Textbook of Pediatric Dentistry

Table of contents :
Chapter-01_Introduction
Chapter-02_First Dental Visit
Chapter-04_Pedodontic Clinic
Chapter-05_Practice Management
Chapter-06_Oral Examination and Diagnosis
Chapter-07_Teeth Identification and Numbering Systems
Chapter-08_Radiographic Techniques
Chapter-09_Digital Radiographic Diagnosis
Chapter-10_Developmental Milestones in Children
Chapter-11_Theories of Growth
Chapter-12_Prenatal and Postnatal Development of Head and Face
Chapter-13_Principles, Assessment and Factors Influencing Growth
Chapter-14_Tooth Eruption and Shedding
Chapter-15_Teething
Chapter-16_Development of Occlusion
Chapter-17_Morphology of Primary Dentition
Chapter-18_Child Psychology
Chapter-19_Fear and Anxiety
Chapter-20_Psychometric Assessment of Dental Fear and Anxiety
Chapter-21_Nonpharmacologic Behavior Management
Chapter-22_Conscious Sedation
Chapter-23_Behavior Management of Handicapped Child
Chapter-24_Diet and Nutrition
Chapter-25_Diet Counseling for the Prevention of Dental Caries
Chapter-26_Pit and Fissure Sealants
Chapter-27_Plaque Control in Children
Chapter-28_Plaque Control for the Disabled Child
Chapter-29_Fluorides
Chapter-30_Oral Habits
Chapter-31_Cephalometric Diagnosis
Chapter-32_Preventive and Interceptive Orthodontics
Chapter-33_Myofunctional Therapy
Chapter-34_Model Analysis
Chapter-35_Pediatric Space Management
Chapter-36_Serial Extractions
Chapter-37_Components of Removable Orthodontic Appliances
Chapter-38_Dental Caries
Chapter-39_Caries Risk Assessment
Chapter-40_Diagnostic Aids in Dental Caries
Chapter-41_Early Childhood Caries
Chapter-42_Rampant Caries
Chapter-43_Chemomechanical Caries Removal
Chapter-44_Pediatric Operative Dentistry
Chapter-45_Commonly Used Restorative Materials in Pediatric Dentistry
Chapter-46_Minimal Intervention
Chapter-47_Atraumatic Restorative Treatment
Chapter-48_Stainless Steel Crowns in Pediatric Dentistry
Chapter-49_Anterior Crowns in Pediatric Dentistry
Chapter-50_Primary Root Canal Morphology
Chapter-51_Pulp and Periapical Diseases
Chapter-52_Diagnostic Pulp Testing
Chapter-53_Endodontic Armamentarium
Chapter-54_Pulp Therapy for Vital Teeth
Chapter-55_Pulp Therapy for Nonvital Teeth
Chapter-56_Rotary Endodontics in Primary Molars
Chapter-57_Normal Features of Gingiva
Chapter-58_Gingivitis in Children
Chapter-59_Periodontal Diseases in Children
Chapter-60_Infection Control
Chapter-61_Local Anesthesia
Chapter-62_Pediatric Exodontia
Chapter-63_Traumatic Injuries to Anterior Teeth
Chapter-64_Pediatric Minor Oral Surgery
Chapter-65_Maxillofacial Trauma in Children
Chapter-66_Medical Emergencies in Dental Practice
Chapter-67_Cardiopulmonary Resuscitation
Chapter-68_General Anesthesia in Pediatric Dentistry
Chapter-69_Pharmacological Considerations in Pediatric Dentistry
Chapter-70_Dental Consideration of Handicapped Child
Chapter-71_Cleft Lip and Palate
Chapter-72_Prosthodontic Management of Pediatric Patient
Chapter-73_Developmental Anomalies of Dentition
Chapter-74_Common Orofacial Syndromes in Children
Chapter-75_Common Oral Pathologic Conditions Associated with Pediatric Dentistry
Chapter-76_Child Abuse and Neglect
Chapter-77_Bite Marks
Chapter-78_Introduction, Principle and Types of Laser
Chapter-79_Applications and Hazards of Laser
Chapter-80_Applications of Nanosciences in Pediatric Dentistry
Chapter-81_Dental Implants in Children
Chapter-82_Biostatistics in Dentistry
Chapter-83_Research Methodology
Chapter-84_Dental Indices

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1

Section

INTRODUCTION TO PEDIATRIC DENTISTRY

This area introduces the reader regarding importance of pediatric dentistry, its society, goals and aims and objectives of pediatric dentistry. It is important to us to know the management of child when he/she comes to the dental clinic for the first time. It also briefs us regarding dental home and its importance. This section also helps to know how to set up a pedodontic clinic to keep the child in a comfortable position until the treatment is completed as well as role of the auxiliaries who help in management of the same.

1

Chapter Introduction Nikhil Marwah

Chapter outline • •

Importance of Primary Teeth Aims and Objectives of Pedodontics

Pedodontics is the art and science and that branch of dental science, which deals with comprehensive, interceptive oral health in children from childhood to adolescent age particularly and complete health in general. In other words, it is branch of dentistry that includes training of child to accept dentistry, restoring and maintaining primary mixed permanent dentition and applying preventive methods for dental care. The value of pedodontist always depends upon how carefully the child has been managed at a young age and so pedodontist should have understanding of the subject. • The word pedodontics is derived from a Greek word; • Pedo is derived from Greek word ‘pais’ meaning child and dontics is the study of teeth. Pedodontics has come a long way from its early days of extraction oriented beginning to the current comprehensive era with the emphasis on diagnosis and treatment planning. There was a time when dental clinics were biased against this specialty and considered it a waste of time and very often clinics displayed “No treatment for children under the age of 14 at this clinic”. Most of the dentists also gave a negative knowledge influence to the parents and the most common excuse that was offered was, “These are milk teeth and fall on their own so treating them would be a waste of time and money”. As the years passed by, times changed and so did the schedule for the initial appointment for the child. The dentistry had now progressed significantly and it was thought that 3 years would be a good time for the child to visit the dentist. Recent knowledge in pediatric dentistry has enabled us to realize that age of 3 years is too old to initiate any type of preventive strategy as the disease will have already taken

• • •

Pedodontic Triangle Indian Society of Pedodontics and Preventive Dentistry Scope of Pediatric Dentistry

its toll on the teeth and it no longer remains preventive but becomes Interceptive Pedodontics. Therefore, it was realized that the first visit should be initiated as soon as the first tooth erupts in oral cavity and the preventive educative aspect should start much earlier, by parental counseling.

DEFINITIONS Stewart 1982 defined Pediatric Dentistry as the practice and teaching of comprehensive, preventive and therapeutic oral health care of child from birth to adolescence. It is construed to include care for special patients who demonstrate physical, mental or emotional problems. According to Pinkham: Pediatric dentistry is synonymous with dentistry for children. Pediatric dentistry exists because  children have dental and orofacial problems. The genesis of dentistry for children unquestionably is allied to dental decay, pulpitis, and the inflammation and pain associated with infected pulpal tissue and suppuration in alveolar bone. American Academy of Pediatric Dentistry (1999) defined “Pediatric dentistry as an age defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs.”

IMPORTANCE OF PRIMARY TEETH It is very important that primary teeth are kept in place until they are lost naturally. These teeth serve a number of critical functions. Primary teeth:

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Introduction to Pediatric Dentistry

• Maintain good nutrition by permitting your child to chew properly. • Involved in speech development. • Helps in the eruption of permanent teeth by saving space for them. A healthy smile can help children feel good about the way they look to others.

AIMS AND OBJECTIVES OF PEDODONTICS • Health of a child as a whole: The pedodontist is a part of the health team concerned with the individuals’, i.e. total physical, mental and emotional well-being of patient. We must be certain that our effort to improve dental health is always in accordance with the general health of patient. • More specifically we are concerned with oral health: The other aim should be preventing disease. The earliest attempt at prevention is at expectant mother. She should be advised on dental health of her future child. After child is born we advise the mother to continue appointments. First dental appointment for a child is usually at 6 months. • Early diagnosis and prompt treatment: Introduce and implement the principles of preventive dentistry from birth so that early diagnosis is initiated. Occlusal guidance and early treatment of developing malocclusion should be done to avoid complications. • Restoring the mouth to good health: During restorative treatment first and foremost necessity is to convince the patient and parent that treatment is worthwhile. Only work of highest technical standards will succeed in primary teeth. However, this must be at the same time being enjoyable and at worst acceptable to patient. If dental treatment is unpleasant then the child will develop resistance and reluctance for further treatment. In order to overcome those problems, early diagnosis leading to proper treatment is required. Regular attendance, sound diagnosis, adequate local analgesia, modern cutting equipments are important but, these only arrest the essential empathy that the dentist must have towards child. • To observe and control the necessary developing dentition of child patient: A general dentist who sees the child every time is in an excellent position to study his oral development and to intervene himself or refer to a specialist for the necessary treatment. • Relief of pain: As and when necessary bearing in mind patient’s total well-being.

• Increase the knowledge: Following this we will produce a service for the child as an individual population which is dentally educated which also leads to elevation of the profession. • Instil a positive attitude and behavior: This not only will help in accomplishing the treatment in a desired manner but also make the child a good dental patient even in adulthood. • Restore the lost tooth structure: To maintain tissue harmony  between the hard and soft tissue. • Management of special patients: Managing physically mentally disabled and medically compromised children in an efficient and orderly manner so as to avoid discomfort to the patient and at the same time avoiding any bias towards the special condition of the children.

PEDODONTIC TRIANGLE The differences between child and adults with respect to treatment have long been emphasized by Hippocrates in the 5th Century BC and by Celsius in 4th Century AD. • An adult requires a service to be carried out in his mouth and if he is not satisfied he will seek satisfaction elsewhere, whereas the child attends the dental service because he is forced to do so and will have to return even if he does not like the treatment. • We may expect the adult to put up with unavoidable discomfort; therefore he has the freedom to choose his treatment and can also appreciate the outcome, whereas the child sees no good reason for dentist’s attention. • Child is in dynamic state of growth and development, whereas the adult is in static state. • Consideration of behavior as an integral part of child oral health care and needs. • Attention to preventive care rather than rehabilitation.

Pedodontic triangle was first explained and conceptualized by GZ Wright in 1975 and was later modified by McDonald et al. in 2004 Fig. 1.1:  Pedodontic triangle

Chapter 1  Introduction

Conventional Model Patient-doctor relation in adults is linear but in Pedodontics the relation is triangular. This is because in Pedodontics, the parent and the child both are involved and child is at the apex of triangle as he is the focus of attention (Fig. 1.1). This was first elaborated best in the pediatric dentistry treatment triangle given by GZ Wright in 1975.1 Moreover the arrows indicated that the communication is not only limited to the benefit of the child but is reciprocal in nature.

Modified Model As community has become a major part of all components of environment therefore, recently a new parameter has also been added, that is society (Fig. 1.2). This depiction looked complete with the fact that the communication is reciprocal and society came into the center of the triangle indicating that management methods acceptable to society and the litigiousness of society are important factors influencing treatment modalities.2

Fig. 1.2:  Modified pedodontic triangle

Pediatric Dentistry Treatment Model Pediatric dentistry is an amalgamation of all the branches of dentistry and most of its components have been either derived from or associated with other dentistry branches but the four principles that stand out in this specialty are prevention, risk assessment and management, child psychology and behavior management. Vivek P et al. (2012) have proposed a new model based on the pedodontic triangle and have termed it pediatric dentistry treatment model.3 It presents the former triangle as a square which has the pediatric dentist, pediatrician, family and society playing important roles and definitely the child patient is the center of attention (Fig. 1.3).

Fig. 1.3:  Pediatric dentistry treatment model

INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY Indian Society of Pedodontics and Preventive Dentistry (ISPPD) is the national society specifically concerned with the oral health of children in India. It aims to improve oral health in children and encourage the highest standards of clinical care. The ISPPD has over 1000 life members from university and hospital pediatric dental departments, pediatric dental practice and general dental practice. The emblem (Fig. 1.4) is based on the famous triad of Keyes (1960). One circle represents the tooth, the other the bacteria and the third diet. The shaded area of intersection of the circles represents dental caries. The stress given is that for caries to develop all the three factors are essential; caries cannot occur if one factor is missing. Incidentally, this area of intersection of circles takes the form of triangles. The triangle denotes two aspects (i) it represents delta, which is the sign of dentistry, (ii)

Fig. 1.4:  Logo of ISPPD

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Introduction to Pediatric Dentistry

it depicts the pedodontic triangle as given by Wright (1975). The three corners of triangles are indicative of (a) child, (b) mother (parent) and (c) dentist. This triangle represents 1:2 transactions for the management of children. The top circle of keys in the emblem carries symbols of the emblem of the Indian Dental Association (IDA) — Staff of Aesculpius with wings of serpents encircling around it. The staff of Aesculpius stands of captor of authority and represents the professional authority of association. The serpents show the power of healing since serpents ages back have been used for healing. Hippocrates adopted this symbol and we have adopted it with two serpents entwined around the staff in opposite directions. The wings on the staff represents the spread of knowledge. The wings have 6 small and 3 large divisions as in the IDA emblem.

Attitudes of Pedodontist • Develop an attitude to adopt ethical principles in all aspects of pedodontic practice. • Professional honesty and integrity are to be fostered. • Treatment care is to be delivered irrespective of the social status, cast, creed and religion of the patients. • Willingness to share the knowledge and clinical experience with professional colleagues. • Willingness to adopt, after a critical assessment, new methods and techniques of pedodontics management developed from time to time, based on scientific researches, which are in the best interest of the child patient. • Respect child patient’s rights and privileges, including child patient’s right to information and right to seek a second opinion. • Develop an attitude to seek opinion from allied medical and dental specialities, as and when required.

Aims and Objectives of ISPPD • The society is formed on the firm belief that “Every child in India has a fundamental right to total dental health”. Every member of the dental profession in general and pedodontists in particular have an obligation to uphold this right. • The society shall have the solemn responsibility towards the maintenance of positive dental health of the children through prevention, involvement of the community and through other necessary measures to achieve this objective. • The society shall make an endeavor to provide suitable medium for honoring the commitment it has so sacredly undertaken. • The society shall be responsible for improvement of education, research and delivery of dental health care in the field pedodontics and preventive dentistry and shall extend cooperation or collaborate with any person,

persons or organizations: national or international with similar ideas, ideals and objectives. To realize and attain above mentioned goals the society may: • Conduct dental health education programs in schools and in community for the promotion of better oral hygiene, better dental health awareness and prevention of dental diseases. • Establish liaison with dental surgeons in general practice to carry the message of the society to term and also to keep them in contact with the new, relevant and advanced knowledge in the field through continuing education programs. • To provide forum for the dental teachers to communicate and exchange knowledge on the current and recent advances in pedodontics and preventive dentistry. • Hold periodical meetings and conferences of the members of society. • Organize courses on new techniques in the field of pedodontics and preventive dentistry for pedodontists and other members of dental profession who would be interested to join such courses. • To promote the publications of scientific literature including a journal of the society, which would be dynamic in character and shall have the possibility to adapt itself to the needs of the society from time to time. The publications shall not only be scientific in nature but shall also undertake publicity and propaganda as per the needs of the society and the community. • Establish rapport with Dental Council of India, union and state governments and other national and inter­ national apex bodies to advise on the various aspects of pedodontics and preventive dentistry including legislative and administrative areas. • Accept endowments and grants from individuals or societies, official or nonofficial, governmental or nongovernmental, national or international. • Make efforts to improve the basic curriculum of pedodontics and preventive dentistry both at the under­ graduate and postgraduate levels. • Establish liaison with associations and societies of other allied sciences like pediatrics, psychiatry, psychology and Basic Sciences like biochemistry, microbiology and pathology, etc. • Encourage research in the specialty of pedodontics and preventive dentistry and other related sciences by the establishment of scholarships, prizes and rewards, by publishing from time to time monographs embodying the results of the research conducted by members independently or under the auspicious of the society. • Consider and express its views on all matters pertaining to public dental health, dental profession and dental education and take such steps from time to time as shall be deemed necessary.

Chapter 1  Introduction Worldwide history of pedodontics 1800 BC – Ancient Egypt: No caries in children’s teeth 1563 – 64 Eustachius: Described and showed illustrations of both primary and permanent dentition 1737 – Gerauldy: Writes about theories regarding tooth eruption and exfoliation 1763 – Joseph Hurlock: Publishes book on children’s dentistry 1764 – Robert Bunon: “Father of Pedodontics” reiterates the importance of deciduous dentition 1865 – First child dental clinic opened at Strasburg, Germany 1877 – O  ttofy: Became the first person in the history of dentistry to make a thorough dental examination of school children 1924 – Book: First textbook of pedodontics was written 1926 – D  etroit Pedodontics Study Club: Dr Samuel D Harris Father of Children’s Dentistry organizations worldwide, starts the Detroit Pedodontics Study Club

First book on children dentistry

1927 – A  APDC: Detroit Study Club is now named the American Academy for Promotion of Dentistry for Children 1935 – Pedodontic course: 6 undergraduates and 8 postgraduate courses in pedodontics were started 1940 – A  SDC: American Academy for Promotion of Dentistry for Children renamed as the American Society of Dentistry for Children 1947 – AAP: American Academy of Pedodontics was founded 1967 – C  DH: First International symposium on child dental health conducted by British Pedodontic Society at the London Hospital Medical College 1969 – I ADC: International Association of Dentistry for Children was established and conducts its first congress in Sienna, Italy 1969 – J ournal: Concept of an IADC Newsletter and Journal of the International Association of Dentistry for Children 1970 – J ournal of the IADC: The first issue was published in September with Theodore C Levitas as editor and the first article to be published was ‘Correlation between clinical and histological indications for pulpotomy of deciduous teeth’ by Goran Koch and Hilding Nyborg (Sweden) 1984 – AAPD: American Academy of Pedodontics was renamed to the American Academy of Pediatric Dentistry 1993 – IAPD: First congresses of International Association of Pediatric Dentistry, Chicago, USA

Samuel D Harris

Evolution of pedodontics in India 1920 – C  alcutta Dental College and Hospital: 1st Dental College started by Dr Rafiuddin Ahmed 1920 – LDSc: Introduced as a 1 year course “Licentiate in Dental Science” 1926 – Changed into 2 year course 1935 – B  DS: Licentiate in Dental Science becomes Bachelor in Dental Surgery—4 year course 1950 – P  edodontics is introduced: Government Dental College, Amritsar starts pedodontics as a speciality not as an independent speciality (one or two questions in operative dentistry) Later–Section ‘B’ in orthodontics 1978 – P  edodontics for undergraduates: Pedodontics was introduced as a speciality in the undergraduate curriculum 1979 – I ndian Society of Pedodontics and Preventive Dentistry: The Association of Indian Pedodontists holds the 1st conference. Dr BR Vacher is made the “Father of Pedodontics in India”

Dr R Ahmed

1982 – A  ffiliated to IADC: Indian Society of Pedodontics and Preventive Dentistry becomes an affiliate member of IADC (International Academy for Dentistry for Children)

Dr BR Vacher

7

8 Section 1 

Introduction to Pediatric Dentistry History of dentistry

+100,000 BC: H  omo Mousteriensis shows that prehistoric man had to contend with impacted teeth, the retention of deciduous teeth, caries, fractures and rickets 3000–525 BC: Confirmation of Herodotus’ statements as to the specialization in medicine in Ancient Egypt that there were individuals who treated only the eye, or teeth, the earliest known dentist being Hesi-Re, Great One (Chief) of the toothers and the physicians 130–201 AD: Galen, the Prince of Physicians, born in Pargamos was the earliest to mention the nerves of teeth in removing the carious defect, and recommended the file

Hesi-Re

1498 AD: Invention of the modern toothbrush by the Chinese, June 24 1542 AD: A  mroise Pare, famous military surgeon, revived the old method of compression of nerve trunks to produce local anesthesia 1685: First dental textbook written in English was called “Operator for the Teeth” by Charles Allen 1723: Pierre Fauchard, a French surgeon publishers. “The Surgeon Dentist”, a treatise on teeth

Amroise Pare

1790: Josaiah Flagg, a prominent American dentist, constructed the first dental chair made specially for dental patients 1828: Dr John M Harris started the world’s first dental school in Bainbridge, Ohio 1833: The Crawcour brothers introduce amalgam in US and advertise it as a substitute for gold restorations 1839: The American Journal of Dental Science, the world’s first dental journal began its publications 1844: H  orace Wells, a connection dentist discovered that nitrous oxide can be used as an anesthesia and successfully uses it to conduct several extractions in his clinic. In 1845 the public demonstration of the same failed 1864: Sanford C Barnum develops the rubber dam which solved the problem of isolating a tooth 1871: George F Green received the patent for the first electric dental engine, a self contained motor and handpiece 1895: Wilhelm, Conrad Roentgen a German physicist discovered the X-ray 1899: Edward Hartley angle classified the various forms of malocclusion 1900: FDI is formed

Pierre Fauchard

1913: A  lfred C Fones opened the Fones clinic for dental hygienists in Bridgeport, connecticut, the world’s first oral hygiene school. Dr Fones uses the term dental hygienist to become known as the Father of Dental Hygiene 1920: Dr Ahmed founded the first dental college of India which was financed by starting the New York Soda Foundation in Calcutta 1931: F luoride is identified by HV Churchill in New Kensington, Pennsylvania, Smith MC, Lantz EM, Smith HV in Arizona and Velu H Balczet L in France 1933: The nylon toothbrush made with synthetic bristles was introduced by DuPoint

Wilhelm Roentgen

1948: D  entist act is passes by the Indian Parliament in close association with All India Dental Association on the 29th of March. This Act was introduced to regulate the profession of dentistry in India. The Act was amended on 1st July 1955 to make the law applicable to the state of Jammu and Kashmir 1957: J ohn Borden introduced a high speed air driven contra-angle handpiece. The airotor obtains speed up to 300,000 rotations per minute 1959: The first electric toothbrush, the broxodent was introduced by Bristol-Myers company at the centannial of ADA 1960s: Lasers were developed and approved for soft tissue procedures

Alfred C Fones

Chapter 1  Introduction • To collect, manage and disburse funds for all or any of the objects of the society. • Do all such things and matters as are conducive to the attainment of the above objectives or any one of them which are subsidiary to the said objectives. The Indian Society of Pedodontics and Preventive Dentistry has been formed on the firm belief that “Every child has a fundamental right to his total oral health”.

SCOPE OF PEDIATRIC DENTISTRY Pedodontics encompasses a variety of disciplines, techniques, procedures and skills that logically share a common basis with other specialties, but are modified, transformed or adapted to the special needs of children and adolescence and those with special health care needs.

Pedodontic dentistry concentrates on the integration of appropriate didactic and clinical knowledge from various specialties into a framework of quality oral health care for children. It deals with parents in their formative years, exhibiting rapid growth and development. Therefore, a pedodontist is in an excellent position to alter the growth pattern and resistance of oral tissues to diseases. Pediatric dentists have extended services to fulfill the needs of the special child including the physically, mentally and medically handicapped. They also have the good fortune of being important team member in the children’s hospital and in the management of cleft lip and palate patients and other such ailments. Therefore, the scope of pediatric dentistry virtually includes the essence of all branches of dentistry like diagnosis, oral surgery, rehabilitation, endodontics, orthodontics, pre­ ventive dentistry and also includes the newer avenues like lasers and nanodentistry.

POINTS TO REMEMBER • • • • • •

Robert Bunon is Father of Pedodontics. BR Vacher is Father of Pedodontics in India. Samuel D Harris is Father of Children’s Dentistry organizations. Joseph Hurlock published first book on children’s dentistry. Indian Society of Pedodontics and Preventive Dentistry is formed in 1979. American Academy of Pediatric Dentistry (1999) defined “Pediatric dentistry as an age defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs.” • Patient-doctor relation in pedodontics: The relation is triangular with the parent and the children both are involved and child is at the apex of triangle as he is the focus of attention. This was first elaborated best in the pediatric dentistry treatment triangle given by Wright in 1975.

QUESTIONNAIRE 1. 2. 3. 4. 5.

Define pediatric dentistry. Give a brief history of pediatric dentistry. What are the aims and objectives of pedodontics? Importance of primary teeth in oral cavity. Explain the concept of pedodontic triangle.

REFERENCES 1. Wright GZ. Behavior Management in Dentistry for Children. 1st Edn. Philadelphia: WB Saunders Co; 1975. 2. McDonald RE, Avery DR, Dean JA. Dentistry for the child and adolescent. 8th Edn. Philadelphia: CV Mosby Co; 2004. 3. Vivek Padmanabhan, Dr Kavitha Rai, Dr Amitha M Hegde. Pediatric dentistry treatment triangle - A Review and A New Model Journal of Health Sciences and Research. 2012;3(1):35-6.

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Introduction to Pediatric Dentistry

BIBLIOGRAPHY 1. Gelbier, Stanley. 125 Years of Developments in Dentistry. British Dental Journal. 2005;199:470–3. 2. Mirella De Civita Patricia L. Dobkin Pediatric Adherence as a Multidimensional and Dynamic Construct, Involving a Triadic Partnership. Journal of Pediatric Psychology. 2004;29(3):157–69. 3. Pinkham JR, Casamassimo PS, McTigue DJ (Eds). Pediatric Dentistry - Infancy Through Adolescence. 4th Edn. Saunders; 2008. 4. S Gelbier. History of the International Association of Pediatric Dentistry Part 1: National associations and societies of dentistry for children. International Journal of Pediatric Dentistry. 1994;4:281-7. 5. S Gelbier. History of the International Association of Pediatric Dentistry Part 2: Early events in the USA-the American Society of Dentistry for Children. International Journal of Pediatric Dentistry. 1995;5:213-6. 6. S Gelbier. History of the International Association of Pediatric Dentistry Part 7: The International Forum of Dentistry for Children. International Journal of Pediatric Dentistry. 1996;6:289-93. 7. S Gelbier. History of the International Association of Pediatric Dentistry Part 9: Publications of the IADC. Journals and Newsletters International Journal of Pediatric Dentistry. 1997;7:49-55. 8. Suddick, Richard P, Norman O. Harris. “Historical Perspectives of Oral Biology: A Series”. Critical Reviews in Oral Biology and Medicine. 1990;1(2):135–51. 9. Wilwerding, Terry. History of Dentistry, hosted on the Creighton University School of Dentistry.

2

Chapter

First Dental Visit Nikhil Marwah

Chapter outline • •

Parents Role in Preparation of Child for First Dental Visit Preappointment Behavior Modifications

Traditionally the first visit of a child to dentist was scheduled around three years of age. This recommendation was based on the child’s ability to cooperate in the dentist’s office and the assumption that most children under 3 years of age did not have any cavities. According to Nowak (1997), a child’s first visit to dentist should occur no later than 12 months of age so that the dentist can evaluate the infant’s oral health, determine the child’s risk for developing dental disease, intercept the potential problems and educate parents in the prevention of dental disease in their child. In 1986, the American Academy of Pediatric Dentistry (AAPD) adopted a position on infant oral health recommending that the first visit of the child to the dental clinic should occur within 6 months of the eruption of the first primary tooth. Recent knowledge in aspects of cariology and prevention have modified this further and it is now stated that the first visit of the child to the dental office must be as soon as the tooth erupts in oral cavity, i.e. 6  months of age. The child’s first dental visit should be organized in such a way that it becomes an enjoyable experience for him. The first visit is more or less a mutual assessment session during which the dentist assesses the child, and the child assesses the dentist and the dental environment. Lenchner (1975) postulated that the incorporation of attitudes and behavior patterns from parents, siblings or peers is as common as contracting measles from a family member or friends. The main hypothesis for disruptive dental behavior were summarized by Lenchner as: • Behavior contagion • Threatening the child with the dentist as a punishment

• • •

Recommended Procedures to be Carried Out on First Visit Examination of the Infant and Toddler Tips to Prepare the Child for First Dental Visit

• Well-intentioned but improper preparation of the child • Discussing dentistry within hearing of the child • Children’s anxieties, generated both externally and internally, with respect to behavior contagion (a term used by Wolking, 1963).

PARENTS ROLE IN PREPARATION OF CHILD FOR FIRST DENTAL VISIT The parents play an important role in the preparation of child for dental visit and also on the behavior which the child will exhibit at the time of appointment. Some of the common but necessary things which parents must perform before the child’s appointment are: • Before the visit, ask the dentist about the procedures of the first appointment so there are no surprises. • Plan a course of action for your child who may exhibit cooperative or noncooperative behavior. Very young children may be fussy and may not sit still. • Talk to your child about what to expect, and build excite­ ment as well as understanding about the upcoming visit. • Bring with you to the appointment any records of your child’s complete medical history.

PREAPPOINTMENT BEHAVIOR MODIFICATIONS A child’s first dental visit can be made successful by a few preappointment preparations which have been discussed in the following sections.

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Introduction to Pediatric Dentistry

Fig. 2.1:  Sample of preappointment mail

Preappointment Mailing • Parents usually try in some way to prepare their child for the dental visit. Some parents, through their own fears or ignorance, do more harm than good in this attempt. Contact with a child’s parents before the first dental visit can alleviate some concerns. • The precontact can provide directions for preparing the child patient for an initial dental visit and, therefore, increase the likelihood of a successful first appointment. • Parents sometimes try to prepare their child for the visit by saying that ‘the dentist will not hurt’, or by bribing them to be good with the promise of a toy (or even a sweet). • It is suggested to the parents through mail (Fig. 2.1) to be as casual as possible. It is advised to simply inform the child, either on the morning of the appointment or on the  day before, that he or she will be visiting the dentist. The child should be said that the dentist is going to count  his or her teeth and he will be helping the child to look after their teeth in a better way. • Suggestion is also given to avoid conversation in the home that might include unfavorable references to dentistry. • The parents are informed through the same mail about the procedures that will be carried out during the first visit. This will alleviate the anxiety and the concerns of the parents regarding the child’s visit to the dental clinic to some extent.

Preappointment Modeling Modeling is a type of behavior modification technique whereby a young patient can learn about the dental experience by viewing other children receiving treatment. Several authors have reported that this technique seems to improve the behavior of apprehensive patients who have

Fig. 2.2:  Audiovisual modeling

no previous dental experience. The goal is for the patient to reproduce the behavior exhibited by a model (Bandura, 1967). Modeling is of two types, viz. audiovisual modeling and live modeling.

Audiovisual Modeling • The child sees a video tape or film before proceeding to the dental clinic (Fig. 2.2). • This is done on the day of the appointment or perhaps at a previous visit. • The presentation explains in terms the child can understand the dental equipment and the procedures to take place. • The biggest advantage of an audiovisual modeling is that it is a prerecorded commercial presentation, thus nothing inadvertently creeps into the presentation that could influence the child negatively. • The disadvantage of this technique is the need for special equipment and space for presentation which makes the technique expensive and unless the procedure is developed by the dentist, it can be impersonal. In a few dental setups some of the members of the dental team are employed to help the child understand the presentation and to draw their attention towards the important aspects of the presentation.

Live Modeling • It can be achieved through siblings, other children or parents. • Since observing child will likely be initiated with a dental examination, a parent’s recall visit offers an excellent modeling opportunity. On these occasions many young children climb into dental chair following their parent’s appointments.

Chapter 2  First Dental Visit RECOMMENDED PROCEDURES TO BE CARRIED OUT ON FIRST VISIT

Fig. 2.3:  Live modeling by sibling

• It has been found that sibling proves to be a better model as compared to their parents (Fig 2.3). At times younger sibling can play the role of a model but it is better to have the older sibling in this role. This is mainly because in the house an elder brother or sister plays the role of role model for the younger ones. This is even better if the model is of the same sex. • When a cooperative sibling is not available a non-related child may be used as a good model. • The disadvantage of live modeling is that, sometimes the model himself or herself may show some disruptive behavior which may result into an improper impact over the behavior of the child. Thus models should be selected carefully.

• Many first visits are nothing more than introductory icebreakers to acquaint your child with the dentist and the practice. • If the child is frightened, uncomfortable or noncooperative a rescheduling may be necessary. • Patience and calmness on the part of the parent and reassuring communication with your child are very important in these instances. • Short, successive visits are meant to build the child’s trust in the dentist and the dental office, and can prove invaluable if your child needs to be treated later for any dental problem. • Appointments for children should always be scheduled earlier in the day, when the child is alert and fresh. • For children under 2 years of age the parent may have to sit in the dental chair and hold the child during the examination whereas for older patients, parents may be asked to wait in the reception area so a relationship can be built between the child and the dentist. Every effort should be made by the complete dental team to make the first dental visit of the child as comfortable and enjoyable as possible. For this reason it is advisable not to carry out any invasive, stressful, painful or traumatic procedure on the first visit. Apart from taking history the dentist can polish a few teeth on the first visit. If radiographs are required it is logical to obtain them at the first visit, not only because they complement the clinical examination and contribute to the diagnosis but also because the procedures are not traumatic and therefore provide a suitable introduction to treatment (Table 2.1).

TABLE 2.1:  Common procedures carried out during the first visit 1.

History taking: • • •

2.

Social Dental Medical

Clinical examination: • •

Extraoral Intraoral

3.

Take radiographs if required

4.

Explain aims of the treatment to the parents: • • •

5.

Emphasize the need for preventive as well as operative treatment Request that the child’s toothbrush be brought at the next visit Inform about the financial aspects and the number of appointments required for the complete treatment of the child

Simple procedures: • • •

Attend to any of the emergency present and treat for pain if present Prophylaxis: Incisors only (in young child) or full mouth including removal of calculus if required Topical fluoride application or other nontraumatic procedure

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Introduction to Pediatric Dentistry

• Pre-appointment assessment: – Obtain and preview information using a questionnaire. – Biographic data and family and social history to provide understanding of parent-child relationships. – Prenatal, natal and neonatal history to explain dental abnormalities providing a means of documenting causative events such as high-risk pregnancies, medication ingested during pregnancy, preterm or low birth weight infants and significant febrile episodes during early childhood. – Development history to discover significant growth alterations and basis for answering parent’s queries. – Medical history regarding frequent episodes of otitis media, frequent ingestion of antibiotic suspensions

containing high concentration of sucrose as it might influence recommendations for dietary management, tooth cleaning and topical fluoride application. – Dental history regarding dental trauma, teething difficulties, non-nutritive sucking habits, current patterns of home oral health care for developing dentist. – Feeding history regarding breast and bottle feeding, frequency and duration, use of a night time bottle or pacifiers, contents of the bottle, weaning and transition to covered feeding cups. • Interview and counseling: Best accomplished prior to the examination – Specific concerns of the parents are identified – If the infant fusses during the examination (normal behavior), the parents predictability will direct their  attention toward the child during the discussion that follows the examination and not toward the dentist. – The child can be occupied with toys in a nonthreatening environment prior to the examination. • The examination procedure (Figs 2.4 and 2.5): – Parent’s assistance in a nonthreatening environment is taken. – Use of dental chair is not necessary. – A pleasant location away from operatory is recom­ mended. – Parent and dentist sit facing each other in a knee to knee position, supporting the child with the head cradled on the dentist’s lap. The parent can restrain the child gently and the dentist has a good visualization. – This position is comfortable and parental contact has a calming reassurance to the child. – Since the psychological development under 30 to 36 months is insufficient to facilitate cooperation so crying and fussing should not interfere with examination.

Fig. 2.4:  Knee to knee examination

Fig. 2.5:  Lap examination

EXAMINATION OF THE INFANT AND TODDLER

Objectives of the Infant Examination • Introduction to dentistry: – Foundation for the development of a positive attitude towards dentistry should be built. – Pleasant, nonthreatening introduction to dentistry for the child and parents. • Risk assessment and oral examination: – Medical history, current feeding and oral health practices, clinical findings, child’s social and physical environment. – Evaluation of the head and neck and inspection of the oral cavity for early detection. • Prevention: – Parents’ preventive counseling including diet, feeding and snatching practices, tooth cleaning, fluoride assessment is done.

Steps of the Infant Examination

Chapter 2  First Dental Visit – Dentist should begin with a general appraisal of the child, using a warm, gentle touch in a nonthreatening manner. The head and neck region should be evaluated for the presence of abnormalities in size, shape and symmetry of the head, lymph nodes, facial symmetry, eyes, ears and nose; lips and mouth. Practitioner should be aware of possibility of child abuse and look for bruising. The examination of the mouth, with an artificial light source, if needed should begin with palpation of the lips, gingiva, and mucosa by placing a forefinger along the cheek and positioning it on the gum pad distal to the most posterior maxillary tooth. Evaluate soft tissues for presence of pathologic processes such as inclusion cysts, congenital epulis, submucous clefts, traumatic ulcers, frenum lacerations, gingivitis. – Positioning and technique for tooth cleaning should be demonstrated. The child should then be positioned with the head on parents lap so that parent can practice tooth cleaning under supervision and appropriate suggestions can be offered. These findings are then collated with previous information and risk is assessed based on which recommendations are made. • Determining a recall schedule: – Appointment should be individualized and not determined on a traditional 6-month interval. – At the recall visit, in addition to the clinical examination, the practitioner assesses the parents’ tooth-cleaning efforts, evaluates feeding and snacking patterns, and investigates the degree to which the parents are following the recommended prevention program that was previously outlined.

TIPS TO PREPARE THE CHILD FOR FIRST DENTAL VISIT Read a story and/or watch a movie with your child about going to the dentist:  Children can relate to characters in a book or on the screen. If they see that their favorite character shows no fear and is having a good time at the dentist, it will help your child be less afraid when he/ she visits the dentist for the first time. Make a dental appointment when the child is well rested and is generally a good time of day for them:  Each child is different. Some children are much more receptive to new things and just generally in a better mood in the morning. Other children are

not ‘morning people’, and an appointment after an afternoon nap may be best. Schedule an appointment for a time of day that works best for your child. Play “dentist” with your child:  Sit down with your child and count his/her teeth, check the gum tissues, and just get your child comfortable with having fingers in his/her mouth. Let your child then be the dentist and allow the child to count your teeth and play with your mouth. Calling the dentist before your child’s first dental visit, will also prepare you for what takes place on the first visit and you can incorporate that into “playing dentist”. Let your dentist know of any psychological, mental, or physical disabilities your child may have: The more informed the dentist is about your child, the easier it will be for the dentist to work with your child to make the first dental visit a pleasant experience and not a traumatic one. Do not be afraid to talk to your dentist: If you have any questions, do not be afraid to ask them. The more you know about your child’s teeth, development, and how to best take care of your child’s teeth and gums, and any treatment that may be needed, the better for your child. You will be able to help prevent cavities and/or other dental health issues, develop a good oral hygiene routine with your child that will most likely carry into adulthood, and also better prepare yourself and your child for any treatment that may be needed. Do not convey anxiety to your child: Your child is very receptive to your moods, tones in your voice, facial movements, and just general body language. If your child senses any kind of fear that you may have, it will make your child more uncomfortable and fearful. Remain as calm and relaxed as you possibly can. Sometimes, it may be better if a spouse, older sibling, or someone close to the child, attends your child’s first dental visit, if you have a fear of the dentist and are concerned about whether or not your child will sense this. Watch what you say around your child:  Never let your child hear of any past dental experiences that you may have had, or someone else experienced, that were traumatic or just generally bad experiences. Be careful not to use words like, “shot”, “needle”, “hurt”, “X-ray”, or “drill”. Instead, explain to

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Introduction to Pediatric Dentistry

your child that the “tooth doctor” will count his/her teeth, and may be take pictures. Talk to your child about the first dental visit, but keep it positive, short, and simple. Its okay if your child cries during the first visit: Crying is perfectly normal during your child’s first visit. Remain strong, supportive, and work with the dentist during this time. No parent enjoys seeing their child cry, but the parents should remain as positive and supportive as possible. Allow some alone time for your child and dentist: When possible, let your child alone with the dentist and staff. Even if you just stand outside of the room so your child can not see or hear you. By allowing your child some alone time with the dentist, this will help to create a bond between the dentist and your child. The dentist will create a comfortable environment for your child, one where the

child can open up to asking questions, or explore around the room on his/her own time. The dentist will talk to your child in terms that your child can relate to, as well as help create a positive experience for your child. Toy support: If your child has a favorite toy, something small, allow them to bring it with them to their first dental visit. The more positive and supportive you can remain before and after your child’s first dental visit, the better. Each time your child visits the dentist, the easier it will be if they had a positive, enjoyable experience the first time. Your child will also be more likely to be willing to learn good oral hygiene skills and will want to take good care of their teeth. Children, who develop good oral hygiene routines, will most often carry these routines well into their adult life.

POINTS TO REMEMBER • • • •

First visit of the child should occur within 6 months of the eruption of the first primary tooth. Preappointment behavior modifications include preappointment mailing and modeling. Live modeling by sibling is the best method to enhance positive behavior in a child. Simple procedures like examination, oral prophylaxis and topical fluoride application should be carried out in the first dental visit.

QUESTIONNAIRE 1. 2. 3. 4.

Explain the role of parent in behavior modification in children. Define and explain modeling. What should be the protocol for the first dental visit of child? Explain some tips which may be useful for parents in alleviating the anxiety of their child.

BIBLIOGRAPHY 1. Friedman LA, Mackler JG, Hoggard GJ, et al. A comparison of perceived and actual dental needs of a select group of children in Texas. Community Dent Oral Epidemiol. 1976;4:89-93. 2. Green M (Ed). Bright futures: Guidelines for health supervision of infant, children and adolescents. Arlington, VA: National Center for Education in Maternal and Child Care. 1994.pp.3-190. 3. Guidelines on infant oral health care. American Academy of Pediatric Dentistry Guidelines. In: American Academy of Pediatric Dentistry Reference Manual 2002–2003. Pediatr Dent. 2002;24:47. 4. Kleinknecht RA, Klepac RK, Aelxander LD. Origins and characteristics of fear in dentistry. J Am Dent Assoc. 1973;86:842. 5. Waldman HB. Oral health status of women and children in the United States. J Public Health Dent. 1990;50(6 Spec No):379-89. 6. Weinstein P, Nathan J. The challenge of fearful and phobic children. Dent Clin North Am. 1988;32:667-92.

4

Chapter

Pedodontic Clinic Ashwin M Jawdekar, Nikhil Marwah

Chapter outline •

Pedodontic Clinic Designing

Dentistry for children is not difficult but is different from what is practiced for adults. This is due to the fact that children are not just miniature adults. They react differently to people and places around them. To treat them comfortably in dental clinics, the approach of the dental clinic staff and the clinic atmosphere play an important role. Children do have a ‘place memory.’ This can be both advantageous and disadvantageous. A child does not like to visit a place where he/she has previously experienced discomfort. Also, they do like to be in places and catch up with people that are fun for them. Often, medical set-ups are stereotype, designed to suit doctor’s requirements and are disliked by children. A child-friendly dental set-up, thus, has to be a little different from a routine clinic. The environmental needs of children differ from those of adults and it is preferable to plan a dental office that encourages feeling of care and familiarity for the child. In general, the area designed specifically for children should reflect the percentage of children in the entire practice. According to Braham and Morris, “The environment should encourage children to have the parents’ side and well facilitate separation when child is transferred to the dental operation.” It is important for dentists to know various aspects of dental experience that can have positive or negative impact on child behavior. Summarized in (Table 4.1) are a few such considerations.

•

Additional Considerations in a Dental Clinic that Treats Young Children

that will last a life-time. The doctor’s goal, along with the staff, must be to help all children feel good about visiting the clinic. Since children constitute about 40 percent of the nation’s population, the dental clinics must be made ‘child­-friendly’. Furthermore, we do live in a ‘child-centered’ society today and, hence, in our clinics, children should be considered as important visitors. The design of pedodontic clinic should have 4 to 5 compartments such as (Fig. 4.1). The dental operatory should be well isolated from other areas and the last place to be introduced to the child during the first visit. In this figure, the arrows indicate direction of movements towards operatory. The orange rectangular area is the front desk. The black area is a rest room. The white area is assistants’ area, sterilization and storage place. To make our

PEDODONTIC CLINIC DESIGNING Children behave, expect and relate to the surroundings much differently. Keeping this in mind, we have to design the set-up of the clinic as well as a system of functioning. Pleasant visits to the dental office promote trust and confidence in a child

Fig. 4.1:  Design of pedodontic clinic

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Introduction to Pediatric Dentistry

TABLE 4.1:  Impact on child behavior Children like

Children may not like

Playful environment

Clinic, hospital environment

Fresh, bright and bold colors like red, yellow, orange

Dull, wooden, tiled walls; gray, black, brown colors

Open spaces to move around

Restricted seating position

Being received with smile on faces who meet them, being called with names

Being unnoticed, ignored or if not greeted well

To touch, feel and play with objects

Asked not to touch here and there

Humor, compliments, praise, positive comparisons

Criticism, verbal ridicule, negative comparisons

Being termed as ‘grown-ups’ (big boys/girls)

Being termed ‘small’, immature, young

Shake-hands, patting on back, giving claps

Too little or too much of physical closeness

Eye-to-eye contact while talking

Indirect talks

Cartoon films, magic shows, advertisements on TV

News, serials, films, other TV-programs

Talking about games, friends, school, TV-programs, movies, etc. Listening Talking otherwise or related to dentistry to stories, answering puzzles ‘I’ message type communications such as “I like children who listen to me Communication styles such as “why do not you stop crying and listen carefully and follow my instructions”; “I like children who do not move hands to me” or “do not move your hands when I am working” while I am working” To be in a ‘comfort zone’; e.g. a comfortable child engages himself in Too many instructions, orders, suggestions; too many distractions watching cartoon film while the dentist is treating him/her (and also follows all instructions like keeping mouth open, rinsing with water) To win prizes, rewards, stars

Being actually punished or verbally ridiculed (criticize the behavior and not the person)

Friendly gestures, simple attire of doctor/staff

Staff attire—apron, mask, gloves, caps, eye-shields

Dental chair moving up/down, ease of getting in and out of it, spittoon, Dental chair moving backward, too bright light, too many arms (of tumbler operations, light buttons instrument tray, X-ray), too many noises (compressor, air-rotor drill, ultrasonic cleaner, suction) Instrument tray with minimum things on it; only 1 to 2 mouth mirrors for Tray loaded with sharp instruments—needles, RC-instruments, burs, initial examination scaler tips, being shown a needle while injecting Simple words (see the list of euphemisms)

Words like pain, blood, injections, drill, pulling out teeth

Attention, quick and graceful approach to work

Too long appointments, too long waiting time, made to sit for long without interaction

Honest, clear and simple talks; for example, being told that to clean the Cheating; for example, being told that he/she would not get pain at tooth, you need to put medicine near it to put it to sleep. It may pain only all before receiving injection (and actually experiencing it) as much as an ant/mosquito-bite

dental clinics child-friendly, the following aspects must be considered important: • Space provision • Reception at the front desk • Waiting area • Attire and presentation of the clinic staff • Colors, smells and sounds • Instructions for children/parents • Readiness to accept children as they are • Gifts and rewards • Audio-visual aids for entertainment • Team approach.

Space Provision/Play Area • Children require free, empty spaces to move around. They usually do not sit in one place. They often stand near a window, move around reception or table or keep looking for interesting things around. Therefore, it is necessary to provide some empty space for them to move around. • A fish tank or a slide may be kept (depending upon the space available) in such a vacant area. • Also, it is better to engage them in some interesting activity to relieve their anxiety before their turn comes for dental check-up or treatment (Fig. 4.2).

Chapter 4  Pedodontic Clinic

Fig. 4.3:  Reception area

Fig. 4.2:  Play room area for children

Front Desk • The receptionist should possess communication skills to deal with children effectively. • He/she must call each and every child by his/her name and converse about the topics of his/her interests. Often, lack of interest on the part of the clinic staff to deal with children fails to generate any excitement in the child. • Also, many times children in our society are threatened by their parents of a doctor’s visit or of injections, for not behaving properly (or a dentist’s visit for eating too many chocolates, for example). Hence, before their initial dental visits they are unsure of what is going to happen. If a friendly-welcome, cheerful conversation and playful atmosphere greet a child, the child feels that they are no longer brought for any punishment and that, in turn, makes the job of the clinician easy. • The reception should be adjoining the play area so that not only can the receptionist keep a watch on behavior of child but also is able to engage them in conversation thereby alleviating their dental anxiety (Fig. 4.3).

Waiting Area • This is especially useful for children, who are big enough for the play area and would like to show their intellect and engage in smarter games (Fig. 4.4). • This can comprise of books and games for elder children and waiting parents.

Fig. 4.4:  Waiting room area

• It is necessary that the waiting time of a child in the dental clinic is made pleasant. Often, children having to wait for long are bored by the time they are taken in for treatment. • Also, 5 to 10 minutes of waiting time spent in playing can distract them from the fact that they have been brought for some treatment, and is ‘refreshing’ for them. • A child, who is in a happy mood just before entering the dental clinic operatory, is more likely to be co-operative for the treatment than a child who is either bored of waiting in a dull room or is anxious about dentistry.

Attire and Presentation of the Clinic Staff • A typical attire of dental staff comprising cap, apron, mask and gloves is certainly not child-friendly. In case of children, it is especially recommended to try and work with alternatives to apron as they have white coat anxiety. • Make an attempt to meet a child casually, and preferably not around the dental chair.

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Introduction to Pediatric Dentistry

• The dentist first meets the child casually in the consulting room, takes a brief history, assesses the behavior and then directs the child to dental chair after showing around the clinic and meeting other staff.

Colors, Smells and Sounds • Often clinics have roof-to-floor tiles for easy maintenance and cleanliness, and colors projecting office ambience. • Children imagine and accept bold, bright fresh colors such as yellow, red, blue, green, orange, pink and may dislike gray, black and white, wooden, brown, etc. (Fig. 4.5). • Also, smell of spirit, eugenol, acrylic, waxes may not really go well with children. The noise of an air-rotor handpiece, suction apparatus, a compressor or an ultrasonic cleaner can be disturbing too. Hence, it is best to mask these sound by use of light instrumental music.

Instructions for Children and Parents • A lot depends on how the children are prepared at home for their dental visits. It is important for us to inform and educate them well. • The notice boards in the consultation room must carry instructions for parents before dental visits of children as well as certain post-treatment instructions (Fig. 4.6). Also, a booklet or a brochure as a pretreatment communication can be mailed to parents beforehand or delivered to them soon as they enter. • An important deterrent to seeking dental care is a fear of dentistry. Often, parents threaten a child of a doctor’s injection for any misbehavior on their part or for eating too many chocolates. A child thus has a negative preparation of mind even before visiting a doctor or a dentist and looks forward to visiting one only for some punishment. Certain instructions need to be given to parents for better

Fig. 4.5:  Bright colors of clinic

preparation of them and their children for receiving dental treatments; such as: – Do not tell your child about pain, blood, injections, etc. in the first place. – Do not tell him/her something like “... because you do not brush your teeth properly, doctor will give you an injection ...” or “because you eat chocolates, your spoiled teeth will be removed by doctor”. – Do not voice your own fears about dentistry (pain, blood, etc.) in front of children. Your dentist can answer your queries separately. – Do not insist on starting the treatment in the first visit itself. Give your doctor enough time to talk to your child. The time spent initially on building rapport and gaining his/her confidence will in turn save the time required for treatment later. – Do not promise him/her in advance about the time the doctor would take to treat, the pain he/she might get, etc. which can mislead him/her. Simply say you do not know. – Report to the doctor any past negative experience. • The discussion regarding the same may preferably take place in the absence of children; for example, in a consulting room while the child is busy in playing in the waiting area or watching cartoon films.

Readiness to Accept Children • Children love fun, they enjoy being admired, interacting with others and making their ‘world’ of people and nonliving things such as places, toys, games, cartoon films, etc. We have to accept them as they are and more importantly become a part of their world by communicating with them verbally as well as nonverbally (with an eye-to-eye contact, physical contact like shaking hands, patting on the back, giving a clap, etc.).

Fig. 4.6:  Notice board displaying important messages

Chapter 4  Pedodontic Clinic • According to Pinkham, no child is competent in language before the second birthday and all normal children are competent in language after fourth birthday. This is because between ages 3 and 6 years, fear of separation from parents, strangers, a new experience diminishes; control, conscience, aggression develop. Children learn interaction with peer, self-discipline; values (sexual as well as adult) develop. Thus, this age-group children are susceptible for distraction, friendship, feeling guilty, praise, emotions of other people, etc. Most of our behavior modification techniques in the linguistic domain (like TSD, modeling, voice control) are based on these basic observations. • During initial visits, therefore, the dental team should focus on communicating with children properly to win their confidence and progress to carrying out treatments gradually. • Also, children do cry at times we should not panic due to a child crying. A child may cry due to various reasons in a dental clinic. Noise of certain machines, taste of certain medicines, not wanting to get the treatment done, getting bored, are a few examples. As long as the child does not cry due to pain, there is nothing to worry at all and so we must be prepared to listen to it.

Gifts and Rewards • Give a child a token of appreciation for good work with a small gift at conclusion of a visit such as cars, dolls, pencil, medals, etc. • Even calling a child a ‘good boy’ or a ‘good girl’ or drawing a ‘star’ on his/her hand can work like rewards and excite children and leave with them fond memories of dental visits. • Never bribe the child before treatment.

Audiovisual Aids for Entertainment • Children forget themselves while watching cartoon films. The TV set in front of dental chair can distract the child enough to forget the dental treatment while that being carried out (Fig. 4.7). • Also, once a child is cooperative, it reduces the need of talking on the part of the dental team. It is a good idea to have a camera attached to a TV set displaying the child on the chair as children do love watching themselves.

Team Approach • The whole team should work with a plan for each visit of a child. The plans, however, should have certain flexibility. • The initial visits are usually sufficient for ascertaining the child cooperation and diagnosis and treatment planning.

Fig. 4.7:  AV set-up of children’s dental operatory

Plan for the subsequent visit (if an uncooperative child is to be scheduled for his first restorative work, have his/ her appointment after a cooperative child whom you can model for a certain procedure. • Plan procedures requiring minimal cooperation initially and the complicated ones, later. It is a good idea to have a separate session of pediatric patients in a busy general practice. • The team should work with a flexible approach, learn communication skills to deal with children effectively and be positive.

Design of Equipment • Very accessible sterilization to meet the needs of the fast and large volume of patients in an office seeing a number of young children. • Large size of multiple units for ultrasonic dug mat, steam or chemical mat sterilization. • A sufficient number of instruments, mouth drops and such to treat a large patient volume. • Storage in every conceivable spot under holding benches in the operatory wall cabinets and under counter cabinets, etc. • Brush up sinks at graduated heights. • Hard surface floor under operatory chairs; carpeted trash disks. • Foot controlled or automatic faneets for operatory sinks. • Trash container in the operatory out of sight and out of reach of children’s hands. • A colorful towel to cover the restrained child. • A camera to take first examination photograph — an excellent marketing activity that phases point. • The equipment must be accommodated to the child not vice versa (Fig. 4.8).

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Introduction to Pediatric Dentistry

Fig. 4.8:  A modern set-up of children’s dental operatory

ADDITIONAL CONSIDERATIONS IN A DENTAL CLINIC THAT TREATS YOUNG CHILDREN • Ground or first floor location if possible; an elevator if above the first floor. • Designated play area for young children in the reception rooms. • Carpet on the wall makes the area more durable. • Horse shoe traffic pattern in which children are called to the operation from one door and exit by a second. • Plenty of check out space: Parents with multiple children and to get backed up at the check out station, particularly in the peak hours. • Marketing coordinator/Dental health educator office/conference room to meet with parents for case presenta­tion home care instruments and diet counseling. • A small dental chair with a light in at least one conference rooms so that, if necessary, the patient can be shown something in the child’s mouth. • Door knobs on operatory doors approximately 5 feet. from the floor, if building codes permit to prevent a child from wandering. • At least one, preferable 2 quiet operatories for performing lengthy complicated procedures with sound proofing.

• Glass as a sound barrier, therefore constructed glass Patco doors make excellent enclosures for quiet room combining visibility and sound proofing. Patco doors are available with built in blinds between 2 planes. • A large glass window in the dentist office looking on to the operation is very helpful. Blinds provide privacy when needed. • Wall paper to take the wear and tear of small hands better than painted walls. • Neat attention getter: Small television with earphones in the ceiling over each choke showing tapes controlled from a central video cassette player. • If individual TV’s are impractical or too expensive, a TV/VCP in one location in operatory preferably mounted on a wall is a good alternative. • Holding benches in the operatory that double as storage. • Arcade style video games for the reception area or in the operatory index areas. Sound effects should be removed. • The play must be such that it serves the interests of all ages. • There are many varieties of stuffed animals, hand puppets and other toys which serve both as distraction and pleasure. • Color is very significant for youngsters’ almost bright colors are preferred to pastels. • Negative sound of any nature may arouse anxiety. Good sound insulation is essential. Carpeting very effectively reduces sound levels. Tones of voice of the dentist and staff may discourage confidence. • The smell of medication such as eugenol or formal­ dehyde pervading the office can be particularly unpleasant. • Cleanliness and neatness are important. They reflect the individuals, who administer therefore encourage or discourage confidence. • Operatory should be designed to minimize potentials negative visual stimuli. • Fear provoking instruments should be located in incons­picuous positions. • Use of preparatory is especially helpful since the time required to prepare for each patient is reduced. This allows a quarter period of time for orientation. • The location and size of the equipment must permit the dentist auxillary and patient to remain comfort­ able for long period. • Dental chairs which are narrow and thin backed enable the dentist and dental assistant to sit closer to the work.

Chapter 4  Pedodontic Clinic “The foundation of practicing dentistry for children is the ability to guide them through their dental experiences”. It is important to plant seeds for the future dental health early in life and to promote positive approach towards dentistry during child­hood. A pediatric dentist or a dental surgeon has to play roles of a behavior therapist and a counselor in order to facilitate this, the clinical atmosphere must be child-friendly. A typical clinic set-up may not be

liked by all children; however, there is no reason as to why adults should not like a child-friendly clinic. Also, the childfriendliness in a set-up can be a distinguishing feature of such a clinic and children may be brought to it by parents undergoing treatments a long with them. Such visits could help reduce fears related to dentistry in a child’s mind and prepare him/her better for a treatment visit, if required, anytime later.

POINTS TO REMEMBER • • • • • • • • •

Pedodontic clinic should be distinctly designed with special provisions of play area for children. The receptionist should be pleasing and should converse with the child in their developmental age pattern. The attire of the pediatric dentist should be nonthreatening as children have white coat fear. Sound of dental equipment should be well-masked with music. The most important fear allaying mechanism is the role of parents and hence a pre-requisite brochure should be mailed to them with detailed instructions. A reward is the best ensuring factor of a positive behavior in subsequent visit. Audiovisual distraction is the best method for distracting child. The dental clinic should have horse shoe traffic pattern in which children are called to the operation from one door and exit by a second. Modifications of dental chair are also an important factor in removing the fear of child.

QUESTIONNAIRE 1. Describe the design of a dental clinic.

BIBLIOGRAPHY 1. Dental Clinics of North America; 1995;39:4. 2. Jawdekar AM. Child Management in Clinical Dentistry. Jaypee Pub. New Delhi; 2010.

27

5

Chapter

Practice Management Ashwin M Jawdekar

Chapter outline • • •

Pedodontic Practice Management Practice Analysis Leadership and Team-building for a Pediatric Dental Practice

Pedodontics is essentially a clinical specialty. There exist several trends in the practice of the specialty. Pediatric dentists can choose to practice pediatric dentistry as an exclusive specialty, or practice general dentistry. A few pediatric dentists work as visiting consultants in general dental practices. A few pediatric dentists may opt to remain in academics and thereby practice the specialty only in the teaching institutes. There are a few principles common to all

Aspect Focus of practice Design of the clinic Pedodontists choosing this style

Advantages of this style of practice

Disadvantages

Pedodontist in general dental practice General patients from all age categories May not be child-friendly May not consider pediatric dentistry quite rewarding May also have interest and aspirations in general dentistry May have tested failures related to exclusive pedodontic practice May have compulsions such as having to practice dentistry with a partner who is a general dentist Wide scope for practice being neither age specific nor procedure specific Practice does not depend on referrals Can practice certain treatment modalities (nonpedodontic) that are lucrative; e.g. implants, esthetic dentistry Pedodontists may not utilize their true potential as pedodontists in general practices Not good for the promotion of the specialty

• • • •

Appraisal of Staff Marketing of a Pedodontic Practice Practical Considerations in Pedodontic Practice Marketing Time Management in Pedodontic Practice

the practices; however, being different in nature, each trend is associated with certain pros and cons. This chapter discusses the important issues pertinent to pedodontic practices in different scenarios. The following table highlights certain differences in the pedodontic practices in three different situations: Although the trends mentioned above will continue to remain and each trend enjoys certain advantages, practicing

Consulting pedodontic practice Children May not be child-friendly May not want to invest in establishing their clinic May want to start earning without making big investments Do not mind traveling Do not mind working in a set-up not designed for children

Exclusive pedodontic practice Children Usually child-friendly Consider pediatric dentistry rewarding Believe that the investments are worth doing Are obsessed with the specialty concept in all respects (such clinic design, focus on getting referrals, believe in giving children and parents an experience different from that obtained in general dental clinics

Low investments No waiting period Quick returns

Set-up and functioning as desired Allows the pedodontist to work without much compromises/compulsions Pedodontists can give more time and consideration for comprehensive treatment planning and behavior management Investments Waiting period May need referrals

Working in compromised conditions may lead to dissatisfaction in terms of behavior management and treatment outcomes

Chapter 5  Practice Management pediatric dentistry exclusively is the most rewarding way to practice in the author’s opinion. A few myths related to pedodontic practices, however, are prevalent such as: 1. It is difficult to promote pedodontics 2. Pedodontics is not as rewarding as general dentistry 3. Treating families (and not only children) is more rewarding Discussed below are the real facts that disapprove these myths: • It is difficult to promote pedodontics: It is actually easy to promote pediatric dentistry for two reasons: First, people are already aware of pediatricians, and take their children to them for treatments bypassing general practitioners. Second, pediatric dentistry is age-specific and not procedure-specific. Therefore, it is not as difficult as promoting implants or microendodontics. It is important that pedodontists believe in practicing pediatric dentistry exclusively so that general dentists and pediatricians can believe in the concept and thereby people believe in it, too. • Pedodontics is not as rewarding as general dentistry: True, a few procedures that a general dentist performs are very rewarding. It is perceived that children require behavior assessment and modification that may be time consuming. However, it is actually more rewarding to practice pediatric dentistry because of many reasons: First, there is little competition as there is still a scarcity of pedodontists; second, pediatric dental procedures are quicker than those practiced for adults (for example, pulp therapy, crowns); third, treating a cooperative child actually saves time only when the time necessary for behavior assessment and modification is invested well initially by the pedodontist. • Treating families (and not only children) is more rewarding: A pediatric dentist has to retain their focus, which is treating children, if he has to do well in practice. By treating families, they cannot do so. Furthermore, general dentists will not be happy referring patients to a pedodontic practice where adults also get treated. It is actually a good practice to treat only children, and refer the adult patients to dentists so that those dentists are happy referring children to the pedodontists in turn. This establishes a good network and an ethical chain of references.

PEDODONTIC PRACTICE MANAGEMENT Practicing pediatric dentistry is an acquired skill. The following sections in this chapter make a reader familiar with several skills that are not routinely taught in a dental curriculum.

Criteria for an Ideal/Best Practice It is difficult to define what an ideal practice is as different practices have different sets of standards. However, a practice has four components in its structure. An ideal practice is based on accumulating necessary strength in each component. The success of practice depends upon how each component performs. The four components are: Marketing, Quality, Finance and Development. It is essential to market services in an ethical manner. The two important processes in marketing are ‘internal’ marketing and ‘external marketing’. The internal marketing deals creat­ ing awareness among all the people in the organization regarding the ideas that are important for business success. External marketing is about creating awareness and excitement in people to use the services that we provide. An ideal practice should have a good internal marketing and external marketing. Quality is a measure of the standards of service, the clinical as well as nonclinical. It is paramount to the success of a practice. The finance component is not only about how much money one has to start the practice, but is about how much money is generated consistently, managed efficiently and gets reinvested sufficiently for the smooth functioning of the practice. Financial planning plays a very important role in the success of a practice. Lastly, the practice should have a development compo­ nent that in a sense relates to the growth of individuals in the team and of the practice. The development can be spread over several aspects such as acquisition of new skills by employees, acquisition of new equipment and materials, recruiting more experienced and efficient staff, etc. The development helps build the reputation, allows more people to access the services satisfactorily. ‘Ideal practice’ can be based on standards that the clinic attempts to attain. Some such criteria are described below: • The clinic should function with a high level of clinical standards. This includes incorporating the best technology, optimally efficient use of resources and having the most competent people to work. • The patient satisfaction level should be high in terms of not only the clinical outcome (treatment results) but also the tangible aspects (such as reducing waiting time, careful attention and facilities provided to patient, etc.). The overall reputation of the practice or the ‘goodwill’ must be high. • The employees must be satisfied with the tasks they are delegated. They must feel that they are involved in the welfare and growth of the practice. They should actively

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•

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•

Introduction to Pediatric Dentistry

contribute to the same. The focus of the leadership in the clinic must be both team oriented and task oriented. The clinic should be a learning organization. People working in the organization must acquire new skills continuously. The clinic should have a future that to a certain extent can be envisaged by all the people working in the clinic. The vision and time-bound goals must be well-understood by the people working there. The practice should make profit. There must be an increase in the profit with increase in productivity as a function of time. The practice must run as a result of a robust system of functioning rather than an individual talent or a lack of it. It must be controlled by the well-laid operational guidelines for its functioning.

•

•

Vision and Objectives for the Practice Any organization builds on its core mission and values. Welch and Welch (2005) describe that “We treat the customers the way we would want to be treated” appears to be the most precise understanding of a mission based on values. The vision of a pediatric dental practice must carefully drafted statement that attempts to convey to people what the practice stands for. It must define the nature of the practice. The overall statement also gives an impression of the uniqueness of the practice focusing on the core issues in pediatric dental care: prevention and treatment. An example of a mission statement of a pediatric dental practice is given below: To be a preferred choice for the preventive and therapeutic dental needs of children from infancy through adolescence. The objectives of the practice outline the steps in the direction dictated by the mission statement. The objectives are as follows: • To provide excellent services to patients in terms of treatments. The clinical staff must efficiently and continuously monitor parameters such as infection control, isolation during restorative procedures, radio­ graphic evaluation of endodontically treated teeth, reduction of pain and discomfort and improvement of function for the patient, reduction of patient anxiety, etc. • To facilitate an overall satisfactory experience of the patients by answering the phone calls promptly, recon­ firming their appointments, reducing their waiting time in

•

•

the clinic, maintaining a friendly and helpful atmosphere at the clinic. To motivate the staff: To maintain excellent communication with the patients, the referring general dental practitioners and other physicians (pediatricians), the persons from the laboratories and the suppliers. Nevertheless, every effort must be done to develop and maintain a high-level of understanding among the staff. To plan the financial aspects effectively: Bulk purchases of frequently consumed goods at a discount, negotiating with the suppliers and the laboratories, regular mainte­ nance of equipment, recovering the outstanding payments, reducing wastage of materials are the ideas for reducing expenditure. Patients must be informed well and in advance about the fees and modes of payments. The front desk must ensure the same and encourage timely payments. Another important consideration for increasing profit is the periodic upward revision of charges. Understanding taxation and planning for the same while working out finances is necessary while financial planning. To retain the staff on the basis of loyalty, honesty, sincerity and usefulness. Each member of the team must contribute to practice growth by carrying out the tasks assigned to him/her in an efficient and effective manner. A performance check is essential for the punctuality and demeanor of all staff and productivity of the clinical staff (pediatric dentists and dentists). The staff-salaries and incentives must be based on their performance. To grow as an organization: To develop a strategy for expanding services by attracting more referrals by con­ tacting new practitioners, introducing new services, improving the soft skills of the nonclinical staff by encouraging their participation in suitable training programs, and of the clinical staff by participating in continuing dental education.

PRACTICE ANALYSIS It is important that the performance of practice is analyzed periodically. A conventional, well-established method such as the SWOT analysis can be used for the purpose. The purpose of a SWOT analysis is to arrive at a precise understanding of the current situation which can be a foundation for the planning for the future. The practice owner as well as employees can discuss the strengths, weaknesses, opportunities and threats of and for the practice.

Chapter 5  Practice Management

An example of the same is discussed below: Strengths • Smooth functioning of the system • Efficiency of the clinical staff • Excellent performance of the senior dental assistants • Team work • Goodwill • Treatment quality • Infection control • Child-friendly set-up

Opportunities • Opening a new branch at another location • Developing a preventive program for prenatal counseling • Using newer methods for endodontic and restorative procedures

Weaknesses • Inconsistent performance at the front desk and of new dental assistants • Space constraints especially during peak hours • Lack of authoritative vigilance on the nonclinical staff • Lack of facilities for sedation and general anesthesia • Failures of anterior composite restorations • Waiting room delays • Inadequate time for appropriate behavior management of children • Differences in the opinion of dentists

Threats • Competition • Potential risk of dividing the practice if another branch opened

The SWOT analysis, however, does not take into consideration specific criteria. Practice analysis must also take into consideration certain objective parameters for a more precise understanding of the practice. A model below describes the certain specific parameters that can be used for the analysis. The three important parameters are financial, quality and personnel.

Financial Parameters In the financial parameters, the profitability and productivity of a practice is determined using the following calculation: NP = TO–OE (NP = Net profit in a month; TO = Turnover in a month and OE = Outgoing expenditure in a month) Outgoing expenditure includes payments of salaries and professional fees to staff, and sum total of expenditure on materials, electricity, telephone, laboratory, maintenance, etc. • Net profit after tax: As per applicable tax rates, the NP after tax is calculated. • Calculating the productivity of the hour by the formula: Total turnover in a month/Total no. of working hours in a month. This helps understand the value of each hour spent at the practice. This is useful for various reasons. It can help in deciding the staff wages, developing policies

for increasing profitability by increasing working hours, etc.

Quality Parameters Quality has two components: Internal and external. Internal component is about what a practice does, and external component is what the patients perceive. The assessment of the same can be done in two manners described below: 1. Audit: Random checks and routine checks must be performed using a checklist system. This can be referred to as an internal audit. An additional external audit may also be considered by a practice. There are several certifying agencies that help establish and monitor quality in healthcare set-ups. 2. Patient satisfaction: Assessment of patient feedback is an important aspect of quality in a practice. A periodic analysis of the same is recommended as it helps the practitioner understand what patients perceive and the areas in which improvement is needed. Given below is a simple feedback form for the patients. The form has a few open ended questions, and a few objective criteria for assessment: Feedback form for patients: • How did you know about us? • Please score your experience with reference to following criteria in the table below: Criteria

Scale Not at all happy-somewhat unhappy- neutral- somewhat happy- very happy

Getting appointment

0—1—2—3—4

Reception services

0—1—2—3—4

Waiting time

0—1—2—3—4

Facilities in the clinic

0—1—2—3—4

Information regarding treatment

0—1—2—3—4

Information regarding preventive care

0—1—2—3—4

Fees

0—1—2—3—4

Mode of payment

0—1—2—3—4

Treatment

0—1—2—3—4

Overall experience

0—1—2—3—4

• Other remarks: A practitioner must periodically evaluate the feedback to monitor the trend in the satisfaction of patients.

Personnel Parameters Meeting staff expectations: Objective assessment by employee feedback (feedback forms) and subjective assessment by interviews of the employees to ascertain whether the expec­

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tations of the employees are met or not and whether they are exceeded or not. Described below is a feedback form for employee satis­ faction. Please encircle anyone choice on the scale in the right column. • 0 = Strongly disagree • 1 = Disagree • 2 = Agree with reservations • 3 = Agree • 4 = Strongly agree Statement

Scale

I enjoy working in the practice

0—1—2—3—4

I am happy with the salary (monthly pay)

0—1—2—3—4

I learn new skills in the practice

0—1—2—3—4

I have a future in the practice

0—1—2—3—4

I can contribute to the growth of the practice

0—1—2—3—4

All practitioners must not only meet the expectations of the staff, but also try to exceed them. A satisfied team always performs well.

LEADERSHIP AND TEAM-BUILDING FOR A PEDIATRIC DENTAL PRACTICE There is no size that fits all. This section describes theoretical aspects and practical considerations in the process of leadership and team building for a pediatric dental practice.

Leadership Leadership is a process whereby an individual influences a group of individuals to achieve a common goal (Northouse, 2007). Although used interchangeably, the terms leadership and management are different in various respects. People have to be led, whereas systems or processes can be managed. McPheat (2010) outlined following differences in the characteristics of managers and leaders. Aspect

Managers

Leaders

Focus

Tasks

People

Thinking

Short-term

Long-term

Looks at

Bottom line

Horizon

Knows

Day-to-day business

Customer

Aims at

Improvement

New development

Build success through

Quality

Employees

Role

Supervisory

Influential

Authority

Positional

Behavioral (due to his/her mindset)

McPheat (2010) stated that “Most effective leaders are those who can successfully influence the way other people influence themselves”.

Style of Leadership Leadership has been classified in various ways. It is beyond the scope of this text to discuss all the classifications. The following table gives an idea about a few categories of leadership. Style of leadership

Autocratic

Democratic

Bureaucratic Charismatic

Advantages Leaders keep decision making to themselves Make quick decisions

Leaders share not only the decision making but also the credit with others

Follows the rules Produces consistency and quality

Influential, encouraging Stimulates creativity

Disadvan­ tages

Timeconsuming

Does not encourage Does not let skills develop

Time consuming

Team building when every member contributes

Well regulated functioning

New projects Rejuvenation

Leaders are often unpopular

Indication/ For shortGood for term projects

McPheat (2010) described following skills that leaders usually demonstrate: • Commitment to a vision • Understanding of the role • Integrity • Leading by example • Motivating others • Communication • Taking risks • Problem-solving Leaders are not necessarily born; as the skills described above can be acquired. The three essential traits that leaders must possess are: willingness to lead, commitment to a vision, and integrity. If a potential leader fails to acquire these traits, he/she may face burnout, fail in completing the task, lose team members or lose respect of team members. Robert Blake and Jane Mountain in 1960s proposed a theory of leadership based on the concern of leaders on people, production or both. By plotting the concern for production against concern for people, they described five different styles of leadership as below:

Chapter 5  Practice Management Style of leadership Concern for production Concern for people Description

Impove­ Country Dicta­ rished club torial Low Low High

Middle of Team the road Medium High

Low

Medium

High

Low

High

Delegate Relation­ Task Balance and Contribute and ship oriented compro­ and commit disappear oriented mise

The styles of leadership that can be routinely recommended for a pediatric dental practice are: • Democratic/Participative • Team management (as per the Black Mountain Managerial Grid Theory). However, depending on the need for rejuvenation or carrying out a short-term project effectively, charismatic style or autocratic style of leadership can be recommended. Also, the style of leadership must also depend on the vision and objectives of the practice.

Action roles

Social roles Coordinator (chairman)

Plant

Implementer (company worker)

Team worker

Monitor-evaluator

Completer finisher

Resource investigator

Specialist

McGregor (1957) proposed two styles of management: Theory X and Theory Y- two opposing perceptions about how people view human behavior at work. McGregor felt that organizations and the managers within them followed either one or the other approach. The salient features of each style are outlined below: Authoritative management

Katzenbach and Smith (1993) described fundamental characteristics of a team as devotion, accountability and skills. They further stated that for a team the purpose is collective. Although often used interchangeably, the terms team and group have certain differences as below: Informal structure

Collective work that matters

Individual performance matters

Shared leadership

Focused leadership

Accountability: Individuals and mutual

Accountability: Individuals

Individuals possess complementary skills

Individuals interact with each other but do not necessarily complement each other

The combined effort is synergistic

The combined effort may not be synergistic

Role (Gündüz, 2008) “Role is an important component of social structure that plays an important part in understanding human behavior in organizations”. There are two perspectives of roles in organizations: Behavioral perspective or anthropologicsociologic perspective; which entails a ‘typically exhibited’ behavior in a specific context, and expectancy perspective or psychological perspective that implies an “expected behavior” of an individual in a specific context. Team roles depend upon the balanced distribution of six factors: personality, mental ability, motivation, values, field restrictions and role learning.

Theory Y Participative management

Individuals dislike and avoid work Individuals work naturally Individuals have to be forced to work with a threat of punishment

Individuals are self-directed to work without any threat

Individuals prefer to be led

Individuals are responsible, imaginative, genuine and creative

Individuals consider security above everything

Individuals are only partly utilized in any organization

Group

Formal structure

Thinking roles

Shaper

Theory X

Team-building

Team

Belbin (1981) described “functional roles” related to the functions for survival and living of a social system. The term “team roles” is not related to the functions, but denotes how suitable a person is for a team. Belbin’s concept is based on the idea that “different people react differently”. She defined eight roles that could in combination lead to success of a team. The roles were grouped in three categories:

In a work place such as a dental practice, as per the Theory Y approach, management’s role is to develop the potential in the staff and help them to release that potential towards common goals. A boss can be viewed as taking the Theory X approach, while a leader takes the Theory Y approach. Hackman (1980) described a concept of work redesign as alteration of specific jobs with the intent of improving productivity and quality of employee’s work experiences. Herzberg (1974) stated that work redesigning is required to create motivating and satisfying jobs for individual employees who work more or less on their own.

Recruitment and Selection The selection of staff at a dental practice must depend upon following criteria. • Qualification • Experience • Skills (work related and other) • References (1–2)

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Introduction to Pediatric Dentistry

• Salary expectations • Other: Proximity of residence to the clinic, readiness to work extra hours, flexibility for role exchange.

Qualification The candidate must possess the qualification as per the needs. Both overqualified and underqualified candidates will not be suitable for a job; the former being difficult to satisfy in terms of their requirements and also may find the job less worthy for themselves; whereas the latter may struggle to keep up to the expectations and struggle with the needs. In either case, the performance can be affected. Although, qualification is a legal consideration while employing a clinical staff (dentist, for example), it may not be so for a nonclinical staff. Thus, it is an important essential criterion, but rarely sufficient entirely for the selection process. The candidate must however present the original quali­ fication records (degree certificates) and they should be verified whenever possible. Also, the performance of the candidate as a student may not be sufficiently noticeable in the degree certificates, and therefore, further probing in the nature of program, the status of the university, the pattern of training (whether it was obtained through a full time course or a online or distance education program) are a few essential clarifications that must be sought.

Experience A candidate’s experience usually demonstrates what he/she has done with the qualification and that is more important to look at than the qualification itself. Experience however, in terms of years may not depict that truly. The experience of working at a place with lower expectations for a longterm might have changed the beliefs, attitudes and habits of a person; and working at a place with much higher expectations although might have benefited the candidate, could have changed his/her perceptions towards a more idealistic approach. The experience of a candidate having worked under similar or slightly better circumstances would be appropriate as the person could adapt to the present job conditions well and also could benefit others having experienced better surroundings. However, experience, as they say, is not a substitute for knowledge. The most important criterion is therefore, the skills that one has acquired with the qualification and experience.

Skills The two categories of skills that need to be assessed for any job in a practice are: technical skills and personal skills. A

dentist applying for a job in a pediatric practice must be able to demonstrate the technical skills such as having performed a few dental procedures in children. Although, it could be difficult to procure records as a proof of evidence, the same can be probed in a well conducted technical interview involving discussions such as case scenarios with radiographic or photographic records. The personal interview must be aimed at identifying the communication skills, the goals and needs of the person, and more importantly his/her competency to work as a team member. The ultimate aim of the selection process is to build a team that works synergistically and not by a summation of individual performances.

References A person applying for a job must be asked to provide references (preferably of the immediate past employers) that can be verified. Usually, the references given by any candidate may confirm what the candidate has already reported; however, the purpose of verification is assessing not only the credibility of the information, but also the qualities and deficiencies of the person that may not have surfaced through the selection process. The interviewer also needs to find why the candidate left the previous job/s and also if there were any disparities in the answer/s given by the candidate and the past employer. Although checking references is essential, the process has a few limitations with respect to accessibility to real information few referees would reveal sufficient details on record about any person, time it would take and how much importance it carries.

Salary Expectations There should be a clear and unambiguous discussion about the salary structure, incentives or the other performance based rewards that a candidate would be entitled for. If the salary structure is not advertized or is dependent on the suitability of the candidate in terms of his/her qualification, experience and skills, it is important for the employer to take into account the expectations of the candidate. A mutual agreement on the terms for a reasonable period (at least one year including the probation) should be sought in the beginning itself.

Other Proximity of residence to the clinic, readiness to work extra hours, flexibility for role exchange, etc. should be discussed. These minor details may help a lot in the planning of the organization which is considering work redesigning and change in the functioning.

Chapter 5  Practice Management Aspect of appraisal system

Application in the dental practice

Who should be appraised?

Ideally, each and every member of the team

Who should appraise?

A system can be developed such as dentists appraising nurses and nurses appraising dentists; both or either of the dentists and nurses appraising the receptionists, with inclusion of patient’s feedback

How frequently?

Formal appraisals should take place at least once a year

Should they be “open”?

Yes. They should be open to be viewed by the employees

A combination of two components

Self-appraisal—in which a staff comments on his/her own performance Appraisal by others (3600)—in which other staff members and customers (patients) comment about the staff

Objectiveness

The appraisal system should have a rating scale or scoring criteria. An example of appraisal system can be: How is the performance of this individual over the past one year? • Outstanding • Surpasses the requirements of the job • Meets the requirements of the job • Has a few minor weaknesses • Has a few major weaknesses • Unacceptable

Comparative

Does the performance match the expectations of the job stated in the job description?

Most important

A future action plan that is agreed by the staff as well as the management

APPRAISAL OF STAFF Evaluation of performance of the staff is an essential process on a periodic basis. It helps the management understand the commitment, contribution, and strengths and weaknesses of the employees in the organization. Staff appraisals also help the management understand various aspects of functioning such as: need for training a certain team member, need to monitor some processes and supervise a certain member, need to balance the composition of the team by recruiting someone or terminating someone or by changing roles effectively. The key aspects of the appraisal system are mentioned below with its application in a pediatric dental practice.

MARKETING OF A PEDODONTIC PRACTICE Pedodontic practice is a part of service-led industry. Today’s customer has a choice, access to knowledge and information and enjoys the status of being called a KING! Also, the industry faces challenges like competitiveness amongst practitioners, price wars, huge investments and recurring expenditure and so on. Thus, to satisfy the patients in addition to making profits in the business while maintaining optimal ethical standards of practice must be the focus of each and every practice. Often, doctors who do not seem to care much about patient satisfaction say: “I am qualified to give good care;

therefore, the care I give is good.” However, this approach may not go well with most patients of today. For quality in terms of patient satisfaction, it must be a balance between what doctors do and what patients feel? “People do not care how much you know until they know how much you care!” (Stephen Covey). The patientcare, must therefore have patient satisfaction as a primary objective. The word ‘satisfaction’ broadly means fulfilment of expectations. The expectations of people from the service-providers are ever-increasing! The service industry heavily depends on the customer and is obsessed about the customer. For a longtime, the healthcare industry enjoyed a unique position in the service industry, and did not succumb to the demands of the customer. However, times have changed! Satisfaction of a customer is never an end result of a process; it is the process itself that satisfies the customer. In a practice, the patient-care is as important as patient-cure! Assessment of patient satisfaction is an important aspect of healthcare as it helps the service provider improve his patient care and in turn the overall quality.

Understanding Patients Types of patients in a practice: • Based on the visit to practice: – New – Old

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Patients reporting for the first time are registered as new patients in Little Smiles, and those having previously visited are considered as old patients. However, a patient having passed three years since their first contact for consultation (without any treatment-record in the past) is also regarded as a new patient. • Based on the attendance pattern: – Regular – Irregular Children maintaining the schedule of six monthly preventive visits are categorized as regular attenders, and those failing to do so are termed as irregular attenders. The group of irregular attenders also includes those who have left the treatment incomplete or have failed to attend a different recommendation, such as a three monthly follow-up because of high caries-risk, or a monthly followup for traumatic dental injuries, etc. • Based on motivation: – Low – Medium – High The level of motivation of patients is judged subjectively on the basis of following characteristics exhibited by them: Interest in understanding and seeking complete care (including the preventive care), desire to report a behavior change on the part of their child with reference to the brushing and dietary routine, and willingness to maintain a continuum of care. Patients in the category of low motivation are often interested only in the solution to their urgent concerns, and exhibit little interest in the comprehensive care. Patients in the category of medium motivation usually are good beginners, but their interest level drops midway, or upon completion of the treatment (in terms of follow-up care) either because of financial issues or due to changed priorities. The highly motivated patients however, usually seek complete advice, take active interest not only in comprehensive treatment and preventive care, but also in

changing their and their children’s oral health behaviors (Fig. 5.1). • Based on the paying capacity and willingness to spend for the care: – Can afford and wants to spend – Can afford but does not want to spend – Wants to spend but can afford with difficulty – Cannot afford and does not want to spend The Figure 5.2 depicts the categories mentioned above: However, it has to be considered that both the concepts (affordability and willingness) are dynamic and particularly the willingness can be influenced in the dental clinic with proper communication. • Based on the referrals: Patients to a pediatric practice are often referred by general dentists, pediatricians, physicians, etc. In addition to those referred by other practitioners, patients also report of being referred to by family, friends, etc. Following can be the categories of references: – Referred by dentists – Referred by pediatricians – Referrred by other medical professions – Referred by family or friends (word of mouth reference) – Self-referred.

Fig. 5.1: Levels of motivation and effect of time

Fig. 5.2: Matrix of affordability and willingness to spend

Patients’ Expectations Customer expectation has been defined as “the perceived value customers seek from the purchase of a good or service” (Customer Management IQ, 2012). Based on this definition, dental patients’ expectations can be defined as “the perceived value patients seek from the purchase of dental services”. Although expectations of people differ and there cannot be an agreement about ‘satisfaction’ in general, some of the commonly observed expectations of patients visiting a pedodontic practice are listed below. The expectations of patients can be summarized under the 2 main domains: • Related to treatment: – Painless treatments – Restoration of function such as efficiency in chewing – Improvement in esthetics

Chapter 5  Practice Management • Related to overall experience: – Promptness of attention received from the doctor and/or the staff – Efficient appointment system – Minimal waiting time – Facilities such as proper seating, entertainment, wash-rooms, etc. – Communication – Affordable fee-structure – Easy mode of payment – A follow-up system with timely reminders – Trust and respect – Transparency in transactions, etc. A service-led industry understands the expectations of customer and works on them in order to satisfy them. Abram and Hawkes (2003) identified seven myths of customer management. Discussed below are these myths related to managing dental patients’ expectations in a service-led dental practice. Myth 1: Patient retention is the key to increasing profitability: Although it costs more in terms of external marketing to acquire a new patient than to retain an old patient; it is not often profitable to retain the patients. Often, two types of patients do not remain profitable to the practice in spite of their retention: First: The patients who have completely taken treatments as prescribed, and on follow ups have little need for new treatment, and second: The patients who irregularly report for treatments. A balance between the number of new registrations and retention of old patients has to be achieved in order to maintain profitability. Myth 2: Removing unprofitable patients will increase overall profitability: Although many retained patients in a practice may not be contributing towards the profit of a clinic, removing them may not be a good idea because it might affect the reputation and the brand image; and there is no guarantee that those will be replaced by more profitable ones. Again, it appears that equilibrium in practice has to be achieved of the patients generating above average fees, and patients costing a great deal of time/money to retain or care for. Myth 3: Patient satisfaction leads to patient loyalty: Patient satisfaction and patient loyalty are two different aspects of patient management (Fig. 5.3). The trade-off between the two can lead to four possible patient types, as explained below:

The two characteristics: Loyalty and satisfaction are not mutually exclusive, and can even coexist in patients who can be termed the ideal patients. The low-levels of either of them may lead to high-risk patients who attend irregularly, do not value treatments sufficiently, and also fail to pay the fees. Myth 4: Repeat purchase is the same as patient loyalty: Repeat purchase can be a behavior related to loyalty; however, all repeat purchasers may not be truly loyal. Loyalty is a characteristic with reference to a long time span; and the repeat purchase can be purely based on the needs of the patients and availability of services at a cost affordable to them. Myth 5: Practices should develop relationships with their patients: Patient-practice relationship is important because it may help prevent ‘switching’ and enhance loyalty. However, mere relationship with existing customers is not sufficient for the growth of practice. It cannot attract new customers. Furthermore, expectations of new patients can be much more complex in terms of value for money and perceptions of satisfaction and priorities. Having good relations desirable, but insufficient alone. Myth 6: One-to-one marketing is the ultimate goal: Marketing of services has several dimensions. One-to-one marketing in dental practice is possibly only one dimension (as in the interaction of a dental team member and a patient). However, there are other dimensions of marketing. Not only patients, but also the dentists (associates), hygienists, nurses, assistants, receptionists, etc. are the customers of any management. An internal marketing is essential to propagate an idea or develop a strategy within the team members. The external marketing also involves brand establishment, advertising and other several other aspects of promotion. Also, there are certain trends and characteristics in the patients’ expectations that can be ‘grouped’, and an effective management has to form strategies to deal with the groups. Myth 7: Technology is the primary enabler of patient focus: Use of technology is critical in patient management. The modern patient management systems are robust, and offer a major support for patient-practice communications; however, inadequate or improper use of them may annoy patients and also may not deliver the expected results. For the effective management of patients’ expectations, following are a few essential prerequisites in a dental practice: • The internal customers are equally, if not more, important than the external customers (patients). • Great customers/patients are made, not born.

Dentist-patient Communication Fig. 5.3: Loyalty vs satisfaction of patients

Communication is a combination of verbal, paralinguistic and nonverbal communications. The verbal communication

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Introduction to Pediatric Dentistry

(exchange utterances) in dental clinics has three purposes: information seeking, information provision and aiding to patient understanding. The paralinguistic and nonverbal communication involves use of vocal cues, postures, facial expressions, eye contacts, amount of space between the dentist and the patient, environmental factors such as furniture placement, lighting, etc. Interactions with patients in dental settings may involve more complex interactions than that those in most other medical settings. Rotter and Hall (1992) reported four models of health care professional (HCP) and patient interactions: • The ‘traditional’ medical model • The ‘patient as the expert’ model • The ‘consumerist’ model • The ‘transformed medical’ model Each of the four models of dentist-patient interaction has different characteristics described below: Model

Features

Dentist as The traditional biomedical approach. the expert Dentist has the primary responsibility of communication model Straight-forward and objective. Treatment recommendations are based on the normative needs assessment by the dentist. Paternalistic and “Victim-blaming”. Disadvantages: Dentists may not sufficiently consider perceptions and priorities of patients, and the impact of care on their quality of life. Not popular with patients as the patients feel intimidated and underpowered Patient as Based on the approach that one knows and decides the expert what is best for their health. model Patient has the primary responsibility of communication. Treatment seeking is based on the perceived needs or wants and demands of patients. Disadvantages: Patients may not have sufficient knowledge and expertise to make decisions for them Not popular with dentists as they feel underpowered Consumer model

Based on the “exchange of services for a cost” approach. Patient as a purchaser has the primary responsibility of communication. Practical and objective. Disadvantages: Has little concern for some critical aspects of care such as trust in the relationship, overall improvement in patient-well-being and quality of life

Mutual model

Both dentist and patient share the responsibility of communication being experts in their respective fields Dentist’s role as a facilitator who provides information and delivers care Patient’s role is describing their wants and demands, and stating their expectations explicitly. Concern for overall improvement in patient-well-being and quality of life. Disadvantages: Requires a great deal of understanding between the dentist and patients; dentists’ role often passive and can be limited by patients’ understanding

It is difficult to state which model is best because there cannot be a “one size fits all” policy. Nevertheless, in the modern times, ‘patient centeredness’, i.e. importance attached to patients’ concerns, priorities and choices, is gaining increased importance in healthcare settings. Asimakopoulou (2007) and Newton and Asimakopoulou (2008) have highlighted the dangers in advocating the dangers in advocating the “one size fits all” policy. According to these researchers, the choice of model depends on following factors: • Length of time a dentist has to spend with a patient • Class of patient (e.g. middle class) • Characteristics of patient (e.g. age, education, dental anxiety, dementia, etc.) • Reason for their visit (e.g. pain) • Patients’ experience of dentists. Another important consideration for dental practice, particularly in times of recession is the competition from other practitioners. In order to understand the significance of various elements of competition, the five-forces model was developed in Porter (1980). The forces, when considered together, determine long-term profitability within the specific industrial sector. The strength of each force is a separate function of the industry structure, which Porter defined as “the underlying economic and technical characteristics of an industry.” Collectively, the five forces affect prices, necessary investment for competitiveness, market share, potential profits, profit margins, and industry volume. The key to the success of an industry, and thus the key to the model, is analyzing the changing dynamics and continuous flux between and within the five forces. Porter’s model (Fig. 5.4) depends on the concept of power within the relationships of the five forces. The five forces are: 1. Industry competitors: Rivalries often exist between companies competing in the same market. According to Porter, “the intensity of this rivalry is the result of factors like equally balanced companies, slow growth within an

Fig. 5.4: Porter’s five forces model

Chapter 5  Practice Management industry, high fixed costs, lack of product differentiation, overcapacity and price-cutting, diverse competitors, high-stakes investment, and the high-risk of industry exit. There are also market entry barriers”. 2. Pressure from substitute products: Substitute products or services can be a result of competition which can affect profitability adversely. Porter used the example of security brokers, who increasingly face substitutes in the form of real estate, money-market funds, and insurance. Substitute products become increasingly important as their availability increases. 3. Bargaining power of suppliers: Price increases and product quality are controlled by suppliers, who therefore have a significant influence over an industry. This particularly happens when there are few alternate products and only a few users of their products. Although, these factors are out of the control of the industry, effective strategies can alter the power of suppliers. 4. Bargaining power of buyers: The buyer’s can affect the profits by: • Forcing the prices down • Demanding higher quality products or services, and • Playing competitors against one another. A company has to develop policies to understand and counter the dynamic nature of buyer’s bargaining power. 5. Potential entrants: According to Porter, the threats of new entrants into an industry depend on six barriers to entry: • Economies of scale, or decline in unit costs of the product, which force the entrant to enter on a large scale and risk a strong reaction from firms already in the industry, or accepting a disadvantage of costs if entering on a small scale. • Product differentiation, or brand identification and customer loyalty. • Capital requirements for entry; the investment of large capital, after all, presents a significant risk. • Switching costs, or the cost the buyer has to absorb to switch from one supplier to another. • Access to distribution channels. New entrants have to establish their distribution in a market with established distribution channels to secure a space for their product. • Cost disadvantages independent of scale, whereby established companies already have product tech­ nology, access to raw materials, favorable sites, advantages in the form of government subsidies, and experience. In summary, Porter’s five-forces model outlines the competitive environment and the means to make profit surviving and outplaying the competition. The concept of five-forces is as applicable to dental practices as it is to most other businesses.

PRACTICAL CONSIDERATIONS IN PEDODONTIC PRACTICE MARKETING Practicing pediatric dentistry is art, science and business. Having good skills of business is as essential as having good clinical skills. Learning the art and science of pediatric dentistry is necessary, but not sufficient to practice pediatric dentistry successfully, unless the business skills are learnt.

What is ‘Business’? According to Kaufman (2012), each business is comprised of five interdependent processes: 1. Value creation 2. Marketing 3. Sales 4. Value delivery 5. Finance In a pedodontic practice, the value already exists because children need dental care. Sales the services, giving the patients what they want in a satisfactory manner, and having the necessary capital and finance to own and run the business are integral aspects of the practice business. This section discusses the ideas for marketing a pedodontic practice:

Networking Coordinating with professional colleagues such as pediatricians, dentists, family physicians can help getting referrals from them. Pediatricians are the best professionals to liaise with as they have the opportunity to make early and timely referrals. Dentists are often unwilling to treat children comprehensively, and thus need the services of pedodontists.

Building an Image It is a good idea to establish a brand with a name and logo so that the information brochures, publications, patients’ records (files), website carry the brand image. A brand identity can attract more popularity than an individual identity such as Dr ABC’s Clinic.

Internet Use of smart phones, wifi, search engines has made possible internet surfing very easy and many people procure information about the practices and dentists prior to making an appointment. A professionally designed and regularly updated website with a provision of making a request for appointment can help immensely. Additionally social networking can also help attracting new patients and remaining in contact with the old ones.

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40 Section 1 

Introduction to Pediatric Dentistry

Word of Mouth There is no better publicity than that obtained through a spread of word from the satisfied customers. People want to build trust with their dentists and doctors. In the context of pediatric dentistry, children are comfortable in familiar and comfortable surroundings. Pedodontists must focus on providing an overall satisfactory experience that children and their parents would wish to share with their families and friends. Carrying out oral health promotion activities in communities, tying up with schools for dental check-ups and parent education, publishing on important aspects of children’s oral health in local newsletters, distributing pamphlets, advertizing on local TV channels and through yellow pages regarding the services offered in the practice are several other means of publicity. However, a pedodontist must take care to consider the means that are ethical and are not considered cheap. At times, over-promotion may be regarded negatively by the potential patients.

TIME MANAGEMENT IN PEDODONTIC PRACTICE Time management is the ability to plan the time more effectively in order to become more productive. The importance of time management while handling pediatric patients need not be stressed. Quite often, only a few of us have the patience and skill to manage both, the child and time on our hands. Planning and organization play very important roles in the completion of any given set of tasks. All said and done, human unpredictability can play havoc even with the best laid plans and organization in the clinic. So it is important to keep a calm mind and concentrate on the things that we have control on. Valuable time can be saved by keeping a few things in mind. A few factors to be considered are as follows: Plan time before the child’s treatment begins:  Spending time to achieve child-cooperation is time investment. Most pediatric dental procedures, per se, are not time consuming, but may be so in uncooperative children. Preparation of parents and gaining trust of children demands time. Preparation of parents:  Educate the parent on the first visit of the child and instruct them to soothe the fears of the child by telling the child that the dentist is going to clean the tooth with a shower and not mentioning about painful things like injections, extractions, etc. Explain to the parents that in the initial visits, the dental team needs time to assess child cooperation and modify the child behavior; thus only a few simple, quick, atraumatic procedures (like taking radiographs, fluoride applications, small restorations, etc.) could be accomplished at times

with restraints. Once the child is acquainted with the dental surroundings, and the behavior is suitable for extensive, long treatments, the same will be begun. By then, the dentist would have also decided about whether to retain parents in the operatory or separate them from the child; whether the child is amenable to distraction, praise, etc. Ask the parents not to feed the child immediately before bringing him to the dentist. Children tend to gag and feel uncomfortable. Antiemetics may be required in some cases. Tell the parents not to commit to the child about the nature of treatment or the time required for it; just tell them to say that they do not know. Preparation in the clinic: Dental care of children requires team work at the dental office. The receptionist, the doctors, and the assistants must be focused to work efficiently and effectively. Following are the considerations for the staff: • Help reduce the child’s anxiety by greeting him well, having a brief chat with him and praising him about something. • Inform the dentist about the child’s mood. • Keep all the previous records and required armamentarium for the scheduled procedure at hand. Keep enough number of instrument sets sterilized and ready to use. • Dead time (time taken for anesthesia to act, time required for the child to rinse, etc.) can be used for the chair-side preparation, i.e. for taking out materials, instruments, making cotton pellets, etc. • Delegate time for time-consuming procedures such as filling and filing case paper, taking consent signature and payments, retrieving records, etc. • Train the staff to exchange duties if required. • Being overstaffed is preferable to being understaffed. • All the appointments should be scheduled and confirmed in advance. Constant monitoring of appointments needs to be done to check if things are going on schedule. Time management by the dentist: Following are a few tips for increasing work efficiency in a pediatric practice: • It is advisable to keep a separate session of pediatric patients in a week for treatment procedures in a busy general dental clinic, so as to make necessary changes in the planning of appointments, decor of the clinic and functioning. • Preferably schedule a new child just after a conditioned child and let them observe the treatment of the cooperative child. • Keep the first couple of appointments as brief as possible, limited to a check-up or only minor work or fluoride treatment and at the same time assess the cooperation level of the child. • Invest little extra time in the initial few sittings to build rapport with the child. This will result in a conditioned child who will take considerably less time later.

Chapter 5  Practice Management • Distract the child by allowing him to watch a cartoon film on the TV during the dental treatment. The treatment of a distracted child is less time consuming. • Use materials which take less time such as resin modified glass ionomers (like RMGIC) for fillings and prefilled syringes of calcium hydroxide and iodoform paste for pulpectomy. Pressure syringe technique is also quite effective but can be little expensive and messy to clean later. Use mouth props wherever required as it helps in the movement of instruments in and out of the mouth. • Find out the average time required to carry out a certain procedure. • Practice 6/8 handed dentistry: Help can and should be taken in the form of 6/8 handed dentistry to minimize the open mouth time. The open mouth time should be reduced in order to avoid fatigue and also helps to save the time used for rinsing. The assisting staff should be trained to anticipate the needs of the dentist and provide necessary assistance without the need of telling again and again and without being a hindrance in the delivery of the treatment. • Practice quadrant dentistry: Divide the treatment plan according to the quadrants and schedule the appoint­ ments according to the urgency of the treatment and time available. • While treating a particular tooth, complete major work in the same quadrant at the same time. If the treatment is being done under local anesthesia, it makes the work that much more easier and faster. Combination of fillings, pulpectomies, crowns, extractions in the same quadrant

can be done. Pit and fissure sealants of the upper and lower arch can also be done. • Avoid unwanted phone calls, medical representatives, dealers on the busy days. • Learn and practice child management techniques which itself is a big time savior. • Take a break: Few minutes spent for refreshing yourself  and the staff helps to avoid fatigue and prevent mistakes. Managed time is always productive, and unmanaged time is often frustrating. Most of the dental procedures in a conditioned child take comparatively less time as compared to the adults, allowing the dentist to see more patients in a day. It is also beneficial to the parents and the child as more work can be accomplished in less number of appointments. Dental practice in the current perspective has to face the challenges such as competition, demand for high quality, high establishment and running costs, etc. because of which the dynamics of practice have changed. A successful organization is an outcome of a team-building and leadership; and a pediatric dental practice is no exception to this rule. Marketing, communication, time management, practice analysis are important aspects of practice management. Practice of dentistry is science, art and business. Understanding patients’ expectations, needs and demands is imperative to provision of satisfactory care. Quality care is essential for satisfying patients, but not sufficient alone. Practicing pediatric den­ tistry as an exclusive specialty offers certain advantages, the main being the focus on children. Pediatric dentists must opt for this option in the author’s opinion.

BIBLIOGRAPHY 1. Abram J, Hawkes P. The seven myths of customer management: how to be customer-driven without being customer-led. John Wiley and Sons Ltd. 2003. 2. Belbin RM. Management Teams: Why they succeed or fail. Oxford. UK: Butterworth Heinemann; 1981. 3. Blanchard K, Johnson S. The one minute manager. Harper Collins. 2009.p.101. 4. Cas A. How to manage performance. Available at http://www.acas.co.uk/media/pdf/g/7/Acas_how_to_manage_performanceaccessible-version-Nov-2011.pdf, 2011. 5. Chapple H. Exploring dental patients’ preferred roles in treatment decision-making – a novel approach. British Dental Journal. 2003;194:321-7. 6. Covey S. The Seven Habits of Highly Effective People. Pocket Books. 2004;46(54):149-63. 7. General Dental Council (UK, 2012) Standards for dental professionals. http://www.gdc-uk.org/dentalprofessionals/standards/Pages/ default.aspx (7 August 2012). 8. Gündüz HB. An Evaluation on Belbin’s Team Roles Theory. World Applied Sciences Journal. 2008;4(3):460-9. 9. Hackman JR. Work Redesign and Motivation. Professional Psychology. 1980;11(3):445-55. 19. Handy C. Understanding Organizations. Penguin Books; 1999. 11. Heppel M. Five star service one star budget: how to create magic moments for your customers that get you noticed, remembered and referred. FT Press; 2006. 12. Herzberg F. The wise old Turk. Harvard Business Review Septemer–October, 1974.pp.70-80. 13. Jacquot J. Trust in the dentist-patient relationship: a review. The Journal of Young Investigators, 12(6) http://www.jyi.org/research/ re.php?id=241 (7 August 2012) 2005. 14. Katzenbach JR, Smith DK. The wisdom of teams: Creating the high-performance organization. Boston: Harvard Business School Press; 1993.

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15. Kotter J, Rathgrber H. Our Iceberg Is Melting. McMillan; 2006.pp.128-34. 16. Maslow A. A theory of human motivation. Psychological Review. 1943;50:370-396. Retrieved June 2001, from http://psychclassics.yorku. ca/Maslow/motivation.htm. 17. McGregor. The Human Side of Enterprise. Management Review. 1957.pp.41-49. Available at http://www.psgoodrich.com/pc/docs/ ARTICLES/Human Side of Enterprise.PDF. 18. McPheat. Leadership Skills. MTD Training and Ventus Publishing ApS. 2010. 19. Newton JT, Brenneman DL. Communication in Dental Settings Scale (CDSS): Preliminary development of a measure to assess communication in dental settings. British Journal of Health Psychology. 1999;4:277-84. 20. Newton P, Asimakopoulou K. When we assume… a response to Prof. Anderson’s commentary. European Diabetes Nursing. 2008;5(1):36. 21. Newton T. Dentist patient communication: a review. Dental Update. 1995;22:118-22. 22. Ong LML, de Haes JCJM, Hoos AM, Lammes FB. Doctor patient communication: a review of literature. Social Science and Medicine 1995;40(7):903-18. 23. Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bulletin of the World Health Organization. 2005;83(9):661-9. 24. Porter ME. Competitive Strategy: Techniques for Analyzing Industries and Competitors. New York: Free Press; 1980. 25. Rotter DL, Hall JA. Doctors talking to patients/ patients talking to doctors: improving communication in medical visits. Westport: Auburn House; 1992. 26. Rotter DL, Hall JA. Studies of doctor-patient interaction. Annual Review of Public Health; 1989;10:163-80. 27. Schouten BC, Hoostraten J, Eijkman MAJ. Patient participation during dental consultations: the influence of patient characteristics and dentist’s behavior. Community Dentistry and Oral Epidemiology; 2003;31:868-77. 28. Tuckman BW. Developmental sequence in small groups. Psychological Bulletin. 1965;63:384-399. Reprinted in Group Facilitation: A Research and Applications Journal Number 3, Spring 2001 available at: http://dennislearningcenter.osu.edu/references/GROUP%20 DEV%20ARTICLE.doc. 29. Turner AN, Lawrence PR. Industrial jobs and the worker. Boston: Harvard Graduate School of Business Administration, 1965. 30. Vroom VH. Work and motivation. New York: Wiley; 1964. 31. Welch J, Welch S. Winning. Harper Collins; 2005.pp.19-20. 32. Whitfield JM, Anthony WP, Kacmar KM. Evaluation of team-based management: A case study. Journal of Organizational Change Management. 1995;8(2):17-28. 33. Zeidan H. The Blake Mouton Managerial Grid Identifying five different leadership styles. The Certified Accountant. 3rd Quarter Issue 2009;39:1-4.

2

Section

DIAGNOSIS IN PEDIATRIC DENTISTRY

This section briefs about case history to approach to the final diagnosis to the problem, different tooth numbering systems, radiographs used in children, different radiographic techniques and surveys. It also provides us an insight into child management while taking the radiographs and recent advances in radiographs/techniques.

6

Chapter

Oral Examination and Diagnosis Ravi GR, Nikhil Marwah, Manju Gopakumar, Vikram Khare

Chapter outline • • •

Recording the History Clinical Examination Provisional Diagnosis

Successful dental treatment for children can be achieved by recording a detailed history, a complete clinical examination, appropriate investigations, a thoughtful diagnosis and an appropriate treatment plan. It is very essential to obtain all relevant information about the patient and family along with an informed consent before embarking upon the comprehensive treatment program for a child patient. In some circumstances, the diagnosis (i.e. an explanation for the patient’s symptoms and identification of other significant disease process) may be self-evident. When clinical data are more complex, the diagnosis may be established by: • Reviewing the patient’s history and physical, radiographic, and laboratory examination data. • Listing those items that either clearly indicate an abnormality or that suggest the possibility of a significant health problem requiring further evaluation. • Grouping these items into primary versus secondary symptoms, acute versus chronic problems, and high versus low priority for treatment. • Categorizing and labeling these grouped items according to a standardized system for the classification of disease.

Components of oral examination and diagnosis • • • • • •

Recording the history Examination of the patient Provisional diagnosis Special examination Final diagnosis Treatment plan (including medical referrals).

• • •

Special Examination Final Diagnosis Treatment Plan

Emphasis on preventive dental care has taken the lead over the direct restorative intervention. Furthermore, recent information suggests that there is a more intimate relationship between oral and systemic health. Thus, the challenge facing dentists in the twenty-first century is a rapidly growing population of patients who have chronic medical conditions, take multiple medications, yet still require routine, safe, and appropriate oral health care. This chapter addresses the rationale and method for gathering relevant medical and dental information (including the examination of the patient) and the use of this information for dental treatment.

RECORDING THE HISTORY This can be further categorized for descriptive purposes into: • Vital statistics • Chief complaint • History of present illness • Family (social) history • Medical history • Drug history • Past dental history • Pre- and postnatal history • Behavioral history • Growth and development • Diet history. Vital statistics: It is a systematic approach to collect and compile all the information related to the vital events like birth, death, recognition, social structure and legislation. Recording personal details of the child is required for both record purposes and for communication.

46 Section 2 

Diagnosis in Pediatric Dentistry

TABLE 6.1: Vital statistics of history Date It records the time the patient reported to the clinic and can be referred back during following appointments

Name

Age

Details of medical practitioner

Knowing the name of • To build rapport with • As growth assessment parameter. Helps in diagnosing the child will help to the child Example: Dental age medical/syndromic establish • To alleviate • To recognize the disparities between conditions • Good rapport with apprehension dental age, mental age, chronological the child age, skeletal age, if any • Communication • As an aid in treatment planning. • Record purpose Example: Growth spurts in girls are • Medicolegal issues ahead of boys (based on chronological age) • Age-related diseases

Sex • As an aid in treatment planning. Example: Growth spurts in girls are ahead of boys • Sex related diseases. Example: Pubertal gingivitis is seen in adolescent females

Nick name

Address

Source of information

Occupation of parents

Drugs

• Communication To check whether the Reflects the socioeconomic status of the Helps to ascertain • Record purpose information provided is family drug interactions • Medicolegal issues genuine or not • To rule out any endemic conditions

All these details should be entered in the case sheet prior to the appointment. Details of the patient’s medical practitioner should also be included (Table 6.1).

Chief Complaint • This is concerned about what made the patient to visit the dentist or what they are seeking from treatment. • It is better to ask the child about his chief complaint before involving the parent which helps to establish a good rapport with the child. But it is mandatory to get an answer from the parent also regarding the child’s complaint. • It is recommended to record the chief complaint in patient’s own words. • History of present illness: It is the elaboration/detailed description of the chief complaint. – Several factors need to be evaluated regarding the chief complaint like duration, mode of onset, severity, nature, aggravating or relieving factors, associated symptoms, diurnal variation, postural variation, any medications or treatment received for the same. – Gives an insight towards the possible cause and nature of disease/condition. – Hint towards the possible disease/condition.

Family (Social) History • It provides relevant information about the social background of the child and his family. • It also should include such factors like number of children in the family, the child’s attendance in the school,

performance in the class, the housing conditions and the parent’s occupation. • The family history should also include the occurrence of any genetic diseases, oral or general. • Furthermore, questions regarding family history must be neither offensive nor intrusive.

Medical History • Various diseases or functional disturbances may directly or indirectly cause or predispose to oral problems and may affect the delivery of oral care. • A comprehensive medical history should commence with information relating to pregnancy and birth, the neonatal period, and early childhood. • Details about the previous hospitalization, operations, illnesses, and traumatic injuries should be recorded along with the information related to the previous and current medical treatment.

Medical history should include • • • • • • •

Cardiovascular system (e.g. congenital heart disease, blood pressure, rheumatic fever) Central nervous system (e.g. seizures, cognitive delay) Endocrine system (e.g. diabetes) Gastrointestinal system (e.g. hepatitis) Respiratory system (e.g. asthma, upper respiratory tract infections) Hematological disorders (include family history of bleeding disorders) Urogenital system (renal disease).

Chapter 6  Oral Examination and Diagnosis

Prenatal, Natal, and Postnatal History • Any infections, systemic conditions during pregnancy • Immunization status during pregnancy • Whether received antiserum D vaccination or not—in case Rh +ve (father) and Rh –ve (mother). Natal events at birth • Time of birth—to rule out preterm birth • Type of delivery—normal/forceps/cesarean • Vaccinations given at birth • Forceps delivery—predisposed factor for temporomandibular (TMJ) disorder. Postnatal events after birth • Developmental milestones—crawling, sitting, walking, etc. • Development of speech • Immunization schedule.

Drug History • Details of the drugs being used for systemic ailments • Any adverse reaction to drugs • Any drugs already used for the condition.

Past Dental History • The child’s past experience with the dental treatment should be assessed. • The kind of dental treatment received, including the pain control measures which has been offered gives the dentist important information about the child’s past behavior for dental treatment which might help us to modify the treatment appropriately. • Dental history should also identify factors that have been responsible for the existing dental problems and those which might have an impact on future health. • These include day to day oral hygiene measures like frequency of brushing and type of toothpaste used the type, duration and frequency of sucking habits and dietary habits which should include duration of breastfeeding, bottle feeding at bed time, frequency of snacking between meals. • Dental history should also give us explanation for the unusual conditions like rampant caries, erosion, and attrition. • Finally by a thorough dental history the dentist can evaluate the attitude of the parent to his or her child’s dental treatment.

Dental history • • • •

Helps in formulation of treatment plan Knowledge about patient’s habits Helps evaluate attitude of parents towards dentistry Medicolegal purpose.

• In addition the survey of the previous dental records and radiographs may give important information for the treatment and also previous dental records help in medicolegal purposes also.

Behavioral History Any clues of negative or unpleasant behavior during the previous dental visit may call upon the need for behavior management or shaping.

Growth and Development Developmental milestones, speech and language develop­ ment, motor skills and socialization should be evaluated.

Diet History • Type of meal (vegetative/mixed) influences the oral hygiene status. • Habits of snacking between meals should be evaluated as they may be cariogenic. • In case of high cariogenic patients, a diet diary with number of sugar exposures should be noted while taking diet history.

CLINICAL EXAMINATION The clinical examination not only includes intra- and extraoral examination but also comprise of complete general examination.

General Examination • Height and weight—both have a direct relation with developmental and nutritional status. • Gait—look for any abnormality in gait, e.g. waddling gait, limping gait. • Posture—look for any abnormality. • Stature and built—indicative of any malnutrition or other abnormality. • Vital signs—pulse, heart rate and respiratory rate differ in child at different ages till these reach the adult value. Hence, the clinician should have a thorough knowledge of these physiological variations. • Any other data like illness, malaise.

Extraoral Examination The extraoral examination should be one of the general appraisals of the child’s well-being. The clinician should assess: • Shape of head (Figs 6.1A to C)—can be classified as: – Mesocephalic—average shape of head and arch

47

48 Section 2 

A

Diagnosis in Pediatric Dentistry

B

A

C

B

Figs 6.2A to C: Facial forms

Figs 6.1A to C: Head shapes. (A) Round oval; (B) Long oval; (C) Wide oval

A

C

B

C Figs 6.3A to C: Facial profiles

•

•

•

•

– Dolicocephalic—long and narrow head; narrow dental arches – Brachycephalic—broad and short head; broad dental arches. Facial form (Figs 6.2A to C)—three common facial forms are: 1. Mesoprosopic—average facial form 2. Euryprosopic—broad and short facial form 3. Leptoprosopic—long and narrow face. Facial profile—this is ascertained by examining the patient sideways. The three facial profiles are straight, convex, concave (Figs 6.3A to C). Facial swelling and asymmetry: 1. Bacterial or viral infections and trauma are the principal causes of facial swelling in a child. 2. Pathological facial asymmetry may be produced by cranial nerve paralysis, fibrous dysplasia and familial developmental disturbances. 3. History and oral examination play a major role in the diagnosis of any swelling of the face. Examination of eyes: – Eyes should be observed for any inflammation, swelling or puffiness around the eye.

•

•

•

•

– Inflammation of maxillary teeth can cause swelling of the eyelids. – Children with upper respiratory tract infection, sinusitis and allergy have puffiness of eyelids. Examination of nose: – Nose should be examined for any abnormalities in size, shape, or color. – Children who encounters nasal discharge indicate upper respiratory tract infection. – Children with chronic upper respiratory tract infection will develop mouth breathing habit. Examination of skin: – The skin of the face should be evaluated for the presence of primary and secondary skin lesions. – Any scars, bruising, laceration, pallor, birth marks also should be documented. Examination of chin: – Prominence of chin and mentalist activity can indicate habits and malocclusion. Examination of lips (Figs 6.4A and B): – Lips should be examined for the presence of cold­ sores, swelling or abnormal coloring.

Chapter 6  Oral Examination and Diagnosis – Competent—lips are in contact when musculature is relaxed – Incompetent—lip seal is not formed in normal circumstances, only hyperactivity of oral musculature can help in forming closure. • Examination of TMJ (Figs 6.5A and B): – Functional examination should include palpation and auscultation of TMJ and associated musculature. – The patient should be examined for any clicking sound, crepitus, pain, deviation, restricted opening. – Mouth opening is also related to TMJ function and should be also examined. Normal mouth opening is 40–45 mm.

TMJ Examination The function of temporomandibular joint (TMJ) is examined by palpating the head of mandibular condyle and observing the patient with mouth closed, open and during random movements.

A

• Lymph nodes examination (Figs 6.6A and B): – A complete examination of neck region including the lymph nodes is mandatory. – Lymphadenopathy is not uncommon in children due to frequent viral infections. – Ask the patient to bend his neck in forward and downward position to palpate the lymph nodes on the side and to bend it forward to palpate the submandibular area. Intraoral examination: Intraoral examination for a young child should begin with the “tell-show-do” approach, i.e. by explaining the child what are you going to do, show him the examination instruments followed by intraoral examination. During and after the intraoral examination explain the parents about the intraoral findings and discuss the treatment plan. This includes the examination of hard as well as soft tissues. • Soft tissue: It includes examination of the oral mucosa and examination of periodontal tissues. Complete inspection and palpation of all soft tissue oral structures is needed.

B Figs 6.4A and B: Competency of lips

A

B Figs 6.5A and B: Method of examination of TMJ

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50 Section 2 

Diagnosis in Pediatric Dentistry

A

B Figs 6.6A and B: Examination of lymph nodes

Fig. 6.7: Examination of lips

Fig. 6.9: Examination of floor of mouth

Fig. 6.8: Examination of tongue

– Examination of oral mucosa: An abnormal appea­ rance of the oral mucosa may be indicative of an underlying systemic disease or nutritional deficiency. It is, therefore, very important to carefully examine the lips (Fig. 6.7), palate and oropharynx, tongue (Fig.  6.8), Floor of the mouth (Fig. 6.9), buccal mucosa (Fig.  6.10). – During examination of intraoral soft tissues check the salivary flow rate and quality. – Check for abnormal frenal attachment or tongue tie as it can have an effect on the development of speech. – Since periodontal disease is very uncommon in children examination of gingival tissues is indicated in young children. – Gingiva should be examined for redness, swelling, ulceration, spontaneous bleeding.

Chapter 6  Oral Examination and Diagnosis

Fig. 6.10: Examination of buccal mucosa

Fig. 6.12: Caries—active/arrested

– Assessment of the oral cleanliness and the presence of plaque and calculus should be done. – The presence of profound gingival inflammation in the absence of gross plaque deposits, prematurely exfoliating teeth, or mobile permanent teeth may indicate a serious underlying disease. • Hard tissue: Evaluation of the overall dentition can be made before the examination of individual teeth. These include variations in number, morphology, color and surface structure. These should be observed under good light and after careful isolation and drying. – Individual teeth should be evaluated for Tooth number—any missing/extra teeth (Fig. 6.11); cariesactive/arrested (Fig. 6.12); restorations—intact/ deficient (Fig. 6.13); trauma—note the extent, site or signs of loss of vitality (Fig. 6.14); tooth mobility (Fig. 6.15)—physiological/pathological; tooth structure—

Fig. 6.11: Tooth number—any missing/extra teeth

Fig. 6.13: Restorations—intact/deficient

record any localized or generalized defect, e.g. fluorosis (Fig. 6.16). – Examination of occlusion (Fig. 6.17) occlusion of the child should be checked for molar and canine interdigitation. Early recognition of malocclusion will help to formulate a treatment plan in a very young age itself. The following should be analyzed: incisal relationship (Fig. 6.18); canine relationship (Fig. 6.19); primary molar relationship (Figs 6.20A to C); midline (Figs 6.21A and B); presence of crowding/spacing (Fig. 6.22); severe skeletal abnormalities.

PROVISIONAL DIAGNOSIS It is the diagnosis based on the clinical impression without any laboratory investigations-based on the history and clinical presentation of the patient we make an assessment

51

52 Section 2 

Diagnosis in Pediatric Dentistry

Fig. 6.14: Trauma—note the extent, site or signs of loss of vitality

Fig. 6.15: Tooth mobility physiological/pathological

Fig. 6.16: Tooth structure—record any localized or generalized defect, e.g. fluorosis

Fig. 6.17: Evaluation of occlusion

Fig. 6.18: Incisal relationship

Fig. 6.19: Canine relationship

Chapter 6  Oral Examination and Diagnosis

A

B

C

Figs 6.20A to C: Primary molar relationship: (A) Distance step terminal plane; (B) Mesial step terminal plane; (C) Flush terminal plane

A

B Figs 6.21A and B: Midline: (A) Normal midline; (B) Teeth with midline shift

of the current condition of the patient. This is followed by the special examinations, final diagnosis and treatment planning.

SPECIAL EXAMINATION These include all necessary investigation that may be required to reach at a final diagnosis like radiographs, pulp sensibility (vitality) testing, blood investigations, micro­ biological investigations, photography, diagnostic casts, caries activity tests, advance diagnosis, biopsy, etc.

FINAL DIAGNOSIS

Fig. 6.22: Presence of crowding

This is the final conclusive answer that has been reached upon by applying investigative reports to our differential diagnosis options.

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Diagnosis in Pediatric Dentistry

TREATMENT PLAN This includes the following phases of treatment: • Emergency: The first and foremost objective of the dentist is to relieve the patient of his acute pain and any other acute symptoms. For example, if a patient has reported with acute swelling and pain the first task is to provide him relief by performing emergency access opening. • Medical: The patients should be referred to medical specialists through or by consultation with the family physician or pediatrician. • Preventive: This phase includes risk assessment by caries diagnosis, dyes, diet charts and other preventive protocols like pit and fissure sealant, fluoride application, ART, etc.

• Preparatory: This includes behavior management and consultations with various other dental disciplines for interdisciplinary approach. Oral prophylaxis is also included in this phase. • Corrective: Includes restorative, endodontic, surgical, orthodontic, periodontic or prosthodontic treatment that are carried out as an active phase. • Maintenance: Its variation depends on the patient’s disease status and begins from one week up to 6 months or even 1 year. To summarize, a clinician can be successful in rendering a comprehensive treatment by means of updating his knowledge timely. Nevertheless the role of examination, diagnosis and treatment planning still play the pivotal role in rendering the same even with the constant development of the science and technology. All the latest techniques do not yield the desired results if these three fundamentals are ignored.

POINTS TO REMEMBER • Components of oral examination and diagnosis are recording the history, examination of the patient, provisional diagnosis, special examination, final diagnosis, treatment plan (including medical referrals). • History includes: History of present illness, family (social) history, medical history, drug history, past dental history, preand postnatal history, behavioral history, diet history. • Use of name is to build rapport with child and to alleviate apprehension. • Age is important to recognize the disparities between dental age, mental age, chronological age, skeletal age, if any. • Chief complaint should be in patient’s own words. • History of present illness is the elaboration of the chief complaint. • Dental history mainly helps in formulation of treatment plan. • Examination of oral mucosa is useful as any abnormal appearance of the oral mucosa may be indicative of an underlying systemic disease or nutritional deficiency. • Examination of occlusion of the child will help in early recognition of malocclusion and will help to formulate a treatment plan in a very young age itself. • Treatment plan includes emergency medical preventive preparatory corrective maintenance.

QUESTIONNAIRE 1. 2. 3. 4. 5.

Explain role of vital statistics in case history. Role of diet history in management of dental patient. Explain the examination of TMJ and lymph nodes. Describe the hard tissue examination. Explain the phases of treatment plan.

BIBLIOGRAPHY

1. Clerehugh V, Tugnait A. Diagnosis and management of periodontal diseases in children and adolescents, periodontal. 2000;26:146-68. 2. Curcio RJ. The art of the dental examination. DCNA 22(2), 1978;22(2):209-28. 3. Curcio RJ. The first phone call. DCNA. 1978;22(2):197-208. 4. Jeffcoat MK. Diagnosing periodontal disease. New tools to solve old problems. J In Dent Assoc. 1999.pp.122-54. 5. Moskow BS, Barr CE. Examination of the patient. In: Goldman HM and others (Eds). Current therapy in dentistry, St. Louis, Mosby; 1970(4).

7

Chapter

Teeth Identification and Numbering Systems Chaitanya Ram, Nikhil Marwah

Chapter outline •

• •

Trait Categories

Dental anthropologists and dentists who are building on a classic anatomic nomenclature will prefer a precise lexicon of terms for designating specific teeth. To say, there would be no confusion when describing a specific tooth as primary human maxillary 1st molar. However, in a dental clinic setting when a dentist would have to extensively and expeditiously document voluminous details this type of tag will prove to be lengthy and cumbersome.1 Thus a practical need for conciseness, precision and succinctness has led dentists and clinicians to develop a variety of tooth coding systems. The purpose of chapter is to delineate the common clinical systems of tooth nomenclature in order to familiarize dentists with a clinical nomenclature.2 Before understanding the need for a tooth numbering one has to understand different terms used in the context of this chapter. The etymology of teeth names are all from Latin. Incisor (Latin word incidere = to cut into); describes the function of incising and nipping. Canines (Latin word Canis = dog, hound); derived from the prominent, well-developed teeth in the family Canidae. The name premolar is merely due to their position in relation to the molars. Since these teeth commonly possess two cusps they are also known to be bicuspids3 (Kraus and Furr, 1953).

Tooth coding •

When identifying a particular tooth, we should follow a specific pattern to name the tooth as mentioned below in the same order: – Dentition—deciduous or permanent – Arch—maxillary or mandibular – Quadrant—right or left – Tooth name—incisor, etc.

Dental Formula Tooth Numbering Systems

Molars (Latin word molaris = millstone) refers to the triturating ability of these teeth with their substantial occlusal surfaces.

TRAIT CATEGORIES4 These are helpful in describing tooth similarities and differences. A trait can be defined as a distinguishing feature, characteristic or an attribute. The trait can be classified as: • Set trait—this distinguishes the teeth in primary dentition from permanent dentition. For example, primary central incisors are wider mesiodistally than cervicoincisally. This type of trait is also called as dentition trait. Premolars do not have any set traits as they do not appear in the primary dentition. • Arch traits—distinguish maxillary from mandibular arch, from maxillary incisors are larger than mandibular incisors, maxillary molars are wider buccolingually and mandibular molars wider mesiodistally. • Class trait—distinguish among individual teeth, i.e. incisors, canines, premolars and molars, e.g. incisors have edges for cutting, canines have pointed cusps for tearing, premolar cusps are modeled for grinding and molars have flat cusps for chewing. • Type traits—used for interclass differentiation like difference between central and lateral incisor or between 1st, 2nd and 3rd molars. Canine although does not have a type trait as it is single in each arch.

DENTAL FORMULA Denomination and number of teeth for all mammalian are expressed by a formula (Table 7.1). Denomination of each

56 Section 2 

Diagnosis in Pediatric Dentistry

TABLE 7.1:  Dental formula for mammals S. No.

Type of mammalian

Tooth numbering systems Dental formula

1.

Humans—primary teeth

I–2/2 C–1/1 M–2/2

2.

Humans—permanent teeth

I–2/2 C–1/1 P–2/2 M–3/3

3.

Apes

I–2/2 C–1/1 P–2/2 M–3/3

4.

Monkeys

I–2/2 C–1/1 P– 3/3 M–3/3

5.

Dogs

I–3/3 C–1/1 P–4/4 M–2/3

6.

Cats

I–3/3 C–1/1 P–3/2 M–1/1

7.

Cows

I–0/3 C–0/1 P–3/3 M–3/3

8.

Horses

I–3/3 C–1/1 P–4/4 M–3/3

9.

Rabbits

I–2/1 C–0/0 P–3/2 M–3/3

10.

Elephants

I–1/0 C–0/0 DM–3/3 M–3/3

11.

Rats

I–1/1 C–0/0 P–0/0 M–3/3

• • • •

Elephants have deciduous molars and no premolars Elephant tusks are central incisors and weigh about 440 pounds Teeth of shrews wear out earliest as they have food every 1 to 2  hours Whales have no teeth.

tooth is noted as an initial letter like I for incisor and each letter is separated by a horizontal line, above which is written the maxillary teeth and below the mandibular teeth. Dental formula expresses the number of teeth on one side, so total number of teeth is usually doubled.

TOOTH NUMBERING SYSTEMS Tooth designation systems have been used for more than hundreds of years and were first reported in early literature of Latin America. The first comprehensive numbering system was developed by Viennese dentist Adolf Zsigmondy in 1861. He designated an eight tooth quadrant plan with the quadrant system symbolized by drawing one of four corners into which 1 to 8 tooth numbers is placed. In 1870 an Ohio dentist Corydon Palmer presented the same system at meeting of American Dental Association (ADA) and claimed it to be his original creation. Later in 1870 when Zsigmondy’s original article was published in British Journal of Dental science and presented at 1889 International Dental Congress in Paris and also appeared in Ohio Journal of Dental science and Dental Cosmos, it came as a great embarrassment to Dr Palmer who in America had taken credit for this system and claimed to discover it. In 1891 he wrote a complete article about his notation system in order to get complete recognition but this was kept pending and never given official status. However, years after his death, ADA acknowledged his contributions in field of numbering systems and began to associate his name with this system

• • • •

The first comprehensive numbering system was developed by Viennese dentist Adolf Zsigmondy in 1861. Danish dentist Viktor Haderup who added the symbols of ‘+’ and ‘–’ along teeth number to designate the jaws. In 1882 a German dentist Julius Parreidt proposed a system of counting consecutive teeth called as Universal system. In end of 1968 FDI came up with a unique two digit system developed by Dr Jochen Viohl of Berlin and this was introduced in 1970.

but never gave him official recognition as discoverer of quadrant numbering system. Although accepted this system underwent many modifications by various dentists all over the world. Out of these the most distinguishing was by Danish dentist Viktor Haderup who added the symbols of ‘+’ and ‘–’ along teeth number to designate the jaws. However, none of these modifications ever sustained the test of time and none were implemented or accepted. Elsewhere in 1882 a German dentist Julius Parreidt proposed a system of counting consecutive teeth called as Universal system. He did this to simplify the quadrant system but he later admitted that this universal system of counting 1 to 32 had many errors and was artificial when imposed upon permanent dentition. This system also did not include the primary teeth and hence he was forced to abandon this system in two months. By the 1940s there were many numbering systems that were being used. The committee on nomenclature was well versed with this problem and in 1947 recommended that 1  to 8 quadrant numbering system, i.e. Zsigmondy-Palmer system will be universally used and accepted; the primary teeth were included as A to E. In end of 1968 Federation Dentaire Internationale (FDI) came up with a unique two digit system developed by Dr Jochen Viohl of Berlin and this was introduced in 1970 and has since been widely accepted and used all over the world. However, ZsigmondyPalmer system still continues to be the most dentist popular notational system of all time.

Zsigmondy-Palmer System • The most popular system of tooth designation for much of the 20th century was developed by the Viennese dentist Adolph Zsigmondy.5 He broke with tradition, substituting numbers for the eight teeth in each quadrant in place of the lengthy Latin names in use to that time.1,6 • The correspondence is (Fig. 7.1): – Central incisor – Lateral incisor – Canine (cuspid) – 1st premolar (bicuspid)

Chapter 7  Teeth Identification and Numbering Systems Key points • •

• •

Given by Adolph Zsigmondy Combined his tooth numbering system with a graphical device to specify the quadrant of mouth Also called as angular system and the grid system Primary teeth are represented by A to E and permanent by 1 to 8.

termed the “quadrant system” by some. (Sharma and Wadhwa), 1977.8 • The Palmer system also has been labeled the “angular system” and the “grid system” because of the horizontal and vertical line segments that denote the tooth’s quadrant. • However, the disadvantage for Zsigmondy-Palmer nota­ tion is that, even though it is easy to sketch the tooth codes  in a patient’s record, it is tedious to type or verbalize them. Indeed, it was the need to computerize the dental recording system that marshaled—in the FDI system—and incidentally promoted the use of the Universal system in the United States. Coding a tooth numerically, as #16 or 28, is easy and lends itself to word processing.

Palmer Analog for Primary Teeth • Letters have commonly been used to denote the primary teeth; some systems use lower-case letters (perhaps mimicking the sub-adult nature of these teeth; Churchill, 1932),9 but capital letters are encountered more often. Again, the side and arcade are denoted by line segments: B is the maxillary right lateral incisor, and E is the mandibular left second molar. • Primary teeth have also been designated by Roman numbers (I—V) (Fig. 7.2), which can further confuse the novice8,9 particularly since still other systems have used Roman numerals to designate quadrants in the permanent dentition. Fig. 7.1:  Zsigmondy-Palmer system (Permanent)

– 2nd premolar (bicuspid) – 1st molar – 2nd molar – 3rd molar (dens sapientiae; wisdom tooth) • Zsigmondy combined his tooth numbering system with a graphical device to specify the quadrant of the mouth. An L-shaped [L] mark was used, with the vertical line segment being the subject’s midline and the horizontal segment his occlusal plane that separates the upper and lower arcades. The clinician could, then, easily code a specific tooth, such as the lower left canine as 3 or the upper right 1st molar 6 . • Conflicts rose because an Ohio dentist Corydon Palmer7 (Palmer) argued for his independent invention of the same coding system and said that the natural division of the dentition into quadrants was a well-known, obvious device. In fact most American dentists in that era have been taught the notation as being Palmer’s (though also

Fig. 7.2:  Zsigmondy-Palmer designation (Primary)

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Diagnosis in Pediatric Dentistry

 édération Dentaire F Internationale System • Excepting the United States dentists all around the world now use the FDI two-digit system (Fédération Dentaire Internationale). • This was proposed by Dr Jochen Viohl of Berlin in 1970. • This scheme was developed by a “Special Committee on Uniform Dental Recording” and passed as a resolution of the FDI General Assembly at its 1970 meeting in Bucharest, Romania. • While the FDI labeled this the “Two-Digit System,” it is more commonly referred to as the FDI system. • According to this system every tooth system is denoted with 2 digits, the first digit denoting the quadrant of the mouth, while the second digit defines the tooth’s normal position in the mouth, front to back. • Most dentists are right handed, so quadrant 1 (maxillary right) is closest to the dentist when examining a patient and is scored first, then the upper left quadrant, then one drops down to the lower left quadrant, finishing with teeth in the lower right quadrant. More formally, the quadrants are numbered “in a clockwise sequence … starting on the upper right side” when viewing the subject from the front.10 • The FDIs description also suggests how to verbalize the system, namely “The digits should be pronounced separately; thus, the permanent canines are teeth onethree, two-three, three-three, and four-three” (Fig. 7.3). • Its advantages are: – Simple to understand and to teach. – Easy to pronounce in conversation and dictation. – Readily communicable in print. – Easy to translate into computer output. – Easily adapted to standard charts used in general practice.

Fig. 7.3:  FDI numbering system (Permanent)

FDI System for Primary Teeth • Even though developing first the convention is that to use as numbers 5 through 8 to denote the primary teeth quadrants (Fig. 7.4). • This numerical oddity was the subject of considerable discussion by the FDI committee, but it was reasoned

Key points • • •

• •

Given by Dr Jochen Viohl Also called as Two-Digit System Every tooth system is denoted with 2 digits, the first digit denotes quadrant of the mouth, and second defines the tooth’s position Quadrant are numbered clockwise starting from maxillary right This system is simple, easy and more communicable.

Fig. 7.4:  FDI tooth numbering system for primary teeth

that, “mainly because deciduous teeth function for such a short time in comparison with permanent teeth that the bulk of dental data to be collected and computerized in the future would obviously concern permanent teeth”.

Universal Numbering System • The Universal system was proposed by Julius Perreidt in 1882 and endorsed by ADA in 1968.

Chapter 7  Teeth Identification and Numbering Systems

Fig. 7.5:  Universal numbering system (Permanent)

• Perreidt disliked the redundancy repetition and potential confusion of Zsigmondy’s use of tooth numbers 1 through 8 in all four quadrants. Instead, he numbered the permanent teeth 1 through 32, starting at the upper right and continuing to the upper left, then the lower left to the lower right. • Today, the Universal system of tooth-coding is an interesting misnomer as it is only used in the United States. The ADA (American Dental Association) by an unanimous decision of its Council on Dental Care Programs adopted the Universal System of numbering teeth on April 18, 1975.1 • Starting with the third molar in the upper right quadrant (tooth #1), the teeth are numbered around the arch so the maxillary left third molar is tooth #16. One then drops down to the mandibular left third molar (#17) and numbers the teeth around the lower arcade, finishing with the mandibular right third molar (#32) (Fig. 7.5). • The compelling value of the Universal system is the ease of computerizing the data, which is its singular selling point for automating office systems thus accelerating communication.

Key points • • •

•

Given by Julius Perreidt Used only in USA Numbered the permanent teeth 1 through 32, starting at the upper right and continuing to the upper left, then the lower left to the lower right. Ease of computerization.

Fig. 7.6:  Universal system for primary teeth

Universal System for Primary Teeth • The 20 primary teeth are coded alphabetically from A through T. • There is no anatomic parallel with this system. • If using this system infrequently, it is of help that one remembers it by simply memorizing A, J, K and T are the second molars (at the distal ends of the quadrants) and that E, F, O and P are the central incisors (Fig. 7.6). There are two major motivations to develop a toothcoding system. One is to conserve energy and communicate telegraphically. Writing or speaking (or typing) “the permanent mandibular right second premolar” is much more taxing than referring to this tooth as #29 or 45, especially if teeth consume one’s professional life. There is the need to be specific but also to be as concise as practical. The other, recent driving force is to computerize ever-increasing masses of data, and numeric codes (and their alphabetic equivalents) lend themselves to this end. A compilation of the tooth numbering system is explained in the schematic diagram (Figs 7.7 and 7.8). One minor spin-off of the trend toward globalization is the need for standardization—so all of the participants understand the same set of “rules” and can communicate effectively. The FDI system seems to be the solution in terms of dental-coding systems. This leaves the US “Universal” system as an anachronism, but it doubtlessly will persist as a system paralleling the FDI system until the US also converts to the metric system. In scientific circles, though, an increasing number of dental journals are requiring its authors to use of the FDI system for tooth designations.

59

60 Section 2 

Diagnosis in Pediatric Dentistry

Fig. 7.7:  Coding systems used while designating the primary teeth (Justi Educational Department Dental Numbering Systems Prim- Rev-9/03)

Chapter 7  Teeth Identification and Numbering Systems

Fig. 7.8:  A schematic diagram of the coding systems used while designating the permanent teeth (Justi Educational Department Dental Numbering Systems Perm- Rev-9/03)

61

62 Section 2 

Diagnosis in Pediatric Dentistry

POINTS TO REMEMBER • When identifying a particular tooth, we should follow a specific pattern to name the tooth as mentioned below in the order dentition, arch, quadrant, tooth name. • Dental formula for humans is primary teeth: I—2/2 C—1/1 M—2/2; permanent teeth I—2/2 C—1/1 P—2/2 M—3/3. • The first comprehensive numbering system was developed by Viennese dentist Adolf Zsigmondy in 1861. • Zsigmondy combined his tooth numbering system with a graphical device to specify the quadrant of mouth. • In 1882 a German dentist Julius Parreidt proposed a system of counting consecutive teeth called as Universal system which numbered the permanent teeth 1 through 32, starting at the upper right and continuing to the upper left, then the lower left to the lower right. • In end of 1968 FDI came up with a unique two digit system developed by Dr Jochen Viohl of Berlin and this was introduced in 1970. Every tooth system is denoted with 2 digits, the first digit denotes quadrant of the mouth, and second defines the tooth’s position.

QUESTIONNAIRE 1. 2. 3. 4. 5.

What are trait categories? Explain mammalian dental formula. Describe Zsigmondy-Palmer system. Explain Universal system. Describe FDI system.

REFERENCES

1. Schwartz S, Stege D. Tooth numbering systems: a final choice. Ann Dent. 1977;36:99-106. 2. Edward F Harris. Tooth-Coding Systems in the Clinical Dental Setting. Dental Anthropology. 2005;18(2):43-9. 3. Kraus BS, Furr ML. Lower first premolars. I. A definition and classification of discrete morphologic traits. J Dent Res. 1953; 32:554-64. 4. Rickne C Scheid. Woelfel dental anatomy: Its relevance to dentistry. 7th Edn. Wolters kluwer Lippincott. Wiliams & Wilkins; 2007. 5. Zsigmondy A. A practical method for rapidly noting dental observations and operations. Br J Dent Sci. 1874;17:580-2. 6. Peck S, Peck L. A time for change of tooth numbering systems. J Dent Ed. 1993;57:643-7. 7. Palmer C. Palmer’s dental notation. Dent Cosmos. 1891;33:194-8. 8. Sharma PS, Wadhwa P. Evaluation of the FDI two-digit system of designating teeth. Quintessence Int. 1977;8(10):99-101. 9. Churchill HR. Human odontography and histology; Philadelphia: Lea & Febiger; 1932. 10. Keiser-Nielsen S. Federation Dentaire Internationale. J Amer Dent Assoc. 1971;82:1034-5.

8

Chapter

Radiographic Techniques Nikhil Marwah, Gopakumar R, Manju Gopakumar

Chapter outline • • • • • •

History Characteristics of an Ideal Radiograph X-ray Machine Intraoral Periapical Radiograph Techniques Supplementary Intraoral Radiographic Technique Radiographic Protocol

The radiographic examination is an essential part of the diagnosis of dental disease. Radiographs of children reveal many conditions that cannot be discovered by any other method. They help the practitioner to make an early diagnosis of carious lesions and development of eruption problems, and they enable him or her to confirm and evaluate a pathology diagnosed clinically. Moreover, the radiographic examination enables the clinician to establish a therapeutic decision. Radiography for children depends on three factors, i.e. age of the child, size of oral cavity and level of patient’s cooperation.

• • • • •

Panoramic Radiography Specialized Radiography Radiation Protection Radiographic Infection Control Behavioral Considerations in Pedodontic Radiography

know what it was he called the phenomenon X-ray, X being the algebraic designation for the unknown. He inadvertently placed his hand between the tube and the screen and saw the faint outline of the bones of his hand. He went on to expose and produce images on photographic plates of his wife Bertha’s hand (Fig. 8.2) and his shotgun (Fig. 8.3). Roentgen presented a paper on his discovery in late December and in January 1896 Dr Otto Walkhoff (Fig. 8.4), a dentist in Germany made the first dental use of an X-ray and radiographed a lower premolar (Fig. 8.5). He used a small glass photographic plate wrapped in black paper and covered

HISTORY The X-ray was discovered in November 1895 by Wilhelm Conrad Roentgen, a professor of physics at the University of Wurzberg in Germany. He was working with a vacuum tube called Crookes tube. Since he was concerned with light, he was working in a darkened room with black cardboard covering the Crookes tube and there were many fluorescent plates in his laboratory (Fig. 8.1). Thus, the stage was set for one of the most important discoveries that would aid medical and dental science. One evening while working in his darkened laboratory, Roentgen noticed that one of the fluorescent plates at the far side of the room was glowing. He quickly realized that something coming from the Crookes tube was striking the fluorescent plate and causing it to glow since he did not

Fig. 8.1: Wilhelm Conrad Roentgen with his X-ray apparatus

64 Section 2 

Diagnosis in Pediatric Dentistry Terminologies

• Radiation: A form of energy carried by waves or a stream of particles • X-radiation: A high energy radiation produced by the collision of a beam of electrons with a metal target in an X-ray tube • X-ray: A beam of energy that has the power to penetrate substances and record image shadows on photographic film • Radiology: The science or study of radiation as used in medicine, a branch of medical science that deals with the use of X-rays, radioactive substances and other form of radiant energy in the diagnosis and treatment of disease • Dental radiograph: A photographic image produced on film by the passage of X-ray through teeth and related structure • Dental radiography: The making of radiographs of the teeth and the adjacent structures by the exposure of film to X-ray • Dental radiographer: A person, who positions, exposes and processes dental X-ray film • Density: The overall degree of darkening of exposed film • Latitude: Measure of range of exposure that will produce distinguishable densities on film

Fig. 8.3: Image of Wilhelm Conrad Roentgen’s shotgun

• Film speed: Amount of radiation needed to produce a standard density • Contrast: The difference in densities between various areas on radiograph • Resolution: Ability to distinguish between small objects that are close together • Radiographic mottle: Appearance of uneven densities of an exposed film • Sharpness: Ability of a radiograph to define an edge

Fig. 8.4: Dr Otto Walkhoff

Fig. 8.2: Image of Wilhelm Conrad Roentgen wife’s hand

with rubber with exposure time of 25 minutes. For his work in the discovery of X-rays Roentgen was awarded the first Nobel Prize in physics in 1901 and for years, the science of imaging with the use of X-ray was called Roentgenology and his name is still used today to express the units of X-ray exposure in Roentgen’s. Many of the early scientist working with dental X-rays suffered from effects of their work. Rollins reported burns to the skin on his hands; Kells, before his death had three fingers of his hand and finally his arm amputated. He used a technique called setting the tube to adjust the X-ray beam before radiographing patients. He held his hand between

Chapter 8  Radiographic Techniques

Fig. 8.5: First dental radiograph

Highlights in the history of dental radiology 1895

Discovery of X-rays

WC Roentigen

1896

First dental radiograph

Otto Walkhoff

1896

First dental radiograph (USA-skull)

WJ Morton

1896

First dental radiograph (US-Live pt)

CE Kells

1901

First paper on dangers of X-radius

WH Rollins

1904

Introduction of bisecting techniques

WA Price

1913

First prewrapped dental films

Eastman Kodak Comp

1913

First X-ray tube

WD Coolidge

1920

First machine made film packets

Eastman Kodak Comp

1923

First dental X-ray machine

Victor X-ray Co-op-Chicago

1925

First dental text

HR Raper

1925

Introduction of bitewing technique

HR Raper

1947

Introduction of long cone 11th technique

FG Fitzgerald

1957

First variable kilovoltage dental X-ray

General Electric machine

Fig. 8.6: William D Coolidge with his X-ray tube

the tube and a fluoroscope and adjusted the beam quality until the bones of his hand were seen clearly. This lead to discovery of new and safer systems. In 1913, William D Coolidge (Fig. 8.6) invented the hot cathode X-ray tube which is the prototype of X-ray tubes today and in 1923, the first American dental X-ray machine was manufactured by Victor X-ray Corporation which later became General Electric X-ray Corporation.

CHARACTERISTICS OF AN IDEAL RADIOGRAPH The radiographic image should have the following charac­ teristics to be ideal: • Radiographic density: Which refers to overall degree of darkening of various regions. It should not be very darker or very light. • Latitude of the film: It is the measurement of range of exposure that may be usefully recorded as a sum of distinguishable density on the film. • Adequate radiographic contrasts: Difference in density of various regions, thus helping in demarcating the structures. • Speed of the film: This refers to the amounts of radiation, required to produce a radiographic film of a standard density. • Sharpness: It is the effectiveness of a radiograph to precisely mark the edge. • Resolution: This describes the ability of radiograph to record separate structures that are close together. • Image quality: Overall appearance of radiograph.

65

66 Section 2 

Diagnosis in Pediatric Dentistry Uses of X-ray General uses

• X-rays are used in health sciences for diagnosis and therapeutic purposes • In industries for casting and welding • Used in preservation of food • Spectroscopy – Identification of elements, their atomic number, etc. • Photochemistry – Ionization of chemicals for oxidation and reduction purpose • Radiobiology • Crystallography – Analysis of molecules • Sterilization of instruments • Autoradiography

Dental uses •

• • • • • •

Pedodontic uses

To detect lesions, disease and conditions of the teeth and surrounding structures that cannot be identified clinically To confirm or classify suspected disease To localize lesions or foreign objects To provide information during dental procedures (e.g. root canal therapy) To evaluate growth and development To illustrate changes secondary to caries, disease and trauma To document the condition of a patient at a specific point of time

• • • • • • • • • • • • • • • • • • • • • •

X-RAY MACHINE (FIG. 8.7) Control panel: This consists of an on/off switch, indicator lights, an exposure button and control devices (Time, Kvp, mA) to regulate the X-ray beam. The control panel is plugged into an electrical outlet and appears as a panel or cabinets that are mounted. Extension arm:  The wall mounted extension arm suspends the X-ray tube head and houses the electrical wires. The

Caries Pulp pathology Traumatic injuries Problems of eruption Anomalies of developments Orthodontic evaluation History of pain Evidence of swelling Unexplained tooth mobility Unexplained bleeding Deep periodontal pocket Fistula formation Unexplained sensitivity of teeth Evaluation of sinus condition Unusual spacing or migration of teeth Lack of response to conventional dental treatment Unusual tooth morphology calcification/ color Evaluation of growth abnormality Altered occlusal relationship Aid in diagnosis of systemic disease Family history of dental anomalies Postoperative evaluation

Properties of X-rays • • • • • • •

They are invisible They travel at the same speed of light – 3 × 108 m/sec They travels in a straight line They cannot be deflected They affect photographic plates They produces fluorescence with some substances, e.g. Bariopalladium crystals They can penetrate opaque objects.

purpose of the cathode is to supply the electrons necessary to generate X-rays. Cathode:  Produced the electrons that are accelerated towards the positive anode. This includes tungsten filaments or coiled wire made of tungsten, which produces electrons when heated and a molybdenum cup, which focuses the electrons into a narrow beam and directs the beam across the tube towards the tungsten targets of the anode.

Fig. 8.7: X-ray machine

Anode:  A positive electrode consists of a wafer thin tungsten plate embedded in a solid copper rod with the purpose of converting electrons into X-ray photon. It includes a tungsten target, or plate of tungsten, which serves as a focal spot and

Chapter 8  Radiographic Techniques converts bombarding electron into X-ray photons and a copper stem, which functions to dissipate the heat away from the tungsten target. Amperage:  It is the measurement of the number of electrons moving through a conductor. Voltage:  It is the measurement of electrical force that causes electrons to move from negative pole to a positive one.

INTRAORAL PERIAPICAL RADIOGRAPH TECHNIQUES (FIG. 8.8) Two intraoral projection techniques that are used for peri­ apical radiography are Paralleling technique and Bisecting angle technique.

Paralleling Technique • Also called right angle technique/long cone technique/ Mc Coarmack’s technique/Fitzgerald technique. • Dr Gordan Fitzgerald is the pioneer of this technique. • The primary purpose of this is to obtain a true radiographic orientation of teeth and supporting structures. • It is based on the principle that central ray should be focused perpendicular to long axis of the film with the X-ray film being parallel to long axis of tooth. • To obtain parallelism and to reduce distortion the film is placed away from tooth but the use of long source to object distance reduces the size of the apparent focal spot and leads to less magnification and increased definition. • Film holders are used to ensure proper position of the film and to maintain it in position. • To assure that the periapical areas will be projected onto the film, it is necessary that the film be positioned away from the teeth and towards the center of the mouth, where the maximum height of the palate can be utilized. • For maxillary projections, the superior border of the film will generally rest at the height of the palatal vault in the midline. For mandibular projections, the film will be used to displace the tongue lingually to allow the inferior border of the film to be depressed into the floor of the mouth away from the mucosa on the lingual surface of the mandible (Fig. 8.8).

Key points • • • • • •

Also called long cone technique Pioneered by Gordon Fitzgerald, Father of modern radiology Central ray should be focused perpendicular to long axis of the film with the X-ray film being parallel to long axis of tooth Film holders like XCP are used More accurate In case of children film is placed within 20° of the parallel to the long axis, with the beam directed to the film.

Fig. 8.8: Diagrammatical representation of paralleling technique

• A variety of film holders are used for this technique. Some are XCP (Extended Cone Positioner), precision X-ray instruments, stable bite block and versatile intraoral positioner. • Paralleling principle of intraoral X-ray is technique of choice, because it is more accurate and produces less distortion than bisecting angle technique. • In case of children there is high muscle activity in the mandible and shallow palate thus the film cannot be placed parallel to the long axis of the teeth but it has been demonstrated that even if the film is placed within 20° of the parallel to the long axis, with the beam directed to the film, the radiograph produced by paralleling technique will be far superior than bisecting angle technique.

Advantages • Accurate images can be obtained with minimum magnification. • Interdental bone levels are very well represented. • Periapical tissue will be accurately shown with minimal foreshortening or elongation. • Horizontal and vertical angulations are automatically determined by positioning device. • X-ray beam is aimed correctly at the center of the film and prevents cone cut.

Disadvantages • Positioning of the film packet is very uncomfortable for patient especially in the posterior aspect of teeth, often causing gagging. • Positioning the holder in the mouth will be difficult for inexperienced operators. • Anatomy of mouth sometimes makes the technique difficult. • Positioning the holders in the lower 3rd molar region can be very difficult.

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Bisecting Angle Technique • This technique was promoted by Weston Price in 1904. • Also called Millers Right angle technique/Short cone Technique/Isometric triangulation technique. • This technique is based on the principle of Cieszynsky Rule of Isometry which states that two triangles are equal when they share one complete side and have 2 equal angles. • In this technique, the film is placed close to the teeth and central ray is directed at right angles to the line bisecting the angle formed by the plane of the film and the long axis of the tooth (Fig. 8.9). • Although film holders are not used in this technique for positioning but we have some special film holders like Renn-Snap or Snap-A-Ray that can be used to prevent exposure of patient’s hand, avoid slippage of film in mouth and prevent cone cut. • Angulations of tube head (Figs 8.10A to F): – Horizontal angulation is 0°. – Vertical angulation is different for all teeth. Maxillary : Incisor: +40°, Premolar: +30°, Canine: +45°, Molar: +20° In deciduous: Anterior: +45°, Posterior: +30°

Key points • • •

• •

Also called short cone technique Pioneered by Weston Price Film is placed close to the teeth and central ray is directed at right angles to the line bisecting the angle formed by the plane of the film and the long axis of the tooth More accurate In case of children film is placed within 20° of the parallel to the long axis, with the beam directed to the film.



Mandibular :

Incisor: -15°, Premolar: -10°, Canine: -20°, Molar: -5° In deciduous: Anterior: -15°, Posterior: -10°

Advantages • Positioning of film or film packet will be reasonably comfortable for patient and for operator in all areas of mouth. • Positioning of film is simple and quick. • If we give proper angulation there will not be any distortion of image.

Disadvantages • Improper vertical angulations may lead to shortening or lengthening of image. • Interdental bone less will be poorly demonstrated. • Shadow of zygomatic bone frequently overlies the roots of upper molars. • Horizontal and vertical angles have to be assessed for every exposure, considerable skill is needed. • Cone-cut may result if improper positioning of tube is done. • Incorrect horizontal angulation will result in horizontal overlapping of crowns and roots. • Crowns of teeth are often distorted, thus preventing detection of proximal caries.

SUPPLEMENTARY INTRAORAL RADIOGRAPHIC TECHNIQUE

Bitewing Radiography • Developed by Howard Raper in 1925. • Periapical films are used to record the coronal portions of both maxillary and mandibular teeth in one image (Fig. 8.11). • Size 1 film is used in children and size 2 films are used in adults. • Used mostly to detect interproximal caries and to check the level of bone.

Occlusal Radiography

Fig. 8.9: Diagrammatical representation of bisecting angle technique

• Used to take the jaw radiographs of maxilla and mandible to detect large lesions, fractures, impactions, supernumerary teeth and to localize foreign bodies (Figs 8.12 and 8.13). • The film is partially held in-between teeth and partially supported by patient. • The vertical angulation for maxilla is +45° and for mandible is – 55°.

Chapter 8  Radiographic Techniques

A

B

C

D

E

F Figs 8.10A to F: X-ray tube film placement in IOPA radiograph

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 pecialized Intraoral S Radiographic Technique

Fig. 8.11: Bitewing radiograph

A

• This technique is used exclusively for children as is called bent film radiographic technique. • This technique works well with young children, requires little skill as patient bites down. • Used when young patient do not tolerate the placing of a film holder inside their mouths. • Top portion of the film is bent at right angle and this serves as a bite block to hold the film in place. Patient is instructed to bite the film slowly and radiograph is taken. Care must be taken to straighten the film before processing. • This can be used both with paralleling cone or bisecting angle technique. • Size 1 or 2 film should be used.

B Figs 8.12A and B: Maxillary occlusal radiograph technique and X-ray

A

B Figs 8.13A and B: Mandibular occlusal radiograph technique and X-ray

Chapter 8  Radiographic Techniques

Radiographic Localization Procedure Clark’s Technique (Fig. 8.14) • This is also called as same side lingual – opposite buccal (SLOB) rule, tube shift localization technique or buccal object rule. • It was discovered by Clark in 1910. • To locate or determine the bucco-lingual relation of an impacted tooth/ foreign body within the maxilla. • Buccal object rule states that the image of a buccally oriented object appears to move in the opposite direction from a moving X-ray source. And the image of any lingually oriented object appears to move in the same direction as a moving X-ray source.

RADIOGRAPHIC PROTOCOL When a new patient is seen at the dental office and no previous radiographs are available, it may be necessary to obtain a base line series of radiographs. This is governed by radiographic protocol (Table 8.1). Radiographic examination/survey:  To accomplish the task of radiographic protocol specific X-rays are needed to be done at each age. These X-rays are mostly individualized for each patient and depending upon age and caries may be classified as four, eight, twelve or sixteen film series (Table 8.2). This entire set of X-ray series is called radiographic survey (Fig. 8.15).

Fig. 8.14: Clark’s technique

Miller’s Technique • This is also called right angle technique. • It is used to achieve the same goal as Clark’s technique but in case of mandible.

Cross-sectional Occlusal Radiograph • X-rays are taken at right angles to each other. • Cross-sectional occlusal radiograph of maxilla with patient’s sagittal plane is perpendicular and ala-tragus line is parallel to the floor.

Fig. 8.15: X-ray film series for radiographic survey

TABLE 8.1: Radiographic protocol Age (Yrs) 3–5 Yrs

Considerations

Radiographs

No apparent abnormalities (Open contacts)

None

No apparent abnormalities (Closed contacts)

2 posterior bitewing

Extensive caries

4-film survey

Deep caries

2 bitewing of size 0, 1 selected periapical radiographs in addition to 4-film survey

6–7 Yrs

No apparent abnormalities/Extensive caries

8 film survey/selected periapical X-ray and 8 film survey

8–9 Yrs

No apparent abnormalities/Extensive caries

12 film survey

10–12 Yrs No apparent abnormalities/Extensive caries

12 or 16-film survey

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TABLE 8.2: Radiographic survey Survey

Radiographs

Four film series

Maxillary and mandibular anterior occlusal and two posterior bitewing radiographs

Eight film series

Maxillary and mandibular anterior occlusal (or periapicals), right and left maxillary posterior occlusal (or periapical), right and left mandibular posterior periapicals and two posterior bitewing radiographs

Twelve film series

Two primary molar-premolar periapical radiographs, four canine periapical radiographs, two incisor periapical radiographs, two posterior bitewing radiographs

Sixteen film series

12 film survey, four permanent molar radiographs

PANORAMIC RADIOGRAPHY • It was developed by Dr H Numata (1933). • This is also called orthopantomography/maxillomandi­bu­ lar radiography/pantomography/rotational tomography. • This uses a mechanism by which the X-ray film and the source of the X-rays move simultaneously in opposite direction at the same speed (Fig. 8.16).

Indications • • • • •

Condylar fracture. Traumatic cysts. Evaluation of tooth development (mixed dentition). Developmental anomalies. Disabled child.

Advantages • • • •

Disadvantages • • • •

Fig. 8.16: Orthopantomography radiograph being taken

Broad anatomic region imaged. Relatively low radiation dose. Convenience, speed and ease. Useful in patients who are unable to open mouth.

Lack of image detail for diagnosis of early carious lesion. Cost of X-ray machine Overlaps images of teeth Staying completely immobile for 15 seconds may not be possible for very young children.

Extraoral radiography This is accomplished with the film placed outside the oral cavity and it includes: • Panoramic radiography • Skull projections which include Reverse-Towne, Submentovertex, PA view, PNS view and lateral cephalogram • Hand and wrists radiograph • Cephalometric radiography.

Uses • • • • • • • • • • • • • • • • •

Evaluation of gross carious status. Assessment of advance bone heights. Extensive cystic and tumor cases. Assessment of mixed dentition. Overall assessment of bone pattern. Fractures (trauma). Preliminary assessment of maxillary sinus diseases. General assessments of condyles morphology. Pre- and postoperative evaluation of oral surgical pro­ cedures and orthodontic treatment. Changes in alveolar bone due to systemic diseases like leukemias, Pagets disease. Evaluation of 3rd molars. To assess lesions in edentulous jaws. To assess the radiologic assessment of implant site. Patient who has gagging sensation to intraoral films. Ankylosis of TMJ. Patient’s with restricted mouth opening. Evaluation of tooth development.

Chapter 8  Radiographic Techniques SPECIALIZED RADIOGRAPHY

Xeroradiography • Xeroradiography which is a method of imaging uses the xeroradiographic copying process to record images produced by diagnostic X-rays. • It differs from halide film technique in that it involves neither wet chemical processing nor the use of dark room. • The imaging method was discovered by an American physicist, Chester Carlson in 1937. • Pogorzelska-Stronczak became the first to use xeroradio­ graph to produce dental images with extraoral dental use in cephalometry, sialography, and panoramic xeroradio­ graphy.

Principle

Advantages • Elimination of accidental film exposure: Large light intensity is required for photoconduction and even when there is exposure, the charged area intrinsically gets erased. As a result, there is minimal need for storage for film protection during processing. • High resolution: Xeroradiography has excellent charac­ teristics of the forces around the electrostatic charges which form the latent image. • Simultaneous evaluation of multiple tissues: Because the technique records tissues of differing thicknesses and densities in a xeroradiograph. • Ease of reviewing: Use of reflected or transmitted light is allowed by xeroradiography so image can be mounted either in a transparent plastic sheet or on opaque paper. • Better ease and speed of production: No special skills are required, dark room requirements are unnecessary, and the entire xeroradiographic process may be completed within 60 seconds. • Economic benefit: When compared with halide radiography, the expenditure is one eighth. • Reduced exposure to radiation hazards: Because there is no need to make multiple exposures as tissues of different densities and thicknesses can be recorded in one exposure, patient is at a very low-risk of radiation hazards. • Wide applications: Generally, xeroradiography has interesting applications in the management of neoplasm of laryngopharyngeal area, mammary and joint region, as well as an aid in cephalometric analysis.

Disadvantages • The electrostatic charges in xeroradiographic process stand the risk of being lost in confined humid oral environment • Technical difficulties • Fragile selenium coat • Transient image retention • Slower speed.

Sialography It is the radiographic examination of the salivary glands. It usually involves the injection of a small amount of contrast medium into the salivary duct of a single gland, followed by routine X-ray projections.

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Procedure

Clinical Picture Variable clinical pictures via Sialography can be seen in Figures 8.17 to 8.21.

Hand wrist radiograph The hand-wrist region is made up of numerous small bones which show a predictable and scheduled pattern of appearance, ossification and union from birth to maturity. Thus by comparing a patients’ radiograph with the standards that represent different skeletal ages, we find out the skeletal maturation status of that individual (Detailed in Chapter 13).

Cephalometrics

Indications • In the evaluation of the functional integrity of the salivary glands • In case of obstructions • To evaluate the ductal pattern • In case of facial swellings, to rule out salivary gland pathology • In case of intraglandular neoplasms.

Contraindications • Persons who have allergy to iodine and/or contrast medium • Cases where there is acute infection • Patients with thyroid function tests • When calculi are located in anterior part of the salivary gland duct.

Key points • • • •

Usually the radiographs taken are lateral oblique views of the face Used for diagnosis of foreign body, calculus or tumor in salivary gland Water soluble contrast media include Conray 480, Hypaque, Renagraffin Fat soluble medias are ethiodol and lipiodol.

It is the study of the dental and skeletal relationships in the head and is used by dentists, as a treatment planning tool to evaluate facial growth abnormalities prior to treatment, in the middle of treatment to evaluate progress or at the conclusion of treatment plan (Detailed in Chapter 31).

RADIATION PROTECTION Radiograph for children should be conducted in a way that the chances for harmful effects from the diagnostic exposure are minimized as much as possible. Rigid rules have been replaced with a philosophy of radiation protection called the concept as low as reasonably achievable (ALARA). The concept is one of minimum exposure without specifying a specific dose or level of exposure to radiation that is unacceptable or deemed potentially harmful. There are many effective methods of minimizing exposure to patients and dental office personnel. • Prescribing needed dental radiographs: The first important step in limiting the amount of X-radiation to a patient is proper ordering of radiograph. A dentist should have professional judgment about the numbers, type and frequency of dental radiographs as per the recommended guidelines. • Proper equipment: The dental X-ray tube head must be equipped with appropriate aluminum filters, lead

Variable clinical pictures via Sialography Normal parotid gland Branching structures like tree (Fig. 8.17)

Normal submandibular gland Bush like appearance (Fig. 8.18)

Salivary calculi appearance Filling defect (Fig. 8.19)

Sialadenitis Dots of media between branching of gland (Fig. 8.20)

Sjögren’s syndrome Huge dots of media between branching of gland like cherry blossom appearance (Fig. 8.21)

Chapter 8  Radiographic Techniques

•

•

•

•

Fig. 8.22: Filtration

Fig. 8.23: Collimation

Fig. 8.24: Position indicating device

Fig. 8.25: Thyroid collar

collimator and position indicating device (PID) and no leakage should be present. Aluminum filtration: The purpose of the aluminum filter in the X-ray tube head is to absorb long wavelength, poorly penetrating X-rays that are not useful in producing the radiographic image thus reducing somatic exposure by as much as 57 percent (Fig. 8.22). Lead collimation (Fig. 8.23): A collimator is a lead plate with a hole in the middle and is fitted directly over the opening of the machine housing where the X-ray beam exits the tube head. Collimation is used to restrict the size and the shape of the X-ray beam and to reduce patient exposure. Position indicating device/cone (PID) (Fig. 8.24): Appears as an extension of the X-ray tube head and is used to direct the X-ray beam. Three types of PID are conical, rectangular and round. All these types are further available in long and short types, the former being more useful as it causes less divergence of X-ray. Rectangular cone irradiates 8085 percent less tissue than short circular cones. Thyroid collar (Fig. 8.25): It is a flexible lead shield that is placed securely around the patient’s neck to protect the thyroid gland from scattered radiation. The use of thyroid collar is recommended for all intraoral films and it reduces thyroid gland exposure of primary beam by 50 percent.

Fig. 8.26: Radiographer with lead apron

• Lead apron (Fig. 8.26): It is a flexible shield that is placed over the patient’s/radiographer’s chest and lap to protect the reproductive and blood forming tissues from scattered radiation from reaching these radiosensitive organs. It is recommended for all intraoral and extraoral films. Reduces scattered radiation to 98 percent and minimizes exposure to chest pelvis, long bones, where major portion of hemopoietic systems are located.

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• Fast film: Is the single most effective method of reducing exposure to X-radiation. E-speed is twice as fast as D-speed film and requires only one half the exposure time. • Film holding devices (Fig. 8.27): Helps to stabilize the film position in the mouth and therefore, the patient’s finger is not exposed to unnecessary radiation. • Proper film handling: It is required to produce a diagnostic radiograph and to limit patient’s exposure to radiation. • Correct film processing procedures: Significantly improves the quality of radiograph. Following factors are important to assure the quality of radiograph viz. dark room free from light leaks, adequate dark room safe-lighting and time-temperature processing.

Operator Protection Guidelines Used to provide basic safety information that is needed when working with X-radiation. Operator protection guidelines include recommendation on distance, position and shielding (Fig. 8.28). • Dental radiographer must avoid the primary beam • Stay 6 feet away from X-ray tube during X-ray procedure • Use protective barriers

Fig. 8.27: Film holding devices

• To avoid the primary beam the dental radiographer must be positioned at 90 to 135° angle to the beam • The dental radiographer must never hold a film in place for a patient during X-ray exposure • Never hold a tube head during X-ray exposure • Should stand behind a protective barrier like lead screens • X-ray machine should be monitored for leakage radiation • Amount of X-radiation that reaches the body of the dental radiographer can be monitored by use of personnel monitoring device known as film badge. This should be worn at waist level. After the dental radiographer has worn the film badge for a specific time interval it has to be returned to service company for dosage calculation.

RADIOGRAPHIC INFECTION CONTROL In dental radiography the main concerns arise from saliva contamination of work areas and equipment. Suitable precautions for prevention and spread of any disease are: • Training of staff in infection control procedures. • All clinical staff should be vaccinated. • Open wounds on hands should be covered with waterproof dressings. • Latex gloves should be worn for all radiographic procedures but eye safety protection and masks are not usually necessary. • Gloved hands should be washed under running water. • Before and after X-raying every patient, using a disinfectant such as povidone iodine 7.5 percent, surgical scrub (betadine) or chlorhexidine 4 percent (Hydrex). • All required film packets and holders should be placed on disposable trays to avoid contamination of work surfaces. • To prevent salivary contamination of film packets, they can be placed in small barrier envelopes before use. After use, the film packets can be emptied out of the barriers envelope into a clean surface and then handled safely. • Film packets must only be introduced into daylight loading processors using clean hands or washed gloves. • All film holders/bite blocks/bite pegs should be rinsed after use and then autoclaved or discarded, if disposable.

Common conditions that can spread due to inadequate radiographic infection control •

Fig. 8.28: Design for operator protection

• • • • • • • •

Infective hepatitis caused by hepatitis B(HBV) or hepatitis C virus (HCV) HIV disease and AIDS caused by HIV Cold sores caused by herpes simplex virus Rubella (German measles) Tuberculosis Syphilis Diphtheria Mumps Influenza.

Chapter 8  Radiographic Techniques • X-ray equipment, including tube head, control panel, time switch and cassettes which have been touched should be wiped after each patient with a surface disinfectant like sodium hypochlorite, quaternary ammonium aldehyde or peroxidase.

BEHAVIORAL CONSIDERATIONS IN PEDODONTIC RADIOGRAPHY

Radiographic recommendations for children with disabilities •

• • •

Only radiographic investigations appropriate to the limitations imposed by the patient’s age, cooperation or disability, should be attempted. Select intraoral films of appropriate size, modifying standard techniques as necessary. Utilize assistants to help hold the film. Avoid dental panoramic radiography because the patient will have to sit still for 18 seconds. Oblique lateral radiograph should be regarded as the extraoral view of choice. Use of paralleling technique, if possible for periapical radiography because with this technique the relative positions of film packet, teeth and X-ray beam are maintained irrespective of position of patient’s head.

A radiographic appointment may be a source of anxiety or discomforts for the young patients. New surroundings, separation from parental support and intimidating machinery create an early sense of fear and apprehension. A balance should be established by the pedodontic radiographs between the child’s inner resources and the demands of the appointment. It is believed that radiographs provide a pleasant and painless means of introducing a patient to dental treatment. Any subjective fears of radiography can easily be dissipated by demonstration of taking of radiographs. • Reduce source of unnecessary anxiety. • Motivate the child to do his best to cooperate. • Use minimum number of films and in as short a time as possible. • The communicating principles of tell, show and do and modeling are effective in radiographic appointment. • At the 1st appointment, the interview may be more personal and less intimidating by giving an invitation “to come in while we take pictures of your teeth”. The decision to invite parent depends upon the assessment of the child patient. In the X-ray room, the operation of the chair is demonstrated by giving the child a ride to an appropriate level for filming. The radiographer introduces the protective lead apron as blankets and X-ray unit as camera (Fig. 8.29). It is also helpful to demonstrate the clicking and buzzing sound associated with an exposure before filming begins.

• In the next visit procedures of biting on the film packets may be modelled by the parent or dental assistant or a child of similar age group. • It is sometimes wise to bring the X-ray tube into contact with your own face to dispel any fears a child may have (Fig. 8.30). • A good idea is to have the X-ray tube set at the needed angulation and placed next to child’s face prior to insertion of film. • Allow the patient to inspect and touch the film packet before it is placed in the mouth. • If the child has a tendency to reject the film dampen the film packet. Such dampening takes away taste of the packet. • Do not insert the packet in directly but place the film in a horizontal plane then gently rotate into vertical position. • Before inverting the film, curve it slightly so as not to impinge on lingual tissue. The film should not be forced into the floor of the mouth (Fig. 8.31).

Fig. 8.29: Dentist explaining the X-ray apparatus

Fig. 8.30: Dentist performing TSD

• •

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Diagnosis in Pediatric Dentistry Clinical significance of radiography in pediatric dentistry

Fig. 8.31: Dampening and bending of film

Fig. 8.32: Modeling during X-ray procedure

Fig. 8.33: Parent lap X-ray technique

I. Pathologic evaluation • Caries detection • Traumatic injuries – Fractured roots or crowns – Fractured alveolar bone – Displaced tooth – Tooth or bone embedded in soft tissue • Degree of pulpal involvement – Proximity of caries to pulp horn – Internal resorption – Calcific degeneration • Periodontal diseases – Thickening of periodontal membrane – Furcation involvement – Periapical infection – Bone loss – External resorption II. Developmental factors • Stages of development • Root formation • Physiologic root resorption • Bony support • Stages of eruption and exfoliation III. Degree of pulp maturity • Size of pulp chamber, size of pulp canals • Amount of apical closure • Location of pulp horns IV. Developmental anomalies • Widely divergent roots • Sharply curved pulp canals • Number and length of roots • Ectopic positioned roots • Ankylosis • Supernumerary teeth • Congenitally missing teeth • Malformed teeth – Microdontia and macrodontia – Dens in dente – Taurodontism – Gemination, fusion – Root dilacerations V. Postoperative results of dental treatment • Accuracy of restoration • Type and success of pulp treatment • Postsurgical healing • Treatment failure

• To ensure an initial success the easiest areas are radiographed first like anterior films. • For posterior projections some form of film holding device is recommended. • The observation of other children getting exposed for radiograph reduces anxiety and increases cooperation in young patients. Imitation or modeling as it is called is

Chapter 8  Radiographic Techniques most effective when the model performs successfully and is reinforced for his behavior (Fig. 8.32). • Movements must be minimized and the child should be asked to focus on a wall objects so that his eyes do not follow the operator when he leaves the room. Once the film is placed, the dentist slowly counts to ten and in the mean time the operator completes his cone-positioning moves to his safe position and exposes the film.

• If the patient is very un-cooperative it is also advisable to take the radiographs while the patient is seated in parent’s lap (Fig. 8.33). The importance of radiographs in dentistry needs no elaboration. It is important to realize that taking of radiographs often is a part of child’s first dental experience which must be a pleasant experience so as to make him a good dental patient.

POINTS TO REMEMBER • Radiology: The science or study of radiation as used in medicine, a branch of medical science that deals with the use of X-rays, radioactive substances and other form of radiant energy in the diagnosis and treatment of disease. • Dental radiograph: A photographic image produced on film by the passage of X-ray through teeth and related structure. • The X-ray was discovered in November 1895 by Wilhelm Conrad Roentgen. • Dr Otto Walkhoff a dentist in Germany made the first dental use of an X-ray and radiographed a lower premolar. • Properties of X-rays: They are invisible, travel at the same speed of light – (3 × 108 m/sec), travel in a straight line, cannot be deflected, affect photographic plates, produces fluorescence with some substances. • Parelleling cone technique was pioneered by Gordon Fitzgerald. In this central ray should be focused perpendicular to long axis of the film with the X-ray film being parallel to long axis of tooth. • In bisecting angle the film is placed close to the teeth and central ray is directed at right angles to the line bisecting the angle formed by the plane of the film and the long axis of the tooth. • Vertical angulations of tube head in maxillary - Incisor: +40°, Premolar: +30°, Canine: +45°, Molar: +20° and in deciduous: Anterior: +45°, Posterior: +30°; Mandibular - Incisor: -15°, Premolar: -10°, Canine: -20°, Molar: -5° and in deciduous: Anterior: -15°, Posterior: -10°. • Clark’s tube shift technique or localization procedure is to locate or determine the bucco-lingual relation of an impacted tooth/foreign body within the maxilla. • SLOB rule: Buccal object rule states that the image of a buccally oriented object appears to move in the opposite direction from a moving X-ray source. And the image of any lingually oriented object appears to move in the same direction as a moving X-ray source. • Panoramic radiography was developed by Dr H Numata (1933) and is used for diagnosis of traumatic injuries, cysts, evaluation of dentition and anomalies. • Xeroradiography which is a method of imaging uses the xeroradiographic copying process to record images produced by diagnostic X-rays. • Radiographic protection can be done by prescribing needed dental radiographs, maintaining proper equip­ment: By aluminum filtration, by lead collimation, use of position indicating device, thyroid collar, wearing lead apron, using fast films and film holding devices • Behavioral modification for pedodontic patient is done by motivating the child: use minimum number of films: communicate using tell, show and do: modeling and euphemisms: use the X-ray on similar age group child to show or even take in parents lap: dampen and curve the film: take anterior radiographs first.

QUESTIONNAIRE

1. 2. 3. 4. 5. 6. 7.

Discuss the history and discovery of X-rays. Describe the uses of X-rays. What are the ideal requisites of an radiograph? Describe the role of radiographs in pediatric dentistry. What is 12 film survey? Explain radiographic protocol. Describe the diagram and working of X-ray unit.

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8. Discuss paralleling and bisecting angle radiographic techniques. 9. What are radiographic localization procedure? 10. Write a note on xeroradiography. 11. What are different radiographic views visible on sailography of common pathological conditions? 12. Describe the patient and operator radiation protection guidelines. 13. Behavioral modifications for radiology in case of pediatric dentistry.

BIBLIOGRAPHY 1. Arav L. Radiographic examination in pediatric dentistry. A review. NY State Dent J. 1991;57(2):36-7. 2. Browne RM, Edmondson HD, Rout PGJ. Atlas of dental and maxillofacial radiology and imaging. St Louis: Mosby-Wolfe; 1995. 3. Christopher I Udoye, Hamid Jafarzadeh. Xeroradiography: Stagnated after a Promising Beginning? A Historical Review. Eur Journ Dentistry. 2010;4(1):95-9. 4. Espelid I, Mejàre I, Weerheijm K. EAPD guidelines for use of radiographs in children. Eur J Paediatr Dent. 2003;4(1):40-8. 5. Goaz PW, White SC, Pharoah MJ. Oral radiology; principles and interpretation, 4th edn. St Louis; Mosby; 2000. 6. Langland OE, Langlais RP, McDavid WD, Delbal S. Panoramic radiology. 1988. 7. Mason RA, Bourne SA. Guide to dental radiography. London: Oxford Medical Publications; 1998. 8. Razmus TF, Williamson GF. Current oral and maxillofacial imaging. Philadelphia: WB Saunders; 1996. 9. Richardson PS. Panoramic radiographic screening: a risk-benefit analysis. Prim Dent Care. 1997;4(2):71-7. 10. White SC. Assessment of radiation risk from dental radiography. Dentomaxillofac Radiol. 1992;21(3):118-26.

9

Chapter

Digital Radiographic Diagnosis Nikhil Marwah, Gopakumar R

Chapter outline • •

Digital Imaging Radiovisiography

• •

Digital or electronic imaging was first made known to dentistry in 1984 when RVG was invented by Dr Francis Mouyens. This type of technique was first described in literature in 1989 and since then its use in dentistry has increased manifold. In the early days, digital radiograph was achieved by digitizing the film by camera or scanner which led to considerable loss of image properties but today we have digital imaging. This can

Terminologies of digital imaging • • • • •

Brightness: Digital equivalent to density or overall degree of image darkening Dynamic range: Numerical range of each pixel or shades of gray that can be represented Linearity: Direct relation between exposure and image density Contrast resolution: Ability to differentiate small differences in density as displayed on image Spatial frequency: Measure of resolution

Digora System Advancements in Dental Imaging

be either of direct–CCD (charged couple device) or indirect– PSP (photo stimulable phosphor) type (Table 9.1).

DIGITAL IMAGING This can be classified into two types, viz. direct and indirect digital imaging which function on the principle mentioned in Flow chart 9.1.

Advantages of Digital Imaging • Digital image is a dynamic image so its contrast, density can be changed according to the diagnostic task. • The digital receptors have wider latitude so in principle should reduce the number of retakes. • PSP is more flexible and is cordless so is easy to place. • Only 5 to 50 percent of the dose is needed so there is a definitive exposure reduction.

TABLE 9.1:  Intraoral receptor comparisons of digital imaging Feature

Film

CCD

PSP

Radiation dose

High

Low

Low

Generation of image

Chemical

Computer

Scanner, computer

Image viewing

Delayed on illuminator view-box

Instant on computer

Delayed on computer

Resolution

16–20 lp/mm

8–10 lp/mm

6–8 lp/mm

Construction

Thin, flexible

Thick, rigid

Thin, flexible

Lifespan

Single

Reusable

Reusable after erasure

Infection control

Drop out

Barrier

Barrier

Image enhancement

Fixed

Multiple operation

Multiple operations

Storage

Patient record

CPU, CD

CPU, CD

82 Section 2 

Diagnosis in Pediatric Dentistry Flow chart 9.1:  Digital imaging (Direct and indirect)

• • • • •

Elimination of processing chemicals Working time is reduced by instant image production Patient education Easy storage Safest method with reduced exposure.

Disadvantages of Digital Imaging • • • • •

Increased rigidity and thickness of sensor in case of CCD Unknown lifespan of sensor High cost Care of usage Inability to perform complete infection control.

RADIOVISIOGRAPHY • Radiovisiography (RVG) was invented by Dr Francis Mouyens in 1981 and introduced commercially in 1989. • Original system was useful in diagnosis of occlusal and approximal caries only whereas the periodontal assessments have been made possible recently with invention of second generation system. • RVG comprises of four basic components, viz. X-ray set with electronic timer, an intraoral sensor, a display processing unit (DPU) and a printer (Table 9.2). • The original system, which was based on digital hardware without a microprocessor, will be referred to as Mark 1.

• An initial second generation (Mark 2) system, outwardly identical to the second generation system, was based on a 32-bit software driven central processing unit, but failed to achieve abilities of Mark 1 system. The first Mark 2 lacked the memory to use fully the resolving power of the sensor chip, and the number of grey levels which could be displayed on the monitor screen was only 64 compared with 256 in the Mark 1 model. Improvements to the system resulted in the second Mark 2 (available in some countries as a mobile unit).

Advantages of RVG • • • • •

Substantial dose reduction Production of instantaneous images Control of contrast Ability to enlarge specific areas, which may be of use in visualizing instrument location during endodontic treatment The potential for computer storage and subsequent transmission of the images.

Disadvantages of RVG • •

•

Sensor size and its greater thickness than conventional film There also appears to be a loss of resolution of the RVG image from the screen to the videoprint due to the transfer of the signal from the DPU to the printer Cost of equipment.

Chapter 9  Digital Radiographic Diagnosis TABLE 9.2:  Components of RVG System X-ray Set

Intraoral Sensor

Display-processing Unit (DPU)

Video Printer

• A  conventional X-ray tube with generation operating at 70 kVp for use with the RVG system (Fig. 9.1). • T his is connected to a microprocessor-controlled timer which allows very short exposure time of 0.02 sec. • T he timer and X-ray set may also be used for conventional intraoral radiography.

• T he original intraoral sensor supplied with the Mark 1 system was approximately 40 × 22 × 14 mm. • The sensor houses a rare-earth intensifying screen which is optically coupled to an array of charge-coupled devices (CCD). • In the Mark 2 system, both normal and ‘zoom high’ resolution (ZHR) was available. • The updated sensor supplied with the Mark 3 has a 25 percent larger sensitive area and less thickness by 16 percent (Fig. 9.2). • A waterproof sensor has been developed which can undergo ‘cold sterilization’ procedures.

• T he analog signal obtained from the CCD after radiation exposure is stored in this unit and converted pixel by pixel into discrete gray levels. • The CCD receiver (originally 256 × 256 pixels, upgraded to 480 × 380 in the Mark 3 system), together with digitizing boards and an 8 bit processor, allows up to 256 levels of gray to be obtained. • In the Mark 2 system, more flexible digital image processing was available along with facility for storing the image data by transmission to a microcomputer. • The Mark 3 model uses a 13-inch color VGA monitor (Fig. 9.3). • The main distinction between the two Mark 3 models is that the ‘stand-alone’ version can be used as such, or may be connected to a compatible PC and used with appropriate software.

• T he original video printer sold in the UK with the Mark 1 system was manufactured by Sony (Sony Corporation, Tokyo, Japan). • A Dry Silver Imager (3M United Kingdom) was used in the Mark 2 mobile unit • The digital graphic printer used with the Mark 3 system is also manufactured by Sony (Fig. 9.4).

Fig. 9.1:  X-ray set

Fig. 9.2:  Intraoral sensor

Fig. 9.3:  Display processing unit

Fig. 9.4:  Video printer

• Very recent developments have resulted in two new RVG (third generation or Mark 3) systems: a ‘stand-alone’ and a ‘PC’ version.

Features of RVG • Image enhancement: The ‘gray-window’ effect, alter­ natively described as the ‘X-function’, allows the operator to select and expand on a specific 60 levels of gray from the 256 available and may aid in diagnosis of accessory root canals. It has also been demonstrated that, using this mode, RVG is as sensitive as conventional radiography for detecting occlusal and approximal caries in vitro in noncavitated teeth. Improvements in the computer boards and further developments of the software available allowed an extensive range of image configurations for use with the Mark 2, which have been integrated into

the third generation. The image can be electronically enhanced by smoothing, edge enhancement and edge detection. A millimeter grid has been incorporated into the Mark 3 system and may prove to be an additional aid when positioning instruments during root canal therapy. The use of pseudo-color, available as part of the Mini-Julie software and integrated in the Mark 3 system. This feature assigns different colors to certain gray levels and can help to visualize particular features unclear on images and also helps in communication with patients. • Radiation dose: Current radiation protection regulations recommend the use of the fastest available films consistent with satisfactory diagnostic results. Horner, Walker determined the radiation dose on the RVG setting on the Mark1 system to be 23 percent of that required for D-speed film or 41 percent of the dose required for exposure of E-speed film.

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• Resolution: The limiting resolution of the Mark 1 system was estimated to be 5 to 6 line pairs/mm in normal mode and 7 to 8.5 line pairs/mm in ‘zoom’ mode 2. The introduction of the ZHR function increased the resolution to 11 line pairs/mm in this mode. In the Mark 3 and the subsequent deletion of the ZHR function, the resulting resolution of the system is 9 line pairs/mm. In vitro and in vivo experiments suggest that, although this is inferior to the resolution achieved by conventional X-ray films, it is adequate for most diagnostic tasks. • Collimation: Incorporating rectangular collimation to the RVG sensor would permit a further decrease in radiation dose. Comparatively little has been published regarding the recently developed (and rapidly developing) digital imaging dental radiographic system known as radiovisiography. The RVG has considerable merit, although it is constrained by certain limitations. Significant improvements in the hardware have occurred and results in vitro for some applications are promising. However, full clinical evalua­ tions across a range of dental applications are required, as are further studies.

Key points • • • • •

Digora was introduced in 1994 Den Optix is the new modification High quality image which can be enhanced Linear measurements are possible Display of histograms is possible

• The Digora image plate system is an alternative, with fundamentally different digital image acquisition from that of CCD systems. • Digora was introduced in 1994 and it provides two sizes of imaging plates comparable with the size = 0 and = 2 film. • A single plate can be scanned for approximately 30 seconds. • In 1997, the Den Optix system was introduced. The system has five sizes of imaging plates which are mounted in a carousel which can hold up to 29 imaging plates for scanning.

• With the Digora system (Figs 9.5A and B), the anatomic area displayed is almost the same as that shown in modern film-based technology. • Read out of the image plate takes less than 30 seconds, during which the image gradually appears on the computer monitor. • The exposure range of the image plate is wide and linear. Because of the expended exposure range, the high sensitivity of the image plate and the high quality of modern photo multiplier tubes, the image plate system can acquire data over many orders of magnitude in exposure compared to CCD or film systems. • As with the other digital systems the Digora images can be altered after exposure to enable task specific image characteristics. • The system works in a Microsoft Windows environment, which simplifies all operating procedures. Image bright­ ness and contrast can be changed by moving and angulating, respectively, a line displayed in a coordinate system where the gray level values in the original image are seen on the X-axis and Y-axis respectively. • The image processing software allows edge enhancement and gray-scale inversion. • In addition, different types of measurements, such as measurements of linear distances (in tenths of millimeters) and angles, can be performed. All values are displayed on the screen.

A

B

DIGORA SYSTEM

Figs 9.5A and B:  Digora system and display

Chapter 9  Digital Radiographic Diagnosis • It is possible to display a histogram of the distribution of the gray levels within a chosen area, the mean gray level value and the deviation around the mean.

ADVANCEMENTS IN DENTAL IMAGING There have been enormous technological advances in medical and dental radiographic imaging over the past several decades encompassing the introduction of electronic image detectors, hardware and software developments, and the introduction of magnetic resonance and radionuclide imaging.

Magnetic Resonance Systems Imaging and analysis using Magnetic Resonance (MR) bring exciting possibilities to oral biology research. Not only is it possible to image without concern about radiation dose, but it is also possible to analyze cellular functions in vivo, virtually noninvasively. • Used for lesions of the extracranial head and neck. • Imaging are tumors of the skull base, paranasal sinuses, nasopharynx, parapharyngeal space, and carcinomas of the oral cavity, pharynx and larynx. • Superior sensitivity in detecting small lesions • More accuracy in staging the lesion and narrowing the diagnostic possibilities.

Nuclear Imaging The advent of clinical nuclear imaging occurred in the early 1950’s, when radiopharmaceuticals were first used to localize radioactive molecules in specific organs for diagnostic pur­ poses. Bone-seeking radiopharmaceutical uptake provided a mechanism for the visualization of physiologic alterations in bone metabolism and blood flow rate, in contrast to standard radiography, wherein imaging was based on the absorption of externally applied X-rays by the patient and the recording of the remnant beam on film. • Useful in diagnosis of disease in the oral and maxillofacial region. • Positron emission tomography (PET) was a test with a good predictive value for identifying recurrent malignancies in the head and neck when used in conjunction with CT. • The high sensitivity of nuclear bone imaging makes this procedure valuable in the initial detection of subtle bone fractures that are not readily apparent on standard radiographs. • Nuclear imaging has been reported to be useful in the evaluation of bone metabolism in bony components of the temporomandibular joint, for assessment of facial skeletal growth.

Computed Tomography J Radon, 1917 was the first person to lay the foundation for such an imaging and later in 1972, the first clinical computed tomography X-ray unit was developed by GN Hounsfield in England. Computed tomography (CT) uses X-rays to portray across-sectional image of an object without superimpositions. The CT scanner makes multiple projections of an object, radiation detectors measure the object’s X-ray attenuation at each of these projections, and a computer reconstructs the attenuation data to produce a cross-sectional image, or “slice”, of the object. Applications of Computed Tomography • Computed tomography can be useful for the study of anatomic or pathologic structure. • It is useful for diagnosis, treatment planning, and postoperative follow-up of patients with craniofacial anomalies. • CT may be used for the noninvasive estimation of bone mass • It has been used for the study of salivary gland disease • Used in the assessment of traumatic injuries to the skeleton. • Used in dental implant treatment planning Disadvantages of Computed Tomography • High radiation dose relative to that of plain-film radiography • High cost • Relatively long time of image acquisition.

Spiral CT Tomography had been one of the pillars of radiologic diagnostics until the 1970s when the availability of minicomputers and of transverse axial scanning method (due to the work of Godfrey Hounsfield and Allan McLeod Cormack) gradually supplanted it as the modality of CT. The technique of “Dental CT” also called as “Dentascan” was developed by Schwartz et al. (1987) when these investigators first used curved multiplanar reconstructions of the jaw. Existing diagnostic methods such as the computerized transverse axial scanning (CT) greatly facilitates access to the internal morphology of the soft tissue and skeletal structures. Recently, a newer CT technique, Spiral Computed Tomography (SCT) or volume acquisition CT has been developed which employs simultaneous patient translation through the X-ray source with continuous rotation of the source detector assembly, SCT acquires raw projection data with a spiral-sampling locus in a relatively short period and without any additional scanning time, these data can be viewed as conventional transaxial images, such as multiplanar reconstructions, or as three dimensional reconstructions. With SCT, it is possible to reconstruct overlapping structures at arbitrary intervals and thus the ability to resolve small objects is increased.

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86 Section 2 

Diagnosis in Pediatric Dentistry

Cone-Beam CT Technology Cone beam computed tomography (or CBCT) is an imaging technique consisting of X-ray computed tomography where the X-rays are divergent, forming a cone. Attilio Tacconi, Piero Mozzo, Daniele Godi and Giordano Ronca are the pioneers of this technology. CBCT allows the creation in “real time” of images not only in the axial plane but also 2-dimensional (2D) images in the coronal, sagittal and even oblique or curved image planes — a process referred to as multiplanar reformation (MPR). In addition, CBCT data are amenable to reformation in a volume, rather than a slice, providing 3-dimensional (3D) information. CBCT scanners are based on volumetric tomography, using a 2D extended digital array providing an area detector. This is combined with a 3D X-ray beam. The cone-beam technique involves a single 360° scan in which the X-ray source and a reciprocating area detector synchronously move around the patient’s head, which is stabilized with a head holder. At certain degree intervals, single projection images, known as “basis” images, are acquired. This series of basis projection images is referred to as the projection data. Software programs incorporating sophisticated algorithms including back-filtered projection are applied to these image data to generate a 3D volumetric data set, which can be used to provide primary reconstruction images in 3 orthogonal planes (axial, sagittal and coronal). The first system introduced was NewTom QR DVT 9000 (Quantitative Radiology s.r.l., Verona, Italy) introduced in April 2001 and the two currently used systems are 3D Accuitomo – XYZ Slice View Tomograph (J Morita Mfg Corp., Kyoto, Japan) and i-CAT (Xoran technologies, Ann Arbor, Mich., and Imaging Sciences International, Hatfield, PA).

Advantages of CBCT • Cone-Beam Computed Tomography (CBCT) is well suited for imaging the craniofacial area. • It provides clear images of highly contrasted structures and is extremely useful for evaluating bone. • X-ray beam limitation as the effective patient dose to approximately that of a film-based periapical survey of the dentition.

• Because CBCT acquires all basis images in a single rotation, scan time is rapid (10–70 seconds). • Reconstruction of CBCT data is performed natively by a personal computer. In addition, software can be made available which provides the clinician with the opportunity to use chair-side image display, real-time analysis. • CBCT images can result in a low level of metal artifact, particularly in secondary reconstructions designed for viewing the teeth and jaws.

Disadvantages of CBCT • Increased susceptibility to movement artifacts. • Lack of appropriate bone density determination. • Dental CBCT systems do not employ a standardized system for scaling the grey levels that represent the reconstructed density values and, as such, they are arbitrary and do not allow for assessment of bone quality.

Uses of CBCT • • • • • •

Implantolgy – To assess osseointegration – To determine quality of bone – To check the relation of implant – During surgical guidance Maxillofacial surgery – To diagnose tumors, impacted teeth, fractures – To identify relation of teeth with nerve canals – Cystic lesions and delimitations – Traumatic injuries to teeth Orthodontics – Planning of orthognathic surgery – Cephalometric analysis Endodontics – In diagnosing of periapical lesions – Identification of canals – Endodontic surgery Pediatric dentistry – Temporomandibular Joint (TMJ) evaluation – Evaluation of growth – In cleft cases Periodontology – Bone lesions and healing

POINTS TO REMEMBER • Dr Francis Mouyens in 1981 invented RVG. • Original system was useful in diagnosis of occlusal and approximal caries only whereas now they have high usage in endodontics. • RVG comprises four basic components, viz. X-ray set with electronic timer, an intraoral sensor, a display processing unit (DPU) and a printer.

Chapter 9  Digital Radiographic Diagnosis • The original system, which was based on digital hardware without a microprocessor, will be referred to as Mark 1. This was followed by Mark 2 an recent developments have resulted in two new RVG (third generation or Mark 3) systems: a ‘standalone’ and a ‘PC’ version. • The advantages of RVG are substantial dose reduction, production of instantaneous images, control of contrast, ability to enlarge specific areas, potential for computer storage and subsequent transmission of the images. • Digora was introduced in 1994 and the most advantageous aspect of this is the possibility of linear measurements.

QUESTIONNAIRE 1. 2. 3. 4.

What are the types of intraoral receptors? Explain the principle of digital imaging. Discuss in detail the components, functions and uses of RVG. Explain the Digora system.

BIBLIOGRAPHY 1. Analoui M, Stookey GK. Direct digital radiography for caries detection and analysis. Monogr Oral Sci. 2000;17:1-19. 2. Borg E, Attaelmanam A, Grondahl HG. Image plate system differ in physical performance. Oral Surg Oral Med Oral Path Oral Radiol Endod. 2000;89(1):118-24. 3. Cederber RA, Tidwell E, Frederiksen NL. Endodontic working length assessment: comparison of PSP and film. Oral Surg Oral Med Oral Path Oral Radiol Endod. 1998;85(3):325-8. 4. C Grace Petrikowski. Introducing digital radiography in the dental office: an Overview. J Can Dent Assoc. 2005;71(9):651. 5. De Vos, W, et al. Cone-beam computerized tomography (CBCT) imaging of the oral and maxillofacial region: A systematic review of the literature. Int J Oral Maxillofac Surg. 2009;38:609–25. 6. Fossum ER. Active pixel sensors. SPIE. 1993;1900:2-14. 7. Freedman ML, Lurie AG, Reiskin AB (Ed). Advances in oral radiology. St Louis: Mosby-Year Book; 1980. 8. Matteson SR, Deahl ST, Alder ME, Nummikoski PV. Advanced imaging methods. Crit Rev Oral Biol Med. 1996;7(4):346-95. 9. Miles DA. Imaging using solid state detectors. In Advances in dental imaging. Dent Clin North Am. 1993;37(4):531-40. 10. Mouyen M, Benz C, Sonnabend E. Presentation and physical evaluation of radiovisiography. Oral Surg Oral Med Oral Path. 1989;68(2): 238-42. 11. Parks ET, Williamson GF. Digital radiography: An overview. J Contem Dent Pract. 2002;3(4):23-39. 12. Russell M, Pitts NB. Radiovisiography: an update. Dental update: anniv issue. 1993.pp.141-4. 13. Sanderink GC, Miles DA. Intraoral detectors. In Miles DA (Ed): Applications of digital imaging modalities of dentistry. Dent Clin North Am. 2000;44(2):249-55. 14. Swennen GRJ, Schutyser F. Three-dimensional cephalometry: spiral multislice vs cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2006;130:410–6. 15. Van der Stelt PF. Digital radiology: deficiency, failures and other adventures. Dentomaxillofac Radiol. 1995;24: 67-8. 16. Van der Stelt PF. Digital radiology using the Digora registration technique. Rev Belge Med Dent. (1984). 1996;51(2):93-100. 17. Van der Stelt PF. Improved diagnosis with digital radiography. Editorial review. Orthodont Pedodont. 1992;2:1-6. 18. Vannier MW. Craniofacial computed tomography scanning: technology, applications and future trends. Orthod Craniofac Res 2003:6(Suppl 1):23–30 discussion 179–182. 19. Versteeg CH, Sanderink GC, Van der Stelt PF. Efficacy of digital intra-oral radiography in clinical dentistry. J Dent. 1997;25(3-4):215-24. 20. Wallace JA, Nair MK, Colaco MF. Comparative evaluation of diagnostic efficacy of film and digital sensors for detection of simulated periapical lesions. Oral Surg Oral Med Oral Path Oral Radiol Endod. 2001;92(1):93-7. 21. Wenzel A. Digital radiography and caries diagnosis. Dentomaxillofac Radiol. 1998;27(1):3-11. 22. Whaites E, Brown J. An update on dental imaging. Br Dent J. 1998;185 (11–12):558-9.

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3

Section

GROWTH AND DEVELOPMENT

This section deals regarding different theories of growth, milestone development of children, embryology/prenatal and postnatal development of head and face, along with different factors influencing growth.

10

Chapter

Developmental Milestones in Children Ravi GR, Nikhil Marwah, Ravichandra KS

Chapter outline • • •

Gross Motor Milestones Fine Motor Milestones Language Milestones

“Infants (and children) are very orderly in their ways; they actually behave (and develop) according to laws that can be explored, discovered, confirmed, reconfirmed, and celebrated.” —Lipsitt LP Infancy and childhood are dynamic periods of growth and development wherein the neural and physical growth proceed in a sequential and predictable pattern under the influence of predetermined intrinsic factors. The skills progress from cephalic to caudal; from proximal to distal; and from generalized, stimulus-based reflexes to specific, goal-oriented reactions that become increasingly precise. By convention, these neurodevelopmental “laws” or sequences often are described in terms of the traditional developmental milestones. The different types of developmental milestones include gross motor, fine motor, problem-solving, receptive language, expressive language, and social-emotional milestones. These milestones provide a framework for observing and monitoring a child over time. A thorough understanding of the normal or typical sequence of development in all these domains will aid the clinician to derive a correct overall impression of a child’s true developmental status. Although neurodevelopment follows a predictable course, yet each child’s developmental path is unique due to the variations produced by both the intrinsic and extrinsic forces. Intrinsic influences include genetically determined attributes (e.g. physical characteristics, temperament) as well as the child’s overall state of wellness. Extrinsic influences during infancy and childhood originate primarily from the family. Parent and sibling personalities, the nurturing methods used

• • • •

Social Milestones Emotional Milestones Developmental Red Flags Tests to Assess Developmental Milestones

by caregivers, the cultural environment, and the family’s socioeconomic status with its effect on resources of time and money all play a role in the development of children.

GROSS MOTOR MILESTONES (TABLE 10.1) • The ultimate goal of gross motor development is to gain independent and volitional movement. • During gestation, primitive reflexes develop and persist for several months after birth to prepare the infant for the acquisition of specific skills. • These brainstem and spinal reflexes are stereotypic move­ ments generated in response to specific sensory stimuli. Examples include the Moro (Fig. 10.1), asymmetric tonic neck (Fig. 10.2), and positive support reflexes. TABLE 10.1: Key development milestones: Gross motor Age

Milestone

3 months

Neck holding

5 months

Sitting with support

8 months

Sitting without support

9 months

Standing with support

10 months

Walking with support

11 months

Crawling (Creeping)

12 months

Standing without support

13 months

Walking without support

18 months

Running

24 months

Walking upstairs

36 months

Riding tricycle

92 Section 3 

Growth and Development

Fig. 10.1: Moro reflex: This reflex occurs spontaneously to loud noises which produces sudden extension and abduction of the upper extremities with hands open, followed by flexion of the upper extremities to midline (the “startle reflex”)

Fig. 10.2: Asymmetric tonic neck reflex (ATNR). With active or passive head rotation, the baby extends the arm and leg on the face side and flexes the extremities on the contralateral side (the “fencer posture”)

Fig. 10.3: Stable seating position (6 months)

Fig. 10.4: Child takes support to stand up (9 months)

• As the central nervous system matures, these reflexes are inhibited which in turn enables the infant to make purposeful movements. For example, Moro reflex interferes with head control and sitting equilibrium. As this reflex lessens and disappears by 6 months of age, the infant gains progressive stability in a seated position (Fig.  10.3). • Higher cortical centers mediate the development of equilibrium responses and permit the infant to pull to stand by 9 months of age (Fig. 10.4) and begin walking

by 12 months. Additional equilibrium responses develop during the second year after birth to allow for more complex bipedal movements, such as moving backward, running, and jumping. • By 18 months of age a child can do a well-coordinated movement that includes rapid change of direction and speed (Fig. 10.5). Simultaneous use of both arms and legs occurs after successful use of each limb independently. • At age 2 years, a child can kick a ball, jump with two feet off the floor, and throw a big ball overhand (Fig. 10.6).

Chapter 10  Developmental Milestones in Children

Fig. 10.5: Ability of child to do multidirectional movement (18 months)

Fig. 10.6: Kick ball and play (2 years)

• By the time a child starts school, he or she is able to perform multiple complex gross motor tasks simultaneously (such as pedaling, maintaining balance, and steering while on a bicycle) (Fig. 10.7). • During the first postnatal year, an infant thus moves from lying prone, to rolling over, to getting to hands and knees, and ultimately to coming to a seated position or pulling to stand (Fig. 10.8).

FINE MOTOR MILESTONES (TABLE 10.2) • Fine motor skills are concerned with the use of the upper extremities to engage and manipulate the environment. These skills are necessary to perform self-help tasks, to play, and to accomplish work. • At birth, infants do not have any apparent voluntary use of their hands. They open and close them in response to touch and other stimuli, but movement otherwise is dominated by a primitive grasp reflex (Fig. 10.9). • As the primitive reflexes decrease, infants begin to prehend objects voluntarily, first using the entire palm toward the ulnar side (5 months) and then predominantly using the radial aspect of the palm (7 months) (Fig. 10.10). • Infant learns to transfer objects from one hand to the other, first using the mouth as an intermediate stage (5 months) and then directly hand to hand (6 months). Between 6 months and 12 months of age, the grasp evolves to allow for prehension of objects of different shapes and sizes. The thumb becomes more involved to grasp objects,

Fig. 10.7: Maintaining balance, steering on a bicycle

TABLE 10.2: Key development milestones: Fine motor Age

Milestone

4 months

Grasps a rattle or rings when placed in hand

5 months

Reached out to an object and holds it with both hands (international reaching with bidextrous grasp)

7 months

Holding objects with crude grasp from palm (palmar grasp)

9 months

Holding small object, like a pellet, between index finger and thumb (pincer grasp)

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Growth and Development

Fig. 10.8: Chronologic progression of gross motor development

Fig. 10.9: Primitive Grasp reflex

using all four fingers against the thumb (a “scissors” grasp) at 8 months, and eventually to just two fingers and thumb (radial digital grasp) at 9 months. A pincer grasp emerges as the ulnar fingers are inhibited while slightly extending and supinating the wrist. By 10 months of age,

Fig. 10.10: Firm grasp (5 months)

infants can release a cube into a container or drop things onto the floor (Fig. 10.11). • As infants move into their second year, their mastery of the reach, grasp, and release allows them to start using objects as tools. Fine motor development becomes

Chapter 10  Developmental Milestones in Children

Fig. 10.11: Development of grasp

Fig. 10.12: Independent eating (20 months)

more closely associated with cognitive and adaptive development, with the infant knowing both what he or she wants to do and how he or she can accomplish it. Intrinsic muscle refinement allows for holding flat objects, such as crackers or cookies. By 15 months of age, voluntary release has developed further to enable stacking of three to four blocks and releasing small objects into containers. The child starts to adjust objects after grasping to use them properly, such as picking up a crayon and adjusting it to scribble spontaneously (18 months of age) and adjusting a spoon to use it consistently for eating (20 months of age) (Fig. 10.12). • By 36 months of age, they can draw a circle, put on shoes, and stack 10 blocks. They make snips with scissors by alternating between full-finger extension and flexion. Their grasp and in-hand manipulation skills allow them to string small beads and unbutton clothes and wash hands independently (Fig. 10.13). • By the age of 5 years, child can dress and undress independently, brush the teeth well, and spread with a knife (Fig. 10.14).

Fig. 10.13: Washing hand independently

LANGUAGE MILESTONES (TABLE 10.3) • Infants communicate long before they speak their first words or phrases. At birth, crying is the primary form of communication. It is nonspecific but very effective in initiating a response from a caregiver. • In a trial-and-error process, the infant begins making vowel and consonant sounds that she can put together into “mama” and “dada” by 9 months of age. Although she is not using the words discriminately, if her caregivers respond to the sounds she makes, she will continue to use them. • By the first birthday the child can say her first word and can point to communicate a request. • By 15 months, the toddler is able to give a clear “no” with a headshake. His ability to imitate sounds increases, and he can repeat an entire word and even mimic environmental sounds. • By 18 to 24 months of age, he is starting to use pronouns such as “me,” and his vocabulary has expanded to 50

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Fig. 10.14: Brushing independently (5 years)

TABLE 10.3: Key development milestones: Language Age

Milestone

1 month

Turns head to sound

3 months

Cooing

6 months

Monosyllables (‘ma’, ‘ba’)

9 months

Bisyllables (‘mama’, ‘baba’)

12 months

Two words with meaning

18 months

Ten words with meaning

24 months

Simple sentence

36 months

Telling a story

words. New words are learnt quickly, and he begins to combine them into two-word phrases (noun-verb). He now is able to communicate basic wants (“more drink”) and social interest (“bye, mama”). • Between 2 and 3 years of age, his vocabulary continues to increase, and the phrases he uses increase to 3 to 4 words in length.

Milestone

2 months

Social smile

3 months

Recognizing mother

6 months

Smile at mirror image

9 months

Waves ‘bye-bye’

12 months (1 year)

Plays a simple ball game

36 months (3 years)

Knows gender

• Visual skills develop as well, and he can recognize his caregivers by sight at 5 months. • Stranger anxiety, or the ability to distinguish between familiar and unfamiliar people, emerges by 6 months. • The infant consistently turns her head to the speaker when her name is called by 10 months (Fig. 10.16). • By 18 months, he brings objects or toys to his caregivers to show them or to share the experience. • Play skills also follow a specific developmental course. Initially, an infant holds blocks and bangs them against each other or on the table, drops them, and eventually throws them. She learns that dropping the blocks from her high chair will cause her caregiver to pick them up and return them to her; so she repeats this “game” over and over. • By 18 months, she engages in simple pretend play, such as using miniature representative items in a correct fashion. For example, she pretends to talk on a toy phone or “feeds” a doll by using a toy spoon or bottle. • After his second birthday, the child begins to play with others his own age.

SOCIAL MILESTONES (TABLE 10.4) • Most children are born with an inherent drive to connect with others and share feelings, thoughts, and actions. • The earliest social milestone is the bonding of a caregiver with the infant, characterized by the caregiver’s feelings for the child. The infant learns to discriminate his mother’s voice during the first month after birth. • The first measurable social milestone is the smile. The infant smiles at first in response to high pitched vocalizations (“baby talk”) and a smile from his caregiver; but over time, less and less stimulation is required (Fig.  10.15).

Fig. 10.15: Social smile (3 months)

Chapter 10  Developmental Milestones in Children

Fig. 10.16: Turning toward the name calling person (10 months)

• Four-year olds usually have mastered the difference between real and imaginary. They become interested in tricking others and concerned about being tricked themselves. • By age 5 years, children have learnt many adult social skills, such as giving a positive comment in response to another’s good fortune, apologizing for unintentional mistakes, and relating to a group of friends.

EMOTIONAL MILESTONES • Coinciding with the development of social skills is a child’s emotional development. • As early as birth, all children demonstrate individual characteristics and patterns of behavior that constitute that individual child’s temperament. Temperament influences how an infant responds to routine activities, such as feeding, dressing, playing, and going to sleep. • Emotional development involves three specific elements: neural processes to relay information about the environ­ ment to the brain, mental processes that generate feelings and motor actions that include facial expressions, speech, and purposeful movements. • Studies have demonstrated that three distinct emotions are present from birth: Anger, Joy, and Fear. All infants demonstrate universal facial expressions that reveal these emotions, although they do not use these expressions discriminately before the age of 3 months.

• At 15 months, a child demonstrates empathy by looking sad when she sees someone else cry. She also develops self conscious emotions (embarrassment, shame, pride) as she evaluates her own behavior in the context of the social environment. Having once performed cute tricks on demand, she suddenly seems embarrassed and refuses to perform when she realizes that others are watching. • By age 2 years, he starts to mask emotions for social etiquette. During the preschool years, children learn more and more behavioral strategies to manage their emotions, depending on a given situation. They begin to understand that their expressed emotion—whether a facial, vocal, or behavioral expression—does not necessarily need to match their subjective emotional experience. • Children learn to substitute their expressions (smile and say “thank you” even though they are disappointed in the birthday present), amplify expressions (exaggerate a painful response to get sympathy), neutralize expression (put on a “poker face” to hide true feelings), or minimize emotion (look mildly upset when feeling extremely angry).

DEVELOPMENTAL RED FLAGS At every pediatric encounter, some form of developmental surveillance occurs. The interaction of the child with the caregiver or examiner often is measured against what is expected. In case, this development is lacking in any aspect this is identified as developmental red flag (Tables 10.5 to 10.7). TABLE 10.5: Motor red flags Age

Red flag

4 months

Lack of steady head control while sitting

9 months

Inability to sit

18 months

Inability to walk independently

TABLE 10.6: Cognitive red flags Age

Red flag

2 months

Lack of fixation

4 months

Lack of visual tracking

6 months

Failure to turn to sound or voice

9 months

Lack of babbling consonant sounds

24 months

Failure to use single words

36 months

Failure to speak in three-word sentences

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TABLE 10.7: Social and emotional red flags Age

Red flag

6 months

• Lack of smiles or other joyful expressions

9 months

• Lack of reciprocal (back-and-forth sharing of) vocalizations, smiles, or other facial expressions

12 months

• Failure to respond to name when called • Absence of babbling • Lack of reciprocal gestures (showing, reaching, waving)

15 months

• Lack of protodeclarative pointing or other showing gestures • Lack of single words

18 months

• Lack of simple pretend play • Lack of spoken language/gesture combinations

24 months

• Lack of two-word meaningful phrases (without imitating or repeating) • Any age loss of previously acquired babbling, speech, or social skills

TESTS TO ASSESS DEVELOPMENTAL MILESTONES Developmental milestones in children can be assessed by various activities which are performed by children in the respective ages (Fig. 10.17).

Fig. 10.17: Developmental milestones checklist of children (with permission from www.cdc.gov/ActEarly)

Chapter 10  Developmental Milestones in Children Neonatal reflexes Neonatal reflexes are inborn reflexes which are present at birth and occur in a predictable fashion. A normally developing newborn should respond to certain stimuli with these reflexes, which eventually become inhibited as the child matures Name of reflex

Explanation

Appearance and Exit

Rooting reflex

Gently stroke the infant from the lips to the cheek and the Appears at birth and is inhibited between 6 and normal response of the infant is to turn his head toward the 12 months of age stimulated side with the mouth opening

Moro reflex

This is stimulated by a sudden movement or loud noise. The Emerges in 8–9 weeks in utero, and is inhibited neonate will respond by throwing out the arms and legs by 16 weeks of age and then pulling them towards the body

Sucking reflex

When a finger or nipple is placed in the infant’s mouth, it responds by rhythmical sucking

Onset is 28 weeks gestation

Palmer reflex

Stimulated when an object is placed into the baby’s palm. A neonate responds by grasping the object

This reflex emerges 11 weeks in utero, and is inhibited 2–3 months after birth

Babinski reflex

Stimulated by stroking the sole of the foot, which results in toes of the foot should fan out and the foot itself should curl in

Emerges at 18 weeks in utero and disappears by 6 months after birth

Asymmetric tonic neck reflex

When we gently turn the infant’s head to one side, a UE flexion tone on the side opposite to the head turn with an increase in UE extensor tone in the side to which the head is turned

This reflex is present at 18 weeks in utero and disappears by 6 months after birth

Tonic labyrinthine reflex

Arms and legs extend when head moves backward (away from spine), and will curl in when the head moves forward

Emerges in utero until four months postnatally

Galant reflex

When the neonates back is stimulated, their trunk and hips should move toward the side of the stimulus

This reflex emerges 20 weeks in utero and is inhibited by 9 months

Landau’s reflex

When neonate is placed on stomach, their back arches and head raises

Emerges at 3 months postnatally and lasts until the child is 12 months old

Developmental milestones in children Age 1 month

2 months

Gross Motor • Chin up in prone position • Turns head in supine position • Chest up in prone position • Head bobs when held in sitting position

Fine Motor

Self-Help

Problemsolving

• Hands fisted near face

• Sucks well

• Gazes at black-white objects • Follows face

• Hands unfisted 50% • Retains rattle if placed in hand • Holds hands together

• Opens mouth at • Visual threat sight of breast present or bottle • Follows large, highly contrasting objects • Recognizes mother

Social-Emotional • Discriminates mother’s voice • Cries out of distress

Receptive Language

Expressive Language

• Startles to voice/sound

• Throaty noises

• Reciprocal • Alerts to smiling: voice/sound responds to adult voice and smile

• Coos • Social smile (6 weeks) • Vowel-like noises

Contd...

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Contd... Age

Gross Motor

Fine Motor

Self-Help

3 months

• Props on • Hands unfisted • Brings hands to forearms in 50% mouth prone position • Inspects fingers • Rolls to side • Bats at objects

4 months

• Sits with trunk support • No head lag when pulled to sit • Props on wrists • Rolls front to back • Sits with pelvic support • Rolls back to front • Anterior protection • Sits with arms supporting trunk • Sits momentarily propped on hands • Pivots in prone • In prone position, bears weight on 1 hand • Bounces when held • Sits without support steadily • Lateral protection • Puts arms out to sides for balance

5 months

6 months

7 months

Problemsolving

Social-Emotional

• Reaches for face • Follows objects in circle (in supine position) • Regards toys • Mouths objects • Stares longer at novel faces than familiar • Shakes rattle • Reaches for ring/rattle

• Expression of disgust (sour taste, loud sound) • Visually follows person who is moving across a room • Smiles spontaneously at pleasurable sight/sound • Stops crying at parent voice • To and fro alternating vocalizations • Turns head • Recognizes to look for caregiver dropped visually spoon • Forms • Regards pellet attachment or small relationship to cracker caregiver

Receptive Language • Regards speaker

Expressive Language • Chuckles • Vocalizes when talked to

• Hands held predominately open • Clutches at clothes • Reaches persistently • Plays with rattle • Palmar grasps cube • Transfers objects: handmouth-hand • Holds hands together • Reaches/grasps dangling ring • Transfers handhand • Rakes pellet • Takes second cube and holds on to first • Reaches with one hand

• Briefly holds onto breast or bottle

• Feeds self • Touches • Stranger • Stops crackers reflection and anxiety momentarily • Places hands on vocalizes (familiar versus to “no” bottle • Removes cloth unfamiliar • Gestures for on face people) “up” • Bangs and shakes toys

• Reduplicative babble with consonants • Listens, then vocalizes when adult stops • Smiles/vocalizes to mirror

• Radial-palmar grasp

• Refuses excess food

• Increasing variety of syllables

• Gums/mouths pureed food

• Explores • Looks from different object to aspects of toy parent and • Observes cube back when in each hand wanting help • Finds partially (e.g. with a hidden object wind-up toy)

• Orients head • Laughs out loud in direction of • Vocalizes when a voice alone • Stops crying to soothing voice

• Begins to respond to name

• Looks toward familiar object when named • Attends to music

• Says “Ah-goo” • Razzes, squeals • Expresses anger with sounds other than crying

Contd...

Chapter 10  Developmental Milestones in Children Contd... Age 8 months

9 months

Gross Motor • Gets into sitting position • Commando crawls • Pulls to sitting/ kneeling position

• “Stands” on feet and hands • Begins creeping • Pulls to stand • Bear walks (all four limbs straight) 10 months • Creeps well • Cruises around furniture using two hands • Stands with one hand held • Walks with two hands held 11 months • Pivots in sitting position • Cruises furniture using one hand • Stands for a few seconds • Walks with one hand held 12 months • Stands well with arms high, legs splayed • Posterior protection • Independent steps

Fine Motor

Self-Help

• Bangs • Holds own spoon after bottle demonstration • Finger feeds • Scissor grasp of Cheerios® or cube string bears • Takes cube out of cup • Pulls out large peg

• Radial-digital grasp of cube • Bangs two cubes together

• Clumsy release of cube • Inferior pincer grasp of pellet • Isolates index finger and pokes

Problemsolving

Social-Emotional

• Seeks object after it falls silently to the floor

• Lets parents know when happy versus upset • Engages in gaze monitoring: adult looks away and child follows adult glance with own eyes • Bites, chews • Inspects bell • Uses sounds to cookie • Rings bell get attention • Pulls string to • Separation obtain ring anxiety • Follows a point, “Oh look at...” • Recognizes familiar people visually • Drinks from cup • Uncovers toy • Experiences held for child under cloth fear • Pokes at pellet • Looks in bottle preferentially • Tries to put when name is cube in cup, called but may not be able to let go

Receptive Language

Expressive Language

• Responds to “Come here” • Looks for family members, “Where’s mama?”...etc

• Says “Dada” (nonspecific) • Echolalia (8 to 30 months) • Shakes head for “no”

• Enjoys • Says “Mama” gesture (nonspecific) games • Nonreduplicative • Orients to babble name well • Imitates sounds • Orients to bell

• Enjoys peeka-boo • Waves “byebye” back

• Throws objects • Cooperates • Stirs with with dressing spoon

• Finds toy under cup • Looks at pictures in book

• Gives objects • Stops activity to adult for when told action after “no” demonstration • Bounces to (lets adult music know he or she needs help)

• Scribbles after • Finger feeds demonstration part of meal • Fine pincer • Takes off hat grasp of pellet • Holds crayon • Attempts tower of two cubes

• Rattles spoon in cup • Lifts box lid to find toy

• Shows objects to parent to share interest • Points to get desired object (protoimperative pointing)

• Says “Dada” (specific) • Waves “bye-bye”

• Says first word • Vocalizes to songs

• Follows • Points to one-step get desired command object (protowith gesture imperative • Recognizes pointing) names of two • Uses several objects and gestures with looks when vocalizing (e.g. named waving reaching)

Contd...

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Contd... Age

Gross Motor

13 months • Walks with arms high and out (high guard)

Fine Motor • Attempts to release pellet in bottle

Self-Help

• Dangles ring by string • Reaches around clear barrier to obtain objects • Unwraps toy in cloth 14 months • Stands • Imitates back • Removes socks/ • Dumps without and forth shoes pellet out of pulling up scribble • Chews well bottle after • Falls by • Adds third cube • Puts spoon in demonstration collapse to a two-cube mouth (turns • Walks well tower over) • Puts round peg in and out of hole 15 months • Stoops to pick • Builds three-to • Uses spoon • Turns pages in up toy four-cube with some book • Creeps up tower spiling • Places circle in stairs • Places 10 cubes • Attempts to single-shape • Runs stiffin cup brush own hair puzzle legged • Releases pellet • Fusses to be • Walks carrying into bottle changed toy • Climbs on furniture

16 months • Stands on • Puts several one foot with round pegs slight support in board with • Walks urging backwards • Scribbles • Walks up spontaneously stairs with one hand held

• Drinks from cup with some spilling

Problemsolving

Social-Emotional

Receptive Language

• Shows desire • Looks to please appropriately caregiver when asked, • Solitary play “Where’s the • Functional play ball?”

• Points at object to express interest (protodeclarative pointing) • Purposeful exploration of toys through trial and error • Shows empathy (someone else cries, child looks sad) • Hugs adult in reciprocation • Recognizes without a demonstration that a toy requires activation; hands it to adult it can’t operate • Picks up and • Dumps pellet • Kisses by drinks from cup out without touching lips to • Fetches and demonstration skin carries objects • Finds toy • Periodically (same room) observed to visually the hidden relocates under layer of caregiver covers • Self-conscious: • Places circle embarrassed in form board when aware of people observing

Expressive Language • Uses three words • Immature jargoning: inflection without real words

• Follows one-step command withoutgesture

• Names one object • Points at object to express interest (protodeclarative pointing)

• Points to one body part • Points to one object of three when named • Gets object from another room upon demand

• Uses three to five words • Mature jargoning with real words

• Understands simple commands, “Bring to mommy” • Points to one picture when named

• Uses 5 to 10 words

Contd...

Chapter 10  Developmental Milestones in Children Contd... Age

Gross Motor

Fine Motor

Self-Help

Problemsolving

Social-Emotional

18 months • Creeps down • Makes fourstairs cube tower • Runs well • Crudely • Seats self in imitates small chair vertical stroke • Throws ball while standing

• Removes garment • Gets onto adult chair unaided • Moves about house without adult

• Matches pairs • Passes M-CHAT of objects • Engages in • Replaces pretend play circle in form with other board after people (e.g. tea it has been party, birthday turned around party) (usually with • Begins to trial and error) show shame (when dose wrong and possessiveness)

20 months • Squats in play • Completes • Carries large round peg object board without • Walks urging downstairs • Makes five-towith one hand six-cube tower held • Completes square peg board

• Places only edibles in mouth • Feeds self with spoon entire meal

• Deduces location of hidden object • Places square in form board

22 months • Walks up • Closes box stairs holding with id rail, putting • Imitates both feet on vertical line each step • Imitates • Kicks ball with circular scribble demonstration • Walks with one foot on walking board

• Uses spoon well • Completes • Drinks from cup form board well • Unzips zippers • Puts shoes on partway

24 months • Walks down • Makes a singlestairs holding line “train” of rail, both feet cubes on each step • Imitates circle • Kicks ball • Imitates without horizontal line demonstration • Throws overhand

• Opens door • Sorts objects using knob • Matches • Sucks through a objects to straw pictures • Takes off • Shows use clothes without of familiar buttons objects • Pulls off pants

Receptive Language

• Points to two of three objects when named • Points to three body parts • Points to self • Understands “mine” • Points to familiar people when named • Begins to have • Points to thoughts about three pictures feelings • Begins to • Engages in understand tea party with her/him/me stuffed animals • Kisses with pucker

Expressive Language • Uses 10 to 25 words • Uses giant words (all gone, stop that) • Imitates environmental sounds (e.g. animals) • Names one picture on demand

• Holophrases (“Mommy?” and points to keys, meaning: “These are Mommy’s keys.”) • Two-word combinations • Answers requests with “no” • Watches • Points to • Uses 25 to 50 other children four to five words intensely pictures when • Asks for more • Begins to named • Adds one to two show defiant • Points to five words/week behavior to six body parts • Points to four pieces of clothing when named • Parallel play • Follows • Two-word • Begins to mask two-step sentence (noun emotions for command + verb) social etiquette • Understands • Telegraphic me/you speech • Points to 5 to • Uses 50 + words 10 pictures • 50% intelligibility • Refers to self by name • Names three pictures

Contd...

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Contd... Age

Gross Motor

Fine Motor

Self-Help

Problemsolving

28 months • Jumps from bottom step with one foot leading • Walks on toes after demonstration • Walks backward 10 steps 30 months • Walks up stairs with rail alternating feet • Jumps in place • Stands with both feet on balance beam • Walks with one foot on balance beam 33 months • Walks swinging arms opposite of legs

• Strings • Holds self and • Matches large beads verbalizes toilet shapes awkwardly needs • Matches • Unscrews jar lid • Pulls pants up colors • Turns paper with assistance pages (often several at once)

3 years

• Copies circle • Cuts with scissors: side-to-side (awkwardly) • Strings small beads well • Imitates bridge of cubes

• Balances on one foot for 3 seconds • Goes up stairs, alternating feet, no rail • Pedals tricycle • Walks heel to toe • Catches ball with stiff arms

Social-Emotional • Reduction in separation anxiety

Receptive Language • Understands “Just one”

• Repeats two digits • Begins to use pronouns (I, me, you) • Names 10 to 15 pictures

• Follows two prepositions: “put block in...on box” • Understands actions words: “playing... washing... blowing”

• Echolalia and jargoning gone • Names objects by use • Refers to self with correct pronoun • Recites parts of well-known story/fills in words • Gives first and last name • Counts to 3 • Begins to use past tense • Enjoys beings read to (short books)

• Makes eight• Washes hands cube tower • Puts things • Makes a “train” away of cubes and • Brushes teeth includes a stack with assistance

• Replaces circle • Imitates adult in form board activities (e.g. after it has sweeping, been turned talking on around (little phone) or no trial and error) • Points to small details in pictures

• Makes 9- to 10- • Toilet trained cube tower • Puts on coat • Puts six unassisted square pegs in pegboard • Imitates cross

• Points to self • Begins to take • Understands in photos turns three • Points to body • Tries to help prepositions parts based with household • Understands on function tasks dirty, wet (“What do you • Points to hear with?”) objects by uses: “ride in...put on feet...write with” • Draws a two- • Starts to share • Points to to three-part with/without parts of person prompt pictures (nose • Understands • Fears imaginary of cow, door long/short, things of car) big/small, • Imaginative • Names body more/less play parts with • Knows own • Uses words to function gender describe what • Understands • Knows own someone else negatives age is thinking • Groups • Matches (“Mom thought objects letters/ I was asleep”) (foods, toys) numerals

• Independent eating • Pours liquid from one container to another • Puts on shoes without laces • Unbuttons

Expressive Language

• Uses 200+ words • Three-word sentences • Uses pronouns correctly • 75% intelligibility • Uses plurals • Names body parts by use • Asks to be read to

Contd...

Chapter 10  Developmental Milestones in Children Contd... Age

Gross Motor

Fine Motor

Self-Help

Problemsolving

Social-Emotional

4 years

• Balances on one foot 4 to 8 seconds • Hops on one foot two to three times • Standing board jump: 1 to 2 feet • Gallops • Throws ball overhand 10 feet • Catches bounced ball (4½ yrs)

• Copies square • Ties single knot • Cuts 5-inch circle • Uses tongs to transfer • Writes part of first name • Imitates gate with cubes

• Goes to toilet alone • Wipes after bowel movement • Washes face/ hands • Brushes teeth alone • Buttons • Uses fork well

• Draws a fourto six-part person • Can give, amounts (usually less than 5 correctly) • Simple analogies: – dad/boy: mother/??? – ice/cold: fire/??? – ceiling/up: floor/??? • Points to five to six colors • Points to letters/ numerals when named • Rate counts to 4 • “Reads” several common signs/ store names

5 years

• Walks down stairs with rail alternating feet • Balances on one foot > 8 seconds • Hops on one foot 15 times • Skips • Running broad jump 2 to 3 feet • Walks backward heel-toe • Jumps backward

• Copies triangle • Puts paper clip on paper • Can use clothes-pins to transfer small objects • Cuts with scissors • Writes first name • Builds stairs from model

• Spreads with knife • Independent dressing • Bathes independently

• Draws an • Has group of 8- to 10-part friends person • Apologizes for • Gives mistakes amounts • Responds ( exposure to dental environment > dental drill > rubber dam > hand instruments > prophylaxis.

Fig. 21.6: Model performing a specific behavior

Objectives of modeling • Stimulates acquisition of new behavior. • Facilitating the behavior already in the patients in a more appropriate manner. • Elimination of avoidance behavior. • Extinction of fear.

•

•

•

MODELING • It is based on Bandura’s social learning theory, which states that one’s learning or behavior acquisition occurs through observation of suitable model performing a specific behavior (Fig. 21.6). • Modeling is based on the psychologic principle that much of one’s learning or behavior acquisition occurs through observation of a suitable model performing a specific behavior. • Modeling and/or learning by observation of a model have many synonymous terms: imitation, obser­vational

•

•

•

learning, identification, internalization, introjections, coping, social facilitation, contagion and role taking. The efficacy of modeling as a learning technique has been demonstrated by producing behavioral changes in situations requiring cooperation, aggressive behavior, language development and moral judgments. Modeling has been used as a technique to eliminate or minimize fear of dentistry in children by allowing the child to observe an older sibling undergoing dental treatment. Johnson and Machen have found that children who viewed a 12-minute video­tape presentation of a child undergoing an examination, radiographs, local anesthetic administration, and restorative treatment similar to their own upcoming experiences exhibited more positive behavior than did a control group with no modeling experience. It is also a proven fact that if the model is of the same age group as the patient the effect is even more pronounced. Chambers DW (1970): Both live and filmed modeling are effective in reducing child’s fear and anxiety about dental treatments and promoting adaptive behavior. Types of modeling: – Audiovisual – Live modeling by sibling or parent Types of models: – Mastery (cooperative patient who enjoys dental treatment) – Coping (just manages to cope up with the treatment).

Chapter 21  Nonpharmacologic Behavior Management Advantages of modeling (Rim and Masters, 1974) • • • •

Patient’s attention is obtained. Designed behavior is modeled. Physical guidance of the desired behavior. Reinforcement of the guided behavior.

BEHAVIOR SHAPING • It is defined as a process which slowly develops a behavior by reinforcing successive approximations of the desired behavior until the desired behavior is expressed (Lenchner and Wright, 1975). • It is based on the established principles of social learning. • Proponents of the theory hold that most behavior is learned and that learning is the establishment of a connec­ tion between a stimulus and a response. For this reason, it is sometimes called stimulus-­response (S-R) theory. • When shaping behavior, the dental assistant or dentist is teaching a child how to behave. Young children are led through these procedures step by step. They have to be communicative and cooperative to absorb information that may be complex for them. The following is an outline for a behavior shaping model: – State the general goal or task to the child at the outset. – Explain the necessity for the procedure. – Divide the explanation for the procedure slowly. – Make all explanations at a child’s level of understanding with use of euphemisms. – Use successive approximations. – Reinforce appropriate behavior. – Disregard minor inappropriate behavior.

CONTINGENCY MANAGEMENT • This behavior management technique is based on BF Skinner’s operant conditioning. • The presentation of positive reinforcers or withdrawal of negative reinforcers is termed contingency management. It includes: – Positive reinforcement – Negative reinforcement – Omission or time out – Punishment. • Levy and Domoto (1979) found out that positive rein­ forcement was one of the highly preferred techniques in the pedodontic dental practices in the state of Washington.

Types of Reinforcers • Positive reinforcers: It is the one whose presentation increases the frequency of desired behavior.

• Negative reinforcers: It is the one whose contingent withdrawal increases the frequency of a behavior. • Material: Stickers, pencils, small toys (preferably not candies and sweets). Rewards are given after the dental procedure and bribes are given before. Bribes should not be given in pediatric dental practice. The reward in one visit will act like a bribe for the next visit and the child will behave properly to receive his gift. • Social: Praise, positive facial expression, hand shake, smile, hug, pat on the shoulder. This is the best kind of positive reinforcer—works well with children. • Activity: Opportunity of participating in a preferred activity like a cartoon show, visit to the park. Before patient can accomplish this activity he has to behave accordingly in the dental office. Positive reinforcement: It is the presentation of the pleasant stimulus and is done to appreciate the child for the good behavior. Either of the above reinforcers can be used. Negative reinforcement: Withdrawal of the unpleasant stimulus like high speed handpiece. Care should be taken not to confuse this punishment. The unpleasant stimulus is withdrawn and not given to the child. It is similar to deemphasis or substitution type of retraining. Time-out (or) omission: It is the withdrawal of the pleasant stimulus to reinforce good behavior. Asking the mother (pleasant stimulus for the child) to stay out of the dental operatory to make the child cooperative is an example of time-out. Punishment: It is the presentation of the unpleasant stimulus to the child, e.g. voice control, hand over mouth exercise (HOME). Probability of response increases

Probability of response decreases

Pleasant stimulus (S1)

S1 Presented Positive reinforcement “Reward”

S1 Withdrawn Omission/Time out

Unpleasant stimulus (S2)

S2 Withdrawn Negative reinforcement “Escape”

S2 Presented Punishment

EXTERNALIZATION • It is a process by which child’s attention is focused away from the sensation associated with dental treatment by involving in verbal or dental activity. • Objectives: – To decrease perception of unpleasantness – To interest and involve children.

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DISTRACTION • This is a newer method of behavior management in which the patient is distracted from the sounds and/or sight of dental treatment thereby reducing the anxiety. • Objective is to relax the patient and to reduce anxiety during treatment. • Use stories and fairy tales. • Use slow instrumental music. • Relaxation effect of music and the sound of music will eliminate unpleasant dental sounds like the sound of handpiece. • Choice of distraction is chosen by the patient; this will help child gain control over the unpleasant stimulus and give them a feeling of being in a familiar environment. • Child seeing the audiovisual presentation will have multisensory distraction as he will tend to concentrate on the TV screen thereby, screening out the sight of dental treatment and the sound of the program will help eliminate the unpleasant dental sounds like the sound of handpiece. • Placebo effect. • Types: – Audio distraction: Patient listens to audio presentation through headphones throughout the course of the treatment (Fig. 21.7). – Audiovisual distraction: Patient is shown audiovisual presentation through television during the entire treatment (Fig. 21.8).

• Behavioral coping: Efforts include physical or verbal activities in which the child engages to deal with stress. These are readily visible to dentist, e.g. inquisitive question about the procedure. • Cognitive coping: Efforts which involve manipulation of emotions. These are not visible to dentist but these play a crucial role in child’s ability to deal with the treatment as well as forming a positive outlook for future. • Children taught coping skills like imagery, relaxation, selftalk demonstrated less stress during treatment. Coping strategies and dentist’s behavior S.no. 1. 2.

3.

4.

ASSIMILATION AND COPING

5. 6.

• Stress can act to increase pain perception while coping decrease it by a process called as assimilation. • Coping refers to cognitive and behavioral efforts made by individuals to master, tolerate or reduce stressful situations.

7.

Fig. 21.7: Audio distraction

Coping strategy Distraction/ displacement Expressive communication (Verbalization fear) Relinquishing control to authority figure Gaining manipulative control over source

Affiliation Conscious instruction to oneself Mental rehearsal

Dentist’s behavior Talk to patient about hobbies, or just babble Ask what the patient is feeling, or describe what you think they feel Display confidence

Tell patient what if something bothers them to put up their hand like this (demonstrate a safe way) Tell patient to count to 10 with you as you go through the procedure, finishing at the end of the count Give patient a mirror to watch with structure choices, e.g. “Would you like orange or strawberry flavor?” “Would you like to play with my chair?” Be empathetic Tell patient to count to “Breath deep”, or “Relax” Inform patient of the steps to be performed prior to the procedure, and use Tell-Show-Do.

Fig. 21.8: Audiovisual distraction

Chapter 21  Nonpharmacologic Behavior Management Research on distraction technique •  Levy and Domoto (1979) found out that distraction was one of the highly preferred techniques in the pedodontic dental practices in the state of Washington. • Magora F (2010) observed audiovisual wireless eyeglasses method of distraction (AVD) was able to replace the visual and auditory signals from the environment by a pleasant movie. As, this method offered the possibility of nonpharmacological sedation in patients undergoing dental treatment AVD may be of benefit especially to uncooperative, very anxious children and prevent pharmacologic means of sedation by offering a pleasurable method without adverse effects. • Frere CL (2001), Bensten B (2001), Prabhakar AR (2007) and Ram D (2010) in their studies observed Audiovisual distraction (AVD) as a promising technique that offers an additional nonpharmacological mode of sedation conceived to diminish the unpleasantness often associated with dental procedures in children and adults.

Research on parental presence or absence from operatory •  Ajlouni (2010) observed that 82% of pediatric dentists allow parents to be present during dental treatment. • Adair SM (2004): Parents may prefer or insist on being with their children during treatment, or they would like to assist the pediatric dentist if any behavioral problem arises. •  Crossley ML (2002) found high percentage of pediatric dentists allowing presence of parents during treatment. •  Grewal N ( 2003) showed that only 61% of respondents allow parents to be in the clinic during treatment, and there is a significant relationship between the length of experience and the allowance of parents in the operatory. •  Carr et al. (1999) reported that 84% of practioners allow parent to be in clinic with their children during treatment.

PARENTAL PRESENCE OR ABSENCE • Objective: – To gain patient’s attention and compliance – To avert avoidance behavior – To establish authority • Advantages of parental presence: – Supporting and communicating with the child – Very young patients • Advantages of parental absence: – Overcoming parental conditioning – Avoiding communication interference – Avoiding parental interference.

RETRAINING • A technique similar to behavior shaping, designed to fabricate positive values and to replace the negative behavior. • Children who require retraining approach the dental office displaying considerable apprehension or negative behavior. This may be due to previous eventful dental visit or the effect of improper parental or peer orientation or even due to the child’s experience in medical setting. • The essence here is to locate the problem that it can either be avoided or distracted. The dentist should try to build up a new relation with the child so that the child is able to forget his previous thought process of dental clinic.

• If the child has had a previous eventful dental experience with some other dentist in another operatory he will always have a fear and associate this clinic and dentist with the same so it is up to the dental team to make his experience different so that he is retrained. • Approaches: – Avoidance (e.g. avoid extensive pulp therapy with pulp capping) – De-emphasis and substitution (e.g. substitute high speed handpiece with spoon excavator) – Distraction (e.g. distract the child with stories/activities/audiovisual aids).

VISUAL IMAGERY • Controlled day dreaming • Subject is asked to imagine being in his favorite place/ performing his favorite activity and this can act as a fantasy during his dental treatment.

FLOODING TECHNIQUE Described as behavior modification technique that elimi­ nates a child’s attempts to avoid experiences that he perceives to be undesirable, e.g. hand over mouth (HOM), physical restraints.

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VOICE CONTROL • Given by Pinkham in 1985 • Sudden and firm commands that are used to get the child’s attention and stop the child from his current activity. • Soft, monotonous soothing conversation can also be used as it is supposed to function like music to set the mood. • In both cases what is heard is more important because the dentist is attempting to influence behavior directly and not through understanding. • The tone of voice and the facial expression of the dentist are also important as they function like a mirror. • Objectives: – To gain the patient attention and compliance – To avoid negative or avoidance behavior – To establish authority. • Indications: Uncooperative and inattentive patients • Contraindications: Children who due to age, disability, mental or emotional immaturity are unable to understand.

USE OF POETRY AND DRAWINGS

Use of Poetry • This technique is employed in children above 7 years of age. • The poem is written as a collective effort, the dentist contributing one line and the child next, e.g. teeth are white, when they are bright; teeth do shine, when you clean; teeth are happy, when they are healthy; teeth stay long, when they are strong. • By selecting words like shine, happy and long it was easy to make the child discover clean, healthy and strong. By doing this, it allows child to discover information about his teeth and their well being.

Use of Drawings • This technique was developed when it was discovered that with a little manipulation the forms of the familiar teeth could be altered to look like common animals, birds and insects. • This is useful for children of 3 to 5 years of age. • Child is given a paper and pencil or a crayon and asked to draw some picture. Then slowly the child is asked to draw teeth and showed how teeth can be made to look like his pets. He is then told that like his pets the tooth also have to be looked after and kept clean.

Advantages • It allows repetition without monotony. • The rhyme and rhythm can be used to guide the child towards the information to be implied.

• It gives the child a sense of achievement and increases self-esteem. • Above all, it will destroy the preconception the child has formed about dentistry, the dentist and the dental clinic.

HYPNOSIS It was first suggested by Franz A Mesmer, a Viennese physician in 1773. It is defined as a state of mental relaxation and restricted awareness in which subjects are usually engrossed in their inner experiences such as imagery, are less analytical and logical in their thinking and have enhanced capacity to respond to suggestions in an automatic and dissociated manner.

Uses Hennon outlined the following uses: • To reduce nervousness and apprehension. • To eliminate defense mechanisms that patients use to postpone dental work. • To control functional or psychosomatic gapping. • To prevent thumb sucking and bruxism. • To induce anesthesia.

Technique • Patient preparation: It is important to gain informed consent from the parent and child in accordance with the Children Act of 1989, which states that children’s wishes and feelings should be incorporated into the decision concerning them. A simple verbal explanation of hypnosis should be given and any questions that the parent or child may have are answered. • The hypnotic induction: Hypnosis begins with an induction technique. The aim is to relax the patient and to encourage them to focus. Induction essentially has three parts: 1. Focus the subject’s attention on a stimuli of particular modality, which may be either visual like a focussing light held in an out-stretched hand or body sensation like warmth, cold, tingling. 2. Giving repeated instructions suggestive of relaxation and comfort. 3. The coupling of focussing and suggestion to develop more powerful effect, e.g. with every breath you feel more relaxed. • Deepening: Deepening the hypnotic state involves the sequential use of three or four different inductions. The use of a number of different inductions, focusing the child’s attention to different modalities allows the clinician to assess how the child responds and select the most appropriate method. • Posthypnotic suggestion: These suggestions given by the clinician during hypnosis are aimed at altering the patient’s feelings, thoughts and behavior afterwards, e.g.

Chapter 21  Nonpharmacologic Behavior Management Suggestion that the patient will be relaxed, calm confident after treatment or at the next visit the hypnotic experience will be deeper, more easily and quickly induced. • Altering patient after therapy: This is a process of bringing the patient out of the hypnotic state and reorienting to their normal surroundings. Informing the patient that on counting from one to five, their eyelid will become lighter and open on five count.

HAND OVER MOUTH TECHNIQUE This technique was first described in 1920 by Dr Evangeline Jordan who wrote “If a normal child will not listen but continues to cry and struggle—hold a folded napkin over the child’s mouth and gently but firmly hold the mouth shut. His scream increases his condition of hysteria, but if the mouth is held closed, there is little sound, and he soon begins to reason (Fig. 21.9).”

Other Terminologies • Aversive conditioning by Lenchner and Wright (1975) • Emotional surprise therapy by Lampshire • Hand over mouth airway restricted (HOMAR) by Levitas (1947) • Aversion by Crammer (1973).

Objective • To gain child’s attention enabling communication with dentist so that appropriate behavioral expectation can be explained. • To eliminate inappropriate avoidance behavior to dental treatment and to establish appropriate learned response. • To increase child’s confidence in coping with anxiety provoking dental stimuli. • To assure child safety in delivery of quality dental care.

Indication A healthy child who is able to understand and cooperate but who exhibits defiant, obstreperous or hysterical behavior to dental treatment.

Contraindications • Immature child • When it prevents child from breathing • When the dentist is emotionally involved with the child.

Technique When indicated, a hand is placed over child’s mouth and behavioral expectations are calmly explained. Child is told that the hand will be removed as soon as the appropriate behavior begins. When child responds, the hand is removed and child’s appropriate behavior is reinforced. If the child shows negative behavior again the procedure is repeated.

Legality of Use of HOME • It has been pointed out that the use of HOME will not subject the dentist to liability by the patient when it is used properly with parental consent. • Use of hand over mouth airway restricted (HOMAR) is more nearly objectionable legally and may result in liability of the dentist.

Research • Association of Pedodontic Diplomates in 1970 found out that 80 percent used HOME technique frequently. • Carr et al. (1999) found out the number of clinicians who did not practice HOME was around 57 percent. • Adair et al. (2004) observed that 79 percent of the clinicians did not use HOME.

Variations of the Techniques Airway uninstructed, hand over both nose and mouth, (HOMAR), towel held over mouth only, dry towel over nose and mouth, wet towel over nose and mouth (Figs 21.10 to 21.12).

PROTECTIVE STABILIZATION

Fig. 21.9: Hand over mouth exercise

Partial or complete immobilization of the patient is sometimes a necessary and effective way to diagnose and deliver dental care to patients who need help in controlling their extremities. Immobilization is also useful for managing combative, resistant patients, so that the patient, practitioner or dental staff may be protected from injury while care is

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Fig. 21.10: Hand over mouth airway restricted

being provided. The parents must be informed and the consent must be documented, before immobilization is used, they should have a clear understanding of the type of immobilization to be used, the rationale, and duration of use. The American Academy of Pediatric Dentistry’s Standard of Care for Behavior Management, revised in May 1996, indicates that the need to diagnose and treat, as well as protect the safety of the patient and practitioner, must justify the use of immobilization. This decision should take into consideration the patient’s emotional development, physical and medical considerations, dental need, other alternative behavioral modalities and the quality of dental care. The older terminology of physical restraints has been replaced with the term medical immobilization or protective stabilization because we are not just strapping the child to the chair minimizing his movement. The idea is to immobilize the child benefiting and protecting both the child and the dentist.

Indications for Using Immobilization

Fig. 21.11: Towel held over mouth only

• A patient who requires diagnosis or treatment and cannot cooperate because of lack of maturity. • A patient who requires diagnosis or treatment and cannot cooperate because of mental or physical disabilities. • A patient who requires diagnosis or treatment and does not cooperate after other behavior manage­ment techniques have failed. • When the safety of the patient or practitioner would be at risk without the protective use of immo­bilization.

Contraindications • A cooperative patient • A patient who cannot be safely immobilized because of underlying medical or systemic conditions • As punishment • It should not be used solely for the convenience of the staff.

Research •

• Fig. 21.12: Towel held over mouth and nose

Association of Pedodontic Diplomats in 1972 conducted a survey and found out that 84 percent of the pedodontist’s used physical restraints in selected patients Nathan JE (1989) observed that only 4 percent of the pedodontist’s employed immobilization technique.

Chapter 21  Nonpharmacologic Behavior Management Types of mechanical aids for protective stabilization Part Mouth

Aid

Features

Tongue blades Open wide mouth prop

• These can be used directly to open mouth • It has a durable foam core on the outside of a tongue depressor • It is also easy to use, durable and available in two sizes

Molt mouth prop

• It can be very helpful in the management of a difficult patient for a prolonged period. It is made in both adult and child sizes, allows accessibility to the opposite side of the mouth • Its disadvantages include the possibility of lip and palatal lacerations and luxation of teeth if it is not used correctly • The patient’s mouth should not be forced beyond its natural limits because patient’s discomfort and panic will result, causing further resistance and perhaps airway compromise

Rubber bite blocks

Available in various sizes to fit on the occlusal surfaces of the teeth and stabilize the mouth in an open position. The bite blocks should have floss attached for easy retrieval if they become dislodged in the mouth

Finger guards

Used directly to open mouth

Contd...

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Contd... Body

Papoose Board

• Simple to store and use • It is available in areas to hold both large and small children • It has attached head stabilizers • It is reusable • Necessary to monitor respiration if it is used in combination with sedation • An extremely resistant patient may develop hyperthermia if immobilized too long • Any restrained patient requires constant attendance and supervision

Triangular sheet

• Mink described this technique using a triangular sheet to control an extremely resistant child • It allows the patient to upright during radiographic examinations • Its disadvantages include the frequent need for straps to maintain the patient’s position in the chair, the difficulty of its use on small patients, and the possibility of airway impingement • Hyperthermia may be another problem during long periods of immobilization • The need for constant supervision is emphasized so that these problems may be avoided

Pedi-Wrap

• Comes in various sizes and allows some movement while still confining the patient • Its mesh fabric prevents developing hyperthermia • Requires straps to maintain body position in the dental chair • Constant supervision to prevent the patient from rolling out of the chair

Beanbag dental chair insert

• Developed to help comfortably accommodate hypnotic and severely spastic persons who need more support and less immobilization in a dental environment • It is reusable and washable, and one size fits most people • Many patients with physical disabilities relax more in this setting

Safety belt and extra assistant

• Useful in controlling movements Contd...

Chapter 21  Nonpharmacologic Behavior Management Contd... Extremities

• Posey straps • Velcro straps • Towel and tape • Extra assistant

• Fasten to the arms of the dental chair and allow limited movement frequently prevents overreaction by resistant or combative patients • Helpful for an athetoid-spastic cerebral palsy patient who tries desperately, but without success, to control body movements

Head

• Head positioner • Plastic bowl • Extra assistant

• Used to stabilize head

POINTS TO REMEMBER • Behavior management is the means by which the dental health team effectively and efficiently performs treatment for a child and at the same time, instils a positive dental attitude. • Factors influencing child’s behavior in dental office are history, maternal anxiety, family and peer influence, dental office environment, growth and development, environmental factors. • Objectives of behavior management are to establish effective communication with child and parent; fain child and parent confidence for dental treatment; teach child positive aspect of preventive dental care and provide a comfortable, relaxing environment to the child. • Role of dentist in child’s behavior: Appearance of dental office should be pleasing; personality of dentist should be impressive; time and length of appointment is short; dentist should be skilled; dentist should use simple words; treat the patient with importance; be realistic and reasonable; exercise self-control. • Frankl found that children in age group of 42 to 49 months are benefited from mother’s presence in operatory. • Frankl in 1962 introduced a behavior-rating scale, which is one of the most reliable tools developed for behavior measurement. It consists of a ratings of determination numbered from 1 to 4, each defining a specific behavior. • Wright in 1975 suggested that a symbol be added to this rating scale, permitting the dentist to record a behavior base at the inception of dental treatment and to keep a progressive record of the child’s behavior. • Psychological approach of behavior management are preappointment behavior modification, communication, use of second language, tell show do, tender love care, desensitization, contingency management, visual imagery, modeling, behavior shaping, assimilation and coping, hypnosis, retraining, distraction, externalization, parental presence or absence, reframing and voice control. • Physical approach of behavior management are hand over mouth exercise and physical restraints.

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• • •

• •

•

Behavioral Pedodontics

Communication acts as a means for the dentist to know the child and his fears and can be of verbal or nonverbal type. Euphemisms is use of second language like camera for X-ray. Animatopia is giving animated sounds to objects like handpeice is called whistling train. Tell-show-do is the cornerstone of behavior management was given by Addleston in 1959. Specifically, the dentist tells the child what is going to be done in words the child can understand. Second, the dentist demonstrates to the child exactly how the procedure will be conducted. Finally, the practitioner performs the procedure exactly as it was described and demonstrated. Objectives of modeling are to stimulates acquisition of new behavior, facilitating the behavior already in the patients in a more appropriate manner, elimination of avoidance behavior and extinction of fear. Live modeling by the same age group peer is one of the best methods of behavior management of a child. Distraction is a newer method of behavior management in which the child seeing the audiovisual presentation will have multisensory distraction as he will tend to concentrate on the TV screen thereby, screening out the sight of dental treatment and the sound of the program will help eliminate the unpleasant dental sounds like the sound of handpiece. Voice control was given by Pinkham in 1985. It is sudden and firm commands that are used to get the child’s attention and stop the child from his current activity. Hand over mouth technique is also called aversive conditioning, emotional surprise therapy, HOME, and aversion by Crammer. Objective is to gain child’s attention enabling communication with dentist so that appropriate behavioral expectation can be explained, to eliminate inappropriate avoidance behavior to dental treatment and to establish appropriate learned response. It is indicated in a healthy child who is able to understand and cooperate but who exhibits defiant, obstreperous or hysterical behavior to dental treatment. Immobilization is indicated in patient who requires diagnosis or treatment and cannot cooperate because of lack of maturity or because of mental or physical disabilities and in patients in whom all other behavior manage­ment techniques have failed. Restraints for mouth—mouth props, tongue blade, rubber bite blocks, finger guard; body—Papoose Board, triangular sheet, Pedi-Wraps, Beanbag dental chair insert; extremities—straps, tapes; head—head positioner.

QUESTIONNAIRE 1. Define behavior and behavior management and enumerate the techniques for child management. 2. What are the factors influencing child behavior in dental office? 3. What are the objectives of behavior management? 4. Describe the role of dentist in child management. 5. Write a note on maternal influence in dental operatory 6. Classify child behavior and give details about Frankl’s classification. 7. Describe preappointment behavior modifications. 8. Differentiate between communication and euphemisms. 9. Explain TSD technique. 10. Write a note on distraction. 11. Describe the indications and procedure of modeling. 12. Give the indications, procedure, modifications of HOME. 13. Explain the different types of mechanical restraints used for immobilization.

BIBLIOGRAPHY 1. Adair SM, Waller JL, Schafer TE, Rackman RA. A survey of members of American Academy of Pediatric Dentistry on their use of behavior management techniques. Pediatr Dent. 2004;26(2):159-66. 2. Adelson R, Goldfried MR. Modeling and the fearful child patient. J Dent Child. 1970;37:476. 3. Ajlouni O, Al-Moherat F, Habahbeh R, Nsour H, Tbeshat J. Behavior management techniques among Jordanian pediatric dentists of J Royal Med Services. 2010;17(Suppl 2):62-6. 4. Allen KD, Stonely RTM. Evaluation of behavioral management technology dissemination in pediatric dentistry. Pediatr Dent. 1990;12(2):79-82. 5. American Academy of Pediatric Dentistry. Clinical guidelines on behavioral management. Pediatr Dent Reference Manual. 2003;25 (7 suppl):69-74.

Chapter 21  Nonpharmacologic Behavior Management 6. Carr KR, Wilson S, Nimer S, Thornton JB. Behavior management techniques among pediatric dentists practicing in the southeastern United States. Pediatr Dent. 1999;21(6):347-53. 7. Chambers DW. Behavior management techniques for pediatric dentists: an embarrassments of riches. ASDC J Dent Child. 1977.pp. 30-4. 8. Chambers DW. Communicating with the young patient. J Am Dent Assoc. 1976;93:793-9. 9. Choate BB, Seale NS, Parker WA, Wilson CF. Current trends in behavior management techniques as they relate to new standards concerning informed consent. Pediatr Dent. 1990;12(2):83-6. 10. Christen A. Pjagetian psychology: some principles as helpful in treating the child dental patient. J Dent Child. 1971.p.44. 11. Connick C, Palat M, Pugliese S. Appropriate use of physical restraints. ASDC J Dent Child. 2000.pp.256-62. 12. Craig W. Hand over mouth technique. J Dent Child. 1971;38:387. 13. Crall JJ. Behavior management conference panel 2 report-third-party payer issues. Pediatr Dent. 2004;26(2):171-4. 14. Crossley ML, Joshi G. An investigation of pediatric dentists’ attitude toward parental accompaniment and behavioral management techniques. 15. Curry SL. The role of coping in children’s adjustment to dental visit. ASDC J Dent Child. 1988.pp.231-46. 16. Florella M, Sarale C, Ram RD. Audiovisual iatrosedation with video eyeglasses distraction method in pediatric dentistry: case history. J Int Dent Med Res. 2010;3:(3):133-6. 17. Gao X, Hamzah SH, Yiu CKY, McGrath C, King NM. Dental fear and anxiety in children and adolescents: qualitative study using YouTube J Med Internet Res. 2013;15(2):e29 URL: http://www.jmir.org/2013/2/e29/doi:10.2196/jmir.2290 PMID:23435094 18. Greenbaum PE, et al. Dentist’s voice control: effects on children’s disruptive behaviors, Health Psychol. 1990;9:46-58. 19. Grewal N. Implementation of behavioral management technique—how well accepted they are today. J Indian Soc Pedo Prev Dent. 2003;21(2):70-4. 20. Hagan PP. The legal status of informed consent for behavior management techniques in dentistry, Pediatr Dent. 1984;6:204-8. 21. Hane AA, Cheah C, Rubin KH, Fox NA. The role of maternal behavior in the relation between shyness and social reticence in early childhood and social withdrawal in middle childhood. Social Development. 2008; doi: 10.1111/j.1467-9507.2008.00481.x 22. Johnson DC. Managing the patient and parent in dental practice. In: Pediatric Dentistry. Total patient care, SHY Wei Ed. Philadelphia: Lea & Febiger;1988.p.140. 23. Kuhn BR, Allen KD. Expanding child behavior management technology in pediatric dentistry: a behavior science perspective. Pediatr Dent. 1994;16(1):13-7. 24. Landry SH, Smith KE, Swank PR, Miller-Loncar CL. Early maternal and child influences on children’s later independent cognitive and social functioning. Child development. 2000;71(2):358-75. 25. Lawrence SM. Parental attitudes toward behavior management techniques in pediatric dentistry. Pediatr Dent. 1991;13:151-5. 26. Lenchner V, Wright GZ. Non-pharmacologic therapeutic approaches to behavior management. In: Behavior Management in Dentistry for Children. GZ Wright (Ed). Philadelphia: WB Saunders Co. 1975.pp.91-114. 27. Levitas TC. HOME—hand over mouth exercise. J Dent Child. 1974;41:178-82. 28. Machen JB, Johnson R. Desensitization, model learning and dental behavior in children. J Dent Res. 1974.pp.83-7. 29. Maruyama S, Koyazu T. Effect of dental drawings and coloring on attitudes of child dental patients. ASDC J Dent Child. 1988.pp.129-32. 30. McKnight-Hanes C, Myers DR, Dushku JC, Davis HC. The use of behavioral management techniques by dentists across practitioner type, age and geographic region. Pediatr Dent. 1993;15(4):267-71. 31. Peretz B, Bimstein E. Use of imagery suggestions during administration of LA in pediatric dental patients. ASDC J Dent Child. 2000.pp. 263-7. 32. Peretz B, Glaicher H, Ram D. Child management technique. Are there differences in the way female male pediatric dentists in Israel practice? Braz Dent J. 2003;14(2):82-6. 33. Peretz B, Gluck GM. Reframing—reappraising an old behavioral technique. J Clin Pediatr Dent. 1999;23(2):103-6. 34. Prabhakar AR, Marwah N, Raju OS. Comparison between audio and audio-visual distraction technique in managing anxious pediatric dental patients. JISPPD. 2007.pp.177-82. 35. Sharma A, Tyagi R. Behavior assessment of children in dental settings: a retrospective study. Int J Clin Pediatr Dent. 2011;4(1):35-9. 36. Shaw AJ, Welbury R. The use of hypnosis in sedation clinic for dental extraction in children. ASDC J Dent Child. 1996.pp.418-20. 37. Suprabha BS, Rao A, Choudhary S, Shenoy R. Child dental fear and behavior: the role of environmental factors in a hospital cohort. J Ind Soc Pedod Prev Dent. 2011;29:95-101. 38. Wepman BJ, Sonnenberg EM. Effective communication with the pedodontic patient. J Pedod. 1979;2:316-21. 39. Wright GZ, Starkey PE, Gardner DE. Child management in dentistry, 2nd Edn. Oxford: John Wright and Sons; 1991.pp.58-75.

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Chapter

Conscious Sedation Nikhil Marwah, Hind Pal Bhatia

Chapter outline • • • •

Clinical Guidelines for use of Conscious Sedation by Dentists Instructions to the Parents for Conscious Sedation Sedation Techniques Nitrous Oxide Sedation

Most children can be managed effectively using the techniques outlined in basic behavior guidance. These basic behavior guidance techniques should form the foundation for all of the management activities provided by the dentist. Children, however, occasionally present with behavioral considerations that require more advanced techniques. These children often cannot cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability. The advanced behavior guidance techniques commonly used include protective stabilization and sedation. Current understanding of pediatric oral health includes absence of dental fear and anxiety as well as healthy oral structures with the aim of forming the basis for good oral

Objectives of sedation in pediatric dentistry • For the child – Reduce fear and perception of pain during the treatment – Facilitate coping with the treatment – Prevent development of dental fear and anxiety – Minimize physical discomfort and pain – Control behavior and/or movement so as to allow the safe completion of the procedure – Minimize psychological trauma, and maximize the potential for amnesia • For the dentist – Facilitate accomplishment of dental procedures – Reduce stress and unpleasant emotions – Prevent “burn-out” syndrome

• • •

Drugs used for Conscious Sedation Reversal Agents Complications Associated with Moderate or Deep Sedation

health throughout life. This implies two main dimensions in pediatric oral care: (1) to keep the oral environment healthy, and (2) to keep the patient capable of, and willing to utilize the dental service. In recognition of the expanding need for both the elective and emergency use of sedative agents and the importance of delivering painless treatment to children, guideline for the use of sedative agents among children are important. Pediatric dentists should be aware that sedation represents a continuum. Thus, a patient may move easily from a light level of sedation to a deeper level, which may result in the loss of the patient’s protective reflexes. The distinction between conscious sedation and deep sedation is made for the purpose of describing the level of monitoring needed, as well as the responsibility of the dentist.

DEFINITIONS Conscious sedation1: A minimally depressed level of con­ sciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appro­ priately to physical stimulation or verbal command and that is produced by a pharmacological or nonpharmacological method or a combination thereof. Deep sedation1:  A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining

Chapter 22  Conscious Sedation Objectives of conscious sedation2,3 • • • • • •

• •

Reduce or eliminate anxiety Reduce untoward movement and reaction to dental treatment Enhance communication and patient cooperation Raise the pain reaction threshold Increase tolerance for longer appointments Aid in treatment of the mentally/ physically disabled or medically compromised patient Reduce gagging Potentiate the effect of sedatives

Indications2,3

Goals of conscious sedation •

• • • •

To provide the most comfortable, efficient and high quality dental service for the patient To control inappropriate behavior that interferes with such provision of care To produce in the patient a positive psychologic attitude towards future care To promote patient welfare and safety To return the patient to a physiologic state in which safe discharge is possible

• • • • • • •

a patent airway, and spontaneous ventilation may be inade­ quate. Cardiovascular function is usually maintained. General anesthesia1: A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Minimal sedation (old terminology “Anxiolysis”):  A druginduced state during which patients respond normally to ver­ bal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

CLINICAL GUIDELINES FOR USE OF CONSCIOUS SEDATION BY DENTISTS1 (According to American Dental Association, October 2012).

Patient Evaluation • Patients considered for minimal sedation must be suitably evaluated prior to the start of any sedative procedure.

Lack of psychological or emotional maturity Medical, physical, cognitive disability Fearful, highly anxious or obstreperous patient A patient whose gag reflex interferes with dental care A cooperative child undergoing a lengthy dental procedure Certain patients with special health care needs A patient for whom profound local anesthesia cannot be obtained

• In healthy or medically stable individuals (ASA I, II) this may consist of a review of their current medical history and medication use. • However, patients with significant medical considerations (ASA III, IV) may require consultation with their primary care physician or consulting medical specialist.

Documentation before Sedation Documentation shall include, but not be limited to, the guidelines that follow: • Informed consent: The patient record shall document that appropriate informed consent was obtained according to local, state, and institutional requirements. • Instructions and information provided to the responsible person. • The practitioner shall provide verbal and/or written instructions to the responsible person. Information shall include objectives of the sedation and anticipated changes in behavior during and after sedation. • Special instructions shall be given to the adult responsible for infants and toddlers who will be transported home in a car safety seat regarding the need to carefully observe the child’s head position so as to avoid airway obstruction. • A 24-hour telephone number for the practitioner or his or her associates shall be provided to all patients and their families.

Classification of patient selection (According to American Society of Anesthesiologists)4 ASA Physical Status I

A normal healthy patient

ASA Physical Status II

A patient with mild systemic disease

ASA Physical Status III

A patient with severe systemic disease

ASA Physical Status IV

A patient with severe systemic disease that is a constant threat to life

ASA Physical Status V

A moribund patient who is not expected to survive without the operation

ASA Physical Status VI

A declared brain-dead patient whose organs are being removed for donor purposes

E

Emergency operation of any variety (used to modify one of the above classifications)

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• Instructions shall include limitations of activities and appropriate dietary precautions.

Preoperative Preparation • The patient, parent, guardian or care giver must be advised regarding the procedure associated with the delivery of any sedative agents and informed consent for the proposed sedation must be obtained. • Determination of adequate oxygen supply and equipment necessary to deliver oxygen under positive pressure must be completed. • Baseline vital signs must be obtained unless the patient’s behavior prohibits such determination. • A focused physical evaluation must be performed as deemed appropriate. • Preoperative dietary restrictions must be considered based on the sedative technique prescribed (Table 22.1). • Preoperative verbal and written instructions must be given to the patient, parent, escort, guardian or care giver.

Personnel and Equipment Requirements • At least one additional person trained in basic life support for healthcare providers must be present in addition to the dentist. • A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available. • When inhalation equipment is used, it must have a fail-safe system that is appropriately checked and calibrated. • The equipment must also have either (1) a functioning device that prohibits the delivery of less than 30 percent oxygen or (2) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm.

• An appropriate scavenging system must be available if gases other than oxygen or air are used.

Preparation and Setting-up for Sedation Procedures • Part of the safety net of sedation is to use a systematic approach so as to not overlook having an important drug, piece of equipment, or monitor that should be immediately available at the time of a developing emergency. • To avoid this problem, it is helpful to use an acronym that allows the same setup and checklist for every procedure. A commonly used acronym useful in planning and preparation for a procedure is SOAPME: S = Size-appropriate suction catheters and a function­ ing suction apparatus O = An adequate oxygen supply and functioning flow meters/other devices to allow its delivery A = Airway: Size-appropriate airway equipment P = Pharmacy: All the basic drugs needed to support life during an emergency, including antagonists M = Monitors: Functioning pulse oximeter and other monitors as appropriate like capnograph E = Special equipment or drugs for a particular case.

Monitoring during Sedation • A dentist, or at the dentist’s direction, an appropriately trained individual, must remain in the operatory during active dental treatment to monitor the patient continuously until the patient meets the criteria for discharge to the recovery area. • The appropriately trained individual must be familiar with monitoring techniques and equipment. • Monitoring must include oxygenation, circulation and ventilation.

TABLE 22.1: Appropriate intake of food and liquids before elective sedation* Ingested material

Minimum fasting period (h)

Clear liquids, water, fruit juices without pulp, carbonated beverages, clear tea, black coffee

2

Breast milk

4

Infant formula

6

Nonhuman milk because nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period

6

Light meal: A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.

6

* American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. A report of the American Society of Anesthesiologists. Available at “http://www.asahq.org/publicationsAndServices/npoguide.html”.

Chapter 22  Conscious Sedation Discharge criteria • • • • • •

Cardiovascular function and airway patency are satisfactory and stable The patient is easily arousable The patient can talk (if age appropriate) The patient can sit up unaided (if age appropriate) Presedation level of responsiveness achieved The state of hydration is adequate

• Postoperative verbal and written instructions must be given to the patient, parent, escort, guardian or care giver. Fig. 22.1: Capnography machine

Oxygenation • Color of mucosa, skin or blood must be evaluated continuously. • Oxygen saturation is measured by pulse oximetry. • Pulse oximetry (Fig. 22.1) measures the amount of oxygen carried on hemoglobin in the arterial blood. It can measure multiple parameters like SpO2, perfusion and heart rate. Its advantages are continuous monitoring, multiple sites of usage, noninvasive and user friendly.

Ventilation • The dentist and/or appropriately trained individual must verify respirations continuously. • Capnography (Fig. 22.1) usually includes capnometry to provide the digital display of a numeric value along with the waveform and it gives a digital display of the CO2 on inspiration and expiration. The principle of capnography is: Gas is diverted from the patient’s airway—A beam of infrared light is passed through the sampled gas—CO2 molecules in the light path absorb some of the infrared light waves—Capnography measures end tidal carbon dioxide (ETCO2).

Circulation Blood pressure and heart rate should be evaluated preoperatively, postoperatively and intraoperatively as necessary (unless the patient is unable to tolerate such monitoring).

Recovery and Discharge • Oxygen and suction equipment must be immediately available if a separate recovery area is utilized. • The qualified dentist or appropriately trained clinical staff must monitor the patient during recovery until the patient is ready for discharge by the dentist.

Emergency Management • If a patient enters a deeper level of sedation than the dentist is qualified to provide, the dentist must stop the dental procedure until the patient returns to the intended level of sedation. • The reversal agents and emergency drugs must be available at all times to the dentist for usage. • The qualified dentist is responsible for the sedative management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administ­ ration of minimal sedation and providing the equipment and protocols for patient rescue.

Summary of conscious sedation

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INSTRUCTIONS TO THE PARENTS FOR CONSCIOUS SEDATION Eating and drinking

Change in health

Arriving

Medications

Activities

Getting home

After treatment

Temperature

Seek advice

To avoid vomiting and complications during treatment with sedation, do not allow your child any food or drink (even water) unless directed by your doctor. The following schedule should be followed: • No milk or solid food, midnight before the scheduled procedure • Children ages 0–3 years, clear liquids up to 4 hours before the procedure • Children ages 3–6 years, clear liquids up to 6 hours before the procedure • Children ages 7 years or greater, clear liquids up to 8 hours before the procedures Any change in the child’s health, especially the development of a cold or fever, within 7 days before the day of treatment is very important. For the child’s safety, a new appointment may be made for another day A responsible adult must accompany the patient to the dental office and must remain until treatment is completed. Plan to arrive early for your appointment Give your child only those medications that he or she takes routinely, such as seizure medications or prophylactic antibiotics, and those prescribed by your child’s physician. Do not give your child any other medicines, before or after treatment, without checking with dental office Do not plan to permit activities for the child after treatment. Allow the child to rest closely supervise any activity for the remainder of the day The patient must be accompanied by a responsible adult. Someone should be available to drive the patient home. The child should be closely watched for signs of breathing difficulty and carefully secured in a car seat or seat belt during transportation After treatment, the first drink should be plain water. Sweet drinks can be given next. Small drinks taken repeatedly are preferable to taking single with large amounts The child’s temperature may be elevated for the first 24 hours after treatment. Acetaminophen every 3–4 hours and fluids will help alleviate this condition • If vomiting persists beyond 4 hours • If the temperature remains elevated. beyond 24 hours or goes above 101°F • If there is any difficulty in breathing • If any other matter causes your concern

SEDATION TECHNIQUES There are a variety of methods for producing sedation or alteration of mood in the pediatric patient. These systemic procedures are based on thoughtful utilization of various drugs that produce sedation as one of their principal effects. Sedative drugs may be administered by inhalation, oral, rectal, submucosal, intramuscular, or intravenous routes. Combinations of drugs and specific selection of routes of administration to maximize effect and increase safety, as well as patient acceptability, are common. The primary objective of these techniques is to produce a quiescent patient to ensure the best quality of care and to help train a child to willingly accept dental care. Another objective might be to accomplish a more complex or lengthy treatment plan in a shorter period by lengthening appointment times, thereby reducing the number of repeat visits required. Various routes of conscious sedation are:

Inhalation Sedation • This is the recommended route for conscious sedation for pediatric dentistry. • The inhalational route (Fig. 22.2) is the most reliable in terms of onset and recovery. • Efficacy is reduced when children object to the nasal hood or have difficulty breathing through the nose. • The use of a rubber dam improves the effect of the sedation and reduces atmospheric pollution.

Fig. 22.2: Inhalational sedation

Oral Sedation • It is the most universally accepted and easiest route of drug administration.

Chapter 22  Conscious Sedation • Disadvantages associated with this are objectionable taste, variable results, variable consistency, difficult reversal of unwanted effect and slow recovery time. • This route is mostly recommended for premedication and combination therapy. • The oral sedative agent (Fig. 22.3) should only be prescribed and administered by the operating dentist

within the facility where the dental procedure is to take place. Children who are given an oral sedative should be placed in a quiet room together with their escort and a competent member of staff and should be monitored clinically and electronically.

Intramuscular Sedation • Anatomic consideration of the injection site and additional training of the operator is required. For most patients the upper outer quadrant of gluteal region is safest but in small children anterior thigh (vastus lateralis muscle) is the preferred site (Figs 22.4A to E). • Operators should consider whether the alternative provision of a general anesthetic might carry a lower risk and give greater long-term psychological benefit to the child. • This is not recommended in children.

Submucosal Sedation • This involves deposition of the drug beneath the mucosa. • Best method is intranasal • The oral site usually chosen is the buccal vestibule.

Fig. 22.3: Oral sedation

A

B

C

D Figs 22.4A to E: Site of intramuscular sedation

E

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248 Section 5 

Behavioral Pedodontics • Nitrous oxide is sweet smelling, colorless, non-inflam­ mable, inert gas and is compressed in cylinders at 750 psi as a liquid that vaporizes on release. It has a blood gas coefficient of 0.47 and has rapid onset and recovery time due to low solubility in blood. • It has low tissue solubility and a minimum alveolar concentration (MAC) value in excess of one atmosphere, rendering full anesthesia without hypoxemia impossible at normal atmospheric air pressure. Poor tissue solubility ensures its effect is characterized by rapid onset and fast recovery. • Is a weak analgesic, although this effect can be influenced by the psychological preparation of the patient.

Fig. 22.5: IV sedation

Intravenous Sedation • This is the easiest most efficient and safest method of parentral sedation (Fig. 22.5) next to inhalation. • The onset of action of the drug is within 30 seconds. • Few disadvantages include frequent monitoring, incidence of phlebitis and hematoma at the site. • Intravenous sedation is not recommended in pre­ cooperative children. Dentists should consider whether the provision of an elective general anesthetic might be preferable in such circumstances. • Single drug intravenous sedation, e.g. midazolam, is recommended for adolescents who are psychologically and emotionally suitable. • Intravenous sedation should only be administered by an experienced dental sedationist with a trained dental nurse in an appropriate facility. • A pulse oximeter, at least, should be used to augment alert clinical observation. • Intravenous sedation for children below the age of 14 years should be carried out in a hospital facility. • Patient-controlled sedation may be of value for anxious adolescents.

Rectal Sedation • Rectal administration is not socially acceptable in the UK. • It is currently not recommended without a hospital facility and requires the assistance of a qualified anesthetist.

NITROUS OXIDE SEDATION5,6 • There is only one inhalation agent that meets the requirement of conscious sedation and that is nitrous oxide. • It is the most frequently used sedation agent by pediatric dentists.

Indications Should be offered to children with mild-to-moderate anxiety to enable them to accept dental treatment better and to facilitate coping across sequential visits.

Contraindications • • • •

Poor attenders and very young children Children having common cold, tonsillitis, nasal blockage Precooperative children First trimester of pregnancy.

Procedure of Administration (Fig. 22.6)6,7

Chapter 22  Conscious Sedation

Fig. 22.6: Nitrous oxide sedation equipment and procedure

Clinical Signs of Sedation8 These signs are clues for the clinician in determining whether the young child has reached a sedative state consistent with good behavior and pharmacologic effectiveness.

Objective Signs • Objective signs were recorded prior to and 5 minutes after nitrous oxide administration. • These signs assessed the clinical features and condition of the patient’s face, hands, legs, and feet to determine the effects of nitrous oxide. • The following signs were examined: (1) open or closed eyes; (2) tears; (3) trance-like expression; (4) smile; (5) speaking; (6) laughing; (7) open or closed hands; (8) limp legs; and (9) abducted feet.

Subjective Symptoms (Fig. 22.7) • Subjective symptoms addressed the child’s perception of the nitrous oxide effects. • Questions regarding the child’s perception of the nitrous oxide effects on the head, abdomen, fingers, toes, and overall condition were asked prior to and 5 minutes after nitrous oxide administration.

Fig. 22.7: Beery criteria for correct drawing of selected figures of the Bender Visual Motor Gestalt Test18

• The questions were: How do you feel; Do you feel different; How does your head feel; How do your fingers feel.

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Psychomotor Effects

Precautions11

• These were evaluated by asking the patient to draw four figures from the Bender Visual Motor Gestalt Test9 before and 5 minutes after nitrous oxide was administered. • This determines the visiomotor capacity10 of the child (Fig. 22.7).

Advantages • It is a viable and cost effective alternative to general anesthesia. • Nitrous oxide sedation has minimal effect on cardio­ vascular and respiratory function and the laryngeal reflex. • Using nitrous oxide inhalation sedation in conjunction with other sedatives may rapidly produce a state of deep sedation or general anesthesia.

Disadvantages • Acute adverse effects associated with this type of sedation are nausea. • Chronic effects may be impotence, liver toxicity and recreational abuse. • Exposure to nitrous oxide can result in depression of vitamin B12 activity resulting in impaired synthesis of RNA.

• Nitrous oxide is heavier than air, and if the gas were colored, which it is not, it would tend to descend from the patient’s level in the reclined position to the floor. This gas should be ejected out of the operatory using an efficient scavenging system. In this installation of laminar air-flow systems could be used to flush out the used gases from the bottom of the operatory and fresh air pumped in from the ceiling.2 • The gas itself does not have an odor, although the tubing and nasal hood may have some odor that the child dislikes. Hence, the dental surgeon would be wise to flavor the inside of the nasal hood by using fluoride foam or drops of flavored liquid to produce vapors that the child finds quite pleasant.2 • Diffusion hypoxia may occur as the sedation is reversed at the termination of the procedure. The nitrous oxide escapes into the alveoli with such rapidity that the oxygen present becomes diluted; thus the oxygen–carbon dioxide exchange is disrupted and a period of hypoxia is created. However, this phenomenon is reported not to occur in healthy pediatric patients. Nonetheless, to minimize this effect, the patient should be oxygenated for 3 to 5 minutes after a sedation procedure, if for no other reason than to allow for proper nasal hood evacuation of the exhaled gas.

Recommendations for controlling nitrous oxide exposure in the dental office Equipment

• • • •

Properly installed nitrous oxide delivery system Appropriate scavenging equipment with a readily visible and accurate flowmeter Vacuum pump with capacity up to 45 liters of air per minute per work station Variety of mask sizes to ensure proper fit

Ventilation

• • •

Vacuum exhaust and ventilation exhaust vented outside Outside venting not in close proximity to fresh air vents Good room air mixing for general ventilation

Inspections

•

With each use and when gas cylinder is changed, pressure connections tested for leaks using a soap solution or a portable infrared spectrophotometer Daily, price to first use, inspected for worn parts, cracks, holes or tears, and replaced as necessary Appropriate flow rates (up to 45 liters/min or per manufacturer’s recommendations) verified

• • Clients • •

• • • • • Dental personnel

•

Before administration Use properly sized masks to ensure a good, comfortable fit Check for over- or under-inflation of reservoir (breathing) bag while the patient is breathing oxygen (before nitrous oxide administration) During administration Minimize talking and mouth breathing by patient while mask is in place Reservoir bag periodically inspected for changes in tidal volume Vacuum flow rate verified After administration 100% oxygen delivered to patient for five minutes before removing mask to purge patient and system of residual nitrous oxide System oxygen flush should not be used Periodic (i.e. semi-annual) sampling of dental personnel, especially chair-side personnel exposed to nitrous oxide (e.g. with a diffusive sampler, such as a dosimeter or infrared spectrophotometer)

Source: ADA council on scientific affairs and the ADA council on dental practice

Chapter 22  Conscious Sedation Special indications nitrous oxide-oxygen inhalation sedation Cardiovascular disease

N2O-O2 inhalation sedation can minimize the risk of myocardial infarction

Cerebrovascular disease

Patient who has cerebrovascular disease, can receive N2O-O2 for stress/anxiety reduction

Respiratory disease

Patients with bronchial asthma can receive nitrous oxide because it is non-irritating to the bronchial and pulmonary tissues

Hepatic disease

N2O-O2 is not bio-transformed anywhere in the body, it can be used in patients with hepatic disease.

Epilepsy and other seizure

N2O-O2 can be useful in these patients to avoid stress

(Bowen DM. Aiding in administration of nitrous oxide analgesia. Idaho: Idaho State Board of Dentistry: Jan. 2005)

DRUGS USED FOR CONSCIOUS SEDATION

Opioids • All opioids produce sedation and analgesia and have the propensity to cause respiratory depression. • Commonly used opioids used for moderate sedation/ analgesia include morphine, meperidine and fentanyl.

Morphine • Produces sedation, analgesia, and mood alteration. • The onset of morphine is 5 minutes for IV doses and 15 minutes for IM doses. • The peak effect of morphine is 20 minutes (IV) and 1 hour (IM). • The duration of action is 3 to 4 hours. • Analgesia can occur without loss of consciousness but large doses can produce obtundation and even coma. • Morphine can produce prolonged postoperative som­nolence, respiratory depression, nausea, vomiting, and itching.

Meperidine (Demerol) • Meperidine is about one-tenth as potent as morphine. • It is a synthetic opioid with atropine-like properties. • The onset of meperi­dine is 3 to 4 minutes (IV) and 10 to 15 minutes (IM). • The peak effect of meperi­ dine is 15 minutes (IV) and 45 minutes (IM). • The duration of action is 2  to 4 hours. • Its effects on respiration and ventilation are simi­lar to morphine. They produce moderate effects on tidal volume and slow respi­ratory rate.

• In large dosages, it can produce tachycardia, tremors, muscle twitching, and seizures.

Fentanyl (Sublimaze) • Fentanyl has more rapid onset and shorter duration than morphine. • It is 100 times more potent than morphine. • The onset of fentanyl is 30 seconds (IV) and 5 to 10 minutes (IM). • The peak effect of fentanyl is 10 minutes (IV) and 30 to 45 minutes (IM). • The duration of action is 30 to 60 minutes. • Fentanyl in moderate doses of 2 to 10 microgram/kg or higher doses when given rapidly intravenous can produce skeletal muscle rigidity called “stiff chest syndrome.” • Fentanyl lacks histamine release and suppresses the stress response associated with surgery or invasive procedures and also depresses the respiratory center in the brainstem so that normal response to hypoxia and hypercarbia is reduced.

Benzodiazepines • Benzodiazepines are a group of medications most commonly used for moderate sedation. • In addition to their sedative properties, most benzo­ diazepines have amnesic, anxiolytic, anticonvulsive and hypnotic effects. • Commonly used benzodiazepines used for moderate sedation include diazepam, lorazepam and midazolam.

Diazepam (Valium)/Lorazepam (Ativan) • Diazepam and lorazepam have similar profiles. • Lorazepam has a similar duration or action but is approximately 5 times as potent as diazepam.

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• Diazepam can cause mild reductions in blood pressure, cardiac output and peripheral vascular resistance. • Due to diazepam and lorazepam prolonged duration of action, they may not be suitable for outpatient procedures.

Midazolam (Versed) • Midazolam is generally reserved for anxious adolescent or adult dental patients. • It can cause disinhibition rather than sedation in children. • High lipophilicity at physiological pH and very high clearance and elimination allow rapidity of onset and speedy recovery. • After oral administration the peak plasma concentration is reached within 20 minutes, faster via the rectal route in about 10 min. After 45 minutes the sedative effect wears off. The elimination half time is 2 hours, which facilitates a fast recovery. IV Midazolam • Use is widely reported in adults, there are few studies to support its routine use in the dental management of anxious children. • It can also cause a paradoxical excitement in children that is known by many as “Angry Child Syndrome.” Oral Midazolam12,13 • Oral midazolam can be administered in tablet form or as a sweetened mixture for delivery either via a drinking cup or drawn into a needleless syringe and deposited in the retromolar area as per explained figures. • Tablets are given 60 min before dental treatment, and oral mixtures given approximately 20 to 30 minutes before. • It reaches the systemic circulation via the portal circulation, this decreases the drug’s bioavailability, necessitating a higher oral dosage compared to intra­ venous administ­ration.

• Midazolam is rapidly absorbed in the gastro­intestinal tract and produces its peak effect in 30 minutes.3 • It has a short half-life of about 1.75 hours. • When given in doses between 0.5 to 0.75 mg/kg of body weight, oral midazolam has been found to be a useful sedative agent for pediatric dental outpatients. • Midazolam has also been shown to enhance anterograde amnesia when used preoperatively in pediatric patients. • Midazolam is a short acting anxiolytic agent, with short duration of action that makes its use limited to short dental procedures only. Intranasal Midazolam14 • It produces a sedative effect within 5 minutes of administration. • The administered dose is limited by the volume of the solution, as large volumes can cause cough­ing, sneezing and expulsion of part of the drug. • There have been reports of occasional respiratory depression and transient burning, discomfort affecting the nasal mucosa. • It is not recommended in children who have copious nasal secretions or who suffer from an upper respiratory tract infection. • It is not recommended for use without a hospital environment. • Midazolam may be given by the intranasal route at doses of 0.2 to 0.4 mg/kg. • Onset time is intermediate between the oral and IV routes of administration (10–15 minutes). • The effectiveness of this route of administration is well established as a premedication for anesthesia but its use is limited by burning on application to the nasal mucosa which most children find very objectionable, as well as the bitter taste of midazolam reaching the oropharynx. • Adverse effects including respiratory depression.7 Rectal Midazolam • Short duration of onset, required a low dosage and was easily adminis­ tered according to the explained diagram. • However, adverse reac­ tions such as agitation, excitement, restless­ness and disorientation together with significantly reduced blood oxygen levels, nausea and vomit­ ing have been reported. • It is an ethical/human right concern in some countries.

Chapter 22  Conscious Sedation • May necessitate the need of hospital setup. • Children under 25 kilogram of weight shall have 0.3 to 0.4 mg midazolam per kilogram bodyweight with maximum dose 10 mg midazolam. • Rectal solution is administered approxi­mately 10 minutes before treatment starts.

Barbiturates • Barbiturates result in a general CNS depression by acting at the GABA receptor and are primarily used when deep sedation is desired. • In general, barbiturates can cause hypotension and doserelated respiratory depression. At lower doses, these medications can also cause paradoxical excitation.

Methohexital15 • Methohexital is an ultra–short acting barbiturate with rapid onset. • Although IV dosing is ideal, methohexital’s high lipid solubility allows intramuscular (IM), oral, or rectal administration. • An IV dose of 0.75 to 1 mg/kg typically produces a sleep-like state without spontaneous movements within 1 minute; patients usually wake up within 10 minutes. • Methohexital is not reversible. • Because methohexital is not an analgesic, administration may potentiate pain perception. • Additional side effects may include heightened airway reflexes, myocardial depression.

Pentobarbital • Short-acting barbiturate that is often used for nonpainful diagnostic studies. • A dose of 2.5 mg/kg should produce deep sedation within 5 minutes, and effects should last between 30 to 60 minutes. • Potential side effect is hypoxia and hypotension.

Chloral Hydrate • Chloral hydrate is a chlorinated derivative of ethyl alcohol that can act as an anesthetic when administered in high doses.

• Oral chloral hydrate is easy to administer and has a low incidence of adverse effects. 8 percent milligram of chloral hydrate and 4.5 percent milligram of Nembutal were found in Marilyn Monroe’s system, and Dr Thomas Noguchi of the Los Angeles County Coroners office recorded cause of death as acute barbiturate poisoning, resulting from a probable suicide.

• The normal oral dose is 50 mg/kg of body weight with a suggested range of 40 to 60 mg/kg. • Following oral administration the onset of action of chloral hydrate is rapid, drowsiness or arousable sleep usually developing within 30 to 45 minutes. • Duration of action is 2 to 5 hours.3 • It is a weak analgesic with an elimination half-life of approximately 8 hours. • In small doses, mild sedation occurs and, in intermediate doses, natural sleep is produced. • Common complications include nausea and vomiting, depress blood pressure and respiratory rate and may cause oxygen desaturation and prolonged drowsiness. • It is a psychosedative and was used for drug abuse in earlier days. Marilyn Munroe was one high profile addict of chloral hydrate and possibly died of its overdose. • Chloral hydrate is contraindicated in children with heart disease as well as those with renal or hepatic impairment.

Propofol16 • Diprivan: 2,6 di-isopropophenol • Fast acting sedative with a narrower margin of safety, i.e. the dose required to produce a sedative effect is close to that used to induce anesthesia. • Also called as milk of amnesia. • Veerkamp et al. (1997) published an account of an exploratory study where children, mainly with nursing bottle caries, had teeth removed using propofol administered by an anesthetist. • Further research evidence is needed to know more about efficacy of this drug. • Recently involved agent in death of Michael Jackson due to overdosing.

Dexmedetomidine (Precedex) • Dexmedetomidine is the S-enantiomer of medetomidine. • It is a highly selective, potent a2-adrenergic agonist, with a short duration of action.

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• It has the ability to provide rapid and stable sedation and provide analgesia while still maintaining patient arousability and respiratory function. • It is shown to exert sedative, analgesic, and anxiolytic effects after intravenous administration. • An IV dose of 0.2 to 0.7 mcg/kg/h produces effective sedation and reduces analgesic requirements. • The unique mechanism of action of dexmedetomidine allows the patient to be awakened and respond to verbal commands, take neurological tests, and be interactive while remaining calm and comfortable. When the awakening stimulus is removed, the patient returns to sleep.

Ketamine17 • Ketamine was first synthesized by Parke-Davis scientist Calvin Stevens and got FDA approval in 1970. • Ketamine is a phencyclidine derivative that results in dissociation between the cortical and limbic systems of the brain called dissociative anesthesia. • Ketamine prevents the higher cortical centers from perceiving visual, auditory, and painful stimuli. • An IV dose of 1 mg/kg induces sedation in 2 minutes, and effects last 15 to 30 minutes. • Patients demonstrate nystagmus and display a blank stare that is characteristic of dissociative anesthesia. • Ketamine maintains cardiovascular stability as well as muscle tone and airway reflexes. • Disadvantages of ketamine may include increased intra­ cranial and intraocular pressures, hypertension, tachycardia and postemergence delirium (i.e. vivid nightmares). • Chronic use of ketamine may lead to cognitive impairments, including memory problems. • It is one of the most prevalent drug for recreational use owing to its dissociative properties. Summary of drugs use for conscious sedation as given in Table 22.2.

REVERSAL AGENTS • Specific reversal agents exist for benzodiazepines and opioids. • Sedation providers must understand their use in order to responsibly utilize either of these classes of agents.

Flumazenil • Flumazenil2 can be used to reverse the effects of benzodiazepines and should be immediately available when using benzodiazepines for sedation.

• A dose of 0.01 mg/kg may be repeated 4 times as needed. • Although rare, resedation may occur and additional doses of flumazenil may be required.

Naloxone • Naloxone2 (Narcan) is an opioid antagonist and can be given intravenously, intramuscularly, or subcutaneously but the preferred route of administration is intravenous. • The drug should be given in a slowly titrated manner when possible. • The standard preparation contains 0.4 mg/cc of naloxone. The neonatal preparation which contains 0.02 mg/kg is not recommended. The dose for children is 0.1 mg/kg for children under 20 kg. The dose for children over 20 kg is 2 mg. • The drug is incredibly effective in reversing the depressive effects of the opioids. • The effect can be very abrupt and children will often be quite disturbed when they are awakened from sedation by administering naloxone. • The most common side effect is nausea.

COMPLICATIONS ASSOCIATED WITH MODERATE OR DEEP SEDATION18,19 Every practitioner administering moderate sedation/ analgesia should be able to recognize a patient in respiratory distress and be able to rescue that patient. Some of the major complications are: • Ineffective ventilation resulting from respiratory depression causing hypoxia and hypercarbia. • Problems with the cardiovascular system including hypotension. • Drug overdose or reaction (anaphylaxis or anaphylactoid reactions). • Aspiration associated with loss of protective airway reflexes. • Nausea and vomiting. • Problems with equipment compromising patient safety.

Airway Obstruction • Airway obstruction is most common complication associated with moderate sedation. • Signs of airway obstruction include: Inspiratory stridor or snoring, rocking chest movements, absence of breath sounds, hypoxemia, hypercarbia. • In patients receiving moderate sedation, the usual source of hypercarbia is respiratory center depression from medications. • Hypercarbia is defined as a PaCO2 greater than 44 mm Hg and is the result of hypoventilation. • Hypoxemia is present when PaO2 is less than 60 mm Hg or SpO2 by pulse oximeter is less than 90 percent. • If airway obstruction is suspected consider: Repositioning the patient’s head providing a head tilt, applying a chin

Benzodiazepine (Binds to GABA receptor resulting in CNB depression)

Benzodiazepine (Binds to GABA receptor resulting in CNS depression)

Benzodiazepine (Binds to GABA receptor resulting in CNB depression)

Opioid narcotic (Binds to opioid receptor in the CNS)

Lorazepam (Ativan)

Diazepam (Valium)

Fentanyl (Sublimaze)

Class & Mechanism of Action

Midazolam (Versed)

Drug

Adults 16–64 years of age: 0.5–1 mcg/kg given in small incremental doses of 25–50 mcg up to a max dose of 250 mcg Elderly (> 65): 0.5–1 mcg/kg given in small incremental doses of 25 mcg up to a max dose of 100 mcg. The elderly are more susceptible to CNS depression.

Adults 16–64 years of age: 5 mg which may be repeated every 5 minutes to a max dose of 20 mg Elderly (> 65) and those with COPD: 2.5 mg which may be repeated every 5 minutes to a max of 10 mg

Adults 16–64 years of age: 0.02–0.05 mg/kg repeated every 3–4 minutes up to a max dose of 4 mg. (Small incremental doses of 1–2 mg every 3–4 minutes up to a max dose of 4 mg) Elderly (> 65) and those with COPD, congestive heart failure, or chronic debilitation: 0.02 mg/kg repeated every 3–4 minutes up to a max dose of 4 mg. (Small incremental doses of 0.5–1 mg repeated every 3–4 minutes up to a max dose of 4 mg)

Adults 16–64 years of age: 0.05 mg/kg repeated every 2–3 minutes to adequate sedation up to a max dose of 2 mg/kg. (Small incremental doses of 1–3 mg every 2–3 minutes up to an average total dose of 5 mg) Elderly (> 0.5) and those with COPD, congestive heart failure, or chronic debilitation: 0.02 mg/kg repeated every 2–3 minutes to adequate sedation up to a max dose of 0.2 mg/kg (small incremental doses of 0.5–1 mg every 2–3 min)

Dosing Guidelines (IV Administration)

TABLE 22.2: Summary of drugs use for conscious sedation

Onset: 1–2 min Peak Effect: 10–15 min Duration of Action 30–60 min

Onset: 1–5 min Duration of Action: 1–8 hours

Onset: 3–7 min Peak Effect: 10–20 min Duration of Action: 6–8 hours

Onset: 1–3 min Peak Effect: 5–7 min Duration of Action: 20–30 min

Onset, Peak Effect, and duration of Action

Hypotension, bradycardia, respiratory depression, nausea, vomiting, constipation, biliary spasm, and skin rash

Respiratory and cardiovascular depression may occur. May also cause ataxia, dizziness, hypotension, bradycardia, blurred vision, and paradoxical agitation.

Respiratory and cardiovascular depression may occur. May also cause ataxia, dizziness, hypotension, bradycardia, blurred vision, and paradoxical agitation.

Respiratory and cardiovascular depression may occur. May also cause ataxic, dizziness, hypotension, bradycardia, blurred vision, and paradoxical agitation.

Adverse Drug Reactions

Advantages include quick onset and short duration of action. Due to quick onset and rapid clearance, is often the most satisfactory opioid narcotic for peri-procedure sedation. Adverse effects are more common in the elderly. When combined with benzodiazepines, use reduced initial doses of each. Causes less histamine release and is associated with less hypotension and skin rash compared with morphine.

Has a longer half-life and several longacting active metabolites compared to midazolam and lorazepam. Due to longer and highly variable duration of action, has limited utility for procedural sedation. May be useful for longer procedures such as HBO treatment. Use with caution in the elderly due to unpredictable duration of action. Combine with an opioid for painful procedures but reduce the dose by 25–50%.

Compared to midazolam, has slower onset and longer duration of action. In upper end of dosing range listed, may causes dysphoria and confusion. Due to slower onset and longer duration of action, has limited utility for procedural sedation. Combine with an opioid for painful procedures but reduce dose by 25–50%.

Advantages include quick onset and short duration of action. Due to quick onset and rapid clearance, is often the most satisfactory benzodiazepine for periprocedure sedation. Combine with an opioid for painful procedures but reduce dose by 25–50%.

Comments

Contd...

Naloxone (0.4 mg initially followed by 0.1–0.2 mg every 2–3 min as needed)

Flumazenil (0.2 mg over 15 seconds, may repeat at 1 min as needed)

Flumazenil (0.2 mg over 15 seconds, may repeat at 1 min as needed)

Flumazenil (0.2 mg over 15 seconds, may repeat at 1 min as needed)

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Hypnotic/anesthetic hindered phenolic compound (General anesthetic and sedative properties; structurally unrelated to opioid, barbiturate, and benzodiazepine drugs)

Dissociative general anesthetic acetylcyclo­ hexanone agent (Produces a catalepticlike state in which the patient is dissociated from the surrounding environment; Produces intense analgesia and sedation without causing hypotension)

Propofol (Diprivan)

Ketamine (Ketalar)

Adults 16–64 years of age: 0.2–1.0 mg/kg May repeat as necessary up to a maximum dose of 2 mg/kg. Elderly (> 65): 0.2–0.75 mg/kg May repeat as necessary up to a maximum dose of 2 mg/kg.

Adults 16–64 years of age: 10–20 mg incremental doses every 5 minutes as needed to a max dose of 100 mg. Give slow IV push to avoid hypotension. Elderly (> 65): 10 mg incremental doses every 5 minutes as needed to max dose of 50 mg. Give slow IV push to avoid hypotension which is more common in the elderly and in hypovolemic patients.

Adults 16–64 years of age: 2–4 mg incremental doses every 5 minutes up to a max dose of 10–20 mg Elderly (> 65): 1–2 mg incremental doses every 5 minutes up to a max dose of 10 mg. The elderly are more susceptible to CNS depression with opioid narcotic drugs.

Opioid narcotic (Binds to opioid receptors in the CNS)

Morphine

Dosing Guidelines (IV Administration)

Adults 16–64 years of age: 25–50 mg incremental doses to a max dose of 150 mg Elderly (> 0.5): 25 mg incremental doses to a max dose of 75 mg. The elderly are more susceptible to CNS depression. The elderly are also more susceptible to selzures form non-meperidine accumulation, a metabolite of meperidine, as a result of reduced renal function in the elderly.

Class & Mechanism of Action

Meperidine Opioid narcotic (Demerol) (Binds to opioid receptors in the CNS)

Drug

Contd...

Onset: 1–2 min Duration of Action: 15–30 min

Onset: 30 sec Duration of Action 10–15 min

Onset: 2–3 min Peak Effect: 20 min Duration of Action: 2–4 hours

Onset: 5 min Peak Effect: 1 hour Duration of Action: 2–4 hours

Onset, Peak Effect, and duration of Action

Emergence CNS reactions including vivid dreams, hallucinations, and delirium; hypertension, tachycardia; increased ICP; tonic clonic movements; respiratory depression. Wide dose range effects, with analgesic action at low doses (≤ 0.2 mg/kg).

Hypotension, heart block, asystole, and other arrhythmias, bradycardia, and possible infection from lipid based vehicle. Allergic reactions in patients with a history of an egg allergy.

Hypotension, bradycardia, respiratory depression, nausea, vomiting, constipation, biliary spasm, and skin rash

Hypotension, bradycardia, respiratory depression, nausea, vomiting, constipation, biliary spasm, and skin rash. Seizures as a result of nonmeperidine accumulation in patients with renal failure may also occure.

Adverse Drug Reactions

In contrast to other sedative/analgesics, can cause hypertension and tachycardia and should be avoided in patents with aneurysms, elevated ICP, or hypertension. Adverse psychotic reactions may be avoided by pre-treatment with benzodiazepines. Many adult patients do not tolerate the negative CNS side-effects. Unlike other agents, produces both sedation and analgesia. Emergence psychotic reactions may last longer than sedative/analgesic effects.

Due to risk of hypotension, and bradycardia with bolus doses, use is restricted to monitored ICU/ ED patients and or use by anesthesia personnel. Has advantages of rapid onset and very short duration of action. Patients who are debilitated, cardio-vascularity compromized, hypovoiemic, elderly, or on concomitant beta blockers are at greatest risk of hypotension. Has minimal to no analgesic effects; combine with an analgesic agent for painful procedures.

Slower onset and longer duration of activity compared to fentanyl. More histamine release associated with hypotension and itching compared to fentanyl. Adverse effects are more common in the elderly. When combined with benzodiazepines, use reduced initial doses of each.

Has no major advantages over other opioids such as fentanyl and morphine, and is associated with a risk of seizures in patients with renal dysfunction. Use is not recommended in the elderly due to increased risk of adverse effects including seizures. When combined with benzodiazepine, use reduced initial doses of each.

Comments

Contd...

Naloxone (0.4 mg initially followed by 0.1–0.2 mg every 2–3 mins as needed)

Naloxone (0.4 mg initially followed by 0.1–0.2 mg every 2–3 mins as needed)

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Barbiturate (Sedative, hypnotic, and anticonvulsant properties; increases GABA activity in the CNS)

Barbiturate anesthetic (Depresses CNS activity by binding to the barbiturate site on GABA-receptor complex, enhancing GABA activity)

Pentobarbital (Nembutal)

Methohexital (Brevital)

Nitrous Oxide General CNS depressant (May act similarly as inhalant general anesthetics by mildly stabilizing axonal membranes: May also act on opioid receptors to cause mild analgesia)

Barbiturate hypnotic/ anesthetic (Depresses CNS activity by binding to the barbiturate site on GABA-receptor complex, enhancing GABA activity)

Class & Mechanism of Action

Thiopental (Pentothal)

Drug

Contd...

Onset: 1–3 min Duration of Action: 10–15 min

Onset: Within 1 minute Duration of Action: 15 min

Onset: 1–2 min Duration of Action: 10–30 min

Onset, Peak Effect, and duration of Action

Adults: Onset: 2–5 For sedation and analgesia, concentrations of minutes 25–50% nitrous oxide with oxygen, inhaled through the nose via a nasal mask. Avoid in pregnant patients, especially during the first two trimesters, due to increased risk of spontaneous abortion and teratogenicity.

Adults 16–64 years of age: 1 mg/kg to a maximum of 2 mg/kg Elderly (> 65): 0.5–1 mg/kg up to a maximum of 2 mg/kg. The elderly are more susceptible to adverse effects of barbiturates.

Adults 16–64 years of age: 100 mg every 1–3 minutes up to a maximum dose of 500 mg. Elderly (> 65): 50 mg every 1–3 minutes up to a maximum dose of 250 mg. The elderly are more susceptible to adverse effects of barbiturates. Also, duration of action is unpredictable due to variable kinetics in this population.

Adults 16–64 years of age: Incremental doses of 50–100 mg up to a maximum of 3 mg/kg Elderly (> 65): 25–50 mg incremental doses up to a maximum of 2 mg/kg. The elderly are more susceptible to excessive sedation and smaller initial doses should be utilized.

Dosing Guidelines (IV Administration)

Prolonged use may produce bone-marrow suppression and/ or neurologic dysfunction. The developing fetus and patients with vitamin B12 and other nutritional deficiencies are at increased risk of developing neurologic disease with exposure to nitrous oxide.

Hypotension, myocardial depression, CNS and respiratory depression, nausea, vomiting, diarrihea, cramping, laryngospasm

Hypotension, cardiovascular depression, respiratory depression, nausea, vomiting, laryngospasm

Hypotension, myocardial depression, CNS and respiratory depression, nausea, vomiting, diarrihea, cramping, laryngospasm

Adverse Drug Reactions

Inhaled gas used for dental and other short procedures which induces sedation and mild analgesia. Should not be administered without oxygen. Should not be administered to patients after eating a meal.

Ultra-short acting barbiturate useful for short procedures. No analgesic effects. Inactive, debilitated, and elderly may be more susceptible to adverse effects. Increased toxicity with other CNS depressants.

Short-acting barbiturate useful for pre-procedure sedation. No analgesic effects. Inactive, debilitated, and elderly may be more susceptible to adverse effects. Increased toxicity with other CNS depressants.

Short-acting barbiturate useful for intubation. No analgesic effects. Inactive, debilitated, and elderly may be more susceptible to adverse effects. Increased toxicity with other CNS depressants.

Comments

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lift or jaw thrust, persistent airway obstruction may require the use of airway adjuncts, suspend further drug administration. • Should the above not correct the situation consider bagmask positive ventilation and even intubation.

Anaphylaxis and Anaphylactoid Reactions • Anaphylaxis and anaphylactoid reactions are acute and are characterized by wheezing, dyspnea, syncope, hypotension, and upper airway obstruction. • Can be caused by histamine release or latex allergy. • Treatment of anaphylactic or anaphylactoid reactions: Prompt recognition of the clinical situation and stopping the administration of the suspected offending drug, Ventilation with 100 percent oxygen, Securing the airway with endotracheal intubation, Prompt use of fluids and epinephrine (IV or SQ) and antihistamines.

Aspiration • Risk factors for aspiration are inadequate fasting or recent oral intake, diabetes, pregnancy, obesity, altered consciousness.

• Suspect aspiration in patient with the above risk factors having respiratory difficulty, tachypnea, tachycardia, cyanosis and oxygen desaturation. • Blood gases may reveal hypoxemia with mixed metabolic and variable respiratory acidosis. • In severe cases of aspiration, systemic hypotension, pulmonary hypertension and pulmonary edema may occur.

Nausea and Vomiting • Nausea and vomiting can cause hypertension or hypotension, tachycardia, bradycardia and aspiration. • Nausea and vomiting is the leading cause of unexpected hospital admission. • Predisposing factors of nausea and vomiting are: Age (younger patient more susceptible), Female gender, history of postoperative emesis, Presence of hypoglycemia, pain, hypotension, or hypoxia. • Treatment of nausea and vomiting: Evaluate and treat causes of hypoglycemia, pain, hypoxia, or hypotension, Metoclopramide (Reglan)—Adult: 10 to 20 mg. IV; Pediatric 0.15 mg/kg IV, Droperidol*—Adult: 0.625 to 1.25 mg IV; Pediatric: 0.01 to 0.02 mg/kg IV.

POINTS TO REMEMBER • Sedation and general anesthesia can prove to be valuable adjunct to regular dental treatment. • Use of sedation is advocated in children lacking cooperation for the short duration periods. • Conscious sedation is defined as: A minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command and that is produced by a pharmacological or nonpharmacological method or a combination thereof. • Objectives of conscious sedation are to reduce or eliminate anxiety, reduce untoward movement and reaction to dental treatment, enhance communication and patient cooperation, raise the pain reaction threshold, aid in treatment of the mentally/physically disabled or medically compromised patient. • Indications of conscious sedation are lack of psychological or emotional maturity, medical, physical, cognitive disability, fearful, highly anxious or obstreperous patient, a patient whose gag reflex interferes with dental care, a patient for whom profound local anesthesia cannot be obtained. • There is only one inhalation agent that meets the requirement of conscious sedation and that is nitrous oxide • Ideal concentration for nitrous oxide sedation is 30 percent N2O and 70 percent O2. • Diffusion hypoxia may occur as the nitrous oxide sedation is reversed, this can be checked by administrating oxygen for 3 to 5 minutes. • Reversal agents used for benzodiazepines sedation is flumazanil and that for opioids sedation is naloxone. • Midazolam is the best drug of choice for sedation in children with oral route being most preferred and intranasal most effective. • Ketamine is the drug most often used for recreational abuse due to induction of dissociative anesthesia. • Day care/ambulatory anesthesia is indicated in healthy ASA I and ASA II patients specifically. • Use of pharmacological methods of managing uncooperative children should be used only after all the other behavior management modalities have proved to be unsuccessful.

Chapter 22  Conscious Sedation

QUESTIONNAIRE 1. Define conscious sedation, deep sedation and general anesthesia. 2. Write about importance of nitrous oxide in pediatric dentistry. 3. Which drugs are used in premedication? 4. Enumerate the indications and objectives of conscious sedation. 5. Classification of patient selection according to American Society of Anesthesiologists. 6. Write a note on Ketamine. 7. Write about reversal agents for benzodiazepines and opioids. 8. What is diffusion hypoxia? 9. Describe Midazolam sedation. 10. What are the complications of sedation? 11. Describe the drugs used for conscious sedation.

REFERENCES 1. American Dental Association. Guidelines for the use of Sedation and General Anesthesia by Dentists. As adopted by the October. 2012 ADA House of Delegates. 2. Wilson S. Management of Child Patient Behavior: Quality of Care, Fear and Anxiety, and the Child Patient. Ped Dent. 2013;35(2):170-4. 3. American Academy of Pediatric Dentistry. Clinical Guideline on the Elective use of Minimal, Moderate, and Deep Sedation and General Anesthesia in Pediatric Dental Patients. Pediatr Dent. 2004;26(7):95-103. 4. American Society of Anesthesiologists. Pediatric Anesthesia Practice Recommendations: Task Force on Pediatric Anesthesia of the ASA Committee on Pediatric Anesthesia. Park Ridge, IL: ASA 2002. 5. American Academy of Pediatric Dentistry. Guideline on use of nitrous oxide for pediatric dental patients. 6. Clark MS, Brunick AL. Handbook of Nitrous Oxide and Oxygen Sedation, 3rd Edn. USA: Mosby, Inc. 2007. 7. Sweeney R. Understanding oxygen-nitrous oxide conscious sedation equipment installations and safety. J Natl Analg Soc. 1974;3(4):6776. 8. Houpt MI, Limb R, Livingston RL. Clinical Effects of Nitrous Oxide Conscious Sedation in Children. Pediatr Dent. 2004;26:29-36. 9. Bender L. Instruction Manual for the Bender Motor Gestalt Test. American Orthopsychiatric Association; 1946. 10. Beery K. Test of Visual-Motor Integration: Administration and Scoring Manual. Chicago: Follett Publishing Company; 1967. 11. American Academy of Pediatric Dentistry. Policy on minimizing occupational health hazards associated with nitrous oxide. Pediatr Dent. 2004;26(7):48-9. 12. Bhatnagar S, Das UM, Bhatnagar G. Comparison of oral midazolam with oral tramadol, triclofos and zolpidem in the sedation of pediatric dental patients: an in vivo study. JISPPD. 2012;30(2):109-14. 13. Alzahrani AM, Wyne AH. Use of oral midazolam sedation in pediatric dentistry: A review Pak. O Dent J. 2012;(32)3:444-55. 14. Karl HW, Keifer AJ, Rosenberger JL, et al. Comparison of the  safety and efficacy of intranasal midazolam or sufentanil for pre-induction of anesthesia in pediatric patients. Anesthesiology. 1992;76:109. 15. Lerman B, Yoshida D, Levitt MA. A prospective evaluation of the safety and efficacy of methohexital in the emergency department. Am J Emerg Med. 1996;14:351–4. 16. Swanson ER, Seaberg DC, Mathias S. The use of propofol for sedation in the emergency department. Acad Emerg Med. 1996;3:234-8. 17. Kaviani N, et al. The effect of orally administered ketamine on requirement for anesthetics and postoperative pain in mandibular molar teeth with irreversible pulpitis. J Oral Sci. 2011;53(4):461-5. 18. Simmons D. Sedation and patient safety. Crit Care Nurs Clin North Am. 2005;17(3):279-85. 19. Malviya S, Voepel-Lewis T, Tait AR. Adverse events and risk factors associated with the sedation of children by non-anesthesiologists. Anesth Analg. 1997;85:1207–13.

BIBLIOGRAPHY 1. Bauman BH, McManus JG Jr. Pediatric pain management in the emergency department. Emerg Med Clin North Am. 2005;23(2):393-414. 2. Dummett CO, Adair SM. Workshop on practical and cost effective issues of behavior management. Pediatr Dent. 1999;21:470-1. 3. Hosey MT. UK National Clinical Guidelines in Paediatric Dentistry. Managing anxious children: The use of conscious sedation in paediatric dentistry. Int J Paediatr Dent. 2002;12:359-72. 4. Mistry RB, Nahata MC. Ketamine for conscious sedation in pediatric emergency care. Pharmacotherapy. 2005;25(8):1104-11. 5. Piira T, Sugiura T, Champion GD, Donnelly N, Cole AS. The role of parental presence in the context of children’s medical procedures: a systematic review. Child Care Health Dev. 2005;31(2):233-43. 6. Spitalnic S, Blazes C, Anderson A. Conscious Sedation: A Primer for Outpatient Procedures. Hospital Physician. 2000. pp.22-32.

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Chapter

Behavior Management of Handicapped Child Nikhil Marwah

Chapter outline • • •

Mental Retardation Cerebral Palsy Childhood Autism

Dental professionals and parental groups alike agree that individuals with a disability, whether developmental or acquired, are entitled to the opportunity to achieve appropriate rehabilitation, to enable them to realize their maximal level of functioning and to assist them in “normalizing” their lives. Historically, five basic reasons have been given to account for the inadequacy of dental care for this group by Plummer: 1. On the part of the profession, there has been lack of knowledge, understanding, and actual experience in treating the handicapped patient. 2. There has been inadequate information on the oral hygiene status and dental needs of the handicapped population. 3. The importance of dental care for the handicapped has been overlooked by health planners and administrators in establishing programs for the noninstitutionalized population. 4. Parents and guardians of handicapped children have not been made aware of the importance of oral health and may lack knowledge of the health care system and financial resources available to them. 5. Home care has been so neglected that most handicapped patients need extensive dental treatment.

MENTAL RETARDATION Mental retardation has been defined by the American Association of Mental Deficiency (AAMD) as “Sub-average general intellectual functioning which originates during the developmental period and is associated with impairment in adaptive behavior.”

• • •

Visual Impairment Hearing Loss Recommendations of AAPD

American academy of pediatric dentistry (1996) A person should be considered dentally handicapped if pain, infection or lack of functional dentition which affects the following: • Restricts consumption of diet adequate to support normal growth and developmental needs. • Delays or alters growth and development. • Inhibits performance of any major life activity including work, learning communication and recreation.

Dental treatment of a person with mental retardation:  Providing dental treatment for a person with mental retar­dation requires adjusting to social, intellectual, and emotional delays. A short attention span, restlessness, hyperactivity, and erratic emotional behavior may characterize patients with mental retardation undergoing dental care. The following procedures have proved beneficial in establishing dentist patient rapport and reducing the patient’s anxiety about dental care: • Give the family a brief tour of the office before attempting treatment. • Introduce the patient and family to the office staff. This will familiarize the patient with the personnel and reduce the patient’s fear of the unknown. • Allow the patient to bring a favorite item (stuffed animal, blanket, or toy) to hold for the visit. • Be repetitive; speak slowly and in simple terms. • If the individual has an alternative communication system, such as a picture board or electronic device, be sure it is available to assist with dental explanations and instructions. • Give only one instruction at a time.

Chapter 23  Behavior Management of Handicapped Child • Reward the patient with compliments after the successful completion of each procedure. • Actively listen to the patient. People with mental retar­ dation often have trouble with communication, and the dentist should be particularly sensitive to gestures and verbal requests. • Invite the parent into the operatory for assistance and to aid in communication with the patient. • Keep appointment short. • Gradually progress to more difficult procedures (e.g. anesthesia and restorative dentistry) after the patient has become accustomed to the dental environment. • Schedule the patient early in the day, when the dentist, the staff and the patient will not be fatigued.

CEREBRAL PALSY Nelson used the term cerebral palsy to describe a group of nonprogressive disorders resulting from malfunctioning of the motor centers and pathways of the brain. Dental treatment of a person with cerebral palsy: To an uninformed dentist, a person with cerebral palsy might be perceived as an uncooperative and unmanageable patient. A clinician who is not knowledgeable about physically and mentally disabling conditions may feel uncomfortable about treating such patients and may refuse to do so. The following suggestions are offered to the clinician as being of practical significance in treating a patient with cerebral palsy: • Consider treating a patient who uses a wheelchair in the same itself. • If a patient is to be transferred to the dental chair, ask about a preference for the mode of transfer. If the patient has no preference, the two person lift is recommended. • Make an effort to stabilize the patient’s head through all phases of dental treatment. • Try to place and maintain the patient in the midline of the dental chair with arms and legs as close to the body as feasible. • Keep the patient’s back slightly elevated, to minimize swallowing, (supine position). • On placing the patient in the dental chair, determine the patient’s degree of comfort and assess the position of the extremities. Do not force the limbs into unnatural positions. • Use immobilization judiciously for controling move­ ments of the extremities. • For control of involuntary jaw movements choose from a variety of mouth props and finger splint. Patient preference should weight heavily, since a patient with cerebral palsy may be very apprehensive about the ability to control swallowing. Such appliances may also trigger the strong gag reflex. • To minimize startle reflex reactions, avoid stimuli, such as abrupt movements, noises and lights, without forewarning the patient.

• Introduce intraoral stimuli slowly to avoid eliciting a gag reflex or to make it less severe. • Consider the use of the rubber dam, a highly recommended technique, for restorative procedures. • Work efficiently and minimize patient’s time in the chair to decrease fatigue of the involved muscles.

CHILDHOOD AUTISM Kanmer (1944) described a clinical syndrome in children with inability to relate appropriately to people and situations. Dental treatment of a person with autism: • A prominent symptom of infantile autism is an intense desire to maintain consistency in the environment. • Minor changes in the environment may elicit extreme anxiety in autistic children. • They often exhibit an extreme resistance on being held and show an inappropriate reaction to fearful situations. • Eye contact is difficult to achieve, and the children are prone to tantrums and aggressive or destructive behavior. • Oral hygiene is often very poor because of finicky dietary habits. • Behavior modification techniques by Lovoos have proved to be effective in producing behavioral changes in autistic children. • The key to all behavior modification programs lies in the use of positive reinforcement to promote desirable behavior. • An appropriate reward is often difficult to find for autistic children. In the early, stages of the program, sweet foods can serve as desirable rewards. In the latter stages of modifying behavior, such oral rewards should be changed to social rewards, such as a pat on the back or a hug.

VISUAL IMPAIRMENT A person is considered to be affected by blindness if the visual acuity does not exceed 20/200 in the better eye, with  correcting lenses or if the acuity is greater than 20/200 but accompanied by a visual field of no greater than 20 degrees. Dental treatment of a person with blindness: • Determine the degree of visual impairment (e.g. can the patient tell light from dark). • If a companion accompanies the patient, find out if the companion is an interpreter. If he or she is not, address the patient. • Establish rapport; offer verbal and physical reassurance. Avoid expressions of pity of references to visual impair­ ment as an affliction. • In guiding the patient to the operatory, ask if the patient desires assistance. Do not grab, move or stop the patient without verbal warning. Encourage the parent to accompany the child.

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• Paint a picture in the mind of the visually impaired child, describing the office setting and treatment. Always give the patient adequate descriptions before performing treatment procedures. It is important to use the same office setting for each dental visit to ally the patient’s anxiety. • Introduce other office personnel very informally. • When making physical contact, do so reassuringly. Holding the patient’s hand often promotes relaxation. • Allow the patient to ask questions about the course of treatment and answer them keeping in mind that the patient is highly individual, sensitive and responsive. • Allow a patient who wears eyeglasses to keep them on for protection and security. • Rather than using the tell-show-feel-do approach, invite the patient to touch, taste, or smell, recognizing that these senses are acute. Avoid sight references. • Describe in detail instruments and objects to be placed in the patient’s mouth. Demonstrate a rubber cup on the patient’s fingernail. • Because strong tastes may be rejected, use smaller quantities of dental materials with such characteristics. • Some patients may be photophobic. Ask parents about light sensitivity and allow them to wear sunglasses. • Explain the procedures of oral hygiene and then place the patient’s hand over yours as you slowly but deliberately guide the toothbrush. • Use audiocassette tapes and Braille dental pamphlets explaining specific dental procedures to supplement information and decrease chair time. • Announce exits from the entrances to the dental operatory cheerfully. Keep distractions minimal, and avoid unexpected loud noises. • Limit the patient’s dental care to one dentist whenever possible. • Maintain a relaxed atmosphere. Remember that your patient cannot see your smile.

HEARING LOSS Dental treatment of a person with hearing loss: • Prepare the patient and parent before the first visit with a welcome letter that states what is to be done and include a medical history form. • Let the patient and parent determine the initial appointment how the patient desires to communicate (i.e. interpreter, lip reading, sign language, writing notes, or a combination of these). • Look for ways to improve communication. It is useful to learn some basic sign language. • Face the patient and speak slowly at a natural pace and directly to the patient without shouting. • Assess speech, language ability, and degree of hearing impairment when taking the patient’s complete medical history.

• Identify the age of onset, type, degree, and cause of hearing loss, whether any other family members are affected. • Enhance visibility for communication. • Watch the patient’s expression. • Have the patient use hand gestures if a problem arises. • Write out and display information. • Reassure the patient with physical contact; hold the patient’s hand initially, or place a hand reassuringly on the patient’s shoulder while the patient maintains visual contact. • The child may be startled without visual contact so explain to the patient if you must leave the room. • Use visual aids and allow the patient to see the instruments, and demonstrate how they work. • Display confidence; use smiles and reassuring gestures to build up confidence and reduce anxiety. • Adjust the hearing aid (if the patient has one) before the hand-piece is in operation, since a hearing aid will amplify all sounds.

RECOMMENDATIONS OF AAPD This guideline by American Academy of Pediatric Dentistry (AAPD) for individuals with Special Health Care Needs (SHCN) is intended to educate health care providers, parents, and ancillary organizations about the management of oral health care needs particular to individuals with SHCN.

Scheduling Appointments • The parent’s/patient’s initial contact with the dental practice allows both parties an opportunity to address the child’s primary oral health needs and to confirm the appropriateness of scheduling an appointment with that particular practitioner. • Along with the child’s name, age, and chief complaint, the receptionist should determine the presence and nature of any SHCN and, when appropriate, the name(s) of the child’s medical care provider(s). • The office staff, under the guidance of the dentist, should determine the need for an increased length of appointment and/or additional auxiliary staff in order to accommodate the patient in an effective and efficient manner.

Dental Home • Patients with SHCN who have a dental home are more likely to receive appropriate preventive and routine care. • The dental home provides an opportunity to implement individualized preventive oral health practices and reduces the child’s risk of preventable dental/oral disease.

Chapter 23  Behavior Management of Handicapped Child

Patient Assessment • Familiarity with the patient’s medical history is essential to decreasing the risk of aggravating a medical condition while rendering dental care. • An accurate, comprehensive, and up-to-date medical history is necessary for correct diagnosis and effective treatment planning. • Information regarding the chief complaint, history of present illness, medical conditions and/or illnesses, medical care providers, hospitalizations/surgeries, anesthetic experiences, current medications, allergies/ sensitivities, immunization status, review of systems, family and social histories, and thorough dental history should be obtained. • At each patient visit, the history should be consulted and updated. Recent medical attention for illness or injury, newly diagnosed medical conditions, and changes in medications should be documented. A written update should be obtained at each recall visit. Significant medical conditions should be identified in a conspicuous yet confidential manner in the patient’s record. • A caries-risk assessment should be performed. An individualized preventive program, including a dental recall schedule, should be recommended after evaluation of the patient’s caries risk, oral health needs, and abilities. • A summary of the oral findings and specific treatment recommendations should be provided to the patient and parent/caregiver.

Medical Consultations The dentist should coordinate care via consultation with the patient’s other care providers. When appropriate, the physician should be consulted regarding medications, sedation, general anesthesia, and special restrictions or preparations that may be required to ensure the safe delivery of oral health care.

Patient Communication • When treating patients with SHCN, similar to any other child, developmentally-appropriate communication is critical. • An attempt should be made to communicate directly with the patient during the provision of dental care. A patient who does not communicate verbally may communicate in a variety of nontraditional ways.

Informed Consent All patients must be able to provide signed informed consent for dental treatment or have someone present who legally can provide this service for them. Informed consent should be

well documented in the dental record through a signed and witnessed form.

Behavior Guidance • Behavior guidance of the patient with SHCN can be challenging because of dental anxiety or a lack of understanding of dental care, children with disabilities may exhibit resistant behaviors. These behaviors can interfere with the safe delivery of dental treatment. • With the parent/caregiver’s assistance, most patients with physical and mental disabilities can be managed in the dental office. • Protective stabilization can be helpful in patients for whom traditional behavior guidance techniques are not adequate. • When protective stabilization is not feasible or effective, sedation or general anesthesia is the behavioral guidance armamentarium of choice.

Preventive Strategies • Individuals with SHCN may be at increased risk for oral diseases; these diseases further jeopardize the patient’s health. • Education of parents/caregivers is critical for ensuring appropriate and regular supervision of daily oral hygiene. • Toothbrushes can be modified to enable individuals with physical disabilities to brush their own teeth. Electric toothbrushes and floss holders may improve patient compliance. Caregivers should provide the appropriate oral care when the patient is unable to do so adequately. • A noncariogenic diet should be discussed for long-term prevention of dental disease. • Patients with SHCN benefit from sealants and fluoride programs. • Preventive strategies for patients with SHCN should address anticipatory guidance about risk of trauma and what to do if dentoalveolar trauma occurs.

Barriers • Dentists should be familiar with community-based resources for patients with SHCN and encourage such assistance when appropriate. • While local hospitals, public health facilities, rehabili­ tation services, or groups that advocate for those with SHCN can be valuable contacts to help the dentist/ patient address language and cultural barriers, other community-based resources may offer support with financial or transpor­tation considerations that prevent access to care.

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POINTS TO REMEMBER • A person should be considered dentally handicapped if pain, infection or lack of functional dentition which affects the following: Restricts consumption of diet adequate to support normal growth and developmental needs; delays or alters growth and development; inhibits performance of any major life activity including work, learning communication and recreation. • Tell show do technique, short appointment time and allowing child his favorite toy in operatory are best approaches in dental management of children with mental retardation. • Treatment in wheelchair and immobilization for extremities are best used for managing children with cerebral palsy. • In case of autism the main precaution is to avoid sudden movements and the focus is to maintain consistency in the environment. • During treatment of patient with hearing loss lip reading, sign language is good tools to be used. • While managing a blind child for dental treatment the use of Braille signs and Feel Show Do technique is the most effective.

QUESTIONNAIRE 1. 2. 3. 4. 5.

Enumerate the reasons for lack of dental care in handicapped children. Describe the management of a child with mental retardation. How will you manage a child with cerebral palsy in dental operatory. Explain dental management of autistic child. What are the dental management strategies in case of a child with vision or hearing loss?

BIBLIOGRAPHY 1. American Academy of Pediatric Dentistry. Definition of special health care needs. Pediatr Dent. 2012;34 (special issue):16. 2. American Academy of Pediatric Dentistry. Symposium on lifetime oral health care for patients with special needs. Pediatr Dent. 2007;29(2):92-152. 3. Anders PL, Davis EL. Oral health of patients with intellectual disabilities: A systematic review. Spec Care Dentist. 2010;30(3):110-7. 4. Charles JM. Dental care in children with developmental disabilities: Attention deficit disorder, intellectual disabilities, and autism. J Dent Child. 2010;77(2):84-91. 5. Glassman P, Subar P. Planning dental treatment for people with special needs. Dent Clin North Am. 2009;53(2):195-205, vii-viii. 6. Mink JR. Dental care for the handicapped child. In: Goldman HM, et al (Eds). Current therapy in dentistry, vol. 2. St. Louis: Mosby; 1966. 7. Nowak AJ, Casamassimo PS, Slayton RL. Facilitating the transition of patients with special health care needs from pediatric to adult oral health care. J Am Dent Assoc. 2010;141(11):1351-6. 8. Nowak AJ. Patients with special health care needs in pediatric dental practices. Pediatr Dent. 2002;24(3):227-8. 9. Nunn JH. The dental health of mentally and physically handicapped children: A review of the literature. Community Dental Health. 1987;4:157-68. 10. Ohmori I, Awaya S, Ishikawa F. Dental care for severely handicapped children. Int Dent J. 1981;31(3):177-84. 11. Shenkin JD, Davis MJ, Corbin SB. The oral health of special needs children: Dentistry’s challenge to provide care. J Dent Child. 2001;86(3):201-5.

6

Section

PREVENTIVE PEDODONTICS

This section deals with balanced diet, diet dairy, diet counseling, nutritional aspects along with the preventive measures of caries control like pits and fissures sealants and fluorides. It also deals with methods of plaque control children.

24

Chapter

Diet and Nutrition Nikhil Marwah

Chapter outline • • • •

Basal Metabolism and Basal Metabolic Rate Energy for Physical Activity Specific Dynamic Action of Food Recommended Dietary Allowance

A balanced diet is one in which nutrients from each food group in recommended servings is present for the optimal functioning of the human. Since, energy is of prime importance in the life process, the study of nutrition is concerned with the basic question of how the human body metabolizes and transforms the elements of food into energy. In fact, our need for energy has such a high priority that a nutrient such as protein, whose primary function is to build tissue, can be used to provide energy when adequate amounts of carbohydrates and fats—the usual nutrient energy sources are not eaten. The energy from food is made available to the body in four basic forms: chemical, for synthesis of new compounds; mechanical, for muscle contraction; electrical, for brain and nerve activity; and thermal, for regulation of body temperature. The overall energy needs of the body are calculated to be the sum of three factors: Basal metabolism, energy for physical activity and the specific dynamic action.

BASAL METABOLISM AND BASAL METABOLIC RATE • Basal metabolism is the minimum amount of energy needed to regulate and maintain the involuntary essential life processes, such as breathing, circulation of the blood, cellular activity, keeping muscles in good tone, and maintaining body temperature. • The basal metabolic rate (BMR) is defined as the number of kilocalories expended by the organism per square meter of body surface per hour (kcal/m2/ hour).

• • •

Food Group Guides Food Guide Pyramid Dietary Goals

• The basal metabolism of healthy men requires about 1600 to 1800 kcal daily; basal expenditure of women is about 1200 to 1450 kcal.

ENERGY FOR PHYSICAL ACTIVITY • Muscular activity affects both energy expenditure and heat production. • Energy expenditure increases with muscular activity. Maintenance activity

Sitting most of the day, about 2 hours of moving about slowly or standing

Light activity

Typing teaching, shop-work, laboratory work; some walking

Moderate activity

Walking, housework, gardening, carpentry, cycling, tennis

Strenuous activity

Picking and shovel work, swimming, basketball, football, running

SPECIFIC DYNAMIC ACTION OF FOOD • Specific dynamic action (SDA) is the term used to describe the expenditure of calories during the digestion and absorption of food. • It is 2 percent for fats, 6 percent for carbohydrates and 12 percent for protein-rich foods.

RECOMMENDED DIETARY ALLOWANCE • Since 1943, the Food and Nutrition Board, a group of nutrition scientists, has published at approximately

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5-year intervals revised and updated editions of the Recommended Dietary Allowances (RDA). • The RDAs are sets of values for levels of intake of the nutrients currently considered essential and which meet the physiological needs of nearly all individuals (Tables 24.1 and 24.2). • The RDAs are primarily designed for planning and procuring nutritionally adequate food supplies for population groups rather than for individuals. • If the foods consumed contain the amounts of nutrients that meet the RDA, the probability of developing nutritional deficiencies is negligible.

• These are recommendations for the average daily amounts of nutrients that will meet nutritional requirements of most people. • In addition to providing standards for the USRDA nutritional labeling, the RDA also serves as the basis for: – The food guides – The development of diets and products for therapeutic uses – The formulation of new food products – A guide for food provided by community resources such as senior centers, home-delivered meals, and food stamps.

TABLE 24.1: Vitamins Vitamin

Name

Functions

Thiamine

B2

Riboflavin

B4

Niacin

B5

Pantothenic • Involved in Kreb’s cycle acid • Component of sterols Biotin • Stimulates growth of yeast • Constituent of DNA Pyridoxine • Co-factor for enzymes • Synthesis of amino acids Cyanoco• Co-enzyme balamin • Maintenance of myelin sheath

Paresthesia, fatigue, abdominal stress Dermatitis, paresthesia, glossitis Dermatitis, glossitis, convulsions Atrophic glossitis, combined system disease

–

Folic acid

C

Ascorbic acid

Malabsorption, anemia, angular cheilosis Scurvy, hemorrhagic skin, follicles, swollen and bleeding gums

A

Retinol

• Maturation of blood cells • Co-enzyme • DNA synthesis • Formation of collagen • Wound healing • Role in hematology • Role in phagocytosis • Metabolism of amino acids • Formation of visual purple • Differentiation of epithelium • Promotion of bone remodeling • Activation of cell membrane

D

Cholecalci­ ferol

• Calcium and phosphorus absorption

Rickets and osteomalacia

E

Tocopherol

K

Menadione

• Antioxidant Anemia • Stabilizes cell membrane • Prevents fats form decay • Synthesis of prothrombin and Clotting disorders other clotting factors

– B6 B12

• Co-enzyme • Helps in DNA, RNA formation • Metabolism of fats, proteins • Role in neurophysiology • Co-enzyme • ATP generation • Metabolism • Co-enzyme • Tissue respiration • CNS functioning

Deficiency

B1

Wet, dry and infantile beriberi

RDA 1 mg/day

Food sources Cereals, meat, liver, peas, beef, Nuts, milk, leafy Legumes, pork, vegetable

Oral manifestations No oral manifestations

Dermatitis, glossitis, angular 1.5 mg/day stomatitis Pellagra

Night blindness, keratomalacia, xerophthalmia, hyperkeratosis, hypoplasia

Milk, liver, cheese, eggs, cereals, whole grains, vegetables 16–33 niacin Liver, yeast, meat, legumes, Equivalents cereals

Angular cheilosis, atrophy of filliform papillae, enlarged fungiform papillae, shiny red lips, magenta tongue, sore tongue Angular cheilosis, mucositis, stomatitis, oral pain, ulceration, ulcerative gingivitis, denuded tongue, glossitis, glossodynia, tip of tongue is red and swollen, dorsum is dry and smooth. 4–7 mg/day Eggs, cereals, legumes, milk, – potatoes 100–200 Liver, milk, egg Yolk, yeast – µg/day 0.3–2 mg/ Meat, liver, yeast, legumes, Angular cheilosis, sore or burning mouth, day wheat bran, cereals glossitis, glossodynia 3 µ/day Meat, egg, milk, cheese, fish Angular cheilosis, mucositis, stomatitis, sore or burning mouth, hemorrhage gingiva, halitosis, epithelial dysplasia of oral mucosa, loss or distortion of taste, ulceration, denuded tongue, glossitis, “beefy” red, smooth and glossy, delayed wound healing, xerostomia, bone loss, apthous ulcers 0.4 mg/day Liver, dark green leafy – vegetables, nuts, orange asparagus, soya 60 mg/day Pepper, turnip, citrus fruits, Scurvy-red swollen gingivae, gingival friability, cabbage, beans, tomatoes, periodontal destruction, sore burning mouth, carrot, tamarind soft tissue ulceration, increased risk of candidiasis, malformed teeth (inadequate dentine) 5000 IU Yellow and vegetables, Inadequate cell differentiation-impaired healing carrot, cabbage, spinach, and tissue regeneration, desquamation of oral potatoes mucosa, keratosis, increased risk of candidiasis, gingival hypertrophy and inflammation, xerostomia, disturbed or arrested enamel development, irregular tubular dentine formation and increased caries risk 400 IU Fish, egg, liver, butter, milk Incomplete mineralization of teeth and alveolar bone excess- Pulp calcification, enamel hypoplasia 10–20 IU Cereals, soybean, corn, No oral manifestation meat, milk, egg 70–140 µg/ day

Lettuce, spinach, cauliflower, Increased risk of bleeding and candidiasis cabbage

Chapter 24  Diet and Nutrition TABLE 24.2: Minerals Mineral Calcium

Phosphorus

Sodium and chlorine

Potassium Magnesium Sulfur

Iron

Iodine

Manganese Copper Zinc Cobalt

Functions • Gives rigidity to bones and teeth • Aids in transmission of impulses across neuromuscular junction • Acts as a chemical trigger in the contraction of muscles • Essential factor in the clotting of blood • Development and maintenance of skeletal structure • Involved in the storage and release of energy in carbohydrate metabolism • Component of RNA and DNA • Component of cell membranes • Major components of extracellular fluid— helps maintain osmotic pressure • Helps regulate acid-base balance

Sources • Milk and milk products • Leafy green vegetables—kale, mustard greens, broccoli (spinach contains oxalic acid which binds calcium so that it cannot be absorbed)

Deficiency Hypocalcemia Tetany

• Meat, poultry, fish, eggs • Milk, dried peas and beans • Whole grain breads and cereals are rich sources, but much of the phosphorus is bound by phytic acid

Irritability, weakness, blood cell disorders, git dysfunction

• Salt used in processing food, cooking, and at the table Sodium – Hyponatremia, Coma, Confusion Chlorine – Alkalosis, failure to thrive • Helps to maintain osmotic pressure and acid- • Bran, Brewer’s yeast, dried peas and beans, oranges Hypokalemia, paralysis, cardiac base balance problems • Role in the body’s anabolic and catabolic • Leafy green vegetables, nuts, soybeans, snails Neuromuscular irritability processes • Component of sulfur-containing amino acids, • Wheat germ, lentils, peanuts, cheese the vitamins thiamine and biotin, enzymes • Major source is the amino acid cystine (coenzyme A) and hormones (insulin) • Component of hemoglobin (carries oxygen • Meat, organ meats, egg yolks, clams, oysters, leafy Anemia, enteropathy, from lungs to tissues) green vegetables decreased work performance, • Component of myoglobin (stores oxygen impaired learning ability temporarily in muscle) • Component of catalysts in the metabolism of glucose • Essential component of thyroxin and • Iodized salt Cretinism, deafmutism, triiodothyronine (regulates the rate of • Seafood impaired fetal growth, oxidation-reduction reactions) • Seaweed retarded brain development • Cofactor in enzyme systems • Dry tea, instant coffee, whole grains, peanut butter Arthralgia, nueralgia • Present in several enzymes essential for • Cocoa powder, dry tea, beef and pork liver, peanut Anemia, menkes syndrome development of young red blood cells butter • Component of several metalloenzymes • Meat, poultry, seafood, eggs Growth retardation, hypogonadism • Constituent of vitamin B12 –

Molybdenum • Not established in man Fluorine • Incorporated into tooth structure, aids in resistance to caries Chromium • Role in glucose tolerance in humans Selenium • Nonspecific antioxidant catalyst

• Legumes, cereal grains, liver • Fluoridated water, seafood, dry tea

Tachycardia, nausea, headache Osteoporosis, dental caries

• American cheese, dry beans, meat, whole grains • Meat, eggs, milk, seafood, whole grains

Impaired glucose tolerance Muscle weakness

FOOD GROUP GUIDES The objective of national food guides has been to translate dietary standards into simple and reliable devices for the nutrition education of the layperson. The factors that were taken into consideration in the development of food guides were the customary food patterns, the availability of food, food economics, and the nutritive value of foods in a

particular locale. The food group guides serve as a practical and workable plan for helping the homemaker select the type and amount of food that needs to be included in each day’s meals in order to provide a balanced diet. The USDA daily food guide divides commonly eaten foods into five groups according to their respective nutritional contributions: (1) vegetable-fruit, (2) bread-cereal, (3) milk-cheese, (4) meat, poultry, fish, and beans, and (5) fats, sweets, and alcohol.

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Vegetable-fruit Group • Vegetables and fruits are important because they contribute vitamins A and C and fiber as well as trace amounts of other nutrients. • In general, the color of the vegetable or fruit is a guide to its food value. • Dark green and deep yellow vegetables are good sources of vitamin A. • Most dark green vegetables, if not overcooked, are also reliable sources of vitamin C as well as riboflavin, folic acid, iron, and magnesium. • The food guide recommends four basic servings daily from this group. This includes one good vitamin C source each day and a dark green and a deep yellow vegetable at least every other day and more frequently if possible. • To ensure adequate fiber, unpeeled raw fruits and vegetables and edible seeds should be eaten when possible. • A serving is one-half cup of a vegetable or fruit, or a portion as ordinarily served, such as one medium-size apple, or potato; one bowl of salad; or half of a mediumsize grapefruit.

Bread Cereal Group • The bread and cereal group is the most economical source of nutrients in our daily diets. • A wide variety of cereal grain is available, including wheat, rice, corn, rye, oats, and barley. • Whole-grain or enriched bread and cereals contain substantial amounts of the B vitamins and iron. • Bread and cereals also provide protein, and are a major source of this nutrient in vegetarian diets. • Whole-grain products also contribute magnesium and fiber. • Many breakfast cereals are enriched at nutrient levels higher than those that occur in natural whole grain. In some cases, fortification adds vitamins, such as A, B, C, and D, not normally found in cereals (which is not desirable or recommended, especially the addition of vitamins A and D). • However, fiber and other still unidentified vitamins and trace minerals that may normally be present in whole grain are not replaced in the usual restoration process of the refined cereals. • Therefore, it is strongly recommended that natural wholegrain products be included in the diet whenever possible. • Four servings daily of breads and cereals, especially of whole-grain products, are recommended. • Counted as one serving are 1 oz of ready-to-eat cereal, ½ to ¾ cup of cooked cereal, corn meal, grits, macaroni, noodles, spaghetti, or rice, and one slice of bread.

Milk Cheese Group • Milk products are an important part of the diet as they provide about two-thirds of the calcium, one half of the riboflavin, and one-fourth of the protein in the foods normally eaten. • Milk is low in vitamin C and iron, but it supplies more of the other essential nutrients in significant amount than any other single food. • An average serving is one 8-oz cup of milk or about a 1-inch cube of cheddar cheese. • Children and adolescents should have the equivalent of 3  to 4 serving daily.

Meat, Poultry, Fish, and Beans Group • The choices within this group are many: beef, lamb, veal, pork, fish, poultry, eggs, dried beans or peas, and nuts. • These foods are valued for protein, phosphorus, niacin, vitamin B12 and iron. Only foods of animal origin provide vitamin B12. • Foods in this group are usually the most expensive items in the diet. • In this group, the organ meats (liver, heart, and kidneys) deserve special mention for their high nutritional value in relation to cost. There is relatively little difference in the protein and iron content of beef, veal, lamb, and pork, although pork is richer in thiamine. • Fish, poultry, and eggs are complete protein foods and can be used as meat equivalents. Nuts and their products, such as peanut butter, can be included in the diet for variety. • It is strongly recommended that the choices among the above-mentioned food be varied, because each has distinct nutritional advantages. For example, red meats and oysters are good sources of zinc. Liver and egg yolks are valuable sources of vitamin A. Dry beans, dry peas, soybeans, and nuts are worthwhile sources of magnesium. Fish and poultry are low in saturated fat. Sunflower and sesame seeds contribute polyunsaturated fatty acids. Cholesterol is found in high concentration in organ meats and egg yolks, whereas fish and shellfish except shrimp are relatively low in cholesterol. • To obtain full advantage of the protein from the foods in this group, it is preferable to have an occasional egg for breakfast, a fish or meat sandwich at noon, and some meat, fish, poultry, or beans at night rather than to have a large serving at only one meal and no food from this group at other meals. • Suggested daily amounts from this group of foods are 2 or more servings. • Count 3 to 4 oz of lean cooked meat, or fish filet as a serving. One half to ¾ cooked beans, dry peas (split peas),

Chapter 24  Diet and Nutrition

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soybeans, or lentils; 2 tablespoons peanut butter, and ¼ to ½ cup nuts, sesame seeds, or sunflower seeds count as 1 oz of meat, poultry, or fish.

Fats, Sweets, and Alcohol Group • This group of foods provides mostly calories. • Included in the group are butter, margarine, mayonnaise, other salad dressings, other fats and oils; candy, sugar, jams, jellies, syrups, sweet toppings, soft drinks and other highly sugared beverages; wine, beer, and liquor. • Refined flour products that are not restored or enriched used as ingredients in prepared foods are also included in this group. • The most desirable food in this group vegetable oils supply vitamin E and essential fatty acids and margarine and butter which provide some vitamin A. • In general, with the exception of the fats just mentioned, these foods provide practically no essential nutrients such as vitamins, minerals, and protein therefore no serving sizes are defined.

FOOD GUIDE PYRAMID • A food guide pyramid is a pyramid shaped guide of healthy foods divided into sections to show the recommended intake for each food group. • The USDAs first dietary guidelines were published in 1894 by Dr Wilbur Olin Atwater. In Atwater’s 1904 publication titled Principles of Nutrition and Nutritive Value of Food, he advocated variety, proportionality and moderation; measuring calories; and an efficient, affordable diet that focused on nutrient-rich foods and less fat, sugar and starch. • The historical perspective of food guides was explained by Welsh S and Shaw in 1992.

Basic Seven • The first food guide proposed in 1943 was basic seven (Fig. 24.1).

Fig. 24.1: Basic seven food guide (Reprinted with permission from USDA Center for Nutrition Policy and Promotion)

Chapter 24  Diet and Nutrition • In 1943, during World War II, The USDA introduced a nutrition guide promoting the “Basic seven” food groups to help maintain nutritional standards under wartime food rationing. The basic seven food groups were: – Green and yellow vegetables (some raw; some cooked, frozen or canned) – Oranges, tomatoes, grapefruit (or raw cabbage or salad greens) – Potatoes and other vegetables and fruits (raw, dried, cooked, frozen or canned) – Milk and milk products (fluid, evaporated, dried milk, or cheese) – Meat, poultry, fish, or eggs (or dried beans, peas, nuts, or peanut butter) – Bread, flour, and cereals (natural whole grain, or enriched or restored) – Butter and fortified margarine (with added vitamin A).

Basic Four • Basic seven was then upgraded in 1957 to the four food groups, the basic four (1956–1992) (Fig. 24.2). • These food groups were: – Vegetables and fruits: Recommended as excellent sources of vitamins C and A, and a good source of fiber. A dark-green or deep-yellow vegetable or fruit was recommended every other day. – Milk: Recommended as a good source of calcium, phosphorus, protein, riboflavin, and sometimes vitamins A and D. Cheese, ice cream, and ice milk could sometimes replace milk.

– Meat: Recommended for protein, iron and certain B vitamins. Includes meat, poultry, fish, eggs, dry beans, dry peas, and peanut butter. – Cereals and breads: Whole grain and enriched breads were especially recommended as good sources of iron, B vitamins and carbohydrates, as well as sources of protein and fiber. Includes cereals, breads, cornmeal, macaroni, noodles, rice and spaghetti. • “Other foods” were said to round out meals and satisfy appetites. • These included additional servings from the Basic Four, or foods such as butter, margarine, salad dressing and cooking oil, sauces, jellies and syrups.

Five Group Guide • In 1979, the USDA recommended a five-food groups daily food guide. • In the five-food groups guide fats, sweets, and alcohol groups were added to the basic four (Fig. 24.3).

Fig. 24.3: Five group guide (Reprinted with permission from USDA Center for Nutrition Policy and Promotion)

Food Wheel Approach

Fig. 24.2: Basic four group guide (Reprinted with permission from USDA Center for Nutrition Policy and Promotion)

• Total diet approach included goals for both nutrient adequacy and moderation • Five food groups and amounts formed the basis for the food guide pyramid • Daily amounts of food provided at three calorie levels • First illustrated for a red cross nutrition course as a food wheel (Fig. 24.4).

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Preventive Pedodontics • On 15th April 2005, the USDA updated its guide with my pyramid [for adults (Fig. 24.6), for children (Fig. 24.7) and for vegetarians (Fig. 24.8)], which replaced the hierarchical levels of the food guide pyramid with colorful vertical wedges, often displayed without images of foods, creating a more abstract design. Stairs were added up the left side of the pyramid with an image of someone climbing them to represent exercise. The share of the pyramid allotted to grains now only narrowly edged out vegetables and milk, which were of equal proportions. Fruits were next in size, followed by a narrower wedge for protein and a small sliver for oils. An unmarked white tip represented discretionary calories for items such as candy, alcohol, or additional food from any other group.

My Plate

Fig. 24.4: Food wheel approach (Reprinted with permission from USDA Center for Nutrition Policy and Promotion)

• The food guide pyramids were discontinued and a new alternative program named my plate (Fig. 24.9) was initiated in 2nd June 2011. • My plate is divided into four slightly different sized quadrants, with fruits and vegetables taking up half the space, and grains and protein making up the other half. • The vegetables and grains portions are the largest of the four (30 percent grains, 30 percent vegetables, 20 percent fruits and 20 percent protein), accompanied by a smaller circle representing dairy, such as a glass of low-fat/nonfat milk or a yogurt cup. • Some of the additional recommendations are “Make half your plate fruits and vegetables,” “Switch to 1 percent or skim milk,” “Make at least half your grains whole,” and “Vary your protein food choices.” • The guidelines also recommend portion control while still enjoying food, as well as reductions in sodium and sugar intakes.

DIETARY GOALS

Fig. 24.5: USDA first food guide pyramid (Reprinted with permission from USDA Center for Nutrition Policy and Promotion)

Food Guide Pyramid • The first food pyramid was published in Sweden in 1974 • But the popular food guide pyramid was proposed in 1992 (Fig. 24.5) which was again modified in March 1999. • The introduction of the USDAs food guide pyramid in 1992 attempted to express the recommended servings of each food group

The following dietary goals and changes in food selection and preparation are recommended so as to provide adequate nutrition. • Increase the consumption of complex carbohydrates and naturally occurring sugars from about 28 percent to about 48 percent. • Reduce the consumption of refined and processed sugars by about 45 percent. • Reduce overall fat consumption from approximately 40 percent to about 30 percent. • Reduce saturated fat consumption. • Reduce cholesterol consumption to about 300 mg/day. • Limit sodium intake by reducing salt to about 5 g/day.

Chapter 24  Diet and Nutrition

Fig. 24.6: Food guide pyramid for adults based on BMR (modified 2005) (Reprinted with permission from USDA Center for Nutrition Policy and Promotion)

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Fig. 24.7: Food guide pyramid for children (modified 2005) (Reprinted with permission from USDA Center for Nutrition Policy and Promotion)

Chapter 24  Diet and Nutrition

Fig. 24.8: Food guide pyramid for vegetarians (Department of Nutrition, Loma Linda University, USA, 2008)

 hanges in Food Selection and C Preparation Suggested by the Dietary Goals • Increase consumption of fruits, vegetables and whole grains. • Decrease consumption of refined sugars. • Decrease consumption of food high in total fat and replace saturated fats with polyunsaturated fats. • Decrease consumption of animal fat, choosing meats such as poultry to reduce saturated fat intake.

Fig. 24.9: My plate program 2011 (Reprinted with permission from USDA Center for Nutrition Policy and Promotion)

• Decrease consumption of butterfat, eggs, and other sources high in cholesterol. • Decrease consumption of salt and foods high in salt content.

Implementation of Dietary Goals • Eat a variety of foods • Eat foods with adequate starch and fiber, such as wholegrain bread, cereals, raw vegetables, and fruits • Eat a minimum to moderate amount of sugar • Eat a minimum to moderate amount of salt • Consume alcohol only in moderation • Achieve and maintain ideal weight.

POINTS TO REMEMBER • A balanced diet is one in which nutrients from each food group in recommended servings is present for the optimal functioning of the human. • The RDAs are sets of values for levels of intake of the nutrients currently considered essential and which meet the physiological needs of nearly all individuals. • The food group guides serve as a practical and workable plan for helping the homemaker select the type and amount of food that needs to be included in each day’s meals in order to provide a balanced diet. • The USDA daily food guide divides commonly eaten foods into five groups according to their respective nutritional contributions: (1) vegetable-fruit, (2) bread-cereal, (3) milk-cheese, (4) meat, poultry, fish, and beans, and (5) fats, sweets, and alcohol. • Vegetables and fruits are important because they contribute vitamins A and C and fiber as well as trace amounts of other nutrients. • Bread and cereal group is the most economical source of nutrients in our daily diets. • Milk products are an important part of the diet as they provide about two-thirds of the calcium, one half of the riboflavin, and one-fourth of the protein in the foods normally eaten. • Meats are valued for protein, phosphorus, niacin, vitamin B12 and iron.

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• The USDAs first dietary guidelines were published in 1894 by Dr Wilbur Olin Atwater. • The first food pyramid was published in Sweden in 1974. • First food guide proposed in 1943 was basic seven; changed to basic four in 1957; upgraded in 5 group guide in 1979; changed to food guide pyramid in 1992; modified with component of BMR in 2005 and a new alternative program named My Plate was initiated in 2nd June 2011.

QUESTIONNAIRE 1. 2. 3. 4. 5.

What is specific dynamic action? Explain RDA. Describe the food group guides. Explain the historical evolution of food guide pyramid. What is My Plate concept?

BIBLIOGRAPHY 1. Burt BA. Diet, nutrition and oral health; A Rational Approach for the dental practice. J Am dent Assoc. 1984;109:21. 2. Committee on Dietary Allowances, Food and Nutrition Board, National Academy of Sciences-National Research Council. Recommended Dietary Allowances, 9th rev. edn. Washington, DC, National Academy Press, 1980. 3. Forrester DJ, Wagner ML, Flemming J. Pediatric Dental Medicine, Lea & Febiger, Philadelphia, 1981. 4. Hertzler AA, Anderson HL. Food guides in the United States. J Am Assoc. 1974;64:19. 5. Mc Donald RE, Avery DR. Dentistry for child and adolescent. 7th Edn. Mosby, St. Louis, 2000. 6. Nizel AE. Nutrition in Preventive Dentistry: Science and Practice. Philadelphia, WB Saunders, 1972. 7. USDA-DHHS nutrition and your Health: Dietary guide­lines for Americans, 2nd Edn. Washington, DC, GPO, 1985. 8. “USDAs My Plate”. United States Department of Agriculture. Retrieved 2 June 2011. 9. Welsh S, Davis C, Shaw A. A brief history of food guides in the United States. Nutrition Today. November/December 1992.pp.6-11. 10. Wilson ED, Fisher KIL, Fuqua MD. Principles of Nutrition, 3rd Edn. New York, John Wiley, 1975.

25

Chapter

Diet Counseling for the Prevention of Dental Caries Nikhil Marwah

Chapter outline •

Principles of Diet Management

During the pre-eruptive period foods exert nutritional effect on the formation of dental matrix and mineralization. However, during the posteruptive periods foods exert a dietary and topical effect. Therefore, when giving dietary counseling some food choices and eating habits merit attention. These include frequency of between meal snacking, physical form and retentiveness of sugar-sweetened snacks and the amount of sugar added to food or beverages for sweetening. A basic prerequisite for accomplishing dietary change is the advice that the patient not the counselor bears the responsibility for making the change. Minimal requirements for a successful dietary counseling service include enrolling, active patient involvement in planning, implementing, and evaluating the diet before and after counseling and insisting on a series of follow-up visits to tailor the diet to the patient’s needs and likes without jeopardizing the dental health status.

PRINCIPLES OF DIET MANAGEMENT A rational nutrition program for dental caries prevention based on the effects of various nutrients and food practices on the production or inhibition of dental caries coupled with some basic dietetics principles can be formulated. Therefore, these four rules should be adopted when making dietary modifications: 1. Maintain overall nutritional adequacy by conforming to the USDA daily food guide for at least the recommended number of servings from each of the food groups. 2. The prescribed diet should vary from the normal diet pattern as little as possible. 3. The diet should meet the body’s requirements for the essential nutrients. 4. The prescribed diet should take into consideration and accommodate the patient’s likes and dislikes, food habits,

•

Diet Counseling

and other environmental factors as long as they do not interfere with the objectives. Effective diet counseling can thus help us formulate the following conclusions: • The dietary guidance advocated here can improve general as well as dental health. • Personalized dietary counseling added to other cariespreventive measures should reduce caries recurrence significantly. • The daily ingestion of a balanced and varied selection of foods from the different food groups, avoidance of sweets that are retained next to tooth enamel, and discontinuance of between-meal snacking are the basic elements in achieving a diet that produces few caries. • To realize maximum patient acceptance and cooperation with the diet prescription, determine and manage the reasons for the original diet, and suit the new diet to the patient’s daily routine and lifestyle. • The objectivity, personalization of the diet, and the time spent in counseling are rewarded both financially and by the satisfaction of performing a useful health care and preventive dentistry service.

DIET COUNSELING

Patient Selection • Diet counseling will not succeed with every dental patient. • Potential candidates for counseling should give high priority to preventive dentistry and should be willing to expend long-term efforts to maintain their natural dentition good health for a lifetime.

280 Section 6 

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• In addition to a positive attitude, they should have a demonstrable need for dietary improvement, based on their current food intake regimen.

Food Diary • A food diary is, as the name implies, a record of all food and beverages consumed during a specific period (Fig. 25.1). • If the child is young the mother usually completes the food diary at home, writing in foods after they are eaten. The patient is instructed to be as accurate as possible in determining quantities and to record in detail everything

Food Milk Meat Fruits and vegetables Vitamin C Others Breads and cereals

eaten or drunk during or between meals, the size serving in household measures, the addition of sugar, milk, syrups, to anything consumed. • A food or diet diary can be either of 24 hours or one week. The 24-hour recall is a valuable tool for obtaining a sketchy picture of a patient’s food intake.

 alculation of Dental C Health Diet Score It is a simple scoring procedure that can disclose a potential dietary problem that is likely to adversely affect a patient’s dental health.

CALCULATION OF DENTAL HEATH DIET SCORE Dental Health Diet Score = [FOOD SCORE (adequate intake of foods from each of the food groups) + NUTRIENT SCORE (consuming foods from especially recommended groups of ten nutrients)] – SWEET SCORE (ingestion of foods that are overtly sweet sugars) Food Group Score Table (Highest possible score is 96) RDA Number of Points servings 3 X8 2 X 12 1 X6 1 X6 2 X6 4 X6 Nutrient Score Table Mark one score for each nutrient consumed

Protein and Vitamin A Cheese, dried peas, dried beans, eggs, fish, meat, milk, apricot, butter, carrot, liver, milk and spinach

Liquid: (X 5) Soft drinks, fruit drinks, cocoa, sugar and honey in beverages, ice cream, flavored yogurt, pudding, custard

Score

Iron Beef, eggs, liver, green leafy vegetables

Folic Acid Cereals, spinach, yeasts

Riboflavin Broccoli, chicken breasts, eggs, milk, mushrooms

Vitamin C Grapefruit, green peppers, oranges, strawberries, tomatoes, Calcium and Phosphorus—cheese, eggs, green leafy vegetables, milk

Sweet Score Table Classify the sweet by its nature and multiply according to severity Solid and Sticky: (X 10) Slowly Dissolving: (X 15) Cake, doughnuts, sweet rolls, Hard candies, breathe mints, antacid tablets, cough drops pastry, canned fruit in syrup, bananas, cookies, chocolate candy, caramel, chewing gum, dried fruit, marshmallows, jelly, jam Assessment of Dental Health Diet Score Result Interpretation

72-96 64-72 56-64 56 or less

Excellent Adequate Barely adequate Not adequate

Counseling not required Educate the patient Counseling required Counseling with diet modifications

Chapter 25  Diet Counseling for the Prevention of Dental Caries Diet workbook Date: Name: What are dental caries? The plaque that forms on your teeth every day contains bacteria (germs). These bacteria change the sugar in your food into acid. Sugar (in food) + Bacteria (germs) = Acid These acids begin the breakdown of the tooth .... dental caries.

Note: Sticky foods that are sweet are much worse than liquid sweet foods. The longer the sugar is on the tooth, the more acid is made by the bacteria. Very bad: candy, cookies, chocolate-covered ice cream, cake, pie, jam. Not so bad: plain ice cream, pudding, jell-O, soft drinks. How many circles are on your food diary? ______________ There are 20 minutes of acid forming on your teeth for each circle ..... ____ × 20 – _____ minutes (or _____ hours) What foods can you eliminate to reduce the number of circles?

How many servings are you having from the four food groups? Now having Should have Difference Milk group Milk—fluid whole evaporated, skim, 3 2-3 or more OK dry, buttermilk servings Cheese—American, natural, cottage Meat group Beef, veal, pork, lamb, poultry, fish, 14/5 2 or more –1/5 eggs, dry peas and beans, peanuts servings Vegetable-fruit group Include a source of: Vitamin C (citrus fruits, green pepper, 3 4 or more –1 cantaloupe, strawberries) servings Vitamin A (dark green or deep yellow vegetables) Read-cereal group Whole gain, enriched or restored. 4 4 or more OK Includes rice, pasta, crackers, and rolls servings

Food group

Day 1

Day 2

Day 3

Day 4

Day 5

Calculate

Average (per day) intake

Milk

√√√

√√

√√√√

√√√√

√√

15/5 = 3

3

14/

14/5

Meat

√√

√

√√√

√√

√

9/5 =

Fruit-vegetable

√√√

√√√√√

√√

√√√

√√

15/5 = 3

3

Bread-cereal

√√√√√

√√√√

√√

√√√√√

√√√√

20/5 = 4

4

Diet prescription

5

Snack suggestions

Continue eating: Milk group Bread-cereal group

Raw vegetables: Celery sticks

Eat more of: Meat group—eggs, cheeseburger, bologna, tuna fish Vegetable-fruit group—apples, peaches, tomato juice, raw carrot A suggested menu for you Breakfast: Orange juice Cereal with fruit and milk Lunch: Bologna sandwich Fruit Milk After school: Juice Crackers and cheese Supper: Meat, fish or poultry Vegetables Rice, milk Jell-O Before bed: Toast with cream cheese Milk

Lettuce wedges —Keep in water in refrigerator all ready to eat Carrot sticks Cucumber sticks —Fill celery stalk with cream cheese, meat or cheese spread or peanut butter Cauliflower bits Radishes Green pepper rings Tomatoes Fruits: Oranges

Melon

Plums Grapes Peaches Apples Pears Grapefruit Pineapple Tangerines Strawberries

—Have a plate of fruit chunks on toothpicks fixed in the refrigerator Add to milk and blenderize to make a fruit shake

Drinks: Milk, unsweetened fruit and vegetable juices, sugar-free carbonated beverages Other snakes: Slices of—turkey, chicken, beef, bologna, salami or cheese, served by itself or as a sandwich, on bread or crackers Unsweetened dry cereal, with milk, nuts, chips, popcorn pretzels Cheese cookies: 1 Jar sharp cheese 1 cup plus Mix all ingredients and form dough 1 Tbsp. flour into roll as for icebox cookies. Chill 1 Stick margarine ½ cup chopped several hours. Slice and bake at 400o nuts for 6-8 minutes. Popsicles: Put unsweetened juices (or mix yogurt or buttermilk with juices) into popsicle molds and freeze

Fig. 25.1:  Sample food diary

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Communication Techniques • Communication is a basic tool in the practice of preventive dentistry. • Communication is the giving and receiving of information; it involves the knowledge, thoughts, and opinions of the counselor and patient. • Both the dentist and the dental hygienist, by virtue of their education and training, should recognize that they render a vital dental health service when they advise patients on diet and nutrition. • Because diet and inadequate nutrition can be major etiological factors in dental-oral health problems, it is necessary that the dentist or dental hygienist give diet counseling when indicated. • During a face-to-face interview keeping eye contact with the patient is a persuasive and powerful device for motivating behavioral change. • Communications can be both verbal and nonverbal. Words transmit information. The interviewer’s tone of voice, facial expression, and gestures convey sincerity, enthusiasm, and empathy. These nonverbal actions can influential in helping the patient to change his or her behavior. • The message must be adapted to the patient’s needs and level of understanding. Personalization of the message is more likely to result in a sustained change in behavior. • To communicate with a patient, a combination of interviewing, teaching, counseling, and motivation is used.

Interviewing • Purpose: The basic goal in interviewing is to understand the problem, the factors that contribute to it and the personality of the patient. • Advantages of a dietary interview: It can serve as a valuable diagnostic aid to provide knowledge of a person’s daily routine for adapting a caries preventive diet. • Physical setting: Privacy, comfortable and relaxed atmosphere are important requisites for an interview. The interview should not take place on chair side in the dental operatory, as it can be a threatening atmosphere that may lead to fear and withdrawal. Rather, it should take place in a separate counseling room that contains a small conference table, few chairs, a blackboard, and visual aids. • Diet interviewer: Good dietary interviewing requires skill, time, and some background knowledge of the science and practice of nutrition, including familiarity with ways in which food habits are formed. • Procedure for interviewing the patient: Start with a brief introductory statement about the purpose of the

interview. Ask questions that will encourage the patient’s expression of feelings about his or her current dental health condition and the importance of preserving the natural dentition. An important advantage is listening before speaking as the patient himself may reveal answers to his problems and provide a direction for the course of action. In general, the interviewer should be encouraging and sympathetic and should not assume an adversary position. Allow the patient to make choices based on what has been learned and with which the patient can cooperate. When closing an interview, it is usually a good plan to end by recapitulating what the patient has learned and the future action that you have agreed on.

Teaching and Learning • Patient education is more than simply giving information: it requires the presentation of information with sufficient impact to stimulate action by the learner. • A number of teaching aids may be used, including booklets on nutrition and dental health, which can be purchased at little cost.

Counseling • Approaches to counseling may be directive or nondirective. • In directive counseling, the role of the patient is passive and the decisions are made by the counselor. • In nondirective counseling, the counselor’s role is merely to aid the patient in clarifying and understanding his or her own situation and to provide guidance so that the patient can make his or her own final decision as to the type of action that should be taken. • The nondirective counseling approach is recommended for diet counseling.

Guidelines for Counseling • A prerequisite for successful nutrition counseling is a realistic and honest statement that the patient, not the counselor, bears the responsibility for making changes in food selections and eating habits. • The guidelines for counseling are: – Gather information: Personal identifying data, likes and dislikes, and the patient’s perception. – Evaluate and interpret information: Relative adequacy of the diet and eating habits. – Develop and implement a plan of action: Qualitative modifications of the diet. – Seek active participation of the patient’s family in all aspects of dietary change. – Follow-up to assess the progress made.

Chapter 25  Diet Counseling for the Prevention of Dental Caries Pre-requirements of Counseling • Elicit a true response: If the counselor is hoping for truthful responses to his questions, he must follow some simple rules which will relax the patient. It is important, to give neither positive nor negative feedback when the patient is recalling his food intake. Since people tend to avoid negative reinforcement and seek positive reinforcement, they may alter their responses in pursuit of these goals. Example Counselor (C): What did you eat for breakfast? Patient (P): An ice cream C: An ice cream??? (Registers shock, displeasure, ridicule) P: (Shyly) Yes. C: What did you eat for dinner last night? P: Meat, potatoes, spinach, and salad. (Patient really did not eat dinner last night, but wants to avoid another negative response from the counselor so she fabricates a dinner.) C: That’s great (Positive reinforcement) Patient then continues to give answers which elicit positive responses only

• Phrase the questions correctly: Do not put words in the patient’s mouth. If information is sought, it is best to ask an open-ended question, one that will allow the patient to answer with a response other than yes or no. Example Right

Wrong

Q:

What did you put in your cereal?

Q:

Did you put milk in your cereal?

A:

Milk and sugar.

A:

Yes

Q:

How much milk?

Q:

Did you put 1/2 cup of milk

A:

About 2/3 cup

A:

Yes

It is easy for the patient to say “Yes” rather than to go to the trouble of explaining a different response. This can give a false picture of food intake

• Listen and wait for an answer: When you ask a question, give the patient time to think of his answer. Example Right

Wrong

Q:

What did you eat for breakfast?

Q:

What did you eat for breakfast?

A:

(Silence)

A:

(Silence)

Q:

(Silence)

Q:

Was it cereal?

A:

I had eggs

A:

(Silence)

Do not let the silence make you uncomfortable so that you rush in with an answer for him

Counseling Visit Step 1: Pursue Diary for Completion: Remember that diaries are often inaccurate, so keep an educated ear open to clues about eating behavior. For example: The patient enters the office chewing gum. You check the food diary and find no gum mentioned on it. It is a good idea to ask “How often do you chew gum?” rather than ignore it because it was not entered Step 2: Determine Daily Routine: It is important to have an understanding of not only what the patient is eating but why he is eating it. This is best accomplished by examining the daily routine Step 3: Explain Cause of Decay: Explain that the bacteria living on our teeth rely on the sugar in our diets for their supply of energy. In the process of breaking down the sugar, an acid is formed which can “dissolve” the tooth Step 4: Isolate Sugar Factor: All the food consumed is scanned and the number of sugar exposures is circled. This includes sugar or syrups added to cookies, cakes, cereals, fruit and beverages. Dried fruits are also included Step 5: Analyze Sweets Intake: Examine the foods that are circled. Explain that it is not the amount of sugar as much as it is the form and the frequency of intake that determines cariogenicity of the diet. Count the circles in the diet workbook and ask the patient which circled foods on the diary can be eliminated Step 6: Determine Adequacy of Diet: This is done by dental health diet score Step 7: Diet Prescription and Suggested Menu: It is now time to put together a personalized diet for the patient based on what we have learned about his usual dietary pattern and daily routine • Commend the patient • Allow the patient to suggest improvements and write his or her own diet prescription • Allow the patient to delete sugar from the plaque-forming foods • Allow the patient to select nonplaque promoting snack substitutes • Allow the patient to select menus starting with the existing menu as a nucleus Step 8: Reinforcement by Follow-up Re-evaluation: Schedule a follow-up visit for 2 weeks later. The patient is asked to complete a second 5-day food diary in the same manner first just before returning. Evaluate the new food diary and compare the results with the original plan to note whether recommendations have been followed. Repetition, clarification, and encouragement are the keys to success in long-term maintenance of the new, acceptable, less cariogenic and more nutritious diet No dentistry should be done on the day that diet counseling occurs, so that the counseling is given due importance Use of Diet workbook is emphasized

Motivation • It is an incentive for action. • The counselor’s positive attitude and conviction as to the necessity and effectiveness of nutrition counseling

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can stimulate the patient to initiate an improved dietary pattern. • A person passes through five preliminary decision stages in changing a dietary pattern-awareness, interest, involvement, action and forming a new habit. – Awareness is recognition that a problem exists, but without an inclination to solve it, e.g. Hard candies produce acid, which can cause my teeth to decay. – Interest is greater degree of awareness but still with no inclination to act, e.g. May be I should give up the hard candies; I do not want any more sensitive or painful teeth. – Involvement is a definite intention to act, e.g. I definitely will give up hard candy.

– Action is a trial performance, e.g. I have given up hard candies and chew sugarless gum instead to prevent the dry feeling in my mouth. – Habit is a commitment to perform this action regularly over a sustained period of time, e.g. I have not consumed a hard candy in six months. The pedodontist is in a unique position to promote good nutrition in his patients and their families as he is treating a disease to which diet contributes dramatically to both etiology and treatment. It is our hope that the dentist who looks into a child’s mouth and thinks “What is this child eating?” will use this chapter to help him evaluate and improve the diets of his patients.

POINTS TO REMEMBER • Diet is important requisite for healthy dentition both in prenatal and postnatal period of life. • A food diary is, as the name implies, a record of all food and beverages consumed during a specific period. • Dental Health Diet Score = [FOOD SCORE (adequate intake of foods from each of the food groups) + NUTRIENT SCORE (consuming foods from especially recommended groups of ten nutrients)]—SWEET SCORE (ingestion of foods that are overtly sweet sugars). • In nondirective counseling, the counselor’s role is merely to aid the patient in clarifying and understanding his or her own situation and to provide guidance so this approach is recommended for diet counseling. • Diet counceling involves the following: Pursue diary for completion, determine daily routine, explain cause of decay, isolate sugar factor, analyze sweets intake, determine adequacy of diet, diet prescription, reinforcement by follow-up.

QUESTIONNAIRE 1. 2. 3. 4. 5.

What are the principles of diet management? Explain the concept of food diary. Describe counceling of a dental patient. What is dental health score? Explain the diet counceling of a child for caries prevention.

BIBLIOGRAPHY 1. Burt BA. What recommendations should dentists make to their patients regarding the effect of diet and nutrition on their oral health? What kind of diet and consumption patterns promotes better oral health and what kinds are less consistent with good oral health? Diet, nutrition and oral health. A rational approach for the dental practice. J Am dent Assoc. 1984;109:21. 2. Committee on Dietary Allowances, Food and Nutrition Board, National Academy of Sciences-National Research Council. Recommended Dietary Allowances, 9th rev. Edn. Washington, D.C., National Academy Press; 1980. 3. Nizel AE, Shulman JS. The science and art of inhibiting caries in adolescents via personalized nutritional counseling. Dent Clin North Am. 1969;13:387. 4. Nizel AE. Nutrition in preventive dentistry: Science and practice. Philadelphia, WB Saunders; 1972. 5. Palmer C, Rounds M. Nutrition counseling. In clinical preventive dentistry student manual; Boston, Tufts University School of Dental Medicine; 1986. 6. Wilson ED, Fisher KIL, Fuqua MD. Principles of nutrition, 3rd Edn. New York, John Wiley; 1975.

26

Chapter

Pit and Fissure Sealants Nikhil Marwah, Shilpa Ahuja

Chapter outline • • • • •

History Morphology of Pits and Fissures Histopathology of Fissure Caries Types of Pit and Fissure Sealants Pit and Fissure Sealant Usage

The prevalence of caries has decreased in the past two decades and contributing to this decline are water fluoridation, dentifrices, improved oral hygiene, changes in diet and awareness. Despite dramatic reduction in caries in fluoridated community, the disease still continues to occur during childhood and there is a sustained caries susceptibility of pits and fissures. Pit and fissure sealants are major cornerstone of modern preventive dentistry in prevention of caries in susceptible teeth. Pit (Ash, 1993):  It is defined as a small pinpoint depression located at the junction of developmental grooves or at terminals of those grooves.

• • • •

Fissure Sealant Cycle Clinical Technique for Placement of Pit and Fissure Sealant Critical Issues Regarding Pit and Fissure Sealant Usage Current Status of Pit and Fissure Sealant

Fissure (Orbans, 1954): Fissure is defined as deep clefts between adjoining cusps. Pit and fissure sealant (Simonsen RJ, 1978): Term used to describe a material that is introduced into the occlusal pits and fissures of caries-susceptible teeth, thus forming a micromechanically-bonded, protective layer cutting access of caries-producing bacteria from their source of nutrients.1 Fissure sealant (R Welbury, M Raadal, N Lygidaks, EAPD Policy Document, 2003):  It is a material that is placed in the pits and fissures of teeth in order to prevent or arrest the development of dental caries.2

HISTORY 1867

Arthur

Stated that decay was inevitable and that obliteration of the fissures could prevent its occurrence

1905

Miller

Used silver nitrate for fissure restoration

1922

Hyatt

In his famous paper “Prophylactic Odontomy,” he advocated filling the fissures of teeth with silver or copper oxyphosphate cement as soon as the teeth erupted and then later, when they were fully into the mouth, preparing a small occlusal cavity and filling it with amalgam

1939

Gore3

The use of polymers as fissure sealants and to a lesser extent as coatings owes its origin to him as had used solutions of cellulose nitrate in organic solvents to fill the surface enamel made porous by the action of acids in the saliva Contd...

286 Section 6 

Preventive Pedodontics

Contd... 1955

Buonocore4

1965

Gwinnett and Showed that an approximately 50% phosphoric acid solution etched enamel and a porosity resulted that was penetrated Buonocore by the cyanoacrylate, with production of a strong bond

1965

Bowen

BIS-GMA was developed at the National Bureau of Standards from the adduct of bis-phenol A and glycidyl methacrylate

1966

Cueto and Buonocore

Initiated critical studies of fissure sealing using a methyl cyanoacrylate monomer filled with silicate filler that had the potential through polymerization of the cyanoacrylate of both bonding to the enamel and (possibly) releasing some fluoride from the silicate filler. They reported an 86.3% reduction in the incidence of caries in the pits and fissures of permanent molars and premolars over a 1-year period and an 85.6% reduction after 2 years. Thus, the principle of reduction of fissure caries by obliteration of the fissure was established

1968

Rodyhouse5

Reported on the use of the BIS-GMA monomer using methyl methacrylate as diluents together with a peroxide amine polymerization system. Over a 3-year period, he demonstrated a 30% reduction in caries in the 130 children studied. However, he did not employ acid etching before application of the sealant to the teeth

1970

Buonocore

Utilized BIS-GMA system but employed an ultraviolet-sensitive polymerization initiator (benzoin methyl ether), which allowed more flexibility in the clinical application of the material to the teeth and more complete filling of the fissures

1971

Nuva-Seal

First pit and fissure sealant developed and commercially introduced by LD Caulk Company

Observed that, after treatment of the enamel with concentrated phosphoric acid solution, attachment of acrylic resin to tooth surfaces was greatly increased

MORPHOLOGY OF PITS AND FISSURES The fissure contains organic plug composed of reduced enamel epithelium, microorganism forming dental plaque and oral debris. The increased susceptibility of this surface to caries is due to the fact that fissure provides a protected niche for plaque accumulation (Rohr et al. 1991, Hicks 1986). Recently erupted teeth have a porous enamel lining and the fissures are rich in cellular and organic debris. Theoretically this porous zone of enamel bordering the fissures offers a three-dimensional honeycombed structure into which fissure sealants could be locked. Any procedure must be carried out at the earliest possible time after eruption to make effective preventive use of fissure sealants.6 The penetration of liquids into cracks and crevices is given by the equation of Bikerman.

S.γ Cosθ 1.50z2 = _____________ t 6 η where, z = Depth of the crevice S = Width of the crevice γ = Surface tension of the liquid θ = Advancing contact angle of the liquid η = Viscosity t = Time There are five types of pits and fissures according to Nagano,7 1961 (Fig. 26.1): 1. V – type (34%) 2. U – type (14%) 3. I – type (19%) 4. IK – type (26%) 5. Inverted Y – type (7%).

Chapter 26  Pit and Fissure Sealants

Fig. 26.1: Morphology of pits and fissures

HISTOPATHOLOGY OF FISSURE CARIES

TYPES OF PIT AND FISSURE SEALANTS The first pit and fissures sealant introduced was an UV light activated sealant, Nuva-Seal. Pit and fissure sealants are classified into five types: 1. According to chemical structures of monomers used (Fig. 26.2): • Methyl methacrylate (MMA) • Triethylene glycol dimethacrylate (TEGDM) • Bis phenol dimethacrylate (BPD) • Bis-GMA is the reaction product of Bis phenol A and glycidyl methacrylate (GMA) with a methyl methacrylate monomer • ESPE monomer • Propyl methacrylate urethane (PMU) 2. Based on generations (Fig. 26.3): • First generation sealants: – Polymerized with UV light with wavelength of 356 µm – Had excessive absorption and incomplete poly­ merization of sealant at its depth – For example, Nuva-lite (Caulk/Dentsply).

287

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Fig. 26.2:  Chemical structures of monomers

Fig. 26.3: Pit and fissure sealants based on generation

Fig. 26.4: Pit and fissure sealants based on color

Chapter 26  Pit and Fissure Sealants • Second generation sealants: – Self cure or chemical cure resins – Based on accelerator catalyst system – For example, Concise White (3M) • Third generation sealants: – Light cured with visible (blue) light of 430–490 µm – For example, Helioseal • Fourth generation: – Fluoride releasing sealants – For example, Seal right (Pulpdent). 3. Based on filler content: • Unfilled: Advantages include better flow and more retention but, abrade rapidly • Filled: Advantages include resistance to wear but, may need occlusal adjustments. 4. Based on color (Fig. 26.4): • Clear: – Esthetic – Difficult to detect in recall visit – For example, Helioseal (changes from green to white) • Tinted/opaque: – Can be identified – For example, Delton • Colored: – Based on color change technology – Easy to see during placement and recall – For example, Clinpro pink (changes to pink on setting) 5. Based on curing: • Autopolymerizing • Light cure.

PIT AND FISSURE SEALANT USAGE

American Academy of Pediatric Dentistry (AAPD) guidelines •

•

•

•

•

• Minimum irritation to tissues • Cariostatic action.

Indications of Pit and Fissure Sealant • Deep, retentive pits and fissures, which may cause wedging of an explorer • Stained pits and fissures with minimum appearance of decalcification • No radiographic or clinical evidence of proximal caries • Possibility of adequate isolation • Questionable enamel caries in pit and fissure • Caries free pit and fissures • If the patient desires • Caries pattern indicative of more than one lesion per year • Morphology of pit at risk of caries • Factors associated with increased caries incidence • Routine dental care with active preventive dentistry program • Community-based sealant program.

Requisites of an Efficient Sealant Brauer8 in 1978 suggested the following prerequisites for a sealant to be effective (Table 26.1): • Viscosity allowing penetration into deep and narrow fissures even in maxillary teeth. • Adequate working time • Rapid cure • Good and prolonged adhesion to enamel • Resistance to wear TABLE 26.1: Properties of an ideal sealant Property Ideal Penetration High Working time Medium Setting time Short Water sorption Low Thermal expansion Low Wear resistance High Ratings 100%

Sealants should be placed into pits and fissures of teeth based upon the patient’s caries risk, not the patient’s age or time elapsed since tooth eruption. Sealants should be placed on surfaces judged to be at high risk or surfaces that already exhibit incipient carious lesions to inhibit lesion progression. Sealant placement methods should include careful cleaning of the pits and fissures without removal of any appreciable enamel. A low-viscosity hydrophilic material bonding layer, as part of or under the actual sealant, is recommended for long-term retention and effectiveness. Glass ionomer materials could be used as transitional sealants.

Contraindications for Sealant Usage • • • • • • •

Self cured Medium Short-medium Medium High High Low 53%

Well-coalesced, self-cleansing pits and fissures Radiographic or clinical evidence of interproximal caries Tooth not fully erupted Isolation not possible Life expectancy of tooth is limited Dentinal caries Lack of preventive practices.

Light cured (Unfilled) Low-high Medium-long On demand High High Low 62%

Light cured (Filled) Low-medium Medium-long On demand Medium Medium Medium 75%

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290 Section 6 

Preventive Pedodontics Pit and fissure treatment alternatives Diagnosis

Caries–free surface: No explorer wedging • • •

Treatment Observation only and re-evaluation at 6-month recall examinations

No explorer wedging Well coalesced, self-cleansing shallow pits and fissures Stained pits and fissures

Caries-free surface: No explorer wedging

Sealant placement

•

• •

•

Stained or minimal decalcified or opacified appearance of pits and fissures No radiographic or clinical evidence of interproximal caries

Adequate isolation from saliva-place sealant Isolation not possible-allow further eruption and place sealant within 1 to 3 months

Caries-free surface: Explorer wedging

Sealant placement

• • •

• •

Explorer wedging due to pit and fissure anatomy Stained or decalcified appearance of pits and fissures No radiographic or clinical evidence of interproximal caries

•

Adequate isolation from saliva-place sealant Isolation not possible-allow further eruption and place sealant within 1 to 3 months Remove overlying tissues and place sealant or allow further eruption, and place sealant within 1 to 3 months

Incipient caries: Minimal involvement

Preventive restoration

•

•

• • •

Explorer catch due to incipient or minimal caries involving limited areas of pits and fissures Decalcified appearance of fissures enamel with involvement of adjacent pit and fissures No radiographic or clinical evidence of interproximal caries Possible radiographic evidence of occlusal caries

• • • •

Preventive restoration placement (Restoration of isolated pits and fissures) Preventive resin restoration placement Glass ionomer preventive restoration Sealant-amalgam preventive restoration (Amalgam in isolated pits and fissures without extension for prevention and sealant) Glass ionomer resin preventive restoration

Carious surface obvious clinical caries

Restoration

• • •

• • • • •

•

Explorer catch with obvious clinical caries Loss of enamel lining the pits and fissures Generalized involvement of pits and fissures by caries with undermining of enamel Probable radiographic evidence of occlusal caries

FISSURE SEALANT CYCLE The use of pit and fissure sealants for high caries risk individuals or groups should form part of an overall caries preventive program, which includes advice on home care, with a focus on twice-daily tooth brushing with fluoride toothpaste containing at least 1,000 ppm fluoride and appropriate dietary advice. Maintenance of fissure sealants is important to ensure their continued effectiveness, and sealant integrity can be assessed at recall. It is recommended that the recall interval for high caries risk children should not exceed 12 months.9

CLINICAL TECHNIQUE FOR PLACEMENT OF PIT AND FISSURE SEALANT (FIGS 26.5A TO H)

Step 1:Tray Set-up • Prior to the start of the procedure, a tray with all necessary instruments, supplies, and equipment should be prepared (Fig. 26.5A).

Posterior composite restoration Amalgam restoration Glass ionomer restoration Glass ionomer resin restoration Glass ionomer/posterior composite restoration

• Each operator needs to determine what should be included on the tray based on personal preferences and the sealant material being used. • The items included in the sample tray set-up are mouth mirror, slow speed handpiece, explorer (No. 5), toothbrush, cotton pliers, material, isolation device, saliva ejector, curing light, syringe tip, articulating tape.

Step 2: Isolation of Tooth • The tooth should be isolated from salivary contamination by use of rubber dam or by cotton rolls and suctioning (Fig. 26.5B). Rubber dam should be used in fully erupted teeth and cotton rolls can be used where that is not possible. • This procedure is very technique sensitive so moisture control is essential to achieve optimum bond strength. • Silverstone, 1984 concluded that salivary contamination allows rapid precipitation of glycoprotiens onto the etched surface, greatly decreasing the bond strength. Even 1 second of exposure to saliva can form a protein layer resistant to 30 seconds of vigorous irrigation.

Chapter 26  Pit and Fissure Sealants

A

B

C

D

E

F

G

H

Figs 26.5A to H: Procedure of application of pit and fissure sealant: (A) Tray set-up; (B) Pre-treatment photograph; (C) Enameloplasty; (D) Acid etching; (E) Etched tooth surface; (F) Application of sealant; (G) Cure the sealant; (H) Post-sealant application Hitt, 1992 and Fiegal,10 2002 postulated that applying halogenated bonding agent after etching can increase bond strength in saliva contaminated enamel (0.0005 to 17.8 Mpa) and in uncontaminated enamel (16.7 to 20.5 Mpa) because bonding agent displaces saliva from enamel, improving sealant wetting of surface.

Step 3: Tooth Preparation • There are different methods of enamel surface preparation prior to etching and sealant application. Early concept was to treat the surface with slurry of pumice and water.

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• Brockleherst, 1992 suggested that air abrasion with aluminum oxide particles is the best method of cleaning as it results in an improved surface for resin wetting, more number of resin tag formation and more depth of sealant penetration. • Sol et al. 2000 found out that use of sodium bicarbonate air polishing system resulted in higher retention of cement. • Garcia Godoy et al. (1994) and Zervou11 et al. (2000) recommended enameloplasty as it increases the surface area and decreases microleakage (Fig. 26.5C). It can be concluded that type of prophylaxis medium is unimportant and unless plaque, debris or stains are present on the tooth surface obscuring diagnosis, a prophylaxis before sealing is not essential, although tooth preparation can be useful.

Fissurotomy burs The fissurotomy system gives you a viable alternative to be conservative and protect as much healthy tooth structure as possible. The fissurotomy bur tip is extremely small (just 0.33 mm) and fast. It cuts a smooth, minimally invasive groove in suspicious fissures to allow for explorer access. Advantages of these burs include exact drilling depth, pain-free use, ideal cavity form and ability to explore and restore in just 3–5 minutes. Fissurotomy burs are available in three different configurations: Fissurotomy original (1.1 mm wide/2.5 mm long), Fissurotomy Micro NTF (0.7 mm wide/2.5 mm long) and Fissurotomy Micro STF (0.6 mm wide/1.5 mm long).12

Step 4: Acid Etching Tooth Surface • Apply the etching agent to the tooth surface using a fine brush or a minisponge according to the manufacturer’s recommendations (Fig. 26.5D). • Buonocore initially used 80 percent phosphoric acid but nowadays 37 percent phosphoric acid is recommended. • Gently rub the etchant applicator over tooth surface including 2 to 3 mm of cuspal inclines and reaching into any buccal or lingual pits and grooves that are present.

• Periodically add fresh etchant to the tooth surface. Be careful to avoid spillage of etchant on the interproximal areas as it may lead to gingival irritation and sealing of adjacent interproximal spaces together. • Etchant can be either in liquid form or gel form but gel is preferred as it is more effective and its flow can be controlled. • Etching time: – Earlier it was recommended that the etching time for primary teeth be double than that of permanent teeth. – Many studies have used different etching times ranging from 15 to 60 seconds. Duggal et al. (1997) have used different etching timing of 15, 30, 45 and 60 seconds and concluded that there is no difference is retention of sealant using different etching time. Tandon S et al. (1989) have proposed an etching time of 15 sec to be sufficient for primary teeth but the most accepted times and the currently applicable times were given in IADR sealant symposium in 1991.

Step Acid etch Wash Dry

Primary tooth 30 seconds 30 seconds 15 seconds

Permanent tooth 20 seconds 30 seconds 15 seconds

• Scientific basis for acid etching (Fig. 26.6): – It was given by Silverstone.13 Acid etching on the surface enamel has shown to produce a degree of porosity. – First, a narrow zone of enamel is removed by etching. In this plaque and pellicles are dissolved. Fully reacted inert mineral crystals in the surface of enamel are also removed, resulting in a more reactive surface, increase in surface area and decrease in surface tension that allows the resin to wet the enamel surface more readily. This zone is 10 µm in depth. – The second zone is qualitative porous zone, which is 20 µm in depth. Because of the porosities created, this zone may be distinguished qualitatively from enamel by polarized light microscopy. – The third zone is quantitative porous zone with small porosities and is 20 µm deep. • Types of etching pattern: Silverstone14 in 1975 identified three basic patterns of etching: – Type 1 (Fig. 26.7A): There is a generalized roughening of enamel surface, but with a distinct hollowing of prism centers and relatively intact peripheral regions. – Type 2 (Fig. 26.7B): Prism peripheries appear to be damaged. Prism cores are left projecting towards original enamel surface. – Type 3 (Fig. 26.7C): Show neither type 1 nor type 2 etching pattern but appear, as generalized surface roughening.

Chapter 26  Pit and Fissure Sealants

Fig. 26.6: Zones of etching

A

B

C Figs 26.7A to C: Patterns of etching

Functions of resin tags • • • •

Provide mechanical means for retention Surround the enamel crystals and provide resistance to demineralization by acid products from plaque Bis–GMA sealants are resistant to acid dissolution and provide protection against caries along enamel resin interface Creates a protective barrier against bacterial colonization of sealed fissure.

Step 5: Rinse and Dry Etched Tooth Surface • Rinse the etched tooth surface with air water spray for 30 seconds. • This removes the etching agent and reaction products from etched enamel surface. • Dry the tooth for 15 seconds with uncontaminated compressed air. • The dried etched enamel should have a frosted white appearance (Fig. 26.5E). • If salivary contamination has occurred, re-etch for 10 seconds and repeat the procedure.

Step 6: Application of Bonding Agent • Application of halogenated bonding agent after etching displaces saliva from enamel thereby improving sealant wetting of surface and increases the bond strength both in saliva-contaminated enamel (0.0005 to 17.8 Mpa) and in uncontaminated enamel (16.7 to 20.5 Mpa). • Feigal came up with the novel concept that hydrophilic bonding materials that contain water, may, when applied under a sealant, minimize the bond strength normally lost when a sealant is applied in a moist environment. • Most of the sealants today are provided with single step etching and bonding agents combined into one (For example, Xeno Bond).

Step 7: Application of Sealant • The sealant material can be applied to the tooth in a variety of methods. Many sealant kits have their own dispensers, some preloaded that directly apply the sealant to the tooth surface.

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• In mandibular teeth, apply the sealant distally and allow it to flow mesially with the converse being true for the maxillary teeth. Allow the sealant to flow in the etched pits and fissures to avoid incorporating air into material and creating voids (Fig. 26.5F). Then using a fine brush or applicator carry a thin layer up the cuspal inclines to seal secondary and supplemental fissures.

Step 8: Cure the Sealant • Cure according to the manufacturer’s recommended time for curing (Fig. 26.5G). • For light cured sealants, polymerization should be initiated quickly after the sealant is placed on the etched surface to help minimize potential contamination. • However, an interesting study by Chosak and Eidelman15 found that the longer sealants were allowed to sit on the etched surface before being polymerized, the more the sealant penetrated the microporosities, creating longer resin tags, which are critical for micromechanical retention. • Hicks et al. (2000) found that argon laser curing of sealant material may enhance caries resistance.

Step 9: Explore the Sealed Tooth Surface and Evaluate Occlusion • Explore the entire tooth surface for pits and voids that may have not been sealed. • Evaluate occlusion of sealed tooth surface with articulating paper to determine if any excessive sealant is present and needs to be removed. • A small discrepancy in occlusion in case of unfilled sealant is easily tolerated as the cement abrades away but in case of filled resin sealant occlusal adjustment is a must to avoid discomfort (Fig. 26.5H).

Step 10: Recall and Re-evaluation • Recall and check the patient at subsequent visits. • It is necessary to re-evaluate sealed tooth surface for loss of material, exposure of voids and caries development, especially in the first 6 month of placement. • Although a single application of resin fissure sealant has been shown to be beneficial in reducing caries of a population, on an individual basis, there is general agreement that the caries preventive effect of resin fissure sealant relies on the maintenance of integrity of the fissure sealants.

CRITICAL ISSUES REGARDING PIT AND FISSURE SEALANT USAGE

Sealant Retention • It is directly dependent on percentage effectiveness which means number of sealants needing replacement. This is by two criteria’s, firstly percentage of sealed teeth which becomes carious and secondly rate at which sealant requires reapplication. • Simonsen16 reported 15-year retention rates for single application of sealants on permanent molars. Around 27.6 percent showed complete retention, 35 percent showed partial retention, 68.8 percent remained caries free but only 17 percent of unsealed teeth were caries free. None of the teeth that either completely or partially retained sealants developed caries (Table 26.3). • Wintrobe 1989 gave review of clinical sealant trials carried over 2 decades regarding the success of sealants (Table 26.4).

Sealant Usage The pit and fissure sealant have been documented as safe and effective but, in spite of the proven benefits, but its, underuse is a major concern (Table 26.5).16

Parental Attitudes Towards Sealants Education of parents regarding the importance of caries prevention is of considerable importance in improving dental health of infants and young children (Table 26.6).

Physician’s Knowledge Regarding Sealants As a medical doctor is the first to see the child in case of a disease or even otherwise it is imperative for him to have TABLE 26.3: Sealant retention Length of time since application

Complete retention

Caries free

Effectiveness of sealant

4%

83%

1 year

92%

2 years

85%

7%

81%

3 years

71%

14%

81%

5 years

67%

26%

69%

7 years

66%

31%

55%

10 years

53%

22%

68%

20 years

28%

31%

53%

Chapter 26  Pit and Fissure Sealants TABLE 26.4: Success of sealant restorations Study

Duration (years)

Success (%)

Simonsen and Stallard

1.0

100

Azhadri et al.

1.0

86

Walker et al.

1.25

82

Houpt et al.

1.5

91

Gray

2.0

67-97

Walls et al.

2.0

97

Simonsen and Jensen

2.5

96

Raadal

2.5

84

Simonsen

3.0

99

Houpt et al.

3.0

77

Houpt et al.

4.0

64

Welbury et al.

5.0

26

Houpt et al.

6.5

65

Simonsen and Landy

7.0

90

Houpt et al.

9.0

54

Merzt-Fairhurst

9.0

28

Cost-effectiveness of a Sealant • Simonson (1987) suggested that over a 10-year period the cost of restoring unsealed surface was 1.64 times the cost of application of sealants. • Burt17 noted that cost-effectiveness of sealants would be enhanced by: (1) using trained auxiliaries to apply sealant to the fullest extent allowed by law, (2) applying the most recently developed sealants in which retention rates appear to be most favorable, and (3) their application in areas where proximal caries is low.

Estrogenicity Issue

TABLE 26.5: Postulated reasons for lack of sealant usage Reasons for limited use of sealants

knowledge about the sealants so as to enhance caries pre­ vention. However, the scenario is extremely poor with respect to their knowledge about sealants preventive protocols. – Not familiar with sealants: 69 percent – Sealant protect against caries: 35 percent – Acceptable to place sealant over initial caries: 3 percent.

Rankings

Dentist users Lack of insurance reimbursement

1

Concern of sealing over caries

2

Concern of sealant retention

3

Cost-effectiveness

4

CURRENT STATUS OF PIT AND FISSURE SEALANT

Fluoride Releasing Sealants (Fig. 26.8)

Dentist nonusers Concern of sealing of decay

1

Occlusal filling preferred

2

Sealants do not last long

3

• This issue was first raised by Olea and his co-worker in Granda, Spain in 1996 and since then many authors have focused their attention to this. • Concern was raised about the safety of monomers leached out of these materials although there is no concrete evidence of this against Bis-GMA. • It should also be remembered that none of the dental sealants that carry the ADA seal release detectable BPA.18

TABLE 26.6: Parental knowledge Important

Not important

Not sure

• Professional cleaning

76%

10%

13%

• Filling decayed teeth

88%

3%

10%

• Sealant placement

45%

6%

49%

• Sealant prevent decay

53%

2%

46%

• Cost-effectiveness

31%

3%

66%

Fig. 26.8: Fluoride releasing sealants

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296 Section 6 

Preventive Pedodontics

• Garcia Godoy (1997) found out that all the fluoridated sealant had the greatest amount of fluoride release by 24 hours after mixing and the fluoride release declined sharply thereafter. • Cooley et al. (1990) and Hicks et al. (1992) conducted lab studies on a fluoride releasing sealant material composed of a modified urethane Bis-GMA resin. They also concluded that fluoride release dips considerably as the days go by. But, they showed that 60 percent reduction in secondary caries and enhanced degree of caries resistance was seen. • For example, Seal-Rite® (Pulpdent), FluoroShield® (Dentsply), Conceal F® (SDI).

• The sealant is clear to begin with but after polymerization it changes its color. • The degree of color change is also an indicator of its setting and adequate polymerization. • Easy to see during placement and recall • For example, Clinpro®—changes to pink on setting.

Fluorescing Pit and Fissure Sealant (Fig. 26.11)

Clear Pit and Fissure Sealant (Fig. 26.9)

Fig. 26.11: Delton Seal-N-Glo Fluorescing pit and fissure sealant

Fig. 26.9: Heliosal® clear pit and fissure sealant

• This type of sealant is esthetic • Difficult to detect in recall visit • For example, Helioseal®: Changes from green to white.

Colored Pit and Fissure Sealant (Fig. 26.10)

Fig. 26.10: Clinpro® colored pit and fissure sealant

• This sealant eliminates the guesswork involved with placing sealants and confirming placement during recall appointments. • Through the use of a UV pen light, this sealant fluoresces a blue/white color • The fluorescent glow provides clinicians with a visual verification of the sealant margins at the time of placement and offers the easiest way to verify retention and inspect margins during patient recall appointments • For example, Delton Seal-N-Glo (Dentsply).

Moist Bonding Pit and Fissure Sealant (Fig. 26.12)

Fig. 26.12: WetBond™ pit and fissure sealant

Chapter 26  Pit and Fissure Sealants • This is the first pit and fissure sealant resin that can be applied in a moist field. • Embrace WetBond incorporates di-, tri- and multifunctional acrylate monomers into an advanced acidintegrating chemistry that is activated by moisture. When placed in the presence of moisture, the sealant spreads over the enamel surface (A traditional sealant does not spread over a moist tooth surface because of its hydrophobic nature). Because of its unique chemistry, Embrace WetBond is miscible with water and flows into moisture-containing etched enamel and combines with it. • It forms a unique resin acid-integrating network (RAIN) that improves penetration into pits and fissures and provides superior sealing of the margins. • It bonds chemically and micromechanically to the moist tooth, integrating with the tooth structure to create a strong, margin-free bond that virtually eliminates microleakage. • Its compressive strength is 3800 psi whereas the film thickness is only 12 microns thus it not only has good strength but also can be applied in thin layers. • Its advantages include wet bonding, tooth integrating, no marginal chipping, no need of bonding agent and contains no Bisphenol A; Bis-GMA or Bis-DMA. • For example, Embrace WetBond™ (Pulpdent Corpo­ ration).

 it and Fissure Sealant with ACP P (Fig. 26.13)

• It is a light-cured sealant that contains the “smart material” amorphous calcium phosphate (ACP) that is more resilient and flexible, creating a stronger, longerlasting sealant. • ACP is referred to as a “smart material” because it only releases calcium and phosphate ions when the pH drops to 5.9. Once the calcium phosphate is released, it will act to neutralize the acid and buffer the pH. ACP acts as reinforcement to the tooth’s natural defense system only when it is needed. • It has a controlled flowability that keeps the sealant on the tooth structure while completely filling occlusal surfaces and it forms a chemical and thermal barrier protecting the tooth enamel on the occlusal surface from carious attacks. • For example, Aegis® Pit and fissure sealant.

Hydrophilic Fluorescent BPA Free Pit and Fissure Sealant (Fig. 26.14)

Fig. 26.14: UltraSeal XT® hydro pit and fissure sealant

• This is a new sealant developed which combines the best properties of nearly all sealants. • Some of its major properties are hydrophilic chemistry, advanced adhesive technology, fluorescent properties, thixotrophic viscosity, BPA-free formula. • Thus not only can it be used in wet environment but also is easy to place owing to thixotrophic viscosity and is easy to follow up due to fluorescence. To prevent nay estrogenicity issues the manufacturer has kept it BPA free. • For example, UltraSeal XT® hydro.

Fig. 26.13: Aegis pit and fissure sealant with ACP

To make significant gain in decreasing caries in children, it is necessary for dental professionals to educate and inform the general public, parents and physicians about cost effectiveness and caries preventive benefits of sealants. The dental profession waits with patience and enthusiasm, the incorporation of dentin bonding technology into the development of modern resin based sealant.

297

298 Section 6 

Preventive Pedodontics

Chapter 26  Pit and Fissure Sealants

POINTS TO REMEMBER • Pit and fissure sealant is a term used to describe a material that is introduced into the occlusal pits and fissures of cariessusceptible teeth, thus forming a micromechanically-bonded, protective layer cutting access of caries-producing bacteria from their source of nutrients (Simonsen RJ, 1978). • Buonocore (1955) Observed that, after treatment of the enamel with concentrated phosphoric acid solution, attachment of acrylic resin to tooth surfaces was greatly increased. • First pit and fissure sealant Nuva-seal developed and commercially introduced by LD Caulk Company in 1971. • Fissure types include V, U, I, IK, inverted Y; most prone to caries being inverted Y. • Procedure for sealant placement is tray set-up, isolation, tooth preparation, acid etching, washing and drying, application of bonding agent, application of sealant, curing and evaluating. • Etching time is 30 seconds for primary teeth and 20 seconds for permanent teeth. • Main functions of resin tags include retention, caries protection and prevention of bacterial colonization • Fluoride releasing sealants—Seal-Rite® (Pulpdent), FluoroShield® (Dentsply), Conceal F® (SDI) • Clear pit and fissure sealant—Helioseal® • Colored pit and fissure sealant—Clinpro® • Fluorescing pit and fissure sealant—Delton Seal-N-Glo® • Moist bonding pit and fissure sealant—Embrace WetBond® • Pit and fissure sealant with acp—Aegis Pit® and fissure sealant • Hydrophilic fluorescent BPA free Pit and fissure sealant—UltraSeal XT® hydro.

QUESTIONNAIRE 1. 2. 3. 4. 5.

Define pit and fissure sealant and discuss the method of its placement. Explain the classification, indications and ideal properties of sealants. Write a note on history of pit and fissure sealants. Explain acid etching. What are the new developments in the field of sealants?

REFERENCES 1. Simonsen RJ. Chapter 2: Pit and fissure sealants. In: Clinical Applications of the Acid Etch Technique, 1st Edn. Chicago, IL: Quintessence Publishing Co. Inc; 1978.pp.19-42. 2. Welbury R, Raadal M, Lygidakis NA. EAPD guidelines for the use of pit and fissure sealants. Eur J Paediatr Dent. 2004;5(3):179-84. 3. Gore JT. Aetiology of dental caries enamel immunization experiments. J Dent Res. 1939;26:958. 4. Buonocore MG. Simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Res. 1955;34:849. 5. Rodyhouse RH. Prevention of occlusal fissure caries by use of a sealant: A pilot study. ASDC J Dent Child. 1968;35:253-62. 6. Grewal N, Chopra R. The effect of fissure morphology and eruption time on penetration and adaptation of pit and fissure sealants: An SEM study. J Indian Soc Pedod Prevent Dent. 2008;26(2):59-63. 7. Nagano T. Forms of pits and fissures. Dent Abst. 1961;6:426. 8. EMG Subramanian, MS Muthu, N Sivakumar. Pit and Fissure Sealants and Preventive Resin Restorations. Chapter 21. In: MS Muthu, N Sivakumar Pediatric Dentistry: Principles and Practice; Elsevier, 2nd Edn. 2011.pp.241-8. 9. Irish Oral Health Services Guideline Initiative. Pit and Fissure Sealants: Evidence-based guidance on the use of sealants for the prevention and management of pit and fissure caries. 2010 available at http://ohsrc.ucc.ie/html/guidelines.html 10. Feigal RJ. The use of pit and fissure sealants. Pediatr Dent. 2002;24(5):415-22. 11. Zervou C, Doherty EH, et al. An in vitro study of microleakage of pit and fissure sealants in the presence of occlusal forces. J Clin Pediatr Dent. 2000;24(4):273-8. 12. Howard E. Strassler. Incisal Edge: Clinical Update: Flowable Composite Resins. 2013;7:61-70. 13. Silverstone LM, Dogon IL. The effect of phosphoric acid on human deciduous enamel surfaces in vitro. J Int Assoc Dent Child. 1976;7:11.

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14. Silverstone LM. In vitro studies with special reference to enamel surface and the enamel-resin interface. In: Silverstone LM, Dogon IL (Eds). Proceedings of an international symposium on the acid etch technique. St Paul: Central Publishing Co; 1975. 15. Chosak A, Eidelman E. Effect of time from application until exposure to light on the tag lengths of a visible light-polymerized sealant. Dent Mater. 1988;4:302-6. 16. Simonsen RJ. Pit and fissure sealant: review of the literature. Pediatr Dent. 2002;24(5):393­-414. 17. Burt BA. Fissure sealants: Clinical and economic factors. J Dent Educ. 1984;48:96-102. 18. Association AD. Estrogenic Effects of Bisphenol A Lacking in Dental Sealants. Available at: http:// www.ada.org/prof/prac/issues/ statements/sealest. html. Accessed. 1998.

BIBLIOGRAPHY 1. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Worthington H, Makela M. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev. 2004;(3):CD001830. 2. Bravon LJ, et al. Dental caries and sealant usage in US children. J Am Dent Assoc. 1996;127:335-43. 3. Donly KJ. Sealants: where we have been; where we are going. Gen Dent. 2002;50(5):438-40. 4. Gilpin JL. Pit and fissure sealants: A review of the literature. J Dent Hyg Summer. 1997;71(4):150-8. 5. Gwinnett AJ, Buonocore MG. Adhesives and caries prevention. Br Dent J. 1965;119:77. 6. Hassall DC, Mellor AC. The sealant restoration: indications, success and clinical technique. Br Dent J. 2001;191(7):358-62. 7. Locker D, Jokovic A. Series Editor Kay EJ. Prevention Part 8: The use of pit and fissure sealants in preventing caries in the permanent dentition of children. Brit Dent Journ. 2003;195(7):375-8. 8. Rethman J. Trends in preventive care: caries risk assessment and indications for sealants. JADA. 2000;131:8S-12S. 9. Waggoner WF, Seigal M. Pit and fissure sealant application: updating the technique. J Am Dent Assoc. 1996;1:351-61.

27

Chapter

Plaque Control in Children Nikhil Marwah, Koya Srikanth

Chapter outline • • • •

Disclosing Solution Dentifrices Toothbrush Toothbrush Modifications and Current Concepts

The emergence of a new philosophy and dentistry based on prevention rather than repair and replacement has been one of the most significant developments in the history of dentistry. Despite these substantial improvements in health, dental disease, however, remains a chronic health problem. Two main dental diseases, dental caries and periodontal disease, frequently begin in childhood and often have long sequelae, therefore to prevent these problems primary preventive dentistry must begin early in life before the insidious onset of these diseases. WHO (1978) defined bacterial dental plaque as a specific but highly variable structural entity resulting from colonization and growth of microorganism consisting of various species and strains embedded on an extracellular matrix. Dental plaque has also been defined as the nonmineralized microbial accumulation that adheres tenaciously to tooth surfaces, restorations and prosthetic appliances, shows structural organization with predominance of filamentous forms and is composed of an organic matrix derived from salivary glycoproteins and extracellular microbial products and cannot be removed by rinsing or water spray. Dental plaque is broadly classified as supragingival or subgingival based on its position on the tooth surfaces. The different regions of plaque are significant to different processes associated with diseases of the teeth and periodontium. For example, marginal plaque is of prime importance in the development of gingivitis; supragingival plaque and tooth associated subgingival plaque are critical in calculus formation; fissure associated subgingival plaque is important in the soft tissue destruction.

• • • • •

Techniques of Toothbrushing Tongue Cleansing Interdental Cleaning Aids Chemotherapeutic Plaque Removal Guidelines for Home Oral Hygiene

Methods of plaque control Mechanical plaque control

Chemical plaque control

• Dentifrice • Mouthwash • Tooth brush • Chlorhexidine • Dental floss • Other compounds • Oral irrigation • Interdental cleaning aids

Plaque control is the removal of plaque and the prevention of its accumulation on the teeth and adjacent gingival surfaces. Plaque control is the key to prevention and successful treatment of periodontal disease. Removal of microbial plaque leads to resolution of gingival inflammation in its early stages, and cessation of plaque control measures leads to its recurrence. Plaque control is accomplished by professional plaque removal and by patient performed oral hygiene practices or both.

DISCLOSING SOLUTION It is a preparation in liquid, tablet or lozenges that contains a dye or other coloring agent used to identify bacterial plaque deposits for instruction, evaluation and research.

Indications • Patient education • Instructions to patient about plaque control

302 Section 6 

Preventive Pedodontics

• Self-assessment by the patient • Evaluation of effectiveness of plaque control measures

• Assessment of the clinician • Preparation of plaque indices.

Formulations Name

Preparation

Skinner solution

Diluted tincture of iodine Water—15.0 mL

Iodine preparations

Iodine crystals—3.3 g Tincture of iodine—21.0 mL Potassium iodide—1.0 g Zinc iodide—1.0 g Water (distilled)—16.0 mL Glycerin—16.0 mL

Mercurochrome preparations

Mercurochrome—1.5 g Water—30 mL Oil of peppermint—3 drops Artificial noncalorigenic sweetener

Bismark brown (Easlick’s disclosing solution)

Bismark brown—3.0 g Ethyl alcohol—10 mL Glycerin—120 mL Flavoring agent—1 drops

Erythrosine

Erythrosine—0.8 g Water—100 mL Alcohol (95%)—10.0 mL Oil of peppermint—2 drops

2-tone solution (Block and his co-workers, 1975)

FD and C green no. 3 FD and C red no. 3 Thicker (older) plaque stains blue Thinner (newer) plaque stains red

Plak light system (Squillaro and co-workers)

Sodium fluorescein Glycerin—75% FD and C yellow no. 8

Topical application

Tablet FD and C red no. 3—15.0 mg Sodium chloride—0.747% Sodium sucaryl—0.747% Calcium stearate—0.975% Soluble saccharin—0.186% White oil—0.124% Flavoring—2.239%

Chapter 27  Plaque Control in Children DENTIFRICES A dentifrice is a substance used with a toothbrush to remove bacterial plaque, material alba, and debris from the

gingiva and teeth for cosmetic and sanitary, prevention and therapeutic purposes (Fig. 27.1). Egyptian medical manual the Ebers Papyrus written about 1500 BC mentions the use of dentifrice for cleaning the mouth and Hippocrates was the first to recommend the use of dentifrices.

Therapeutic dentifrices •

•

• •

A tooth paste is an excellent delivery system and has been widely used to deliver oral health benefits and different therapeutic agents Dental caries prevention by stannous fluoride, sodium fluoride (NaF) 0.24 percent (1100 ppm), sodium mono­ fluorophosphate (Na2 PO4 F2) 0.76 percent (1000 ppm) Reduction of tooth sensitivity, calculus promotion, bacterial plaque formation and gingivitis Used for tooth whitening for cosmetic effect.

Fig. 27.1: Dentifrices for children

Composition of dentifrices Component Detergent

% Added 1.2%

Cleaning and polishing

20 to 40%

• • • • •

Use To lower surface tension Penetrate and loosen surface deposits and strains. Emulsify debris for easy removal by the toothbrush Contribute to the foaming action A dentifrice may have a combination of agents in an abrasive system to accommodate both cleaning and polishing objectives Abrasive is used to clean A polishing agent is used to produce a smooth, shining tooth surface that resists discoloration, bacterial accumulation and retention To prevent separation of the solid and liquid ingredients during storage Contribute to the stability and consistency of the toothpaste These are added to retain moisture Prevent hardening on exposure to air To stabilize the preparation To prevent bacterial growth and to prolong shelf life

• • • • • •

To impart a pleasant flavor for patient’s acceptance To make the dentifrices desirable To mask other ingredients that may have less pleasant flavor For medicinal value Added for attractiveness Main transport medium

• • • • • • •

Binders

1 to 2%

Humectants

20 to 40%

Preservatives Sweetener Flavoring agent

2 to 3% 1 to 15%

Therapeutic agent Coloring agent Water

1 to 2% 2 to 3% 20 to 40%

•

Example Sodium lauryl sulphate

Calcium carbonate, calcium pyrophosphate, bicalcium phosphate

Organic hydrophilic colloids, alginates, magnesium aluminum silicate, colloidal silica Glycerin, sorbitol

Alcohols, formaldehyde and dichlorinated phenols Sorbitol and glycerin Peppermint, cinnamon, menthol Fluoride

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• The mechanical cleaning of teeth can be traced back to ancient times. • Evidence says that oral hygiene was practiced by Egyptians 5000 years ago; Romans used toothpick made up of bone and metals (Fig. 27.2). • The first bristle toothbrush was found in China during the Tang dynasty. • In 1223, Japanese Zen master DÅ Gen Kigen recorded that he saw monks in China clean their teeth with brushes made of horse-tail hairs attached to an ox-bone handle. • Tooth was adopted in Europe during the 17th century with the earliest identified use of the word toothbrush in English was in the autobiography of Anthony Wood, who wrote in 1690 that he had bought a toothbrush from J Barret. • In Europe, William Addis of England is believed to have produced the first mass-produced toothbrush in 1780.

William was basically a rag picker and in 1770, he had been jailed for causing a riot; while in prison he decided that the method used to clean teeth by rubbing a rag with soot and salt on the teeth was ineffective and could be improved. To that end, he saved a small animal bone left over from the meal he had eaten the previous night, into which he drilled small holes. He then obtained some bristles from one of his guards, which he tied in tufts that he then passed through the holes in the bone, and which he finally sealed with glue. After his release, he started a business that would manufacture the toothbrushes he had built under the name of Wisdom Toothbrushes (Fig. 27.3). • The first patent for a toothbrush was by HN Wadsworth in 1857 (US Patent No. 18,653) in the United States, but mass production in the United States only started in 1885. The rather advanced design had a bone handle with holes bored into it for the Siberian boar hair bristles (Fig. 27.4). • During the 1900s, celluloid handles gradually replaced bone handles in toothbrushes. Natural animal bristles were also replaced by synthetic fibers, usually nylon, by

Fig. 27.2: Ancient toothbrushes

Fig. 27.3: First toothbrush by Addis

TOOTHBRUSH

History

Fig. 27.4: Earlier toothbrushes

Chapter 27  Plaque Control in Children Toothbrush development timeline 3000 BC Egyptians use small branches to clean teeth 1223 Chinese invent bristle toothbrush 1690 First reference to word toothbrush in Europe 1780 William Addis invents toothbrush 1857 First patent for a toothbrush by HN Wadsworth 1938 First nylon bristles introduced by DuPont 1954 Electric toothbrush invented by Philippe-Guy Woog 1960 1st electric toothbrush in the US—Broxodent 1980 First modified angulation of toothbrush-Reach 1987 1st rotary action electric toothbrush for home use 2000 Low-price power toothbrushes become popular

• •

• •

DuPont in 1938. The first nylon bristle toothbrush, made with nylon yarn, went on sale on February 24, 1938 (Fig. 27.5). The first electric toothbrush was invented in Switzerland in 1954 by Dr Philippe-Guy Woog. The first American electrical toothbrush in the United States called the Broxodent was released in 1960 by Squibb. General Electric introduced a rechargeable cordless toothbrush in 1961. In 1987, Interplak was the first rotary action electrical toothbrush for home use.

Fig. 27.5: First nylon toothbrush by DuPont

• Johnson and Johnson, (1980) developed Reach tooth­ brush as the first to have a specialized design intended to increase its effectiveness. • In January 2003, the toothbrush was selected as the number one invention (Lemelson-MIT survey).

Parts of Toothbrush Toothbrushes should be able to reach and effectively clean most areas of the teeth. The type of brush is a matter of individual preferences. Parts of manual toothbrush include (Fig. 27.6): • Handle—grasped in the hand during toothbrushing • Head—the working part and consists of tufts of bristles or filaments • Shank—the location that connects the head and the handle.

ADA specifications Length—1 to 1.25 inches Width—5/16 to 3/8 inches Surface area—2.54 to 3.2 cm No of rows—2 to 4 rows of brushes No of tufts—5 to 12 per row No of bristles—80 to 85 per tuft Diameter for soft brushes—0.007 inch for medium brushes—0.12 inch and for hard brushes—0.014 inch

Fig. 27.6: Parts of manual toothbrush

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Size of Toothbrush According to Age A toothbrush with any kind of brush head cleans teeth effectively. However, the size of the brush head should be considered according to the size of the oral cavity Age 0–2 years

2–6 years

6–12 years

Size of brush

Description Brush head size should be approximately the diameter of 15 mm

Brush head size should be approximately the diameter of 19 mm

Brush head size should be approximately the diameter of 22 mm

• The recently introduced rippled bristle pattern may increase the efficiency of plaque removal especially in the proximal areas (Fig. 27.8). Different types of toothbrush bristle patterns Toothbrush

Bristle pattern Block pattern The bristles are of the same length and are arranged neatly like a block Wavy or V-shape pattern The bristles form a V-shape or wavy pattern. According to the manufacturer, this is intended to give the bristles a better contact with the areas around the adjacent tooth surfaces Multilevel trim pattern The manufacturer claimed that it enables the brush to reach difficult-to-clean areas Criss-cross pattern According to the manufacturer, this design can lift up plaque effectively Cross-action with gum stimulator Removes plaque more efficiently and also stimulates gingiva

Above 12 years

Brush head size should be approximately the diameter of 25 mm

Types of Toothbrush Bristles • There are two kinds of bristle material used in toothbrushes. • Natural bristles from logs and artificial filaments made predominantly of nylon. • Both types remove plaque, however, in homogenecity of the material, uniformity of bristle size, elasticity, resistances to fracture and repulsion of water and debris, nylon filament is clearly superior (Fig. 27.7). • Research has found out that soft nylon, multitufted bristles remove more plaque than hard bristles even when applying more pressure. It is also noted that brushes that have end-rounded filaments produce less gingival abrasion then filaments cut across.

Fig. 27.7: Geometrical design of bristles

Fig. 27.8: Rippled bristle pattern

Chapter 27  Plaque Control in Children

Types of Toothbrush Handles Type of handle

Feature

Description

Straight All conventional handle toothbrushes have straight handles that are easier to control Contraangle handle

This handle design is similar to a dental instrument, intending to access to the difficult-to-clean areas

Flexible handle

This kind of handle intends to reduce gum injury caused by excessive brushing force

Grip handle

This handle intends to prevent the toothbrush from slipping away during toothbrushing

Frequency and Duration of Brushing • Jenkins suggested that toothbrushing before meal is optimal. • He says that saliva is a good remineralizing agent that will neutralize and buffer the lowered pH of oral fluids caused by acidic foods and fermentable carbohydrates. • So, if tooth brushing is done after meals, it may remove saliva and decrease the remineralizing action (Fig. 27.9).

Fig. 27.9: Jenkins concept

Powered toothbrush The first electric toothbrush was conceived in Switzerland in 1954 by Dr. Philippe-Guy Woog and was manufactured in Switzerland and later in France for Broxo SA. The device plugged into a standard wall outlet and run on AC line voltage. Electric toothbrushes were initially created for patients with limited motor skills, as well as orthodontic patients.

TOOTHBRUSH MODIFICATIONS AND CURRENT CONCEPTS

Powered Toothbrush • The level of oral hygiene achieved by an individual is dependent on technique, motivations, dexterity and perseverance. Since the behavioral practices can’t be modified, the greatest potential for improving oral hygiene will come from advancements of brush design that enhance plaque removal. • First electric toothbrush (Fig. 27.10) was conceived in Switzerland in 1954 by Dr Philippe-Guy Woog. • The Broxo Electric Toothbrush was introduced in the USA by ER Squibb and Sons Pharmaceuticals 1959. After introduction, it was marketed in the USA by Squibb under the names Broxodent (Fig. 27.11). In the 1980s Squibb transferred distribution of the Broxodent line to the Somerset Labs division of Bristol Myers/Squibb.

• The GE Automatic Toothbrush was introduced in the early 1960s; it was cordless with rechargeable NiCad batteries, and although portable, was rather bulky. The GE Automatic Toothbrush came with a charging stand which held the hand piece upright. Also early NiCad batteries tended to have a short lifespan. The batteries were sealed inside the GE device, and the whole unit had to be discarded when the batteries failed. • In 1987, Interplak was the first rotary action electrical toothbrush for home use. • Braun-Oral B kids power toothbrush D10 is most effective in removing plaque in children. It has an oscillatory round brush head so causes no soft tissue damage. It appeals to children as it plays music at one minute interval thereby monitoring brushing time (Fig. 27.12).

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Fig. 27.12: Braun Oral-B kids power toothbrush D10

Fig. 27.10: First electrical toothbrush Difference between manual and powered toothbrushes Characteristic

Manual

Powered

Brushing duration

20–40 sec

1–3 min

Teeth brushed at a time

Multiple

One/multiple

Brush head motion

Cross and multiple

Minimal

Brush head speed

Zero

1000s/min

Brush head strokes

40–100/min

10–40/min

Brush head load

150–1000 gm

50–250 gm

Superbrush

Fig. 27.11: Broxodent toothbrush

• Current modifications of powered brushes have three motions: – Back and forth – Circular – Elliptical • Indications of powered toothbrush – Individual lacking motor skill – Handicapped patients – Patients who have orthodontic appliances – Whosoever wants to use

• It is designed to simultaneously clean the outer, inner and chewing surfaces of teeth. • Three brush heads are combined together in the Superbrush. When the brush is placed on the chewing surface, all the three surfaces of the tooth are cleaned simultaneously (Fig. 27.13). • It shortens the brushing time • Mostly indicated in disable children.

Pulsar Toothbrush • New concept in toothbrush technology where a pulsating chip is embedded on the base of bristles. • Pulsar has soft vibrating bristles that help break up plaque between teeth and facilitate easy removal. • Oral-B Pulsar is first to incorporate this technology in manual toothbrushes (Fig. 27.14).

Chapter 27  Plaque Control in Children

Fig. 27.13: Superbrush

Fig. 27.14: Oral-B Pulsar

Ultrasonic Toothbrush • The newest development in this field is the ultrasonic toothbrushes, or simply sonic toothbrushes using ultrasonic waves to clear the teeth. • In order for a toothbrush to be considered “ultrasonic”, it has to emit a wave at a minimum frequency of 20,000 hertz or 2,400,000 movements per minute. Typically ultrasonic toothbrushes approved by the FDA operate at a frequency of 1.6 MHz, which translates to 192,000,000 movements per minute. • Any toothbrush operating at a frequency or vibration less than 2,400,000 movements per minute (20,000 hertz) is a “sonic” toothbrush. It is called sonic because its operating

frequency (movements per minute) falls into the human hearing range of between roughly 20 hertz to about 20,000 hertz. • Emmident ultrasonic toothbrush generates ultrasound with its patented ultrasonic microchip, which is embedded inside the brush head. This chip creates up to 96 million ultrasonic (air oscillations) impulses per minute and transmits them via the bristles together with the specially formulated Nano Bubble toothpaste onto the teeth and gums. This popular and revolutionary beyond sonic toothbrush is a unique method of cleaning your teeth and removing harmful bacteria even in hard to reach areas and beats other toothbrushes in many ways (Fig. 27.15).

Fig. 27.15: Emmident ultrasonic toothbrush

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Chewable Toothbrush • A chewable toothbrush is a miniature plastic moulded toothbrush that can be used when no water is available. • They tend to be very small, but should not be swallowed. • They are available in different flavors such as mint or bubblegum and should be disposed of after use.

• Other types of disposable toothbrushes include those that are a small breakable plastic ball of toothpaste on the bristles, can be used without water and prove to be quite handy to travellers.

TECHNIQUES OF TOOTHBRUSHING • There are 6 major techniques of toothbrushing (Fig. 27.16) viz Scrub, Bass, Charters, Fones, Roll and Stillmans. • The most recommended technique for brushing in small children Scrub followed by Bass as they grow up after they achieve full manual dexterity.

Fig. 27.16: Toothbrushing methods

Chapter 27  Plaque Control in Children Method Scrub

Bristle placement Horizontal, on gingival margin

Bass

Apical, towards gingival into sulcus at 45°, to tooth surface

Motion Scrub in anterior-posterior direction keeping brush horizontal Short back and forth vibratory motion while bristles remain in sulcus

Charters

Coronally, 45°, sides of bristles half on teeth and half on gingiva

Small circular motions with apical movement towards gingival margin

Fones

Perpendicular to the tooth

Roll

Apically, parallel to tooth and then overtooth surface

Stillman’s

On buccal and lingual, apically at an oblique angle to long axis of tooth. Ends rest on gingiva and cervical part Pointing apically at an angle of 45° to tooth surface

With teeth in occlusion, move brush in rotary motion over both arches and gingival margin On buccal and lingual inward pressure, then rolling of head to sweep bristle over gingiva and tooth On buccal and lingual slight rotary motions with bristle ends stationary

Modified Stillman’s

Apply pressure as in Stillman’s method but vibrate brush and also move occlusally

TONGUE CLEANSING • Tongue is one such structure which retains plaque and requires brushing. • The tongue is anatomically perfect for harboring bacteria. The fungiform papillae create elevation and depressions in the tongue, which can house debris and microorganisms • The brushing of the tongue helps reduce the debris, plaque and number of microorganisms. • Place the head of the tongue cleaning brush (Fig. 27.17) near the middle of the tongue, with bristles pointed toward the throat, then the tongue is extruded, and the

Advantage/Disadvantage • Easy to learn • Best suited for children • Remove plaque from cervical area and sulcus • Easily learned • Good gingival stimulation • Hard to learn and position brush • Clears interproximal • Gingival stimulation • Easy to learn • Interproximal areas not cleaned • May cause trauma • Does not clean sulcus area • Easy to learn • Good gingival stimulation • Excellent gingival stimulation • Moderate dexterity required • Moderate cleaning of interproximal area • Good gingival stimulation • Cleaning of interproximal area • Easy to master

brush is swept forward and this motion is repeated 6 to 8 times • The patient is advised to use firm, overlapping scrub-type strokes starting at the back of the tongue and moving towards the tip.

INTERDENTAL CLEANING AIDS Anatomy of the interdental area is a major factor in the selection of interdental aids. The most frequent interdental aids include dental floss, interproximal brush, wooden tips,  oral irrigation devices, dental tapes and end-tufted brushes.

Dental Floss

Fig. 27.17: Tongue cleaning brush

• First paper on dental floss was published by Parmly in 1819 and he is credited as the inventor of floss. • Later in 1882, Codman and Shurtuff made first commercial floss made of silk. A lot of research had been going on about the different types of flosses and their benefits but it was Dr Charles C Bass who in 1948, recommended nylon floss is superior to silk. • The Johnson and Johnson Company of New Brunswick, New Jersey were the first to patent dental floss in 1898. • Size of dental floss can vary from 300 to 1500 denier (D). Floss is constructed with the help of individual filaments 2 to 3D thick. • Floss is dispensed in boxes and can be readily used and disposed off from there (Fig. 27.18). For additional ease

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Fig. 27.18: Dental floss

Fig. 27.20: String floss method

Fig. 27.19: Dental floss with holders

of flossing various floss holders are available throughout which vary in designs (Fig. 27.19).

Types of Floss • • • • •

Twisted and nontwisted Banded and nonbanded Thin and thick Microfilament and multifilament. According to ADA specification: – Type I: Unbonded dental floss composed of yarn having no additives. – Type II: Bonded dental floss composed of yarn having no additives other than binding agent or agent for cosmetic performance. – Type III: Bonded or unbonded having drug for therapeutic usage.

Fig. 27.21: Circle of floss method

Technique of Flossing • String floss method: Use 18 inches of floss. Wrap 2 to 3  inches of floss around middle finger of left hand and similarly to the right hand (Fig. 27.20). • Circle of floss method: Take floss and tie a double knot to secure it. The size of the circle is like an orange. Position the knot to the left side of working area and place middle, little and ring fingers of both hand on the inside of circle to keep it taut. Rotate counter-clockwise for fresh segments (Fig. 27.21).

Chapter 27  Plaque Control in Children Application (Figs 27.22 and 27.23)

Additional Suggestions • Slide the floss to a new, unused portion for succeeding proximal tooth surfaces. • Floss may be doubled to provide a wide rubbing surface.

Precaution • The col area in not keratinized and is vulnerable to bacterial innovation. Too great a pressure with floss one or more times a day, particularly by fine floss that tends to tear more easily than the thicker floss, can be destructive to the attachment and is particularly significant in children in whom teeth are in the process of eruption and the functional epithelium in less firmly attached. • Do not use long piece of floss between the fingers when held for insertion. • Snapping the floss through the contact area should be avoided.

Flossing for Children • Not all children can floss effectively. • The ability to use floss is a function of age and manual dexterity. • The ability to manipulate floss and remove plaque is highly dependent on hand and eye coordination and age.

A

B

Figs 27.22A and B

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314 Section 6 

Preventive Pedodontics

C

D

Figs 27.22C and D Figs 27.22A to D: Flossing according string of floss method

A

B

C

D

E

F

G

H

I

Figs 27.23A to I: Flossing according to circle of floss method

Chapter 27  Plaque Control in Children Brush Brush color color

Brush size size

Wire size

Pink

0

0.4 mm

Passage Passagehole hole diameter diameter(PHD) (PHD)

Orange 1

0.45 mm

1.9 mm

Gray

7

1.3 mm

Black

7

1.5 mm Fig. 27.24: Interproximal brushes

Interproximal Brushes • These are cone shaped brushes made of bristles mounted on handle, single-tufted brushes or small conical brushes. • Interdental brushes are particularly suitable for cleaning large irregular or concave tooth surface adjacent to wide interdental spaces. • They are inserted interproximally and are activated in short back and forth strokes in between the teeth. • For best cleaning efficiency the diameter of the brush should be slightly larger than the gingival embrasure so that the bristles can exert pressure on the tooth surfaces. • Single tufted brushes are slightly effective on the lingual surface of mandibular molar and premolar whereas a regular toothbrush is often impeded by the tongue. • These brushes are classified as: – Tapered ( Christmas tree appearance) – Nontapered (Bottle neck appearance) • Interdental brushes are classified according to ISO standard 16409:2006. The ISO brush sizes range from 1 to 7 (Fig. 27.24). The ISO brush size is determined by the PHD or Passage Hole Diameter in mm.

Fig. 27.25: End-tufted brush

End-tufted Brush • An end-tufted brush is a type of toothbrush used specifically for cleaning along the gumline adjacent to the teeth. • The bristles are usually shaped in a pointed arrow pattern to allow closer adaptation to the gums (Fig. 27.25). • An end-tufted brush is ideal for cleaning specific difficultto-reach areas, such as between crowns, bridgework, crowded teeth and fixed orthodontic appliances.

Wooden Tips • Soft triangular wooden tips such as a Stim-U-Dent (Fig.  27.26) are placed in the interdental space in gingiva and they slide with contact the proximal tooth surface.

Fig. 27.26: Stim-U-Dent wooden tips

• Made up of bass wood or balsa wood • Repeatedly moved in and out of the embrasures, removing soft deposit for the teeth and mechanically stimulating the gingiva. • Use is limited to the facial surfaces.

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Oral Irrigation • Irrigation is the targeted application of a pulsated or steady stream of water or other irrigant for a cleansing and therapeutic purpose which can be done by the patient or the clinician. • Oral irrigation cleans adherent bacteria and debris from the oral cavity more effectively than toothbrush and mouth rinse. They are particularly helpful for removing debris from inaccessible areas around orthodontic appliance and fixed prosthesis. • When used as adjuncts to tooth brushing, these devices can have a beneficial effect on periodontal health by retarding the accumulation of plaque and calculus and by reducing gingival inflammation. • Contraindicated in patients with advanced periodontitis and medically compromised patients like leukemia, AIDS, diabetes, bleeding disorders. • It is delivered by: – Power driven device (Fig. 27.27) • Generates an intermittent or pulsating jet of fluid. • An adjustable dial for regulation of pressure is provided along with a hand-held interchangeable tip that rotates 360° for application at the gingival margin. – Nonpower driven device (Fig. 27.28) • It is attached to a household water supply and delivered through a hand-held interchangeable tip that can be used for application at the gingival margin. • Its disadvantages are uncontrolled water pressure and nonpulsatile water jet thereby limiting its subgingival effect.

Fig. 27.27: Power driven Oral irrigation device

Fig. 27.28: Non-Power driven Oral irrigation device

Procedure of Irrigation • The target of the oral irrigation in the loosely attached subgingival bacterial plaque. • Some tips that are used to deliver the oral irrigants may be classified as: – According to composition of tip—metal, rubber – According to angulation—straight, angulated – According to use—standard specialized.

Chapter 27  Plaque Control in Children CHEMOTHERAPEUTIC PLAQUE REMOVAL Classification of chemotherapeutic plaque removal agents Bisguanides and related compounds • Chlorhexidine • Alhexidine

Fluoride and inorganic ions • Stannous fluoride • Hydrogen peroxide

Quaternary ammonium compounds • Cetylpyridinium

Antibiotics • Penicillin • Metronidazole

Enzymes • Dextranase • Glucose–amyloglucosidase

Organic compound • Sanguinarine • Menthol/thymol

Chlorhexidine • The dental profession has used chlorhexidine for over two decades. It is recognized, as the primary agent for chemical plaque control and its clinical efficacy is well known to the profession. • In addition to having gained the acceptance of dental profession, chlorhexidine has also been recognized by the pharmaceutical industry as the positive control against which the efficacy of alternate anti-plaque agent should be measured.

Antibacterial Activity • It is a cationic bisbiguanide with broad-spectrum anti­ bacterial activity, low mammalian toxicity and strong affinity for binding to skin and mucous membranes.

• Chlorhexidine has a wide spectrum of activity encom­ passing gram-positive and gram-negative bacteria, yeasts, dermatophytes and some lipophylic viruses. • Chlorhexidine shows different effects at different concent­ ration. At low concentration the agent is bacteriostatic and at high concentration it is bactericidal. • Antibacterial action of chlorhexidine: • Anti-plaque mode of action: Chlorhexidine (0.12 to 0.2%) binds to the different surfaces within the mouth (teeth and mucosa) and also to the pellicle and saliva. After a single rinse with chlorhexidine, the saliva itself exhibits antibacterial activity for up to 5 hours, whereas persistence at the oral surfaces has been shown for over 12 hours. The following are the mechanism of plaque inhibition: An influence on pellicle by blocking the acidic groups on the salivary glycoprotein, thus reducing the protein adsorption to the tooth surface

An influence on the adsorption of plaque onto the tooth surface by binding to the bacterial surface in sublethal amounts

The key feature of chlorhexidine is its substantivity. Substantivity is the ability of an agent to be retained in the oral cavity and slowly released in its active form over an extended period of time.

An influence on the formation of plaque by precipitating the agglutination factors in saliva and displacing calcium from the plaque matrix.

• Disadvantage: – Yellowish staining of the teeth. – Alteration in taste.

Essential Oils • These are the oldest form of mouthwashes. The most popular one being Listerine. • It is a combination of the phenol related essential oils, thymol and eucalyptol mixed with menthol and methyl salicylate. • Mechanism of action is by cell wall disruption and inhibition of bacterial enzymes. • Goodson (1985) has pointed out that most phenolic compounds have anti-inflammatory and prostaglandine synthetase inhibitor activity. Phenolic compounds are also known to act as scavengers of oxygen-free-radicals (Kuehl et al. 1977) and should have an effect on leucocyte activity.

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• It has shown effectiveness in plaque reduction in the range of 20 to 34 percent and gingivitis reduction about 28 to 34 percent. • Adverse effects include initial burning sensation and bitter taste in the mouth.

Quaternary Ammonium Compounds • The agent most commonly used in this category is Cetylpyridinium chloride at a concentration of 0.05 percent. • This group of chemical agents is cationic and binds to the oral tissues but not as strongly bisbiguanide. When used orally, they bind strongly to plaque and tooth surfaces but are released from these binding sites more rapidly than chlorhexidine. This rapid release is one of the reasons why they are not as effective as chlorhexidine. • Mechanism of action is related to their ability to rupture the cell wall and alter the cytoplasmic contents. • Adverse effects include a yellow brownish discoloration of the tongue and around gingival margin of the tooth, burning sensation and occasional desquamation. • Commercial names are Cepacol (0.05%) and Scope (0.45%).

Triclosan • Trichloro - 2-hydroxyl diphenyl ether • Triclosan is available in dentifrices and mouthrinses. • Triclosan is both a bisphenol and a nonionic germicide with low toxicity. It has broad spectrum of antibacterial activity and lack the staining effects of cationic agents. • Since it does not bind well to oral sites due to its lack of a strong positive charge ions, therefore, it is used in combination with zinc citrate to take advantage of its potential anti plaque property; copolymer of methoxyethylene and maleic acid to increase its retention time and combination with pyrophosphates to enhance its calculus-reducing properties. • Triclosan also acts as an anti-inflammatory agent in morthrinses. It has been shown to inhibit both cyclooxygenase and lipoxygenase and thus decrease synthesis of prostaglandin and leukotiene which are key mediators in inflammation.

Sanguinarine • It is currently used in both mouth rinse and toothpaste. • It is an alkaloid extract from the bloodroot plant –Sanguinaria canadensis. • It contains the extract at 0.03 percent (equivalent to 0.01% Sanguinarine and 0.2% zinc chloride). • Seventeen to fourty-two percent plaque reduction and 18 to 57 percent reduction in gingivitis is seen. • The only adverse effect reported with this agent has been a burning sensation when used initially.

Propoile • Naturally occurring bee product used by bees to seal opening on their hives. • Consists of wax, plant extracts and contains flavones, flavanones and flavonls. • It has been shown that is had very low level of clinical effectiveness but significant plaque inhibitory action.

Stannous Fluoride • In addition to decreasing the solubility of enamel to bacterial acids and enhance mineralization, stannous fluoride has shown a secondary benefit of inhibiting microbial plaque accumulation. • Mechanism of action is that it interference with bacterial biochemical synthesis, metabolism and aggregation. • 0.04 percent concentration is the most effective. • Available as an aqueous gel and suggested usage is one or two times daily.

Prebrushing Rinse • PLAX is the only available agent. • The chemical composition is sodium benzoate. When combined with a soapy agent, may have a surfactant action on plaque. • Nonapproved by the ADA.

Chapter 27  Plaque Control in Children GUIDELINES FOR HOME ORAL HYGIENE Prenatal counseling

The infant

The toddler

The goal of prenatal dental counseling is one counseling of education. Even before the baby is born, parents should be counseled on how to provide an environment that will nurture good oral health habits that contribute to lifelong dental health for their child. Prenatal counseling can be quite effective because during this period the parents are more open to health information for their children than during any other time. It is generally recommended that parents begin  clearing the infant’s mouth by the time first tooth erupts. It is suggested that secure and consistent physical support with slow, careful movement is to be employed at all time. Most have suggested that the parent wraps a damp washcloth or a piece of gauze around the index finger and clean the teeth and gum pads once a day. As more teeth erupt the parent can begin using a small soft toothbrush. At this age toothpaste is not necessary and may interfere with visibility for the parent. Additionally, the infant will be unable to effectively expectorate, causing unwanted toothpaste ingestion. Several methods of positioning the infants for daily oral hygiene procedures have been suggested. One effective method is to have the parent cuddle the infant in his or her arm with one of the child arms gently slipped around the parents back. In this way the parent can stabilize the child with one hand and work with the other. The parent should be totally responsi­ ble for oral hygiene of the t o d d l e r, as for the infant. Establishing a specific routine is generally most convenient for parents and encourages the young child to develop good dental habits. As more teeth begin to

The early school age child

erupt, parents should approach brushing systematically by beginning in one area of the mouth and progressing up in an orderly fashion. This is best accomplished by the use of a dampened, soft bristled toothbrush. If adjacent teeth are in contact, parents should also begin to floss these areas. Although parents still have the responsibility of performing a thorough, daily plaque removal for their toddler and children at the age begin to demonstrate an interest in the procedure and a desire to take part. Parents should encourage this behavior and allow the child’s to attempt brushing procedures. Parents should, however, be advised that the child efforts will be inadequate in thoroughly removing plaque. Therefore, the parent must perform a thorough plaque removal for the child at least once a day. As for the infant, it is important to the parent’s methods of positioning and stabilizing the child so that the parents will have maximum visibility as well as control over the child’s movements. The position selected for home plaque removal procedures will depend on the cooperation of the child. Many of the techniques employed with the infants may also be applied to the toddler. One of the most effective positions is to have the parents face each other while the child is supine on the parent’s knees. In this position, one parent assumes the role of brusher while the other parent stabilizes the child. The preschool child is usually unable to expectorate effectively, and to any dentifrice that is placed on the toothbrush is generally ingested. Repeated ingestion of large amount of dentifrice may increase the systemic fluoride intake to undesirable levels. Thus until the child can expectorate effectively, the parent should be responsible for dispensing the toothpaste and should place only a small pea sized portion of dentifrice on the brush for the child. Because they are beginning to develop the necessary skill, early school aged children should be encouraged to routinely attempt brushing and flossing. How­ever, the parent must continue to main­tain the major res­ ponsibility

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320 Section 6 

The pre- adolescent

Preventive Pedodontics by providing a thorough pla­que removal for the child each evening before bed. Dis­closing agents may be particularly use­­ful in this age group when one is teaching brushing and flossing techniques. The key to the success of an oral hygiene program for the preadolescent child is to encourage parents to reinforce the instructions given in the dental office. After the child attempts plaque removal procedures, the parent can promote learning by staining the teeth with disclosing solution and showing where the improvement is needed. The child should also be praised for his or her efforts when plaque has been successfully removed. Children in this age group generally demonstrate the ability to expectorate and should use a fluoridated dentifrice each time they brush. During preadolescence, the child will gradually assume more responsibility for his or her own hygiene. By 10 or 11 years of age the child has often achieved the coordination

The adolescent

necessary for eff­ective brushing and flossing. The children in this age group require instruction on pro­per brushing and flossing techniques. The adolescent has generally attained the manual dexterity needed to properly brush and floss without direct help from an adult. Although children in this age group probably have the ability to adequately perform thorough oral hygiene procedure, they may lack the motivation to do so on a routine basis.

POINTS TO REMEMBER • WHO defined bacterial dental plaque as a specific but highly variable structural entity resulting from colonization and growth of microorganism consisting of various species and strains embedded on an extra cellular matrix. • Plaque control is the removal of plaque and the prevention of its accumulation on the teeth and adjacent gingival surfaces. • Mechanical plaque control is done by dentifrice, toothbrush, dental floss, oral irrigation and interdental cleaning aids. • Chemical plaque control is mostly by mouthwash of chlorhexidine or other compounds. • Two-tone disclosing solution was discovered by Block, 1975 and has FD and C Green No. 3 and FD and C Red no. 3. It stains thicker (older) plaque stains blue and thinner (newer) plaque stains red. • William Addis of England discovered toothbrush. • The first nylon bristle toothbrush, made with nylon yarn, went on sale on February 24, 1938 by DuPont. • The first electric toothbrush was invented in Switzerland in 1954 by Dr Philippe-Guy Woog. • ADA Specifications of toothbrush: Length—1 to 1.25 inches; Width—5/16 to 3/8 inches; Surface area—2.54 to 3.2 cm; No. of rows—2 to 4 rows of brushes; No. of tufts—5 to 12 per row; No. of bristles—80 to 85 per tuft. • Jenkins concept states that toothbrushing before meal is optimal. He postulates that saliva is a good remineralizing agent that will neutralize and buffer the lowered pH of oral fluids caused by acidic foods and fermentable carbohydrates. So, if tooth brushing is done after meals it may remove saliva and decrease the remineralizing action. • Indications of powered toothbrush are individual lacking motor skill, handicapped patients, patients who have orthodontic appliances. • The newest development in plaque control is the ultrasonic toothbrushes, using ultrasonic waves to clear the teeth. • New concept in manual toothbrush technology is where a pulsating chip is embedded on the base of bristles that help break up plaque by vibrations (Oral B Pulsar). • There are 6 major techniques of toothbrushing viz Scrub, Bass, Charters, Fones, Roll and Stillman’s technique. • Scrub is the best method for brushing in small children and Bass is the best for older children. • Flossing for children is difficult as the ability to use floss is a function of age and manual dexterity. • Home oral hygiene guideline suggests that care of teeth must start as soon as they erupt by cleaning with warm gauze, later we can shift to use of finger brush. For infants, best is to position them in lap and do their oral cleaning; preschool children can usually accomplish brushing with parental help; preadolescent children can do the brushing on their own but under adult supervision; whereas older children can take care of their oral need like brushing and mouthwash on their own.

Chapter 27  Plaque Control in Children

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Define dental plaque and enumerate the methods of plaque control. Write a note on disclosing solutions. What is the composition of a dentifrices? Explain the evolution of toothbrush. What is Jenkins concept? Write a note on powered toothbrush. What are the newer modifications of toothbrush? Explain various techniques of toothbrushing with special reference on the technique used in children. What are interdental cleaning aids? Write a note on chlorhexidine. What are the guidelines of home oral hygiene for children from infancy to adolescence?

BIBLIOGRAPHY 1. Biesbrock AR, Bayuk LM, Santana MV, et al. The clinical effectiveness of a novel power toothbrush and its impact on oral health. J  Contemp Dent Pract. 2002;2(3):001-10. 2. C Deery. The effectiveness of manual versus powered toothbrushes for dental health: a systematic review. J Dentisty. 1999;32(3):197-211. 3. Cochran DL, Kalkwarf KL, Brunsvold MA. Plaque and calculus removal: Considerations for the professional, 2nd Edn. Quintessence Publishing Co, Inc; China. 1994. 4. Gibson TA, Nash DN. Practice patterns of board-certified pediatric dentists: frequency and method of cleaning children’s teeth. J Pediat Dent. 2004;26(1):97-9. 5. Grossman E, Proskin H. A comparison of the efficacy and safety of an electric and a manual children’s toothbrush. J Am Dent Assoc. 1997;128:469-74. 6. Kimmelman BB, Tassman GL. Research in design of children’s toothbrushes. J Dent Child. 1960;27:60-4. 7. M Addy, J Moran, RM Davies, A Beak, A Lewis. The effect of single morning and evening rinses of chlorhexidine on the development of tooth staining and plaque accumulation. J Period Research. 2000;(2):134-40. 8. McClure DB. A comparison of toothbrushing techniques for the preschool child. J Dent Child. 1966;33:205-10. 9. Mentes A, Atukeren J. A study of manual toothbrushing skills in children aged 3 to 11 years. J Clin Pediatr Dent. 2002;27:91-4. 10. Steven E, Schonfeld, Ali Farnoush, Suzan G. Wilson in vivo antiplaque activity of a sanguinarine-containing dentifrice: Comparison with conventional toothpastes. J Period Research. 2004;21(3):298-303. 11. Wright GZ, Banting DW, Feasby WH. Effect of interdental flossing on the incidence of proximal caries in children. Journal of Dental Research. 1977;56(6):574-8.

321

28

Chapter

Plaque Control for the Disabled Child Nikhil Marwah

Chapter outline • •

Development of a Personal Oral Hygiene Program Level of Caregiver Support

Home dental care should begin in infancy; the dentist should instruct the parents to gently cleanse the teeth daily with a soft cloth or an infant toothbrush. For older children who are unwilling or physically unable to cooperate, the dentist should teach the parent or guardian correct toothbrushing techniques the safely restrain the child when necessary. The goals and purpose of preventive dental services for persons with severe disabilities, including personal oral hygiene procedures, are no different than those for the general population. However, the physical, cognitive and behavioral limitations presented by severely disabled individuals require modification of usual preventive practices including the choice of materials and techniques utilized. Although the dentist maintains overall responsibility for preventive as well as restorative services, the dental hygienist together with other auxiliaries usually are the dental professionals most involved with these programs.

DEVELOPMENT OF A PERSONAL ORAL HYGIENE PROGRAM • The dental hygienist usually leads the dental team in the development and monitoring of an individual’s personal oral hygiene (POH) program. • This program is developed utilizing information obtained at the first dental examination, discussions with appropriate direct care staff, consultations with other professionals from the program team and occasionally from visits to the residential area where oral hygiene procedures will be carried out.

• •

Oral Hygiene Aids Guidelines for Home Oral Care of Disabled Children

• Pertinent information including the person’s cognitive and physical limitations and abilities, the ability to cooperate with POH procedures, the level of periodontal health and caries risk, the level and rate of plaque, and calculus accumulation, significant drugs used (including sugar content) and type and consistency of diet will impact the selection and prescription of specific POH techniques. • The procedures prescribed include toothbrush selection and use, flossing techniques and materials (e.g. floss holder) needed, antimicrobial agents prescribed, mouth props or restraints required, and positioning techniques indicated. • One of the vital components of a successful POH program is monitoring to determine, if the procedures are being performed as prescribed. This will allow the dental practitioner to evaluate the program’s effectiveness and make modifications as needed. Monitoring is often accomplished using a “checklist” or other measure­ ments of staff compliance with prescribed procedures. Evaluation of effectiveness is often made at the time of recall.

LEVEL OF CAREGIVER SUPPORT The level of mental functioning and the individual’s capacity for interaction with others dictates the level of home care that can be performed by the individual and his/her degree of dependency on the care giver. There are numerous strategies for categorizing the level of caregiver support necessary for

Chapter 28  Plaque Control for the Disabled Child adequate oral hygiene. One of these includes the following categories: • Independent toothbrushing—no assistance; • Partial independent toothbrushing—with staff assistance including prompting by verbal instructions or by physical manipulation (staff’s hand over person’s hand); • Complete staff dependence requiring no significant behavior management; • Complete staff dependence requiring head stabilization, lip retraction and mandibular pressure to maintain oral access; or • Complete staff dependence requiring more than one staff person. The additional staff person(s) would provide physical stabilization of the person necessary for adequate oral hygiene procedures to be safely completed.

ORAL HYGIENE AIDS Devices used in the mouth to control plaque should be selected on an individual basis and training in their use is necessary to prevent damage to oral tissues. There are a wide variety of oral care products available for use. When deciding on the appropriate devices to be tried, the following issues should be considered: • Ability of the individual or caregiver performing daily oral hygiene; • Time constraints placed on staff or caregiver; • Level of person’s cooperation; • Physical and environmental conditions where oral care is provided; • Degree of parent involvement.

Toothbrush • The choice of a toothbrush for persons with disabilities is often the same as for the general population. • Usually a soft nylon bristle, rounded end, multi-tufted brush with a long strong neck is the preferred choice. Brushes with longer handles facilitate reaching the posterior teeth. The size of the brush-head is determined by the size of the oral cavity and the person’s ability to open. • As with any individual, the proper application of the toothbrush is far more important than toothbrush choice. • There are numerous commercially available modified toothbrushes that have been designed for special patients. This usually entails the modification of the handle and special designs for bristle placement. A list including description and source of some modified brushes and other materials currently available are presented in Table 28.1. • Several studies have found the automatic toothbrush to be superior to manual brushes for some individuals. • However, most studies that compare the effectiveness of toothbrush choices, whether manual, adapted,

commercially modified or automatic, have found that improvement in oral hygiene levels occurs regardless of which toothbrush is used, indicating that toothbrush choice is far less important than conscientious use and follow-up.

Toothbrush Modifications • The most common tool for effective mechanical control of dental plaque is a toothbrush but the presence of physical and/or cognitive disabilities can create difficulties both in holding and manipulating a toothbrush. • For patients whose main deterrent to personal self-care is related to grasp, manipulation or control of the brush, adaptations have been devised which include enlarged handles, hand attachments and elongated handles. • The aim of the toothbrush adaptation is to provide a handle with a stable grip, whilst its shape enables the person to feel how to manipulate the brush in the mouth adequately during cleaning. • Grasp: For people who cannot grasp and hold, the objective is to fasten the brush handle to the hand. This can be achieved by using a velcro strap with a pocket on the palm side into which the toothbrush can be inserted (Fig. 28.1). • Fixed fingers: For a patient with fingers permanently flexed or fixed in a fist, toothbrushes with variation in the grip and handle width in all shapes and sizes are available commercially and a suitable brush that inserts directly into the patient’s grasp can be selected (Fig. 28.2). • Limited hand closure or reduced manual dexterity: Objective is to enlarge the diameter of the brush handle to fit the hand. The simplest method of improving the grip involves inserting the brush handle into another material to improve its size, shape or surface characteristics. Simple and successful methods of adapting the toothbrush grip include the use of sponges, tubing, bicycle handlebar grips or pushing it into a soft rubber ball (Fig. 28.3).

Fig. 28.1: Velcro strapped brush

323

324 Section 6 

Preventive Pedodontics

TABLE 28.1: Commercially available modified toothbrushes Brush name

Description

Findings

COLLIS CURVE®

Three rows of bristles, outer two rows are curved inward with a single short straight row running down the center.

The Collis Curve brush is a popular, commercially available adapted brush. It has the advantage of being able to cover buccal, occlusal and lingual surfaces simultaneously.

IMPROVE®

Standard-shaped head with the bristles arranged in a deep “V” groove design.

Position over teeth to do simultaneous lingual-buccal brushing. However, when one side is at 45o angle, then other side no longer makes contact with the corresponding gingiva and cervical surface.

ACTION 2®

Double-headed brush with sides angled at 45o.

This brush is very difficult to insert correctly, and when in the mouth, the heads are too small to cover the crowns and reach the gingiva.

TWINBRUSH®

Twin-heads angled at 45o with outside rows softer than inside rows.

Easy to use and insert and seems to work best with a small amount of toothpaste. It is most effective for brushing the lingual posteriors. Brush by placing over the anterior teeth and moving backward.

OMNIA-DENT®

A six (6) sided brush with very small heads to allow brushing of all surfaces (both arches) at the same time.

This brush is very impractical. The double side is not as useful as the size of the brush makes it uncomfortable to use and interproximal tips are too large to clean as they are intended.

VAC-U-BRUSH®

A suction brush designed for bedside use on patients who may be at risk of aspiration while receiving mouth care. It has a moderate length, wide handle with a suction attachment on the end.

The brush fits easily on all the bedside suction units tested. The head is small enough for a child-size mouth. The handle is able to be maneuvered comfortably by the operator. The head is small with a row of soft bristles set in a horseshoe pattern with a suction groove in the center for fluid removal.

COLGATE PLUS®

Diamond-shaped head with a long-curved handle. The outer bristles are very soft while the inner bristles are more firm.

The tapered head may help in insertion when the patient remains clenched. The long handle is comfortable and helps to reach the posteriors.

FLEX (AQUAFRESH)® Large, tapered head with soft bristles. The handle is long with section that is bent into a fan-like arrangement.

Except for the textured handle which offered a more secure grip, this brush did not offer any benefit over a standard tapered headbrush. The flexed section did not seem to serve any real purpose.

RADIUS®

The larger head allows for all sides to be brushed at the same time. Also available in child size.

Brush has a larger than average head with soft nylon bristles and large built-up handle-shaped for left or right hands.

Chapter 28  Plaque Control for the Disabled Child • Manipulation: Those patients who can position a toothbrush but cannot manipulate it sufficiently to clean  all the surfaces of the teeth, double-headed brushes are useful and commercially available. Kaschke  et al. in his trial to evaluate the effectiveness of different toothbrushes showed that a three-headed brush (such as  the ‘Superbrush’) performed best for adults who otherwise required help with their toothbrushing (Fig.  28.4). Use of powered toothbrush is also best indicated in these individuals. • Limited shoulder or arm movement: For this group of people, where there is limited arm and hand movement, the objective is to lengthen the handle of the brush with a material strong enough to maintain the brush in contact with tooth surfaces so as to apply sufficient lateral pressure to remove plaque effectively (Fig. 28.5).

Dentifrices • For many severely disabled patients, the foaming caused by toothpaste together with copious amounts of saliva stimulated by toothbrushing obstructs visualization of the areas to be brushed and can stimulate gagging. • Some individuals may ingest excessive amounts of toothpaste. • An alternative for these persons is the elimination of toothpaste during brushing. The toothbrush can simply be moistened with water or a flavorful mouthwash. • A commercially available dentifrice that is non-foaming, safe for ingestion and has a pleasant taste (NASA Dent®) is available but the need for such toothpaste with this population is questionable.

Fig. 28.2: Gripped toothbrush

Fig. 28.3: Toothbrush grip modifications

Fig. 28.4: Superbrush

Fig. 28.5: Long handle modification

325

326 Section 6 

Preventive Pedodontics

Mouthwash • The use of antimicrobial agents, especially chlorhexidine mouth rinse, has been proven effective in reducing the severity of plaque accumulation and gingivitis. There has been an increased interest in use of these agents with the disabled population since adequate mechanical plaque removal remains a problem. • Since the usual method of rinsing and expectorating is difficult for the person with severe disabilities, alternative methods such as a spray or application by swab (e.g. Toothette®) is often indicated. • The use of other anti­ microbial agents may also be indicated. These include Listerine® mouthwash, stannous fluoride gels and mouthwashes, povidone iodine (Betadine®) mouthwashes, sanguinarine products (e.g.

Viadent®) and similar mouthwashes have proven effective antiplaque agents, are cheaper than chlorhexidine and do not cause problems with staining and taste alteration. They do, however, contain alcohol and should be used with caution in patients who may swallow them.

Fluoride Application • Professionally prescribed stannous fluoride gels are generally more effective anti-plaque agents than commercially available fluoride mouthwashes, but their application is more difficult with this population. • Foam or plastic trays are usually contraindicated due to lack of patient cooperation and frequent bruxism. Professionally constructed acrylic mouthguard-type trays are difficult to fabricate for uncooperative individuals, difficult for direct care staff to use and are frequently misplaced. • The application of fluoride gels by toothbrush after normal brushing has been completed is often the method of choice.

GUIDELINES FOR HOME ORAL CARE OF DISABLED CHILDREN (FIG. 28.6)

Fig. 28.6: Guidelines for home oral care of disabled children

Chapter 28  Plaque Control for the Disabled Child

POINTS TO REMEMBER • Home dental care should begin in infancy. • For older children who are unwilling or physically unable to cooperate, the dentist should teach the parent or guardian correct toothbrushing techniques the safely restrain the child, when necessary. • Usually a soft nylon bristle, rounded end, multi-tufted brush with a long strong neck is the preferred choice. • Powered brushes are preferred choice in disabled children. • For people who cannot grasp and hold brush handle is attached to velcro strap on the palm. • In case of limited hand closure or reduced manual, simplest method of improving the grip involves inserting the brush handle into another material to improve its size, shape or surface characteristics, like bicycle handlebar grips or pushing it into a soft rubber ball. • Those patients who can position a toothbrush but cannot manipulate it sufficiently to clean all the surfaces of the teeth, double-headed brushes and powered toothbrush are best indicated. • When there is limited arm and hand movement, the objective is to lengthen the handle of the brush with a material strong enough to maintain the brush in contact with tooth surfaces so as to apply sufficient lateral pressure to remove plaque effectively. • Use of dentifrices has a limited role whereas the mouthwashes form and important component of maintenance control of oral hygiene in handicapped children.

QUESTIONNAIRE 1. Explain plaque control for a disabled child. 2. What are the modifications of toothbrush for a handicapped child? 3. Explain the guidelines for home care of oral hygiene in handicapped children.

BIBLIOGRAPHY

1. Dougall A, Fiske J. Access to Special Care Dentistry, part 4. Education. British Dental Journal. 2008;205:119-30. 2. Albertson D, Johnson R. Plaque control for the institutionalized child. JADA. 1973;87(7):1389-94. 3. Bay LM, et al. Effect of chlorhexidine on dental plaque and gingivitis in mentally retarded children. Comm Dent Oral Epid. 1975;3(6):267-70. 4. Bratel J, et al. Electric or manual toothbrush? A comparison of effects on the oral health of mentally handicapped adults. Clin Prevent Dent. 1988;10(3):23-6. 5. Crawford PJ, et al. The effect of modifying toothbrush handles on plaque control in handicapped children: preliminary report. Proc Br Paedod Soc. 1977;7:11-3. 6. Dickinson C, Millwood J. Toothbrush Handle Adaptation using Silicone Impression Putty. Dent Update. 1999;26:288-98. 7. Ettinger RL, et al. Oral hygiene and the handicapped child. J Int Asso Dent Child. 1978;9(1):3-11. 8. Ettinger RL, et al. Toothbrush modifications and the assessment of hand function in children with hand disabilities. J Dent Handi. 1980;5(1):7-12. 9. Johnson R, et al. Plaque control for handicapped children. JADA. 1972;84:824-8. 10. Kaschke I, Klaus-Roland J, Zeller A. The effectiveness of different toothbrushes for patients with special needs. J Disabil Oral Health. 2005;6:65-71. 11. Loesche WJ. Plaque control in the handicapped: the treatment of specific plaque infections. Can Dent Assoc J. 1981;47(10):649-56. 12. Nowak AJ. Dentistry for the handicapped patient. St Louis: CV Mosby Co., 1976. p.3. 13. Scully C, Dios PD, Kumar N. Special care in dentistry. Chapter 2. London: Churchill Livingstone; 2007. 14. Soncini JA, et al. Individually modified toothbrushes and improvement of oral hygiene and gingival health in cerebral palsy children. Jr Pedo. 1989;13(4):331-4. 15. Southern Association of Institutional Dentists: Self-Study Course Module 11. Preventive Dentistry for Persons with Severe Disabilities. 16. Williams NJ, et al. The curved bristle toothbrush: an aid for the handicapped population. J Dent Child. 1988;55(4):291-3.

327

29

Chapter

Fluorides Puneet Goenka, Nikhil Marwah

Chapter outline • • • • • • • • • •

Fluoride in the Environment Fluoride Content in Some Commonly used Foods Metabolism of Fluoride History of Fluorides Mechanism of Action of Fluoride Water Fluoridation School Water Fluoridation Salt Fluoridation Milk Fluoridation Dietary Fluoride Supplements

The greatest contribution of last century to the improvement of oral health is perhaps the discovery and utilization of fluoride as a caries preventive measure. Extensive research has been carried out about the utility of this salt in variety of ways to draw maximum systemic and topical benefits of its cariostatic properties. Fluoride is one of those remarkable elements, which have not only notable chemical qualities, but also physiological properties of great interest and importance for human health. Fluoride has been described as an essential nutrient in the Federal Register of United States Food and Drug Administration (1973) and World Health Organization (WHO) expert committee on trace elements and human health. They have also included fluoride in the list of 14 elements recognized to be physiologically essential for the normal development and growth of human beings. The term fluoride is derived from a Latin word Fluore, which means to flow. Its atomic weight is 19 and atomic number is 9. Fluoride is never encountered in nature in the elemental form, as it is the most electronegative and reactive of all elements and thus it is found in salt form.

• • • • • • • • • •

Topical Fluorides Sodium Fluoride Stannous Fluoride Acidulated Phosphate Fluoride Newer Topical Fluorides Fluoride Varnish Fluoride Dentifrices Fluoride Toxicity Defluoridation Recent Advances in Fluoride

FLUORIDE IN THE ENVIRONMENT

Lithosphere • In the lithosphere fluoride is present as a wide variety of minerals like fluorspar, cryolite, apatite mica and hornblende. • High concentrations of fluoride are also present in certain pegmatite like topaz and tourmaline, as well as volcanic and hypabyssal rocks. Salt deposits of marine origin also contain abundance of fluoride.

Facts file Concentration of fluoride in: • Rain water: Negligible • Lake Nakuru (Kenya) water: 2800 ppm • Tea leaves: 56.640 ppm • Coconut water: Negligible

Chapter 29  Fluorides • In spite of being in abundance very little fluoride is biologically available. This is mainly because of its reactive nature thus rendering it to be bound firmly to minerals and other chemical compounds. The availability of free fluoride ions in the soil is governed by the natural solubility of the fluoride compound considered, the acidity of the soil, the presence of other minerals or chemical compounds, and the amount of water present. • The concentration of fluoride in soil also increases with depth.

Leafy Vegetables Spinach

2.113

Fenugreek leaves

3.011

Cabbage

1.880

Colocasia leaves

4.959

Amaranth leaves

6.154 Roots and tubers

Potatoes

1.856

Onions

2.088

Carrots

3.425

Hydrosphere

Other vegetables

• Due to universal presence of fluorides in Earth’s crest, all water contains fluoride in various concentrations. • For example, negligible in rain water, high in lakes and wells like, fluoride in sea water – 0.8-1.4 mg/L and in river – 0.5 mg/L. • Highest content of fluoride in water is in Lake Nakuru (Kenya) – 2800 ppm.

Atmosphere • Fluoride mainly enters the atmosphere through the dusts of fluoride-containing soil, from gaseous industrial waste, from burning of coal fires and from gases emitted in areas of volcanic activity. • The fluoride content in the air in some factories can reach levels as high as 1.4 mg/m.

FLUORIDE CONTENT IN SOME COMMONLY USED FOODS The mean value of fluoride content, in ppm, of commonly used food items in India as given by Dilnawaz R, Lakdawala and BD Punekar (1973)1 are tabulated below: Type of food

Fluoride content (ppm) Cereals

Cucumber

2.457

French beans

1.530

Tomato

1.366

Brinjal

2.024

Ladies finger

2.730 Fruits

Banana

1.096

Chikoo

1.238

Grapes

1.360

Oranges

1.745

Mango

1.320

Water melon

0.739

Apple

1.744

Guava

0.392 Animal foods

Milk

0.499

Eggs

1.531

Mutton

3.083

Beef

4.416

Pork

3.533

Fish

0.933-3.149

Prawns

2.749 Beverages

Whole wheat

2.920

Wheat flour milled

5.402

Tea

56.640

Rice

7.720

Coca cola

10.393

Bajra

1.885

Sugar cane juice

1.198

Coconut water

0.508

Pulses and legumes

Miscellaneous

Bengal gram flour, milled

8.065

Bengal whole gram

4.215

Ground nuts

2.088

Green gram dal

2.965

Coconut fresh

2.148

Green gram whole

5.882

Sugar

0.420

Red gram dal

3.590

Betel leaves

2.680-9.320

329

330 Section 6 

Preventive Pedodontics

Fluoride Distribution (Figs 29.1 and 29.2)

Fig. 29.1: Fluorosis distribution in India according to Sushila AK; 20012

Fig. 29.2: Countries with endemic fluorosis (According to UNICEF)3

Chapter 29  Fluorides METABOLISM OF FLUORIDE

Absorption Fluoride is primarily absorbed from stomach. This process occurs by passive diffusion and is also inversely related to pH so that factors which promote the secretion of gastric acid increase the rate of fluoride absorption, which leads to earlier and high peak plasma levels and vice versa.

Transportation • In plasma, fluoride exists in two forms: Ionic fluoride (inorganic or free fluoride) and nonionic or bound fluoride. • Almost all fluoride in plasma is in ionic form and is not bound to any macromolecules. The plasma half-life of fluoride is reported to be 4 to 10 hours. Studies have indicated that the fluoride is not bound to the plasma proteins or to any other constituent of plasma. Therefore, it may be assumed that the interstitial fluid and the plasma have virtually the same composition. • The plasma concentration of fluoride is variable, being dependant on the level of intake and several physiological factors. • Considering the above facts the height of plasma peak is proportional to the fluoride dose ingested, the rate of absorption and the body weight (volume of distribution) of the subject, i.e. the larger the body weight, the lower is the plasma peak and vice versa.

Soft Tissue Distribution • Once absorbed, fluoride is distributed within minutes through the extracellular fluid to most organs and tissues. • The fluoride concentration in most soft tissues is lower than the plasma level except in the healthy kidney where, because of urine production, an occasional fluoride accumulation may result. • Fluoride passes through the placenta, and studies have shown that the fetal fluoride level is about 75 percent of that of the maternal blood. Gedalia has described that when the fluoride intake is low, fluoride freely passes

through the placenta, but when the fluoride intake is high the placenta plays a regulatory role and protects the fetus from excess. • The fluoride concentration of human breast milk is lower than that of maternal plasma. Thus the fluoride intake of infants who are solely or mainly breastfed is unusually low. • In subjects with a normal diet, the fluoride concentration in the saliva is about 1 µM/L.

Excretion • The main route of fluoride excretion is via the kidneys. • Because ionic fluoride is not bound to plasma proteins, its concentration in the glomerular filtrate is undoubtedly the same as in plasma. Also, there exists a “steady-state” between the concentrations of fluoride in the plasma and the urine, i.e. the fluoride concentrations in plasma and urine tend to parallel each other very closely. • The kidneys are very efficient in removing fluoride from the body. The renal clearance of fluoride in the adult typically is 30 to 50 mL/min. Compared to the other halogens whose clearance rates are normally about 1.0 mL/min or less. • Excretion of fluorides – Renal: 30 percent within 3 hours and 40 to 60 percent in 24 hours – Gut: 10 percent in faeces – Breast milk: 0.01 to 0.05 ppm – Sweat: 10 to 25 percent in 1 hour.

Distribution of Fluoride in the Body • It depends upon physical form of dose, presence of food in stomach, gastric pH, gastric motility and concurrent oral administration. – Plasma Concentration: 0.7 to 2.4 um – Kidney: 4.16 ppm – Bone: 99 percent – Enamel: 2200 to 3200 ppm – Dentin: 200 to 300 ppm – Cementum: 4500 ppm – Pulp: 100 to 650 ppm.

331

332 Section 6 

Preventive Pedodontics

HISTORY OF FLUORIDES 1901

Dr. Fredrick McKay of Colorado, USA observed apparently permanent stain on the teeth of many of his patients: commonly known as “Colorado stains” by the local inhabitants. McKay at this stage failed to relate this stain with any factor and named it as “mottled enamel”.

1908

Dr McKay presented a case at the annual meeting of State Dental Association in Boulder and found that the condition was not confined to Colorado but extended to other towns as well

1912

Dr McKay came across an article written by Dr JM Eager (1902), a US Marine Hospital surgeon who reported that a high proportion of Italian residents in Naples had brown stains on their teeth known as ‘denti di chiae’

1916

McKay and Black conducted a survey over 6,873 individuals in 26 communities in USA reporting that an unknown factor possibly present in domestic water during the period of tooth calcification may be the cause of mottled enamel

1918

McKay observed that individuals reared up in Britton since 1898 had mottling whereas all those who had passed through childhood before had normal teeth. It was also observed that prior to 1898, Britton had changed its water supply from individual shallow wells to deep drilled artesian wells. Thus, it was concluded by McKay that some mysterious element in water supply was the causative agent for Mottled enamel

1925

The inhabitants of Oakley, Idaho were so much convinced by the water supply hypothesis that they switched their water supply from deep artesian wells to shallow water supply following concerns about discolouration to teeth. McKay found no brown stains in the permanent teeth of 24 children born in Oakley, seven and half years later following the change in water supply

1931

Churchill developed a method for determining concentrations of fluoride in drinking water. He found 13.7 ppm of fluoride in Bauxite. In addition the level of fluoride was very high in the water from other endemic areas for mottled teeth. Thus this was finally established that “Fluoride” was the culprit behind this ugly condition. Further supported by the experimental production of dental lesions similar to human fluorosed enamel, in experimental animals by water from endemic areas and water to which fluoride had been added (Smith 1931)

1934

Dean conducted the famous ‘Shoe Leather Survey’ and established that concentration of fluoride in drinking water was directly correlated to the severity of fluorosed enamel. Dean also developed a standard classification of mottling and an index to quantify it mottling index

1939

To test the correlation of fluoride in water and dental caries, a survey of four Illinois cities was planned by Dean. The cities were Galesburg and Monmouth (1.8 and 1.7 ppm fluoride respectively) and MaComb and Quincy (0.2 ppm Fluoride). The results showed that caries experience in low fluoride areas with 0.2 ppm fluoride was more than twice as high as that in the areas with 1.7 and 1.8 ppm

1942

Dean finally concluded that at 1 ppm of fluoride in drinking water near maximal reduction of caries experience, i.e. 60 percent was achieved and only “sporadic instances” of the mildest form of dental fluorosis of no practical or esthetic significance were observed

1945

First community level water fluoridation program started in Grand Rapids, USA

1950s

Water fluoridation started in the US in the states of Florida, Illinois, California (1952), Ohio (1955) and Missouri (1957)

1964

The World Health Organization (WHO) and the Pan American Health Organization endorsed the practice of water fluoridation

Shoe Leather Survey • The study of relationship between fluoride concentration in drinking water, mottled enamel and dental caries was given an impetus by the decision of Dr Clinton T Messner, Head of US Public Health service in 1931, to assign a young Dental Officer Dr H Trendley Dean to pursue full time research on mottled enamel.

• His first task was to continue Mckay’s work and to find the extent and geographical distribution of mottled enamel in USA. • He sent a questionnaire to the secretary of every local and state Dental Society in the country and asked if mottled enamel existed in their areas, if so how extensive and also enquired about the water source. Out of 1197, questionnaires 632 replies were received. Dean reported that 97 localities in the country where mottling had occurred.

Chapter 29  Fluorides • His aim was to find out the minimal threshold of fluoride— The level at which fluorine began to blemish the teeth. He showed conclusively that the severity of mottling increased with increasing fluoride concentrations in the drinking water. • He gave the following observations: – Water concentration was 4 ppm or more—Signs of discrete pitting. – Water concentration was 3 ppm or more—Mottling was widespread. – Water concentration was 2 to 3 ppm—Teeth had dull chalky appearance. – Water concentration was 1 ppm or less—No mottling of any esthetic significance. – He also reported that the incidence of caries in these teeth was less as compared to nonfluoridated teeth.

MECHANISM OF ACTION OF FLUORIDE

(CO–23). The spatial arrangement of these ions forms microcrystals in enamel and dentin called as hydroxyapatite {Ca10(PO4)6 (OH)2}. CO–23 is an integral part of the relatively large apatite crystals of enamel. Along with these the inorganic phase of teeth contains a large number of trace elements like F–, Mg, Mo, Sr, Cl, Na, etc. The most significant among these is the Fl–. The hydroxyapatite is formed by the spatial arrangement of a large number of repeating units called as crystal. The smallest space unit of the HA crystal is called as unit cell which is formed by 10Ca++, 6PO–34 and OH–. Individual or isolated unit cell cannot exist. Thus, Ca10(PO4)6 (OH)2 does not represent the molecular formula of unit cell, rather, it is the minimum number of atoms necessary to form an unit cell through their spatial interaction. Each unit forms a rhomboid with a- and b-axes lying in the same plane, forming the floor and the roof of the rhomboid. Each side measure 9.42 Ao and with two angles each of 60o and 120o. The height of the unit cell, the C-axis, at right angle to the a-b plane and parallel to the long axis of the crystal, measures 6.88 Ao. Figure  29.5

The mechanism of action of fluoride or the methods by which fluoride exhibits its anticariogenic or antimicrobial effect are improved crystallinity, void theory, acid solubility, enzyme inhibition, suppressing the flora, antibacterial action, lowering free surface energy, desorption of protein and bacteria and alteration in tooth morphology (Table 29.1). To understand these phenomenons it is most ideal to first understand the structure of hydroxyapatite4 (Fig. 29.3).

Structure of Hydroxyapatite The hard tissues of the body viz. bone and teeth are made of an organic part and an inorganic part. The primary chemical constituents of enamel are Ca++, PO–34, OH– and carbonate

Fig. 29.3: Hydroxyapatite structure

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TABLE 29.1: Mechanism of action of fluoride Improved crystallinity

Fluoride increases the crystal size and produces less strain in crystal lattice. This takes place through conversion of amorphous calcium phosphate into crystalline hydroxyphosphate.

Void theory

Incorporation of fluoride results into formation of larger and more stable crystals. Fluoride replaces OH– from the center of the Ca++ triangle. It forms strong coulomb interaction forces with Ca++, thereby decreasing the dimension of this axis. Hydroxyapatite crystals are known to have inherent voids due to missing hydroxyl groups which makes it unstable. In hydroxyapatite crystal OH– group is present slightly above or below the plane formed by Ca++ ion. To maintain symmetry equal number of OH– ions should be present on both the sides of the Ca++ plane. At times when hydrogen of adjacent OH– groups point towards each other, this results in to stearic interference resulting into the elimination of one OH– group, thereby forming a void in the place. Voids in the crystal decreases the stability and increases chemical reactivity. When these voids are filled by Fl–, the stability of the crystal increases and the reactivity decreases greater stability of the crystal impart lower solubility and greater resistance to dissolution in acids. Incorporation of a small amount of Fl– in the apatite crystal improves its properties considerably. Fl– ions also form hydrogen bonds with neighboring OH– ions this further helps in the stabilization of the crystal

Acid solubility

(FAP vs HAP) Fluorapatite or fluoridated hydroxyapatite (solubility constant of 10.60) is less soluble than hydroxyapatite (10.55), therefore has greater stability

Enzyme inhibition

Fluoride has enolase inhibition effect and it also inhibits glucose transport. Enolase is a metalloenzyme that requires a divalent cation for its activity; fluoride due to its increased reactivity forms a complex with this cation thus inhibiting the enzyme. It also inhibits nonmetalloenzymes like phosphatases thus leading to reduced acid production

Suppressing the flora

Stannous fluoride is a potent suppressor of the bacterial growth because it oxidizes the thiol group present in bacteria thus inhibiting bacterial metabolism

Antibacterial action

The concentration of fluoride above 2 ppm in solution progressively decreases the transport of uptake of glucose into cells of oral streptococci and also reduces ATP synthesis

Lowering free surface energy

Fluoride incorporated in enamel by substitution of hydroxyl ions reduces the free surface energy and thus indirectly reduces the deposition of pellicle and subsequent plaque formation

Desorption of protein and bacteria

Hydroxyapatite crystals are amphoteric with both positive and negative receptor sites. Acidic protein group binds to calcium site and basic to phosphate site. Fluoride inhibits the binding of acidic protein to hydroxyapatite thereby displaying its beneficial effects

Alteration in tooth morphology

Dentition in fluoridated communities showed a tendency towards rounded cusps, shallow fissures due to selective inhibition of ameloblasts

represents the location of the OH– and Ca+2 in a repeating unit cell. The OH– are arranged in columns parallel to the C-axis at distances of 1/4th and 3/4th the height of the C-axis. Surrounding this column, Ca++ forms an equilateral triangle lying parallel to the a-b plane. Successive Ca++ triangles are rotated 180o with respect to each other, thereby forming a screw axis symmetry. This stacking of two such triangles shows that they do not superimpose each other but are out of phase by 60o. In addition, Ca++ ions are also located in vertical columns, parallel to the C-axis. One of it is situated just above or below the halfway point between ends of the cell and the other just above or below the a-b plane. The phosphate ions occupy the bulk of the space within each unit call. They have a tetrahedral structure with the phosphorus of the center and oxygen at each apex.

WATER FLUORIDATION It is defined as the upward adjustment of the concentration of fluoride ion in public water supply in such way that the concentration of fluoride ion in the water may be

consistently maintained at one part per million (ppm) by weight.

History of Water Fluoridation • History of water fluoridation dates back many years when Fredrick McKay and Trendley Dean began their initial research but the most significant change took place in 1942 during Grand Rapids – Muskegon study.5 • During many previous researches it was noted that fluoride decreased the incidence of caries, crucial step was to see if dental caries would be reduced in a community by adding fluoride at 1 ppm to water supply. • US public health service in December 1942 began this study in 2 cities Grand Rapids and Muskegon. They came to a conclusion that 1 ppm fluoride was not only best for caries control, but was also well within limits of safety. • On 25th January 1945 it was the moment of truth NaF was added to water supply. It was for the first time that permissible quantity of a beneficial dietary nutrient was added to communal drinking water (Fig. 29.4).

Chapter 29  Fluorides

Fig. 29.4: Timeline photos of Grand Rapids—Muskegon study of water fluoridation

Countries using water fluoridation Argentina, Australia, Brazil, Brunei, Canada, Chile, Fiji, Guatemala, Guyana, Hong Kong, Irish Republic, Israel, Libya, Malaysia, New Zealand, Panama, Papa New Guinea, Peru, Serbia, Singapore, South Korea, Spain, United Kingdom, United States, Vietnam Countries which refused water fluoridation Portugal, Romania, Denmark, Austria, China, The Netherlands, Belgium, Hungary, Switzerland, Luxembourg, Sweden, Norway, Finland, Japan, France, Czech Republic, India, Germany

 luoride Compounds Used F in Water Fluoridation • Fluorspar • Sodium fluoride

• • • •

Silicofluorides Sodium silicofluoride Hydrofluosilicic acid Ammonium silicofluoride.

Equipment for Water Fluoridation There are three systems for water fluoridation: 1. Saturator system 2. Dry feeder system 3. Solution feeder system.

Optimum Level of Fluoride • Based on extensive research, the United States Public Health Service (USPH) (1986) established the optimum concentration for fluoride in the water in the range of 0.7 to

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336 Section 6 

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System

Procedure

Factors limiting usage

4 percent saturated solution of NaF is produced and injected at the desired concentration in the water distribution source with aid of a pump

Need to clean gravel bed used for filtration

Suitable for medium sized towns requiring less than 3.8 million lit/ day

Dry feeder

NaF or silicofluoride in the form of powder is introduced into a dissolving basin

Care in handling fluoride, obstruction of pipes and compacting of fluoride while storage

Suitable for medium sized towns requiring 3.8 million lit/day to 19 million lit/day

Solution feeder

Volumetric pump permitting the addition of a given quantity of hydrofluosilicic acid in proportion to the amount of water treated

The equipment must be resistant to attack by Suitable for medium sized and hydrofluosilicic acid, necessitating construction large towns with a capacity of in polyvinyl chlorides or another plastic more than 7.6 million lit/day

• •

•

•

1.2 parts per million. This range effectively reduces tooth decay, with minimal chances to cause dental fluorosis. The water intake of individuals varies widely and is influenced significantly by climate. Children living in a 1 ppm fluoridated area are assumed to receive an optimal intake of fluoride from water and food of 1mg fluoride daily. The US Public Health Service Drinking Water Standards has recommended optimal fluoride concentration as a function of temperature. Galagan and Vermillion (1957)6 developed an empiric formula for estimating the amount of daily fluid intake based on body weight and climatic conditions, using the mean annual maximum daily air temperature as follows: ppm F = 0.34/E E = –0.038 + 0.0062 × t E – Estimated daily water intake of children in oz/lb of body weight T– Mean maximum daily air temperature in degree Fahrenheit of the area

• In 1967, Richards et al. made a comprehensive study of temperature and recommended water fluoridation

Recommendation

Saturator system

Temperature in °C Recommended ppm

26.7

1.1-1.3 0.8-1.0 0.5-0.7

Advantage of Water Fluoridation • Large number of people are benefited • Consumption is regular • Fluoridated drinking water not only acts systemically during tooth formation to make dental enamel more resistant to dental decay, but also has topical effect through the release in saliva after ingestion

• Fluoridation of community water is the least expensive and most effective way to provide fluoride to a large group of people.

Disadvantage of Water Fluoridation • Interfere with human rights • Other modes are not considered • Common source of water supply may not be present.

Landmark studies of water fluoridation • 1931- HV Churchill devised method to measure of level of fluoride in water. • 1938-Klein H and several branches of the US Public Health Service conducted studies jointly in Texas—in Amarillo and in Wichita Falls, and confirmed that fluorosis was associated with low levels of tooth decay. • 1939-TH Dean conducted study to test the correlation of fluoride in water and dental caries, in a survey of four Illinois cities Galesburg, Monmouth, MaComb and Quincy. • 1943-David Ast made a monograph, to determine the benefits of adding fluoride to drinking water. • 1943-David Ast, Smith DJ, Wachs B, Cantwell KT did NewburghKingston caries-fluorine study XIV: combined clinical and roentgenographic dental findings after ten years of fluoride experience. • 1961-Backer Dirks O, Houwink B, Kwant GW conducted a study on artificial fluoridation of drinking water in the Netherlands called The Tiel-Culemborg experiment. • 1965-Brown and Poplove carried out study on water fluoridation in Canada.

SCHOOL WATER FLUORIDATION • This program helps in limiting caries in school children who are our prime concern. School water fluoridation is a suitable alternative where community water fluoridation is not feasible.

Chapter 29  Fluorides • The amount of fluoride added in school drinking water should be greater than normal because children have to stay in school for a short time of the day and to compensate for holidays and vacations. • This procedure was first started in 1954 in St Thomas VS Virgin Islands by US Public Health Service Division. • The current recommended regimen for school water fluoridation is adding 4.5 times more fluoride. • There has been around 25 to 40 percent decrease in dental caries with this program. Simple fluoridators particularly that employ the Venturi system are most suitable, because they require almost no maintenance and can be utilized effectively in small installations of small or medium sized schools.

Advantages • Good results in reducing caries • Minimal equipment • Not expensive.

Disadvantages • Children do not receive the benefit until they go to school • Not all children go to school in poor countries like India • Amount of water drunk can not be regulated.

• No supervision of set up or distribution system • Low cost • Depends on individual acceptance and rejection.

Disadvantages • No precise control over indicated consumption, since salt intake varies greatly among people. • International efforts to reduce sodium uptake. • Fluoridated salt consumption is lowest when the need for fluorides is greatest: in the early years of life.

MILK FLUORIDATION • Ziegler in 1956 was the first person to mention milk fluoridation as a method of systemic fluoridation. • The concentration of fluoride in 250 mL milk bottle was 0.625 mg. • It targets the fluoride directly to the children and this could be less expensive than water fluoridation. But considerable number of children in most countries will not drink milk for one or another reason. • The mode of action of fluoride is both systemic as well as topical. • The amount of fluoride to be added depends upon the age of the child and the fluoride concentration in water. This is further complicated by the fact that different children consume varying quantities of milk per day.

SALT FLUORIDATION • As a dietary vehicle for ensuring adequate ingestion of fluoride domestic salt comes second to drinking water. • Wespi in 1955 introduced salt fluoridation in Switzerland. • Initially the concentration of fluoride was 90 mgF/kg but has been recently made 200 to 350 mgF/kg. • Antioquia, Colombia was the first American country to follow salt fluoridation in 1967. • In 1982, WHO and FDI recommended that sat fluoridation start as soon as possible in all countries. • The procedure of salt fluoridation can be either by spraying concentrated solutions of NaF or KF on salt on a conveyor belt or by mixing with PO4 carrier salt and then adding to the main bulk. Till now salt fluoridation has been tried in Columbia, Hungary, Mexico and Switzerland, with Switzerland being the oldest. • A study conducted by Toth, in Hungary after 8 years of use of fluoridated salt, showed a reduction of 39 percent in deft in 6 years old children.

Advantages • Fluoridated salt is safe. • Theoretically fluoridated salt prevents dental caries by both systemic as well topical action.

Compounds Used for Milk Fluoridation • • • •

Calcium fluoride Sodium fluoride Disodium monofluorophosphate Disodium silicofluoride.

Feasibly of Milk Fluoridation in India • In spite of the controversy concerning the binding and complexing of fluoride with calcium and protein of the milk and thus making it unavailable for its anticariogenic action, Ericsson (1985) using radioactive isotope technique proved that availability of fluoride from milk is the same as from water 4 hours after consumption. • Though theoretically milk fluoridation is advantageous, in addition to being the staple food for children and its consumption can be confined to groups who need it most, that practically speaking this method does not seem to be viable and feasible because of the following facts: – In India, majority of the children population living in rural and urban areas cannot afford milk daily and moreover there does not exist a central milk supply system in these areas. – Variation of intake and quantity of milk is another factor which cannot be controlled since it depends upon the socioeconomic religious and ethnic factors.

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DIETARY FLUORIDE SUPPLEMENTS • When introduced dietary fluoride supplements were perceived to be a reasonable alternative where water fluoridation was not possible. But supplements need cooperation to a high degree and so these should be directed only to needy population for whom caries or its treatment may be difficult. • Some examples of supplements are fluoride drops, fluoritab liquid, Vi-Daylin/F ADC drops, pediaflor drops, etc. • The dosage will depend upon the age of the child and the concentration of fluoride in the area. American Academy of Pediatrics recommends that fluoride supplements can be started 2 weeks after birth and continue till 16 years of age. Dietary fluoride supplementation schedule7 Age Birth-6 months

0.6 ppm F

proved that individuals continuously living in a fluoride rich area had less caries as compared to the individuals who had lived in the same fluoride rich areas during calcification of teeth but had shifted to nonfluoride areas thereafter. Simultaneously in early 1940s, it was demonstrated that extracted teeth when exposed to dilute solutions of fluoride on for a few seconds were found to have completely bound fluoride on the enamel surface which subsequently was less soluble than the original enamel surface. These two facts brought forth the idea of topical application of fluoride solution of dental caries prevention. In 1941, began the era of topical fluorides when the first clinical study of NaF was carried out by Bibby using a 0.1 percent NaF solution. Subsequently over the years various other topical fluoride agents have been evolved which in sequential order are SnF2 (1947), APF (1963), Na MPP (1963), amine fluoride (1965) and varnish containing fluoride (1968). Topical fluorides can be divided into:

0

0

6 month–3 years 0.25 mg

0

0

Professionally applied fluorides

3–6 years

0.50 mg

0.25 mg

0

6 years up to at least 16 years

1.00 mg

0.50 mg

0

Neutral NaF Stannous fluoride Acidulated phosphate fluoride Amine fluoride Fluoride varnishes Fluoride gels

• Prior to 1969, fluoride was prescribed in prenatal supplements for potential caries prevention in teeth whose development began before birth. It was assumed that fluoride would cross the placental barrier and that it would be acquired by the developing teeth sufficiently to provide caries protection. The United States Food and Drug Administration concluded that sufficient evidence did not exist to support claims of efficacy of prenatal fluoride supplements therefore in 1966 the Food and Drug Administration banned advertising claiming that prenatal fluoride supplements provided a dental benefit, but it did not ban their sale by prescription. • Fluoride supplements extend its cariogenic effect by acting both locally and systemically. For its local or topical effect fluoride must either contact the tooth surface before it is swallowed or pass through the circulation and be secreted is saliva. • It is recommended that a child consume no more than 1 mg of fluoride per day from fluoride supplements and from the drinking water. • According to Ripa, the appropriate marketed dosage forms may be given full strength of half strength, depending upon the patient’s age and level of fluoride in the drinking water. The American Academy of Pediatrics has subsequently adopted this approach.

TOPICAL FLUORIDES Fluoride has been proved to be the single most effective weapon in our limited arsenal of anticaries agents. Dean

Self applied fluorides Tooth brushing dentifrices Tooth brushing solutions Tooth brushing prophylaxis pastes Mouth rinses

SODIUM FLUORIDE • Milestone studies were con­ducted by Bibby8 in 1941 and JW Knutson in 1942, which varied not only in concentration of NaF used but also in number of applications per year. • Knutson and Feldman9 (1948) recommended a technique of 4 applications of 2 percent NaF at weekly intervals in a year at 3, 7, 11 and 13 years. • Sodium fluoride has neutral pH, 9200 ppm of F– • Caries reduction in 1st year was 45 percent and in 2nd year was 36 percent.

Method of Preparation • Two percent NaF solution can be prepared by dissolving 20  g of NaF powder in 1 liter of distilled water in a plastic bottle. • It is essential to store fluoride in plastic bottles because if stored in glass containers, the fluoride ion of solution can react with silica of glass forming SiF2, thus reducing the availability of free active fluoride for anticaries action.

Chapter 29  Fluorides

 ethod of Application M (Knutson’s Technique)

Advantages • • • • •

Chemically stable Acceptable taste Nonirritating to gingival tissues Does not discolor the teeth Cheap and inexpensive.

Disadvantages • Continuous application for 4 minutes • Patient has to make four visits in a short time • Follow-up is difficult.

STANNOUS FLUORIDE • Stannous fluoride in early 1950s occupied a central role in the saga of preventive dentistry. After the discovery of NaF, a wide variety of other fluoride compounds were tried like Potassium, Lead, Silicon, Tin and Zirconium. • All yielded some cariostatic benefit but SnF2 was found to be three times more effective than NaF. • Dudding and Muhler in 1957 tried single annual application of 8 percent SnF2 and reported 32 percent caries reduction.

Method of Preparation

Mechanism of Action

• Stannous fluoride solution has to be freshly prepared before use each time (stannous form of Tin gets oxidized to stannic form, thus making the SnF2 inactive for anticaries action), as it has no shelf life. • For convenient preparation number ‘o’ gelatin capsules are priorly filled with 0.8 g powdered SnF2 and are stored in airtight plastic containers. Just before application the content of one capsule is dissolved in 10 mL of distilled water in a plastic container and the solution thus prepared is shaken briefly. The solution is then applied immediately.

Method of Application

Ca (PO4) 6 (OH)2 + 20 F = 10 CaF2 + 6 PO4 + 2 OH CaF2 + 2 Ca5 (PO4)3 OH = 2 Ca5 (PO4) 3F + Ca (OH)2

• The recommended procedure for application of SnF2 begins with thorough prophylaxis followed by isolation with cotton rolls and drying preferably with compressed air. • Either a quadrant or half of the mouth can be treated at one time. • A freshly prepared 8 percent solution of SnF2 is applied continuously to the teeth with cotton applicator and reapplication of the solution to a particular tooth is done every 15 to 30 seconds so that the teeth are kept wet for 4 minutes. • The recommended frequency of application is once per year.

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340 Section 6 

Preventive Pedodontics

Mechanism of Action

• For the preparation of APF gel, a gelling agent like Methylcellulose or Hydroxyethyl cellulose is to be added to the solution and the pH is to be adjusted between 4 to 5.

Method of Application

Low conc. – Ca5 (PO4) 3OH + 2 SnF2 = 2 CaF2 + Sn2 (OH) PO4 + Ca3 (PO4)2 High conc. – Ca5 (PO4) 3OH + 16 SnF2 = 2 CaF2 + 2 SnF3PO4 + Sn2 (OH) PO4 + 4 CaF2 (SnF3)2 – 2 Ca5 (PO4) 3OH + CaF2 = 2 Ca5 (PO4) 3F + Ca (OH)2

Disadvantage • • • • • •

Should be prepared freshly Low pH Metallic taste Causes gingival irritation Produces discoloration of teeth Causes staining on margins of restorations.

ACIDULATED PHOSPHATE FLUORIDE • The idea of acidulated phosphate fluoride as a topical agent in the prevention of dental caries emerged with the in vitro investigation by Bibby in 1947, which reported that as the pH of the NaF solution was lowered, fluoride was absorbed into enamel more effectively. • Finn Brudevold10 and his coworkers did systematic investi­ gation to find out an optimal fluoride acid solution which would provide maximal fluoride deposition while causing minimal demineralization. • They concluded that semiannual application of 1.23 percent APF for 4 minutes is helpful in reducing caries by 28 percent. • One of the practical difficulties of doing the topical application is that the teeth must be kept wet with solution for 4 minutes and, moreover, APF solution is acidic and sour and bitter in taste, so repeated applications are often difficult.

Mechanism of Action

Method of Preparation • It is prepared by dissolving 20 g of NaF in 1 liter of 0.1M phosphoric acid. To this 50 percent hydrofluoride acid is added to adjust the pH at 3.0 and F concentrations at 1.23 percent.

Ca5 (PO4) 3OH + 4 H = 5 Ca + 3 HPO4 + H2O Ca + HPO4 = Ca. HPO4.2H2O (DCPD) 5 Ca.HPO4.2H2O + F = Ca5 (PO4) 3F + 2 HPO4 + 3 H + 2H2O

Chapter 29  Fluorides

Advantages • • • • •

Has acceptable taste No staining No gingival irritation Stable with long shelf life Cheap.

Disadvantages • Teeth have to be kept wet for 4 minutes • Solution is acidic.

NEWER TOPICAL FLUORIDES

Amine Fluoride • In 1945 Muhlemann of the University of Zurich first studied effects of AMF. • Amine fluoride is superior to inorganic fluorides in reducing enamel solubility because of chemical protection by fluoride and physicochemical protection by organic portion. • They are also surface active because they hold fluoride on enamel surface for longer time.

Stannous Hexafluorozirconate

solutions that are currently in use have a major disadvantage that they remain in contact with teeth for a very short time, i.e. 5 to 10 minutes before getting diluted by saliva and consequently can exert relatively a superficial effect on the dental enamel. A second drawback with topical fluoride solutions is that soon after application much of the acquired fluoride, probably representing unreacted F and CaF2, leaches away. To enhance the caries inhibitory property of topical fluorides, experiments were carried out aiming at overcoming above mentioned drawbacks, by developing methods for prolonging the contact of fluoride solutions with tooth enamel leading not only to deeper penetration but also a more permanently bound form of fluoride. To achieve prolonged fluoride action in mouth Schmidt in 1964 developed a new coating method in which the teeth were coated with a lacquer containing fluoride called F-lacquer, which released fluoride ions to the dental enamel in high concentrations for several hours in the moist atmosphere of the mouth. Consequently the use of fluoride containing varnishes in caries prevention has become the treatment of choice. The two most commonly used varnishes are Duraphat (NaF varnish containing 2.26% F) in organic lacquer and Fluor protector (Silane fluoride with 0.7% F).

Composition of Duraphat and Fluor Protector

The cariostatic effect of topical fluoride agents has generally been related to their ability to deposit fluoride in the enamel and also their depth of penetration. The topical fluoride

• Fluor protector is a colorless, polyurethane lacquer dissolved in chloroform and dispensed in 1 mL ampules. The fluoride compound is a difluorosilane. The fluoride content in fluor protector is 0.7 percent by weight and the active fluoride available is 7000 ppm (Fig. 29.5). • Duraphat is sodium fluoride in varnish form containing 22.6 mg F/mL (2.26%) suspended in an alcoholic solution of natural organic varnishes. It’s available in bottles of 30 mL suspension containing 50 mg NaF/mg. The active fluoride available is 22,600 ppm (Fig. 29.6).

Fig. 29.5: Fluor protector varnish

Fig. 29.6: Duraphat varnish

Researchers at Indiana University have developed SnZrF6 effective in reducing the solubility of enamel and in preventing dental caries.

FLUORIDE VARNISH

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342 Section 6 

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Technique of Varnish Application

that the fluoride deposited in enamel is more in case of fluorprotector as compared to Duraphat. R-SiF2 OH + H2O = R-Si (OH)3 + 2 HF

Safety Aspect of Fluoride Varnish • Due to the increasing use of caries prevention of fluoride varnishes with high concentrations of fluoride, it is necessary to evaluate the risk of possible side effects by examining plasma levels following such applications. • The recommended dose of 0.5 mL of duraphat for single application contains 11.3 mg F, and 0.5 mL of fluor protector contains 3.1 mg F. The highest plasma fluoride concentration varied between 60 and 120 mg/mL and was seen within 2 hours of application. These values are far below the toxic doses and hence adjudged to be safe.

FLUORIDE DENTIFRICES

Mechanism of Action • Duraphat is NaF in varnish form with neutral pH. When applied topically under clinically controlled conditions, a reservoir of fluoride ions gets built up around the enamel of teeth. From this, fluoride keeps on slowly releasing and continuously reacting with the hydroxyapatite crystals of enamel over a long period of time leading to deeper penetration of fluoride and more formation of fluorapatite.

Fluoride dentifrices have been proven to be effective anticaries agents since 1955. Today, in industrialized countries, their sales have dominated the major part of the market of dentifrices. In most of the western countries, viz. Norway, Sweden, Denmark, UK USA, Netherlands and Australia almost 95 percent of the available toothpastes in the market are fluoridated. The most commonly evaluated fluoride dentifrices are sodium fluoride and stannous fluoride and more recently the sodium monofluorophosphate and amine fluoride, are also being used.

Sodium Fluoride and Stannous Fluoride Dentifrices • NaF was the first fluoride compound to be added as an active ingredient but its efficacy was very limited (Fig. 29.7).

10Ca5 (PO4) 3OH + 10 F = 6 Ca5 (PO4) 3F + 2CaF2 + 6 Ca3 (PO4)2 + 10 OH

• A part of CaF2 so formed in low concentrations further reacts with crystals of hydroxyapatite and forms fluorapetite. 2Ca5 (PO4) 3OH + CaF2 = 2 Ca5 (PO4) 3F + Ca (OH)2

• The literature shows that in spite of lower fluoride content in fluorprotector as compared to duraphat, the fluoride deposited in enamel is twice as much, but on the contrary, its ability to inhibit caries is far less than duraphat. • Silane fluoride of fluorprotector reacts with water to produce considerable amount of hydrofluoric acid (HF), which penetrates into enamel more readily than fluoride. Fluorosilanes also enhance retention and penetration of fluoride in enamel by utilizing enamel network as a conduit. These observations support the fact

Fig. 29.7: Sodium fluoride toothpaste

Chapter 29  Fluorides • In 1955 another milestone development in history of dentifrices was the introduction of divalent tin fluoride compound (SnF2) in dentifrices containing 0.4 percent SnF2 in a calcium pyrophosphate abrasive system (Fig. 29.8). • However, this also failed to get the desired results because of its compatibility with abrasives, staining of anterior restorations of composites resins and a metallic astringent taste, which was not acceptable.

• Monofluorophosphate (MFP) is the basic incompatibility of the NaF and SnF2 compounds with calcium abrasives leading to decrease available fluoride has been overcome with the introduction of MFP, which has become the preferred chemical form of fluoride in most of the major commercial fluoridated tooth pastes used throughout the world ever since 1969 (Fig. 29.10).

Fig. 29.8: Stannous fluoride toothpaste

Fig. 29.10: Monofluorophosphate toothpaste

Monofluorophosphate

Amine Fluoride Dentifrices • This was first tested for its cariostatic potential in Zurich, Switzerland. • This showed organic fluorides to have antibacterial and anticariogenic properties, which were superior to inorganic fluorides and demonstrated significant reduction in caries rate. • These dentifrices are marketed only in Europe (Fig. 29.9).

• Dentifrices containing MFP at a concentration of 0.76 percent, 0.1 percent F with sodium metaphosphate as abrasive, have led to variable reductions in caries rates ranging from 17 percent for unsupervised brushing and about 34 percent for supervised brushing in nonfluoridated areas. • At present there are two possible modes of action regarding caries inhibitory mechanism of mono-fluoriophosphate (MFP). The first mode is essentially a fluoride effect given by Ericsson (1963), MFP is deposited in the crystalline lattice and in subsequent intracrystalline transposition, and fluoride is released and replaces the hydroxyl group to form fluorapatite. The second mode of action according to Ingram (1972) attributes to the anticariogenic activity. MFP differs from other agents, in the aspect that its F-atom is covalently bonded to phosphorous atom. The mechanisms include direct incorporation into hydroxyapatite or hydrolysis to phosphate and fluoride ions, followed by reaction to form fluoroapatite. PO3F + H2O = H2PO4 + F PO3F + OH = PO4 + F + H

Fig. 29.9: Amine fluoride toothpaste

• Advantages include Neutral pH, greater stability to oxidation and hydrolysis, longer shelf life, increased availability of fluoride and no staining of teeth.

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344 Section 6 

Preventive Pedodontics

Recommendations for use of fluoride dentifrice Age

Recommendation

Below 4 years 4 to 6 years

Not recommended Once daily with fluoride paste and twice without paste Twice daily with fluoride paste and once without paste Thrice daily with fluoride paste

6 to 10 years Above 10 years

• • • •

Generalized weakness and carpopedal spasms. Weak thready pulse, fall in blood pressure. Depression of respiratory center. Decreased plasma calcium level, increased potassium level. • Cardiac arrhythmia. • Coma and death.

Management Immediate

FLUORIDE TOXICITY During the latter half of 19th century and the first half of the 20th century, sodium fluoride was used as a pesticide. It was often stored in places where the residents had access to the compound. Because of this, many cases of accidental and intentional acute fluoride poisoning occurred. Lidbech et al. (1943) described one of the mass poisonings that occurred during that period. At the Oregon State Hospital, an evening meal of scrambled eggs was prepared with sodium fluoride which had been mistaken for powdered milk. Approximately 17 pounds of NaF was added to 10 gallons of eggs. There were 263 cases of acute poisoning, of which 47 terminated fatally. Fluoride can be very harmful if large amounts are ingested in a single dose or over a period of time. This may be followed by rapidly developing signs and symptoms. It is divided into acute toxicity and chronic toxicity.15 Probably toxic dose (PTD): Defined as the threshold dose that could cause serious or life threatening systemic signs and symptoms. Safely tolerated dose: 8 mg – 16 mg/kg body weight Toxic dose: 16 mg – 32 mg/kg body weight Lethal dose: 32 mg – 64 mg/kg body weight

Acute Toxicity Ingestion of large doses of fluoride at one time.

Factors Affecting Acute Toxicity • • • • •

Bioavailability Route of administration Age Rate of absorption Acid base status.

Signs and Symptoms • Nausea, vomiting. • Abdominal pain, diarrhea. • Excess salivation and mucosal discharge.

Less than 5 mg/kg fluoride ingested More than 5 mg/kg fluoride ingested

More than 15 mg/kg fluoride ingested

Aimed at reducing fluoride absorption Induce vomiting Fluid replacement Monitoring levels of plasma calcium and potassium Give milk Induce vomiting Give milk Induce vomiting 5% Calcium gluconate Hospitalization Induce vomiting Hospitalization Cardiac monitoring (peaking of T-wave or prolonged Q-T interval) Slow administration of 10% Calcium gluconate Maintain urinary output– Supportive measures for shock

Methods to Reduce Intake of Nondietary Fluorides • • • • • • •

Parental supervision. Small amount of paste to be used. Products with low fluoride level to be used. Teaching children not to swallow the paste. Strict adherence to professional advice. Should not be used by young children without supervision. Should be kept out of the reach of children.

Chronic Toxicity It is defined as ingestion of variant doses of fluoride over a prolonged period of time. It is of two types: dental fluorosis and skeletal fluorosis.

Dental Fluorosis • Dental fluorosis is a developmental disturbance of dental enamel, caused by successive exposures to high concentrations of fluoride during tooth development, leading to enamel with lower mineral content and increased porosity.14 • It can be hypoplasia or hypomaturation of tooth enamel or dentin.

Chapter 29  Fluorides • Both primary and permanent teeth will be affected but greater fluorosis in permanent teeth is seen because, much of the mineralization of primary teeth occurs before birth and also because the placenta serves as the barrier to the transfer of high concentrations of plasma fluoride from a pregnant mother to her developing fetus. • Etiopathogenesis: – There is direct inhibitory effect on enzymatic action of ameloblasts leading to defective matrix formation and subsequent hypomineralization. • Causes for dental fluorosis: – Excessive fluoride in water – Nonprescribed use of fluoride supplements – Ingestion of topical fluoride

• Clinical features (Figs 29.11A to F) – The first signs of dental fluorosis are thin white striae across the enamel surface. These fine lines follow the perikymata pattern and can best be distinguished by drying the surface of the tooth. Even at this stage of dental fluorosis, the cusp tips, incisal edges or marginal ridges may appear opaque white, the “snow cap” phenomenon. – In slightly more affected teeth, the white lines are broader and more pronounced. Occasional merging of several lines occurs to produce smaller, irregular, cloudy or paper-white areas scattered over the surface. – With increasing severity, the entire tooth surface exhibits distinct, irregular, opaque, or cloudy white

A

B

C

D

E

B F Figs 29.11A to F: Different grades of dental fluorosis

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areas. Frequently, the cervical enamel appears more homogenously opaque, and the mesioincisal part of the maxillary incisors may exhibit varying degrees of Brownish discoloration. Such brown stains are a result of posteruptive staining. – The next degree of severity manifests as irregular opaque areas which merge so that the entire tooth surface appears chalky white. When such surfaces are probed vigorously, part of the surface enamel may flake off. – In even more severe stages, the tooth surface is entirely opaque with focal loss of the outermost enamel. Such small enamel defects are usually designated “pits”. With increased severity these pits merge to form horizontal bands. – Ultimately, the most severely fluorotic teeth exhibited an almost total loss of surface enamel whereby the normal tooth morphology is severely affected. The loss of surface enamel may be so extensive that only a  cervical rim of intact, markedly opaque enamel is left. The remaining part of the tooth often exhibits a dark brownish discoloration. The discoloration is entirely dependent on such posteruptive environ­ mental conditions as dietary habits, and the degree of discoloration should, therefore, not be used as an indication of severity of fluorosis as such. Dental fluorosis indices:  The extent of dental fluorosis can be evaluated by various indices, like Dean’s index, Thylstrup and Fejerskov’s index, Horowitz index, Moller’s index, FDI index, etc. Dean’s index Given by Trendly H Dean in 1934. Examination of all tooth surfaces was done in good natural light with the child seated facing window Rating Public health Characteristics significance 0 Normal The enamel shows the usual translucency. The surface is smooth, shiny and usually of a pale, creamy white to grey white color 0.5 Questionable The enamel shows slight aberrations ranging from a few white flecks to occasional white spots 1 Very mild Small, opaque, paper white areas scattered irregularly over tooth but not involving more than 25 percent 2 Mild Opaque, paper white areas that is more extensive, involving more than 25 percent but less than 50 percent 3 Moderate All enamel surfaces are affected and also show attrition 4 Severe All enamel surfaces are affected and hypoplasia is so marked that general form of tooth is affected. Discrete or confluent pitting with brown stains is a characteristic feature

Score 0 1 2 3 4 5 6 7 8 9

Thylstrup and Fejerskov’s index Criteria Normal enamel Narrow wide lines corresponding to perikymata More pronounced lines Merging and irregular cloudy areas Entire surface is chalky white Surface has opacity with pits Regularly arranged pits and horizontal bands Loss of outer enamel but less than half surface Loss of enamel in more than half surface Loss of tooth structure leading to change in anatomic appearance of tooth FDI index

Dental developmental index modified in 1989 Score

Criteria

1

Normal

2

Demarcated opacities • White/Cream • Yellow/Brown

3

Diffuse opacities • Diffuse – lines • Diffuse – patchy • Diffuse – confluent • Confluent/patchy/staining/loss of enamel

4

Hypoplasia • Pits • Missing enamel

5

Any other defects

Skeletal Fluorosis • This is also called osteofluorosis. • Etiology: Water fluoride levels over 4 ppm causes a mild variant but levels over 8 ppm cause severe skeletal fluorosis.

Clinical Features • • • •

Increase in bone density Change in bone contours Irregular periosteal growth Spinal column and the pelvis show roughening and blurring of the trabeculae • Bone appears as marble white shadows and the configuration is wooly. The cortex of long bone is thick  and dense and the medullary cavity is diminished. • Ligamental and tendon calcification with vague pain in joints. • Stiffness and limitation of joint movements, immobilizing the patient – crippling fluorosis.

Chapter 29  Fluorides Systemic effects of chronic exposure to fluorides GIT: Nonulcer dyspepsia, drying of goblet cells and fissure in the gastric mucosa, delayed emptying of stomach, nausea, bloated abdomen, loss of appetite.11 Skeletal muscles: Destruction of the actin and myosin filaments, weakness, loss of muscle energy, inability to stand in erect position.12 RBCs: Erythrocyte membrane becomes pliable and is thrown into folds due to loss of calcium content- RBCs attain a shape similar to amoeba with pseudopodia-like folds projecting into different directions and are termed echinocytes.12 Reproductive system: Male infertility with abnormality in sperm morphology, low testosterone levels and testicular oxidative stress. Repeated abortions and still births due to fetal blood vessels calcification. Neurological system: Adversely affects brain leading to nervousness, depression/tingling sensation in fingers and toes, excessive thirst and tendency to urinate more frequently.8 Li et al.13 from China also reported low IQ among children exposed to high fluoride as compared to non exposed children.

• Arthritic changes, cataract, thyroid problems, fractures, urinary and gallstones may also be seen.

Classification According to the severity, Teotia et al. classified skeletal fluorosis: • Clinical – Mild: Generalized bone and joint pains – Moderate: Mild symptoms with stiffness, rigidity and restricted movement of spine and joints. – Severe: Symptoms of moderate fluorosis along with flexion deformities of spine, hips and knees, genu-valgum, genu-varum, bowing and rotational deformities of legs, neurological complications, crippling and bedridden stage. • Radiological – Mild: Osteosclerosis only – Moderate: Signs of mild fluorosis along with periosteal bone formation, calcifications of interosseous mem­ brane, ligaments, muscular attachments, capsules and tendons. – Severe: Signs of moderate fluorosis with associated metabolic bone disease (rickets neo-osseous­malacia, osteoporosis), exostosis, osteophytosis.

DEFLUORIDATION It is the process of removing excess, naturally occurring fluorides from drinking water in order to reduce the prevalence and severity of dental fluorosis. World Health Organization in 1963 has recommended that optimum limit

of fluoride in drinking water for the prevention of dental caries is 0.7 to 1.2 ppm. In India, the work on defluoridation was taken up by National Environmental Engineering Research Institute (NEERI) at Nagpur, Maharashtra, India in 1961 where various methods for removal of fluoride from potable waters have been tried. Defluoridation techniques can be broadly classified in to four categories:16 1. Adsorption technique 2. Ion-exchange technique 3. Precipitation technique 4. Other techniques, which include electrochemical defluoridation and reverse osmosis.

Adsorption Technique of Defluoridation • This technique functions on the adsorption of fluoride ions onto the surface of an active agent. Activated alumina, activated carbon and bone char were among the highly tested adsorbing agents. • Activated alumina – Application of domestic defluoridation plant, based on activated alumina, was launched by UNICEF in rural India. – Herschel S Horowitz and Stanley B Helfetz, in 1972 discussed about a successfully functioning, activated alumina community defluoridation plant, which was commissioned in Bartlett, Texas, USA in the year 1952. – The disadvantages with activated alumina are adsorption of fluoride is possible only at specific pH range, needing pre-and post- pH adjustment of water. – Frequent activation of Alumina is needed, which make the technique expensive. • Bone char – Nutthamon Fangsrekam described the process of Defluoridation by bone char as the ion exchange and adsorption between fluoride in the solution and carbonate of the apatite comprising bone char. – The efficacy of the plant depends upon temperature and pH of raw water; duration for which the bone-char is in contact with raw water. The maximum amounts of fluoride adsorbed per gram of bone char surface at 25o, 35o and 45oC are about 21.1, 22.4, and 25.7 μ mol respectively. The optimum time for the adsorption to reach saturation is 9 hours and optimum pH of fluoride solution is between 7.00 and 7.50. – Disadvantages of this technique are; the bone char harbors bacteria and hence unhygienic. Without a regular fluoride analysis, nothing indicates when the material is exhausted and the fluoride uptake is ceased. • Brick pieces column – The basic principle of functioning of brick piece column is the same as that of activated alumina.

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– The soil used for brick manufacturing contains Aluminum oxide. During burning operation in the kiln, it gets activated and adsorbs excess fluoride when raw water is passed through. • Mud pot – The raw pots are subjected to heat treatment as in the case of brick production. Hence the mud pot also will act as an adsorbent media. – The major advantages of mud pots are they are economic and readily acceptable for the rural communities. • Natural adsorbents – Seeds of the Drumstick tree, roots of Vetiver grass and Tamarind seeds were tried as defluoridation agents.

Ion-exchange Technique • Anion Exchange Resins – These include polystyrene anion exchange resins and basic quarternary ammonium type resins. – Bhakuni found that although these resins did remove fluoride but they had some disadvantages like Ionising fluoride removal capacity on prolonged use, cost and alteration of taste of water. • Cation Exchange Resins – Defluoron–1: Bhakuni developed this combination of sulphonated saw dust impregnated with 2 percent alum solution. The disadvantages of this were poor hydraulic properties and heavy attritional losses. – Carbion: It is a cation exchange resin of good durability and can be used both on sodium and hydrogen cycles. – Magnesia: Investigations conducted by VP Thergaonkar (1971) established that magnesia removed the excess fluorides but pH of treated water was beyond 10 and its correction by acidification or recarbo­nation was necessary. – Defluoron–2: To overcome the problems faced with previous methods, defluoron-2 was developed in 1968. Defluoron-2 is a sulphonated coal and works on the aluminum cycles. This type of defluoridation gave excellent results, had a good shelf life of 2 to 4 years and was very cost effective.

Defluoridation by Precipitation Technique • Precipitation methods are based on the addition of chemicals (coagulants and coagulant aids) and the subsequent precipitation of a sparingly soluble fluoride salt as insoluble fluorapatite. • Aluminum salts (e.g. Alum), lime, Poly Aluminum Chloride, Poly Aluminum Hydroxyl sulphate and Brushite are some of the frequently used materials in defluoridation by precipitation technique.

Other Techniques of Defluoridation • Reverse osmosis – In reverse osmosis, the hydraulic pressure is exerted on one side of the semi permeable membrane which forces the water across the membrane leaving the salts behind. – The removal of fluoride in the reverse osmosis process had been reported to vary from 45 to 90 percent as the pH of the water was raised from 5.5 to 7. • Defluoridation by electrolysis – The basic principle of the process is the adsorption of fluoride with freshly precipitated aluminum hydroxide, which is generated by the anodic dissolution of aluminum or its alloys in an electro chemical cell. – The driving force is an electric current which carries the ions through the membranes (Hall and Crow, 1993). – Advantages are it does not require addition of chemicals, low volume of sludge, units can be designed for any capacity, electrochemical reactor occupies less floor space, operator friendly and requires less electric energy.

Nalgonda Technique17 Although defluoron-2 was successful in removing fluorides, the regeneration and maintenance of the plant required skilled operation, which may not be readily available. In order to overcome this problem a method was evolved by WG Nawalakhe in 1974, which is so simple  and adaptable that even illiterate persons can make use of it.

Working Principle • This involved the addition of three readily available chemicals, i.e. sodium aluminate or lime, bleaching powder and filter alum to the fluoride water in the same sequence which leads to flocculation, sedimentation and filtration. Sodium aluminate or lime hastens settlement of precipitate and bleaching powder ensures disinfection. This technique can be used both for domestic as well as for community water supplies. • For domestic treatment any container of 20 to 25 lit capacity is suitable. A tap 3 to 5 cm above the bottom of the container is useful to withdraw treated water but is not essential. Adequate amount of lime water and bleaching powder are sprinkled into water first and mixed well with it. Alum solution is then poured and the water is stirred for 10 minutes. The contents are settled for 1 hours and the clear water is withdrawn either through the tap or decanted slowly without disturbing the sediment (Fig. 29.12).

Chapter 29  Fluorides – Generation of higher quantity of sludge compared to electrochemical defluoridation – Large amount of alum needed to remove fluoride.

Modifications for Nalgonda Technique – Poly Aluminum Chloride: It is evident that for higher concentrations of fluoride, the removal efficiency of fluoride is higher with Poly Aluminium Chloride (PAC) when compared with Alum. – Poly Aluminum Hydroxy Sulfate (PAHS): It is found to require less flocculation time and settling time.

Two bucket technique in Tanzania

The designed defluoridator consists of two buckets equipped with taps and a sieve on which a cotton cloth is placed. Alum and lime are added simultaneously to the raw water bucket where it is dissolved/suspended by stirring with a wooden paddle. The villagers are trained to stir fast while counting to 60 (1 minute) and then slowly while counting to 300 (5 minutes). The flocs formed are left to settle for about one hour. The treated water is then tapped through the cloth into the treated water bucket from where it is collected as needed for drinking and cooking (Fig. 29.13).

Fig. 29.12: Nalgonda technique

Advantages – – – – – – –

No regeneration of media No handling of caustic acids and alkalies Readily available chemicals are used Adaptable to domestic usage Simplicity in design, construction and maintenance Little wastage of water Needs minimal mechanical and electrical equipment.

Disadvantages – Desalination may be necessary – Hardness of the raw water in the range of 200 mg/l to 600 mg/l requires precipitation softening

Fig. 29.13: Two-bucket defluoridation technique

RECENT ADVANCES IN FLUORIDE18

Copolymer Membrane Device • Developed by Cowsar (1976) in USA • This system was designed as a membrane-controlled reservoir-type and has an inner core of hydroxyethyl methacrylate (HEMA)/methyl methacrylate (MMA) copolymer (50:50 mixture), containing a precise amount

349

350 Section 6 

Preventive Pedodontics

of sodium fluoride (NaF). This core is surrounded by a 30:70 HEMA/MMA copolymer membrane which controls the rate of fluoride release from the device. • When the matrix becomes hydrated, small quantities of granulated NaF are diluted until the matrix itself becomes saturated. The precise water absorption rates by the inner and the outer cores enables the devices to act accurately and reliably as a release controlling mechanism. • The device is approximately 8 mm in length, 3 mm in width, and 2 mm in thickness (Fig. 29.14) and is usually attached to the buccal surface of the first permanent molar by means of stainless steel retainers that are spot welded to plain, standard orthodontic bands or are bonded to the tooth surfaces using adhesive resins. • Depending on the amount of F in the inner core, the rate of F release of these devices can be between 0.02 and 1.0 mg F/day for up to 180 days.

Fig. 29.15: Original glass device

Fig. 29.14: Copolymer device

Fluoride Glass Device • Developed in Leeds, United Kingdom. • The F glass device dissolves slowly when moist in saliva, releasing F without significantly affecting the device’s integrity. • The original device was dome shape, with a diameter of 4 mm and about 2 mm thick, being usually attached to the buccal surface of the first permanent molar using adhesive resins (Fig. 29.15). Due to the low retention rates of the original device, it was further substantially changed to a kidney-shaped device, being 6 mm long, 2.5 mm in width and 2.3 mm in depth (Fig. 29.16), and it was proven to be effective regarding both F release and retention rate. • A new modification was introduced more recently, in order to facilitate device handling, attachment and replacement. This new device has been shaped in the form of a disk that is placed within a plastic bracket (Fig. 29.17). • Concentration of fluoride in glass: 13.3 to 21.9 percent • Longer shelf life with continuous release up to 2 years.

Fig. 29.16: Modified glass device

Fig. 29.17: New modification of glass device

Chapter 29  Fluorides

 ydroxyapatite-Eudragit RS100 Diffusion H Controlled F System • This is the newest type of slow-release F device, which consists of a mixture of hydroxyapatite, NaF and Eudragit RS100. • EUDRAGIT® RS 100 is a copolymer of ethyl acrylate, methyl methacrylate and a low content of methacrylic acid ester with quaternary ammonium groups. The

ammonium groups are present as salts and make the polymers permeable. • It contains 18 mg of NaF and is intended to release 0.15 mg F/day. • It was demonstrated that the use of this device is able to significantly increase salivary and urinary F concentrations for at least 1 month. • Placed on labial aspect of maxillary incisors, buccal aspect of molars and lingual aspect of mandibular incisors.

POINTS TO REMEMBER • Fluoride has been described as an essential nutrient in the Federal Register of United States Food and Drug Administration (1973). • The term fluoride is derived from a Latin word Fluore, which means to flow. • Lake Nakuru (Kenya) has most concentration of fluoride i.e. 2800 ppm. • Tea leaves have most fluoride content among common food items: 56.640 ppm. • In case of teeth maximum conc. Of fluoride is found in cementum (4500 ppm). • Fluoride can cross the placental barrier. • Shoe Leather Survey by Dean was done as an to McKay work on fluoridation. • First community level water fluoridation program started in Grand Rapids, USA on 25th January 1945. • Mechanism of action of fluoride is by Improved Crystallinity, filling of voids of hydroxyapetite, less acid solubility, enzyme inhibition, suppressing the flora, anti-bacterial action, lowering free surface energy, desorption of protein and bacteria and alteration in tooth morphology. • Galagan and Vermillion formula is ppm F = 0.34/E. • The current recommended regimen for school water fluoridation is adding 4.5 times more fluoride. • Salt and milk fluoridation was done by Wespi and Zieglar respectively. • Knutson and Feldman recommended a technique of 4 applications of 2 percent NaF at weekly intervals in a year at 3, 7, 11 and 13 years. • Finn Brudevold did the study on APF and concluded that semi annual application of 1.23 percent APF for 4 minutes is helpful in reducing caries by 28 percent. • Duraphat is the most effective varnish in caries reduction. • Monofluorophosphate is the most commonly used active ingredient of toothpastes today. • Acute toxicity: Ingestion of large doses of fluoride at one time. Its signs and symptoms include nausea, vomiting, diarrhea, excess salivation and mucosal discharge, weakness and carpopedal spasms, fall in blood pressure, cardiac arrhythmia and maybe even death. • Chronic toxicity includes dental and skeletal fluorosis. • The extent of dental fluorosis can be evaluated by various indices, like Dean’s index, Thylstrup and Fejerskov’s index, Horowitz index, Moller’s index, FDI index, etc. • Defluoridation is the process of removing excess, naturally occurring fluorides from drinking water in order to reduce the prevalence and severity of dental fluorosis. • First defluoridation project was taken up by NEERI at Nagpur in 1961. • Defluoridation techniques are adsorption technique, ion-exchange technique, precipitation technique and electro chemical/reverse osmosis. • Nalgonda technique was given by WG Nawalakhe in 1974 and it involves addition of three readily available chemicals, i.e. sodium aluminate or lime, bleaching powder and filter alum to the fluoride water in the same sequence which leads to flocculation, sedimentation and filtration. Sodium aluminate or lime hastens settlement of precipitate and bleaching powder ensures disinfection. This technique can be used both for domestic as well as for community water supplies. • The newer fluoride developments include co-polymer membrane device, Fluoride glass device and HydroxyapatiteEudragit RS100 diffusion controlled F system.

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QUESTIONNAIRE 1. Discuss the distribution of fluoride in environment. 2. Describe the metabolism of fluoride. 3. Give a brief description on history of fluoride. 4. What is shoe leather survey? 5. Explain the mechanism of action of fluoride. 6. Write a note on water fluoridation. 7. What is Galagan and Vermillion formula? 8. Discuss school water fluoridation. 9. What are topical fluorides? Write a note on Knutson’s technique. 10. Write a short note on APF. 11. Explain choking off mechanism. 12. What are fluoride varnishes? 13. Discuss acute toxicity with its clinical features and management. 14. Explain dental fluorosis. 15. Note on fluorosis indices. 16. Discuss defluoridation with special reference to Nalgonda technique. 17. What are the recent advancements in intraoral fluoride?

REFERENCES 1. BD Punekar, Dilnawaz R Lakdawala. Fluoride Content of Water and Commonly Consumed Foods in Bombay and A Study of the Dietary Fluoride Intake. Indian J Med Res. 1973;61(11):1679-87. 2. AK Susheela. Epidemiology and Control of Fluorosis in India. J of Nutrition foundation of India; 1984. 3. Fluoride in water: An overview, Unicef. (Accessed on 29-09-2007). Available from: URL: http://www.unicef.org/programme/wes/info/ fluor.htm. 4. Amrit Tewari, Ved Prakash Jalili. Fluorides and dental caries, Indian Dental Association; 1986. 5. Dean HT, Arnold FA, Jay P, Knutson JW. Studies on mass control of dental caries through fluoridation of the public water supply. Public Health Rep. 1950;65(43):1403–8. 6. Galagan DJ, Vermillion JR. Determining optimum fluoride concentrations. Public Health Rep. 1957;72(6):491–3. 7. Clinical guidelines by AAPD revised in 2012 reference manual V 34 / NO 6 12 / 13. 8. Bibby BG. A new approach to caries prophylaxis. Tufts Dent. Outlook. 1942;15:4-8. 9. Knutson JW, Armstrong WD, Feldman FM. Effect of topically applied sodium fluoride on dental caries experience. iv. Report of findings with two, four and six applications. Publ Health Rep. 1947;62:425. 10. Brudevold F, Savory A, Gardner DE, Spinelli M, Speirs R. A study of acidulated fluoride solutions I. In vitro effects on enamel. Arch Oral Biol. 1963;8:167-77. 11. AK Susheela, TK Das, IP Gupta, RK Tandon, SK Kacker, P Ghosh, RC Deka. Fluoride ingestion and its correlation with gastrointestinal discomfort. Fluoride. 1992;25(1):5-22. 12. Susheela AK. A treatise on fluorosis. 2nd Edn, 2003. Fluorosis Research and Rural Development foundation, New Delhi. 13. XS Li, JL Zhi, RO Gao. Effect of fluoride exposure on intelligence in children. Fluoride. 1995;28(4):189-92. 14. Fejerskov O, Manji F, Baelum V. The nature and mechanisms of dental fluorosis in man. J Dent Res. 1990;69 spec Iss: 692-700. 15. Whitford GM. Acute and Chronic fluoride toxicity. J Dent Res. 1992;71(5):1249-54. 16. Renuka P, Pushpanjali K. Review on Defluoridation Techniques of Water. The Int J of Engin and Sci. 2013;2(3):86-94. 17. Nawalakhe WG, Paramasivam R. Defluoridation of potable water by Nalgonda technique. Curr Sci. 1993;65: No. 10. 18. Pessan JP, Al-Ibrahim NS, Buzalaf MAR, Toumba JK. Slow-release fluoride devices: a literature review. J Appl Oral Sci. 2008;16(4):238-44.

BIBLIOGRAPHY 1. Bali RK, Mathur VB, Talwar PP, Chanana HB. National Oral Health Survey and Fluoride Mapping 2002-2003. India. Available from: URL: http://www.docstoc.com/docs/83028952/summary---PDF. 2. Ekstrand J, Zeigler EE, Nelson Se, Formon SJ. Absorption and retention of dietary and supplemental fluoride. Adv Dent Res. 1994;8:17580. 3. Fejerskov O, Richards A, DenBesten P. In: Fejerskov O, Ekstrand J, Burt BA. Fluoride in dentistry. 2nd Edn. Munksgaard, Copenhangen; 1996.pp.112-52.

Chapter 29  Fluorides 4. Finn SB. Clinical pedodontics, 2nd Edn, Philadelphia, Saunders; 1965. 5. Koch G, Petersson LG. Caries Preventive effect of a fluoride containing varnish (Duraphat) after 1 year’s study. Comm Dent Oral Epidemiol. 1975;3:262-6. 6. McCann HG. The effect of fluoride complex formation on fluoride uptake and retention in human enamel. Archs Oral Biol. 1969;14:52131. 7. Moller IJ, Holst JJ, Sorensen E. Caries reducing effect of a sodium monofluorophosphate dentifrice. Br Dent J. 1968;124:209-13. 8. Muhler JC, Radhike AW, Nebergall WH, Day HG. A comparison between the anticariogenic effect of dentifrices containing stannous fluoride and sodium fluoride. J Amer Dent Assoc. 1955;51:556-9. 9. Muhler JC, Stookey GK, Bixler D. Evaluation of the anticariogenic effect of mixtures of stannous fluoride and soluble phosphates. J Dent Child. 1965;32:154-69. 10. Murray JJ, Winter GB, Hurst CP. Duraphat fluoride varnish-a 2 year clinical trial in 5 years old children. Br Dent J. 1977;143:11-7. 11. Susheela AK, Koacher J, Jain SK, Sharma K, Jha M. Fluroide toxicity: A molecular approach. In: Highlights of the 13th conference of the international society for fluoride research, organized by Dr Susheela AK, in New Delhi (India). 1993.pp.13-7. 12. Tewari A, Chawla HS, Utreja, Ashok. Caries preventive effect of three topical fluorides (1½ years clinical trial) in Chandigarh school children of North India. J Inf Ass Dent Child. 1984;15:71-81. 13. US Department of Health and Human Services, Centers for Disease Control, Dental Disease Prevention Activity. Water fluoridation: a manual for engineers and technicians. Atlanta; 1986. 14. Whitford GM. The metabolism and toxicity of fluoride. In: Myers HM, editor. Monographs in oral science. No. 13. Basel (Switzerland): Karger; 1989. 15. Whitford GM. The physiological and toxicological Charac­teristics of fluoride. J Dent Res. 1990;69(Spec Iss):539-49. 16. World Health Organisation. Fluorides and Human Health, Geneva. (WHO Monograph Series No. 59) 1970.

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Section

PEDIATRIC ORTHODONTICS

This section deals with pediatric interphase or orthodontics like preventive and interceptive orthodontics it also includes detail on oral habits, cephalometrics, serial extraction and model analysis. The concept of space management in primary and mixed dentition period is explained along with myofucntional and other removable appliances used in children.

30

Chapter

Oral Habits Nikhil Marwah

Chapter outline • • • •

Classification of Habits Thumb Sucking Pacifier Habit Tongue Thrusting

Oral habits may be a part of normal development; a symptom with a deep rooted psychological basis that may be the result of abnormal facial growth. Digit sucking, lip and nail biting, bruxism, mouth breathing, tongue thrusting may be considered as normal habits seen in children. These habits bring about harmful unbalanced pressures to bear upon the immature, highly malleable alveolar ridges, the potential changes in position of teeth and occlusion, which may become decidedly abnormal if these habits are continued for a long time. Boucher OC defined habit as a tendency towards an act or an act that has become a repeated performance, relatively fixed, consistent, easy to perform and almost automatic.

CLASSIFICATION OF HABITS

 seful and Harmful Habits U (James—1923) Useful Habits

• • • • •

Mouth Breathing Bruxism Lip Biting Nail Biting Self-injurious Habits

 Compulsive and Noncompulsive Habits (Finn—1987) Compulsive Habit Acquired as a fixation in the child to the extent that he retreats to the practice whenever his security is threatened.

Noncompulsive Habit Children appear to undergo continuing behavior modification, which permit them to release certain undesirable habit patterns and form new ones which are socially accepted.

Primary Habit and Secondary Habits Secondary habit is a habit that is due to a supplemental problem, e.g. large tongue causes tongue thrusting habit.

Meaningful and Empty Habits (Klein—1971)

Should include all those habits of normal function such as correct tongue position proper respiration and deglutition.

Meaningful Habit

Harmful Habits

Empty Habit

All those that exert perverted stress against the teeth and dental arches, e.g. mouth breathing, tongue thrusting.

Meaningless habit that can be treated easily by a dentist using reminder therapy.

Habit with a deep-rooted psychological problem.

358 Section 7 

Pediatric Orthodontics

Normal and Abnormal Habits Normal Habits

THUMB SUCKING Thumb sucking is defined as the placement of the thumb in varying depths into the mouth (Fig. 30.1).

Those habits that are deemed normal by children of a particular age group.

Abnormal Habits Those habits that are pursued after their physiological period of cessation.

Physiologic and Pathologic Habits Physiologic Habits Physiologic habits are those that are required for normal physiologic fractioning, e.g. nasal respiration, sucking during infancy.

Pathological Habits

Fig. 30.1: Child performing the act of thumb sucking

Habits that are pursued due to pathological reasons such as adenoids and nasal septal defects that may lead to mouth breathing.

Retained and Cultivated Habits Retained Habit

Classification Normal Thumb Sucking The thumb sucking habit is considered normal during the first one and half years of life. Such a habit is usually seen to disappear as the child matures.

Those that are carried over from childhood into adulthood.

Abnormal Thumb Sucking

Cultivated Habit Those cultivated during the socio-active life of an individual.

 ew Classification (Morris and N Bohanna—1969) Habit

Example

Nonpressure habits

Mouth breathing

Pressure habits

a.

Sucking habit •

Lip sucking

•

Thumb and digit sucking

b. Biting habit •

Nail biting/Needle holding

•

Pillow rest

Postural habit

•

Chin rest

Miscellaneous

•

Bruxism

When thumb sucking habit persists beyond the pre school period then it could be considered as an abnormal habit. If the habit is not controlled and treated during this stage, it may cause deleterious effects on the dentofacial structures.

Psychological The habit may have a deep-rooted emotional factor involved and may be associated with neglect and loneliness experien­ ced by the child. • Habitual: The habit does not have a psychological bearing, however the child performs the act. • Nutritive sucking habits: Breastfeeding, bottle feeding. • Non-nutritive sucking habit: Thumb or finger sucking, pacifier sucking.

According to Subtelny (1973) (Fig. 30.2) Type A:  This type is seen in almost 50 percent of the children wherein whole digit is placed inside the mouth with the pad

Chapter 30  Oral Habits Oral Drive Theory (Sears and Wise—1982) They suggest that the strength of the oral drive is in part a function of how long a child continues to feed by sucking. It is not the frustration of weaning that produces thumb sucking but in fact it is the prolonged nursing that causes it.

Rooting Reflex (Benjamin—1962) The rooting reflex is movement of the infant’s head and tongue towards an object touching its cheeks. He suggested that thumb sucking arises from the rooting and placing reflexes common to all mammalian infants during the first 3 months of life.

Sucking Reflex (Ergel—1962)

Fig. 30.2: Pathophysiology of thumb sucking

of the thumb pressing over the palate, while at the same time maxillary and mandibular oral contact is present. Type B:  This type is seen in almost 13 to 24 percent of the children wherein the thumb is placed into the oral cavity and at the same time maxillary and mandibular contact is maintained. Type C:  This type is seen in almost 18 percent of the children wherein the thumb is placed into the mouth just beyond the first joint and contacts hard palate and the maxillary incisors, but there is no contact with mandibular anterior incisors. Type D:  This type is seen in almost 6 percent of the children wherein only a little portion of the thumb is placed into the mouth.

Theories and Concepts of Thumb Sucking Classical Freudian Theory (Sigmund Freud – 1919) The psychoanalytic theory has proposed that a child goes through various distinct phases of psychological development. In oral phase, it is believed that the mouth is the erogenous zone. During this phase the child takes anything and everything to the oral cavity. It is believed that any kind of the deprivation of this activity will probably cause an emotionally insecure individual.

The process of sucking is a reflex occurring in the oral stage of development and is seen even at 29 weeks of intrauterine life and may disappear during normal growth between the ages of 1 to 3½ years. It is the first coordinated muscular activity of the infant. Babies who are restricted from sucking due to disease or other factors become restless and irritable. This deprivation may motivate the infant to suck the thumb and finger for additional gratification.

Learning Theory (Davidson—1967) This theory advocates that non-nutritive sucking stems from an adaptive response. The infant associates sucking with feelings like pleasure and hunger and recalls these events by sucking the suitable objects available, which is mainly thumb or finger.

Etiological Factors Associated with Thumb Sucking Socioeconomic Status In high socioeconomic status the mother is in a better position to feed the baby and in a short time the baby’s hunger is satisfied. Whereas in the low socioeconomic group mother is unable to provide sufficient breast milk to the infants, hence in the process the infant suckles intensively for a long time thereby exhausting the sucking urge. This theory explains the increased incidence of thumb sucking in industrialized areas when compared to rural area.

Working Mother The sucking habits is commonly observed to be present in children with working parents because such children are brought up in the hands of caretaker and develop feelings of insecurity.

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Number of Siblings The development of the habit can be related to the number of siblings because more the number increases the attention meted out by the parents to the child gets divided. A child who feels neglected by the parents may attempt to compensate his feelings of insecurity by means of this habit.

 entofacial Changes Associated with D Thumb Sucking (Figs 30.5 to 30.7)

Order of Birth of the Child Later the sibling ranks in the family, greater is the chance of having an oral habit.

Social Adjustment and Stress Digit sucking has also been proposed as or emotionally based behavior.

Age of the Child The time of appearance of digit sucking habit has significance. • In the neonate: Insecurities are related to primitive demands as hunger • During the first weeks of life: Related to feeding problems • During the eruption of the primary teeth: It may be used to relieve teething.

Diagnosis of thumb sucking habit History Once the positive history of habit is determined the question regarding the frequency, intensity and duration of the habit is determined. The remedies that have been tried at home, the feeding patterns, parental care of the child is also ascertained. Emotional Status It is essential to determine if the habit is meaningful or empty. This requires an insight into the emotional security and familial wellbeing of the child. Extra Oral Examination (Figs 30.3 and 30.4) Digits that are involved in the habit will appear reddened, exceptionally clear, chapped and a short fingernail, i.e. a clean dishpan thumb.

Management The strategy for management of thumb sucking should be started when the child shows any signs of the habit or whenever a familial tendency of the habit is discovered.

Lips: The position of the lips at rest or during swallowing should be observed. A short, hypotonic upper lip frequently characterizes chronic thumb suckers. Lower lip is hyper­active and this leads to further proclination of upper anterior teeth. Profile: Usually convex profile. Other Features Active thumb sucking also have a higher incidence of middle ear infections and frequently have enlarged tonsils accompanied by mouth breathing. Intraoral Examination The type of malocclusion produced by digit sucking is dependent on a number of variables like position of the digit, associated orofacial muscle contractions, mandibular position during sucking, facial skeletal pattern, intensity, frequency and duration of habit.

Fig. 30.3: Callus formation on nails

Chapter 30  Oral Habits

Fig. 30.4: Skin keratotic lesions

Fig. 30.5: Open bite

Fig. 30.6: Proclination of incisors

Fig. 30.7: Deep palate

Preventive Treatment (Hughes, 1941) Firstly, feed the child whenever he is hungry and let him eat as much as he wants. Secondly, feed the child the natural way; importance of breastfeeding is primarily psychological and secondarily nutritive. Thirdly, never let the habit to be started, the practice must be discontinued at its inception. Use of a dummy/Pacifier: Encouraging the baby to suck a dummy instead of his thumb can prevent him from acquiring the habit.

β-hypothesis or Dunlop’s hypothesis:  He believed that if a subject can be forced to concentrate on the performance of the act at the time he practices it, he could learn to stop performing the act. Forced purposeful repetition of habit eventually associates with unpleasant reactions and the habit is abandoned. The child should be asked to sit in front of the mirror and asked to observe himself as he indulges in the habit.

Six Steps in Cessation of Habit (Larson and Johnson)

Psychological Therapy

Step 1:  Screening for psychological component.

Nagging, scolding or frightening the child should be avoided since this could cause negativism and tend to make him resort to the habit.

Step 2:  Habit awareness. Step 3:  Habit reversal with a competing response.

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A

B Figs 30.8A and B: Antithumb sucking solutions

Step 4:  Response attention. Step 5: Escalated DRO (differential reinforcement of other behaviors). Step 6:  Escalated DRO with reprimands. (Consists of holding the child, establishing eye contact and firmly admonishing the child to stop the habit. Three Alarm System: (Norton and Gellin—1968) A chart is designed with days of the week and blank spaces. When the child engage in his habit he is told to wrap the digit he sucks with coarse adhesive tapes. The child feels the tape in his mouth it is the first alarm and this reminds him to stop the habit. The elbow of the arm with the offending thumb is firmly wrapped in two inch elastic bandage safety pins are placed at proximal and distal ends of bandage and one safety pin is placed lengthwise at the mesial end of the elbow and when the child sucks the thumb again, the closed pin on the medial end of elbow, mildly jabbing the elbow indicates second alarm. If the habit persist, the bandage is tightened this is the final or third alarm, which will definitely remind the child of the habit.

Chemical Treatment It is the least effective method. Bitter and sour chemicals have been used over the thumb to terminate the practice but with very minimal success, e.g. quinine, asafetida, pepper, caster oil, etc. Nowadays new antithumb sucking solutions like femite, thumbup, antithumb are also being marketed but they have also had a very moderate success (Figs 30.8A and B).

Fig. 30.9: Thumb guard

Mechanical Therapy or Reminder Therapy Extraoral approach:  Mechanical restraints applied to the hand and digits like splints, adhesive tapes. Thumb guard is the most effective extraoral appliance for control of the habit (Fig. 30.9). Intraoral approach: The early years of life culminating in the oedipal period at the age of 5 years are inappropriate psychologically for this approach therefore the optimal time for appliance placement is between the ages of 3 and 4½ years preferably during spring or summer, when the child’s health is at its peak and the sucking desires can be sublimated in outdoor play and social activity. Following appliances are recommended:

Chapter 30  Oral Habits

A

B

C Figs 30.10A to C: Palatal crib

• Removable or fixed palatal crib (Figs 30.10A to C): It breaks the suction force of the digit on the anterior segment, reminds the patient of his habit and makes the habit a nonpleasurable one. • Oral screen: Oral screen is a functional appliance introduced by Newell in 1912. It produces its effects by redirecting the pressure of the muscular and soft tissue curtain of the cheeks and lips. It prevents the child from placing the thumb or finger into the oral cavity during sleeping hours. • Hay rakes (Fig. 30.11): Mack (1951) advocated the use of dental appliance in children over 3½ years of age who are persistent thumb suckers. The device was called hay rake as it was designed with a series of fence like lines that prevented sucking. • Blue grass appliance: Developed by Bruce S Haskell (1991). It is a fixed appliance using a Teflon roller, together with positive reinforcement. Used to manage thumb sucking habit in children between 7 and 13 years of age. The patient believes that he has acquired a new toy to

Fig. 30.11: Hay rakes

play with. Instructions are given to them to roll the roller instead of sucking the digit.

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• Quad helix: The quad helix is fixed appliance used to expand the constricted maxillary arch. The helixes of the appliance serve to remind the child not to place the finger in the mouth. • Modified blue grass appliance (Fig. 30.12): This is a modification of the original appliance with the difference being that this has two rollers of different colors and material instead of one. If the patient tries to suck on his thumb the suction will not be created and his thumb will slip from the rollers thus breaking the act.

Fig. 30.12: Modified blue grass appliance

Current Strategies • Increasing the arm length of the night suit: This is useful in children who sincerely want to discontinue the habit and only perform during their sleep. The arms of their night suit are lengthened so that they cannot reach the thumb during night.

• Thumb-home concept (Figs 30.13A to C): This is the most recent concept. In this a small bag is given to the child to tie around his wrist during sleep and it is explained to the child that just as the child sleeps in his home, the thumb will also sleep in its house and so the child is restrained from thumb sucking during night. • Currently the use of hand puppets is gaining popularity (Fig. 30.14): – Fill toe sock with stuffing. Pack very tightly. – Cut tag board approximately 2 inches wide and 4 inches long. – Roll tag board loosely around index finger and then wrap thread around it to make a tube. – Make hole in filling with index finger. – Insert tag board tube in filling. – Cut sock off about 1 inch below heel. – Wrap thread around sock at exposed end of tube and sew sock to end of tube. – Dress your puppet with cloth and trimmings. – Paint face on puppet with marking pen, crayons, or fabric paints or stitch on with colored thread. • Thumb sucking book (Fig. 30.15): ‘The Little Bear who Sucked his Thumb’ is a book directed at children, for children. The book has been written and illustrated by Dr Dragan Antolos, an experienced dentist with a special interest in thumb sucking habits in children. He deals first-hand in management of dental, social, and functional problems which can arise with persistent thumb sucking. The book and chart are a noninvasive and effective strategy for stopping thumb sucking, and have received positive support from psychiatrists, speech pathologists, and pedodontic societies. He is very mindful that parents and practitioners should not place pressure

A

B

C Figs 30.13A to C: Thumb-home concept

Chapter 30  Oral Habits

Fig. 30.14: Hand puppets

thumb sucker between the ages of two and seven, then The Little Bear who Sucked his Thumb is a simple, inexpensive and effective way to help your child address the habit.” Oliver is a little bear with a thumb sucking habit. Initially Oliver finds it comforting and fun, but soon decides it is time to stop his thumb sucking. This proves to be more difficult than Oliver had first thought. So off he goes into the woods, to seek out a mystical dragon, who he is sure can help. The dragon shows Oliver how, with determination, and a little help, he can stop his thumb sucking. The book is beautifully illustrated, with characters that will appeal to both boys and girls. As well as a stand-alone story, The Little Bear who Sucked his Thumb is especially useful to parents with children that have a thumb sucking habit. It addresses the problem in a fun and nonthreatening way. The wall chart can be personalized with your child’s name, helping to further motivate them, and in conjunction with the book, find the desire to stop sucking their thumb. • My special shirtTM (Fig. 30.16): This helps in minimizing the damage of finger sucking by providing a number of tools to address the habit in a phased manner. This shirt keeps the child busy thereby avoiding the habit. By working as a team your child will gain confidence, balance emotions and stop their dependence on need to suck.

Fig. 30.15: Parents and child reading thumb sucking book

on children to stop as this is only met with resistance and can entrench the problem. Dr Dragan Antolos, “It is important to balance the psychological benefits of thumb sucking with the negative impact it has on developing, permanent teeth. If you read books to your child, and your child is a thumb sucker, The Little Bear who Sucked his Thumb is a book you should have. The child will relate to the story and it will deliver a positive message without pressure. The book empowers parents to proactively encourage their child to stop sucking on their own terms, when they are ready. I am totally against unremoveable restraining aids placed on children’s thumbs to forcefully prevent children thumb sucking, especially in young toddlers. If your child is a

Fig. 30.16: Special shirt

PACIFIER HABIT Pacifiers have been used by mankind for more than thousands of years. They have been identified to help children in transitioning to sleep, to soothe infants, to provide comfort while teething. The effects of pacifier sucking are the same as NNS or thumb sucking but some other associated risks with pacifier sucking are explained here.

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Effect of Pacifier use on Breastfeeding Newman hypothesized that the use of pacifier causes ‘nipple confusion’ in the infant and a faulty technique of breastfeeding which eventually leads to early weaning. This was also supported by Mitchell who found out that infants given pacifiers in hospitals are less likely to breastfeed mothers on discharge as compared to those who were not given pacifiers. Although there are a variety of authors like Schubiger, Franco, Fleming who feel that pacifier and breastfeeding have no correlation.

Pacifier and Caries Prolonged use of pacifiers in children and specially those used with sugar syrups or sweetened liquids have a positive relation with caries.

Safety Issues These are due to: • Physical safety: Materials and designs of pacifiers that have been associated with asphyxia, infection and death. • Chemical safety: Due to presence of N-nitrosamines in pacifiers which are proven to be carcinogenic. • Immunologic safety: Latex allergy and early sensitization.

Recommendations • Educate parents and caregivers about the safe use of pacifiers. • Withhold the use of pacifiers until breastfeeding is established. After that point, limit their use for soothing breastfeed infants. • Advise parents and caregivers to exercise judgment and restraint regarding pacifier use. • Clean pacifiers routinely and avoid sharing between siblings. • Suggest to parents that pacifier use be curtailed beginning at 2 years of age.

TONGUE THRUSTING Tongue thrusting is the most controversial of all oral habits. There is a wide range of attitudes and opinions among various authors regarding diagnosis and effect of tongue thrusting. Tulley (1969) defined tongue thrust as the forward movement of the tongue tip between the teeth to meet the lower lip during deglutition and in sounds of speech, so that the tongue lies interdentally (Fig. 30.17).

Fig. 30.17: Tongue thrusting

Classification of Tongue Thrusting • Physiologic: This comprises of the normal tongue thrust swallow of infancy. • Habitual: The tongue thrust swallow is present as a habit even after the correction of the malocclusion. • Functional: The tongue thrust mechanism is an adaptive behavior developed to achieve oral seal. • Anatomic: Persons having enlarged tongue can have an anterior tongue posture. James S Brauer and Townsend V Holt classification of tongue thrusting Type

Clinical presentation

Type 1

Nondeforming tongue thrust

Type 2

Deforming anterior tongue thrust (Fig. 30.18) Subgroup 1: Anterior open bite Subgroup 2: Associated procumbency of anterior teeth Subgroup 3: Associated posterior crossbite

Type 3

Deforming lateral tongue thrust (Fig. 30.19) Subgroup 1: Posterior open bite Subgroup 2: Posterior crossbite Subgroup 3: Deep overbite

Type 4

Deforming anterior and lateral tongue thrust Subgroup 1: Anterior and posterior open bite Subgroup 2: Associated procumbency of anterior teeth Subgroup 3: Associated posterior crossbite

Etiology of Tongue Thrusting • Genetic influence: There is a complexity of factors that might predispose a child towards this habit like

Chapter 30  Oral Habits

Fig. 30.18: Anterior tongue thrust

•

•

•

•

•

• •

•

an extremely high narrow palatal arch, an imbalance between the number and size of teeth and the size of the oral cavity. Thumb sucking: This act depresses the tongue and keeps the teeth apart so one can suspect that it also induces malfunctions of the tongue during deglutition. Mixed dentition: When a child loses deciduous teeth especially a canine or an incisor the tongue frequently protrudes into the space at rest, during speech and swallowing activity. Gap filling tendency: Any space around the dental arches not occupied by teeth will tend to be filled by the tongue partly due to exploratory excursions and partly for preventing the escape of food during deglutition. Allergies: Allergies affecting the upper respiratory tract cause their effects on tonsils and adenoid leading to mouth breathing and tongue thrusting. Macroglossia and microglossia: In these situations tongue is inadequate to fill the oral space resulting in a forward thrusting. Soft diet: Oral laxity is encouraged with resulting under­ development of orofacial muscles. Oral trauma: When a traumatic condition persists for a sufficient time its effects can cause changes in deglutition pattern. Sleeping habits: Some patients who sleep on their back on a low pillow or with open mouth, the tongue rests in the mandibular arch and moves forward against the teeth during swallowing.

Fig. 30.19: Lateral tongue thrust

Moyer’s classification of swallowing patterns Type

Inference

Normal infantile During this swallow the tongue lies between the swallow gum pads and mandible is stabilized by contraction of facial muscles especially buccinator. This type of pattern disappears on eruption of the buccal teeth of primary dentition Transitional swallow

Intermixing of normal infantile swallow and mature swallow during the primary dentition and early mixed dentition period

Normal mature swallow

During this swallow there is very little lip and cheek activity. Mainly there is contraction of mandibular elevators

Simple tongue thrust swallow

During this swallow there is contraction of lips, mentalis muscle and mandibular elevators. Tongue protrudes into an open bite that has a definite beginning and ending

Complex tongue thrust swallow

This is characteristically known as teeth apart swallow. There are marked contractions of the lip, facial and mentalis muscles but absence of temporal muscle contraction during swallow. Anterior open bite is also present

Anterior Tongue Thrust Extraoral Features • Usually dolichocephalic face • Increased lower anterior facial height • Incompetent lips

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• Expresion less face as the mandible is stabilized by facial muscles instead of masticatory muscles during deglutition • Speech problems like sibilant distortions and lisping, etc. • Abnormal mentalis muscle activity is seen.

Intraoral Features • Proclined, spaced and sometimes flared upper anteriors resulting in increased overjet. • Retroclined or proclined lower anteriors depending upon the type of tongue thrust. • Presence of an anterior open bite. • Presence of posterior crossbites. • The simple tongue thrust is characterized by a normal tooth contact during the swallowing act. They exhibit good intercuspation of posterior teeth in contrast to complex tongue thrust. • The tongue is thrust forward during swallowing to help establish an anterior lip seal. At rest the tongue tip lies at a lower level.

Complex Tongue Thrust Features • Proclination of anterior teeth • Bimaxillary protrusion • This kind of tongue thrust is characterized by a teeth apart swallow. • The anterior open bite can be diffuse or absent. Proffit and Mason measured the data of the force, duration, intensity, and frequency of tongue thrust and concluded that the tongue thrust habit may sustain an open bite instead of create one. • Absence of temporal muscle constriction during swallowing. • Patients with a complex tongue thrust combine contrac­ tions of the lip, facial and mentalis muscle. • The occlusion of teeth may be poor. Poor occlusal fit, no firm intercuspation. • Posterior open bite in case of lateral tongue thrust. • Posterior crossbite.

Diagnosis of tongue thrusting Careful differentiation must be made among a simple, complex and retained infantile swallow. The prognosis is usually excellent for correction of simple tongue thrust, good for complex tongue thrust and very poor for retained infantile swallowing pattern. Examination of the tongue thrusting: Check for size, shape and movements.

Functional examination • Observe the tongue position while the mandible is in the rest position • Observe the tongue during various swallows – Conscious swallow – Command swallow of saliva – Command swallow of water – Conscious swallow during mastication. Palpatory examination • Place water beneath the patients tongue tip and ask him to swallow – Normal: Mandible rises and teeth are brought together but no contraction of lips or facial muscles – Tongue thrusting: Marked contraction of lips and facial muscles • Place hand over temporalis muscle and ask to swallow – Normal: Temporalis contracts and mandible is elevated – Tongue thrusting: No temporalis contraction • Hold the lower lip and ask the patient to swallow – Normal: Swallow can be completed – Tongue thrusting: Patient cannot complete swallow.

Clinical Features

Chapter 30  Oral Habits Lemon Candy Exercise Instead of the elastic, a lemon candy is put on the tongue tip. Patient is asked to hold the candy against the palate by the tongue tip and then asking the child to swallow.

4S Exercise This includes identifying the spot, salivating, squeezing the spot and swallowing. Using the tongue the spot is identified, the tongue tip is pressed against this spot and the child is asked to swallow keeping the tongue at the same spot.

Other Exercises Fig. 30.20: Anterior open bite with proclination

Treatment Considerations Tongue thrusting often self corrects by 8 to 9 years of age by the time permanent teeth erupt. If tongue thrusting is associated with other habits then the associated habit must be treated first. Cayley AS et al. performed a prospective clinical study and assessed the effect of tongue re-education therapy on tongue function and dentofacial form in anterior open bite patients using electropalatography and lateral head cephalometric radiographs. She concluded that there was some evidence of a trend for eruption of upper and lower incisors with concomitant reduction of the anterior open bite and implied that the therapy was partially successful in improving tongue function during swallowing and in reducing anterior open bite.

Myofunctional Therapy Garliader proposed this method in which the patient can be guided regarding the correct posture of the tongue during swallowing by various exercises like asking the child to place the tip of the tongue in the rugae area for 5 minutes and then asking him to swallow.

Orthodontic Elastics The tongue tip is held against the palate using orthodontic elastic of 5/16” and sugarless fruit drop.

The child is asked to perform a series of exercise such as whistling, reciting the count from 60 to 69, gargling, yawning, etc. to tone the respective muscles.

Lip Exercises Tug of war and button pull exercise: A string is tied to two buttons, one of the buttons is placed between the lips of the patient while the other is held by the patient outside. The outer button is pulled outwards and at the same time the inside button is resisting the forces thereby strengthening the lips on both aspects.

Subconscious Therapy Once the voluntary swallowing pattern is acquired the patient proceeds to subconscious therapy, viz. subliminal therapy in which the patient is asked to place a reminder sign or auto suggestion which requires the patient to give self-instructions like repeat 6 times “I will swallow correctly all night long”— for 10 nights.

Mechanotherapy Both fixed and removable appliances can be fabricated. The appliance re-educates tongue so that the dorsum of tongue approximates the palatal vault and the tip of the tongue contacts palatal rugae during deglutition. Some of the appli­ ances that can be used to prevent tongue thrusting are: • Preorthodontic trainer • Modifications of Hawley’s appliance • Tongue crib (Figs 30.21A and B) • Oral screen.

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A

B Figs 30.21A and B: Tongue crib

New concept Galella habit appliance is primarily used to correct aberrant tongue habits, however, a secondary function of the appliance is to deter thumb sucking. The appliance is designed to be physiologically congruent with normal tongue function and is a simple appliance consisting only of a large coffin loop and a lingual arch wire that supports a habit bead. It is built on bands placed on the first permanent molars. The appliance is inserted into horizontal tubes (Mia tubes) that are placed on the lingual of the bands and it is in the family of ‘fixed-removable’ appliances. It is the design, position, and function of these components that make this appliance unique and highly effective. Coffin loop is large, about a third the width of the entire palate, and is positioned approximately 8 to 10 mm away from the palate. The lingual arch wire supports a habit bead that is positioned over the posterior third of the incisive papilla. When the patient swallows they are instructed to wedge their tongue in between the bead and the roof of the mouth. They are also instructed to ‘pull’ the bead towards the back of the mouth throughout the day. The coffin loop functions to remind the heel of the tongue of aberrant tongue swallows but also, because of its position away from the roof of the mouth, helps to intrude the molars thus aiding in the closing of the bite. The anterior position of the bead, combined with the patient’s exercise of ‘pulling’ the bead towards the back of the mouth, functions both to retrain the tip of the tongue and as a deterrent to aberrant tongue thrusting.

Fig. 30.22: Child doing mouth breathing

MOUTH BREATHING Sassouni (1971) defined mouth breathing as habitual respiration through the mouth instead of nose (Fig. 30.22).

Classification of Mouth Breathing Given by Finn in 1987 • Obstructive: Increased resistance to or complete obstruc­ tion of normal airflow through nasal passage. • Habitual: As a matter of habit or persistence of the habit even after elimination of the obstructive cause. • Anatomical: Short upper lip leads to incompetence of lips and hence mouth breathing.

Etiology • Developmental and morphologic anomalies like abnor­ mal development of nasal cavity, nasal turbinates, and short upper lip.

Chapter 30  Oral Habits • Partial obstruction due to deviated nasal septum, locali­ zed benign tumors. • Infection and inflammation of nasal mucosa, chronic allergic stomatitis, chronic atropic rhinitis, enlarged ade­ noids and tonsils, nasal polyps. • Traumatic injuries to the nasal cavity. • Genetic pattern—ectomorphic children having a genetic type of tapering face and naso-pharynx are prone to nasal obstruction.

Diagnosis • Observe the patient – Mouth breathers: Lips will be apart – Nasal breather: Lips will be touching • Ask the patient to take a deep breath through nose –  Mouth breathers: No change in shape or size of external nares – Nasal breathers: Demonstrates good control of alar muscles • Mirror test: It is also called as Fog test. Two-surfaced mirror is placed on the patient’s upper lip. If air condenses on upper side of mirror the patient is nasal breather and if it does so on the opposite side then he is a mouth breather. • Massler’s water holding test: Patient is asked to hold the mouth full of water. Mouth breathers cannot retain the water for a long time. • Jwemen’s butterfly test: Take a few fibers of cotton and place it just below the nasal opening. On exhalation if the fibers of the cotton flutter downwards patient is nasal breather and if fibers flutter upward he is a mouth breather. • Rhinometry (Inductive plethysmography): The total airflow through the nose and mouth can be quantified using inductive plethysmography. • Cephalometrics: It can be used to calculate amount of nasopharyngeal space.

Clinical Features

Treatment The main aspect of management of a mouth-breathing patient is to treat and eliminate the underlying cause or pathology that has created the habit. This should be followed by symptomatic treatment. Other procedures and appliances that can be used are: • Deep breathing exercises • Lip exercises 15 to 30 min/day for 4 to 5 months • Oral screen (Figs 30.23A and B).

BRUXISM Ramfjord in 1966 defined bruxism as the habitual grinding of teeth when an individual is not chewing or swallowing.

Classification • Daytime: Diurnal bruxism/Bruxomania. It can be conscious or subconscious and may occur along with para-functional habits. • Night time bruxism: Nocturnal bruxism. Subconscious grinding of teeth characterized by rhythmic patterns of masseter.

Etiology • Central nervous system: It could be a manifestation of cortical lesions, e.g. in children cerebral palsy.

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A

B Figs 30.23A and B: Oral screen

• Psychological factors: A tendency to gnash and grind the teeth has been associated with feeling of anger and aggression or be a manifestation of the inability to express emotions such as anxiety and hate. • Occlusal discrepancies. • Genetics. • Systemic factors: Magnesium deficiency, chronic abdomi­ nal distress, intestinal parasites. • Occupational factors: An over enthusiastic student and compulsive overachievers may also develop the habit.

Clinical Manifestations The signs and symptoms of bruxism depend on frequency, intensity, and age of patient. The forces of bruxism are transmitted to the structures of masticatory apparatus and depending on the resistance of the individual, certain amount of the forces are absorbed and the rest are passed to other structures. • Occlusal trauma: THis include tooth ache, mobility mainly in morning. • Tooth structure: Extreme sensitivity due to loss of enamel, atypical wear facets, pulp may be exposed and many fractured teeth can also occur. • Muscular: Tenderness of the jaw muscles on palpation, muscular fatigue on waking up in the morning, hyper­ trophy of masseter. • Temporomandibular Joint: Pain, crepitation, clicking in joint, restriction of mandibular movements. • Associated features: Headache.

• Drugs: Local anesthetic injections, tranquilizers, muscle relaxants • Biofeedback • Electrical method: Electrogalvanic stimulation for muscle relaxation • Acupuncture • Orthodontic correction.

LIP BITING Normal lip anatomy and function is important for speaking, eating and maintaining the balanced occlusion. The lip habit may involve either of the lips, higher predominance towards the lower lip. This is defined as a habit that involves manipulation of lips and perioral structures (Fig. 30.24).

Treatment • • • • •

Occlusal adjustments of any premature contacts Occlusal splints/night guards Restorative treatment Relaxation training Physiotherapy

Fig. 30.24: Lip habit

Classification • Lip licking/Wetting of lips by the tongue • Lip sucking habit: Pulling the lips into the mouth between the teeth.

Chapter 30  Oral Habits

Etiology • Malocclusion • In conjunction with other habits • Emotional stress.

Clinical Manifestations • • • • • •

Protrusion of upper incisors Retrusion of lower incisors Lip trap (Fig. 30.25) Muscular imbalance Lower incisor collapse with lingual crowding. Lip has reddened and chapped area below the vermilion border (Fig. 30.26). • Mentolabial sulcus becomes accentuated.

child’s growth. Treatment of lip sucking habit should be directed initially towards the etiology followed by appliance therapy like lip protector (Fig.  30.27), oral screen and lip bumper (Fig. 30.28).

NAIL BITING Nail biting is one of the most common habits in children and adults. It is the sign of internal tension. Incidence as reported by Weschsher (1931) is 43 percent in adolescents 25 percent in college students.

Etiology • Insecurity • Psychosomatic successor of thumb sucking • Nervous tension.

Effects

Treatment Lip habit is not self-correcting and may become more deleterious with age because of the muscular force interacting

• Crowding, rotation and alteration of incisal edges of incisors. • Inflammation of the nail bed.

Fig. 30.25: Lip trap

Fig. 30.26: Reddened and chapped area below the vermilion border

Fig. 30.27: Lip protector

Fig. 30.28: Lip bumper

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Management • • • •

Patient is made aware of the problem Scolding, nagging and threats should not be used Treat the basic emotional factors causing the act Encouraging outdoor activities may help in easing tension • Application of nail polish, light cotton mittens as reminder.

Many oral habits may be considered normal for a certain stage of child’s development but it is the duty of the pedodontist to work with the parents and children towards resolution of habit before it causes any deleterious effects because he is most often the first to see the patient.

SELF-INJURIOUS HABITS (Masochistic habits, sado-masochistic habits, self-mutilating habits) Repetitive acts that result in physical damage to the individual (Fig. 30.29). These habits show an increased incidence in the mentally retarded population. Seen in 10 to 20 percent in mentally retarded children and in children with psychological abnormalities. Fig. 30.29: Child doing cheek biting

Etiology • Organic: Associated with Lesch-Nyhan disease and De Lange’s syndrome. • Functional: Given by Stewart and Kernohan in 1972. Type A:  Injuries superimposed on a pre-existing lesion, e.g. 3-½ year-old child who was treated for herpetic stomatitis, all but one of the numerous lesions responded well to treatment. This single ulcer was found to be perpetuated by a fingernail habit occurred mainly at night.

A

Type B:  Injuries secondary to another established habit, e.g. rotation of thumb while thumb sucking can harm soft tissues. Type C:  Injuries of the unknown or complex etiology. This type of behavior has a greater psychogenic component.

B Figs 30.30A and B: Picking of gingiva

Clinical Features • • • •

Biting of fingers, knees, shoulders Frenum thrusting Picking of gingiva (Figs 30.30A and B) Insertion of sharp objects into the oral cavity (Fig. 30.31).

Treatment First initiated towards psychotherapy because some children experience a feeling of neglect, abandonment and loneliness and thus use this behavior in an attempt to solicit attention and love. Treatment of self-injurious behavior generally requires a multidisciplinary approval. Care should be taken in dealing with this form of behavior of underlying emotional component. Palliative therapy followed by mechanotherapy using protective padding and mouth guards has also been advocated.

Fig. 30.31: Pin insertion inside endodontic cavity

Chapter 30  Oral Habits Interplay of habits

POINTS TO REMEMBER • Boucher OC defined habit as a tendency towards an act or an act that has become a repeated performance, relatively fixed, consistent, easy to perform and almost automatic. • Thumb sucking is defined as the placement of the thumb in varying depths into the mouth. Its etiology varies from oral theory, rooting reflex, working mother, low socioeconomic status, stress and age of child. The classical features include dishpan thumb with keratotic lesions, proclination of maxillary incisors, open bite, high palate. The management strategies include psychological approach, chemical approach, reminder therapy, mechanotherapy using rakes and new reminder advancements like thumb home concept, book reading, long sleeves, etc. • Tongue thrust as the forward movement of the tongue tip between the teeth to meet the lower lip during deglutition and in sounds of speech, so that the tongue lies interdentally. It can be physiologic, anatomic, functional or habitual. The classical features are open bite, crossbite, bimaxillary protrusion and incompetent lips. Diagnosis is made by asking the patient to swallow water while observing musculature. Treatment is by mechanotherapy, subconscious therapy, myofunctional exercises, lip and elastic exercises. • Mouth breathing as habitual respiration through the mouth instead of nose. It may be obstructive, habitual or anatomic. The most common diagnostic tests are rhinometry, massler’s water holding test, jewmenn butterfly test, water holding test. The main clinical features include adenoid facies, gingivitis and anterior maxillary caries. Treatment is by removal of obstruction, lip exercises and oral screen. • Bruxism is the habitual grinding of teeth when an individual is not chewing or swallowing. • Self-injurious habits are also called as masochistic habits, sado-masochistic habits, self-mutilating habits. They are repetitive acts that result in physical damage to the individual. Its etiology is either organic which is associated with LeschNyhan disease and De Lange’s syndrome or functional. Clinical features include biting of fingers, knees, shoulders, frenum thrusting and picking of gingiva.

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QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7.

Define and classify oral habits. Describe the etiology, clinical features and management of thumb sucking habit. Classify tongue thrusting and explain its clinical features. Write a note on management of thrusting habit by exercise. What are the diagnostic test and clinical features of mouth breathers? What is bruxism? Explain self-injurious habits.

BIBLIOGRAPHY 1. Andrews RG. Tongue thrusting. J South Calif Dent Assoc. 1960;28:47-53. 2. Cayley AS, et al. Electropalatographic and cephalometric assessment of myofunctional therapy in openbite subjects. Aust Orthod J. 2000;16(1):23-33. 3. Gulati MS, Grewal N, Avninder Kaur. A comparative study of effects of mouth breathing and normal breathing on gingival health in children. J Indian Soc Pedo Prev Dent. 1998;16(3):72-83. 4. Haas, Magda. The different sucking habits and their influence on the development of dentition. D Record. 1937;57:633-53. 5. Haskell BS, Munk JR. An aid to stop thumb sucking: the ‘Bluegrass appliance’. Pediatr Dent. 1991;13:83-5. 6. Johnson, Leland R. Habits and their control during childhood. JADA. 1937;24:1409-21. 7. Josell SD. MDentSci: Habits affecting dental and maxillofacial growth and development. Dent Clin North Am. 2000;44(3):659-69. 8. Josell SO. Habits affecting dental and maxillofacial growth and development. Dent Clin North Am. 1995;39(4):851-60. 9. Lewis SJ. Thumb-sucking; a cause of malocclusion in the deciduous teeth. JADA. 1930;17:1060-72. 10. Nowak AJ, Warren JJ. Infant oral health and oral habits. Pediatr Clin North Am. 2000;47(5):1043-66. 11. Nowak AJ, Warren JJ. Infant oral health and oral habits. Pediatr Clin North Am. 2000;47:1034-66. 12. Popovich F, Thompson GW. Thumb and finger sucking: its relation to malocclusion. Am J Orthod. 1973;63:148-55. 13. Proffit WR, Mason RM. Myofunctional therapy for tongue thrusting: background and recommendations. J Am Dent Assoc. 1975;90:403-11. 14. Pullen HA. Abnormal habits in their relation to malocclusion and facial deformity, internat. J Orthodontia. 1927;13:233-52. 15. Ramfjord SP. Bruxism: a clinical and electromyographic study. J Am Dent Assoc. 1961;62:21-44. 16. Tulley WJ. A critical appraisal of tongue thrusting. Am J Orthod. 1969;55(6):640-50. 17. Umberger FG, Van Reenen JS. Thumb sucking management: a review. Int J Orofacial Myology. 1995;21:41-7. 18. Van Norman RA. Digit-sucking: a review of the literature, clinical observations and treatment recommendations. Int J Orofacial Myology. 1997;23:14-34.

31

Chapter

Cephalometric Diagnosis Harsh Pandey, Ankur Mangal, Nikhil Marwah

Chapter outline • • •

• • • •

Cephalometric Technique Reference Points Reference Planes

The primary aim of cephalometrics is to assess the dental, skeletal and facial relationships as seen on radiograph. Cephalometric has long been studied and researched by all scientists and is an integral part of orthodontics as well as Pedodontics. The development of craniofacial morphology has evolved a great deal over 50 years. The earliest reference to the shape and morphology of face was in 4th century BC by Greeks. In 1922 Simon introduced a photographic technique to evaluate facial morphology. Rancini and Carrera in 1926 performed first lateral view of skull. It was in 1931 that B Holly Broadbent recognized the need of assessment of craniofacial morphology and later TW Todd, went on to develop first cephalometer based on anthropometer used at case Western Reserve University.

A

Analysis of the Cephalogram Down’s Analysis Steiner’s Analysis Tweed Analysis

CEPHALOMETRIC TECHNIQUE For the radiograph the patient is positioned next to the X-ray apparatus and positioned by adjusting the ear rods and nasal piece so that the Frankfort horizontal plane is parallel to floor. The film cassette is positioned as close as possible to the patient and the X-ray beam should be at the level of ear rods, perpendicular to film (Figs 31.1A and B).

REFERENCE POINTS Critical knowledge of anatomical landmarks is of para­ mount importance in cephalometrics as multiple structures

B Figs 31.1A and B: Technique for lateral cephalostat

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TABLE 31.1: Lateral reference points Symbol

Point

Details

A

Subspinale

Deepest point on maxilla

ANS

Anterior nasal spine

Tip of anterior nasal spine

Ar

Articulare

Point of intersection of dorsal contour of mandibular process and temporal bone

B

Supramentale

Most posterior point between infradentale and pogonion, anterior point of mandible

Ba

Basion

Lowest point on anterior aspect of foramen magnum

Bo

Bolton point

Highest point of retrocondylar fossa

Cd

Condylion

Most superior point on articular head of condyle

CF

Center of face

Intersection of FH plane and a line perpendicular to Pt point

Gn

Gnathion

Inferior most point on contour of chin

Go

Gonion

Point on jaw angle that is inferiorly, posteriorly and outwardly directed

Me

Menton

Inferior most point on mandibular symphysis

N

Nasion

Intersection of internasal suture with nasofrontal suture

Or

Orbitale

Lowermost point on lower border of orbit

PNS

Posterior nasal spine

Tip of posterior spine of palatine bone in hard palate. Denotes posterior limit of maxilla

Po

Porion

Most superior point on external auditory meatus

Pog

Pogonion

Anterior most point on contour of chin

Ptm

Pterygomaxillary fissure

Projected tear drop shaped fissure created by anterior border of pterygoid plate and posterior border of maxilla

Pt

Pt point

Intersection of inferior border of foramen rotundum with posterior wall of Ptm

R

Broadbent registration point

Midpoint of perpendicular from center of sella turcica to Bolton plane

S

Sella turcica

Midpoint of hypophyseal fossa

SO

Spheno-occipital synchondrosis

Uppermost point of suture

TABLE 31.2: Frontal reference points Symbol

Point

Details

LZF/RZF

Zygomaticofrontal

Bilateral points on medial aspect of zygomaticofrontal sutures at the intersection of orbit

ANS

Anterior nasal spine

Tip of anterior nasal spine

LJ/RJ

Jugal process

Bilateral points on jugal processes at the junction of maxillary tuberosity and zygomatic buttress

LAG/RAG

Antegonial points

Points at inferior margin of antegonial protuberances

M

Menton

Inferior point of mental protuberance

I

I point

Point at the junction of crown and gingiva in maxillary and mandibular region

TABLE 31.3: Soft tissue reference points

• Glabella

• Soft tissue Nasion



• Nasal tip

• Subnasale



• Upper lip point

• Stomion



• Lower lip point

• Supradentale



• Infradentale

• Soft tissue pogonion

sometimes make it difficult to assess the relationship on radiograph alone. The radiograph is placed on a view-box and traced using a tracing paper and drawing pencil to demarcate all the reference points and planes. There are 18 main reference points on face; in addition to these anthropologic landmarks there are certain arbitrary points which are also helpful in

cephalometric analysis (Tables 31.1 to 31.3). Reference points can be divided into (Fig. 31.2) lateral and frontal (Fig. 31.3).

REFERENCE PLANES Linear assessment is by joining two lines and angular assessment is by joining three lines. By combining various linear and angular cephalometric measurements, joining various landmarks, cephalometrics offers valuable infor­ mation on facial types, growth, case diagnosis, functional analysis and progress reports and all other treatment aspect of patients (Figs 31.4A to J). • A-Pog line: Line from point A to Pogonion • Basion-Nasion plane (BN Plane): From Nasion (N) to Basion (Ba) representing the cranial base

Chapter 31  Cephalometric Diagnosis

Fig. 31.2: Lateral cephalometric landmarks

Fig. 31.3: Frontal cephalometric landmarks

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A

B

C

D

E

F Figs 31.4A to F

Chapter 31  Cephalometric Diagnosis

G

H

I

J Figs 31.4G to J

Figs 31.4A to J: Cephalometric reference planes. (A) A pogonion plane; (B) Basion-nasion plane; (C) Esthetic plane; (D) Facial axis; (E) Facial plane; (F) Frankfurt horizontal plane; (G) Mandibular plane; (H) Occlusal plane; (I) Plalatal plane; (J) Sella-nasion plane

• E-plane: Esthetic plane is denoted by a line between anterior point on nose and anterior point on chin • Frankfort horizontal plane (FH Plane): From Porion (Po) to Orbiatle (O) • Facial plane (FP): Line through Nasion (N) perpendicular to FH plane • Facial axis (FX): From Pt point (Pt) to Gnathion (Gn) which crosses BN plane at right angle • Mandibular plane (MP): Tangent to inferior border of mandible • Occlusal plane (OP): Separates the maxillary and mandibular teeth • Palatal plane (PP): Extends from ANS to PNS • Pterygoid vertical plane (PTV plane): Line perpendicular to FH plane through Pt point • Sella-Nasion plane (SN Plane): From Sella (S) to Nasion (N).

ANALYSIS OF THE CEPHALOGRAM • The methods currently available to evaluate craniofacial form include anthropometry, cephalometry, ultrasound, computed tomographic (CT) scanning, magnetic reso­ nance imaging (MRI), and optical surface scanning. • Arguably, cephalometry continues to be the most versatile technique in the investigation of the craniofacial skeleton because of its validity and practicality. Despite the inherent cephalometric distortion and differential magnification of the craniofacial complex, in comparison with newer imaging techniques, the cephalogram pro­ duces a high diagnostic yield at a low physiological cost. • Nevertheless, there are problems in deriving a numerical representation of craniofacial form using cephalometry. This is because ‘form’ is the combination of ‘size’ and

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‘shape’ and separating shape from size is complex. Perhaps the most important limitation of cephalometry relates to the errors inherent with the identification and recording of the structures there in. • The traditional method of analyzing cephalograms (conventional cephalometric analysis, CCA) has, in recent years, been supplemented with a variety of sophisticated morphometric methods. Although these newer methods possess mathematical and statistical advantages, each has limitations. There are two distinct groups of scientifically valid analytical methods used in cephalometry: landmarkbased techniques and boundary outline methods. • Landmark-based techniques are dependent on cephalo­ metric landmarks: discrete points defined intrinsically in terms of the surrounding anatomy to represent the craniofacial form. Landmarks convey information relat­ ing only to their location, providing no information either about the inter landmark or surrounding anatomy. In particular, landmarks cannot represent curving anatomy and all are not equally valid and reproducible. Landmark-based techniques include CCA, Procrustes superimposition techniques, Euclidean distance matrix analysis (EDMA), thin-plate spline analysis (TPS), biorthogonal-grids (BOG), and finite element morpho­ metry/finite element scaling analysis (FEM/FESA). • Boundary outline techniques do not require cephalo­ metric landmarks to represent the craniofacial form. As their generic term suggests, they only investigate the shape of the perimeter of a structure. Medial axis analysis (MAA), resistant-fit theta RHO analysis, Eigen shape analysis and elliptical fourier functions (EFF) are considered under the boundary outline technique umbrella.

• Average value – 87.8˚ • Range – 82 – 95˚ • Indication of anterio posterior positioning of mandible in relation to upper face. It is used to measure degree of protrusion or retrusion of lower jaw. • Magnitude increase in case of Class III malocclusion with prominent chin. • Decrease in case of Class II malocclusion.

Fig. 31.5A Facial angle

Angle of Convexity (Fig. 31.5B) • The angle is formed by the intersection of lines N-A and A-Pog. • Reveals convexity or concavity of skeletal profile. • Average value – 0˚ • Range –8.5 to 10˚ • A positive value in convex profile suggesting prominant maxilla relative to mandible • Negative value in concave profiles.

DOWN’S ANALYSIS • One of the most frequently used cephalometric analysis. • He did study on 20 caucasian individuals of 12–17 yrs age group belonging to both sexes. • Consists of 10 parameters: • 5 skeletal • 5 dental

Skeletal Parameters • • • • •

Facial angle Angle of convexity AB plane angle Mandibular plane angle Y-axis.

Facial Angle • The inferior posterior angle formed by the intersection of  the Frankfort horizontal and the facial plane (N-POg) (Fig. 31.5A).

Fig. 31.5B Angle of convexity

A-B Plane Angle (Fig. 31.5C) • Line connecting point A and point B and a line joining N-POG. • Average value –4.6˚ • Range –9 to 0˚ • Indicative of maxillo mandibular relationship in relation to facial plane.

Chapter 31  Cephalometric Diagnosis • Usually negative as point B is behind point A. • Positive angle found in Class III mo.

Y-axis (Growth axis) (Fig. 31.5E) • • • •

Angle formed by joining S — Gn line with FH Plane. Average value – 59˚ Range – 53 – 66˚ Angle- larger – Class II facial pattern and vertical growth of mandible • Smaller angle — Class III pattern and horizontal growth of mandible.

Fig. 31.5C A–B plane angle

Mandibular Plane Angle (Fig. 31.5D) • The anterior angle formed by the intersection of the Frankfort horizontal plane and a tangent to the lower border of the mandible and symphysis. • Average value – 21.9˚ • Range – 17 – 28˚ • Increased angle suggestive of vertical grower with hyperdivergent facial pattern.

Fig. 31.5E Y-axis (Growth axis)

Dental Parameters • • • • •

Cant of occlusal plane Interincisal angle Incisor occlusal plane angle Incisor mandibular plane angle Upper incisor to A — POG line.

Cant of Occlusal Plane (Fig. 31.6A)

Fig. 31.5D Mandibular plane angle

• Angle between occlusal plane and FH Plane. • Down described occlusal plane as A line passing through the cusp tips of the maxillary and mandibular first permanent molars and midway between the incisal edges of the maxillary and mandibular central incisors (bisecting the overbite). • Average value – 9.3˚ • Range – 1.5 – 14˚ • It gives us slope of occlusal plane relative to FH Plane.

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Pediatric Orthodontics

Fig. 31.6A Cant of occlusal plane

Fig. 31.6B Interincisal angle; incisor occlusal plane angle; incisor mandibular plane angle

Interincisal Angle (Fig. 31.6B)

Upper Incisor to A – POG Line (Fig. 31.6C)

• A measurement of the degree of procumbency of the incisor teeth, introduced by WB Downs as the (posterior) angle formed by the intersection of the long axes of the maxillary and mandibular central incisors. • Average – 135.4˚ • Range – 130 – 150.5˚ • Angle decrease in class II div. 1 and bimax. cases • Increase in class II div. 2 cases.

• Linear measurement between incisal edge of maxillary central incisor and the line joining point A to POG. • Average – 2.7 mm • Range – 1 to 5 mm • More value — upper incisor proclination.

Incisor Occlusal Plane Angle • Inside inferior angle formed by intersection between the long axis of lower central incisor and occlusal plane • Read as + or – from right angle • Average – 14.5˚ • Range – 3.5 to 20˚ • Increase in angle shows lower incisor proclination.

Incisor Mandibular Plane Angle • Angle formed by intersection of long axis of LI and mandibular plane. • Average – 1.4˚ • Range –8.5 to 7˚ • Increase in angle — LI proclination

Fig. 31.6C Upper incisor to A–POG Line

Chapter 31  Cephalometric Diagnosis Parameter

Minimal (degrees)

Maximol (degrees)

Meon (degrees)

Facial angle

82

95

87.0

Angle of convexity

–8.5

+10

0

A–B plane angle

–9

0

–4.6

Mandibular plane angle

17

28

21.9

Y-axis

53

66

59.4

Skeletal pattern

Dental pattern Cont of occlusal plane

+1.5

+14

+9.3

1 to 1

130

150.5

135.4

1 to occlusal plane

+3.5

+20

+14.5

1 to mandibular plane

–8.5

+7

+1.4

1 to A–P plane

–1 mm

+5 mm

+2.7 mm

• The inferior posterior angle formed by the intersection of lines SN and NA is measured. • Mean – 82˚ • Larger value — prognathic maxilla (Class II)

SNB Angle (Fig. 31.7B) • Evaluate the anteroposterior position of the mandible in relation to the cranial base. • The inferior posterior angle formed by the intersection of lines NA and NB is measured. • Mean – 80˚ • Larger angle — prognathic mandible (Class III)

STEINER’S ANALYSIS Skeletal analysis

Dental parameters

• SNA angle

• Upper incisor to N-A (angle)

• SNB angle

• Upper incisor to N-A ( linear)

• ANB angle

• Lower incisor to N-B (angle)

• Mandibular plane angle

• Lower incisor to N-B ( linear)

• Occlusal plane angle

• Interincisal angle

Soft tissue analysis • S-line

Skeletal Parameters SNA Angle (Fig. 31.7A) • A commonly used measurement for assessment of the antero posterior position of the maxilla with regards to the cranial base.

Fig. 31.7A SNA angle

Fig. 31.7B SNB angle

ANB Angle (Fig. 31.7C) • The difference between angles SNA and SNB, aim at providing an evaluation of the anteroposterior relationship between the maxillary and mandibular apical bases. • Formed by N – point A and N – point B • Mean – 2˚ • Increase in angle – class II skeletal tendency.

Fig. 31.7C ANB angle

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Mandibular Plane Angle (Fig. 31.7D)

• Determine upper incisor position • Increase in case of proclination.

• A measurement introduced by CC Steiner for assessment of the steepness of the mandibular plane in relation to the cranial base. • The anterior angle formed by the intersection of SN and Go-Gn is measured. • Mean – 32˚ • Lower angle — horizontal GP.

Fig. 31.8A Upper incisor to N–A (Angle and Linear)

Lower Incisor to N-B (Angle)

Fig. 31.7D Mandibular plane angle

• Formed by intersection of the long axis of lower central incisor and line joining N – point B. • Average – 25˚ • Indicate relative inclination of the lower incisors • Increased angle — proclination.

Occlusal Plane Angle

Lower Incisor to N-B (Linear) (Fig. 31.8B)

• A line drawn through the occlusal surfaces of the maxillary and mandibular first permanent molars and 1st premolars • Formed between occlusal plane and SN plane • Mean – 14.5˚ • Represent relation of the occlusal plane to cranial base and face. • Indicate growth pattern.

• Linear measurement between the labial surface of lower central incisor and the line joining N – point B • Average - 4 mm • Determine lower incisor position • Increase in case of proclination

Dental Parameters Upper Incisor to N-A (Angle) (Fig. 31.8A) • Formed by intersection of the long axis of upper central incisor and line joining N – point A. • Average – 22˚ • Indicate relative inclination of the upper incisors • Increased angle — proclination. Fig. 31.8B Lower incisor to N–B (Angle and Linear)

Upper Incisor to N-A (Linear)

Interincisal Angle (Fig. 31.8C)

• Linear measurement between the labial surface of upper central incisor and the line joining N – point A • Average — 4 mm

• Interincisal angle relates the relative position of upper incisor to that of the lower incisor • Mean – 130o

Chapter 31  Cephalometric Diagnosis TWEED ANALYSIS (FIG. 31.10A) • A set of three angular measurements (which constitute what has come to be known as the Tweed triangle), introduced by CH Tweed in 1946. • The three angles that were originally described are the FMA (Frankfort-mandibular plane angle-mean 25o) (Fig. 31.10B) the IMPA (Incisor-mandibular plane angle-mean 90o) (Fig. 31.10C) and the FMIA (Frankfort-mandibular incisor angle-mean 65o) (Fig. 31.10D). Fig. 31.8C Interincisal angle

Soft Tissue Analysis S-line (Esthetic Plane of Steiner) (Fig. 31.9) • Formed by a line extending from soft tissue contour of chin to the middle of ‘S’ formed by lower border of nose. • The lips should fall on this line and any deviation shows prominence or flatness of the lips. • If lips beyond this line — protrusive lips/convex profile.

Fig. 31.10A The tweed triangle

Fig. 31.9 S-line (Esthetic plane of steiner) Parameter

Reference measurements

SNA (angle)

82 degrees

SNB (angle)

80 degrees

ANB (angle)

2 degrees

1 to N–A (mm)

4 mm

1 to N–A (angle)

22 degrees

1 to N–B (mm)

4 mm

1 to N–B (angle)

25 degrees

Po to N–B (mm)

Not established

Po and 1 to N–B (difference)

—

1 to 1 (angle)

131 degrees

Occl to S–N (angle)

14 degrees

GoGn to S–N (angle)

32 degrees

Fig. 31.10B Frankfort-mandibular plane angle

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Pediatric Orthodontics

Wit’s Appraisal (Figs 31.11A and B) • Measure of extent to which maxilla and mandible are related to each other in antero posterior or sagittal plane. • Used in cases where ANB not reliable. • In Class II – BO behind AO • In Class III – BO ahead of AO.

Fig. 31.10C Incisor mandibular plane angle

A

B Figs 31.11A and B Wit’s appraisal

Fig. 31.10D Frankfort-mandibular incisor angle

Chapter 31  Cephalometric Diagnosis

POINTS TO REMEMBER • • • • • • •

Pioneer of cephalometrics is B. Holly Broadbent TW Todd, went on to develop first cephalometer at Western Reserve University. There are 18 main reference points on face and 12 reference planes E-plane: Esthetic plane is denoted by a line between anterior point on nose and anterior point on chin Frankfort horizontal plane (FH Plane): From Porion (Po) to Orbiatle (O) The two major techniques for cephalometric assessment are landmark-based techniques and boundary outline techniques Down’s analysis includes skeletal assessment by Facial angle, Angle of convexity, AB plane angle, Mandibular plane angle, Y-axis and dental assessment by Cant of occlusal plane, Inter-incisal angle, Incisor occlusal plane angle, Incisor mandibular plane angle, Upper incisor to A-Pog line.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

What are lateral reference points? Explain lateral cephalometric assessment. Write a note on soft tissue assessment. SNA and SNB angle. What is Down’s analysis? Explain Steiner’s analysis.

BIBLIOGRAPHY

1. Bookstein FL. On the cephalometrics of skeletal changes; 1982. 2. Broadbent BH. A new X-ray technique and its application to orthodontia. Angle Orthod. 1931;7:183. 3. Krull JT, Lapp TH, Bussard DA. Cephalometrics and facial esthetics: The key to complete treatment planning. 4. Lele S, Richtsmeier JT. Euclidean distance matrix analysis: a coordinate-free approach for comparing biological shapes using landmark data. American Journal of Physical Anthropology. 1991;86:415-27. 5. Lestrel PE. Method for analyzing complex two-dimensional forms: elliptical fourier functions. American Journal of Human Biology. 1989;1:149-64. 6. Mcintyre GT, Mossey PA. Size and shape measurements in contemporary cephalometrics. Europ J Orthod. 2003;25:231-52. 7. Moyers RE, Bookstein FL. The inappropriateness of conventional cephalometrics. American Journal of Orthodontics. 1979;75:599-617. 8. Profitt WR. Contemporary orthodontics; St. Louis: CV Mosby; 1986. 9. SI Bhalajhi. Orthodontics: The Art and Science; 3rd (edn): Arya (Medi) publishing house; 2006. 10. Slice DE, Bookstein FL, Marcus LF, Rohlf FJ. A glossary for geometric morphometrics: Part 1. http://129.49.19.42/morph/glossary/ gloss1html 1998. 11. Stewart RE, Barber TK, Troutman KC. Wei SHY Pediatric Dentistry: scientific foundation and clinical practice. CV Mosby, St. Louis; 1982. 12. Straney DO. Median axis methods in morphometrics. In: Rohlf FJ, Bookstein FL (Ed.) Proceedings of the Michigan Morphometrics Workshop. University of Michigan Museum of Zoology, Ann Arbor. 1990.pp.180-200.

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32

Chapter

Preventive and Interceptive Orthodontics Mridula Trehan

Chapter outline •

Preventive Orthodontics

A number of procedures can be carried out by the orthodontist, so as to prevent or intercept a malocclusion that may develop or is developing. The terms preventive and interceptive orthodontics are sometimes used synonymously. Preventive orthodontic procedures are undertaken when the dentition and occlusion are perfectly normal, while interceptive procedures are carried out when the signs and symptoms of a malocclusion have appeared. Some of the procedures carried out in preventive orthodontics can also be carried out in interceptive orthodontics but the timings are different. For example, extraction of supernumerary teeth before they cause displacement of other teeth is a preventive procedure, while their extraction after the signs of malocclusion have appeared is an interceptive procedure. Preventive orthodontic procedures are aimed at elimination of factors that may lead to malocclusion, while interceptive orthodontics is undertaken at a time when the malocclusion has already developed or is developing.

Procedures undertaken in preventive orthodontics • • • • • • • • • • • •

Parent education Caries control Care of deciduous dentition Extraction of supernumerary teeth Occlusal equilibration Maintenance of quadrant wise tooth shedding time table Management of ankylosed tooth Management of abnormal frenal attachments Checkup for oral habits Prevention of damage to occlusion, e.g. Milwaukee braces Management of deeply locked first permanent molar Space maintenance

•

Interceptive Orthodontics

PREVENTIVE ORTHODONTICS Preventive orthodontics according to Graber (1966) can be defined as the action taken to preserve the integrity of what appears to be normal occlusion at a specific time. Proffit and Ackerman (1980) defined Preventive orthodontics as the prevention of potential interference with occlusal development.

Parent Education Knowledge of preventive dentistry for the parents especially mothers should ideally begin during the prenatal period as this is the time they are most encouraged about the wellbeing of the unborn child and should continue till at least 6 years of age after which the focus shifts on child dental education.

Prenatal Education • The expecting mother should be educated on matters such as nutrition to provide an ideal environment for the developing fetus. • The importance of oral hygiene maintenance (Fig. 32.1) by the mother is important as recent studies have indicated a possible co-relationship between the mothers’ poor oral hygiene and premature births. • The mother should be advised to have natural foods containing calcium and phosphorus, e.g. milk, milk pro­ ducts, egg, etc. especially during the third trimester as they would allow proper formation of deciduous teeth crowns.

Chapter 32  Preventive and Interceptive Orthodontics

Fig. 32.2: Physiologic nipple

Fig. 32.1: Relation of oral hygiene and pregnancy

Postnatal Education This is more age specific and can be divided into four types: Fig. 32.3: Finger brush

1. Birth to one year of age: • This is the most important period of counseling. • Stress on breastfeeding • Bottle feeding with high sugar exposures should be avoided. • In case the child is being bottle fed, the mother is advised on the use of physiologic nipple and not the conventional nipple. The physiologic nipple (Fig. 32.2) is designed to permit suckling of the milk which more or less resembles the normal functional activity as in breastfeeding. • Gum pads and newly erupted teeth should be cleaned with a clean, soft cotton cloth dipped in warm saline. • Gradual progression should be made from cloth cleaning to finger brush (Fig. 32.3) without the use of dentifrices. 2. One to three years of age: • Importance of weaning • Bottle-feeding should be withdrawn completely by 18 to 24 months of age • Brushing should be initiated twice in a day • Parents should be taught the correct method of brushing the teeth as at this age they have to brush their children’s teeth.

3. Three to six years of age: • The parents should be informed about the effects of oral habits on the development of occlusion (Fig. 32.4). • The parents should encourage the child to begin brushing on his own at least once a day. 4. Six years onwards of age: • The parents should be informed about the initiation of exfoliation of deciduous teeth and the eruptive pattern of permanent teeth (Fig. 32.5). • Parents should be educated about the need for constant review and recall on a regular basis. • In case of extraction of deciduous teeth due to decay, etc. the need, advantages and importance of space main­ tainers should be explained to the parents.

Caries Control • Caries involving the proximal surface of deciduous teeth if not restored at the earliest may lead to loss of arch length by movement of adjacent teeth into that space (Fig. 32.6).

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Pediatric Orthodontics • Caries initiation can also be prevented by diet counseling, topical fluoride application and pit and fissure sealants.

Care of Deciduous Teeth

Fig. 32.4: Developing open bite

• All efforts should be made to prevent early loss of deciduous dentition by way of prevention of caries and timely restoration of carious teeth. Simple preventive procedures such as proper and timely application of topical fluoride or pit and fissure sealant application help in preventing caries. • Deciduous teeth by themselves act as the best natural space maintainers, which not only maintain the space for their succeeding permanent teeth but also guide the latter teeth into their proper position in the dental arches.

Consequences of premature loss of deciduous teeth • • • • •

Migration of adjacent teeth into the space created Noneruption or altered path of eruption of succedaneous tooth Tongue thrusting may develop Hampered phonation in the case of anterior tooth loss Unesthetic appearance when there is an anterior tooth loss which leads to psychological effect on the child.

Extraction of Supernumerary Teeth

Fig. 32.5: Parents being informed about eruptive pattern

• Supernumerary teeth are an additional entity to the normal series and are seen in any region of the dental arch (Fig. 32.7). • Their reported prevalence ranges between 0.3 and 0.8 percent in the primary dentition and 0.1−3.8 percent in the permanent dentition with more predilections for males and the anterior region. • Some of the orthodontic complications caused by supernumerary teeth include delay of eruption, ectopic eruption, crowding, incomplete space closure during orthodontic treatment and root resorption of adjacent teeth.

Fig. 32.6: Mesiodistal caries leading to loss of arch dimension

• The most effective tool in detecting proximal caries is the Bitewing radiograph. • Once detected, the affected teeth should be restored immediately to their proper mesiodistal dimension so as to prevent loss of arch length.

Fig. 32.7: Supernumerary teeth

Chapter 32  Preventive and Interceptive Orthodontics • Thus supernumerary teeth should be identified and extracted before they cause any of these complications.

Occlusal Equilibration • Occlusal equilibration may be carried out not only in the preventive phase but also in the interceptive phase as well as during the corrective orthodontic treatment. • It is the systematic reshaping of the occlusal anatomy of teeth to minimize or eliminate the role of occlusal interferences in reflexly determined mandibular positions. • Occlusal equilibration is done more during active growth. Fig. 32.8: Ankylosed primary second molar preventing eruption of premolar

Management of Ankylosed Teeth • Ankylosis is a condition characterized by absence of the periodontal membrane in a small area or the whole of the root surface. • Ankylosed deciduous teeth do not get resorbed and therefore either prevent the permanent teeth from erupting or deflect them to erupt in abnormal locations. (Fig. 32.8). • These ankylosed teeth should be diagnosed and surgically removed at an appropriate time to permit the permanent teeth to erupt.

 aintenance of Quadrant Wise Tooth M Shedding Time Table • There should not be more than 3 months difference between the shedding of deciduous teeth and eruption of permanent teeth in one quadrant as compared to other quadrants. • Delay in eruption may be due to any one of the following reasons: – Presence of over retained deciduous teeth/roots – Presence of supernumerary tooth – Cysts and tumors of the jaw – Overhanging restoration in deciduous teeth – Fibrosis of gingiva – Ankylosis of deciduous teeth – Absence of permanent tooth bud. • As a rule of thumb, the shedding of the deciduous dentition should be kept on schedule by extracting the tooth or teeth on one side of the arch, when they have been lost through natural process on the other side. • Space maintainers should be given until the eruption of succedaneous teeth.

Management of Abnormal Frenal Attachment • The presence of a thick and fleshy maxillary labial frenum that is attached relatively low prevents the maxillary central incisors from approximating each other (Fig.  32.9). This causes the development of diastema or excess spacing between the teeth, which in turn may not allow the eruption of succedaneous teeth. • The procedure for frenectomy is usually done along with orthodontic treatment and not before it. The space should be closed at least partially, so that orthodontic movement to bring the teeth together should be resumed immediately after the frenectomy, so that the teeth are brought together quickly after the procedure. When this is done, healing occurs with the teeth together and the inevitable postsurgical scar tissue stabilizes the teeth instead of creating obstacles to final closure of the space.

Key to successful frenectomy The key to successful surgery is removal of the interdental fibrous tissue. It is unnecessary, and in fact undesirable, to excise a large portion of the frenum itself. Instead, the fibrous connection to the bone is removed, and the frenum is then sutured at a higher level.

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Fig. 32.9: Lased high frenal attachment

Fig. 32.10: Tongue tie

• Presence of ankyloglossia or tongue tie prevents normal functional development due to lowered position of tongue and abnormalities in speech and swallowing and hence should be surgically corrected (Fig. 32.10).

Oral Habits Check-up and Education Habits such as finger and thumb sucking, nail biting, tongue thrusting and lip biting should be identified and the patient/ parents should be educated on the ill effects of these habits and should be motivated to stop the habit (Fig. 32.11).

Preventing Milwaukee Brace Damage • Milwaukee brace is an orthopedic appliance used for the correction of scoliosis (Fig. 32.12). • This appliance exerts tremendous force on the mandible and the developing occlusion leading to retardation of mandibular growth and possible deformities. • Specially designed intraoral splints, activators, positio­ ners and dentofacial orthopedic appliances may prevent malocclusion, or at least reduce the deleterious effects.

Fig. 32.11: Identify the habits at an early age

Management of Deeply Locked Permanent First Molars • Occasionally, the first permanent molar may get deeply locked under the crest of contour of the distal surface of deciduous 2nd molar (Fig. 32.13). • Slicing the distal surface of the 2nd deciduous molars helps in guiding the eruption of first permanent molars. • Sometimes, locked permanent 1st molars may resorb the 2nd deciduous molar at the cervical part of the tooth. If root resorption is severe, deciduous 2nd molar has to be extracted and space maintained for the 2nd premolars. • Slightly locked permanent 1st molar usually erupts without treatment. Passing a ligature wire or separators interdentally frees the slight lock.

Fig. 32.12: Milwaukee brace

Chapter 32  Preventive and Interceptive Orthodontics Factors affecting planning for space maintenance • • • • • •

Time elapsed since tooth loss Dental age of the patient Thickness of bone covering the unerupted teeth Sequence of eruption of teeth Delayed eruption of permanent teeth Congenital absence of permanent tooth

INTERCEPTIVE ORTHODONTICS

Fig. 32.13: Locked first permanent molar

Space Maintainers (Detailed in Chapter 35) • Premature loss of deciduous teeth can cause drifting of the adjacent teeth into the space. It can result in abnormal axial inclination of teeth, spacing between teeth and shift in the dental midline. This prevents the normal eruption path of permanent teeth leading to malocclusion. • So corrective procedure may require some type of passive space maintainers, active tooth guidance or a combination of both, depending on the present problem. • Space maintainer is a device used to maintain the space created by the loss of a deciduous tooth (Figs 32.14A to J). • An important part of preventive orthodontics is the correct handling of spaces created by the untimely loss of deciduous teeth.

American Association of Orthodontists defined Interceptive orthodontics as “That phase of the science and art of orthodontics employed to recognize and eliminate potential irregularities and malpositions in the developing dentofacial complex”. According to Graber, Interceptive orthodontics refers to the “Measures undertaken to intercept a malocclusion that has already developed or is developing, and the goal is to restore a normal function”. According to Ackerman and Proffit (1980), Interceptive orthodontics can be defined as, “Elimination of existing inter­ ferences with the key factors involved in the development of the dentition”.

Procedures undertaken in interceptive orthodontics • • • • • • •

Pre-requisites for space maintainers • • • • • • • • • •

• •

They should maintain the mesiodistal dimension of the space created by the lost tooth. They should be functional, if possible, at least to the extent of preventing the over-eruption of the opposing tooth. They should be simple in construction. They should be strong enough to withstand occlusal forces. They must not endanger the remaining teeth by imposing excessive stresses on them. They should not interfere with normal vertical eruption of the adjacent teeth. They should be easily adjustable. Their construction should be such that they do not restrict normal growth and developmental processes. They should not interfere with functions such as mastication, speech or deglutition. They must be easily cleansable and not serve as traps for food debris, etc. which might enhance dental caries and soft tissue pathology. Durable and corrosion resistant Reasonable in cost

Serial extraction Correction of developing cross bite Control of abnormal habits Space regaining Muscle exercises Interception of skeletal malrelation Removal of soft tissue or bony barrier to enable eruption of teeth

Serial Extraction (Detailed in Chapter 36) • It is an interceptive orthodontic procedure usually initiated in the early mixed dentition. • Serial extraction is a process of extracting certain deciduous teeth and later specific permanent teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth into a more favorable position. • It is done in cases which show signs of persistent irregularities of teeth due to insufficient space in the arch to accommodate the present amount of tooth substance.

History • • •

Kjellgren (1929) Sweden—coined the term serial extraction Nance (1940)—termed serial extraction as “Planned progressive extraction” and has been called the “Father” of serial extraction Rudolf Hotz (1970) Switzerland—termed serial extraction as “Active supervision of teeth by extraction”.

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A

B

C

D

E

F

G

H

I

J

Figs 32.14A to J: Different types of space maintainers: (A) Removable non-functional; (B) Removable functional; (C) Band and loop; (D) Crown and loop; (E) Band and bar; (F) Crown and bar; (G) Lingual arch; (H) Nance palatal arch; (I) Transpalatal arch; (J) Distal shoe

Chapter 32  Preventive and Interceptive Orthodontics Indications • Class I malocclusion showing harmony between skeletal and muscular system. • Arch length deficiency as compared to the tooth material. • Where growth is not enough to overcome tooth material and arch length discrepancy. • Patients with straight profile and pleasing appearance.

Procedure The three most popular techniques are: 1. Dewel’s method:  (CD4) Removal of deciduous canine → Removal of deciduous 1st molars → Removal of erupting 1st premolars. 2. Tweed’s method:  (D4C) Removal of deciduous 1st molars → Removal of erupting 1st premolars → Removal of deciduous canine. 3. Nance method:  (D4C) Removal of deciduous 1st molars → Removal of erupting 1st premolars → Removal of deciduous canine.

Fig. 32.15: Dentoalveolar crossbite

Correction of Developing Anterior Crossbite • Anterior cross bite is a condition in which one or more maxillary anterior teeth are in lingual relation to the mandibular teeth. • Anterior cross bites should be intercepted and treated at an early stage because it is a self-perpetuating condition which if not treated early has the potential of growing into skeletal malocclusion and might at a later stage require major orthodontic treatment combined with surgical procedures. It is of three types viz: dentoalveolar, functional and skeletal anterior crossbite.

A

B Figs 32.16A and B: Tongue blade therapy

Dentoalveolar Anterior Crossbite • This type is often manifested as single tooth crossbite (Fig. 32.15) and usually occurs due to over retained deciduous teeth. • If there is adequate space for the tooth in crossbite to be moved into its correct position, the tooth can be guided with the help of the tongue blade (Figs 32.16A and B). The proper use of the tongue blade for an hour or two a day for 10 to 14 days is sufficient to deflect the lingually erupting tooth into a proper relationship. Tongue blade therapy The blade is placed in such a manner that it rests on the mandibular incisors opposing the tooth in cross-bite and the patient is asked to bite with a constant pressure on the tongue blade.

• It can also be intercepted by means of Catalan’s appliance (Fig. 32.17) and double cantilever springs with posterior

Fig. 32.17: Catalan’s appliance

bite plate for bite opening. A removable appliance of this type requires nearly fulltime wear to be effective and efficient.

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• It also is possible to tip the maxillary incisors forward with a 2 × 4 appliance (2 molar bands, 4 bonded incisor brackets) and fixed mechanotherapy (Figs 32.18A to C). This may be the best choice for a somewhat older mixed dentition patient with crowding, rotations, and more permanent teeth in crossbite.

Functional Anterior Crossbite • The presence of occlusal prematurities deflects the mandible into a more forward path of closure. So this type of crossbite results from the functional shift of the mandible. • These are commonly seen in pseudo Class III type of malocclusion and are treated by eliminating the occlusal prematurities.

Skeletal Anterior Crossbite

A

• This occurs due to skeletal discrepancies in growth of maxilla or mandible. • This type of crossbite usually involves the whole segment instead of one or two teeth (Fig. 32.19). • It can be because of maxillary retrognathism or mandi­ bular prognathism or both. • This type of crossbite is best intercepted by growth modification using myofunctional or orthopedic appli­ ances.

B

Fig. 32.19: Skeletal crossbite

 ontrol of Abnormal Habits C (Detailed in Chapter 30)

C Figs 32.18A to C: Crossbite correction using fixed mechanotherapy

• Habits are referred to certain actions involving the teeth and other oral or perioral structures which are repeated often enough to have a profound and deleterious effect on the dentofacial structures. These deleterious oral habits include thumb sucking, tongue thrusting and mouth breathing (Fig. 32.20).

Chapter 32  Preventive and Interceptive Orthodontics

Fig. 32.20: Common oral habits and where clinical feature with treatment

Space Regaining (Detailed in Chapter 35) • If a primary molar is lost early and space maintainers are not used, a reduction in arch length by mesial migration of the 1st molar is expected. In such cases the space lost by mesial movement of the 1st molar can be regained by distalizing it.

• The space regaining procedures are preferably undertaken at an early age prior to the eruption of 2nd molar. • Commonly used space regainers are shown in Figures 32.21 to 32.23.

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Fig. 32.21: Gerber space regainer

Fig. 32.22: Space regainers using jack screws

TABLE 32.1: Muscle exercises Exercise for the masseter muscle

Exercise for the lips (circum-oral muscles)

Patient is asked to clench the teeth while counting to ten. Now the patient is asked to relax for ten seconds and it has to be repeated over a period of time until the masseter muscle feels fatigued. •

If the upper lip is hypotonic and flaccid, the child is instructed to extend the upper lip as far as possible curving the vermilion border under and behind the maxillary incisors. This exercise should be done 15 to 20 minutes a day for a period of 4 to 5 months.

•

Stretching of the upper lip to maintain lip seal: The patient is asked to hold a thin piece of paper between the lips.

•

If the maxillary incisors are protruded, the lower lip can be used to augment the upper lip exercise. The upper lip is first extended under and behind the maxillary incisors. The vermilion border of the lower lip is then placed against the outside of the extended upper lip and pressed as hard as possible against the upper lip. This type of exercise exerts a strong retracting influence on the maxillary incisors while increasing the tonicity of both upper and lower lips. This exercise is particularly valuable for mouth breathers and should be done for at least thirty minutes a day.

•

Massaging of the lips

•

Button pull exercise: A button of 1 ½ inch diameter is taken and a thread is passed through the button holes. Then, the patient is asked to place the button behind the lips and pull the thread, while restricting it from being pulled out by lip pressure.

•

Tug of war exercise: This involves use of two buttons, with one placed behind the lips while the other button is held by another person to pull the thread.

•

Holding and pumping of water back and forth behind the lips: Patient is asked to hold and pump water back and forth behind the lips until they get tired.

•

For a developing class II div 1 malocclusion, the playing of a wind instrument may be an interceptive procedure.

•

One elastic swallow: This exercise is used for correction of improper positioning of the tongue. 5\16 inch intraoral elastic is positioned on the tip of the tongue and the patient is asked to raise the tongue and hold the elastic against rugae area and swallow.

•

Tongue hold exercise: 5\16 inch intraoral elastic is positioned in a designated spot of the tongue over a prescribed period of time with the lips closed. The patient is then asked to swallow with elastic in place and lips apart.

•

Two elastic swallow: Two 5\16 inch elastics are placed on the tongue, one in the midline and the other at the tip and the patient is asked to swallow with the elastics in position.

•

The hold pull exercise: The tip of the tongue and the mid point are made to contact the palate and the mandible is gradually opened. This helps in stretching the lingual frenum.

Exercises for the tongue

Chapter 32  Preventive and Interceptive Orthodontics that may occur. Class II and class III malocclusions are largely maxillo-mandibular basal mal-relationships. • Interception of class II malocclusion: This occurs as a result of either excessive maxillary growth, deficiency in mandibular growth or a combination of both. Maxillary growth can be restricted by use of face bow with head gear. Mandibular deficiency is usually treated by myofunctional appliances, e.g. FR-II. • Interception of class III malocclusions: This develops as a result of mandibular prognathism, maxillary retrognathism or combination of both. Chin cup with head gear are used to restrict mandibular growth and maxillary deficiency can be intercepted by orthopedic appliance, such as face mask or by means of myofunctional appliances like FR-III. Fig. 32.23 Space regaining using cantilever spring

Muscle Exercises (Table 32.1) Normal development of dental and skeletal tissues depends on the presence of normal oro-facial muscle function. Muscle exercises help in improving aberrant muscle activity.

Interception of Skeletal Mal-relations Skeletal malocclusion if diagnosed at an early age can be intercepted so as to reduce the severity of the malocclusion

Removal of Soft Tissue and Bony Barriers • Over retained primary teeth, fibrous or bony obstructions, ankylosed primary teeth and supernumerary teeth are causes of noneruption of succedaneous teeth. • If the permanent tooth fails to erupt because of fibrous or bony obstructions, its eruption may be stimulated by surgically exposing the crown. • The surgical procedure involves excision of the soft tissue and removal of any bone overlying the crown of the unerupted tooth. The extent of tissue removal should be such that the greatest diameter of the crown of the tooth is exposed.

POINTS TO REMEMBER • Preventive orthodontics can be defined as the action taken to preserve the integrity of what appears to be normal occlusion at a specific time. • Interceptive orthodontics is defined as “That phase of the science and art of orthodontics employed to recognize and eliminate potential irregularities and mal-positions in the developing dentofacial complex.” • Procedures undertaken in preventive orthodontics are Parent education, caries control, care of deciduous dentition, extraction of supernumerary teeth, occlusal equilibration., maintenance of quadrant wise tooth shedding time table, management of ankylosed tooth, management of abnormal frenal attachments, checkup for oral habits, prevention of damage to occlusion, management of deeply locked first permanent molar and space maintenance. • Procedures undertaken in interceptive orthodontics are serial extraction, correction of developing cross bite, control of abnormal habits, space regaining, muscle exercises, interception of skeletal malrelation and removal of soft tissue or bony barrier to enable eruption of teeth. • Space maintainer is a device used to maintain the space created by the loss of a deciduous tooth. • Factors affecting planning for space maintenance are time elapsed since tooth loss: dental age of the patient: thickness of bone covering the un-erupted teeth: sequence of eruption of teeth: Delayed eruption of permanent teeth: congenital absence of permanent tooth. • Kjellgren (1929) Sweden—coined the term serial extraction. • Nance (1940)—is called the “Father” of serial extraction. • Anterior crossbite is a condition in which one or more maxillary anterior teeth are in lingual relation to the mandibular teeth. It is of three types viz. Dentoalveolar, functional, skeletal anterior crossbite. • Commonly used space regainers are: Gerber space regainer, space regainers using jack screws, space regaining using cantilever spring.

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QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8. 9.

Define preventive orthodontics and enumerate the procedures involved. Define interceptive orthodontics and explain its components. Explain postnatal dental education for parents. Explain the consequences of premature loss of deciduous teeth. What are the treatment options for anterior tooth crossbite? Describe the procedure of frenectomy. Enumerate the factors affecting planning for space maintainers. Define serial extraction and its methods. Explain common exercises for orofacial musculature.

BIBLIOGRAPHY

1. Graber TM. Orthodontics: Principles and Practice, 3rd Edn. Philadelphia; 1972. 2. Kharbanda OP. Diagnosis and management of malocclusion, 2nd Edn, 2013. 3. Proffit WR. Contemporary orthodontics, 4th Edn, Elsevier publications. 4. S Gowri Shankar. Textbook of Orthodontics, 1st Edn, 2011. 5. Shobha Tondon. Textbook of Pedodontics, 2nd Edn. Paras Medical Publisher; 2009. 6. Soben Peter. Essentials of Preventive and Community Dentistry, 3rd Edn. 2006.

33

Chapter

Myofunctional Therapy Mridula Trehan, Nikhil Marwah

Chapter outline • • • • •

Classification of Myofunctional Appliances Advantages of Myofunctional Appliances Limitations of Myofunctional Appliances Vestibular Screen Activator

An early article in American orthodontic literature, “The three Ms’: Muscles, Malformation, and Malocclusion,” by Graber (1963) described the effects of function and malfunction. Functional appliances are considered to be primarily orthopedic tools to influence the facial skeleton of the growing child in the condylar and sutural areas. However, these appliances also exert orthodontic effects as the dentoalveloar area. The influences of natural forces and functional stimulation on form were first reported by Roux in 1883 as results of studies, he performed on tail fins of dolphins. Häupl (1938) saw the potential of the Roux’s hypothesis and applied his concepts to correction of jaw and dental arch deformities using functional stimuli. Häupl explained the way functional appliance worked through the activity of orofacial muscle; function is inherent in all cells, tissue and organs and influences these media as a functional stimulus. A myofunctional appliance is defined as an appliance that harnesses the natural forces of the orafacial musculature and transmits it to the teeth and alveolar bone in a predetermined direction.

CLASSIFICATION OF MYOFUNCTIONAL APPLIANCES • Tooth-borne passive appliances: They have no intrinsic force generating components such as springs or screws and depend on the soft tissue stretch and muscular activity to produce the derived treatment results, e.g. activator, bionator, Herbst appliance.

• • • • • •

Function Regulator Bionator Herbst Appliance Jasper Jumper Lip Bumper Twin Block Appliance

Action of myofunctional appliances Orthopedic changes • • • •

Accelerate the growth in the condylar region. Bring about remodeling of glenoid fossa. Designed to have restrictive influence on growth. Change the direction of growth of jaws.

Dentoalveolar changes •

Can bring about changes in sagittal, transverse and vertical directions.

Muscular changes •

Improve the tonicity of orofacial muscles.

Tooth-borne active appliances: These include modifica­ tions of activator and bionator that include springs and screws to provide force for transverse or anteroposterior changes. Tissue-borne appliances: These are mostly located in the vestibule and have little or no contact with the dentition, e.g. functional regulator of Frankel. • Mytonic appliances: They are functional appliances that depend on the muscle mass for their action. Myodynamic appliance: They are functional appliances that depend on the muscle activity for their function. • Removable functional appliances: These can be removed and inserted by the patient. Fixed functional appliances: These are fitted to the teeth by the operator and can not be removed by the patient at will.

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• Group I appliances: They transmit muscle forces directly to the teeth for the correction of malocclusion, e.g. oral screen, inclined planes. Group II appliances: These appliances reposition the mandible and the resultant force is transmitted to the teeth and other structures, e.g. activator, bionator. Group III appliances: These also reposition the mandible but their area of operation is the vestibule outside the dental arch, e.g. frankel appliance, vestibular screen.

ADVANTAGES OF MYOFUNCTIONAL APPLIANCES • Enables elimination of abnormal muscle function thereby aiding in normal development. • Treatment can be initiated at mixed dentition. • As it is started at an early age, psychological disturbances associated with malocclusion can be avoided. • Less chair side time as these appliances are mostly fabricated in laboratory. • Do not interfere with oral hygiene. • Frequency of patients visit to orthodontist is less.

LIMITATIONS OF MYOFUNCTIONAL APPLIANCES • They cannot be used in adult patients when growth has ceased. • They cannot be used to bring about individual tooth movement. • Most functional appliances are dependent on the patient for timely wear. Thus patient cooperation is essential for the success of the treatment. • They may require pre-functional tooth movement for correction of minor tooth irregularities that may interfere with functional therapy. • Fixed appliance therapy may be required at the termi­ nation of treatment for detailing of the occlusion.

VESTIBULAR SCREEN The basic appliance for screening therapy is the vestibular screen (Fig. 33.1). Common modifications include lower lip shield, tongue crib, combination vestibular screen and tongue crib and vestibular screen with breathing holes. The appliance is effective in eliminating abnormal sucking habits and lip dysfunction if it is properly made and worn. It helps establish a proper lipseal and indirectly influences the posture of tongue. The shield interrupts contact between the tip of the tongue and lower lip, a vestige of the infantile suckling pattern, leading to maintenance of deglutitional cycle and creates a somatic swallowing pattern.

Fig. 33.1:  Vestibular screen

Indications Deciduous Dentition • Screening appliances intercept and eliminate all abnormal perioral muscle function in acquired malocclusions resulting from abnormal habits. • It can also be used in the deciduous dentition as pretreatment devices, if an activator is going to be placed later, to help in reducing the severity of malocclusion. • For hyperkinetic children or those with potential behavior problems who exhibit persistent finger sucking and conco­ mitant tongue thrust, the use of vestibular shield first is more likely to be successful and produce less psychologic trauma. • It can be used in patients with nasorespiratory problems. The use of vestibular screen with breathing holes can help reestablish normal nasal breathing.

Mixed Dentition • It can be used with other appliances if correction cannot be achieved by screens alone • It is used in pretreatment to eliminate the influence of abnormal perioral muscles function. • Retention adjunct in dentofacial orthopedic therapy.

Fabrication See Flow chart 33.1.

ACTIVATOR • In 1880, Kinsley introduced the concept of “Jumping the bite” for patients with mandibular retrusion. He inserted

Chapter 33  Myofunctional Therapy Flow chart 33.1:  Fabrication of vestibular screen

Fig. 33.2:  Activator

• •

•

•

a vulcanite palatal plate consisting of an anterior incline that guided the mandible to a forward position when patient closed on it. This maneuver corrected the sagittal relationship without tipping the lower incisors forward. Hotz used the appliance in cases of deep bite retrognathism. Some years before Anderson started experimenting with his working retainer; Robin created an appliance quite similar in its objectives, called the monoblock appliance and positioned the mandible forward in patients with glossoptosis and severe mandible retrognathism. Activator was first used by Viggo Andresen (1908) with vertical extensions to contact contiguous lingual surfaces of the mandibular teeth. He used modified Kinsley plate as a retainer over summer vacation for his daughter after he removed fixed appliances to correct a disto-occlusion. Seeing the continued improvement with this retainer, he called it a biomechanical working retainer. When Andresen moved from Denmark to Norway, he became associated with Karl Häupl at University of Oslo. Andresen and Häupl teamed up to write about their appliance, they called it an activator, because of its ability to activate the muscle forces.

Mode of Action of Activator According to Anderson and Häupl, the activator (Fig. 33.2) induces musculoskeletal adaptation by introducing a new pattern of mandibular closure. The appliance loosely fits into

the mouth. The patient has to move the mandible forward to engage the appliance. This results in stretching of elevator muscles of mastication. This generates kinetic energy which causes: • Prevention of further forward growth of maxillary dento­ al­veolar process • Movement of maxillary dentoalveolar process distally • A reciprocal forward force on mandible • Condylar adaptation by backward and upward growth.

Construction Bite • The construction bite is an intermaxillary wax record used to relate the mandible to the maxilla in three dimensions of space. • The bite registration involves repositioning the mandible in a forward direction as well as opening the bite vertically. • In most cases, the mandible is advanced by 4 to 5 mm and the bite opened to the extent of 2 to 3 mm beyond the freeway space.

Parts of Activator • Wire elements: Upper labial bow (0.8-0.9 mm wire) • Acrylic portion: Maxillary part; mandibular part, interoc­ clusal part.

Management of Appliance • Patient should be sufficiently convinced about the benefits of the appliance. • Patient should be taught how to use, place and remove the appliance. • Patient should be asked to wear 2 to 3 hours during day time during first week. During 2nd week increase use up to 3 hours a day as well as while sleeping.

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Trimming • For vertical control: THis can be done to extrude or intrude the teeth. • For sagittal control: This can be done to protrude or retrude the anterior teeth. Teeth in buccal segment can be moved mesially and distally. • For transverse plane: THis is done by allowing the contact of acrylic on the lingual surfaces of the teeth to be moved transversely.

Indications • Class II div 1, Class II div 2, Class III • Class I open bite, deep bite • Preliminary treatment before fixed appliance therapy to improve skeletal jaw relationship • Post-treatment retention • Children with lack of vertical development.

Contraindications • The appliance is not used in correction of Class I problems with crowding • Excess lower facial height and extreme vertical mandi­bular growth • Severely proclined lower incisor • Children with nasal stenosis caused by structural problems • Limited application in non growing children.

Advantages • • • • •

Uses existing growth of jaws Minimal oral hygiene problems Interval between appointments is long Short appointment duration It is economical.

Disadvantages • Requires good patient cooperation • Cannot produce precise detailing and finishing • May produce moderate mandibular rotation.

Modifications of Activator • One bow activator of AM Schwarz: Maxillary and mandibular portions are connected together by an elastic bow, this allows stepwise sagittal advancement of the mandible by adjustment of the bow. • Wunderer’s modification: It is used in treatment of class III malocclusion. It is characterized by maxillary and mandibular portions connected by the anterior screw. By opening the screw the maxillary portion is moved anteriorly, with a reciprocal backward thrust in the mandibular portion.

• The reduced activator: This appliance resembles a bionator with acrylic portion of activator reduced from the maxillary anterior area leaving a small flange of acrylic on palatal slopes. The two halves may be connected by palatal wire. • Palate free activator: Palate is free of acrylic. • Karwetzky modification: Maxillary and mandibular plates are joined by a U-loop in region of first permanent molar. • Herreus modification: Over compensating the neutral position of mandible in construction wax bite by sealing the appliance firmly against the maxillary dental arch.

FUNCTION REGULATOR • Developed by Professor Rolf Frankel of Germany • It is also called Frankel appli­ance, vestibular appliance and oral gymnastic appliance (Figs 33.3A to C). • It has two main treatment effects: 1. Serves as a template against which the cranio­ facial muscles function. The frame­ work of appli­ance provides an artificial balancing of environment thereby promoting normal pattern of muscle activity. 2. It removes muscle forces in labial and buccal areas that restrict skeletal growth thereby providing an environment which enables skeletal growth.

Mode of Action of Frankel Appliance Increase in the transverse and sagittal intraoral space: The buccal shields and lip pads play an important role in eliminating the abnormal forces acting on the dentoalveolar structures from the perioral region and at the same time favor forces acting from within the oral cavity. In addition, the buccal shields and lip pads exert a constant outward pull in the connective tissue and muscles which is transmitted to the underlying bone by means of fibers inserted into the periosteum of the bone. This tissue pull on the periosteum causes bone formation and also aids in lateral movement of the dentoalveolar shell. Increase in vertical space: This is possible as the Frankel appliance is kept free from the posterior teeth. The posterior teeth are free to erupt. Mandibular protraction:  The lingual pad guides the mandible to a more mesial portion. Muscle function adaptation: The Frankel appliance helps in overcoming the abnormal perioral muscle activity and rehabilitates the muscles that are causing the problem. The

Chapter 33  Myofunctional Therapy

A

B

C Figs 33.3A to C:  Frankel Appliance

A

B Figs 33.4A and B:  Bionator

lip pads and shields massage the soft tissues and improve blood circulation. The shields loosen up the tight muscles and improve muscle tone. The lip pad prevents hyperactivity of the mentalis muscles, eliminates lip trap and help in establishing proper lip seal.

Types of Frankel appliance FR I : They are used for treatment of Class I and Class II div  1 malocclusion. FR Ia : Class I with minor crowding, deep bite FR Ib : Class II div 1 where overjet does not exceed 7 mm FR Ic : Class II div 1 in which overjet is more than 7 mm. FR II : Class II div FR III : Class III malocclusion FR IV : Open bite and bimaxillary protrusion FR V : Functional regulators that incorporate head gear.

Wear time • • •

First 2 weeks: 2-4 hours/day After 3 weeks: 4-6 hours/day After 8 weeks: Full time wear

BIONATOR • The bionator was developed by Batlers during the early 1950s (Figs 33.4A and B). • It had much in common with the activator. However, it differed from the conventional activator in that it was less bulky and more elastic.

Types of Bionator Standard Appliance • This is used for the treatment of Class II div 1 and class I malocclusions having narrow dental arches. • It consists of a slender acrylic body fitted to the lingual aspects of mandibular arch and a part of maxillary arch. The acrylic extends up to the distal of the first permanent molars. The maxillary plate covers only the molars and premolars with the anterior region remaining uncovered. The acrylic extends 2 mm below the gingival margin. The interocclusal space of some of the buccal teeth is filled with acrylic extending one half of the occlusal surface of the teeth to stabilize the appliance.

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• The wire components of the bionator are the palatal arch and the vestibular wire. The palatal arch is made of 1.2 mm diameter wire. It emerges opposite the middle of the 1st premolars and follows the contour of the palate forming a curve that reaches the distal surface of first permanent molars. The palatal arch is kept 1 mm away from mucosa. • The vestibular wire is made up of 0.9 mm stainless steel wire. It emerges from the acrylic below the contact point between the upper canines and premolars. It rises vertically and is bent at right angles to go distally along the middle of the upper premolar crowns. Mesial to the molar, a round bend is made so that the wire runs at the level of the lower papilla upto mandibular canine where it is bent to reach the upper canine. It forms a mirror image on the opposite side. The vestibular wire is kept away from the surface of incisors by the thickness of a sheet of paper. The lateral portions of the wire are sufficiently away from the teeth to allow expansion of the arch.

Class III Appliance • This is used in mandibular prognathism. • The acrylic parts are similar to the standard appliance. • The palatal arch is placed in the opposite direction so that the rounded arch is placed anteriorly. The vestibular wire runs in front of the lower incisors instead of terminating at the lower canines.

Open Bite Appliance • The maxillary acrylic portion is modified so that even the anterior area is covered. • Its purpose is to prevent the tongue from thrusting between the teeth as the tongue is responsible in most cases for the open bite.

Indications of bionator • • •

Class II, div 1 malocclusion having following features: – Well-aligned dental arches – Retruded mandible – Not very severe skeletal discrepancy – Labial tipping of upper incisors Class III malocclusion where reverse bionator can be used. Open bite cases.

HERBST APPLIANCE • It is a fixed functional appli­ ance that was developed by Emil Herbst in early 1900s. • Hans Pancherz again popu­ larized its use in 1979. • The appliance can be com­ pared to an artificial joint working between the maxilla and mandible, keep­ing man­ dible in anterior position. The

Fig. 33.5:  Herbst appliance

device consists of a tube into which the plunger fits. The tube is fixed to the distal end of the maxillary molars, while the rod is fixed to the lower first premolar (Fig. 33.5). • It can be either of bonded type or banded type.

Indications • Correction of skeletal Class II malocclusion due to retrograthic mandible • It can be used as anterior repositioning splints in patients having Temperomandibular joint (TMJ) disorders. • Postadolescent patients • Mouth breathing • Uncooperative patients.

Advantages • Fixed appliance cannot be removed by the patients, action it produces is continuous. • The treatment duration is short due to continuous nature of action. • Less patient cooperation is needed. • It can be used successfully in patients who are at the end of their growth. • It can be used in patients who have mouths breathing habit due to nasal airway obstruction.

Disadvantages • Initial discomfort is usually present. • It can cause minor functional disturbances in masticatory system which are temporary. • Repeated breakage and loosening of the appliance occurs. • Plaque accumulation and enamel decalcification. • Tendency for posterior open bite at the termination of therapy.

Chapter 33  Myofunctional Therapy JASPER JUMPER • It is a relatively new type of flexible, fixed, tooth borne functional appliance that was introduced by JJ Jasper in 1980. • Its actions are similar to Herbst appliance but it lacks rigidity. • It uses a modular system commonly known as Jasper jumper, which can be attached to fixed appliance that is placed on the upper and lower arches (Fig. 33.6). • It is analogous to the tube and the plunger of Herbst appliance but it is more flexible. It is made-up of a stainless steel coil that is attached at both the ends to stainless steel end caps. The module is given an opaque covering of polyurethane for hygiene and comfort. It is available in seven sizes ranging from 26 to 38 mm in length.

Indications Indicated in skeletal class II malocclusion with maxillary excess and mandibular deficiency.

Effects of Jasper Jumper • According to Rankin, Parker and Blockwood the Jasper Jumper brings about both skeletal and dentoalveolar changes in the ratio of 40:60. • Skeletal effects: – Holds and displaces the maxilla distally – A small shift of point A distally – Clockwise rotation of mandible – Condyle moves forward • Dental changes: – Posterior tipping and intrusion of upper molar. – Backward tipping of maxillary incisors. – Anterior translation and tipping of mandibular teeth – Intrusion of mandibular incisor.

Fig. 33.6:  Jasper Jumper appliance

Advantages • Continuous force • Increased patient compliance • Greater degree of freedom as compared to Herbst appliance. • Oral hygiene is easier to maintain.

LIP BUMPER • The lip bumper or lip plumber as, it is sometimes called is a combined removable fixed appliance. • The lip bumper can be called a modified vestibular screen that is used for muscular force application or for elimination. • The appliance can be used in both the maxilla and the mandible to shield the lips away from the teeth. • It is made up of thick stainless steel wire extending from one molar to the opposite molar. The wire is made to lie away from the anterior teeth. The lip bumper is inserted into round molar tubes of 0.93 mm diameter soldered to bands on 1st molars. The anterior portion of the wire from canine to canine can be reinforced with acrylic (Fig. 33.7). • Although lip bumpers are mostly used in the mandibular arches, they can also be used in the maxillary arch. Such an appliance is similar in design and is called Denholtz appliance.

Uses • They are used in patients exhibiting lower lip habits such as lip sucking. The lip bumper shields the lower lip away. • They are also used in patients exhibiting hyperactive mentalis activity that causes flattening or crowding of the lower anteriors. • Lip bumpers can be used to augment anchorage. • Distalization of first molar can be achieved by use of lip bumpers.

Fig. 33.7:  Lip bumper

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• These can be used as space regainers, if the lower molar has drifted mesially due to early loss of deciduous molars.

wear to take full advantage of all functional forces applied to the dentition, including the forces of mastication and patient can eat comfortably with appliance in place (Figs 33.8A to D).

TWIN BLOCK APPLIANCE • The twin block appliance was developed by William Clark in 1977 as a two piece appliance resembling a Schwartz double plate and a split activator. • These are simple bite blocks that effectively modify the occlusal inclined plane. These devices use upper and lower bite blocks that engage on occlusal inclined planes. • Twin blocks are designed for full times wear and they correct the maxillomandibular relationship through functional mandibular displacement. Achieve rapid functional correction of malocclusion by modifying occlusal inclined plane, guiding the mandible forward into correct occlusion. Upper and lower bite blocks interlock at a 70 degree angle, they are designed for full time

Features • Twin blocks are constructed in a protrusive bite that effectively modifies the occlusal inclined plane by means of acrylic inclined planes on occlusal bite blocks. • The unfavorable cuspal contacts of distal exclusion are replaced by favorable proprioceptive contacts of inclined planes of the twin blocks. • The bite blocks interlock at a 70 degree angle usually covering the upper and lower teeth in the buccal segment. • Muscle behavior is immediately influenced through the placement of inclined planes between the teeth. • Bony changes are gradual and take several months to become established. Favorably directed occlusal forces transmitted through the dentition provide constant proprioceptive stimuli to influence the growth rate and architecture of trabecular structure of supporting bone.

A

B

C

D Figs 33.8A to D:  Construction design of twin block

Chapter 33  Myofunctional Therapy

Indications • The primary indication for twin blocks in early mixed denti­ tion is in Class II div 1 in which prominent upper incisors rest outside the lower lip and is vulnerable to fracture. • Twin blocks can fulfill three objectives at this stage of development: 1. They can reduce overjet and correct distal occlusion. 2. They can control overbite if overbite is deep or anterior open bite is present. 3. They can improve arch form by transverse or sagittal development.

Stages of Treatment (Figs 33.9A to D) Stage 1: Active phase — twin blocks:  During the active phase of treatment, twin blocks are worn full time. The objective is to correct arch relationships in anteroposterior, vertical and transverse dimensions. Normally, overjet and overbite are corrected within 6 months, and the lower molars have erupted into occlusion within 9 months. The average wear time for twin blocks is 6 to 9 months.

• First visit: On fitting twin block appliances, the overjet is measured for future reference. The lingual flange must be relieved slightly lingual to the lower incisors to avoid gingival irritation as the appliance is driven in by the occlusion during the first few days. The clinician should check that the patient bites in a comfortable position in a protrusive bite. • Second visit: After 10 days, the patient should be wearing the appliances comfortably and eating with them in position after 10 days. In cases of deep overbite, the upper block should be slightly trimmed occlusodistally to leave the lower molars 1 mm clear of the occlusion to allow eruption and reduce the overbite by increasing lower facial height. • Third visit: After 4 weeks at each visit, progress is reviewed by measuring the overjet. At the same time, the occlusion is checked for the correction of the buccal segment relationship. Minor adjustment is necessary only to keep the labial bow out of contact with the upper incisor and ensure that the lower molars are not in contact with the upper block in cases of deep overbite. • Fourth visit: After 6 weeks, a similar pattern of adjustment and checking of occlusion and overjet should occur

A

B

C

D Figs 33.9A to D:  Stages of twin block appliance treatment therapy: (A) pre-treatment occlusion with appliance; (B) post-treatment occlusion; (C) pre-treatment profile; (D) post-treatment profile

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412 Section 7 

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after 6 weeks. The clinician should trim the blocks in the recommended sequence to reduce the deep overbite. • Progress: An overjet as large as 10 mm can be corrected without reactivating the bite block if the rate and direction of mandibular growth are favorable. Full correction of sagittal arch relationship can be achieved in as little as 2 to 6 months, thus producing a normal incisor relationship. At this stage, the overjet is fully corrected and the buccal segments are still out of occlusion because of presence of the bite block. Stage 2: Support phase — Anterior inclined plane:  The objec­ tive of the second stage of treatment is to retain the corrected incisor relationship until buccal segment occlusion is fully established.

• To achieve this objective an upper removable appliance is fitted with an anterior inclined plane to engage the lower incisors and canines. This appliance is worn full time initially to allow the buccal segment occlusion to settle; it is then used as a retainer. • The upper and lower buccal teeth are usually in occlusion within 4 to 6 months. Full time appliance wear is continued during the support phase for another 3 to 6 months to allow functional reorientation of trabecular system before any reduction of appliance wear occurs during the retention period. • Stability is excellent after twin block treatment; this can be attributed partly to the support phase, during which a functional retainer is used to stabilize the corrected incisor relationship while the buccal teeth settle fully into occlusion.

POINTS TO REMEMBER • Tooth borne passive myofunctional appliances have no intrinsic force generating components such as springs or screws and depend on the soft tissue stretch and muscular activity to produce the desired treatment results, e.g. activator, bionator, Herbst appliance. • Tissue borne passive myofunctional appliances are mostly located in the vestibule and have little or no contact with the dentition, e.g. functional regulator of Frankel. • Advantages of myofunctional appliances are that it enables elimination of abnormal muscle function thereby aiding is normal development, treatment can be initiated at mixed dentition, less chair side time as these appliances are mostly fabricated in laboratory and patient acceptance is good. • Limitations of myofunctional appliances are that they cannot be used in adult patients when growth has ceased, they cannot be used to bring abort individual tooth movement and these appliances are dependent on the patient for timely wear. • Andresen and Häupl developed activator which induces musculoskeletal adaptation by introducing a new pattern of mandibular closure. Indicated in Class II div 1, Class II div 2, Class III and Class I open bite and deep bite. • Frankel appliance was developed by Professor Rolf Frankel and it helps in overcoming the abnormal perioral muscle activity and rehabilitates the muscles that are causing the problem. • Bionator is used for the treatment of Class II div 1 and Class I malocclusions having narrow dental arches. • Herbst appliance is a fixed functional appliance that was developed by Emil Herbst and is indicated in corrections of Class  II malocclusion. • The lip bumper can be called a modified vestibular screen that is used for muscular force application or for elimination. The appliance can be used in both the maxilla and the mandible to shield the lips away from the teeth. • The twin block appliance was developed by Clark in 1977 as a two piece appliance resembling a Schwartz double plate and a split activator that has simple bite blocks that effectively modify the occlusal inclined plane. The primary indication for twin blocks in early mixed dentition is in Class II div 1 in which prominent upper incisors rest outside the lower lip.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8.

Define myofunctional appliance and give its classification. Write a note on vestibular screen. Discuss the indications, contraindications, mode of action and modifications of activator. Explain the Bionator. What is Frankel appliance and what are its various types? Write a note on Herbst appliance. What are the uses of lip bumper? Describe the features, construction and treatment with twin block appliance.

Chapter 33  Myofunctional Therapy

BIBLIOGRAPHY 1. Ackerman JL, Proffit WR. Preventive and interceptive orthodontics: a strong theory proves weak in practice. Angle Orthod. 1980;50: 75-87. 2. Blomgren GA, Moshiri F. Bionator treatment in Class II, Division 1. Angle Orthod. 1986;56:255-62. 3. Bogue EA. Orthodontia of the deciduous teeth. D Digest. 4. Chadwich SM, Banks P, Wright JL. Use of myofunctional appliances in the UK: A survey of British orthodontists. Dent Update. 1998;25(7):302-8. 5. Cheney EA. Aims and methods of treatment in the deciduous dentition, Am J Orthod. 1957;43:721-42. 6. Chen JY, Will LA, Niederman R. Analysis of efficacy of functional appliances on mandibular growth. Am J Orthod Dentofacial Orthop. 2002;122(5):470-6. 7. Frankel R. The role of Class II division 1 malocclusion with functional correctors. Am J Orthod. 1969;55:265-75. 8. Freeman JD. Preventive and interceptive orthodontics: a critical review and the results of a clinical study. J Prev Dent. 1977;4:7-23. 9. Harvold EP, Vargervik K. Morphogenetic response to activator treatment. Am J Orthod. 1971;60:478-90. 10. Hasler R, Ingervall B. The effect of a maxillary lip bumper on tooth positions. Eur J Orthod. 2000;22(1):25-32. 11. Houston WJB, Stephen CD, Tulley WJ. A Textbook of Orthodontics, 2nd edn, 1992.pp.1-12. 12. Kloehn SJ. Mixed dentition treatment. Angle Orthod. 1950;20: 75-96. 13. McNamara JA, Bookstein FL, Shaughnessy TG. Skeletal and dental changes following functional regulator therapy on Class II patients. Am J Orthod. 1985;88:91-110. 14. Moshe D, McInnis D, Lindauer J. The effects of lip bumper therapy in the mixed dentition. Am J Orthod Dentofac Orthop. 1997;111:52-8. 15. Moyers RE. Handbook of orthodontics for the student and general practitioner, 3rd edn. Chicago, Year Book Medical Publish; 1973. 16. Nance HN. The limitation of orthodontic treatment I. Mixed dentition diagnosis and treatment. Am J Orthod and Oral Surg. 1947;33:177233. 17. Popovich F, Thompson GW. Evaluation of preventive and interceptive orthodontic treatment between three and eighteen years of age. Tr Third Intern Orthod Congress. 1973.pp.260-81. 18. Proffit WR, Fields HW. Contemporary Orthodontics, 2nd edn. The development of orthodontic problems. 1993.pp.128-33. 19. Quadrelli C, Gheorgiu M, Margchetti C, Ghiglione V. Early myofunctional approach to skeletal Class II. Mondo Orthodontica 2/2002. pp.109-22. 20. West EE. Treatment objectives in the deciduous dentition. Am J Orthod. 1969;55:617-32. 21. Woodside DG, Metaxas A, Altuna G. The influence of functional appliance therapy on glenoid fossa remodeling. Am J Orthod. 1987;92: 181-98. 22. Woodside DG, Reed RT, Doucet JD, Thompson GW. Some effects of activator treatment on the growth rate of the mandible and position of the midface. Tr. Third Intern Orthod Congress. 1973.pp.459-80.

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34

Chapter

Model Analysis Nikhil Marwah

Chapter outline •

Permanent Dentition Model Analysis

•

Mixed Dentition Model Analysis

Model analysis is one of the most essential diagnostic aids to visualize the patient’s occlusion from all aspects and also helps in making necessary measurements of teeth, dental arches, basal bone to carry out space analysis. The main advantage of this over other aids is that model analysis offers a three-dimensional view of the same. Model analysis can be defined as the study of maxillary and mandibular arches in all the three planes of space (sagittal, vertical, transverse) and is a valuable tool in orthodontic diagnosis and treatment planning.

TYPES OF MODEL ANALYSIS Permanent dentition

Mixed dentition

•

Pont’s index

•

Huckaba’s analysis

•

Korkhaus analysis

•

Hixon and old father’s method

•

Linder Harth analysis

•

Moyers mixed dentition analysis

•

Arch perimeter analysis

•

Nance analysis

•

Carey’s analysis

•

Total space analysis

•

Bolton’s analysis

•

Tanaka-Johnston analysis

•

Ashley Howe’s analysis

•

Peck and Peck index

•

Sanin-Savara tooth size analysis

Pont’s Index Pont’s in 1909 presented a system whereby the measurement of the four maxillary incisors automatically established the width of the arch in the premolar and molar region (Fig. 34.1).

Fig. 34.1:  Pont’s index

Uses • Determining whether the dental arch is narrow or is normal. • Determining the need for lateral arch expansion. • Determining how much expansion is possible at the premolar and molar region.

Inference If the measured value is less than calculated value, it indicates the need for expansion. Thus, it is possible to know how much expansion is needed in the premolar and molar regions respectively.

Chapter 34  Model Analysis Procedure

Fig. 34.2:  Korkhaus analysis

Korkhaus Analysis

Drawback • This is based on the study of French population and hence its universal validity is questionable. • This analysis does not take into consideration the alignment of teeth. • This analysis does not consider malformation of the teeth like peg laterals.

Linder Harth Index This analysis is similar to Pont’s analysis except that a new formula was used to determine the calculated premolar and molar values. Premolar value was calculated by = SI × 100 85 SI × 100 Molar value was calculated by = 64

• This analysis is also similar to Pont’s analysis but he used Linder Harth’s formula to determine the ideal arch width in the premolar and molar region (Fig. 34.2). In addition he also uses the measurements made from the midpoint of the interpremolar line to a point between the two maxillary incisors. • According to Korkhaus, for a given width of upper incisors a specific value of the distance between the midpoint of interpremolar line to the point between the two central incisors should exist. • Korkhaus devised an instrument “The Orthometer” which helps to measure the ideal arch width in premolar and molar region and also to know the perpendicular distance from the interpremolar line to the patient in between the 2 incisors for a given sum of mesiodistal widths of the maxillary incisors.

Inference If there is an increase in the perpendicular measurement than ideal then the anterior are proclined and if it is less than they are retroclined.

Advantages This analysis not only tells about the ideal arch width but also about the ideal positioning of the anterior teeth.

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Arch Perimeter Analysis This is an upper arch analysis. This analysis helps us to find out the difference between the basal bone and the tooth material, i.e. it helps in determining the extent of discrepancy (Fig. 34.3).

Procedure

Fig. 34.3:  Arch perimeter analysis

Inference • By comparing the tooth material and arch length required we can obtain the extent of arch length discrepancy • If tooth material more than space available – crowding • If tooth material less than space available – spacing • If it is between 0 and 2.5 mm → non-extraction • If it is between 2.5 and 5 mm → 2nd premolars extraction • If it is more than 5 mm → 1st premolar extraction.

Carey’s Analysis This is same as arch perimeter analysis done for maxillary arch except that this is done on mandibular arch (Fig. 34.4). The same steps as in arch perimeter analysis must be followed to determine: • Tooth material (space required) • Arch perimeter (space available) • Arch length discrepancy.

Fig. 34.4:  Carey’s analysis

Treatment Plan • If the discrepancy is 0 to 2.5 mm, it indicates minimal tooth material excess where proximal stripping is carried out to reduce the tooth material. • If the discrepancy is between 2.5 and 5 mm, it indicates the need to extract the 2nd premolars. • A discrepancy of more than 5 mm indicates the need to extract the 1st premolars.

Chapter 34  Model Analysis

Bolton’s Analysis • Also called as Bolton’s tooth size ratio analysis. • According to Bolton, a ratio exists between the mesiodistal widths of maxillary and mandibular teeth. He studied the interarch effects of discrepancies in tooth size to devise a procedure for determining the ratio of total mandibular versus total maxillary tooth size versus maxillary anterior teeth size. • Average proportion between upper and lower teeth in overall and anterior region helps to create a normal over jet and overbite.

Procedure Fig. 34.5:  Ashley Howe’s analysis

• If the anterior ratio is less than 77.2 percent it indicates maxillary anterior excess which is determined by

Sum of mandibular 6 = Sum of mandibular 6 × 100 77.2

• If the anterior ratio is more than 77.2 percent it indicates mandibular anterior excess which is determined by

Sum of maxillary 6 =

Sum of maxillary 6 × 77.2 100

Ashley Howe’s Analysis • According to Ashley Howe crowding is not only due to tooth size but it can also result when there is inadequate apical base, i.e. crowding is due to deficiency in arch width rather than arch length (Fig. 34.5). • He found the relation between the total width of the 12 teeth anterior to the 2nd molars and the width of the dental arch in the 1st premolar region. For this he devised a formula to determine whether apical base of the patient could accom­modate the teeth. It is done in both upper and lower arches.

Inference • If over all ratio is less than 91.5 percent it indicates maxillary tooth material excess which can determined by:

Sum of mandibular 12 = Sum of mandibular 12 × 100 91.3

• If overall ratio is more than 91.3 percent it indicates maxillary tooth material lack which is determined by

Sum of maxillary 12 =

Sum of maxillary 12 × 91.3 100

Inference • If PMD > PMBAW, expansion is contraindicated • If PMBAW percent is: – Less than 37 percent → basal arch deficiency case which requires extraction of teeth to manage the case. – If it is 44 percent, → ideal case and extraction not required. – It is between 37 and 44 percent → borderline case, which may or may not require extraction.

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Procedure

Procedure

• Mean value for mandibular central incisor = 88 to 92 percent. • Mean value for mandibular lateral incisor = 90 to 95 percent.

Inference If the value for a given case is more than the mean value then mesiodistal width of the tooth is more than the labiolingual width and hence proximal stripping is indicated in such cases.

Hixon and Oldfather’s Method

Sanin-SavaraTooth Size Analysis • Devised by Sanin and Savara and colleagues (scholars of the University of Oregon). • This is a simple and ingenious procedure to identify individual and group tooth size disharmonies. • It makes use of precise mesiodistal measurements of crown size of each tooth, appropriate tables of tooth size distribution in the population and a chart for plotting the patients measurements. The teeth measured with Boley gauge and tabulated.

Peck and Peck Index • This done on the lower arch. • Persons with ideal incisal arrangement had smaller mesiodistal width and comparatively larger labiolingual width than in persons with incisal crowding.

Nance Carey’s Analysis

Chapter 34  Model Analysis

Huckaba’s Analysis • He used both study casts and radiographs for determining the width of unerupted tooth. • To compensate for enlargement of radiographic images measure an object that can be seen both in radiograph and on the cast such as primary molar tooth. Accuracy of this method of determining the width of the unerupted tooth is fair to good, depending upon the quality of the radiographs and their position in the arch. • This technique can be used both in maxillary and mandibular arches in all ethnic groups. • Then a simple proportional relationship can then be established as follows:



Actual width of primary molar (X1) Apparent width of primary molar (X2)

=

Actual width of unerupted premolar (Y1) Apparent width of unerupted premolar (Y2)



X1 × Y2 X2

Y1 =

Moyer’s Mixed Dentition Analysis

Fig. 34.6:  Moyer’s mixed dentition analysis

• • • •

It is not time consuming It requires no special equipment It can be done in the mouth as well on the cast It may be used on both the arches.

Inference

There is high co-relation between sizes of different teeth in same individual, thus making it possible to predict the size of unerupted tooth by looking at the teeth present in oral cavity (Fig. 34.6).

If the predicted value is greater than available arch length crowding of teeth can be expected.

Procedure (Table 34.1)

• This analysis was developed by Levenn Merrifield. • Here the lower arch is divided into three areas— anterior, middle and posterior to analyze the space required in the lower arch. • Measurements from the study models and cephalograms are used in this analysis. This discrepancy for each area has to be calculated and the resultant value is added together to yield the discrepancy of the arch.

Total Space Analysis

Anterior Area

Advantages • It has minimal error and the range of possible error is precisely known • It can be done with equal reliability either by a beginner or by an expert

Space required • Measure the width of the mandibular incisors on the cast and the width of the cuspids from the radiographs. • Cephalometric correction for the incisor positioning is calculated according to Tweed’s method, TMIA is taken into consideration instead of IMPA of Tweed. The incisors are repositioned and the difference in the actual and proposed TMIA is determined. The difference in angulation is multiplied by 0.8 to get the difference in mm. • Soft tissue modification: Upper lip thickness is measured from the vermilion border of the upper lip to the greatest curvature of the labial, surface of the central incisors. The total chin thickness is measured from the soft tissue chin to the NB line. If the lip thickness is greater than chin

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TABLE 34.1:  Probability tables for predicting the sizes of unerupted cuspids and biscuspids* A. mandibular bicuspids and cuspids 21/12 = % 95 85 75 65 50 35 25 15 5

Males 22.5

19.5

20.0

20.5

21.0

21.5

22.0

21.6 20.8 20.4 20.0 19.5 19.0 18.7 18.2 17.5

21.8 21.0 20.6 20.2 19.7 19.3 18.9 18.5 17.7

22.0 21.2 20.8 20.4 20.0 19.5 19.1 18.7 18.0

22.2 21.4 21.0 20.6 20.2 19.7 19.4 18.9 18.2

22.4 21.6 21.2 20.9 20.4 20.0 19.6 19.2 18.5

22.6 21.9 21.4 21.1 20.6 20.2 19.8 19.4 18.7

95 20.8 21.0 21.2 85 20.0 20.3 20.5 75 19.6 19.8 20.7 65 19.2 19.5 19.7 50 18.7 19.0 19.2 35 18.2 18.5 18.8 25 17.9 18.1 18.4 15 17.4 17.7 18.0 5 16.7 17.0 17.2 B. Maxillary bicuspids and cuspids

21.5 20.7 20.3 20.0 19.5 19.0 18.7 18.3 17.5

21.7 21.0 20.6 20.2 19.8 19.3 19.0 18.5 17.8

22.0 21.2 20.8 20.5 20.0 19.6 19.2 18.8 18.1

22.8 22.1 21.6 21.3 20.9 20.4 20.1 19.6 18.9 Females 22.2 21.5 21.1 20.7 20.3 19.8 19.5 19.1 18.3

21/12 = (%) 95 85 75 65 50 35 25 15 5

19.5

20.0

20.5

21.0

21. 5

22.0

Males 22.5

21.2 20.6 20.3 20.0 19.7 19.3 19.1 18.8 18.2

21.4 20.9 20.5 20.3 19.9 19.5 19.3 19.0 18.5

21.6 21.1 20.8 20.5 20.2 19.9 19.6 19.3 18.8

21.9 21.3 21.0 20.8 20.4 20.1 19.9 19.6 19.0

22.1 21.6 21.3 21.0 20.7 20.4 20.1 19.8 19.3

22.3 21.8 21.5 21.3 20.9 20.6 20.4 20.1 19.6

95 85 75 65 50 35 25 15 5

21.4 20.8 20.4 20.1 19.6 19.2 18.9 18.5 17.8

21.6 20.9 20.5 20.2 19.3 19.4 19.1 18.7 18.0

21.7 21.0 20.6 20.3 19.9 19.5 19.2 18.8 18.2

21.8 21.1 20.8 20.5 20.1 19.7 19.4 19.0 18.3

21.9 21.3 20.9 20.6 20.2 19.8 19.5 19.1 18.5

22.0 21.4 21.0 20.7 20.3 19.9 19.6 19.3 18.6

22.6 22.1 21.8 21.5 21.2 20.9 20.6 20.3 19.8 Females 22.2 21.5 21.2 20.9 20.5 20.1 19.8 19.4 18.8

23.0

23.5

24.0

24.5

25.0

25.5

23.0 22.3 21.9 21.5 21.1 20.67 20.3 19.9 19.2

23.2 22.5 22.1 21.8 21.3 20.9 20.5 20.1 19.4

23.5 22.7 22.3 22.0 21.5 21.1 20.7 20.3 19.6

23.7 23.0 22.5 22.2 21.7 21.3 21.0 20.5 19.8

23.9 23.2 22.8 22.4 22.0 21.5 21.2 20.7 20.0

24.2 23.4 23.0 22.7 22.2 21.7 21.4 20.9 20.2

22.5 21.8 21.3 21.0 20.5 20.1 19.7 19.3 18.6

22.7 22.0 21.6 21.3 20.8 20.3 20.0 19.6 18.9

23.0 22.3 2.9 21.5 21.1 20.6 20.3 19.8 19.1

23.3 22.6 22.1 21.8 21.3 20.9 20.5 20.1 19.3

23.6 22.8 22.4 22.1 21.6 21.1 20.8 20.3 19.6

23.9 23.1 22.7 22.3 21.8 21.4 21.0 20.6 19.8

23.0

23.5

24.0

24.5

25.0

25.5

22.8 22.3 22.0 21.8 21.5 21.1 20.9 20.6 20.1

23.1 22.6 22.3 22.0 21.7 21.4 21.1 20.8 20.3

23.4 22.8 22.5 22.3 22.0 21.6 21.4 21.1 20.6

23.6 23.1 22.8 22.5 22.2 21.9 21.6 21.3 20.8

23.9 23.3 23.0 22.8 22.5 22.1 21.9 21.6 21.0

24.1 23.6 23.3 23.0 22.7 22.4 22.1 21.8 21.3

22.3 21.7 21.3 21.0 20.6 20.2 19.9 19.6 18.9

22.5 21.8 21.5 21.2 20.8 20.4 20.1 19.7 19.1

22.6 22.0 21.6 21.3 20.9 20.5 20.2 19.8 19.2

22.8 22.1 21.8 21.4 21.0 20.6 20.3 20.0 19.3

22.9 22.3 21.9 21.6 21.2 20.8 20.5 20.1 19.4

23.1 22.4 22.1 21.7 21.3 20.9 20.6 20.2 19.5

* Measure and obtain the mesial-distal widths of the four permanent mandibular incisors and find that value in the horizontal row of the appropriate male or female table. Reading downward in the appropriate vertical column obtain the values for expected width of the cuspids and premolars corresponding to the level of probability you wish to choose. Ordinarily I use the 75% of probability rather than the mean of 50% since although the values distribute normally toward crowding and spacing, crowding is a much more serious clinical problem and the 75% predictive values thus protects the clinician on the safe side. Note: That the mandibular incisors are used for the prediction of both the mandibular and maxillary cuspid and bicuspid widths.

Chapter 34  Model Analysis • Curve of occlusion: A flat object is placed on the occlusal surface of mandibular teeth contacting the incisors and the first permanent molars. The deepest point between this flat surface and the occlusal surface of primary molars was measured on both the sides. This formula is applied to know the space required for leveling the curve of occlusion. =

Depth on right side + depth of left side + 0.5 mm 2

Space available:  It is measured using a brass wire from the mesiobuccal line angle of 1st primary molar to the distobuccal line angle of 1st permanent molar on either side.

Posterior Area

Fig. 34.7:  ‘Z’ angle of Merrifield

thickness, the difference is determined and multiplied by 2 and added to the space required. If it is less than or equal to chin thickness, no soft tissue modification is necessary. • Measure the ‘Z’ angle of Merrifield (Fig. 34.7) and add the cephalometric correction to it. If the correction ‘Z’ angle is greater than 80 degree the mandibular incisor angulation was modified as necessary (up to IMPA of approximate 92 degree). If the corrected angle is less than 75 degree additional uprighting of the mandibular incisor is necessary. Space available:  Measure the space available by using a brass wire from the mesiobuccal line angle of first primary molar of one side to the other.

Middle Area Space required • MD width of the 1st permanent molars on the cast and measure the width of the unerupted premolar from the radiographs.

Space required MD width of 2nd and 3rd molars is obtained from the radiographs as they might be unerupted. If these molars are not visible on the radiographs, Wheeler’s method is used for calculation, i.e. X = Y – X1 Y2 X – Estimated value of 3rd molar in the individual patient. Y – Actual size of permanent mandibular 1st molar. X1 – Wheeler’s value of 3rd molar. Y1 – Wheeler’s value of 1st molar. Space available: The amount of space available consisted of space presently available on the casts and the estimated increase.

Inference • Space presently available: This was obtained by measuring the distance on the occlusal plane tangent to distal surface of 1st permanent molars to the anterior border of ramus on a lateral cephalogram. • Estimated increase or prediction: The estimated increase is 3 mm per year, i.e. 1.5 mm on either side until 14 years of age in girls and 16 years of age in boys. The age of the patient is subtracted from 14 or 16 according to the sex of the patient and in multiplied by 3 to obtain the estimated increase. • Total space deficit/discrepancy: The total space deficit is arrived at by comparing the space required and space

421

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Pediatric Orthodontics

available in anterior, middle and posterior areas. Thus this analysis tells us precisely where the discrepancy is present, i.e. in the anterior, middle or the posterior areas.

Tanaka-Johnston Analysis (1974) Procedure

Available arch length = total arch length – sum of incisors + 2  predicted width + value : space surplus – value : space deficit Tanaka and Johnston prediction values One half of the mesio-distal width of four lower incisors + 10.5 mm = estimated width of mandibular canine and premolar in one quadrant. One half of the mesio-distal width of four lower incisors + 11.0 mm = estimated width of maxillary canine and premolar in one quadrant.

Inference • If the result is positive, there is more space available in the arch than is needed for the unerupted teeth. • If the result is negative, the unerupted teeth require more space than is available to erupt into ideal alignment.

Advantages • Improving on the Moyer’s analysis, it is relatively accurate for children of European ancestry. • The technique involves simple, easily repeated procedures and minimal material needs. • It does not use prediction charts.

Limitations There may be error in the predicted size of the unerupted teeth if patients are not of Northwestern European descent.

POINTS TO REMEMBER • Model analysis can be defined as the study of maxillary and mandibular arches in all the three planes of space (sagittal, vertical, transverse) and is a valuable tool in orthodontic diagnosis and treatment planning. • Permanent dentition analysis are Pont’s index, Korkhaus analysis, Linder Harth analysis, Arch perimeter analysis, Carey’s analysis, Bolton’s analysis, Ashley Howe’s analysis, Peck and Peck index, Sanin-Savara tooth size analysis. • Mixed Dentition analysis are Huckaba’s analysis, Hixon and Old father’s method, Moyers mixed dentition analysis, Nance analysis, Total space analysis. • Korkhaus analysis is used to measure arch width in premolar and molar region. • Carey’s analysis is most frequently used for assessment of minor space issues. • Bolton’s analysis is used for tooth size ratio analysis. • Huckaba’s analysis is used for determining the width of unerupted tooth. • Moyers analysis is the most reliable and comprehensive tool for space analysis.

Chapter 34  Model Analysis

QUESTIONNAIRE 1. 2. 3. 4. 5.

Define model analysis and enumerate the mixed dentition analysis. What is Carey’s analysis? Describe Huckaba model analysis. Write a note on Bolton’s analysis. Describe Moyer’s mixed dentition analysis.

BIBLIOGRAPHY

1. Bolton WA. Am J Orthod. 1962;48:504. 2. Bolton WA. Angle Orthod. 1958;28:115. 3. C Philip Adams. The design, construction and use of removable orthodontic appliances. 4. Graber TM. Orthodontics: Principles and Practice 3rd Edn. 5. Janaka MM, Johnston LE. J Am Dent Assoc. 1974;88:798. 6. Joondeph DR, Riedel RA, Moore AW. Angle Orthod. 1970;40:112. 7. Profitt WR. Contemporary Orthodontics 3rd Edn. 8. SI Bhalajhi. Art and Science of Orthodontics. 2nd Edn.

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35

CHAPTER

Pediatric Space Management Nikhil Marwah, Ravi GR, Sharath Asokan

Chapter outline • • • • • • • • •

Changes Seen after Premature Loss of Teeth Loss of Individual Teeth Indications of Space Maintainers Contraindications of Space Maintainers Determinants of Appliance Selection Factors Contributing for Space Closure Factors Affecting Planning for Space Maintainers General Guidelines for Management of Space Maintenance (AAPD-2012) General Guidelines for Management of Space Regainers (AAPD-2012)

Pediatric dentistry has increasingly shifted from a conservative restorative approach towards a concept of total pediatric patient care. Thus, all aspects of oral health care including diagnosis, prevention, oral medicine, restoration and correction of malocclusion have increasingly become the responsibility of the pediatric dentist. Guidance of the eruption and development of the primary and permanent dentitions is an integral part of pediatric dentistry and it should contribute to the development of a permanent dentition that is in harmonious, functional and esthetically acceptable occlusion. In the quest for providing optimal dental care the age old saying ‘prevention is better than cure’ holds true. In this endeavor, the pedodontist is most evenly poised to carry the mantle of providing the required services. For the preventive approach to be truly effective it needs to apply at its earliest, i.e. at the primary prevention level. This key difference between prevention and interception lies primarily in the matter of timing. Unlike preventive orthodontic procedures that are aimed at elimination of factors that may lead to

• • • • • • • • • • •

Fixed Space Maintainers Band and Loop Space Maintainer Lingual Arch Space Maintainer Nance Palatal Arch Space Maintainer Transpalatal Arch Distal Shoe Space Maintainer Functional Space Maintainer Anterior Esthetic Functional Space Maintainer Space Maintenance in Primary Anterior Region Removable Space Maintainers Space Regainers

malocclusion, interceptive orthodontics is undertaken at a time when malocclusion is developing. Thus interceptive orthodontics basically refers to measure undertaken to prevent a potential malocclusion from progressing into a more severe one.

DEFINITIONS

Preventive Orthodontics Graber (1966) has defined preventive orthodontics as the action taken to preserve the integrity of what appears to be normal occlusion at a specific time.

Interceptive Orthodontics American Association of Orthodontists (1969) defined it as that phase of science and art of orthodontics employed to recognize and eliminate the potential irregularities and malposition’s in the developing dentofacial complex.

Chapter 35 Pediatric Space Management

Space Maintenance This term was coined by JC Brauer in 1941. It is defined as the process of maintaining a space in a given arch previously occupied by a tooth or a group of teeth. •

Space Control Gainsforth in 1955 defined it as careful supervision of the developing dentition; it reflects an understanding of the dynamic nature of occlusal development.

Space Maintainer According to Boucher it is a fixed or removable appliance designed to preserve the space created by the premature loss of a primary tooth or a group of teeth.

ObjecƟves of space maintenance • • • •

PreservaƟon of primate space. PreservaƟon of the integrity of the dental arches. PreservaƟon of normal occlusal planes. In case of anterior space maintenance, it should aid in estheƟcs and phoneƟcs.

CHANGES SEEN AFTER PREMATURE LOSS OF TEETH

Anterior Segment •

The dentition is designed to function as a single unit, retained spatially by the sum of forces exerted upon each individual member. Three district forces, i.e. occlusal, muscular and eruptive forces contribute to space closure. The effort on each segment of the arch is different.

Buccal Segment •

First primary molar area: In the loss of first deciduous molar may be maxillary, mandibular or both; unilateral or bilateral space maintainers should always be placed. An abnormally high tongue position coupled with a strong mentalist and buccinators muscle may be damaging to the occlusion after the loss of a mandibular primary molar. A collapse of the lower dental arch and distal drifting of anterior segment will be the result. The potential for space loss is greater during eruption of 1st permanent molars since this is the time when the permanent molar exerts a strong eruptive force against the distal crown surface of second deciduous molar. A space maintainer should be in place at this time to prevent second primary molar from being displaced by 1st permanent molar. The maxillary 1st permanent molar usually erupts distally and begins a rotation to swing forward once the cusp tips appear through the tissue at the eruption site. The permanent

molar then contacts the second deciduous molar in a less direct eruptive force. However, at the time of contact, there should be a space maintainer in place to resist the potential for mesial displacement of second deciduous molar. Second primary molar area: The potential for space loss is even greater when second deciduous molars are lost because they normally serve as a buttress for permanent molar eruption. The earlier the tooth is lost, the greater is the space management problem because of the influence these deciduous molar have on 1st permanent molar eruption. Maxillary permanent molar erupts distally and then swings forward to contact the second deciduous molar. If the latter is missing and no space appliance is placed, it is common for the maxillary 1st permanent molar crown to continue to swing mesially, until it come in contact with 1st molar thus blocking out the second premolar. The mandibular 1st permanent molar strongly depends on the presence of second deciduous molar distal crown surface for eruptive guidance. Thus, if the deciduous tooth is lost during permanent molar eruption the latter will continue its mesial eruption pathway to produce a severe space loss and tipped position.

•

Primary canine area: Early loss of deciduous canines is more common due to erupting lateral incisors rather than caries. If the loss is unilateral there will be midline shift due to the migration of larger permanent incisor segment into the space during the process of adjustment. The midline will deviate to the side of space loss. Loss of primary cuspid could contribute to an additional decrease in circumference of arch by permitting lingual tipping of permanent incisors from the force of orbicularis oris and its associated muscles. When early loss of a primary cuspid has occurred as a result of insufficient length of the arch, it is best to remove the opposite primary cuspid to permit the permanent incisors to tip towards a symmetrical alignment and reinforce with a space maintainer. Primary incisor area: Deciduous incisors may be lost prematurely through early childhood caries or by traumatic injuries at any age. When loss of teeth occurs at ages close to normal exfoliation space maintenance is not needed. But if there is still time for the permanent incisors to erupt, a space maintainer must be given for speech development, esthetics and prevention of social trauma for child.

LOSS OF INDIVIDUAL TEETH No other factor plays a more significant role in preventive and interceptive orthodontics than the preservation of deciduous dentition till its normal time of exfoliation. The deciduous

425

426 Section 7

Pediatric Orthodontics

teeth provide a mould for the proper growth of the jaws, so that the permanent teeth may have an adequate space for aligning themselves. Premature loss of a deciduous tooth or a group of teeth will lead to a wide range of implications (Tables 35.1 to 35.3). Cavalcanti AL studied the prevalence of early loss of primary molars in schoolchildren in the city of Campina Grande, PB, Brazil. The results showed that 24.9 percent of the sample had loss of primary molars, but no differences were observed between genders (P>0.05). There was larger loss prevalence among the 9 year-olds (27.2%) and the most commonly missing teeth were the lower primary molars (74.3%).

INDICATIONS OF SPACE MAINTAINERS • • • • • •

If the space after premature loss of deciduous teeth shows signs of closing. If the use of space maintainer will aid in or make the future orthodontic treatment less complicated. If the need for treatment of malocclusion at a later date is not indicated. When the space for a permanent tooth should be maintained for two years or longer. To avoid supraeruption of a tooth from the opposing arch. To improve the physiology of a child’s masticatory system and restore dental health optimally.

TABLE 35.1: Loss of individual teeth Loss of maxillary • The deciduous cuspid shi s distally in the first year only, if at all deciduous 1st • The 1st permanent molar and second deciduous molar shi mesially, with the amount depending on the dura on of absence molar and age at loss • An erup ng first bicuspid is guided along the mesial surface of the mesially migra ng second deciduous molars, eventually lying close to the lateral incisor Loss of maxillary • If the maxillary second deciduous molar is lost early, the second bicuspid is generally impacted deciduous 2nd • The permanent molar shi s mesially molar • The cuspid and first deciduous molar shi distally • As the first bicuspid generally has an erup on ming advantage over the second bicuspid, will erupt earlier into the site, maintained by the first deciduous molar, o en with distal dri • The resultant lack of space between the permanent molar and first bicuspid causes impac on of the second bicuspid Loss of • The effect of mandibular extrac ons tends to be similar for all three situa ons, i.e. loss of primary 1st molar, 2nd molar or both mandibular • Timing differen als between the cuspid, first bicuspid and second bicuspid in the mandible appear to account most for the deciduous molar similarity among groups • In case of loss of first primary mandibular molar, the permanent molar and second primary molar both ps forward • In case of loss of second primary mandibular molar, the permanent molar ps forward • In case of loss of first and second primary mandibular molars, the permanent molar will p forward and primary canine will p distally leading to impac on of bicuspids and also causing midline shi TABLE 35.2: Space maintenance in the primary den Missing primary tooth Maxillary incisor

on

Suggested treatment No space maintenance required

Reason No consequence. Excep on: If incisor(s) is (are) lost prior to primary canine erup on, space closure may be observed

Maxillary canine

Band and loop space maintainer

Decrease possibility of midline shi

Maxillary 1st molar

Band/crown loop space maintainer

Prevents loss in arch dimension

Maxillary 2nd molar

Distal shoe space maintainer*

• Guides 1st permanent molar into proper posi on • Prevents loss in arch dimension

Mandibular incisor

No space maintenance required

No consequence. Excep ons: • If incisor(s) is (are) lost prior to primary canine erup on, space closure may be observed • Pre-exis ng incisor crowding (tendency of incisors to p linqually)

Mandibular canine

Band and loop space maintainer

Decreases possibility of midline shi

Mandibular 1st molar

Band/crown loop space maintainer

Prevents loss in arch dimension

Mandibular 2nd molar

Distal shoe space maintainer*

• Guides 1st permanent molar into proper posi on • Prevents loss in arch dimension

* If second primary molar extrac on site has healed, space maintenance may be deferred un l bony erup on of the 1st permanent molar. At that me, a reverse band and loop space maintainer or space-regaining procedure can be employed to guide or reposi on the 1st permanent molar into proper posi on.

Chapter 35 Pediatric Space Management TABLE 35.3: Space maintenance in the mixed den Missing primary tooth

on

Suggested treatment

Reason

Maxillary lateral incisor Maxillary canine

Extract an mere Prior to erup on of permanent lateral incisor (s): removable space maintainer A er erup on of permanent lateral incisor(s): extract an mere

Decrease possibility of midline shi • Guides permanent lateral incisor into proper posi on • Decreases possibility of midline shi

Maxillary 1st molar

Prior to erup on of permanent lateral incisor(s): Nance appliance

• Prevents loss in arch dimension • Does not interfere with erup on of permanent laterals

A er erup on of permanent lateral incisor(s): band/crown loop space maintainer

Prevents loss in arch dimension

Nance appliance Extract an mere Prior to erup on of permanent lateral incisor(s): removable space maintainer

Prevents loss in arch dimension Decreases possibility of midline shi • Requires only minor adjustment to afford normal posi oning of permanent incisors. • Decreases possibility of midline shi

A er erup on of permanent lateral incisor(s): stopped lingual arch space maintainer

• Decreases possibility of midline shi • Prevents lingual pping of permanent incisors

Prior to erup on of permanent lateral incisor(s): band/crown loop space maintainer

• Prevents loss in arch dimension • Does not interfere with erup on of permanent incisors

A er erup on of permanent lateral incisor(s): lingual arch space maintainer

• Prevents loss in arch dimension • Permits distolateral reposi oning of primary canine

Prior to erup on of permanent lateral incisor(s): band/crown loop space maintainer

• Prevents loss in arch dimension • Does not interfere with erup on of permanent incisors

A er erup on of permanent lateral incisor(s): lingual arch space maintainer

• Prevents mesial pping of 1st permanent molar • Prevents loss in arch dimension

Maxillary 2nd molar Mandibular lateral incisor Mandibular canine

Mandibular 1st molar

Mandibular 2nd molar

CONTRAINDICATIONS OF SPACE MAINTAINERS

DETERMINANTS OF APPLIANCE SELECTION

•

(According to DCNA 1978). There are some factors that govern the selection of space maintaining appliance: • Patient cooperation: Greater patient cooperation is needed for removable appliance. Unlike fixed appliance patients, removable appliance wearers should wear the appliance for a given time. • Integrity of the appliance: When considering long-term wear, the frequency with which the appliance breaks or is lost must be considered. • Maintenance: With normal usage, the clasps or the acrylic or removable appliances may require minor adjustments. The cement on the abutment areas of fixed appliances often disintegrates with time and loose bands will lead to decalcification of the underlying enamel due to food stagnation and acid production. Thus, periodic removal of appliance, checking for decalcification, polishing of tooth and cementation is necessary. • Modifiability: If a successor tooth erupts out of alignment the wire of a fixed appliance may be difficult to adjust. Anticipating future modifications owing to occlusal

• •

• •

If the radiograph of extraction region shows that the succedaneous tooth will erupt soon. If the radiograph of extraction region shows one third of the root of succedaneous tooth is already calcified. When the space left by prematurely lost primary tooth is greater than the space needed for the permanent successor as indicated radiographically. If the space shows no signs of closing. When succedaneous tooth is absent.

Requirements of space maintainers • • • • • • • •

It should maintain the enƟre space created by the lost tooth It must restore funcƟon Prevent supraerupƟon of opposing tooth It should be simple in construcƟon Should be strong enough to withstand occlusal forces Should permit maintenance of oral hygiene Must not restrict the growth of jaws It should not exert undue forces of it’s own.

427

428 Section 7

Pediatric Orthodontics ClassificaƟon of space maintainers

According to Hitchcock

According to Raymond C Thourow

According to Hinrichsen

• Removable or fixed or semi fixed

• Removable

• Fixed space maintainers

• With bands or without bands

• Complete arch — Lingual arch and Extraoral anchorage

(a) NonfuncƟonal types – Bar type, Loop type

• FuncƟonal or nonfuncƟonal

• Individual tooth

(b) FuncƟonal types – PonƟc type, Lingual arch type

Class I

Class II

• •

• AcƟve or passive

(a) CanƟlever type (Distal shoe, Band and loop)

• Certain combinaƟons of the above

• Removable space maintainers—Acrylic parƟal dentures

development can reduce the number of appliances required. Limitations: The clinician should project the number of appliances needs for the patient whenever possible. Time: Usually the time required to construct removable acrylic appliances is greater than for fixed appliance.

• •

Maxilla D

FACTORS CONTRIBUTING FOR SPACE CLOSURE •

• • • •

Inclination of long axis of permanent molars — tendency of molar to shift mesially because their long axis is mesially inclined. Premature loss of deciduous teeth Influence of buccal musculature — buccinators exerts forces that can derange occlusion. Path of least resistance — this is created following loss of support because of extraction or missing tooth. Effect of position of center of rotation of mandible: Smyd pointed out that more the axis of mandibular rotation is lowered in respect to occlusal plane less is the amount of horizontal thrust transmitted to teeth in occlusion.

•

•

• •

It was stated by Mc Donald and Avery that if space closure is going to occur, it will usually take place within six months after the loss of tooth. Therefore, the appliance must be placed as soon as possible, following the extraction of tooth.

Amount of Space Loss

•

Maxillary spaces close faster as compared to mandibular spaces. Pederson et al. 1978 documented a frequency of 50 percent population who underwent changes owing to premature extractions.

E

D

E

First year

1.3 mm

2.8 mm

1.8 mm

2.4 mm

Second year

1.8 mm

4.5 mm

2.7 mm

3.1 mm

Third year

3.2 mm

8.0 mm

3.3 mm

4.5 mm

According to Breakspear: – Space loss after loss of 1st maxillary molar is 0.8 mm – Space loss after loss of 1st mandibular molar is 0.9 mm – Space loss after loss of 2nd maxillary molar is 2.2 mm – Space loss after loss of 2nd mandibular molar is 1.7 mm According to Clinch and Healy: – Space loss before eruption of permanent molar is 6.1 mm – Space loss after eruption of permanent molar is 3.7 mm Younger the patient, more is the space loss Maximum space is lost during first 6 months of extraction and most immediate loss is within 76 hours.

Direction of Space Closure •

•

Mandible

Rate of Space Closure

FACTORS AFFECTING PLANNING FOR SPACE MAINTAINERS

Time Elapsed Since Tooth Loss

Olsen, 1959 stated that greater loss occurs in mandible owing to a mesial axial orientation of 1st molar. Cohen (1941), Seipel (1949), Richardson (1965) stated that loss of 2nd deciduous molar will cause greater space loss.

•

Stewart FS (1965) noted that, in maxilla all except one of 12 extraction spaces closed by mesial migration of teeth distal to the extraction space. In mandible all space losses greater than 2 mm were brought about mainly by a distal movement of the teeth mesial to the space. Rose JS (1966) states that, space closure can occur in two ways either through forward migration or rotation of teeth distal to the site of extraction.

Chapter 35 Pediatric Space Management

Eruption Status of the Adjacent Teeth It helps us ascertain mesial shift for molars and distal tipping for canines.

Amount of Bone Coverage Over the Tooth According to Mc Donald 1mm of bone resorbs in 4 to 5 months and so if the bone is present over the succedaneous tooth it is an indication for space maintainer.

Eruption Status of the Succedaneous Tooth It is estimated by the amount of root completion (Tooth erupts in oral cavity after 2/3rd root formation).

Dental Age of Patient It is the age calculated according to the last tooth erupted in oral cavity in normal eruption sequence. This involves recognizing the teeth clinically present in the oral cavity in comparison to dental eruption charts. It can also be calculated according to the methods of Gustafson and Koch or Gron and Moorees.

Sequence of Eruption Knowledge of usual eruption sequence is important. For example, if the mandibular primary 2nd molar is prematurely lost and mandibular 2nd permanent molar is erupting before the 2nd premolar, arch length loss secondary to mesial forces generated on 1st permanent molar as the 2nd permanent molar erupts can occur with subsequent space loss.

Arch Length Adequacy This will be estimated by position of incisors, Leeway space and Incisor liability.

Curve of Spee According to Andrews, ideal occlusion will have a near flat curve of Spee thus additional space can be gained (1 mm of space is gained per 1mm of depth of curve of Spee).

Abnormal Oral Habits They will exert abnormal pressure on dental arches and so may influence the type and planning of space maintainer.

Miscellaneous Factors These factors influence planning because they may be associated with either space gain or space loss. Some of these factors are growth of jaws, proximal caries, wear and attrition.

Research Padma Kumari B and Retnakumari N (2006) conducted a longitudinal study among forty children in the age group of 6 to 9 years to evaluate the space changes, dental arch width, arch length and arch perimeter, a er the unilateral extrac on of lower 1st primary molar in the mixed den on period., who reported for extrac on of lower Ist primary molar. Study models were made from alginate impression taken before extrac on and a er extrac on at the periodical intervals of two months, four months, six months and eight months. The results of the study showed sta s cally significant space loss in the extrac on side and no significant space loss in the control side. The rate of loss was greatest in the first four months.

Delayed Eruption of Permanent Teeth Over-retained or ankylosed primary teeth, or impacted permanent teeth, can result in a delay of the eruption process. With the removal of these types of primary teeth an appliance may be needed to hold the space until the permanent tooth erupts into a normal position.

Available Space An evaluation of the available space should be performed to determine whether the deficiency is developmental or a result of the pre-existing condition. A space analysis conducted in the mixed dentition, will aid the practitioner in a prediction of the amount of available space for the unerupted permanent teeth. A decision may be made at this point on the type of space maintenance that is appropriate.

GENERAL GUIDELINES FOR MANAGEMENT OF SPACE MAINTENANCE (AAPD-2012) The premature loss of primary teeth due to caries, trauma, ectopic eruption, or other causes may lead to undesirable tooth movements of primary and/or permanent teeth including loss of arch length. Arch length deficiency can produce or increase the severity of malocclusions with crowding, rotations, ectopic eruption, cross bite, excessive overjet, excessive overbite, and unfavorable molar relationships. The dental profession has recommended the use of space maintainers to reduce the prevalence and severity of malocclusion following premature loss of primary teeth. Space maintenance may be a consideration in the primary dentition after early loss of a maxillary incisor

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when the child has an active digit habit. An intense habit may reduce the space for the erupting permanent incisor. Adverse effects associated with space maintainers include: (1) dislodged, broken, and lost appliances; (2) plaque accumulation; (3) caries; (4) interference with successor eruption; (5) undesirable tooth movement; (6) inhibition of alveolar growth; (7) soft tissue impingement; and (8) pain. Premature loss of a primary tooth of any type has the potential to cause loss of space available for the succeeding permanent tooth, but there is a lack of consensus regarding the effectiveness of space maintainers in preventing or reducing the severity of malocclusion. Treatment considerations: It is prudent to consider space maintenance when primary teeth are lost prematurely. Factors to consider include: (1) specific tooth lost; (2) time elapsed since tooth loss; (3) pre-existing occlusion; (4) favorable space analysis; (5) presence and root development of permanent successor; (6) amount of alveolar bone covering permanent successor; (7) patient’s health status; (8) patient’s cooperative ability; (9) active oral habits; and (10) oral hygiene. If a space analysis is required prior to the placement of a space maintainer, appropriate radiographs and study models should be considered. The literature pertaining to the use of space maintainers specific to the loss of a particular primary tooth type include expert opinion, case reports, and details of appliance design. Treatment modalities may include, but are not limited to: • Fixed appliances (e.g. band and loop, crown and loop, passive lingual arch, distal shoe, Nance appliance, transpalatal arch); • Removable appliances (e.g. partial dentures, Hawley appliance). The placement and retention of space maintaining appliances requires ongoing compliant patient behavior. Follow-up of patients with space maintainers is necessary to assess integrity of cement and to evaluate and clean the abutment teeth. The appliance should function until the succedaneous teeth have erupted into the arch. Objectives: The goal of space maintenance is to prevent loss of arch length, width, and perimeter by maintaining the relative position of the existing dentition. The American Academy of Pediatric Dentistry (AAPD) supports controlled randomized clinical trials to determine efficacy of space maintainers as well as analysis of costs and side effects of treatment.

(4) ankylosis of a primary molar; (5) dental impaction; (6) transposition of teeth; (7) loss of primary molars without proper space management; (8) congenitally missing teeth; (9) abnormal resorption of primary molar roots; (10) premature and delayed eruption of permanent teeth; and (11) abnormal dental morphology. Loss of space in the dental arch that interferes with the desired eruption of the permanent teeth may require evaluation. Space loss may occur unilaterally or bilaterally and may result from teeth tipping, rotating, extruding, being ankylosed, or translating or from extrusion of teeth and the deepening of the curve of Spee. The degree to which space is affected varies according to the arch affected, site in the arch, and time elapsed since tooth loss. The quantity and incidence of space loss also are dependent upon which adjacent teeth are present in the dental arch and their status. The amount of crowding or spacing in the dental arch will determine the degree to which space loss has a significant consequence. Treatment considerations: Treatment modalities may include, but are not limited to, fixed appliances or removable appliances (e.g. Hawley appliance, lip bumper, headgear). Space loss and dentofacial skeletal development may dictate that space regaining not be indicated. This should be determined as the result of a comprehensive analysis. The timing of clinical intervention subsequent to premature loss of a primary molar is critical. Objectives: The goal of space regaining intervention is the recovery of lost arch width and perimeter and/or improved eruptive position of succedaneous teeth. Space regained should be maintained until adjacent permanent teeth have erupted completely and/or until a subsequent comprehensive orthodontic treatment plan is initiated.

FIXED SPACE MAINTAINERS Fixed space maintainers are the appliances, which are fixed onto the teeth and utilize bands or crowns for their construction.

Advantages of Fixed Space Maintainers • • • • •

GENERAL GUIDELINES FOR MANAGEMENT OF SPACE REGAINERS (AAPD-2012) Some of the more common causes of space loss within an arch are (1) primary teeth with interproximal caries; (2) ectopically erupting teeth; (3) alteration in the sequence of eruption;

Bands require no tooth preparation Do not interfere with eruption of abutment teeth Jaw growth is not hampered Succedaneous tooth is free to erupt Can be used in uncooperative patients.

Disadvantages of Fixed Space Maintainers • • •

Elaborate instrumentation and skills required Banded tooth is more prone to caries and decalcification Supraeruption of opposing tooth.

Chapter 35 Pediatric Space Management

Fabrication of Fixed Space Maintainers • • • • • •

Band construction Taking the impression and cast preparation Loop fabrication Soldering Polishing Cementation.

Armamentarium (Figs 35.1A and B) • •

• • • •

Stainless steel band material or preformed bands Pliers — contouring pliers, band forming pliers, band seater or pusher, band adapter, hoe pliers straight and curved, band cutting scissors, bird beak pliers, crimping pliers, three pronged pliers, universal pliers. Stainless steel wires (round) Spot welding unit, soldering unit, silver solder, flux Wire cutter Finishing burs, polishing stones.

Band Construction The making of a properly fitting, contoured, strong band is a very important undertaking for fixed appliances or space maintainers. The band forms can be classified as:

According to Fabrication Loop bands • Precious metal (first introduced by Johnson) • Chrome alloy bands. Tailored bands • Precious metal • Chrome alloy. Preformed seamless bands Chrome alloy or precious metal, which are adapted, festooned and stretched to fit. A range of preformed bands from 1 to 32 depending on the mesiodistal width of the tooth for the maxillary and mandibular arch are available commercially.

According to Band Material • • • •

Anterior teeth: 0.003 × 0.125 × 2 inches Bicuspids: 0.004 × 0.150 × 2 inches Primary molars: 0.005 × 0.180 × 2 inches Permanent molars: 0.006 × 0.180 × 2 inches.

Impression Taking and Cast Preparation An alginate impression of the banded tooth and appropriate abutment is made. Full arch impression is taken for lingual arch and Nance appliance whereas a sectioned impression can be taken when planning a band and loop space maintainer. After taking the impression band remover pliers is used to remove the band and place it into the impression in the same position that it occupied on the tooth. Stabilize and pour the cast.

Loop Fabrication (Figs 35.3A to G) This is formed using round stainless steel wire. The thickness and the design of loop is different for all space maintainers and is discussed individually. Fig. 35.1A: Band forming armamentarium

Soldering (Figs 35.4A to C) Quick set plaster is used to position the adapted wire on the working model. Reducing zone of the solder torch is used for soldering. A generous amount of flux should be applied above and below the point where wire contacts band. A piece of solder is transferred to solder joint with a pair of utility pliers. The flame is redirected toward the cast and the joint is heated till it is red hot and the solder flows evenly. Immediately dip this in water and remove appliance.

Finishing and Polishing (Fig. 35.5) Fig. 35.1B: Loop forming armamentarium

A finished solder joint should be smooth and free of porosity. A green stone is used to contour the soldered joint to a smooth

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Chapter 35 Pediatric Space Management

Fig. 35.2A: Ini al spot weld

Fig. 35.2B: Rounding off margins

Fig. 35.2C: Buccal grove adapta on

Fig. 35.2D: Pinching with hoe pliers

Fig. 35.2E: Festooning

Fig. 35.2F: Final pinching with peak pliers

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Fig. 35.2G: Spot welding aŌer final adapƟon

Fig. 35.2H: PresentaƟon of band

Fig. 35.2 I: SeaƟng of band

Fig. 35.2J: Infolding of seam

Fig. 35.2K: Final spot welding of band seam

Fig. 35.2L: Completely adapted band

Chapter 35 Pediatric Space Management

Fig. 35.3A: IniƟal loop fabricaƟon

Fig. 35.3B: Curve formaƟon with three prong plier

Fig. 35.3C: AdapƟon according to mucosa

Fig. 35.3D: Marginal adapƟon of loop

Fig. 35.3E: RetenƟve band of loop

Fig. 35.3F: Complete loop placement

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Fig. 35.3G: Final loop presentaƟon

Fig. 35.4A: StabilizaƟon

Fig. 35.4B: ApplicaƟon of flux

Fig. 35.4C: Soldering

transition with the band. Rubber wheels are relied upon to reduce surface roughness and gold rouge or rag wheel is used for final polishing.

BAND AND LOOP SPACE MAINTAINER It is a unilateral, nonfunctional, passive, fixed appliance indicated for space maintenance in the posterior segments when single tooth is lost (Fig. 35.6).

Indications • •

It is usually indicated for preserving the space created by the premature loss of single primary molar. Bilateral loss of single primary molar before eruption of permanent incisors. This is because the developing succedaneous tooth buds are placed lingually to permanent incisors so other space maintainers like lingual arch can lead to obstruction of these teeth.

Fig. 35.5: Finishing and polishing

•

It is also indicated when 2nd primary molar is lost after the eruption of 1st permanent molar.

Chapter 35 Pediatric Space Management

Disadvantages • • • • •

Cannot stabilize the arch Nonfunctional Slippage of loop by masticatory forces Cannot be used for multiple loss of teeth Most of the time primary 2nd molar (E) is lost before eruption of premolar.

Modifications •

•

Fig. 35.6: Band and loop space maintainer

•

Design of the Wire Loop (Figs 35.7A and B) •

• • •

•

The arms of the loop should be placed in the junction of middle and cervical third, at the same time not interfering with occlusion. The contour of the loop should be similar and as close as possible to the gingival contour. The final width of the loop should be wide enough to allow eruption of premolar inside the loop. The loop should be placed just above the contact area of the supporting tooth in a passive manner so as not to slip down.

Construction is easy and faster Few appointments by patient Many modifications are possible.

A

• • •

LINGUAL ARCH SPACE MAINTAINER (FIG. 35.12)

Advantages • • •

•

Robert Rapp and Isik Demiroz (1983): Stoppers can be used to prevent gingival as well as buccal movements of loop. Crown and loop (Figs 35.8A and B): Same as band and loop but a stainless steel crown is used on abutment tooth instead of a band. Crown-band and loop: Stainless steel crown is first placed on abutment tooth and then it is banded. Meyne’s space maintainer: Band and loop but the loop is halved. Reverse band and loop (Figs 35.9A and B): Given when there is premature loss of primary 2nd molar and the permanent molars have not erupted fully to support a band. In such cases primary 1st molar is banded and a loop is made that touches just below the marginal ridge of permanent molars. Band and bar: Prevents eruption of premolar (Fig. 35.10) Bonded band and loop Long band and loop (Fig. 35.11).

It is a bilateral, nonfunctional, passive/active, mandibular fixed appliance. It is the most effective appliance of space maintenance and minor tooth movement in lower arch.

B Figs 35.7A and B: Design of the wire loop

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A

B Figs 35.8A and B: Crown and loop

A

B Figs 35.9A and B: Reverse band and loop

Fig. 35.10: Band and bar

Fig. 35.11: Long band and loop

Chapter 35 Pediatric Space Management

Indication •

• • •

The appliance is usually indicated to preserve the space created by multiple loss of primary molars when there is no loss of space in the arch. The use of the lingual arch is a good preventive measure, since it helps in maintaining the arch perimeter by preventing both mesial drifting and lingual movement of the molar teeth and also lingual collapse of the anterior teeth. Bilateral loss of primary molars after eruption of lower lateral incisors. Unilateral loss of primary molars after eruption of lower lateral incisors. Minor space regaining.

Design of the Wire Loop (Figs 35.13A to D) Arch design should be directed towards minimizing the maintenance problems. The arch wire should contact the erupted permanent incisors at the cingulum. Arch wire should be located 2 mm below the gingival margin or edentulous ridge in the posterior regions to prevent distortion under process of mastication and should be located 1 to 2 mm lingual to the posterior teeth to permit satisfactory eruption of the bicuspids in a buccolingual plane. The arch wire should meet the band at the mesiobuccal cusp and at the same time place the soldered joint in the middle third of the band to avoid occlusal interference.

Fig. 35.12: Lingual arch

anterior palate via an acrylic button that contacts the palatal tissue, which provides resistance to the anterior movement of posterior teeth in a horizontal direction.

Indications Nance palatal arch may be used in maintaining the maxillary 1st permanent molar positioning when there is bilateral premature loss of primary teeth with no loss of space in arch and a favorable mixed dentition analysis.

Advantages • • •

Many modifications are possible Can also be used to regain space Arch holding space maintainer.

Disadvantages • • •

Construction is difficult More chances of distortion of appliance by tongue pressure May cause unwanted movements.

Design of the Wire Loop The arch wire extends anteriorly without touching against the surface of the primary molars; as the successor bicuspids usually are broader buccolingually, and the wire could deflect them from their natural position. At the rugae area, a small U-shaped bend should be incorporated in the wire, which is approximately 1 to 2 mm away from the soft tissue. The bend will enhance the retention of acrylic to the wire. The acrylic button, 0.5 inch in diameter is placed usually on the descending portion of the palatal vault 1 to 2 mm below the incisive papilla.

Modifications • • •

Hotz lingual arch — with U-loop used for space regaining Removable lingual arch Omega bends — in canine region to prevent interference.

NANCE PALATAL ARCH SPACE MAINTAINER (FIGS 35.14 A TO C) Bilateral, nonfunctional, passive, maxillary fixed appliance that does not contact the anterior teeth, but approximates the

Advantages Arch stabilizing.

Disadvantages • • • •

May cause tissue hyperplasia Irritation to palatal tissues Pressure effects Cannot be used in patients allergic to acrylic.

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A

B

C

D Figs 35.13A to D: Design of the wire loop

A

B

C Figs 35.14A to C: Nance palatal arch space maintainer

Chapter 35 Pediatric Space Management

A

B Figs 35.15A and B: Transpalatal arch

Disadvantages

Modifications Modified Nance appliance for unilateral molar distalization.

TRANSPALATAL ARCH Unilateral, nonfunctional, passive, maxillary fixed appliance that has been recommended for stabilizing the maxillary 1st permanent molars when primary molars require extraction (Figs 35.15A and B).

Indications •

• • •

The best indication for transpalatal arch is when one side of arch is intact and several primary teeth on the other side are missing. It is also indicated when primary molars are lost bilaterally. The appliance is designed to prevent the molars from rotation. In arch expansion.

• •

Rotation of molars Both molars may tip together.

DISTAL SHOE SPACE MAINTAINER (FIG. 35.16) Distal shoe appliance is otherwise known as the intraalveolar appliance. One of the early designs of distal shoe space maintainers was Willet’s distal shoe. This appliance is rarely used these days because of the increased cost of the materials, difficulties in tooth preparation, and more complicated fabrication procedure. The appliance, which is in practice, is Roche’s distal shoe or modifications of it

Design of the Wire Loop The transpalatal arch runs directly across the palatal vault avoiding contact with the soft tissues. U-shaped bend must be given to the wire in middle of palate if any manipulation is required. As it approaches the mesial part of the palatal surface of the band, the wire should be bent to the distal part of the band to assure a better joint.

Advantages • •

Used in multiple unilateral loss Can be used for expansion.

Fig. 35.16: Distal shoe space maintainer

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using crown and band appliances with a distal intra gingival extension. Roche’s appliance offers a V-shaped end, which offers a broader surface and helps prevent rotations. The broader surface also holds a greater chance of success if the unerupted tooth is positioned buccally or lingually in the dental arch. Distal surface of the 2nd primary molar provides a guide for unerupted 1st permanent molar. When the 2nd primary molar is removed prior to the eruption of 1st permanent molar, the intra-alveolar appliance provides greater control of the path of eruption of the unerupted tooth and prevents undesirable mesial migration.

Indications When the second primary molar is extracted or lost before the eruption of 1st permanent molar.

Fig. 35.17A: PreoperaƟve presentaƟon

Contraindications • • • •

•

Inadequate abutments due to multiple losses of teeth. Poor oral hygiene Lack of parent and patient cooperation. Medically compromized patients like patients with congenital heart disease, kidney problems, juvenile diabetes, history of rheumatic fever, generalized debilitation and hemophiliacs. Congenitally missing 1st permanent molar.

Design of the Wire Loop (Figs 35.17A to C) Using 1st primary molar as abutment the stainless steel band is adapted. If the morphology of tooth does not permit easy placement and adaptation of band then the tooth is prepared for stainless steel crown and on that band is fitted. An alginate impression is made, the band is removed and placed in the impression and a stone model is prepared. The tissue bearing loop is then contoured with a 0.0040” wire extending distally into the prepared opening on the model and the free ends of the loop are soldered to the band. The primary function of the distal shoe appliance is to provide a guide plane for the eruption path of the 1st permanent molar. To fulfil this purpose successfully we should have an understanding of the normal paths of eruption of maxillary and mandibular 1st permanent molar. Because of this the distal extension of the appliance will differ for upper and lower arches. In the lower arch, the contact area of distal extension of the appliance should have a slight lingual position over the crest of the alveolar ridge in order to engage the mesial contact area of the 1st permanent molar as it begins its mesial and lingual movements. By contrast the contact area of distal extension of the maxillary appliance should be slightly facial to the crest of the alveolar ridge. These considerations are important in preventing the

Fig. 35.17B: Distal shoe post inserƟon aŌer extracƟon

Fig. 35.17C: Radiographic presentaƟon

Chapter 35 Pediatric Space Management erupting permanent molar from slipping contact with the appliance. The width should closely approximate the normal contact area of the distal surface of the 2nd primary molar being replaced. Length of the distal extension (horizontal bar) is another decision confronting in determining of the appliance. Problem is simplified somewhat when the 2nd primary molar is still present to serve as a guide on the working model. In this case the 2nd primary molar should be maintained if possible until the appliance is ready to be sealed. If the 2nd primary molar is already missing, it is recommended the distal surface of the 1st primary molar and mesial surface of the unerupted 1st permanent molar be used as guide. Depth of the gingival extension (vertical bar) is also an important factor. If the extension is left too long, possible harm to the developing 2nd molar may result. If the extension is too short, the 1st permanent molar could erupt underneath the appliance. A good preoperative radiograph that is slightly under exposed to show the thickness of overlying soft tissue. This will aid in determining the depth of the groove to be cut in working model for constructing the gingival extension. Gingival extension should extend about 1 mm below the mesial marginal of the 1st permanent molar or just sufficient to capture its mesial surface. Before final placement of the space maintainer in the mouth, a radiograph is taken to determine whether the tissue extension of the appliance is in proper relationship with the unerupted 1st permanent molar. Final adjustments in length and contour of the distal shoe can be made at this time. It is best to cement this appliance immediately after the extraction.

Advantages

the appliance or procedure second it is felt that the normal eruption of the lower 1st permanent molar rarely contacts the root surface of second deciduous molar and does not use the root for eruption guidance at all. Instead, the lower 1st permanent molar erupts occlusally to contact first, the distal crown surface of a deciduous molar and uses it as buttress for up righting and establishing a mesial position. In that case it is felt that an appliance is necessary only to replace and to stimulate, the distal crown surface of the lost deciduous molar and hence, it is not necessary to consider an appliance that inserts into the tissue.

Modifications •

•

•

Only space maintainer, which can be used if there is premature loss of primary 2nd molar before eruption of permanent molars. •

Disadvantages • • • • • • •

Can cause deviation of permanent tooth bud May permit tipping if not placed properly Interfere with epithelialization of socket Can cause infection Can only be used in specific patients Retention is not good Construction is difficult.

Controversy The appliance has been controversial and has fallen into disfavor in recent years. First there have been reports of trauma and damage to the unerupted permanent tooth by

A combination of lingual arch and distal shoe appliance was suggested for use in patients in whom both primary molars are lost and the patient’s strong gag reflex prevented the use of a removable appliance. A combination appliance was designed to maintain in position the remaining primary 2nd molar and provide guidance for unerupted permanent molar on the opposite side. The right primary 2nd molar was fitted with an orthodontic band and left primary canine was prepared for stainless steel crown. An orthodontic wire was placed and extended from the soldered lingual connection on the band to the canine in a fashion typical of a passive lingual arch wire. It was then extended back to the unerupted molar on both buccal and lingual sides of the edentulous alveolar ridge. The extension was soldered to the canine crown a double bar was constructed to provide extra support for the long ended extension. Placing loops in the horizontal arm of the space maintainer. These loops will permit the precise adjustments needed for accurate placement of molar. Space maintainer is placed after signs of eruption of 1st molar are seen. Vertical extension is short and is not placed intra-alveolarly; it just touches the mesial surface of erupting permanent molar. Gingival saddle appliance (Fig. 35.18).

FUNCTIONAL SPACE MAINTAINER Loss of arch-length has been related mainly with tooth migration, following premature loss of primary teeth. This condition has been observed since the 18th century, when Fauchard reported it. When a primary tooth is prematurely lost especially a molar, a careful clinical and radiographic examination should be done, in order to determine the correct treatment to maintain the arch-length. When the space for a permanent tooth should be maintained for two years or longer, a unilateral fixed space maintainer should always be placed after the premature loss of the second primary molar. There are two methods for constructing a fixed functional space maintainer:

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Fig. 35.18: Gingival saddle appliance

Chapter 35 Pediatric Space Management

Indirect Technique

A

D

B

E

C

F

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446 Section 7

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Direct Technique: Double Abotment

A

E B

F C

G D

Chapter 35 Pediatric Space Management

Direct Technique: Cantilever

A

C

B

D

ANTERIOR ESTHETIC FUNCTIONAL SPACE MAINTAINER (FIGS 35.19A TO D) Premature loss of primary tooth is one of the most common etiologies for malocclusion. When a primary tooth is lost prematurely the teeth, present both mesial and distal to the created space tend to drift in to the space. In the situation where an anterior primary tooth is lost before the schedule, the drifting of adjacent teeth in to the space created rarely occurs but these results into an unesthetic smile and difficulty in biting, i.e. loss of function thus making the situation which cannot be left unattended. A esthetic functional space maintainer is thus fabricated to take care of the esthetics and maintain function as well. An alginate impression was made for both maxillary and mandibular arch and was poured in

gypsum stone. The shade of the natural teeth was recorded using a proper shade guide. The distance from the distal surface of the maxillary right primary lateral incisor to the distal surface of the maxillary left primary central incisor was measured on the cast and a strip of fiber reinforced composite (FRC) resin was cut of the same length. The FRC strip was adapted over the palatal surface extending from the distal surface of the maxillary right primary left incisor through the distal surface of the maxillary left primary central incisor. Now an acrylic tooth (maxillary right central incisor) of the appropriate shade was selected and was trimmed properly to replace the missing tooth in an esthetic manner. Grooves were made on the palatal surface of the acrylic tooth so as to enhance bonding between the acrylic resin and the composite resin. Now flowable composite was applied

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A

B

C

D Figs 35.19A to D: Anterior estheƟc funcƟonal space maintainer

throughout the length of the FRC and over the palatal surface of the acrylic tooth. The FRC strip and the acrylic tooth were placed in position over the cast. Care was taken to establish a good contact between the FRC and the acrylic tooth. The FRC and the flowable composite were light cured together from the palatal aspect of the cast. The occlusion was checked over the cast to remove any premature contacts. The appliance was removed from the cast and selective grinding was done wherever necessary. On the next appointment the appliance was tried in the oral cavity and occlusion was checked for any premature contact. Now the appliance was removed and the palatal surfaces of the tooth on either side of the edentulous space were acid etched. Bonding agent was applied and was cured as per manufacturer’s instructions. A thin layer of flowable composite was also applied over the etched surfaces of the abutment teeth. The appliance was placed in position and then the flowable composite was cured using a light curing unit.

SPACE MAINTENANCE IN PRIMARY ANTERIOR REGION The space maintainer consists of artificial teeth (polycarbonate or acrylic) processed onto a lingual arch which in turn is attached to bands for the molars. Stainless steel bands or crowns are fitted to the deciduous 2nd molars. An arch is constructed and fitted to rest at the base of the cingulum. An attachment post is prepared form 0.028” wire and soldered to the lingual arch in the site of the missing tooth. The post wire should be placed so that it will lie in the middle of the replacement tooth when the replacement tooth is set in the arch on the model. The postwire should be looped around the lingual arch tightened and held in place, while it is being soldered. Adjoining teeth should be covered with clay and double thickness of aluminum foil to prevent damage during soldering. After soldering the post is bent incisally to conform to the curvature of the arch. The appliance is removed from

Chapter 35 Pediatric Space Management model, polished and the tooth is contoured to the gingival contour and positioned in the arch. Crown cutting is then done on this tooth and finally the tooth is built up using composite resin.

REMOVABLE SPACE MAINTAINERS They are space maintainers that can be removed and reinserted into the oral cavity by the patients (Figs 35.20A to F).

Classification of Removable Space Maintainers Brauer classified removable dentures for children as follows: Class 1: Unilateral maxillary posterior. Class 2: Unilateral mandibular posterior. Class 3: Bilateral maxillary posterior. Class 4: Bilateral mandibular posterior. Class 5: Bilateral maxillary anterior posterior. Class 6: Bilateral mandibular anterior posterior. Class 7: One or more primary of permanent anterior. Class 8: Complete primary.

Indications • • • • • •

Esthetics is of importance. The abutment teeth cannot support a fixed appliance. A cleft palate patient. Child has reached a mental age of 2½ years. Permanent teeth are not fully erupted for adaptation of bands. Multiple loss of deciduous tooth.

Contraindications • • • • •

Lack of patient parent cooperation. It the child has not attained a mental age of 2½ years. It the patients are allergic to acrylic materials. Epileptic patients. Children with possible caries activity.

Advantages of Removable Space Maintainers • • • • • • •

Easy to clean and permit maintenance of proper oral hygiene. Restore vertical dimension. Help in mastication. Post insertion check up is easy. Stimulate eruption of underlying tooth. Band construction and elaborate skills and instrumentation are not required. Alterations can be made without changing the appliance.

Disadvantages of Removable Space Maintainers • • • • •

May be lost or broken by the patient. Cannot be used in uncooperative patients. Patient may not wear them. Lateral jaw growth may be hampered. May cause irritation and allergy to underlying tissues.

Research Sasa IS, Hasan AA, Qudeimat MA (2009) inves gated the success and median survival rate of band and loop space maintainers using glass ionomer lu ng cement for a achment in 40 children (22 females and 18 males) between the ages of 3.4 and 7.3 years. Each pa ent received only one band and loop space maintainer. For each child, the same pediatric den st carried out all diagnosis, band selec on, and impression taking and appliance cementa on. The same dental technician fabricated all appliances. Regular follow-up appointments were scheduled at 4 to 6 months intervals. 40 percent of the band and loop space maintainers were successful and 57.5 percent failed during the study period (40 months). The most common cause of failure was decementa on (82% of all failed cases). The overall median survival me was 19.9 months. Appliances fi ed in the maxillary and mandibular le side of the mouth showed a sta s cally higher survival rate than those fi ed in the right side. Qudeimat MA, Fayle SA (1998) in their retrospec ve study inves gated the longevity of 301 space maintainers fi ed in 141 pa ents aged 3.4-22.1 years in the Department of Pediatric Den stry at Leeds Dental Ins tute between 1991 and 1995. Failure occurred in 190 space maintainers (63%), of which 36 percent were due to cement loss, 24 percent breakage, 10 percent design problems, and 9 percent were lost. Using the life table method, the median survival me (MST) for space maintainers was found to be 7 months. Band and loop (B&L) appliances had the highest MST of 13 months, while the lower lingual holding arch (LLHA) had the lowest of 4 months. Unilateral space maintainers survived longer than bilateral space maintainers (MST of 13 months vs 5 months). Lefi B & Ls had a MST of l6 months, compared to only 4 months for right B&Ls. Gender, age, arch in which the appliance was placed, the operator planning it, fixed vs removable, and adequacy of pretreatment assessment did not have a significant effect on survival me.

SPACE REGAINERS (FIGS 35.21A TO H) Space maintenance is necessary in early loss of posterior primary teeth because early loss contributes to the development of occlusal disharmonies. However, when space is progressively lost, the therapy should be considered to regain it so that additional disharmonies do not develop. For regaining space or any movement of teeth, the most important procedure is the diagnosis. The attention is not limited to the segment in which tooth is missing.

449

450 Section 7

A

Pediatric Orthodontics

B

C

E

D

F

Figs 35.20A to F: Removable space maintainers: (A) Bilateral nonfuncƟonal space maintainer; (B) Unilateral nonfuncƟonal space maintainer; (C) Unilateral funcƟonal removal maintainer; (D) Bilateral funcƟonal removal space maintainer; (E and F) Removable space maintainer in a paƟent

Chapter 35 Pediatric Space Management

A

B C

D

E

F

G

H

Figs 35.21A to H: Space regainer

Considerations for treatment should include the alignment and space needs of other teeth in the arch, the relationships of teeth to denture base, the transverse and sagittal dental relationships, the vertical denture relationships, the skeletal relationships of the denture bases to the cranium and profile of the soft tissue. The diagnostic aids necessary to develop a database for above consideration include study models, radiographs of all the periapical structures, clinical assessment of facial symmetry and proportions and possibly cephalometric analysis. It is important to recognize whether

teeth have moved bodily into the space or have tipped axially, because forces applied to tip teeth back into a proper alignment are easier to manage than forces required to bodily return teeth to their proper position in the arch. Several problems are associated with the regaining procedures. Usually minimal space loss can be regained better. The space regaining procedure that involves tipping of 1st permanent molar can be accomplished more easily in the maxillary arch than in the mandibular arch. Some of the appliances that can be used to regain space are:

451

452 Section 7

Pediatric Orthodontics

Jaffe’s Appliance

molar has drifted mesially, but the premolar or cuspid has not drifted distally.

An appliance for certain minor tooth movement was described by Paul E Jaffe in 1963. It is useful in the presence of ankylosed tooth, early loss of a deciduous molar or an extraction result in filling of adjacent segments into proximal dental area. Movement is obtained by the use of light spring pressure against a sliding section or arch.

Gerber’s Appliance This type of appliance may be fabricated directly in the mouth during or relatively short appointment and requires no lab work.

Hotz Lingual Arch It is another method for distalization of molars. This is appropriate in a situation where the lower 1st permanent

A

King’s Appliance King in 1977 described an appliance for regaining of space in both maxillary and mandibular arch.

Removable Appliances (Figs 35.22A to C) Hawley’s appliance with dumbbell spring, Hawley’s appliance with split acrylic and Hawley’s appliance with elastics.

Miscellaneous Screws, quad helix and expansion appliances.

B Figs 35.22A to C: Removable space regainer

C

Chapter 35 Pediatric Space Management

Anterior Space Regainer Bayardo in 1986 described an anterior space regainer utilizing direct bond technique. The enamel of the labial

surface of left central and right lateral incisors was etched with 35 percent phosphoric acid and labial tube was individually bonded to each abutment tooth thus causing space regaining.

POINTS TO REMEMBER • • • • • • • • • • • •

Space maintenance was coined by JC Brauer in 1941. According to Boucher, space maintainer is a fixed or removable appliance designed to preserve the space created by the premature loss of a primary tooth or a group of teeth. In the premature loss of first deciduous molar may be maxillary, mandibular or both; unilateral or bilateral space maintainers should always be placed. Maximum space is lost during the first six months of extraction and most immediate loss is with in 76 hours. Maxillary spaces close faster as compared to mandibular spaces. 1 mm of bone resorbs in 4 to 5 months and so if the bone is present over the succedaneous tooth it is an indication for space maintainer. Space regained by space regainers should be maintained until adjacent permanant teeth have erupted completely and/or until a subsequent comprehensive orthodontic treatment plan is initiated. Fixed space maintainers are the appliances, which are fixed onto the teeth and utilize bands or crown for their construction. Reverse band and loop is given when there is premature loss of primary second molar and the permanent molar have not erupted fully. Lingual arch space maintainer is the most effective appliance of space maintenance and minor tooth movement in lower arch. Distal shoe space maintainer otherwise known as intra-alveolar appliance, currently in practice is Roche’s distal shoe or modifications of it. Space maintainer in the primary anterior region consists of artificial teeth (Polycarbonate or Acrylic) processed onto a lingual arch which in turn in attached to the bands to the molars.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Define space maintenance and explain the factors influencing the placement of space maintainer. Classify space maintainers and give its indications and contraindications. Write a note on arch holding space maintainers. What are the modifications of band and loop space maintainers? Describe in detail the distal shoe space maintainer. Write a note on space regaining.

BIBLIOGRAPHY 1. 2. 3. 4.

Baroni D, Ranchini A, Rimondini L. Survival of different type of space maintainers. 1994;16:360-1. Breakspear EK. Further observations on early loss or deciduous molars. Dent Pract Dent Record. 1961;11:233. Brill WA. The distal shoe space maintainer: chairside fabrication and clinical performance. Pediatr Dent. 2002;24:561-5. Clinch L. A longitudinal study of the results of premature extraction of deciduous teeth between 3-4 and 13-14 years of age. Pract Dent Record. 1959;9:109. 5. Croll TP, Sexton TC. Distal extension space maintainer: a new technique. Quint Int. 1981;12:1075-80. 6. Cavalcanti AL, Barros de Alencar CR, Medeiros Bezerra PK, Granville-Garcia AF. Prevalence of early loss of primary molars in School children in Campina Grande, Brazil. Pakistan Oral and Dental Journal. 28(1):113-6. 7. Gerber WE. Facile space maintainer. JADA. 1964;69:691-4.

453

454 Section 7

Pediatric Orthodontics

8. Graber TM. Orthodontics principles and practice. 3rd Edn, WB Saunders; 1998. 9. Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry. Aapd Clinical Guidelines Reference Manual V 34/NO 6 12/13:239-51. 10. Hicks EP. Treatment planning for the distal shoe space maintainer. Dent Clin North Am. 1973;17:135-50. 11. Irwin RD, Meerold JS, Richardson A. Mixed dentition analysis: a review of methods and their accuracy. Int J Pediatr Dent. 1995;5:137-42. 12. Kargul B, Caglar E, Kabalay U. Glass Fiber-reinforced Composite Resin as Fixed Space Maintainers in Children: 12-month Clinical Follow-up. J Dent Child. 2005;72:109-12. 13. Martinez NP, Elsbach HG. Functional maintenance of arch length. J Dent Child. 1984.pp.190-3. 14. McDonald RE, Avery DR. Management of space maintenance problems. In: Dentistry for the Child and adolescent. R E McDonald, David R Avery (Eds). St Louis: The CV Mosby Company; 1994.pp.707-43. 15. Miyamoto W, Chung CS, Yee PK. Effect of premature loss of deciduous canines and molars on malocclusion of the permanent dentition. J Dent Res. 1976;55:584-90. 16. Nayak UA, Louis J, Sajeev R, Peter J. Band and loop space maintainer—Made easy. J Indian Soc Ped Prev Dent. 2004;22(3):134-6. 17. Proffit WR. Treatment of nonskeletal problems in preadolescent children. In, Contemporary orthodontics. William R. Proffit. St. Louis: The CV Mosby Company; 1986.pp.312-53. 18. Padma Kumari B, Retnakumari N. Loss of space and changes in the dental arch after premature loss of the lower primary molar: A longitudinal study. J Indian Soc Pedod Prev Dent. 2006.pp.90-6. 19. Quidemat MA, Fayle SA. The longevity of space maintainers: a retrospective study. Pediatr Dent. 1998;20(4):267-72. 20. Richardson M. The relationship between the relative amount of space present in the deciduous dental arch and the rate of degree of space closure subsequent to the extraction of the deciduous molar. Dent Pract Dent Rec. 1965;16:111. 21. Rapp R, Demiroz I. A new design for space maintainers replacing prematurely lost first primary molars. Pediatr Dent. 1983;5(2): 131-4. 22. Sasa IS, Hasan AA, Quidemat MA. Longevity of band and loop space maintainers using glass ionomer cement: a prospective study. Eur Arch Paediatr Dent. 2009;10(1):6-10. 23. Ulusoy AT, Cehreli ZC. Provisional use of a natural tooth crown following failure of replantation: a case report. Dent Traumatol. 2008;24(1):96-9. 24. Willett RC. Preventive orthodontics. J Am Dent Assoc. 1936;23:2257. 25. Willett RC. Premature loss of deciduous teeth. Angle orthod. 1933;3:106. 26. Wright GZ, Kennedy DB. Space control in primary and mixed dentitions. DCNA. 1978;22(4):579-602. 27. Wright GZ, Kennedy DB. Space control in the primary and mixed dentitions. Oral Health. 1981;71:65-75. 28. Yeluri R, Munshi AK. Fibre reinforced composite loop space maintainer: An alternative to the conventional band and loop. Contemp Clin Dent. 2012;3:S26-8.

36

Chapter

Serial Extractions Nikhil Marwah, Anirudh Agarwal

Chapter outline • • • • •

Principles of Serial Extraction Indications Contraindications Advantages Disadvantages

Serial extraction procedures have been of interest to dentists for many years. The term serial extraction describes an orthodontic treatment procedure that involves the orderly removal of selected deciduous and permanent teeth in a predetermined sequence (Dewel, 1969). Serial extraction is an interceptive orthodontic procedure usually initiated in the early mixed dentition when one can recognize and anticipate potential irregularities in the dentofacial complex and is corrected by a procedure that includes the planned extraction of certain deciduous teeth and later specific permanent teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth into a more favorable position. Every serial extraction diagnosis is based on the promise that future growth will be inadequate to accommodate all of the teeth in a normal alignment. Serial Extraction should be diagnosed in the early mixed dentition period and is most effective when undertaken in Class I malocclusions. Serial extraction can be defined as the correctly timed removal of certain deciduous and permanent teeth in mixed dentition cases with dentoalveolar disproportion in order to alleviate crowding of incisor teeth; allow unerupted teeth to guide themselves into improved positions; lessen (or eliminate) the period of active appliance therapy.

PRINCIPLES OF SERIAL EXTRACTION The treatment objective for a serial extraction is to intercept an arch length deficiency problem to reduce or eliminate the need for extensive appliance therapy.

• • • • • •

Technique and Stages in Serial Extraction Therapy Tweed’s Technique for Serial Extraction Dewel Method Nance Method Moyer Method Role of the Pedodontist

History of serial extraction Year

Name

Findings

1600s

Paisson

The first person who pointed the extraction procedure in order to improve the irregular alignment and crowding of teeth

1743

Bunon

In his “Essay on the Diseases of the teeth” proposed the removal of deciduous teeth to achieve a better alignment of permanent teeth

1929

Kjellgren

Coined the term ‘‘serial extraction’’ to describe a procedure where some deciduous teeth followed by permanent teeth were extracted to guide the rest of the teeth into normal occlusion

1940

Nance

Presented clinics on his technique of ‘pro­ gressive extraction’ and has been called as the Father of Serial Extraction philosophy in the United States

1941

Hotz

Named the procedure “Guidance of eruption”. According to him the term guidance of eruption is comprehensive and encompasses all measures available for influencing tooth eruption

Arch Length: Tooth Material Discrepancy • Whenever there is an excess of tooth material as compared to the arch length, it is advisable to reduce the tooth material in order to achieve stable results.

456 Section 7 

Pediatric Orthodontics

• This principle is utilized in serial extraction procedures where tooth material is reduced by selective extraction of teeth so that the rest of the teeth can be guided to normal occlusion.

Physiologic Tooth Movement Human dentition shows a physiologic tendency to move towards an extraction space. Thus by selective removal of some teeth the rest of the teeth which are in the process of eruption are guided by the natural forces into the extraction space.

INDICATIONS Serial extraction procedure is generally indicated when there is severe discrepancy between total tooth material and basal bones in patients having Class I malocclusion and having good facial profile. The severity of the crowding should be such that mixed dentition analysis should indicate a discrepancy of at least 8 to 10 mm excess tooth material in an unmutilated mandibular arch. The indication for doing a serial extraction must correspond to the patient’s needs and biologic characteristics and must fulfil the desired objectives. Indications of this procedure are as follows: • Premature loss of deciduous teeth • Arch length deficiency and tooth size discrepancy • Absence of physiologic spacing • Lingual eruption of lateral incisors • Unilateral deciduous canine loss and midline shifting • Canines erupting mesial to the lateral incisors • Mesial drift of buccal segment • Abnormal eruption direction and eruption sequence • Gingival recession on labially displaced incisors • Flaring, ectopic eruption, ankylosis, etc. • Abnormal or asymmetric primary canine root resorption • Crowded maxillary and mandibular incisors with extreme labial proclination • Deleterious oral habits • Class I malocclusion showing harmony between skeletal and muscular system.

CONTRAINDICATIONS • Congenitally absent/missing lower 2nd premolars • Extensive caries of permanent 1st molars • Severe class II and III malocclusions of dental as well as skeletal origin • Unilateral congenital absence of teeth • Abnormal tooth size, shape, color, etc. • Cleft lip and cleft palate cases

• Reverse overjet, deep bite, open bite, rotation, gross malposition, cross bite, etc. • Spaced dentition • Class I malocclusions with minimal space deficiency • Mild disproportion between arch length and tooth material that can be treated by proximal stripping.

ADVANTAGES • Treatment is more physiologic as it involves guidance of teeth into normal positions making use of the physiologic forces. • The removal of deciduous canine allows spontaneous alignment of crowded incisors which simplify later appliance treatment. • The extraction of 1st premolar before crowding allows permanent canines to drift into natural alignment without any appliance. • It lessens the period of future appliance therapy and cost of treatment. • Psychological trauma associated with malocclusion can be avoided by treatment of the malocclusion at an early age. • Better oral hygiene is possible thereby reducing the risk of caries. • Health of investing tissues is preserved. • Lesser retention period is indicated at the completion of treatment.

DISADVANTAGES • This procedure cannot be applied in Class II and III malocclusion cases. It is avoided in Class II division 2. Serial extraction may cause an increase in overbite. • Psychological trauma: It is unpleasant for a child to have four teeth extracted each time or at three or four occasions. • If extractions are carried out too early this result in space loss or delayed eruption of permanent successors. • Lower permanent canines may erupt ahead of 1st premolar into extraction space of the first deciduous molar, impacting premolar and making its removal difficult. • Quite frequently patients require appliance treatment. • There is no single approach that can be universally applied to all patients. Each patient has to be assessed and a suitable extraction time table planned. • Treatment time is prolonged as the treatment is carried out in stages spread over 2 to 3 years. • It requires the patient to visit the dentist often • Thus patient cooperation is needed. • As extraction spaces are created that close gradually, the patient has a tendency of developing tongue thrust. • Ditching or space can exist between the canine and 2nd premolar.

Chapter 36  Serial Extractions canine is erupting ahead of the mandibular 1st premolar, either of two procedures should be carried out. – In a combined procedure, extract deciduous mandi­ bular 1st molars and surgically remove the unerupted permanent 1st premolar, or – To avoid the surgical procedure extract the deciduous mandibular 1st molars and, approximately six months later remove the deciduous mandibular 2nd molars. This allows the unerupted 1st premolars to move distally in the alveolar bone as the canine erupts.

TECHNIQUE AND STAGES IN SERIAL EXTRACTION THERAPY

Diagnosis and Treatment Plan • Deciding on the timing and the sequencing for extracting primary and permanent teeth is the key to success. • The technique of serial extraction usually involves a period of incisor adjustment followed by a period of canine adjustment. • Diagnostic records are obtained by study model, periapical radiographs, panoramic and cephalometric radiographs. • The diagnostic exercise prior to treatment should involve comprehensive assessment of the dental, skeletal and soft tissues. A tooth material-arch length discrepancy must ideally exist. According to most authors, an arch length deficiency of not less than 5 to 7 mm should exist to undertake this procedure. Study model analysis should be carried out to determine the arch length discrepancy. • Carey’s analysis in the lower arch and arch perimeter analysis in the upper arch should be carried out. • Mixed dentition analysis helps in determining the space required for the erupting buccal teeth. • The eruption status of the dentition is evaluated from an orthopantogram (OPG). • The skeletal tissue assessment should involve comprehen­ sive cephalometric examination to study the underlying skeletal relation. • The soft tissue assessment by clinical examination and cephalograms help in the diagnosis.

Removal of Deciduous Canine • The purpose is to permit the eruption and optimal alignment of lateral incisors. • It prevents the mesial migration of canines into severe malpositions. • The four deciduous canines are removed as upper permanent lateral incisors are erupting (at about 8.5 years of age). The alignment of incisors should improve at the expense of space for permanent canine.

Removal of 1st Deciduous Molars • The 1st deciduous molars are removed in order to encourage the early eruption of 1st premolar. • This will be most successful if premolar roots have half formed (at about 9.5 years of age). It is desirable that the 1st premolar should erupt in advance of canines, although this is often not in the case of lower arch. It is sometimes done earlier in the mandible than maxilla to enhance early eruption of lower 1st premolar. If the mandibular

Removal of Erupting 1st Premolars • When the upper permanent canine has just emerged through oral mucosa, the 1st premolar should be extracted. • This is the most important stage of serial extraction procedure and it is essential to recheck that the case is suitable for treatment by extraction of 1st premolars. • All teeth must be present and sound and the permanent canines must be mesially inclined. There must be crowding sufficient to justify the extraction of 1st premolars.

Selection of teeth for extraction •

C C

Extraction will C C produce maximum amounts of selfimprovement in crowding with greatest interception of lingual cross bite

•

Extracting

21 12 21 12 D D D D

produces earliest eruption of

4 4 4 4

but 21 12 21 12

reduces speed and amount of improvement in crowding and position due to retention of C that it has limited application •

Extracting

DC CD DC CD

is

a

compromise

between

improvement in and desired early eruption of simultaneous

4 4 4 4

Enucleation of

3 3 3 3

rapid due to

eruption of with this extraction sequence

reduced distal translation occurs and as with extraction only •

21 12 21 12

43 34 43 34

are often impacted

buds permits maximum distal translation

4 4 4 4

of which undesirable in certain cases because it produces excessive chin and reduces resistance value of anterior teeth for final space closure.

TWEED’S TECHNIQUE FOR SERIAL EXTRACTION Tweed in 1966 proposed this extraction sequence (Fig. 36.1). At approximately 8 years of age, all 1st deciduous molars are extracted. Unless there is unhealthy soft tissue involvement around the lower incisors, or blocked out maxillary incisors, it is preferable to maintain the deciduous canine to retard the eruption of permanent canines.

457

458 Section 7 

Pediatric Orthodontics

After 4 to 10 months of extraction, the 1st premolar tooth has erupted up to gum level. Do not remove them until their crowns are through alveolar bone. At this time all four erupting 1st premolar teeth are removed along with all four deciduous canines. If this is done at least 4 to 6 months prior to eruption of permanent cuspids, they erupt and migrate posteriorly into good position. The irregularities of mandibular incisors correct themselves.

Fig. 36.1:  Tweed method of serial extraction D-C-4

DEWEL METHOD Dewel has proposed a 3-step serial extraction procedure. In the first step the deciduous canines are extracted to create space for the alignment of the incisors (Fig. 36.2). This step is carried out at 8 to 9 years of age. A year later, the deciduous 1st molars are extracted so that the eruption of 1st premolars is

Fig. 36.2:  Dewel method of serial extraction C-D-4

Chapter 36  Serial Extractions accelerated. This is followed by the extraction of the erupting 1st premolars to permit the permanent canines to erupt in their place. In some cases a modified Dewel’s technique is followed wherein the 1st premolars are enucleated at the time of extraction of the first deciduous molars. This is frequently necessary in the mandibular arch where the canines often erupt before the 1st premolars.

NANCE METHOD This is similar to the Tweed technique and involves the extraction of the deci­ duous 1st molars followed by the extraction of the 1st premolars and the deciduous canines (Fig. 36.3).

Fig. 36.3:  Nance method of serial extraction D-4-C

MOYER METHOD Indicated when crowding is seen in central incisor region. First is to extract all deciduous lateral incisors to help in alignment of central incisors. This is followed by extraction of all deciduous canines after 7 to 8 months to provide space for lateral incisors. After this extraction of all deciduous 1st molars is done to stimulate eruption of 1st premolars. The last sequence is to extract 1st premolars after 7 to 8 months, which will not only provides space for canines but also stimulates its eruption (Fig. 36.4).

Fig. 36.4:  Moyer method of serial extraction B-C-D-4

459

460 Section 7 

Pediatric Orthodontics

ROLE OF THE PEDODONTIST Pedodontist and orthodontist are mutually dependent on each other’s skills for treatment planning of serial extraction. The ideal plan for the pedodontist is to observe the problem, make a decision that a serial extraction might be appropriate, explain the plan to the patient or parents and refer the patient to the orthodontist. After having seen the patient and arrived

at a decision as to the sequence of extractions and after communicating with the pedodontist, orthodontist should explain the serial extraction plan to the parents as well as advise them that further orthodontic treatment may be needed. At this time, the pedodontist will proceed with the planned sequence of extractions. The pedodontist will thus share in the decision making process and the orthodontist does not have a reason to question the decision.

POINTS TO REMEMBER `• Serial extraction can be defined as the correctly timed removal of certain deciduous and permanent teeth in mixed dentition cases with dentoalveolar disproportion in order to alleviate crowding of incisor teeth; allow unerupted teeth to guide themselves into improved positions; lessen (or eliminate) the period of active appliance therapy. • Kjellgren (1929) proposed the term serial extraction. • Nance is known as the father of serial extraction. • Serial extraction procedure is generally indicated when there is severe discrepancy between total tooth material and basal bones in patients having Class I malocclusion and having good facial profile. The severity of the crowding should be such that mixed dentition analysis should indicate a discrepancy of at least 8 to 10 mm excess tooth material. • Tweed method of serial extraction D-C-4. • Dewel method of serial extraction C-D-4. • Nance method of serial extraction D-4-C. • Moyer method of serial extraction B-C-D-4.

QUESTIONNAIRE 1. 2. 3. 4. 5.

Define serial extraction and give its brief history. Explain Nance method of serial extraction. Describe Dewel method of serial extraction. What is Tweed method of serial extraction? Write a note on Moyer method of serial extraction.

BIBLIOGRAPHY

1. Graber TM. “Serial extraction: A continuous diagnostic and decisional process”. Am J Orthod. 1971;60(6):541-75. 2. Graber TM. Orthodontics-Principles and Practice. 3rd Edn. Philadelphia: WB Saunders Co. 1972.pp.709-45. 3. Housten WJB. Walther’s orthodontics Notes-Wright PSG Britol, 4th Edn. 1983.pp.126-7. 4. Jack G. Dale “Serial extraction part I”. JCO. 1976.pp.44-60. 5. Jack G. Dale “Serial extraction part II”. JCO. 1976.pp.116-36. 6. Jack G. Dale “Serial extraction part III”. JCO. 1976.pp.196-216. 7. Jacobs SG. Re-assessment of serial extraction. Austral Orthodontic Journ. 1987;10(2):90-7. 8. Naragond A, Kenganal S. Serial Extractions – A Review. Journ Dent Med Scienc. 2012;3(2):40-7. 9. Proffit WR. “Contemporary orthodontics, 2nd Edn”. Boston: Mosby; 1986. 10. Rani MS. “Synopsis of orthodontics”. All India Publications; 1993. 11. Stewart RE. Paediatric Dentistry-Scientific Foundation and Clinical Practice, 1st Edn. St Louis: CV Mosby Co; 1982. 12. Tweed CH. Clinical orthodontics. St Louis: CV Mosby Co. 1966;1:261-4. 13. White TC, Gardiner JH. Orthodontics for Dental students, 3rd Edn. London: McMillan Press Ltd. 1983.pp.135-8.

37

Chapter

Components of Removable Orthodontic Appliances Mridula Trehan, Nikhil Marwah

Chapter outline • • •

Parts of Removable Orthodontic Appliances Clasps Springs

A removable appliance is one of the most critical aids in pediatric-orthodontic interphase as this appliance can be used to modulate growth and to intercept and correct dentofacial anomalies of malocclusion. Lischer defined an orthodontic appliance as a mechanism for the application of force to the teeth and their supporting tissues, to produce changes in their relations and to control the growth and development of this structure. Graber explained that a removable orthodontic appliance is a device through which an optimal force is delivered to a tooth or a group of teeth in a predetermined direction. The first such appliance was introduced by Charles Hawley in 1908 when he developed the Hawley’s appliance.

TYPES OF REMOVABLE APPLIANCE (ACCORDING TO GRABER AND NEUMANN) • Active appliances: That exerts force within the appliance. • Functional appliances: That use muscular forces.

Ideal Requirements of Appliance • Biologic – Should not interfere with normal growth – Free from inherent qualities harmful to oral tissues – Should not interfere with normal functions such as mastication, speech – Not cause damage to tooth, bone or soft tissue – Should bring about desired tooth movements efficiently.

• • • •

Canine Retractors Labial Bow Vestibular Screen Hawley’s Appliance

Indications • • • • •

Simple tipping movements Overbite reduction Elimination of occlusal interferences Space maintenance Minor derotations of incisor teeth

• Mechanical – Less bulky – Adequate retention – Should exert sufficient force in the desired direction – Easy to construct and repair – Easy to remove and wear – Should be light and inconspicuous. • Esthetic – Color matching with individual’s mucosa – Should be well trimmed, finished and polished • Hygienic – Easy to clean daily – Avoid depositions o f food and calculus – Should not interfere with oral hygiene maintenance.

PARTS OF REMOVABLE ORTHODONTIC APPLIANCES Retentive component: This part of removable orthodontic appliance holds the appliance in position and is called as

462 Section 7 

Pediatric Orthodontics Advantages and disadvantages of removable appliances Advantages of removable appliances

Disadvantages of removable appliances

•

The patient can continue with routine oral hygiene procedures without any hindrance

•

The treatment can become prolonged depending on patient compliance

•

Most forms of tipping movement can be carried out successfully

•

These appliances cannot be used in cases where bodily movements of the teeth are required

•

Less conspicuous than fixed appliances

•

They can hamper with the phonation

•

More acceptable to the patients

•

Dexterity and skill to remove and replace the appliance for successful treatment

•

Can be delivered and monitored by the general dentist

•

The chance of appliance loss and/or breakage is more

•

Chair side time for appliance delivery is considerably less

•

Limited inventory required to be maintained

•

Relatively cheap

clasp. It can also be referred to as the anchor unit of the removable orthodontic appli­ ance. Active component: This part of removable orthodontic appliance brings about the actual tooth movement. The active tooth movement can be brought about by various components like labial bows, springs, expansion screws. Base plate:  This unit of removable orthodontic appliance carries all the other components of the appliance. Autopolymerizing (self-curing) acrylic resin is the material generally used for fabricating the base plate, sometimes heat curing acrylic resins can also be used. The acrylic base can be modified to have bite planes which serve special functions such as reduction of overbite, reinforcing anchorage, etc.

CLASPS Clasp can be defined as a component of removable orthodontic appliance that retains and stabilizes an orthodontic appliance in the oral cavity by contacting the surface of the teeth or by engaging the interproximal embrasures.

Types of Clasps • Adam’s clasp – Adam’s clasp with soldered hook – Adam’s clasp with distal extension – Adam’s clasp with helix – Adam’s clasp with single arrowhead – Adam’s clasp with soldered buccal tube – Double clasp — Adam’s clasp on incisors and premolar – Adam’s clasp with editional arrowhead.

• • • • • • • •

‘C’ clasp or three-quarter clasps Full clasp or Jackson’s clasp Triangular clasp Ball end clasp Southend clasp Duyzing clasp Schwarz clasp Eyelet clasp.

Mode of Action of Clasps Between the maximum circumference of any tooth and anatomical neck, there are sloped surfaces called undercuts. Clasps engage these undercut areas to aid in retention of a removable appliance.

Requirements of an Ideal Clasps • • • • • •

Easy to fabricate. Provide adequate retention. No interference with occlusion. Should not apply active force. Able to use on both fully and partially erupted teeth. No impingement on soft tissues.

SPRINGS Spring is an active component of removable orthodontic appliances which brings about the desired tooth movement.

Classification of Springs • Based on the presence/absence of helices – Simple spring: No helix present – Compound spring: Helix incorporated • Based on whether helix or loop present – Helical springs – Looped spring

Chapter 37  Components of Removable Orthodontic Appliances CLASPS Adam’s clasp

•

Devised by Professor C Philip Adams in 1948

•

Also known as modified arrowhead, Universal and Liverpool clasp

•

Made from 0.7 mm round SS wire

•

Offers maximum retention

•

Can be used on premolars, permanent molars and even deciduous molars in which case 0.6 mm diameter wire is used

•

Parts of the Adam’s clasp

•

Modification of Adam’s clasp – Adam’s clasp with single arrowhead: Indicated in a partially erupted tooth. The single arrowhead is positioned in the mesial undercut and bridge is modified to encircle the tooth distally and end in a retentive arm

– Adam’s clasp with additional arrowhead: When additional retention is required an accessory arrowhead clasp is fabri­ cated on the adjacent tooth and soldered to the bridge of the main Adam’s clasp

– Adam’s with distal extension: A distal extension can be incorporated in the distal arrowhead of the Adam’s which acts as a traction hook for engaging elastics

– Adam’s clasp with J-hook: Another accessory for engaging elastics is a J-hook that is soldered to the bridge of the clasp – Bridge: It should be straight and midway between the occlusal surface and gingival margin. It should be 2 mm away from the tooth surface and parallel to it. When viewed from the side, the bridge should be at 45° angle to tooth surface – Arrowheads: They should be parallel to each other and should sit in the mesial and distal undercuts

– Adam’s clasp with helix: It is for engaging elastics

– Retentive arms: The outer ends of both arrowheads continue occlusally over the mesial and distal embrasures to end lingually as two retentive arms •

Advantages – Simple, strong and easily constructed

– Adam’s clasp with soldered buccal tube: For use of extraoral attachment

– Offers excellent retention – It can be used on any tooth be it incisor, canines, premolars or molars – It can be used on partially or fully erupted tooth

– Adam’s clasp on incisors and premolars: For additional retention

– Good patient compliance as it is comfortable to wear and resistant to breakage – It can be used on both deciduous and permanent teeth – A number of modifications enable its use in a wide variety of appliances Contd...

463

464 Section 7 

Pediatric Orthodontics

Contd... Circumferential clasp

• • • • •

Duyzing’s clasp

Also known as the three quarter clasp • or C-clasp Simplest in fabrication Made from 0.7 mm diameter SS wire Engages the buccal cervical undercut • It cannot be used in teeth that are • partially erupted •

Two stainless steel wires are bent over the maximum contour of the tooth from the mesial and distal aspect and then curved back below the maximum contour and ends are sprung 21 gauge wires are used Advantage is that it is possible to use only onehalf of the clasp and it does not irritate the gingiva Disadvantage is that it provides limited retention

Jackson’s clasp

Triangular clasp

• • • •

• • • •

•

Also called as full clasp or U-clasp Introduced by Jackson in 1906 Made from 0.7 mm SS wire Cannot be used on partially erupted teeth In fully erupted teeth, it provides adequate retention

Schwartz clasp

• •

•

•

• • •

Used for retention in the anterior region Constructed along the gingival margin of both the maxillary central incisors Used when upper incisors are not proclined and there is a limited undercut

Its length is increased because occlusal part of clasp arm projects 1.5 to 2 mm buccally Fits perpendicular to the long axis of the tooth into the interdental space A 21 gauge wire is used Extraoral traction—retention is increased by multiple eyelets, between the poste­ rior teeth

Ball end clasp

Small triangular-shaped clasps • Used to provide additional retention Used as accessory clasps Engages the proximal undercuts between the • 2 posterior teeth • •

Southend clasp

It is called the arrowhead clasp • Its drawbacks are that it occupies a lot • of space in the buccal vestibule and can irritate the soft tissues • Need special pliers for fabrication

Eyelet clasp

Made up of a SS wire (0.7 mm diameter) with a sphere or ball-like structure on one end Mesial and distal undercuts between 2 adjacent posterior teeth Fabricated with a silver solder Provide additional retention

Delta clasp

• • • • •

Designed by WJ Clark of Scotland A 0.8 mm wire is used Provides excellent retention for lower premolar Requires minimal adjustments Used in twin block appliance

Chapter 37  Components of Removable Orthodontic Appliances SPRINGS No.

Name

Function

1.

Single cantilever spring (Z-spring)

• Movement of incisior in labial direction • Correction of rotation

2.

T spring

To move premolar and canine to buccal side

3.

Finger spring

Movement labio-lingually when tooth is in line of arch

4.

5.

Flapper spring

Coffin spring

No.

Name

Function

6.

Up righting spring

Move root in a mesial or distal direction

7.

Torquing spring

Move root in lingual on palatal direction

8.

Open coil spring

Springs are compressed between two teeth to open up space between them

9.

Closed coil spring

They are stretched between teeth to close space

Correction of minor rotation

Dento-alveolar expansion of maxillary arch

• Based on the nature and stability of the spring – Self-supported springs – Supported springs.

CANINE RETRACTORS Springs that bring about distal movement of canines are called as canine retractors.

Classification • Based on their location – Buccal – Palatal • Based on design – Helical canine retractor – Looped canine retractor • Based on mode of action – Push type – Pull type.

465

466 Section 7 

Pediatric Orthodontics CANINE RETRACTORS

Palatal canine retractors

Buccal self supported canine retractor

• • • • • •

• Made from a thicker gauge wire (0.7 mm), which helps resist defor­ mation of the spring • Helix of 3 mm diameter positioned distal to the long axis of the canine • The active arm-placed away from the tissues • Indicated for retraction of buccally placed canines and is particularly useful when the canine overlaps the lateral incisor and is not accessible from the lingual side of the arch

Made up of 0.6 mm diameter SS wire Active arm placed mesial to the canine Helix of 3 mm diameter and a guide arm The coil is placed along the long axis of canine Indicated for retraction of palatally positioned canines Activation by opening the helix 2 mm at a time

U-loop canine retractor

Helical canine retractor

• • • •

• Made up of 0.6 mm round SS wire • Consists of an active arm (towards the tissue), a helix of 3 mm diameter and a retentive arm • Loop with helix at its base is placed 3–4 mm below the gingival margin • Distal arm-right angles to form the active arm, which engages the canine • Mesial arm is adapted between the premolars and ends in a retentive tag • Activation by opening the helix by 2 mm or by cutting off 2 mm from the end of the active arm and readapting it around the canine

• • • •

Made up of 0.6 or 0.7 mm SS wire Consists of an active arm, U-loop and a retentive arm The base of the U-loop is placed 2–3 mm below the cervical margin The active arm is bent at right angles from the mesial leg of the loop and adapted around the canine The distal leg of the loop extends as the retentive arm Indications are minimal canine retraction (1–2 mm) It is mechanically less effective than the other retractors Activation is done by compressing the loop or by cutting the free end of the active arm by 2 mm and readapting it

LABIAL BOW

VESTIBULAR SCREEN

These are active components that are used for overjet reduction, space closure in the anterior segment and also used to close space distal to canines (Table 37.1).

It is a simple functional appliance that takes the form of a curved shield of acrylic placed in labial vestibule. It was introduced by Newell in 1912.

Uses of Labial Bow • Retraction of anterior teeth. • Retention of teeth, after active orthodontic treatment is completed. • Used for reinforcement. • For attachment of auxiliary springs. • It can also be used for carrying soldered attachments.

Principle:  It can be used either to apply the forces of circumoral musculature to certain teeth or to relieve those forces from the teeth thereby allowing them to move due to forces exerted by the tongue. Thus, it works on principle of both force application as well as force elimination. Indications:  These appliances have been used mostly to intercept mouth breathing habit but can also be used to

Chapter 37  Components of Removable Orthodontic Appliances TABLE 37.1:  The function of each types of labial bow 1.

2.

Types of labial bow Short labial bow

Long labial bow

Function •

Minor overjet reduction

•

Anterior space closure

•

For retention

• •

Anterior space closure Closure of space distal to canine

•

For guidance of canine during retraction

3.

Split labial bow

•

Correction of midline diastema

4.

Robert’s retractor

•

Used in patients with severe anterior proclination with an overjet of 4 mm as it produces lighter forces over longer duration of time

5.

Mill’s retractor or extended labial bow

•

Used for retracting teeth with severe proclination or large overjet

6.

High labial bow with a apron spring

•

Used in retraction cases with large overjet as it is highly flexible and is also used in adult patients

7.

Reverse loop labial bow

•

Used to retain anterior teeth after treatment is completed

8.

Fitted labial bow

•

For retention

467

468 Section 7 

Pediatric Orthodontics

intercept habits like thumb sucking, tongue thrusting, lip biting, cheek biting. Some of the other usages are treatment of mild disto-occlusions, to perform muscle exercises and to correct mild anterior proclination. Management:  In case of treating mouth breathing with this appliance a prior ENT clearance is mandatory because you will be closing the mouth breathing passage and patient should be able to freely breathe with nose and not have any nasal problems like adenoids, nasal polyp or deviated nasal septum. At the start of the therapy make around 50 holes in the appliance. Later on in a few days time as the patient gets comfortable wearing the appliance recall the patient every week and close 10 holes in each visit thereby eliminating the probability of mouth breathing at the same time giving the patient an opportunity to acclimatize to the situation. Slowly all the holes are sealed and the patient manages to breathe through the nose while appliance is in place thereby correcting the habit.

HAWLEY’S APPLIANCE It is a removable wire and acrylic palatal appliance.

Purpose A Hawley appliance can be used both as a passive retainer (for retaining or stabilizing teeth in their new position following orthodontic treatment) and as an active appliance in order to achieve minor tooth movements.

Advantages • As the Hawley is a removable appliance, it can be removed for brushing, flossing and special social occasions. • The palatal acrylic offers significant anchorage.

Disadvantages • Like any other removable appliance, the success or failure depends entirely on patient compliance. • Speech might be affected. • Only tipping movements can be achieved. • Rotated teeth are extremely difficult to correct.

Indications • To hold teeth in a new position after orthodontic correction and to prevent relapse until bone fill around the moved teeth is achieved. • To move teeth mesiodistally and buccally (minor, tipping movement), it can be used to correct simple anterior crossbites.

Components of the Hawley’s Appliance • Acrylic base to support the elements of the appliance • Adam’s clasp for retention of the appliance • Labial bow for retraction and stabilization. Recall schedule: Recall visits of 4 to 6 week intervals are indicated to assess the tooth movement and to perform the required adjustments.

Modification of Hawley’s Appliance • Hawley’s appliance with anterior bite plane: Used for treatment of anterior deep bite. This is fabricated by extending the base plate behind the maxillary incisors on palatal rugae from canine to canine. When teeth are in contact with this bite plane there should be a gap of 1 to 2 mm in the posterior region. This will lead to supra-eruption of the lower posterior teeth and thus effectively correcting deep bite. • Hawley’s appliance with posterior bite plane: Used for treatment of anterior crossbites along with springs. The posterior bite plane extends from premolar region to the last erupted molar in the arch. The main function of this bite is to prevent the anterior teeth from closing thus enabling the appliance to break the bite and allow for crossbite correction. • Hawley’s appliance with tongue crib: It is a passive removable appliance that consists of additional tongue crib with Hawley’s appliance. It is used as habit breaker such as thumb sucking and tongue thrusting depending on the type and placement of cribs.

Insertion and Instructions • The posterior of the appliance should be inserted first, then the anterior • The appliance should be placed by pressing on the occlusal surfaces of the teeth • To remove the appliance, a simple pull with a fingernail on the back clasps is sufficient. Never pull on the labial bow as this will bend the wires and result in undesired tooth movements • Wear the appliance day and night (while sleeping) • Remove the appliance while eating • After each meal and before bedtime, clean teeth and the appliance

Chapter 37  Components of Removable Orthodontic Appliances • Do not rinse the appliance under hot water • Avoid chewing gum, candy or anything hard such as crusty bread or nuts

• If the appliance is broken or becomes uncomfortable, an appointment should be made to fabricate a replacement.

POINTS TO REMEMBER • Lischer defined an orthodontic appliance as a mechanism for the application of force to the teeth and their supporting tissues, to produce changes in their relations and to control the growth and development of this structure. • The first removable orthodontic appliance was introduced by Charles Hawley in 1908. • Removable appliance can be either active appliances, that exert force from within the appliance or functional appliances that use muscular forces. • Indications for removable orthodontic appliance are simple tipping movements; Overbite reduction; Elimination of occlusal interferences; Space maintenance; Minor derotations of incisor teeth. • The components of removable orthodontic appliance are retentive component (clasp), active (Springs, labial bows, screws) and base plate. • Clasp can be defined as a component of removable orthodontic appliance that retains and stabilizes an orthodontic appliance in the oral cavity by contacting the surface of the teeth or by engaging the interproximal embrasures. • Various types of clasps are Adam’s clasp, ‘C’ clasp or three-quarter clasp, full clasp or Jackson’s clasp, triangular clasp, ball end clasp Southend clasp, Duyzing clasp, Schwarz clasp, Eyelet clasp. • Adam’s clasp was devised by Professor C Philip Adams in 1948. It is also known as modified arrowhead, Universal and Liverpool clasp. The bridge should be straight and midway between the occlusal surface and gingival margin. It should be 2 mm away from the tooth surface and parallel to it. When viewed from the side, the bridge should be at 45° angle to tooth surface. Arrowheads should be parallel to each other and should sit in the mesial and distal undercuts. • Modifications of Adam’s clasp are with soldered hook, with distal extension, with helix, with single arrowhead, with soldered buccal tube and on incisors. • Buccal self supported canine retractor is the only canine retractor made of 0.7 mm wire, which helps resist deformation of the spring. • Oral screen was introduced by Newell in 1912 for use of interception of mouth breathing habit. • Hawley’s appliance can be either active for retraction or passive for retention. Modification of Hawley’s appliance can be with bite planes or cribs.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7.

Define, classify and give indications of removable orthodontic appliances. Describe various types of clasps. Write a note on Adam’s clasps. Explain springs in appliances. Give various modifications of labial bow and their uses. Summarize Hawley’s appliance. Management of mouth breathing habit through oral screen.

BIBLIOGRAPHY 1. Adams C Philip. Design, construction and use of removable orthodontic appliances. 2. Bhalajhi SI. Orthodontics – The art and science. 4th Edn. 2009. 3. Graber TM, Vanarsdall RL. Orthodontics, current principles and techniques, “Diagnosis and Treatment Planning in Orthodontics”, DM Sarver, WR Proffit, JL Ackerman, Mosby, 2000. 4. McNamara JA, Brudon, WI. Orthodontics and dentofacial orthopedics. 1st edition, Needham Press, Ann Arbor, MI, USA, 2001. 5. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics. 4th Edn, Mosby Inc., St. Louis, MO, USA, 2007. 6. Singh G. Textbook of orthodontics. 2nd Edn. Jaypee, 2007.

469

8

Section

CARIOLOGY

This section explains all the concepts of dental caries including its classification, etiopathogenesis, risk assessment. It also lays emphasis on diagnosis and detection of caries in oral cavity and at microbiological levels and also presents the methods of caries prevention and caries control. New dimensions like rampant and early childhood caries are also detailed in this unit.

38

Chapter

Dental Caries Nikhil Marwah, Puneet Goenka

Chapter outline • • • • •

Classification of Caries Epidemiology of Caries Theories of Dental Caries Current Concept of Dental Caries Histology of Dental Caries

Throughout the history of man, diseases have come and diseases have disappeared. For most of the major diseases, it has been possible to clearly identify the means how the disease was brought under control. Such means may include, nationwide or even global vaccination programs, change in living conditions with improved nutrition and noncontaminated drinking water. For other diseases, it may be more difficult to explain the reasons for a change. This is particularly true for diseases with a multifactorial background like dental caries. During the decades of caries decline, a number of actions have been taken to control the disease, and the literature describes numerous studies where one or several factors have been evaluated for their impact. Still, it is difficult to get a full picture of what has happened, as the background is so complex and because so many factors may have been involved both directly and indirectly. • Caries is defined as microbial disease of the calcified tissues of teeth that leads to demineralization of the inorganic components and the subsequent breakdown of the organic moieties of enamel and dentin. • The word caries is derived from the Latin word meaning ‘rot’ or ‘decay’. It is akin to the Greek word ‘Ker’ meaning death. • Ernest Newbrun (1989) “Dental caries is defined as a pathological process of localized destruction of tooth tissues by microorganisms.” • Shafer (1993) “Dental caries is an irreversible microbial disease of the calcified tissues of the teeth, characterized by

• • • • •

Saliva and Dental Caries Diet and Dental Caries Food Sugar Substitutes Caries Vaccine Global Decline in Dental Caries

demineralization of the inorganic portion and destruction of the organic substance of the tooth, which often leads to cavitation.”

CLASSIFICATION OF CARIES • According to occurrence: – Incipient—initial primary caries often reversible (Fig. 38.1) – Recurrent—secondary caries (Fig. 38.2) – Residual—carries left due to mistake of dentist (Fig. 38.3) • According to speed: – Acute—fast spreading – Chronic—slow spreading • According to location: – Pit and fissure (Fig. 38.4) – Smooth surface (Fig. 38.5) – Root surface (Fig. 38.6) • According to direction: – Forward caries—when caries in enamel is in a V-shape, i.e. base pointed towards DEJ. – Backward caries—when the more extensive destruction is towards DEJ with small apex. • According to age: – Early childhood caries (Fig. 38.7) – Adolescent caries – Senile caries

474 Section 8 

Cariology

Fig. 38.1: Incipient caries

Fig. 38.2: Secondary caries

Fig. 38.3: Residual caries

Fig. 38.4: Pit and fissure caries

Fig. 38.5: Smooth surface caries

Fig. 38.6: Root surface caries

Chapter 38  Dental Caries

Fig. 38.7: Early childhood caries

Fig. 38.8: Caries complexity according to surface

Fig. 38.9: Occlusal caries

Fig. 38.10: Proximal caries

• According to surface: (Fig. 38.8) – Simple—one surface – Compound—two surfaces – Complex—more than two surfaces • According to type of surface: – Occlusal (Fig. 38.9) – Proximal (Fig. 38.10).

EPIDEMIOLOGY OF CARIES • There was no evidence of dental caries in the relatively few teeth found in skull fragments of our earliest known direct ancestors, the Pithecanthropus. • But, there was evidence of fairly extensive decay in Rhodesian man from the Neanderthal age and in prehistoric European Ofnet race, the prevalence being least

in prehistoric Asiatic man (2.0 DMF) and most in the Europeans (7.2 DMF). There is also a direct evidence of linking progress of civilization to the number of carious lesions. • The prevalence and pattern of dental caries did not change significantly during the 2,000 years or more from the beginning of the Iron age to the Medieval period (1066-1500 AD). During this period the overall caries level was very low, and the most frequent site of caries was the occlusal surface, unlike the pattern in modern man where the carious lesions are at or just below the interproximal contact areas. • The caries experience varies greatly among coun­tries, and even within countries. • Caries prevalence is generally lowest (0.5-1.7 DMF) for Asian and African countries and highest (12-18 DMF) for the Americans and other Western countries.

475

476 Section 8 

Cariology

Prevalence rates of caries in Indian children at various ages Children below the age of 5 years Year

Place

Sarkar and Chaudhary

Investigators

1992

West Bengal

20.2

Sethi and Tandon

1996

Karnataka

65.5

1997

Punjab

28.5

Goyal et al.

Prevalence

Children of 5–6 years of age Investigators

Year

Place

Prevalence

Shourie

1941

Delhi

50.8

Chaudhary

1967

Lucknow

52.3

Tiwari and Chawla

1977

Chandigarh

70.6

Damle et al.

1982

Haryana

74.0

Chopra

1985

Delhi

34.1

Gupta et al.

1987

Karnataka

50.8

Sharma et al.

1988

Shillong

88.33

Norboo et al.

1998

Leh

74.6

Menon and Indushekhar

1999

Karnataka

2.56

Children at the age of 12 years Investigators

Year

Place

Prevalence

Shourie

1941

Delhi

54.8

Gill

1968

Lucknow

43.8

Damle et al.

1982

Haryana

89.5

Tiwari et al.

1985

Orissa (Odisha)

63.8

Sahoo et al.

1986

Orissa (Odisha)

67.9

Chawla et al.

1993

Chandigarh

31.4

Damle and Patel

1994

Bombay (Mumbai) 80.1

Norboo et al.

1998

Leh

Rodriguez and Damle

1998

Bombay (Mumbai) 63.4

Menon and Indushekhar

1999

Karnataka

31.0

Singh et al.

1999

Haryana

33.1

47.7

THEORIES OF DENTAL CARIES It is clear that fossil teeth provide an accurate record of the state of dentitions of man through the ages. Evidence for caries has been found in Homosapiens since Paleolithic times. Numerous references to dental caries, including early theories attempting to explain its etiology, have been found in recorded history of ancient people. A brief review of the history and early theories of the etiology of caries provides an interesting background for the understanding of the current concepts of dental caries.

Legend of the Worm Probably the earliest reference to tooth decay and toothache came from the ancient Sumerian text known as the ‘Legend

of the Worm’. This text was discovered from an ancient city within the Euphrates Valley of the lower Mesopotamian era, which dates from about 5000 BC. A remedy for toothache, recorded during this period, reads as follows: “Mix beer, the plant sa-kil-bir and oil together, repeat thereon the incantation thrice and put it on the tooth.” Chinese and Egyptians used fumigation, which consisted of burning leeks and hyoscyamus.

Humoral Theory The legend of the worm faded over the early centuries as the Greek Physician’s advanced to the humoral theory of caries. The four elemental humors of the body were blood, phlegm, black bile and yellow bile. An imbalance in these humors resulted in disease. According to Galen, the ancient Greek physician and philosopher, ‘dental caries was produced by internal action of acid and corroding humors’. The cure must consist of local or general medicaments according to circumstances and also provide strengthening of the teeth by the use of astringents and tonic remedies.

Vital Theory It was almost certainly apparent to the early Greek physicians Hippocrates, Celsius, Galen and to more enlightened physicians of the middle ages, the teeth are an integral part of the body, and that they were vitally affected by and in turn affected the body. A vital theory of tooth decay was advanced, towards the end of the 18th century, which postulated that tooth decay originated, like bone gangrene, from within the tooth itself.

Chemical Theory Robertson in 1835 proposed that dental decay was caused by acid formed by fermentation of food particles around teeth. Since fermentation was at this time considered to be a strictly nonvital process, the possibility that microorganisms were involved was not, as yet, recognized.

Parasitic Theory Long before the demonstration of the germ theory of disease, the possibility that microorganisms can have toxic and destructive effects on tissue was postulated. These postulations spelled the end of the vital theory and gave rise to the idea that chemicals can destroy teeth. In 1843, Erdl described filamentous parasites in the membrane removed from teeth. Early microscopic observations of scrapings from teeth and of the carious lesions, by Antonie van Leeuwenhoek, indicated that microorganisms were associated with the carious process. A text of what he saw is “I am in the habit of rubbing my teeth with salt in the morning

Chapter 38  Dental Caries and then rising my mouth with water and often after eating, to clean my back teeth with a toothpick, as well as rubbing them hard with a cloth, therefore my teeth back and front remain as clean and white that only a few people of my age can compare with me. Also when I rub my gums with hard salt, they will not bleed. Yet all this does not make my teeth so clean I can see, looking at them with a hollow mirror, that something will stick and grow between the molars, a little white matter, as batter. Observing it I judged that although I could not see anything moving in it there were yet living animalcules in it. I then mixed it several times with pure rain-water, in which there were no animalcules, I then again and again saw that there were many small living animalcules in the said matter, which moved very prettily.”

Miller’s Chemoparasitic Theory A synthesis of the ideas that acid and microorganisms were involved in the etiology of dental caries occurred in 1889 when Miller, an American working at the University of Berlin, published a text entitled “Die Mikroorganismen der Mundhohle”. At this time, Pasteur had discovered that microorganisms mediate the process of conversion of sucrose to lactic acid. This enabled Miller to assign to oral microorganism the role of acid formation and thus assigned a chemical role to flora, which is the basis of his chemoparasitic theory of dental caries. • The microorganisms of the mouth, by secretion of enzymes or by their own metabolism, degrade the fermentable carbohydrate food material so as to form acids. • Carbohydrate food material lodged between and on surfaces of teeth is the source of the acid, which demineralizes the lime salts of the tooth. • The enamel is destroyed by the acid of fermentation and the disintegrated enamel is subsequently mechanically removed by forces of mastication. • After penetration of the enamel, the dissolution of dentin is brought about in the same manner with the organisms penetrating along the dentinal tubules. • The final breakdown of dentin results from the secretion of proteolytic enzymes that digest the organic part of dentin and form a cavity. Miller concluded that caries was caused not by a single species of microorganisms but was related to multiple microbial activities involving acid production and protein degradation. Miller summarized his theory, as follows “Dental decay is a chemoparasitic process consisting of two stages: decalcification or softening of the tissues and dissolution of softened residue”.

Proteolytic Theory The surface coverings found on the tooth, in grooves and pits, are organic in nature; also enamel contains small but significant amount of organic material. These observations

and the fact that carious lesions are characterized histologically by pigmentation, a phenomenon that was interpreted, without evidence, as being indicative of proteolysis, led to the development of the proteolytic theory espoused primarily by Gottlieb (1947), Frisbie, Nuckolls (1947) and Pincus (1950). They described caries like lesions that were initiated by proteolytic activity at a slightly alkaline pH, and considered that the process involved depolymerization and liquefaction of the organic matrix of enamel. Gottlieb proposed that microorganisms invade the organic pathways of enamel and initiate caries by proteolytic action. Subsequently, the inorganic salts are dissolved by acidogenic bacteria.

Proteolysis: Chelation Theory This theory proposed by Schatz et al. in 1955 implies a simultaneous microbial degradation of the organic components (hence, proteolysis), and dissolution of the minerals of the tooth by the process of chelation. According to the proteolytic chelation theory, dental caries results from an initial bacterial and enzymatic, proteolytic action on the organic matter of enamel without preliminary demineralization. Such action, the theory suggests, produce an initial caries lesion and the release of a variety of complexing agents, such as amino acids, polyphosphates and organic acids. The complexing agents then dissolve the crystalline apatite.

Sulfatase Theory Pincus (1950) advanced the sulfatase theory, whereby bacterial sulfatase hydrolyzes the ‘mucoitinsulfate’ of enamel and the chondroitin sulfate of dentin producing sulfuric acid that, in turn, causes decalcification of the dental tissues.

Complexing and Phosphorylation Theory It can be readily demonstrated that an uptake of phosphate by plaque bacteria occurs during aerobic and anaerobic glycolysis and the synthesis of polyphosphates. According to this theory, the high bacterial utilization of phosphate in plaque causes a local disturbance in the phosphate equilibrium in the plaque and the tooth enamel resulting in loss of inorganic phosphate from enamel. Soluble calcium complexing compounds produced by bacteria cause further tooth disintegration.

CURRENT CONCEPT OF DENTAL CARIES • In the epidemiological model (Fig. 38.11), a disease state is due to interplay of three primary factors (Keyes and Jordan, 1960): THe host, the agent or recruiting factor and environmental influences.

477

478 Section 8 

Cariology

Fig. 38.11: Keyes model

• Newbrun in 1982 postulated that many secondary factors also influence the rate of progression of caries (Fig. 38.12). • Interaction between three primary factors is essential for the initiation and progression of caries: A susceptible host tissue, the tooth; microflora with a cariogenic potential; and a suitable local substrate to meet the requirements of the pathodontic flora. • The tooth is the target tissue destroyed in the dental caries process. The cariogenic oral flora, which is localized to specific sites on teeth, is the agent that produces and secretes the chemical substances that causes the destruction of the inorganic components and the subsequent breakdown of the organic moieties of enamel and dentin. The local substrate provides the nutritional and energy requirement for the oral microflora, thereby permitting them to colonize, grow, and metabolize on selective surfaces of teeth. The third factor, the resistance of the tooth, is obviously important since this determines the overall effects of the attack. • The hypothesis that bacteria are a prerequisite for the initiation and progression of dental caries was clinched by Orland (1954) at the University of Chicago. Germfree animals obtained by cesarean delivery and directly transferred to a sterile isolator were fed sterile food. 22 rats, which were fed a cariogenic diet and maintained in a germ-free environment, were caries free. Out of the 39 control rats fed the same diet but maintained in a conventional laboratory environment, 38 developed carious lesions. This study laid to rest debates extending over a century about the role of bacteria in dental caries. Fitzgerald in 1968 concluded that:

Fig. 38.12: Current concept of dental caries

– Microorganisms are a prerequisite for caries initiation. – A single type of organism is capable of inducing caries. – The ability of producing acid is prerequisite for caries induction but not all acid-producing organisms are cariogenic. – Organisms vary greatly in their capacity (virulence) to induce caries.

Demineralization-remineralization Concept • Dental caries is not a result of a single acid attack caused by the acid formed as a result of fermentation of dietary substrates by the oral microflora. Rather it is an outcome of the imbalance occurring in the demineralizationremineralization cycle that is continuously operating in the oral cavity. • This balance is governed by a number of factors which is either caries promoting (promotes demineralization) or caries inhibiting (promotes remineralization). These factors have been depicted in Figure 38.13. • An important point to be mentioned is all these factors are present in every individual’s oral cavity but in different proportions determining the direction of the demineralization-remineralization cycle.

Stephan Curve • In 1940’s, Dr Robert Stephan, an officer in the US Public Health Service, suggested there was a continuous change

Chapter 38  Dental Caries

Fig. 38.13: Demineralization-remineralization cycle

Fig. 38.14: Stephan curve

in salivary pH following consumption of foods and beverages, especially with fermentable carbohydrates. • Stephan curve is a graph (Fig. 38.14) published by Stephan and Miller in 1944 which reflected the fall in salivary pH following a glucose rinse. • Stephan selected patients who were either caries-free or caries-inactive or who exhibited various degrees of caries activity. Subjects were asked not to brush their teeth for three to four days prior to the measurement of the plaque biofilm pH on the labial surfaces of the anterior teeth. Prior to rinsing with 10 mL of a 10 percent glucose solution for 10 seconds, pH readings were obtained. After rinsing with the glucose solution, pH readings were obtained at various time intervals until the pH returned to its original value. The graph has four landmarks viz: resting pH, the rapid fall in pH, the critical pH and the recovery phase.

pH decrease is the buffering capacity of unstimulated saliva. The rate at which plaque pH decreases is also influenced by the density of plaque. Less dense plaque can be penetrated more easily by buffering saliva and oxygen causing slower pH decreases than very dense plaque, which cannot be accessed by saliva and oxygen. Critical pH:  The critical pH is the pH at which saliva no longer remains saturated with calcium and phosphate, thereby permitting the hydroxyapatite in dental enamel to dissolve. It is the highest pH at which there is a net loss of enamel from the teeth, which is generally accepted to be about 5.5 for enamel.

Resting plaque pH:  This describes plaque that has not been exposed to fermentable carbohydrates  for approximately 2  hours and generally has a pH of between 6 and 7. The resting plaque pH value for an individual tends to be stable and may remain so for long periods. One example of an exception is if antibiotics have been taken, which may alter the oral flora.

Increase in plaque pH:  The low pH remained for some time, taking 30 to 60 minutes to return to its normal pH (in the region of 6.3–7.0). Differences were seen between the cariesfree group and the caries-active group, with the later group having significantly lower plaque pH. The gradual recovery of the plaque pH is influenced by various factors. These include the buffering capacity of saliva, whether fermentable carbohydrate remains in the mouth and the diffusion of acids from plaque into saliva or teeth.

Decrease in plaque pH:  After exposure of dental plaque to fermentable carbohydrates, the pH decreases rapidly. The rate at which the pH decreases is due in part to the microbial composition of dental plaque. In general, if more acidogenic, aciduric bacteria is present in plaque, the pH would lower more rapidly. The rate of pH decrease is also dependent on the speed with which plaque bacteria are able to metabolize the dietary carbohydrate. While sucrose would be metabolized quickly, prompting a more rapid decrease, larger molecules, like starch, would diffuse into plaque more slowly because it would need to be broken down before it can be assimilated by plaque microbes. Another factor that affects the rate of

Application of Stephan’s curve in day-to-day life: • Figure 38.15 shows the plotting of the variation of salivary pH after various meals and snacks. • The initial flat part of the graph represents the resting pH of saliva which is mostly constant for an individual. • The first dip in the graph represents the fall in salivary pH soon after the breakfast. The degree of fall depends upon the constituents of the breakfast. A breakfast more rich in fermentable carbohydrates will lead to a steeper fall of pH and to a lower level of pH. • Once the pH goes below the critical pH the saliva no longer remains saturated with calcium and phosphate

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Fig. 38.15: Applicability of Stephan’s curve in daily routine

ions. This results in the shifting of the demineralizationremineralization equilibrium towards demineralization. By the action of buffering agents of saliva and other protective actions like the washing and flushing action of saliva the pH starts rising. During this event if the pH rises above the critical pH remineralization of the tooth will start. • In a situation where an individual consumes snacks before the pH rises above the critical pH (as showed between the lunch and dinner), the salivary pH again falls and does not allow the repair process of remineralization. This outlines the deleterious effect of frequent snacking on the caries process in oral cavity. • In contrast to this if an individual rinses his oral cavity or brushes his teeth after meals (as showed after dinner) this leads to the flushing out of the acid produced by the microorganisms. In addition this also lowers the microbial load of the oral cavity and removes the trapped food particles which acts as a reservoir for the substrate required for acid production. All these events results into a steeper rise in the pH thus exposing the tooth to the acid attack for a lesser time period. • To conclude all those factors which try to maintain the pH of the oral cavity above the critical pH are caries protective in nature and those which lowers the pH below this level may be considered caries promoting.

HISTOLOGY OF DENTAL CARIES Knowledge of the histopathologic features of dental caries is important in detecting and diagnosing the lesion. Familiarity with the shape of lesion is of fundamental importance in understanding the design of cavity preparations.

Histopathology of Enamel Caries A radiographically detectable initial enamel lesion when examined histologically will show the carious process penetrating to the underlying dentin, although the dentinal tissue is not yet invaded by bacteria. A carious lesion on the smooth surface of enamel is conical shape with its broad base on enamel and the apex toward the dentin. When the lesion reaches the enamel-dentin junction it spreads laterally along the junction, thus undermining normal enamel. Light microscopy studies of carious lesions of enamel without cavitation have revealed four distinct zones, which represent varying degrees of hard tissue transformation. Starting from the advancing front of the lesion these zones are classified as (Fig. 38.16): • A translucent zone which is the advancing front of the lesion. • A dark zone separating the translucent zone from the body of the lesion. • The body of the carious lesion, which is markedly radiolucent. • A relatively intact enamel surface layer. – Translucent zone: The advancing front of a carious lesion is represented by the translucent zone. The first discernible signs of enamel breakdown are seen in this area. This zone is not a consistent feature of enamel caries and is only seen when longitudinal ground section of carious teeth are examined. Enamel alteration in this zone results in spaces or pores at junction sites such as the prism boundaries. Microdensitometric and chemical studies of this zone indicate some loss of mineral, and a resultant pore

Chapter 38  Dental Caries Determinants of dental caries Primary factors Plaque

Substrate

Tooth

Secondary factors

Bacterial metabolites

Dissolve

Role in caries

•

Oral hygiene

•

Oral flora

•

Saliva-pH, composition, flow, buffer

•

Fluoride in plaque

•

Diet

•

Transmissibility

•

Type of carbohydrates

Chelators

Bind calcium ions

•

Chemical composition of food

Proteolytic enzymes

Breakdown of organic matrix Major in dentinal caries

•

Physical characteristics of food

•

Oral clearance

•

Frequency of eating

•

Sugar intake and frequency

•

Fluoride concentration

•

Carbonate and citrate level

•

Age of tooth

•

Morphology of tooth

•

Trace elements

•

Nutrition

•

Saliva

•

Composition of enamel

Fig. 38.16: Histopathology of enamel caries

Organic acids

Mechanism of destruction

Major

Organic phase

Minor

Major

volume of about 1 percent as compared to 0.1 percent in normal enamel. The preferential removal of acidlabile moieties, such as carbonate and magnesium together with calcium and phosphate, is responsible for the increase in porosity but there is no evidence that organic material is removed or significantly altered in the translucent zone. – Dark zone: The dark zone lies deep to the body of the lesion and just superficial to the translucent zone. This zone is positively birefringent and has a pore volume of 2 to 4 percent. This molecular sieving effect permits the micropores to remain filled with air. Light passing through this zone causes the brown discoloration of the dark zone. This is also the reason why the dark zone shows a reversal in its birefringence from negative to positive. Because of this phenomenon the dark zone is often referred to as the positive zone. – Body of lesion: Deep to the relatively unaffected enamel surface layer is the body of the carious lesion. Ground sections, when viewed in transmitted light, reveal

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enhanced Striae of Retzius and cross-striations in the enamel prisms. This zone, unlike normal, enamel, is positively birefringent denoting a significant degree of mineral loss. The body of the lesion has a minimum pore volume of 5 percent at its periphery and, even in a small subclinical lesion; there is a 25 percent pore volume. – Surface zone: An important feature of the initial carious lesion is the presence of an apparently intact enamel surface overlying an area of subsurface demineralization. Quantitative studies of the sur­ face layer, 20 to 100 mm thick, indicate that partial demineralization equivalent to about 1 to 10 percent loss of mineral salts has taken place. The surface zone has been defined as the zone of negative birefringence superficial to the positively birefringent body of lesion.

Histopathology of Dentinal Caries As the carious lesion invades the dentin, the dentinal tubules become involved. This is divided into five zones, proceeding from the lesion inward to normal dentin (Fig. 38.17): 1. Zone of decomposed dentin 2. Zone of bacterial invasion 3. Zone of demineralization 4. Zone of dentinal sclerosis 5. Zone of fatty degeneration. • These zones are only discrete and distinguishable as separate entities in slowly advancing carious lesions and are probably passive changes imparted on the dentin by the invading microorganisms, including their indirect effect due to demineralization. • The acute carious lesion is characterized by rapid decomposition and demineralization. The chronic type, on the other hand, exhibits typical changes in the degree of mineralization subjacent to the demineralized zone.

Fig. 38.17: Histopathology of dentinal caries

Abbreviations: (A) Zone of decomposed dentin; (B) Zone of bacterial invasion; (C) Zone of demineralization; (D) Zone of dentinal sclerosis; (E) Zone of fatty degeneration.

• The translucent zone is identical to the sclerosed dentin (zone 4). Presumably the sclerosis is an attempt to block the advancing carious lesion. Next to the sclerosed dentin is a narrow zone of demineralization, affecting the intertubular matrix. Occlusion of dentinal tubules observed in this zone and in the sclerotic dentin is probably due to a reprecipitation of crystalline material that had dissolved during the carious process. • The most noticeable change in carious dentin is the zone of bacterial invasion. Frequently, the lumen of the tubule is distended, giving a ballooned or dilated appearance variously described liquefaction foci. These dilations eventually coalesce, forming the outermost zone of decomposed dentin. • Additional changes that may occur in carious dentin are the formation of clefts at right angles to tubules or follow contour lines of Owen and of dead tracts.

SALIVA AND DENTAL CARIES Clearance from the oral cavity

One of the most important fun­ctions of saliva with respect to its role in caries is the removal of bacteria and food debris from the mouth. When saliva is swallowed, any bacteria contained therein are removed from the oral cavity and pass into the stomach. The average unstimulated salivary flow rate is about 0.3 mL/min. Thus, the halflife in the oral cavity for any inert material suspended in saliva is only a few minutes and is certainly very much less than the oral cavity for any inert material suspended in saliva is only a few minutes and is certainly very much less than the mean generation time of oral microorganisms.

Inorganic constituents of saliva

Na+, Cl–, HCO3, K+, F–

Fluoride concentration in saliva

The level of fluoride ions in ductal saliva is in the range of 0.01 to 0.03 ppm. Fluoride levels in saliva are largely independent of salivary flow rate and are determined by the amount ingested. Administration of 3.0 to 10.0 mg of fluoride daily results in a significant increase in fluoride concentrations in secretions from the major salivary glands.

Chapter 38  Dental Caries Calcium and phosphate These ions help in remine­raliconcentration in saliva zation. Salivary proteins with digestive functions

Salivary antibacterial substances







These include amylase and other hydrolytic enzymes. The main functions of amy­lase in the oral cavity may be to increase the rate of dissolution and removal of starch-containing food debris retained around the teeth and on the oral mucosa. In addition to amylase, small amounts of other enzymes with digestive functions have been detected. These include acid phosphatase, ribonuclease, esterase and aminopeptidase. A number of antibacterial factors, such as lysozyme, lactoperoxidase lactoferrin and immunoglobulin A, are present in saliva. The role of the salivary antibacterial factors in the oral microbial ecology is largely unknown but possibly they function to prevent the establishment of more pathogenic transient invaders. Lysozyme: It is an enzyme, which has the property of cleaving the cell walls of certain microorganisms, thereby causing their lysis. Lactoperoxidase: It has been known for a number of years that a factor exists in milk, tears and saliva, which can inhibit the growth, and acid formation of some bacteria. Subsequently, the substance was identified as an enzyme called lactoperoxidase. Lactoperoxidase oxidizes thiocyanate (SCN) in the presence of hydrogen peroxide that is formed by many oral organisms. This antibacterial system is known to be inhibitory towards lactobacilli and some streptococci. Lactoferrin: The bactericidal effect of lactoferrin is due to its strong iron-binding capacity thereby removing iron from solution and making it unavailable as an essential bacterial nutrient. Lactoferrin has been shown to be antagonistic to S. mutans.

Salivary proteins with protective functions



Glycoproteins: They are covalent complexes of protein and carbo­ hydrate. They are usually classified according to the nature of the linkage of the carbohydrate side chain bound to the protein molecule. The most important glycoproteins in saliva that have protective function are the mucinous type. Salivary agglutinins: Recent evidence indicates that some of the salivary glycoproteins can interact specifically with microorganisms. It has been demonstrated by Gibbons (1970) that salivary glycoproteins can cause an aggregation of various strains of oral microorganisms. Agglutination of microorganisms could either result in their rapid removal from the oral cavity when the saliva is swallowed or, if the agglutinated microorganisms are more adherent, could promote their colonization on epithelial and dental surfaces.

Salivary proteins, which Several salivary proteins bind cal­inhibit formation of cium and inhibit formation of hydroxyapatite hydroxyapatite. These proteins are statherin and a group of prolinerich proteins. Statherin: It is a polypeptide of molecular weight 5,380, consists of 43 amino acids. Statherin, in addition to inhibiting formation of hydroxyapatite, also prevents precipitation of calcium phosphate salts. The physiological advantages of the presence of salivary statherin are that saliva can be supersaturated with respect to hydroxyapatite, thus facilitating remineralization of early carious lesions, without the spontaneous precipitation of calcium phosphate, which would otherwise occur. Proline-rich proteins: A number of proteins have been isolated from saliva, which is characterized by a high content of proline varying from about 25 to 40 percent of the total number of amino acid residues. They inhibit hydroxyapatite formation and

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484 Section 8 

Cariology constitute a substantial amount of the protein.

Buffering capacity of saliva

Saliva has three buffering systems but bicarbonate system is the most powerful of all. The buffering capacity of saliva is a very important property that affects the caries process. The bicarbonate in saliva is able to diffuse into dental plaque to neutralize the acid formed by microorganisms.

Physical properties of foods and cariogenicity



DIET AND DENTAL CARIES Our diet habits have undergone considerable changes, both in quantity and quality, since our evolution. Food can have a two-fold effect because the effects of nutrition are mediated systemically and the effects of diet are manifested locally. The interaction between diet and tooth is of great importance in relation to caries. Although, it is true that microorganisms are chiefly responsible for caries but the importance of substrate cannot be undermined because micro­organisms cannot cause caries without a suitable substrate. The occurrence of caries is dependent on two factors—preeruptive (blood, saliva) and posteruptive factors (maturation, mineralization, chelation, plaque, bacteria).

Dietary Constituents and Dental Caries Polysaccharides and sugars

The four carbohydrates—starch, sucrose, fructose and glucose comprise the greatest proportion of foods consumed by man. The main polysaccharide (starch) is not highly cariogenic in man at least in some circumstances. Controlled studies in experimental animals and in humans have confirmed that excessive and frequent use of highly fermentable mono and disaccharides is correlated with high caries rates. While glucose, fructose, lactose and mannose have been shown to be cariogenic in animal experiments they are usually minor constituents of human foods as they are present only in dried fruits, honey and milk. Sucrose is by far the most common dietary sugar and most cariogenic.



We know little about the significance of physical properties of foods and their effects on cariogenicity, since few studies involving human subjects have been conducted to explore this relationship. Some important phy­ sical properties that determine food texture are: • Mechanical properties: Hard­ ness, cohesiveness, viscosity • Geometric properties: Particle size and shape • Others: Moisture and fat con­ tent. From a dental standpoint the physical properties of food may have significance by affecting food retention, food clearance, solubility and oral hygiene. Obviously if a type of food is more sticky then there are more chances of getting caries as compared to a food that is readily cleared from oral cavity.

The physical texture and It is known to effect salivary chemical composition of flow rates. Saliva that is rapidly food flowing is more alkaline than resting saliva and more super­ saturated with calcium and phosphate and thus may be more caries inhibitory. Physical properties of food

Those foods that improve the cleansing action and reduce the retention of food within the oral cavity and increase saliva flow are to be encouraged in everyday diets. However, clinical evidence that consumption of these food items will significantly reduce caries per se is lacking.

Acidity of foods

Some dietary items are highly acidic and therefore, affect, usually in a transient manner, the pH in plaque and saliva. Natural foods, such as lemons, apples, fruit juices and carbonated beverages, are sufficiently acidic so as to cause demineralization of enamel that is in prolonged contact with them.

Chapter 38  Dental Caries These items, under normal dietary use, are of no consequence in the dental caries process. However, excessive (habitual) use of these foods and beverages may cause etching of enamel with cavitations. Vitamins

Lipids

Vitamin D and vitamin A are most important with respect to develop­ ment of teeth. Decrease of vitamin D will lead to calcium and phosphate derangement and, in turn, cause hypoplasia of teeth. Deficiency of vitamin A can lead to changes in ameloblasts thereby causing alteration in tooth morphology and can also have deleterious effects on salivary glands. Fat consumed has been somewhat responsible for anticariogenic effect. This mechanism can be due to protection from demi­ neralization by formation of fatty film in proximal areas.

Evidence of Relation between Diet and Caries The single most important determinant of cariogenicity in the oral cavity is the availability of a suitable local substrate for the oral flora. Some studies have been conducted in human that effectively summarize the diet-caries relation.

Hopewood House Study • In 1942 an eccentric, wealthy Australian businessman transformed what was formerly a spacious country mansion, Hopewood House, into a ‘motherhouse’ for young children at NSW, Australia. Since the businessman had attributed his own dramatic recovery in health to a drastic change in dietary habits he stipulated that the children of Hopewood House should be raised on a natural diet that excluded refined carbohydrates. • The basically vegetarian diet of these children was adequate but spartan porridge, biscuits, wheat gram, fresh and dried fruit, vegetables (cooked and raw), along with butter cheese, eggs, milk and fruit juices. Vitamin concentrates and an occasional serving of nuts and a sweetening agent such as honey supplemented the meals. The food was uncooked as far as possible in order to retain its natural state. • The most striking feature of this diet was the notable absence of sugar.

• The fluoride content of the water and food was insignificant and no tea was consumed. All meals and between meal eating were controlled with great regularity. • At the end of a 10-year period, the 13-year-old children of Hopewood House had a mean DMF per child of 1.6; the corresponding figure for the general child population of the State of NSW was 10.7. Only 0.4 percent of the 13-year-old state school children were free from dental caries, whereas 53 percent of the Hopewood children experienced no caries. The children’s oral hygiene was poor, dental calculus was uncommon, but gingivitis was prevalent in about 75 percent of the children. • This work shows that in insti­tutionalized children, at least, dental caries can be reduced to insignificant levels by a spartan diet, and without the beneficial influence of fluoride and in the presence of unfavorable oral hygiene.

Vipeholm Study • In 1939, the Swedish Government requested the Royal Medical Board to investigate the measures that should be taken to reduce the frequency of the most common dental disease in Sweden. This request led to a study at the Vipeholm Hospital, Lund an institution for mentally disabled individuals, of the relationship between diet and dental caries. The purpose of the study was to find answers to the questions like: – Does an increase in carbohydrate (mostly sugar) intake cause an increase in dental caries? – Does a decrease in carbohydrate (sugar) intake produce a decrease in dental caries? • The 436 patients involved in this study were divided into control and 6 experimental groups. All patients received for 1 year a diet relatively low in sugar, with no sugar inbetween meals. The groups were divided as: – Control groups: Received a low carbohydrate (mostly starch), high fat diet practically free from refined sugar. Caries activity was almost completely suppressed. After 2 years this diet was replaced by an ordinary diet to which was added 100 g of sugar a day at meal times, which was accompanied by a small but statistically significant rise in caries activity. – Sucrose group: Received 300 g of sucrose in solution at meal times. – Bread group: 345 g of sweet bread containing 50 g of sugar. – Chocolate group received the 300 g sugar with meals, which was reduced to 100 g supplemented by 65 g of milk chocolate between meals during the second 2 years. – Caramel group: Received 22 caramels daily in 2 portions between meals. – 8-toffee groups: Received 8 toffees in two portions. – 24-toffee group received 24 toffees between meals.

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Cariology

• The main conclusion of the Vipeholm study summarized as: – The risk of sugar increasing caries activity is great if the sugar is consumed in a form with a strong tendency to be retained on the surfaces of the teeth. – The risk of sugar increasing caries activity is greatest if the sugar is consumed between meals. – Increase in caries activity due to the intake of sugar rich foodstuff consumed in a manner favoring caries the lesion disappear on withdrawal of such foodstuffs from the diet. – Carious lesions may continue to appear despite the avoidance of refined sugar, maximum restriction of natural sugars and total dietary carbohydrates. – The risk of an increase in caries activity is intensified with an increase in the duration of sugar clearance from saliva.

Turku Study • Another large scale and important experiment on caries in human subject was carried out in Turku, Finland, and reported in detail by Scheinin and Makinen in 1975. • The aim of this study was to compare the cariogenicity of sucrose, fructose and xylitol. • 125 subjects were divided into three groups on a basis of their own preference. The three groups were, first was sucrose group who received their ordinary sucrose containing diet, in the second group received xylitol and in the third group fructose. • The results after 1 year showed that sucrose and fructose had equal cariogenicity whereas xylitol produced almost no caries. But the second year, caries had continued to increase in the sucrose group but remained unchanged in the fructose group implying that sucrose was more cariogenic than fructose. But the important finding was that in the xylitol group some early white spot lesions had been remineralized to a point where they could not be scored. These results provided sufficient evidence to link cariogenicity of carbohydrates, especially sucrose.

Experimental Production of Caries in Man • Two such experiments have been tried one in Denmark by Vonder Fehr in 1970 and second in Britain by Edgar in 1978. • The procedures followed in these studies were 9 daily rinses with 10 mL of 50 percent sucrose and discontinuance of active oral hygiene procedure. White-spot lesions on smooth surfaces were produced in 3 weeks in the experimental group. • At the end of the experiment meticulous oral hygiene measures were reinstituted along with a daily mouth rinse

of 0.2 percent NaF, which resulted in remineralization of the white spots and a reversal of the caries index scores to the same values as in the control group. • This investigation again produced the required evidence of diet-caries correlation.

Hereditary Fructose Intolerance • In 1959, Froesch described an inborn error of fructose metabolism transmitted by an autosomal recessive gene. The metabolic error in this condition is due to deficiency of hepatic fructose-1-phosphate aldolase. This causes a cellular accumulation of fructose-1-phosphate, which, in turn, inhibits fructose phosphorylation. This condition results in episodes of pallor, nausea, vomiting, coma and convulsion following ingestion of fruit containing fructose or cane sugar. • Persons with HFI show a strikingly reduced dental caries experience when compared to a control population of the same age.

FOOD SUGAR SUBSTITUTES The importance of diet in the development of caries was suspected in antiquity and established in modern times. The process has been shown to be multifactorial in nature, but it has been generally accepted that sugars in the diet are a major contributor to the disease. Sucrose is the most common sugar added to beverages and food products with the consumption in developed countries reported to be 40 to 60 kg/person/year. In recognition of the caries potential of sucrose, investigators have searched for alternative sweetness. The ideal agent would provide sweetness, but with no unpleasant after-taste, have little or no calories, not be carcinogenic or mutagenic, be economical to produce, and would not be degraded by heat when cooked. Identification of such a product has been challenging. Although several non-nutritive sweetening agents have been marketed, none have processed all of the preferred properties. Some of the agents approved by FDA are: Aspartame

It is a dipeptide methyl ester, sold under the brand names of Nutrasweet and Equal. It was discovered in 1965 and is approximately 200 times sweeter than sucrose. Aspartame was approved in 1981 for limited use as a sweetener and extended to a larger market in 1983. Aspartame is the most widely used noncariogenic artificial sweetener. Its primary

Chapter 38  Dental Caries use is in diet soft drinks, yogurt, puddings, gelatin and snack foods. Aspartame has been shown to have a protective effect against some mycotoxins and is claimed to be safe for use by type II diabetics. But some of the disadvantages of this are reduced number of sickle cells in the blood of patients with homogeneous sickle cells anemia, relative toxic affects on growth, glucose homeostasis, and liver functions with long-term usage.

sweetener in a variety of food substances such as chewing gum, chocolates, and confectionaries. It is half as sweet as sucrose and is considered noncariogenic but it may be absorbed from the gastrointestinal tract and can cause diarrhea if ingested in large quantities. Xylitol

It was discovered in wood chips in 1890 and in wheat in 1891. It is a nonfermentable, pleasant tasting, noncariogenic polyol derived from pentose sugar xylose and is relatively expensive to manufacture. Xylitol is as sweet as sucrose and was approved as safe for use in humans in 1986. It is used primarily in chewing gum and possesses approximately the same sweetness potency as sucrose. Recently, xylitol has been credited in reducing the transmission of cariogenic bacteria from mother to infant and has been shown to have bactericidal qualities. The FDA has not yet approved additional uses of xylitol as a sweetener. However, numerous studies have established the safety for human consumption.

Stevia

It is natural occurring, heat stable sweetener, which is extracted from Stevia rebaudiana Bertoni a member of the chrysanthemum family. The active ingredient, stevioside, is a white crystalline material that contains three glucose molecules and steviol, a ditepenic carboxylic alcohol. Its sweetness potency is 100 to 300 times greater than sucrose. Stevia is caloriefree, noncariogenic and has been used by the indigenous peoples of Paraguay for centuries as a sweetner. It is widely used commercially in Brazil and Japan, and to a lesser extent in China, Germany. In 1995, the FDA approved the importation and use of Stevia as dietary supplement, but not as a sweetener.

Neotame

It is a new product similar in chemical structure to aspartame being developed commercially by the Nutrasweet Company. Neotame is a high intensity sweetener reported to have a clean taste with no unpleasant characteristics. It has sweetness potency 6000 to 9000 greater

Acesulfame A non-nutritive produce, approved by the potassium FDA in 1988 for use as a sweetener in dry food products. In 1994 yogurt, refrigerated deserts, syrups and baked foods were added to the approved list. The use of Acesulfame potassium is approved for use in foods, beverages, cosmetics and pharmaceutical products in more than 30 countries. Although considered safe for consumption by humans there have been some health issues raised relative to dose-dependent cytogenetic toxicity. Saccharin

Sucralose

Sorbitol

It is 200 to 500 times sweeter than sucrose and is the oldest of the artificial sweeteners used. It is noncario­genic and noncaloric and is available in liquid and tablet form as a table sweetener but has a slightly bitter after-taste. But in 1970 saccharin was identified as a potential bladder carcinogen and its use has hence been limited. It is a non-nutritive, noncaloric, trichlori­nated derivative of sucrose. Sucralose is widely used throughout the world in many food products such as tea and coffee sweetener, carbonated and noncarbonated beverages, baked goods, chewing gum and frozen desserts. No health concerns have been reported with it. It is a sugar alcohol that occurs naturally in many fruits and berries. It is produced commercially from glucose, but is expensive to manu­facture. Sorbitol is often used as a “bulk”

487

488 Section 8 

Cariology than sucrose and is reported to be heat stable in baking applications. Similar to other sweeteners the potency of Neotame may vary depending upon the food or how it is used. Neotame is reported to be functional and stable in carbonated soft drinks, powdered soft drinks, yellow cake, and yogurt. Neotame has been submitted to the FDA or consideration as a new sweetener in several food categories. However, it has not yet been approved.

CARIES VACCINE Dental caries remains one of the most widespread diseases of mankind. Advances in prophylactic measures to deal with this disease have significantly reduced the overall caries rate. However, the Surgeon General’s 2000 report on oral health in America stated that a majority of five to nine years old children have at least one lesion on their teeth. This percentage increases to 84.7 percent in adults who are at least 18 years of age. In developing countries dental caries is often at epidemic proportions, especially among the poor. Landmark experiments in the 1960s established that mutans streptococci are the primary etiologic agents of this disease and that this infection is transmissible. A strong association exists between level of colonization with mutans streptococci (Fig. 38.18) and dental caries, although other organisms, such as lactobacilli, have also been implicated in this disease.

Fig. 38.18: Streptococcus mutans cell wall

Molecular Pathogenesis of the Disease The molecular pathogenesis of mutans streptococci appears to involve several phases, each of which may offer targets for immunological intervention. Acidogenic streptococci require the hard surfaces furnished by teeth for sustained colonization and accumulation (Figs 38.19 and 38.20). Initial

Fig. 38.19: Models of mutans streptococcal (MS) colonization and accumulation in dental biofilms

attachment to the tooth is achieved via the interaction of bacterial proteins with dentin in the dental pellicle covering the tooth surface. This trait is characteristic of a family of streptococcal adhesions, referred to as antigen I/II or Pac in Strepto­coccus mutans, which have been demonstrated to bind to salivary components. The ultimate pathogenicity of infant’s streptococci occurs through adhesion of hydroxyapatite in dental enamel by lactic acid. However, significantly destructive concentrations of this acid require the substantial accumulation of these acidogenic streptococci in dental plaque. This accumulation process is initiated by the activity of glucosyltransferases (GTF), insoluble forms of glucans (S. mutans GTF-B and GTF-C) that have been most closely associated with pathogenicity. These glucose polymers provide scaffolding for the aggregation of mutans and other oral streptococci through interaction with bacterial cellassociated glucan-binding proteins.

Chapter 38  Dental Caries

Fig. 38.20: Molecular approach to a caries

Fig. 38.21: Candidate antigens

Effective Molecular Targets Several stages in the molecular pathogenesis of dental caries are susceptible to immune intervention. Microorganisms can be cleared from oral cavity by antibody mediated aggregation, blocking off colonization and inactivation of GTF enzymes. Some of the target sites for caries vaccine are: • Adhesins: Antigen I/II, Pac, P1. • Glucosyl transferases (GTF): gtfB, gtfC, gtfD, gtfl, gtfS (Fig.  38.21). • Glucan binding proteins: GbpA, GbpB, GbpC (Fig. 38.22).

Fig. 38.22: Glucosyltransferase

Types of Vaccine Subunit vaccines

These contain structural elements of either adhesions or GTF or GBP. Since it had been observed that, immune responses in animals protected by immunization were associated with measures of functional inhibition thus subunit vaccines are so designed that they contain single or multiple copies of epitopes from each

domain. Such designs would also eliminate unwanted antibody specificities. Recombinant vaccines

These are also called attenuated expression vectors. These approaches afford the exp­ ression of larger portions of functional domains. These are also helpful in targeting vaccine to appropriate lymphoid tissue for mucosal response.

489

490 Section 8  Conjugate vaccines

Cariology This is another group of vaccine approach, which intercepts more than one aspects of mutans streptococcal molecular pathogenesis by chemical conjugation of functio­ nally associated peptide components with bacterial polysaccharides.

mucosal plasma cells which secrete polymeric IgA, and is then taken up and transported by a receptor, secretory component, expressed on the basolateral surface of glandular epithelial cells and released into the saliva as S-IgA (Mestecky et al. 1991).

Routes to Protective Response (Active Immunization) Mucosal applications of dental caries vaccine are generally preferred for induction of secretory IgA antibody in the salivary compartment, since it constitutes the main immune component of major and minor salivary glands. Consequently, several routes have been tried to induce protective immune responses to dental caries vaccine antigens: • Oral: This functions by oral induction of immunity in gut associated lymphoid tissue (GALT) to elicit protective salivary IgA antibody response. Smith and Taubman, 1987 concluded that although oral route was not ideal for this approach but it esta­blished that mucosal immunity alone was sufficient to change the course of mutans infection. • Intranasal: These attempts have been made due to its close relation with oral cavity. These include intranasal installation of antigen which targets nasal associated lymphoid tissue (NALT). • Tonsillar: Tonsillar application of antigen generates a good antimicrobial response with the help of IgG (Van Kempen, Boyoka et al. 2000). Palatine and nasopharyngeal tonsils contribute precursor cells to mucosal sites. • Minor salivary gland: These have been selected as their ducts can facilitate retrograde access of bacteria and their products (Crawford, Nair, Schroder, 1983). Smith and Taubman conducted a study in which antigens were administered in lips of patients and over a six weeks period found out lower proportions of streptococcal flora as compared to placebo group. • Rectal: These have been tried with nonoral bacterial antigens as it may result in appearance of S-IgA in salivary sites. Lam et al. 2001 suggested that this route could be used to induce IgA response to streptococcal antigens because colorectal region has the capacity of inductive mucosal immune response.

Secretory Immunity Specific immune defense against the bacteria that are commonly held responsible for the initiation of dental caries, the ‘mutans streptococci’, mainly comprising Streptococcus mutans and Streptococcus sobrinus, is thought to depend upon salivary secretory IgA antibodies which are generated by mucosal system. Secretory IgA (S-IgA) whose concentration varies from 100 to 300 ug/mL in adults is produced in the salivary glands by

Source: Modified from Tenovuo; Abbreviations: GALT, Gut-associated lymphoid tissues; DALT, Duct-associated lymphoid tissues

 assive Immunization against P Cariogenic Mutans Streptococci • Passive immunization strategies have also been used in experimental animals and humans to determine their effectiveness in protecting against infection by mutans streptococci and dental caries formation. • The concept of protecting a host with passively admi­ nistered antibodies is not new, and sources of passive antibodies to mutans streptococci that have been studied include bovine milk and hen egg yolk. • Studies on immune bovine milk, or egg yolk IgY antibodies, specific for mutans streptococcal antigens, have reported a reduction in caries activity in experimental animals [reviewed in Michalek and Childers, 1990; Smith and Taubman, 1997] and a reduction in the number of recoverable S. mutans in humans [Filler et al. 1991; Hatta et al. 1997]. • IgG antibodies induced in bovine milk against S. mutans and S. sobrinus inhibit glucose uptake as well as GTF and fructosyltransferase activities of these bacteria [Loimaranta et al. 1997]. Topical application of mouse monoclonal antibody with specificity to AgI/II inhibits the recolonization of non-human primates and humans with indigenous mutans streptococci after thorough

Chapter 38  Dental Caries Possible mechanisms of antibody-mediated intervention against mutans streptococci Isotype

Steps in caries pathogenesis

Mode of action

Antibody specificity

HgA

Adherence to salivary pellicle

Blocking of adhesin-receptor interaction

AgI/II

Reduction of hydrophobicity

Surface antigens

Agglutination and clearance

Surface antigens

Binding to early colonizers

Blocking of adhesin-receptor interaction

AgI/II

Sucrose dependent accumulation

Inhibition of glucan production:

GTF:

– Inhibition of substrate binding

– Catalytic region

– Inhibition of polymer synthesis

– Glucan-binding region

Blocking of adhesion

GTF

Blocking of glucose uptake

GBP

Synergism with:

Not known

– Peroxidase (inhibition of acid production)

Not known

– Lactoferrin (inhibition of iron acquisition)

Iron-uptake molecules

Colonization at cervical tooth sites

Opsonization and phagocytosis

AgI/II; other surface antigens

Invasion of dentinal tubules

Inhibition of collagen binding

AgI/II

Acid production and other metabolic activities

IG

cleaning and chlorhexidine treatment [Ma et al. 1990; Ma and Lehner 1990]. • They have also developed a transgenic approach to generate functional S-IgA monoclonal antibodies specific for AgI/II in tobacco plants [Ma et al. 1995], and have demonstrated that these antibodies afford specific protection in humans against oral recolonization by mutans for at least 4 months.

Adjuvants and Delivery System for Caries Vaccine Mucosal routes of antigen delivery often require additional components, which can potentiate aspects of the immune response and induce sufficient antibody to achieve protective effect. • Heat labile enterotoxins–(Cholera and E. Coli): Used to enhance the induction of mucosal immunity in bacterial and viral pathogens. • Microcapsules and microparticles–(Poly lactide – co – gylcolide (PLGA)): These enhance particulari­zation of antigens by increasing association with M-cells overlying inductive regions of secretory immune system. • Liposomes: Phospholipid membrane vesicles containing drugs or antigens enhance response to mutans strepto­ coccal carbohydrate and GTF.

• Miscellaneous: Monophosphoryl lipid A with GTF induces primary and secondary IgA responses.

Final Report of Panel or Caries Vaccine The National Institute of Dental and Craniofacial Research (NIDCR) is the primary sponsor for the ongoing research in caries vaccine. The panel was convened on January 28, 2003 and the following are the general discussions, which took place during the final report: • Do small children have different safety issues or different side effects than older children and adults because of the extent of the development of their immune system? • There is public concern about the number of vaccines that infants/children currently receive. The assurance of safety is paramount. Any vaccine that is targeted for use in children will need to take into account this factor, as well as the impact that such a vaccine will have on other routinely adminis­tered vaccines. • The lack of colonization in a subset of the infant population. • There is some idea on the cost of treatment, but there is really no accurate information on the real burden (i.e. lost school or work days) or the cost in terms of pain and suffering. • The lack of longitudinal studies that identify risk factors for colonization and outcomes.

491

492 Section 8 

Cariology

• The question of the role of fluoride solution or just an ancillary approach? There is a subset of children who experience high rates of tooth decayed even though they live in fluoridated communities. Fluoride cannot be, therefore, the sole solution. • Elements of successful vaccine development.

Recommendations of the Review Panel • More research is needed in bioimmunology. • Real world barriers would have to be considered and overcome. • There might be some advantage of passive immunity. • Role and relation with other vaccines has to be considered. • Need for more longitudinal epidemiology corre­lates. • More research has to be conducted in natural examples like in patients who are not colonized despite significant exposures.

Current status of caries vaccine

Dr Martin Taubman and Dr Danial Smith from the Forsyth Institute indicated that this disease occurs in three phases: an initial interaction with the tooth surface mediated by adhesins; the accumulation of the bacteria in a biofilm and the production of glucose and glucans by the bacterial enzyme glycosyltransferase and the formation of lactic acid. The target for vaccine development in his research group has been the glycosyltransferase (GTF) and the glucan binding protein (GbP). The basic hypothesis is that mucosal induction of salivary Ig antibody to GTF interferes with the accumulation of S. mutans in hard surfaces like teeth. Their research has extended to sub-unit vaccines, delivery systems, mucosal adjuvants and several routes of application. The group has utilized several delivery system, mucosal adjutants and various routes of application. The group has utilized several delivery methods, including subcutaneous injection, intragastric incubations, oral capsular and topical application. More recently, they have used intranasal administration in aluminum phosphate or PLGA micro particles. Dr Noel Childers from the University of Alabama indicated that the pathogenesis of dental carries is complex, but that the idea is that, if you can prevent the initial colonization, this will have an effect on the disease process. Their studies have focussed on the two antigens, the first is that involved in the initial attachment (antigen I-II) and the second, one is associated with the more tenacious attachment medicated by GTF. One such system involves the use of biologically safe liposomes of 100 nm diameter. Oral, nasal and tonsillar administration of the liposomal antigen was found to be safe. The nasal spray vaccine induced the best specific mucosal IgA responses and these appeared to be dosespecific.

Dr Michael Russel, SUNY at Buffalo, indicated his work has focussed on the antigen I-II and on saliva-blinding region where certain residues appear to be important in attachment to the salivary pellicle tooth surface. Antibodies against this part of the molecule can exert an anti-adherence function. Dr Debra Trantolo from Cambridge Scientific, Boston, spoke about her work in developing a delivery system for GTF. The delivery system uses the biopolymer polyactide (PLGA), which is a bioabsorbable substance used in sutures and in drug delivery. The system is called a matrix system and is a non-encapsulation system where the biological or drug is dispersed throughout the polymer. There are no organic solvents used in the manufacturing process. An aqueous solution of the biological is sucked under vacuum into the polymer foam, which is then lyophilized and compressed to yield a spaghettilike rod that can be ground into a particulate for suspension. A better uptake is seen in the oral and nasal applications in the presence of an adhesive. Dr James Larrick from Planet Biotechnology, California, explained their work in developing secretory IgA antibodies in a product called cario Rx. The company has focussed on manufacturing monoclonals in plants that can make large amount of IgA. Cario Rx is a nominal therapy to reduce the adherence of S. mutans to teeth and it’s devoid of any adverse effect. The hypothesis is that in an altered biofilm, the antibody blocks the repopulation dynamics of S. mutans.

 enetically Modified Streptococcus mutans G for the Prevention of Dental Caries As reviewed by Florey (1946), the use of beneficial bacteria to fight harmful bacteria was first attempted over a century ago when Cantani employed a harmless organism referred to as ‘Bacto-Termo’ to treat tuberculosis. Since then, there have been dozens of reports describing both positive and negative bacterial interactions in which the presence of a particular indigenous microorganism promotes or deters the presence of a pathogen. The reason for the abiding interest in this area of microbiology is the prospect of preventing an infection by an approach traditionally called ‘replacement therapy’, or, more recently, ‘probiotics’. In this approach, a naturally occurring or laboratory derived effector strain is used to intentionally colonize the niche in susceptible host tissues that is normally colonized by the pathogen. By being better adapted than the pathogen, a well-designed effector strain will prevent colonization or outgrowth of the pathogen by blocking attachment sites, competing for essential nutrients, or other mechanisms. In this fashion, the host is protected for as long as the effector strain persists as a member of the indigenous flora, which, ideally, is for the lifetime of the host. Since Streptococcus mutans is the principle etiologic agent of dental caries (Anderson 1992), S. mutans strain BCS3-L1

Chapter 38  Dental Caries is a genetically modified effector strain designed for use in replacement therapy of dental caries. The prerequisites for this strain are: (Hillman et al. 2000). • It must have a significantly reduced pathogenic potential. • It must persistently and preemptively colonize the S. mutans niche, thereby preventing colonization by disease-causing strains whenever the host comes into contact with them. • Should be able to aggressively displace indigenous strains of S. mutans, thereby allowing even previously infected subjects to be treated with replacement therapy. • It must be generally safe and not predispose the host to other disease conditions. As most of the studies have documented the appearance of pathogenic organisms as soon as the tooth makes its appearance in the oral cavity, therefore replacement therapy of caries and implantation of an effector strain would best be accomplished in children immediately after the onset of tooth eruption and before their acquisition of a disease strain. In order to prevent supercolonization by wild-type strains when the host comes in contact with them, an effector strain should have some significant selective advantage to colonization. This would also enable subjects who have already been infected with wild-type S. mutans to be treated by replacement therapy. The ability of an effector strain to preemptively colonize the human oral cavity and aggressively displace indigenous wild-type strains was initially thought to be a complex phenomenon dependent on a large number of phenotypic properties. However, it was discovered that a single phenotypic property could provide the necessary selective advantage. A naturally occurring strain of S. mutans was isolated from a human subject that produces a bacteriocin called mutacin 1140 that is capable of killing virtually all other strains of mutans streptococci against which it was tested (Hillman et al. 1984). A correlation was also made between mutacin 1140 production and the

ability of S. mutans to persistently colonize the oral cavities of human subjects and aggressively displace indigenous mutans streptococci (Hillman et al. 1985, 1987). Three years following a single, 3 min infection regimen involving brushing and flossing of a concentrated cell suspension onto and between the teeth, all of the subjects remained colonized by the mutant strain producing 3-fold elevated amounts of mutacin 1140 (Hillman  et al. 1989). No other strains of mutans streptococci were observed in saliva and plaque samples of these colonized volunteers. The same results were found recently, years after colonization. These results indicate that this strain of S. mutans succeeded in satisfying the prerequisites for use as an effector strain in replacement therapy. It persistently and preemptively colonized the S. mutans niche in the human oral cavity and it aggressively displaced indigenous strains of this organism. Consequently, mutacin 1140 and JH 1140 were used in construction of BCS3-L I. Advantages of replacement therapy: • Needs only single colonization regimen by the effector strain. • Provide life-long protection. • Reapplication could be performed as the need arises without added concern for safety or effectiveness. • No need for patient compliance.

GLOBAL DECLINE IN DENTAL CARIES Has there been a real decline in the prevalence of dental caries? Several excellent reviews have been published during recent years and there is a general agreement that a marked reduction in caries prevalence has occurred among children in most of the industrialized countries. This is true for countries using water fluoridation as a preventive measure, as well as for countries without such programs.

Global decline in dental caries • • • • •

The wide-spread use of fluoride toothpastes Fluoride tables, fluoride gels Fluoride rinsing programs Dietary fluoride supplements Increased dental awareness

• • • • • •

Availability of dental resources Decrease in sugar consumption Dental health education programs Oral prophylaxis Fissure sealants Preventive approach in practice

• • • •

The wide-spread use of antibiotics Changes in diagnostic criteria Herd immunity As-yet-unknown factors

493

494 Section 8 

Cariology Global decline in dental caries

Diet

Fluorides

Plaque

Miscellaneous

Factors

Significant

Non-significant

• Change in diet leading to improved nutrition

35

65

• Decrease in amount of sugar consumption

20

80

• Reduced frequency of sugar consumption

55

45

• Antimicrobial effects of diet additives

0

100

• Use of sugar substitutes

30

70

• Water fluoridation

85

15

• Salt or milk fluoridation

10

90

• Fluoride toothpastes

95

5

• Fluoride tablets

50

50

• Fluoride school programs

40

60

• Fluoride applications by dentists

35

65

• Reduced plaque due to better brushing habits

80

20

• Reduced plaque due to better professional removal

50

50

• Better chemical plaque control

10

90

• Use of antibiotics or other medicines

5

95

• Change in composition or virulence of the oral microflora

10

90

• Pit and fissure sealants

25

75

• Better dental materials

40

60

• Better training of dentists

10

90

• Better instrumentation

30

70

POINTS TO REMEMBER • Caries is defined as microbial disease of the calcified tissues of teeth that leads to demineralization of the inorganic components and the subsequent breakdown of the organic moieties of enamel and dentin. • Classification of caries can be: According to occurrence (incipient, recurrent, residual); According to speed (acute, chronic); According to location (pit and fissure, smooth surface); According to direction (forward, backward caries); According to age (ECC, adolescent, senile); According to surface (simple, compound, complex). • Theories of caries: The Legend of the Worm, Humoral Theory, Vital Theory, Chemical Theory, Parasitic Theory, Miller’s Chemoparasitic Theory, Proteolytic Theory, Proteolysis – Chelation Theory, Sulfatase Theory, Complexing and Phosphorylation Theory. • Concept of caries was given by Keyes as an epidemiological model which state that a disease state is due to interplay of three primary factors–host, agent or recruiting factor and environmental influences. Newbrun in 1982 postulated that many secondary factors also influence the rate of progression of caries (Fig. 38.14). • Demineralization-Remineralization concept is that caries is not a result of a single acid attack caused by the acid formed as a result of fermentation of dietary substrates by the oral microflora. Rather it is an outcome of the imbalance occurring in the demineralization-remineralization cycle that is continuously operating in the oral cavity. • Stephan curve is a graph published by Stephan and Miller in 1944 which reflected the fall in salivary pH following a glucose rinse. • Histologically enamel caries has four zones viz. translucent zone which is the advancing front of the lesion, dark zone separating the translucent zone from the body of the lesion, body of the carious lesion, which is markedly radiolucent and relatively intact enamel surface layer. • Histologically dentinal caries has five zones viz. zone of decomposed dentin, bacterial invasion, demineralization, dentinal sclerosis and fatty degeneration. • Evidence of relation between diet and caries is proved by three landmark studies namely Hope Wood House Study, Vipeholm Study and Turku Study.

Chapter 38  Dental Caries • Food sugar substitutes are Aspartame, Acesulfame potassium, Saccharin, Sucralose, Sorbitol, Xylitol, Stevia, Neotame. • The research on caries vaccine was pioneered by Martin Taubman and Daniel Smith. The effective molecular targets are adhesions, GTF and glucan binding proteins and the most used routes for vaccination are oral, intranasal, tonsillar and rectal. • Global decline in dental caries are due to wide-spread use of fluorides, increased dental awareness, availability of dental resources, decrease in sugar consumption, preventive approach in practice, changes in diagnostic criteria and herd immunity.

QUESTIONNAIRE 1. Define and classify dental caries. 2. Epidemiology of caries in India. 3. Describe the theories of dental caries. 4. Explain the current concept of dental caries. 5. What is demineralization and remineralization cycle? 6. Explain Stephan’s curve with its applicability in daily routine. 7. Histopathology of enamel and dentinal caries. 8. Role of saliva in dental caries. 9. Explain the relation of diet and dental caries. 10. Write a note on food sugar substitutes. 11. Enumerate the reasons for decline in dental caries. 12. Write a note on caries vaccine.

BIBLIOGRAPHY 1. Anderson MH. Changing paradigms in caries management. Curf Opin Dent. 1992. pp. 2157-62. 2. Anderson MH. Current concepts of dental caries and its prevention. Oper Dent Suppl. 2001;6:11-8. 3. Caufield PW, Walker TM. Genetic diversity within Streptococcus mutans evident from chromosomal DNA restriction fragment polymorphisms. J Clin Microbial. 1989;27:274-8. 4. Chen A, Hillman JD, Duncan ML. Lactate dehydrogenase deficiency is lethal in Streptococci mutans. J Baeteriol. 1994;176:1542-45. 5. Childers NK, Michalek SM. Liposomes; in O’Hagan DT (Ed): Novel delivery systems for oral vaccine develop­ment. Boca Raton, CRC Press. 1994.pp.241-54. 6. Clarkson BH. Introduction to cariology. Dental Clinics North America. 1999;43:569-78. 7. Crowe CC, Sanders Jr ES. Bacterial interference II. Role of the nomal throat flora in prevention of colonization by group A streptococci. Infect Dis. 1973;128:527-32. 8. Dowd FJ. Saliva and dental caries. Dent Clin North America. 1999;43:579-97. 9. Dowd FJ. Saliva and dental caries. Dental Clinics North America. 1999;44;579-97. 10. Edgar WM. Saliva: Its secretion, composition and functions. Br Dent J. 1992;172:305-12. 11. Ettinger RL. Epidemiology of dental caries: A broad review. Dent Clinics North America. 1999;43:679-94. 12. Featherstone JOB. The science and practice of caries prevention. JADA. 2000;131:887-99. 13. Fejerskov O. Concepts of dental caries and their conse­quences for understanding the disease. Community Dent Oral Epidemiol. 1997;25:5-12. 14. Filler SJ, Gregory RL, Michalek SM, Katz J, Mc Ghee JR. Effect of immune bovine milk in development of dental plaque. Arch Oral Biol. 1991;36:41-7. 15. Florey HW. The use of micro-organisms for therapeutic purposes. Yale J BioI Med. 1946;19:101-17. 16. Guggenheim B. Extracellular polysaccharides and microbial plaque. Int Dent J. 1970;20:657-78. 17. Gustfsson BE,Wuensel CE, Lanke LS, et al. The vipeholm dental caries study. The effect of different levels of carbohydrate intake on caries activity in 436 individuals observed for 5 years. Acta Odontol Scand. 1954;11:232-364. 18. Harel-Raviv N, Laskaris H, Chu KS. Dental caries and sugar consumption into the 21st century. Am J Dent. 1996;9:184-90. 19. Hicks J, Godoy GF, Flaitz C. Biological factors in dental caries: Role of saliva and plaque in the dynamic process of demineralization and remineralization. J Clin Pediatr Dent. 2003;28(1):47-52. 20. Hicks MJ, Flaitz CM. Epidemiology of dental caries in the pediatric and adolescent population: A review of past and current trends. J Clin Pediatr Dent. 1993;18:43-9. 21. Hillman JD, Andrews SW, Painter S, Stashenko P. Adaptive changes in a strain of Streptococcus mutans during colonization of the human oral cavity. Microb EcolHlth Dis. 1989;2:231-9. 22. Hillman JD, Brooks T, Michalek SM, Harmon CC, Snoep JL. Construction and characterization of an effector strain of Streptococcus mutans for replacement therapy of dental caries. J Dent Res. 2000;68:543-9.

495

496 Section 8 

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23. Hillman JD, Duncan MJ, Stashenko KP. Cloning and expression of the gene encoding the fructose-1.6-diphosphate­dependent. Laclate dehydrogenase of Streptococcus mutans. Infect Immun. 1990;58:1290-5. 24. Hillman JD, Dzuback AL, Andrews SW. Colonization of the human oral cavity by a Streptococcus mutans producing increased bacteriocin. J Dent Res. 1987;66:1092-4. 25. Hillman JD, Novak J, Sagura E, Gutierrez JA, Brooks TA. Crowley PJ, Azziz A, Leung K-P, Cvitkovitch D, Bleiweis AS. Genetic and biochemical analysis of mutacin 1140, a lantibiotic from Streptococcus mutans. Infect Immun. 1998;66:2743-9. 26. Hillman JD, Yaphe BI, Johnson KP. Colonization of the human oral cavity by a strain of Streptococcus mutans. J Dent Res. 1985;64:1272-4. 27. Hillman JD. Genetically modified Streptococcus mutans for the prevention of dental caries. Antonie Van Leeuwenhoek. 2002;82:361-6. 28. Hurst A Nisin. In: Perlman and Laskin (Eds) Advances in Applied Microbiology Academic Press, London. 1981;27:85-123. 29. Jensen ME. Diet and dental caries. Dental Clinics North America. 1999;43:615-33. 30. Johnson CP, Gross SM, Hillman JD. Cariogenic potential in vitro in man and in vivo in the rat of lactate dehydro­genase mutants of Streptococcus mutans. Arch Oral Biol. 1980;25:707-13. 31. Kandelman D Sugar. Alternative sweeteners and meal frequency in relation to caries prevention: New perspectives. Br J Nutr. 1997;77(Suppl 1):S121-8. 32. Kidd EAM. Caries management. Dental Clinics North America. 1999;43:743-64. 33. Koulourides T, Bodden R, Keller S, et al. Cariogenicity of nine sugars tested with an intraoral device in man. Caries Res. 1976; 10:427-41. 34. Krasse B, Edwardsson S, Svensson I, Trell L. Implantation of caries-inducing streptococci in the human oral cavity. Arch Oral Biol. 1967;12:231-6. 35. Lenander-Lumikari M, Loimaranta V. Saliva and dental caries. Adv Dent Res. 2000;14:40-7. 36. Ma JK-C, Hiatt A, Hein M, Vine ND, Wang F, Stabila P, van Dolleweerd C, Mostov K, Lehner T. Generation and assembly of secretory antibodies in plants. Science. 1995;268:716-9. 37. Ma JK-C, Hikmat BY, Wycoff K, Vine NO, Chargelegue D, Yu L, Hein MB, Lehner T. Characterization of a recombinant plant monoclonal secretory antibody and preventive immunotherapy in humans. Nat Med. 1998;4:601-6. 38. Ma JK-C, Hunjan M, Smith R, Kelly C, Lehner T. An investigation into the mechanism of protec­tion by local passive immunization with monoclonal antibodies against Streptococcus mutans. Infect Immun. 1990;58:3407-14. 39. Ma JK-C, Lehner T. Prevention of colonization of Strepto­coccus mutans by topical application of monoclonal antibodies in human subjects, Arch Oral Biol. 1990;35(Supp1):115s-122s. 40. Mandel ID. Impact of saliva on dental caries. Compend Suppl. 1989;54:76-81. 41. Mandel ID. The function of saliva. J Dent Res. 1987;66:623-7. 42. McNabb PC, Tomasil B. Host defense mechanisms at mucosal surfaces. Annu Rev Microbiol. 1981;J5:447-9. 43. Michalek SM, Childers NK. Development and outlook for a caries vaccine. Crit Rev Oral Biol Med. 1990;1:37-54. 44. Newbrun E. Sucrose the arch criminal of dental caries. Odontol Revy. 1967;18:373-86. 45. Robert Harris. Biology of the children of Hopewood House, Bowral, Australia. 4. Observations on Dental-Caries Experience Extending over Five Years (1957-61) J Dent Res. 1963;42(6):1387-99. 46. Roberts MW, Wright JT. Food sugar substitutes: A brief review for dental clinicians. J Clin Pediatr Dent. 2002;27(1):1-4. 47. Rugg-Gunn AJ. Diet and dental caries. In: the prevention of dental diseases, 2nd Ed. JJ Murray Ed, Oxford, Oxford University Press; 1989. pp.4-114. 48. Russell MW, Hajishengallis G, Childers NK, Michalek SM. Secretory immunity in defense against cariogenic mutans streptococci. Caries Res. 1999;33:4-15. 49. Russell MW. Immunization against dental caries. Curr Opin Dent. 1992;2:77-80. 50. Scheinin A, Makinen KK. Turku sugar studies I-XXI. Acta Odontol Scand. 1975;33(Suppl 70):1-349. 51. Sheinin A, Makinen KK. Turku sugar studies: An overview. Acta Odontol Scand. 1976;34:405-8. 52. Smith DJ, Taubman MA. Vaccines against dental caries infection. In: Levine MM, Woodrow GC, Kaper M, Cobon GS (Eds): New Generation Vaccines, New York, Dekker; 1997.pp.913-30. 53. Smith DJ. Dental caries vaccines: Prospects and concern. Crit Rev Oral Biol. 2002;13(4):335-49. 54. Smith DJ. Taubman MA. Salivary IgA antibody to oral strepto­coccal antigens inpredentate children. Oral Microbiol Immunol. 1990;5:57-62. 55. Sprunt K, Leidy G. The use of bacterial interference to prevent infection. Can J Microbiol. 1988;34:332-8. 56. Sreebny L. Sugar and human dental caries. World Rev Nutr Diet. 1982;40:19-65. 57. Stephan RM. Effect of different types of human foods on dental health in experimental animals. J Dent Res. 1966;45:1551-61. 58. Sullivan HR, Goldsworthy NE. The biology of the children of Hopewood House, Bowral, NSW II. Observations Extending over Five Years (1952-1956). Review and Correlation of the Data Presented in Papers 1-6, Aust Dent J. 1958;3:395-8. 59. Svanberg M, Krasse B. Oral implantation of saliva-treated Streptococcus mutans in man. Arch Oral Biol. 1981;26:197-201. 60. Tenovuo J. Antimicrobial function of human saliva – how important is it for oral health. Acta Odontol Scand. 1998;56:250-6. 61. Weiss RL, Trithart AH. Between-meal eating habits and dental caries experience in preschool children. Am J Public Health. 1960;50: 1097-104. 62. WHO. The etiology and prevention of dental caries. Techn Rep Ser No. 494. Geneva, Switzerland; 1972.p.12.

39

Chapter

Caries Risk Assessment Nikhil Marwah

Chapter outline • • • •

Components of Caries Activity Test Risk Assessment Microbial Tests for Mutans Streptococci Detection Microbial Tests for Lactobacilli Detection

The concept of caries risk assessment is, from one point of view, simple and straightforward. The idea is to: (a) identify those persons who will most likely develop caries and (b) provide these individuals proper preventive and treatment measures to stop the disease. Beck’s risk model is used when it is important to identify one or more risk factors for the disease so that likely points for intervention can be planned. A risk model, therefore, should exclude risk predictors such as past disease, number of teeth, etc., as such factors do not cause further disease. A prediction model, on the contrary, is used when one is mainly interested in identifying who is at high risk. The main goal is to maximize sensitivity and specificity of the prediction, so that any good predictor may be included in the model. Broadly speaking, one could define three main approaches for risk assessment, which are based on: (i) past caries experience, (ii) socioeconomic factors and (iii) biological factors. • Caries risk assessment can be defined as a procedure to predict future caries development before the clinical onset of the disease. • Caries activity test are defined as tests that estimate the actual state of disease activity (progression/regression). • Risk factor is defined as factor which plays an essential role in the etiology and occurrence of the disease, like the lifestyle and biochemical determinants to which the tooth is directly exposed and which contribute to the development or progression of the lesion (plaque, saliva, diet, etc.). • Risk indicator is a factor or circumstance that is indirectly associated with the disease like socioeconomic factors and epidemiologic factors.

• • • •

Caries Activity Tests Salivary Buffer Capacity Test Cariogram Caries-Risk Assessment Tool

COMPONENTS OF CARIES ACTIVITY TEST These were summarized by Snyder as: • Should have sound theoretical basis • Simple • Easy to perform • Inexpensive • Time for test and result should be small • Should be adaptable for chair-side • Results should be accurate and reproducible • Test should have maximal corelation with clinical status • Should have good validity, reliability and feasibility.

RISK ASSESSMENT There are at least two different, but related, situations where so called caries tests are important. The first one concerns the individual treatment of a patient. The tests can provide

Caries risk assessment • • • • • • • •

Determine need and extent of personalized preventive measures Motivation of patient Monitor the effectiveness of programs Criteria for the success of therapeutic measures To identify high-risk groups Determine need for caries control measures Aid in recall appointments Aid in selection of patient for caries study

498 Section 8 

Cariology

Fig. 39.1: Diagrammatic view of caries risk factors in children using the ‘nonexclusive’ contributory disease model classifications

information about the caries etiological factors that are present. This information can be used to institute the correct and most efficient treatment. Repeated use of the tests can check if the treatment has had the expected effect. The second situation concerns prediction of caries. In most populations, a certain portion develops much more caries than others. If this group can be identified at an early stage causal measures can be introduced before any irreversible lesions have become established. Both for explaining an ongoing disease, and for the prediction of future disease, a single, simple caries test has often been requested by the profession (Fig. 39.1). Unfortunately, such a test is not available, for the uncomplicated reason that dental caries is a complex disease. However, saying that, it does not mean that it is impossible to identify and evaluate important etiological or risk factors, in order to institute causal treatment directed against the main problems. Thus, the treatment of the caries disease can be based on biological principles and not on chance or beliefs. Such procedures are therefore recommended for anyone who wants to treat the caries disease, not only to fill the cavity.

MICROBIAL TESTS FOR MUTANS STREPTOCOCCI DETECTION Several methods are available to measure the levels of mutans streptococci in saliva and plaque and on individual tooth surfaces, when such information is needed.

Laboratory Method • Saliva (or dental plaque) is collected from the individual to be sampled. • Mixed with a proper transport medium, the sample is sent to a microbiological laboratory. • After incubation using a selective medium, mutans colonies on the plates are counted and the results are expressed as number of colony-forming units per ml saliva. A common type of selective agar plate for mutans streptococci is the mitis-salivarius-bacitracin agar, MSBagar. • For screening surveys using agar-plates, a simplified method has been described in which wooden spatulas are contaminated by saliva and then directly pressed against selective agar plates. After incubation, the number of colonies on a predetermined area of the agar is calculated. Thus, no steps involving transportation, dilution and plating of saliva are necessary.

Chair-side Method • The so-called ‘Strip Mutans® test’ is based on the ability of mutans streptococci to grow on hard surfaces and the use of a selective broth (high sucrose concentration in combination with bacitracin). • The Dentocult SM-Strip Mutans kit for estimation of mutans streptococci in saliva contains test strips,

Chapter 39  Caries Risk Assessment

bacitracin discs, test tubes with broth, paraffin for chewing and a standard chart to evaluate the level of mutans after incubation. • The level of mutans streptococci is given as ‘class’ after comparison with a chart, indicating low (‘0’) to high (‘3’, equivalent to 106 mutans CFU per mL saliva) numbers in saliva. The mutans streptococci colonies will appear on the strip as small blue dots but the color can vary from dark blue to pale blue.

Adherence Method • Categorizes salivary samples based on ability of S. mutans to adhere to glass surfaces when grown in sucrosecontaining broth. • Equipment includes tube to collect saliva, rack to hold culture tubes, disposable pipettes, incubator and MSB broth (Showa YakuhinKako Co. Ltd., Tokyo, Japan). The

Survey Method • For field studies the plates can be placed into plastic bags containing expired air, which are then sealed (Seal-aMeal) and incubated at 37°C. • Counts of more than 100 colony-forming units (CFU) by this method are proportional to greater than 108 CFU of S. mutans per mL of saliva by conventional methods. • This simplified and practical method for field studies.

Selective Method • For the demonstration of mutans streptococci at specific sites, a simple technique has been described by Kristoffersson and Bratthall. • This test involves simple screening of diluted plaque sample streaked on a selective culture media. • Equipment involves sterile toothpicks, sterile ringer solution, platinum loop, mitis-salivarious agar plates containing sulphadimetine and incubator.

Result of adherence method +++

S. mutans is present at a level higher than 105 CFU per mL of whole saliva

–

S. mutans is present at less than 104 CFU per mL of saliva

Value Inference –

No growth expressed

+

A few deposits ranging from 1–10

++

Scattered deposits of smaller size

+++

Numerous minute deposits with more than 20 large size deposits

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broth is marketed in a sealed vial, to which is added a strip of paper bearing bacitracin, tellurite, and crystal violet to elute within 10 minutes, after which the broth is ready for use.

MICROBIAL TESTS FOR LACTOBACILLI DETECTION • This lactobacilli count test was introduced by Hadley in 1933. • The number of lactobacilli in saliva seems to be significantly higher in the early morning, before breakfast and tooth brushing. • This test estimates the number of acidogenic and aciduric bacteria in the patient’s saliva by counting the number of colonies appearing on LBS agar (Rogosa). The total number of colonies on this medium reflects the proportion of the aciduric flora in the saliva. • The necessary equipment includes saliva-collecting bottles, paraffin, two 9-mL tubes of saline, two agar plates, two bent glass rods, facilities for incubating, and a Quebec Counter and pipettes.

Results of lactobacillus count No. lactobacilli per mL saliva

Caries activity

0–1000

Little or none

1000–5000

Slight

5000–10,000

Moderate

> 10,000

Marked

CARIES ACTIVITY TESTS

Snyder Test • It measures the ability of salivary microorganisms to form organic acids from carbohydrate medium. • The Snyder test measures the rapidity of acid formation when a sample of stimulated saliva is inoculated into glucose agar adjusted to pH 4.7 to 5 and with bromcresol green as color indicator. • The equipment includes saliva-collecting bottles, paraffin, a tube of Snyder glucose agar containing bromcresol green and adjusted to pH 4.7 to 5, pipettes, and incubating facilities. • Advantages include simplicity of equipment and doing, only some training is needed and is cost effective. • High correlation between the Snyder acid production test and the lactobacillus plate count.

Results of Snyder test 24 hours Color

48 hours

72 hours

If yellow

If yellow

If yellow

Caries activity Marked

Definite

Limited

Color

If green

If green

If green

Caries activity Continue to incubate Continue to incubate Caries inactive

Chapter 39  Caries Risk Assessment

Alban Test

Reductase Test

• It is a simplified substitute for the Snyder test. • Its advantages are that it is simple, cost effective and can act as motivational tool for patient. • Color change from blue to yellow is indicative of caries activity.

Scoring is based on the depth in medium to which color has changed

• This test measures the ability of reductase enzyme present in salivary bacteria. • The test measures the rate at which an indicator molecule, diazoresorcinol, changes from blue to red to colorless on reduction by the mixed salivary flora. • The reductase test comes in a kit “Treatex (CW Erwin and Co.) which includes calibrated saliva collection tubes with the reagent on the inside of the tube’s cap, plus flavored paraffin.

Results of Reductase test Color

Results of Alban test

Time

Score

Caries activity

Blue

15 min

1

Non-conducive

¾

Orchid

15 min

2

Slightly conducive

Beginning color change

+

Red

15 min

3

Moderate conducive

One half color change

++

Red

Immediate

4

Highly conducive

Three fourths color change

+++

White

Immediate

5

Extremely conducive

Total color change to yellow

++++

Color change

Score

No color change

Swab Test

SALIVARY BUFFER CAPACITY TEST

• This test was developed by Grainger et al. in 1965. • This can be used in young and uncooperative patients as there is no need for salivary collection. • The oral flora is sampled by swabbing the buccal surfaces of the teeth with a cotton applicator which is subsequently incubated for 48 hours. Result of swab test pH

Caries activity

4.1

Marked caries activity

4.2–4.4

Active

4.5–4.6

Slightly active

Over 4.6

Caries inactive

Salivary buffer capacity is important in maintaining a pH level in saliva and plaque which counteracts dissolution of mineral but buffer capacity of whole stimulated saliva is weakly correlated to caries increment, however, below a threshold value, the caries process is facilitated. • There is a trend of an inverse relationship between buffering capacity of saliva and caries activity. • The saliva of individuals whose mouths contain a considerable number of carious lesions frequently has a lower acid-buffering capacity than the saliva of those who are relatively caries-free. • This test, however, does not correlate adequately with caries activity.

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• Buffer capacity can be evaluated by pH or color indicators. The test measures the number of milliliters of acid required to lower the pH of saliva through an arbitrary pH interval, such as from pH 7.0 to 6.0, or the amount of acid or base necessary to bring color indicators to their end point. • Needed equipment includes a pH meter and titration equipment, 0.05 N lactic acid, 0.05 N base, paraffin, and sterile glass jars containing a small amount of oil.

CARIOGRAM • A challenge for the biological factor approach is to correctly summarize the complex picture of the various inter-related caries risk factors, so that it can easily be used by the dental professional routinely in the clinic. • The pioneering work of Bo Krasse and his team at the Dental School in Göteborg laid the foundation for the development of a comprehensive model of the caries risk profile. Building on this work, Douglas Bratthall (1997) and coworkers at the Dental School in Malmö have attempted to make the practical application of risk assessment more accessible by developing a computer-based caries risk assessment model called Cariogram (Fig. 39.2). • It is a computer program showing a graphical picture that illustrates a possible overall caries risk scenario. The program contains an algorithm that presents a ‘weighted’ analysis of the input data, mainly biological factors. It expresses as to what extent different etiological factors of caries affect caries risk. • The Cariogram identifies the caries risk factors for the individual and provides examples of preventive and treatment strategies to the clinician. The computer version of the Cariogram presents a graphical picture that illustrates a possible overall caries risk scenario.

How is a Cariogram Created?

Result of buffer capacity test Buffer capacity

Color change

Low buffer capacity

Yellow color

Intermediate buffer capacity

Green color

Normal buffer capacity

Blue color

• The patient is examined and data collected for some factors of direct relevance for caries including bacteria, diet and susceptibility related factors. • The various factors/variables are given a score according to a predetermined scale and entered in the computer program. According to its built-in formula, the program presents a pie diagram where ‘bacteria’ appears as a red sector, ‘diet’ as a dark blue sector and ‘susceptibility’related factors as a light blue sector. In addition, some ‘circumstances’ are presented as a yellow sector. The four sectors take their shares, and what multifactorial risk assessment is left appears as a green sector and represents the chance of avoiding caries. • The bigger the green sector, the better from a dental health point of view; small green sector means low chance of avoiding caries = high caries risk. For the other sectors, the smaller the sector, the better from a dental health point of view. • In summary, the Cariogram shows if the patient over all is at high, intermediate or at low risk for caries. It also shows for every individual examined, which etiological factors are considered responsible for the caries risk. The results also indicate where targeted actions to improve the situation will have the best effect. • The Cariogram expresses caries risk only.

Chapter 39  Caries Risk Assessment

Fig. 39.2: Cariogram

• • • • •

Advantages

Evaluation of cariogram

The dark blue sector ‘diet’ is based on a combination of diet contents and diet frequency. The red sector ‘bacteria’ is based on a combination of amount of plaque and mutans streptococci. The light blue sector ‘susceptibility’ is based on a combination of fluoride program, saliva secretion and saliva buffer capacity. The yellow sector ‘circumstances’ is based on a combination of caries experience and related diseases. The green sector shows an estimation of the ‘chance of avoiding caries’.

• • • • •

The model is affordable User-friendly Easy to understand Tool for motivating the patient Model can also serve as a support for clinical decision making when selecting preventive strategies for the patient.

Caries related factors according to the program Factors Caries experience

Related general diseases Diet, contents Diet, frequency Plaque amount

Mutans streptococci Fluoride program Saliva secretion Saliva buffer capacity Clinical judgement

Comment Past caries experience, including cavities, fillings and missing teeth due to caries. Several new cavities definitely appearing during preceding year should score ‘3’ even if number of filling is low. General disease or conditions associated with dental caries. Estimation of the cariogenicity of the food, in particular fermentable carbohydrate content. Estimation of number of meals and snacks per day, mean for a normal day. Estimation of hygiene, for example according to Silness-Löe Plaque Index (PI). Crowded teeth leading to difficulties in removing plaque interproximally should be taken into account. Estimation of levels of mutans streptococci (Streptococcus mutans, Streptococcus sobrinus) in saliva, for example using Strip mutans test. Estimation of as to what extent fluoride is available in the oral cavity over the coming period of time. Estimation of amount of saliva, for example using paraffinstimulated secretion and expressing results as mL saliva per minute. Estimation of capacity of saliva to buffer acids, for example using the Dentobuff test. Opinion of dental examiner, ‘clinical feeling’. Examiners own clinical and personal score for the individual patient.

Info/data needed DMFT, DMFS, new caries experience in the past one year. Medical history, medications. Diet history, (lactobacillus test count). Questionnaire results (24 hours recall or 3 days dietary recall). Plaque index.

Strip mutans test or other similar test. Fluoride exposure, interview the patient. Stimulated saliva test—secretion rate. Dentobuff test or other similar test. Opinion of dental examiner, ‘clinical feeling’. A pre-set score of 1 comes automatically.

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504 Section 8 

Cariology Low risk

Moderate risk

High risk

Clinical conditions

• No decayed teeth in past 24 months • Decayed teeth in the past 24 months • Decayed teeth in the past 12 month • No enamel demineralization (enamel • One area of enamel demineralization • More than one area of enamel caries “while-spot lesions”) (enamel caries “while-spot lesions”) demi­neralization (enamel caries • No visible plaque; no gingivitis. • Gingivitis. “while spot lesions”) • Radiographic enamel caries • Visible plaque on anterior (front) teeth • High titers of mutans-treptocced • Wearing dental or orthodontic appliances.

Environmental characteristics

• Optimal systemic and topical fluoride • Suboptimal systemic fluoride exposure exposure with optimal topical exposure • Consumption of simple sugars or foods • Occasional (e.g. 1–2) between meal strongly associated with caries initiation exposures to simple sugars or foods primarily at mealtimes strongly associated with caries • Regular use of dental care in an • Mid-level caregiver socio-economics established Dental Home. (e.g., eligible for school lunch pro­gram or SCHIP) • Irregular use of dental services.

General health conditions

• Enamel hypoplasia • Suboptimal topical fluoride exposure • Frequent (e.g., 3 or more) between meal exposures to simple sugars or foods strongly associated with caries • Low-level caregiver socioeconomic status (e.g. eligible for Medicaid) • No usual source of dental care • Active decay present in the mother of a preschool child. • Children with special health care needs • Conditions impaing saliva com­ position/flow.

CARIES-RISK ASSESSMENT TOOL The American Academy of Pediatric Dentistry (AAPD) recognizes that caries risk assessment is an essential element of contemporary clinical care for infants, children, and adolescents. Over the past fifteen years, strategies for managing dental caries increasingly have emphasized the concept of risk assessment. However, a practical tool for assessing caries risk in infants, children, and adolescents has been lacking. While assessment of caries risk undoubtedly will benefit from emerging science and technologies, the AAPD believes that sufficient evidence exists to support the creation of a framework for classifying caries risk in infants, children, and adolescents based on a set of physical, environmental and general health factors. The table represents a first step toward incorporating avai­lable evidence into a concise, practical tool to assist both dental and nondental health care providers in assessing levels of risk for caries development in infants, children, and adolescents.

 sers of the AAPD Caries-Risk U Assessment Tool (CAT) must Understand the Following Caveats • CAT provides a means of classifying dental caries risk at a point in time and therefore should be applied periodically to assess changes in an individual’s risk status. • CAT is intended to be used when clinical guidelines call for caries risk assessment. • CAT can be used in any clinical setting that allows the assessor to obtain reliable clinical, environmental, and general health information. • CAT can be used by both dental and nondental personnel. It does not render a diagnosis. However, clinicians using CAT must be familiar with the clinical presentation of dental caries and factors related to caries initiation and progression. • Because clinicians with various levels of skill working in a variety of settings will use this instrument, advanced technologies such as radiographic assessment and microbiologic testing (shaded areas) have been included but are not essential for using this tool.

POINTS TO REMEMBER • Caries risk assessment can be defined as a procedure to predict future caries development before the clinical onset of the disease. • Caries activity test are defined as tests that estimate the actual state of disease activity (progression/regression).

Chapter 39  Caries Risk Assessment • Caries risk assessment is used to determine need and extent of personalized preventive measures, motivation of patient, monitor the effectiveness of programs, to identify high-risk groups. • Dentocult SM-Strip mutans is used to measure strep mutans count at chair-side. • The best evaluated caries activity tests are Snyder, Albans, Reductase, and Swab test. • Salivary buffer capacity and pH level in saliva are correlated to caries increment. • The pioneer of Cariogram is Bo Krasse and its development and functionality as a comprehensive model of the caries risk profile was done by Douglas Bratthall (1997). • Cariogram is a computer program showing a graphical picture that illustrates a possible overall caries risk scenario. It expresses as to what extent different etiological factors of caries affect caries risk and provides examples of preventive and treatment strategies to the clinician.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Define and explain caries risk assessment? What are the microbial tests for mutans streptococci detection? Write a note on Snyder test? What are the color changes in Reductase test? Explain Salivary buffer capacity test? Describe the Cariogram?

BIBLIOGRAPHY 1. Abernathy JR, Graves RC, Bohannan HM, Stamm JW, Greenberg BG, Disney JA. Development and application of a prediction model for dental caries. Comm Dent Oral Epidemiol. 1987;15:24-8. 2. Agus H, Schamschula R. Lithium content, buffering capacity and flow rate of saliva and caries experience of Australian children. Caries Res. 1983;17:139-44. 3. Alaluusua S, Kleemola-Kujala E, Gramos L, et al. Salivary caries related tests as predictors of future caries increment in teenagers. A three-year longitudinal study. Oral Microbial Immunol. 1990;5:77-81. 4. Axelsson P. An introduction to risk prediction and preventive dentistry. Chicago, IL: Quintessence Publishing Co; 2000. 5. Beighton D, Manji F, Baelum V, Fejerskov O, Johnson, NW, Wilton JMA. Associations between salivary levels of Streptococcus mutans, Streptococcus sobrinus, Lactobacilli, and caries experience in Kenyan adolescents. J Dent Res. 1989;68:1242-6. 6. Bratthall D, Hänsel Petersson G, Stjernswärd JR. Assess­ment of caries risk in the clinic—a modern approach. In: Advances in Operative Dentistry. Vol 2. Ed: Wilson NHF, Roulet JF, Fuzzi M. Quintessence Publishing Co, Inc. 2001.pp.61-72. 7. Bratthall D, Hänsel Petersson G, Stjernswärd JR. Cariogram. www.db.od.mah.se/car/cariogram/cariograminfo. April 2, 2004, 8. Douglass CW. Risk assessment in dentistry. J Dent Educ. 1998;62:756-61. 9. Dutchin S, van Houte J. Colonization of teeth in humans by Streptococcus mutans as related to its concentration in saliva and host age. Infect Immun. 1978;20:120-5. 10. Eisenberg AD, Mundorff SA, Featherstone JDB, Leverett DH, Adair SM, Billings RJ, et al. Associations of microbiological factors and plaque index with caries prevalence and water fluoridation status. Orill Microbiol Immunol. 1991;6:139-45. 11. El-NadeffMAl, Bratthall D. Intraindividual variations in counts of mutans streptococci measured by ‘Strip mutans’ method. Scand J Dent Res. 1990;99:8-12. 12. Ericsson D, Bratthall D. Simplified method to estimate buffer capacity. Scand J Dent Res. 1989;97:405-7. 13. Ericsson Y, Hardwick L. Individual diagnosis, prognosis and counselling for caries prevention. Caries Res. 1978;12(suppl):94-112. 14. Ericsson Y. Clinical investigation on the salivary buffering action. Acta Odont Scand. 1959;17:131-65. 15. Grainger R, Jarrett T, Honey F. Swab test for dental caries activity: An epidemiological survey. J Can Dent Assoc. 1965;31:515-26. 16. Hänsel Petersson G, Bratthall D. Caries risk assessment: a comparison between the computer program ‘cariogram’, dental hygienists and dentists. Swed Dent J. 2000;24:129-37. 17. Hänsel Petersson G, Twetman S, Bratthall D. Evaluation of a computer program for caries risk assessment in school children. Caries Res. 2002;36:327-40. 18. Kidd EA. Assessment of caries risk (Review). Dent update. 1998; 25:385-90. 19. Larmas MA. A new dip-slide method for the counting of salivary lactobacilli. Proc Finn Dent Soc. 1975;71:31-5. 20. Newbrun E, Matsukubo T, Hoover CI, Graves RC, Brown AT, Disney JA, et al. Comparison of two screening tests for Streptococcus mutans and evaluation of their suitability for mass screenings and private practice. Comm Dent Oral Epidemiol. 1984;12:325-31. 21. Pitts NB. Risk assessment and caries prediction. J Dent Educ. 1998;62:762-70. 22. Powell LV. Caries prediction: A review of the literature (Review). Comm Dent Oral Epidemiol. 1998;26:361-71. 23. Snyder M. Laboratory methods in the clinical evaluation of caries activity. J Am Dent Assoc. 1951;42:400-13.

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40

Chapter

Diagnostic Aids in Dental Caries Manju Gopakumar, Nikhil Marwah

Chapter outline •

Conventional Diagnostic Methods

Childhood is the period of life’s greatest physical, psychologic and emotional growth; the child we see today is no longer the same tomorrow. The child patient presents a challenge to the dentist, who must solve the problems of today with an eye to the future and the dental health of an adult. The proper management of dental caries in clinical practice requires an accurate clinical diagnosis. Accurate diagnosis can only be achieved by systematic and methodical collection of data. At the clinical dental practice level, caries diagnosis also has a significant impact since it rules treatment decisions. The diagnosis of early caries lesions has been considered the cornerstone of cost-effective health care delivery and quality of dental care. Early diagnosis of the caries lesion is important because the carious process can be modified by preventive treatment so that the lesion does not progress. If the caries disease can be diagnosed at an initial stage (e.g. white spot lesion) the balance can be tipped in favor of arrestment of the process by modifying diet, improving plaque control, and appropriate use of fluoride. Using noninvasive quantitative diagnostic methods it should be possible to detect lesions at an initial stage and subsequently monitor lesion changes over time during which preventive measures could be introduced.

CONVENTIONAL DIAGNOSTIC METHODS

Visual Inspection • Visual inspection, the most ubiquitous caries detection system, is subjective. • Assessment of features such as color and

•

Advanced Diagnostic Methods

texture are qualitative in nature. These assessments provide some information on the severity of the disease but fall short of true quantification. • They are also limited in their detection threshold and their ability to detect early, noncavitated lesions restricted to enamel is poor. • The clinical accuracy of visual examination with regards to caries detection is only 25 to 50 percent. • Lussi, Whitehead, Wilson and Ricketts in their respective studies came to the conclusion that visual examination is not an ideal means of diagnosing dental caries as most of the lesions go undetected.

Tactile Examination with a Probe • GV Black in 1924 suggested that the use of a sharp explorer, based on tug back action for diagnosis of dental caries. • However, tactile examination of dental caries has been criticized because of the possibility of transferring cariogenic microorganisms from one site to another, leading to the fear of further spread of the disease in the same oral cavity. • Moreover, use of an explorer can cause irreversible damages to the iatrogenic and demineralized tooth structure (Ekstrand et al. 1987; Stookey, 2005; Loesche et al. 1979). Because of this a mirror and a blunt probe visual examination is now advocated.

Chapter 40  Diagnostic Aids in Dental Caries Diagnostic aids of caries used in pediatric dentistry Visual Tactile sensation

Illumination Dyes Radiography

Illumination

Conventional methods Eyes Magnifying lens Probe Dental floss Mechanical separation UV illumination Basic fuchsin Procion dyes Intraoral periapical Bitewing Xeroradiography Recent advances Fiberoptic transillumination (FOTI) Wavelength dependent fiberoptic transillumination (WFOTI) Digital imaging fiberoptic transillumination (DIFOTI) Fluorescence camera

Endoscopy

Ultrasonic Electrical conductance measurement

Radiography

Lasers

Miscellaneous

Dental Floss When a string of unwaxed floss is moved on the carious proximal tooth surfaces there is resistance on withdrawal and the fibers appear torn.

Tooth Separation • Separating the tooth for visualizing the posterior approximal surfaces is now regained popularity. • This method uses orthodontic modules or bands and achieves slow separation. Taking impressions of the

Endoscopically viewed filtered fluorescence White light fluorescence Videoscope Ultrasonic system scanning acoustic microscope Ultrasound caries detector Vanguard electronic caries detector Caries meter CarieScan Pro Digital radiography Digital subtraction radiography Magnetic resonance microimaging Photo stimulable phosphor radiography Tuned aperture computed tomography DIAGNOdent Midwest Caries ID Dye enhanced laser fluorescence D-Carie mini Species specific monoclonal antibodies Intraoral television camera Infrared thermography

approximal surfaces thus separated have been used to assist in the detection of cavitations. • Studies have shown that tooth separation have detected more noncavitated enamel lesions than visual-tactile examination without separation or bitewing examination (Hintze et al. 1998; Pitts and Rimmer, 1992).

Ultraviolet Illumination • Ultraviolet (UV) light has been used to increase the optical contrast between carious lesion and the surrounding soft tissue.

507

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• In area of less mineral content like the carious lesion, the natural fluorescence of tooth enamel as seen under UV illumination is decreased. Under UV illumination carious lesion appears as a dark spot against fluorescent background.

Caries Detector Dyes • The property of dyes to enhance contrast by their color can be used in clinical dentistry. • They are applied for about 10 seconds and rinsed off. Any deeply stained tooth structure should be removed, usually with slow speed burs or spoon excavators. They should be reapplied after you remove all the stained dentin to confirm no residual caries remains in the tooth. • Following dyes are used to detect carious enamel specifically: – 0.5 percent basic fuchsin – Procion dyes – 1 percent acid red in propylene – Methylene blue – Procion dyes react with OH– and NH 2+.

Conventional Radiographs • Dental radiographs are indispensable part of the contemporary dentist armamentarium for diagnosis of caries. • The accuracy of radiographs to diagnose dental caries is between 40 and 65 percent. • Rickets, Wenzell found out that radiographs increase the diagnostic ability but only when combined with good visual examination. • Though conventional radiographs like bitewing and intraoral periapical radiograph are most frequently used for the detection of caries, they may cause overlapping of teeth due to faulty angulations and may also miss the initial lesion. During the primary dentition, the occlusal surface is most susceptible to caries attack, but with the eruption of first permanent molars the incidence

of proximal lesions greatly increases. In such situation bitewing radiographs are abso­ lutely required to detect proximal lesions in primary molars. • The limitations of radio­ graphs are that it is not able to differentiate between an active and an arrested caries lesion, and also to distinguish a cavitated and a non-cavitated lesion.

ADVANCED DIAGNOSTIC METHODS Novel diagnostic systems are based upon the measurement of a physical signal—these are surrogate measures of the caries process. Examples of the physical signals that can be used in this way include X-rays, visible light, laser light, electronic current, ultrasound, and possibly surface roughness. For a caries detection device to function, it must be capable of initiating and receiving the signal as well as being able to interpret the strength of the signal in a meaningful way. A range of new caries detection systems have been developed and these are therefore aimed at augmenting the diagnostic process by facilitating either earlier detection of the disease or enabling it to be quantified in an objective manner.

Digital Radiography • Digital radiography is a filmless technique for intraoral radio­graphy, utilizes very little of the radiation to which the patient has been exposed and avoid the need for developing films. This technique has offered the potential to increase the diagnostic yield of dental radiographs. • Advantages – The image is displayed immediately and no need of processing – Reduction in radiation dose – Digital manipulation of the image is possible to enhance the viewing – It can be used as a visual aid to be shown to the patient on the computer screen – It increases the confidence and credibility in the treatment-decision making process. • Disadvantages – The rigidity and thickness of sensor can cause discomfort to the patient

Chapter 40  Diagnostic Aids in Dental Caries – The lifespan of sensor is unknown – High initial system cost (Bin-Shuwaish et al. 2008; van der Stelt, 2008; Wenzel, 1998).

Digital Subtraction Radiography • Digital subtraction radiography (DSR) is a more advanced image analysis tools which allows professionals to distinguish small differences between subsequent radiographs that otherwise would have remained unobserved because of over­projection of anatomical structures or differences in density that are too small to be recognized by the human eye. • The procedure is based on the principle that two digital radiographic images obtained under different time intervals, with the same projection geometry, are spatially and densitometrically aligned using specific software. • If the two digital images are identical, this method will produce an image without details (the result is zero). However, if caries has regressed or progressed in the mean time, the result will be different from zero. When there is caries progression, the outcome will be a value above zero (increase in pixel values). In case of caries regression, the result is opposite and the outcome will be a value below zero (decrease in pixel values) (Hekmatian et al. 2005). • The major disadvantage of this technique is very sensitive to any physical noise occurring between the radiographs and even minor changes leads to large errors in the results.

Fiberoptic Transillumination • Fiberoptic transillumination, it is a practical method of imaging teeth in the presence of multiple scattering (Marcus and Friedman, 1970). • The illumination is delivered via light source to tooth surface. The light propagates from the fiber illumination across tooth tissue to nonilluminated surfaces. The result­ ing images of light distribution are then used for diagnosis. • Carious area appears as darkened shadow that follows the decay (Oogard and Ten Bosch).

• The equipment includes a 150 w halogen lamp and a rheostat to provide light of maximum intensity. A mouth mirror mounted on steel cuff and fiberoptic probe are placed in embrasure region below contact point to produce a narrow beam for transillumination. • Peers et al. evaluated FOTI and concluded that it was as accurate as bitewing radiography and superior to visual examination in diagnosis of inter-proximal caries. • It is used for diagnosis of caries and identification of necrotic canals. • Advantages are that it is simple noninvasive examination technique, no radiation hazards, can be used on all surfaces. • Disadvantage is that the system is subjective rather than objective, as there is no continuous data outputted and it is not possible to record what is seen in the form of an image. • Another modification is wavelength-dependent fiber­optic transillumination (WFOTI) which is used for detection of early incipient and approximal carious lesion.

Quantitative Light-induced Fluorescence • Fluorescence is a phenomenon by which an object is excited by a particular wavelength of light and the reflected light is of a larger wavelength. When the excitation light is in the visible spectrum, the fluorescence will be of a different color. • In the case of the quantitative lightinduced fluorescence (QLF) the visible light has a wavelength of 370 nm, which is in the blue region of the spectrum. The resultant autofluorescence of human enamel is then detected by filtering out the excitation light using a band pass filter at > 540 nm by a small intraoral camera. This produces an image

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510 Section 8 

•

•

•

•

•

Cariology

that is comprised of only green and red channels (the blue having been filtered out) and the predominant color of the enamel is green. D emineraliza­ tion of enamel results in a re­ duction of this auto-fluorescence. This loss can be quantified using proprietary software and has been shown to correlate well with actual mineral loss; r = 0.73–0.86. The QLF equipment is comprised of a light box containing a xenon bulb and a handpiece, similar in appearance to an intraoral camera. Light is passed to the handpiece via a liquid light guide and the handpiece contains the bandpass filter. Live images are displayed via a computer and accompanying software enables patient’s details to be entered and individual images of the teeth of interest to be captured and stored. Once an image of a tooth has been captured, the next stage is to analyze any lesions and produce a quantitative assessment of the demineralization status of the tooth. This is undertaken using proprietary software and involves using a patch to define areas of sound enamel around the lesion of interest. Following this the software uses the pixel values of the sound enamel to reconstruct the surface of the tooth and then subtracts those pixels which are considered to be lesion. Advantages are high reproducibility, detection of small incipient lesions in enamel and dentin, image storage and transmission and can act as motivational tool for patient. Disadvantage is that it is a isolation sensitive procedure.

Fluorescence Camera (Vista Proof) • This device is an intraoral camera which consists of six blue LEDs emitting a 405nm light, chargecouple device (CCD) sensor and DBSWIN software for analysis. With this camera it is possible to digitize the video signal from the dental surface during fluorescence emission using a CCD sensor. On these images, it is possible to see different areas of the dental surface that fluoresce in green (sound

dental tissue) and in red (carious dental tissue) (Thoms, 2006). • Advantages include motivation for patient and storage of data.

 igital Imaging Fiberoptic D Transillumination • This was suggested as a tool for caries assessment by Scheneiderman A et al. in 1997. • This is a new method for detec­ tion of dental caries in which the images of teeth are obtained through visible light fiberoptic transillumination and digital CCD camera. • These images are then sent to a computer for analysis with specific algorithms. These algorithms are developed to facilitate the location and diagnosis of the carious lesion and provide quantitative characterization for monitoring the lesions. • Advantage is that it can indicate the presence of incipient and recurrent caries even when radiological images fail to show their presence.

Laser Fluorescence (DIAGNOdent) • The DIAGNOdent (DD) instrument (KaVo, Germany) is another device employing fluore­ scence to detect the presence of caries. • Using a small laser the system pro­ duces an excita­tion wavelength of 655 nm which produces a red light. This is carried to one of two intraoral tips; one designed for pits and fissures, and the other for smooth surfaces. The tip

Chapter 40  Diagnostic Aids in Dental Caries Diagnostic interpretations of DIAGNOdent Signal reading 0–4 4.01–10

Values of caries meter

Inference

Light

No caries, or histological caries limited to outer half of enamel

Green

Above 600 K

No caries

No treatment

Yellow

250–600 K

Histological caries extending beyond the outer half but confined to enamel

10.01–18

Histological dentinal caries limited to outer half of dentin

>18.01

Histological dentinal caries extending into inner half of dentin

both emits the excitation light and collects the resultant fluorescence. This is then displayed as a numerical value on two LED displays. The signal comes out as a number on instrument on a scale of 0 to 99. Higher the number more is caries. • Principle of DIAGNOdent is based on the fact that the caries induced changes in teeth lead to increased fluorescence at specific excitation wavelength. • Advantages are early detection of lesion, quantification of caries and improved diagnostic accuracy. • Disadvantages are that it cannot detect secondary caries and proximal caries accurately.

Electrical Conductance Measurement • The idea of electrical method for caries detection was proposed by Magitot. • It is based on the principle that sound tooth surfaces possess limited conductivity whereas demineralized or carious enamel act as conductive pathway. Based on the differences in the electrical conductance of carious and sound enamel, two instruments were developed and tested in 1980, i.e. vanguard electronic caries detector and caries meter. – Vanguard electronic caries detector i. Resistance measurements are made between a hand-held connector and probe tip placed in fissure of teeth and superficial saliva is removed to prevent surface conduction. ii. Machine gives a reading on scale of 0 to 9 which is directly proportional to degree of demineralization. – Caries meter i. Teeth are dried and isolated before starting the treatment. Tooth fissure is moistened with a drop of saliva to ensure good electrical

Electric impedance value (K)

Status of tooth

Recommended treatment

Enamel caries

Observe

Orange 15–250 K

Dentinal caries

Need for restoration

Red

Pulpal involvement Pulpal treatment

Below 15 K

conductance. The resistance measurement is made between probe tip and clip attached to oral electrode and colored lights reflect the status of tooth. ii. Advantage is that it is small, handy and provides accurate diagnosis. iii. Disadvantages are that area of diagnosis is confined to dimension of probe, it is technique sensitive and the status of lesion is not known like arrested or active.

Ultrasound Caries Detector • This is a new ultrasonic proximal caries detector that works by transmitting surface ultrasonic waves. • The ultrasound caries detector (UCD) device is based on pulseecho method and has software, hard­ware and trans­ducer as com­ponents. A medical grade silicon wedge is positioned in front of probe to yield surface waves on the tooth surface when the transducer comes in contact with the tooth. This detector records specific profiles of ultrasonic echoes obtained from the enamel surface, dentino-enamel junction and pulpo-dentinal junction. Changes in this profile have been described in demineralized lesions, suggesting a substantial difference in the sonic conductivity between sound and demineralized enamel. • Matalon et al. (2003) compared and found UCD to be superior in sensitivity and specificity as compared to bitewing radiography in detection of approximal caries.

Midwest Caries ID (LED technology) • This technology utilizes a handheld device which emits a soft light emitting diode (LED) between 635 nm and

511

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880 nm and analyzes the reflectance and refraction of the emitted light from the tooth surface, which is captured by fiberoptics and is converted to electrical signals for analysis. • The demineraliza­tion leads to a change in the LED from green to red with a simultaneous audible signal, which is directly related to the severity of caries lesions. • Advantage is that sensitivity and specificity is higher than that of DIAGNOdent. (H Ciaburro, Krause et al.). • Disadvantage is that Midwest Caries ID is not able to differentiate enamel lesions from sound surfaces (Rodrigues et al. 2011).

CarieScan Pro • It involves the passing of an insensitive level of electrical current through the tooth to identify the presence and location of the decay. • The device is indicated for the detection, diagnosis, and monitoring of primary coronal dental caries (occlusal and accessible smooth surfaces), which are not clearly visible to the human eye. • This device uses disposable tufted sensors for single use and a test sensor (non-disposable), which is used to check if the device is operating correctly. For assessment of caries, while tufted sensor brush contacts the tooth surface being examined, a soft tissue contact, which is a disposable metal clip that is placed over the lip in the corner of the patient’s mouth, connects to the CarieScan via a soft tissue cable to complete the circuit. • During measurement, a green color display indicates sound tooth tissue, while a red color indicates deep caries requiring operative, and a yellow color associated with a range of numerical figures from 1 to 99 depicts varying severity caries, which require only preventive care. • A systematic review comparing CarieScan with clinical visual examination, bitewing radiograph, and DIAGNOdent reported CarieScan to have a superior sensitivity and specificity (92.5%) over other methods (JD Bader, DA Shugars, AJ Bonito). • Disadvantage is that it cannot be used to assess secondary caries, the integrity of a restoration, dental root caries, and the depth of an excavation within a cavity preparation.

Intraoral Television Camera • Through intraoral television camera (IOTV) the dentist can educate the patient and at the same time can also improve their own diagnostic expertise as they see magnified oral conditions, which are significantly better than direct vision. • Forgie et al. (2003) concluded that IOVC can achieve very high level of sensitivity but this is accompanied with drop in specificity. • Advantages are increased vision and magnification. • Disadvantage is loss of specificity.

D-Carie Mini • This is a new device introduced by Neks technology in October 2006 at ADA annual session in Las Vegas. • This was initially developed in Canada. • This is pen-sized, light weight, cord­ less, fully sterilizable unit that uses laser fluorescence to detect occlusal lesions. • The D-Carie mini has been shown to detect more than 92 percent of occlusal caries and over 80 percent of interproximal caries. • Approved by FDA in 2007.

Advanced Radiographic Techniques • Magnetic resonance microimaging (MRMI) – The basis of MRMI is that different species of atomic nucleus have different intrinsic nuclear spins. When a magnetic field is applied, the nuclear spins align in a finite number of allowed orientations. If these orientations are perturbed by a pulse of radio frequency energy, the energy gets absorbed and then retransmitted. The chemical environment of tooth determines the frequency of the retransmitted energy peak. – Carious regions give an intense image that is readily distinguishable from other soft tissues.

Chapter 40  Diagnostic Aids in Dental Caries – Advantage is that this technique is noninvasive and allows a specimen to be re-imaged after further exposure to clinically relevant environment. – Major drawbacks include cost and clinical testing. • Photo stimulable phosphor radiography – A latent image is produced by exposing the storage phosphor screen with X-rays. – Advantages are that it can be used with existing X-ray sources, wider exposure range and transfer of images is possible. – Disadvantages are high cost and chances of cross infection. • Tuned aperture computed tomography (TACT) – TACT is a new imaging device which enhances the image by decreasing the superimposition of anatomical structures. – It uses digital radiographic images and its software correlates these images into layers so that sliced sections can be viewed. – A series of 8 radiographs can be assimilated one TACT image. – It is effective in evaluating primary stimulated recurrent caries and simulated osseous defects and can localize a lesion accurately with minimal radiation.

Advanced Dye Detection Techniques • Confocal laser scanning microscopy (CLSM) – This is operated simultaneously with AR and Kr ion lasers and an appropriate set of filters, the reflection image of the dentin structure and the fluorescent images of the labeled Carisolv can be recorded simultaneously. • Dye-enhanced laser fluorescence (DELF) – This technique is based on a hypothesis that if a fluorescent dye penetrates a carious lesion the

accuracy of current laser fluorescence for caries detection is enhanced. – Useful in diagnosis of subsurface lesion.

Species Specific Monoclonal Antibodies • This was given by Shi et al. in 1998, who identified specific monoclonal antibodies that recognize the surface of cariogenic bacteria. • The probes are tagged with fluorescent molecules that measure quantitatively with spectrometer. • They can be used at chair side by dentist and provide instant results.

Infrared Thermography • Thermal radiation energy travels in the form of waves. It is possible to measure changes in thermal energy when fluid is lost from a lesion by evaporation. The thermal energy emitted by sound tooth structure is compared with that emitted by carious tooth structure. • The technique has been described by Kaneko et al. (1999) and has been proposed as a method of determining lesion activity rather than a method of determining the presence or absence of a lesion. • The clinical data regarding this technique is however still insufficient. It is clear that the differences in caries presentations and behavior in different anatomical sites make it unlikely that any one diagnostic modality will have adequate sensitivity and specificity of detection of carious lesions for all sites. Hence a combination of both conventional and novel diagnostic tools is mandatory to diagnose lesions earlier so that the clinician can restrict to a preventive treatment mode. However, the clinician should be aware of the correct use of the novel diagnostic aids, their advantages and disadvantages and also should strictly follow the manufacturer instructions.

POINTS TO REMEMBER • Conventional methods of caries diagnosis are visual and tactile examination, radiographs, UV light examination and use caries detector dyes. • Digital subtraction radiography (DSR) is a more advanced image analysis tools which allows professionals to distinguish small differences between subsequent radiographs that otherwise would have remained unobserved because of over projection of anatomical structures or differences in density that are too small to be recognized by the human eye. • The DIAGNOdent employs fluorescence to detect the presence of caries as it induces changes in teeth lead to increased fluorescence at specific excitation wavelength. • Caries meter diagnoses caries on the basis of electric impedance. • Ultrasound caries detector is a new ultrasonic proximal caries detector that works by transmitting surface ultrasonic waves. • Midwest Caries ID is a recent diagnostic aid that analyzes the reflectance and refraction of the emitted light from the tooth surface, which is captured by fiberoptics and is converted to electrical signals for analysis.

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• CarieScan Pro is the most advanced and most accurate development in caries diagnosis which involves the passing of an insensitive level of electrical current through the tooth to identify the presence and location of the decay. • D-Carie Mini was introduced by Neks technology in 2006 is pen-sized, light weight, cordless, fully sterilizable unit that uses laser fluorescence to detect occlusal lesions. • Tuned aperture computed tomography is a new imaging device which enhances the image by decreasing the superimposition of anatomical structures with series of 8 radiographs can be assimilated one TACT image.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Classify the diagnostic aids in dental caries. Write a note on cries detector dyes. What are the advanced methods of radiographic diagnosis? What is QLF? Explain the principle and working of DIAGNOdent. Describe D-Carie mini and CarieScan Pro.

BIBLIOGRAPHY 1. Al-Katie S, et al. Quantification of formation and remineralization of artificial enamel lesions with a new portable fluorescence device. Adv Dent Res. 1997;11:502-6. 2. American Dental Association, Council on Access, Prevention, and Interprofessional Relations. Caries diagnosis and risk assessment: a review of preventive strategies and management. J Am Dent Assoc. 1995;126(suppl):1s-24s. 3. Angmar-Månsson BE, Al-Khateeb S, Tranaeus S. Caries diagnosis. Journal of Dental Education. 1998;62(10):771-80. 4. Angmar-Månsson B, Al-Khateeb S, Tranaeus S. Quantitative light fluorescence: current research. In: Stookey GK (Ed): Proceedings of 4th annual Indiana conference, early detection of dental caries II. Bloomington: Indiana University School of Dentistry, 2000.pp.203-18. 5. Ashley PF, Blinkhorn AS, Davies RM. Occlusal caries diagnosis: an in vitro histological validation of the electronic caries monitor (ECM) and other methods. J Dent. 1998;26:83-8. 6. Bader JD, Shugars DA, Bonito AJ. Systematic reviews of selected dental caries diagnostic and management methods. Journal of Dental Education. 2001;65:960-8. 7. Bennett T Amaechi. Emerging technologies for diagnosis of dental caries: The road so far. Journ applied physics. 2009;105:1020-47. 8. Bin-Shuwaish M, Dennison JB, Yaman P, Neiva G. Estimation of clinical axial extension of class II caries lesions with ultraspeed and digital radiographs: an in vivo study. Operative Dentistry. 2008;33(6):613-21. 9. Eggertsson H, Analoui M, van der Veen M, Gonzalez-Cabezas C, Eckert G, Stookey G. Detection of early interproximal caries in vitro using laser fluorescence, dye-enhanced laser fluorescence and direct visual examination. Caries Res. 1999;33:227-33. 10. Ekstrand KR, Ricketts DN, Kidd EA. Reproducibility and accuracy of three methods for assessment of demineralization depth of the occlusal surface: an in vitro examination. Caries Res. 1997;31(3):224-31. 11. Hafström-Björkman U, Sundström F, de Josselin de Jong E, Oliveby A, Angmar-Månsson B. Comparison of laser fluorescence and longitudinal microradiography for quantitative assessment of in vitro enamel caries. Caries Res. 1992;26:241-7. 12. Hekmatian E, Sharif S, Khodaian N. Literature review: digital subtraction radiography in dentistry. Dental Research Journal. 2005;2(2): 1-8. 13. Hintze H, Wenzel A, Danielsen B, Nyvad B. Reliability of visual examination, fiber-optic transillumination, and bite-wing radiography, and reproducibility of direct visual examination following tooth separation for the identification of cavitated carious lesions in contacting approximal surfaces. Caries Res. 1998;32:204-9. 14. Huysmans MC, Longbottom C, Pitts N. Electrical methods in occlusal caries diagnosis: an in vitro comparison with visual inspection and bite-wing radiography. Caries Res. 1998;32(5):324-9. 15. Iain A Pretty. Caries detection and diagnosis: novel techno­logies. Journal of Dentistry. 2006;34:727-39. 16. Ketley CE, Holt RD. Visual and radiographic diagnosis of occlusal caries in first permanent molars and in second primary molars. Br Dent J. 1993;174:364-70. 17. Lagerweij M, van der Veen M, Ando M, Lukantsova L, Stookey G. The validity and repeatability of three lightinduced fluorescence systems: an in vitro study. Caries Res. 1999;33:220-6. 18. Loesche WJ, Svanberg ML, Pape HR. Intraoral transmission of Streptococcus mutans by a dental explorer. Journal of Dental Research. 1979;58(8):1765-70. 19. Lussi A, Imwinkelried S, Pitts N, Longbotton C, Reich E. Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro. Caries Res. 1999;33(4):261-6. 20. Lussi A. Comparison of different methods for the diagnosis of fissure caries without cavitation. Caries Res. 1993;27:409-16. 21. Pitts NB, Rimmer PA. An in vivo comparison of radiographic and directly assessed clinical caries status of posterior approximal surfaces in primary and permanent teeth. Caries Research. 1992;26(2):146-52.

Chapter 40  Diagnostic Aids in Dental Caries 22. Rodrigues JA, Hug I, Neuhaus KW, Lussi A. Light-emitting diode and laser fluorescence-based devices in detecting occlusal caries. Journal of Biomedical Optics. 2011;16(10):107003-1-107003-5. 23. Ricketts DN, Kidd EA, Smith BG, Wilson RF. Clinical and radio graphic diagnosis of occlusal caries: a study in vitro. Journal of Oral Rehabilitation. 1995;22(1):15-20. 24. Russell M, Pitts NB. Radiovisiographic diagnosis of dental caries: initial comparison of basic mode videoprints with bitewing radiography. Caries Res. 1993;27:65-70. 25. Schneiderman A, Elbaum M, Shultz T, Keem S, Greenebaum M, Driller J. Assessment of dental caries with digital imaging fiber-optic transillumination (DIFOTI): in vitro study. Caries Res. 1997;31:103-10. 26. Shi XQ, Welander U, Angmar-Månsson B. Occlusal caries detection with KaVo DIAGNOdent and radiography: an in vitro comparison. Caries Res. 2000;34:151-8. 27. Stookey G. Should a dental explorer be used to probe suspected carious lesions? No – use of an explorer can lead to misdiagnosis and disrupt remineralization. Journal of the American Dental Association. 2005;136(11):1527, 1529, 1531. 28. Ten Bosch JJ, Angmar-Månsson A. Characterization and validation of diagnostic methods. Monogr Oral Sci. 2000;17:174-89. 29. Thoms, M. Detection of intraoral lesions using a fluore­scence camera. Proceedings of SPIE Lasers in Dentistry XII. 2006;6137(5): 1-7. 30. Verdonschot EH, Wenzel A, Truin GJ, Konig KG. Performance of electrical resistance measurements adjunct to visual inspection in the early diagnosis of occlusal caries. J Dent. 1993;21:332-7. 31. White SC, Yoon DC. Comparative performance of digital and conventional images for detecting proximal surface caries. Dent-MaxilloFac Radiol. 1997;26:32-8.

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41

Chapter

Early Childhood Caries Nikhil Marwah, Rupinder Bhatia

Chapter outline • • • •

Definitions of Early Childhood Caries Overview of Early Childhood Caries Developmental Stages of Early Childhood Caries Primary Etiological Risk Factors of Early Childhood Caries

Caries in infants and young children have long been recognized as a clinical syndrome, which was described as early as the middle of the last century. Beltrami characterized this pattern of early caries in young children in the 1930s as les dents noire de tout-petits or literally translated, “black teeth of the very young”. In 1962, Dr Elias Fass published the first comprehensive description of caries in infants, which he termed as nursing bottle mouth. The first sentence of his paper begins “Nothing is so shocking to dentist as the examination of child patient suffering from rampant caries,” and this is particularly the thought we get on observing a child with nursing caries. Since that first description in 1962 the term nursing bottle mouth has been succeeded by many names but only recently have the original concepts been rethought. In 1994, conference at the centers for disease control and prevention recommended the use of a less specific term such as early childhood caries (ECC) because it was the consensus of the attendees that the link between bottle habits and caries was not absolute. However, this term did not negate the basic reasons for tooth demineralization in very young children— extensive exposure to a cariogenic diet and early infection with cariogenic bacteria.

• • •

Secondary Etiological Risk Factors of Early Childhood Caries Prevention of Early Childhood Caries Barriers in Early Childhood Caries

DEFINITIONS OF EARLY CHILDHOOD CARIES Davies1 (1998):  Complex disease involving maxillary primary incisors within a month after eruption and spreading rapidly to other primary teeth is called childhood caries. Classification of ECC by Wayne H4 Type Type I

Type II

Terminologies for ECC • • • • •

Nursing caries: Winter (1966) Tooth clearing neglect: Moss (1996) Infant and early childhood dental decay: Horowitz (1998) ECC: Davies (1998) MDSMD: Maternally derived Streptococcus mutans disease.

Type III

Clinical features •

Mild-to-moderate

•

Existence of isolated carious lesion involving molars and incisors

•

Number of carious teeth increase as cariogenic challenge persists

•

Cause is usually a combination of cariogenic semi-solid food and lack of oral hygiene

•

Seen in 2–5 years old

•

Moderate-to-severe

•

Labiolingual carious lesion affecting maxillary incisors

•

Mandibular incisors are not affected

•

Use of feeding bottle or at will breastfeeding or a combination of both with or without poor oral hygiene

•

Seen soon after eruption of teeth

•

Severe

•

Carious lesions affecting all the teeth including lower incisors

•

Cause is cariogenic food and poor oral hygiene

•

Condition is rampant

Chapter 41  Early Childhood Caries Abid Ismail2 (1998):  Early childhood caries (ECC) is defined as occurrence of any sign of dental caries on the tooth surface during first 3 years of life. AAPD3:  The disease of early childhood caries is the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in

a child 71 months of age or younger. In children younger than 3 years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥ 4 (age 3), ≥ 5 (age 4), or ≥ 6 (age 5) surfaces constitutes S-ECC.

OVERVIEW OF EARLY CHILDHOOD CARIES

DEVELOPMENTAL STAGES OF EARLY CHILDHOOD CARIES Stage

Clinical stage

Stage I

Initial reversible stage (Fig. 41.1)

10–18 months

Stage II

Damaged carious stage (Fig. 41.2)

18–24 months

Stage III

Deep lesion (Fig. 41.3)

24–36 months

Stage IV

Traumatic stage (Fig. 41.4)

Age

36–48 months

Features •

Cervically and occasionally interproximal areas of chalky white demineralization

•

No pain

•

Lesion in maxillary anterior teeth, may spread to dentin and show yellowish brown discoloration

•

Pains on having cold food items

•

Depending on time of eruption, cariogenicity of sweetener and frequency of its use, this stage can be reached in 10–14 months also

•

Molars are also affected

•

Frequent complaint of pain

•

Pulpal involvement in maxillary incisors

•

Teeth become so weakened by caries that relatively small forces can fracture them

•

Parents may report a history of trauma

•

Molars are now associated with pulpal problems

•

Maxillary incisors become nonvital

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Fig. 41.1:  Initial reversible stage

Fig. 41.2:  Damaged carious stage

Fig. 41.3:  Deep lesion

Fig. 41.4:  Traumatic stage

PRIMARY ETIOLOGICAL RISK FACTORS OF EARLY CHILDHOOD CARIES Dental decay in infants and toddlers is now collectively known as early childhood caries or ECC. Although the etiology of ECC is similar to that of other types of coronal smooth surface caries the biology may differ in some respects. The bacterial flora and host defence systems in the young infant are in the process of being established; in addition the tooth surfaces are newly erupted and immature and may show hypoplastic defects. Thus, in ECC there may be a unique risk factor in infants and young children.

•

•

•

Dental Plaque • Although there are few studies on the formation and development of plaque in young children, relevant

•

information may be extrapolated from in vivo studies in young adults. Besides modulation of the oral flora the acquired pellicle has functions such as lubrication, protection from acid attack, prevention of crystal growth on enamel surfaces and a role in enamel remineralization. In the absence of fermentable carbohydrates, organic acids such as acetate, propionate, and butyrate are produced. In contrast, when fermentable carbohydrates are present, lactate is mainly produced, which coincides with a pH drop in plaque. Bacteria and their alkaline products provide major contributions to the pH rise in plaque and the basegenerating metabolism of plaque bacteria is considered by many to be a significant determinant for cariogenicity of plaque. The presence of visible plaque and its early accumulation have been related to caries occurrence among children.5

Chapter 41  Early Childhood Caries Alaluusua and Malmivirta6 found that 91 percent of the children studied were correctly classified into caries risk groups, based solely on the presence or absence of visible plaque.

Mutans Streptococci • As in other types of coronal dental decay, the main bacteria implicated in ECC are of the group now termed “mutans streptococci” of which the species S. mutans and S. sobrinus are most commonly isolated in human dental caries. • Virulence of mutans streptococci: Mutans streptococci possesses a wide range of cariogenic traits, which are significant determinants of the cariogenicity of plaque. These characteristics confer them with an ecological advantage over other oral bacteria. – Mutans streptococci synthesize α-1,3 rich water insoluble glucans from sucrose (Tanzer JM et al.7 1984). In addition to the mediation of irreversible adhesion and colonization of mutans streptococci to the teeth, these glucans increase the thickness of plaque, and result in enhanced rates of sugar diffusion and acid production at the deeper plaque layers (Van Houte J et al.8 1985). – Synthesize intracellular polysaccharides (IPS), which support continual acid production during periods of low concentration of exogenous substrate. This activity maintains acidogenicity and fosters tooth demineralization during periods of low salivary secretion such as during sleep (Spatafora G et al.9 1995). – Mutans streptococci produce large amounts of acid, particularly lactic acid, which are potent in driving tooth demineralization (Johnson EP et al. 1980). – The aciduricity or acid tolerance of the bacteria is extremely high, thus allowing colonization and persistence under cariogenic conditions. – Lastly, it has been suggested that the production of dextranase allows the invasion of mutans streptococci to replace earlier colonizing dextran-producing bacteria such as S. sanguis (Tanzer JM,10 1989). • Colonization of mutans streptococci in dental plaque: – Initial attachment of the mutans streptococci is now thought to be independent of sucrose, and mediated by adhesions on the bacterial surface interacting directly with the salivary proteins. – In the absence of sucrose, other bacteria such as S. sanguis have a higher affinity for pellicle-coated teeth than mutans streptococci. But in the presence of fermentable carbohydrates, especially sucrose, mutans streptococci irreversibly adhere to the pellicle through the synthesis of glucans mediated

by glucosyltransferases produced by the bacteria (Bowen  WH, et al. 1991; Loesche WJ,11 1986). • Establishment of mutans streptococci in infants: – Most studies including predentate children show that mutans streptococci are usually not cultured from the oral cavity prior to the eruption of teeth. The reason for the low prevalence in predentate children may be related to the fact that mutans streptococci generally require nonshedding surface to colonize. Thus the organisms are usually first detected when the first primary teeth emerge into the oral cavity, or when obturators for palatal clefts are inserted. – The infection rate of mutans streptococci increases with age, as well as the number of teeth present in the infant’s mouth. This probably reflects the increasing number of retentive sites for bacterial colonization. – The age at which mutans streptococci are first acquired in infants is thought to influence their susceptibility to caries, i.e. the earlier colonization, the higher is caries risk (Berkovitz RJ,12 et al. 1980; Caufield PW,13 1993). – Kohler,14 1988 conducted a study in a 4-year-old children and found out that 89 percent of children colonized with mutans streptococci at the age of 2  years had a higher DMFT as compared to children who were noncolonized. • Transmission of mutans streptococci: – As mutans streptococci are predominantly found in the mouth, transmission is likely to be mediated via the saliva. – Strong correlation between salivary mutans streptococci counts in mothers and their children have been reported. Salivary concentrations of 105 CFU (colony forming units) mutans streptococci/mm of maternal saliva were associated with a 52 percent infection rate in their children, compared to only 6 percent infection rate when the maternal saliva concentration was 103 CFU or below (Berkovitz RJ,15 et al. 1981).

Infant Feeding Patterns • Reports suggest that putting a child to bed with a baby bottle is a widespread behavior, seen in 18 to 85 percent parents. A limited number of studies have examined reported bedtime bottle use in children with and without maxillary anterior decay, but many of these studies have been carried out in the dental office, potentially leading to bias. • Although the use of bottle is predominant in children with ECC but it is not the sole factor. Length of contact with the bottle at night time is also important. Greater length of bottle contact appears to be positively associated with caries. • Although commonly believed to be the cause of maxillary anterior caries, use of a bedtime bottle appears to be

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highly prevalent in children with and without anterior caries, and there is evidence to support the conclusion that use of the bottle beyond the age of 1 is a major caries risk factor. It is seen that children with caries eliminate bottle use 4-7 months later than those without caries (Marino RV16 et al. 1989). • Furthermore, children who are exclusively breastfed also appear to be susceptible to caries. These findings suggest that the role of the bottle in caries development is not as clear as previously thought and further clarification of the association of infant feeding patterns and caries is required.

Tooth Brushing • As early childhood caries starts on surface that can be easily accessed by routine tooth brushing, oral hygiene levels may be associated with caries risk. • Increased frequency and better oral hygiene levels are associated with lower caries levels in preschool children. • A major problem confronting the investigation of the relationship between tooth brushing and ECC is the methodological issue of assessing the frequency of brushing, quality of plaque removal, and actual levels of oral hygiene.

Salivary Factors • Saliva provides the main host defence systems against dental caries. It has major roles in the clearance of foods and the buffering of acid generated by dental plaque. • Saliva also mediates selective adhesion and colonization of bacteria on tooth surface, and contains several antimicro­ bial systems, which may aid in the elimination of bacteria. • Saliva contains several antimicrobial proteins, including lysozyme, lactoferrin, agglutinins that are likely to be of significance in dental caries. • Saliva also contains several organic compounds, which agglutinate oral bacteria and enhance their removal. These agglutinins include mucins, agglutinating glycoprotiens, fibronectin, lysozyme and secretory immunoglobulins. • Flow rates of saliva are important as oral clearance, buffering capacity, and antimicrobial activities are largely dependent on this.

Sugars • General cariogenicity of sugars: – Sucrose, glucose and fructose found in fruit juices and vitamin C drinks as well as in solids are probably the main sugars associated with infant caries. – Sucrose, the most widely used sugar, is considered the most important in dental caries, as it is the only substrate used for bacterial generation of plaque dextrans (Newbrun,17 1982). This is essential for

bacterial adherence and thus facilitates the implan­ tation of cariogenic bacteria in the oral cavity. • Frequency of consumption of sugars: – There are now many studies which suggest that children with ECC have a high frequency of sugar consumption, not only of fluids given in the nursing bottle, but also of sweetened solid foods. – It is noted that increased frequency of eating sucrose increases the acidity of plaque and enhances the establishment and dominance of the aciduric mutans streptococci. The increased total time sugar is in the mouth increases the potential for enamel demineraliza­ tion and there is inadequate time for remineralization by saliva. As a result of this demineralization becomes the predominant mechanism.

Oral Clearance of Carbohydrates • In infants with ECC, the sleep time consumption of sugar is another common characteristic. The low salivary flow during sleep decreases oral clearance of the sugars and increases the length of contact time between plaque and substrates, thus increasing the cariogenicity of the substrate significantly. • In this regard, Hanaki M,18 et al. (1993) reported that clearance of glucose is slowest on the labial surfaces of the maxillary incisors and buccal surface of mandibular molars. These site differences in oral clearance may explain, in part the distribution of the carious lesions in ECC, which are characteristically localized to the maxillary primary incisors and 1st molars.

Bovine Milk • The cariogenicity of milk is often questioned because plain bovine milk is the common fluid placed in the feeding bottle in many cases of ECC and also because prolonged breast feeding has been putatively associated with ECC. • But most of the studies prove that milk is not cariogenic and in fact, it may exhibit some cariostatic effect. • In vitro studies showed that milk decreases the solubility of enamel and these results have been extended by intraoral cariogenicity tests (ICT), which demonstrated that cheese extracts, prevented enamel softening caused by sucrose. • The mechanisms of protection by milk appear to work are decreasing demineralization and increasing remineralization of enamel, increasing the calcium and phosphate concentrations in plaque and increasing the acid buffering capacity of plaque. • The main components of milk involved in reducing demineralization and increasing remineralization have been reported to be various forms of casein, namely µ– casein and sodium caseinate.

Chapter 41  Early Childhood Caries • The mechanism involved is that α–casein may concentrate in the acquired pellicle and act as inhibitors of mutans streptococci adherence to saliva-coated hydroxyapatite and also reduce the adherence of Streptococcus mutans glucosyltransferases to saliva–coated hydroxyapatite (Reynolds E,19 et al. 1995).

Human Milk • There has been a paucity of studies, reporting on the cariogenicity of human breast milk. • Compared to bovine milk, human breast milk has a lower mineral content, higher concentration of lactose (7% vs 3%), and less protein (1.2 g vs 3.3 g per 100 mL), but these differences are probably insignificant in terms of cariogenicity (Drake SJ, 1976). • However, the relationship between breastfeeding and dental caries is likely to be complex, and confounded by many biological variables such as mutans streptococci infection, enamel hypoplasia, intake of sugars, as well as social variables such as education and socioeconomic status, which may affect behavior, related to oral health.

Fluorides • Although the benefits of water fluoridation and postnatal fluoride supplementation in the primary dentition are well known, there is minimal information on the cariostatic effects of topical fluoride in the early primary dentition, particularly in the prevention of ECC. • The topical effects of fluoride are complex, and include changes on the mineral phases, as well the modulation of metabolic effects on mutans streptococci and other bacteria in dental plaque. • Even at very low concentration, fluoride can affect the demineralizing process in a carious lesion by decreasing the rate of subsurface dissolution and enhancing the deposition of fluoridated apatite in the surface zone. • In dental plaque, fluoride can act as a direct inhibitor of enzymes, which affects the metabolic activity of mutans streptococci. This reduces the acid tolerance of mutans streptococci by affecting the functioning of proton extruding ATPases, which results in cytoplasmic acidification and inhibition of glycolytic enzymes.

SECONDARY ETIOLOGICAL RISK FACTORS OF EARLY CHILDHOOD CARIES

Immunological Factors • As the hard dental tissues are immunologically inactive, the host defence mechanism involved in dental caries is centered on the prevention of colonization and pathogenic activity of cariogenic bacteria.

• Host immune mechanisms include specific immune factors derived from saliva (secretory immunoglobulin A, sIgA), or serum and gingival crevicular fluid (immuno­ globulin G, IgG) and nonspecific antimicrobial systems derived mainly from saliva. • Secretory Immunoglobulin A (sIgA) may inhibit bacterial adherence or agglutination, as well as neutralization of bacterial enzymes. Although the protective effects of sIgA in other mucosal areas are well known, there is little evidence that naturally occurring sIgA antibodies protect against dental caries. (Brandtzaeg P,20 1979).

Tooth Maturation and Defects • An important area in caries etiology, which is currently not well emphasized, is the area of tooth defects. • Tooth is most susceptible to caries in the period immediately after eruption and prior to final maturation. Thus, in many infants, a combination of recently erupted immature enamel in an environment of cariogenic flora with frequent ingestion of fermentable carbohydrates would render the tooth particularly susceptible to caries. • In addition to lack of maturation, the presence of developmental structural defects in enamel may increase the caries risk.

Race and Ethnicity • Children living in ethnic areas demonstrate an extremely high rate of ECC, ranging from 70 to 80 percent, despite efforts to educate parents to reduce baby bottle use. • Milnes21 notes that ECC is so pervasive among these children that parents consider it a normal childhood disease that affects all children. Some of the factors that have been postulated for this increased incidence of ECC are: – Increased risk that could be associated with cultural norms including concern for oral health – Prenatal diet that could contribute to enamel hypoplasia – Care of primary teeth – Child rearing practices – Access to dental and medical care – Minorities may experience significant barriers to dental care, including cost of care and availability of accessible services.

Acid Fruit Drink It is now well known that acid in fruit juices and soft drinks may decrease the oral pH. In the presence of sugars in the drinks, this fall in pH is likely to enhance fermentation of carbohydrates and thus cause more profound enamel demineralization.

521

522 Section 8 

Cariology

Socioeconomic Status • Social class may influence caries risk in several ways. • Individuals from lower socioeconomic status experience financial, social and material disadvantages that compromise their ability to care for themselves, obtain professional health care services, and live in a healthy environment, all of which lead to reduced resistance to oral and other diseases.

used for the prevention of ECC. There are three general approaches that have been used to prevent ECC; first is the community-based strategy that relies on educating mothers in the hope of influencing their dietary habits as well as those of their infants, second approach is based on the provision of examination and preventive care in dental clinics, the third involves the development of appropriate dietary and self-care habits at home. Recommendations for preventive maneuvers for early childhood caries

Dental Knowledge • Dental knowledge is regarded as an important variable in the etiology of ECC because understanding the relationship between the microbiology of caries, the role of cariogenic foods, and use of baby bottle is necessary for prevention of ECC. • But contrary to this thinking there was a very interesting finding in this group and it was that higher the knowledge of the caregiver, more was the incidence of caries.

Stress • One of the underlying mechanisms that could account for the effects of social class on oral health status is the increased stress experienced in families with financial and social instability related to lower socioeconomic status. • Brown studied the relationship between caries and stress and demonstrated a positive relationship between parent’s anxiety about dental treatment and children’s caries levels. But the role of stress in ECC bears further investigation, particularly whether stress affects immuno­logy, coping skills, or preventive oral health behaviors.

PREVENTION OF EARLY CHILDHOOD CARIES Early screening for signs of caries development, starting from the first year of life, could identify infants and toddlers showing the risk of developing ECC and could also assist in providing information of parents about how to promote oral health and prevent the development of tooth decay. High-risk children should be targeted with a professional preventive program that includes fluoride varnish application, fluoridated dentifrices, fluoride supplements, sealants, diet counseling, and chlorhexidine. Prevention of ECC also requires addressing the social and economic factors that face many families where ECC is endemic. The education of mothers or caregivers to promote healthy dietary habits in infants has been the main strategy

Interventions

Target

Chlorhexidine varnish

High-ECC risk groups

Dietary counseling

High-ECC risk groups

Early detection

All infants before the age of 1 year

Education

All infants and toddlers

Education

High-ECC risk communities

Fluoride supplements

High-ECC risk groups

Fluoride dentifrices

All infants and toddlers

Fluoride varnish

High-ECC risk groups

Prenatal fluoride supplements

All infants and toddlers

Sealants

High-ECC risk groups

Water fluoridation

Community

Xylitol substitutes

High-ECC risk groups

Control of mother-infant infection High-ECC risk groups with cariogenic bacteria

RAPIDD Scale • The Readiness Assessment of Parents concerning Infant Dental Decay (RAPIDD) Scale was developed to/assess a parent’s stage of change precontemplative, contemplative, or action with regard to his/her child’s dental health. • This instrument based on the work by Prochaska and DiClemente, measures pro and con parental beliefs about caring for their child’s teeth. Parents in precontemplative stage show low openness and low health score whereas those in action stage show high scores. • Readiness assessment of parents concerning infant dental decay scale consisted of thirty-eight-items with responses on five-point scale ranging from strongly agree to strongly disagree. The patient or primary caretaker was instructed to select a box under one of the five categories after the interviewer read them the question in their native language. Each of the thirty-eight-items were placed into one of four constructs: 1. Openness to health information 2. Valuing dental health

Chapter 41  Early Childhood Caries 3. Convenience and change difficulty 4. Child permissiveness. In order to categorize respon­ dents as precontemplators, contemplators, or action individuals the responses to the questions within each construct were summed, these slimmed values were ranked, and percentiles were calculated for each individual within each construct. • The RAPIDD instrument is a tool that is used to determine parent’s stage of change for their child’s oral health. Once a particular stage of change has been established the counselor then determines the best approach to move into next stage.

Community Based Education • The goal of education is to increase the knowledge of mothers about ECC, and to improve the dietary and nutritional habits of infants and mothers. It is assumed that an increase in the knowledge of mothers or caregivers will influence their self-care habits and dietary practices and, in turn, improves the dietary and oral hygiene habits of infants leading to the prevention of ECC. • Positive changes in infant feeding practices have been found to be modest, even when a community educational program was designed and implemented in collaboration with members of a high ECC risk community. • One such study was carried out a decade ago in American Indian and Alaskan native communities. The goal of the study was to reduce the number of children with ECC by 50 percent in a 5-year period. The study sites were divided into three intervention approaches: high, medium, and low intensity. In the high-intensity sites, community coordinators of the project and parent volunteers were trained to administer the educational program on site directly by the project development team. In the medium-intensity sites, the coordinators only attended a training session organized by the development team of the project. In low-intensity sites, only the project educational material and guidelines were mailed and no training was provided. The educational program was designed to address the feeding problems identified in the communities: unwillingness of parents to wean children from the bottle, weaning a child to the bottle instead of a cup, and the lack of knowledge about ECC. The program included one-to-one counseling, where volunteers, health professionals and employees from the community discussed ECC and its prevention with mothers or caregivers. The logo used in the project was appropriately labeled “Stop BBTD” (baby bottle tooth decay). After 3 years, there was 33 percent reduction in ECC prevalence in high-intensity sites, 18 percent in medium-intensity sites, and 27 percent in low-intensity sites.

Prevention of Transmission of Cariogenic Bacteria • There is evidence that cariogenic bacteria are transmitted from mothers to their infants. Genotypes of mutans streptococci in infants appeared identical to those of the mothers in 71 percent of mother-infant pairs. • A nonrandomized study divided mothers who had at least 106 mutans streptococci per mm of saliva into test and control groups. The test program included provision of dental education, oral hygiene instruction, dental treatment, tooth cleaning, application of 2 percent sodium fluoride, fluoride varnish. This program was started when the child was 3 to 8 months in age and continued until they reached the age of 3 years. On re-examination, it was found that children whose mothers were in the experimental group had a DMFT of 5.2, which was much lower as compared to the DMFT of control group, which was 8.6.14

 rofessional and Home-based P Preventive Approaches • Some of the professionally applied and home-based approaches that could be employed in the prevention of ECC are listed based on risk status (Table 41.1). • Professional treatment for early childhood caries ranges from diet counceling to the prosthodontic rehabilitation of patient. Restorations are accomplished by GIC and composites, endodontic therapy is done as indicated followed by placement of crowns and grossly decayed teeth are extracted followed by placement of space maintainers (Figs 41.5A to F). • The use of fluoride is done according to the level of fluoride in water (Table 41.2).

BARRIERS IN EARLY CHILDHOOD CARIES Any proposal to improve social, mental and physical health of children cannot be successful without adequate funding, political leadership and support. Some of the potential barriers in providing optimum care for children are: • Lack of involvement and commitment from dental and other health organizations. • The dental community lacks a shared vision of the definition of the problem, how to prevent it and who is responsible for planning and implementation. • There is no integrated plan to fight the social, economic and nutritional issues facing people in low socioeconomic group. • There is weak direct support for research on epidemiology, etiology and prevention of ECC. • Dental health is not a priority of most programs and insurance packages.

523

524 Section 8 

Cariology

A

B

C

D

E

F

Figs 41.5A to F:  Full mouth rehabilitation case: (A and B) Compomer restoration of central incisors; (C and D) Pulpetomy done irt 54, 55 followed by stainless steel crown irt 55; (E and F) Pulpectomy done irt 75 and 85 followed by stainless steel crown and band and loop space maintainer irt 75

TABLE 41.1:  Risk-based treatment methodology No signs of ECC or low-ECC risk status

Signs of ECC or high-ECC risk status

TABLE 41.2: Recommended fluoride supplemental dosage schedule (mg F/day) Fluoride level in water

Fluoridated dentifrices

Fluoride varnish

0.7

Review of dietary and oral hygiene

Sealants

0–2

0.25

0.00

0.00

Chlorhexidine varnish

2–3

0.50

0.25

0.00

Xylitol pacifiers

3–16

1.00

0.50

0.00

Fluoridated supplements and dentifrices Dietary counseling

Age

Chapter 41  Early Childhood Caries

Model for prevention of early childhood caries The literature on ECC is growing, but before real gains can be accomplished in preventing the onset and progression of ECC investigators need to come to some consensus on the following issues: • A definition of ECC specifying what constitutes ECC and its applicable age. • Need for larger, more representative epidemiological studies of ECC using heterogeneous populations. • Longitudinal studies are needed to assess the natural history for the ECC. • Additional attention is needed to investigate baby bottle usage and its roles in the etiology of ECC. • ECC screening efforts should be integrated with Pediatricians • Additional attention needs to be paid to the role of professional dental care and access to dental care in the incidence, prevalence and severity of ECC.

POINTS TO REMEMBER • • • • • •

•

•

•

First terminology used for ECC was nursing caries by Winter (1966) The term ECC was given by Davies (1998) The newest term according to its causative agent is called MDSMD—Maternally derived Streptococcus mutans disease The disease of early childhood caries is defined as presence of 1 or more decayed, missing or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. The various stages in development of ECC lesion are initial reversible stage, damaged carious stage, deep lesion, traumatic stage. Risk factors for ECC include dental plaque, mutans streptococci, stress, dental knowledge, socioeconomic status, race and ethnicity, Tooth maturation and defects, immunological factors, bovine milk, oral clearance of carbohydrates, cariogenicity of Sugars, tooth brushing and infant feeding patterns. Mutans streptococci is most prevalent in dental caries because it synthesize α-1,3 rich water insoluble glucans from sucrose which increase the thickness of plaque, and result in enhanced rates of sugar diffusion and acid production at the deeper plaque layers; synthesize intracellular polysaccharides (IPS), which support continual acid production; produce large amounts of lactic acid, which are potent in driving tooth demineralization; production of Dextranase allows the invasion of mutans streptococci to replace earlier colonizing dextran-producing bacteria such as S. sanguis; mutans streptococci irreversibly adhere to the pellicle through the synthesis of glucans mediated by glucosyltransferases produced by the bacteria. Use of baby bottle is not the sole factor for ECC. Length of contact with the bottle at night time is also important. Greater length of bottle contact appears to be positively associated with caries. Use of the bottle beyond the age of 1 is a major caries risk factor. Milk is not cariogenic and in fact, it may exhibit some cariostatic effect.

525

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Cariology

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7.

Define and classify early childhood caries. What are the developmental stages of ECC? Explain the primary and secondary etiological factors of ECC. Describe the role of mutans streptococci in ECC? Describe the management of a child with ECC? What are the barriers in treatment of caries? Explain the fluoride protocol for ECC patients.

REFERENCES 1. Davies GN. Early childhood caries: A synopsis. Community Dent Oral Epidemiol. 1998;26(Suppl 1):106-16. 2. Selwitz RH, Ismail AI, Pitts AI. Dental caries. Lancet. 2007;369:51–9. 3. American Academy of Pediatric Dentistry. Symposium on the prevention of oral disease in children and adolescents. Chicago, Ill, November 11-12, 2005: Conference papers. Pediatr Dent. 2006;28(2):96-198. 4. Wyne AH. Early childhood caries: nomenclature and case definition. Community Dent Oral Epidemiol. 1999;27:313-15. 5. Tinanoff N, Kanellis MJ, Vargas CM. Current understanding of the epidemiology mechanisms, and prevention of dental caries in preschool children. Pediatr Dent. 2002;24:543-51. 6. Alaluusua S, Malmivirta R. Early plaque accumulation, a sign for caries risk in young children. Community Dent Oral Epidemiol. 1994;22:273-6. 7. Tanzer JM, Freedman ML, Fitzgerald RJ. Virulence of mutants defective in glycosyltransferase, dextran-mediated aggregation, or dextran activity. In: Mergenhagen S, Rosan B, (Eds). Molecular basis of oral mirobial adhesion. Washington, DC: American Society for Microbiology; 1984.pp.204-11. 8. Van Houte J, Russo J, Prostak KS. Increased pH-lowering ability of Streptococcus mutans cell masses associated with extracellular glucanrich matrix and the mechanisms involved. J Dent Res. 1989;68:4511-9. 9. Spatafora G, Rohrer K, Barnard D, Michalek S. A Streptococcus mutans mutant that synthesizes elevated levels of intracellular polysaccharide in hypercariogenic in vivo. Infect Immun. 1995;63:2556-63. 10. Tanzer JM. On changing the cariogenic chemistry of coronal plaque. J Dent Res. 1989;68(Spec Iss):1576-87. 11. Loesche WJ. Role of Streptococcus mutans in human dental decay. Microbiol Rev. 1986;50:353-80. 12. Berkowitz RJ, Jordan HV, White G. The early establishment of Streptococcus mutans in the mouth of infants. Arch Oral Biol. 1975;20:171-4. 13. Caufield PW, Cutter GR, Dasanayake AP. Initial acquisition of mutans streptococci by infants: evidence for a discrete window of infectivity. J Dent Res. 1993;72:37-45. 14. Kohler B, Andreen I, Johnson B. Earlier is the colonization of mutans streptococci higher is the incidence of caries in a 4-year-old children. Oral MicrobilImmunol. 1988;3:14-7. 15. Berkovitz RJ, Turner G, Green P. Maternal salivary levels of mutans and primary oral infections in infants. Arch Oral Biol. 1981;26:17-9. 16. Marino RV, Bomze K, Scholl TO, Anhalt H. Nursing bottle caries: characteristics of children at risk. ClinPediatr. 1989;28:129-31. 17. Newbrun E. Sugar and dental caries: A review of human studies. Science. 1982;217:418-23. 18. Hanaki M, Nakagaki H, Nakamura H, Kondo K, Weatherell JA, Robinson E. Glucose clearance from different surfaces of human central incisors and the first molars. Arch Oral Bioi. 1993;38:479-82. 19. Reynolds EC, Cain CJ, Webber FL, Black CL, Riley PF, Johnson IH, et al. Anticariogenicity of calcium phosphate complexes of tryptic casein phosphopeptides in the rat. J Dent Res. 1995;74:1272-9. 20. Brandtzaeg P. The oral secretory immune system with special emphasis on its relation to dental caries. Proc Finn Dent Soc. 1979.pp.71-84. 21. American academy of pediatric dentistry. Infant oral health care. Pediatr dent. 1994;16:29.

BIBLIOGRAPHY

1. Darke SJ. Human milk versus cow’s milk. J Hum Nutr. 1976;30:233-8. 2. Fass EN. Is bottle feeding of milk a factor in dental caries? Dent child. 1962;29:245-51. 3. Firestone AR. Effects of increasing contact time of sucrose solution of powdered sucrose on plague pH in vivo. J Dent Res. 1982;61:124-34. 4. Ismail AI. Fluoride supplements: Current effectiveness, side effects and recommendations. Community Dent Oral Epidemiol. 1994;22:164-72. 5. Keyes PH, Jordan HV. Factors influencing the initial transmission and inhibition of dental caries. In: Harris RS, editor. Mechanisms of hard tissue destruction. New York: NY Acad Pr. 1963.pp.261-83. 6. Kohler B, Birkhed D, Olsson S. Acid production of human strains of Streptococcus mutans and Streptococcus sobrinus. Caries Res. 1995;29:402-6. 7. Mandal ID. Functions of saliva. Dent Res. 1987;66:623-7. 8. Milnes AR, Bowden GHW. The microflora associated with developing lesions of nursing caries. Caries Res. 1985;19:289-97. 9. Ripa JW. Nursing caries: A comprehensive review. Pediatr Dent. 1988;10:268-82. 10. Seow WK. Bottle caries: A challenge for preventive dentistry. Dentistry Today. 1987;3:1-9. 11. Winter GB, Hamilton MC, James PMC. The role of the comforter as an aetiological factor in rampant caries of the deciduous teeth. Arch Dis Child. 1966;41:202-12.

42

Chapter

Rampant Caries Nikhil Marwah

Chapter outline • •

Terminologies Clinical Appearance

Caries in early stages of life is an unsolved enigma for most of us around the world. Rampant caries is appearance of more than 5 new lesions in an individual of any age group in a year whereas nursing caries is any caries which occurs in children or may be attributed to bottle feeding habit. The essence here is that nursing caries is a type of rampant caries. Nursing bottle caries is characterized by a rampant caries pattern initially involving maxillary deciduous anterior teeth; posterior teeth are then involved and mandibular anterior are usually spared. This condition is attributable to frequent prolonged contact with bottle containing sweet beverages or milk. Massler (1945) defined rampant caries as suddenly appearing widespread, rapidly spreading, burrowing type of caries, resulting in early involvement of pulp and affecting those teeth, which are usually regarded as immune to decay. Winter et al. (1966) defined rampant caries as caries of acute onset involving many or all the teeth in areas that are usually not susceptible. They further defined the condition to be associated with rapid destruction of crowns with frequent involvement of dental pulp.

Terminologies for nursing caries • • • • • • •

Nursing caries—Winter (1966) Nursing bottle mouth—Kroll (1967) Nursing bottle syndrome—Shelton (1977) Night bottle syndrome—Dilley (1980) Nursing bottle caries—Tsintaosaurus (1986) Baby bottle tooth decay—Min Kelly (1987) Milk bottle syndrome—Ripa (1988).

• •

Prevention Treatment

CLINICAL APPEARANCE • The pattern of rampant caries in the primary dentition is usually related to the order of tooth eruption with the exce­ ption of the mandibular primary incisor. The mandibular incisors are probably more resistant to caries because of their close proximity to the secretions of the submandibular salivary glands as well as the cleansing action of the tongue during the process of suckling the bottle. • The initial lesion usually appears on the labial surface of the maxillary incisors, close to the gingival margins, as a whitish area of decalcification or pitting of the enamel surface shortly after eruption. • These lesions soon become pigmented to a light yellow and at the same time, extend laterally to the proximal surfaces and downward to the incisal edge (Fig. 42.1). • Less commonly, the decalcification may present initially on the palatal surfaces, or even at the incisal edge in some extreme cases. • At a more advanced stage, the carious process will often extend around the circumference of the tooth, leading to pathologic fracture of the crown on minimal trauma (Fig. 42.2). • Other teeth, namely the first primary molars, the second primary molars, and eventually the canines, will gradually become involved. • Nursing bottle caries is a form of rampant dental caries in the primary dentition of infants and children. In most cases, the problem is found in an infant who frequently falls asleep with a baby bottle filled with milk or sugar-

528 Section 8 

Cariology

Fig. 42.1:  Initial clinical appearance of rampant caries

•

•

•

•

containing substances like vitamin C syrup, sweetened fruit juice, or even carbonated drinks. The condition can also be associated with breastfed infants who have prolonged feeding habits or with children whose pacifiers are frequently dipped in honey, sugar, or syrup. The decrease in salivary flow rate during sleep, as well as the pooling of sweet fluids around the teeth, results in a highly cariogenic environment. Rampant caries may also occur in the permanent dentition of teenagers, because of their frequent intake of cariogenic snacks and sweet drinks between meals. Typical rampant caries in adolescents is characterized by buccal and lingual caries of premolars and molars and proximal and labial caries in the mandibular incisors. A specific form of rampant caries may occur in children and adolescents who have a greatly reduced salivary flow as a result of radiotherapy for the treatment of cancer of the head and neck region or as a result of the surgical removal of neoplasm in the oral cavity, this is called radiation caries.

TREATMENT • The type of treatment instituted for patients with rampant caries depends on the patients and parents motivation toward dental treatment, the extent of the decay, and the age and cooperation of the child. These factors should be assessed during the child’s first few visits to the dentist. • Initial treatment, including provisional restorations, diet assessment, oral hygiene instruction, and home and pro­ fessional fluoride treatments, should be performed before any comprehensive restorative treatment commences. • Caries stabilization and provisional restorations should be placed in symptom-free teeth with established

Fig. 42.2:  Advanced clinical appearance of rampant caries

•

•

•

•

dentinal caries to minimize the risk of pulpal exposure in the future and to improve function. However, in patients presenting with acute and severe signs and symptoms of gross caries, pain, abscess, sinus, or facial swelling, immediate treatment is indicated. Because diet is one of the major factors in the initiation and development of caries, a dietary assessment should form a fundamental part of the examination. Parents should be educated to reduce the frequency of sucrose consumption by their child, especially between meals. Consumption of sugar-containing foods and beverages should be restricted to meal times. Parents can be instructed to record the amount and quantities of food and beverages consumed during and between meals for 3 consecutive days. Dietary vitamin supplements as well as oral medications must also be included. If bottlefeeding is still being practiced, particularly at night, it should be stopped by gradually diluting the bottle contents with water as well as decreasing the amount of added sugar over a 2 or 3 weeks period and finally substituting the bottle with a feeding cup. Young adults usually brush their teeth for less than 40 seconds and spend only 30 percent of the time on the caries-susceptible surfaces. Therefore, it is important to teach children the proper techniques of toothbrushing at different age groups. Generally speaking, children under the age of 8 years can best manage the circular scrub technique under parental supervision, whereas after the age of 11 to 12 years the Bass technique, can be taught. Both systemic and topical fluoride treatments are useful for preventing dental caries; the choice depends on the level of fluoride in the drinking water and the stage of development of the dentition (Table 42.1). Children with a primary dentition will benefit from both fluoride tablets

Chapter 42  Rampant Caries TABLE 42.1: Fluoride treatment for children with rampant caries (0.3 to 0.7 ppm water fluoride level) Type

0–2 years

2–3 years

3–13 years

>13 years

Dietary fluoride supplement

Not indicated

0.25 mg F daily

0.5 mg F daily

Not indicated

Operator-applied topical fluoride

APF topical solution or gel, 1.23% F, applied four times a year

APF topical solution or gel, 1.23% F, applied four times a year

APF topical solution or gel 1.23% F, applied four times a year

APF topical solution or gel, 1.23% F, applied four times a year

Self-applied topical fluoride

Not indicated

Not indicated

Self-application of gel-tray daily for approximately 4 weeks; thereafter continue with a daily fluoride rinse (0.05%NaF)

Self-application of gel-tray daily for approximately 4 weeks; thereafter continue with a daily fluoride rinse (0.05%NaF)

Fluoride dentifrice

Brush with F-containing dentifrice

Brush with F-containing dentifrice

Brush with F-containing dentifrice

Brush with F-containing dentifrice

and the use of a small amount of fluoride toothpaste. The child should be encouraged to chew or suck the tablet, preferably at bedtime. This provides a topical effect on dental enamel of the erupted teeth followed by a systemic effect on developing enamel after swallowing. • Once rampant caries is under control, comprehensive restorative treatment can be carried out (Fig. 42.3). If the patient is seen at an early stage, when caries is still in the incipient or white spot stage, and there is minimal or no loss of enamel surface integrity, an improvement in oral hygiene technique, a change in dietary habits, and weekly home or professionally applied topical fluoride therapy will help arrest the lesions, and the need for restorations may be obviated. Unfortunately, dental treatment is only sought for most children with rampant caries when extensive cavitation has occurred and restorative treatment is required. Acid-etched composite resin restorations can be used to restore anterior maxillary teeth whereas pedo-form strip crowns, which are more esthetic, functional, and durable, are indicated in anterior teeth with gross caries and extensive crowns, which are more esthetic, functional, and durable, are indicated in anterior teeth with gross caries and extensive coronal destruction. Alternatively, glass-ionomer cement, which adheres, to enamel and dentin as well as releases fluoride, can also be used as the restorative material; however, the results are esthetically less pleasing than those achieved with composite resin restorations. Acidetched composite resin restorations, glass-ionomer-silver cermet cements, and stainless steel crowns can be used to store the posterior teeth. Depending on the extent of the lesions, pulpotomies, pulpectomies, or extraction may be indicated. Where extractions of teeth have been carried out, a prosthesis should be provided for maintenance, function, and esthetics.

Age specific prevention of rampant caries Dentition: 0–5 years Advice

Diet counseling with parents on good nursing techniques

Therapy

•  Toothpaste •  Fluoride tablets, if in area without water fluoridation •  Professional topical fluoride application every 6 months

Control

•  Oral hygiene instructions to parents •  Toothbrushing with parental supervision •  six-month recall

Advice

Diet counseling with parents and patients

Therapy

•  Toothpaste • Fluoride tablets up to 8 years if in area without water fluori­dation • Mouth rinse • Professional topical fluoride application every 6 months

Control

Oral hygiene instructions to patient Toothbrushing without parental supervision Sealants Six-month recalls

Dentition: 5–12 years

Permanent dentition: 12 years-onward Advice

Diet counseling with parents and patients

Therapy

• Toothpaste • Mouth rinse • Professional topical fluoride application every 6 months

Control

• Oral hygiene instructions to patient • Toothbrushing • Interdental cleaning with floss • Sealants

Rampant caries is a distressing clinical condition confronting the child, parents, and dentist. With the advances in knowledge about the etiology and pathogenesis of dental

529

530 Section 8 

Cariology

Fig. 42.3:  Full mouth rehabilitation of rampant caries patient

Chapter 42  Rampant Caries caries, rampant caries can now be prevented. Successful management of rampant caries depends on a coordinated team approach among the pediatrician, pediatric dentist, parents, and child. The pediatrician should educate the parents about good nursing and dietary habits and the importance of good oral hygiene to their child’s teeth and should encourage parents to bring their child to the dental office before he or she is 12 months of age for a screening examination and counseling, because pediatricians are often the first medical

personnel to see the newborn baby. Pediatric dentists, who are more experienced in the implementation of preventive and restorative dentistry to infants and young children, should play a vital role in the management of rampant caries in children. However, interest and cooperation from the parents and children are equally important. Consequently, educational efforts should be emphasized and reinforced, especially in areas where the prevalence of rampant caries is high.

POINTS TO REMEMBER • Nursing bottle caries is a type of rampant caries • Massler (1945) defined rampant caries as suddenly appearing widespread, rapidly spreading, burrowing type of caries, resulting in early involvement of pulp and affecting those teeth, which are usually regarded as immune to decay. • Initial lesion appears on the labial surface of the maxillary incisor as a whitish area of decalcification. In advanced stage, the carious process will often extend around the circumference of the tooth, leading to pathologic fracture in anterior teeth and deep caries in posterior teeth. • A specific form of rampant caries may occur in children who have a greatly reduced salivary flow as a result of radiotherapy, this is called radiation caries. • The treatment for rampant caries extends from dietary counceling to endodontic therapy followed by crowns.

QUESTIONNAIRE 1. Define rampant caries. 2. Give the clinical features and treatment options for rampant caries. 3. What is the fluoride regimen for children with rampant caries?

BIBLIOGRAPHY 1. Berkowitz RJ, Jordan HV, White G. The early establishment of Streptococcus mutans in the mouth of infants. Arch Oral Biol. 1975;20: 171-4. 2. Berkowitz RJ. Turner J, Green P. Maternal salivary levels of Streptococcus mutans and primary oral infection of infants. Arch Oral Biol. 1981;26:147-9. 3. Boue D, Armau E, Tiraby G. A bacteriological study of rampant caries in children. J Dent Res. 1987;66:23-8. 4. Derkson GD, Ponti P. Nursing bottle syndrome: Prevalence and etiology in a non-fluoridated city. J Can Dent Assoc. 1982;48:389-93. 5. Hackett AF, Rugg-Gunn AJ, Murray JJ, et al. Can breastfeeding cause dental caries? Hum Nutr Appl Nutr. 1984;38(1):23-8. 6. Hamada S, Slade HD. Biology, immunology and cariogenicity of Streptococcus mutans. Microb Rev. 1980;44:331-84. 7. Johnsen DC, Gerstenmaier JH, DiSantis TA, et al. Susceptibility of nursing-caries children to future approximal molar decay. Pediatr Dent. 1986;8(3):168-70. 8. Kohler B, Andreen I, Jonsson B, et al. Effect or caries preventive measure on Streptococcus mutans and Lactobacilli in selected mothers. Scand J Dent Res. 1982;90:102-8. 9. Kotlow LA. Breastfeeding: A cause of dental caries in children. J Dent Child. 1977;44:192-3. 10. Marino RV, Bomze K, Scholl TO, et al. Nursing bottle caries, characteristics of children at risk. Clin Pediatr. 1989;28:129-31. 11. National Foundation of Dentistry for the Handicapped: A guide to the use of fluoride for the prevention of dental caries with alternative recommendations for patients with handicaps. J Am Dent Assoc. 1986;113:515,522,531,535. 12. Richardson BD, Cleaton-Jones PE, McInnes PM, et al. Infant feeding practices and nursing bottle caries. J Dent Child. 1981;48:423-9. 13. Rugg-Gunn AJ. Fluorides in the prevention of caries in the preschool children. J Dent. 1990;18:304-7. 14. Van Houte J, Gibbs G, Butera C. Oral flora of children with “nursing bottle caries.” J Dent Res. 1982:61:382-5. 15. Van Houte J. Bacterial specificity in the etiology of dental caries. Int Dent J. 1980;30:305-26. 16. Winter GB, Hamilton MC, James PMC. Role of the comforter as an etiological factor in rampant caries of the deciduous dentition. Arch Dis Child. 1966;417:207-21.

531

43

Chapter

Chemomechanical Caries Removal Nikhil Marwah

Chapter outline •

Caridex

Caries continues to affect a significant portion of the world population and treatment of the decay is associated with pain in many patients. Conventional caries removal and cavity preparation entail the use of burs. Disadvantages of this system include: (i) the perception by patients that drilling is unpleasant, (ii) local anesthesia is frequently required, (iii) drilling can cause deleterious thermal effects, (iv) drilling can also cause pressure effects on the pulp, and (v) the use of a handpiece may result in removal of softened, but uninfected dentin, resulting in an excessive loss of sound tooth tissue. As a result, there is a growing demand for procedures or materials that facilitate caries management. The chemomechanical method for caries removal was developed to overcome these shortcomings. It is not only more comfortable for the patient but also able to better preserve the healthy tissue. According to Banerjee et al. the chemomechanical method is an effective alternative for caries removal because it brings together atraumatic characteristics and bactericide/bacteriostatic action. The method was created so as that an active ingredient would soften the predegraded collagen of the lesion without pain or undesirable effects to adjacent healthy tissues.

• • • • • • •

Advantages of chemomechanical caries removal

Its proven effectiveness Method’s safety Elimination of local anesthesia and bur Lower anxiety built in patients Conservation of the sound tissue Only demineralized dentin containing denatured collagen is affected Gel consistency simplifies control of the application and reduces the risk of spillage.

• •

Carisolv Papain Gel

In 1975, Habib et al. introduced a method using 5 percent sodium hypochlorite to remove carious tissues and since then, many studies have attempted to improve this early technique. The sole use of 5 percent sodium hypochlorite was known to be toxic and aggressive to adjacent healthy tissues. Therefore, a new solution was developed adding sodium hydroxide, sodium chloride and glycine to the 5 percent sodium hypochlorite. This modified formula was known as GK-101 and it was comprised of N-monochloroglycine. It was more effective than the hypochlorite alone but was very slow in carious tissue removal. Also, at the time of the introduction of GK-101, the use of adhesive dental materials was not common, and dentists still prepared teeth according to Black’s cavity design. Therefore, the use of a method that only removed carious dentin could not significantly reduce the need of drilling to create mechanical retention.

CARIDEX® • Caridex (National Patent Medical Products Inc) was later developed by CM Habib from a formula made of N-monochloroglycine and aminobutyric acid and was called as GK-101E. • Krogman, Goldman published first report on this material in 1975 and it gained Food and Drug Administration (FDA) approval in 1984. It was initially introduced on the US market in 1985. • The system involved the intermittent application of preheated N-monochloro-DL-2-aminobutyric acid (GK-101E) to the carious lesion. The solution was claimed to cause disruption of collagen in the carious dentin, thus facilitating its removal. The mechanism of softening involved chlorination of remaining partially degraded

Chapter 43  Chemomechanical Caries Removal dentinal collagen and the conversion of hydroxyproline to pyrrole-2-carboxylic acid, which initiated disruption of the altered collagen fibers in the caries. • Caridex was not widely adopted, possibly due to the expense, additional clinical time and the bulky Caridex delivery system, which consisted of a reservoir, a heater, a pump and a handpiece with an applicator tip. It also transpired that conventional tooth preparation was significantly faster in removing caries than the Caridex system. However, Caridex did demonstrate the possible potential for chemomechanical caries removal and laid foundation for further research.

CARISOLV® • During the 1980s studies at the universities by Malmö, Huddinge at Chalmers Technical University in Göteborg was directed towards a more efficient and effective chemomechanical caries removal system than Caridex®. • Chriser Hedwards with Lars Strid of MediTeam (Dentalutveckling Göteberg AB) collaborated with Dan Ericson and Rolf Bornstein in Sweden in January 1998 led to the development of a new patented system for chemomechanical caries removal called Carisolv® (Fig. 43.1).

• It was initially approved for clinical use in dental practice by the Swedish counterpart to the FDA and was recently, introduced to the European market as a successor to the Caridex system. Carisolv key difference to other products already in the market was the use of three amino acids—lysine, leucine, and glutamic acid—instead of the aminobutyric acid. These amino acids counteracted the sodium hypochlorite aggressive behavior at the oral healthy tissues. • Despite its effectiveness, Carisolv was not a blockbuster mainly because it required: (i) extensive training and registration of professionals and (ii) customized instru­ ments which increased the cost of the solution. As a result, few people had access to the Carisolv solution.

Constituents of Carisolv® The formulation of Carisolv® is isotonic in nature and consists of the following: • Available as single mix or multi mix syringes (Figs 43.2 and 43.3) • Syringe one: Sodium hypochlorite (0.5%) • Syringe two: Three amino acids (glutamic acid, leucine, lysine) • Gel substance: Carboxymethylcellulose • Adjunct: Sodium chloride/sodium hydroxide • Vehicle: Saline solution • Coloring indicator: Red.

Fig. 43.1: Carisolv®

• • • • • • • • • •

Indications for use

Where the preservation of tooth structure is important The removal of root/cervical caries The management of coronal caries with cavitation The removal of caries at the margins of crowns and bridge abutments The completion of tunnel preparations Where local anesthesia is contraindicated The care of caries in dentally anxious patients, notably needle phobics Management of primary carious lesions in deciduous teeth Atraumatic restorative technique procedures Caries management in patients with special needs

Fig. 43.2: Single mix syringes

533

534 Section 8 

Cariology and sodium hypochlorite without increasing the total amount of fluid used, therefore reducing the total volume required. • The solution does not need to be heated, or applied through a pump mechanism. • The increased viscosity of Carisolv® enhances precision placement. • The overall stability is increased, giving an improved shelf-life.

Mode of Action (Figs 43.4A to D) See Flow chart 43.1.

Hand Instruments

Fig. 43.3: Multi mix syringes

To ensure the most effective removal when the Carisolv® gel has softened the carious dentin, specially-designed instruments and tips have been developed. They are atraumatic, help to preserve tissue and speed up the treatment. The tips have different shapes and sizes to suit cavities of all kind. Hand instruments can be classified as: • Depending upon type of tips (Fig. 43.5) – Instruments with permanent tips: The instrument tips are paired together in double ended Carisolv® instruments.

Advantages • Three amino acids are incorporated instead of one, and  the different changes have improved the interaction with the degraded collagen within the lesion, thus increasing the efficacy. • Carisolv® has a higher viscosity, which allows for the appli­ cation of higher concentrations of amino acids

A

C

B

D

Figs 43.4A to D: Mode of action of Carisolv®

Chapter 43  Chemomechanical Caries Removal Flow chart 43.1: Mode of action of Carisolv®

– Instruments with interchangeable tips: A single handle can be used with a range of different interchangeable Carisolv® instruments. • Standard instrument classification (Fig. 43.6) – Carisolv® hand instrument 1 (extra bend; star 3, flat 0): Primarily used for crown margins and areas that are difficult to access. – Carisolv® hand instrument 2 (multistar, star 3): The basic instrument to apply gel and start removing caries. The multistar tip promotes penetration of the gel. When getting closer to healthy dentin, use the star-shaped tip, scraping in all directions with its fourpronged design.

Fig. 43.5: Hand instruments

535

536 Section 8 

Cariology

Fig. 43.6: Tips of hand instruments

– Carisolv® hand instrument 3 (star 2, star 1): To remove caries in smaller cavities; for example, root caries or deciduous teeth. – Carisolv® hand instrument 4 (flat 3, flat 2): To be used, for example, close to the pulp and to remove the softened carious dentin from the cavity. – Carisolv® hand instrument 5 (flat 1, flat 0): Flat 0 and flat 1 are used to remove caries at the dentino-enamel junction.

Power Drive™ • It is a combined electronic instrument for poweroperated, minimally-invasive caries removal with Carisolv® and for endodontic treatment (Fig. 43.7).

Fig. 43.8: Cavity preparation using Carisolv®

Fig. 43.7: Power drive

• Selective and precise—removes only carious dentin • Fast, simple and efficient removal of caries • Power Drive operates with high tissue control and at a low sound level • Patients can operate the control unit themselves • Useful for patients with dental phobia.

Chapter 43  Chemomechanical Caries Removal

Clinical Procedure of Caries Removal with Carisolv (Fig. 43.8)

537

538 Section 8 

Cariology

Treatment of Children using Carisolv® The clinical procedure undertaken is the same but there are a few behavioral modifications that have to be made: • Do not to rush. • Be sure to give the gel 30 seconds to react. • Keep the patient well informed during the treatment. • If the patient experiences any pain, check that the cavity is completely covered with gel and consider the potential benefit of local anesthesia. • It is very important not to work with too much force – use speed and not pressure in your movement of the Carisolv® instruments. • Rub/massage the gel into the carious lesion.

Fig. 43.9: Papain gel

Comparison of Caridex and Carisolv Characteristic

Caridex

Carisolv

Solution 1

1% NaOCl

0.5% NaOCl

Solution 2

0.1 M aminobutyric acid Glycine M NaCl 0.1 M NaOH

0.1M glutamic acid Leucine/lysine NaCl NaOH

Dye

–

Erythrocin (pink)

pH

11

11

Physical properties

Liquid

Gel

Volume needed

100–500 mL

0.2–1.0 mL

Time required

30–45 mins

5–15 mins

Equipment

Applicator unit

Basic hand instruments

Active time after mixing 1 hour

•

•

•

20 mins

•

PAPAIN GEL • In 2003, a research project in Brazil led to the development of a new formula to universalize the use of chemomechanical method for caries removal and promote its

use in public health. The new formula was commercially known as Papacarie® (Fig. 43.9). It is basically comprised of papain, chloramines, toluidine blue, salts, thickening vehicle, which together are responsible for the Papacarie’s bactericide, bacteriostatic and anti-inflammatory characteristics. Papain comes from the latex of the leaves and fruits of the green adult papaya. Carica papaya, for instance, is cultivated in tropical regions, such as Brazil, India, South Africa, and Hawaii, and is largely used in the food, beverage, and drug industries. Papain accelerates the cicatricial process and according to Mandelbaum, papain is indicated in all phases of the cicatricial process and it promotes (i) chemical debridement, (ii) granulation and epithelialization, (iii) stimulation of the tensile strength of the scars. Dawkins showed that Carica papaya has bactericide and bacteriostatic properties which inhibits growth of grampositive and gram-negative organisms. Pereira et al. used samples of infected dentin cultivated in brain-heart infusion (BHI) broth in Petri dish to assess the Papacarie’ antimicrobial activity. The results showed the largest papacarie’ activity was in case of Streptococcus and Lactobacillus.

Chapter 43  Chemomechanical Caries Removal

Clinical Procedure

539

540 Section 8 

Cariology

POINTS TO REMEMBER • GK-101 was the first chemomechanical agent for caries removal • Advantages of chemomechanical caries removal are safety, elimination of local anesthesia and bur, lower anxiety, conservation of the sound tissue. • Caridex was developed by CM Habib from a formula made of N-monochloroglycine and amino butyric acid and was called as GK-101E. Disadvantages of this were expense, additional time consumption and bulky armamentarium. • Chriser Hedwards with Lars Strid of MediTeam collaborated with Dan Ericson and Rolf Bornstein in Sweden in January 1998 to develop Cariosolv®. • Indications for Cariosolv® are where the preservation of tooth structure is important, removal of root caries, removal of caries at the margins of crowns and bridge abutments, tunnel preparations, when local anesthesia is contraindicated, needle phobics, management of primary carious lesions in deciduous teeth. Cariosolv® can be used with either hand instruments or Power Drive which is a combined electronic instrument for power-operated, minimally-invasive caries removal. • A new type of chemomechanical agent was developed in Brazil in 2003 comprised of papain, chloramines, toluidine blue, salts, thickening vehicle and called as Papain gel.

QUESTIONNAIRE 1. What are the indications and advantages of chemomechanical caries removal? 2. Write a note on Caridex®. 3. Describe the composition, instrumentation, mode of action and clinical procedure for application of Criosolv®.

BIBLIOGRAPHY 1. Atraumatic restorative treatment approach to control dental caries manual, WHO collaborating centre for oral health services research. Groningen; 1997. 2. Banerjee A, Watson T, Kidd E. Dentine caries excavation: A review of current clinical techniques. Br Dent J. 2000;188:476-82. 3. Beeley JA, Yip HK, Stevenson AG. Chemomechanical caries removal: A review of the techniques and latest developments. Br Dent J. 2000;188:427-30. 4. Burke FM, Lynch E. Glass polyalkenote bond strength to dentine after chemomechanical caries removal. J Dent. 1994;22:283-91. 5. Chemomechanical caries removal: A comprehensive review of the literature. Int Dent J. 2001;51(4):291-9. 6. Ericson D, Zimmerman M, Raber H, et al. Clinical evaluation of efficacy and safety of a new method for chemo-mechanical removal of caries. Caries Res. 1999;33:171-7. 7. Ericson D, Zimmerman M, Raber H, Gotrick B, Bornstein R,Thorell J. Clinical evaluation of efficacy and safety of a new method for chemomechanical removal of caries. Caries Res. 1999;33:171-7. 8. Goldman M, Kronman JH. A preliminary report on a chemomechanical means of removing caries. J Am Dent Assoc. 1976;93(6):1149-53. 9. Hannig M. Effect of Carisolv solution on sound, demineralized and denatured dentin – an ultrastructural investigation. Clin Oral Invest. 1999;3:155-9. 10. Kidd EA, Joyston-Bechal S, Beighton D. The use of a carious detector dye during cavity preparation: a microbiological assessment. Br Dent J. 1993;174(7):245-8. 11. Kimmel JR, Smith EL. Crystalline papain: preparation, specificity and activation. J Bio Chem. 1954;207:514-73. 12. Kimmel Jr, Smith EL. The properties of papain. Adv Enzymol Rel Subj Biochem. 1957;19:267-334. 13. Mandelbaum SH, Santis EP, Mandelbaum MHS. Cicatrization: current concepts and auxiliary resources – Part II. An Bras Dermatol. 2003;78(5):525-42. 14. Mjör IA. The morphology of dentin and dentinogenesis. In: Linde A (Ed): Dentin and dentinogenesis. Boca Raton: CRC Press Inc. 1984;4:351-3. 15. Osato JA, Santiago LA, Remo GM, Cuadra MS, Mori A. Antimicrobial and antioxidant activities of unripe papaya. Life Sci. 1999;53(17): 1383-9. 16. Wennerburg A, Sawasa T, Kultje C. The influence of Carisolv on enamel and dentin surface topography. Eur J Oral Sci. 1999;106:1-10. 17. Yip HK, Samaranayake LP. Caries removal techniques and instrumentation: a review. Clin Oral Invest. 1998;2:148-54. 18. Zu-Qian G, Qian-Min C, Wei S. The clinical application of the chemo-mechanical caries removal system (Caridex): a comparative study. Compend Contin Educ Dent. 1987;8:638-40.

9

Section

RESTORATIVE DENTISTRY

This section deals with definition, principles and types of cavity preparation along with its modifications in primary teeth. It also explains about various restorative materials used in children, along with recent advances like ART, air abrasion and ozone therapy. Special focus of this unit is on semi-permanent restorations like stainless steel crowns and esthetic crowns for anterior teeth in children.

44

Chapter

Pediatric Operative Dentistry Nikhil Marwah

Chapter outline • • • •

Classification of Cavity Preparation Principles of Cavity Preparation Modifications of Cavity Preparation in Primary Teeth Matrix

Operative dentistry is the art and science of the diagnosis, treatment and prognosis of defects of teeth that do not require full coverage restorations for correction. Such treatment should result in the restoration of proper tooth form, function and esthetics while maintaining the physiologic integrity of the teeth in harmonious relationship with the adjacent hard and soft tissues, all of which should enhance the general health and welfare of the patient. Pediatric operative dentistry is a dynamic combination of ever improving materials and new techniques. In 1924 GV Black outlined several steps for the preparation of carious permanent teeth to receive an amalgam restoration. Same steps have been adopted, though slightly modified for the restoration of primary teeth. No longer is it excusable to provide substandard care for primary teeth on the basis that they will exfoliate, ignoring the duration required for the restoration and value of teeth in maintaining arch integrity. Moreover ignoring and neglecting dental caries in primary dentition sends a wrong message that teeth are not important. Before going in the details of Pediatric Operative Dentistry one must first realize that the primary teeth vary considerably from their permanent counterparts, not only in morphology but also in composition. These differences are tabulated as (Table 44.1) (Fig. 44.1).

• • •

Wedges Rubber Dam Air Abrasion (Microabrasion and Kinetic Cavity Preparation)

CLASSIFICATION OF CAVITY PREPARATION

Black’s Classification (Fig. 44.2) Class I : All pit and fissure lesions on occlusal surface of premolars and molars, lesions on occlusal 2/3rd of the facial and lingual surfaces of molars, and lesions on lingual surface of maxillary incisors.

Importance of primary teeth • Help in mastication • Speech-premature loss of maxillary primary anteriors before the age of 3 years results in impairment of speech that may last later in life • Maintenance and improvement of appearance (esthetics) • Maintenance of arch length • Prevent development of abnormal oral habits like tongue thrusting • Prevent psychological effects associated with premature tooth loss.

544 Section 9 

Restorative Dentistry

TABLE 44.1: Differences between deciduous and permanent teeth Deciduous dentition

Permanent dentition General differences

1

20 in number

1

32 in number

2

Do not have premolars

2

Have 8 premolars

3

Only two molars are present

3

Third molar is also present

4

White in color

4

Less white as compared to primary teeth

5

Crowns are more bulbous

5

Less bulbous

6

Broad contact area between the teeth

6

Contact point is present

7

Enamel-dentin junction is more sinuous and the enamel end abruptly

7

Enamel ends in a gradual manner

8

Buccal and lingual surface of primary molars are flat

8

Buccal and lingual surfaces are rounded

9

Buccal and lingual surfaces of 1st molar converge toward the 9 occlusal surface so the buccolingual diameter is much less than cervical diameter

There is no such convergence of the buccal and lingual surfaces so the buccolingual diameter is more than cervical diameter

10

Primary teeth have marked constriction at the neck

10

Less constriction

11

Mamellons are absent

11

Mamellons are present in anterior teeth

12

Enamel cap end in a marked ridge

12

Enamel cap end in a feather-edge

13

Enamel is thin but shows consistent depth (1 mm)

13

Thicker enamel of varying depth

14

Show more attrition

14

Less attrition

15

Less tooth structure covering the pulp

15

There is more covering of enamel and dentin

16

Enamel rods at cervix slope occlusally

16

Enamel rods at cervix slope gingivally

17

The mineral content of enamel is more organic

17

Less organic content than primary tooth

18

All primary teeth show neonatal line

18

Only 1st molars exhibit neonatal line

19

Dentinoenamel junction is flat

19

Dentinoenamel junction is scalloped

20

Crowns are wider in mesiodistal diameter as compared to cervico-occlusal height

20

Crowns are larger cervico-occlusally than mesiodistally

21

Occlusal table is narrow

21

Occlusal table is wider

Morphological differences (Crown)

Morphological differences (Root) 22

Roots of primary teeth are long and slender

22

Roots are short and robust

23

Roots have a short trunk

23

Larger undivided portion of root is present

24

Roots are more divergent and flaring, as they have to accommodate the permanent tooth bud

24

Roots are less divergent and do not flare to a great degree

25

Undergo physiologic resorption

25

Do not undergo physiologic resorption, only pathologic changes can take place

Pulpal differences 26

Greater thickness of dentin over the pulpal wall at occlusal fossa

26

Less covering of dentin

27

Pulp chambers are large

27

Small sized pulp chambers

28

Pulp horns are higher, especially the mesial pulp horn in case of primary 1st molar

28

Pulp horns are low

29

Accessory canals in the primary teeth are located in the furcation area

29

Accessory canals in the primary teeth are located in the root apices

(Contd ...)

Chapter 44  Pediatric Operative Dentistry (Contd ...) Deciduous dentition

Permanent dentition

30

No regressive changes can be seen

30

Regressive changes in the form of calcifications and pulp stones are seen

31

Root canals are ribbon like

31

Root canals are more tortuous and curved

32

Presence of a cap like zone of reticular and collagenous fibers

32

No such zone present

33

Enlarged apical foramen

33

Constricted apical foramen

34

Abundant blood supply

34

Less blood supply as compared to primary teeth

35

Response to external stimuli is typical inflammatory reaction

35

Response is by calcification or calcific scarring

36

Nerve fibers terminate in odontoblastic region as free nerve endings

36

Nerve fibers end among odontoblasts and beyond predentin

37

Density of innervation is less so the teeth are less sensitive to operative procedures

37

Density of innervation is greater, thereby leading to more sensitivity

38

Reparative dentin formation below arrested caries is more extensive

38

Less reparative dentine formation as compared to primary teeth

39

Poor localization of infection and inflammation

39

Better localization of infection and inflammation

Histological differences

Finn’s Modification Class I : Pit and fissure cavities on occlusal surface of molars and the buccal and lingual pits of all teeth. Class II : Cavities on the proximal surfaces of posterior teeth with access established from occlusal surface. Class III : Cavities on the proximal surfaces of anterior teeth that may or may not involve the labial or lingual extension. Class IV : Restorations on the proximal surfaces of anterior teeth that involve the incisal edge. Class V : Cavities on the cervical third of all teeth, including proximal surfaces where the marginal ridge is not included in cavity preparation.

Mount and Hume’s Classification Fig. 44.1: Difference between deciduous and permanent teeth

Class II : Lesions on the proximal surfaces of posterior teeth. Class III : Lesions on the proximal surfaces of anterior teeth that do not involve the incisal angle. Class IV : Lesions on the proximal surfaces of anterior teeth that involve the incisal edge. Class V : Lesions on the gingival third of the facial or lingual surfaces of all teeth. Class VI : Lesions on the incisal edge of anterior teeth or the occlusal cusp tips of posterior teeth (Simon’s modification).

This is a new system that identifies the site as well as the complexity of the lesion. Site I : Pits and fissure on occlusal surfaces Site II : Proximal areas just below the contact point Site III : Cervical 1/3rd of crown Size I : Minimal involvement of dentin Size II : Moderate involvement of dentin but remaining tooth structure strong enough to support restoration Size III : Large cavity with weakened tooth structure Size IV : Extensive caries with loss of bulk of tooth structure.

PRINCIPLES OF CAVITY PREPARATION Although the Black’s principles of cavity preparation are now not being used but a brief mention of these principles is a

545

546 Section 9 

Restorative Dentistry

Fig. 44.2: Black’s classification and modification

must before we explain newer principles of “Constriction for Conviction”, “Minimal Intervention” and “ART”.

Initial Tooth Preparation Initial tooth preparation is at a specific limited depth so as to provide access to the caries or defect, reach sound tooth structures (except for later removal of infected dentin on the pulpal or cranial walls), resist fracture of the tooth or restorative material from masticatory forces principally directed along the long axis of the tooth, and retain the restorative material in the tooth. Step 1: Outline form and initial depth: Defined as the location that the peripheries of the completed tooth preparation will occupy on tooth surfaces. Step 2: Primary resistance form: That shape and placement of the preparation walls that best enable both the restoration and the tooth to withstand, without fracture, masticatory forces delivered principally in the long axis of the tooth. Step 3: Primary retention form: It is that shape or form of the conventional preparation that resist displacement or removal of the restoration from tipping or lifting forces. Step 4: Convenience form: That shape or form of the preparation that provides for adequate observation, accessibility, and ease of operation in preparing and restoring the tooth.

Final Tooth Preparation Step 5: Removal of any remaining infected dentin and old restorative material, if indicated. Step 6: Pulp protection if indicated.

Step 7: Secondary resistance and retention forms: Many preparations require additional retentive features. When tooth preparation includes both occlusal and proximal surfaces, each of those areas should have independent retention and resistances features. For example, Locks for amalgam, grooves for cast metal, skirts for cast restorations. Step 8: Procedures for finishing external walls: It is the further development, when indicated of a specific cavosurface design and degree of smoothness or roughness that produces the maximum effectiveness of the restorative material being used. The objectives are to create best marginal seal possible between the restorative material and tooth structure, afford a smooth marginal junction and provide maximum strength of both the restorative material and tooth. Step 9: Final procedures: Cleansing, inspecting, sealing. Includes removing all chips and loose debris that have accumulated, drying the preparation and making a final complete inspection of the preparation for any remaining infected dentin, unsound enamel margins or any condition that renders the preparation unacceptable to receive the restorative material. Kidd and Smith (1994) recommended that during cavity preparation the following sequence should be followed: • Gain access to the caries • Excavate all caries • Consider design of the cavity in relation to: – Final choice of the material – Retention of the restoration – Protection of the remaining tooth structure – Optimal strength of the restoration – Shape and protection of cavity margins

Chapter 44  Pediatric Operative Dentistry • Refine and debride the cavity • Placement of restoration.

MODIFICATIONS OF CAVITY PREPARATION IN PRIMARY TEETH Owing to multiple anatomical, morphological and histological differences between the primary and permanent teeth, the cavity preparation among the two also varies greatly. Some of the common modifications in case of primary teeth are:

Class–I:  Cavity Preparation • Due to narrow occlusal table the buccolingual dimensions of occlusal part of cavity are reduced. • The chance of inadvertent pulp exposure is minimized by limiting the cavity to 0.5 mm pulpal to enamelo-dentinal junction. • Maximum intercuspal cavity width should be limited. • Walls of preparation should be parallel or slightly convergent occlusally. • The central pit of lower first primary molar usually becomes carious before mesial pit, which decays less frequently. The outline form should be limited to central pit; it is adjacent buccal and lingual grooves and distal triangular fossa. It is advisable not to cross ridge to join mesiobuccal and mesiolingual cusp because of its proximity to pulp horns. Pulpal roof in primary teeth is concave as compared to permanent teeth where it is nearly flat so cavity floor should be kept little concave. • Depth should be just 0.5 mm into the dentin so the total depth from the cavosurface should not be more than 1.5 to 2.0 mm. • Include all pits and fissures and lateral extension should be such so as to just accommodate the amalgam condenser. • Flat or slightly concave pulpal floor with rounded line and point angles. • While extending laterally on the buccal side, bur should be kept parallel to the buccal surface and while extending lingually, bur should be parallel to lingual surface. This makes the occlusal convergence without much cutting.

• Rounded/beveled/grooved axiopulpal line angle in order to reduce stresses on this point and to allow greater bulk of material. • Isthmus width should be ½ the intercuspal width. • Proximal box: Greater width of the proximal box in order to keep the cavity margins in the self-cleansing areas. • More buccolingual extension of the gingival floor/seat • Occlusal convergence. • Axial wall should follow the contour of the external surface. • The direction of enamel roads at the cervical line is either horizontal or occlusal and therefore gingival bevel is not given while preparing class II cavity. • Retention grooves should not be given. • Kennedy (1997) contraindicated the idea of dovetail lock. He said that when occlusal fissure are prepared this does not result in straight-line cavity that would require dovetail lock, instead it produces a curved shape that itself provides retention. Hence if the dovetail was given it would lead to unnecessary cutting of sound tooth structure. • The distance between mesial surface of lower 1st mandibular molar and pulp horn is only 1.6 mm. Although 1.5 mm depth has been suggested for class I cavity, establishing this depth may lead to pulp exposure and hence Rodda recommended 1 mm of depth.

MATRIX Matricing is a procedure where by a temporary wall is created opposite the axial wall surrounding the areas of tooth structure lost during preparation. The appliance used for building these walls is called matrix (Fig. 44.3).

Rationale for Using Matrix • • • • •

Accurate reproduction of contour of teeth To prevent interproximal excess To establish tight contact areas To maintain integrity of normal gingival papillae To maintain arch dimensions in primary dentition.

Class–II:  Cavity Preparation • Occlusal box: Same principles applied as for class I but extension of outline is different for different teeth. – For all first primary molars: Extend the occlusal box half the way mesiodistally in a dovetail like fashion. – For mandibular second primary molars: All pits and fissure should be involved. – For maxillary second primary molars: Nearest occlusal pit should be involved. Oblique ridge should not be involved until undermined by the caries. • Sharp cavosurface angle.

Fig. 44.3: Matrix band and retainer

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Functions of Matrix • • • •

To replace the missing wall Close adaptation of restorative material Retain restorative material during placement Allows restoration of contact point and external crown contour • Isolation of cavity.

Ideal Requirements of Matrix • • • • • • •

Rigid to allow condensation Promote desired contour Should form positive contact with tooth Should be of minimal thickness Compatible with restorative material Easy of application Economical. Fig. 44.4: Sectional matrix

Classification of Matrix According to place of application

• Posterior – T-band, Toffelmire • Anterior – Celluloid matrix

According to constituents

• Metallic – Ivory no.1, Ivory No. 8, Toffelmire • Nonmetallic – Mylar strips

According to • With retainer - Ivory No. 1, Ivory No. 8 presence or • Without retainer – S-band absence of retainer According to form

• Anatomical – Celluloid crown form • Non-anatomical – Ivory No. 1

According to patent

• Patent – Ivory No. 1 • Nonpatent – Celluloid crown form

According to use

• Universal – Ivory No. 8, Toffelmire • Unilateral – Ivory No. 1

Recent Modifications in Matrix • Sectional matrix: This system is easy to place, gives a large preparation area thus reducing the working time. An added advantage of this system is that both mesial and distal proximal restorations can be accomplished by one matrix placement (Fig. 44.4). • Smartview matrix system: The SmartView Matrix System also comes with SmartBands Sectional Matrices and titanium instruments. The SmartBands have a nonstick surface, are anatomically contoured, and integrate a reinforced placement tab while the instruments are made of high-grade, blue titanium. The specially designed titanium instruments are strong, durable, and lightweight. These are mostly used for composite restorations (Fig. 44.5).

Fig. 44.5: Smartview matrix

WEDGES • It is used along with the matrix to prevent gingival overhangs of restorations. It is defined as a piece of wood, metal, etc. one end of which is an acute angled edge formed by two converging planes used to tighten or exert force in various ways (Fig. 44.6). • The earliest description of wedges is during 1883 when wedges of boxwood, orangewood, balsam wood are described. The metal wedges came into existence a little later and the first one was Ottolengui steel wedge. In

Chapter 44  Pediatric Operative Dentistry Ideal requirements of wedges • • • • • • • •

Easy to apply and withdraw Should be of the shape of embrasure Should not cause deformation of matrix Be disposable Be radiopaque Be rigid Nontoxic and non-irritant Stable in oral fluids.

4. Concavity of side walls—dictates proximal contour of the restored tooth surface.

Functions Fig. 44.6: Wedges

1960 Messing elaborated the disadvantages of preformed chair side wedges and Products Dentaires introduces anatomical PD silver wedges that even had a hole for the floss. • Currently all types of wedges like plastic, metal, wood and celluloid are available depending upon side and type of tooth. The newest type of wedge is the light reflecting one introduced by Luci-wedge, Hawe-Neos dental, Switzerland.

Types • According to anatomy – Anatomical—in shape of embrasure – Nonanatomical—round • According to material used – Wooden—can be made of either hard or soft wood – Plastic—available in various shapes • According to color – Colored—all types – Light reflecting—to be used with composites.

• • • • • •

RUBBER DAM The need to work under dry conditions, free of saliva, has been recognized for centuries, and the idea of using a sheet of rubber to isolate the tooth dates almost 150 years. The introduction of this notion is attributed to a young American dentist from New York, Sanford Christie Barnum, who in 1864 demonstrated for the first time the advantages of isolating the tooth with a rubber sheet. At that time, keeping the rubber in place around the tooth was problematic, but things soon improved a few years later, when in 1882 SS White introduced a rubber dam punch similar to that used still now. In the same year, Dr Delous Palmer introduced a set of metal clamps which could be used for different teeth.

Selection of Wedges A wedge should compress the matrix band to remaining healthy tooth structure through its entire buccolingual length apically to gingival cavosurface line angle. To select a correct wedge four variables are to be selected: 1. Convergence angle of the base—dictated by tangential line drawn to adjacent tooth structures at gingival cavosurface line angles. The angle created by these two lines should match the convergence angle of wedge to ensure maximum rigid support. 2. Gingival base width—should be slightly greater than inter-dental space width in order to achieve stability. 3. Wedge height—is critical to establish contact point.

Assures close adaptation of matrix band to tooth Prevents gingival overhang Assures proper health of interdental col Tooth separation Stabilization of band Absorbs fluid.

Advantages • • • • • • • •

Dry clean operating field Access with visibility Moisture control Retraction of soft tissue Aseptic environment Improved properties of dental materials Protection of patient and operator Prevents aspiration or swallowing of small instruments and restorative materials • Prevents tissue irritation by etchant • Prevents tissue damage by rotary burs and sharp objects • Effective infection control—Aerosol prevention

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Restorative Dentistry

Reduce patient conversation Retainer provides some amount of mouth opening Quadrant restorative procedures are facilitated Minimization of mouth breathing.

Disadvantages • • • • • • • •

Patient acceptance Poorly retentive clamps Trauma to tissues Frame can cause pressure marks on face Latex allergy Build up of saliva Partially erupted tooth can’t receive a retainer Psychological intolerance.

Contraindications • • • •

Rubber Dam Sheets (Fig. 44.8) • Available sizes are 5″ × 5″ or 6″ × 6″ • Available thickness are: – Thin – 0.15 mm – Medium – 0.2 mm – Heavy – 0.25 mm – Extra heavy – 0.30 mm – Special heavy – 0.35 mm • Available colors are green, blue, black, pink, and burgundy. • Also available in different flavors like mint, banana, and strawberry. • The rubber dam sheet has a dark side and a shiny side. The shiny side is always towards the tissues so that the dam can pass easily over them with minimal irritation, whereas the dull side should be toward the occlusal aspect so that no light reflects from it to obstruct vision.

Absolute contraindication is known allergy to latex Patients with respiratory problems Patient at risk with transient bacteremia Severe gingival disease.

Euphemisms used for preparation of child for rubber dam placement

Raincoat Hanger Clip

– – –

Rubber dam sheet Frame Clamp

Armamentarium The entire armamentarium for the rubber dam placement is supplied as a package either for permanent or deciduous dentition. This contains rubber dam sheets, clamps for all teeth, template, retainer, rubber dam punch, retraction cord and frame (Fig. 44.7).

Fig. 44.8: Rubber dam sheet

Retainers or Clamps • It has 4 prongs and 2 jaws that are connected by a bow as shown (Fig. 44.9). • Various types and sizes are present for each tooth (Fig. 44.10).

Fig. 44.7: Rubber dam armamentarium

Fig. 44.9: Parts of clamp

Chapter 44  Pediatric Operative Dentistry

Fig. 44.10: Clamps for different teeth

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• Its use is to anchor the most posterior tooth to be isolated and also to retract gingival tissue. • Can be classified as wingless or winged. • A newer type of clamps have recently been introduced called as cushion clamps (Fig. 44.11).

Rubber Dam Retaining Forceps • Used for placement and removal of clamps (Fig. 44.12). • This instrument is necessary to open the clamp and position it around the tooth. • The ivory forceps are preferable, because they allow the dentist to apply direct pressure toward the gum, which is frequently necessary to position the clamp securely below the bulge of the tooth crown.

Rubber Dam Punch

Fig. 44.11: Cushion clamps

• It is a precision instrument having a rotating metal table with six holes of varying sizes and a tapered, sharp, pointed plunger (Fig. 44.13). • It is used to make round holes of different diameters (0.7 – 2 mm). • The largest hole being for molars and the smallest for mandibular incisors.

Rubber Dam Frame • This is necessary to maintain tension in the dam so that the lips and cheeks may be retracted • It holds and positions the border of rubber dam • It is of two types – Metallic—Young’s frame (Fig. 44.14). – Plastic—Nygaard Ostby (Fig. 44.15), Starlite Visi (Fig. 44.16), LeCadre Articule (Fig. 44.17).

Fig. 44.12: Rubber dam retainer forceps

Rubber Dam Napkin • It is placed between rubber dam and patient’s skin. It has the following uses: – Prevents allergy – Acts as a cushion – Prevents pressure marks on patient’s cheeks – Convenient method for wiping the patient’s lips on removal of dam.

Adjuncts • Lubricant: To facilitates passing of dam through posterior contacts and also help the dam to pass over clamps. It is also applied over patient’s tissues to prevent injury and dryness. Commonly used lubricants are soap solution, petroleum jelly and cocoa butter.

Fig. 44.13: Rubber dam punch

Chapter 44  Pediatric Operative Dentistry

Fig. 44.14: Young’s frame

Fig. 44.17: LeCadre Articule frame

Fig. 44.15: Nygaard Ostby frame Fig. 44.18: Rubber dam template

• Dental floss: To secure the rubber dam. • Rubber dam template: To check for exact placement of rubber dam (Fig. 44.18).

Misadventures and Complications

Fig. 44.16: Starlite Visi frame

• • • • • •

Trauma to lips and gingiva Poor clamp selection leading to laceration of gingiva Loss of springiness of clamp may lead to loss of retention Pressure marks on face High dam can block nasal passage Worn out clamps can fracture during treatment.

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Procedure for Placement of Rubber Dam (Figures 44.19A to C) A

B

Chapter 44  Pediatric Operative Dentistry C

Figs 44.19A to C: Rubber dam placement procedures

Recent Modifications Quick Dam or Insta-Dam • These are new types of rubber dams that have preattached frame • Ease of application • Minimal time consumption in placement • Use of X-ray is more simplified with this type of dam • They can either have a rectangle or circle pattern (Fig. 44.20).

Fig. 44.20: Insta dam

Optra Dam • This is a type of quick dam for anterior segment where it can be fixed directly without use of any retainer clamps (Fig. 44.21). • Its method of application is quiet simple (Fig. 44.22):

Fig. 44.21: Optra dam

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Restorative Dentistry by removing the rubber between them with scissors or by punching the third hole to connect the first two holes. The rubber dam is stretched over the rubber dam clamps or the teeth and then the frame is placed to secure the sheet. The exposed area between the teeth is then sealed with a caulking agent like Oraseal. This ensures that there is no leakage.

OraSeal OraSeal® Caulking and OraSeal® Putty are specially designed, cellulose based caulking and blockout materials that are syringe delivered to seal rubber dams to optimize tissue isolation, to block out undercuts associated with large gingival embrasures and to prevent displacement during intraoral pick-up of anchoring attachments.

AIR ABRASION (MICROABRASION AND KINETIC CAVITY PREPARATION)

Fig. 44.22: Placement of optra dam

The study of the use of air abrasion technology for dental applications initiated by Dr Robert Black of Corpus Christi Texas in the 1940’s was successfully introduced in 1951 with the Airdent air abrasion unit (SS White). In spite of showing promising results, the concept did not gain popularity due to three major factors. Firstly, air abrasion was not able to prepare cavities with well-defined walls and margins, and the materials during that time (mostly amalgam and direct or indirect gold) demanded such preparations since the concept of bonding had not been introduced. Secondly, the introduction of the air turbine handpiece in the late 1950s made conventional cavity preparations less time consuming. Thirdly, as high-velocity suction had not been developed, evacuation of the powder was difficult. Though the basic concept of the air abrasion device has remained the same, it has experienced a rebirth not due to changes in the device per se, but due to improvements in bonding, restorative materials, isolation, and high volume suction. Air abrasion can be best described as a pseudomechanical, nonrotary method of cutting and removing dental hard tissue. The terms “micro air-abrasion” and “kinetic cavity preparation” have been used synonymously to describe air abrasion.

Advantages

Split Dam Technique Isolation of badly broken down tooth is challenging as there might not be sufficient tooth structure to permit four-point stable contact around tooth and retain the clamp. In such cases split dam technique is advised. In this technique, the rubber dam clamp is placed on the neighbouring tooth. Two holes are punched approximately 5 mm apart and linked up

There are many advantages to the patient when the dentist uses air abrasion: • It is painless • Local anesthesia is rarely needed • It works quickly and the tooth with a small lesion is ready to restore in seconds • It work quietly without the whine of the all too familiar dental headpiece • There is no vibration or pressure to cause micro fractures that weaken tooth

Chapter 44  Pediatric Operative Dentistry • There is no production of heat to damage the dental pulp • Lesser sound tooth structure is removed.

Principle • Air abrasion for restoration preparation removes tooth structure using a stream of aluminium oxide particles generated from compressed air or bottled carbon dioxide or nitrogen gas. The abrasive particles strike the tooth with high velocity and remove small amounts of tooth structure. • Efficiency of removal is relative to the hardness of the tissue or material being removed and the operating parameters of the air abrasion device.

Operating Parameters • A number of air abrasion systems are available today (Fig. 44.23) such as the PrepMaster (Groman Inc.), Airbrator (North Bay/Bioscience, LLC), PrepStart and PrepAir (Danville Engineering) all of which work on the same principle. Some like the RONDOflex plus (KaVo) work on the principle of air abrasion technology with water spray.

Fig. 44.23: Air abrasion system

• Generally, air pressures range from 40 to 160 psi. The recommended levels are at 100 psi for cutting and 80 psi for surface etching. • The most common particle sizes are either 27 or 50 μm in diameter. The larger particles allow the clinician to work faster but will result in comparatively larger-sized cavity preparations than those with the 27 μm particles. Higher particle flow rate will allow more particles to abrade the working surface faster.

• The speed of the abrasive particles when they hit the tooth depends upon the gas pressure, nozzle diameter, particle size, and distance from the surface. • Typical operating distances from the tooth range from 0.5 to 2 mm. Further distances produce a more diffuse stream that results in a diminished cutting ability.

Procedure

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Precautions • • • • • • • • •

Need to protect patient with glasses, rubber dam if possible Dental team needs masks and glasses Stop frequently to check the progress Start with low pressure and low power then increase as needed Hold tip 1 to 2 mm away from tooth at a 45 degree angle then activate Always keep tip moving Requires external suction and air evacuation for the room Use disposable mirrors Like any air stream air abrasion can cause subcutaneous emphysema.

Clinical Uses • Class I, II, III, IV and V cavity preparations • Sealants and preventive restorations

• Repair of composite and porcelain especially margin of veneers • Removal of composite and amalgam.

Accessories for Air Abrasion System • • • • • • • •

Grades of the powder particles Various tip diameter sizes and tip angulations Air abrasion resistant intraoral mirror Sand trap traps the abrasive particles from where they can be evacuated through the suction Power plus booster recompresses the compressed air up to 135 psi to increase the air pressure Disposable air abrasion handpiece—Airbrator® (North Bay/Bioscience, LLC) Super high volume evacuation systems—RapidVac (Union Medical Evacuation System) MicroVibe tip generates mechanical vibrations that help resin penetrate narrow gaps.

POINTS TO REMEMBER • Operative dentistry is the art and science of the diagnosis, treatment and prognosis of defects of teeth that do not require full coverage restorations for correction. Such treatment should result in the restoration of proper tooth form, function and esthetics while maintaining the physiologic integrity of the teeth in harmonious relationship with the adjacent hard and soft tissues, all of which should enhance the general health and welfare of the patient. • GV Black in 1924 outlined the classification of cavity preparation into 5 types and later on the 6th modification was added by Simon. • Finn classification is used for pediatric dentistry. • Mount and Hume classification exemplifies the complexity of lesion. • In the principles of tooth preparation initial tooth preparation includes outline form, resistance form, retention form, convenience form whereas final tooth preparation includes removal of any remaining infected dentin and old restorative material, pulp protection, secondary resistance and retention forms, procedures for finishing external walls and cleansing, inspecting, sealing. • Modifications in Class I cavity preparation for primary teeth includes narrow occlusal table, limiting the cavity to 0.5 mm pulpal to enamelodentinal junction, walls of preparation should be parallel or slightly convergent occlusally, flat or slightly concave pulpal floor with rounded line and point angles. • Modifications in Class II cavity preparation for primary teeth includes rounded axiopulpal line angle, isthmus width should be ½ the intercuspal width, greater width of the proximal box, occlusal convergence, gingival bevel is not given, dovetail lock should be present. • Matricing is a procedure where by a temporary wall is created opposite the axial wall surrounding the areas of tooth structure lost during preparation. Conventional matrix retainers are ivory no.1 and 8, Toffelmire matrix retainer. The newer modifications are sectional matrix, Palodent plus that can be used on both side in a single placement and smartview which can be used for composites. • SC Barnum in 1864 discovered the rubber dam and Delous Palmer discovered the rubber dam retainers. The main advantages of rubber dam are dry clean operating field, access with visibility, moisture control, retraction of soft tissue, aseptic environment and prevent aspiration or swallowing of small instruments and restorative materials. • The armamentarium for the rubber dam placement contains rubber dam sheets, clamps for all teeth, template, retainer, rubber dam punch, retraction cord and frame. • Rubber dam frames include Metallic (Young’s frame) and Plastic (Nygaard Ostby, Starlite Visi, LeCadre Articule).

Chapter 44  Pediatric Operative Dentistry • Dr Robert Black in the 1940’s introduced air abrasion. • The first air abrasion system was introduced in 1951 as Airdent air abrasion unit (SS White). • RONDOflex plus (KaVo) uses air abrasion technology with water spray.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Define operative dentistry and give the importance of primary teeth. Differentiate between primary and permanent teeth. Classify cavity preparation and the principles of cavity preparation. What is matricing. Enumerate the new systems? Describe rubber dam components and its placement techniques. What is air abrasion technology?

BIBLIOGRAPHY

1. Banerjee A, Watson TF. Air abrasion: its uses and abuses. Dent Update. 2002;29(7):340-6. 2. Baum L, Phillips RW, Lund MR. Text­book of Operative Dentistry. Philadelphia: WB Saunders; 1981.pp.295-8. 3. Bennett N. The Science and Practice of Dental Surgery. Oxford: Oxford Medical Publications; 1931;11:795-9. 4. Black CV. Operative Dentistry 5th edn. Chicago: Medico-Dental Publishing Co. 1922;II:262-3. 5. Christensen G. Cavity preparation: cutting or abrasion? J Am Dent Assoc. 1996;127:1651-4. 6. Clark TD, MjorlA. Current teaching of cariology in North American dental schools Operath’e Dentistry. 2001;26:412-8. 7. Curzon MEJ, Roberts JF, Kennedy DB. Kennedy’s Paediatric Operative Dentistry, 4th Edn. 32-3. 8. Elderton RJ. The prevalence of failure of restorations: a literature review. J Dent. 1976;4:207-10. 9. Gilmore HW, Lund MR, Bales OJ, et al. Operative Dentistry 4th Edn. 51. Louis: CV Mosby Co., 1982.pp.139-40. 10. Gordan VV. Clinical evaluation of replacement of Class V resin based composite restorations. Journal of Dentistry. 2001;29:485-8. 11. Harris CA. The Principles and Practice of Dentistry 11th edn. Philadelphia: Blakistan Sons and Co, 188S’ pp. A06-527. 12. Jø rgensen KD, Wakumoto S. Occlusal amalgam fillings: marginal defects and secondary caries. Odontologisk Tidskrift. 1968;73:43-54. 13. Kamann WK. The rubber dam: the change in indications and techniques. Schweiz Monatsschr Zahnmed. 1998;108(8):771-81. 14. Klausner LH, Green TG, Charbeneau GT. Placement and replacement of amalgam restorations: a challenge for the profession Operative Dentistry. 1987;12:105-12. 15. McComb D. Systematic review of conservative operative caries management strategies. J Dent Educ. 2001;65:1154-61. 16. Messing J. A new style of interdental wedge. Br Dent J. 1960;108:18-9. 17. Mjorl A. Placement and replacement of restorations Operative Dentistry. 1981;6:49-54. 18. Murdoch-Kinch CA, McLean ME. Minimally invasive dentistry. J Am Dent Assoc. 2003;134(1):87-95. 19. Ottolengui R. Methods of Filling Teeth. Philadelphia: 55 White. 1891. pp. 27-47, 83-104. 20. Peter Heasman. Master Dentistry, Restorative Dentistry. Paediatric Dentistry and Orthodontics. 2004;2:172-3. 21. Qualtrough AJE, Wilson NHF. History, development of interproximal wedges in clinical practice. Dental update. 1991.pp.66-70. 22. Rainey J. Air abrasion: an emerging standard of care in conservative operative dentistry. Dent Clin North Am. 2002;46:185-209. 23. Ribeirao Preto. Biological restorations as a treatment option for primary molars with extensive coronal distruction Braz, Dent J. 2007;18:(3). 24. Ryge G. Biological evaluation of dental materials in pro­ceedings of the 50’h Anniversary Symposium on Dental Materials Research National Bureau of Standards Special Publication 352 Dental Materials Research June 1972. 25. Taft J. A Practical Treatise on Operative Dentistry 4th Edn. London: T Ruber, 1883.pp.118-23. 26. van Pelt AW. Kinetic cavity preparation. Ned Tijdschr Tandheelkd. 2000;107(2):67. 27. White JM, Eakle SW. Rationale and treatment approach in minimally invasive dentistry. J Am Dent Assoc. 2000;131:18S.

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Chapter

Commonly Used Restorative Materials in Pediatric Dentistry Deepak Raisinghani, Nikhil Marwah

Chapter outline • •

Silver Amalgam Bonded Amalgam Restoration

• • •

SILVER AMALGAM Dentists have used it for restoring teeth for more than 150 years. The popularity of dental amalgam likely will continue to decline as the longevity of these other materials and their suitability as general amalgam replacements in the dentition is demonstrated. Dental amalgam is produced by mixing liquid mercury with solid particles of an alloy of silver, tin, copper, and sometimes zinc, palladium, indium, and selenium. This combination of solid metals is known as the amalgam alloy. •

Classification • Based on copper content – High copper content: Copper content more than 12 percent – Low copper content: Copper content less than 6 percent • Based on zinc content – Zinc containing alloy with more than 0.01 percent zinc – Zinc free alloys with less than 0.01 percent zinc • Based on particle shape and type – Lathe-cut: Irregularly shaped filings produced by cutting an ingot of alloy on a lathe. – Spherical particle: Produced by atomizing the alloy, whilst still liquid into a stream of inert gas.

•

•

Physical Properties • Compressive strength – Resistance to compression forces is the most favorable strength characteristic of amalgam.

•

Composite Calcium Hydroxide Glass Ionomer Cements

– The high-copper unicompositional materials have the highest early-compressive strengths of more than 250 Mpa at 1 hour. – The compressive strength at 1 hour was lowest for lathe-cut alloy (45 Mpa) – High values for early-compressive strength are an advantage for an amalgam, because they reduce the possibility of fracture by prematurely high contact stres­ses from the patient before the final strength is reached. Tensile strength – Tensile strengths are only a fraction of their compressive strengths; therefore cavity designs should be constructed to reduce tensile stresses resulting from biting forces. Transverse strength – These values are sometimes referred to as the modulus of rupture. – Because amalgams are brittle materials, they can withstand little deformation during transverse strength testing. The main factors related to the high values of deformation are: (1) the slow rates of load application, (2) high creep of the specific amalgam, and (3) higher temperature of testing. Elastic modulus – When the elastic modulus is determined at low rates of loading, such as 0.025 to 0.125 mm/min, values in the range of 11 to 20 GPa are obtained. – High-copper alloys tend to be stiffer than low-copper alloys. Creep – Higher the creep magnitude the greater the degree of marginal deterioration.

Chapter 45  Commonly Used Restorative Materials in Pediatric Dentistry – The highest value of 6.3 percent was found for the low-copper cut alloy, and the lowest values (0.05% to 0.09%) were determined for the high-copper unicompositional spherical alloys. • Corrosion – Corrosion is the progressive destruction of a metal by chemical or electrochemical reaction with its environment. Excessive corrosion can lead to increased porosity, reduced marginal integrity, loss of strength, and the release of metallic products into the oral environment. – The presence of a relatively high percentage of tin in low copper alloys reduces the corrosion resistance. The average depth of corrosion for most amalgam alloys is 100 to 500 pm.

• As the mercury disappears the amalgam hardens and is ready for condensation in the cavity. Ag-Sn-Cu Alloy particles + Hg → Υ1 + h + Unconsumed alloy particles.

Indication of Amalgam • Moderate-to-large restorations • Restorations that are not in highly esthetic areas of the mouth • Restorations that have heavy occlusal contacts • Restorations that cannot be well isolated • Restorations that extend onto the root surface • Foundations • Abutment teeth for a removable partial denture • Temporary or caries control restorations.

Clinical Considerations • Recommended mercury alloy ratios for most modern lathecut alloys is approximately 1:1, or 50 percent mer­ cury and in case of spherical alloys the recommended amount of mercury is closer to 42 percent because spherical particles have lower surface/ volume to completely wet the particles. • Alloy and mercury were mixed by hand with a mortar and pestle or in an amalgamator. This process is called trituration. As alloy particles are coated with a film of oxide, which is difficult for the mercury to penetrate, this film must be rubbed off so that a clean surface of alloy can come in contact with mercury. This removal of oxide layer by abrasion is done by trituration. • Amalgamation occurs when mercury contacts the surface of silver tin alloy particles. When powder is triturated, the silver and tin in the outer portion of the particles dissolve into mercury. Mercury has limited solubility for silver 0.035 wt percent and tin 0.6wt percent. When the solubility in mercury is exceeded, crystals of two binary compounds precipitate into the mercury forming Υ1 (Ag2Hg3) and Υ2 (Sn7 Hg). Because the solubility of silver in mercury is much lower than that of tin, Υ1 phase precipitate first and Υ2 phase precipitate later. • Immediately after trituration, the alloy powder coexists with the liquid mercury, giving the mix a plastic consistency. Υ1 and Υ2 crystals grow as the remaining mercury dissolves the alloy particles. • The next step in amalgamation is mulling, which is rubbing of the mixture to remove excess mercury and give a cohesive form. This is done by squeezing the mixture with a muslin cloth to drain out the extra mercury.

Contraindication of Amalgam • Esthetically prominent areas of posterior teeth • Small-to-moderate classes I and II restorations that can be well isolated • Small class VI restorations.

Mercury Toxicity • The initiation of toxic effects of mercury was first evaluated in fishermen when they contacted Minamata disease due to excess mercury in water. • Mercury penetrates from the restoration into tooth structure. An analysis of dentin underlying amalgam restorations reveals the presence of mercury, which in part may account for a subsequent discoloration of the tooth. Use of radioactive mercury in silver amalgam has also revealed that some mercury might even reach the pulp. • The maximum level of occupational exposure considered safe is 50 µg of mercury per cubic meter of air per day. • Amalgam tattoo is a common pitfall of the amalgam restoration.

Advantages of amalgam

Disadvantages of amalgam

•

Ease of use

• Noninsulating

•

High tensile strength

• Nonesthetic

•

Excellent wear resistance

• Less conservative

•

Favorable long-term clinical • Weakens tooth structure research results

•

Lower cost than for composite restorations

• More technique sensitive • More difficult tooth preparation • Initial marginal leakage

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Operatory Prevention • The operatory should be well ventilated. • All excess mercury, including waste, disposable capsules, and amalgam removed during condensation should be collected and stored in well sealed containers containing water. • Proper disposal through reputable dental vendors is mandatory to prevent environmental pollution. • Amalgam scrap and materials contaminated with mercury or amalgam should not be incinerated or subjected to heat sterilization. • If mercury comes in contact with the skin, the skin should be washed with soap and water. • Use of carpeting is limited as it may incorporate mercury vapors and waste.

• Marginal leaking: Marginal leakage and loss of marginal integrity around conventional amalgam restorations have been recognized as serious disadvantages. Bonded amalgam restorations, however, show significantly less marginal leakage than conventional amalgam restorations. • Cuspal flexure: The use of bonded restorations in posterior teeth has been shown to reduce cuspal flexure and increase the structural integrity of the  tooth when compared to conventional restorations.

Clinical Technique

BONDED AMALGAM RESTORATION Recent concepts have suggested that posterior composite resin restorations may replace amalgam as a restorative material. Concern regarding mercury toxicity and greater interest in improved esthetics has encouraged a move away from amalgam as the material of choice for posterior restorations. However, some of the physical properties of composite resins used in the restoration of posterior teeth, combined with problems associated with technique sensitivity during placement, have led some to question their widespread use. The bonded amalgam restoration resulted from technology developed for use with resin-retained prostheses. Panavia EX (Kuraray), a chemically active resin that bonds to both enamel and metal, is one such material. Amalgambond (Parkell) is an alternative material that has been developed specifically for bonding amalgam to etched enamel and dentin.

Properties • Bonded amalgam restorations have significant advan­ tages over both conventional amalgam restorations and posterior composite resin restorations. • Cavity design: Conventional amalgam restorations are retained by mechanical retention like undercut cavity design but bonded amalgam incorporation technique reduces the need for removal of sound tooth tissue to create mechanical retention. • Handing properties: Good esthetics and the ability to bond to enamel and dentin by the acid-etch technique, with and without bonding resins. • Polymerization contraction: No polymerization contraction.

COMPOSITE In material science, a composite is a mixture produced from at least two of the different classes of materials, i.e. metals, ceramics, and polymers. Dental composites are complex, tooth-colored filling materials composed of synthetic polymers, particulate ceramic reinforcing fillers, molecules which promote or modify the polymerization reaction that produces the crosslinked polymer matrix from the dimethacrylate resin monomers, and silane coupling agents which bond the reinforcing fillers

Chapter 45  Commonly Used Restorative Materials in Pediatric Dentistry to the polymer matrix. Composite (componere = to combine) is the universally used tooth-colored direct restorative material developed in 1962 by combining dimethacrylates (epoxy resin and methacrylic acid) with silanized quartz powder by Bowen 1963.

•

Properties of Composites

•

• Linear coefficient of thermal expansion: It is the rate of dimensional change of a material per unit change in temperature. The closer the LCTE of the material is to the LCTE of enamel, the less chance there is for creating voids or openings at the junction of the material and the tooth when temperature changes occur. The LCTE of improved composites is approximately three times that of tooth structure. • Water absorption: When a restorative material absorbs water, its properties change, and therefore its effectiveness as a restorative material is usually diminished. Materials with higher filler contents exhibit lower water absorption values. • Wear resistance: It refers to a material’s ability to resist surface loss as a result of abrasive contact with opposing tooth structure, restorative material, food boli, and

•

•

such items as toothbrush bristles and toothpicks. Wear resistance of composite materials is generally good. Surface texture: It is the smoothness of the surface of the restorative material. Microfill composites offer the smoothest restorative surface; hybrid composites also provide surface textures that are both esthetic and compatible with soft tissues. Radiopacity: Esthetic restorative materials must be sufficiently radiopaque, so that the radiolucent image of recurrent caries around or under a restoration can be more easily seen in a radiograph. Most composites contain radiopaque fillers, such as barium glass, to make the material radiopaque. Modulus of elasticity: It is the stiffness of a material. A material having a higher modulus is more rigid; conversely, a material with a lower modulus is more flexible. A microfill composite material with greater flexibility may perform better in certain Class V restorations than a more rigid hybrid composite. Solubility: Is the loss in weight per unit surface area or volume due to dissolution or disintegration of a material in oral fluids, over time, at a given temperature. Composite materials do not demonstrate any clinically relevant solubility.

Classification of composites according to matrix components Matrix

Chemical system

Conventional matrix

Pure methacrylate

Inorganic matrix

Inorganic polycondensate

Group

Example of material

Hybrid composite

Tetric EvoCerarm®

Nano composite

Filtek supreme XT®

Ormocers

Admira® Definite®

Acid modified methacrylate

Polar groups

Compomers

Dyract eXtra®

Ring opening epoxide

Cationic polymerization

Silorans

Filtek Silorane®

Classification of composites according to filler particles (Lutz & Phiups 1983) Filler

Macro-filler (>10 ųm)

Macro-filler (0.01–0.1 ųm)

Micro-filter complexes

Composite type

Macro-filler composite

Hybrid composite

Homogenic micro-filler composite

Inhomogenic micro-filler composite

Properties

+ Physical properties

+ Radiopacity

+ Polishability

+ Polishability

+ Radiopacity

+ Polishability

– Wear resistance

+ Esthetics

– Polishability

+ Physical properties

– Water absorption

– Physical properties

– Wear resistance

– Polymerization shrinkage

– Radiopacity – Polymerization shrinkage

Purpose

Core build-up material under indirect restoration? No longer indicated

All classes of restoration

Small anterior restorations Class V

Small anterior restorations Class V

Example

Prisma-Fil®

Tetric Ceram®

Palfique®

Filtek AI l0®

+: Positive property, performance acceptable

–: Negative property, performance unacceptable

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• Polymerization: Full polymerization of the material is determined by the degree of conversion of monomers into polymers, indicating the number of methacrylate groups that have reacted with each other during the conversion process. The factors that influence the degree of conversion of the composite are shown in Table 45.1. TABLE 45.1: Factors that influence the composite resin polymerization process Factor

Clinical repercussions

Curing time

It depends on: resin shade, light intensity, box deep, resin thickness. curing through tooth structure. Composite filling.

Shade of resin

Darker composite shades cure more slowly and less deeply than lighter shades (60 seconds at a maximum depth of 0.5 mm).

Temperature

Composite at room temperature cure more completely and rapidly.

Thickness of resin

Optimum thickness is 1 to 2 mm

Type of filler

Microfine composites are more difficult to cure than heavily loaded composites.

Distance between light and resin

Optimum distance < 1 mm, with the light positioned 90 degrees from the composite surface.

Light source quality

Wavelength between 400 to 500 nm. A power density about 600 mW/cm2 is required to ensure that 400 mW/cm2 reaches the first increment of composite in a posterior box.

Polymerization shrinkage

Depends on the amount of organic phase.

Types of Composite • Hybrid composite resins: – These composites are so called because they are made up of poly­ mer groups (organic phase) rein­ forced by an inorganic phase, comprising 60 percent or more of the total content. It is composed of glasses of different compositions and sizes, with particle sizes ranging from 0.6 to 1 micrometers, and containing 0.04 micrometer sized colloidal silica. – The characteristic properties of these materials are: availability of a wide range of colors and ability to mimic the dental structure, less curing shrinkage, low water absorption, excellent polishing and texturing properties, abrasion and wear very similar to that of tooth structures, similar thermal expansion coefficient to that of teeth, universal formulas for both the anterior and posterior sector, different degrees of

opaqueness and translucency in different tones and fluorescence. • Flowable composites: – These are low-viscosity composite resins, making them more fluid than con­ ventional composite resins. – The percentage of inorga­ nic filler is lower and some substances or rheo­ logical modifiers which are mainly intended to improve handling properties have been removed from their composition. – Their main advantages are: High wettability of the tooth surface, ensuring penetration into every irregularity; ability to form layers of minimum thickness, so improving or eliminating air inclusion or entrapment; radiopaqueness and availability in different colors. – The drawbacks are: High curing shrinkage, due to lower filler load, and weaker mechanical properties. – These are indicated in Class V restorations, cervical wear processes and minimal occlusal restorations or as liner materials in Class I or II cavities or areas of cavitated enamel. • Condensable composites: – Condensable composites are composite resins with a high percentage of filler. – The advantages are: Con­ densability (like silver amalgam), greater ease in achieving a good contact point and better reproduc­ tion of occlusal anatomy. – Their main disadvantages are difficulties in adaptation between one composite layer and another, difficult handling and poor esthetics in anterior teeth. – Indication is Class II cavity restoration in order to achieve a better contact point. • Ormocers: – Ormocers, a word originally derived from organically modified ceramic, were originally developed for science and technology (e.g. for special surfaces like protective coatings, nonstick surfaces, antistatic coatings and nonreflective coatings). – The organic polymers influence the polarity, the ability to cross link, hardness and optical behavior. – The glass and ceramic components (inorganic constituents) are responsible for thermal expansion and chemical stability.

Chapter 45  Commonly Used Restorative Materials in Pediatric Dentistry – The polysiloxanes influence the elasticity, interface properties and processing. – Bottenberg et al. 2009 compared Admira® (ormocer) and Tetric Ceram® (hybrid composite) and found no difference. – Ormocers have a reduced polymerization shrinkage compared to hybrid composites (Yap and Soh 2004). • Compomer: – The word “Compomer” comes from composite and glassionomer. – The material itself is a polyacrylic/polycarboxylic acid modified composite. Compomer are composed of composite and glass ionomer components in an attempt to take advantage of the desirable qualities of both materials: the fluoride release and ease of use of the glass ionomers and the superior material qualities and esthetics of the composites. – Compomer restorations have been shown to have insufficient retention without pretreatment of the dental hard tissue with an adhesive system (Folwaczny et al. 2001, Moodley and Grobler, 2003). – Compomer are most suitable for restorations in the deciduous dentition due to their low abrasion resistance (Zantner et al. 2004, Krämer et al. 2006). – In cervical restorations, compomer restorations per­ formed better than resin-modified glass ionomers but not as well as hybrid composites (Folwaczny et al. 2000).

– The fluoride release of compomer increased quickly initially (24 hrs), but decreased equally quickly. The ability of compomer (Dyract eXtraR®) to be recharged with fluoride from its environment resulting in longer lasting caries prevention has been discussed by Vieira  et al. 1999. • Silorane – The name of this material class refers to its chemical composition from Siloxanes and Oxirans. – This product class aims to have lower shrinkage, longer resistance to fading and less marginal discoloration. – The fillers in Filtek SiloraneR®, the only silorane material on the market at the moment, consist of 0.1 to 2.0 μm quartz particles and radiopaque yttrium fluoride. – The adhesion of streptococci observed on the surface of silorane restorations was low, may be because of its hydrophobic properties (Bürgers et al. 2009). • Giomer: – It is a recently intro­duced hybrid esthetic restorative material based on prereacted glass ionomer techno­logy (PRG). – Chemically it is fluroalu­ mino silicate glass reacted with polyalkeonic acid in water prior to inclusion into silica filled urethane resin.

Properties of composite Indications • Classes I, II, III, IV, V and VI restorations • Foundations or core build-ups • Sealants • Preventive resin restorations • Esthetic enhancement procedures – Partial veneers – Full veneers – Tooth contour modifications – Diastema closures • Cements (for indirect restorations) • Temporary restorations • Periodontal splinting

Contraindications • If the operating site cannot be isolated from contamination by oral fluids • If all of the occlusal load will be on the restorative material • Economics • Restorations that extend onto the root surface may result in less than ideal marginal integrity

Advantages • Esthetic • Conservative of tooth structure removal • Tooth preparation is simple • Have low thermal conductivity • Used almost universally • Bonded to tooth structure • Repairable

Disadvantages • May have a gap formation • Time-consuming • Costly • Establishing proximal contacts, axial contours, embrasures may be more difficult • Technique sensitive • Exhibit greater occlusal wear in areas of high occlusal stress • Marginal leakage can occur

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– These are mainly indicated for restoration of root caries, cervical caries, class V cavities and also in restoration of primary teeth. – Its advantages include continuous fluoride release, clinical stability, high biocompatibility, highly esthetic and ease of bonding.

CALCIUM HYDROXIDE Limestone is a natural rock mainly composed of calcium carbonate (CaCO3) which forms when the calcium carbonate solution existing in mountain and sea water becomes crystallized (Alliet and VandeVoorde, 1988). The calcium oxide (CaO) formed is called ‘quicklime’ and has a strong corrosive ability. Calcium hydroxide is a white odorless powder with the formula Ca (OH)2, and a molecular weight of 74.08. It has low solubility in water which decreases as the temperature rises; it has a high pH (about 12.5±12.8) and is insoluble in alcohol. This low solubility is, in turn, a good clinical characteristic because a long period is necessary before it becomes soluble in tissue fluids when in direct contact with vital tissues. The earliest reference to calcium hydroxide has been attributed to Nygren (1838) for the treatment of the ‘fistula dentalis’ but its introduction to dentistry of is credited to Hermann (1936). Calcium hydroxide was introduced in United States by Teuscher and Zander in 1938, and is since then being used as a pulpal medicament. Although the overall mechanisms of action of calcium hydroxide are not fully understood, many articles have been published describing its biological properties, role of the high pH and the ionic activity in the healing process, diffusion through dentinal tubules and influence on apical microleakage.

Properties • • • • • • •

Arrangement is amorphous matrix, crystalline fillers Bonding = covalent; ionic Setting reaction = acid base reaction Insulator for thermal and electrical conductivity Solubility: 0.3-0.5 Elastic modulus is 588 Compressive strength >24 hr is 138.

Mechanism of Action of Calcium Hydroxide • Machanism of action (MOA) of hydroxyl ions bacteria: Calcium hydroxide is an antibacterial agent due to its elevated pH which influences the specific activity of the proteins of the membrane with a combination with specific chemical groups and can lead to alterations in the ionization state of organic components, depending on pH, there will be an intense transfer of available nutrients through membrane, inducing inhibition and toxic effect on cell. Thus, the influence of elevated pH (12.6) of OHions, transfer capacity and permeability of cytoplasmic

membrane explains the action of calcium hydroxide on bacteria, this is known as lipidic peroxidation. • MOA on tissues: Elevated pH of calcium hydroxide activates alkaline phosphatase from the tissue. This is hydrolytic enzyme that liberates phosphate from esters of phosphates. This phosphate ion, once free, reacts with calcium ion from the blood stream to form a precipitate, calcium phosphate, in the organic matrix. This precipitate is the molecular unit of hydroxyapatite. Calcium hydroxide when in direct contact with adjacent tissue gives origin to a zone of necrosis through rupture of glycoproteins resulting in protein degeneration within 7 to 10 days.

Uses of Calcium Hydroxide • Calcium hydroxide as an intracanal medicament: – It is the most commonly used dressing for treatment of the vital pulp. – It also plays a major role as an intervisit dressing in the disinfection of the root canal system. – Calcium hydroxide cannot be categorized as a conventional antiseptic, but it kills bacteria in root canal space. – Calcium hydroxide is normally used as slurry of calcium hydroxide in a water base paste. – Calcium hydroxide is a slowly working antiseptic and direct contact experiments in vitro require a 24 hour contact period for complete kill of enterococci and reduce the effect of the remaining cell wall material. • Calcium hydroxide as an endodontic sealer – In the root canal obtu­ ration, sealer plays an important role, as it fills the gap between the walls of the prepared dentine and the gutta-percha. – Recently introduced seve­ ral calcium hydroxide sealers are Sealapex (Kerr), Apexkit (Vivadent). • Calcium hydroxide as a pulp capping agent – Calcium hydroxide is generally accepted as the material of choice for pulp capping. – Histologically there is a complete dentinal bridging with healthy radicular pulp under calcium hydroxide dressings. – When calcium hydroxide is applied directly to pulp tissue there is necrosis of adjacent pulp tissue and an

Chapter 45  Commonly Used Restorative Materials in Pediatric Dentistry inflammation of contiguous tissue. Dentinal bridge formation occurs at the junction of necrotic tissue and vital inflamed tissue. Beneath the region of necrosis, cells of underlying pulp tissue differentiate into odontoblasts and elabo­ rate dentin matrix. – Three main calcium hydroxide products for pulp capp­ ing are Pulpa­ dent, Dycal, Hydrex (MPC). • Calcium hydroxide in apexification – In apexification technique canal is cleaned and disinfected, when tooth is free of signs and symptoms of infection, the canal is dried and filled with stiff mix of calcium hydroxide and CMCP. – Commercial paste of calcium hydroxide like Calasept, Pulpdent, Meta­ pex may be used to fill the canals. – Histologically the for­ mation of osteodentin after placement of cal­ cium hydroxide paste immediately on conclusion of a vital pulpectomy has been reported. There appears to be a differentiation of adjacent connective tissue cells; there is also deposition of calcified tissue adjacent to the filling material. The calcified material is continuous with lateral root surfaces the closure of apex may be partial or complete but consistently has minute communications with the periapical tissue. • Calcium hydroxide in pulpotomy – It is the most recommended pulpotomy medicament for pulpally involved vital young permanent tooth with incomplete apices. – It is acceptable because it promoted reparative dentin bridge formation and thus pulp vitality is maintained. Advantages of calcium hydroxide Initially bactericidal then bacteriostatic Promotes healing and repair High pH stimulates fibroblasts Neutralizes low pH of acids Stops internal resorption Inexpensive and easy to use

Disadvantages of calcium hydroxide Associated with primary tooth resorption Dissolve after one year with cavosurface dissolution May degrade during acid etching Degrades upon tooth flexure Marginal failure with amalgam condensation Does not adhere to dentin or resin restoration

– Three histologic zones under calcium hydroxide in 4 to 9 days: 1. Coagulation necrosis. 2. Deep staining areas with varied osteo­dentin. 3. Relatively normal pulp tissue, slightly hypere­ mic, underlying an odontoblastic layer. • Calcium hydroxide in weeping canals – Sometimes a tooth undergoing root canal treatment shows constant clear or reddish exudate associated with periapical radiolucency. Tooth can be asymptomatic or tender on percussion but when opened in next appointment, exudates stops but it again reappear in next appointment, this is known as “weeping canal”. – In these cases tooth with exudates is not ready for obturation, since culture reports normally show negative bacterial growth so, antibiotics are of no help. For such teeth, dry the canals with sterile absorbent paper points and place calcium hydroxide in canal which helps in controlling the exudates because pH of periapical tissues is acidic in weeping stage which gets converted into basic pH by calcium hydroxide.

GLASS IONOMER CEMENTS Glass ionomer cements (GICs) were developed in an attempt to capitalize on the favorable properties of both silicate and polycarboxylate cements. Unfortunately, the first generation materials had severe limitations. Excessive opacity, limited shade selection, mixing and handling problems, and a troublesome clinical technique quickly doused the enthusiasm surrounding this new product. As a result, glass ionomer has struggled to gain popularity even though continued research and development has produced a clinically useful restorative material.

Development 1969 — First developed by AD Wilson and BE Kent 1973 — First material marketed (ASPA IV) (USA 1977) 1975 — First luting material 1978 — Cermet ionomer cements 1982 — Water-activated cements 1986 — Resin modified cements 1988-89 — First commercial product from 3M (VitrebondTM) 1990-93 — Several “Resin-Ionomer Hybrid” liners and restoratives introduced 1994 — Resin-glass ionomer hybrids officially names “Resin Modified Glass Ionomer Cements” at the International Symposium on Glass Ionomer Cements 1995 – Present – introduction of compomers and packable glass ionomers

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Properties of Glass Ionomer Cement • • • • • • • • • • • •

Low solubility Coefficiant of thermal expansion similar to dentin Fluoride release and fluoride recharge High compressive strengths Bonds to tooth structure by primarily chemical (calciumcarboxyl groups), micromechanical Low flexural strength Low shear strength Dimensional change (slight expansion) (shrinks on setting, expands with water sorption) Brittle Lacks translucency Rough surface texture Biocompatible to tissues. Property

GIC

Hybrid composite

Compressive strength (MPa)

Up to 200

350 – 500

Tensile strength (MPa)

15

34 – 62

Modulus of elasticity (MPa)

20,000

13,500 – 18,000

Coefficient of thermal expansion (× 10-6/oC)

10.2 – 11.4

25 – 38

Thermal diffusivity (mm2/sec)

0.198

0.675

Composition of Glass Ionomer Cement Liquid • Polyacid (Acrylic, maleic, itaconic) • Water • Comonomer: D-Tartaric: accelerates set, increases working time, translucency, strength • Recently added: Poly vinyl phosphoric acid.

Powder • Alumina (Al2 O3) – 16.6 percent – Forms the skeletal structure – Increase opacity • Silica (SiO2) – 29 percent – Increase translucency • Calcium fluoride (CaF2) – 34.2 percent – Increases opacity – Acts as flux • Aluminum phosphates (AlPO4) – 9.9 percent

Classification of Glass Ionomer Cement According to philips Type I - Luting Type II - Restorative Type III - Liner and base

According to Davidson and Major • Conventional/traditional –  Glass ionomer for direct restorations –  Metal reinforced GIC –  High viscosity GIC –  Low viscosity GIC –  Base/Liner –  Luting • Resin modified GIC –  Restorative –  Base/Liner –  Pit and fissure sealant –  Luting –  Orthodonic cementation material •  Polyoid modified resin composites/compomers According to McLean, Nicholson and Wilson • Glass ionomer cement –  Glass polyalkenoates –  Glass polyphosphonates •  Resin modified GIC •  Polyacid modified GIC

According to Sturdvent •  Traditional or conventional • Metal modified GIC –  Ceremets –  Miracle mix •  Light cured GIC •  Hybrid (resin modified GIC) •  Polyacid modified resin composites According to GJ Mount • Glass ionomer cements – (i)  Glass polyalkenoates (ii)  Glass polyphosphonates   –  Rein modified GIC   –  Polyacid modified composite resin •  –  Auto cure   –  Dual cure   –  Tri cure •  –  Type I–Luting   – Type II–Restorative Type II–1. Restorative esthetic Type II–2. Restorative reinforced   –  Type III–Lining or base

According to Wilson and McLean •  Type I Luting • Type II –  Esthetic filling material –  Bis-reinforced filling material •  Type III–Lining base and fissure sealant

According to intended applications (Fig. 45.1) •  Type I – Luting •  Type II – Restorative •  Type III – Fast setting lining •  Type IV – Fissure sealants •  Type V – Orthodontic cements •  Type VI – Core build up material •  Type VII – Command set •  Type VIII – GIC for ART •  Type IX – Geriatric and pediatric

Based on chemical constituents of cement •  Conventional • Metal reinforced –  Miracle mix –  Ceremets •  Resin modified

Chapter 45  Commonly Used Restorative Materials in Pediatric Dentistry

A

B

D

E

G

C

F

H

I

Figs 45.1A to I:  (A) Type I – Luting; (B) Type II – Restorative; (C) Type III – Fast setting lining; (D) Type IV – Fissure sealants; (E) Type V – Orthodontic cements; (F) Type VI – Core build up material; (G) Type VII – Command set; (H) Type VIII – GIC for ART; (I) Type IX – Geriatric and pediatric

– Decrease melting temperature – Increase translucency • Cryolite (Na3AlF6) – 5 percent – Increases opacity – Acts as flux • Other ions: NA+, K+, Ca+, Sr+3 • Fluoride – Decrease fusion – Anticariogenecity – Increase translucency. Powder is basically an acid soluble calcium alumino­ silicate glass containing fluoride. It is formed by fusing silica + alumina + calcium fluorite, metal oxides and metal phosphates at 11000 to 15000°C and then pouring the melt onto a metal plate/into water. The glass formed is crushed,

milled and ground to a form powder of 20 to 50u size depending on what it’s going to be used for.

Dispensing of Glass Ionomer Cement • Conventional glass ionomer cements are supplied as powder and a liquid system. • The dispensing and mixing of the powder and liquid are critical and may introduce a considerable variability in the mechanical and physicochemical properties of the set cement. • The variation in different types of GIC (lining/ restorative/luting) is based on the particle size of power only. All the other constituents as well as liquid is the same for all. • Powder: Liquid ratio for luting 1.5 : 1 and for restoration is 3:1.

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Setting Reaction of Glass Ionomer Cement

Advantages • Bonds to enamel and dentin • Significant fluoride release, can be recharged • Coefficient of thermal expansion similar to tooth structure • Tooth colored • Low thermal conductivity.

Disadvantages • • • • •

Opacity higher than resin Less polishability than resin Poor wear resistance Brittle, poor tensile strength Poor longevity in xerostomic patients.

 ecent Developments of R Glass Ionomer Cement

Indications • • • • • •

Nonstress bearing areas Class III and V restorations in adults Class I and II restorations in primary dentition Temporary or “caries control” restorations Crown margin repairs Cement base under amalgam, resin, ceramics, direct and indirect gold • Core build-ups when at least 3 walls of tooth are remaining (after crown preparation).

Contraindications • • • •

High stress applications Class IV and class II restorations Cusp replacement Core build-ups with less than 3 sound walls remaining.

• Modified powder — liquid system – The rational of this development was to enhance the manual mixing procedure with a product with improved handling features and high reproducibility of dosing. – To be able to accomplish this task specialized processing procedure for powder was followed (specialized granulates). – This system has improved wetting of the powder by the liquid rendering the mixing process much easier and faster. • Capsules – The glass ionomer cement in the form of capsule system is a modern application method, which simplifies and allows procedures to be performed with greater ease and efficiency. – These capsules contain premeasured glass ionomer powder and liquid, which ensures correct ratio, consistency of mix and a predictable result. – These capsules have angled nozzles that act as a syringe for accurate placement of the material into a cavity or a crown for cementation. • Paste-paste dispensing system – This is the latest development in the glass ionomer cement technology. This dispensing system was designed with the objectives of providing optimum ratio, easy mixing, easy placement, total reliability,

Chapter 45  Commonly Used Restorative Materials in Pediatric Dentistry using a specially designed cartridge and an easy-to-use material dis­penser. – In order to provide the material in a paste–paste consistency, an ultra fine glass powder was designed specifically. The low particle size provides the mixed cement with a thixotropic creamy consistency.

Modifications of Glass Ionomer Cement • Metal modified glass ionomer – Silver alloy admix (silver amalgam alloy particles mixed with glass parti­ cles) - The addition of metal powders or fibers to glass ionomer ce­ ments can improve strength; Sced and Wilson found that metal fibers were best for increasing flexural strength. - Simmons suggested mixing amalgam alloy powders into the cements and developed this system clinically under the name “Miracle mix”. He used this alloy/glass ionomer mix for core building and for the treatment of mouths with high caries incidence. However, their esthetics are poor and they do not burnish. – Cermet (glass sintered with silver) - The solution to the problem of improving resistance to abrasion was the development of Cermet– ionomer cements by McLean and Gasser. By sintering the metal and glass powders together, strong bonding of the metal to the glass was achieved. - Cermet–ionomer cements have greatly improved resistance to abrasion when compared with glass ionomer cements and their flexural strength is also higher. - However, their strength is still insufficient to replace amalgam alloys and their use should be confined to low stress-bearing cavity prepa­ rations.

• Resin modified glass ionomer – Visible Light Cure Glass Ionomers, hybrid glass ionomers - Despite all the improvements, the two problems of conventional glass ionomer cements still remained: moisture sensitivity and lack of command cure. To overcome these problems, attempts have been made to combine glass ionomer chemistry with the well-known chemistry of composite resins. - So, resin modification of glass ionomer cement was designed to produce favorable physical properties similar to those of resin composites while maintaining the basic features of the conventional glass ionomer cement. - In these newer materials the fundamental acid/base curing reaction is supplemented by a second curing process, which is initiated by light or chemical. These products are considered to be dual– cure cements if only one polymerization mechanism is used; if both mechanisms are used, they are considered to be tricure cements. - In their simplest form, these are GICs with the addition of a small quantity of a resin such as hydroxyethyl methacrylate (HEMA) or Bis – GMA in the liquid. More complex materials have been developed by modifications of the polyacid with side chains that can be polymerized by a light – curing mechanism. - The first commercial RMGICs were liners, Vitrebond (3M). • “High strength,” “packable,” or “high viscosity” glass ionomers – These glass ionomers are particularly useful for atraumatic restorative treatment technique (ART). – They were designed as an alternative to amalgam for posterior preventive restorations. – Examples of highly viscous glass ionomer cements are Fuji IX and Ketac Molar. – These cements set only by a conven­ tional neutralization reaction but have properties that exceed those of the resin modified systems. Setting is rapid, early moisture sensitivity is considerably reduced and solubility in oral fluids is very low.

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POINTS TO REMEMBER • • • • • • • • • •

Dentists have used silver amalgam as a restorative material for more than 150 years. Corrosion is the progressive destruction of a metal by chemical or electrochemical reaction with its environment. Recommended mercury alloy ratios for most modern lathe cut alloys is 1:1, or 50% mercury. The initiation of toxic effects of mercury was first evaluated in fishermen due to excess mercury in water. The maximum safe level of occupational exposure to mercury is 50 microgm. Composite is the universally used tooth colored direct restorative material developed in 1962 by combining dimethacrylates with silanized quartz powder by Bowen 1963. Ormocers, a word originally derived from organically modified ceramics, were originally developed for science and technology. Ormocers have a reduced polymerization shrinkage compared to hybrid composites. The word “Compomer” comes from composite and glass ionomer. Calcium hydroxide was introduced to dentistry by Hermann in 1936.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8.

Classify amalgam and write a note on its clinical application. Write about mercury toxicity. Describe waste management of amalgam and other restorative materials. Classify composites and explain its various types. What are the uses, advantages and disadvantage of calcium hydroxide? Describe the role of calcium hydroxide in endodontics. Classify GIC and give its composition. What are the modifications of GIC?

BIBLIOGRAPHY 1. American Dental Association. Comparison of direct restorative dental materials. ADA News, 2002;33:9 (insert). 2. American Dental Association/National Institute of Dental Research. 1991 Symposium on Esthetic Restorative Materials. Chicago: American Dental Association; 1993.p.167. 3. Craig RG, (Ed). Restorative dental materials. 10th Edn. St. Louis: Mosby; 1997.p.231. 4. Desai S, Chandler N. Calcium hydroxide-based root canal sealers: a review. J of Endo. 2009;35(4):475-80. 5. Farhad A, Mohammadi Z. Calcium hydroxide: a review. Int Dent J. 2005;55(5):293-301. 6. Foreman PC, Barnes IE. Review of calcium hydroxide. Int Endo J. 1990;23(6):283-97. 7. Hickel, et al. New direct restorative materials. Int Dent J. 1998;8(1):3-16. 8. Mohammadi Z, Dummer PM. Properties and applications of calcium hydroxide in endodontics and dental traumatology. Int Endo J. 2011;44(8):697-730. 9. Mohammed M, Saujanya KP, Jain D. Sajjanshetty S, Arun A, Uppin L, Kadri M. Role of calcium hydroxide in endodontics: a review. GJMEDPH. 2012;1(1):66-72. 10. Morfis AS, Sykaras S. Clinical use of calcium hydroxide in dentistry — Review. Hell Stomatol Chron. 1987;31(3):169-75. 11. Mount GJ. Glass-ionomer cements past present and future. Oper Dent. 1994;19:82-90. 12. Rozaidah T. Dental composites: a review. J Nihon Sch Dent. 1993;35:161-70. 13. Tyas MJ. Reaction and discussion. Clinical performance of glass-ionomer cements. In: Symposiurn on esthetic restorative materials. 1991 Chicago IL: American Dental Association. 14. Willems G, Lambrechts P, Braem M, Vanherle G. Composite resins in the 21st century. Quintessence Int. 1993;24:641-58. 15. Wilson AD, Kent BE. The glass-ionomer cement: a new translucent dental filling material. J Appl Chem Biotechnol. 1971;21:313.

46

Chapter

Minimal Intervention Nikhil Marwah, Deepak Raisinghani

Chapter outline • •

Principles of Minimal Intervention Cavity Design Modifications

The term minimal intervention is relatively new in dentistry and has been introduced to suggest to the profession that it is time for change in the principles of operative dentistry. The original approach to the treatment of caries was purely surgical. It was thought that the only effective method of eliminating the disease was to completely remove all of the demineralized areas of tooth structure and rebuild it with an inert restoration that would simply obturate the cavity. The margin of the cavity had to be placed on a so-called cariesfree surface to avoid the risks of further plaque accumulation that could lead to recurrence of the disease. This led to the development of a standardized system of intervention regardless of the size and extent of the original lesion. Even the smallest area of demineralization required the removal of a standard amount of sound tooth structure to prevent progression. Cavity designs were classified and standardized, and sound natural tooth structure was sacrificed in the name of geometric perfection to accommodate the shortcomings of the restorative material. A number of problems arise from this approach. First, it fails to recognize that cavitation is essentially a symptom of a bacterial disease. Second, it denies the ability of the tooth structure to remineralize and heal. Once tooth structure is removed, for whatever reason, it cannot be remineralized, and the original form, anatomy, esthetics, and strength are lost forever. The concept of preventive dentistry was developed along with the early understanding of demineralization, but, with the poor understanding of remineralization at that time, the full cycle was not appreciated. The philosophy of minimal intervention dentistry has now arisen in an attempt to combine all the present knowledge of prevention,

• • •

Tunnel Cavity Preparation Slot Cavity Preparation Proximal Approach

remineralization, ion exchange, healing, and adhesion with the object of reducing carious damage in the simplest and least invasive manner possible.

PRINCIPLES OF MINIMAL INTERVENTION The surgical approach has been proven to be inefficient and destructive and is obviously maximally interventionist. A recent policy document produced for the World Dental Federation suggested that there are four basic principles that must be applied to fulfill the description of minimal intervention dentistry. 1. Control the disease through reduction of cryogenic flora: Only in the absence of disease will restorative dentistry succeed. This is why control of the disease is the primary focus and only when such control has been achieved will it be possible to offer long-term repair of the damage. Correct diagnostic procedures must be carried out for any at-risk patient to determine the potential for carious activity. Modification of the oral microflora is essential in the initial stage, and a number of oral lavages are available to modify the balance of the oral flora although chlorhexidine is probably the most effective of these. 2. Remineralize early lesions: Remineralization should be recognized and utilized as far as possible for any tooth that has been subject to attack by caries, because there is no real substitute for natural tooth structure. It has been known for many years that “white-spot” lesions on the visible surfaces of teeth can be remineralized and repaired. Successful remineralization requires intensive patient education and cooperation; the patient must

574 Section 9 

Restorative Dentistry of the remaining crown. This steady progression should be limited as far as possible; with the advent of adhesion, biomimetic materials, and minimal intervention cavity designs, it is often possible to repair, rather than replace, a restoration that has suffered a limited failure.

CAVITY DESIGN MODIFICATIONS It is apparent that it should now be possible to review the GV Black approach to cavity design and be far more conservative in removing natural tooth structure. Minimal intervention cavity designs have been discussed for more than 20 years (Knight 1984; Hunt 1984), and a new classification that encourages the profession to see operative dentistry in a new light has been proposed (Mount and Hume, 1997). The GV Black classification does not address this new philosophy thus; it is in the interest of both the patient and operator to adopt a new method. The proposed classification takes into account the fact that there are only three surfaces of the crown of a tooth that can be subject to caries attacks. These surfaces are: • Site 1: Pits and fissures on the occlusal surface of posterior teeth and other defects on otherwise smooth enamel surfaces. • Site 2: Contact areas between any pair of teeth, anteriors or posteriors. • Site 3: Cervical areas related to gingival tissues, including exposed root surfaces.

have a full understanding of the implication of food types, the need for plaque removal, and the possible need for additional oral lavages for control of bacterial populations. 3. Perform minimal intervention surgical procedures, as required: If the disease has progressed to cavitation on the tooth surface, it is no longer possible to completely control plaque accumulation without some degree of surgical intervention. In view of the potential for remineralization and healing a minimal intervention approach is encouraged. The principle of preservation of natural tooth structure should dominate decisions about both new and old lesions. 4. Repair, rather than replace, defective restorations: The replacement of any failed restoration will also lead to further loss of tooth structure and subsequent weakening

A neglected lesion will continue to extend in an area of demineralization in relation to one of the sites noted above. As it extends, so will the complexities of the restoration increase. The sizes that can be readily identified include: • Size 0: Initial lesion at any site can be identified but has not yet resulted in surface cavitation. It can possibly be healed. • Size 1: Smallest minimal lesion requiring operative intervention. The cavity is into dentin just beyond healing through remineralization. • Size 2: Moderate-size cavity. There is still sufficient sound tooth structure to maintain the integrity of the remaining crown. • Size 3: The cavity needs to be modified and enlarged to provide some protection for the remaining crown from the occlusal load. There is already a split at the base of a cusp or, if not protected, a split will likely develop. • Size 4: The cavity is now extensive, following the loss of a cusp from a posterior tooth or an incisal edge from an anterior.

Chapter 46  Minimal Intervention Site 1, Size 0

The concept of the fissure seal, as discussed by Simonsen (1989) and others is particularly sound in a newly erupted tooth. Sealing a deep fissure before it becomes partially occluded by plaque and pellicle, and in advance of demineralization into dentin, has an acceptable clinical history (Feigal, 1998; Ekstrand, 1998). The earliest fissure sealants were unfilled or lightly filled resins, but recent research has shown that there are some doubts about the integrity of the acid etch union between resin and enamel in these regions. It has been shown that a glass ionomer will successfully occlude such a fissure (Wilson and McLean, 1988). This is now being termed “fissure protection” to differentiate it from a “resin seal”

Site 1, Size 1

As the fissure walls become demineralized, the dentin will become involved as well. This may pose a rather dangerous situation because there is often some difficulty in diagnosing the presence of a dentin lesion. Radiographs will not show this early lesion very clearly and laser detector and electrical impedance machines have limitations. In the presence of strong, fluoridated enamel, the occlusal surface entry to the lesion will remain limited, and bacteria-laden plaque can be forced down into a defective fissure. Under these circumstances, dentin involvement can become advanced before symptoms are noted. The fissure system is a complex series of pits and fissures; therefore, a carious defect will often be limited to a very restricted area, leaving the remaining fissure system sound and uninvolved. This means that only the carious defect needs to be instrumented. However, prudence suggests that minor apparent defects should be explored in a very conservative manner before sealing the fissure system

Site 1, Size 2

In this classification, the lesion will either have progressed to some degree or it may represent replacement of a failed Class I restoration. The same conservative principles should apply, as discussed above, in as much as it is only necessary to deal with the carious lesion and there is no need to open up the remaining fissures any further. If there is any part of the fissure system that is in doubt, it can be explored very conservatively, but there is no doubt that it is sufficient to seal the fissures and any carious process below will be arrested. However, the occlusal involvement will be more extensive and, if there is any doubt about the ability of the glass ionomer to withstand the occlusal load, it can be cut back conservatively and laminated with resin composite

Site 1, Size 3, 4

When a restoration requires replacement, the existing cavity will be relatively large. The previous surgical approach to cavity design required the removal of all infected tooth structure and softened affected dentin on floor of the cavity and also required removal of all unsupported enamel on the occlusal surface. Consequently, there was a potential for loss of occlusal contact with the opposing tooth. To avoid such procedures a temporary restoration is placed over the carious structure and this helps in remineralizing the lesion and decreasing pulpal inflammation. Glass ionomer should be used for the transitional restoration following removal of infected layer of dentin from the surface of a large cavity. It will adhere to both enamel and dentin through an ion-exchange mechanism, thus eliminating microleakage. It will also adhere to the collagen of demineralized dentin on the cavity floor through either hydrogen bonding or metallic-ion bridging. In the absence of bacterial activity, the pulpal inflammation will subside. In the presence of water from the positive dentinal fluid flow that follows, there will be calcium, phosphate, and fluoride ions exchanged between the glass ionomer and the demineralized dentin. Further ions will be available from the pulpal fluid, and the dentin will remineralize

Site 2, Size 0

It should be noted that radiographic evidence of demineralization at the contact area does not necessarily mean that there is cavitation on the proximal surface and, in the absence of cavitation, it is often possible to heal the lesion. In fact, proximal lesions progress very slowly because that surface is not under masticatory load and is, to a degree, protected from traumatic damage (Pitts, 1983; Shwartz, 1984). In contrast to the occlusal fissure lesion, it may take up to four years to penetrate the full thickness of the enamel and an additional four years to progress through the dentin to the pulp

Site 2, Size 3, 4

The principles for the restoration of an extensive proximal lesion are essentially the same as those for an occlusal lesion. In gaining access to the affected demineralized dentin, there is no need to remove enamel just because it appears to be unsupported according to the old surgical principles. However, the walls of the cavity should be cleaned of all infected dentin to allow development of the full ion-exchange adhesion with the glass ionomer. Demineralized dentin can remain on both the axial and pulpal walls on the assumption that it will remineralize under the influence of the glass ionomer. First increment should be placed and tamped over the entire floor of the cavity using a small, dry plastic sponge. A further increment must be applied and if the size of the cavity requires it, this one should be tamped in as well to adapt it properly to the walls. The cavity must be overfilled, the glass ionomer allowed to set, and lastly, the occlusion adjusted. With active caries this restoration may be regarded as a long-term transitional restoration, destined to be replaced after 3 months or more, by which time the caries should be controlled. On the other hand, if the glass ionomer is intended to complete the restoration at the same appointment, it should be allowed to set before trimming it back and re-preparing the cavity for resin composite to be laminated over it

575

576 Section 9 

Restorative Dentistry

TUNNEL CAVITY PREPARATION • This is indicated if the cavity is small and if placed 2 to 2.5 mm below the marginal ridge. • The aim is to develop an access via the occlusal aspect so as to preserve the strength of marginal ridge and also to prevent formation of proximal cavity (Fig. 46.1). • The early proximal lesion on a posterior tooth will commence in enamel immediately below the contact area because this is where plaque will accumulate and mature. As the lesion develops, some degree of breakdown and cavitation of the enamel will eventually occur, but this will remain confined to the area below the contact until it is quite advanced. There will generally be a zone of demineralized enamel surrounding the cavitation, but as long as the surface is smooth, this remains capable of remineralization in the presence of fluoride. The contact area may remain sound and the marginal ridge may be quite strong, provided the lesion is more than 2.5  mm

below the crest of the marginal ridge (Wilson and McLean, 1988). • Access to the lesion through the occlusal surface should be limited to the extent required to achieve visibility and should be undertaken from an area that is not under direct occlusal load (Knight, 1984). • Fossa immediately next to medial marginal ridge is the most suitable position for entry. • Glass ionomer is best suited for such cavities as it readily flows into a small cavity and has the ability to remineralize the enamel margins and any dentin on axial wall.

SLOT CAVITY PREPARATION

Fig. 46.1:  Tunnel cavity preparation

• As the name denotes it is creation of a small slot on the proximal aspect of posterior teeth. • Indicated if there is a small lesion involving the area of or below the marginal ridge only in deciduous teeth. • The outline form will be dictated entirely by the extent of the breakdown of the enamel, removing only that which is friable and easily eliminated without applying undue pressure. Retention will be through adhesion, so it is only necessary to clean the walls around the full circumference of the lesion, leaving the axial wall because it will be affected by dentin only. • Cavity preparation is done only on the proximal aspect after establishing entry over marginal ridge and the extent of cavity is defined by the extent of the lesion with the intention to preserve as much tooth as possible (Fig. 46.2). • The material of choice is glass ionomer but resin composite may be a useful material because on many occasions there will be an enamel margin around the full circumference.

Chapter 46  Minimal Intervention

Fig. 46.2:  Slot cavity preparation

PROXIMAL APPROACH • This is a very conservative approach used when the proximal surface of a tooth becomes accessible at the time of cavity preparation in an adjacent tooth. The lesion may have been revealed through radiographs or it may be noted only during cavity preparation. • The larger cavity in the adjacent tooth will normally need to be of reasonably generous proportions to allow room to maneuver, but when such an approach is possible, it leads to considerable conservation of natural tooth structure. It is only necessary to remove enamel that is broken down beyond remineralization. There will often be a residual area of demineralized enamel around the circumference of the lesion and this should be retained because it is quite capable of being remineralized (Fig. 46.3).

Fig. 46.3:  Proximal approach

• As this entire restoration will be hidden by adjacent tooth, it is essential to use a radiopaque material. Glass ionomer is preferred because the limited access will make it difficult to assure full polymerization of the resin through light activation. It is apparent that it is time for a change in operative dentistry. It is not possible to really imitate natural tooth structure on a long-term basis so it is best that it be retained as far as possible. Therapeutic methods for the control of the disease are available, and these should be the first line of defence. In the presence of early carious lesions there is no justification for removal of tooth structure simply to provide a theoretic resistance to further carious attack or to develop mechanical retention for restorative materials. It is important that the profession embraces modern science and move into the new century.

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Restorative Dentistry

POINTS TO REMEMBER • Preservation of tooth structure and maintenance of occlusal relationships are essential in the design and construction of all restorations. • Extension for prevention is no longer a valid concept and focus is shifted to preservation with use of adhesive materials. • Concept of minimal intervention was initiated by Knight and Hunt, 1984 and the classification was proposed by Mount and Hume, 1997. • Principles of minimal intervention include control the disease through reduction of cryogenic flora; Remineralize early lesions; Perform minimal intervention surgical procedures, as required; Repair, rather than replace, defective restorations  • Tunnel cavity design is indicated if the cavity is small and if placed 2 to 2.5 mm below the marginal ridge. The aim is to develop an access via the occlusal aspect so as to preserve the strength of marginal ridge and also to prevent formation of proximal cavity. • Slot cavity design is creation of a small slot on the proximal aspect of posterior teeth and is indicated if there is a small lesion involving the area of or below the marginal ridge only in deciduous teeth. • Proximal cavity design approach is a conservative approach used when the proximal surface of a tooth becomes accessible at the time of cavity preparation in an adjacent tooth.

QUESTIONNAIRE 1. 2. 3. 4. 5.

Define, classify and explain the concept of minimal intervention. What is Mount and Hume’s classification? Explain the design of tunnel cavity preparation. Write a note on slot cavity design. What is proximal approach of cavity preparation?

BIBLIOGRAPHY

1. Axelsson P. An Introduction to Risk Prediction and Preventive Dentistry. Quintessence Publishing Co Ltd; Illinois; 1999.p.7. 2. Black GV. A work on operative dentistry: The technical procedures in filling teeth. Medico-Dental Publishing Company; Chicago; 1917. 3. Hasselrot L. Tunnel restorations in permanent teeth. A 7-year follow-up. Swedish Dent Journ. 1998;22:1-7. 4. Hunt PR. A modified Class II cavity preparation for glass­ionomer restorative materials. Quintessence Int. 1984;15:1011-8. 5. Knight GM. The use of adhesive materials in the conservative restoration of selected posterior teeth. Austral Dent Journ. 1934;29:324-31. 6. Mount GJ, Hume WR. Preservation and Restoration of Tooth Structure. Mosby International London Chapter. 1998b;11:129. 7. Mount GJ, Hurne WR. A revised classification of carious lesions by site and size. Quintessence Int. 1997;28:301-3. 8. Mount GJ, Ngo H. Minimal intervention: A new concept for operative dentistry. Quintessence Int. 2000;31:527-33. 9. Mount GJ. Longevity in glass-ionomer restorations: Review of a successful technique. Quintessence Int. 1997;28:643-50.

47

Chapter

Atraumatic Restorative Treatment Nikhil Marwah

Chapter outline •

Armamentarium, Methods, Materials and Patient Preparation for Atraumatic Restorative Treatment

The Atraumatic Restorative Treatment (ART) is a procedure based on removing carious tooth tissues using hand instruments alone and restoring the cavity with an adhesive restorative material. Another terminology used for ART is Alternate Restorative Treatment. Usually carious lesions are left untreated in children of underprivileged communities of developing and underdeveloped countries mainly because of financial problems and lack of awareness. Over the last two to three decades although dental caries has decreased substantially in the few industrialized countries but from a global perspective, it still remains a widespread problem. The treatment requires qualified personnel and expensive equipment. The absence of clean and pressurized water and irregular supply of electricity make it impossible for oral healthcare personnel to work efficiently. A group in Zimbabwe and another in Thailand began experimentation to check longevity and efficiency of ART and their result were so encouraging that the system has been adopted by the World Health Organization (WHO) and is being promoted world wide as a useful technique for communities that lack regular dental facilities. A new method was presented for treating dental caries, which involved neither drill or water nor electricity at the headquarters of the WHO, Geneva, on World Health Day (April 8th, 1994).

• •

Procedure for Atraumatic Restorative Treatment Material Usage for Atraumatic Restorative Treatment

area of the mouth. The correct positioning of both the operator and patient is essential to achieve good quality care. This section describes the most appropriate working positions for both oral examination and treatment.

 he Operator’s Work Posture T and Positions • The work posture and position of the operator should provide the best view of the inside of the patient’s mouth. At the same time, both patient and operator should be comfortable. • The operator sits firmly on the stool, with straight back, thighs parallel to the floor and both feet flat on the floor. The head and neck should be still, the line between the eyes horizontal and the head bent slightly forward to look at the patient’s mouth. • The height of the stool must then be adjusted so that the operator can see the patient’s teeth clearly. • The distance from the operator’s eye to patient’s tooth is usually between 30 and 35 cm. The operator should be positioned behind the head of the patient. The exact position will depend on the area of the patient’s mouth to be treated (Fig. 47.1).

Assistance ARMAMENTARIUM, METHODS, MATERIALS AND PATIENT PREPARATION FOR ATRAUMATIC RESTORATIVE TREATMENT Restorative oral health care tasks require precise work and high levels of control as they are performed in the restricted

• Oral care is best provided by a team consisting of an operator and an assistant. • When treating patients, particularly children using ART, it is a great advantage if another person can mix the glassionomer. This allows the operator to concentrate on the cavity and maintain effective saliva control.

580 Section 9 

Restorative Dentistry

Fig. 47.1:  The operator’s work posture and position

Fig. 47.3:  Patient position

Fig. 47.2:  With assistance

Fig. 47.4:  Operating positions for right handed dentist

• The assistant works at the left side of a right-handed operator and does not change position (Fig. 47.2). • The assistant should sit as close to the patient support as possible, facing the patient’s mouth. • The assistant’s head should be 10 to 15 cm higher than the operator, so that the assistant can also see the operating field and can pass the correct instruments when needed.

comfortable and stable position for lengthy periods of time (Fig. 47.3).

Patient Position As with any other oral treatment, ART requires correct patient and operator positions. A patient lying on the back on a flat surface will provide safe and secure body support and

Operating Positions (Fig. 47.4) Position for upper right posterior tooth surfaces

The operator sits directly behind the patient’s head. Mirror vision is used and the patient’s head is tilted backwards with the mouth fully open. Turning of the patient’s head will depend on the surfaces to be treated on, i.e. for a palatal surface of an upper right molar-turned slightly to the right, for a buccal surface of an upper right molar-turned slightly to the left.

Chapter 47  Atraumatic Restorative Treatment Position for upper left posterior tooth surfaces

Position for lower left posterior tooth surface

Position for lower right posterior tooth surfaces

Position for lower anterior tooth surfaces Position for upper anterior tooth surfaces

For occlusal and buccal surfaces, the operator sits directly behind the patient’s head. Tilt the patient’s head backwards and turn it slightly to the right with the mouth fully open for occlusal and partly closed for buccal surfaces. For working on the palatal surface, the operator sits slightly to the right of the patient’s head. Tilt the patient’s head backwards and turn it slightly to the left with the mouth fully open for direct vision. The operator sits to the right rear of the patient’s head. The patient’s head is placed in the central position and tilted slightly forwards. For occlusal and buccal surfaces, turn the head slightly to the right. The mouth should be fully open for occlusal views and partly closed for buccal surfaces to allow access for the mouth mirror. Direct vision may be used for most of the teeth. The operator sits to the right rear of the patient’s head, which should be tilted forwards. For occlusal and lingual working surfaces, turn the head slightly to the right with the mouth fully open for direct vision. To view the buccal surfaces, turn the head slightly to the left with the mouth partly closed to allow access for the mouth mirror and hand instruments. The operator sits directly behind the patient’s head. Tilt the patient’s head forwards in the central position. The mouth should be fully open and direct vision is used. The operator sits directly behind the patient. Tilt the patient’s head backwards with the mouth open. The buccal surfaces are then viewed directly and the lingual surfaces are viewed through the mouth mirror.

Operating Light • Good vision is essential for working in the oral cavity. • The light source can be the sun (natural) or artificial. Artificial light is more reliable and constant than natural light and can also be focused on a particular spot. Therefore, in a setting a portable light source is recommended, e.g. a headlamp, glasses with a light source attached or a light attached to the mouth mirror.

Arrangements in the Mouth • A very important aspect for the success of ART is control of saliva around the tooth being treated. • Cotton wool rolls quite effective at absorbing saliva and can provide short-term protection from moisture or saliva. Rolls can be either bought or prepared form bulk cotton

dressing pack. The location in the mouth and method of placement of cotton wool rolls is described below: – Upper Teeth: Retract the lip and cheek with the mouth mirror to make space between the cheek and teeth for the cotton wool roll. Place the cotton roll in position with a slight rotating action from the tooth towards the gingiva. This will help prevent the cotton wool roll from coming out easily. – Lower Teeth: Ask the patient to stick the tongue out. Push the tongue aside with the mouth mirror. Place a cotton wool roll on each side of the floor of the mouth. Then ask the patient to retract the tongue back to its normal position.

Essential Instruments and Materials The success of any treatment depends on the operator knowing the functions of the various instruments and using them correctly. Following instruments and materials are used for ART: Mouth mirror

This instrument is used to reflect light onto the field of operation, to view the cavity indirectly, and to retract the cheek or tongue.

Explorer

This instrument is used to identify where soft carious dentine is present.

Tweezers

This instrument is used for carrying cotton wool rolls, cotton wool pellets, wedges and articulation paper from the tray to the mouth and back.

Spoon excavator This instrument is used for removing soft carious dentin. Dental hatchet

This instrument is used for widening the entrance to the cavity, for slicing away thin unsupported and carious enamel left after carious dentin has been removed.

Carver

This double-ended instrument has two func­ tions. The blunt end is used for inserting the mixed glass-ionomer into the cleaned cavity and into pits and fissures. The sharp end is designed to remove excess restorative material and to shape the glass-ionomer.

Mixing pad and These are spatula ionomer.

necessary

for

mixing

glass-

Cotton wool rolls

These are used to absorb saliva so that the tooth to be treated can be kept dry.

Cotton wool pellets

These are used for cleaning cavities. They are available in various sizes.

Petroleum jelly

This material is used to keep moisture away from the glass-ionomer restoration and to prevent the examination glove from sticking to the glass-ionomer as it sets hard.

Plastic mylar strip

This material is used for contouring the proximal surface of multiple surface restorations.

Wedges

These are used to hold the plastic strip close to the shape of the proximal surface of a tooth so that restorative material is not forced between the gums and teeth.

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Restorative Dentistry

PROCEDURE FOR ATRAUMATIC RESTORATIVE TREATMENT (FIGS 47.5A TO H)

Chapter 47  Atraumatic Restorative Treatment

A

B

C

D

E

F

G

H

Figs 47.5A to H:  (A) Preoperative; (B) Excavation of caries; (C) Cavity after caries removal; (D) Cavity conditioning; (E) Dispensing of glass ionomer cement; (F) Mixing of glass ionomer cement; (G) Insertion of glass ionomer cement; (H) Restored cavity

Advantages of ART • Easily available inexpensive hand instruments are used rather than the expensive electrically driven dental equipment. • As it is almost a painless procedure the need for local anesthesia is eliminated or minimized. • ART involves the removal of only decalcified tooth tissues, which results in relatively small cavities and conserves sound tooth tissue as much as possible. • Sound tooth tissue need not be cut for retention of filling material. The retention is obtained by the micro tags produced due to etching and also because of the chemical adhesion of glass ionomer restorative material with cavity walls.

• A practice of straightforward and simple infection control is used without the need to use autoclaved hand pieces. • The leaching of fluoride from glass ionomer probably remineralizes sterile demineralized dentin and prevents development of secondary caries. • The combined preventive and curative treatment can be done in one appointment. • Repairing of defects in the restoration can be easily done. • It is less expensive and less time consuming as in one sitting several fillings can be done. • One of the greatest advantages of ART is that it enables to oral health workers to reach people who otherwise never would have received any oral health service.

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Restorative Dentistry • Simplified infection control; hand instruments can be easily cleaned and sterilized after every patient.

Disadvantages of ART • ART restorations are not long lasting. The average life is two years depending upon the rate of caries activity of the individual oral cavity. • As fundamental principles of cavity preparation are not followed all oral health workers may not accept it. • Because of the low wear resistance and low strength of the existing glass ionomer materials their use is limited to small and medium sized one surface cavity only. • The continuous use of hand instruments over long period of time may result in hand fatigue. • A relatively unstandardized mix of glass ionomer may be produced due to hand mixing.

MATERIAL USAGE FOR ATRAUMATIC RESTORATIVE TREATMENT

 he Reasons for Using Hand Instruments T Rather Electric Driven Handpiece • It makes restorative care accessible to all population groups. • The use of a biological approach, which requires minimal cavity preparation that conserves sound tooth. • The low cost of hand instruments compared to electrically driven dental equipment. • The limitation of pain that reduces the need for local anesthesia to a minimum and reduce psychological trauma to patients.

The Reasons for Using Glass Ionomer • As the glass ionomer chemically bonds to both enamel and dentin, the need to cut sound tooth tissue to prepare the cavity is reduced. • Fluoride is released from the restoration to prevent secondary caries. • Glass ionomer is biocompatible, does not cause any irritation to pulp and gingival and has a coefficient of thermal expansion similar to tooth structure. As ART is based on modern concepts of cavity preparation where minimal intervention and invasion is emphasized; this approach is applicable also in the industrialized countries for special groups such as the physically and mentally handicapped and the elderly. In 2000, the division of public oral health implemented a training, research and service program in the ART approach. The aim was the promotion of ART in public health services, private oral health care services, tertiary oral health training institutions and health services for refugee communities. A revolution in dentistry!! It may be too early to say, but Grossman sums it up: “There are always detractors who poohpooh at new techniques, but the ART approach at present serves a purpose. It is minimally invasive by saving tooth and maximally preventive by preventing further decay. It is a wonderful way of introducing a nervous patient to dental care thereby laying the foundation for a lifetime of good oral health care.”

POINTS TO REMEMBER • The atraumatic restorative treatment (ART) is a procedure based on removing carious tooth tissues using hand instruments alone and restoring the cavity with an adhesive restorative material. Another terminology used for ART is alternate restorative treatment. • Adapted by WHO on World Health Day April 8th, 1994. • The distance from the operator’s eye to patient’s tooth is usually between 30 and 35 cm. • The operator should be positioned behind the head of the patient. • A patient lying on the back on a flat surface will provide safe and secure body support and comfortable and stable position for lengthy periods of time. • The assistant works at the left side of a right-handed operator. • Advantages of ART are inexpensive hand instruments; painless procedure; involves the removal of only decalcified tooth tissues; fluoride effect; less expensive and less time consuming.

QUESTIONNAIRE 1. Define ART and explain the working positions of operator. 2. What are the instruments and materials of ART? 3. Describe the procedure of ART.

Chapter 47  Atraumatic Restorative Treatment

BIBLIOGRAPHY

1. Baum L, Phillips RW, Lund MR. Text­book of Operative Dentistry. Philadelphia: WB Saunders; 1981.pp.295-8. 2. Black CV. Operative Dentistry, 5th Edn. Chicago: Medico-Dental Publishing Co. 1922;2:262-3. 3. Curzon MEJ, Roberts JF, Kennedy DB. Kennedy’s Paediatric Operative Dentistry, 4th Edn.pp.32-3. 4. Smales RJ, Yip HK. The Atraumatic restorative treatment (ART) approach for the management dental caries. Quintessence Int. 2002;33(6):407-32. 5. Smales RJ, Yip HK. The Atraumatic restorative treatment (ART) approach for primary teeth: Review of literature. Pediatr Dent. 2000;22(4):294-8. 6. Taft J. A Practical Treatise on Operative Dentistry, 4th Edn. London: T Ruber. 1883.pp.118-23. 7. TascÓn J. Atraumatic restorative treatment to control dental caries: history, characteristics, and contributions of the technique. Rev Panam Salud Publica. 2005;17(2):110-5.

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Chapter

Stainless Steel Crowns in Pediatric Dentistry Nikhil Marwah, Ravichandra KS, Ravi GR

Chapter outline • • • •

Indications of Stainless Steel Crowns Contraindications for Stainless Steel Crowns Classification of Stainless Steel Crowns Composition of Stainless Steel Crowns

Rehabilitation of grossly lost tooth structure in primary/young perma­ nent teeth by means of stainless steel crowns (SS crowns) has become a viable assistance to pediatric dentist ever since Rocky mountain company introduced them in 1947 but familiarized by Humphrey and Engel in 1950s.1-3 The initial crown preparation as suggested by Mink and Bennett4 is still being used. Other techniques frequently quoted in the literature include the simplified ones presented by Rapp and Castaldi5 but none have been as comprehensive and successful as Mink’s technique. Stainless steel crowns (SSC) can be defined as prefabricated crown forms that are adapted to individual teeth and cemented with a biocompatible luting agent.6 The distinctive anatomical characteristics of primary teeth, petite life span of primary teeth in the oral cavity, short attention span of the child, prolonged duration and intricate treatment planning involved in preparation of Willets inlay/cast crown restorations favors SS crowns as an alternative in pediatric dentistry. This chapter will attempt to make a comprehensive review of the SS crowns.

• • • •

Biological Approach or Hall Technique for Placement of Stainless Steel Crowns Conventional Approach for Placement of Stainless Steel Crowns Clinical Modifications of Stainless Steel Crowns Complications Associated with SSC

INDICATIONS OF STAINLESS STEEL CROWNS • Extensive caries: If the caries is involving three or more surfaces this leads to insufficient tooth structure to hold a restoration and in such cases crown proves to be more cost effective and prevents further damage. • Extensive decalcification: On any one surface like proximal is also an indication as it might lead to space loss at a later stage. • Rampant caries: In such cases there is need for multiple restorations on a single tooth so it is much cost effective and much less traumatic to place a stainless steel crown on the tooth. • Recurrent caries: Placement of crown will also help in removing the possibility of recurrent caries around existing restoration. • After pulp therapy: Following pulp therapy the tooth structure is weakened due to removal of dentin. Such teeth are prone to fractures and hence crown coverage is mandatory to avoid it. • Inherited or acquired enamel defects, e.g. hypoplasia, amelogenesis imperfecta (permanent and primary teeth): Such patients have a tendency to fracture teeth while

Chapter 48  Stainless Steel Crowns in Pediatric Dentistry

•

•

•

• •

normal eating practices along with the common associated pain. It is imperative to provide crown for these patients to avoid pain and fracture and also restore the vertical dimension. Intermediate restoration: In children with class 2 division 1 malocclusion with hypoplastic or carious molar, this can be planned till eruption of premolar and 2nd molars. Fractures of permanent and primary incisors: If an incisor is fractured, crowns in anterior teeth can be given as a temporary dressing to cover the exposed dentin. Severe bruxism: When teeth show extreme wear and tear owing to bruxism crown is a good restorative choice. This is because stainless steel crown can neither wear down nor fracture and at the same time restore lost vertical dimension. Abutment teeth to prosthesis: These are useful extra coronal restorations in abutment teeth to removable prosthesis. As part of a space maintainer: Crowns can be a part of crown and loop or crown band and loop space maintainer.

CONTRAINDICATIONS FOR STAINLESS STEEL CROWNS • • • • •

Primary molars close to exfoliation. Primary molars with more than half the roots resorbed. Teeth that exhibit mobility. Teeth which are not restorable. Patients with known nickel allergy.

CLASSIFICATION OF STAINLESS STEEL CROWNS According to Untrimmed crowns: These crowns are trimming neither trimmed nor contoured and (Figs 48.1A to C) require lot of adaptation, thus are time consuming, e.g. The Rocky Mountains. Pretrimmed crowns: These crowns have straight, noncontoured sides but are festooned to follow at line parallel to the gingival crest. They still require contouring

A

B

and some trimming, e.g. Unitek, 3M Co. and Denovo crowns. Precontoured crowns: These crowns are festooned and are also precontoured though a minimal amount of festooning and trimming may be necessary, e.g. Ni-Chro Ion crowns and Unitek stainless steel crowns, 3M Co. Stainless steel crowns—18-8 Austenitic stainless steel (67% iron, 18% chromium, 8% nickel), e.g. Unitek stainless steel crowns, 3M Co. Nickel-chromium crowns—Nickel chrome Alloy (70% nickel,15% chromium,10% iron) e.g. Ni-Chro Ion crowns, Iconel. Crowns for posterior teeth, e.g. Unitek stainless steel crowns, 3M Co.



According to composition (Figs 48.2 A and B)

According to position (Figs 48.3 A and B) Crowns for anterior teeth, e.g. NuSmile crowns, Orthodontic Technologies, USA7 According The Rocky Mountains to company Unitek 3M Iconel NuSmile crowns According to Ion—compact occlusal anatomy occlusal Unitek—best occlusal anatomy anatomy Rocky Mountains—occlusally small Ormco—smallest and least occlusally carved.

COMPOSITION OF STAINLESS STEEL CROWNS

Stainless Steel Crowns – (18-8 crowns) • Stainless steel are low-carbon alloy steels that contain at least 11.5 percent chromium.

C

Figs 48.1A to C: Crowns according to the trim

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Nickel-base Crowns

A

B Figs 48.2A and B: Crowns according to the composition

• These are Ion crowns constructed of Iconel 600, a relatively new addition to the category of preformed crowns, and is primarily nickel-chromium. • The metallurgic characteristics of the nickel-chromium alloy permit these crowns to be strain hardened during manufacture. Higher hardness renders the Ion crown more difficult to contour and adapt to the prepared tooth.

Composition

A

B Figs 48.3A and B: Crowns according to the location



Nickel Chromium Iron Carbon Manganese Silicon

– – – – – –

76% 15% 8% 0.08% 0.35% 0.2%

Composition

Iron

–

67%



Chromium

–

17 to 19%



Nickel

–

10 to 13%



Minor elements

–

4%

• There are three general classes of stainless steel: The heat hardenable 400 series martensitic types; the non-heat hardenable 400 series ferrite types; the austenitic types of chromium nickel-manganese 200 series and chromium nickel 300 series. • The austenitic types have high ductility, low yield strength, and high ultimate strength, which make them outstanding for deep drawing and forming procedures. They are readily welded and can be work hardened to high levels. • The austenitic types provide the best corrosion resistance of all of the stainless steels, particularly when they have been annealed to dissolve chromium carbides and then rapidly quenched to retain the carbon in solution. • Chromium contributes to the formation of a very thin surface film, probably oxide that protects against corrosive attack. • The Rocky Mountains, Unitek and 3M stainless steel crowns use the austenitic types for their crowns referred to as 18-8 since they contain about 18 percent chromium and 8 percent nickel.

BIOLOGICAL APPROACH OR HALL TECHNIQUE FOR PLACEMENT OF STAINLESS STEEL CROWNS This method of stainless steel crowns is based on biologic or minimal cutting approach and was named after Dr Norna Hall, a general dental practitioner from Scotland who developed and used the technique with good success.8

Advantages • • • • •

Quick and noninvasive. No tooth preparation is needed. No need for caries removal. No need for local anesthesia and rubber dam. Acceptable to dentist, parent and child.

Disadvantages • Untreated caries may cause pulp pathology. • Difficulty in retreatment. • It is a supplement to conventional technique but not a substitute.

Indications • Class I—noncavitated lesion where in the child is unable to accept fissure sealant.

Chapter 48  Stainless Steel Crowns in Pediatric Dentistry • Class I—cavitated lesion where in the child is unable to accept caries removal or conventional restoration. • Class II—cavitated or noncavitated lesions.

Contraindications • • • •

Signs or symptoms of irreversible pulpitis. Clinical or radiographic signs of pulp exposure. Unrestorable crowns. Patient at risk for bacterial endocarditis.

Technique The placement of separators is mandatory for placement of stainless steel crowns using this technique. The six stages of crown placement9 are: (Figs 48.4A to F). 1. Size: The smallest crown that covers all the surfaces is selected. 2. Fill: Dry the crown and fill with glass ionomer cement. 3. Locate and seat: Seat the crown by using finger pressure and ask the child to bite on it. 4. Wipe: Excess cement has to be wiped off with a cotton wool roll. 5. Seat further: Ask the child to bite on the crown firmly for 2 to 3 minutes. 6. Clean: Remove excess cement by means of a scaler and floss the contacts.

CONVENTIONAL APPROACH FOR PLACEMENT OF STAINLESS STEEL CROWNS This is the most followed up approach for placement of stainless steel crowns which requires both tooth and crown reduction.

Armamentarium (Figs 48.5A and B) • Crown cutting burs—pear shaped, tapering fissure, needle shaped, smoothening burs • Pliers—Hoe pliers, No. 114 Johnson contouring pliers, No. 417 Crimping pliers, No. 112 Ball and Socket pliers • Scaler or any sharp instrument • Crown and bridge scissors • Crown seater and remover • Stone and finishing burs for crown finishing • For cementation—luting cement, glass slab, spatula • Miscellaneous—articulating paper, wax sheet, glass marking pencil.

Evaluation of Preoperative Occlusion • The objective is to replicate the existing occlusion after the SS crown placement.

• Dental midline and cusp-fossa relationships bilaterally must be assessed. • Before starting the tooth preparation we should evaluate the occlusion by visual examination and transfer this relation on to the wax sheet by asking the patient to bite on it.

Crown Selection • The main considerations in selecting the proper stainless steel crown are adequate mesiodistal diameter, light resistance to seating, and proper occlusal height. • A crown should be somewhat larger than the tooth to which it is being adapted, especially when the gingival part of the crown is trimmed and crimped. The goal is to select the smallest crown that completely covers the preparation and establish proper proximal contacts. • Any of the following three different methods can be used for crown selection with predictable success: 1. Trial and error method by arbitrarily selecting different sizes. 2. Measuring the internal mesiodistal measurement by using a boley gauge or venire calipers (Fig. 48.6). 3. By using charts (Table 48.1). • Pick the crown with the help of sterile tweezers or thumb forceps.

Occlusal Reduction Start the occlusal reduction with pear shaped bur. Reduce the occlusion by about 1.0 to 1.5 mm uniformly along the cuspal structure so as to create a reduced tooth but the same occlusal anatomy. The reduction is determined by comparing the marginal ridges of adjacent teeth (Figs 48.7A and B).

Proximal Reduction • The proximal reduction is done with the help of tapering fissure and needle burs with the main objective of breaking the contact. • Slice the mesial and distal surfaces with needle shaped bur and then break the contact between the teeth with tapering fissure (No. 169L) bur. Hold the bur slightly at an angle to the long axis of the tooth and extend the slice to the buccal and lingual line angles giving 2 to 5° taper (Figs 48.8A and B). The objective is to produce near vertical reduction with the gingival margin of the preparation to be a feather (knife) edge without any shoulder or ledge. Excessive taper may reduce retention while a shoulder or ledge may pose difficulty in seating the crown (Myers, 1976).10 • Avoid bur damage or marks on adjacent teeth. Some other methods of prevention of damage to adjacent teeth

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A

B

C

D

E

F Figs 48.4A to F: Procedure for placement of SSC using Hall technique given by Nicola Innes and Dafydd Evans (The Hall technique manual)9

Chapter 48  Stainless Steel Crowns in Pediatric Dentistry

A

B Figs 48.5A and B: Armamentarium for SSC

TABLE 48.1: Stainless steel crown dimensions

Fig. 48.6: Measuring of crown diameter

include cutting with safe sided discs, use of separators or wedges.

Buccal/Lingual Reduction • Although stainless steel crowns require no reduction on the buccal or lingual aspect but some authors feel that it is needed due to the space usage. • Tongue is very critical to anything extra near it, even a small piece of food on the lingual aspect will trouble tongue and it will keep on touching it till it gets dislodged. So even if we place a well finished 0.05 mm worth of crown structure in the lingual aspect without cutting it will be perceived by the tongue as extra and it will hence act to dislodge it. It is therefore necessary according

Tooth diameter

Mesiodistal (mm)

Labiolingual diameter (mm)

Occlusocervical length (mm)

D3

8.1

6.6

5.0

D4

8.5

6.9

5.4

D5

8.9

7.2

5.6

D6

9.2

7.7

6.0

E3

9.7

8.8

6.0

E4

10.1

9.1

6.3

E5

10.6

9.6

6.6

E6

11.0

10.0

6.9

D3

6.9

7.6

5.2

D4

7.3

8.0

5.4

D5

7.8

8.4

5.9

D6

8.3

8.7

6.1

E3

9.3

10.0

6.0

E4

9.6

10.3

6.3

E5

10.0

10.8

6.5

E6

10.4

11.0

6.8

to these authors to reduce at least 0.5 mm buccal and lingual surface also. • The buccal and lingual preparation is confined to occlusal one-third only by mesiodistal strokes using the taper fissure bur at a 30 to 45 degree angle to the occlusal surface. Natural undercuts on the buccal and lingual surfaces are retained in this way which aid in the retention of the crown.

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A

A

B

B Figs 48.7A and B: Occlusal reduction

• In some cases particularly 1st primary molar, it is desirable to reduce the buccal bulge when it interferes with crown seating. • However, further research is needed on this aspect and as of now no lingual or buccal reduction is followed.

Finishing • Reduce and round off all line angles and sharp corners of the preparation with the help of finishing burs. • The occlusal as well as the proximal aspect must be rounded of but with utmost care so as to avoid any further reduction. • Verify the occlusion and proximal contacts (Figs 48.9A and B). There should be a gap of 1 to 1.5 mm between the prepared tooth and the opposing tooth during occlusion. This is verified by asking the patient to bite on the wax block and no marking of the prepared tooth should be observed. Verify the proximal cutting by passing a

Figs 48.8A and B: Proximal reduction

thin probe onto the mesial and distal sides and feel for ledges.

Crown Attachment • This is the most critical step in usage of stainless steel crown by pedodontists so as to prevent any type of injury to child like accidental injection or inhalation of crown due to slippage. • This can be achieved by: – Soldering a hook on the lingual aspect of crown to which floss is tied – Soldering a lingual attachment to which floss is tied – Attachment of floss to crown structures on the buccal aspect by special glues. This is the best method as it provides no interference during crown manipulation.

Chapter 48  Stainless Steel Crowns in Pediatric Dentistry

A

B Figs 48.9A and B: Finished crown preparation

Fig. 48.10: Method for crown fit

Crown Adaptation • If rubber dam is being used then it is necessary to remove it at this stage. • Festooning of the proximal surface should be performed before trying the crown as it will facilitate in ease of placement and will limit false blanching signs. The buccal and lingual gingiva around second primary molars and the lingual marginal gingiva of first primary molars resemble smile (∪) while the buccal marginal gingiva mimic S shape that looks stretched (∼). The proximal contours of all the primary molars look like frown (∩). The gingival margins of the trimmed crowns must correspond to their respective gingival margins of the tooth. • Place the crown on the lingual side and rotate it towards the buccal side (Fig. 48.10).

Fig. 48.11: Trimming of excess crown

• The crown should fit loosely, with 2 to 3 mm excess gingivally. With a scaler, scratch around the gingival margin on the crown or mark with a glass marking pencil. This scratch line indicates the gingival line and the gingival contour, as well as the portion of the crown to be removed. • Remove the crown from the prepared tooth, exposing the scratch line. With the help of crown and bridge scissors, cut the crown 1 mm below the scratch line (Fig. 48.11). • Now smoothen the edges with finishing burs (Fig. 48.12). Retry the crown on the tooth. If there is blanching of the gingiva, it may be necessary to rescribe the crown and retrim it. Trim only in the areas where blanching is visible. • Check the gingival extent of crown with the help of probe; it should not be more than 1mm on buccal aspect and 0.5 mm on the lingual side (Fig. 48.13). Spedding11

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Fig. 48.12: Finishing of crown

Fig. 48.13: Check for crown excess

described two principles pertaining to length and gingival margins of the crowns for better adaptation of the crowns to the teeth. The goal is to extend the crown 1 mm beneath the free margin of the gingival sulcus and to approximate the gingival margins of the crown to the gingival crest around the tooth. The subgingival placement of crown margin is justified since for primary teeth the buccal, lingual and proximal contours are just above the gingival crest and the objective is to engage the crown in natural undercuts.

Contouring • The next step in adaptation is to contour the crown with pliers so as to reciprocate the original contour of the tooth. • Most of the crowns provided today are precontoured but minimal contouring aids in better anatomy hence better retention and its obvious advantages. • Contouring is done with the help of No. 114 Johnson contouring pliers. A ball and socket pliers is used to contour the buccal and lingual surfaces by holding the crown firmly with the pliers and force is exerted from the opposite side of the crown to bend the gingival one-third of the crown inward (Fig. 48.14). • The advantage of contouring is that the crown gets work hardened by manipulation and becomes more retentive.

Fig. 48.14: Contouring the crown

Crimping of the Crown • This is very important to the gingival health of the supporting tissue as a poorly adapted crown will serve as a collection point for bacteria, contributing to recurrent caries or incipient periodontal disease. • Using the No. 417 Crimping pliers the crown is crimped in the gingival third. • The procedure of crimping is that the pliers must be ‘walked’ through the entire crown continuously without

Fig. 48.15: Crimping the crown

lifting. After completion of crimping there will be a gradual bend in the gingival third of crown (Fig. 48.15).

Chapter 48  Stainless Steel Crowns in Pediatric Dentistry • The uses of crimping are protection of soft tissues, prevention of leakage of cements, prevention of contami­ nation and adequate retention.

Checking the Final Fit • After the contouring and crimping is complete retry the crown and with an explorer, check all the margins for adaptation (Figs 48.16A and B). • Seat the crown in a lingual to buccal direction and it should snap into position under firm finger pressure. • The quality of retention of crown is directly dependent on its snugly fit into the tooth. • This is the best time to evaluate occlusal harmony and compare it with preoperative occlusion. • After final adaptation check for any destabilization or rocking of crown by pressing an explorer on the occlusal aspect to apply load. • Critical evaluation of blanching all around the tooth structure must be done and a precementation radiograph must be taken at this stage.

Crown Finishing • The finishing of the margins of the crown form is done using a green stone held at angle to the margin. • A slow speed handpiece will give better and produce a sharp featheredge margin that can be closely adapted to the prepared tooth at the gingival margin. • Crown is then smoothened with finishing burs and polished with rubber wheel or rouge.

Crown Cementation • Remove, clean and dry the crown as well as the tooth surface. Isolate with cotton and instruct the patient not to close the mouth. • Myers (1983) has advocated the application of varnish before cementing crown especially in case of a vital tooth to prevent any postoperative sensitivity due to exposed tubules. • Mix the luting cement and load onto the crown with the help of nonsticky instruments. At least 2/3rd of the crown must be filled with the luting consistency of cement (Fig. 48.17). • The commonly used cements are—zinc phosphate, zinc oxide eugenol, reinforced zinc oxide eugenol, polycarboxylate and glass ionomer cements. • Seat the crown, usually first on the lingual side and then the buccal side at the same time supporting the child’s mandible with one hand as you seat the crown. Ask the patient to bite slowly so as to seat the crown completely in accurate position. • Remove excess cement with a scaler or explorer after it has set and gently but firmly check all the areas of the gingival sulcus for retained cement (Fig. 48.18).

A

B Figs 48.16A and B: Final fit of SSC

Fig. 48.17: Loading of crown for cementation

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Fig. 48.19: Two adjacent crowns Fig. 48.18: Removal of excess cement

Polishing of SSC and Discharge of Patient • Polish the crown with acidulated phosphate fluoride prophylaxis paste prior to discharging the patient. • It is best to evaluate the occlusion and fit again at this stage. • After the cement sets it is advisable to move a waxed floss in the inter-proximal aspect to check for any excess cement as it may cause irritation and inflammation of tissues. • A completely cleaned, shining crown is shown to the child for appreciation and positive reinforcement. Fig. 48.20: Crown with amalgam restoration

CLINICAL MODIFICATIONS OF STAINLESS STEEL CROWNS Although there are various types and sizes of crowns available but there are some instances where some modifications are the only available options. Some of those conditions are:

Adjacent Stainless Steel Crowns • Nash13 described additional reduction of adjacent proximal surfaces of teeth when adjacent teeth are to be restored with SS crowns simultaneously. • When more than one stainless steel crown needs to be done in a quadrant then one crown is finished and cemented before proceeding to next one because if both are prepared at one time it might lead to encroachment of space for either one of them (Fig. 48.19). • When a stainless steel crown and a class II amalgam restoration are to be done at one appointment then the crown is finished first and then the restoration is done. After the crown is cemented, clean the excess cement from

and around the crown. Adapt and wedge a matrix band and now insert an amalgam restoration. The stainless steel crown is used as guide in reproducing the anatomy and morphology of the silver amalgam restoration (Fig. 48.20).

Adjacent Stainless Steel Crowns with Arch Length Loss • Extensive and long-standing carious lesions can cause a shift of primary teeth into the interproximal contact areas. With this mesiodistal dimension loss, it is very difficult to restore the lost arch length. • Usually crowns will adjust to the tooth preparation individually but cannot be placed at the same time because of the mesial drift of the adjacent teeth. The crown preparations must be reduced further. Now flatten the contacts of the crowns by using the Hoe pliers (Fig. 48.21).

Chapter 48  Stainless Steel Crowns in Pediatric Dentistry • Myers10 suggested modifications of SS crowns in case of arch length loss where he told that more than usual reduction in the tooth to be crowned can be done so as to enable the crown to fit into the available mesiodistal space.

Undersized crown

Fig. 48.21: Manipulation of crowns in arch length loss

Oversized/Undersized Crown Mink and Hill12 described modification of crowns for smaller or larger teeth. A larger crown can be altered by cutting the edges, overlapping and welding them to reduce the crown circumference so as to fit a smaller tooth (Fig. 48.22). Similarly, the circumference of a smaller crown can be increased to fit a larger tooth by cutting the edges and welding an additional piece of orthodontic band material (Fig. 48.23). Oversized crown

Fig. 48.23: Undersized crown

Crown extension for deep proximal lesions

Other Suggested Modifications

Fig. 48.22: Oversized crown

• Hartman13 advocated esthetic modification of stainless steel crown by cutting away the labial metal, leaving a labial window that is restored with composite resin. This restoration is called open-face stainless steel crown. • McEvoy14 recommended additional tooth reductions in space lost quadrants. • Croll15 described a technique of increasing the occlusal thickness of crown to compensate for the wear in children with grinding habits.

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598 Section 9 

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Disadvantages of Stainless Steel Crowns

Consideration for successful use of SSC •

Removal of caries, and where needed, appropriate pulpal therapy.

•

Optimum reduction of tooth structure for adequate crown retention.

•

Lack of damage to adjacent teeth after opening interproximal contacts.

•

Selection of appropriately sized crown to maintain arch length.

•

Accurate marginal adaptation and gingival health.

•

Good functional occlusion.

•

Optimum cementation procedure.

Research pertaining to use of SSC •

A comparative review by Randall16 encompassing 5 clinical studies on the performance of stainless steel crowns with that of multi-surface amalgam restorations concluded that the crowns were superior to multi-surface amalgam restorations.

•

Seale17 compiled scientific evidence favoring the stainless steel crowns as restorations of choice in children with high-risk for caries.

•

Rector18 Noffsinger19 confirmed that the cement retention of the crown is critical than mechanical retention. However, clinical studies are not available to determine the differences, if any, between various types of cement as well as types of preparation.

Advantages of Stainless Steel Crown • • • • • • • • • •

Can be completed in a single appointment. Less time consuming than cast restorations. No need for laboratory procedures. Less sensitive to moisture. Less prone to fractures. Longevity. Durable as compared to multi-surface restorations Cost effective. Premature contacts are well tolerated by the child. Comfortable to the patient.

• • • • •

Significant amount of tooth structure is removed. Unesthetic. Poor marginal adaptation may cause gingivitis. Gingival inflammation due to excess unremoved cement. Overhanging distal margins may cause impaction of permanent 1st molars.

COMPLICATIONS ASSOCIATED WITH SSC • Interproximal ledge: A ledge will be produced instead of a shoulder free interproximal slice if the angulation of the tapered fissure bur is incorrect. Failure to remove this ledge will result in difficulty in seating the crown. • Crown tilt: This is seen if complete lingual or buccal wall is destructed by caries or improper use of cutting instrument. The disadvantage of this is that supraeruption of the opposing tooth may occur. • Poor margins: When the crown is poorly adapted, its marginal integrity is reduced. This can lead to recurrent caries, plaque accumulation and subsequent gingivitis. • Inhalation or ingestion of crown: This may happen because of slippage from hand or by jerky reaction of patient. Some methods of prevention are use of rubber dam, upright seating of the patient while doing adaptation or by soldering a hook onto the buccal surface of crown and attaching long floss with it. If this occurs, attempt can be made to remove the crown by holding the child upside down as soon as possible. If this is unsuccessful, medical referral should be done for an immediate chest X-ray to verify if the crown is in lungs or in alimentary tract. Stainless steel crowns are an excellent option for restoring primary and young permanent teeth and are to be considered whenever possible since their advantage over conventional restorations is proven without qualm. Conventional approach of crown placement is a better option for pediatric dentist where as Hall technique may be appropriate for general dental practitioner or by a pediatric dentist in case of special circumstances. Since, cement retention is very critical, GIC is preferred over zinc phosphate luting cement because of its adhesive and anticariogenic properties.

Chapter 48  Stainless Steel Crowns in Pediatric Dentistry Summary of crown placement procedure (Fig. 48.24)

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600 Section 9 

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Fig. 48.24: Stepwise stainless steel crowns preparation

Chapter 48  Stainless Steel Crowns in Pediatric Dentistry

POINTS TO REMEMBER • Stainless steel crowns can be defined as prefabricated crown forms that are adapted to individual teeth and cemented with a biocompatible luting agent. • Humphrey was the one who popularized SSC. • Mink and Bennett gave the method of tooth and crown preparation for SSC. • Indications of SSC include extensive caries, rampant caries, after pulp therapy, acquired enamel defects, intermediate restoration, fractures of permanent and primary incisors, severe bruxism, abutment teeth to prosthesis and as part of a space maintainer. • Stainless steel crowns can be divided according to trimming, composition, company, position and occlusal anatomy. • Untrimmed crowns are neither trimmed nor contoured e.g. The Rocky Mountains; pretrimmed crowns are noncontoured but are festooned, e.g. 3M; precontoured crowns are festooned and precontoured, e.g. Ni-Chro Ion crowns. • Hall method of stainless steel crowns placement is based on no cutting approach and was named after Dr Norna Hall. It is mainly indicated in Class I noncavitated lesion where in the child is unable to accept fissure sealant. It involves selection of smallest crown that covers all the surfaces and its directly fitting it onto the tooth without any tooth or crown preparation. • Convention procedure for placement of SSC involves occlusal reduction, proximal reduction, finishing and rounding of all sharp margins, trimming of crown, festooning, contouring, crimping and cementation. • Occlusal reduction is done with pear shaped bur and about 1.0 to 1.5 mm reduction is done uniformly along the cuspal structure. • Proximal reduction is done to create a 2 to 5° taper and break contact. • Contouring is done with the help of No. 114 Johnson contouring pliers. • Crimping is done using the No. 417 crimping pliers wherein the crown is crimped in the gingival third. The uses of crimping are protection of soft tissues, prevention of leakage of cements, prevention of contamination and adequate retention. • Complications of SSC are interproximal ledge formation, crown tilt, poor margins, inhalation or ingestion of crown.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Give the indication, and classification of stainless steel crown. What is Hall’s approach for placement of stainless steel crown? Describe in detail the procedure of stainless steel crown placement. How is crimping accomplished and what are its uses? Explain the modifications of stainless steel crown. What are the complications associated with stainless steel crown?

REFERENCES 1. Pokorney RL. Stainless steel preformed crowns. Rev Dent Lib. 1965;15(4):20-6.

2. Humphrey WP. Use of chromic steel in children’s dentistry. Dent Surv. 1950;26:945-7. 3. Engel RJ. Chrome steel as used in children’s dentistry. Chron Omaha District Dent Soc. 1950;13:255-8. 4. Mink JR, Bennett IC. The stainless steel crown. J Dent Child. 1968;35:186. 5. Rapp R. A simplified yet precise technique for the placement of stainless steel crowns on primary teeth. J Dent Child. 1966;33:101. 6. Academy of Pediatric Dentistry. Special issue. Reference Manual. 21(5):105. 7. Fuks AB, Ram D, Eidelman E. Clinical performance of esthetic posterior crowns in Primary molars: a pilot study. Ped Dent. 1999;2:445-8. 8. Innes NPT, Stirrups DR, Evans DJP, Hall N, Leggate M. A novel technique using preformed metal crowns for managing carious primary molars in general practice – A retrospective analysis. British Dent J. 2006;200(8):451-4. 9. The Hall Technique Manual Scottish Dental.www.scottishdental.org/index. 10. Myers DR. The restoration of primary molars with stainless steel crown. J Dent Child. 1976;43(6):406-9. 11. Spedding RH. Two principles for improving the adaptation of stainless steel crowns to primary molars. Dent Clin North Am. 1984;28(1):157-75. 12. Mink JR, Hill CJ. Modifications of stainless steel crown for primary teeth. J Dent Child. 1971;38(3):197-205. 13. Hartmann CR. The open-face stainless steel crown: an esthetic technique. J Dent Child. 1983;50(1):31-3.

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14. McEvoy SA. Approximating stainless steel crowns in space-loss quadrants. J Dent Child. 1977;44(2):105-7. 15. Croll TP. Increasing occlusal surface thickness of stainless steel crowns: A clinical technique. Pediatr Dent. 1982;2(4):297-9. 16. Randall RC. Preformed metal crowns for primary and permanent molar teeth: review of the literature. Pediatric Dent. 2002;24:489-500. 17. Seale NS. The use of stainless steel crowns. Pediatr Dent. 2002;24:501-5. 18. Rector JA, Mitchell RJ, Spedding RH. The influence of tooth preparation and crown manipulation on the mechanical retention of SS crowns. J Dent Child. 1985;52(6):422-7. 19. Noffsinger DP, Jedrychowski JR, Caputo AA. Effect of polycarboxylate and glassionomer cements on stainless steel crown retention. J Pediatr Dent. 1983;5(1):68-71.

BIBLIOGRAPHY

1. Clemens A, Walkar D, Pinkham JR. Stainless steel crown for deciduous molars. JADA. 1974;89:360-4. 2. Full CA, et al. Stainless steel crowns for deciduous molars. J Am Dent Assoc. 1974;89:360. 3. Goldberg NL. The stainless steel crowns in pediatric dentistry. Dent Dig. 1969;75:352. 4. Helm HW. Simplified procedure for stainless steel crowns in pedodontics. J Can Dent Assoc. 1963;29:369. 5. Henderson HZ. Evaluation of the preformed stainless steel crown. J Dent Child. 1973;40(5):353-8. 6. Kennedy DB. The stainless steel crown. In Kennedy DB (Ed): Pediatric Operative Dentistry, Bristol. J Wright and Sons Ltd; 1976. 7. Troutman KC, Reisbick MH. Steel crowns. In: Stewart RE, Barber TK, Troutman KC, Wei SHY (Eds). Pediatric Dentistry: Scientific Foundations and Clinical Practice, CV Mosby co., St. Louis; 1982. 8. Wei SHY. Stainless steel crowns. Pediatric dentistry: total patient care, Leas and Febiger, Philadelphia; 1988.

49

Chapter

Anterior Crowns in Pediatric Dentistry Ravichandra KS, Ravi GR, Nikhil Marwah

Chapter outline • • •

Anterior Stainless Steel Crowns Preveneered Stainless Steel Crowns Bonded Crowns

The healthy oral cavity is a primary requisite for beautiful looks. Despite the fact that it is largely preventable, dental caries is the most common chronic disease of childhood. Clinical examination of ECC discloses a distinctive pattern, and the teeth most often involved are the maxillary central incisors, lateral incisors, and the maxillary and mandibular 1st primary molars. The maxillary primary incisors are the most severely affected with deep carious lesions usually involving the pulp. In extreme cases, early childhood caries can even lead to total loss of the crown structure. The early loss of primary anterior teeth may result in reduced masticatory efficiency, loss of vertical dimension, development of parafunctional habits (tongue thrusting, speech problems), esthetic-functional problems such as malocclusion and space loss, and psychologic problems that can interfere in the personality and behavioral development of the child. In addition trauma to primary anterior teeth can result in displacement injuries such as luxation, uncomplicated or complicated crown fractures or discoloration of teeth. In any of these clinical situations parents often seek for esthetic rehabilitation of the primary teeth of their children. Esthetic requirement of severely mutilated primary anterior teeth in the case of early childhood caries has been challenge to pediatric dentist. In the last half century, the emphasis on treatment of extensively decayed primary teeth shifted from extraction to restoration. Early restorations consisted of placement of stainless steel bands or crowns on severely decayed teeth. While functional, they were unesthetic and their use was limited to posterior teeth. Over

• • •

Strip Crowns Shell Crowns Recent Developments for Anterior Crowns in Pediatric Dentistry

the last two decades there has been an explosive interest by adults in esthetic restoration of their compromised dentition. Similarly, a higher esthetic standard is expected by parents for restoration of their children’s carious teeth. Thus the choice of full coverage restorations for primary teeth must provide an esthetic appearance in addition to restoring function and durability. This chapter highlights the different materials and the various means of approach in restoring anterior teeth. Among restorative treatment options, biological and resin composite restoration either by means of direct or indirect technique and prefabricated crown are mentioned in the literature. Severely decayed primary teeth in anterior region may not be able to withstand occlusal forces if restored with conventional cements. Therefore, the use of full coverage anterior crowns in such cases is more cost effective and a viable option. These can either be polycarbonate crowns, strip crowns, veneered stainless steel crowns (NuSmile crowns), Artglass crowns, Zirconia crowns (Cheng crowns, Kinder krowns).

ANTERIOR STAINLESS STEEL CROWNS • Stainless steel crowns are considered to be the most durable, economical and reliable for restoring severely carious and fractured primary incisors. • They are easy to place, fracture proof, wear resistant and attached firmly to tooth until exfoliation. • However, there is a compromise in esthetics due to the unsightly silver metallic appearance (Fig. 49.1).

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• The disadvantage of these crowns is that they are not easily removed.

Technique (Figs 49.2A to I)

Fig. 49.1: Anterior stainless steel crowns

Facial Cut Out Stainless Steel Crowns • These are indicated in maxillary canines where strength is a major requirement as compared to esthetics. • The labial portion of anterior stainless steel crown is removed and composite is placed in the labial fenestration of stainless steel crown (SSC) as a facing thereby providing adequate strength and acceptable esthetics. • Although there is an improvement in the appearance, the technique is time consuming and metal margins are still visible.

Chapter 49  Anterior Crowns in Pediatric Dentistry

A

B

C

D

E

F

G

H

I

Figs 49.2A to I: Placement of SSC with composite facing: (A) Remove decay with slow speed handpiece; (B) After restoration or RCT reduce the facial surface by 1 mm and lingual by 0.5 mm creating a feather edge gingival margin; (C) Try the crown; (D) Trim the crown for fit; (E) Contour and crimp the crown for snug fit; (F) Cement the crowns; (G) Cut a facial window; (H) Trim and Smoothen the edges; (I) Restore with composite facing (with permission from Steven Schwartz Full Coverage Aesthetic Restoration of Anterior Primary Teeth Crest® Oral-B® at dentalcare.com Continuing Education Course, January 9, 2012)

PREVENEERED STAINLESS STEEL CROWNS • In these crowns the composite resins and thermoplastics are bonded to the metal.

A

B

E

• This type of preveneered crown was developed to serve as a convenient, durable, reliable, and esthetic solution to the difficult challenge of restoring severely carious primary incisors (Figs 49.3A to G).

D

C

F

G

Figs 49.3A to G: Placement of preveneered SSC: (A) Select the crown; (B) Prepare the tooth; (C) Refine the prep; (D) Trim the crown; (E) Crimp the crown; (F) Cement the crown; (G) Cemented crowns in place (with permission from Steven Schwartz Full Coverage Aesthetic Restoration of Anterior Primary Teeth Crest® Oral-B® at dentalcare.com Continuing Education Course, January 9, 2012)

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• Various commercially available veneered SSCs include Cheng crowns, Kinder krowns, NuSmile and Whiter biter, pedo compu crowns and Dura crowns. • The drawbacks of these types of crowns are limited crimpability as crimping of the metal portion will weaken the esthetic facing and may lead to premature failure; requires more aggressive tooth reduction; the shape of the preveneered stainless steel crowns (PVSSC) is not alterable. • The advantages are esthetics, full coverage, ease to place and satisfaction for the child and parent.

• Study has shown that these crowns with veneer facings were significantly more retentive than the nonveneered ones when cement and crimping were combined.

Cheng Crowns • Cheng crowns (Fig. 49.4) made their public debut in 1987. • These are stainless steel pediatric anterior crowns faced with a high quality composite, mesh-based with a light cured composite. It presents a unique solution for natural looking stain resistant crowns. • It is available for the right and left central and lateral as well as cuspids. It is available in short and regular lengths and sizes suitable for centrals, lateral and cuspids. • Most crown procedures can be completed in one patient visit and with less patient discomfort. • They can undergo heat sterilization without significant effect on their bond strength and color. • Disadvantages of all preveneered crowns are fracture of veneers during crimping and they are expensive.

Fig. 49.5: Dura crowns

Kinder Krowns™ • Kinder Krowns offer the most natural shades and contour available for the pediatric patient (Fig. 49.6). • The great depth and vitality from the lifelike composite reveal a natural smile without the bulky “Chiclet” look of other restorations. • They come in 2 esthetically pleasing shades, Pedo 1 and Pedo 2. The Pedo 2 shade is the most natural shade while Pedo 1 shade is for those cases when the bleached white shade is wanted. • Kinder Krowns are designed with IncisaLock—the optimal union of state-of-the-art bonding procedures and mechanical retention. • By adding mechanical retention and more composite, Kinder Krowns are strong without sacrificing form or function.

Fig. 49.4: Cheng crowns

Dura Crowns • Crowns can be crimped labially and lingually, can be easily trimmed with crown scissors, easily festooned and has got a full-knife edge (Fig. 49.5).

Fig. 49.6: Kinder Krowns

Chapter 49  Anterior Crowns in Pediatric Dentistry

Pedo Pearls™ • These are beautiful heavy gauge aluminum crowns coated with US Food and Drug Administration (FDA) food grade powder coating and epoxy resin (Fig. 49.7). • They have universal anatomy and so can be used on either side. • Easy to cut and crimp, without chipping or peeling. • Composite can be added if required • Disadvantages are less durability and softer crowns.

• Advantages are that they are extremely stable dimen­ sionally and unaffected by acids, ether and alcohol. • Disadvantage is their poor abrasion resistance.

Indications • Full coverage restoration of primary maxillary anterior teeth with extensive caries • Early childhood caries • Deformities in structure of teeth • Discolored teeth.

Contraindications • Deep bite • Bruxism • High functionality of teeth.

Technique (Figs 49.9A to F)

Fig. 49.7: Pedo pearls

BONDED CROWNS

Polycarbonate Crowns • Polycarbonates are aromatic linear polyesters of carbonic acid. • They exhibit high impact strength and rigidity and are termed thermoplastic resins since they are molded as solids by heat and pressure into the desired form. • It is esthetic than SSC, easy to trim and can be adjusted with pliers (Fig. 49.8). • These crowns do not resist strong abrasive forces thus leading to occasional fracture, hence it is contraindicated in cases of severe bruxism and deep bite.

Fig. 49.8: Polycarbonate crowns

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Restorative Dentistry

A

B

C

D

E

F

Figs 49.9A to F: Placement of polycarbonate crowns: (A) Following reduction of 2 mm, try the crown; (B) Trim the crown; (C) Check for sungingival fit of crown; (D) Remove the crown for final inspection; (E) Cement crowns; (F) Final fit of crown (with permission from Steven Schwartz Full Coverage Aesthetic Restoration of Anterior Primary Teeth Crest® Oral-B® at dentalcare.com Continuing Education Course, January 9, 2012)

Modified Polycarbonate Crowns • 3M ESPE polycarbonate prefabricated crowns (Figs 49.10A to D). • The crowns are made of a polycarbonate resin incorporating microglass fibers which not only permit crown adjustment with pliers but also give these crowns good durability and strength. • They are a time saver as they are easy to trim with dental burs or crown scissors, and can then be easily adjusted with pliers • Crown composition permits crown adjustment • Provides good durability and strength • Smooth surface finish for patient comfort and to help minimize plaque build-up • They have good anatomic form and esthetics • They are manufactured in a universal shade which is translucent enough to allow shade adjustment by the type of lining material used.

STRIP CROWNS • These are celluloid crown forms that are the most effective for use in pediatric patients with extensive caries in anterior teeth. • These are commonly used crown forms filled with composite and bonded on the tooth.

A

B

C

D Figs 49.10A to D: Placement of modified polycarbonate crowns

Advantages • • • • • • • •

Easy to place and remove Less time consuming Parent/patient pleasing Ideal for ankylosed tooth build-ups Simple to fit and trim Removal is fast and easy Easily matches natural dentition Easy shade control with composite

Chapter 49  Anterior Crowns in Pediatric Dentistry • Superior esthetic quality • Large selection of size • Easy to repair.

Technique (Figs 49.12A to F)

Technique (Figs 49.11A to R)

SHELL CROWNS • A novel technique for esthetic rehabilitation of the maxillary anterior teeth with custom made composite shell crowns with an indirect approach.

• Perfection of the restoration using a silicone positioner. • Indirect approach so most of the work is done on the cast thereby reducing the chair side time.

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610 Section 9 

Restorative Dentistry

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

Figs 49.11A to R: Strip crown placement: (A) Carious anterior teeth should be anesthetized and properly isolated; (B) Size of celluloid crown form is selected by measuring mesio distal diameter of teeth; (C) Caries is removed using a small round bur in a slow speed hand-piece; (D) Teeth are then prepared using tapered diamond or tungsten carbide bur. Incisal, mesial and distal sides are prepared; (E) Celluloid crowns are trimmed using curved scissors. Care should be taken not to distort the crown form; (F) Trimmed crown forms are fitted onto prepared incisors. Length and cervical fit should be checked ; (G) Vent holes are made in the mesial and distal corners of the incisal edge to allow air and excess composite resin to escape; (H) Proper shade of composite resin is chosen; (I) Composite resin is squeezed into the crown form and hollowed in the center to reduce the excess; (J) Teeth are etched for 1 minute with a proprietary etchant, washed and dried to get frosty appearance; (K) Bonding agent is applied and curved for 15 seconds; (L) A proprietary calcium hydroxide paste or glass ionomer cement is applied to the pulpal wall of exposed dentin; (M) Excess resin is removed from the edges which makes the final finish easier; (N) Composite resin is cured for 1 minute, labially and palatally; (O) An excavator or probe is inserted beneath the edge of the celluloid and the crown form is stripped off; (P) Crown forms containing composite are firmly seated on the prepared teeth. Excess pressure should not be applied; (Q) Smooth and polish the crowns; (R) Labial view of the finished crown restoration

Chapter 49  Anterior Crowns in Pediatric Dentistry

A

B

C

D

E

F

Figs 49.12A to F: Placement of shell crowns: (A) Clinical presentation of caries; (B) Composite build-up on cast after excavation and impression; (C) Fabrication of Silicone positioner; (D) Shell crowns seated in position; (E) Cementation of crown using positioner; (F) Completely rehabilitated anterior segment with composite shell crowns [with permission from Prashant S. Indirect composite shell crown: An Esthetic Restorative Option for Mutilated Primary Anterior Teeth. Journal of Advanced Oral Research, Jan-Apr 2013;4(1)]

RECENT DEVELOPMENTS FOR ANTERIOR CROWNS IN PEDIATRIC DENTISTRY

Pedo Jacket • It is a tooth colored copolyester material which is filled with resin and left on tooth after polymerization instead of being removed. • It does not split, stain or crack. • Crowns can be easily trimmed with scissors. • Disadvantage is that only one size is available.

New Millenium • These crowns are made up of lab enhanced composite resin material or Zirconia. • No longterm studies are available regarding these crowns.

Artglass Crowns • These are the only patented, preformed crowns for pediatric usage. • Artglass contains multi­ functional methacrylate (methacrylates with multiple reaction sites); which has the ability to form threedimensional molecular networks with a highly crosslinked structure. The total filler content of Artglass is only 75 percent (55% microglass and 20% silica filler) but when the matrix is cured, the amorphous, highly cross-linked organic glass forms, which we call polymer glass which is one of the toughest materials available to dentistry. • Wear of Artglass is similar to enamel and kind to opposing dentition. • High inorganic filler, makes Artglass color stable and plaque resistant. • Matched to the Vita shade system, simplifies shade selection. • Flexural strength over 50 percent higher than porcelain, less chance of fracture. • Easily adjusted or repaired intraorally, less chair time for dentists. • Provides the esthetics and lasting qualities of porcelain. • Offers the ease and bondability of a composite.

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Restorative Dentistry

POINTS TO REMEMBER • Facial cut out stainless steel crowns are indicated in maxillary canines where strength is a major requirement as compared to esthetics. The labial portion of anterior stainless steel crown is removed and composite is placed in the labial fenestration of SSC as a facing thereby providing adequate strength and acceptable esthetics. • Preveneered SSC are crowns in which the composite resins and thermoplastics are bonded to the metal. This type of crown was developed to serve as a convenient, durable, reliable, and esthetic solution to the difficult challenge of restoring severely carious primary incisors. Various commercially available veneered SSCs include Cheng crowns, Kinder krowns, NuSmile and Whiter biter, pedo compu crowns and Dura crowns. • Polycarbonate crowns are esthetic than SSC, easy to trim and can be adjusted with pliers but they have poor abrasion resistance. • Strip crowns are celluloid crown forms that are the most effective for use in pediatric patients with extensive caries in anterior teeth. These are commonly used crown forms filled with composite and bonded on the tooth. Advantages are easy to place and remove, less time consuming, matches natural dentition, superior esthetic quality and large selection of size. • Shell crown is a novel technique for esthetic rehabilitation of the maxillary anterior teeth with custom made composite crowns with an indirect approach. • Some recent modifications of anterior crowns are Pedo Jacket (It is a tooth colored copolyester material which is filled with resin and left on tooth after polymerization instead of being removed); New Millenium (crowns are made up of lab enhanced composite resin material) and Artglass crowns. • Artglass crowns are the only patented, preformed crowns for pediatric usage. They are made up of micro glass and silica filler and have the ability to form three-dimensional molecular networks with a highly cross-linked structure. It provides esthetics of porcelain and bondability of a composite.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

What are the options for restoring primary anterior teeth? Describe stainless steel crowns for anterior teeth and their modifications. Write a note on polycarbonate crowns. Describe the indications, advantages and the technique for placement of strip crowns. What are Artglass crowns? Explain the procedure of fabrication of Shell crowns?

BIBLIOGRAPHY 1. AAPD, Reference Manual, Clinical Guidelines V 33 / No 6 11/12. 2. Arens D. The role of bleaching in esthetics. Dent Clin N Am. 1989;33:319-36. 3. Austinglastech.com [Internet]. Austin, TX: Glastech Inc.; C 2001 [Cited 2010 Feb 11]. Available from: http://www.austinglastech.com/ comp.htm. 4. Baker LH, Moon P, Mourino AP. Retention of esthetic veneers on primary stainless steel crowns. ASDC J Dent Child. 1996;63:185-9. 5. Carla Cohn. Pre-Veneered Stainless Steel Crowns—An Esthetic Alternative. pp.1-6. 6. Croll TP, Helpin ML. Preformed resin-veneered stainless steel crowns for restoration of primary incisors. Quintessence Int. 1996;27:30913. 7. Croll TP. Primary incisor restoration using resin veneered stainless steel crowns. J Dent Child. 1998;65:89-95. 8. Guelmann M, Gehring DF, Turner C. Retention of veneered stainless steel crowns on replicated typodont primary incisors: an in vitro study. Pediatr Dent. 2003;25:275-8. 9. Kilpatrick NM. Durability of restorations in primary molars. Journal of Dentistry. 1993;21(2):67-73. 10. Kupietzky A, Waggoner WF, Galea J. The clinical and radio-graphic success of bonded resin composite strip crowns for primary incisors. Pediatr Dent. 2003;25:577-81. 11. Lee JK. Restoration of primary anterior teeth: review of the literature. Pediatr Dent. 2002;24:506-10. 12. Luke LS, Reisbick MH. Steel crowns. In: Stewart RE, Barber TK, Troutman KC, Wei SHY (Eds). Pediatric dentistry: Scientific foundations and clinical practice, CV Mosby Co., St Louis, 1982. 13. MacLean, Jeanette K, Champagne, Cariann E, Waggoner, William F, Ditmyer, Marcia M, Casamassimo, Paul. Clinical outcomes for primary anterior teeth treated with preveneered stainless steel crowns. Pediatric Dentistry. 2007;29(5):377-81.

Chapter 49  Anterior Crowns in Pediatric Dentistry 14. Mandrolip S. Biologic restoration of primary anterior teeth: A case report. J Indian Soc Pedo Prev Dent. 2003;21:95-7. 15. Mendes FM, De Benedetto MS, del Conte Zardetto CG, Wanderley MT, Correa MS. Resin composite restoration in primary anterior teeth using short-post technique and strip crowns: a case report. Quintessence Int. 2004;35:689-92. 16. Messer LB, Levering NJ. The durability of primary molar restorations: II. Observations and predictions of success of stainless steel crowns. Pediatr Dent. 1988;10(2):81-5. 17. Mortada A, King NM. A simplified technique for the restoration of severely mutilated primary anterior teeth. J Clin Pediatr Dent. 2004;28:187-92. 18. Peretz B, Ram D. Restorative material for children’s teeth: preferences of parents and children. Journ Dentis Children. 2002;69(6)243-8. 19. Prashanth Sadashiva murthy, Seema Deshmukh. Indirect composite shell crown: an esthetic restorative option for mutilated primary anterior teeth. Journ Advan Oral Resear. 2013;4(1):29-32. 20. Ram D, Fuks AB, Eidelman E. Long-term clinical performance of esthetic primary molar crowns. Pediatr Dent. 2003;25(6):582-4. 21. Randal RC, Vrijhoef MM, Wilson NH. Efficacy of preformed metal crowns vs. amalgam restorations in primary molars. A systematic review. JADA. 2000;31:337-43. 22. Randall RC. Preformed metal crowns for primary and permanent molar teeth: Review of the literature. Pediatr Dent. 2002;24(5):489-500. 23. Roberts C, Lee JY, Wright JT. Clinical evaluation of and parental satisfaction with resin-faced stainless steel crowns. Pediatr Dent. 2001;23(1):28-31. 24. Roberts JF, Sherriff M. The fate and survival of amalgam and preformed crown molar restorations placed in a specialist paediatric dental practice. Br Dent J. 1990;169(8):237-44. 25. Seale NS. The use of stainless steel crowns. Pediatr Dent. 2002;24(5):501-5. 26. Shah PV, Lee JY, Wright JT. Clinical success and parental satisfaction with anterior preveneered primary stainless steel crowns. Pediatr Dent. 2004;26:391-5. 27. Sharaf AA. The application of fiber core posts in rest oring badly destroyed primary incisors. J Clin Pediatr Dent. 2002;26:217-24. 28. Steven Schwartz. Full coverage esthetic restoration of anterior primary teeth. Crest® Oral-B® at dentalcare.com. Continuing Education Course. 2012.pp.1-25. 29. Suzan Sahana, Aron Arun Kumar Vasa, Ravichandra Sekhar. Esthetic crowns for primary teeth: a review. Annals and Essences of Dentistry. 2010;2(2):87-93. 30. Usha M, Deepak V, Venkat S, Gargi M. Treatment of severely mutilated incisors: a challenge to the pedodontist. J Indian Soc Pedod Prev Dent. 2007;25(Suppl):S34-6. 31. Waggoner WF. Restoring primary anterior teeth: Review. Pediatr Dent. 2002;24:511-6. 32. Wei SHY. Stainless steel crowns. In: Pediatric dentistry: Total patient care. Philadelphia: Leas & Febiger, 1988. 33. Yilmaz Y, Guler C. Evaluation of different sterilization and disinfection methods on commercially made preformed crowns. J Indian Soc Pedod Prev Dent. 2008;26:162-7. 34. Yilmaz Y, Gurbuz T, Eyuboglu O, Belduz N. The repair of preveneered posterior stainless steel crowns. Pediatr Dent. 2008;30(5):429-35. 35. Zimmerman JA, Feigal RJ, Till MJ, Hodges JS. Parental Attitudes on Restorative Materials as Factors Influencing Current Use in Pediatric Dentistry. Pediatric Dentistry V. 31, No 1, Jan/Feb 09.

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Section

PEDIATRIC ENDODONTICS

This part briefs about morphology of primary root canal, classification of pulp and periapical diseases, conventional and advance pulp testing techniques, armamentarium required for endodontic therapy and standardization of instruments. The main focus of this section is on different pulp therapy techniques or procedures used in vital and nonvital primary and permanent teeth including rotary endodontics.

50

Chapter

Primary Root Canal Morphology Nikhil Marwah

Chapter outline • General Features of the Pulp Cavities of Deciduous Teeth • Deciduous Incisors

Maintenance of pediatric dental integrity is important for ensuring correct tooth spacing, mastication, phonation, esthetics, and prevention of psychological effects due to tooth loss. The roots of the primary teeth are formed completely approximately 16 to 20 months following eruption and the form and shape of the root canals roughly correspond to the form and shape of the external anatomy of the teeth. The main goal of root canal therapy for deciduous teeth is to clean the root canals of infected tissues therefore, knowledge of the size, morphology, and variation of the root canals of a primary tooth is useful in visualizing the pulp cavity during treatment.

 ENERAL FEATURES OF THE PULP G CAVITIES OF DECIDUOUS TEETH (FIGS 50.1A AND B) • Smaller depth of dentin between the pulp chamber and the enamel, especially in the mandibular second deciduous molar. • Very thin, highly projecting pulp horns in the molars, especially mesial. • The pulp chamber is relatively larger than in the corresponding permanent tooth as a result of the thinner dentin walls which enclose it. • There are no clearly defined root canal entrances. • Long root canals; in the molars the root canals are often irregular and ribbon-like. • The root canals of the deciduous molars diverge greatly. • Thin enamel.

• •

Deciduous Canine Deciduous Molars

A

B Figs 50.1A and B:  Pulp cavities of the deciduous teeth

DECIDUOUS INCISORS The simple pulp chamber of this tooth is fan-shaped when viewed from the labial aspect, and corresponds with the shape of the crown. It is relatively wider than that of the permanent incisor and extends further incisally so that the pulp lies closer under the thin enamel covering the crown. Pulp exposures during even the most simple clinical cavity

618 Section 10 

Pediatric Endodontics

Fig. 50.2:  Maxillary central incisor

Fig. 50.3:  Maxillary lateral incisor

preparations occur quite frequently because of this. The pulp horns are less pointed than in the permanent incisors. The pulp chamber is wedge-shaped labiolingually, and becomes narrower at the incisive edge. The root canal is wide and splays out more than in the permanent incisors resulting in a relatively wider apical cross-section, without a clearly-defined apical constriction. The root canal is widest labiolingually so that the mesiodistal flattening results occasionally in a partial division of the canal into two canals separated by a mesiodistal dentin dividing wall. In most cases, however, the deciduous incisors have only one root canal with an oval cross-section, ending in a relatively wide apical foramen. The apical third of the root is perforated by many accessory canals.

Maxillary Central Incisor The pulp chamber and canals resemble the exterior form of the tooth. The pulp chamber has three small projections on its incisal border and tapers evenly toward the cervix, with no distinct constriction at its junction with the pulp canal. The pulp canal varies from a round shape to a slight labiolingual compression, but in either case tapers evenly toward the apex (Fig. 50.2).

Maxillary Lateral Incisor The pulp morphology is similar to that of the central incisor, but there is generally a demarcation between the pulp chamber and the pulp canal (Fig. 50.3).

Fig. 50.4:  Mandibular central incisor

Mandibular Central Incisor The pulp chamber conforms to the external anatomy of the crown and there is usually a definite constriction between the pulp chamber and the pulp canal. The pulp canal tapers evenly toward the apex (Fig. 50.4).

Chapter 50  Primary Root Canal Morphology

Fig. 50.5:  Mandibular lateral incisor

Mandibular Lateral Incisor The pulp chamber and canal generally conform to the external morphology of the tooth. There is no constriction between the pulp chamber and pulp canal such as that found in the mandibular central incisor (Fig. 50.5).

DECIDUOUS CANINE The pulp chamber of this tooth is similar in many ways to that of the deciduous incisors, except that it has a single pulp horn, corresponding with the external morphology of the crown. There is no obvious morphological border between the pulp chamber and the root canal, so that the entire pulp cavity tapers evenly from the roof of the pulp chamber to the root apex, without being interrupted by constrictions. In cross-section, the root canal appears flattened on the mesial and distal sides giving it a slightly oval shape. The root canal of this tooth is longer than that of all the other deciduous teeth, and ends in an obvious apical foramen with many small accessory apical canals. The apical third tends to curve distally. The root canal is proportionally longer relative to the crown height, than in the permanent canines. As is the case with all deciduous teeth, the dentin between the pulp chamber and the enamel layer covering the crown, is much less than in the permanent canine.

Fig. 50.6:  Maxillary canine

Maxillary Canine Pulp morphology shows three projections at the incisal aspect of the pulp chamber; the central is the largest and longest, followed by the distal and mesial projections. There is little demarcation between the pulp chamber and the root canal, which tapers evenly as it approaches the apex (Fig. 50.6).

Mandibular Canine The pulp morphology conforms to the external morphology of the tooth, with no demarcation between the pulp chamber and pulp canal (Fig. 50.7).

DECIDUOUS MOLARS The pulp chamber of these teeth is very large relative to the external dimensions of the crown. This is especially true of the mandibular 2nd molar. The dentin and enamel walls of these teeth are fairly thin, and the distance between the pulp horns and the enamel surface is sometimes as little as 2 mm. Special ‘Eastman’ burs are often advised for the preparation of cavities in deciduous molars in the hope of reducing the chances of pulp exposure during treatment. The pulp chamber has the same number of pulp horns as there are cusps on the crown, and these extend quite far under

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Maxillary 1st Molar The coronal pulp morphology is similar to the external form. There are generally three pulp horns; the mesiobuccal is the largest, followed by mesiolingual and the distobuccal. There are three pulp canals corresponding to the three roots. According to Hibbard and Ireland and Barker variations from this basic pulp canal anatomy are fairly common. The most frequently found are anastomoses and branching in the apical region, often connecting the lingual and distobuccal pulp canals (Fig. 50.8).

Fig. 50.7:  Mandibular canine

Maxillary 2nd Molar The pulp morphology shows a pulp chamber that conforms to the external contours of the crown. There is one pulp horn

Fig. 50.8:  Maxillary 1st molar

Chapter 50  Primary Root Canal Morphology

Fig. 50.9:  Maxillary 2nd molar

Fig. 50.10:  Mandibular 1st molar

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Fig. 50.11:  Mandibular 2nd molar

corresponding to each cusp; the mesiobuccal is the largest, followed by the mesiolingual, distobuccal, and distolingual. The pulp canals do not show a high incidence of branching and anastomosing such as is seen in the maxillary first primary molar (Fig. 50.9).

Mandibular 1st Molar The pulp chamber is typical, with four pulp horns, the mesiobuccal the largest and longest. There are generally three pulp canals, the distal, mesiobuccal, and mesiolingual. The two mesial canals generally extend from the chamber

separately or in a ribbon shape, but usually become more confluent via branching and anastomosing as they approach the apex (Fig. 50.10).

Mandibular 2nd Molar The pulp morphology generally shows a pulp chamber with five pulp horns and three pulp canals. The mesiobuccal and mesiolingual pulp horns are the largest and longest. The mesiobuccal and mesiolingual pulp canals are usually confluent and ribbon shaped as they leave the chamber but divide into separate canals with occasional branching as they approach the apex (Fig. 50.11).

POINTS TO REMEMBER • In case of incisors pulp chamber is fan-shaped when viewed from the labial aspect, and corresponds with the shape of the crown. It is relatively wider than that of the permanent incisor and extends further incisally so that the pulp lies closer under the thin enamel covering the crown. • The root canal is wide and splays out more than in the permanent incisors resulting in a relatively wider apical crosssection, without a clearly-defined apical constriction. • The pulp chamber of canines is similar in many ways to that of the deciduous incisors, except that it has a single pulp horn, corresponding with the external morphology of the crown.

Chapter 50  Primary Root Canal Morphology • The root canal of this tooth is longer than that of all the other deciduous teeth, and ends in an obvious apical foramen with many small accessory apical canals. The apical third tends to curve distally. • The pulp chamber of molars is very large relative to the external dimensions of the crown. This is especially true of the mandibular second molar. • The pulp chamber has the same number of pulp horns as there are cusps on the crown, and these extend quite far under the cusps. • The root canals are irregular, often ribbon-like and much more complicated than those in the permanent molars.

QUESTIONNAIRE 1. What are the features of deciduous pulp cavity? 2. Describe the endodontic morphology of deciduous dentition.

BIBLIOGRAPHY 1. Barker BCW, Parsons KC, Williams GL, Mills PR. Anatomy of root canals. IV deciduous teeth. Aust Dent J. 1975;20:101-6. 2. Gupta D, Grewal N. Root canal configuration of deciduous mandibular first molars: an in vitro study. J Indian Soc Pedod Prev Dent. 2005;23:134-7. 3. Hibbard ED, Ireland RL. Morphology of the root canals of the primary molar teeth. J Dent Child. 1957;24:250-7. 4. Woelfel JB. Dental anatomy: It’s Relevance to dentistry. 4th Edn. Philadelphia: Lea & Febiger; 1990.pp.201-30. 5. Zircher E. The anatomy of the root canals of the teeth of the deciduous dentition, and of the first permanent molars. New York: William Wood & Co, 1925.pp.163-93. 6. Zoremchhingi, Joseph T, Varma B, Mungara J. A study of root canal morphology of human primary molars using computerized tomography: an in vitro study. J Indian Soc Pedod Prev Dent. 2005;23:7-12.

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Chapter

Pulp and Periapical Diseases Nikhil Marwah

Chapter outline • •

General Features of Pulp Pulp Diseases

Toothache has been a scourge to mankind from the earliest times. Chinese and Egyptians were the first to describe caries and alveolar abscess, whereas Greeks and Romans were the initiators of pulpal treatment by cauterization using hot needle, boiling oil and fomentation of opium. Special problems in dealing with primary dentition are due to differences in pulp anatomy, differences in pulp response and changes caused by normal receptive process. With the advances in material, instruments, technique, some sort of success has been tried to achieve in pediatric endodontics over the past decades.

GENERAL FEATURES OF PULP The dental pulp occupies the center of each tooth and consists of soft connective tissue. Primary teeth have 20-pulp organs, their shape confines to the tooth with the mean volume of a single pulp being 0.01 cc.

Coronal Pulp Coronal pulp is located in center of the crown and resembles outer surface of coronal dentin. It has 6 surfaces namely, buccal, lingual, occlusal, mesial, distal and the floor. Due to continuous deposition of dentin, coronal pulp becomes smaller with age.

Radicular Pulp This extends from cervical region of the pulp to the root apex. It is single in anterior and multiple in posterior teeth. It also decreases with age due to continuous deposition of dentin.

• •

Periapical Lesions Diagnosis of Pulp Pathology

Apical Foramen Average size of this foramen in maxillary anteriors is 0.4 mm, and in mandibular anteriors is 0.3 mm. The location and shape of apical foramen depends on the functional influence, e.g. if tooth migrates, the apical foramen exerts pressure causing resorption. At the same time cementum is laid on opposite side this is called apical foramen relocation.

Accessory Canals These are seen laterally in the apical third of root. Exact mechanism is not known, but these are due to premature loss of root sheath cells.

Primary Pulp Organs These function for short period of time (Average-8.3 years) and are divided into three periods:

Pulp Organ Growth Takes place during the time the crown and roots are developing (1 year).

Pulp Maturation Time period after root is completed until root resorption begins (3 years).

Pulp Regression Beginning of root resorption till exfoliation (3–6 years).

Chapter 51  Pulp and Periapical Diseases

Permanent Pulp Organs Pulp of permanent teeth requires 12 years to develop and maxillary arch requires longer time to complete each process than the mandibular arch.

PULP DISEASES The dental pulp consists of loose connective tissue inter­ spersed with tiny blood vessels, myelinated and unmyelinated nerves, lymphatics. The cellular components of pulp consist of odontoblasts, fibroblasts, undifferentiated cells and certain cells from immune system. The pulp responds to changes in environment in the same way as any other loose connective tissue. However, lack of collateral circulation, presence of dentin forming cells (odontoblasts) and its encasement in unyielding hard tissue (dentin) make its inflammatory response unique from any other organ in the human body.

Etiology of Pulp Diseases The most common cause of pulp and periapical diseases is the presence of microorganisms within the involved tooth. However, there are several other factors which may affect the health of pulp. These may broadly be classified into: • Bacterial: Via direct invasion or indirectly by its toxins. • Mechanical: Trauma, attrition, abrasion, erosion, cavity preparation, crown preparation, orthodontic movement, osteotomy, cracked tooth. • Thermal: Friction during tooth cutting, exothermic reaction of dental materials, conduction of heat in deep fillings, laser burn. • Electrical: Galvanism. • Chemical: Etchants, cements, cavity disinfectants and dessicants.

Dentinal hypersensitivity

• When pain occurs with thermal, chemical, tactile, or osmotic stimuli associated with exposed dentine, the diagnosis is dentine sensitivity. • The pain is consistent with an exaggerated response of the normal pulpo-dentinal complex, and it is severe and sharp on application of the stimulus to the exposed dentine. • Nonetheless, there is no lingering discomfort once the stimulus is removed. • Not only do the nerves in these exposed tubules respond to hot and cold and sweet and sour, but also to scratching with a finger nail or during tooth brushing. For this reason, patients often avoid brushing the area. This only worsens the situation from plaque build-up. Treatment An insulating cement base under amalgam fillings will prevent the shock of hot or cold to the pulp. Eventually, irritation dentin will build up to protect the pulp from thermal shock. Marginal microleakage around restorations may also lead to hypersensitivity. Replacement of restoration in such cases leads to alleviation of symptoms. In order to further desensitize the exposed dentin, dentifrices may be prescribed which reduces pain by nerve desensitization or by occluding dentinal tubules.

Reversible pulpitis

• Pulp with reversible pulpitis has mild inflammation and it is capable of healing once the irritating stimulus has been removed. • Pain is only felt when a stimulus (usually cold or sweet foods but sometimes heat) is applied to the tooth, and the pain ceases within a few seconds or immediately upon removal of the stimulus. This is due to the movement of dentinal fluid towards the pulpal tissue. • The pain is short and sharp in nature but it is never spontaneous. • There are no radiographic changes evident in the periapical region. Treatment As Grossman has stated, “The best treatment for reversible pulpitis is its prevention.” Removal of noxious stimulus generally is sufficient to allow the pulp to return back to its healthy state.

Irreversible pulpitis

• In case of irreversible pulpitis, the pulp has been damaged beyond repair, and even the removal of the noxious stimulus will not allow its proper healing. The pulp generally degenerates progressively, causing necrosis and reactive destruction. • One of the classic symptoms of irreversible pulpitis is lingering pain induced by thermal stimuli. • The initial reaction is a very sharp pain to hot or cold stimuli followed by dull ache or a throbbing pain for minutes to hours after the stimulus is removed. • Pain increases on bending or lying down. • Spontaneous pain is another hallmark feature of irreversible pulpitis. • If the periapical tissues are involved, the tooth is tender to percussion. • In most cases, radiographs are not useful in diagnosis but they can be helpful in identifying the possible cause of the disease, e.g. associated caries, or fracture of tooth, etc. Treatment The treatment comprises of pulp extirpation and endodontic therapy if the tooth is salvageable and extraction otherwise. Contd...

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Contd...

Hyperplastic pulpitis

• Hyperplastic pulpitis (pulp polyp) is a productive inflammatory response of pulp. • It usually involves chronically inflamed young pulp, widely exposed by caries on its occlusal aspect. • It is characterized by proliferative growth of inflamed connective tissue rising out of the carious crown. The tissue is mostly firm, insensitive to the touch and occasionally may cause mild discomfort during mastication. • Often covered with epithelium, it resembles a pyogenic granuloma of the gingiva from which it may be easily differentiated by lifting it away from the walls with a spoon excavator to view the pedicle of its origin. • The tooth will respond to pulp testing which is often delayed. • No significant radiographic changes (except for the cause of the problem—for example, caries, fractured restoration, etc.) are evident unless there is also periapical involvement. Treatment Frequently, the teeth involved in hyperplastic pulpitis are so badly decayed that restoration is virtually impossible. Hence, extraction is usually indicated. On the other hand, if the tooth can be restored, pulpectomy and endodontic therapy are recommended prior to restoration.

Necrosis

• There are no true symptoms of complete pulp necrosis for the simple reason that the pulp, together with its sensory nerves, is totally destroyed. • Pain usually does not present unless the periodontal ligament is affected. However, if only partial necrosis has occurred, the patient may have the some mild pain and discomfort. • A routine radiographic survey or coronal discoloration may present the first indication that something is amiss in the case of the tooth with a necrotic pulp. • On questioning, the history may reveal past trauma, previous episodes of pain or history of restorations and caries. • The radiograph may be helpful if a periradicular lesion exists because it generally indicates associated pulp death. Per se, no changes in the canal are noted radiographically to indicate necrosis. Treatment If the tooth is salvageable endodontic therapy is indicated, else extraction is the only solution.

Internal resorption

• The term internal resorption is applied to the destruction of predentin and dentin. • Often only recognized during a routine radiographic examination, it is asymptomatic and unidentifiable clinically until the lesion has progressed considerably. • It may begin anywhere in the pulp space and if left untreated, can perforate either above bone or into the periodontal ligament within bone. • When confined to the crown, enough tooth structure may be destroyed for the pulp to show through the enamel— hence the synonym for internal resorption, “pink tooth.” • The etiology is unclear but it is probably due to a metaplastic change or activation of dentinoclasts within the inflamed pulp tissue. • History of impact trauma has often been found to be associated with internal resorption. Treatment Since the pulp tissue cells are responsible for the destructive process, its removal by endodontic therapy arrests any further resorption.

Pulp degenerations

The pulp will usually respond to noxious stimuli by becoming inflamed, but it may also respond by degeneration which includes atrophy and fibrosis and calcification. Although these changes are not evident clinically, it is appropriate to discuss these changes along with other pulp diseases. Atrophy Atrophy is a normal physiologic process that occurs with age and is asymptomatic. The cellularity of the pulp tissue is decreased with an increase in intercellular material. Pulp sensivity tests responses may be normal or delayed. No significant radiographic or clinical signs are present. Fibrosis As the pulp atrophies, there may also be fibrosis of the pulp tissue and the extent of this will be largely determined by the number of irritant episodes suffered by that particular pulp throughout its history. Calcification In calcific degeneration, pulp tissue is replaced with calcific material. It may occur anywhere in the pulp space and may be diffuse or localized (pulp stones). Teeth with calcifications are usually asymptomatic. There are usually no or delayed response to electrical test. Radiographically, there is no evidence of the usual pulp chamber outline and the root canal may appear narrow or it may not be evident at all.

Chapter 51  Pulp and Periapical Diseases PERIAPICAL LESIONS Teeth with normal periradicular tissues are nonsensitive to percussion and palpation testing. Radiographically, periradicular tissues are normal with an intact lamina dura and a uniform periodontal ligament space. Exposure of the dental pulp to bacteria and their by-products, acting as antigens, may elicit nonspecific inflammatory responses as

well as specific immunological reactions in the periradicular tissues, and cause the periapical lesion. These periapical lesions resulting from necrotic dental pulp are among the most frequently occurring pathologies found in alveolar bone. As already mentioned in case of pulpal diseases, the various lesions described below are interrelated and if allowed to progress undeterred, one may lead to another.

Acute apical periodontitis

• It is painful inflammation of the periodontal tissues. Usually a result of microbes spreading from root canal to periapical tissues. Other reasons include trauma, irritation to periapical area. • The patient will generally complain of discomfort to biting or chewing. • Sensitivity to percussion is a hallmark diagnostic test result of acute periradicular periodontitis. • Tooth is usually not sensitive to hot or cold. • Depending on the cause of inflammation, it may or may not respond to vitality tests. • Palpation testing may or may not produce a sensitive response. • Radiographically, the PDL space may appear normal, widened, or there may be a distinct radiolucency. Treatment Determination of cause and relieving the symptoms. In case it is because of pulpal involvement, endodontic therapy is indicated.

Acute perirapical abscess

• It refers to painful localized collection of pus in the periapical connective tissue. • It is characterized by rapid onset, spontaneous pain, pus formation, and often swelling of the associated tissues. • Depending upon the location of the apices of the tooth and muscle attachments, a swelling will usually develop in the buccal vestibule, on the lingual/palatal, or as a facial space infection. • Percussion testing produces a response that is usually exquisitely sensitive. Palpation testing may produce a sensitive response. • The tooth gives negative response to vitality tests. • Radiographically, the PDL space may be normal, slightly widened, or demonstrate a distinct radiolucency. Treatment Endodontic treatment concomitant with the drainage of abscess. Suitable measures must also be taken to control any systemic manifestations.

Chronic periradicular abscess (Suppurative periradicular periodontitis)

• An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and intermittent discharge of pus through an associated sinus tract. • The resultant inflammatory process causes periradicular bone resorption that manifests as periradicular radiolucency on the radiograph. • Clinically, the patient is asymptomatic or very rarely has mild pain and the lesion is detected with a routine radiograph. • Percussion and palpation testing produce nonsensitive responses. • Tooth generally responds negatively to vitality tests. Treatment Endodontic therapy if the tooth can be restored otherwise extraction is the solution. The sinus tract does not generally require any special treatment.

Recrudescent abscess

• It refers to an acute exacerbation arising from a pre-existing chronic lesion. • Tooth feels elevated in its socket. • The tooth is severely tender. • Palpation may produce positive response with signs of inflammation evident on overlying mucosa. • Negative response to EPT. • The radiograph shows a well defined radiolucency. Treatment Since it is essentially similar to acute alveolar abscess, its treatment is also similar to the latter. Contd...

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Contd...

Focal sclerosing osteomyelitis (condensing osteitis)

• The involved tooth will have an etiologic factor for low-grade, chronic inflammation such as a necrotic pulp, extensive restorative history or a crack. • The patient may be asymptomatic or demonstrate a wide range of pulpal symptoms. • EPT and thermal tests may or may not be responsive. • Percussion and palpation testing may or may not be sensitive. • Radiographically, the involved tooth will present with increased radiodensity and opacity around one or more of the roots. Treatment These periradicular radiodensities resolve after endodontic therapy if they have a pulpal diagnosis of irreversible pulpitis.

Periapical granuloma

• This disease entity is characterized by growth of granulation tissue in relation to the periodontium at the apex in response continued bacterial irritation. • Patient usually is asymptomatic. • The tooth is generally nonvital and not responsive to percussion. • Although there is a growth of granulation tissue in the area, there is rarely any swelling or expansion of cortical plates. • Radiograph shows loss of lamina-dura and periapical radiolucency. Treatment Root canal therapy of the concerned tooth.

Periapical cyst

• The radicular cyst is a chronic inflammatory lesion with a closed pathologic cavity, lined either partially or completely by epithelium. • A cyst may develop in relation to an infected tooth due to continuous irritation and stimulation of epithelial rests of malassez, which are normally present in the periodontal ligament. • Majority of cases of periapical cyst are asymptomatic. The tooth is seldom painful or sensitive to percussion. • Pressure due to growth of the cyst may make it obvious as a swelling or cause movement of the root. • Radiograph shows a distinct rarefaction at the apex with a thin radiopaque border. Treatment Treatment of periapical cyst is conservative initially by root canal treatment. Surgical intervention is advisable only if the conservative means fail.

DIAGNOSIS OF PULP PATHOLOGY

Pain An accurate history must be obtained of the type of pain, duration, frequency, location, spread, aggregating and relieving factors. In young children the pain history should not be considered as a sole criteria in diagnosing pulpal conditions.

Mode Is the onset spontaneous or provoked?

Periodicity Do symptoms have temporal pattern or are they sporadic or occasional? Early pulpitis—symptoms seen in evening or after meal.

Frequency Have the symptoms persisted since they began/have they been intermittent?

Duration How long do symptoms last when they occur?

Quality of Pain Dull, aching—pain of bony origin. Throbbing, pounding, pulsing—pain of vascular origin sharp, recurrent. Stabbing— pathosis of nerve root complexes, irreversible pulpitis.

Postural Change Pain accentuated by bending over, blowing the nose— maxillary sinus involvement.

Chapter 51  Pulp and Periapical Diseases Time of Day Pain in the masticatory muscles on working may indicate occlusal disharmony or TMJ dysfunction or possible acute pulpalgia.

Hormonal Menstrual toothache occurs due to increase in body fluid retention. Teeth may ache and become tender on percussion. Symptoms disappear when cycle ends.

Types of Pain Momentary pain: Immediate response to hot or cold that disappears on removal of the stimulus indicates that the pathosis is limited to the coronal pulp. Persistent pain: Pain from thermal stimuli would indicate wide spread inflammation of the pulp, extending into the radicular filaments. Spontaneous pain:  Throbbing, constant pain that may keep the patient awake at night. This type of pain indicates pulpal damage—irreversible pulpitis. Provoked pain:  Stimulated by thermal, chemical or mechanical irritant, and is eliminated when noxious stimulus is removed. Indicates dentine sensitivity due to deep carious lesion or faulty restoration. Pulp is in reversible stage.

Visual and Tactile Examination This is one of the simplest tests, but most often it is done casually during examination and as a result valid information is lost. A thorough visual, tactile examination of hard and soft tissue relies on checking the three C’s, i.e. color, contour, consistency.

Mobility Mobility in a primary tooth may result from physiological or pathological cause. Tooth mobility is directly proportional to the integrity of the attachment apparatus. Clinician should use two mouth mirror handles to apply alternating lateral forces in a facial lingual direction to observe the degree of mobility of the tooth. A measure of mobility is:

Grading of mobility 0 1 2 3

Wymans Index (1975) Horizontal < 0.2 mm Horizontal 0.2 – 1 mm Horizontal 1 – 2 mm Horizontal > 2 mm and vertically

Percussion Pain from pressure on a tooth indicates that periodontal ligament is inflamed. A useful clinical test is to apply finger pressure to the tooth and check the child’s response by watching the eyes.

Palpation Simple test done with fingertips using light pressure to examine tissue consistency and pain response. It determines presence, intensity and location of pain and presence of bony crepitus.

Radiographs Recent preoperative radiographs are prerequisites to pulp therapy in primary and young permanent teeth. It demonstrates pathological conditions, position of the succedaneous permanent tooth. These will dictate the decision on performing pulp therapy for primary tooth.

The Exposure Site The size of the exposure site and the nature of exudate expressed from it are useful diagnostic aids. Light red blood that can be arrested easily is associated with inflammation that is limited to the coronal pulp in primary teeth. Deep red blood histologically indicates that inflammation has extended into the root canals of primary molars.

Pulp Testing Pulp testing is widely used to assess vitality of mature permanent teeth but these are not reliable in deciduous teeth as fear of unknown makes child patient apprehensive of the electric vitalometer and may give inaccurate results. Another reason is that newly erupted teeth may have incomplete innervation and therefore may not give correct results. The detailed overview of pulp testing has been explained in chapter 52.

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POINTS TO REMEMBER • • • • •

• •

• • • • • • • •

Average size of apical foramen in maxillary anteriors is 0.4 mm, and in mandibular anteriors is 0.3 mm. Accessory canals are seen laterally in the apical third of root due to premature loss of root sheath cells. Primary pulp organs function for short period of time of average-8.3 years Diseases of pulp include hypersensitivity, reversible pulpitis, irreversible pulpitis, hyperplastic pulpitis, necrosis, pulp degeneration. Diseases of periapical tissues include acute apical periodontitis, acute perirapical abscess, chronic periradicular abscess (suppurative periradicular periodontitis), recrudescent abscess, focal sclerosing osteomyelitis (condensing osteitis), periapical granuloma, periapical cyst. Reversible pulpitis is characterized when pain is only felt when a stimulus is applied to the tooth, and the pain ceases within a few seconds or immediately upon removal of the stimulus. One of the classic symptoms of irreversible pulpitis is lingering pain induced by thermal stimuli. The initial reaction is a very sharp pain to hot or cold stimuli followed by dull ache or a throbbing pain for minutes to hours after the stimulus is removed. Hyperplastic pulpitis (pulp polyp) is a productive inflammatory response of pulp. It involves chronically inflamed young pulp, widely exposed by caries on its occlusal aspect. The term internal resorption is applied to the destruction of predentin and dentin and is only recognized during a routine radiographic examination. Acute apical periodontitis is painful inflammation of the periodontal tissues. Acute periapical abcess refers to painful localized collection of pus in the periapical connective tissue. Chronic periradicular abcess is an inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, and intermittent discharge of pus through an associated sinus tract. Recrudescent abscess refers to an acute exacerbation arising from a pre-existing chronic lesion. In focal sclerosing osteomyelitis (condensing osteitis) the involved tooth will have an etiologic factor for low-grade, chronic inflammation such as a necrotic pulp, extensive restorative history or a crack. Periapical cyst a chronic inflammatory lesion with a closed pathologic cavity, lined either partially or completely by epithelium.

QUESTIONNAIRE 1. Explain the diseases of pulp. 2. Describe the diseases of periapical tissues. 3. What are the methods for diagnosis of pulp and periapical pathologies?

BIBLIOGRAPHY 1. Camp J. Pediatric endodontics: Endodontic treatment for the primary and young permanent dentition. In: Cohen S, Burns RC (Eds). Pathways of the pulp. 8th Edition. St. Louis, Mosby: Mosby Year Book, Inc; 2002. 2. Fuks AB. Pulp therapy for the primary dentition. IN: Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ, Nowak A (Eds). Pediatric Dentistry: Infancy through the adolescence. 3rd Edition. Philadelphia, Pennsylvaniaa: WB Saunders Co; 1999. 3. McDonald RE, Avery DR, Dean JA. Treatment of deep caries, vital pulp exposure, and pulpless teeth: In: McDonald RE, Avery DR, Dean JA (Eds). Dentistry for the Child and Adolescent. 8th Edition. St. Louis, Mosby: Mosby Inc; 2004. 4. Murray PE, About I, Franquin JC, et al. Restorative pulpal and repair responses. J Am Dent Assoc. 2001;132(4):482-91.

52

Chapter

Diagnostic Pulp Testing Nikhil Marwah

Chapter outline • • • •

Classification of Pulp Testing Thermal Tests Electric Pulp Testing Safety Concerns of Pulp Sensibility Tests

Dental pulp tests are investigations that provide valuable diagnostic and treatment planning information to the dental clinician. If pathosis is present, pulp testing combined with information taken from the history, examination, and other investigations such as radiographs leads to the diagnosis of the underlying disease which can usually be reached relatively easily.

CLASSIFICATION OF PULP TESTING Pulp tests are broadly classified according to the component that they test like blood supply, nerve supply, etc.

Pulp Vitality Testing • Assessment of the pulp’s blood supply. • Pulp tissue may have an adequate vascular supply, but is not necessarily innervated. Hence, most of the current pulp testing modalities do not directly assess the pulp vascularity and this is exemplified by clinical observations that traumatized teeth can have no response to a stimulus (such as cold) for a period of time following injury. • Done by laser Doppler and pulse oximeter.

Pulp Sensibility Testing • Assessment of the pulp’s sensory response. • Sensibility is defined as the ability to respond to a stimulus, and hence this is an accurate and appropriate term for the typical and common clinical pulp tests such as thermal

• • • •

Pulp Vitality Tests Experimental Noninvasive Vitality/Sensibility Tests Experimental Invasive Vitality/Sensibility Tests Limitations of Pulp Testing

and electric tests given that they do not detect or measure blood supply to the dental pulp.

Pulp Sensitivity • Condition of the pulp being very responsive to a stimulus. • Thermal and electric pulp tests are not sensitivity tests although they can be used as sensitivity tests when attempting to diagnose a tooth with pulpitis since such teeth are more responsive than normal. • If the pulp responds to a stimulus (indicating that there is innervation), then clinicians generally assume that the pulp has a viable blood supply and it is either healthy or inflamed, depending on the nature of the response (with respect to pain, duration, and so forth), the history, and the other findings. The three types of responses can be summarized: 1. The pulp is deemed normal when there is a response to the stimulus provided by the sensibility test and this response is not pronounced or exaggerated, and it does not linger. 2. Pulpitis is present when there is an exaggerated response that produces pain. Typically mild pain of short duration is considered to indicate reversible pulpitis while severe pain that lingers indicates irreversible pulpitis. 3. The absence of responses to sensibility tests is usually associated with the likelihood of pulp necrosis, the tooth is pulpless, or has had previous root canal therapy.

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THERMAL TESTS This was first reported by Jack in 1899 and it involved application of agents to the teeth to increase or decrease temperature and to stimulate pulp sensory responses through thermal conduction. Although these techniques may be primate and old but they are still useful in diagnosis of pulp sensibility.

Responses to thermal test • • • •

No response – Nonvital pulp Mild – Moderate pain subsides in 1–2 sec – Normal Strong – Momentary pain subsides in 1–2 sec – Reversible pulpitis Moderate to strong painful response that lingers for several seconds after the stimulus has been removed –Irreversible pulpitis.

Cold Tests • Cold thermal testing causes contraction of the dentinal fluid within the dentinal tubules, resulting in a rapid outward flow of fluid within the patent tubules. This rapid movement of dentinal fluid results in ‘hydrodynamic forces’ acting on the ä nerve fibers within the pulp– dentine complex, leading to a sharp sensation lasting for the duration of the thermal test. • A variety of cold tests may be employed, the major difference between them is the degree of cold that is applied to the tooth. • Ideally, cold testing should be used in conjunction with an electric pulp tester so that the results from one test will verify the findings of the other test. • If a mature, nontraumatized tooth does not respond either to EPT or cold, then the tooth may be considered nonvital. However, caution should be exercised when testing multi-rooted teeth, as they may respond positively to cold, even though only one root actually contains vital pulp tissue. The cold test alone may be used to differentiate between reversible and irreversible pulpitis. • Overall, cold tests appear to be more reliable than heat tests. Furthermore, there is a general consensus that the colder the stimulus, the more effective the assessment of tooth innervation status. • Ethyl chloride and ice have been popular in the past, but CO2 snow and other refrigerants such as dichlorodifluoromethane (DDM) have been shown to be effective and superior to ice and ethyl chloride.

Ice • This is perhaps the simplest cold testing agent requiring practically zero cost to prepare and it can be made in a

Fig. 52.1:  Cold test with ice stick

standard household freezer. A common way to make ice in useful sizes and dimensions involves freezing water in empty local anesthetic cartridges. • Direct application of ice can be difficult and problematic and hence pencil sticks of ice would be useful. • Application is done for 5 seconds on the facial surface of teeth (Fig. 52.1).

Refrigerant Spray • Due to its ease of storage, relatively cheap cost, and simple application technique, refrigerant spray is widely used in clinical settings. • More effective agents such as dichlorodifluoromethane (DDM) have superseded traditional refrigerants such as ethyl chloride. However, DDM, being a chlorofluorocarbon, has decreased in popularity and market availability due to environmental concerns of atmospheric ozone layer depletion. Consequently, manufacturers have replaced DDM with other gases, including tetrafluoroethane (TFE) or a propane/butane/isobutane gas mixture stored in a pressurized can (Endo Frost, Germany). • The application of the refrigerant spray requires a carrier such as a cotton pellet saturated with the substance prior to direct contact with the teeth as described by Jones (Fig. 52.2). • Refrigerant sprays have also been shown to evoke faster pulp responses by one to three seconds.

Carbon Dioxide Snow • CO2 snow, or dry ice, is prepared from a pressurized liquid CO2 cylinder using a commercially available apparatus known as the Odontotest (Fricar AG Zurich, Switzerland). This involves the liquid CO2 being forced through a small orifice such that when it comes under atmospheric pressure most of the liquid will be converted into dry ice.

Chapter 52  Diagnostic Pulp Testing • The major disadvantage of this method is that excessive heating may result in pulp damage. • Prolonged heat application will result in biphasic stimulation of A ä fibers initially, followed by the pulpal C fibers. Activation of C fibers may result in a lingering pain, therefore heat tests should be applied for no more than 5 seconds.

ELECTRIC PULP TESTING

Fig. 52.2:  Refrigerant spray

Fig. 52.3:  Heat test

• The dry ice is collected in a “pencil stick” form that can then be applied to one tooth at a time with the aid of the supplied plunger.

Heat Test • Heat testing can be undertaken using gutta-percha sticks (Fig. 52.3) or compound material heated to melting temperature and directly applied to the tooth being tested with lubricant in order to facilitate removal of the material; Heated ball-ended metallic instruments placed near the tooth (but without touching the tooth surface); battery-powered controlled heating instruments such as Touch n’ Heat. • This test may be difficult to use on posterior teeth because of limited access.

The use of electricity in dentistry is attributed to Magitot and described in his book Treatise on Dental Caries published in France in 1867 (cited in Prinz 1919). Later, Marshall (1891) and Woodward in 1896 used electricity to demonstrate vital and nonvital pulps. Roentgen in 1895 was probably the first to introduce the use of electricity clinically for diagnosing diseases of the pulp (Grossman 1976). In 1901, investigators in Europe attempted to standardize the instrument used for electrical stimulation of the dental pulp, and in the same year, Futy used a device where the primary current of an induction coil fed two electrodes. One was held in the patient’s hand, and the other applied to the tooth with a platinum pin covered with water-saturated cotton. Futy observed that: Normal teeth reacted when moist; Devitalized teeth did not react, even to much greater amounts of current; Teeth with inflamed pulps had a much lower threshold of irritability, requiring less current for a response; Teeth with normal enamel responded best when tested near the neck of the tooth. Over the years many studies were done to analyze the effect of EPT like Kaletsky and Furedi 1936, Stephan 1937, Ziskin and Zegarelli 1945. Seltzer et al. (1963) showed that ‘the electric pulp test was of some value in suggesting the possibility of an inflammatory state, but it was far from definitive’. In the 1970s EPT regained popularity when new designs of instrument were introduced which were monopolar and battery opearted. Currently testers have many different electric impulses and have digital readout for ease of application (Dummer et al. 1986) (Fig. 52.4).

Working Principle • Electric pulp testing (EPT) works on the premise that electrical stimuli cause an ionic change across the neural membrane, thereby inducing an action potential with a rapid hopping action at the nodes of Ranvier in myelinated nerves. • The pathway for the electric current is thought to be from the probe tip of the test device to the tooth, along the lines of the enamel prisms and dentine tubules, and then through the pulp tissue. The “circuit” is completed via the patient wearing a lip clip or by touching the probe handle with his/her hand (Fig. 52.5). • A “tingling” sensation will be felt by the patient once the increasing voltage reaches the pain threshold, but this

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Fig. 52.4:  Electric pulp tester

•

•

Fig. 52.5:  Procedure of performing EPT

threshold level varies between patients and teeth, and is affected by factors such as individual age, pain perception, tooth surface conduction, and resistance. • In order to ensure that the appropriate current pathway is followed, correct placement of the EPT probe tip flat against the contact area, and having a conducting medium such as toothpaste between the probe tip and the tooth surface is essential. • Jacobson found in an in vitro experiment involving incisors and premolars, that placing the probe tip labially within the incisal or occlusal two-thirds of the crown gave more consistent results.

• •

•

Limitations of EPT • Electric pulp testing depends on the vital sensory fibers present in the pulp. Its disadvantage is that it does not

provide any information about the vascular supply of pulp, which is a true determinant of pulp vitality. Electric pulp tests are known to be unreliable in many instances, producing false results in healthy immature teeth with incompletely formed roots which may be erupting since these teeth may take up to five years before the maximum number of myelinated fibers reaches the pulp-dentin border at the plexus of Rashkow. Recently traumatized teeth undergoing pulp repair may also have false results and thus may not respond to EPT. In humans, many clinical observations from dental trauma studies have indicated that it can take pulps a minimum of 4 to 6 weeks following trauma for sufficient recovery of sensation to obtain valid pulp testing results. Theories proposed by Öhman for this loss of pulp sensibility include pressure or tension on the nerve fibers, blood vessel rupture, and ischemic injury. It is then assumed that these effects were reversible in the cases where the pulp sensation recovered. Pileggi et al. have shown that 10 to 12 days is required for the sensory component of the pulp to start to respond EPT again as damage from trauma heals. They are not recommended for use on crowned teeth or in patients wearing orthodontic bands. Anxious or young patients may have a premature or falsepositive response due to the expectation of feeling an unpleasant sensation. False positive response: This means that the pulp is necrotic, yet the patient will signal that there is sensation in the tooth. This may be due to electrode contact with a metal restoration or the gingiva, patient’s anxiety, liquefaction necrosis, failure to isolate tooth before testing.

Chapter 52  Diagnostic Pulp Testing • False negative response: Means that the pulp is vital, yet the patients will be unresponsive to electric pulp tests. This may be seen in inadequate contact between the electrode and enamel, recently traumatized tooth, calcification of root canal, recently erupted tooth with an immature apex, partial necrosis and in a patient who has been heavily premedicated with analgesics, narcotics or alcohol tranquillizers.

SAFETY CONCERNS OF PULP SENSIBILITY TESTS

Safety Concerns of Heat Tests • The temperature of melting gutta-percha used in pulp testing is approximately 78°C to 150°C. • Zach et al. noted that an increase of 11°C that occurs during restorative procedures without adequate cooling can harm the pulp. Therefore, prolonged contact with heat is a safety concern. • An in vitro study by Fuss et al. showed that heat testing using gutta-percha increased pulp temperature by less than 2°C with less than five seconds of application—a temperature change that is unlikely to have caused pulp damage.

Safety Concerns of Cold Tests • Concerns have been raised in the past about the possible damaging effects of cold testing agents. • Lutz et al. found that cracks may be formed on enamel surfaces from direct CO2 snow contact. • However, subsequent studies by Peters et al. and Fuss et al. concluded that these concerns were insignificant.

Safety Concerns of EPT In electric pulp testing (EPT), the current produced by the testing device may cause danger to patients who have cardiac pacemakers, with the risk of precipitating cardiac arrhythmia via pacemaker interference but more recent studies have shown no interference from EPT or similar electrical dental devices.

PULP VITALITY TESTS

Laser Doppler Flowmetry • It is a new method of evaluating pulp vitality by measuring the velocity of RBC in capillaries. • The laser Doppler flowmetry technique was first described in dental literature in 1986 by Gazelius et al.

Fig. 52.6:  Laser Doppler flowmeter

• A near infrared with a wavelength of 632.8 nm is produced by 1 mw helium neon laser within the flowmeter and this is transmitted along a flexible fiber optical conductor inside a specially designed round dental probe with a diameter of 2 mm. • This electro-optical technique uses a laser source that is aimed at the pulp, and the laser light travels to the pulp using the dentinal tubules as guides. The backscattered reflected light from circulating blood cells is Dopplershifted and has a different frequency to the static surrounding tissues. The total backscattered light is processed to produce an output signal. The signal is commonly recorded as the concentration and velocity (flux) of cells using an arbitrary term “perfusion units” (PU), where 2.5 volts of blood flow is equivalent to 250 PU (Fig. 52.6). • In order to record the Doppler shift of the blood cells, both the probe and tooth need to be completely still. Hence, a stabilizing splint made of polyvinyl siloxane or acrylic is usually used. • Two to three mm from the gingival margin is the ideal position for the probe tip as this creates a balance between minimizing the noise and having a recognizable signal volume. • There have been differing views with regards to the accuracy of pulp testing using LDF, given that false results suggesting no blood flow are possible when the laser pathway is interfered with or obstructed. Likewise, the amount of signal contamination from nonpulp sources, primarily the periodontium, can lead to false readings suggesting the presence of pulp blood flow.

Pulse Oximetry • This is an oxygen saturation monitoring device widely used in medical practice for recording blood oxygen

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Pediatric Endodontics • TLL uses similar sending/receiving probes as conventional LDF, but the probes are separate. Thus, the laser beam is passed through from the labial or buccal side of the tooth to the receiver probe which is situated on the palatal or lingual side of the tooth. • The limitations with TLL are the same as with any laser technology where obstruction and/or interference from within the tooth structure will affect the results.

Transillumination

Fig. 52.7:  Pulp oximeter

• This utilizes a strong light source which identifies color changes that may indicate pulp pathosis. • This technique may not be useful in large posterior teeth and especially in teeth with large restorations. However, it is a helpful adjunct to conventional pulp tests and it can help to identify cracks in teeth.

Ultraviolet Light Photography

• • •

• •

saturation levels during the administration of intravenous anesthesia. It was invented by Aoyagi in the early 1970s. Pulse oximetry is an entirely objective test, requiring no subjective response from the patient. The pulse oximeter (Fig. 52.7) sensor consists of two light-emitting diodes, one to transmit red light (640 nm) and the other to transmit infrared light (940 nm), and a photodetector on the opposite side of the vascular bed. The light emitting diode transmits light through a vascular bed such as the finger or ear. Oxygenated hemoglobin and deoxygenated hemoglobin absorb different amounts of red/infrared light. The pulsatile change in the blood volume causes periodic changes in the amount of red/ infrared light absorbed by the vascular bed before reaching the photodetector. The relationship between the pulsatile change in the absorption of red light and the pulsatile change in the absorption of infrared light is analyzed by the pulse oximeter to determine the saturation of arterial blood. Compared to laser Doppler flowmeters, pulse oximeters are relatively inexpensive. An in vitro study by Noblett et al. compared pulse oximetry with blood gas saturation in a simulated pulp blood flow model and showed promising results.

EXPERIMENTAL NONINVASIVE  VITALITY/SENSIBILITY TESTS

Transmitted Laser Light (TLL) • It is an experimental variation to LDF, aimed at elimi­ nating the nonpulp signals.

• It examines different fluorescence patterns that may allow additional contrast of otherwise more difficult to observe visible changes. • It has similar limitations as transillumination, and it is only an adjunct to conventional pulp tests, at best.

Surface Temperature Measurement • It has not found practical clinical use in pulp testing, even though there have been reports that a measurable temperature difference can be found over time in teeth with healthy pulps in contrast to teeth with diseased pulps. • Potential interfering factors such as breathing by the patient and the lengthy time required for this technique are the major drawbacks.

Physiometric Tests Taylor in 1960 coined the word “physiometric” to describe such tests that assess the state of the pulpal circulation, rather than the integrity of the nervous tissue thus providing valuable information.

Photoplethysmography • This was given by Reich in 1952. • This method involves passing light on the tooth and measuring the existing wavelengths using a photocell and galvanometer. • If a tooth with an intact blood supply is warmed there should be vascular dilatation, and this would register as a current from the photocell.

Chapter 52  Diagnostic Pulp Testing

Thermography • A hot object emits infrared radiation in proportion to its temperature. Measurement of this radiation may provide information on pulpal circulation. • Temperature measurement, as a diagnostic procedure for human teeth, has been described with the use of thermistors infrared thermography, and liquid crystals. • The underlying principle was that teeth with an intact pulp blood supply (vital/healthy pulp tissue) had a warmer tooth surface temperature compared with teeth that had no blood supply. • The disadvantages of using this technique are that the teeth must be isolated with rubber dam, after which a period of acclimatization is necessary prior to imaging and requires the subjects to be at rest for 1 hour prior to testing.

 ransmitted Light T Photoplethysmography • It is a noninvasive technique used to monitor pulpal blood flow, and has been successfully applied in animal and human studies. • It has been suggested that transmitted light photo­ plethysmography (TLP) incurs less signal contamination from the periodontal blood flow than is the case for LDF however studies have to be evaluated before it can be put to practice.

Dual Wavelength Spectrometry Measures blood oxygenation changes within the capillary bed of dental tissue and thus is not dependent on a pulsatile blood flow.

Hughes Probeye Camera This is used in detecting temperature changes as small as 0.1°C hence can be used to measure pulp vitality experimentally.

EXPERIMENTAL INVASIVE VITALITY/SENSIBILITY TESTS

Test Cavity • Given by Seltzer and Bender in 1975. • This test is performed when other methods have failed. • The test cavity is made by drilling the enamel dentin junction of an unanesthetized tooth using a slow speed hand piece without water coolant. If patient feels sensitivity it is an indication of pulp vitality. • This test may serve as a last resort in testing for pulp vitality. It is only considered when the results of all other tests have

proved inconclusive. Its value in clinical practice has been largely anecdotal as there is no evidence base to support its effectiveness.

Anesthetic Testing • Given by Grossman in 1978 • If the patient continues to have vague, diffuse, strong pain and prior testing has been inconclusive, intraligamentary anesthetic may be used to identify the source of pain. • When dental symptoms are poorly localized or referred, an accurate diagnosis is extremely difficult. Sometimes, patients may not even able to specify whether the symptoms are from the maxillary or mandibular arch. In such cases, and where pulp testing has proved inconclusive, an anesthetic test may be helpful. • The technique is as follows: using either infiltration or an intraligamentary injection, the most posterior tooth in the area suspected of causing the pain is anesthetized. If pain persists once the tooth has been fully anesthetized, the tooth immediately mesial to it is then anesthetized, and so on, until the pain disappears. If the source of the pain cannot be even localized to the upper or lower jaw, an inferior alveolar nerve block injection is given; cessation of pain indicates involvement of a mandibular tooth. • This approach has an advantage over a test cavity, which may incur iatrogenic damage.

Pulp Hemogram • Suggested by Guthrie and Baume in 1966. • It was suggested that taking the first drop of blood from an exposed pulp and subjecting it to a differential white cell count might be useful in diagnosis of pulpal conditions.

LIMITATIONS OF PULP TESTING

False Positive Results • A false positive response is where a nonvital tooth appears to respond positively to testing. • This may occur in anxious or young patients who may report a premature response because they are anticipating an unpleasant sensation. • Necrotic breakdown products in one part of a root canal system can conduct electric currents to viable nerve tissue in adjacent areas, thereby resulting in a false positive result. • Contact with metal restorations may also result in conduction of the current to the periodontium, giving a false vital response; the same may occur with inadequately dried teeth.

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False Negative Results • A false negative result means that a vital tooth has not responded positively to testing. • This may be seen in teeth with incomplete root development, which have a higher threshold to testing, and require a stronger stimulation than normal to elicit a response. • Following injury, traumatized teeth may not respond to thermal or EPT due to nerve rupture. The pulps of these teeth, however, may still be vital as their blood vessels remain intact or have revascularized. Therefore, traumatized teeth should always be carefully monitored at periodic intervals as their nerve fibers may subsequently regain function. • Patients with psychotic disorders may not respond to pulp testing.

Sensitivity and Specificity • Sensitivity denotes the ability of a test to detect disease in patients who actually have the disease. Thus, the sensitivity of a pulp vitality test indicates the test’s ability to identify nonvital teeth. It is defined as the ratio of the number of persons with a positive test result who have the disease divided by the total number of persons with the disease who were tested. A test with a sensitivity of 0.80 therefore has an 80 percent chance of achieving a positive result when individuals with the disease are tested. • Specificity, on the other hand, describes the ability of a test to detect the absence of disease. Thus, specificity of a pulp vitality test indicates the test’s ability to identify vital teeth. It is defined as the ratio of the number of patients with a negative test result who do not have disease divided by the total number of tested patients without the disease. A test with a specificity of 0.80 has an 80 percent chance of returning negative results when performed on persons without the disease.

Correlation with Pulp Histopathology Conservative procedures, aimed at preserving pulp vitality, can only be effective if the status of the pulp is accurately assessed. Responses to vitality testing, however, correlate poorly with histological findings.

Objectivity • Ingle and Beveridge have proposed that patient responses to pulp testing procedures may be considered objective. • The use of a ‘control’ tooth, on the opposite side of the mouth, has been proposed to remove subjectivity from an individual’s response. This, approach, however, is still

open to criticism as there is no way of knowing whether the ‘control’ tooth itself is normal.

Reproducibility • Reiss and Furedi have reported that patients respond differently to pulp tests on different days, and at different hours of the same day. • Reproducibility of pulp testing is therefore an area for concern and may relate to the variable state of mind of the patient as well as the lack of intrinsic accuracy of several types of commercial electrical pulp testers.

Unpleasant Sensation • All methods of pulp testing require the patient to indicate when he or she feels a sensation. • Naylor and Greenwood consider that pain is the only sensation elicited by stimulation of pulpal nerves. • Mumford and Newton, reported that patients use many words other than ‘pain’ to describe the sensation. In most cases, however, the resultant sensation is perceived as ‘unpleasant’.

Effect of Dental Development • Many authors have observed that erupting teeth show an increased threshold value to EPT or may give no response, even though their vitality is assured. • Sensitivity to electrical stimulation appears to be related to the stage of root development. • Fulling and Andreasen found that thermal testing with carbon dioxide snow gave consistently positive responses irrespective of the stage of dental development.

Effect of Drugs Several authors have stated that sedative, tranquillizing, or analgesic medications increase the threshold of stimulation of pulpal nerves in some patients.

Effect of Periodontal Disease There are conflicting reports as to the effect of periodontal disease on pulp testing responses. No increase in pulpal stimulus threshold has been reported in the presence of periodontal disease or bone loss.

Effect of Trauma • Several authors have highlighted the unpredictable response of a tooth to pulp testing following trauma. • Immediately following traumatic injury, teeth often fail to respond to conventional pulp testing methods

Chapter 52  Diagnostic Pulp Testing due to temporary loss of response caused by injury, inflammation, pressure, or tension to apical nerve fibers. It may take 8 weeks, or longer, before a normal pulpal response can be elicited. • Bhaskar and Rappaport found vital pulp tissue in a series of 25 teeth which has sustained trauma and did respond to conventional vitality tests. They concluded that conventional pulp tests are simply tests of sensitivity, and as such, have questionable value in predicting pulp vitality. For this reason, they recommended that endodontic therapy be delayed in the case of traumatized teeth, and the pulp tissue considered vital in the absence of sinus tract or periapical radiolucency. • A more accurate assessment of pulp vitality would be made by determining the presence of a functioning blood supply, thus allowing the healing potential to be evaluated at an earlier stage.

Limitations in Children • According to Mumford, pulp testing in children below the age of 10 years is unreliable because children may not cooperate for the test. The incomplete innervations

of newly erupted teeth may affect the results (as neural sensitivity in primary teeth varies with the stage of root development and resorption). They may elicit false positive or false negative results if the dentist asks the child leading questions and also the unpleasant stimuli produced by the tester may affect behavior management/ cooperative problems with pediatric patients. Though the use of traditional tests helps establish an empirical diagnosis, none of these tests are completely reliable. Thus the validity of children’s response in pulp vitality testing has been questioned.



Recent studies have shown that blood circulation and not innervation as the most accurate determinant in assessing pulp vitality, as it provides an objective differentiation between necrotic and vital pulp tissue. The unpredictability of testing tooth pulp nerve response is well recognized. When nerve sensations are inhibited or abolished in the tooth traditional tests are of little value, but method based upon the pulpal vasculature response is a better option. Finally, one should consider recent methods of pulp vitality testing that attempt to measure the pulpal condition objectively.

POINTS TO REMEMBER • • • • • • • •

Pulp vitality testing is assessment of the pulp’s blood supply and is done by Laser Doppler and Pulse Oximeter. Pulp sensibility testing is assessment of the pulp’s sensory response and is done by thermal and electric tests. Pulp sensitivity testing checks the responsive of pulp to a stimulus. Thermal tests were first reported by Jack in 1899. Ice, Ethyl chloride, CO2 snow, Dichlorodifluoromethane (DDM) are used for cold tests. Heat test can be done either by heated gutta-percha sticks or by heated ball burnisher. Electric pulp testing was initiated by Magitot. In case of trauma we must wait for 4 to 6 weeks before conducting pulp vitality tests as it is the minimum time required for pulp to heal. • Laser Doppler flowmetry is a new method of evaluating pulp vitality by measuring the velocity of RBC in capillaries and was described in dental literature in 1986 by Gazelius et al. • Pulse oximetry measure the blood oxygen saturation levels. • Some recent advancements in pulp diagnosis are transmitted laser light, transillumination, ultraviolet light photography, surface temperature measurement, photoplethysmography, thermography, transmitted light photoplethysmography, dual wavelength spectrometry, Hughes Probeye camera.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Define and classify pulp testing. Write a note on thermal tests of pulp vitality. Explain electric pulp testing with its principle and procedure. Describe pulp vitality tests. What are the recent modifications in the area of pulp testing? Enumerate and explain the limitations of pulp testing.

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BIBLIOGRAPHY 1. B Gazelius, L Olgart, B Edwall, L Edwall. “Noninvasive recording of blood flow in human dental pulp,” Endodontics and Dental Traumatology. 1986;2(5):219-21. 2. B Gazelius, U Lindh-Strömberg, H Pettersson, PAÖberg. “Laser Doppler technique: a future diagnostic tool for tooth pulp vitality,” International Endodontic Journal. 1993;26(1):8-9. 3. Chen E, Paul V. Dental Pulp Testing: a Review. International Journal of Dentistry, Volume. 2009.pp.1-12. 4. CM Hill. “The efficacy of transillumination in vitality tests.” International Endodontic Journal. 1986;19(4):198-201. 5. DD Peters, JC Baumgartner, L Lorton. “Adult pulpal diagnosis. I. Evaluation of the positive and negative responses to cold and electrical pulp tests,” Journal of Endodontics. 1994;20(10):506-11. 6. DS Ramsay, J Artun, SS Martinen. “Reliability of pulpal blood-flow measurements utilizing laser Doppler flowmetry,” Journal of Dental Research. 1991;70(11):1427–30. 7. EH Ehrmann. “Pulp testers and pulp testing with particular reference to the use of dry ice,” Australian Dental Journal. 1977;22(4):272–9. 8. F Lutz, W Mormann, T Lutz. “Enamel cracks caused by vitality tests with carbon dioxide snow,” SSO: Schweizerische Monatsschrift für Zahnheilkunde. 1974;84(7):709-25. 9. G Chambers. “The role and methods of pulp testing in oral diagnosis: a review,” International Endodontic Journal. 1982;15(1):1-15. 10. Gopikrishna V, Pradeep G, Venkateshbabu N. Assessment of pulp vitality: A review. International Journal of Paediatric Dentistry. 2009;19:3-15. 11. HJ Fulling, JO Andreasen. “Influence of maturation status and tooth type of permanent teeth upon electrometric and thermal pulp testing.” Scandinavian Journal of Dental Research. 1976;4(5):286-90. 12. H Rowe, TR Pitt Ford. “The assessment of pulpal vitality,” International Endodontic Journal. 1990;23(2):77-83. 13. JM Mumford. “Thermal and electrical stimulation of teeth in the diagnosis of pulpal and periapical disease,” Proceedings of the Royal Society of Medicine. 1967;60(2):197-200. 14. J Mumford. “Evaluation of gutta-percha and ethyl chloride in pulp testing,” British Dental Journal. 1964;116:338-42. 15. Kayalvizhi G, Subramaniyan B. Traditional Pulp Vitality Testing Methods: an overview of their limitations. J Oral Health Comm Dent. 2011;5(1):12-4. 16. K Fuhr, W Scherer. “Prüfmethodik und Ergebnisse vergleichender Utersuchungen zur vitalitätsprüfung von Zähnen,” Dtsch Zahnarztl Z. 1968;23:1344-9. 17. KJ Penna, RS Sadoff. “Simplified approach to use of electrical pulp tester,” The New York State Dental Journal. 1995;61(1):30-1. 18. LC Stoops, D Scott Jr. “Measurement of tooth temperature as a means of determining pulp vitality,” Journal of Endodontics. 1976;2(5): 141-5. 19. L Zach. “Pulp lability and repair; effect of restorative procedures,” Oral Surgery, Oral Medicine, Oral Pathology. 1972;33(1):111-21. 20. M Brännström. “The hydrodynamics of the dental tubule and pulp fluid: its significance in relation to dentinal sensitivity,” in Proceedings of the Annual Meeting of the American Institute of Oral Biology. 1966;23:219. 21. Öhman. “Healing and sensitivity to pain in young replanted human teeth. An experimental, clinical, and histological study,” Odontologisk Tidskrift. 1965;73:166–227. 22. PC Foreman. “Ultraviolet light as an aid to endodontic diagnosis,” International Endodontic Journal. 1983;16(3):121-6. 23. Petersson, C Soderstrom, M Kiani-Anaraki, G Levy. “Evaluation of the ability of thermal and electrical tests to register pulp vitality,” Dental Traumatology. 1999;15(3):127-31. 24. PM Dummer, R Hicks, D Huws. “Clinical signs and symptoms in pulp disease,” International Endodontic Journal. 1980;13(1):27-35. 25. Shoher, Y Mahler, S Samueloff. “Dental pulp photo-plethysmography in human beings,” Oral Surgery, Oral Medicine, Oral Pathology. 1973;36(6):915-21. 26. SN Bhaskar, HM Rappaport. “Dental vitality tests and pulp status,” The Journal of the American Dental Association. 1973;86(2):409-11. 27. S Radhakrishnan, AK Munshi, AM Hegde. “Pulse oximetry: a diagnostic instrument in pulpal vitality testing,” The Journal of Clinical Pediatric Dentistry. 2002;26(2):141-5. 28. S Seltzer, IB Bender, M Ziontz. “The dynamics of pulp inflammation: Correlations between diagnostic data and actual histologic findings in the pulp,” Oral Surgery, Oral Medicine, Oral Pathology. 1963;16(8):969-77. 29. T Sasano, D Onodera, K Hashimoto, et al. “Possible application of transmitted laser light for the assessment of human pulp vitality— part  2: increased laser power for enhanced detection of pulpal blood flow,” Dental Traumatology. 2005;21(1):37-41.

53

Chapter

Endodontic Armamentarium Satish V, Nikhil Marwah

Chapter outline • • • •

Goals of Mechanical Root Canal Preparation Classification of Endodontic Instruments ISO Standardization of Endodontic Instruments General/Basic Endodontic Instruments

Preparation of the root canal system is recognized as being one of the most important stages in root canal treatment. It includes the removal of vital and necrotic tissues from the root canal system, along with infected root dentin and, in cases of retreatment, the removal of metallic and nonmetallic obstacles. Although mechanical preparation and chemical disinfection cannot be considered separately and are commonly referred to as chemomechanical or biomechanical preparation the following chapter is intended to focus on the endodontic armamentarium only. Although Fauchard, one of the founders of modern dentistry described instruments for trepanation of teeth, preparation of root canals and cauterization of pulps in his book ‘Le Chirurgien Dentiste’, no systematic description of preparation of the root canal system could be found in the literature at that time. First endodontic hand instrument has been developed by Edward Maynard. Notching a round wire (in the beginning watch springs, later piano wires), he created small needles for extirpation of pulp tissue. In 1852, Arthur used small files for root canal enlargement and in 1915 the K file were introduced. The standardization of instruments was first proposed in 1929 by Trebitsch and by Ingle in 1958, but ISO specifications for endodontic instruments were published in 1974.

GOALS OF MECHANICAL ROOT CANAL PREPARATION As stated earlier, mechanical instrumentation of the root canal system is an important phase of root canal preparation

• • • •

Exploring Endodontic Instruments Debridement Instruments Cleaning and Shaping Instruments Obturating Instruments

as it creates the space that allows irrigants and antibacterial medicaments to more effectively eradicate bacteria and eliminate bacterial byproducts. However, it remains one of the most difficult tasks in endodontic therapy. The major goals of root canal preparation are: • Removal of vital and necrotic tissue from the main root canal. • Creation of sufficient space for irrigation and medication. • Preservation of the integrity and location of the apical canal anatomy. • Avoidance of iatrogenic damage to the canal system and root structure. • Facilitation of canal filling. • Avoidance of further irritation and/or infection of the periradicular tissues. • Preservation of sound root dentin to allow long-term function of the tooth.

CLASSIFICATION OF ENDODONTIC INSTRUMENTS

According to Grossman • • • •

Exploring instruments, e.g. smooth broaches Debridement instruments, e.g. barbed broaches Cleaning and shaping instruments, e.g. files Obturating instruments, e.g. spreaders, pluggers.

According to Ingle ISO Group I: Hand use only, e.g. K files, H files, broach, pluggers.

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ISO Group II:  Engine driven latch type, e.g. lentulo-spiral. ISO Group III:  Engine driven latch type, e.g. Gates Glidden, paeso-reamer. ISO Group IV: Root canal filling points, e.g. gutta-percha, silver points.

ISO STANDARDIZATION OF ENDODONTIC INSTRUMENTS (FIGS 53.1 TO 53.3)

Fig. 53.1:  Original ISO standardization given by Ingle and Levine (1958)

Fig. 53.3:  Color coding of files according to new standardization

GENERAL/BASIC ENDODONTIC INSTRUMENTS (FIGS 53.4A TO D)

Fig. 53.2:  New standardization proposed in 2002 (No. from 6 to 140 / D1 became D0 / D2 became D16 / Half sizes in 0.02 flare were introduced like 2.5, 17.5 / Ni-Ti Profile named 0.29 series)

• Plastic instruments: It has two ends; the first is used to carry temporary filling material. The opposite end is used as a plugger to condense cement and base materials in the root canal. • Endodontic excavator: It is larger than a spoon excavator, used to allow excavation of the contents of the pulp chamber. It is also used in curettage of periapical lesions in surgical endodontics (apicectomy). • Endodontic locking pliers (tweezer): It has a lock that allows materials to be held without continuous finger pressure; also it has a groove which facilitates holding gutta-percha and absorbing points. • Endodontic ruler: It is a metal ruler made of 0.5 mm divisions. It is a convenient instrument to measure reamers, files and gutta-percha. • Instrument organizer (endodontic kit): It is used for arrangement of reamers and files according to the size and length. The organizer provides holes for the files to be placed vertically in a sponge which is saturated with disinfectant to maintain its sterility. • Endodontic syringe: It is used to carry irrigating solution into the root canal. The tip of the instrument is flat to

Chapter 53  Endodontic Armamentarium

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B

C

D Figs 53.4A to D:  Basic endodontic instruments

prevent penetration of the needle to the small canals; also it has a groove in its tip to permit the irrigation which might be under pressure to flow coronally rather than forcing it to the apical foramen causing postoperative pain. • Transfer sponge: It is sponge saturated with disinfectant solution. The reamers and files can be placed in it after being used. • Instrument stopper (rubber stopper): It is used to mark the length of the tooth on reamers and files; it should be perpendicular to the long axis of the reamer. It may be made of rubber or metal.

Smooth Broaches • Also called as Miller needles. • These are smooth, pointed and tapered with either round, pentagonal or square cross-section. • Smooth broaches are useful as pathfinder in curved fine canals because of their flexibility and fine diameter.

EXPLORING ENDODONTIC INSTRUMENTS These are used to locate the root canal orifice and to determine or assist in obtaining patency of root canal, e.g. smooth broach and endodontic explorer.

Endodontic Explorer • A double end instrument. • One end is straight used to locate the root canal orifices after the removal of the pulp chamber, and the other end is L-shaped which aids in detecting the unremoved parts of the tooth as the roof of pulp chamber.

DEBRIDEMENT INSTRUMENTS The instruments which are used to extirpate the pulp from the root canal or from pulp chamber or necrotic tooth debris.

Endodontic Excavator • It is larger than spoon excavator and is used to allow excavation of the contents of the pulp chamber. • It is also used in curettage of periapical lesions in surgical endodontics.

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Barbed Broaches • It is a short handled instrument with a shaft having projections directed obliquely towards the handle. • It is used to extirpate pulp in the root canal, remove cotton and paper points from the root canal, loosen debris in necrotic canals. • It is manufactured from a tapered round soft steel wire of varying diameter into which, angle cuts are made to produce barbs. • The disadvantage of this instrument is it can be used in straight canals not the blunt canals.

however differ in design, number of flutes and cross-section which is directly proportional to the action and cutting efficiency of each of these cleaning and shaping instruments (Fig. 53.5).

K Files • Designed as early as 1904 by Kerr. • Originally made from a square or triangular blank, machine twisted to form a tight spiral with more cutting flutes than a reamer. • 1½ to 2½ flutes/mm • Less susceptible to breakage • Decreased flexibility • Lesser cutting efficiency • Rasping or pulling action.

Modifications of K File

CLEANING AND SHAPING INSTRUMENTS These instruments are used to shape the root canal laterally and apically. These include K files, H files, reamers and Ni-Ti files. Although the basic function of all files is the same they

• K-Flex File: It is introduced in 1982. It is made of a diamond or rhomboid cross-section bar. This instrument is more flexible because of decreased crosssection diameter. The rhomboidal blank produces alternating high and low flutes those are supposed to make the instrument more efficient to remove debris. It is available in stainless steel and Ni-Ti types. • Flex-O File: This employs a more flexible type of file which does not fracture easily. These instruments are developed from triangular cross-section bar. They have 1.81 flutes/mm hence have more cutting efficiency. • Triple-Flex: These have more flutes than reamer but less than K file.

Reamer

Fig. 53.5:  Variable flute designs of files

• They are constructed from a square or triangular blank, twisted into a spiral but with fewer cutting flutes than a file. • It cuts only dentin if it is rotated. • ½ to 1 flute/mm • More cutting efficiency • Pushing, rotating and retracting action.

Chapter 53  Endodontic Armamentarium

H Files • They are called Hedstrom files • They are made of stainless steel and are machined from a round tapered blank. • They have good cutting efficiency and are used in pulling action. • They are flexible and are indicated in tortuous canals as in primary teeth. • The procedure for shaping using H files is that file is inserted into the root canal to the apex, laterally pressed against one side of the canal wall, and withdrawn with a pulling motion to file the dentinal wall. • Kennedy strongly recommends use of H files in primary teeth, since they remove hard tissue only on withdrawal which prevents pushing the infected material through the apices. • Sizes—0.10 to 1.40 mm and Tip size—0.15 to 0.60 mm • The main disadvantage of H files is that they tend to fracture.

OBTURATING INSTRUMENTS The function of these instruments is to pack root canal with obturating material or help in accomplishing the task. These include spreader, pluggers and lentulo-spirals.

Spreader • Long tapered and pointed end instrument • Used to compress gutta-percha in lateral condensation • It can be classified as hand spreader (Fig. 53.6) and finger spreader (Fig. 53.7). • Finger spreader is like files and is smaller and shorter to be used in posterior teeth.

Modifications of H File • Safety H files: Introduced by Kerr manufacturing Co. in 1998. A noncutting side characterizes the spiral of the working end of these files with smoothened edges to prevent ledging in curved canals. A flat side on the handle orients the operation to the smoothened edge of the instrument while using it in the root canal. • Sharpie® Hedstrom files: These are designed for teeth with irregular walls or for removing instruments from a canal. • Miltex ® Hi-5 ® files: These are designed with helically ground flutes and pentagonal cross-section which is good for penetration in small or calcified canals.

Fig. 53.6:  Hand spreader

Fig. 53.7:  Finger spreader

Plugger • Long and blunt flat tip blade instrument used for vertical condensation of the obturating material. • It is of two types: Long handled (Fig. 53.8) and finger type (Fig. 53.9).

Nickel – Titanium Files • They are introduced by Elizabeth S Bair in 1999-2000. • They have nickel (55%) and titanium (45%). • The flexibility and the instru­ment design allow the files to closely follow the original root canal path. • The tortuous and irregular canal walls of primary molars are effectively cleaned with NiTi files since the clockwise motion of the rotary files, pulls pulpal tissue and dentin out of the canal as the files are engaged. • Advantages – Tissue and debris are more easily and quickly removed – Faster results – Allows easy access to all canals – It possesses a memory effect. • Disadvantages – Cost – Learning the technique.

Fig. 53.8:  Hand plugger

Fig. 53.9:  Finger plugger

Lentulo-Spiral • Function is placement of sealer in canal. • Also used in obturation of primary teeth with paste system. • It can be used as hand held or in a slow speed handpiece. • They have reverse spiral shape which enables easy insertion of material in canal. • Advantage is ease of work and minimal time con­ sumption. • Disadvantage is breakage or frocking of spiral.

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POINTS TO REMEMBER • • • • • • • • • • • • • • • •

First endodontic hand instrument has been developed by Edward Maynard. Arthur, 1852 was the first to use files. K file was introduced in 1915. The standardization of instruments was first proposed in 1929 by Trebitsch and by Ingle in 1958 A new standardization of instruments was proposed in 2002 which changed the numbers, added new components like half diameters and protaper files. The major goals of root canal preparation are removal of vital and necrotic tissue from the main root canal, creation of sufficient space for irrigation and medication and preservation of the integrity and location of the apical canal anatomy. Exploring instruments: Smooth broaches; debridement instruments: Barbed broaches; Cleaning and shaping instruments: Files; Obturating instruments: Spreaders, pluggers. Endodontic explorer is used to locate the root canal orifices. Smooth broaches are useful as pathfinder in curved fine canals. Barbed broaches are used to extirpate pulp in the root canal. K files were designed as early as 1904 by Kerr and made from a square or triangular blank. They have less cutting efficiency and flexibility but are less susceptible to breakage. Newer modification of K-files include K-Flex File and Flex-O-File which have better cutting efficiency H files are machined from a round tapered blank, work on pulling action and have high flexibility and cutting efficiency. Kennedy strongly recommends use of H files in primary teeth, since they remove hard tissue only on withdrawal which prevents pushing the infected material through the apices. Nickel–Titanium files were introduced by Elizabeth S Bair in 1999-2000. These have shape memory and the instrument design allow the files to closely follow the original root canal path. Obturating instruments are used to pack root canal with obturating material or help in accomplishing the task. These include spreader, pluggers and lentulo-spirals.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Classify endodontic instruments and outline the goals of biomechanical preparation. Explain the concept of ISO standardization of endodontic instruments. Write a note on broaches. What are the recent modifications of K files? Explain and differentiate between K files, H files, reamers and Ni-Ti files. What are obturating instruments?

BIBLIOGRAPHY 1. Anthony LP, Grossman LI. A brief history of root canal therapy in the United States. J Am Dent Assoc. 1945;32:43-50. 2. Briseno BM, Sonnabend E. The influence of different root canal instruments on root canal preparation: an in vitro study. Int Endod J. 1991;24:15-23. 3. Bryant ST, Dummer PMH, Pitoni C, Bourba M, Moghal S. Shaping ability of 0.04 and 0.06 taper profile rotary nickel–titanium instruments in simulated root canals. Int Endod J. 1999;32:155-64. 4. Bryant ST, Thompson SA, Al-Omari MAO, Dummer PHM. Shaping ability of Profile rotary nickel–titanium instruments with ISO sized tips in simulated root canals: Part 1. Int Endod J. 1998a;31:275-81. 5. Curson I. History and endodontics. Dent Pract. 1965;15:435-9. 6. Fauchard P. (1733) Tractat von den Zähnen. Heidelberg: Reprint Hüthig-Verlag; 1984. 7. Grossman LI. Pioneers in endodontics. J Endod. 1987;13:409-15. 8. Ingle JI. A standardized endodontic technique using newly designed instruments and filling materials. Oral Surg Oral Med Oral Pathol. 1961;14:83-91. 9. Lilley JD. Endodontic instrumentation before 1800. J Br Endod Soc. 1976;9:67-70. 10. Ruddle C. Cleaning and shaping the root canal system. In: Cohen S, Burns R (Eds). Pathways of the Pulp, 8th Edn. St Louis, MO: Mosby; 2002.pp.231-92. 11. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18:269-96. 12. Walia H, Brantley WA, Gerstein H. An initial investigation of bending and torsional properties of nitinol root canal files. J Endod. 1988;14:346-51.

54

Chapter

Pulp Therapy for Vital Teeth Nikhil Marwah, Satish V

Chapter outline • •

Indirect Pulp Capping Direct Pulp Capping

Pulp exposure of the dental pulp exists when the continuity of the dentin surrounding the pulp is broken by physical or bacterial means leading to direct communication between the pulp and external environment. Pieter Van Forest was the first to speak about root canal therapy and in 1910 Glove designed instruments that could prepare a canal to a certain size and taper. The objectives of pulp therapy are conservation of the tooth in a healthy state of functioning as an integral component of the dentition; preservation of the arch space; enhances esthetics, mastication; helps in maintenance of a healthy oral environment; prevention of deleterious effects on the succedaneous tooth, and the periapical tissue.

INDIRECT PULP CAPPING • Indirect pulp capping is defined as a procedure where in small amount of carious dentin is retained in deep areas of cavity to avoid exposure of pulp, followed by placement of a suitable medicament and restorative material that seals off the carious dentin and encourages pulp recovery. (Ingle). • A procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a time with a biocompatible material (McDonald).

Objective of indirect pulp capping These were given by Eidelman in 1965: • Arresting the carious process • Promoting dentin sclerosis • Stimulating formation of tertiary dentin • Remineralization of carious dentin.

• • •

Pulpotomy Current Concepts in Pulpotomy Apexogenesis

• Ricketts et al. stated that “in deep lesions, partial caries removal is preferable to complete caries removal to reduce the risk of carious exposure.” • In 1961, Damle SG termed IPC as “Reconstructed Dentin” to prevent pulp exposure.

Rationale • Its rationale is that carious dentin consists of two distinct layers. An outer layer that is irreversibly denatured, infected, not remineralizable and should be removed and an inner layer that is reversibly denatured, not infected, remineralizable and should be preserved. • Removing the outer layers of the carious dentin, that contain the majority of the microorganisms thus reducing the continued demoralization of the deeper dentin layers from bacterial toxins, and sealing the lesion to allow the pulp to regenerate reparative dentin.

Layers of Carious Dentin Outer layer

Middle layer

Inner layer

Necrotic, soft, brown dentin outer layer

A firm (leathery), discolored dentin layer

A hard, discolored dentin deep layer

Teeming with bacteria

Fewer bacteria

Minimal amount of bacterial invasion

Not painful to remove

Painful to remove

Painful to instrumentation

648 Section 10 

Pediatric Endodontics Indications of IPC History

• Mild pain associated with eating • Negative history of spontaneous, extreme pain

Clinical examination • Deep carious lesion, which are close to, but not involving the pulp in vital primary or young permanent teeth • No mobility • When pulp inflammation is seen as nominal and there is a definite layer of affected dentin after removal of infected dentin

Radiographic examination • Normal lamina dura and PDL space • No radiolucency in the bone around the apices of the roots or in the furcation

Contraindications of IPC History

Clinical examination

• Sharp, penetrating pulpalgia indicating acute • Mobility of the tooth pulpal inflammation • Discoloration of the tooth • Prolonged spontaneous pain particularly at • Negative reaction of electric pulp testing night

Treatment Procedure (Figs 54.1A to D) • The earlier approach was the 2 appointment procedure but now single session is preferred as: – The re-entry to remove the residual minimal carious dentin may not be necessary if the final restoration maintains a seal and the tooth is asymptomatic.

Radiographic examination • Definite pulp exposure • Interrupted or break in lamina dura • Radiolucency about the apices of the roots • Widened periodontal ligament space

– After cavity preparation, if all the carious dentin was removed except the portion that would expose the pulp, re-entry might be unnecessary. – If a pulp exposure occurs during a re-entry. A more invasive vital pulp therapy technique would be indicated.

A

B

C

D Figs 54.1A to D: Procedure of pulp capping

Chapter 54  Pulp Therapy for Vital Teeth

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Procedure of application of pulp capping agent •

•

Most frequent used material for indirect pulp capping is Dycal (calcium hydroxide). This is supplied as two paste system one containing base (brown) (titanium dioxide in glycol salicylate) and the other catalyst (white) (calcium hydroxide and zinc oxide in ethyl toluene sulfonamide). One drop of each paste is dispensed in the mixing pad. Now the catalyst paste (white) is lifted with a blunt probe and carried to the cavity where it is spread all over the cavity floor only. In similar fashion the base paste (brown) is taken to the cavity and the two pastes are then mixed in the cavity and spread evenly with the help of ball burnisher. This not only evenly mixes the pastes but also allows a uniform thickness to be attained in cavity. Although dycal can be mixed on the pad and carried to the cavity also the above described method is more convenient as dycal sets very fast after mixing.

Sequelae/Outcome of IPC Three distinct types of new dentin formation take place1 1. Cellular fibrillar dentin—first 2 months 2. Globular dentin—3 months 3. Tubular dentin (uniform mineralized dentin) • 1/5th of reparative dentin formation begins in less than 30 days • After 3 months, 0.1 mm is formed.

• Exposure should have bright red hemorrhage that is easily controlled by dry cotton pellet with minimal pressure. • True pin point exposure.

Contraindications • • • • • • • •

Severe toothache at night Spontaneous pain Tooth mobility Radiographic appearance of pulp, periradicular de­ generation. Excess of hemorrhage at the time of exposure Serous exudate from the exposure External/internal root resorption Swelling/fistula.

Treatment considerations •

•

•

DIRECT PULP CAPPING

•

It is defined by Kopel (1992) as the placement of a medicament or nonmedicated material on a pulp that has been exposed in course of excavating the last portions of deep dentinal caries or as a result of trauma.



Debridement: Necrotic and infected dentin chips have to be removed else they will invariably be pushed into the exposed pulp during last stages of caries removal and impede healing and increase pulpal inflammation. Hemorrhage and clotting: A blood clot should not be allowed to form at the exposure site because it may impede pulpal healing or formation of reparative dentin. Bacterial contamination: Once all the caries or debris is removed, the cavity should be irrigated with saline, if not the debris may interfere with healing. Exposure enlargement: The exposure site must be enlarged because: – It removes inflammation and infected tissue in the exposed area. – It facilitates washing away carious and noncarious debris. – It allows a closer contact of more capping medicament material to the actual pulp tissue.

Objective To create new dentin in the area of the exposure and subsequent healing of the pulp.

Rationale To achieve a biologic closure of the exposure site by deposition of hard tissue barrier (dentin bridge) between pulp tissue and capping material thus walling off the exposure site.

Indications • Small mechanical exposure surrounded by sound dentin in asymptomatic vital primary teeth or young permanent teeth.

Histological Changes after Pulp Capping (Fig. 54.2) • These were illustrated be Glass and Zander in 1949. – After 24 hours: Necrotic zone adjacent to calcium hydroxide paste is separated from healthy pulp tissue by a deep staining basophilic layer. – After 7 days: Increase in cellular and fibroblastic activity. – After 14 days: Partly calcified fibrous tissue lined by odontoblastic cells is seen below the calcium protienate zone; disappearance of necrotic zone. – After 28 days: Zone of new dentin.

Chapter 54  Pulp Therapy for Vital Teeth

Technique of Direct Pulp Capping (Figs 54.3A to C)

Fig. 54.2: Zone of histological changes

A

B

C Figs 54.3A to C: Direct pulp capping

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 edications and Materials Used M for Pulp Capping • Calcium hydroxide: – Calcium hydroxide is a white, crystalline, slightly soluble basic salt that dissociates into calcium ions and hydroxyl ions in solution and exhibits a high alkalinity (pH 11). It is used in both setting and nonsetting forms in dentistry. Dentists also use calcium hydroxide because of its antimicrobial properties and its ability to induce hard-tissue formation. – Calcium hydroxide forms a dentin bridge when placed in contact with pulpal tissues (Rasmussen P, Mjor IA, 1971).2 – Initially, a necrotic zone is formed adjacent to the material, and, depending on the pH of the calcium hydroxide material, a dentin bridge is formed directly against the necrotic zone. Under this the tissue differentiates into odontoblasts, which then elaborate into matrix. – The necrotic zone is resorbed and replaced by a dentin bridge, however this barrier is not always complete. (Holland R et al. 1979).3 – Several theories exist as to how calcium hydroxide induces hard-tissue formation. These include the high alkalinity (pH of 11), which produces a favorable environment for the activation of alkaline phosphatase, an enzyme involved in mineralization. (Foreman PC, Barnes IE, 1990; Heithersay GS, 1978; Siqueira JF Jr, Lopes HP, 1999).4-6 – Some common calcium hydroxide agents used for direct pulp capping are calcium hydroxide powder with distilled water, pulpdent (52.5% calcium hydroxide in an aqueous sol. of methyl cellulose), Dycal and Hydrex (calcium hydroxide, barium sulfate, titanium dioxide). • Corticosteroids and antibiotics: – Brosch JW introduced this combination in 1966. – These agents include neomysin and hydrocortisone; ledermix [Ca(OH)2 and prednisolone], penicillin or vancomycin with Ca(OH)2. • Inert materials: – Isobutyl cyanoacrylate and tricalcium phosphate ceramic. • Collagen fibers: – Collagen fibers influence mineralization and are less irritant than Ca(OH)2 with dentin bridge formation in 8 weeks. • 4-META adhesive: – The main advantage of 4-META adhesive is that it can soak into the pulp, polymerize there and form a hybrid layer with the pulp thereby providing adequate sealing.

• Direct bonding: – Recent advances in total etch direct bonding have evoked an interest in application for pulp therapy. The attractiveness of these systems is that a polygenic film can be layered over an exposure site without displacing pulp tissue and onto surrounding dentin where it penetrates the tubules. The adhesive film is cured by light and acts as a barrier as a composite resin is gently spread over the pulp onto the surrounding dentin.7 • Isobutyl cyanoacrylate: – Berkman in 1971 used it as capping agent and proved it to be an excellent hemostatic agent as well as a reparative dentin bridge stimulator. – The disadvantage of this material is that it is cytotoxic when freshly polymerized. • Denatured albumin: – This protein has calcium-binding properties. – If a pulp exposure is capped with a protein, the protein may become a matrix for calcification, thereby increasing the chances of biologic obliteration. • Mineral trioxide aggregate: – Mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in pulpal tissues and it promotes rapid cell growth. – Histologic evaluation of pulpal tissue demonstrated that MTA produces a thicker dentinal bridge, less inflammation, less hyperemia and less pulpal necrosis compared with calcium hydroxide. MTA also appears to induce the formation of a dentin bridge at a faster rate than does calcium hydroxide. – The process by which MTA acts to induce dentin bridge formation, however, is not known. Ford8 et al. theorized that the tricalcium oxide in MTA reacts with tissue fluids to form calcium hydroxide, resulting in hard-tissue formation in a manner similar to that of calcium hydroxide. – Caicedo et al. (2006) demonstrated good pulp res­ ponse in primary teeth after direct pulp capping MTA. – According to Farsi9 et al. (2006) and Bogen10 et al. (2008) they have shown high success rate in pulp capping nearly about 93 to 98 percent. • Laser: – Andreas Meritz in 1998 evaluated the effect of laser on direct pulp capping and reported a success rate of 89 percent. • Bone morphogenic protein: – Urist discovered bone morphogenic protein (BMP) in 1965. – He observed that demineralized bone matrix could stimulate new bone formation when implanted to ectopic sites such as muscles. He also observed that demineralized dentin also had inductive properties and it forms both bone and dentine.

Chapter 54  Pulp Therapy for Vital Teeth – The implications for pulp therapy are immense as it is capable of inducing reparative dentin. – They concluded that recombinant human osteogenic protein-1 in a collagen carrier matrix appeared to be suitable as bioactive capping agent for surgically exposed dental pulp.

Limitation of direct pulp capping in primary teeth Direct pulp capping is primarily contraindicated in primary teeth, however, recently lasers are the only option that have demonstrated success of direct pulp capping in primary teeth. Some of the reasons for this contraindication are: • As the inherent potential of primary tooth cells is to resorb the tooth hence more odontoclasts are present as compared to odontoblasts. So when pulp capping material is placed it stimulates the undifferentiated mesenchymal cells that differentiate into odontoclastic cells. These cells exert their resorptive potential which leads to internal resorption. • High cellular content, abundant blood supply and consequently faster inflammatory response and poor localization of infection are some of the other reasons that direct pulp capping is contraindicated in primary teeth.

PULPOTOMY • Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp, followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth.

• American Academy of Pediatric Dentistry (1998) defined pulpotomy as the amputation of affected, infected coronal portion of the dental pulp preserving the vitality and function of the remaining part of radicular pulp.

Objectives • Removal of inflamed and infected coronal pulp at the site of exposure thus preserving the vitality of the radicular pulp and allowing it to heal. • The next main objective is to maintain the tooth in the dental arch.

Rationale (Figs 54.4A to D) • Radicular pulp is healthy and capable of healing after surgical amputation of the infected coronal pulp • Preserves vitality of the radicular pulp • Maintains tooth in a physiologic condition.

Indications of Pulpotomy • Mechanical pulp exposure in primary teeth. • Teeth showing a large carious lesion but free of radicular pulpitis • History of only spontaneous pain • Hemorrhage from exposure sites bright red and can be controlled • Absence of abscess or fistula • No interradicular bone loss • No interradicular radiolucency

Classification of pulpotomy Vital pulpotomy Features It is intended to destroy or mummify the vital tissue.

Types Devitalization

Other name Mummification, cauterization

Preservation

Minimal devitalization, noninductive

This implies maintaining the maximum vital tissue, with no induction of reparative dentin

Regeneration

Inductive, reparative

This has formation of dentin bridge

Mortal pulpotomy

—

Nonvital pulpotomy It is done in compromised cases

Examples Single sitting • Formocresol • Electrosurgery • Laser Two stages • GysiTriopaste • Easlick’s formaldehyde • Paraform devitalizing paste • ZnO Eugenol • Glutaraldehyde • Ferric sulfate • Ca(OH)2 • Bone morphogenic protein • Mineral trioxide aggregate • Enriched collagen • Freezed dried bone • Osteogenic protein • Beechwood cresol • Formocresol

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A

B

C

D

Figs 54.4A to D: Pulpotomy: (A) Carious tooth; (B) Pulpotomized tooth; (C) Tooth restored; (D) Complete rehab with SSC

• At least 2/3rd of root length still present to ensure reasonable functional life • In young permanent tooth with vital exposed pulp and incompletely formed apices.

Contraindications of Pulpotomy • • • • • • • • • •

Persistent toothache. Tenderness on percussion Root resorption more than 1/3rd of root length Large carious lesion with nonrestorable crown Highly viscous, sluggish hemorrhage from canal orifice, which is uncontrollable Medical contradictions like heart disease, immuno­ compromised patient Swelling or fistula External or internal resorption Pathological mobility Calcification of pulp.

Formocresol Pulpotomy/Single Stage Pulpotomy Formocresol was introduced by Buckley in 1904 and since then a lot of modifications have been tried and advocated regarding the techniques of formocresol pulpotomies.

Criteria for case selection (Heilig J et al. 1984 and Waterhouse et al. 2000) • • •

• •

•

Teeth with deep carious lesion (radiographically the caries should be approximating to the pulp). Teeth should be restorable after completion of the procedure. Absence of symptoms indicative of advanced pulpal infla­ mmation such as spontaneous pain or history of nocturnal pain. Absence of clinical signs or symptoms. Absence of clinical or radiographic signs of pulpal necrosis, i.e. furcation involvement, periapical pathology, internal resorption, calcification in canal. Hemorrhage should stop within five minute from the amputated pulp stumps using a sterile pledget of moist cotton. After assessment of clinical and radiographical criteria, single visit pulpotomy procedure was performed on the selected molars.

• Sweet (1930): Formulated multi visit technique • Doyle (1962): Advocated 2 sitting procedure (complete devitalization) • Spedding (1965): Gave 5 minute protocol (partial devitali­ zation) • Venham (1967): Proposed 15 seconds procedure • Current concept uses 4 minutes of application time.

Chapter 54  Pulp Therapy for Vital Teeth Composition of formocresol: Buckley’s Formula • • • •

Procedure of formocresol pulpotomy (Figs 54.6A to G)

Cresol – 35 percent Glycerol – 15 percent Formaldehyde – 19 percent Water – 31 percent.

Preparation Currently we use 1/5th conc. of Buckley’s formula, which is prepared by the following method: Dilute 3 parts (90 mL) glycerine with 1 part (30 mL) diluted sterile water ↓ Add 1 part [30 mL] formocresol to 4 parts diluent ↓ Add 30 mL of formocresol to 120 mL of diluent to obtain 150 mL of dilute formocresol, i.e. 1/5th strength.

Mechanism of Action It prevents tissue autolysis by bonding to the proteins. This bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without changing the basic structure of protein molecules.

Histological Changes • These were demonstrated by Mass and Zilbermann11 in 1933 and also by Massler and Mansokhani in 1959 (Fig.  54.5). • Immediately the pulp becomes fibrous and acidophillic. • Seven to forteen days: Three zones appear: a. A broad eosinophilic zone of fixation b. A broad pale-staining zone of atrophy with poor cellular definition c. A broad zone of inflammation extending apically into normal pulp tissue • One year – Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year.

Concerns about Formocresol

Fig. 54.5: Zones after fixing with formocresol

• Toxicity: Formocresol and formaldehyde have shown to be cytotoxic, mutagenic and carcinogenic in animal experiments by Lewis in 1981. But Ranly calculated that, over 3000 pulpotomies must be performed in the same individual for formocresol to reach toxic level. • Systemic distribution: Myers in 1978 demonstrated systemic distribution of radioisotope labeled formal­ dehyde. When used in pulpotomies in animals, labeled

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A

B

C

D

E

F

G

Figs 54.6A to G: Procedure of pulpotomy: (A) Cavity preparation; (B) Excavating coronal pulp; (C) After complete removal of coronal pulp; (D) Postformocresol fixation; (E) Temporization of cavity; (F) Preoperative X-ray of mandibular second molar showing carious lesion; (G) Postoperative X-ray after pulpotomy

formaldehyde has been found in periodontal ligament, bone, dentine and urine. • Antigenocity: Thoden Valzen in 1977 has shown immuno­ genic potential of formaldehyde in rabbits, dogs and guinea pigs.

• Mutagenicity and cytogenicity: Nongentini in 1980 postulated that mutational changes were achieved by application of formaldehyde and cytogenicity for 15 minutes, in monkey kidney cells. Formaldehyde denaturates nucleic acids by forming methylol

Chapter 54  Pulp Therapy for Vital Teeth derivatives that renders genetic machinery inoperable. It may also effect biosynthesis and cell reproduction by interacting with DNA and RNA. Milnes,12 2006 published an extensive and detailed review of the more recent research on the metabolism, pharmacokinetics, and carcinogenicity of formaldehyde and concluded that formaldehyde is not a potent human carcinogen under conditions of low exposure. He concluded that extrapolation of these research results to pediatric dentistry suggests an inconsequential risk of carcino­ genesis associated with formaldehyde use in pediatric pulp therapy.

Procedure

Modified Formocresol Pulpotomy • This technique was used by Trask (1972) in young permanent molars that have to be retained for a short period of time only. • The technique is identical to that described for primary teeth, except that the formocresol pellet is sealed permanently in the tooth.

Two-visit Devitalization Pulpotomy This is two-stage procedure involving the use of para­ formaldehyde to fix the entire coronal and radicular pulp tissue in two visits.

Indications • There is evidence of sluggish bleeding at the amputation site that is difficult to control • Pus in the chamber, but none at the amputation site • There is thickening of the PDL • History of pain.

Contraindications • Nonrestorable tooth • Tooth with necrotic pulp.

Materials used for two-visit pulpotomy Gysitriopaste

Easlick’s paraformaldehyde paste

Paraform devitalizing paste

• Tricresol

• Paraformaldehyde

• Paraformaldehyde

• Cresol

• Procaine base

• Lignocaine

• Glycerin

• Powdered asbestos

• Propylene glycol

• Paraformaldehyde • Petroleum jelly

• Carbowax

• ZOE

• Carmine to color

Glutaraldehyde Pulpotomy • It was first suggested by S Gravenmade and was introduced by Kopel in 1979. • He suggested that inflamed tissue that produces toxic by products should be fixed, rather than being treated with strong disinfectants. He felt that satisfactory fixation with formocresol required, an excessive amount of medication, as well as longer period of interaction but glutaraldehyde solution might replace formocresol in endodontics, because it appears to have fixative properties with less destruction of tissue and at the same time appears to be bactericidal.

Mechanism of Action • Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue.

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• A narrow zone of eosinophilic, stained and compressed fixed tissue is found directly beneath the area of application, which blends into vital normal appearing tissue apically. • With time, the glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue, thus the entire root canal tissue is vital.13

Advantages of Glutaraldehyde over Formocresol • It is bifunctional reagent, which allows it to form strong intra and intermolecular protein bonds leading to superior fixation by cross linkage. • It is excellent antimicrobial. • Superior fixative properties, self-limiting penetration, • Causes less necrosis of the pulpal tissue. • Causes less dystrophic calcification in pulp canals. • Less toxicity does not perfuse through the pulp tissue to the apex. • Demonstrates less systemic distribution. • It is low tissue binding, readily metabolized, eliminated in urine and expired in gases—90 percent of the drug is gone in 3 days. • Mutagenicity and antigenicity—Less as compared to formocresol.

Ferric Sulfate Pulpotomy • Ferric sulfate as a 15.5 percent solution has been commonly used as a coagulative and hemostatic retraction agent for crown and bridge impressions and is slightly acidic. • The mechanism of action is still debated but agglutination of blood proteins results from the reaction of blood with both ferric and sulfate ions. The agglutinated proteins form plugs to occlude the capillary orifices. • Ferric sulfate as a pulpotomy agent on the theory that its mechanism of controlling hemorrhage might minimize the chances for inflammation and internal resorption. • Ranly proposed that metal protein clot at the surface of the pulp stump acts as a barrier to irritating components of the sub base. • Fuks13 (1997) showed 93 percent of success rate of ferric sulfate when compared with formocresol pulpotomy which showed 84 percent of success rate. • Smith14 (2000) reported a clinical success rate of 99 percent but radiographic success rate of 74 percent in ferric sulfate pulpotomy.

• Markovic et al. (2005) showed 91 percent success rate with formocresol and 89 percent success rate with ferric sulfate pulpotomy.

Laser Pulpotomy • In 1985, Ebimara reported the effects of Nd: YAG laser on the wound healing of amputed pulps. • After complete extirpation of pulp from pulp chamber exposure to Nd: YAG laser at 20 Hz was done. Then IRM paste was placed over the pulp stumps and restoration was done. • Liu JF15 (2006) compared the effects of Nd:YAG laser pulpotomy with formocresol on human primary teeth. In the Nd:YAG laser group, clinical success was 97 percent, and radiographic success was 94 percent. Whereas in formocresol pulpotomy the success rates were 85 percent and 78 percent respectively.

Electrosurgical Pulpotomy • Mark was the first US dentist routinely to perform elec­ trosurgical pulpotomies in 1993 with a success rate of 99  percent for primary molars.

Procedure

Chapter 54  Pulp Therapy for Vital Teeth

Cvek’s Pulpotomy

Mortal Pulpotomy

• This is also called as calcium hydroxide pulpotomy or young permanent partial pulpotomy. • This was proposed by Mejare and Cvek16 in 1978. • Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial means and the remaining radicular tissue is judged vital by clinical and radiographic criteria whereas the root closure is not complete. • Rationale – To preserve vitality of radicular pulp and allow for normal root closure.

• It is also called nonvital pulpotomy • Ideally, nonvital tooth should be treated by pulpectomy, but sometimes it is impracticable due to non-negotiable root canals and limited patient cooperation, mortal pulpotomy is indicated for such patients.

Procedure

Procedure (Figs 54.7A and B)

CURRENT CONCEPTS IN PULPOTOMY

Use of MTA

A

B Figs 54.7A and B: Cvek’s pulpotomy

• Torabinejad described the physical and chemical properties of MTA in 1995. • It is ash colored powder made primarily of fine hydrophilic particles of tricalcium aluminate, tricalcium silicate, silicate oxide, tricalcium oxide and bismuth oxide is added for radio-opacity. Hydration of the powder results in a colloidal gel composed of calcium oxide crystals in an amorphous structure. This gel solidifies into a hard structure in less than three hours. • It has a compressive strength equal to zinc oxide eugenol with polymer reinforcement [IRM]. • It is available commer­cially as ProRoot MTA (Dentsply Tulsa Dental, Tulsa, Okla) • Properties of MTA – It is biocompatible material and its sealing ability is better than that of amalgam or ZOE.

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A

B Figs 54.8A and B: Mineral trioxide aggregate pulpotomy

– Initial pH is 10.2 and set pH is 12.5 – The setting time of cement is 4 hours – The compressive strength is 70 MPA, which is comparable with that of IRM. – Low cytotoxicity–It presents with minimal inflam­ mation if extended beyond the apex. • Mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in pulpal tissues and it promotes rapid cell growth. • According to Torabinejad17 et al. MTA has an antibacterial effect on some facultative bacteria but no effect on strict anaerobic bacteria. This limited antibacterial effect is less than that demonstrated by calcium hydroxide pastes. The ability of MTA to resist the penetration of microorganisms appears to be high. – The use of MTA as an agent for pulp capping or for providing apical seal is well documented.18 The use of this agent in pulp capping was doubted as it was hypothesized that the hard tissue barrier formed by MTA could deflect the permanent tooth bud once the primary tooth was near to exfoliation. But recent studies have indicated that MTA can be used successfully as a pulpotomy agent also (Figs 54.8A and B).

•

•

Cuisia19 et al. (2001) conducted pulpotomy in 60 molars and showed clinical success rate was 93 percent for formocresol and 97 percent for MTA, whereas the radiographic success was 77 percent for formocresol and 93 percent for MTA. Agamy20 et al. (2004) conducted a clinical trial and compared gray MTA, white MTA, and formocresol in 72 molars of 24 children. They found 100 percent clinical and radiographic success rate with MTA and 90 percent success rate with formocresol.

• •

Naik and Hedge21 (2005) showed 100 percent clinical and radiographic success rate both with formocresol and MTA. Godhi B22 et al. (2011) evaluate the effects of mineral trioxide aggregate and formocresol on vital pulp after pulpotomy of primary molars and concluded that MTA has more success rate as compared to formocresol.

 se of Lyophilized Freeze Dried U Platelet with Calcium Hydroxide as Pulpotomy Agent • These compounds act as signaling proteins that could be directly involved in the regulation of cell proliferation, migration and extracellular matrix production in the dental pulp. • A lyophilized freeze dried platelet derived preparation is containing transforming growth factor (TGF), platelet derived growth factor (PDGF), bone morphogenetic proteins (BMPs), insulin growth factor (IGF). • These proteins have been used extensively in oral and maxillofacial reconstruction, adjunctive procedures related to the placement of osseo integrated implant in humans and periodontal regeneration.

•

•

Animal and human in vivo and in vitro studies have shown that these proteins stimulates differentiated cell of pulp to differentiate into odontoblast to deposit a layer of cementum. Kalaskar R and Damle SG (2004)23 evaluate the potential of lyophilized freeze dried platelet with calcium hydroxide as pulpotomy agent and found out that it had 100 percent success.

Chapter 54  Pulp Therapy for Vital Teeth Pulpotomy made with lyophilized freeze dried platelet

 namel Matrix Derivative E as Pulpotomy Agent • Enamel matrix derivate (EMD) is obtained from embryonic enamel as amelogenin has been demonstrated in vitro to be capable of stimulating periodontal ligament cell proliferation sooner when compared to gingival fibroblasts and bone cells. • The ability of EMD to facilitate regenerative processes in mesenchymal tissues is well-established. The EMDinduced processes actually mimic parts of normal odontogenesis. It is believed that the EMD proteins participate in the reciprocal ectodermal-mesenchymal signaling that control and pattern these processes. Based on these observations, it has been suggested that amelogenin participates in the differentiation of odontoblasts and the subsequent predentin formation.

• Emdogain gel (Straumann, Switzerland) has been successfully employed for pulpotomies in uninfected teeth in animal studies. • EMD components act as a signal for induction of mesenchymal cell differentiation, matu­ration and biominerali­­ zation. • Form a stable extra­ cellular matrix that provides a beneficial and protective pulp environment. • Emdogain is a bioinductive material that is compatible with vital human tissues. • It offers a good healing potential and is capable of inducing dentin formation leaving the remaining pulp tissue healthy and functioning. • Emdogain may act in a multitude of ways on mesenchymal cells that provide pulp protection.

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According to Nakamura et al. when a pulp wound is exposed to EMD, substantial steps occur in a process resembling classic wound healing with subsequent neogenesis of normal pulp tissues and repair of dental pulp which includes rapid fibrodentin matrix formation and subsequent reparative dentinogenesis. The pulp matrix itself showed homogeneous fibrous deposition together with reparative dentin islands. The formation of new dentin started from within the pulp at some distance from the amputated site. There was also a marked tendency for angiogenesis in the deeper parts of the pulps, indicating an increased level of cell growth and/ or metabolism. After the initial phase of healing in these teeth a web of odontoblast-like cells was also observed growing from the central part of the pulp toward the pulp chamber walls, forming a dentin bridge. The EMD induced hard tissue closely resembled osteodentin early in the process and later became more like secondary dentin.

• No hemorrhage. • Normal radiographic appearance.

Contraindications • Evidence that radicular pulp has undergone degenerative changes • Purulent drainage • History of prolonged pain • Necrotic debris in canal • Periapical radiolucency.

Procedure (Figs 54.9A to C)

APEXOGENESIS It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued growth of the root and closure of the open apex.

Rationale Maintenance of integrity of the radicular pulp tissue to allow for continued root growth.

Indications • Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed. • No history of spontaneous pain • No sensitivity on percussion.

A

B

C

Figs 54.9A to C: Apexogenesis: (A) Traumpic injury to young permanent teeth; (B) Calcium hydroxide apexogenesis done; (C) Continued root growth with maintenance of vitality

Chapter 54  Pulp Therapy for Vital Teeth

POINTS TO REMEMBER • Indirect pulp capping is defined as a procedure where in small amount of carious dentin is retained in deep areas of cavity to avoid exposure of pulp, followed by placement of a suitable medicament and restorative material that seals off the carious dentin and encourages pulp recovery. • Direct pulp capping is defined by Kopel (1992) as the placement of a medicament or nonmedicated material on a pulp that has been exposed in course of excavating the last portions of deep dentinal caries or as a result of trauma. • Finn (1995) defined pulpotomy as the complete removal of the coronal portion of the dental pulp, followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth. • Objective of indirect pulp capping are arresting the carious process, promoting dentin sclerosis, stimulating formation of tertiary dentin and remineralization of carious dentin. • Indication for direct pulp capping is small mechanical exposure surrounded by sound dentin in asymptomatic vital primary teeth or young permanent teeth. • Medications used for pulp capping are calcium hydroxide, corticosteroids and antibiotics, collagen fibers, 4-META adhesive, direct bonding, isobutyl cyanoacrylate, mineral trioxide aggregate, laser and bone morphogenic protein. • Direct pulp capping is primarily contraindicated in primary teeth, however, recently lasers are the only option that have demonstrated success of direct pulp capping in primary teeth. As the inherent potential of primary tooth cells is to resorb the tooth hence more odontoclasts are present as compared to odontoblasts. So when pulp capping material is placed it stimulates the undifferentiated mesenchymal cells that differentiate into odontoclastic cells. These cells exert their resorptive potential which leads to internal resorption. • Types of pulpotomy: Devitalization–formocresol; preservation–glutaraldehyde and ferric sulfate; regeneration–calcium hydroxide, BMP, MTA; mortal pulpotomy–beechwood cresol. • Indication of pulpotomy is mechanical pulp exposure in primary teeth. • Formocresol was introduced by Buckley in 1904 its composition is cresol – 35 percent, glycerol – 15 percent formaldehyde  – 19 percent and water – 31 percent. • Current newer materials for pulpotomy are MTA, lypholized platelet and enamel matrix derivatives.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8.

Define indirect pulp capping and explain its procedure. What are the materials used for direct pulp capping? Why is direct pulp capping contraindicated in primary teeth? Write a note on Cvek’s pulpotomy. Give the definition, indication, contraindications and classification of pulpotomy. Describe the procedure of formocresol pulpotomy. What are the newer materials used for pulpotomy? Write a note on MTA.

REFERENCES 1. Stewart DJ, Kramer IRH. Effects of calcium hydroxide on the unexposed pulp. J Dent Res. 1958;37:758. 2. Rasmussen P, Mjor IA. Calcium hydroxide as an ectopic bone inductor in rats. Scand J Dent Res. 1971;79(1):24-30. 3. Holland R, de Souza V, de Mello W, Nery MJ, Bernabe PF, Otoboni Filho JA. Permeability of the hard tissue bridge formed after pulpotomy with calcium hydroxide: a histologic study. JADA. 1979;99:472-5. 4. Foreman PC, Barnes IE. Review of calcium hydroxide. Int Endod J. 1990;23:283-97. 5. Heithersay GS. Calcium hydroxide in the treatment of pulpless teeth with associated pathology. J Br Endod Soc. 1975;8(2):74-93. 6. Siqueira JF Jr, Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: a critical review. Int Endod J. 1999;32:361-9. 7. Falster CA, Araujo FB, Straff on LH, Nor JE. Indirect pulp treatment: In vivo outcomes of an adhesive resin system vs calcium hydroxide for protection of the dentin-pulp complex. Pediatr Dent. 2002;24(3):241-8. 8. Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate as a pulp-capping material. JADA. 1996;127:1491-4. 9. Farsi N, Alamoudi N, Balto K, Al Mushayt A. Clinical assessment of mineral trioxide aggregate (MTA) as direct pulp capping in young permanent teeth. J Clin Pediatr Dent. 2006;31:72–6.

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10. Bogen G. Direct pulp capping with mineral trioxide aggregate: an observational study. J Am Dent Assoc. 2008;139:305–15. 11. Mass E, Zilberman U. Clinical and radiographic evaluation of partial pulpotomy in carious exposures of permanent molars. Pediatr Dent. 1993;15(4):257-9. 12. Milnes AR. Persuasive evidence that formocresol use in pediatric dentistry is safe. J Can Den Assoc. 2006;72:247–8. 13. Garcia-Godoy F. A 42 month clinical evaluation of gluteraldehyde pulpotomies in primary teeth. J Pedodont. 1986;10:148-55. 14. Fuks AB. Pulp therapy for the primary dentition. IN: Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ, Nowak A (Eds). Pediatric Dentistry: Infancy through the adolescence. 3rd Edn. Philadelphia, Pa: WB Saunders Co; 1999. 15. Smith DR. Ferric sulfate pulpotomies in primary molars, a retrospective study AAPD. 2000;22:3. 16. Liu JF. Effects of Nd:YAG laser pulpotomy on human primary molars. J Endod. 2006;32:404–7. 17. Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fractures. J Endod. 1978;4(8):232-7. 18. Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Antibacterial effects of some root end filling materials. J Endod. 1995;21:403-6. 19. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod. 1999;25(3):197-205. 20. Cuisia ZE, Musselman R, Schneider P, Dummet CJR. A study of mineral trioxide aggregate pulpotomies in primary molars. Pediatr Dent. 2001;23:168. 21. Agamy HA, Bakry NS, Mounir MM, Avery DR. Comparison of mineral trioxide aggregate and formocresol as pulp-capping agents in pulpotomized primary teeth. Pediatr Dent. 2004;26:302–9. 22. Naik S, Hegde AM. Mineral trioxide aggregate as a pulpotomy agent in primary molars: an in vivo study. J Indian Soc Pedod Prev Dent. 2005;23:13–6. 23. Godhi B, Sood PB, Sharma A. Effects of mineral trioxide aggregate and formocresol on vital pulp after pulpotomy of primary molars: An in vivo study. Contemp Clin Dent. 2011;2:296-301.

BIBLIOGRAPHY 1. Camp J. Pediatric endodontics: Endodontic treatment for the primary and young permanent dentition. In: Cohen S, Burns RC (Eds). Pathways of the pulp. 8th Edn. St Louis, Mo: Mosby Year Book, Inc; 2002. 2. Kalaskar RR, Damle SG. Comparative evaluation of lyophilized freeze dried platelet derived preparation with calcium hydroxide as pulpotomy agents in primary molars. J Indian Soc Pedod Prev Dent. 2004;22(1):24-9. 3. Rafter M. Vital pulp therapy- a review. J Ir dent Assoc. 2001;47(4):115-21.

55

Chapter

Pulp Therapy for Nonvital Teeth Nikhil Marwah, Satish V

Chapter outline • •

Pulpectomy Materials and Method of Obturation of Primary Teeth

The concept of pediatric endodontics being divided in to vital and nonvital pulp therapy has been outlined by most of the guidelines of pulp therapy (AAPD, UK, etc). Their basic recommendation is that if the infection has spread to radicular pulp and the tooth is showing signs of irreversible pulpitis then such teeth be termed as nonvital. The recommended treatment for such cases is pulpectomy for primary teeth, apexification for young permanent teeth and RCT for permanent teeth. The historical view has never been in favor of pulpectomy in primary teeth. Cohen stated that primary teeth were not suitable for proper biomechanical endodontic procedures. Massler felt that only the most dedicated of pediatric dentists should attempt endodontic procedures on primary teeth. Brauer claimed that endodontic procedures were impractical in children. However, as time passed by the views changed and pulpectomy became an essential part of treatment. Rabinowitch published an extensively documented study

A

B

•

Apexification

of 1363 root canals on nonvital primary molars and reported that an average of 5.5 visits were required for nonperiapically involved teeth and 7.7 visits were required for teeth with periapical involvement.

PULPECTOMY Although, pulpectomy is the total removal of the pulp tissue from the root canals, this cannot be achieved in primary dentition, because of the complexity and irregularity of the canals, accessory canals, ever present resorption and inability to determine an anatomical apex, therefore the term pulpectomy should not be used, but rather the term pulp canal treatment should be used (Figs 55.1A to D). • Mathewson (1995) defined it as the complete removal of the necrotic pulp from the root canals of primary teeth and filling them with an inert resorbable material so as to maintain the tooth in the dental arch.

C

D

Figs 55.1A to D: Pulpectomy: (A) Carious tooth; (B) Access opening; (C) BMP; (D) Obturation

666 Section 10 

Pediatric Endodontics

• Finn defines pulpectomy as removal of all pulpal tissue from the coronal and radicular portions of the tooth.

Objectives of Pulpectomy • • • •

Maintain the tooth free of infection Biomechanically cleanse and obturate the root canals Promote physiologic root resorption Hold the space for the erupting permanent tooth.

Indications of Pulpectomy General Indications • Patient should be in good general health with no serious disease. • Maximum cooperation of patient and parents.

Clinical Indications • A tooth previously planned for a pulpotomy that shows uncontrolled pulpal hemorrhage. • Indicated for any primary tooth in absence of its permanent successor. • Any deciduous tooth with severe pulpal necrosis provided there is no radiographic contraindication. • Primary teeth with necrotic pulps and minimum of root resorption. • Pulpless primary teeth with stomas. • Pulpless primary teeth in hemophiliacs. • Pulpless primary anterior teeth when speech, esthetics are a factor. • Pulpless primary molars holding orthodontic appliance.

Radiographic Indications • Adequate periodontal and bony support.

Contraindications of Pulpectomy General Contraindications • Young patient with systemic illness such as congenital ischemic heart disease, leukemia. • Children on long-term corticosteroids therapy.

Clinical Contraindications • Excessive tooth mobility. • Communication between the roof of the pulp chamber, and the region of furcation. • Insufficient tooth structure to allow isolation by rubber dam and extra coronal restoration.

Radiographic Contraindications • External root resorption. • Internal root resorption in the apical 3rd of the root. • Radicular cyst, dentigerous/follicular cyst in association with the primary tooth. • Inter-radicular radiolucency that communicates with the gingival sulcus.

Single Visit Pulpectomy This is carried out as an extension of pulpotomy procedure, probably on the spot decision when hemorrhage from amputated pulp stumps is uncontrollable but the tooth does not show any periapical changes.

Indication • Large carious exposure with frank involvement of radicular pulp but without any periapical changes. • Primary teeth with inflammation extending beyond coronal pulp, indicated by hemorrhage from the amputated radicular stumps that is dark red, a slowly oozing and uncontrollable.

Procedure (Figs 55.2A to J)

Chapter 55  Pulp Therapy for Nonvital Teeth

A

B

C

D

E

F Figs 55.2A to F: (A) Preoperative carious tooth; (B) Preoperative radiograph; (C) Access opening; (D) Pulp extirpation with broach; (E) Biomechanical preparation; (F) Working length radiograph

667

668 Section 10 

Pediatric Endodontics

G

H

I

J Figs 55.2G to J: Pulpectomy in primary teeth: (G) Clean and enlarged canals; (H) Drying of canals with paper point; (I) Obturating the canals; (J) Postoperative X-ray

Multiple Visit Pulpectomy Indications (Given by Paterson and Curzon in 1992) • Indicated where infection, an abscess or chronic sinus exists • Nonvital primary teeth • Teeth with necrotic pulp and periapical involvement.

Procedure First Appointment (Access Opening)

Chapter 55  Pulp Therapy for Nonvital Teeth Second Appointment (Cleaning and Shaping)

I deal Requirements of Root Canal Filling Material Given by Castagnola: • The material should resorb as the primary tooth root resorbs. • It should neither irrigate the periapical tissues nor coagulate any organic remnants in the canal. • It should have a stable disinfecting power. • Any surplus material passed beyond the apex should be resorbed easily. • It should be inserted easily into the root canal and also removed easily if necessary. • It should not be soluble in water. • It should not discolor the tooth. • It should be radiopaque. • It should be harmless to the adjacent tooth germ.

Obturation

Third Appointment (Obturation)

The aim in obturating the root canal system is to prevent recontamination of the canal from either apical or coronal leakage and to isolate and neutralize any remaining pulpal tissue or bacteria. • Endodontic pressure syringe: It was developed by Greenberg and the technique was described by Spedding and Krakow in 1965. This apparatus con­sists of a syringe barrel, threaded plunger, wrench and threaded needle. Needle is placed 1  mm short of apex and with a slow withdrawing type of motion, the needle is withdrawn 3  mm with each quarter turn of the screw until the canal is visibly filled at the orifice. • Mechanical syringe: This method was proposed by Greenberg in 1971. Cement is loaded into the syringe with 30 gauge needle as per the manufactures recommendation and expressed into the canal. Press using continuous pressure while withdrawing the needle. • Tuberculin syringe Jiffy tubes: Syringe utilized by Aylord and Johnson in 1987 was a standard 26 gauge, 3/8th inch needle. Material was expressed into the canal by slow finger pressure on the plunger until the canal was visibly filled at the orifice. This technique was popularized by Riffcin in 1980. • Incremental filling technique: This was first used by Gould in 1972. Endodontic plugger, corresponding to the size of the canal with rubber stop is used to place a thick mix of cement into the canal. Thick mix was prepared into a flame shape corresponding to size and shape of the canal and then tapped gently into the apical area with the help of plugger.

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• Lentulospiral technique: This was advocated by Kopel in 1970. Lentulospiral was dipped into the mixture and then introduced into the canal to its predetermined length and rotated in the canal. Additional amount of paste is added into the canal, till it is filled. • Other techniques: Amalgam plugger by Nosonwitz (1960) and King (1984), Paper points by Spedding (1973), Plugging action with wet cotton pellet by Donnenberg (1974), Incremental filling with reamer.

Materials used for Obturation A wide variety of materials have been used for obturation of primary teeth with varying success (Table 55.1). Some of the most commonly used materials are (Figs 55.3A to H): Material Zinc oxide eugenol

Composition

Contd... Material

Composition

Iodoform

Derivative of iodine

Vitapex®

Calcium hydroxide + iodoform + oil additives

Walkhoff paste

Parachlorophenol + camphor + menthol

KRI paste

Iodoform + camphor + parachlorophenol + menthol

Maisto paste Zinc oxide + iodoform + thymol + chlor­ phenolcamphor + lanolin Mineral Tricalcium aluminate + tricalcium silicate + trioxide silicate oxide + tricalcium oxide + bismuth aggregate oxide

Zinc oxide powder + eugenol oil

Calcium ____ hydroxide

Endoflas

Barium sulfate + calcium hydroxide + iodoform + zinc oxide eugenol

Contd...

TABLE 55.1: Summary of the success rates of pulpectomy procedures in primary molars using different filling materials Investigator

Year

Follow-up (months)

Number of teeth examined

Filling material

Success rate (%)

Rabinowitch

1953

N/A

1363

Black ZOE

99.5% (calculated)

Gould

1972

7-26

29

ZOE

82.9% (calculated)

Fuchino T et al.

1978

1-19

130

Vitapex®

86.2-97.7%

Rifkin

1980

12

26

KRI

89.0%

Hideki C et al.

1981

24-54

183

Vitapex®

93.5%

Coll et al.

1985

6-36

33

ZOE

80.5%

Col et al.

1985

60-82

29

ZOE

86.1%

Garcia-Godoy

1987

6-24

55

KRI

95.6%

Reyes

1989

6-24

53

KRI + FC + Ca(OH)2

100.0%

Barr et al.

1991

12-74

62

ZOE + FC

82.3%

Holan et al.

1993

6-48

34

ZOE

65%

Holan et al.

1993

6-48

44

KRI

84%

Coll et al.

1999

3-22

33

Vitapex®

100%

Fuks et al.

2002

6-52

55

Endoflas

70%

Chapter 55  Pulp Therapy for Nonvital Teeth

A

B

C

D

E

F

G

H Figs 55.3A to H: Different obturating materials

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Zinc Oxide Eugenol

Endofloss

• Most commonly used • Bonastre (1837) discovered zinc oxide eugenol (ZOE) and it was subsequently used in dentistry by Chisholm (1876). • Zinc oxide eugenol paste the first root canal filling material to be recommended for primary teeth, as described by Sweet in 1930. • Zinc oxide eugenol is said to have anti-inflammatory and analgesic properties. • Its limitations are slow resorption, irritation to the periapical tissues, necrosis of bone and cementum and alters the path of erupting teeth. • When ZOE mixture is used, thin mixture is used to coat the walls of the canal, followed by a thick mixture that can be manually condensed into the lumen of the canal. • Barr et al. showed 82.3 percent clinical success rate, Gould showed 86.1 percent, Coll et al. showed 86.1 percent clinical success rate. • Barcelos et al. showed 85 percent of clinical success with ZOE but the overfilling was evident even after evaluation period.

• Endofloss is a resorbable paste produced in South America which contains components similar to that of Vitapex®, zinc oxide and eugenol. • This paste is obtained by mixing a powder containing tri-iodomethane and iodine dibutilorthocresol (40.6%), zinc oxide (56.5%), calcium hydroxide (1.07%), barium sulfate (1.63%) with a liquid consisting of eugenol and paramonochlorophenol. • The advantages are that they are hydrophilic, so used in humid canals; provide a good seal; has the ability to disinfect dentinal tubules due to its broad spectrum of antibacterial activity, and is biocompatible. • Ramar K et al. (2010) showed 100 percent clinical success and 81.1 percent radiographic success.

Iodoform Paste Iodoform has been added to various obturating material to improve the properties as these pastes are bactericidal.

APEXIFICATION It is a method of inducing apical closure by formation of a mineralized tissue in the apical region of a nonvital permanent tooth with an incompletely formed root apex (Fig. 55.4). It is defined as a method to induce development of the root apex of an immature pulpless tooth by formation of osteocementum/bone like tissue (Cohen). Apexification is a method of inducing apical closure through the formation of mineralized tissue in the apical pulp region of a nonvital tooth with an incompletely formed root and an open apex (Morse et al. 1990).

Calcium Hydroxide • Since its introduction by Herman calcium hydroxide has been used in various forms in dentistry. In present generation calcium hydroxide has been used as a prime root filling material for primary teeth. It is commercially available as Vitapex® and Metapex®. • The rate of resorption of the material from within the canals is faster than the rate of physiologic root resorption. • Studies have reported a success rate of 80 to 90 percent.

Vitapex • The advantage of Vitapex® as a resorbable material is obvious. When extruded into furcal or apical areas, it can either be diffused away or resorbed in part by macrophages, in a short time as 1 or 2 weeks and causes no foreign body reaction. • Nurko C et al. and Kawakami T et al. have reported favorable results with Vitapex® for root canal filling of primary teeth with a success rate ranging from 96 to 100 percent. • Barcelos et al. showed 89 percent of clinical success with vitapex, but also showed evident resorption of material which was overfilled.

Fig. 55.4: Diagrammatic representation of open apex

Indication For nonvital permanent teeth with open apex (Blunder­buss canals).

Objective To induce either closure of open apical third of root canal or the formation of an apical calcific barrier against which obturation can be achieved.

Chapter 55  Pulp Therapy for Nonvital Teeth

Materials Used • • • • • • •

Zinc oxide eugenol Metacresylacetate – compahorated parachlorophenol Tricalcium phosphate + β-tricalcium phosphate Resorbable tricalcium phosphate Collagen – calcium phosphate gel Calcium hydroxide Mineral trioxide aggregate.

Procedure (Figs 55.5A to D) First Visit A

B

C

D Figs 55.5A to D: Procedure of apexification

Second Visit

Follow-up Apical development (Figs 55.6A to D) is monitored by comparison of preoperative and postoperative radiographs. • Formation of calcific bridge • Continued apical development • Absence of internal resorption or periapical radio­ lucency. Teeth that undergo inflammation because of caries do not represent a normal physiological system and therefore pulp treatment of primary teeth is considered the only means to keep them functional for a limited time. The anatomical and physiologic properties of deciduous teeth make them more

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Pediatric Endodontics Frank's criteria for apexification

• • • •

Apex is closed, through minimum recession of the canal. Apex is closed with no change in root space. Radiographically apparent calcific bridge at the apex. There is no radiographic evidence of apical closure but upon clinical instrumentation there is definite stop at the apex, indicating calcific repair.

susceptible to caries and the proximity of the permanent tooth germ and its relation to the deciduous tooth, makes delicate, and its conservation by endodontic therapy. The success of this attempt is related to a good case selection, based on the general condition of the child, parent's motivation, the condition of cariogenicity of the mouth and the follow-up of the case. The pedodontist is often faced with the challenge of preserving the caries susceptible deciduous teeth so he must bear in mind that the tooth is the best space maintainer and the pulp is the ideal filling material. So, an updated knowledge of the various materials and methods to accomplish pulp therapy could go a long way in sparing the young child from extraction of the deciduous teeth, without endangering the permanent dentition and the general health of the child.

B

A

D

C

Figs 55.6A to D: Calcific responses following apexification

Comparative assessment of apexification using MTA and calcium hydroxide

Chapter 55  Pulp Therapy for Nonvital Teeth

POINTS TO REMEMBER • Mathewson (1995) defined pulpectomy as the complete removal of the necrotic pulp from the root canals of primary teeth and filling them with an inert resorbable material so as to maintain the tooth in the dental arch. • Clinical indications for single sitting pulpectomy is large carious exposure with Frank involvement of radicular pulp but without any periapical changes and for multiple sitting pulpectomy are primary teeth with pulpal necrosis or periapical changes. • Obturation of root canal system is done to prevent recontamination of the canal from either apical or coronal leakage and to isolate and neutralize any remaining pulpal tissue or bacteria. Various obturation methods are endodontic pressure syringe by Spedding and Krakow (1965), mechanical syringe by Greenberg (1971), tuberculin syringe by Aylord and Johnson (1987), jiffy tubes by Riffcin (1980), incremental filling with plugger, lentulospiral technique by Kopel (1970), amalgam plugger by Nosonwitz (1960) and King (1984), paper points by Spedding (1973), plugging action with wet cotton pellet by Donnenberg (1974), incremental filling with reamer. • Materials used for obturation are zinc oxide eugenol, calcium hydroxide, Vitapex®, Walkhoff paste, KRI paste, Maisto paste, mineral trioxide aggregate and Endoflas. • Apexification is a method of inducing apical closure by formation of a mineralized tissue in the apical region of a nonvital permanent tooth with an incompletely formed root apex. Indicated for nonvital permanent teeth with open apex (Blunderbuss canals). • Frank’s criteria for apexification is apex is closed, through minimum recession of the canal; apex is closed with no change in root space; radiographically apparent calcific bridge at the apex; there is no radiographic evidence of apical closure but upon clinical instrumentation there is definite stop at the apex, indicating calcific repair.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7.

Define pulpectomy and give its indications and contraindications. Explain the procedure of pulpectomy. Enumerate materials used for obturation of primary teeth and explain its ideal properties. What are the techniques used for obturation of primary teeth? Differentiate between apexogenesis and apexification. What is the procedure of apexification? Write a note on Frank’s criteria of apexification.

BIBLIOGRAPHY 1. Barcelos R, et al. ZOE paste pulpectomies outcome in primary teeth: a systematic review. J Clin Pediatr Dent. 2011;35(3):241-8. 2. Barr ES, Flaitz CM, Hicks JM. A retrospective radiographic evaluation of primary molar pulpectomies. PD 1991;13(1):4-9. 3. Camp J. Pediatric endodontics: Endodontic treatment for the primary and young permanent dentition. In: Cohen S, Burns RC, (Eds.). Pathways of the pulp. 8th Edn. St. Louis, Mo: Mosby Year Book, Inc; 2002. 4. Chawla HS, et al. Calcium hydroxide as a root canal filling material in primary teeth-a pilot study-JISPPD. 1998;16(3):90-1. 5. Coll JA, Josell S, Casper JS. Evaluation of a one-appointment formocresol pulpectomy technique for primary molars. Pediatr Dent. 1985;7(2):123-9. 6. Goldman M. Root-end closure techniques, including apexifi­cation. Dent Clin North Am. 1974;18:297-308. 7. Gould JM. Root canal therapy for infected primary molar teeth: preliminary report. J Dent Child. 1972;39:269-73. 8. Kawakami T, Nakamura C, Eda S. Effects of the penetration of a root canal filling material into the mandibular canal. Tissue reaction to the material. Endod Dent Traumatol. 1991;7:36–41. 9. Llewelyn DR. UK national clinical guidelines in pediatric dentistry. The pulp treatment of the primary dentition. Int J Paediatr Dent. 2000;10(3):248-52. 10. Massler M. Therapy conducive to healing of the human pulp. Oral Surg. 1972;34:122-30. 11. McDonald RE, Avery DR, Dean JA. Treatment of deep caries, vital pulp exposure, and pulpless teeth: In: McDonald RE, Avery DR, Dean JA, eds. Dentistry for the Child and Adolescent, 8th. St. Louis, Mo: Mosby Inc; 2004. 12. Nurko C, Garcia – Godoy F. Evaluation of a calcium hydroxide/iodoform paste (Vitapex) in root canal therapy for primary teeth. J Clin Pediatr Dent. 1999;23:289–94. 13. Ramar K, Mungara J. Clinical and radiographical evaluation of pulpectomies using three root canal filling materials : an in vivo study. JISPPD. 2010;28:25-9.

675

56

Chapter

Rotary Endodontics in Primary Molars Thejo Krishna

Chapter outline • •

Classification and Development of Rotary Systems Technique of Biomechanical Preparation using Rotary System in Children

Endodontic treatment in primary teeth can be challenging and time consuming, especially during canal preparation which is considered as one of the most important steps in root canal therapy. Root canal instrumentation is performed with files, reamers, burs, sonic instruments or mechanical apparatus, and more recently with rotary instruments. Considering that rotary files are more convenient to use and can facilitate root canal treatment, their application may be more appropriate in children with behavior management problems. However, the use of rotary endodontics in children has limited usage over these years owing to altered canal morphology but the development of Ni-Ti alloys and possibility of changing the traditional design and taper have allowed use of rotary instruments in pediatric endodontics. Some systems that have been used for pediatric endodontics are ProFile 0.4 (Dentsply), ProTaper (Dentsply), Hero 642 (Micro-Mega).

CLASSIFICATION AND DEVELOPMENT OF ROTARY SYSTEMS The first description of the use of rotary devices was given by Oltramare. He reported the use of fine needles with a rectangular cross-section, which could be mounted into a dental handpiece. In 1889, William H Rollins developed the first endodontic handpiece for automated root canal preparation. In 1928, the ‘Cursor filing contra-angle’ was developed by the Austrian company W&H (Bürmoos, Austria). This handpiece created a combined rotational and vertical motion of the file. Finally, endodontic handpieces became popular in Europe with the marketing of the Racer-

• • •

Precautions for Rotary System Cleaning of Rotary Ni-Ti Endodontic Instruments Recent Modifications in Rotary Endodontic System

handpiece (W&H) in 1958 and the Giromatic (Micro-Mega, Besanc¸ France) in 1964. A period of modified endodontic handpieces began with the introduction of the Canal Finder System (S.E.T., Gröbenzell, Germany) by Levy. Some of the rotary systems are developed over period of time are summarized in Table 56.1.

Light-speed Instrument • • • •

Appeared like Gates Glidden drill Used in beginning of 1990 Low torque handpiece at 1500 rpm Disadvantage is too many instruments in sequence.

ProFile Instrument • • • • •

First rotary Ni-Ti Developed in 1994 Blunt non cutting tip Used at high torque of 150–300 rpm Disadvantage of high fracture incidence.

GT Rotary Instrument Noncutting end with variable tapers.

K3 Instrument • • • •

Designed by McSpadden 0.02–0.06 tapers Better cutting efficiency 350–500 rpm

Chapter 56  Rotary Endodontics in Primary Molars TABLE 56.1: Rotary system Handpiece

Manufacturer

Mode of action

Conventional systems Racer

Cardex, via W&H, Bürmoos, Austria

Vertical movement

Giromatic

Micro-Mega, Besan�on, France

Reciprocal rotation (90°)

Endo-Gripper

Moyco Union Broach, Montgomeryville, PA, USA

Reciprocal rotation (90°)

Endolift

Sybron Endo, Orange, CA, USA

Vertical movement + reciprocal rotation (90°)

Excalibur

W&H

Lateral oscillations (2000 Hertz, 1.4–2 mm amplitude)

Endoplaner

Microna, Spreitenbach, Switzerland

Vertical motion + free rotation

Canal-Finder-System

S.E.T., Gr�benzell, Munich

Vertical movement (0.3–1 mm) + free rotation under friction

Flexible systems

Sonic systems Sonic Air 3000

MicroMega

Endostar 5

Medidenta Int, Woodside, NY, USA

6000 Hz

Ultrasonic systems Cavi-Endo

Dentsply DeTrey

Magnetostrictive 25000 Hertz Ni-Ti systems

Lightspeed

Light speed, San antonio TX, USA

Rotation (360°)

ProTaper

Dentsply Maillefer, Ballaigues, Switzerland

Rotation (360°)

K3

Sybron Endo

Rotation (360°)

Profile 0.04 and 0.06

Dentsply Maillefer

Rotation (360°), taper 0.4–0.8

HERO 642

Micro-Mega

Rotation (360°), taper 0.02–0.06

Hero Instrument • • • • •

2nd generation that put positive rake angle in its design Looks like H file High torque low speed at 300–600 rpm Available in sizes of 25–40 with variable tapers New version is Heroshaper.

Race Instrument • • • • •

Appears like reamer with alternate cutting edges Triangular and square taper Advantage is more flexibility Non cutting tip Operates with low torque handpiece at 600–700 rpm.

Protaper Instrument • • • • • •

This is the best and the recent-most rotary system Design has variable taper along the length Triangular cross-section Appears like modified K file Comprises of 3 files each of shaping and finishing type High torque 150–300 rpm.

TECHNIQUE OF BIOMECHANICAL PREPARATION USING ROTARY SYSTEM IN CHILDREN Curvatures and irregularities of root canal wall of deciduous teeth can be cleaned efficiently with Ni-Ti instruments with clockwise rotation, resulting in removal of pulp tissue, dentin, and necrotic residue from the root canal, similar to action of manual files. The same principles of cleaning and shaping of the root canal for rotary instrumentation in permanent teeth should be applied to deciduous teeth, however there are some variations. Described below are some recommendations for rotary endodontic preparation in primary teeth using ProTaper Ni-Ti rotary system (Dentsply) (Figs 56.1A and B). • The gradual taper of SX files can selectively remove dentin in a safe way. • The technique recommended for deciduous teeth uses 4 percent taper instruments in narrow canals and 6 percent taper can be used in larger canals. • The S2 file has a tip size of 20 and an apical taper of 4 percent, which approximates the root canal size of primary molars (Figs 56.2A and B).

677

678 Section 10 

Pediatric Endodontics

A

A

B Figs 56.2A and B: ProTaper S files

B Figs 56.1A and B: ProTaper Ni-Ti rotary system (Dentsply)

• The S1 file is not recommended as it is too small to efficiently prepare the root canal of primary molars, and the F series files are not recommended either, because of the increased taper (7–9%) and tip size results in excessive apical dentin removal. • The Ni-Ti files with a conic predefined form should be used with a low-speed handpiece with continuous torque and 150 to 300 rpm rotation, obtaining a conical and smooth root canal that facilitates sealing of the root canal system. • It is not necessary to use a “Crown-Down” instrumentation technique in primary teeth since the dentin cuts more easily than in permanent teeth. • Care must be taken not to enter the primary root canal more than twice with each rotary file, for over preparation can lead to unexpected lateral perforation, especially in severely curved canals. • The Ni-Ti rotary files are designed mostly for conical root canal shapes. However, most of the primary molar root canals are ribbon-shaped. It is necessary to use an additional H-File (No. 20 or No. 30) combined with

copious sodium hypochlorite irrigation to remove any loose pulp tissue with a brushing motion. • Using this modified protocol, it takes only 4 to 5 minutes to prepare all of the root canals, followed by obturation using standard medicament like Vitapex, Endoflass, Metapex, etc. and results in a consistently dense fill (Figs 56.3A and B).

Chapter 56  Rotary Endodontics in Primary Molars

A

B Figs 56.3A and B: Obturation with Hero shaper: 4% taper and ProTaper 4% taper

PRECAUTIONS FOR ROTARY SYSTEM • Irrigation and keeping a moist canal is the most important in rotary endodontics as instrumenting dry canals can result in broken file tips, especially in the smaller size files. • Frequently inspect each file for flute unwinding or distortion and discard immediately. If no flute distortion is detected discard the files after use in five primary teeth. • Always use a straight line access. • Use minimal or no pressure on the handpiece while filing. • No skipping of files should be done and they should be used in correct sequence. • The file should be inserted and ejected from the canals while in rotation as stopping or starting of files in canals can cause file fracture.

CLEANING OF ROTARY NI-TI ENDODONTIC INSTRUMENTS The protocol comprises of: • Vigorous strokes in a scouring sponge soaked in 0.2 percent chlorhexidine solution. • Around 30 minutes pre-soak in an enzymatic cleaning solution.

• 15 minutes of ultrasonication in the same solution. • Around 20 seconds rinse in running tap water.

RECENT MODIFICATIONS IN ROTARY ENDODONTIC SYSTEM • New Ni-Ti systems • Wave-one and Reciproc • Multiple reciprocation motion to complete 360 degree rotation. Mode of action

Introduced by

System used

Material

Reciprocation clockwise Yared in 2007 and anticlockwise

Protaper F2 file Ni-Ti

Multiple reciprocation motion to complete 360° rotation

Dentsply

Wave-One

M-WireTM

VDW

Reciproc

M-WireTM

Root canals of deciduous teeth can instrument by manual or rotary or combination (hybrid) techniques. Rotary technique generates less dentin removal, allows more uniform root canal preparation and presents shortest instrumentation time. It shall not be surprising that rotary endodontics will soon make manual technique adjuvant or obsolete.

POINTS TO REMEMBER • The first description of the use of rotary devices was given by Oltramare. • William H Rollins developed the first endodontic handpiece for automated root canal preparation. Cursor filing contraangle was first handpiece. • Ni-Ti rotary systems included Light-speed instrument, ProFile instrument, GT rotary instrument, K3 instrument, Hero instrument, Race instrument and ProTaper instrument. • Heroshaper is 2nd generation instrument that puts positive rake angle in its design.

679

680 Section 10 

Pediatric Endodontics

• ProTaper is the recent-most rotary system. It has variable taper along the length and appears like modified K file. • The technique recommended for deciduous teeth uses 4 percent taper instruments in narrow canals and 6 percent taper can be used in larger canals. • The S2 file has a tip size of 20 and an apical taper of 4 percent, which approximates the root canal size of primary molars. • It is necessary to use an additional H-File (No. 20 or No. 30) combined with copious sodium hypochlorite irrigation to remove any loose pulp tissue with a brushing motion.

QUESTIONNAIRE 1. 2. 3. 4.

Classify rotary endodontic systems. Describe the technique of biomechanical preparation using ProTaper rotary system in children. What are the precautions to be exercised while using rotary system in children? What are the recent modifications in rotary endodontics?

BIBLIOGRAPHY

1. Barr B, Barr N. Posterior pulpectomies: using rotary files. Children’s Dentistry a partnership newsletter. 1999;6:1-3. 2. Barr ES, Kleier DJ, Barr NV. Use of Nickel Titanium rotary files for root canal preparation in primary teeth. Pediatr Dent. 1999;21:453-4. 3. Barr ES, Kleier DJ, Barr NV. Use of Nickel Titanium rotary files for root canal preparation in primary teeth. Pediatr Dent. 2000;22:77-8. 4. Coleman CL, Svec T, Wang M, Suchina J, Glickmaan GN. Stainless steel versus Nickel-titanium K files: analysis of instrumentation in curved canal. J Endod. 1995;2:237. 5. Glossen CR, Haller RH, Dove SB, Del Rio CE. A comparison of root canal preparations using Ni-Ti hand, Ni-Ti engine drive, and K flex endodontic instruments. J Endod. 1995;21:146-51. 6. Guelzow A, Stamn O, Martus, Kielbassa AM. Comparative study of six rotary Nickel Titanium systems and hand instrumentation for root canal preparation. Int Endod J. 2005;38(10):743-52. 7. Hulsman M, Herbst U, Schafers F. Comparative study of root-canal preparation using Light and Quantec SC rotary Ni-Ti instruments. Int Endod J. 2003;36(11):748-56. 8. I Kuo C, LinWang Y, et al. Application of Ni-Ti rotary files for pulpectomy in primary molars. J Dent Sci. 2006;1:10-15. 9. Leonardo MR, Leanardo RT. Sistemas rotatorios em endondon­tia-Instrumentos de Niquel- Titanio. Sao Paula: Artes Medicas. 2002. 10. Linsuwanont P, Parashos P, Messer HH. Cleaning of rotary nickel-titanium endodontic instruments. Aus Dent J. 2004;49:1. 11. Mc Donald RE, Avery DR. Dentistry for the child and adolescent. 7th Ed. St Louis: Mosby. 2004. 12. Pettiette MT, Metzger Z, Phillips C, Trope M. Endodontic complications of root canal therapy performed by dental students with stainless steel K files and Nickel Titanium hand files. J Endod. 1999;25:230-4. 13. Short JA, Morgan LA, Baumgartner JC. A comparison of canal centering ability of four instrumentation techniques. J Endod. 1997;23: 503-7. 14. Silva LAB, Leonardo MR, Nelson Filho P, Tanomaru JMG. Comparison of rotary and manual instrumentation techniques on cleaning capacity and instrumentation time in deciduous molars. J Dent Child. 2004;71:45-7. 15. Walia HM, Brantley WA, Gerstein H. An Initial investigation of the bending and torsional properties of Nitinol root canal files. J Endod. 1988;14:346-51. 16. Zmener O, Balbacham L. Effectiveness of Nickel- Titanium files for preparing curved root canals. Endod Dent Tramatol. 1995;11:121-3.

11

Section

GINGIVA AND PERIDONTIUM IN CHILDREN

This section deals with salient features of gingiva and periodontium in primary dentition and briefs about common gingival and periodontal diseases in children along with their management.

57

Chapter

Normal Features of Gingiva Nikhil Marwah

Chapter outline •

Normal features of children gingiva

The periodontium is the foundation for the dentition. The components of periodontium—the alveolar mucosa, gingiva, cementum, periodontal ligament, and alveolar bone, serve as the supporting apparatus for the teeth in function and in occlusal relationships. By learning the fine knitting details of its embryonic origin, composition, histological and clinical appearance with normal physiologic variations, it enables us to develop an understanding of their relationships in health and to understand the processes that occur in pathology. This will include macroscopic, microscopic, and radiographic details of the components of the periodontium. The knowledge of the details of the tissue compartments, the cells which are involved, and how the cellular products and the cells interact will provide a greater understanding of the functions of the periodontium. Thus, it is important to know about the anatomy and physiology of the healthy periodontium and its relationship to the natural dentition, jaws, and the oral environment.

•

Normal features of adult gingiva

about 2 mm coronal to the cementoenamel junction of the tooth and the attached gingiva extends from the base of the free gingiva to the mucogingival junction. The gingiva

A

 acroscopic Appearance M of the Periodontium The periodontium is composed of the gingiva, alveolar mucosa, cementum, periodontal ligament, and alveolar bone (Figs 57.1A and B). The gingiva is firmly bound to the underlying bone and is continuous with the alveolar mucosa that is situated apically and is unbound. The border of these two tissue types is clearly demarcated and is called the mucogingival junction. There is no mucogingival junction on the palatal aspect of the maxilla as the gingiva is continuous with the palatal mucosa. The gingiva consists of a free gingival margin and attached gingiva (Figs 57.2A and B). The free gingival margin is situated

B Figs 57.1A and B:  Components of the periodontium (Garant 2003)

684 Section 11 

Gingiva and Peridontium in Children on the mandibular molars and the narrowest were on the incisor and canine regions, about 1.8 mm. There is a general increase of width of the attached gingiva from the primary to permanent dentition as well as with increasing age. The attached gingiva allows the gingival tissue to withstand mechanical forces of mastication, tooth brushing and also prevents free gingiva from being pulled away from the tooth when tension is applied to the alveolar mucosa. The tissue that resides in the interproximal embrasure is called the interproximal papilla. The shape of this tissue is influenced by the shape of the interproximal contact, the width of the interproximal area, and the position of the cementoenamel junction of the involved teeth. The shape of this papilla varies from triangular and knife-edge in the anterior regions with point sized contacts of the teeth to broader and more square shaped tissue in the posterior sextants due to the teeth having broad contact areas. Also present in the wider papillary areas is the col. This is a valleylike structure situated apical to the contact area (Fig. 57.3).

A

B Figs 57.2A and B:  Parts of gingiva Fig. 57.3:  Interdental col (Garant 2003)

is typically pink in color, but may vary due to physiologic pigmentation among some races. Unattached portion of the gingiva that surrounds the tooth in the region of the cemento enamel junction (CEJ) is called as free or marginal gingiva. It fits closely around the tooth but is not directly attached to it and forms soft tissue wall of gingival sulcus. It meets the tooth in a thin rounded edge called the gingival margin which follows the contours of the teeth. Attached gingiva that is tightly connected to the cementum on the cervical third of the root and to the periosteum (connective tissue cover) of the alveolar bone. The width of the attached gingiva varies with the location in the oral cavity as well as with physiologic age and studies have shown an average depth of 0.7mm but variations may range from 0 to 6 mm (Gargiulo 1961). The facial gingiva is typically widest in the incisor region and narrowest in the premolar region for the maxillary arch and ranged from 1 to 9 mm. In the mandible, the facial attached gingiva is narrowest in the premolar and canine regions. When the lingual attached gingiva was examined, it was found that the widest areas were

The texture of the gingiva varies with age and is typically smooth in infancy, stippled from 3 years onwards and again becomes smoother with advanced age. Stippled tissue has a texture similar to the kind of an orange peel and its presence does not necessarily mean healthy (Fig. 57.4).

Fig. 57.4:  Stippling of gingival tissue

Chapter 57  Normal Features of Gingiva Studies on Normal Features of the Gingiva in Children Ihn- Ah Yoo conducted a study on children in Korea and concluded that—The mean width of attached gingiva of the children aged 6 to 12 proved to be wider in the maxilla than in the mandible when the same teeth on both jaws were compared. Of the primary teeth, the widest width was found in the areas of maxillary primary lateral incisors and maxillary primary canines (3.50 mm) and the narrowest zone was noted in the area of mandibular first primary molars (1.34 mm). In the permanent dentition, the greatest width was found in the areas of maxillary permanent lateral incisors (3.00 mm) and the narrowest zone in mandibular first premolars (0.55 mm); At the age of tooth change, the attached gingivae of primary teeth were wider than those of successive permanent teeth except for maxillary central incisors of boys; The maximum in the frequency of mucogingival problems was found in the areas of upper and lower first primary molars of primary dentition, and in the upper and lower first premolars of permanent dentition regardless of sex. Takashi Hanioka et al. 2005 conducted a case-control study to investigate the relationship between gingival pigmentation in children and passive smoking. The findings suggest that excessive pigmentation in the gingiva of children is associated with passive smoking. The visible pigmentation effect in gingiva of children could be useful in terms of parental education. Bimstein E, Peretz B, Holan G 2003 conducted study to describe the prevalence of gingival stippling in children of various ages. Stippling was evident from 3 years of age and thereafter and no particular changes were observed with the increasing age or gender. Stippling was more evident in maxillary arch than the mandibular arch, which was not statistical significant.

Differentiating features of children and adults gingiva (Figs 57.5A and B) Characteristic

Children

Adult

Color

Pale pink

Coral pink

Surface

Smooth

Stippled

Gingiva

Thick and round

Knife edged

Free gingiva

Keratinized saddle area

Non-keratinized interdental col

Interdental gingiva

Interdental clefts

Not present

Attached gingival

Retrocuspid papilla

Retrocuspid papilla not present

Sulcus depth

2.1–2.3 mm

2–3 mm

Alveolar mucosa

Red, thin, vascular

Pink

Periodontal ligament

Wide

Narrow

Collagen bundles

More hydrated, less differentiated

More differentiated

Polypeptide chains

Normal cross-linking

Tight cross-linked

Ground substance

Low ratio of collagen to ground substance

Ground substance to collagen ratio normal

Fibers

Gingival fibers are immature

Mature and organized

Trabeculae

Thick trabeculae with large marrow spaces

More trabeculae with less marrow spaces

A

B Figs 57.5A and B:  Gingiva of children and adults

685

686 Section 11 

Gingiva and Peridontium in Children

QUESTIONNAIRE 1. Describe the features of children’s gingiva.

BIBLIOGRAPHY 1. Ainamo J, Löe H. Anatomical characteristics of gingiva: a clinical and microscopic study of the free and attached gingiva. J Periodontol. 1966;37:5-13. 2. Orban B. Clinical and histologic study of the surface characteristics of the gingiva. Oral Surg Oral Med Oral Pathol. 1948;1:827-41.

58

Chapter

Gingivitis in Children Mandeep Virdi

Chapter outline •

Stages of Gingivitis

•

Gingivitis or inflammation of the gingiva, is the most common oral disease in children and adolescents. It is characterized by the presence of gingival inflammation without detectable bone loss or clinical attachment loss. The causes and risks are as varied in children as in adults and range from local to systemic causes. The most important local predisposing factor in children however is poor oral hygiene. This chapter aims to discuss the various forms of gingivitis encountered in children and adolescents.

STAGES OF GINGIVITIS Page and Shroeder (1976) reported the sequence of changes during the development of gingivitis and peridontitis under four stages, according to prominent histopathological signs (Table 58.1).

Types of Gingivitis in Children

• Stage 1: Initial lesion, which occurs within 2 to 4 days after allowing plaque to accumulate, an increased volume of junctional epithelium (JE) is occupied by polymorphonuclear leukocytes (PMNL). Blood vessels subjacent to the JE become dilated and exhibit increased permeability. A small cellular infiltrate of PMNL and mononuclear cells forms and collagen content in the infiltrated areas markedly decreases. • Stage 2: Early stage, which is about 4 to 7 days of plaque accumulation, gingivitis in humans evolves at this stage, the differentiating sign being accumulation of large numbers of lymphocytes as an enlarged infiltrate in the connective tissue. • Stage 3: Established stage, which is about 2 to 3 weeks of plaque accumulation, there is preponderance of plasma cells in an expanded inflammatory lesion with

TABLE 58.1:  Stages of gingivitis Stages

Days

Vascular changes

Predominant immune cells

Clinical findings

Stage I

2–4

↑ Permeability of vascular bed PMNs

↑ Gingival fluid flow

Stage II

4–7

Vascular proliferation

Lymphocytes

Erythema, bleeding on probing

Stage III

14–21

Stage II + Blood stasis

Plasma cells and B lymphocyte

Change in color, size, texture, etc.

Stage IV

> month

Degeneration

Plasma cell

Loss of connective tissue attachment and alveolar bone

688 Section 11 

Gingiva and Peridontium in Children

continuance of earlier changes. The established lesion may persist for a long time before becoming ‘aggressive’ and progressing to the advanced lesion. • Stage 4: Advanced lesion, the infiltrate is dominated by plasma cells. Collagen destruction continues with loss of alveolar bone and apical migration of JE, with “pocket” formation now being apparent. Throughout the sequence, viable bacteria remain outside the gingiva, on the surface of the tooth and in the periodontal pocket against, but not invading the soft tissue.

TYPES OF GINGIVITIS IN CHILDREN

Plaque-induced Gingivitis Gingivitis is also regarded as the most common periodontal disease in children, with the primary etiology as plaque. In poor oral hygiene, food debris, plaque and microorganisms also accumulate and the process of inflammation starts. This leads to gingivitis, which, if not taken care of can progress to gradual destruction of supporting soft and hard tissues of the teeth (Fig. 58.1).

• During the eruptive phase, the epithelium displays degenerative changes at the site of fusion between dental and oral epithelia. These areas are vulnerable to plaque accumulation and sets up a bacterial reaction and since the child may be experiencing discomfort which will therefore make tooth brushing difficult. This will lead to plaque accumulation and inflammation.

Infective Gingivitis These are of viral or bacterial origin and caused by viruses or bacteria which are normal commensals of the oral cavity becoming virulent when present in high proportions.

Herpetic Gingivostomatitis

• This is gingival inflammation occurring around an erupting permanent tooth.

• It affects both the gingiva and other parts of the oral mucus membrane. • It is commonly seen in children less than three years of age. • It is caused by the herpes simplex virus type 1. • Infection usually follows bouts of childhood fevers such as malaria, measles and chickenpox. The onset of is preceded by a prodromal period with symptoms such as irritability, malaise, vomiting and fever and the appearance of small vesicles which rupture to reveal small yellowish painful ulcers with erythematous margins (Fig. 58.3). • The condition is associated with drooling of saliva, inability to chew and swallow and the child may become increasingly uncooperative during tooth brushing. • The condition is self-limiting and the management is to encourage bed rest, plenty of fluid and maintenance of good oral hygiene through gentle debridement. Analgesics are prescribed to relieve the pain and application of a mild topical anesthetic gel has been found useful in young children.

Fig. 58.1:  Plaque-induced gingivitis

Fig. 58.2:  Gingivitis due to habit

Gingivitis Due to Habit Gingivitis is a very common finding in the maxillary anterior region in individuals with mouth breathing habit. This habit is common among young children and it predisposes to dryness of the gingival when the lubricating effect of saliva is absent (Fig. 58.2).

Eruption Gingivitis

Chapter 58  Gingivitis in Children

Fig. 58.3:  Herpetic gingivostomatitis

HIV-associated Gingivitis • Oral manifestations of human immunodeficiency virus (HIV) disease are an important part of the natural history of HIV disease. • Many studies have reported that hairy leukoplakia, pseu­domembranous candidiasis, Kaposi sarcoma, nonHodgkin’s lymphoma, linear gingival erythema, necroti­ zing ulcerative gingivitis and periodontitis were common lesions seen in patients with HIV infection and AIDS.

Acute Necrotizing Ulcerative Gingivitis • Acute necrotizing ulcerative gingivitis (ANUG) used to be known as “trench mouth” because it was seen frequently in soldiers occupying trenches during the World War I and was also called “Vincent’s angina”, after the French physician Henri Vincent (1862-1950). • This is an acute multiple bacterial infection of the gingivae. • The lesion starts at the interdental papillae, spreading along the gingival margins and if untreated, starts to destroy the underlying connective tissue and bone. There is a characteristic necrotic odor associated with this condition and the mouth becomes progressively painful with sloughing off of the necrotic ulcers on the gingivae. The ulcers become erythe­matous and bleed following minimal trauma, especially tooth brushing (Fig. 58.4). • Regional lymph nodes are enlarged and tender. • If untreated, destruction of the soft tissues of the mouth and cheek and facial bones result, a condition referred to as Cancrum Oris or Noma. • It occurs with low frequency ( 1-2 mm CAL; moderate: 3-4 mm CAL; severe: > 5 mm CAL) • Localized • Generalized (> 30% of sites are involved)

III.

Aggressive periodontitis (slight: 1-2 mm CAL; moderate: 3-4 mm CAL; severe: > 5 mm CAL) • Localized • Generalized (> 30% of sites are involved)

IV.

Periodontitis as a manifestation of systemic diseases • Associated with hematological disorders • Associated with genetic disorders • Not otherwise specified

V.

Necrotizing periodontal diseases • Necrotizing ulcerative gingivitis • Necrotizing ulcerative periodontitis

VI.

Abscesses of the periodontium • Gingival abscess • Periodontal abscess • Pericoronal abscess

VII.

Periodontitis associated with endodontic lesions

TYPES OF PERIODONTITIS IN CHILDREN AND ADOLESCENTS

Early-onset Periodontitis • The term early-onset periodontitis usually diagnosed in patients under the age of 35 years. • The destruction of the periodontium is advanced for the age of onset of the condition. • Early-onset periodontitis has a tendency to aggregate in families (Table 59.2).

Prepubertal Periodontitis • Extremely rare category of periodontitis, usually having an onset during or soon after the eruption of the deciduous teeth. • Both familial clustering of prepubertal periodontitis and a higher incidence in females have been documented. • The associated plaque deposits are moderate and there is little inflammation of the gingivae, but bleeding upon probing is present at affected sites. • There are no associated systemic conditions, and patients do not suffer from frequent upper respiratory tract infections. The destruction is not as rapid as in the generalized form, and the condition usually responds to treatment.

Localized Early-onset Periodontitis • This form of early-onset periodontitis is also referred to as localized juvenile periodontitis. • According to Hart et al. diagnosis of localized early-onset periodontitis is based on attachment loss of more than 4  mm on at least two permanent 1st molars and incisors (one of which must be a 1st permanent molar). • Not more than two other permanent teeth, which are not 1st permanent molars or incisors, should be affected. • Most striking feature is the presence of deep pockets. • Premature and excessive mobility of maxillary and mandibular primary incisors and 1st primary molars are seen. • As the disease progresses, other symptoms may arise, deep, dull, radiating pain during mastication may be observed. • Individuals must be systemically healthy and under 35  years of age.

• Combined periodontic-endodontic lesions VIII.

Developmental or acquired deformities and conditions • L ocalized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis • Mucogingival deformities and conditions around teeth •M  ucogingival deformities and conditions on edentulous ridges • Occlusal trauma

Generalized Early-onset Periodontitis • Generalized early-onset periodontitis has its onset from puberty until 35 years of age. • According to Hart et al. clinical diagnosis is based on attachment loss of more than 5 mm on a minimum of eight permanent teeth (one of which must be a 1st molar),

693

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Gingiva and Peridontium in Children Recent developments in classification of the periodontal diseases relevant to children and adolescents

at least three of which should not be 1st molars or incisors. Individuals must be systemically healthy.

Adult Periodontitis • Adult periodontitis is probably initiated at or soon after puberty but does not manifest symptoms until the middle of the fourth decade. • Adult periodontitis is a slowly progressing form of periodontitis. • However, it may at any stage undergo an acute exacerbation with associated attachment loss.

Necrotizing Forms of Periodontal Disease • Necrotizing ulcerative gingivitis is characterized by gingival necrosis presenting as ‘punched-out’ papillae, with gingival bleeding and pain. • Halitosis and pseudomembrane formation may be secondary diagnostic features. • Fusiform bacteria, other anaerobic gram-negative bacteria and Spirochetes have been associated with the gingival lesions. • Related factors may include emotional stress, poor diet, cigarette smoking, seasonal changes and HIV infection.

Chapter 59  Periodontal Diseases in Children TABLE 59.2: Comparison of key types of periodontitis that can affect adolescents Incipient adult periodontitis

Early-onset periodontitis: Localized

Early-onset periodontitis: Generalized

Early-onset periodontitis: Incidental attachment loss

Age of onset

May begin in early teens

Puberty or later. Bone loss may be detectable in deciduous dentition

Puberty or later but usually before age 35 years

Puberty or later

Clinical presentation

Loss of attachment of 1 mm or 2 mm. 1st molars, incisors commonly affected on mesial and distal sites, but other teeth affected also

Loss of attachment >3 mm. Lack of precise criteria. Generally agreed 1st molar(s) and incisor(s) must be affected, and up to one or two other teeth may be affected

Loss of attachment >3 mm. Distinct from and more generalized than localized early-onset periodontitis. Affects at least three teeth other than 1st molars and incisors

Loss of attachment >3 mm. One to three sites

Radiographic features Incipient horizontal crestal bone loss, affecting a few sites. May be detected on serial bitewing radiographs

Severe bone loss in 1st molars and incisors. Characteristic presentation as arc-shaped lesions and angular defects

Severe bone loss. More generalized than localized early-onset periodontitis

Severe bone loss at a few sites

Prevalence, severity, extent, progression

Prevalent. Not very severe attachment loss. Variable extent, depends on factors such as age and ethnic group. Relatively slow rate of progression of attachment loss

Low prevalence. Severe attachment loss >3 mm. Some tooth loss may occur. Extent and rate of progression variable, but generally lower than generalized early-onset periodontitis. May progress to generalized early-onset periodontitis

Low prevalence. Severe attachment loss >3 mm. Some tooth loss may occur. Greater extent than localized early-onset periodontitis. Rate of progression variable but generally greater than for localized early-onset periodontitis or incidental attachment loss

Low prevalence. Severe attachment loss >3 mm. Very low extent. Rate of progression variable. May progress to localized earlyonset periodontitis or even generalized early-onset periodontitis

Altered host function

No evidence

Some earlier reports of altered Some earlier reports of neutrophil function altered neutrophil function

Little research

Microflora

As for adult periodontitis, including Spirochetes, Porphyromonas gingivalis, Prevotella intermedia and Actinobacillus actinomycetemcomitans

A. actinomycetemcomitans is key organism

Bacteroides forsythus, P. gingivalis, P. intermedia, A. actinomycetemcomitans, Compylobacter rectus, Fusobacterium nucleatum

Little research

Subgingival calculus, gingival inflammation

Significant association between plaque, subgingival calculus, gingival inflammation and subsequent development and progression of loss of attachment

Concept of little subgingival calculus, gingival inflammation has been challenged, Significant association between presence of subgingival calculus and gingival inflammation and subsequent attachment loss

As for localized earlyonset periodontitis, but teeth with subgingival calculus and inflammation in generalized early-onset periodontitis group develop even more attachment loss than localized early-onset periodontitis group

Weak association between presence subgingival calculus, gingival inflammation and subsequent loss of attachment

Ethnic status

Increased prevalence in some ethnic groups, such as Indo-Pakistani

Increased prevalence in some ethnic groups, such as Blacks

As for localized early-onset periodontitis

Increased prevalence in Blacks

Genetic basic

Not a key feature

Yes

Yes

Little research

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• Necrotizing ulcerative periodontitis is characterized by necrosis of gingival tissues, periodontal ligament and alveolar bone. Lesions are commonly observed in individuals with systemic conditions including, but not limited to viral infections, severe malnutrition and immunosuppression. • Necrotizing ulcerative periodontitis is preceded by necrotizing ulcerative gingivitis, which is an acute inflammatory condition associated with a fusospirochetal microbiota.

MICROBIOLOGY OF PERIODONTITIS (TABLES 59.3 AND 59.4)

TABLE 59.3: Suspected pathogens in localized early-onset periodontitis Organism/species A. actinomycetemco­ mitans

Criteria Increased prevalence in localized earlyon periodontitis sites/patients Decrease in health or gingivitis Increase in active/progressing sites Elimination/reduction with treatment

P. gingivalis

Increased prevalence Decrease in health/gingivitis Increase in active disease Elimination/reduction with treatment

P. intermedia

Increased prevalence Decrease in health/gingivitis Increase in active disease Elimination/reduction with treatment

Capnocytophaga

Increased prevalence Decrease in health/gingivitis Elimination/reduction with treatment

F. nucleatum

Increased prevalence Increase in active disease Elimination/reduction with treatment

E. corrodens

Increased prevalence Increase in active disease Elimination/reduction with treatment

Campylobacter

Increased prevalence

Spirochetes

Increased prevalence Decrease health/gingivitis

Eubacterium

Increased prevalence

B. forsythus

Unaware of any studies

Black-pigmented anaerobic rods

Increased prevalence

TABLE 59.4: Other species investigated in localized early-onset periodontitis Species

Suspected role in localized early-onset periodontitis

Haemophilus

Associated with health

Enterococcus

Occur frequently and may contribute in high numbers

Streptococcus

Found in higher numbers but not associated with disease

Peptostreptococcus

More prevalent in adult periodontitis

Staphylococcus

Occur frequently and may contribute in high numbers

Kingella

No correlation with disease

Mycoplasma

Invade oral epithelial tissue, numbers increase in disease

Actinomyces

A. naeslundii associated with health

Yeasts

Associated with tissue invasion

ETIOPATHOGENESIS (FIGS 59.1A AND B)

Host Response The host defense system comprises a collection of tissues, cells and molecules whose function is to protect the host against infectious agents.

Protective Mechanisms • Physical barriers such as the skin and mucous membranes represent a component that infectious agents must breach to gain access to the host. • The washing action of fluids such as tears, saliva, urine and gingival crevicular fluid keeps mucosal surfaces clear of invading organisms and also contain bactericidal agents. • The intact epithelial barrier of the gingiva, sulcular and junctional epithelium normally prevents bacterial invasion of the periodontal tissues. It is normally an effective physical barrier against bacterial products and components. • The epithelial cell wall, secreted proteins and fatty acids are toxic to many microbes. • Salivary secretions provide a continuous flushing of the oral cavity as well as providing a continuing supply of agglutinins and specific antibodies. • Furthermore, the gingival crevicular fluid flushes the gingival sulcus and delivers all the components of serum, including complement and specific antibodies.

Chapter 59  Periodontal Diseases in Children

A

B Figs 59.1A and B: Etiopathogenesis of periodontitis

• Macrophage produce cytokines (such as interleukin-1) induce fibroblasts and osteoblasts to produce proteases, which result in bone and tissue breakdown.

INFLUENCES OF SYSTEMIC DISEASES ON PERIODONTITIS IN CHILDREN AND ADOLESCENTS There are various systemic conditions that may reduce the host response in children and adolescents, thus increasing their susceptibility to periodontal bone loss and ultimately loss of teeth.

Leukocyte Disorders As far as neutrophils are concerned, inborn (genetic) defects leading to a depressed or to a complete loss of cellular chemotaxis are always accompanied by a severe prepubertal periodontitis.

Neutropenia These diseases have periodontal manifestations, and the group includes agranulocytosis, cyclic neutropenia, chronic benign neutropenia, chronic idiopathic neutropenia and familial benign chronic neutropenia.

Other systemic condition that manifests as periodontal diseases • • • • • • • • • •

Leukocyte adhesion deficiency syndrome Down’s syndrome Histiocytosis syndromes Ehlers-Danlos syndrome Virus-associated hemophagocytic syndrome Hypophosphatasia Juvenile hyaline fibromatosis of gingiva Acquired immunodeficiency syndrome Malnutrition Diabetes mellitus

Dental Aspects • The attached, papillary and marginal gingival are enlarged, edematous and erythematous and bleed easily on a gentle probing. • Extreme inflammation with proliferation of marginal gingiva is noticed.

Treatment In patients with malignancies of the blood and bloodforming organs and other cancers, recombinant human granulocyte colony-stimulating factor is effective at correcting chemotherapy-induced neutropenia and is useful in the management of infections that complicate neutropenia.

Chédiak-Higashi Syndrome • Chédiak-Higashi syndrome has frequently been linked with severe periodontitis. • It is a rare autosomal recessive immunodeficiency disorder characterized by large lysosomal granules in granulocytes, partial oculocutaneous infections and intermittent febrile episodes.

Dental Aspects Extreme periodontal manifestations along with mobility of teeth.

Treatment • Functional defects in Chédiak-Higashi syndrome leuko­ cytes are corrected by ascorbic acid.

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• Other treatments consisted of management regimens such as vincristine–corticosteroids, etoposide–corticosteroids– intrathecal methotrexate and high doses of intravenous globulin, inducing a transient remission.

Dental Aspects Swollen gingival, migration and mobility of teeth, periodontal pockets, fetor oris and exfoliation of teeth.

Treatment

Papillon-Lefèvre Syndrome In 1924, Papillon and Lefèvre first described a syndrome characterized by hyerkeratosis of palms and soles combined with precocious periodontal destruction and shedding of the deciduous and permanent dentitions.

A combined approach including meticulous plaque control, administration of chlorhexidine in combination with a systemic antibiotic therapy for the eradication of known periodontal pathogens in conjunction with retinoids.

Genetic conditions associated with periodontal destruction in children and adolescents Condition

Nature of condition

Periodontal effects

Leukocyte disorders • Neutropenia • Chédiak-Higashi syndrome • Leukocyte adhesion deficiency syndrome

Reduction in number of granulocytes. Various types Rare autosomal recessive immunodeficiency disorder Large lysosomal granules in granulocytes Neutrophil and monocyte defects Recurrent infections, may be severe Defects in integrin receptors of leukocytes. Impaired adhesion and chemotaxis Increased susceptibility to infection, including otitis media, septicemia, impaired pus formation, delayed wound healing

Ulceration gingivitis, periodontitis Severe gingivitis periodontitis. Tooth loss due to periodontal destruction. Ulceration mucosa, tongue, hard palate. Early-onset prepubertal periodontitis. Rapid attachment loss and bone loss shortly after eruption of deciduous dentition. Early exfoliation

Papillon-Lefèvre syndrome

Autosomal recessive inheritance. Rare 1:3 or 4 million. Often history of consanguineous families. Palmoplantar hyperkeratosis Impaired neutrophil chemotactic, phagocytic and bactericidal activities and decreased migration may play a role in the disease pathogenesis and defects in immune function have also been cited

Early-onset prepubertal periodontitis. Rapid attachment loss and bone loss affecting deciduous dentition. Early exfoliation or need for extraction. Therapy difficult. Permanent dentition may be affected resulting in tooth loss. Bacterial associated include Porphyromonas gingivalis, Fusobacterium nucleatum and Eikenella corrodens, but the etiological role of Actinobacillus actinomycetemcomitans seems pivotal. High antibody titers to A. actinomycetemcomitans have been reported in some cases

Down’s syndrome

Autosomal chromosomal anomaly associated with trisomy of chromosome 21. Affects 1 of 700 live births. Mental handicap. T-cell immunodeficiency and inappropriate enzyme regulation. Functional defects in neutrophils and monocytes. Abnormal capillary morphology. Connective tissue disorders. Hyperinnervation of gingivae

Periodontal disease very prevalent and more severe than in age-matched controls especially in lower anteriors. Differences not explained by plaque levels. Rapid progression. Onset apparent in deciduous dentition

Hypophosphatasia

Autosomal inherited trait. Inborn error of metabolism. Deficiency serum alkaline phosphatase, increased urinary excretion phosphoethanolamine, defective bone/tooth mineralization. Three form: lethal neonatal/perinatal, severe infantile, milder form in childhood/late adolescence

Cementum hypoplasia or aplasia. Periodontal destruction may affect deciduous dentition, resulting in premature exfoliation, tooth loss. Variable effects on permanent dentition, not necessarily as severe

Ehlers-Danlos syndrome Collagen disorder affecting joints (loose-jointedness) and Type VIII: Aggressive early-onset periodontitis leading skin (fragile and hyperextensible). The mucosa is easily to premature loss of permanent teeth traumatized. Prolonged bleeding may be a feature, and therefore hematological investigations are warranted. Ten types; type VIII has periodontal implications: autosomal dominant inheritance. Distinguish by skin biopsy from type IV (autosomal dominant/ recessive) which has life-threatening potential complications.

Chapter 59  Periodontal Diseases in Children

Periodontal Screening

Fig. 59.2: Screening using the basic periodontal examination for the child/adolescent

Periodontal screening in children and adolescents provides a simple and quick method of identifying periodontal problems which is comfortably tolerated and gives the dental practitioner an indication of the need for treatment or further assessment (Fig. 59.2).

DIAGNOSIS AND MANAGEMENT A number of different forms of periodontal disease can present in children and adolescents, ranging from reversible conditions limited to the gingival tissues to those characterized by destruction of the periodontal connective tissue attachment and alveolar bone, which may jeopardize the longevity of the deciduous or permanent dentition. The prevalence, extent, severity and prognosis of periodontal disease in the younger age groups vary according to the disease in question. The diagnostic options are determined by an up-to-date classification of the periodontal diseases, and this has been an area of ongoing debate and review. Fundamental principles need to be applied to identify and manage periodontal problems in these patients together with an understanding of the causation and contributory risk factors and an appreciation of the different strategies inherent in working with a younger age group compared with the adult patient.

The patient’s history, in conjunction with the examination, forms the basis for the diagnosis of the periodontal condi­ tion and should involve both the child or adolescent and the parents or guardians of minors.

699

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Health promotion and behavioral approaches in the prevention of periodontal disease in children and adolescentst Chairside activities

Societal activities

Smoking cessation

Smoking cessation

• R  emember the simple method of the four A’s: ask, advise, assist and arrange in smoking cessation • Make a note a smoking on a patient’s dental chart and assess the level of nicotine dependence using, for example, Fageström test for nicotine dependence • An approached oriented towards family and peer group is preferable. At least remember their influence on your patient’s smoking behavior • Assess the smoker’s reasons for quitting and obstacles to doing so to assist in building up the smoker’s motivation for change • Avoid victimizing your patient and his or her family or friends • Try to delay the age of smoking initiation rather than strictly banning it • Show your expertise in common risk-factor thinking • Supply your smoking patients with written information too

• Influence your local school authorities for a strict and supervised ban on smoking at schools • Collaborate with your partners and local colleagues in sharing knowledge and establishing practical plans of action • Collaborate with other health professionals in the spirit of common risk-factor thinking • Contact local coalitions for preventing tobacco use for possible collaboration

Oral health education

Oral health education

• A  n approach oriented towards the mother and father and peer group is preferable • Avoid victimizing your patient or his or her parents • Try to look for options in which the easy choice is the healthy choice, such as where to buy an electric toothbrush and how much it will cost • Keep it simple — self-assessment of bleeding approach could be useful for many people Recall and intensive prevention • Prefer family check-ups if alarming signs of early-onset periodontitis are evident. Behavioral and genetic factors dominate: siblings may need your help and you need good family support and collaboration to improve your patient’s oral hygiene to the required exceptionally high level

• C  heck the availability and quality of oral health leaflets in your local area—schools, drug stories, etc. • Organize meetings with people responsible for general health education in schools and other institutions and upgrade their knowledge and motivation to bring the message to the children • Collaborate with your local dental association for back-up support • Collaborate with your local toothpaste, toothbrush and other related companies for material support

POINTS TO REMEMBER • The term ‘periodontal disease’ may encompass all pathological conditions of the periodontal tissues. • The classification of the periodontal diseases has undergone considerable iterations over the years. • Physical barriers such as the skin and mucous membranes represent a component that infectious agents must breach to gain access to the host. • Salivary secretions provide a continuous flushing of the oral cavity as well as providing a continuing supply of agglutinins and specific antibodies. • There are various systemic conditions that may reduce the host response in children and adolescents, thus increasing their susceptibility to periodontal bone loss and ultimately loss of teeth. • Periodontal screening in children and adolescents provides a simple and quick method of identifying periodontal problems which is comfortably tolerated gives the dental practitioner an indication of the need for treatment or further assessment. • Periodontal diseases can present in children and adolescents, ranging from reversible conditions limited to the gingival tissues to those characterized by destruction of the periodontal connective tissue attachment and alveolar bone. • The patient’s history, in conjunction with the examination, forms the basis for the diagnosis of the periodontal condition and should involve both the child or adolescent and the parents or guardians of minors.

Chapter 59  Periodontal Diseases in Children

QUESTIONNAIRE 1. 2. 3. 4.

Classify gingival and periodontal disease in children. Enumerate the organisms causing gingival and periodontal disease in children. Risk factors associated with gingival manifestations in children and adolescents. Write a note on LJP.

BIBLIOGRAPHY 1. Clerehugh V, Tugnait A. Diagnosis and management of periodontal disease in children and adolescents. Periodontology. 2000-01;26:14668. 2. Darby I, Curtis M. Microbiology of periodontal disease in children and young adults. Periodontology. 2000-01;26:33-53. 3. Hodge P, Michalowicz B. Genetic predisposition to periodontitis in children and young adults. Periodontology. 2000-01;26:113-34. 4. Jenkins WMM, Papapanou PN. Epidemiology of periodontal disease in children and adolescents. Periodontology. 2000-01;26:16-32. 5. Kallio PJ. Health promotion and behavioral approaches in the prevention of periodontal disease in children and adolescents. Periodontology. 2000-01;26:135-45. 6. Kinane DF. Periodontal disease in children and adolescents: introduction and classification. Periodontology. 2000-01;26:7-15. 7. Kinane DF, Podmore M, Ebersole J. Etiopathogenesis of periodontitis in children. Periodontology. 2000-01;26:54-91. 8. Meyele J, Gonzales JR. Influences of systemic diseases in children and adolescents. Periodontology. 2000-01;26:92-112.

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Section

ORAL SURGICAL PROCEDURES IN CHILDREN

This section focuses on asepsis and sterilization in dental procedures along with exodontia, local anesthesia and minor oral surgical procedures. It also explains the traumatic injuries to primary dentition and its management including the concepts of management of maxillofacial trauma in children.

60

Chapter

Infection Control Chaitanya P, Nikhil Marwah

Chapter outline • • • •

Personal Protective Equipment Handwashing and Handcare Surface Barriers Chemical Disinfectants

Microorganisms cause virtually all pathoses. It reminds about Florence Nightingale’s favorite dictum “The first requirement of a hospital is that it should do the sick no harm”. The scientific study of hospital or nosocomial crossinfection began during the first-half of 18th century, and from that time until the start of the “Bacteriological Era” many notable contributions originated and remarkable among these early pioneers was the physician Sir John Pringle, who strongly believed that overcrowding and poor ventilation added greatly to the problem of hospital infection.1,2 The understanding of hospital infection followed upon the discoveries of Pasteur, Koch and Lister, it was the beginning of the ‘Bacteriological Era’. With the opening of numerous hospitals in the 20th century, it was soon realized that infections occurred not only in obstetric, surgical and medical patients, but in dental patients as well and air could be a source of such infection and that many viral, as well as bacterial, infections might spread via this route.1,2 It was not until Joseph Lister 1867, in Scotland proposed his Germ Theory and put forward the idea of antisepsis to reduce infections in surgical patients. This was one of the major fundamental advances. WD Miller who authored a book Microorganisms of the Human Mouth in 1890 associated the presence of bacteria with pulpal and periapical disease and is considered to be the father of oral microbiology. In 1910, a British physician, William Hunter presented a lecture on the role of sepsis and antisepsis to the faculty of McGill University condemned the practice of dentistry in United States, which emphasized restorations instead of tooth extraction.3 Hunter stated

• • •

Sterilization Management of Dental Biowaste Regulations by Osha to be Followed to Prevent Cross Infection

that the restorations were “a veritable mausoleum of gold over a mass of sepsis” which he believed was the cause of illness. Antony Van Leeuwenhoek, the inventor of single lens microscope, was the first to observe oral flora and his descriptions of animalcules observed in microscope included those from dental plaque and from an exposed pulp cavity.

DEFINITIONS Sterilization: Defined as the process by which an article, surface or a medium freed of all microorganisms including viruses, bacteria, their spores and fungi both pathogenic and nonpathogenic. Disinfection: The elimination of virtually all pathogenic microorganism on inanimate objects with the exception of large number of bacterial endospore reducing the level  of microbial contamination to an acceptable safe level. Sanitization: Used as a synonym for disinfection, particularly with reference to food processing and catering. Antisepsis: Is used as to indicate the prevention of infection, usually by inhibiting the growth of bacteria in wounds or tissues. Antiseptics: Chemical disinfectants, which can be safely applied to skin or mucous membrane and are used to prevent infection by inhibiting the growth of bacteria. Bactericidal agents: The agents those are able to kill bacteria. Bacteriostatic agents: Only prevent the multiplication of bacteria, which may however remain alive.

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Oral Surgical Procedures in Children

Contamination: It is any activity that reduces the microbial load to prevent inadvertent contamination or infection. Universal precautions: It refers to the method of infection control in which all human blood and certain human body fluids (saliva in dentistry) are treated as infectious for HIV, HBV and other blood borne pathogens.4 Standard precautions: A set of combined precautions that include the major components of universal precautions (designed to reduce the risk of transmission of blood borne pathogens) and body substance isolation (designed to reduce the risk of transmission of pathogens from moist body substances).

PERSONAL PROTECTIVE EQUIPMENT The World Health Organization (WHO) has launched its Global safety challenge promoting ‘clean care is safer care’ which identifies the dangers of health care associated infections. The WHO’s clean care is safer care focuses on clean hands, clean equipment, clean clinical procedures and clean environment. It is important to put on a barrier or personal protective equipment whenever there is risk of coming in contact with mucous membranes or body fluids.5 Dentists, other dental health care personnel and dental students have been categorized as high risk groups for occupationally acquired infections as they are continually exposed to the potential risk of needle stick injuries, contact with blood and other body fluids from patients.6,7

Gloves • The most important worn personal protective equip­ ment is quality vinyl gloves. • Remove gloves promptly after use and perform hand hygiene before touching clean items, environmental surfaces, your eyes, nose and mouth, and before going on to another client. • Properly fitting gloves should be snug but not restrictive, and should cover the cuffs of a long sleeved gown. Care should be taken to avoid injury during procedures. If gloves are torn, cut or punctured they must be changed as soon as it is safely possible. Wash hands thoroughly and replace gloves before continuing with the procedure. • Some health care workers have reported allergies to the latex or the powder used in gloves which may be as irritation contact dermatitis, delayed contact dermatitis (rash), and immediate allergic urticaria. Powdering of hand and cotton glove liners are available to provide a barrier between the skin and the latex. • Nonlatex glove (vinyl or other nonsynthetic polymer) are also available for usage.

Masks (Surgical) Face Protection • These provide protection to nose and mouth from likely splashes and sprays of blood or body fluids. Splashes and sprays can be generated from a client’s behavior (e.g. coughing or sneezing) or during procedures (e.g. suctioning, irrigation, cleaning equipment). • Mask can be dome-shaped or surgical masks with or without a fluid resistant membrane layer.8 • Surgical masks with ear loops are the easiest to put on and remove. Wear within three to five feet of the coughing, sneezing client. This prevents transmission of microorganisms to the dentist. • Absence of an airtight fit around the periphery of the mask increases the chances of air to get inside the mask through the periphery and this phenomenon is called “blow-by”.2 • Dental aerosols that are generated during patient care are usually smaller than 5 microns in diameter and are suspended in air. The passing of the liquids from the outer layer of the mask on to the inner surface is called “strike through” and this should be avoided by using masks that are impervious for liquid passage. • The surgical mask may have three layers: The outer (esthetic layer), the middle (fluid shield layer), and the inner layer (that is soft and compatible with the skin of the face). The mask may be shaped for a good fit such as being pleated or being duckbill shaped.

Gowns • Put on the gown as first procedure, mask and eye protection as the second procedure (Fig. 60.1). • Wear long sleeved gowns to protect uncovered skin and clothing from likely splashes, sprays during procedures and client care activities. • Gowns are to be changed between patients to control cross contamination between patients.8 • It is recommended that all dental students undergraduate and postgraduates wear hospital clinical attire while treating patients in the clinical areas based on the level of anticipated exposure. It is also recommended that dentists and faculty members who guide dental students in clinical area should routinely wear clinical attire while working on patients or in laboratories and while working chair side with students.8 • Practicing universal precautions in the form of personal barrier technique for all patients is considered one of the most efficient methods to minimize the risk of cross infection in the dental office.7

Chapter 60  Infection Control Glove types and indications Glove Patient examination gloves§

Surgeon’s gloves§

Nonmedical gloves

Indication

Comment

Material

Attributes*

Patient care, examinations other nonsurgical procedures involving contact with mucous membranes, and laboratory procedures

Medical device regulated by the food and drug administration (FDA) Nonsterile and sterile single-use disposable. Use for one patient and discard appropriately

Natural-rubber latex (NRL) Nitrile Nitrite and chloroprene (neoprene) blends Nitrile and NRL blends Butadiene methyl methacrylate Polyvinyl chloride (PVC or vinyl) Polyurethane Styrene-based copolymer

1,2 2,3 2,3

Surgical procedures

Medical device regulated by the FDA Sterile and single-use disposable. Use for one patient and discard appropriately

NRL Nitrile Chloroprene (neoprene) NRL and nitrile or chloroprene blends Synthetic polyisoprene Styrene-based copolymer Polyurethane

1,2 2,3 2,3 2,3

NRL and nitrile or chloroprene blends Chloroprene (neoprene) Nitrile Butyl rubber Fluoroelastomer Polyethylene and ethylene Vinyl alcohol copolymer

2,3

Housekeeping procedures (e.g. cleaning and disinfection) Handling contaminated sharps or chemicals

Not for use during patient care

Not a medical device regulated by the FDA Commonly referred to as utility, industrial or general purpose gloves. Should be puncture or chemical-resistant, depending on the task. Latex gloves do not provide adequate chemical protection Sanitize after use

1,2,3 2, 3 4 4 4,5

2 4,5 4

2,3 2,3 2,3 3,4,6 3,4,6

*Physical properties can vary by material, manufacturer, and protein and chemical composition  1 contains allergenic NRL proteins   2 vulcanized rubber, contains allergenic rubber processing chemicals   3 likely to have enhanced chemical or puncture resistance   4 nonvulcanized and does not contain rubber processing chemicals   5 inappropriate for use with methacrylates   6 resistant to most methacrylates. §Medical or dental gloves include patient-examination gloves and surgeons (i.e. surgical) gloves and are medical devices regulated by the FDA. Only FDA cleared medical or dental patient-examination gloves and surgical gloves can be used for patient care

Fig. 60.1:  Procedure of wearing and removal gown

707

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Oral Surgical Procedures in Children

Protective Eyewear • In dentistry, polycarbonate glasses with side-shields, face-shields and glasses with disposable side-shields are used.5,8 • While trimming models, dentures, cutting wires and doing lab work or during reprocessing of instruments, use of protective eyewear is a must to reduce the probability of exposure to hazardous materials and hard matter that may damage the eyes.8 Eye injuries may occur from projectiles such as bits of calculus during scaling procedures and splatters from body fluids while using high speed hand pieces and another potential source of eye injury is the intense dental curing light.9 • Two types of products generally available are goggles or eye shields which cover only eyes and face shields that cover entire face.5 Protective eyeglasses benefits as a barrier against physical and chemical injuries.10

• Before wearing personal protective equipment, staffs need to remove jewelry, wrist watch and examine their hands for cuts, bruises and nails. Cuts and bruises should be medicated and covered using band-aid/dressing to avoid coming in contact with patient material. • Hands should be washed with water and antimicrobial soap but use of solid soap without adequate drainage and of fabric towels may compromise its efficacy.10 • Handwashing with water and plain soaps is adequate for patient examination and nonsurgical procedures and for surgical procedures an anti microbial hand scrub should be used.4 • Surgical handwashing involves scrubbing hands all the way up to the elbow for about 2 to 6 minutes using a single

HANDWASHING AND HANDCARE • Patients notice most things in the clinic from cleanliness to personal hygiene and clinician’s professionalism. Sometimes they even take into notice whether the clinician and staff have clean finger nails, washed hands with soap before donning gloves, whether the hair is unkept and also whether the clothes are clean and presentable as a clinic staff or dentist.8 • Hand hygiene is one of the simplest inexpensive and effective measures of infection control in the health care setting including dentistry.10 Hands have been identified as important vectors in cross infection. • It was reported that orthodontists have the highest incidence of hepatitis B among dental professionals.11

Sequence followed in handwash procedure (Fig. 60.2). • Remove jewelry, wrist watch and examine hands. • Wet hands with warm water and dispense an adequate amount of soap. • Thoroughly rub both surfaces of hands around the thumb and fingers for about 30 to 60 seconds. • Wash hands with warm water to remove the soap and dry hands with paper towels. • Examine hands for injuries such as nicks, cuts and bruises and treat as needed. • Wear single use disposable gloves.

Fig. 60.2:  Effective handwashing technique

Chapter 60  Infection Control Hand hygiene methods and indications Methods

Agents

Technique

Routine handwash

Water and nonmicrobial detergent (e.g. plain soap)

• Wet hands and rinse under cool running water • Dispense handwashing agent sufficient to cover hands and wrists

Antiseptic handwash

Water and antimicrobial agent/detergent (e.g. chloriodine, iodine and chlorocylonol triclocon

• Rub the agent into all areas, with particular emphasis around nails and between fingers before running under cool water • Dry hands completely with disposable towels before wearing gloves • Use a towel to turn off the tap if automatic contacts are not available

Antiseptic handrub

Alcohol-based handrub

• Apply the product to palm of one hand • Rub hands together covering surfaces of hands and fingers until hands are dry • Follow manufacturer’s recommendations regarding volume of product

Surgical

Water and antimicrobial agent detergent (e.g. chlorodine, iodine and iodophors, chlorocylonol

• Remove rings, watches, and bracelets • Remove debris from under-wash fingernails using a nail cleaner under running water • Wet hands and wrists under cool running water

2–4 minutes

Water and nonantimicrobial detergent (e.g. plain soap) followed by an alcohol-based surgical hand scrub product with persistent activity

• Using an antimicrobial agent, scrub hands and forearms for the length of time recommended by the manufacturer’s instructions before rinsing with cool water • Dry hands completely using a sterile towel in idea before downing sterile surgeon’s gloves  Follow manufacturer instructions for surgical hand scrub product

Follow manufacturer instructions for surgical hand scrub with persistent air-way

use disposable sponge or a soft scrub brush and antimicrobial soap.

SURFACE BARRIERS • Barriers can be sterile or nonsterile depending on whether they are used for a surgical or a nonsurgical routine dental care. • Barriers need to be routinely changed between patients, disinfection of surfaces may be done at beginning of the clinic session and at the end of clinic session and when visibly soiled.8 • Air/water syringes, HVE and saliva ejector syringe may be covered to at least 6 inches below the couplings.

Duration 15 seconds

Indications • When variably soiled • After barehanded touching of inanimate objects likely to be contaminated by blood or saliva • Before and after treating each patient • Before leaving patient care, laboratory or instrument processing area • Before and after removing gloves that are torn out or punctured

• Before wearing sterile surgeon’s gloves for surgical procedures

• Work surfaces that are in immediate proximity to the clinician and within hands reach are at a higher risk of contamination. • Aluminum foils can be used as this type of barrier • Single use disposable barriers used over commonly or regularly touched surfaces are: – Dental unit light handles, electrical or mechanical controls – Dental chair head and arm rest – Handpiece – Air/water syringe – Saliva ejector – Intraoral digital sensors and RVG equipment – Apex locators, endosonic ultrasonic units and NI-TI Torque control hand pieces.8

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CHEMICAL DISINFECTANTS • Chemical disinfectants or germicides that are commonly used in dentistry can be classified into three main categories such as: 1. Liquid sterilants/High level disinfectants – Glutaraldehyde – Chlorine dioxide – Hydrogen peroxide 2. Intermediate and low level disinfectants surface – Hydrogen peroxide – Sodium hypochlorite – Chlorine dioxide – Iodophors – Synthetic phenols – Quaternary ammonia compounds 3. Antiseptics2 – Active chlorine dioxide germicides – Essential oil compounds – Iodinated compounds – Chlorhexidine compounds – Cetylpyridium compounds – Sanguinarine based compounds – Parachlorometaxylenol compounds – Other bacteriostatic/bactericidal compounds • Surfaces that cannot be immersed such as bracket table, light handles, hoses, counter surfaces, chair controls, X-ray unit head/handles/controls and other surfaces that have a tendency to get contaminated during patient care must be disinfected.8 • Certain surfaces such as electrical controls, the chair surfaces including the headrest, arm rest and seat may be sanitized and disinfected by initially spraying the disinfectant on a disposable paper towel and wiping the surfaces thoroughly once to remove the bioburden. • Reusable sponges or cloth towels must not be used, as they tend to harbor bioburden, bacterial debris and hinder the efficacy of the disinfectant. • Sodium hypochlorite is used as a traditional disinfectant. Formaldehyde is used as an antimicrobial bactericide and fungicide for maintenance of critical and semicritical dental equipment, floors, walls and other areas. • Most commonly used disinfectants are summarized in below:

STERILIZATION

Instrument Reprocessing • Instrument reprocessing is the most important aspect of dental infection control. • The dental team must ensure the safety of both patients and personnel by adequately sterilizing dental instruments and other equipment before their use.12 Any

dental instrument that enters the oral cavity is classified as critical or semicritical surfaces as per Spaulding’s classification and must be sterilized.

Instrument Processing Area • DHCP should process all instruments in a designated central processing area to more easily control quality and ensure safety. • The central processing area should be divided into sections for receiving, cleaning, and decontamination; preparation and packaging; sterilization; and storage. Ideally, walls or partitions should separate the sections to control traffic flow and contain contaminants generated during processing. • When physical separation of these sections cannot be achieved, adequate spatial separation might be satisfactory if the DHCP who process instruments are trained in work practices to prevent contamination of clean areas.

Receiving, Cleaning, and Decontamination • Reusable instruments, supplies, and equipment should be received, sorted, cleaned, and decontaminated in one section of the processing area. • Prior to sterilization, instruments must be cleaned to reduce bioburden.12,13 • Cleaning should precede all disinfection and sterilization processes; it should involve removal of debris as well as organic and inorganic contamination. Removal of debris and contamination is achieved either by scrubbing with a surfactant, detergent, and water, or by ultrasonic cleaner. After cleaning, instruments should be rinsed with water to remove chemical or detergent residue. • Ultrasonic cleaning (sonication) is very efficient process that helps tear away dirt and debris from instrument surfaces. Sometimes, even after an ultrasonic process patient material may still be on the surface of instruments that may need to be physically removed by using a long handle brush. Sonication of loose instruments should be carried out for 8 to 10 minutes. • To avoid injury from sharp instruments, DHCP should wear puncture resistant, heavy-duty utility gloves when handling or manually cleaning contaminated instruments and devices along with a mask, protective eye wear or face shield, and gown or jacket to prevent effect of spillage.

Inspection of Cleaned Instruments • After cleaning, the instruments should be pat dried using a small stack of paper towels and inspected for residual bioburden or debris. The inspected instruments can now be made into sets and bagged.8

Intermediate

Intermediate

High

Low

Intermediate

Intermediate

Intermediate

High

Phenol (4–5%), cresol, chloroxylenol (Dettol)

Glutaraldehyde (2–5%)

Quaternary ammonia compounds (Cetrimide, Savlon)

Iodophors (30-1,000 ppm I2, povidone-I2)

Chlorine 100–1000 ppm

Sodium hypochlorite

Hydrogen peroxide

Level of disinfection

Alcohol (ethyl and isopropyl 60–85%)

Name

+

+

+

+

+

+

+

+

Bacteria

+

+

+

+

–

+

+/–

+/–

Virus

+

+

+

+/–

+/–

+

+

+

Fungi

In dental labs

Regular dental surfaces

Disinfecting instrument and linen after surgery

2% oral wounds, 5% skin

0.5% for washing skin wound

Used on metal, plastics

Disinfection of walls, floors, swab prior to use

Antiseptics of skin, solution of choice 70%

Advantages

Hydrogen peroxide (7%) •  Very potent germicide, sporicidal •  Active in the presence of bioburden •  Prolonged shelf and active life, reusable • Compatible with plastics and impressions •  Good for use in dental labs

Synthetic phenols •  Triphenols are better than dual phenols •  Compatible with most materials •  Residual biocidal action •  Fast acting, long shelf life

Glutaraldehyde • Potent germicide, sporicidal • Active in the presence of bioburden • Prolonged shelf and active life, reusable • Good for use in dental laboratories

Chlorine •  Three minutes for disinfection •  Six hours for sterilization •  No trihalomethanes

Sodium hypochlorite (Bleach) •  Rapid antimicrobial action •  Broad spectrum kill •  Effective in dilute solution •  Economical

Iodophors •  Broad spectrum •  Short biocidal activity •  Few reactions •  Residual biocidal action

Disinfection methods Uses

•  Can be corrosive on metals •  Cab be dangerous to skin (burns) •  Not tested widely

•  May affect some polymers •  Some have film accumulation • May not be used in neonatal and pediatric practices due to possible adverse reaction

• Items must be rinsed with sterile water • Severe tissue/respiratory irritant • Must have good ventilation and evacuation •  Can sensitize users

• Highly corrosive to metals and certain plastics •  To be mixed daily •  Adequate ventilation needed

•  Very corrosive to metals • Damages plastic and rubber, clothes •  To be prepared daily •  Unpleasant odor •  Toxic disinfection by-products

•  Unstable at high temperatures • Dilution and contact time critical •  Solution to be prepared daily •  Rust inhibitor needed •  Inactivated by hard water •  May discolor some surfaces

Disadvantages

Chapter 60  Infection Control

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• Safe and effective decontamination procedures must be carried out before instruments are put into the appropriate equipment for sterilization.12 • Packaged sterile instruments can be stored for as long as the integrity of the pouch/package is not broken, damaged or affected by moisture. • If instruments are to be “cold sterilized” in glutaraldehyde or any approved immersion sterilant, they should be rinsed with sterile water to remove residual chemical sterilant from the surfaces of the instrument and used immediately.8

Preparation and Packaging • In another section of the processing area, cleaned instruments and other dental supplies should be inspected, assembled into sets or trays, and wrapped, packaged, or placed into container systems for sterilization. • Hinged instruments should be processed open and unlocked. An internal chemical indicator should be placed in every package. In addition, an external chemical indicator (e.g. chemical indicator tape) should be used when the internal indicator cannot be seen from outside the package. • Critical and semicritical instruments that will be stored should be wrapped or placed in containers designed to maintain sterility during storage. • Materials for maintaining sterility of instruments during transport and storage include wrapped perforated instrument cassettes, peel pouches of plastic or paper, and sterilization wraps (i.e. woven and nonwoven).

Sterilization Procedures • Heat-tolerant dental instruments usually are sterilized by: – Steam under pressure (autoclaving) – Dry heat – Unsaturated chemical vapor. • All sterilization should be performed by using medical sterilization equipment cleared by FDA. The sterilization times, temperatures, and other operating parameters recommended by the manufacturer of the equipment used, as well as instructions for correct use of containers, wraps, and chemical or biological indicators, should always be followed. • Instrument packs should be allowed to dry inside the sterilizer chamber before removing and handling. Packs should not be touched until they are cool and dry because

hot packs act as wicks, absorbing moisture, and hence, bacteria from hands.

Autoclave • Autoclaving or sterilization using steam and pressure is the most common and reliable method of sterilization.13 • This method could be more corrosive for instruments that have a high content of carbon steel (especially if packages are not adequately dried).8,13 Parameters

Standard cycle

Fast cycle

Sterilization time

15–20 minutes

3–5 minutes

Temperature

121° celsius (250°F)

134° C (273°F)

Pressure

15 pounds per square inch (psi)

30 pounds per square inch

Chemiclave • It is sterilization with chemical vapors • A combination of liquid chemicals (with 3–5 minutes): Coma, absent vital signs, dilated pupils

•

Hydrocortisone sodium succinate (Solution cortef) 100–500 mg IV or IM. Dexamethasone (Decadron) 4–12 mg IV or IM

Signs of partial airway obstruction

•

Repeat dose at 1, 3, 6, and 10 hours as indicated by severity of symptoms.

Forceful cough

Individuals with good air flow Wheezing between coughs Ability to breath

Respiratory emergencies Airway obstruction Acute airway obstruction is the major cause of nontraumatic cardiac arrest in infants and children. •

Sit down dentistry (Supine or semisupine) → increased incidence of airway obstruction

•

If swallowed → GI blockage, peritoneal abscess, perforations, peritonitis

Individuals with poor air exchange Weak, ineffectual cough “Crowing” sound on inspiration Absent or altered voice sounds Possible cyanosis Possible lethargy Possible disorientation

Chapter 66  Medical Emergencies in Dental Practice Management

•

Monitor vital signs

Step 1: Position → supine with feet elevated Step 2: Head tilt-chin lift → Step 3: A + B (look, listen, feel) Step 3a: Jaw-thrust maneuver if indicated Step 4: A + B repeat step 3 Step 5: Rescue breathing, if indicated Establishing an emergency airway: •N  oninvasive procedure: –B  ack blows –M  anual thrust –A  bdominal thrust (Heimlich maneuver) –C  hest thrust – F inger sweep •P  rocedure for obstructed airway in infants and children: Combination of back slaps and chest thrust is still recommend protocol for the infant under 1 year • Surgical procedure: – Invasive procedures are tracheostomy and cricothyrotomy

•

If no improvement call EMS

•

Start IV

•

Consider epinephrine 1:1,000, 0.3 g every 20 minutes

Bronchospasm

Dental treatment considerations for the asthmatic patient •

Take a good medical history prior to treatment; determine how often the patient has an asthma attack and what precipitates it

•

Consider scheduling morning appointments

•

If patient uses an inhaler they should have it on hand during treatment. Consider prophylactic use prior to treatment

Hyperventilation It denotes the increase in alveolar ventilation disturbing the optimum levels of oxygen and carbon dioxide. It is caused by abnormally rapid and deep breathing leading to respiratory alkalosis. Hyperventilation syndrome in dental clinic is often precipitated by anxiety, fear, nervousness and emotional stress in a hysterical form at the conscious level. It is more commonly seen in females. It results in lower carbon dioxide level in the blood.

Patients with a history of bronchial asthma may develop acute bronchospasm. It may be triggered by emotional stress and anxiety during the course of treatment

Signs and symptoms •

Dizziness

•

Hard to breathe

Types of asthma

•

Shaking and trembling

•

Extrinsic: Allergic asthma, younger patients, Type 1 hypersensitivity Rx

•

Cold clammy hands (Diaphoresis)

•

Tight feeling in chest, chest pain, and palpitations

Intrinsic: Older patients, nonallergic factors, cold temperatures, exercise, stress

•

Lightheaded, giddy, impaired consciousness

•

Uncontrolled overbreathing. Respiration rate increase to 25–30/ minute

Sense of suffocation, patient will sit up like they are fighting for air

•

Globus hystericus: Feeling of lump in throat and suffocating

•

Tingling in hands, feet, and perioral areas

•

Pressure or tightness in chest

•

Increase in blood pressure and increase heart rate

•

Nonproductive cough

Treatment

•

Expiratory and inspiratory wheezes

•

•

Expiration is prolonged and harder than inspiration

Discontinue treatment and remove any foreign objects from the patient’s mouth

•

Chest is distended

•

Position patient upright

•

Thick stringy mucous. At termination of a period of intense coughing the patient will expectorate this mucous

•

Assess airway

•

Reassure patient and try to calm them

•

Have patient breath slowly and shallowly into a paper bag or mask 6–10 times/minute

•

Monitor vital signs

•

If available it can use versed IV 1 mg/minute up to 4–6 mg or IM 5 mg to calm the patient

•

Determine what precipitated attack.

•

Signs and symptoms of an asthma attack •

Severe asthma attack •

Cyanosis of the nail beds

•

Perspiration and flushing of the skin

•

Use of accessory muscle of respiration: Sternocleidomastoid, and shoulder/abdominal muscles

•

Patient may also appear confused and agitated

Management of an asthma attack •

Discontinue dental treatment

•

Place patient in easiest position for them to breath. This is usually upright with arms outstretched

•

Albuterol inhaler (Proventil) 2 puffs every 2 minutes

•

Supplemental oxygen at 10 L/minute

Hypertension When a patient exhibits blood pressure above 160/100 Hg is in the preoperative phase, he is labelled as hypertensive. Patient complains of headache, dizziness, nausea and even vomiting. Fundus examination reveals hemorrhages or exhibits blood spots over the retina with increased intracranial tension.

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Treatment

•

Injection atropine should be given if there is bradycardia

•

This can be avoided by proper premedication

•

•

Should this emergency arise intraoperatively the patient is allowed to take rest in a semi sitting position

In case of recent history of myocardial infarction, any elective surgery should not be undertaken for a period of 6 months.

•

Oxygen may be administered to bring down the blood pressure

Cardiopulmonary arrest

•

Injection diazepam may be administered. This normally settles the stress related hypertension

•

Injection frusemide IV and is maintained as a preparation to any serious emergency

•

10 mg capsule nifedipine sublingually to bring the blood pressure down.

There is sudden arrest of ventilation and circulation. It may occur in patients with already existing cardiovascular disease, anaphylaxis, toxic reactions of medicines, asphyxia, etc. Clinically it is characterized by absence of chest and abdominal movements, breath sounds, carotid and femoral pulse. The patient is unconscious with dilated pupils.

Hypotension A fall in blood pressure or hypotension during oral surgical procedures can be due to a simple common fainting attack. Signs and symptoms •

There is associated weak pulse, bradycardia

•

Confusion, restlessness, nausea, stupor.

Treatment •

Put the patient in supine position with legs raised

•

100 percent oxygen should be administered

•

IV line maintained with ringer lactate solution

•

Atropine 0.6 mg in 5 mL of sterile water is given intravenously slowly if the pulse is less than 6 per minute. Atropine should be stopped when a good volume radial pulse with rate of 72 per minute appears

•

Injection mephentermine 15 mg can be administered intramuscularly

•

Injection hydrocortisone succinate 100 mg should be administered for combating stress. Ischemic heart disease

It denotes ischemia of the myocardium leading to arrhythmias, angina pectoris, myocardial infarction and sudden death. The condition is characterized by tightness in the chest, sensation of choking and a referred pain in the left arm and shoulder. The pain may be referred to jaw and neck. The attack may be precipitated on exertion or by the stress during the dental treatment. Treatment •

In case of an acute attack of angina pectoris occurs in dental chair, the dental treatment should immediately be stopped, adjust the chair in semireclining position

•

A tablet of nitroglycerin is placed sublingually and can be repeated after 5 times

•

Oxygen administration

•

Patient physician should be immediately called

•

In case of myocardial infarction pain may be controlled with small amounts of morphine

Treatment Basic life support. Airway: The airway must be patent. If foreign body is suspected, the patient must be rolled on one side and 4–5 forceful blows must be delivered rapidly between the shoulder blades with the heel of the hand. The patient is then put in supine position and abdominal thrust in the upward direction just below the sternum. After the foreign body is excluded the patient should be kept in supine position as he requires external cardiac massage and artificial respiration. The patient head must be lifted with one hand under the neck and the other hand pressing the forehead so that the head is tilted backwards to keep the airway patent. Breathing: Once the airway patency is maintained and if breathing is inadequate, artificial ventilation must be given. With the above position patient nostrils must be sealed with thumb and index finger and mouth to mouth respiration must be given. This is done by taking a deep inspiration and exhaling it into the patient’s mouth. Circulation: With the patient in supine position, a sudden sharp thrust is given on the chest wall. This may restore the effective beating of the heart. Cardiac massage: The heel of both the hands, one above the other, the arms straight and extended and in kneeling position, the lower sternum should be compressed firmly to depress it for 1–1½ inch. This is carried out at the rate of 60–80/minute. Advanced life support •

Adrenalin: 1 mL of 1:1000 IV followed by bolus of dextrose

•

Calcium: 10 mL calcium gluconate 10 percent injected IV

•

Sodium bicarbonate 1 mEq/kg should be given intravenously in order to overcome acidosis. Precordial thump ↓ DC shock ↓ DC shock ↓ DC shock ↓ Endotracheal intubation ↓ Adrenalin ↓ CPR in ratio of 5:1 (Cardiac massage: Ventilation) ↓ DC shock

Chapter 66  Medical Emergencies in Dental Practice Chest pain/angina The development of central chest discomfort frequently results from stressful situations in patients with coronary artery disease. In angina episodes, the coronary artery narrowed by atherosclerosis is unable to supply the heart muscle with adequate amounts of oxygenated blood, causing chest pain. Signs and symptoms Central, substernal discomfort May radiate to shoulder, neck, jaw or epigastric region Dull heavy pressure sensation of short duration Prompt relief with rest or nitroglycerin Treatment Position patient semi-upright or upright Administer oxygen Administer nitroglycerin 0.5 mg SL every 5 minutes. Monitor, assess and record vital signs Acute myocardial infarction Signs and symptoms Central, substernal discomfort May radiate to shoulder, neck, jaw or epigastric region Dull heavy pressure sensation of short duration Dyspnea, syncope, diaphoresis, sudden death Pain not relieved by rest or nitroglycerin and is of long duration. Women may experience different signs— upper abdominal pain and fatigue. Treatment Position patient semi-upright or upright. Administer oxygen. Administer nitroglycerin 0.5 mg SL every 5 minutes. Initiate fibrinolysis: If possible have the patient to chew 162–325 mg of aspirin. Calm and reassure the patient. Diabetic emergencies There are two types of problems associated with diabetes getting treatment in dental office. • Hypoglycemia or insulin shock • Diabetic coma or ketoacidosis or hyperglycemia. Signs and symptoms Hypoglycemia is presented by pallor, sweating and tremors. There is palpitation, generalized weakness and hunger pains. Patient exhibit symptoms like tachycardia, headache, confusion, visual and disturbances of speech. Ultimately coma may develop. Hyperglycemia is characterized by dry skin and hypotension. There is history of polydipsia, polyurea and polyphagia. Patient has typical acetone breath with a rapid deep breathing. Patient looks ill, dehydrated with dry skin, dry mouth and enophthalmos. Ultimately diabetic coma will develop. Management Hypoglycemia •

In a conscious patient administer 20 gm of oral glucose

•

In an unconscious patient 50 cc 50 percent glucose given IV

•

Adrenalin: 0.5 cc of 1:1000 adrenalin is given subcutaneously. It stimulates hepatic gluconeogenesis and counteracts hypoglycemia

•

Glucocorticoid: 100 mg of hydrocortisone hemisuccinate IV

•

Glucagon: 1–2 mg IM raises blood sugar.

Hyperglycemia •

Circulating insulin present is ineffective because of poor tissue perfusion. Hence, tissue perfusion must be improved. One liter of fluid can be given in the first half hour and subsequently 1 liter per hour till dehydration is corrected

•

Insulin therapy forms the main stay of hyperglycemia. It not lowers the blood sugar but also prevents further lipolysis thereby preventing accumulation of ketones and hydrogen ions. Adrenal insufficiency

The adrenal cortex produces over 25 different steroids. These steroids are broken into three groups: sex steroids, mineralocorticoids, and glucocorticoids. Of primary concern in dentistry are the glucocorticoids. A physiologic dose of approximately 20 mg/day of cortisol is produced. This plays a key role in the bodies ability to adapt to stress. Cortisol provides a chemical link within the cells of the body allowing regulation of vital functions including blood pressure and glucose utilization. Cortisol production is triggered by real or threatened “stress” such as trauma, illness, fright, and anesthesia. In a patient with suppressed adrenal function a failure of this cortisol production eliminates the chemical link to regulate vital functions resulting in sudden shock and possibly death. Suppressed adrenal function or adrenal failure is classified as either primary (Addison’s disease caused by disease states such as TB, bacteremia, carcinoma, and amyloidosis.) or secondary (Caused by pituitary disorder, hypothalamic disorders, or steroid therapy.) Steroid therapy suppresses the function of the adrenal cortex reducing the production of natural cortisol. Because of this suppression patient’s who have been on long-term steroid therapy lose their ability to respond to stress. If these patients are stressed symptoms of acute adrenal insufficiency may result. Signs and symptoms of acute adrenal insufficiency •

Mental confusion

•

Muscle weakness

•

Fatigue

•

Nausea and vomiting

•

Hypotension

•

Intense pains in abdomen, lower back, and/or legs

•

Mucocutaneous pigmentation

•

Hypoglycemia

•

Hyperkalemia

•

Increase heart rate, decreased blood pressure

Management of suspected acute adrenal insufficiency •

Discontinue all treatment and remove foreign objects from the patients mouth.

•

Initiate BLS and activate EMS

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•

Place patient supine.

•

Pallor, tremor, palpitation

•

Monitor and record vital signs.

•

Sharp rise in blood pressure and heart rate.

•

Oxygen at 5–10 L/minute.

Signs and symptoms of local anesthetic toxicity

•

Hydrocortisone 100 mg IV (Dexamethasone 4 mg) over 30 seconds or IM if IV not available. Repeat dose every 6 hours for 24 hours. If the patient is stable then reduce to 50 mg (Dexamethasone 4 mg) every 6 hours then taper orally over 4–5 days. Should initiate if there is any suspicion of AAI.

•

Agitation

•

Muscular twitching and tremors

•

Increased blood pressure and heart rate

•

Light-headedness

Dental treatment considerations

•

Visual and auditory disturbances (Tinnitus, difficulty focussing)

For patients with a history of glucocorticoid therapy use stress reduction protocols.

•

If moderate to high overdose of Local anesthetic can also have convulsions and depression of blood pressure, heart rate, and respiration.

The following guidelines can be used to determine if replacement therapy is indicated. This is a change from the old rule of two’s based on an article done at NNDC. It is always a good idea to get a medical consult in such cases.

Management of toxic reactions to epinephrine: Toxic effect of epinephrine is transitory rarely lasting more than a few minutes. •

Stop dental treatment

If the patient has undergone supraphysiologic (More than 20 mg/day) glucocorticoid therapy that was discontinued more than 30 days prior to the planned dental treatment no supplementation is required.

•

Place patient in most comfortable position

•

Monitor vital signs

If the patients has undergone supraphysiologic glucocorticoid therapy within 30 days of the planned dental procedure considered the patients suppressed and provide steroid supplementation equivalent to 100 mg of cortisol.

•

Consider administering oxygen

•

Allow time for the patient to recover.

If the patient has undergone or is undergoing alternate day dosing schedule glucocorticoid therapy no supplementation is required but it is best to provide dental treatment on the off day of the patients dose schedule. If the patient is currently receiving daily glucocorticoid therapy at a supraphysiologic level (More than 20 mg) supplementation is required. If the daily dose is subphysiologic supplementation is not required. Hypochlorite Accident It is due to expelling of an irrigant such as NaOCl beyond the apex. This happens only by locking the needle of the irrigating syringe in the canal and forcefully injecting the irrigant.

Dental treatment considerations for use of epinephrine •

Due to its cardiovascular effects limit use in patients with history of heart disease or stroke

•

Can cause uterine contractions in the pregnant female

•

Possible drug interactions (Especially MAO inhibitors and cocaine)

•

Remember the patient has endogenous epinephrine. Production of this is increased in stressful situations.

Management of toxic reactions to local anesthetic: Treatment varies with the onset and severity of the reaction. Mild reaction/rapid onset (Example is an intravascular injection) •

Reassure patient

•

Administer oxygen

Signs and symptoms

•

Monitor and record vital signs

•

Within minutes the patient feels sudden extreme pain

•

•

Swelling within minutes

Allow for recovery; determine if patient can be allowed to leave unescorted.

•

Profuse, prolonged Bleeding through the root canal.

This bleeding is the body’s reaction to the irrigant.

Mild reaction/slow onset •

Toxic reaction with a delayed onset is most likely a result of impaired biotransformation

Allow the bleeding to continue. If the body rids itself of toxic fluid healing may be faster.

•

Evolves slowly, use caution

•

Monitor patient, record vital signs.

•

If the treated tooth is pulpless consider prescribing an antibiotic and an analgesic for 5 and 3 days respectively.

Severe overdose/rapid onset, severe overdose/slow onset •

ABC’s

•

Since this may be hypersensitive reaction consider prescribing an antihistaminic.

•

Activate EMS

•

Administer oxygen by mask at 10–15 L/minute

•

Start IV if available (18 gauge catheter with normal saline)

•

If needed and available administer anticonvulsant, versed 2 mg, then 1 mg/min to effect (Monitor respiration)

•

Monitor and record vital signs

Treatment •

Toxic reaction due to drug (Local anesthesia) over dosage: Local anesthetic and epinephrine toxicity Signs and symptoms of epinephrine toxicity •

Agitation, weakness, and headache

Chapter 66  Medical Emergencies in Dental Practice •

Allow for recovery and discharge with appropriate escort or transport to hospital if required.

Treatment considerations to avoid adverse drug reaction •

Prevention is the key. Take a complete medical history. Determine if there are any diseases present that affect the use of a drug

•

Monitor vitals, pulse oxymetry.

•

Suction available.

•

If seizure is lasting > 2 minutes, establish IV, administer medicines.

•

Diazepam Adult: 5 to 10 mg IV/IM Pediatric: 0.2 to 0.5 mg/kg IV/IM

•

Know what medications the patient is taking and possible drug interactions

•

•

Careful injections make sure to aspirate to avoid an intravascular injection.

Midazolam 0.05 to 0.1 mg/kg IV 0.2 mg/kg IM (Max 10 mg) Pharmacologic management.

•

EMS not arrived > 5 minutes Adult: Dextrose 50 mL bolus off 50 percent glucose. Pediatric: 2 mL/kg 25 percent dextrose solution.

•

Evaluate airway maintenance.

•

Evaluate cardiac rhythm.

Maximum recommended doses of local anesthetic Lidocaine “Plain” Lidocaine 2 percent with 1:100 k Epinephrine Mepivacaine “Plain” Mepivacaine with 1:20 k Neocobefrin Bupivacaine with 1:200 k Epinephrine

4.4 mg/kg 7.0 mg/kg 4.4 mg/kg 6.6 mg/kg 3.2 mg/kg

Maximum recommended doses of epinephrine Healthy adult Cardiac patient

0.2 mg/kg 0.04 mg/kg

Epilepsy This is a central nervous system disturbance involving convulsions followed by loss of consciousness. Majority of the patients are conscious of their problem and should be warned about the importance of medicine which is generally recommended on long-term basis. An emergency can arise in the dental clinic when the epileptic seizures occur during treatment. When two or more seizures occur in succession, it is labelled as status epilepticus. And it is a serious emergency. Convulsions can also be seen in high grade fever, brain tumor, and head injury, hypoglycemia and drug toxicity. Therefore a careful history prior to treatment is important. The airway should be kept patent during an epileptic fit. Crush injury to the tongue should be avoided by holding a blunt object between the teeth. Generalized seizures Tonic-clonic Clonic seizures Tonic seizures Atonic seizures Myoclonic seizures Absence (petit mal) seizures Partial seizures Simple partial seizures Complex partial seizures Partial seizures secondarily generalized Treatment protocol •

Most seizures last < 2 minutes

•

EMS activated.

•

Assure patient and staff safety.

•

Administer oxygen.

•

Manage airway.

Medical emergencies in the pediatric dental patient Most of the recommendations for treating emergencies in the dental office are oriented towards the adult patient and recommendations for the management of medical emergencies in the child patient are not readily available. The pedodontist must have equipment specifically for the pediatric dental patient, “Basic Emergency Kit for the Pedodontist.” The dosages of emergency drugs as well as the techniques for providing supportive therapy for the pediatric dental patient need to be altered. Since consideration must be given to the persons in the reception room some of whom in a pedodontic practice approach the age and size where adult recommendations for emergency therapy may apply, the pedodontist must be capable of treating medical emergencies in adults as well as in children   When confronted with a medical emergency, the pedodontist should remain calm and act swiftly and definitively in order to provide immediate therapy without causing undue panic in the patient or the auxiliary personnel. The pedodontist should be concerned with maintaining airway, breathing, and circulation and then should treat symptomatically. The pedodontist should never administer a drug without a definite indication for its use and should also avoid multiple drug therapy since it will complicate the diagnosis for medical personnel. Pediatric dosage schedule The dosage schedules presented for children in each of the following emergency situations are reported as a range. The first dose in the range corresponds to the approximate dose for a 30-pound child, and the second dose corresponds to a 60-pound child. The milligrams per kilogram dose is listed along with the maximum dose. The adult dose is based on a 150-pound adult. However, the author recommends that a concise reference chart and instructions in an emergency kit list the doses as a range to facilitate the estimation of the proper dose to be given during an emergency. If the dosages were listed as milligrams per kilogram, it would be too time-consuming and impractical to calculate the exact dose to be given during an emergency episode especially if the exact weight of the child is unknown or cannot be readily determined by the pedodontist.

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Cerebrovascular accidents/transient ischemic attacks

•

Hyperpnea

A cerebrovascular accident (CVA or stroke) or a transient ischemic attack (TIA) is caused by an interruption of blood flow to the brain. These episodes are usually seen in older patients as a consequence of atherosclerosis or untreated hypertension. The interruption in flow may be due to a blood clot, spasm of the arteries, or even due to rupture of a blood vessel in the brain. Blood flow to the cerebral cortex is insufficient and the patient will exhibit symptoms within seconds. The signs and symptoms may be of short duration (TIA) which resolve spontaneously or persist for months or years. A transient ischemic attack is a forewarning of a major ischemic CVA; these patients must be evaluated by a physician to prevent such an occurrence.

•

Cold peripheries

•

Hypotension

•

Bradycardia

•

Visual disturbances

•

Dizziness

•

Finally syncope.

Signs and symptoms Altered level of consciousness Aphasia Unilateral muscle weakness or paralysis

Stages clinically Presyncope presents as… (Precedes about 30 seconds) Syncope presents as… •

Jerky irregular/shallow imperceptible breathing/apnea

•

Dilated pupils

Treatment

•

Convulsions

Maintain airway Position patient in semi supine position Suction Monitor, assess and record vital signs

•

Bradycardia

•

Asystole

•

Hypotension

•

Weak pulse.

Syncope It is a transient loss of consciousness due to cerebral anoxia. It is perhaps the most common untoward accident seen in the dental clinic. Predisposing factors These are anxiety, fear, and sight of blood, pain, fasting and hot environment. These emotional stresses lead to release of catecholamine. Resultantly, there is lower peripheral resistance and hence peripheral pooling of blood and fall in blood pressure leading to a sudden decrease in cerebral blood flow.

Postsyncope presents as … •

Regains consciousness

•

Short period of disorientation

•

BP begins to rise

•

Heart rate comes to base line

•

Pulse becomes stronger.

Treatment •

Position of the patient: Made to lie own in supine position with legs raised to improve venous return. In case the patient is sitting in the dental chair, the back of the chair should be immediately lowered so the head of the patient is at lower level than the feet. It helps in venous return to the heart and oxygenated blood to the brain

•

Loosening of the clothes: Tight clothing should be loosened

•

A patent airway should be maintained. Any foreign body should be removed manually or with suction apparatus

•

Inhalation of the aromatic spirit of ammonia or application of cold sponges to the face helps in securing reflex stimulation

Signs and symptoms Patient feels weakness, warmth, nausea and pain in the epigastrium and hunger etc. Following this sweating, dizziness, pallor and light headedness and low pulse pressure develops. If the treatment is not instituted at this stage, unconsciousness develops with ashen gray color of the skin, shallow respiration, low blood pressure and weak pulse. Clinical manifestations Early •

Warmth

•

100 percent oxygen should be administered

•

Pallor

•

•

Perspiration

If bradycardia atropine injection 0.6 mg in 5 mL of water should be given slowly given intravenously

•

Nausea

•

•

Blood pressure may be normal

If hypotension persists, drugs like phenylephrine should be administered.

•

Significant tachycardia (80–120 beats/min).

Late •

Pupillary dilation

•

Yawning

Dental treatment considerations •

Delay further dental treatment 24 hours especially if the patient lost consciousness.

•

If the patient lost consciousness they must not be permitted to leave unescorted or drive a motor vehicle.

Chapter 66  Medical Emergencies in Dental Practice •

Determine the cause of the syncopal episode prior to completing further treatment.

•

Stress is the major cause of syncope in the dental practice. Prevention is the key to management of syncope. This includes taking a complete medical history and thorough evaluation of the patient.

•

Use stress management protocols, morning appointments, consider sedation.

•

Ensure that patients do not miss meals prior to treatment.

The best form of emergency therapy is prevention. Thorough medical histories and follow-up consultations for underlying disease states can be invaluable in avoiding potential medical emergencies. There can be no argument against practicing defensively. A valuable adjunct toward preventing medical emergencies is a good rapport and proper consultation with the local medical personnel. It is important to have a manual on the treatment of potential medical emergencies which includes the duties required of the various members of the office staff available for periodic review. In addition, a quick reference on emergency therapy should be readily available.

Medical emergency—quick reference Emergency

Signs and symptoms

Treatment

•

Anaphylaxis

Acute anxiety, rash, itching, respiratory distress, wheezing, cyanosis, severe drop in blood pressure

Epinephrine 1:1000 IV or intraligual, 0.125–0.25 cc (child) 0.5 cc (adult), oxygen, Benadryl IM 25–50 mg (child), 50–100 mg (adult)—hospitalization

•

Allergic reaction

Itching, swelling of face, hands, and eyelids, rash

Mild—Benadryl orally 25–50 mg (child), 50–100 mg (adult)—physician. Moderate—Benadryl IM 25–50 mg (child), 50–100 mg (adult),—physician

•

Acute asthmatic attack

Wheezing, rapid and full pulse, prolonged expirations

Mild—patient use own medical inhaler, oxygen. Severe—Epinephrine 1:1000 subcutaneously 0.125– 0.25 cc (child), 0.25–0.5 cc (adult), semierect position, oxygen—physician

•

Syncope

Slow, weak pulse, drop in blood pressure, cold, clammy skin, dilated pupils, loss of consciousness

Trendelenburg position, oxygen, loosen clothing, cold towel on forehead, ammonia stimulant

•

Respiratory obstruction

Choking, coughing, wheezing, violent attempts to breathe, cyanosis

Blows on back, Heimlich maneuver, suction, ventilate, attempt removal with forcep, cricothyrotomy

•

Epileptic seizure

Grand mal—clonic convulsions, frothing at mouth, unconsciousness

Patient on floor, protect from injury, loosen clothing— physician

•

Insulin shock

Hunger, weakness, dizziness, mental confusion, disorientation, irritability

Oral sugar if conscious. 50% dextrose, IV 20–30 cc (child), 50 cc (adult), if unconscious—physician

•

Diabetic acidosis

Thirst, frequent urination, loss of appetite, fruity (acetone) Keep warm until hospitalized breath, vertigo, coma

•

Drug toxicity

Central nervous system excitement, then central nervous system depression-convulsions, unconsciousness

Supportive treatment until hospitalized

•

Cerebrovascular accident (CVA)

Hemiplegia, slow, deep breathing, eyes deviate to one side, speech impairment

Avoid unnecessary movements, keep warm, oxygen until hospitalized

•

Angina pectoris

Substernal and precordial pain radiating to arm, rapid pulse

Oxygen, sublingual nitroglycerin tablet, repeat 3 minutes (× 3), hospitalization

•

Myocardial infarction

Severe, persistent substernal gain radiating to left arm, possible cyanosis, cold clammy skin, no relief with nitroglycerin

Oxygen, supportive therapy, keep warm until hospitalized

•

Cardiac arrest

20–30 seconds of gasping respirations, respiratory arrest, no pulse, cyanosis, pupils dilated, centric and fixed

Place patient on floor, CPR until hospitalization

•

Adrenal crisis

Past history of episodes, weakness, pallor, perspiration, weak and rapid pulse

Oxygen and supportive therapy until hositalized. Decadron IV or IM 1–4 mg (child) and 4–6 mg (adult)

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BIBLIOGRAPHY

1. Alty CT. Coping with a Medical Crisis. RDH. 2002. 2. Anderson PE. Effectively handling medical emergencies. Dental Econ. 1989.pp.54-61. 3. Being prepared for office emergencies. The Dental Assistant Update. 1994;3(3):3-8. 4. Bertold M. Florida mandates defibrillators in dental offices. http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle. asp?articlesid=1371. Accessed 2/06. 5. Bird D, Robinson D. Modern Dental Assisting, 9th Edn, Elsevier, St. Louis, MO. 2009. 6. Braun RJ. The dental assistant’s role in medical emergencies. The Dental Assistant. 1985.pp.19-22. 7. Curriculum guidelines for management of medical emergencies in dental education. J Dental Educ. 1981;45(6):379-81. 8. Curriculum guidelines for management of medical emergencies in dental education. J Dental Educ. 1990;54(6):337-8. 9. Fast TB, Martin MD, Ellis TM. Emergency preparedness: A survey of dental practitioners. J Amer Dental Ass’n. 1986;112:499-500. 10. Grimes E. Medical Emergencies: Essentials for the Dental Professional. Pearson Education, Upper Saddle River, NJ, 2009. 11. Highlights of the 2010 American Heart Association CPR Guidelines. http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/ documents/downloadable/ucm_317350.pdf. Accessed 3/9/2011. 12. Malamed S. Emergency Medicine. Dental Econ. 2010.pp.38-43. 13. Malamed SF. Managing medical emergencies. J Amer Dental Ass’n. 1993;124:40-51. 14. Stephen J. Goepferd: Medical emergencies in the pediatric dental patient. Pediatric Dentistry. 1979;1(2):115-21. 15. Theisen FC, Feil PH, Schultz R. Self perceptions of skill in office medical emergencies. J Dental Educ. 1990;54:(10):623-5. 16. Wahl MJ. Myths of dental-induced endocarditis. Compend. Cont Educ Dent. Vol. XV, No. 9, 1100-19. 17. Wakeen LM. Dental office emergencies: Do you know your legal obligations? J Amer Dental Ass’n. 1993;124:54-7. 18. Wall HK, Beagan BM, O’Neill HJ, Foell KM, Boddie-Willis CL. Addressing stroke signs and symptoms through public education: the Stroke Heroes Act FAST campaign. Prev Chronic Dis 2008;5(2). http://www.cdc.gov/pcd/issues/2008/apr/07_0214.htm. Accessed April 20, 2011. 19. Weissman D. Emergency education. J of the Amer Dental Ass’n. 1993;124:51-3.

67

Chapter

Cardiopulmonary Resuscitation MK Jindal, Nikhil Marwah, Saima Khan

Cardiopulmonary resuscitation (CPR) is a lifesaving procedure useful in many emergencies. Cadiopulmonary resuscitation involves a combination of mouth-to-mouth rescue breathing and chest compression that keeps oxygenated blood flowing to the brain and other vital

organs. The 2010 AHA Guidelines for CPR and emergency cardiovascular care (ECC) recommend a change in the BLS sequence of steps from A-B-C (Airway, Breathing, Chest compressions) to C-A-B (Chest compressions, Airway, Breathing) (Fig.  67.1).

Fig. 67.1: New modified CPR approach of C-A-B (used with permission from American Health Association, USA)

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Hospital Dentistry

The reason for this change from A-B-C (Airway, Breathing, Chest compressions) to C-A-B (Chest com­pressions, Airway, Breathing) is that in vast majority of cardiac arrests, the highest survival rates from cardiac arrest are reported among patients who have a witnessed arrest and an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). In these patients, the critical initial elements

of BLS are chest compressions and early defibrillation. In the A-B-C sequence, chest compressions are often delayed while the responder opens the airway to give mouth-to-mouth breaths, retrieves a barrier device, or gathers and assembles ventilation equipment. By changing the sequence to C-A-B, chest compressions will be initiated sooner and the delay in ventilation should be minimal.

CPR GUIDELINES FOR ADULTS (Fig. 67.2)

Check Unresponsive: No breathing or no normal breathing (only gasping) − Call for Help. Compressions • Push chest at least 2 inches, 30 times in the center of the chest • Push 2-handed, with one hand on top of the other • Push at a rate of at least 100 pushes per minute • Allow complete chest recoil after each push • Limit interruptions in chest pushes to less than 10 seconds Airway • Open the airway and check for breathing • Watch the rise of chest • Listen for air movement Breathing • Head Tilt-Chin Lift: Tilt the head back and lift the chin • Give 2 breaths. Give each breath over 1 second • The victim’s chest should rise with each breath Continue • Continue cycles of 30 pushes and 2 breaths • Rotate compressors every 2 minutes

Fig. 67.2: Conventional CPR by old method of A-B-C (used with permission from American Health Association, USA)

Chapter 67  Cardiopulmonary Resuscitation CPR GUIDELINES FOR CHILDREN (Fig. 67.3)

Check Unresponsive: No breathing or no normal breathing (only gasping) − Provide 2 minutes of CPR before calling for help CPR • Push chest at about 2 inches, 30 times just below the nipple line • You may use either 1 or 2 hands for chest pushes • Push at a rate of at least 100 pushes per minute • Allow complete chest recoil between each push • CPR ratio for one-person CPR is 30 pushes to 2 breaths • CPR ratio for two-person CPR is 15 pushes to 2 breaths • In two-person CPR, the rescuers should change positions after every 2 minutes Breathing • Head tilt-chin lift: Tilt the head back and lift the chin • Give 2 breaths. Give each breath over 1 second • The victim’s chest should rise with each breath Continue • Continue cycles of 30 pushes and 2 breaths • Rotate compressors every 2 minutes

Fig. 67.3: CPR for children (used with permission from American Health Association, USA)

817

818 Section 13 

Hospital Dentistry CPR GUIDELINES FOR INFANTS (Fig. 67.4)

Check Unresponsive: No breathing or no normal breathing (only gasping) − Provide 2 minutes of CPR before calling for help CPR • Push chest about 1½ inches, 30 times just below the nipple line • Push with the two-finger push technique • Push at a rate of at least 100 pushes per minute • Allow complete chest recoil between each push • CPR ratio for one-person CPR is 30 pushes to 2 breaths • CPR ratio for two-person CPR is 15 pushes to 2 breaths • Use the two-thumb encircling technique for pushes Breathing • Head tilt-chin lift: Tilt the head back and lift the chin • Give 2 breaths. Give each breath over 1 second • The victim’s chest should rise with each breath Continue • Continue cycles of 30 pushes and 2 breaths • Rotate compressors every 2 minutes

Fig. 67.4: CPR for infants (used with permission from American Health Association, USA)

Chapter 67  Cardiopulmonary Resuscitation Summary of Key BLS Components for Adults, Children, and Infants Component

Adults

Children

Recognition

No breathing or no normal breathing (i.e. only gasping)

Infants

Unresponsive (for all ages) No breathing or only gasping

No pulse palpated within 10 seconds for all ages (HCP only) CPR sequence

C-A-B

Compression rate Compression depth

At least 100/min At least 2 inches (5 cm)

At least ½ AP diameter About 2 inches (5 cm)

At least ½ AP diameter About 1 ½ inches (4 cm)

Chest wall recoil

Allow complete recoil between compressions HCPs rotate compressors every 2 minutes

Compression interruptions

Minimize interruptions in chest compressions Attempt to limit interruptions to 12 hour. The patient should not be allowed to leave the hospital without an attendant before this time.

Methohexitone Sodium • It is similar to thiopentone but is three times more potent, has a quicker and briefer (5–8 min) action and is more

Chapter 68  General Anesthesia in Pediatric Dentistry rapidly metabolized (t½ 4 hr) than thiopentone, thus the patient will recover more quickly. • Excitement during induction and recovery is more common.

Propofol • Currently, propofol has superseded thiopentone as an IV anesthetic, both for induction as well as maintenance. • It is an oily liquid employed as a 1 percent emulsion. Unconsciousness after propofol injection occurs in 15 to 45 sec and lasts 5 to 10 min as it distributes rapidly (distribution t ½–4 min). • Elimination t ½ (1–2 hr) is much shorter than that of thiopentone due to rapid metabolism. • Intermittent injection or continuous infusion of propofol is frequently used for total IV anesthesia when supple­ mented by fentanyl. • It lacks airway irritancy and is particularly suited for outpatient surgery, because residual impairment is less marked and shorter lasting. • Incidence of postoperative nausea and vomiting is low; patient acceptability is very good. • Disadvantages include induction apnea lasting 1 minute; bradycardia and dose-dependent respiratory depression. • Dose: 2 mg/kg bolus IV for induction; 9 mg/kg/hr for maintenance.

Benzodiazepines • Benzodiazepines (BZDs) are frequently used for inducing, maintaining and supplementing anesthesia as well as for conscious sedation. Relatively large doses (diazepam 0.2– 0.3 mg/kg or equivalent) injected IV produce sedation, amnesia and then unconsciousness in 5 to 10 min. If no other anesthetic or opioid is given, the patient becomes responsive in 1 hour or so due to redistribution of the drug (distribution t½ of diazepam is 15 min), but amnesia persists for 2 to 3 hours and sedation for 6 hours or more. • BZDs are poor analgesics so an opioid or N2O is usually added if the procedure is painful. • Lorazepam in a dose 2 to 4 mg (0.04 mg/kg) is three times more potent, slower acting and less irritating than diazepam. • Midazolam is water soluble, nonirritating to veins, faster and shorter acting and is being preferred over diazepam for anaesthetic use in a dose of 1 to 2.5 mg IV followed by 1/4th supplemental doses.

Ketamine • It is pharmacologically related to the hallucinogen phencyclidine; induces a so-called dissociative anesthesia characterized by profound analgesia, immobility, amnesia with light sleep and feeling of dissociation from one’s own body and the surroundings.

• Respiration is not depressed; airway reflexes are main­ tained, muscle tone increases; limb movements occur and eyes may remain open. • A dose of 1 to 3 (average 1.5) mg/kg IV or 5 mg/kg IM produces the above effects within a minute, and recovery starts after 10 to 15 minutes, but patient remain amnesic for 1 to 2 hours. • Ketamine is metabolized in the liver and has an elimination t½ of 3 to 4 hours.

Fentanyl • This short acting (30–50 min) potent opioid analgesic related to pethidine is generally given IV at the beginning of painful surgical procedures. • It is frequently used to supplement anesthetics in balanced anesthesia which permits use of lower anesthetic concentrations with better hemodynamic stability. • After IV fentanyl (2–4 pg/kg) the patient remains drowsy but conscious and his cooperation can be commanded. • Respiratory depression is marked, but predictable; heart rate decreases; nausea, vomiting and itching often occurs during recovery. • Fentanyl is also employed as adjunt to spinal and nerve block anesthesia, and to relieve postoperative pain.

Dexmedetomidine • Activation of central α2 adrenergic receptors has been known to cause sedation and analgesia. Clonidine (a selective α2 agonist antihypertensive) given before surgery reduces anesthetic requirement. • Dexmedetomidine is a centrally active selective α2 agonist that has been recently introduced for sedating critically ill/ventilated patients in intensive care units. • Side effects are hypotension, bradycardia and dry mouth.

COMPLICATIONS OF GENERAL ANESTHESIA During anesthesia

After anesthesia

• Respiratory depression and hypercarbia • Salivation, respiratory secretions • Cardiac arrhythmias, asystole • Fall in blood pressure • Aspiration of gastric contents: Acid pneumonitis • Laryngospasm and asphyxia • Delirium, convulsions • Fire and explosion: Rare now due to use of noninflammable gases

• Nausea and vomiting • Persisting sedation: Impaired psychomotor function • Pneumonia, atelectasis • Organ toxicities: Liver, kidney damage • Emergence delirium • Cognitive defects—prolonged excess cognitive decline has been observed in some patients, especially the elderly, who have undergone general anesthesia, particularly of long duration

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POINTS TO REMEMBER • • • •

• •

• • • • •

Wells was the first to use nitrous oxide Morton was the first dentist to experiment with ether anesthesia in 1846. Preanesthetic medication refers to the use of drugs before anesthesia to make it more pleasant and safe. General anesthesia is defined as a controlled state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command. Objectives of general anesthesia are to provide safe, efficient, and effective dental care, eliminate anxiety, aid in treatment of the mentally, physically, or medically compromised patient. General anesthesia is indicated in patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability; patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent; patients requiring immediate, comprehensive oral/dental care. Procedure of anesthesia includes explanation of risk, treatment planning, consent, preoperative assessment, clinical setup with required personal and equipment, starting of anesthesia, working, monitoring and discharge. Inhalation agents for GA are nitrous oxide, ether, halothane, isoflurane, desflurane, sevoflurane. Intravenous agents for GA are thiopentone sodium, methohexitone sodium, propofol, etomidate, diazepam, lorazepam, ketamine and fentanyl. Side effects during procedure of anesthesia are respiratory depression and hypercarbia, salivation, respiratory secretions, cardiac arrhythmias, fall in blood pressure, aspiration of gastric contents, laryngospasm, delirium, and fire and explosion. Side effects after procedure of anesthesia are nausea and vomiting, persisting sedation, pneumonia, atelectasis, organ toxicities, emergence delirium and cognitive defects.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

What is preanesthetic medication? Define general anesthesia and give its indications, contraindications and goals. Explain in details the procedure for general anesthesia. What are the stages of anesthesia? Write a note on drugs used for general anesthesia. Describe the complications of general anesthesia.

BIBLIOGRAPHY 1. A Conscious decision—a review of the use of general anaesthesia and conscious sedation in primary dental care. Department of Health; 2003. 2. American Academy of Pediatric Dentistry. Clinical Guideline on the Elective use of Minimal, Moderate, and Deep Sedation and General Anesthesia in Pediatric Dental Patients. Pediatr Dent. 2004;26(7):95-103. 3. American Dental Association. Guidelines for the use of Sedation and General Anesthesia by Dentists. As adopted by the October 2012 ADA House of Delegates. 4. Camilleri C, Roberts G, Ashley P, Scheer B. Analysis of paediatric dental care under general anaesthesia and levels of dental disease in two hospitals. Br Dent J. 2004;196(4):219-23. 5. Davies C, Harrison M, Roberts G. UK National Clinical Guidelines in Paediatric Dentistry Guideline for the Use of General Anaesthesia (GA) in Paediatric Dentistry. May; 2008. 6. Holt RD, Rule DC, Davenport ES, Fung DE. The use of general anaesthesia for tooth extraction in children in London: a multi-centre study. Br Dent J. 1992;173(10):333-9. 7. Landes DP, Clayton-Smith AJ. The role of pre-general anaesthetic assessment for patients referred by general dental practitioners to in the Community Dental Service. Community Dent Health. 1996;13(3):169-71. 8. O’Sullivan EA, Curzon ME. The efficacy of comprehensive dental care for children under general anesthesia. Br Dent J. 1991;171(2):56-8. 9. Simmons D. Sedation and patient safety. Crit Care Nurs Clin North Am. 2005;17(3):279-85. 10. Smallridge JA, Al GN, Holt RD. The use of general anaesthesia for tooth extraction for child out-patients at a London dental hospital. Br Dent J. 1990;168(11):438-40. 11. Standards and Guidelines for General Anaesthesia for Dentistry. Royal College of Anaesthetists; 1999. 12. Tochel C, Hosey MT, Macpherson L, Pine C. Assessment of children prior to dental extractions under general anaesthesia in Scotland. Br Dent J. 2004;196(10):629-33.

69

Chapter

Pharmacological Considerations in Pediatric Dentistry Nikhil Marwah

Chapter outline •

General Principles of Pediatric Pharmacology

The physiologic processes that determine drug disposition undergo radical changes during biological maturation. Thus, the process of drug absorption, distribution, metabolism and excretion are modified throughout infancy and childhood. The body of the pediatric patient is not simply a miniaturized version of his adult counterpart but significantly differs from those of adults. Route and rate of drug administration, dosage, onset and duration of action, and possibility of toxicity are all influenced by the unique physiology of childhood. Some of the systems of the body that are mostly affected are: Gastrointestinal system







The GIT undergoes continuous developmental change from birth to old age. Because many drugs are absorbed and metabolized by the gut, these changes must be considered when administering medications to children. • Low acidity in infants gut favors absorption of weakly acidic drugs, e.g. penicillin and cephalosporin whereas the absorption of weakly basic drugs such as the benzodiazepines is delayed. • Lower secretion of gastric acid, prolong gastric emptying; slower peristalsis in first few days of life may affect absorption of drugs. • Infants also have low concentration of bile acids and lipase therefore there is decreased absorption of lipid soluble drugs.

•

Drug Dosages

Hepatic metabolism

Renal system

• Many drugs are metabolized by the liver. • Hepatic enzymes may act to detoxify a drug or to alter it into a more potent metabolite. Because infants and young children are relatively deficient in these enzymes, they are at high-risk for toxicity, if not dosed correctly. Although drugs can be excreted by a number of physiologic routes, e.g. sweat, bile and feces: while vast majority undergo renal excretion. Because of its immature capacity, the young kidney is less competent to excrete drug.

GENERAL PRINCIPLES OF PEDIATRIC PHARMACOLOGY • The metric rather than the Apothecary system should be used to determine dosage. • The younger the patient, the more atypical is the therapeutic and toxicological response to drug therapy. • The younger the patient, the more atypical is the disease manifestation. For example, seizures in infants and young children differ clinically from those in adults. In infancy, motor seizures appear as limited tonic stiffening or partial movement of the face and limbs. • Prolonged therapy with agents that affect the Endocrine system retards growth. For example, large doses of corticosteroids impairs skeletal growth. • Childhood is a time of high water turnover when fever, vomiting and diarrhea contribute to variable and oftentimes dangerously high drug levels.

830 Section 13 

Hospital Dentistry

• The excessive use of syrups should be avoided especially at night. These medicinal vehicles have high sugar content and are highly cariogenic. • General anesthesia should be discussed with the parent as part of the hospital admission program. • During anesthesia, concentration of the oxygen supply for induction and maintenance should never be less than 20 percent because it can cause cerebral hypoxia and irreparable brain damage. • Allergenicity is greatest during childhood. More than half of all allergens appear, first during childhood. • To obviate tetracycline staining of permanent incisors, canines and 1st premolars the antibiotic should be administered sparingly. • Genetic inheritance can influence drug responsiveness. For example, hepatic porphyria, from overproduction of

porphyrin precursors, is caused by an autosomal inherited dominant trait. Barbiturates are contraindicated in these patients because they increase porphyrin synthesis and provoke acute attacks.

DRUG DOSAGES No rules guarantee efficacy and safety of drugs in children, especially the newborn. Dosages based on pharmacokinetic data for a given age group, adjusted to the desired response and each person’s drug-handling capability, offer the most rational approach. Dosage requirements constantly change as a function of age. Dosage based on body weight, age is practical but not ideal concept. Current dosage recommendations are usually based on basal metabolism of child.

Clark’s rule This is based upon the relative weight of the child as compared with the weight of the average adult. The average weight of the adult is taken to be 150 pounds. The rule is to divide the weight of the child in pounds, by the average weight of the adult, 150, and to take this fraction of the adult dose.

Child dose =

Weight (pounds) 150

× Adult dose

Young’s rule This rule is based upon the age of the child, regardless of the weight. It is to divide the age of the child by the age plus 12, and the resulting fraction is the portion of the adult dose, which is to be used.

Child dose =

Age of child Age + 12

× Adult dose

Cowling’s rule It is also based upon the age of the child. In this fraction of the adult dose, which is to be used, is obtained by dividing the age at the next birthday by 24.

Child dose =

Age at next birthday 24

× Adult dose

Dilling’s rule He made a new analysis of extensive weight statistics of children and found that Young’s formula is sufficiently accurate up to the 11th year and Cowling’s is accurate until the 15th year, but that thereafter, it is very inaccurate and wholly unsatisfactory. Dilling has worked out a new formula on the basis of his analysis. It consists of dividing the age by 20, to obtain the fraction of the adult dose, which is required. Child dose =

Age of child 20

× Adult dose

Gabius’ rule Stated a series of fractions of the adult dose, which were to be used at different ages. Thus, for a child of 1 year – 1/12th of 7 years – 1/3rd of adult dose adult dose 2 years – 1/8th of 14 years – 1/2nd of adult dose adult dose 3 years – 1/6th of 20 years – 2/3rd of adult dose adult dose 4 years – 1/4th of 21 years – adult dose adult dose Bastedo’s rule Child dose =

Age of child + 3 30

of the fraction of the adult dose

Contd...

Chapter 69  Pharmacological Considerations in Pediatric Dentistry Contd... Fried’s rule For Infants under one year, Child dose =

Age of infant (in months) 150

of the fraction of the adult dose.

Catzel’s rule It offers a safe guide based on surface area and expressed as a percentage of adult dose for a patient. Age % of Adult dose 1 25 3 35 7 50 12 75 Augsberger’s rule {[(1.5 × weight in kg) + 10]/100} × Adult dose = Child’s dose {[(4 × age in years) + 20]/100} × Adult dose = Child’s dose Body surface area (BSA) It is determined from a nomogram using the child’s height and weight. The body surface area (BSA) of an individual can also be calculated from DuBois formula: BSA (m)2 = BW (kg)0.425 × Height (cm)0.725 × 0.007184 The formula for calculating child’s dosage is Child dose =

Child’s BSA 1.7

× adult dosage

Use of Analgesics in Children (AAPD Guidelines) Pain assessment in children should not only account for intensity and duration of pain that may be perceived from a given dental procedure but also the psychological status of the patient. Analgesics should initially be administered on a regular time schedule if moderate to severe pain is considered likely during the first 36 to 48 hours and not “as needed” so as to create stable plasma levels of analgesics and decrease the chance of breakthrough pain. Since most cases of postoperative pain include an inflammatory component, NSAIDs are considered first line agents in the treatment of acute mild to moderate postoperative pain. Opioid analgesics provide analgesia for moderate to severe pain but have side effects including sedation and respiratory depression and hence are often added to nonopioids to manage moderate to severe pain rather than being administered alone. The American Academy of Pediatric Dentistry (AAPD) recognizes that children experience pain and exhibit variability in the expression of pain and that inadequate pain management may have significant physical and psychological consequences for the patient. Therefore, the AAPD encourages health care professionals to: • Recognize and assess pain, documenting in the patient’s chart; • Use nonpharmacologic and pharmacologic strategies to reduce pain experience preoperatively;

• Be familiar with the patient’s medical history to avoid prescribing a drug that would be otherwise contraindicated; • Comprehend the consequences, morbidities, and toxicities associated with the use of specific therapeutics; • Consider nonopioid analgesics as first line agents for postoperative pain management; • Utilize drug formularies in order to accurately prescribe medications for the management of postoperative pain; • Consider combining NSAIDs with acetaminophen to provide a greater analgesic effect than the single agent alone.

 se of Antibiotic Therapy for Pediatric U Dental Patients (AAPD Guidelines) The widespread use of antibiotics even in minimally required scenarios has led to development of resistance to drugs and hence currently the use of antibiotics has been made conservative.

Oral Wound Management • Factors related to host risk and type of wound must be evaluated when determining the risk for infection and subsequent need for antibiotics. • Facial lacerations may require topical antibiotic agents.

831

832 Section 13 

Hospital Dentistry Commonly used antibiotics and analgesic in children

Sr. No.

Drugs

Adult Dose

Pediatric Dose

1.

Amoxicillin

250–500 mg 3 Times/day

Children > 3 months of age up to 40 kg: 20–40 mg/kg/day in divided doses every 8 hours Children > 40 kg and adults: 250–500 mg every 8 hours

2.

Amoxicillin + Clavulanic acid (Coamoxi clav)

250–500 mg amoxicillin + 125–250 mg clavulanic acid 3 times a day

Children > 3 months of age up to 40 kg: 25–45 mg/kg/day in doses divided every 12 hours Children > 40 kg and adults: 500–875 mg every 12 hours

3.

Ciprofloxacin

250–500 mg every 12 hours

25 mg/Kg/day divided in 2 doses (12 hrs each) To be avoided in children below 18 years

4.

Azithromycin

500 mg OD

Children ≥ 6 months up to 16 years: 5–12 mg/kg 1 time/ day (maximum 500 mg/day) OR 30 mg/kg as a single dose (maximum 1500 mg) Children ≥ 16 years and adults: 250–600 mg 1 time/day OR 1–2 g as a single dose

5.

Cephalexin

Adults: 250–1000 mg every 6 hours (maximum 4 g/day)

Children > 1 year: 25–100 mg/kg/day in divided doses every 6–8 hours (maximum 4 g/day)

6.

Cefixime

200 mg 2 times a day for 7–10 days

8 mg/Kg/day in 2 divided doses

7.

Erythromycin

250–500 mg (stearate or estolate salts) or 400 mg ethylsuccinate salt every 6 hours

30 to 50 mg/kg/day in divided doses every 6 hours

8.

Doxycycline

200 mg on day 1 (100 mg every 12 hours) then 100 mg daily

(age 8 years or older): 4.4 mg/Kg in 2 divided doses on day 1 than 2.2 mg/Kg/day

9.

Tetracycline

250–500 mg every 6 hours

(age 8 yrs or older) 25–50 mg/kg/day divided into 6 hrly doses

10.

Metronidazole

250–750 mg every 8 hours, not to exceed 4 g in 24 hours

For anaerobic skin and bone infections: Children: 30/mg/day in divided doses every 6 hours Adolescents and adults: 7.5 mg/kg every 6 hours For periodontal disease, including necrotizing ulcerative gingivitis 2 Adolescents and adults: 250 mg every 6–8 hours for 10 days For aggressive oral infections 250 mg 3 times/day with amoxicillin (250–375 mg 3 times/ day) for 7–10 days

11.

Paracetamol

0.5–1 gm every 4–6 hours Maximum dose 4 g/day

Children < 12 years: 10–15 mg/kg/dose every 4–6 hours as needed (maximum 90 mg/kg/24 hours but not to exceed 2.6 g/24 hours Children ≥ 12 years and adults: 325–650 mg every 4–6 hours or 1000 mg 3–4 times/day as needed

12.

Nimesulide

100 mg/dose every 12 hours

5 mg/Kg/day divided every 8–12 hours

13.

Diclofenac sodium

75–150 mg/day in 2–4 divided doses, max. dose – 150 mg/day

2–3 mg/Kg/day in 2–4 divided doses

14.

Mefenamic acid

500 mg TID

Analgesic dose—10-25 mg/Kg/day (divided into 6 hrly doses) Antipyretic dose—3 mg/Kg/dose every 6 hours

15.

Ibuprofen

400–600 mg/dose every 6–8 hours maximum dose 2400 mg/day

Children < 12 years: 4–10 mg/kg/dose every 6–8 hours as needed (maximum 40 mg/kg/24 hours) Children 12 years: 200 mg every 4–6 hours as needed (maximum 1.2 g/24 hours)

Chapter 69  Pharmacological Considerations in Pediatric Dentistry • Open fractures and joint injuries should be covered with antibiotics. The drug should be administered as soon as possible for the best result and the minimal duration of drug therapy should be limited to five days beyond the point of substantial improvement or resolution of signs and symptoms.

Pulpitis/Apical Periodontitis/Draining Sinus Tract/ Localized Intra-oral Swelling Bacteria can gain access to the pulpal tissue through caries, exposed pulp or dentinal tubules, cracks into the dentin, and defective restorations. If a child presents with acute symptoms of pulpitis, treatment (i.e. pulpotomy, pulpectomy, or extraction) should be rendered. Antibiotic therapy usually is not indicated if the dental infection is contained within the pulpal tissue or the immediately surrounding tissue.

Dental Trauma • Local application of an antibiotic to the root surface of an avulsed tooth with an open apex and less than 60 minutes extraoral dry time has been recommended. • Systemic antibiotics have been recommended as adjunctive therapy. • Tetracycline is the drug of choice, but consideration must be exercised in the systemic use of tetracycline due to the risk of discoloration in the developing permanent dentition and hence Penicillin V can be given as an alternative.

Pediatric Periodontal Diseases Antibiotic therapy is advised after culture and suscepti­bility testing of isolates from the involved sites.

Acute Facial Swelling of Dental Origin

Viral Diseases

A child presenting with a facial swelling secondary to a dental infection should receive immediate dental attention and the treatment should be initiated immediately with antibiotic coverage for seven days to contain the spread of infection.

Conditions such as acute primary herpetic gingivosto­matitis should not be treated with antibiotic therapy unless there is strong evidence to indicate that a secondary bacterial infection exists.

QUESTIONNAIRE 1. What are the principles of pediatric pharmacology? 2. Enumerate the various drug dosage formulas and explain in detail about dosage calculation using body surface area.

BIBLIOGRAPHY 1. RxList: The internet drug index. http://www.rxlist.com. 2. Wilson W, Taubert KA , Gewitz M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association. Circulation. 2007; 116(15):1736-54. Correction Circulation 2007;116:e376-e377. http://circ.ahajournals.org/cgi/content/full/116/15/1736. 3. Wynn RL, Meiller TF, Crossley HL. Drug Information: Handbook for Dentistry, 13th Edn. Lexi-Comp, Hudson, Ohio. 2007.

833

14

Section

DENTISTRY FOR THE SPECIAL CHILD

This area discusses about classification of various handicapped children and management of handicapped children with special emphasis on cleft lip and palate patients including its etiology and management. It also details the prosthodontic rehabilitation of pediatric dental patients.

70

Chapter

Dental Consideration of Handicapped Child Priya Verma, Nikhil Marwah

Chapter outline • • • • • •

Attitudes Regarding Handicapped Child Barriers in Providing Care to Handicapped Children The Role of the Dental Assistant Classification of Handicapped Child Concerns of the Pediatric Dentist Mental Retardation

Oral health of a handicapped child has been one of the grey areas in the field of pediatric dentistry. There has been a general agreement that the disabled population has increase prevalence of poor oral hygiene, compromised gingival and periodontal health and increased prevalence of dental caries than the general population. In the past the emphasis were made on providing basic dental care but in recent years, the dental profession and parental groups have shown increased concern in providing complete oral health care to the mentally or physically disabled children. This is due to the result of the realization that individuals with a disability, whether developmental or acquired, are entitled to the opportunity to achieve appropriate rehabilitation, to enable them to realize their maximal level of functioning and to assist them in not only “normalizing” their lives but also lengthening their life span. Unfortunately, the service provided to this unique population by both community-based dental care facilities and individual providers has been grossly inadequate. Historically, five basic reasons have been given to account for the inadequacy of dental care for this group by Plummer: • On the part of the profession, there has been lack of knowledge, understanding, and actual experience in treating the handicapped patient. • There has been inadequate literature on the oral hygiene status and dental needs of the handicapped population. • The importance of dental care for the handicapped has been overlooked by health planners and administrators in establishing programs for the noninstitutionalized population.

• • • • •

Cerebral Palsy Childhood Autism Visual Impairment Hearing Loss Treatment Considerations of Medically Compromised Children

• Parents and guardians of handicapped children have not been made aware of the importance of oral health and may lack knowledge of the health care system and financial resources available to them. • Home care has been so neglected that most handicapped patients need extensive dental treatment. Besides all these things, lack of acceptance, increased financial pressures, results from the needs of special equipments and medical care result in lower priority of dental care. Therefore, to plan appropriate treatment for the handicapped individual and to deliver it effectively, it is necessary for the dental care provider to understand the total implications of his own attitudes toward the handicapped.

DEFINITION • Disability represents a departure from the norm in terms of individual performance • Handicap is a social phenomenon, representing the social and environmental consequences for the individual stemming from the presence of impairment and disability • Special health care needs (AAPD, 2013) defined as “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental

838 Section 14 

•

•

•

•

Dentistry for the Special Child

cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Health care for individuals with special needs requires specialized knowledge acquired by additional training, as well as increased awareness and attention, adaptation, and accommodative measures beyond what are considered routine. Handicapped child (American public health association) A child who cannot within limits play, learn, work or do things other children of his age can do; he is hindered in achieving his full physical, mental and social potentialities. Handicapped child (WHO): One who over an appreciable period of time is prevented by physical or mental conditions from full participation in the normal activities of their age group including those of social, recreational, educational and vocational nature. Dental Handicap (AAPD, 1996): A person should be considered dentally handicapped if pain, infection or lack of functional dentition which affects the following: – Restricts consumption of diet adequate to support normal growth and developmental needs. – Delays or alters growth and development. – Inhibits performance of any major life activity including work, learning communication and recreation. Disabled person (Americans Disabilities Act of 1990): An individual is disabled if the person – Has a physical or mental impairment that substantially limits one or more major life activities. – Has a record of such an impairment – Is regarded as having such as impairment.

ignoring or drawing attention of the child. Most parents also reported that they were able to adjust better with the difficulties of the child after knowing their clinical condition or diagnosis. However, it is not only the parents of the family who get affected but a family in totality. • The intense effort that is required to take care of a special child is often at the expense of the normal child. The normal child is expected to behave like a mature child who he is unable to rationalize with. He might also have to face increased demands for the supervision of the child with disabilities that lead to frustration and eventual refusal of corporation. • Basically, if a parent believes in good dental care and prevention of dental disease, he will provide this care to his child irrespective of his disability. • One intervening variable in providing dental care is the degree of disability. In children with a high degree of disability, the parent may feel that there are so many other physical difficulties to cope with and so, dental care is low on the list of priorities.

ATTITUDES REGARDING HANDICAPPED CHILD

Parental Attitude • The attitudes of parents of mentally or physically handicapped children often present a substantial barrier to dental treatment. Provision of service may be directly interfered with by the inability of dentists to understand these attitudes, so it is important for the provider to realize the massive impact that a disability can have on a family. • Parents seem to go through several emotional and psy­ chologic stages after becoming aware that their child is handicapped. The initial feeling that parents experience is shock and depression and also likely to be negative during the early postpartum period. The reaction to this catastrophic event may be characterized by denial and by refusal to recognize symptoms that are present. Subsequent stages may include self-pity, depression, guilt, rejection, hostility and overprotection. • Parents also describe stress associated with social habits that includes staring, discomfort, inappropriate

Patient Attitude • “I do not want to be considered abnormal and I do not want to be limited in reaching my full potential. I know I am not as capable as I was and have somehow lost a lot of confidence in my own abilities. I do not want to be considered inferior. Do not embarass me by asking me to do something that it is obvious I cannot do, yet give me every opportunity to do all that I can.” This comment is from a person afflicted with a progressively debilitating disease. • Such children also demonstrate reluctance in inter- act­ing and generally tend to isolate themselves from the society.

Chapter 70  Dental Consideration of Handicapped Child BARRIERS IN PROVIDING CARE TO HANDICAPPED CHILDREN According to Miller et al. in 1965 said that dental treatment for disable children has usually been restricted to relief of painful emergency procedures but then over a period of time there was a transient shift that was seen in the attitude of the dentist. Fenton et al. 1993 said that there was particular number of lecture hours in predoctoral curriculum devoted to teaching dental management of child with disability ranging up to 40, twentythree of dental schools reported 5 or few hours. This shows that the need of dental treatment for such children is considered less important thereby providing them limited services. Insufficient undergraduate and postgraduate education resulting in dentists who are not prepared or willing to manage and treat these patients in their private setup. • Accessibility: The person with disability experiences physical and mental obstacles to access, the most overt being the architectural barrier and more width of the door way: – Provision of wheel chair turning space – Operatory designed with movable dental unit, instrument control unit and suction unit – Dental chair should be adjustable to match different wheel chair designs – Provision of free space around the unit giving dentist a flexi access to patient.

Gradient

• Psychosocial: The person with special care needs may develop in an environment of chronic care, painful procedures, and emphasis on aspects of health other than dentistry. • Financial: Cost of dental care is an issue for many patients. • Communication: The dentist patient chair side relation­ ship demands a functional communication cycle. • Medical: Special health needs often translate into chronic illness and polypharmacy. Dentists are faced with pathology and therapy that present risks for the patient, and complicate treatment. • Mobility and stability: Dental offices are designed for fully functional humans. Some patients with special needs require stabilization, support and assistance while seating or leaving the dental chair. • Preventive: Basic oral hygiene and home care may need to be supplemented with fluoride rinses, antimicrobials, saliva substitutes, and other adjunctives. • Treatment planning: The special needs patient may need and want the treatment that balances cost, longevity, difficulty of achievement, esthetics, and function. • Continuity of care: Crisis often brings the special needs patient to the dentist, and the myriad of problems they experience can force them into oral neglect. • Lack of trained personnel: Treatment for these children are very time consuming, thus the need of trained assistant becomes a necessity thereby reducing chair side time. • Disruption of normal office routine and other patients. • Ignorance by parents and institutions.

Disabled accessibility guidelines Length Width

External/Internal building features Parking space

1:50 max slope

Standard

Walkway

1:12 max slope

Not applicable

Auto: 90 inches Van: 144 inches 36 inches

Passenger loading zone Curb ramps door

Flat 1:12 max slope 5 foot entrance and exist platform area

20 feet Standard

36 inches 32 inch

Interior ramp Wheelchair lift Corridor flooring

72 inch 8 foot max drop Standard not applicable

36 inches 48 inches ½ inch max thickness

Signs Waiting room

1:20 max slope Bilevel Not applicable flat, firm carpet Braille, raised letters Flat

Above 5 feet Standard

Readable 36 inch aisle

Restrooms Public telephone

Flat No higher than 4 feet

3 feet above floor

32 inch stall 26 inch clearance

Elevator

Flat

Operatory

Flat 8 × 10 feet

54 × 68 inches Standard

32 to 36 inch door

Surface, other specifies Nonskid; paved; sign posted; adjacent walkway Nonskid; no obstructions overhangs; smooth Same as above Nonskid; side flair 25

Slight

Difficulty with faint speech; language and speech development within normal limits

May show a slight verbal deficit

>40

Mild-moderate

Frequent difficulty with normal speech at 3 feet; language skills are mildly affected

Psychologic problems can be recognized

>55

Marked

Frequent difficulty with loud speech at 3 feet; difficulty understanding with hearing aid in school situation

Child is likely to be educationally retarded, with more pronounced emotional and social problems than in children with normal hearing

>70

Severe

Might understand only shouts or amplified speech at 1 foot from ear

The prelingually deaf show pronounced educational retardation and evident emotional and social problems

>90

Extreme

Usually no understanding of speech even when amplified; child does not rely on hearing for communication

The prelingually deaf usually show severe educational retardation and also emotional underdevelopment

Chapter 70  Dental Consideration of Handicapped Child Endocarditis prophylaxis recommended

Endocarditis prophylaxis not recommended

• Dental extraction • Restorative dentistry-restoration of decayed teeth, replacement of • Periodontal surgery, scaling, root planning, probing and recall missing teeth with or without retraction cord maintenance • Local anesthetic injection (non ligamentary) • Placement of dental implants • Intracanal endodontic therapy, postplacement, crown buildup • Reimplantation of avulsed tooth • Placement of rubber dams • Endodontic instrumentation or surgery beyond the apex of the • Postoperative suture removal tooth • Placement of removable prosthodontic or orthodontic appliances • Subgingival placement of antibiotic fibers/strips • Taking oral impressions • Initial placement of orthodontic bonds but not brackets • Fluoride treatments • Intraligamentary local anesthetic injections • Taking oral radiographs • Prophylactic cleaning of teeth or implants where bleeding is • Orthodontic appliance adjustment anticipated • Shedding of primary teeth

Antibiotic phylaxis Regimen: Single Dose 30 to 60 min Before Procedure Situation

Agent

Adults

Children

Oral

Amoxicillin

2g

50 mg/kg

Unable to take medication

Ampicillin or Cefazolin or ceftriaxone

2 g IM or IV

50 mg/kg IM or IV

1 g IM or IV

50 mg/kg IM or IV

Allergic or penicillins of ampicillin—oral

Cephalexin*† or Clindamycin or Azithromycin or clarithromyin

2g

50 mg/kg

600 mg

20 mg/kg

500 mg

15 mg/kg

1 g IM or IV

50 mg/kg IM or IV

600 mg IM or IV

20 mg/kg IM or IV

Allergic to penicillin or ampicillin and unable to take oral medication

ceftriazone†

Cefazolin or or Clindamycin

IM indicates intramuscular: IV, intravenous *Or other first-or-generation oral cephalosporin in equivalent adult or pediatric dosage †Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin

TREATMENT CONSIDERATIONS OF MEDICALLY COMPROMISED CHILDREN

Cardiovascular System Diseases of heart can be divided into two general types— congenital and acquired. The cause of congenital heart defect is obscure but may be related to aberrant embryonic development of a normal structure. These types of defects include aortic stenosis, tetralogy of Fallot. Acquired heart disease includes rheumatic fever and infective bacterial endocarditis. Rheumatic fever is a serious inflammatory disease that occurs as a sequel to pharyngeal fever and is commonly seen in patients less than 40 years of age. Infective endocarditis is characterized by microbial infection of heart valves. Both require special precautions during treatment so, a dentist should closely evaluate the medical history to ascertain the cardiovascular status.

Antibiotic Prophylaxis • Previously, the 1997 guidelines recommended prophylactic antibiotics for patients in high-risk aid moderate-risk categories. • The 2007 guidelines now recommend that only patients in this high-risk category require coverage. • Amoxicillin remains the first choice as the prophylactic antibiotic. In 1997, amoxicillin was to be administered 1 hour before the procedure. The 2007 guidelines recommend administration of amoxicillin (and any other recommended antimicrobial) 30 to 60 minutes before the procedure. • According to the revised guidelines by AAPD (2011), minimal use of antibiotics is indicated to avoid the risk of developing resistance due to antibiotic usage; however dentist should consider the use of antibiotics in patients with underlying cardiac conditions for all dental procedures that involve manipulation of gingival

853

854 Section 14 

Dentistry for the Special Child

tissue, involvement of the periapical area or breach of oral mucosa. • It will also be worthwhile to mention that medically compromised patients with noncardiac factors may also have a compromised immune system and may not be able to tolerate transient bacteremia following any invasive dental procedure. This category may include diseases secondary to immunosuppression such as AIDS, HIV, autoimmune diseases, post radiotherapy, prolong use of steroid and metabolic disorders such as diabetes by AHA for prevention of infective endocarditis.

Diabetes Mellitus Diabetes mellitus often simply referred to as diabetes—is a condition in which a person has high blood sugar levels because either the body does not produce sufficient amount of insulin or the patient does not respond to the insulin that is produced. This high blood sugar levels are classically manifested as polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). There are three main types of diabetes: 1. IDDM (Type 1 diabetes): Results from the body’s failure to produce insulin due to deficient insulin production caused by the destruction of the beta cells of the islets of langerhans (pancreas) and require the person to inject insulin. 2. NIDDM (Type 2 diabetes): Results from insulin resis­ tance, a condition in which cells fail to use insulin pro­ perly, sometimes combined with an absolute insulin deficiency. 3. GDM (Gestational diabetes mellitus): When pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM.

Oral Manifestations • Altered salivary levels also known as xerostomia may act as a predisposing factor in the development of oral infections. Dry and damaged mucosa is more susceptible to opportunistic infections by Candida albicans. • Concomitant diffuse non tender bilateral enlargement of Parotid glands (diabetic sialadenosis). • Altered taste and burning mouth/tongue syndrome has been reported in poorly controlled diabetes. • Higher incidence of dental caries in patients with poorly controlled diabetes is seen. This is attributed to increased glucose levels in the saliva and crevicular fluid. • Poor healing, xerostomia with subsequent increased accumulation of plaque and food debris, higher susceptibility to infections, and pronounced hyperplasia of attached gingiva all contribute to the progressive periodontitis in diabetics.

Dental management It is aimed at implementation of a preventive protocol, symptomatic relief of any oral manifestations of the disease and immediate provision of primary care. • Dental appointments should be short, stress free, as atraumatic as possible. • Early morning appointments are preferred and the patient should eat a normal breakfast before the appointment to prevent hypoglycemia. • Use of pulp capping and pulpotomy procedures is questionable in the child with uncontrolled diabetes. • Vital pulp therapy may be preferred to a stressed extraction procedure under local anesthesia. • Prophylactic antibiotic may be recommended in use of surgical procedures. • Vasoconstrictor drugs with LA to ensure profound anesthesia are advocated, but excessive adrenaline dosage is contraindicated to prevent an increase in blood glucose levels and for this reason glucocorticosteroids should be avoided.

• Delayed wound healing, pulpitis in noncarious tooth, acetone breath are few of the other oral manifestations of diabetes.

Idiopathic Thrombocytopenic Purpura Etiology • Transient bone marrow suppression owing to cytotoxic chemotherapy • Gold salts, indomethacin, digitoxin, alcohol, thiazide diuretics have been implicated in decreased platelet production • Leukemia, lymphomas, aplastic anemia, hypersplenism • Immune mediated (HIV) • Sudden onset of purpura • Bruising.

General Manifestation • Conjunctival and retinal hemorrhages • Epistaxis • Hemorrhages, bullae and vesicles of mucous membrane often occur as a result of platelet count below 20,000/cu mm • Ecchymoses and frank hemorrhages • Profuse gingival hemorrhages.

Oral Manifestations • Petechiae also occur in the mucosa, and commonly in palate appear as numerous, tiny, grouped clusters of reddish spot only a millimeter or less in diameter

Chapter 70  Dental Consideration of Handicapped Child • Elective dental treatment should be deferred until a platelet count is above 50,000/mm3 • Give steroids at a dose of 1 to 2 mg/kg to bring up the platelet level.

General and dental management •

• • •

Replacement therapy usually involves platelet concentrate transfusion or whole blood transfusion before oral surgical procedures. Use local measures of hemostasis. IV immune globulin 19 mg/kg/day twice before dental extraction. Avoid NSAID’s and aspirin 7 days preoperatively before any surgical procedures.

•

• •

•

•

Leukemia Leukemia is a hematopoietic malignancy in which there is a proliferation of abnormal leukocytes in the bone marrow and dissemination of these cells into the peripheral blood. The abnormal leukocytes (blast cells) replace normal cells in bone marrow and accumulate in other tissues and organs of the body.

Classification • Leukemia is clinically and pathologically subdivided into a variety of large groups. • Acute leukemia is characterized by the rapid increase of immature blood cells • Chronic leukemia is distinguished by the excessive build up of relatively mature, abnormal, white blood cells. • Four main categories of leukemia are – Acute lymphoblastic leukemia (ALL) – Chronic lymphocytic leukemia (CLL) – Acute myelogenous leukemia (AML) – Chronic myelogenous leukemia (CML).

Oral Manifestations • Gingivitis and mucositis are one of the first manifestations seen in the oral cavity. • Mucosal pallor, petechiae, ecchymoses, bleeding, ulceration, gingival enlargement, trismus, mental nerve neuropathy (“numb chin syndrome”), may be the presenting complaint along with facial palsy and oral infections. • Enlargements of mucosa, gingiva, or masticatory muscles are typically the result of direct infiltration by malignant leukoctyes. • Oral complications of leukemia frequently include gingival hypertrophy, petechiae, ecchymosis, mucosal

•

ulcers, hemorrhage are the consequences of anemia, thrombocytopenia, and leukopenia. Infiltration of leukemic cells along vascular channels can result in strangulation of pulpal tissue and spontaneous abscess formation as a result of infection or focal areas of liquefaction necrosis in the dental pulp of sound teeth. Skeletal lesions caused by leukemic infiltration of bone are common in childhood leukemia. The most common finding is a generalized osteoporosis caused by enlargement of the haversian canals and volkmann’s canals. Manifestations in the jaws include generalized loss of trabeculation, destruction of the crypts of developing teeth, loss of lamina dura, widening of the periodontal ligament space, and displacement of teeth and tooth buds. Treatment of leukemia with chemotherapeutic agents can result in reactivation of herpes simplex virus (HSV) leading to oral mucositis. Oral mucositis can also occur from chemotherapy without an HSV component, since thinning of the surface layer of mucosa and/or bone marrow suppression allows for opportunistic organisms to invade the mucosa.

Dental management • •

•

• •

A platelet level of 100,000/mm3 is adequate for most dental procedures. Routine preventive and restorative treatment, including injections, may be considered when there are at least 50,000 platelets/mm3. If there are fewer than 20,000 platelets/mm3, no dental treatment should be performed at such a time without a preceding prophylactic platelet transfusion. If the count is less than 20,000 cells/mm3 the patient should probably be given prophylactic platelets before dental procedures. Prophylactic platelet transfusions are given for platelet levels below 10,000 cells/mm3. The use of a soft nylon toothbrush for the removal of plaque is recommended.

Hemophilia Hemophilia is a group of hereditary genetic disorders that impair the body’s ability to control blood clotting or coagulation.

Classification • Hemophilia A or classic hemophilia is a deficiency of factor VIII is the most common form of the disorder, occurring at about 1 in 5,000–10,000 male births. • Hemophilia B or Christmas disease is caused by a deficiency in factor IX occurs at about 1 in about 20,000– 34,000 male births.

855

856 Section 14 

Dentistry for the Special Child

• Von Willebrand’s disease is a hereditary bleeding disorder resulting from an abnormality of the Von Willebrand’s factor (VWF).

• Mouth lacerations are a common cause of bleeding in children.

Manifestations

Hemophilia A

• Frequent bleeding episodes. • Hemarthroses are common and symptoms include pain, stiffness, limited motion. • Individuals may develop debilitating painful arthritis. • Pseudotumors (hemorrhagic pseudocysts).



Treatment

Hemophilia B Von Willebrand’s Disease

• Factor VIII concentrate is used for treatment of hemophilia A. • DDAVP (1-deamino-8- D-arginine vasopressin) • Purified coagulation factor IX concentrate • DDAVP

Acquired Immune Deficiency Syndrome Local anesthesia • • •

In the absence of factor replacement, periodontal ligament (PDL) injections may be used. Infiltration anesthesia can generally be administered without replacement therapy. A minimum of a 40 percent factor correction is mandatory before block anesthesia.

Periodontal therapy • •

Rubber cup prophylaxis and supragingival scaling may be safely performed without replacement therapy. If subgingival scaling is planned, replacement therapy may be considered, depending on the hemorrhaging anticipated and the severity of the factor deficiency.

Restorative procedures • • •

Most restorative procedures on primary teeth can be successfully completed. Thin rubber dam is preferred. Wedges and matrices can be used conventionally.

Pulpal therapy • •

A pulpotomy or pulpectomy is preferable to extraction but instrumentation in periapical area should be avoided. Nonvital teeth should be obturated 2 to 3 mm short of apex.

Oral surgery • •

•

For simple extractions, a 30 to 40 percent factor is administered within 1 hour before dental treatment. Antifibrinolytic therapy—These agents include epsilon-amino­ caproic acid (Amicar) or tranexamic acid (Cykloka­pron). In children, epsilon-aminocaproic acid is given immediately before dental treatment in an initial loading dose of 100 to 200 mg/kg by mouth. Subsequently, 50 to 100 mg/kg of epsilon-aminocaproic acid is administered orally every 6 hours for 5 to 7 days. After extractions are completed, the direct topical application of hemostatic agents, such as bovine thrombin may help with local hemostasis. The socket should be packed with an absorbable gelatin sponge (e.g. Gelfoam). Topical thrombin may then be sprinkled over the wound. Direct pressure with gauze should then be applied to the area. Stomadhesive may be placed over the wound for further protection from the oral environment.

AIDS is the condition diagnosed when there are a group of related symptoms that are caused by severe HIV infection. Popovic in 1983 made identification of HTLV III as the causative agent of AIDS.

Modes of Transmission • • • • •

Parentral transmission Perinatal transmission Sexual transmission Body fluids transmission Dental transmission—Michael Glick et al. (1989) have detected HIV proviral DNA in the dental pulp.

Oral Manifestations of AIDS • Bacterial Infections: Gingivo-periodontal disease • Fungal infections: – Candidiasis – Other fungi • Viral infections: – Epstein-Barr Virus – Herpes simplex Virus – Varicella-Zoster Virus – Human Papilloma Virus – Cytomegalovirus • Neoplasms – Kaposi’s sarcoma – Lymphoma – Other neoplasms • Other oral lesions – Oral ulcers – Salivary gland enlargement.

Management of AIDS Prevention • Barrier techniques • Proper sterilization – HIV is sensitive to autoclaving at 121°C for 15 min at 1 atmospheric pressure

Chapter 70  Dental Consideration of Handicapped Child – Dry heat of instruments up to 170°C – Virus can be inactivated by heating lyophilized factor at 68°C for 72 hours. • Disinfectants for innate objects: – Calcium hypochlorite – 0.2 percent sodium hypochlorite – 6 percent hydrogen peroxide for more than 30 minutes – 2 percent glutaraldehyde and 6 percent hydrogen peroxide – Sodium dichloroisocyanate – HIV is inactivated by treatment for 10 minutes at room temperature with 10 percent household bleach, 50 percent ethanol and 3 percent hydrogen peroxide – Gloves may be disinfected by immersing them in boiling water for 20 minutes and alternatively overnight soaking in 1 percent sodium hypochlorite. Drugs used for AIDS • Acyclovir 1 to 2 gm daily orally or IV • Zidovudine (AZ7), which attacks the virus through the enzyme reverse transcriptase

• Three other inhibitors are also in market, namely Dideoxycytosine (ddc), Dideoxyinosis (dd I), Stavudine (d4 T) • Use of protease inhibitors like saquinavir, indinavir and ritonavir.

AIDS Vaccine • A lot of research on this aspect is coming up, but is still not successful because throughout the course of HIV infection the, genetic makeup of virus is constantly changing from one method of transmission to the other. In addition, the genetic makeup of HIV virus varies across regions as well as within individuals. Therefore, different vaccines will be needed in different regions of the world. An individual’s best chance for protection against any infection requires a vaccine prepared from a virus that exactly matches the virus to which he is exposed, which is near to impossible therefore as the saying goes “Prevention is Better Than Cure”.

POINTS TO REMEMBER • Special health care needs (AAPD, 2013) defined as “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs. The condition may be congenital, developmental, or acquired through disease, trauma, or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. • Handicapped child is the one who over an appreciable period of time is prevented by physical or mental conditions from full participation in the normal activities of their age group including those of social, recreational, educational and vocational nature. • Barriers in care for handicapped children are accessibility, psychosocial, financial, communication, mobility and stability, preventive, lack of trained personnel and ignorance by parents. • Dental assistant is helpful in obtaining preliminary information, instructing the patient assisting and advising the dentist of any noteworthy or unusual patient, family, or guardian problems. • Mental retardation is defined as an overall intelligence quotient lower than 70, associated with functional deficit in adaptive behavior, such as daily-living skills, social skills and communication. It can be due to genetic disorders, maternal and fetal infections, fetal alcohol syndrome, birth injuries, cerebral trauma or hypoglycemia. It oral manifestations include tooth decay, altered salivary flow, abnormal jaw development, marked alterations in mastication, poor esthetics, gingival overgrowth and bruxism. • Cerebral Palsy a group of disorders of the development of movement and posture, causing activity limitations that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. Spastic palsy is caused by a lesion in the cerebral cortex and has impaired chewing and swallowing, hyper tonicity of facial muscles, spastic tongue thrust, drooling of saliva, constricted mandibular and maxillary arches. Athetosis is caused by a lesion in the basal ganglion and its classical dental sign is perioral muscles hypotonic with mouth breathing. Ataxia is due to a lesion of the cerebellum and has lack of balance leading to staggering gait, poor sense of balance and uncoordinated voluntary movements. • Autistic disorder is a pervasive developmental disorder defined behaviorally as a syndrome consisting of abnormal development of social skills (withdrawal, lack of interest in peers), limitations in the use of interactive language (speech as well as nonverbal communication), and sensorimotor deficits (inconsistent responses to environmental stimuli). Most often the cause is genetic. These children seem to be self sufficient and introvert and want to be left alone and have no attachment to their parents and relate well to objects like moving or shiny inanimate objects.

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• In case of prophylaxis for infective endocarditis and other heart ailments Amoxicillin remains the first choice as the prophylactic antibiotic. The 2007 guidelines recommend administration of amoxicillin 30 to 60 minutes before the procedure. • According to the revised guidelines by AAPD (2011), minimal use of antibiotics is indicated to avoid the risk of developing resistance due to antibiotic usage; however, dentist should consider the use of antibiotics in patients with underlying cardiac conditions for all dental procedures that involve manipulation of gingival tissue, involvement of the periapical area or breach of oral mucosa.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8.

Define handicapped child and list out its classification. What are the barriers in providing care to handicapped children? Write a note on disability accessibility guidelines. Explain the features, oral manifestations and treatment implications in case of dental treatment of a child of mental retardation. What is cerebral palsy? How do you manage the dental treatment for such patients? Write a note on autism. Explain prophylactic antibiotic regimen. Discuss the oral manifestation and management of hemophilic patient in dental operatory.

BIBLIOGRAPHY 1. Agerholm M. Handicaps and the handicapped. Journal of Royal Society of Health. 1975;1:3. 2. American Heart Association. Prevention of bacterial endocarditis; recommendation by the American heart Association by the committee on rheumatic fever and endocarditis. J Am Med Assoc. 1997;277:1794-801. 3. Bill D, Weddell JA. Dental office access for the disabled. Spec care Dentist. 1987;7:246-52. 4. Franks AST and Winter GB. Management of the handicapped and chronic sick patient in dental practice. Brit dent J. 1974;13(5):107-10. 5. Mink JR. Dental care for the handicapped child. In Goldman HM, et al: current therapy in dentistry, St. Louis, Mosby; 1966.p.2. 6. Nunn JH. The Dental health of mentally and physically handicapped children: a review of the literature. Community Dental Health. 1987;4:157-68. 7. Ohmori I, Awaya S, Ishikawa F. Dental care for severely handicapped children. Int Dent J. 1981;31(3):177-84. 8. Guideline on Management of Dental Patients with Special Health Care Needs. Reference manual V 34 /NO 6 12 /13 pg.152-7.

71

Chapter

Cleft Lip and Palate Nikhil Marwah, Prabhadevi C Maganur

Chapter outline • • • • • • •

Historical Perspective Definitions Pathogenesis of Clefting Incidence of Cleft Etiology of Cleft Lip and Palate Development of Palate Factors Affecting Development of Palate

• • • • • • •

Cleft lip and palate are one of the most common congenital deformities seen at birth. It can be defined as congenital abnormal gap in the palate that may occur alone or in conjunction with lip and alveolus cleft. In historical times there were numerous theories and misbelieves that were associated with clefting. Some thought that it was due to effect of solar eclipse, while other thought it to be a bad

Classification of Cleft Clinical Features of the Cleft Parental Attitudes Management of Cleft Lip and Palate Treatment Plan Age Specific Intervention Branch Specific Intervention

omen and message of anger from the god and so such children were killed or they and their families were banished from the tribe. However, now the concept has changed with the scientific knowledge of embryology of cleft. But the etiology of cleft lip and palate still remains a mystery although various reasons and postulations have been put forward.

HISTORICAL PERSPECTIVE AD 1000

Ancient Egyptian writings

Indicated the speech difficulties due to cleft palate, and the condition thought to have been not uncommon among primitive people

1561

Pare

Described the making of obturators to fill the cavity of palate. There are records of attempts to repair a hair lip

1764

Le Monnier

1st operated a cleft of the palate surgically, mainly to facilitate eating and drinking

1826

Dieffen Bach

Suggested separation of the soft tissues of the palate from the underlying bone, when attempting to repair the hard palate

1844

Fergusson

Advancement of cleft palate

1862

Von Langenbeck

Using median suture, were among those surgeons who contributed notably to the surgery at that time

1923

Brophy

Suggested that midline suture would be simplified if the palatal gap were first narrowed by compression Contd...

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Contd... 1930

Victor Veau

Used various methods to elongate the soft palate, sometimes described as pushback operations

1942

Anderson

Conducted extensive studies of genetic pattern, found 2 different hereditary genes

1943

American Cleft Palate Association

To bring together members of all various professions to contribute to the knowledge of cleft palate and its treatment

1950

R Millard

Comprehensive cleft lip repair procedure identified

DEFINITIONS Cleft:  Split or divided; refers to muscle, skin, bone. Cleft lip: Congenital deformity of the upper lip that varies from a notching to a complete division of the lip; any degree of clefting can exist. Cleft palate:  A congenital split of the palate that may extend through the uvula, soft palate, and into the hard palate; the lip may or may not be involved in the cleft of the palate. Submucous cleft palate:  A cleft of the muscle layer of the soft palate with an intact layer of mucosa lying over the defect. Velopharyngeal insufficiency (VPI):  Inadequate velo­pharyngeal closure resulting in hypernasality (excessive flow of air through the nose); also called velopharyngeal incompetence. Fistula:  Abnormal opening from the mouth to the nasal cavity remaining after surgical closure of the original cleft.

achieve velopharyngeal closure in order to promote clear speech.

PATHOGENESIS OF CLEFTING The theory of mesodermal reinforcement of epithelial membranes (given by Victor Veau and later developed by Stark in 1954): According to this theory, the upper lip and jaw are formed by the penetration of mesoderm between the layers of pre-existing epithelial membrane formed by the invagination of the oral pit (Fig. 71.1). The mesenchyme may originate from neuroectoderm at the neural crest and migrate from the back of the head by three routes. The 1st route is over the top of the developing head and down into the central part of the face which is called as the frontal prominence. The two routes are around the sides of the head into the areas of developing cheeks. As the mesoderm penetrates between the layers of epithelium it gives to the surface swelling known as medial and lateral nasal process and maxillary process. A congenital cleft of the lip, alveolus, or anterior palate is due to failure of mesoderm and the subsequent breakdown of the

Cheiloplasty:  Surgical repair of cleft lip. Cleft palate–Craniofacial team: Group of professionals involved in the care and treatment of patients having cleft lip/palate and other craniofacial malformations; consists of representatives from some of the following specialties: pediatrics, plastic surgery, otolaryngology, audiology, speechlanguage pathology, pedodontics, psychiatry, orthodontics, prosthodontics, psychology, social service, nursing, radiology, genetics and oral surgery. Maxillary orthopedics:  The movement of palatal segments by the use of appliances (also called dentofacialorthopedics). Obturator:  A plastic (acrylic) appliance, usually removable, used to cover a cleft or a fistula in the hard palate, or to help

Fig. 71.1: Victor Veau’s theory

Chapter 71  Cleft Lip and Palate • • • • •

Cleft palate is more in females Unilateral clefts are more common as compared to bilateral Left side has more predisposition for clefts Incidence is increased with increase in parental age More chances of cleft in patients with family history of the same and in consanguin marriages.

ETIOLOGY OF CLEFT LIP AND PALATE

Fig. 71.2: Pathogenesis of clefting

Theories of clefting • • • • • • • • •

Dursy–His hypothesis: Failure of fusion between median nasal and maxillary process Veau’s hypothesis: Failure of in-growth of mesoderm between the two palatal shelves Alternations in intrinsic palatal forces Excessive head width or diminutive palatal shelves Excessive tongue resistance Nonfusion of shelves Fusion of shelves with subsequent breakdown Failure of tongue to drop down as in case of Pierre Robin syndrome Inclusion cyst pathology.

unsupported epithelial membrane and not to the failure of fusion of separate process (Fig. 71.2).

Some of the postulated reasons are: • Heredity: Defect seems to run in families. • Environment: Teratogens like rubella virus, thalidomide. • Mutant genes: Some syndromes follow Mendelian inheritance, e.g. lobster defect-cleft with ectodermal dysplasia. • Chromosomal aberrations: Cleft can occur with many chromosomal defects like Trisomy 21. • Increased maternal age. • Decreased blood supply in nasomaxillary region. • Deficiency of folic acid and vitamin A. • Multifactorial inheritance: Recent studies have shown that cleft cannot be attributed to one single factor and is a conglamation of multiple genetic and environmental factors.

DEVELOPMENT OF PALATE

Primary Palate At the end of the 5th week of intrauterine life as a result of the medial growth of the maxillary process and the medial nasal process forms the intermaxillary component/single globular process (Fig. 71.3). This contains three components (Fig. 71.4): 1. Labial component includes philtrum of upper lip, tip of nose, columella. 2. Upper jaw component contains four incisors. 3. Palatal component includes triangular primary palate.

INCIDENCE OF CLEFT Cleft lip and palate affects approximately 1:1000 Caucasian, 1:500 Asians, and 1:2000 African Americans. Although the majority of patients with cleft lip and palate are otherwise healthy, approximately 25 percent have associated birth defects/chromosomal abnormality, or a genetic syndrome. Although there are more than 400 syndromes reported in association with cleft lip or cleft palate the three syndromes should receive special consideration. • Overall incidence varies from 0.3 to 6.5 per 1000 live births • Negroid race has least incidence while mongoloid have the maximum • Cleft lip is more common in males

Fig. 71.3: Development of primary palate

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Fig. 71.4: Three components of palate

Secondary Palate • By the 6th week of development, primitive nasal cavities are separated by a primary nasal septum and are partitioned from the primitive oral cavity by the primary palate (Fig. 71.5). The primary palate and primary nasal septum are derived by the frontonasal process. At this stage the stomatodeal chamber is divided into: – Small primitive oral cavity beneath primary palate – Relatively large oronasal cavity behind the primary palate. • During this 6th week 2 lateral palatal shelves develop behind the primary palate from the maxillary process, a secondary nasal septum grows down from the roof of the stomodeum behind the primary nasal septum, thus dividing the nasal part of the oronasal cavity into two (Fig. 71.6). • During the 7th week of development the oral part of the oronasal cavity becomes completely filled by the developing tongue. Growth of the palatal shelves continues such that they come to lie vertically. Two peaks of DNA synthesis occur as the palatal shelves are formed 1. During initial shelf outgrowth 2. During vertical shelf elongation. • During 8th week of development the stomodeum enlarges, the tongue drops down and vertically inclined palatal shelves become horizontal. On becoming horizontal, palatal shelves contact each other in the midline to form the definitive or secondary palate (Fig. 71.7). • The shelves contact the primary palate anteriorly so that the oronasal cavities become subdivided into its constituent oral and nasal cavities. After the contact the medial edge epithelia of the 2 shelves fuse to form the midline epithelial seam. Subsequently this degenerates so that mesenchymal continuity is established across the now intact and horizontal secondary palatal palate.

Fig. 71.5: Secondary palate initiation

Fig. 71.6: Fusion of palatal shelf

• Fusion of the palatal process is complete by the 12th week of development. After elevation of the palatal shelves they contact each other and adhere by means of sticky glycoprotein which coats the surface of the medial edge epithelia of the shelves.

Chapter 71  Cleft Lip and Palate FACTORS AFFECTING DEVELOPMENT OF PALATE

Fig. 71.7: Secondary palate formation

• Several mechanisms have been proposed to account for the rapid movement of the palatal shelves from the vertical to the horizontal position. – Biochemical transformation in the physical consistency of the connective tissue matrix of the shelves – Variations in the vasculature and blood flow to these structure – Sudden increase in their tissue turgor – Rapid differential mitotic growth – Muscular movements, jaw movements, forces derived from the tongue – Intrinsic factors - Role of glycosaminoglycans - Role of matrix components - Role of collagen - Role of mesenchymal cells.

Palatal Ossification • Once the fusion is complete, hard palate ossifies intramembraneously from 4 centers of ossification, 1 in each developing maxilla and 1 in each developing palatine bone. • Maxillary ossification centers lies above the developing deciduous canine tooth germ and appears in 8th week of development. • Palatine centers of ossification are situated in region forming the future perpendicular plate; appear in 8th week of development.

CLASSIFICATION OF CLEFT • Davis and Ritchie’s classification • Veau’s classification •

Based on embryology: – Fogh-Anderson classification – Kernahan’s and Starks classification – American Cleft Palate Association

•

Graphic methods of recording clefts: – Pfiefer classification – Kernahan’s striped Y classification – Millard’s modification of striped Y classification – Tessier system of classification of orofacial clefts

Davis and Ritchie’s Classification (1922) • Group 1: Prealveolar clefts: Lip clefts only with subdivision, unilateral medial and bilateral. • Group 2: Postalveolar clefts: Degree of involvement of the soft and hard palate could specified, up to the alveolar ridge, submucous clefts also included. • Group 3: Alveolar cleft: Complete clefts of palate, alveolar ridge, with subdivision of unilateral, medial, and bilateral.

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Veau’s Classification (1931) • Group 1: Cleft of the soft palate only • Group 2: Cleft of the hard and soft palate to the incisive foramen • Group 3: Complete unilateral cleft of the soft, hard palate and lip and alveolar ridge on one side • Group 4: Complete bilateral cleft of the soft hard palate and lip and alveolar ridge on both sides.

Fogh–Anderson Classification (1942) • Hare lip—includes alveolus and as for back as incisive foramen • Hare lip and cleft palate • Isolated cleft of the palate as forward as the incisive foramen.

Kernahan’s and Stark’s Classification of Clefts A. Clefts of primary palate • Unilateral (r/ l) – Complete – Incomplete. • Median – Complete (premaxilla absent) – Incomplete (premaxilla rudimentary). • Bilateral – Complete – Incomplete B. Clefts of secondary palate only • Complete • Incomplete • Submucous C. Clefts of primary and secondary palate • Unilateral (r/l) – Complete – Incomplete • Median – Complete – Incomplete • Bilateral – Complete – Incomplete

American Cleft Palate Association’s Classification Clefts of Prepalate Cleft lip

• Unilateral • Bilateral

• Median • Prolabium • Congenital scar Cleft of alveolar • Unilateral process – Bilateral – Median • Any combination of foregoing types Cleft of prepalate • Prepalate protrusion – Prepalate rotation – Prepalate arrest (median cleft)

Clefts of Palate Cleft soft palate • Extent – Palatal shortness – Submucous cleft Cleft hard palate • Extent – Vomer attachment – Submucous cleft Cleft of soft and hard palate

Clefts of Prepalate and Palate Any combination of clefts described under clefts of prepalate and clefts of palate.

Schuchardt and Pfeiffer’s Classification (Fig. 71.8) This is symbolic classification in which different regions depicted and then shaded according to type of cleft depending on whether its total or partial.

Fig. 71.8: Schuchardt and Pfeiffer’s classification

 ernahan’s Striped ‘Y’ Classification K (Fig.  71.9) This is a symbolic classification in which numbering is given to each site representing the oral cavity. The shaded area denotes presence of cleft in the particular area.

Chapter 71  Cleft Lip and Palate

Fig. 71.9: Kernahan’s striped ‘Y’ classification

A

 illard’s Modification of Striped ‘Y’ M (Fig.  71.10) He added another parameter to the Kernahan’s classification and that was the addition of nasal floor.

B Figs 71.11A and B: V tessier system of classification of orofacial clefts

CLINICAL FEATURES OF THE CLEFT Fig. 71.10: Millard’s modification of striped

 Tessier System of Classification of V Orofacial Clefts (Figs 71.11A and B) • • • • • •

Clefts—0-14 Orbit—landmark. Clefts above the upper eyelid—cranial clefts Clefts below the lower eyelid—facial clefts Combination of clefts—craniofacial clefts Craniofacial clefts—well defined course with extension from face to cranium. 0-14, 1-13, 2-12, 3-11, 4-10.

Easy way to examine a cleft lip/ palate baby is with its head gently lowered on to the dentist lap and the parent sitting facing the dentist, supporting and controlling arms and legs. Use of small dental mirrors – No. 2, 18 mm diameter (Busch and co Engelskirchen, Germany) is very useful. Careful examination of cleft area especially on the hard palate and alveolus should be done to evaluate type of cleft (Figs 71.12A to C) and to note down the: • Number of teeth • Eruption patterns • Morphology • Position

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A

B

C Figs 71.12A to C: Different types of cleft lip and palate

Chapter 71  Cleft Lip and Palate • Missing teeth • Enamel hypoplasia • Supernumerary teeth. Any one of the following feature should be looked out for as these can occur in greater incidence in cleft than in normal population: • Natal or neonatal teeth usually observed in maxillary central incisor is common finding in complete unilateral/ bilateral cleft palate • Increase incidence of congenital absent lateral incisor – primary/permanent adjacent to cleft alveolar teeth • Increase incidence of congenital missing of premolar • Increase frequency of supernumerary teeth is another finding complete unilateral/bilateral cleft • Presence of ectopic primary LI—palatally adjacent to or with in cleft side • Permanent canines on side of alveolar clefts may erupt palatally into the clefts • Various anomalies of tooth like enamel hypoplasia, microdontia, macrodontia, fused teeth, aberration in crown shape primary • Presence of increased overbite leads to stripping of labial attached gingiva overlying mandibular incisor which causes traumatic anterior deep bite • Lateral facial profile is noticeably convex in complete U/B clefts, which increases as child grows • Presence of protuberant and mobile premaxilla in infants with complete bilateral CL • Presence of posterior cross bite in patients with U/B cleft palate

Major syndromes associated with cleft lip/palate

• Increase incidence of rotated permanent central incisor adjacent to the alveolar cleft area • Premature loss, deficiency of alveolar bone is seen in permanent teeth adjacent to cleft of alveolar ridge.

Associated Conditions • Presence of middle ear disease with attendant hearing loss in children. • Otitis media develops quite early in most, if not all infants with cleft palate and it probably develops within the 1st month of life. • Speech problems are usually created by cleft lip and palate. Retardation of consonant sound (p, b, t, d, k, g) is most common finding. • Language activity is omitted because consonant sounds are necessary for the development of early vocabulary which leads to good sound discrimination. • Most commonly seen in individual with cleft lips. If the clefts extend into the floor of the nose, alar cartilage on that side is flared; columella of the nose is pulled to the noncleft side. • Surgical correction of the nasal deformities should not be done until all cleft deformities and associated problems have been corrected, as the correction of alveolar cleft defect and maxillary skeletal retrusion will alter osseous foundation of nose. Chief complaints

• Deformity of face • Unable to feed • Nasal regurgitation of fluids

Dental problems

• • • • • • • • • • •

Esthetic concerns

• Loss of facial morphology • Missing structure

Hearing and speech pathology

• Disorders of middle ear • Nasal twang in voice • Difficulty in articulation

Psychological effects

• Due to the defect the patients are object of curiosity, pity and are often separated from their normal counterparts in society. This can result in life long trauma be it social, mental or recreational

Autosomal dominant • Van der Woude syndrome (lip pits with cleft lip/palate) • EEC syndrome (ectrodactyl, ectodermal dysplasia and clefting) • Larsen syndrome (originally thought to be recessive) Autosomal recessive • Chondrodysplasia punctata (Conradi syndrome) • Meckel syndrome • Orofaciodigital syndrome, type II • Fryns syndrome X-linked • Orofaciodigital syndrome, type I (dominant, lethal in male) • Isolated X-linked cleft palate with ankyloglossia Chromosomal • Trisomy 13 • Trisomy 18 Non-mendelian • Pierre Robin sequence • Clefting with congenital heart disease.

Congenital missing teeth Neonatal teeth Ectopic eruption Supernumerary teeth Anomalies of tooth size and shapes Micro and macrodontia Fused teeth Enamel hypoplasia Deep bite Cross bite Crowding or spacing of teeth

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PARENTAL ATTITUDES • Psychosocial issues are a critical part of the assessment and management of the child with cleft lip/palate, and must be addressed from the onset of care. • The birth of a child is always a time of great family adjustment, and it is especially stressful when the child is born with a birth defect such as cleft lip/palate. Parents often experience feelings of sadness, guilt, anger and fear for their child’s future social acceptance. Some parents feel the extent of their emotional turmoil is unwarranted with such a repairable birth defect, and experience guilt that a facial deformity is so disturbing to them. • In addition, the feeding difficulties these infants experience can be threatening to new parents, who may doubt their own ability to feed and nurture an infant with such differences. The loss of the ability to breastfeed is especially traumatic for some mothers. • In part, through good psychosocial support and proper instructions, most families are able to work through their own emotional turmoil and effectively master the skills needed to feed and nurture these babies. • As the child grows, the family will have other concerns, often relating to teasing, peer acceptance, speech difficulties, learning and behavior problems. For many families, securing appropriate community and financial resources remain important issues. • During adolescence there are new challenges, as the maturing teen strives for independence and copes with being different in a highly appearance-conscious culture. Adolescents and pre-teens should be given an opportunity to confidentially share feelings and concerns with a qualified professional. • Psychosocial assessment and support may also become necessary when a high level of patient compliance and family commitment are required for certain interventions, such as obturator therapy. Other important circumstances that are often addressed by a psychosocial professional include child abuse/neglect, substance abuse, domestic violence and other family dysfunction. • There is research to suggest that unless such emotional issues are addressed prior to surgery, such interventions alone are less likely to change self-image and improve quality of life. A detailed and specific psychosocial assessment is appropriate for all families presenting to a cleft palate team, regardless of socioeconomic status and perceived stability.

• Weachter (1959) reported 10 parental attitudes of the parents towards the cleft lip and palate. – Child appearance – Request for immediate surgery – Speech development – Feeding – Reaction of the spouse – Action of the siblings – Reaction of family and friends – Intellectual development – Financial problems – Recurrence of the defect in other unborn children.

MANAGEMENT OF CLEFT LIP AND PALATE There are many problems that are associated with cleft palate patients and so these have to be successfully treated so as to complete the comprehensive rehabilitation of these patients. Until the foundation of Lancaster Cleft Palate clinic in Pennsylvania, independent clinicians carried out the treatment of children with clefts. The patient had to go from one clinic to the other for the next correction. Later it was Copper who came up with the idea that all clinicians providing treatment to the child can act as a team, such an association would result in better understanding of the problem and more helpful in alleviating the problems associated with it. Cleft team may vary in composition but generally consists of persons who are associated with patient’s general development, dental development, speech, facial esthetics and psychologic well-being.

Fundamentals of cleft palate team • • • • •

• • •

•

Requires an interdisciplinary team of specialists with experience in cleft lip/palate Team must see sufficient numbers to maintain expertize Optimal time for team evaluation is in first few days or weeks of life Team should assist families in adjustment to the birth defect Team should adhere to principles of informed consent, form partnership with parents, and allow participation of the child in decision making Care is coordinated by the team, and is provided locally if possible and appropriate Team should be sensitive to cultural, psychosocial and other contextual factors Team is responsible for monitoring short- and long-term outcomes, including quality management and revision of clinical practices, when appropriate Treatment outcomes include psychosocial well-being, and effects on growth, function and appearance.

Chapter 71  Cleft Lip and Palate

Cleft Palate Team Patient care coordinator

He who arranges the appointment, maintain the records of the patient

Obstetrician

First to observe the child and sends for referral

Pediatrician

Provides routine care and contacts other team members. Often is family doctor, perform complete physical evaluation and helps to assess the patient physiological status and developmental milestones

Plastic surgeon

Carries out esthetic repair. He plans out the timing of surgery, will be responsible for obtaining alveolar bone grafts and examines nasopharyngeal for speech. Pharyngoplasty — improve velopharyngeal function, correct internal nasal deformities

Surgeon

Helps during surgery

Oral surgeon

Carries out lip and palate repair. Plans the treatment along with other team members. Surgically alter skeletal relationship of maxillomandibular complex and repair cleft lip and palate

Neurologist

Identifies syndromes

Pedodontist

Helpful during all steps like presurgical orthopedics, obturator fabrication, maintenance of growth

Orthodontist

Carries out all types of orthodontic interventions during the treatment and also after it. Plays a major role in the diagnosis and treatment of the cleft condition. Maintain records, OPG, study model and diagnostic photographs. He also works with surgeon to plan and to render an appropriate treatment to the child

Speech therapist

Monitors speech development and prevents any mishap

Psychologist

Prevents stress for the child and family

Prosthodontist

Helps in appliance fabrication. Replaces, restores or rehabilitates orofacial structure that may be congenitally missing or malformed

ENT specialist

For any associated defects

Social worker

Important part in today’s changing world and helps with the social component

Parents

Since the child is small so the parents are required to provide consent on his behalf

Genetic counsellor

Examines the patient to find characteristics of syndromes associated with cleft lip and palate

Audiologist

Performs test for hearing difficulties and also performs middle ear surgery if needed

Nurse

Advisor, support family during time of anxiety/ Daily care of infant/Teaches mother to take care of nose, facial skin, cleaning of splints at each feeding time/Actively communicate with team members

Management of the Neonate When a child with cleft palate is born, medical and nursing attendants do face two types of problems 1. Neonatal respiratory obstruction: Neonatal respiratory obstruction: Infants born with a very small and posteriorly displaced mandible and tongue which falls back causes severe obstruction to the airway, e.g.: Pierre Robin syndrome. 2. Difficulty in feeding • Almost all babies with oral clefts do have difficult in feeding. • Breastfeeding should be encouraged. • Feeding by bottle rather than spoon is much more natural for the baby and encourages the biting action of lower lip and jaw function and development. • Nostril must be cleaned. Lips should be well lubricated with vaseline. When the feeding is finished, small amount of 2 to 3 teaspoonful of sterile water is used to clean the mouth and palate. • Area around the folds of the neck should also be carefully washed and dried as the baby often dribbles excessive saliva.

Parental Counseling • The most important people associated at this stage are the parents. The parents need support and information regarding treatment aspects. • The parents should be told to hold and nurse the infant so that increased bonding occurs. • It is also very important to negate any fears and guilt regarding the child that a parent might have. The mother plays a major part in the form of a nurse as well as mother.

Nursing Management • The mother acts as a very important nurse at this time. After the obturator has been fitted the mother will take care of this appliance. • After each feed the plate is removed and cleaned with running water and soaked once a day for 20 minutes in hibitane solution.

Feeding Management Knowing how to feed the child with a cleft lip or palate is very important. • For those infants with a cleft lip only: If newborn child has a cleft lip only (with a normal palate), he/she should be able to eat normally using standard techniques. They can be even breastfeed, if you desire some problem-solving may be needed to ensure that the infant can get a tight

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seal around the breast or nipple. Early referral to the infant-feeding specialists or nurses associated with cleft lip/palate teams can facilitate this problem-solving. • For those infants with a cleft palate, with or without a cleft lip: The infant with a cleft palate will require specific bot­ tles and a special feeding technique. Breastfeeding and use of a regular bottle are rarely possible. The purpose of the palate is to separate the mouth from the nose. Normally the soft palate at the back of the mouth moves up to close off the passage to the nose during feeding. This creates a closed system, and the sucking motions create negative pressure which pulls the milk out of the breast or bottle. A cleft palate prevents the infant from creating a closed system in his/her mouth, and makes it impossible for the milk to be pulled out. The infant will look like he/she is sucking, but he/she will be using up precious calories in a futile attempt to gain adequate nutrition.

Feeding Bottles • The proper bottle is the key to a successful feeding plan. There are three options currently widely used all of which work without the infant needing to create intraoral suction in order to pull milk out of the nipple. • The first is the cleft palate nurser made by the MeadJohnson Company. It is a soft-sided bottle that is squeezed in coordination with the infant’s sucking efforts, and thus milk is delivered into the mouth (Fig. 71.13).

Fig. 71.14: HabermanTM feeder

• The third option is the pigeon cleft palate nurser distributed by children’s medical ventures. This system also makes use of a one-way valve at the base of the nipple. In addition, the nipple is constructed with a thinner, more compressible side so that the infant’s tongue is effective in compressing the nipple to produce the flow (Fig. 71.15).

Fig. 71.15: Pigeon nipple one-way valve

Fig. 71.13: Mead-Johnson bottle

• The second is the Haberman™ feeder available from the Medela Company. This feeder consists of a large, compressible nipple with a one-way valve at its base that keeps the nipple full of milk. The infant’s effort to compress the soft nipple is often sufficient to dispense the milk into the infant’s mouth, but this can also be assisted by squeezing the nipple to increase the flow (Fig. 71.14).

• The regular bottles can also be supplemented with special teats namely Newborn Teat, Orthodontic shaped teat, MAM soft sipper spout, NUK cleft palate teat, MAM vented teat size 2, tapered teat (Figs 71.16A to G).

Special Techniques for Feeding • Make sure your child is eating in an upright position. Gravity will help to prevent milk from coming through the baby’s nose. This limits choking and gas. It also helps to decrease the risk of ear infections. • If you want to breastfeed, you will need to pump your breast milk, then feed it to your baby through a bottle.

Chapter 71  Cleft Lip and Palate

A

B

D

C

E

F

G

Figs 71.16A to G: Feeding teats

Direct breastfeeding is not an option because a child with a cleft palate cannot generate any suction. • Use a cleft palate bottle or other squeezable bottle. With a squeezable bottle, you can actually push the milk into your child’s mouth and he/she does not need to suck. • Burp your baby frequently. Infants with cleft palate tend to swallow a lot of air during feedings—even when eating in the upright position. • Eventually, feeding time should be no more than 30 minutes for 2 to 3 ounces. Please schedule weekly visits with your pediatrician until your child is eating well and gaining appropriate weight.

TREATMENT PLAN

•

•

•

Sequencing of cleft treatment: The comprehensive treatment of cleft patients can be divided into 4 stages:

Stage 1: Maxillary Orthopedic Stage • This lasts from birth to 18 months. • The treatment modalities in this stage are management of feeding problems, fabrication of feeding obturators, presurgical orthopedics, surgical management of cleft lip and surgical management of cleft palate. The feeding

•

problems can be effectively dealt with using appliances like plates, pumps and nipples as explained earlier. Initial obturator therapy (Figs 71.17A and B): This is done from birth to 3 months. The appliance is fabricated after taking impression and is made of acrylic. Appliance should be cleaned before and after each feed. Presurgical orthopedics (birth to 5 months): The aim of this is to achieve an upper arch from that conforms to lower arch. In cases where the premaxilla is positioned very anterior it may present difficulty in surgical lip closure therefore has to be corrected first. This can be accomplished by retraction plate or premaxillary retraction tape. Surgical lip closure (3 to 9 months): This is the best time for lip repair as lip is not much developed and the vermilion border is not very conspicuous. ‘Rule of Ten’ is an important criterion for lip repair. It states that at the time of surgery the age of the child should not be less that 10 weeks of age, have no less that 10 gm% of hemoglobin and should weigh at least 10 pounds. Various types of lip repair are Millard’s repair (Figs 71.18A to E), Tennisonrandall repair (Figs 71.19A to C), Veau’s repair (Figs 71.20A and B) and Rose Thompson repair. Surgical plate repair (10 to 18 months): The time of palatal repair is very vital for further growth and esthetics. If

871

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Dentistry for the Special Child

A

B Figs 71.17A and B: Obturator therapy

A

C

B

D Figs 71.18A to E: Millard’s repair

E

Chapter 71  Cleft Lip and Palate

A

B

C

Figs 71.19A to C: Tennison-randall repair

A

B

A

B

C

D

Figs 71.20A and B: Veau’s repair

the repair is done too early then we will establish good esthetics but growth will be hampered and if we repair too late facial growth will be better but esthetics will be compromised. There are two types of palatal repair: 1. Single stage: Von Langenbeck repair (Figs 71.21A to D) and V-Y pushback palatoplasty (Figs 71.22A to D). This is carried out at 1½ year. The disadvantages include midfacial growth retardation. 2. Two-stage repair: Soft palate is repaired around 18 months and then hard palate is repaired at 4 years by Schweckendiek procedure (Figs 71.23A to E).

Figs 71.21A to D: Von Langenbeck repair

A

B

Stage II: Primary Dentition Stage This extends from 18 months to 5 years of age. The treatments carried during this stage are: • Adjustments to obturators • Restoration of decayed teeth

C

D Figs 71.22A to D: V-Y pushback palatoplasty

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874 Section 14 

Dentistry for the Special Child Age range

A

B

D

C

Prenatal

• • • • •

Birth-1 month

• • • •

1–5 months

• • • •

5–15 months

• Monitor feeding, growth development • Monitor ears and healing; consider ear tubes if indicated • Repair cleft palate • Instruct parents in oral hygiene

16–24 months

• Assess ears and hearing • Assess speech-language • Monitor development

2–5 years

• • • •

Assess speech-language; manage VPI Monitor ears and hearing Consider lip nose revision before school Assess development and psychosocial adjustment

6–11 years

• • • •

Assess speech-language; manage VPI Orthodontic interventions Alveolar bone graft Assess school psychosocial adjustment

12–21 years

• • • •

Jaw surgery, rhinoplasty (as needed) Orthodontics: bridges, implants as needed Genetic counseling Assess school psychosocial adjustment

E

Figs 71.23A to E: Two-stage repair by Schweckendiek procedure

• Maintenance of oral hygiene • Evaluating the erupting dentition.

Stage III: Mixed Dentition Stage The main problems encountered during this stage are due to ectopic eruption of teeth and malalignments. The procedures in this are: • Correction of cross bites • Maxillary expansion • Secondary grafting.

Stage IV: Permanent Dentition Stage • During this stage the patients can be treated in conventional manner. • Mainly the treatments undertaken during this phase are fixed orthodontic treatments. All types of dental and skeletal irregularities are corrected during this period. • Cosmetic repair is also carried out during this phase but is probably the last treatment to be undertaken.

Intervention Refer to cleft lip palate team Medical diagnosis and genetic counseling Address psychosocial issues Provide feeding instructions Make feeding plan

Refer to cleft lip palate team Medical diagnosis and genetic counseling Address psychosocial issues Provide feeding instructions and monitor growth • Begin presurgical orthopedics if indicated Monitor feeding and growth Repair cleft lip Monitor ears and hearing Begin, continue presurgical orthopedics if indicated

AGE SPECIFIC INTERVENTION

BRANCH SPECIFIC INTERVENTION

According to The Center for Children with Special Health Needs, Children’s Hospital and Regional Medical Center, Seattle, WA.

According to The Center for Children with Special Health Needs, Children’s Hospital and Regional Medical Center, Seattle, WA.

Chapter 71  Cleft Lip and Palate

Psychology Age range

12–21 years Intervention

Birth to 1 month

• Assessment of grief and loss issue • Identify and validate other concerns • Assess; family functioning recognize strengths, weaknesses, cultural differences • Assess family understanding medical informations • Help incorporate family needs into treatment plan • Make appropriate community referrals

1–15 months

• Follow-up on psychological needs of family • Check family arrangements for surgical strays (lip and palms repairs) • Address family stresses surrounding surgery • Ensure family understands postoperative care needs • Review financial issues

16–24 months

• Review family’s experiences with hospital and surgery • Explore how parents believe child’s perceived by others because of appearance speech differences • Screen for developmental problems: Make referral of appropriate

2–5 years

6–11 years

• Review family functioning • Review issues surrounding future pregnancies including the availability of genetic counseling and prenatal ultrasound and preconceptional folic acid supplementations • At school entry review concerns related to speech appearance differences and peer acceptance • Screen for developmental behavioral problems, refer if appropriate • Assess family’s understanding of team treatment plan including management speech problems • Talk directly with child to assess his/her concerns • Review family function and new stresses • Assess family need for community resources and help getting to medical appointments • Assess child fears and concerns before surgeries and hospital strays, especially before bone graft • Assess child concerns related to peer acceptance, speech and facial differences • Model refer for social skills training if needed • Screen for learning behavioral disorders, refer as appropriate • Acknowledge child’s evolving role in the decision making process • Review plans requiring high patients family compliance (e.g. orthodontic interventions obtrusion), including financial issues and family and child’s ability to follow through with treatment

• Acknowledge team’s evolving role in the decision making process • Assess team’s fears and concerns before surgeons/hospital strays • Check for unrealistic expectations of surgery • Assess team’s concerns related to peer acceptance, speech and facial differences • Model refer for social skills training needed • Screen for school problems review academic vocational plans • Assess psychosocial adjustment of teen and possibility of depression, substance abuse, etc. make referals as needed • Assess teen and family in understanding of recurrence risks, need for additional generic counseling

Genetics Age range

Intervention

Prenatal

• Genetics consultation if ultrasound is abnormal, or parents have questions about recurrence risks

Birth to 1 month

• Complete medical and family history • Dysmorphology genetics assessment • Discuss prognosis and implications for treatment • Address etiology • Offer family additional counseling and resources when appropriate

2–15 months

• Discuss recurrence risks, prenatal diagnosis for clefts (ultrasound)

16–24 months • Consider genetic syndrome if developmental delays or other apical features are present • Additional genetics work-up as indicated 2–5 years

• Consider genetic syndrome if developmental delays are present • Additional genetics work-up as indicated

6–11 years

• Consider genetic syndrome, especially if learning problems present • Additional genetics work-up as indicated

12–21 years

• Revisit recurrence risk issues and offer formal genetics consultation

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Plastic Surgery Age range

Oral Surgical Intervention

Age range

Intervention

Prenatal

• Meet parents and child, outline plan

6–11 years

Birth to 1 month

• Meet parents and child outline plan • Consider presurgical orthopedics in consultation with the appropriate dental specialists

• Bone graft of alveolar cleft and closure of oronasal fistulae • Selective tooth extraction as needed

12–21 years

1–3 months

• Monitor progress of presurgical orthopedics with orthodontist

• If needed, orthognathic (jaw) surgery in consultation with the orthodontist

3–15 months

• Repairs cleft lip and possible nose, usually at 3–5 months • Repair cleft palate, usually at 9–15 months

16 months – 5 years

• Monitor speech-language development with speech language pathological (refer for speech language therapy as needed) • Monitor for symptomatic fistulae • Consider prosthetic or surgical management as needed for VPI • Lip/nasal surgery as needed for residual deformity

6–11 years

• Consider prosthetic or surgical management as needed for VPI • Bone graft to alveolar cleft with closure of oronasal fistulae • Lip/nasal surgery as needed for residual deformity

12–21 years

• Rhinoplasty as needed (nasal revision) • Lip/nasal surgery as needed for residual deformity • Orthognathic surgery

Orthodontic Age range

• Presurgical orthopedics

5–24 months

• Parent teaching regarding oral hygiene, dental development and future treatment plans • Monitor eruption of teeth and dental hygiene

2–5 years

• Orthodontic dental records (X-rays photos) at 5 years of age in preparation for evaluation of teeth and cleft size • Monitor dental hygiene provide appropriate preventive and restorative care • Orthodontic records as needed to determine thining of bone graft • Assist with speech prosthesis as needed

6–11 years

• Positioning of maxillary segments in preparation for alveolar bone graft • Recommend extractions as needed • Monitor dental hygiene provide appropriate preventive and restorative care • Assist with speech prosthesis as needed • Monitor growth maxillary protraction as needed

12–21 years

• Dental records to monitor jaw growth, dental development and bone graft • Braces for dental alignment as needed • If retrusion is severe, combination of jaw surgery and braces is needed • Prosthetic replacement of missing teeth as needed • Monitor dental hygiene, provide appropriate preventive and restorative care

Speech and Language Age range

Intervention

6–9 months

• Speech language consultation to address abnormal speech parents

9–24 months • Speech language evaluation three months after palate repair 2–5 years

• Annual speech language evaluation • Violence prevention intervention work-up if needed • Proceed with prosthetic or surgical management (if child cannot cooperate, interventions may be recommended in the absence of a full work-up) • If indicated provide or refer for articulation and/or language therapy • Communicate with school and/or outside speechlanguage pathologist

6–11 years

• Annual speech-language evaluate involution of adenoids • Violence prevention intervention work-up and interventions if needed • Provide or refer for speech language therapy if needed • Communicate with school and/or outside speech language pathologist and monitor progress of therapy

12–21 years

• Speech language evaluation every 2–3 years or as needed • Speech language therapy if needed • Communicate with school and/or outside speech language pathologist • Interventions for violence prevention intervention if needed

Intervention

Birth-5 months

Prenatal and Genetic Counseling • In the past, prenatal diagnosis of a cleft lip was almost always made in association with other abnormalities in the fetus. With improvements in ultrasound technology, the prenatal diagnosis of isolated cleft lip is increasingly common. However, it is easy to miss cleft lip on diagnostic ultrasounds, particularly those performed for routine indications in the physician’s office. • In the United Kingdom, routine views of the face and lips were added to antenatal ultrasound guidelines in 2000 and detection rates of cleft lip in low-risk populations increased from 16 to 75 percent with 2D ultrasound between week 18–23 gestation.

Chapter 71  Cleft Lip and Palate • The use of 3D ultrasound of the face improves detection rate significantly. • Thus, if there is a family history of clefting or if there is a concern about a possible cleft for other reasons, a referral should be made for a complete diagnostic ultrasound (including 3D images if possible) and genetic counseling. • Ultrasound can often establish whether a cleft lip is unilateral or bilateral. • It is still very difficult to make the diagnosis of a cleft palate antenatally, unless it is detected in association with a large cleft lip. • Recently, fetal MRI has been used to detect fetal abnormalities including cleft palate but experience and availability of fetal MRI, however, is extremely limited at this time. • Once a cleft lip/palate is identified, the family should be referred for genetic counseling to discuss other testing, including amniocentesis. During the genetic counseling session, a complete pregnancy and family history should be performed. This should include information on any teratogenic exposures, and the presence of family members with clefts or other birth defects, developmental problems and genetic syndromes. Even if genetic tests are negative, parents should be informed that an accurate diagnosis and complete discussion of prognosis and recurrence risks can only take place after the baby is born. • When a cleft lip/palate is detected prenatally, the family should be referred to a cleft lip/palate team to learn about the care and management of children with clefts. At the family’s first visit with the cleft lip/palate team, feeding instructions should be provided, and a clear plan for the newborn period should be formulated. Additional medical information provided at this visit should include a general description of the types of problems the baby may encounter. This opportunity to formulate a feeding plan, learn about the future care their child will receive,

and meet the providers involved in this care can greatly increase a parent’s sense of control and preparedness in the face of this unanticipated diagnosis. • A dysmorphology or genetics assessment is part of the complete evaluation of every child with a cleft. Parents typically have many questions about the etiology of clefts to be addressed by the cleft lip/palate team. There is considerable cultural and social variability in family attitudes towards birth defects and their causation. These issues should be explored and, when appropriate, correct information supplied, recognizing that western medical information will not necessarily supplant other cultural and ethnic beliefs. • Since genetic factors play a role in clefting conditions even in the nonsyndromic child, information on causation and empirical recurrence risks should be provided to all families with clefts based upon the family history. For parents with one affected child, the recurrence risk for future pregnancies is 2 to 5 percent. This risk increases if there are additional family members with clefts. • Condition-specific recurrence risks and prenatal testing options should be provided to families of a child with syndromic clefting condition. Parents should be informed of the option of ultrasonography for future pregnancies. Similarly, a discussion regarding the potential preventative role of preconception/prenatal folate supplementation and avoidance of environmental risk factors (tobacco smoke, alcohol, and isotretinoin) should be considered. The advantage of dealing with the child in these separate stages, with distinct targets in mind, within set time scales is to avoid the parent and the child making frequent visits throughout the child’s developing years. All clinicians involved in the treatment of cleft palate child should recognize that above all he or she is a developing child who should be allowed and encouraged to live life as normally as possible.

POINTS TO REMEMBER • Le Monnier in 1764 operated a cleft of the palate surgically, mainly to facilitate eating and drinking. • Cleft lip: Congenital deformity of the upper lip that varies from a notching to a complete division of the lip; any degree of clefting can exist. • Cleft palate: A congenital split of the palate that may extend through the uvula, soft palate, and into the hard palate; the lip may or may not be involved in the cleft of the palate. • Theories of clefting are Dursy—failure of fusion between median nasal and maxillary process, Veau’s hypothesis: Failure of in-growth of mesoderm between the two palatal shelves, alternations in intrinsic palatal forces, excessive tongue resistance, fusion of shelves with subsequent breakdown, failure of tongue to drop down and inclusion cyst pathology. • Etiology of clefting is due to heredity, teratogens, chromosomal aberrations, increased maternal age, decreased blood supply in nasomaxillary region and deficiency of folic acid and vitamin A.

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• Classification of CL/CP are Davis and Ritchie’s classification, Veau’s classification, based on embryology (Fogh-Anderson classification, Kernahan’s and Starks classification, American Cleft Palate association) and based on graphic methods of recording clefts (Pfeiffer classification, Kernahan’s striped Y classification, Millard’s modification of stripped Y classification, Tessier system of classification of orofacial clefts). • Dental problems with cleft patients are congenital missing teeth, neonatal teeth, ectopic eruption, supernumerary teeth, enamel hypoplasia, deep bite, cross bite, crowding or spacing of teeth. • Management of clefting firstly includes taking care of the neonate which is mainly dealing with feeding. Special bottles and teats are available for accomplishing this task. The next step is the maxillary orthopedic stage in which treatment modalities are feeding obturators, presurgical orthopedics, surgical management of cleft lip and surgical management of cleft palate. The next stage is primary dentition stage in which essence is on restoration and maintenance. Subsequent to this is mixed dentition stage which deals with malalignments and the last stage is permanent dentition stage where fixed orthodontic treatments are done. • ‘Rule of Ten’ is an important criterion for lip repair. It states that at the time of surgery the age of the child should not be less that 10 weeks of age, have no less that 10 g% of hemoglobin and should weigh at least 10 pounds. • Surgical lip closure (3 to 9 months): Millard’s repair, Tennison-randall repair, Veau’s repair and Rose-Thompson repair. • Surgical plate repair (10 to 18 months): Single stage by Von Langenbeck repair and V-Y pushback palatoplasty and twostage repair by soft palate repair at 18 months and hard palate repair at 4 years by Schweckendiek procedure.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8. 9.

Discuss the development of palate. Describe the etiopathogenesis of clefting. Classify the clefts. What are the dental features of cleft patients? Describe the cleft management team. Write a note on feeding management of a cleft neonate. What is the age specific management of cleft child? Explain the treatment plan of managing a child with cleft lip and palate with special reference to the cleft lip surgery. Write a note on prenatal genetic counseling of clefts.

BIBLIOGRAPHY 1. American Association of Oral and Maxillofacial Surgeons (1995). Standards of Care for Cleft Lip and Palate. Berkowitz S. The Cleft Palate Story. Chicago: Quintessence Publishing Co. Inc, 1994. 2. American Cleft Palate-Craniofacial Association. Parameters for the evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Cleft Palate-Craniofacial Journal, 1993;30(Suppl. 1). 3. American Cleft Palate-Craniofacial Association. Team Standards Self-Assessment Instrument, 1996. 4. Badwal RDA, Mabry K, Frassinelli JD. Impact of cleft lip and palate on nutritional health and oral motor development. DCNA. 2002;47: 305-17. 5. Batra P, Duggal R, Prakash H. Genetics of cleft lip and palate revisited. J ClinPed Dent. 2003;27(4). 6. Chakravati A. Finding needles in haystacks—IRF6 gene variants in isolated cleft lip and palate. New England Journal of Medicine 2004;351:822-4. 7. Cleft Palate Foundation. As You Get Older: information for Teens Born with Cleft Lip and Palate, 2002. 8. Cleft Palate Foundation. Cleft Lip and Cleft Palate: the First Four Years, 2001. (Also available in Spanish). 9. Cleft Palate Foundation. Cleft Lip and Palate: the school-aged child. (Also available in Spanish), 1998. 10. Cleft Palate Foundation. Feeding An Infant with a Cleft, (Also available in Spanish), 2002. 11. Cleft Palate Foundation. The Genetics of Cleft Lip and Palate: information for Families, 2001. 12. Cohen MM. Etiology and pathogenesis of clefting. OMSCNA. 2000;12(3). 13. Ghi T, Tani G, Savelli L, Colleoni G, Pilu G, Bovicelli L. Prenatal imaging of facial clefts by magnetic resonance imaging with emphasis on the posterior palate. Prenatal Diagnostics. 2003;23:970-5. 14. Hanikeri M, Savundra J, Gillett D, Walters M, McBain W. Antenatal transabdominal ultrasound detection of cleft lip and palate in Western Australia from 1996 to 2003. Cleft Palate-Craniofacial Journal. 2006;43:61-5. 15. Johnson N, Sandy J. Prenatal diagnosis of cleft lip and palate. Cleft Palate-Craniofacial Journal. 2003;40:186-9.

Chapter 71  Cleft Lip and Palate 16. LaRossa D. The state of the art in cleft palate surgery. Cleft Palate-Craniofacial Journal. 2000;37(3):225-8. 17. Millard D, Latham R. Improved primary surgical and dental treatment of clefts. Plastic and Reconstructive Surgery. 1990;86:856-71. 18. Moller KT, Starr CD (Eds). 1993. Cleft Palate: Interdisciplinary Issues and Treatment. Austin, TX: Pro-ed. Office of Maternal and Child Health US Department of Health and Human Services, 1987. 19. Mulliken JB. Primary repair of bilateral cleft lip and nasal deformity. Plastic and Reconstructive Surgery. 108(1): 181-94; examination; 2001.pp.195-6. 20. Rivkin CJ, Keith O, Crawford PJM, Hathorn IS. Dental care of patients with cleft lip and palate from birth to mixed dentition stage. BDJ. 2000;188(2):78-83. 21. Schendel SA. Unilateral cleft lip repair—state of the art. Cleft Palate-Craniofacial Journal. 2000;37(4):335-41. 22. Sloan GM. Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art. Cleft Palate-Craniofacial Journal. 2000;37(2): 112-22. 23. Sphrintzen RJ, Bardach J. Cleft Palate Speech Management: a Multidisciplinary Approach. St Louis, MO: Mosby;1995. 24. The annual report of the Cleft Lip and Palate Register for England and Wales from the Cleft Development Group. NHS cleft lip and palate service, 2005. CRANE Annual Report. 2004-2005. 25. The Center for Children with Special Health Needs Children’s Hospital and Regional Medical Center, Seattle, WA. Cleft lip and palate elements of critical care. 4th Edn, 2006. 26. Turner SR, Rumsey N, Sandy JR. Psychological aspect of cleft lip and plate. Euro J Orthod. 1998;20:407-15. 27. Wilcox AJ, et al. Folic acid supplements and risk of facial clefts: national population based case-control study. British Medical Journal. 2007;334:464-70. 28. Wyszynski D. Cleft Lip and Palate: From Origin to Treatment. New York: Oxford University Press; 2002.

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72

Prosthodontic Management of Pediatric Patient

Chapter

Nikhil Marwah, Pragati Kaurani

Chapter outline • • • •

Prosthodontic Rehabilitation with Crowns Fixed Partial Denture Resin Bonded Retainers Removable Partial Denture

The current status of caries may be decreasing all over the world but there are many issues which still affect and cause loss of teeth in children such as trauma, neoplasm, systemic disorders, infection, congenital abnormalities such as clefts or inborn defects such as ectodermal dysplasia. Some of the esthetic treatment needs resulting from these conditions can be managed with resin bonding procedures and porcelain laminate veneers, and whenever possible they should be considered as the treatment of first choice. When these procedures have not been able to provide a satisfactory result or when there are missing teeth, then prosthodontic

Prosthodontic treatment options A. Fixed prosthesis • Single crowns – Anterior crowns – Posterior crowns • Fixed partial dentures – Full veneer retainers – Partial veneer retainers – Resin bonded retainers • Radicular retained prosthesis (post and core) • Implant prosthesis B. Removable prosthesis • Overdentures • Removable partial dentures • Implant retained prosthesis C. Maxillofacial prosthesis • Obturators • Rehabilitation prosthesis D. Prosthesis in special case considerations.

• • • •

Complete Denture Rehabilitation in Ectodermal Dysplasia Patients Overdentures in Children Obturators Maxillofacial Prosthesis

procedures such as single crowns, fixed partial dentures, implant prostheses, or removable prostheses are indicated. Because children are often affected psychologically by the unacceptable appearance of diseased, damaged, or missing teeth, one should not allow chronologic age to preclude performing whatever treatment is necessary to provide proper function and esthetics. If the teeth involved are fully erupted, have achieved complete root formation, and may be prepared without causing irreversible damage to the pulp, successful prosthodontic treatment can often be provided for patients as young as 12 to 14 years of age. Prosthodontics in children is more challenging because of the anatomy, erupting teeth, growth patterns, patient cooperation and understanding. Pediatric patients may be required to follow-up more often than adult patients needing procedures like relines or refits of removable prosthesis because of growth patterns. There are various prosthodontic treatment options that can be rendered to a patient with missing teeth. However, careful diagnosis and understanding of the clinical findings is essential for the success of the treatment.

PROSTHODONTIC REHABILITATION WITH CROWNS

All-ceramic Crowns • These are the most esthetic complete coverage restorations currently available in dentistry. • Optimal longevity with all ceramic crowns requires normal tooth preparation form because the prepared

Chapter 72  Prosthodontic Management of Pediatric Patient

• •

• •

tooth must provide support for the restoration. There­ fore, if a large portion of tooth structure is miss­ing because of trauma, caries, or if previous resto­rations become dislodged during tooth reduction, then a separate restoration that is well-retained in remaining tooth structure should be placed to establish an ideal preparation form. All ceramic crowns are able to achieve superior esthetics. Patients with heavy occlusal forces, parafunctional habits are a definite contraindication to receive all ceramic crowns. It is essential that the centric occlusal contacts are located over the cingulum concavity. Tooth preparation for an all-ceramic crown: A well-defined shoulder margin with 0.8 mm depth is recommended to provide the marginal integrity of the restoration. The finish line should be smooth and uniform around the entire tooth with uniform reduction of the axial walls of 0.8 mm. The lingual reduction is recommended of about 1 mm with 1.5 to 2 mm reduction on the incisal edges (Fig. 72.1). The margin placement should be equigingival. Subgingival placement of the margins should be avoided in adolescent patients as it can lead to accelerated recession of the gingiva, or interfere with the normal relocation of the gingiva as the patient matures (Figs 72.2A to C). – Possess a well-defined smooth shoulder finish line that is 0.8 mm deep – Axial surfaces reduced to a depth of 0.8 mm. – The lingual reduction for occlusal clearance should be 1.0 mm. – An incisal edge reduction of 1.5 to 2.0 mm.

ceramic crown, stronger metal ceramic crown is indicated (Figs 72.3A to C). • Tooth preparation design for metal ceramic crown: This restoration consists of a ceramic layer bonded to a thin cast metal coping that fits over the tooth preparation. These restorations combine the strength and accurate fit of a cast crown with the cosmetic effect of a ceramic crown. The labial surface is prepared with over all 1.2 mm

A

Metal Ceramic Crowns • When the ideal tooth preparation form is compromised or the magnitude of occlusal forces contraindicates an all

Fig. 72.1: Two views of all-ceramic (procelain jacket crown) preparation showing recommended reduction depths and shoulder finish line

B

C Figs 72.2A to C: All ceramic crown fabrication

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Dentistry for the Special Child

Fig. 72.4: Two views of metal ceramic crown preparation showing minimal facial reduction and shoulder finish line, minimal incisal reduction, lingual axial reduction depth and chamfer finish line, and lingual reduction for occlusal clearance

A

– Lingually finish line should not be more than 0.5 mm – The lingual reduction for occlusal clearance should be 1.0 mm. – An incisal edge reduction of 2.0 mm.

Crown in Single Posterior Tooth B

• When all or most of the axial surfaces of a posterior tooth have been affected by caries, or they have been restored or endodontically treated, the tooth requires a full crown. • The preparation is started by the occlusal reduction of about 1.5 mm on the functional cusps and 1.0 mm on the nonfunctional cusps. The axial reduction of the buccal and the lingual walls is done to obtain a uniform chamfer finish line. Functional cusp bevel is placed on the buccal inclines of the mandibular buccal cusps and lingual inclines of the maxillary lingual cusps. All sharp angles in the preparation are rounded (Figs 72.5A to D).

Crowns with Post and Core Build-up C Figs 72.3A to C: Porcelain fused metal (PFM) crown fabrication

reduction using planar reduction. The palatal surface is reduced maintaining the tooth anatomy. A uniform reduction of 1.5 mm is done and sufficient clearance from the opposing teeth is maintained. 2 mm of incisal reduction is desirable to achieve optimum esthetics (Fig. 72.4). – Possess a well-defined smooth chamfer finish line that is 1 mm deep

• For the teeth that do not have sufficient coronal struct­ ure for the support of the crown, radicular retained restorations with core build-ups should be done. • Used in teeth with pulpal involvement when remaining coronal tooth structure does not provide adequate retent­ ion for the definitive restoration. • The posts are primarily used to retain a core in the tooth with extensive loss of tooth structure. • The post can be of a variety of materials like metal, fiber, glass fiber or preformed depending on the requirement of the operating dentist. Any type of post can be used anywhere however glass fiber posts are more indicated

Chapter 72  Prosthodontic Management of Pediatric Patient

A

B

C

D Figs 72.5A to D: Posterior ceramic crown placement

in anterior region where esthetics is of prime importance and metal posts are used in posterior teeth where load bearing capacity is of significance. • After the endodontic treatment of the tooth, up to 2/3rd obturative material is removed (only apical 3–6 mm for maintaining the apical seal). The canal is prepared to receive a post of appropriate length and width. The post is then cemented, and core build-up is done with a restorative material like composite. Once sufficient coronal structure is restored, it is prepared to receive a crown (Figs 72.6A to I).

FIXED PARTIAL DENTURE • Fixed partial dentures is a tooth borne partial denture that is intended to be permanently attached to teeth or roots that furnish support to the restorations (Figs 72.7A and B). • Fixed partial denture (FPD) can be defined as a partial denture that is lasted or securely retained to natural teeth,

roots or dental implant abutment that furnishes primary support for prosthesis (GPT). • In a child, when a tooth is lost the space maintenance should be provided immediately to prevent tipping or rotation of the abutment teeth or eruption of the opposite teeth. A fixed partial denture usually requires complete coronal preparations of the abutment teeth to receive the retainers. Thus, it should not be given in teeth with high pulp horns. In case of children, it is now advisable to place an interim prosthesis like RPD, wait till the growth is completed and then replace the missing teeth using implants. However, if implants cannot be given or are not indicated, FPD becomes an appropriate definitive treatment plan.

Indications • • • •

Missing teeth Endodontically treated teeth Congenital malformed or missing teeth For obtaining proper function and esthetics.

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A

D

G

B

C

F

E

H

I Figs 72.6A to I: Post and core with crown

A

B Figs 72.7A and B: Missing teeth and fixed denture rehabilitation

Chapter 72  Prosthodontic Management of Pediatric Patient

Contraindications

RESIN BONDED RETAINERS

• Age of patient (young or advanced age) • Great length of edentulous span • Excessive bone loss in area of missing teeth.

Components of a Fixed Partial Denture • Retainers: The retainers used can be full veneer crowns or can be resin bonded retainers. • Connectors: It is the portion of a fixed partial prosthesis that unites the retainer and pontic. • Pontics: It is an artificial tooth on a fixed dental prosthesis that replaces a missing natural tooth, restores function, and usually fills the space previously occupied by the clinical crown.

Treatment Options for Single or Multiple Missing Teeth • • • • •

Porcelain fused to metal fixed partial denture All metal fixed partial denture Resin bonded partial denture All ceramic partial denture Cantilever prosthesis.

Technique Clinical and Laboratory Steps in FPD (Metal crown) Clinical steps

Laboratory steps

• Examination, diagnosis and treatment planning

• Die preparation

• Tooth preparation

• Articulation of dies and casts

• Impression of the prepared tooth

• Wax pattern fabrication and casting

• Temporization

• Finishing and polishing

Clinical and Laboratory Steps in FPD (Porcelain fused to metal crown) Laboratory steps

• Examination, diagnosis and treatment planning

• Die preparation

• Tooth preparation

• Articulation of dies and casts

• Impression of the prepared tooth

• Wax pattern fabrication and casting of coping

• Temporization

• Ceramic build up

• Coping trial and shade matching • Finishing • Bisque trial • Cementation

Indications • Most common indication is congenitally missing single anterior teeth, e.g. lateral incisor. • Missing mandibular incisors.

Contraindications • Patients with affected enamel like enamel hypoplasia as bonding is poor. • Replacement of posterior teeth. • Replacements in cases with parafunctional activity. It cannot be given where there is crowding in the abutment teeth.

Advantages • Minimal tooth preparation thereby preventing any trauma to the pulp. Ideal for large pulp horns. • Excellent esthetics as the labial surface of the teeth is not prepared. • Local anesthesia need not be administered as the preparation is minimal.

Disadvantages

• Cementation

Clinical steps

Recent advances in bonding techniques have encouraged the use of more conservative approach towards replacing missing teeth, i.e. using resin bonded retainers. They were first introduced by Rochette in 1973. These prosthesis are most ideal to be given in a young patient as the preparation of the teeth is minimal reducing any damage to the pulp. However, case selection is extremely important as these bridges cannot withstand stronger occlusal forces or cannot replace more number of teeth. Dunne and Millar found higher success rates with single pontics than long span prosthesis.

• Most common failure noted is frequent debonding of the prosthesis. • The laboratory techniques for fabrication have to be very exacting for a perfect fit of the restoration.

REMOVABLE PARTIAL DENTURE • Removable partial denture (RPD) is defined as any prosthesis that replaces some teeth in a partial dentate arch. It can be removed from mouth and replaced at will (GPT) (Figs 72.8A to D). • When treatment is planned for an adolescent patient who needs a removable partial denture, there are three major objectives:

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A

B

C

D Figs 72.8A to D: Removable partial denture

1. The restoration of the functions of mastication and speech 2. The restoration of dental and facial esthetics 3. The preservation of the remaining teeth and their supportive tissues.

Indications • • • • • •

Long edentulous span contraindicated for FPD Distal extension cases Compromised periodontal support of remaining teeth Purpose of achieving cross arch stabilization Excessive bone loss Replacement of teeth immediately after extraction.

Contraindication • When FPD is possible • Esthetics a primary concern in replacing less number of anterior teeth • Disabled patients who cannot maintain RPD.

Design of the Partial Denture The removable partial denture is made of acrylic resin that could be either heat cured or self cured. These resins provide advantages like ease of fabrication, biocompatiblity and adequate strength to with stand occlusal forces. As the patient is a growing child, refabrication, relines, repairs or minor adjustments of the partial denture can be easily done with an acrylic denture as compared to a cast partial denture. An acrylic removable partial denture consists of: • Denture base • Retentive clasps • Artificial Teeth.

Advantages • Removable prosthesis can be easily relined and refitted • Removable prosthesis can be used as space maintainers • They are easy to fabricate and economical option for the patient

Chapter 72  Prosthodontic Management of Pediatric Patient • Maintenance of oral hygiene is easy as it is a removable prosthesis.

Disadvantages • Patient cooperation is essential as it is a removable prosthesis. • The patient has to be motivated to wear the prosthesis. • It may be uncomfortable for the patient due to palatal coverage. • Accidental aspirations of the prosthesis may occur.

Steps for Construction of RPD

COMPLETE DENTURE REHABILITATION IN ECTODERMAL DYSPLASIA PATIENTS There are a lot of conditions which cause anodontia in patients and warrant the need of complete denture re­habilitation in pedodontics. The most important and commonly encountered condition is ectodermal dys­plasia. The term “ectodermal dysplasias” indicates a heterogeneous group of hereditary diseases involving the epidermis and its appendages. Freire-Maia-Pinheiro have described 154 patterns of ectodermal dysplasias, divided them into 11  subgroups, and then classified them according to the involved structures (the hair, the teeth, some or all of the sweat glands). The most frequent form is the ChristSiemens-Touraine syndrome, a recessive autosomal disorder characterized by an anomalous development of the ecto­ dermal structures and depending on the severity of clinical manifestations, it can be classified as hypo­hidrotic ectodermal dysplasia, or as anhydrotic ectodermal dysplasia. The hypohidrotic-anhidrotic type, or Christ-Sie­mensTouraine syndrome was first described in 1848 by Thurman, and is characterized by the triad of hypotrichosis (skin, hair and nail anomalies), either hypodontia, or anodontia and hypohidrosis (partial or total absence of exocrine sweat glands) and other features such as frontal bossing, saddleshaped nose, everted lips, etc. The hidrotic type was first defined in 1929 by Clouston and is distinguished by hypo­tri­ chosis, lingual dystrophy and hyperkeratosis of the palms and soles. The etiology of this disease is unknown; never­theless genetic studies showed ectodermal dysplasia is due to a mutation of the gene “EDA” (Ectodermal dysplasias anhidrotic). This gene is located in posi­tion q12 to q13 of the chromosome X. The EDA gene enco­ des a predicted transmembrane protein of 135 amino acids found to be expressed in keratinocytes, hair follicles, and sweat glands. The mutation responsible for ectodermal dysplasia has been thought to be attributed to a change in the histidine/tyrosine in position 54 of the protein. Another mutation (A1270G) has also been revealed to be responsible for Tyr343Cys substitu­ tion in a patient with anhydrotic ectodermal dysplasia.

Clinical Signs • • • •

Trichondrodysplasia (abnormal hair) Abnormal dentition Onchondysplasia (abnormal nails) Dyshidrosis (abnormal or missing sweat glands).

Manifestations • The skin is usually dry, scaly, and easily irritated as a result of poorly developed or absent oil glands.

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• Sweat glands can be absent, few in number, or non­ functioning which may result in a high body temperature. • Scalp hair may be absent, sparse, very fine pigmented, or abnormal in texture. Eyebrows, eyelashes, and other body hair may also be sparse or absent. When hair is present, it may be fragile, dry, and generally unruly because of the lack of oil glands. • Recurrent ocular infections • Chronic rhinitis • Dystrophic nails • Epistaxis • Dysphagia • Dysphonia • Alopecia • Extramedullary hematopoiesis of cranial dura • Diminished resistance to respiratory infections • Nasopharyngeal rhabdomyosarcoma • Supraorbital ridges, frontal bossing, and a saddle nose • The nose may appear pinched and the alahypoplastic • Dental features include: Complete or partial anodontia of the primary and permanent dentition, malformation of teeth, peg-shaped incisors and canines, primary second molar tooth, if present, is mostly affected by taurodontism, absence or deficiency of alveolar ridges, reduced vertical dimension, vermilion border disappears, maxilla may be underdeveloped and the lips thick and prominent. The oral rehabilitation of these cases is often difficult, and patients must be attentively followed by a multidisciplinary team involving pediatric dentistry, orthodontics, prosthodontics, and oral-maxillofacial surgery. The patient’s age, the pattern of dysplasia, and the morphology of the alveolar ridges influence dental treatment. Following factors should be considered when constructing complete dentures in a child: • Patients using dentures during growth years must be examined periodically (at least once a year, to assess the need to reline/rebase or remake depending on the fit). It has been observed that the dentures need to be relined every 2 to 4 years, while they need replacement every 4 to 6 years. The number of reline procedures necessary is directly related to the growth patterns of the child. • As permanent teeth erupt, the dentures must be relieved internally to accommodate them. • Once full growth of the patient takes place, it has been noticed that the dentures function well for about 10 years. • It has been seen that mandibular dentures fracture at the midline due to its shape to accommodate the narrow anterior mandibular ridge. Thus the acrylic resin in this region needs to be thick enough to resist fractures. • It can be very challenging to make a preliminary diagnostic impression in a child due to limited mouth opening and developing swallowing mechanisms. It has been recommended to make the mandibular impression

and then the maxillary impression in order to decrease anxiety in a child. The usage of higher viscosity and fast setting irreversible hydrocolloid material is helpful in preventing aspiration of the impression material. The impression of the mandibular arch is recommeded before the maxillary to avoid gagging. • Various impression materials such as irreversible hydrocolloid, polysulfide rubber base, and vinyl polysiloxane have been described in the literature. Some clinicians have used border molding techniques, using a warm green stick compound prior to making the final impression. However, this technique has limited advantages for a child because of the requisite time, patient discomfort related to the procedure, and potential risk of thermal injury. • Jaw relations: In case of young children, recording jaw relations may be difficult as neuromuscular development is completed only by seven years. • Teeth selection and arrangement: Sometimes adult incisor teeth can be incorporated to simulate a mixed dentition.

Chapter 72  Prosthodontic Management of Pediatric Patient Selection of posterior teeth molds is done based on the arch size and space availability. It has been recommended to use monoplane occlusion due to its simplicity and freedom of mandibular movement for the growing child. Attention must be paid to incorporating this spacing to make the prosthesis look natural and age appropriate. It has also been advocated to incorporate an orthodontic arch wire in the denture prosthesis to simulate a “normal” appearance.

OVERDENTURES IN CHILDREN • Overdenture is defined as any removable dental prosthesis that covers and rests on one or more remaining natural teeth, roots of natural teeth and/or implants. • It is a complete or a partial removable denture supported by retained roots to provide support, stability, tactile and proprioceptive sensation. • The retained roots or teeth are called ad abutments and are treated to receive the overdenture. The abutments usually require intentional endodontics as the coronal structure is reduced to receive the denture.

Advantages • Presence of abutments preserves bone and improves proprioception. • As the support is derived from the abutments and the denture bearing mucosa, the stability and retention of the dentures is superior compared to conventional dentures. • Masticatory efficiency is markedly increased.

• Improved speech. • Increased psychological support for the patient.

Disadvantages • It requires more clinical settings thus greater cooperation from the child. • It is more expensive treatment compared to conventional dentures as abutments need to be treated.

Complications • Abutment teeth prone to decay • Patient compliance is must • Recall of 6 months must be done to reevaluate the need of reline or refit.

OBTURATORS • An obturator is a disc or plate, natural or artificial, which closes an opening or defect of the maxilla as a result of a cleft palate or partial or total removal of maxilla for a tumor mass (Chalian 1971). • It is derived from a Latin word Obturare meaning to stop up).

Indications • To act as a framework over which tissues may be shaped by the surgeon • To serve as a temporary prosthesis during the period of surgical correction • To restore a patient’s cosmetic appearance rapidly for social contacts

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• When surgical primary closure is contraindicated as the patient’s age contraindicates surgery • When the local avascular condition of the tissues contraindicates surgery • When the patient is susceptible to recurrence of the original lesion which produced the deformity.

Uses • For feeding purposes • It may be used to keep the wound or defective area clean and may enhance the healing of traumatic or postsurgical defects • It may help to reshape and reconstruct the palatal contour and/or soft palate • It improves speech or, in some instances makes speech possible. In the impression area of esthetics, the obturator can be used to correct lip and cheek contour • It can benefit the morale of patients with maxillary defects. • When deglutition and mastication are impaired, it can be used to improve function • It reduces the flow of exudates into the mouth • The obturator may be used as a stent to hold dressings or packs postsurgically in maxillary resec­tions. It reduces the possibility of postoperative hemorrhage, and maintains pressure either directly or indirectly on split thickness skin grafts, thus causing close adaptation of the graft to the wound which prevents the formation of a hematoma and ultimate failure of the graft.

Types of Obturator • Feeding obturator: Used to cover maxillary defects in newborns to aid in feeding and suckling • Surgical obturator: Given after surgery to aid in wound healing, hold dressings, maintain pressure on split thickness skin grafts • Functional obturator: To help in deglutition • Speech obturator: (Speech aid prosthesis, naso­pharyngeal obturator, speech appliance, prosthetic speech aid, speech bulb). A temporary or interim prosthesis used to close a defect in the hard and/or soft palate to replace tissue lost due to develop­mental or surgical alterations which is necessary for the production of intelligible speech.

MAXILLOFACIAL PROSTHESIS It is God given right of every human being to appear human. Few areas of dentistry offer more challenges to the technical skills or greater satisfaction for the successful rehabilitation of function and esthetics in the patient with gross anatomic defects and deformities of the maxillofacial region. Although remarkable advances in surgical management of oral and

facial defects but cannot be satisfactorily required by plastic surgery alone so. The demand for maxillofacial prosthetic devices for the rehabilitation of patients with congenital or acquired defects has intensified in recent years. Maxillofacial prosthetics is the art and science of anatomic, functional or cosmetic reconstruction by means of nonliving substitutes of those regions in the maxilla, mandible and face that are missing or defective because of surgical intervention, trauma, pathology or development or congenital malformation.

History of Maxillofacial Prosthetics • Early records indicate that artificial eyes, ears and nose were found on Egyptian mummies. • The Chinese also made facial restoration with waxes and resins of various types. • Tycho-Brache, a Danish astronomer in 16th century lost his nose in a duel and replaced it with an artificial nose made of silver and gold. • The London Medical Gazette of 1832 describes the case of the “Gunner with silver mask” French soldier whose face was seriously injured in battle.

Objectives of Maxillofacial Prosthetics The most important objectives of maxillofacial prosthetics and rehabilitation include: • Restoration of esthetics or cosmetic appearance of the patient • Restoration of function • Protection of tissues • Therapeutic or healing effect • Psychologic therapy.

Types of Maxillofacial Prosthetics • Nasal prosthesis: A removable prosthesis which artificially restores a missing nose. • Orbital prosthesis: A removable replacement of the contents and surrounding structures of the eye socket. • Ocular prosthesis: An artificial replacement for a missing or damaged eyeball. • Auricular prosthesis: A removable prosthesis which artificially restores a missing ear. • Midfacial prosthesis: A large removable prosthesis which restores a defect in the middle third of the face which may include upper jaw, lip, nose, and orbit. • Somato prosthesis: A prosthesis that replaces external parts of the body such as fingers, breasts, and soft tissue defects. • Implant craniofacial prosthesis: Also known as a skull plate, it is a permanently implanted replace­ment for a portion of the skull (auricular, nasal, orbital, etc.).

Chapter 72  Prosthodontic Management of Pediatric Patient • Obturators for hard and soft palate defects: A pros­thesis used to replace a missing portion of the hard palate or the soft palate. • Mandibular resection prosthesis: A prosthesis that replaces a missing portion of the jaw and teeth. • Cleft palate prosthesis: A prosthesis which can improve speech and eating ability by obturating a palatal cleft or fistula. • Palatal augmentation prosthesis: A prosthesis used for patients with a partially removed tongue or lower jaw and who have difficulty lifting the ton­ gue to positions that would allow for more normal speech and swallowing. • Speech aid prosthesis: A prosthesis used to improve speech in neurologic impairment. • Trismus appliance: Prosthesis that assist in increasing the mouth opening.

 dvantages of Maxillofacial A Prosthetics The maxillofacial prosthetic approach has three main advant­ ages. • It requires little surgery or no surgery. • The patient spend less time away from home and job • Reconstruction is often more natural looking.

Disadvantages of Maxillofacial Prosthetics • The necessity of fastening the appliance to the skin and removing it everyday • The occasional need of constructing a new pros­thesis.

POINTS TO REMEMBER • There are many issues which still affect and cause loss of teeth in children such as trauma, neoplasm, systemic disorders, infection, congenital abnormalities such as clefts or inborn defects such as ectodermal dysplasia. • Resin bonding procedures and porcelain laminate veneers, whenever possible should be considered as the treatment of first choice. • All ceramic crowns are the most esthetic complete coverage restorations currently available in dentistry. • Teeth that donot have sufficient coronal structure, post with core build-ups should be done • The most important and commonly encountered condition is ectodermal dysplasia, which causes anodontia in patients. • An obturator is a disc or plate, natural or artificial, which closes an opening or defect of the maxilla as a result of a cleft palate or partial or total removal of maxilla for a tumor mass (Chalian 1971).

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8.

Explain the crowns used for permanent anterior teeth rehabilitation. Describe post and core fabrication in detail. Write a note on removable partial denture. What are the indication, advantage and techniques for fixed partial denture? What is the rationale for use of overdentures in children? Explain the dental rehabilitation of a child with ectodermal dysplasia. Describe obturators. Classify the various types of maxillofacial prosthesis.

BIBLIOGRAPHY 1. Beumer J III, Curtis TA, Firtell DN. Maxillofacial Rehabilitation Prosthodontic and Surgical Consideration. Mosby, St Louis; 1979. pp.286-7. 2. Hickey AJ, Vergo JT. Prosthetic treatments for patients with ectodermal dysplasia. J Prosthet Dent. 2001;8:364-8. 3. Itthagarun A, King NM. Ectodermal dysplasia: a review and case report. Quintessence Int. 1997;28:595-602. 4. Pigno MA, Blackman RB, Cronin RJ, Cavazos E. Prosthodontic management of ectodermal dysplasia: a review of literature. J Prosthet Dent. 76;541-5. 5. Rahn AO, Boucher LJ. Maxillofacial Prosthetics Principles and Concepts. WB Saunders, Toronto; 1970.pp.215-7. 6. Shobha Tandon Textbook of Pedodontics, 2nd Edn, CH: Pediatric Prosthodontics. Paras Publication, Hyderabad. 2008.pp.704-20. 7. Taylor TD. Clinical Maxillofacial Prosthetics. Quintessence Pub Chicago; 2000.pp.129-31.

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15

SECTION

PEDIATRIC ORAL PATHOLOGY

The focus of this unit is on the developmental and acquired anomalies of dentition and on the common syndromes and conditions which may affect children.

73

CHAPTER

Developmental Anomalies of Dentition Nikhil Marwah, Parvind Gumber

Chapter outline • •

Developmental Anomalies of Number Developmental Anomalies of Size

Malformations or defects resulting from disturbance of growth and development are known as developmental anomalies. A large number of such developmental anomalies, which involve the body in general and oral structure in particular can occur during the embryonic life.

TYPES OF DEVELOPMENTAL ANOMALIES Congenital anomalies: The defects, which are present at or before birth during the intrauterine life. Hereditary developmental anomalies: When certain defects are inherited by the offspring from either of the parent, it is called hereditary developmental anomalies. Such types of anomalies are always transmitted by genes.

• •

Developmental Anomalies of Shape Developmental Anomalies of Structure

Idiopathic anomalies: Developmental anomalies of unknown cause. Developmental anomalies of denƟƟon Number

AnodonƟa HypodonƟa HyperdonƟa

Size

MicrodonƟa MacrodonƟa

PosiƟon

TransposiƟon

Shape

GeminaƟon Fusion Concrescence Accessory cusps Dens invaginatus Ectopic enamel TaurodonƟsm Hypercementosis Accessory roots DilaceraƟon

Structure

Amelogenesis imperfecta DenƟnogenesis imperfecta Regional odontodysplasia

Acquired anomalies: Developed during intrauterine life due to some pathological environmental conditions. They are not transmitted through genes. Hamartomatus anomalies: A hamartoma can be defined as an excessive, focal overgrowth of mature, normal cells and tissues, which are native to that particular anatomic location.

896 Section 15

Pediatric Oral Pathology

Name of anomaly Anodon a (Fig. 73.1)

DefiniƟon Total lack of tooth development

Hypodon a (Fig. 73.2)

Lack of development of one or more teeth

Oligodon a (Fig. 73.3)

More than 6 teeth are missing

Hyperdon a (Supernumerary teeth) (Figs 73.4 to 73.8)

Development of addi onal teeth in addi on to normal den on

Types of supernumerary teeth According to the site • Mesiodens • Distomolar • Paramolar • Extralateral incisor According to morpology • Conical type • Tuberculate type • Supplemental type • Odontoma associated

Fig. 73.1: Anodon a

Anomalies of number EƟology Clinical features Treatment • Gene c • No teeth are present Prosthe c • Lack of alveolar growth rehabilita on • Associated with ectodermal dysplasia Prosthe c and • Prevalence is 3 to 8% • Gene c orthodon c • Female dominance • Hereditary rehabilita on • Less than 1% in deciduous den on • Associated with • Predominance is 3rd molars > 2nd premolars syndromes > lateral incisors • Gene c • Rare in primary den on Prosthe c and • Hereditary • Mul ple missing teeth from either arch orthodon c • It can result in collapse of arch and dri ing due rehabilita on to excess space Extrac on of • Prevalence is 1 to 3% • Gene c supernumerary • 80% associated with single tooth hyperdon a • Hereditary tooth followed • Occurs mostly in permanent den on in • Associated with by orthodon c maxillary anterior region syndromes rehabilita on • Male predominance • Develop as a • Supernumerary in maxillary anterior region is consequence of called as mesiodens, in 4th molar region it is prolifera on of distomolar and if it is buccal to molars it is called epithelial cells from as paramolar dental lamina • Frequent cause of crowding type of malocclusion Syndromes associated with hypodonƟa Syndrome associated with hyperdonƟa • Cleidocranial dysplasia • Down’s syndrome • Down syndrome • Ectodermal dysplasia • Ehlers-Danlos syndrome • Turner’s syndrome • Oral facial digital types I and III • Robinson syndrome • Nance-Horan syndrome • Octodental dysplasia • Focal dermal hypoplasia • Sturge-Weber syndrome • Oral facial digital types I

Fig. 73.2: Hypodon a

Chapter 73 Developmental Anomalies of Dentition

Fig. 73.3: OligodonƟa

Fig. 73.4: Supernumerary teeth

Fig. 73.5: Extracted supernumerary teeth

Fig. 73.6: Supernumerary teeth in primary denƟƟon

Fig. 73.7: Inverted mesiodens

Fig. 73.8: MulƟlobed supernumerary teeth

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898 Section 15

Pediatric Oral Pathology

Name of anomaly Transposi on (Fig. 73.9)

DefiniƟon Erup on of normal teeth in an inappropriate posi ons

Name of anomaly Microdon a (Fig. 73.10)

DefiniƟon Teeth that are usually smaller than normal

Macrodon a (Fig. 73.11)

Teeth that are bigger than average size for the specific age

Anomalies of posiƟon EƟology Retained deciduous teeth or loss of space

Clinical features • Maxillary canine and premolars are involved • It may cause crowding

Treatment Orthodon c rehabilita on

Anomalies of size EƟology Clinical features • Gene c • Associated with hypodon a, Down’s • Hereditary syndrome • Environmental • Prevalence is 0.8 to 8% • Maxillary lateral incisor called as peg lateral is most affected • Mesiodistal diameter is reduced • Gene c • Hereditary • Environmental

• Associated with hyperdon a • Usually incisors are involved • Frequent cause of crowding

Fig. 73.9: Transposi on

Fig. 73.10: Microdon a

Fig. 73.11: Macrodon a

Treatment Porcelain crowns can be provided

Prosthe c and orthodon c rehabilita on

Chapter 73 Developmental Anomalies of Dentition

Name of anomaly Fusion (Figs 73.12 to 73.14)

DefiniƟon Tooth fusion is defined as union between the den n and/or enamel of two or more separate developing teeth

Gemina on (Figs 73.15 and 73.16)

Abor ve a empt by the single tooth bud to divide, with the resultant forma on of bifid crown and common root

Concrescence (Fig. 73.17)

Union of teeth by cementum alone without confluence of den n

Accessory cusp (Fig. 73.18)

Cuspal morphology of teeth exhibit minor varia ons among different popula ons

A

Anomalies of shape EƟology Clinical features • The fusion may be par al or total Shafer – pressure depending upon the stage of tooth produced by physical development at the me of union: force prolongs fusio-totalis, par alis-coronaries and the contact of the par alis-radicularis developing teeth • If the contact occurs before the causing fusion calcifica on stage, the teeth unite Lowell and Soloman completely and form one large tooth physical ac on •  Incomplete fusion may be at root causes the tooth level if the contact and union occurs germs to come a er forma on of crown into contact, thus •  Prevalence of 0.5–2.5% producing necrosis •  Most commonly occurs in primary of the intervening teeth with more predilec ons for ssue, allowing the anterior teeth enamel organ and •  Radiographically, the den n of fused dental papilla to fuse teeth always appears to be joined together in some region with separate pulp chambers and canals • Gene c • More frequently in the primary • Hereditary den on • Environmental • Prevalence of 1% • Predilec on in maxillary primary incisors and canine • Two teeth joined in coronal aspect but with single root and single root canal Environmental • Two separate teeth joined by cementum • Posterior maxillary region is favored

Unknown

Treatment • It may cause malocclusion • Restora ve, periodontal and endodon c considera ons are needed before proceeding with any type of treatment

• It may cause malocclusion • Restora ve, periodontal and endodon c considera ons are needed before proceeding with any type of treatment • No treatment required if pa ent is asymptoma c • Extrac on if it interferes with erup on of succeeding tooth Extra cusp like structure seen on palatal • No treatment cusp in maxillary and on lingual cusp in mandibular

B Figs 73.12A and B: Fusion of triple teeth

Fig. 73.13: Bilateral fusion of teeth

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Pediatric Oral Pathology

Fig. 73.14: Fusion in primary and permanent teeth

Fig. 73.15: GeminaƟon in primary teeth

Fig. 73.16: Extracted geminated teeth

Fig. 73.17: Concrescence

Fig. 73.18: Accessory cusp

Chapter 73 Developmental Anomalies of Dentition Anomalies of shape Name of anomaly

DefiniƟon

EƟology

Clinical features

Treatment

• Prevalence is 0.06 to 7.7% • The anomaly also appears to be more prevalent in pa ents with Rubinstein-Taybi syndrome, Mohr syndrome and SturgeWeber syndrome • Lateral incisors followed by central incisors and canines are affected • Pulp horn may project from the cusp • Compromised esthe cs, occlusal interference, carious developmental grooves, displacement of teeth, periodontal problems, irrita on of the tongue and diagnos c problems • This may contain enamel, den n, pulp like normal tooth • Radiographically pulp extension can be seen • Mostly on molars or maxillary incisors • May cause occlusal problems • 1 to 10% • Predominance is lateral incisor > central incisors > premolars > molars • It can be of coronal or radicular type • Type 1 confined to crown • Type 2 extends below CEJ • Type 3 extends ll root • Extends inside tooth giving it tooth in a tooth (dens in dente) appearance • 1st molar • Deep groove may predispose to caries

• Gradual reduc on with fluoride applica on as desensi zing agent • Single appointment reduc on with or without pulp therapy • Sealant applica on in the dental grooves • Par al reduc on with composite camouflage

Talon’s cusp (Figs 73.19 and 73.20)

Presence of an accessory cusp like structure projec ng from cingulum area of cementoenamel junc on (CEJ)

During the morphodifferen a on stage of tooth development as an outward folding of inner enamel epithelial cells and transient focal hyperplasia of peripheral cells of mesenchymal dental papilla

Dens evaginatus (Fig. 73.21)

Cusp like eleva on of enamel in central groove

Dens invaginatus (Dens in dente) (Fig. 73.22)

Deep surface invagina on of crown lined by enamel

Prolifera on and evagina on of an area of IEE and adjacent mesenchyme into the enamel organ during tooth development Invagina on of crown filled with so ssue like dental follicle and on erup on this loses its blood supply and turns necro c

Cusp of Carabelli (Fig. 73.23)

Accessory cusp located Unknown on palatal surface of mesiolingual cusp of maxillary molar Presence of enamel Localized bulging of in unusual loca on odontoblas c layer that provides excess contact between HERS and den n triggering induc on of enamel forma on

Ectopic enamel (Enamel pearl) (Fig. 73.24)

Taurodon sm (Fig. 73.25)

Enlargement of body and pulp chamber of mul rooted teeth with apical displacement of pulpal floor

It may be as result of chromosomal abnormality or associated with a syndrome

Hypercementosis (Fig. 73.26)

Non-neoplas c deposi on of excessive cementum

• Hereditary factor • Abnormal occlusal trauma • Nonantagonist teeth

• It may contain only enamel or may even have pulp • Mostly seen on roots of maxillary molars • Prevalence of 1 to 9% • Seen in furca on or CEJ area • Radiographically appear as circular well defined area of radiodensity • Plaque reten ve area • Tauro-bull, do not-teeth • Pulp chambers are large with decreased bifurca on of roots • Mostly in molars • Radiographic iden fica on • It can be of three types: 1. Mild—hypotaurodon sm 2. Modrate–mesotaurodon sm 3. Severe—hypertaurodon sm • Thickening of root • Localized or generalized • Increases with age • Associated with Paget’s disease, acromegaly, calcinosis

Selec ve reduc on with subsequent pulp therapy to remove the cusp and keep the teeth on posi on Depending on type of dens invaginatus treatment can be restora ve or pulp therapy

No treatment un l groove is deep, may need restora ve interven on Me culous hygiene and periodontal preven on is must

Endodon c therapy has to be done carefully because of the dimensions of the chamber

No treatment is needed but such teeth may have to be sec oned during exodon a Contd...

901

902 Section 15

Pediatric Oral Pathology

Contd...

Anomalies of shape Name of anomaly

DefiniƟon

EƟology

Dilacera on (Fig. 73.27)

Abnormal angula on of root or crown of a tooth

Injury to calcified por on of tooth germ during development

Supernumerary roots (Fig. 73.28)

Development of increased number of roots compared to normal

Unknown

Clinical features

Treatment

• Maxillary incisors are most affected • Treatment depends • Rare in primary teeth upon the degree of • Teeth may have altered path of erup on, dilacera ons can be associated with periapical lesions or • Small devia on may be impacted needs no treatment • Larger devia on may indicate the need for hemisec on or even extrac on Permanent den on and molars are most No treatment is affected required but during endodon c therapy due considera on has to be given to the presence of such roots

Fig. 73.19: Talon’s cusp

Fig. 73.20: Talon’s cusp on supernumerary teeth

Fig. 73.21: Dens evaginatus

Fig. 73.22: Dens invaginatus

Chapter 73 Developmental Anomalies of Dentition

Fig. 73.23: Cusp of Carabelli

Fig. 73.24: Enamel pearl

Fig. 73.25: TaurodonƟsm

Fig. 73.26: Hypercementosis

Fig. 73.27: DilaceraƟon

Fig. 73.28: Supernumerary roots

903

904 Section 15

Pediatric Oral Pathology Anomalies of structure (Den n)

Name of anomaly

Defini on

Den nogenesis imperfecta (Cap De Pont’s teeth) (Fig. 73.29)

Defec ve den n forma on in the absence of any systemic disease

Den n dysplasia (Rootless teeth) (Fig. 73.30)

Regional odontodysplasia (Ghost teeth) (Fig. 73.31)

E ology

Clinical features

Treatment

Autosomal dominant

• More in whites • More in deciduous teeth • Molars and incisors are most affected • Blue to brown discolora on with translucence • Accelerated a ri on • Thin and early obliterated pulp chamber and canals • Type 1 osteogenesis imperfecta with opalescent teeth • Type 2 hereditary isolated opalescent teeth • Type 3 Brandywine isolated opalescent teeth • Altered den n, which may be due to anomaly of matrix or structure or mineraliza on

Full coverage crowns, overlays are best op on because of enhanced a ri on, thin den n and more chances of pulp exposure and tooth fracture

Loss of organiza on of root den n

Autosomal dominant

• Enamel and coronal den n is formed normally but radicular den n loses its organiza on and shortens • No detectable roots or pulp • Mobility is a feature • Permanent teeth are affected

Preven ve strategy is of most importance owing to the structure of these teeth. In case of endodon c therapy it can only be done in short roots but the rootless teeth have to undergo extrac on due to loss of support

Localized, hereditary developmental anomaly with adverse effects on enamel, den n, pulp

• Abnormal migra on of neural crest cells • Local circulatory deficiency • Local trauma or infec on • Hyperpyrexia • Malnutri on • Medica on during pregnancy

• Occurs in both den on • Bimodal peak at 2–4 years and 7–11 years • More in anterior teeth • Teeth fail to erupt or erupt with yellow to brown discolora on and other enamel defects • Den nal cle and long pulp horns are present • Radiographically tooth shows as thin enamel and den n with large pulp thereby giving it a floa ng appearance called ghost tooth • Associated with syndromes like nevi, ectodermal dysplasia, neurofibromatosis

• Therapy is to retain the altered teeth and to allow for development of arch • Unerupted teeth are not touched • Crowns can be given • Endodon c therapy in exposed teeth

Classifica on of den nogenesis imperfecta Shields

Clinical presenta on

Witkop

Den nogenesis imperfecta I

Osteogenesis imperfecta with opalescent

Den nogenesis imperfecta

Den nogenesis imperfecta II

Isolated opalescent teeth

Hereditary opalescent teeth

Den nogenesis imperfecta III

Isolated opalescent teeth

Brandywine isolate

Modified classifica on of hereditary disorders affec ng den n Disorder

Inheritance

Involved Gene or Genes

Osteogenesis imperfecta with opalescent teeth

Autosomal dominant or recessive

COL 1A1, COL1A2

Den nogenesis imperfecta

Autosomal dominant

DSPP

Den n dysplasia type I

Autosomal dominant

Den n dysplasia type II

Autosomal dominant

DSPP Contd...

Chapter 73 Developmental Anomalies of Dentition Contd...

DDIa DDIb DDIc DDId

Sub-classificaƟon of denƟn dysplasia type I No pulp chambers, no root formaƟon, and frequent periapical radiolucencies A single small horizontally oriented and crescent-shaped pulp, roots only a few millimeters in length, and frequent periapical radiolucencies Two horizontally oriented and crescent-shaped pulpal remnants surrounding central islands of denƟn, significant but shortened root length, and variable periapical radiolucencies Visible pulp chambers and canals, near normal root length, enlarged pulp stones that are located in the coronal porƟon of the canal and create a localized bulging of the canal and root, constricƟon of the pulp canal apical to the stone, and few periapical radiolucencies

Mild

Severe

Fig. 73.29: DenƟnogenesis imperfecta

Fig. 73.31: Regional odontodysplasia

Fig. 73.30: DenƟn dysplasia

905

906 Section 15

Pediatric Oral Pathology

Name of anomaly Amelogenesis imperfecta (Fig. 73.32)

Defini on

E ology

Complicated group of condi ons that demonstrate developmental altera ons in structure of enamel in absence of systemic disease

Autosomal dominant or recessive depending on subtype

Type IA IB IC ID IE IF IG IIA IIB IIC IID IIIA IIIB IVA IVB

Anomalies of structure (Enamel) Clinical features HypoplasƟc AI • Generalized pa ern: – Inadequate deposi on of enamel matrix – Pits are present on teeth – Buccal surfaces are affected and enamel is normal • Localized pa ern: – Large area of hypoplas c enamel surrounded by zone of hypocalcifica on – Only middle third of buccal surface is involved – Mostly primary teeth are affected • Smooth pa ern: – Enamel is smooth surfaced, thin, hard and glossy – Teeth are small like post crown prepara on • Rough pa ern: – Enamel is thin hard and rough surfaced – Yellow to white color – Open contacts present HypomaturaƟon AI • General: – Enamel matrix is laid down normally and begins mineraliza on but fails to mature – Teeth exhibit mo led brown discolora on – Enamel is so and chips away • Pigmented pa ern: – Surface enamel is mo led and deep brown – Excessive calculus deposi on – Enamel chips away and den n is so and can be punctured • X-linked pa ern: – Deciduous teeth are opaque white with translucent mo ling – Permanent teeth are yellow but darken with age – Enamel is chipped away leaving brown discolora on • Snow capped pa ern: – Exhibit zone of opaque enamel on incisal third – Both den ons are affected Hypocalcified AI – Enamel matrix is laid down but mineraliza on does not occur – On erup on enamel is yellow to orange and is gradually discolored – Teeth usually erupt as in normal shape but tend to fracture as they are so – Over a period of me only cervical aspect of enamel of tooth remains

Classifica on of amelogenesis imperfecta Specific features Hypoplas c Generalized pi ed Hypoplas c Localized pi ed Hypoplas c Localized pi ed Hypoplas c Diffuse smooth Hypoplas c Diffuse smooth Hypoplas c Diffuse rough Hypoplas c Enamel agenesis Hypomatura on Diffuse pigmented Hypomatura on Diffuse Hypomatura on Snow capped Hypomatura on Snow capped Hypocalcified Diffuse Hypocalcified Diffuse Hypomatura on-hypoplas c Taurodon sm present Hypoplas c-hypomatura on Taurodon sm present Pa ern

Treatment Treatment varies according to the type of AI but focus is on loss of ver cal dimension, endodon c therapy, esthe cs

Inheritance Autosomal dominant Autosomal dominant Autosomal recessive Autosomal dominant X-linked dominant Autosomal dominant Autosomal recessive Autosomal recessive X-linked recessive X-linked Autosomal dominant Autosomal dominant Autosomal recessive Autosomal dominant Autosomal dominant Contd...

Chapter 73 Developmental Anomalies of Dentition

Fig. 73.32: Amelogenesis imperfecta

Contd...

Inheritance Autosomal dominant Autosomal dominant Autosomal dominant Autosomal dominant Autosomal dominant Autosomal recessive Autosomal recessive Autosomal recessive Autosomal recessive X-linked X-linked X-linked

Modified classificaƟon of amelogenesis imperfecta Phenotype Generalized pi ed Localized hypoplas c Generalized thin Hypocalcifica on With taurodon sm Localized hypoplas c Generalized thin Pigmented hypomatura on Hypocalcifica on Generalized thin Diffuse hypomatura on Snow-capped hypomatura on

Related Genes ENAM ENAM DLX3

MMP20, KLK4 AMELX AMELX

POINTS TO REMEMBER •

• •

• •

Anomalies of number: Anodontia, hypodontia, hyperdontia; Size: Microdontia, macrodontia; Position: Transposition; Shape: Gemination, fusion, concrescence, accesory cusps, dens invaginatus, ectopic enamel, taurodontism, hypercementosis, accessory roots, dilaceration; Structure: Amelogenesis imperfecta, dentinogenesis imperfecta, regional odontodysplasia. Fusion is joining of two tooth buds, germination is attempt of tooth bud to split into two and concrescence is joining of two teeth by cementum. Talon’s cusp is an accessory cusp like structure projecting from cingulum area of cementoenamel junction. Lateral incisors followed by central incisors and canines are most affected. Treatment is gradual reduction with fluoride application as desensitizing agent. Taurodontism is enlargement of body and pulp chamber of multirooted teeth with apical displacement of pulpal floor. Dentinogenesis imperfecta is defective dentin formation in the absence of any systemic disease. It is an autosomal dominant trait and is found more in white, primary teeth, molars and incisors. Clinical picture of these teeth ranges from blue to brown discoloration with translucence.

907

908 Section 15 • •

Pediatric Oral Pathology

Dentin dysplasia is characterized as rootless teeth as enamel and coronal dentin are formed normally but radicular dentin loses its organization and shortens. Amelogenesis imperfecta is a complicated group of conditions that demonstrate developmental alterations in structure of enamel in absence of systemic disease. It is of three types: Hypoplastic (Inadequate deposition of enamel matrix), Hypomaturaion (Enamel matrix is laid down normally and begins mineralization but fails to mature) and Hypocalcified (Enamel matrix is laid down but mineralization does not occur).

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7.

Classify developmental anomalies of dentition and explain anomalies of number. Write a note on supernumerary teeth. Differentiate between fusion, gemination and concrescence. Describe the developmental anomalies of shape. Explain taurodontism. What are the developmental anomalies of dentinal structure? Give the classification, etiology and clinical features of amelogenesis imperfecta.

BIBLIOGRAPHY 1. Andreason JO. The effect of traumatic injuries to primary teeth on their permanent successor. Scand J Dent Res. 1971;145:229. 2. Chosack A, Edelmann E, Wisotski I, Choen T. Amelogenesis imperfecta among israel jews and the description of a new type of local hypoplastic autosomal recessive amelogenesis imperfecta. Oral Surg. 1979;47:148. 3. Chow MH. Natal and neonatal teeth. J Am Dent Assoc. 1980;100(2):215-6. 4. Mena CA. Taurodontism. Oral Surg Oral Pathol Oral Med. 1971;32:812-23. 5. Thomas JG. A study of Dens-in-dente. Oral Surg Oral Pathol Oral Med. 1974;38:653. 6. Thérèse Garvey M, Hugh J Barry, Marielle Blake. Supernumerary teeth: an overview of classification, diagnosis and management. J Can Dent Assoc. 1999;65:612-6. 7. Witkop CJ Jr. Amelogenesis imperfect, dentinogenesis imperfect and dentinal dysplasia revisited: problems in classification. J Oral Pathol. 1988;17:547-53.

74

Chapter

Common Orofacial Syndromes in Children Kshitij Rohilla

A syndrome is a group of signs and symptoms that occur together and characterize a particular abnormality or c­onditio­n. The number of syndromes affecting the human race is virtually countless. One subset of this group includes the syndromes which manifest primarily in the pediatric age group. Another subset includes those syndromes in which oral manifestations form a significant component of the clinical spectrum. The overlap zone of these two subsets includes the entities which this chapter deals with. This chapter outlines the important features of more commonly occurring syndromes and also those syndromes with some peculiar and/or characteristic features which hold historic/academic relevance. An arbitrary categorization of syndromes of the oral and maxillofacial region, aimed at a better understanding of the disease process, is as follows: • Chromosomal syndromes: – Trisomy 21 syndrome (Down syndrome) – Trisomy 13 (Patau) syndrome – Trisomy 18 (Edwards) syndrome – Turner syndrome – Klinefelter syndrome • Syndromes affecting bone: – Osteogenesis imperfecta – Skeletal dysplasias - Cleidocranial dysplasia - Infantile cortical hyperostosis (Caffey-Silverman syndrome) - Marfan syndrome - McCune-Albright syndrome – Craniotubular bone disorders - Osteopetrosis

•

•

•

•

•

•

•

– Chondrodysplasias and chondrodystrophies - Achondrogenesis - Achondroplasia - Ellis-van Creveld syndrome (Chondroectodermal dysplasia) Proportionate short stature syndromes: – Bloom syndrome – Rubinstein-Taybi syndrome Overgrowth syndromes and postnatal onset obesity syndromes: – Beckwith-Wiedemann syndrome [EMG (ExomphalosMacroglossia-Gigantism) syndrome] – Hemihyperplasia (Hemihypertrophy) Syndromes with craniosynostosis: – Apert syndrome (Acrocephalosyndactyly) – Crouzon syndrome (Craniofacial Dysostosis) – Carpenter syndrome (Acrocephalopolysyndactyly) – Pfeiffer syndrome Branchial arch and Oral-Acral disorders: Mandibulofacial dysostosis (Treacher-Collins syndrome, FranceschettiZwahlen-Klein syndrome) Orofacial clefting syndromes: – Van der Woude syndrome – Pierre-Robin syndrome Syndromes with unusual facies: – Noonan syndrome – Romberg syndrome (Progressive hemifacial atrophy) Syndromes with gingival/periodontal components: – Hyperkeratosis palmoplantaris and periodontoclasia in childhood (Papillon-Lefèvre syndrome).

910 Section 15 

Pediatric Oral Pathology Trisomy 21 (Down’s syndrome)

•  Described by Langdon Down in 1866 as a condition that he named “Mongolian idiocy” •  Most common and best known of all malformation syndromes •  Occurs in offspring of mothers of all ages, but the risk increases with increasing maternal age •  Three cytogenetics variants have been recognized: 1. Nondisjunction—95% 2. Unbalanced chromosomal translocation (arising de novo or being transmitted from one of the parents)—4.8% 3. Mosaicism—3% Clinical features: Fetal brain growth is delayed (infants commonly are microcephalic at birth). Newborn infants are frequently described as being “good babies” because they are not easily disturbed and cause their mothers very little trouble. Such traits probably reflect reduced response to external stimuli and marked hypotonia •  Mental retardation is considered to be a hallmark (IQ varies between 30 and 50) •  Very few patients are judged to be aggressive or hostile or to display other varieties of maladaptive behavior Growth and skeletal abnormalities: Prenatal and postnatal growth deficiency; also a tendency toward premature birth. Osseous maturation is significantly delayed Craniofacial features: Brachycephaly and flat occiput (cephalic index is usually > 0.80 and may exceed 1.00 (normal value is 0.75 to 0.80). •  Large fontanels exhibiting delayed closure •  Frontal and sphenoidal sinuses may be absent and maxillary sinuses may be hypoplastic •  Bony midface hypoplasia produces ocular hypotelorism, a small nose with flattening of the nasal bridge, and relative mandibular prognathism •  Upward slanting of palpebral fissures, epicanthic folds, Brushfield spots, fine lens opacities, convergent strabismus, nystagmus, keratoconus, and cataract •  The ears tend to be small and misshapen •  The lips are broad, irregular, fissured, and dry. An open mouth with a protruding tongue is observed. Relative macroglossia is observed, so is fissured tongue •  The palate is narrower and shorter but palatal height is not higher than that observed in the general population; it ‘appears’ high because it is narrow •  Articulation defects (pronunciation is often slurred, making speech incomprehensible) •  The voice is often hoarse, raucous and low pitched •  Periodontal disease has been observed in over 90% of cases. Severe involvement even below the age of 6 years is particularly common in the mandibular anterior and maxillary molar regions. Exfoliation of the lower central incisors from periodontal bone loss occurs frequently •  The prevalence of dental caries has been stated to be low by several authors, although these findings have been challenged by others •  Eruption of both deciduous and permanent teeth is delayed. An irregular sequence of eruption is common. Third molars, second premolars, and lateral incisors are most frequently absent in the permanent dentition •  Malalignment of teeth is common. Posterior crossbite, mandibular overjet, mesio-occlusion, anterior open bite, crowded teeth, and widely spaced teeth Other findings: Broad, short neck, umbilical hernia, hypogenitalia, cryptorchidism, short broad hands showing brachydactyly, single palmar crease, clinodactyly, hyperflexibility of joints Immune system: Immunodeficiency in Down’s syndrome is related to an increased susceptibility to infection, an increased risk for developing neoplasia, particularly leukemia, an increased frequency of autoantibodies, and early aging Trisomy 13 (Patau syndrome) •  Identified by Patau et al. in 1960, this syndrome is characterized by microcephaly, scalp defects, frequent holoprosencephaly, microphthalmia, orofacial clefting, congenital heart defects, polydactyly, severe developmental retardation, and early demise •  Mean life expectancy is 130 days. Approximately 45% die during the first month, 70% during the first 6 months, and 86% during the first year. Survival beyond 3 years is exceptional Growth: Failure to thrive

Chapter 74  Common Orofacial Syndromes in Children Central nervous system: Microcephaly, holoprosencephaly, apneic episodes, seizures, hypotonia, hypertonia, severe developmental retardation and presumptive deafness Craniofacial features: Scalp defects, sloping forehead, capillary hemangiomas, ocular hypotelorism, epicanthic folds, microphthalmia, iris coloboma, cleft lip, cleft palate, micrognathia and malformed ears Neck: Short neck, loose skin on the nape, nuchal translucency and fetal cystic hygroma Cardiovascular anomalies: Patent ductus arteriosus, ventricular septal defect, atrial septal defect, dextrocardia and coarctation of aorta Other findings: Inguinal/umbilical hernia, cryptorchidism, bicornuate uterus, polydactyly Trisomy 18 (Edward’s syndrome) •  Identified by Edwards et al. in 1960; features included growth deficiency, developmental retardation, prominent occiput, low-set malformed ears, micrognathia, short sternum, congenital heart defects, overlapped flexed fingers, dorsiflexed halluces and prominent calcaneus •  The median life expectancy for liveborn infants with trisomy 18 is 4 days with a range of 1 hour to 18 months Growth: Growth deficiency Central nervous system: Severe developmental retardation, hypertonia Craniofacial features: Microcephaly, dolichocephaly, prominent occiput, narrow palpebral fissures, small mouth, micrognathia, low-set and malformed ears Neck: Short neck and loose skin on the nape Other findings: Inguinal/umbilical hernia, cryptorchidism, short sternum, small pelvis, limited hip abduction, overlapped, flexible fingers, hypoplastic nails and syndactyly Turner’s syndrome •  In 1938, Turner recognized the syndrome that consists of short stature, streak gonads, webbed neck, shield chest, peripheral lymphedema at birth, coarctation of the aorta, hypoplastic nails, short metacarpals and multiple pigmented nevi •  Approximately, 98 to 99% of Turner’s syndrome fetuses are spontaneously aborted •  Minimal diagnostic criterion is an abnormal karyotype in which all or part of one of the X-chromosomes is absent. Most patients have gonadal dysgenesis and short stature Growth: Growth pattern could be divided into four phases: 1. Intrauterine growth retardation 2. Height development, which is normal up to a bone age of 2 year 3. Bone age of 2 to 11 years, when growth is markedly stunted; and 4. Bone age after 11 years when the growth phase is prolonged but total height gain is below normal Central nervous system: IQ may be reduced or even normal. Intelligence is normal. Several psychiatric disturbances have been reported, especially depression, low self-esteem and anorexia nervosa Head and neck abnormalities: •  Epicanthic folds, ptosis of the eyelids, prominent abnormal ears, and low hairline •  Visual abnormalities, particularly strabismus, and myopia •  Chronic suppurative otitis with resultant hearing loss •  Webbed neck. Excess skin on the nape of the neck in infants. Neck blebs or cystic hygromas during embryonic life •  High-arched palate with higher than normal frequency of cleft palate •  Premature eruption of teeth (first permanent molars appearing between 1.5 and 4 years of age) •  Increased molarization of premolars •  Reduced cusp height as well as crown size •  Micrognathia. Short cranial base, so the face is retrognathic •  Short mandible, maxilla being of normal length •  Midfacial hypoplasia, deepening of posterior cranial fossa and widely spaced mandibular rami Other findings: Gonadal dysgenesis, coarctation of the aorta, ventricular septal defect, hypoplastic nails, and multiple pigmented nevi

911

912 Section 15 

Pediatric Oral Pathology Klinefelter syndrome

Klinefelter et al. in 1942 reported postpubertal males with small testes, azospermia and gynecomastia. Classic Klinefelter syndrome is diagnosed most commonly at puberty, although rarely clinical clues may be evident in childhood Growth: Until 3 years of age, height distribution is unremarkable. In adulthood, typical Klinefelter individuals are of average or somewhat above-average height. Tall stature is primarily the result of increase in leg length, which is present before puberty but not particularly obvious Central nervous system and performance: Delayed speech, delays in emotional development, school maladjustment and poor gross motor coordination •  Average IQ is approximately 90 (Individuals are usually neither highly intelligent nor severely retarded) •  In adults, there may be disturbances of behavior, deviations in personality, neurotic and psychotic reactions, antisocial behavior, alcoholism, aggressiveness, depression, and periods of mania. Many Klinefelter individuals lead normal married lives Hormones: Leydig cells are defective; plasma testosterone is low in the presence of normal or high follicle-stimulating hormone (FSH) and leutinizing hormone (LH). Typically, patients have 50% or less of normal levels of plasma testosterone and a four-fold increase in urinary excretion of pituitary gonadotropin Craniofacial features: Cephalometric investigation shows smaller calvarial size, smaller cranial base angle, and larger gonial angle than normal. Both maxillary and mandibular prognathisms tend to occur. Permanent tooth crowns tend to be larger. Taurodontism has been reported in some instances Other findings may include microcephaly, cleft palate, “third” fontanel, nerve deafness, ear anomalies, down-slanting palpebral fissures, corneal opacity and strabismus Cleidocranial dysostosis •  First descriptions were those by Martin in 1765 and Meckel in 1760. Marie and Sainton, in 1897, named the syndrome “cleidocranial dysostosis” reporting the combination of aplasia or hypoplasia of one or both clavicles, exaggerated development of the transverse diameter of the cranium, and delayed ossification of fontanels •  The syndrome has autosomal dominant inheritance and occurs due to mutations were found in the Core-Binding factor A (CBFA1) gene which controls differentiation of precursor cells into osteoblasts Facies and general appearance: •  The appearance is generally pathognomonic. Affected individuals are usually short. Brachycephalic skull, pronounced frontal and parietal bossing, hypoplastic maxilla and zygomas; these features make the face appear small. The nose is broad at the base, with the bridge depressed. There is hypertelorism •  Neck appears long, and the shoulders are narrow and droop markedly •  Increased mandibular length, vertically short maxilla Cranium: Large and short skull with biparietal bossing, cephalic index > 80, delayed closure of the anterior fontanel and sagittal and metopic sutures, segmental calvarial thickening in the supraorbital portion of the frontal bone, the squama of the temporal bones and the occipital bone above the inion •  Presence of many wormian bones. Parietal bones may be absent at birth. Paranasal sinuses and mastoids often underdeveloped or absent •  Cranial base has short sagittal diameter. Large foramen magnum, with defects in the posterior wall Clavicle: Clavicles are absent unilaterally or bilaterally in about 10; more frequently, they are defective at the acromial end. Ability of the patient to approximate the shoulders in front of the chest, is remarkable Oral manifestations: •  High arched palate, submucous cleft palate, complete cleft of the hard and soft palates •  Delayed union at the mandibular symphysis is characteristic. Deficient ossification of the hyoid bone. Underdeveloped premaxilla, along with normal mandibular growth causes relative prognathism. Newborns may have prolonged feeding problems •  Multiple supernumerary teeth, multiple crown and root abnormalities, crypt formation around impacted teeth, ectopic localization of teeth, and lack of tooth eruption. The extra teeth are most often in the mandibular premolar and maxillary incisor areas. It is known that extraction of deciduous teeth does not promote eruption of permanent teeth. Roots lack a layer of cellular cementum •  Deciduous root resorption is extremely delayed or arrested, and can probably be explained by diminished bone resorption. Abnormalities of root morphology in the permanent dentition appear secondary to arrested eruption

Chapter 74  Common Orofacial Syndromes in Children Infantile cortical hyperostosis (Caffey-Silverman syndrome) •  Originally, described by Roske in 1930, but detailed by the clinical and radiographic studies of Caffey and Silverman in 1945–1946 •  Affects infants under 6 months of age; generally a benign and self-limited disorder Most constant features: Bilateral swelling over the mandible or other bones, radiographic evidence of new bone formation in the area, hyperirritability and mild fever Facies: Because of the swelling, the facies is so striking that the condition may be diagnosed with considerable assurance even prior to confirmatory X-ray evidence. The swelling is symmetric and located over the body and ramus of the mandible, often with pallor Soft tissues: Tender, soft-tissue swelling over the face, around the orbits, thorax, or extremities which undergoes remission and exacerbation.  It is firm, brawny, and often so painful as to cause pseudoparalysis of an extremity; not accompanied by redness or increased heat Fever and irritability: Pain, fever of mild degree, and hyperirritability commonly seen; one or all may, however, be absent. Anemia, leukocytosis, and elevation of ESR may also occur Skeletal system: The most frequently affected bone is the mandible; less commonly involved are the clavicle, tibia, ulna, femur, rib, humerus, maxilla and fibula •  New periosteal bone formation, appearing most often during the 9th week, undergoes resolution slowly. Though complete clinical resolution takes place within 3 to 30 months, radiographic evidence may persist for many years •  Leg length inequality and forward bowing of the tibia are common Oral manifestations: Jaw swelling is the most common presenting sign. Fever seems to have no effect on the enamel or on the eruption sequence, although radiographic evidence of residual bony asymmetry of the mandible (angle and ramus) and severe malocclusion in some patients may be seen. Dysphagia has also been reported Marfan syndrome •  French pediatrician Antoine-Bernard Marfan described a 5-year-old girl with skeletal manifestations of the disorder whose main features included disproportionate skeletal growth with dolichostenomelia, ectopia lentis, and fusiform and dissecting aneurysms of the aorta. It has been suggested that Abraham Lincoln had Marfan syndrome •  Mutations in Fibrillin type I gene; autosomal dominant pattern of inheritance Craniofacial features: Dolichocephaly with prominent supraorbital ridges resulting in a characteristic long face with deeply set eyes, prominent brows, downslanting palpebral fissures, hypoplastic malar eminences and retrognathia •  Cleft palate or bifid uvula •  Teeth: Long and narrow and frequently maloccluded •  Mandibular prognathism is common and temporomandibular joint disease is found with increased frequency. Large maxillary sinuses noted radiographically Musculoskeletal system: Dolichostenomelia, arachnodactyly, pectus excavatum and hyperextensibility of joints with recurrent dislocation. •  In later life, secondary arthritic changes occur commonly •  Scoliosis may develop in childhood and worsen during periods of rapid growth, such as puberty, and can be accompanied by a thoracic or thoracolumbar kyphosis •  The skull shows often dolichocephaly Ocular changes: Ectopia lentis, increased tendency to myopia, megalocornea Cardiovascular abnormalities: Aorta aneurysm, mitral valve prolapse Pulmonary pathology: Thoracic cage deformities, increased risk for spontaneous pneumothorax, pulmonary infections, chronic emphysematous changes and reduced pulmonary vital capacity Miscellaneous findings: Abnormalities of CNS include dural ectasia, sacral meningocele, and dilated cisterna magna, but neurological manifestations are rare. Other symptoms in Marfan syndrome are nephrotic syndrome, hematologic abnormalities, hypogonadism, myopathic symptoms due to a diminished amount of skeletal muscles, sleep apnea, diminished amount of subcutaneous fat, biliary tract anomalies and alopecia

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Pediatric Oral Pathology McCune-Albright syndrome

The McCune-Albright syndrome is characterized by: (a) Polyostotic fibrous dysplasia; (b) Multiple areas of cutaneous light brown pigmentation or cafe-au-lait spots; and (c) Autonomous hyperfunction of one or more endocrine glands, especially gonads and thyroid Skeletal manifestations: Long bones are most frequently affected Bowing resembling a hockey stick may be produced, resulting in leg-length discrepancy. Limp, leg pain, or fracture is the presenting complaint. Fractures may be multiple and recurrent Histopathology: Bone is replaced by a yellowish to red-brown fibrous tissue, the stroma may vary from a finely fibrillar one with a loose whorled arrangement to one that is densely collagenous. Some areas appear edematous, with numerous small cystic spaces. Foci of hemorrhage and multinucleated giant cells may be observed. The trabeculae are irregular in form, and occasionally a few fragments of cartilage are present Craniofacial findings: Facial asymmetry, accompanied by protrusion of an eye with associated visual disturbances. The skull base becomes thickened and dense, bulging upward into the cranial cavity. The calvaria may also become thickened, with marked occipital and frontal bulging. Bossing may be asymmetric, with unilateral, and occasionally bilateral, obliteration of the sinuses and nasal passages. Overgrowth of bone around foramina may result in deafness and blindness The jaws may be enlarged, expanded, and distorted. Radiographic examination may show a dense mass, especially in the maxilla, extending into and obliterating the sinuses and expanding the buccal plate in the tuberosity areas, or there may be a radiolucent area, more common in the mandible, similar to that seen in long bones. Often there is loss of trabeculae and a “ground-glass” appearance on radiographic examination Cutaneous manifestations: Café-au-lait type of pigmentation; well-defined, generally unilateral, irregular macular spots scattered over the forehead, nuchal area, and buttocks. Face, lips, or mucosa rarely involved Endocrine manifestations: Sexual precocity occurs in both males and females. Precocious puberty in males may be accompanied by gynecomastia. Hyperthyroidism, Cushing’s syndrome, hypersomatotropinism, hyperprolactinemia, hyperparathyroidism, hypophosphatemic vitamin D-resistant rickets or osteomalacia without hypercalcemia have been reported Central nervous system: Most patients have normal intelligence, mental deficiency is rare and may be secondary to factors such as prematurity, hypercorticalism, or grossly malformed skull Severe autosomal recessive osteopetrosis (Albers-Schönberg disease) This disorder is characterized by increased density of nearly all bones and the following complications that occur from failure of resorption of the primary spongiosa and its resultant persistence: anemia, hepatosplenomegaly, blindness, deafness, facial paralysis and osteomyelitis Clinical findings: All tubular bones may be involved, but growth is usually normal. The skull is thickened and dense, mainly at its base, but the calvaria, mastoid bones, and paranasal sinuses are poorly aerated, and the facial bones appear denser than normal. Facial paralysis results from the pressure of dense bone on the foramen of the 7th cranial nerve. The ossicles lack medullary cavities. Intracerebral calcifications at birth have been described Musculoskeletal findings: The bones are extremely uniformly dense but not distorted in form. The epiphyses, metaphyses, and diaphyses are similarly affected. The cortical and cancellous bones are indistinguishable radiographically. Fractures are common. Older children may show a “hair-on-end” phenomenon in the calvaria Hematopoietic findings: Although the liver and spleen are normal at birth, they enlarge in childhood because of extramedullary hematopoiesis. Hemolytic anemia, thrombocytopenia, and generalized lymphadenopathy can occur Oral manifestations: Osteomyelitis of the jaws, presumably the result of deficient blood supply, seems to be a significant complication of dental extraction; may lead to extraoral fistulas •  Primary molars and all permanent teeth are greatly distorted and remain totally or partially embedded in basal bone. The teeth appear to be secondarily affected by failure of bone resorption and/or osteomyelitis •  Ankylosis of cementum to bone; and higher incidence of dental caries Achondrogenesis The term “achondrogenesis” was coined by Fraccaro in 1952. It is a type of lethal chondrodysplasia; half of the infants being stillborn and the rest succumbing within the first few hours Facies: The (usually normocephalic) head is disproportionately large relative to reduced neck, trunk, and limb length, causing the infant to be erroneously considered to have hydrocephaly. In type 1A, the forehead slopes and the face appears puffy. The nose is small with anteverted nares and long philtrum, and there is retrognathia with double chin. Type 1B and 2 infants have a large prominent forehead, flat face, depressed nose with marked anteversion of nostrils, normal philtrum, and more normal chin. The neck is short in all types. Cleft palate is common

Chapter 74  Common Orofacial Syndromes in Children Skeletal alterations: The extremities are bowed, rarely exceeding 10 cm in length. The fingers and toes are similarly short and stubby. Polydactyly may be found. The belly is greatly enlarged, partly from the short chest cavity and partly from hydrops. The genitalia are normal. Marked underossification of vertebral bodies, sternum, ilia, ischia pubic bones, talus, and calcaneus. The ribs are short and cupped with flared ends Histopathology: The cartilage is hypercellular with clustered chondrocytes within a diffuse matrix. The resting chondrocytes contain PASpositive, diastase-resistant, round to oval intracytoplasmic inclusions. The lacunae are dilated Achondroplasia •  The term “achondroplasia” was first used by Parrot in 1878 to describe a rhizomelic form of short-limbed dwarfism associated with enlarged head, depressed nasal bridge, short stubby trident hands, lordotic lumbar spine, prominent buttocks and protuberant abdomen •  One of the most common of the nonlethal bone dysplasias •  Homozygous achondroplastic infants are more severely affected, clinically and radiologically, than are infants heterozygous for the disorder, and the condition is lethal during infancy Molecular findings: The basic defect is a mutation in fibroblast growth factor receptor 3 (FGFR3) Growth and development: There is a tendency toward obesity. Motor milestones are slow, possibly because acquisition of motor skills is influenced by the large head and short extremities. Head control may not occur until 3 to 4 months and affected children may not walk until 24 to 36 months. Ultimately, however, development falls within the population-based normal range and most individuals with achondroplasia are able to lead an independent and productive life •  Reproductive fitness is considerably reduced among those with achondroplasia because of social difficulties in finding mates and because of obstetrical problems of achondroplastic women (prematurity and the necessity for cesarean deliveries due to cephalopelvic disproportion) •  Furthermore, premature menopause and an increased incidence of leiomyomata have been reported Facies and skull: The head is enlarged, with frontal bossing and low nasal bridge. Occasionally, these features are not present at birth, but disproportionate growth of the head occurs during the first year of life Central nervous system: Mild ventricular dilatation; significant hydrocephaly; obstructive sleep apnea due to brainstem compression; neurologic complications with age due to narrow spinal canal Skeletal system: Enlarged calvaria, basilar kyphosis and small foramen magnum •  The anterior cranial base length is normal and posterior cranial base length is shorter •  Hypoplastic maxilla, resulting in midface deficiency and relative mandibular prognathism. The frontal, occipital bones and, in some cases, the temporal bones may be prominent •  The sacrum is narrow and horizontally oriented; pelvis is broad and short •  The thoracic cage is relatively small in anteroposterior diameter •  Legs are frequently bowed because of lax knee ligaments; limb bones are shortened in a rhizomelic pattern, which is more prominent in the upper extremities; there is incomplete extension at the elbows Otolaryngologic findings: Otitis media is likely common during the first 6 years of life. History of ear infections; significant hearing loss Ellis–van Creveld syndrome (Chondroectodermal dysplasia) •  The disorder consists of bilateral postaxial polydactyly of the hands, chondrodysplasia of long bones resulting in acromesomelic dwarfism, ectodermal dysplasia affecting nails and teeth and congenital heart anomalies •  Autosomal recessive inheritance •  Ellis-van Creveld syndrome is the most common type of dwarfism among the Amish •  The life expectancy is mainly determined by the congenital heart defect and the respiratory problems due to the thoracic cage deformity Facies: The facies is not especially characteristic except for a mild defect in the middle of the upper lip, which, although often present, is usually not striking. Some patients have been noted to have hypertelorism Skeletal anomalies: Extremities are plump and markedly shortened progressively distalward, that is, from the trunk to the phalanges •  Frequently, the patient cannot make a tight fist •  Radiographically, the tubular bones are short and thickened. The diaphyseal ends of the humerus and the femur are plump. Fibula is most severely shortened, syncarpalism (hamate and capitate), synmetacarpalism, and polymetacarpalism are frequent •  Histopathologic studies in three fetuses showed chondrocytic disorganization in the physeal growth zone, both in the long bones and vertebrae

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Pediatric Oral Pathology

Hair and nails: The hair, particularly the eyebrows and pubic hair, is thin and sparse. Severe dystrophy of the fingernails, which are markedly hypoplastic, thin, and often wrinkled or spoon-shaped Oral manifestations: The most striking and constant finding is fusion of the middle portion of the upper lip to the maxillary gingival margin so that no mucobuccal fold or sulcus is present anteriorly •  The middle portion of the upper lip appears to have a notch •  Natal teeth commonly observed, so are congenitally missing teeth, particularly in the mandibular anterior region. Supernumerary teeth have also been noted •  Erupted teeth are usually small, have conical crowns, and are irregularly spaced Bloom syndrome Bloom syndrome consists of intrauterine growth retardation, sunlight sensitivity leading to telangiectatic erythema, immunologic deficiency, hypogonadism and infertility in males and an increased risk of neoplasia Clinical features: Light sensitivity is noticed early in infancy and leads to development of telangiectatic erythema, appearing by 2 years of age. Erythema involves light-exposed areas of the face; superficially it resembles lupus erythematosus because of the butterfly distribution across the nose. Severe lesions also may occur on the lower eyelids, lips, ears and neck. A chronic fissure or ulcer of the lower lip is a bothersome complication and chronic cheilitis is a prominent feature. The eyelashes may be lost. Exposure to sunlight may cause bullae and vesicles Rubinstein-Taybi syndrome In 1963, Rubinstein and Taybi observed a combination of broad thumbs and halluces, characteristic facial dysmorphism, growth retardation, and mental deficiency Growth: Length, weight and head circumference at birth are below normal Craniofacial features: The facial appearance is striking, with microcephaly, prominent forehead, downslanting palpebral fissures, epicanthal folds, strabismus, broad nasal bridge, beaked nose with the nasal septum extending below the alae, highly arched palate, and mild micrognathia. The features are recognizable in the newborn. Other findings may include long eyelashes, nasolacrimal duct obstruction, ptosis of eyelids, congenital or juvenile glaucoma, refractive error, and minor abnormalities in shape, position, and degree of rotation of ears •  Low-frequency abnormalities have included bifid uvula, submucous palatal cleft, bifid tongue, macroglossia, short lingual frenum, natal teeth, and thin upper lip •  Talon cusps have been observed in over 90% of subjects Beckwith-Wiedemann syndrome [EMG (exomphalos-macroglossia-gigantism) syndrome] This syndrome includes macroglossia, omphalocele, cytomegaly of adrenal cortex, hyperplasia of gonadal interstitial cells, renal medullary dysplasia, hyperplastic visceromegaly, postnatal somatic gigantism, mild microcephaly, and severe hypoglycemia. Early diagnosis of this striking condition alerts the clinician to the dual threat of hypoglycemia and possible neoplasia Craniofacial features: Macroglossia is very common at birth but is not an obligatory feature of the syndrome, and it may not present until the first few months of life. Chronic alveolar hypoventilation has been reported secondary to macroglossia on occasion •  Tongue biopsies have been normal •  In some cases, macroglossia tends to regress, with gradual accommodation of the tongue to the oral cavity. At present, it is not known whether this is caused by enlargement of the oral cavity relative to the tongue, shrinkage of the tongue relative to the oral cavity, or a combination of both processes. Persistent macroglossia, seen in almost 100%, leads to anterior open-bite, and requires surgical intervention •  Patients with the syndrome have also been observed to be prognathic; prognathism may reflect the generalized somatic gigantism that occurs in the syndrome •  Facial nevus flammeus, mild microcephaly, persistent anterior fontanel, malformed cerebellum, preauricular pits, cleft palate, conductive hearing loss from fixation of the stapes are some of the other features

Chapter 74  Common Orofacial Syndromes in Children Hemihyperplasia (Hemihypertrophy) Although the term hemihypertrophy has been used conventionally and frequently in the medical literature, it is inappropriate, as the condition so obviously refers to hemihyperplasia. In hemihyperplasia, the enlarged area may vary from a single digit, a single limb, or unilateral facial enlargement to involvement of half the body. Hemihyperplasia may be segmental, unilateral, or crossed. In some cases, the defect is limited to a single system, for example, muscular, vascular, skeletal, or nervous system, but it may frequently involve multiple systems. The etiology and pathogenesis are poorly understood Clinical manifestations: Asymmetry is usually evident at birth and may become accentuated with age, especially at puberty. Occasionally, asymmetry has been stated not to be present at birth, but to develop later. However, such observations are valid only when measurements are taken at birth. A variety of non-neoplastic abnormalities have been observed to affect the limbs, teeth, skin, central nervous system, cardiovascular system, liver, kidneys and genitalia. Cutaneous anomalies include telangiectasia, nevus flammeus and hirsutism. Various neoplasms have been reported in association with hemihyperplasia Oral and dental anomalies include enlarged hemitongue, enlarged teeth on affected side with early eruption, abnormal tooth roots and an enlarged alveolar ridge on affected side Apert syndrome (Acrocephalosyndactyly) Apert syndrome is characterized by craniosynostosis, midfacial malformations and symmetric syndactyly of the hands and feet, minimally involving digits 2, 3, and 4. Although most cases are sporadic, representing new mutations, autosomal dominant transmission with complete penetrance has also been reported Craniofacial features: During infancy, there is a wide midline calvarial defect that extends from the glabella to the posterior fontanel that gradually fills in with bony islands that coalesce •  Hyperacrobrachycephaly, flat occiput, steep forehead, supraorbital groove, bulging at the bregma or malformed and asymmetric cranial base, and short anterior cranial base are observed. The cranial base angle is variable, but platybasia occurs most commonly. Cloverleaf skull may be observed •  The middle third of the face is retruded and commonly hypoplastic, resulting in relative mandibular prognathism •  Depressed nasal bridge, beaked nose and deviated nasal septum •  Hypertelorism, shallow orbits, proptosis, downslanting palpebral fissures and strabismus are seen. The absence of the superior rectus muscle has been noted •  The ears may appear lowest. Minor anomalies are frequent. Otitis media is common, related to the high frequency of cleft palate and to eustachian tube dysfunction •  In the relaxed state, the lips frequently assume a trapezoidal configuration •  The palate is highly arched, constricted, and usually has a median furrow. Lateral palatal swellings are present, which increase in size with age. Cleft soft palate, or bifid uvula, may be observed. The hard palate is shorter than normal, but the soft palate is both longer and thicker than normal •  Alterations in the nasopharyngeal architecture consist of reduction in pharyngeal height, width and depth. The combination of reduced nasopharyngeal dimensions and decreased patency of the posterior nasal choanae poses the possible threat of respiratory embarrassment and cor pulmonale, especially in the young child •  The maxillary dental arch is V-shaped (due to maxillary hypoplasia) with severely crowded teeth and bulging alveolar ridges. Class III malocclusion, irregular positioning of teeth, anterior open bite, anterior and posterior crossbite and delayed eruption of teeth are common findings Growth: The growth pattern in infancy and childhood consists of a gradual decrease in height. A significant proportion of patients is mentally retarded Hands and feet: Syndactyly, some degree of brachydactyly and associated synonychia are common Synostosis of adjacent distal phalanges occurs with age, so does stiffening of interphalangeal joints. Progressive calcification and fusion of the bones of the hands, feet and cervical spine also becomes visible radiographically with age

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Pediatric Oral Pathology Crouzon syndrome (Craniofacial dysostosis)

•  Crouzon syndrome, first described by Crouzon in 1912, is characterized by craniosynostosis, maxillary hypoplasia, shallow orbits and ocular proptosis •  Autosomal dominant transmission Craniofacial features: Cranial malformation depends on the order and rate or progression of sutural synostosis. Brachycephaly is most commonly observed, but scaphocephaly, trigonocephaly, and cloverleaf skull may be observed. Craniosynostosis commonly begins during the first year of life and is usually complete by 2 to 3 years of age; may be evident at birth in some cases •  Shallow orbits and ocular proptosis are diagnostic features; may be evident at birth or during the first year of life. This proptosis predisposes to exposure conjunctivitis or keratitis, luxation of the eyeglobes, exotropia, poor vision and blindness •  Various sutures may be prematurely synostosed, and multiple sutural involvement is found eventually in most cases •  Lateral palatal swellings, sometimes large enough to produce the median pseudocleft palate appearance may be found •  Cleft lip and cleft palate are anomalies of low frequency •  Maxillary hypoplasia shortens the anteroposterior dimension of the maxillary dental arch. Dental arch width is also reduced, and the constricted arch gives the appearance of highly arched palate, although palatal height is normal by measurement. Crowding of maxillary teeth and ectopic eruption of maxillary first molars also occur •  Unilateral or bilateral posterior crossbite may be evident. Anterior open bite, mandibular overjet and crowding of mandibular anterior teeth are also commonly observed Carpenter syndrome (Acrocephalopolysyndactyly) •  Carpenter syndrome is characterized by craniosynostosis, commonly but not always preaxial polysyndactyly of the feet, short fingers with clinodactyly, and variable soft tissue syndactyly, sometimes postaxial polydactyly, and other abnormalities, such as congenital heart defects, short stature, obesity and mental deficiency •  Autosomal recessive inheritance •  Height is below normal, weight is often above average. Obesity of the trunk, proximal limbs, face and neck is common Craniofacial features: Craniosynostosis usually involves the sagittal and lambdoid sutures first, the coronal being last to close. The calvaria may be grossly malformed in some instances, but variable in shape •  Unilateral involvement of the coronal or lambdoid suture produces marked cranial asymmetry. The cloverleaf skull anomaly may also be observed •  Downslanting palpebral fissures, epicanthic folds, microcornea, corneal opacity, slight optic atrophy and blurring of the disc margins have been reported •  Low set ears, short neck, preauricular fistulas, small mandible, narrow or highly arched palate Hands and feet: The hands are short and the fingers stubby. Marked soft tissue syndactyly may be present. Clinodactyly of the fingers, single flexion crease and sometimes postaxial polydactyly may be observed Pfeiffer syndrome In 1964, Pfeiffer described a syndrome consisting of craniosynostosis, broad thumbs, broad great toes, and a variable feature, partial soft tissue syndactyly of the hands Craniofacial features: Maxillary hypoplasia and relative mandibular prognathism seen Depressed nasal bridge, beaked nose, hypertelorism, downslanting palpebral fissures, ocular proptosis and strabismus are common. Highly arched palate, broad alveolar ridges, crowded teeth and sometimes even natal teeth are found Hands and feet: Mild soft tissue syndactyly, brachydactyly, clinodactyly are common Symphalangism of both hands and feet has been reported Mandibulofacial dysostosis (Treacher-Collins syndrome; Franceschetti-Zwahlen-Klein syndrome) •  Mandibulofacial dysostosis involves structures derived from the first and second pharyngeal arches grooves and pouches •  Treacher-Collins described the essential components of the syndrome; Franceschetti et al. coined the term mandibulofacial dysostosis •  Autosomal dominant inheritance. The gene for the syndrome (Treacle or TCOF1) has been mapped to 5q32–33.1 and it encodes a putative nucleolar phosphoprotein

Chapter 74  Common Orofacial Syndromes in Children Facies: The facial appearance is characteristic. Abnormalities are bilateral and usually symmetric. The nose appears large but this appearance is secondary to hypoplastic supraorbital rims and hypoplastic zygomas. The face is narrow. Downward-sloping palpebral fissures, depressed cheekbones, malformed pinnae, receding chin and large down-turned mouth are characteristic Few patients manifest a tongue-shaped process of hair that extends toward the cheek Skull: The calvaria are essentially normal, but supraorbital ridges are poorly developed. Malar bones may be totally absent but more often are grossly and symmetrically underdeveloped, with nonfusion of the zygomatic arches •  Zygomatic process of the frontal bone, as well as lateral pterygoid plates and muscles show hypoplasia •  Mastoids are not pneumatized and are frequently sclerotic •  The paranasal sinuses are often small and may be completely absent •  The orbits are hyperteloric, lower margin may be defective and the infraorbital foramen is usually absent •  Mandibular condyle and coronoid process are severely hypoplastic, flat, or even aplastic. The undersurface of the body of the mandible is quite concave. The angle is more obtuse than normal, and the ramus is deficient. The condyle is covered with hyaline cartilage rather than fibrocartilage. The condylar neck is short. There is no articular eminence, and the articular area is atypically medial Eyes: The palpebral fissures are short and slope laterally downward; there is a coloboma in the outer third of the lower lid Ears: The pinnae are often malformed, crumpled forward, or misplaced toward the angle of the mandible. Agenesis or hypoplasia of the mastoid, absence of the external auditory canal, narrowing or agenesis of the middle ear cleft, agenesis or malformation of the malleus and/ or incus, absence of stapes and oval window, ankylosis of stapes in the oval window, deformed suprastructure of stapes, complete absence of middle ear and epitympanic space have been seen. The inner ears are normal. Extra ear tags and blind fistulas may occur Nose: Obliterated nasofrontal angle, raised bridge of the nose, narrow nares and hypoplastic alar cartilages. Nose appears large because of the lack of malar development and hypoplastic supraorbital ridges Oral findings: Cleft palate, congenital palatopharyngeal incompetence (agenesis of soft palate, foreshortened soft palate, submucous palatal cleft, immobile soft palate) macrostomia (unilateral or bilateral), deficient elevator muscles of the upper lip, absent or hypoplastic parotid salivary glands and pharyngeal hypoplasia (main cause of neonatal death) Van der Woude syndrome (Cleft lip-palate and paramedian sinuses of the lower lip) Autosomal dominant inheritance with variable expressivity Manifestations of the syndrome in other than the oral or facial areas are unusual Oral manifestations: Usually bilateral, often symmetrically placed depressions are observed on the vermilion portion of the lower lip, one on each side of the midline. The depressions represent blind sinuses that descend through the orbicularis oris muscle to a depth of 1 mm to 2.5 cm and communicate with the underlying minor salivary glands through their excretory ducts Adhesions between maxilla and mandible (syngnathia) have been noted. Absence of maxillary and mandibular 2nd premolars and natal teeth has been described Pierre-Robin syndrome (Robin sequence) The well-recognized combination of micrognathia, cleft palate and glossoptosis, was first reported in 1923 by Pierre-Robin Clinical manifestations: The facies is striking at birth (small mandible which is symmetrically receded, flattened base of nose, U-shaped or V-shaped palatal cleft) •  Difficulty in respiration is apparent, with periodic cyanotic attacks, labored breathing, and recession of the sternum and ribs. Although there is no complete agreement concerning the exact mechanism by which respiratory and feeding difficulties are produced, the classic explanation suggests that the micrognathia makes for little support of the tongue musculature allowing the tongue to fall downward and backward (glossoptosis) into the lower postpharyngeal space, obstructing the epiglottis •  Feeding problems are because of inadequate control of the tongue; nursing is difficult Musculoskeletal abnormalities: Syndactyly, hypoplastic digits, polydactyly, clinodactyly, oligodactyly, Poland anomaly, hyperextensible joints, congenital hip dislocation, as well as rib and sternal anomalies have been reported CNS defects: Language delay, epilepsy, hypotonia, hydrocephalus Other findings: Microphthalmia, glaucoma, low-set and malformed ears, otitis media, hearing loss, nasal deformity and philtrum malformation

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Pediatric Oral Pathology Noonan syndrome

•  Noonan syndrome is characterized by short stature, various congenital heart defects, broad or webbed neck, chest deformity, hypertelorism with characteristic facial appearance and, in some cases, mild mental deficiency •  Autosomal dominant inheritance Craniofacial features: Facial characteristics change with age •  In the newborn, features include tall forehead, hypertelorism, downslanting palpebral fissures, epicanthal folds, depressed nasal root with upturned nasal tip, deeply grooved philtrum with high, wide peaks of the vermilion border, highly arched palate, micrognathia, low-set and posteriorly angulated ears with thick helices, and excessive nuchal skin with low posterior hairline •  During infancy, the head is relatively large. Hypertelorism, prominent eyes and thick hooded eyelids are characteristic. The nasal bridge is low and the nose has a wide base with bulbous tip •  During childhood, the face may appear coarse or myopathic. Facial contour becomes more triangular with age •  During adolescence and young adulthood, the eyes become less prominent and the nose has a thin, high bridge and a wide base. The neck appears longer with accentuated webbing or prominent trapezius •  In older adults, the nasolabial folds are prominent, the anterior hairline is high and the skin appears wrinkled and transparent •  Features present regardless of age include blue-green irides, halo iris, arched eyebrows and low-set posteriorly angulated ears with thick helices Romberg syndrome (Parry-Romberg syndrome; progressive hemifacial atrophy) Romberg syndrome consists of slowly progressive atrophy of the soft tissues of essentially half the face accompanied most frequently by contralateral Jacksonian epilepsy, trigeminal neuralgia and changes in the eyes and hair Face, skin, and hair: In advanced cases, the face is quite distinct. The ear may become misshapen and smaller than normal or, because of lack of supporting tissues, may project from the head. Early facial change, usually appearing during the first decade, involves the paramedian area of the face and slowly spreads, resulting in atrophy of underlying muscle, bone, and cartilage. First to be involved is usually the area covered by the temporal or buccinator muscles. The process extends to involve the brow, angle of the mouth, neck, or even half the body. The overlying skin often becomes darkly pigmented. The condition slowly progresses for several years (about 9 years) and then usually becomes stationary for life Oral manifestations: Atrophy of half of the upper lip and tongue are characteristic. Maxillary teeth on the involved side are exposed. Spontaneous fracture on the affected side of the mandible has also been noted. Other dental anomalies include delayed tooth eruption, abnormal root morphology, and, in rare cases, root resorption Radiographically, the body and ramus of the mandible are shorter on the involved side, and delayed development of the mandibular angle may be observed, resulting in malocclusion. Teeth on the affected side occasionally are delayed in eruption or have atrophic roots Hyperkeratosis palmoplantaris and periodontoclasia in childhood (Papillon-Lefèvre syndrome) •  Papillon and Lefèvre, in 1924, described a syndrome consisting of hyperkeratosis of palms and soles and destruction of the supporting tissues of both primary and secondary dentitions •  Autosomal recessive inheritance Skin: Sometime between the second and fourth years of life, or on rare occasions even earlier, the palms and soles become diffusely red and scaly. The degree of hyperkeratosis is not severe, but normal skin markings become accentuated and involved skin may assume a parchmentlike quality. The degree of involvement seems to fluctuate, possibly becoming worse during winter. The skin apparently improves somewhat with age but some degree of palmoplantar hyperkeratosis remains throughout life Other findings: Increased susceptibility to infection with A. actinomycetemcomitans has been suggested, but its specificity is dubious Oral manifestations: The development and eruption of the deciduous teeth proceed normally, but almost simultaneously with the appearance of palmar and plantar hyperkeratosis, the gingiva swell, bleed, and become boggy. Marked halitosis develops. Destruction of the periodontium follows almost immediately the eruption of the last primary molar tooth. The teeth are involved in roughly the same order in which they erupt. Deep periodontal pocket formation precedes the exfoliation of teeth. By the age of 4 years, nearly all primary teeth are lost. After exfoliation, the inflammation subsides and the gingiva resumes its normal appearance. The mouth then appears normal until the permanent dentition erupts, when the process is repeated in essentially the same manner. Most teeth are lost by 14 years. The alveolar process is often completely destroyed. Even during active periodontal breakdown, the rest of the oral tissues appears perfectly normal

Chapter 74  Common Orofacial Syndromes in Children

QUESTIONNAIRE 1. 2. 3. 4. 5.

Write in details clinical features of downs syndrome. Oral manifestations of cleidocranial dystosis. Write a note on aperts syndrome. Explain Rubinstein tyabis syndrome. Short note on turner’s syndrome.

BIBLIOGRAPHY

1. Beighton P. McKusick’s heritable disorder of connective tissue, 5th Edn. Mosby; 1991. 2. Cahuana, et al. Oral manifestations in Ellis-van Creveld syndrome. Pediatric Dentistry. 2004;26(3):282. 3. Cole WG. Etiology and pathogenesis of heritable connective tissue diseases. J Pediatr Orthop. 1993;13(3):392-403. 4. Gorlin RJ, Cohen MM, Levi LS. Syndrome of the head and neck, 3rd Edn. Oxford; 1990. 5. Hennequin M, Faulks D, Veyrune JL, Bourdiol P. Significance of oral health in persons with Down syndrome: a literature review. Dev Med Child Neurol. 1999;41(4):275-83. 6. Welbury RR. Ehlers-Danlos syndrome: historical review, report of two cases in one family and treatment needs. ASDC J Dent Child. 1989; 56(3):220-4.

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Chapter

Common Oral Pathologic Conditions Associated with Pediatric Dentistry Parvind Gumber, Asmita Sharma

Chapter outline • • • •

Dentigerous Cyst Odontogenic Keratocyst Radicular Cyst Pleomorphic Adenoma (Mixed Tumor)

Cyst is a pathological cavity containing fluid, semifluid or gas, which is usually lined by epi­thelium and is not formed by the accumulation of pus. Pathological cavity means any cystic lesion in the body must arise as a result of some pathologic processes and these cavities are filled with a variety of materials like fluid, keratin, blood or gases. A cyst may be designated as true cyst if the lining epithelium is present in a cyst and pseudo cyst if the lining epithelium is absent.

DENTIGEROUS CYST • Dentigerous cyst is the developmental odontogenic cyst of epithelial origin • It is the most common type of odontogenic cyst which encloses the crown of an unerupted tooth by expansion of its follicle and is attached to the neck • It was also known as follicular cyst or pericoronal cyst • Browne and Smith changed the name from follicular cyst to dentigerous cyst.

Etiopathogenesis • The epithelial lining of this cyst is derived from the reduced enamel epithelium • The cyst arises around the crown of an erupted tooth, lying impacted within in the bone • Mechanical disturbance in the eruptive process may lead to fluid accumulation either within the reduced enamel

• • • •

Sjögren’s Syndrome Odontoma Ameloblastoma Cherubism

epithelium or between it and the enamel surface resulting in cyst formation. • The initiation of this cyst formation can be explained by the pressure created in the follicle surrounding the crown of the interrupted tooth as consequence of fluid transudation. It has been suggested that thin walled venous channels are constricted by the impacted tooth, so leading to extravasation of fluid. • In addition to physical mechanisms, cellular mechanisms are also involved. It has been demonstrated that large numbers of mast cells and IgE staining cells are present in the tissues surrounding the crown of erupting tooth. Interaction of IgE with mast cells results in histamine release and thus vasodilation and exudation.

Clinical Features • Dentigerous cysts may grow to a large size before they are diagnosed. • Most of them are discovered on radiographs when these are taken because a tooth has failed to erupt or a tooth is missing. • Many patients first become aware of the cysts because of slowly enlarging swelling (Fig. 75.1), and this is the common form of presentation with edentulous patients in whose jaws unerupted teeth have inadvertently been retained. • Dentigerous cysts may occasionally be painful particularly if infected.

Chapter 75  Common Oral Pathologic Conditions Associated with Pediatric Dentistry Decision tree for oral mucosa lesions (Revised 3/08)

Fig. 75.1: Clinical presentation of dentigerous cyst

Fig. 75.2: OPG showing radiographic picture of cyst

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Fig. 75.3: IOPA showing well defined margins

Fig. 75.4: Histological appearance of dentigerous cyst

• Some patients may give a history of a slowly enlarging swelling.

Prevalence • More frequency in whites than black race • Found mostly in first decade • Most common region is mandibular 3rd molar and maxillary permanent canine region • Significantly greater in men than women, i.e. 1.8:1.

Radiographic Features • Radiographs show unilocular radiolucent areas associated with the crowns of unerupted teeth (Figs 75.2 and 75.3). • The cysts have well defined sclerotic margins unless they become infected. • Occasionally, trabeculations may be seen and this may give an erroneous impression of multilocularity. • The unerupted teeth may be impacted as a result of inadequate space in the dental arch or as a result malpositioning such as by a horizontally impacted of the crown.

Histopathological Features ( Figs 75.4 and 75.5) • It is composed of thin cystic wall • The lining is a thin layer of nonkeratinized stratified squamous epithelium • In very few instances the lining may be keratinized and it may be mistaken as keratocyst or keratin may be produced rarely as due to metaplastic changes • As the lining is derived from reduced enamel epithelium it is 2 to 4 cell layer thick primitive type of epithelium

Fig. 75.5: Histological picture of dentigerous cyst

• The cells are cuboidal or low columnar • Rete pegs formation is absent.

ODONTOGENIC KERATOCYST • Odontogenic keratocyst (OKC) is a developmental odontogenic cyst of epithelial origin • Previously termed primordial cyst by Robinson (1945) • According to Pindborg and Hansen the designation keratocyst was used to describe any jaw cyst exhibiting keratinization in their lining which may occur in follicular, residual and very rarely in a radicular cyst

Chapter 75  Common Oral Pathologic Conditions Associated with Pediatric Dentistry • Recently in World Health Organization (WHO) classi­ fication of odontogenic tumor this cyst has given a name of keratocystic odontogenic tumor.

Radiological types of keratocysts Replacement type

When a keratocyst develops in place of a developing normal tooth, it is called the replacement type. In such cases, there will be absence of a normal tooth in the dental arch

Envelopmental type

When a cyst entirely encloses an impacted tooth within the bone, it is called the envelopmental type of keratocyst

Extraneous type

When a keratocyst develops away from the tooth bearing areas of the jaws, it is called extraneous type of keratocyst

Collateral type

When a cyst develops between the roots of a tooth, it is called collateral type of keratocyst

Pathogenesis • OKC arises mainly from the: – Dental lamina or its remnants – Primordium of the developing tooth germ or enamel organs. – Sometimes from the basal layer of the oral epithelium • It is mostly believed that the keratocyst develops due to the cystic degeneration of the cells of the stellate reticulum in a developing tooth germ (before its calcification starts). Daughter cysts, are a common finding in this lesion.

Prevalence • • • • • •

One percent among all types of jaw cysts Seen in mostly second and third decade of life Males > females Site is mostly mandible (75%) as compared to maxilla Angle of the mandible is the prime most location in jaws Maxillary lesions more frequently involve anterior part of the jaw, however some can develop from the posterior region lesions can even develop in relation maxillary air sinus • On rare occasions, this cyst may occur in gingiva.

Clinical Features • In the initial stages odontogenic keratocyst does not produce signs or symptoms and the lesion may be dis­ covered only during routine radiographic examinations • Larger lesions often produce pain and swelling • Pain and mobility and displacement of involved teeth seen • Buccal expansion of bone • Multiple lesion may also develop in the jaw as a mani­ festation of the nevoid basal cell carcinoma syndrome • Paresthesia of the lower lip and teeth may be present occasionally • Excessive expansion and thinning of bone may result in pathological fracture in some cases • Discharge of pus may be seen in case the cyst is secondarily infected • Multiple odontogenic keratocyst are found in Gorlin Goltz syndrome, Marfan syndrome, Ehler’s Danlos syndrome and Noonan’s syndrome.

Radiographic Features (Fig. 75.6) • Majority of lesions are unilocular with smooth borders but some unilocular lesions are large with irregular borders

Fig. 75.6: Radiographic presentation of OKC

• Radiolucency is usually hazy due to keratin filled cavity and it is surrounded by thin sclerotic rim due to reactive osteocytes. • Bone can expand in anterior posterior direction and perforate the buccal and lingual cortical plates of bone and involve the adjacent soft tissue. • Keratocysts often radiographically present multilocular radiolucent areas, with a typical “soap-bubble” appearance.

Histopathological Features (Figs 75.7A and B) • The odontogenic keratocyst shows two types of linings, i.e. parakeratinized stratified squamous epithelium and orthokeratinized. • The parakeratinized epithelium is more common, (80–90%) cases. The orthokeratinized OKC shows less common occurrence. • The characteristic feature of the lining of is pathognomic corrugated, with a regular thickness of the epithelium between 5 to 8 cell layers. The lining is without rete ridges. • The basal cell layer is columnar with palisaded arrangement of the nuclei. The nuclei tend to be placed

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A

B Figs 75.7A and B: Histologic appearance of OKC

away from the basement membrane. The nuclei of the basal cells are darkly staining, show basal cell hyperplasia, this is not present in other keratocyst. • Connective tissue shows islands of odontogenic epithelium forming small duplicate daughter cysts or small satellite cysts. The satellite cysts are more common in patients with multiple cysts and nevoid basal cell carcinoma syndrome. • Another most important feature of this cyst is that there is a weak epithelial-connective tissue attachment. This causes the detachment of the epithelium and further recurrences as it becomes difficult during removal of the cyst.

RADICULAR CYST • Radicular or periapical cyst is the most common odonto­ genic cystic lesion of inflammatory origin, which occurs in relation to the apex of a nonvital tooth. • In a radicular cyst if the involved tooth is exfoliated or extracted and the cystic lesion remains within the bone, the condition is known as residual cyst.

Prevalence • Radicular cyst constitutes about 50 percent or more among all types of jaw cysts • Mostly seen in 3rd, 4th, 5th decade of life • More common among males • The cyst can occur in relation to any of either jaw, but maxilla (60%) is usually commonly affected than mandible (40%).

Clinical Presentation • The involved tooth is always nonvital can be easily detected by the presence of fractures or discolorations, etc.

• Radicular cyst may occur rarely in association with nonvital deciduous tooth. • The smaller cystic lesions are usually as symptomatic and are detected only with radiograph is taken. • The larger lesions on the other hand, often produce a slow enlarging, bony hard swelling of the jaw with expansion and distortion of the cortical plates or disturbance in occlusion mostly of the regional teeth. • Severe bone destruction by the cystic lesion results in thin­ ning of the cortical plates and it may produce a “springiness” of the jawbone when digital pressure is applied. • A radicular cyst may persist in the jaw after the attached tooth has been extracted; such cyst is often called a ‘residual cyst’.

Radiographic Features • Radicular cysts present well-defined, unilocular, round shaped radiolucent areas of variable size (few millimeters to several centimeters in diameter). • The cyst is always found in contact with the root apex of a nonvital tooth and it is bordered on the periphery by a well-corticated margin. • The infected cysts often have hazy or an ill-defined border.

Histopathology (Figs 75.8A to C) • Histologically, radicular cyst shows presence of a cystic cavity, which is lined by nonkeratinized, stratified squamous epithelium of about 6 to 20 cell layers thickness. • Epithelium is nonkeratinized and it often show localized areas of increased cell proliferation and edema. • The proliferating cystic epithelium may sometimes grow in a peculiar fashion, by enclosing or encircling a mass of connective tissue capsule from all sides. This pattern of growth is called “arcading pattern.” • Presence of inflammatory cell infiltration and edema is often seen the cystic lining.

Chapter 75  Common Oral Pathologic Conditions Associated with Pediatric Dentistry • It is a benign neoplasm consisting of cells exhibiting the ability to differentiate to epithelial (ductal and nonductal) and mesenchymal (chondroid, myxoid and osseous) cells. • The complexity and diversity of appearance of this neoplasm account for the term “Pleo­morphic”. • According to the multicellular theory, these tumors originate from intercalated duct cells and myoepithelial cells of the salivary glands.

Prevalence • Can occur at any age but they develop more frequently in the 5th and 6th decade of life • Ten percent cases occur in children • More common among females than males (60:40) • It accounts for 60 to 65 percent of all neoplasms of the parotid, 50 percent of submandibular and 25 percent of sublingual gland • Approximately 45 percent of minor gland lesions are pleomorphic adenomas.

A

Clinical Features

B

C Figs 75.8A to C: Histologic appearance of radicular cyst under 4,10,40X magnification

• The cyst capsule is made up of vascular connective tissue, which is often infiltrated by chronic inflammatory cells.

PLEOMORPHIC ADENOMA (MIXED TUMOR) • It is also called enclavoma, branchioma, endothelioma, enchondroma.

• Eighty percent of tumors that occur in the parotid gland are benign: of these, 75 percent are pleomorphic adenomas and 5 percent are Warthin’s tumors. • Pleomorphic ad­enomas can occur in any location where minor salivary glands exist. • The two most common clinical presentations are a painless firm mass in the superficial lobe of the parotid gland and a painless firm mass in the posterior palatal mu­cosa. • Small, painless, quiescent nodule which slowly begins to increase in size, sometimes intermittently. • The growth is a slow growing firm mass and the patient will be usually aware of the lesion for months and years before seeking professional help in diagnosis and treatment. • The tumor tends to be round or oval when it is small, as it grows bigger it becomes lobulated, not more than 1 to 2 cm in diameter. • The minor gland neoplasms in the oral cavity frequently exhibit smooth surfaced, soft or slightly firm, domeshaped. • Nodular swellings on the hard or soft palate without any ulceration on the surface. • The palatal neoplasms are usually firm in consistency and are less movable due to the tough nature of the palatal mucosa, these lesions sometimes exhibits surface ulceration especially when traumatized. • Large intraoral lesions are often associated with distur­ bance in speech and mastication. • Malignant transformation is uncommon in pleomorphic adenomas but may occur on rare occasions.

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 istopathological Features H (Figs 75.9A and B) • Foote and Frazewell (1954) categorized the tumor histologically in following types: – Principally myxoid – Myxoid and cellular components present in equal proportion – Predominantly cellular – Extremely cellular • The epithelial component consists of epithelial duct like cells, polygonal cells, cuboidal cells, spindle cells arranged in different patterns. The epithelial cells may be arranged in sheets, clumps, islands or interlace strands. Cuboidal cells shows duct like arrangement. • These ducts like spaces may contain eosinophilic coagulum and mucoid material. Epithelial cells resembling squamous cells have distinct intercellular bridges. • Cystic spaces are also uncommonly seen. • Few stellate cells or spindle cells called myoepithelial cells are also seen with variable morphology. These cells have rounded eccentric nucleus and eosinophilic hyalinized cytoplasm resembling plasma cells. These cells are called plasmacytoid cells. • Hyaline cells are also seen with dense eosinophilic cytoplasm. • Squamous cells and keratin pearls may be present. Occasionally, there may be cribriform areas, suggesting the pattern of adenoid cystic carcinoma. • Glandular epithelium is mainly found. A neoplastic altered cell with the potential for multidirectional differentiation is histogenetically responsible for pleomorphic adenoma. • Malignant degeneration is possible within pleomorphic adenomas, and the incidence increases with tumor duration and size. Histologic features suggestive of malignant transformation include extensive hyalinization, cellular atypism, necrosis, calcification, and invasion.

A

SJÖGREN’S SYNDROME • It is a chronic inflammatory disease that predominately affects salivary, lacrimal and other exocrine glands. • It was first described by Henrik Sjögrenin in 1933 as a triad consisting of keratoconjuctivitis sicca, xerostomia and rheumatoid arthritis. • It predominately affects middle-aged and elderly women.

Types • Primary Sjögren’s – It is also called sicca syndrome – It consists of dry eyes (xerophthalamia) and dry mouth (xerostomia). Eye lesion called keratocon­junctivitis sicca • Secondary Sjögren’s syndrome – It consists of dry eyes, dry mouth and collagen disorders usually rheumatoid arthritis or systemic lupus erythematous.

Etiology • • • •

Genetic Hormonal Infectious Immunologic.

Clinical Features • Clinically, the mouth may appear moist in early stages of Sjögren’s syndrome but later, there may be a lack of the usual pooling of saliva in the floor of the mouth and frothy saliva may form along the lines of contact with oral soft tissue. In advanced cases the mucosa is glazed, dry and tends to form fine wrinkles.

B Figs 75.9A and B: Histologic appearance of pleomorphic adenoma under 4, 10X magnification

Chapter 75  Common Oral Pathologic Conditions Associated with Pediatric Dentistry • The tongue typically develops a characteristic lobulated, usually red surface with partial or complete depapillation. There is also decrease in number of taste buds, which leads to an abnormal and impaired sense of taste. • Female:Male ratio 10:1 • Painful burning sensation of oral mucosa. • Dryness of nose, larynx, pharynx and tracheobranchial tree is seen. • Some patients will present with fatigue and mild arthralgia, but most will be active and tolerant of their disease. • Many patients will have tooth loss secondary to caries. • The constant polyclonal B cell over activity selects a single clone (usually of B cells) that overtakes the population, resulting in a lymphoma. • Difficulty in eating dry food, soreness or difficulty in controlling dentures. • Pus may be emitted from the duct. Angular stomatitis and denture stomatitis also occur. • Dry mouth may be accompanied by unilateral or bilateral enlargement of parotid gland, which occurs in about one third of the patients and may be intermittent. • Enlargement of submandibular gland may also occur. • Soreness and redness of mucosa is usually the result of candidial infection.

Histopathology • There may be intense infiltration of the glands by lymphocyte cells replacing all acinar structure. • In some cases, there may be proliferation of ductal epithelium and myoepithelium to form epimyoepithelial island. • Lymphocytic infiltration of exocrine glands is the hallmark of Sjögren’s syndrome. In major salivary glands, the previously described benign lymphoepithelial lesion is considered typical. However, it is not consistently seen in minor salivary glands. • The parotid gland will show an early lymphocytic infiltration, acinar atrophy, and epimyoepithelial islands. Proliferation of ductal epithelium and myoepithelium to form ‘myoepithelial islands’ are seen in some cases.

Diagnostic Tests • Rose Bengal staining test: Keratoconjunctivitis sicca is characterized by corneal keratotic lesion, which stains pink when rose Bengal dye is used. • Schirmer test: The reduced lacrimal flow rate is measured by this test. A strip of filter paper is placed in between the eye and the eyelid to determine the degree of tears which is measured in millimeter. When the flow is reduced to less than 5 mm in a 5 minute sample, patient should be considered positive for Sjögren’s syndrome.

• Sialometry: Salivary flow rate estimation is a sensitive indicator of salivary gland function. Parotid glands make the major contribution to total salivary flow and are the most consistently affected glands in patients with Sjögren’s syndrome. Stimulated flow rate in symptomatic primary and secondary Sjögren’s syndrome is usually below 0.5 to 1.0 mL/minute (normal 1 to 1.5 mL/minute). • Sialochemistry: Parotid saliva in Sjögren’s syndrome contains twice as much total lipid and has elevated content of phospholipids and glycolipids than the normal saliva. The sodium chloride and phospholipids levels are higher in saliva of Sjögren’s syndrome patient.

ODONTOMA It is hamartoma of odontogenic origin in which both epithelial and mesenchymal cells exhibit complete differentiation with enamel and dentin laid down in abnormal position.

Types • Compound odontome: It consists of a completely disorganized and diffuse mass of odontogenic tissue with haphazardly arranged enamel, dentin and cememtum. • Complex odontome: Compound odontome presents collections of numerous small, discrete, tooth-like structures. Odontogenic tissues in compound odontome bear superficial anatomical resemblance to normal teeth.

Pathogenesis Hamartomatous proliferation of odon­togenic origin. It is thought that local trauma, infection and genetic mutations cause this proliferation of odontogenic epithelium. These result in unsuccessful or altered ecto­mesenchyme inter­action during early or later phases of tooth development leading to haphazard formation of enamel, dentin and cementum. Both the epithelial and mesenchymal cells exhibit complete differentiation with the result that functional ameloblasts and odontoblasts form enamel and dentin. It is laid down in an abnormal pattern because of failure of cells to reach the morpho differentiation stage.

Clinical Features • Seen mostly in 1st and 2nd decades of life • There is slight predilection for occurrence in males • Compound occurs in incisor, canine area of maxilla and complex occurs in mandibular 1st and 2nd molar area • Slow growing, expanding and mostly painless lesions. Pain and inflammation associated with odontomas occur only in four percent of cases.

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• In few cases, they may produce large, bony hard swellings of the jaw, with expansion of the cortical plates and displacement of the regional teeth. • Multiple odontomes can occur in the jaw simultaneously in some patients.

Radiographic Features • Complex odontome appears as an irregular mass of calcified material surrounded by narrow radiolucent bands with a small outer periphery (Fig. 75.10). • The compound odontome appear as numerous, small, miniature teeth or tooth-like structures, which are projecting from the roots of the erupted permanent teeth or above the crown of an impacted tooth (Fig. 75.11). • The complex odontome radiographically appears as round or oval or sunburst-like, conglomerated radiopaque mass within the jawbone.

Histopathology • Fully developed compound odontome histolo­gically reveals the presence of an encapsulated mass of multiple separate denticles, embedded in a fibrous tissue stroma. • A thin layer of cementum may be present about the periphery of the tumor. • Small islands of epithelial ghost cells are seen in the tumor, which are remnants of the odontogenic epithelium. • There is presence of enamel, dentin, cementum and pulp tissues, which are arranged in a similar fashion as seen in a normal tooth.

AMELOBLASTOMA • WHO definition: Solid multicystic ameloblastoma is polymorphic neoplasm consisting of proliferating odontogenic epithelium, which usually has a follicular or plexiform pattern, lying in a fibrous stroma. • Broca in 1868 was the first to report to ameloblastoma. • Ameloblastoma is a benign, locally invasive, polymorphic neoplasm, presumably derived from intraosseous rem­ nants of odontogenic epithelium. • It is the second most common tumor of the odontogenic tissues after odontomas. • Tumor may be derived from cell rests of enamel organ either remnants of dental lamina or remnants of Hertwig’s sheath the epithelial rests of Malassez.

Etiology

Fig. 75.10: Complex odontome

• • • • • •

Trauma Infection Previous inflammation Extraction of tooth Dietary factors Viral infection.

Clinical Features

Fig. 75.11: Compound odontome

• Commonly seen in second, third, fourth and fifth decade of life • More commonly in blacks than whites • Males are affected more often than females • Ameloblastoma in most of the cases involve the mandible (80%), especially in the molar-ramus area (70%) • Clinically ameloblastoma presents a slow enlarging, painless, ovoid or fusiform, bony hard swelling of the jaw. • Larger lesions of ameloblastoma often cause severe expansion, destruction and thinning of the cortical plates, which often result in “fluctuations” in the affected area. This thin shell of bone cracks under digital pressure and the phenomenon is called “egg shell crackling”. “Pathological fractures”, may occur in many such affected bones.

Chapter 75  Common Oral Pathologic Conditions Associated with Pediatric Dentistry • The mucosa overlying the tumor appears normal and the regional teeth are usually vital. • Many untreated lesions may reach to an enormous size with time and cause extensive deformity of the jaws and face, thereby leading to pressure sensation in the eyeball or nasal obstruction, etc. • Pain, paresthesia and mobility of the regional teeth may be present only in few cases. • Most of the patients report with a typical long time history of presence of an “abscess” or a ‘cyst’ in the jaw bone that was operated on several occasions but has recurred after each attempt.

Radiological Findings (Fig. 75.12) • Multilocular type: Bone is replaced by a number of small, well-defined radiolucent areas giving honeycomb or larger soap bubble appearance. • Unilocular type: Well-defined area of radiolucency that forms single compartment.

Histological Variants • Follicular type – Most common and constitutes about 32 percent among all ameloblastomas. – Follicular islands consist of central mass of polyhedral cells or loosely connected angular cells resembling stellate reticulum. Surrounded by peripherally arranged cuboidal or columnar cells resembling inner  enamel epithelium or preameloblasts (Figs 75.13A and B). • Plexiform type – Second most common—28 percent among amelo­ blastomas. – Tumor epithelium is arranged as a network which is bound by a layer of cuboidal to columnar cells and include cells resembling stellate reticulum (Figs 75.14A and B). – Cyst formations occur due to stromal degeneration rather than cystic changes within epithelium.

Ameloblastoma Acanthomatous Type • Third most common—12 percent among ameloblastoma. • Usually in follicular type, there is extensive squamous metaplasia, sometimes with keratin formation within islands of tumor cells (Fig. 75.15).

Desmoplastic Type It occurs mostly in old age (Fig. 75.16).

CHERUBISM

Fig. 75.12: Ameloblastoma

A

• Cherubism is a rare benign hereditary condition/being inherited as an autosomal dominant which affects only the jawbones of children bilaterally and symmetrically, usually producing the so called cherubic look. • Cherubism, a non-neoplastic hereditary bone lesion.

B Figs 75.13A and B: Follicular ameloblastoma on 4, 10 X

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B

A

Figs 75.14A and B: Plexiform ameloblastoma on 4, 10 X

Fig. 75.15: Ameloblastoma acanthomatous type on 10 X

Types According to Ramon and Engelberg • Grade I: Involving ascending ramus on both sides • Grade II: Involving ramus with maxillary tuberosities bilaterally • Grade III: Involvement of whole maxilla and mandible except for condylar process • Grade IV: Same as grade III along with involvement of floor of orbit.

Clinical Presentation • The disease commonly affect between 1 to 5 years of age • More common among males than females

Fig. 75.16: Desmoplastic type

• The disease follows a familial pattern and several members of the same family may be affected • Cherubism does not occur in any other bone and will not cross a bony suture to an adjacent bone • At birth the appearance of the patient is absolutely normal. However, between the age of 1 and 5 years a bilateral, painless, symmetric swelling develops in mandible or sometimes in maxilla in severe cases. • Is very extensive, pressure on the floor of the orbit may result in an upward turn of pupils of the patient’s eyes and thus revealing a rim of white sclera below the iris; this phenomenon is often referred to as the “heavenward look”. Hence the name cherubism is given as cherub means angel. • The child will present with nasal obstruction, lympha­ denopathy, dry mouth, drooling, missing teeth, multiple diastemas, and misplaced teeth.

Chapter 75  Common Oral Pathologic Conditions Associated with Pediatric Dentistry

Radiographic Features

Histopathology Features

• “Cyst-like” radiolucent areas or cavities on both sides of mandible • The initial destruction of bone starts at angle of the mandible, which can be detected by X-rays even before the clinical manifestation of the disease. • Cherubism in later stages causes severe bilateral expan­ sion of the jaw with thinning of the cortical plates. • In few cases, there may be presence of tin classic ‘ground glass’ appearance in cherubism. • Sometimes, multiple unerupted and displaced teeth appear to be floating within the cyst like spaces and the condition is often referred to as ‘floating tooth syndrome.’

• The lesions of cherubism consist of a vascular fibrous stroma, extravasated erythrocytes, and scattered multi­ nucleated giant cell. • An increase in the amount of fibrous tissue and a corres­ ponding decrease in the number of giant cells is probably associated with regressing lesions. • Clinical and radiographic correlation is necessary, as the histologic features strongly resemble those seen in central giant cell tumors and the lesions of hyperparathyroidism. • A distinctive feature of the disease is the presence of an “eosinophilic perivascular cuffing” of collagen fibers, which often surrounds the blood capillaries.

POINTS TO REMEMBER • Cyst is a pathological cavity containing fluid, semifluid or gas, which is usually lined by epi­thelium and is not formed by the accumulation of pus. • Dentigerous cyst is the developmental odontogenic cyst of epithelial origin which encloses the crown of an unerupted tooth by expansion of its follicle and is attached to the neck. Most of them are discovered on radiographs when these are taken because a tooth has failed to erupt or a tooth is missing. It is composed of thin cystic wall of nonkeratinized stratified squamous epithelium. • Odontogenic keratocyst (OKC) is a developmental odontogenic cyst of epithelial origin developed from cystic degeneration of the cells of the stellate reticulum in a developing tooth germ. Keratocysts often radiographically present multilocular radiolucent areas, with a typical “soap-bubble” appearance. Histologically they have both orthokeratinized and parakeratinized epithelium. Characteristic feature of the lining of epithelium between 5 to 8 cell layers without rete ridges. • Radicular or periapical cyst is the most common odontogenic cystic lesion of inflammatory origin, which occurs in relation to the apex of a nonvital tooth. Radicular cysts present well-defined, unilocular, round shaped radiolucent areas of variable size and histologically epithelium is nonkeratinized and it often show localized areas of increased cell proliferation by enclosing or encircling a mass of connective tissue capsule from all sides called “arcading pattern.” • Pleomorphic adenoma is a benign neoplasm consisting of cells exhibiting the ability to differentiate to epithelial (ductal and nonductal) and mesenchymal (chondroid, myxoid and osseous) cells. Presents as small, painless, quiescent nodule which slowly begins to increase in size, sometimes intermittently. It can be myxoid or cellular. Compound odontome is a diffuse mass of odontogenic tissue and complex odontome is collection of small tooth like structures. • WHO defines ameloblastoma as polymorphic neoplasm consisting of proliferating odontogenic epithelium, which usually has a follicular or plexiform pattern, lying in a fibrous stroma. Ameloblastoma is a benign, locally invasive, polymorphic neoplasm, presumably derived from intraosseous remnants of odontogenic epithelium. It may be derived from cell rests of enamel organ either remnants of dental lamina or remnants of Hertwig’s sheath and epithelial rests of Malassez. Mandibular molar ramus are is most favored. Starts as slow growing bony hard swelling whereas large lesions of ameloblastoma often cause severe expansion, destruction and thinning of the cortical plates called “egg shell crackling.” Radiographically presents as well-defined radiolucent areas giving honeycomb or larger soap bubble appearance. Its histological variants are follicular, plexiform, acanthamatous and desmoplastic type. • Cherubism is a rare benign hereditary condition/being inherited as an autosomal dominant which affects only the jawbones of children bilaterally and symmetrically, usually producing the so called cherubic look.

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Pediatric Oral Pathology

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8. 9.

Define cysts and classify the oral mucosal lesions. Describe the etiopathogenesis, clinical features, radiographic and histologic picture of dentigerous cyst. Explain the radiographic and histological features of OKC. What is radicular cyst? Describe pleomorphic adenoma in detail. What are the clinical features and diagnostic tests for Sjorgen’s syndrome? Write a note on odontome. What is ameloblastoma? Classify its histological variants. Write a note on cherubism.

BIBLIOGRAPHY 1. Aldred MJ, Cameron A. Pediatric oral medicine and pathology. In: Cameron AC, Widmer RP, (Eds). Handbook of pediatric dentistry. 3rd Edn. St. Louis, MO: Mosby Elsevier; 2008.pp.169-216. 2. Bezzera S, Costa I. Oral conditions in children from birth to 5 years: the findings of a children’s dental program. J Clin Pediatr Dent. 2000; 25:79-81. 3. Finkelstein MW. A Guide to Clinical Differential Diagnosis of Oral Mucosal Lesions Crest-Oral-B Continuing Education Course, Revised 2013. 4. Langlais Rp, Miller CS. Color Atlas of Common Oral Diseases. Philadelphia, Lea & Febiger; 1992. 5. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology, 3rd Edn. WB Saunders Co, Philadelphia; 2009. 6. Neville BW, Damm DD, White DK. Color Atlas of Clinical Oral Pathology, 2nd Edn. Lippincott Williams & Wilkins Co, Philadelphia; 1999. 7. Regezi JA, Sciubba J (Eds). Oral Pathology: Clinical-Pathologic Correlations, 2nd Edn. Philadelphia, WB Sanders; 1993.

16

SECTION

FORENSIC PEDODONTICS

This unit discusses about forensic pedodontics which helps in diagnosing the physical abuse and neglect to the children.

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CHAPTER

Child Abuse and Neglect Nikhil Marwah

Chapter outline • • • •

Historical Background Definitions Characteristics of Child Abuse Physical Child Abuse

Childhood should be a care-free time of life filled with love, new world to explore and with joy of mastery of oneself and the environment. However, for many children, this is only a dream, not reality. Child abuse and neglect (CA/CN) is an increasing social problem not limited to medical, legal or social service professions. The dentist treating the children must also be able to detect, document, report and often help manage these needy patients and their families.

• • • • •

Child Sexual Abuse Child Neglect Munchausen Syndrome by Proxy Battered Child Syndrome Role of Pedodontist in Child Abuse and Neglect

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In 1974, Child Abuse Prevention and Treatment Act was signed into law. For the first time, it established within the federal government—National Center on Child Abuse and Neglect. The contribution of dentists to recognition of CA/CN emerged during late 1960s. Initially, dentistry focused on the forensic aspects of battered child syndrome and homicide. Only recently has the dental profession seriously considered its role in detecting and reporting CA/CN.

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HISTORICAL BACKGROUND •

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A review by Radbill (1973) indicated that historically, children were considered to be their parent’s property, having a few rights of their own. It was taken for granted that parents and guardians had every right to treat their children as they wished. The first documented and reported case of CA/CN occurred in 1874 with a child named Mary Ellen. In 1946, in a classic article by Caffey, some common features of CA/CN were first described, and it reported the common association of subdural hematomas and long bone pathosis. In 1962, the term battered child syndrome was coined by Henry Kempe (Fig. 76.1) in his milestone article. It was further elaborated by Kempe and Helfer in 1972.

DEFINITIONS •

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Child abuse: According to Gill 1968, it is defined as the ‘nonaccidental physical injury, minimal or fatal, inflicted upon children by persons caring for them’. It is an overt act of commission of a caretaker—physical, emotional or sexual. Battered baby: A child who shows clinical or radiographic evidence of lesions. (PITS) (Caffey) or Parent–Infant Traumatic Stress Syndrome’ that are frequently multiple and involve mainly the head, soft tissues, long bones and the thoracic cage, and that cannot be unequivocally explained (Selwyn, 1985). Neglected child: It is one who shows evidence of physical or mental health primarily due to failure on the part of the parent or caretakers to provide adequately for child’s needs.

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Forensic Pedodontics

Persecuted child: It is one who shows evidence of mental ill health caused by a deliberate infliction of physical or psychological injury that is often continuous in nature. Forensic science: It refers to areas of endeavor that can be used in a judicial setting and is accepted by the court and the general scientific community to separate truth form untruth. It deals with the study of collection of information connected with the crime. Forensic odontology: It is defined as the branch of odontology, which deals with the proper handling and examination of dental evidence and with the proper examination of dental evidence and with the proper evaluation a presentation of dental findings in the interest of justice (Pederson, 1969). Sexual abuse: Child sexual abuse to include contacts or interactions between a child and an adult when the child is being used for the sexual stimulation of the perpetrator or another person. Dental neglect: The failure by a parent or guardian to seek treatment for visually untreated caries, oral infections and/ or oral pain, or, failure of the parent or guardian to follow through with treatment once informed that the above condition(s) exists.

CHARACTERISTICS OF CHILD ABUSE The abused child

The abuser

When all forms of child abuse are considered, the distribu on between male and female is nearly equal. Some of the iden fying features of the abused child are: • Unduly afraid or passive child • Evidence of prolonged confinement like delay is speech • Evidence of repeated skin or other injuries • Child is undernourished and is given inappropriate food or drink • Evidence of poor overall care. • Child is cranky irritable or cries easily • Physically abused children were more aggressive than neglected.

Child abuse can occur in any cultural, occupa onal, socioeconomic and ethnic group but a higher incidence is found in minority and low-income families. One parent is the ac ve ba erer, whereas the other passively approves of this maltreatment. The parent o en has a history of being abused personally, so this prac ce is passed down for one genera on to the other. Parents may have following characteris cs, which may indicate abusive behavior: • Poor self-esteem • Violent temper or outbursts. • Overly cri cal behavior towards the child • Embarrassment when discussing child’s trauma • Avoidance of looking at or touching the child.

Types of Child Abuse and Neglect 1.

• Physical abuse • Sexual abuse • Failure to thrive

2.

• Inten onal drugging or poisoning • Munchausen syndrome by proxy • Health (Medical) care neglect • Dental neglect • Safety neglect

3.

• Emo onal abuse and neglect • Physical neglect

PHYSICAL CHILD ABUSE (Nonaccidental trauma) is one of the most common types of child abuse with the incidence being more than 10 percent. Physical abuse is probably the most important subtype of child maltreatment, because without intervention and services, it is potentially fatal. Often the injury stems from an angry response of the caretaker to punish the child for misbehavior. Although many child abuse cases are based on physical findings but history is a helpful tool when child reports with nondescriptive findings.

History •

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Eyewitness history: This usually has three aspects: i. Child himself states that injury is caused by parent ii. One parent accuses the other about the injury iii. Parent accepts that one of the many injuries is caused by him but not all. Unexplained injury: Some parents or caretakers deny knowledge of the injury; others can tell about the injury but can offer no explanation as to how the injury happened. They hope others believe that the injury was spontaneous. When pressed, they may become evasive or offer a vague explanation. These explanations are selfincriminating. As most parents know exactly how, where, and when their child was hurt. Implausible history: Many parents offer an explanation for the injury, but one which is implausible and inconsistent with common sense like describing a minor injury whereas the marks on the child prove otherwise. Alleged self-inflicted injury: An alleged self-inflicted injury in a small baby is most serious. In general, if a child cannot crawl, he can not cause self injury.

Chapter 76 Child Abuse and Neglect •

Delay in seeking medical care: Most nonabusive parents seek immediate care when their child is injured. In contrast, some abused children are not presented for care for a considerable length of time even in major injury. Another feature of abusive parent will be that he will not accompany the child to the healthcare facility.

DaƟng bruises Age 0–2 days 0–5 days 5–7 days 7–10 days 10–14 days 2–4 weeks

Bruises in Physical Child Abuse •

Inflicted bruises: Occur at typical sites or fit in recognizable patterns. Accidental bruises: A thorough knowledge of common and unusual accidental bruising will help in recognizing inflicted injuries. Understanding unusual customs or practices that leave bruises is also helpful. Lastly, it is important to remember that all bluish discolorations of the skin are not bruises. Most children acquire 1 or 2 bruises in daily activity like on knee and legs while walking and on forehead while jumping. The characteristics of these are similar to grab marks or abuse marks, however, the accidental bruises mostly lie over bony prominences whereas the abuse marks are on soft tissues. Unusual bruises: Some common ethnic practices can result in bruises that should not be confused with child abuse. The Vietnamese can induce symmetrical, linear bruises, from coin rubbing (Cao giÓ). For symptoms of fever, chills, or headaches, the back and chest are covered with oil and then massaged in downward strokes with the edge of a coin. Pseudo bruises: Some skin conditions like Mongolian spot or allergic periorbital discolorations, Haemophillus influenza may give appearance abusive marks.

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LocaƟon of bruise • Genital or inner thigh

BuƩocks and lower back (Paƫng) Genitals and inner thighs Cheek (Slap marks) Earlobe (Pinch marks) Upper lip and frenum (Forced feeding) Neck (Choke marks)

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Vascularity of the tissue injured: Bruising in the loose and highly vascularized tissues around the eyes is more pronounced than skin in areas such as the palm of the hand or the soles of the feet. Age: Children and the elderly bruise more easily because of loose delicate skin. Metabolic rate: Women bruise more easily than men. Medications: Such as aspirin can increase bleeding.

IndicaƟve of • Toilet mishaps or sexual abuse

• Cheeks

• Slapping of child

• Earlobes

• Pinching or pulling

• Upper lip/labial frenum

• Impa ent or forceful feeding

• Neck

• Strangula on

• Circumferen al bruises on ankles/wrists

• Placement of restraints

• Corners of mouth

• Gagging of child

Marks in Physical Child Abuse

Variables Affecting the Appearance of Bruises •

Normal skin color: The pigmentations on stain may affect the observation of a bruise. Mass and velocity of the impact: May have an influence on the depth and surface of the injury, as well as the rate of healing. For example, deep subcutaneous injury can prolong bleeding time or previous bruising at the same site may affect subsequent bruising by increasing the rate of resolution. Time of injury: The time of appearance of bruise is related to the time required for the extravasated blood to reach the surface. This lag time will allow antemortem bruises to appear postmortem. Other factors that affect bruising: Rapidity of death after injury and environmental conditions.

Type of Abuse

Typical sites for inflicted bruises • • • • • •

Color Swoollen, tender Red, blue, purple Green Yellow Brown Cleared

•

Human hand marks: These are classified here. The most common type is grab marks which is oval-shaped bruise that resemble fingerprints due to holding of child in violent shaking. Some of the nonabusive grab marks are when the parent holds the child’s legs to help him walk or on the cheeks, if an adult squeezes it in an attempt to get food or medicine into his mouth leaving a thumb mark bruise on one cheek and 2 to 4 fingermark bruises on the other cheek. Strap marks: These are 1 to 2 inches wide, sharp-bordered, rectangular bruises of various lengths, sometimes covering a curved body surface often caused by a belt.

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Forensic Pedodontics

Lash marks: These are narrow, straight, edges bruises or scratches caused by thrashing with tree branch or switch. Loop marks: These are secondary to being struck with a doubled-over lamp cord, rope or fan-belt. The distal end of the loop strikes with the most force, commonly breaking the skin and leaving loop-shaped scars. Bizarre marks: These are always inflicted when a blunt instrument is used in punishment with the resulting bruise that will resemble it in shape. Circumferential tie marks: These are present on the ankles or wrists and are caused, when a child is restrained. If a narrow rope or cord is used, the child will be left with circumferential cut. If a strap or piece of sheet is used to restrain a child about the wrists or ankles, a friction burn or rope burn may result, usually presenting as a large blister that encircles the extremity. Gag marks: Seen as abrasions that appear near the corner of the mouth. Children may be gagged because of screaming or yelling.

Victim • • •

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CHILD SEXUAL ABUSE This has increased dramatically over the last decade. An estimate of the incidence of the number of sexual assaults on children at 3 lakhs annually but authorities agree that these estimates are probably low, due to underreporting as a result of a number of factors: • Cultural mores make sexual abuse a stigma for victim, perpetrator, and family and an issue not easily broached. • Victims are often young children whose fear, lack of awareness, or lack of language skills make them easy prey and victims who may not be ready or believable witnesses. • Health professionals may be unaware of the signs or symptoms of child sexual abuse. • Child sexual abuse often is hidden with no visible physical manifestations. • Health professionals may be unwilling to report cases of sexual abuse where clear physical evidence is lacking for fear of error, reprisal or loss of patients. • Verification of sexual abuse by physical examination may be beyond the legal extent of practice of many professionals. • Lack an accepted definition of sexual abuse. Federal statues define sexual abuse in the context of child abuse and include such acts like child pornography, rape, molestation, incest, and child prostitution. National Center on Child Abuse and Neglect offers a more general definition of child sexual abuse to include contacts or interactions between a child and an adult when the child is being used for the sexual stimulation of the perpetrator or another person. It can also be defined as any sexual activity with a child under age 18 by an adult.

The sexually abused child is most often a female, with the ratio of victimized females to males of 9:1. Children of all ages are abused sexually but those in the early teens seem to be most at risk. Most offenders are family related, some are family acquaintances and the least common are strangers. This close relationship between victim and perpetrator compounds the problem of reporting which leads to a victim who may be abused repeatedly. The psychological profiles of sexually abused children vary widely and appear to have some relation to age, closeness to perpetuator and the type of abuse. Young children often do not suffer long-term effects of sexual abuse as they do not identify the act with society’s concepts of right and wrong. Some of the features that are noted are: – Emotional effects – Functional disturbances such retention of feces – Frequent masturbation – Preoccupation with the genital area – Regression in behavior – Guilt and anxiety.

Perpetrator •

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The perpetrator of sexual abuse is no longer considered to be the impersonal stranger who victimizes an unknown child. The numbers of sexual assaults by those familiar to the child have increased dramatically. The type of abuse may characterize the perpetrator. Incest most often is committed by a male parent against a female child. The father may have one of several profiles like, he may be abusive or shy or withdrawn; sexual problems with spouse or alcoholism. Mother-son, or father-son incest is less common, but indicates psychological pathosis.

Act •

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Types include molestation (fondling or masturbation), intercourse (vaginal, anal, or oral intercourse on a nonassaultive basis), or family-related rape. Pregnancy or venereal disease may be the sequelae of repeated sexual abuse. The act of sexual abuse is rarely a singular event, if perpetrated by someone familiar to victim. In many cases, abuse may involve repeated fondling of genitals or other body parts. Of interest to dentists is the association of oral features with child sexual abuse due to kissing or oral penetration.

Chapter 76 Child Abuse and Neglect CHILD NEGLECT

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Nutritional Neglect •

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Failure to thrive can be defined as an underweight, malnourished condition who has a weight that is below the third percentile and a height and head circumference that are above third percentiles on growth curves. On physical examination, the infants have gaunt faces, prominent ribs, wasted buttocks, and spindly extremities and is expressed in first 2 years of life. The causes of failure to thrive are estimated as 30 percent organic, 20 percent underfeeding due to understandable error and 50 percent underfeeding from parental neglect. The mother may neglect to feed her baby because she feels overwhelmed with responsibilities or is chronically depressed and hostile toward the baby.

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Safety Neglect •

Healthcare Neglect •

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When a child with a treatable chronic disease has serious deterioration of the condition because the parents or caretakers repeatedly ignore healthcare recommendations, healthcare neglect occurs. Healthcare neglect may occur in situations where an emergency exists and the parents or caretakers will not acknowledge it as much. Refusals because of religious beliefs also lead to healthcare neglect. The child’s right, however, to life and health must override the parents or caretakers constitutional right to religious freedom. If the disease is incurable, the parents or caretakers wishes regarding non-intervention; be they religious or philosophical, often are respected.

•

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The problem of dental neglect is ubiquitous; yet, only recently has been defined apart from the broader category of child abuse and neglect. Consequently, the recognition and report of dental neglect by professionals has been difficult.

Physical Developmental Behavioral

Although most accidents are due to a breach in safety and theoretically could have been prevented, the interruption of the fateful event would have required unusual prediction and timing on the part of the parent or caretaker. These are legitimate accidents, and every child has some. Safety neglect, however, has occurred when injury results from lack of supervision. These situations usually involve children younger than 4 years of age, when it is important that parents directly supervise them. This leads to injuries like burns, poisonings, falls because children are not being watched.

Emotional Neglect • • •

Dental Neglect

Child neglect occurs when a parent or caretaker deliberately or unintentionally permits the child to experience suffering or falls to provide the necessities for the child’s physical, emotional and intellectual developments. Ad Hoc Committee on Child Abuse and Neglect of the American Academy of Pediatric Dentistry defined dental neglect as: The failure by a parent or guardian to seek treatment for visually untreated caries, oral infections and/or oral pain, or, failure of the parent or guardian to follow through with treatment once informed that the above condition(s) exists.

Emotional abuse can be defined as the continual scapegoating and rejection of child by parent or caretaker. Severe verbal abuses are also apart of emotional abuse and so is the neglect of student by teacher. Emotional abuse is often difficult to detect and involves: – Severe psychopathology and disturbed behavior in child of a degree making it unlikely that he will be able to function and cope as an adult – Abnormal child rearing practices of the parent that have caused behavior disturbances in child – Refusal by the parent to get the treatment for the child.

Effects on children of neglect (Skuse, 1993) Infant Pre-school School child FTT Short/thin Short/thin Dirty infect skin nappy rash Dirty, unkempt thin hair Dirty, unkempt thin hair Generalized delay quiet Language delay Learning difficul es Poor a en on immature Lacks confidence immature Anxious Overac ve Over-ac ve Avoidant unresponsive Aggressive over friendly Aggressive withdrawn No peer or friends Wet, soils the bed

Young person Short/thin/obese Dirty, unkempt delayed puberty School failure School truancy Smoking, drinking, substance misuse Runs away Sexual precocity Stealing, lying, self-harm

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Forensic Pedodontics

Physical Neglect Failure to care for children according to accepted or appreciated standard. This is usually coaxial with physical abuse and involves presentation of child with dirty hair, dirty or insufficient clothing, inadequate lunches, incomplete immunization, unsanitary home environment and inadequate after school supervision.

MUNCHAUSEN SYNDROME BY PROXY • •

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Munchausen syndrome was first described by Dr Richard Asher in 1951. He reported adults who fabricated symptoms about themselves and produced signs of illnesses. They presented themselves for medical care but did not inform the medical professional about the deception. On the other hand in cases of Munchausen syndrome by proxy, a parent or caretaker attempts to bring medical attention to themselves by injuring or inducing illness in their children. Dr Roy Meadow first coined the term “Munchausen syndrome by proxy” to describe the preservation of the deception in regard to the child. This describes children who are victims of parentally fabricated or induced illness. The fabricated symptoms and signs lead to unnecessary medical investigations, hospital admissions, and treatment. The mother often is a nurse or has a similar illness herself. Factitious symptoms are often of bleeding from various sites. If specimens are requested, the mother adds her own blood to the material. Factitious signs include recurrent sepsis from injecting contaminated fluids, chronic diarrhea from laxatives, fever from rubbing thermometers, or rashes from rubbing the skin or applying caustic substances.

BATTERED CHILD SYNDROME It was Dr C Henry Kempe monumental work published in 1962 in the Journal of the American Medical Association which brought the full impact of physical maltreatment to the medical community and subsequently, to the attention of the general public. His article was entitled, “The Battered Child Syndrome”. The impact of Dr Kempe’s publication led to the passage of laws (1963 to 1968) in all states requiring health professionals to report to welfare departments and/ or police departments. However, it is important to realize that the “battered child syndrome” is only one small, even though severe, portion of the physical abuse of children.

ROLE OF PEDODONTIST IN CHILD ABUSE AND NEGLECT If the initial examination reveals trauma including oral cavity and it is within the scope of the attending dentist, the

definitive treatment should begin. In suspected cases of child abuse, follow-up dental care may not be possible because of lack of familial compliance or delay in disposition of the case by the investigating agency. The dentist’s role in identifying and preventing child abuse is as follows: • To observe and examine any suspicious evidence that can be ascertained in office. • To record according to the law, any evidence which may be helpful in the case. • To it any dental injuries. Dentist should be acquainted with management of injuries to both primary and permanent dentitions. • To establish and maintain a professional therapeutic relationship with the family. • To transfer the child to a physician or hospital for proper care.

Intervention and Prevention Once a case of child abuse is suspected and reported, the multidisciplinary team of the institution initiates the screening process. A pedodontist can contribute towards prevention of this Criminal Act by understanding various issues related to child abuse and applying them at different levels. • Primary level: Dentist should follow approaches, which are applicable to a population in general, without targeting a particular high-risk group. – Greater attention should be given towards screening children at a higher risk of maltreatment. – Parents at risk for abusing children are frequently very needy themselves, so they need to be screened and counseled. – Comprehensive evaluation of child and family situation should be done assisted by a social worker and mental health professional. • Secondary level: Concerns and effects directed to those who are known to be especially at high-risk. – The pedodontist must recognize his limitation and assume responsibilities for applying an interdisciplinary approach. – Goal of intervention should be to enhance parenting capabilities to enable them to a more adequate care for their children and avoid possible maltreatment. • Tertiary level: It refers to intervention after the condition is already identified. Prevention is considered, as the goal is to prevent recurrence of the condition. – Pedodontist should ensure that child is referred to a designated child protection agency. – He should not make the report and disengage, as he often has valuable information, which might help in treatment and monitoring the situation.

Legal Aspects A dentist should be well versed with current legal system for child protection. A separate doctrine ‘Parens Patriae’

Chapter 76 Child Abuse and Neglect

Fig. 76.1: Types of child abuse

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Forensic Pedodontics

is important in understanding laws developed to protect children. Dentists should know the definitions of child abuse and existing related laws proposed under the Draft Model Child Protection Act 1977, to protect himself and apply it correctly in such cases. The same laws that mandate dentists to report suspected abuse often also protect them from legal litigation, often brought by angry or vengeful parents. This law also makes the dentist liable for any damage to child caused by the failure to report abuse. Although the laws vary from State-to-State, generally the dentist who fails to report such case is considered guilty of sample misdemeanor and is subject to a fine or jail sentence, usually 30 days in length. In most situations, parents can be informed as follows, “Based on my training, I am concerned that this injury could not have happened this way. Because of this, I am required by law to make a report to child protective services”. The principles that a dentist must remember in forensic pedodontics: • Should be fully aware of legal standards of care and legal responsibilities • Records should be made in presence of patients • Should keep legibly written, accurate case records • Should keep update knowledge • Diagnostic tools like radiographs should always be used

•

Should always consult a legal or medicolegal expert to review insurance policies or any financial or legal matter.

Management of a Child Abuse Patient •

Many institutions, especially schools and hospitals, teams have been set-up to discuss management of cases and whether or not a report to the state agency ought to be filed. Ideally, such teams consist of representatives of different disciplines and different ethnic groups. A team offers the ideal approach to deal with the complex and frequently painful situations. They offer a shared responsibility and remove some of the burden placed on the individual. When a report is made then it goes through a screening process in the state agency. Depending on the state of urgency of the circumstances, the agency then investigates the case immediately or within a set time frame. This evaluation generally includes meeting with key family members, a home visit, and contact with professionals involved with the family such as a physician, dentist or teacher. The investigation determines whether or not the report is substantiated. If not, there still remains the possibility

Chapter 76 Child Abuse and Neglect

•

•

that services can be offered on a voluntary basis, which the family can choose to accept or reject. When the case is substantiated a service plan is developed. Once a report has been substantiated, the social worker needs to assess the degree of the child’s immediate risk so as to determine the appropriate placement. In the majority of cases, the child will remain in the home, but when there is serious concern about the child’s safety, he will be removed. This is avoided because removing the child will cause deleterious psychological impact when an abused child when taken out of the home and placed away from the security of loved family members. For example, this could exacerbate the guilt felt by a child for “provoking” family problems. In such cases, it is best for the adult perpetrator to move out. When children are placed out of the home, reunion of the family is always the ultimate goal. Visits of the family are arranged. At first, these are supervised by a social worker in an office. Should these contacts go satisfactorily, visits gradually might be increased in frequency, length, and become unsupervised. In contrast, if visits present major difficulties for the child, they might be shortened, and become less frequent. A comprehensive social service plan should be developed as soon as possible that identifies the needs of the family

and implements the appropriate services to meet these needs. In addition, clear goals should be articulated to the family in a supportive but for the right manner. It is critical that difficulties be addressed, both for individuals and the family as a whole. Frequently, a graduated stepwise approach is necessary. The social worker can be valuable in helping the family to obtain services and welfare benefits that they might be entitled to. These include payments for disabled children, or nutrition supplements for pregnant women, infants, and young children. Guidance in securing reasonable housing, help with transportation to important intervention programs, and information on work opportunities might be needed. Social worker can facilitate the development and learning of abused children by placing the intervention programs, therapeutic day care or advocating a suitable school program. It is valuable to include the parent in plan, to support and improve their parental skills. Social isolation is known to be an important, relate of child abuse, so it is important to facilitate supportive relationships within the extended neighborhood, and community. Monitoring the family situation and coordinating services are the crucial functions of the social worker as he must be empathic and supportive, persistent in pursuing needed services, and astute and sensitive in working with families.

POINTS TO REMEMBER • • • • •

•

• • • • •

The first documented and reported case of CA/CN occurred in 1874 with a child named Mary Ellen. In 1962, the term battered child syndrome was coined by Henry Kempe Child abuse is defined as the ‘non accidental physical injury, minimal or fatal, inflicted upon children by persons caring for them’. It is an overt act of commission of a caretaker—physical, emotional or sexual. Neglected child: It is one who shows evidence of physical or mental health primarily due to failure on the part of the parent or caretakers to provide adequately for child’s needs. Forensic odontology is defined as the branch of odontology, which deals with the proper handling and examination of dental evidence and with the proper examination of dental evidence and with the proper evaluation a presentation of dental findings in the interest of justice. Dental neglect is the failure by a parent or guardian to seek treatment for visually untreated caries, oral infections and/or oral pain, or, failure of the parent or guardian to follow through with treatment once informed that the earlier discussed condition(s) exists. Identifying features of the abused child are unduly afraid or passive child, delay in speech, repeated skin injuries, undernourishment and poor overall care. Various types of child abuse are physical and sexual abuse and various types of neglect are emotional, physical, mental, dental, safety and nutritional. Location of bruise is a significant indicator of type of abuse, e.g. bruise on genitals or thighs indicate sexual abuse; cheeksphysical abuse; circumferential marks on legs and hands-placement of restraints. Marks in physical child abuse are human hand marks, Strap marks, Lash marks, bizarre Marks, circumferential tie marks and gag marks. Role of a pediatric dentist in identification and reporting of abused child is to observe, examine and record any suspicious evidence, to maintain a professional therapeutic relationship with the family and to transfer the child to a physician or hospital for proper care.

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QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Define child abuse and give the characteristics of the abused and abuser. Describe physical abuse with special reference to the bruises. Write a note on child sexual abuse. Explain the phenomenon of child neglect and its various implications. What is battered child syndrome? Describe the role of pedodontist in child abuse and neglect.

BIBLIOGRAPHY 1. Casamassimo PS. Child sexual abuse and pediatric dentist. Ped Dent. 1986;8(Spl 1):102-5. 2. Child abuse reporting laws. J Am Dent Assoc. 1967;75:1070. 3. DeFrancis Y, Lucht C. Child abuse legislation in the 1970s. Revised Edition. Denver: The American Humane Association Children’s Division, 1974. 4. Gammon JA. Ophthalmic manifestations of child abuse. In child abuse and neglect: a Medical Reference, EJ1erstein NS, edition. New York: John Wiley and Sons. 1981.pp.121-39. 5. Hazelwood AI. Child Abuse: The dentist’s role. New York Stat. Dent J. 1970;36:289-91. 6. Jaffe AC, Dynneson L, Ten Bensel RW. Sexual abuse of children, an epidemiologic study. Am J Dis Child. 1975;129:689-92. 7. Johnson CF, Showers J. Injury variables in child abuse. Child Abuse Negl. 1985;9:207. 8. Kempe CH, Silverman FN, Steele BF, Droegemuelkr W, Silver HK. The battered child syndrome. J Am Med Asso. 1962;181:17. 9. Krugman RD, Krugman MK. Emotional abuse in the classroom: The pediatrician’s role in diagnosis and treatment. Am J Dis Child. 1984;138:28-S6. 10. Laskin DM. The battered-child syndrome. J Oral Surg. 1973;31:903. 11. Laskin DM. The recognition of child abuse. J Oral Surg. 1978;36:349. 12. Luther SL, Price JH. Child sexual abuse: a review. Sch Health. 1980;50:1-5. 13. Merten OF, Radkowki MA, Leonidas JC. The abused child: a radiological reappraisal. Radiology. 1983;146:377-81. 14. National Study of the Incidence and Severity of Child Abuse and Neglect: May 1, 1979 to April 30, 1980, Denver: American Humane Association, 1981. 15. Schmitt BD. The child with nonaccidental trauma, in The battered child. Kempe CH, Helfer RE (Eds). Chicago: University of Chicago Press; 1980.pp.128-46. 16. Schwartz S, Woolridge E, Stege D. Oral manifestations and legal aspects of child abuse. J Am Dent Assoc. 1977;95:586-91. 17. Shamroy JA. A perspective on childhood sexual abuse. Soc Work. 1980;25:128-31. 18. Simley DO. Abused and neglected. J Wisc Dent Assoc. 1975;51:377. 19. Teuscher CW. The battered child: a social enigma. J Dent Child. 1974;41:335-6. 20. Wilson EF. Estimation of the age of cutaneous contusions in child abuse. Pediatrics. 1977;60:750-2.

77

Chapter

Bite Marks Nikhil Marwah, Kirti Asopa

Chapter outline • • •

• • • •

Factors Influencing Appearance of Bite Marks Bite Mechanisms Identification of Bite Marks

One of the most intriguing, complex and sometimes contro­ versial challenges in forensic dentistry is the recognition, recovery and analysis of bite marks. These can be defined as marks caused by teeth alone or in combination with other oral parts. These can be on the skin or on inanimate objects like foods, cigarette, etc. and can also be differentiated as human or animal bite marks. The term ‘Bite Mark’ is used in reference to human bite marks only and more specifically in relation to bite marks found on skin. Sorup, 1924 was the first to publish an analysis of bite marks. The markings found on the skin of

Analysis of Bite Marks Recent Advancements Role of Dentists in Forensics Dental Identification

the victim are more than just bite marks. The musculature of the lips, tongue, cheeks and the mental state of the biter, each seen to play a role in infliction of tooth mark pattern on the skin and this is identified as a bite mark. Bite marks in children represent child abuse until proven differently. The majority of child abuse patients are brought, to hospital emergency rooms, pediatric clinics, or emergency centers with a history of accidental trauma supplied by the parents or adult guardian. They are rarely accidental and are good indicators of genuine child abuse.

Classification of bite marks According to causative agent Human • Children • Adults

Animals • Mammals • Reptiles • Fish

Mechanical • Full denture • Saw blade tooth marks • Electric cords, belt marks

According to the material bitten Skin • Human • Animal

Perishable items • Food items like cheese, apple, etc.

Nonperishable items • Unanimated objects like pipes, pens, pencils, etc.

According to the degree of biting Definite marks Tissue damage due to direct application of pressure by the biting edge

Amorous marks These are made in amorous circumstances, slowly with the absence of movement between teeth and tissue

Aggressive marks These show evidence of scraping tearing or avulsion of tissues and may be difficult to interpret

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FACTORS INFLUENCING APPEARANCE OF BITE MARKS • Vascularity of the tissue: Bruising of the loose and highly vascularized tissues around the eyes is more pronounced than skin in areas such as the palm of the hand or the soles of the feet. • Age: Children and the elderly bruise more easily because of loose delicate skin. • Metabolic rate: Women bruise more easily than men. • Medications: Such as aspirin can increase bleeding. • Normal skin color: The pigmentations on stain may affect the observation of a bruise. • Mass and velocity of the impact. • Time of injury: The time of appearance of bruise is related to the time required for the extravasated blood to reach the surface. This lag will allow the antemortem bruises to appear postmortem. • Other factors that affect bruising: Rapidity of death after injury and environmental conditions.

BITE MECHANISMS • Tooth pressure: It is caused by direct application of incisal edges of anterior teeth or occlusal surfaces of posterior teeth. Most commonly seen in battered child syndrome. • Tongue pressure: It is caused when the material is taken into mouth and pressed by tongue against teeth or palatal surface. They exhibit a central ecchymotic or ‘suck’ mark with radiating pattern surrounding a central area. Most commonly seen in sexually abused cases. • Tooth scrape: By scraping of teeth across the surfaces of skin.

IDENTIFICATION OF BITE MARKS • Bite marks are found in a significant number of child abuse victims. Most reported cases are the result of attack bites and are recognized and documented only when the victim is examined by a medical examiner. In this environment, the bite mark is recognized early, a forensic odontologist is called as a consultant, and the evidence is preserved for future prosecution. • The nature and location of the bite is likely to change with increasing age of the child. Bite marks in infants occur in body locations and under circumstances different from these of the preschooler, school age child, or adolescent. In infants, bite marks tend to be punitive and are often a response to crying or soiling. As a result, bitemarks may appear anywhere, but tend to be concentrated on the cheek, arm, shoulder, buttocks, or genitalia. In childhood bitemarks tend to be less punitive and more a function of assault or defense. Sexually oriented bitemarks and occur more frequently in adolescents and adults.

American society of forensic odontology protocol for bite mark analysis, 1993 • • • •

Description of the bite mark Collection of evidence from victim – Photography – Saliva swab – Impression – Tissue samples Collection of evidence from the suspect – Dental records – Photography – Clinical examination – Impression Comparing the bite marks

• Bite marks resulting from sexual attack may be present on the victim or assailant. The marks on assailant usually are caused by the anterior teeth of victim biting in selfdefense. These bites are found frequently on the hand of the assailant and may be severe, resulting in laceration or avulsion of tissue. The most common bite marks are caused by the assailant which feature bites on either neck, cheek, arms, thighs or nipples. Such marks are welldefined and show area of contusion of dental arch, which is a result of sucking which brings the tissue in apposition to palate. • Human bite marks characteristics include an elliptical or ovoid pattern containing tooth and arch marks. Tooth mark is the bite mark produced by antagonist teeth. Arch mark is when 4 to 5 adjacent marks of teeth are present. The duration of bite mark is dependent up on force applied and the extent of tissue damage. Thin bitemarks will remain for longer time. Tooth marks that do not break skin last from 7 to 24 hours, whereas if skin is broken it may last for several days depending upon thickness of tissue.

 haracteristics of Human Bite C Marks for Identification • A human bite mark is usually of elliptical or ovoid pattern. • Simplest form of bite mark consists of tooth marks produced by antagonist teeth. • An arch mark may indicate presence of 4 to 5 teeth marks reflecting the shape of their incisal or occlusal surfaces. • The puncture marks of incisors are narrow rectangular in shape. • Canines leave triangular-shaped lesions, which tend to be more defined in adult than child bites. • Premolars leave ovoid marks. • Bite marks left by maxillary teeth tend to be more diffuse, while those left by mandibular teeth are more distinct. • It is important to distinguish human bite from animal bite marks. Animal bite marks can be distinguished from

Chapter 77  Bite Marks human bites on the basis of arch width (animals tend to have longer, narrower bites), the width of individual teeth (animals have narrower teeth) and type of bite (animal bites usually result in deep tissue penetration with accompanying tearing and lacerations, whereas human bite marks tend to leave more superficial lesions, like bruising or abrasions). • Class characteristics: These are commonly referred to as the measurable features and shapes that allow the forensic dentist to ascertain the biter and to determine which teeth are present in the pattern. • Individual characteristics: These are deviations from standard class characteristics. For example, rotated tooth or a fractured tooth.

ANALYSIS OF BITE MARKS • The first method of analysis of bite marks was reported in 1968 by Furness. • To maintain uniformity in the bite mark applications and to standardize the analysis of bite marks the American Board of Forensic Odontostology (ABFO) established the following guidelines in 1986. • Guidelines for bite marks analysis: – History: Obtain a thorough history of any dental treatment carried out after the suspected date of the bite mark. – Photography: Extraoral photographs including full face and profile views, intraorals should include frontal views, two lateral views and an occlusal view of each arch. Often it is useful to include a photograph of maximal mouth opening. If inanimate materials, such as foodstuffs, are used for test bites the results should be preserved photographically. – Extraoral examination: Record and observe soft and hard tissue factors that may influence biting dynamics. – Measurements of maximal opening and any deviations on opening or closing should be made. – Intraoral examination: Salivary swabs should be taken. The tongue should be examined to assess size and function. The periodontal status should be noted with particular reference to mobility. Prepare a dental chart if possible. – Impressions: Take two impressions of each arch using material that meet the American Dental Association specifications. The occlusal relationship should be recorded. – Sample bites: Whenever possible, sample bites should be made into an appropriate material, simulating the type of bite under study. – Study casts: Casts should be prepared using Type II stone. • Procedure for bite mark analysis: It is the comparison of bite evidence to the suspect evidence to determine

if a correlation exists. Analysis involves visualization, comparison, formation of the opinion and often court testimony. – Description of bite marks: ■ Demographic description ■ Anatomic location including surface, contour, color, size and shape. – Collection of evidence from victim: ■ Photography is essential to document bite marks and it should be initiated early and sequentially. ■ The photographs should be in color and black and white with and without scale. ■ Stains for elastic and collagen fibers and standard hemotoxylin and eosin stain are useful. ■ Using absorption elution techniques and electro­ phoresis, a serological “fingerprint” can be developed to help individualize the assailant. ■ The suspect bite mark, after being photographed is swabbed with cotton moistened in saline, bottled, labeled and refrigerated for processing by a forensic serologist. – Collection of evidence from suspect: ■ Only after the legal consent has been obtained. ■ Includes photographs, casts, saliva samples. – Analysis of all evidence: ■ If adequate photographs have been obtained then the bite marks can be digitalized and viewed 3-dimensionally. ■ The same is true with any impressions that might be relative to the case. These tool marks can be compared in detail. ■ The addition of computer manipulation to tool mark identification has added greatly to the possibilities of bitemark analysis. ■ Recent advances for collecting and analyzing evidence are xeroradiography, transillumination, videotape analysis, superimposition technique, scanning microscopy and DNA fingerprinting.

RECENT ADVANCEMENTS • A recent advancement in documenting the bite mark records is the epiluminescence microscopy. It is a dermatological technique developed for evaluation of pigmented skin lesions. This technique, through rendering the stratum corneum translucent, aids is the visualization and photographic documentation. • The recently developed imaging software CAPMI and WinID and other image capturing devices, such as scanners and digital cameras have further created an opportunity to better control the human errors. • Use of ABFO scale number 2 and alternate light imaging (ALI) helps in reducing the errors of bite mark analysis. ABFO scale number 2 helps us get 1:1 life like size of the

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photograph, 18 percent gray color and three circles help to rule out photographic distortion. With the help of ALI photography the marks, which are not visible, fluoresce and become distinct. Fibers which are not easily located under normal light can become like beacons as they fluoresce under alternate light. • Forensic DNA profiling methods uses the polymerase chain reaction (PCR) techniques to amplify small amounts of recovered DNA.

ROLE OF DENTISTS IN FORENSICS The positive identification of living or deceased persons using the unique traits and characteristics of the teeth and jaws is a cornerstone of forensic science. The teeth are the hardest substances in the human body and may be the only method available to identify the insults and consequences encountered at death and during decomposition. Currently, there are three types of personal identification circumstances that use the teeth, jaws and orofacial characteristics. They are: • Comparative dental identification: It involves comparison of antemortem and postmortem dental records to identify the body. Congenital (anatomic) and acquired (treatment) characteristics of the teeth are compared between the antemortem and postmortem records. Discrepancies may exist because it is possible that the person may have had additional dental treatments completed in the time interval between the dates represented by the antemortem and postmortem dental records. These discrepancies are explainable, however, still can provide an opportunity for a positive identification. • Reconstructive postmortem dental printing: The circum­ stantial evidence required to establish a putative identi­ fication is not always present. To determine who the deceased person may have been, it is often necessary to assess personal features such as age at death, sex and other associated findings. • DNA profiling of oral tissues: Used when dental treat­ ments or other traits from dental records are not available for comparison. The DNA is the same in all the cells of the body and it does not change from birth to death and hence can be used to discriminate one individual from another. Forensic DNA profiling methods uses the polymerase chain reaction (PCR) techniques to amplify small amounts of recovered DNA. The dental DNA comes from two potential sites: i. The pulp tissue-including fibroblasts, odontoblasts and blood cells ii. Developmental cells that are trapped during minerali­ zation of the tooth can be liberated from the predentin and dentin layers to provide additional sources of DNA evidence.

DENTAL IDENTIFICATION

Role of Radiographs and Photographs • No matter how thorough the visual investigation of any forensic dental evidence is, it is of little or no value unless it is recorded permanently and accurately. • Radiographs and photographs are necessary for proper evaluation, detailed comparison at a later date and subsequent preparation of evidence. • An accurate and reliable source for identification is a comparison of antemortem and postmortem radiographs. • Photographs, if properly taken, are one of the most reliable and useful tools in forensic dentistry. These must be clear to show the precise the size and shape measurements of the area of concern.

Role of Craniofacial Characteristics • A proper knowledge of time of eruption and root completion of all deciduous and permanent teeth is important to determine the age of the deceased from the teeth present. • Knowledge of time of suture closure of the skull is also an important parameter to determine the age.

Role of Blood Group Determination • The use of saliva in forensic science is based on the presence of ABH blood group substances, which is in fairly high concentrations in saliva and bones of secretors. • This finding is used in identification with the absorptionelution technique.

Computer-assisted Dental Identification • The computerized identification system for comparison process of postmortem and antemortem records is called as computerized-assisted postmortem identification (CAPMI) system. • Computer can be used to process large numbers of dental records, such as would be encountered in mass fatality incidents or in the creation of central rewards repository for missing person investigations.

 ole of Dental Team in Mass R Fatality Incidents • The very nature of a mass disaster implies the presence of an enormously destructive force but it is surprising that only the most durable structure of the human body, i.e. the teeth, remains intact.

Chapter 77  Bite Marks • Since dental evidence may be the principal method of resolving vital questions of identification, progressive agencies responsible for investigating disasters now recognize the forensic dentist as a key member of the investigating team. The dental identification team can be divided into several different sections based on its mission including recovery, postmortem examination, antemortem records and comparison.

Above all, the forensic dentist must be knowledgeable and appreciate the constraints that may be imposed by the judicial process. Attention to dental, conscientious application of knowledge to the problem at hand, and most importantly, good common sense would appear to be the most important attributes of those, who by intent or by obligation to society enter this challenging field.

POINTS TO REMEMBER • • • • • • • • •

Bite marks can be defined as marks caused by teeth alone or in combination with other oral parts. Sorup, 1924 was the first to publish an analysis of bite marks. The first method of analysis of bite marks was reported in 1968 by Furness. Factors influencing appearance of bite marks are vascularity of the tissue, age, metabolic rate, skin color, time of injury and type of impact. Characteristics of human bite: A human bite mark is usually of elliptical or ovoid pattern; consists of tooth marks produced by antagonist teeth; arch mark may indicate the shape of their incisal or occlusal surfaces. The puncture marks of incisors are narrow rectangular in shape, canines leave triangular-shaped lesions, premolars leave ovoid marks. Bite marks left by maxillary teeth tend to be more diffuse, while those left by mandibular teeth are more distinct. Procedure for bite mark analysis involves visualization, description of bite marks, collection of evidence from victim and suspect, comparison and analysis of evidence, formation of the opinion and often court testimony. Role of dentist in forensic is comparative dental identification, reconstructive postmortem dental printing and DNA profiling of oral tissues.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Define and classify bite marks. What are the factors influencing bite marks? Write a note on human bite marks. Describe the analysis of bite marks. What is the role of the dentist in forensic? Explain dental identification.

BIBLIOGRAPHY 1. Aboshi H, Taylor JA, Takei T, Brown KA. Comparison of bitemarks in foodstuffs by computer imaging: a case report. J Forensic Odontostomatol. 1994;12:41-4. 2. American Board of Forensic Odontology (ABFO), Inc: Guidelines for bite mark analysis. J Am Dent Ass. 1986;112:383-6. 3. American Board of Forensic Odontology, Inc. ABFO Bite mark Analysis Guidelines. In Bowers CM, Bell GL (Eds). Manual of Forensic Odontology, 3rd Edn. Saratog Springs: American Society of Forensic Odontology; 1997.pp.299-357. 4. Barbenel JC, Evans JH. Bite marks in skin–mechanical factors. Int J Forens Dent. 1977;4:6. 5. Furness J. Teeth marks and their significance in cases of homicide. J For Sci Soc. 1969;9:169. 6. Levine LJ. Bitemark evidence. Dent Clin North Am. 1977;21:1-58. 7. Shashikala K. Human Bitemarks: The fingerprints of the mouth. JIAOMR. 2003;15(4):165-71. 8. Sorup A. Odontoskopie. Ein Zahnirzhlicher Beitrag Zur gerichtillichen Medicine. 1924;40:385. 9. Wagner GN. Bitemark identification in child abuse cases. Ped Dent. 1986;8(Spl 1):96-100. 10. Wald M. Child abuse in Wisconsin. The dentist’s responsibility in reporting. Great Milwaukee Dent Bull. 1968;34:113-6. 11. Wright FD, Golden GS. Forensic Photography. In, Stimson PG, Mertz CA (Eds). Forensic Dentistry, 1st ed USA, Stern Robert; 1997. pp.101-36.

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Section

LASERS IN PEDIATRIC DENTISTRY

This section details the concept of Lasers, its classification, types and majorly explains the uses of laser in the field of pediatric dentistry.

78

Chapter

Introduction, Principle and Types of Laser Nikhil Marwah, Ena Mathur, Sham S Bhat, Sundeep Hegde K

Chapter outline • • •

Basic Laser Science Principal of Laser Radiation Laser Delivery Systems

• • •

Components of Laser Laser Tissue Interaction Types of Lasers

LASER is an acronym for Light Amplification by Stimulated Emission of Radiation As we enter the next millennium, we see that dentistry has advanced by leaps and bounds. Among the various advances, the one, which has a good scope of improvement, is the use of lasers in dentistry. Recent advances in laser technology and research has set the stage for a revolution in dental practice. The dental lasers of today have benefited from decades of

research and have their basis in certain theories from the field of quantum mechanics, initially formulated during the early 1900s by Danish physicist Bohr. In 1958, Schawlow and Townes discovered LASER and the first working laser, a pulsed ruby instrument, was built by Maiman of Hughes Research Laboratories in 1960.

956 Section 17 

Lasers in Pediatric Dentistry Historical review

• •

• •

•

Goldman, Stem and Segnnaes carried out the original research in the 1960s. Vahl used a ruby laser and reported extensive deep destruction of carious areas along with crater formation and melting of dentin. Kantola experimented with a CO2 laser. Paghdiwala (1988) in the United States tested for the first time the ability of the Erbium: Yttrium-Aluminum-Garnet (Er:YAG) laser to ablate dental hard tissues. In May 1997, the Er:YAG (2.94 um) laser was cleared for marketing by the US Food and Drug Administration (FDA).

BASIC LASER SCIENCE

Light • Light is a form of electromagnetic energy that exists as a particle, and travels in waves, at a constant velocity. • Laser light is distinguished from ordinary light by two properties. • Laser light is monochromatic because it only generates a laser beam of a single color, which is sometimes invisible.  • Laser light is coherent or identical in physical size and shape, and produce a specific form of electromagnetic energy.

Amplification by Stimulated Emission Amplification is part of a process that occurs inside the laser. The laser machine has a specific design an optical cavity is at the center of the device. The core of the cavity is comprised of chemical elements, molecules, or compounds and is called the active medium. Lasers are generically named for the material of the active medium, which can be a container of

gas, a crystal, or a solid-state semiconductor. Surrounding this core is an excitation source, either a flash lamp strobe device, an electrical circuit, or an electrical coil, which pumps the energy into the active medium. There are two mirrors one at each end of the optical cavity, placed parallel to each other; or in the case of a semiconductor, two polished surfaces at each end. These mirrors act as resonators and help to collimate and amplify the developing beam. A cooling system, focusing lenses, and other controls complete the mechanical components.

Stimulated Emission It is the process taking place within the active medium due to the pumping mechanism, and was postulated by Albert Einstein in 1916. Einstein used that concept and further theorized that an additional quantum of energy may be absorbed by the already energized atom and that would result in a release of two quanta. This energy is emitted, or radiated, as identical photons, traveling as a coherent wave. These photons are then in turn able to energize more atoms in a geometric, which further emit additional identical photons, resulting in an amplification of the light energy, thus producing a laser.

Radiation The light waves produced by the laser are a specific form of radiation, or electromagnetic energy. The electromagnetic spectrum is the entire collection of wave energy ranging from gamma rays, whose wavelength are about 10 to 12 meters, to radio waves, whose wavelength can be thousands of meters. All available dental laser devices have emission wavelengths of approximately 0.5 microns, or 500 nanometers to 10.6 microns or 10,600 nanometers. That places them in either the visible or the invisible portion nonionizing portion of the electromagnetic spectrum (Fig. 78.1).

Fig. 78.1: Location of laser on electromagnetic spectrum

Chapter 78  Introduction, Principle and Types of Laser PRINCIPAL OF LASER RADIATION The process of lasing occurs when an excited atom can be stimulated to emit a photon before the process occurs spontaneously. When photon of exactly the right energy (wavelength) enters the electromagnetic field of an excited atom, the incident photon triggers the decay of the excited electron to the lower energy state. This is accompanied by the release of the stored energy in the form of a second photon. The first photon is not absorbed but continues on to encounter another excited atom. Stimulated emission can only occur when the incident photon has exactly the same energy as released photon. Thus, the result of stimulated emission is two photons of identical wavelength traveling in the same direction. The release of the second photon is time linked to the oscillations of the first photon, so that the 2 photons oscillate together in phase of a collection of atoms includes more that are pumped up into the excited state that remain in the resting state, a population inversion exists. This is a necessary condition for lasing. Now, the spontaneous emission of a photon by one atom will stimulate the release of a second photon in a second atom, and these two photons will trigger the release of two more photons, these 4 then yield 8, 8 yield 16 and so on. In a small space at the speed of light this photon chain reaction produces a brief, intense flash of monochromatic (same wavelength) and coherent (same phase) light (Fig. 78.2).

Fig. 78.2: Principle of laser radiation

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958 Section 17 

Lasers in Pediatric Dentistry Laser emission modes

Continuous wave: The beam is emitted at one power level continuously as long as the device is activated. Gated-pulse mode: There are periodic alternations of the laser energy being on and off. Free-running pulsed mode: This mode is unique in that large peak energies of laser light are emitted for an extremely short time span, usually in microseconds, followed by a relatively long time in which the laser is off.

• For lasers using the optic fiber, the focal point is at or near the tip of the fiber. When the handpiece is moved away from the tissue and away from the focal point, the beam is defocused (or out of focus) and becomes more divergent. • At a small divergent distance, the beam can cover a wider area, which is useful in achieving hemostasis. At a greater distance away, the beam loses its effectiveness because the energy dissipates.

COMPONENTS OF LASER There are three main parts of a laser delivery system (Fig. 78.3): (i) Lasing or active medium (ii) Energy or pumping source (iii) Optical or resonating chamber.

LASER DELIVERY SYSTEMS The coherent, collimated beam of laser light must be able to be delivered to the target tissue in a manner that is ergonomic and precise. Two delivery systems are used in dental lasers.

Flexible Hollow Waveguide • Flexible hollow waveguide or tube that has an interior mirror finish. • The laser energy is reflected along this tube and exits through a handpiece at the surgical end, with the beam striking the tissue in a noncontact fashion (i.e. without directly touching the tissue).

Glass Fiberoptic Cable • This cable is pliant and comes in various diameters, with sizes ranging from 200 to 1000 m. • Although the glass fiber is encased in a resilient sheath, it can be somewhat fragile and cannot be bent into a sharp angle. The fiber fits snugly into a handpiece with the bare end protruding or, in some cases, with an attached glasslike tip. • This fiber system can be used in contact or noncontact mode; however, most of the time it is used in contact fashion, touching the surgical site directly.

Lasing or Active Medium A lasing medium is a material, which is capable of absorbing the energy, produced by an external source through the subatomic configuration of its component molecules and subsequently giving off this excess energy as photons of light. Lasing media can be solid (crystal or semiconductor), liquid or gas.

Energy or Pumping Source An energy source is used to excite or pump the atoms in the lasing medium to their higher energy levels that are necessary for the production of laser radiation. The pumping source can be electrical, chemical, thermal or optical energy.

Optical or Resonating Chamber The lasing medium is located within resonating chamber, which has a cylindrical structure with a fully reflecting mirror on one side, partially reflecting mirror at other side. They are precisely mounted so that they are exactly parallel to one another. This arrangement allows for the reflection of photons of light back and forth across the chamber, eventually resulting

Fig. 78.3: Components of laser system (Nd:YAG)

Chapter 78  Introduction, Principle and Types of Laser • As stated previously, the laser beam generally becomes more divergent as the distance from the handpiece increases. The beam from some lasers can still have adequate energy at distances greater than 3 m. • However, this reflection can be dangerous because the energy would be directed to an unintentional target, such as the eyes. This is a major safety concern for laser operation.

Absorption Fig. 78.4: Possible tissue interactions

in the production of an intense photoresonance within the medium. The second mirror, which is partially reflective, allows some of the laser light to escape as the output device.

LASER TISSUE INTERACTION Many of the basic principles governing laser tissue interactions are relatively simple. The effects of laser emissions on biologic structures can, to some extent, be evaluated in terms of what occurs when radiant light energy reacts with matter. Therefore, a practical knowledge of the biologic process of tissue and the physical properties of laser light will provide the clinician with the ability to understand and to control the outcome of laser. The light energy from a laser can have four different interactions with the target tissue, and these interactions depend on the optical properties of that tissue and the wavelength used (Fig. 78.4).

Reflection • It is simply the beam redirecting itself off of the tissue surface, having no effect on the target tissue. • The reflected light could maintain its collimation in a narrow beam or become more diffuse.

• Absorption of the laser energy by the intended target tissue. • This effect is the usual desirable effect, and the amount of energy that is absorbed by the tissue depends on the tissue characteristics, such as pigmentation and water content, and on the laser wavelength and emission mode. • Certain wavelengths are absorbed preferentially by certain tissue components and by water. In general, the shorter wavelengths, from about 500 to 1000 nm, are absorbed readily in pigmented tissue. • Argon has a high affinity for melanin and hemoglobin in soft tissue. Diode and Neodymium: Yttrium-AluminumGarnet (Nd:YAG) have a high affinity for melanin and less interaction with hemoglobin. The longer wavelengths are more interactive with water and hydroxyapatite. Erbium is well absorbed by hydroxyapatite and water. CO2 is wellabsorbed by water and has the greatest affinity for tooth structure.

Transmission • Transmission of the laser energy directly through the tissue, with no effect on the target tissue. • This interaction also is highly dependent on the wavelength of laser light. Water, for example, is relatively transparent to the Nd:YAG wavelength, whereas tissue fluids readily absorb CO2 at the outer surface so that there is little energy transmitted to adjacent tissues. An Nd:YAG laser would work better in an environment difficult

Fig. 78.5: Thermal interactions

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Lasers in Pediatric Dentistry Tissue interactions

Interaction

The basic principle of the photochemical process is that specific wavelength of laser light are absorbed by naturally occurring chromophores that are able to induce certain biochemical reactions at the cellular level. Derivatives of naturally occurring chromophores or dyes can be used as photosensitizers to induce biologic reactions within the tissue for both diagnostic and therapeutic applications

Photothermal interactions

In this, radiant light energy is Absorption absorbed by tissue and molecules become transformed into heat energy, which produces the tissue effect

This is the usual desirable effect, and the amount of energy that is absorbed by the tissue depends on the tissue characteristics, such as pigmentation and water content, and on the laser wavelength and emission mode. In general, the shorter wavelengths, from about 500 to 1000 nm, are absorbed readily in pigmented tissue, e.g. Argon. The longer wavelengths are more interactive with water and hydroxyapatite, example CO2

Photomechanical interactions

Include photo-disruption or photodisassociation, which is the breaking apart of structures by laser light and photo-acoustic interactions, which involve the removal of tissue with shock wave generation

Transmission

The laser energy transmits through the tissue, with no effect on the target tissue. Example Nd:YAG lasers can be transmitted through the lens, iris, cornea, anterior chamber, posterior chamber, vitreous, and aqueous humors of the eye without affecting them, yet can be absorbed easily by the tissues of the retina

Photoelectrical interactions

Include photo-plasmolysis, which describes the removal of tissue by the formation of electrically charged ions and particles that exist in a semigaseous high-energy state

Scattering

This weakens the energy and possibly produces no useful biologic effect apart from curing of composite resins

to keep dry, whereas a CO2 laser would be less effective because of its absorption by saliva, water, and tissue fluids.

Scattering • This weakens the energy and possibly producing no useful biologic effect. • Scattering of the laser beam could cause heat transfer to the tissues adjacent to the surgical site, and unwanted thermal damage could occur. A beam deflected in different directions would be useful in facilitating the curing of composite resins.

Reflection

Tissue effects

Photochemical interactions

The beam redirecting itself off the tissue surface, having no effect on the target tissue

Thermal Interaction of Tissue The thermal effect of laser energy on tissue primarily revolves around the water content of tissue and the temperature rise of the tissue (Fig. 78.5).

TYPES OF LASERS

Based on Wavelength • Hard lasers: Longer wavelength lasers producing thermal effect, which cuts the tissue by coagulation, vaporization and carbonization. These lasers have been used for surgical soft tissue application.

Chapter 78  Introduction, Principle and Types of Laser • Soft lasers or low level lasers: Provide cold thermal low energy wavelengths of less than about 450 nm. These wavelengths are believed to stimulate circulation and cellular activity and cause various effects such as antiinflammatory, vascular, muscle relaxation, analgesia and tissue healing.

Based on Active Lasing Medium • • • • • • • •

Carbon dioxide laser Argon laser Nd:YAG Potassium titanyl phosphate (KTP) Helium-Neon (He-Ne) Ruby laser Er:YAG laser Erbium-Chromium (Er-Cr): Yttrium-Selenium-GalliumGarnet (YSGG) laser.

Based on Emission • Emit visible light: – Argon laser: Blue wavelength of 488 nm – Argon laser: Blue-green wavelength of 514 nm – Nd:YAG – Potassium-titanyl phosphate (KTP) lasers wavelength of 532 nm – Red nonsurgical wavelengths of 635 nm. • Emit invisible laser light in the near, middle and far infrared portion of the electromagnetic spectrum. – Diode laser – Er-Cr:YSGG laser: 2,780 nm. – Er:YAG laser: 2940 nm – Carbon dioxide (CO2) laser: 10600 nm.

Laser type

Carbon Dioxide Laser • In the United States, Stern at UCLA and Lobene the Forsyth Dental Center in Boston shifted their attention to the carbon dioxide laser because its wavelength of 10.6 um is well absorbed by enamel. • In a series of studies employing scanning electron microscopy, X-ray diffraction and electron probe microanalysis techniques, they determined the chemical and physical transformation that resulted from exposure of enamel and dentin by this wavelength (Kantola 1972). • While these studies confirmed the ability of the carbon dioxide laser to induce resistance to acid penetration of enamel, attempts to use this laser of the sealing of pits and fissures and for the welding or fusion of materials such as hydroxyapatite to enamel were unsuccessful due to the excessively high surface temperatures generated during the process. • During this same period Melcer and others were actively involved in the clinical application of the carbon dioxide laser for the vaporization of caries. They reported the successful treatment of over 1000 human patients in clinical trials of caries removal. • The CO2 laser is a gas-active medium laser that must be delivered through a hollow tube-like waveguide in continuous or gated-pulse mode. The wavelength of 10,600 nm, places it at the end of the mid-infrared invisible nonionizing portion of the spectrum. It is well-absorbed by water. • It is a rapid soft tissue remover and has a shallow depth of penetration into tissue, which is important when treating mucosal lesions. It is especially useful in cutting dense fibrous tissue. It has the highest absorption in

Wavelength

Waveform

Applications

Carbon dioxide

10.6 micrometers

Gated (or interrupted) or continuous

Soft-tissue incisions and ablation; deepithelialization of gingiva during periodontal regenerative procedures

Neodymium: Yttrium-Aluminum-Garnet

1.064 µm

Pulsed

Soft-tissue incision and ablation; incipient caries removal

Erbium: Yttrium-Aluminum-Garnet

2.94 µm

Pulsed

Caries removal; cavity preparation in enamel and dentin; US FDA clearance for use on cementum and bone; root canal preparation

Erbium-Chromium: Yttrium-SeleniumGallium-Garnet

2.78 µm

Pulsed

Enamel etching; caries removal; cavity preparation; cutting bone in vitro with no burning, melting or alteration of the calcium: phosphorus ratio; root canal preparation

Argon

457 to 502 nanometers

Pulsed or continuous

Curing resins; soft-tissue incisions and ablation; bleaching

Holmium: Yttrium-Aluminum-Garnet

2.1 µm

Pulsed

Soft-tissue incisions and ablation

Gallium-Arsenide (or Diode)

904 nm

Pulsed or continuous

Soft-tissue incisions and ablation

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962 Section 17 

Lasers in Pediatric Dentistry

hydroxyapatite of any dental laser, about 1000 times greater than the erbium series of lasers. • The CO2 laser is delivered in a hollow waveguide with a handpiece. The laser energy is conducted through the waveguide and is focused onto the surgical site in a noncontact fashion. The loss of tactile sensation is a disadvantage for the surgeon, but the tissue ablation can be precise with careful technique. Large lesions can be treated easily using a simple back-and-forth motion.

Argon Laser • The argon laser is one of the rare gas ion lasers capable of outputs of several watts continuous till the visible green and blue portion of the spectrum. • These systems have found applications in the excitation of tissue fluorescence, in making diagnostic measurements, and in materials processing, such as polymerization and stereolithography. The surgical argon laser is most useful for the treatment of vascular disorders due to selective absorption of hemoglobin in the green portion of the spectrum. • This laser has two emission wavelengths, and both are visible to the human eye: 488 nm, which is blue in color, and 514 nm, which is blue-green. • Argon lasers have an active medium of argon gas that is fiberoptically delivered in continuous-wave and gatedpulse modes. Because of the short wavelength of green and blue light, it is possible to focus the argon beam into an extremely small spot. • The 488 nm emission is exactly the wavelength needed to activate camphorquinone, the most commonly used photoinitiator that causes polymerization of the resin in light-cured composite restorative materials. • The 514 nm wavelength has its peak absorption in red pigment. Tissues containing hemoglobin, hemosiderin and melanin readily interact with this laser. It is a useful surgical laser with an excellent hemostatic capabilities used in contact with the tissue, treatment of acute inflammatory periodontal disease and highly vascularized lesions, such as a hemangioma.

Neodymium Laser • The first report of dental application of the neodymium laser to vital oral tissue in experimental animals was that by Yamamoto School of Dentistry in Japan in 1974. • In a series of experiments Yamamoto determined that the Nd:YAG laser was effective for inhibiting the formation of incipient caries both in vitro and in vivo.

• Nd:YAG has a solid active medium, a crystal of yttriumaluminum-garnet doped with neodymium, and is fiberoptically delivered in a free-running pulsed mode, used most often in contact with the tissue. It was the first laser designed exclusively for dentistry, and it is the laser with the largest market share. • The emission wavelength is 1064 nm, in the near-infrared invisible nonionizing part of the spectrum. It is highly absorbed by pigmented tissue and is about 10,000 times more absorbed by water than an argon laser.

Potassium Titanyl Phosphate Laser • The KTP laser is a frequency doubled Nd:YAG laser, producing a 532 nm visible green beam by passing the Nd:YAG laser’s output through a potassium-titanylphosphatic crystal. • It is absorbed by hemoglobin and melanin pigment. The tissue penetration is 1 to 3 mm.

Ruby Laser • The first laser developed by Maiman in 1960. • A solid state optically pumped laser that emits in the visible range. • Taylor first reported the histologic effects of the ruby laser on the dental pulp.

Excimer Laser An excimer is molecule consisting of a halogen atom combined with an atom of a noble gas, existing only when the constituent atoms are in excited and ionized states. After this transient molecule exists radiation, it decomposes into its atomic parts, which are, then in their ground states. Because the excimer molecule has a lifetime measure in nanoseconds, and the excimers are 2 level energy systems, XeCI laser can deliver 180 millijoules of radiant energy in a 30-nanosecond pulse.

Holmium:YAG Laser • The lasing medium in this laser is a man made, holmium doped crystal rod of yttrium, aluminum and garnet (HO: YAG) and is fiber optically delivered in contact with the tissue in free-running pulsed mode. • The wavelength produced by this laser is 2120 nm, also in the infrared invisible nonionizing part of the spectrum. In conjunction with erbium and thulium, which enhances the efficiency of optical pumping of holmium.

Chapter 78  Introduction, Principle and Types of Laser • It emits radiation in the midinfrared band of the electromagnetic spectrum; with a wavelength of 2.1um. Its energy source that excites the crystal is a high intensity flash lamp. This laser emits pulsed radiation of 250 microseconds duration. This wavelength has the ability to be transmitted through an optical fiber (quartz) and the radiation is delivered to the tissues in a noncontact free beam mode.

Erbium:YAG Laser and Er-Cr:YAG Laser • The lasing medium is erbium doped with yttrium aluminum garnet. • This material emits laser radiation at 2940 nm wavelength. It is a 4 level energy system but the lower laser level has a long lifetime, causing the erbium ions to accumulate in this lower level after emitting radiation. This accumulation interrupts the population inversion and limits the laser to pulsed operation. • Er-Cr: YSGG (2790 nm) has an active medium of a solid crystal of yttrium- scandium-gallium-garnet that is doped with erbium and chromium. • Both of these lasers are delivered fiberoptically in the free-running pulsed mode. The fibers are air-cooled and have a larger diameter than the other lasers mentioned, making the delivery system somewhat less flexible. At the end of the fiber, a handpiece and small-diameter glass tips concentrate the laser energy down to a convenient surgical size, approximately 0.5 m. • These lasers are ideal for caries removal and tooth preparation when used with a water spray. The sound tooth structure can be preserved better when the carious

material is being ablated; the increased water content of dental caries allows the laser to interact preferentially with that diseased tissue. • The advantage of these lasers for restorative dentistry is that carious lesion in close proximity to the gingiva can be treated, and the soft tissue recontoured with the same instrumentation.

Diode Laser • These have a solid active medium; it is a solid-state semiconductor laser that uses some combination of aluminum, gallium and arsenide to change electric energy into light energy. • The available wavelengths for dental use range from about 800 to 980 nm, placing them at the beginning of the near-infrared invisible nonionizing part of the spectrum. • Each machine delivers laser energy fiberoptically in continuous-wave and gated-pulse modes, used ordinarily in contact with the tissue. • These lasers are relatively poorly absorbed by tooth structure, so that soft tissue surgery can be performed safely in close proximity to enamel, dentin and cementum. • The diode is an excellent soft tissue surgical laser indicated for cutting and coagulating gingiva and mucosa and for soft tissue curettage, sulcular debridement. • The chief advantage of the diode lasers is use of a smaller size instrument. The units are portable and compact, are easily moved with minimum setup time, and are the lowest-priced lasers currently available.

POINTS TO REMEMBER • • • • • • •

LASER is an acronym for Light Amplification by Stimulated Emission of Radiation. Bohr was the first to talk about the concept of lasers. In 1958, Schawlow and Townes discovered laser. First working laser, a pulsed ruby instrument, was built by Maiman. Delivery systems for lasers are flexible hollow waveguide and glass fiberoptic cable. Components of laser are lasing medium, energy source and resonating chamber. Laser tissue interaction are reflection (It is simply the beam redirecting itself off of the tissue surface, having no effect on. the target tissue); Absorption (By the intended target tissue); Transmission (Onto the target tissue without affecting the medium tissue) and scattering. • Hard lasers have longer wavelength lasers producing thermal effect. • Soft lasers provide cold thermal low energy wavelengths of less than about 450 nm. • Carbon dioxide and Nd:YAG are used for soft tissue; Er:YAG for caries removal; Argon for curing resins; diode can be used both for hard and soft tissues.

963

964 Section 17 

Lasers in Pediatric Dentistry

QUESTIONNAIRE 1. 2. 3. 4. 5.

Define laser and give the principle of laser radiation. What are laser delivery systems? Write a note on components of laser. Explain laser tissue interactions. Classify and compare lasers.

BIBLIOGRAPHY 1. Donald J Coluzzi. Lasers in Dentistry: From Fundamentals to Clinical Procedures. Seminar Series. American Dental Association. 2. Fred S Margolis. Clinical Uses of the Erbium Laser. Clinical Instructor, Loyola University’s Oral Health Center Maywood, Illinois. 3. Fried D, Radagio J, Akrivou M, et al. Dental hard tissue modification and removal using sealed transverse excited atmospheric-pressure lasers operating at 9.6 and 10.6 micrometer. J Biomed Optics. 2001;6:231-8. 4. Hibst R, Gall R. Development of a diode laser-based fluorescent caries detector. Caries Research. 1998;32:294. 5. JR Boj, C Poirier, M Hernandez, E Espasa, A Espanya. Review: laser soft tissue treatments for paediatric dental patients. European archives of Paediatric Dentistry. 2011;12(2). 6. LC Martens. Laser physics and a review of laser applications in dentistry for children. European archives of Paediatric Dentistry. 2011;12(2). 7. Luc C Martens. Laser-assisted Pediatric Dentistry: Review and Outlook. J Oral Laser Application. 2003;3:203-9. 8. Norbert Gutnecht, Rene Franzen, Leon Vanweersch, Friedrich Lampert. Lasers in Pediatric Dentistry – A Review. J Oral Laser Application. 2005;5:207-18. 9. Sun G, Turnér J. Low-level laser therapy in dentistry. Dent Clin N Am. 2004;48:1061-76. 10. Walsh LJ. The current status of low level laser therapy in dentistry. Part 1 Soft tissue application. Aust Dent J. 1997;42(4):247-54.

79

Chapter

Applications and Hazards of Laser Sham S Bhat, Nikhil Marwah, Sundeep Hegde K

Chapter outline • •

Applications of Lasers in Pediatric Dentistry Advantages of Laser

The basic principle and different types of lasers have already been dealt in previous chapter of this unit. The main focus of this chapter would be to delineate the applications of lasers in pediatric dentistry and the hazards associated with the machinery and laser radiation.

APPLICATIONS OF LASERS IN PEDIATRIC DENTISTRY These are manifold and can be summarized as: • Caries detection by laser induced fluorescence • Caries removal • Prevention of enamel and dental caries • Pit and fissure sealants • Bleaching of vital and nonvital tooth • Etching and bonding agents • Curing light activated resins • Cavity preparation • Pulp therapy.

Diagnosis of Dental Caries • Laser induced fluorescence: Kutsch (1992) reported clinical findings comparing carious and noncarious tissue illuminated with an argon laser with dark field photography. When illuminated with argon laser light, carious tissue has a clinical appearance of a dark, fiery, orange-red color and is easily differentiated from sound tooth structure. • Tetrahertz pulse imaging: Tetrahertz waves or millimeter waves are located just below the infrared band in the electromagnetic spectrum and are generated

• •

Disadvantages of Laser Laser Hazards

by lasing semiconductors with ultra fast pulses of visible laser light. • Quantitative laser fluorescence: A hardware and software system was developed in the Netherlands and Sweden that collects images, of lesions based on excitation at 488 nm with an argon lasers. The blue light is used to irradiate the surface of the tooth by a specially constructed hand piece, and computer captures the fluorescent image. • Fluorescence resulting from red light excitation of occlusal surfaces: Hibst and Gall systematically studied this phenomenon and used a 655 nm laser as the excitation source and measured the fluorescent signal at higher wavelengths. This work culminated in the development of a commercial device (DIAGNOdent, KaVo, Germany) that is in use in several countries for diagnosis of caries. The red laser diode light is directed to the occlusal surface by a specially designed probe tip and the fluorescent signal is filtered from the incident light and feedback to the detector through the same device. The signal comes out as a number on the instrument on a scale of 0 to 99. • Optical coherence tomography: An imaging technique that is capable of two-dimensional or three-dimensional images of subsurface tissue. The differences in scattering or polarization between sound and carious enamel can be exploited.

Prevention of Dental Caries • The role of lasers in the prevention of caries has been explored since the 1960s by using different types of lasers based on increasing the resistance to caries by reducing the rate of demineralization of subsurface of enamel and dentin.

966 Section 17 

Lasers in Pediatric Dentistry

• Argon laser has been shown to alter the surface characteristics of enamel to make it more caries resistant. • Apparently in addition to rendering the enamel less susceptible to caries attack, the argon laser also facilitates the uptake of fluoride by the tooth. The lased enamel shows a high positive birefringence suggesting the formation of micro spaces within the enamel. These micro spaces would impart an increased acid resistance to the enamel by trapping ions formed during acid demineralization Westerman et al. 1991. • Ralph H Stern and Reidan F Segnnaes (1972) reported intact tooth enamel exposed to a super pulsed CO2 laser at an energy densities of 10 to 15 J/cm2. They observed lased enamel showed much more resistant than unlased control enamel to the oral environmental. • S Tagomori and T Morioka (1989) demonstrated the combined effects of laser and fluoride on acid resistance of human dental enamel applied with solution of sodium fluoride of APF solution before and after laser irradiation with normal pulsed Nd:YAG. They concluded that APF application after laser irradiation caused a remarkable increase in acid resistance of the enamel while before irradiation showed lesser effect and APF application after laser irradiation produced a greater fluoride uptake in the enamel than before irradiation.

• Melcu et al. (1984) reported results from two clinical cases in which 400 patients were treated by CO2 laser energy following conventional cavity preparations. The dentin walls of each cavity were exposed to the laser beam to sterilize the surface structure and to stimulate cellular dentinogenesis activity. They concluded that the laser beam of 4 to 5 watts and power with an energy density of 9­25 kw/cm2 caused sterilization and healing of the dentin. • TO Myers and WO Myers (1985) investigated the effect of a pulsed YAG laser on enamel fissures. 30 recently extracted human teeth with pit and fissure incipient lesions were used for the study Nd:YAG laser with a wavelength of 1600A and pulse duration 30 Pico seconds. They found that Nd:YAG laser has the potential to remove organic and inorganic debris from pits and fissures without causing pulpal or enamel injury due to the minimal laser energy.

 rgon Laser Photo-polymerization A of Composite Resins For polymerization camphorquinone-activated composite resins, the argon laser increases the depth of cure, increases the diametric tensile strength, increases the adhesive bond strength, increases the degree of polymerization of the material, reduces the acid solubility of the surrounding enamel and decreases the time of activation significantly.

Lasers in Soft Tissue Surgery • Lasers have been employed as surgical tools in many branches of medicine for nearly two decades. Dental surgical applications have also been reported primarily for soft tissue incision and for controlled destruction of a number of oral pathogens. • A Pfizer model O-C surgical laser (Pfizer laser system, Irvine, California) is used as the source of the laser beam in soft tissues. Soft tissue procedures Treatment of Treatment of apthous pericoronal problems ulcers and herpes in erupting teeth labialis Exposure of teeth Removal of Exposure of for orthodontic hyperplastic tissue unerrupted teeth care caused by drugs or poor oral care in orthodontic patients Removal of lesions Pulp capping Pulpotomies and biopsies Frenum revisions

Removal of Caries • Goldman, Sogannaes, Stern and Gordon were the first scientists to investigate the use of the laser technology to remove dental caries. They used pulsed ruby laser with high densities. They found extensive deep destruction of carious areas with sharply demarcated areas of affected enamel and dentin.

Frenum Revisions • Indication of frenum revision in the infant, child or adolescent patients range from an inability to nurse in newborns to speech pathologies in children to orthodontic problems in the preadolescent and adolescent patient.

Chapter 79  Applications and Hazards of Laser • Although all laser wavelengths can be used successfully to perform maxillary and mandibular frenectomies. • Patients with bleeding and clothing disorders who require hemostasis during soft tissue surgery benefit from diode, CO2 or Nd:YAG laser.

A

• Figures 79.1A to E show pictures of a 12-year-old boy with hyperfunctional upper and lower labial frenum. Figures 79.2A to C depict lingual frenectomy in a child with 810 nm diode in CW mode with 1.5 watts under local anesthesia to treat tongue tie.

B Figs 79.1A and B:  Treatment of maxillary high labial frenum (Photo Courtesy: Vidya Bhat S)

C

D

E

Figs 79.1C to E:  Treatment of mandibular labial frenum (Photo Courtesy: Vidya Bhat S)

A

B

C

Figs 79.2A to C:  Treatment of tongue tie by lingual frenectomy (Photo Courtesy: Vidya Bhat S)

967

968 Section 17 

Lasers in Pediatric Dentistry

A

B Figs 79.3A and B:  Tooth exposure by removal of soft tissue (Photo Courtesy: Vidya Bhat S)

Treatment of Pericoronal Problems in Erupting Teeth • Children whose first permanent molars are erupting to develop often experience discomfort, swelling or injection in the tissue overlying the emerging tooth. • Lasers can be used to ablate the involved tissue and expose the clinical crown of the involved tooth.

Hyperplastic Gingival Tissue In instances where gingival tissue has become hypertrophied due to medications or instances where poor oral care occurs while the patient is wearing orthodontic appliances, the laser can be used to reshape or remove excessive tissue growth.

Tooth Exposure • Removal of soft tissue covering an unerupted permanent tooth usually requires no local anesthetic. • Direct contact of an erbium laser with the tooth could ablate tooth structure. • Figures 79.3A and B depict 13-year-old patient for whom exposure of canines for orthodontic banding was done with 810 nm diode in CW mode with 0.5 watts without local anesthesia.

Herpes Labialis and Apthous Ulcer • Dental lasers can immediately relieve symptoms of apthous ulcers and often stop or reduce herpes labialis lesions. • This treatment is usually performed at low power settings in a defocused mode.

Lesion Removal and Biopsy • Fibrotic lesions, gingival growths, mucoceles and other types of lesions can be quickly and safely removed using lasers. Bleeding is minimal and there is little or no postoperative discomfort. • Figures 79.4 A to E show a lobulated, pedunculated, soft lesion in relation to 11 and 12. Excisional biopsy was per­ formed with 1 watt in CW mode without local anesthesia.

Bleaching The basic mode of action is a thermal one: The laser’s light is converted to heat as it strikes the bleaching gel, accelerating the oxidation (bleaching function) of the peroxide contained in the substance. This causes bleaching to occur.

Dentin Desensitization Mechanism of action includes the narrowing or occlusion of dentinal tubules and nerve analgesia through depression of nerve transmission.

Analgesia • Laser induced analgesia is a phenomenon the rationale of which is not well understood. Researchers have theorized that certain wavelengths of laser energy interfere with the sodium pump mechanism, change cell membrane permeability, alter temporarily the endings of the sensory neurons and block the depolarization of C and A fibers of the nerves. • In this area, the pulsed Nd: YAG laser has commanded the most attention.

Chapter 79  Applications and Hazards of Laser

A

B

D

C

E Figs 79.4A to E:  Excision of mucocele and subsequent healing

Diagnosis of Pulpal Vitality The principle of vital and nonvital diagnosis of dental pulp by laser Doppler flowmetry is based on the changes in red blood cell flux in the pulp tissue.

 ccessory Treatment by Laser A for Indirect Pulp Capping • When lasers were introduced to dentistry, nobody thought that laser could perform the treatment of indirect pulp capping. • The discovery that they help in closure of dentinal tubules and also have sedative effects on pulpitis has led to the development of several new treatments that are soon to be put into practice. • Deep cavities, hypersensitive cavities, and cavities that require sedative treatment are some of the indications for this treatment. • When using the pulsed Nd:YAG laser, it is necessary to combine the application of black ink to the tooth surface and air spray cooling to prevent dental pulp damage resulting from the laser energy provided by 2 W and 20 pps for less than 1 second on the area.

Treatment by Laser for Direct Pulp Capping • Laser treatment has advantages with respect to control of hemorrhage and sterilization and so it has attracted dentist’s attention for pulp capping. • When using the CO2 laser for this treatment, laser irradiation of the exposed dental pulp must be performed to stop bleeding and sterilize the area around the exposure. Laser irradiation should be performed at 1 or 2 W after irrigating alternatively with 8 percent sodium hypochlorite and 3 percent hydrogen peroxide for more than 5 minutes. Calcium hydroxide paste must be used to dress the exposed pulp after the laser treatment, after which the cavity should be tightly sealed with cement such as carboxylate cement. An 89 percent success rate is reported. • In 1996 and 1998 Moritz A et al. studied the effects of continuous wave CO2 laser and a pulsed CO2 laser in direct pulp capping in addition to conventional calcium hydroxide dressing technique. The results indicated that 93 percent of the teeth had remained vital after 2 years in the group treated by the super pulsed laser. The study concluded that the pulsed CO2 laser seems to be a valuable aid in direct pulp capping.

969

970 Section 17 

Lasers in Pediatric Dentistry

Pulpotomy

should be performed after carrying out the usual root canal preparation using reamers and files.

• Vital pulp amputation by laser therapy was one of the most highly anticipated laser treatments in endodontics because this treatment appeared to offer amputation of the pulp tissue at a satisfactory level. • The CO2 laser usually is used at a power of 1 to 4 W. The laser irradiation should be conducted as intermittently as possible to prevent excessive exposure of laser energy. When it is necessary to ablate the pulp tissue into the apical portion of the root canal, several laser exposures are required. As a result, the carbonization layer formed on the surface of the pulp tissue by the laser energy must be removed by irrigating alternatively with 3 percent hydrogen peroxide and 5.25 percent sodium chloride. Although it is possible to use only the CO2 laser, this requires significant time, and the pulp tissue may be damaged by the laser energy. A CO2 laser technique that is carried out only for pulpal hemostasis after vital pulp amputation with an excavator or a bur is recommended. • In 1989, Ehihara reported the effects of Nd:YAG laser on the wound healing of amputated pulps. He reported better wound healing in pulps, exposed to laser than in controls during the first week and facilitation of dentinal bridge formation in the fourth and twelfth postoperative weeks. • In 1999, Jeng-Icn Liu et al. studied the effects of laser pulpotomy of primary teeth. All the teeth, which underwent laser treatment, were clinically successful with no signs or symptoms and only one tooth had internal resorption at the six-month follow-up visit.

Pulpectomy • A laser that can cut enamel and dentin with fine optical fibers has been developed, making it possible to remove pulp tissue and prepare straight and slightly curved canals. • Er: YAG laser at 8 Hz and 2 W (KaVo Co, Dim, Germany) is used to prepare root canals. • The laser tip must slide gently from the apical portion to the coronal portion, while pressing the laser tip to the root canal wall under water spray. When the laser fiber is unable to be inserted into root canals, the laser treatment

I rrigation, Sterilization or Disinfection of Infected Root Canals • Straight and slightly curved root canals, as well as wide root canals are indications for this treatment. • The pulsed Nd:YAG laser and Er:YAG laser are recommended for this treatment. • The laser irradiation is carried out by using laser with 5.25 percent sodium chloride or 14 percent ethylene­ diaminetetraacetic acid (EDTA).

Prevention of Tooth Fracture by Laser • Pulpless teeth have a tendency to fracture therefore to prevent such cases new laser techniques are being developed. • Teeth that are lased with pulsed Nd:YAG or CO2 laser and 38 percent silver ammonium solution became more resistant to fracture.

 revention of Microleakage of P Retrograde Root Canal Filling • Microleakage of retrograde root canal fillings is one of the causes of failure of apicectomies. • The closure of exposed dentinal tubules on the cut surface at the root end is observed by scanning electron microscopy when pulsed Nd:YAG and CO2 lasers in combination with 38 percent silver ammonium solution are used.

 aser Treatment of Periapical L Lesions or Sinus Tract • Although sinus tracts almost always can be closed by standard endodontic treatment, a few cases require special treatment. • Pulsed Nd:YAG laser is recommended. • The fiber tip during lasing must be inserted into the tract and drawn slowly from the root apex to the exit through the sinus tract.

Laser specific uses Soft tissue surgical lasers CO2, Diode, Argon, Ho:YAG, Er:YAG

Aphthous ulcers Nd:YAG, Diode, CO2, Argon lasers

Caries removal and cavity preparation Er:YAG, Er:YSGG, Nd:YAG

Composite polymerization Argon laser

Tooth whitening Argon laser, Pulsed Nd:YAG

Sulcular debridement Nd:YAG, Diode lasers

Pulpotomy Diode lasers

Welding dental prostheses Nd:YAG

Desensitization Argon, Nd:YAG, Ho:YAG, CO2

Chapter 79  Applications and Hazards of Laser Applicability of available laser devices for use in pediatric dentistry Laser device

Caries prevention

ARGON



CO2



Caries diagnosis

Pit-fissure and cavity preparation

Hemostasis during pulpotomy

Tooth vitality

Biostimulation pain control

Bleaching

 

Er:YAG Er:YSSGG





Nd:YAG

 





KTP Laser diode DIAGNOdent

Soft tissue surgery







Laser diode



Laser Doppler Flowmetry



Low level laser



• This treatment generally is performed three or four times during one visit.

ADVANTAGES OF LASER

Conventional Advantages • Minimal damage to surrounding tissues. • Laser beam exerts a hemostatic effect by sealing blood vessels. • Precision in tissue destruction because of good visualization of tissue planes by means of an operating microscope. • Reduction of postoperative inflammation and edema due to sealing of lymphatic vessels. • There is little postoperative scarring. • Reduced postoperative pain sensation since nerve endings are sealed and closed. • Dressing or suturing is not required for wound closing. • Operating time is reduced. • Sterilization of the wound due to reduction in amount of microorganism exposed to laser radiation. • Excellent wound healing. • Laser exposure to tooth enamel causes reduction in the caries activity.

 dvantages of the Laser Over A Conventional Surgery • Analgesia: The use of lasers reduces the amount of local analgesia required and can reduce the perception of pain in some cases. • Hemostatic properties: These properties are significant, due to the high vascularity of the oral cavity. They are

• •

•

•

extremely useful in vascular lesions and in areas with a rich blood supply, such as the sublingual region, in the case of frenectomies. The carbon dioxide laser provides the best intraoperative control of bleeding, which enables precise surgery to be performed, as it is easier to identify anatomical structures when there is no bleeding in the surgical field. Erbium lasers have less of a hemostatic effect than CO and Nd:YAG lasers. Sutures: The need for sutures is eliminated, as hemostasis enables wounds to heal by secondary intention. Lasers are cicatrizants: They improve wound healing, which occurs faster and with less scarring than after conventional treatments. Lasers are good treatment options for ulcers and mucositis. Healing is fastest after the application of erbium lasers, as they have a low thermal effect. In addition, the defocused use of a CO laser at the base of a lesion completes hemostasis and enables immediate contraction of the surgical site, with a 30 to 40 percent reduction in wound size. As no mucosal tissue is lost, unesthetic scar formation caused by wound tension is avoided. Antibacterial/disinfectant properties: These properties enhance postoperative recovery and reduce the required dose of antibiotics Türkün et al. 2006. According to Kato et al. 2007, lasers are very useful in developing countries where patients have high postoperative morbidity and mortality, as infections are prevented. Anti-inflammatory properties: Treatments that are undertaken with CO and Er, Cr:YSGG lasers cause less edema and postoperative pain, which reduces the required doses of analgesics and anti-inflammatory drugs. As the CO2 laser cuts soft tissue, it seals nerve endings, blood and lymph vessels, which reduces the inflammatory reaction. The anti-inflammatory

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properties of low level lasers can be used to treat muscle contractures and traumas. • Operating time: Lasers reduce the operating time needed for soft tissue management. • Vibration: The patient does not feel any vibration, pressure, or the contact of the optical fiber on the tooth, as occurs with a rotary instrument. This increases a patient’s collaboration and acceptance of the procedure. • Postoperative care: Lasers improve postoperative comfort, due to hemostasis, the lack of sutures, and the pain reduction. This is very useful in young patients (Fornaini et al. 2007).

LASER HAZARDS The types of hazards that may be encountered within clinical practice of dentistry may be grouped as follows: • Ocular hazard • Tissue damage • Respiratory hazards • Fire and explosion • Electrical shock They can also be classified according to ANSI and OSHA standards as: Class

DISADVANTAGES OF LASER

General Disadvantages • Laser beam could injure the patient or operator by direct beam or reflected light causing retinal burn. • General anesthesia is usually required for patient undergoing laser treatment in the mouth. • Combustion hazards. • Loss of tactile feedback incising the laser instrument. • Removal of soft tissue overlying the bone can damage the underlying bone. • Its availability only in hospitals. • Specially trained person needed for operation. • High cost of the equipment.

Limitations of Lasers • Requires training: This introduction to the use of dental lasers discussed their scientific basis and tissue effects. It is most important for the dental practitioner to become very familiar with those principles, have clinical experience, and receive proper laser training. • No single wavelength will optimally treat all dental diseases: Dentist can choose the proper laser(s) for the intended clinical application. Although there is some overlap of the type of tissue interaction, each wavelength has specific qualities that will accomplish a specific treatment objective. • High cost of the dental laser equipment. • Lasers are end cutting instrument. Because a majority of dental instruments are both side and end cutting, a modification of clinical technique will be required. • Accessibility to the surgical area can sometimes be a problem with the existing delivery system and the clinician must prevent overheating the tissue and guard against the possibility of surgically produced embolism that could be produced by excessive pressure of the air and water spray used during the procedure.

Description

I

Low powered lasers that are safe to view

II a

Low powered visible lasers that are hazardous only when viewed directly for longer than 1,000 seconds

II

Low powered visible lasers that are hazardous when viewed for longer than 0.25 seconds

III b

Medium powered lasers (0.5 W max) that can be hazardous if viewed directly

IV

High powered lasers (> 0.5 W) that produce ocular, skin and fire hazards

Occular Hazard • Potential injury to the eye can occur either by direct emission from the laser or by reflecting from a mirror like surface. Dental instruments have been capable of producing reflections that may result in tissue damage to both operator and patient. • Direct and specular reflections of relatively low intensity are capable of causing retinal damage because of the focusing effect of the lens and cornea. • Energy from the CO2 laser is absorbed in the cornea and can cause denaturation and coagulation of the proteins in the epithelial layers of the cornea, resulting in corneal calcification, resulting in permanent blindness. • The maximum permissible exposure limits for visible lasers is less than 0.003 watts/cm for a 0.25 second exposure. • Light produced by lasers presents a potential hazard for occular damage by either direct viewing or reflection of the beam. Therefore operator and staff and patient must wear adequate eye protection. This can be provided by either safety goggles or screening devices. This eye protector designed specifically for use with the particular wavelength of laser radiation (Fig. 79.5). • CO2 laser protection can be afforded with clean safety glasses; for Nd:YAG laser energy, both the doctor and the staff need to wear green safety glasses; for Argon laser orange safety glasses. To protect the patients eyes cover with moist swabs taped into place.

Chapter 79  Applications and Hazards of Laser

Fig. 79.5:  Eye protection for lasers

Tissue Hazard • Laser induced damage to skin and other nontarget tissue can result from the thermal interaction of radiant energy with tissue proteins. • Temperature elevations above the normal temperature (37°C) can produce cell destruction by denaturation of cellular enzymes and structural proteins, which interrupts basic metabolic processes.

Environmental Hazards • Inhalation of air borne bio hazardous materials may be released as a result of the surgical application of lasers. Inhaled airborne contaminants can be emitted in the form of smoke or plume generated through the thermal interaction of surgical lasers with tissue or through the accidental escape of toxic chemicals and gases from the laser itself. • Inhalation of toxic or infectious matter in the form of aerosols and particles has been found to be potentially damaging to the respiratory system following both longterm and short-term exposure. • Adequate suction must be available to collect the entire carbon plume from the operating field to prevent the plume from being inhaled by operating room personnel. • Air borne contaminants may be controlled by ventilation, evacuation or other methods of respiratory protection. • Surgical staff should wear masks that remove particles as small as 0.3 um.

Combustion Hazards • In the presence of flammable materials, the laser may produce other significant hazards. • Flammable solids, liquids and gases used within the surgical room can easily ignite if exposed to the laser beam. • Combustion of flammable gases and endotracheal tubes used during general anesthesia due to their proximity

during head and neck procedures, when anesthetic tube lies within the operative field. It must be protected by covering aluminum tape over it, which reflects the beam away from the tube. • The use of explosives or flammable anesthetic agents such as a cyclopropane or ether is contraindicated when the Argon laser is in operation. • Surgical drapes can be ignited by the laser results in burns to the patient, surgeon or other personnel. So, to prevent this surgical drapes should be fire retardant and should be wet to absorb the laser energy, use of flame resistant material and other precautions is recommended. Flammable materials: — Solids: Clothing, paper products, plastics, waxes and resins — Liquids: Ethanol, acetone, methylmethacrylate, solvents — Gases: O2, N2O a general anesthetics, aromatic vapors.

Electrical Hazards • Surgical lasers often use very high currents and high voltage power supplies. Electrical hazards of lasers can be grouped as electrical shock hazard, electric fire hazards or explosion hazards. High voltages in main power box can cause pain, burns, ventricular fibrillation and death. • Insulated circuit, shielding, grounding and housing of high voltage electrical components provide adequate protection from electrical injury.

Equipment Hazard • The mechanical shutters of laser are kept closed until the laser is ready to use. When the laser is in use, the shutter of the aiming beam is kept open at all times. • Room lights should be positioned so that they will not interfere with the motion of a rigid laser arm. Interference has the potential for damaging either the laser in arm mirrors or the room light. This damage could interfere with the proper function of the unit or contaminate the operative field. • Pedals for the laser and for any auxiliary equipment should be on different sides of the surgical table to prevent unintended activation of the laser. Lasers and their uses have captured the imagination of dentists, clinicians and researchers alike. An array of exciting applications has been described, including soft tissue management and analgesia, desensitization, endodontic uses, caries removal and prevention and curing composite resins. The ideal laser system, capable of performing hard tissue procedures consistently and effectively, without causing pulpal

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damage is still nonexistent. One of the problems encountered is the large number of variables like dentin thickness, laser wavelength, absorption peak, pulse power, pulse width, pulse

repetition rate, spot size and exposure duration. However, future aspects of lasers in dentistry show many very interesting trends and possibilities, but a long development period lies ahead.

POINTS TO REMEMBER • Diagnosis of dental caries is by laser induced fluorescence, tetrahertz pulse imaging, quantitative laser fluorescence, fluorescence resulting from red light excitation of occlusal surfaces, optical coherence tomography. • The best instrument associated with laser for caries diagnosis is the DIAGNOdent. • Argon laser is best used for prevention of caries as it alter the surface characteristics of enamel to make it more caries resistant. • Er:YAG laser is the best for caries hard tissue removal. • Mostly all lasers can be used in soft tissue treatments. Some of the common laser assisted treatments are frenum revisions, exposure of teeth, removal of lesions and biopsies, treatment of pericoronal problems in erupting teeth, treatment of apthous ulcers and herpes labialis, removal of hyperplastic tissue. • Laser induced analgesia is induced as laser energy interfere with the sodium pump mechanism, change cell membrane permeability, alter temporarily the endings of the sensory neurons and block the depolarization of C and A fibers of the nerves. • Laser can be used for direct or indirect pulp capping even in primary teeth and CO2 laser is used for this. • Laser pulpotomy with Nd:YAG laser has successful results. • Er:YAG laser is used for pulpectomy. • Advantages of laser are minimal damage to surrounding tissues, precision in tissue destruction, reduction of postoperative inflammation, reduced postoperative pain, operating time is reduced and wound healing. • Disadvantages are injury to operator or patient, combustion hazards, loss of tactile feedback, specialized training required to use and high cost of the equipment. • Laser hazards include ocular hazard, tissue damage, respiratory hazards, fire and explosion and electrical shock.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6. 7. 8.

Describe the applications of laser in pediatric dentistry. Explain the role of lasers in dental caries. What are the uses of lasers in soft tissue treatments? Uses of lasers in endodontics. Classify the lasers according to their uses. Enumerate the advantages and disadvantages of laser. Classify lasers according to OSHA standards. Describe the hazards of dental laser.

BIBLIOGRAPHY 1. Bjelkhajen H, Sundström F, Angmar-Mansson B, et al. Early detection of enamel caries by the luminescence excited by visible laser light. Swed Dent J. 1982;6:1-7. 2. Boj JR, Poirier C, Hernandez M, Espasa E, Espanya A. Case series: laser treatments for soft tissue problems in children. European archives of Paediatric Dentistry. 2011;12(2):113-17. 3. Boj JR, Poirier C, Hernandez M, Espasa E, Espanya A. Review: laser soft tissue treatments for paediatric dental patients. European archives of Paediatric Dentistry. 2011;12 (2):100-5. 4. Convissar RA. The Dental Clinics of North America. Philadelphia: WB Saunders; 2000. 5. Donald J. Coluzzi. Lasers in Dentistry: From Fundamentals to Clinical Procedures. Seminar Series. American Dental Association. 6. Eggertsson H, Analoui M, van der Veen, et al. Detection of early interproximal caries in vitro using laser fluorescence, dye-enhanced laser fluorescence and direct visual examination. Caries Res. 1999:33(3):227-33.

Chapter 79  Applications and Hazards of Laser 7. Ferreira-Zandona AG, Analoui M, Beiswanger BB, et al. AN in vitro comparison between laser fluorescence and visual examination for detection of demineralization in occlusal pits and fissures. Caries Res. 1998;32(3):210-8. 8. Fred S Margolis. Clinical Uses of the Erbium Laser. Clinical Instructor, Loyola University’s Oral Health Center Maywood, Illinois. 9. Fried D, Radagio J, Akrivou M, et al. Dental hard tissue modification and removal using sealed transverse excited atmospheric-pressure lasers operating at 9.6 and 10.6 micrometer. J Biomed Optics. 2001:6:231-8. 10. Glenn van As. Erbium lasers in dentistry. Dent Clin N Am. 2004;48:1017-59. 11. Hibst R, Gall R. Development of a diode laser-based fluorescent caries detector. Caries Research. 1998:32:294. 12. Hicks MJ, Flaitz CM, Westerman GH, et al. Enamel caries initiation and progression following low fluence (energy) argon laser and fluoride treatment. J Clin Pediatr Dent. 1995;20(1):9-13. 13. Irinea Gregnanin Pedron, Vivian Cunha Gatetta, Ludare Hramatsu Azeveda, Ludana Correa. Treatment of mucocele of the lower lip with diode laser in pediatric patients: presentation of 2 clinical cases. Pediatric Dentistry. 2010;32(7). 14. Kotlow L. Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YaG and 1064 diode lasers. European archives of Paediatric Dentistry. 2011;12(2):106-12. 15. Lawrence A. Kotlow. Pediatric Dentistry: The New Standard of Care. US Dentistry; 2006. 16. Luc C. Martens. Laser-assisted Pediatric Dentistry: Review and Outlook. J Oral Laser Application. 2003;3:203-9. 17. Lussi A, Megert B, Longbottom C, et al. Clinical performance of a laser fluorescence device for detection of occlusal caries lesions. Eur J Oral Sci. 2001;109(1):14-9. 18. Martens LC. Laser physics and a review of laser applications in dentistry for children. European archives of Paediatric Dentistry. 2011;12(2):61-7. 19. Norbert Gutnecht, Rene Franzen, Leon Vanweersch, Friedrich Lampert. Lasers in Pediatric Dentistry : a Review. J Oral Laser Application. 2005;5:207-18. 20. Panagiotis Kafas, Christos Stavrianos, Waseem Jerjes, Tahwinder Upile, Michael Vourvachis, Marios Theodoridis, Irene Stavrianou. Upper-lip laser frenectomy without infiltrated anaesthesia in a paediatric patient: a case report. Cases J. 2009;2:7138. 21. Roeykens H, De Moor R. The use of laser Doppler flowmetry in paediatric dentistry. European archives of Paediatric Dentistry. 2011;12(2):85-9. 22. Stookey GK, Jackson RD, Ferreira-Zandona, et al. Dental caries diagnosis. Den Clin N Amer. 2000;43(4):665-77. 23. Sun G, Turnér J. Low-level laser therapy in dentistry. Dent Clin N Am. 2004;48:1061-76. 24. Walsh LJ. The current status of low level laser therapy in dentistry. Part 1 Soft tissue application. Aust Dent J. 1997;42(4):247-54.

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Section

ADVANCEMENTS IN PEDIATRIC DENTISTRY

This unit encompasses the recent advancements in pediatric dentistry which includes nanodentistry, nanorobotics, nanoionomers and implementation of dental implants in primary dentition.

80

Chapter

Applications of Nanosciences in Pediatric Dentistry Arun Bhupathi

Chapter outline •

Size Dependent Altered Properties

The concept of miniaturization was first put forth at an annual meeting held at California Institute of Technology by the American Physical Society by Dr Richard Phillips Feynmann on December 29, 1959. In his seminar lecture, “There’s plenty of room at the bottom” the concept of miniaturization was exclusively presented, i.e. about data storage on minute devices, atomic scale script engraving and interpretation, reduction in computer size, fabrication of atomic electronic circuits, etc. However, the term nanotechnology was not used by Feynmann, but was proposed by Taniguchi in his paper “On the basic concept of nanotechnology”, which was published in 1974. In a book published in 1986, “Engines of creation: The coming era of nanotechnology”, by Dr Eric Drexler considered the Feynmann’s concept of numerous tiny factories, expressed his idea that huge number of one’s own copies can be made with the aid of computer control instead of human operator control. With the advent of science and technology the futuristic concept has turned into reality and nanotechnology has expanded its horizons to every aspect of the scientific world including the dentistry. The incorporation of nanotechnology has changed the properties of certain materials used in dentistry and research is still on to overcome the challenges faced by the clinician. This chapter highlights the applications of the nanosciences in pediatric dentistry. According to US government, “Nanotechnology is re­ search and technology development at the atomic, mole­cular or macromolecular level in the length scale of approxi­mately 1 to 100 nm range, to provide a fundamental understanding of phenomena and materials at the nanoscale and to create and use structures, devices and systems that have novel properties and functions because of their small and/or intermediate size”.

•

Nanosystems in Pediatric Dentistry

SIZE DEPENDENT ALTERED PROPERTIES With the alteration in size, the quantum mechanical properties of the nano-materials/particles changes and exhibits various adaptable physical, chemical and biological properties which are drastically different from their bulk counter parts of the same material (Fig. 80.1).

Nanomaterials Synthesis • For the fabrication of nanomaterials two approaches are developed which includes bottom up and top-down procedures. However, a hybrid approach can also be used which has both the above mentioned procedures to develop a complete nanostructure, e.g. lithography. With these approaches, zero, one, two-dimensional and special nanostructures can be developed. • Bottom-up approach is typically the construction of the material atom by atom, molecule by molecule. The biophysiological molecules often follow this synthesis procedure to develop into a complete stable and functional nanostructure, e.g. protein molecules, hemoglobin, etc. The various procedures included in this approach are solgel method, electrospinning, electrochemical deposition, co-precipitation method, etc. The particles developed by this procedure will be smaller than the top-down synthesis procedures. • Top-down approach is the procedural reduction in the di­ mensions of the bulk material till they attain a stable nanodimension structure. The nanostructures formed through this approach will have more structural imperfections. The nanofabrication procedures included in this approach are milling or attrition and quenching repeatedly.

980 Section 18 

Advancements in Pediatric Dentistry

Fig. 80.1:  Depicting size dependent altered properties

• In the synthesis and processing of nanostructure materials the following challenges must be encountered: – Due to large surface area to volume ratio, the high surface energy has to be overcome. – Certainty in the development of desired uniform size and shape distribution, chemical structure and composition which together show the impact on physical properties. – Coarsening with time through agglomeration or Ostwald ripening should be prevented. • After the fabrication of nanomaterials successfully, thorough screening will be performed at in vitro (cellular level), in vivo (preclinical/animal model) and clinical analysis (human volunteers) levels. Due to the increased activity of the nanosystems with the biological system their retention in the body and toxic effect has been noticed and is still under research investigation. • The nanoscience is still a developing research field, so the long-term toxicological screening methods have to be developed yet.

NANOSYSTEMS IN PEDIATRIC DENTISTRY The existence of nano-dimensioned hydroxyapatite crystallites and collagen fibrils in the dentoalveolar structures led the introduction of nanotechnology into dentistry which today

we term it as nanodentistry. With the advent of nanoprecision equipment like scanning electron microscope (SEM), probe based atomic force microscope (AFM), positron-resolved small angle X-ray scattering (SAXS), transmission electron microscopy (TEM), X-ray photoelectron spectroscopy (XPS), etc. the nanoscopic awareness over the macroscopic dentoalveolar structures was revealed and studied. This nano-dimension knowledge could furnish a basis for hand­ ling the physiological and pathological variants of the dento­ alveolar structures. The description regarding the clinically implemented nanoscience products such as the nano­ composite restorative materials, nano-bonding adhesives, nano-glass ionomer restorative materials and nano-implants are discussed in the following:

Nanocomposite Restorations • In 1950’s the research and development of resin based composites was initiated in the field of restorative dentistry which underwent various innovations and the recent advancements over the last decade were nanoparticle and or nanocluster embedded conventional composite resins. With the advent of nanotechnology in dentistry, the nanoparticle incorporated dental materials have evolved.

Chapter 80  Applications of Nanosciences in Pediatric Dentistry • The color based dental filling material consisted of an organic matrix phase, inorganic filler phase and an activator system. The size of the nanoparticles governs the optical properties, i.e. the nanoparticle size (∼20 nm) is lesser than the visible light wavelength 400 nm to 800 nm, thus the nanocomposites developed with these nanoparticles have exceedingly less opaque property. • Along with optical property, the increase in content of inorganic filler phase and their shape also become significant in imparting enhanced physical and mecha­ nical properties like elastic modulus, hardness, etc. • The filler particle’s size defines the type of composite as either microfilled, nanofilled or nanohybrids. The microfilled composite restorative materials consists of micron sized filler particles have been were used for anterior restorations due to their esthetic properties such as high initial gloss and luster retention. But unfortunately as their strength parameters are compromising they are not the material of choice in high load bearing areas (e.g. Class I, II and IV restorations). • The nanofilled composites consist of filler particles in the range of 1 to 100 nm in size, and a blend of both the larger sized particles (0.4–5 µm) and nanosized particles consti­ tute the nanohybrids. The incorporation of nanoparticles impart high mechanical strength and long-term polish retention to the nanocomposite restorative materials. The addition of heavy metal fillers in nanofilled compos­ ites such as barium, aluminum, silicates, etc. increases the radio opacity. Even though the nanocomposites have excellent wear resistance they form smoother wear facets when compared to the other conventional composites. Due to increased contact surface area of nanofillers the exclusive nanocomposite resins are more susceptible to solubility and water sorption. • The commercially available minifilled composites in 1970 comprised of silicon dioxide filler particles of 0.04 µm size (i.e. 40 nm), but the recently available nanofilled composites differ in the route of synthesis of the silica filler particles. However, the variation between the filler particles of minifilled composites and nanofilled composites is the route of synthesis in which the former was by pyrogenic method and the later is by ordered growth of filler particles. The maximum allowable load for minifilled composites is 55 wt percent and that of nanofilled is 87 percent. The nanofill composites were synthesized by incorporation of silane functionalized spherical silica nanoparticles of 5 to 40 nm, where the bifunctional silane coupling agents (e.g. 3-methacryloxypropyl–trimethoxysilane, MPTS) act as surfactant in pre-cured resin matrix and during curing as bonding agent to resin matrix. One terminal functional group of the bifunctional coupling agent is a silica ester group which aids in bonding to the inorganic surface and

other terminal functional group is methacrylate group which prevents the aggregation of nanofiller particles and maintains the compatibility in pre-cured resin matrix system. • In the beginning of this century the nanotechnology has laid a commercial milestone by the inclusion of aggregated zirconia/silica nanoclusters into the composite resin with an average particle size of 20 nm for silica and 5 to 20 nm in the agglomerated cluster form. In the recently combined microhybrid and nanofilled composites, the filler weight percentage is increased from 75.75 to 87 percent by filling the lacunae between the bigger particles with the tiny. • Irrespective of the storage and environmental conditions the nanoclusters possess a distinct reinforcing mechanism and thus exhibit improved strength and reliability which may be due to the infiltration of silane within the lacunae of the nanoclusters, thereby heightening the scathe allowance.

Nano-adhesive Bonding Agents • Due to the effect of gravity, the larger filler particles which are meant to increase the cohesive strength of moderately viscous adhesives settle out during storage, thereby cause an inconsistency in the performance of the dental adhesive. • In order to overcome this problem, with the coordination of nanotechnology, a nanofiller particle embedded dental adhesives were developed. The nanofiller particles were silica or zirconia within the range of 5 to 7 nm which remained stable and unaggregated under the gravitational forces. The zirconia nanoparticle embedded adhesive systems exhibit radiopaque property.

Nano-glass Ionomer Cement • The recent innovation in resin modified glass ionomer cement is by the incorporation of silica-zirconia nano­ fillers and nanoclusters and silica nanofillers in 2007, which has enhanced esthetic properties and retained the conventional properties of resin modified glass ionomer cements. • The silane functionalized nanofillers (5–25 nm) and loosely bound aggregates of nanoclusters (1 µm–1.6  µm) addition enhanced the optical property, i.e. tooth shade toning potential, less visual opacity, low surface roughness, high polishability and gloss reflectance, low wear rate and few other physical properties clinically. • The filler loading was nearly 69 percent of fluoro­ aluminosilicate glass content and had no effect on the cumulative fluoride release pattern suggesting that incorporation of nano-filler particles into the resin matrix does not interfere with cumulative fluoride release.

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Nano-implants • One among the recent advances in the clinical prosthetic replacement therapy is the dental implant system, which is providing a successful clinical solution. • One of the main features of a dental implant is its surface topography. The host cellular response towards the dental implant determines the biocompatibility, ability to osseointegrate and functional retentivity. • To enable these features the topography of dental implant has transformed from micron scale to nanoscale level. The natural nanoscale features such as the surface roughness of bone nearly 32 nm and the epithelial basement membrane pore size approximately is 70 to 100  nm biomimics the implant nanotopography. • Nanoscale surface modified dental implants possess unique features that alter the cell attachment by the following mechanisms: – Plasma protein/surface interactions: The protein such as plasma fibronectin or vitronectin adsorption which occurs immediate to implant placement will mediate the subsequent cellular adhesion and behavior. The conformational changes in these RGD proteins can be achieved by nanoscaled features, which affect the cellular activity. – Contact angle or wettability: The change in the contact angle influences the wettability or surface energy which determines the adsorption of extracellular matrix proteins. – Cell adhesion and motility: These two cell traits are affected by nanoscaled surfaces. Integrins and adherent proteins influence these traits directly and indirectly respectively. The establishment of interface between the nanoscaled dental implant–alveolar bone and oral mucosa is attributed to the cellular spreading and motility.

– Cell proliferation: The outcome of nanoscaled implant surface to the adhered cell signaling, determines the cellular proliferation rate. Even though the osteoblast proliferation is increased, the underlying mechanism of cellular (osteoblast) response to the nanoscaled surface still remains unclear. – Cell differentiation: The mesenchymal cells adhered to the nanoscaled implant differentiates along the bone cell lineage, i.e. osteoblast lineage. An elevated level of alkaline phosphatase and calcium mineral content was noticed in the cell layers formed on nanoscaled materials which promote the osteoblastic activity and osseoinduction process. Up regulation of gene expression responsible for osteoblastic differentiation occurs in nanoscaled implants. – Cell adhesion selectivity: The selectivity in cellular adhesion especially the fibroblast or osteoblast depends on the topographic features of the implant. The nano-scaled implants have shown higher affinity towards osteoblasts than fibroblasts in the ratio of 3:1, where as in the conventional systems it is 1:1. Similar response was noticed even with smooth muscle cells and chondrocytes which facilitate the adaptability of the implant to the mucosal surfaces. Reduced bacterial adhesion, colonization and proliferation which further implicate the exploration of biofilm formation and peri-implantitis. The nanoscience is progressing rapidly in the deve­ lopment of new materials in dentistry. Nanobots are under the process of designing for various applications in dentistry which include the dentin hypersensitivity, dental caries, orthodontic tooth repositioning, perio­dontal management, anesthesia, dental flourosis, etc. Apart from it an extensive research is focused on cancer nanodiagnostics and nanotherapeutics. Polymer encapsulated nanoparticles to reduce the immune rejection and perform multifunctional activities in the biological systems are under research.

POINTS TO REMEMBER • Dr Richard Phillips Feynmann was the first to describe the use of nanotechnology. • Term nanotechnology was proposed by Taniguchi. • Nanotechnology is research and technology development at the atomic, molecular or macromolecular level in the length scale of approximately 1 to 100 nm range, to provide a fundamental understanding of phenomena and materials at the nanoscale and to create and use structures, devices and systems that have novel properties and functions because of their small and/or intermediate size. • Nanosystems used in pediatric dentistry are nanocomposite restorations, nanoadhesive bonding agents, nanoglass ionomer cement and nanoimplants.

Chapter 80  Applications of Nanosciences in Pediatric Dentistry

QUESTIONNAIRE 1. 2. 3. 4. 5.

Enumerate the various nanosystems used in pedodontics. Briefly describe the nanoadhesive systems used in pediatric dentistry. Elaborate the features of nano-implant, which is one of the prosthetic replacement choices for the missing dentition. What are size dependant properties of a nanosystem? Write a note on Nano GIC.

BIBLIOGRAPHY

1. Bayne SC. Dental biomaterials: where are we and where are we going? J Dent Educ. 2005;69(5):571-85. 2. Bushan B. Springer Handbook of Nanotechnology pp.147-80. 3. Feynman RP. There is plenty of room at the bottom, Eng. Sci. 23 (1960) 22–36 and www.zyvex.com/nano-tech/feynman.html 1959. 4. Ford P, Seymour G, Beeley JA, et al. Adapting to changes in molecular biosciences and technologies. Eur J Dent Educ. 2008;12(Suppl 1): 40-7. 5. Gustavo Mendonça, Daniela BS Mendonça, Francisco JL Aragao, Lyndon F. Cooper. Advancing dental implant surface technology-from micron to nanotopography, biomaterials. 2008;29:3822-35. 6. Mitra SB, Wu D, Holmes BN. An application of nanotechnology in advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90. 7. Scott A Saunders. Current practicality of nanotechnology in dentistry. Part 1: Focus on nanocomposite restoratives and biomimetics Clinical, Cosmetic and Investigational Dentistry. 2009;1:47-61. 8. Sebastian Gaiser, Hans Deyhle, Oliver Bunk, Shane N. White, Bert Muller. Understanding nano-anatomy of Healthy and Carious Human Teeth: a Prerequisite for Nanodentistry. Bio-interphase. 2012;7(4):1-14. 9. Sharma S, Cross SE, Hsueh C, Wali RP, Stieg AZ, Gimzewski JK. Nanocharacterization in dentistry. Int J Mol Sci. 2010;11(6): 2523-45. 10. Tanaguchi N. On the basic concept of nanotechnology, Proc. ICPE; 1974. 11. Tomisa AP, Launey ME, Lee JS, Mankani MH, Wegst UG, Saiz E. Nanotechnology approaches to improve dental implants. Int J Oral Maxillofac Implants. 2011;26(Suppl):25-44; discussion 45-9.

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Chapter

Dental Implants in Children Pragati Kaurani, Nikhil Marwah

Chapter outline • • •

Growth and Implant Placement Timing and Placement of Implant Factors to be Considered for Implant Placement in Growing Patients

Dental implants for children are a new treatment modality. The use of implants in children or in individuals where growth is not completed is a controversial one. Before placement of an implant, it is essential to understand growth, development and the dynamics of a placed implant in a biologic environment of a growing patient. Dental implants have been defined as a prosthetic device made of alloplastic material implanted into the oral tissues beneath the mucosa or/and periosteal layer, and on/or within the bone to provide retention and support for a fixed or a removable partial denture. From a physiologic standpoint, the conservation of bone may be the most important reason for the use of dental implants in growing patients and it even may be beneficial in some cases to stimulate alveolar bone development in cases of congenital partial anodontia and traumatic tooth loss where oral rehabilitation is required even before skeletal and dental maturation has occurred. Other factors that favor implant placement in children are their excellent local blood supply, positive immunobiologic resistance, and uncomplicated osseous healing. However, in spite of these positives the issue of timing of placement of implant in children is still under critical evaluation as there are two major concerns: 1. First, if implants are present during several years of facial growth, there is a danger of them becoming embedded, relocated, or displaced as the jaw grows. 2. Second area of concern is the effect of prosthesis on growth.

Review of the literature • Bjork implanted pins in the jaws of children for longitudinal cephalometric studies and reported that those in the path of

• •

• •

•

•

Recommendation for Implant Placement by Quadrant Suggestions for Implant Placement in Unaffected Patients

erupting teeth were displaced and those placed in resorptive areas were lost Thilander et al. concluded that osseointegrated implants in pigs remained stable in space Ledermann et al. in their 7-year follow-up with a mean length of 35.5 months, reported a 90 percent success rate on 42 endosseous dental implants placed in 34 patients aged 9 to 18 years. There was a positive soft and osseous tissue reaction to the implants. The major complication reported was the failure of dental implants to respond to the vertical growth of adjacent teeth and alveolus due to ankylosis According to Smith et al. implant use in children with ectodermal dysplasia is a treatment of choice, since its placement in the mandibular anterior region of a 5-year-old patient did not affect adjacent tooth buds Guckes et al. described a case of a 3-year-old patient with ectodermal dysplasia in which dental implants located in the mandible and maxilla have not moved despite growth. During the 5-year follow-up, the prosthesis was remodeled to accommodate eruption of the maxillary teeth and facial growth

GROWTH AND IMPLANT PLACEMENT The most crucial aspect to be considered in implant placement in children is the effect of growth. As they are rigid fixations, any incorrect placement can have serious consequences on the growth and development of the arches, trauma to the developing tooth buds or a deviation of the path of an erupting tooth. Therefore, it is important

Chapter 81  Dental Implants in Children that clinicians understand the impact of growth and the potential risks involved in implant placement in a growing child.

 Vertical Craniofacial Growth • Placement of implant is influenced by the great amount of growth in the vertical direction along with the eruption of maxillary teeth. Increase in anterior facial height due to vertical growth of the craniofacial skeleton is especially rapid during the early teenage years. • If an implant is placed too early (before growth and eruption are complete), the implant crown will become submerged. • Brugnolo et al. described 3 patients (11.5–13 years of age) who received implants in the anterior regions of the maxilla. After 2.5 to 4.5 years, all patients had implant crowns in infraocclusion. • Ödman showed that implants placed in young patients may show implant infraposition after several years due to craniofacial growth, which may continue in the young adult patient.

 Transverse Craniofacial Growth • Moorrees et al. suggested that a decrease of incisorcanine circumference noted from 13 to 18 years of age was associated with a decrease in arch length, rather than a narrowing in arch width. Overall, the changes are those that would contribute to crowding in the dental arches. • Bishara et al. observed that tooth size arch length discrepancy increases significantly from early adolescence to mid adulthood in both maxillary and mandibular arches. The decrease was calculated to be 1.9 mm in males and 2.0 mm in females in the maxillary arch, 2.7 and 3.5 mm in the mandibular arch respectively. • Increased crowding and changes in arch form could have a significant effect on a single-tooth implant in a patient who undergoes maximum growth changes, resulting in an implant crown that is out of alignment with adjacent natural teeth.

Sagittal Growth The sagittal growth of the mandible has no impact on the implant placement in children. Only the rotation of the mandible in the sagittal plane has to be considered.

Growth Spurt In a study carried out by Iseri and Solow, the average velocity of eruption of maxillary incisors in girls 9 to 25 years of age was 1.2 to 1.5 mm per year during active growth and 0.1 to

0.2 mm per year after age 17 to 18. Changes of this magnitude are difficult to compensate for if an implant is placed in a 9 to 10-year-old girl. The change in boys is even more.

Maxillary Growth • The midpalatal suture is an important growth site that must be allowed to grow undisturbed, and any interference during its growth can result in dental crossbite. A fixed prosthesis that crosses the midpalatal suture and is attached to implants may restrict transverse growth, and the restriction becomes greater as the implants are placed more and more posterior. • When the maxilla widens at its midline suture, the central incisor teeth change their position in the bone to compensate and are prevented from separating by the periodontal fibers. Implants are not subject to this compensatory system, and if located in the anterior on opposite sides of the midpalatal suture of a child, they will be carried apart for a significant distance by transverse growth, creating esthetic and functional problems.

TIMING AND PLACEMENT OF IMPLANT Replacing a permanent tooth lost from trauma with an implant poses a challenging dilemma because of the implant’s lack of eruption potential can lead to discrepancies in the occlusal plane, esthetic problems and possible disruption of the normal development of the jaw. • Op Heij et al. summarized the growth patterns of each jaw, noting their implications and giving treatment recommendations (Table 81.1). • The key to implant placement in these patients appears to be the determination of cessation of growth. The average age of growth spurts in girls is 12 years, while the average age in boys is 14 years. However, growth changes occur beyond the time of the growth spurt and may vary by as much as 6 years. • Shaw reported that the dramatic growth changes occurring in infancy and early childhood were not conducive to the maintenance of implants. • According to Dietschl and Schatz implant placement in children younger than 16 to 18 years must be avoided, or they will remain in infraocclusion due to adjacent alveolar bone growth. • Bergendal et al. stated that implants must be placed when growth is almost complete, except for rare cases of total aplasia, as in ectodermal dysplasia. • According to Guckes et al. bone volume in children may not be sufficient for the placement of implants. • Osseointegrated implants behave like ankylosed teeth, arresting both eruption and alveolar bone growth and not adapting to changes secondary to alveolar bone

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TABLE 81.1: Implication of early implant placement by location and type of growth Transverse growth

Sagittal growth

Vertical growth

Anterior region completed prior to adolescent growth spurt Sutural widening greater in posterior

Closely associated with skeletal growth: when it follows the mandibular growth, loss of sutural growth via resorption results

Maxilla displaced downward via sutural growth, remodeling and eruption; adult levels of vertical growth usually reached at age 17–18 in girls and later in boys

Implication

• Can lead to diastema and shifting of midline to the implant side

• Anterior resorption could result in loss of bone on labial side of implant

• Leads to infraocclusion; unfavorable • Endosseous-supraosseous ratio

Mandible

Anterior growth ceases early; limited remodeling causes least problems

Endochondral growth at condyle and remodeling of ramus

Height increase by condylar growth and bone apposition

Maxilla

Posterior growth continues longer through remodeling and bone apposition

Facial types develop in different ways • Normal; minor rotation • Short; horizontal growth, forward rotation, deep bite • Long; vertical growth posterior rotation, skeletal open bite

Implication

• Premolar or molar implant • No impact on implant could be shifted into a placement lingual position • Rotation in sagittal plane must be considered

growth. Therefore, an implant placed in growing patient can become embedded in bone hence changes in growth, disturbances in alignment and occlusion occur. • The timing of implant placement in growing patients was discussed at a Scandinavian Consensus Conference in Jönköping, Sweden where there was a general agreement that implant placement should be postponed until skeletal growth is completed or nearly completed in normal adolescents. In the individual with oligodontia or anodontia, however, earlier intervention could be indicated, especially in the mandible. Anodontia and severe oligodontia were mentioned as exceptions to the rule.

FACTORS TO BE CONSIDERED FOR IMPLANT PLACEMENT IN GROWING PATIENTS

Skeletal Maturity Level/Age of the Patient Implants placed after 15 years in girls and 18 years in boys or when two annual cephalograms show no change in position of adjacent teeth and alveolus are said to be most predictable prognosis.

Recommendation Delay implant palcement until skeletal growth complete • In anodontic child, implant placement in the posterior could be considered under well planned conditions

Delay implant placement until skeletal growth complete • In a severe anodontic or oligodontic child, implants may be placed in the anterior mandible • Lack of reports with regard to implants in posterior mandible

• Affects anteroposterior and vertical eruption patterns • Affects relationship between implant and adjacent tooth in vertical and labiolingual direction

Sex of the Patient As males grow for a longer time period than females, implants in adolescent boys must be delayed longer than adolescent girls to allow growth completion.

Number and Location of Missing Teeth In patients with complete anodontia, implants can be planned in the maxilla and anterior mandible as early as 7 years. However, it must be kept in mind that the implants may have to be replaced, or prosthesis may have to be modified. It is advisable to restore a larger edentulous area with implants than to place a single implant supported crown.

RECOMMENDATION FOR IMPLANT PLACEMENT BY QUADRANT • Maxillary anterior quadrant is an important area for consideration due to traumatic tooth loss and frequent congenital tooth absence. The vertical growth of the maxilla exceeds all other dimensions of the growth in this quadrant; therefore premature implant placement can result in the repetitive need to lengthen the transmucosal

Chapter 81  Dental Implants in Children implant connection which leads to poor implant-toprosthesis ratios. According to Krant, the placement of implants in the anterior maxillary quadrant before the age of 15 in female patients and 17 in male patients should be attempted to achieve unique treatment planning goals and with particular emphasis on the only determination of skeletal age, informed consent, and the possibility of future implant replacement. • Maxillary posterior quadrant is subjected to same general growth factors described for the maxillary anteroposterior area. An additional growth factor is transverse maxillary growth at midpalatal suture. Placement of osseointegrated dental implants in the maxillary posterior quadrant is best delayed until the age of 15 years in females and 17 years in males. • Mandibular anterior quadrant is the best site for the placement of an osseointegrated implant before skeletal maturation as mandibular anterior quadrant presents fewer growth variables and closure of the mandibular symphyseal suture occurs during the first 2 years of life. Reports were published by Cronin et al. and Smith et al. documenting the placement of endosseous implants in the anterior mandibular region as early as 5 years of age with positive treatment results.

According to the 1988 National Institute of Health Consensus Development Conference on Dental Implants at Bethesda, it was agreed that oral implants in young patients, should not be placed until growth and skeletal development is completed or nearly completed; the area best suited for implants in children was anterior mandible and least indicated was maxillary anterior segment.

SUGGESTIONS FOR IMPLANT PLACEMENT IN UNAFFECTED PATIENTS • Whenever possible, implant placement must be delayed until the age of 15 years for girls and 18 years for boys. • Growing patient treated with dental implant should have adequate follow-up. • Further research is needed in the areas of implants in growing children. • Implant location, the sex of the patient, and the skeletal maturation level are the most important factors in the final decision of when to place implant. • It is still recommended to wait for the completion of  dental and skeletal growth, except for severe cases of ED.

POINTS TO REMEMBER • Dental implants have been defined as a prosthetic device made of alloplastic material implanted into the oral tissues beneath the mucosa or/and periosteal layer, and on/or within the bone to provide retention and support for a fixed or a removable partial denture. • Bjork was the first one to implant pins as implants. • If an implant is placed too early (before growth and eruption are complete), the implant crown will become submerged. • Increased crowding and changes in arch form could have a significant effect on a single-tooth implant in a patient who undergoes maximum growth changes, resulting in an implant crown that is out of alignment with adjacent natural teeth. • The timing of implant placement in growing patients was discussed at a Scandinavian Consensus Conference in Jönköping, Sweden where there was a general agreement that implant placement should be postponed until skeletal growth is completed or nearly completed in normal adolescents. • Factors to be considered for implant placement in growing patients are skeletal maturity level, age of the patient, sex of patient and number and location of missing teeth. • The area best suited for implants in children was anterior mandible and least indicated was maxillary anterior segment. • Whenever possible, implant placement must be delayed until the age of 15 years for girls and 18 years for boys.

QUESTIONNAIRE 1. Discuss growth and implant placement. 2. Explain the implications of timing on implant. 3. What are the factors to be kept in consideration while placement of implants in children?

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BIBLIOGRAPHY 1. Agarwal N, Godhi BS, Verma P. Pediatric Implants: a Clinical Dilemma. JOHCD. 2012;6(3). 2. Bergendal B, Koch G, Karol J, Wanndahl G, (Eds). Consensus conference on ectodermal dysplasia with special reference to dental treatment. Stockholm, Sweden: Forlagshuset Gothia AB; 1998. 3. Bergendal B. When should we extract deciduous teeth and place implants in young individuals with tooth agenesis. J Oral Rehabil. 2008; 35(suppl 1):55-63. 4. Bishara SE, Jakobsen JF, Treder JE, Stasi MJ. Changes in the maxillary and mandibular tooth size/arch length relationship from early adolescence to early adulthood. Am J Orthod Dentofacial Orthop. 1989;95:46-59. 5. Björk A. Growth of the maxilla in three dimensions as revealed radiographicaily by the implant method. Br J Orthod. 1977;4:53-64. 6. Björk A. Variations in the growth pattern of the human mandible: A longitudinal radiographic study by the implant method. Dent Res. 1963;42:400-4n. 7. Brahmin JS. Dental implants in children. Oral Maxillofacial Surg Clin N Am. 2005;17:375-81. 8. Brugnolo E, Mazzocco C, Cardioli G, Majzoub Z. Clinical and radiographic findings following placement of single tooth implants in young patients. Case reports. Int J Periodont Res Dent. 1996;16:421-33. 9. Brugnolo E, Mazzocco C, Cordioll G, Majzoub Z. Clinical and radiographic findings following placement of single tooth implants in young patients: case reports. Int J Periodont Rest Dent. 1996;16:421-33. 10. Consensus statement. In: Koch G, Bergendal T, Kvint S, Johansson U, (Eds). Consensus conference on Oral Implants In Young Patients. Stockholm, Sweden: Forlagshuset Gothia AB. 1996.pp.125-33. 11. Cronin RJ, Oesterle L. Implant use in growing patients. Dent Clin North Am. 1998;42:1-35. 12. Cronin RJ Jr, Oesterle LJ. Implants use in growing patients. Dent Clin North Am. 1998;42:1-35. 13. Guckes AD, McCarthy GR, Brahim J. Use of endosseous implants in a 3-year-old child with ectodermal dysplasia: case report and 5-year follow-up. Pediatr Dent. 1997;19:282-5. 14. Kraut RA. Dental implants for children: creating smiles for children without teeth. Pract Periodont Aesthet Dent. 1996;8:909-13. 15. Macitie IC, Quaylc AA. Implants in children: a case report. Endod Dent Traumatol. 1993;9:124-6. 16. Mishra SK, Chowdhary N. Dental implants in growing children. JISPPD. 2013;31(1):1-6. 17. Moorrees CFA, Lebret LML, Kent RL. Changes in the natural dentition after second molar emergence 13-18 years. IADR. 1979.p.276. 18. Oesterle LJ, Cronin RJ Jr, Ranly D. Maxillary implants and the growing patient. Int J Oral Maxillofac Implants. 1993;8:377-87. 19. Op Heij DG, Opdebeeck H, van Steenberghe D, et al. Facial development, continuous tooth eruption, and mesial drift as compromising factors for implant placement, hit. J Oral Maxillofac Implants. 2006;21:867-78. 20. Percinoto C, Ana EMV, Barbieri CM, Melhado FL, Moreira KS. Use of dental implants in children: a literature review. Quintessence Int 2001;32:381-3. 21. Percinoto C, Vieiera AE, Barbieri CM, Melhado FL, Moreira KS. Use of dental implants in children: a literature review. Quintessence Int. 2001;32:381-3. 22. Smith RA, Vargervik K, Kearns G, Bosch C, Koumjian J. Placement of an endosseous implants in a growing child with ectodermal dysplasia. Oral Surg Oral Med Oral Pathol. 1993;75:669-73.

19

Section

RESEARCH METHODOLOGY IN PEDODONTICS

This unit discusses about basic concepts of biostatistics, different statistical analysis and the commonly used indices in children.

82

Chapter

Biostatistics in Dentistry Anupma Sharma, Rajesh Sharma

Chapter outline • • •

Uses of Biostatistics in Dentistry Sample Presentation of Data

• • •

Measures of Central Tendency Measures of Variability Tests of Significance

“When you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of meager and unsatisfactory kind.” –Lord Kelvin ‘Statistic’ or ‘Datum’ is measured or counted fact or piece of information stated as figure. Statistics or data is the plural of the same, stated in more than one figures. The word statistics is derived from Italian word ‘Statista’ meaning Statesman and from german word ‘Statistik’ meaning political state. John Graunt (1620–1674) is known as father of health statistics. • Statistics: Principles and methods for collection, presen­ tation, analysis and interpretation of numerical data. • Biostatistics: Tool of statistics applied to the data that is derived from biological sciences.

USES OF BIOSTATISTICS IN DENTISTRY • In physiology and anatomy – To define the limits of normality for variable such as height or weight or blood pressure, etc. in a population. – Variation more than natural limits may be pathological, i.e. abnormal due to play of certain external factors. – To find correlation between two variables like height and weight. • In pharmacology – To find the action of drugs. – To compare the action of two drugs or two successive dosages of same drug. – To find the relative potency of a new drug with respect to a standard drug.

• In medicine – To compare the efficiency of a particular drug, operation or line of treatment. – To find association between two attributes such as cancer and smoking. – To identify signs and symptoms of disease. • In community medicine and public health – To test usefulness of sera or vaccine in the field. – In epidemiologic studies the role of causative factors is statistically tested.

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• In research – It helps in compilation of data, drawing conclusions and making recommendations. • For students – By learning the methods in biostatistics a student learns to evaluate articles published in medical and dental journals or papers read in medical and dental conferences. – He also understands the basic methods of observation in his clinical practice and research.

SAMPLE It is defined as a part of a population generally selected so as to be representative of the population whose variables are under study. Population: Group of all individuals who are the focus of investigation. Sample: Group of sampling units (individuals) that form part of population generally selected so as to be representative of the population whose variables are under study. Sampling units: Individuals who form the focus of study. Sampling frame: List of sampling units.

Simple Random Sampling • Every unit in population has an equal chance of being selected in the sample • Applicable when: Small population, homogeneous, readily available • Methods are: Lottery method and table of random numbers.

Systematic Random Sampling • Selecting one unit at random and then selecting additional units at evenly spaced intervals till the sample of required size is obtained. • Used in cases where a complete list of population available. • Applied to field studies. • K = sample interval. • K = total population/sample size desired.

Stratified Random Sampling • Target population divided into homogeneous groups or classes called strata • Strata—age, sex, classes, geographical area • More representative sample

• Greater accuracy • Covers wide area.

Multistage Sampling • Sampling in stages using random sampling technique • Employed in large surveys.

Multiphase Sampling • Part of information collected from whole sample part from subsample • Useful for studying a specific disease.

Cluster Sampling • This method is used when population forms natural groups or clusters. For example, villages, school children, etc. • Grouping the population then selecting the groups or clusters rather than the individual elements • Commonly all units in the cluster are included in the study.

Pathfinder Survey • Stratified cluster sampling technique used • Most important population subgroups (index groups) likely to have differing disease levels are chosen covering a standard number of subjects in a specific group in a selected location. • Suitable to evaluate: Overall prevalence of various oral diseases • Variations in disease levels, severity and treatment needs are evaluated • Can be pilot survey or national survey.

Chapter 82  Biostatistics in Dentistry

Sample Size

number of items (frequency) which occurs in each group is shown in adjacent column.

Factors Influencing

Structure

Degree of difference expected

Determine difference

Degree of variation among subjects

Determine SD of groups

Level of significance desired

Set alpha error

Power of the study

Decide power of the study

Drop out rate

Select appropriate formula

Non compliance to treatment

Calculate sample size, give allowance to drop out and Noncompliance

Sample Size Formulae n = [2SD/SE]2: SD and SE from previous studies with 95 percent CI n = z2 σ p2/e2: Z = constant, σ = SD of population, e = acceptable error n = Z2 pq/e2: p = Sample proportion

PRESENTATION OF DATA • Statistical data once collected should be systematically arranged and presented: – To arouse interest of readers – For data reduction – To bring out important points clearly and strikingly – For easy grasp and meaningful conclusions – To facilitate further analysis – To facilitate communication • Two main types of data presentation are: – Tabulation – Graphic representation with charts and diagrams.

Tabulation

Number of cavities

Number of patients

0 to 3

78

3 to 6

67

6 to 9

32

9 and above

16

Charts and Diagrams • Useful method of presenting statistical data • Powerful impact on imagination of the people • Can be classified as: – Bar chart – Histogram – Frequency polygon – Frequency curve – Line diagram – Cumulative frequency diagram or ogive – Scatter diagram – Pie chart – Pictogram – Spot map or map diagram.

Bar Chart • Length of bars drawn vertical or horizontal is proportional to frequency of variable. • Suitable scale is chosen • Bars usually equally spaced • They are of three types: 1. Simple bar chart (Fig. 82.1) 2. Multiple bar chart: Two or more variables are grouped together (Fig. 82.2)

• It is the most common method • Data presentation is in the form of columns and rows • It can be of the following types: – Simple tables – Frequency distribution tables. • Simple table Month

Number of patients at MGDCH, Jaipur

Jan 06

2,800

Feb 06

1,900

March 06

1,750

• Frequency distribution table – In a frequency distribution table, the data is first split into convenient groups (class interval) and the

Fig. 82.1:  Simple bar chart

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Fig. 82.2:  Multiple bar chart

Fig. 82.3:  Component bar chart

Fig. 82.4:  Histogram

3. Component bar chart: Bars are divided into two parts each part representing certain item and proportional to magnitude of that item (Fig. 82.3).

Histogram (Fig. 82.4) • • • •

Pictorial presentation of frequency distribution Consists of series of rectangles Class interval given on vertical axis Area of rectangle is proportional to the frequency.

Frequency Polygon (Fig. 82.5) Obtained by joining midpoints of histogram blocks at the height of frequency by straight lines usually forming a polygon.

Frequency Curve (Fig. 82.6) When number of observations is very large and class inter­ val is reduced the frequency polygon losses its angulations becoming a smooth curve known as frequency curve.

Chapter 82  Biostatistics in Dentistry

Fig. 82.5:  Frequency polygon

Fig. 82.6:  Frequency curve

Fig. 82.7:  Line diagram

Fig. 82.8:  Cumulative frequency diagram

Line Diagram (Fig. 82.7) Line diagram are used to show the trends of events with the passage of time.

Cumulative Frequency Diagram (Fig. 82.8) • Graphical representation of cumulative frequency. • It is obtained by adding the frequency of previous class.

Scatter or Dot Diagram (Fig. 82.9) • Shows relationship between two variables • If the dots are clustered showing a straight line, it shows a relationship of linear nature.

Fig. 82.9:  Dot diagram

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Fig. 82.10:  Pie chart

Fig. 82.11:  Pictogram

Fig. 82.12:  Spot diagram

Pie Chart (Fig. 82.10)

Spot Map or Map Diagram (Fig. 82.12)

• In this frequencies of the group are shown as segment of circle • Degree of angle denotes the frequency. Class frequency × 360 • Angle is calculated by  Total observations

These maps are prepared to show geographic distribution of frequencies of characteristics.

Pictogram (Fig. 82.11)



Popular method of presenting data to the common man.

MEASURES OF CENTRAL TENDENCY

Mean Sum of all the observations Total number of observation

Chapter 82  Biostatistics in Dentistry For grouped data: Total (value of variable × frequency) Mean = Total frequency For grouped data with range: Total (mid point of class internal × frequency) Mean = Total frequency

Uses of Standard Deviation • Summarizes the deviations, of a large distribution • Indicates whether the variation from mean is by chance or real • Helps in finding standard error • Helps in finding the suitable size of sample.

Calculation of Standard Deviation

Median

• • • • •

Calculate the mean = x Difference of each observation from mean, d = xi – x Square these = d² Total these = Σ d² Divide this by no. of observations minus 1, variance = d²/ (n–1) • Square root of this variance is SD = Σ d²/ (n–1).

• Arrange the observations in ascending or descending order. The middle observation is the median. • For example, DMFT of 7 children is 7, 4, 5, 6, 7, 3, 4, it is then arranged in order = 3, 4, 4 ,5, 6, 7, 7, hence median is 5.

Mode

Mean Deviation

• It is that value which in a series of observation occurs with greatest frequency • For example, if the values are 1, 2, 2, 8, 5, 2, 7, 3, 2, then mode is 2.

∑ (X-X) Mean deviation = N

MEASURES OF VARIABILITY

• Compare relative variability • Variation of same character in two or more series • CV is used to compare the variability of one character in two different groups having different magnitude of values or two characters in the same group by expressing in percentage. • Higher the CV greater variability. • CV = SD × 100 Mean

Coefficient of Variation

Standard Deviation • Root mean square deviation • Summary measure of differences of each observations from mean of all observations • Greater the standard deviation greater will be magnitude of dispersion from the mean • Small SD higher degree of uniformity of observations.

Class interval

Frequency

Mid point

Xi fi

Xi-x–

(Xi-x–)2

(Xi-x–)2f

0.2–0.3

1

0.25

0.25

–08

0.64

0.64

0.4–0.5

1

0.45

0.45

–06

0.36

0.36

0.6–0.7

1

0.65

0.65

–04

0.16

0.16

0.8–0.9

5

0.85

4.25

–02

0.04

0.2

1–1.1

10

1.05

10.5

0

0

0

1.2–1.3

4

1.25

5

0.2

0.04

0.16

1.4–1.5

1

1.45

1.45

0.4

0.16

0.16

1–1.7

1

1.65

1.65

0.6

0.36

0.3

1.8–1.9

0

1.85

0

0.8

0.64

0

1

2.05

2.05

1

1

2–2.1

25

26.25

(Xi–x–)2f SD = S    =  N-1

1 2.98

2.98 25-1

  = 0.124

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TESTS OF SIGNIFICANCE Whatever is the sampling procedure or the care taken while selecting sample, the sample statistics will differ from the population parameters. Also variations between 2 samples drawn from the same population may also occur, i.e. differences in the results between two research workers for the same investigation may be observed. Thus, it becomes important to find out the significance of this observed variation, i.e. whether it is due to chance or biological variation (statistically not significant) or due to influence of some external factors (statistically significant). To test whether the variation observed is of significance, the various tests of significance are parametric tests and nonparametric tests.

Parametric Tests • Parametric tests are those tests in which certain assumptions are made about the population. – Population from which sample is drawn has normal distribution – The variances of sample do not differ significantly – The observations found are truly numerical thus arithmetic procedure such as addition, division, and multiplication can be used. • Since these test make assumptions about the population parameters hence they are called parametric tests. • These are usually used to test the difference. • They are: – Student T test (paired or unpaired) – ANOVA – Test of significance between two means.

Nonparametric Tests • In many biological investigations, the research worker may not know the nature of distribution or other required values of the population. • Also some biological measurements may not be true numerical values hence, arithmetic procedures are not possible in such cases. • In such cases distribution free or nonparametric tests are used in which no assumption are made about the population parameters, e.g. – Mann-Whitney test – Chi-square test – Phi coefficient test – Fischer’s exact test – Sign test – Friedman’s test

Chi-square Test • Chi-square test unlike Z and T test is a nonparametric test • The test involves calculation of a quantity called chisquare • Chi-square is denoted by X2 • It was developed by Karl Pearson • The most important application of chi-square test in medical statistics are: – Test of proportion – Test of association – Test of goodness of fit • Test of proportion – Used as an alternate test to find the significance of difference in two or more than two proportions. • Test of association – To measure the probability of association between 2  discreet attributes, e.g. smoking and cancer • Test of goodness of fit – Tests whether the observed values of a character differ from the expected value by chance or due to play of some external factor X2 = ∑ ( O – E ) 2/E ■ X2 denotes Chi-square, O = Observed value, E = Expected value.

ANOVA (Analysis of Variance) • Investigations may not always be confined to comparison of two samples only. • For example, we might like to compare the difference in vertical dimension obtained using three or more methods like phonetics, swallowing, Niswonger’s method. • In such cases where more than two samples are used ANOVA can be used. • Also when measurements are influenced by several factors playing their role e.g. factors affecting retention of a denture, ANOVA can be used. • ANOVA helps to decide which factors are more important. • Requirements – Data for each group are assumed to be independent and normally distributed – Sampling should be at random • Oneway ANOVA – Where only one factor will affect the result between two groups • Twoway ANOVA – Where we have two factors that affect the result or outcome • Multiway ANOVA – Three or more factors affect the result or outcomes between groups.

Chapter 82  Biostatistics in Dentistry

F Test • F = Mean square between samples/Mean square within samples • F = variance ratio • The values of mean square are seen from the analysis of variance table if we have the values of sum of squares and degree of freedom (which are calculated) • Mean square between samples – It denotes the difference between the sample mean of all groups involved in the study (A, B, C, etc.) with the mean of the population. • Mean square within samples – It denotes the difference between the means in between different samples

• The greater both these value more is the difference between the samples • The F value observed from the study is compared to the theoretical F value obtained from the tables at 1 percent and 5 percent confidence limits. • The results are then interpreted. • If the observed value is more than theoretical value at 1 percent, the relation is highly significant. • If the observed value is less than the theoretical value at 5 percent it is not significant. • If the observed value is between 1 and 5 percent of theoretical value it is statistically significant.

POINTS TO REMEMBER • Biostatistics is the tool of statistics applied to the data that is derived from biological sciences. • John Graunt is known as father of health statistics. • Uses of biostatistics in dentistry—to define the limits of normality for variable; to find correlation between two variables; to compare the efficiency; to find association between two attributes; in epidemiologic studies and helps in compilation of data, drawing conclusions and making recommendations. • Types of sampling are simple random, systematic random, stratified random, multistage, multiphase and cluster sampling. • Standard deviation is root mean square deviation and is a measure of differences of each observation from mean of all observations. • Tests of significance include student T test, ANOVA, Mann Whitney test, Chi square test, Fischer’s extract test. • Chi square test was developed by Karl Pearson and is used as test of proportion, association and goodness of fit. • ANOVA (Analysis of variance) is used when there are more than 2 samples and when measurements are influenced by several factors playing their role.

QUESTIONNAIRE 1. 2. 3. 4. 5. 6.

Define biostatistics and explain its uses in dentistry. What are sampling methods? Write a note on standard deviation. Classify different types of charts of presentation of data. Explain standard deviation. What are tests of significance?

BIBLIOGRAPHY

1. Armitage P, Berry G. Statistical Methods in Medical Research 2nd Edn London Blackwell Scintific; 1987. 2. Darby ML, Bowen DM. Research Methods for Oral Health Professionals: CV Mosby; 1980. 3. Dunning JM. Principles of Dental Public Health. Cambridge, Massachusetts; 1975. 4. Gupta SC. Fundamentals of Statistics 6th Edn Himalaya Publishing House, New Delhi;1997. 5. Mahajan BK. Methods in Biostatistics 5th Edn New Delhi: Jaypee Brothers, New Delhi; 1989.

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Chapter

Research Methodology Rajesh Sharma, Anupma Sharma

Chapter outline • • •

Categories of Research Scientific Foundations of Research Components of a Research Project

Research: It is the quest for knowledge through diligent search or investigation or experimentation aimed at the discovery and interpretation of new knowledge.

• • • •

Research Strategies and Design Clinical Trials Sampling Ethical Aspect of Health Research

Dental research: It is the study of laws, theories and hypothesis through a systematic examination of pertinent facts and their interpretation in the field of dentistry.

• Basic research is usually considered to involve a search for knowledge without a defined goal of utility or specific purposes. • Applied research is problem oriented and is directed towards a defined and a purposeful end; it is frequently generated by a perceived need, and is directed toward the solution of an existing problem.

Methodology: It is procedures by which researchers go about describing, explaining and predicting phenomenon.

SCIENTIFIC FOUNDATIONS OF RESEARCH

CATEGORIES OF RESEARCH

Empirical and Theoretical Research • It is based upon observation and experience more than theory and abstraction. • It involves quantifications for the most part. • This is achieved by three related numerical procedures: 1. Measurement of variables. 2. Estimation of population parameters (the determina­ tion and comparison of rates, ratios). 3. Statistical testing of hypothesis, or the extent to which chance alone may account for our findings. • Theoretical research is based solely on theory and abstraction (conceptual, hypothetical and nonrealistic).

Basic and Applied Research • Research can be functionally divided into basic research and applied research.

The scientific method differs from common sense in arriving at conclusions by employing an organized observation of entities or events which are classified or ordered on the basis of common properties and behaviors.

Inference and Chance • Reasoning, or inference, is the force of advance in research. • In terms of logic, it means that the statement or conclusion ought to be accepted because one or more other statements or premises (evidences) are true. • Two distinct approaches or arguments have evolved in the development of inferences, deductive and inductive: 1. In deduction the conclusion necessarily follows the premises, as in a syllogism or an algebraic equation. Deduction can be distinguished by the fact that it moves from the general to the specific and does not allow for the element of chance. 2. In inductive reasoning, the conclusion does not necessarily follow the evidence or facts. We can say

Chapter 83  Research Methodology only that the conclusion is more likely to be valid if the facts are true. There is a possibility that the facts may be true but the conclusions false. Inductive reasoning can be distinguished by the fact that it moves from specific to general.

Maintenance of Probability • The critical in the design of research is the maintenance of probability—the one which ensures the validity. • The most salient element of design, which are meant to ensure the integrity of probability and prevention of bias are the representative sampling; randomization in the selection of study groups; maintenance of comparison groups as controls; binding of experiments and subjects and the use of probability methods in the analysis and interpretation of outcome.

Hypothesis • Hypotheses are the carefully constructed statements generated from the inferences, and they use the argument of induction. • Although we cannot draw definitive conclusions or claim proof, we can come closer to the truth by knocking down the existing hypotheses and by replacing them with new ones of greater strength. • Mill’s canon of inductive reasoning are frequently utilized in the forming of hypotheses which relate association and causation. These are: – Method of difference: When the frequency of a disease is markedly dissimilar under two circumstances and a factor can be identified in one circumstance and not in the other, this factor, or its absence may be the cause of disease. – Method of agreement: If a factor or its absence is common to a number of different circumstances that are found to be associated with the presence of a disease, that the factor or its absence may be causally associated with the disease. – Method of concomitant variation. – Method of analogy: The distribution and frequency of a disease or effect may be similar enough to that of some other disease to suggest the commonality in cause.

COMPONENTS OF A RESEARCH PROJECT

 election and Formulation of S the Research Problem The statement of the research problem is the basis for the development of a research proposal, including the research objectives and hypothesis, the method and the budget. It

allows the investigator to describe the problem systematically and to point out why the proposed research should be undertaken. The research hypothesis should be clearly and acceptably stated. The value to scientific work depends on the originality and the logic with which the hypotheses are formulated. Hypotheses may be formulated only if researchers know enough to make predictions about what they are studying. During planning stage, the research variables should be clearly identified and their methods of measurement, as well as the unit of measurement clearly indicated.

Research Design The selection of the research strategy depends on the study objective. It comprises the following: • Descriptive, validating and surveillance strategies, using an interview, survey or mailed questionnaire. • Observational or analytical strategies including pros­ pective studies (cohort), historical cohort studies, retrospective (case-controlled) studies, cross-sectional studies and follow-up studies. • Experimental strategies, including animal studies, thera­ peutic clinical trials, prophylactic clinical trials. • Operational strategies which include operation studies.

Sampling It is the way in which a study population is chosen. When using experimental studies, the inclusion of control groups should be considered when practical. The experimental and control groups should be as similar as possible except for the factors being studied.

Data Collection A short description of plans for collecting data should be included in the research proposal in order to minimize the possibility of confusion, delays and errors. Pilot testing of the research methods and research designs when appropriate, should be included as part of the project.

Analysis and Interpretation Plans for analysis are an integral part of the research design, since they can prevent the investigator from realizing at the end of the study that certain required information has not been collected, or that some data has not been gathered in an appropriate form for statistical analysis.

Reporting Tentative plans for disseminating research results should be clearly outlined. Major emphasis should be placed in these plans and on distribution of the results to potential users.

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RESEARCH STRATEGIES AND DESIGN

Descriptive Studies • When an epidemiological study is not structured formally as an analytical or experimental study, i.e. when it is not aimed specifically to test an etiological hypothesis, it is called a “descriptive study” and belongs to the observational category of studies. • The wealth of material obtained in most descriptive study allows the generation of hypothesis, which can then be tested by analytical or experimental study designs. • Descriptive studies are usually the first phase of an epide­ miological investigation. These studies are concerned with observing the distribution of disease in human populations and identifying the characteristics with which the disease seems to be associated. • Descriptive studies entail the collection, analysis and interpretation of data. • Both qualitative and quantitative techniques may be used, including questionnaires, interviews, observation of participants, service statistics and documents describing communities, groups, situations, programs and other individual or ecological units. • The distinctive feature of this approach is that its primary concern is with the description rather than with the testing of hypothesis or proving causality. The descriptive approach may, nevertheless, be integrated with or supplement methods that address these issues, and may add considerably to the information bases.

Types • Case series: This kind of study is based on reports of a series of cases of a specific condition or a series of treated cases, with no specifically allocated control group. They represent the numerator of the disease occurrence and should not be used to estimate risks. • Community diagnosis and needs assessment: This kind of study entails the collection of data on existing health problems, programs, achievements, constraints, social stratification, leadership patterns, focal points of high resistance or high risk. Their purpose is to identify existing needs and to provide base-line data for the design of further studies or action. • Epidemiological description of disease occurrence: This common use of descriptive approach entails the collection of data on the occurrence and distribution of disease in popu­lation according to specific characteristics of individuals (age, sex, education, marital status, health status, personality, etc.) place (rural/urban, local, national, international); and time (epidemic, seasonal, cyclic, secular). A description may also be given by

familial characteristics such as birth order, family size, maternal age, family type, etc. this type of information is used in every part of every study. • Descriptive cross-sectional studies or community (population) surveys: Cross-sectional studies entails the collection of data on, as the term implies, a cross section of the population, which may comprise the whole population or a proportion (a sample). Many cross sectional studies do not aim at testing a hypothesis about an association and are thus descriptive. They provide a prevalence rate at a point in time (point prevalence) or over a period of time (period prevalence). The study population is the denominator for these prevalence rates. Included in this type of studies are surveys, in which the distribution of a disease, disability, pathological condition, immunological condition, nutritional study, fitness, intelligence, etc. is assessed. • Ecological descriptive studies: When the unit of study is an aggregate (e.g. family, clan or school) or an ecological unit (village, town or district), the study becomes a ecological descriptive study.

Analytical Studies • Analytical studies are observational means used in the epidemiological investigations to test the specific etiologic hypothesis. The term “analytical” implies that the study is designed to establish the cause of the disease by looking for associations between exposure to risk factor and disease occurrence. • The basic approach in analytical studies is to develop a testable hypothesis and to design the study to control for extraneous variables that could confound the observed relationship between the studied factor and the disease. The approach varies according to the specific strategy used.

Types Observational studies • Case control studies (retrospective): It is an efficient and common experimental strategy. It is designed particularly to establish the causes of diseases by investigating associations between the exposure to a risk factor and the occurrence of disease. The design is relatively simple, except that, it is “backward looking” (retrospective), based on the exposure histories of the cases and controls. With this type of study, one investigates an association by contrasting the exposure of a series of cases of the specified disease with the exposure pattern of carefully selected control groups free from that particular disease. Thus, the data are analyzed to determine whether the exposure was different for the cases and controls. In other words, if greater proportion of cases than controls give the history

Chapter 83  Research Methodology of exposure, or have records or indications of exposure in the past, the factor or attribute can be suspected of being the causative factor. – Design

– Selection of cases: What constitutes a case in the study should be clearly defined with regard to histological type and other specifying characteristics, such as date of diagnosis and geographical location. Cases that do not fit these criteria should be excluded from the study. Because this design is particularly efficient for rare disease, all cases that fit the study criteria in a particular setting within a specific period are often included. – Sources of cases may be from any case reported or diagnosed during a survey or surveillance program within a specified period. – Selection of controls: It is crucial to set-up control groups of people who do not have the specified disease condition in order to obtain estimates of the frequency of the attribute or risk factor for comparison with its frequency among cases. – Collection of data on exposure: Such a data may be amas­sed through interviews, questionnaires and examination of records. – Advantages of case control studies - Feasible when studying rare diseases. - Relatively efficient, requiring a smaller sample than a cohort study. - Little problem with attrition. - Sometimes the earliest practical observational strategy for determining an association. – Disadvantages and biases of case control studies: - The absence of epidemiological denominators makes the calculation of incidence rates impossible. - Temporality is a serious problem in many case control studies where it is not possible to deter­ mine whether the attribute led to the disease condition or vice versa. - There is a great chance for bias in the selection of cases and controls. - It may be difficult or impossible to obtain information on exposure if the recall period is too long. - Selective survival, which operates in case control studies, may bias the comparison. There is no way

to ascertain whether the exposure was the same for those who died and those who survived. - Measurement bias may exist, including selective recall or misclassification. There is possibility of the Hawthorne effect; with repeated interviews, respondents may be influenced by being under study. - Case control studies are incapable of disclosing other conditions related to the risk factor. • Prospective cohort studies: The common strategy of cohort studies is to start with a reference population (or a represen­tative population), some of whom have certain characteristics or attributes relevant to the study (exposed groups), and others who do not have those characteristics (unexposed groups). Both the groups, should at the outset of the study, be free of the conditions under consideration. Both the groups are then observed over a period to find out the risk each group has of developing the condition of interest. – Design

– Advantages of a cohort study - Cohort studies allow the possibility of measuring directly. - Knowledge of antecedent—consequent relation­ ship is necessary to determine whether or not there is a cause—effect relationship. - There is no chance of bias being introduced. - Cohort studies are capable of disclosing other diseases related to the same risk factor. – Disadvantages - Studies are long-term and thus are not always feasible. - Very costly in time, personnel, space and patient follow-up. - Sample sizes required for cohort studies are extre­ mely large, especially for infrequent conditions. - The most serious problem is that of attrition or loss of people from the sample or control during the course of the study as a result of migration or refusal to continue to participate in the study. • Historical cohort studies: It is also called trohoc study. In a prospective cohort study, the investigators or their substitutes are typically present from the beginning to the end of the observation period. However, it is possible to maintain the advantages of the cohort studies without the

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continuous presence of the investigators, through the use of historical cohort study. It depends on the availability of data or records which allow reconstruction of the exposure of the cohorts to a suspected risk factor and the follow-up of their mortality or morbidity over time. In other words, although the investigator is not present when the exposure is first identified, he reconstructs exposed and unexposed populations from the records and then proceeds as though he had been present throughout the study. – Disadvantages - All of the relevant variables may not be available in the original records. - It may be difficult to ascertain that the study population was free from the condition at the start of the comparison. - Attrition problems can be serious due to the losses of records, incomplete records or difficulties in tracing or locating all of the population for further study. - These studies require ingenuity identifying the suita­ble populations and in obtaining reliable information concerning exposure and other relevant information. • Analytical cross-sectional studies: In an analytical cross- sectional study, the investigator measures exposure and disease simultaneously in a representative sample of population. By taking a representative sample, it is possible to generalize the results obtained in the sample to the population as a whole. Cross-sectional studies measure the association between the exposure variable and the existing disease (prevalence) unlike cohort studies which measure the rate of developing of the disease (incidence). – Design



– Advantages of cross-sectional studies - They have the great advantage over case-control studies of starting with a reference population from which the cases and control are drawn. - They can be short-term and therefore less costly than prospective studies. - They are the starting point in prospective cohort studies of screening out already existing conditions.

-

They provide a wealth of data that can be of great use in health systems use. - They allow a risk statement to be made although not precise. – Disadvantages of cross-sectional studies - They provide no direct estimate of risk. - They are prone to bias from selective survival. - Since exposure and disease are measured at same point in time, it is not possible to establish temporality. • Ecological studies: They can take the form of any strategy, as long as the unit of observation is an aggregate, a geographical administrative locality, a cluster of houses, town. Thus, these studies may be descriptive, casecontrol, cross-sectional, cohort or experimental. While such studies are of interest as sources of hypothesis and as initial or quick methods of examining association they cannot be used as basis for making causal interferences. Their most serious flaw is the risk of ecological fallacy, when the characteristics of the geographical unit are incorrectly attributed to individuals.

Experimental Studies • An experiment can be viewed as the final or definitive step in the research process, a mechanism for confirming or rejecting the validity of ideas, assumptions, postulates and hypothesis about the behavior of objects, or effects upon them, which result from interventions under defined sets of conditions. • An experiment or trial is an investigation in which the researcher studies the effects of exposure to a defined factor. • As in other designs, the investigator is rarely able to study all the units within a universe, a sample must be drawn from a target population for the purpose of the experiment, which will preserve the integrity of the representatives for generalization. This is done through a probabilistic process of random selection of study units. • In addition the units must be selected in sufficient numbers to be able to determine the best estimate, and a measure of its reliability from a set of observations or to determine the significance of difference between the outcomes of comparison groups. • Although the experiments are an important step in establishing causality, it is often neither feasible nor ethical to subject human beings to risk factors in etiological studies. However, in one area of epidemiology, experimental strategies are used extensively; this is the area of field and clinical trials and intervention programs. • Experimental design – Randomized design: In which treatment are allocated to the units entirely by chance. – Block design: The simplest method for reducing variability between treatment groups by a more homo­

Chapter 83  Research Methodology geneous combination of subject and experimental condition is through “block design”. – Latin square block: It is a further advance upon single grouping.

CLINICAL TRIALS Clinical trials are essentially experimental designs used by clinicians. The most common form is the “randomized, controlled, double blind clinical trial”.

Types of Clinical Trials • • • • • •

Prophylactic trials—immunization, contraception Therapeutic trials—drug treatment, surgical procedures Safety trials—side effects of injectables Effectiveness trials Risk factor trials Efficiency trials.

Phases of Clinical Trials Phase I clinical trials:  This first phase in humans is preceded by considerable research, including toxicological and phar­ macological studies in experimental animals to establish that the new agent is effective and may be suitable for human use and to estimate roughly the dose to be used in man. Phase I trial includes studies of volunteers who receive, initially, a fraction of what the anticipated dose is likely to be and are monitored for effects on body functions. This phase, which may not exceed one or two months, requires high technology in biochemistry, endocrinology and developed laboratory facilities. This trial is carried out under ideal conditions. Phase II clinical trials:  This phase is carried out on volunteers selected according to strict criteria. The purpose of phase II is to assess the effectiveness of the drug or appliance, to determine the dosage and safety. Further information on the pharmacology of the drug is collected. In case of appliance, its effectiveness is assessed. Phase III clinical trials:  This is the classical phase (the one usually referred to when the term clinical trials is used). It is performed on patients, who should consent to being in clinical trial. Strict criteria of inclusion and exclusion from the trial are followed. The purpose of this phase is to assess the effectiveness, safety and continued use of the drug or device in a larger and a more heterogeneous population than in phase II. It includes more detailed studies and monitoring than that given in a usual service situation. This phase is usually carried out on hospital in patients, but may be carried out on out-patients with extensive follow-up. It requires proper planning, organization and strict coherence to preformulated

protocols and instructions. Emphasis is also given to record keeping, follow-up and supervision. Phase IV trial:  Although it has been customary to approve drugs and devices for general use following phase III trials, increasing interest has been shown by governments, World Health Organization (WHO) to put drugs and devices through still another phase, i.e. a trial in normal field or program settings. The purpose of phase IV is to reassess the effectiveness, safety and acceptability. Although this phase is carried out under conditions that are as close to normal as possible, phase IV requires additional epidemiological and biostatistical skills as well as research requirements including record keeping and computer facilities.

 actors that Influence the Design and F Analysis of Clinical Trials • The agent, treatment or experimental factor: A complete knowledge about the treatment should be available to the researchers. This information usually comes from the Phase I and II Trials, as well as from many auxiliary sources. • Conditions to be treated: Adequate clinical and epidemiological knowledge about the conditions to be treated should be available to the researchers. This includes the natural history of the condition, diagnostic criteria, other variables that can influence the progress of the condition. Detailed treatment procedures should be explicitly stated and adhered to. • Target population: The type of cases to be included in the trial should be carefully specified, with explicit criteria for inclusion in and exclusion from the trial. The sample size should be predetermined and if one institution cannot provide the required sample, collaborative trials should be carefully planned with rigid protocols. Strict procedures should be used in allocating cases to groups. The ratio preferred is 1:1. • Ethical issues: No clinical trial should be performed without due consideration of ethical issues. • Outcome to be measured: One should specify explicitly what outcomes are expected and what criteria are to be applied for the success or failure of the trial. • Side effects: Criteria for observing and recording side effects should also be made. If side effects would endanger the health of the patient, he/she should be excluded from the trial and treated appropriately. • Study instruments: These are also to be specified including the laboratory tests, clinical diagnostic procedures, etc. • Blinding: It is highly desirable to enhance the objectivity of measurements by “blinding”, or hiding the identity of whether the person being examined or interviewer belongs to the experimental or the control group. • Plans for analysis: No clinical trial should be undertaken in the absence of epidemiological and statistical talent

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•

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•

Research Methodology in Pedodontics

of the research team. Detailed plans for analysis must be made prior to the trial. Selective attrition: This is the most serious to clinical trials because the sample size is usually small. Thus, many investigations prior to use as candidates in their captive populations such as hospitalized patients, reliable volunteers, students and colleagues, among whom attrition is minimal. Selective attrition can be due to secondary refusal, death or discharge from hospital, etc. Methods for ensuring the integrity of the data: Data collection procedures and adequate supervision, record keeping, quality control and blinding are crucial. If these are not guaranteed, no trial should be undertaken. The choice of design: There are a variety of experimental designs from clinical trials. The choice depends on the nature of the trial components and the composition of the research team. The usual design is the randomized, controlled double blind clinical trial. Time required: One should allow several months (up to 1 year) for planning the trial, including; preparation of protocol, sampling procedures, determination of sample size, identification of sources for cases and controls, outlining management procedures and planning the analysis. A feasibility study may be needed in the preparatory stage.

SAMPLING A sample is a part of a population. Sampling is the process or technique of selecting a sample of appropriate characteristics and adequate size. It is the cornerstone of research design which is set up to carry out the research. The reference population may be a population of people who are healthy or sick, clients of a clinic, acceptors of a certain program, having a set of problems, or people exposed to a certain stimulus. The population may not be people at all, as in the case of vital events (births, deaths) or records (medical or vital) or sampling may be of time as Wednesday Clinics, February births, etc. The individuals, records, units or time are considered to be elements in the sample. An element is the unit of observation or unit about which information is collected and which is the subject of analysis. The total of the elements of the population under the survey is called “sampling frame”. The sample is drawn from this survey population and is subset of the sampling frame. The sampling frame may be used in toto for sampling (simple random sampling) or may be divided into subgroups or strata decided by age, sex, class (stratified sampling); or the frame may consist of areas or clusters of big units containing smaller units (cluster and multistage sampling).

Advantages of Sampling • Sampling reduces the cost of investigation, the time required and the number of personnel involved.

• Sampling is especially important when the tests used are highly technical or detailed or must be administered or interpreted by experts. • Sampling allows through investigation of the units of observation. • It is obvious that a sample can be covered more adequately and in more depth in a research project than in a total population.

Requisites for a Reliable Sample • Efficiency: It means the ability of the sample to yield the desired information. • Representativeness: A sample should be representative of the parent population so that inferences drawn from the population can be generalized to that population with measurable precision and confidence. • Measurability: The design of the sample should be such that valid estimates of its variability can be made. In other words, the investigator should be able to estimate the extent to which the findings from the sample are likely to differ from what we would have found had we studied the entire parent population. • Size: A sample should be large enough to minimize sample variability to allow estimates of the population characteristics to be made with measurable precision. • Coverage: Adequate coverage of the sample is essential if it is to remain representative. High rates of refusal, unavailability, loss of follow-up and other missing data can render a sample unrepresentative of the parent population. • Goal orientation: Sample selection and estimation procedures should be oriented towards the study objectives and research design and considerations. • Feasibility: The design should be simple enough to be carried out in practice. • Economy and cost efficiency: The design of the sample should be such that appreciable savings in time and cost can be achieved without determining the study objectives. The sample should therefore yield the desired information within expected but tolerable limits of sampling error for the lowest cost.

Classification of Sampling • Random sampling: It guarantees that each member of the population has an equal chance of being included in the sample. The two common methods of random sampling are lottery and tables of random numbers. The lottery method assigns numbers to the population; these numbers are then thoroughly mixed and a sufficient number drawn (without replacement) to provide the desired sample size. Tables of random numbers are used after numbers (e.g. sequential counts) have been assigned to members of the study population.

Chapter 83  Research Methodology • Systemic sampling: The first unit is chosen at random and then other units for the sample are chosen in a systematic way, e.g. every other person or every fifth person. • Panels for studying trends: A sample is randomly selected and then data are collected from the sample on several occasions, e.g. person examined every six months. • Stratified sampling: The population to be sampled is divided into groups known as strata, such that each group is homogeneous in its characteristic. A simple random sample is then drawn from each stratum. This type of sampling is used when the population is heterogeneous with regard to the characteristic under study. For example, population divide into different age groups and then samples are selected from the groups randomly. This method ensures more representativeness, provides greater accuracy and can concentrate on wider geographical area. Care must be taken while dividing the population into strata. • Area sampling: It is a type of random sampling in which maps rather than lists are used. The area to be covered in a study is divided into smaller areas and a random sample is selected from the smaller areas. • Cluster sampling: It involves choosing groups of units or clusters at random. All the units in each group, or samples of them are then used in the study. For example, villages, wards, school children. This method is simpler and involves less time and cost, but gives a higher standard error. • Multistage sampling: It is subsampling within groups chosen from cluster samples. The first is to select the groups or clusters. Then the subsamples are then taken in as many subsequent stages as necessary to obtain the desired sample size. • Multiphase sampling: It is used to take basic data from a large sample and details from subsample. This is different from multistage sampling, in which the same amount of information is obtained for every unit. • Sequential sampling: Here a small sample is tested in order to answer certain questions about the population. If the questions are not answered, the number of subjects or units in the sample is increased gradually until conclusions may be drawn.

Determination of Sample Size • It is imperative that the sample size be sufficient to be dependable and to allow tests of significance to be applied to the data collected. • The degree of difference or strength of association one wants to be able to detect also influences the required sample size. Sometimes it is advisable to obtain an idea of the required sample size through a “Pilot study”. • Statisticians should be consulted for methods of calculating sufficient sample size.

• There are two basic ways of approaching the problem of determining sample size—the empirical and the analytical. • The empirical approach usually requires sample sizes that have been used by others in similar situations. This approach is least recommended by statisticians. • The analytical method of sample size determination requires an understanding of statistical concepts such as sampling techniques, sampling errors, hypothesis testing, significance levels and powers of tests. It is a statistically sound method.

Sampling Errors • Coverage errors: Caused by failure to sample the entire population adequately, which may arise from inadequacy of the sampling frame or from unsatisfactory coverage of the sample units. These errors are exaggerated in the use of postal questionnaires; interviews, etc. inability to make the required observations on all the assigning sampling units is called nonresponse. • Processing error: These might arise during data process­ing. Includes theoretical errors in the methods of statistical analysis; clerical errors in the copying of material and computational errors. • Observational errors: May be introduced by the fault committed by the investigator or through use of imperfect test instruments and techniques.

ETHICAL ASPECT OF HEALTH RESEARCH An experiment is an attempt to discover the unknown, or test a principle, but we cannot be sure of an outcome. The experiment involves a chance. It is because of this chance or element of the unknown that ethics become a paramount issue in those experiments involving humans. Animal based do not show the same results in humans. Therefore all scientific interventions should be ultimately evaluated in human subjects. Several codes have been developed for protection of human subjects. The three underlying prin­ciples are: 1. Beneficence: Which requires that good should result, harm should be avoided. 2. Respect from rights: Includes the free choice of the subject. 3. Justice: Which requires an equal distribution of burden and benefit.

 uidelines as Per International G Declarations The first code was “the Nurenberg Code of 1947”. This was followed by the “Declaration of Helsinki” which was adopted by The World Medical Association and the WHO in 1975. • Biomedical research should follow scientific principles and should be based on adequately performed laboratory and criminal experimentation.

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• The design of each procedure involving humans should be clearly formulated in an experimental protocol. • The experiment should be conducted by scientifi­ cally qualified persons under supervision of medical experts. • The right of the research subject to safeguard his/her integrity must always be respected. • The accuracy of the research results must be preserved. • In any research on humans, each subject is informed about the aim, methods, benefits and potential hazards of the study. • When obtaining informed consent for research, a doctor should be cautious if the subject is in a dependant relationship to him/her. • In case of legal competence, informed consent should be obtained from the legal guardian.

• Subjects should be informed that they are free to abstain or to withdraw from participation at any time. Thus the study of the research procedures and methods is a very important aspect of all postgraduate studies and at the same time provides guidelines on which our future research will be based. It also shows us the procedures that need to be followed while undertaking research and also shows us the data or findings of our study should be presented for correct interpretation and for publication. As stated by Beveridge, a successful research method would be for: “the person who possess the flair for choosing profitable lines of investigation, is able to see further where his work is leading than are other people, because he has the habit of using his investigation to look far ahead, instead of restricting his thinking to established knowledge and immediate problem.”

POINTS TO REMEMBER • Research is the quest for knowledge through diligent search or investigation or experimentation aimed at the discovery and interpretation of new knowledge. • Dental research is the study of laws, theories and hypothesis through a systematic examination of pertinent facts and their interpretation in the field of dentistry. • Empirical research is based upon observation and experience. • Theoretical research is based solely on theory and abstraction. • Components of a research project are selection and formulation of the research problem, research design, sampling, data collection, analysis and interpretation, reporting. • Observational studies include case control studies. Prospective cohort studies, analytical cross-sectional studies. • Types of clinical trials prophylactic trials, therapeutic trial, drug treatment, safety trials, effectiveness trials, risk factor trials and efficiency trials. • Factors that influence the design and analysis of clinical trials are agent, conditions to be treated, target population, ethical issues, side effects, blinding, plans for analysis, selective attrition, integrity of data, choice of design and time required. • Classification area sampling of sampling are random sampling, systemic sampling, panels for studying trends, stratified sampling, cluster sampling, multistage sampling, multiphase sampling, sequential sampling.

QUESTIONNAIRE 1. 2. 3. 4. 5.

What are components of research projects? Describe various strategies and designs of research. Explain clinical trials, its phases and designs. Define sampling and explain its types and requisites. What are international declaration guidelines?

BIBLIOGRAPHY 1. Health Research Methodology- A Guide for Training In Research Methods - World Health Organization. 2. Park K. Preventive and Social Medicine. 3. Soben Peter. Essential of Preventive and Community Dentistry.

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Chapter

Dental Indices Asmita Sharma, Nikhil Marwah

Chapter outline • • •

Classification of Indices Ideal Requisites of an Index Objectives and uses of Index

Dental indices and scoring methods are used in clinical practice and community programs to determine and record the state of health of individuals and groups. Several wellknown and widely used indices and scoring methods are described in this chapter. • An index is a graduated, numerical scale having upper and lower limits, with scores on the scale corresponding to specific criteria, which is designed to permit and facilitate comparison with other population classified by the same criteria and methods – Russel AL • Epidemiological indices are attempts to quantitative clinical conditions on a graduated scale, thereby facilitating comparison among populations examined by the same criteria and methods – Irving Glickman

• • • •

Oral Hygiene and Plaque Indices Indices used for Dental Fluorosis Gingival and Periodontal Disease Indices Caries Indices

• An index is an expression of clinical observations in numeric values. It is used to describe the status of the individual or group with respect to a condition being measured. The use of a numeric scale and a standardized method for interpreting observations of a condition results in an index score that is more consistent and less subjective than a word description of that condition – Esther M Wilkins • Oral indices are essentially sets of values, usually numerical with maximum and minimum limits, used to describe variables or specific conditions on a graduated scale, which use the same criteria and method to compare a specific variable in individuals, samples or populations with that same variable as is found in other individuals, samples or population – George P Barnes

CLASSIFICATION OF INDICES Based upon the direction in which their scores can fluctuate Irreversible index Reversible index Index that measure conditions that will not change. In this index score once established Index that measure conditions that can be changed. cannot decrease in value on subsequent examinations. For example, index that Reversible index scores can be changed i.e. can increase measures dental caries or decrease on subsequent examinations. For example, indices that measure periodontal conditions Upon the extent to which the areas of oral cavity are measured Full mouth indices Simplified indices These indices measure the patient’s entire periodontal or dentition. For example, These indices measure only representative samples of Russell’s periodontal index dental apparatus. For example, Green and Vermillion’s simplified oral hygiene index. – OHI-S

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According to the entity which they measure Disease index Symptom index Treatment index ‘D’ (Decay) portion of the DMF index Measuring gingival or sulcular bleeding are ‘F’ (Filled) portion of DMFT index is best example for is the best example for disease index essentially examples for symptom indices treatment index General indices Simple index Cumulative index Index that measure the presence or absence of condition. For example, silness and Index that measures all the evidence of a condition, post Loe plaque index that measure the presence of dental plaque without evaluation of and present. For example, DMFT index for dental caries its effect on gingiva

IDEAL REQUISITES OF AN INDEX

Clarity, Simplicity and Objectivity • Easy to apply: No undue time lost • Clear and unambiguous with mutually exclusive categories.

Validity • Measure what it is intended to measure • Should correspond to clinical stages of disease under study at each point.

Reliability • Measure consistently at different times and under a variety of conditions • Reproducibility: Same or different examines to interpret and use the index in the same way.

Quantifiability • Amenable to statistical analysis • Expressed by distribution, mean median and other statistical measures.

Sensitivity Detect reasonably small shifts.

Acceptability Should not be painful or demeaning to the subject.

A useful and effective index • • • • • • • •

Is simple to use and calculate. Requires minimal equipment and expense. Uses a minimal amount of time to complete. Does not cause patient discomfort nor is otherwise unacceptable to a patient. Has clear-cut criteria that are readily understandable. Is as free as possible from subjective interpretation. Is reproducible by the same examiner or different examiners. Is amenable to statistical analysis; has validity and reliability.

OBJECTIVES AND USES OF INDEX

For Individual Patient • Provide individual assessment to help patient recognize an oral problem. • Reveal degree of effectiveness of present oral hygiene practices. • Motivation in preventive and professional care for control and elimination of diseases.

In Research • Determine baseline data before experimental factors are introduced. • Measure the effectiveness of specific agents for prevention, control or treatment of oral condition. • Measure the effectiveness of mechanical devices for personal care.

In Community Health • Show the prevalence and trends of incidence of a particular condition. • Provide baseline data to show existing dental health practices. • Assess the needs of a community. • Compare the effects of a community program and evaluate the results.

ORAL HYGIENE AND PLAQUE INDICES

Oral Hygiene Index The oral hygiene index was developed in 1960 by John C Greene and Jack R Vermillion to classify and assess oral hygiene status.

Purpose The oral hygiene index (OHI) is a method for classifying the oral hygiene status of a patient. It can be used over time to monitor progress in corrective interventions.

Methodology The OHI has two components, the debris index (DI) and the calculus index (CI). Each of these indexes is based on 12

Chapter 84  Dental Indices numerical determinations representing the amount of debris or calculus found on the buccal and lingual surfaces of each of the three segments of each dental arch.

Segment 5:  Mesial to the right and left first bicuspid on the mandibular arch.

Selection of Teeth and Surfaces (Fig. 84.1)

Rules

Segment 1:  Distal to the right cuspid on the maxillary arch.

• Only fully erupted (occlusal and incisal surface has reached the occlusal plane) permanent teeth are scored. • Third molars and incompletely erupted teeth are not scored because of the wide variations in heights of clinical crowns. • The buccal and lingual debris scores are both taken on the tooth in a segment having the greatest surface area covered by debris. • The buccal and lingual calculus scores are both taken on the tooth in a segment having the greatest surface area covered by supragingival and subgingival calculus.

Segment 2:  Mesial to the right and left first bicuspid on the maxillary arch. Segment 3:  Distal to the left cuspid on the maxillary arch. Segment 4:  Distal to the left cuspid on the mandibular arch.

Segment 6:  Distal to the right cuspid on the mandibular arch.

Procedure • For the debris index: The surface area covered by debris is estimated by running the side of a number 23 explorer (Shepherd’s Hook) along the buccal/labial and lingual surfaces and noting the occlusal or incisal extent of the debris as it is removed from the tooth surfaces. • For the calculus index: A number 5 explorer is used for estimating the amount of supragingival and subgingival calculus. • The oral hygiene examination and scoring for the DI should always precede the oral examination and scoring for the CI.

Fig. 84.1:  Selection of teeth and surface

Scoring Criteria Grading debris No debris or stain present Soft debris covering not more than one third of the tooth surface,  and/or  the presence of extrinsic stain without other debris regardless of surface area covered Soft debris covering more than one third, but not more than two thirds, of the exposed tooth surface Soft debris covering more than two thirds of the exposed tooth surface

Points 0

Grading calculus No calculus present Supragingival calculus covering not more than one third of the exposed tooth surface Supragingival calculus covering more than one third but not more than two thirds of the exposed tooth surface, and/or the presence of individual flecks of subgingival calculus around the cervical portion of the tooth Supragingival calculus covering more than two thirds of the exposed tooth surface  and/or  a continuous heavy band of subgingival calculus around the cervical portion of the tooth

Points 0 1

1 2 3

2

3

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Calculation • Debris index = (SUM (points along buccal surface for all segments present) + SUM (points along lingual surface of all segments present))/(number of segments present) • Calculus index = (SUM (points along buccal surface for all segments present) + SUM (points along lingual surface of all segments present))/(number of segments present) • Oral hygiene index = (debris index) + (calculus index).

Interpretation • The minimum number of points for all segments in either the debris or calculus portions is 0. • The maximum number of points for all segments in either the debris or calculus score is 36. • Since there are up to 6 segments, the individual indices range from 0 to 6. • Since the oral hygiene index is the sum of the two indices, its range of values is from 0 to 12. • The higher the score, the poorer the oral hygiene.

Simplified Oral Hygiene Index • The simplified oral hygiene index (OHI-S) was developed in 1964 by John C Greene and Jack R Vermillion. • Even though the oral hygiene index was determined to be simple and sensitive, it was time consuming and required more decision-making. So, an effort was made to develop a more simplified version with equal sensitivity. • The simplified oral hygiene index (OHI-S) differ from the oral hygiene index in the below mentioned aspects however, the criteria and scoring for the tooth surfaces remain the same (Fig. 84.2). – The number of tooth surfaces scored (6 rather than 12) – The method of selecting the surfaces to be scored – The scores, which can be obtained • At least two of the six possible tooth surfaces must have been examined. Third molars are included only if they are functional. • Natural teeth with full crown restorations and surfaces reduced in height by caries or trauma are not scored.

Fig. 84.2:  Teeth selection for simplified oral hygiene index

Calculation of the Index For each individual, the debris and calculus scores are totaled and divided by the number of tooth surfaces scored. Total score Calculation of DI-S score = ___________________________________________ Number of surfaces examined Total score Calculation of CI-S score = ___________________________________________ Number of surfaces examined Once the DI-S and CI-S are calculated separately, then they are added together to get the OHI-S score.

Interpretation For the DI-S and CI-S scores

For the OHI-S score

Good – 0.0-0.6

Good- 0.0-1.2

Fair- 0.7-1.2

Fair- 1.3-3.0

Poor-1.3-6.0

Poor-3.1-6.0

Uses of OHI-S Index Substitution For tooth 16 If 17 is missing For tooth 11 For tooth 26 If 27 is missing For tooth 36 If 37 is missing

Tooth 17 Tooth 18 Tooth 21 Tooth 27 Tooth 28 Tooth 37 Tooth 38

• It has been widely used in studies of the epidemiology of periodontal disease. • It is useful in evaluation of dental health education programs in public school systems. • It is used in evaluating the cleansing efficiency of tooth brushes. • It is used to evaluate an individual’s level of oral clean­ liness.

Chapter 84  Dental Indices

Plaque Index

Plaque index for a tooth:  Scores from the four areas of the tooth are added and then divided by four.

• The Plaque index was developed by Silness and Loe (1964) assesses the thickness of plaque at the cervical margin of the tooth (closest to the gum). Four areas, distal, facial or buccal, mesial and lingual, are examined (Fig. 84.3). • Each tooth is dried and examined visually using a mirror, an explorer, and adequate light. The explorer is passed over the cervical third to test for the presence of plaque. A disclosing agent may be used to assist evaluation. • Missing teeth are not substituted. • Four different scores are possible. • Each of the four surfaces of the teeth (buccal, lingual, mesial and distal) is given a score from (0 to 3). The scores from the four areas of the tooth are added and divided by four in order to give the plaque index for the tooth with the following scores and criteria.

Scoring Criteria Score

Criteria

0

No plaque

1

A film of plaque adhering to the free gingival margin and adjacent area of tooth. The plaque may be seen in situ only after application of disclosing solution or by using probe on tooth surface

2

Moderate accumulation of soft deposits within the gingival pocket, or the tooth and gingival margin which can be seen with the naked eye

3

Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin

Plaque index for group of teeth:  Scores for individual teeth may be grouped and totaled and divided by the number of teeth. Plaque index for the individual:  Indices for each of the teeth are added and then divided by the total number of teeth examined. Plaque index for a group: Indices for each member of a group or population is added up and then divided by the total number of individuals in the group or population.

Interpretation for PI Scores Rating

Scores

Excellent

‘0’

Good

0.1 – 0.9

Fair

1.0 – 1.9

Poor

2.0 – 3.0

Uses • Reliable technique for evaluating both mechanical antiplaque procedures and chemical agents • Used in longitudinal studies and clinical trials.

INDICES USED FOR DENTAL FLUOROSIS Dental fluorosis is a hypoplasia or hypo mineralization of tooth enamel or dentin produced by the chronic ingestion of excessive amounts of fluoride during the period when teeth are developing. The intensity of fluorosis ranges from barely noticeable whitish striations that may affect only a small portion of enamel to confluent pitting of almost the entire enamel surface and unsightly dark brown to black staining. The most common indices used for fluorosis are Dean’s fluorosis index, Thylstrup–Fejerskov index of fluorosis and community fluorosis index. All these indexes have been explained in detail in chapter 26 (fluorides).

GINGIVAL AND PERIODONTAL DISEASE INDICES

Gingival Index Fig. 84.3:  Selection of tooth surface in plaque index

Calculation of Plaque Index Plaque index for area:  Each area (distal-facial, facial, mesialfacial, lingual) is assigned a score from 0-3.

• Also attributed to Loe and Silness (1963), the GI assesses the severity of gingivitis based on color, consistency and bleeding on probing. • It describes the clinical severity of gingival inflammation as well as its location.

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• Mesial, lingual, distal and facial surface of each teeth are examined. • A probe is used to press on the gingiva to determine its degree of firmness, and to run along the soft tissue wall adjacent to the entrance to the gingival sulcus. • Teeth examined are 16 12 24 32 26 44.

Scoring Criteria Score

is scored according to the condition of the surrounding tissues.

Scoring Criteria Score

Criteria (field studies)

‘0’

- ve, neither overt inflammation nor loss of function due to destruction of supporting tissue

Criteria

Radiographic criteria for clinical studies Normal

‘0’

Absence of inflammation/normal gingiva

‘1’

Mild inflammation, slight change in color, slight edema; no bleeding on probing

‘1’

Mild gingivitis, inflammation does not circumscribe tooth

‘2’

Moderate inflammation; moderate glazing, redness, edema and hypertrophy. Bleeding on probing

‘2’

‘3’

Severe inflammation; marked redness and hypertrophy ulceration. Spontaneous bleeding

Gingivitis, inflammation circumscribes the tooth, no break in epithelial attachment

‘4’

Used only when radiographs are available

Early, notch like resorption of alveolar crest

‘6’

Gingivitis with pocket, epithelial attachment broken, tooth firm, no drift

Horizontal bone loss involving entire alveolar crest, up to ½ of root length

‘8’

Advanced destruction with loss of masticatory function, tooth loose, drifted, dull on percussion

Advanced bone loss involving ½ of root, or a infrabony pocket, widened PDL, root resorption

Calculation of the Index • Totaling the scores around each tooth obtains the gingival index score for the area. • If the scores around each tooth are totaled and divided by four, the gingival index score for the tooth is obtained. • Totaling all of the scores per tooth and dividing by the number of teeth examined provides the gingival index score per person.

Interpretation Gingival scores

Condition

0.1–1.0

Good (mild gingivitis), mild inflammation

1.1–2.0

Fair (moderate gingivitis), moderate inflammation

2.1–3.0

Poor (severe gingivitis), severe inflammation