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McDonald and Avery’s
DENTISTRY ELEVENTH EDITION
for the CHILD

and ADOLESCENT
Jeffrey A. Dean, DDS, MSD, FFD(Hon)RCSI
Ralph E. McDonald Professor of Pediatric Dentistry
Professor of Orthodontics and Dentofacial Orthopedics
Indiana University School of Dentistry
Riley Hospital for Children at IU Health
Indianapolis, Indiana
ASSOCIATE EDITORS: LaQuia A. Walker Vinson, DDS, MPH

James E. Jones, DMD, MSD, EdD, PhD Associate Professor and Graduate Program Director
Department of Pediatric Dentistry
Paul E. Starkey Research Professor of Pediatric Dentistry
Adjunct Clinical Faculty
Clinical Professor of Pediatrics
Indiana University School of Medicine
Brian J. Sanders, DDS, MS Juan Fernando Yepes, DDS, MD, MPH, MS, DrPH
Professor, Department of Pediatric Dentistry
Sarah Jane McDonald Professor and Chair of Pediatric
Dentistry
Director, Department of Pediatric Dentistry
Adjunct Professor, CES University, Medellin, Colombia
Adjunct Clinical Faculty, Department of Pediatric and
Community Dentistry
University at Buffalo, State University of New York
VIDEO PRODUCER FOR ONLINE TEXT:

Allison C. Scully, DDS, MS
Clinical Assistant Professor
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
MCDONALD AND AVERY’S DENTISTRY FOR ISBN: 978-0-323-69820-7

THE CHILD AND ADOLESCENT, ELEVENTH EDITION
Copyright © 2022 by Elsevier, Inc. All rights reserved.
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(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary. Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds or experiments described
herein. Because of rapid advances in the medical sciences, in particular, independent verification of
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The associate editors of this edition, Jim Jones, Brian Sanders, LaQuia Vinson,
Juan Yepes, and I would all like to affectionately dedicate this edition’s labor of love
to our spouses and children, and our many colleagues and students, both former
and current. To our families, we all know the time away from you to work on this
project can never be gained back, but your patience, love, and support throughout
its production are so wonderfully appreciated by us all.
“May the hinges of friendship never rust, nor the wings of love lose a feather.”
EDWARD B. RAMSAY, CIRCA 1857
Jeffrey A. Dean
Contributors
Jeffrey D. Bennett, DMD Burton L. Edelstein, DDS, MPH
Oral and Maxillofacial Surgery Professor of Dental Medicine and Health Policy &
Indiana University School of Dentistry Management
Roudebush VA Medical Center Section of Growth and Development, Division of
Indianapolis, Indiana Pediatric Dentistry
Columbia University Medical Center
Mathew David Bojrab, DDS, MS, FACS New York, New York
Indiana Oral and Maxillofacial Surgery Associates Senior Policy Fellow and President Emeritus
Fishers, Indiana Children’s Dental Health Project
Oral and Maxillofacial Surgery Washington, District of Columbia
Assistant Clinical Professor
Oral and Maxillofacial Surgery John D. Emhardt, BSE, MD
Indiana University School of Dentistry Associate Professor
Indianapolis, Indiana Anesthesia
Chairman Indiana University School of Medicine
Oral and Maxillofacial Surgery and Hospital Dentistry Indianapolis, Indiana
Indiana University Health-Methodist Hospital Medical Director
Indianapolis, Indiana Riley Outpatient Surgery Center
Chairman Indianapolis, Indiana
Oral and Maxillofacial Surgery and Hospital Dentistry
Community Hospitals Indianapolis Sabrina Feitosa, DDS, MSc, PhD
Indianapolis, Indiana Clinical Assistant Professor
Biomedical Sciences and Comprehensive Care
Judith Chin, DDS, MS Indiana University School of Dentistry
Professor, Pediatric Dental Resident Program Director Indianapolis, Indiana
Nova Southeastern University College of Dental Donald J. Ferguson, DMD, MSD
Medicine Professor of Orthodontics & Dean
Fort Lauderdale, Florida Orthodontics
European University College
Lilly Cortes-Pona Dubai
Owner, CDMP United Arab Emirates
LCP Dental Team Coaching
AAPD Speaker’s Bureau Member Elie M. Ferneini, DMD, MD, MHS, MBA, FACS
John Maxwell Leadership Coach Medical Director
Castle Rock, Colorado Beau Visage Med Spa
Private Practice, Greater Waterbury OMS
Jeffrey A. Dean, DDS, MSD, FFD(Hon)RCSI Cheshire, Connecticut
Ralph E McDonald Professor of Pediatric Dentistry Associate Clinical Professor
Professor of Orthodontics and Dentofacial Orthopedics Division of Oral and Maxillofacial Surgery
Indiana University School of Dentistry University of Connecticut
Riley Hospital for Children at IU Health Farmington, Connecticut
Indianapolis, Indiana Associate Clinical Professor
Department of Surgery
Kevin Donly, BS, DDS, MS Frank H Netter MD School of Medicine Quinnipiac
Professor and Chair University
Department of Developmental Dentistry Hamden, Connecticut
University of Texas Health Science Center at San Antonio
San Antonio, Texas Roberto Flores, MD
Professor Joseph G. McCarthy Associate Professor of Reconstructive
Department of Pediatrics Plastic Surgery
University of Texas Health Science Center at San Antonio Hansjorg Wyss Department of Plastic Surgery
San Antonio, Texas NYU Langone Health
New York, New York
vi
Contributors vii
Tasha Hall, DMD, MSD Carrie Klene, DDS

Director of Craniofacial Orthodontics Oral and Maxillofacial Surgeon
Department of Orthodontics Klene Center Oral & Facial Surgery
Indiana University Indiana University Health
Indianapolis, Indiana Carmel, Indiana
James Kennedy Hartsfield Jr., DMD, MS, MMSc, PhD Joan Elizabeth Kowolik, BDS, LDS, RCS Edin,
Professor and E. Preston Hicks Endowed Chair in Dip. Clin. Hyp.
Orthodontics and Oral Health Research Director, Associate Professor
Oral Health Science Pediatric Dentistry
University of Kentucky College of Dentistry Indiana University School of Dentistry
Lexington, Kentucky Indianapolis, Indiana
Adjunct Professor
Medical and Molecular Genetics George Krull, DDS
Indiana University School of Medicine Private Practice, Pediatric Dentistry (Retired)
Indianapolis, Indiana Clarkston, Michigan
Adjunct Professor
Orthodontics and Oral Facial Genetics John T. Krull, DDS
Indiana University School of Dentistry Department of Pediatric Dentistry
Indianapolis, Indiana Indiana University School of Dentistry
Adjunct Clinical Professor Indianapolis, Indiana
Orthodontics
University of Illinois at Chicago College of Dentistry John J. Manaloor, MD
Chicago, Illinois Assistant Professor of Clinical Pediatrics
Ryan White Center for Pediatric Infectious Diseases
Kerry Hege, MD, MSc Riley Hospital for Children, Indiana University School of
Assistant Professor Medicine
Pediatric Hematology/Oncology Indianapolis, Indiana
Riley Hospital at IU Health
Indiana University School of Medicine E. Angeles Martinez Mier, DDS, MSD, PHD
Indianapolis, Indiana Professor and Chair
Cariology, Operative Dentistry and Dental Public Health
Christopher V. Hughes, DMD, PhD Indiana University School of Dentistry
Professor and Chair Indianapolis, Indiana
Pediatric Dentistry
School of Dentistry, University of Mississippi Medical Hannah L. Maxey, PhD, MPH
Center Associate Professor
Jackson, Mississippi Family Medicine
Vanchit John, DDS, MSD Indianapolis, Indiana
Chairperson and Tenured Professor Director
Department of Periodontology Bowen Center for Health Workforce Research and Policy
Indiana University School of Dentistry at Indiana University School of Medicine
Indianapolis, Indiana Indianapolis, Indiana
James Earl Jones, DMD, MSD, EdD, PhD Lorri Ann Morford, PhD
Starkey Research Professor Assistant Professor
Department of Pediatric Dentistry Oral Health Science
Indiana University School of Dentistry University of Kentucky
Indianapolis, Indiana Lexington, Kentucky
Clinical Professor
Department of Pediatrics Charles Nakar, MD
Indiana University School of Medicine Pediatric Hematologist
Indianapolis, Indiana Department of Pediatric
Indiana Hemophilia and Thrombosis Center
Mathew Thomas Kattadiyil, BDS, MDS, MS Indianapolis, Indiana
Professor and Director
Advanced Specialty Education Program in
Prosthodontics
Loma Linda University School of Dentistry
Loma Linda, California
viii Contributors
Jeffrey A. Platt, DDS, MS Kenneth J. Spolnik, DDS, MSD

Professor and Chair Chair and Program Director
Biomedical Sciences and Comprehensive Care Enododontics
Indiana University Indiana University School of Dentistry
Laura Marie Romito, DDS, MS, MBA Jenny Stigers, DMD

Professor Associate Professor
Biomedical Sciences and Comprehensive Care University of Kentucky College of Dentistry
Indiana University School of Dentistry Lexington, Kentucky
Assistant Dean Dan Stoeckel, DDS, MS
IU Interprofessional Practice and Education Center Program Director
Indiana University Graduate Pediatric Dentistry
Indianapolis, Indiana Saint Louis University
Oral Pathologist
Brian Sanders, DDS, MS Department of Pathology
Sarah Jane McDonald Professor and Chair Saint Louis University
Department of Pediatric Dentistry St. Louis, Missouri
Indiana University School of Dentistry Pediatric Dentist
Riley Hospital for Children at IU Health St. Louis Children’s Hospital
Indianapolis, Indiana St. Louis, Missouri
Mark Saxen, DDS, PhD Shannon Thompson, MD

Adjunct Clinical Associate Professor Assistant Professor of Clinical Medicine
Oral Pathology, Medicine and Radiology IU Child Protection Programs
Indiana University School of Dentistry Indiana University School of Medicine
Dentist Anesthesiologist
Indiana Office-Based Anesthesia Erwin G. Turner, DMD
Indianapolis, Indiana Associate Professor and Residency Director
Pediatric Dentistry
Allison Scully, DDS, MS University of Kentucky College of Dentistry
Clinical Assistant Professor Lexington, Kentucky
Indiana University School of Dentistry Indianapolis Jose Luis Ureña-Cirett, CD, MS
Indianapolis, Indiana Pediatric Dentistry
United States Universidad Tecnológica de México, Mexico City
CDMX
Amy D. Shapiro, MD Mexico
Medical Director
Pediatric Hematology LaQuia Walker Vinson, DDS, MPH
Indiana Hemophilia & Thrombosis Center Associate Professor, Pediatric Dentistry
Indianapolis, Indiana Graduate Program Director, Pediatric Dentistry Indiana
Adjunct Senior Investigator University School of Dentistry Indianapolis
Blood Research Institute Indianapolis, Indiana
Blood Center of Wisconsin
Milwaukee, Wisconsin John Walsh, BDentSc, MSD (Ped), IUSD, MSD(Orth)
UW, FFDRCSI
Daniel Shin, DDS, MSD Course Lead,
Clinical Assistant Professor, Director Predoctoral Faculty of Dentistry
Periodontology Royal College of Surgeons
Department of Periodontology Dublin
Indiana University School of Dentistry Ireland
Pooya Soltanzadeh, DDS, MS

Assistant Professor
Advanced Prosthodontics
Loma Linda University School of Dentistry
Loma Linda, California
Contributors ix
Julie Weir, BS Juan Fernando Yepes, DDS, MD, MPH, MS, DrPH
Founder Professor
Consultant Pediatric Dentistry
Julie Weir & Associates Indiana University School of Dentistry Indianapolis
Middleburg, Virginia Indianapolis, Indiana
Clinical Associate Professor
Ghaeth Yassen, BDS, MSD, PhD Pediatric and Community Dentistry
Endodontist University at Buffalo School of Dental Medicine
Department of Endodontics Buffalo, New York
Case Western Reserve University Visiting Professor
Cleveland, Ohio Pediatric Dentistry
CES University
Medellin, Antioquia
Colombia
Reviewers
Dorothy Lynne Cataldo, DMD Cody Hughes, DMD, MSD

Private Practice, Pediatric Dentist Valley Pediatric Dental
Pediatric Dentistry Faculty Mesquite/Logandale, Nevada
NYU Langone Advanced Education Sunrise Children’s Dentistry
Tampa, Florida Las Vegas, Nevada
Brenda Bohaty, DDS, MSD, PhD Yuming Zhao, DDS, PhD

Professor and Chair, Pediatric Dentistry - UMKC School of Professor in the Department of Pediatric Dentistry
Dentistry Peking University School and Hospital of Stomatology
Director, Residency Program in Pediatric Dentistry - Beijing, China
Children’s Mercy Hospital
Kansas City, Missouri Man Qin, BDS, PhD
Professor of Department of Pediatric Dentistry
Farhad Yeroshalmi, DMD Peking University School and Hospital of Stomatology
Professor of Dentistry President of Chinese Society of Pediatric Dentistry
Albert Einstein College of Medicine Beijing, China
Chief & Residency Program Director
NYC Health + Hospitals/Jacobi
Bronx, New York
Foreword to the 11th edition of McDonald
and Avery’s Dentistry for the Child and
Adolescent: a historical review
when many American dentists had notices in their offices
that no children under the age of 12 years were accepted.
Harris opened a practice specializing in pediatric dentistry
in Detroit and decided a formal organization was needed
to spread good care. In 1927, he and others founded the
American Society for the Promotion of Children’s Dentistry,
which became the American Society of Dentistry for Chil-
dren (ASDC) in 1940. In 1947, he was also influential in
establishment of the American Academy of Pedodontics,
renamed the American Academy of Pediatric Dentistry
(AAPD) in 1984. In 1943, Harris was the founding editor
of the Review of Dentistry for Children, precursor of the Jour-
nal of Dentistry for Children. In the 1930s, Harris began to
formulate ideas on an international organization to bring
together children’s dentists from around the world. It was
1969 before his dream was fulfilled with establishment of
the International Association of Dentistry for Children,
which became the International Association of Paediatric
Dentistry in 1991. This all began to put children’s dentistry
Ari Kupietzky, DMD, MSc on a sounder footing, both at the general practitioner and
Private practice, Jerusalem, Israel specialist levels.
Department of Pediatric Dentistry, Rutgers School of Dental Walter E. McBride was the first president of ASDC. He
Medicine, Rutgers University, Newark, NJ and Harris devoted many hours to setting up the new orga-
Department of Pediatric Dentistry, Hebrew University‐ nization. He was also a president of the American Acad-
Hadassah School of Dental Medicine, Jerusalem, Israel emy of Pedodontics, the American Association of Dental
Editors, and the Detroit District Dental Society. McBride
was professor of pedodontics at the University of Detroit, so
Stanley Gelbier, Hon FFPH, MA, PhD,
anything he wrote or said was listened to. In 1933, he told
FDSDDPH, DHMSA a meeting of the American Dental Association that when
Honorary Professor in History of Dentistry, King’s College a general practice dentist refuses to treat children, he is
London, London, UK disregarding a major factor in practice building. He quoted
Emeritus-Professor in Dental Public Health, University of a new graduate who opened an office in a town of 2000
London, London, UK inhabitants where two dentists had practiced successfully
Past President and National Secretary, British Paedodontic for many years. They didn’t like the idea of a newcomer
Society, London, UK with the audacity of a beginner, who installed beautiful
new equipment and even employed an office assistant,
potentially taking from their income. As he especially liked
Introduction children, he suggested that they, not enjoying children’s
work, should refer them to him, and they agreed. The chil-
In 1963, when Ralph McDonald wrote Pedodontics, den- dren came, liked the new dentist, gave favorable reports
tistry for children was still in its infancy. McBride in 1952 to their parents and their mothers came for treatment: a
wrote that children were sometimes described as being practice builder.
“temperamental and hysterical, notional and incorrigible.” McBride published his Juvenile Dentistry in 1932, which
Many practitioners saw them as small adults and offered probably remained the leading text until McDonald entered
little treatment. Nevertheless, there had been for a long the field, although there were others. McBride said of his
time some enthusiastic dentists. One name to remember is own book, “It was not scientific nor theoretical, but purely
Sam Harris, who qualified from Ann Arbor Dental School a résumé of practical procedures employed over ten years
in 1924. Almost immediately, he enrolled at Boston’s in a private practice devoted entirely to children.” It is not
Forsyth Dental Infirmary for Children. He and his fellow surprising that McBride’s book was highly popular, but by
students learned much about child dental care at a time
xi
xii Foreword to the 11th edition of McDonald and Avery’s Dentistry for the Child and Adolescent: a historical review
the end of the 1950s there was room for something new: a recently changed its policy and guidelines from behavior
text based on scientific methodology. management to behavior guidance as was proposed by
We have to remember that when McDonald began his McDonald over 50 years ago. Pedodontics was upgraded in
career in the 1940s, children suffered from massive dental 1969 as Dentistry for the Child and Adolescent, which con-
caries, the prevalence being five times more than current tained his original 11 chapters from 1963 plus an addi-
(Bernabé & Sheiham, 2014). Prevention was needed. Fol- tional 17 chapters written by 14 contributors. From the
lowing pressure from H. Trendley Dean, in 1945, Grand beginning, the editors and contributors of McDonald’s Den-
Rapids became the first city in the world to fluoridate its tistry for the Child and Adolescent have been amongst the
drinking water. Over 15 years, Dean researched decay in specialty’s pioneers and top academicians, clinicians, and
30,000 schoolchildren and found that caries in children scientists. Early contributors included Maynard Hine, Wil-
born after fluoridation was reduced by over 60 percent, liam Shafer, Ralph Phillips, Roland Dykema, James Roche,
revolutionizing dental care. For the first time, tooth decay and Paul Starkey. Many of them had their own names on
became a preventable disease! Widespread use of fluoride the cover of dental textbooks. The list of contributors was
toothpastes came way after McDonald’s first book. and remains tremendous, including esteemed colleagues
Ralph E. McDonald (1920-2015) commenced his career such as Gerald Wright, Howard Needleman, and George
in 1944 with a DDS from Indiana University School of Stookey. Amongst contemporary contributing pediatric
Dentistry. During his service as a naval dental officer, he dentist authors are Johon Aps, Ron Bell, Angus Cameron,
observed much dental disease amongst young recruits Judith Chin, Kevin Donly, Burton Edelstein, Hala Hender-
and realized the need for good dentistry already in child- son, Donald Huebener, Christopher Hughes, James Jones,
hood. McDonald read every textbook and journal about Joan Kowolik, George Krull, Jasper Lewis, Brian Sanders,
children’s dentistry that he could get his hands on. He con- Jenny Stigers, Erwin Turner, John Walsh, James Weddell,
tinued to study once he returned home. Since a degree in LaQuia Vinson, and Juan Yepes.
pediatric dentistry had not yet been established, he earned Almost until he died, McDonald remained its author.
a master’s degree in microbiology. The year 1946 saw However, in 1969, McDonald became dean of dentistry.
McDonald become an instructor in Indiana University’s This placed an added burden on his shoulders. And so,
Children’s Dental Clinic, where he pioneered the pediat- after completing the second edition in 1974, McDonald
ric dentistry program (Fig. 1). Although he didn’t realize saw the need for a co-editor. He said: “I was getting further
it, whilst writing his lecture notes, they were a textbook and further away from clinical dentistry. After producing
waiting to happen. In 1952, McDonald became chair of two editions, I realized there were areas I could no longer
the Children’s Dentistry Department. During this period of cover by myself. I brought Dave in for his clinical expertise
time, much of the dental treatment for children was given and research experience in dental materials.” For the third
by general practitioners, but some dentists trained as spe-
cialist pediatric dentists (“pedodontists” when the book was
first published). It goes without saying that both groups
needed good textbooks.
In 1963, McDonald published his book, Pedodontics, a
479-page compilation of material drawn from McDon-
ald’s lectures (Fig. 2). It contained eleven chapters and
was highly successful as a textbook for graduate students.
Interesting to note is the terminology used for Chapter 2,
“Behavior guidance in the dental office.” The AAPD only
Fig. 1 Dr. McDonald (right foreground) with patients and students in the
school’s pedodontic clinic in 1952. Fig. 2 Cover of Pedodontics published in 1963.
Foreword to the 11th edition of McDonald and Avery’s Dentistry for the Child and Adolescent: a historical review xiii
edition in 1978, McDonald guided David R. Avery through

the whole process and gave him full credit. The fourth edi-
tion in 1983 “was very much a shared piece of work,” said
Avery. In the sixth edition, a new author by the name of Jef-
fery A. Dean was added, but it was not until the eighth edi-
tion that he would join the editorial team of McDonald and
Avery. 2016 saw the book’s 50th anniversary 10th edition
published. As they handed over the editorship to Dr. Dean,
McDonald said: “As we entrust the continuing editions of
this textbook to others, we reflect on the many rewards we
have realized by our participation in the previous editions.
There are rewards for students, colleagues who teach and/
or practice pediatric dentistry and most importantly their
patients.” He went on: “We wish Godspeed to Dr. Dean…,
and all other future contributors as they proceed with this
work of love. We have the utmost confidence in their abili-
ties to carry on.” Fig. 3 The late Dr. Ralph E. McDonald (middle) with Dr. David R. Avery
Dentistry for the Child and Adolescent is internationally (left) and Dr. Jeffrey A. Dean (right), celebrating in 2000 the release of the
popular and has been considered a classic text for graduate 7th edition of the textbook. With that edition becoming the pediatric den-
tistry textbook with the most editions ever by surpassing Hogeboom’s total
programs worldwide. It has been translated from English of 6 editions, Drs. Avery and Dean honored Dr. McDonald with a new world
into several foreign languages, including Chinese, Farsi, record gold medal and olive wreath.
Japanese, Italian, Portuguese, Spanish, and Russian. The
textbook is now the world’s longest-running children’s den-
tistry textbook (Fig. 3). References
The specialty of pediatric dentistry has grown over the Bernabé E, Sheiham A: Period and cohort trends in caries of permanent
past century in popularity. For the 2020–21 academic year, teeth in four developed countries, Am J Public Health 104:e115–e121,
the number of positions offered and residency positions filled 2014. https://doi.org/10.2105/AJPH.2014.301869
surpasses all specialties and advanced education in general McBride, WC: Juvenile dentistry. 1952 (ed. 5), Lea & Febiger, Philadelphia.
dentistry programs. McDonald and Avery’s Dentistry for the McBride, Walter C: The business phase of Children’s Dentistry Journal of
the American Dental Association, 20(6):1003-1010, 1933.
Child and Adolescent has grown alongside, providing gradu- The health policy institute of the American Dental Association, https://
ates and specialists with knowledge, science, and technique www.ada.org/en/science-research/health-policy-institute/data-
as envisioned by McDonald so many years ago. center/dental-education
Preface and Acknowledgements
It is a great pleasure for me to introduce the next iteration of techniques and philosophies continue to positively impact
this long standing and successful textbook on the essence, outcomes for our child and young adult patients. Increased
foundation, and innovations in the science and practice of emphasis on patient, centered care, parent and child con-
pediatric dentistry. After formally requesting and receiving sent and assent, continued public health and private prac-
fantastic feedback, compliments, and suggestions from a tice improvements, advances in minimalist approaches
broad representation of notable academics and clinicians, to restorative care, new science on dental materials, pulp
as well as adding two new associate editors with specific regeneration and revascularization, as well as a wide array
expertise in their areas covered in the text, we analyzed, of other advances, have enhanced our abilities to care
planned, and developed this edition to continue the nearly for our patients and have been incorporated into these
60-year history of the book. chapters.
As I am writing this introduction, the world is mired in Specifically, I am pleased to highlight a few additions and
the Covid-19 pandemic and slowly learning how to adapt significant updates:
to the “new abnormal.” While impacting our care and - Thirteen new authors have been added
practice, this remains an exciting time in dentistry and - Complete update of the online video contribution with
specifically pediatric dentistry, as new concepts, research, the expertise of a new video producer
Front row, left to right: Jones, Dean

Back row, left to right: Yepes, Vinson, Sanders
xiv
Preface and Acknowledgements xv
- Rewrite of the community dentistry chapter with three Dentistry, in particular Terry Wilson, Jr. and Caleb Clem-
critical components—dental workforce, dental delivery ents for their excellent production and editing work on all
sites and organizations, and payment source of the new videos, Amy Edmunds, Joyce Marlatt and Jas-
- Updates on preventive, interceptive, and early orth- mine Pence for their administrative support, Abby Morgan
odontic treatment, including information on pediatric and Nicole Alderson in dental illustrations for their work,
sleep apnea and Sean Stone for his guidance on the citation reference
- New emphasis on the use of silver diamine fluoride manager.
- New author update of the oral pathology chapter I’m proud of the dedication and work of our associate
- New section on vaping and oral implications editors and authors for once again helping to maintain
- Updated pain management section related to opioid use the tradition of excellence established by our mentors
and misuse and predecessors, Drs. McDonald and Avery. We hope
- New section on pediatric dental bleaching you enjoy this new edition, and as always, I look for-
- Information on coronavirus and Covid-19 in children ward to your comments and constructive criticism as we
- Updated on Periodontal Classification for children continuously strive for improvement and the highest in
- Expert Consult website with fully searchable access to quality. All the best to you, our colleagues, friends, and
the text, videos and multiple-choice questions students.
All of these enhancements take the assistance and dedi-
cation of multiple people. In particular, I’d like to thank all Jeffrey A. Dean
the great support staff at the Indiana University School of
1 Examination of the Mouth
and Other Relevant
Structures
JUAN F. YEPES and JEFFREY A. DEAN
CHAPTER OUTLINE Introduction Infant Dental Care

Initial Parental Contact with the Dental Detection of Substance Abuse
Office Etiologic Factors in Substance Abuse
The Diagnostic Method Specific Substances and Frequency of use
Preliminary Medical, Dental, Family, and Vaping and Electronic Cigarettes
Social History Suicidal Tendencies in Children and
Clinical Examination Adolescents
Temporomandibular Evaluation Infection Control in the Dental Office
Uniform Dental Recording Biofilm
Radiographic Examination Emergency Dental Treatment
Early Examination
Introduction procedures. Parents with even moderate income usually

find the means to have oral health care performed if the
A dentist is traditionally taught to perform a complete oral dentist explains that the child’s future oral health and
examination of the patient and to develop a treatment even general health are related to the correction of the
plan based on the examination findings. The dentist subse- oral defects.
quently makes a case presentation to the patient or parents,
outlining the recommended course of treatment. This pro-
cess should include the development and presentation of a Initial Parental Contact with the
prevention plan that outlines an ongoing comprehensive Dental Office
oral health care program for the patient and establishment
of the “dental home.” We most often think of parents’ first contact with the den-
The plan should include recommendations designed to tal office as being by telephone or electronic contact for-
correct the existing oral problems (or halt their progression) mats (Instagram, Facebook, etc). This initial conversation
and to prevent anticipated future problems. It is essential to between the parent and the office receptionist is very impor-
obtain all relevant patient and family information, to secure tant. It provides the first opportunity for the receptionist to
parental consent, and to perform a complete examination attend to the parents’ concerns by pleasantly and concisely
before embarking on this comprehensive oral health care responding to questions and by offering an office appoint-
program for pediatric patients. Anticipatory guidance is the ment. The receptionist must have a warm, friendly voice
term often used to describe the discussion and implemen- and the ability to communicate clearly. The receptionist’s
tation of such a plan with the patient and/or parents. The responses should assure the parent that the well-being of
American Academy of Pediatric Dentistry has published the child is the chief concern.
guidelines1 concerning the periodicity of examination, pre- The information recorded by the receptionist during this
ventive dental services, and oral treatment for children as conversation constitutes the initial dental record for the
summarized in Table 1.1. patient. Filling out a patient information form is a conve-
Each pediatric patient should be given an opportunity nient method of collecting the necessary initial information.
to receive complete dental care. The dentist should not Of course, most dental practices are moving toward online,
attempt to decide what the child, the parents, or a third- website-driven information and completion of patient forms
party agent will accept or can afford. If parents reject a for use even before a parent calls an office for an appoint-
portion or all of the recommendations, the dentist has ment or schedules an appointment online. Practices need to
at least fulfilled the obligation of educating the child and make accommodations to their patient information systems
the parents about the importance of the recommended to manage these very productive changes.
3
4 PART 1 • Diagnoses
TABLE 1.1 Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/
Counseling
Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are
developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests
variations from normal. The American Academy of Pediatric Dentistry (AAPD) emphasizes the importance of very early professional intervention
and the continuity of care based on the individualized needs of the child. Refer to the text of this guideline for supporting information and
references. Refer to the text in the Guidelines on Periodicity of Examinations, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment
for Infants, Children, and Adolescents (www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf) for supporting information and references.
AGE
6–12 months 12–24 months 2–6 years 6–12 years ≥12 years
Clinical oral examination1 • • • • •
Assesses oral growth and • • • • •
development2
Caries-risk assessment3 • • • • •
Radiographic assessment4 • • • • •
Prophylaxis and topical fluoride3,4 • • • • •
Fluoride supplementation5 • • • • •
Anticipatory guidance/counseling6 • • • • •
Oral hygiene counseling7 Parent Parent Patient/parent Patient/parent Patient
Dietary counseling8 • • • • •
Injury prevention counseling9 • • • • •
Counseling for nonnutritive habits10 • • • • •
Counseling for speech/language • • • • •
development
Assessment and treatment of • • •
developing malocclusion
Assessment for pit-and-fissure • • •
sealants11
Substance abuse counseling • •
Counseling for intraoral/perioral • •
piercing
Assessment and/or removal of third •
molars
Transition to adult dental care •
1First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as indicated by child’s risk status/susceptibility to
disease. Includes assessment of pathology and injuries.
2By clinical examination.
3Must be repeated regularly and frequently to maximize effectiveness.
4Timing, selection, and frequency determined by child’s history, clinical findings, and susceptibility to oral disease.
5Consider when systemic fluoride exposure is suboptimal. Up to at least 16 years of age or later in high-risk patients.
6Appropriate discussion and counseling should be an integral part of each visit for care.
7Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child.
8At every appointment; initially discuss appropriate feeding practices, followed by the role of refined carbohydrates and frequency of snacking in caries
development and childhood obesity.

9Initially for play objects, pacifiers, car seats; then while learning to walk; and then with sports and routine playing, including the importance of mouthguards.
10At first, discuss the need for additional sucking: digits vs. pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For
school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism.
11For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed as soon as possible after eruption.
The Diagnostic Method

newly fractured crown needs immediate treatment, but the
Before making a diagnosis and developing a treatment plan, treatment will likely be only palliative, and further diagnostic
the dentist must collect and evaluate the facts associated with and treatment procedures will be required later.
the patient’s or parents’ chief concern and any other identi- The importance of thorough collection and evaluation of
fied problems that may be unknown to the patient or parents. the facts concerning a patient’s condition cannot be over-
Some pathognomonic signs may lead to an almost immediate emphasized. A thorough examination of the pediatric den-
diagnosis. For example, obvious gingival swelling and drain- tal patient includes an assessment of the following:
age may be associated with a single, badly carious primary

molar. Although these associated facts are collected and evalu- ᑏ General growth and health
ᑏ
ated rapidly, they provide a diagnosis only for a single problem ᑏ Diet
ᑏ
area. On the other hand, a comprehensive diagnosis of all of the ᑏ Chief complaint, such as pain
ᑏ
patient’s problems or potential problems may sometimes need ᑏ Extraoral soft tissue and temporomandibular joint (TMJ)
ᑏ
to be postponed until more urgent conditions are resolved. For evaluation
example, a patient with necrotizing ulcerative gingivitis or a ᑏ Intraoral soft tissue
ᑏ
1 • Examination of the Mouth and Other Relevant Structures 5
ᑏ ᑏ
Oral hygiene and periodontal health procedures can be planned to help the child overcome the
ᑏ Intraoral hard tissue fear and accept dental treatment.
ᑏ
ᑏ Developing occlusion Occasionally, when the parents report significant disorders,
ᑏ
ᑏ Caries risk it is best for the dentist to meet privately. They are more likely
ᑏ
ᑏ Behavior to discuss the child’s problems openly, and there is less chance
ᑏ
for misunderstandings regarding the nature of the disorders. In

Additional diagnostic aids are often also required, such addition, the dentist’s personal involvement at this early time
as radiographs, study models, photographs, pulp tests, and, strengthens the parents’ confidence. When an acute or chronic
infrequently, laboratory tests. In certain unusual cases, all systemic disease or anomaly is indicated, the dentist should con-
of these diagnostic aids may be necessary before a compre- sult the child’s physician to learn the status of the condition, the
hensive diagnosis can be made. Certainly, no oral diagnosis long-range prognosis, and the current drug therapy.
can be complete unless the diagnostician has evaluated the When a patient’s medical and dental history is recorded,
facts obtained by medical and dental history taking, inspec- the presence of current illnesses or history of relevant dis-
tion, palpation, exploration (if teeth are present), and often orders signals the need for special attention. In addition to
imaging (e.g., radiographs). For a more thorough review consulting the child’s physician, the dentist may decide to
of evaluation of the dental patient, refer to the chapter by record additional data concerning the child’s current physi-
Glick et al.2 in Burket’s Oral Medicine. cal condition, such as blood pressure, body temperature,
heart sounds, height and weight, pulse, and respiration.
Before any treatment is initiated, certain laboratory tests
Preliminary Medical, Dental, may be indicated and special precautions may be necessary.
Family, and Social History A decision to provide treatment in a hospital that possibly
involves general anesthesia may be appropriate.
It is important for the dentist to be familiar with the medical, The dentist and the staff must also be alert to identify poten-
dental, family, and social history of the pediatric patient. tially communicable infectious conditions that threaten the
Familial history may also be relevant to the patient’s oral health of the patient and others. Knowledge of the current
condition and may provide important diagnostic infor- recommended childhood immunization schedule is helpful.
mation in some hereditary disorders. Before the physical It is advisable to postpone nonemergency dental care for a
examination is performed, the dentist can obtain sufficient patient exhibiting signs or symptoms of acute infectious dis-
information to provide with knowledge of the child’s gen- ease until the patient recovers. Further discussions of man-
eral health from the parent or the child’s physician. Dental agement of dental patients with special medical, physical, or
assistants as well as dental hygienists can start collecting behavioral problems are presented in Parts III and V.
information/pre-screening with the parents. The dentist The pertinent facts of the medical history can be transferred
will follow this initial contact and expand or explore in more to the oral examination record (Fig. 1.2) for easy reference by
detail issues with a clear repercussion in the treatment plan. the dentist. A brief summary of important medical information
The form illustrated in Fig. 1.1 can be completed by the par- serves as a convenient reminder to the dentist and the staff,
ent. However, it is more effective for the dentist to ask the who will refer to this chart at each treatment visit.
questions marked by the parents and obtain more critical The patient’s dental history should also be summarized
details to have a better prospective of the patient. The ques- on the examination chart. This should include a record of
tions included on the form will also provide information previous care in the dentist’s office and the facts related by
about any previous dental treatment. the patient and parent(s) regarding previous care, if any, in
Information regarding the child’s social and psycho- another office. Information concerning the patient’s cur-
logical development is important. Accurate information rent oral hygiene habits and previous and current fluoride
reflecting a child’s learning, behavioral, or communication exposure helps the dentist develop an effective dental dis-
problems is sometimes difficult to obtain initially, especially ease prevention program. For example, if the family drinks
when the parents are aware of their child’s developmental well water, a sample may be sent to a water analysis labora-
disorder but are reluctant to discuss it. Behavior problems tory to determine the fluoride concentration.
in the dental office are often related to the child’s inability
to communicate with the dentist and to follow instructions.
This inability may be attributable to a learning disorder. An Clinical Examination
indication of learning disorders can usually be obtained by
the dentist when asking questions about the child’s learn- Most facts needed for a comprehensive oral diagnosis in the
ing process; for example, asking a young school-aged child young patient are obtained by thorough clinical and radio-
how he or she is doing in school is a good lead question. The graphic examination. In addition to examining the oral
questions should be age appropriate for the child. cavity structures, the dentist may wish to note the patient’s
If a young child was hospitalized previously for general size, stature, gait, or involuntary movements in some cases.
anesthetic and surgical procedures, it should be noted. Hos- The first clue to malnutrition may come from observing a
pitalization and procedures involving general anesthesia patient’s abnormal size or stature. Similarly, the severity of
can be a traumatic psychological experience for a preschool a child’s illness, even if oral in origin, may be recognized by
child and may sensitize the youngster to procedures that observing a weak, unsteady gait or lethargy and malaise as
will be encountered later in a dental office.3 If the dentist is the patient walks into the office. All relevant information
aware that a child was previously hospitalized or that the should be noted on the oral examination record (Fig. 1.2),
child fears strangers in clinic attire, the necessary time and which becomes a permanent part of the patient’s chart.
UUN
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Riley Hospital for Children IU Health | ROC | Pediatric Dentistry DOB: EDR:
705 Riley Hospital Drive, Room #4205
Indianapolis, IN 46202-5109 NA:
317.944.3865 office | 317.944.9653 fax
www.pediatricdentistryassociates.org LC: DATE:
Birth Date: Gender: Female Male

City & State of Birth: Race: Height:_______ Weight____
Primary Care Physician:
Physician Address:
Physician Phone: Last Dental Visit:
Date of Last Medical Exam: Last Dental X-rays:
Dental History:
What is the primary reason for today’s visit?
YES NO Explain:
YES NO Explain:
Private Well City Water, City Name: Other:
With Help
Yes / No Y es / N o Yes / No
Suck Thumb/Fingers Bite/Chew Finger Nails Clench/Grind Teeth
Use Pacifier Have Speech Issues Mouth Breather
Medical History:
YES NO Explain:
YES NO Explain:
YES
Dose: Frequency of Use:
YES NO
Hospital Facility: When: Reason:
Yes / No Y es / N o Yes / No
Congenital Heart Defect/Disease Visual/Hearing Impairment Failure to Thrive
Heart Surgery Abnormal Bleeding Issues
Heart Murmur Sickle Cell Trait/Disease Born Prematurely
High Blood Pressure Hemophilia
Anemia
Asthma/Breathing Issues Kidney Problems Blood/Blood Product Transfusion
Cerebral Palsy Liver Problems HIV/AIDS
Seizures/Convulsions/Epilepsy Diabetes Varicella Vaccine / Chicken Pox
Muscle/Joint/Bone Problems TB / Tuberculosis
Thyroid/Glandular Problems MRSA
ADD/ADHD Skin Problems / Hives / Cold Sores Limited Mobility
onsibility to inform this

are providers as is necessary for
Guardian Signature:
Resident Signature: Date: Time:
Form #UPDDR217 Rev. 12/2013
Fig. 1.1 Form used in completing the preliminary medical and dental history. (Printed with permission from Indiana University–University Pediatric
Dentistry Associates.)
Fig. 1.2 Chart used to record the oral findings and the treatment proposed for the pediatric patient. (Printed with permission from Indiana University–Uni-
versity Pediatric Dentistry Associates.)
Fig. 1.2—Cont’d
The clinical examination, whether the first examination

or a regular recall examination, should be all inclusive.
The dentist can gather useful information while getting
acquainted with a new patient. Attention to the patient’s
hair, head, face, neck, and hands should be among the first
observations made by the dentist after the patient is seated
in the chair.
The patient’s hands may reveal information pertinent
to a comprehensive diagnosis. The dentist may first detect
an elevated temperature by holding the patient’s hand.
Cold, clammy hands or bitten fingernails may be the first
indication of abnormal anxiety in the child. A callused or
unusually clean digit suggests a persistent sucking habit.
Clubbing of the fingers or a bluish color in the nail beds sug-
gests congenital heart disease, which may require special
precautions during dental treatment.
Fig. 1.3 Evidence of head lice infestation. Usually the insects are not
Inspection and palpation of the patient’s head and neck seen, but their eggs or nits cling to hair filaments until they hatch.
are also indicated. Unusual characteristics of the hair or (Courtesy Dr. Hala Henderson.)
skin should be noted. The dentist may observe signs of
problems such as head lice (Fig. 1.3), ringworm (Fig. 1.4),
impetigo (Fig. 1.5A,B), herpes labialis, or pink eye during
the examination. Proper referral is indicated immediately
because these conditions are contagious. After the child’s
physician has supervised treatment to control the condi-
tion, the child’s dental appointment may be rescheduled. If
a contagious condition is identified, but the child also has a
dental emergency, the dentist and the staff must take appro-
priate precautions to prevent spread of the disease to others
while the emergency is alleviated. Further treatment should
be postponed until the contagious condition is controlled.
Variations in the size, shape, symmetry, or function of the
head and neck structures should be recorded. Abnormali-
ties of these structures may indicate various syndromes or
conditions associated with oral abnormalities.
Temporomandibular Evaluation
A systematic review and meta-analysis published by da
Silva et al.4 assessed the prevalence of clinical signs of tem-
poromandibular (TMJ) disorders in children and adoles-
cents. One in six children and adolescents has clinical signs
of disorders. Okeson5 published a special report on TMJ dis-
orders in children, indicating that although several studies Fig. 1.4 Lesion on the forehead above the left eyebrow is caused by
ringworm infection. Several fungal species may cause lesions on vari-
included children aged 5–7 years, most observations have ous areas of the body. The dentist may identify lesions on the head,
been made in young adolescents. Studies have placed the face, or neck of a patient during a routine clinical examination. (Cour-
findings into the categories of symptoms or signs—those tesy Dr. Hala Henderson.)
reported by the child or parents and those identified by the
dentist during the examination. Prevalence of signs and
symptoms increases with age and may occur in 30% of that temporomandibular disorders in children can be man-
patients. aged effectively by the following conservative and revers-
One should evaluate TMJ function by palpating the head ible therapies: patient education, mild physical therapy,
of each mandibular condyle and by observing the patient behavioral therapy, medications, and occlusal splints.6 Dis-
while the mouth is closed (teeth clenched), at rest, and in cussion of the diagnosis and treatment of complex TMJ dis-
various open positions (Fig. 1.6A–D). Movements of the orders is available from many sources; we suggest Okeson’s
condyles or jaw that do not flow smoothly or that deviate Management of Temporomandibular Disorders and Occlusion
from the expected norm should be noted. Similarly, any (2020).7
crepitus that may be heard or identified by palpation as The extraoral examination continues with palpation of
well as any other abnormal sounds should be noted. Sore the patient’s neck and submandibular area (Fig. 1.6C and D).
masticatory muscles may also signal TMJ dysfunction. Again, deviations from normal, such as unusual tenderness or
Such deviations from normal TMJ function may require enlargement, should be noted and follow-up tests performed
further evaluation and treatment. There is a consensus or referrals made as indicated.
A B
Fig. 1.5 Characteristic lesions of impetigo on the (A) lower face and (B) left ear. These lesions occur on various skin surfaces, but the dentist is most likely
to encounter them on upper body areas. The infections are of bacterial (usually streptococcal) origin and generally require antibiotic therapy for control.
The child often spreads the infection by scratching the lesions. (Courtesy Dr. Hala Henderson.)
A B
C D
Fig. 1.6 (A) and (B) Observation and palpation of the temporomandibular joint function. (C) and (D) Palpation of the neck and submandibular areas.
If the child is old enough to talk, speech should be evalu- the developing occlusion. If the soft tissues and the occlu-
ated. The positions of the tongue, lips, and perioral muscu- sion are not observed early in the examination, the den-
lature during speech, while swallowing, and at rest may tist may become so engrossed in charting carious lesions
provide useful diagnostic information. and in planning for their restoration that other important
The intraoral examination of a pediatric patient should anomalies in the mouth are overlooked. Furthermore, any
be comprehensive. There is a temptation to look first unusual breath odors and abnormal quantity or consis-
for obvious carious lesions. Although controlling cari- tency of saliva should also be noted.
ous lesions is important, the dentist should first evalu- The buccal tissues, lips, floor of the mouth, palate, and gingi-
ate the condition of the oral soft tissues and the status of vae should be carefully inspected and palpated (Fig. 1.7A–C).
The tongue and oropharynx should be closely inspected.

Enlarged tonsils accompanied by purulent exudate may be
the initial sign of a streptococcal infection, which can lead
to rheumatic fever. When streptococcal throat infection
is suspected, immediate referral to the child’s physician is
indicated. In some cases, it may be helpful to the physician
and convenient for the dentist to obtain a throat culture
specimen while the child is still in the dental office, which
contributes to an earlier definitive diagnosis of the infection.
The diagnosis and treatment of soft tissue problems are dis-
cussed throughout this book (see Chapters 5, 26, and 27.)
After thoroughly examining the oral soft tissues, the
dentist should inspect the occlusion and note any dental
A or skeletal irregularities. The dentition and resulting occlu-
sion may undergo considerable change during childhood
and early adolescence. This dynamic developmental pro-
cess occurs in all three planes of space, and with periodic
evaluation the dentist can intercept and favorably influence
undesirable changes. The patient’s facial profile and sym-
metry; molar, canine, and anterior segment relationships;
dental midlines; and relation of arch length to tooth mass
should be routinely monitored in the clinical examination.
More detailed evaluation and analysis are indicated when
significant discrepancies are found during critical stages
of growth and development. Diagnostic casts and cepha-
lometric analyses may be indicated relatively early in the
mixed-dentition stage and sometimes in the primary denti-
tion. Detailed discussions of analyses of developing occlu-
B sions and interceptive treatment recommendations are
presented in Chapters 21, 22, and 23.
Finally, the teeth should be inspected carefully for evi-
dence of carious lesions and hereditary or acquired anom-
alies. The teeth should also be counted and identified
individually to ensure that supernumerary or missing teeth
are recognized. Identification of carious lesions is important
in patients of all ages, but it is especially critical in young
patients because the lesions may progress rapidly in early
childhood if not controlled. Eliminating the etiology of the
caries activity, preventive management of the caries pro-
cess, and restoration of cavitated lesions will prevent pain
and the spread of infection and will contribute to the stabil-
ity of the developing occlusion.
Since it is preferable for the dentist to perform the clini-
C cal examination of a new pediatric patient before the radio-
graphic and prophylaxis procedures, it may be necessary to
Fig. 1.7 Inspection and palpation of the (A) buccal tissues, (B) lips, and correlate radiographic findings or other initially question-
(C) floor of the mouth.
able findings with the findings of a second brief oral exami-
nation. This is especially true when the new patient has
The use of the periodontal screening and recording program poor oral hygiene. Detailed inspection and exploration of
(PSR) is often a helpful adjunct when working with children. the teeth and soft tissues cannot be performed adequately
PSR is designed to facilitate early detection of periodontal dis- until the mouth is free of extraneous debris.
eases with a simplified probing technique and minimal docu- During the clinical examination for carious lesions, each
mentation. Clerehugh and Tugnait8 recommend initiation of tooth should be dried individually and inspected under a
periodontal screening in children following eruption of the good light. A definite routine for the examination should
permanent incisors and first molars. They suggest routine be established. For example, a dentist may always start in
screening in these children at the child’s first appointment and the upper right quadrant, work around the maxillary arch,
at regular recare appointments so that periodontal problems move down to the lower left quadrant, and end the exami-
are detected early and treated appropriately. Immunodeficient nation in the lower right quadrant. Morphologic defects
children are especially vulnerable to early loss of bone support. and incomplete coalescence of enamel at the bases of pits
A more detailed periodontal evaluation is occasionally and fissures in molar teeth can often be detected readily by
indicated, even in young children. Periodontal disorders of visual and explorer examination after the teeth have been
children are discussed further in Chapter 15. cleaned and dried. The decision whether to place a sealant
or to restore a defect depends on the patient’s history of The committee found that only one system, the two-
dental caries, the parents’ or patient’s acceptance of a com- digit system, seems to comply with these requirements.
prehensive preventive dentistry program (including dietary According to this system, the first digit indicates the
and oral hygiene control), and the patient’s dependability quadrant and the second digit the type of tooth within
in returning for recare appointments. the quadrant. Quadrants are allotted the digits 1 to 4 for
In patients with severe dental caries, caries activity tests the permanent teeth and 5 to 8 for the primary teeth in a
and diet analysis may contribute to the diagnostic process clockwise sequence, starting at the upper right side; teeth
by helping define specific etiologic factors. These procedures within the same quadrant are allotted the digits 1 to 8 (pri-
probably have an even greater value in helping the patient mary teeth, 1 to 5) from the midline backward. The digits
and/or parents understand the dental caries disease process should be pronounced separately; thus, the permanent
and in motivating them to make the behavioral changes canines are teeth one-three, two-three, three-three, and
needed to control the disease. The information provided to four-three.
them should include instructions in plaque control and the In the “Treatment Proposed” section of the oral exami-
appropriate recommendations for fluoride exposure. Den- nation record (Fig. 1.2B), the individual teeth that require
tal caries susceptibility, caries disease process, caries activ- restorative procedures, endodontic therapy, or extraction
ity tests, diet analysis, and caries control are discussed in are listed. Gingival areas requiring follow-up therapy are
Chapter 10. Plaque control procedures and instructions are also noted. A checkmark can be placed beside each listed
detailed in Chapter 8. tooth and procedure as the treatment is completed. Addi-
The dentist’s comprehensive diagnosis depends on the tional notations concerning treatment procedures com-
completion of numerous procedures but requires a thor- pleted and the date are recorded on supplemental treatment
ough, systematic, and critical clinical examination. Any record pages.
deviation from the expected or desired size, shape, color,
and consistency of soft or hard tissues should be described in
detail. The severity of associated problems and their causes Radiographic Examination
must be clearly identified to the patient or parents before a
comprehensive oral health care program can be expected When indicated, radiographic examination for children
to succeed. must be completed before a comprehensive oral health care
During the initial examination and at subsequent plan can be developed (but after the detail clinical exami-
appointments, the dentist and auxiliary staff members nation), and subsequent radiographs are required periodi-
should be alert to signs and symptoms of child abuse and cally to enable detection of incipient carious lesions or other
neglect. These problems are increasing in prevalence, and developing anomalies.
the dentist can play an important role in detecting their A child should be exposed to dental ionizing radiation
signs and symptoms; this subject is thoroughly covered in only after the dentist has determined that radiography is
Chapter 7. necessary to make an adequate diagnosis for the individual
child at the time of the appointment.
Obtaining isolated occlusal, periapical, or bitewing films
Uniform Dental Recording is sometimes indicated in very young children (even infants)
because of trauma, toothache, suspected developmental
Many different tooth-charting systems are currently in use, disturbances, or proximal caries. It should be remembered
including the universal system illustrated in the hard tis- that carious lesions appear smaller on radiographs than
sue examination section of Fig. 1.2A and B. This system of they actually are.
marking permanent teeth uses the numbers 1 to 32, begin- As early as 1967, Blayney and Hill10 recognized the
ning with the upper right third molar (No. 1) and progress- importance of diagnosing incipient proximal carious
ing around the arch to the upper left third molar (No. 16), lesions with the appropriate use of radiographs. If the pedi-
down to the lower left third molar (No. 17), and around the atric patient can be motivated to adopt a routine of good
arch to the lower right third molar (No. 32). The primary oral hygiene supported by competent supervision, many
teeth are identified in the universal system by the first 20 of these initial lesions can be arrested. The dentist must be
letters of the alphabets, A through T. In case of a supernu- aware of other non-ionizing radiation techniques available
merary tooth, in the permanent dentition the number 50 for the detection of interproximal caries. Each technique
is added to the tooth number that is closest to the super- (e.g., transillumination) comes with clear indications. The
numerary tooth. In the primary dentition, the letter “S” is interpretation of the non-ionizing radiation techniques
added to the tooth number that is the closest to the super- must be done carefully by the dentist.
numerary tooth.9 Radiographic techniques for the pediatric patient are
The Fédération Dentaire Internationale’s Special Commit- described in detail in Chapter 2.
tee on Uniform Dental Recording has specified the following
basic requirements for a tooth-charting system:
Early Examination

1. Simple to understand and teach
2. Easy to pronounce in conversation and dictation Historically, dental care for children has been designed pri-
3. Easily communicable in writing and electronic format marily to prevent oral pain and infection, occurrence and
4. Easy to translate into computer input progression of dental caries, premature loss of primary
5. Easily adaptable to standard charts used in general practice teeth, loss of arch length, and development of an association

between fear and dental care. The dentist is responsible Thus it is appropriate for a dentist to perform an oral
for guiding the child and parents, resolving oral disorders examination for an infant of any age, even a newborn, and
before they can affect health and dental alignment, and pre- an examination is recommended anytime the parent or
venting an oral disease. The goals of pediatric dental care physician calls with questions concerning the appearance
are, thus, primarily preventive. The dentist’s opportunity to of an infant’s oral tissues. Even when there are no known
conduct an initial oral examination and parental consulta- problems, the child’s first dental visit and oral examination
tion during the patient’s infancy is a key element in achiev- should take place by at least 1 year of age. This early dental
ing and maintaining these goals. visit enables the dentist and parents to discuss ways to nur-
Some dentists, especially pediatric dentists, like to coun- ture excellent oral health before any serious problems have
sel expectant parents before their child is born. They con- had an opportunity to develop. An adequate oral examina-
sider it appropriate to discuss with expectant mothers the tion for an infant is generally simple and brief, but it may be
importance of good nutrition during pregnancy and prac- the important first step toward a lifetime of excellent oral
tices that can influence the expected child’s general and health.
dental health. Some dentists may prefer to “preside” during the entire
It is also appropriate to inquire about medication that the first session with the infant and parents. Others may wish
expectant mother is taking. For example, prolonged inges- to delegate some of the educational aspects of the session
tion of tetracyclines may result in discolored, pigmented, to auxiliary members of the office staff and then conduct
and even hypoplastic primary teeth. the examination and answer any unresolved questions. In
The expectant mother should be encouraged to visit her either case, it is sometimes necessary to have an assistant
dentist and to have all carious lesions restored. The pres- available to help hold the child’s attention so that the par-
ence of active dental caries and accompanying high levels of ents can concentrate on the important information being
Streptococcus mutans can lead to transmission by the mother provided.
to the infant and may be responsible for the development of It is not always necessary to conduct the infant oral
carious lesions at a very early age. examination in the dental operatory, but it should take place
It is not intended that the pediatric dentist usurp the where there is adequate light for a visual examination. The
responsibility of the expectant mother’s physician in rec- dentist may find it convenient to conduct the examination
ommending dietary practices; rather, the dentist should in the private consultation room during the initial meeting
reinforce good nutritional recommendations provided by with the child and parents. The examination procedures
medical colleagues. may include only direct observation and digital palpation.
However, if primary molars have erupted or if hand instru-
ments may be needed, the examination should be performed
Infant Dental Care in an area where instrument transfers between the dental
assistant and the dentist can proceed smoothly.
The infant oral health care visit should be seen as the foun- The parents should be informed before the examination
dation on which a lifetime of preventive education and that it will be necessary to restrain the child gently and that
dental care can be built to help ensure optimal oral health it is normal for the child to cry during the procedure. The
into childhood. Oral examination, anticipatory guidance infant is held on the lap of a parent, usually the mother.
including preventive education, and appropriate therapeu- This direct involvement of the parent provides emotional
tic intervention for the infant can enhance the opportunity support to the child and allows the parent to help restrain
for a lifetime of freedom from preventable oral disease. The the child. Both parents may participate or at least be present
2018 American Academy of Pediatric Dentistry guidelines during the examination.
on Perinatal and Infant Oral Health Care1 included the fol- The dentist should make a brief attempt to get acquainted
lowing recommendations: with the infant and to project warmth and caring. However,
many infants and toddlers are not particularly interested in

1. All primary health care professionals who serve mothers developing new friendships with strangers, and the dentist
and infants should provide parent/caregiver education should not be discouraged if the infant shuns the friendly
on the etiology and prevention of early childhood caries approach. Even if the child chooses to resist (which is com-
(ECC). mon and normal), only negligible extra effort is necessary
2. The infectious and transmissible nature of bacteria that to perform the examination procedure. The dentist should
cause ECC and methods of oral health risk assessment not be flustered by the crying and resistant behavior and
(e.g., caries risk assessment tool), anticipatory guidance, should proceed unhurriedly but efficiently with the exami-
and early intervention should be included in the cur- nation. The dentist’s voice should remain unstrained and
riculum of all medical, nursing, and allied health profes- pleasant during the examination. The dentist’s behavior
sional programs. should reassure the child and alleviate the parents’ anxiety
3. Every infant should receive an oral health risk assess- concerning this first dental procedure.
ment from his or her primary health care provider or One method of performing the examination in a private
qualified health care professional by 6 months of age. consultation area is illustrated in Fig. 1.8A. The dentist
4. Parents or caregivers should establish a dental home for and the parent are seated face to face with their knees
infants by 12 months of age. touching. Their upper legs form the “examination table”
5. Health care professionals and all stakeholders in chil- for the child. The child’s legs straddle the parent’s body,
dren’s health should support the identification of a den- which allows the parent to restrain the child’s legs and
tal home for all infants at 12 months of age. hands (Video 1.1). An assistant is present to record the

A B
Fig. 1.8 (A) One method of positioning a child for an oral examination in a small, private consultation area. The dental assistant is nearby to record find-
ings. (B) If space allows three people to sit in a row, this method may make it easier for the dental assistant to hear the findings dictated by the dentist.
The dental assistant also helps restrain the child’s legs.
hands but also the lower arms and abdomen may be avail-
able for supporting the child’s head, if necessary.
The infant oral examination may often be performed by
careful direct observation and digital palpation. The den-
tist may need only good lighting for visibility and gauze for
drying or debriding tissues. Sometimes a tongue depressor
and a soft-bristled toothbrush are useful. At other times, as
previously mentioned, the dentist will want the complete
operatory available. The examination should begin with a
systematic and gentle digital exploration of the soft tissues
without any instruments. The child may find this gentle pal-
pation soothing, especially when alveolar ridges in teething
areas are massaged. The digital examination may help relax
the child and encourage less resistance. If hand instruments
are needed, the dentist must be sure to have a stable finger
Fig. 1.9 Oral examination for a very young child in the dental operatory.
rest before inserting an instrument into the child’s mouth.
Although there is little effective communication between
the dentist and patient, the child realizes at the conclusion
Video 1.1 Oral Examination for Preschooler: knee-to-knee technique of the examination that nothing “bad” happened and that
for an oral exam of a preschool aged child. the procedure was permitted by the parents, who were pres-
ent and actually helped with the examination. The child
dentist’s examination findings as they are dictated and to will not hold a lasting grudge against anyone, and the expe-
help restrain the child if needed. If adequate space is avail- rience will not have a detrimental effect on the child’s future
able in the consultation area, the approach illustrated in behavior as a dental patient. On the contrary, our experi-
Fig. 1.8B may be useful. The dental assistant is seated at a ences suggest that such early examinations followed by
desk or writing stand near the child’s feet. The dental assis- regular recall examinations often contribute to youngsters
tant and the parent are facing the same direction, side by becoming excellent dental patients without fear at very
side and at a right angle to the direction that the dentist is young ages. These children’s chances for enjoying excellent
facing. The dental assistant is in a good position to hear and oral health throughout life are thus enhanced.
record the dentist’s findings as they are dictated, even if the
child is crying loudly. These positions (Fig. 1.8A and B) are
also convenient for demonstrating oral hygiene procedures Detection of Substance Abuse
to the parents.
The positions of the dentist, parent, child, and dental It is within the scope of pediatric dentistry to be concerned
assistant during the examination at the dental chair are with life-threatening habits and illnesses, such as alcohol-
illustrated in Fig. 1.9. The dental assistant is standing to ism and drug addiction, which may occur in the older child.
permit good visibility and to better anticipate the dentist’s Gigena et al.11 and Marshall and Werb12 have reported
needs. The assistant is also in a good position to hear and that abusers in the teen years and younger are as common
record the dentist’s findings. The parent and the dental as adult addicts. Drug abuse problems interact directly with
assistant restrain the child’s arms and legs. The child’s head the dental care of a patient. Oral health in teens who use
is positioned in the bend of the parent’s arm. The dentist drugs is statistically different and worse than that in teens
establishes a chairside position so that not only the dentist’s who are not drug abusers. Obtaining and maintaining a
satisfactory history is important. The office health ques- of those who had never smoked, more than 22% were con-
tionnaire, as presented in this chapter, must be worded to sidered susceptible to start smoking.15
enable the patient or parent to give some indication of a
drug problem. It is often difficult to detect addiction from ETIOLOGIC FACTORS IN SUBSTANCE ABUSE
casual observation. Therefore, input from the patient giving
an indication of addiction is needed. At subsequent visits, Drug abuse in young people can be traced to many causes,
the dentist must also consider changes in the general health the most important of which is considered to be rebellion
history as well as answers to specific questions. against parents and society. Other factors may include
It is also important to know if the patient is taking drugs a need to forget the pressures of daily living, a desire for
at the time of the dental visit because there could be an pleasure, and a need to conform to a group with which
interaction with drugs, such as nitrous oxide, administered the young people want to be associated.16 Through drugs,
at the dental office. If the patient is under the influence of young people obtain a momentary feeling of independence
an abused substance, dental treatment should be postponed and power because they have disobeyed the rules of their
until a time when the patient is not “high.” parents and society. The satisfaction gained through rebel-
Symptoms of substance abuse may include depression, ling against parents can give adolescents a reinforcing
feelings of inadequacy, frustration, helplessness, immatu- motive for persisting in drug abuse.
rity, self-alienation, poor object relations, and major defi- Children of wealthy parents are increasingly recognized
ciencies in ego structure and functioning. Heavy drug users as a high-risk group for the development of traits such as
tend to have poor impulse control and frequently neglect narcissism, poor impulse control, poor tolerance of frustra-
hygiene in general and oral hygiene specifically. In addition, depression, and poor coping ability. Therefore, it is not
tion, because a patient is taking drugs that affect normal surprising that a large number of children within this group
thought processes, the pain from untreated dental condi- use drugs to cope with frustrations, boredom, anxiety, and
tions may be masked. This combination of factors results in depression.
a patient with very little dental interest who is practicing In general, compared with youngsters who do not use
unsatisfactory prevention, leading to increased oral disease. drugs, drug users have been found to be less interested
Identification of substance abusers is difficult, even for in formal education, less involved in organized activities
an experienced observer. There are specific clues, however. such as athletics, and less likely to have well-defined goals.
Abrupt changes in behavior are common, as are signs of Adolescents who use drugs heavily have been described as
depression and moodiness. Interest in the opposite sex often manifesting more psychological problems than do nonus-
decreases. Without any apparent consumption of alcohol, ers. Significantly higher percentages of nonusers of drugs
a drug-addicted person can appear intoxicated. There may reported close relationships with their parents. Children
be a desperate need for money, as well as loss of weight and involved in abusing drugs are more often found to have
appetite. The presence of scars along the veins could indi- experienced the loss of a parent or to have parents who are
cate drug injection. Addicts frequently wear long-sleeved divorced.
shirts, regardless of the weather, in an effort to cover iden-
tifying scars. SPECIFIC SUBSTANCES AND FREQUENCY OF USE
Fletcher et al.13 state that the use of illegal drugs and vol-
atile substances is common among young people in devel- Since 1975, the University of Michigan’s Institute for Social
oped countries, such as the United States and the United Research, funded by the National Institute of Drug Abuse,
Kingdom. In addition to presenting direct health risks, drug has collected data on past month, past year, and lifetime
use is associated with accidental injury; self-harm; suicide; drug use among 12th graders. It was expanded in 1991
and other “problem” behaviors, such as alcohol misuse, to include 8th and 10th graders. The most recent report
unprotected sex, and antisocial behavior. Drug use at an (http://www.monitoringthefuture.org//pubs/monograph
early age is also associated with future use of particularly s/mtf-overview2018.pdf) says that in the early 21st cen-
harmful drugs, such as heroin or cocaine. In turn, depen- tury, young Americans reached extraordinarily high levels
dence on these drugs is associated with high rates of mor- of illicit drug use. In 1975, majority of young people (55%)
bidity and mortality, social disadvantage, and crime. It is had used an illicit drug by the time they left high school. This
because of these health and social problems that reducing rose to 66% in 1981, but declined to 41% by 1992—the
teenage drug use is a priority. low point. After 1992, in what the report calls the “relapse
Their review of the literature, however, suggests that phase” of the epidemic, the proportion rose considerably to
positive ethos and overall levels of strong school relation- 55% in 1999 and gradually declined to 47% in 2009 before
ships and engagement are associated with lower rates of rising slightly to 50% by 2013 and keeping similar levels
drug use, and that at the individual level, negative behav- by 2018.
iors and attitudes relating to school are also associated with
drug use. VAPING AND ELECTRONIC CIGARETTES
MacDonald14 reports that experimentation is a normal
adolescent learning tool, but when combined with normal Vaping, also known as JUULing, means using an electronic
adolescent curiosity and fearlessness, it may be danger- cigarette (e-cigarette) or another vaping device. Vaping is
ous. Tobacco smoking is an example of a common teenage a relatively new trend with a dramatic increase in use by
experiment. In a study by the National Survey on Drug Use adolescents in the last 10 years. Liquid nicotine is involved
and Health, 12% of adolescents of 12 to 17 years of age had in most vaping and is a highly addictive substance. The liq-
smoked one or more cigarettes in the preceding month; and uid comes in flavors, such as mint, fruit, and bubble gum,
which appeal to adolescents. The use of nicotine is associ- ᑏ Frequent complaints about physical symptoms, often
ᑏ
ated with learning and attention difficulties in adolescents, related to emotions, such as stomach aches, headaches,
and can lead to addiction. Furthermore, some sweet fla- or fatigue
vors may increase the risk for dental caries. In a study, Kim ᑏ Loss of interest in pleasurable activities
ᑏ
et al.17 evaluated that the sugary, gelatinous aerosols in the ᑏ Not tolerating praise or rewards
ᑏ
flavors interact with the enamel, thereby changing the sur-

A teenager who is planning to commit suicide may also
face characteristics and increasing the risk for demineral-
exhibit the following signs:
ization and subsequent development of caries.

Suppose the dentist identifies a person who needs help. ᑏ Complain of being a bad person or “feeling rotten” inside
ᑏ
What can be done? Unless the dentist is exceptionally qualified ᑏ Give verbal hints with statements such as, “I won’t be a
ᑏ
to handle addiction problems, the answer is direct or indirect problem for you much longer,” “Nothing matters,” “It’s
referral to a treatment center. If the person expresses a need, no use,” and “I won’t see you again”
the dentist may directly inform that person or the parents ᑏ Put his or her affairs in order; for example, give away
ᑏ
about area agencies that provide assistance. However, addicts favorite possessions, clean his or her room, or throw
may react defensively, even with hostility, if a direct approach away important belongings
is used. As with any problem related to general or dental ᑏ Become suddenly cheerful after a period of depression
ᑏ
health, preventive efforts must begin with the young. Children ᑏ Have signs of psychosis (hallucinations or bizarre
ᑏ
at a very young age need to be helped to develop a positive self- thoughts)
image, a sense of self-worth, and a separate identity.

Children who say they want to kill themselves should
not be ignored, and further expressions of concern and
Suicidal Tendencies in Children discussion with the child are important. Moreover, assis-
tance from a mental health professional should be actively
and Adolescents sought. With appropriate counseling and family support,
intervention can be successful.
During the examination of the child, the pediatric dentist It should be recognized that the pediatric dentist and the
should be alert to signs and symptoms of suicidal tenden- orthodontist are in a unique position to recognize early
cies. How prevalent is suicide in the young child and ado- warning signs of adolescent suicide. Loochtan and Cole19
lescent? According to the American Academy of Child and surveyed 1000 practicing orthodontists and 54 depart-
Adolescent Psychiatry (http://www.aacap.org), thousands ment chairs of postdoctoral programs. Of those surveyed,
of teenagers commit suicide each year. It is the sixth lead- 50% had at least one patient who had attempted suicide
ing cause of death in 5- to 14-year-olds and the third lead- and 25% had at least one young patient who actually did
ing cause in 15- to 24-year-olds. Suicidal tendencies follow commit suicide.
a pattern and background that can be observed by the
astute professional or parent. The following excerpt is from the
American Academy of Child and Adolescent Psychiatry18: Infection Control in the Dental
Teenagers experience strong feelings of stress, confusion, Office
self-doubt, pressure to succeed, financial uncertainty, and
The dental team is exposed to a wide variety of microorgan-
other fears while growing up. For some teenagers, divorce, isms in the saliva and blood of their patients. These may
the formation of a new family with step-parents and step- include hepatitis B and C, herpes viruses, cytomegalovi-
siblings, or moving to a new community can be unsettling rus, measles virus, mumps virus, chickenpox virus, human
and can intensify self-doubts. For some teens, suicide may immunodeficiency virus, Mycobacterium tuberculosis, strep-
tococci, staphylococci, and other non–vaccine-preventable
appear to be a solution to their problems and stress. infections. Because it is impossible to identify all of those
Depression and suicidal feelings are treatable mental dis- patients who may harbor dangerous microorganisms, it is
orders. The child or adolescent needs to have his or her ill- necessary to use standard precautions and practice infec-
ness recognized and diagnosed, and appropriate treatment tion control procedures routinely to avoid spread of disease.
plans developed. When parents are in doubt as to whether The following infection control procedures as described by
their child has a serious problem, a psychiatric examination Miller and Palenik20 and Miller21 are based on those recom-
can be helpful. Many of the signs and symptoms of suicidal mended for dentistry by the Centers for Disease Control and
feelings are similar to those of depression. Prevention in the Public Health Service of the U.S. Depart-
Parents should be aware of the following signs from ado- ment of Health and Human Services:22
lescents who may attempt suicide:

ᑏ Always obtain (and update) a thorough medical history

ᑏ Changes in eating and sleeping habits
ᑏ
(as discussed previously in this chapter) and include
ᑏ
ᑏ Withdrawal from friends, family, and regular activities
questions about medications, current illnesses, hepatitis,
ᑏ
ᑏ Violent actions, rebellious behavior, or running away
unintentional weight loss, lymphadenopathy, oral soft
ᑏ
ᑏ Drug and alcohol use
tissue lesions, or other infections.
ᑏ
ᑏ Unusual neglect of personal appearance
ᑏ Clean all reusable instruments in an ultrasonic cleaner
ᑏ
ᑏ Marked personality change
ᑏ
or washer/disinfector, and minimize the amount of
ᑏ
ᑏ Persistent boredom, difficulty concentrating, or a decline
hand scrubbing. Wear heavy rubber gloves, mask, and
ᑏ
in the quality of schoolwork
protective clothing and eyewear to protect against punc- BIOFILM

ture injuries and splashing.
ᑏ Sterilize all reusable instruments that penetrate or come The goal of infection control in dentistry is to reduce or
ᑏ
into contact with oral tissues or that become contami- eliminate exposure of patients and dental team members
nated with saliva or blood. Metal or heat-stable instru- to microorganisms. Potential pathogens can usually come
ments should be sterilized in a steam autoclave, a dry from patients and practitioners. Another source, however,
heat oven, or an unsaturated chemical vapor steril- could be from the environment, such as via air or water.
izer. Heat-sensitive items may require up to 10 hours of Dental unit water lines contain relatively small amounts
exposure time for sterilization in a liquid chemical agent of water, much of which is in continuous contact with the
approved by the U.S. Food and Drug Administration as inner surfaces of the tubing. The water is not in constant
a disinfectant/sterilant, followed by rinsing with sterile motion, with extended dormant periods. Movement of
water. High-level disinfection may be accomplished by water varies, with greatest flow being in the middle of the
submersion in the disinfectant/sterilant chemical for the tubing. Dental unit water lines readily become colonized by
exposure time recommended on the product label, fol- a variety of microorganisms, including bacteria, viruses,
lowed by rinsing with water. and protozoa. Water entering dental units usually contains
ᑏ Monitoring of sterilization procedures should include a few microorganisms. However, water coming out of the
ᑏ
combination of process parameters, including mechani- unit is often highly contaminated. Proliferation of microor-
cal, chemical, and biological. These parameters evaluate ganisms occurs within biofilms that adhere to internal sur-
both the sterilizing conditions and the procedure’s effec- faces of dental unit water lines.
tiveness. Biological monitoring must occur weekly. Current guidelines22 for proper treatment of dental unit
ᑏ Dental instruments must be wrapped before sterilization. water lines include the following:
ᑏ
Unwrapped instruments have no shelf life and must be

1. Dental unit water lines should contain <500 colony-
used immediately after being processed. forming units per mL (CFU/mL).
ᑏ Personal protective equipment (gloves, masks, protec- 2. For surgical procedures, use sterile or saline water from
ᑏ
tive eyewear, and clinical attire) should be worn when a single-use source.
treating patients. 3. Start each day by purging all lines by flushing thor-
ᑏ Contamination of clinical contact surfaces with patient oughly with water.
ᑏ
materials can occur by direct spray or spatter generated 4. Purge all air and water from high-speed handpieces for
either during dental procedures or by contact with gloved 20–30 seconds after each patient.
hands. Barrier protection of surfaces and equipment can 5. Consider separate reservoirs, chemical treatment proto-
prevent contamination of clinical contact surfaces, but is cols, and sterile water delivery systems.
particularly effective for those that are difficult to clean. 6. Use antiretraction valves and terminal flush devices into
Barriers include clear plastic wrap, bags, sheets, tubing, the dental unit.
and plastic-backed paper or other materials impervious 7. Drain the water lines at the end of the day.
to moisture. If barriers are not used, cleaning and disin- 8. Disinfect dental units attached to hospital main water
fection of surfaces between patients should involve use of supplies every 4 months with 500 ppm chlorinated water.
an EPA-registered hospital disinfectant with a tuberculo-
cidal claim (i.e., intermediate-level disinfectant).
ᑏ Hand hygiene (e.g., handwashing, hand antisepsis, or Emergency Dental Treatment
ᑏ
surgical hand antisepsis) substantially reduces potential
pathogens on the hands. Evidence indicates that proper A patient’s initial dental appointment is often prompted by
hand hygiene is the single most critical measure for reduc- an emergency situation. The diagnostic procedures neces-
ing the risk of the transmission of organisms. For routine sary for an emergency dental appointment were outlined
dental examinations and nonsurgical procedures, hand- in this chapter previously, but the emergency appointment
washing and hand antisepsis is achieved by using plain or tends to focus on and resolve a single problem or a single set
antimicrobial soap and water. If the hands are not visibly of related problems rather than provide a comprehensive
soiled, an alcohol-based hand rub is adequate. oral diagnosis and management plan. Once the emergency
ᑏ Regulated medical waste is only a limited subset of waste, problem is under control, the dentist should offer compre-
ᑏ
constituting 9% to 15% of total waste in hospitals and hensive services to the patient or parents.
1% to 2% of total waste in dental offices. Regulated medi- The remainder of this book presents information for den-
cal waste requires special storage, handling, neutraliza- tists and dental students to augment their diagnostic and
tion, and disposal and is covered by federal, state, and management skills in providing oral health care services to
local rules and regulations. Examples of regulated waste children and adolescents during both emergency and pre-
found in dental practice settings are solid waste materi- planned dental visits.
als soaked or saturated with blood or saliva (e.g., gauze
saturated with blood after surgery), extracted teeth, sur- References
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sharp items (e.g., needles, scalpel blades, and wires). anticipatory guidance/counseling, and oral treatment for infants,
ᑏ Dental prostheses, appliances, and items used in their children, and adolescents. In Reference manual, Chicago, IL, 2018,
ᑏ
fabrication (e.g., impressions, occlusal rims, and bite reg- American Academy of Pediatric Dentistry, pp 194–203.
2. Glick M: Burket’s oral medicine, ed 12, xv. Shelton, Connecticut, 2015,
istrations) are potential sources for cross-contamination People’s Medical Publishing House USA, p 716.
and require handling in a manner that prevents expo- 3. Fuhrer III CT, Weddell JA, Sanders BJ, Jones JE, Dean JA, Tomlin A:
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31(7):492–497, 2009. 138(2):117–125, 1984.
4. da Silva CG, Pachêco-Pereira C, Porporatti AL, et al.: Prevalence of 15. Gfroerer J, Caraballo R: Report on racial and ethnic differences among
clinical signs of intra-articular temporomandibular disorders in chil- youths in cigarrete smoking and susceptibility to start smoking—
dren and adolescents: a systematic review and meta-analysis, J Am United States, 2002-2004, MMWR 55:1275–1277, 2006.
Dent Assoc 147(1):10–18.e8, 2016. 16. Gopiram P, Kishore MT: Psychosocial attributes of substance abuse
5. Okeson JP: Temporomandibular disorders in children, Pediatr Dent among adolescents and young adults: a comparative study of users
11(4):325–329, 1989. and non-users, Indian J Psychol Med 36(1):58–61, 2014.
6. Guideline on acquired temporomandibular disorders in infants, chil- 17. Kim SA, Smith S, Beauchamp C, et al.: Cariogenic potential of sweet fla-
dren, and adolescents. In Reference manual, Chicago, IL, 2018, Ameri- vors in electronic-cigarette liquids, PLoS One 13(9):e0203717, 2018.
can Academy of Pediatric Dentistry, pp 366–372. 18. American Academy of Child and Adolescent Psychiatry: AACAP offi-
7. Okeson JP: Management of temporomandibular disorders and occlusion, cial action. Summary of the practice parameters for the assessment
ed 8, St. Louis, 2020, Elsevier. and treatment of children and adolescents with schizophrenia. Ameri-
8. Clerehugh V, Tugnait A: Periodontal diseases in children and adolescents: can Academy of Child and Adolescent Psychiatry, J Am Acad Child
I. Aetiology and diagnosis, Dent Update 28(5):222–230, 2001, 232. Adolesc Psychiatry 39(12):1580–1582, 2019. Available at: https://
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74(2):225–302, 1967. 20. Miller CH, Palenik CJ: Infection control and management of hazardous
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Another random document with
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me hours to go over a five-foot bookshelf with a dust-rag. And to-
night was no exception. Particularly fascinating were the books of
the New Captain on esoteric philosophy. There was no getting away
from them; here was the “foreign religion” he and Mattie had
embraced and the “books to prove it by.”
There was nothing modern. One great tome was Madame
Blavatsky’s “Isis Unveiled,” Eastern theosophy set forth in defiant
terms to a skeptical audience of 1875. Luckily, I had read it before, or
I should have been reading it yet. I was already informed as to the
writings on the Temple of Karnac that were identical with those on
the walls of a ruin in Yucatan, proving that the religious rites of Asia
and America were the same in the days before the Pyramids, when
Atlantis was a continent in the middle of the ocean and the British
Isles were under the sea. I wished that the New Captain had heard a
certain lecture that I had recently heard delivered by a savant, who
claimed that the secret of how to cut a canal from the Mediterranean
to the Indian Ocean was well understood by the Magi of the Orient
and that it was only due to international politics that it had never
been attempted. Because, forsooth, it would incidentally cause the
Sahara to be partially inundated and to “bloom like a rose,” but that
the redistribution of the waters of the world would engulf all of
England. Poor England! As if she, like myself, did not have enough
trouble with what was in her house, without being swamped by what
was under it! However, this erudite lecturer had just been released
from a sanitarium, we learned afterward, and to it he was shortly
returned, the Mecca of most of those who follow worlds too far.
Blavatsky’s story of the ball of fire which turned itself into a cat and
frisked around the room, before floating up the chimney, was
marked. It could have happened in this very room. There was a
white sheet of paper pinned to the wall opposite me, with a round
black disk on it, that might have been there when she wished to go
into a trance. I felt that if I looked at it long enough I might see
means by which Mattie aided concentration a ball of fire turning into
a cat. I wondered what they would have thought of Hudson’s
drummer, who, although locked up in a cell, played upon his drum
which was left behind in his lodging-house to keep awake the
enemies who had thrown him into jail? Or of Conan Doyle’s
poltergeists who threw pebbles at the man seeking shelter in a
bomb-cellar? But they had manifestations of their own, no doubt, and
perhaps I should come across some record of them, although they
had worked out their philosophy before the days when one could
simply seize a pencil and write upon a roll of wall-paper facts
dictated by one’s “control.”
Mattie and the New Captain had had no opportunity to be influenced
by the great mass of post-war spiritualistic literature. The fragments
from which they formed their code were bits of gold for which they
had to wash many cold streams of Calvinistic thought. They must
have gloated over each discovery like misers. I could see them
sitting here in this room on a winter evening, the shutters closed, the
lean fire crackling, the two heads bent beneath the oil-lamp,
exclaiming over some nugget of wisdom which would corroborate
their own experiences. Those were the times when “old Mis’ Hawes”
must have called and bellowed and pounded on the floor without
getting Mattie to answer any summons to the front bedroom on the
other side of the house.
Mattie and the New Captain may not have known anything about
photographing fairies, or the S. P. R., or the S. P. C. A., for that
matter, but cats they knew. I had found the saucers of seven of them
in the kitchen and strings on all the chairs, as if Mattie had
sometimes tied them up. There was a book on the shelves about a
cat: “The World of Wonders, or Divers Developments Showing the
Thorough Triumph of Animal Magnetism in New England, Illustrated
by the Power of Prevision in Matilda Fox,” published in Boston in
1838. It was enlivened with pen-and-ink drawings showing Mrs.
Matilda Fox being hypnotized by a feather, with the cat in her lap,
which, according to the text, licked her neck until it sent her spirit
soaring from her body in aërial journeys to distant lands. As far as I
had time to read I could not ascertain whether the author was in
earnest or whether he was trying to ridicule animal magnetism, but I
could not help wondering if the book had not had some influence on
the legacy in favor of a home for cats, which had defrauded Mattie. If
any one could be put in a trance by the manipulation of the tongue of
a cat, perhaps she had not been entirely altruistic in her harboring of
the creatures. Certainly, the one who had rushed wildly out of the
house as we came in was glad to make its escape. Where were the
rest of the cats that belonged to the saucers? Catching fish on the
beach in the moonlight, possibly, and hypnotizing sand-pipers.
The books that told of cataleptic sleep were all well worn. The New
Captain lived in the days when the subject of a wandering mesmerist
would allow himself to be stretched out in a village drugstore window,
remaining inert between two chairs for days at a time, while the
curious glued their eyes to the glass and tried to stay there long
enough to see him move or catch a confederate sneaking in to feed
him. But this sleep was only the imperfect imitation of the
somnambulance which the East Indians had practised for centuries.
Theirs was true life-in-death, when the heart ceased to beat and the
body grew cold, and yet, to a disciple of the occult, there was a way
of reviving it. The theory of vampires rose from this phenomenon,
and that of catalepsy, for if a tomb were opened and the corpse
found without decay it was easy enough to ascribe the wilting of a
child, in the meantime, to the thirst of the absent spirit for blood to
satisfy its coffined body. More persons would have lived for longer
periods if, instead of making sure of death by driving a stake through
the possessed one’s heart, they had made sure of life by breathing
into his mouth and unwinding the tight shroud. The ancient Orientals
understood this. The holy fakirs permitted themselves to be buried
and dug up again, to the glory of God, only making sure beforehand
that their bodies were not interred in ground infested with white ants.
But the New Captain had the Puritan’s respect for life and death. He
dreaded that he would come to life again in an iron-bound box, or he
would not have despised undertakers or written into the will which
we had seen at the Winkle-Man’s the clause about Mattie spending a
week beside his body. He must have thought it was only due to her
that he had been called back before from the first of the seven
planes, and that his celestial passport was spurious unless she
signed it. Poor Mattie! No one had sat beside her after her tired spirit
had freed itself.
I picked up another book.
French, this time. It was called “Les Secrets du Petit Albert,” and
dealt with necromancy of the eighteenth century. There was also a
French book on astrology, illustrated with crude drawings of the
sacred signs of the zodiac and diagrams of potent numbers. Another
one, “Le Dragon Rouge, ou L’Art de Commander les Esprits
Célestes,” was not more than three by four inches, and half an inch
thick. Its brittle yellow pages were bound in worn calfskin, and gave
explicit directions how to conjure up the devil and how to send him
back to his own kingdom when one had done with him. My scant
school French could barely master the archaic forms, but I gave
Mattie full credit for being able to read all the volumes stored on her
top shelf. Her ancestry was traditionally French, according to the
judge’s story, for she had been picked up from a ship just off
Quebec, and the grooves of her mind would run easily to the mother-
tongue. A recluse will master a foreign language for the mental
exercise it affords. Perhaps in some other nook of the house I should
find her French grammar, but here, indeed, were books that some
one must have been able to read,—a significant part of their highly
specialized library.
I began reading aloud from “Le Dragon Rouge”:
“Je te conjure, O Esprit! Deparoitre dans la minute par la force du
grand Adonay, par Eloim, par Ariel, par Jehovam, par Agla, Tagla,
Mathon, Oarios, Almouzin, Arios, Menbrot, Varios, Pithona, Magots,
Silphae, Cabost, Salamandre, Tabots, Gnomus Terrae, Coelis,
Godens, Aqua, Gingua, Janua, Etituamus, Zariatnatmik, A. E. A. J.
A. T. M. O. A. A. M. V. P. M. S. C. T. G. T. C. G. A. J. E. Z.”
[“I conjure thee, O Spirit, to appear instantly through the will of the
great Adonay”—etc.]
The little magic book then went on to say that if this were repeated
twice, Lucifer would appear immediately. I thought perhaps it would
be just as well to discontinue reading.
Had they actually attempted materialization up here in this very room
in the old house on the tip end of the cape? There was nothing
against it. If it were possible anywhere to conjure up the shades of
the dead, or the devils themselves, this was as apt a place as any—
a hamlet at the tip of a barren cape that extended into the ocean a
hundred and forty miles, a house separated from that hamlet by its
bad repute, as well as its location, a room cut off from the rest of the
house, and two people in it who had no contact with realities, to
whom each was the other’s world and this world not all. If any one
was able to cut through the opaque cloud of dogma surrounding
metaphysical subjects to a glimpse of realities beyond, I believed
that Mattie had done so. And then, I realized that I had come by a
circuitous path of my own to the very same conclusion that all the
townspeople had long since come to—that Mattie was clairvoyant.
Would that help her now? Did she know where her spirit would dwell
more accurately than those who were orthodox? Could she return
the more easily from Stygian shores? Or was that power of prevision
only a mortal faculty that passed with her passing and that, while it
was able to call up others from the further world, could not bring
back itself?
There was a story of an old nurse of mine that I wished I had
forgotten—how she was once governess in a house where a strange
foreign gentleman had intercourse with spirits; how he used to talk to
them as he walked about the rooms—and was happy in their
friendship and sullen when they would not appear.
“That was all right for him,” she used to say; “but after he left, the
spirits that he had called up to amuse him still hung around. That
they did, and I could never get rid of them. Try as I would,—paint,
paper, or insect-powder,—every dark night when I was alone one or
the other of them would brush up against me and stay just where I
could never quite see it until dawn.”
It was a dark night and I was alone. I sincerely hoped that whatever
had been conjured up by Mattie would not brush past me. At any
rate, I had no mind to sleep upstairs again in that little gabled room. I
did not argue with myself about the headboard; it was too late at
night for that. I opened up a folding sofa in the room that I was in,
where the New Captain must have slept many times, and lay down.
The sound of the full tide on the rising, answering the questioning of
the Five Pines trees, made a lullaby.
It was with a shock and the feeling that I had been asleep a long
time that I woke up, hearing some one coming down the stairs. The
little kitchen-stairs, it must be, that pitched down from the upper
room like a ladder, for the main stairs were too far away for me to
have heard any footfall on them. And this was not the clumping step
of a full-sized man. This was the stealthy, soundless tread of a body
without weight. But still it was unmistakable.
I sat up in chilled terror, gathering the bed-clothes around me with
that involuntary gesture known to all women surprised in their sleep,
and waited for whoever it was to come through the kitchen into my
room.
But no one entered my room.
At the foot of the stairs some one tried a door, rattled a latch, and
went back up again. For a brave second I thought I would leap out of
bed and run and push the bolt on the kitchen door, but before I
managed to start I heard the footsteps coming down upon me. This
time they would keep on, I thought; but again slowly, laboriously,
they went back up, and every time they lost themselves upstairs it
seemed as if I heard the weight of a person thrown against a door.
Or did it go through the door and then throw its weight against it? I
strained to listen. Then the steps would come down again. The
inside door of the eaves closet upstairs was locked. I had left it the
way I had found it, but the steps seemed not to be within that secret
room to-night, but without, as if last night a presence had been
struggling to get through the closet into my room and now was trying
to get back. Tortured, restless footsteps going up and down the
stairs, up and down, up and down.
Every time they reached the bottom and tried the kitchen door, I
swooned with terror. When they rattled the latch and went back up
again I clutched my knees and did not breathe till they returned.
At cockcrow they ceased of their own volition, and, my will released,
my body fell exhausted.
CHAPTER X
THE CAT OR THE CAPTAIN
WHEN I awoke the sun was shining in the windows on both sides of
the study where I had gone to bed, the neighbor’s chickens were
clucking through my back-yard, and the boats on the bay were
putting up their sails. The past night seemed unreal.
The door at the foot of the kitchen companionway was not only wide
open, but fastened back with a brick. I had forgotten that. Then how
could I have heard some one trying the latch? And upstairs the little
room was just as I had left it, not a thing disturbed. No one could
have thrown himself against the small eaves-closet door from this
side, because the bed was still in front of it, and no one could have
been shut in on the other side and at the same time be pacing up
and down steps. I went into the upper hall and looked at the big main
stairs. Had any one been climbing them? But if any one had, I should
have hardly been able to hear him, away off in the wing behind the
kitchen. Perhaps I could persuade the judge to come to the house
and practise going up and down the flight of stairs, while I listened
from the study.
I had been reading too much last night in the old vellum-bound
books of occult sciences. Without understanding the manner of
doing so, I had evidently hypnotized myself into the condition in
which the thing that I thought probable seemed to be true. I had
made up my mind that Mattie was a clairvoyant and could
materialize spirits and that those spirits might still linger in the house;
thereupon I myself had materialized one, unconsciously. The first
night I had half-expected to hear or see something uncanny, and it
had followed that I had. These manifestations were due to the
influence upon me of what I had heard about the House of the Five
Pines, and to nothing else. Jasper had not known all the harrowing
stories that were in circulation, and so he had not seen the moving
headboard. If he had been with me on the second night he doubtless
would not have heard footsteps. It was all perfectly simple when you
understand psychology; that was it, to keep a firm hold on yourself,
not to be carried away by imaginings.
And then I defended myself that any one left alone in a big house
like that would be hearing things at night and that I was no more
weak-minded than the rest.
After breakfast I began again upon the settling.
One of the features of the House of the Five Pines was that
everything in it was included in the sale. Perhaps because there
were no heirs, or because Judge Bell, as the trustee, was not
grasping; perhaps, and most probable of all, because the
townspeople had such a dread of it that they would take nothing from
it. The family linen still was packed away in the big sea-chest—
homespun sheets and thin yellow blankets, pillow-cases with
crocheted lace. The family china remained in the cupboard behind
the front hall—firestone pitchers and teapots, in pink and faded
purple, luster bowls, and white plates as heavy as dumb bells, each
with a gold leaf in the center; and in a corner cupboard in the dining-
room was almost a full set of willow-ware, with all the lids unbroken
on the little rice-cups. The big mahogany bureaus, and there were at
least two in each room, four drawers below and three little ones
above, contained the clothing of two generations of Haweses. This
meant more in the Old Captain’s family than the usual sixty years; it
meant a hundred, for two more generations could easily have been
born in the old homestead if “Mis’ Hawes” had not been so set
against the New Captain’s marriage. Her brass-handled high-boy
held calico dresses and muslin underwear, yellow and stiff with
starch, that Mattie had neither disposed of nor used. Upstairs there
was apparel that must have dated back past the era of the New
Captain into that of his father, Jeremiah. In Mattie’s room was less
than in the others. She had found herself at the end of her life with
barely a change of linen.
In the study two doors at either side of the finely carved mantel
opened into closets. One was filled with shelves on which were
papers and magazines that had been stored for twenty years. The
other was filled with the out-of-door clothes of the New Captain—a
worn cardigan jacket, and a thick blue coat with brass buttons, two
felt hats, and a yellow oilskin. A red shawl hung on a hook at the end
of the closet. I took it down to see if there were moths in it, then
dropped it and backed away. The hook that I had lifted the shawl
from was an old iron latch. The whole end of the closet was a wall-
paper covered door.
I was afraid. The flat sealed door might open on the latch, or it might
not. It might be fastened on the other side. I could not tell. But I did
not want to know what was on the other side. I did not want to stay
here any longer.
I fled out to the sunlight and around to the back of the house. There
was nothing visible; I had known that all the time. The wall-paper
covered door inside must lead either up or down. Down, there was
nothing but space beneath the house, the “under,” filled with rubbish.
Up—?
I remembered the footsteps of the night before and knew now why
the kitchen door and the little one in the upper room had looked so
unmolested. Those steps that I had heard had been traveling not the
kitchen companionway nor the main front stairway, but secret stairs
built in this wall behind the chimney, connecting with the room
above. That was where the restless spirit had been promenading,
just as it had been the first night, and that was where it still must be.
I could not wait for Jasper to return from New York to solve this
mystery. Neither did I dare to face it alone nor put it off longer. I
would go and get Judge Bell, and together we would hurry back and
find out who or what was living in my house.
But the Judge was not at home. Dropping down on his front porch I
thought of what Ruth had said to me last summer, that the first three
times you attempted to call on any one that person was always out!
Well, I could wait. I was in no rush to return to the House of the Five
Pines. I could stay here all day, if necessary.
At noon Judge Bell’s Portuguese cook came out and looked me
over.
“The judge he won’t be back,” she volunteered.
“Why not?”
She only smirked without replying.
“Why not? Doesn’t he come for lunch?”
She stuck her second finger in the roof of her mouth and looked
away.
“Not always, he don’t. Not to-day, anyhow.”
“Where is he?” I intended to follow him to his lair, wherever it was,
but Isabella seemed to think I was prying.
“I ain’t to say where he went,” she answered, twisting one bare foot
over the other. “He says if anybody asts me I don’ know.”
“And don’t you?” I could not resist.
But she only stuck her finger further into her mouth until I was afraid
that she would choke. I saw that I was tempting her to be unfaithful
to a trust, and dropped the matter. The judge must have gone off
down the cape to a séance, leaving orders with Isabella to uphold
the majesty of the law.
My next stop was the Sailor’s Rest.
I hoped to find Alf there. He would not be so stanch an ally as the
judge in this emergency, because he believed in ghosts himself and
could scarcely be convincing in his reassurances. But he might be
persuaded to break open those doors for me, and I would repay him
by promising to look over all the antique correspondence tucked
away in the pigeonholes of the desk for stamps. There might well be
some rare ones left at the House of the Five Pines. I opened the
office door carefully this time, remembering not to raise a draft that
would blow his collection away.
Behind the ledger sat a strange girl in a georgette waist, dressed to
take tickets at a motion-picture window, who informed me firmly that
“Mr. Alfred had gone to Boston.”
To Boston! It was then that I realized how dear Alf was to me.
I turned sadly into the dining-room and tried to eat the beef-hash.
One could follow the developments of the hotel’s cuisine by lunching
there daily. First the roast and then the stew, then the hash, and then
the soup—just like home. And fresh clams every day,—unless they
were the same clams! After lunch I loitered around the lobby for an
hour, trying to pick out some one among the strangers who came in
and out at infrequent intervals who would be likely to go back to the
House of the Five Pines with me willingly, as a matter of course,
without asking too many pertinent questions. I planned what I would
say and what the man thus addressed would answer.
I would say, “There is a door at my house that is locked on the
further side of a secret closet behind the bed that I want to open, and
another one downstairs, in—” How absurd! If it were only one door it
might not sound so preposterous.
I might begin: “My husband is in New York, and I want you to come
up to my house and open a door of a secret room—” No, that was
worse yet. To a beginning like that a man would only say, “Indeed?”
and walk off; or he might reply, “Thanks awfully!”
There was no use in accosting any one. They all looked as if they
would turn and run. If only some summer people were here—
adventurous artists, or intrepid college boys, or those Herculean
chauffeurs that haunt the soda-fountains while their grande dames
take a siesta! But there was no one.
Finally I remembered the Winkle-Man, and hurried up there.
I was surprised to find outside that the wind had turned, the sun had
gone, and a storm was coming up—a “hurricane,” as they call it on
the cape. A fisherman knocked into me, hurrying down to the beach
to drag his dory up beyond the rising. Outside of the point, where the
lighthouse stood, one could see a procession of ships coming in, a
whole line of them. I counted seven sweeping up the tip of the cape,
like toys drawn by children along the nursery floor. They seemed to
ride the sand rather than the sea, their sails appearing above that
treacherous neck which lay between them and me. Their barometers
must have registered this storm hours ago, for they were converging
from all the far-off fishing-banks. The bay was black. Near shore the
sailors were stripping their canvas, letting out their anchors, or tying
up to the wharves. There was a bustle and a stir in the harbor like
the confusion of a house whose occupants run wildly into one
another while they slam the windows. I ought to go up to the House
of the Five Pines and shut mine.
The tide was far out. Beyond the half-mile of yellow beach it beat a
frothy, impatient tattoo upon the water-line. When it came in it would
sweep up with a rush, covering the green seaweed and the little rills
with white-capped waves, pounding far up against the breakwaters,
setting the ships rocking and straining at their ropes, carrying away
everything that it could pry loose. Now it was waiting, getting ready,
lashing itself into a fury of anticipation. There was a feeling of
suspense to the air itself, cold in an under-stratum that came across
the sea, hot above where it hung over the torpid land. It seemed as if
you could feel the wind on your face, but not a leaf stirred. People
were hastening into their homes, even as the boats were scurrying
into the harbor. No one wanted to be abroad when the storm struck.
The Winkle-Man’s loft was deserted. I saw him far out upon the flats,
still picking up his winkles with his pronged fork, hurrying to get all he
could before the tide covered them, knowing with the accuracy of an
alarm-clock when that would be. Should I wait for him? He might not
come back, for he did not live in this shack and where his home was
I did not know. I stood wondering what to do, when suddenly down
the street came a horse and wagon, the boy beating the beast to
make it go even faster, although it was galloping up and down in the
shafts and the stones were rattling out of the road. The dust flew into
my face when they flashed by. Then, as quickly, the whole fantastic
equipage stopped.
“Whoa!” yelled the boy. You could hear him up and down the street.
He jumped over the back of the seat and threw something—a great
box, as nearly as I could make out—into the road, and then, turning
the wagon on two wheels, came careening back again, still beating
the horse as he went past me, standing up and lashing it with the
whip, cursing like a sailor, and vanishing in his own cloud.
All this to get back before it rained?
I looked down the street to where the box lay in the middle of the
road, and then I saw that he had dropped it in front of my house. It
was my box he had delivered, and his hurry had not been entirely
because of the storm. I suppose I might expect to have all my
packages dropped in the road by fleeing rogues too craven to go
near the dwelling.
Vexed with him for being such a fool, knowing I could not leave my
belongings there in the street through a hurricane that might develop
into a three days’ storm, yet still having no one to help me, I ran up
the path as the first drops came down on my head and, getting an
old wheelbarrow out of the yard, hoisted the heavy thing into it and
pushed it up to the door. It was a box of books, packed in my
husband’s sketchy manner, with openings between the boards on
top through which newspapers showed. Not the sort of covering to
withstand a northwest storm! And it was very heavy. A bitter gust
drove a flying handful of straw up the street and whirled it round and
round in the yard till it caught in the tops of the pine-trees like a
crow’s-nest. They bent and swayed and squeaked under the high
wind. A sheet of solid rain swept across the bay like a curtain just as
I succeeded in shoving the box of books over the threshold and shut
the door behind me.
Something had come in with me. It eyed me from under the stove.
There was the skinny cat that had bounded out of the house with our
arrival and had never been seen since! Tired with my futile trip,
overwrought with the approaching storm, angry over my struggles
with the box, I leaped upon the creature as if it was the cause of all
my troubles.
“Get out! You can’t stay here! I don’t want you! Scat!”
But the cat thought otherwise.
It leaped past my clutch, scampering through the kitchen and on into
the study beyond. I followed fast. The room was half-dark with the
storm that beat around it; the rain made a cannonade upon the roof
and blinded the windows with a steady downpour. The whole house
shook. The five pine-trees outside bent beneath the onslaught as if
they would snap and crash down upon me. I knew that the old
shingles must be leaking, but first of all I must get that cat, I must put
that horrible beast out!
As if it knew my thoughts it jumped upon the mantel and raised its
back at me. Its eyes were green in its small head and its tail waved
high above it. It did not seem to be a cat at all, but the reincarnation
of some sinister spirit, tantalizing and defiant, aloof, and at the same
time inexorable. I was so excited that I picked up the poker and
would have struck it dead. But it dodged and leaped away—into the
coat-closet, and I after it. I made a lunge with the poker, missed the
cat, and struck the latch of the forbidden door. It flew open. The cat
sprang—and disappeared. I followed. As I found myself climbing
steep steps hand over hand in a black hole, I had time to think, like a
drowning man, that anyway I had the poker, and if it was the captain
hiding up there, he must be an old man and I could knock him down.
I did not want to be locked in the house in a hurricane with a black
cat and God knows what. I wanted to find out.
What I found was more of a shock than what I was ready to meet.
CHAPTER XI
THE THIRD NIGHT
THIS was a child’s room; there were playthings on the floor.

The rain fell heavily on the low roof, blanketing the skylight and
making the loft so dark that for a few seconds I could not see.
A sound came from a far corner. High-strung with terror, I thought it
was some witless creature who had been concealed up here for
many years, waiting for death to unburden it from a life that could
never grow old.
It moved—and I saw it was the cat.
Again I could have killed it, but instead I sank down on the floor and
began to laugh and cry.
“Come here, Cat! I won’t hurt you. We’re all mad together.”
But the cat mistrusted me. She slunk away, and for a while watched
me very carefully, until, deciding that I had lost interest in her, she sat
up and licked her tail. I wondered if this was her regular abode and if
it was she whom I had heard walking above me at night, and, if so,
how she managed an entrance when the doors were closed.
Perhaps she was feline by day and by night was psychic. But she
was not a confidential cat. Something fell coldly on my hand. I looked
up. The skylight was leaking.
I could distinguish the furniture in the loft now. I saw a wash-bowl on
a little stand, and put it under the loose-paned glass in the roof
beneath which a pool was spreading. There was a low bureau in the
room and a short turned bed, painted green, with a quilt thrown over
one end, two little hand-made chairs, and one of those solid wooden
rocking-horses, awesomely brave in the dusk. An open sea-chest
held picture-books and paints and bent lead soldiers, and strewn
upon the floor were quahaug-shells and a string of buoys. The room
appeared as if its owner had just stepped out, and once more I took
a cautious look around, behind me and in all the corners. Running
my hand over the quilt I found that the dust of years was thick upon
it. This attic had not been lived in recently. Its disturbed face was
only the kind of confusion that is left after some one has died whose
belongings are too precious to touch.
I opened one of the drawers of the cherry bureau and discovered
that it was full of the clothes of a little boy, of a period so long ago
that I could not fathom the mystery of who he might have been.
Tears came to my eyes as I unfolded the little ruffled shirts made by
hand out of faded anchor-printed calico, and picked up the knitted
stockings. This had been a real child; there were real holes in the
stockings.
My theory that it was the captain who was living up here was
exploded. Like a percussion-cap under a railroad train it had gone off
when I blundered into the room. Nothing remained of it now but a
wan smile and a sensation of relief. I only regretted that I had not
broken open both doors behind my bed after the first night and rid
my mind of the obsession at once. I walked across the room to the
door at the far end and found it was not locked after all, only that the
rusty latch was stuck. Forcing it up, I found myself, as I had
expected, in the eaves closet, where the little door ahead of me led
into Mattie’s room. I would have to go down the other way and move
the bed in order to open it, but I felt assured that no one had been
before me and escaped by retreating through here. I peered up and
down the black length of the closet, whose floor was the adjacent
edge of the roof of the old part of the house. Obviously no one was
concealed. But from the rain that filtered in and the shaking of the
attic beneath the storm, I felt that drafts alone might have caused the
bending of the wall. Wind was sure to be playing tag at midnight in
this space between two partitions, and a neurasthenic imagination
could supply the rest.
I only wished that I had all those miserable hours back that I had
wasted during the day, wrestling with the mystery. The best theory
that I had evolved was that the New Captain had not died at all, but
that Mattie, watching him during that legendary week, had managed
to raise him out of his cataleptic sleep, and, although the
townspeople thought he had been buried, she had kept his life a
secret for the last five years. She could easily have hidden him in
this unknown room. That would explain why she was so loath to
show the house to any one. It would also explain why she refused to
move out and why, in the end, she committed suicide rather than do
so. Not daring to abandon him and have him discovered by the next
occupant, an event which would end by their both being incarcerated
in the same poor-house, she had done away with herself. The
significance of this move would have been that Mattie was no longer
dependent on the New Captain nor enchained to him by the spirit, as
she was always reported to have been. Loving him, she would never
have deserted him. But thinking of him in the rôle of a cataleptic old
man, resuscitated after his second death, it was plausible to suppose
that he would be so loathsome as to have worn out all her emotions,
even faithfulness. He must have been no more than a crazy man,
shut up in that loft, and love, though as strong as Mattie’s had been,
cannot live forever on mere remembrance. So, according to my
solution, she had at last forsaken him, after having provisioned him
beforehand, as for a siege. It had been only the short length of a
month after her drowning that we had moved in, and during that time
no one else had been near the place. After my arrival, perhaps as
before, he had lain quiet all day. By night he had prowled around
trying to get out.
It was a grand theory—while it lasted. I did not analyse the flaws in it,
now I had given it up. Another night did that!
However, so many things had been solved by my heroic journey into
the unknown and the unknowable, and I was so interested in them,
that I forgot the rest. Here was the crux of the building of the
captain’s wing, the reason for not hiring workmen in the town, and
why Mattie alone had helped to carry lumber and worked until she
fell exhausted from her own roof. Without dwelling on the secret
room that had become a nursery, considering that room in its original
aspect as part of the passageway between Mattie’s room and the
New Captain’s, here was cause enough for not wanting any outside
help. Mrs. Dove had been wrong in her conclusion that because he
had employed no village carpenters they had afterward boycotted
him. He would never have given them the opportunity. Also, the
architectural idiosyncrasies of that room were her excuse for not
showing the house when the judge had tried to sell it. A person who
would buy it as I had, without going inside the door, was an
exception. There were not many whose need was so urgent; most
house-shoppers would have poked behind her bed and pried into all
the closets before the deal was closed.
Mattie had managed to keep this room hidden all her life. Alf, at the
Sailor’s Rest, had told me squarely that there was no attic, and he
knew as much as any one else in the town about the House of the
Five Pines. Old Mis’ Hawes had died without knowing that after
Mattie had plumped up her pillows and thrust the brass warming-pan
into her bed, and taken her candle and gone upstairs, she was able
to come down again and spend the evening with the New Captain. I
would keep the secret, too, partly out of loyalty to Mattie, who had
bequeathed it to me, and partly because it would be a lark to have it
known only to my dear one. I could hear Jasper’s exclamation of
pleased surprise when, some night after he had tucked me in, I
appeared again through his study-closet. It would be a game for
winter evenings.
I let myself down the steep steps behind the chimney and, going
through the study and the kitchen, came up into Mattie’s room.
Shoving the bed away from the little door in the eaves closet, I
opened it and walked straight back into the attic-chamber. That was
the way of it—a complete loop through the house!
Mattie’s room was to be mine for no other reason than its mysterious
means of egress. If I had any servants or any visiting relatives, I
would put them in the two big bedrooms on the other side of the
upper hall and turn the hall bedroom into a bath-room. But if I ever
had any babies, if we ever had, I knew where I would put them.
There was a room next mine waiting for some child to play with the
wall-eyed rocking-horse and sleep in the little turned bed. Dormer-
windows could be cut on both sides and running water be brought
up, and such a nursery would bloom beneath the old roof that the art
magazines would send up representatives to take pictures of it. I
could hardly restrain my impatience to begin to make it ready,
although as yet there was no need for it. For the first time since we
moved into the house I was happy and contented.
I was in the mood to write Jasper a long and intimate letter, telling
him of my hopes for our life up here and how the House of the Five
Pines was all ready for us. Of my hallucinations about the attic I said,
“Nothing was locked in the room but my own fears.”
The tide had turned, and from my window at the big desk in the
lower room I watched the lines of foaming spray licking up the
beach. There was no longer any horizon between sea and sky. All
was one blur of moving gray water, picked out with breaking white-
caps and roaring as it fought to engulf the land. I thought, as I often
had before: suppose the tide does not pause at the crest and retreat
into the ocean, but keeps on creeping up and over, over the bank
and over the road, over the hedge and over the house. However, as
always, it halted in its race, pawed upon the stone breakwater, and I
knew that by morning it would have slunk out again, and that
children would be wading where waves had been, and Caleb Snow
would be picking up winkles. Living was like that; the tide of our
passions turns. The New Captain had built this double room for the
great storm that had swept through his life, bearing away the
barricades of his traditions; but its force was spent now, and the
skeleton laid as bare as a fish-bone on the sandy flats where
strangers walked.
As I sat at the desk I smelled coffee cooking. The impression was so
strong that I went into the kitchen and walked over to the stove to
shove back the coffee-pot that I fancied had been left there since
morning. The fire must have caught on a smoldering coal and the
grounds were boiling up. But the coffee-pot was not on the stove. I
found it still on the shelf, and the coffee was safe in the can. The
odor must have come from out-of-doors.
I was too tired to figure the matter out, and ended by making some
for myself, and going to bed. This was my third night at the House of
the Five Pines, and I retired peacefully, in confidence, without any
disturbing inhibitions. Everything had been solved.
I had shut the door in the secret stairs in the study-closet and
fastened it with a piece of wire. In Mattie’s room I dropped down on
the bed where I had shoved it across the floor that afternoon.
Afterward I rose and pushed the bureau in front of the little door. I do
not know what subconscious motive impelled this, but a woman who
is living alone in a house with nine known rooms, none of which are
in their right places, and three stairs, front, back, and secret, ought to
be forgiven for locking up what she can.
Rain fell in wearied gusts; the worst was over. The wind, still high,
blew dense clouds across the face of the moon and carried them on
again over the sea, so that the waste was momentarily illumined.
Whenever the veils of mist were torn aside the oval mirror in its
frame above my bureau reflected the moonlight. I watched it for a
long time on my way to sleep.
At exactly twelve o’clock I found myself sitting up in bed.
There was moonlight in the room, that fell in quivering patches on
the bed-quilt and lightened up the dark walls, throwing into relief all
the five white doors. But there was also another light, on the ceiling,
that moved steadily up and down. Forcing my hypnotized glance
away from it, I turned to the haunted door and the bureau that I had
placed in front of it, and saw with sickening understanding that the
mirror above it was swaying on its hinges, swinging back and forth.
This caused the moonlight reflected from the water to dance like a
sun-spot. The glass turned as if it were being pushed and could not
keep its balance. I crawled over to it and put my hand out to steady
it, and the whole thing turned.
As I drew back, the pressure on the other side of the wall withdrew. I
could hear footsteps receding until they fell away down what I now
knew was the stairway at the other end of the secret room. I had
heard them the night before and I was sure. Whatever was in there
had given up trying to get out at this side and was going back to try

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McDonald and Avery's Dentistry for the

Child and Adolescent, 11th Edition

Handbook of Child and Adolescent Anxiety Disorders Dean

Child and Adolescent Psychopathology for School

Study Guide to Child and Adolescent Psychiatry Second

Child and Adolescent Psychopathology 3rd Edition

Grace for the Children Finding Hope in the Midst of

Case Studies in Abnormal Child and Adolescent

Health Safety Nutrition for the Young Child 11th

Child and adolescent suicidal behavior school based

DENTISTRY ELEVENTH EDITION

for the CHILD

ASSOCIATE EDITORS: LaQuia A. Walker Vinson, DDS, MPH

VIDEO PRODUCER FOR ONLINE TEXT:

MCDONALD AND AVERY’S DENTISTRY FOR  ISBN: 978-0-323-69820-7

Library of Congress Control Number: 2020948301

Content Strategist: Joslyn Dumas

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Tasha Hall, DMD, MSD Carrie Klene, DDS

Jeffrey A. Platt, DDS, MS Kenneth J. Spolnik, DDS, MSD

Laura Marie Romito, DDS, MS, MBA Jenny Stigers, DMD

Mark Saxen, DDS, PhD Shannon Thompson, MD

Pooya Soltanzadeh, DDS, MS

Dorothy Lynne Cataldo, DMD Cody Hughes, DMD, MSD

Brenda Bohaty, DDS, MSD, PhD Yuming Zhao, DDS, PhD

edition in 1978, McDonald guided David R. Avery through

Front row, left to right: Jones, Dean

CHAPTER OUTLINE Introduction Infant Dental Care

Introduction procedures. Parents with even moderate income usually

development and childhood obesity.

The Diagnostic Method

Birth Date: Gender: Female Male

onsibility to inform this

The clinical examination, whether the first examination

The tongue and oropharynx should be closely inspected.

protective clothing and eyewear to protect against punc- BIOFILM

THIS was a child’s room; there were playthings on the floor.

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MCDONALD AND AVERY’S DENTISTRY FOR ISBN: 978-0-323-69820-7