration of antimicrobial
with a passive and flexible splint for 2 weeks. Even though preparations and root canal treatment performed as soon
antimicrobial medication is sometimes prescribed (e.g., as pulp necrosis is confirmed (. Fig. 16.49) [104].
until later, only if pulp necrosis gets confirmed external bleaching may be attempted (see 7 Chap. 17).
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a b
c d e
.. Fig. 16.48 a Avulsion of 5 maxillary teeth in 6.5-year-old girl: obliteration of the pulp space is occurring in the avulsed right central
both permanent central incisors and 3 primary, left canine, and incisor. d The teeth are asymptomatic with no sign of ankylosis. e
both lateral incisors. Central incisors remained dry for 10 minutes The 30-month radiograph shows complete obliteration of the right
and then placed in milk for another 1 hour 40 minutes. Following central incisor’s pulp space. Meanwhile paucity of root development
replantation, sutures to the attached gingiva (secured with a spot and apical radiolucency of the left central incisor had dictated ini-
of composite) held teeth in place for 1 week in the absence of adja- tiation of endodontic treatment. An apexification procedure using
cent teeth to splint with. b Radiograph immediately after replanta- Ca(OH)2 was selected
tion. c Radiographs at 14 months show that revascularization and
a b c d
e f g h
.. Fig. 16.49 a Avulsion of the maxillary permanent right central f Following the restoration of the crown fracture, after 12 weeks,
incisor (dry for 10 minutes, in milk for another 40 minutes) and an apical radiolucency is observed on the right central incisor. g
partial extrusion of right lateral incisor with alveolar fracture and After Ca(OH)2 filling followed by Portland cement apical plug (not
lacerations to labial gingiva in an 8-year-old boy. b Avulsed incisor radiopaque), the remaining canal was filled with gutta-percha. The
rinsed with saline. c, d Replantation of avulsed central incisor and 6-month radiograph shows apical healing while the extruded lateral
repositioning of extruded lateral incisor, sutured gingiva and splint- incisor shows root canal obliteration. h At 2 years, infraocclusion is
ing using passive orthodontic wire and composite resin. Exposed the result of ankylosis of the avulsed tooth
dentin was protected with GIC and hygiene instructions given. e,
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.. Table 16.5 Follow-up table for avulsion injuries of permanent teeth, according to IADT Guidelines 2020 [21]
Despite radiographically appearing full root canal oblit- changes; and radiographic findings such as presence of
eration, a minimal canal space might exist, depending radiolucencies and signs or root and/or bone resorption.
on how the obliteration evolved. Pulp space oblitera- Laser Doppler flowmetry and oximetry are promising
tions are most often observed in cases of immature teeth technologies that have been shown to allow reading of
(with open apices), which suffered extrusion traumas or pulp status or pulp space revascularization status in a
lateral luxation and intrusion, thus raising suspicions matter of few weeks [112–114].
that the disorder may be related to pulp space revascular-
ization mechanisms [108]. Only in 8–13% of such cases Change of tooth color Even relatively mild trauma such
was pulp necrosis observed, and periapical inflamma- as concussion and subluxation may lead to blood supply
tion appeared 5–20 years after the injury, which brings rupture or disruption at the apical foramen. Intrapulpal
the 20-year pulp survival estimation to 84% [105, 109, hemorrhage can cause the crown to become slightly pink.
110]. Endodontic treatment is usually feasible even in If the blood supply recovers, which means that the pulp
such necrotic cases, albeit with some difficulty, because preserves its vitality, normal tooth color is self-restored. If
the root canal remains accessible and prognosis is good the tooth crown gradually turns gray – several weeks or
[111]. However, the calcified tissue may form from a even months after the injury – then suspicion of necrosis
coronal to apical direction without leaving a canal space is raised, since this discoloration likely indicates necrotic
as we usually know it. Or the pulp space might get colo- pulp tissue decomposition [115].
nized by an osteoid or cementoid type of calcified tis-
sue (. Fig. 16.48) originating from the periradicular
Pulp sensibility testing Most permanent teeth that have
tissues, in which cases there is no presence of a “canal” suffered loosening (subluxation) or displacement (luxa-
structure. That’s why, before intervening endodontically tion) do not initially respond to cold or electrometric
on those teeth, a careful preoperative investigation must vitality testing; yet, several regain their sensitivity later,
be made by comparing previous periapical radiographs within 2–3 months. However, there have been cases, when
to understand how the obliteration developed. Addi- it was up to 2 years before teeth regained their normal
tionally, a preoperative cone beam tomographic exami- reaction. Besides, young patients and immature teeth
16 nation (CBCT) is recommended (. Fig. 16.50). The use
seem to respond in an unreliable fashion to pulp sensitiv-
of the operative microscope is helpful to find and treat ity testing [116]. Therefore, a negative response to cold or
infected obliterated canals. Referral to a trained endo- to electric sensibility test per se is not sufficient, and root
dontist is advised. canal treatment should be postponed until at least one
more clinical or radiographic indication of pulp necrosis
16.3.3.2 Pulp Necrosis arises. Last but not least, sometimes the nerve fibers seem
Pulp necrosis is the most common post-traumatic to be the last ones to die, possibly giving false-positive
complication. It often occurs in cases of displacement responses to testing [117]. For all these reasons, pulp sen-
(luxation) injuries, where pulp neurovascular supply sitivity interpretation can be seen as a “challenging art.”
has usually been severed [51]. It occurs less often in
teeth with open apices, because small displacements of Radiographic signs of pulp necrosis Radiographic tech-
those teeth do not necessarily lead to apical blood ves- nique should be reproducible, so that, as time passes,
sel rupture; even if rupture does occur, a young pulp images may be compared to each other. Radiographs to
has a higher potential for healing. Pulp necrosis usu- help diagnose pulp necrosis should only be taken at a
ally appears in the first 3 months after the injury; how- point in time when pathologic findings are expected to be
ever, in some cases, it might take up to 2 years for it to present. This may be 3 weeks after the injury, although it
be confirmed. Diagnosis is based on symptom assess- often takes quite a few months before an apical radiolu-
ment; clinical examination, including palpation, percus- cency becomes visible in the radiograph [24]. In teeth with
sion, sensibility testing, and evaluation of tooth color open apices, necrosis of Hertwig’s epithelial root sheath
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Dentoalveolar Trauma of Children and Adolescents
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a b c
.. Fig. 16.50 Pulp canal obliteration. Maxillary permanent right absence of a visible canal. b, c Cone beam examination (CBCT)
central incisor of a 28-year-old female had suffered a severe luxa- shows no trace of a visible canal. The tooth is asymptomatic with no
tion injury while she was a child. a Periapical radiograph showing signs of pathology. No treatment other than follow-ups is necessary
the affected tooth tends to become infraoccluded as both Inflammatory root resorption As in replacement root
growth of the alveolar process and eruption of adjacent resorption, this type of resorption is related to severe and
teeth continue. Decoronation has been suggested as a extensive damage to the cementum and periodontal liga-
temporary measure to maintain alveolar ridge dimen- ment, the root protective layers. But it’s also related to
sions [120, 121] (. Fig. 16.52). If replacement root
associated pulp necrosis and infection. Bacterial by-
resorption evolves slowly, buccal, lingual, and vertical products and endotoxins from the infected pulp travel
bone dimensions will be better preserved for longer, and through the dentinal tubules toward the root surface. In
this facilitates implant placement later. Implants should areas deprived of cemental and precemental layers, they
be placed as late as possible since alveolar bone growth act as stimuli for the body’s defense mechanisms. An
has been shown in patients aged 35–45 years old, indicat- intense odontoclastic activity results on the root surface,
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400 C. Bourguignon et al.
a b c f
d e g h
.. Fig. 16.52 Replacement resorption and decoronation. Maxillary decoronation surgery. g Radiographic view immediately after dec-
permanent right central incisor was avulsed, replanted, and splinted. oronation. h Radiographic view 13 months post-decoronation. Note
The extra-alveolar time was 3 hours dry. a Radiographic view imme- the bone formation coronally to the resorbing root. The presence of
diately after replantation and splinting. b–d Ankylosis evolution at the decoronated root helps to delay bone volume loss and maintain
4 weeks, 15 months, and 30 months. e The avulsed incisor became alveolar ridge dimensions
severely infrapositioned due to ankylosis. f Clinical view of the
which is responsible for the resorption. In children aged Cervical root resorption These resorptions are usually
6–10 years, this type of resorption tends to be extremely late complications of dental trauma, so they will not be
aggressive, causing sometimes tooth loss in a matter of a fully discussed in the scope of this chapter. In short words,
few weeks. This happens, because at this age, dentinal cervical resorptions tend to appear below the epithelial
tubules are wide and the distance from the pulp canal to attachment of the tooth and are inflammatory in nature.
the root surface is small [126, 127]. It has been assumed that the presence of sulcular bacteria
Radiographically, inflammatory root resorptions is responsible for the maintenance of the lesion once it has
may appear initially as if the periodontal ligament formed [129]. They occur equally in vital and in non-vital
space is wider and irregular on both the alveolar bone teeth.
16 and on the root side. Subsequently, distinctive radio-
lucent lesions will form on the root surface and in the
Radiographic evaluation will reveal a radiolucent
area in the cervical area of the tooth adjacent to the
adjacent bone. The first signs of inflammatory root crestal bone (. Fig. 16.54). The lesion seems to have
resorption (most commonly located in the cervical the tendency to develop confined in dentin, in an apical/
1/3rd of the root) can be apparent radiographically as incisal direction along the pre-cementum and the pre-
early as 2 weeks after the injury, especially in young dentin, but without perforating those protective layers
teeth [128]. and without penetrating into the pulp canal space or
If diagnosed early, inflammatory root resorption can into the PDL space [130–133]. Their management can
be successfully treated. The key to successful treatment be complex, particularly if diagnosed late, where either
is to completely disinfect the root canal space. Calcium the involved tooth ends up with a periodontal pocket or
hydroxide intracanal medication has been shown to be needs to be extracted.
beneficial to treat inflammatory root resorption, and its
use is recommended [21, 24, 105] (. Fig. 16.53). Once
Internal resorption This is a rare post-traumatic com-
the canal space is disinfected, radiolucencies around the plication likely caused by chronic pulp inflammation. It
root should disappear, and the periodontal ligament appears without any clinical symptoms and is usually
width may return to normalcy and follow the new con- diagnosed radiographically years after the injury. If the
tours of the root surface. Final filling of the canal with tooth involved is treated early, before the resorption
gutta-percha and sealer ensues. extends and causes root perforation, root canal treat-
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Dentoalveolar Trauma of Children and Adolescents
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a b c d e
.. Fig. 16.53 Inflammatory root resorption. Accident of an radiolucent zones around the root have subsided; there is calcified
11-year- old female caused avulsion of maxillary permanent left tissue apposition on the root resorption lacunas; normal periodon-
central incisor, which was replanted several hours after the injury. a tal ligament width is reestablished. These signs are positive as they
Diagnostic radiograph 1 year after the injury. There is a radiolucent indicate that healing is in progress and that the resorption process
zone in the bone all around the root. Radiolucent “holes” on the root has likely stopped. d The root canal is filled and the access cavity
and on the adjacent bone are also visible. Diagnosis of inflammatory is restored. e 2 year follow-up. The tooth is fine but still has to be
resorption is made. b Endodontic treatment with calcium hydroxide frequently monitored, especially that orthodontic treatment was
is started and the canal space “disappears.” c After 5 months, the deemed necessary
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402 C. Bourguignon et al.
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Dentoalveolar Trauma of Children and Adolescents
403 16
infection). Only when a pulp is definitely diagnosed [153, 154]. Additionally, but only after its wide-
as necrotic should endodontic treatment be initiated. spread use during many years, it was observed
Several approaches exist: classical apexification, api- that MTA™ causes tooth discoloration. New bio-
cal plug apexification or the so-called Regendo, or ceramic materials such as Biodentine® or Total
pulp space “revascularization” procedures. Fill® have been suggested recently to replace
a. Classical apexification MTA. As of today, there is neither enough data
The classical apexification is a procedure where yet regarding outcome when these materials are
the root canal of an open apex tooth is cleaned used nor regarding the possibility that they may
and filled repeatedly with calcium hydroxide cause late discolorations.
[Ca(OH)2] dressings to stimulate the formation of Given that bacteria are the single most impor-
a natural hard tissue barrier at the apical portion tant factor to maintain inflammatory root resorp-
of the root. After this biological calcified barrier tion, it is strongly advised to follow a two- to
has formed, it is possible to obturate the canal three-step apexification procedure when the canal
system without or with decreased risk of over space is likely infected. The protocol is to disin-
extending the root filling material [149, 150]. fect and medicate the canal for 7–14 days with a
It is a prerequisite to disinfect the canal space thin calcium hydroxide paste. Secondly, an arti-
to create a suitable environment for stimulating ficial apical barrier is created by compacting the
apical barrier formation. Disinfection is achieved chosen apical plug material into the apical area
by thorough, but gentle, irrigation with sodium (. Fig. 16.58). When MTA was used as the plug
hypochlorite and by placing a relatively thin material, a wet cotton pellet needed to be placed
mixture (less than tooth paste thick) of calcium in the canal for at least about 4 hours, so that the
hydroxide powder mixed with anesthetic solution MTA could set. An extra treatment session was
or saline solution. It is not recommended to use thus required.
barium sulfate in the mixture because it prevents CollaCote™ or calcium sulfate can be placed
assessment of the calcium hydroxide placement apically beforehand to help preventing extrusion
in the canal space. The mixture is spun into the of the material in the apical area. The rest of the
canal space. After 3 weeks, the patient is recalled, canal is then obturated. It is delicate to place the
and the thin mixture irrigated out. At this time, a apical plug material correctly at the apex. An
thick, almost dry, mixture of calcium hydroxide operating microscope is needed, as magnification
and sterile solution is packed to the full length of and good lighting are essential.
the tooth using pluggers or inverted gutta-percha c. Pulp space revascularization of necrotic infected
cones to seat it to the full length of the root. Once teeth (Revitalization or ‘Regenerative’ endodon-
a radiograph indicates that the intracanal mix- tics)
ture is as dense as dentine all the way to the apex
(. Fig. 16.56), a temporary restoration such as
a b
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404 C. Bourguignon et al.
a b c d e
9m 9m obtur 4 years
.. Fig. 16.57 Calcium hydroxide apexification. a Pre-op radiograph 9 months of Ca(OH)2 protocol, an apical barrier has formed and is
of very immature maxillary permanent right central incisor with a clearly visible. d Trial with a gutta-percha cone to check the apical
wide-open apex and very thin root walls. Endodontic treatment had stop. Full canal obturation is then performed. e At 4-year follow-up.
been started by another dentist. The canal is gently but thoroughly The tooth is asymptomatic and stable
cleaned, irrigated, disinfected, and packed with Ca(OH)2. b, c After
to stimulate tissue growth inside the canal space Post-endodontic considerations for immature
of these teeth [158, 159]. This is accomplished by traumatized teeth
reducing the bacterial load, first by thorough irri- Non-vital immature teeth have thin roots with
gation and then by intracanal placement of either weak dentine walls and are especially at risk of
a dual or triple mix of antibiotics (metronida- root fracture at the neck of the tooth [105, 150,
zole, ciprofloxacin, and possibly minocycline) or 169]. The cervical area of the tooth may be rein-
alternatively a Ca(OH)2 dressing for a few weeks forced using etched and bonded composite resin,
[160–163]. Minocycline is not used anymore in allowing space, if indicated, for a post [170, 171].
the antibiotic mixtures because it causes tooth If little coronal tooth structure remains, a fiber
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Dentoalveolar Trauma of Children and Adolescents
405 16
a b c
.. Fig. 16.59 “Revitalization” of necrotic and infected immature the canal space, and placement of a hermetic access cavity restora-
tooth. a Pre-op radiograph. The incisor is very immature. b Aspect tion. c At 4-year follow-up. Some “revitalization” of the pulp canal
after the main treatment steps irrigation, disinfection of the canal space has occurred, with calcified tissue formation in some areas
with a dual antibiotic paste for 3 weeks, creation of bleeding to fill
post may be bonded into the root canal. Metallic severe (i.e., in cases of avulsions and intrusions). Several
posts should be avoided. Compared to metal posts, older studies show this [94, 118, 174], and the current
fiber posts have the advantage of some flexibility. knowledge about factors affecting the survival of these
If they fail, they are more likely to become de- teeth has considerably improved in recent years [85, 88].
cemented rather than cause a root fracture [172]. In particular, teeth treated in compliance with today’s
3. Endodontic treatment in the presence of inflammatory IADT’s Guidelines seem to have an even better chance
root resorption of survival than those treated years ago [136, 175]. If
As seen earlier in this chapter, calcium hydrox- proper emergency management is provided, as well
ide as an intracanal medication has proven to be an as later treatment as deemed necessary on follow-ups
effective method to halt the progression of external (such as timely endodontic treatment), the prognosis of
inflammatory root resorption (. Fig. 16.53) espe-
injured teeth turns out to be very good.
cially if detected early [104, 173]. Ca(OH)2 paste In the case of avulsed teeth, for instance, the most
should be used in a thick, almost dry consistency. It important factor affecting prognosis, apart from extra-
should be renewed at 3 weeks and every 3 months oral dry time and timely endodontic treatment, has
because it may wash out. Treatment should be con- been reported to be the stage of root development. A
tinued until all signs of inflammatory root resorption better survival rate was observed for mature teeth [98].
have healed and until a normal periodontal ligament Certainly, as seen earlier in this chapter, endodontic
width has reestablished. This can take anywhere treatment of immature teeth is quite challenging when
from 6 to 24 months. The access of the tooth should compared to mature teeth, but the main reason why
be temporized with an appropriate restorative mate- their survival rate is reduced is their thin and fragile den-
rial such as IRM™ as it is of upmost importance to tinal walls. Immature teeth tend to fracture easily even
keep bacteria away of the canal space. to minor impacts occurring repeatedly in everyday life,
especially if they developed areas of resorption located
cervically [105]. That’s why attempts should be made to
16.4 Prognosis of Injured Teeth prevent those resorptions. Some years ago, the long-term
use of calcium hydroxide has been blamed as a causative
Injured mature and immature teeth treated in an appro- factor for immature teeth fractures. The study design of
priate and timely fashion have a good chance of sur- these in in vitro studies was far from ideal though [169].
vival, up to 20 years or more and even if the injury was It’s worth noting that calcium hydroxide apexification
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406 C. Bourguignon et al.
has been successfully used (97%) for decades in the treat- mild luxation injuries, such as concussion and sublux-
ment of injured teeth [105, 176]. ation, a 3-month observation time should be sufficient.
In situations where the prognosis of an injured tooth In moderate to severe injuries, such as extrusion, intru-
is deemed dark due to developing ankylosis in a grow- sion, lateral luxation, and replantation of avulsed teeth,
ing child, or due to high risk of tooth fracture (related a minimum of 6 months to 1 year is advised. In root-frac-
to fragile dentinal walls or loss of tooth structure due tured teeth, the recommended observation time is 1 year.
to the presence of resorption areas), it’s advisable to In crown-fractured teeth, when the dentist is certain that
check if the patient will need premolar extraction for no associated luxation injury occurred at the time of
orthodontic reasons. In the affirmative, one should trauma, a 3-month observation time is still advised [179].
consider the possibility of extracting the problematic
traumatized incisor, rather than the healthy premolar.
Autotransplantation of a premolar to replace the incisor Eye Catcher
might be a possibility. Proper overall treatment planning
and coordination between different dental specialties is Traumatized teeth presenting root resorption before
then needed (. Fig. 16.60) [177].
orthodontic treatment are at high risk of further
resorption as a result of intense orthodontic force
application [180]. Thus, no orthodontic treatment
16.5 Orthodontic Management should be initiated on teeth presenting apical or lat-
of the Traumatized Dentition eral radiolucencies or signs of root resorption. The
related pathologies should be treated first, usually
The particular orthodontic management of intruded with endodontic treatment. Only when healing is
teeth, crown-root fractured, and ankylosed teeth is pre- observed, orthodontic forces may begin to be applied
sented in this chapter within the specific injury types. but under careful and frequent clinical and radio-
Orthodontic treatment is so common nowadays, that it graphic monitoring every 3 months. Parents should
often involves movement of anterior teeth with a history be informed about possible contingencies happening
of trauma. Before any treatment is initiated, the ortho- during or after treatment of injured teeth, as compli-
dontist needs to inquire with the patient and his parents cations may occur. Sometimes a treatment paucity or
if any dental injury occurred, both recently and in the even total orthodontic treatment interruption is nec-
past. Additionally, full mouth periapical radiographs essary for those teeth.
should be taken, not only a panoramic radiograph, in
order to make a thorough preoperative evaluation. The
orthodontist also needs to take into consideration the From a preventive perspective, increased overjet with
impact of orthodontic treatment on long-term progno- protrusion of maxillary incisors is a common pre-
sis of such traumatized teeth [178]. Orthodontic treat- disposing factor for dental injuries in the permanent
ment should always be interpreted as an added trauma dentition. It has been reported that an increase from
to the teeth. Therefore, orthodontic forces should be 0–3 mm to 3–6 mm leads to twice as many trauma rates,
light and short-acting and aimed at limited goals when while if protrusion exceeds 6 mm, incidence triples [14]
16 moving previously injured teeth. (. Fig. 16.9). Insufficient lip coverage seems to play a
Depending on the severity of trauma, it’s wise to wait role as well. Preventive consultation with an orthodon-
before initiating orthodontic treatment. In the case of tist is thus advisable for these patients.
a b c d e
.. Fig. 16.60 Autotransplantation of a premolar. a These avulsed incisors. c Radiographic view of the premolars 2 weeks after the
and replanted maxillary central incisors were undergoing severe operation and after the splint had been removed. d One-year fol-
replacement root resorption at follow-ups. It was decided to use the low-up radiographic examination showing sound progress in apical
patient’s premolars to substitute them. b Clinical view 2 weeks after development. e Reshaping of the premolars into incisor crowns by
autotransplantation of the immature second maxillary premolars palatal grinding and composite reconstruction after the end of orth-
and their splinting in the position of the extracted compromised odontic treatment. (Courtesy of Dr. Μ. Duggal)
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Dentoalveolar Trauma of Children and Adolescents
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16.6 Prevention of Dentoalveolar Trauma 16.6.1 Mouth-guards
Accidents, including road accidents, are a major threat A dentist does not only provide treatment but can also
against the physical integrity and life of children. They assist in preventing trauma consequences by fabricating a
are the top death cause during the first year of life and a mouth-guard. This is a sturdy functional device that pro-
major cause for hospital care and disability in industri- tects against dental, periodontal, and supporting alveolar
ally developed countries. bone trauma. Depending on the sport and the level of
Facial and dental trauma is due to various causes, involvement in it (professional, amateur), the appropriate
many of which cannot be easily prevented. They hap- type of mouth-guard should be used. A study investigat-
pen more often during children’s leisure time and dur- ing amateur athletes among newly recruited soldiers in the
ing play [11, 13]. In preschool years, and particularly in army, who were issued with free-of-charge type II mouth-
early infancy, when balance in movement and percep- guards, showed that, although very few of them wore the
tion of danger are limited, there should be no obstacles device, users suffered milder dental trauma [182].
on the ground, no stairs, furniture, or other hard objects A mouth-guard has to meet numerous requirements:
with sharp angles in areas within which children move. It should be resilient, comfortable, odorless, affordable,
Furthermore, athletic activities among children and ado- retentive, and properly fitting; its borders should be
lescents have significantly expanded in recent years, par- smooth and even, it should have the necessary thick-
ticularly related to body contact sports. Injuries occurring ness at critical regions, it should not prevent speech or
during high speed and impact force sports, such as on ice breathing, it should not be cumbersome, and it should be
or snow, result in more facial or skull trauma, which may easy to fabricate [183]. No type of mouth-guard fulfils all
be life-threatening, and require protective equipment, such these requirements, and every type has its own pros and
as a helmet. Lower speed and impact force sports (e.g., cons. In general, disadvantages have to do with difficul-
basketball) result in dental trauma. Injuries in sports are ties caused to speech or breathing, with the effect on an
more frequent than those due to fights or road accidents athlete’s appearance, with the difficulty of their adapt-
[181]. The need for educating children, parents, teachers, ability to various individuals, their volume, and their
coaches, and owners of recreational venues in prevention cost. The use of commercial mouth-guards prevents
and first-aid management of injuries is self-evident. intense voluntary exhaling but has no negative conse-
In the permanent dentition, patients having pro- quences on pulmonary ventilation during the athlete’s
clined incisors with increased overjet and insufficient lip training.
coverage tend to suffer more dental injuries. A preven- There are three types of mouth-guards. Their advan-
tive consultation with an orthodontist is thus advisable tages and disadvantages are presented in . Table 16.6
.. Table 16.6 Advantages and disadvantages of the three basic types of mouth-guards based on Bourguignon and Sigurdsson [184]
Advantages Disadvantages
Type I +Very low cost −Limited size numbers (small, medium, and large)
+Immediate placement −reduced fit
−Lack of retention
−Continuous occlusion/bite necessary
−Obstruct athlete’s speech/breathing
Type II +Relatively low cost −No absolute fit
+Better protection than Type I (better than type I)
+Possibility of Refit −Lack of retention,
+ Immediate placement −Continuous occlusion/bite necessary
−They are more cumbersome
−They loosen easily with use
Type III + Good fit and stay in place −High cost
+ Sound retention −Increased fabrication time
+They cover the entire dentition
+Less discomfort for breathing/speech
+More acceptable to athletes
+Choice of thickness
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408 C. Bourguignon et al.
55 Type I: Various, commercially available, prefabri- hot water). The mouth-guard is then transferred to
cated mouth-guards which cannot be adjusted to a the mouth, where it is adjusted and fitted while cool-
specific individual, one or two sizes that are intended ing (. Fig. 16.62).
to fit most. Some have a “spring” fit and do cover 55 Type III: One layer or multilayer custom-made
both arches others require the athlete to clench to mouth-guards, fabricated by a dentist. They allow
keep the mouth-guard in place. (. Fig. 16.61).
any type of adaptation during their fabrication, tak-
55 Type II: These are fabricated from a thermoplastic ing into consideration regions of chronic trauma,
material. They are heat adapted to the teeth, albeit dental-mandibular problems and the type of sport.
not ideal, by the athlete and can provide satisfactory An athlete can enjoy free flow of air during strenu-
protection. The right size of mouth-guard is selected ous exercise, while teeth and mandible are protected.
and rendered relatively pliable, following the manu- This type is ideal for athletes undergoing orthodon-
facturer’s instructions (by submerging it into very tic treatment with fixed devices on both jaws
(. Fig. 16.63).
16
.. Fig. 16.61 Type I – Prefabricated mouth-guards. (With permis- .. Fig. 16.63 Type III – Custom-made mouth-guards require an
sion [184]) impression. (With permission [184])
a b c d
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Dentoalveolar Trauma of Children and Adolescents
409 16
are easily visible at the bottom of the pool. Sound and mild head injury: meta-analysis. J Neurol Neurosurg Psychiatry.
hygienic maintenance is ensured by keeping the guards 2000;68:416–22.
19. McCrory P, Meeuwisse WH, Aubry M, Cantu RC, Dvorak J,
in a special case, by avoiding very hot water when clean- Echemendia RJ, et al. Consensus statement on concussion in
ing them and by placing them, every so often, in an anti- sport: the 4th International Conference on Concussion in Sport,
septic solution. Furthermore, such guards should not be Zurich November 2012. J Athl Train. 2013;48:554–75.
exposed to the sun or high temperatures to avoid warp- 20. American Academy on Pediatric Dentistry Council on Clinical
ing [185]. Affairs Committee on the A. Guideline on management of acute
dental trauma. Pediatr Dent. 2008–2009;30:175–83.
21. Bourguignon C, Cohenca N, Lauridsen E, Flores MT, O'Connell
AC, Day P, et al. International Association of Dental Traumatol-
References ogy guidelines for the management of traumatic dental injuries:
1. Fractures and luxations. Dent Traumatol. 2020;36:314–30.
1. Andreasen JO, Andreasen FM. Essentials of traumatic injuries 22. Kullman L, Al SM. Guidelines for dental radiography imme-
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415 17
Developmental Defects
of the Teeth and Their Hard
Tissues
Nikolaos Kotsanos, Petros Papagerakis, Haim Sarnat,
and Agnès Bloch-Zupan
Contents
References – 459
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17.1 Disturbances in Tooth Number, Size, about the completion of primary tooth formation or its
and Morphology eruption. This means that formation of the first perma-
nent tooth (first molar) begins at about the 20th week in
17.1.1 Short Introduction to Dental
A utero and of the third molars at about the age of 5 years,
but traces of mineralized tips of cusps cannot be seen
Development radiographically before birth for the first and before
year 8 for the third permanent molar [1].
Primary teeth develop from oral ectoderm-derived cells, Like the formation of other organs of the fetus, the
which differentiate into ameloblasts that form enamel, histodifferentiation of ameloblasts, odontoblasts, and
and cranial neural crest-derived mesenchyme cells, cementoblasts and the deposition of their matrix are
which differentiate into odontoblasts and cementoblasts regulated by complex mechanisms [1, 4]. Interaction
forming dentin and cementum, respectively. These two between epithelial and mesenchymal cells, also between
cell types (epithelial and mesenchyme) interact to con- extracellular matrix and cells, and between different
trol the entire process of tooth initiation, morphogen- types of epithelial and mesenchymal cells is continu-
esis, and cytodifferentiation [1]. ous and tightly regulated. The gene regulation of cell
Oral ectoderm-derived epithelial cells first form the differentiation has been examined in animal studies
dental laminae. Tooth formation begins with the thick- using molecular biology. Advances in molecular genet-
ening of the dental lamina and its ingrowth into the ics have allowed the identification of hundreds of genes
underlying cranial neural crest-derived mesenchyme at that are related to dental developmental disorders. The
the sixth to eighth week in utero for the entire primary regulating (signaling) molecules (growth factors) are
dentition. This folding of the epithelium along with a peptides which are secreted and bind to specific recep-
condensation of the adjacent ectomesenchymal cells tors in adjacent cells. These molecules belong to specific
leads to the formation of tooth germs or buds. Organized families, like bone morphogenetic protein (BMP), fibro-
clusters of these cells are called the dental placodes. A blast growth factor (FGF), hedgehog signaling routes,
very important transient structure named the enamel and Wnt families [2, 3, 5]. Their role has been studied in
knot is derived from the dental placodes. The enamel transgenic mice and shown that the inhibition of tran-
knot functions as a signaling center of epithelial/mes- scription activity inhibited odontogenesis [3].
enchymal interactions, which are responsible for tooth In addition to growth factor signaling initially char-
morphogenesis. In fact, the enamel knot’s signaling cen- acterized in mice models, the last few years, direct DNA
ters will determine the individualized crown shape for sequencing of patients with genetic traits has discovered
each tooth. This is done by controlling the appropri- an increasing number of genes involved in tooth number,
ate size and number of cusps by complex mechanisms tooth form, and dental structural anomalies (. Tables
involving the differential expression of numerous genes 17.1, . 17.2, and . 17.3).
including MSX for incisors, BARX-1 for molars, etc., These genes include almost any type of proteins such
and then going through the morphological cap and bell as transcription factors, extracellular proteins, adhesion
stages [2, 3] (. Figs. 17.1 and 17.2).
molecules, and even proteins with still unknown func-
Once morphogenesis is completed, the dental crown tions. Most of these newly discovered genes with key
cytodifferentiation stage starts, during which neural roles in tooth development play also key roles in differ-
crest-derived ectomesenchymal cells facing the enamel ent organs, but some are only expressed in dental tissues
17 organ differentiate into odontoblasts and subsequently and have only tooth-specific phenotype such as amelo-
epithelial cells from the inner dental epithelium differ- genin mutations causing amelogenesis imperfecta (AI).
entiate into ameloblasts. Both odontoblasts and ame- However, even amelogenin, the so-called “exclusive”
loblasts produce extracellular organic matrix (dentin enamel protein, might be present in other tissues and
and enamel, respectively) in the space between them, organs like the brain [28].
as they move apart from each other. Almost simultane- During the morphogenesis of the teeth includ-
ously, mineralization of these two tissues with calcium ing their root formation, the dental papilla constantly
phosphate (hydroxyapatite) starts at the cusps and then interacts directly and indirectly with the surrounding
proceeds cervically [1]. The permanent teeth develop periodontal and bone tissues. During the eruption of
by further proliferative activity lingual to each primary the tooth, the surrounding cementum and bone tissues
tooth bud (anterior teeth and premolars) and backward undergo continuous remodeling, with resorption in
extension (molars) of the dental lamina. Their budding front of the erupting bud and apposition behind it, thus
(anlage) starts during the bell stage of primary tooth allowing for tooth eruption (see 7 Chap. 10).
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.. Fig. 17.1 Dental develop-
ment from tooth bud stage
through to enamel mineraliza-
tion at cusp tips. (From Bekes K.
(Ed) Pit and Fissure Sealants.
2018, Springer. By permission)
Wnt
Shh BMP
BMP FGF
FGF Activin
Edar
.. Fig. 17.2 Epithelial-mesenchymal tissue interactions and epithe- regulates the shift from the bud to cap stage and then to the bell
lial signaling centers regulating tooth morphogenesis. Epithelial sig- stage. The secondary enamel knots regulate tooth cusp formation in
naling centers express signals of four signal families and Edar, the molar teeth. Reciprocal signals (in green square) are expressed in
receptor of ectodysplasin (Eda). The early signaling center in the mesenchyme. Arrows indicate signaling across the two tissues and
placode regulates epithelial budding, while the primary enamel knot within the epithelium [3]. (By permission)
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418 N. Kotsanos et al.
.. Table 17.1 Non-syndromic oligodontia: selected gene mutations responsible for non-syndromic variations in number and shape
of teeth
MSX1 [6] M61K and R196P (missense) Transcription factor (binds Hypodontia (AD or AR)
S105X, Q187X, and S202X (nonsense) DNA through its homeodo- Oligodontia (AD)
main) Possible cleft palate
PAX9 [7] K114X (nonsense) Transcription factor (binds Oligodontia (AD)
L21P, R26W, R28P, G51S, and K91E (missense) DNA through its paired Molar Hypodontia (AD)
G73fsX316, R59fsX177, and V265fsX316 domain) Peg-shaped laterals (AD)
(frameshift)
AXIN2 [8] Arg656Stop, 1994–1995insG (LOF) Wnt signaling regulator Incisor agenesis (unknown)
Associated with
Colorectal carcinoma
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.. Table 17.2 (continued)
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420 N. Kotsanos et al.
by the term supernumerary teeth or hyperdontia. The majority of gene mutations that have been iden-
Many of the disturbances in tooth development are tified as causes of variations in the number and shape
attributed to local or systemic environmental causes, while of teeth are related to genes responsible for the tran-
there are some whose etiology remains unclear. Genetically scription of macromolecules of odontogenesis that act
regulated disturbances are caused by gene mutations, and at very early stages summarized here for non-syndromic
thanks to advances in genetic research, many of these oligodontia (. Table 17.1) and syndromic oligodontia
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The main genes associated with tooth agenesis,
regardless of the presence or not of a general syndrome,
include the MSX1, PAX9, IRF6, AXIN2, WNT10A,
EDA, EDAR, and EDARADD genes [3, 33].
As an example, the autosomal dominant trait of
hypodontia is caused by gene mutation in MSX1 and
PAX9, which are mediators in the interaction of epi-
thelial/mesenchymal cells. Agenesis of the second pre-
molars and third molars is almost always associated
with mutations in MSX1. On the other hand, the eti-
ology of hypohidrotic ectodermal dysplasia, which is
characterized by severe oligodontia, small peg-shaped
anterior teeth, and severe reduction of the hair, nails, .. Fig. 17.4 Cleidocranial dysplasia. Supernumerary teeth, delayed
sweat glands, and other epithelial appendages, is associ- eruption, and retention of the primary teeth
ated with the loss of function of ectodysplasin (EDA),
the signaling molecule that together with the EDAR and (Gardner syndrome) [37]. However mutations in AXIN2
EDARADD belongs to the family of tumor necrosis fac- and APC genes are rare.
tors (TNF). However, these same genes (EDA, EDAR, On the other hand, genetic mutations are also found
EDARADD) are responsible for non-syndromic hypo−/ in patients presenting supernumerary teeth as phenotypic
oligodontia and may not be associated with additional traits (. Table 17.3). Among the most common syndromic
ing with non-syndromic oligodontia in a specialized nificantly affects osteoblasts and bone remodeling and the
center had bi- or monoallelic WNT10A mutations [34], epithelial/mesenchymal cell interactions during early odon-
which means that the mutations in this gene are the togenesis [2]. Typically manifested by underdeveloped or
most common cause of these types of oligodontia [35]. missing clavicles, in severe cases the shoulders can be brought
Furthermore, WNT10A mutations have been identified together in the midline. Other signs are delayed closure of
in a large proportion of patients with oligodontia and the fontanelle, prominent forehead, hypertelorism, multiple
mild phenotypes of ectodermal dysplasia. Significant teeth, delayed eruption, and retention of the primary teeth.
differences are found among the ectodermal dysplasia
phenotypes caused by the EDA and WNT10A genes.
Those indicate that there are at least two different routes 17.1.3 linical Expression of Disturbances
C
of occurrence [36].
and their Treatment
In other cases of non-syndromic oligodontia, there
may also be other genetic mutations, such as in AXIN2,
an inhibitor of the Wnt signaling pathway [5]. Research Eye Catcher
has linked genetic background of dental agenesis of this
The management of dental anomalies and associated
pathway with some forms of cancer. The normal route
rare diseases requires interactions with specialized
of Wnt catenin shows such a relation. For example, a
dedicated centers with long term expertise. In Europe,
strong relationship has been found between the gene
per definition, rare diseases affect less than 1 in 2,000
AXIN2, tooth agenesis, and the development of colon
persons. Among 7,000 rare mostly genetic diseases,
cancer, suggesting that tooth agenesis may in some cases
900 have orodental manifestations. These diseases
be a sensitive cancer indicator [8]. This is particularly
affect 25 million people in Europe. Expert centers
true for cases of oligodontia without ectodermal dys-
have been identified and certified by national health
plasia, where the dentist should inform the physician,
authorities and plans focused on rare diseases [33]. As
in order to suggest to the patient a genetic mutation test
examples, one could mention TAKO – Resource cen-
of AXIN2 to exclude the possibility of predisposition
ter for oral health in rare medical condition in Norway
to cancer. It has also been reported that mutations in
and the Rare disease reference center for rare oral and
the APC gene, another “tumor suppressor gene” of the
dental diseases O-Rares in Strasbourg France (see
Wnt pathway, involved in tooth number variations, may
7 https://www.orpha.net/ for a list of centers).
be associated with polyps in the colon and osteomas
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422 N. Kotsanos et al.
tia is 0.6% and of supernumerary teeth is 0.3% or The prevalence of supernumerary permanent teeth
less. Both hypodontia and hyperdontia appear more not related to syndromes is about 1.5%. They are more
frequently in the maxillary lateral incisor region [38], frequently found in boys in the pre-maxilla, mostly near
while oligodontia and anodontia occur very rarely in the midline and called mesiodens (see 7 Chap. 10) [42,
the primary dentition – mainly in cases of ectodermal 43]. They are sometimes multiple hypoplastic supernu-
dysplasia (. Fig. 17.5). Hypodontia in the primary
meraries found in the form of compound odontomas
dentition usually leads to missing corresponding per- (see later in this chapter). The presence of one or more
manent teeth [39]. forth molars is relatively rare (. Fig. 17.7). In children
In the permanent dentition, hypodontia is much more with cleft lip and palate, supernumerary as well as miss-
frequent, ranging from 2.6% to 11.3%, depending on ing teeth at the cleft area are common. However, in cleft
ethnicity and sample characteristics. Terminal reduction lip and palate, missing teeth may not concern solely
is manifested and includes the third molar, second pre- teeth in the cleft area but also more distant teeth point-
molar, as well as the maxillary lateral incisor and man- ing toward a role of the responsible gene both in palate
dibular incisors at a prevalence of 4% [40]. In a young and tooth development [ 44].
Korean population with hypodontia in the high end of
prevalence spectrum, mandibular incisors were missing zz Treating Children with Missing Teeth
about equally as frequent (34%) as the second premolars In the primary dentition, there is often no need for treat-
[41]. Hypodontia involves usually one to two teeth, is ment, unless aesthetics or function (mastication) is sig-
often symmetrical, and is rather more frequently found nificantly affected, as in cases of syndromic oligodontia.
in girls than in boys [40]. Non-syndromic oligodontia is The problem then might also be social, and, for opti-
more rare, while anodontia occurs very rarely in cases mized integration of the child in society, prosthesis in
of ectodermal dysplasia. Hypodontia and microdontia the primary dentition would be considered from 3 years
of the maxillary lateral incisors are related, and they are onward. Depending on the severity of the deficit, vari-
inherited as an autosomal dominant trait, but knowl- ous types of partial dentures can be constructed once
edge about the exact pathogenetic mechanism is limited child cooperation can be achieved. In the permanent
[41] (. Fig. 17.6). There are more than 100 syndromes
dentition, the treatment plan should have a long-term
that include missing teeth. Information about these can vision. Orthodontic assessment and treatment should
be found in digital databases such as OMIM (Online come before any prosthetic solution, particularly in the
Mendelian Inheritance in Man) and ORPHANET. The anterior area. The most common problem is the agenesis
a b
17
c d e
.. Fig. 17.5 a Congenitally missing primary mandibular canines sor. e Anodontia of a 5.5-year-old boy with ectodermal dysplasia. (e:
resulting in diastemas. b The radiograph confirms their agenesis. c, d courtesy Dr. E. Kotsiomiti)
Agenesis of the right and a large (fused?) left maxillary primary inci-
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Developmental Defects of the Teeth and Their Hard Tissues
423 17
a b
c d
e f
.. Fig. 17.6 Agenesis of permanent teeth. a, b Hypodontia in a of 11 permanent teeth (8 premolars, maxillary canines, and right lateral).
10-year-old boy and his father. Both have aplasia of a permanent lower Microdontia of her left lateral incisor. e, f Syndromic oligodontia in a girl
incisor. c, d Non-syndromic oligodontia of a 10-year-old girl. Agenesis with incontinentia pigmenti. Clinical and radiographic appearance
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424 N. Kotsanos et al.
zz Treating Children with Supernumerary Teeth Tooth type, size, and morphology are genetically
In the primary dentition, there is usually no need for determined, but genetic factors may control mineral-
intervention, unless the treatment plan requires an ization, too, as seen, for example, in certain types of
extraction of the superfluous tooth/teeth. The timing amelogenesis imperfecta. Environmental factors how-
ever may play their role in the morphology and shape
17 of the extraction is of great importance, especially when
it comes to extraction of a supernumerary permanent of the teeth and beyond those importantly disturb
tooth. It depends mainly whether or not it is performed their mineralization. Environmental factors can cause
around the eruption time of the permanent tooth. injuries to the developing tooth bud through direct
Waiting for the supernumerary tooth to erupt can reduce trauma; deregulation of biological mechanisms by
the degree of difficulty of the extraction (. Fig. 17.9).
high fever, inflammation, drugs, and chemicals; radio-
Impacted supernumerary teeth that are not expected therapy of adjacent tissues; effect of cytotoxic agents;
to erupt, such as inverted mesiodens, require exact and other serious insults.
localization with various radiographic means, such as
CBCT. Usually, a surgical flap is prepared under local
anesthesia to carefully access and extract the tooth zz Variations in Size
(. Fig. 17.10). In cases where surgical exposure of the
Abnormal tooth size may be local or generalized.
tooth requires bone removal, care should be given to the Microdontia is a relatively common finding. It may
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Developmental Defects of the Teeth and Their Hard Tissues
425 17
a b c
d e
.. Fig. 17.10 a Over-retention of the primary right central incisor impeded by the already erupted lateral. This indicates its traction
in a 7.5-year-old girl is being investigated radiographically. b The along with space regaining. d This is now possible with a partial wire
presence of a mesiodens in a labio-palatal direction inhibits the suc- arch. e A patient at a 3-year recall. No further orthodontic treatment
cessor’s eruption. c Eight months following surgical removal of the was necessary
mesiodens, the impacted central incisor descent is slow, possibly
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426 N. Kotsanos et al.
a b
.. Fig. 17.13 a Stunted root formation (at age 15). At age 8.5 years, molars are unaffected, while maxillary laterals have near-terminal
the patient was diagnosed with leukemia and received chemotherapy. root resorption
b A 12-year-old girl with generalized short root anomaly. The first
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a b c
.. Fig. 17.15 a One year after sealing this seemingly intact second treatment, a large void in the dentin (arrow) is thought as infection
permanent molar, the patient complains of pain at biting. b The channel prior to sealing. The anomalous mesio-buccal cusp should
radiograph shows apical periodontitis. c In drilling for endodontic have raised suspicion
a c
.. Fig. 17.16 a Invagination of mandibular lateral incisor with pulp necrosis and a fistula in a 10-year-old boy. b Lingual aspect. c The
radiograph shows an anomalous wide root with enamel submergence
a
a missing permanent successor [49]. The crown may be
twinned or simply very wide and thus be wrongly per-
ceived as isolated macrodontia (. Fig. 17.19). The pulp
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428 N. Kotsanos et al.
a b c
.. Fig. 17.18 a Fusion of maxillary lateral with a supernumerary tion with composite inhibits further caries in the fusion line and
tooth in a 3-year-old boy, with advanced caries in the fusion line. b improves aesthetics in the primary dentition
Radiograph showing the fused root ending in two apices. c Restora-
17
c d
.. Fig. 17.19 a Abnormally wide left permanent maxillary central gual aspect reveals fusion with the respective supernumerary teeth.
incisor of this 7-year-old appears as a macrodont. Its incisal edge has The course of cervical line and the exogenous pigmentation in the
one more mamalon than usual. b The root does not reveal signs of teeth “mid-line” support this diagnosis; a radiograph can verify it
fusion. c Wide mandibular central incisors in a 5-year-old boy. d Lin-
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Developmental Defects of the Teeth and Their Hard Tissues
429 17
.. Fig. 17.20 a, b Compound
odontoma located palatally to a b c
maxillary central incisor of a
7-year-old girl, merely affecting
its eruption path. c The eight
surgically extracted supernu-
merary microdonts. d Complex
odontoma in an 8-year-old girl
prevents eruption of mandibu-
lar left first permanent molar.
Its eruption occurred spontane-
ously after extraction of the d
odontoma with local anesthesia
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430 N. Kotsanos et al.
double tooth, if the shape of the pulp chamber permits At the formation of the organic substrate, mineralization
it, endodontic treatment is indicated, provided that an plays an essential role with simultaneous incorporation of
aesthetic restoration, either conservative or prosthetic, inorganic minerals at about 30%. Then, a period of matu-
can follow. The sharp angulation in dilaceration often ration follows. This is a period of slower (lasting several
results in impaction of the tooth. If possible, the tooth is months to a few years) completion of mineralization by
surgically exposed and guided into the correct position removal of the remaining matrix proteins by proteases and
in the dentition [51] (. Fig. 17.22). Surgical removal of
replacement by minerals. The process advances from the
odontomas is usually carried out under local anesthe- cusps to the cervical margin of the tooth and right down
sia. In young children, nitrous oxide inhalation or some the root. Cementum and periodontal ligament are essen-
other kind of sedation will aid child cooperation. tial for root formation and tooth eruption. Cementum
is an avascular mineralized tissue that covers the entire
root surface. It is the interface between the dentin and
17.2 Malformations of Dental Tissue
the periodontal ligament and contributes to periodontal
Structure tissue repair and regeneration after damage. The organic
extracellular matrix of cementum contains proteins that
17.2.1 he Structure of Enamel, Dentin,
T selectively enhance the attachment and proliferation of
and Cementum cell populations residing within the PDL space [1].
All dental mineralized tissues are formed in a circa-
Enamel, dentin, and cementum are three of the body’s dian rhythm, which in light microscope sections are seen
mineralized tissues. Enamel is of epithelial origin and as curved incremental lines, called after Retzius in enamel
covers the crown of each tooth. In contrast, dentin and von Ebner in dentin. In the enamel of primary teeth
and cementum are of mesenchymal origin. Dentin and sometimes also in the bucco-mesial cusp of the first
forms the bulk of the tooth and extends within both permanent molar, an accentuated incremental line can be
the crown and root. It is of yellowish tint, in contrast seen that corresponds to the time of birth which leaves a
to the much whiter and harder enamel. Cementum is record of the change from intra- to extra-uterine life – the
deposited only in the root area. Each tooth is anchored neonatal line [54] (. Fig. 17.24). Its importance is that it
onto its socket (alveolar bone) by the periodontal liga- helps estimate the timing of events in the child’s life. In
ment (PDL) that connects cementum to the alveolar forensics, it allows to decide if a child was born alive.
bone through s pecialized made-of-collagen fibers [52]. Formation of enamel and dentin is circadian, char-
acterized by daily repeated activity that controls cell
morphology, gene expression, secretion, and degrada-
Eye Catcher
tion/removal of the proteins. All secretory, mineraliza-
Enamel, dentin, and cementum contain about 96%, tion, and maturation stages are of vital importance for
70%, and 50% (by weight) inorganic minerals, respec- the final product and are regulated by relevant genes. As
tively, mostly calcium and phosphate salts, such as a result of differences in the circadian rhythm profile, the
hydroxyapatite and others, as in other calcified tissues thickness and hardness of the enamel can vary greatly;
in the body [53]. Their organic matrices are different. this will affect the susceptibility of the tooth to caries,
The ameloblasts that are derived from ectoderm pro- abrasion, and breakdown [53, 55]. Malformations in the
structure of both hard tissues may occur due to disor-
17 duce mainly amelogenin, enamelin, ameloblastin,
kallikrein, and other proteins. The odontoblasts, orig- ders during tissue differentiation, formation, mineral-
inating from mesenchyme (ectomesenchyme neural ization, and maturation stages. They are associated with
crest), produce mainly collagen type 1 and some non- many causative factors, environmental and/or genetic. A
collagenous materials such as mucopolysaccharides. mild disturbance may be seen in light microscopy as an
The apposition of the matrix occurs between the accentuated line or if more severe as a hypoplastic defect
ameloblasts and odontoblasts as they keep retreating or opacity. These insults may be chronologically associ-
from the dentino-enamel junction. The ameloblasts ated with possible causative events and assist diagnosis.
end up at the surface of the rod-structured enamel
17.2.1.1 Mineralization Chronology
they had produced. The odontoblasts having left
behind the dentinal tubules (that contain their den-
of the Teeth
tinal processes) remain at the periphery of the pulp Despite its variation, chronology of odontogenesis is
and continue to function throughout the life of the always described as the mean average of observations
tooth pulp, producing secondary and tertiary dentin and shown in . Fig. 17.25. The mineralization of the
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431 17
c d
.. Fig. 17.22 a Maxillary central incisor dilaceration in a periapical treatment made aligning possible [51]. (By permission from Am J
radiograph. b The CBCT gives a three-dimensional spatial relation- Orthod Dentofacial Orthop)
ship of the dilacerated incisor. c, d Traction through orthodontic
of the fifth month in utero (second molars). The crowns while canines and the upper lateral incisors start to min-
are completed during the first year of life, during the eralize at the start and the end of the first year, respec-
first months for the incisors and the last months for the tively. Premolars and second molars mineralize between
canines and second molars. The formation of roots is the age of 2 and 4 years (delays for the second premolars
completed at the age of 1.5–3 years (. Table 17.4). The
are frequent), and third molars between the age of 8 and
mineralization of the first permanent molars and inci- 13 years (. Table 17.5). The completion of mineraliza-
sors (excluding the upper lateral) begins roughly at birth, tion of the crown takes about 5–7 years, while the roots
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432 N. Kotsanos et al.
require about equal time, with the pace of mineraliza- ing the stages of the mineralization of the teeth in the
tion and ultimately its duration being greater in the teeth panoramic radiograph is useful in calculating dental age.
formed later (like the second molars and premolars).
Girls are usually about 6 months ahead of boys in
completing mineralization of the teeth. The figure show- 17.2.2 Clinical and Histological
Appearance, Etiology, and Diagnosis
a b A detailed clinical examination and history-taking help
diagnose the type of dental defect and deliver appropri-
ate treatment, possibly by multi-disciplinary approach
with other health professionals if a systemic disorder is
suspected (. Table 17.6).
a b
17
.. Fig. 17.24 a Photomicrograph of hard longitudinal tooth section showing the neonatal line (NNL) [54]. (By permission). b Drawing of
human primary incisor showing the neonatal line (P pulp, D dentin, E enamel)
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433 17
.. Fig. 17.25 The chronology
14
of the formation/mineralization
of all teeth (except for the third 12
permanent molars) appears on 10
the left (in months) for primary 32 8
teeth and on the right (in years) 24 6
for permanent teeth (0 is birth
16 4
time). The curved lines on the
.. Table 17.4 The chronology of mineralization and eruption of the primary teeth
.. Table 17.5 The chronology of mineralization and eruption of the permanent teeth
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434 N. Kotsanos et al.
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435 17
.. Table 17.6 (continued)
Shields type Multiple pulp exposures in the deciduous DSPP (AD) Dentin sialophos- 125,500
I-DGI-III teeth phoprotein
(Brandywine Bell-shaped permanent teeth
isolate) [ 59] Early abscess
Shell teeth
Dentin dysplasia Permanent and deciduous teeth crowns SMOC2 (AD) – 125,400
type I (DD-I) [ 60] have normal shape and color in most
cases
Diminished root development with
unusual mobility and early exfoliation
Periapical radiolucencies in non-carious
teeth
Dentin dysplasia Dentin dysplasia II is distinguished from DSPP (AD) Dentin sialophos- 125,420
type II (DD-II) [61] DGI-II because the permanent teeth are phoprotein
normal in color but show “thistle-tube
pulp chambers” and pulp stones on
radiographs
Cementum
hypoplasia
Tricho-dento- Taurodontism DLX3 (AD) Transcription factor
osseous (TDO) Enamel hypoplasia
syndrome [62] Kinky, curly hair at birth
Increased thickness and density of the
cranial bones
Amelogenesis Hypomaturation-hypoplastic AI type DLX3 (AD) Transcription factor 104,510
imperfecta (type IV; Taurodontism
AI4) [63]
Cleidocranial Supernumerary teeth RUNX2 Transcription factor 119,600
dysplasia [64] Impaired eruption
Deficient bone and cementum
Formation
Epidermolysis Enamel hypoplasia PLEC1 Intermediate 226,650
bullosa (several) Cementum dysplasia COL17A1; LAMA3; filament-binding 226,670
Taurodontism LAMB3; LAMC2; Components of 226,700
ITGB4 hemidesmosomes 226,730
Hypophosphatasia Increased urine phosphoethanolamine ALPL Membrane enzyme 241,510
[65] bowing of long bone that converts
Bony fractures pyrophosphate to
Cementum hypoplasia or aplasia phosphate
Premature exfoliation of primary teeth
(around age 3–4 years old)
Cementum
hyperplasia
Gnathodiaphyseal Various amounts of cementum-like ANOCTAMIN 5;(ANO5) 166,260
dysplasia calcified mass are found in x-rays
Cemento-osseous It is a benign condition of the jaws that Unknown
dysplasia may arise from the fibroblasts of the
periodontal ligaments it is most common
in African-American females
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insult occurs at the initial formation phase of the organic searching for similar defects in first-degree relatives may
substrate of the enamel, it can cause hypoplasia, i.e., quan- be very useful for diagnosis [66].
titative deficit of enamel. The enamel can be thinner or A single-affected tooth usually signifies a local cause,
of relatively normal thickness but with pits or grooves. a group of symmetric teeth affected a systemic envi-
If it affects mineralization, either initial or late stage, the ronmental (chronological) one, and when whole denti-
result would be hypomineralization or hypomaturation, tions are affected (primary and permanent) signifies a
respectively, i.e., qualitative defect of enamel with loss of genetic cause. Systemic defects of environmental origin
its translucency. In hypomineralization there is usually a often involve the enamel as the ameloblasts are consid-
more severe deficiency in minerals than in hypomaturation ered sensitive to low oxygen pressure and to high body
resulting in softer less protective enamel. temperature. At birth, for example, the normal but sud-
The opacities may be diffuse or well demarcated. den change in diet and oxygenation is being recorded in
Literally speaking, these terms are clinical as they are enamel – and dentin – of primary teeth with the neo-
observed visually, while the terms hypomineraliza- natal line. Difficult or premature birth/low birth weight
tion and hypomaturation are histological ones despite of the infant might cause accentuation of that line [67].
they are often being used interchangeably. The DDE Clinically apparent developmental dental defects
(Developmental Defects of Enamel) Index was pro- caused by environmental reasons may occur throughout
posed by the International Dental Federation (FDI) to the course of tooth formation, before, during, and after
distinguish and epidemiologically record these develop- birth. After the age of 7, mineralization and maturation
mental defects of enamel, namely, 1) hypoplasia, 2) dif- of all crowns are expected to be complete, apart from the
fuse opacities, and 3) demarcated opacities. There are third molars (. Fig. 17.25). When the causes are systemic,
however other means or indices for classifying some there would usually be relatively symmetrical defects in all
defect entities like amelogenesis imperfecta or molar teeth developing during the time of the insult. When the
incisor hypomineralization (see later in the chapter). causes are local, they involve a single region or a single
Histological examination with a polarizing micro- tooth. If the cause, either systemic or local, acts for a given
scope shows that the appearance of hypomineralized period, it may affect only a part of the crown of the tooth.
enamel under the microscope is not very different than Knowing the time of the formation of all teeth, a clinician
enamel demineralized by the carious process, i.e., it is can figure out the time and inquire for the specific cause.
porous and opaque. Thus, other clinical characteristics
like the topography are important for differential diag- zz Molar Incisor Hypomineralization (MIH)
nosis. Hypomineralization opacities may be white or Molar incisor hypomineralization (MIH) affects the
yellowish to brown. Discoloration may increase in time, enamel of one or more first permanent molars and usu-
due to degradation of the organic components and/or ally the incisors, too. MIH is the most common qualita-
the influx of pigments from the oral environment. After tive, developmental disorder of the enamel. The crown
tooth eruption, severely hypomineralized enamel may of the first permanent molar erupts with irregular, well-
be broken down by mastication forces (post-eruptive demarcated, opaque discolored areas (hypomineralized
breakdown). This is an acquired finding and may not enamel). At the time of eruption, the tooth surface is
be mistaken as hypoplasia. The distinction is based on believed to be intact. With time, depending on the sever-
the rounded defect boundaries in the case of hypopla- ity of hypomineralization, progressive discoloration
sia. Opaque enamel adjacent to a hypoplastic defect is and/or post-eruptive breakdown (PEB) of enamel may
17 not uncommon and indicates more lasting disturbance, occur [68, 69] (. Fig. 17.26). The consequent increased
initiated at the formation stage of enamel. plaque accumulation often causes severe caries, leading
The medical history is important for diagnosis of to rapid crown destruction.
developmental disturbances, i.e., maternal health dur- In the past high caries era, molars with severe MIH
ing pregnancy, perinatal period events, and child health became heavily carious very quickly, often resulting in
in the infantile period. Any disturbance, like high fever, extraction. Diagnosis was difficult and escaped attention
sickness, or use of certain drugs, can be a contributing (. Fig. 17.27), but, as the prevalence of dental caries in
factor to the defect, if it disturbs ameloblast function children and adolescents became significantly reduced,
and mineralization, so the child’s medical history should MIH came to be easily recognized. Epidemiology finds
also be accurately recorded. Type of birth, full term or prevalence varying greatly throughout the countries
premature birth, whether intubation was necessary, between 3.5 and 40% with a mean world average of
complications during childbirth, breastfeeding, fluoride 14.2%, as suggested by a meta-analysis [70]. The high-
supplementation, and past serious illnesses or high fever est has reported in countries of Northern Europe and
are important notes of history-taking. Radiographic Brazil, but this is constantly updated as new reports
findings, other relevant findings in the hair or nails, and are increasingly published (. Fig. 17.28). Most cases
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Developmental Defects of the Teeth and Their Hard Tissues
437 17
are mild, and more severe forms of MIH with enamel The typical appearance of MIH involves mainly
breakdown accounted for 13% in 8-year-olds and signif- the first permanent molars and, in at least half of the
icantly more, i.e., 35%, in 14-year-olds of all MIH cases cases, the permanent incisors. These 12 teeth are fre-
in one of those studies [69]. quently mentioned as the index teeth for MIH. The
lesions in incisors cause mostly aesthetic concerns
a b and present breakdown infrequently. Those in the
molars can cause significant destruction, pain, and
functional problems. Microscopically the pulp shows
signs of hyperemia and mild inflammation, probably
due to the invasion of bacteria and bacterial prod-
ucts through the porous enamel and via the dentinal
tubules [71]. These histological findings in the pulp
might explain the intense sensitivity of the affected
teeth to thermal and osmotic stimuli, which tend
to drive children to avoid brushing, reinforcing the
vicious caries cycle, and are responsible for the dif-
ficulties in reaching adequate anesthesia levels during
restoration.
c
Eye Catcher
the potential to become severe with time). b Severe MIH at newly rare, opacities often appear less well demarcated in
erupted molar with breakdown becoming carious. c Demarcated premolars and second permanent molars [73].
white opacity (mild form) in a central incisor. MIH severity of the
child is determined by the worst affected tooth
.. Fig. 17.27 Three mandibular molars of this 8-year-old with severe MIH have become heavily carious. The same is true for one of the
hypomineralized second primary molars (HSPM)
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438 N. Kotsanos et al.
.. Fig. 17.28 Histogram based on MIH prevalence reports in the literature until 2013. In some countries a second or third study (in red and
green, respectively) had been conducted with the majority of studies being in European countries (left half of the horizontal axis) until that time
a b c d
.. Fig. 17.29 a, b Hypomineralized primary molars and caries. lary second permanent molar. d Mandibular second permanent
Radiolucent dentinal lesions on both mandibular right molars are molar with severe MIH-type lesion with breakdown-driven carious
due to caries, but the clinical view suggests lesions are developed on cavity while at an eruption process
a HSPM background. c Brown opacity (still mild MIH) in a maxil-
17
Histologically, the lesions usually involve the entire albumin entrapment, which blocks normal enamel pro-
thickness of the enamel (. Fig. 17.31). Therefore,
tein removal for uneventful replacement by mineral [75],
unless very mild, they cannot be removed by superficial but this is still open to further research. Causative fac-
(micro-)abrasion. The hardness of the porous enamel is tors have not been fully clarified. Among those impli-
significantly reduced, with rods appearing thinner and cated are premature birth and low birth weight, birth
with empty spaces between them in scanning electron complications and cesarean section, mother illness at
microscope [74]. Despite the systemic nature of the late pregnancy, early childhood diseases especially in the
disease, the lesions are not characterized by symmetry respiratory system in combination with high fever epi-
as they affect from one to four molars with defects of sodes, administration of amoxicillin, varicella, exposure
various sizes and in different tooth locations [68]. Con- to bisphenol A during pregnancy, and late introduc-
sidering the period of formation/mineralization of the tion of gruel [76]. A genetic component involving gene
enamel, causative factors of typical MIH should act expression during dental enamel formation or affect-
mainly during the perinatal period or in the first year ing the immune response cannot be ruled out, while no
of life (. Fig. 17.32). The etiology is primarily environ-
explanation has yet been offered for the asymmetrical
mental, and a proposed mechanism incriminates serum clinical presentation of MIH.
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Developmental Defects of the Teeth and Their Hard Tissues
439 17
.. Fig. 17.30 Per tooth 140
prevalence and severity of White opacity yellow/brown opacity
MIH-type opacities in all 120 poster uptive breakdown atypical restoration
permanent teeth of 14-year-old atypical extraction
adolescents. [73] (By permission) 100
80
60
40
20
0
17 16 15 14 13 12 11 21 22 23 24 25 26 27
47 46 45 44 43 42 41 31 32 33 34 35 36 37
0
20
40
60
80
100
120
140
a b
.. Fig. 17.31 a Longitudinally split surface of MIH molar. Areas of enamel hypomineralization are more opaque and extend in its full
depth being absent in the cervical area. b Similar appearance of HSPM mainly in its occlusal enamel. [74] (By permission)
zz Restoration of Teeth with MIH sealants in occlusal fissures, despite the reduced reten-
Older studies reporting MIH restorative outcomes tion expected in molars with MIH [79]. The applica-
reported that children with MIH had a tenfold chance tion of 5% NaOCl rinse to remove part of the organic
of restorative needs in their first permanent molars and content of hypomineralized enamel before etching does
three times more chance of repeated treatment in the not appear to increase the tag length of resin sealant
same teeth [77]. A treatment plan should respect the [80], while the use of adhesive agents before the sealant
severity level; mild MIH may be treated by remineraliza- application seems to increase its retention [79]. In cases
tion or sealants, and severe MIH requires restorations where breakdown of severely hypomineralized enamel
or crowns [77, 78]. Thus, in mild cases, monitoring and is observed or anticipated, the extent of its removal at
preventive programs are sufficient, including placing cavity preparation poses a dilemma. A good clinical
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440 N. Kotsanos et al.
.. Fig. 17.32 Typical severe MIH in an 8-year-old boy. The mother tion started prenatally – are more resistant to breakdown than the
had prolonged labor with full-term birth complications. It is remark- rest of the enamel. Incisors have a mild form, so far
able that cusp tips of the first permanent molars – where mineraliza-
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Developmental Defects of the Teeth and Their Hard Tissues
441 17
a b c
.. Fig. 17.35 a, b An 11-year-old boy with severe MIH in the man- permanent molars justifies a decision to extract the affected first
dibular first molars, one with endodontic needs and normal relation molars. c Complete eruption of mandibular permanent teeth in
of incisors. The recent formation of bifurcation of mandibular sec- 18 months. Persisting spaces may be managed with orthodontic
ond permanent molars together with the existing developing third treatment
a b
and appropriate shade of resin composite produces usu-
ally good aesthetic results (. Fig. 17.36), while micro-
toms of non-cariogenic pulp inflammation or necrosis. ate cases, superficial enamel is worn away in time by
These teeth often become mobile and lost early; if not, occlusal forces. This may be mimicked in the dental
their malformed roots rarely can be successfully treated clinic for aesthetic purposes. The fluorosis severity is
endodontically. No treatment other than their extrac- classified into five to nine categories according to vari-
tion seems appropriate, as MIM is typically seen early ous existing indices (Dean, TSIF, TFI, etc.) [87]. The
in panoramic radiographs when molar space closure is pathogenic mechanism of fluorosis also involves other
still possible. factors such as matrix metalloproteinases (MMPs)
mentioned also in the mechanism of amelogenesis
zz Enamel Fluorosis imperfecta.
Fluoride (F) has led to significant reduction in den- Severe fluorosis occurs after chronic ingestion
tal caries incidence in the previous decades world- of water containing much higher than the desired
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442 N. Kotsanos et al.
a b
.. Fig. 17.37 a Maxillary incisors with demarcated white opacities. b The centrals were treated with microabrasion (scrubbing the affected
areas with slurry of 18% hydrochloric acid and pumice) and additional resin infiltration in the right one
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Developmental Defects of the Teeth and Their Hard Tissues
443 17
a b
.. Fig. 17.39 a Mild enamel fluorosis of an adolescent (TFI = 1–2). about 2 ppm fluoride during her preschool years. Points of break-
Even in the recommended concentration of artificially fluoridated down are seen in the superficial enamel (TFI = 5), while the discolor-
water, 10% of the children may present mild fluorosis. b Moderate ation is acquired, attributed to pigment penetration (TFI,
fluorosis (TFI = 4–5) in a young woman after drinking water with Thylstrup-Fejerskov index of fluorosis)
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444 N. Kotsanos et al.
a b
c d
17
.. Fig. 17.41 a Severe enamel hypomineralization of a toddler aged lary canine is primary). d Chronological enamel hypoplasia of an
16 months with a history of premature birth at 25 weeks of preg- 8-year-old girl with a history of meningococcal septicemia in the age
nancy. b Chronological enamel hypoplasia of a 10-year-old with a of 10 months. e The unilateral full-depth enamel hypoplasia of a
history of hypoparathyroidism diagnosed soon after birth. c Chron- newly erupted second permanent molar could be attributed to the
ological enamel hypoplasia of an 11-year-old girl with no recorded young patient’s medical history of severe respiratory infection at age
history. It is proposed that the insult occurred during the first year of 3 years
life, and it did not affect the upper lateral incisors (intact left maxil-
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Developmental Defects of the Teeth and Their Hard Tissues
451 17
gene) transmission [119] associated with major microdon- eruption is usually delayed, or they do not erupt at all.
tia, oligodontia, and tooth shape abnormalities. The prev- Following eruption, local infections of the alveolar bone
alence is rare (1:100,000). DD type II may resemble DGI are frequently observed [122]. In favorable cases full
type II radiographically and clinically in the permanent coverage could prevent pulp inflammation. Otherwise,
teeth but with milder discoloration/opalescence. Subtypes the management consists of surgical extraction of the
of the two main types have even been proposed. It is sug- dysplastic teeth and the placement of prosthesis, par-
gested that type II is caused by mutations in DSPP, the tial dentures in childhood, and implants/fixed following
largest member of SIBLING family of glycoproteins, or it adolescence (. Fig. 17.52).
dental anomaly with unclarified etiology. Recently, a may be of non-progressive or progressive nature, and,
suggestion of common genetic background with genes in the latter case, following eruption, these teeth may
involved in tooth agenesis, namely, a codon mutation of become cavitated and therefore not be recognized
the PAX9, has been put forward [121]. This disorder is as such. The term used is pre-eruptive intra-coronal
characterized by severe malformation of all dental tis- radiolucency/resorption (PEIR), suggesting that they
sues of some teeth in a certain region, seemingly having are a result of resorption of as yet unexplained cause.
affected the specific part of the dental lamina. It affects In that sense they may not belong in developmental
primary and permanent teeth in that side of the jaw, dental defects but are presented here until their etiol-
more often the maxilla, rarely crossing the midline and ogy is clarified. Their presence has been associated
even more rarely affecting both jaws. The affected teeth with unfavorable tooth position or eruption path.
have radiographically a “ghost tooth” appearance. Their Their prevalence is reported as about 3%, but this
varies greatly in studies [123].
.. Fig. 17.50 a, b The radiographs of a 20-year-old man with DGI is caused by prolonged deficiency in vita-
show pulp chamber and root canal obliteration in all teeth. c Their min D that is essential for calcium absorption and
clinical side view with brown opalescent color
a b c
.. Fig. 17.51 a Panoramic radiograph of adolescent with Dentin Dysplasia type I. Arrows show clinically caries-free molars with periapical
radiolucencies. b, c Rootless teeth erupt and are shed soon
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452 N. Kotsanos et al.
cal history. Her mother had idiopathic very short stature. The tooth This is attributed to decreased and dysplastic cementum,
will be restored as soon as it erupts to prevent pulp complications while dentin is rather normal [131]. Similar dental find-
ings have been recorded in young adults and may lead to
thus mineralization of bones and teeth [127]. Vitamin loss of the teeth.
D is absorbed from food but needs sun exposure to is a group of rare heteroge-
the skin for its activation. Rickets affects children neously inherited diseases of mucosal and epidermal
and adolescents. It is called osteomalacia in adults, bonding to the connective tissue, which are gener-
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Developmental Defects of the Teeth and Their Hard Tissues
453 17
ally characterized by blister formation in response to cial precautions, as light pressure or tension on the lips
mechanical trauma. In one of the three types in which or cheeks, for example, causes blisters. It is interesting
it mainly manifests, generalized enamel hypoplasia is a to notice that genes involve in epidermolysis bullosa
common finding. Dental treatment is difficult with spe- (AR) have also been reported as causative in hypoplas-
tic AI when transmitted as an autosomal dominant dis-
ease [132].
is a group of connective tis-
sue disorders; at least eight types are related to the syn-
thesis of collagen, mainly transmitted as an autosomal
dominant trait. The physical findings are loose joints
(including TMJ) and super elastic skin, while dental
findings include hypoplastic enamel, abnormal dentin
and tooth roots with pulp stones, and also early loss of
the teeth [133].
(autoimmune polyendocrinopathy-candi-
diasis-ectodermal dystrophy, OMIM #240300) is a rare
autosomal recessive autoimmune disease. It is due to a
.. Fig. 17.55 A 9-year-old boy with hypophosphatemia and class
III occlusion. Hypoplastic enamel is evident in all anterior teeth,
mutation in a single gene named AIRE in chromosome
permanent and primary, mostly noticeable in their incisal parts region 21q22.3. Among other ectodermal disorders,
enamel defects in both primary and permanent denti-
tions appear to be common (. Fig. 17.57). Inherited
a b
.. Fig. 17.57 A 10-year-old boy with APECED. a Enamel hypoplasia is evident in an erupting second premolar. b Drug-resistant tongue
candidiasis
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454 N. Kotsanos et al.
a b c
.. Fig. 17.58 a, b Clinical view and panoramic radiograph of a (under antibiotic coverage until prolonged bone healing) shows
7-year-old girl with osteopetrosis and neglected mouth. c One of two anomalous root with cementosis
mandibular first permanent molars removed because of infection
a b
.. Fig. 17.59 a Green discoloration of primary teeth of a 4-year- bilirubinemia. In the anterior teeth, it is evident only cervically
old girl (with manifest caries), which was operated for liver trans- because most of their crown had been formed and mineralized
plantation in the seventh month. The discoloration is due to already. b The second primary molars suggest coexistence of HSPM
55 Incorporation of drugs or dyes during mineraliza- While staining of bones is lost in a few years due to its
tion (e.g., tetracycline) remodeling, it remains permanently in the dentin. When
55 Hypoplasia/hypomineralization (e.g., some types of the teeth are exposed to light, the integrated tetracy-
AI and DI) cline becomes darker and thus unsightly (. Fig. 17.60).
cially adolescents are often concerned not only with allows dating the time of drug intake, as well as animal
discolored teeth but with the natural overall tooth color, research on bone and tooth development. Histologically
all too often asking for “tooth whitening.” it seems that tetracycline does not color the enamel as
much, but its transparency allows the discolored den-
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Developmental Defects of the Teeth and Their Hard Tissues
455 17
a a b
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456 N. Kotsanos et al.
b c
.. Fig. 17.62 Bleaching methods with trays. a, b At home (with carbamide peroxide 16% in transparent tray). c At the dental office (with
hydrogen peroxide 35%) with the assistance of a ZOOM lamp. (Curtesy Dr. K. Giannakopoulos)
17.4 Conclusion of the causes and differential diagnosis for each den-
tal anomaly to precisely diagnose and be able to offer
Dental anomalies have extremely complex causes and the optimal treatment to each patient. The attached
phenotypes making often clinical decisions very diffi- table aims to contribute toward a successful differen-
cult for general, pediatric, and other dental specialists. tial diagnosis and provide useful clues for treatment
It is imperative for dentists to acquire a good knowledge (. Table 17.8).
17
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457 17
.. Table 17.8 Differential diagnosis and clinical decision guidance for dental anomalies
Selected 1. MSX1: No significant difference between the number of teeth missing The dentist is expected to order
non-syndromic on the left and right; the absence of maxillary first premolars is the most genetic tests: [142]
familial tooth distinguishing feature of an MSX1 mutation [141] 1. Defects are often first discovered
agenesis 2. PAX9: No significant difference between the number of teeth missing by the dentist
on the left and right; the absence of the second molars is the most 2. Can be associated with cancer
distinguishing feature of PAX9 mutations 3. The list of candidate genes is
3. AXIN2: Incisor agenesis and colorectal cancer or precancerous lesions short: WNT10, LRP6…
of variable types
Syndromic 1. Ectodermal dysplasia (EDA, EDAR, EDARΑDD): Abnormalities of two Because dental treatment is complex;
oligodontia or ectodermal structures such as the hair, teeth, nails, sweat glands, a multi-disciplinary approach is best
(most likely salivary glands, cranial-facial structure, and digits. Frontal bossing, longer Children may need dentures as early
candidates) or more pronounced chins, and broader noses are very common [143] as 2 years of age
2. Achondroplasia (FGFR3): Disproportionate short stature, shortening of Multiple denture replacements are
the proximal limbs, short fingers and toes with trident hands, and often needed as the child grows, and
intelligence are generally normal [144] dental implants may be an option in
3. Incontinentia pigmenti (IKBKG): Development of harder skin growths late adolescence or adulthood, once
with grey or brown patches. Hair loss (alopecia), dental abnormalities, the jaw is fully grown
eye abnormalities that can lead to vision loss, and lined or pitted finger- Orthodontic treatment may also be
nails and toenails. Mainly affects males (X-linked) necessary
4. Orofaciodigital syndrome-I (OFD1): Malformations of the face, oral
cavity, and digits with polycystic kidney disease and variable involve-
ment of the central nervous system. X-linked (males) [145]
5. Robin sequence (SOX9): A sequential chain of signs that start with
micrognathia, followed by retraction of the tongue (glossoptosis) and
upper airway obstruction. U-shaped cleft palate is very common [146]
6. Rieger syndrome (PITX2, FOXC1): Mild craniofacial abnormalities,
and various abnormalities of the eye, especially glaucoma [147]
Supernumerary teeth/hyperdontia
Non-syndromic Mostly single or double supernumeraries, results in crowding, delayed Rare in relation to syndromic
supernumerary eruption, diastema, rotations, cystic lesions, and resorption of the
teeth adjacent teeth
Syndromic 1. Cleidocranial dysplasia (RUNX2): Clavicles are poorly developed or There are several treatment strategies
hyperdontia absent so the shoulders are brought close together, supernumerary to treat CCD
(most likely teeth, enamel-dentin hypoplasia, delayed teeth eruption, bone Dental practitioners’ awareness for
candidates) hypoplasia clinical/radiological characteristics of
2. Gardner’s syndrome (APC): Adenomatous polyps of the gastrointesti- Gardner’s syndrome; early detection
nal tract which usually undergoes malignant change by the fourth of associated polyps could be
decade. Mandibular lesion consisting of clumped toothlets [147–150] lifesaving
Enamel defects
AI variants Type I (AMELX/ENAM): Hypoplastic, thin enamel. Enamel on the Subjects with AI regardless of the
cervical 1/3 of the crowns is usually most severely affected, and horizontal variant showed accelerated dental
groves of severely hypoplastic enamel could be evident age [151]
Type II (MMP20/KLK4/WDR72/C4orf26/ SLC24A4): Hypomaturation, There is a sixfold increase in
softer enamel with normal thickness. The enamel has a milky to shiny tendency of AI patients to show
agar-brown color in newly erupted teeth but may become more deeply impaction of the permanent teeth
stained in contact with exogenous agents; it tends to chip away and associated anomalies such as
Type III (FAM83H): Hypocalcified. The enamel has a cheesy consistency follicular cysts
and can be scraped from the dentin with a dental explorer. Newly erupted Forty-two percent of AI patients
teeth are covered with a dull, opaque white honey-colored or yellow- presented with skeletal and/or dental
orange-brown enamel open bite compared to 12% in
Type IV (DLX3): Hypomature hypoplastic enamel with taurodontism. unaffected family members
Enamel has a variation in appearance, with mixed features from type 1
and type 2 AI. All type 4 AI have taurodontism in common
Dental fluorosis Mottled teeth: Early stage or mild (opaque, white spots, narrow white
lines following the perikymata) and late stage or severe (enamel appears
yellowish and pitted with white-brown lesions that look like cavities) [152]
(continued)
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Fraser GJ, Bloomquist RF, Streelman JT. Common develop-
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144. Horton WA, Hall JG, Hecht JT. Achondroplasia. Lan-
Schinke T, et al. A novel ANO5 mutation causing gnathodi-
cet. 2007;370(9582):162–72. https://doi.org/10.1016/S0140- aphyseal dysplasia with high bone turnover osteosclerosis. J
6736(07)61090-3. Bone Miner Res. 2017;32(2):277–84. https://doi.org/10.1002/
145. Gurrieri F, Franco B, Toriello H, Neri G. Oral–facial–digi- jbmr.2980.
tal syndromes: review and diagnostic guidelines. Am J Med 159. Alsufyani NA, Lam EW. Osseous (cemento-osseous) dyspla-
Genet A. 2007;143(24):3314–23. https://doi.org/10.1002/ sia of the jaws: clinical and radiographic analysis. J Can Dent
ajmg.a.32032. Assoc. 2011;77:b70.
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Contents
References – 472
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466 N. Kotsanos and D. Birkhed
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Tooth Wear in Children and Adolescents
467 18
a understandably, does not correlate with age [17]. The
most frequently affected tooth surfaces of attrition both
in children and adults are the occlusal surfaces of molars
and the incisal edges of anterior teeth by being the prime
surfaces subject to the function of mastication
(. Figs. 18.4 and 18.5).
b
Eye Catcher
cal factor [14]. The combination of these processes can vent severely worn teeth in such children include restora-
cause synergistic results (. Fig. 18.3), as the softer
tion of occlusal surfaces of primary or permanent teeth
enamel and dentin after an erosive acid attack are more with composite or preformed metal crowns.
prone to abrasion by an immediate brushing action [15].
Such effects are more obvious in some enthusiastic
brushers in adolescence. 18.3 Dental Erosion
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468 N. Kotsanos and D. Birkhed
b c
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Tooth Wear in Children and Adolescents
469 18
a
newer index (BEWE, Basic Erosive Wear Examination, .. Fig. 18.7 a Erosive tooth wear in a 15-year-old admitting overus-
which does not evaluate wear depth but measures ero- ing lemon in his diet. Maxillary central incisors present glossy sur-
sive tooth wear semi-quantitatively by its extent on face with obvious enamel thickness reduction. b Incisal view of
thinness
tooth surfaces), recorded erosion in 65% of primary
teeth of 8-year-olds and in 37% of permanent teeth of
14-year-olds [36]. small amount of phosphate and fluoride) in juices
may reduce their erosive potential [45].
2. Medicines: Several studies have discussed the use of
18.3.2 Aetiology of Dental Erosion various medicines and their role for causing dental
erosions in primary and permanent teeth [46–48].
The aetiological factors for dental erosion can be divided One factor to take into consideration is the length of
into those of extrinsic and intrinsic origin. the treatment and the intake frequency of the drug.
Thus, a causal relationship has been found for the
18.3.2.1 Extrinsic Factors frequent use of acetylsalicylic acid (aspirin) that is
1. Diet: The parameter of diet has been the most exten- used in the treatment of juvenile rheumatoid arthri-
sively studied factor regarding dental erosion. There tis as well as for ascorbic acid (vitamin C) [49, 50].
are several reviews on the influence of diet on tooth Both positive [51] and negative relationships [52]
erosion prevalence in children and adolescents [37– with erosion have been reported with asthma inhala-
39]. Overconsumption of acidic drinks (soft drinks tion drugs.
and fruit juices), citrus fruits and lemon or vinegar is 3. Behaviour factors: There are some factors related to
the most common aetiological factor (. Fig. 18.7). diet and particularly to drinking habits that can affect
Despite the wide variation among populations – in the erosion risk, such as swishing or retaining the soft
1995 one in ten US students consumed at least four drink, lemon or citrus fruits in the mouth before
soft drinks daily [40] and in 2001 in Britain at least swallowing [53]. Other patient- related factors are
three soft drinks daily [41] – children generally con- intake frequency, lifestyle and oral hygiene [54]. It is
sume more soft drinks and juices than adults. In Brit- not clear how socioeconomic status affects the preva-
ain, 2/5 of fruit drinks are consumed by children up lence of dental erosion. Most studies show a positive
to 9 years old [42]. The soft drink consumption has association with low socioeconomic status, but there
been tripled in the USA in the last 20 years of the are also some studies showing the opposite. A Chi-
past century [43]. The acidity of some popular drinks nese study in particular found that preschool children
aimed at young people ranges from pH = 2.6 (Coca- of higher socioeconomic status (higher parent educa-
Cola, Sprite) and 3.0 (ice tea) to 3.4 (Red Bull) [44]. tional level) drank more fruit juices daily [29]. When
Except for the acidity, the erosive potential of a bev- comparing factors potentially related to the occur-
erage depends on its inorganic content, its resistance rence of dental erosion in high- and low-erosion
to pH neutralization (buffer capacity) and possibly groups of young Saudi men, it was found that drink-
other chemical properties. At the same acidity levels, ing habits was a significant factor [55]. Moreover, the
citric acid causes more erosion in vitro than phos- contact time between the tooth and the acid may be a
phoric acid [44], while the addition of calcium (and a more important risk factor for dental erosions com-
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470 N. Kotsanos and D. Birkhed
The clinical examination includes inquiring for dietary mary molars and palatal or labial surfaces of upper
habits, tooth brushing method, other habits, presence of anterior teeth [34, 35]. This is associated with the pre-
GERD and estimation of salivary secretion rate and dominant erosive factor, e.g. GERD or frequent con-
buffer capacity. Diagnosis is based on visual examina- sumption of acidic products. In advanced stages, dentin
tion because all types of dental wear occur in clinically exposure can be observed (. Fig. 18.10). Depending on
accessible surfaces. A relatively early finding of erosive the prime aetiological and contributing factors, this may
tooth wear is the glossy appearance due to loss of sur- be in the palatal surface of anterior teeth or the occlusal
face structure (perikymata) of the enamel. A frequent surfaces of posterior teeth, starting with cupping in the
later finding is an increased incisal edge transparency of cusp tips (. Fig. 18.6). Generally, the early stages of
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Tooth Wear in Children and Adolescents
471 18
a proved wrong, revealing the difficulties in identifying
true depth or lesions [65].
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472 N. Kotsanos and D. Birkhed
a b
c d
.. Fig. 18.11 a Erosive tooth wear of a young female needing resto- Final restorations of the six maxillary anterior teeth. (Courtesy Dr.
ration. b Initial reduction of labial tooth surfaces using a special bur P. Gerasimou)
with depth guide. c Near-final preparations for porcelain veneers. d
because they are susceptible to erosion too [75, 76], 2. Carvalho TS, Lussi A, Jaeggi T, Gambon DL. Erosive tooth
although resin-modified glass ionomers are likely be wear in children. Monogr Oral Sci. 2014;25:262–78.
3. Johansson AK, Omar R, Carlsson GE, Johansson A. Dental
more durable and suitable. In severely worn anterior erosion and its growing importance in clinical practice: from
teeth except for composite resin restorations with cellu- past to present. Int J Dent. 2012;2012:632907.
loid matrix (strip crown), porcelain veneers can be used 4. Ganss C. Is erosive tooth wear an oral disease? Monogr Oral Sci.
at the end of adolescence (. Fig. 18.11). There is no
2014;25:16–21.
data available about their longevity, other to limited evi- 5. Ganss C, Lussi A. Diagnosis of erosive tooth wear. Monogr Oral
Sci. 2014;25:22–31.
dence in teeth with caries or crown fractures. 6. Xhonga FA. Bruxism and its effect on the teeth. J Oral Rehabil.
There have been many publications lately on the 1977;4:65–7.
management of tooth wear with crowns and indirect 7. Dyer D, Addy M, Newcombe RG. Studies in vitro of abrasion by
restorations [77–81]. The conclusions from these litera- different manual toothbrush heads and a standard toothpaste. J
18 ture reviews are that there is no strong evidence to sug- Clin Periodontol. 2000;27:99–103.
8. Addy M, Hunter ML. Can tooth brushing damage your health?
gest that any material is better than another. Direct or Effects on oral and dental tissues. Int Dent J. 2003;53(Suppl
indirect materials may be feasible options to restore 3):177–86.
severely worn teeth. However, most of these reviews are 9. Philpotts CJ, Weader E, Joiner A. The measurement in vitro of
focusing on rehabilitation of severely worn teeth in enamel and dentine wear by toothpastes of different abrasivity.
adults and very few on younger individuals. Int Dent J. 2005;55:183–7.
10. Schemehorn BR, Moore MH, Putt MS. Abrasion, polishing,
and stain removal characteristics of various commercial denti-
frices in vitro. J Clin Dent. 2011;22:11–8.
References 11. Hunter ML, West NX, Hughes JA, Newcombe RG, Addy
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Creugers NH, Bartlett DW. Systematic review of the prevalence 12. Amaechi BT, Higham SM. Eroded enamel lesion remineraliza-
of tooth wear in children and adolescents. Caries Res. tion by saliva as a possible factor in the site-specificity of human
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13. Grippo JO. Abfractions: a new classification of hard tissue
34. Jaeggi T, Lussi A. Prevalence, incidence and distribution of ero-
lesions of teeth. J Esthet Dent. 1991;3:14–9. sion. Monogr Oral Sci. 2006;20:44–65.
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Monogr Oral Sci. 2006;20:190–9. sanos N. Erosive tooth wear and related risk factors in 8- and
15. Attin T, Siegel S, Buchalla W, Lennon AM, Hannig C, Becker 14-year-old Greek children. Caries Res. 2016;50:
K. Brushing abrasion of softened and remineralised dentin: an 349–62.
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16. Lambrechts P, Braem M, Vuylsteke-Wauters M, Vanherle
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17. Bartlett D, Dugmore C. Pathological or physiological erosion--is 37. Salas MM, Nascimento GG, Vargas-Ferreira F, Tarquinio SB,
there a relationship to age? Clin Oral Investig. 2008;12(Suppl Huysmans MC, Demarco FF. Diet influenced tooth erosion
1):S27–31. prevalence in children and adolescents: results of a meta-analy-
18. Kaifu Y. Changes in the pattern of tooth wear from prehis- sis and meta-regression. J Dent. 2015;4:865–75.
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19. Okura K, Shigemoto S, Suzuki Y, Noguchi N, Omoto K, Abe S, 39. Lussi A, Jaeggi T, Zero D. The role of diet in the aetiology of
Matsuka Y. Mandibular movement during sleep bruxism dental erosion. Caries Res. 2004;38(Suppl 1):34–44.
assoc ated with current tooth attrition. J Prosthodont Res. 40. American Academy of Pediatrics, Committee on School Health.
2017;61:87–95. Soft drinks in school. Pediatrics. 2004;113:152–3.
20. Jonsgar C, Hordvik PA, Berge ME, Johansson AK, Svensson P, 41. Al-Dlaigan YH, Shaw L, Smith A. Dental erosion in a group of
Johansson A. Sleep bruxism in individuals with and without British 14-year-old school children. Part II: influence of dietary
attrition-type tooth wear: an exploratory matched case-control intake. Br Dent J. 2001;190:258–61.
electromyographic study. J Dent. 2015;43:1504–10. 42. Rugg-Gunn AJ, Lennon MA, Brown JG. Sugar consumption in
21. Insana SP, Gozal D, McNeil DW, Montgomery-
Downs the United Kingdom. Br Dent J. 1986;161:359–64.
HE. Community based study of sleep bruxism during early 43. Cavadini C, Siega-Riz AM, Popkin BM. US adolescent
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22. Peres AC, Ribeiro MO, Juliano Y, César MF, Santos RC. Occur- 2000;83:18–24.
rence of bruxism in a sample of Brazilian children with cerebral 44. Lussi A, Jaeggi T. Chemical factors. Monogr Oral Sci.
palsy. Spec Care Dentist. 2007;27:73–6. 2006;20:77–87. West NX, Hughes JA, Addy M. The effect of pH
23. Rios D, Magalhães AC, Honório HM, Buzalaf MA, Lauris JR, on the erosion of dentine and enamel by dietary acids in vitro. J
Machado MA. The prevalence of deciduous tooth wear in six- Oral Rehabil. 2001;28:860–4.
year-old children and its relationship with potential explanatory 45. Barbour ME, Parker DM, Allen GC, Jandt KD. Human enamel
factors. Oral Health Prev Dent. 2007;5:167–71. erosion in constant composition citric acid solutions as a func-
24. Seligman DA, Pullinger AG, Solberg WK. The prevalence of den- tion of degree of saturation with respect to hydroxyapatite. J
tal attrition and its association with factors of age, gender, occlu- Oral Rehabil. 2005;32:16–21.
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25. Nunn JH, Gordon PH, Morris AJ, Pine CM, Walker A. Dental substances and medications on deciduous teeth. PLoS One.
erosion - changing prevalence? A review of British National chil- 2015;10:e0143957.
drens' surveys. Int J Paediatr Dent. 2003;13:98–105. 47. Hellwig E, Lussi A. Oral hygiene products, medications and
26. Schlueter N, Luka B. Erosive tooth wear - a review on global drugs - hidden aetiological factors for dental erosion. Monogr
prevalence and on its prevalence in risk groups. Br Dent J. Oral Sci. 2014;25:155–62.
2018;224:364–70. 48. Scatena C, Galafassi D, Gomes-Silva JM, Borsatto MC, Serra
27. Isaksson H, Birkhed D, Wendt LK, Alm A, Nilsson M, Koch MC. In vitro erosive effect of pediatric medicines on deciduous
G. Prevalence of dental erosion and association with lifestyle tooth enamel. Braz Dent J. 2014;25:22–7.
factors in Swedish 20-year olds. Acta Odontol Scand. 49. Sullivan RE, Kramer WS. Iatrogenic erosion of teeth. J Dent
2014;72:448–57. Child. 1983;50:192–6.
28. Mulic A, Tveit AB, Skaare AB. Prevalence and severity of dental 50. Asher C, Read MJ. Early enamel erosion in children associated
erosive wear among a group of Norwegian 18-year-olds. Acta with the excessive consumption of citric acid. Br Dent J.
Odontol Scand. 2013;71:475–81. 1987;162(10):384–7.
29. Luo Y, Zeng XJ, Du MQ, Bedi R. The prevalence of dental ero- 51. Al-Dlaigan YH, Shaw L, Smith AJ. Is there a relationship
sion in preschool children in China. J Dent. 2005;33:115–21. between asthma and dental erosion? A case control study. Int J
30. Al-Malik MI, Holt RD, Bedi R. Erosion, caries and rampant Paediatr Dent. 2002;12:189–200.
caries in preschool children in Jeddah, Saudi Arabia. Commu- 52. Dugmore CR, Rock WP. Asthma and tooth erosion. Is there an
nity Dent Oral Epidemiol. 2002;30:16–23. association? Int J Paediatr Dent. 2003;13:417–24.
31. Harding MA, Whelton H, O’Mullane DM, Cronin M. Dental 53. Johansson AK, Lingström P, Imfeld T, Birkhed D. Influence of
erosion in 5-year-old Irish school children and associated fac- drinking method on tooth-surface pH in relation to dental ero-
tors: a pilot study. Community Dent Health. 2003;20:165–70. sion. Eur J Oral Sci. 2004;112:484–9.
32. Corica A, Caprioglio A. Meta-analysis of the prevalence of 54. Buzalaf MAR, Magalhães AC, Rios D. Prevention of erosive
tooth wear in primary dentition. Eur J Paediatr Dent. tooth wear: targeting nutritional and patient-related risks fac-
2014;15:385–8. tors. Br Dent J. 2018;224:371–8.
33. Tschammler C, Müller-Pflanz C, Attin T, Müller J, Wiegand 55. Johansson AK, Lingström P, Birkhed D. Comparison of factors
A. Prevalence and risk factors of erosive tooth wear in 3-6 year potentiall related to the occurrence of dental erosion in high-
old German kindergarten children – a comparison between and low-erosion groups. Eur J Oral Sci. 2002;110:
2004/05 and 2014/15. J Dent. 2016;52:45–9. 204–11.
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56. O'Toole S, Bartlett D. The relationship between dentine hyper- 69. Carvalho TS, Colon P, Ganss C, Huysmans MC, Lussi A, Schlu-
sensitivity dietary acid intake and erosive tooth wear. J Dent. eter N, et al. Consensus Report of the European Federation of
2017;67:84–7. Conservative Dentistry: erosive tooth wear, diagnosis and man-
57. Hasselkvist A, Johansson A, Johansson AK. Association
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between soft drink consumption, oral health and some lifestyle 70. Lindquist B, Lingström P, Fändriks L, Birkhed D. Influence of
factors in Swedish adolescents. Acta Odontol Scand. five neutralizing products on intra-oral pH after rinsing with
2014;72:1039–46. simulated gastric acid. Eur J Oral Sci. 2011;119:301–4.
58. O'Sullivan E, Milosevic A. UK National Clinical Guidelines in 71. Ganss C, Schlueter N, Friedrich D, Klimek J. Efficacy of waiting
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59. Bartlett D. Intrinsic causes of erosion. Monogr Oral Sci.
72. O’Toole S, Bernabé E, Moazzez R, Bartlett D. Timing of dietary
2006;20:119–39. acid intake and erosive tooth wear: a case-control study. J Dent.
60. Osatakul S, Sriplung H, Puetpaiboon A, Junjana CO, Cham- 2017;56:99–104.
nongpakdi S. Prevalence and natural course of gastroesophageal 73. Lussi A, Lussi J, Carvalho TS, Cvikl B. Toothbrushing after an
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Gastroenterol Nutr. 2002;34:63–7. 2014;122:353–9.
61. O'Sullivan EA, Curzon ME, Roberts GJ, Milla PJ, Stringer
74. Huysmans MC, Young A, Ganss C. The role of fluoride in ero-
MD. Gastroesophageal reflux in children and its relationship to sion therapy. Monogr Oral Sci. 2014;25:230–43.
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1998;106:765–9. Monogr Oral Sci. 2006;20:200–14.
62. Smith BG, Knight JK. An index for measuring the wear of teeth. 76. Johansson A, Johansson AK, Omar R, Carlsson GE. Rehabili-
Br Dent J. 1984;156:435–8. tation of the worn dentition. J Oral Rehabil. 2008;35:548–66.
63. Mulic A, Tveit AB, Wang NJ, et al. Reliability of two clini- 77. Milosevic A. Clinical guidance and an evidence-based approach
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18
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475 19
Temporomandibular Disorders
in Children and Adolescents
Linda Van den Berghe and Louis Simoen
Contents
References – 482
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476 L. Van den Berghe and L. Simoen
The content of this chapter is not intended to represent functional movements, on the other hand. The rest posi-
the extensive knowledge of the normal and pathological tion of the lower jaw is a variable position without tooth
function of the temporomandibular system. The basic contacts, depending on the momentarily orofacial mus-
aim is to help the dentist understand the basic principles cular tension status.
of normal functioning of the masticatory system [1, 2] These relationships should also be considered in the
and the extent, symptomatology, and etiology of tem- temporomandibular joint. The TMJ is often the subject
poromandibular disorders in children and adolescents, of diagnostic failure of certain signs or symptoms in the
in order to enable general practitioners to contribute to masticatory system, due to incomplete or even absent
treatment. “medical” knowledge concerning its anatomy and physi-
ological functioning. It is a specific type of joint: it is a
twin joint and contains an articular disc; it is about the
19.1 he Orofacial System: Principles
T strongest joint of the whole human body. Both units
of Occlusion and Function (condyles) move simultaneously according to their ana-
tomic features and in harmony with the occlusal or den-
The orofacial system (OFS) is the biological system of tal configuration and enable functional luxation,
an individual where physiological functions of mastica- generally throughout lifetime.
tion, swallowing, speech, and breathing are performed.
It consists of a number of elements and tissues that act
together and form functional units. The components of 19.1.1 entric Positions of the Lower Jaw
C
the OFS are: and Temporomandibular Joint
(a) The temporomandibular joints (TMJs).
(b) The maxilla or upper jaw and mandibula or lower 19.1.1.1 Maximum Intercuspation
jaw. The maxillomandibular position also known as maxi-
(c) The teeth and periodontium. mal occlusion represents the relation of both jaws with
(d) The attached muscles of mastication. existing maximal contacts of opposing occlusal surfaces.
The proprioceptive sense develops during infancy.
Functions of the OFS are neuromuscular driven, involv- Clinical reproducibility of this relation in the TMJs is
ing both the central and peripheral nervous system and doubtful and, therefore, it is never recommended to be
muscles. What we accept as normal or efficient function- used as a reference for dental reconstruction purposes.
ing of the OFS is not only determined by the mandibu-
lar movements but also by the proprioceptive control of 19.1.1.2 Centric Relation/Centric Occlusion
the spatial positions of the lower jaw. Centric relation (CR) is known as the maxillomandibu-
lar relation in the TMJ where the hinge movement or
Eye Catcher rotation of the mandible takes place, around the so-
called hinge axis, virtually connecting the center of both
In the literature and in practice, the topic dental condyles. This determination is important as it is repro-
occlusion and its role in function or dysfunction of ducible and therefore an important parameter in restor-
the masticatory system is often the subject of discus- ative dentistry, for instance, in youngsters with
sions and controversy. The variety of theories offer- oligodontia or amelogenesis imperfecta or even in eden-
ing different specific guidelines for clinical approach tulous patients. The articular condyles effortlessly hold
is confusing and, moreover, often only based on per- the rearmost, upmost, and midmost (RUM) position or
sonal clinical expertise or foundations and not always centric relation in the TMJs. This position is individu-
relying on actual scientific evidence [1, 2]. ally determined and varies according to the personal
19 anatomy of the condyles and the morphology of the gle-
noid fossa.
Maxillomandibular relationships exist as the positions or The corresponding interocclusal contact between
movements of the mandible with or without contacts of upper and lower jaws can be registered between antagonis-
the occlusal surfaces of the teeth present in the oral cav- tic premolars and molars, not in the anterior region
ity of each individual. The mandibular position with (canines and incisors), and is called centric occlusion (CO).
tooth contacts should be differentiated in a static posi- According to the epidemiologic research, in a major-
tion or occlusion and an eccentric or dynamic position ity of individuals, there is indeed a difference between
or articulation. Without dental contacts the mandibular centric and maximal occlusions, the so-called long
movements are generated with distinction between the centric occlusion. Centric and maximal occlusion can be
eccentric or border movements, on the one hand, and the similar, always showing maximal intercuspation of all
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Temporomandibular Disorders in Children and Adolescents
477 19
present teeth with the condyles in the reproducible RUM these movements are reproducible, and within these lim-
position, which is called the point centric occlusion [1, 2]. its, functional movements are developed. The latter are
highly variable, depending on the neuromuscular status
of the system.
19.1.2 Rest Position When recorded at the anterior teeth, a characteristic
three-dimensional diagram is generated known as the
Is a postural position of the mandible depending highly Posselt envelope of motion:
on the neuromuscular activation or state of the mastica- 1. In the horizontal plane, we distinguish maximal pro-
tory system. The mandible is suspended with an interoc- trusion, maximal retrusion to centric relation, and
clusal distance, the freeway space, which is supposed to maximal lateral excursions.
be maintained after dental reconstruction, but which is 2. In the frontal or coronal plane, we distinguish maxi-
also able to adapt to minimal and slow changes in the mal opening and closing in maximal intercuspation
equilibrium between elevator and depressor masticatory and maximal lateral excursions.
muscles. It cannot be considered as strictly reproducible 3. In the sagittal plane, we distinguish maximal protru-
and is mostly calculated by clinicians as an interdental sion, maximal retrusion to centric relation, and max-
space between 1 and 4 mm. It can be adversely affected imal opening and closing.
by certain emotional conditions (anxiety, depression)
and loss of teeth related to parafunctional habits or When recorded at the TMJ:
bruxism as these conditions can influence the neuromus- 1. In the horizontal projection, we distinguish the ante-
cular balance in the masticatory system. rior-posterior translation and the lateral eccentric
movements, at the working side, with the rotating
condyle making the so-called Bennet movement or
19.1.3 Eccentric Positions Bennet shift*, and at the non-working (balancing)
side, with the translating condyle following the path-
Eccentric Occlusal Positions of the Mandible (Also way of the Bennet angle.
Known as Articulation). 2. In the frontal projection, we distinguish the opening
These positions are static, with certain tooth con- movement and the lateral eccentric movements, with
tacts, depending on the occlusal or articulating type of the Bennet shift* at the working side and the path-
the individual dentition. The ideal features in the adult way of the Bennet angle at the non-working side.
dentition are: 3. In the lateral projection, we distinguish the opening
1. Lateral excursion to the working side featuring only movement with the condyle moving according to the
canines, called the canine guidance. condylar rotation around the hinge axis and followed
2. Lateral excursion to the working side with involve- by an anterior-inferior translation, following the
ment of canines, premolars, and/or molars, called a pathway of the condylar plane, making an average
group contact. angle of 30–35° with a reference horizontal line or
3. After lateral excursion, at the non-working or bal- plane.
ancing side, tooth contacts disappear and is called
the unilateral clearance. *The Bennet movement or shift of the working condyle
4. Maximal protrusion is reached with frontal or incisal is a bodily displacement and may be absent or very dis-
guidance, involving incisors and/or canines with crete.
bilateral disocclusion or clearance between premo- For extensive documentation of all these principles,
lars and molars. see Dos Santos Jr. (2007) [2].
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478 L. Van den Berghe and L. Simoen
between the ages of 12 and 16 years during the last and a lack of clinical reports on striking comorbidities
growth phase. in adults as well as in children and adolescents, e.g.,
During the function of the masticatory system (e.g., sleep or sleep breathing disorders. Nevertheless in gen-
chewing, swallowing, speech), the feature of the mobile eral, the signs and symptoms in children and adolescents
lower jaw or mandible and fixed upper jaw or maxilla, are light and variable over time in the vast majority and
the organization of the dental arches and the dental can be characterized as mild or moderate [4–9].
anatomy (shape) determine the individual ability of the Exceptionally, in some cases with rare diseases, such as
natural mandibular movements. In other words, har- juvenile idiopathic arthritis (JIA), it can progressively
mony should exist between shape and function. Careful lead to severe functional limitations and pain [10].
evaluation and registration of the individual determi- Although at an early age (5–7 years) signs and symp-
nants are mandatory in clinical practice, however with- toms of temporomandibular disorders are not usually
out overestimation as well as oversimplification of the found, some disorders can be detected in one third of
basic principles of occlusion. In biologic or anatomic children with primary teeth [4]. The existence of com-
absence of harmony or even installed disharmony (after plaints (headaches, clicking TMJ), with some of them
restorative treatment), adaptation mechanisms derive in already known by the parents, is confirmed in 36% of
the majority of the human beings; in other words, dis- children aged 7–14 years old, while 64% of those chil-
harmony not necessarily causes traumatic events, such dren apparently show also symptoms (mainly pain on
as temporomandibular pain or dysfunction. palpation of the masticatory muscles) [11, 12].
In long-term studies, signs and symptoms show great
variation in their appearance with the progress of time.
19.2 Disorders of the Orofacial System Some findings, such as clicking, seem to come and go in
an unpredictable way. Indeed, in a 10-year monitoring
Temporomandibular disorders (TMD, the term adopted of children of 7, 11, and 15 years old, no significant pro-
in 1983 by the ADA) contain a number of problems portion of unchanged signs or symptoms of TMD
involving the masticatory muscles, the TMJ, and associ- could be registered [13], while 20 years after the comple-
ated structures. This term is synonymous with the term tion of the monitoring of the same individuals, not any
craniomandibular disorders (CMD) of the OFS. The recrudescence could be found within this remarkably
American Academy of Pediatric Dentistry (AAPD) long period of time [14].
accepts in its guidelines that TMD can also be observed
in adolescents, children, or infants [3]. The role of the
general dentist is regularly underestimated as it comes to 19.2.2 Etiology
observation, detection, differential diagnosis, and treat-
ment strategies. In the majority of patients, temporomandibular disor-
ders are of multifactorial origin. A long time ago, the
dental profession associated occlusal relationships with
19.2.1 Epidemiology temporomandibular pain and dysfunction. Unfortunately,
no or little scientific evidence can be found any longer for
The prevalence of TMD signs in adults is estimated the majority of these associations as in the past only
between 30 and 50% in general population samples. assumptions were made regarding the relationship
They are the most common cause of pain of the non- between what is known, the principles of occlusion, and
odontogenic origin in the orofacial system in about 5 to what was not known, the pathophysiology of pain.
12% of the patients seeking treatment. An important Mechanistic concepts can no longer be accepted as expla-
distinction should be made between signs and symp- nation or as therapy models for pain-related disorders.
toms, on the one hand, and patients’ complaints, on the A possible etiologic factor, which can contribute to
19 other hand. the occurrence of temporomandibular disorders in chil-
The occurrence of temporomandibular disorders in dren, is trauma. Lateral or bilateral intra-articular or
children is much more difficult to map and tends to be epicondyle fractures are often the result of trauma to
lower than in adults, with an increasing trend in the sec- the chin, after falling, which is a very common finding in
ond and third decade of life. The variation in reports is childhood [15] and can eventually lead to ankylosis of
mostly due to study design concerning, among others, the maxilla [16]. In isolated cases of condylar fractures
study populations (general population or patient sam- in children, conservative treatment, using functional
ples), examination methods, and discrepancies between orthodontic appliances as activator, may result in com-
definitions and variables. Important confounders are the plete recovery of the fracture and lead to the natural
study methods and/or results from adult populations function of the TMJ and the OFS [17].
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Temporomandibular Disorders in Children and Adolescents
479 19
Oral parafunctional behaviors such as lip, cheek bit- correction of UPCB is recommended in children to
ing, thumb sucking, and abnormal posturing of the jaw reduce the physiologic adaptation demands [23, 24].
have no functional purpose, are common in all age
groups, and occasionally can have some negative effects 19.2.2.3 Does TMD Cause Malocclusion?
on the masticatory system. Nail biting and excessive Structural and developmental changes and acquired and
chewing gum use on the contrary can cause more impor- inflammatory disorders of the TMJ cause skeletal and
tant overloading of the masticatory muscles and the dental changes and frequently lead to marked facial
TMJ, compared to the negative effects of bruxism. asymmetry. This is known for unilateral condylar hyper-
plasia and osteochondroma of the condyle, together with
19.2.2.1 Bruxism condylar asymmetry and open bite, but without the emer-
In adults, bruxism is classified as either sleep bruxism, gence of functional disturbances and TMD. Idiopathic
mainly characterized by tooth grinding, or awake brux- condylar resorption causes frontal open bite but in a
ism, often characterized as tooth clenching. Both forms majority of cases without functional limitations or risk
can be found in children and adolescents, with a global of development of TMD [23].
prevalence of 8–38% [18–21]. On the contrary, idiopathic juvenile rheumatoid
The etiology of bruxism cannot be explained by arthritis (IJRA) is known to involve the TMJs (50–78%)
mechanistic concepts but is multifactorial. Its origin has and to cause arthralgia, progressive limitation of jaw
to be searched in the central nervous system. Genetic movements, destructive changes during mandibular
but also peripheral environmental factors should be growth, progressive class II, frontal open bite, and
considered as the most evident influences nowadays. arthritic condylar changes (flattening and erosions) [23].
Tooth clenching while awake can lead to masticatory Recognition before the start of orthodontic therapy is
muscle fatigue and numbness (with difficulties to open the mandatory (clinical and magnetic resonance imaging
mouth widely or chewing hard food), clicking of the TMJ, (MRI)) and should be confirmed with laboratory tests
and sometimes an uncomfortable occlusion. In other as it is an inflammatory disorder.
words, awake bruxism is a potentially higher etiologic risk
factor for the emergence of myogenous or arthrogenous 19.2.2.4 TMD and Orthodontics
symptoms of TMD in childhood and adolescence [20]. If the patient shows signs or symptoms of TMD before
Sleep bruxism will mostly do no harm in children the start of orthodontic therapy, a tailor-made treat-
concerning the teeth and the masticatory system, regard- ment plan is mandatory and should consider the demand
less the, sometimes, loud sounds produced and reported and preferences of the patient (even in adolescents, cer-
by the parents. They should always be informed about tainly in young adults) together with extensive informa-
possible non-dental comorbidities. In fact, in the litera- tion search. Timing and balance between function and
ture, sleep bruxism can be found to be associated with esthetics are important issues.
headache and sleep breathing disorders (snoring and The relationship of the occurrence of symptoms of
obstructive sleep apnea), possibly resulting in growth TMD with occlusal factors and orthodontic treatment
disturbances of the maxilla and mandible [21], sleep dis- in childhood has been the subject of controversy for a
turbances, and behavioral disorders (e.g., hyperactivity, long time. Systematic reviews and meta-analyses espe-
attention-deficit/hyperactivity disorder ADHD, fatigue, cially from the last decade are reassuring concerning the
and attention deficit at school), but evidence is still risk for developing TMD during and after orthodontic
insufficient to establish a cause-effect relationship [21]. treatment [23–28].
The same lack of evidence exists about permanent dam- Orthodontic therapy performed during adolescence
age to the dentition resulting from sleep bruxism during generally does not increase or decrease the chances of
childhood. Tooth wear of primary teeth has a low pre- developing TMD later in life. Signs and symptoms of
dictive value for wear of the permanent dentition [22]. TMD occur also in healthy individuals and can increase
with age, particularly during adolescence; thus, TMD
19.2.2.2 Does Malocclusion Cause TMD? originating during orthodontic treatment is mostly not
Occlusal interferences, open bite, cross bite, and missing related to that treatment [24]. Occlusal interferences are
posterior teeth cannot be considered as etiologic risk fac- temporarily created, but in a majority of the patients,
tors for TMD [23]. Unilateral posterior cross bite this will cause transient discomfort with a temporarily
(UPCB) is shown to be weakly associated with clicking risk for increased muscle pain or clicking in the
of the TMJ and masticatory muscle pain [23, 24] but can TMJ. Only in cases with a history of low adaptive capac-
on the other hand strongly be associated with facial ity (bruxism, parafunctions) or occlusal hypervigilance,
asymmetry, disturbance of the masticatory cycle, reduced mandibular loading should be decreased, and conserva-
bite force, and masticatory muscle hypertrophy. Therefore tive TMD management should be considered first.
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480 L. Van den Berghe and L. Simoen
signs or symptoms [24]. No method of prevention for During examination so-called functional pain on (maxi-
TMD has been demonstrated yet. mal) opening of the mouth (. Fig. 19.3) and lateral
Before, during, and after orthodontic therapy, always movements of the mandible, or possible irregular jaw
screen for TMD and for oral behaviors, and instruct the deviations or TMJ sounds have to be recorded. Except
patient to avoid parafunctions. The psychological pro- for dental (e.g., tooth wear, caries) and periodontal (e.g.,
file of the patient including his capacity of amplification gingivitis, early-onset periodontitis) inspection, the
of sensations (e.g., occlusal changes) has to be evaluated intraoral examination for the presence of muscle pain
in advance and has to result in a customized treatment on palpation is optional and not considered as manda-
plan. tory any longer. The examination for the determination
of the pain must be done very carefully, because the
child can express any pressure on palpation as a pain
19.2.3 Anamnestic Records experience. Children must be able to open their mouth
maximally between 35 and 40 mm like adults. The lat-
Any dentist who works with children should include in eral excursions of the mandible in children reach
the dental examination the TMJs and orofacial struc- approximately 8–12 mm (each side), but the measure-
tures, being capable of evaluating related complaints, ment is not reliable in very young children, due to the
symptoms, or findings. The anamnestic record should possible problem for them to follow instructions.
include a dental as well as a medical part, and the patient
should be asked about possible complaints such as head-
ache, ear pain, or more extensive facial pain, clicking in 19.2.5 Imaging
the TMJs (. Fig. 19.1) [7]. Previous dental trauma and
all the conditions causing, especially, chronic orofacial The panoramic radiograph is the recommended primary
pain, with information on the origin, location, quality, imaging tool to document the history and examination
intensity, and duration of pain, should be recorded. protocol in case of TMD in children as well as in adults.
It is not always obvious to obtain the right answers The obtained dental, periodontal, and TMJ information is
to some questions; parents should be involved and in most cases sufficient to identify or confirm the presence
informed extensively. The nature of the questions should or absence of structural pathology and rarely will affect
certainly avoid confusion, as the same limitations can be the primary diagnosis and choice of baseline conservative
experienced in adults as well. Adapted visual analogue therapy. Only in cases where there is injury, long-lasting
scales like the Universal Pain Assessment Tool (UPAT) pain, significant limitation of mobility, abnormal change
can be useful tools for TMD pain history-taking in of the occlusion, a progressive pathologic joint condition
youngsters (. Fig. 4.10) [29].
with facial asymmetry, numbness in the region of the man-
dible, a general joint disease (IRA), etc., further imaging
of the TMJs is desired [31]. In these cases magnetic reso-
Questions for TMD history taking: nance imaging (MRI) and cone-beam computed tomogra-
• Do you feel pain in the face or jaw or the mandible?
19 • Do you often suffer from headache?
phy (CBCT) are the tools of choice nowadays.
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Temporomandibular Disorders in Children and Adolescents
481 19
.. Fig. 19.2 a Palpation of
the temporal muscle. b
Palpation of the masseter
muscle
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Temporomandibular Disorders in Children and Adolescents
483 19
4. Bonjardim LR, Baviao MB, Carmagnani FG, et al. Signs and 19. Manfredini D, Restrepo C, Diaz-Serrano K, Winocur E, Lob-
symptoms of temporomandibular joint dysfunction in children bezoo F. Prevalence of sleep bruxism in children: a systematic
with primary dentition. J Clin Pediatr Dent. 2003;28(1):53–8. review of the literature. J of Oral Rehab. 2013;40:631–2.
5. Magnusson T, Carlsson GE, Egermark I. Changes in subjective 20. Saulue P, Carra MC. Bruxism in children and adolescents. In:
symptoms of craniomandibular disorders in children and ado- Laluque JF, Brocard D, d’Incau E, editors. Understanding Brux-
lescents during a 10 year period. J Orofac Pain. 1993;7(1):76–2. ism. Current Knowledge and Practice. Quintessence Publishing;
6. Magnusson T, Carlsson GE, Egermark I. Changes in clinical 2017. p.63–71.
signs of craniomandibular disorders from the age of 15 to 25 21. Carra MC, Bruni O, Huynh N. Topical review: sleep bruxism,
year. J Orofac Pain. 1994;8(2):207–5. headaches and sleep-disordered breathing in children and ado-
7. Magnusson T, Helkimo M. Temporomandibular disorders. In: lescents. J Orofac Pain. 2012;26:267–6.
Koch G, Poulsen S, Espelid I, Haubek D, editors. Pediatric den- 22. Nyström M, Könönen M, Alaluusua S, Evälahti M, Vartiovaara
tistry. a clinical approach. Wiley Blackwell; 2017. p. 309–15. J. Development of horizontal tooth wear in maxillary anterior
8. Nilsson IM. Reliability, validity, incidence and impact of tem- teeth from five to 18 years of age. J Dent Res. 1990;69:1765–70.
poromandibular pain disorders in adolescents. Swed Dent J 23. Michelotti A, Iodice G. The role of orthodontics in temporo-
Suppl. 2007;183:7–6. mandibular disorders. J Oral Rehab. 2010;37(6):411–7.
9. Toscano P, Defabianis P. Clinical evaluation of temporoman- 24. Sonnesen L, Bakke B, Solow B. Temporomandibular disorders
dibular disorders in children and adolescents: a review of the in relation to craniofacial dimensions, head posture and bite
literature. Eur J Paediatr Dent. 2009;10(4):188–2. force in children selected for orthodondic treatment. Eur J
10. Juvenile CR, Arthritis I. Overview and involvement of the tem- Orthod. 2001;23(2):179–92.
poromandibular joints, prevalence, systemic therapy. Oral Max- 25. Mc Namara JA Jr, Seligman DA, Okeson JP. Occlusion orth-
illofacial Surg Clinics. 2015;27(1):1–10. odontic treatment and temporomandibular disorders. A review.
11. Alamondi N, Farsi N, Salako N, Feteih R. Temporomandibular J Orofac Pain. 1995;9(1):73–90.
disorders among school children. J Clin Pediatr Dent. 26. Vanderas AP, Papagiannoulis L. Multifactorial analysis of the
1998;22:323–9. etiology of craniomandibular dysfunction in children. Int J Pae-
12. Bertoli FM, Antoniuk SA, Bruck I, Xavier GR, Rodrigues DC, diatr Dent. 2002;12(5):336.
Losso EM. Evaluation of the signs and symptoms of temporo- 27. Dibbets JM, van der Weele LT. Long-term effects of orthodontic
mandibular disorders in children with headaches. Arq Neurop- treatment, including extraction, on signs and symptoms attrib-
siquiatr. 2007;65(2A):251–5. uted to CMD. Eur J Orthod. 1992;14(1):16–20.
13. Motegi E, Miyazaki H. Oqura I, et al. an orthodontic study of 28. Kim MR, Graber TM, Viana MA. Orthodontics and temporo-
temporomandibular joint disorders. Part 1: epidemiological mandibular disorders: a meta-analysis. Am J Orthod Dentofac
research in Japanese 6-18 year olds. Angl Orthodontist. Orthop. 2002;121:438–6.
1992;62(4):249–6. 29. Dugashvili G, Van den Berghe L, Menabde G, Janelidze M,
14. Verdonck A, Takada K, Kitai N, et al. The prevalence of cardi- Marks L. Use of the universal pain assessment tool for evaluat-
nal TMJ dysfunction symptoms and its relationship to occlusal ing pain associated with TMD in youngsters with an intellectual
factors in Japanese female adolescents. J Oral Rehabil. disability. Med Oral Patol Oral Cir Bucal. 2017;22(1):88–4.
1994;21(6):687. 30. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria
15. Kaban LB, Mulliken JB, Murray JE. Facial fractures in children: for temporomandibular disorders (DC/TMD) for clinical and
an analysis of 122 fractures in 109 patients. Plast Reconstr Surg. research applications: recommendations of the international
1977;59:15–20. RDC/TMD consortium network and orofacial pain special
16. Kaban L. Acquired abnormalities of the temporomandibular interest group. J Orof Pain Headache. 2014;28(1):6–27.
Joint. In: Kaban L, Troulis M, editors. Pediatric Oral and Max- 31. American Academy of Pediatric Dentistry. Treatment of tem-
ilofacial Surgery. Philadelphia PA Saunders; 2004. p.340–376. poromandibular disorders in children: summary statements and
17. Chatzistavrou EK, Basdra EK. Conservative treatment of iso- recommendations. J Am Dent Assoc. 1990;120:265–9.
lated condylar fractures in growing patients. World J Orthod. 32. Visscher CM, Ohrbach R, van Wijk AJ, Wilkosz M, Naeije
2007;8(3):241–8. M. The Tampa scale for kinesiophobia for temporomadibular
18. Barbosa Tde S, Miyakoda LS, Pocztaruk Rde L, et al. Temporo- disorders (TSK-TMD). Pain. 2010;150:492–500.
mandibular disorders and bruxism in childhood and adoles-
cence: review of the literature. Int J Pediatr Otorhinolaryngol.
2008;72(3):299–4.
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Contents
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20.7 Hematological Disease – 505
20.7.1 ematological Malignancies – 505
H
20.7.2 Disorders of Blood Cells – 506
20.7.3 Bleeding Disorders – 508
References – 512
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Oral Lesions in Children and Adolescents
487 20
While the majority of child patients attending an oral
health care service will have plaque-related oral disease
such as caries and gingivitis, and more rarely congeni-
tally driven disease of the teeth and/or jaws, a spectrum
of disease can occasionally affect the mouths of chil-
dren. In particular, a wide variety of disorders can affect
the oral mucosa and more rarely the salivary glands.
Such disease may reflect many different pathological
mechanisms, and while most usually arise in adults,
some such as the autoinflammatory disorder periodic
fever, aphthous ulceration, pharyngitis, and adenitis
(PFAPA) and recurrent parotitis of childhood seem to .. Fig. 20.1 a, b Erythema migrans of the tongue – often termed
geographic tongue
be almost unique to pre-pubertal individuals. Similarly,
very occasionally children manifest disease expected of
adulthood (e.g., lichen planus or Sjogren’s syndrome).
Regardless of these trends, it is essential that clinicians
managing the oral health of children have an awareness
of the more common disorders and when to refer the
patient to an appropriate specialist.
Some of the disorders relevant to oral medicine that
arise in children:
1. May be the first manifestation of significant systemic
disease (e.g., ulceration or purpura of acute leuke-
mias)
2. Can be the most troublesome manifestation of a sys-
temic disease (e.g., oral ulceration of Crohn’s dis- .. Fig. 20.2 Erythema migrans of the buccal mucosa
ease)
3. Can lessen the quality of life of the affected patients change in site and appearance without an identifiable
(e.g., oral ulceration of any cause) precipitant. Sometimes there is accompanying fissuring
4. May compromise the general health of child (e.g., of the tongue, and rarely areas of erythema can arise on
failure to thrive due to loss of appetite caused by oral other oral mucosal surfaces (. Fig. 20.2).
Erythema migrans is a common disorder, perhaps occur- Diagnosis can be based solely upon the clinical features,
ring in up to 3% of individuals and may often arise in and there is no requirement for any additional investiga-
childhood. It affects both genders and occurs in children tions. The treatment of erythema migrans remains unsat-
of all ethnic groups [1, 2]. It manifests as discrete areas isfactory and principally comprises avoidance of
of erythema surrounded by a creamy white border on identified precipitants and local application of anesthetic
the dorsum of the tongue (. Fig. 20.1). The areas may
agents such as benzydamine hydrochloride. There is no
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488 S. Porter and A. Kolokotronis
Palatal tori are common and arise in all genders and all
ethnic groups [3]. They become more manifest as a child
grows. They present as symmetrically enlarged, painless,
bony enlargements of the vault of the hard palate. Tori do b
not warrant any treatment in childhood and do not seem
to interfere in the use of removable orthodontic appliances.
spherical shape and white color, and when their size extends are a number of cyst types that may occur in childhood
over 3 mm, they may be visible at birth or a few days after. (e.g., cyst of the incisive papilla (. Fig. 20.4) or other
Similarly appearing swellings termed Bohn’s nodules are a odontogenic cysts), details of which are available in
single or multiple small cysts which are located on buccal or appropriate maxillofacial surgery textbooks.
lingual aspects of the alveolar mucosae, more often the
mandibular surface [5] (. Fig. 20.3).
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Oral Lesions in Children and Adolescents
489 20
speech and/or eating and if repeatedly bitten may bleed pyogenic granulomas, can be initiated by plaque-
or occasionally enlarge. Occasionally a long-standing retaining factors, and can only be truly distinguished
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490 S. Porter and A. Kolokotronis
taken but is rarely warranted. They usually arise on the tongue or buccal mucosae
although if part of Sturge-Weber syndrome are exten-
sive and follow the distribution of one or more divisions
20.2.6 Other Swellings of usually one trigeminal nerve.
a b
20
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Oral Lesions in Children and Adolescents
491 20
a b c
.. Fig. 20.9 a Clinical image of a small hemangioma. b Picture of a The same case when the patient was aged 12 years. The expansion of
large hemangioma of the lower lip in a 7-year-old girl. There were the lower lip hemangioma is notable
also hemangiomas at the right half of the tongue and the pharynx. c
20.3.2 Lymphangioma
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492 S. Porter and A. Kolokotronis
The areas usually heal with little scarring; however, if term Riga-Fede granuloma is sometimes used as a
there is extensive ulceration, as may occur with chemical descriptor. The treatment of these disorders is discussed
injuries, scarring is possible and can lead to restricted in 7 Chap. 10.
a Eye Catcher
a b c
20
.. Fig. 20.12 a Electric burn on the lips due to biting an electrical cable. b Construction of a mobile device with flaps to aid ulcer healing
without complications on the corner of the mouth. c Clinical view after healing
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Oral Lesions in Children and Adolescents
493 20
Eye Catcher
.. Fig. 20.16 a Two minor aphthous ulcers on the lateral aspect of
Recurrent aphthous stomatitis usually arises in the the tongue. b Clinical image of a major aphthous ulcer at a similar
second decade of life, but about 10% of the affected location
individuals develop disease younger than this. The
cause of RAS is unknown and certainly does not that there is no specific means of lessening the duration of
reflect psychological distress, allergic reactions or ulcers, but typical strategies center upon topical cortico-
foodstuffs, or viral or other infections. steroids such as fluticasone (given as a spray or mouth-
wash), betamethasone mouthwash, or prednisolone
mouthwash. Painful symptoms may be lessened with ben-
There remains no effective means of stopping the emer- zydamine hydrochloride dabbed on areas of ulceration or
gence of the ulceration of RAS; hence the goal of treat- used as a spray or, less appropriately, for children, as a
ment is to lessen the duration (and hence associated pain) mouthwash. Occlusive pastes such as carboxymethylcel-
of each episode [20, 21]. The present evidence suggests lulose-based agents can also be useful, but it is often dif-
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494 S. Porter and A. Kolokotronis
use of biological disease-modifying drugs. lesions which may resemble aphthous ulcerations, or
large deep ulcers surrounded by mucosal tags which can
20.4.2.1 Systemic Autoinflammatory be present on the buccal mucosae or the buccal vesti-
Disorders bules. In addition, there may be swelling of the buccal
Periodic fever, aphthous ulceration, pharyngitis, and and/or labial mucosa that is soft and termed “cobble-
adenitis (PFAPA, previously termed Marshall’s syn- stoning.” In some patients, there may be erythema
drome) is a rare systemic autoinflammatory disorder migrans of the tongue (geographic tongue). A lower
(SAID) characterized clinically by periodic episodes of motor neuron palsy of the facial nerve is possible but
fever, sore throat, cervical lymphadenopathy, and super- extremely rare in children. In some individuals there
ficial oral ulceration [23] (. Fig. 20.17). The accompa- may be pyostomatitis vegetans which is characterized by
20
nying fever thus sets it apart clinically from RAS. It the development of multiple, diffuse small abscesses
represents a periodic release of IL-1β that then drives [24–27] (. Fig. 20.19). The management of the oral
inflammation. The exact trigger for the episodes is not aspects of Crohn’s disease is out with the clinical prac-
known although as the disease may abate following ton- tice of pediatric dentistry although as with all child
sillectomy there is a suggestion that it is bacterially patients affected individuals should be provided with
driven. Present management is centered upon tonsillec- appropriate advice to minimize the risk of plaque-
tomy and use of anti-IL1 monoclonal therapies. related oral disease.
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Oral Lesions in Children and Adolescents
495 20
severity. Oral ulceration similar in appearance to that of The clinical features are particularly distinct, the
RAS is not uncommon and indeed may be the first clin- only differential diagnosis realistically being ery-
ically detectable sign of GSE. The ulceration arises as a thema multiforme (see below). There is a little need
consequence of hematinic deficiencies (e.g., folate and for any confirmatory investigations such as viral
iron) secondary to the loss of small bowel function [13, DNA identification or establishing a rise in anti-HSV
28–30]. Additionally, the affected children may also have antibody levels between the acute and convalescent
enamel defects (see also 7 Chap. 17).
phases.
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496 S. Porter and A. Kolokotronis
The clinical features usually resolve over about clinically characterized by episodes of infection, usually
1 week, and treatment is generally directed toward at the same site of the vermillion border of the lip that
reducing the pain and pyrexia with non-steroidal anti- comprises a sequence of paresthesia, erythema, vesicu-
inflammatory drugs (e.g., paracetamol or ibuprofen) lation, pustule formation, ulceration, and eventual heal-
and ensuring adequate fluid intake. Antiviral therapy is ing. The cycle of clinical features occurs over about
rarely warranted unless (1) the clinical picture seems to 5 days, and affected individuals do not have any other
be notably severe at an early stage and/or (2) the child is clinical features directly caused by the HSV infection.
known to be immunocompromised. The antiviral of Episodes of herpes labialis usually have a precipitant
choice is aciclovir (e.g., 15 mg/kg of body weight, 5 times that presumably causes a mild reduction in immunosur-
a day for 5–7 days – although higher doses may be con- veillance and resultant viral replication within the tri-
sidered for immunocompromised patients). The pro- geminal ganglion. Commonly reported precipitants
drugs valaciclovir and famciclovir are sometimes used include upper or lower respiratory tract infections,
for immunocompromised children, and cidofovir is a exposure to sunlight, pregnancy, and psychological dis-
possible option when aciclovir resistance (which is rare) tress. Many patients however report that they felt “run
is likely. down” just prior to the onset of herpes labialis.
Most children do not have later episodes of herpetic The diagnosis of herpes labialis is based upon the
gingivostomatitis, this being most likely in some child clinical history and features. There is usually no justifi-
patients with immunodeficiency states. Herpetic infec- cation for confirmatory investigations. Therapy that
tion will have episodes of the secondary infection – her- only reduces the symptoms and signs by 1–2 days can be
pes labialis. topical aciclovir (5% cream) or topical penciclovir (1%
Herpes labialis (sometimes termed “cold sores”) is cream). Each agent needs to be applied before the onset
common and actually can arise in individuals who have of vesiculation; otherwise clinical benefit is unlikely –
no recollection of having had the illness of primary her- although it is suggested that penciclovir can still be of
pes simplex infection. Herpes labialis is rare in the first some benefit when applied late (as opposed to aciclovir).
decade of life but becomes more likely after this age. It is
Eye Catcher
a b c
20
.. Fig. 20.21 a Typical clinical picture of primary herpetic gingivo- of the right labial angle of the young patient. b, c Cases of the same
stomatitis. There are multiple vesicles surrounded by red halo. There disease localized in the tongue and the palate, respectively
also is coexisting, disease-specific, gingivitis together with a crusting
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Oral Lesions in Children and Adolescents
497 20
tion in groups of children that typically arise in the win- a
ter months of a country. The affected children experience
gradual onset of pyrexia, headache, and malaise fol-
lowed by the emergence of a red vesiculopapular rash
that gives rise to small pustules that ulcerate and heal.
Complications such as meningitis and encephalitis are
possible but rare. The complete clinical picture lasts
about 7–10 days. Oral ulceration – usually just a small
number of superficial ulcers – can occur alongside the
cutaneous rash and should be managed symptomati-
cally (. Fig. 20.22) [32, 34].
infection has a long incubation period of 4–7 weeks [32]. The numbers of leukocytes in peripheral blood are,
Clinically IN commences with general symptoms typically, moderately increased (10.000–15.000/mm3),
onset. The first symptoms are malaise, headache, high but in some cases, they are intensely increased. There are
also atypical lymphocytes. It is essential for the disease
to be distinguished from acute leukemias since they
share some similar clinical and laboratory features. The
detection of antibodies to EBV (heterophile antibodies)
is a specific laboratory examination called mono-test
and previously the Paul Bunnell test.
The normal course of the disease is self-limiting.
Complications or recurrence is rare and only likely in
those with immunodeficiency or immunosuppression.
Because there are no specific therapeutic agents against
the particular virus, the treatment of the patient is symp-
.. Fig. 20.22 Clinical image of mild varicella infection. On the
tomatic – for example, with analgesics and/or antipyret-
perioral cutaneous region, there are a small number of erosive lesions
(rash), while on the vermillion border of the lips, there are small ero- ics. Systemic corticosteroids have occasionally been used
sions resulting from vesicular rupture (arrows) when there is severe pharyngeal edema.
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498 S. Porter and A. Kolokotronis
b
.. Fig. 20.24 Petechiae and bruising on the border of soft and hard
palate in a teenager with infectious mononucleosis
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Oral Lesions in Children and Adolescents
499 20
and then the body and lower limbs. After the fever There is no specific treatment for mumps, analgesia
which, usually, lasts 6–9 days, the rash starts to dimin- and appropriate fluid intake being the mainstays of
ish and after a week resolves [32]. therapy. It has been suggested that corticosteroids may
Concerning the defense against measles, there is a be effective for severe parotitis, but generally these are
preventive vaccination, which protects young people not required unless the patients have other systemic
around 90%. Usually the measles vaccine is applied symptoms such as orchitis. Mumps can generally be pre-
along with that for mumps and rubella (MMR vaccine), vented with appropriate vaccination (mumps/measles/
in two doses. rubella (MMR)) [36].
tends to diminish after approximately 4–5 days and may gingival surface and are painless. They have no malig-
precede more complicated aspects of the illness. nant potential and should be removed by scalpel exci-
Affected patients may be unwell for about 1 week, sion (which allows histopathological confirmation of
but complications can include orchitis (infection of the the diagnosis) or less commonly by laser ablation or
testes – usually in post-pubertal years), mild pancreati- thermocoagulation. In general these lesions do not
tis, and viral meningitis or encephalitis. Cardiac, hepatic, recur. Occasional children with immunodeficiencies
and joint infection can occur, and they are rare and do such as HIV disease may have multiple or recurrent oral
not generally cause notable complications. However
long-term neurological damage, including deafness, is
rarely possible [35].
a b
.. Fig. 20.27 Mumps. a Bilateral swelling of the major salivary .. Fig. 20.28 Wart of the vermillion border of the upper lip in a
glands. b Unilateral swelling of the right parotid gland 17-year-old patient (arrow)
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500 S. Porter and A. Kolokotronis
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Oral Lesions in Children and Adolescents
501 20
and spreads to the rest of the body. It is characteristic
a
that the rash is absent from the perioral and paranasal
region (Filatoff sign).
In the oral cavity-intensive inflammatory, mucosal
erythema and white tongue coating can be present from
the initial stages of the disease. The tip and the lateral
borders of the tongue are intensively erythematous.
During the third to fifth day of the disease, the white
coating of the tongue is gone, and the tongue is inten-
sively erythematous with swollen fungiform papillae and
b
is called raspberry tongue. The disease results in perma-
nent immunity to erythrogenic toxin but not to strepto-
cocci. Penicillins are typically effective.
20.5.2.3 Tuberculosis
Tuberculosis (TB) is caused by Mycobacterium tubercu-
losis usually acquired via the droplet route from some-
one with open pulmonary TB. It can be acquired via
other routes, but this is most unusual. TB remains a sig-
.. Fig. 20.30 a, b Bullous impetigo of the perioral area skin affect- nificant health problem in countries with poor econo-
ing a male and a female teenager. In such cases differential diagnosis mies where there is social poverty, malnutrition, and
from herpetic infections is important
lack of health care resources. However, in view of migra-
tion and travel, children and adults living in high-
resource countries can present to clinics with clinically
in extreme cases, it can affect several other sites of the detectable TB. In addition, undetected HIV disease
face. It tends to arise in young infants and early-year increases the risk of TB [42].
school children without any pre-existing skin disease, In childhood and adolescence, the disease appears
although it may complicate disease such as eczema or more often as chronic submandibular or cervical lymph-
arise the following simple injuries such as cuts and adenopathy which is called scrofula (. Fig. 20.31). Oral
grazes. Children with diabetes mellitus may be at ulceration – usually single ulcers – or labial enlargement
increased risk of impetigo. It is usually caused by can be features of TB but are remarkably rare. Although
Streptococcus pyogenes and/or Staphylococcus aureus. highly unlikely in children, TB can cause destruction of
There are two types of impetigo: bullous impetigo
(usually caused by Staphylococcus), which affects neo-
nates, infants, and toddlers, and the non-bullous impe-
tigo, which affects more often school-age children
(. Fig. 20.30). The prognosis is generally good, and the
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502 S. Porter and A. Kolokotronis
the adrenal cortex and the later development of hyper- Eye Catcher
pigmentation of the buccal mucosae (“Addisonian pig-
mentation”). The diagnosis of TB is out with the clinical White patches of the mouth can be subgrouped into
practice of pediatric dentistry but typically requires adherent (i.e., do not easily wipe off) and non-
identification of the causative organism via molecular adherent. Except for thrush, non-adherent white
analyses – culture is now considered to be a second line patches may usually be just food debris. They may
for the identification of TB. The management of TB is also be found as necrotic tissue in oral mucositis sec-
typically undertaken by infectious disease specialists. ondary to local radiotherapy or systemic chemother-
Protection from TB is achieved with BCG vaccination – apy [13]. Adherent white lesions may be seen in
hence why all healthcare providers must receive this congenital rare disorders, such as dyskeratosis con-
prior to commencing clinical work. genita and pachyonychia congenita.
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Oral Lesions in Children and Adolescents
503 20
tion of courses of antibiotics or systemic corticoste- children, can only be diagnosed by histopathological
roids, while with some patients, it is impossible to remove examination of lesional tissue, and if present may be a
any underlying cause – for example, corticosteroid sign of known or unknown long-standing immunodefi-
inhaler use for asthma. In such instances there may be ciency (e.g., worsening HIV disease, congenital defects
no need to provide therapy as thrush is usually not of cell immunity, or chronic mucocutaneous candidia-
symptomatic and is not known to have any malignant sis) (see below). Topical or systemic anti-fungal agents
potential. Where therapy is required, topical agents such may lessen or resolve such disease, but there is little good
as nystatin suspension may be useful, and when disease data on effective therapy, and in any case, there should
is severe, does not resolve with nystatin, and/or is symp- be a focus upon identifying and where possible resolving
tomatic, there may be a need for systemic fluconazole any underlying cause.
therapy. Topical anti-fungal gels such as those with
miconazole or clotrimazole may be alternative thera- kChronic mucocutaneous candidiasis (CMC)
pies, but they are unlikely to be easy to apply. There is This is a group of rare disorders that reflect a number
rarely any requirement to confirm the diagnosis of of defects of cell-mediated immunity [46]. They are col-
thrush by microbiological means (e.g., culture): (1) can- lectively characterized by recurrent candida infection of
dida is a common commensal of healthy persons and (2) mucosal surfaces and/or skin. Oral disease can manifest
the candida load (or count) does not predict disease in childhood and presents as recurrent episodes of any
severity or likely response to therapy. Long-term use of of the above clinical presentations of candida infection
anti-fungals can increase the risk of the emergence of of the mouth. The most significant CMC type is auto-
anti-fungal resistance, but this is only a concern in immune polyendocrinopathy-candidiasis-ectodermal
patients who are severely immunocompromised. dystrophy (APECED) characterized by autoimmune
Candida can give rise to a number of clinical presen- destruction of the endocrine tissue (e.g., parathyroid,
tations other than thrush and they include the following: adrenal cortex, pancreas, ovaries, testes) such that the
affected children may have enamel hypoplasia or hypo-
kDenture-associated stomatitis calcemia of the developing teeth and Addisonian pig-
In children, a red appearance beneath the acrylic plate mentation [46, 47]. CMC is sometimes accompanied by
of a prosthetic or a removable orthodontic appliance. an iron deficiency; hence, children may have oral ulcer-
This is painless, and therapy is directed to improving ation angular cheilitis and/or glossitis (i.e., a smooth
appliance hygiene and occasionally placing miconazole tongue). The management of CMC is out with the
gel on the fitting surface of the appliance. practice of pediatric dentistry although clearly enamel
anomalies in APECED may warrant treatment.
kChronic erythematous candidiasis Except for candidiasis, there are some systemic
A red patch in the center of the dorsum of tongue. This mycotic infections such as mucormycosis, aspergillosis,
is painless and may arise in children using corticosteroid histoplasmosis, and blastomycosis, which may cause
inhalers for long periods. A similar patch may occasion- ulceration in immunocompromised children.
ally also arise on the hard palate (sometimes termed
chronic erythematous candidiasis). This rarely warrants
any therapy (i.e., anti-fungals) as it is painless, is not 20.6 Mucocutaneous Disease
potentially malignant, and in any case is unlikely to
resolve if the patient continues to have corticosteroids. Immune-mediated mucocutaneous disease that may
affect the mouths of children is extremely rare.
kAngular cheilitis Pemphigus types have been reported in children (ero-
Red patches at the corners of the mouth. This is rare in sions/ulcers), but perhaps the most common, although
children and if present may be associated with severe rare, of these disorders to arise in children would be ery-
anemia or immunodeficiency (e.g., HIV disease). The thema multiforme.
lesions can be painful and are infected with Candida
and/or Sstaphylococcus aureus. Treatment should be
principally directed toward resolving the underlying 20.6.1 Erythema Multiforme
cause, although nystatin suspension plus local applica-
tion of miconazole gel may hasten healing. Erythema multiforme (EM) very rarely arises in children.
This is an unusual hypersensitivity disorder that may
kChronic hyperplastic candidiasis arise in response to medication and occasionally infec-
This manifests as adherent white or speckled (i.e., red tion (e.g., HSV or Mycoplasma pneumoniae. The more
and white) patches of the oral mucosa. It is very rare in different drugs that an individual is receiving, the greater
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504 S. Porter and A. Kolokotronis
a Eye Catcher
milion borders of the lips with materials which do not contain latex (e.g., various
metals, such as nickel which is used in orthodontic mate-
the likelihood of EM. This disorder comprises four clini- rials [50, 51]) (. Fig. 20.35). The reactions to these
cal presentations: erythema multiforme minor, EM, agents vary in severity and timing; some may be rapid
major, Steven’s Johnson syndrome (SJS) (. Fig. 20.33), (within a few minutes, e.g., angioedema in response to
and toxic epidermal necrolysis syndrome (TENS). The an impression material) or slow (within 48–72 hours,
minor type comprises ulceration of a mucosal surface or e.g., perioral rash with some instruments) [50–53].
less than 10% of the skin, while the other types involve Reactions to local anesthetics are almost unheard of
more extensive mucocutaneous ulceration with TENS although some patients or their parents report that they
giving rise to more than 30% of the skin being affected are “allergic” when in fact upon closer discussion they
[48, 49]. are found to have possibly fainted or just “felt unwell”
Mucosal and/or cutaneous disease may sometimes, or “tired.” If a genuine allergy to components of local
but not always, be accompanied by target lesions (con- anesthetic solutions is suspected, then it is important
centric rings of white and red) that may affect any cuta- that the patient is referred to a suitable specialist for
neous surface but particularly the palmar and plantar detailed evaluation.
surfaces. A detailed discussion of EM is out with the
scope of this chapter, but if EM is suspected, it is essen-
tial that patients are rapidly referred to appropriate spe- 20.6.3 Other Mucocutaneous Disease
cialists.
Unlike adults, children are not liable to develop autoim-
mune disease such as immunobullous disease nor oral
20.6.2 Allergic Reactions lichen planus, although clearly these can occasionally
arise in children or young adults. A detailed discussion
Allergic reactions, i.e., hypersensitivity responses in of these is out with the scope of this book. However, it
response to oral healthcare procedures, are very rare. must be borne in mind that oral lichen planus-like dis-
20 The most common allergic reaction that is likely to arise ease can arise in children with graft-versus-host disease.
is a type 1 reaction (i.e., immediate hypersensitive) to Graft-versus-host disease (GvHD) arises in children
penicillin. This is clearly most likely when a patient with who receive a bone marrow allograft (e.g., in the man-
known allergy to penicillin is mistakenly prescribed this agement of leukemia) in which, as the term suggests, the
drug. The clinical presentation of penicillin allergy var- graft exerts a cytotoxic response upon the host. The oral
ies from mild urticaria (i.e., skin rash) to angioedema consequences of GvHD include early oral superficial
(swelling of the lips, tongue, pharynx, and larynx) and ulceration and later the emergence of white patches, ero-
anaphylaxis (urticaria, asthma, angioedema, anoxia, sions, and ulcers on the mucosae and/or gingivae that
and possible death). mimic those of oral lichen planus. Other features include
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Oral Lesions in Children and Adolescents
505 20
a loss of salivary gland function (hence xerostomia), mul-
tiple mucoceles, and pyogenic granulomas (that may be
driven by cyclosporin). This immunosuppressant may
also cause gingival enlargement [54].
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506 S. Porter and A. Kolokotronis
This is usually a localized disease that arises in late child- festations encompass those of loss of bone marrow
hood. The skull and often the jaws, especially the man- function, complications (both short- and long-term) of
dible, are common sites of involvement. Jaw disease can therapy, leukemic deposits (as with acute lymphoblastic
cause mobility of the teeth in the affected area, and leukemia), and gingival deposits of acute myeloid leuke-
pathological fracture (of the mandible) can rarely occur. mia that manifests as gingiva enlargement [64].
Radiology can reveal radiolucent areas that are observed,
and the teeth may have the appearance of floating on the
top of the radiolucency. Usually, the overlying oral 20.7.2 Disorders of Blood Cells
mucosa may be ulcerated. The jaws can be affected
in localized multisystem disease (that can involve the The majority of red cell defects in children center around
lungs, liver, spleen, bone marrow, or CNS) [61]. anemia (i.e., a reduction in hemoglobin and red cells).
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Oral Lesions in Children and Adolescents
507 20
The dominating anemias of childhood and in par- kβ-Thalassemia intermedia
ticular certain parts of the globe are the hemolytic ane- This may be caused by double heterozygosity (combina-
mias due to hemoglobinopathies – thalassemia and tion of α- and β-thalassemia). It is rare and presents
sickle cell disease. almost the same clinical picture of with thalassemia
major – but is milder.
20.7.2.2 Thalassemia
kβ-Thalassemia minor
Thalassemias are a group of hemolytic inherited (fol- 55 This rarely gives rise to severe anemia or the features
lowing the autosomal recessive pattern) diseases which of major disease.
are caused by hemoglobin composition disorders and
particularly by reduced production of α (α-thalassemia) 20.7.2.3 Sickle Cell Disease
or β (β-thalassemia) hemoglobin A (HbA) peptide The sickle cell diseases reflect a defect in the structure of
chains. In the Mediterranean there are in general three the globin chain – i.e., there are a normal number of
following forms of β-thalassemia; other thalassemias chains (unlike thalassemias), but the structure and func-
tion are defective. When there is a reduction in blood oxy-
are much less common and indeed can be life-
genation, the reticulocytes become sickle in shape, do not
threatening. pass along small blood vessels with ease, and may cause
obstruction of vessels. Sickle cell disease has some nota-
kβ-Thalassemia major ble racial (hence geographical) variation being most likely
55 This manifests in the first few months of life and is in individuals of a Black Africa decent. Affected individ-
characterized by severe hemolytic anemia, delayed uals are prone to hemolytic anemia and intermittent
body development, recurrent infections, and spleno- vaso-occlusal disease. The abnormal red blood cells
megaly. Affected individuals have features of ane- become sequestered in the spleen, and with severe disease,
mia. With time bony enlargement can arise as a there is a loss of splenic function and risk of pneumococ-
cal infection. The vaso-occlusal disease varies in presenta-
consequence of extra-medullary bone marrow
tion between patients but in its most severe form can
expansion, and this particularly affects the long
cause acute pain crisis that may be precipitated by infec-
bones and skull. Radiologically there may be expan- tion, extreme temperature, hypoxia, dehydration, psycho-
sion of the diploic space with trabeculae having a logical or physical stress, or even menstruation [70, 71].
“hair on end” appearance [66–69] (. Fig. 20.36). A detailed discussion of sickle cell disease is out with
Enlargement of the mandible and more commonly the scope of this chapter but key issues relevant to pedi-
the maxilla can give rise to a liontine (“lion-like”) atric dentistry include effective preventative care to
appearance. The oral features of thalassemia are avoid a risk of periapical infection precipitating a pain-
ful crisis, the need for general anesthesia, avoidance of
now rare in children in view of the advances in treat-
the use of agents likely to suppress respiratory function,
ment – indeed bone marrow transplantation is now
avoidance of non-steroidal anti-inflammatory drugs in
sometimes undertaken. patients with possible or known renal disease, and
awareness that patients with severe sickle cell anemia
can develop pain in single non-carious teeth that is a
manifestation of a pulpal infarct.
20.7.2.4 Neutropenia
Neutropenia reflects a reduction in the number of poly-
morphonuclear neutrophils. In children this can reflect
congenital disease such as chronic neutropenia and cyclic
neutropenia or be a consequence of bone marrow failure
(e.g., with leukemias and lymphomas) or due to a reduc-
tion in bone marrow function due to drug therapy (e.g.,
cytotoxics or immunosuppressives). Rarely autoimmune
disease may cause an autoimmune neutropenia [72, 73].
In general, neutropenias increase the risk of recur-
.. Fig. 20.36 Lateral skull radiograph of a child with thalassemia rent infections of the respiratory and urinary tracts
major. The “hair-on-end” skull is depicted and skin, and children may have recurrent episodes
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508 S. Porter and A. Kolokotronis
of pyrexia of unknown cause. Depending upon the tures may include the risk of brain abscess, hemorrhagic
cause and hence severity of the neutropenia, the oral stroke, hepatic failure, and risk of high-output cardiac
cavity can be greatly affected. Common features are failure.
deep ulceration of the mucosae or gingivae (these are Aside from its oral manifestations, the implications
sometimes said to lack an inflammatory halo), pro- of HHT for pediatric dentistry center upon the need
found gingivitis, and cervical lymphadenopathy. Oral for effective preventative dental care to avoid the need
pseudomembranous candidiasis can also arise. In for general anesthesia, careful nasal intubation (if
long-standing profound anemia, there is a risk of essential) to avoid epistaxis, and cessation of spontane-
aggressive periodontitis with resultant tooth mobility ous bleeding of oral telangiectasias with chemical cau-
and even early loss of the primary dentition. In cyclic terization and post-surgical (e.g., post-extraction)
neutropenia the neutrophil count tends to spontane- bleeding with chemical cauterization and/or tranexamic
ously reduce about every 3–4 weeks such that patients acid [76].
develop all of the above features in a cyclical manner.
20.7.3.2 Thrombocytopenia
Eye Catcher Thrombocytopenia – reduced platelet count – is uncom-
mon in childhood although when present it has many
There are a wide range of rare disorders in which neu- causes that range from autoimmune disease such as idio-
trophil function (e.g., adherence, chemotaxis, phago- pathic thrombocytopenic purpura (ITP) and systemic
cytosis, or killing) can be defective. In general, these lupus erythematosus (SLE), viral infection (when there is
disorders increase the risk of aggressive periodontitis usually a short-term fall in platelet count), congenital
although some may also cause orofacial disease (e.g., Wiskott-Aldrich syndrome and Fanconi
granulomatosis-type disease. anemia), malignancy (e.g., leukemias or other tumors of
the bone marrow), or loss of bone marrow function due
to radiotherapy, chemotherapy, or immunosuppressives.
20.7.3 Bleeding Disorders As detailed previously the oral features of thrombo-
cytopenia comprise a variable number of petechiae and/
Cessation of bleeding rests upon vasoconstriction, the or ecchymoses. The petechiae (small red-to-purple flat
formation of the primary platelet plug, and the subse- dots that when larger are termed purpura) can arise on
quent establishment of a clot. Defects of any of these any oral mucosal and/or gingival surface, while the
elements have the potential to increase the risk of ecchymoses (large bruises) are more likely at sites of
post-injury bleeding and in severe disease cause spon- trauma such as the palate and buccal mucosae. When
taneous bleeding. The present discussion focuses upon there is a severe reduction in platelet numbers (e.g.,
the more common or well recognized of this group of below 20,000/mm3), there may be spontaneous gingival
disorders. bleeding. Cleary children with severe thrombocytopenia
will have cutaneous purpura and bruising and be liable
to epistaxis and gastrointestinal tract bleeding. Bleeding
20.7.3.1 Hereditary Hemorrhagic within viscera is uncommon.
Telangiectasia (HHT, The management of thrombocytopenia clearly
Osler-Weber-Rendu Syndrome) depends upon the severity of the platelet deficiency and
This is an uncommon autosomal dominant disorder of the underlying cause. Aside from its oral features, the
blood vessel formation characterized by mucocutaneous implications of thrombocytopenia center upon avoiding
telangiectasias and arteriovenous malformations in var- bleeding with infiltrations (in general the platelet count
ious internal organs (e.g., lungs, liver, and brain). The should be above 20,000/mm3) or regional blocks (the
telangiectasias have a high likelihood to occur in the count should be above 50,000/mm3), ensuring effective
nose, mouth, and gastrointestinal tract; they bleed easily post-surgical hemostasis and avoidance of drugs likely
causing, for example, repeated and/or severe epistaxis to increase bleeding (e.g., NSAIDs), and considering
20 and unknown gastrointestinal bleeding leading to ane- any interaction between dentistry and the underlying
mia [74, 75]. disease or its treatment (e.g., possible corticosteroid
Affected children and adults may have multiple small cover for children receiving long-term corticosteroids).
1–3-mm-diameter telangiectasias on the face, periorally, Finally, there should be a focus upon the prevention of
on the lips, and on any oral mucosal of gingival surface. childhood dental disease – hence avoiding the need for
Patients may also have oral signs of anemia. Other fea- any invasive dental treatment [77].
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Oral Lesions in Children and Adolescents
509 20
There are a number of disorders in which platelet AIDS. Similarly, HCV transmission occurred in some
numbers are normal but their function abnormal instances. It is now highly unlikely that any child or
(thrombasthenias). In general patients with such disease young adult who has received factor concentrates in
should be managed with the similar considerations as recent years will be infected with HCV and certainly not
for thrombocytopenia. HIV [77–80].
20.7.3.3 Coagulopathies
There is a wide spectrum of defects of the clotting mech- Eye Catcher
anism. These may be of congenital defects of the clotting
factors (e.g., the hemophilias) or secondary to hepatic or The implications of hemophilia A to pediatric den-
gastrointestinal disease (e.g., vitamin K deficiency sec- tistry principally center upon preventative care to
ondary to gluten-sensitive enteropathy) or the use (all be ensure avoidance of invasive dental procedures (or
it rarely in children) of anti-coagulants – especially cou- the need for local anesthesia) and avoidance of post-
marin agents such as warfarin. The present discussion surgical bleeding. This latter must include:
will center upon more well recognized congenital clot- 1. Early liaison with the patient’s hematology team
ting factor deficiency disorders. to determine the need for, and provision of, factor
concentrates or DDAVP and the appropriateness
Hemophilia A of any planned local anesthesia
Hemophilia A is an X-linked (i.e., the affected gene lies 2. As atraumatic as possible dental treatment
on the chromosome X) recessive inherited disease that 3. Assurance of prolonged post-surgical hemostasis
gives rise to a reduction or absence of Factor VIII. As with placement of hemostatic agents in extraction
an X-linked recessive disorder, females may be carriers sockets, effective closure of wounds with resorb-
or very rarely affected, while males are at risk of having able sutures, and the use of tranexamic acid
the disease. mouthwash
Hemophilia A accounts for 85% of all instances of
hemophilia and has an incidence of about 1:5000 live Non-steroidal anti-inflammatory drugs such as ibu-
births. Depending upon the level of the Factor VIII defi- profen should be avoided for pain relief in view of
ciency, there are three forms: severe (when levels are their potential to induce gastric erosion or reduce
<1% of normal), moderate (2–5% of normal), and mild platelet function.
(6–40%). Carriers can also have reduced levels of Factor
VIII but not to the same degree as those with the dis-
ease. Severe disease accounts for about 50% of the Hemophilia B (“Christmas Disease”)
affected individuals and can give rise to spontaneous This is another X-linked recessive coagulopathy in which
bleeding, particularly joints and deep structures. there is a deficiency of Factor IX. Although less com-
Moderate disease may cause spontaneous bleeding, mon than hemophilia A, its clinical presentation, man-
while mild does not – although as with all types of dis- agement, and dental implications mirror those of
ease there is a risk of prolonged bleeding after trauma. hemophilia A.
Without treatment hemophilia may cause anemia, hem-
arthroses (that may limit mobility), and a risk of infec- von Willebrand’s Disease
tion. Life-threatening bleeding is possible with severe von Willebrand’s disease (vWD) is the most common of
disease. all congenital bleeding disorders. It is an autosomal
The general management of hemophilia depends dominant disorder that reflects a deficiency of the
upon the severity of the clotting defect but in general amount or function of von Willebrand factor (vWF)
centers upon the use of factor replacements (now recom- that stabilizes Factor VIII and also allows platelets to
binant and not derived from blood donations), agents to adhere to blood vessel endothelium. There are three
stimulate release of endogenous stores of clotting fac- types of vWD (I, mild; II, moderate; and III, severe)
tors (e.g., desmopressin, desamino-8-D-argininine vaso- with patients with the mild type generally only requiring
pressin (DDAVP), the use of antifibrinolytic agents such DDAVP, while those with moderate and severe require
as tranexamic acid to stabilize clot retention, and avoid- concentrates of Factor VIII and vWF. In general, the
ance of trauma. Patients who develop inhibitors (i.e., implications of vWD are similar to those of hemophilia
antibodies to Factor VIII) may be given activated pro- A, although patients who are affected occasionally have
thrombin complex concentrate (FEIBA). In the past the only been identified following episodes of prolonged
use of human-derived factor concentrates led to patients post-extraction bleeding. In addition, in view the com-
with hemophilia A (or indeed any type) acquiring HIV bined platelet/clotting factor defects, patients may have
resulting in most instances in early death from oral petechiae or spontaneous gingival bleeding [81].
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510 S. Porter and A. Kolokotronis
20.8.1 Mucocele
.. Fig. 20.37 Mucocele located at the ventral surface of the tongue,
Mucoceles are swellings of minor salivary glands that the second most frequent location following the lower lip mucosa
typically present as a single painless sessile translucent
blue swelling, typically of the lower lip (although can
occasionally arise within the mouth) (. Fig. 20.37).
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Oral Lesions in Children and Adolescents
511 20
fying and where possible treating any underlying risk
factor. Typical therapeutic regimes are effective hydra-
tion and systemic antimicrobials. Typically employed
antibiotics are anti-staphylococcal penicillins (e.g., flu-
cloxacillin, amoxicillin, or co-amoxiclav), cephalospo-
rins, or clindamycin, although the precise choice of
antibiotic will often depend upon any likely causative
organism that is identified (although as noted above in
most instances there is a little need for detailed microbio-
logical evaluation of pus or saliva). Complications of
acute suppurative sialadenitis in childhood are rare [91].
.. Fig. 20.39 Occlusal radiograph of the mandible in which a sialo-
lith (marked with the arrow) is depicted as circular, homogeneous,
and radiopaque entity located at the left half of the floor of the 20.8.5 ecurrent Parotitis of Childhood
R
mouth
(Juvenile Recurrent Parotitis)
nephrocalcinosis has been suggested (but not hyper- Recurrent parotitis of childhood is characterized by
parathyroid disease). It has also been observed in a small recurrent parotid inflammation. It can arise at any age,
number of children with HIV salivary gland disease. but the usual age of onset is 3–6 years. Childhood-onset
The management of possible sialolithiasis tends to fall disease is usually more common in males, while adult-
under the specialties of oral medicine or oral surgery but onset disease normally arises in females. The disease gives
is centered upon identification of the site and size of sial- rise to pain and swelling in one parotid gland that may
oliths (e.g., via plain radiography (. Fig. 20.39), ultra-
last up to 14 days. Fever and overlying erythema are com-
sound scanning, and/or sialoendoscopy) and removal of mon, and occasionally white muco-pus can be expressed
calculi directly (e.g., those within the submandibular from the parotid duct. The number of attacks varies from
duct) via sialoendoscopic retrieval (with or without litho- 1 to 5 per year, but some patients may have up to 20 epi-
tripsy), or, rarely, removal of a chronically inflamed sodes of swelling per year. The frequency of recurrence
gland. Sialolithiasis is rarely recurrent [35, 88, 89]. tends to peak between 5 and 7 years of age, and up to 90%
of patients have resolution of disease by puberty.
Sialography and ultrasonic scans reveal sialectasis.
20.8.4 cute Suppurative Sialadenitis
A The precise etiology of recurrent parotitis remains
(Suppurative Parotitis, Bacterial unclear, but certainly almost all affected patients are
Sialadenitis, Bacterial Parotitis) otherwise well.
Analgesia is the mainstay of therapy. Antibiotics do
Acute suppurative sialadenitis is an uncommon disorder not shorten attacks. Intraductal saline with or without
characterized by painful swelling – usually of the parotid dilatation of Stenson’s duct and intraductal antibiotics
glands (suppurative parotitis), purulent discharge from (or methyl violet to induce sclerosis) have been proposed
the duct of the affected gland, associated dysgeusia, and as have included sialoendoscopy and ductal dilatation
cervical lymphadenopathy. When the disease is severe, with a sialoballoon. Suggested invasive procedures
there may be accompanying pyrexia, malaise, and a risk include ligation of Stenson’s duct, transection of chorda
of abscess formation and parapharyngeal space infec- tympani, or transection of Jacobsen nerve in the middle
tion – including Ludwig’s angina. ear. Radical methods such as total or sub-total paroti-
Acute suppurative sialadenitis can affect children and dectomy have also been proposed, but as the disease
adults. Prematurity may be a risk factor for disease in tends to resolve, spontaneously there seems a little place
childhood, and sialadenitis can occur in newborns. Acute for such invasive measures [35, 92, 93].
suppurative sialadenitis may also be a feature of Sjogren’s
syndrome. Aseptic sialadenitis has been observed in pre-
term children receiving long-term orogastric tube feed- 20.8.6 Xerostomia (Oral Dryness)
ing. Immunodeficiency and concurrent illness may
predispose to childhood suppurative parotitis [35, 90]. Reduced salivary gland function with resultant oral dry-
The causative infection is usually mixed, and hence ness is rare in children and young adults. A loss of sali-
microbiological investigation of pus or saliva is rarely of vary output can greatly impact upon oral function and
notable diagnostic benefit. Management is principally hence lessen quality of life. Affected individuals may
directed toward resolving the infection and later identi- have dysarthria, dysphagia (especially with dry foods),
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512 S. Porter and A. Kolokotronis
dysgeusia, an increased risk of caries (e.g., of the cervi- tion of the ducts of the submandibular glands such that
cal areas or at the margins of restorations), plaque- they open into the pharynx.
related gingivitis, oral candidiasis, and acute suppurative Pharmacological therapy for drooling encompasses
sialadenitis) [94]. the use of anticholinergic agents, such as glycopyrrolate,
Despite its reported rarity, it is likely that some chil- benztropine, and scopolamine to decrease saliva secre-
dren will have long-standing oral dryness. The most tion through the parasympathetic autonomic nervous
likely cause will be long-term use of medication that system. Botulinum toxin decreases the severity of drool-
have an anti-muscarinic action (e.g., benzodiazepines, ing with statistical significance in children. The duration
tricyclic (or other) antidepressants, opiates, antihista- of effect can vary from 6 weeks to 6 months. However,
mines). Other possible causes in childhood would there remains the need of establishing the ideal dose and
include radiotherapy-induced salivary gland destruction form of application. Botulin toxin treatment may how-
(some children will have had radiotherapy for unusual ever cause increased saliva thickness, dysphagia, dry
head and neck malignancies), salivary gland agenesis mouth, and risk of pneumonia. Resection of the major
(that may be an isolated anomaly or arise as part of glands is possible, but there is a risk of xerostomia, visi-
ectodermal dysplasia), HCV sialadenitis, HIV salivary ble scar, and facial nerve weakness [96, 97].
gland disease, or autoimmune disease (e.g., Sjogren’s
syndrome). A detailed discussion of these disorders is
out with the scope of this chapter; however the key prin- References
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Vielsmeier V. Hereditary hemorrhagic telangiectasia. Otolaryn- options. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
gol Clin N Am. 2018;51(1):237–54. 2006;101(1):48–57.
76. Scully C. Scully’s medical problems in dentistry. Edinburgh:
96. Scully C, Limeres J, Gleeson M, Tomás I, Diz P. Drooling. J Oral
20 Elsevier; 2014. p. 212–75.
77. Malmquist JP. Complications in oral and maxillofacial surgery:
Pathol Med. 2009;38(4):321–7.
97. Reddihough D, Erasmus CE, Johnson H, McKellar GMW,
management of hemostasis and bleeding disorders in surgical Jongerius PH. Botulinum toxin assessment, intervention and
procedures. Oral Maxillofac Surg Clin North Am. aftercare for paediatric and adult drooling: international consen-
2011;23(3):387–94. sus statement. Eur J Neurol. 2010;17(SUPPL. 2):109–21. https://
78. Rasaratnam L, Chowdary P, Pollard D, Subel B, Harrington C, doi.org/10.1111/j.1468-1331.2010.03131.x.
Darbar UR. Risk-based management of dental procedures in
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Contents
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517 21
21.1.1 Dental Findings and Treatment due to less radiation dose or due to greater regenerative
capacity of their salivary glands. The use of substitutes
In the most acute lymphoblastic leukemia cases, clinical for saliva, soda or 50% glycerol solution in water with
signs in the mouth are painful ulcerations in the mucous added drops of lemon juice, reduce the feeling of dry
membranes and automatic or evoked gum bleeding. The mouth [8]. Sugar-free chewing gums with xylitol contrib-
white blood cells in the peripheral blood are increased ute to activation of salivary glands (. Fig. 21.1).
Dry mouth Dry mouth, caused by radiotherapy due to Dysgeusia and eating disorders Dysgeusia (foul taste)
dramatic decrease of saliva production from the salivary can be a lasting symptom in young patients undergoing
glands, increases the likelihood of infections in the mouth chemotherapy or radiotherapy and affects especially the
and affects speech, chewing, and swallowing. Dry mouth taste of bitter and acidic, while that of salt and sweet is
is accompanied by a feeling of burning tongue and thirst. not seriously affected. It can be treated by the administra-
For children these symptoms are usually temporary, either tion of zinc sulfate during meals. These changes are due to
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518 A. Arhakis and N. Kotsanos
for children at high caries risk, with dry mouth, and those
undergoing head and neck radiation [6]. When there is no
time for complete dental rehabilitation before the start of
b the antineoplastic therapy, dental infections should at
least be removed, e.g., by extractions and periodontal
therapy, because they can lead to systemic infections when
the patient will become immunocompromised [12]. In pri-
mary teeth, extraction is a safer treatment option to end-
odontic treatment, while in permanent dentition, the latter
is acceptable if it could be completed and allow at least a
week for assessing a successful outcome [7]. Tooth extrac-
.. Fig. 21.2 a An improved stage of mucositis following chemother- tions, after platelet and blood neutrophil counts, can be
apy of a patient with leukemia at ages 4 and 6 years. b His panoramic performed at least 10 days beforehand, to allow time for
radiograph at age 14 years shows several teeth with short roots wound healing. Fixed orthodontic appliances are removed
if patient do not apply adequate oral hygiene or if there is
swelling of the taste buds, becoming normal 6–12 months a severe mucositis.
after therapy [10]. Eating disorders are associated with the During antineoplastic therapy toothbrushing is regu-
disease itself, while anorexia may be related to complica- larly performed despite the reduction of platelets [6], if
tions of antineoplastic therapy such as mucositis, dry necessary with extra soft toothbrush respecting the sensi-
mouth, and loss of taste or nausea. tive soft tissues. Dental treatment is done only in emer-
gency situations, in cooperation with attending physician
Abnormalities of teeth and jaws Children being at the [7, 12]. After the end of antineoplastic therapy, any unfin-
growth period are subject to developmental abnormali- ished dental treatment could be completed and a recall
ties. These may be related to dental and/or skeletal devel- program followed, as in healthy children. In those suffer-
opment, like maxillary or mandibular hypoplasia or ing from severe mucositis, the remaining mucosal lesion is
dental root growth (short roots, early root completion) taken care of and examined histologically if needed.
(. Fig. 21.2), oligodontia, enamel hypoplasia, and dis-
Compliance in preventive program is often poor because
turbance of tooth eruption time, all dependent on the of both children and parents’ fatigue, after a long demand-
radiotherapy or chemotherapy time and duration [10]. ing process of therapy. Burnout by cancer treatment is
usually greater by adolescents than children [13].
Neurotoxicity Neurotoxicity is a side effect resulting
from certain types of chemotherapy drugs such as alka-
loids and vincristine. The resulting facial pain is continu-
ous and dull but may be reported by the young patient as 21.2 Cardiovascular Diseases
toothache. Usually the symptoms subside a week after the and Chemoprophylaxis
end of chemotherapy [11].
Heart diseases in infants and children are among the
Rampant caries Particularly, in those patients undergo- most frequent chronic diseases of childhood and are
ing head and neck radiation therapy, there is the risk of divided into congenital and acquired forms. Congenital
a rampant form of dental caries within months after heart diseases, owed to malformation of the heart and/
21 therapy, as a result of a combination of dry mouth and or large vessels, have a prevalence of five to eight cases
per 1000 live births. The time of occurrence and the
negligence of undertaking preventive measures, i.e., very
good oral hygiene and use of fluoride (. Fig. 21.3). severity vary. Almost half of them are diagnosed in the
Extractions and minor surgical interventions can be first year of life, while others may remain undetected for
done under prophylactic antibiotic chemotherapy with- years. Cardiomyopathies and some types of arrhythmias
out fear of necrosis or infection, if they are least trau- usually coexist with other congenital anomalies of the
matic [6, 11]. heart or occur as a complication of the surgical correc-
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The Young Dental Patient with Systemic Disease
519 21
a b
c d
e f
.. Fig. 21.3 a, b Dental treatment needs of a 4-year-old boy with ization of permanent incisors, visible after new supervised oral
acute lymphoblastic leukemia. All needs were met before chemother- hygiene. e Juice-drinking abuse and bruxism have contributed to
apy. c New caries in primary molars and burnout neglect of oral additional erosive wear. f The 18-month recall shows arrest of caries
hygiene following a 3-year miss of recalls. d Extensive hypomineral- lesions as a result of the reinstituted preventive program
tion. Acquired heart diseases are rare in infancy. These A small number of incidents have been directly
include endocarditis, myocarditis, Kawasaki disease, correlated with previous dental treatment [15]. Micro-
pericarditis, and acquired arrhythmia. Some of these organisms – especially virulent streptococci – cause
can be fatal or lead to disabilities. endocarditis typically associated with the normal flora
of the mouth. Colonization occurs at irregularities of
cardiovascular endothelium due to anatomical defects,
21.2.1 Microbial Endocarditis disease, or foreign body. The real cause is considered
and Dental Care to be consecutive bacteremia episodes and not isolated
incidents, e.g., tooth extraction or the placement of rub-
Endocardial microbial infection is characterized by for- ber dam and matrix with wedge [16]. Thus, the most
mation of shoots, mainly in heart valves, and has a high important bacterial endocarditis prevention measure
mortality rate if not treated promptly (. Fig. 21.4).
in high-risk individuals is daily oral hygiene, since the
Chemoprophylaxis recommendations along with the extent of bacteremia (the number of bacteria entering
views on morbidity causes for bacterial endocarditis the blood flow) is related to the severity and extent of
have undergone many changes over time. Theoretical the already existing gingivitis [17]. Preventing bacterial
risk prevalence is very low (1:150,000 for adults at high endocarditis is not only by chemoprevention, but is sup-
risk who received chemoprophylaxis and three times ported by the treatment of any infection that could lead
higher for those who did not) [14]. to bacteremia [14].
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520 A. Arhakis and N. Kotsanos
The protocol adopted by the European Academy of • Tooth extraction or any other surgical procedure
• Periodontal treatment, root scaling, and pocket depth
Paediatric Dentistry for the prevention of bacterial measurement
endocarditis in children with an increased risk is as fol- • Implant placement or avulsed tooth re-implantation
lows: amoxicillin, 50 mg/kg body weight (maximum • Chemo-mechanical root canal preparation, if exceeding
dose of 2 gr) as a single dose per os 1 hour before dental root apex
surgery. In case of allergy to penicillin, clindamycin is • Subgingival placement of antimicrobial fibers or films
• Orthodontic band placement
selected, 20 mg/kg body weight (maximum dose of • Intraligamentary local anesthesia
600 mg). In case of intramuscular or intravenous admin- • Scaling and tooth or peri-implant prophylaxis
istration, the above is proposed to be done, half an hour
before the dental treatment: ampicillin 50 mg/kg body
weight (maximum dose of 2 gr). In case of allergy to
penicillin, clindamycin is administered, 15 mg/kg body Studies have shown that, in children who had recently
weight (maximum dose of 600 mg) [15]. received chemotherapy (antibiotics), colonization of
strains resistant to the antibiotic administered was
>>Important more frequent [18]. The British Society for Antimicro-
Patients proposed to take chemoprophylaxis are classified into bial Chemotherapy proposes revision of the current
two groups protocol, by administering preventive chemoprophy-
laxis only in high-risk patients for endocarditis as well
High risk. Patients with a history of bacterial endocarditis, as in those with high mortality risk when ill. Generally,
congenital cyanotic heart diseases (e.g., transposition of the
great vessels, tetralogy of Fallot), and iatrogenic arteriovenous
there is a worldwide debate and frequent revisions on
communications in systemic or pulmonary circulation. Patients chemoprophylaxis necessity for various patient catego-
with cardiac implants who develop cardiac valvular diseases. ries. For patients who require multiple appointments
21 Congenital heart defects, which are fully treated, surgically or
using a catheter, requiring antibiotic coverage in the first
for dental treatment, an interval of at least 14 days
between sessions is proposed, in order to reduce the
6 months after surgery.
risk of developing resistant strains of the administered
Medium risk. Patients with congenital heart defects, acquired antimicrobial for chemoprophylaxis. Furthermore,
valve dysfunction, hypertrophic cardiomyopathy, mitral valve mouthwash with chlorhexidine 0.2% solution for
prolapse with valvular regurgitation, and/or thickening of the
leaflets.
1 minute prior to dental treatment, if possible, is pro-
posed.
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521 21
21.3 Diabetes Mellitus Eye Catcher
Diabetes is characterized by elevated blood sugar levels Diabetes’ implications on a young patient could be:
due to reduced production of insulin by the beta cells of 1. Hypoglycemic coma: Chills and cold skin, fast
pulse, stress, confusion, convulsions, and coma. If
the islets of Langerhans in the pancreas. Diabetes is
the patient retains his/her senses, sugar or honey
divided in type I (insulin-dependent or teenage) and type
through the mouth must be given. The patient
II (non-insulin-dependent or adult) form. The incidence
recovers usually within 5–10 minutes. If they lost
of diabetes is low in infants, increases in school age chil-
their senses, 1 mg of glycogen intramuscularly or
dren, and reaches the rate of 1:500 among children at the 10–20 ml 20–50% dextrose is intravenously
age of 17, in Europe. Diagnosis is made by medical his- injected [19].
tory, clinical presentation, and laboratory urine and 2. Hyperglycemic coma: (Due to lack of insulin) dry
blood tests. Originally, a child suffering from this disease mouth and skin, fast and weak pulse, low blood
has symptoms such as polyuria, polydipsia, drowsiness, pressure, and tendency to vomit. Immediate intra-
anorexia, weight loss, and constipation. Regarding the venous administration of fluids (bicarbonate salt
treatment, monitoring blood sugar is needed as well as 8.4%) and direct communication with the physi-
suitable diet and daily insulin administration. Three cian or hospital for insulin are required [19].
meals and two to three sugar-free between-meal snacks,
low fat and rich in fiber, are required [19, 20].
21.4 Asthma
21.3.1 Dental Findings and Treatment Asthma is a chronic inflammatory condition of the air-
ways, characterized by recurrent episodes of wheezing,
Flow rate of saliva in diabetic children is reduced due to breathlessness, retrosternal (back of chest) dull pain,
the dehydration associated with polyuria, but caries and coughing, particularly at night and early morning
index is not affected, probably due to low frequency of [23]. More severe bronchial obstruction leads to diffi-
carbohydrate intake. Only in uncontrolled diabetes and culty in breathing and tachycardia [24]. Asthma is a het-
erogeneous disease, especially in early childhood, and is
uncontrolled diet a child can be considered as high car-
caused both by endogenous and environmental factors.
ies risk [19]. More correlation has been established
The most common of the latter is exposure to allergens,
between diabetes and periodontal disease, especially in
infections, and airway exposure to nonspecific stimuli
adults. The longer the diabetes history, the more serious such as cigarette smoke. Activity at low temperatures
are the periodontal problems, particularly in non- causes symptoms in 80% of children with asthma. The
insulin-dependent diabetes and uncontrolled one [21]. emotional state and stress may also trigger an asthma
When blood glucose is elevated, increased amounts of attack [25].
glucose are found in the saliva and gingival fluid.
The best time for dental treatment is during morning
Eye Catcher
hours, when blood sugar is stable. Before treatment the
dentist is necessary to consult the pediatrician for the Asthma affects 5–10% of children. Depending on the
patient’s dosage, and frequency of insulin administra- frequency and intensity of symptoms and the need for
tion, diet, blood glucose level, and any other problem medication, it is classified into four categories: mild,
may coexist. Low resistance of diabetic children to moderate, severe, and very severe. Three quarters
infections has to be always in mind. Orofacial infections belong to the mild category with little daily episodes
must be treated immediately as they can trigger the or short-term crises [26]. The majority (60%) of chil-
appearance of ketosis. Conducting ordinary dental dren with asthma show no symptoms until the age of
treatment and minor surgical procedures under local 6 years.
anesthesia does not require special precautions. In more
extensive surgical procedures, special attention has to be Medicinal treatment of chronic asthma in children
given to avoid hypoglycemia, in order to prevent a pos- includes two main groups of drugs, bronchodilators,
sible delay in healing because of impaired phagocytosis. and anti-inflammatory. Mild asthma is usually treated
Adrenaline contained in local anesthetics does not by inhaling beta-2 agonists alone, usually every
increase the blood glucose levels [22]. 4–6 hours. In patients with moderate asthma, anti-
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522 A. Arhakis and N. Kotsanos
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The Young Dental Patient with Systemic Disease
523 21
21.5.1 Dental Findings and Treatment clots. Their administration should be stopped 48 hours,
in order for normal hemostasis to be achieved if hem-
The oral manifestations of the disease depend on the orrhagic dental procedures are anticipated [41]. The
age at which the disease occurs, the duration, severity, number of transfusions these children undergo because
and the cause. Changes are observed in both the soft of blood loss classifies them at high risk for hepatitis.
and the hard tissues. One of the most important findings The dentist should therefore take the necessary precau-
in the soft tissue is pale mucosa from anemia which is tions.
due to decreased secretion of erythropoietin by the kid- For a patient who has had a kidney transplant, fur-
ney [36]. Intraoral hematomas and ecchymosis and mild ther precautions are needed, because of taking cortico-
coagulation problems are due to the sensitivity of the steroids and immunosuppressants to prevent foreign
walls of the capillaries and the reduced energy of the body expulsion. One of the side effects of these drugs
plasma II agent. is that they cover the symptoms of inflammation so
that infections become a frequent cause of death in
these patients. Therefore, it is vital to communicate
Dental Findings at Chronic Renal Failure with the attending physician for antibiotic coverage
before any dental procedure, for minimizing inflamma-
The teeth and bones of the jaws are affected when
tion chances [37].
kidney failure occurs during tooth formation/min-
eralization (chronologic enamel hypoplasia/hypo-
mineralization) or in critical periods of bone
growth, possibly leading to orthodontic anomalies
21.6 Gastroesophageal Reflux Disease
[37]. The uremia affects the bone remodeling caus-
ing disappearance of lamina dura and creating bone
Gastroesophageal reflux disease (GERD) is the entrance
lesions which histologically resemble giant cell
of gastric or intestinal contents into the esophagus with
tumors, as in hyperparathyroidism [36]. Despite the
or without vomiting [42, 43]. About 7–8% of infants and
disappearance of the lamina dura, if there are no
toddlers manifest daily episodes of GERD of short
other bone lesions, mobility of the teeth is not usu-
duration (<3 minutes), especially after meals and at bed-
ally observed. Discolored teeth have been reported
time, with no or minimal symptoms [44]. A low degree
from deposition of blood pigments due to uremia or
of reflux with no other symptoms is observed in normal
by prolonged use of tetracyclines [38]. Reduced den-
neonates, especially preterm, and up to 7–week-old
tal caries and increased deposition of calculus are
infants due to immaturity of the lower esophageal
also reported [39].
sphincter [45]. In cases of very intense reflux, blood tests
and urine tests should be carried out to rule out other
causes such as gastroenteritis or pylorostenosis [46]. In
Dental treatment varies depending on the child’s medi- children and adults, drugs are administered to increase
cal condition and its treatment phase. Routine dental the base pressure of the lower esophageal sphincter
treatment should be avoided when the serum urea nitro- (metoclopramide, domperidone) and antacids to neu-
gen is >60 mg/dl and the rate of creatinine is >1.5 mg/dl. tralize stomach acid [47]. Surgical treatment for children
Arterial blood pressure and hemorrhagic tendency of is reported in cases of failure of medical treatment, per-
the patient should be monitored. Aspirin should be sistent vomiting, stenosis, recurrent pneumonia, and
avoided, and the responsible physician contacted before life-threatening complications, such as respiratory arrest
administering any medication, because of the limited [48].
ability of the kidneys to metabolize and excrete it.
Antibiotics are not considered necessary, unless there is
active inflammation. If herpetic gingivostomatitis 21.6.1 Dental Findings and Treatment
occurs in very young children, total liquid intake is mon-
itored to ensure electrolyte balance [40]. Dental findings relate to erosion of the teeth by stomach
A child who is receiving hemodialysis needs some hydrochloric acid regurgitation, and, together with their
extra precautions. Before any dental restoration is prevention and treatment, they are described in the rel-
undertaken in patients with surgically inserted artificial evant 7 Chap. 18. However, findings in children with
anastomosis, chemoprophylaxis is necessary. The hand GERD are not as frequent as one would expect, as only
or foot on which the anastomosis is mounted should a limited percentage (14–17%) of them exhibit erosive
not be used to administer drugs and be free to move for tooth wear [49, 50]. This is possibly because other fac-
preventing blood clotting. Many of these children are tors are involved in the association between GERD and
taking anticoagulants (coumarin) to prevent blood dental erosion.
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524 A. Arhakis and N. Kotsanos
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1061–74. 44. Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of
25. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, symptoms of gastroesophageal reflux during childhood: a pedi-
FitzGerald JM, et al. Global strategy for asthma management atric practice-based survey. Pediatric Practice Research Group.
and prevention: GINA executive summary. Eur Respir J. Arch Pediatr Adolesc Med. 2000;154:150–4.
2008;31:143–78. https://doi.org/10.1183/09031936.00138707. 45. Poets CF. Gastroesophageal reflux: a critical review of its role in
26. Thomas M, Kay S, Pike J, Williams A, Rosenzweig JR, Hillyer preterm infants. Pediatrics. 2004;113:e128–32.
EV, et al. The Asthma Control Test (ACT) as a predictor of 46. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R. Global
GINA guideline-defined asthma control: analysis of a multina- Consensus Group The Montreal definition and classification of
tional cross-sectional survey. Prim Care Respir J. 2009;18:41–9. gastroesophageal reflux disease: a global evidence-based consen-
https://doi.org/10.4104/pcrj.2009.00010. sus. Am J Gastroenterol. 2006;101:1900–20. https://doi.
27. Zhu JF, Hidalgo HA, Holmgreen WC, Redding SW, Hu J, Henry org/10.1111/j.1572-0241.2006.00630.x.
RJ. Dental management of children with asthma. Pediatr Dent. 47. Ray SW, Secrest J, Ch'ien AP, Corey RS. Managing gastroesoph-
1996;18:363–70. ageal reflux disease. Nurse Pract. 2002;27:36–53.
28. Boothe DM. Drugs affecting the respiratory system. Vet Clin 48. Sunku B, Marino RV, Sockolow R. A primary care approach to
North Am Exot Anim Pract. 2000;3:371–94. pediatric gastroesophageal reflux. J Am Osteopath Assoc.
29. Thomas MS, Parolia A, Kundabala M, Vikram M. Asthma and 2000;100:S11–5.
oral health: a review. Aust Dent J. 2010;55:128–33. https://doi. 49. Linnett V, Seow WK, Connor F, Shepherd R. Oral health of
org/10.1111/j.1834-7819.2010.01226.x. children with gastro-esophageal reflux disease: a controlled
30. Paganini M, Dezan CC, Bichaco TR, de Andrade FB, Neto AC, study. Aust Dent J. 2002;47:156–62.
Fernandes KB. Dental caries status and salivary properties of asth- 50. Ersin NK, Onçağ O, Tümgör G, Aydoğdu S, Hilmioğlu S. Oral
matic children and adolescents. Int J Paediatr Dent. 2011;21:185– and dental manifestations of gastroesophageal reflux disease in
91. https://doi.org/10.1111/j.1365-263X.2010.01109.x. children: a preliminary study. Pediatr Dent. 2006;28:279–84.
31. Mehta A, Sequeira PS, Sahoo RC, Kaur G. Is bronchial asthma 51. Weiss JE, Ilowite NT. Juvenile idiopathic arthritis. Pediatr Clin N
a risk factor for gingival diseases? A control study. N Y State Am. 2005;52(2):413–42. https://doi.org/10.1016/j.pcl.2005.01.007.
Dent J. 2009;75:44–6. 52. Kahn P. Juvenile idiopathic arthritis - an update on pharmaco-
32. Malamed SF. Sedation: a guide to patient management. Mosby: therapy. Bull NYU Hosp Jt Dis. 2011;69:264–76.
St Louis; 1985. p. 529–30. 53. Sidiropoulou-Chatzigianni S, Papadopoulos MA, Kolokithas
33. Widmer RP. Oral health of children with respiratory diseases. G. Mandibular condyle lesions in children with juvenile idio-
Paediatr Respir Rev. 2010;11:226–32. https://doi.org/10.1016/j. pathic arthritis. Cleft Palate Craniofac J. 2008;45:57–62. https://
prrv.2010.07.006. doi.org/10.1597/07-014.1.
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Behrman RE, Jenson HB, Stanton BF, editors. Nelson Textbook and case report. J Dent Child (Chic). 2013;80:25–30.
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Child-Centred Dentistry:
Engaging and Protecting
Children
Zoe Marshman and Helen Rodd
Contents
References – 560
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554 Z. Marshman and H. Rodd
23.1 Introduction
a suffix to indicate the age range for which the instru-
All children have a right to high-quality dental care and ment has been validated (e.g. CPQ8–10 is intended for
to be involved in decisions about their own oral health. children aged 8 to 10 years) and the number of items
This fundamental principle is embedded in many global included in the questionnaire (e.g. CPQ-16SF indi-
policies, such as the United Nations Convention on the cates that it is a 16-item ‘short form’ version of the
Rights of the Child [1] and the Council of Europe full CPQ). Each measure has inherent strengths and
Guidelines on Child-Friendly Health Care [2]. These limitations which have been critiqued in a previous
publications seek to promote the welfare and wellbeing review [3].
of children as a whole. Regrettably, there are still many
countries and cultures around the world where children’s
positions remain tokenistic or violated (see 7 https://
The past two decades have seen a steady increase in the
www.humanium.org/en/child-rights for the current sit- development of validated questionnaires for measuring
uation). children’s OHRQoL. In essence, these seek to quantify
The goal of child-centred dentistry is not simply to the degree to which a child’s oral status affects their lives
ensure that children’s mouths are disease- and symptom- in relation to a variety of psychosocial and functional
free. Rather, emphasis is placed on listening to and valu- domains (. Fig. 23.1). The most commonly used
ing young patients’ opinions in order to better meet their response format requires the participant to state how
perceived oral health needs. This chapter will highlight often their mouth/lips/teeth have affected them over a
concepts which are inherent to child-centred practice, given time period (e.g. 3 months). In contrast, a few
principally oral health-related quality of life, decision-OHRQoL instruments ask the respondent about the
making and consent, safeguarding, service evaluation, severity, rather than frequency, of any impacts. The
research and ethics. majority of current measures are not condition specific,
meaning that they can be applied to all children, irre-
spective of their oral status. However, some investiga-
23.2 Oral Health-Related Quality of Life tors have argued the case for more ‘sensitive’ measures
which are designed to measure the impact (and evaluate
The notion of health-related and, more specifically, oral the subsequent treatment effect) of a specific condition,
health-related quality of life (OHRQoL) is now well such as caries, malocclusion or developmental enamel
integrated within modern clinical practice. The premise defects. The recently developed caries-specific measure
underlying OHRQoL is that an individual’s oro-facial (CARIES-QC) is one such example, and this has been
condition may impact more widely than on function and validated for use with 5- to 16-year-old children who
symptoms alone, having potential effects on social and have caries experience [4]. To illustrate these fundamen-
emotional aspects. Thus, dental disease/disorders, as tal differences, . Fig. 23.2 provides examples of both a
well as associated dental interventions, can be evaluated generic OHRQoL measure which has a frequency
in terms of how they impact on OHRQoL. The tradi- response format (CPQ11–14) and a condition-specific
tional biomedical (surgical) approach to treating dental measure which has a severity response format
disease has been largely superceded by a more biopsy- (CARIES-QC).
chosocial approach, where treatment outcomes can be It should also be noted some child OHRQoL mea-
measured in terms of positive or negative change to self- sures have been designed for completion by adults/car-
reported wellbeing. ers/clinicians, as a proxy, rather than by children
themselves, such as the parental perceptions of child
OHRQoL questionnaire (P-CPQ) [5]. These question-
23.2.1 Measures Used naires require the parent/carer to indicate how much
they think their child’s oral health condition is having an
impact on the given areas. This approach is clearly
Eye Catcher appropriate for very young children or those with severe
learning disabilities, but it is recognised that
To date, the most well-known and widely translated child-reported and parental/proxy-reported impacts do
instruments for measuring children’s OHRQoL not necessarily concur [6–8]. Indeed, there is evidence to
include the Child Perceptions Questionnaire (CPQ), suggest that parents tend to under-report the severity of
the Child Oral Impact on Daily Performances impacts associated with their own child’s oral condition.
(C-OIDP) and the Child Oral Health Impact Profile The child OHRQoL literature is a rapidly emerging
23 (COHIP). The questionnaire notation often includes field. The main body of work, to date, has used OHRQoL
measures to describe the oral health of a target popula-
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Child-Centred Dentistry: Engaging and Protecting Children
555 23
Items
Theoretical domains
• Interactions
• Friendships
Social well-being
• Being teased
• School performance
• Pain (acute/chronic)
Oral symptoms
• Discomfort
OHRQoL
• Self esteem
Psychological well-being • Self concept
• Embarrassment/shyness
• Eating/drinking
• Speaking
Function
• Sleeping
• Sports, music etc
.. Fig. 23.1 Theoretical domains and examples of different items that may be included within oral health-related quality of life (OHRQoL)
questionnaires
How much do your teeth annoy you? Clinicians have a responsibility to ensure that they
actively involve young patients, along with their parents/
Not at all
carers, in managing their oral health. This aspiration
A bit presents acknowledged challenges, especially when
A lot looking after very young children or those with learning
disabilities. It should also be recognised that children
may differ greatly as to how much or little they actually
wish to be involved in decision-making, taking an active
.. Fig. 23.2 Examples of different response formats used in child
oral health-related quality of life measures: a response according to
or passive role [14]. Nonetheless, the overarching prin-
the frequency of an impact as used in the generic Child Perceptions ciple remains: children have the right to be involved in
Questionnaire (CPQ) and b response according to the severity of an treatment decisions that relate to them [2]. To achieve
impact in the caries-specific Child Experiences of Caries Question- this aim, children should be presented with information
naire (CARIES-QC) in a format and language that they can understand,
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556 Z. Marshman and H. Rodd
whilst being sensitive to the values and views of their Eye Catcher
carers. The UK Patient Information Forum provides
invaluable advice for how to develop high-quality and The child’s best interests are central, and in the case
developmentally appropriate information for young ser- of a very young pre-cooperative child who requires an
vice users [15]. urgent examination, it would seem appropriate to
The value of shared decision-making is well recog- seek the parent’s approval to hold the child, in a safe
nised within paediatric healthcare as a whole, and a and controlled manner. However, restraining an older
number of interventions have been used to facilitate this child against their will, thereby posing physical dan-
process [16]. In recent years there has been a growth in ger to the child and staff, would not be a good prac-
the popularity and availability of patient decision aids tice. This serves only to reinforce the child’s dental
(PDAs) to support healthcare encounters. These inter- anxiety and mistrust with the potential for long-term
ventions seek to help patients in healthcare decisions, negative impacts.
thereby reducing decisional conflict and increasing
patient satisfaction and knowledge. Although these have
mostly been directed towards parents, some PDAs have 23.4 Safeguarding
been specifically designed for adolescent dental patients,
in the context of choices relating to orthodontic treat- It is abhorrent that we live in a world where children are
ment [17] and sedation/general anaesthesia [18]. Rapid exposed to emotional, physical or sexual abuse as well as
advances in social media and information technology neglect. It remains imperative therefore that the whole
may also offer child-appropriate and engaging means of dental team is vigilant and competent in the identifica-
providing information about dental conditions and tion and expedient management of all types of abuse. It
treatment options. is widely cited that non-accidental injuries involve the
head and neck regions in 50% of all injuries; thus, pre-
sentation in the dental setting may be more common
23.3.2 Principles of Consent than other healthcare services [21]. Children under the
age of 2 years are reportedly at greatest risk of safe-
Integral to decision-making is the formal consent/ guarding concerns. Some important signs and risk fac-
assent process. The legalities of the consent process tors of a child’s vulnerability may include those shown
vary across the world, but the parent/guardian is usu- below [22, 23].
ally required to sign a written consent form prior to
>>Important
treatment. Where possible, the assent of the child is to
Patient/parent interactions
be encouraged. The legal age at which the child can pro-
–– Delayed presentation of injury
vide written consent again varies across the world but is
–– History of any injury inconsistent with clinical
usually over the age of 16–18 years. There has been
findings
much debate as to whether a child, younger than the
–– Withdrawn child
required legal age, can in fact agree to treatment them-
–– Lack of parental empathy
selves. The principle of ‘Gillick’ or ‘Fraser’ competence
–– Inappropriate comments
supports the right of children in the United Kingdom
to agree to treatment themselves, providing they are
Physical signs
perceived to fully understand the treatment options and
–– Failure to thrive (low body mass index)
implications [19]. The clinician has the overarching
–– Dirty and smelly
responsibility of ensuring that they always act in the
–– Inappropriately dressed
child’s best interests.
–– Untreated head lice or other infections (e.g. impe-
The issue of physically restraining a child for neces-
tigo)
sary dental treatment remains controversial [20]. In
–– Multiple bruises, of different vintage
some countries it is an accepted practice to use physical
–– Unusual injuries, bites, burns, pinch marks
restraint, also referred to as protective stabilisation, with
or without additional pharmacological regimens.
Family risk factors
However, in other countries, this is not part of routine
–– History of drug/alcohol dependency
care, with some bodies viewing it as an ‘assault’ or
–– History of domestic violence
infringement of the child’s rights.
–– Parent subject to abuse as a child
23
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Child-Centred Dentistry: Engaging and Protecting Children
557 23
–– Low socioeconomic status looked and a clear pathway is identified for subsequent
–– Chaotic and lifestyle stressors, multiple children information sharing, multiagency support and social
from different fathers care referral where necessary.
–– Unemployment, financial stress
–– Frequent past attendances at emergency depart-
ments
23.5 Service Evaluation
–– Child not attending school
There are currently around 2.2 billion children in the
This is an area that clinicians find particularly difficult,
world, representing a large sector of health service users.
with many reported barriers to addressing potential
Thus one can readily see the argument for greater child
abuse, including lack of training, concern about how
representation, as key stakeholders, in consultations about
their questioning may be received by the family and
quality assurance and planning of healthcare services. An
worry that they may make things worse for the child.
example of this commitment to involve children comes
Support and resources should be available to support
from a 2016 survey of the quality of care received by
clinicians in this challenging area. Furthermore, manda-
British children during their hospital admission (see
tory training in safeguarding should be undertaken by
7 http://www.cqc.org.uk/sites/default/files/20171128_
all dental health professionals. It is also important that
tocol for following up on children who were not brought ity, established in 2000, that provides expertise for devel-
to their scheduled dental appointments. This will ensure oping effective tools to capture patients’ experiences,
that children who are known to be ‘at risk’ are not over- thereby improving the quality of health and social care.
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558 Z. Marshman and H. Rodd
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Child-Centred Dentistry: Engaging and Protecting Children
559 23
.. Fig. 23.3 Two young sisters engaged in a participatory activity relating to genetic research about amelogenesis imperfecta, drawing their
‘family trees’
including interviews, focus groups, film-making, video can be ethically be involved in research as well as identi-
or written diaries. These techniques can also be sup- fying roles and responsibilities of all involved.
ported by participatory activities such as drawing,
model-making or role play (. Fig. 23.3). Qualitative
Tip
methods offer some advantages to quantitative
approaches in that they facilitate participation of The accompanying website provides excellent films, ani-
younger children or those with specific learning or lan- mations and other resources for involving children in
guage disabilities. They also allow a deeper insight into health research (accessed at 7 http://nuffieldbioethics.
https://t.me/DentalBooksWorld
560 Z. Marshman and H. Rodd
should be made aware that if they disclose something 13. Aimée NR, Damé-Teixeira N, Alves LS, et al. Responsiveness of
that concerns the research team from a child protection Oral health-related quality of life questionnaires to dental caries
interventions: systematic review and Meta-analysis. Caries Res.
point of view, the researcher may have to share this
2019;53(6):585–98.
information. 14. Hall M, Gibson B, James A, Rodd HD. Children's experiences of
participation in the cleft lip and palate care pathway. Int J Paedi-
atr Dent. 2012;22:442–50.
23.7 Conclusion 15. Patient Information Forum. Guide to Producing Health Information
for Children and Young People. 2014. https://www.pifonline.org.uk/
wp-content/uploads/2014/11/PiF-Guide-Producing-Health-Informa-
Paediatric dentistry, by the very nature of the specialty, tion-Children-and-Young-People-2014.pdf. Accessed 11.2.21.
has always striven to be patient-centred. However, con- 16. Wyatt KD, List B, Brinkman WB, Prutsky Lopez G, et al. Shared
tinued transformation within social, educational and decision making in pediatrics: a systematic review and Meta-
health policy has driven more robust and evidence-based analysis. Acad Pediatr. 2015;15:573–83.
approaches to the way in which children are engaged 17. Marshman Z, Eddaiki A, Bekker HL, Benson PE. Development
and evaluation of a patient decision aid for young people and
within dentistry.
parents considering fixed orthodontic appliances. J Orthod.
2016;43:276–87.
18. Hulin J, Baker SR, Marshman Z, Albadri S, Rodd HD. Develop-
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tal research. Int J Paediatr Dent. 2015;25:310–6. 36. Gilchrist F, Rodd HD, Deery C, Marshman Z. Involving chil-
33. Marshman Z, Gibson BJ, Owens J, Rodd HD, et al. Seen but not dren in research, audit and service evaluation. Br Dent J.
heard: a systematic review of the place of the child in 21st-cen- 2013;214:577–82.
tury dental research. Int J Paediatr Dent. 2007;17:320–7.
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563
Supplementary
Information
Index – 565
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565 A–B
Index
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566 Index
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Index
567 B–D
Class I amalgam restorations 307 –– tooth brushing 268, 269
Class II cavities 296–297 –– diagnosis and record keeping
Class II malocclusion 212–214, 218 –– detection of early caries 255
Class II RMGIC restoration 310 –– DIFOTI 256
Class III malocclusion 213 –– digital radiography 257–259
Classical apexification 403 –– direct visualization 255
Clefts 544, 545 –– laser/light fluorescence 256
Cleidocranial dysplasia (CCD) 183–185, 239 –– non-operative diagnostic methods 255
Coagulopathies 509 –– QLF 257
Coeliac disease 495 –– radiographic examination 255
Cognitive development –– tactile sensation 255
–– children’s thought process 12 –– diet 273–274
–– concrete operational stage 12, 17, 18 –– epidemiology and treatment 252
–– formal operational thought 12, 18, 19 –– fluoride gels 264
–– preoperational stage 12, 15–17 –– fluoride rinses 264
–– preventing dental fear 20, 21 –– fluoride tablets and drops 263
–– sensorimotor stage 12–15 –– fluoride toxicity 266–267
–– short-and long-term goals 12 –– fluoride varnish 265
–– tailoring oral messages 21, 22 –– mechanism of action 262–263
Colony-stimulating factor-1 (CSFL1) 180 –– milk fluoridation 263
Communication –– pathogenesis of
–– aspects 52 –– caries microbiology 248–250
–– with children 54 –– dental appliances and restorations 250–251
–– empathy and 55, 56 –– fermentable carbohydrates 248
–– nonverbal communication 52, 53 –– hereditary (genetic) factors 251
–– with parents 53, 54 –– physico-chemical process 248
–– verbal communication 53 –– salivary flow 250
–– written information 54 –– socio-economic status 250
Complicated crown fracture 383–386 –– thickness/maturation of dental plaque 248
Computer controlled administering of anesthesia (C-CLAD) 114, –– tooth morphology and structure 250
115 –– patient motivation 274–277
Concussion 372–373 –– presence of black stains 261
Cone beam computed tomography (CBCT) 102–104, 388 –– prevention and control of 262
Cone beam tomographic examination (CBCT) 398 –– probiotics 267–268
Congenital granular cell tumor 490 –– recall visit 277
Congenital heart disease 81, 540 –– silver diamine fluoride 265
Consent 556 –– toothpaste 264
Contemporary attrition 467 –– treatment strategy of 261
Cotton wool pellet 335 –– water fluoridation 263
COVID-19 6, 142 –– xylitol 267
Coxsackie virus 498 Dental education 2
Craniofacial anomalies 546–548 Dental erosion
Craniomandibular disorders (CMD) 478 –– abfraction 467
Crohn’s disease 494, 495 –– clinical examination and diagnosis 470, 471
Crouzon and Apert syndromes 546, 547 –– definition 466
Crowding 229 –– extrinsic factors 469, 470
Crown angulation 379 –– intrinsic factors 470
Crown dilaceration 379 –– prevalence and severity 467–469
Crown-root fracture 366, 370, 386, 387 –– prevention 471
Cvek’s partial pulpotomy 385 –– restoration 471, 472
Cystic fibrosis 542, 543 Dental fear
Cystic fibrosis transmembrane conductance regulator (CFTR) 542 –– behavior rating scale 47, 48
–– child misbehavior 39–41
–– classical conditioning 41, 42
–– cognitive vulnerability 43
D –– communication
Decision-making 555, 556 –– aspects 52
Dental amalgam 307 –– with children 54
Dental anxiety 40 –– empathy and 55, 56
Dental caries 85 –– nonverbal communication 52, 53
–– caries risk assessment 259–261 –– with parents 53, 54
–– chlorhexidine 267 –– verbal communication 53
–– clinical manifestation 252–253 –– written information 54
–– CPP-ACP 267 –– definition 40
–– dental plaque removal –– dental environment 56, 57
–– depth and morphology of pits and fissures 270–273 –– family stressors 44
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568 Index
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569 D–G
–– dental rehabilitation 446, 449 –– contraindications 145
–– gene investigation and correlation 448 –– dental treatment 146–149
–– hypomatured-hypoplastic with taurodontism 446, 447 –– indications 145
–– hypoplastic type 445, 446 –– induction 146–148
–– masticatory forces 446, 447 –– operating room procedure 146
–– mechanisms 445 –– oral rehabilitation goals 145
–– dentin dysplasia 451 –– patient history 150
–– dentinogenesis imperfecta 449–451 –– pre-operative evaluation 145, 146
–– enamel dysplasia 442–444 –– safety 151
–– enamel fluorosis 441–443 –– stages 139, 140
–– histological examination 436 Genetic diseases
–– hypomineralization and hypomaturation 436 –– clefts 544, 545
–– intra-coronal dentin radiolucencies 451, 452 –– cystic fibrosis 542, 543
–– medical history 436 –– down syndrome 540–542
–– MIH 436–442 –– ectodermal dysplasia 541, 542
–– mineralization and maturation 436 –– familial mediterranean fever 544
–– molar incisor malformation 441, 442 –– muscular dystrophy 543, 544
–– ROD 451, 452 –– osteogenesis imperfecta 545, 546
–– systemic diseases and syndromes 451–454 –– syndromes and craniofacial anomalies 546–550
–– systemic/local causes 432, 434–435 Gingival health 3
Eosinophilic granuloma 506 Gingival hyperplasia 351, 352
Epidermolysis bullosa 453 Gingival index (GI) 83
Epilepsy 537 Gingival recession 358
Epstein Barr virus (EBV) 497 Gingivitis 348–350
Er:YAG laser 287 Glass ionomer cements (GIC) 303, 304
Erythema migrans 487, 488 Gluten-sensitive enteropathy (GSE) 495
Erythema multiforme (EM) 503, 504 Graft-versus-host disease (GvHD) 504, 505
Eudomembranous candidiasis 502 Growth
European Academy of Pediatric Dentistry (EAPD) 62 –– area relocation 160, 161
Ewing’s sarcomas 516 –– bone age 27, 30
Extraoral examination 81, 83, 84 –– bone and cartilage 162, 163
Extra oral wound 364 –– cephalometrics 170–172
Extrusive luxation 374, 393–395 –– childhood growth 26
–– dental age 27, 30
–– growing face features 156, 157
–– growth fields 160
F –– infantile growth 26
Facemask 213 –– IUGR 30
Facemask treatment 217 –– malocclusions 172–175
Familial hypophosphatemia 452 –– mandible
Familial mediterranean fever 544 –– lingual tuberosity 168
Family and social history 80 –– mandibular condyle 168, 169
Ferric sulphate 331 –– ramus 167, 168
Fibroepithelial polyp 489 –– ramus uprighting 169, 170
Fluoride 471 –– mandibular condyle 160, 161
Fluoride gels 264 –– MPH/target height 27
Fluoride rinses 264 –– nasomaxillary complex
Fluoride tablets and drops 263 –– arch lengthening 165
Fluoride toxicity 266–267 –– maxillary tuberosity 165, 166
Fluoride varnish 265 –– palatal remodeling and alveolar development 166
Formocresol 331 –– primary displacement 167
Fragile X chromosome syndrome 546 –– neurocranium
Frankel applian 213 –– basicranium 164, 165
Frankl rating scale 47, 48 –– calvaria 164
Frenum pull 358–359 –– palate inferiorly relocation 161
Functional posterior crossbite 229 –– prenatal facial growth and development
Fungal infections 502, 503 –– characteristic postnatal resorptive fields 160
Furcation bone infection 322 –– cranial nerve 157, 158
–– eyes location 157, 158
–– hyoid arch 158, 159
–– interorbital dimension 157, 158
G –– mandibular arch 158, 159
Gastroesophageal reflux disease (GERD) 470, 523 –– oral and paired nasal chambers 159
Gastrointestinal disease 494 –– prenatal growth 26
Gene mutations 539 –– primary displacement 161–163, 165
General anesthesia (GA) 285 –– process 26
–– admission to hospital 145, 146 –– pubertal growth 26
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570 Index
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571 G–O
–– rate/speed 114 Molar incisor malformation (MIM) 441, 442
–– temperature 114 Monofluorophosphate fluoride (MFP) 264
–– injection within bone Mouth breathing 243
–– intraseptal anesthesia 120 Mouth-guards 407–409
–– IO anesthesia 120, 121 Moyers' analysis 233
–– injectors and needles 112, 113 Moyers' mixed dentition analysis 233
–– intrapulpal anesthesia 122 Mucoceles 510
–– jet injection technique 115, 116 Mucocutaneous disease 503
–– local complications –– allergic reactions 504, 505
–– cheek, lip/tongue injury 125, 126 –– erythema multiforme 503, 504
–– edema 125 –– GvHD 504, 505
–– hematoma 125 Mucositis 517
–– needle breakage 125 Multifactorial disease 248
–– pain and sense of burning 125 Multifocal epithelial hyperplasia (MEH) 500
–– paraesthesia 125 Mumps 499
–– trismus 125 Muscular dystrophy 543, 544
–– vasoconstrictors 125, 127
–– local infiltration anesthesia 116–119
–– palatal techniques N
–– AMSA injection 119 Nail biting 243
–– nasopalatine nerve block 119, 120 Nance button anchorage 211
–– P-ASA 120 Necrotic immature (open apex) teeth 402
–– systemic complications 126 Necrotic mature (closed apex) teeth 402
–– topical anesthesia 115, 117 Needle-phobia 74, 75
–– topical anesthetics 112 Neoplasms
–– vasoconstrictor 113 –– acute lymphoblastic leukemia 516
Local infiltration anesthesia 116–119 –– clinical finding and treatment 517–519
Localized aggressive periodontitis 353 –– dental care protocol 518
Localized anterior crossbite 208, 210, 217 –– osteosarcomas 516
Localized gingivitis 349 Neurofibromatosis type I (NF1) 352, 547, 549
Localized juvenile spongiotic gingival hyperplasia (LJSGH) 350, Neuropsychiatric/psychological disorders
351 –– ADHD 535–537
Localized periodontitis 356 –– ASD 534–536
Luxation injuries 372–375 –– epilepsy 537
Lymphangiomas 491 –– nutrition and weight 537–539
Lymphomas 505 Neurotoxicity 518
Neutropenia 507, 508
M Nitrous oxide (N2O)
–– adverse effects 142
Malocclusion 479, 546 –– breathing practice 140
Mandibular anterior teeth 284 –– contraindications 141, 142
Mandibular primary molars 317 –– in COVID-19 era 142
Mandibular torus 488 –– informed consent 140
Marginal fractures 305 –– inhalation sedation 137–140
Masticatory system 478 –– monitoring 141
Maxillary impacted permanent canine 240 –– personnel safety 142
Maxillary incisors 297 –– rapid induction technique 141
Maxillary lateral incisor agenesis 238 –– rubber dam 141
Maxillary primary canine 319 –– standard titration technique 141
Maxillary primary left central incisor 373 Non-complicated crown fracture 392
Maxillary primary right central incisor 291, 372 Non-Hodgkin’s lymphoma (NHL) 500, 506
Maxillofacial disorders 548 Noonan syndrome 547, 548
McNamara-type RME 212 NuSmile 307
Measles 498, 499 NuSmile zirconium crown 308
Medical history 80–82 Nutrition 537–539
Medicines, dental erosion 469 Nyvad’ visual-tactile classification system 254
Medium ankyloglossia 360
Melanocorin-1 receptor gene (MC1R) 44
Mesio-buccal root 333
Mesiodens 238
O
Methacryloyl-oxy-dodeca-pyridinium bromide (MDPB) 311 Obesity 539
Microflora transmission 250 Odontoma-type dysplasia 379
Midparental height (MPH) 27 Omni-matrix ™ 302
Milk fluoridation 263 One-phase treatment 212
Mineral trioxide aggregate paste (ΜΤΑ) 326, 329–330 OptiView™ (Kerr) 301
Mixed dentition analysis 233 Oral dryness 511, 512
Molar-incisor hypomineralization (MIH) 296, 378, 436–442 Oral hairy leukoplakia (OHL) 500
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572 Index
Oral health-related quality of life (OHRQoL) 554, 555 Orofacial system (OFS)
Oral hygiene 106 –– anamnestic records 480
Oral hygiene instructions 350 –– centric relation/centric occlusion 476, 477
Oral lesions –– clinical examination 480, 481
–– bacterial infections –– components 476
–– acute necrotizing ulcerative gingivitis 502 –– diagnosis 480, 481
–– impetigo 500, 501 –– eccentric mandibular movements 477
–– scarlet fever 501 –– eccentric positions 477
–– tuberculosis 501, 502 –– epidemiology 478
–– fungal infections 502, 503 –– etiology 478–480
–– hematological disease –– functions 476
–– anemia 506 –– imaging 480
–– bleeding disorders 508, 509 –– maxillomandibular relationships 476
–– Hodgkin’s disease 505 –– maximum intercuspation 476
–– langerhans cell histiocytosis 506 –– rest position 477
–– leukemias 506 –– treatment strategies 482
–– lymphomas 505 –– vertical dimension 477, 478
–– neutropenia 507, 508 Orofacial-myofunctional therapy 243
–– NHL 506 Orthodontic brackets 239, 251
–– sickle cell diseases 507 Orthodontic management
–– thalassemias 507 –– harmful oral habits
–– lymphangiomas 491 –– lip sucking 243–244
–– mucocutaneous disease 503 –– mouth breathing 243
–– allergic reactions 504, 505 –– nail biting 243
–– erythema multiforme 503, 504 –– pacifier overuse 240–242
–– GvHD 504, 505 –– position of tongue at swallowing 242–243
–– oral mucosal and boney abnormalities –– thumb sucking 240–242
–– cysts 488 –– intervention in mixed dentition
–– erythema migrans 487, 488 –– arch space anomalies 229–233
–– mandibular torus 488 –– dental spacing 233–234
–– palatal torus 488 –– Moyers' mixed dentition analysis 233
–– reactive overgrowths –– occlusal anomalies 234–237
–– congenital granular cell tumor 490 –– partial archwire and springs 232
–– fibroepithelial polyp 489 –– Staley and Kerber analysis 233
–– peripheral giant cell lesion 489, 490 –– Tanaka and Johnston analysis 233
–– peripheral ossifying fibroma 489 –– tooth number and eruption related anomalies 237–240
–– pyogenic granulomas 488, 489 –– intervention in primary dentition
–– swellings 490 –– arch space anomalies 218–223
–– salivary gland disease –– occlusal anomalies 223–229
–– acute suppurative sialadenitis 511 –– profile evaluation
–– drooling 512 –– convex profile 212–218
–– mucoceles 510 –– orthodontic vs. orthopedic treatment 208
–– ranula 510 –– straight profile 208–210
–– recurrent parotitis 511 Orthodontic treatment 2
–– sialolithiasis 510, 511 Orthodontics 479, 480
–– xerostomia 511, 512 Orthopantomographic (OPG) radiograph 27, 30
–– ulceration (See Oral ulceration) Osler-Weber-Rendu syndrome 508
–– vascular malformations 490, 491 Osteogenesis imperfecta (OI)
–– viral infections –– bisphosphonates 545, 546
–– hand foot and mouth disease 498 –– classification 545
–– herpangina 498 –– malocclusion 546
–– herpes simplex 495, 496 –– prevalence 545, 546
–– herpes zoster 496, 497 Osteopetrosis 453
–– HIV 500 Osteosarcomas 516
–– HPV 499 Over-the-counter fluoridated toothpaste 264
–– infectious mononucleosis 497, 498
–– measles 498, 499
–– MEH 500 P
–– mumps 499 Palatal anterior superior alveolar block (P-ASA) 120
–– warts 499 Palatal torus 488
Oral ulceration Panoramic radiography 101, 102
–– aphthous ulceration 492–494 Partial pulpotomy 337, 338, 341, 384, 385
–– Crohn’s disease 494, 495 Passive immobilization 72–74
–– gastrointestinal disease 494 Patient-reported experience measures (PREMs) 557
–– GSE 495 Patient-reported outcome measures (PROMs) 557
–– traumatic oral ulceration 491–493 Perikymata 258
Orange plaque (biofilm) 262 Perimylolysis 470
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Index
573 O–R
Periodontal diseases Preventive resin restoration (PRR) 292–293
–– frenum pull 358–359 Prevotella sp. 348
–– gingival hyperplasia 351, 352 Primary failure of eruption (PFE) 183
–– gingival recession 358 Primary molar hypomineralization 254
–– gingivitis 348–350 Primary molar pulpotomy 328–331
–– LISGH 350, 351 Primary molar restorations 286–287
–– periodontitis Probably toxic dose (PTD) 266
–– acute ulcerative gingivitis 357–358 Pseudomembraneous candidiasis 500
–– chronic periodontitis 353–356 Psychotropic analgesic nitrous oxide (PAN) 139
–– diabetes mellitus and 357 Puberty
–– localized aggressive periodontitis 353 –– delayed puberty 35
–– with systemic disease 356 –– development 34
Peripheral giant cell lesion 489, 490 –– environmental, metabolic and genetic factors 34
Peripheral ossifying fibroma 489 –– precocious puberty 34, 35
Permanent teeth Public health systems 85
–– endodontic evaluation and management of 401–405 Pulp canal obliteration 399
–– follow-ups of 390, 398, 401 Pulp necrosis 398
–– fractures of Pulp sensibility testing 398
–– complete enamel fracture 380–381 Pulp therapy
–– complicated crown fracture 383–386 –– cariously necrotic primary teeth 316
–– crown-root fractures 386, 387 –– diagnostic procedure
–– enamel infraction 380 –– clinical examination 318–320
–– root fracture 387–389 –– dental surgery 316–318
–– uncomplicated crown fracture 381–383 –– medical history 316
–– luxation injuries to –– radiographic examination 320–321
–– avulsion 394–396 –– symptoms and signs in 323
–– concussion 389–390 –– management of emergency 321–324
–– extrusive luxation 393, 394 –– treatment of
–– intrusive luxation 391, 393 –– direct pulp capping 325–327
–– lateral luxation 390–391 –– indirect pulp capping 323, 325
–– subluxation (loosening) 390 –– primary molar pulpotomy 328–331
–– post-traumatic complications of 396–401 –– pulpectomy/root canal treatment 331–334
Pervasive developmental disorder (PDD) 534 –– young carious permanent teeth
Pharmacologic behavioral management –– cervical pulpotomy 337
–– general anesthesia (See General anesthesia (GA)) –– direct pulp capping 336–337
–– sedation –– immature carious teeth immature carious teeth 337–341
–– acceptance and preferences 133, 134 –– indirect pulp capping 335–336
–– anatomical airway 134, 135 –– partial pulpotomy 337
–– anxiolysis (See Anxiolysis) –– restoring color of discolored teeth 341–342
–– BLS training 135 Pulpitis 376
–– child and parent preparation 135 Pyogenic granulomas 488, 489
–– deep sedation 133
–– definition 132
–– documentation 136, 137 Q
–– general anesthesia 133 22q11 deletion syndrome 549
–– guidelines 132 Qualitative methods 559
–– health status and cooperation assessment 134, 135 Quantitative light-induced fluorescence (QLF) 257
–– informed consent 135 Quantitative methods 558
–– minimal sedation 132
–– moderate sedation 133
–– monitoring and resuscitation equipment 136, 137
–– parental expectations 132
R
–– physical status 134 Rampant caries 518
–– pre-operative assessment and consultation 134 Ranula 510
–– respiratory airway 134 Rapid induction technique 141
–– safety 151 Rearmost, upmost, and midmost (RUM) 476
Phenoxymethylpenicillin 323 Recurrent aphthous stomatitis (RAS) 492
Physical disability 530–532 Recurrent parotitis 511
Plaque index (PI) 83 Regenerative’ endodontic approach 339, 403
Plasma cell gingivitis (PCG) 351 Regional odontodysplasia (ROD) 451, 452
Polyacid modified composites 306 Relative analgesia (RA) 139, 140
Posterior cross bite 228 Replacement resorption (ankylosis) 387, 399
Postgraduate education 8 Resin based composites 305–307
Post-traumatic root resorptions 377 Resin-modified glass ionomer cement (RMGIC) 304, 440
Prader-Willi syndrome 549 Revised Iowa Dental Control Index (R-IDCI) 19
Predominant type 540 Rickets 452
Preformed metal crowns (PMCs) 145, 287–289, 307 Riga-Fede disease 492, 493
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575 R–Z
–– factors 105–108 –– herpangina 498
–– presentation to parents 105 –– herpes simplex 495, 496
–– specialist pediatric dentist, referral to 109 –– herpes zoster 496, 497
Tourette syndrome 546 –– HIV 500
Toxic epidermal necrolysis syndrome (TENS) 504 –– HPV 499
Transmission electron microscope 250 –– infectious mononucleosis 497, 498
Transpalatal arch 231 –– measles 498, 499
Transverse discrepancy 208, 210 –– MEH 500
Traumatic dental injuries (TDI) 367 –– mumps 499
Traumatic oral ulceration –– warts 499
–– causes 491 VistaProof (Durr Dental) systems 256
–– chronic mucosal biting 492, 493 Visual impairment blindness 533
–– diagnosis 491 Vomiting 470
–– Riga-Fede disease and granuloma 492, 493 von Recklinghausen disease 352, 547, 549
Treacher Collins syndrome 546, 547 von Willebrand’s disease (vWD) 509
Tricho-dento-osseous syndrome 549
Tuberculosis (TB) 501, 502
Tuberous sclerosis 453 W
Tunnel restorations 297
Warts 499
Turner syndrome 547
Water fluoridation 263
Two-phase treatment 212
Weight loss 538
White or yellow-brown spots 378
White ΜΤΑ 329
U
Unilateral posterior crossbite (UPCB) 479
Upper left canine 219 X
Upper lip edema 365
US dental schools 2 Xerostomia 511, 512
X-linked recessive trait (Xq13.1 gene) 542
Xylitol 267
V
Varicella zoster 496, 497
Verruca vulgaris 499
Z
Viral infections Zone of proximal development (ZPD) 15
–– hand foot and mouth disease 498 Z-shaped spring 236
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